Wake Forest School of Medicine

Elsayed Z. Soliman MD, MSc, MSEpidemiological Cardiology Research Center (EPICARE)Wake Forest School of Medicine, Winston Salem, NC

Innovations in Management of Cardiovascular Disease for Global Health

2011 Global Health Conference- Montreal, Canada November 13, 2011

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Outline

• Global burden of CVD

• Paradigm shift in concepts• Public health approach vs. high risk strategy

• Individual vs. global (total) CVD risk assessment/management

• Applications • WHO/ISH risk prediction charts

• Polypill

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Distribution of major causes of death

WHO 2011

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Global burden of CVD

• 17.3 million people died from CVDs in 2008

• 80% of CVD deaths take place in low- and middle-income countries

• 23.6 million expected to die from CVD By 2030

WHO 2011

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Meeting the challenge

Life saving interventions are available, but the challenge is to increase its use by enhancing:

• Availability

• Affordability

• Adherence

• Sustainability

A paradigm shift in concepts is needed!!!

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Public health approach vs. high risk strategy

Prevention paradox:

“An intervention which brings much benefit to population brings little benefit to individual and inversely”

Rose G. 1995

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10 year cardiovascular disease risk

05 10 15 20 25 30 35 40

% of Population Present distribution

Optimal distribution

.

.

.

Population StrategyPopulation Strategy High Risk StrategyHigh Risk Strategy

WHO publications

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Global risk assessment • An assessment of total (global) risk based on the sum

of all major CVD risk factors can be useful for:

(1) Identification of high-risk patients who deserve immediate attention and intervention

(2) Motivation of patients to adhere to risk-reduction therapies

(3) Modification of intensity of risk-reduction efforts based on the total risk estimate

Grundy et al. Circulation doi: 10.1161/01.CIR.100.13.1481

•Indicates total 10-year risk of a fatal or non-fatal CVD events, based on: age, sex, blood pressure, presence or absence of diabetes, smoking status, and cholesterol level (if available)

•Geographic region-specific

Global risk assessment: WHO CVD risk predication charts

Global vs. individual CVD risk management

Source: Global Health Risks: Mortality and burden of disease attributable to selected major risks. WHO 2009

Global vs. individual CVD risk management

Neaton JD et al Arch Intern Med. 1992;152:56-64

Global risk managementPolypill

• A combination of multiple CVD drugs in one pill

• Proponents:

• Tackles multiple risk CVD factors

• Addresses adherence

• Expected to be inexpensive

• Opponents:

• Concerns about individualized medicine

• Negative impact on lifestyle

BMJ 206:141903;32

Global risk managementPolypill

• Wald and Law proposed Polypill strategy

• Combination of statin, thiazide diuretic, β blocker, ACE-I, folic acid and aspirin

• To be given to everyone above the age of 55 years

• No need for risk factor monitoring

• 88% estimated reduction in CHD and 80% in stroke

• Current Polypill strategies:

• Exclude folic acid

• Not for everyone

• Estimated effect on risk reduction is less than that of Wald and Law

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Polypill efficacyTIPS- Indian Polycap

Indian Polycap Study (TIPS) investigators. Lancet 2009;373:1341–1351.

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Soliman et al (Trials 2011).

Patient acceptability• 203 patients who completed the study and 207 who were screened but deemed ineligible to be enrolled •Approx. 90% of the patients who completed the study indicated that they would "definitely" or "probably" take the pill for life if it were shown to be effective in reducing CVD risk•A similar response level (89%) was obtained from those who were screened but found to be ineligible for the study

Polypill acceptabilityWHO-sponsored Sri-Lanka pilot study

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Polypill acceptabilityWHO-sponsored Sri-Lanka pilot study

Soliman et al (Trials 2011).

Physician acceptability

• 84 physicians from the participating clinical sites and the Council of General Practitioners in Sri Lanka•86% would prescribe it for primary prevention •93% would prescribe it for secondary prevention•Results did not vary by specialty

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Polypill acceptabilityUSA physicians

Preventive Medicine 2011

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Summary

• CVD is a major global health issue

• A combination of population wide and high risk strategies are required to shift the CVD risk distribution of populations to more optimal levels

• There is a call for a paradigm shift from assessment and treatment of risk factors in isolation, to a comprehensive CVD risk assessment and management approach