1. Epidemiology, Burden and Primary Prevention of Cardiovascular Disease Dr Shanthi Mendis MBBS MD FRCP FACC Coordinator Chronic Disease Prevention and Management World Health Organization Geneva, Switzerland

2. Mortality/Morbidity Incidence/Prevalence Primary prevention
Cardiovascular Diseases

3. 10% 31% 59% Global magnitude of deaths from noncommunicable diseases
70 million
60 million
10%
5.8M
31%
50 million
35.0M
40 million
59%
30 million
20 million
18.0M
Source:
10 million
Total number of deaths (2004)
Group III - Injuries
Low-income countries
Group II – Deaths from noncommunicable diseases
Group I – Communicable diseases, maternal, perinatal and nutritional conditions

4. Global mortality cardiovascular diseases 29% (17 million)
Communicable
maternal
infant
All other Non communicable diseases
Cancer
13%
16%
40%
Diabetes
29%
(17 million) 2%
Look at potential contribution of effective 2 P to the overall CVD epidmic
cardiovascular diseases
( Three quarters of the burden in LMIC) 4 4

5. Cardiovascular Diseases
- CVD contributes 29% of global deaths
- 88% of the global CVD burden is in LMICs
-Total CVD deaths 17.1 million
million deaths ( coronary heart disease deaths 7.2 million, cerebrovascular disease deaths 5.7 million ) due to atherosclerotic disease

6. Cardiovascular Disease Burden (DALYs)
Total (10% GDB ) Africa SEA America EMR Europe WPR
Cardiovascular Disease Burden (DALYs)

7. Age standardized NCD burden by country income group (2004

8. Noncommunicable Diseases (2006-2015)
2005
(cumulative)
Geographical regions (WHO classification)
Total deaths (millions)
NCD deaths (millions)
Trend: Death from infectious disease
Trend: Death from NCD
Africa
10.8
2.5 28
+6%
+27%
Americas
6.2
4.8 53
-8%
+17%
Eastern Mediterranean
4.3
2.2 25
-10%
+25%
Europe
9.8
8.5 88
+7%
+4%
South-East Asia
14.7
8.0 89
-16%
+21%
Western Pacific
12.4
9.7
105 +1
+20%
Total
58.2
35.7
388
-3%
These are projections showing the rapidly rising NCD mortality trend worldwide. They indicate that there will be an overall 17% increase in the number of deaths caused by these conditions over the ten year period up to However, the greatest increase will be seen in the African region followed by the Eastern Mediterranean region where we will have a 27% and 25% increase respectively.
(WHO, Chronic Disease Report, 2005)
WHO projects that over the next 10 years, the largest increase in deaths from cardiovascular disease, cancer, respiratory disease and diabetes will occur in developing countries. 8

9. Cardiovascular mortality trends In high income countries CV mortality is declining In middle income countries CV mortality is high and rising In low income countries CV mortality will rise.

10. Leading causes of burden of disease
Leading causes of burden of disease, 2004 and 2030

11. CVD
In 2002, the World Health Report , published the results of a global risk factor study conducted by WHO.
The aim was to quantify some of the most important risks to health
The list of 26 risk factors surveyed included cardiovascular risk factors.
> 75% of the global CVD burden was due to tobacco, blood pressure, cholesterol or a combination of the three

12. Few risk factors account for the global burden of cardiovascular disease

13. Blood pressure, stroke and IHD
8.00
8.00
4.00
4.00
2.00
Relative Risk & 95% CI
2.00
1.00
1.00
0.50
Stroke
0.50
IHD
(-10 mmHg = - 42%)
(-10mmHg = - 24%)
0.25
0.25
110
120
130
140
150
160
170
110
120
130
140
150
160
170
Usual SBP (mmHg)
Usual SBP (mmHg)
APCSC J Hypertens, 2003

14. CVD
WHOs Project for MONItoring of trends and determinants in CArdiovascular disease (MONICA)
Trends in CVD in 38 populations in 21 countries.
During the 10-year period covered by the MONICA Project, mortality from CHD and stroke reduced dramatically.
The greatest reduction 6.5% per year over a 10-year period in North –Karelia , Finland.

15. CVD
Across all MONICA populations with declining CHD mortality, reduced incidence contributed to 75% of the change in men and 66% in women, the remainder being attributed to reduced case fatality.
For stroke, 33% of the changes were attributed to reduced incidence and two thirds to reduced case fatality.
The change in incidence reflected risk factor changes in the populations.

16. CVD
Supported the findings of the Framingham study and the view that population-wide prevention strategies and strategies targeting people with disease or with high risk, are complimentary approaches for reduction of the burden of CVD

17. Synergism of population-wide and high risk strategies
Mendis S 2005

18. CVD The INTERHEART study ; case-control study of acute MI in 52 LMIC
Provided evidence that five established risk factors (tobacco use, lipids, hypertension, diabetes and obesity), which can be measured relatively easily, predict about 80% of the population attributable risk of AMI.
WHO estimates published in 2009, show that eight preventable risk factors (tobacco use, physical inactivity, raised blood pressure, raised blood glucose, raised blood cholesterol, alcohol use, high body mass index and low fruit and vegetable intake) account for 61% of total CVD deaths.

19. Why are there economic consequences?
High health care budgets
Health care budgets will rapidly increase
Resources for other areas (education), suffer
Lost productivity due to premature mortality

20. Primary Prevention

21. Action Plan of the WHO Global Strategy
Endorsed by the World Health Assembly in May 2008 by all Member States
Six objectives:
1. Raising the priority accorded to NCD in development work at global and national levels
2. Establishing and strengthening national policies and programmes
3. Reducing and preventing risk factors
4. Prioritizing research
5. Strengthening partnerships
6. Monitoring NCD trends and assessing progress at country level
Here are the objectives of the plan. Under each of the six objectives there are three sets of actions to be implemented during the six year period, one set for member sates, another for WHO and a third for international partners

22. CVD and salt Positive association between salt and BP
Significant relationship between the rise in BP with age and salt intake
Systematic review (17 trials HBP and 11 trials with NBP)
Correlation between magnitude of salt reduction and BP reduction within the range 3-12 gm/day
Intensive interventions reduce BP significantly (DASH trial)
Individual efforts work in the short term, more difficult in the long-term (0.6 mm Hg diastolic, 1.1 mm Hg systolic)

23. CVD and Trans-fat
Trans-fats (unsaturated fatty acids with that contain one or more isolated (non conjugated )double bonds in a trans configuration
Formed during partial hydrogenation of liquid vegetable oils resulting in semi solid fats used in margarines, cooking oils and bakery products
Stability during frying and long shelf life
Consumption may be 4.5 – 7 gms per day, 2-3% of total calories
Conclusive evidence that trans-fats increases the risk of CHD

24. Reduce Trans-fat
Denmark, Canada, France, USA, Russia (labelling and regulation)
Argentina, Chile, Brazil , Paraguay, Uruguay
Significant reduction is feasible
Total elimination should be the goal
Less than 2% in cooking oils and <5% in other foods

25. Cost to implement the package of interventions (US$ per person per year, 2005)
Asaria et al, Lancet 2007;370:

26. Thank You