53654 Cardiovascular Health at a glance pressure levels are dietary patterns (especially salt intake), body Why address cardiovascular health? weight and physical activity. Cardiovascular diseases (predominantly affecting blood vessels of s High cholesterol levels are responsible for about 20% of the the heart and brain) are a major cause of premature death and global burden of cerebrovascular disease, and 60% of coro- disability worldwide. nary heart disease. Important determinants of cholesterol levels In 2001, 16.6 million deaths globally were due to cardiovascular can be modified: intake of saturated and trans-fatty acids, and diseases (CVD); this figure will increase to 25 million by 2025. physical activity. The two leading causes of death worldwide are cardiovascular - s Tobacco consumption has risen sharply in many low- and coronary heart disease (which causes heart attack and heart fail- middle-income countries. Tobacco use contributes an estimated ure) and cerebrovascular disease (which causes stroke).* The one-eighth of the global burden of CVD. direct and indirect costs of CVD are high: enormous health care costs and productivity/income losses. s The number of adults with diabetes is projected to rise sharply from 135 million in 1995, to over 300 million by 2025. By Of all global deaths from CVD, 65% occur in developing coun- 2025, >75% of adults with diabetes will reside in developing tries. This will increase to 75% by 2025. By then, cardiovascular countries. The major modifiable risk factors for diabetes are disorders will be the biggest cause of lost disability-adjusted life overweight/obesity and physical inactivity. years (DALYs) worldwide, and the second leading cause of DALY loss in developing countries. There are over 1 billion overweight or obese people globally. Overweight and obesity are associated with raised blood pressure In developing countries, cardiovascular diseases predominantly and cholesterol levels, and an increased risk of developing dia- affect people of working age (30-64 years). Death and disability betes. Excess body fat (generalised or abdominal) accounts for in middle age has major social and economic consequences. about 60% and 20% of the global burden of diabetes and coro- As health transitions advance, there is a reversal in the socio-eco- nary heart disease, respectively. Major modifiable determinants of nomic gradient, and poorer and disadvantaged groups suffer the overweight and obesity are unhealthy diet and physical inactivity. largest burden of CVD. This has already occurred in developed The latter is estimated to account for about one-fifth of the global nations, and seems to be manifesting in many middle and low burden of coronary heart disease. income countries, especially for CVD risk factors that predict future events. DALYs lost to cardiovascular Prevention or treatment of risk factors for CVD is effective and sus- diseases in regions of the world 1990-2020 tainable in the long run. The risk of CVD can be reduced quickly 50 DALYs (millions) and substantially with successful preventive practices. This also has a favourable impact on other non-communicable diseases (NCDs) IND 40 that share the same risk factors. CHI Treatment of established CVD is expensive and resource intensive. 30 SSA Unregulated private health systems tend to direct a large propor- tion of resources to costly cardiovascular technologies available MEC 20 LAC only to the wealthy few. EME FSE Risk Factors for CVD 10 OAI The most important risk factors for CVD are well-established. They 0 include high blood pressure, glucose and lipids, and exposure to tobacco smoke. The lower the level of the risk factors, the lower 1990 2000 2010 2 the CVD risk. In any population, more individuals have CVD due to small concurrent adverse changes in multiple risk factors rather IND-India; CHI-China; SSA-Sub-Saharan Africa; MEC-Middle Eastern Crescent; LAC-Latin American Countries; EMA-Established Market Economies; FSE-Former than extreme deviations in any single risk factor. Socialist Economies; OAI-Oceania. Source: WHO Levels of cardiovascular risk factors are rising in most developing regions. s 60% of the burden of cerebrovascular disease and about one- How to improve cardiovascular health half of coronary heart disease globally is attributable to high There are two complementary approaches to preventing cardio- blood pressure. The major modifiable factors influencing blood vascular diseases: * This fact sheet does not cover Rheumatic Heart Disease and Chaga's Disease that contribute to CVD burdens in many developing countries, and are related to infectious causes. October 2003 Key Actions to Reduce CVD Essential Package Comprehensive Package Beneficiaries/ Area (core components) (other components Target Groups Indicators INCREASED Sensitize governments and NGOs Policy-makers Surveillance of knowledge, AWARENESS attitudes and practice OF CVD Community/school/workplace related Media coverage Entire population among health policy-makers, awareness promotion programmes health care providers, patients and the general Continuing medical education (CME), Context-specific changes in medical Health care community. training for multipurpose health care curricula. providers workers, nurses, physicians Identification and referral of individuals at high risk of CVD. PREVENTION Tobacco Control (see tobacco Whole population Real price of tobacco control at a glance) (taxation, products, tobacco free regulation, education) places, no advertising Promote Healthy Diets (production, National Nutrition Policy (involving Whole population Saturated fat production, pricing, consumer empowerment) agriculture and industry) availability of low fat/salt including preparing and disseminating alternatives, fruits and national food based dietary guidelines vegetables Promote Physical Activity National Transport Policy (pollution Whole population Availability of dedicated (planning of cities and work-sites, control and promotion of physical cycle and pedestrian lanes, community education) activity) gymnasiums/sports facilities at work-place School/workplace programs for School children/ Health awareness, changes `Learning to Live Healthy' Employees in health related behaviour (e.g. tobacco use, physical activity etc) SURVEILLANCE Risk factors (core panel from Step I · Risk factors (extended panel from Adult population and Step II of WHO-STEPS program) WHO STEPS program) (initially restricted ­ Tobacco consumption habits ­ Blood lipids (total and HDL to special groups, ­ H/o diabetes, hypertension cholesterol; others like triglycerides later extended ­ Blood pressure if resources permit) to everyone) ­ Pulse rate ­ Blood glucose ­ Body mass index · Health beliefs ­ Waist circumference · Dietary consumption patterns CVD mortality · Physical activity patterns National aggregate indicators · CVD morbidity (disability) (e.g., production and consumption of · Effectiveness of prevention strategies tobacco, fruit and vegetables) SCREENING `Opportunistic' evaluation for: `Targeted' evaluation for presence of : Individuals at risk Level of appropriate/ ­ Tobacco consumption ­ Diabetes inappropriate case finding ­ High blood pressure, overweight and ­ Dyslipidemia at various levels through obesity, known history of CVD, ­ Coronary heart, cerebrovascular audits and surveillance. diabetes and peripheral vascular disease Audit of referral linkages MANAGEMENT Primary and secondary prevention in Individuals: Level of appropriate/ Individuals at high overall risk for ­ at high-risk inappropriate prescription/ CVD (diabetes; multiple risk factors) ­ with chronic practice through healthcare forms of CVD facility audit or surveillance Cost-effective clinical algorithms for: Clinical Algorithms for: ­ presenting with ­ Chronic coronary heart disease; ­ Dyslipidemia acute vascular chronic cerebrovascular disease ­ Stroke events ­ Congestive Heart Failure ­ Acute Coronary Syndromes ­ Hypertension HEALTH · Integrate core components of · Strengthen quality assurance in CVD Health Services Qualitative research/audits SYSTEMS prevention, surveillance, screening related health care delivery Managers/ for the capacity/ practices and management into primary and · Perform technology audits to identify Administrators for CVD prevention in the secondary health care and correct inappropriate use of Health Services · Strengthen healthcare provider expensive technologies education (learning and skills · Strengthen the production and relevant to CVD control) distribution of cost-effective drugs and · Enhance knowledge and decision devices for CVD care in collaboration making ability of health care with industry managers in elements of CVD control · Implement essential drugs policy for providing CVD related drugs RESEARCH Strengthen capacity for research Support innovative research in the Research Bodies Audits of proportion/level relevant to CVD control through aetiology of CVDs (as relevant to local of funds/projects allocated national and international partnerships population groups) and to identify new to research relevant to CVD (implementation research, to effectively technologies which are contextually prevention and control. 1. The population-wide approach targets the whole community A focus of the individualized approach, as currently recom- and aims to shift the entire population distribution of risk factors in mended, is on treating individuals based on an assessment of their a favourable direction. These strategies act through creating a overall risk of developing cardiovascular disease, rather than on conducive environment by policy changes or by raising aware- the basis of the presence of an individual risk factor (See Box on ness, motivation and skills for behaviour change through health Relative Risk below). For example, individuals should be selected education and promotion. Population-wide strategies, if successful, for blood pressure lowering because they are at high risk due to have the potential to result in large reductions in disease inci- having multiple risk factors and/or pre-existing vascular disease, dence. Strategies include: rather than on the basis of a screening process that identifies them s Promoting the importance of CVD as a public health priority at as "hypertensive". all levels. This requires a national commitment to prevention and The individual approach to management has proved effective, but control of CVD, that can be promoted through advocacy and identifying cost-effective methods to detect and risk-stratify individu- awareness activities influencing policymakers, people and als in resource-limited countries is a research priority. Education health professionals. for healthcare providers is needed to ensure wider application of s Reducing tobacco consumption: raising taxes on tobacco prod- algorithms for evidence based high-risk primary and secondary ucts reduces consumption (which is price sensitive); a compre- prevention of CVD. hensive ban on tobacco advertising and smoke-free policies in Controlling the epidemic of cardiovascular diseases requires both a public places are effective and among the evidence-based population-wide and an individualized approach. The latter pro- measures endorsed by the WHO Framework Convention on vides a cost-effective strategy to reduce disease burdens in the Tobacco Control. short term while the former provides sustainable benefits in the s Modifying behaviour relating to diet and physical activity using long term. The threshold of absolute risk (based on risk evaluation policy and educational interventions. Available evidence sug- of individuals) at which the interventions for individual approach gests that policy changes influencing fruit and vegetable con- are initiated, will depend on locally available resources. Similarly, sumption (e.g. in Poland) and altered patterns of dietary fat population-wide approaches require policy and educational inter- intake (e.g. in Mauritius and Poland) have a substantial effect ventions that are tailored to specific needs, capacity and on reducing cardiovascular risk. Community based educational resources. interventions have had variable effects in demonstration proj- Both these approaches require promoting health system reforms ects, but nationwide impact was achieved in Finland by scaling that will enable context-specific and resource-sensitive integration up the experiences of the North Karelia Project. Other measures of CVD prevention in existing healthcare infrastructure, particularly like provision of recreational and dedicated walking space, and at the primary care level. environmental changes like availability of foods which have a low content of saturated and trans- fats, and salt also help pre- vent CVD. Where to start Each region/country would need to decide, based on its resources 2. The individualized approach aims to detect individuals at great- and health system capacity, on a `core' essential package to be est absolute risk of experiencing a cardiovascular event, and implemented in the short-term, and a `comprehensive' long-term target them for risk reduction therapy. A number of non-pharma- CVD prevention policy and program. A model package is sug- cological and pharmacological treatments have proved highly gested (see table). effective in reducing CVD risk by changing the level of risk factors (e.g. blood pressure, cholesterol, glucose) or by other mechanisms Important steps for countries to take: (aspirin, beta- blockers, ACE Inhibitors, w-3 fatty acids). Health s Establish surveillance systems, within the constraints of available diets like the Mediterranean diet and more physical activity have resources, to enable ongoing assessment of risk factors, disease been proven to reduce cardiovascular risk significantly. Several burden and prevention programs. It is best to develop surveil- drugs used for risk reduction are available at low cost in generic lance systems for non-communicable diseases and their common form in developing nations. risk factors as a group (see WHO STEPS programme at www.who.int>>WHO Sites>> NCD Surveillance) The RELATIVE RISK OF DEVELOPING A CVD EVENT is approximately similar across populations for changes in the level of any risk factor, for example: · For every 20 mm Hg increase in systolic blood pressure, the risk of coronary heart disease (CHD) doubles; · For every 1% increase in total cholesterol, the risk of CHD increases by 2%; · Smokers have 2-3 times higher risk of developing CHD than non-smokers BUT ABSOLUTE RISK FOR DEVELOPING A CVD EVENT DIFFERS · Across populations, due to determinants like ethnicity, dietary patterns and other population-specific factors (e.g. in the Seven Countries Study, the risk of CHD at any given cholesterol level was different in the populations of Japan, Southern Europe, Western Europe and USA). and · Within each population, at the individual level, due to a variable combination of ­ Non-modifiable risk factors like age and gender, and ­ Modifiable risk factors like diabetes, high blood pressure, dyslipaedemia · In presence of pre-existing vascular disease which greatly increases the risk of future CVD events For example: · A smoker with SBP of 132-141 mmHg. and serum cholesterol of 203-220 mg% has a CHD mortality risk of 28.9 per 10,000 person years compared to a risk of 12.4 in a non-smoker with SBP below 118 mmHg, and serum cholesterol exceeding 245 mg% · A 65 year old man with diabetes, TIAs, and BP of 145/90 mmHg will have annual risk of major CVD events 20 times greater than 40-year old man with same BP but without diabetes or history of CVD, while a · 40-Year old man with BP of 170/155 mm Hg will have risk of major CV event 2-3 times greater than man of same age with BP of 145/90 mm Hg and similar other risk factors s Assess local capacity of human and financial resources within existing health care, to introduce preventive strategies for car- References diovascular diseases. The assessment should include absolute s de Lorgeril M, Salen P, Martin JL et al 1999. Mediterranean diet, tradi- tional risk factors, and the rate of cardiovascular complications after risk thresholds for intervention as well as resources required to myocardial infarction: final report of the Lyon Diet Heart Study. identify high-risk individuals. Circulation 99:779­785. s Increase awareness of cardiovascular diseases, their causes, s Dowsen GK, Gareeboo H, George K, et al 1995. Changes in popula- tion cholesterol concentration and other cardiovascular risk factor levels and their prevention among policy-makers, health care workers, after five years of non-communicable disease intervention programme in and the general community. Mauritius. Br Med J. 311:1255­1259. s Murray CJL, Lopez AD, eds 1996. The Global Burden of Disease: A s Emphasize the importance of population-wide public policy ini- Comprehensive Assessment of Mortality and Disability From Diseases, tiatives, particularly in relation to tobacco control, diet and Injuries, and Risk Factors in 1990 and Projected to 2020. Harvard physical activity. Population strategies require both `bottom up' University Press, Cambridge, Mass. (community health education and empowerment) and `top s Murray CJ, Lopez AD 1997. Alternative projections of mortality and dis- ability by cause 1990-2020: Global Burden of Disease Study. Lancet down' (legislation and regulation) approaches. 349:1498-504. s Develop and promulgate local context-specific and resource-sen- s Murray CJL, Lauer JA, Hutubessy RCW, Niessen L, Tomijima N, Rodgers sitive guidelines that incorporate clinical algorithms to identify A, Lawes CMM, Evans DB 2003. Effectiveness and costs of interven- tions to lower systolic blood pressure and cholesterol: a global and high-risk individuals. Integrated practices for CVD prevention regional analysis on reduction of cardiovascular-disease risk. Lancet and management should be emphasised, especially at primary 361: 717-725. care level. This also requires allocation of resources to ensure s Neaton JD, Wentworth D 1992. Serum cholesterol, blood pressure, cig- adequate training of health care workers to implement relevant arette smoking and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med guidelines. 152:56-64. s Ensure the availability of low-cost drugs that have proved effec- s Sacks FM, Svetkey LP, Vollmer WM, Appel LJ, Bray GA, Harsha D, tive in preventing cardiovascular diseases, (e.g. aspirin, beta- Obarzanek E et al 2001. DASH-Sodium Collaborative Research Group. Effects on blood pressure of reduced dietary sodium and the Dietary blockers and low-dose diuretics), possibly in the form of an Approaches to Stop Hypertension (DASH) diet. N Engl J Med.344:3-10. "essential vascular package". Even the more expensive but s Vartiainen E, Puska P, Pekkanen J et al 1994. Changes in risk factors highly effective drugs like statins and ACE Inhibitors could be explain changes in mortality from ischemic heart disease in Finland. Br used widely in the form of generics or off-patent formulations Med J. 309:23­27. s Verschuren WM, Jacobs DR, Bloemberg BP, Kromhout D, Menotti A, where available. Aravanis C, Blackburn H, et al 1995. Serum total cholesterol and long- s Initiate measures for multi-sectoral coordination of actions to term coronary heart disease mortality in different cultures. Twenty-five- prevent CVD, among the various stakeholders, public and pri- year follow-up of the seven countries study. JAMA Jul 12;274(2):131-6. s World Health Reports 2000, 2002. WHO, Geneva. vate. s WHO 2002. Integrated Management of Cardiovascular Risk, Report of a WHO Meeting. WHO, Geneva. Do's and Don'ts s Yusuf S, Reddy S, Ounpuu S, Anand S 2001. Global burden of cardio- vascular diseases: part I: general considerations, the epidemiologic tran- DO combine population-wide strategies (in particular legislative sition, risk factors, and impact of urbanization. and fiscal controls on tobacco use) with individualized approaches Circulation 104:2746-53. s Yusuf S, Reddy S, Ounpuu S, Anand S 2001. Global burden of cardio- for cardiovascular disease prevention. vascular diseases: Part II: variations in cardiovascular disease by spe- DO encourage the treatment of individuals based on level of cific ethnic groups and geographic regions and prevention strategies. Circulation104:2855-64. absolute risk of developing cardiovascular disease, rather than s Zatonski WA, McMichael AJ, Powles JW 1998. Ecological study of rea- treating individual risk factors to try and reach arbitrary targets. sons for sharp decline in mortality from ischemic heart disease in Poland since 1991. Br Med J. 316:1047­1051. DO integrate practices for detecting and managing high-risk indi- viduals into existing health delivery services at the primary health care level. Useful websites www.ichealth.org DO ensure that primary health care services allow for long-term www.procor.org extremely useful website including the "Links' Section follow-up to ensure adherence to prescribed therapy. www.who.int/ncd/cvd/index http://www5.who.int/cardiovascular-diseases/download.cfm?id=680 DO encourage evidence-based use of effective but inexpensive WHO CVD Risk Management Package for low-and-medium resource drugs through adherence to an essential drugs list. settings. DO reserve a pharmacological approach for those at high-risk of http://nhlbi.nih.gov/health/index.htm CVD. Use non-pharmacological approaches for individuals at http://www.cdc.gov/cvh/index.htm Cardiovascular disease website of the CDC moderate risk. The low-risk individuals will continue to benefit from http://www.cdc.gov/nccdphp/bb_heartdisease/index.htm Chronic population based interventions. disease website of CDC- heart disease section DO NOT allow, promote or prescribe expensive diagnostic or ther- www.heartfile.org apeutic measures particularly when they are inappropriate and a www.worldheart.org World Heart Federation website reasonable evidence-base is absent. http://www.nzgg.org.nz/library/gl_complete/bloodpressure/table1.cfm New Zealand Guidelines for assessing absolute cardiovascular risk DO NOT invest in expensive and technology intensive tertiary care of CVD without ensuring adequate and widely available primary Prepared with Technical Assistance from the `Initiative for Cardiovascular Health Research care for CVD. in the Developing Countries'. Expanded versions of the "at a glance" series, with e-linkages to resources and more information, are available on the World Bank Health-Nutrition-Population web site: www.worldbank.org/hnp