Professor Shahryar A. Sheikh - Healthy Caribbean …...Professor Shahryar A. Sheikh World Heart...

Professor Shahryar A. SheikhWorld Heart Federation

17th Asian Pacific Congress of CardiologyKyoto, Japan20 May, 2009

Professor Shahryar A. SheikhWorld Heart Federation

17th Asian Pacific Congress of CardiologyKyoto, Japan20 May, 2009

Global Burden of Cardiovascular Disease

“CHALLENGES AHEAD”

Global Burden of Cardiovascular Disease

“CHALLENGES AHEAD”

Global Burden of Cardiovascular Diseases

Burden in the Asia Pacific Region

Risk Factors Prevalence and Trends

Major Challenge for the 21st Century

CVD Burden of Disease and Investment: The Great Disconnect

Is There Hope?

Call to Action

Global Burden of Cardiovascular Disease:Challenges AheadGlobal Burden of Cardiovascular Disease:Challenges Ahead

Noncommunicable diseases:Noncommunicable diseases: Infectious diseases:Infectious diseases:

Deaths by cause in the world (2005)Deaths by cause in the world (2005)

(WHO, Chronic Disease Report, 2005)

Heart disease30.2%

Cancer15.7%Diabetes1.9%Other chronic diseases15.7%

HIV/AIDS 4.9%

Tuberculosis 2.4%

Malaria 1.5%

OtherInfectiousDiseases

20.9%

Injuries 9.3%

Total58.2M

18 Million

Asian Contribution for Global Burden of CVDAsian Contribution for Global Burden Asian Contribution for Global Burden of CVDof CVD

Murray C J L and Lopez D The Lancet 1997; 349:1269

Sub-Saharan Africa10%

Latin American andCaribbean counties

7%India, China and other Asian Pacific Island countries

50%

Formerly socialist economies

8%

Established marketeconomies

14%

Middle Eastern8%

AsiaAsiaAsiaCountries: 46

Population: 3.8 billions60.5% world population

India and China have the highest number of deaths in the world from coronary heart disease

India and China have the highest number of deaths in the world from coronary heart disease

702 925

1 531 534

Source: WHO Atlas of Heart Disease and Stroke, 2004

A Threat to Socioeconomic DevelopmentProjected Foregone National Income due to

Heart Disease, Stroke and Diabetes

Brazil 2.7 49.2

China 18.3 557.7

India 8.7 236.6

Pakistan 1.2 30.7

Russian Federation 11.1 303.2

United Kingdom 1.6 32.8

US$ BillionUS$ Billion

Source: Preventing Chronic Disease: A Vital Investment, WHO 2005

2005200510 years

accumulated10 years

accumulated

Window of Opportunity for Prevention of CVDProjected deaths by cause and income

(2004 to 2030) WHO

Window of Opportunity for Prevention of CVDProjected deaths by cause and income

(2004 to 2030) WHO

HIV, TB, malaria

Other infectious

Mat//peri/nutritional

CVD

Cancers

Other NCD

Road traffic accidentsOther unintentionalIntentional injuries

0

5

10

15

20

25

30

2004 2015 2030 2004 2015 2030 2004 2015 2030

Dea

ths

(mill

ions

)

High income Middle income Low income

A Challenge and An OpportunityA Challenge and An Opportunity

The rapid rise of cardiovascular diseases represents one of the major health challenges to global development in the coming century. This growing challenge threatens economic and social development as well as the lives

and health of millions of people.

The rapid rise of cardiovascular diseases represents one of the major health challenges to global development in the coming century. This growing challenge threatens economic and social development as well as the lives

and health of millions of people.

There now exists, however, a vast body of knowledge and experience regarding the preventability of such diseases and immense opportunities of global action

to control them.

There now exists, however, a vast body of knowledge and experience regarding the preventability of such diseases and immense opportunities of global action

to control them.






Is There Hope?

Call to Action


Causes For the Rising Burden of CVDCardiovascular Risk Factors `

Causes For the Rising Burden of CVDCauses For the Rising Burden of CVDCardiovascular Risk FactorsCardiovascular Risk Factors `̀

World Health Organization, 2002

Non-modifiableRisk Factors

NonNon--modifiablemodifiableRisk FactorsRisk Factors

• TobaccoTobacco•• DietDiet•• AlcoholAlcohol•• Physical ActivityPhysical Activity

Socio-economic, cultural & environmental

factors

Socio-economic, cultural & environmental

factors

INTERMEDIATERISK

FACTORS

INTERMEDIATEINTERMEDIATERISKRISK

FACTORSFACTORS

• Hypertension• Diabetes• Obesity

• Coronaryheart disease

• Stroke

• Peripheralvascular disease

AgeAgeSexSex

GenesGenes

BEHAVIOURALRISK FACTORSBEHAVIOURALRISK FACTORS

ENDPOINTSENDPOINTSENDPOINTS

3 RISK FACTORS - TOBACCO USE, POOR DIET AND LACK OF PHYSICAL ACTIVITY

FOUR MAJOR CHRONIC DISEASE - HEART DISEASE, DIABETES, LUNG DISEASE AND CANCERS

50 PERCENT OF DEATHS IN THE WORLD

3FOUR5033FOURFOUR5050

Source : “Global Burden of Disease and Risk Factors”, Lopez and others, Oxford University Press, 2006

6 of top 10 risk factors in low- and middleincome countries lead to CVD

6 of top 10 risk factors in low- and middleincome countries lead to CVD

Risk factor for CVD

www.who.int/whr/2002

GLOBAL DISTRIBUTION OF BURDEN OF DISEASE ATTRIBUTABLE TO 14 LEADING SELECTED RISK FACTORS

GLOBAL DISTRIBUTION OF BURDEN OF DISEASE GLOBAL DISTRIBUTION OF BURDEN OF DISEASE ATTRIBUTABLE TO 14 LEADING SELECTED RISK FACTORSATTRIBUTABLE TO 14 LEADING SELECTED RISK FACTORS

Kearney et al. Lancet 2005;365:217-23.

Frequency of Hypertension in People Aged 20 Years and Older by World Region and Sex in

2000 (Upper) and 2025 (Lower)

Frequency of Hypertension in People Aged 20 Years Frequency of Hypertension in People Aged 20 Years and Older by World Region and Sex in and Older by World Region and Sex in

2000 (Upper) and 2025 (Lower)2000 (Upper) and 2025 (Lower)

37.4 35.3

20.6

40.7

22 22.617

26.9

37.2 39.1

20.9

34.8

23.719.7

14.5

28.3

0

10

20

30

40

50Men

Womwn

41.6 39.1

22.9

44.5

24 27.718.8

27

42.5 45.9

23.6

40.227 27

17.128.2

01020304050

Establishedmarket

economies

Formersocialist

economies

India Latin Americaand the

Caribean

Middleeastern

crescent

China Other Asiaand islands

Sub-SaharanAfrica

2000

2025

Rat

e of

hyp

erte

nsio

n (%

)

All smoking prevalence

05

1015202530354045

Low income Low er-middleincome

Upper-middle income High income

%

Q1 Q2 Q3 Q4 Q5

Range: from Q1 = poorest quintile to Q5 = Highest income quintile

Cardiovascular DiseasesThe poorest people in developing countries are the ones who smoke the most

Cardiovascular DiseasesThe poorest people in developing countries are the ones who smoke the most

Source: World Health Survey 2006

SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)

SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)

P Jha et al., Lancet 2006; 368:367

50

40

30

20

10

0

Englandand Wales

USA Canada Poland

Social class NeighborhoodIncome

EducationEducation

Ris

kof

dyi

ng a

t age

s 35

-69

year

s (%

)

High (I/II)

Med (II

I/IV)

Low (V)

Low (<12

yrs)

Med (1

2 yrs)

High (>12

yrs)

Low (<12

yrs)

Med (1

2 yrs)

High (>12

yrs)

High (20%

)Med

(60%

)Low (2

0%)

43%

31%

21% 20%

37%34%

36%

21%24%

26%

50%

32%

22%

10%

5%6% 8%

13%14% 15%

4%4%

10%

19%

SmokingAny Cause





CVD Burden of Disease and Investment:

The Great Disconnect

Is There Hope?

Call to Action


Millennium Development GoalsMillennium Development Goals1. Eradicate poverty and hunger2. Achieve primary universal education3. Promote gender equality and empower

women4. Reduce child mortality5. Improve maternal health6. Combat HIV/AIDS, malaria and other

diseases7. Ensure environmental sustainability8. Develop a global partnership for

development

Cardiovascular diseasemust be included

Yet current investment in chronic NCDs

is very low…

Yet current investment in chronic NCDs

is very low…For the 2008-2009 biennum, the WHO will allocate almost US$ 900 million to communicable disease whereas the budget allocated to non-communicable disease barely reaches US$ 160 million

The Global Fund for HIV/AIDS, TB and Malaria total pledges paid to date: USD 11.8 billion

Half of the US$ 1.8 billion allocated to health programmes by USAID in 2003 were for HIV/AIDS and infectious diseases. Another 45% were for maternal health, child survival and population control.

Out of US$20.6 billion in Official Development Assistance in 2006 provided by 24 OECD/DAC countries and the EC, $ 0.1 billion went to basic nutrition and there was no specific investment in the prevention and control of NCDs.

Specific example of tobacco control: under-funded compared with other leading causes of deathSpecific example of tobacco control: under-funded compared with other leading causes of death

$0

$5

$10

$15

$20

AIDS TB Malaria Tobacco

Glo

bal F

undi

ng ($

Bill

ions

)

0

1

2

3

4

5

Ann

ual D

eath

s (m

illio

ns)

Global Funding, 2007 (allsources, $ billions)

Annual Deaths (millions)

World Health Organization

Comparison of total DALYs by region and total health expenditure by region

Comparison of total DALYs by region and total health expenditure by region

(CJ L Murray, Global burden of disease study. The Lancet, 1997

DALYs by region(% total DALYs worldwide, 1990)

DALYs by region(% total DALYs worldwide, 1990)

CHN

FSE

EME

SSA

IND

MEC

OAILAC

Health expenditure by region(% health expenditure worldwide, 990)

Health expenditure by region(% health expenditure worldwide, 990)

7.2%

CHN

FSE

EME

SSA

IND

MEC

OAI

LAC

87.3%

The 10/90 Gap in Health Financing

The 10/90 Gap in Health Financing

Cardiovascular Care in Pakistan: Treatments by SESCardiovascular Care in Pakistan: Treatments by SES

In Patients(2006)

In Patients(2006)

60 %

21 %

10 %

9 %

Out Patients (2006)

Out Patients (2006)

8 %8 %

7 %

77 %

Total PCI 1886

Total PCI 1886

64 %

7 %

13 %

16 %

■ Paying ■ Poor

■ G. User ■ Entitled

S. Sheikh, ESC, 2007

CREATE REGISTRY: Treatments by SESCREATE REGISTRY: Treatments by SES

Key Treatments RichUpper middle class

Lower middle class

Poor p value

N 5.3% 22.5% 52.5% 19.6%

<0.0001

0.12

<0.0001

<0.0001

ACE inhibitors or ARB 63.2% 57.1% 57.1% 54.1% <0.0001

Anticoagulants 89.4% 84.0% 82.2% 75.2% <0.0001

PCI 15.3% 13.0% 6.4% 2.0% <0.0001

CABG 7.5% 4.9% 2.4% 0.7% <0.0001

Thrombolysis† 60.6% 64.5% 98.0% 97.9%

Antiplatelet drug 97.0% 97.6% 98.0% 97.9%

Beta blockers 58.8% 61.2% 62.0% 49.6%

Lipid-lowering drugs 61.2% 58.7% 54.2% 36.2%

Xavier D et al Lancet 2008






Is There Hope?

Call to Action


Age-adjusted Mortaligy rates of

Coronary heartDisease in North

Karelia and theWhole of Finland

among males aged35-64 years from

1969 to 1995.

Age-adjusted Mortaligy rates of

Coronary heartDisease in North

Karelia and theWhole of Finland

among males aged35-64 years from

1969 to 1995.0

200

400

600

800

69 71 73 75 77 79 81 83 85 87 89 91 93 95

Start of the North Karelia ProjectExtension of the Project Nationwide

North KareliaNorth Karelia

All FinlandAll Finland

Mortality per100 000

Population

-65%-65%

-73%-73%

Year

Knowledge: Prevention Works 1Knowledge: Prevention Works 1

VartiainenVartiainen E, P. E, P. PuskaPuska, BMJ , BMJ 309309; 1994 ; 1994

9%Treatment of AMI

Contribution of treatments and risk factor changes to the decline in CHD mortality in

Finland 1982-1997

Contribution of treatments and risk factor Contribution of treatments and risk factor changes to the decline in CHD mortality in changes to the decline in CHD mortality in

Finland 1982Finland 1982--19971997

8%Invasive treatment

2%Medical Treatment

of Angina

22%Not explained

2%Heart Failure Treatment

7%Blood Pressure

30%Cholesterol

9%Smoking

8%Secondary prevention

Exploring the fall in CHD deaths in USA in 1980-2000

Exploring the fall in CHD deaths in USA in 1980-2000

Risk Factors Worse +17%Risk Factors Worse +17%Obesity (Increase) +7%Diabetes (Increase) +10%

Risk Factors Better -65%Risk Factors Better -65%Population BP fall -20%Smoking -12% Cholesterol (diet) -24%Physical Activity -5%

Treatments -47%Treatments -47%AMI Treatments -10%Secondary Prevention -11% Heart Failure -9%Angina: CABG & PTCA -5%Hypertension Theropies -7%Statin (Primary Prevention) -5%

Unexplained -9%Unexplained -9%

342,000fewer deathsin 2000

342,000fewer deathsin 2000

19801980 20002000

NEJM 2007, 256, 2388






Is There Hope?

Call to Action


Risk

of M

I

Risk

of M

I

77.5%77.5%

15%15%

7.5%7.5% > 20%> 20%

< 10%< 10%

“High Risk” vs “Population”“High Risk” vs “Population”

POPULATIONPOPULATION

10-20%10-20%

CVD PREVENTIONCVD PREVENTION

RISKRISK

TAKE

AIM

TOGETHER

TAKE TAKE

AIM AIM

TOGETHERTOGETHER

Chol

este

rol

Chol

este

rol

Toba

cco

Toba

cco

Hyp

erte

nsio

n

Hyp

erte

nsio

n

Obe

sity

Obe

sity

Phy

sica

l

Phy

sica

l

Inac

tivi

ty

Inac

tivi

ty

FAMILY &

COMMUNITY LEVEL

FAMILY &

COMMUNITY LEVEL

RISK FACTORSRISK FACTORS

POLITICAL WILL

PUBLIC AWARENESS

INTERNATIONAL SUPPORTMEDIA

SCIENTIFIC EVIDENCE

Working togetherfor

WAR ON HEART DISEASE

SummarySummaryGrand ChallengesGrand Challenges

« A crucial aspect of establishing programs for disease control globally is to identify priorities. To galvanize the health science and public policycommunities into action on this epidemic… »

Socioeconomic gradient remains the most important barrier amongst the countries, or within a developing country, for appropriate application of cardiovascular care.

Source : Nature, Vol. 450, 22 November 2007

Knowing is not enough; we must apply.Willing is not enough; we must do.

Johann Wolfgang von Goethe(1749–1832)

Knowing is not enough; we must apply.Knowing is not enough; we must apply.Willing is not enough; we must do.Willing is not enough; we must do.

Johann Wolfgang von Goethe(1749–1832)

UNITE FOR WAR ON HEART DISEASE

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