WHO data on Cardiovascular Diseaseand

Nuclear Cardiology Utilization Worldwide

DISCLOSURESDISCLOSURESHonorarium Honorarium –– Research / Advisor, Expert Services and Conferences in NuclearResearch / Advisor, Expert Services and Conferences in Nuclear CardiologyCardiology

BMS, CVT, Astellas, Lantheus, PPGx, IAEABMS, CVT, Astellas, Lantheus, PPGx, IAEARoyalties Royalties –– Publications in Nuclear CardiologyPublications in Nuclear CardiologySpringerSpringer--VerlagVerlag--Nuclear Cardiology and Correlative Imaging: a teaching file,Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004NY, 2004Lippincott Williams & Wilkins, Lippincott Williams & Wilkins, -- Nuclear Medicine teaching FileNuclear Medicine teaching File, 2009, 2009

João V. Vitola, MD, PhDJoão V. Vitola, MD, PhD

Cardiologist and Nuclear Medicine Physician Cardiologist and Nuclear Medicine Physician Quanta Diagnostico NuclearQuanta Diagnostico Nuclear

Curitiba Curitiba -- BrazilBrazil

http://www.who.int/cardiovascular_diseases/en/

Leader Cause of Mortality in Adults Men and Women80% of 17.5 mi Deaths Due to CVD are in Low to Mid Income Countries

Significant Economic Burden

General Overview

Downloaded from www.who.int in Jan 2010

Ischemic Heart Disease

Downloaded from www.who.int in Jan 2010

Cerebrovascular Disease

Death from CAD - variation by country and gendercause of mortality age > 60 yo

OLD AND NEW CHALLENGES TO FACE IN CARDIAC CAREOLD AND NEW CHALLENGES TO FACE IN CARDIAC CARE

Rising health care cost of chronic disease Rising health care cost of chronic disease (obesity/lack of exercise/smoking)(obesity/lack of exercise/smoking)

OBESITY OBESITY –– SPECIALLY WOMENSPECIALLY WOMENDM DM –– IMPACTING THE YOUNGIMPACTING THE YOUNGAGING AGING –– WORLDWIDEWORLDWIDE

Downloaded from www.who.int in Jan 2010

OBESITY

Downloaded from www.who.int in Jan 2010

Downloaded from www.who.int in Jan 2010

DIABETES

Downloaded from www.who.int in Jan 2010

World Scenario – Estimation for 2025Diabetes International Federation

Diabetes Atlas: 2006; DIFDiabetes Atlas: 2006; DIF

Resultado anormal: idade x DM

33% 33%

44%50%

62%

73%

Até 39 40 a 49 50 a 59 60 a 69 70 a 79 80 ou mais

Não diabéticoDiabético

DM, Age and SPECT Abnormalities

%ABNORMAL

(n=10594)(n=10594)

Vitola JV et al , Quanta Database – Curitiba - Brazil

Diabetes is Increasing Mostly in Developing Countries (middle age)

Source WHO

Projected Percentage of Deaths from Cardiovascular Projected Percentage of Deaths from Cardiovascular Disease Among Those 35 Disease Among Those 35 -- 64 yrs64 yrs

Health Affairs Jan/Feb 2007

36 yo, ManDM, Obese (IMC: 30.1), HTN, High CholesterolDenies Chest Pain

TMTRest ECG – LAHBBruce : 10 minHR: 84 .... 159 (85% = 156 bpm)BP: 130/80 ....180/90 mmHgNo ST segment changes At peak exercise right should pain, Not LimitingDuke ScoreDuke: exer min – 5x ST – 4x anginaDuke = (+10) – (5x0) – (4x1) = + 6

Clinical Case

Eje Corto

Eje Largo Vertical

Eje Largo Horizontal

Cortes Tomográficos-Referencia

ESV: 70 ml, LVEF: 45%High Risk Findings

Revascularization + Optimized Medical Therapy

IncreaseDeaths (%)

02040

6080

100120

140

Developing Nations Developed Nations

WomenMen

Projected Increase Deaths due to CVD from 1990 to 2020

Yusuf S et al, Circulation 2001; 104:2746-2753Leeder, S et al. A Race against time: the challenges of cardiovascular disease in developing countries. New York: Trustees of Columbia University; 2004

Life tables for WHO member states, Geneva, Word Health Organization , 2006http://www.who.int/whosis/database/life_tables.cfm

Country Men WomenRussia 59 72India 62 64Brazil 68 75China 71 74Argentina 72 78Cuba 75 79USA 75 80Canada 78 83Italy 78 84Australia 79 84Japan 79 86

Population is aging

BRIC Emerging Economies Developing Countries

Life Expectancy at Birth

Implications for NCRATIONAL INVESTMENTS

The Elderly Population is Increasing

Source: WHO

Resultado anormal: idade x sexo

10%

19% 21%

30%

41%

52%

14%

23%

33%

46%

55%

68%

Até 39 40 a 49 50 a 59 60 a 69 70 a 79 80 ou mais

FemininoMasculino

RR 1,5 (CI 1,0-2,2)RR 1,1 (CI 0,9 – 1,3)RR 1,4 (CI 1,2 - 1,7)RR 1,2 (CI 1,0 – 1,5)RR 1,9 (1,3 – 2,7)

P<0.048P<0.611P<0.001P<0.036P<0.001

Age as a Predictor of SPECT AbnormalityAge as a Predictor of SPECT AbnormalityVitola JV et al. Quanta Database – Curitiba, Brazil (n=10594)

PREVALENCIA DE EAC PREVALENCIA DE EAC -- EUAEUA

5,510,4

17,4

34,2

51,0

65,270,7

4,60 4,20

13,60

28,90

79,00

48,10

65,20

0102030405060708090

20-24 25-34 35-44 45-54 55-64 65-74 75+Ages

Perc

ent o

f Pop

ulatio

n

MalesFemales

American Heart Association. 2002 Heart and Stroke Statistical Update. 2001

Prevalence of Heart Failure by Gender Prevalence of Heart Failure by Gender and Age in the Framingham Studyand Age in the Framingham Study

0,1 0,51,3

3,4

6,6

9,7

0,10,7

1,8

6,26,8

9,8

0

2

4

6

8

10

20-34 35-44 45-54 55-64 65-74 75+Age

patie

nts pe

r 100

perso

ns

WomenMen

Ho, Pinsky, Kannel, Levy. J Am Coll Cardiol 1993; 22:6A

$

Chronic Heart Failure in the United States. A Manifestation of Coronary Artery Disease

Mihai Gheorghiade, MD; Robert O. Bonow, MD Circulation 1998;97:282-289

CAD68%

non-CAD32%

CAD non-CAD $

NEW CHALLENGES TO FACE IN CARDIAC CARENEW CHALLENGES TO FACE IN CARDIAC CAREOBESITY OBESITY –– SPECIALLY WOMENSPECIALLY WOMENDM DM –– IMPACTING THE YOUNGIMPACTING THE YOUNGAGING AGING –– WORLDWIDEWORLDWIDE

LIMITED / RATIONAL USE OF RESOURCES:LIMITED / RATIONAL USE OF RESOURCES:PREVENTIONPREVENTION

(Long Term Investment: exercise/quit smoking/diet)(Long Term Investment: exercise/quit smoking/diet)INVESTIGATIONINVESTIGATION

(Mostly Non Invasive (Mostly Non Invasive –– Nuclear/IAEA)Nuclear/IAEA)MANAGEMENT MANAGEMENT

(Guided by APPROPRIATE Investigation)(Guided by APPROPRIATE Investigation)

Cost Effectiveness treating CVD U$ per DALY = Disability Adjusted Life – Year averted

WHAT ARE THE ECONOMIC COSTS OF CARDIOVASCULAR DISEASES ?

1. CVDs affect many people in middle age, very often severely limiting the incomeand savings of affected individuals and their families.

2. Lost earnings and out of pocket health care payments undermine the socioeconomic development of communities and nations.

3. CVDs place a heavy burden on the economies of countries. 4. Lower socioeconomic groups in high income countries generally have a greater prevalence of risks factors, diseases and mortality, a similar pattern is emerging as the CVD epidemic evolves in low and middle income countries.

Rationale for a investments in meetings involving Nuclear Cardiology at the IAEA .....

Adel Allam – EgyptAmalia Peix – Cuba

Annare Ellmann – South AfricaBon Nang Lee – Malaysia

C. Siritara - ThailandFelix Keng – Singapore

Fernando Mut- (Co-chairman) - UruguayGianmario Sambucetti – Italy

Gregory Thomas – USAJoão V. Vitola (Chairman) - Brazil

Kevin Allman – AustraliaLeslee Shaw – USA

Maurizio Dondi - IAEA - AustriaMarla Kiess – CanadaPilar Orellana – Chile

Raffaele Giubbini – SwitzerlandSalaheddine Bouyoucef – Algeria

Zuo – Xiang He – China

IAEA, Vienna, Austria, 2008IAEA, Vienna, Austria, 2008Organized by Maurizio DondiOrganized by Maurizio Dondi

Vitola JV, Shaw L, Allam A et al JNC, 2009

Worldwide Utilization of Nuclear Cardiology – Underutilized in Many Nations

HighModerate – HighModerateModerate – LowLowInexistente

Influenced by:- Economy

GDPHealthcare Policies

-InformationOrganized scientific groupsLocal Scientific Production

Training-Neighboring coutries

ComunicationTraining

Scientific meetings

Vitola JV, Shaw L, Allam A et al. JNC 2009

USA budget for health care – 2 trillion US $16% of GDPBeller G, JNC 2008

Leppo J, JNC, 2009

Porter ME, Teisberg EO: Redefining Health Care Harvard Business School Press, 2006

What investment is ideal (Prevention + Investigation + Management) ?

AMERICA LATINA

Leppo J, JNC, 2009

What information should we be looking for to change What information should we be looking for to change management and result in better patient outcome in a management and result in better patient outcome in a

cost effective way ?cost effective way ?

Leslee Shaw et al. JACC 1999;33:661-669

ECONOMIC IMPLICATIONS OF REVASCULARISATIONWITHOUT SELECTING BASED ON ISCHEMIA

Shaw JACC 1999;33:661-669

What is the utilization of Nuclear Cardiology in India ?Only about 20 thousand SPECT / year / entire India 100 MPI/mo

•• Obesity and DM will contribute to Obesity and DM will contribute to increased CVD mortality worldwideincreased CVD mortality worldwide

•• Prevention of CAD is essentialPrevention of CAD is essential

•• Imaging can be used to assess risk Imaging can be used to assess risk and guide management cost and guide management cost effectivellyeffectivelly

•• Wide variation under and over Wide variation under and over utilization of technology utilization of technology –– regional regional differences differences -- GDP but also GDP but also InformationInformation

•• Considering increasing costs Considering increasing costs --essential to rationalize investigation essential to rationalize investigation and managementand management

Confronting the Epidemics of CVD Worldwide:Time to Stop and Think About Cardiac Care

Imaging Utilization in 2010