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