Global burden of

Cardiovascular Diseases

Andrew M Tonkin, MD
PROJECTED GLOBAL BURDEN OF CVD
30
CVD Deaths (millions)

25
Established market
6 economies and
20 former socialist
economies of
15 Europe
5
10 19 Demographically
developing countries
5 9

0
1990 2020
Deaths
Global CVD B. Neal et al. Eur. Heart J 2002
GLOBAL BURDEN OF DISEASE:
COMMON CVD RISK FACTORS
Risk factor Exposure Variable Theoretical Contribution
Minimum to GBD
High BP Usual SBP 115mmHg (SD6) 4.4%
Tobacco Smoking impact ratio; No use 4.1%
oral tobacco use
High cholesterol Usual TC 3.8mmol/L (SD0.6) 2.8%
High BMI BMI 21kg/m2 (SD1) 2.3%
Low fruit and Intake daily 600g (SD50) 1.8%
veg. Intake
Inactivity Categories >2.5h/week, mod. 1.3%

M. Ezzati et al. Lancet 2003;362:271-80

Global CVD
EPIDEMIOLOGIC TRANSTION

•Age •Pestilence •Receding •Degenerative •Delayed

and famine pandemics “man-made” degenerative
diseases diseases

•Predominant •Rheumatic •Hypertension- •CHD, stroke, •CHD, stroke at

CVD •heart disease •related diabetes at young older ages
•diseases ages

•% of deaths •5-10 •10-35 •35-65 •<50

due to CVD

•Current examples •Sub-Saharan •Rural China •Urban India •North America,

•Africa Australasia

Global CVD From S Yusuf et al. Circulation 2001;104:2746-53

DRIVERS OF THE CVD EPIDEMIC

• Urbanisation
• Global trade and marketing developments
• Tobacco industry
• Physical inactivity
Tobacco use, inappropriate diet and physical
inactivity (expressed through unfavourable lipid
profiles, overweight and raised BP) explain at
least 75% of new CHD cases
Global CVD
CHD TRENDS IN BEIJING 1984 TO 1999

Global CVD Critchley J et al. Circulation 2004;110:1236-1244

CURRENT AND PROJECTED POPULATION
PERCENTAGES FOR 2000, 2020 AND 2040
30

25
% population 65+

20

15

10

0
S. Africa India Brazil China Russia Portugal U.S.

2000 2020 2040 S. Leeder 2003

CVD IN AUSTRALIA:
11% TOTAL HEALTH SPENDING
Total
$6,563.7m Outpatients
5%
Inpatients 41% 5% Aged care
10%

6%
3% GPs
4%
Research 26% 4% Imaging &
OHPs 1% pathology

Out-of-hospital
Pharmaceuticals specialists
USE OF MEDICATION IN STROKE AND CHD

Aspirin Statins
95 96
% 100
89
90 83 81
79 78 78
80
70 66 66
58
60
50
38 38
40
29 31 28 28
30 23
20 16
9
10
0
Brazil Egypt India Indonesia Iran, Pakistan Sri Lanka Turkey Russian Tunisia
Islamic Federation
Republic of

Global CVD WHO PREMISE project,

 ANTIHYPERTENSIVE DRUGS
Available Affordable
Locally manufactured
57%
67% 30%
48%
45%
91% 89%
74% 64% 83%
7%

46%
92% 100% 96%
88%
70% 71%

Africa Americas Eastern Europe South-EastWestern

Mediterranean Asia Pacific
entage of countries in each region where drugs are availabl
rdable to low income groups, or manufactured locally
Global CVD WHO 2001
 POLYPILL: EFFECTS AFTER TWO YEARS,
AGE 55-64
RRR (95% CI) (%)
Factor Agent Reduction IHD Stroke
LDL-C Statin 1.8 mmol/L 61 (51,71) 17 (9-25)
BP Three agents, 11 mmHg 46 (39-68) 63 (55-70)
half dose DBP
Platelet funct. ASA (75mg) Not quant. 32 (23-40) 16 (7-25)
Homocysteine Folic acid, 3 μmol/L 16 (11-20) 24 (15-33)
(0.5mg)
Combined All 88 (84-91) 80 (71-87)

BMJ, 28 June 2003

Polypill
 FIVE-YEAR HARD CHD EVENTS
HHP Japanese American Men

Deciles based on Framingham function

Absolute risk D'Agostino, Sr, R. B. et al. JAMA 2001;286:180-187
FRAMEWORK CONVENTION ON TOBACCO CONTROL

Key provisions encourage countries to:

• Enact comprehensive bans on tobacco advertising,
promotion and sponsorship;
• Obligate placement of rotating health warnings on tobacco
packaging that cover at least 30% (but ideally ≥ 50%) of
principal display areas;
• Ban use of deceptive terms such as “light” and “mild”;
• Protect citizens from exposure to tobacco smoke in
workplaces, public transport and indoor public places;
• Combat smuggling, including placing of final destination
markings on packs;
• Increase tobacco taxes
Tobacco
PUBLIC HEALTH POLICY
• Comprehensive health programs led by primary care
• Appropriate balance between primary and secondary
prevention
• Particularly population approaches (Only 5% in
wealthy countries at ideal cholesterol, BP, weight)
• Also high-risk approaches to primary prevention
(although latter may increase inequalities)
• Acute management and secondary prevention
• Surveillance and monitoring
Global CVD
 NCD PREVENTION AND CONTROL
94%
88% 88%
76%
65%

39%

Africa Americas Eastern Europe South-East Western

Mediterranean Asia Pacific
ountries with integration of components of NCD prevention
rammes in primary health care
Global CVD WHO 2001
PRIORITIES FOR DEVELOPING COUNTRIES

• Control strategies, initially based on extrapolation

from knowledge from other population, e.g.
tobacco control: whole population initiatives

• Cross-sectional surveys (ecological comparisons),

case-control studies and prospective longitudinal
studies for incidence data

• Workforce training and capacity building

• Low cost, high yield interventions

CHD prevention
PRIORITIES FOR DEVELOPED COUNTRIES

• Prevention including implementation of

proven strategies

• Chronic disease strategies

• Health inequalities

• Primary care strategies

• Strategies to combat overweight

CHD prevention