for healthy life “ re-planning our strategies towards most effective cardiovascular prevention”...
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For Healthy Life
“ Re-planning our Strategies Towards Most Effective
Cardiovascular Prevention”
Director of Cardiology Dep. Asklepeion Hospital, Athens, Greece
Chairman Working Group “Hypertension and Heart” of the ESC
Council Member of the European Society of Hypertension
Athanasios J. ManolisAthanasios J. Manolis
What is CVD prevention?
“A coordinated set of actions, at public and individual level,
aimed at eradicating, eliminated or minimizing the impact of
cardiovascular diseases and their related disability.
The bases of prevention are rooted in cardiovascular
epidemiology and evidence-based medicine”.
A Dictionary of Epidemiology. 4th ed New York: Oxford University Press; 2001
Ancient Greek Proverb
Prevention is Preferable to Curing
( The earlier the better )
Hippocrates (c. 460-377 B.C)Hippocrates (c. 460-377 B.C)
Number of Deaths Worldwide/year
0
10
20
30
NCD
23.6 millions
40
18 millions
36 millions
CVD(2012) CVD(2030)
The Evolution of Mankind
50 years2.5 million years
What are the Main Targets for CVD Prevention?
Smoking No exposure to tabacco in any form
Diet Health diet, low in saturated fat with a focus on wholegrain products, vegetables, fruits and fish.
Physical Activity 2.5 to 5 hours moderately vigorous physical activity per week or 30-60 minutes most days
Body Weight BMI 20-25 kg/m2 . Waist circumference < 94 cm (men) or <80 cm (women)
Blood Pressure BP <140/90 mmHg
Lipids Very high risk: LDL <1.8 mmol/L (70 mg/dL) or >50% reduction
High risk: LDL <2.5 mmol/L (100 mg/dL)
Moderate risk: LDL <3 mmol/L (115 mg/dL)
Diabetes mellitus HbAIc: <7% (53mmol/mol), BP<140/80
Today’s Portions
Atherosclerosis:a Multifactorial Disease
EUROSPIRE I1995/6
0%0%
20%20%
40%40%
60%60%
Anti-platelet therapy
Anti-platelet therapy
Beta-blockersBeta-blockers
Reported Medication Use In Hospital Patients With Established CHD, 1995/96, 1999/2000 And 2006/07,
EUROSPIRE Survey Populations
10%10%
30%30%
50%50%
70%70%
80%80%
90%90%
100%100%
EUROSPIRE II1999/00
EUROSPIRE III2006/07
ACE-inhibitors & AT2
antagonists
ACE-inhibitors & AT2
antagonists
Lipid lowering drugs
Lipid lowering drugs
StatinsStatins
Reported Medication At Discharge: Hospital Patients With Established CHD, 2006/07, EUROASPIRE III Survey
2012: Deaths By Cause, in Europe
Coronary heart disease
Stroke
Other CVD
Stomach cancer
Colo-rectal cancerLung cancer
Other cancer
Respiratory disease
injuries and poisoning
all other causes
Hypertension Detection and Follow-up ProgramC
ard
iova
scu
lar
even
ts (
% in
5 y
ears
)
Organ Damage
B. StrokeB. Stroke
YesNoYesNo
4.8
5.8
15.3
18.7
1.32.1
5.4
7.4
U
A. Total MortalityA. Total Mortality
Organ Damage
SUSUSUS
Zanchetti J Hypertens 2009Zanchetti J Hypertens 2009
0
10
20
The high incidence of CV events persists despite
intense BP reduction and other RF,
when therapeutic interventions are
made once damage is
advanced and clinically disease is presentThe high incidence of CV events persists despite
intense BP reduction and other RF,
when therapeutic interventions are
made once damage is
advanced and clinically disease is present
30%30%
20%20%
10%10%
5%5%
CV riskCV risk% in 10 years% in 10 years
40%40%
50%50%
Treatment Benefits -25%Treatment Benefits -25%
5050
37.537.5
303022.522.5
2020
1515
1010
7.57.5 CVCVriskrisk
Death
Zanchetti A. Nat Rev Cardiol 2010;7:66-7
The Cardiovascular Continuum :
Treatment Benefits and Residual Risk at Increasing CV Risk
00
1010
2020
3030
5050
4040
Maj
or
card
iova
scu
lar
even
tsM
ajo
r ca
rdio
vasc
ula
r ev
ents
(% in
5 y
ears
)(%
in 5
yea
rs)
ACCACC
6868606023231313--
13136868656500
132132
CAMCAM
57571818383844
100100--
86869494
139139124124
PEAPEA
64641717555577
100100--
70709090
109109129129
EUEU
6060--
656533
100100--
57579292
102102128128
INVINV
66662828323255
10010022223737575700
131131
JMJM
656522224242--
100100--
2828555500
136136
ALLALL
67673636
2323
525216.516.52525363600
135135
ACTACT
646415155252--
100100--
686886863737
130130
ONTONT
64643737494921219191
13.613.662628181118118133133
TRTR
67673636464622229191131355557979
131131136136
HOPHOP
666638385252111188888.58.528287676
101101135135
VALVAL
6767323246462020606015154646737300
139139
PROGPROG
646413131616100100100100
--7760605050132132
PROFPROF
66662828--
10010010010015.515.54747
100100103103136136
PATSPATS
6060----
100100100100
------00
143143
MOSMOS
6868373788
100100100100
3131787800
136136
Trial
Age (y)DM (%)MI (%)
Stroke (%)Any CVD (%)
LVH (%)LLT (%)APT (%)AHT (%)
SBP (mmHg)
}}
TIATIA
65655566
1001001001001111--
494900
150150
8.08.08.38.3
10.510.5 10.610.6 11.011.011.511.5
11.711.711.411.4 12.212.2
13.913.9 13.913.9 14.014.0
16.116.1
19.219.2
25.625.6 25.425.4
34.34.33
40.040.0
10.510.511.711.7 11.211.2
13.013.0
11.011.012.412.4
12.112.1 14.014.012.512.5
14.114.115.815.8
17.817.816.816.8
25.425.4
26.926.9 27.027.0
43.543.5
50.050.0
8.512.012.0
LIFELIFE
6767363616*16*882525
100100----00
144144
Zanchetti J Hypertens 2009Zanchetti J Hypertens 2009
Trials in High-Risk PatientsTrials in High-Risk Patients
Residual Risk
1990 2000
No dataavailable
Less than 4% 4%-6% Above 6%
Adults With Diagnosed Diabetes*
Mokdad AH, et al. JAMA. 2001;286(10):1195-1200.
*Includes women with a history of gestational diabetes.
4.9% DM Prevalence 7.3% DM Prevalence
11.1 % Obesity 19.8 % Obesity
132
129130
124
136
130130
122
140
136
130
124
133
128
138
135
140
136
150
150
141
132
149
143
100
110
120
130
140
150
160
136
133133
119
144
141
145
143144
140
137
128
138
132
140
134
143
134
162
153
143
139
154
144
155
145
148
145
110
120
130
140
150
160
170
Diabetes PreviousPrevious CVDCVD
BP BP BenefitBenefit No benefit No benefit
Zanchetti, Grassi, Mancia J Hypert Zanchetti, Grassi, Mancia J Hypert 2009; 27: 923 ; 27: 923
SBP (SBP (mmHg))
HOTHOTSHEPSHEP
UKPDSUKPDS S. EurS. Eur ADVADV ABCDABCDRENRENHOPEHOPE PROGPROG
HTHT
IDNTIDNT
AMAMNTNT IRIR
IDNTIDNT
PLPL
ActiveActive
SBP (SBP (mmHg))
PATSPATS
PLPL
ActiveActive
PROGPROG
ACCACC
PROFPROF
HOPEHOPE
EUEU
CAM-AMCAM-AM PREVPREV
ACTACT
CAM-ENCAM-EN
PEAPEATRTR
Stroke CHD
ACRDACRDNAVNAV
preDMpreDM
Achieved BP in TrialsAchieved BP in Trials
Change In Smoking Rates Among 15 Year Olds, By Sex, 1993/94 To 2009/10, Europe
Health Behaviors and Attitudes in Young and Middle-Aged Saint-Petersburg Citizens (Russia) : A Pilot Study
Parameters Young participants
(<4 years old) (n=75)
Older participants
(≥40 years old) (n=28)
P-value
Tobacco smokers 26(34.7%) 5(17.9%) NS
Alcohol Consumption
Each day
1(1.3%)
Alcohol Consumption One or several times per week
23 (30.7%) 4 (14.3%) <0.05
Regularly (at least once per week) participate in active leisure or sport
40( 53.3%) 12 (42.9%) NS
Systolic BP (mmHG) (M m)
123.9 1.9 147.2 4.6 <0.001
Systolic BP>140mmHg 11 (14.7%) 15 (53.6%) <0.001
Diastolic BP>90mmHg 7( 9.3%) 5 (17.9%) NS
BMI >25 kg/m2 14 (18.7%) 7 (25.0%) NS
Praying or Acting?
Dear God
My prayer for 2012 is forA fat bank account and a thin body
Please don’t mix these like you did last year
AMEN !
2007 ESH/ESC GuidelinesLifestyle Changes in MS
Modest Modest of caloric intake of caloric intake Saturated fat < 7%Saturated fat < 7% Transfatty acidsTransfatty acids Cholesterol <200 mgCholesterol <200 mg Simple carbohydrates 50%Simple carbohydrates 50% Fruit / vegetablesFruit / vegetables Whole grainWhole grain
Physical exercisePhysical exercise30 min daily of 30 min daily of moderate exercisemoderate exercise
At least 7-10% At least 7-10% BW in 6-12 months BW in 6-12 months
Marked reduction (~60%) of NODMarked reduction (~60%) of NODMarked reduction (~40-50%) of MS prevalenceMarked reduction (~40-50%) of MS prevalence
Exercise Capacity and Mortality in Black and White Men, in Diabetics, Prehypertensives, and High Risk
RR of all cause mortality in individuals with no CVD
Relative RiskRelative Risk
00
0.20.20.40.4
0.60.6
0.80.8
11
1.21.2
ALLALL African-AmericanAfrican-
AmericanCaucasianCaucasian
0.790.79
0.510.51
0.270.27
0.790.79
0.520.52
0.230.23
0.780.78
0.50.5
0.30.3
Kokkinos P, Pittaras A, Manolis AJ et al. Circulation 2008 Kokkinos P, Pittaras A, Manolis AJ et al. Diabetes Care 2009 Kokkinos P, Pittaras A, Manolis AJ et al. Diabetes Care 2009
Kokkinos P, Pittaras A, Manolis AJ et al. Am J Hypertens. 2009 Kokkinos P, Pittaras A, Manolis AJ et al. Am J Hypertens. 2009 Kokkinos P, Pittaras A, Manolis AJ et al. Hypertension2009Kokkinos P, Pittaras A, Manolis AJ et al. Hypertension2009
POWER Study: Evolution of Score®
≤1%
2%
3-4%
5-9%
10-14%
≥15%
Final visit
Baseline visit
Percentage of patientsScore
® –
10-y
ear
risk o
f fa
tal C
VD
22%
13%
17%
28%
12%
8%
37%
16%
19%
24%
3%
1%
0 5 10 15 20 25 30 35 40
Mean SCORE® risk at V3 3.5 3.5%
Mean Score® change = -2.5 3.1%
Relative Risk reduction of - 41%
p<0.001
The Polypill
Three antihypertensive drugsThree antihypertensive drugsBeta-blockerBeta-blockerACE-inhibitorACE-inhibitorDiureticDiuretic
StatinStatin
Low dose aspirinLow dose aspirin
Potential Cumulative Impact of Four Single Secondary Prevention Treatments
Relative riskRelative riskreductionreduction
- - -- - -
25%25%
25%25%
30%30%
25%25%
2-year2-yearevent rateevent rate
8%8%
6%6%
4.5%4.5%
3.0%3.0%
2.3%2.3%
NoneNone
AspirinAspirin
Beta-blockersBeta-blockers
Lipid lowering (by 1.5 mmol)Lipid lowering (by 1.5 mmol)
ACE inhibitorsACE inhibitors
Cumulative relative risk reduction if all four drugs are used is Cumulative relative risk reduction if all four drugs are used is about 75%about 75%
Polypill and Cardiovascular Cost
CV Disease Cost
$ 863 billion globally
Polypill 17.9 million deaths in 10 yrs
Driving Behavioral Change and Improving Health and Productivity
October 2012
27What is KNOW YOUR NUMBERS?
KYN and a healthy lifestyle can: Prevent onset of metabolic conditions Help reverse chronic metabolic
conditions and prevent individuals living with these conditions from getting worse.
Increase morale
Know Your Numbers is a cardiovascular risk assessment tool designed to help drive health
improvement and behavioral change.
Biometric Input Lab Values
Fasting Glucose
Lipid Panel
Clinical Measures
Height
Weight
Waist
Blood Pressure
Pulse Rate
Limited Health History
SynthesisAnalysisEngine
KYN
Chronic Disease Risk for:
Heart DiseaseStroke
DiabetesHeart Failure
COPDLung CancerOther Cancer
Assessment Output
Provides Powerful, Actionable Knowledge
How Know Your Numbers Works
Why Know Your Numbers in Russia
KYN has consistent results in helping patients identify their cardiovascular risk factor, the main cause of death in Russia today.
KYN allows patients to be pro-active and engaged with their healthy lifestyle by providing more opportunities to be educated on proper nutrition and physical fitness.
92% of participants of KYN in other countries have been able to reduce or eliminate cardio-metabolic risk factors, which is much needed in Russia, a country where cardiovascular risk is growing compared to other parts of Europe where these risks have shown a decline.
KYN coincides with President Putin’s goal in dedicating more funding to these types of programs. The 2012 national budget has 820 million Rubles allocated for healthy lifestyle.
Cost of healthcare is growing worldwide and KYN’s model shows a reduction in costs associated with cardiovascular diseases.
NOW IS THE RIGHT TIME FOR RUSSIA!
30
Worldwide locations where Know Your Numbers has been implemented (2005-2012)
Organization Participating in Know Your Numbers Around the World
*Initial enrollment of participants are not reflected in this data, only those that attended both pre and post health screenings required to capture data to measure health improvement results . Data includes 2,611 participants.
Program Sponsor* Locations Market Segment
Abbott (2006, 2008, 2009) Illinois, UK, Puerto Rico, Chile Private Payer
TriCity Challenge (2005 - 2006) Navistar Chevron ArvinMeritor Wayne County Airport Authority
Illinois, Ohio (3 locations) Houston, TX Detroit, MI Detroit, MI
Private Payer
Toyal America (2009, 2010, 2011) Illinois Private Payer
Dreyer Medical Clinic (2008) Illinois (3 locations) Health Care System
St. Luke’s Hospital System (2007) Kansas Health Care System
Family Doctors MA Health Care - Group Practice
MC-21 (2009-2010) Puerto Rico Health Care - PBM
State of Washington (2008) Washington (5 locations) Public Payer
Military (2008) Singapore Public Payer
City of Albuquerque (2008) New Mexico Public Payer
Santa Cruz County (2010-2011) CA Public Payer
SuperValu (2010) Illinois Retail
Know Your Numbers &Behavioral Change Program Components
Pre and Post Challenge screenings
Individual chronic disease risk assessment (KYN report)
Educational sessions on key health topics (nutrition, physical
fitness)
Team or individual competition
Reward and recognition program
Summary data of health improvements
Risk of Onset, Modifiable Risk and Risk Comparison for a 45 male participant
He has an 36% chance of developing type 2 diabetes in the next 5 years
92% of his diabetes risk is in his control
(modifiable)Compared to other 45 yr old men, 98% have
a lower risk of diabetes than he does
Being in the 98% percentile (compared to
his peers) puts his diabetes risk in the
Relatively High category
Risk Factors with the Most Impact on Disease Risk Reduction
Smoking is a major risk factor that is contributing a majority of his disease risk. By modifying just this one risk factor, he
would decrease his risk of onset for several conditions significantly.
Provides the participant with an Action Plan!
Automated Treatment/Action Plan Report
Physicians receive a treatment action plan report based on
widely accepted guidelines for the region which helps save time
and encourages consistent therapy.
624 employees began the Challenge 233 employees completed the Challenge Average reduction per person
weight loss of 9.5 lbs waist reduction of 2.9 inches
100
60
40
0
weight
91%
55%
45%
28%
93%
23%
20
80
Waist size
Mets
New onsetType Diabetes
CHDStroke
Abbott Puerto Rico-Success Story(August-November 2009)
How are some partners using Know Your Numbers in helping to promote a healthy
lifestyle in Russia?
Pilot in Kazan
Epidemiology of CV Disease in HIV Patients
Patients living longer with HIV are presenting new concerns related to ART and chronic viral infection
The risk for CVD may be greatly elevated in the HIV + population for a number a reason:
-Increased prevalence of known CAD risk factors
(smoking, HTV, etc)
-HIV virus-related pathology?
-ART-related lipodystrophies, dyslipidemias, diabetes mellitus, insulin-resistance, etc.
Health Promotion February 10, 2011Company Confidential
Social Partner Development Fund (People Living With HIV)
Non-profit organization established in 2005 to develop public health care facilities in combating diseases of social significance.
The mission of the Fund is to improve people’s quality of life through constructive interaction between all parties involved in the public health system.
The strategy of the Fund is based on the fact that a key factor in ensuring the sustainable development of public health care in the fight against socially significant diseases in the current climate is the involvement in these processes of—and the level of interaction between—the government, the private sector and civil society.
Social Partnership Development Fund: Pilot Overview
Participants – 250 HIV+ patients to be enrolled
Locations: Kazan (a diverse population of over 1.1 million people)
Patient enrollment began on September 1, 2012 and baseline
measurements were taken to evaluate cardiovascular risk, utilizing
the unique tool, Know Your Numbers, that provides a predictive look
at future risk of developing chronic diseases.
12-week follow up with patient support and education by doctors
and experts on nutrition, physical fitness, and benefits of less
alcohol and tobacco use.
Re-evaluation of the participants risk after the intervention to
identify progress.
Results of the pilot to be available in Qtr1, 2013.
50
30
20
0
overweight or obese
55%
2%
31%
21%
24%
31%
10
40
pre-hypertensive hypertensive
pre-diabetestotal cholesterol
LDL cholesterol
10%
triglycerides
60
29 participants enrolled to date (expect 250)
20 female / 9 males
32 mean age
Russian Preliminary Baseline Data(As of 10/5/12)
Actions to prevent CVD should be incorporated into everyone’s daily lives, starting in early childhood and continuing throughout adulthood and senescence
The physician in general practice is the key person to initiate, coordinate and provide long-term follow-up for CVD prevention.
Nurse-coordinated prevention programmes should be well integrated into healthcare systems
The practising cardiologist should be the advisor in cases where there is uncertainty over the use of preventive medication or when usual preventive options are difficult to apply
All patients with CVD must be discharged from hospital with clear guideline-orientated treatment recommendations to minimize adverse events
All patients requiring hospitalization or invasive intervention after an acute ischaemic event should participate in a cardiac rehabilitation programme to improve prognosis by modifying lifestyle habits and increasing treatment adherence.
Patients with cardiac disease may prticipate in self-help programmes to increase or maintain awareness of the need for risk factor management.
Non-governmental organisations are important partners to health care workers in promoting preventive cardiology
The Eyropean Heart Health Charter marks the start of a new era of political engagement in preventive cardiology.
Where should CVD prevention programmes be offered?
To Smoke or not to Smoke
RussiAction
TARGETS 2012-2015
Modifiable Risk Factors
Physical activity Tobacco Salt intake Blood Pressurecontrol
10% 30% 30%25%
25% in mortality
Global CV Disease Task Force 2012
TARGETS 2012-2015
Fat intake
Cholesterol
Obesity
Excessive alcohol intake
Drug therapy
Plus :
RussiAction
GovernmentPoliticiansArmyOpinion leadersActorsOlympic championsMedia
Cardiovascular SocietiesDoctorsNursesVolunteers
FoundationsCompanies
Doing Nothing in CV Prevention
$500 billion/year in low and middle income
countries
$47 trillion cost in the next 25 yrs
Conclusions
We now have the opportunity to make important We now have the opportunity to make important changes in our countries by adopting evidence-based changes in our countries by adopting evidence-based targets and implementation of the guidelines that will targets and implementation of the guidelines that will guide health policy, with the collaboration of the guide health policy, with the collaboration of the government, national societies, parents, teachers, government, national societies, parents, teachers, nurses, volunteers, politicians and opinion leaders.nurses, volunteers, politicians and opinion leaders.
Collaboration with other groups, such as stakeholders, Collaboration with other groups, such as stakeholders, foundations, media etc. will be necessary to address foundations, media etc. will be necessary to address this emerging 21this emerging 21stst global health priority and begin to global health priority and begin to reverse the devastating toll of CV disease and NCDs reverse the devastating toll of CV disease and NCDs in our communities. in our communities.
Zakynthos Island, GreeceZakynthos Island, Greece
Santorini Greece