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The World Heart Federation’s vision for worldwide cardiovascular disease prevention Salim Yusuf, David Wood, Johanna Ralston, K Srinath Reddy

Atherosclerotic cardiovascular disease is the world’s number one cause of death and disability, and disproportionately affects individuals living in low-income and middle-income countries (LMICs).1 Cardiovascular disease was recognised as common in high-income countries in the 1960s and 1970s,2 but the age-standardised mortality from cardiovascular disease has halved since then, through better prevention (such as lifestyle changes and risk factor control) and wider use of simple but effective treatments for acute events and secondary prevention.3 However, the use of these proven strategies, even in wealthy countries, is far from optimum and more widespread implementation could further reduce the rates of cardiovascular disease in the next two decades in most high-income countries. By contrast, cardiovascular disease was thought to be uncommon in LMICs in the 1950s and 1960s, but increased substantially over the past three decades. Nowadays, more than 80% of the global burden of cardiovascular disease occurs in these countries.1 This high percentage is partly due to the much larger populations in these countries, progress in avoidance of deaths from childhood diseases so that now more individuals live to older ages when they are at risk of developing cardiovascular disease, and increased tobacco use, decreased physical activity, increased consumption of animal products, and increased obesity (with resultant elevations in blood pressure, cholesterol, and diabetes),4 especially in LMICs. Additionally, many factors have delayed or even prevented the implementation of the lessons learnt from experiences in high-income countries to LMICs. First, governments in LMICs spend only a very small proportion of their gross domestic product on health, for example, only 2% in low-income countries and about 3–5% in middle-income countries (compared with about 12% in high-income countries).5 Second, most high-income countries, with the exception of the USA, have some form of universal health coverage, but such coverage is uncommon in low-income countries. Third, health systems in LMICs have to divide their modest budget between treatment of undernutrition, childhood and infectious diseases, and the rising burden of non-communicable diseases. Fourth, in LMICs, far fewer health-care professionals are present than in high-income countries and the existing workforce is concentrated in cities that cater mainly to the wealthier individuals.6 Fifth, health care in many LMICs is disproportionately oriented at providing curative, rather than preventive services. The high costs of curative services are unaffordable for most individuals in these populations.

The burden of health-care expenses is exemplified by private hospitals providing high quality care for the wealthy few, but weak, underfunded, and poorly governed public systems for most people. Corrupt and unethical practices can be common in LMICs and unnecessary and expensive tests can be useless or even harmful.7 Family debt due to high health-care costs is now common in many low income countries.8 Although overall risk factor levels (based on an integrated score) are highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries, the incidence of major cardiovascular disease and mortality is highest in LMICs,9 suggesting the need for better health systems in these countries. The UN General Assembly has expressed a collective political will to control premature mortality from cardiovascular disease and other non-communicable diseases. Additionally, the WHO has set a target of 25% reduction by 2025.10 To achieve this goal, the WHO has adopted eight voluntary targets in relation to tobacco, physical activity, salt, alcohol, blood pressure, diabetes, essential medicines, and technologies. A Global Action Plan through 2020 was adopted by the World Health Assembly and calls for National Action Plans in every country to reduce the burden of non-communicable diseases, especially cardiovascular disease. So what can be done to contain the epidemic of cardiovascular disease in LMICs? As leaders of the World Heart Federation, we suggest the following nine steps (panel). First, develop national professional alliances of all major stakeholders committed to the improvement of cardiovascular health—cardiology, internal medicine, general practice, nursing, and allied professionals and patient organisations. These alliances should influence government policies and actions on secondary, primary, and primordial prevention, in addition to the provision of essential low-cost treatments for cardiovascular disease. Ideally alliances involving several non-communicable diseases including diabetes, cancer, and chronic respiratory disease (eg, the NCD Alliance) would be more effective because of their combined strengths, and because many risk factors and treatments are common. Such national alliances should develop core guidelines which are simple, and can then be modified by region depending on cultural and economic contexts, and then monitor their uptake and impact. Second, in addition to the use of existing surveys, simple documentation of incidence of events, prevalence, deaths from cardiovascular disease, and other conditions from sentinel sites (eg, 1% of the households in a few regions) in as many countries from around the world as

www.thelancet.com Published online April 17, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60265-3

Published Online April 17, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)60265-3 Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (S Yusuf DPhil); International Centre for Circulatory Health, Imperial College, London, UK (D Wood FRCP); and World Heart Federation, Geneva, Switzerland (J Ralston MBA); Public Health Foundation of India, New Delhi, India (K S Reddy DM) Correspondence to: Dr Salim Yusuf, Population Health Research Institute, Hamilton General Hospital, Ontario L8L 2X2, Canada [email protected]

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Panel: Necessary strategies to reduce cardiovascular disease worldwide by 25% by 2025 1 Build coalitions and partnerships across health disciplines, non-medical and medical organisations, and governments for control of non-communicable disease 2 Develop reliable health-information systems to monitor mortality, morbidity, and health behaviours 3 Vigorously enforce tobacco control, implement hypertension detection and control, and secondary prevention 4 Develop efficient systems of integrated care with trained non-physician health workers for hypertension detection and control, for secondary prevention in uncomplicated patients, and to counsel lifestyle modification 5 Improve access and affordability of proven drugs with the facilitation of use of low-cost combination pills 6 Develop expertise in knowledge translation and implementation 7 Engage civil society and community organisations in cardiovascular disease control 8 Build partnerships between high-resource and low-resource countries for cardiovascular disease and control of non-communicable disease with use of the transfer of expertise and the provision of modest funding 9 Establish large population studies in different regions of the world as the types and patterns of diet, activity, alcohol consumption, and tobacco use vary by region; regional studies are essential to document their effect in each region

possible to create a global health observatory. A rapid assessment of incidence of events in the previous few years (eg, major clinical conditions such as heart attacks or strokes for cardiovascular disease), and death rates from common diseases with simultaneous information on diet, smoking, physical activity, and alcohol consumption recorded at periodic intervals (eg, 5 years), can efficiently provide reliable information on disease burden in each country or region, and the contribution of health behaviours and risk factors to several conditions. Such information is essential for the development of evidencebased health policies and health systems to efficiently allocate health-care resources, and to document their impact on morbidity and mortality. Local information can also be a powerful educational resource (for health professionals, policy makers, and the public) as each country has ownership of their problems, and will likely be motivated to implement solutions. Third, more vigorous tobacco control and enforcement of the Framework Convention on Tobacco Control should be accompanied by monitoring to document to what extent national declarations and laws are actually being followed.11 Improved control of hypertension could substantially reduce cardiovascular disease, and yet the majority of individuals with hypertension remain 2

undetected, and of those detected, most are not effectively controlled.12 A combination of healthy diet, increased activity, and cheap and effective generic medications taken over a lifetime will reduce premature morbidity and mortality substantially.13 For patients with known cardiovascular disease, the adoption of healthier lifestyles, and increased widespread use of cheap and effective generic secondary prevention medications can also have large benefits, but these are yet to be fully realised in most countries.14 In LMICs these simple medicines are often not available in many communities, and when available, they are unaffordable to a high proportion of individuals.15 Patients with cardiovascular disease and hypertension are easily identified, and effective and inexpensive treatments are available. Therefore, these treatments should be the priority for implementation in all countries, but many barriers exist. These include poor tobacco control, inadequate number of health-care professionals, long distances to clinics (necessitating travel, related expenses, and lost wages) and the high fees for these services, and the unavailability or unaffordability of drug classes such as angiotensinconverting enzyme inhibitors and statins. By contrast, aspirin, β blockers, and diuretics are more widely available and affordable, therefore guidelines should promote their use, while working with governments to make other key drugs for cardiovascular disease widely available and affordable. Fourth, a need exists to create new models of care for chronic diseases that are community based and can be done mainly by primary care physicians and non-physician health professionals, such as nurses, allied professionals, and different kinds of community health workers appropriate to different cultural and health-care settings.16,17 Straightforward cardiovascular risk screening with non-laboratory methods will identify many people at high risk of developing cardiovascular disease or diabetes.18,19 In view of the difficulties of access to physicians and the restricted average time (2–3 min per patient) available for consultations in LMICs, trained non-physician health workers could be an effective alternative to deliver simple lifestyle messages (especially quitting smoking) and also to prescribe and monitor the effects of a limited number of medications that are safe and effective. Fifth, provision is needed for basic acute and longer term cardiovascular disease care (eg, streptokinase for acute myocardial infarction; aspirin, clopidogrel, heparin, or inexpensive antithrombotics for acute coronary syndromes; and β blockers, angiotensinconverting enzyme inhibitors, diuretics, and statins for all patients with cardiovascular disease) at low or no cost. Many of these drugs are generic and can collectively reduce mortality and morbidity to a large extent, (perhaps as much as 75%).13 Combined with avoidance of tobacco, as many as 90% of recurrent events could be prevented, but this requires extensive implementation and patients to adhere to recommendations. Widespread

www.thelancet.com Published online April 17, 2015 http://dx.doi.org/10.1016/S0140-6736(15)60265-3

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availability of polypills and their provision at no or subsidised costs could overcome the present gaps in availability and unaffordability of key drugs, and could be an important part of a package of essential services to control cardiovascular disease. However many commercial, regulatory, and intellectual barriers exist in the development and marketing of polypills. These can only be overcome if governments recognise the clinical, public health, and economic value of polypills and take steps to remove barriers and help with their use. Sixth, health professionals need to be trained to translate proven evidence of prevention and treatment strategies into clinical practice. Effective knowledge translation requires expertise in documentation and overcoming barriers to prevention and treatment, and engagement of the public, patients and their families and policy makers. Seventh, because cardiovascular disease affects a third of adults in the world, it is the largest epidemic ever known to mankind. Controlling epidemics requires the engagement of multiple sectors with a broad range of strategies across national boundaries, and the extensive engagement of civil society, organisations that are publically focused, work places, the education system, families, and patient engagement. Eighth, building partnerships for cardiovascular disease control between high, and LMICs would lead to the valuable exchange of knowledge, but given the distinct differences in economics, health-care systems need to be contextualised. A small proportion of funds from organisations committed to cardiovascular disease control in rich countries given to partner LMICs, could facilitate the establishment of successful cardiovascular disease control campaigns in many poor countries. These partnerships could leverage local funds from governments and other organisations in the recipient countries. Knowledge exchange can be bidirectional. Knowledge of cost-efficient approaches that have been successful in high-income countries could be simplified and made contextually appropriate for LMICs. Equally, many ideas from LMICs can be transferred to high-income countries, which could enhance their prevention efforts. Ninth, much remains to be learnt about cardiovascular disease, especially in LMICs. Most of the available data for risk factors of cardiovascular disease are based on studies done in high-income countries. Although recent studies9,20–25 have provided substantial new information, a lot is not known about diet, other health behaviours, the environment, or health systems that influence cardiovascular disease in LMICs. Collection of reliable data on these influences requires large, region-specific population studies. In 2011, the UN General Assembly recognised the growing importance and challenges posed by noncommunicable diseases, including cardiovascular disease.26 The World Health Assembly agreed on eight voluntary targets to reduce premature mortality

from non-communicable diseases by 25% by 2025.10 The World Heart Federation, as a key WHO partner with a membership of 220 societies and foundations on all continents, is committed to the reduction of premature mortality from cardiovascular disease by working with the WHO, and also directly with the cardiology societies and heart foundations in each country to reduce cardiovascular disease. Sustained high level advocacy to governments by national alliances (eg, national NCD alliances) of all professional and patient stakeholders is central to this ambition. Of the eight targets, the World Heart Federation has prioritised three strategies (tobacco control, hypertension control, and secondary prevention) as its primary focus and is developing global roadmaps for their widespread adoption. Through its emerging leaders programme, the World Heart Federation expects to develop more than 250 experts in knowledge translation from 80–100 countries over the next decade.27 Recent estimates suggest that cardiovascular disease mortality is declining worldwide by about 1% per year.28 The WHO and World Heart Federation strategies are aimed at the acceleration of this decline and the joint efforts of national cardiovascular societies, foundations, non-governmental organisations, and governments are essential to achieve a 25% reduction in premature cardiovascular disease mortality by 2025. If successful, these efforts could avoid tens of millions of premature deaths worldwide. The time for all of us to act together is now. Contributors SY conceived the paper, wrote the first draft and revised all subsequent drafts. All authors are developing the vision of the World Heart Federation and provided comments on drafts of the manuscript. Declaration of interests SY is President of the World Heart Federation (2015–16), DW is the President Elect, and KSR is the immediate past President. JR is the chief executive officer of the World Heart Federation. References 1 GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; 385: 117–71. 2 Dalen JE, Alpert JS, Goldberg RJ, Weinstein RS. The epidemic of the 20th century: coronary heart disease. Am J Med 2014; 127: 807–12. 3 Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in US deaths from coronary disease, 1980–2000. N Engl J Med 2007; 356: 2388–98. 4 Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001; 104: 2746–53. 5 World development indicators: Health systems. The World Bank, 2014. http://wdi.worldbank.org/table/2.15 (accessed Dec 12, 2014). 6 WHO. World Health Statistics 2014. Geneva: World Health Organization, 2014. 7 Berger D. Corruption ruins the doctor-patient relationship in India. BMJ 2014; 348: g3169. 8 Huffman MD, Rao KD, Pichon-Riviere A, et al. A cross-sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries. PLoS One 2011; 6: e20821. 9 Yusuf S, Rangarajan S, Teo K, et al, and the PURE Investigators. Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med 2014; 371: 818–27.

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The World Heart Federation's vision for worldwide cardiovascular disease prevention.

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