Anwar SantosoDept. of Cardiology – Faculty of Medicine; Universitas Indonesia

National Cardiovascular Centre – Harapan Kita Hospital

Immediate Past President of IHA

Jakarta - Indonesia

Managing CVD in Indonesia:How well are we doing and

where can we improve?

Introduction

• Preventing CVD is the insurmountable challenge for

clinicians worldwide

• Lipid lowering therapy represents the cornerstone of

treatment of patients with CVD

• For years statins have been regarded as a key intervention

to lower lipids and improve clinical outcome

• However, despite statins therapy at maximally tolerated

doses many patients do not achieve their lipid goals

and still suffered a residual ischemic risk of recurrent CVD

Prevalences of Hypertension based on

Basic Health Research 2007 & 2013

0

10

20

30

40

50

60

High TC High LDL-C Low HDL-C

Male

Female

Prevalences of Dyslipidemia in Indonesia(Basic Health Research - 2007)

Recruited 19.114 person-across 438 districts

(Indonesian Basic Health Research – 2007)

37.6

(percentage)

41.540.6

43.8

48.9

36.6

Indonesian Basic Health Research 2013

Prevalence of Dyslipidemia by gender and

residence in Basic Health Research 2013

Male Female Urban Rural

Percentage of Central Obesity based on

Basic Health Research 2007 & 2013

Prevalences of Diabetes Mellitus based on

Basic Health Research 2007 & 2013

Prevalence of smoking habit in Indonesia

34,236,3

0

10

20

30

40

2007 2013

Series 1

Year

%%

Indonesia Basic Health Research – 2007 & 2013

How to measure impact of

CV prevention?

12

Population Attributable Risk (PAR%)

• Proportion of cases in the total population

attributable to the exposure

• Proportion of disease in the total population that

could be prevented if we could eliminate the risk

factor

• Determines exposures relevant to public health in

community

• Only use if causality “exposure outcome”

PAR(%) according to RR for various level

of exposure frequency among cases

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1 2 3 4 5 6 7 8 9 10

Relative risks

Po

pu

lation

att

rib

uta

ble

fra

ction

Pe 10%

Pe 25%

Pe 50%

Pe 75%

Pe 100% (AFe)

Age- and sex-specific PAR (95%CI) associated with

CV risk factors for all CHD in Indonesia

Hussain MA, et al. J Epidemiol 2016; doi.10.2188/jea.JE20150178

PAR = 77.4% PAR = 65.6%

Prevalences of Stroke based on

Basic Health Research 2007 & 2013

Proportion of Mortality Rate in Indonesia

(Basic Health Research – 2007)

(Indonesia Ministry of Health Affair– 2007)

10%

Cause of mortality in SEA Region

Annually + 7.9 million NCD’s attributable death (55% of all mortality)

Source: WHO global Health observatory 2011 http://apps.who.int/ghodata/

CAD

Peripheral VascDisease

Cerebrovascular Disease

All cause mortality rate in

SEA =14.5 million/year

Hurdles in preventing CVD?

Maharani A and Tampubolon G. Plos One 2014; 9 (8): e 105831

By gender By urban vs rural

• There is a significant burden of 4 primary NCD on Indonesian household

• Hypertension, diabetes, CHD and stroke account for 8% of nation’s out of pocket health expenditures

Proportions of patients attaining LDL-C goals

according to gender and region

Chiang CE, et al. J Atheroscler Thromb 2015; 22: 000 – 000 (epubahead_

AsPac ACS Medical Management Working Group, Int J Cardiol 2015; (183): 63 - 75

Barriers Recommendations

Accessibility & system of care • Shorten the community delay

• Improving the ambulance services

Validity of risk assessment • Develop and revalidation

• Recommends risk assessment at FMC

Low public awareness • Educate public and medical professional

• Develop the Clinical Guidelines

Cost and affordability • Universal coverage

• Standardize the medical management

Area: 129.54 km2

Population: 2,260,341

6 HUB & 14 SPOKES20 Healthcare Facilities:

2 Government Hospitals, PCI (+), UHC (+)4 Private Hospitals, PCI (+), UHC (-)8 Primary Health Care Center, UHC (+)4 Private Hospitals Hospital, UHC (+)2 Private Hospital, UHC (-)* UHC: Universal Health Coverage

iSTEMI partner with Medtronic

Alternative Referral

Main Referral

iSTEMI NETWORK PILOT PROGRAMWest Jakarta

PCI & Lytic Capable (6)Lytic Capable (2)ACS Diagnostic Capable (12)

Courtesy: Soeryanata S 2016

iSTEMI Network + Tertiary FacilityWest Jakarta (2 Years)

24 months data from June 30, 2014 – June 30, 2016 in iSTEMI network (West Jakarta + NCC-HK)

STEMIN= 2433(38.5%)

ReperfusionN=1394(57.2%)

FibrinolysisN= 283 (20.3%)

PPCIN= 1059(75.9%)

AutolysisN=52(3.8%)

No ReperfusionN= 1039(43.8%)

UAP/NSTEMIN= 3880(61.9%)

ACS

N=6313

Courtesy: Soeryanata S 2016

6,2%

13,5%

4,4%

12,9%

Reperfusion Without Reperfusion

Year 1

Year 2

In Hospital Mortality RateReperfusion vs Without Reperfusion

24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)

P-value= 0.001OR= 0.46

(0.31 to 0.67) 95% CI

P-value= 0.001OR= 0.34

(0.22 to 0.55) 95% CI

(47)

(76)

N= 762 N= 563

(29)

N= 632 N= 476

(58)

Courtesy: Soeryanata S 2016

26

West Jakarta Pilot

Collaborate to develop and implement STEMI protocols

Measure and compare 30-day and 1 year mortality

Expand in Jakarta

Present Phase 1 pilot clinical/economic data to Health Authority

STEMI protocol adoption in other Jakarta facilities

Expand across

Indonesia

Secure funding and support to expand STEMI program nationwide

Initiate Indonesia-wide STEMI registry

Go to appendix

Phase 1 Phase 2 Phase 3

Long –term vision to improve STEMI care throughout Indonesia

Courtesy: Soeryanata S 2016

341,745

fewer deaths

in 2000

Risk Factors worse: +17%Obesity (increase) +7%

Diabetes (increase) +10%

Risk Factors better: -65%Population BP fall -20%

Smoking -12%

Cholesterol (diet) -24%

Physical activity -5%

Treatments: -47%AMI treatments -10%

Secondary prevention -11%

Heart failure -9%

Angina: CABG & PTCA -5%

Hypertension therapies -7%

Statins (primary prevention) -5%20001980

Ford, ES et.al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000.

NEJM 2007; 356: 2388.

Ch

an

ge

in

nu

mb

ers

of

de

ath

s

0

+

-

Major Shifts in Population Risks and

Expanded Treatment, U.S.

WHO, Prevention of cardiovascular disease: guidelines for assessment and management of total cardiovascular risk., 2007

Population Strategy for CVD Prevention

Is Primary Prevention cost effective?

Lifetime risk of death from CVD according to

regimen strategies for World Bank regions

Gaziano AT et al. the Lancet 2006; 368: 679 - 86

Primary regimen:

Aspirin

Statin

ACE-I and/or CCB

Secondary regimen:

Aspirin

Statin

Beta blockers

ACE-I

Lifetime costs and QALYs of strategies assessed in

World Bank regions

Gaziano AT, et al. the Lancet 2006; 368: 679 - 86

Incremental cost-effectiveness ratios ($/QALY) for

treatment regimens vs no-treatment

Gaziano AT, et al. the Lancet 2006; 368: 679 - 86

• Aspirin and 2 blood pressure drugs and statin halve the risk of CVD death in high-risk subjects

• This approach is cost-effective according to WHO recommendations and robust

NCD’s Prevention and Control Program in Indonesia 2015 – 2019

LEADERSHIP• National leadership• Improve awareness• Partnership

PREVENTION• Prevention for high risk population• Risk assessment model• Community, working site and

environment

MANAGEMENT• National advocation program • Promotion program• Capacity building

RESEARCH• Publications• Financial support• Comprehensive planning

Population with

NCD

High-risk

population

Indonesian Heart Association Guidelines 2013 - 2015

ACS Guideline CHF Guideline AF Guideline

CVD Prevention in Women GuidelineDyslipidemia GuidelineHypertension Guideline

Important Points in IHA Lipid Guidelines

1. Assessment of global risk

2. High-risk subjects: CVD, DM and FH

3. Global risk consider both lipid and non-lipid risk factors

4. Major emphasis on life-style intervention

5. LDL-C is a primary target

6. Statins are indicated in high-risk subjects

7. Non-HDL cholesterol is alternate target

35

Sp

Household air pollution

50% reduction in

SFU for cooking

Essential NCD

medicines and

technologies

80% coverage

Drug therapy &

counseling

50% coverage

Diabetes/obesity

0% increase

Raised blood

pressure

25% reduction

Tobacco use

30% reduction

Salt/sodium intake

30% reduction

Physical inactivity

10% reduction

Harmful use of alcohol

10% reduction

Regional Targets for NCD

25% reduction in NCD mortality

by 2025

Risk FactorNational System ResponseRegional Target

Thank You