Pascal Bovet, FMH int. med, FMH public health

Consultant NCD, Ministry of Health Seychelles

Associate professor, University Medical Center, Lausanne, Switzerland

African Heart Network (Affiliate of WHF in Africa)

Joint Pan-African Society of Cardiology (PASCAR) and the Cardiovascular

Society of Mauritius CVS Congress, Mauritius, 4 -6 Oct 2015

Reducing Premature Cardiovascular Morbidity and

Mortality in People With Atherosclerotic Vascular Disease:

The World Heart Federation Roadmap for

Secondary Prevention of Cardiovascular Disease

Focus on interventions for conditions which are frequent in a population, have clear evidence, are affordable, and therefore

have potential large impact → 3 roadmaps by WHF

• Tobacco avoidance • Hypertension control • Secondary prevention Approach: Identify gaps & barriers to make interventions more impactful

Reducing CVD

by25* by 2025

Roadmap for CVD

secondary prevention

Roadmap for

hypertension

Roadmap for

tobacco control

Next steps

Secondary prevention of CVD morbidity and mortality

• Any strategy aimed at reducing the probability of a

recurrent CVD event in patients with known

atherosclerotic CVD, including coronary heart disease,

cerebrovascular artery disease, peripheral artery disease

and atherosclerotic aortic disease

• Treatment with proven drugs and smoking cessation

can prevent up to 80% recurrent events, including

death and disability

Secondary prevention interventions

• Pharmacotherapy:

– Aspirin

– ACE inhibitors

– Statins

– Beta-blockers (IHD)*

• Behavioral interventions (rehabilitation/prev. cardiology)

– Multifactorial & multdisciplinary

– Smoking cessation

– Physical activity

– Healthy diet

– Stress management: aim to return patient to full physical, emotional and vocational function [i.e. optimize quality of life]

Effects of different drugs, measured as relative risk, on fatal and non-fatal IHD and stroke

Joint effect could prevention up to 80% of premature CVD in secondary prevention

Lim SS et al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries:

health effects and costs. Lancet 2007; 370: 2054–62

~all: RR 0.27 ~all: RR 0.30

Distribution of risk factors in population at baseline and subsequent CVD events (PURE, n=152,609)

Baseline condition Risk factor (%) Follow-up major CVD

N = 3,488 (2.23 %)

Had prior CVD (i.e. sec. prev) 7,743 (5.1) 673 (19.3)

Hypertension (Hx or ≥140/90) 62,034 (40.7) 2,317 (66.4)

Current smoker 31,397 (20.6) 1,021 (29.4)

CVD, hypertension or smoker

(i.e. CVD high risk) 84,078 (55.0) 2,822 (80.9)

Diabetes (Hx or FPG ≥7mmol) 16,071 (10.5) 905 (26.0)

CVD, hypertension, smoker or

DM 88,326 (57.9) 2,929 (84.0)

Estimated costs for medications for all high CVD risk

individuals in different countries

Beaglehole R et al. Priority actions for the non-communicable disease crisis. Lancet 6 apr 2011

Cecchini M, Sassi F, Lauer JA, et al. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-eff

ectiveness. Lancet 2010; 376: 1775–84.

Treatment gap: CVD event rates (left) and annualized case fatality (right) in LICs, MICs and HICs (PURE)

Yusuf et al . Cardiovascular Risk and Events in 17 Low-, Middle-, and High-Income Countries. N Engl J Med 2014;371:818-27.

Treatment gap in CVD secondary prevention: Drug use in participants with IHD, by region (PURE)

0

10

20

30

40

50

60

70

80

North Am. &Europe

SouthAmerica

Middle East South Asia China Africa

Antiplatelet drugs

β blockers

ACE inhibitors or ARBs

Diuretics

Calcium-channel blockers

BP-lowering drugs

Statins

Africa

Ysuf S et al. Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-

income, and low-income countries (the PURE Study): a prospective epidemiological survey. Lancet 2012

0

10

20

30

40

50

60

70

North Am. &Europe

SouthAmerica

Middle East South Asia China Africa

Antiplatelet drugs

β blockers

ACE inhibitors or ARBs

Diuretics

Calcium-channel blockers

BP-lowering drugs

Statins

Africa

CVD secondary prevention gap: Drug use in participants with stroke by region (PURE)

Treatment effectiveness cascade: need to identify and address modifiable health system barriers at each level and implement

contextual strategies to overcome them

Efficacy 75%

Real effectiveness

21% 8% (*hypothetical numbers)

* 20%

* 20%

* 30%

First step: mapping health system requirements to

achieve secondary prevention targets

• Priority interventions (ACEI, BB, aspirin, statin, lifestyle

interventions) available

• Factors related to adherence and adequate case

management

• A number of factors related to adequate health system

function

Health system requirements to achieve CVD prevention target (WHF roadmap) (more specific than 6 blocks or CCM)

Human

resources

• Availability of HCPs who can prescribe proven therapies at hospital discharge and

ensure their long-term use

Physical

resources

• Health care system facility available /accessible to patients when / where needed

• Availability of priority interventions at hospital and primary care or outpatient

clinics within or near the community neighborhood

Intellectual

resources • Availability of practical and locally relevant clinical guidelines

Healthcare

delivery

• Healthcare organized to integrate existing resources to ensure efficiency in the

interaction between HCPs and patients and facilities are close to patients

Healthcare

recipient • Patients aware and willing to follow recommendations (patient centered care)

Financing

• Patients can afford the access to healthcare facilities and recommended interventions

• Priority interventions are affordable to both the healthcare system and the patient

• Adequate investment in health care

Governance • Adequate political and regulatory framework supporting the strategy to implement

and sustain priority interventions (including their availability and affordability)

Information

system

• A simple, timely, acceptable, and representative information system to provide

reliable data about the incidence of fatal and non-fatal CVD events, prognosis and

quality of care (including the use of priority interventions) of patients with known CVD

Roadblocks, strategies and solutions to overcome barriers to the achievement of CVD secondary prevention targets (1/2)

Roadblock Strategies Potential solutions

Patients with

known CVD do not

have access to

the HC system

Improve access to

HC system

• Strengthen the role of the PHC for secondary CVD prevention

• Increase opening times of clinics; location close to patients

• Integrate secondary CVD prevention interventions with simple

cardiac rehabilitation programs

• Integrate secondary CVD prevention with management of other

chronic conditions (HIV, tuberculosis)

Lack of HCPs to

prescribe priority

interventions

Increase

availability of HCPs

• Shift roles of HCPs towards allowing non-specialized workers

to prescribe priority interventions

Guidelines are not

available or

recommendations

are too complex

Simplify treatment

• Develop simple and locally applicable guidelines

• Simplify use of multiple drugs by using fixed-dose combinations

• Pre-packaged blisters with multiple medications

HCPs are not

aware of guidelines Educate HCPs

• Education of HCPs

• Audit and feedback

• Decision support systems (new ICT)

HCPs are aware

but do not follow

guidelines

Ensure HCPs

follow

recommendations

• Local opinion leaders

• Financial incentives to promote care

• Decision support systems

Roadblock Strategies Potential solutions

Priority

interventions

are not available

Increase

availability of

priority

interventions

• Include priority interventions in the national list of essential medicines

• Improve efficiency of pharmaceutical distribution chain

• Ensure priority interventions are available at sec. & prim. care levels

• Ensure priority interventions are available at community level

Priority

interventions

are not

affordable

Universal

health

coverage

• Promote use of quality, safe and inexpensive generic medications

• Promote local manufacturing, bulk purchasing and/or efficient system to

streamline medication supply

• Provide financial and social support for patients to purchase priority

interventions, or provide them free of charge (or at very low cost)

Patients are not

aware of the

importance and

need of long-term

treatment

Help patients

adhere to

recommend-

ations

• Education (health literacy)

• Public awareness campaigns

• Empower patients to share decisions with HCPs: patient centered care

Patients do not

remember to

follow

recommendations

Help patients

adhere to

recommenda-

tions

• Use information and communication technology to remind patients

about recommendations

• Use fixed-dose combinations of key priority interventions to simplify

treatment

• Use patient-nominated, non-professional treatment supporters

(spouse, friends, family)

Roadblocks, strategies and solutions to achieve CVD secondary prevention target (2/2)

It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.

Sir William Osler

Product Units per

month

Median

Unit Cost

Monthly cost

($)

Yearly

cost (US$)

Source

Aspirin (ASA) 100 mg tab 30 $ 0.0028 0.084 1.0 MSH 2013

Hydrochlorothiaz. 25 mg 30 $ 0.0041 0.123 1.5 MSH 2013

Atenolol 50 mg tab 30 $ 0.0118 0.354 4.2 MSH 2013

Simvastatin 20 mg tab 30 $ 0.0235 0.705 8.5 MSH 2013

Glibenclamide 5 mg tab 30 $ 0.0067 0.201 2.4 MSH 2013

Metformin 500 mg tab 60 $ 0.0178 1.068 12.8 MSH 2013

Insulin NPH 100IU/ml 10ml 1 $ 6.70 6.7 80.4 MSH 2013

Tamoxifen 20 mg tab 30 $ 0.0998 2.994 35.9 MSH 2013

Cost of NCD medicines without tariffs, taxes and mark-ups

Sources: MSH International Drug Price Indicator Guide 2013 and ADF Catalogue 2011

Selected successful examples (1/2)

• Integration of sec. prevention of CVD in primary care (Family Health

Program in Brazil reduced CVD mortality by 18% (BMJ 2014;348:1-10)

• Cardiac rehabilitation programs can be low cost: a nurse –led,

home-based program of RF control in China (J Clin Nurs 2007)

• Reliance on non physician health workers – Review in Plos 2014;9:3103754

– SPREAD trial in India, better adherence to sec prev Rx (Kamath et al, AmHJ 2014)

– SimCard trial India Tibet (Tian et al, Circulation 2015;132:815-824)

• Simplifying treatment of with fixed dose combinations for high risk

patients; many trials in several countries: improved adherence, improved RF control,

data on mortality ongoing (Law, Yusuf, etc)

• Ensuring adherence of HCPs to guidelines (yet generally in high income

countries, e.g. AHA Get with the Guidelines, many papers)

• Increasing availability and affordability of key interventions (FHP Brazil):

few studies in LICs, but ecological evidence from LIC to HIC for secondary

prevention of other diseases (e.g. HIV, TB), eg, case study in Egypt (PEPFAR)

• Helping patients to adhere to recommendations: challenging since life long

(and often few symptoms): need for behavior change (Rashid et al, review, Ann

Fam Med 2014;224-32; use text messages (not definite evidence yet)

– Important area for further studies in LICs/Africa (discount future events,

role of individual vs family/community, etc)

• Strengthening governance structures and stewardship and commitment,

e.g. Australian National Secondary Prevention Alliance: 19 organizations

involved in healthcare, consumer, gov and non gov)

• Strengthening health information systems (registers in HIC; LMIC: periodic

surveys, including building on surveillance mechanisms existing ones)

Selected successful examples (2/2)

*Prevention*

Population

wide

strategies

to reduce

the level of

exposure to risk

factors in the

population

**Management*

Individual

(clinical) based

strategies

Strengthen health

care for people

with NCDs

"Best buy" Interventions Risk factor / disease

- Raise taxes on tobacco

- Protect people from tobacco smoke (smoking bans)

- Warn about the dangers of tobacco (health warnings)

- Enforce bans on tobacco advertising

Tobacco use

- Raise taxes on alcohol

- Restrict access to retailed alcohol

- Enforce bans on alcohol advertising

Harmful use of alcohol

- Reduce salt intake in food

- Replace trans fat with polyunsaturated fat in foods

- Promote public awareness about diet and physical activity

Unhealthy diet and

physical inactivity

- Multi-drug therapy for people with medium-high risk of

developing heart attacks and strokes

- Treat heart attacks with aspirin

Cardiovascular disease

and diabetes

- Hepatitis B immunization to prevent liver cancer

- Screening and treatment of pre-cancerous lesions to

prevent cervical cancer Cancer

Emphasis on CVD secondary prevention is supported by WHO NCD Global Action Plan 2013-2020 : “best buys”

UN General Assembly. Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. A/66/L.1. 16 September 2011. http://www.un.org/ga/search/view_doc.asp?symbol=A/66/L.1

Halt the

rise in

diabetes

and

obesity

A 10% relative

reduction in

prevalence of

insufficient

physical

activity

At least a 10%

relative

reduction in

harmful use of

alcohol

A 25% relative reduction in

risk of premature mortality

from CVD, cancer, diabetes

or chronic respiratory

diseases

An 80%

availability of affordable basic

technologies

and essential

medicines,

incl. generics,

to treat NCDs

A 30% relative

reduction in

prevalence of

tobacco use

A 30%

relative

reduction in

mean pop.

intake of salt

A 25% relative

reduction in

prevalence of

high blood

pressure

At least 50% of

eligible people

receive drug

therapy and

counselling to

prevent heart

attacks and

strokes

Consistency of WHF roadmap with WHO global NCD targets agreed by all countries at the World Health Assembly (2025 vs 2010)

Goal 3: Ensure healthy lives and promote well-being for all at all ages

Target 3.4: By 2030, reduce by 1/3 premature mortality from NCDs

Target 3.a Strengthen the implementation of the FCTC in all countries

Target 3.b Support research and development of vaccines and

medicines for the communicable and non communicable diseases that

primarily affect LMICs

Target 3.8: Achieve universal health coverage, including financial risk

protection, access to quality essential health-care services and safe,

effective, quality and affordable essential medicines and vaccines for all

Focus on high CVD risk is supported by Sustainable Development Goals agreed in Sep 2015 at WA (2016-2030)

Population and individual-based approaches are

mutually beneficial

• Need to improve the currently unacceptably low uptake of cost

effective secondary prevention interventions in LMICs.

• Strengthen the role of primary care providers in CVD sec. prevention.

• Task sharing: allow non-specialized workers to prescribe priority Rx.

• Develop simple and practical (and context sensitive) guidelines.

• Promote good quality, low cost and affordable generic medications.

• Use fixed-dose combinations to simplify Rx and increase adherence.

• Ensure priority interventions are available down to community levels.

• Provide financial/social support for patients to purchase priority Rx.

• Use IC technology to support clinical decision making by HWs.

• Use IC technology to increase patient adherence.

• Develop simple information systems for patients with known CVD.

• Establish/ strengthen accountable governance structures from

ministerial to the primary healthcare level.

Conclusions: WHF roadmap underlies one way

forward to improve CVD secondary prevention

Next steps

• Create a national coalition to achieve 25 x 25 objective led by WHO

• Perform situation analysis in different contexts

• Epidemiological profile (CVD, risk factors)

• Health system assessment (resources, financing, governance, delivery)

• Policy mapping (national plans, laws)

• Rapid reviews, secondary data analysis and interviews

• Produce situation analysis reports and follow up on them

• Policy dialogues

• Stakeholders mapping

• Discuss roadmaps solutions and roadblocks in the context of situation

analyses

• Produce specific regional/national roadmaps and update them

Thank you !

With acknowledgements to WHF, Pablo Perel, Salim Yusuf and WHO for content of some slides