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WHO 心血管病管理建议 刘力生

WHO 心血管病管理建议 刘力生. International Society of Hypertension Meeting Prevention of Hypertension and Associated Disease Anatalya – Turkey 2-4 April 2006. How WHO can help Shanthi Mendis MD FRCP FACC Senior Adviser, Cardiovascular Diseases World Health Organization.

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WHO 心血管病管理建议 刘力生

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  1. WHO心血管病管理建议刘力生

  2. International Society of Hypertension Meeting Prevention of Hypertension and Associated Disease Anatalya – Turkey 2-4 April 2006

  3. How WHO can help Shanthi Mendis MD FRCP FACC Senior Adviser, Cardiovascular Diseases World Health Organization

  4. WHO has received several global mandates from its governing bodies to take action • Global Strategy for Prevention and Control of NCDs • Global Strategy on Diet, Physical Activity and Health • WHO Framework Convention on Tobacco Control. These provide the basis for taking international action WHO Mandate

  5. Provide scientific and technical leadership • Articulate evidence-based policy options • Set norms and standards WHO's fundamental role

  6. Population wide approach High risk approach How do countries achieve the correct balance ?

  7. High Risk Strategy Population Strategy ...

  8. Per capita expenditure on health (International dollars ) Expenditure Number of countries 33 25 72 24 19 18 Less than 50 $ 50 – 99 100-499 500-999 1000-1999 >2000

  9. Sri Lanka China Indonesia Myanmar Nigeria Out of pocket expenditure on Health Developing Developed 15% 10% 14% 15% 16% Canada UK Norway New Zealand Australia 45% 62% 70% 82% 79% Poverty 25-33% Financing systems .

  10. Public health vs Curative care • Primary HC vs Tertiary • Peripheral vs Central Imbalance

  11. Imbalance • Insufficiency • Inefficiency • Inequalities Barriers

  12. Strengthen health systems (equitable and responsive) • Health prioritised (within development and economic policies) • Design CE strategies (respond to diverse and evolving needs) • Mobilize more resources for health • Improve quality of health data for monitoring Major challenges

  13. A renewal of primary health care • Support a policy of universal Access to HC • Integrate care of CVD into PC Primary Health Care

  14. Advocate sustainable approaches • Look beyond health- to broad determinants (education, poverty, gender, environment) • Position right to health as a human right (new initiative to scale up Rx) Strategies

  15. Poor availability of medicines in the public sector

  16. Beclomethasone inhaler Affordability ;No of days wages Sri Lanka 1.7 Nepal 4.2 Malawi 1.1 Salbutamol inhaler Sri Lanka 0.6 Pakistan 0.6 Nepal 1.2 Malawi 2.8 Insulin zinc or isophane (40 IU/day) Sri Lanka (innovator) 6.1 Pakistan 4.7 Nepal 2.4 Malawi (innovator) 19.6 Glibenclamide Sri Lanka < 0.1 Pakistan 0.5 Malawi 0.5 Aspirin + statin +, +ACEI+Atenolol Sri Lanka 1.5 Nepal (public) 5.4 Pakistan 6.1 17.4 Malawi 0 5 10 15 20

  17. Advocacy; global and regional • Promote intersectoral collaboration • Position CVD/NCD within CCS • Technical assistance for upstream policy • Articulate CE and evidence based (quality) care • Strengthen capacity at country level • Align health with development WHOs role

  18. International Society of Hypertension Meeting Prevention of Hypertension and Associated Disease Anatalya – Turkey 2-4 April 2006

  19. Cardiovascular Risk Assessment -in Low Resource Settings Shanthi Mendis MD FRCP FACC Senior Adviser, Cardiovascular Diseases World Health Organization

  20. Context WHO/ISH Collaboratıon Translatıng evıdence ınto actıon Future actıvıtıes Potantıal to strengthen collaboratıon

  21. Context • WHA resolutıon 2000 : NCD preventıon & control • 1 Populatıon based and upstream actıvıtıes • Framework conventıon on tobacco control • Global strategy for dıet, physıcal actıvıty & health • Socıoeconomıc determınants of health • Maınstreamıng health ın the development agenda • 2 Strategıes targetıng hıgh rısk groups (down stream)

  22. Global Cardiovascular Disease Burden 17 million global deaths due to CVD ¾ in Developing Countries FOCUS

  23. Unhealthy diet • Physical inactivity • Smoking Cardiovascular risk 75% of strokes and HA explained • Hypertension • Diabetes • Hypercholesterolemia • Age • Gender

  24. WHO / ISH collaboration Categorıes of rısk Rısk stratıfıcatıon

  25. Context WHO/ISH Collaboratıon Efforts to fınd solutıons so far Future actıvıtıes Potantıal to strengthen ISH collaboratıon

  26. Introduce multiple risk factor approach to low resource settingsWHO CVD-Risk Management Package • Model for integrating absolute risk approach to PHC • PHC settings with NPH or Physicians • Categories of risk used (simple) • Hypertension or diabetes used as entry point • High risk patients are referred to next level (Safe)

  27. Subject X 60 old man BP 140/100 TC 5.9 Non Smoker Diabetes CVR > 30% Subject Y 60 year old man BP140/100 TC 5.9 Non smoker No diabetes CVR < 10% Quantifying Cardiovascular Risk Specialist physician vs PHC Physician 10

  28. Brazil Bangladesh Chile China India Indonesia Kenya Malawi Mozambique Sri Lanka Tunisia Scenario 1 –PHC

  29. Barriers Cardiovascular Risk Management Implementing in PHC a challenge Competency of HCP Weak infrastructure (Access, lab facilities) Limited financial resources Disorganised referral systems BPMD

  30. `

  31. Most ımportant barrıers • Matchıng avılable reources wıth prıorıtıes and what ıs feasıble • Makıng decısıons regardıng cutoffs for ınterventıon

  32. One solutıon • Inadequate investment in health • Efficient use of limited (public sector ) resources • Target those likely to benefit most; higher risk groups

  33. Traditionally, by thresholds of individual risk factors, e.g. systolic blood pressure ≥ 140mmHg Take into account the role of multiple risk factors as well as the continuous nature of risk Absolute risk of CVD, e.g. risk prediction equations based on the Framingham Heart Study Targeting individuals with high-risk of CVD

  34. Italian, German, British, Spanish, North Am, Chinese • 10 year risk • CHD and CeVD • Fatal and Non Fatal • Diabetes • SBP/TC/Smoking/Age/gender/ • 14 WHO regions (3 in AMR & EUR) WHO Risk Prediction Charts

  35. Cardiovascular risk levels(10 year combined AMI and stroke risk ) < 10% 10-20% 20-30% 30-40% >40% Very low Low Moderate High Very high

  36. WHO sub-regions

  37. 20

  38. Methodology for WHO Risk Prediction charts • WHO Comparative Risk Assessment study 2002 • Risk factor prevalence and RR (14 regions) • Global Burden of Disease Study 2000 • Effectiveness and costs of interventions to lower SBP and cholesterol (Murray et al 2003)

  39. CVD risk threshold for intervention(polıcy decısıon) • High resource setting >20% • Medium resource setting >30% • Low resource setting >40%

  40. Risk Prediction charts compliment PP GL • More accurate assessment of risk • Target limited resources to those most likely to benefit • Assist in drug treatment decisions for primary prevention • Motivate patients to change risky behaviour by risk communication • Helps physician to monitor progress of risk management

  41. Risk Prediction charts (Caveats) • For WHO regions with no cohort data /resources for development of population specific charts • Accuracy relates to the background risk of the population • Need to be validated • True risk in low risk populations is likely to be overestimated (unnecessary treatment) • In high risk populations such as diabetics CV risk underestimated

  42. CVR >30% Persistent BP >130/80 eligible Unless compelling indication least expensive (thiazide, ACEI, CCB, BB) Persistent TC >4.0 mmol/l use least expensive statin Persistent FBG >6mmol/L Low dose aspirin CVR 20-30% Persistent BP >140/90 eligible Unless compelling indication least expensive (thiazide, ACEI, CCB, BB) Persistent TC >4.5 mmol/l least expensive statin Persistent FBG >6mmol/L (Aspirin not recommended) Recommendations for drug Rx

  43. CVR 20-30% Persistent BP >140/90 eligible Unless compelling indication least expensive (thiazide, ACEI, CCB, BB) Persistent TC >4.5 mmol/l use least expensive statin Persistent FBG >6mmol/L CVR <20% Persistent BP >140/90 eligible If resources permit as for moderate risk least expensive (thiazide, ACEI, CCB, BB) Persistent TC >5.0 mmol/l least expensive statin if resources permit Persistent FBG >6mmol/L) Recommendations for drug Rx

  44. CHD / CeVD • Diabetes with nephropathy • Markedly elevated single RF (BP 170/100, TC 8 mmol/l ) • LVH or hypertensive retinopathy Risk assessment not required for treatment decisions

  45. Context WHO/ISH Collaboratıon Efforts to fınd solutıons so far Future actıvıtıes Potantıal to strengthen collaboratıon

  46. Target those at high risk • Assess and predict risk better • Make evidence based treatment decisions • Improve quality of care, health outcomes • Non drug treatment / aggressive treatment • Motivate patients • Accurate BPMD Some solutıons

  47. WHO / ISH collaboration First PP guideline / Risk charts Peer review in 2 weeks Validation of charts Implementation

  48. ` THANK YOU

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