Man anaging ging CVD VD in in In Indonesia: donesia: How ow - - PowerPoint PPT Presentation

Anwar Santoso

• Dept. of Cardiology – Faculty of Medicine; Universitas Indonesia

National Cardiovascular Centre – Harapan Kita Hospital Immediate Past President of IHA Jakarta - Indonesia

Man anaging ging CVD VD in in In Indonesia: donesia:

How

• w wel

ell l ar are e we e doi

• ing

ng an and whe here e ca can n we e im improve? e?

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

10 20 30 40 50 60 High TC High LDL-C Low HDL-C Male Female

Pr Preval alen ences ces of Dy Dyslipidemia emia in Indon donesi esia

(Basic sic Health lth Resear search h - 2007) 7)

Recrui uited ted 19.114 person son-ac across

• ss 438 district

stricts s

(Indonesian Basic Health Research – 2007)

37.6

(percentage)

41.5 40.6 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

34,2 36,3

10 20 30 40

2007 2013

Series 1

Year %

%

Indonesia Basic Health Research – 2007 & 2013

Ho How w to to me measur asure e im impa pact ct of CV V pr prevention? ention?

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

• f 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 Population attributable fraction 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

Pr Propor

• rtion

tion of Mortal tality ity Rate te in Indon donesi esia (B (Bas asic c Hea ealth th Res esea earch h – 2007) 2007)

(Indonesia Ministry of Health Affair– 2007)

10%

Cause use of

• f mo

morta tali lity ty in in SE SEA Regio gion

Annual ually y + 7.9 million NCD’s attributable death (55% 5% of all l mortality) lity)

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

CAD

Peripheral Vasc Disease Cerebrovascular Disease

All cause use mor

• rtal

ality ity rate e in SEA SEA =14.5 .5 million ion/year /year

Hu Hurdles dles in in pr preventing enting CV CVD? D?

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 SPOKES

20 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 par tner w ith Medtr

• nic

Alternative Referral Main Referral

iSTEMI NETWORK PILOT PROGRAM

West Jakarta

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

Courtesy: Soeryanata S 2016

iSTEMI Network + Tertiary Facility

West Jakarta (2 Years)

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

STEMI N= 2433 (38.5%) Reperfusion N=1394 (57.2%) Fibrinolysis N= 283 (20.3%) PPCI N= 1059 (75.9%) Autolysis N=52 (3.8%) No Reperfusion N= 1039 (43.8%) UAP/NSTEMI N= 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 Rate

Reperfusion vs Without Reperfusion

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

P-value= 0.001 OR= 0.46 (0.31 to 0.67) 95% CI P-value= 0.001 OR= 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%

2000 1980

Ford, ES et.al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. NEJM 2007; 356: 2388.

Change in numbers of deaths

+

• 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 Pri rima mary ry Prevention ention co cost t ef effectiv ective? e?

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

LEADE DERSHI RSHIP

• National
• nal leader

dershi hip

• Improve
• ve awareness

eness

• Partnershi

nership

PREVENTIO VENTION

• Prev

reven entio ion n for r high gh risk popula pulatio ion

• Ris

isk asses essmen ent model del

• Com
• mmun

unit ity, work rkin ing g site and nd env envir iron

• nmen

ent

MANAGEMENT AGEMENT

• Nat

atio ional nal adv dvoc

• cat

ation ion progra rogram

• Prom

romotio ion n prog

• gra

ram

• Capac

apacit ity buildin ilding

RESEARCH ARCH

• Publ

blications

• ns
• Financ

ancial al suppor pport

• Comprehens

ehensive e planni nning ng

Populat ulation ion with NCD NCD High-risk isk populat pulation ion

Indonesian Heart Association Guidelines 2013 - 2015

ACS Guideline CHF Guideline AF Guideline

CVD Prevention in Women Guideline

Dyslipidemia Guideline Hypertension 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/

• besity

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 Factor National System Response Regional Target

Thank You