[PPT] - Understanding CVD drivers trends and policy options to improve CVD PowerPoint Presentation

SLIDE 1

Professor Martin O’Flaherty

Department of Public Health and Policy University of Liverpool moflaher@iverpool.ac.uk @moflaher

Understanding CVD drivers trends and policy

ptions to improve CVD health.

SLIDE 2

In this talk

The determinants of CVD mortality associated with both treatment

and lifestyle (i.e. what proportion is due to treatment versus lifestyle/prevention)

An overview of evidence in high-income countries on population-level

policy strategies (including the IMPACT model)

Reflecting on the consequent implications for policy action.
Lag times and speed
Impact on other diseases
Impact on health equity

SLIDE 3

20+ years of continuous decline in CVD mortality in EU countries

Graph shows standardized death rates due to all CVDs, people aged 25-74

Capewell & O’Flaherty Eur Heart J 2011

SLIDE 4

But in Eastern Europe, trends went up and then, abrupt decline

Graph shows standardized death rates due to all CVDs, people aged 25-74

Capewell & O’Flaherty Eur Heart J 2011

SLIDE 5

The “Rapid Changes” evidence

Recent flattening (and reversals) of CHD

mortality rates in young adults

Trials on hypertension and blood lipid

treatment showing effects within months

Healthy diet trials show results within months
Sudden reversals in Central European countries

(IMPACT Poland ,Czech Republic Slovakia)

Natural experiments:
Cuba special period 1990-2000
Norway & Dutch starvation winters in WWII
Implementation of Smoking Bans

Capewell & O’Flaherty Lancet 2011 Capewell & O’Flaherty Eur Heart J 2011 5

SLIDE 6

The “Rapid Changes” evidence

Recent flattening (and reversals) of CHD

mortality rates in young adults

Trials on hypertension and blood lipid

treatment showing effects within months

Healthy diet trials show results within months
Sudden reversals in Central European countries

(IMPACT Poland ,Czech Republic Slovakia)

Natural experiments:
Cuba special period 1990-2000
Norway & Dutch starvation winters in WWII
Implementation of Smoking Bans

Capewell & O’Flaherty Lancet 2011 Capewell & O’Flaherty Eur Heart J 2011 6

WHAT DRIVES THESE RAPID CHANGES?

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Understanding trend drivers

SLIDE 8

SLIDE 9

The IMPACT CHD Model

Deaths observed deaths time

SLIDE 10

The IMPACT CHD Model

Deaths observed Deaths EXPECTED if rates stay the same

SLIDE 11

The IMPACT CHD Model

Deaths observed Deaths postponed Deaths EXPECTED

SLIDE 12

The IMPACT CHD Model

Deaths observed

Deaths prevented or postponed

Deaths EXPECTED A mathematical model that integrates evidence on

Demographics
Risk factor trends
Treatment trends
Validated

And takes into account how uncertain we are about the science.

SLIDE 13

The IMPACT CHD Model:

Change attributed to MEDICAL CARE Change attributed to RISK FACTORS changes in the population unexplained

Blood pressure Blood cholesterol Diabetes Obesity Smoking Physical Activity

Risk factor at pop level

Acute Coronary Statins Hypertensi

n Rx

Revasculari zation Secondary Prevention Heart Failure

Treatments

SLIDE 14

The IMPACT FAMILY OF MODELS AROUND THE WORLD

IMPACT CHD IMPACT FOOD IMPACT STROKE IMPACT DIABETES IMPACT USPTREAM IMPACT NCD IMPACT BAM IMPACT WORKHORSE

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Countries formerly at high risk and decreasing CHD mortality trends, Risk factors explained ~70% of the fall in deaths Countries with medium risk and decreasing CHD mortality trends: Risk factors explain ~50-60% of fall in deaths Countries with INCREASING CHD mortality trends, Risk factors explain ~70% of the rise in deaths

Here, There and Everywhere:IMPACT MODELS AROUND THE WORLD

We know what drives heart attacks trends in most populations.

SLIDE 16

IM IMPACT: CHD mort

rtali lity fall ll Poland 1991-2005

P. Bandoz et al BMJ 2012

Change attributed to MEDICAL CARE Change attributed to RISK FACTORS changes in the population unexplained

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IM IMPACT: CHD mort

rtali lity fall ll Poland 1991-2005

1991 26,200 fewer deaths in 2005 

Risk Factors worse +7%

Obesity (increase) +4.5% Diabetes (increase) +2.5%

Risk Factors better -66%

Cholesterol (diet)

39%

Smoking

11%

Physical activity

10%

Population BP fall 0% (Men Women)

Treatments -38%

AMI treatments

5 %

Unstable angina

4%

Secondary prevention

7%

Heart failure

12%

Angina: CABG surgery

2%

Angina

1 %

Hypertension therapies

2%

Statins (Primary prevention)

3%

Unexplained

10%

2005

P. Bandoz et al BMJ 2012

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500

500 1000 1500 2000

1999

Chole lesterol 77%

Diabetes 19% BMI 4% 4% Smok

kin

ing 1%

370 370 FEW FEWER DE DEATH THS BY Y TRE TREATMENTS AMI AMI tr treatments 41% Hyp Hypertension tr treatment 24% Sec Secondary ry pr preventio ion 11% Hea Heart fai ailu lure 10% 10% As Aspi pirin in for

r Ang

Angin ina 10% Ang Angin ina:C :CABG & & PTCA CA 2% 2%

IM IMPACT model: CHD mortality RIS ISE in in Beijin

ijing

1984 – 1999

1984

Critchley, Capewell et al Circulation 2004 110: 1236-1244

Trends The Model Drivers: High Risk Drivers: Low Risk Drivers: Cent Europe Drivers: Rising deaths Drivers: Over time Conclusions

In In 1999 1999: 1820 1820 EX EXTRA DE DEATHS ATTRIBUTABLE TO RI RISK FACT CTOR CHA CHANGES

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Syria and Tunisia: In Increasing CHD mortality

Treatments Risk Factors

20
10

10 20 30 40 50 60

Acute Myocardial Infarction (AMI) Unstable Angina Secondary Prev Post AMI Secondary Prev Post CABG/PCI Chronic Angina Hospital Heart Failure Community Heart Failure Hypertension Treatment Statins primary prevention Smoking SBP (mmHg) Cholesterol (mmol/l) BMI (kg/m2) Diabetes % Physical inactivity%

% of observed DPPs Tunisia Syria

Trends The Model Drivers: High Risk Drivers: Low Risk Drivers: Cent Europe Drivers: Rising deaths Drivers: Over time Conclusions

SLIDE 20

Key drivers of NCDs in UK 1990 – 2016

40% 19% 9% 2%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

SLIDE 21

Key drivers of NCDs in UK 1990 – 2016

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THREE “HOW TO” QUESTIONS

Reduce CVD Burden
Reduce the equity gap
Reduce stress in health care

systems

SLIDE 23

Tackling unhealthy food and smoking with fiscal & regulatory policies