THE ATLAS OF
HEART DISEASE
AND STROKE
DR JUDITH MACKAY AND DR GEORGE A. MENSAH
Published by the WORLD HEALTH ORGANIZATION
in collaboration with the CENTERS FOR DISEASE
CONTROL AND PREVENTION
The Atlas of
Heart Disease
and Stroke
World Health Organization Geneva
In the same series:
The Tobacco Atlas
Inheriting the World: The Atlas of Children's Health and the Environment
The Atlas of
Heart Disease
and Stroke
Dr Judith Mackay and Dr George A. Mensah
Wl
ith
Dr Shanthi Mendis and Dr Kurt Greenlund
World Health Organization
o
Geneva
The Atlas of Heart Disease and Stroke © World Health Organization 2004 All rights reserved
O
First published 2004 1 3 5 7 9 10 8 6 4 2
WHO Library Cataloguing-in-Publication Data
Mackav, Judith. The atlas of heart disease and stroke / Judith Mackay and George Mensah;
with Shanthi Mendis and Kurt Greenlund.
1 .Heart diseases - epidemiology 2 . Cerebrovascular accident — epidemiology
3. Risk factors 4. Atlases I. Mensah, George. II. Mendis, Shanthi.
III. Greenlund, Kurt. IV.Title.
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o o7
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Contents
Foreword
by Dr LEE Jong- Wook, Director-General, World Health Organization 9
Preface 1 1
Acknowledgements 12
About the authors 1 5
CARDIOVASCULAR DISEASE 16
Types of cardiovascular disease 18
Different types of cardiovascular diseases. Global deaths from cardiovascular diseases.
Rheumatic fever and rheumatic heart disease 20
Deaths from rheumatic heart disease. Cases of rheumatic heart disease in children. Deaths among Aboriginal and non- Aboriginal populations in Australia.
Part Two: RISK FACTORS 22
Risk factors 24
Overview of modifiable, non-modifiable and "novel" risk factors. Percentage contribution of leading risk factors to
o o
disease burden. Contributory factors in coronary heart disease and ischaemic stroke.
Risk factors start in childhood and youth 26
Tobacco use in youth. Overweight youth. Over weight trends in the USA.
Risk factor: blood pressure 28
Average systolic blood pressure worldwide. Trends of high blood pressure in USA and India. Changes in blood pressure with age in Gambia, and with education in South Africa.
Risk factor: lipids 30
Cholesterol levels in women worldwide. Trends in cholesterol levels in Beijing, China. Current recommended lipid levels.
Risk factor: tobacco 32
Smoking rates worldwide. Cardiovascular risks of smoking and passive smoking. Smokers' lack of knowledge of the risks.
Risk factor: physical inactivity 34
Physical activity levels: energy expenditure in work, leisure and transport. Time spent seated. Various physical activities with similar health benefits. Physical inactivity by social class in India. Participation in sport in Singapore. Motor vehicle ownership and trends. Ratio of bicycles to cars in China and USA.
9 Risk Factor: obesity 36
Average adult body mass index (BMI) worldwide. Food consumption trends. Apple shape at higher risk of CVD than pear shape.
10 Risk factor: diabetes 38
Prevalence of diabetes worldwide. Diabetes trends to 2030.
1 1 Risk factor: socioeconomic status 40
Socioeconomic influences on cardiovascular risk factors and diseases. Education, income levels and occupation in Canada, China, India, Italy, Saudi Arabia, South Africa, Trinidad and Tobago, Uganda and USA.
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12 Women: a special case? 42
Similar and different risks in women compared with men. Smoking, physical activity and hormone replacement therapy.
Part Three: THE BURDEN 44
1 3 Global burden of coronary heart disease 46
Healthy years of life lost to coronary heart disease. Leading causes of disease burden by sex.
14 Deaths from coronary heart disease 48
Deaths from coronary heart disease. Comparison with other causes of death. Trends in coronary heart disease.
1 5 Global burden of stroke 50
Healthy years of life lost to stroke. Stroke in young people. Risks of the oral contraceptive pill.
16 Deaths from stroke 52
Deaths from stroke. Predictors of death from stroke in Italy. Comparison with other causes of death.
Economic costs 54
Cost of cardiovascular diseases and their risk factors in selected
countries, regions and worldwide. Price of medications
o
compared with cheapest crop available. Lifetime costs of coronary heart disease. Expenditure on cardiovascular medications. Cost of risk factors.
Part Four: ACTION 56
18 Research 58
Number of publications on cardiovascular research by country. Regional research. Clinical trials on humans: cardiovascular disease compared with other health problems. Research funding in the USA: CVD compared with other diseases.
Organizations 60
International and regional organizations involved with
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cardiovascular disease. World conferences on cardiovascular diseases.
Prevention: personal choices and actions 62
Personal choices in lifestyles and behaviours in children, adolescents and adults: stopping smoking, eating more fruit and cereals, reducing salt intake, physical activity, and prevention and control of obesity and high blood pressure.
Prevention: population and systems approaches 64
Noncommunicable disease prevention and control. Availability of basic equipment, medical professionals, and availability, affordability, and local manufacture of drugs. Use of medications in stroke and coronary heart disease. Profiles of Finland, Japan, Mauritius and New Zealand. Dieticians in the United Kingdom promote healthy eating.
Health education 66
World Heart Day participation, themes and trends. Medical activities, physical activities and promotion of healthy diet. Giving up smoking: the International Quit and Win campaign.
Policies and legislation 68
Smoke-free government buildings and private workplaces. The first five countries to ratify the WHO Framework Convention on Tobacco Control (FCTC). National plans for CVD prevention and control. Tobacco, food and nutrition legislation. Smoking ban in the USA led to reduction in heart attacks.
24 Treatment 70
Medication, devices, and operations. Simple secondary prevention. Proportion of patients reaching blood pressure and cholesterol treatment goals. Participation in cardiac rehabilitation. Proportion of people with diabetes treated with medication or diet. Trends in cardiovascular operations and procedures in the USA.
Part Five: THE FUTURE AND THE PAST 72
The future 74
Predictions to 2030 of the cardiovascular disease epidemic, risk factors, economic costs, research, UN Conventions, technology and treatment.
Milestones in knowledge of heart and vascular disorders
History of key events, developments and research, including epidemiology, risk factors, economic costs, inventions and interventions.
BCE-1852 76
1856-1967 78
1969-2004 80
Part Six: World Tables 82
World data tables 84
Glossary 92
Sources 94
Useful contacts 109
Index 1 1 1
Foreword
A message from
Dr LEE Jong-Wook
Director- General
World Health Organization
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11 cart disease and stroke are currently the leading cause of death in all developed countries and in most developing countries. There were approximately 17 million deaths due to cardiovascular disease in 2003 — one-third of all deaths in the world.
It is disturbing to note that at least 75% of deaths from heart disease and stroke now occur in the poorer regions of the world, which also face major threats from communicable diseases. These regions thus suffer under the so- called "double burden" of disease. If preventive action is not taken urgently, heart disease and stroke — which are already major public health problems — will rapidly advance across regions and social classes to reach epidemic proportions worldwide.
We know that the major risk factors for heart disease and stroke are high blood pressure, high blood cholesterol, tobacco use, physical inactivity, unhealthy diet and obesity. Many of these risk factors result from unhealthy lifestyles. These unhealthy lifestyle habits, which are linked to urbanization, often start in childhood and youth, encouraged by the influence of mass advertising and social pressures. This underscores the importance of targeting children and young people in all programmes that aim to prevent heart disease and stroke.
Prevention and control of heart disease and stroke in developing countries represent a challenging task. There are a number of major barriers to progress, including lack of reliable epidemiological information, inaccessibility of health care, shortages of trained manpower and resources, and misconceptions about heart disease and stroke among policy-makers and the public.
However, the good news is that knowledge about the causes of heart disease and stroke is growing, and various countries are gaining experience in translating this knowledge into effective action.
I believe that our efforts to control heart disease and stroke can only succeed if they are focused at country level. Current WHO activities in this area are based on the WHO Global Strategy for the Prevention and Control of Noncommunicable Disease, which was adopted by the World Health Assembly in 2000. Our goals are to:
• provide guidance to countries on policy, legislative and financial measures that can help prevent cardiovascular disease;
• assess and track the magnitude of the cardiovascular disease epidemic and its social, economic, behavioural and political determinants in developing countries;
• reduce cardiovascular risk factors and their determinants and promote cardiovascular health for all age groups;
• strengthen the health care of people with cardiovascular disease by developing norms and guidelines for cost-effective interventions.
To achieve these goals, WHO has developed standardized approaches to strengthen national surveillance systems for key risk factors. Further, WHO has initiated programmes at country level to scale up health care for those with established cardiovascular disease and to introduce affordable and innovative approaches for managing cardiovascular risk factors and cardiovascular disease in low-resource settings.
WHO is also in the process of addressing some of the main risk factors for cardiovascular disease through global action, such as the Framework Convention on Tobacco Control and the Global Strategy on Diet, Physical Activity and Health. These strategies will help countries in their efforts to develop and implement policies to reduce the burden of cardiovascular disease.
We recognize that advocacy, resource mobilization, capacity development, and research are necessary to galvanize global action against the causes of cardiovascular disease. WHO is working with other UN agencies, research institutions, nongovernmental organizations, the private sector and civil society to promote these activities. Together we can move the global public health agenda forward to avert unnecessary deaths and suffering due to this eminently preventable disease.
10
Preface
"We have the scientific knowledge to create a world
in which most heart disease and stroke could be eliminated."
The Victoria Declaration on Heart Health, 1992
"Change before you have to." Jack Welch,
former Chairman and Chief Executive Officer of General Electric, USA (193 5-)
lleart disease and stroke, the main cardiovascular diseases, are truly global epidemics. They deserve the attention of governments, policy-makers, national and international organizations, committed individuals and families everywhere.
Heart disease and stroke are no longer diseases of old men in developed countries. They are also diseases of women, young adults, and even children. They affect the wealthy and the poor. Already they claim more lives in developing than developed countries. The Asian girl on the cover is at risk, as are many children and young adults throughout the world.
o
The risk factors for heart disease and stroke begin in youth, and most can be prevented or controlled. Yet, worldwide, most people who have risk factors are either not treated or are inadequately treated. Special attention to high blood pressure, high blood cholesterol, tobacco and other major risk factors is crucial.
Cardiovascular diseases are more than just health problems: both the diseases and their underlying causes have major financial implications for governments, businesses and individuals. The "globesity" epidemic is causing international concern. The tobacco epidemic is linked to smuggling, big business and politics. If people are to be encouraged to take regular physical activity, commitment is needed from both individuals and society. The prevention and control of high blood pressure and high blood cholesterol require action from governments and the pharmaceutical industry, not just individual patients.
Research achievements in the field of heart disease and stroke have been phenomenal. We know a lot today, but as Goethe put it, "knowing is not enough, we must apply." We must apply what we already know, and translate the best science into practice for the benefit of all, worldwide.
The good news, as stated most eloquently in the Victoria Declaration on Heart Health more than a decade ago, is that we know what we need to do to eliminate most heart disease and stroke. What is needed now is the combination of necessary resources and political will on a global scale to take effective action. Now is the time to act — and to change before we have to.
Judith Mackay, Hong Kong SAR, China George A. Mensah, Atlanta, GA, USA
11
Acknowledgements
Special thanks go to the following WHO staff for their support for this project: Catherine Le Gales-Camus, Assistant Director-General, Noncommunicable Diseases and Mental Health; Robert Beaglehole, Director, Department of Chronic Diseases and Health Promotion; Rafael Bengoa, Director, Health Systems Policy and Operations; and Derek Yach, Representative of the Director-General.
Particular thanks go to the Centers for Disease Control and Prevention (CDC), United States of America, for their generous financial support of this atlas.
For their creativity, artistic talent and innovative suggestions in the design and cartography of this atlas, we would like to thank the Myriad Editions team of Candida Lacey, Corinne Pearlman, Hay ley Ann and Isabelle Lewis.
Sincere thanks go to Pat Butler for her editorial input, and to all colleagues at the World Health Organization: Dele Abepunde, Technical Officer, Cardiovascular
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Diseases, Noncommunicable Diseases and Mental Health;
Timothy Armstrong, Technical Officer, Surveillance and Information for Policy, Noncommunicable Diseases and Mental Health;
Vishal Arora, Noncommunicable Diseases and Mental Health, South East Asia Region (SEARO);
Fabienne Besson, Secretary, Management of Noncommunicable Diseases, Noncommunicable Diseases and Mental Health;
Ties Boerma, Director, Measurement and Health Information Systems, Evidence and Information for Policy;
Ruth Bonita, Director, Surveillance, Office of Assistant Director- General, Evidence and Information for Policy;
Gian Luca Burci, Senior Legal Officer, Office of the Legal Counsel;
Somnath Chatter] i, Scientist, Classification, Assessment, Surveys and Terminology, Evidence and Information for Policy;
Charles Gollmar, Group Leader, School Health and Youth Health Promotion, Noncommunicable Diseases and Mental Health;
Carina Marquez, Technical Officer, Surveillance and Information for Policy, Noncommunicable Diseases and Mental Health;
Colin Mathers, Scientist, Epidemiology and
12
Burden of Disease, Evidence and Information for Policy;
Shanthi Mendis, Coordinator, Cardiovascular Diseases, Noncommunicable Diseases and Mental Health;
Patricia Mucavele, Technical Officer, Nutrition for Health and Development, Noncommunicable Diseases and Mental Health;
Mona Nassef, Secretary, Cardiovascular Diseases, Noncommunicable Diseases and Mental Health;
Chizuru Nishida, Scientist, Nutrition for Health and Development, Noncommunicable Diseases and Mental Health;
Tomoko Ono, Technical Officer, Surveillance and Information for Policy, Noncommunicable Diseases and Mental Health;
Leanne Riley, Scientist, School Health and Youth Health Promotion, Noncommunicable Diseases and Mental Health;
Gojka Roglic, Technical Officer, Diabetes Mellitus, Noncommunicable Diseases and Mental Health;
Jukka Sailas, Scientist, Management Support Unit, Evidence and Information for Policy, Noncommunicable Diseases and Mental Health;
Bakuti Shengelia, Medical Officer, Cardiovascular Diseases, Noncommunicable Diseases and Mental Health;
Kate Strong, Acting Team Coordinator, Surveillance and Information for Policy, Noncommunicable Diseases and Mental Health;
Bedirhan Ustun, Coordinator, Classification, Assessment, Surveys and Terminology, Evidence and Information for Policy;
Pierre-Michel Virot, Audiovisual and Training Team, Information Technology and Telecommunications;
Amalia Waxman, Project Manager, Noncommunicable Diseases and Mental Health.
Thanks to our colleagues at the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), United States of America:
Laurie D. Elam-Evans, Deputy Associate Director for Science, Division of Adult and Community Health;
Wayne H. Giles, Associate Director of Science, Division of Adult and Community Health;
Kurt J. Greenlund, Senior Epidemiologist, Science and Communication Unit, Cardiovascular Health
Branch, Division of Adult and Community Health;
Mary E. Hall, Public Health Analyst, Office of the Director;
Virginia Bales Harris, Director, Division of Adult and Community Health;
Marsha L. Houston, Health Communication Specialist, Cardiovascular Health Branch, Division of Adult and Communitv Health;
Frederick L. Hull, Deputy Chief, Technical Information and Editorial Services Branch, Office of the Director;
Margaret Malone, Deputy Chief, Cardiovascular Health Branch, Division of Adult and Community Health;
James S. Marks, Director.
For their input on particular maps and subjects, we would like to thank the following:
4 Risk factors start in childhood and youth Samira Asma, Associate Director, Global Tobacco Control, Office on Smoking and Health, Centers for Disease Control and Prevention, USA; Jonathan R. Carapetis, Consultant in Paediatric Infectious Diseases, Centre for International Child Health, University of Melbourne, Australia; Gilles Paradis, Division of Preventive Medicine, McGill University Health Center, Montreal, Canada; Neville Rigby, Director of Policy and Public Affairs, International Obesity TaskForce, International Association for the Study of Obesity; Charles W. Warren, Distinguished Consultant /Demographer, Global Tobacco Control, Office on Smoking and Health, Centers for Disease Control and Prevention, USA.
5 Risk factor: blood pressure Yussuf Saloojee, tobacco control advocate, South Africa.
6 Risk factor: lipids Robert Clarke, Clinical Trial Service Unit, Oxford University, United Kingdom; Rory Collins, Clinical Trial Service Unit, Oxford University, United Kingdom.
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7 Risk factor: tobacco Omar Shafey, Manager, International Tobacco Surveillance, American Cancer Society, USA.
8 Risk factor: physical inactivity Krishnan Anand, Associate Professor, Centre for Community Medicine, All India Institute of Medical Sciences, India.
12 Women: a special case? Sandra Coney, women's
health advocate, New Zealand.
18 Research Rory Collins, Clinical Trial Service Unit,
Oxford University, United Kingdom; Hugh Tunstall- Pedoe, Cardiovascular Epidemiology Unit, University of Dundee, United Kingdom (MONICA study). 19 Organizations Children's Heart Link (USA): Karen Baumgaertner, International Programs Associate; John Gushing, International Programs Director. International Association for the Study of Obesity: Neville Rigby, Director of Policy and Public Affairs, International Obesity TaskForce. International Stroke Society: Julien Bogousslavsky, President-Elect; Frank M. Yatsu, Treasurer. World Heart Federation: Carola Adler, World Heart Day Manager; Sara Bowen, Website /IT Manager; Sania Nishtar, Chairman, World Heart Day Committee; Philip Poole-Wilson, President; Janet Voute, Chief Executive Officer.
22 Health education World Heart Federation (as above); Eeva Riitta Vartiainen, Project Manager, International Quit and Win, Finland.
23 Policies and legislation Omar Shafey, Manager, International Tobacco Surveillance, American Cancer Society, USA.
25 The future Rory Collins, Clinical Trial Service Unit, Oxford University, United Kingdom; Anthony Rodgers, Clinical Trials Research Unit, University of Auckland, New Zealand.
26 Chronology Julien Bogousslavsky, President-Elect, International Stroke Society; Rory Collins, Clinical Trial Service Unit, Oxford University, United Kingdom; John W. Farquhar, Stanford Prevention Research Center, USA; David Simpson, International Agency on Tobacco and Health, London, United Kingdom.
We are also extremely grateful to our families for their support during the preparation of this atlas.
For the use of photographs, we would like to thank the
following:
Front cover Amy, Hong Kong © Guy Nowell, Hong
Kong SAR, China, http://www.guynowell.com
Back cover photographs Cardiology operation,
Mauritius © WHO /Harry Anenden; man selling
vegetables, India © WHO /Pierre Virot; man on bench
© iStock/Tomaz Levstek; Woman and girl buying
sweets, India © WHO/Pierre Virot
Part 1 Child health examination, Cuba ©
WHO /Carlos Gaggero
Part 2 Woman cooking, Guatemala © WHO/Armando
Waak
13
Part 3 Cardiology operation, USA © WHO/Jean
Mohr
Part 4 Youth sport, Germany © WHO/Tibor Farkas
Part 5 Adolescent group, Peru © WHO /Julio Vizcarra
Part 6 Man selling vegetables, India © WHO/Pierre
Virot
I Types of cardiovascular disease Heart © Hemera Photo-Objects
4 Risk factors start in childhood and youth Boy
smoking, Seychelles © WHO/Harry Anenden; burger © Hemera Photo-Objects
6 Risk factor: lipids Arteries © American Heart Association; rice bowl © Hemera Photo-Objects
7 Risk factor: tobacco Smoking hand; young people, Canada © WHO/J L Ray; road signs, USA © Corinne Pearlman
8 Risk factor: physical inactivity TV viewer, biker, wheelchair user, woman with push-chair © Hemera Photo-Objects; people on scooter, New Delhi © Candida Lacey
9 Risk factor: obesity Groceries, USA © USDA/ Ken Hammond; apple and pear © Woodrow Phoenix/ Comic Company /British Dietetic Association
10 Risk factor: diabetes Men playing basketball, Finland © WHO /Farkas Tibor
I 1 Risk factor: socioeconomic status Young boy smoking, China © Carol Betson
12 Women: a special case? Hospital patient, Finland © WHO/Tibor Farkas; smoking woman © iStock/ Tan Kian Khoon; obese woman © iStock/Annette Birkenfeld; women walking © iStock/ Leah- Anne Thompson; menopausal woman © iStock/Joseph Jean Rolland Dube
13 Global burden of coronary heart disease Cardiology operation, Mauritius © WHO/Harry Anenden
14 Deaths from coronary heart disease
Cardiology operation, USA © WHO/Jean Mohr; heart © Hemera Photo-Objects
15 Global burden of stroke Pills © iStock/ Amanda Rohde
16 Deaths from stroke Man on bench © iStock/ Tomaz Levstek
17 Economic costs Rice © USDA /Ken Hammond; potatoes © USDA/Ken Hammond
19 Organizations WHO HQ Geneva © WHO/Pierre Virot
20 Prevention: personal choices and actions Salad, USA © Corinne Pearlman; Amv, Hong Kong ©
J ' O O
Guy Nowell; grapefruit, runner © Hemera Photo- Objects
21 Prevention: population and systems approaches Good Heart Food leaflet © British Dietetic Association/ Comic Company; hospital computer, UK © WHO/P Larsen; health examination © WHO /Julio Vizcarra
22 Health Education Posters © World Heart Federation
23 Policies and legislation Singapore bus © WHO/ Tibor Farkas; display, gymnasium, Singapore, © WHO; fried food, USA (bar chart) © Corinne Pearlman; man smoking, Sri Lanka (bar chart) © Garrett Mehl; burger © Hemera Photo-Objects
24 Treatment Man on bike, Finland © WHO/Tibor Farkas
25 The future Woman, Rwanda © WHO/J. L. Ray
Whilst every reasonable effort has been made to contact the copyright holders of images used in the atlas, the authors and publisher will gladly receive information that will enable them to rectify any inadvertent errors in subsequent editions.
14
About the authors
Dr Judith Mackay MBChB, FRCP (Edin), FRCP (Eng)
Dr Judith Mackay is a medical doctor based in Hong
Kong Special Administrative Region, China, and a
Senior Policy Adviser to the World Health Organization.
After an early career as a hospital physician, she became
a health advocate. She is a Fellow of the Royal Colleges
of Physicians of Edinburgh and of London, and an
Honorary Fellow of the Hong Kong College of
Cardiology. Dr Mackay has received many international
awards, including the WHO Commemorative Medal,
the Fries Prize for Improving Health, the Luther Terry
Award for Outstanding Individual Leadership, the
International Partnering for World Health Award, and
the Founding International Achievement Award from the
Asia Pacific Association for the Control of Tobacco.
She is the author of The Tobacco Atlas, The State of Health
Atlas and The Penguin Atlas of Human Sexual Behavior.
Dr George A. Mensah MD, FACC, FACP, FESC
Dr George Mensah is acting director, the National
Center for Chronic Disease Prevention and Health
Promotion, and chief of the Cardiovascular Health
Branch at the Centers for Disease Control and
Prevention in Atlanta, Georgia, USA, and clinical
professor of medicine and cardiology at the Medical
College of Georgia. He is a fellow of the American
College of Cardiology, American Heart Association,
and the European Society of Cardiology, and a
foundation fellow of the Ghana College of Physicians
and Surgeons. Recent honours include the
Distinguished Research Award of the International
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Society of Hypertension in Blacks, the 25th Bernard
Pimstone Memorial Lecturer at the University of Cape
Town in South Africa, and the National Heart
Foundation of Australia Lecturer at the
50th Anniversary Celebration of the Cardiac
Societies of Australia and New Zealand.
15
16
PART 1
CARDIOVASCULAR DISEASE
"When man is serene, the pulse of the heart flows and connects, just as pearls are joined together or like a string of red jade,
then one can talk about a healthy heart."
17
The Yellow Emperor's Canon of Internal Medicine, 2500 BCE
1
"All the knowledge I possess everyone else
can acquire, but my heart is all my own."
Johann Wolfgang von Goethe
The Sorrows of Young Werther 1774
The human heart is only the size of a fist, but it is the strongest muscle in the human body.
The heart starts to beat in the uterus long before birth, usually by 21 to 28 days after conception. The average heart beats about
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1 00 000 times daily or about two and a half billion times over a 70 year lifetime.
With every heartbeat, the heart pumps blood around the body. It beats approximately 70 times a minute, although this rate can
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double during exercise or at times of extreme emotion.
Blood is pumped out from the left chambers of the heart. It is transported through arteries of ever-decreasing size, finally reaching the capillaries in all the tissues, such as the skin and other body organs. Having delivered its oxygen and nutrients and having collected waste products, blood is brought back to the right
O O
chambers of the heart through a system of ever-enlarging veins. During the circulation through the liver, waste products are removed.
This remarkable system is vulnerable to breakdown and assault from a variety of factors, many of which can be prevented and treated. Risk factors will be explored on pages 24 — 43.
Types of cardiovascular disease
2 265 824
Deaths from cardiovascular diseases (CVD)
Number of deaths globally per year from different types of CVD,
bY age / 1868 339
Highest numbers shown
2002
coronary heart disease
stroke
other cardiovascular diseases
hypertensive heart disease
inflammatory heart disease
rheumatic heart disease
996 183
280819
104 116
66542
0-4 years 5-14 15-29 30-44 45-59 60-69 70-79 80+ years
Global deaths from CVD
millions
2002
total deaths: 16.7 million
other forms of
heart disease
2.4m
inflammatory heart disease 0.4m
hypertensive heart disease 0.9m
rheumatic heart disease 0.3m
18
coronary heart disease 7.2m
Coronary heart disease
Disease of the blood vessels
supplving the heart muscle.
Major risk factors High blood pressure,
high blood cholesterol, tobacco use,
unhealthy diet, physical inactivity,
diabetes, advancing age, inherited
(genetic) disposition.
Other risk factors Poverty, low educational
status, poor mental health (depression),
inflammation and blood clotting disorders.
Rheumatic heart disease
Damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria. J— ^— •— •
Congenital heart disease
Malformations of heart structures existing at birth may be caused bv
o -* *
genetic factors or by adverse
exposures during gestation.
Examples are holes in the
heart, abnormal valves,
and abnormal heart
chambers.
Riskfactors
Maternal alcohol
use, medicines
(for example
thalidomide, warfarin) used by the expectant
mother, maternal infections such as rubella,
poor maternal nutrition (low intake of folate),
close blood relationship between parents
(consanguinity).
Other cardiovascular diseases
Tumours of the heart; vascular tumours of the brain; disorders of heart muscle (cardiomyopathy); heart valve diseases; disorders of the lining of the heart.
Other factors that can damage the heart and blood vessel system
Inflammation, drugs, high blood pressure, unhealthy diet, trauma, toxins and alcohol.
Stroke
Strokes are caused by disruption of the blood supply to the
brain. This may result from either blockage (ischaemic
stroke) or rupture of a blood vessel (haemorrhagic stroke).
Riskfactors High blood pressure, atrial fibrillation (a heart
rhythm disorder), high blood cholesterol, tobacco use,
unhealthy diet, physical inactivity, diabetes,
and advancing age.
Aortic aneurysm and dissection
Dilatation and rupture of the aorta.
Riskfactors Advancing age, long- L standing high blood pressure, Mar fan syndrome, congenital heart disorders,
o
syphilis, and other infectious and inflammatory disorders.
Peripheral arterial disease
Disease of the arteries supplying the arms and legs. Riskfactors As for coronary heart disease.
Deep venous thrombosis (DVT) and pulmonary embolism
Blood clots in the leg veins, which can dislodge and move to the
O
heart and lungs.
Riskfactors Surgery, obesity, cancer, previous episode of DVT, recent childbirth, use of oral contraceptive and hormone replacement therapy, long periods of immobility, for example while travelling, high homocysteine levels in the blood.
19
Rheumatic fever usually follows an untreated beta-haemolytic streptococcal throat infection in children. It can affect many parts of the body, and may result in rheumatic heart disease, in which the heart valves are permanently damaged, and which may progress to heart failure, atrial fibrillation, and embolic stroke.
Nowadays, rheumatic fever mostly affects children in developing countries, especially where poverty is widespread. Up to 1 % of all schoolchildren in Africa, Asia, the Eastern Mediterranean region and Latin America show signs of the
o
disease.
Of 1 2 million people currently affected by rheumatic fever and rheumatic heart disease, two- thirds are children between 5 and 15 years of age. There are around 300 000 deaths each year, with two million people requiring repeated hospitalization and one million likely to require surgery in the next 5 to 20 years.
Early treatment of streptococcal sore throat can preclude the development of rheumatic fever. Regular long- term penicillin treatment can prevent rheumatic fever becoming rheumatic heart disease, and can halt disease progression in people whose heart valves are already damaged by the disease. In many developing countries, lack of awareness of these measures, coupled with shortages of money and resources, are important barriers to the control of the disease.
Rheumatic fever and rheumatic heart disease
EL SALVADOI
COSTA Rl
I(JRAS ST KinS a NEVIS | ANTIGUA a BARBUDA
ST VINCENT a GRENADINES (5ST LJ^A A
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01%^* ^H '^TRINIDAD a TOBAGO
PANAMA^! VENEZUELA miYAN;A
COLOMBIA
MA
CAPE VERDE
SEr GAMBIA
GUINEA-BISSAL SIERRA
Deaths from rheumatic fever and rheumatic heart disease in the Aboriginal * and non-Aboriginal populations of Australia
1979-1996
Average age at death
Aboriginal population 3
non-Aboriginal population
Percentage of deaths
67 Years
20
Deaths from rheumatic heart disease
Number of deaths
2002
•
10 000 and above
H 500-999
0-9
•
5000-9999
100-499
no data
•1
1000-4999
| 10-99
H£EA YEMEN
oun
5
^•jyr KENYA
DEM. REP. RIVANDA
Rheumatic heart disease in children
Estimated number of cases in 5 to 14-year-olds reported 2003
136971 153679
Sub-Saharan
Africa
China South-Central Asia Asia (other)
Latin America Eastern Eastern
Mediterranean Europe and North Africa
Pacific Developed
countries
21
/„*
PART 2
RISK FACTORS
"He that eats but one dish seldom needs the doctor."
Old Scottish proverb
23
"The gods are just, and of our pleasant vices
Make instruments to plague us."
King Lear, V.iii. 193 William Shakespeare
(1564-1616)
Over 300 risk factors have been associated with coronary heart disease and stroke. The major established risk factors meet three criteria: a high prevalence in many populations; a significant independent impact on the risk of coronary heart disease or stroke; and their treatment and control result in reduced risk.
Risk factors for cardiovascular disease are now significant in all populations. In the developed countries, at least one-third of all CVD is attributable to five risk factors: tobacco use, alcohol use, high blood pressure, high cholesterol and obesity.
In developing countries with low mortality, such as China, cardiovascular risk factors also figure high on the top 10 list. These populations face a double burden of risks, grappling with the problems of undernutrition and communicable diseases, while also contending with the same risks as developed nations.
Even in developing countries with high mortality, such as those in sub-Saharan Africa, high blood pressure, high cholesterol, tobacco and alcohol use, as well as low vegetable and fruit intake, already figure among the top risk factors.
Some major risks are modifiable in that they can be prevented, treated, and controlled. There are considerable health benefits at all ages, for both men and women, in stopping smoking, reducing cholesterol and blood pressure, eating a healthy diet and increasing physical activity.
24
Risk factors
high blood pressure tobacco use high cholesterol
Leading risk factors
As percentage burden of all diseases 2002
major CVD risk factors • other risk factors
10.2% unsafe sex
5.5% unsafe water, sanitation ft hygiene indoor smoke from solid fuels 3.2% zinc deficiency iron deficiency 3.0% vitamin A deficiency
High-mortality developing countrie
high blood pressure tobacco use | high cholesterol
alcohol obesity
low fruit ft vegetable intake 3.1% underweight 1 .9% indoor smoke from solid fuels 1.8% iron deficiency 1.7% unsafe water, sanitation ft hygiene
Jjsjr * Low-mortality developing countrie
9% high blood pressure
12.2% tobacco use 7.6% high cholesterol 9.2% alcohol obesity
I low fruit ft vegetable intake [ physical inactivity 1.8% illicit drug use 0.8% unsafe sex 0.7% iron deficiency
eveloped countrie
Contributory factors
Percentage contribution of selected risk factors to coronary heart disease and ischaemic stroke 2002
62%
56%
^p low frui physical
31%
ll ll.
M suboptimal systolic blood pressure more than 115 mmHg
high cholesterol low fruit ft vegetable intake inactivity
coronary heart disease ischaemic stroke
Major modifiable risk factors
• High blood pressure
Major risk for heart attack and the most important risk factor for stroke.
• Abnormal blood lipids
High total cholesterol, LDL-cholesterol and triglyceride levels, and low levels of HDL- cholesterol increase risk of coronary heart disease and ischaemic stroke.
• Tobacco use
Increases risks of cardiovascular disease, especially in people who started young, and heavy smokers. Passive smoking an additional risk.
O
•Physical inactivity Increases risk of heart disease and stroke by 50%.
75%
of
C0
•Obesity
Major risk for coronary heart
disease and diabetes. •Unhealthy diets
Low fruit and vegetable
intake is estimated to cause
about 3 1 % of coronary
heart disease and 1 1 % of
stroke worldwide; high saturated fat intake
increases the risk of heart disease and stroke through
its effect on blood lipids and thrombosis. • Diabetes mellitus
Major risk for coronary heart disease and stroke.
ely
ar
to
Other modifiable risk factors
• Low socioeconomic status (SES)
Consistent inverse relationship with risk of heart disease and stroke.
• Mental ill-health
Depression is associated with an increased risk of coronary heart disease.
• Psychosocial stress
Chronic life stress, social isolation and anxiety increase the risk of heart disease and stroke.
Non-modifiable risk factors
•Advancing age
Most powerful independent risk factor for cardiovascular disease; risk of stroke doubles every decade after age 55. • Heredity or family history Increased risk if a first-degree blood relative has had coronary heart disease or stroke before the age of 55 years (for a male relative) or 65 years (for a female relative).
•Alcohol use
One to two drinks per day may lead to a 30% reduction in heart disease, but heavy drinking damages the heart muscle.
•Use of certain medication
Some oral contraceptives and hormone
replacement therapy increase risk of heart disease. 1 Lipoprotein(a)
Increases risk of heart attacks especially in
presence of high LDL-cholesterol. • Left ventricular hypertrophy (LVH)
A powerful marker of cardiovascular death.
1 Gender
Higher rates of coronary heart disease among men compared with women (premenopausal age); risk of stroke is similar for men and women. 1 Ethnicity or race
Increased stroke noted for Blacks, some Hispanic Americans, Chinese, and Japanese populations. Increased cardiovascular disease deaths noted for South Asians and American Blacks in comparison with Whites.
"Novel" risk factors
•Excess homocysteine in blood
High levels may be associated with an increase in
cardiovascular risk. • Inflammation
Several inflammatory markers are associated with
increased cardiovascular risk, e.g. elevated
O
C-reactive protein (CRP).
• Abnormal blood coagulation Elevated blood levels of fibrinogen and other markers of blood clotting increase the risk of cardiovascular complications.
25
"Encased in fat in youth, encased in a
coffin in middle age."
Ancient Chinese proverb
Although cardiovascular diseases typically occur in middle age or later, risk factors are determined to a great extent by behaviours learned in childhood and continued into adulthood, such as dietary habits and smoking.
Throughout the world, these risks are starting to appear earlier. Physical activity decreases markedly in adolescence, particularly in girls. Obesity has increased substantially, not only in Europe and North America, but also in traditionally slender populations such as the Chinese and Japanese. Type 2 diabetes was previously rare in children, but is increasing in adolescents in, for example, North America, Japan and Thailand.
Markers of CVD can be seen in young children. Post-mortems of children who died in accidents have found fatty streaks and fibrous plaques in the coronary arteries. These early lesions of atherosclerosis were most frequently found in children whose risk factors included smoking, elevated plasma lipids, high blood pressure and obesity.
Programmes to address childhood and youth risk factors are mostly confined to developed countries, but urgent action is required worldwide. Families, schools, communities, health professionals, public health officials and policy-makers all need to promote healthy lifestyles in children and young people. Unless the spread of risk factors is stemmed, the world faces an epidemic of CVD.
26
Risk factors start in childhood and youth
Both sexes aged 6 to 1 1 years 6.5°/o
Both sexes aged 12 to 19 years
5.0%
1 0.5%
Overweight trends in the USA
Percentage of young people who are overweight 7976-2000
Overweight youth
Percentage of 15-year-olds who are overweight 7997-7998
selected countries
5.1% W males
^0 females
10.8%
Belgium (Flemish) zech public Denmark
f
o-o
RUS5IAN FEDERATION
CUBA
MEXICO HK^^^B
JAMAICA , \ BELIZE
GUATEMALA 'r.^Sft NEVIS
ELSAIVAOOR • \DURAS ST VINCENT ft _ . -SUTJCIA
COSTA RICA GRENADA nuKMO ft TOBAGO
PANAMA VENEZUELA GUYANA
COLOMBl F 4
•UNISIA LEBANON' "' ^ IS1. REp,
WEST BANk"*" JORDAN LIBYAN AND GAZA ARAB JAMAHIRIYA EGYPT
V
BAHAMAS MEXICO CU6*
^JAMAICA ^ 7GANT'luA>;ftB.!.BUDA
GUATEMALA x \ ST POTS fl NEVIS v ^unNTSfRRAI |UK1 EL SALVADOR hONBURAS S^J™E^- ST LUCIA
COSTARICA GRENADA IRINIDAD ft TOBAGO
PANAMA VENEZUELA GUYANA
COLOMBIA T SL'RINAME
ECUADOR
TUNISIA LEBANON- ISl. REP
MOROCCO j- IRAN
WEST BANK JORDAN LIBYAN AND GAZA KUWAIT
ARAB BAHRAIN^
JAMAHIRIYA EOYPI
MAURITl
' ^X%v SENEGAL
TANIA
%
NIGER NIGERIA
Early starters
Percentage of students, primarily aged 13 to 15 years,
using tobacco
7999-2003
45% and above 300/0-44.9% 15%-29.9% below 1 5% no data
.
^
^™°£ ^ — . ^
I- MYANMAR l^S
OO -<
^J
CAMBODIA VIETNAM PHILIPPINES SRI LANKA PALflu,
N D 0 N E S
Girls
ZIMBABWE
oooo
<> URUGUAY ARGENTINA
SWAZILAND SOUTH AFRICA LESOTHO
27
"There are six flavours and, of them all,
salt is the chief."
Hindu proverb
High blood pressure (hypertension) is one of the most important preventable causes of premature death worldwide. Even a blood pressure at the top end of the normal range increases risk. High blood pressure is defined as a systolic blood pressure (SBP) above 140 mmHg and/or a diastolic blood pressure (DBF) above 90 mmHg.
In most countries, up to 30% of adults suffer from high blood
O
pressure and a further 50% to 60% would be in better health if they reduced their blood pressure, by increasing physical activity, maintaining an ideal body weight and eating more fruits and vegetables .
O
In people aged up to SO years, both DBF and SBP are associated with cardiovascular risk; above this age, SBP is a far more important predictor. Blood pressure usually rises with age, except where salt intake is low, physical activity high, and obesity largely absent.
Most natural foods contain salt, but processed food may be high in salt; in addition, individuals may add salt for taste. Dietary salt increases blood pressure in most people with hypertension, and in about a quarter of those with normal blood pressure, especially with increasing age. A high intake of salt independently increases the risk of CVD in overweight persons.
In addition to lifestyle changes, effective medication is available for control of high blood pressure.
28
Risk factor: blood
pressure
Black non-Hispanic female Black non-Hispanic male
White non-Hispanic male
White non-Hispanic female
Mexican male 125.6 Mexican female 22.
igh blood pressure in the USA
Percentage of people aged 20 to 74 years with blood pressure of 140/90 mmHg or above, or taking anti-hypertensive medicine, age-adjusted / 976-2000
1988-1994
1999-2000
Blood pressure changes with age in the Gambia
7996-7997
\ \
16-24 26-35 36-45 years years years
46-55 56-65 years years
66-75 76-100 years years
High blood pressure by years of education HI I in South Africa
Percentage of people aged 15 and above with blood pressure higher than 160/95 mmHg 7998 female
Blood pressure in India
Average systolic blood pressure
in urban men
aged 40 to 49 years
7942-7997
mmHg
Average systolic blood pressure of people : aged 30 years and above estimated to 2005
mmHg
• data from urban populations only
Risk factor: lipids
High levels of LDL-cholesterol,
o
and other abnormal lipids (fats), are risk factors for cardiovascular disease. Cholesterol is a soft, waxy substance found among the lipids in the bloodstream and in all the body's cells. It is needed to form cell membranes and hormones, and for other bodily functions.
The body can make cholesterol, or it can obtain it from food, especially animal products such as meats, poultry, fish, eggs, and dairy products. Certain saturated vegetable fats and oils, including coconut fat and palm oil, are cholesterol -free but cause an increase in blood cholesterol. Some foods that do not contain animal products may contain trans-fats, which also cause the body to make more cholesterol. Fruit, vegetables and cereals do not contain cholesterol .
Cholesterol is transported around the body in two kinds of lipoproteins: low-density lipoprotein, or LDL, and high- density lipoprotein, or HDL. A high level of LDL can lead to clogging of the arteries, increasing the risk of heart attack and ischaemic stroke, while HDL reduces the risk of coronary heart disease and stroke.
The female sex hormone estrogen tends to raise HDL- cholesterol levels, which may help explain why premenopausal women are relatively protected from developing coronary heart disease.
Current recommended lipid levels
European guideline
less than 5.0 mmol/l less than 3.0 mmol/l
Total cholesterol
LDL-cholesterol
HDL-cholesterol
US guideline
less than 240 mg/dl (6.2 mmol/l)
less than 160 mg/dl (3.8 mmol/l)
1.0 mmol/l or more in males 40 mg/dl (1 mmol/l) or more 1.2 mmol/l or more in females
Triglycerides (fasting) less than 1.7 mmol/l
less than 200 mg/dl (2.3 mmol,
30
Cholesterol
Average cholesterol levels in women aged 30 and above
mmol/litre
estimated to 2005
# data from urban populations only
rf 9
Average cholesterol levels
in men more than 0.4 mmol/litre
higher than in women
Average cholesterol levels
in women more than 0.4 mmol/litre
higher than in men
6.0 and above 5.5-5.99 5.0-5.49 3.0-4.99
no data
Fatty deposits along the inside of artery walls lead to atherosclerosis and narrowing of the arteries.
Trends in cholesterol levels in Beijing, China
Average total cholesterol in people aged 25 to 64 years 5 25
7984-7999
mmol/l
'1999
1996
1996
1984
1993
31
Risk factor: tobacco
"From a short pleasure can come a long
repentance."
French proverb
The public may believe that the major risk from cigarettes is lung cancer, but far more smokers develop cardiovascular disease — mainly heart attacks and stroke. In 1940, a link was identified between cigarette use and coronary heart disease, and there is now a huge body of scientific literature linking tobacco with CVD. The risks are much higher in people who started smoking before the age of 16. Tobacco use, other than smoking, and passive smoking are also implicated as CVD risks.
Smoking promotes CVD through several mechanisms. It damages the endothelium lining of the blood vessels, increases cholesterol plaques (fatty deposits in the arteries), increases clotting, raises LDL-cholesterol levels and lowers HDL, and promotes coronary artery spasm . Nicotine accelerates the heart rate and raises blood pressure.
A gene has been discovered that
o
increases smokers' risk of developing coronary heart disease by up to four times. Around a quarter of the population carries one or more copies of this gene.
Women smokers are at particular risk, with a higher risk of heart attack than male smokers. Women who smoke only three to five cigarettes a day double their risk of heart attack, while men who smoke six to nine cigarettes a day double their risk.
32
Cardiovascular risks of smoking
Percentage increase in risk
100% increase in risk
300%
increase in risk
more than 300%
increase in risk
400%
increase in risk
stroke; coronary
heart disease;
impotence
death from
undiagnosed
coronary heart
disease
Aim
''
peripheral arterial disease
aortic aneurysm
Cardiovascular risks of passive smoking
Adults
Harms, clogs, and weakens arteries Heart attack, angina, stroke
Children
• Reduces amount of oxygen the blood can carry
• Damages arteries
• Earlv-onset atherosclerosis
• Sudden infant death svndrome (cot death)
Smokers don't know the risks of heart attack
Percentage of smokers in the USA
who believe they have higher-than-average i/ftThf heart attack -, 1399
39%
heavy Y4 smokers (40 or
more per day)
ft
"S,
1 <2»>
*$*
'*••'.
DOMINICAN
~^W~ r~*
"'"T VINCENT E, ^ST LUCIA.
GRENABI«S-«0 BARBADOS. COSTA RICA ,,* PANAMA*
MAURITANIA **Al SENEG*
KIIAIKM
UWJGUAv
Men
Smoking prevalence
Percentage of people aged 18 years and above
who smoke
2003 or latest available data
* data from urban populations only
IB 6Qo/o and above B 45o/o-59.9% 300/0-44.9%
— LATVIA — LITHUANIA -BELARUS Y POLAND
• JAMAICA "*'" «EP EMALA STVINCENTE, ^ LUCIA.
GRENADINES^ O B^BOS,
COST*RI" VtNBUBA.
CAMBODIA PHIUPP.NB
URUd AB6ENTINA
Women
8
"Take a stroll after meals and you won't
have to go to the medicine shop."
Ancient Chinese proverb
Industrialization, urbanization and mechanized transport have reduced physical activity, even in developing countries, so that currently more than 60% of the global population are not sufficiently active.
Physical exercise is linked to longevity, independently of genetic factors. Physical activity, even at an older age. can
O '
significantly reduce the risk of coronary heart disease, diabetes, high blood pressure, and obesity, help reduce stress, anxiety and depression, and improve lipid profile. It also reduces the risks of colon cancer, breast cancer and ischaemic stroke.
Doing more than 1 50 minutes of moderate physical activity or 60 minutes of vigorous physical activity a week — whether at work, in the home, or elsewhere — can reduce the risk of coronary heart disease by approximately 30%.
Despite documented evidence of the benefit of physical activity in preventing and treating cardiovascular and other chronic diseases, more than a quarter of a million individuals die each year in the United States because of a "lack of regular physical exercise".
Only 8% of the world's population currently owns a car. Between 1980 and 1998, the global fleet of cars, trucks and buses grew by 80%, with a third of the increase taking place in developing countries.
34
Risk factor: physical inactivity
Sitting
Time spent seated each week,
people aged 18 years and above
2000
selected countries
j/nours 35 hou|
U^!S 29 hours • •
Finland, Italy Netherlands Spain United France Kingdom
Physical activity
The following activities have similar benefits to health:
Washing and waxing a car for 45-60 minutes
Washing windows or floors for 45-60 minutes
Playing volleyball for 45 minutes
Wheeling self in wheelchair for 30-40 minutes
Bicycling 8 km in 30 minutes
Pushing a pushchair 2.5 km in 30 minutes
Walking 3 km in 30 minutes
Swimming laps for 20 minutes
Playing basketball for 15-20 minutes
Physical inactivity by social class in India
Percentage of time spent seated, at work or in spare time, by people aged 25 years and above in two Indian villages 7993-7995
82o/o
69%
27%
D
lowest
6% 6%
CDCD
next lowest next highest highest
37%
r
UNITED KINGDOM omuHK
INLAND
SWEDEN
^u.
•JIIH
GERMANY
BELGIUM -
MflVAKiA LUXEMBOURG ^^
FRANCE ^«a
CROATI
ITAIY SPAIN ff^H PORTUGAL GREECE
BRAZIL
Mf ^
URUGUAY MM|^^B|j^HH|^H|^HHjj^^^^^«|^^HHHHBMB|
Physical activity levels
Energy expenditure per week in work, leisure and transport
MET-mins
2002-2003
1 MET is the amount of energy expended while sitting quietly at rest
H 6000 and above below 1300 ^
HI 3500-5999 no data
Singapore keeps moving
Percentage participation in any form of sport for
at least 20 minutes, on 3 or more days a week, by age
1998
750
^y female
240/0
9 male
16%
11 O/n
^^^^
1 1 /U
16%
32%
25%
9%|
24%
=s 14%
1 6%
Transport
Number of motor vehicles
per 1000 people
7996
selected countries
The global fleet
Number of vehicles 1000 1950-1994, million
2025 projected
630
million
97
81
8
USA Japan Brazil Hong China India Konq
1950 1994 2025
18-29 30-39 40-49 50-59 60-69 years years years years years
35
"Eat less at dinner and you will live to
ninety-nine."
Ancient Chinese proverb
Belt size, abdominal girth and
O
waist-to-hip ratio are useful indicators of obesity. The Body Mass Index (BMI), a measure of weight in relation to height, is commonly used for classifying overweight and obesity.
The risks of cardiovascular disease and type 2 diabetes tend to increase on a continuum with increasing BMI, but for practical purposes a person with a BMI of over 25 is considered overweight,
o '
while someone with a BMI of over 30 is obese. But one size does not fit all. In women, a BMI as low as 2 1 may be associated with the greatest protection from coronary heart disease death. The BMI for observed risk in different Asian populations varies from 22 to 25 kg/m2.
Availability of food, changes in the kind of food eaten, and decreased exercise are presenting humanity with one of its greatest challenges. Low fruit and vegetable intake accounts for about 20% of CVD worldwide. Obese smokers live 1 4 fewer years than nonsmokers of normal weight.
More than 60% of adults in the USA are overweight or obese. Triple-width coffins, capable of holding a 300 kg (700 Ib) body, are in increasing demand. Worldwide, airlines are having to recalculate
O
their passenger "payload" weight. There are 70 million overweight people in China. South Pacific populations used to be physically active and slim, but the region now has some of the world's highest rates of obesity.
Risk factor: obesity
Food consumption
Trends in food consumption in developing and industrialized countries 7964- 7999, 2075 projected kcal per capita per day
Industrialized 29_4Z countries
Developing 2Q54 countries •
1964-66
1974-76
1984-86
1997-99
2015
"If you and three
friends together
weigh more than
360kg, you get a
free bottle of
whisky."
Ichub Club.
fat-themed
karaoke bar in
Bangkok,
Thailand,
2002
Apple shape at higher risk of CVD than pear shape
Waist-to-hip ratio of 0.91 and above is associated with nearly threefold increased risk of coronary heart disease.
Increased CVD risk if: Men
Women
Waist to hip ratio Waist measurement
more than 0.90
more than 101cm (40 inches)
more than 0.85
more than 89cm (35 inches)
Cartoon characters used to promote the WeightWise campaign of the British Dietetic Association.
36
NIGERIA GHANA .CAMEROON
JAfAN REP KOREA
COOK ISLANDS
THAILAND •
PHILIPPINES
N D 0 N E S I A
Men
Body
HiHHH
MALAWI ZIMBABWE
Mass Index (BMI)
Average BMI of people aged 1 5 years and above
estimated to 2005
kg/m2
* data from urban populations only
18-22.9 no data
Women
10
"The urine of diabetics is wonderfully
sweet as if imbued with honey or sugar."
Thomas Willis (1621-1675), physician to
King Charles II, England
Diabetes is a risk factor for coronary heart disease and stroke, and is the most common cause of amputation that is not the result of an accident.
Insulin is a hormone produced by the pancreas and used by the body to regulate glucose (sugar). Diabetes occurs when the body does not produce enough insulin, or cannot use it properly, leading to too much sugar in the blood. Symptoms include thirst, excessive urination, tiredness, and unexplained weight loss.
There are two main types of diabetes. Type 1 diabetes, in which the pancreas stops making insulin, accounts for 10% to 15% of cases. The majority of people with diabetes have type 2 disease, in which insulin is produced in smaller amounts than needed, or is not properly effective. This form is preventable, because it is related to physical inactivity, excess calorie intake and obesity. People with type 1 diabetes need insulin injections to lower blood sugar, but many people with type 2 do not.
At least half of all people with diabetes are unaware of their condition. Diabetes is more prevalent in developed countries, but modernization and lifestyle changes are likely to result in a future epidemic of diabetes in developing countries.
Risk factor: diabetes
CANADA
Lifestyle changes can be more effective than drugs in preventing type 2 diabetes.
GREENLAND (DK)
DOMINICAN
JAMAICA BELIZE
GUATEMALA HONDURAS
EL SALVADOR
HAITI
ST Kins Et NEVIS I
NICARAGUA COSTA RICA
r-. ANTIGUA ft BARBUDA O DOMINICA ST VINCENT ft GRENADINES 0O$T LUCIA
GRENADA 6 O BARBADOS
^ TRINIDAD Et TOBAGO VENEZUELA
GUYANA
COLOMBIA
CAPE VERDE O
SENEGAL
GAMBIA
GUINEA-BISSAU
GUI
SIERRA LEONE
38
Prevalence of diabetes
D
DM
NETH BELGIUM I
LATVIA DENMARK LITHUANIA
BELARUS GERMANY "OWN° "PUBLIC SLOVAK,A "*»**
HI 10%-14.9% 50/o-9.90/o
Percentage of people aged 20 and above Top 5
with diabetes 2000 largest numbers
^_ of people aged 20 and above
15% and above below 5% with diabetes
2000 no data
RnMANIA
.
AUSTRIA HUNGARY FRANCE SWITZ. SIOVENIA BOSNIA ft
S MARINO HERZEGOVINA
"CROATIA ' SERBIA & BULGARIA
-ORRA MONACO ITALY
RUSSIAN FEDERATION
KAZAKHSTAN
TURKEY "\. TURKMENISTAN
Vlfcj TAJIKISTAN
"* CYPRUS SYRIAN ARAB
LEBANON- "EPUBUC ISL REP' AFGHANISTAN
ISRAEL-
LIBYAN ARAB
JAMAHIRIYA
EGYPT
CHAD SUDAN
IRAQ IRAN
SAUDI ARABIA
PAKISTAN
MONGOLIA
C H I
BANGLADESH
MYANMAR
ERITREA YEMEN
DJIBOUTI ETHIOPIA ^
EQUATORIAL CAMEROON GUINEA
GABON
DEM. REP. RWANDA
CONGO CONGO BURUNDI
UNITED REP TANZANIA
COMOROS
MALAWI IBIA
MADAGASCAR ZIMBABWE MAURITIUS
SOUTH AFRICA
SWAZILAND LESOTHl
Diabetes prevalence and trends
c
8.4%
Percentage of people aged 20 and above with diabetes
2000 2030
developed countries
2000 2030
developing countries
4444444-4-4
4 \ +—
39
11
"Wealth is both an enemy and a friend." Nepalese proverb
In developing countries, coronary heart disease has historically been more common in the more educated and higher socioeconomic groups, but this is beginning to change. In industrial countries, such as Canada, the United Kingdom, and the United States, there is a widening social class difference in the opposite direction.
Studies in developed countries suggest that low income is associated with a higher incidence
o
of coronary heart disease, and with higher mortality after a heart attack. The prevalence of risk factors for heart disease, such as high blood pressure, smoking and diabetes, is also higher. The use of medications is lower, especially of lipid-lowering agents and ACE inhibitors, as well as other treatments, such as cardiac catheterization.
The pathways by which socioeconomic status might affect cardiovascular disease include: lifestyle and behaviour patterns; ease of access to health care; and chronic stress.
Risk factor: socioeconomic status
Prevalence of CVD risk factors by education in Canada
Percentage of people aged 1 8 to 74 years with high levels of physical inactivity and high cholesterol, by educational level, age standardized 1986-1992
men
f women
physical inactivity
high cholesterol
secondary school not complete' 47% 46%
secondary school completed 37%
45%
physical inactivity high cholesterol
university degree obtained physical inactivity 37%
high cholesterol
38%
The CVD mortality gap in the USA
Percentage increased CVD mortality
of lowest socioeconomic (SE) group
over highest SE group,
in people aged 25 to 64 years
7969-7998
49%
94%
79%
30% 1969-1970 1997-1998
Prevalence of high blood pressure by income in Trinidad and Tobago
Percentage of women aged 24 to 85 years with blood pressure
of 140/90 mmHg or above, or currently treated
2007
1%
• III ~
less than US$134
US$ 134-267
US$ 268-533
US$ US$ more than
534-1067 1068-2133 US$2133
monthly household income
I
Educational level and obesity in Italy
Percentage increased risk of obesity in people
aged 35 to 74 years, 380%
in comparison
with university graduates
7998
2200/0
I
250%
upper secondary education 60% diploma
no qualification
In China, years of education are more important than occupation, income or marital status in relation to cardiovascular risk factors, especially cigarette smoking.
Smoking and occupation in Uganda
Percentage of women aged 1 5 to 54 years and men aged 1 5 to 59 years
who currently smoke daily by category of work
2000-2007
34%
33%
29%
** ^% ^%
14%
10/Q
0%
3%
agriculture, unskilled self-employed manual
skilled manual
* Smo
sales professional, unemployed technical, (previous managerial, 12 months) clerical
Smoking by years of education in South Africa
Percentage of people aged 15 years and above who currently smoke daily 7998
;f men r women
45o/o
45o/o
39%
35%
33%
25o/o
100/°
jl
8% 9% 8%
no up to 6-7 8-11 12 more than
education 5 years years years years 12 years
Income and obesity in Saudi Arabia
Percentage of people aged 20 years and above with Body Mass Index of more than 30 kg/m2 7990-7993
income less than US$ US$ more than
US$533 533-1066 1067-2133 US$2134
Prevalence of diabetes by income in India
Percentage of people aged 20 years and above with diabetes, by income level 2000
22%
less than
more than
US$111 112-223 US$223
41
12
Women: a special case?
Widespread misconceptions persist about heart disease, often thought to be primarily a disease of middle-aged men. In reality, cardiovascular disease affects as many women as men, albeit at an older age. Many women still believe that they are more at risk from cancer than from heart disease.
Risk factors for CVD are similar for men and women, but tobacco use is more dangerous in women. In addition, high blood triglycerides are an important cause of atherosclerosis in young women, but not in young men. The menopause has no direct effect, but hormone replacement therapy increases the risk of CVD.
Heart disease is under-detected in women, particularly younger women. In developed countries, women are less likely to be referred to a heart specialist, to be hospitalized, to be prescribed medicine or invasive treatment, or to be referred for exercise testing or echocardiography. Women are more likely to enter the medical system with the diagnosis of a second heart attack.
After a first stroke, women are kept in hospital longer, and remain more disabled than men receiving similar care. More research is needed to improve our understanding of the differences in responses to treatment in men and women.
In the interim, however, adherence to the published guidelines for the prevention and control of heart disease and stroke seems prudent.
42
Risk factors
Modifiable risks - risk or prevalence is higher in women than men
Tobacco use (higher risk) High triglyceride levels (higher risk) Diabetes (more prevalent) Obesity (more prevalent) Depression (more prevalent)
Modifiable risks - risk is similar in men and women
• High blood pressure
• High total cholesterol
• Low HDL-cholesterol
• Combined hyperlipidaemia
• Unhealthy diet
• Physical inactivity
• Stress
Risks for women only
• Oral contraceptive use
• Hormone replacement therapy
• Polycystic ovary syndrome
• Risk of heart attack highest early in each menstrual cycle
Non-modifiable risks for men and women
• Advancing age
• Gender
• Heredity
• Ethnicity/race
Smoking
Percentage increase in risk of heart attack in people who smoke in Denmark 7976-7993
60%
ex-smokers light smokers moderate smokers heavy smokers
(1-Hg/day) (15-24 g/day) (>24g/day)
Women who smoke are at
higher risk of heart attack
than men who smoke.
No time to walk
Percentage of women in the United Kingdom aged 15 years and above who do not exercise more because of lack of time or motivation 2003 40%
Walking re coronary heart disease
Percentage reduction in risk of coronary heart disease by non- vigorous walking in women 45 and above in the USA 7992-7999
Hormone replacement therapy
Percentage increase in risk of CVD in healthy women using HRT in the USA 7997-2000
41%
111%
29%
lul
no time not motivated to exercise to exercise
1-59 minutes a week
1-1.5 2 or more
hours hours
a week a week
22%
coronary
heart
disease
stroke
deep
venous
thrombosis
43
PART 3
THE BURDEN
"You don't get to choose how you're going to die, or when. You can only decide how you're going to live now."
Joan Baez, folk singer and activist, USA (1941-)
45
13
"Misfortunes always come in by a door
that has been left open for them."
Czechoslovakian proverb
Disability-adjusted life years (DALYs) lost can be thought of as "healthy years of life lost". They indicate the total burden of a disease, as opposed to simply the resulting deaths.
Cardiovascular disease is responsible for 10% of DALYs lost in low- and middle-income countries, and 18% in high-
O
income countries.
A heart attack occurs when the blood vessels supplying the heart muscle become blocked, starving
O
it of oxygen, leading to the heart muscle's failure or death. Heart attack has the same risk factors as CVD in general. Cold weather.
O
exercise, or strong emotion can precipitate a heart attack.
Coronary heart disease is decreasing in many developed countries, but is increasing in developing and transitional countries, partly as a result of increasing longevity, urbanization, and lifestyle changes.
Risk of heart attack can change when people migrate. Japan has a low rate of coronary heart disease, but after moving to the USA,
O
Japanese people have been found to have a gradually increasing risk. This
O
eventually approaches that of people born in the USA.
Global burden of coronary heart disease
Coronary heart disease burden is projected to rise from around 47 million DALYs globally in 1990 to 82 million DALYs in 2020.
USA
JAMAICA BELIZE HONDURAS
REP
ST KITTS ft NEVIS 0O ANTIGUA ft BARBUDA
EL SALVADOR
NICARAGUA
ST VINCENT ft GRENADINES
COSTA RICA
PANAMA
6RENADA .3 O BARBADOS
'-' TRINIDAD ft TOBAGO VENEZUELA
GUYANA
GUINEA-BISSAU
GUINI SIERRA LEC
46
sase burden in men
Percentage of DALYs lost due to top ten diseases n men aged 15 years and above 2002
HIV/AIDS coronary 7.4% heart disease 6.8%
chronic obstructive pulmonary hearing disease loss. 3.1% adult 2.7%
alcohol
use disorders
tuberculosis 4.2%
ElANP
UNITtD
KINGDOM
MNLAND SWEDEN NORWAY
ESTONIA
LATVIA
LITHUANIA
DENMARK
Healthy years of life lost to coronary heart disc
DALYs lost per 1000 population, age-standardized estimates for 2002
Disability-adjusted life years combine years of potential life lost due to premature death with years of productive life lost due to disability
3 NIGERIA |||
OIRt * 2 CENTRAL AFRICAN •
REPUBLIC EQUATORIAL CAMEROON
GUINEA UGANDA
GABON KENYA
^PRINC^E DEM-REP. RWANDA
CONGO BURUMO,
UNITED REP TANZANIA
MALAWI
ANGOLA
ZAMBIA
ZIMBABWE
NAM'BIA BOTSWANA
MOZAMBIQUE
COMOROS
MAURITIUS
SOUTH
AFRICA LESOTHO
SWAZILAND
AUSTRALIA
unipolar depressive disorders
HIV/AIDS 7.2%
-4-4
coronary heart disease stroke
5.3% 5.2%
Disease burden in women
Percentage of DALYs lost due to top ten diseases in women aged 15 years and above 2002
chronic obstructive cataracts h"ring pulmonary
3'1% ->8% doS™C tuberculosis osteo- diabetes 1.8% 2.7% 26% arthrit.s mdijtus
47
14
"People live with their own idiosyncrasies
and die of their own illnesses."
Vietnamese proverb
Civilization kills. Since 1990, more people have died from coronary heart disease than from any other cause. Unlike stroke, coronary heart disease is a comparative newcomer on the world stage. Variations in death rates are marked: they are lower in populations with short life expectancy.
Heart disease mortality rates are also affected by differences between countries in the major risk factors, especially blood pressure, blood cholesterol, smoking, physical activity and diet. While genetic factors play a part, 80% to 90% of people dying from coronary heart disease have one or more major risk factors that are influenced by lifestyle.
Death rates from coronary heart disease have decreased in North America and many western European countries. This decline has been due to improved prevention, diagnosis, and treatment, in particular reduced cigarette smoking among adults, and lower average levels of blood pressure and blood cholesterol. It is expected that 82% of the future increase in coronary heart disease mortality will occur in developing countries.
Of all coronary heart disease patients who die within 28 days after the onset of symptoms, about two-thirds die before reaching hospital. This highlights not only the need for early recognition of the warning signs of a heart attack, but also the need for prevention.
48
Deaths from coronary heart disease
Despite implements in survival
1 in 4 men^Bi 1 in 3 women still die withir
of a recogn^B first heart attack.
Deaths from coronary heart disease compared with other causes
Number of deaths of people aged 15 to 59 years, and 60 years and over 2002 thousands
CAPE
VERDE MAfl
GUINEA-BISSAUj OUINfl
15-59 years
60 years and above
Deaths from coronary heart disease
Number of deaths from coronary heart disease 2002
1000-9999 T°P 3
highest number of deaths from coronary heart disease
500 000 and above 100000-499999 10 000-99 999
-49%
increase in death rates
Croatia Kazakhstan Belarus Ukraine Romania Japan -10%
Hungary -2% ||+2%
-11% -15% Greece -19% l^HB^l Portugal USA
Netherlands -40% -Mi Sweden
Luxembourg Australia
Denmark decrease in death rates
Change of heart
Percentage change in
coronary heart disease death rates,
in people aged 35 to 74 years
7988-7998
selected countries
women™ men
49
15
"I waked and sat up.. .when I felt a
confusion and indistinctness in my head
which lasted, I suppose about half a
minute. Soon after I perceived that I had
suffered a paralytick stroke, and that my
Speech was taken from me."
Samuel Johnson, England, 1783
Stroke is the brain equivalent of a heart attack. Blood must flow to and through the brain for it to
o
function. If its flow is obstructed, by a blood clot moving to the brain, or by narrowing or bursting of blood vessels, the brain loses its energy supply, causing damage to tissues leading to stroke .
Annually, 1 5 million people worldwide suffer a stroke. Of these, 5 million die and another 5 million are left permanently disabled, placing a burden on family and community. Stroke is uncommon in people under 40 years; when it does occur, the main cause is high blood pressure. Stroke also occurs in about 8% of children with sickle cell disease.
The major risk factors for stroke are similar to those for coronary heart disease, with high blood pressure and tobacco use the most significant modifiable risks. Atrial fibrillation, heart failure and heart attack are other important risk factors.
The incidence of stroke is declining in many developed countries, largely as a result of better control of high blood
o
pressure, and reduced levels of smoking. However, the absolute
O
number of strokes continues to increase because of the ageing population.
Global burden of stroke
CANADA
The increased risk of stroke from taking contraceptive pills is substantially reduced by using the modern, low-dose pill.
EL SALVADOR
NICARAGUA
COSTA RICA
PANAMA
ST VINCENT ft GRENADINES «
GRENADA^ £ T VENEZUELA
J BARBADOS •RINIDAD a TOBAGO
MAURIlB
CAPE VERDE O fl
GAMBIA 2| GUINEA-BISSAU'
COLOMBIA
^ UINI
GUI SIERRA LEO
50
Healthy years of life lost to strol
DALYs lost per 1000 population, age-standardized
2002
Disability-adjusted life years combine years of potential life lost due
to premature death with years of productive life lost due to disability
NETH. BELGIUM GERMANY
IMK.TDIA HUNGARY MOiDOV
AUSTRIA ROMANIA
SWITZ. SLOVtNIA BOSNIA ft ^Kff
HERZEGOVINA
ChVAtt* I SERBIA h _...-.„ MONTENeSROBUlGAI1 ANDORRA' MONACO lwy
1 "" CH'° »•«• "
I NIGERIA
I^H CENTRAL AFRICAN
REPUBLIC ^P^^^pq
OUATORIAL'VEROON GUINEA «
• JKBfl »NYA
': «, ias- —
MARSHALL ISLANDS
•
1
£ KIRIBATI 0 NAURU
9 SAMOA TUVALU A
COOK
h
PHILIPPINES
ISLANDS FUI NIUE ,
VANUATU •^ *
N D 0 N E S I A
^ ^rTMOR-LESTE
Stroke in young people
Number of new cases of stroke per 100 000 people per year selected populations 7986-7997
10
14
AUSTRALIA
26
/ ? ? f ? /
NEW ZEALAND
age 17-49 years 15-44 15-44 Israel Italy Italy
Florence North
0-39 40-49 Kuwait Kuwait
15-40 20-54 11-50
Libyan South Africa Spain Arab Blacks
Jamahiriya
Benghazi
Cantabria
20-44 20-44 20-44
USA USA USA
Northern Northern Northern
Manhattan Manhattan Manhattan
Blacks Hispanics Whites
51
16
Stroke carries a high risk of death.
O
Survivors can experience loss of vision and /or speech, paralysis, and confusion. Historically called "apoplexy", "stroke" is so called because of the way it strikes people down.
Previous stroke significantly increases risk of further episodes. Certain racial, ethnic and socioeconomic groups are also at greater risk of stroke. The most important modifiable cause of stroke is high blood pressure; for every ten people who die of stroke, four could have been saved if their blood pressure had been regulated. Among those aged under 65, two-fifths of deaths from stroke are linked to smoking. Other modifiable risk factors include unhealthy diet, high salt intake, underlying heart disease, diabetes and high blood lipids.
The risk of death depends on the type of stroke. Transient ischaemic attack or TIA — where symptoms resolve in less than 24 hours — has the best outcome, followed by stroke caused by carotid stenosis (narrowing of the
v o
artery in the neck that supplies blood to the brain). Blockage of an artery is more dangerous, with rupture of a cerebral blood vessel the most dangerous of all.
Even where advanced technology and facilities are available, 60% of those who suffer a stroke die or become dependent. Given these dismal statistics and the high cost of treatment of stroke, high priority should be accorded to preventive strategies.
52
Deaths from stroke
Stroke is the second leading cause of death above the age of 60 years, and the fifth leadir cause in people aged 15 to 59 years old.
...
%
DOMINICAN
JAM*'^ Hafliir
'.>
GUATEI
EL SALVADOR^-
ST KITTS ft NEVIS • C
, ANTIGUA Et BARBUDA
:NADAO O BARBADOS
* TRINIDAD it TOBAGO
MAURI™
CAPE VERDE e.
GAMB GUINEA-BISSA
SENM
GUINl SIERRA LEO
420%
Predictors of death from stroke in Italy
Percentage increased risk of death from stroke
in people aged 65 years and above
2007
140%
84%
83%
60%
38%
previous atrial high impaired cigarette coronary stroke fibrillation blood glucose smoking heart pressure tolerance disease
(systolic >163 mmHg)
Number of deaths from stroke 2002
Top 3
highest number of deaths from stroke
200 000 and above 100000-199999 10 000-99 999
1000-9999 below 1000 no data
100/0
stroke
5.5 million
27%
other causes 15.6 million
heart disea 7.2 milli
Total
deaths
57 million
12% cancer 1 million
respiratory infections 3.7 million 5%
HIV/AIDS 2.8 million
Stroke compared
with other causes of death
Percentages and numbers of deaths worldwide from stroke and other leading causes 2002
malaria 1.2 million
3%
tuberculosis 1.6 million
30/0
diarrhoeal diseases 1.8 million
40/0
perinatal causes 2.5 million
5%
chronic obstructive
pulmonary disease
2.7 million
53
17
Economic costs
"The art of economics consists in looking
not merely at the immediate but at the
longer effects of any act or policy; it
consists in tracing the consequences of
that policy not merely for one group but
for all groups."
Henry Hazlitt, USA (1894-1993)
The costs of cardiovascular disease are diverse: the cost to the individual and to the family of heath care and time off work; the cost to government of health care; and the cost to the country of lost productivity.
We attempt here to quantify some of these costs. However, the value of a human life is beyond our analysis.
Global costs of smoking
Health care costs associated with smoking-related illnesses result in a global net loss of US$200 billion per year, with one third of those losses occurring in developing countries. Estimated 1994.
USA, Australia and Europe
2002 reports indicate that up to 10% of health budgets are spent on diabetes-related illnesses.
USA
Latin America and the Caribbean
Permanent disabilities resulting from diabetes cost US$50 billion in 2000, while costs associated with insulin, hospitalization, consultations and care totalled US$10.6 billion.
uiooai COSTS or uiaoeies
Between 4% and 5% of health budgets are spent on diabetes- related illnesses. WHO, 2003
Price of weekly dose of medication
Expressed in kg of cheapest crop available (yam, rice or potato)
2003
selected countries
Mk "*' -"''
Simvastatin 63.0
^P Aspirin
50.6
50.6
38.4
33.6
/ "If just 10% of adults began walking regularly, Americans could save US$5.6 billion in costs related to heart disease." - President George W. Bush, 2002.
The direct costs of physical inactivity accounted for an estimated US$24 billion in health care costs in 1995.
I Health problems related to obesity, such as heart disease and type 2 diabetes, cost the USA an estimated US$177 billion a year.
Cholesterol reducers were the top-sellinc medications in 2003, generating US$13.9 billion in sales.
The American Heart Association estimates that stroke will cost a total of US$53.6 billion in 2004. Direct costs for medical care and therapy will average US$33 billion and indirect costs from lost productivity will be US$20.6 billion.
In 2001, the National Stroke Association estimated that the average cost per patient for the first 90 days after a stroke was US$15 000, although 10% of cases cost more than US$35 000.
30.0
25.7
0.9
Chile
1.5
4.0
1.4
13.9
1.2
0.5
4.2
0.2
1.6
China Egypt Georgia Ghana Indonesia Pakistan Sri Lanka Turkey
54
United Kingdom
stroke
"The direct cost of obesity to the National Health Service is £0.5 billion [about US$0.9 billion] per year, while the indirect cost to the UK economy is at least £2 billion [about US$3.5 billion]." - Liam Donaldson, Chief Medical Officer, 2003
More than 4% of National Health Service spending was on stroke services in 2000.
The economics of CVD
fctto physical exercise
B obesity ^ CVD
cholesterol ^^™* tobacco
Global costs of heart disease medication
The average total costs of care per patient for six months following a stroke were estimated at €16 000 in 2003.
Stroke was estimated to be responsible for 3% of total health care costs in the Netherlands in 1994, and 7% of costs for the population aged 75 and over. Stroke ranked second on the list of most costly diseases for the elderly, after dementia, and these costs are expected to increase by 40% by 2015.
The number of people who die or are disabled by coronary heart disease and stroke could be halved with wider use of a combination of drugs that costs just US$1 4 a year. WHO, 2002
>mgapore
/Average hospital costs for stroke were reported in 2000 as US$5000 per patient. Ward charges accounted for 38%, radiology 15%, doctors' fees 10%, medications 8%, therapy 7%.
The cost of risk factors
Cumulative Medicare costs of treatment of cardiovascular disease in people aged 65 years to death, in the USA
Risk factors: US$38044 US$38059
US$ high blood pressure,
high cholesterol, cigarette smoking, US$18604 abnormal
electrocardiograms,
a history of
diabetes or
previous heart attacks
Lifetime costs of coronary heart disc
US$11 711
men women
low risk no heart disease risk factors
men women
3 or more risk factors
Germany
7996
US$
Total direct costs
Including: primary care, clinical care, rehabilitation
US$48 billion
US$26 billion
Expenditure on cardiovascular medications
Percentage of total annual drug expenditure
7989-7997
OECD countries
Total indirect costs
Lost productivity caused by: short-term and long-term disability, death
Average cost per case: US$82 000
55
-
56
PART 4
"Keeping your body healthy is an expression of gratitude to the whole cosmos, the trees, the clouds, everything."
Most Venerable Thich Nhat Hanh, Vietnamese Buddhist monk (1926—)
57
18
Research
"Science knows no country, because
knowledge belongs to humanity, and is the
torch that illuminates the world."
Louis Pasteur, France (1822-1892)
From the description of how a heart muscle cell contracts to the elucidation of the human genome,
o
scientific advances in basic, clinical, and population research in cardiovascular disease, and their global impact, have been phenomenal. New and improved treatments have become possible, and novel markers of future risk have been identified.
Yet several key challenges remain. There is a widespread lack of research capacity, standardized data, communication networks, and human and financial resources, especially in developing countries.
The MONICA (Multinational MONItoring of trends and determinants in CArdiovascular disease) Project involved teams from 38 populations in 2 1 countries from the mid- 1 980s to the mid-1990s, the largest such collaboration ever undertaken. It was set up to explain the diverse trends in cardiovascular disease mortality observed from the 1970s onwards. The project monitored a study population of 10 million men and women, aged 25 to 64 years.
MONICA was important in measuring levels and trends in cardiovascular diseases and their risk factors in different populations, in monitoring prevention policies in different countries, and in demonstrating the importance of the new acute and long-term treatments that were being introduced.
58
Regional research
Percentage of publications on
CVD by region countries jndexed in Med|ine not assigned
developing countries _
^m
Eastern Europe
BARBADOS
•
• TRINIDAD h TOBAGO
2007
.**
Clinical trials
Number of published clinical trials on humans in any language in the National Library of Medicine's PubMed 2004
1 83 Road traffic accidents
6539
HIV/AIDS Arthritis Stroke
6687 i
6912
9758
Diabetes
22468
ped market onomies SENJ
f GAMBIA 8
78%
Pulmonary diseases
Cancer Coronary heart disease
CVD research publications
••••••^••••••^••••••i
Number of publications on cardiovascular disease indexed in Medline 7997-2007
Top three countries
Research funding by the National
r™*
Institute of Health in the USA
Spending on disease research
on/r:
1
Emerging
^Stroke^^^ $330m
Mental health
$1762m
Biodefense $1554m
infectious I diseases
$1362m
Drug abuse $1023m
Nutrition $1016m
Diabetes $9 10m
59
19
Organizations
"Don't agonize. Organize."
Florynce Kennedy, Lawyer, and Civil and
Womens' Rights Activist (1916-2000)
The World Health Organization's Cardiovascular Disease Programme is conducted through its Geneva headquarters, and regional and national offices worldwide. The World Heart Federation helps people achieve a longer, better life through prevention and control of heart disease and stroke, focusing on low- and middle-income countries.
In addition to the nongovernmental organizations (NGOs) highlighted here, there are many international NGOs - from the World Medical Association to Consumers International — that include cardiovascular disease control as part of their activities.
Only international and regional organizations are shown here. Not mentioned are the many national organizations, whose impact may extend outside their own country, such as the Centers for Disease Control and Prevention in the USA, the British Heart Foundation, and ThaiHealth in Thailand. Other national NGOs also work part time on CVD issues.
There are numerous other partners in a vast arena of varied but related interests, including organizations involved with women, youth, law, economics, human rights, religion and development.
The capacity of virtually all cardiovascular disease control organizations is inadequate to meet the challenge of the CVD epidemic.
60
World Health Organization headquarters, Geneva
Mexico
InterAmerican Society of Cardiology
USA
WHO RO Americas/Pan American Health Organizatic
CardioStart International Inc.
Cardiothoracic Surgery Network
Children's HeartLink
Congenital Heart Information Network
Gift of Life International Inc.
HeartGift Foundation
Heart-to-Heart International
Heart-to-Heart Int. Children's Medical Alliance
International Children's Heart Foundation
International Children's Heart Fund
International Hospital for Children (IHC)
International Stroke Society
Loma Linda University Overseas Heart Surgery Team
Save A Child's Heart Foundation
World Heart Foundation
Heart of the Americas
InterAmerican Heart Foundation
World Conferences on Cardiovascular
World Congresses of Cardiology
1st 1974 Buenos Aires, Argentina
2"(l 1978 Tokvo, japan
V'(1 1982 MOM <m , Russian Federation
4th 1986 Washington, DC, USA
5''1 1990 Manila, Philippines
6th 19^4 Berlin, (ii-i-mam
7th 1998 Rio do Janeiro, Brazil
8th 2002 Svdnov, Australia
l"1' 2006 Barcelona, Spain
International Conferences on Preventive Cardiology
l»t 1985 Mosom, USSR
2nd 1989 Washington, DC, USA
3"! 1993 Oslo, Nor\\a\
4th 1997 Montreal, Canada
5th 2001 Osaka, Japan
6th 2005 Iguassu, Bra/il
United Kingdom
World Federation of Neurology European Heart Institute
Belgium
European Heart Network
CVD organizations
WHO, Headquarters (HQ) and regional offices (RO) International CVD organizations Regional CVD organizations
Denmark
Austria
WHO RO Europe
Furnnpan A<;«;nriatinn for
Switzerland
WHOHQ
Coeurs pour Tous (Hearts for All)
World Heart Federation
•ranee
European Society )f Cardiology
Egypt
WHO RO Eastern Med.
Nigeria
African Heart Network
Congo
WHO RO Africa
China
International Chinese Heart Health Network
Pakistan
Asia Pacific Society of Cardiology
India
WHO RO South-East Asia Initiative for Cardiovascular Health Research in Developing Countries
Philippines
WHO RO Western Pacific Asian Pacific Heart Network
'an African Society )f Cardiology
World Stroke Congresses
!•>' 1989 ' Kyoto, Japan
2nd 1992 Washington, IK , USA
3ri1 1996 Munich, Germany
4th 2000 Melbourne, Australia
5th 2004 Vancouver, Canada
International Heart Health Conferences
2n(l
3r(l
4th
th
1995 1998
2001 2004
Victoria, British Columbia, Canada
Barcelona, Spain Singapore Osaka, Japan Milan, Italv
61
20
"No matter how far you have gone
on the wrong road, turn back."
Turkish proverb
Good control of blood pressure, blood cholesterol and blood sugar levels, and other cardiovascular risk factors is the key to reducing risks of heart disease and stroke.
Personal behaviour and lifestyle choices can make a big difference to the risk of coronary heart disease and stroke. It is estimated that having a high-risk lifestyle may account for 82% of coronary events in women. Here, we identify personal choices that can lower individual risk for heart disease and stroke. The choices apply to young people and adults alike.
Prevention: personal choices and actions
Personal choices in lifestyles and behaviour
1 Take moderate physical activity for a total of 30 minutes on most days of the week.
2 Avoid tobacco use and exposure to environmental smoke; make plans to quit if you already smoke.
3 Choose a diet rich in fruits, vegetables and potassium, and avoid saturated fats and calorie-dense meals.
4 Maintain a normal body weight; if you are overweight, lose weight by increasing physical activity and reducing calorie intake.
5 Reduce stress at home and at work.
Personal actions for safeguarding cardiovascular health Young people
1 Discuss all questions with your health care provider.
2 Have regular check-ups from your health care provider.
3 Have your blood pressure and levels of blood sugar and cholesterol checked. -^
4 Follow your health care provider's instructions regarding physical activity, nutrition, weight management, and any medications you have been prescribed.
5 Know the signs and symptoms of heart attack and stroke and remember that both conditions are medical emergencies.
6 Know your blood pressure and cholesterol level, and keep them at the recommended levels through lifestyle changes and by taking any prescribed medication.
7 Lower your total fat and saturated fat intake in accordance with your health care provider's instructions.
62
1 Actions and choices for children and adolescents with cardiovascular disease, or risk factors, should be discussed with a paediatrician or health care provider.
Choose a diet containing a variety of fruits, vegetables, whole grains, dairy products, fish legumes, poultry, and lean meat.
There is no need to restrict fat intake in children under two years of age.
4 For children over two years and adolescents, limit foods high in saturated fats (to less than 10% of daily calorie intake), cholesterol (to less than 300 mg per day), and trans-fatty acids.
Increase physical activity, and avoid tobacco use or exposure to environmental tobacco smoke.
Eat fruit and cereals
Percentage reduction in risk
with each daily increment of 10 g of dietary fibre
reported 2004
all coronary events ^P coronary deaths _7(y
intzke
30%
14%
Fibre intake
25%
10%
16%
total dietary fibre
cereal
fruit
The benefits of stopping smoking
Time since last cigarette Effect
20 minutes
1 day
3 months
1 year
5 to 1 5 years later
1 5 years later
Blood pressure and pulse rate drop to normal.
Probability of heart attack begins to decrease.
Circulation improves.
Excess risk of coronary heart disease is half that of a continuing smoker.
Risk of stroke is reduced to that of people who have never smoked.
Risk of coronary heart disease is similar to that of people who have never smoked, and the overall risk of death almost the same, especially if the smoker quits before illness develops.
63
21
"Thinking well is wise; planning well,
wiser; doing well wisest and best of all."
Old Iranian proverb
Significant health gains in cardiovascular health can be made within short time spans, through public health and treatment interventions that have an impact on large segments of the population.
As shown here, there is a gap between what is known and what is done in practice, for both prevention and treatment of cardiovascular disease.
Governments are stewards of health resources, and have a fundamental responsibility to protect the health of citizens. Ministries of Health and the health profession can play various roles in reducing CVD, by making data available, educating the public, making treatments affordable and available, advising patients on healthy living practices, and advocating for policy and environmental change. These have been the essential messages of the International Heart Health Conferences and the related declarations on heart health.
UK dieticians promote the benefits for heart health of eating oily fish, more fruit and vegetables, and less saturated fat.
64
Prevention: population and systems approaches
Noncommunicable disease (NCD) prevention and control
Percentage of countries with integration of components
of NCD prevention and control programmes in primary health care
2007
WHO regions 940/Q
88% 880/0
65%
Africa
Americas Eastern
Minca Americas tasicrn Europe South-East Western
Mediterranean Asia Pacific
EASTERN
MEDITERRANEAN WESTERN
PACIFIC
Availability of equipment
Percentage availability of basic equipment at primary health care level for diagnosis and management of high blood pressure and diabetes
2001 96%
WHO regions
86% 81%
for high blood pressure for diabetes
97%
94%
96%
n
Africa
Americas Eastern
Mediterranean
Europe
South-East Asia
Western Pacific
Bh
Medical professionals
Number of medical professionals working in
noncommunicable disease control
per 100 000 population
2007
WHO regions
685
cardiologists
primary health care physicians
nurses
56
247
0.4 13
I
0.3
Africa
Americas Eastern
Mediterranean
Europe
South-East Asia
Western Pacific
Antihypertensive drugs
Percentage of countries in each re are available, affordable to low in or manufactured locally 2007 WHO regions
gion where drugs :ome groups,
r 30% 1 890^
57% 91o/o
67%
480/o
45%
9 locally manufactured
9 affordable
70/0
p==5
740/o
640/o
83%
^7 available
460/o
88%
920/o
100%
960/o
70o/o
M
(
71o/o
I
Western Pacific
Africa
Americas
Eastern ;diterranean
Europe
>outh-East Asia
Use of medication in stroke and coronary heart disease
Percentage prescription of
aspirin and statins
to persons with established
coronary heart disease
and post-stroke in the WHO
PREMISE demonstration
project
2002
selected countries
^ aspirin statins
95%
96%
83%
66%
29%
S
90/0
790/o 81o/o
38%
i
31%
28%
i
16%
Brazil Egypt India Indonesia Iran, Pakistan Sri Turkey Russian Tunisia
Islamic Lanka Federation
Republic of
.
89%
78%
660/0
38%
j
23%
i
78o/o
28%
I
58%
22
Health education
"Education is the most powerful weapon
which you can use to change the world."
Nelson Mandela, South Africa (191 8-)
For successful prevention and control of the cardiovascular disease epidemic, changes to policy, legislation and taxation are not enough. These interventions will not be effective if there is no public understanding, support and demand for them. Some areas lie beyond legislation — for example, the choice of food for families, the amount of salt added in cooking, whether or not to smoke — and here health education is essential to promote healthy choices.
Schools provide an ideal venue for health education. They can teach about risk factors, refusal skills, and the strategies of the tobacco and food industries. For example, young people can analyse how tobacco industry promotion attempts to manipulate them by equating smoking with growing up, freedom and being cool.
Increasing knowledge, and
O O '
changing beliefs, attitudes and intentions, on their own are not enough to change behaviour. School programmes must also lead by example, by making healthy food available, providing exercise facilities, prohibiting tobacco use at all school facilities and events, and helping students and staff lose weight and quit smoking. Ideally, these activities should be part of a coordinated school health programme, reinforced by community-wide efforts.
The WHO Global School Health Initiative is designed to strengthen international, national
66
World Heart Federation event
participating countries and territories 2003
The Victoria Declaration on Heart Health
Heart Health Declarations
See Milestones pp76-81 for further details
The Victoria Declaration on Women, Heart Disease and Stroke
and local support for effective school health programmes or "health-promoting schools". Guidelines have been developed on various factors that affect health, such as tobacco, diet and physical activity.
The WHO Global School-based Student Health Survey is aimed at adolescents aged 13 to 15 years, and covers nine risk or protective factors. Survey results will provide information on trends over time, which is useful for formulation of risk reduction policies.
World Heart Day Themes
• 2000 Physical Activity
• 2001 A Heart for Life
• 2002 Nutrition and Physical Activity
World Heart Day Activities 200?
medical activities (e.g. blood pressure ] testing)
2003 Women, Heart Disease and Stroke
2004 Children, Adolescents and Heart Disease
2005 Obesity /
activities to engage the public in
physical activity I f
scientific activities
(e.g. conferences
or workshops)
activities to advocate for a heart healthy diet
other activities
(e.g. charity
gala, dance,
concert, carnival)
The Catalonia Declaration Investing in Heart Health
The Osaka Declaration: Health, Economics and Political Action Stemming the Global Tide of Cardiovascular Disease
The Milan Declaration: Positioning Technology to Serve Global Heart Health
998 Singapore
The Singapore Declaration: Forging the Will for Heart Health in the Next Millennium
valuation of World Heart Days 2000-2003 Number of participating countries and territories
till
2000 2001 2002 2003
Giving up smoking: International Quit and Win
1994-2002, 2004 projected
Up to 25% of participants in the International
Quit and Win Campaign are off tobacco after one year
1 000000
Number of participants
Number of
website hits more than 2 000 000
200 000
60 000 70000
420 000
2000
2002
1998
1994
1996
2000
2001
2002
2003
Number of countries 48
€
1998
67
23
Policies and legislation
"The welfare of the people
is the ultimate law."
So/us Populi Supreme Est Lex.
Cicero (1 06 BCE-43 BCE)
Laws, treaties, policies and regulations have played important roles in the prevention and control of disease. Only governments can legislate for health warnings on cigarettes, introduce mandatory food standards and labelling, crack down on smuggling, set a "pro- health tax policy", or implement national transport policy. Often governments are the main providers of health care; they decide how funding is allocated, from prevention programmes to treatment, research, and training.
The first international convention that relates specifically to cardiovascular disease is the WHO Framework Convention on Tobacco Control. It was adopted without dissent by the World Health Assembly in Geneva in May 2003, and is currently in the process of ratification. Once 40 countries have ratified the Convention, it will come into effect as a legally binding treaty among those countries. The
O
Convention includes clauses on advertising bans, smoke-free areas, health warnings, taxation, smoking cessation and smuggling.
Cardiovascular disease plans worldwide
Percentage of countries by region
with national plans for CVD prevention and control
2007
WHO regions
Africa 8%
Americas Eastern Mediterranean
South-East Asia Western Pacific
50°/o
4QQ/0
Smoke-free workplaces
Smoke-free areas in government buildings
2004 or latest available data
r^ Smoking in private workplaces banned.
• Exceptions or limited restrictions may
smoking banned apply to restaurants, bars,
and other venues.
First five countries to ratify the Framework Convention on Tobacco Control.
smoking restricted not regulated unknown
1970 Singapore: smoking banned in buses, cinemas, theatres and other specified buildings.
Legislation
Percentage of countries by region
with tobacco, and food and nutrition legislation
2007
WHO regions
^ tobacco ? food and nutrition
Africa Americas Eastern Europe South-East Western
Mediterranean Asia Pacific
69
24
Treatment
"If you do not repair your gutter, you will
have your whole house to repair."
Old Spanish proverb
In 1931, Paul Dudley White noted that there was no specific treatment for coronary heart disease. He described the treatment of high blood pressure as "difficult and almost hopeless". Today, effective and relatively inexpensive medication is available to treat nearly all cardiovascular diseases, including high blood pressure.
Improvements in surgical techniques have led to safer operations. Effective devices have been developed, such as pacemakers, prosthetic valves, and patches for closing holes in the heart. Other developments have led to a wide array of interventions that often make
surgerv unnecessar
7- Together, these advances in
o
treatment improve quality of life and reduce premature death and disability. They also add to the rising costs of health care. Increasingly, high-technology procedures are chosen over less expensive, but nevertheless effective, strategies.
In addition, marked disparities in the quality of treatment can be seen in groups of different race, ethnicity, sex, and socioeconomic status. In essence, many patients who could benefit from treatment remain untreated, or inadequately treated. In future, increased emphasis needs to be placed on the appropriate use of proven treatments for everyone with coronary heart disease or stroke.
70
Cardiac rehabilitation
Percentage of people with established
coronary heart disease advised
to participate in cardiac rehabilitation
2007
selected European countries
71%
Patients reaching blood pressure and blood cholesterol goals during treatment
Percentage of people aged 70 years or below with established CVD who achieve blood pressure
goal of less than 140/90 mmHg, or blood cholesterol goal of less than 5.0 mmol/l
2007
selected European countries
^ blood cholesterol goal achieved
46% 50%
23%
55%
63<>/o
Types of treatment
Selected medication, devices and operations
Medication used in treatment of
1 High blood pressure
2 Coronary heart disease
3 Heart failure
4 Arrhythmia (heart rhythm disorders)
5 Blood clotting disorders Devices
1 Pacemakers
2 Implantable defibrillators
3 Coronary stents
4 Prosthetic valves
5 Artificial heart Operations
1 Coronary artery bypass
2 Balloon angioplasty
3 Valve repair and replacement
4 Heart transplantation
5 Artificial heart operations
Trends in cardiovascular operations and in the USA
Number of operations and procedures
7987-2007
thousands
* heart catheterization ^ open heart surgery
'•• coronary artery bypass surgery f carotid endarterectomy
* cardiac pacemakers
ACE
inhibitors
aspirin
Simple secondary 25% prevention
medication treatments
Percentage reduction in 250/0 two-year risk of heart attack, stroke or death from CVD in patients with previous coronary heart disease or stroke 2002
card
Diabetes treatment
Percentage of persons with diabetes
being treated with medication or special diet
2002-2003
selected countries
1981
1986
1991
1996
2001
71
*•
s
PART 5
THE FUTURE AND THE PAST
"Let my heart be wise, It is the gods' best gift."
Euripides Medea, 431 BCE
73
25
The future
"I never think of the future - it comes
soon enough."
Albert Einstein (1879-1 955)
I Inlike I instein, \\e have ID iliink ol the lui m . . HI- |)l.in n. P\\ , to reduce (In- numbers ol deaths I'roin coronary heart disease .mil stroke.
Predictions arc by dicir nature .speculative. Nevertheless, tliis nun li is certain: the gloh.il epidemic of cardiovascular disi-asc is nol only increasing, hut also shifting from developed to developing nations.
Action can work. There are MMI mily ahout 800 million people1 with high hlood pressure worldwide. Studies now indicate that in North America, Western Kurope, and the Asia Pacific region, each 10 mmllg lowering ol systolic hlood pressin . [| assoi iated with a decrease in risk ol stroke ol approximately one third, in people aged (•>() to 7C) years. (Jobally, if diastolie blood pressure (l)UI') can he redu. i d h\ 2%, and by 7% in those with DBP over- l)S mmllg, a million deaths a
yi .n li HI. n \ heart disease
and stroke could he averted hy 2020 in Asia alone.
No matter what advances there are in high technology medicine, the rundameiit.il message is that am major reduction in deaths and disability I'rom ('VI ) will i Mini liom prevention, not i ure. This must involve robust reduction of risk (actors.
"Unless current trends are halted or reversed, over a billion people will die from cardiovascular disease in the first half of the 21st century. The large majority will be in developing countries and much of the life years will be lost in middle age. This would be an enormous tragedy, given that research in the last half of the 20th century showed that cardiovascular disease was largely preventable."
Anthony Rodgers, Clinical Trials Research Unit, University of Auckland, New Zealand, 2004
DALYs
DALYs
by 2010
Disability-adjusted life years combine
yi-ur, nl piilfiilinl
life lost due to
CVD DALYs
Annual number of DALYs
153 million
premature death
w
with years of
V
productive life lost
Burden of CVD
due to disability.
Percentage
10.4%
of all DALYs
m*
by 2020
169 million
11.(
by 2030 187 million
11.6%
CVD
rankings globally
CVD rankings
in developing
countries
DEATHS
CVD deaths
Annual number of deaths
CVD deaths
Percentage of all deaths
Coronary heart disease deaths
Percentage of all male deaths
Coronary heart disease deaths
Percentage of all female deaths
Stroke deaths
Percentage of all male deaths
Stroke deaths Percentage of all female deaths
CVD deaths from cigarette smoking
Annual number of deaths
3rd: coronary
he.irl disease Mh stroke
4th rtirnti.iry
heart disease 8th: stroke
3rd: coronary 3rd: coronary
hi-,-iri diMMM' heart disease
4th: stroke 4th: stroke
3rd: coronary 3rd: coronary
hr;iti disease heart disease
6th: stroke 5th: stroke
by 2010 by 2020 by 2030
24.2 million
18.1 million
30.8%
13.1%
13.6%
9.2%
20.5 million
31.50/0
1 4.3%
1 3.0%
9.8%
11. !•% 11.5%
¥
3 2. !>%
14.9%
13.1% 10.4%
11.8%
2.6 million
l-'l m m
74
RISK FACTORS
by 2010 by 2020
by 2030
THfATMiNT 1,,
by 2020 by 2030
Smokers
1.4-1. 6 billion 1.3-1.4 billion
1.4-1.8 billion
Miscellaneous lull |irr.nrul
meili< .il
Health systems driven Patients' by primary health care knowledge of their
Number
AA •— -»— * *^Bw*
records
to ensure universal own health equals
V
stored on
access to quality that of doctors in
MM. Ill 1 .11(1
health care services, the 1990s.
Diabetes
366 million
Number of
300 million
Irr.l.mtancOUl
people aged 20 years
221 million
computer language
iMM-.l.ltlllfl rtl.llill",
and above
^P
ii.iiimi-, in he-
understood by doctors
Miscellaneous
Serious increases
Short-term, long-
in any country.
in LDL-cholesterol
term, and lifetime
in many
absolute risk of
Investigation ECOs, X-rays,
Minuscule computer, "Trial and error" In
developing
coronary heart
ultrasound
with microsensors, drug prescription
populations.
disease and stroke
Images, etc.
automatically sensing abandoned In
routinely
Ir.msmittnl
and recording health favour of
calculated by
electronically
d.it.i, (i)iil(l hr rvrryil.iy |iOMin.ili/ril
health care
t()lll.l(|MI>Ml<
wear. prescription
providers for
through
everyone.
in another
Biochemical pharmacogenomlc
country.
inflammation and testing for
genetic markers used predictable
Wireless ECGs.
routinely in blood tests responses to drugs.
to screen patients for
ECONOMIC COSTS
by 20 10 by 2020
by 2030
heart problems.
Obesity-related
'"*'
complications Percentage of
70%
Genetics CVD- modifying
Genetic manipulation to prevent and treat
health care spending in the USA, people aged
15% W
gcna
identified.
CVD, including post- operative prevention of re-stenosis of arteries.
50 to 69 years
W
ACTION by 2010 by 2020 by 2030
Research New causal All newborn babies Bio-
and factors discharged home with engineered
development discovered CD-ROM containing their tissues
for heart unique genomic maps, with available for
disease, summaries of CVD, of which all heart and
including they may be at increased vascular
bacteria structures, and viruses.
External glucose sensor will drive insulin pumps to deliver continuous microdoses of insulin.
Vaccine produced to switch off nicotine receptors.
Convention on Food ratified Convention
(covering content, labelling, on universal
taxation, advertising). access to essential
Millennium Development preventive
Goals (201 5): access to health care,
affordable essential drugs in and
developing countries principles of
provided, in cooperation equity in
with pharmaceutical quality care
companies. delivery.
UN WHO
Conventions Framework and Goals Convention on Tobacco Control (FCTO ratified.
WHO Global Strategy on Chronic Diseases, Diet and Physical Inactivity (2004).
Artificial Heart body parts developed
Transplant surgery
High technology
Medication
luni)'. lir.im.idil orr.
Nerves to transplanted
hr.irf.
Xenotransplantatlon Pig-napping of
with pig hearts soars personal
as rejection problem transgenic pigs a
overcome. new crime.
Nano-surgeons, or sub- microscopic robots, will crawl through arteries, scraping away fatty deposits and repairing damaged or diseased parts.
Angiogenesis, the growth of new blood
/rv.rl-., m.if l.r. ,,,,<r
an alternative to coronary bypass, angioplasty or clot- buster drugs.
Computerized "auto-doc" machine externally detects and treats illness by magnetic
Off-pump beating
hr,,rl -..H'l'T/
predominates.
Automated external defibrillators offered as f- . electronic options in new homes for persons at high
M'> .,1 VJ'I'I'T
death,
Six-drug "polypill" will reduce CVD by more than 80% if taken by everyone aged 55 and older, and everyone with existing CVD,
Drugs developed to raise HDL-
effective as statins are today for lowering LDL- cholesterol),
75
TJ /"^T"1
-
1 QC1
A>I * 1 .*- '1 1J Cf
[3 v^ l-^1
-
L03Z
Milestones in knowledge ol
i . -| "ii* ^^ i
lit
— I
Palaeolithic era Spain Oldest anatomical drawing in El Pindal
o
cave of a mammoth with a dark smudge at the shoulder, which is thought to represent the heart.
2698-2598 BCE China Huang Ti, the Yellow Emperor, was thousands of years ahead of his time in writing in Nei Ching (Canon of Medicine): "The blood current flows continuously in a circle without a beginning or end
O O
and never stops" and "all the blood is under control of the heart". He also recorded the association between salt intake and a "hardened pulse".
1550 BCE Egypt Papyrus Ebers stated that after death the heart becomes the witness of the body's behaviour during life. To avoid incriminating testimony, the Egyptians buried the heart separately from the body.
_L _i- 600 BCE Greece Alcmaeon noted
empty arteries in animals after death and inferred that arteries normally contained air.
400 BCE Gree, Hippocrates, the Father of Medicine (460-370 BCE), challenged the belief that illness was caused by the ^ gods; he
o
believed illness was caused by an imbalance of the four bodily humours: yellow bile, black bile, blood, and phlegm. He was also the first to recognize stroke.
310-250 BCE Egypt Erasistratus described the heart, veins, arteries and valves, but claimed that
arteries contained "pneuma" (air or spirit or soul), which was replaced each time a person breathed; when
artery was cut, blood rushed in
the pneuma escaped.
& 131-201 CE
Graeco-Roman physician Claudius Galen, with knowledge gained from animals killed by Roman gladiators,
described the heart and the movement of blood in the arteries, but claimed that the liver was the ntre of the circulation and that the blood passed from the right to the left side of the heart.
980-1037 Persia Avicenna
(Ibn Sina) stated that the heart is
located centrally to all organs of
J O
the body, and that the left side of the heart was created as a store of spirit and soul.
1210-1288 Syria Ibn al-Nafis described the pulmonary and coronary circulation in he Perfect Man.
1452-1519 Italy Leonardo da Vinci incorrectly drew the liver as the centre of circulation. But he stated "vessels in the elderly through the thickening of the tunics, restrict the transit of the blood." This is one of the earliest descriptions of arteriosclerosis.
1553 Spain Michael Servetus described the pulmonary circulation in his book Christianismi Restitutio.
1510-1559 Padua, Italy Matteo Realdo Colombo described the heart valves.
1525-1603 Rome, Italy Andrea Cesalpino noted that the circulation system is a closed system, and was the first in modern times to coin the term "blood circulation".
1553-1 61 9 /Wua, Italy Hieronymus Fabricius demonstrated valves in veins, which help to "prevent dilatation of veins".
15 55 Padua, Italy Andreas Vesalius (1514-1564) stated that the heart, and not the liver, was the centre of the circulation.
1 559 Italy Riva di Trento discovered that there are two coronary arteries, each supplying blood to half of the heart.
1628 England William Harvey (1578-1657), a physician, published his thesis that the heart pumped blood around the body, in De Motu Cordis.
mid- 1600s Switzerland Jacob Wepfer found that patients who died with "apoplexy" had bleeding in the brain. He also discovered that a blockage in one of the brain's blood vessels could cause apoplexy.
1 706 France Anatomy professor Raymond de Vieussens first described the structure of the heart's chambers and vessels.
1712-1 780 England John Fothergill both forecast the role of psychosocial factors and advised
that a restricted diet "might greatly retard the progress" of coronary heart disease.
1677-1761 England Stephen Hales, an English clergyman and scientist, first measured blood pressure In inserting a brass tube into the artery of a horse. This was a scientific experiment, published in 1733, demonstrating that the heart exerts pressure in order to pump blood. The horse died.
1745-1827 Italy Alessandro Volta discovered that electric energy was produced by heart muscle contractions.
1 749-1 832 England Edward Jenncr, better know for smallpox vaccine, made the essential link between angina pectoris and disease of the coronary arteries.
1752-1832 Italy Antonio Scarpa described arterial aneurvsm.
1772 England William Heberden (1710-1801) described angina pectoris: "they who are afflicted with it, are sei/ed while thev are walking (especially if it be uphill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life if it were to increase or to continue; but the moment they stand still, all this uneasiness vanishes". He was also the first to write about byperlipidaemia as a risk factor when he noticed that the serum of an obese patient who suddenly died was "thick like cream".
1775 Scotland John Hunter (1728 1793), a surgical pathologist, wrote "in a sudden and violent transport of anger, he fell down and expired immediately", illustrating the importance of
emotion, stress and anger in precipitating coronary death. Hunter himself suffered from angina pectoris and died suddenly alter a violent argument with a hospital colleague.
1785 England William Withering described the use of digitalis in coronary heart disease in his monograph An Account of the Foxglove. Foxglove had been used tor centuries bv American Indians.
1791 Italy Luigi Galvani discovered that electrical
L
stimulation of a frog's heart led to contraction of the cardiac muscle.
1799 England Caleb Hillier found something hard and gritty in the coronary arteries during an autopsy and "well remembered looking up to the ceiling, which was old and crumbling, conceivii that some plaster had fallen down". He discovered, however, that the vessels had hardened, and stated that "a principle cause of the syncope anginosa is to be looked for in disordered coronary arteries".
1815 England London surgeon Joseph Hodgson claimed inflammation was the underlying cause of atherosclerosis and it was not a natural degenerative part of the ageing process.
1815 France M.E. Chevreul name the fatty substance extracted from gallstones "cholesterol" from the
O
Greek "khole" (bile) and "stereos" (solid).
symptoms as he was reluctant to apply his ear to the chest.
1838 France Louis Rene Lecanu showed that cholesterol was present in human blood.
1841 Austria Carl Von Rokitansky championed the thrombogenic theory, proposing that deposits observed in the inner layer of the arterial wall derived primarily from fibrin and other blood elements rather than being the result of a purulent process. This theory came under attack from Rudolf Virchow.
— f-t-
H
1843 J. Vogel showed that cholesterol was present in atherosclerotic plaques.
1 844 Denmark First pathology report of plaque rupture in a coronary artery in Bertel Thorvaldsen, the celebrated neoclassical
Danish artist and sculptor, who died of sudden cardiac death in the Royal Theatre in Copenhagen.
1 850 Ventricular fibrillation first described.
1850s Ophthalmoscope invented, allowing direct visualization of
O
arteries at the back of the eye.
1852 England Fatty material in the coronary arteries described by Sir Richard Quain, which he attributed to nutrition. He linked the fatty heart to "languid and feeble circulation, a sense of uneasiness and oppression in the chest, embarrassment and distress
1819 France Rene Theophile Laennec (1781-1826), invented the stethoscope. He rolled paper into a cylinder while examining a young woman with cardiac
J o
f
in breathing, coma, syncope, angina pectoris, sudden death. . ."
onzjq^
77
1856 Germany Rudolf Virchow, a Pole, believed that disease occurred at cellular level, and also described cerebral emboli causing stroke. Virchow also emphasized the societal causes of disease as "disturbances of human culture".
1867 England Lauder Brunton, pharmacologist, discovered that amyl nitrite relieved angina.
lIIlXEtCEII
1 872 France Gabriel Lippmann invented the capillary electrometer, the precursor of the electrocardiograph .
:
advertisements said that the drug
o
did "not affect the heart".
1906 Germany M. Cremer, first oesophageal ECG by a professiona sword swallower. First fetal ECG from the abdominal surface of a pregnant woman.
1 907 England First case report of atrial fibrillation by Arthur Cushnv professor of pharmacology at University College, London.
1893 Holland Willem Einthoven (1 860-1927) introduced the term electrocardiogram or ECG/EKG; distinguished five deflections — PQRST (1895); constructed the first electrocardiograph in 1901, which weighed 270 kg, occupi two rooms and required five people to operate it; transmitte the first ECG from hospital to his laboratory 1 . 5 km away via telephone cable (in 1905); published the first normal an< abnormal ECGs (1906) and won the Nobel Prize (1924).
1912 James B. Herrick described heart disease resulting from hardening of the arteries.
1912 First human cardiac catheterization (no X-ray visualization) by Frizt Bleichroeder, E. Linger and W. Loeb.
1915 USA Establishment of organization in New York City, which became the American Heart Association.
920 USA First ECG of acute
yocardial infarction by Harold
1 895 Germany Physicist Wilhem Konrad Roentgen (1845-1923)
1923 USA First operative widening of scarred cardiac valve by E. Cutler and S.A. Levine.
^L • 1 925 United Kingdom Widening of
narrowed mitral valve by Souter, who stretched the valve ring with his fingers.
disco\
ered X-rays, which ar o visualize the heart.
T :
e still
„
'
used t
—
1896/ta/jScif invented the s to measure bl<
1897 The intr aspirin. In one ironies, Bayer
lione Riva- jhygmoma )od pressur
aduction o of life's lit s first aspii
&
10
e.
in tic- •in
CCl
m od
tei
en
\
bl
to
ac V
n
hi
1
U!
1928 United Kingdom
Sir Alexander Fleming discovered
O
penicillin, which is used to treat umatic fever.
Apoplexy" divided into tegories based on the cause of the blood vessel problem, and replaced by the term "cerebral vascular accident (CVA)".
1 929 Germany First documented right heart catheterization in
1931 USA First description of the use of exercise to provoke attacks of angina pectoris by Charles Wolferth and Francis Wood.
1931 USA
First artificial
cardiac
pacemaker,
which
stimulated
the heart by
transthoracic
needle,
developed
bv Dr Albert Hvman.
1937 USA First prototype heart- lung machine built by physician John Heysham Gibbon, and tested on animals. He performed the first human open heart operation in 1953 using the machine.
1938 USA First human heart surgery, first surgical correction o: a congenital heart defect: closure
o
of patent ductus arteriosus performed by surgeon Robert E. Gross.
1944 China First repair of patent ductus arteriosus in China.
1 944 USA First operation on "blue baby" (Fallot's tetralogy) at Johns Hopkins.
human by Werner Forssmann using radiographic techniques.
1944 USA /Sweden First repair of coarctation of aorta by Crafoord and Grosse.
1947 USA First defibrillation of human heart during cardiac
O
surgery, by Claude Beck in Cleveland.
1948 USA "Blind finger" closed heart surgery for mitral stenosis reintroduced by Dr Dwight Harken and Dr Charles Bailey.
1948 USA California physician I a\\ rrnce Craven noticed that 400 of his male patients who took aspirin tor two years had no heart attacks. By 1956, he had chronicled the health of 8000 patients taking aspirin and found no heart attacks in the group.
1948 USA Start of the Framingham Heart Study where, for the first time, a large cohort of healthy men and women were studied prospectively.
1954 United Kingdom First carotid endarterectomy by Eastcott, Pickering and Rob.
1954 India Called on WHO to address the coming epidemic of cardiovascular disease in developing countries.
'55 United Kingdom First reportec
1949 USA Portable Holter Monitor invented bv Norman Jeff Holter to record ambulatorv ECG.
1950 The International Society of Cardiology established, later joined with International Cardiology Federation and renamed World Heart Federation.
1 950 Canada First pacemaker invented by John Hopps.
1952 USA First prosthetic valve implanted in aorta by surgeon Charles Hufnagel.
1952 USA First successful human open heart surgery under hypothermia bv Walton Lillehei and John Lewis, who implanted the first synthetic valve in a live year-old girl who had been born with an atrioseptal defect (hole in her heart).
1952 USA External cardiac pacemaker designed by Paul Zoll.
itral valve replacement by Judson Chesterman.
950s Minimization of bias for the
le assessment of cardiovascular treatments by introduction of randomization into clinical trials (at instigation of Sir Austin Bradford Hill).
1960 USA First replacement of heart valve with Starr- Ed wards mechanical valve, developed by Albert Starr (left) and Lowell Edwards.
1956 USA First report of the successful ending of ventricular fibrillation in humans by externally applied countershock published by Dr Paul Zoll.
1957 First battery-powered
external pacemaker.
1 958 USA Seymour Furman inserted a pacemaker in a patient lived for 96 days.
1958 Sweden Internal long-term cardiac pacing by Ake Senning.
1953 USA First demonstrated
programme.
• •;"-
coronary artery disease among young US soldiers killed in action in Korea (later observed in the casualties of the Viet Nam Wa too) by William F. Enos, Robert
H. Holmes and James Beyer.
1 958 Start of development of a selective coronary angiography procedure by Mason Sones.
1959 WHO established Cardiovascular Diseases
1 960s High blood pressure identified as a treatable risk factor for stroke .
1960 USA First Coronary Care Unit in Bethany, Kansas.
1960 Framingham, USA Cigarette smoking found to increase the risk of heart disease.
._
1961 USA Framingham Heart Study investigators coined the term "risk factors" for the development of coronary heart disease. High cholesterol level, blood pressure, and electrocardiogram abnormalities found to increase the risk of coronary heart disease.
-j-4
1961 USA First use of external cardiac massage to restart a heart byJ.R. Jude.
1961 USA First direct current dcfibrillation with external paddle; by Bernard Lown and Barough Berkowitz.
1960s First human implant of totally implantable pacemak
1964 USA First transluminal angioplasty performed on a narrowed artery in the leg by- Charles T. Dotter.
1965 USA Michael DeBakey am Adrian Kantrowitz implanted mechanical devices to help a diseased heart.
1967 South Ajrica First whole heart transplant from one person to another by Dr Christiaan Barnard.
1 967 USA Saphenous vein coron bypass graft by Dr Rene Favaloro.
1967 Framingham, USA Physical inactivity and obesity found to increase the risk of heart disease.
1969 USA First use of artificial heart in human by Denton Cooley.
1972 USA The Stanford Three Community Study started (later becoming The Stanford Five-City Project); this showed a 23% reduction in coronary heart disease risk caused by community-based interventions that change lifestyle- related risk factors such as physical activity, dietary habits and tobacco
1972 Finland North Karelia Project began, aimed at preventing cardiovascular disease among residents. Cardiovascular mortality rates for men, aged between 35 and 64 years, decreased by 57% from 1970 to 1992.
1974 Framingham, USA Diabetes linked to cardiovascular disease.
1 970s Aspirin recognized as
preventing heart attacks and
i
stroke.
1970s Development of computerized tomography (CT) to aid early diagnosis of stroke .
1977
Switzerland
First coronary
PTCA
(percutaneous
transluminal
coronary
angioplasty);
Andreas
Gruentzif
He- inserted a balloon-tipped catheter
into a coronary artery and inflated the balloon, and thus successfully opened a blockage and restored blood flow.
1977 Italy The Martignacco Project community prevention trial
resulted in reduction of coronary heart disease through community- >ased interventions that change lifestyle-related risk factors such as physical activity, dietary habits and tobacco use.
1977 Framingham, USA Effects described of triglycerides and LDL- and HDL- cholesterol on heart disease.
1978 Framingham, USA Psvchosocial factors found to affect heart disease.
1978 Australia North Coast Healthy Lifestyle Programme showed
significant reduction in smoking.
5 &
1978 Switzerland Swiss National Research Programme community prevention trial resulted in reduction of smoking, blood pressure and obesity.
1978 Atrial fibrillation (irregular heart beat) found to increase the risk of stroke .
1979 South Africa Coronary Risk Factor Study community prevention trial resulted in reduction of smoking, blood pressure and composite coronary heart disease risks.
1983 USA List of 246 coronary risk factors published by Hopkins and Williams (list now much longer).
1980s Minimization of random error for the reliable assessment of cardiovascular treatments by introduction of large-scale "mega- trials" (at instigation of Sir Richard Peto).
1979 Germany First use by Peter Rentrop of intracoronary streptokinase, a clot-dissolving drug to stop a heart attack in progress.
1981 Framingham, USA Filter cigarettes found to carry as much risk for coronary heart disease as unfiltered cigarettes.
1981 USA Report on relationship between diet and heart disease.
1982 USA First permanent artificial heart, designed by Robert Jarvik, and implanted by Willem DeVries, in a 61 -year-old man.
*
1 986 France First coronary stent implanted by Jacques Puel and Ulrich Sigwart.
1987 Japan M. Okada used a laser to burn channels in the heart muscle to help revascularize the heart in patients with coronary heart disease.
1 987 Framingham, USA High blood cholesterol levels found to correlate directly with risk of death in young men.
J O
1988 Framingham, USA High levels of HDL-cholesterol found to reduce risk of death.
1988 ISIS- 2 trial shows emergency treatment for heart attacks with aspirin and fibrinolytic "clot- busting" drugs saves lives.
~~H^H 1988 Framingham, USA Isolated
systolic hypertension found to increase risk of heart disease.
1 988 Framingham, USA Cigarette smoking found to increase risk of stroke.
1990 Randomized trials showed that lowering blood pressure lowers the risk of stroke.
1990 United Kingdom Meta-analysis of trials by Clinical Trial Service Unit (CTSU) in Oxford showed
that lowering blood pressure lowers the risk of coronarv disease.
1991 China Tianjin CVD Intervention Programme community prevention trial led to the creation of non-smoking
O
environments and increased sales ol low-sodium seasonings.
Ilh/IIla receptor blockcr drugs prevent blood clots; the importance of inflammation in cardiovascular disease recognized;
O
study on the deadly effects of smoking fewer than 1 0 cigarettes per day.
re
1 992 Canada The Victoria Declaration on Heart Health affirmed that CVD is large Iv preventable, that there is the scientific knowledge to eliminate most CVD, and that the public health infrastructure and capacity to address prevention were lacking.
1990s USA Hostility (including traits such as anger, cynicism, and mistrust), a major component of type A behaviour, shown to be associated with an increased risk of heart attack and other cardiac complications in healthy persons and patients with coronary heart disease.
1992 China First heart-lung transplant in China.
mid-1990s Scandinavia, United Kingdom, USA Remarkable improvement in survival of coronary heart disease patients treated with statins.
1 998 Singapore The Singapo Declaration: Forging the Will
O O
Heart Health in the Next Millennium.
2000 Canada The Victoria Declaration on Women, Heart Disease and Stroke addressed the importance of science and polic in action and the need to tackle gender disparities in health. It called upon all stakeholders to join forces and take appropriate actio to control the cardiovascular disease epidemic.
1 995 Spain The Catalonia Declaration: Investing in Heart Health, and its follow-up convention in 1997, emphasized the importance of investments in heart health and provided examples of many successful CVD prevention programmes worldwide.
2000 First World HeartJOay, whu has become a global annual event.
2000 The entire human genome is mapped.
2000 WHO 53rd World Health Assembly endorsed Global strateg' for noncommunicable disease (NCD) prevention and control, which outlines major objectives for monitoring, preventing and managing NCDs with special emphasis on major NCDs with common risk factors and determinants cardiovascular disease, cancer, diabetes and chronic respiratory disease.
Cardiovascular Disease emphasized the global nature of the CVD burden and highlighted the need to address economic and political factors in order to tackle CVD.
2002 United Kingdom The Heart Protection Study showed that statins could benefit people with diabetes and those with cholesterol
levels previously considered low.
1 J
2002 USA
NASA's Commercial Invention of the Year Award given for the DeBakey Ventricular Assist Device, based on space shuttle technology, and developed by Michael DeBakey (above) and NASA engineer David Saucier. The pump, used to treat heart failure, was one-tenth the size of previous heart-assist devices, and was first used in a patient in 2000.
2003 Switzerland WHO Framework Convention on Tobacco Control adopted at the
56th World Health Assembly.
J
1998 USA Hypertension gene in men identified.
1998 New advances:
gene therapy grows new blood vessels to the heart; strong
confirmation that "superaspirin" 1 *
2001 Japan The Osaka
Declaration: Health, Economics and Political Action: Stemming the Global Tide of
2003 Switzerland The World Health Report: "Shaping the Future" highlighted CVD as the first of three growing threats that
O O
make up the "neglected global epidemics". The report called for action at the national and global
O
levels to prevent and control CVD.
2004 Switzerland WHO Global Strategy on Diet, Physical
Activity and Health endorsed by World Health Assembly.
2004 Italy Milan Declaration on Heart Health: Positioning
O
Technology to serve Global Heart Health.
%'*•
f
PART 6
WORLD TABLES
"Live as if you were to die tomorrow. Learn as if you were to live forever."
Mahatma Gandhi (1869 1948)
83
World Data Table
Country
Afghanistan
i
Population
Thousands 2002
22930
2 Heart disc Disability
DALYS lost |HT 1000 population 2002 36
ase
3 Stroke
4 Rheumatic heart disease
Number of deaths
2002
1 938
Mortality Number
ol 'deaths 2002 33 157
Disability
DAI.YS lost per 1000 population 2003 or Idlest iii(j//()/)/r ,/,»,!
13
Mortality Number
ol deaths 2002 11 532
Albania
3 141 13
3989
13
4 169
42
Algeria
31 266 7
14948
8
16223
756
Andorra
69 3
67
3 52
3
Angola
13 184 13
7 130
15 7 640
615
Antigua and Barbuda
73 6
52
13
92
0
Argentina
37 981 6
34292
6
22 668
234
Armenia
3072
20
8515
10
4212
151
Australia
19544 5 25474
3
11 730
243
Austria
8 111 6 15418
4
7 559
185
Azerbaijan
8297
28
22302
9
6 540
184
Bahamas
310 5 154 6
155
1
Bahrain
709 8 283 3
84
6
Bangladesh
143809 18
130006
9
64515
10253
Barbados
269 6
286
7
270
2
Belarus
9940 28
59 719
14
22 892
550
Belgium
10296 5
14985
4
9 234
68
Belize
251 8
153
7
111
1
Benin
6 558 10
3017
12
3 279
236
Bhutan
2 190 20
2672
10
1 370
195
Bolivia
8645 6
3948
7
3 138
70
Bosnia and Herzegovina
4 126
10
5590
13
6508
21
Botswana
1 770 8
697
8
670
15
Brazil
176257 9
139601
11
129 172
3055
Brunei Darussalam
350
5
92
6
90
7
Bulgaria
7965 14
26243
13
20882
232
Burkina Faso
12624 11
5877
13
6604
466
Burundi
6602
10
3084
12
3 492
82
Cambodia
13810
13
7635
11
5963
614
Cameroon
15729
10
9443
12
10 198
621
Canada
31 271
5
43246
3
15621
422
Cape Verde
454
6
202
Q
266
4
Central African Rep.
3 819
10
2 513
12
2 727
51
Chad
8348
10
4385
12
4747
300
Chile
15613
4
9075
5
8 142
315
China
1 294 867
4
702 925
12
1 652 885
97 245
Colombia
43 526
8
31 289
6
17 745
380
Comoros
747
8
282
10
310
23
Congo
3633
9
1 577
10 1 718
39
Congo, Dem. Rep.
51 201 11
24217
13
26439
1 930
Cook Islands
18 10
11
12
11
0
Costa Rica
4094
6
2937
3
1 194
45
Cote d'lvoire
16365
11
9257
12
9530
233
Croatia
4439
10
11 653
11
8653
152
Cuba
11 271
8
16275
5
7 684
196
Cyprus
796
7
1 358
3
795
1
Czech Republic
10246
11
25899
7
15663
286
Denmark
5351
5
10013
4
4871
17
84
imoking prevalence
Percentage ol people 1 N ears and above who smoke .W.J or latest available Jata
46.2% 22.8%
40.2% 11.5%
49.6% 35.9%
32.0% 67.4% 30.706 37.4% 32.0%
29.5% 63.0% 19.8% 63.60/0 33.2o/o
36.7% 54.6%
29.4%
47.3o/o 25.6%
20.70/0 30.0o/o
19.7%
44.1% 58.9%
30.5% 20.806
24.3% 21.0% 41.4% 48.8%
42.6% 40.3%
18.90/0
4.1o/o
23.1%
26.3%
1.706
16.0% 34.506 3.0% 22.00/0 22.906
5.4o/o
19.20/0 31.5%
18.406
28.206 13.2%
6.50/0
2.40/o
26.6%
3.1%
36.6%
3.6%
18.4% 3.9%
10.0%
4.0%
27.4%
28.5%
26.2% 36.9%
6 Diabetes
I'erc enlace ol |>eople ji <l 'II \ears and alxive with dialx-tes 2000
7 Ki-search
Number D| publications mi c ardio\ast ular disease 1991 2001
8 Policies ami legislation
Ix-gal st. it us K| smoking in government building 2004 or latest available data
4.7%
-
unknown
4.5%
-
not regulated
2.6%
1
unknown
8.8%
-
banned
0.9%
HHHHHHH
not regulated
7.3%
-
unknown
6.1%
110
not regulated
4.7%
1
not regulated
6.8%
710
restricted
3.8%
320
restricted
6.8%
1
banned
6.2%
-
unknown
9.1%
4
unknown
4.6%
3
restricted
5.8%
1
banned
9.9%
3
restricted
4.0%
345
restricted
4.2%
-
restricted
3.3%
1
unknown
3.5%
-
unknown
4.9%
HHHHHHI
restricted
3.8%
-
banned
3.6%
HHHHHHH
restricted
4.3%
307
banned
9.4%
HHHHHHI
banned
7.70/0
18
banned
2.7%
2
not regulated
1.0%
-
not regulated
1.9%
HHHHHHI
restricted
1.0%
4
restricted
8.8%
1 237
restricted
3.4%
-
restricted
1.0%
HHHHHHH
not regulated
2.8%
-
not regulated
5.2%
53
restricted
2.4%
472
restricted
3.6%
11
unknown
1.4%
-
unknown
1.1%
2
restricted
1.4%
-
unknown
6.3%
HHHHHHI
not regulated
3.3%
2
restricted
3.6%
HHHHHHH
restricted
4.4%
41
banned
6.0%
15
restricted
9.2%
-
restricted
4.3%
78
banned
3.8%
308
restricted
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep.
Chad
Chile
China
Colombia
Comoros
Congo
Congo, Dem. Rep.
Cook Islands
Costa Rica
Cote d'lvoire
Croatia
Cuba
Cyprus
Czech Republic Denmark
85
World Data Table
Country
1 2 3 Population Heart disease Stroke
4 Rheumatic heart diseas
Number of deat 2002
Thousands i Disability Mortality Disability Mortality 2002 ! DALYS lost per 1000 Number DA LYS lost per 1000 Number population of deaths population of deaths 2002 2002 2003 or latest available data 2002
Djibouti
693 21
727 7 248
27
Dominica
78 3
30 4 30
0
Dominican Republic
8616 11
7 271 9 4 833
54
Ecuador
12810 5
5 826 5 4 374
117
Egypt
70 507 21 103 829 8
35054
3398
El Salvador
6415 10
5328 4
1 684
39
Equatorial Guinea
481 11
313 12
333
18
Eritrea
3991 9
1 326 10 1 474
42
Estonia
1 338 16
6 235 9 2 964
65
Ethiopia
68 961 10
32477 11 35329
2 482
Fiji
831 18
783 17 685
21
Finland
5 197 7
12488 4 4875
77
France
59 850 3
46132 3 37750
1 136
Gabon
1 306 11
1 001 11 951
57
Gambia
1 388 10
789 11
837
48
Georgia
5177 23
26035 17 15680
59
Germany
82414 6 172717 4
79326
2 241
Ghana
20471 9
10471 11 11 337
705
Greece
10970 7
16825 6 22694
10
Grenada
80 9
85 13
91
1
Guatemala
12036 4
2 796 4
2232
14
Guinea
8359 11
4137 12
4415
289
Guinea-Bissau
1 449 11
783 13
•
844
52
Guyana
764 12
791 18
880
8
Haiti
8218 5
2469 16
6764
62
Honduras
6781 , 10
4 544 8
2 786
79
Hungary
9923 13
29 502 8
17 148
354
Iceland
287 5
416 3 189
3
India
1 049 549 20 1 531 534 10 771 067
103913
Indonesia
217 131 14 220372 8 123 684
11 660
Iran, Isl. Rep.
68070 17
81 983 8 31 768
1 138
Iraq
24510 19
22 036 8 8 291
695
Ireland
3911 8
6 527 4 2 650
51
Israel
6304 4
5 705 3 2 233
170
Italy
57 482 4
92 928 4 69 075
1 790
Jamaica
2627 5
1 877 11
3 559
59
Japan
127478 3
90 196 5
134952
2 585
Jordan
5329 13
3 788 6
1 428
127
Kazakhstan
15469 28
51 948 17
26874
919
Kenya Kiribati
31 540 9 87 1
13661 10 7 18
14843 81
360
o
Korea, Dem. People's Rep. of
22 541 13
26 953 8
14337
1 317
Korea, Republic of
47 430 3
15811 9
46 151
202
Kuwait
2 443 10
940 3
213
7
Kyrgyzstan
5 067 22
10 850 22
8366
351
Lao People's Dem. Rep.
5529 19
5539 12
3 620
484
Latvia
2329 17
9928 12
7278
109
Lebanon
3596 17
5471 7
2072
119
86
5 6
7 8
Smoking prevalence Diabetes
Research Policies and
Percentage
of people 18 fcroeotage of people Number of publications legislation
Country
c.irs .mil -ilicnr \\ ho smoke aged 20 vears and above on cardiovascular disease
Legal status of smoking
2003 or lute*! atailahlc data with diabcU-s 1991- 2001
in government buildings
men
women 2000
2004 or latest available data
-
2.50/0
unknown
Djibouti
-
| - 6.20/0
unknown
Dominica
22.1%
16.2% 5.2o/o HH
restricted
Dominican Republic
31.9%
7.4% 4.80/0 3
banned Ecuador
47.9%
1 .80/0 7.20/o
20
restricted Egypt
-
3.0% unknown El Salvador
-
3.8o/o
-
unknown
Equatorial Guinea
-
2.8o/o
4
not regulated
Eritrea
57.1%
28.8% 4.4o/o
7
banned
Estonia
9.7%
0.8% 2.80/0
4
not regulated
Ethiopia
47.3%
14.0% 8.30/0
1
not regulated
Fiji
31.6%
22.3% 3.90/o
331
banned
Finland
42.6%
33.9o/o 3.9%
1 407
restricted
France
-
1.20/o
not regulated
Gabon
43.40/0
6.20/o 3.3%
4
restricted
Gambia
61 .4%
6.30/o
5.30/0
159
not regulated
Georgia
39.0%
30.90/0
4.1o/o
2276
restricted
Germany
1 4.2%
1 .9%
3.3o/o
1
restricted
Ghana
53.5%
33.6%
10.30/0
245
restricted
Greece
-
-
7.30/o
-
unknown
Grenada
24.5%
3.70/o
2.70/o
HHHHHHi
restricted
Guatemala
-
0.9% 3
banned
Guinea
!
3.1o/o
HHHHUHJi
not regulated
Guinea-Bissau
-
-
4.20/o
unknown
Guyana
25.2%
5.4o/o
4.1o/o
-
unknown
Haiti
-
2.70/o
unknown
Honduras
47.2%
27.70/0
4.40/o
103
banned
Hungary
26.5%
27.1o/o 3.20/0 9 banned
Iceland
34.6%
3.4o/o 5.5o/o 294
banned
India
59.8%
5.3o/o 6JO/o
4
restricted
Indonesia
33.4%
3.5o/o
6.0%
-
banned
Iran, Isl. Rep.
-
-
6.1o/o
1
unknown
Iraq
33.8%
26.5o/o
3.2o/o
142
restricted
Ireland
35.8%
19jo/o 6.70/0
634
banned
Israel
37.9%
29jo/o
9.20/0
1 976
banned
Italy
56.10/0
21.2%
5.40/o
23
not regulated
Jamaica
52.5%
12.4%
6.70/o
3 769
restricted
Japan
66.80/0
5.3%
8.10/0
6
banned
Jordan
57.50/0
6.40/o
4.40/o
HHHHHH
restricted
Kazakhstan
66.3o/o
27.30/0
1.4%
3
not regulated
Kenya
•m
HHHI
8.60/o
-
not regulated
Kiribati
-
-
2.50/0
-
unknown Korea, Dem. People's Rep. of
69.5o/o
5.10/0
5.60/0
19
restricted Korea, Republic of
35.7%
2.70/0
9.8o/o
17
restricted
Kuwait
64.1%
41.4%
3.6%
HHHHHH
not regulated
Kyrgyzstan
68.90/0
16.1%
1.8%
-
restricted
Lao People's Dem. Rep.
64.50/0
29.20/0
4.50A)
1
restricted
Latvia
60.70/0
46.90/0
7.00/0
65
restricted
Lebanon
87
World Data Table
Country
i
Population
Thousands 2002
2 Heart disease
3 Stroke
4 Rheumatic heart diseas
Number of deal
2002
Disability Mortality Disability Mortality
DALYS lost per 1000 Number DALYS lost per 1000 Number population of deaths population of deaths 2002 2002 ; 2003 or latest available data 2002
Lesotho
1 800
9
1 200 11
1 299
24
Liberia
3 239
12
1 442 14 1 559
130
Libyan Arab Jamahiriya
5445
15
5 309 6 1 762
130
Lithuania 3 465
16 14662 7 5089
186
Luxembourg
447
4
455 5 390
0
Macedonia, Former Yugos. Rep. of 2 046
9
2544 13
3 772
41
Madagascar
16916
10
8327 11
9020
609
Malawi
11 871
10
6773 11
7 249
106
Malaysia
23965
8 13445 7
10 169
464
Maldives
309
17
282 10
152
16
Mali
12623
11
5406 13
5946
478
Malta
393
9
865 4
338
6
Marshall Islands
52
20
57 20
54
2
Mauritania
2807
11
1 640 13
1 756
111
Mauritius
1 210
18 2034 11
1 235
5
Mexico
101 965
6 51 454 4
26478
1 093
Micronesia, Federated States of
108
12
64 14
69
2
Moldova, Republic of
4270
23 1
8559 15
7 848
264
Monaco
34
3
27 3
22
1
Mongolia
2 559
8
1 153 25
2 515
145
Morocco
30072
14 29934 5
10607
808
Mozambique
18537
8
7 969 10
8896
246
Myanmar
48852
17 58478 11
33 406
3 746
Namibia
1 961
8
996 10
1 108
25
Nauru
13
22
17 10
7
0
Nepal
24609
18 23314 10
11 961
1 648
Netherlands
16067
5 1
9045 4
12459
16
New Zealand
3 846
7
6 141 4
2 699
139
Nicaragua
5335
8
2 680 7
1 768
70
Niger Nigeria
11 544 120911
11 4423 13 11 64778 12
4831 69932
439 4795
Niue
Norway
2 4514
10 5
1 12
8 886 3
1
4817
0 103
Oman
2768
17
1 765 4
375
12
Pakistan
149911
18 154338 9
78 512
11 604
Palau Panama
20 3064
14 5
17 14 1 628 5
16 1 489
0 30
Papua New Guinea
5586
18
3 994 10
1 960
351
Paraguay
5740
7
2 606 10
2881
36
Peru
26 767
4 10615 4
8084
157
Philippines
78 580
10 4
5378 7
24368
2812
Poland
38622
10 7
7 151 7
43032
1 277
Portugal
10049
5 1
0927 9
20069
189
Qatar
601 22387
9 238 4 13 60718 13
75 52272
4 566
Russian Federation
144082
27 674881 19
517424
8 126
Rwanda
8272
10 3 493 12
3811
101
Saint Kitts and Nevis
42
10
46 19
84
0
88
5 moking prevalence Percentage ol people IN
ars and lbove \\lio smoke (Hb1 i>r Aiiiv ,ir.;i/<iMr i/iitj nu'ii women
6 7 Diabetes Research
Percentage of people Numl>iT of publications aged 2(1 ve.irs ami abo\e on cardiovascular disease \\ithdiabetcs 1W1 .'()()/
2000
8 Policies and legislation
; Legal status of smoking in government buildings
o o 2004 or latest available Jata
Country
-
-
3.1%
unknown Lesotho
-
i
3.10/0
unknown
Liberia
-
pHHHi
3.1% banned
Libyan Arab Jamahiriya
46.4%
15.90/0
4.2o/o 5 restricted
Lithuania
41 .4%
30.20/0
3.6o/o
3
restricted
Luxembourg
-
;
3.8o/o
5 banned Macedonia, Former Yugos. Rep. of
-
-
1.4o/o
2 not regulated Madagascar
31.0%
; 7.40/0
1.1%
1 not regulated
Malawi
52.40/0
3.00/0
7.60/o
16 banned
Malaysia
-
-
5.0%
banned
Maldives
26.9%
4.70/o
2.90/o
restricted
Mali
DH^MBBMH
-
13.90/0
5 not regulated
Malta
-
8.60/o
9 banned
Marshall Islands
25.0%
i 4.30/o
2.80/o
not regulated
Mauritania
54.70/0
3.10/0
14.6%
2 restricted
Mauritius
36.5%
14.3%
3.90/o
201 restricted
Mexico
HH1
IHHHi
8.6%
not regulated Micronesia, Federated States of
-
~
5.90/o
I restricted Moldova, Republic of
••
8.80/0
7
unknown
Monaco
46.20/0
7.30/0
2.50/o
1 restricted
Mongolia
32.6Q/0
0.60/o
2.6o/o
7
restricted
Morocco
-
-
1.6o/o
1 unknown
Mozambique
55.50/0
12.20/0
2.00/0
mwmuam
unknown
Myanmar
33.80/0
16.1%
3.10/0
not regulated
Namibia
56.80/0
64.70/0
27.80/0
banned
Nauru
61.5%
34.60/0
3.9% 3 banned
Nepal
38.30/0
32.80/0
3.5% 917
restricted
Netherlands
28.10/0
28.70/0
6.70/0 131 restricted
New Zealand
HHI
HHHHH
2.90/0
restricted
Nicaragua
-
-
2.50/0
-
unknown
Niger
16.30/0
3.60/o
3.4%
18
banned
Nigeria
36.80/0
14.00/0
6.30/0
-
restricted
Niue
40.3o/o
39.00/0
3.9%
185
restricted
Norway
23.60/0
2.90/o
9.9o/o
19
unknown
Oman
30.30/0
3.80/o
7jo/o
12
banned
Pakistan
50.9o/o
22.6%
8.60/0
-
banned
Palau
35.1%
17.70/0
3.5%
1
unknown
Panama
48.9%
-
6.50/o
3
banned
Papua New Guinea
45.80/0
15.60/0
3.70/o
restricted
Paraguay
-
-
5.20/0
3 restricted
Peru
59.6o/o
13.8%
7.10/0
2 restricted
Philippines
51.50/0
27.90/0
4.1o/o
187 banned
Poland
44.20/0
19jo/o
8.60/o
51
restricted
Portugal
-
-
10.10/0
7 unknown
Qatar
33.3o/o
10.80/0
6.6o/o
16
unknown
Romania
58.10/0
15.80/0
4.20/o
13 banned Russian Federation
HHI
HHHH
0.9o/o
not regulated Rwanda
-
-
7.3%
unknown Saint Kitts and Nevis
89
World Data Table
Country
i
Population
Thousands 2002
2 Heart disease
Stroke
4 Rheumati heart disea
Number ot tie 2002
Disability
DALYS lost per 1000
population 2002
Mortality Disability Mortality
Number DALYS lost per 1000 Number of deaths population of deaths 2002 2003 or latest available data 2002
Saint Lucia
148
6
71
11 120
4
Saint Vincent and Grenadines
119 9
103 10 88
2
Samoa
176 14
117
14 128
3
San Marino
27 5
40 3 26
1
Sao Tome and Principe
157
7
81 10 107
2
Saudi Arabia
23 520
17
16438 4 3818
126
Senegal
9855
10
3838 12 4154
355
Serbia and Montenegro
10535
12
23 610 12 21 756
238
Seychelles
80
7
54 2 15
1
Sierra Leone
4764
13
2813 15 3035
216
Singapore
4 183
7
3 946 3 1 716
39
Slovakia
5398
12
14609 5
4445
131
Slovenia
1 986
6
2803 6
2003
87
Solomon Islands
463
12
213 13
220
6
Somalia
9480
19
6818 13
4426
333
South Africa
44759
9
27013 11
30306
792
Spain
40977
4
45018 3
34880
1 738
Sri Lanka
18910
8
16297 7
13 348
175
Sudan
32 878
15
28 458 10
16532
800
Suriname
432
13
397
12
362
4
Swaziland
1 069
8
529
8
499
13
Sweden
8867
5
20 122 3
9 984
143
Switzerland
7 171
4
10 746 2
4 508
112
Syrian Arab Republic Tajikistan
17381 6 195
13 23
11 168 11 447
11 7
7 675 3 048
1 715 419
Tanzania, United Republic of 36 276 Thailand 62 193
10 6
14720
28425
12 5
16 115 24810
439 456
Timor-Leste
739 18
635
10 315
49
Togo
4801
10
2474
12
2675
175
Tonga
103
10
70
12 79
2
Trinidad and Tobago
1 298
15
2 156
10 1 253
23
Tunisia
9728
15
12956 6
4798
I 298
Turkey
70318
16
102 552
13
62 782
1 584
Turkmenistan
4794
34
11 671
7
2 182
; 221
Tuvalu
10
18
11
20
11
0
Uganda
25004
10
10 163
11
11 043
288
Ukraine
48 902 28
335610
13
126 117
3085
United Arab Emirates
2937 17
2235 4
363
16
United Kingdom
59 068 7
120530 4
59322
1 712
United States of America 291038
8
514450 4
163 768
3 479
Uruguay
3391
6
3980
7
3 773
32
Uzbekistan
25705
24
55693
12
23 436
1 558
Vanuatu
207
13
120
13
122
3
Venezuela
25226
10
17967
5
8 720
208
Viet Nam
80278
10
66 179
8
58308
4210
Yemen
19315
22
16217 9
6464
743
Zambia
10698
8
4 153 9
4604
135
Zimbabwe
12 835
8
5752
10
6264
158
90
5 6 Smoking prevalence Diabetes
1'iTii'iitasje of people 18 IVrivntaiy <>l proplr M-ars aiul above \vlio smoke aged 20 years and alxwe -003 IT lau-it iiuJi/iiWi' Juta with di.ibrh-s w,,nu-n ^00
7 Research
Number of publications on cardiovascular disease 1991 2001
8 Policies and legislation
Legal status of smoking in government buildings 2004 or latest available data
Country
34.6%
5.0% 6.2%
restricted
Saint Lucia
34.6%
5.6% 7.3%
-
unknown Saint Vincent and Grenadines
67.4%
28.8% 6.1o/o
HHHHHHi
banned
Samoa
-
- , 9.2o/o
-
unknown
San Marino
•m
0.90/o
HHHHHMHI
not regulated
Sao Tome and Principe
29.1%
1.20/0 9.3o/o 51
banned Saudi Arabia
21.2%
1.50/o 3.4o/o
3
not regulated Senegal
55.5%
51 .80/0 4.20/o
21
not regulated
Serbia ft Montenegro
32.5%
15.00/0 14.6o/o
HBHBHMH93
unknown
Seychelles
-
3.3%
-
unknown
Sierra Leone
23.7%
3.2% 11.40/0
76
restricted
Singapore
42.3%
28.00/0 3.9%
25
banned
Slovakia
32.7%
20.80/0 4.30/o
34
restricted
Slovenia
-
-
6.40/0
-
restricted
Solomon Islands
HUH
-
2.70/0
HBHHHBHi
unknown
Somalia
43.4%
13.9% 3.40/o
77
restricted
South Africa
43.9%
31.20/0 8.70/0 689
restricted
Spain
38.7%
3.1% 5.4o/o 6
banned
Sri Lanka
27.7%
2.7% 2.9o/o
-
restricted
Sudan
-
- j 3.8%
-
not regulated
Suriname
19.6%
4.9o/o 2.9o/o
HBHHHHI
not regulated
Swaziland
21.3% 37.6%
24.90/0 28.3%
4.3% 3.9%
654 440
banned restricted
Sweden Switzerland
44.0%
16.70/0
8.20/0
banned
Syrian Arab Republic
IHH
HHBSHI
3.1o/o
-
not regulated
Tajikistan
48.9%
7.20/o
1 .30/0
_
not regulated
Tanzania, United Republic of
32.2%
2.7o/o
3.80/o
59
restricted
Thailand
-
-
-
-
unknown
Timor-Leste
Bin
HHMI
3.1%
*
not regulated
Togo
62.10/0
14.20/0 i 6.30/0
-
banned
Tonga
-
-
7.30/o
5
not regulated
Trinidad and Tobago
52.90/0
2.50/o
2.90/o
8
restricted
Tunisia
51.10/0
18.50/0
7.30/o
578
banned
Turkey
-
-
3.20/o
-
banned
Turkmenistan
BBH
-
6.3%
HHHHHHi!
banned
Tuvalu
33.40/0
7.1o/o
1.1%
2
restricted
Uganda
55.5%
14.70/0
4.40/o
19
restricted
Ukraine
27.6%
4.00/0
20.5o/o
8
restricted United Arab Emirates
34.60/0
34.40/0 3.90/o
2 667
not regulated
United Kingdom
27.80/0
22.3% 8.80/0
12 502
restricted
United States of America
39.40/0
30.80/0 6.80/o
2
restricted
Uruguay
28.70/0
1 .40/o 3.20/o 1
not regulated
Uzbekistan
47.90/0
4.80/o 6.9%
restricted
Vanuatu
51.90/0
20.5o/o 4.3% unknown
Venezuela
53.2%
3.0%
1.80/o
banned
Viet Nam
60.00/0
29.0o/o
4.40/o
unknown
Yemen
21.40/0
8.8%
1 .6%
restricted
Zambia
32.2o/o
4.6o/o
2-QO/o 2
unknown Zimbabwe
91
Glossary of terms used in this publication
ACE inhibitors: angiotensin-converting-enzyme inhibitors. Drugs used to treat high blood pressure, and to aid healing after a heart attack.
Angina (angina pectoris): pain or discomfort in the chest that occurs when part of the heart does not receive enough blood. Typically, it is precipitated by effort and relieved by rest.
Angioplasty: a non-invasive surgical procedure used to open up blockages in blood vessels, particularly the coronary arteries that feed the heart. Often performed with either a balloon or a wire mesh (stent).
Anticoagulant: medication that delays the clotting (coagulation) of blood.
Arrhythmia: a change in the regular beat or rhythm of the heart. The heart may seem to skip a beat, or beat irregularly, or beat very fast or very slowly.
Arteriosclerosis: a general term for the hardening of the arteries.
Asymptomatic: without symptoms. This term may apply either to healthy persons or to persons with preclinical (prior to clinical diagnosis) disease in whom symptoms are not yet apparent.
Atherosclerosis: one form of arteriosclerosis, where the hardening and narrowing of the arteries is caused by the slow build-up of fatty deposits on the inside lining.
Atrial fibrillation: a common heart rhythm disorder in which the two small upper chambers of the heart (the atria) quiver instead of beating effectively. This quivering makes the heart less efficient, allows blood to pool and form clots, and predisposes to stroke.
Blood pressure: the force of the blood pushing against the walls of arteries. Blood pressure is given as two numbers: systolic pressure (the pressure while the heart is contracting) and diastolic pressure (the pressure when the heart is resting between contractions).
Body mass index (BMI): a measure of weight in relation to height. It is calculated as weight (in kilograms) divided by the square of height (in metres). A BMI of less than 25 is considered normal, 25-30 is overweight, and greater than 30 defines obesity.
Cardiovascular disease (CVD): any disease of the heart or blood vessels, including stroke and high blood
o o
pressure.
Carotid stenosis: narrowing of the carotid arteries,
O
the main arteries in the neck that supply blood to the brain.
Cerebrovascular disease: also called a stroke or the brain equivalent of a heart attack. A condition in which a blood vessel in the brain bursts or is clogged bv a blood
oo 7
clot, leading to inadequate blood supply to the brain and death of brain cells.
Cholesterol: a waxy substance that circulates in the bloodstream.
Cholesterol plaques: deposits of fat, cholesterol, cellular waste products, calcium and other substances that build up on the inner lining of an arterv.
1 O J
Congestive heart failure: a condition in which the heart cannot pump enough blood to meet the needs of the body's other organs.
Coronary artery bypass surgery (CABG): A type of heart surgery that re-routes blood around clogged arteries — or "bypasses" them - to improve the supply of blood and oxygen to the heart.
Coronary heart disease: heart disease in which the coronary arteries are narrowed and the supply of blood and oxygen to the heart therefore decreased. Also called coronary artery disease or ischaemic heart disease. It includes heart attack and angina.
o
Developing country, high mortality: a developing country with high child mortality and high or very high adult mortality.
Developing country, low mortality: a developing country with low child mortality and low adult mortality.
Diabetes mellitus: a chronic disease due to either insulin deficiency or resistance to insulin action or both, and associated with hyperglycaemia (elevated blood glucose levels).
Direct costs: costs associated with an illness that can be attributed to a medical service, procedure, medication, etc., such as X-ray examination, pharmaceutical drugs (for example, insulin), surgery, or a clinic visit.
Disability adjusted life years (DALYs): a measure of overall burden of a disease by combining the years of potential life lost due to premature death and the years of productive life lost due to the disability. One DALY is one lost year of healthy life.
92
Epidemic: tin- occurrence1 in a community or region of cases ol an illness, specific health-related behaviour, or other health-related events clearly in excess of what would normally be expected.
Health: a state of complete physical, mental, and social \u-ll being and not merely the absence of disease or infirmity.
HDL (high-density lipoprotein) cholesterol: the
so-called "yood cholesterol". HDL helps remove cholesterol from the blood vessels. High levels of blood HDL protect against heart disease.
Heart attack (myocardial infarction): death of part ol the heart muscle as a result of a coronary artery becoming completely blocked, usually by a blood clot (thrombus), resulting in lack of blood flow to the heart muscle and therefore loss of needed oxygen.
Heart failure: see Congestive heart failure.
High blood pressure: a systolic blood pressure of 140 mmHg or greater or a diastolic pressure of 90 mmHg or greater.
Homocysteine: an amino acid produced by the body. Elevated levels of homocvsteine in the blood can damage blood vessels and disrupt normal blood clotting, and possibly increase the risk of heart attack, stroke, and peripheral vascular disease.
Indirect costs: costs associated with an illness that occur because an individual or familv members cannot work at their usual jobs, because of premature death, sickness, or disability.
Ischaemic heart disease: see Coronary heart disease.
LDL (low-density lipoprotein) cholesterol: the
so-called "bad cholesterol". High levels of LDL put people at risk of heart attack.
Lipid: fat or fat-like substance, such as cholesterol, present in blood and body tissues.
MET: metabolic equivalent; a measure of energy expenditure. One MET/min is the amount of energy expended while sitting quietly at rest for one minute.
Obesity: a condition characterized by excessive body fat. Usually defined as a body mass index greater than 30.
Peripheral vascular disease: disease of certain blood vessels outside the heart or disease of the lymph vessels, for example the arteries supplying the limbs, which leads to inadequate blood supply and claudication (intermittent pain on exercise such as walking).
Physical activity: bodily movement that substantially increases energy expenditure.
Premature death: death that occurs at an age earlier than the average life expectancy for the population.
Primary prevention: a strategy that helps to prevent the onset of a disease or condition in people who are at risk but do not already have the disease or condition. Examples are promotion of exercise in the general population, smoking prevention in young people, and also the treatment and control of high blood pressure as a strategy for primary prevention of stroke.
Rheumatic heart disease: damage to the heart valves and other heart structures from inflammation and scarring caused by rheumatic fever. Rheumatic fever begins with a sore throat due to streptococcal infection.
Secondary prevention: a strategy that helps to prevent recurrent disease or complications in people who already have the disease. For example, the use of a daily dose of aspirin by heart attack survivors is an effective strategy for preventing a second heart attack.
Sedentary: denotes a person who is relatively inactive and has a lifestyle characterized by a lot of sitting.
Stent: a device used to support tissues while healing takes place. A stent can keep "tube-shaped" structures, such as blood vessels, open after a surgical procedure. Anintraluminal coronary artery stent is a small, self- expanding, stainless steel mesh tube, which is placed within a coronary artery to keep the vessel open.
Stroke: the brain equivalent of a heart attack. A condition in which a blood vessel in the brain bursts (haemorrhagic stroke) or is clogged (embolic or ischaemic stroke) by a blood clot. This leads to inadequate blood supply to the brain and death of the brain cells, and usually results in temporary or permanent neurological deficits.
Transient ischaemic attack (TIA): small stroke-like event, which resolves in a day or less. It is often a warning sign of an impending stroke.
Triglyceride: the chemical form in which most fat exists in food and in the body.
93
Sources
PART 1 CARDIOVASCULAR DISEASE
1 Types of cardiovascular disease
Deaths from cardiovascular diseases
Mortality and burden of disease estimates for countries provided by Colin Mathers (Evidence and Information for Policy, WHO) from analyses prepared for The World Health Report 2003.
Global deaths from CVD
World Health Organization. The World Health Report 2003: shaping the future. Geneva, WHO, 2003, Annex Table 2:156.
Clipboard
WHO. The World Health Report 2003: shaping the future. Geneva, WHO, 2003, Annex Table 2:156.
2 Rheumatic fever and rheumatic heart disease
Map: Deaths from rheumatic heart disease
Mortality and burden of disease estimates for countries provided by Colin Mathers (Evidence and Information for Policy, WHO) from analyses prepared for The World Health Report 2003.
Rheumatic heart disease in children
Carapetis JR. The current evidence for the burden of group A streptococcal diseases. A review of WHO activities in, the burden of, and the evidence for strategies to control group A streptococcal diseases. Geneva, WHO, 2004.
Deaths from rheumatic fever and rheumatic heart disease in the Aboriginal and non- Aboriginal populations of Australia
Carapetis JR, Currie BJ. Mortality due to acute rheumatic fever and rheumatic heart disease in the Northern Territory: a preventable cause of death in Aboriginal people. Australian and New Zealand journal of public health, 1999, 23:159-163.
Clipboard
Rheumaticfever and rheumatic heart disease: report of a WHO Expert Committee. Geneva, WHO, 2003 (WHO Technical Report Series, No. 923).
Text
Stollerman GH. Rheumatic fever in the 21st century. Clinics in infectious diseases, 2001 , 33:806—814.
Treating acute rheumatic fever. British medical journal, 2003, 327:631 63 (editorial).
WHO. The World Health Report 2003: shaping the future. Geneva, WHO, 2003, Annex Table 2:156.
Veasy LG, Hill HR. Immunologic and clinical correlations in rheumatic fever and rheumatic heart disease. Pediatric infectious diseases journal, 1997, 16:400^1-07.
PART 2 RISK FACTORS
3 Risk factors
Leading risk factors
WHO. Leading 10 selected risk factors as percentage cause of disease burden measured in DALYs. The World Health Report 2002: reducing risks, promoting healthy life. Geneva, WHO, 2002, 162.
Contributory factors
WHO. Quantifying selected major risks to health. The World Health Report 2002: reducing risks, promoting healthy life. Geneva, WHO, 2002, 57-61.
Clipboard
Beaglehole R, Magnus P. The search for new risk factors for coronary heart disease: occupational therapy for epidemiologists? International journal of epidemiology , 2002, 3 1(6): 11 17 22; author reply 1134-5.
Text
Inter-Society Commission for Heart Disease Resources A: Primary prevention of the atherosclerotic diseases. Circulation, 1970, 42:A55-A95.
94
4 Risk factors start in childhood and youth
Maps: Early starters; Clipboard
Global Youth Collaborating Group. Special report: Differences in worldwide tobacco use by gender: findings from the Global Youth Tobacco Survey. Journal of school health, 2003, 73(6):207 21 5. Detailed country information available at: http://www.cdc.gov/tobacco/global/GYTS.htm
Overweight trends in the USA
CDC, National Center for Health Statistics. Health, United States, 2003 with Chartbook on trends in the health of Americans. Hyattsville, MD, 2003. BMI at or above the sex-age-specific 95th percentile http://www.cdc.gov/nchs/data/hus/tables/2003/ 03hus069.pdf
Overweight youth
Lissau I, Overpeck MD, Ruan WJ, Due P, Holstein BE, Hedinger M, and the Health Behaviour in
o
School-aged Children Working Group. Body mass index and overweight in adolescents in 1 3 European countries, Israel, and the United States. Archives of pediatric and adolescent medicine, 2004, 158:27—33. Table 3. Prevalence of BMI at or above the 95th percentile (overweight) by sex (self-reported).
Wow: USA
Kimm SYS et al. Decline in physical activity in black girls and white girls during adolescence. New England journal of medicine, 2002, 347:709-15.
Clipboard
Overweight: WHO Fact Sheet, Global Strategy on Diet, Physical Activity and Health. Obesity and overweight. Geneva, WHO, 2003
o
http://www.who.int/hpr/gs.facts.shtml
Text
Zimmet P. The burden of type 2 diabetes: are we doing enough? Diabetes and metabolism, 2003, 29(4Pt2):6S9-6S18.
Kitagawa T, Owada M, Urakami T, Yamauchi K. Increased incidence of non-insulin dependent diabetes mellitus among Japanese schoolchildren correlates with an increased intake of animal protein and fat. Clinical pediatrics (Philadelphia), 1 998, 37(2): 111115.
Likitmaskul S, Kiattisathavee P, Chaichanwatanakul K, Punnakanta L, Angsusingha K, Tuchinda C. Increasing prevalence of type 2 diabetes mellitus in Thai children and adolescents associated with increasing prevalence of obesity. Journal of pediatric endocrinology and metabolism, 2003, 16(l):71-77.
Berenson GS, Srinivasan SR, Bao W, Newman WP 3rd, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. New England journal of medicine, 1998, 338(23):1650-1656.
5 Risk factor: blood pressure
Maps: Blood Pressure
WHO Global NCD InfoBase [online database].
Geneva, WHO, 2004
http : / / www. who. int /ncd_sur veillance / infobase /
High blood pressure in the USA
Trends, USA, 1960-2000; Health, United States 2002; Table 68. Hypertension among persons 20 years of age and over, according to sex, age, race, and Hispanic origin: United States, 1960-62,1971-74, 1976-80, 1988-94, and 1999-2000. Referencing Centers for Disease Control and Prevention, National Center for Health Statistics, National Health and Nutrition Examination Survey, Hispanic Health and Nutrition Examination Survey (1982-84), and National Health Examination Survey (1960-62) http://www.cdc.gov/nchs/data/hus/hus02.pdf
Blood pressure changes with age in the Gambia
van der Sande MA, Bailey R, Faal H et al. Nationwide prevalence study of hypertension and related non-communicable diseases in The Gambia.
Tropical medicine and international health, 1997, 2(11):1039-1048.
Blood pressure in India
Singh RB, Suh IL, Singh V. et al. Hypertension and stroke in Asia: prevalence, control and strategies in developing countries for prevention. Journal of human hypertension, 2000, 14:749-763.
95
High blood pressure by years of education in South Africa
South Africa Demographic and Health Survey 1 998 http://www.doh.gov.za/facts/1998/sadhs98/
Text
Vasan RS, Larson MG, Leip EP, Evans JC, O'Donncll CJ, Kannel WB, Levy D. Impact of high-normal blood pressure on the risk of cardiovascular disease. New England journal of medicine, 2001 , 345:1291 1297.
World Hypertension League. The high blood pressure /heart failure link: a new concern for older Americans http://www.mco.edu/org/whl/hrtfail.html
Huxley R, Neil A, Collins R. Unravelling the fetal origins hypothesis: is there really an inverse association between birthweight and subsequent blood pressure? Lancet, 2002, 360:659-665.
Systolic blood pressure. British medical journal, 2002, 325:917-918 (editorial).
Sleight P. Fact sheet: isolated hypertension (ISH). World Hypertension League http://www.mco.edu/org/whl/isyshype.html
Weinberger MH, Miller JZ, Luft FC, Grim CE, Fineberg NS. Definitions and characteristics of
o
sodium sensitivity and blood pressure resistance. Hypertension, 1986, 8(2): 1 27-1 34.
He J, Ogden LG, Vupputuri S, Bazzano LA, Loria C, Whelton PK. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults.
o
Journal of the American Medical Association, 1999, 282:2027-2034.
6 Risk factor: lipids
Map: Cholesterol
WHO Global NCD InfoBase [online database].
Geneva, WHO
http : / / www. who. int / ncd_sur veillance / infobase /
Current recommended lipid levels
De Backer G, Ambrosioni E, Borch-Johnsen K et al.; Third Joint Force of European and other Societies on Cardiovascular Disease and Prevention in Clinical Practice. European guidelines on cardiovascular disease prevention in clinical practice. Atherosclerosis, 2003, 171(1):145-155.
Third Report of the National Cholesterol Education
Program (NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol
in Adults (Adult Treatment Panel III) final report.
Circulation, 2002, 106:3143-3421
http: / /circ. ahajournals.org/cgi /reprint/ 1 06/2 5 /
3143.pdf
Trends in cholesterol levels in Beijing, China
Tolonen H, Kuulasmaa K, Ruokokoski. MONICA population survey data book. 2000 (data from 1984 — 1993). Zhao Dong, personal communication (data from 1996-1999).
Wow: USA
American Heart Foundation. About cholesterol http: / / www.americanheart.org/presenter.jhtml? identified 185
Clipboard
WHO. The World Health Report 2002: reducing risks, promoting healthy life. Geneva, WHO, 2002.
Text
American Heart Foundation. About cholesterol http://www.americanheart.org/
7 Risk factor: tobacco
Maps: Smoking prevalence
WHO Global NCD InfoBase [online database].
Geneva, WHO
http: //www. who. int/ncd_surveillance/infobase/
Cardiovascular risks of smoking
Price JF, Mowbray PI, Lee AJ, Rumley A, Lowe GD, Fowkes FG. Smoking and cardiovascular risk factors
o
in the development of cardiovascular disease and coronary artery disease: Edinburgh Artery Study.
European heart journal, 1999, 20:344-353.
96
Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men: longitudinal population study. British medical journal, 1998, 316:1043 104?"
Smoking and stroke: a causative role. Heavy smokers with hypertension benefit most from stopping. British medical journal, 1998, 317:962-963 (editorial).
Cole CW, Hill GB, Farzad E, Bouchard A, Moher D, Rody K, Shea B. Cigarette smoking and peripheral arterial occlusive disease. Surgery, 1993, 1 14(4):75 3-756; discussion, 756-757.
Lederlc FA, Johnson GR, Wilson SE et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Annals of internal medicine, 1997, 1 26(6) :44 1-449.
Smoking and urology: male fertility and sexuality dysfunctions. Cigarettes: what the warning label doesn't tell you: the first comprehensive guide to the health consequences of smoking. New York. The American Council on Science and Health, 1996, Chapter 1 1:95-100.
Smoking harms men. Sydney Morning Herald, 24 March 1997, 3 (quoting Australian and New Zealand journal of medicine).
Cardiovascular risks of passive smoking
Panagiotakos DB, Pitsavos C, Chrysohoou C, Skoumas J, Masoura C, Toutouzas P, Stefanadis C. Effect of exposure to secondhand smoke on markers of inflammation: the ATTICA study. American journal of medicine, 2004, 1 16(3):145-150.
Bonita R, Duncan J, Truelsen T, Jackson RT, Beaglehole R. Passive smoking as well as active
o o
smoking increases the risk of stroke. Tobacco control, 1999, 8:156-161.
International Consultation on Environmental Tobacco Smoke (ETS) and Child Health, 11-14 January 1999. Geneva, WHO, 1999 (WHO/NCD/TFI//99.10).
Smokers don't know the risks of heart attack
Ayanian JZ, Cleary PD. Perceived risks of heart disease and cancer among cigarette smokers. Journal of the American Medical Association, 1999, 281 : 101 9-102 1 .
Wow: USA
National Cancer Institute. Health ejfects of exposure to environmental tobacco smoke: the report of the California Environmental Protection Agency. Bethesda, MD, US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, 1999 (Smoking and Tobacco Control Monograph no. 10; NIH Pub. No. 99-4-645).
Wow: China
Smoking and health in China. 1996 National Prevalence
o
Survey of Smoking Pattern. Beijing, China Science and Technology Press, undated, 89.
Cv
Text
English IP, Willius FA, Berkson I. Tobacco and
o J ' J
coronary disease. Journal of the American Medical Association, 1940, 115:1327-1329.
Smoking study reveals grim disease risks. Australian
Associated Press, 20 May 2002
http:/ /news, ninemsn. com. au/Health/story_3 1927.
asp?MSID=6d40353f6b864cd7806381801f7fdcOa
Bonita R, Duncan J, Truelsen T, Jackson RT, Beaglehole R. Passive smoking as well as active smoking increases the risk of acute stroke. Tobacco control, 1999,8:156-160.
Lehr HA, Weyrich AS, Saetzle RK et al. Vitamin C blocks inflammatory platelet-activating factor mimetics created by cigarette smoking. Journal of clinical investigation, 1997, 99(10):2358-2364.
Davis JW, Shelton L, Watanabe IS, Arnold J. Passive smoking affects endothelium and platelets. Archives of internal medicine, 1989, 149(2):386-389.
McBride PE. The health consequences of smoking: cardivascular disease. Medical clinics of North America, 1992,76:333-353.
Aronow W. Effect of passive smoking on angina pectoris. New England journal of medicine, 1978, 299:21-24.
97
Humphries SE, Talmud PJ, Hawc E, Bolla M, Day INM, Miller GJ. Apolipoprotein E4 and coronary heart disease in middle-aged men who smoke- a
o
prospective study. Lancet, 2001, 358:1 15-1 19.
Gene linked to heart disease risk. BBC online, 1 3 July 2001
http: / 7www.bbc.co.uk
Prescott E, Scharling H, Osier M, Schnohr P. Importance of light smoking and inhalation habits on risk of myocardial infarction and all cause mortality. A 22 year follow up of 12 149 men and women in The Copenhagen City Heart Study. Journal of epidemiology and community health, 2002, 56:702—706 http://jech.bmjjournals.com/cgi/content/abstract/ 56/9/702
Willett WC, Green A, Stampfer MJ et al. Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. New England journal of medicine, 1987, 317:1303-1309.
8 Risk factor: physical inactivity
Map: Physical activity levels Non-EU countries
Unpublished preliminary analysis of the World Health Survey 2002-2003. Geneva, WHO.
Riitten A et al. Using different physical activity measurements in eight European countries. Results of the European Physical Activity Surveillance System (EUPASS) time series survey. Public health nutrition, 2003, 6(4): 371 376.
World Health Survey. Eurobarometer: International Physical Activity Questionnaire (IPAQ). Geneva, WHO http : / / www. who. int / ncd_sur veillance / infobase /
EU countries
Riitten A, Abu- Omar K. Prevalence of physical activity in the European Union. Sozial- und
Praventivmedizin/ Social and Preventative Medicine, 2004, 49(4).
World Health Survey. Eurobarometer: International
Physical Activity Questionnaire (IPAQ). Geneva,
WHO
http : / / www. who. int / ncd_sur veillance / infobase /
Sitting
Rutten A et al. Using different physical activity measurements in eight European countries. Results of the European Physical Activity Surveillance System (EUPASS) time series survey. Public health nutrition, 2003, 6(4): 371-376.
Physical activity
Department of Health, Hong Kong. Fact sheet on physical activity
http://www.info.gov.hk/dh/do_you_k/eng/ exercise.htm
Physical inactivity by social class in India
Singh RB, Sharma JP, Rastogi V, Niaz MA, Singh NK. Prevalence and determinants of hypertension in the Indian social class and heart survey. Journal oj human hypertension, 1997, 11:51-56.
Singapore keeps moving
National Health Survey 1998. Singapore, Epidemiology and Disease Control Department, Ministry of Health, 1998.
Transport
American Automobile Manufacturers Association (A AM A). Motor vehicle facts and figures 1996. Proceed with caution: growth in the global motor vehicle Jleet. Washington DC, World Resources Institute, 1996,44^7 http://www.wri.org/trends/autos2.html
The global fleet
American Automobile Manufacturers Association (AAMA). World motor vehicle data 1993; and Motor vehicle facts and figures 1996. Proceed with caution: growth in the global motor vehicle Jleet. Washington, DC, World Resources Institute, 1996 http://www.wri.org/trends/autos2.html
Wow: Being physically active...; Text
Bull FC, Armstrong T, Dixon T, Ham S, Neiman A,
o '
Pratt M. Physical inactivity. Ezzati M, Lopez A, Rodgers A, Murray C, eds. Comparative quantification oj health risks: global and regional burden of disease due to selected major riskfactors. Geneva, WHO, 2004 (in press).
98
Wow: Worldwide, physical inactivity...
The World Health Report 2002: reducing risks, promoting healthy life. Geneva, WHO, 2002:61.
Wow: In 1997, in China...
Matters of scale: November/ December 1997. Driving up CO2
http://www.worldwatch.org/pubs/mag/1997/106 /mos/
Wow: 25% of the world's cars...
Renner M. Live online discussions. Five hundred million cars, one planet — Who's going to give? 8 August 2003 http://www.worldwatch.org/live/discussion/83/
Text
World Heart Federation. A global embrace for World Heart Day. Message from the President, 29 Sept 2002 http : / / www. worldheartday. org/ WHDArchive / whd2002/ news/news. asp#
Kujala UM, Kaprio J, Sarna S, Koskenvuo M. Relationship of leisure-time physical activity and mortality: the Finnish twin cohort. Journal of the American Medical Association, 1998, 279:440-444.
HeartBytes. Reduce heart disease risk: encourage and prescribe exercise Jbr your patients. http://www.medscape.com/viewarticle/4701 15? mpid=25341
Cervero R. Shapeless, spread out, skipped over and scattershot — sprawl sweeps the globe. The World Paper, http : / / w w w. worldpaper. com / 2000 / mar 2 000 / cervero.html
9 Risk factor: obesity
Maps: Body mass index
WHO Global NCD InfoBase [online database].
Geneva, WHO
http: //www. who. int/ncd_surveillance/infobase/
Food consumption
Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. Geneva, WHO, 2003 (WHO Technical Report Series No. 916): Table 1:15. Data from: Popkin BM. The shift in stages of the nutritional transition in the developing world differs from past
experiences! Public health nutrition, 2002, 5:205-214.
Apple shape at higher risk of CVD than pear shape
Lakka HM, Lakka TA, Tuomilehto J, Salonen JT. Abdominal obesity is associated with increased risk of acute coronary events in men. European heart journal, 2002,23:706-713 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal cf medicine, 2003, 115(8A):37S-4-lS).
Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes care, 2001, 24:683-689 (cited in Sowers JR. Obesity as a cardiovascular risk factor. American journal of medicine,
2003, 11S(8A): 375-^1 S).
Overweight and obesity: defining overweight and obesity http: / /www. cdc.gov/nccdphp/dnpa/obesity/ defining.htm
Wow: Thailand
Associated Press in Bangkok. Thailand: Chubby nights soothe the heavyweight clubbers. South China Morning Post, 12 September 2002, 1 1 .
Text
WHO expert consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet, 2004, 363:157 63.
Eckel RH, Krauss RM. American Heart Association call to action: obesity as a major risk factor for coronary heart disease. Circulation, 1998, 97:2099-2100.
WHO. The World Health Report 2002: reducing risks, promoting healthy life. Geneva, WHO, 2002.
Peeters A, Barendregt JJ, Willekens F, Mackenbach JP, Mamun AA, Bonneux L. Obesity in adulthood and its consequences for life expectancy: a life table analysis. Annals of internal medicine, 2003, 138:24-32.
The catastrophic failures of public health. Lancet,
2004, 363(9411): 157-63 (editorial)).
99
Buncombe A. American undertakers offer 'super-size' coffins as population piles on the pounds. The Independent, 29 September 2003 http : / / news . independent .co.uk/ world / amer icas / story.jsp?story =448034
Fast food takeaways China. BBC online, 1999 http: / /news. bbc.co.uk/hi/english/health/ newsid_364000/364273.stm
Easen N. Asia Jails foul tojat. CNN, 21 Feb 2002 http://www.cnn.com/2002/WORLD/asiapcf/ auspac / 02 / 2 1 / asia . obesity / Prelated
Associated Press. New Zealand. Boarding pass and scales, please — NZ weighs the trend for heavier passenger loads. South China Morning Post, 4 October 2003, A10.
10 Risk factor: diabetes
Map: Prevalence of diabetes; Diabetes prevalence and trends; Clipboard
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030. Diabetes care, 2004, 27:1047-1053.
Text
International Diabetes Federation
http:// www.idf.org/home/index.cfmPnode =2 64
1 1 Risk factor: socioeconomic status
Prevalence of CVD risk factors by education in Canada
Choiniere R, Lafontaine P, Edwards AC. Distribution of cardiovascular disease risk factors by socioeconomic status among Canadian adults.
o
Canadian Medical Association journal, 2000, 162(9 Suppl):S13— 24. Note: Definitions used: Physical inactivity: leisure exercise less than once per week during previous month. Elevated cholesterol: >5.2 mmol/1 after fasting 8 hours or more.
The CVD mortality gap in the USA
Singh GK, Siahpush M. Increasing inequalities in all- cause and cardiovascular mortality among US adults aged 25—64 years by area and socioeconomic status,
1969—1998. International journal of epidemiology , 2002, 31(3):600 613.
Prevalence of high blood pressure by income in Trinidad and Tobago
Gulliford MC, Mahabir D, Rocke B. Socioeconomic inequality in blood pressure and its determinants: cross- sectional data from Trinidad and Tobago. Journal of human hypertension, 2004, 18:61—70.
Education level and obesity in Italy
Giampaoli S, Palmieri L, Dima F, Pilotto L, Vescio MF, Vanuzzo D. Socioeconomic aspects and cardiovascular risk factors: experience at the Cardiovascular Epidemiologic Observatory. Italian heart journal, 2001, 2(3 Suppl): 294-302.
Smoking and occupation in Uganda
Uganda Demographic and Health Survey 2000—2001 .
Smoking by years of education in South Africa
South Africa Demographic and Health Survey (SADHS) 1998.
Income and obesity in Saudi Arabia
Al-Nuaim AA et al. Overweight and obesity in Saudi Arabian adult population, role of socio-demographic variables. Journal of community health, 1997, 22(3):211-23.
Prevalence of diabetes by income in India
Ramachandran A, Snehalatha C, Kapur A et al. Diabetes Epidemiology Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diahetologia, 2001, 44(9): 1094-101 .
Wow: Canada
Evenson B. When rich and poor kids eat the same diet, poor ones get fatter. ProCOR, 12 September 2003.
Clipboard
Steptoe A, Feldman PJ, Kunz S, Owen N, Willemsen G, Marmot M. Stress responsivity and socioeconomic status: a mechanism for increased cardiovascular disease risk? European heart journal, 2002, 23(22): 1757-63.
100
Text
Terris M. The development and prevention of cardiovascular disease risk factors: socioenvironmental influences. Preventive medicine, 1999, 29(6 Pt2):Sl 1-17.
Pickering T. Cardiovascular pathways: socioeconomic status and stress effects on hypertension and cardiovascular function. Annals of the New York Academy of Sciences, 1999, 896:262 277.
Rao SV, Kaul P, Newby K et al. Poverty, process of care, and outcome in acute coronary syndrome. Journal of the American College of Cardiology , 2003, 41:1948-54.
12 Women: a special case?
Smoking
Prescott E, Hippe M, Schnohr P, Hein HO, Vestbo J. Smoking and risk of myocardial infarction in women and men: longitudinal population study. British medical journal, 1998, 316:1043-1047.
No time to walk
Clark J. News roundup: Women too busy to exercise. British medical journal, 2003, 326:467.
Walking reduces coronary heart disease
Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women. Is "no pain, no gain" passe? Journal of the American Medical Association, 2001, 285:1447-1454.
Hormone replacement therapy
Trevisan MM. Hormone replacement therapy. Global Symposium on Cardiovascular Prevention, Marbella, Spain, 11-13 April 2003.
Clipboard
WHO. The World Health Report 2003: Shaping the future. Geneva, WHO, 2003: Annex Table 2.
Text
Kmietowicz Z. News roundup: Women fail to recognise risk of heart disease. British medical journal, 2003, 326:355.
Ulmer H, Kelleher C, Diem G, Concin H. Why Eve is not Adam: prospective follow-up in 149650 women and men of cholesterol and other risk factors related to cardiovascular and all-cause mortality. Journal of women's health (Larchmount), 2004,
Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26- year follow-up of the Framingham population. American heart journal, 1986, 111:383-390.
McKinlay JB. Some contributions from the social system to gender inequalities in heart disease. Journal of health and social behaviour, 1996, 37:1-26.
Giles WH, Anda RF, Casper ML, Escobedo LG, Taylor HA. Race and sex differences in rates of invasive cardiac procedures in US hospitals: data from the National Hospital Discharge Survey. Archives of internal medicine, 1995, 155:318-324.
Dustan HP. Coronary artery disease in women. Canadian journal of cardiology, 1 990, 6(SupplB):19B-21B.
LeKmann JB, Wehner PS, Lehmann CU, Savory LM. Gender bias in the evaluation of chest pain in the emergency department. American journal of cardiology , 1996,77:641-644.
Roquer J, Campello AR, Gomis M. Sex differences in first-ever acute stroke. Stroke, 2003, 34(7): 158 1-1 585.
Adams KF Jr, Sueta CA, Gheorghiade M, O'Connor CM, Schwartz TA, Koch GG, Uretsky B, Swedberg K, McKenna W, Soler-Soler J, Califf RM. Gender differences in survival in advanced heart failure. Insights from the FIRST study. Circulation, 1999, 99(14): 1816-1821.
Mosca L et al. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation, 2004, 109:672-693.
101
PART 3 THE BURDEN
13 Global burden of coronary heart disease
Map: Healthy years of life lost to coronary heart disease
Mortality and burden of disease estimates for countries provided by Colin Mathers (Evidence and Information for Policy, WHO) from analyses prepared for The World Health Report 2003.
Disease burden in men; in women
WHO. The World Health Report 2003: Shaping the future. Geneva, WHO, 2003.
Clipboard; Text
Ounpuu S, Anand S, Yusuf S. The global burden of cardiovascular disease. Medscape cardiology, 24 January 2002
http://www.medscape.com/viewarticle/420877PWe bLogicSession=Pj4P2wsr611rYWKbLSDskpUMbsjmJ xtWvxSNaGHCVd2ranocYJpC 1 42976445789882471 33/1 84161 393/6/7001/7001/7002/7002/7001 /-I
Text
Nayha S. Cold and the risk of cardiovascular diseases. A review. International journal ofcircumpolar health, 2002,61(4):373-380.
14 Deaths from coronary heart disease
Map: Deaths from coronary heart disease
Mortality and burden of disease estimates for countries provided by Colin Mathers (Evidence and Information for Policy, WHO) from analyses prepared for The World Health Report 2003.
Deaths from coronary heart disease compared with other causes
WHO. The World Health Report 2003: Shaping the Juture. Geneva, WHO, 2003, Table 1.3:17.
Change of heart
British Heart Foundation Statistics database. 1. Mortality. Table 1.5 http: // www.heartstats.org
Wow: 3.8 million men...
WHO. The World Health Report 2003: Shaping the future. Geneva, WHO, 2003, Annex Table 2:154-1 59.
Text
Ounpuu S, Anand S, Yusuf S. The global burden of
cardiovascular disease. Medscape cardiology,
24 January 2002
http: // www.medscape.com/viewarticle/420877PWe
bLogicSession=Pj4P2wsr6 1 1 rYWKbLSDskpUMbsjmJ
xtWvxSNaGHCVd2ranocYJpC 1 42976445789882471
33/1 84161 393/6/7001/7001/7002/7002/7001 /-I
Khot UN, Khot MB, Bajzer CT et al. Prevalence of conventional risk factors in patients with coronary heart disease. Journal of the American Medical Association, 2003, 290:898-904.
Chambless L, Keil U, Dobson A, Mahonen M, Kuulasmaa K, Rajakangas AM, Lowel H, Tunstall- Pedoe H. Population versus clinical view of case fatality from acute coronary heart disease: results from the WHO MONICA Project 1985-1990. Multinational MONItorinp of Trends and
o
Determinants in CArdiovascular Disease. Circulation, 1997, 96(1 1):3849-59.
15 Global burden of stroke
Map: Healthy years of life lost to stroke
Mortality and burden of disease estimates for countries provided by Colin Mathers (Evidence and Information for Policy, WHO) from analyses prepared for The World Health Report 2003.
Stroke in young people
Jacobs BS, Boden-Albala B, Lin IF, Sacco RL. Stroke in the young in the northern Manhattan stroke study. Stroke, 2002, 33(1 2):2789-93.
Oral contraceptives
Lidegaard 0, Kreiner S. Contraceptives and cerebral thrombosis: a five-year national case-control study. Contraception, 2002, 65:197-205.
Wow: United Kingdom
Wise J. News: New clinical guidelines for stroke published. British medical journal, 2000, 320:823.
102
Wow: Stroke burden, 2020
Murray CJL, Lope/. AD. The global burden of disease. Boston, Harvard School of Public Health (for WHO and the World Bank), 1996, Table 17i:830.
Clipboard
Chobanian AV, Bakris GL, Black HR et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. Journal of the American Medical Association, 2003, 289:2560-2572.
Text
McCarron P, Davey Smith G, Okasha M, McEwen J. Blood pressure in young adulthood and mortality from cardiovascular disease. Lancet, 2000, 355:1430-31.
Adams RJ, McKie VC, Brambilla D et al. Stroke prevention trial in sickle cell anemia. Control clinical trials, New England journal of medicine, 1998, 19:110 129.
Bonita R, Scragg R, Stewart A, Jackson R, Beaglehole R. Cigarette smoking and risk of premature stroke in men and women. British medical journal, 1986, 293:6-8.
Lip GYH, Kamath S, Hart RG. Clinical review: ABC of antithrombotic therapy. Antithrombotic therapy for cerebrovascular disorders. British medical journal, 2002, 325:1161-1163.
16 Deaths from stroke
Map: Struck down
Mortality and burden of disease estimates for countries provided by Colin Mathers (Evidence and Information for Policy, WHO) from analyses prepared for The World Health Report 2003.
Predictors of death from stroke in Italy
Mazza A, Pessina AC, Pavei A, Scarpa R, Tikhonoff V, Casiglia E. Predictors of stroke mortality in elderly people from the general population. The CArdiovascular STudy in the ELderly. European journal of epidemiologj, 2001, 17(12): 1097-1 104.
Stroke compared with other causes of death; Wow: Worldwide...
WHO. The World Health Report 2003: Shaping the future. Geneva, WHO, 2003, Annex Table 2:154-159.
Wow: USA
American Stroke Association
http: / /www.strokeassociation.org/presenter.jhtml?
identified 103 3
Clipboard
Lip GYH, Kamath S, Hart RG. Clinical review: ABC of antithrombotic therapy. Antithrombotic therapy for cerebrovascular disorders. British medical journal, 2002, 325:1161-1163.
Text
The Stroke Association, United Kingdom. Stroke
prevention programmes
http : / / www. stroke, org. uk / Campaign / prevention . htm
Mensah GA. Global burden of hypertension: good news and bad news. Cardiology clinics, 2002, 20:181-186.
Heller RF, Langhorne P, James E. Improving stroke outcomes: the benefits of increasing availability of technology. Bulletin of the WHO, 2000, 78:1337-1343.
17 Economic costs
Global costs of smoking
WHO. World No Tobacco Day 2004
http: / / www. who.int/tobacco/areas/communications
/events/wntd/2004/en/
Global costs of heart disease medication
Kmietowicz Z. News: WHO warns of heart disease threat to developing world. British medical journal, 2002, 325:853.
Global costs of diabetes
International Diabetes Federation
http://www.idf.org/home/index.cfmPunode
=3B9691D3-C026-2FD3-87B7FAOB63432BA3
Latin America and the Caribbean
PAHO cites impact of diabetes in Latin America http: // www.unwire.org
103
USA, Australia, Europe
Reuters. Asia-Pacific Type 2 Diabetes Policy Group: spread of diabetes in Asia alarms experts. South China Morning Post, 1 May 2002, 10.
USA
Runners beat around the Bush. Knight Ridder in
o
Washington. South China Morning Post, 24 June 2002, 13.
Diet, nutrition and the prevention of chronic diseases: report of a Joint WHO/FAO Expert Consultation. Geneva, WHO, 2003 (WHO Technical Report Series No. 916):61.
Elliot A. US food industry ensures that consumers are not told to eat less. British medical journal, 2003, 327:1067.
Reuters Health Information 2004. US. drug sales $216.4 billion in 2003 - IMS report http://www.medscape.com/viewarticle/469471? mpid=25157
American Heart Association. Heart disease and stroke statistics — 2004 update. Dallas, American Heart Association, 2003, Chapter 12:42.
National Institute of Neurological Disorders and
O
Stroke. Questions and answers about stroke
http : / / www. ninds. nih . gov / health_and_medical /pub
s / stroke_backgrounder. htm
United Kingdom
Vlad I. Obesity costs UK economy £2 bn a year. British medical journal, 2003, 327:1308.
Wise J. News: New clinical guidelines for stroke published. British medical journal, 2000, 320:823.
Netherlands
van Exel J, Koopmanschap MA, van Wijngaarden JDH, Scholte op Reimer WJM. Costs of stroke and stroke services: determinants of patient costs and a comparison of costs of regular care and care organised in stroke services. Cost effectiveness and resource allocation, 2003, 1:2 http: / /www. resource-allocation, com/content/ 1/1/2
Polder JJ, Meerding WJ, Koopmanschap MA, Bonneux L, van der Maas PJ. Cost of illness in the Netherlands 1994. Rotterdam, Instituut Maatschappelijke Gezondheidszorg [Institute for Medical Technology Assessment], Erasmus University, 1997
http : / / www. ri vm . nl / kostenvanziekten / site_en / index.htm (in Dutch)
Evers SMAA, Struijs JN, Ament AJHA, van Genugten MLL, Jager JC, van den Bos GAM. The disease impact, health care management, and costs of stroke in the Netherlands. Bilthoven, National Institute for Public Health and the Environment (RIVM), 2002 (Report 282701001/2002).
Singapore
Venketasubramanian N, Yin A. Hospital costs for stroke care in Singapore. Cerebrovascular diseases, 2000, 10:320-326.
Price of weekly dose of medication
WHO cardiovascular Disease Programme. Pilot survey
O J
on cost of cardiovascular drugs 2003 (unpublished data).
The cost of risk factors
Liu K, Daviglus ML, Van LJ, Garside DB, Greenland P, Manheim LM, Dyer AR, Stamler J. Cardiovascular disease (CVD) risk factor status earlier in adulthood and cumulative health care costs from age 65 to the point of death. Circulation, 2004, 108:IV-722.
Lifetime costs of coronary heart disease
Klever-Deichert G, Hinzpeter B, Hunsche E, Lauterbach KW. Zeitschriftfur Kardiologie, 1999, 88:991-1000.
Expenditure on cardiovascular medications
Dickson M, Jacobzone S. Pharmaceutical use and expenditure for cardiovascular disease and stroke: a study of 1 2 OECD countries. Paris, Organisation for Economic Co-operation and Development, 2003 (OECD Health working papers, DELSA/ELSA/WD/HEA(2003)1), Table 1.
Wow: Aspirin
Ebrahim S. Cost-effectiveness of stroke prevention. British medical bulletin, 2000, 56:557-570.
104
PART 4 ACTION
18 Research
Map: CVD research publications; Regional research
Mendis S, Yach D, Benpoa R. Narvaez D, Zhang X.
o o
Research gap in cardiovascular disease in developing countries. Lancet, 2003, 361:2246-2247.
Clinical trials
Search by authors, 24 February 2004.
Research funding by the National Institute of Health in the USA
United States Department of Health and Human Services. National Institutes of Health. Estimates of funding Jbr various diseases, conditions, research areas http : / / www. nih . gov / ne ws / fundingresearchareas . htm
Wow: United Kingdom
Roth well PM. The high cost of not funding stroke research: a comparison with heart disease and cancer. Lancet, 2001, 357(9268): 1612-1616 (review).
Bennett R, Burden S. UK funding for stroke research. Lancet, 2001, 358:1275 (correspondence).
Clipboard
Mendis S, Yach D, Bengoa R, Narvaez D, Zhang X. Research gap in cardiovascular disease in developing countries. Lancet, 2003, 361:2246-2247.
WHO. The World Health Report 1 999: Making a difference. Geneva, WHO, 1999, Annex Table 3:108
Text
Baris E, Waverley Brigden L, Prindiville J, da Costa e Silva VL, Hatai C, Chandiwana S. Research priorities for tobacco control in developing countries: a regional approach to a global consultative process. Tobacco control, 2000, 9:217-23.
Tunstall-Pedoe H, ed. MONICA monograph and multimedia sourcebook. Prepared by Tunstall-Pedoe H, Kuulasmaa K, Tolonen H, Davidson M, Mendis S with 64 other contributors for The WHO MONICA Project. Geneva, WHO, 2003.
20 Prevention: personal choices and actions
Personal choices in lifestyles and behaviour; Personal actions for safeguarding cardiovascular health
Bulletin of the WHO, 1999.
Young people
Kavey RW, Daniels SR, Lauer RM, Atkins DL, Hayman LL, Taubert K. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation, 2003, 107:1562.
Eat fruit and cereals
Pereira MA, O'Reilly E, Augustsson K et al. Dietary fiber and risk of coronary heart disease. A pooled analysis of cohort studies. Archives of internal medicine, 2004, 164:370-376
http://archinte.ama-assn.org/cgi/content/abstract/ 164/4/370
The benefits of stopping smoking
American Lung Association. When smokers quit, within twenty minutes of smoking that last cigarette the body begins a series of changes http: //www.lungusa.org/tobacco/quit_ben. html
Wow: USA; Clipboard: Burning calories
New "food pyramid" to address obesity epidemic. Reuters Health Information 2004 http: / /www.lifetimefitness.com/health_info/index.c fm?strWebAction=health_article&intArticleId= 1 384
Wow: Japan
Schnirring L. Can exercise gadgets motivate patients?
The physician and sportsmedicine, news briefs,
2001, 29(1)
http : / / www. physspor tsmed . com / issues / 200 1 /
01_01 /news. htm
Wow: Compared with less active...
HeartBytes. Reduce heart disease risk: encourage and
prescribe exercise for your patients. Medscape
cardiology, 2004, 8(1)
http : / / w w w. medscape . com / viewar ticle / 470 115?
mpid=25341
105
Wow: People with low fitness...
Carnethon MR, Gidding SS, Nehgme R, Sidney S, Jacobs DR Jr, Liu K. Cardiorespiratory fitness in young adulthood and the development of cardiovascular disease risk factors. Journal of the American Medical Association, 2003, 290(23):3092-100.
Clipboard: For people with diabetes...
Standards of medical care in diabetes. Diabetes care, 2004, 27(Suppl 1):S1S-3S.
Bilous R. Blood pressure control in type 2 diabetes — what does the United Kingdom Prospective Diabetes Study (PDS) tell us? Nephrohgj dialysis and transplantation, 1999, 14:2562 2564.
Clipboard: Reducing salt intake...
He FJ, MacGregor GA. How far should salt intake be reduced? Hypertension, 2003, 42(6): 1093-9.
Text
O'Keefe JH Jr, Cordain L. Cardiovascular disease resulting from a diet and lifestyle at odds with our Paleolithic genome: how to become a 21st-century hunter-gatherer. Mayo Clinics proceedings, 2004, 79:101-108.
Carlsson CM, Stein JH. Cardiovascular disease and the aging woman: overcoming barriers to lifestyle
o o o J
changes. Current women's health report, 2002, 2:366-372.
Wows: Finland; Japan; New Zealand; Mauritius
World Health Report 2002: reducing risks, promoting healthy life. Cardiovascular death and disability can be reduced more than 50%. Press Release WHO 783. 17 October 2002:6.
Clipboard
Institute of Medicine. Crossing the quality chasm: a new health system Jor the list Century. Washington, DC, National Academy Press, 2001 http://books.nap.edu/books/0309072808/html/ 1 .html#pagetop
Text
Mendis S. Role of governments in improving prevention of cardiovascular disease. Global Symposium on Cardiovascular Prevention, Marbella, Spain, 11-13 April 2003.
Salim Y. Two decades of progress in preventing vascular disease. Lancet, 2002, 360 http://www.thelancet.com/journal/vol360/iss9326 /full/Han. 360. 9326. editorial and re view. 2 1674.1
22 Health education
Map: World Heart Day
World Heart Federation. World Heart Day
http : / / www. worldhear tday. com / news / news . asp?
Page=HeartNews#
21 Prevention: population and systems approaches
Noncommunicable disease prevention and control; Availability of equipment; Medical professionals; Antihypertensive drugs
Alwan A, Maclean D, Mandil A. Assessment of national capacity Jor noncommunicable disease prevention and control; the report of a global survey. Geneva, WHO, 2001 .
Use of medications in stroke and coronary heart disease
Gaps in secondary prevention of myocardial infarction and stroke: WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE) in low and middle income countries. WHO-PREMISE (Phase I) Study Group.
World Heart Day: themes; activities; Evaluation of
World Heart Day, A World Heart Federation enterprise promoting the prevention of heart disease and stroke across the world. Circulation, 2003, 108:1038-1040.
Grizeau-Clemens D. Evaluation of 2001 World Heart Day coverage. World Heart Federation, 2003.
Giving up smoking: International Quit and Win
Vartiainen ER, Project Manager, International Quit&Win, personal communication, 20 January 2004.
106
23 Policies and legislation
Map: Smoke-free workplaces
Shafcy O, Dolwick S, Guindon GE, eds. Tobacco control country profiles 2003. Atlanta, GA, American Cancer Society, WHO, International Union Against Cancer, 2003.
Cardiovascular disease plans worldwide; Legislation
Policy data from: WHO. Capacity for NCD prevention and control survey 2001 . Assessment of national capacity for noncommunicable disease prevention and control. The report of a global survey. Geneva, WHO, 2001.
Wow: 2002 USA
Sargent RP, Shcpard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. British medical journal, 2004, 328:977-980.
24 Treatment
Cardiac rehabilitation; Patients reaching blood pressure and blood cholesterol goals during treatment
EUROASPIRE II Study Group (2001). Lifestyle and risk factor management and use of drug therapies in coronary patients from 1 5 countries. Principal results from EUROASPIRE II Euro Heart Survey Programme. European heart journal, 2001, 22:554-572.
Simple secondary prevention medication treatments
Yusuf S. Two decades of progress in preventing vascular disease. Lancet, 2002, 360:2—3 http : / / www. thelancet . com
Diabetes treatment
Ustun TB, Chatterji S, Mechbal A, Murray CJL, WHS Collaborating Groups. The World Health Surveys in Health Systems Performance Assessment: debates, methods and empiricism. Murray CJL and Evans DB, eds, Geneva, WHO, 2003.
Trends in cardiovascular operations and procedures in the USA
American Heart Association. Heart disease and stroke statistics - 2004 update. Dallas, American Heart Association, 2003.
Wow: Proportion of people...
Mensah GA. The global burden of hypertension: good news and bad news. Cardiology clinics, 2002, 20(2):181-185
Wolf-Maier K, Cooper RS, Banegas JR et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. Journal of the American Medical Association, 2003, 289(18):2363-2369.
Wow: In the USA, only 24%... Ford ES, Mokdad AH, Giles WH, Mensah GA. Serum total cholesterol concentrations and awareness, treatment, and control of hypercholesterolemia among US adults: findings from the National Health and Nutrition Examination Survey, 1999 to 2000. Circulation, 2003, 107(17):2185-2189.
Text
Gunn J, Grossman D, Grech ED, Cumberland D. New developments in percutaneous coronary intervention. British medical journal, 2003, 327(7407): 150-1 5 3.
Mensah GA. Eliminating health disparities: the time for action is now. Ethnicity and disease, 2002,
PART 5 THE FUTURE AND THE PAST
25 Future
DALYs; Deaths
WHO (2004). Unpublished projections from 2000 baseline, prepared for The World Health Report 2002, using projection methods developed by Murray CJL, Lopez AD. The global burden of disease. Boston, Harvard School of Public Health, 1996, Chapter 7:325-395.
107
Risk factors
Mackay J, Eriksen M. The tobacco atlas. Geneva, WHO, 2002:90-91.
Wild S, Roglic G, Green A, Sicree R, King H.
o o
Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030. Diabetes care, 2004, 27:1047-1053.
Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabetes medicine, 1997, 14(Suppl5):Sl-S5.
Collins R, Clinical Trial Service Unit, University of Oxford, England, personal communication, 6 January 2004.
Economic costs
REUTERS in Washington. United States: US obesity weighs heavy on health costs. South China Morning Post, 10 March 2004, A12 (study by Rand Corporation).
Action
Guttmacher AE, Collins FS. Genomic medicine: a primer. New England journal of medicine, 2002, 347:1512-1550.
Wolf CR, Smith G, Smith RL. Science, medicine, and the future: pharmacogenetics. British medical journal, 2000, 320:987-990.
Mackay J, Eriksen M. The tobacco atlas. Geneva, WHO, 2002:90-91.
Treatment
Pearson I. Atlas of the future. New York, Macmillan, 1998:32-33.
American Federation for Aging Research. What is the future of heart disease research likely to tell us?
http://www.infoa2inp.orp/d-heart-l 1 -future. html
r o o o
Roden DM. Cardiovascular pharmacogenomics. Circulation, 2003, 108:3071 3074.
Grossman D. Science, medicine, and the future. The future of the management of ischaemic heart disease. British medical journal, 1997, 314:356-359.
Wald NI, Law MR. A strategy to reduce
J ' c>j
cardiovascular disease by more than 80%. British medical journal, 2003, 326:1419.
Collins R, Clinical Trial Service Unit, University of Oxford, England, personal communication, 6 January 2004.
Text
Rodpers A, Lawes C. MacMahon S. Reducing the
o o
global burden of blood pressure-related cardiovascular disease. Hypertension, 2000, 18(1 Suppl):S3— 6.
Lawes CM, Bennett DA, Feipin VL, Rodpers A.
to o
Blood pressure and stroke: an overview of published reviews. Stroke, 2004, 35(3):776-85.
Milestones in knowledge of heart and vascular disorders
Major sources
Baddarni K. Historic aspects of cardiology
http: / / www.geocities.com/baddarni/Cardiology-
History.html
Weisse AB. Heart to heart: the twentieth century battle against cardiac disease: an oral history. London, USA, Rutgers University Press, 2002.
Stamler J. Lectures on preventive cardiology. New York, Grune & Stratton, 1967 (cited in Vance DE, van den Bosch H. Cholesterol in the year 2000. Biochemica et biophysica acta, 2000, 1529:1 8
Wan S, Yim APC. The evolution of cardiovascular surgery in China. Annals of thoracic surgery, 2003, 76:2147-55.
A timeline of milestones from The Framingham Heart Study http://www.framingham.com/heart/timeline.htm
Schooler C, Farquhar JW, Fortmann SP, Flora JA. Synthesis of findings and issues from community prevention trials. Annals of epidemiology, 1997, S7:S54-68.
108
Useful contacts
World Health Organization
http://www.who.int
Cardiovascular disease:
http://www5.who.int/cardiovascular iliseasfs/ Diabetes:
http:// www. who. int /health_topicsAliabetes_mellitus /en/ Diet:
http: // vvwvv. who.int/health_topics/dict/en/ Nutrition:
http:// www. who. int /health_topics/ nutrition /en/ ( )l>r-.it\ :
http: //www. who. int/health_topics/obesity/en/ Public Health Surveillance:
http: / / www. w ho. int / health_topics / public_hcalth_sur veillance /en / Tobacco Free Initiative:
http://ww-w.who.int/tobacco/en/
Centers for Disease Control and Prevention, USA
http://www.cdc.gov/
Cardiovascular Health Program:
http : / / www. cdc . gov / cvh / Nutrition and Physical Activity Program:
http://www.cdc.gov/nccdphp/dnpa/ Tobacco Program:
to
http : / / www. cdc . gov / tobacco / Diabetes Program:
http: // www.cdc.gov/diabetes/ Laboratory Sciences Program:
http://www.cdc.gov/nceh/dls/programs.htm Office of Global Health:
http: // www.cdc.gov/ogh/ Behavioral Risk Factor Surveillance System:
http: / /www.cdc.gov/brfss National Center for Health Statistics:
http: / /www.cdc.gov/nchs
International and Regional Organisations
Asian Society for Cardiovascular Surgery:
http: / / www.ascvs.org/
Association for European Paediatric Cardiology /Association Europeenne pour la Cardiologie Pediatrique:
http : / / www. aepc . org / home . htm Brain Aneurysm Foundation:
http : / / www. bafound . org Cairdes: http://www.cairdes.com CardioStart International Inc:
http://www.cardiostart.com/ Cardiothoracic Surgery Network:
http: / / www.ctsnet.org/ Chain of Hope: http://www.chainofhope.org Children's HeartLink:
http: / /www.childrensheartlink.org/ Children's Hearts: http://www.childrenshearts.org.uk Clearinghouse for Tobacco Control (South East Asia):
http://www.prn2.usm.my/pages/about.asp Coeurs pour Tous (Hearts for All):
http : / / www. cptg. ch / fr / start . htm Congenital Heart Information Network:
http: / /www. tchin.org/
Congress of Neurological Surgeons: to c> to
http://www.neurosurgeon.org Consortium for Southeastern Hypertension Control (COSEHC):
http://www.cosehc.org/
East Meets West: http://www.eastmcetswest.org Eastern Mediterranean Network on Heart Health, (EMNHH):
http://emnhh.homestead.com/files/index.htm The Endocrine Society: http://www.endo-society.org/ European Association for Cardiothoracic Surgery:
http://www.eacts.org/ European Heart Institute:
http: / / www.european-academy.at European Heart Network:
http://www.ehnheart.org/index2.asp EMASH European Medical Association on Smoking and Health:
http: / /emash. globalink.org/ ENSH European Network for Smoke-free Hospitals:
http://ensh.free.fr/ ENSP European Network for Smoking Prevention:
http://www.ensp.org European Network of Young People and Tobacco:
http://www.ktl.fi/enypat/ European Network of Quitlines:
http://www.quitlines-conference.com/ European Society for Noninvasive Cardiovascular Dynamics:
http://www2.mf.uni-lj.si/~esnicvd/ European Society of Cardiology:
http: / /www. escardio.org/ European Society of Hypertension:
http: / / www.eshonline.org/ European Stroke Initiative:
http://www.eusi-stroke.com/index.shtml European Union of Non-smokers:
http://www.globalink.org/tobacco/docs/eu-docs/uene.htm Framework Convention Alliance (FCA):
http: / / www.fctc.org/ G8 Telematics Heart Health Project:
http://www.med.mun.ca/g8hearthealth/ Gift of Life International Inc.:
http://www.giftoflifeinternational.org/ Global Connection International:
http : / / w w w. gci world . org Global Cardiovascular Infobase (in English and Spanish):
http://www.cvdinfobase.ca/
Global Healing: http://www.globalhealing.org to r b to to
Global Health Information Network:
http: / / www.healthnet.org/ Global Partnerships for Tobacco Control:
http: / / www.essentialaction.org/tobacco/ Globalink, UICC International Union against Cancer:
http: // www.globalink.org/ Healing the Children:
http://www.healingchildren.org Heart Care International:
http: / /www. heartcareintl.org HeartGift Foundation:
http://www.heartgift.org/index.html The Heart of a Child Foundation - Little Hearts on the Mend:
http : / / www. littleheartsonthemend . org Heart-to-Heart International:
http : / / www. hearttoheart . org/
109
Heart-to-Heart International Children's Medical Alliance:
http://www.heart-2-heart.org/ Initiative for Cardiovascular Health Research in Developing Countries:
http://www.globalforumhealth.org/pages/index.asp? ThePage=page1_OOOS00040001_l.htm&Nav=OOOS00040001 Inter American Heart Foundation:
http : / / www. interamericanhear t . org Inter American Society of Cardiology (in Spanish and English):
http :// www. soinca . org Inter-American Society of Hypertension:
http://org.umc.edu/iash/homepage.htm:
http://www.musc.edu/iash/generale.htm International Academy of Cardiology:
http://www.cardiologyonline.com/ International Agency on Tobacco and Health (IATH):
Email: [email protected]
^~s o
International Atherosclerosis Society:
http : / / w ww.athero. org/ International Children's Heart Foundation:
http://www.ichf.org/ International Children's Heart Fund:
http://www.ichfund.org/ International Diabetes Federation:
http: / / www.idf.org/ International Diabetes Institute, Australia:
http :// www. diabetes . com . au / home . htm International Federation of Sports Medicine:
http://www.fims.org/ International Hospital for Children (IHC):
http: / / www.healachild.org International Network of Women against Tobacco (IN WAT):
http://www.inwat.org/ International Network towards Smoke-Free Hospitals (INTSH):
http://intsh.plobalink.org/ r o o
International Non Governmental Coalition against Tobacco (INGCAT):
http://www.ingcat.org/ r o o
International Obesity Task Force:
http://www.iotf.org/ International Pediatric Hypertension Association:
http://www.pediatrichypertension.org/ International Society for Adult Congenital Cardiac Disease:
http://www.isaccd.org/ International Society for Aging and Physical Activity:
http://www.isapa.org/ International Society for Cardiovascular Surgery:
http://www.vascsurg.org/doc/ 1 S76.html##.htm International Society for Heart Research:
http : / / www. ishrworld . org/ International Society for Heart & Lung Transplantation:
http://www.ishlt.org/ International Society for Minimally Invasive Cardiac Surgery:
http://www.ismics.org/
International Society for the Prevention of Tobacco Induced Diseases (PTID): http://www.ptid.org International Society of Cardiovascular Ultrasound:
http://www.iscu.org/ International Society of Hypertension:
http://www.hypertension2004.com.br/ International Society of Nephrology:
http: / / www.isn-online.org/ International Society on Hypertension in Blacks (ISHIB):
http: //www.ishib.org/main/ishib_opcn. htm International Stroke Society:
http://www.internationalstroke.org/index.php International Task Force for the Prevention of Coronary Heart Disease:
http://www.chd-taskforce.de/
International Tobacco Evidence Network (ITEN):
http : / / w w w. tobaccoevidence . net / The Internet Stroke Center:
http://www.strokecenter.org/pat/organi7.ations.htm Legacy Foundation, tobacco document site:
http://legacy.library.ucsf.edu/cgi/b/bib/bib-idx?g=tob Mediterranean Stroke Society:
http://www.hsanmartino.liguria.it/cictus/med.htm OTAF L'Observatoire du Tabac en Afrique Francophone:
http: / /otaf.globalink.org/
Physicians lor Peace: http://www.physiciansforpeace.org ProCOR: Conference on Cardiovascular Health:
http://www.procor.org/ Project Hope: http://www.projecthope.org Project Kids Worldwide:
http: / /www.projectkidsworldwide.org Project Open Hearts: http://www.poh.org Repace's site, especially on passive smoking (Jim Repace):
http://www.repace.com/ Save A Child's Heart Foundation:
http://www.saveachildsheart.com Society for Research on Nicotine and Tobacco (SRNT):
http: / / www.srnt.org/ Smokescreen Action Network:
http://www.smokescreen.org Southeast Asian Tobacco Control Alliance:
http: / /www. tobaccofreeasia.net/ Stroke Awareness for Everyone:
http://www.strokesafe.org/ Stroke Clubs International:
Email: [email protected] Stroke Net:
http : / / www. strokenet . info /resources/ stroke / internationalsites. htm Surgeons of Hope Foundation:
http : / / w w w. surgeonsofhope . org Tobacco, org : http : / / www. tobacco, org Tobacco Control journal:
http : / / w w w. tobaccocontrol . com
Tobacco Control Resource Center /Tobacco Products Liability Project (TCRC/TPLP): http://tobacco.neu.edu/ TCRC Tobacco Control Resource Centre, BMA, UK:
http: / /www.tobacco-control.org/ Tobacco Control Supersite:
http : / / www. health .usyd.edu.au/ tobacco / Tobacco Documents Online (TDO, Smokescreen:
http: / /www. tobaccodocuments.org Tobaccopedia:
http: / / TobaccoPedia.org
Treatobacco Database & Educational Resource for Treatment of Tobacco Dependence:
http://www.treatobacco.net/ World Federation of Neurology:
http://www.wfneurology.org/ World Heart Federation:
http://www.worldheart.org/ World Heart Foundation:
http://www.world-heart.org/ World Hypertension League:
http ://www.mco.edu/ org / whl / World Kidney Foundation:
http : / / www. worldkidneyfund .org/ World Medical Association:
http://www.wma.net/
110
Index
activity see physical activity and
inactivity
ACE inhibitors 40, 71,92 age, advancing 19, 25, 42 alcohol use 19, 24-25 ancurysm see aortic aneurysm and
dissection
angina pectoris 32, 77, 78 angioplasty 71, 79, 92 anticoagulant 92 antihypertensive drugs 65 aortic aneurysm and dissection 19, 32 arrhvthmia 71 , 92 arteriosclerosis 76, 92 artificial body parts 71 , 75, 80 arterial disease, peripheral 19, 32, 76 aspirin 55, 65, 71, 78,79, 80, 81 atherosclerosis 26, 31, 32, 42, 77, 92 atrial fibrillation 19, 20, 50, 52, 78,
80, 92
beta-blockers 71 blood clotting
O
disorders 19, 25, 32; see also
stroke
treatment of 80, 81 blood pressure 28-29, 32, 48,
62-63, 66, 70, 77, 78, 80, 92
high 19, 24-25, 26, 28-29, 32,
34, 40, 42, 50, 52, 63, 64, 70,
79, 93
see also hypertension and
hypertensive heart disease blood sugar levels 62 body mass index (BMI) 36-37, 92 brain tumours, vascular 19 bypass see coronary artery bypass
surgery
cardiac
defibrillation71,78, 79
pacemakers 71, 78, 79
rehabilitation 70
see also coronary and heart cardiovascular disease (CVD) 92
deaths from 18, 74
disability-adjusted life years
(DALYs) 74
investigations for 75
economic costs of 5 5
medication for 65, 71, 75, 77
prevention of 62— 63, 64—65, 66-
67, 68, 80, 81
research into 58-59, 75
risk factors 24 — 43
surgery 70-71, 75, 78, 79, 80, 81
types of 18-19 carotid
endarterectomy 71
stenosis 52, 92 cars see motor vehicles Centers for Disease Control and
Prevention (USA) 60 cerebrovascular disease see stroke childbirth 19 children and youth 20—21, 25,
26-27, 38, 51, 62, 66 cholesterol 19, 24-25, 30-31, 40,
42,48, 62, 65, 70-71, 77, 79,
80, 81, 92
HDL (high-density lipoprotein)
25, 30, 32,42, 80, 93
LDL (low-density lipoprotein)
25, 30, 32, 80, 93
plaques 32, 77, 92 cigarettes see tobacco use clotting see blood clotting contraceptive, oral 19, 25, 42, 50 coronary
artery bypass surgery 71 , 92
artery disease 79
artery spasm 32
stent71, 80, 93
see also cardiac and heart coronary heart disease 19, 32,
34-35, 40, 52, 92
burden 46—47
deaths from 1819, 35, 46-47,
48-49, 74
disability-adjusted life years
(DALYs) 46-4-7, 74
economic costs of 55
medication for 65, 71, 81
prevention of 48
research into 58—59
risk factors 19, 79 costs see economic costs
deaths from
cardiovascular disease 18, 74 coronary heart disease 18—19, 35, 48-49, 74
diabetes mellitus 48
hypertensive heart disease 18, 48
inflammatory heart disease 1 8
physical inactivity 35
rheumatic heart disease
18, 20-21
stroke 18-19, 48, 50-51, 52-53,
74
tobacco use 74 deep venous thrombosis 1 9 diabetes mellitus 19, 25, 34, 38-39,
40-41,42,48, 52, 63, 64, 75,
80, 81,92
deaths from 48
economic costs of 54
predicted number of people with
75
research into 58-59
treatment of 7 1
type 1 diabetes 38
type 2 diabetes 26, 36, 38, 54 diet 19, 24-25, 26, 28, 36, 42, 48,
52, 62-63, 64, 66, 77, 80;
see also food digitalis 77 disability-adjusted life years (DALYs)
46-4-7, 50-51, 74, 92
economic costs 54—55, 75, 92, 93 education
health 66 67
level of 19, 28, 40,41 electrocardiogram (ECG) 78, 79 embolism see pulmonary embolism ethnicity and race 25, 42
food 30, 36, 62 cereals 63 fast 68
fruit and vegetables 24, 28, 36, 62-63, 64 labelling of 65, 68 legislation on 69
O
processed 28 see also diet future 74-75
gender differences 25, 27, 28—29, 32-33,42-43,81; see also women
111
genetic
disposition 19, 25,48, 81
science 75
therapy 8 1
see also heredity
HDL-cholesterol see cholesterol,
HDL health see also education, health and
mental health and public health
and tobacco use, health warnings health care
access to 40
economic costs of 54 — 55 heart 1 8
attack 30, 32, 93
catheterization 71, 78
congenital disease 1 9
failure, congestive 92
inflammatory disease 18—19, 81
muscle 18-19, 77
transplantation 71, 75, 79, 81
tumours 19
valves 19, 20, 71, 76, 79
see also cardiac and coronary and
hypertensive heart disease heredity 25, 42 see also genetic homocysteine levels in blood
19, 25,93 hormone replacement therapy
19, 25,42-43 hypertension 28
see also blood pressure, high hypertensive heart disease
deaths from 18, 48
see also blood pressure, high
inactivity see physical activity and
inactivity International Conferences on
Preventive Cardiology 60 International Heart Health
Conferences and Declarations 6 1 ,
64, 66-67, 81
labelling see food
LDL-cholesterol see cholesterol, LDL
left ventricular hypertrophy 25
legislation 68-69
Iipids25, 26, 30-31, 34, 52,93
lowering medication 40, 71
see also cholesterol
medical professionals 42, 62, 65 medication 42, 54-55, 62, 65, 71 , 75,
77,81
mental health 19, 25 MET (metabolic equivalent) 35, 93 motor vehicles 34—35 myocardial infarction see heart attack
nutrition see food and diet
obesity 19, 24-25, 26, 34, 36-37, 41,42, 62, 65, 66, 79, 80, 93 economic costs of 54—55, 75
open heart surgery 71,79
operations 71
organizations 60—61
physical activity and inactivity 19, 24-25, 26-27, 28, 34-35, 40, 42-4-3, 48, 54, 62-63, 66, 78,79,80,81,93
policies 68—69
poverty 19, 20
prevention see cardiovascular disease, prevention of
public health
initiatives 64—65 policy 68-69
pulmonary embolism 1 9
Quit and Win 67
race see ethnicity and race rehabilitation 70 research 58^59, 75, 76-81 rheumatic fever 20, 78, 93 rheumatic heart disease 19, 20— 21 , 93
deaths from 18, 20-21 risk factors 19, 24-43, 55, 62-63,
66-67, 79, 80
salt intake 28, 52, 63, 65 schools
health education in 66 smoking see tobacco use socioeconomic status 25, 34, 40—41,
52
sphygmomanometer 78 statins 65, 81 stent see coronary stent streptococcal infection 19, 20 stress 25, 34, 40, 42, 62, 77 stroke 19, 20, 30, 32, 34, 50-53,
76, 78, 80, 93
burden 50-5 1
carotid stenosis 52 deaths from 18-19,48, 50-51, 52-53, 74
disability-adjusted life years (DALYs) 505 1 economic costs of 54—55 medication for 65, 71 , 80 research into 58-59 risk factors 19, 63, 79, 80 young people 5 1
surgery see coronary artery bypass surgery and open heart surgery and cardiovascular disease surgery
o J
technology 70-71 , 75, 77-81 thrombosis see deep venous thrombosis tobacco use 19, 24-25, 26-27, 32-33, 40-41, 42-4-3, 48, 50, 52, 62, 74, 79, 80, 81 deaths from 74 economic costs of 54—55 health warnings about 68 knowledge of risks 32—33 legislation on 69 passive smoking 32, 62 prevalence of 27, 33, 75 quitting smoking 33, 62 63, 67 smoke-free areas 68—69, 81 transplant see heart transplantation treatment 64-65, 70-71, 75, 80 triglycerides 30, 42, 80, 93
United Nations Conventions and Goals 75
vascular disease, peripheral 92
women 25, 28-29, 30, 32-33, 42-43 World Congresses of Cardiology 60 World Health Assembly 68, 81 World Health Organization 60-6 1 , 79, 81
Framework Convention on Tobacco Control 68-69, 81 Global School Health Initiative 66 Global School-based Student Health Survey 66 Global Strategy on Diet, Physical Activity and Health 8 1 World Heart Days 66-67, 81 World Heart Federation 60, 66-67,
79 World Stroke Congresses 61
youth see children and youth
112
"Heart disease and stroke rob too many people of
precious years of quality life. This one-of-a-kind
atlas serves as a key resource for those on the
frontlines of health. " Dr Julie Gerberding, Director,
Centers for Disease Control and Prevention, Atlanta, Georgia, USA
"We applaud the authors for producing such a comprehensive document in such a user-friendly
format." World Heart Federation
Heart disease can no longer be seen as the problem of overworked, overweight middle-aged men; in today's world, we are all - women and children too - at risk. One in three deaths worldwide -17 million deaths each year - is due to cardiovascular disease.
These full-colour maps and graphics illustrate the wide range of issues relating to this global epidemic, including:
Risk factors:
high blood pressure, tobacco, inactivity, obesity, lipids, diabetes
Women, childhood and youth
The global burden of cardiovascular disease
Research Prevention
Policies and legislation Treatment The future
Trends in cholesterol levels in Beijing,
Mean total cholesterol in people aged 25-64 year
1984- 1999
mmol/l
Men
4.15
* 1984
Front cover photograph:
Amy, Hong Kong ® Guy Nowell
Back cover photographs: Cardiology operation, Mauritius e WHO/Harry Anenden; Man selling vegetables, India ® WHO/ Pierre Virot; Man on bencl ® iStock/Tomaz Levstek; Woman and girl buying sweets, India * WHO/Pierre Virot; Bowl of rice ® Hemera Photo-Objects
Cover design: Corinne Pearlman
o
m
a myriad edition
ISBN 92 4 156276 8
World Health Organization
www.who.int
9 789241 562768