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

Man anaging ging CVD VD in in In Indonesia: donesia: How ow wel ell l ar are e we e doi oing ng an and whe here e ca can n we e im improve? e? Anwar Santoso Dept. of Cardiology – Faculty of Medicine; Universitas Indonesia National Cardiovascular Centre – Harapan Kita Hospital Immediate Past President of IHA Jakarta - Indonesia

Introduction Preventing CVD is the insurmountable challenge for • clinicians worldwide Lipid lowering therapy represents the cornerstone of • treatment of patients with CVD For years statins have been regarded as a key intervention • to lower lipids and improve clinical outcome However, despite statins therapy at maximally tolerated • doses  many patients do not achieve their lipid goals and still suffered a residual ischemic risk of recurrent CVD

Prevalences of Hypertension based on Basic Health Research 2007 & 2013

Preval Pr alen ences ces of Dy Dyslipidemia emia in Indon donesi esia (Basic sic Health lth Resear search h - 2007) 7) Recrui uited ted 19.114 person son-ac across oss 438 district stricts s (percentage) 60 50 48.9 43.8 40 41.5 40.6 37.6 36.6 Male 30 Female 20 10 0 High TC High LDL-C Low HDL-C (Indonesian Basic Health Research – 2007)

Prevalence of Dyslipidemia by gender and residence in Basic Health Research 2013 Male Female Urban Rural Indonesian Basic Health Research 2013

Percentage of Central Obesity based on Basic Health Research 2007 & 2013

Prevalences of Diabetes Mellitus based on Basic Health Research 2007 & 2013

Prevalence of smoking habit in Indonesia Series 1 40 36,3 34,2 30 % % 20 10 0 2007 2013 Year Indonesia Basic Health Research – 2007 & 2013

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

Population Attributable Risk (PAR%) • Proportion of cases in the total population attributable to the exposure • Proportion of disease in the total population that could be prevented if we could eliminate the risk factor • Determines exposures relevant to public health in community • Only use if causality “exposure  outcome” 12

PAR(%) according to RR for various level of exposure frequency among cases 100.0% Pe 10% 90.0% Pe 25% Pe 50% 80.0% Pe 75% Population attributable fraction Pe 100% (AFe) 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1 2 3 4 5 6 7 8 9 10 Relative risks

Age- and sex-specific PAR (95%CI) associated with CV risk factors for all CHD in Indonesia PAR = 77.4% PAR = 65.6% Hussain MA, et al. J Epidemiol 2016; doi.10.2188/jea.JE20150178

Prevalences of Stroke based on Basic Health Research 2007 & 2013

Pr Propor ortion tion of Mortal tality ity Rate te in Indon donesi esia (Bas (B asic c Hea ealth th Res esea earch h – 2007) 2007) (Indonesia Ministry of Health Affair – 2007)

Cause use of of mo morta tali lity ty in in SE SEA Regio gion Annual ually y + 7.9 million NCD’s attributable death (55% 5% of all l mortality) lity) CAD Peripheral Vasc Disease Cerebrovascular Disease 10% All cause use mor ortal ality ity rate e in SEA SEA =14.5 .5 million ion/year /year Source: WHO global Health observatory 2011 http://apps.who.int/ghodata/

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

By gender By urban vs rural There is a significant burden of 4 primary NCD on Indonesian household • Hypertension, diabetes, CHD and stroke account for 8% of nation’s out of pocket health expenditures • Maharani A and Tampubolon G. Plos One 2014; 9 (8): e 105831

Proportions of patients attaining LDL-C goals according to gender and region Chiang CE, et al. J Atheroscler Thromb 2015; 22: 000 – 000 (epubahead_

Barriers Recommendations • Accessibility & system of care Shorten the community delay • Improving the ambulance services • Validity of risk assessment Develop and revalidation • Recommends risk assessment at FMC • Educate public and medical professional Low public awareness • Develop the Clinical Guidelines • Cost and affordability Universal coverage • Standardize the medical management AsPac ACS Medical Management Working Group, Int J Cardiol 2015; (183): 63 - 75

iSTEMI NETWORK PILOT PROGRAM West Jakarta Area: 129.54 km 2 Population: 2,260,341 6 HUB & 14 SPOKES 20 Healthcare Facilities: 2 Government Hospitals, PCI (+), UHC (+) 4 Private Hospitals, PCI (+), UHC (-) 8 Primary Health Care Center, UHC (+) 4 Private Hospitals Hospital, UHC (+) 2 Private Hospital, UHC (-) * UHC: Universal Health Coverage PCI & Lytic Capable (6) Lytic Capable (2) ACS Diagnostic Capable (12) Main Referral Alternative Referral i STEMI par tner w ith M edtr onic Courtesy: Soeryanata S 2016

iSTEMI Network + Tertiary Facility West Jakarta (2 Years) ACS N=6313 STEMI UAP/NSTEMI N= 2433 N= 3880 (38.5%) (61.9%) Reperfusion No Reperfusion N=1394 N= 1039 (57.2%) (43.8%) PPCI Autolysis Fibrinolysis N= 1059 N=52 N= 283 (75.9%) (3.8%) (20.3%) 24 months data from June 30, 2014 – June 30, 2016 Courtesy: Soeryanata S 2016 in iSTEMI network (West Jakarta + NCC-HK)

In Hospital Mortality Rate Reperfusion vs Without Reperfusion P-value= 0.001 OR= 0.34 (0.22 to 0.55) 95% CI 13,5% 12,9% (76) P-value= 0.001 (58) OR= 0.46 (0.31 to 0.67) 95% CI Year 1 6,2% Year 2 (47) 4,4% (29) N= 563 N= 476 N= 632 N= 762 Reperfusion Without Reperfusion Courtesy: Soeryanata S 2016 24 months data from 30 June 2014 – 30 June 2016 in iSTEMI network (West Jakarta + NCC-HK)

Long – term vision to improve STEMI care throughout Indonesia Phase 3 Phase 2 Phase 1 Expand West Jakarta Expand in across Pilot Jakarta Indonesia Collaborate to develop Present Phase 1 pilot Secure funding and and implement STEMI clinical/economic data to support to expand STEMI protocols Health Authority program nationwide Measure and compare 30- STEMI protocol adoption Initiate Indonesia-wide day and 1 year mortality in other Jakarta facilities STEMI registry 26 Courtesy: Soeryanata S 2016 Go to appendix

Major Shifts in Population Risks and Expanded Treatment, U.S. + Risk Factors worse: +17% Change in numbers of deaths Obesity (increase) +7% 0 Diabetes (increase) +10% Risk Factors better: -65% Population BP fall -20% Smoking -12% Cholesterol (diet) -24% Physical activity -5% Treatments: -47% 341,745 AMI treatments -10% fewer deaths Secondary prevention -11% Heart failure -9% in 2000 - Angina: CABG & PTCA -5% Hypertension therapies -7% 1980 2000 Statins ( primary prevention ) -5% Ford, ES et.al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. NEJM 2007; 356: 2388.

Population Strategy for CVD Prevention WHO, Prevention of cardiovascular disease: guidelines for assessment and management of total cardiovascular risk., 2007

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

Lifetime risk of death from CVD according to regimen strategies for World Bank regions  Primary regimen:  Aspirin  Statin  ACE-I and/or CCB  Secondary regimen:  Aspirin  Statin  Beta blockers  ACE-I Gaziano AT et al. the Lancet 2006; 368: 679 - 86

Lifetime costs and QALYs of strategies assessed in World Bank regions Gaziano AT, et al. the Lancet 2006; 368: 679 - 86

Incremental cost-effectiveness ratios ($/QALY) for treatment regimens vs no-treatment Aspirin and 2 blood pressure drugs and statin halve the risk of CVD death in high-risk subjects • This approach is cost-effective according to WHO recommendations and robust • Gaziano AT, et al. the Lancet 2006; 368: 679 - 86

NCD’s Prevention and Control Program in Indonesia 2015 – 2019 LEADE DERSHI RSHIP MANAGEMENT AGEMENT • National onal leader dershi hip • Nat atio ional nal adv dvoc ocat ation ion progra rogram • Improve ove awareness eness • Prom romotio ion n prog ogra ram • Partnershi nership • Capac apacit ity buildin ilding Populat ulation ion with NCD NCD High-risk isk populat pulation ion PREVENTIO VENTION RESEARCH ARCH • Prev reven entio ion n for r high gh risk popula pulatio ion • Publ blications ons • Ris isk asses essmen ent model del • Financ ancial al suppor pport • Com ommun unit ity, work rkin ing g site and nd • Comprehens ehensive e planni nning ng env envir iron onmen ent

Indonesian Heart Association Guidelines 2013 - 2015 AF Guideline ACS Guideline CHF Guideline Hypertension Guideline Dyslipidemia Guideline CVD Prevention in Women Guideline

Important Points in IHA Lipid Guidelines 1. Assessment of global risk 2. High-risk subjects: CVD, DM and FH 3. Global risk consider both lipid and non-lipid risk factors 4. Major emphasis on life-style intervention 5. LDL-C is a primary target 6. Statins are indicated in high-risk subjects 7. Non-HDL cholesterol is alternate target 35

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