For Healthy Life

“ Re-planning our Strategies Towards Most Effective

Cardiovascular Prevention”

Director of Cardiology Dep. Asklepeion Hospital, Athens, Greece

Chairman Working Group “Hypertension and Heart” of the ESC

Council Member of the European Society of Hypertension

Athanasios J. ManolisAthanasios J. Manolis

What is CVD prevention?

“A coordinated set of actions, at public and individual level,

aimed at eradicating, eliminated or minimizing the impact of

cardiovascular diseases and their related disability.

The bases of prevention are rooted in cardiovascular

epidemiology and evidence-based medicine”.

A Dictionary of Epidemiology. 4th ed New York: Oxford University Press; 2001

Ancient Greek Proverb

Prevention is Preferable to Curing

( The earlier the better )

Hippocrates (c. 460-377 B.C)Hippocrates (c. 460-377 B.C)

Number of Deaths Worldwide/year

0

10

20

30

NCD

23.6 millions

40

18 millions

36 millions

CVD(2012) CVD(2030)

The Evolution of Mankind

50 years2.5 million years

What are the Main Targets for CVD Prevention?

Smoking No exposure to tabacco in any form

Diet Health diet, low in saturated fat with a focus on wholegrain products, vegetables, fruits and fish.

Physical Activity 2.5 to 5 hours moderately vigorous physical activity per week or 30-60 minutes most days

Body Weight BMI 20-25 kg/m2 . Waist circumference < 94 cm (men) or <80 cm (women)

Blood Pressure BP <140/90 mmHg

Lipids Very high risk: LDL <1.8 mmol/L (70 mg/dL) or >50% reduction

High risk: LDL <2.5 mmol/L (100 mg/dL)

Moderate risk: LDL <3 mmol/L (115 mg/dL)

Diabetes mellitus HbAIc: <7% (53mmol/mol), BP<140/80

Today’s Portions

Atherosclerosis:a Multifactorial Disease

EUROSPIRE I1995/6

0%0%

20%20%

40%40%

60%60%

Anti-platelet therapy

Anti-platelet therapy

Beta-blockersBeta-blockers

Reported Medication Use In Hospital Patients With Established CHD, 1995/96, 1999/2000 And 2006/07,

EUROSPIRE Survey Populations

10%10%

30%30%

50%50%

70%70%

80%80%

90%90%

100%100%

EUROSPIRE II1999/00

EUROSPIRE III2006/07

ACE-inhibitors & AT2

antagonists

ACE-inhibitors & AT2

antagonists

Lipid lowering drugs

Lipid lowering drugs

StatinsStatins

Reported Medication At Discharge: Hospital Patients With Established CHD, 2006/07, EUROASPIRE III Survey

2012: Deaths By Cause, in Europe

Coronary heart disease

Stroke

Other CVD

Stomach cancer

Colo-rectal cancerLung cancer

Other cancer

Respiratory disease

injuries and poisoning

all other causes

Hypertension Detection and Follow-up ProgramC

ard

iova

scu

lar

even

ts (

% in

5 y

ears

)

Organ Damage

B. StrokeB. Stroke

YesNoYesNo

4.8

5.8

15.3

18.7

1.32.1

5.4

7.4

U

A. Total MortalityA. Total Mortality

Organ Damage

SUSUSUS

Zanchetti J Hypertens 2009Zanchetti J Hypertens 2009

0

10

20

The high incidence of CV events persists despite

intense BP reduction and other RF,

when therapeutic interventions are

made once damage is

advanced and clinically disease is presentThe high incidence of CV events persists despite

intense BP reduction and other RF,

when therapeutic interventions are

made once damage is

advanced and clinically disease is present

30%30%

20%20%

10%10%

5%5%

CV riskCV risk% in 10 years% in 10 years

40%40%

50%50%

Treatment Benefits -25%Treatment Benefits -25%

5050

37.537.5

303022.522.5

2020

1515

1010

7.57.5 CVCVriskrisk

Death

Zanchetti A. Nat Rev Cardiol 2010;7:66-7

The Cardiovascular Continuum :

Treatment Benefits and Residual Risk at Increasing CV Risk

00

1010

2020

3030

5050

4040

Maj

or

card

iova

scu

lar

even

tsM

ajo

r ca

rdio

vasc

ula

r ev

ents

(% in

5 y

ears

)(%

in 5

yea

rs)

ACCACC

6868606023231313--

13136868656500

132132

CAMCAM

57571818383844

100100--

86869494

139139124124

PEAPEA

64641717555577

100100--

70709090

109109129129

EUEU

6060--

656533

100100--

57579292

102102128128

INVINV

66662828323255

10010022223737575700

131131

JMJM

656522224242--

100100--

2828555500

136136

ALLALL

67673636

2323

525216.516.52525363600

135135

ACTACT

646415155252--

100100--

686886863737

130130

ONTONT

64643737494921219191

13.613.662628181118118133133

TRTR

67673636464622229191131355557979

131131136136

HOPHOP

666638385252111188888.58.528287676

101101135135

VALVAL

6767323246462020606015154646737300

139139

PROGPROG

646413131616100100100100

--7760605050132132

PROFPROF

66662828--

10010010010015.515.54747

100100103103136136

PATSPATS

6060----

100100100100

------00

143143

MOSMOS

6868373788

100100100100

3131787800

136136

Trial

Age (y)DM (%)MI (%)

Stroke (%)Any CVD (%)

LVH (%)LLT (%)APT (%)AHT (%)

SBP (mmHg)

}}

TIATIA

65655566

1001001001001111--

494900

150150

8.08.08.38.3

10.510.5 10.610.6 11.011.011.511.5

11.711.711.411.4 12.212.2

13.913.9 13.913.9 14.014.0

16.116.1

19.219.2

25.625.6 25.425.4

34.34.33

40.040.0

10.510.511.711.7 11.211.2

13.013.0

11.011.012.412.4

12.112.1 14.014.012.512.5

14.114.115.815.8

17.817.816.816.8

25.425.4

26.926.9 27.027.0

43.543.5

50.050.0

8.512.012.0

LIFELIFE

6767363616*16*882525

100100----00

144144

Zanchetti J Hypertens 2009Zanchetti J Hypertens 2009

Trials in High-Risk PatientsTrials in High-Risk Patients

Residual Risk

1990 2000

No dataavailable

Less than 4% 4%-6% Above 6%

Adults With Diagnosed Diabetes*

Mokdad AH, et al. JAMA. 2001;286(10):1195-1200.

*Includes women with a history of gestational diabetes.

4.9% DM Prevalence 7.3% DM Prevalence

11.1 % Obesity 19.8 % Obesity

132

129130

124

136

130130

122

140

136

130

124

133

128

138

135

140

136

150

150

141

132

149

143

100

110

120

130

140

150

160

136

133133

119

144

141

145

143144

140

137

128

138

132

140

134

143

134

162

153

143

139

154

144

155

145

148

145

110

120

130

140

150

160

170

Diabetes PreviousPrevious CVDCVD

BP BP BenefitBenefit No benefit No benefit

Zanchetti, Grassi, Mancia J Hypert Zanchetti, Grassi, Mancia J Hypert 2009; 27: 923 ; 27: 923

SBP (SBP (mmHg))

HOTHOTSHEPSHEP

UKPDSUKPDS S. EurS. Eur ADVADV ABCDABCDRENRENHOPEHOPE PROGPROG

HTHT

IDNTIDNT

AMAMNTNT IRIR

IDNTIDNT

PLPL

ActiveActive

SBP (SBP (mmHg))

PATSPATS

PLPL

ActiveActive

PROGPROG

ACCACC

PROFPROF

HOPEHOPE

EUEU

CAM-AMCAM-AM PREVPREV

ACTACT

CAM-ENCAM-EN

PEAPEATRTR

Stroke CHD

ACRDACRDNAVNAV

preDMpreDM

Achieved BP in TrialsAchieved BP in Trials

Change In Smoking Rates Among 15 Year Olds, By Sex, 1993/94 To 2009/10, Europe

Health Behaviors and Attitudes in Young and Middle-Aged Saint-Petersburg Citizens (Russia) : A Pilot Study

Parameters Young participants

(<4 years old) (n=75)

Older participants

(≥40 years old) (n=28)

P-value

Tobacco smokers 26(34.7%) 5(17.9%) NS

Alcohol Consumption

Each day

1(1.3%)

Alcohol Consumption One or several times per week

23 (30.7%) 4 (14.3%) <0.05

Regularly (at least once per week) participate in active leisure or sport

40( 53.3%) 12 (42.9%) NS

Systolic BP (mmHG) (M m)

123.9 1.9 147.2 4.6 <0.001

Systolic BP>140mmHg 11 (14.7%) 15 (53.6%) <0.001

Diastolic BP>90mmHg 7( 9.3%) 5 (17.9%) NS

BMI >25 kg/m2 14 (18.7%) 7 (25.0%) NS

Praying or Acting?

Dear God

My prayer for 2012 is forA fat bank account and a thin body

Please don’t mix these like you did last year

AMEN !

2007 ESH/ESC GuidelinesLifestyle Changes in MS

Modest Modest of caloric intake of caloric intake Saturated fat < 7%Saturated fat < 7% Transfatty acidsTransfatty acids Cholesterol <200 mgCholesterol <200 mg Simple carbohydrates 50%Simple carbohydrates 50% Fruit / vegetablesFruit / vegetables Whole grainWhole grain

Physical exercisePhysical exercise30 min daily of 30 min daily of moderate exercisemoderate exercise

At least 7-10% At least 7-10% BW in 6-12 months BW in 6-12 months

Marked reduction (~60%) of NODMarked reduction (~60%) of NODMarked reduction (~40-50%) of MS prevalenceMarked reduction (~40-50%) of MS prevalence

Exercise Capacity and Mortality in Black and White Men, in Diabetics, Prehypertensives, and High Risk

RR of all cause mortality in individuals with no CVD

Relative RiskRelative Risk

00

0.20.20.40.4

0.60.6

0.80.8

11

1.21.2

ALLALL African-AmericanAfrican-

AmericanCaucasianCaucasian

0.790.79

0.510.51

0.270.27

0.790.79

0.520.52

0.230.23

0.780.78

0.50.5

0.30.3

Kokkinos P, Pittaras A, Manolis AJ et al. Circulation 2008 Kokkinos P, Pittaras A, Manolis AJ et al. Diabetes Care 2009 Kokkinos P, Pittaras A, Manolis AJ et al. Diabetes Care 2009

Kokkinos P, Pittaras A, Manolis AJ et al. Am J Hypertens. 2009 Kokkinos P, Pittaras A, Manolis AJ et al. Am J Hypertens. 2009 Kokkinos P, Pittaras A, Manolis AJ et al. Hypertension2009Kokkinos P, Pittaras A, Manolis AJ et al. Hypertension2009

POWER Study: Evolution of Score®

≤1%

2%

3-4%

5-9%

10-14%

≥15%

Final visit

Baseline visit

Percentage of patientsScore

® –

10-y

ear

risk o

f fa

tal C

VD

22%

13%

17%

28%

12%

8%

37%

16%

19%

24%

3%

1%

0 5 10 15 20 25 30 35 40

Mean SCORE® risk at V3 3.5 3.5%

Mean Score® change = -2.5 3.1%

Relative Risk reduction of - 41%

p<0.001

The Polypill

Three antihypertensive drugsThree antihypertensive drugsBeta-blockerBeta-blockerACE-inhibitorACE-inhibitorDiureticDiuretic

StatinStatin

Low dose aspirinLow dose aspirin

Potential Cumulative Impact of Four Single Secondary Prevention Treatments

Relative riskRelative riskreductionreduction

- - -- - -

25%25%

25%25%

30%30%

25%25%

2-year2-yearevent rateevent rate

8%8%

6%6%

4.5%4.5%

3.0%3.0%

2.3%2.3%

NoneNone

AspirinAspirin

Beta-blockersBeta-blockers

Lipid lowering (by 1.5 mmol)Lipid lowering (by 1.5 mmol)

ACE inhibitorsACE inhibitors

Cumulative relative risk reduction if all four drugs are used is Cumulative relative risk reduction if all four drugs are used is about 75%about 75%

Polypill and Cardiovascular Cost

CV Disease Cost

$ 863 billion globally

Polypill 17.9 million deaths in 10 yrs

Driving Behavioral Change and Improving Health and Productivity

October 2012

27What is KNOW YOUR NUMBERS?

KYN and a healthy lifestyle can: Prevent onset of metabolic conditions Help reverse chronic metabolic

conditions and prevent individuals living with these conditions from getting worse.

Increase morale

Know Your Numbers is a cardiovascular risk assessment tool designed to help drive health

improvement and behavioral change.

Biometric Input Lab Values

Fasting Glucose

Lipid Panel

Clinical Measures

Height

Weight

Waist

Blood Pressure

Pulse Rate

Limited Health History

SynthesisAnalysisEngine

KYN

Chronic Disease Risk for:

Heart DiseaseStroke

DiabetesHeart Failure

COPDLung CancerOther Cancer

Assessment Output

Provides Powerful, Actionable Knowledge

How Know Your Numbers Works

Why Know Your Numbers in Russia

KYN has consistent results in helping patients identify their cardiovascular risk factor, the main cause of death in Russia today.

KYN allows patients to be pro-active and engaged with their healthy lifestyle by providing more opportunities to be educated on proper nutrition and physical fitness.

92% of participants of KYN in other countries have been able to reduce or eliminate cardio-metabolic risk factors, which is much needed in Russia, a country where cardiovascular risk is growing compared to other parts of Europe where these risks have shown a decline.

KYN coincides with President Putin’s goal in dedicating more funding to these types of programs. The 2012 national budget has 820 million Rubles allocated for healthy lifestyle.

Cost of healthcare is growing worldwide and KYN’s model shows a reduction in costs associated with cardiovascular diseases.

NOW IS THE RIGHT TIME FOR RUSSIA!

30

Worldwide locations where Know Your Numbers has been implemented (2005-2012)

Organization Participating in Know Your Numbers Around the World

*Initial enrollment of participants are not reflected in this data, only those that attended both pre and post health screenings required to capture data to measure health improvement results . Data includes 2,611 participants.

Program Sponsor* Locations Market Segment

Abbott (2006, 2008, 2009) Illinois, UK, Puerto Rico, Chile Private Payer

TriCity Challenge (2005 - 2006) Navistar Chevron ArvinMeritor Wayne County Airport Authority

Illinois, Ohio (3 locations) Houston, TX Detroit, MI Detroit, MI

Private Payer

Toyal America (2009, 2010, 2011) Illinois Private Payer

Dreyer Medical Clinic (2008) Illinois (3 locations) Health Care System

St. Luke’s Hospital System (2007) Kansas Health Care System

Family Doctors MA Health Care - Group Practice

MC-21 (2009-2010) Puerto Rico Health Care - PBM

State of Washington (2008) Washington (5 locations) Public Payer

Military (2008) Singapore Public Payer

City of Albuquerque (2008) New Mexico Public Payer

Santa Cruz County (2010-2011) CA Public Payer

SuperValu (2010) Illinois Retail

Know Your Numbers &Behavioral Change Program Components

Pre and Post Challenge screenings

Individual chronic disease risk assessment (KYN report)

Educational sessions on key health topics (nutrition, physical

fitness)

Team or individual competition

Reward and recognition program

Summary data of health improvements

Risk of Onset, Modifiable Risk and Risk Comparison for a 45 male participant

He has an 36% chance of developing type 2 diabetes in the next 5 years

92% of his diabetes risk is in his control

(modifiable)Compared to other 45 yr old men, 98% have

a lower risk of diabetes than he does

Being in the 98% percentile (compared to

his peers) puts his diabetes risk in the

Relatively High category

Risk Factors with the Most Impact on Disease Risk Reduction

Smoking is a major risk factor that is contributing a majority of his disease risk. By modifying just this one risk factor, he

would decrease his risk of onset for several conditions significantly.

Provides the participant with an Action Plan!

Automated Treatment/Action Plan Report

Physicians receive a treatment action plan report based on

widely accepted guidelines for the region which helps save time

and encourages consistent therapy.

624 employees began the Challenge 233 employees completed the Challenge Average reduction per person

weight loss of 9.5 lbs waist reduction of 2.9 inches

100

60

40

0

weight

91%

55%

45%

28%

93%

23%

20

80

Waist size

Mets

New onsetType Diabetes

CHDStroke

Abbott Puerto Rico-Success Story(August-November 2009)

How are some partners using Know Your Numbers in helping to promote a healthy

lifestyle in Russia?

Pilot in Kazan

Epidemiology of CV Disease in HIV Patients

Patients living longer with HIV are presenting new concerns related to ART and chronic viral infection

The risk for CVD may be greatly elevated in the HIV + population for a number a reason:

-Increased prevalence of known CAD risk factors

(smoking, HTV, etc)

-HIV virus-related pathology?

-ART-related lipodystrophies, dyslipidemias, diabetes mellitus, insulin-resistance, etc.

Health Promotion February 10, 2011Company Confidential

Social Partner Development Fund (People Living With HIV)

Non-profit organization established in 2005 to develop public health care facilities in combating diseases of social significance.

The mission of the Fund is to improve people’s quality of life through constructive interaction between all parties involved in the public health system.

The strategy of the Fund is based on the fact that a key factor in ensuring the sustainable development of public health care in the fight against socially significant diseases in the current climate is the involvement in these processes of—and the level of interaction between—the government, the private sector and civil society.

Social Partnership Development Fund: Pilot Overview

Participants – 250 HIV+ patients to be enrolled

Locations: Kazan (a diverse population of over 1.1 million people)

Patient enrollment began on September 1, 2012 and baseline

measurements were taken to evaluate cardiovascular risk, utilizing

the unique tool, Know Your Numbers, that provides a predictive look

at future risk of developing chronic diseases.

12-week follow up with patient support and education by doctors

and experts on nutrition, physical fitness, and benefits of less

alcohol and tobacco use.

Re-evaluation of the participants risk after the intervention to

identify progress.

Results of the pilot to be available in Qtr1, 2013.

50

30

20

0

overweight or obese

55%

2%

31%

21%

24%

31%

10

40

pre-hypertensive hypertensive

pre-diabetestotal cholesterol

LDL cholesterol

10%

triglycerides

60

29 participants enrolled to date (expect 250)

20 female / 9 males

32 mean age

Russian Preliminary Baseline Data(As of 10/5/12)

Actions to prevent CVD should be incorporated into everyone’s daily lives, starting in early childhood and continuing throughout adulthood and senescence

The physician in general practice is the key person to initiate, coordinate and provide long-term follow-up for CVD prevention.

Nurse-coordinated prevention programmes should be well integrated into healthcare systems

The practising cardiologist should be the advisor in cases where there is uncertainty over the use of preventive medication or when usual preventive options are difficult to apply

All patients with CVD must be discharged from hospital with clear guideline-orientated treatment recommendations to minimize adverse events

All patients requiring hospitalization or invasive intervention after an acute ischaemic event should participate in a cardiac rehabilitation programme to improve prognosis by modifying lifestyle habits and increasing treatment adherence.

Patients with cardiac disease may prticipate in self-help programmes to increase or maintain awareness of the need for risk factor management.

Non-governmental organisations are important partners to health care workers in promoting preventive cardiology

The Eyropean Heart Health Charter marks the start of a new era of political engagement in preventive cardiology.

Where should CVD prevention programmes be offered?

To Smoke or not to Smoke

RussiAction

TARGETS 2012-2015

Modifiable Risk Factors

Physical activity Tobacco Salt intake Blood Pressurecontrol

10% 30% 30%25%

25% in mortality

Global CV Disease Task Force 2012

TARGETS 2012-2015

Fat intake

Cholesterol

Obesity

Excessive alcohol intake

Drug therapy

Plus :

RussiAction

GovernmentPoliticiansArmyOpinion leadersActorsOlympic championsMedia

Cardiovascular SocietiesDoctorsNursesVolunteers

FoundationsCompanies

Doing Nothing in CV Prevention

$500 billion/year in low and middle income

countries

$47 trillion cost in the next 25 yrs

Conclusions

We now have the opportunity to make important We now have the opportunity to make important changes in our countries by adopting evidence-based changes in our countries by adopting evidence-based targets and implementation of the guidelines that will targets and implementation of the guidelines that will guide health policy, with the collaboration of the guide health policy, with the collaboration of the government, national societies, parents, teachers, government, national societies, parents, teachers, nurses, volunteers, politicians and opinion leaders.nurses, volunteers, politicians and opinion leaders.

Collaboration with other groups, such as stakeholders, Collaboration with other groups, such as stakeholders, foundations, media etc. will be necessary to address foundations, media etc. will be necessary to address this emerging 21this emerging 21stst global health priority and begin to global health priority and begin to reverse the devastating toll of CV disease and NCDs reverse the devastating toll of CV disease and NCDs in our communities. in our communities.

Zakynthos Island, GreeceZakynthos Island, Greece

Santorini Greece