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CVD Mortality in Brazil:SOCESP/SBC/IDPC/HAOC Proposal

for Effective Reduction

Álvaro Avezum, MD, PhD, FESC, FACC

São Paulo, Brazil

Director, Research Division, Dante Pazzanese Institute of Cardiology

Professor, São Paulo University

International Associate Researcher, PHRI, McMaster University, Canada

Health Systems Research Workshop MRC and CONFAP

Brasilia June 2017

AGENDA

– Scope of the problem and Brazilian CVD landscape

(the real challenge)

– SOCESP/SB/C/IDPC/HAOC Roadmaps

(focus on Health System Component)

– Coalition for CVD mortality reduction

(Saving lives and generating relevant knowledge)

The Team

Alvaro Avezum (IDPC)

SOCESP/SBC

HAOC (Jefferson Fernandes)

LSH - UK (Pablo Perel)

PHRI – Canada (Salim Yusuf)

WHF - Geneve (David Wood)

Brazilian Cardiovascular Network

Primary Care Units (Family Health Strategy)

Milestones

From EMERAS to COMPASS (60 RCTs – 28 yr)

From OASIS-Registry to PURE (20 Epi-Studies)

Key relevant areas in CVD research (AMI, ACS, HF, AF,

1ary & 2ary CV prevention, DM, Obesity, PCI, CABG, etc)

Consolidated Research Network (300 hospitals: in- and

outpatient research + 700 private offices + 500 PCUs)

Beyond Institutional borders

Publication policy – always focusing on high-impact journals

BRAZIL: MI Mortality CoefficientRelative Variation - 2003/2012

Colombo F, Magalhaes C, Gagliardi S, Avezum A. Submitted 2016

Força da Associação e Impacto Clínico do risco

de IAM na América do Sul, por países

Lanas F, Avezum A, Bautista L, Yusuf S, et al. Circulation 2007;115:1067-1074

ESTUDO INTERSTROKE: FATORES DE RISCO PARA

TODOS OS TIPOS DE AVC (TODAS REGIÕES)

Overall PAR 90.2% (88.0-92.1)

0.25 0.5 1 2 4 8

Odds ratio (99% CI)

Risk Factor Control(%) Ischemic(%) ICH(%) OR(99% CI) PAR(99% CI)

ApoB/ApoA1 (T3 vs T1)

Cardiac Causes

Psychosocial

High Alcohol Intake

Diabetes Mellitus

Physical Activity

modified AHEI (T3 vs T1)

Waist-to-Hip Ratio (T3 vs T1)

Current Smoker

Hypertension

33.0

5.0

2.5

22.0

16.3

33.0

32.9

22.4

47.4

46.4

16.8

5.3

30.7

11.1

28.9

42.0

30.6

72.0

38.0

4.4

4.3

19.2

7.9

24.2

35.0

29.3

74.8

1.84(1.65 to 2.06)

3.17(2.68 to 3.75)

2.20(1.78 to 2.72)

2.09(1.64 to 2.67)

1.16(1.05 to 1.30)

0.60(0.52 to 0.70)

0.60(0.53 to 0.67)

1.44(1.27 to 1.64)

1.67(1.49 to 1.87)

2.98(2.72 to 3.28)

26.8(22.2 to 31.9)

9.1(8.0 to 10.2)

17.4(13.1 to 22.6)

5.8(3.4 to 9.7)

3.9(1.9 to 7.6)

35.8(27.7 to 44.7)

23.2(18.2 to 28.9)

18.6(13.3 to 25.3)

12.4(10.2 to 14.9)

47.9(45.1 to 50.6)

Overall PAR 90.7% (88.7 to 92.4)

O´Donnel M,….Avezum A, ….Yusuf S. Lancet 2016, in press

Hypertension Control accross HIC/MIC/LIC – PURE Study

25

32

27

8

3943

37

12

4951

47

15

0

10

20

30

40

50

60

Hipertension HT aware HT treated HT controlled

no risk factor ≥1 risk factor ≥2 risk factors

Risk factors: diabetes, smoking, obesity, male and age>65 anos

Chow CK, Teo KK,…Avezum A,…Yusuf S, PURE Study Investigators. JAMA 2013;310:959-68

% receiving proven medications in CAD (154,000 people from 17 countries: PURE Prospective Study)

0

10

20

30

40

50

60

70

80

90

100

Overall HIC UMIC LMIC LIC

0 1 2 3 4

5593 671 1338 2879

Yusuf S, Rangarajan S, Avezum A, et al. The Lancet, August 28, 2011

Proportion of medication use in individuals

with CHD by countries in South America

Avezum A, ..., Yusuf S. Global Heart 2016, Oct 20

Proportion of medication use in individuals

with stroke by countries in South America

Avezum A, ..., Yusuf S. Global Heart 2016, Oct 20

Cardiovascular Risk and Events in 17 Low-, Middle-,

and High-Income Countries – PURE Study

Yusuf S, Rangarajan S, Teo K, Ilsam S, Avezum A et al, for the PURE Investigators. NEJM 2014,371;9:818-827

Performance Measures

Adherence Rates

PERFORMANCE MEASURES N %

Blood Pressure Control (<140/90 mmHg) 695 22.0

LDL-c < 100 mg/dL 450 14.3

Smoking Cessation Program Referral 0 0

Antiplatelet Therapy 817 74.3

ACEi/ARB (DM and/or systolic dysfuncion)

Betablocker Therapy (systolic dysfuncion)

Oral Anticoagulation (AF patients – CHADS2>2)

521

92

153

67.0

22.0

33.0

Real-World Scenario

• Epidemic increase on CVD mortality (varying from region to region)

• Regional Heterogeneity and lack of common applicable guidelines and

Intrinsic limitation of guidelines to improve clinical practice

• Urgent need for KT strategies (regional and locally applicable) – policy

implementation science

• Health system not considered for health care improvement

• Possibly, shift from guidelines to EB practical recommendations

• Lack of community (primary care) interventions

• Urgent need for building a nationwide coalition for better CVD care

Need for comprehensive approach-coalition

for fighting CVD

• Inclusive and comprehensive strategy: medical societies,

government (all levels), hospitals, universities, NGOs, funding

agencies, private stakeholders.

• Platform: Brazilian Health Family Strategy (70% coverage)

• Indicators to be monitored (metrics): CV death, MI, stroke, HF,

Risk Factors (awareness/treated/controlled), 2ary prevention

• Roadmaps Interventions customized for Brazil – HS component

Achieving 25x25 together

• In September 2011, the United Nations

launched a Political Declaration which led to a

common goal of 25 percent reduction in

premature mortality from CVD and other non-

communicable diseases by 2025.

• This declaration represents a tremendous

opportunity and challenge for the medical

profession, multinational corporations,

advocacy groups, governments and other

stakeholders.

The WHF has adopted the overall goal for premature

CVD mortality and has identified three targets as being of

highest priority for CVD control: Roadmap

1. Preventing AMI and stroke through drug therapy and

counseling for high risk individuals (known CVD);

2. Reducing tobacco use by 30%

3. Increasing hypertension control by 25%

Roadblocks and potential solutions

Situational AnalysisSmoker Ex-Smoker

Never

Smoke

17% 26% 58%

Cigarrettes/day>10 10-20 > 20

59% 17% 24%

Awareness of the risk 88%

Sim Não

Attempts for quitting smoking 78% 22%

Successful quitting 25% 75%

Seeking specialized service 20% 80%

Scheduled appointment 64% 36%

Specific medication use 5% 95%

% of monthly family income 35% 65%

43%Hypertensives

33% Diagnosis > 10yr

28% Diagnosis< 5 yr

71% Regular appointments

82%Awareness of hypertension

relevance

30% Uncorrect medication use

5%Not using a single

medication

43%Hypertension

Awareness

35% BP<140x90mmHg

65% BP>140x90mmHg

20% Hypertensives unware of the hypertension diagnosis

Treatment

48% Hidroclorotiazide

26% Losartan

24% Enalapril

20% Atenolol

20% Anlodipine

Reasons for treatment non-adherence

61% Forgetfulness

30% Preference for not using

7% Highh cost

Eventos (20,3%)IAM AVC

Angin

aStent

Rev.

CirúrgicaDAOP

72% 53% 33% 29% 10% 5%

MedicaçõesAAS

Beta-

BloqueadorIECA Estatina BRA 4 Med.

38% 29% 19% 18% 15% 20%

Indivíduos com evento

prévio e sem nenhuma

medicação

28%

Medication PrescriptionPC Physician

Hospital

PhysicianPrivate Cardiologist

67% 13% 20%

Getting medication from PCU 93%

Correct use of medicaiton 73%

Awareness of 2ary.

prevention relevance66%

Difficult to access health

system for 2ary prevention43%

CVD Events (20,3%)AMI Stroke Angina PCI CABG PAD

72% 53% 33% 29% 10% 5%

MedicationsASA BB ACEI Statin ARB

4

Med.

38% 29% 19% 18% 15% 20%

Previous event without

using a single medication28%

Next Steps

• Create a national coalition to achieve CVD mortality reduction

• Situation analysis • Epidemiological profile (CVD, risk factors)

• Health system assessment (resources, financing, governance,

delivery)

• Policy mapping (national plans, laws)

• Rapid reviews, secondary data analysis and interviews

• Produce a situation analysis report

• Policy dialogues• Stakeholders mapping

• Discuss roadmaps solutions (in the context of situation analysis)

• Produce a concrete plan of action “National Roadmap”

Brazilian Government Ministry of

Health

WHFMedical

Societies (SBC, SBMF, ABN, SBCM,

etc )

Health Professional

Societies (ABEN, SBP, SBAFS, SBF,

ABN)

Brazilian Government –

Ministry of Education

(municipal and state schools)

Media (viral dissemination):

TV, radio, newspaper

(major, minor, regional), websites

CVD Prevention-

aligned Private

Initiative Stakeholders

NGOs

Health Professional Organization

Medical Organization (AMB, APM)

Brazilian Coalition for CVD Prevention – Stakeholders Mapping

Key Messages

The problem

• Cardiovascular diseases are the leading cause of death and disability in Brazil

being responsible for one third of the total cause of mortality.

• Despite the availability for decades of evidence-based treatment to prevent

cardiovascular diseases, including anti-hypertensive, lipid lowering, and

secondary prevention medications there use is still very low.

• Recent data suggest that only 20% of post-MI and 30% of post-stroke patients

are not taking a single evidence-based medication and only 5% of post-MI

patients are taking four evidence-based therapies.

• The main challenge now is to develop and evaluate innovative models of care to

implement “what we know it works” for cardiovascular diseases.

Key Messages

Leadership in Brazil

• Dante Pazzanese Institute of Cardiology and Research Team in Sao Paulo is one

of the most recognized cardiovascular research group in Latin America.

• Dante Pazzanese Institute of Cardiology is one of the largest cardiovascular

institution in Latin America, 65 years old, with solid and meaningful contribution to

the Brazilian cardiovascular health, through clinical care, teaching and research

(about 100 randomized clinical trials and 20 epi-studies conducted in Brazil under

our coordination through a long-term established nationwide network in Brazil.

• Researcher has been a steering committee member of 60 studies (RCTs and Epi-

studies), author and co-author of 200 peer-reviewed scientific papers, h-index of

60, reviewer of key relevant journals and one of world´s most influential scientific

minds in clinical medicine by Thompson Reuters.

• Jointly with his team we have been working on better understanding existing

roadblocks to implementation of effective cardiovascular preventive treatments.

Key MessagesThe proposed area of work

• Under this call we propose to develop and evaluate an innovative and scalable

model of care at the primary care and community level for cardiovascular primary and

secondary prevention.

• Although the exact scope of the proposed model of care is still to be decided we

anticipate that it could include some of the following components: use of information

& communication technology, task sharing, and simplification of treatment by fixed

dose combination.

• Collaborative Institution: London School of Hygiene & Tropical Medicine Centre

for Global NCDs (Director: Pablo Perel, MD, PhD)

• MRC: Picking research that delivers, research to people, global research (global

science and population science)

• Newton Fund (neglected and emerging diseases and health systems research)

• CVD community; neglected and vulnerable (cutting edge policy-relevant research

for strengthening HS in Brazil is in perfect alignment with the proposed project)