Debates en Cardiología; Novedades más relevantes. La prevención cardiovascular en el nuevo contexto de la gestión de enfermedades crónicas

1. Diabetes and the Heart Meet the experts August 30 2009 Cardiovascular prevention in the context of chronic illness management Lars Rydén Cardiology Unit Karolinska Institutet Stockholm, Sweden Debates en Cardiología: Novedades más relevantes Barcelona October 22 2009

2. Health and disease The ideal solution Lucas Cranach 1546 - The Youth Fountain

3. Epidemiological reality Expanding technology Competing fields Health economy Reorientation The European Heart Health Charter John W Waterhouse 1902 Crystal ball with skull Health and disease A look in the crystal ball

4. Epidemiological reality Ageing populations

5. Epidemiological reality Mortality and morbidity trends

6. Future heart failure management? biventricular pacemaker combined with implanted hemodynamic monitor Expanding technology Cardiac care increasingly technical and expensive Chronicle ® IHM Home Monitor Clinician access Secure Network

7. Competing fields Cardiovascular disease Diabetes Cancer Chronic inflammatory diseases

8. A global health catastrophe underway over 350 million within a generation Diabetes in Europe The global picture

10. Cardiovascular disease Chronic inflammatory diseases New theraputic options Inhibition of immune-defense signal transmission From relief to cure Yesterday 300 €/year + indirect costs Today 10 000 €/year for care providers

11. Cardiovascular disease Priori- tise!! Health economy Priority settings in health care Vertical Provider responsibility Prevention Diagnostics Screening Treatment Rehab

12. Reorientation Theraputic progress – obviously not enough .....what about preventing the disease??? 1952 Open heart surgery 1958 Implanted pacemaker 1958 Coronary angiography 1962 Beta-blockade 1964 By pass surgery 1965 ACE-inhibition 1967 Heart transplantation 1969 Calciumantagonism 1976 Intracoronary fibrinolysis 1977 PTCA 1980 Implanted defibrillator 1984 Statins 1988 Cardiovasc use of ASA and more…… W Morton´s first operation under ether 1846 Painting by RC Hinckley 1883

13. (By courtesy: The EUROASPIRE study group) Patients within recommended target (%) Why not better protection in particular among those at risk but still not with established CVD? Preventing cardiovascular disease EUROASPIRE III - Prevention in clinical practice 100 80 60 40 20 0 Blood pressure Total cholesterol Hospital Gen practice Abdominal obesity BMI >30 Smoking Life style oriented variables 100 80 60 40 20 0

14. It´s time to phase reality. We´re not exactly rocket scientists Reorientation Discrepancies between reality and clinical practice

16. The European Heart Health Plan Challenges on the way towards the goal ♦ Create a s trong and simple message ♦ Harmonize the application of available knowledge ♦ Have strong belief in success ♦ Promote a unified approach based on collaboration with respect for autonomy ♦ Improve adherence & compliance ♦ Have patience & be persistant

17. The strong and simple message ♦ Heart disease kills more people in the European Union than any other disease ♦ The European Union spends more money on cardiovascular illness than any other disease ♦ Cardiovascular disease can be prevented by lifestyle changes and better use of medicines we already have ♦ This plan would decrease suffering and save money

18. The strong and simple message CVD behind > 50% of deaths in Europe Cardiovascular mortality (≤65 years) in Europe A major contributor to the almost 20 year difference in life expectancy across Europe

19. The strong and simple message Costs Primary care Inpatient care A&E Outpatient care Medications

20. Application of available knowledge The Interheart study All Smoking Diabetes Overweight Psykosoc 1+2+3 Hypertension ApoB/ApoA1 1+2+3+4 All combined (Yusuf et al. Lancet 2004; 364:937) Odds Ratio (99% CI) 2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 337.7 Conclusion ”… .nine easily identified risk factors explain >90% of the risk to develop myocardial infarction…”

21. (The European Health Report 2005; WHO European Region) Application of available knowledge Blood pressure Tobacco Alcohol Cholesterol Overweight Low fruit and vegetable intake Physical inactivity Seven leading risk factors cause a great proportionate loss of DALYS in Europe 12.6 12.3 10.1 8.7 7.8 4.4 3.5 %

22. Diabetes and the Heart Meet the experts August 30 2009 1992 ” The primary determinants of disease are mainly economic and social. Therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.” Geoffrey Rose 1926 - 1993

23. …… Have a strong belief in success Encouraged by the good example East Karelia the first example of community based prevention encourages

24. 1975 1980 1985 1990 -70 -60 -50 -40 -30 -20 -10 0 Percent decline Smoking Cholesterol Predicted reduction three factors Blood pressure Have a strong belief in success Observed CHD mortality in East Finland (Vartiainen et al. BMJ 1994;309:445)

25. 1975 1980 1985 1990 -70 -60 -50 -40 -30 -20 -10 0 Percent decline Observed mortality Smoking Cholesterol Predicted reduction three factors Blood pressure Have a strong belief in success Observed CHD mortality in East Finland (Vartiainen et al. BMJ 1994;309:445) Enhanced by treatment

26. Have a strong belief in success Explaining fall in CHD deaths in the US 1980-2000 (New Engl J Med 2007: 356:2388)

27. Actions and policies for a healthier Europe February 14th 2000 To promote a unified approach Based on alliances Every child born in the new millennium has the right to live until the age of at least 65 without suffering from avoidable cardiovascular disease In the parliament

28. To promote a unified approach Based on political support 2002 Spanish Presidency Declaration created an opportunity 2002-03 Positioning within the EC 2004 Irish Presidency Cork conference - Council Conclusions 2005 Luxembourg Presidency Luxembourg Declaration 2006 Austrian Presidency Declarations on diabetes and women

29. European phone number to health 14090530 The European Heart Health Charter The essential message 0 smoking 3 km of daily walking 5 portions of fruit & vegetables/day <140/90 mm Hg blood pressure <5.0 mmol/l total cholesterol <3.0 mmol/l LDL-cholesterol 0 diabetes

30. To promote a unified approach Based on political support 2002 Spanish Presidency Declaration created an opportunity 2002-03 Positioning within the EC 2004 Irish Presidency Cork conference - Council Conclusions 2005 Luxembourg Presidency Luxembourg Declaration 2006 Austrian Presidency Declarations on diabetes and women 2007 The European Heart Health Charter Launched at the European Parliament

31. Launched June 12 2007 by In collaboration with European Heart Health Charter The Launch

32. ♦ Minimum requirements to set up heart healthy environments ♦ Proposal of practical tools to implement Council Conclusions European Heart Health Charter What is it? and not the least a moral agreement between signatories

33. European Heart Health Charter … ..and since then

36. A group of European Parliamentarians has been created by ESC and EHN Regular meetings At the European Parliament 2-3 times/year Charter related topics European Heart Health Charter Parliamentarian support

37. Translations 24 languages European Heart Health Charter Present distribution Launches 30 nations Serbian Russian Czech

38. Using EU legislation to promote cardiovascular health Cardiovascular disease prevention Examples of succesful health policies

39. European phone number towards health 0-3-5-140-90-5-3-0 European Heart Health Charter The targets 0 smoking 3 km of daily walking 5 portions of fruit & vegetables/day <140/90 mm Hg blood pressure <5.0 mmol/l total cholesterol <3.0 mmol/l LDL-cholesterol 0 diabetes

40. Prepared by the ASPECT* consortium with funding from the Directorate-General for Health and Consumer Protection European Commission October 2004 *Analysis of the Science and Policy for European Control of Tobaccoo Obstacles to cardiovascular health Tobacco At a conservative estimate tobacco kills over 650 000 people each year in the EU

41. Oppositional voices Political achievements Smoking ban in public places European pioneers Early 2005 Ireland and ItalyC

42. The strong and simple message CVD behind > 50% of deaths in Europe Cardiovascular mortality (≤65 years) in Europe A major contributor to the almost 20 year difference in life expectancy across Europe

43. (Source http://www.smokefreepartnership.eu) February 2009 >200 million European citizens protected by smokefree laws Political achievements Smoking ban in EU Close or 100% according to article 8 Limited laws excemptions allowed Locally variable protection Currently updating the law Currently considering legislation No protection

44. (Glantz Preventive Medicine 2008; 47:452) Hospital admissions for AMI in eight studies 2004 - 2008 Reduction 19% (95% CI 14-24) Political achievements Impact of smoking ban in public places

45. Acute coronary syndromes in Scotland 67% Political achievements Impact of smoking ban in public places (Pell et al. N Engl J Med 2008; 359:482) Before After Category Reduction % (95% CI) Overall 17 (16 - 18) Smokers 14 (12 - 16) Former smokers 19 (17 - 21) Nonsmokers 21 (18 - 24)

46. Political achievements Tobacco advertising EC directive 2001/37 and 2003/33 Tobacco Advertising Directive National legislation July 2005

47. Directive 2001/37/EC increases size of health warnings front 30%; back 40% adopt rules for the use of color photos explaining consequences Belgium first November 2006 Romania July 2008 Latvia from March 2010 other nations will soon follow Political achievements Tobacco advertising

49. The battle goes on… Price differences create an environment for Cross border shopping Smuggling Fraud Political plans Tobacco pricing and taxation € 400 300 200 100 0 Cigarette prices across EU (€/1000) Pre-tax Tax inclusive Price

50. European phone number towards health 0-3-5-140-90-5-3-0 European Heart Health Charter The targets 0 smoking 3 km of daily walking 5 portions of fruit & vegetables/day <140/90 mm Hg blood pressure <5.0 mmol/l total cholesterol <3.0 mmol/l LDL-cholesterol 0 diabetes

51. Vertumnus (Rudolf II) Giuseppe Arcimboldo 1591 Obstacles to cardiovascular health Fruit and vegetables Recommended >400 grams/capita/day

52. 1800 1500 1200 900 600 300 0 Tonnes x 10 3 1997/1998 1998/1999 1999/2000 2000/2001 (Elinder et al 2003) Obstacles to cardiovascular health Use of fruit and vegetables in EU 1997 - 2001 Compostation Distillation Animal feed Human consumption

53. gram/capita/day Apparent consumption in EU Obstacles to cardiovascular health Fruit and vegetable consumption (Source: DG AGRI ) GR PT ES IT CY DK NL FR MT EU SI AT DE BE LU RO SE UK IE BG HU FI LT EE PL CZ LV SK 800 700 600 500 400 300 200 100 0 WHO/FAO min recommended intake

54. 2000 2001 2002 2003 2004 2005 2006 415 405 395 385 375 gram/capita/day Evolution of consumption in EU Trend Obstacles to cardiovascular health Fruit and vegetable consumption (Source: DG AGRI )

55. Proportion obesity and overweight in 7-11 year-old children (Source: Internat Obesity Task Force 2005 ) Obstacles to cardiovascular health Childhood obesity Obese Overweight 30 20 10 0

56. Political achievements School fruit scheme TOWARDS A POSSIBLE EUROPEAN SCHOOL FRUIT SCHEME CONSULTATION DOCUMENT FOR IMPACT ASSESSMENT One of the objectives…. To reverse the declining consumption of fruit and vegetables

58. European phone number towards health 0-3-5-140-90-5-3-0 European Heart Health Charter The targets 0 smoking 3 km of daily walking 5 portions of fruit & vegetables/day <140/90 mm Hg blood pressure <5.0 mmol/l total cholesterol <3.0 mmol/l LDL-cholesterol 0 diabetes

59. (Roberts Am J Cardiol 1984; 53: 261) … .with lipid-lowering, antihypertensive, positive inotropic, negative chronotropic, vasodilating, diuretic, anorexogenic, weight-reducing, cathartic, hypoglycemic, tranquilizing, hypnotic and antidepressive qualities Physical activity A wonderful agent

60. (Source: European Commission 2006) Proportion without moderate physical activity a typical week in European countries Obstacles to cardiovascular health Lack of physical activity Adults % 80 60 40 20 0

61. Obstacles to cardiovascular health Lack of physical activity 36 sec to the top 36 steps to health Your health – Your choice SvD Januari 2009 The environment must make physical activity a natural choice 10 000 steps not enough to keep your shape

62. 1 Amsterdam 2 Portland 3 Copenhagen 4 Boulder 5 Davis 6 Sandnes 7 Trondheim 8 San Francisco 9 Berlin 10 Barcelona 11 Basel Political possibilities Bicycle friendly cities

63. Future steps to be taken Cardiovascular disease prevention Towards a successful health policy

64. Lars Rydén Karolinska Institutet Stockholm, Sweden Represented organisations Cardiovascular Respiratory Cancer Diabetes Topics Smoking, alcohol, nutrition, overweight physical inactivity Policy conference June 2009 Cardiovascular disease prevention Transprofessional collaboration EC organised meeting November 10, 2009

65. Why Recommendations? ♦ Highest soft law tool in European Legislation ♦ Stronger sign than just new conclusions ♦ Politically commit Member States who adopt the recommendations European Heart Health Charter Towards Council Recommendations

66. Objective of Recommendations Give strong legal and political orientations from the EU Council indicating to Member States the right options for them to ♦ reduce the burden of CVD ♦ promote CV health European Heart Health Charter Towards Council Recommendations The platform

67. Timelines 15/10 2008 1/2010 3/2010 6/2010 Brussels meeting Spanish Presidency Council Recommendations Conference Spanish Presidency European Heart Health Charter Potential collaboration with Spain

68. European Heart Health Charter Closing the loop of a long process 2002 Spanish Presidency Declaration created an opportunity 2002-03 Positioning of ESC within EU/EC 2004 Irish Presidency Cork conference - Council Conclusions 2005 Luxembourg Presidency Luxembourg Declaration 2006 Austrian Presidency Declarations on women and diabetes 2010 Spanish Presidency Council recommendation ◄ ◄

69. Dante Gabriel Rosetti … poet, artist and designer Dante Gabriel Rosetti 1828 - 1882

70. Dante Gabriel Rosetti … .who disliked his physcian already 1862 My doctor ’ s issued his decree That too much wine is killing me And furthermore his ban he hurls Against my touching naked girls How then, must I no longer share Good wine and beauties dark and fair? Doctor, goodbye, my sail ’ s unfurl ’ d I ’ m off to try the other world

71. http://se.youtube.com/watch?v=zbKRSYAuSNg Important To know one´s enemies

72. ” To enable people to make and to implement healthy choices requires information and facilities which must be centrally funded and provided.” Choices will and should always be made by the individual! Our task is to make the healthy choices attractive, affordable and available Geoffrey Rose 1926 - 1993

73. ♦ To work towards a better integration of preventive and curative medicine ♦ To build necessary alliances for the improvement of public health ♦ To take political initiatives Cardiovascular care of the future What is our responsibility

74. EC - Matti Rajala, Katrin Saluvere, Michael Huebel Ireland - Michael Martin, Emer Shelley, Peter Kearney, Chris Fitzgerald, Brian Brogan Luxemburg - Jean Beissel, Mars Bartolomeo Austria - Kurt Huber, Ines Stamm Spain - Maria Jesus Salvador, Esther Gil ESC- The Presidents, Board members, John Martin, Alan Howard, William Wijns, EU relations Cttee, Joint Prevention Cttee, EACPR particularly David Wood, Guy de Backer and Ian Graham, EHN - Peter Hollins, Susanne Logstrup, Susanne Volqvartz, Marleen Kestens, WHO - Jill Farington, Albena Arnaudova National Cardiac Societies - Presidents of Spain, Ireland, Luxemburg , Austria, Germany, Portugal, Sweden and Presidencies of National Cardiac Societies in the EuroHeart Programme. People who made this lecture possible Important collaborators during the years with the EHHC

75. People who made this lecture possible The marvelous “back up office” at the European Heart House Florence B Camille P Britta R Ilaria L Muriel M Sophie S Sophie O´K

76. People who made this lecture possible The great door opener and enthusiast John Martin

77. Diabetes and the Heart Meet the experts August 30 2009 Debates en Cardiología: Novedades más relevantes Barcelona October 22 2009 Thanks for listening to me!!!