Technical package for cardiovascular disease management in primary health care Technical package for cardiovascular disease management in primary health care WHO Library Cataloguing-in-Publication Data: Hearts: technical package for cardiovascular disease management in primary health care. 1.Myocardial Infarction – prevention and control. 2.Cardiovascular Diseases. 3.Primary Health Care. I.World Health Organization. ISBN 978 92 4 151137 7 (NLM classification: WG 310) © World Health Organization 2016 All rights reserved. Publications of the World Health Organization are available on the WHO website (http://www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; email: [email protected]). 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Table of contents Abbreviations 6 Preface 8 Introduction 11 Rationale and strategic approach 15 Scope of HEARTS 21 Elements of HEARTS 23 Healthy lifestyle 25 Evidence-based treatment protocols 29 Access to essential medicines and technology 33 Risk-based management 37 Team care and task-sharing 43 Systems for monitoring 49 Approach to implementation 53 References 56 Annex 1. Evidence-based protocols 60 a. Protocol for prevention of heart attacks, strokes and kidney disease within integrated management of diabetes and hypertension (WHO-PEN protocol 1) 60 b. Health education and counselling on healthy behaviour (WHO-PEN protocol 2) 64 c. Tobacco cessation counselling protocol 66 d. Self-care among patients with CVD or diabetes (WHO-PEN protocol 5) 67 Annex 2. Essential medicines and basic technology for implementing CVD interventions in primary health care 69 a. Core list of medicines required for implementing essential CVD interventions in primary care 69 b. Core list of basic technology and tools for implementing essential CVD interventions in primary care 70 Annex 3. WHO and International Society of Hypertension cardiovascular risk prediction charts 71 Annex 4. Clinical and process indicators for implementation of HEARTS 72 5 Abbreviations CDC Centers for Disease Control and Prevention (United States) CVD cardiovascular disease HIV human immunodeficiency virus ISH International Society of Hypertension LMICs low- and middle-income countries NCD noncommunicable disease PAHO Pan American Health Organization WHO World Health Organization WHO-PEN WHO Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-resource Settings Measurements cm centimetre dL decilitre L litre mg milligram mmHg millimetre of mercury mmol millimole 6 HEARTS: Technical package for cardiovascular disease management in primary health care 7 Preface Nearly everyone reading this document has been affected by cardiovascular disease (CVD) in some way, either personally or through someone they know. If current trends continue, the annual number of deaths from CVD will rise from 17.5 million in 2012 to 22.2 million by 2030. Four of five people who die from CVD are killed by a heart attack or a stroke, and one third of these deaths occur in people under 70 years of age. Heart attacks and strokes, which are often avoidable outcomes, cause a lot of suffering for individuals and families affected. They also impose a substantial cost on society, particularly in low- and middle-income countries (LMICs), where over three quarters of deaths from these conditions occur. Millions of people worldwide struggle to control the risk factors that lead to cardiovascular disease, many others remain unaware that they are at high risk. A large number of heart attacks and strokes can be prevented by controlling major risk factors through lifestyle interventions and drug treatment where necessary. Improvements in prevention and treatment have led to decreases in the rates of CVD in many high-income countries but similar trends have not been seen in many other parts of the world where the burden is greatest. The world’s leaders committed themselves to ambitious reductions in premature CVD deaths in the United Nations 2030 Agenda for Sustainable Development, the World Health Organization (WHO) Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs) 2013–2020 and the Political Declaration of the High-level Meeting of the United Nations General Assembly on NCDs. Bold action to scale up services across the spectrum of prevention and management of risk factors is necessary to reach these targets. The HEARTS technical package provides a set of effective, practical interventions for strengthening the management of risk factors for CVDs in primary health care. The aim is to prevent cardiovascular disease (heart attacks and strokes) by ensuring equitable access to continuous, standardized, high-quality care for people at high risk. HEARTS is aligned with and builds on the WHO Package of Essential Noncommunicable Disease Interventions for Primary Health Care in Low-resource Settings for strengthening NCD management, and it complements 8 HEARTS: Technical package for cardiovascular disease management in primary health care WHO strategies and packages for population-based primary prevention of CVD, including tobacco control and salt reduction. HEARTS represents an unprecedented alignment among stakeholders in global CVD management. It responds to the agreement that sustainable, effective action is urgently required to prevent cardiovascular diseases. Millions of lives could be saved through the implementation of the HEARTS package. Dr Margaret Chan Hon. Michael Bloomberg Director-General WHO Global Ambassador for NCDs World Health Organization Dr Tom Frieden Dr Salim Yusuf Director President United States Centers for Disease World Heart Federation Control and Prevention Dr Steve Davis Dr Daniel Lackland President President World Stroke Organization World Hypertension League Prof Rhian Touyz President International Society of Hypertension 9 10 HEARTS: Technical package for cardiovascular disease management in primary health care Introduction More people die from cardiovascular diseases (CVDs) worldwide than from any other cause – an estimated 17.5 million people in 2012. Of these deaths, 80% are due to heart attacks and strokes, and over three quarters occur in low- and middle- income countries (LMICs) (1). In 2012, 34% of CVD deaths occurred in people under 70 years of age (1). CVDs disproportionately affect LMICs, and in many countries the economic and social burden is highest amongst poor and disadvantaged groups. The risk factors for CVD include behavioural factors, such as tobacco use, an unhealthy diet, harmful use of alcohol and inadequate physical activity, and physiological factors, including high blood pressure (hypertension), high blood cholesterol and high blood sugar or glucose which are linked to underlying social determinants and drivers (Fig. 1). Fig. 1. Factors contributing to the development of cardiovascular disease and complications Social Behavioural Metabolic Cardiovascular determinants risk factors risk factors disease and drivers Globalization Unhealthy diet High blood Hearts attacks Urbanization Tobacco use pressure Strokes Ageing Physical inactivity Obesity Heart failure Income Harmful use High blood sugar Kidney disease (diabetes) Education of alcohol High blood Housing cholesterol Source: WHO Package of essential noncommunicable disease interventions (8). 11 Hypertension is a major risk factor and key driver of CVD globally and is estimated to have caused 9.4 million deaths in 2010 but remains widely undetected, undertreated and poorly controlled (2). Furthermore, a significant number of people with prior heart disease or stroke do not have access to essential medicines, such as aspirin, statins, beta-blockers and angiotensin-converting enzyme inhibitors which have proven to be effective to prevent recurrent events and