Our Time: A Call to Save Preventable Death From Cardiovascular Disease (Heart Disease and Stroke)
Worldwide, the aging population, globalization, rapid urbanization, and population growth have fundamentally changed disease patterns. Noncommunicable diseases (NCDs), of which cardiovascular disease (CVD) accounts for nearly half, have overtaken communicable diseases as the world's major disease burden. CVD remains the No. 1 global cause of death, accounting for 17.3 million deaths per year, a number that is expected to grow to >23.6 million by 2030. Increasingly, the populations affected are those in low- and middle-income countries, where 80% of these deaths occur, usually at younger ages than in higher-income countries, and where the human and financial resources to address them are most limited.1
The epidemiological transition occurring is exacerbated by the lack of vital investment in sustainable health policies to address and curtail the risk factors associated with CVD and NCDs. Recognizing the profound mismatch between the need for investment in the prevention and control of CVD at the global and national level and the actual resources allocated, the international CVD community, under the umbrella of the World Heart Federation, joined the NCD community to call for a United Nations (UN) High-level Meeting on Non-communicable Diseases, held in September 2011. At this meeting, heads of state signed a Political Declaration that committed governments to the development of 4 specific measures to address the NCD burden in a specific timeline: (1) Recommendations for a global monitoring framework that included NCD targets to be completed by the end of 2012; (2) development of a plan for an effective multisector partnership by the end of 2012; (3) national NCD plans by 2013; and (4) a comprehensive review to evaluate progress, to take place in 2014.2
Celebrating the 2025 Global NCD Mortality Target
Celebrating the 1-year anniversary of the passage of the UN Political Declaration, it is timely that our respective organizations speak with a single voice to advocate for a set of public health interventions that have the potential to mitigate and reverse the rising rates of CVD and NCDs. In May 2012, during the World Health Assembly, Ministers of Health took the first critical step by agreeing to adopt a global target to reduce premature NCD mortality 25% by 2025, a target the global CVD community has been advocating since the UN High-level Meeting on Non-communicable Diseases.3 We applaud the World Health Assembly for reaching a consensus on this bold goal.
The UN Political Declaration on NCDs and the recent resolution to reduce premature NCD deaths by 25% are landmark achievements for the health and CVD community. For the first time in history, NCDs have been recognized as a development issue. These targets and indicators have the potential to address longstanding health challenges, including the fragmentation of health funding, gaps in the healthcare infrastructure, and the lack of local and reliable data, and will address the growing demand for integrated disease management. As the Millennium Development Goals come to a close in 2015, the CVD community is set to ensure that the single largest cause of death—CVD—is addressed. As such, all relevant stakeholders need to be part of the process, putting optimal health at the cornerstone of development.
It is our desire to see heart disease and stroke receive the attention they deserve. We recognize that the process is complex and the time is short, but we have an opportunity to ensure that the commitments made in September 2011 translate into real global, and thus national, action for years to come. Collaboration among appropriate stakeholders will be necessary to address this emerging 21st century global health priority and begin to reverse the devastating toll of CVD and NCDs in our communities.
Maintaining the Momentum to Address Other Targets
A first step toward global action has been the passage of the global mortality target, which will provide a shared vision on NCDs for all stakeholders and ensure that all targets are appropriately developed to achieve this overarching goal. As the leading organizations that represent thousands of members in nearly every country, and for the millions of individuals with, or at risk of CVD, we are aligning with the broader NCD community in support of a comprehensive set of additional targets that will ensure this global reduction is achieved.
The challenge faced by countries will be to reach agreement concerning the additional targets and indicators to be part of the comprehensive monitoring framework to achieve the overarching global mortality target. In the summer of 2010, a World Health Organization (WHO) technical working group developed 10 proposed global targets (Appendix A), which remained virtually unchanged until the spring of 2012.4 At that time, Member States, civil society organizations, and other relevant stakeholders were asked to comment on and make specific recommendations regarding the global monitoring framework for NCDs and the specific targets and indicators that would be used to guide countries and measure progress. The original set of 10 targets was reduced before completion of regional consultations and with limited input of Member States (Appendix B).5 Calls to action from the CVD, NCD, and specific risk-factor communities did, however, lead to positive changes within this reduced set of targets and included the insertion of a new target on physical activity. The inclusion of this target in the list of recommendations was a milestone in NCD advocacy efforts, ensuring that each of the major risk factors leading to NCDs was addressed. With the release of the third WHO discussion paper,6 the NCD community's advocacy efforts are to be noted as the list of recommended targets for adoption includes 10 strong, evidence-based strategies. Together, the Global Cardiovascular Disease Taskforce calls on the CVD community to endorse and support the top 4 widely supported exposure targets (Table 1) on physical inactivity, hypertension/blood pressure, dietary salt intake, and tobacco as those required to achieve the overarching goal of a 25% reduction in premature mortality by 2025.
Other, originally proposed targets to address NCDs that were dropped in the second WHO discussion paper include evidence-based targets on obesity, trans fat/fat intake, alcohol, and multidrug therapy to prevent and treat CVD (Table 2).7 Although these targets have been included in the most recent discussion paper, they have been identified as having limited support and will need further advocacy to ensure their adoption.7 In addition to supporting the NCD community in their call for Member States to agree on this global set of 10 voluntary targets, we also explicitly call for Member States to be ambitious and ensure that they address those persons at highest risk now by adopting the additional exposure and health systems targets currently under consideration.
To halt and reverse the NCD epidemic, it is paramount that the CVD burden be adequately addressed, which requires that those living with CVD and at highest risk of developing CVD have access to treatment and care. The 2011 report by the WHO, Scaling Up Action Against Noncommunicable Diseases: How Much Will It Cost?, details a core set of low-cost strategies, identified as “Best Buys” that all countries can implement to prevent and treat NCDs. This list includes population-based measures to address risk factors and specific individual-based interventions, including a multidrug therapy regimen of aspirin, a statin, and blood pressure–lowering agents to prevent heart disease and stroke and to treat those with, or at highest risk of, heart disease and stroke.8 As Member States determine how best to achieve this global target, the global CVD community looks to this package of the WHO's “Best Buys” as a critical way forward.
CVD and the WHO Best Buys
With CVD as the largest single contributor to global mortality, accounting for nearly half of the 36 million NCD deaths, and with a global cost of nearly US $863 billion, achieving the global target to reduce premature NCD deaths by 25% requires that CVD and its risk factors be adequately addressed.9 The Global Cardiovascular Taskforce supports the set of recommendations identified by the WHO as “Best Buys,” feasible and cost-effective interventions that can be undertaken regardless of the income level of a country. This core set of interventions are recommended at 2 levels—population-wide measures to reduce exposure to risk factors and interventions targeting individuals who already have NCDs or are at high risk of developing them—and are implemented through a systematic layered approach. Regarding population-wide risk factor measures, the WHO has identified “Best Buys” in the areas of tobacco use, harmful use of alcohol, salt intake, physical activity, and replacement of trans fat with polyunsaturated fat. Interventions targeting individuals include evidence-based, cost-effective medical therapies alongside counseling, as well as aspirin therapy for acute myocardial infarction.10
On the occasion of the UN High-level Meeting in September 2011, the WHO introduced a tool for low-, middle-, and high-income countries to guide and estimate the feasibility of the implemention of this core set of NCD interventions.8 The cost of the interventions is <US$11.4 billion per year in low- and middle-income settings. Yearly, per person, this translates to <US$1 a day (US$0.43–US$0.90) across low-income countries and <US$3 a day (US$0.54–US$2.93) across middle-income countries.11
Several of the 10 targets being supported by the NCD community have been identified within this core set of “Best Buy” interventions and are at risk of failing to be adopted as global targets, including the evidence-based drug therapy regimen to address those at highest risk for developing CVD. Studies have indicated that nearly 17.9 million deaths could be averted over a 10-year period with the implementation of multidrug therapy.11 The cost would amount to just over US$1 a day annually. Beyond the lives saved and the life-years extended, reducing the mortality rate for ischemic heart disease and stroke by 10% would also reduce economic losses in low- and middle-income countries by an estimated US$25 billion per year.12 Drug therapy, singly or in combination with multiple drugs, is documented to be a concrete investment and should be a target to be accomplished.
As Member States look to finalize targets in the coming months, doubt regarding country-level compliance in the implementation of NCD interventions, as a result of underdeveloped monitoring and surveillance systems, must not overshadow the real, cost-effective, and feasible solutions offered by the WHO “Best Buys.” Collection of data, for all targets, remains a critical issue that can, and should, be addressed through the Global Monitoring Framework. It is recognized that target levels may vary slightly in different regions of the world. As such, when considering national NCD action plans, all targets will require adequate and well-developed indicators that encourage the improvement of data at the country level and provide an impetus to countries that have the tools to collect and monitor data. Moreover, improved healthcare delivery and an expanded health workforce with coordination of local and national approaches are paramount in building comprehensive health systems to achieve this end.
Global Cardiovascular Taskforce Summary Position: Prevention, Risk Factors, and Treatment
Member States have taken the first step and set a bold overarching goal of reducing mortality from NCDs by 25% by 2025. We now have the opportunity to make meaningful changes in our countries by adopting evidence-based targets and implementing tactics that will guide health policy, chronic disease plans and, ultimately, resources for national public health interventions. Many of these are feasible and cost-effective. Reducing NCDs are central to a country's economic growth. As such, we respectfully request Member States to consider our recommendations and adopt the evidence-based targets to address CVD and NCDs and avert millions of deaths by 2025.
The World Heart Federation, American Heart Association, American College of Cardiology Foundation, European Heart Network, and European Society of Cardiology make every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This document was approved by the World Heart Federation, American Heart Association Science Advisory and Coordinating Committee, American College of Cardiology Foundation Board of Trustees, European Heart Network Board, and European Society of Cardiology Board on August 10, 2012.
The American Heart Association requests that this document be cited as follows: Smith SC Jr, Collins A, Ferrari R, Holmes DR Jr, Logstrup S, McGhie DV, Ralston J, Sacco RL, Stam H, Taubert K, Wood DA, Zoghbi WA. Our time: a call to save preventable deaths from cardiovascular disease (heart disease and stroke). Circulation. 2012;126:2769–2775.
This article has been copublished in Global Heart, Journal of the American College of Cardiology, and European Heart Journal.
Copies: This document is available on the World Wide Web sites of the World Heart Federation (http://www.world-heart-federation.org), American Heart Association (my.americanheart.org), American College of Cardiology Foundation (www.cardiosource.org), European Heart Network (www.ehnheart.org), and European Society of Cardiology (www.escardio.org). A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail email@example.com.
Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.
- © 2012 American Heart Association, Inc.
World Health Organization World Heart Federation World Stroke Organization. Global atlas on cardiovascular disease prevention and control: policies, strategies, and interventions. Published 2011. Available at: http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/. Accessed August 7, 2012.
United Nations General Assembly. Resolution adopted by the General Assembly: 66/2: Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. Adopted September 19, 2011; published January 24, 2012. Available at: http://www.who.int/nmh/events/un_ncd_summit2011/political_declaration_en.pdf. Accessed June 26, 2012.
World Health Organization. 65th World Health Assembly document A65/54: Second report of Committee A. Published May 25, 2012. Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_54-en.pdf. Accessed August 7, 2012.
World Health Organization. WHO discussion paper: a comprehensive global monitoring framework and voluntary global targets for the prevention and control of NCDs. Updated December 21, 2011. Available at: http://www.who.int/nmh/events/2011/consultation_dec_2011/WHO_Discussion_Paper_FINAL.pdf. Accessed August 7, 2012.
World Health Organization. WHO discussion paper: summary of feedback from member states on the first discussion paper on the proposed global monitoring framework and indicators and targets for the prevention and control of noncommunicable diseases. Published March 22, 2012. Available at: http://www.who.int/nmh/events/2012/targets_feedback_summary_22032012.pdf. Accessed August 7, 2012.
World Health Organization. Revised [third] WHO discussion paper on the development of a comprehensive global monitoring framework, including indicators, and a set of voluntary global targets for the prevention and control of NCDs. Published July 2012. Available at: http://www.who.int/nmh/events/2012/ncd_discussion_paper/en/index.html. Accussed July 25, 2012.
World Health Organization. Second WHO discussion paper: a comprehensive global monitoring framework including indicators and a set of voluntary global targets for the prevention and control of noncommunicable diseases. Published March 22, 2012. Available at: http://www.who.int/nmh/events/2012/discussion_paper2_20120322.pdf. Accessed August 7, 2012.
World Health Organization, 2011. Scaling up action against noncommunicable diseases: how much will it cost? Published September 2011. Available at: http://www.who.int/nmh/publications/cost_of_inaction/en/. Accessed August 7, 2012.
- Bloom DE,
- Cafiero ET,
- Jané-Llopis E,
- Abrahams-Gessel S,
- Bloom LR,
- Fathima S,
- Feigl AB,
- Gaziano T,
- Mowafi M,
- Pandya A,
- Prettner K,
- Rosenberg L,
- Seligman B,
- Stein AZ,
- Weinstein C
World Health Organization. Global status report on noncommuni cable diseases 2010. Published April 2011. Available at: http://www.who.int/nmh/publications/ncd_report2010/en/. Accessed August 7, 2012.
World Economic Forum and World Health Organization. From burden to “best buys”: reducing the economic impact of non-communicable diseases in low- and middle-income countries. Published September 2011. Available at: http://www.who.int/nmh/publications/best_buys_summary/en/index.html. Accessed August 7, 2012.