A major finding in the World Health Report 2002 from the World Health Organization (WHO; Geneva, Switzerland) is that blood pressure alone causes around 50% of cardiovascular (CV) disease worldwide. Cholesterol causes around one-third, while inactive lifestyles, tobacco use and low fruit and vegetable intake account for 20% each (the percentages add up to more than 100% because risk factors can overlap).
The WHO report estimates that about 9 million deaths and more than 75 million lost healthy life years each year were due to high blood pressure or cholesterol levels. It attributes almost 75% of CV disease to the established risks evaluated in the report, much higher than the 30% to 50% level previously assumed – and these risks are equally shared between men and women. In a majority of countries worldwide, 10% to 30% of adults have high blood pressure and another 50% to 60% would be in better health if their blood pressure was lower. A very similar pattern exists for cholesterol, says WHO.
The most immediate improvements in cardiovascular health, according to the World Health Report, can be achieved with a combination of drugs – statins for cholesterol lowering, low-level doses of common blood pressure lowering drugs and aspirin – given daily to people at elevated risk of heart attack and stroke. "This combination could cut death and disability rates from CV diseases by more than 50% among people at risk of cardiovascular disease," said Christopher Murray, executive director of the Cluster on Evidence and Information Policy at WHO. "More people at elevated risk for CV disease should start taking the combination now, before they have heart attacks or strokes."
WHO estimates that this recommended drug combination would cost under $14 to treat each person annually. "Our new research suggests that many established approaches to cutting CV disease risk factors are very inexpensive, so that even countries with limited health budgets can implement them and cut their CV disease rate by 50%," said Derek Yach, executive director of the Cluster on Non-communicable Diseases. "In addition, established drug treatments are increasingly affordable in middle and low income countries as effective drugs come off patent."
The report also shows for the first time that most of the global burden due to cardiovascular risks occurs in the developing world. Tobacco, blood pressure and cholesterol are acknowledged leading risks in industrial countries. But they are also figuring prominently among the top risks in middle income countries and are beginning to appear as leading risks in poorer developing countries.
"The world once thought of CV disease as a Western problem, but clearly this is not the case. We can no longer frame diseases in terms of where they occur, but rather with what frequency they occur in any given population," said Anthony Rogers of the University of Auckland (Auckland, New Zealand), one of the report's main writers.
CV diseases once affected wealthier people in disproportionate numbers. As knowledge of cardiovascular health has increased, the wealthy have been able to reduce the frequency with which they suffer from these conditions. Simultaneously, the incidence of CV disease is increasing among the poor and minorities. The report suggests that population-wide interventions are the most cost-effective methods of reducing risks across an entire population and should always be considered first. The best approaches will be different between countries and lessons can be learned from past experiences.
The report instances a number of successes:
In Japan, government-led education programs and increased blood pressure treatment have reduced blood-pressure nation-wide and stroke rates have fallen by more than 70%.
In Finland, community-based interventions, including health education and nutrition labeling led to population-wide reductions in cholesterol and many other risks, closely followed by a precipitous decline in heart disease.
In the U.S., a decrease in saturated fat uptake in the late 1960s began the substantial decline in coronary heart disease seen over the past few decades.
The report is likely to provide a challenge to current priorities for health systems in many industrialized countries. Few governments have yet to develop a collaboration with the food industry to reduce salt and high fat in processed food although the UK has successfully reduced salt content in almost 25% of manufactured foods. The report suggests that a paradigm shift in strategy is needed for many physicians who will need to consider multi-modal treatment for all at elevated risk, largely irrespective of what initially caused their risk to be high and what their current risk factor levels are.
More controversially, the WHO report also proposes that the large resources now devoted to detecting, treating and monitoring people at comparatively low risk of heart disease or stroke be reduced, while greater resources be given to those with multiple risk factors who are at the highest risk and who are often undertreated.
New products in Europe
Vivolution (Rungsted, Denmark) has launched in Europe the Vivostat system, which uses autologous fibrin sealant, derived from the patient's blood prior to surgery, thus minimizing the risk of a viral or prion infection. It is administered by means of a patented Microspray device that allows the surgeon to use the sealant during the surgical procedure both at close range for individual bleeding or at a distance for diffuse surface bleeding. Fibrin sealants are well known as hemostats to reduce or stop bleeding during surgery. The Vivostat system is claimed to offer additional advantages in that using autologous blood as a source, it is inherently safer, and being part of an overall system, it is straightforward to use.
The MR20 pediatric monitor from Graseby Medical (Watford, UK) provides both respiration and ECG data on a hand-held monitor which is battery operated with an AC/DC power supply adaptor. The small instrument incorporates a high-capacity event memory which can capture up to 1,750 events in physiological waveform and stored waveform data and which can be PC downloaded and viewed in tabular or graphical formats.
Heine Optotechnik (Herrsching, Germany) has developed the Memotronic PC2 blood pressure monitor, comprised of both wrist pressure-cuff and monitor with a LCD screen. Pressing on one button inflates the wrist-cuff and provides systolic and diastolic blood pressures as well as pulse rate. The system can store up to 250 measurements with date function. With optional Memotronic Profile software, readings can be downloaded for blood pressure curve analysis.
Myosix, Genzyme collaborate on cell therapy
Genzyme Biosurgery (Cambridge, Massachusetts) is collaborating with Myosix (Paris) to develop further an advanced series of clinical trials on the use of cell therapy to treat heart disease. A European multicenter Phase II trial is starting to examine the effectiveness of autologous cell therapy to restore function in areas of the heart damaged in a heart attack. The trials will involve harvesting the patient's own skeletal muscle cells, multiplying them using cell culture techniques and injecting them into the heart muscle during a coronary bypass operation.
EMEA warns on Refludan
The European Medicines Evaluation Agency (EMEA; London) has revealed the deaths of five European patients as a result of grave allergic reactions to Refludan, an anticoagulant marketed by Schering (Berlin, Germany). The sole marketing rights to Refludan were reacquired last year by Schering from Aventis, with 2001 sales being in the region of $20 million.