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Cost Effective Secondary Prevention of
Myocardial Infarction and Stroke

Shanthi Mendis, MD

Cardiovascular Area, Word Health Organization (WHO)

   In 1999, Cardiovascular Diseases (CVD) accounted for 16.9 million deaths, a third of total global mortality. Based on current trends, by the year 2020 noncommunicable diseases including CVD are expected to account for 73 % of deaths and 60 % of the disease burden. Half of these deaths and one fourth of the disease burden will be from CVD. Low and middle income countries suffer the major burden of the CVD epidemic; two thirds of global CVD deaths and three quarters of the global DALYs being from these countries in 1998. The root cause of this CVD epidemic is the increase in lifestyle related risk factors and their environmental, economic, social and behavioral determinants. There are immense opportunities to reduce the impact of the epidemic through effective reduction of risk factors and cost effective secondary prevention strategies. Actions to prevent common risk factors (primary prevention) and to provide equitable and cost-effective secondary prevention interventions have been given the highest priority in the WHO global strategy for the prevention and control of non-communicable diseases.

WHAT IS THE POTENTIAL FOR PREVENTION?
   Patients with established coronary heart disease and cerebral vascular disease are at the highest risk for further coronary and cerebral events. They also provide the greatest potential for cost savings, through cost effective interventions. The effectiveness of secondary interventions in the control of stroke and myocardial infarction alone or among people with diabetes mellitus are well established. They include either modification of risk behaviors (smoking cessation, diet regulation and promotion of physical activity) together with the use of medications such as aspirin, beta-blockers, angiotensin converting enzyme inhibitors, lipid lowering drugs and anti-hypertensive. However patients in most parts of the world do not get the full potential benefit of these cost effective therapies. as they are not optimally utilized in different health system settings particularly in low and middle income countries.

WHAT IS WHOs STRATEGY FOR PROMOTING SECONDARY PREVENTION ?
   To mitigate these difficulties WHO will be launching an initiative to assist Member States in strengthening health care for people with major CVD, by supporting the implementation of cost-effective secondary prevention interventions, with emphasis on primary health care and community-based action.

   Phase one of the project will begin with a meeting of international experts and potential investigators on `cost effective secondary prevention of major NCDs`scheduled for August 2001. During this meeting an essential package of evidence-based, cost effective interventions for secondary prevention CVD (coronary heart disease and stroke) will be identified based on scientific evidence. Thereafter a protocol for a multi-country pilot project that and organizational models for implementing the protocol in primary care will be developed.

   During Phase two pilot testing will be carried out in selected low and middle income countries from the 6 WHO Regions. This will involve adapting the protocol and organizational models developed in phase one local contexts, training of local teams and identifying the basic changes required in the infrastructure of the existing health system to implement the project.

   Phase three involves Implementation and evaluation. During this phase the project will be implemented as demonstration projects in selected member states. Evaluation will focus on the process of the program, short term impact of the interventions, and the suitability of program to serve as demonstration projects for initiation of national programs.

WHAT IS THE EXPECTED OUTCOME OF THE PROJECT ?
   The project will develop context specific, resource sensitive, high impact model programs that could be integrated into existing health systems. The program is expected to facilitate national policy development and capacity building required for cost effective secondary prevention of major non communicable diseases particularly in low and middle income countries.

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
apacher@fac.org.ar
apacher@satlink.com

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