CARDIOVASCULAR DISEASE IN VIETNAM: WHAT ARE THE …€¦ · Prof Pham Nguyen Vinh, MD, PhD, FACC...

Cardiovascular disease in VietnamWhat are the issues and opportunites?

Prof Pham Nguyen Vinh, MD, PhD, FACCPham Ngoc Thach University of Medicine

Tam Duc Heart Hospital

Cardiovascular disease in Vietnam: what are the issues and opportunities?

Vietnam profile

2Source: Who @ vtn- wpro. Who. Int 2014


Adult risk factors/ VN

3Source: WHO data. www. Who- int/gho- last update May 2014


Proportional mortality in Vietnam/ 2008

(% of total death, all ages)

4Source: http:// www. Who. Int/nmh/ countries/ Vnm en. Pdf? Na = 1. 2011


Distribution of causes of death among adults

aged 20 years and over, Bavi district,

Vietnam, 1999-2003

5

Source: Minh V Hoang. Epedemiology of

cardiovascular disease in rural Vietnam Umea

university SE 901 87 Umea, Sweden 2006


Distribution of CVD causes of death among

adults aged 20 years and over, Bavi district,

Vietnam, 1999-2003

6Source: Minh V Hoang. Epedemiology of cardiovascular disease in rural Vietnam Umea university SE 901 87 Umea, Sweden 2006


Pattern of

selected CVD

risk factors

among adults

in Bavi district

7

Source: Minh V Hoang.

Epedemiology of

cardiovascular disease in

rural Vietnam Umea university

SE 901 87 Umea, Sweden

2006


CV Diseases recognized in

Vietnam• Atherosclerotic cardiovascular diseases+++

• Valcular heart diseases: rheumatic fever VHD,

non rheumatic fever VHD

• Congenital heart disease

• Cardiomyopathies

• Hypertension

• Stroke

8


Issues for CVD in Vietnam

• Education:

– Patients: journals, patient club, others Media

– Health workers: guidelines, CME

• Prevention:

– Government based preventive departement

– National programme: tobacco, low salt diet..

• Management

– Updates class, CME, scientific symposium

– Primary care

– Specialized centers.

9


How to do?

• Private sectors:

– Clinics and hospitals

– Symposium, training courses

• Government sectors

– Media, journals

– Health workers training

– Public education

10


Prevention of hypertension

• Lifestyle modification for primary and

secondary prevention

• Blood pressure measurement / each

consultation

11


Lifestyle modification/ systemic

hypertension

12


Dietary Sodium

Less than 2300mg / day

(Most of the salt in food is ‘hidden’ and comes from processed food)

Dietary Potassium

Daily dietary intake >80 mmol

Calcium supplementation

No conclusive studies for hypertension

Magnesium supplementation

No conclusive studies for hypertension

Lifestyle Recommendations for

Hypertension: Dietary

High in: • Fresh fruits

• Fresh vegetables

• Low fat dairy products

• Dietary and soluble fibre

• Plant protein

Low in:• Saturated fat and cholesterol

• Sodium

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php. 13


Potential Benefits of a Wide Spread

Reduction in Dietary Sodium in Canada

• 1 million fewer hypertensives

• 5 million fewer physicians visits a year for hypertension

• Health care cost savings of $430 to 540 million per year related

to fewer office visits, drugs and laboratory costs for hypertension

• Improvement of the hypertension treatment and control rate

• 13% reduction in CVD

• Total health care cost savings of over $1.3 billion/year

1. Penz ED. Cdn J Cardiol 2008

2. Joffres MR. Cdn J Cardiol 2007:23(6)

Reduction in average dietary sodium from about

3500 mg to 1700 mg1,2

14


Recommendations for adequate daily

sodium intake

2,300 mg sodium (Na)

= 100 mmol sodium (Na)

= 5.8 g of salt (NaCl)

= 1 level teaspoon of

table salt

• 80% of average sodium intake is in processed foods

• Only 10% is added at the table or in cooking

Age Adequate

Intake

(mg)

Upper Limit

(mg)

19-50 1500 2300

51-70 1300 2300

71 and over 1200 2300

Institute of Medicine, 2003 15


Sodium: Meta-analyses

The Cochrane Library 2006;3:1-41

Average Reduction of sodium

in mg/day

1800 mg/day

2300 mg/day

Hypertensives

Reduction of BP

5.1 / 2.7 mmHg

7.2/3.8 mmHg

Average Reduction of sodium

in mg/day

1700 mg/day

2300 mg/day

Normotensives

Reduction of BP

2.0 / 1.0 mmHg

3.6/1.7 mmHg

16


Exercise should be prescribed as an adjunctive to pharmacological therapy


Hypertension: Physical Activity

Should be prescribed to reduce blood pressure

Frequency - Four to seven days per weekF

Intensity - ModerateI

Time - 30-60 minutesT

Type Cardiorespiratory Activity

- Walking, jogging

- Cycling

- Non-competitive swimming

T

17



Hypertension: Weight Loss

Height, weight, and waist circumference (WC) should be measured

and body mass index (BMI) calculated for all adults.

Hypertensive and all patients

BMI over 25 - Encourage weight reduction

- Healthy BMI: 18.5-24.9 kg/m2

Waist Circumference Men <102 cm Women <88 cm

For patients prescribed pharmacological therapy: weight loss has

additional antihypertensive effects. Weight loss strategies should employ a

multidisciplinary approach and include dietary education, increased physical

activity and behaviour modificationCMAJ 2007;176:1103-6

18

Asian:

Men < 90 cm

Woman < 80 cm


Courtesy J.P. Després 2006

Measure here

Iliac crest

Waist Circumference

Measurement

19



Hypertension: Alcohol

Low risk alcohol consumption

• Women: maximum of 9 standard drinks/week

• Men: maximum of 14 standard drinks/week

• 0-2 standard drinks/day

A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or

12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).

20



Hypertension: Stress Management

Hypertensive patientsin whom stress appears to be an important issue

Individualized cognitive behavioural interventions are

more likely to be effective when relaxation techniques

are employed.

Stress management

Behaviour Modification

21


Impact of Lifestyle Therapies on Blood

Pressure in Hypertensive Adults

Intervention Intervention SBP/DBP

Reduce sodium intake-1800 mg/day sodium

Hypertensive-5.1 / -2.7

Weight loss per kg lost -1.1 / -0.9

Alcohol intake -3.6 drinks/day -3.9 / -2.4

Aerobic exercise 120-150 min/week -4.9 / -3.7

Dietary patternsDASH diet

Hypertensive -11.4 / -5.5

Padwal R et al. CMAJ 2005;173;(7);749-751 22


Lifestyle Therapies in Adults with

Hypertension: Summary

Intervention Target

Reduce foods with added sodium

< 2300 mg /day

Weight loss BMI <25 kg/m2

Alcohol restriction < 2 drinks/day

Physical activity 30-60 minutes 4-7 days/week

Dietary patterns DASH diet

Smoking cessation Smoke free environment

Waist circumference Men <102 cm Women <88 cm

23


Prevention of dyslipidemia

• Early detection of dyslipdemia

• Primary prevention

• Secondary prevention

24


Dyslipidemia in children

Deficiency of 2 genes coding for the LDL-C receptor protein

(homozygote familial hypercholesterolemia), LDL-C from 500

mg- 1000 mg/dL

Deficiency of gene coding LDL-C (heterozygote FH): LDL-C

from 200-300 mg/dL

Coronary artery events occur in the first 10 years of life of

children with homozygote FH

CA event occur in the second or third decades of children with

heterozygote FH

25


Management of dyslipidemia in

children

• Lifestyle modifications: weight loss, diets

(the mainstay of treatment for cholesterol/

dietary therapy)

• Cholestyramine, colestipol, colesevelam

• Statins

26

TL: Davis WW, Brown WV. In Cardiology, ed by MH Crawford, JP DiMarco, WJ Paulus; Mosby

Elsevierd 2010, 3rd ed, p. 109-117


Management of dyslipidemia in

the elderly

• Benefits: more benefit than younger patients

due to high incidence of CVD

• Warnings:

– Metabolism of statins

– Drug interactions

27


28

Clinical pharmaco kinetics of

statins

TL: Harper CR et al. J Am Coll Cardiol 2008; 51: 2375-2384


29

Dosing modifications for lipid

lowering drugs in CKD

TL: Harper CR et al. J Am Coll Cardiol 2008; 51: 2375-2384

Agent GFR 60- 90 GFR 15-59 GFR < 15 Note

ml/min/1.73m2 ml/min/1.73m2 ml/min/1.73m2

Statins

Atorvastatin No No No

Fluvastatin No Not defined Not defined ↓dose to one- half at GFR <30ml/min/1.73 m2

Lovastatin No ↓to 50% ↓to 50% ↓dose to one-half at GFR <30ml/min/1.73m2

Pravastatin No No No Start at 10mg/day for GFR <60ml/min/1.73m2

Rosuvastatin No 5-10 mg 5-10 mg Start at 5 mg/day for GFR<30ml/min/1.73m2,

max dose 10 mg/day

Simvastatin No No 5 mg Start at 5 mg if GFR < 10 ml/min/1.73 m2


Prevention of diabetes

TL: Hughes DA et al. 2014- ADA Standards of Medical Care- Jan 2014 30


Recommendations:Prevention/Delay of Type 2 Diabetes

• Refer patients with IGT A, IFG E, or A1C 5.7–6.4% E to

ongoing support program

– Targeting weight loss of 7% of body weight

– Increasing physical activity to at least 150 min/week of moderate

activity (eg, walking)

• Follow-up counseling appears to be important for success B

• Based on cost-effectiveness of diabetes prevention, such

programs should be covered by third-party payers B

ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2014;37(suppl 1):S20 31


Recommendations:Prevention/Delay of Type 2 Diabetes

• Consider metformin for prevention of type 2 diabetes if IGT

A, IFG E, or

A1C 5.7–6.4% E

– Especially for those with BMI >35 kg/m2,

age <60 years, and women with prior GDM A

• In those with prediabetes, monitor for development of

diabetes annually E

• Screen for and treat modifiable risk factors for CVD B

ADA. IV. Prevention/Delay of Type 2 Diabetes. Diabetes Care 2014;37(suppl 1):S20 32


Prevention of tobacco

• High cost for tobacco: high tax

• Tobacco banning in public place

• Tobacco-free in recruitment of workers:

teacher, doctor…

33


Conclusion

• Trends of increasing CVD in developing

countries

• Education and Banning Measures: need to

apply simultaneously

• Prevention is always cheaper than treatment

34

CARDIOVASCULAR DISEASE IN VIETNAM: WHAT ARE THE …€¦ · Prof Pham Nguyen Vinh, MD, PhD, FACC...

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