Global atlas on cardiovascular disease prevention and control policies, strategies and interventions

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1. Published by theWorld Health Organization in collaboration with theWorld Heart Federation and theWorld Stroke Organization. Global Atlas on cardiovascular disease prevention andcontrol Published by theWorld Health Organization in collaboration with theWorld Heart Federation and theWorld Stroke Organization. ISBN 978 92 4 156437 3 GlobalAtlasoncardiovasculardiseasepreventionandcontrol GlobalAtlas oncardiovasculardisease preventionandcontrol CVDs 20 Avenue Appia CH-1211 Geneva 27 Switzerland www.who.int/ Joint Publication of theWorld Health Organization theWorld Heart Federation and theWorld Stroke Organization Global Atlas on cardiovascular disease prevention andcontrol Joint Publication of theWorld Health Organization theWorld Heart Federation and theWorld Stroke Organization ISBN 978 92 4 256419 8 9 789242 564198 GlobalAtlasoncardiovasculardiseasepreventionandcontrol GlobalAtlas oncardiovasculardisease preventionandcontrol CVDs 20 Avenue Appia CH-1211 Geneva 27 Switzerland www.who.int/ International efforts aimed at poverty reduction will be derailed if the rapidly growing global cardiovascular disease burden is ignored. In the absence of prevention strategies, increasing numbers of people will succumb to heart attacks and strokes due to continuing exposure to risk factors. Millions of premature deaths due to cardiovascular disease can be prevented by scaling up the implementation of affordable, high impact interventions, which already exist.

2. CORRIGENDUM Global Atlas on cardiovascular disease prevention and control. ISBN: 978 92 4 156437 3 The list of Figures on pages 127-129 should be amended as follows: Figure 1. Normal heart with its blood supply (i). Ties van Brussel, http://en.wikipedia.org/wiki/File:Anatomy_Heart_English_Tiesworks.jpg. Image placed in the public domain. Figure 2. Normal brain with its blood supply (i). Image licensed under the Creative Commons Attribution ShareAlike 3.0 licence, https://creativecommons.org/licenses/by- sa/3.0/. Figure 59. Electrocardiogram ; atrial fibrillation compared with normal sinus rhythm. Atrial fibrillation (top) and normal sinus rhythm (bottom). The purple arrow indicates a P wave, which is lost in atrial fibrillation (i). J. Heuser. Image licensed under the Creative Commons Attribution ShareAlike 3.0 licence, https://creativecommons.org/licenses/by-sa/3.0/. Photograph: Cardiac arrest due to an arrhythmia requires emergency resuscitation (i) U.S. Navy photo by Photographer's Mate Airman Apprentice Nicholas Garrett US Navy 040421-N-8090G-001 Figure 60. Congenital heart disease; diagram of a healthy heart and one suffering from tetralogy of Fallot. (i). Mariana Ruiz Villarreal http://en.wikipedia.org/wiki/Tetralogy_of_Fallot#/media/File:Tetralogy_of_Fallot.svg. Image placed in the public domain. Figure 61. Diagram of a heart with patent ductus arteriosus; an abnormality seen in 50% of children with congenital rubella syndrome (i). http://en.wikipedia.org/wiki/File:Patent_ductus_arteriosus.jpg. Original source NIH National Heart, Lung and Blood Institute. Figure 62. Rheumatic heart disease at autopsy with characteristic findings (thickened mitral valve, with its attachments (chordae tendineae), and hypertrophied left ventricular wall (i). Group A streptococci (i) Centers for Disease Control and Prevention's Public Health

3. Image Library (PHIL) http://phil.cdc.gov/phil/details.asp Streptococcal pharyngitis with typical exudate on tonsils (i). James Heilman MD. Image licensed under the Creative Commons Attribution ShareAlike 3.0 licence, https://creativecommons.org/licenses/by-sa/3.0/. Page 68 Photograph: Better housing can help to prevent Chagas disease through vector control (i). http://en.wikipedia.org/

4. Global Atlas on cardiovascular disease preventionandcontrol Published by theWorld Health Organization in collaboration with theWorld Heart Federation and theWorld Stroke Organization . editors: Shanthi Mendis, Pekka Puska and Bo Norrving

5. WHO library Cataloguing-in-Publication Data Global atlas on cardiovascular disease prevention and control 2011/ edited by Shanthi Mendis …[et al]. 1.Cardiovascular diseases - prevention and control. 2.Cardiovascular diseases - epidemiology. 3.Cardiovascular diseases - economics. 4.Cardiovascular diseases - mortality. 5.Health promotion. 6.Atlases. I.Mendis, Shanthi. II.Puska, Pekka. III.Norrving, B. IV.World Health Organization. V.World Heart Federation. VI.World Stroke Organization. ISBN 978 92 4 156437 3 (NLM classification: WG 120) Suggested citation: Global Atlas on Cardiovascular Disease Prevention and Control. Mendis S, Puska P, Norrving B editors. World Health Organization, Geneva 2011. This document was developed by the World Health Organization (Shanthi Mendis) in collaboration with the World Heart Federation (Pekka Puska) and the World Stroke Organization (Bo Norrving) Contributions were made by A. Alwan, T. Armstrong, D. Bettcher, T. Boerma, F. Branca, J. C.Y. Ho, C. Mathers, R. Martinez, V. Poznyak, G. Roglic, L. Riley, E. d`Espaignet, G. Stevens, K.Taubert and G. Xuereb. Others who provided assistance in various ways in the compilation of this document include A. Ayinla, X. Bi, F. Besson, L. Bhatti, A. Enyioma, N. Christenson, F. Lubega, P. Nordet, M. Osekre-Amey and J. Tarel. © World Health Organization 2011 All rights reserved. Publications of the World Health Organization are available on the WHO web site (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; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/ licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in France

6. IIIGlobal Atlas on Cardiovascular Diseases Prevention and Control Table of contents Abbreviations and Measurements V Foreword VI Section A – Cardiovascular diseases (CVDs) due to atherosclerosis 1 1. What are cardiovascular diseases (CVDs)? 2 2. Death and disability due to CVDs (heart attacks and strokes) 8 3. The underlying pathology of heart attacks and strokes 14 4. Evidence for prevention of heart attacks and strokes 16 5. Reducing cardiovascular risk to prevent heart attacks and strokes 18 6. Tobacco: The totally avoidable risk factor of CVDs 26 7. Physical inactivity: A preventable risk factor of CVDs 28 8. Harmful use of alcohol: A preventable risk factor of CVDs 30 9. Unhealthy diet: A preventable risk factor of CVDs 32 10. Obesity: A risk factor of CVDs 36 11. Raised blood pressure (hypertension): A major risk factor of CVDs 38 12. Raised blood sugar (diabetes): A major risk factor of CVDs 40 13. Raised blood cholesterol: A major risk factor of CVDs 42 14. Social determinants and CVDs 44 15. Risk factors take root in the womb, childhood and youth 46 16. Heart attacks and strokes in women 48 17. Other determinants of CVDs: Ageing, globalization and urbanization 50 18. Inequities and CVDs 54 Section B – Other cardiovascular diseases 57 19. Cardiac arrhythmia 58 20. Congenital heart disease 60 21. Rheumatic heart disease: A neglected heart disease of the poor 62 22. Chagas disease (American trypanosomiasis): A neglected disease of the poor 66

7. IV Global Atlas on Cardiovascular Diseases Prevention and Control Section C – Prevention and control of CVDs: Policies, strategies and interventions 69 23. Prevention and control of CVDs: How do we know what works? 70 24. Prevention and control of CVDs: The need for integrated and complimentary strategies 72 25. Prevention and control of CVDs: Health in All Policies 74 26. Prevention and control of CVDs: The need for a national NCD policy framework 76 27. Policies and strategies for tobacco control 78 28. Policies and strategies to facilitate healthy eating 80 29. Policies and strategies to facilitate physical activity 84 30. Policies and strategies to address the harmful use of alcohol 88 31. Individual interventions for prevention and control of CVDs 92 32. Role of primary health care in prevention and control of CVDs 94 33. Best buys for cardiovascular disease (CVD) prevention and control 96 34. Bridging the implementation gap for prevention and control of CVDs 100 35. Monitoring CVDs 102 36. Social mobilization for prevention and control of CVDs 104 37. Prevention and control of CVDs and socioeconomic development 106 38. Generating resources for CVD prevention and control 108 39. CVD prevention and control: Why it should not be ignored any longer? 110 40. CVD prevention and control : Vision, roadmap and a landmark event 114 World Health Organization, World Heart Federation and World Stroke Organization 118 References 119 List of figures 127 References for figures 131 Annexes 133 Annex i – World Health Assembly resolution A64/61 134 Annex ii – Moscow Declaration 136 Annex iii – Regional Declarations on NCDs 139 Annex iv – Contact information 144 Annex V – Age-standardized death rates per 100,000 both sexes by cause and Member State, 2008 (1) 148 Index 153

8. VGlobal Atlas on Cardiovascular Diseases Prevention and Control Abbreviations AIDS acquired immunodeficiency syndrome BMI body mass index CVD cardiovascular disease DALY disability-adjusted life year FCTC Framework Convention on Tobacco Control GDP gross domestic product GNP gross national product G20 Group of 20 countries HDL cholesterol high-density lipoprotein cholesterol HIV human immunodeficiency virus ISH International Society of Hypertension LDL cholesterol low-density lipoprotein cholesterol LMIC low- and middle-income country MDG Millennium Development Goal NCD noncommunicable disease NGO nongovernmental organization UN United Nations USA United States of America WHA World Health Assembly WHO World Health Organization WHO Global NCD Action Plan WHO 2008–2013 Action Plan for the Global Strategy for Prevention and Control of Noncommunicable Diseases WHO NCD Research Agenda WHO Prioritized Research Agenda for Prevention and Control of Major Noncommunicable Diseases YLD years living with disability Measurements dl decilitre g gram kg kilogram l litre M/m metre mg milligram mmHg millimetre of mercury mmol millimole

9. VI Global Atlas on Cardiovascular Diseases Prevention and Control Cardiovascular diseases (CVDs) remain the biggest cause of deaths worldwide. More than 17 million people died from CVDs in 2008. More than 3 million of these deaths occurred before the age of 60 and could have largely been prevented.The percentage of premature deaths from CVDs ranges from 4% in high-income countries to 42% in low-income countries, leading to growing inequalities in the occurrence and outcome of CVDs between countries and populations. There are also new dimensions to this alarming situation. Over the past two decades, deaths from CVDs have been declining in high-income countries, but have increased at an astonishingly fast rate in low- and middle-income countries (LMIC). CVDs are largely preventable. Both population wide measures and improved access to individual health care interventions can result in a major reduction in the health and socioeconomic burden caused by these diseases and their risk factors. These interven- tions, which are evidence based and cost effective, are described as best buys in the Global Status Report on Noncommunicable Diseases (NCDs) 2010. At present, public health services in developing countries are overstretched by increasing demands to cope with heart disease, stroke, cancer, diabetes and chronic respiratory disease. At the same time, health care systems in many LMIC are let down by a model based on hospital care focused on the treatment of diseas- es, often centred around high-technology hospitals that provide extensive treatment for only a small minority of citizens. Hospitals consume huge amounts of resources, and health ministries may spend more than half their budgets on treatment services which depend on hospitals. As a result, a large proportion of people with high cardiovascular risk remain undiagnosed, and even those diagnosed have insufficient access to treatment at the primary health-care level; while evidence suggests two-thirds of prema- ture deaths due to NCDs including CVDs can be prevented by primary prevention and another one-third by improving health systems to respond more effectively and equitably to the health- care needs of people with NCDs. Two new developments have led to this report at this juncture. The first development is the growing international awareness that premature deaths from CVDs and other NCDs reduce pro- ductivity, curtails economic growth, and pose a significant social challenge in most countries. The second development is that there is now unequivocal evidence that best buy interventions to reduce the toll of premature deaths due to CVDs and other NCDs are workable solutions and that they are excellent econom- ic investments -- including in the poorest countries. As the magnitude of CVDs continue to accelerate globally, the pressing need for increased awareness and for stronger and more focused international and country responses is increasingly recognized. This atlas on cardiovascular disease prevention and control is part of the response to this need. It documents the magnitude of the problem, using global cardiovascular mortal- ity and morbidity data. It demonstrates the inequities in access to protection, exposure to risk, and access to care as the cause of major inequalities between countries and populations in the occurrence and outcome of CVDs. It also highlights the causes responsible for the declining cardiovascular mortality in devel- oped countries, and sends the message that, to break this cycle of growing inequalities, we must use this knowledge to benefit people in all countries. Addressing CVDs require concrete and sustained action in three areas which represent the key components of any global or na- tional strategy; surveillance and monitoring, prevention and re- duction of risk factors, and improved management and health care through early detection and timely treatment. Actions should include setting national goals and targets and measuring results, advancing multisectoral partnerships and health-in-all- policies approaches, strengthening health systems and primary health care, and developing the appropriate national capacity and institutional arrangements to manage NCD programmes. Halting premature deaths from CVDs and other NCDs will also require global solidarity and broad alliances that go beyond national, cultural and ethnic boundaries. Eleven years since the landmark World Health Assembly endorsed the Global Strategy for the Prevention and Control of NCDs to reduce the toll of pre- mature deaths due to CVDs and other NCDs. Heads of State and Government will come together to address the prevention and control of NCDs worldwide at the 2011 High-level Meeting of the United Nations General Assembly on the Prevention and Control of NCDs between 19-20 September 2011 in New York. This is the second time in the history of the United Nations that the General Assembly will meet on a health issue with major socio-economic impact. National leaders are expected to adopt a concise action- oriented outcome document that will shape the international agenda for years to come. TheopportunityprovidedbytheHigh-levelMeetingisunprecedent- ed. By ensuring that the response to CVDs is placed at the forefront of international efforts to promote development and protect health, we will be achieving a more balanced distribution of the benefits of globalization and, in turn, reinforce the broader scope of human se- curity. And this gives me an occasion for great optimism. Dr Ala Alwan Assistant Director General Noncommunicable Diseases and Mental Health Cluster World Health Organization Foreword

10. SectionA Cardiovascular diseases (CVDs) due to atherosclerosis

11. 2 Global Atlas on Cardiovascular Diseases Prevention and Control The normal heart The heart is a muscular organ about the size of a fist (Fig- ure 1). With every heartbeat, the heart pumps blood that carries oxygen and nutrients to all parts of the body. The heart beats about 70 times per minute in a person at rest. The heart rate increases when a person is active or expe- riences strong emotions. Heart muscle receives its own blood supply from a system of coronary arteries. A good blood supply is vital for the normal function of the heart. Key messages ■■ CVDs are the leading causes of death and disability in the world. ■■ Although a large proportion of CVDs is preventable they continue to rise mainly because preventive measures are inadequate. ■■ Out of the 17.3 million cardiovascular deaths in 2008, heart attacks were responsible for 7.3 million and strokes were responsible for 6.2 million deaths. !What are cardiovascular diseases (CVDs)? The normal brain The brain is a complex organ that controls intellectual func- tions as well as other organ systems (Figure 2). The central- ized control of the brain allows the body to make rapid and coordinated responses to changes in the environment. Normal function of the brain depends on its blood sup- ply. Two large vessels that run along either side of the neck carry blood from the heart to the brain. The blood vessels branch off into cerebral arteries and carry oxygen and nu- trients to all parts of the brain. A good blood supply is vital for the normal function of the brain. Figure 1 Normal heart with its blood supply (i). Reproduced with permission. Figure 2 Normal brain with its blood supply (i). Reproduced with permission. Superior vena cava Anterior cerebral artery Middle cerebral artery Internal carotid artery Posterior communicating artery Posterior cerebral artery Superior cerebellar artery Basilar artery Anterior inferior cerebellar artery Posterior inferior cerebellar artery Anterior spinal artery Frontal lobe Temporal lobe Spinal cord Cerebellum Auricle of right atrium Right atrium Right coronary artery Conus arteriosus brevis Right ventricular artery and vein Right marginal artery Right ventricle Aorta Left pulmonary artery Pericardium (cut away) Pulmonary trunk Auricle of left atrium Left coronary artery Left marginal artery Diagonal artery Anterior interventricular artery Great cardiac vein Left ventricle Apex Anterior communicating artery

12. 3Global Atlas on Cardiovascular Diseases Prevention and Control CVDs include diseases of the heart, vascular diseases of the brain and diseases of blood vessels. CVDs are responsible for over 17.3 million deaths per year and are the leading causes of death in the world (1) (Figure 3). The different types of CVDs are listed below. 1. CVDs due to atherosclerosis: ■■ ischaemic heart disease or coronary artery disease (e.g. heart attack) ■■ cerebrovascular disease (e.g. stroke) ■■ diseases of the aorta and arteries, including hyperten- sion and peripheral vascular disease. 2. Other CVDs ■■ congenital heart disease ■■ rheumatic heart disease ■■ cardiomyopathies ■■ cardiac arrhythmias. Deaths due to heart attacks, strokes and other types of CVDs as a proportion of total cardiovascular deaths for males and females are shown in Figures 4 and 5, respectively (1). Fig- ures 6 and 7 show the global CVD mortality rates in males and females, respectively (1). Figures 8 and 9 show the global disease burden (DALYs) due to CVDs in males and females, respectively (2). The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death (prema- ture death). CVDs and their risk factors are major contribu- tors to global morbidity and mortality (1­–5). Atherosclerotic disease The underlying disease process in the blood vessels that results in coronary heart disease (heart attack) and cere- brovascular disease (stroke) is known as atherosclerosis. It is responsible for a large proportion of CVDs. In 2008, out of the 17.3 million cardiovascular deaths, heart attacks were responsible for 7.3 million deaths and strokes were respon- sible for 6.2 million deaths (1). Atherosclerosis is a complex pathological process in the walls of blood vessels that develops over many years. In atherosclerosis, fatty material and cholesterol are depos- ited inside the lumen of medium- and large-sized blood vessels (arteries). These deposits (plaques) cause the inner surface of the blood vessels to become irregular and the lumen to become narrow, making it harder for blood to flow through. Blood vessels also become less pliable as a result. Eventually, the plaque can rupture, triggering the formation of a blood clot. If the blood clot develops in a coronary artery, it can cause a heart attack; if it develops in the brain, it can cause a stroke. Factors that promote the process of atherosclerosis are known as risk factors (2–6), and include: Behavioural risk factors: 1. tobacco use 2. physical inactivity 3. unhealthy diet (rich in salt, fat and calories) 4. harmful use of alcohol. Metabolic risk factors: 5. raised blood pressure (hypertension) 6. raised blood sugar (diabetes) 7. raised blood lipids (e.g. cholesterol) 8. overweight and obesity. Other risk factors: 9. poverty and low educational status 10. advancing age 11. gender 12. inherited (genetic) disposition 13. psychological factors (e.g. stress, depression) 14. other risk factors (e.g. excess homocysteine). There is strong scientific evidence that behavioural and metabolic risk factors play a key role in the aetiology of ath- erosclerosis. Rheumatic heart disease Rheumatic heart disease is caused by damage to the heart muscle and heart valves from rheumatic fever, following a streptococcal pharyngitis/tonsillitis. Congenital heart disease Malformations of heart structures present at birth are known as congenital heart defects. They may be caused by: (i) a close blood relation between parents (consanguin- ity); (ii) maternal infections (e.g. rubella); (iii) maternal use of alcohol and drugs (e.g. warfarin); and (iv) poor maternal nutrition (e.g. deficiency of folic acid). In some cases the cause remains unknown. Examples of congenital heart dis- ease include holes in the septum of the heart, abnormal valves and abnormalities in heart chambers. Other CVDs Other CVDs such as disorders of the heart muscle (e.g. car- diomyopathy), disorders of the electrical conduction sys- tem of the heart (e.g. cardiac arrhythmias) and heart valve diseases are less common than heart attacks and strokes.

13. 4 Global Atlas on Cardiovascular Diseases Prevention and Control Figure 3 Distribution of major causes of death including CVDs (1). Other NCDs 33% Cardiovascular diseases 31% Injuries 9% Communicable, maternal, perinatal and nutritional conditions 27% Figure 4 Distribution of CVD deaths due to heart attacks, strokes and other types of cardiovascular diseases, males (1). Figure 5 Distribution of CVD deaths due to heart attacks, strokes and other types of cardiovascular diseases, females (1). Inflammatory heart diseases 2% Other cardiovascular diseases 11% Rheumatic heart diseases 1% Hypertensive heart diseases 6% Cerebrovascular diseases 34% Ischaemic heart diseases 46% Inflammatory heart diseases 2% Other cardiovascular diseases 14% Rheumatic heart diseases 1% Hypertensive heart diseases 7% Cerebrovascular diseases 37% Ischaemic heart diseases 38%

14. 5Global Atlas on Cardiovascular Diseases Prevention and Control Figure 6 World map showing the global distribution of CVD mortality rates in males ( age standardized , per 100 000) (1). © WHO 2011. All rights reserved. CVD mortality rate (per 100 000) 120–238 239–362 363–443 444–861 Data not available Figure 7 World map showing the global distribution of CVD mortality rates in females (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. CVD mortality rate (per 100 000) 76–180 181–281 282–372 373–711 Data not available

15. 6 Global Atlas on Cardiovascular Diseases Prevention and Control Figure 8 World map showing the global distribution of the burden of CVDs (DALYs), in males (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. CVD burden (DALYs per 100 000) 114–2137 2138–3314 3315–4228 4229–10772 Data not available Figure 9 World map showing the global distribution of the burden of CVDs (DALYs) , in females (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. CVD burden (DALYs per 100 000) 573–1489 1490–2583 2584–3438 3439–6261 Data not available

16. 7Global Atlas on Cardiovascular Diseases Prevention and Control There is a clear vision on how to address CVDs Surveillance Map and monitor the epidemic of CVDs Prevention Reduce exposure to risk factors Management Equitable health care for people with CVDs Address social determinants of health

17. 8 Global Atlas on Cardiovascular Diseases Prevention and Control Tobacco smoking, physical inactivity, unhealthy diets and the harmful use of alcohol are the main behavioural risk factors of CVDs.These risk factors are shared by other major NCDs such as cancer, diabetes and chronic respiratory dis- ease. Long-term exposure to behavioural risk factors results in raised blood pressure (hypertension), raised blood sugar (diabetes), raised and abnormal blood lipids (dyslipidae- mia) and obesity. Major cardiovascular risk factors such as hypertension and diabetes link CVD to renal disease. Of the 57 million global deaths in 2008, 36 million (63%) were due to NCDs (Figure 10) and 17.3 million (30%) were due to CVDs. Nearly 80% of NCD deaths occur in LMICs and is the most frequent cause of death in most countries, ex- cept in Africa (1). In Africa, NCDs are rising rapidly and are projected to exceed communicable, maternal, perinatal and nutritional diseases as the most common causes of death in another two decades. Over 80% of cardiovascular and diabetes deaths occur in LMICs. While 29% of NCD deaths occurs among people below the age of 60 in LMICs, in high-income countries only 13% of deaths occur below the age of 60 (1, 6) (Figure 11). Among people below the age of 70, CVDs were responsible for the largest proportion (39%) of NCD deaths (Figure 12). There has been a doubling of CVD rates in LMICs during recent decades, with rates, for example, for stroke and heart attack exceeding those in high-income countries (1, 6, 7). According to the Global Burden of Disease estimates (5), 68% of the 751 million years living with disability (YLD) worldwide is attributable to NCDs, and 84% of this burden of NCD disability arises in LMICs. Heart disease is one of the five leading contributors to YLD in elderly people in LMICs. Stroke is also reported as a leading cause of disability in LMICs, second only to dementia. CVDs are responsible for 151 377 million DALYs, of which 62 587 million are due to coronary heart disease and 46 591 million to cerebrovascu- lar disease (2, 5). The contribution of different CVDs to the global CVDs bur- den in males and females is shown in Figures 13 and 14, re- spectively. Figures 15–18 show mortality rates of ischaemic heart disease (Figures 15 and 16) and stroke (Figures 17 and 18) for males and females, respectively. Figures 19–22 show healthy years of life lost due to ischaemic heart dis- ease (Figures 19 and 20) and stroke (Figures 21 and 22) for males and females, respectively. Key messages ■■ CVD is the leading noncommunicable disease ; nearly half of the 36 million deaths due to noncommunicable diseases (NCDs) are caused by CVDs. ■■ In 2008, nine million people died of NCDs prematurely before the age of 60; some eight million of these premature deaths occurred in low- and middle-income countries (LMICs). ■■ 10% of the global disease burden (DALYs) is attributed to CVD. ■■ Tobacco smoking, physical inactivity, unhealthy diets and the harmful use of alcohol are the shared causative risk factors of heart disease, stroke, cancer, diabetes and respiratory disease. @Death and disability due to CVDs (heart attacks and strokes)

18. 9Global Atlas on Cardiovascular Diseases Prevention and Control Figure bo Distribution of global CVD burden (DALYs) due to heart attacks, strokes and other types of CVDs in males (5). Figure bp Distribution of global CVD burden (DALYs) due to heart attacks, strokes and other types of CVDs in females (5). Inflammatory heart diseases 4% Other cardiovascular diseases 14% Rheumatic heart disease 3% Hypertensive heart disease 5% Cerebrovascular disease 29% Ischaemic heart disease 45% Inflammatory heart diseases 4% Other cardiovascular diseases 17% Rheumatic heart disease 4% Hypertensive heart disease 6% Cerebrovascular disease 33% Ischaemic heart disease 37% Figure bl Distribution of global NCD by cause of death, both sexes (1, 6). Cancer 21% Other NCDs 16% Diabetes melitus 3% Respiratory diseases 12% Cardiovascular diseases 48% Figure bm Distribution of global NCD by cause of death for less than 60 year old persons, both sexes (1, 6). Cancer 28% Other NCDs 26%Diabetes melitus 3% Respiratory diseases 8% Cardiovascular diseases 35% Figure bn Distribution of global NCD by cause of death for less than 70 year old persons, both sexes (1, 6). Cancer 27% Other NCDs 21% Diabetes melitus 4% Respiratory diseases 9% Cardiovascular diseases 39%

19. 10 Global Atlas on Cardiovascular Diseases Prevention and Control Figure bq World map showing the global distribution of ischemic heart disease mortality rates in males (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. Ischemic heart disease mortality rate (per 100 000) 19–94 95–135 136–190 191–541 Data not available Figure br World map showing the global distribution of ischemic heart disease mortality rates in females (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. Ischemic heart disease mortality rate (per 100 000) 6–54 55–83 84–111 112–334 Data not available

20. 11Global Atlas on Cardiovascular Diseases Prevention and Control Figure bs World map showing the global distribution of cerebrovascular disease mortality rates in males (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. Cerebrovascular disease mortality rate (per 100 000) 0–54 55–95 96–130 131–236 Data not available Figure bt World map showing the global distribution of cerebrovascular disease mortality rates in females (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. Cerebrovascular disease mortality rate (per 100 000) 9–44 45–83 84–128 129–293 Data not available

21. 12 Global Atlas on Cardiovascular Diseases Prevention and Control Figure bu World map showing the burden of ischemic heart disease (DALYs),in males (age standardized, per 100 000) (5). © WHO 2011. All rights reserved. Ischemic heart disease (DALYs per 100 000) 229–884 8885–1 205 1 206–1 894 1 895–5 736 Data not available Figure cl World map showing the burden of ischemic heart disease (DALYs) in females (age standardized, per 100 000) (5). © WHO 2011. All rights reserved. Ischemic heart disease (DALYs per 100 000) 61–396 397–715 716–944 945–2 663 Data not available

22. 13Global Atlas on Cardiovascular Diseases Prevention and Control Figure cm World map showing the burden of cerebrovascular disease (DALYs) in males (age standardized, per 100 000) (5). © WHO 2011. All rights reserved. Cerebrovascular disease (DALYs per 100 000) 50–484 485–857 858–1 203 1 204–2453 Data not available Figure cn World map showing the burden of cerebrovascular disease (DALYs) in females (age standardized, per 100 000) (5). © WHO 2011. All rights reserved. Cerebrovascular disease (DALYs per 100 000) 150–389 390–778 779–1 162 1 163–2 037 Data not available

23. 14 Global Atlas on Cardiovascular Diseases Prevention and Control Atherosclerosis; the underlying basis of heart attacks and strokes One of the main underlying pathological processes that leads to heart attacks (coronary heart disease) and strokes (cerebrovascular disease) is known as atherosclerosis. The early changes of atherosclerosis develop in childhood and adolescence due to the overall effect of a number of risk factors (4–6). They include tobacco use, physical inactivity, unhealthy diet, harmful use of alcohol, hypertension, dia- betes, raised blood lipids, obesity, poverty, low educational status, advancing age, male gender, genetic disposition and psychological factors. Atherosclerosis is an inflammatory process affecting me- dium- and large-sized blood vessels throughout the cardio- vascular system (8–10). When the lining (endothelium) of these blood vessels is exposed to raised levels of low-density lipoprotein cholesterol (LDL cholesterol) and certain other substances, such as free radicals, the endothelium becomes permeable to lymphocytes and monocytes. These cells mi- grate into the deep layers of the wall of the blood vessel. A series of reactions occur, attracting LDL cholesterol par- ticles to the site. These particles are engulfed by monocytes, which are then transformed into macrophages (foam cells). Smooth muscle cells migrate to the site from deeper layers of the vessel wall (the media). Later, a fibrous cap consisting of smooth muscle and collagen is formed. At the same time, the macrophages involved in the original reaction begin to die, resulting in the formation of a necrotic core covered by the fibrous cap. These lesions (atheromatous plaques) en- large as cells and lipids accumulate in them and the plaque Key messages ■■ Tobacco use, physical inactivity, unhealthy diet, obesity, hypertension, diabetes, and dyslipidaemia, together with ageing and genetic factors, promote atherosclerosis and narrowing of the blood vessels. ■■ The process of atherosclerosis starts in childhood and adolescence and manifests as heart attacks and strokes in later years. #The underlying pathology of heart attacks and strokes begins to bulge into the vessel lumen (Figures 23–26).When the process continues, there is thinning of the fibrous cap accompanied by fissuring of the endothelial surface of the plaque, which may rupture. With the rupture of the plaque, lipid fragments and cellular debris are released into the vessel lumen. These are exposed to thrombogenic agents on the endothelial surface, resulting in the formation of a thrombus. If the thrombus is large enough, and a coronary blood vessel or a cerebral blood vessel is blocked, this results in a heart attack or stroke (9, 10). Heart attack When the blood flow to the heart is cut off, due to a throm- bus on a ruptured atherosclerotic plaque, the decrease in the supply of oxygen and nutrients can damage the heart muscle, resulting in a heart attack. When the blood flow is decreased due to a blockage, it causes chest pain (angina) due to ischaemia. Stroke The pathophysiology of ischaemic stroke is more diverse and includes, besides thrombus formation in atheroscle- rotic cerebral blood vessels (ischaemic stroke), small vessel disease in the brain linked to vascular risk factors. Another cause of stroke is haemorrhage (bleeding) due to a rupture of a blood vessel because of the presence of an aneurysm, for example, or due to damage from uncontrolled high blood pressure or atherosclerosis (haemorrhagic stroke). In addition, strokes can also be caused by a travelling blood clot. If a person has an irregular heartbeat, blood clots may form in the heart and travel through the blood vessels to the brain. A clot carried to the cerebral circulation in this way can be trapped in a cerebral blood vessel and block the blood flow to an area of the brain.

24. 15Global Atlas on Cardiovascular Diseases Prevention and Control Figure co Endothelial dysfunction: Leukocyte adhesion and migration into the deep layer of the intima (9). (From Ross I. Reproduced with permission. © 1999 Massachusetts Medical Society.) Endothelial permeability Leukocyte migration Endothelial adhesion Leukocyte adhesion Figure cq Fibrous cap formation and the necrotic core (9). (From Ross I. Reproduced with permission. © 1999 Massachusetts Medical Society.) Figure cr The ruptured plaque (9). (From Ross I. Reproduced with permission. © 1999 Massachusetts Medical Society.) Macrophage accumulation Formation of necrotic core Fibrous-cap formation Plaque rupture Thining of fibrous cap Hemorrhage from plaque microvessels Figure cp Fatty streak formation revealing platelet aggregation on the endothelial surface, foam-cell formation and smooth muscle migration (9). (From Ross I. Reproduced with permission. © 1999 Massachusetts Medical Society.) Smooth- muscle migration Foam-cell formation T-cell activation Adherence and entry of leukocytes Adherence and aggregation of platelets

25. 16 Global Atlas on Cardiovascular Diseases Prevention and Control Figures 27 and 28 show mortality rates of ischemic heart disease and cerebrovascular disease. Over the past two decades, cardiovascular mortality rates have declined substantially in high-income countries (6, 11–13). There is clear evidence that population-wide primary prevention and individual health-care intervention strategies have both contributed to these declining mortality trends. For example, during the 10-year period covered by the World Health Organization (WHO) Multinational Monitoring of Trends and Determinants of Cardiovascular Disease initia- tive (WHO MONICA Project), mortality from coronary heart disease and stroke declined dramatically in many of the 38 MONICA populations (13). The decline in mortality has been attributed to reduced incidence rates and/or improved survival after cardiovas- cular events due to prevention and treatment interven- tions. Across all populations with declining coronary heart disease mortality, reduced cardiovascular risk contributed to 75% and 66% of the change in men and women, respec- tively; the remainder being attributed to providing health care resulting in improved survival in the first four weeks after the event. For stroke, about one third of the changes in populations with declining mortality was attributed to reduced incidence and 66% to improved survival. There has been a dramatic decline in coronary heart dis- ease mortality in the United Kingdom from 1981 to 2000 (14). Nearly 42% of this decrease has been attributed to treatment (including 11% to secondary prevention, 13% to heart failure treatment, 8% to initial treatment of acute myocardial infarction and 3% to hypertension treatment). About 58% of the decline has been attributed to popula- tion-wide risk factor reductions (14). The above data and similar experiences in Finland (15) and other countries (16, 17) strongly support the view that pop- ulation-wide primary prevention and individual health- care approaches go hand-in-hand to reduce the popula- tion burden of CVDs (6). Key messages ■■ CVDs are eminently preventable. ■■ Investment in prevention is the most sustainable solution for the CVD epidemic. ■■ Over the last two decades, CVD mortality has declined in developed countries due to a combination of prevention and control measures. $Evidence for prevention of heart attacks and strokes

26. 17Global Atlas on Cardiovascular Diseases Prevention and Control Figure cs World map showing ischemic heart disease mortality rates (age standardized, per 100 000) (1). © WHO 2011. All rights reserved. Ischaemic heart disease mortality (per 100 000) 12–74 75–108 109–151 152–405 Data not available Figure ct World map showing cerebrovascular disease mortality rates (age standardized, per 100,000) (1). © WHO 2011. All rights reserved. Cerebrovascular disease mortality (per 100 000) 11–49 50–88 89–131 132–240 Data not available

27. 18 Global Atlas on Cardiovascular Diseases Prevention and Control A large percentage of CVDs (and other NCDs) is prevent- able through the reduction of behavioural risk factors (to- bacco use, unhealthy diet, physical inactivity and harmful use of alcohol) (3, 6). Unhealthy behaviours lead to metabolic/physiologi- cal changes: raised blood pressure (hypertension); over- weight/obesity; raised blood sugar (diabetes); and raised blood lipids (dyslipidaemia).These intermediate risk factors cause damage to coronary and cerebral blood vessels due to atherosclerosis, a process that develops over many years, starting in childhood and manifesting as heart attacks and strokes in people of middle age. Since the underlying path- ological process that causes heart attacks and strokes is similar, common approaches that address behavioural risk factors and metabolic risk factors are effective for preven- tion of both conditions. In terms of attributable deaths, the leading cardiovascular risk factor globally is raised blood pressure (to which 13% of global deaths is attributed), followed by tobacco use (9%), raised blood glucose (6%), physical inactivity (6%) and overweight and obesity (5%) (2) (Figure 29). These behavioural and metabolic risk factors often coexist in the same person and act synergistically to increase the individual’s total risk of developing acute vascular events such as heart attacks and strokes. Strong scientific evi- dence demonstrates that reducing total cardiovascular risk results in the prevention of heart attacks and strokes (4). Pioneering work conducted by the Framingham Heart Study project in the United States (18, 19) and the Seven Countries study (20) in the 1960s and many other studies since then, including the WHO MONICA Project (13) and the INTERHEART study (21), have provided further insights into the risk factors and determinants of CVDs. If people at risk of developing myocardial infarctions and strokes can be identified and measures taken to reduce their cardiovascular risk, a vast majority of fatal and non-fa- tal cardiovascular events can be prevented (4, 21, 22). WHO ISH (International Society of Hypertension) risk prediction charts and other risk prediction tools can be used to assess the risk of developing heart attacks and strokes (Figure 30). Cardiovascular risk distribution of the population can be lowered through national health policies targeting the whole population as well as those at high risk (Figure 31). Population-wide strategies should address behavioural risk factors. Simultaneously, those at high risk need to be identified and targeted through health systems using inte- grated risk assessment and management approaches that are cost effective (4, 6, 23). Figure 32 shows the distribution of the population across different levels of cardiovascular risk in all WHO regions. Key messages ■■ Cardiovascular risk factors such as hypertension, diabetes and hyperlipidaemia cluster together and are major risk factors for strokes and heart attacks. ■■ To prevent heart attacks and strokes, the total cardiovascular risk needs to be reduced by lowering all modifiable risk factors. ■■ Prevention of heart attacks and strokes by reducing the total cardiovascular risk is cost effective. %Reducing cardiovascular risk to prevent heart attacks and strokes

28. 19Global Atlas on Cardiovascular Diseases Prevention and Control 0 1000 2000 3000 4000 5000 6000 7000 8000 Raised blood pressure Tobacco High blood glucose Physical inactivity Overweight and obesity High cholesterol Unsafe sex Alcohol use Childhood underweight Indoor smoke from solid fuels Attributable deaths due to selected risk factors (in thousands) Figure cu Ranking of 10 selected risk factors of cause of death (2). CVD Prevention needs a life course approach

29. 20 Global Atlas on Cardiovascular Diseases Prevention and Control WHO/ISH Risk prediction chartsfor 14 WHO epidemiological sub-regions 8 Figure 1. WHO/ISH risk prediction chart for AFR D. 10-year risk of a fatal or non-fatal cardiovascular event by gender, age, systolic blood pressure, total blood cholesterol, smoking status and presence or absence of diabetes mellitus. AFR D People with Diabetes Mellitus Age (years) Male Female SBP (mm Hg)Non-smoker Smoker Non-smoker Smoker 70 180 160 140 120 60 180 160 140 120 50 180 160 140 120 40 180 160 140 120 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 Cholesterol (mmol/l) Risk Level 10% 10% to 20% 20% to 30% 30% to 40% ≥40% AFR D People without Diabetes Mellitus Age (years) Male Female SBP (mm Hg)Non-smoker Smoker Non-smoker Smoker 70 180 160 140 120 60 180 160 140 120 50 180 160 140 120 40 180 160 140 120 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 Cholesterol (mmol/l) This chart can only be used for countries of the WHO Region of Africa, sub-region D, in settings where blood cholesterol can be measured (Algeria, Angola, Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Comoros, Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Madagascar, Mali, Mauritania, Mauritius, Niger, Nigeria, Sao Tome And Principe, Senegal, Seychelles, Sierra Leone, Togo). Figure dl WHO and International Society of Hypertension (ISH) cardiovascular risk prediction chart (Shows the 10 year risk of a fatal or nonfatal cardiovascular event by gender, age, smoking status, systolic blood pressure, blood cholesterol and presence or absence of diabetes. Different charts are available for all WHO subregions).

30. 21Global Atlas on Cardiovascular Diseases Prevention and Control Population strategy Optimal distribution 10–year cardiovascular disease risk Present distribution Percentofpopulation High risk High-risk strategy 0 5 10 15 20 25 30 35 40 Figure dm A combination of population wide and high risk strategies are required to shift the cardiovascular risk distribution of populations to more optimal levels (23). Prevention of Cardiovascular Disease Pocket Guidelines for Assessment and Management of Cardiovascular Risk Geneva, 2007 Predicting Heart Attack and Stroke risk

31. 22 Global Atlas on Cardiovascular Diseases Prevention and Control Figure dn Distribution of cardiovascular risk categories in selected WHO subregions (4). 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 1.26% 1.45% 1.24% 96.05% 1.87% 4.21% 7.49% 86.43% 4.05% 7.18% 15.53% 73.26% 3.84% 10.10% 28.08% 57.98% Age Group (years) 1. African Region D (Males) 2. African Region D (Females) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.37% 0.03% 4.22% 95.38% 1.34% 3.39% 11.93% 83.33% 2.43% 17.18% 11.48% 68.90% 3.93% 20.83% 18.42% 56.83% Age Group (years) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.85% 0.51% 2.63% 96.00% 8.40% 5.14% 17.18% 69.27% 31.77% 13.69% 35.27% 19.27% 54.23% 23.86% 18.76% 3.15% Age Group (years) 3. Americas Region A (Males) 4. Americas Region A (Females) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.24% 0.40% 1.18% 98.18% 3.13% 3.51% 6.45% 86.91% 14.38% 8.50% 27.03% 50.09% 31.59% 20.47% 32.09% 15.84% Age Group (years)

32. 23Global Atlas on Cardiovascular Diseases Prevention and Control 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.19% 0.29% 0.89% 98.63% 4.65% 3.95% 9.31% 82.09% 18.73% 15.73% 35.33% 30.20% 38.46% 27.76% 28.35% 5.44% Age Group (years) 5. Eastern Mediterranean Region D (Males) 6. Eastern Mediterranean Region D (Females) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.16% 0.16% 0.67% 99.01% 2.60% 3.79% 9.18% 84.43% 15.49% 11.35% 26.62% 46.54% 31.91% 19.32% 34.28% 14.49% Age Group (years) Figure dn Distribution of cardiovascular risk categories in selected WHO subregions (4) (continued). Essential technology need to be affordable and simple for application in the field

33. 24 Global Atlas on Cardiovascular Diseases Prevention and Control 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.47% 0.25% 1.30% 97.99% 5.12% 4.41% 7.45% 83.02% 22.23% 14.32% 27.48% 35.97% 31.39% 14.42% 44.02% 10.17% Age Group (years) 9. South-East Asia Region C (Males) 10. South-East Asia Region C (Females) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.22% 0.74% 0.65% 98.39% 3.31% 3.39% 8.72% 84.58% 19.23% 12.45% 38.52% 29.80% 29.75% 22.95% 40.66% 6.64% Age Group (years) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 1.31% 1.05% 5.06% 92.57% 13.70% 6.07% 10.54% 69.69% 40.29% 18.10% 28.02% 13.59% 58.69% 22.81% 14.20% 4.30% Age Group (years) 7. European Region C (Males) 8. European Region C (Females) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.50% 0.47% 1.73% 97.30% 3.16% 5.66% 11.68% 79.51% 22.48% 13.26% 16.24% 48.02% 51.89% 7.10% 24.24% 16.78% Age Group (years) Figure dn Distribution of cardiovascular risk categories in selected WHO subregions (4) (continued).

34. 25Global Atlas on Cardiovascular Diseases Prevention and Control 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.16% 0.40% 0.52% 97.86% 3.78% 2.51% 8.72% 84.99% 15.06% 10.03% 25.37% 49.54% 21.63% 14.25% 39.98% 24.15% Age Group (years) 11. Western Pacific Region B (Males) 12. Western Pacific Region B (Females) 0 10 20 30 40 50 60 70 80 90 100 70+60–6950–5950 Risk categories: ■ 10% ■ 10–19.9% ■ 20–29.9% ■ ≥30% 0.10% 0.16% 0.58% 99.16% 1.99% 2.29% 4.33% 91.39% 6.74% 13.00% 7.54% 72.72% 15.28% 10.08% 26.53% 48.11% Age Group (years) Figure dn Distribution of cardiovascular risk categories in selected WHO subregions (4) (continued). Public health burden hidden and underestimated Heart attacks and strokes are only the tip of the iceberg Risk factor burden; unrecognised • Obesity • Raised blood sugar • Physical activity • Raised blood lipids • Unhealthy diet • Air pollution • Tobacco use • Poverty • Raised blood pressure 2 Billion

35. 26 Global Atlas on Cardiovascular Diseases Prevention and Control There are currently about one billion smokers in the world. Manufactured cigarettes represent the major form of smoked tobacco; other forms of tobacco consumed include “bidis” (a type of filter-less hand-rolled cigarette), cigars, hookahs and chewed tobacco (24, 25). Figure 33 and 34 show the prevalence rates of current daily tobacco smoking. The prevalence of daily tobacco smoking varied widely among the six WHO regions in 2009. The highest overall prevalence for smoking is estimated at nearly 31% in the WHO European Region, while the lowest is in the WHO African Region at 10% (26). Risks to health from tobacco use result not only from di- rect consumption of tobacco, but also from exposure to second-hand smoke (24, 25). Nearly six million people die from tobacco use and exposure to second hand smoke each year, accounting for 6% of all female and 12% of all male deaths in the world (1, 6). By 2030, tobacco-related deaths are projected to increase to more than 8 million deaths every year (2, 6). Smoking is estimated to cause nearly 10% of CVD (2). There is a large body of evidence from prospective cohort stud- ies regarding the beneficial effect of smoking cessation on coronary heart disease mortality (4). A 50-year follow-up of British doctors demonstrated that, among ex-smokers, the age of quitting has a major impact on survival prospects: those who quit between 35 and 44 years of age had the same survival rates as those who had never smoked (27). There is an inverse relationship between income level and prevalence of tobacco use and its related consequences. In addition, tobacco consumption inflicts a greater harm among disadvantaged groups due to tobacco-related ill- ness and the impact on household expenditure. There- fore, policies and interventions focusing on prevention of tobacco use, promotion of smoke free environments and smoking cessation should be important components of national and international efforts to improve the health and well being of populations, especially the less affluent (28). Key messages ■■ Tobacco use is a principal contributor to the development of heart attacks, strokes, sudden death, heart failure, aortic aneurysm and peripheral vascular disease. ■■ Smoking cessation and avoidance of second-hand smoke reduce the cardiovascular risk and thereby help to prevent CVDs. ^Tobacco:The totally avoidable risk factor of CVDs

36. 27Global Atlas on Cardiovascular Diseases Prevention and Control Figure do World map showing the prevalence of current daily tobacco smoking in males (age standardized adjusted estimates) (6). © WHO 2011. All rights reserved. Prevalence of current daily tobacco smoking (%) 6–18 19–27 28–38 39–74 Data not available Figure dp World map showing the prevalence of current daily tobacco smoking in females. (age standardized adjusted estimates) (6). © WHO 2011. All rights reserved. Prevalence of current daily tobacco smoking (%) 0–2 3–7 8–18 19–62 Data not available

37. 28 Global Atlas on Cardiovascular Diseases Prevention and Control Insufficient physical activity can be defined as less than 5 times 30 minutes of moderate activity per week, or less than 3 times 20 minutes of vigorous activity per week, or equivalent. Insufficient physical activity is the ­­fourth leading risk factor for mortality. Approximately 3.2 million deaths and 32.1 million DALYs – representing about 2.1% of global DALYs – each year are attributable to insufficient physical activity (2). People who are insufficiently physically active have a 20% to 30% increased risk of all-cause mortal- ity compared to those who engage in at least 30 minutes of moderate intensity physical activity most days of the week. In 2008, 31.3% of adults aged 15 or older (28.2% men and 34.4% women) were insufficiently physically active (6). In adults, participation in 150 minutes of moderate physical activity each week (or equivalent) is estimated to reduce the risk of ischaemic heart disease by approximately 30% and the risk of diabetes by 27% (4). Many studies that have examined the association between physical activity and CVDs (4, 6, 29–32) have reported re- duced risk of death from coronary heart disease and re- duced risk of overall CVDs, coronary heart disease and stroke, in a dose–response fashion. Physical activity is a key determinant of energy expenditure and thus fundamen- tal to energy balance and weight control. Physical activity improves endothelial function, which enhances vasodilata- tion and vasomotor function in the blood vessels (33). In addition, physical activity contributes to weight loss, gly- caemic control, improved blood pressure, lipid profile and insulin sensitivity (34, 35). The beneficial effects of physical activity on cardiovascular risk may be mediated, at least in part, through these effects on intermediate risk factors. The Global Status Report on NCD (6) showed that the prev- alence of insufficient physical activity was highest in the WHO Region of the Americas and the WHO Eastern Medi- terranean Region. In all WHO regions, men are more active than women, with the biggest difference in prevalence between males and females in the WHO Eastern Mediter- ranean Region (Figures 35 and 36). The prevalence of insufficient physical activity is higher in high-income countries compared to low-income countries due to increased automation of work and use of vehicles for transport in high-income countries. High-income coun- tries have more than double the prevalence of insufficient physical activity compared to low-income countries for both men and women, with 41% of men and 48% of wom- en being insufficiently physically active in high-income countries compared to 18% of men and 21% of women in low-income countries (6). Key messages ■■ Regular physical activity reduces the risk of heart attacks and strokes. ■■ Physical activity is a key determinant of energy expenditure and thus fundamental to energy balance and weight control. Physical inactivity: A preventable risk factor of CVDs

38. 29Global Atlas on Cardiovascular Diseases Prevention and Control Figure dq World map showing the prevalence of insufficient physical activity *, in males (age 15+, age standardized) (6), (* less than 5 times 30 minutes of moderate activity per week or less than 3 times 20 minutes of vigorous activity per week, or equivalent). © WHO 2011. All rights reserved. * Less than 5 times 30 minutes of moderate activity per week or less than 3 times 20 minutes of vigorous activity per week, or equivalent. Prevalence of insufficient physical activity (%) 3–20 21–30 31–43 44–71 Data not available Figure dr World map showing the prevalence of insufficient physical activity *, in females (age 15+, age standardized) (6), (* less than 5 times 30 minutes of moderate activity per week or less than 3 times 20 minutes of vigorous activity per week, or equivalent). © WHO 2011. All rights reserved. Prevalence of insufficient physical activity (%) 7–24 25–39 40–52 53–76 Data not available * Less than 5 times 30 minutes of moderate activity per week or less than 3 times 20 minutes of vigorous activity per week, or equivalent.

39. 30 Global Atlas on Cardiovascular Diseases Prevention and Control The harmful use of alcohol is a risk factor for multiple ad- verse health and social outcomes, including hypertension, acute myocardial infarction, cardiomyopathy, cardiac ar- rhythmia, cirrhosis of the liver, pancreatitis, neuropathy, en- cephalopathy, sexually transmitted diseases, unintended pregnancy, fetal alcohol spectrum disorders, sudden infant death syndrome, violence, suicide and unintentional inju- ries (e.g. motor vehicle crashes). In addition, people are af- fected by other people's drinking, including that of their families, friends, co-workers and strangers. These harms range in magnitude from noise and fear to physical abuse, sexual coercion and social isolation (2–6, 36). The adult per capita consumption of pure alcohol (litres) is shown in Fig- ure 37. Hazardous and harmful drinking was responsible for 2.5 million (3.8%) deaths worldwide in 2004 (2,37,38). More than 50% of these deaths were due to CVDs, liver cirrho- sis and cancer. An estimated 4.5% of the global burden of disease – as measured in DALYs – is caused by the harmful use of alcohol (2). The relationship between alcohol consumption and coro- nary heart disease and cerebrovascular diseases is complex. It depends on both the level and the pattern of alcohol consumption. There is a direct relationship between high- er levels of alcohol consumption and the pattern of binge drinking (defined as 60 or more grams of pure alcohol per day) with the risk of CVD. Drinking at low levels without ep- isodes of heavy drinking may be associated with a reduced risk of multiple cardiovascular outcomes (overall mortality from CVDs, incidence of and mortality from coronary heart disease and incidence of and mortality from stroke) in some segments of the population (36–38). However, these effects tend to disappear if the patterns of drinking are characterized by heavy episodic drinking (39, 40). Various mechanisms have been proposed for the protec- tive effect of light to moderate alcohol consumption, in- cluding the beneficial effects of alcohol on the HDL cho- lesterol level, thrombolytic profile and platelet aggregation (39–42). Overall alcohol consumption is associated with multiple health risks that, at the population level, clearly outweigh potential benefits. Key messages ■■ 14% of alcohol-attributable deaths globally are due to CVD and diabetes mellitus. ■■ There is a direct causal relationship between levels and patterns of alcohol consumption and risk of CVD. ■■ High levels of alcohol consumption and heavy episodic (binge) drinking are associated with increased risk of CVD. ■■ Harmful use of alcohol damages the heart muscle, increases the risk of stroke and promotes cardiac arrhythmia. *Harmful use of alcohol: A preventable risk factor of CVDs

40. 31Global Atlas on Cardiovascular Diseases Prevention and Control Figure ds World map showing the adult per capita consumption of pure alcohol (litres), in males and females (6). © WHO 2011. All rights reserved. Adult per capita consumption of alcohol (litres) 0–3 4–6 7–10 11–23 Data not available Strategies are needed to prevent the harmful use of alcohol

41. 32 Global Atlas on Cardiovascular Diseases Prevention and Control There is a considerable body of evidence regarding the nutritional background of atherosclerosis in general and coronary heart disease in particular. High dietary intakes of saturated fat, trans-fat cholesterol and salt, and low intake of fruits, vegetables and fish are linked to cardiovascular risk (2–6, 43). Obesity is a cardiovascular risk factor closely linked to diet and physical inactivity. Obesity results, when there is an imbalance between energy intake in the diet and energy expenditure. Regular physical activity can pre- vent obesity by increasing the expended energy. Figures 38 and 39 show the prevalence of obesity in adults and Fig- ure 40 shows the per capita intake of fruits and vegetables. Approximately 16 million (1.0%) DALYs and 1.7 million (2.8%) of deaths worldwide are attributable to low fruit and vegetable consumption (2).The amount of dietary salt con- sumed is an important determinant of blood pressure lev- els and overall cardiovascular risk (43–45). Adequate con- sumption of fruit and vegetables reduces the risk of CVD (2, 46, 47). Frequent consumption of high-energy foods, such as processed foods that are high in fats and sugars, promotes obesity compared to low-energy foods (48). A healthy diet can contribute to a healthy body weight, a desirable lipid profile and a desirable blood pressure (44). WHO recommends a population salt intake of less than 5 grams/person/day to help the prevention of CVD (43). However, data from various countries indicate that most populations are consuming much more salt than this (44). It is estimated that decreasing dietary salt intake from the current global levels of 9–12 grams/day to the recom- mended level of 5 grams/day would have a major impact on blood pressure and CVD (45, 49). A modest reduction in salt intake has a significant, and from a population viewpoint, important effect on blood pressure in individuals with either normal or raised blood pressure (50). There is also a correlation between the magnitude of salt reduction and the magnitude of blood pressure reduc- tion within the daily intake range of 3–12 grams/day; the lower the salt intake, the lower the blood pressure (49, 50). High consumption of saturated fats and trans-fatty acids is linked to heart disease; elimination of trans-fat and re- placement of saturated with polyunsaturated vegetable oils lowers coronary heart disease risk (43). Energy from saturated fats usually accounts for one third of the energy from total fat, with the notable exception of the WHO South-East Asia Region, where saturated fatty acids account for over 40% of total fat intake. The availability of total fat increases with i

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