NCD Lecture (PDF)

Non communicable diseases Noncommunicable diseases (NCDs), including heart disease, stroke, cancer, diabetes and chronic lung disease, are collectively responsible for 74% of all deaths worldwide. More than three-quarters of all NCD deaths, and 86% of the 17 million p...

Non communicable diseases Noncommunicable diseases (NCDs), including heart disease, stroke, cancer, diabetes and chronic lung disease, are collectively responsible for 74% of all deaths worldwide. More than three-quarters of all NCD deaths, and 86% of the 17 million people who died prematurely, or before reaching 70 years of age, occur in low- and middle-income countries. NCDs share five major risk factors: tobacco use, physical inactivity, the harmful use of alcohol , unhealthy diets and air pollution. The epidemic of NCDs poses devastating health consequences for individuals, families and communities, and threatens to overwhelm health systems. The socioeconomic costs associated with NCDs make the prevention and control of these diseases a major development imperative for the 21st century. WHO’s mission is to provide leadership and the evidence base for international action on surveillance, prevention and control of NCDs. Urgent government action is needed to meet global targets to reduce the burden of NCDs.  people at risk People of all age groups, regions and countries are affected by NCDs. These conditions are often associated with older age groups, but evidence shows that 17 million NCD deaths occur before the age of 70 years. Of these premature deaths, 86% are estimated to occur in low- and middle-income countries. Children, adults and the elderly are all vulnerable to the risk factors contributing to NCDs, whether from unhealthy diets, physical inactivity, exposure to tobacco smoke or the harmful use of alcohol or air pollution.  These diseases are driven by forces that include rapid unplanned urbanization, globalization of unhealthy lifestyles and population ageing. Unhealthy diets and a lack of physical activity may show up in people as raised blood pressure, increased blood glucose, elevated blood lipids and obesity. These are called metabolic risk factors and can lead to cardiovascular disease, the leading NCD in terms of premature deaths.  Risk factors Modifiable behavioural risk factors Modifiable behaviours, such as tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol, all increase the risk of NCDs. Tobacco accounts for over 8 million deaths every year (including from the effects of exposure to second-hand smoke). 1.8 million annual deaths have been attributed to excess salt/sodium intake. More than half of the 3 million annual deaths attributable to alcohol use are from NCDs, including cancer. 830 000 deaths annually can be attributed to insufficient physical activity  metabolic risk factor metabolic risk factors contribute to four key metabolic changes that increase the risk of NCDs: raised blood pressure overweight/obesity hyperglycemia (high blood glucose levels); and hyperlipidemia (high levels of fat in the blood). In terms of attributable deaths, the leading metabolic risk factor globally is elevated blood pressure (to which 19% of global deaths are attributed) followed by raised blood glucose and overweight and obesity.  Environmental risk factors Several environmental risk factors contribute to NCDs. Air pollution is the largest of these, accounting for 6.7 million deaths globally, of which about 5.7 million are due to NCDs, Including stroke ischaemic heart disease chronic obstructive pulmonary disease, and lung cancer.  Socioeconomic impact NCDs threaten progress towards the 2030 Agenda for Sustainable Development which includes a target of reducing the probability of death from any of the four main NCDs between ages 30 and 70 years by one third by 2030. Poverty is closely linked with NCDs. The rapid rise in NCDs is predicted to impede poverty reduction initiatives in low-income countries, particularly by increasing household costs associated with health care  Vulnerable and socially disadvantaged people get sicker and die sooner than people of higher social positions, especially because they are at greater risk of being exposed to harmful products, such as tobacco, or unhealthy dietary practices, and have limited access to health services. In low-resource settings, health-care costs for NCDs quickly drain household resources. The exorbitant costs of NCDs, including treatment, which is often lengthy and expensive, combined with loss of income, force millions of people into poverty annually and stifle development.  Prevention and control An important way to control NCDs is to focus on reducing the risk factors associated with these diseases. Low-cost solutions exist for governments and other stakeholders to reduce the common modifiable risk factors. Monitoring progress and trends of NCDs and their risk is important for guiding policy and priorities. To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed requiring all sectors, including health, finance, transport, education, agriculture, planning and others, to collaborate to reduce the risks associated with NCDs, and to promote interventions to prevent and control them.  Investing in better management of NCDs is critical. Management of NCDs includes detecting, screening and treating these diseases, and providing access to palliative care for people in need. High impact essential NCD interventions can be delivered through a primary health care approach to strengthen early detection and timely treatment. Evidence shows such interventions are excellent economic investments because, if provided early to patients, they can reduce the need for more expensive treatment.  Evidence shows such interventions are excellent economic investments because, if provided early to patients, they can reduce the need for more expensive treatment. Countries with inadequate health care coverage are unlikely to provide universal access to essential NCD interventions NCD management interventions are essential for achieving the SDG target on NCDs.  WHO response The 2030 Agenda for Sustainable Development recognizes NCDs as a major challenge for sustainable development. As part of the Agenda, heads of state and government committed to develop ambitious national responses, by 2030, to reduce by one third premature mortality from NCDs through prevention and treatment (SDG target 3.4). WHO plays a key leadership role in the coordination and promotion of the global fight against NCDs and the achievement of the Sustainable Development Goals target 3.4.  In 2019, the World Health Assembly extended the WHO Global action plan for the prevention and control of NCDs 2013–2020 to 2030 and called for the development of an Implementation Roadmap 2023 to 2030 to accelerate progress on preventing and controlling NCDs. The Roadmap supports actions to achieve a set of nine global targets with the greatest impact towards prevention and management of NCDs. Hypretention  Obective learning Define hypertention and understand its type Identify cause and risk factor Discuss the symptoms and complication Prevention Diagnosis and treatnent Treatnement for special hypertention Follow up and routine care  Hypretention Hypertention is a clinical condition where the arterial blood pressure is persistently elevated. It is a serious medical condition that significantly increases the risks of heart, brain, kidney and other diseases. An estimated 1.13 billion people worldwide have hypertension, most (two- thirds) living in low- and middle-income countries.  According to the National WHO STEPS survey conducted in 2015 the prevalence of hypertension in Ethiopia is estimated to be 16%. In Ethiopia and other low- and middle-income countries, there is a wide gap between evidence- based recommendations and current practice. Treatment of major CVD risk factors remains suboptimal, and only a minority of patients who are treated reach their target  their target levels for blood pressure, blood sugar and blood cholesterol. In other areas, overtreatment can occur with the use of non-evidence-based protocols.  HYPERTENSION DETECTION AND TREATMENT When to measure blood pressure Measuring blood pressure is the only way to diagnose hypertension, as most people with raised blood pressure have no symptoms Blood pressure measurements should be conducted on all patients during health facility visits as part of the vital sign. The Ministry of Health-Ethiopia recommends all adults are advised to check their blood pressure But the focus will be screening all adults aged ≥ 30 years of age as the yield of getting individuals with raised blood pressure will be higher based on the National WHO Steps Survey report and pilot program in ethiopia  Every patient with an elevated blood pressure reading requires repeated measurements to confirm the reading and enroll into care. More frequent screening with blood pressure measurements is particularly important to rule out or rule in hypertension in adults who: Have had a prior heart attack or stroke Have diabetes Have chronic kidney disease (CKD) Are obese Use tobacco Have a family history of heart attack stroke  Type of hypertension Primary hypertension:most common type,with no identifiable cause Develops gradually over years Genetic factors Secondary or identifiable hypertension Primary renal diseases Drug induced  Risk factors older age genetics being overweight or obese not being physically active high-salt diet drinking too much alcohol  Modifiable risk factors unhealthy diets (excessive salt consumption, a diet high in saturated fat and trans fats, low intake of fruits and vegetables) , physical inactivity, consumption of tobacco and alcohol, and being overweight or obese. In addition, there are environmental risk factors for hypertension and associated diseases, where air pollution is the most significant  Non-modifiable risk factors a family history of hypertension, age over 65 years and co-existing diseases such as diabetes or kidney disease  Complication of hypertention Heart disease: hear tattak and failure Stroke Kidney damage Vision loss aneurysm  Prevention Lifestyle changes Diet Exercise Regular check-up Stress management Health eduction  Diagnosis of Hypertension The diagnosis of hypertension should be confirmed at an additional patient visit, usually with in 1 to 4 weeks after the first measurement depending on the measured values and other circumstances. In general, hypertension is diagnosed if, on two visits, on different days Systolic blood pressure on both days is ≥140 mmHg, and/or Diastolic blood pressure on both days is ≥90 mmHg. Clinical Condition If there is no evidence of end-organ damages (hypertension mediated organ damage < 140/90 : Re-measure after 1year 140-159/90-99 :Confirm within one Month 160-179/100- 109 :confirm as soon as possible with in one week >180/110 :Diagnose HTN, initiate treatment and refer If there is evidence of hypertension mediated organ damage (or endorgan damages )  If there is evidence of hypertension mediated organ damage (or endorgan damages) Confirm HTN, initiate treatment and/or refer to the next level Hypertensive Crises (BP> 180/110 mmHg) with or without target organ damage. Confirm HTN, initiate treatment and/or refer to the next level Once the diagnosis of hypertension is confirmed  Sign and symptoms History: Symptoms of heart failure (SOB, unusual fatigue and body swelling), history of sudden onset body weakness (stroke), severe headache and blurring of vision Physical Examination: Pulse rate and rhythm signs of heart failure (edema, elevated JVP, crackles on the lungs), focal neurologic deficit eye signs. The physical examination should be done to the maximum capacity of the health work force including fundoscopic retinal examination if possible  Laboratory and other diagnostic tests Mandatory tests at diagnosis Do urine dipstick to check for protein , serum creatinine to check for renal function) Optional tests at diagnosis (ECG to look for effect of blood pressure on the heart, serum electrolytes mainly potassium, thyroid function ) test to assess a secondary cause of hypertension Indication based tests : Do echocardiography for heart failure patients, brain imaging for suspicion of stroke) Comorbidity and risk factor assessment tests Do blood sugar and serum cholesterol Look for risk factors Smoking, excess salt intake , sedentary life, low fruit and vegetable intake, excess alcohol consumption measure weight, height and abdominal circumference Calculate BMI: Weight in kg / square of height in meter3 Cardiovascular Risk Assessment: More than 50% of hypertensive patients have additional CV risk factors. Most commonly: metabolic syndrome, T2DM, lipid disorders, high uric acid  Classification of Hypertension and Recommended Management Normal 10%)  Hypertensive Crises (SBP ≥180 mmHg or DBP ≥110 mmHg) (see below) Treatment targets For most patients, blood pressure is considered controlled when SBP 20 weeks of gestation, and lasts 300 mg/24 h or ACR >30 mg/mmol [265 mg/g]). Predisposing factors are preexisting  Predisposing factors are preexisting hypertension, hypertensive Eclampsia: Hypertension in pregnancy with seizures, severe headaches, visual disturbance, abdominal pain, nausea and vomiting, low urinary output: Immediate treatment and delivery required. o HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome: Immediate treatment and delivery required  Management of hypertensive disorders of pregnancy Initiate Drug treatment if BP persistently: o >150/95 mmHg in all women >140/90 mmHg if gestational hypertension or subclinical HMOD First Line Drug Therapy Options: Methyldopa, Amlodipine, Nifedipine If SBP ≥170mmHg or DBP ≥110mmHg (Emergency): Immediately hospitalize o Initiate IV hydralazine and magnesium Sulfate o If pulmonary edema, IV nitroglycerin  Delivery in Gestational Hypertension or Pre-Eclampsia At 37 weeks if asymptomatic Expedite delivery in women with pre-eclampsia with visual disturbances or hemostatic disorders or HELLP syndrome  HYPERTENSIVE CRISES Hypertensive emergencies are diagnosed if there is a SBP ≥180 mmHg or DBP ≥110 mmHg) 180 mmHg or with the presence of acute target organ damage Patients with hypertensive emergencies include those who have: Hypertensive encephalopathy and retinopathy Ischemic and Hemorrhagic Stroke Acute Coronary Syndrome Acute Cardiogenic Pulmonary edema Acute Renal failure Acute Kidney Injury/Thrombotic microangiopathy (Malignant hypertension) Severe Preeclampsia / eclampsia Aortic Dissection First Line Treatment hypertensive emergencies Labetalol Alternative Hydralazine Follow Up after hypertensive emergency investigation of potential underlying causes and assessment of Hypertensive Mediated Organ  lifestyle modification will assist to improve adherence and long- term BP control. Regular and frequent follow-up is recommended until target BP and ideally regression of HMOD has been achieved.  ROUTINE CARE FOR HYPERTENSION BP Check 2 readings at every visit. If BP < 140/90 (< 150/90 if ≥ 60 years), BP is controlled: continue current treatment and review 3-6 monthly. If BP ≥ 140/90 (≥ 150/90 if ≥ 60 years), BP is not controlled: decide based on If ≥ 180/110: also check if patient needs urgent attention.  Thank you