Control and Management of Cardiovascular Disease in Turkey
2019; Lippincott Williams & Wilkins; Volume: 141; Issue: 1 Linguagem: Inglês
10.1161/circulationaha.119.037606
ISSN1524-4539
Autores Tópico(s)Health Promotion and Cardiovascular Prevention
ResumoHomeCirculationVol. 141, No. 1Control and Management of Cardiovascular Disease in Turkey Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBControl and Management of Cardiovascular Disease in Turkey Meral Kayikcioğlu, MD and Ali Oto, MD Meral KayikcioğluMeral Kayikcioğlu Ege University Medical School Cardiology Department, Izmir, Turkey (M.K.). and Ali OtoAli Oto Ali Oto, MD, Chairman, Department of Cardiology, Memorial Hospital, Cinnah Caddesi 98/4, Ankara, Turkey. Email E-mail Address: [email protected] Department of Cardiology, Memorial Hospital, Ankara, Turkey (A.O.). Originally published30 Dec 2019https://doi.org/10.1161/CIRCULATIONAHA.119.037606Circulation. 2020;141:7–9Turkey's 80 million inhabitants face a growing burden of noncommunicable diseases. Noncommunicable diseases are estimated to account for 86% of total deaths, and nearly 1 in 5 adults dies prematurely.1 Cardiovascular diseases (CVDs) are responsible for nearly half (47%) of all deaths. In 2018, 19.6% of deaths were caused by cancers, and 39.7% were caused by CVDs. By 2030, CVD mortality is projected to increase ≈2.3-fold in men and 1.8-fold in women. Turkey is among the countries with the highest CVD mortality in Europe, and Turkish women have the highest overall mortality (Table).1–3Table 1. Comparison Between Turkey and Europe of Adult Cardiovascular DataTurkeyRest of EuropeStandardized circulatory death rate by residence (2018)521.9381.4Risk of adult mortality (per 1000 population 15–59 y of age; 2013), F/M60.0/150.0…Age-standardized prevalence rate per 100 000 of cardiovascular diseases (2014), M/F7998/73927217/3941Age-standardized prevalence of raised blood pressure (2014), total (M/F), %23.0 (23.0/22.0)28.4 (24.2/20.2)Prevalence of diabetes mellitus (2017), total (M/F), %11.1 (10.6/11.5)6.5 (7.9/6.5)Current smoking (2017), total (M/F), %31.6 (43.6/19.7)27.9 (31.5/15.8)Age-standardized prevalence of obesity (BMI ≥30 kg/m2; 2017), total (M/F), %28.8 (22.9/35.8)21.4 (21.4/22.9)Cardiologists*28.086.3Interventional cardiologists*19.611.8Cardiac surgeons*12.710.3Cardiac surgery centers*3.71.3Transplantation centers*0.20.3Centers undertaking electrophysiology study*1.11.5Centers undertaking PCIs*3.42.8Coronary angiographies*7 094.64 121.9PCIs/primary PCIs*2708.8/670.81808.3/475.2Percutaneous interventions for congenital heart disease *58.033.5Coronary artery bypass grafting*838.5361.8Electrophysiology procedures*96.7179.2ICD implantations*90.392.9Pacemaker implantations*129.0486.2Consanguinity (2017), %23.4<5Frequency of familial hypercholesterolemia1/100–1501/250 (Holland)BMI indicates body mass index; ICD, implantable cardioverter-defibrillator; and PCI, percutaneous coronary intervention.*Infrastructure or procedures per million people, 2014 or latest year.Turkey enacted fundamental reforms to its health system called the Health Transformation Program between 2003 and 2013.2 The Health Transformation Program improved health insurance coverage and access to healthcare services for all citizens and reduced regional inequalities in access to care. The majority of the population is followed up by family practitioners, and they are free to admit to hospitals or specialists. Most citizens are covered by governmental insurance. All costs of pharmaceutical and nonpharmaceutical disease management are covered by an obligatory general health insurance.The European standard of a minimum of 3 cardiologists per 100 000 inhabitants was reached in 2014, and the current number of cardiologists exceeds 3000.2 Since 1990, training in cardiology has been a separate specialization track. The cardiology training period is 5 years. Cardiology training is under the legal authority of Ministry of Health and follows the recommendations of the European Union for Medical Specialists. The Turkish Society of Cardiology plays a pivotal role in the postgraduate education of cardiologists with several continuing medical educational activities, including standardized semiannual courses for cardiology fellows (Cardiology School), as well as meetings organized by working groups. Electronic learning opportunities are also continuously available for improving cardiologists' knowledge, skills, and training experiences. Since 2002, a voluntary National Board Examination has been performed by the independent National Accreditation Council of Cardiology within the Turkish Society of Cardiology.4Research is an important priority for cardiology in Turkey. Use of websites and social media is extremely high in accessing information. Governmental institutes and the Turkish Society of Cardiology have many research funding programs. Other funds are available from foundations such as the Heart and Health Foundation of Turkey to support education and research in cardiovascular medicine. Almost 60% to 70% of the cardiovascular research is supported by the government, and <5% of support is received from outside Turkey.CVD prevention is a priority Ministry of Health target, and multiple regulatory efforts are underway to promote healthy lifestyle habits.2 Turkey has succeeded in setting a national noncommunicable diseases policy and action plan that targets and collects reliable mortality data and risk factor surveys. A Multisectoral Action Plan was launched in 2017 with 4 strategic pillars: strengthening national capacities, leadership, governance, and partnerships; reducing modifiable and preventable risk factors; strengthening the response of the health system; and monitoring the trends and determinants of noncommunicable diseases and evaluating progress in their prevention and control.1The most impressive success has been in tobacco control. Between 2008 and 2012, smoking rates declined by 13.4% (a relative reduction from 31.2% to 27.1%, ie, from 16 to 14.8 million smokers) thanks to a set of consistently implemented, comprehensive policies to reduce the demand for tobacco, including tax increases, large graphic health warnings on cigarette packages, bans on advertising, promotion and sponsorship campaigns within mass media, and smoke-free policies in public buildings, working environments, and transportation. The first antitobacco law restricting smoking in health and educational establishments and public transport was introduced in 1996. It also banned the sale of tobacco products to individuals <18 years of age. Tobacco taxes were raised to 81.7% of the sale price, meeting the levels recommended by World Health Organization. Extensive warnings have been in place on cigarette packages, taking up 65% of the front and back panels, since 2010. A free national 24-hour quit-line service is also available.1Nutritional risk factors are also a major concern in Turkey, especially overweight, obesity, and salt consumption, which are much higher than the average for Europe. Moreover, the metabolic syndrome is a major public health problem, particularly in women. Efforts to reduce unhealthy dietary foods, including the adoption of policies on salt/sodium and saturated and trans fats and restrictions on food marketing, are targets. As a result, the mean salt intake declined from 18 to 9.9 g/d between 2011 and 2017. The Ministry of Health also promotes public education and awareness campaigns on physical activity and childhood obesity. As another component, action plan regulations such as restricting marketing and media advertisements of unhealthy food in childhood programs have been introduced. A regulation banning the sale of potato chips and cola beverages in school canteens has been in place since 2011, which helped blunt the increase in childhood obesity prevalence (6.5% in 2009, 8.8% in 2013, and 9.9% in 2016).Turkey has also succeeded in managing CVD by increasing the availability of percutaneous cardiac interventions countrywide. All interventions are uploaded and followed by a government-run electronic system.2 For the last 6 months, submission of patients' information to a national data center has become obligatory for reimbursement of percutaneous implantation of transcatheter aortic valves (1800 cases by 2018) and cardiac implantable electronic devices (average, 190 cases per year; Table). Basic electrophysiology services have been developed and are now available in most provinces in the country. Cardiac implantable electronic devices are available and fully reimbursable for all, whereas advanced ablation procedures are limited to the specialized centers in major cities. Turkey has an average of 80 cardiac transplantations per year, comparable to Eastern Europe. Cardiac assist devices are also available both for bridge to transplantation and as destination therapy.In-hospital management of acute coronary events is satisfactory with a mean door-to-balloon time of 36 minutes (25–65 minutes). However, the TURK-MI registry revealed that only 18% of patients with myocardial infarction called emergency medical services for an ambulance, and a public campaign promoting emergency medical services reach-out is underway. Unfortunately, secondary prevention is not meeting the targets of current guidelines. The number of nurses specialized in cardiovascular prevention is limited; nurse-based programs are lacking; and sustained lifestyle changes cannot be implemented in the majority. Family practitioners are the key individuals to initiate and provide long-term follow-up in secondary prevention. The Turkish Society of Cardiology recalibrated the SCORE charts according to Turkish mortality and morbidity data for the development of risk-adjusted prevention to the Turkish healthcare system. Recalibrated SCORE-TURKEY risk charts are provided online as a family physician–patient follow-up program called e-nabiz ("e-pulse"). However, target lipid levels have not been achieved in most patients, probably as a result of reluctance of physicians, promotion of misconceptions by the media, and high use of alternative medicine products.Another country-specific problem is the high prevalence of rare diseases such as familial hypercholesterolemia, peripartum cardiomyopathy, and pulmonary hypertension resulting from the geographic structure, founder effects, and high consanguinity rates (23%) compared with overall Europe <5%.5 Ongoing rare CVD awareness programs, including registries, will address the burden of these diseases, enhance our understanding of the nature of these diseases, and stimulate improvements in quality and consistency of practice in the region. Affording new agents for rare CVDs such as new antilipid agents is another obstacle decreasing practitioner enthusiasm.In summary, remarkable progress has been made in the awareness, prevention, and management of CVDs in the last decade in the Turkey. The increase in the burden on health economics, reimbursement issues, the aging of the population, and the rise in heart failure, obesity, and diabetes mellitus will be the focus for the future.DisclosuresDr Kayikcioğlu has received honoraria (for lectures and consultancy) from Abbott and Menarini and research funding from Amryt Pharma, Amgen, and Sanofi. Dr Kayikcioğlu has participated in clinical trials with Amgen, The Medicines Company, Regenerone, Sanofi, and Pfizer. Dr Oto has received speaker honoraria from Daiichi Sankyo, Menarini, Bayer, and Pfizer/BMS, as well as research funding from BMS/Pfizer (ERISTA), Merck, and Bayer.Footnoteshttps://www.ahajournals.org/journal/circAli Oto, MD, Chairman, Department of Cardiology, Memorial Hospital, Cinnah Caddesi 98/4, Ankara, Turkey. Email [email protected]orgReferences1. World Health Organization, Republic of Turkey Ministry of Health. Multisectoral action plan of Turkey for noncommunicable diseases, 2017–2025.http://www.euro.who.int/__data/assets/pdf_file/0005/346694/BOH_ENG.pdf. Accessed March 25, 2019.Google Scholar2. European Society of Cardiology website. https://www.escardio.org/Sub-specialty-communities/European-Association-of-Preventive-Cardiology-(EAPC)/Advocacy/Prevention-in-your-country/Country-of-the-Month-Turkey. Accessed March 25, 2019.Google Scholar3. Timmis A, Townsend N, Gale C, Grobbee R, Maniadakis N, Flather M, Wilkins E, Wright L, Vos R, Bax J, et al; ESC Scientific Document Group. European Society of Cardiology: cardiovascular disease statistics 2017.Eur Heart J. 2018; 39:508–579. doi: 10.1093/eurheartj/ehx628CrossrefMedlineGoogle Scholar4. Oto A. A view from Ankara.Circulation. 2006; 113:f21–f22.MedlineGoogle Scholar5. Kayikcioglu M, Tokgozoglu L, Dogan V, Ceyhan C, Tuncez A, Kutlu M, Onrat E, Alici G, Akbulut M, Celik A, et al. What have we learned from Turkish familial hypercholesterolemia registries (A-HIT1 and A-HIT2)?Atherosclerosis. 2018; 277:341–346. doi: 10.1016/j.atherosclerosis.2018.08.012CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Tokgozoglu L, Kayikcioglu M and Ekinci B (2021) The landscape of preventive cardiology in Turkey: Challenges and successes, American Journal of Preventive Cardiology, 10.1016/j.ajpc.2021.100184, 6, (100184), Online publication date: 1-Jun-2021. Meng Y, Liu Z, Hao J, Tao F, Zhang H, Liu Y and Liu S (2022) Association between ambient air pollution and daily hospital visits for cardiovascular diseases in Wuhan, China: a time-series analysis based on medical insurance data, International Journal of Environmental Health Research, 10.1080/09603123.2022.2035323, (1-12) January 7, 2020Vol 141, Issue 1 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.037606PMID: 31887081 Originally publishedDecember 30, 2019 Keywordscardiovascular diseasesTurkeyPDF download Advertisement SubjectsHealth Services
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