Challenges in the use of preventive cardiovascular medications in Indonesia and the
Netherlands
Irawati, Sylvi
DOI:
10.33612/diss.146680004
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Publication date: 2020
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Irawati, S. (2020). Challenges in the use of preventive cardiovascular medications in Indonesia and the Netherlands. University of Groningen. https://doi.org/10.33612/diss.146680004
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CHAPTER
GENERAL
Burden of cardiovascular disease (CVD)
Cardiovascular disease (CVD) is one of the significant causes of life lost due to morbidity and mortality in the world. In 2017, 366 million disability-adjusted life years (DALYs) were lost due to CVD. This number, dominated by ischemic or coronary heart/artery disease (IHD/CHD/CAD, 46%) and stroke (36%), contributed to around 15% of total DALYs lost globally.1 The main driver of life years lost is premature death,
with CHD and stroke ranking first and third, respectively, as the leading causes of premature death worldwide.2,3
According to the World Health Organization (WHO), low and middle-income countries (LMICs),4 of which Indonesia (The Republic of Indonesia) is one, account
for at least 75% of CVD-related deaths worldwide.5 With a total population of
around 260 million and inhabiting an archipelago located in the South-East Asia region, Indonesia is the fourth most populated country in the world. CVD is the leading cause of death, accounting for 35% of all deaths in 2016.6,7 In the same year,
CHD and stroke were the cause of approximately 49% and 39% of CVD-related deaths, respectively. However, this estimation should be interpreted with caution, as death registration data may be unavailable or unreliable.7
In contrast, the Netherlands is a high-income country belonging to Western Europe. The current size of the Dutch population is estimated at approximately 17 million.8,9
CVD accounted for 26% of all deaths in 2016 and is no longer the leading cause of death in the Netherlands, having been replaced by cancer. Of all CVD-related deaths, approximately 48% and 26%, respectively, were due to CHD and stroke. These numbers are estimated from national death registration data that is highly comprehensive, with the cause-of-death assignment available.7
General Introduction
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CVD prevention
To reduce the burden of CVD, the World Health Organization (WHO) has established nine global targets for the prevention and control of non-communicable disease (NCD) which must be attained by 2025. One of the voluntary targets is the use of drugs or medications to prevent myocardial infarction (MI) or heart attacks, which are an acute manifestation of CHD.10 This intervention is directed to people who
are at high risk of a fatal or non-fatal cardiovascular (CV) event in the next 10 years (primary prevention) and to people who have already had MI or a stroke (secondary prevention).10,11 Along with WHO, international CVD prevention guidelines
recommend the prescription of preventive CV medications based on an estimation of total CV risk rather than only considering CV risk factors individually.12–14
Several classes of preventive CV medications that have proven to be cost-effective and recommended by the guidelines for CVD prevention and control are antithrombotic agents (aspirin, P12Y12 inhibitors, anticoagulants), antihypertensive agents (beta blockers, angiotensin-converting enzyme inhibitors [ACEIs], angiotensin receptor blockers [ARBs]) and statins.13–19 Nevertheless, the use of these medications according to the
guidelines remains a challenge.20,21 Not surprisingly, these challenges are different in
Indonesia as an LMIC and the Netherlands as an HIC.
Since studies on the use of preventive medications for CVD prevention and control in the Indonesian population are scarce, the guidelines for CVD prevention and control for Indonesia are adapted from guidelines of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS).22,23 Nevertheless, WHO has
reported that the country does not have any CVD guidelines that are used in at least 50% of its health facilities, with the proportion of primary healthcare centres that use CVD risk stratification reported to be very low (less than 25%).6 In 2014, however,
Indonesia introduced a new mandatory National Health Insurance System (NHIS) (Jaminan Kesehatan Nasional-Kartu Indonesia Sehat, JKN-KIS) to provide universal health cover to all Indonesians.24–26 This system might introduce a new role for primary
In contrast, a strategy aiming to prevent fatalities due to CVD was initiated much earlier in the Netherlands. It is known that primary care there plays a strong prevention role (almost 10,000 general practitioners) and that there are strong incentives for health insurance companies to engage and contract with healthcare providers. Moreover, the strategy of CVD prevention has moved from an ‘old’ approach (including primary and secondary prevention) to a ‘new’ method (selective and indicated prevention). The relevant Dutch clinical guidelines have been in place and updated since the mid-2000s.27,28
Consequently, the proportion of primary healthcare centres that offer CVD risk stratification is reported to be more than 50%, and the country has also reported having CVD guidelines that are utilized in at least 50% of all healthcare facilities in general.8
The different circumstances in each country present unique challenges to CVD prevention and control. While guideline-based preventive medications for MI are being used in both countries, the challenges and effectiveness of the approach remain largely unknown in Indonesia.6 The Dutch, in contrast, may need to deal with the
more specific challenge of how to optimize guideline implementation to ensure the attainment of the targets required for CVD prevention.
Thesis objectives and outlines
The general objective of this thesis is to identify current challenges in the use of guideline-based preventive medications for CVD prevention in Indonesia and the Netherlands.
The thesis will focus on CHD as the main type of CVD in both countries. The thesis will be divided into two parts: the first part will investigate the long-term CVD burden in Asians and the challenges in using preventive medications for CVD in Indonesia, while the second part will investigate the challenges in using specific preventive medications in the Netherlands.
Part 1 consists of four chapters. As Indonesian data on the burden of CVD is not based on death registration or prospective studies, in Chapter 2 we aim to systematically review the published literature to identify any such studies.
General Introduction
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The specific aim of the review is to estimate the long-term (> 10 years) CVD burden, including CHD and stroke, as well as associated risk factors in Asian populations.
In Chapter 3, we study the use of preventive medications in patients with acute
coronary syndrome (ACS), a condition which can lead to non-fatal and fatal MI. This study aimed to assess the association between adherence to guideline-recommended preventive medications and in-hospital mortality among a subset of a high-risk patient population.
In Chapter 4 we investigate factors which may challenge the use of guideline-based preventive medications in individuals with a high risk of CVD.
In Chapter 5, we conduct a qualitative study to gauge physician’s perspective on
factors influencing the decision to prescribe a certain guideline-based preventive medication in a clinical setting in Indonesia.
Part 2 consists of two chapters. In Chapter 6 we investigate the challenges in using one preventive medication in particular, statins, in the Dutch population. We aimed to quantify the differences in the effect of statins on lipid parameters between men and women.
In Chapter 7, we aim to estimate the association between statin adherence and the
lipid parameter response in statin initiators on standard dose and low dose, and to detect how adherence and sex interact with these dosage schemes.
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