Prevention:

The Ferrara Example

Roberto Ferrari

Introduction

• In the last 30 years, life span has increased by 8 years

• Cardiology has contributed to at least 6 of these years

• CV death continues to be the number 1 killer worldwide

Introduction

• We have only delayed CV death and transformed an acute disease into a chronic one

• We should not drop our guard - and we will not

•We are trained to treat

•We have proven that we are able to do so

•Only recently we pay attention to prevention

Treatment vs Prevention

• Role of therapy (Asprin, ACE-inhibitors, statins, β-blockers) is enormous.

• The more costly interventions (although highly advocated by cardiologists) contribute little.

Treatment vs Prevention

• Revascularisation explains 5% of the fall in CV death.

• It is applied too late or to toofew and is too expensive

• Even doubling revascularisation would make little difference

Treatment vs Prevention

•Treatment accounts for between 25-55% of the CV mortality decline

•Prevention accounts for between 45-75%

Prevention vs Treatment

•Treatment rests in the hands of cardiologists

•Prevention does not and should not

Prevention vs Treatment

Which prevention strategy?

1 - A population strategy

•Paramount importance

•Dealt with by doctors, institutions, cities, nations, policy makers, politicians

2 - High risk strategy

• Important for a minority of asymptomatic individuals

• Dealt with by GPs and cardiologists

Which prevention strategy?

3 - Secondary prevention

• Important but limited for survivors

•Dealt with by cardiologists

Which prevention strategy?

What is prevention?

• Awareness, behavior, laws, education, lifestyle, etc.

• Alteration of majority (if not all) aspects of the Western civilisation.

• Too important to be left to medical doctors alone.

What is prevention?

•More than a list of do’s and don’ts

•More than forbidden pleasures or imposed burdens

Prevention and lifestyle

•Changing the lifestyle of a population for the better is not an easy task

• Ironically it is easier to deteriorate it

Changing lifestyle

• A battle against the negative subliminal messages from consumer society (movies, TV, internet).

• A challenge to important economic interests.

Walking the dog

Ferraraa city of

prevention

Why Ferrara?

• A city of 131.000 inhabitants

• With more than 600 years of university culture

• With close links between different institutions

Why Ferrara?

• 9 Km of medieval wall

Why Ferrara?

• 9 Km of medieval wall

• A city of bicycles

Why Ferrara?

• 9 Km of medieval wall

• A city of bicycles

• Number 1 producer of fruit and vegetables in Italy

Why Ferrara?

• 9 Km of medieval wall

• A city of bicycles

• Number 1 producer of fruit and vegetables in Italy

• Heavy fishing industry

Why Ferrara?

• 9 Km of medieval wall

• A city of bicycles

• Number 1 producer of fruit and vegetables in Italy

• Heavy fishing industry

• Only 1 cardiological department!

An integrated project with the:

• Italian Ministry of Health

• Italian National Institute of Health

• University and Hospital of Ferrara

• Regional Health Government

• Ferrara Municipality and District Councils

Ferrara: City of Prevention

An integrated project with the:

• GVM Hospitals of Care and

Research

• Anna Maria Sechi Foundation

• Various patient associations

• Hospitality and catering industry

• Fruit and vegetable industry

• Fishing industry

Ferrara: City of Prevention

An integrated project of:

• Surveillance of disease burden

• Preventative action at population

and individual levels

• Assessment of the efficacy

Ferrara: City of Prevention

Surveillance: determination of risk

chart of different populations:

• Cultured “Arte e Prevenzione”

• Specialised Ferrara Hospital

• Daily life Supermarkets

• Workers Mechanic industry

Ferrara: City of Prevention

We calculated the risk chart

of visitors to the first

exhibition of the Hermitage

Foundation on “Garofalo”

at the Estense Castle.

Benvenuto Tisi detto il Garofalo

Le Nozze di Cana di Galilea, 1531

Olio su tela, cm 306x248

San Pietroburgo, Museo Statale

Ermitage

Benvenuto Tisi detto il Garofalo

Allegoria di Ercole d’Este e di

Ferrara, 1534

Olio su tela, cm 86x116

Vienna, Liechtenstein Museum

Two risk charts:

• The Italian Ministry of Health

• Ours, enriched by BMI, abdominal circumference, HR, anamstetic and educational data

• Determined by cardiologist, audited by Italian National Institute of Health

•The experience will be

repeated yearly.

•100 individuals at very low

and very high risk will have

regular CV check-ups.

Objectives

•Determine the prevalence of cardiovascular risk factors in a population of motivated subjects attending the “Garofalo” exhibition.

•4208 medical records

Outcome

Measures

How many – likely low-risk

individuals – are on target for CV

disease prevention as per:

• Italian National Institute of Health

• 2007 Joint ESC Guidelines on

CVD Prevention

73% 73% 73%

0%

20%

40%

60%

80%

100%

N=3072

ALL MEN WOMEN

N=1405 N=1677

% with high level of education

17% 18% 16%

0%

20%

40%

60%

80%

100%

N=704

ALL MEN WOMEN

N=340 N=364

% of smokers

Prevalence of

diabetes, elevated

blood pressure

and lipids.

3% 3% 2%

0%

20%

40%

60%

80%

100%

N=144

ALL MEN WOMEN

N=56 N=48

% of diabetes

56%50%

61%

0%

20%

40%

60%

80%

100%

N=2370

ALL MEN WOMEN

N=973 N=1397

% of Heart Rate > 70 bpm

Even in the low-risk population studied

• hypertension

• overweight

• sedentary

• optimal HR

are not at target – they are a lifestyle problem

Therefore

Ferrara: City of Prevention

Preventative action

University

and

GVM

FASC

Foundation,

School of

Prevention

Food

Industry

National

TV

Frozen

Products

Industry

University

and

GVM

FASC

Foundation,

School of

Prevention

Food

Industry

Dedicated

Health

Channel

Frozen

Products

Industry

Ferrara: City of Prevention

Preventative action

University

and

GVM

FASC

Foundation,

School of

Prevention

Production

of adequate

food

Dedicated

Health

Channel

Frozen

Products

Industry

Ferrara: City of Prevention

Preventative action

University

and

GVM

FASC

Foundation,

School of

Prevention

Production

of adequate

food

Dedicated

Health

Channel

Frozen

adequate

menus

Ferrara: City of Prevention

Preventative action

University

and

GVM

Awareness

Website

Professionals

Books

Production

of adequate

food

Dedicated

Health

Channel

Frozen

adequate

menus

Ferrara: City of Prevention

Preventative action

Preventative individual action

• Creation of “home of prevention”

strategically located – Palazzo

Turchi di Bagni in front of the

Palazzo dei Diamanti in the heart

of the city

Ferrara: City of Prevention

Ferrara: Home of prevention – what is it?

•A place where citizens

can assess their

individual cardiovascular

risk whenever they want.

Ferrara: Home of prevention – what is it?

• A place where ad hoc trained

personnel (from the school)

dedicate time to citizens to

help them remain healthy and

to provide suggestions to

high risk patients.

Ferrara: The home of prevention – what is it?

• A place to learn how to:

stop smoking

shop for appropriate ingredients

prepare appropriate menus

exercise

Ferrara: The home of prevention – what is it?

•A place with an operative

kitchen for proper cookery

courses.

•A place where educational

material can be found.

• Website: “Cuore al Centro”

• TV: 1 hour daily education at a national level.

• Constitution of a university certified digital health channel

Ferrara: City of Prevention Global preventative action

•Preparation of frozen portions of adequate food

•Production of heart healthy bread and cakes

•Preparation of adequate frozen menus for hospitals

Ferrara: City of Prevention Global preventative action

White, no salt, high omega3, fibres and… tasty!

•The concept will be exported to ten cities where GVM is operating.

•Data will be horizontally collected yearly for at least 10 years and compared with the general population.

Ferrara: City of Prevention Project assessment

• This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning…

• We hope in 10 years to:

understand how and why people make the wrong decision regarding diet and lifestyle

convince a city to have the courage to advocate policy changes for the better

produce a model for CV prevention

Conclusion

Conclusion

Roberto Ferrari

25% 23%26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

N=1037

17%18% 16%

ALL MEN WOMEN

N=450 N=587

% of sedentary

METTERE INSIEME A ADDOMINAL OBESIY

46%

36%

55%

0%

20%

40%

60%

80%

100%

N=1948

18% 16%

ALL MEN WOMEN

N=689 N=1259

% of abdominal obesity(Waist circumference > 102 cm in Men and > 88 cm in Women)

49%

37%

58%

0%

20%

40%

60%

80%

100%

N=2051

BMI < 25

ALL MEN WOMEN

N=722 N=1329

% with BMI < 25

METTERE INSIEME i 3 BMI

35%

45%

26%

0%

20%

40%

60%

80%

100%

N=1475

25 < BMI < 30

ALL MEN WOMEN

N=881 N=594

% with 25 < BMI < 30

12% 12% 12%

0%

20%

40%

60%

80%

100%

N=489

BMI > 30

ALL MEN WOMEN

N=236 N=253

% with BMI > 30

60%

51%

67%

0%

20%

40%

60%

80%

100%

N=2505

% with DBP < 90 mmHg AND

SBP < 140 mmHg

ALL MEN WOMEN

N=987 N=1518

6% 9%4%

0%

20%

40%

60%

80%

100%

N=267

90 < DBP < 95 mmHg AND

140 < SBP < 160 mmHg

ALL MEN WOMEN

N=181 N=86

% with 90 < DBP < 95 mmHg

and 140 < SBP < 160 mmHg

4% 5% 3%

0%

20%

40%

60%

80%

100%

N=152

DBP > 95 mmHg AND

SBP > 160 mmHg

ALL MEN WOMEN

N=100 N=52

% with DBP > 95 mmHg

and SBP > 160 mmHg

61%

69%

55%

0%

20%

40%

60%

80%

100%

N=2582

Total Cholesterol < 200 mg/dl

ALL MEN WOMEN

N=1331 N=1251

% with Total Cholesterol < 200 mg/dl

27%22%

30%

0%

20%

40%

60%

80%

100%

N=1099

200 < Total Cholesterol < 240

mg/dl

ALL MEN WOMEN

N=422 N=677

% with 200 < Tot Cholesterol < 240 mg/dl

12%9%

13%

0%

20%

40%

60%

80%

100%

N=435

Total Cholesterol ≥ 240

mg/dl

ALL MEN WOMEN

N=141 N=294

% with total cholesterol ≥ 240 mg/dl

CARTA DEL RISCHIO

ISTITUTO SUPERIORE DI SANITA’

3346 SUBJECTS, AGE 40 - 69

12%

28%

22%

5%

0%

4%

10%

4%

0% 0%

5%4%

0% 0%

2%1%

0% 0%1% 1%

0%

5%

10%

15%

20%

25%

30%

40-44 45-54 55-64 65-69

Years

risk <5% risk 5-10% risk 10-15%

risk 15-20% risk 20-30% risk >30%

CV RISK – EUROSCORE

3753 SUBJECTS ELIGIBLE TO

EUROSCORE

4%

9%

8%

1%

0% 0%0%

3%

12%

14%

5%

1%

0% 0%

5%

14%

11%

3%

0% 0% 0%

2%

4%

3%

0%

4%

8%

12%

16%

20%

<35 35-44 45-54 55-64 65-74 >=75

Years

risk 5% risk 5-10% risk 10-20% risk 20-40%

37% 34%40%

0%

20%

40%

60%

80%

100%

N=1553

ALL MEN WOMEN

N=653 N=900

% with familiarity for CVD

64

276

499 572391

13096

287

611

759

418

105

0

200

400

600

800

1000

1200

1400

< 35 35 - 44 45 - 54 55 - 64 65 - 74 ≥ 75

Years

Vis

ito

rs

Age and gender MEN

WOMEN

LIFESTYLE