Cardiovascular Disease Prevention in Indonesia: Epidemiology, Risk Factors, Organization of Care and Prevention

Abstract

This thesis explores the epidemiology, risk factors, and healthcare services associated with cardiovascular disease (CVD) in Indonesia, focusing on the disease burden and the capacity of healthcare systems. The first part emphasizes the high prevalence of modifiable risk factors, such as smoking, unhealthy diets, low physical activity, mental health disorders, obesity, hypertension, diabetes, and dyslipidemia. These risk factors vary significantly based on age, sex, and the presence of existing CVD. In addition, CVD patients often experience multiple risk factors, which highlights the urgent need for comprehensive strategies to manage these risks. Machine learning techniques applied to national health data identified significant predictors of obesity, including dietary and lifestyle factors, with notable regional variations across Indonesia’s diverse population. These findings underscore the importance of tailoring interventions to address local needs and disparities in risk factor prevalence and behaviors to prevent disease such as obesity. The study also highlights the substantial risk of recurrent CVD events among individuals with established disease. Using the SMART2 risk score, it was found that 65% of patients with CVD were at very high risk of experiencing fatal or non-fatal events within ten years. Despite guideline-recommended treatments, a significant proportion of these individuals remain at elevated risk, with younger patients and those without diabetes benefiting most from interventions. Furthermore, only 1.8% of patients achieved all the recommended treatment targets, and LDL cholesterol management showed the lowest achieved, with only 5.1% of patients reaching the desired treatment target. These findings suggest that the current “one-size-fits-all” approach to managing high-risk individuals is inadequate, emphasizing the need for personalized care and the use of validated risk stratification tools to optimize treatment outcomes. The second part of the thesis focuses on the healthcare system’s capacity to manage CVD in Indonesia. It reveals significant shortcomings in primary care, with limited availability of essential medications and diagnostic tools, as assessed using the World Health Organization’s Service Availability and Readiness Assessment (SARA). These deficiencies contribute to the poor quality of care for CVD patients. However, the implementation of Indonesia’s National Health Insurance (NHI) program has shown promising outcomes, particularly in reducing in-hospital mortality for acute coronary syndrome (ACS) patients. Improvements in treatment accessibility, reduced time to intervention, and adherence to clinical guidelines were observed following NHI implementation, resulting in better survival rates and care quality for hospitalized patients. To address the ongoing challenges, particularly in the population with established CVD, the PIENTER study was initiated. This prospective observational cohort aims to monitor recurrent CVD events, assess care standards, and establish a comprehensive database to track changes in risk factors among these patients. The study seeks to provide valuable insights into disease progression and inform strategies to improve patient outcomes and healthcare practices in Indonesia. Overall, the thesis underscores the urgent need for targeted interventions, strengthened healthcare infrastructure, and robust data-driven approaches to reduce the burden of CVD in the country. By addressing both epidemiological and healthcare system challenges, the findings provide a roadmap for improving prevention and care for CVD in Indonesia.