international guidelines for prevention of atherosclerotic cardiovascular disease

International Guidelines for Prevention of Atherosclerotic

Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic

Cardiovascular Disease

Prof. Mohamed Sobhy, MD, FACCProfessor of Cardiology, Alex. UniversityFellow of American College of Cardiology

Prof. Mohamed Sobhy, MD, FACCProfessor of Cardiology, Alex. UniversityFellow of American College of Cardiology

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Guidelines:Aim to present all the relevant evidence on a

particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or

therapeutic procedure.They should be helpful in everyday clinical decision-

making.

Guidelines:Aim to present all the relevant evidence on a

particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or

therapeutic procedure.They should be helpful in everyday clinical decision-

making.

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Prevention programs.

Public health Challenges and Community programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Prevention programs.

Public health Challenges and Community programs.

The Rationale for an active approach to the prevention of cardiovascular diseases (CVD) is firmly based on five observations:

The Rationale for an active approach to the prevention of cardiovascular diseases (CVD) is firmly based on five observations:

CVD is the major cause of premature death in most populations; it is an important source of disability and contributes in large part to the escalating

costs of health carethe underlying pathology is usually atherosclerosis, which develops

insidiously over many years and is usually advanced by the time symptoms occur

death, myocardial infarction and stroke nevertheless frequently occur suddenly and before medical care is available, and many therapeutic

interventions are therefore inapplicable or palliative the mass occurrence of CVD relates strongly to lifestyles and modifiable

physiological factors risk factor modifications have been unequivocally shown to reduce mortality and morbidity, especially in people with either unrecognized or recognized

CVD.

CVD is the major cause of premature death in most populations; it is an important source of disability and contributes in large part to the escalating

costs of health carethe underlying pathology is usually atherosclerosis, which develops

insidiously over many years and is usually advanced by the time symptoms occur

death, myocardial infarction and stroke nevertheless frequently occur suddenly and before medical care is available, and many therapeutic

interventions are therefore inapplicable or palliative the mass occurrence of CVD relates strongly to lifestyles and modifiable

physiological factors risk factor modifications have been unequivocally shown to reduce mortality and morbidity, especially in people with either unrecognized or recognized

CVD.

Objectives of Cardiovascular PreventionObjectives of Cardiovascular Prevention

To reduce the incidence of first or recurrent clinical events due to coronary heart disease, ischemic

stroke and peripheral artery disease.The focus is prevention of disability and early

death.Lifestyle changes, management of major CV

factors, use of different prophylactic drug therapies.Intermediate end-points… subclinical organ

damage [LVH, CA plaque, ED, electrical instability]

To reduce the incidence of first or recurrent clinical events due to coronary heart disease, ischemic

stroke and peripheral artery disease.The focus is prevention of disability and early

death.Lifestyle changes, management of major CV

factors, use of different prophylactic drug therapies.Intermediate end-points… subclinical organ

damage [LVH, CA plaque, ED, electrical instability]

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Recent international guidelinesRecent international guidelines

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

Recent international guidelinesRecent international guidelines

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

Recent international guidelinesRecent international guidelines

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

Recent international guidelinesRecent international guidelines

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

Canadian Cardiovascular Society 1998 Consensus Conference On The Prevention Of Cardiovascular Diseases:

The Role Of The cardiovascular Specialist

Recommendations for assessment with fasting lipid profile (total cholesterol, high density lipoprotein cholesterol, triglyceride and low

density lipoprotein levels) in various patient groups

Recommendations for assessment with fasting lipid profile (total cholesterol, high density lipoprotein cholesterol, triglyceride and low

density lipoprotein levels) in various patient groups

Patient group Frequency

Patients with coronary artery disease, CAD or peripheral vascular disease

Annually

Patients with xanthomata or a family history of early CAD with genetic dyslipidemia

One measurement during youth, repeated at age 30 years; if no evidence of genetic dyslipidemia, resume testing every five years from age 40 (for men) or 50 (for women)

Adults with diabetes Repeat every one to three years or as clinically indicated

Men aged 40 to 70 years, women aged 50 to 70 years

Every five years

Clinical judgement should be used for patients with multiple risk factors who are approaching these target ages. Note that the translation of number of risk factors into risk

levels is incorrect outside of these age ranges. CAD Coronary artery disease

Recent international guidelinesRecent international guidelines

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

Recent international guidelinesRecent international guidelines

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

Editorial

New British recommendations for prevention of coronary heart disease in clinical practice

Heart 1999; 81:335 (April)

Priorities for CHD prevention in clinical Practice

Priorities for CHD prevention in clinical Practice

1. A. Patients with established CHD.B. Patients with other major atherosclerotic

disease.2. Patients with HTN, dyslipidemia, DM, FH of

premature CHD or combination.

1. A. Patients with established CHD.B. Patients with other major atherosclerotic

disease.2. Patients with HTN, dyslipidemia, DM, FH of

premature CHD or combination.

Using the coronary risk prediction chart for primary prevention

Using the coronary risk prediction chart for primary prevention

Charts are not appropriate for:Coronary Heart Disease or other major atherosclerotic

disease.Familial hypercholeserolemia or other inherited

dyslipidemiaEstablished hypertension (Systolic >160mmHg or

diastolic > 100mmHg or associated TOD)DM with associated TOD

Renal dysfunction

Charts are not appropriate for:Coronary Heart Disease or other major atherosclerotic

disease.Familial hypercholeserolemia or other inherited

dyslipidemiaEstablished hypertension (Systolic >160mmHg or

diastolic > 100mmHg or associated TOD)DM with associated TOD

Renal dysfunction

People at high risk without clinically overt CHD or other major atherosclerotic disease People at high risk without clinically overt

CHD or other major atherosclerotic disease Patients with HTN, dyslipidemia, diabetes mellitus,

FH of premature CHD or combination are at high risk of developing CHD

Patients with DM are at particularly high risk Individuals at high multifactorial risk of developing

CHD or other atherosclerotic disease As absolute risk of coronary heart disease

increases, so lifestyle intervention should be intensified

Patients with HTN, dyslipidemia, diabetes mellitus, FH of premature CHD or combination are at high

risk of developing CHDPatients with DM are at particularly high risk

Individuals at high multifactorial risk of developing CHD or other atherosclerotic disease

As absolute risk of coronary heart disease increases, so lifestyle intervention should be

intensified

New British recommendations for prevention of coronary heart disease in clinical practiceNew British recommendations for prevention of coronary heart disease in clinical practice

The joint British recommendations on prevention of coronary heart disease in clinical practice closely

mirror the European guidelines.The difference reflect intelligent adaptations to

national conditions and concerns The recommendations concerning primary

prevention are based on the assessment of risk, in absolute terms of developing clinical coronary

disease within the next year

The joint British recommendations on prevention of coronary heart disease in clinical practice closely

mirror the European guidelines.The difference reflect intelligent adaptations to

national conditions and concerns The recommendations concerning primary

prevention are based on the assessment of risk, in absolute terms of developing clinical coronary

disease within the next year

The assessment is based onThe assessment is based on

Framingham risk function (age, sex, smoking status, SBP, lipids measurements)

British recommend ratio of total HDLLevel of risk at which to intervene in primary

preventionEuropean recommends 10 year risk of CHD 20%

British a staged approachHigh risk >30%

Low risk 15%

Framingham risk function (age, sex, smoking status, SBP, lipids measurements)

British recommend ratio of total HDLLevel of risk at which to intervene in primary

preventionEuropean recommends 10 year risk of CHD 20%

British a staged approachHigh risk >30%

Low risk 15%

BP …. Based on BP alone rather than BP in the context of absolute CV risk.

British recommendations:BP>160/110 mmHg should be lowered irrespective of

other factors because of established benefit in reducing the cerebrovascular component of CV risk

15% risk of CHD corresponds to 20% overall CV risk.

In persons of BP 140-160/90-100 mmHg. British Society starts treatment when risk of CAD >15%

BP …. Based on BP alone rather than BP in the context of absolute CV risk.

British recommendations:BP>160/110 mmHg should be lowered irrespective of

other factors because of established benefit in reducing the cerebrovascular component of CV risk

15% risk of CHD corresponds to 20% overall CV risk.

In persons of BP 140-160/90-100 mmHg. British Society starts treatment when risk of CAD >15%

Introducing drug treatment for raised BP or lipid concentration should be strongly determined by the

absolute risk of developing disease.An absolute risk of coronary heart disease >15% (equivalent to a CV risk of 20%) over 10 years is

sufficiently high to justify drug treatment.

Introducing drug treatment for raised BP or lipid concentration should be strongly determined by the

absolute risk of developing disease.An absolute risk of coronary heart disease >15% (equivalent to a CV risk of 20%) over 10 years is

sufficiently high to justify drug treatment.

Exceptions to treatment based on absolute risk are:Exceptions to treatment based on absolute risk are:

Hypertension (SBP>160mmHg or diastolic BP>100mmHg) or HTN with associated target

organ damage.Familial hypercholestrolemia or other inherited

dyslipidemia.Diabetes Mellitus with associated target organ

damage.Drug treatment is required for all these patients to

reduce the risk of CHD (and CV risk).

Hypertension (SBP>160mmHg or diastolic BP>100mmHg) or HTN with associated target

organ damage.Familial hypercholestrolemia or other inherited

dyslipidemia.Diabetes Mellitus with associated target organ

damage.Drug treatment is required for all these patients to

reduce the risk of CHD (and CV risk).

A staged approach to managing patients at high risk is advised.

As a minimum, those with absolute CHD risk >30% should be targeted and treated now.

As resources allow individuals with a risk >15% should be progressively targeted

For all high risk patients every effort should be made to achieve the lifestyle, risk factor and

therapeutic targets.

A staged approach to managing patients at high risk is advised.

As a minimum, those with absolute CHD risk >30% should be targeted and treated now.

As resources allow individuals with a risk >15% should be progressively targeted

For all high risk patients every effort should be made to achieve the lifestyle, risk factor and

therapeutic targets.

Recent international guidelinesRecent international guidelines

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

American College of Cardiology (ACC)2001 update

American Heart Association (AHA)2002 update

CANADIAN Cardiovascular Society 1998 Consensus.

International Task Force for prevention of Coronary heart disease

Joint British recommendation for prevention of CHD2002

European guidelines on CVD prevention in clinical practice2003

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of high total risk for developing fatal cardiovascular event.

Definition of high total risk for developing fatal cardiovascular event.

Patients with established cardiovascular disease.Asymptomatic subjects who have

2-1 Multiple risk factors resulting in a 10 year risk ≥ 5% now or if extrapolated to age 60.

2-2 Markedly raised levels of single risk factors: total cholesterol(320 mg/dl), LDL (240 mg/dl), BP ≥

180/140 mmHg 2-3 Diabetes type 2 and diabetes type 1 with

microalbuminuria.

Patients with established cardiovascular disease.Asymptomatic subjects who have

2-1 Multiple risk factors resulting in a 10 year risk ≥ 5% now or if extrapolated to age 60.

2-2 Markedly raised levels of single risk factors: total cholesterol(320 mg/dl), LDL (240 mg/dl), BP ≥

180/140 mmHg 2-3 Diabetes type 2 and diabetes type 1 with

microalbuminuria.

New imaging methods to detect asymptomatic individuals at high risk for cardiovascular eventsNew imaging methods to detect asymptomatic

individuals at high risk for cardiovascular events

Coronary Calcification (EC-CT or MS-CT)Carotid-intimal median thickness

LVH (ECG, echo)

Coronary Calcification (EC-CT or MS-CT)Carotid-intimal median thickness

LVH (ECG, echo)

Management of CVD risk in clinical practice:Management of CVD risk in clinical practice:

Behavioral risk factorsStop smoking tobacco

Make healthy food choices Increase physical activity

Management of other risk factors:Overweight and obesity

Blood pressurePlasma lipids

DiabetesScreening close relatives

Behavioral risk factorsStop smoking tobacco

Make healthy food choices Increase physical activity

Management of other risk factors:Overweight and obesity

Blood pressurePlasma lipids

DiabetesScreening close relatives

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Why Egyptian Guidelines are mandatory?Why Egyptian Guidelines are mandatory?

Religion Habits

Cost-benefit ratioRole of university

Role of physiciansRole of Ministry of Health

Religion Habits

Cost-benefit ratioRole of university

Role of physiciansRole of Ministry of Health

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

When public intervention strategies address the diversity of racial, ethnic, cultural, linguistic,

religions, and social factors in the delivery of their services, the like hood of their acceptance by

community increases.

When public intervention strategies address the diversity of racial, ethnic, cultural, linguistic,

religions, and social factors in the delivery of their services, the like hood of their acceptance by

community increases.

Public health approach can provide an attractive opportunity to interrupt and prevent the continuing

costly of cycle preventing atherosclerotic cardiovascular disease and its complications.

Public health approach can provide an attractive opportunity to interrupt and prevent the continuing

costly of cycle preventing atherosclerotic cardiovascular disease and its complications.

Public health challenge and community programs

Public health challenge and community programs

Public health approaches, such as reducing calories, saturated fat and salt in processed food

Increasing community and school opportunities for physical activity can achieve a downward shift in the

distribution of population’s BP, reduce morbidity, mortality and the lifetime risk of an individual becoming

hypertensive.Food manufactures and restaurants should reduce sodium

in food supply by 50% during the next decade

Public health approaches, such as reducing calories, saturated fat and salt in processed food

Increasing community and school opportunities for physical activity can achieve a downward shift in the

distribution of population’s BP, reduce morbidity, mortality and the lifetime risk of an individual becoming

hypertensive.Food manufactures and restaurants should reduce sodium

in food supply by 50% during the next decade

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

International Guidelines for Prevention of Atherosclerotic Cardiovascular Disease

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Definition of guidelines.Rationale and objectives of guidelines.

What are the international guidelines for prevention of atherosclerotic CVD

Total CV risk as a guide to preventive strategies.Management of CV risk as a guide to preventive strategies

Importance of Egyptian guidelines.Public health Challenges and Community programs.

Prevention programs.

Prevention programsPrevention programs

Current programsBridge the gap (clinical trials application)

E Quit, computers soft ware Strengths

Nationally and internationally recognized physician researchersA medical clinic staffed by registered nurses and certified medical

technicianProject managers and site monitors experienced with managing and

running clinical trials A data coordinating center to collect, input and analyze data generated from

prevention researchAffiliation with some of the major medical research and healthcare

providers.Make a contribution, Foundations and individuals

Current programsBridge the gap (clinical trials application)

E Quit, computers soft ware Strengths

Nationally and internationally recognized physician researchersA medical clinic staffed by registered nurses and certified medical

technicianProject managers and site monitors experienced with managing and

running clinical trials A data coordinating center to collect, input and analyze data generated from

prevention researchAffiliation with some of the major medical research and healthcare

providers.Make a contribution, Foundations and individuals