Cardiovascular risk and events in 17 low-, middle-, and high-income countries

Prevalence, awareness, treatment and control of hypertension in four Middle East countries

OBJECTIVE

We report the prevalence, awareness, treatment, and control of hypertension across four Middle Eastern countries (Iran, Occupied Palestinian Territory, Saudi Arabia, and United Arab Emirates), using a standardized and uniform method.

METHODS

The Prospective Urban Rural Epidemiology study enrolled participants from 52 urban and 35 rural communities from four countries in the Middle East. We report results using definitions of hypertension, prevalence, awareness, treatment, and control, and the standards for uniform reporting of hypertension in adults as recently recommended by the World Hypertension League expert committee.

RESULTS

Data for analyses were available on 10 516 participants, of whom 5082 (48%) were men. The mean age was 49 (±9.4) years for men and 48 (±9.3) years among women. A total of 3270 participants had hypertension (age-standardized rates, 33%), and n = 1807 (49%) of these participants were aware of their diagnosis. Of those with hypertension, n = 1754, (47%) were treated and only n = 673, (19%) had controlled blood pressure levels. Only 17% (n = 541) of those treated for hypertension received two or more blood pressure-lowering medications and 15% (n = 499) received statins. The prevalence, awareness, treatment, and control of blood pressure were higher among women and older (50-69 years) participants compared with men and younger individuals (30-49 years) (P < 0.0001 for all). The prevalence was higher in rural communities; however, awareness, treatment, and control were significantly higher among urban dwellers.

CONCLUSION

Findings from this study indicate the need for improvements in hypertension diagnosis and treatment in the Middle East, especially in rural communities, men and younger individuals.

SIRT3: A New Regulator of Cardiovascular Diseases

Cardiovascular diseases (CVDs) are the leading causes of death worldwide, and defects in mitochondrial function contribute largely to the occurrence of CVDs. Recent studies suggest that sirtuin 3 (SIRT3), the mitochondrial NAD⁺-dependent deacetylase, may regulate mitochondrial function and biosynthetic pathways such as glucose and fatty acid metabolism and the tricarboxylic acid (TCA) cycle, oxidative stress, and apoptosis by reversible protein lysine deacetylation. SIRT3 regulates glucose and lipid metabolism and maintains myocardial ATP levels, which protects the heart from metabolic disturbances. SIRT3 can also protect cardiomyocytes from oxidative stress-mediated cell damage and block the development of cardiac hypertrophy. Recent reports show that SIRT3 is involved in the protection of several heart diseases. This review discusses the progress in SIRT3-related research and the role of SIRT3 in the prevention and treatment of CVDs.

Cardiovascular risk factor burden in Africa and the Middle East across country income categories: a post hoc analysis of the cross-sectional Africa Middle East Cardiovascular Epidemiological (ACE) study

Background

A significant number of cardiovascular disease (CVD)-related deaths occur in developing countries. An increasing prevalence of CVD is associated with a change in the macro-economy of these countries. In this post hoc analysis, CVD risk factor (CVDRF) prevalence is evaluated across countries based on national income in the Africa and Middle East Region (AfME).

Methods

Data from the Africa Middle East Cardiovascular Epidemiological (ACE) study were used; a cross-sectional study in 14 AfME countries (94 clinics) from July 2011–April 2012, which evaluated CVDRF prevalence in stable adult outpatients. World Bank definitions were used to classify countries as low-income (LI), lower-middle-income (LMI), upper-middle-income (UMI) or high-income (HI) countries. Four thousand three hundred seventy-eight subjects were recruited where 260 (6%), 1324 (30%), 1509 (35%) and 1285 (29%) were from LI, LMI, UMI, and HI countries, respectively.

Results

Of all the CVDRFs evaluated, almost two-thirds of the study population across the national income groups had abdominal obesity and dyslipidemia. Countries in the HI category were associated with a higher prevalence of diabetes (32%), obesity (44%) and smoking (16%). UMI and HI countries were associated with higher clustering of CVDRFs where at least one-third of subjects having four or more CVDRFs. Lower income countries had lower blood pressure control rates and lower percentages of outpatients achieving LDL-cholesterol targets.

Conclusion

The burden of CVDRFs in stable outpatients is high across the national income categories in the AfME region, with HI countries showing a higher prevalence of CVDRFs. The high burden in lower income countries is associated with sub-optimal control of dyslipidemia and hypertension. Lowering the CVDRF burden would need specific public health actions in line with positive changes in the macro-economy of these countries.

Trial registration

The ACE trial is registered under NCT01243138.

National Prevalence of Self-Reported Coronary Heart Disease and Chronic Stable Angina Pectoris: Factor Analysis of the Underlying Cardiometabolic Risk Factors in the SuRFNCD-2011

BACKGROUND

Coronary heart disease (CHD) is one of the most common causes of mortality worldwide. The national prevalence remains unclear in most of the developing countries.

OBJECTIVE

This study sought to estimate national prevalence of self-reported CHD and chronic stable angina pectoris in the general adult population of Iran using data from the fourth round of the Surveillance of Risk Factors of Non-Communicable Diseases (SuRFNCD-2011) survey.

METHODS

The analysis comprised data of 11,867 civilian, nonhospitalized and noninstitutionalized residents ages 6 to 70 years of age. The calculated prevalence of self-reported CHD and chronic stable angina pectoris were extrapolated to the Iranian adult population who were >20 years old using the complex sample analysis. The factor analysis was performed for clustering of the associated cardiometabolic risk factors among people ages >40 years of age.

RESULTS

The estimated national prevalence of self-reported CHD and chronic stable angina pectoris were 5.3% (95% confidence interval: 4.6 to 5.9) and 7.7% (95% confidence interval: 4.6 to 8.7), respectively. Higher prevalence of these conditions were observed among the older people, urban residents, and women. Factor analysis generated 4 distinct factors that were mainly indicators of dyslipidemia, hypertension, central obesity, hyperglycemia, and tobacco smoking. The factor incorporating hypertension was a significant correlate of self-reported CHD.

CONCLUSIONS

We report concerning prevalence of self-reported CHD and chronic stable angina pectoris in the adult population of Iran. The constellation of raised systolic and diastolic blood pressures was significantly predictive of the presence of self-reported CHD.

Does greater individual social capital improve the management of hypertension? Cross-national analysis of 61 229 individuals in 21 countries

Introduction

Social capital, characterised by trust, reciprocity and cooperation, is positively associated with a number of health outcomes. We test the hypothesis that among hypertensive individuals, those with greater social capital are more likely to have their hypertension detected, treated and controlled.

Methods

Cross-sectional data from 21 countries in the Prospective Urban and Rural Epidemiology study were collected covering 61 229 hypertensive individuals aged 35–70 years, their households and the 656 communities in which they live. Outcomes include whether hypertensive participants have their condition detected, treated and/or controlled. Multivariate statistical models adjusting for community fixed effects were used to assess the associations of three social capital measures: (1) membership of any social organisation, (2) trust in other people and (3) trust in organisations, stratified into high-income and low-income country samples.

Results

In low-income countries, membership of any social organisation was associated with a 3% greater likelihood of having one’s hypertension detected and controlled, while greater trust in organisations significantly increased the likelihood of detection by 4%. These associations were not observed among participants in high-income countries.

Conclusion

Although the observed associations are modest, some aspects of social capital are associated with better management of hypertension in low-income countries where health systems are often weak. Given that hypertension affects millions in these countries, even modest gains at all points along the treatment pathway could improve management for many, and translate into the prevention of thousands of cardiovascular events each year.

Trends in Coronary Heart Disease Epidemiology in India

Cardiovascular diseases, especially coronary heart disease (CHD), are epidemic in India. The Registrar General of India reported that CHD led to 17% of total deaths and 26% of adult deaths in 2001-2003, which increased to 23% of total and 32% of adult deaths in 2010-2013. The World Health Organization (WHO) and Global Burden of Disease Study also have highlighted increasing trends in years of life lost (YLLs) and disability-adjusted life years (DALYs) from CHD in India. In India, studies have reported increasing CHD prevalence over the last 60 years, from 1% to 9%-10% in urban populations and <1% to 4%-6% in rural populations. Using more stringent criteria (clinical ± Q waves), the prevalence varies from 1%-2% in rural populations and 2%-4% in urban populations. This may be a more realistic prevalence of CHD in India. Case-control studies have reported that important risk factors for CHD in India are dyslipidemias, smoking, diabetes, hypertension, abdominal obesity, psychosocial stress, unhealthy diet, and physical inactivity. Suitable preventive strategies are required to combat this epidemic.

Normal LDL-Cholesterol Levels Are Associated With Subclinical Atherosclerosis in the Absence of Risk Factors

BACKGROUND

Absence of cardiovascular risk factors (CVRFs) is traditionally considered low risk for atherosclerosis; however, individuals without CVRFs, as currently defined, still have events.

OBJECTIVES

This study sought to identify predictors of subclinical atherosclerosis in CVRF-free individuals.

METHODS

Participants from the PESA (Progression of Early Subclinical Atherosclerosis) study (n = 4,184) without conventional CVRFs were evaluated (n = 1,779; 45.0 ± 4.1 years, 50.3% women). CVRF freedom was defined as no current smoking and untreated blood pressure <140/90 mm Hg, fasting glucose <126 mg/dl, total cholesterol <240 mg/dl, low-density lipoprotein cholesterol (LDL-C) <160 mg/dl, and high-density lipoprotein cholesterol ≥40 mg/dl. A subgroup with optimal CVRFs (n = 740) was also defined as having blood pressure <120/80 mm Hg, fasting glucose <100 mg/dl, glycosylated hemoglobin <5.7%, and total cholesterol <200 mg/dl. We evaluated ultrasound-detected carotid, iliofemoral, and abdominal aortic plaques; coronary artery calcification; serum biomarkers; and lifestyle. Adjusted odds ratios (with 95% confidence interval) and ordinal logistic regression models were used.

RESULTS

Subclinical atherosclerosis (plaque or coronary artery calcification) was present in 49.7% of CVRF-free participants. Together with male sex and age, LDL-C was independently associated with atherosclerosis presence and extent, in both the CVRF-free and CVRF-optimal groups (odds ratio [×10 mg/dl]: 1.14 to 1.18; p < 0.01 for all). Atherosclerosis presence and extent was also associated in the CVRF-free group with glycosylated hemoglobin levels.

CONCLUSIONS

Many CVRF-free middle-aged individuals have atherosclerosis. LDL-C, even at levels currently considered normal, is independently associated with the presence and extent of early systemic atherosclerosis in the absence of major CVRFs. These findings support more effective LDL-C lowering for primordial prevention, even in individuals conventionally considered at optimal risk. (Progression of Early Subclinical Atherosclerosis [PESA] Study; NCT01410318).

Soft Tissue Surgery for Adults With Nonfunctional, Spastic Hands Following Central Nervous System Lesions: A Retrospective Study

PURPOSE

Soft tissue surgery for upper extremity contractures can improve hygiene, pain, and appearance in adults with central nervous system lesions. The goal of such interventions is highly individual; thus, goal attainment scaling (GAS; a method of scoring the extent to which patient's individual goals are achieved [5 levels] in the course of intervention and using T score values) is pertinent to evaluate outcome. The objective of this study was to assess the effect of soft tissue surgery for upper extremity muscle contractures in patients with central nervous system lesions using GAS.

METHODS

Retrospective data from 70 interventions were included (63 patients; 23 women). The mean age was 51.3 ± 16.2 years (range, 24.2-87.0 years). The primary goal was to improve hygiene (n = 58), pain (n = 10), or appearance (n = 2). The etiologies were stroke (n = 35), traumatic brain injury (n = 16), cerebral anoxia (n = 4), neurodegenerative disease (n = 6), and cerebral palsy (n = 2). The GAS score was calculated before surgery and 3 months after surgery.

RESULTS

The T score (which took into account the weight of each goal) was 52.3 at 3 months (38.5 before surgery), corresponding to a "better than expected" outcome. The mean of the differences of the GAS score for each goal before and after surgery increased by 1.27 for hygiene, 1.06 for pain, and 1.00 for appearance.

CONCLUSIONS

Soft tissue surgery can safely and effectively improve hygiene, pain, and appearance in adults with cerebral damage. The preoperative evaluation should be multidisciplinary. The GAS is a useful tool to assess the effectiveness of orthopedic surgery for these patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Implementing Evidence-Based Practices for Acute Stroke Care in Low- and Middle-Income Countries

PURPOSE OF REVIEW

Most strokes occur in low- and middle-income countries where resources to manage patients are limited. We explore the resources required to providing optimal acute stroke care and review barriers to implementing evidence-based stroke care in settings with limited resources using the World Stroke Organization's Global Stroke Services Action Plan framework.

RECENT FINDINGS

Major advances have been made during the past few decades in stroke prevention, treatment, and rehabilitation. These advances have been translated into practice in many high-income countries, but their uptake remains suboptimal in low- and middle-income countries. The review highlights the resources required to providing optimal acute stroke care in settings with limited resources. These resource levels were divided into minimal, essential, and advanced resources depending on the availability of stroke expertise, diagnostics, and facilities. Resources were described for the three stages of acute care: early diagnosis and management, acute management and prevention of complications, and early discharge and rehabilitation. Barriers to providing acute care at each of these stages in low- and middle-income countries are reviewed, explaining that some barriers persist in essential or advanced settings where some aspects of organized stroke units are available.

Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study

BACKGROUND

The relationship between macronutrients and cardiovascular disease and mortality is controversial. Most available data are from European and North American populations where nutrition excess is more likely, so their applicability to other populations is unclear.

METHODS

The Prospective Urban Rural Epidemiology (PURE) study is a large, epidemiological cohort study of individuals aged 35-70 years (enrolled between Jan 1, 2003, and March 31, 2013) in 18 countries with a median follow-up of 7·4 years (IQR 5·3-9·3). Dietary intake of 135 335 individuals was recorded using validated food frequency questionnaires. The primary outcomes were total mortality and major cardiovascular events (fatal cardiovascular disease, non-fatal myocardial infarction, stroke, and heart failure). Secondary outcomes were all myocardial infarctions, stroke, cardiovascular disease mortality, and non-cardiovascular disease mortality. Participants were categorised into quintiles of nutrient intake (carbohydrate, fats, and protein) based on percentage of energy provided by nutrients. We assessed the associations between consumption of carbohydrate, total fat, and each type of fat with cardiovascular disease and total mortality. We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random intercepts to account for centre clustering.

FINDINGS

During follow-up, we documented 5796 deaths and 4784 major cardiovascular disease events. Higher carbohydrate intake was associated with an increased risk of total mortality (highest [quintile 5] vs lowest quintile [quintile 1] category, HR 1·28 [95% CI 1·12-1·46], p_trend=0·0001) but not with the risk of cardiovascular disease or cardiovascular disease mortality. Intake of total fat and each type of fat was associated with lower risk of total mortality (quintile 5 vs quintile 1, total fat: HR 0·77 [95% CI 0·67-0·87], p_trend<0·0001; saturated fat, HR 0·86 [0·76-0·99], p_trend=0·0088; monounsaturated fat: HR 0·81 [0·71-0·92], p_trend<0·0001; and polyunsaturated fat: HR 0·80 [0·71-0·89], p_trend<0·0001). Higher saturated fat intake was associated with lower risk of stroke (quintile 5 vs quintile 1, HR 0·79 [95% CI 0·64-0·98], p_trend=0·0498). Total fat and saturated and unsaturated fats were not significantly associated with risk of myocardial infarction or cardiovascular disease mortality.

INTERPRETATION

High carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. Total fat and types of fat were not associated with cardiovascular disease, myocardial infarction, or cardiovascular disease mortality, whereas saturated fat had an inverse association with stroke. Global dietary guidelines should be reconsidered in light of these findings.

FUNDING

Full funding sources listed at the end of the paper (see Acknowledgments).

Albuminuria and kidney function as prognostic marker of left ventricular mass among South Asians with hypertension

We aimed to evaluate the association of albuminuria and estimated glomerular filtration rate (eGFR) at baseline and changes in these parameters with left ventricular mass index (LVMI) at 7 years in adults with hypertension from communities in Pakistan. A nested cohort of 539 hypertensives aged 40 years and older from a community-living population in Karachi, Pakistan, followed up for 7 years in the Control of Blood Pressure and Risk Attenuation trial. Urine spot albumin-to-creatinine ratio (UACR) and serum creatinine-based eGFR were assessed at baseline and 7 years, and echocardiography at 7 years. Mean age of participants was 50.9 ± 9.1 (standard deviation) years; 63% were female. Mean eGFR was 91.0 ± 15.9 (standard deviation) mL/min/1.73 m² and median (interquartile range) UACR 6.2 (3.9, 11.3) mg/g. In multivariate analysis, although baseline eGFR was marginally associated with LVMI, a strong association was found between higher LVMI with greater rate of decline in eGFR (β = -1.05; 95% confidence interval [CI]: [-1.94, -0.17]). Higher baseline UACR was significantly associated with higher follow-up LVMI (β = 2.26; 95% CI: [0.87, 3.65]), as was rate of UACR increase of ≥1.07 mg/g/y versus of <0.14 mg/g/y. (β = 4.19; 95% CI: [0.75, 7.63]). Associations with developing left ventricular hypertrophy were found for reduced baseline eGFR, higher baseline UACR, and greater rate of UACR increase, but not for rate of eGFR decline. Comparable results were observed for the outcomes of posterior wall thickness and septal wall thickness. Higher baseline albuminuria, lower baseline eGFR, and their longitudinal worsening were significantly associated with higher LVMI or the development of left ventricular hypertrophy among individuals with hypertension in Pakistan.

Disparities in Management of Cardiovascular Disease in Rural South Africa: Data From the HAALSI Study (Health and Aging in Africa: Longitudinal Studies of International Network for the Demographic Evaluation of Populations and Their Health Communities)

BACKGROUND

Optimal secondary prevention is critical for the reduction of repeated cardiovascular events, and the control of cardiovascular risk factors in this context is essential. Data on secondary prevention of cardiovascular disease (CVD) in sub-Saharan Africa are needed to inform intervention strategies with a particular focus on local disparities. The aim of this study was to assess CVD management in a rural community in northeast South Africa.

METHODS AND RESULTS

We recruited adults aged ≥40 years residing in the Agincourt subdistrict of Mpumalanga province. Data collection included socioeconomic and clinical data, anthropometric measures, blood pressure, human immunodeficiency virus status, and point-of-care glucose and lipid levels. CVD was defined as self-report of myocardial infarction and stroke or angina diagnosed by Rose Criteria. A linear regression model was built to identify variables independently associated with the number of cardiovascular risk factors controlled. Of 5059 subjects, 592 (11.7%) met CVD diagnostic criteria. Angina was reported in 77.0% of these subjects, stroke in 25.2%, and myocardial infarction in 3.7%. Percent controlled of the 5 individual risk factors assessed were as follows: tobacco 92.9%; blood pressure 51.2%; body mass index 33.8%; low-density lipoprotein 31.4%; and waist-to-hip ratio 29.7%. Only 4.4% had all 5 risk factors controlled and 42.4% had ≥3 risk factors controlled. Male sex (β coefficient=0.44; 95% confidence interval, 0.25-0.63; P<0.001), absence of physical disability (β coefficient=0.40; 95% confidence interval, 0.16-0.65; P=0.001), and socioeconomic status (β coefficient=0.10; 95% confidence interval, 0.01-0.19; P=0.035) were directly associated with the number of risk factors controlled.

CONCLUSIONS

Currently, CVD is not being optimally managed in this rural area of South Africa. There are significant disparities in control of CVD risk factors by sex, socioeconomic status, and level of disability. Efforts to improve secondary prevention in this population should be focused on females, subjects from lower socioeconomic status, and those with physical disabilities.

Urban-Rural Comparisons in Hospital Admission, Treatments, and Outcomes for ST-Segment-Elevation Myocardial Infarction in China From 2001 to 2011: A Retrospective Analysis From the China PEACE Study (Patient-Centered Evaluative Assessment of Cardiac Events)

BACKGROUND

In response to urban-rural disparities in healthcare resources, China recently launched a healthcare reform with a focus on improving rural care during the past decade. However, nationally representative studies comparing medical care and patient outcomes between urban and rural areas in China during this period are not available.

METHODS AND RESULTS

We created a nationally representative sample of patients in China admitted for ST-segment-elevation myocardial infarction in 2001, 2006, and 2011, using a 2-stage random sampling design in 2 urban and 3 rural strata. In China, evidence-based treatments were provided less often in 2001 in rural hospitals, which had lower volume and less availability of advanced cardiac facilities. However, these differences diminished by 2011 for reperfusion therapy (54% in urban versus 57% in rural; P=0.1) and reversed for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (66% versus 68%; P=0.04) and early β-blockers (56% versus 60%; P=0.01). The risk-adjusted rate of in-hospital death or withdrawal from treatment was not significantly different between urban and rural hospitals in any study year, with an adjusted odds ratio of 1.13 (0.77-1.65) in 2001, 0.99 (0.77-1.27) in 2006, and 0.94 (0.74-1.19) in 2011.

CONCLUSIONS

Although urban-rural disparities in evidence-based treatment for myocardial infarction in China have largely been eliminated, substantial gaps in quality of care persist in both settings. In addition, urban hospitals providing more resource-intensive care did not achieve better outcomes.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883.

Hypertension and Cardiovascular Risk Profile in a Middle-Income Setting: The HELISUR Study

BACKGROUND

Hypertension is the leading risk factor responsible for premature death worldwide, but its burden has shifted to low- and middle-income countries. Therefore, we studied hypertension and cardiovascular risk in the population of Suriname, a middle-income country with a predominantly urban population of African and Asian ancestry.

METHODS

A random sample of 1,800 noninstitutionalized men and women aged 18-70 years was selected to be interviewed at home and examined at the local hospital for cardiovascular risk factors, asymptomatic organ damage, and cardiovascular disease.

RESULTS

The 1,157 participants examined (37% men) were mainly of self-defined Asian (43%) or African (39%) ancestry, mean age 43 years (SD 14). The majority of the population (71%) had hypertension or prehypertension, respectively, 40% and 31%. Furthermore, 72% was obese or overweight, while 63% had diabetes or prediabetes. Only 1% of the adult population had an optimal cardiovascular risk profile. Hypertension awareness, treatment, and control were respectively 68%, 56%, and 20%. In line with this, 22% of the adult population had asymptomatic organ damage, including increased arterial stiffness, left ventricular hypertrophy, microalbuminuria, or asymptomatic chronic kidney disease.

CONCLUSIONS

In this first extensive cardiovascular assessment in the general population of this middle-income Caribbean country, high prevalence of hypertension with inadequate levels of treatment and control was predominant. The findings emphasize the need for collaborative effort from national and international bodies to prioritize the implementation of affordable and sustainable public health programs that combat the escalating hypertension and cardiovascular risk factor burden.

Perindopril arginine and amlodipine besylate for hypertension: a safety evaluation

INTRODUCTION

Controlling blood pressure is a global health priority; single-pill antihypertensive combinations may improve adherence, persistence, and outcomes. Areas covered: A novel combination of perindopril arginine and amlodipine besylate was recently approved. A systematic review of the literature revealed its most common adverse effects as: peripheral edema (depending on the dose of amlodipine, but attenuated by perindopril), cough, dizziness and hypotension. Dose-dependent hyperkalemia, impairment of renal function (especially in renovascular hypertension), angioedema, and teratogenicity were derived from experience with other ACE-inhibitors. Expert opinion: Substantial clinical trial experience with amlodipine or perindopril suggests that these two agents effectively lower blood pressure, and can reduce the risk of major adverse cardiovascular events, as in the Anglo-Scandinavian Cardiac Outcomes Trial. The incidence of adverse effects reported in clinical trials is lower than expected, likely due to exclusion of subjects previously exposed to its components; the nature of open-label, uncontrolled observational studies; and difficulty in recognizing and measuring cough and pedal edema. This new formulation of perindopril arginine protects its ethyl ester, without requiring physical separation from amlodipine in a single tablet, and is less hygroscopic than perindopril erbumine. These and other attributes may make this combination an attractive addition to the antihypertensive armamentarium.

Prognostic validation of a non-laboratory and a laboratory based cardiovascular disease risk score in multiple regions of the world

Objective

To evaluate the performance of the non-laboratory INTERHEART risk score (NL-IHRS) to predict incident cardiovascular disease (CVD) across seven major geographic regions of the world. The secondary objective was to evaluate the performance of the fasting cholesterol-based IHRS (FC-IHRS).

Methods

Using measures of discrimination and calibration, we tested the performance of the NL-IHRS (n=100 475) and FC-IHRS (n=107 863) for predicting incident CVD in a community-based, prospective study across seven geographic regions: South Asia, China, Southeast Asia, Middle East, Europe/North America, South America and Africa. CVD was defined as the composite of cardiovascular death, myocardial infarction, stroke, heart failure or coronary revascularisation.

Results

Mean age of the study population was 50.53 (SD 9.79) years and mean follow-up was 4.89 (SD 2.24) years. The NL-IHRS had moderate to good discrimination for incident CVD across geographic regions (concordance statistic (C-statistic) ranging from 0.64 to 0.74), although recalibration was necessary in all regions, which improved its performance in the overall cohort (increase in C-statistic from 0.69 to 0.72, p<0.001). Regional recalibration was also necessary for the FC-IHRS, which also improved its overall discrimination (increase in C-statistic from 0.71 to 0.74, p<0.001). In 85 078 participants with complete data for both scores, discrimination was only modestly better with the FC-IHRS compared with the NL-IHRS (0.74 vs 0.73, p<0.001).

Conclusions

External validations of the NL-IHRS and FC-IHRS suggest that regionally recalibrated versions of both can be useful for estimating CVD risk across a diverse range of community-based populations. CVD prediction using a non-laboratory score can provide similar accuracy to laboratory-based methods.

Circulating adipocyte fatty acid-binding protein is a predictor of cardiovascular events in patients with stable angina undergoing percutaneous coronary intervention

Background

Adipocyte fatty acid-binding protein (A-FABP) is expressed in both adipocytes and macrophages. Recent studies have shown that A-FABP is secreted by adipocytes and that the A-FABP concentration is associated with obesity, insulin resistance, and atherosclerosis. We have reported that the coronary atherosclerotic burden is associated with the serum A-FABP concentration. In the present study, we investigated whether the serum A-FABP concentration is associated with prognosis in patients with stable angina pectoris who have undergone percutaneous coronary intervention (PCI).

Methods

This was a prospective single-center trial. In total, 130 patients with stable angina pectoris undergoing their first PCI were enrolled from August 2008 to July 2010 at Kagawa Prefectural Central Hospital. The primary endpoints were cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, revascularization, and hospitalization for heart failure.

Results

During the follow-up (median, 50 months; interquartile range, 23–66 months), 49 cardiovascular events occurred. Kaplan–Meier analysis showed that the cumulative incidence of the primary endpoints in the high A-FABP group (median A-FABP concentration of ≥ 18.6 ng/ml) was greater than that in the low A-FABP group. Cox analysis showed that the A-FABP concentration was an independent predictor of cardiovascular events adjusted for age and the presence of multi-vessel disease (hazard ratio, 1.03; 95% confidence interval, 1.01–1.04; p = 0.01).

Conclusion

The serum A-FABP concentration is associated with prognosis in patients with stable angina undergoing PCI, suggesting that the serum A-FABP concentration could be useful for risk assessment of secondary prevention.

Trial registration

UMIN Clinical Trials Registry UMIN000029283 (registration date: September 25, 2017), retrospectively registered.

Impact of type 2 diabetes mellitus on in-hospital-mortality after major cardiovascular events in Spain (2002-2014)

BACKGROUND

Diabetes mellitus has long been associated with cardiovascular events. Nevertheless, the higher burden of traditional cardiovascular risk factors reported in high-income countries is offset by a more widespread use of preventive measures and revascularization or other invasive procedures. The aim of this investigation is to describe trends in number of cases and outcomes, in-hospital mortality (IHM) and length of hospital stay (LHS), of hospital admissions for major cardiovascular events between type 2 diabetes (T2DM) and matched non-diabetes patients.

METHODS

Retrospective study using National Hospital Discharge Database, analyzed in 4 years 2002, 2006, 2010, 2014, in Spain. We included patients (≥ 40 years old) with a primary diagnosis of myocardial infarction, ischemic and hemorrhagic stroke, aortic aneurysm and dissection and acute lower limb ischemia in people with T2DM. Cases were matched with controls (without T2DM) by ICD-9-CM codes, sex, age, province of residence and year.

RESULTS

We selected 130,011 matched couples (50,427 with myocardial infarction, 60,236 with stroke, 2599 with aortic aneurysm and dissection and 16,749 with acute lower limb ischemia. Among T2DM patients we found increasing numbers of admissions overtime for stroke (10,794 in 2002 vs 17,559 in 2014), aortic aneurysm and dissection (390 vs 841) and acute lower limb ischemia (3854 vs. 4548). People were progressively older (except for myocardial infarction), had more comorbidities (especially T2DM patients), and were more frequently coded overtime for cardiovascular risk factors (smoking, obesity, hypertension, lipid disorders) and renal diseases. LHS and IHM declined overtime, though IHM only did it significantly in T2DM patients. Multivariable adjustment showed that T2DM patients had a significantly 15% higher mortality rate during admission for myocardial infarction, a 6% higher mortality for stroke, and a 6% higher mortality rate for "all cardiovascular events combined", than non-diabetic matched controls.

CONCLUSIONS

The number of hospital admissions for stroke, aortic aneurysm and dissection and acute lower limb ischemia increased overtime, but remained stable for myocardial infarction. T2DM is associated to higher IHM after major cardiovascular events. Further research is needed to help us understand the reasons for an apparently increased mortality in T2DM patients when admitted to hospital for some major cardiovascular events.

Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional analysis from the PURE study

BACKGROUND

The relation between dietary nutrients and cardiovascular disease risk markers in many regions worldwide is unknown. In this study, we investigated the effect of dietary nutrients on blood lipids and blood pressure, two of the most important risk factors for cardiovascular disease, in low-income, middle-income, and high-income countries.

METHODS

We studied 125 287 participants from 18 countries in North America, South America, Europe, Africa, and Asia in the Prospective Urban Rural Epidemiology (PURE) study. Habitual food intake was measured with validated food frequency questionnaires. We assessed the associations between nutrients (total fats, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, carbohydrates, protein, and dietary cholesterol) and cardiovascular disease risk markers using multilevel modelling. The effect of isocaloric replacement of saturated fatty acids with other fats and carbohydrates was determined overall and by levels of intakes by use of nutrient density models. We did simulation modelling in which we assumed that the effects of saturated fatty acids on cardiovascular disease events was solely related to their association through an individual risk marker, and then compared these simulated risk marker-based estimates with directly observed associations of saturated fatty acids with cardiovascular disease events.

FINDINGS

Participants were enrolled into the study from Jan 1, 2003, to March 31, 2013. Intake of total fat and each type of fat was associated with higher concentrations of total cholesterol and LDL cholesterol, but also with higher HDL cholesterol and apolipoprotein A1 (ApoA1), and lower triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ratio of apolipoprotein B (ApoB) to ApoA1 (all p_trend<0·0001). Higher carbohydrate intake was associated with lower total cholesterol, LDL cholesterol, and ApoB, but also with lower HDL cholesterol and ApoA1, and higher triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ApoB-to-ApoA1 ratio (all p_trend<0·0001, apart from ApoB [p_trend=0·0014]). Higher intakes of total fat, saturated fatty acids, and carbohydrates were associated with higher blood pressure, whereas higher protein intake was associated with lower blood pressure. Replacement of saturated fatty acids with carbohydrates was associated with the most adverse effects on lipids, whereas replacement of saturated fatty acids with unsaturated fats improved some risk markers (LDL cholesterol and blood pressure), but seemed to worsen others (HDL cholesterol and triglycerides). The observed associations between saturated fatty acids and cardiovascular disease events were approximated by the simulated associations mediated through the effects on the ApoB-to-ApoA1 ratio, but not with other lipid markers including LDL cholesterol.

INTERPRETATION

Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk.

FUNDING

Full funding sources listed at the end of the paper (see Acknowledgments).

Socially disadvantaged city districts show a higher incidence of acute ST-elevation myocardial infarctions with elevated cardiovascular risk factors and worse prognosis

BACKGROUND

The importance of socioeconomic status (SES) for coronary heart disease (CHD)-morbidity is subject of ongoing scientific investigations. This study was to explore the association between SES in different city-districts of Bremen/Germany and incidence, severity, treatment modalities and prognosis for patients with ST-elevation myocardial infarctions (STEMI).

METHODS

Since 2006 all STEMI-patients from the metropolitan area of Bremen are documented in the Bremen STEMI-registry. Utilizing postal codes of their home address they were assigned to four groups in accordance to the Bremen social deprivation-index (G1: high, G2: intermediate high, G3: intermediate low, G4: low socioeconomic status).

RESULTS

Three thousand four hundred sixty-two consecutive patients with STEMI admitted between 2006 and 2015 entered analysis. City areas with low SES showed higher adjusted STEMI-incidence-rates (IR-ratio 1.56, G4 vs. G1). This elevation could be observed in both sexes (women IRR 1.63, men IRR 1.54) and was most prominent in inhabitants <50 yrs. of age (women IRR 2.18, men IRR 2.17). Smoking (OR 1.7, 95%CI 1.3-2.4) and obesity (1.6, 95%CI 1.1-2.2) was more prevalent in pts. from low SES city-areas. While treatment-modalities did not differ, low SES was associated with more extensive STEMIs (creatine kinase > 3000 U/l, OR 1.95, 95% CI 1.4-2.8) and severe impairment of LV-function post-STEMI (OR 2.0, 95% CI 1.2-3.4). Long term follow-up revealed that lower SES was associated with higher major adverse cardiac or cerebrovascular event (MACCE)-rates after 5 years: G1 30.8%, G2 35.7%, G3 36.0%, G4 41.1%, p (for trend) = 0.02. This worse prognosis could especially be shown for young STEMI-patients (<50 yrs. of age) 5-yr. mortality-rates(G4 vs. G1) 18.4 vs. 3.1%, p = 0.03 and 5-year-MACCE-rates (G4 vs. G1) 32 vs. 6.3%, p = 0.02.

CONCLUSIONS

This registry-data confirms the negative association of low socioeconomic status and STEMI-incidence, with higher rates of smoking and obesity, more extensive infarctions and worse prognosis for the socio-economically deprived.

Differences in the Prevalence of Non-Communicable Disease between Slum Dwellers and the General Population in a Large Urban Area in Brazil

Residents of urban slums are at greater risk for disease than their non-slum dwelling urban counterparts. We sought to contrast the prevalences of selected non-communicable diseases (NCDs) between Brazilian adults living in a slum and the general population of the same city, by comparing the age and sex-standardized prevalences of selected NCDs from a 2010 survey in Pau da Lima, Salvador Brazil, with a 2010 national population-based telephone survey. NCD prevalences in both populations were similar for hypertension (23.6% (95% CI 20.9⁻26.4) and 22.9% (21.2⁻24.6), respectively) and for dyslipidemia (22.7% (19.8⁻25.5) and 21.5% (19.7⁻23.4)). Slum residents had higher prevalences of diabetes mellitus (10.1% (7.9⁻12.3)) and of overweight/obesity (46.5% (43.1⁻49.9)), compared to 5.2% (4.2⁻6.1) and 40.6% (38.5⁻42.8) of the general population in Salvador. Fourteen percent (14.5% (12.1⁻17.0)) of slum residents smoked cigarettes compared to 8.3% (7.1⁻9.5) of the general population in Salvador. The national telephone survey underestimated the prevalence of diabetes mellitus, overweight/obesity, and smoking in the slum population, likely in part due to differential sampling inside and outside of slums. Further research and targeted policies are needed to mitigate these inequalities, which could have significant economic and social impacts on slum residents and their communities.

Trend in prevalence of coronary artery disease and risk factors over two decades in rural Punjab

OBJECTIVES

The burden of coronary artery disease (CAD) has increased in the last three decades in low-income and middle-income countries including India. CAD is responsible for 20% deaths in India. The burden of CAD has increased due to a higher prevalence of risk factors related to the changing lifestyle. We studied the change in prevalence of CAD and risk factors over 20 years in a rural area.

METHODS

A rural population of adults over the age of 30 years from three villages of Punjab was surveyed for the prevalence of CAD and its risk factors in 1994 and 2014 using similar research methodology. CAD was diagnosed by Epstein and clinical criteria. Blood pressure, anthropometry, ECG and biochemical analysis were carried out. The findings of two surveys were compared with a look at the change in the prevalence of CAD and its risk factors over 20 years.

RESULTS

The overall age standardised prevalence of CAD increased from 2.79% in 1994 to 4.06% (p<0.05) in 2014. There was a significant increase in the prevalence of several risk factors including sedentary lifestyle (8.2% vs 41.3%, p<0.001), hypertension (14.5% vs 26.5%, p<0.001), diabetes (4.7% vs 9.7%, p<0.001), obesity (16.6% vs 35.4, p<0.001) and hypercholesterolaemia (7% vs 9.6%, p 0.011). In contrast, cigarette smoking (8.9% vs 3%, p<0.001) and use of desi ghee (51.4% vs 28.5%, p<0.001) decreased.

CONCLUSIONS

In a rural population of Punjab, the prevalence of several CAD risk factors like sedentary lifestyle, hypertension, diabetes, obesity and hypercholesterolaemia increased over 20 years. These changes in risk factors were associated with a modest increase in prevalence of CAD.

Prevalence and pattern of cardiovascular risk factors in a population in India

Background

Cardiovascular disease is the leading cause of mortality in India. Since it is largely driven by risk factors such as hypertension, diabetes and smoking, it is important to study the treatment cascade for these conditions and identify areas for improvement.

Methods

This is a cross-sectional study from Project SEHAT (Study to Enhance Heart Associated Treatments), an ongoing cluster randomised controlled trial testing the hypothesis that a community health worker-led intervention can improve the control of cardiovascular risk factors in a community in West Bengal, India. For the baseline data, 3556 adults, between the ages of 35 and 70, were screened for hypertension, diabetes and smoking. For hypertension and diabetes, an elevated reading was confirmed on a repeat visit.

Results

18.3% (n=650), 9.0% (n=317) and 14.1% (n=500) of adults were diagnosed with hypertension, diabetes and smoking, respectively. Overall, 35.0% (n=1242) adults had at least one of the three risk factors. 55.1% (n=358) of participants with hypertension and 40.4% (n=128) of participants with diabetes were unaware of their respective condition. 36.6% (n=238) of those with hypertension and 58.0% (n=184) of diabetics were on treatment. 8.2% (n=53) hypertensives were controlled (blood pressure <140/90 mm Hg) while 13.6% (n=43) diabetics were controlled (defined as fasting blood sugar <126 mg/dL). Less than 1% diabetics were on insulin, and average number of medications for a patient with hypertension was 1.2.

Conclusions

In our population in semiurban India, one in three adults have a major cardiovascular risk factor, with low control rates. There is a large burden of undiagnosed cardiovascular risk factors and a large gap between treatment and control, which may be explained by lack of treatment intensification.

Incidence of cancers in patients with atherosclerotic cardiovascular diseases

BACKGROUND

To address a clinical impact of atherosclerotic cardiovascular diseases (CVD) on cancer developments, we investigated an issue whether any difference in an incidence of cancers is present between patients with atherosclerotic CVD and those with non-atherosclerotic CVD.

METHODS

Of a total of 32,095 consecutive patients with acquired CVD enrolled in the Sakakibara Health Integrative Profile cohort study, we segregated patients based on a presence of atherosclerotic or non-atherosclerotic CVD to investigate an incidence of cancers and mortality. We also evaluated an incidence of cancers in patients with a singular presence versus a plural presence of atherosclerotic CVD. Atherosclerotic CVD included coronary artery diseases, aortic diseases and peripheral artery diseases. Non-atherosclerotic CVD were any acquired CVD except atherosclerotic CVD.

RESULTS

During a median follow-up of 1020 days (interquartile range, 665-1340 days), an incidence of cancers (5% vs. 2%, p = 0.0001) and overall mortality (6% vs. 3%, p = 0.0001) were more than two-fold higher in 10,592 patients with atherosclerotic CVD than in 21,503 patients with non-atherosclerotic CVD. A presence of atherosclerotic CVD (hazard ratio 1.372 with 95% confidence interval 1.199-1.569) was independently associated with an incidence of cancers. In patients with atherosclerotic CVD, 61 of 640 patients with a plural presence and 470 of 9932 patients with a singular presence developed cancers (9% vs. 5%, p = 0.0001). An incremental risk of death was found according to a presence of atherosclerotic CVD, cancers, and both of them (all p = 0.0001).

CONCLUSIONS

A presence of atherosclerotic CVD itself may have a potential risk for cancer developments.

TRIAL REGISTRATION

ClinicalTrials.gov. number, NCT03005834.

High sensitivity cardiac troponin I detection in physiological environment using AlGaN/GaN High Electron Mobility Transistor (HEMT) Biosensors

In this study, we report the development of a high sensitivity assay for the detection of cardiac troponin I using electrical double layer gated high field AlGaN/GaN HEMT biosensor. The unique gating mechanism overcomes the drawback of charge screening seen in traditional FET based biosensors, allowing detection of target proteins in physiological solutions without sample processing steps. Troponin I specific antibody and aptamer are used as receptors. The tests carried out using purified protein solution and clinical serum samples depict high sensitivity, specificity and wide dynamic range (0.006-148ng/mL). No additional wash or sample pre-treatment steps are required, which greatly simplifies the biosensor system. The miniaturized HEMT chip is packaged in a polymer substrate and easily integrated with a portable measurement unit, to carry out quantitative troponin I detection in serum samples with < 2µl sample volume in 5min. The integrated prototype biosensor unit demonstrates the potential of the method as a rapid, inexpensive, high sensitivity CVD biomarker assay. The highly simplified protocols and enhanced sensor performance make our biosensor an ideal choice for point of care diagnostics and personal healthcare systems.

Control of blood pressure and risk attenuation: a public health intervention in rural Bangladesh, Pakistan, and Sri Lanka: feasibility trial results

BACKGROUND

High blood pressure (BP) is the leading attributable risk for cardiovascular disease globally. There is little information on effective and sustainable public health system strategies for managing hypertension in South Asian countries. We conducted a feasibility study to gather preliminary data to optimize BP-lowering strategies for a public health intervention in rural communities in Bangladesh, Pakistan, and Sri Lanka.

METHODS

A mixed method feasibility study comprised a 3-month pre and postevaluation of a multicomponent intervention (MCI), including BP screening and home health education by trained government community health worker (CHW); providers trained in hypertension management, and compensation of CHW for additional services. Checklists were used to document care. Stakeholder interviews were also conducted. Individuals aged 40 years and above with high BP (systolic ≥140 mmHg or diastolic ≥90 mmHg based on two readings from 2 separate days, or receiving antihypertensive medications) were enrolled from rural communities in Bangladesh, Pakistan, and Sri Lanka. BP was measured at baseline and 3 months postintervention.

RESULTS

A total of 412 (90%) of the 454 eligible individuals were recruited. Of those recruited, 90% received home health education session by trained CHWs, 80% were referred to trained providers, of whom 83% completed the management checklist. A follow-up rate of 95.6% was achieved. The mean SBP declined significantly by 4.5 mmHg 95% confidence interval (2.3, 6.7) mmHg (P < 0.001) in the overall pooled analysis in three countries; however, it varied among countries. BP decline was 10.5 mmHg (8.1, 13.0 mmHg) (P < 0.001) in the pooled analysis of individuals with uncontrolled hypertension at baseline, and was also significant each of the three countries. All 98 stakeholders strongly supported upscaling the proposed MCI strategies.

CONCLUSION

The proposed MCI is feasible for implementation and requires long-term, large-scale evaluation in the rural public health infrastructure in South Asian countries to determine sustainability of health system changes and BP control. If these long-term effects are confirmed, MCI may be a long-term strategy for tackling rising rates of cardiovascular disease in low-resourced countries.Clintrial.gov NCT02341651.

Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors

Current global health policy goals include a 25% reduction in premature mortality from noncommunicable diseases by 2025. In this 2-part review, we provide an overview of the current epidemiological data on cardiovascular diseases (CVD), its risk factors, and describe strategies aimed at reducing its burden. In part 1, we examine the global epidemiology of cardiac conditions that have the greatest impact on CVD mortality; the predominant risk factors; and the impact of upstream, societal health determinants (eg, environmental factors, health policy, and health systems) on CVD. Although age-standardized mortality from CVD has decreased in many regions of the world, the absolute number of deaths continues to increase, with the majority now occurring in middle- and low-income countries. It is evident that multiple factors are causally related to CVD, including traditional individual level risk factors (mainly tobacco use, lipids, and elevated blood pressure) and societal level health determinants (eg, health systems, health policies, and barriers to CVD prevention and care). Both individual and societal risk factors vary considerably between different regions of the world and economic settings. However, reliable data to estimate CVD burden are lacking in many regions of the world, which hampers the establishment of nationwide prevention and management strategies. A 25% reduction in premature CVD mortality globally is feasible but will require better implementation of evidence-based policies (particularly tobacco control) and integrated health systems strategies that improve CVD prevention and management. In addition, there is a need for better health information to monitor progress and guide health policy decisions.

Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease

In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.

Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data

BACKGROUND

Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development.

METHODS

We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level.

FINDINGS

The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59-3·12); p<0·0001), combination therapy (1·53, 1·13-2·07; p=0·054), and have their blood pressure controlled (2·06, 1·69-2·50; p<0·0001) than were those in communities where blood pressure-lowering medicines were not available. Participants with known hypertension from households able to afford four blood pressure-lowering drug classes were more likely to use at least one blood pressure-lowering medicine (adjusted OR 1·42, 95% CI 1·25-1·62; p<0·0001), combination therapy (1·26, 1·08-1·47; p=0·0038), and have their blood pressure controlled (1·13, 1·00-1·28; p=0·0562) than were those unable to afford the medicines.

INTERPRETATION

A large proportion of communities in low-income and middle-income countries do not have access to more than one blood pressure-lowering medicine and, when available, they are often not affordable. These factors are associated with poor blood pressure control. Ensuring access to affordable blood pressure-lowering medicines is essential for control of hypertension in low-income and middle-income countries.

FUNDING

Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Canadian Institutes of Health Research Strategy for Patient Oriented Research through the Ontario SPOR Support Unit, the Ontario Ministry of Health and Long-Term Care, pharmaceutical companies (with major contributions from AstraZeneca [Canada], Sanofi Aventis [France and Canada], Boehringer Ingelheim [Germany amd Canada], Servier, and GlaxoSmithKline), Novartis and King Pharma, and national or local organisations in participating countries.

Educational strategies for the prevention of diabetes, hypertension, and obesity

Objective:

The main goal of this work was to produce a review of educational strategies to prevent diabetes, hypertension, and obesity.

Method:

PubMed database was consulted using combined descriptors such as [Prevention], [Educational Activities], [Diabetes], [Hypertension], and [Obesity]. Data from randomized trials published between 2002 and 2014 were included in spreadsheets for analysis in duplicate by the reviewers.

Results:

A total of 8,908 articles were found, of which 1,539 were selected about diabetes mellitus (DM, n=369), arterial systemic hypertension (ASH, n=200), and obesity (OBES, n=970). The number of free full text articles available was 1,075 (DM = 276, ASH = 118 and OBES = 681). In most of these studies, demographic characteristics such as gender and age were randomized, and the population mainly composed by students, ethnic groups, family members, pregnant, health or education professionals, patients with chronic diseases (DM, ASH, OBES) or other comorbidities. Group dynamics, physical activity practices, nutritional education, questionnaires, interviews, employment of new technologies, people training and workshops were the main intervention strategies used.

Conclusion:

The most efficient interventions occurred at community level, whenever the intervention was permanent or maintained for long periods, and relied on the continuous education of community health workers that had a constant interference inside the population covered. Many studies focused their actions in children and adolescents, especially on students, because they were more influenced by educational activities of prevention, and the knowledge acquired by them would spread more easily to their family and to society.

A Review of Cardiac Rehabilitation Delivery Around the World

Herein, 28 publications describing cardiac rehabilitation (CR) delivery in 50 of the 113 countries globally suspected to deliver it are reviewed, to characterize the nature of services. Government funding was the main source of CR reimbursement in most countries (73%), with private and patient funding in about ¼ of cases. Myocardial infarction patients and those having revascularization were commonly served. The main professions delivering CR were physicians, nurses, and physiotherapists. Programs offered a median of 20 sessions, although this varied. Most programs offered the core components of exercise training, patient education and nutrition counselling. Alternative models were not commonly offered. Lack of human and/or financial resources as well as space constraints were reported as the major barriers to delivery. Overall, CR delivery has been characterized in less than half of the countries where it is offered. The nature of services delivered is fairly consistent with major CR guidelines and statements.

Multimorbidities Are Associated to Lower Survival in Ischaemic Stroke: Results from a Brazilian Stroke Cohort (EMMA Study)

BACKGROUND

Stroke prognosis is related to the multimorbidity profile. Moreover, performing an individual evaluation of most common cerebrovascular risk factors (CVRF) not always identifies patients with poor prognosis. Thus, we decided to evaluate multimorbidity profile, focusing on the Charlson Comorbidity Index (CCI) validated by Goldstein for ischaemic stroke (IS) patients, a score that measures a burden of comorbidities and its related mortality in the long-term survival of the EMMA Study (Study of Stroke Mortality and Morbidity).

METHODS

Nine hundred fifty-nine individuals (median age 70 years) had validated data on the diagnosis of IS, main CVRF and clinical comorbidities pre index event such as atrial fibrillation (AF), stroke recurrence, diabetes, hypertension, heart failure and cancer. CCI modified by Goldstein was calculated, which includes 17 clinical conditions with scores ranging from 1 to 6 (0-31 points). Survival analyses were performed by Kaplan-Meier curves and Cox logistic regression models (cumulative hazard ratio [HR] with [95% CI]) for all-cause mortality at 180 days, and every 3 years up to 9-year follow-up. Mortality analyzes were performed by CCI categorized according to weight added to comorbidities (Reference group: zero, moderate: 1, severe: 2 and very severe: ≥3 points). We also tested the modification effect of AF and stroke recurrence including these conditions in the CCI.

RESULTS

The overall survival rate was 47% (508 deaths/959). The worst survival (577, 95% CI 381-773 days) and the highest risk of death after stroke were observed in the very severe CCI group (HR 3.18; 95% CI 2.16-4.69) up to 9 years. The inclusion of previous AF and stroke in the CCI slightly increased the risk of death for very severe CCI (HR 3.27; 95% CI 2.07-5.18).

CONCLUSIONS

A high burden of comorbidities represented an independent predictor of poor prognosis increasing the risk of dying by 2 to 3 times among IS up to 9 years in the EMMA study. The inclusion of other CVRF such as AF and stroke recurrence slightly modified all-cause mortality risk.

Examination of a Nurse-led Community-based Education and Coaching Intervention for Coronary Heart Disease High-risk Individuals in China

PURPOSE

Early detection and management of coronary heart disease (CHD) are embedded into many community health service and primary care practices in western countries. The Framingham CHD risk score has been used to predict CHD and mortality for nearly 20 years, and it has predicted CHD event risk accurately in multiethnic populations. The aim of this study was to access the effect of a 6-month community-based intervention on CHD risk in individuals at high risk.

METHODS

A randomized controlled trial of individuals with a high 10-year CHD risk were recruited from two communities in China. Individuals in the intervention group (n = 53) received a 3-month group education and a 3-month coaching session. Physical examination and self-report questionnaires were used to collect both pre- and postintervention data on blood pressure, glucose, cholesterol, body mass index, smoking, depression, and health-related quality of life (HRQoL).

RESULTS

A total of 102 participants (85.0%) completed the 6-month study. Compared with the usual care group, the intervention group had a 5 mmHg greater reduction in systolic blood pressure (t = 2.01, p = .047), larger declines in glucose (t = -2.49, p = .015), cholesterol (t = -2.44, p = .017), body mass index (t = -2.58, p = .011), and depression (t = -2.05, p = .043), and better reports of HRQoL (t = 3.36, p = .001). No significant group differences in smoking behaviors were reported.

CONCLUSION

A 6-month community-based intervention in a CHD high-risk population improved disease-related risk factors, depression, and HRQoL. Results provide preliminary evidence for primary prevention of cardiovascular disease risk in a community high-risk population.

An analytics based clinical decision support system for CVD risk assessment and management

Cardiovascular disease (CVD) is a major cause of disability and premature death throughout the world. Acute coronary events and other cardiovascular events frequently occur suddenly, and are often fatal before medical care can be given. Risk factor modification can reduce clinical events and premature death in people with established cardiovascular disease as well as in those who are at high cardiovascular risk due to one or more risk factors. In this work, India specific World Health Organization-International Society of Hypertension (WHO-ISH) guidelines has been implemented to stratify the subjects by their risk profile. It provides simplified approach to detect those people at high risk and provides guidance on what should be done for prevention of heart attack. Further, based on the risk stratification, lifestyle coaching, medication management and the next tests are advised to the subjects. This approach will help in early detection of cardiovascular risk subjects and provide necessary interventions at appropriate time frame. Also, it acts as motivation to the individuals to comply with recommended lifestyle changes.

World Heart Federation Cholesterol Roadmap

BACKGROUND

The World Heart Federation has undertaken an initiative to develop a series of Roadmaps.

OBJECTIVES

The aim of these is to promote development of national policies and health systems approaches and identify potential roadblocks on the road to effective prevention, detection and management of cardiovascular disease (CVD) in low-and middle-income countries (LMIC), and strategies for overcoming these. This Roadmap focuses on elevated blood cholesterol, a leading risk factor for myocardial infarction, stroke, and peripheral arterial disease.

METHODS

Through a review of published guidelines and research papers, and consultation with a committee composed of experts in clinical management of cholesterol and health systems research in LMIC, this Roadmap identifies (1) key interventions for primordial, primary and secondary prevention of CVD through detection, treatment, and management of elevated cholesterol and familial hypercholesterolemia (FH); (2) gaps in implementation of these interventions (knowledge-practice gaps); (3) health system roadblocks to treatment of elevated cholesterol in LMIC; and (4) potential strategies for overcoming these.

RESULTS

Despite strong evidence of the importance of cholesterol levels in primary or secondary prevention of CVD, and the effectiveness of statin therapy for cholesterol lowering and reduction of CVD risk, gaps exist in the detection, treatment, and management of high cholesterol globally. Some potential roadblocks include poor access to laboratory facilities or trained professionals for cholesterol management, low awareness of FH among the general population and health professionals, unaffordability of statins for patient households, and low awareness of the importance of persistent adherence to lipid-lowering medication. Potential solutions include point-of-care testing, provision of free or subsidized lipid-lowering medication, and treatment adherence support using text message reminders.

CONCLUSIONS

Known effective strategies for detection, treatment, and management of elevated cholesterol and FH exist, but there are barriers to their implementation in many low-resource settings. Priorities for health system intervention should be identified at the national level, and the feasibility and effectiveness of proposed solutions should be assessed in specific contexts. Many solutions proposed in this Roadmap may apply to other cardiovascular conditions and present opportunities for integration of CVD care in LMIC.

Prevalence of Stroke and Vascular Risk Factors in China: a Nationwide Community-based Study

We aimed to investigate the prevalence of stroke and related vascular risk factors in adult population aged 40 years and older in China. We conducted a prospective cross-sectional survey in nationally representative sample of 207323 individuals from all 31 Chinese provinces in 2013. Data were used to analyze the prevalence of stroke by age, sex, geographical regions and educational level. The age-standardized prevalence of stroke was significantly higher in men than in women in all age groups (P < 0.001). The age-standardized prevalence of stroke was significantly higher in rural than in urban residents among both men and women (P < 0.001). The prevalence of stroke was inversely associated with educational level. There were striking geographical variations in stroke prevalence in China with a higher prevalence of stroke in northern provinces as compared with southern provinces of the country. The age-standardized prevalence of hypertension, diabetes, dyslipidemia, atrial fibrillation and obesity in the Chinese population aged 40 years and older were 35.24%, 9.55%, 58.72%, 1.57% and 4.09%, respectively. Stroke and related vascular risk factors remains a major public threat in China and effective primary preventive strategies that aimed at reducing the burden of stroke and its risk factors are urgently needed.

Biomass fuel smoke exposure was associated with adverse cardiac remodeling and left ventricular dysfunction in Peru

While household air pollution from biomass fuel combustion has been linked to cardiovascular disease, the effects on cardiac structure and function have not been well described. We sought to determine the association between biomass fuel smoke exposure and cardiac structure and function by transthoracic echocardiography. We identified a random sample of urban and rural residents living in the high-altitude region of Puno, Peru. Daily biomass fuel use was self-reported. Participants underwent transthoracic echocardiography. Multivariable linear regression was used to examine the relationship of biomass fuel use with echocardiographic measures of cardiac structure and function, adjusting for age, sex, height, body mass index, diabetes, physical activity, and tobacco use. One hundred and eighty-seven participants (80 biomass fuel users and 107 non-users) were included in this analysis (mean age 59 years, 58% women). After adjustment, daily exposure to biomass fuel smoke was associated with increased left ventricular internal diastolic diameter (P=.004), left atrial diameter (P=.03), left atrial area (four-chamber) (P=.004) and (two-chamber) (P=.03), septal E' (P=.006), and lateral E' (P=.04). Exposure to biomass fuel smoke was also associated with worse global longitudinal strain in the two-chamber view (P=.01). Daily biomass fuel use was associated with increased left ventricular size and decreased left ventricular systolic function by global longitudinal strain.

Cardiovascular risk factors in Middle Eastern patients undergoing percutaneous coronary intervention: Results from the first Jordanian percutaneous coronary intervention study

Background and aims: Cardiovascular disease (CVD) is the leading cause of death in the Middle East. We sought to study the prevalence and coexistence of 6 cardiovascular risk factors (RFs) among patients who underwent percutaneous coronary intervention (PCI), and to evaluate the impact of age and gender on the presence of multiple RFs.

METHODS AND RESULTS

In this prospective, multicenter study, 2426 consecutive patients were enrolled. Mean age was 59.0 ± 10.1 years and 500 (20.6%) were women. Acute coronary syndrome and stable coronary disease were the indications for PCI in 77.1% and 22.9%, respectively. Hypertension was present in 62.3%, diabetes in 53.8%, hypercholesterolemia in 48.8%, smoking in 43.5%, family history of premature CVD 39.4% and obesity in 28.8%. Only 3.8% did not have any of these RFs. Presence of ⩾3 and ⩾4 RFS was observed in 57.4% and 29.5% of patients, respectively. Presence of ⩾3 RFs was more common in women than men (69.0% vs. 54.5%, p < 0.0001), and among patients 41-65 years of age than older or younger patients (60.1% vs. 52.0% vs. 48.3%, respectively, p = 0.017). Conclusions: Cardiovascular RFs are highly prevalent in this PCI Middle Eastern population undergoing PCI. More than half and more than one-fourth of the patients had at least 3 or 4 RFs; respectively. More women than men and more middle aged patients than older or younger patients had significantly higher rates of presence of multiple RFs.

Prevalence, Treatment, and Control Rates of Conventional and Ambulatory Hypertension Across 10 Populations in 3 Continents

Hypertension is a major global health problem, but prevalence rates vary widely among regions. To determine prevalence, treatment, and control rates of hypertension, we measured conventional blood pressure (BP) and 24-hour ambulatory BP in 6546 subjects, aged 40 to 79 years, recruited from 10 community-dwelling cohorts on 3 continents. We determined how between-cohort differences in risk factors and socioeconomic factors influence hypertension rates. The overall prevalence was 49.3% (range between cohorts, 40.0%-86.8%) for conventional hypertension (conventional BP ≥140/90 mm Hg) and 48.7% (35.2%-66.5%) for ambulatory hypertension (ambulatory BP ≥130/80 mm Hg). Treatment and control rates for conventional hypertension were 48.0% (33.5%-74.1%) and 38.6% (10.1%-55.3%) respectively. The corresponding rates for ambulatory hypertension were 48.6% (30.5%-71.9%) and 45.6% (18.6%-64.2%). Among 1677 untreated subjects with conventional hypertension, 35.7% had white coat hypertension (23.5%-56.2%). Masked hypertension (conventional BP <140/90 mm Hg and ambulatory BP ≥130/80 mm Hg) occurred in 16.9% (8.8%-30.5%) of 3320 untreated subjects who were normotensive on conventional measurement. Exclusion of participants with diabetes mellitus, obesity, hypercholesterolemia, or history of cardiovascular complications resulted in a <9% reduction in the conventional and 24-hour ambulatory hypertension rates. Higher social and economic development, measured by the Human Development Index, was associated with lower rates of conventional and ambulatory hypertension. In conclusion, high rates of hypertension in all cohorts examined demonstrate the need for improvements in prevention, treatment, and control. Strategies for the management of hypertension should continue to not only focus on preventable and modifiable risk factors but also consider societal issues.

Synergistic cardioprotective effects of rAAV9-CyclinA2 combined with fibrin glue in rats after myocardial infarction

The present study aimed to investigate the protective effects of rAAV9-CyclinA2 combined with fibrin glue (FG) in vivo in rats after myocardial infarction (MI). Ninety male Sprague-Dawley rats were randomized into 6 groups (15 in each group): sham, MI, rAAV9-green fluorescent protein (GFP) + MI, rAAV9-CyclinA2 + MI, FG + MI, and rAAV9-CyclinA2 + FG + MI. Packed virus (5 × 10¹¹vg/ml) in 150 µl of normal saline or FG was injected into the infarcted myocardium at five locations in rAAV9-GFP + MI, rAAV9-CyclinA2 + MI, and rAAV9-CyclinA2 + FG + MI groups. The sham, MI, and FG + MI groups were injected with an equal volume of normal saline or FG at the same sites. Five weeks after injection, echocardiography was performed to evaluate the left ventricular function. The expressions of CyclinA2, proliferating cell nuclear antigen (PCNA), and phospho-histone-H3 (H3P), vascular density, and infarct area were assessed by Western blot, immunohistochemistry, immunofluorescence, and Masson staining. As a result, the combination of rAAV9-CyclinA2 and FG increased ejection fraction and fractional shortening compared with FG or rAAV9-CyclinA2 alone. The expression level of CyclinA2 was significantly higher in the rAAV9-CyclinA2 + FG + MI group compared with the rAAV9-CyclinA2 + MI and FG + MI groups (70.1 ± 1.86% vs. 14.74 ± 2.02%, P < 0.01; or vs. 50.13 ± 3.80%; P < 0.01). A higher expression level of PCNA and H3P was found in the rAAV9-CyclinA2 + FG + MI group compared with other groups. Comparing with other experiment groups, collagen deposition and the infarct size significantly decreased in rAAV9-CyclinA2 + Fibrin + MI group. The vascular density was much higher in the rAAV9-CyclinA2 + FG + MI group compared with the rAAV9-CyclinA2 + MI group. We concluded that fibrin glue combined with rAAV9-CyclinA2 was found to be effective in cardiac remodeling and improving myocardial protection.

Fighting fake medicines: First quality evaluation of cardiac drugs in Africa

BACKGROUND

The growing menace of poor quality and falsified drugs constitutes a major hazard, compromising healthcare and patient outcomes. Efforts to assess drug standards worldwide have almost exclusively focused on anti-microbial drugs; with no study to date on cardiovascular drugs. Our study aims to assess quality of seven routinely used cardiovascular medications (anticoagulants, antihypertensives and statins) in ten Sub-Saharan African countries.

METHODS

Drugs were prospectively collected using standardized methods between 2012 and 2014 from licensed (random pharmacies) and unlicensed (street-markets) places of sale in Africa. We developed a validated reversed-phase liquid chromatography with tandem mass spectrometry method to accurately quantify the active ingredient in a certified public laboratory. Three quality categories were defined based on the ratio of the measured to the expected dosage of the active ingredient: A (good quality): 95% to 105%, B (low quality): 85 to 94.99% or 105.01 to 115%, C (very low quality): <85% or >115%.

RESULTS

All expected medicines (n=3468 samples) were collected in Benin, Burkina-Faso, Congo-Brazzaville, the Democratic Republic of Congo, Guinea, Côte d'Ivoire, Mauritania, Niger, Togo and Senegal. Out of the 1530 samples randomly tested, poor quality (types B and C) was identified in 249 (16.3%) samples. The prevalence of poor quality was significantly increased in certain specific drugs (amlodipine 29% and captopril 26%), in generic versions (23%) and in drugs produced in Asia (35%). The proportion of poor quality reached 50% when drugs produced in Asia were sold in street-markets.

CONCLUSION

In this first study assessing the quality of cardiovascular drugs in Africa, we found a significant proportion of poor quality drugs. This requires continued monitoring strategies.

Multicomponent intervention versus usual care for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: study protocol for a cluster randomized controlled trial

BACKGROUND

High blood pressure (BP) is the leading attributable risk for cardiovascular disease (CVD). In rural South Asia, hypertension continues to be a significant public health issue with sub-optimal BP control rates. The goal of the trial is to compare a multicomponent intervention (MCI) to usual care to evaluate the effectiveness and cost-effectiveness of the MCI for lowering BP among adults with hypertension in rural communities in Bangladesh, Pakistan and Sri Lanka.

METHODS/DESIGN

This study is a stratified, cluster randomized controlled trial with a qualitative component for evaluation of processes and stakeholder feedback. The MCI has five components: (1) home health education by government community health workers (CHWs), (2) BP monitoring and stepped-up referral to a trained general practitioner using a checklist, (3) training public and private providers in management of hypertension and using a checklist, (4) designating hypertension triage counter and hypertension care coordinators in government clinics and (5) a financing model to compensate for additional health services and provide subsidies to low income individuals with poorly controlled hypertension. Usual care will comprise existing services in the community without any additional training. The trial will be conducted on 2550 individuals aged ≥40 years with hypertension (with systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, based on the mean of the last two of three measurements from two separate days, or on antihypertensive therapy) in 30 rural communities in Bangladesh, Pakistan and Sri Lanka. The primary outcome is change in systolic BP from baseline to follow-up at 24 months post-randomization. The incremental cost of MCI per CVD disability-adjusted life years averted will be computed. Stakeholders including policy makers, provincial- and district-level coordinators of relevant programmes, physicians, CHWs, key community leaders, hypertensive individuals and family members in the identified clusters will be interviewed.

DISCUSSION

The study will provide evidence of the effectiveness and cost-effectiveness of MCI strategies for BP control compared to usual care in the rural public health infrastructure in South Asian countries. If shown to be successful, MCI may be a long-term sustainable strategy for tackling the rising rates of CVD in low resourced countries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02657746 . Registered on 14 January 2016.

Let Us Talk About Moving: Reframing the Exercise and Physical Activity Discussion

Noncommunicable and chronic disease are interchangeable terms. According to the World Health Organization, "they are of long duration and generally slow progression. The 4 main types of chronic diseases are cardiovascular diseases (ie, heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma), and diabetes." We have known about the benefits of physical activity (PA) for thousands of years. Perhaps our approach, from public health messaging to the individual clinical encounter, as to how PA and exercise are discussed and prescribed can be improved upon, with the ultimate goal of increasing the likelihood that an individual moves more; ultimately moving more should be the goal. In fact, there is an incongruence between the evidence for the benefits of physical movement and how we message and integrate PA and exercise guidance into health care, if it is discussed at all. Specifically, evidence clearly indicates any migration away from the sedentary phenotype toward a movement phenotype is highly beneficial. As we necessarily move to a proactive, preventive healthcare model, we must reconceptualize how we evaluate and treat conditions that pose the greatest threat, namely chronic disease; there is a robust body of evidence supporting the premise of movement as medicine. The purpose of this perspective paper is to propose an alternate model for promoting, assessing, discussing, and prescribing physical movement.

Socioeconomic Factors and Severity of Coronary Artery Disease in Patients Undergoing Coronary Angiography: A Multicentre Study of Arabian Gulf States

INTRODUCTION

Coronary artery disease (CAD) is a leading cause of death worldwide. The association of socioeconomic status with CAD is supported by numerous epidemiological studies. Whether such factors also impact the number of diseased coronary vessels and its severity is not well established.

MATERIALS AND METHODS

We conducted a prospective multicentre, multi-ethnic, cross sectional observational study of consecutive patients undergoing coronary angiography (CAG) at 5 hospitals in the Kingdom of Saudi Arabia and the United Arab Emirates. Baseline demographics, socioeconomic, and clinical variables were collected for all patients. Significant CAD was defined as ≥70% luminal stenosis in a major epicardial vessel. Left main disease (LMD) was defined as ≥50% stenosis in the left main coronary artery. Multi-vessel disease (MVD) was defined as having >1 significant CAD.

RESULTS

Of 1,068 patients (age 59 ± 13, female 28%, diabetes 56%, hypertension 60%, history of CAD 43%), 792 (74%) were from urban and remainder (26%) from rural communities. Patients from rural centres were older (61 ± 12 vs 58 ± 13), and more likely to have a history of diabetes (63 vs 54%), hypertension (74 vs 55%), dyslipidaemia (78 vs 59%), CAD (50 vs 41%) and percutaneous coronary intervention (PCI) (27 vs 21%). The two groups differed significantly in terms of income level, employment status and indication for angiography. After adjusting for baseline differences, patients living in a rural area were more likely to have significant CAD (adjusted OR 2.40 [1.47, 3.97]), MVD (adjusted OR 1.76 [1.18, 2.63]) and LMD (adjusted OR 1.71 [1.04, 2.82]). Higher income was also associated with a higher risk for significant CAD (adjusted OR 6.97 [2.30, 21.09]) and MVD (adjusted OR 2.49 [1.11, 5.56]), while unemployment was associated with a higher risk of significant CAD (adjusted OR 2.21, [1.27, 3.85]).

CONCLUSION

Communal and socioeconomic factors are associated with higher odds of significant CAD and MVD in the group of patients referred for CAG. The underpinnings of these associations (e.g. pathophysiologic factors, access to care, and system-wide determinants of quality) require further study.

Cardiovascular risk status of Afro-origin populations across the spectrum of economic development: findings from the Modeling the Epidemiologic Transition Study

BACKGROUND

Cardiovascular risk factors are increasing in most developing countries. To date, however, very little standardized data has been collected on the primary risk factors across the spectrum of economic development. Data are particularly sparse from Africa.

METHODS

In the Modeling the Epidemiologic Transition Study (METS) we examined population-based samples of men and women, ages 25-45 of African ancestry in metropolitan Chicago, Kingston, Jamaica, rural Ghana, Cape Town, South Africa, and the Seychelles. Key measures of cardiovascular disease risk are described.

RESULTS

The risk factor profile varied widely in both total summary estimates of cardiovascular risk and in the magnitude of component factors. Hypertension ranged from 7% in women from Ghana to 35% in US men. Total cholesterol was well under 200 mg/dl for all groups, with a mean of 155 mg/dl among men in Ghana, South Africa and Jamaica. Among women total cholesterol values varied relatively little by country, following between 160 and 178 mg/dl for all 5 groups. Levels of HDL-C were virtually identical in men and women from all study sites. Obesity ranged from 64% among women in the US to 2% among Ghanaian men, with a roughly corresponding trend in diabetes. Based on the Framingham risk score a clear trend toward higher total risk in association with socioeconomic development was observed among men, while among women there was considerable overlap, with the US participants having only a modestly higher risk score.

CONCLUSIONS

These data provide a comprehensive estimate of cardiovascular risk across a range of countries at differing stages of social and economic development and demonstrate the heterogeneity in the character and degree of emerging cardiovascular risk. Severe hypercholesterolemia, as characteristic in the US and much of Western Europe at the onset of the coronary epidemic, is unlikely to be a feature of the cardiovascular risk profile in these countries in the foreseeable future, suggesting that stroke may remain the dominant cardiovascular event.