The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review

Effect of exercise on kidney-relevant biomarkers in the general population: a systematic review and meta-analysis

OBJECTIVE

Physical activity (PA) has been generally recognised as beneficial for health. The effect of a change in PA on kidney biomarkers in healthy individuals without kidney disease remains unclear. This manuscript synthesised the evidence of the association of changes in PA with kidney biomarkers in the general population free from kidney disease.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, PubMed, MEDLINE and Web of Science databases were searched from inception to 12 March 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies of longitudinal or interventional design were selected initially. The following studies were excluded: (1) case-control studies, (2) studies where PA was measured at a single time point, (3) populations with known kidney disease, (4) studies evaluating the impact of a single episode/event of PA and (5) non-English language studies.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from a pre-designed table and assessed the risk of bias using the Cochrane Risk of Bias tool. Data were pooled using a random-effects model. Hedge's g was used to synthesise effect sizes and obtain an overall estimate. Heterogeneity between studies was measured using I2. Funnel plots and Egger's test were performed to evaluate the risk of biased results.

RESULTS

16 interventional studies with randomised or non-randomised designs involving 500 participants were identified. The median follow-up was 84 days. 10 studies were at high risk of bias. Studies with low quality were published prior to the year 2000. Changes in PA were found only to have a positive association with serum creatinine (SCr) (Hedge's g=0.69; 95% CI 0.13, 1.24; I2=81.37%) and not with plasma renin activity (PRA), urea, or urine albumin-to-creatinine ratio (UACR). The positive association was only observed in people with obesity and those who exercised for more than 84 days.

CONCLUSIONS

Higher levels of PA are associated with increased SCr levels in healthy people. It remains unclear if this association is related to impaired kidney function or gain in muscle mass, as data on other kidney biomarkers did not support a certain link.

PROSPERO REGISTRATION NUMBER

This review has been registered on PROSPERO (CRD42023407820).

Evaluation of health-related quality of life changes in an Australian rapid access chest pain clinic

OBJECTIVE

To evaluate the impact of absolute cardiovascular risk counselling on quality-of-life indices within a chest pain clinic.

DATA SOURCES AND STUDY SETTING

Primary data was collected at the Royal Hobart Hospital, Australia, between 2014 and 2020.

STUDY DESIGN

Patients attending an Australian chest pain clinic were randomised into a prospective, open-label, blinded-endpoint study over a minimum 12-months follow-up.

DATA COLLECTION / EXTRACTION METHODS

The SF-36 questionnaire was completed at baseline/follow-up and SF-6D multi-attribute utility instrument's health state utilities (HSU) were generated using SF-36 responses and the SF-6D's Australian tariff. SF-6D minimal important difference was 0.04 points. Absolute cardiovascular risk was also stratified into high/intermediate/low-risk categories for exploratory analysis of summary HSUs and dimensional scores. ANZCTR registration number 12617000615381 (registered 28/4/17).

PRINCIPAL FINDINGS

Of n = 189 patients enrolled, HSUs were generated for 96% at baseline (intervention n = 93, usual care n = 88) and 61% at follow-up. There were no statistical differences in age, sex, absolute cardiovascular risk or mean HSU between groups at baseline. Summary HSUs improved more for the intervention group and the median between-group difference exceeded the minimal important difference threshold (intervention 0.16 utility points, control 0.10 utility points). For Intervention patients with high absolute risk (≥ 15%), HSU did not significantly change.

CONCLUSIONS

Absolute cardiovascular risk counselling in a chest pain clinic yielded clinically meaningful improvement in health-related quality of life.

Development of a CVD mortality risk score using nutritional predictors: A risk prediction model in the Golestan Cohort Study

BACKGROUND AND AIM

We aimed to develop a dietary score using prediction model method for evaluating the risk of cardiovascular disease (CVD) mortality and suggesting a simple and practical scoring system within the healthcare context.

METHOD AND RESULTS

A total of 43878 adult participants (aged 37-80 years) from the Golestan Cohort Study (GCS) were included in analysis. A random split of the subjects into the derivation (n = 28930) and the validation sets (n = 14948) was done. The Cox proportional hazard model was used to develop prediction model for the 8-year risk of CVD mortality. The model's discrimination and calibration were assessed by C-statistic and calibration plot, respectively. To enhance clinical utility, we devised a point-based scoring system derived from our model. This prediction model was developed by nine predictors including age, physical activity level (MET minutes/week), waist-to-hip ratio, tea intake (cup/day), vegetable intake (gr/1000 kcal/day), white meat intake (gr/1000 kcal/day), salt intake (gr/1000 kcal/day), dairy intake (Cup/1000 kcal/day), and percentage of protein intake. The model had an acceptable discrimination in both derivation (C-statistic: 0.76, p < 0.001) and validation (C- statistic: 0.77, p < 0.001) samples. Also, the calibration of model in both derivation and validation datasets was 0.81.

CONCLUSION

This is the first attempt to develop a risk prediction model of CVD mortality and the risk scoring system by the majority of nutritional predictors in a large cohort study. This nutritional risk assessment tool is suitable for motivating at-risk individuals to make lifestyle and dietary pattern changes to reduce future risk to prevent health problems.

Social and economic impacts of non-communicable diseases by gender and its correlates: a literature review

BACKGROUND

Tackling social impacts derived from gender disparities is a pathway to universal health coverage (UHC). Gender intersects with other factors behind social and health inequalities, exacerbates them and influences health systems' performance. However, there is scarcity of gender-based studies that assess the social and economic impacts of non-communicable diseases (NCDs). This study aims to identify economic and social impacts of NCDs by gender and its correlates.

METHODS

Following the guidelines proposed in the Cochrane Manual for Systematic Reviews of Interventions and the PRISMA Statement, we conducted a narrative and structured literature review to identify the economic (direct medical and non-medical, and indirect costs) and social (right to health, employment, poverty, social exclusion, and others) impacts of NCDs by gender, and its structural, sociodemographic, health conditions, political and health systems correlates, for the period 2002-2022, in English and Spanish. Reviewed studies were described according to country and research context, temporal evolution, gender, impacts of NCDs and correlates.

FINDINGS

Five thousand five hundred fifty-one publications by title and abstract were reviewed, and 185 articles were selected. There is limited evidence with gender perspective addressing the social and economic impacts of NCDs (around 10% of publications) that helps to better understand the difference in the burden of these conditions between men and women. We identified that the social burden primarily affects women in their quality of life, where gender inequities are observed in aspects such as: health care, employment status and living conditions. In addition, a greater responsibility falls on them as caregivers. On the other hand, the economic burden affects more to men, both in terms of direct medical costs and indirect costs. Among the factors that most influenced the identified impacts, we found gender, age, and socioeconomic level. We also identified that access to health insurance that offers financial protection against these conditions is essential to reduce these impacts.

CONCLUSIONS

NCDs pose a significant social and economic burden due to their impact on the health of the population, healthcare systems, and the economies of households and nations, which will likely increase over time. This impact is closely related to gender, although it has been scarcely documented. Public policies aimed at enhancing access and achieving UHC are essential to guarantee effective financial protection in health, especially for the most vulnerable sectors of the population.

Effectiveness of an online food shopping intervention to reduce salt purchases among individuals with hypertension - findings of the SaltSwitch Online Grocery Shopping (OGS) randomised trial

BACKGROUND

Online grocery shopping is a growing source of food purchases in many countries. We investigated the effect of nudging consumers towards purchases of lower sodium products using a web browser extension.

METHODS

This trial was conducted among individuals with hypertension who shopped for their groceries online in Australia. From July 2021 to June 2023, participants were randomised to use the SaltSwitch Online Grocery Shopping web browser extension or continue their usual grocery shopping for 12 weeks. The SaltSwitch extension modified a retailer's online shopping interface to suggest similar but lower sodium alternative products to those initially selected. The primary outcome was the difference in mean sodium density (mg sodium per 1000 kcal of energy) of packaged food purchases between the intervention and control groups.

RESULTS

We randomised 185 participants of average age 56.0 (SD 11.0) years. Most were women (64%), White (89%), had BMI > 25 kg/m2 (91%), and were taking anti-hypertensive medication (83%). Demographic and medical characteristics were similar across the randomised groups. 182 (98%) completed the trial. Over the 12-week intervention, the sodium density of groceries purchased by the intervention group compared to the control group was 204 mg/1000 kcal lower (95%CI, -352 to -56) (P = 0.01). The reduction in sodium density of purchases was apparent in weeks 1-4 and sustained through the end of the trial. 86% of participants in the intervention group made at least one switch to a lower sodium product. There were no detectable effects on blood pressure, spot urine sodium concentration, or other secondary outcomes across the 12-week study period.

CONCLUSIONS

Online shopping platforms provide a novel opportunity to support purchases of lower sodium foods. While the reductions in sodium density of purchases were moderate in size, population health benefits could nonetheless be large if they were sustained over time and at scale, with large and growing numbers of online grocery shoppers and a high prevalence of elevated blood pressure amongst adults.

TRIAL REGISTRATION

ACTRN12621000642886.

Hypertension: A Continuing Public Healthcare Issue

Hypertension is a cardiovascular disease defined by an elevated systemic blood pressure. This devastating disease afflicts 30-40% of the adult population worldwide. The disease burden for hypertension is great, and it greatly increases the risk of cardiovascular morbidity and mortality. Unfortunately, there are a myriad of factors that result in an elevated blood pressure. These include genetic factors, a sedentary lifestyle, obesity, salt intake, aging, and stress. Although lifestyle modifications have had limited success, anti-hypertensive drugs have been moderately effective in lowering blood pressure. New approaches to control and treat hypertension include digital health tools and compounds that activate the angiotensin receptor type 2 (AT2), which can promote cardiovascular health. Nonetheless, research on hypertension and its management is vital for lessening the significant health and economic burden of this condition.

Zinc-alpha2-glycoprotein modulates blood pressure by regulating renal lipid metabolism reprogramming-mediated urinary Na+ excretion in hypertension

AIMS

Organs modulating blood pressure are associated with a common cytokine known as adipokines. We chose Zinc-alpha2-glycoprotein (ZAG) due to its prioritized transcriptional level in the database. Previous studies showed that ZAG is involved in metabolic disorders. The aim of this study was to investigate its role in hypertension.

METHODS AND RESULTS

Serum ZAG levels were assessed in hypertensive and healthy participants. Blood pressure was monitored in Azgp1-/- mice and other animal models by 24-hour ambulatory implanted telemetric transmitters and tail-cuff method. Multi-omics analysis of proteomics and metabolomics were performed to explore possible mechanisms. Serum ZAG levels were significantly decreased and associated with morning urine Na+ excretion in hypertensive participants in a cross-sectional study. This study firstly reported that Azgp1-/- mice exhibited increased blood pressure and impaired urinary Na+ excretion, which were restored by AAV9-mediated renal tubule Azgp1 rescue. Azgp1 knockout caused the reprogramming of renal lipid metabolism, and increased Na+/H+-exchanger (NHE) activity in the renal cortex. Administration with a NHE inhibitor EIPA reversed the impaired urinary Na+ excretion in Azgp1-/- mice. Moreover, the activity of carnitine palmitoyltransferase 1 (CPT1), a key enzyme of fatty acid β-oxidation, was decreased, and the levels of malonyl-CoA, an inhibitor of CPT1, were increased in renal cortex of Azgp1-/- mice. Renal Cpt1 rescue improved urinary Na+ excretion and blood pressure in Azgp1-/- mice, accompanied by decreased renal fatty acid levels and NHE activity. Finally, administration of recombinant ZAG protein improved blood pressure and urinary Na+ excretion in spontaneous hypertension rats.

CONCLUSION

Deficiency of Azgp1 increased the malonyl CoA-mediated inhibition of CPT1 activity, leading to renal lipid metabolism reprogramming, resulting in accumulated fatty acids and increased NHE activity, subsequently decreasing urinary Na+ excretion and causing hypertension. These findings may provide a potential kidney-targeted therapy in the prevention and treatment of hypertension.

The Western and Chinese exercise training for blood pressure reduction among hypertensive patients: An overview of systematic reviews

Hypertension remains the world's leading cause of premature death. Interventions such as exercise, diet modification, and pharmacological therapy remain the mainstay of hypertension treatment. Numerous systematic reviews and meta-analyses demonstrated the effectiveness of western exercises, such as aerobic exercise and resistance exercise, in reducing blood pressure in hypertensive patients. There is recently emerging evidence of blood pressure reduction with Chinese exercises, such as Tai Chi, Baduanjin, and Qigong. The current overview of systematic reviews aims to evaluate the quality and descriptively summarize the evidence for the effectiveness of western and Chinese exercises for hypertension management. Thirty-nine systematic reviews were included in this overview, with 15 of those being on Chinese exercise. Evidence suggests that exercise training, regardless of Western or Chinese exercise, generally reduced both systolic and diastolic blood pressure. High-intensity intermittent training did not further reduce blood pressure when compared to moderate-intensity continuous training. Conflicting results on the effectiveness of blood pressure reduction when comparing Chinese and Western exercise training were observed. This suggests the comparable effectiveness of Chinese exercise training, in particularly Tai Chi, to general or aerobic exercise training in terms of blood pressure reduction. The Chinese exercise modality and intensity may be more suitable for the middle-aged and elderly population.

Effects of the discharge plan on the caregiving load of people with chronic disease: Quasi-experimental study

OBJECTIVE

To determine the effect of an anticipated care plan, structured around hospital discharge (PC-AH-US), regarding the caregiving load of people with NTCD residing in Colombia, 2019-2021.

METHOD

This is a quasi-experimental study with pre- and post-intervention measurements. It includes 1170 participants who represented 585 chronic disease patient-caregiver pairs. We compared the PC-AH-US intervention, to the regular intervention.

RESULTS

The PC-AH-US intervention group showed better results in all dimensions when compared to the regular intervention group: Awareness 8.7 (SD: 0.7) and 6.8 (SD: 1.7); Acknowledgement of their unique conditions 11.3 (SD: 1.0) and 9.4 (SD: 1.8); Capacity to fulfill care tasks 8.8 (SD: 0.7) and 7.5 (SD: 1.5); Wellbeing 11.4 (SD: 0.90) and 8.87 (SD: 2.3); Anticipation 5.88 (SD: 0.4) and 4.7 (SD: 1.1) and Support Network 11.4 (SD: 0.8) and 9.9 (SD: 2.5).

CONCLUSION

The PC-AH-US intervention group showed a statistically significant decrease in the caregiving load for people with NTCD (p < 00). There were no significant institutional differences in readmissions or deaths. The PC-AH-US intervention backs institutional policies meant to care for people with NTCD.

Trends in Cardiovascular Diseases and Costs Among Type 2 Diabetes Mellitus (T2DM) Patients in Malaysia: A Cohort Study of 240,611 Public Hospital Inpatients

BACKGROUND

Identifying trends of hospital admissions and costs for cardiovascular disease events (CVDEs) is crucial for public health intervention and the economic burden for future clinical improvements and better outcomes. This study aims to define the admission trends and cost of CVDE among type 2 diabetes mellitus (T2DM) patients in Malaysia between 2014 and 2020.  Methodology: An ecological study was conducted using hospital admission data taken from the Casemix database in public hospitals in Malaysia. Hospital admission data for CVDE among T2DM patients were extracted for the period between 2014 and 2020. The cost data were retrieved from the Malaysian Disease Related Group (MalaysianDRG) costing section, and the median and total costs were calculated per CVDE per year. Descriptive statistical analysis and multiple logistic regression models were used to analyze trends and factors associated.

RESULTS

A total of 240,611 T2DM admissions, representing 35.1% of 684,809 CVDE admissions, were included in this study. Among these, 32.9% were treated for myocardial infarction (MI), 20.1% for cerebrovascular accident (CVA), 19.4% for heart failure, 12.8% for ischemic heart disease (IHD), 8.2% for hypertensive heart disease (HHD), 5.6% for cardiomyopathy, and 1.0% for atherosclerosis and peripheral vascular disease (PVD). CVDE admissions were prevalent among males (59.2%) and associated with higher cost of admission (β = 1.13, P < 0.001), patients aged 40-49 years old had 24% high odd for high cost (β = 1.24, P < 0.001) compared to those aged 19-29 years. Compared to Malay, Chinese and other ethnicities were significantly associated with high cost (β = 1.13, P < 0.001). Patients with severity level III were 10 times more likely to have higher costs as compared to severity level I (β = 10.39, P < 0.001), 72.6% were admitted in less than five days, and 23.1% were less likely to incur high cost as compared to patients admitted more than five days (β = 0.769, P < 0.001). The trend of admissions is increasing each year, with the median total hospital expenditure higher in IHD patients with T2DM, which increased by 55.5% from 2014 to 2020 (from RM 4,187.98 to RM 6,510.43). This was followed by MI, which saw an 8% increase (from RM 3,881.80 to RM 4,211.18).

CONCLUSIONS

The findings of this research indicated cardiovascular disease (CVD) admission trends and costs increased substantially over the years and higher costs in dual noncommunicable diseases (NCDs). These findings underscore the urgent need for enhanced preventive strategies targeting high-risk populations, such as males, individuals with severe disease levels, and specific ethnic groups. Policies should emphasize lifestyle modification programs, early diagnosis of cardiovascular risks among T2DM patients, and cost-effective treatments to mitigate the growing financial burden. Furthermore, resource allocation must be adjusted to address the increasing demand for care, particularly for conditions like IHD and MI, ensuring equitable access to quality care while containing healthcare costs.

Associations Among Reduced Income, Unhealthy Habits, the Prevalence of Non-Communicable Diseases, and Multimorbidity in Middle-Aged and Older US Adults: A Cross-Sectional Study

INTRODUCTION

Evidence supports the relationships between socioeconomic status and access to health care, incidence of pathologies, and lifestyle.

OBJECTIVE

The aim of this research was to investigate whether there are associations between having a household income below the poverty line, and participation in unhealthy lifestyle habits, the prevalence of non-communicable diseases, and the number of comorbidities in US middle-aged and older adults.

METHODS

This cross-sectional study is based on the NHANES 2011-2020. A total of 10,788 US middle-aged and older adults (5653 males and 5135 females) participated in this research. Associations were studied through the Chi-squared test, and odds ratios were calculated using a binary logistic regression model.

RESULTS

There were associations between a household income below the poverty line and physical inactivity, unhealthy diet, and being or having been an alcoholic. Associations were found between this adverse economic situation and having hypertension, diabetes, liver disease, kidney problems, arthritis, congestive heart failure, angina pectoris, heart attack, stroke, and also with having two or more, three or more, four or more, and five or more comorbidities. Increased odds of being involved in these unhealthy habits and of suffering these diseases and multimorbidity were found for those with a family income below the poverty threshold.

CONCLUSIONS

The existence of associations between having a family income under the poverty threshold and having unhealthy habits, suffering non-communicable diseases, and having multimorbidity is confirmed in US middle-aged and older adults. Increased odds for various non-communicable diseases, multimorbidity, and for being involved in these unhealthy habits were found for this low-income group. These findings should serve to draw the attention of policy makers to the increased health vulnerability of the adult population below the poverty line in the US.

The comparison of the prevalence, awareness, treatment and control of hypertension among adults along the three provinces of the Lancang-Mekong River countries-China, Laos and Cambodia

BACKGROUND

Under the background of similar geography and culture in Lancang-Mekong countries and rapid changes in the regional economy and lifestyle, this study aimed to describe and compare the prevalence, awareness, treatment, and control of hypertension and assess the hypertension care cascade in three provinces of China, Laos, and Cambodia.

METHODS

A cross-sectional study was conducted between 2021 and 2023 in the three provinces of Lancang-Mekong River countries using consistent investigative procedures. We included 11,005 participants aged ≥ 18 years from three provinces, and data were collected through questionnaires, physical examinations, and biochemical tests. We analyzed the cascade of hypertension care and compared the prevalence, awareness, treatment, and control of hypertension.

RESULTS

The hypertension care cascade indicated that 46.3%, 51.6%, and 63.1% of patients in Yunnan Province (China), Oudomxay Province (Laos), and Ratanakiri Province (Cambodia), respectively, were not diagnosed, and 10.7%, 12.8% and 21.1% of patients, respectively, did not receive treatment. After sex-age standardization, the prevalence rates of hypertension in the three provinces were 33.4%, 34.5%, and 23.6%, respectively. Higher awareness rate in Yunnan Province (53.4%) and Oudomxay Province (46.5%) than in Ratanakiri Province of Cambodia (39.7%). The treatment rate of hypertension in Yunnan Province (42.4%) was higher than that in Oudomxay Province (34.5%), and Ratanakiri Province (16.9%). In addition, less than 20% of the patients in the three provinces had their blood pressure under control. The factors associated with hypertension differed across the three provinces.

CONCLUSIONS

In the three provinces of the Lancang-Mekong River Basin countries, there is a high burden of hypertension and a significant unmet need for hypertension care. Targeted and precise intervention strategies are urgently needed to improve the awareness, treatment, and control of hypertension in low- and middle-income regions.

Prevention and control of cardiovascular disease in "real-world" settings: sustainable implementation of effective policies

Global progress in addressing cardiovascular diseases (CVD) has been insufficient to attain the nine WHO non-communicable disease (NCD) targets and the Sustainable Development Goal (SDG) target of reducing premature NCD mortality by one-third by 2030. Progress has been slowest in low- and middle-income countries (LMIC) where addressing the CVD burden is a foremost development imperative. This review examines the reasons for this situation to propose a way forward. First, we review policy instruments to address behavioral and metabolic risk factors of CVD and health system interventions to improve cardiovascular outcomes. Second, we illustrate the financial, health workforce, health system challenges, and weak national capacity that impede the implementation of these policy instruments. Third, we discuss how LMIC might move forward despite these challenges by (a) giving due consideration to contextual and other factors that determine the success of policy implementation (b) including affordable, high-impact interventions as the core of the universal health coverage health benefit package with primary health care as the foundation and (c) by taking note of the WHO guidance provided in the 2023-2030 implementation roadmap for the Global Action Plan for prevention and control of NCD.

Atherogenic Combined Index: Validation of a Coronary Artery Disease Predictive Biomarker

BACKGROUND/AIM

The balance between atherogenic and antiatherogenic lipid particles significantly influences coronary artery disease (CAD), as an imbalance may contribute to the development and progression of atherosclerosis, which affects the risk and severity of CAD. This study aims to introduce and validate the atherogenic combined index (ACI) as a novel lipid biomarker that, comprehensively assesses the balance between atherogenic and antiatherogenic particles in the blood to effectively reflect the cumulative atherogenic effect and its association with the presence and severity of CAD.

MATERIAL AND METHODS

In this cross-sectional study, 1,830 patients diagnosed with CAD and a total of 650 patients without CAD were included in the study cohort for comprehensive analysis and comparison. Based on the tertiles of the SYNTAX score (SS), three subgroups of patients with CAD were identified. ACI and other atherogenic indices were compared to predict the presence and severity of CAD.

RESULTS

The levels of ACI and other non-traditional lipid markers levels were higher in the CAD group compared to the non-CAD group (p <0.05, for all). ACI showed a good linear association with the SYNTAX score (r = 0.527; p <0.001). The multivariate logistic regression model showed that ACI was an independent predictor of the presence (OR: 1.602, 95% CI: 1.509-1.701, p <0.001) and severity (OR: 1.296, 95% CI: 1.243-1.351, p <0.001) of CAD after adjustment for various confounders.

CONCLUSION

The results suggest that ACI may serve as a promising and stronger tool for predicting the presence and severity of CAD.

Differences in cardiovascular disease mortality between northern and southern China under exposure to different temperatures: a systematic review

Background

Due to differences in climate and other environmental factors, exposure to different temperatures in China has different effects on the relative risk (RR) of cardiovascular disease (CVD) mortality. It is therefore important to compare the effects of exposure to different temperatures on CVD mortality in different regions of China.

Methods

To compare these effects, we performed a meta-analysis of 21 studies identified by a search of the Web of Science and China National Knowledge Infrastructure databases from January 1, 2014 to January 1, 2024. We performed the Cochran Q test and I 2 statistics test to evaluate heterogeneity and Egger's test to evaluate publication bias.

Results

The pooled estimated size of the relationship between exposure to different temperatures and CVD mortality was 1.60 (95% confidence interval [CI]: [1.42-1.80]) for the extreme cold, 1.17 (95% CI [1.10-1.25]) for the extreme heat, and 1.16 (95% CI [1.10-1.24]) for extremely high diurnal temperature range (DTR). The Egger's test showed potential publication bias in studies analyzing both the extreme cold and the extreme heat.

Discussion

Extreme cold, extreme heat, and extremely high DTR are associated with an increase in CVD mortality in China, with extreme cold having the most significant effect. Residents of northern regions are more susceptible to high temperatures, while residents of southern regions are more sensitive to low temperatures.

Deep Learning-Enhanced Paper-Based Vertical Flow Assay for High-Sensitivity Troponin Detection Using Nanoparticle Amplification

Successful integration of point-of-care testing (POCT) into clinical settings requires improved assay sensitivity and precision to match laboratory standards. Here, we show how innovations in amplified biosensing, imaging, and data processing, coupled with deep learning, can help improve POCT. To demonstrate the performance of our approach, we present a rapid and cost-effective paper-based high-sensitivity vertical flow assay (hs-VFA) for quantitative measurement of cardiac troponin I (cTnI), a biomarker widely used for measuring acute cardiac damage and assessing cardiovascular risk. The hs-VFA includes a colorimetric paper-based sensor, a portable reader with time-lapse imaging, and computational algorithms for digital assay validation and outlier detection. Operating at the level of a rapid at-home test, the hs-VFA enabled the accurate quantification of cTnI using 50 μL of serum within 15 min per test and achieved a detection limit of 0.2 pg/mL, enabled by gold ion amplification chemistry and time-lapse imaging. It also achieved high precision with a coefficient of variation of <7% and a very large dynamic range, covering cTnI concentrations over 6 orders of magnitude, up to 100 ng/mL, satisfying clinical requirements. In blinded testing, this computational hs-VFA platform accurately quantified cTnI levels in patient samples and showed a strong correlation with the ground truth values obtained by a benchtop clinical analyzer. This nanoparticle amplification-based computational hs-VFA platform can democratize access to high-sensitivity point-of-care diagnostics and provide a cost-effective alternative to laboratory-based biomarker testing.

The economic burden of type 2 diabetes on the public healthcare system in Kenya: a cost of illness study

BACKGROUND

The burden of chronic non-communicable diseases (NCDs) is a growing public health concern. The availability of cost-of-illness data, particularly public healthcare costs for NCDs, is limited in Sub-Saharan Africa (SSA), yet such data evidence is needed for policy action.

OBJECTIVE

The objective of this study was to estimate the economic burden of type 2 diabetes (T2D) on Kenya's public healthcare system in 2021 and project costs for 2045.

METHODS

This was a cost-of-illness study using the prevalence-based bottom-up costing approach to estimate the economic burden of T2D in the year 2021. We further conducted projections on the estimated costs for the year 2045. The costs were estimated corresponding to the care, treatment, and management of diabetes and some diabetes complications based on the primary data collected from six healthcare facilities in Nairobi and secondary costing data from previous costing studies in low and middle-income countries (LMICs). The data capture and costing analysis were done in Microsoft Excel 16, and sensitivity analysis was conducted on all the parameters to estimate the cost changes.

RESULTS

The total cost of managing T2D for the healthcare system in Kenya was estimated to be US$ 635 million (KES 74,521 million) in 2021. This was an increase of US$ 2 million (KES 197 million) considering the screening costs of undiagnosed T2D in the country. The major cost driver representing 59% of the overall costs was attributed to T2D complications, with nephropathy having the highest estimated costs of care and management (US$ 332 million (KES 36, 457 million). The total cost for T2D was projected to rise to US$ 1.6 billion (KES 177 billion) in 2045.

CONCLUSION

This study shows that T2D imposes a huge burden on Kenya's healthcare system. There is a need for government and societal action to develop and implement policies that prevent T2D, and appropriately plan care for those diagnosed with T2D.

Machine learning-based risk prediction for major adverse cardiovascular events in a Brazilian hospital: Development, external validation, and interpretability

BACKGROUND

Studies of cardiovascular disease risk prediction by machine learning algorithms often do not assess their ability to generalize to other populations and few of them include an analysis of the interpretability of individual predictions. This manuscript addresses the development and validation, both internal and external, of predictive models for the assessment of risks of major adverse cardiovascular events (MACE). Global and local interpretability analyses of predictions were conducted towards improving MACE's model reliability and tailoring preventive interventions.

METHODS

The models were trained and validated on a retrospective cohort with the use of data from Ribeirão Preto Medical School (RPMS), University of São Paulo, Brazil. Data from Beth Israel Deaconess Medical Center (BIDMC), USA, were used for external validation. A balanced sample of 6,000 MACE cases and 6,000 non-MACE cases from RPMS was created for training and internal validation and an additional one of 8,000 MACE cases and 8,000 non-MACE cases from BIDMC was employed for external validation. Eight machine learning algorithms, namely Penalized Logistic Regression, Random Forest, XGBoost, Decision Tree, Support Vector Machine, k-Nearest Neighbors, Naive Bayes, and Multi-Layer Perceptron were trained to predict a 5-year risk of major adverse cardiovascular events and their predictive performance was evaluated regarding accuracy, ROC curve (receiver operating characteristic), and AUC (area under the ROC curve). LIME and Shapley values were applied towards insights about model interpretability.

FINDINGS

Random Forest showed the best predictive performance in both internal validation (AUC = 0.871 (0.859-0.882); Accuracy = 0.794 (0.782-0.808)) and external one (AUC = 0.786 (0.778-0.792); Accuracy = 0.710 (0.704-0.717)). Compared to LIME, Shapley values suggest more consistent explanations on exploratory analysis and importance of features.

CONCLUSIONS

Among the machine learning algorithms evaluated, Random Forest showed the best generalization ability, both internally and externally. Shapley values for local interpretability were more informative than LIME ones, which is in line with our exploratory analysis and global interpretation of the final model. Machine learning algorithms with good generalization and accompanied by interpretability analyses are recommended for assessments of individual risks of cardiovascular diseases and development of personalized preventive actions.

Real-world evidence study on the impact of SPECT MPI, PET MPI, cCTA and stress echocardiography on downstream healthcare utilisation in patients with coronary artery disease in the US

BACKGROUND

Coronary artery disease (CAD) is associated with a large clinical and economic burden. However, consensus on the optimal approach to CAD diagnosis is lacking. This study sought to compare downstream healthcare resource utilisation following different cardiac imaging modalities, to inform test selection for CAD diagnosis.

METHODS

Claims and electronic health records data from the Decision Resources Group Real-World Evidence US Data Repository were analysed for 2.5 million US patients who underwent single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI), positron emission tomography myocardial perfusion imaging (PET MPI), coronary computed tomography angiography (cCTA), or stress echocardiography between January 2016 and March 2018. Patients were stratified into nine cohorts based on suspected or existing CAD diagnosis, pre-test risk, and prior events or interventions. Downstream healthcare utilisation, including additional diagnostic imaging, coronary angiography, and cardiac-related health system encounters, was compared by cohort and index imaging modality.

RESULTS

Among patients with suspected CAD diagnosed within 3 months of the index test, PET MPI was associated with lower downstream utilisation; 25-37% of patients who underwent PET MPI required additional downstream healthcare resources compared with 40-49% of patients who received SPECT MPI, 35-41% of patients who underwent cCTA, and 44-47% of patients who received stress echocardiography. Patients who underwent PET MPI experienced fewer acute cardiac events (5.3-9.4%) and generally had lower rates of healthcare encounters (0.8-4.1%) and invasive coronary angiography (ICA, 15.4-24.2%) than those who underwent other modalities. SPECT MPI was associated with more downstream ICA (31.3-38.2%) and a higher rate of cardiac events (9.5-13.2%) compared with PET MPI (5.3-9.4%) and cCTA (6.9-9.9%). Across all cohorts, additional diagnostic imaging was 1.6 to 4.7 times more frequent with cCTA compared with PET MPI.

CONCLUSION

Choice of imaging modality for CAD diagnosis impacts downstream healthcare utilisation. PET MPI was associated with lower utilisation across multiple metrics compared with other imaging modalities studied.

The financial burden of noncommunicable diseases from out-of-pocket expenditure in sub-Saharan Africa: a scoping review

The growing financial burden of noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA) hinders the attainment of the sustainable development goals. However, there has been no updated synthesis of evidence in this regard. Therefore, our study summarizes the current evidence in the literature and identifies the gaps. We systematically search relevant databases (PubMed, Scopus, ProQuest) between 2015 and 2023, focusing on empirical studies on NCDs and their financial burden indicators, namely, catastrophic health expenditure (CHE), impoverishment, coping strategies, crowding-out effects and unmet needs for financial reasons (UNFRs) in SSA. We examined the distribution of the indicators, their magnitudes, methodological approaches and the depth of analysis. The 71 included studies mostly came from single-country (n = 64), facility-based (n = 52) research in low-income (n = 22), lower-middle-income (n = 47) and upper-middle-income (n = 10) countries in SSA. Approximately 50% of the countries lacked studies (n = 25), with 46% coming from West Africa. Cancer, cardiovascular disease (CVD) and diabetes were the most commonly studied NCDs, with cancer and CVD causing the most financial burden. The review revealed methodological deficiencies related to lack of depth, equity analysis and robustness. CHE was high (up to 95.2%) in lower-middle-income countries but low in low-income and upper-middle-income countries. UNFR was almost 100% in both low-income and lower-middle-income countries. The use of extreme coping strategies was most common in low-income countries. There are no studies on crowding-out effect and pandemic-related UNFR. This study underscores the importance of expanded research that refines the methodological estimation of the financial burden of NCDs in SSA for equity implications and policy recommendations.

The Association Between Direct Health Costs Related to Non-communicable Diseases and Physical Activity in Elderly People

The aim of this study was to evaluate the association between direct health costs related to non-communicable diseases (NCDs) and the level of physical activity in Chinese elderly people. In this longitudinal study, 410 people over 64 years old were selected from health centers. The direct health costs caused by NCDs were recorded on a weekly basis for a period of six months. Also, physical activity was measured using FitBit Flex2™ and as the number of daily steps as well as calories burned during this six month. The multiple linear regression analysis was used to identify the predictors of direct health costs caused by NCDs as the dependent variable. Age, gender, marital status, education level, currently working, Fitbit steps and calories, and BMI were entered into the model as predictor variables to perform a stepwise regression analysis. Four variables of age, BMI, Fitbit steps and Fitbit calories were able to enter the regression model. The model explained 24.8% of the variability of direct health costs due to NCDs. The strongest predictor of health costs was Fitbit calories (B = - 2.113, t =  - 4.807, p < 0.001), followed by BMI (B = 1.267, t = 3.482, p < 0.001), Fitbit steps (B =  - 1.157, t =  - 3.118, p < 0.001), and age (B = 1.115, t = 2.599, p < 0.001). It can be said that having regular physical activity can reduce health costs due to NCDs in Chinese older people.

Burden of cardiovascular disease attributable to lead exposure in China: a comprehensive analysis of data from 1990 to 2019

OBJECTIVE

To analyze the burden of cardiovascular disease (CVD) caused by lead pollution exposure in China from 1990 to 2019.

METHODS

Utilizing data from the Global Burden of Disease 2019 (GBD 2019), this research examines the changes in the number of CVD deaths, deaths rates, disability-adjusted life years (DALYs) and DALY rates, as well as their age-normalization rates, due to lead pollution exposure in China from 1990 to 2019. Joinpoint was used to estimate average annual percentage of change (AAPC) and reflect the time change trend of the burden of CVD caused by lead pollution exposure in China, the world and different socio-demographic index (SDI) regions.

RESULTS

The age-standardized mortality rate and age-standardized DALY rate showed a decreasing trend in China from 1990 to 2019, with an average annual decrease of -1.17% (95% confidence interval (CI): -3.49~-3.14, P<0.05) and -1.90% (95% CI: -2.04~-1.75, P<0.05), respectively. In 2019, age-standardized CVD mortality and DALY rates attributed to lead exposure in China were higher than those in the global, high-SDI, medium-high SDI and moderate SDI regions. In 2019, 5.94% of CVD deaths in China were caused by lead exposure. Compared to 1990, the number of attributable deaths and mortality increased by 0.73% and 0.44%, respectively, and the attributable DALY and DALY rates increased by 30.04% and 8.22%, respectively. From 1990 to 2019, the mortality rate and DALY rate of males were higher than those of females, and the mortality rate and DALY rate increased with the increase of age, reaching the highest in the age group of 70 years and above.

CONCLUSION

In 2019, the standardized death rate of CVD and the standardized DALY rate attributed to lead pollution exposure in China were higher than those in the global regions with high SDI, medium-high SDI and medium SDI. The findings highlight demographic disparities in CVD deaths and DALYs attributable to lead exposure, with males and the elderly identified as high-risk groups.

Dynamic trends of ischemic heart disease mortality attributable to high low-density lipoprotein cholesterol: a joinpoint analysis and age-period-cohort analysis with predictions

AIMS

The purpose of this study was to analyze the dynamic trends of ischemic heart disease (IHD) mortality attributable to high low-density lipoprotein cholesterol (LDL-C).

METHODS

Data on IHD mortality attributable to high LDL-C from 1990 to 2021 were extracted from the global disease burden database. Joinpoint software was used to estimate the average annual percentage change (AAPC) in the age-standardized mortality rate (ASMR). An age‒period‒cohort model was used to analyze the impacts of age, period, and cohort on these changes. The Bayesian framework was used to predict IHD mortality attributable to high LDL-C from 2022 to 2040.

RESULTS

The overall ASMR of IHD attributable to high LDL-C decreased from 50. 479 per 100,000 people in 1990 to 32.286 per 100,000 people in 2021, and ASMR of IHD attributable to high LDL-C was higher in males than in females. The longitudinal age curves of the overall IHD mortality attributable to high LDL-C showed a monotonic upward trend, especially after 65 years of age. The period and cohort effect relative risk (RR) values of overall IHD mortality attributable to high LDL-C showed a downward trend. The overall ASMR of IHD attributable to high LDL-C is predicted to show a downward trend, and male IHD mortality attributable to high LDL-C is expected to be higher than that of females.

CONCLUSION

This study revealed a sustained decrease in IHD mortality attributable to high LDL-C over three decades, with a continued decline expected. Despite this, gender disparities persist, with males experiencing higher mortality rates and elderly individuals remaining a vulnerable group.

Cardiovascular risk assessment using non-laboratory based WHO CVD risk prediction chart with respect to hypertension status among older Indian adults: insights from nationally representative survey

Introduction

Knowledge of the risk of developing cardiovascular diseases (CVD) in the population is an important risk management strategy for the prevention of this disease. This is especially true for India, which has resource-restrained settings with an increased risk in a younger population for the development of the disease. An important modifiable risk factor for CVD is hypertension, with its influence on the development of CVD.

Methods

The data from the first wave of the Longitudinal Ageing Study in India (LASI) was used to calculate the 10-year CVD Risk Score among older adults ≥45 years using a WHO (2019) non-laboratory- based chart for South Asia. Univariate analysis was done using Pearson's chi-square test, and multivariable analysis using ordinal logistic regression. Categories of CVD risk score were considered as dependent variable. Socio-demographic variables, regular exercise, history of diabetes and hyperlipidaemia were considered as the independent variables. Relationship between CVD Risk score and hypertensives and self-reported hypertensives were presented using restricted cubic splines.

Result

Two-thirds (68.8%) of the population had a 10-year CVD risk of <10, and 2.8% had a risk of ≥20%. The self-reported hypertensives were distributed linearly in restricted cubic splines, with a more scattered distribution in higher scores, while actual hypertensives showed a sigmoid pattern. Urban residents (OR-0.88), being unmarried (OR-0.86), being in the richer (OR-0.94) and richest (OR-0.86) monthly per capita expenditure (MPCE) quintile and exercising regularly (OR-0.68) decreased the odds of being in a higher CVD risk score. Less than primary schooling (1.21) and diabetics (1.69) had higher odds for a higher CVD risk score.

Conclusion

In this population, two-thirds had <10% risk for the development of CVD. The study shows a higher risk among rural, poor, and those with a lower education and lower CVD risk for those undertaking physical activity. The sigmoid pattern in actual hypertensives highlights the need for early detection. Even those with undiagnosed hypertension but with a higher BP had a similar risk for disease development, thus highlighting the need for an early detection of hypertension.

The impact of social relationships on the risk of stroke and post-stroke mortality: a systematic review and meta-analysis

BACKGROUND

The association between poor social relationships and post-stroke mortality remains uncertain, and the evidence regarding the relationship between poor social relationships and the risk of stroke is inconsistent. In this meta-analysis, we aim to elucidate the evidence concerning the risk of stroke and post-stroke mortality among individuals experiencing a poor social relationships, including social isolation, limited social networks, lack of social support, and loneliness.

METHODS

A thorough search of PubMed, Embase, and the Cochrane Library databases to systematically identify pertinent studies. Data extraction was independently performed by two researchers. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using either a random-effects or fixed-effects model. Sensitivity analyses were conducted to evaluate the reliability of the results. Random-effects meta-regression was performed to explore the sources of heterogeneity in stroke risk estimates between studies. Assessment for potential publication bias was carried out using Egger's and Begg's tests.

RESULTS

Nineteen studies were included, originating from 4 continents and 12 countries worldwide. A total of 1,675,707 participants contributed to this meta-analysis. Pooled analyses under the random effect model revealed a significant association between poor social relationships and the risk of stroke (OR = 1.30; 95%CI: 1.17-1.44), as well as increased risks for post-stroke mortality (OR = 1.36; 95%CI: 1.07-1.73). Subgroup analyses demonstrated associations between limited social network (OR = 1.52; 95%CI = 1.04-2.21), loneliness (OR = 1.31; 95%CI = 1.13-1.51), and lack of social support (OR = 1.66; 95%CI = 1.04-2.63) with stroke risk. The meta-regression explained 75.21% of the differences in reported stroke risk between studies. Random-effect meta-regression results indicate that the heterogeneity in the estimated risk of stroke may originate from the continent and publication year of the included studies.

CONCLUSION

Social isolation, limited social networks, lack of social support, and feelings of loneliness have emerged as distinct risk factors contributing to both the onset and subsequent mortality following a stroke. It is imperative for public health policies to prioritize the multifaceted influence of social relationships and loneliness in stroke prevention and post-stroke care.

TRIAL REGISTRATION

The protocol was registered on May 1, 2024, on the Prospero International Prospective System with registration number CRD42024531036.

Predicting high blood pressure using machine learning models in low- and middle-income countries

Responding to the rising global prevalence of noncommunicable diseases (NCDs) requires improvements in the management of high blood pressure. Therefore, this study aims to develop an explainable machine learning model for predicting high blood pressure, a key NCD risk factor, using data from the STEPwise approach to NCD risk factor surveillance (STEPS) surveys. Nationally representative samples of adults aged 18-69 years were acquired from 57 countries spanning six World Health Organization (WHO) regions. Data harmonization and processing were performed to standardize the selected predictors and synchronize features across countries, yielding 41 variables, including demographic, behavioural, physical, and biochemical factors. Five machine learning models - logistic regression, k-nearest neighbours, random forest, XGBoost, and a fully connected neural network - were trained and evaluated at global, regional, and country-specific levels using an 80/20 train-test split. The models' performance was assessed using accuracy, precision, recall, and F1 score. Feature importance analysis identified age, weight, heart rate, waist circumference, and height as key predictors of blood pressure. Across the 57 countries studied, model performances varied considerably, with accuracy ranging from as low as 58.96% in some models for specific countries to as high as 81.41% in others, underscoring the need for region and country-specific adaptations in modelling approaches. The explainable model offers an opportunity for population-level screening and continuous risk assessment in resource-limited settings.

Health lifestyles of six Zhiguo ethnic groups in China: a latent class analysis

BACKGROUND

Zhiguo ethnic groups, commonly known as "the directly-entering-socialism ethnic groups", represent Chinese ethnic minorities who have undergone a unique social development trajectory by transforming directly from primitive societies to the socialist stage. In recent decades, significant lifestyle transformations have occurred among Zhiguo ethnic groups. Understanding their health lifestyles can play a strategic role in China's pursuit of universal health coverage. This study aims to examine patterns of health-related lifestyle among Zhiguo ethnic groups and explore whether sociodemographic features and specific indicators related to health status are associated with particular classes.

METHODS

A cross-sectional study was conducted in Yunnan Province, China, from July to December 2022. Stratified random sampling method was employed to recruit residents belonging to six Zhiguo ethnic groups aged between 15 and 64. Latent class analysis was performed to identify clusters of health-related behaviors within each ethnic group. Logistic regression was utilized to determine the predictors of health lifestyles.

RESULTS

A total of 1,588 individuals from the Zhiguo ethnic groups participated in this study. Three latent classes representing prevalent health lifestyles among the Zhiguo ethnic groups were identified: "unhealthy lifestyle" (31.80%), "mixed lifestyle" (57.37%), and "healthy lifestyle" (10.83%). In the overall population, individuals belonging to the "healthy lifestyle" group exhibited a higher likelihood of being non-farmers (OR: 2.300, 95% CI: 1.347-3.927), women (OR: 21.459, 95% CI: 13.678-33.667), married individuals (OR: 1.897, 95% CI: 1.146-3.138), and those residing within a walking distance of less than 15 min from the nearest health facility (OR: 2.133, 95% CI: 1.415-3.215). Conversely, individuals in the age cohorts of 30-39 years (OR: 0.277, 95% CI: 0.137-0.558) and 40-49 years (OR: 0.471, 95% CI: 0.232-0.958) showed a decreased likelihood of adopting a healthy lifestyle.

CONCLUSIONS

A considerable proportion of the Zhiguo ethnic groups have not adopted healthy lifestyles. Targeted interventions aimed at improving health outcomes within these communities should prioritize addressing the clustering of unfavorable health behaviors, with particular emphasis on single male farmers aged 30-49, and expanding healthcare coverage for individuals residing more than 15 min away from accessible facilities.

The impact of health insurance on hypertension care: a household fixed effects study in India

INTRODUCTION

Hypertension is highly prevalent in India, but the proportion of patients achieving blood pressure control remains low. Efforts have been made to expand health insurance coverage nationwide with the aim of improving overall healthcare access. It is critical to understand the role of health insurance coverage in improving hypertension care.

METHODS

We used secondary data from the nationally representative sample of adults aged 15-49 years from the 2015-2016 National Family Health Survey (NFHS) in India. We defined the hypertension care cascade as four successive steps of (1) screened, (2) diagnosed, (3) treated, and (4) controlled, and operationalized these variables using blood pressure measurements and self-reports. We employed household fixed effect models that conceptually matched people with and without insurance within the household, to estimate the impact of insurance coverage on the likelihood of reaching each care cascade step, while controlling for a wide range of additional individual-level variables.

RESULTS

In all 130,151 included individuals with hypertension, 20.4% reported having health insurance. For the insured hypertensive population, 79.8% (95% Confidence Interval: 79.3%-80.3%) were screened, 49.6% (49.0%-50.2%) diagnosed, 14.3% (13.9%-14.7%) treated, and 7.9% (7.6%-8.2%) controlled, marginally higher than the percentages for the uninsured 79.8% (79.5%-80.0%), 48.2% (47.9%-48.6%), 13.3% (13.1%-13.5%), and 7.5% (7.4%-7.7%) for each cascade step, respectively. From the household fixed effects model, health insurance did not show significant impact on the hypertension care cascade, with the estimated relative risks of health insurance 0.97 (0.93-1.02), 0.97 (0.91-1.03), 0.95 (0.77-1.30), and 0.97 (0.65-1.10) for each cascade step, respectively. We further performed stratified analyses by sociodemographic and behavioral risk factors and a sensitivity analysis with district fixed effects, all of which yielded results that confirmed the robustness of our main findings.

CONCLUSIONS

Health insurance did not show significant impact on improving hypertension care cascade among young and middle-aged adults with hypertension in India. Innovative strategies for overcoming practical barriers to healthcare services in addition to improving financial access are needed to address the large unmet need for hypertension care.

Prevalence and influencing factors of kinesiophobia in patients with heart disease: a meta-analysis and systematic review

This study aims to assess the global prevalence of kinesiophobia and the potential influencing factors among patients with heart disease. A comprehensive search was conducted in PubMed, Embase, Web of Science, PsycINFO, and Scopus databases to identify studies reporting on the prevalence of kinesiophobia and its influencing factors in heart disease patients up to January 2024. A random-effects model was employed to aggregate prevalence rates. Heterogeneity sources were investigated through subgroup analysis, while differences in the prevalence of kinesiophobia across regions, types of heart disease, and gender were evaluated. Additionally, a qualitative analysis of the factors influencing kinesiophobia was performed. This research incorporated 15 studies from six countries, with 14 providing data on the prevalence of kinesiophobia and nine exploring its potential influencing factors. The findings indicated that the overall prevalence of kinesiophobia among heart disease patients was 61.0% (95% CI 49.4-72.6%). Subgroup analysis revealed that the prevalence in upper-middle-income countries was 71.8% (95% CI 66.2-77.4%), while it stands at 49.9% (95% CI 30.2-69.5%) in high-income countries. The prevalence rates among patients with coronary artery disease, heart failure, and atrial fibrillation were 63.2% (95% CI 45.2-81.3%), 69.2% (95% CI 57.6-80.8%), and 71.6% (95% CI 67.1-76.1%), respectively. Gender-wise, no significant difference was observed in the prevalence of kinesiophobia between men and women (52.2% vs. 51.8%). A total of 24 potential influencing factors of kinesiophobia were identified, with education level, monthly income, anxiety, and exercise self-efficacy being the most recognized. The prevalence of kinesiophobia in patients with heart disease is notably high and is influenced by a multitude of factors. Early implementation of targeted preventive measures is imperative to mitigate the incidence of kinesiophobia in this population.

Reduced Income and Its Associations with Physical Inactivity, Unhealthy Habits, and Cardiac Complications in the Hypertensive Population

(1) Background: A low socioeconomic status significantly increases the risk of hypertension and its associated cardiovascular diseases due to limited access to healthcare and may be even more accentuated by the presence of unhealthy lifestyle habits. The aim of the present research was to study if associations exist between having a family income under the poverty threshold and having an unhealthy diet, being physically inactive, being an alcohol drinker, perceiving one's own health as bad, and suffering from congestive heart failure, coronary heart disease, angina pectoris, heart attack, or stroke. Additionally, the odds ratios of having these unhealthy habits and of suffering from the abovementioned cardiac complications of participants under the poverty threshold were calculated. (2) Methods: This cross-sectional study was based on the National Health and Nutrition Examination Survey (NHANES) 2011-2020. The sample comprised 6120 adults with hypertension (3188 males and 2932 females). A descriptive analysis and non-parametric chi-squared tests were used to study the associations. A binary logistic regression model and backward LR method were used to calculate the odds ratios, normalized by age and sex. (3) Results: The chi-squared test showed associations between having a family income under the poverty threshold and being physically inactive (p < 0.001), having an unhealthy diet (p < 0.001), being an alcohol drinker (p < 0.001), perceiving one's own health as bad (p < 0.001), and suffering from congestive heart failure (p = 0.002), heart attack (p = 0.001), or stroke (p = 0.02). A significantly increased odds ratio for these unhealthy habits and cardiac complications, and also for having coronary heart disease and angina pectoris, were found for hypertension sufferers under the poverty threshold. (4) Conclusions: It was confirmed that having a family income under the poverty threshold is associated with perceiving one's own health as bad, having a series of negative habits in terms of physical activity, diet, and alcohol consumption, and with suffering from congestive heart failure, heart attack, or stroke. Increased odds ratios for these unhealthy habits and these conditions, plus coronary heart disease and angina pectoris, were found for hypertension sufferers under the poverty threshold.

Estimation and determinants of direct hospitalisation cost for coronary heart disease in a low-middle-income country: evidence from a nationwide study in Iranian hospitals

BACKGROUND

Coronary heart disease (CHD) is the most prevalent type of cardiovascular disease in Iran. This study aims to investigate the estimation and determinants of direct hospitalisation cost for patients with CHD in Iranian hospitals.

METHODS

We identified patients with CHD in Iran in 2019-2020. Data were gathered from the Iran Health Insurance Organisation information systems and the Ministry of Health and Medical Education. This was a cross-sectional prevalence-based study. Generalised linear models were used to find the determinants of hospitalisation cost for patients with CHD. A total of 86 834 patients suffering from CHD were studied.

RESULTS

Mean hospitalisation cost per CHD patient was US$382.90±US$500.72 while the mean daily hospitalisation cost per CHD patient was US$89.71±US$89.99. In-hospital mortality of CHD was 2.52%. Hospitalisation accommodation and medications had the highest share of hospitalisation costs (25.59% and 22.63%, respectively). Men spent 1.12 (95% CI 1.11 to 1.13) times more on hospitalisation costs compared with women, and individuals aged 60 to 69 had hospitalisation costs 1.04 (95% CI 1.02 to 1.06) times higher than those in the 0-49 age range. Patients insured by the Iranian Fund have significantly higher costs 1.17 (95% CI 1.14 to 1.19) than the Rural fund. Hospitalisation costs for patients with CHD who received surgery and angiography were significantly 2.36 (95% CI 2.30 to 2.43) times higher than for patients who did not undergo surgery and angiography.

CONCLUSION

Applying CHD prevention strategies for men and the middle-aged population (50-70 years) is strongly recommended. Prudent use and prescribing of medications will be helpful to reduce hospitalisation cost.

Using machine learning to predict acute myocardial infarction and ischemic heart disease in primary care cardiovascular patients

BACKGROUND

Early recognition, which preferably happens in primary care, is the most important tool to combat cardiovascular disease (CVD). This study aims to predict acute myocardial infarction (AMI) and ischemic heart disease (IHD) using Machine Learning (ML) in primary care cardiovascular patients. We compare the ML-models' performance with that of the common SMART algorithm and discuss clinical implications.

METHODS AND RESULTS

Patient-level medical record data (n = 13,218) collected between 2011-2021 from 90 GP-practices were used to construct two random forest models (one for AMI and one for IHD) as well as a linear model based on the SMART risk prediction algorithm as a suitable comparator. The data contained patient-level predictors, including demographics, procedures, medications, biometrics, and diagnosis. Temporal cross-validation was used to assess performance. Furthermore, predictors that contributed most to the ML-models' accuracy were identified. The ML-model predicting AMI had an accuracy of 0.97, a sensitivity of 0.67, a specificity of 1.00 and a precision of 0.99. The AUC was 0.96 and the Brier score was 0.03. The IHD-model had similar performance. In both ML-models anticoagulants/antiplatelet use, systolic blood pressure, mean blood glucose, and eGFR contributed most to model accuracy. For both outcomes, the SMART algorithm was substantially outperformed by ML on all metrics.

CONCLUSION

Our findings underline the potential of using ML for CVD prediction purposes in primary care, although the interpretation of predictors can be difficult. Clinicians, patients, and researchers might benefit from transitioning to using ML-models in support of individualized predictions by primary care physicians and subsequent (secondary) prevention.

Do patients need additional coverage for chronic ailments? Insights from hospital data

BACKGROUND

Eliminating financial barriers and improving healthcare accessibility pertain to be key elements of the United Nation's sustainable development goals. These have directed health policymakers to advocate private health insurance as a health promotion strategy to enable patients to obtain absolute and affordable medical care when needed. Against this backdrop, the current study investigates the coverage trend and financial risk-protective nature of private health insurance plans.

MATERIALS AND METHOD

We examined 12 months' hospital billing data of private health insurance holders with cancer, cardiac, neurological, and renal diseases. The billing and insurance claim data of 5002 patients were extracted from the billing section of a tertiary care teaching hospital located in southern India from April 2022 through March 2023. Five per cent of patients from each disease condition were selected through proportionate random sampling for analysis (n = 250). The cost incurred and reimbursement trend under various cost heads were investigated by examining the cost incurred by the patient during the hospitalization and comparing it with the amount reimbursed by the insurance company.

RESULTS

The scrutiny exhibits that private health insurance fails to provide comprehensive coverage, resulting in under-insurance among subscribers. Reimbursement received for each cost category is also discussed. To the best of our knowledge, this is the first study that has used institutional data instead of large survey data or patient data.

CONCLUSION

The research concludes by soliciting policymakers, healthcare providers, and insurers to develop strategies to enhance the affordability and accessibility of healthcare to promote health and wellness.

Burden of diseases due to high systolic blood pressure in the Middle East and North Africa region from 1990 to 2019

High systolic blood pressure (HSBP) is associated with several metabolic and non-metabolic disorders. This research aimed to document the deaths and disability-adjusted life-years (DALYs) attributable to HSBP in the Middle East and North Africa (MENA) region between 1990 and 2019, by age, sex, underlying cause and socio-demographic index (SDI). We used the methodological framework and data drawn from the Global Burden of Disease study 2019 to identify the burden of diseases attributable to HSBP, from 1990 to 2019, in the MENA region. The estimates reported were presented as counts, population-attributable fractions, and age-standardised rates (per 100,000), along with 95% uncertainty intervals. In 2019, 803.6 thousand (687.1 to 923.8) deaths were attributed to HSBP in MENA, which accounted for 25.9% (22.9-28.6%) of all deaths. The number of regional DALYs caused by HSBP in 2019 was 19.0 million (16.3-21.9 million), which accounted for 11.6% (10.1-13.3%) of all DALYs, and was 23.4% (15.9-31.5%) lower than in 1990. The highest age-standardised DALY rate for 2019 was observed in Afghanistan, with the lowest in Kuwait. Additionally, the DALY rate in MENA rose with age for both sexs. Furthermore, a negative linear relationship was found between SDI and the age-standardised DALY rates. The region has a substantial HSBP-related burden. Policymakers and healthcare professionals should prioritize interventions that effectively promote the early detection of HSBP, access to quality healthcare, and lifestyle modifications to mitigate the HSBP burden in the MENA countries.

Modifiable risk factors of inequalities in hypertension: analysis of 100 million health checkups recipients

Inequalities in health behaviors are thought to contribute to inequalities in hypertension. This study examined the extent to which modifiable mediating factors explain income inequalities in hypertension. This repeated cross-sectional study used data from National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) from 2009 to 2015. Those aged between 40 and 74 were enrollees in the Specific Health Checkups. Hypertension was defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90, or the use of antihypertensive medication. The mediating effects of exercise, obesity, smoking, and alcohol drinking on the association between income, as an indicator of SES, and hypertension were determined by the Karlson-Holm-Breen (KHB) method. The mean age of the 68,684,025 men and 59,118,221 women was 54.7 (SD = 9.6) and 56.7 (SD = 10.0) years, respectively. Prevalence of hypertension was higher in the lowest income group (48.6% for men, 40.2% for women) than in the highest income group (33.3% for men, 21.5% for women). Inequalities tended to increase over time. Inequalities were larger among those who did not use antihypertensive medication. Modifiable risks explained 10.6% of the association between income and hypertension for men and 15.1% for women. In men, drinking and obesity explained 8.8% and 5.5% of the inequalities in hypertension, respectively. In women, obesity explained 18.8%. Exercise increased the proportion mediated over time. Smoking explained 5.5% among women taking antihypertensive medication. There were health inequalities in hypertension among Japanese adults, and the modifiable risk factors partially explained the inequalities.

A resuscitation systems analysis for South Africa: A narrative review

With a growing incidence in cardiovascular diseases in Africa, including South Africa, and with it a greater incidence of out-of-hospital cardiac arrest (OHCA) there is a need to understand the readiness of these emergency care systems to support a response. Yet, OHCA is expensive and requires comprehensive development across an entire chain of survival in order to gain any benefit in mortality or morbidity. In this narrative review, we provide a resuscitation systems analysis using the Global Resuscitation Alliance's Frame of Survival. We provide evidence or commentary on the elements of the outer frame and inner frame, and make an assessment of the South African system's readiness to support OHCA care, and provide suggestions for priority areas that need to be developed. The South African resuscitation system demonstrates reasonable readiness to respond to OHCA but is characterised by considerable variation and fragmentation. Given the cost ineffectiveness of many interventions and the anticipated rise in OHCA incidence, there is a pressing need for context-specific strategies in South Africa. These strategies should focus on enhancing both outcomes and resource efficiency, while respecting community ethics and sociocultural dynamics.

The Polypill: A New Alternative in the Prevention and Treatment of Cardiovascular Disease

Cardiovascular disease (CVD) is the primary cause of death and disability worldwide. Although age-standardized CVD mortality rates decreased globally by 14.5% between 2006 and 2016, the burden of CVD remains disproportionately higher in low- and middle-income countries compared to high-income countries. Even though proven, effective approaches based on multiple-drug intake aimed at the prevention and treatment of CVD are currently available, poor adherence, early discontinuation of treatment, and suboptimal daily execution of the prescribed therapeutic regimes give rise to shortfalls in drug exposure, leading to high variability in the responses to the prescribed medications. Wald and Law, in their landmark paper published in BMJ 2003, hypothesized that the use of a fixed-dose combination of statins, β-blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and aspirin (classic Polypill composition) may increase adherence and decrease CVD by up to 80% when prescribed as primary prevention or in substitution of traditional protocols. Since then, many clinical trials have tested this hypothesis, with comparable results. This review aims to describe the available clinical trials performed to assess the impact of fixed-dose combinations on adherence, cost-effectiveness, and the risk factors critical to the onset of CVD.

The natural polyphenol fisetin in atherosclerosis prevention: a mechanistic review

The incidence and mortality rate of atherosclerotic cardiovascular disease (ASCVD) is increasing yearly worldwide. Recently, a growing body of evidence has unveiled the anti-atherosclerotic properties of fisetin, a natural polyphenol compound. In this article, we reviewed the pharmacologic actions of fisetin on experimental atherosclerosis and its protective effects on disease-relevant cell types such as endothelial cells, macrophages, vascular smooth muscle cells, and platelets. Based on its profound cardiovascular actions, fisetin holds potential for clinical translation and could be developed as a potential therapeutic option for atherosclerosis and its related complications. Large-scale randomized clinical trials are warranted to ascertain the safety and efficacy of fisetin in patients with or high risk for ASCVD.

Identifying Risk Indicators of Cardiovascular Disease in Fasa Cohort Study (FACS): An Application of Generalized Linear Mixed-Model Tree

BACKGROUND

Today, cardiovascular disease (CVD) is the most important cause of death around the world. In this study, our main aim was to predict CVD using some of the most important indicators of this disease and present a tree-based statistical framework for detecting CVD patients according to these indicators.

METHODS

We used data from the baseline phase of the Fasa Cohort Study (FACS). The outcome variable was the presence of CVD. The ordinary Tree and generalized linear mixed models (GLMM) were fitted to the data and their predictive power for detecting CVD was compared with the obtained results from the GLMM tree. Statistical analysis was performed using the RStudio software.

RESULTS

Data of 9499 participants aged 35‒70 years were analyzed. The results of the multivariable mixed-effects logistic regression model revealed that participants' age, total cholesterol, marital status, smoking status, glucose, history of cardiac disease or myocardial infarction (MI) in first- and second-degree relatives, and presence of other diseases (like hypertension, depression, chronic headaches, and thyroid disease) were significantly related to the presence of CVD (P<0.05). Fitting the ordinary tree, GLMM, and GLMM tree resulted in area under the curve (AUC) values of 0.58 (0.56, 0.61), 0.81 (0.77, 0.84), and 0.80 (0.76, 0.83), respectively, among the study population. In addition, the tree model had the best specificity at 81% but the lowest sensitivity at 65% compared to the other models.

CONCLUSION

Given the superior performance of the GLMM tree compared with the standard tree and the lack of significant difference with the GLMM, using this model is suggested due to its simpler interpretation and fewer assumptions. Using updated statistical models for more accurate CVD prediction can result in more precise frameworks to aid in proactive patient detection planning.

Influencing factors of hospitalization cost of hypertension patients in traditional Chinese medicine hospitals

Objectives

This study aimed to analyze the influencing factors of hospitalization cost of hypertensive patients in TCM (traditional Chinese medicine, TCM) hospitals, which can provide a scientific basis for hospitals to control the hospitalization cost of hypertension.

Methods

In this study, 3,595 hospitalized patients with a primary diagnosis of tertiary hypertension in Tianshui City Hospital of TCM, Gansu Province, China, from January 2017 to June 2022, were used as research subjects. Using univariate analysis to identify the relevant variables of hospitalization cost, followed by incorporating the statistically significant variables of univariate analysis as independent variables in multiple linear regression analysis, and establishing the path model based on the results of the multiple linear regression finally, to explore the factors influencing hospitalization cost comprehensively.

Results

The results showed that hospitalization cost of hypertension patients were mainly influenced by length of stay, age, admission pathways, payment methods of medical insurance, and visit times, with length of stay being the most critical factor.

Conclusion

The Chinese government should actively exert the characteristics and advantages of TCM in the treatment of chronic diseases such as hypertension, consistently optimize the treatment plans of TCM, effectively reduce the length of stay and steadily improve the health literacy level of patients, to alleviate the illnesses pain and reduce the economic burden of patients.

Effects of a dietary intervention on cardiometabolic risk and food consumption in a workplace

BACKGROUND

Worksite-based health programs have shown positive impacts on employee health and have led to significant improvements in cardiovascular risk factor profiles. We aimed to determine the effect of cafeteria intervention on cardio-metabolic risk factors diet in a worksite setting (Dhulikhel Hospital) in Nepal.

METHODS

In this one-arm pre-post intervention study, we recruited 277 non-pregnant hospital employees aged 18-60 with prediabetes or pre-hypertension. The study was registered in clinicaltrials.gov (NCT03447340; 2018/02/27). All four cafeterias in the hospital premises received cafeteria intervention encouraging healthy foods and discouraging unhealthy foods for six months. We measured blood pressure, fasting glucose level, glycated hemoglobin, cholesterol in the laboratory, and diet intake (in servings per week) using 24-hour recall before and six months after the intervention. The before and after measures were compared using paired-t tests.

RESULTS

After six months of cafeteria intervention, the median consumption of whole grains, mono/polyunsaturated fat, fruits, vegetable and nuts servings per week increased by 2.24(p<0.001), 2.88(p<0.001), 0.84(p<0.001) 2.25(p<0.001) and nuts 0.55 (p<0.001) servings per week respectively. The median consumption of refined grains decreased by 5.07 servings per week (p<0.001). Mean systolic and diastolic blood pressure decreased by 2 mmHg (SE = 0.6; p = 0.003) and 0.1 mmHg (SE = 0.6; p = 0.008), respectively. The low-density lipoprotein (LDL) was significantly reduced by 6 mg/dL (SE = 1.4; p<0.001).

CONCLUSION

Overall, we found a decrease in consumption of refined grains and an increase in consumption of whole grains, unsaturated fats, fruits, and nuts observed a modest reduction in blood pressure and LDL cholesterol following a 6-month cafeteria-based worksite intervention incorporating access to healthy foods.

Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation

BACKGROUND

Depression and anxiety occur frequently (with reported prevalence rates of around 40%) in individuals with coronary heart disease (CHD), heart failure (HF) or atrial fibrillation (AF) and are associated with a poor prognosis, such as decreased health-related quality of life (HRQoL), and increased morbidity and mortality. Psychological interventions are developed and delivered by psychologists or specifically trained healthcare workers and commonly include cognitive behavioural therapies and mindfulness-based stress reduction. They have been shown to reduce depression and anxiety in the general population, though the exact mechanism of action is not well understood. Further, their effects on psychological and clinical outcomes in patients with CHD, HF or AF are unclear.

OBJECTIVES

To assess the effects of psychological interventions (alone, or with cardiac rehabilitation or pharmacotherapy, or both) in adults who have a diagnosis of CHD, HF or AF, compared to no psychological intervention, on psychological and clinical outcomes.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2009 to July 2022. We also searched three clinical trials registers in September 2020, and checked the reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing psychological interventions with no psychological intervention for a minimum of six months follow-up in adults aged over 18 years with a clinical diagnosis of CHD, HF or AF, with or without depression or anxiety. Studies had to report on either depression or anxiety or both.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were depression and anxiety, and our secondary outcomes of interest were HRQoL mental and physical components, all-cause mortality and major adverse cardiovascular events (MACE). We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

Twenty-one studies (2591 participants) met our inclusion criteria. Sixteen studies included people with CHD, five with HF and none with AF. Study sample sizes ranged from 29 to 430. Twenty and 17 studies reported the primary outcomes of depression and anxiety, respectively. Despite the high heterogeneity and variation, we decided to pool the studies using a random-effects model, recognising that the model does not eliminate heterogeneity and findings should be interpreted cautiously. We found that psychological interventions probably have a moderate effect on reducing depression (standardised mean difference (SMD) -0.36, 95% confidence interval (CI) -0.65 to -0.06; 20 studies, 2531 participants; moderate-certainty evidence) and anxiety (SMD -0.57, 95% CI -0.96 to -0.18; 17 studies, 2235 participants; moderate-certainty evidence), compared to no psychological intervention. Psychological interventions may have little to no effect on HRQoL physical component summary scores (PCS) (SMD 0.48, 95% CI -0.02 to 0.98; 12 studies, 1454 participants; low-certainty evidence), but may have a moderate effect on improving HRQoL mental component summary scores (MCS) (SMD 0.63, 95% CI 0.01 to 1.26; 12 studies, 1454 participants; low-certainty evidence), compared to no psychological intervention. Psychological interventions probably have little to no effect on all-cause mortality (risk ratio (RR) 0.81, 95% CI 0.39 to 1.69; 3 studies, 615 participants; moderate-certainty evidence) and may have little to no effect on MACE (RR 1.22, 95% CI 0.77 to 1.92; 4 studies, 450 participants; low-certainty evidence), compared to no psychological intervention.

AUTHORS' CONCLUSIONS

Current evidence suggests that psychological interventions for depression and anxiety probably result in a moderate reduction in depression and anxiety and may result in a moderate improvement in HRQoL MCS, compared to no intervention. However, they may have little to no effect on HRQoL PCS and MACE, and probably do not reduce mortality (all-cause) in adults who have a diagnosis of CHD or HF, compared with no psychological intervention. There was moderate to substantial heterogeneity identified across studies. Thus, evidence of treatment effects on these outcomes warrants careful interpretation. As there were no studies of psychological interventions for patients with AF included in our review, this is a gap that needs to be addressed in future studies, particularly in view of the rapid growth of research on management of AF. Studies investigating cost-effectiveness, return to work and cardiovascular morbidity (revascularisation) are also needed to better understand the benefits of psychological interventions in populations with heart disease.

Current status of hypertension care and management in the Philippines

AIMS

In this paper, we discuss the existing data on the burden of hypertension in the Philippines and present the status of management, prevention, and control of hypertension in the country.

METHODS

A literature review was conducted to synthesize the status of hypertension care in the Philippines.

RESULTS

Hypertension continues to contribute to the country's leading causes of death. Similar to the global trend, almost half of hypertensive Filipinos are still not aware of their condition, and only 27 % have it under control. The prevalence of hypertension has steadily increased from 22 % in 1993 to 25.15 % in 2013. The 2020 Philippine Society for Hypertension clinical practice guideline defines hypertension as an office BP of 140/90 mm Hg or above following the proper standard BP measurement. During the past decade, monotherapy has been the mode of treatment in more than 80 % of Filipino patients. This could also explain why the BP control rates have been low. The most prevalent complications of hypertension in the Philippines were stroke (11.6 %), ischemic heart disease (7.7 %), chronic kidney disease (6.30 %), and hypertensive retinopathy (2.30 %). Hypertension causes economic tolls on patients, from the cost of drugs to hospitalization and complications. Hospitalization from hypertensive complications can easily wipe out the savings of middle-class families and is catastrophic for lower-income Filipinos.

CONCLUSION

In this review, we summarize the existing data on the burden of hypertension among Filipinos and the risk factors associated with the disease. We present the current screening tools, diagnostics, treatment, and prevention strategies for hypertension in the Philippines. Lastly, we propose solutions to meet the global targets of hypertension management and help relieve the growing burden of this disease.

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

The effect of coronary stent policies on the risk of percutaneous coronary intervention among acute coronary syndrome patients in Shanghai: Real-world evidence

OBJECTIVE

This study aimed to analyze the effect of coronary stent policies implemented in Shanghai on the risk of percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) inpatients based on real-world data.

METHODS

Two retrospective cohorts of inpatients with a first diagnosis of ACS who had undergone PCI for the first time in the previous year in Shanghai hospitals were examined (one for the postpolicy period and the other for the prepolicy period). χ2 tests were used to compare categorical variables between the two cohorts. Single- and multivariate Cox proportional hazards models were used to compare the risk of major adverse cardiovascular events (MACEs) between the two cohorts.

RESULTS

A total of 31,760 ACS patients were included in this study. The proportion of ACS inpatients who had at least one bid-winning stent and 3 or more coronary stents implanted for first-time PCI in the postpolicy cohort was higher than that in the prepolicy cohort (86.52% vs. 55.67% and 6.27% vs. 4.39%, respectively; all p values < 0.0001). The single- and multivariate Cox proportional hazards models revealed that the unadjusted and adjusted hazard ratios for MACEs at 1 year after PCI for the postpolicy cohort relative to the prepolicy cohort were 0.869 (P<0.0001) and 0.814 (P = 0.0007), respectively.

CONCLUSIONS

The implementation of coronary stent policies changed coronary stent utilization but had no significant adverse effects on the risk of PCI among ACS patients in Shanghai in the short term. However, the reasons for changes in the number of coronary stents implanted should be analyzed and addressed in the future.

The economic burden of obesity in 4 south-eastern European countries associated with obesity-related co-morbidities

OBJECTIVE

To provide an assessment of the cost burden of obesity across a spectrum of obesity-related comorbidities (ORCs) for four countries in South-Eastern Europe (SEE).

METHODS

A micro-costing analysis from the public payer perspective was conducted to estimate direct healthcare costs associated with ten obesity-related comorbidities (ORCs) in Czech Republic, Greece, Hungary, and Romania. A survey was administered to obtain healthcare resource use and unit cost data. Cost estimates were validated by local steering committees which comprised at least one public sector clinician and a panel of independent industry experts.

RESULTS

Chronic kidney disease and cardiovascular diseases were the costliest ORCs across all 4 countries, where annual cost burden per ORC exceeded 1,500 USD per patient per year. In general, costs were driven by the tertiary care resources allocated to address treatment-related adverse events, disease complications, and associated inpatient procedures.

CONCLUSIONS

Our findings confirm that the high prevalence of obesity and its comorbidities result in substantial financial burden to all 4 SEE public payers. By quantifying the burden of obesity from a public healthcare perspective, our study aims to support policy efforts that promote health education and promotion in combating obesity in the region.

Machine learning-based models to predict the conversion of normal blood pressure to hypertension within 5-year follow-up

BACKGROUND

Factors contributing to the development of hypertension exhibit significant variations across countries and regions. Our objective was to predict individuals at risk of developing hypertension within a 5-year period in a rural Middle Eastern area.

METHODS

This longitudinal study utilized data from the Fasa Adults Cohort Study (FACS). The study initially included 10,118 participants aged 35-70 years in rural districts of Fasa, Iran, with a follow-up of 3,000 participants after 5 years using random sampling. A total of 160 variables were included in the machine learning (ML) models, and feature scaling and one-hot encoding were employed for data processing. Ten supervised ML algorithms were utilized, namely logistic regression (LR), support vector machine (SVM), random forest (RF), Gaussian naive Bayes (GNB), linear discriminant analysis (LDA), k-nearest neighbors (KNN), gradient boosting machine (GBM), extreme gradient boosting (XGB), cat boost (CAT), and light gradient boosting machine (LGBM). Hyperparameter tuning was performed using various combinations of hyperparameters to identify the optimal model. Synthetic Minority Over-sampling Technology (SMOTE) was used to balance the training data, and feature selection was conducted using SHapley Additive exPlanations (SHAP).

RESULTS

Out of 2,288 participants who met the criteria, 251 individuals (10.9%) were diagnosed with new hypertension. The LGBM model (determined to be the optimal model) with the top 30 features achieved an AUC of 0.67, an f1-score of 0.23, and an AUC-PR of 0.26. The top three predictors of hypertension were baseline systolic blood pressure (SBP), gender, and waist-to-hip ratio (WHR), with AUCs of 0.66, 0.58, and 0.63, respectively. Hematuria in urine tests and family history of hypertension ranked fourth and fifth.

CONCLUSION

ML models have the potential to be valuable decision-making tools in evaluating the need for early lifestyle modification or medical intervention in individuals at risk of developing hypertension.

Barriers to Cardiac Rehabilitation among Patients Diagnosed with Cardiovascular Diseases-A Scoping Review

BACKGROUND

Cardiovascular diseases (CVDs) are a rising global burden. Preventative strategies such as cardiac rehabilitation (CR) have shown a marked reduction in disease burden. Despite this, CR is underutilized worldwide. This study aims to identify the barriers to CR among patients diagnosed with CVD.

METHODS

A scoping review of the literature was conducted following the Joanna Briggs Institute (JBI) guidelines. Four major databases, including CINAHL, PubMed, EBSCOhost, and Scopus, were used to obtain studies published between 2010 and 2023. Search terms such as "Cardiac rehab*", "Barrier*", "Cardiovascular", "Disease", and "diagnosis*" were utilized in order to obtain subject-specific studies relevant to the research question.

RESULTS

From the initial 2098 studies, only 14 were included in the final analysis, consisting of both qualitative and quantitative designs. The thematic analysis included "healthcare system-related factors", "Socioeconomic factors", and "individual characteristics". Healthcare system-related factors were mostly related to the poor availability of CR programs, lack of proper referral strategies, inadequate knowledge of CR provider and inter-provider communication issues, and lack of alternative methods of CR delivery. The socioeconomic barriers were lack of education, longer distance to CR facilities, high cost of care, unemployment, and poor income status. The identified individual characteristics were female gender, older age, and comorbidities.

CONCLUSIONS

Lack of resources, poor access, educational attainment, and high cost of care were some of the barriers to CR, particularly in low- and middle-income countries (LMICs). Health policymakers and healthcare providers should implement strategies incorporating the issues identified in this scoping review. Systematic reviews may be required to confirm these findings.