Cardiovascular Risk Assessment and Management in Developing Countries

Causes of the burgeoning cardiovascular epidemic in developing countries (DC) are known. Whilst there are many prevention strategies and policies demonstrated to be effective in reducing the trends of cardiovascular disease in developed countries, applying them in DCs is challenging and complex. To utilize resources efficiently, two key decisions have to be made by policy makers in all DCs. The first is to decide on the appropriate mix of population and high-risk interventions. The second is to determine the threshold for implementing high-risk interventions. In making such decisions, due consideration needs to be given to scientific evidence, affordability, sustainability, opportunity costs, and social and political realities. High-risk approaches can be made cost-effective if individuals that are most likely to benefit from treatment can be identified through risk stratification systems. Although several such risk prediction systems are available, they have limited applicability to non-Western populations. Further, health systems in DCs do not have basic infrastructure facilities to support resource intensive risk prediction tools, particularly in primary healthcare. The World Health Organization has developed a flexible cardiovascular disease risk management package that is implemented in a range of less resourced settings. A risk prediction tool that enables more accurate prediction of cardiovascular risk in DCs is in development

Coconut fat and serum lipoproteins: effects of partial replacement with unsaturated fats

The aim of the present study was to examine the effect of reducing saturated fat in the diet, or partly replacing it with unsaturated fat, on the serum lipoprotein profile of human subjects. The study had two intervention periods, 8 weeks (phase 1) and 52 weeks (phase 2). In phase 1, total fat was reduced from 31 to 25 % energy (polyunsaturated fatty acids (PUFA):saturated fatty acids (SFA) ratio increased from 0.2 to 0.4) by reducing the quantity of coconut fat (CF) in the diet from 17.8 to 9.3 % energy intake. In phase 2, subjects were randomised to groups A and B. In group A total fat was reduced from 25 to 20 % energy (PUFA:SFA ratio increased from 0.4 to 0.7) by reducing the quantity of CF in the diet from 9.3 to 4.7 % total energy intake. In group B, the saturated fat content in the diet was similar to group A. In addition a test fat (a mixture of soyabean oil and sesame oil, PUFA:monosaturated fatty acids ratio 2) contributed 3.3 % total energy intake and total fat contributed 24 % energy intake (PUFA:SFA ratio increased from 0.7 to 1.1). At the end of phase 1, there was a 7.7 % reduction in cholesterol (95 % CI -3.6, -12.2) and 10.8 % reduction in LDL (95 % CI -4.9, -16.5) and no significant change in HDL and triacylglycerol. At the end of phase 2, the reduction in cholesterol in both groups was only about 4 % (95 % CI -12, 3.2) partly due the concomitant rise in HDL. The reduction in LDL at 52 weeks was significantly higher in group B (group A mean reduction 11 %, 95 % CI -20.1, -2.0 and group B mean reduction 16.2 % 95 % CI -23.5, -8.9). In phase 2, triacylglycerol levels showed a mean reduction of 6.5 % in group 2A and a mean increase of 8.2 % in group 2B. The reduction of saturated fat in the diet is associated with a lipoprotein profile that would be expected to reduce cardiovascular risk. The reduction of dietary saturated fat with partial replacement of unsaturated fat brings about changes in total cholesterol, HDL- and LDL-cholesterol that are associated with a lower cardiovascular ris

Cost effectiveness of strategies to combat cardiovascular disease, diabetes, and tobacco use in sub-Saharan Africa and South East Asia: mathematical modelling study

Objective To determine the relative costs and health effects of interventions to combat cardiovascular disease, diabetes, and tobacco related disease in order to guide the allocation of resources in developing countries.Design Cost effectiveness analysis of 123 single or combined prevention and treatment strategies for cardiovascular disease, diabetes, and smoking by means of a lifetime population model.Setting Two World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE) and countries in South East Asia with high adult and high child mortality (SearD).Data sources Demographic and epidemiological data were taken from the WHO databases of mortality and global burden of disease. Estimates of intervention coverage, effectiveness, and resource needs were drawn from clinical trials, observational studies, and treatment guidelines. Unit costs were taken from the WHO-CHOICE (Choosing Interventions that are Cost-Effective) price database.Main outcome measures Cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005.Results Most of the interventions studied were considered highly cost effective, meaning they generate one healthy year of life at a cost of 25$Int150 and <$Int230 per DALY averted in AfrE and SearD respectively); and retinopathy screening and glycaemic control for patients with diabetes (<$Int2100 and <$Int950 per DALY averted in AfrE and SearD respectively).Conclusion This comparative economic assessment has identified a set of population-wide and individual strategies for prevention and control of cardiovascular disease that are inexpensive and cost effective in low resource settings

Cost effectiveness of strategies to combat cardiovascular disease, diabetes, and tobacco use in sub-Saharan Africa and South East Asia: mathematical modelling study

Objective To determine the relative costs and health effects of interventions to combat cardiovascular disease, diabetes, and tobacco related disease in order to guide the allocation of resources in developing countries

World Health Organization definition of myocardial infarction: 2008-09 revision

Background WHO has played a leading role in the formulation and promulgation of standard criteria for the diagnosis of coronary heart disease and myocardial infarction since early 1970s. Methods The revised definition takes into consideration the following: well-resourced settings can use the ESC/ACC/AHA/WHF definition, which has new biomarkers as a compulsory feature; in resource-constrained settings, a typical biomarker pattern cannot be made a compulsory feature as the necessary assays may not be available; the definition must also have provision for diagnosing non-fatal events with incomplete information on cardiac biomarkers and the ECG; to facilitate epidemiologic monitoring definition must recognize fatal events with incomplete or no information on cardiac biomarkers and/or ECG and/or autopsy and/or coronary angiography. Results Category A definition is the same as ESC/ACC/AHA/WHF definition of MI, and can be applied to settings with no resource constraints. Category B definition of MI is to be applied whenever there is incomplete information on cardiac bio-markers together with symptoms of ischaemia and the development of unequivocal pathological Q waves. Category C definition (probable MI) is to be applied when individuals with MI may not satisfy Category A or B definitions because of delayed access to medical services and/or unavailability of electrocardiography and/or laboratory assay of cardiac biomarkers. In these situations, the term probable MI should be used when there is either ECG changes suggestive of MI or incomplete information on cardiac biomarkers in a person with symptoms of ischaemia with no evidence of a non-coronary reason. Conclusions This article presents the 2008-09 revision of the World Health Organization (WHO) definition of myocardial infarction (MI) developed at a WHO expert consultatio

A Polypill for primary prevention of cardiovascular disease: A feasibility study of the World Health Organization

<p>Abstract</p> <p>Background</p> <p>The feasibility of conducting a large-scale Polypill clinical trial in developing countries remains unclear. More information is needed regarding the efficacy in reducing the risk factors of cardiovascular disease (CVD), side effects, improvement in adherence and physician/patient "acceptability" of the Polypill.</p> <p>Methods</p> <p>We conducted an open-label, parallel-group, randomized clinical trial involving three sites in Sri Lanka that enrolled a total of 216 patients without established CVD. The trial compared a Polypill (75 mg aspirin, 20 mg simvastatin, 10 mg lisinopril and 12.5 mg hydrochlorothiazide) to Standard Practice. After randomization, patients were followed monthly for three months. Pre-specified primary outcomes included reduction in systolic blood pressure, total cholesterol and estimated 10-year CVD risk. We also evaluated the recruitment process and acceptability of the Polypill by both physicians and patients.</p> <p>Results</p> <p>Patients were recruited in a six-month period as planned. Two hundred three patients (94.0%) completed the treatment program and returned for their three-month follow-up visits. No safety concerns were reported. These findings suggest a high rate of patient acceptability, a finding that is bolstered by the majority of patients completing the trial (90%) indicating that they would take the Polypill "for life" if proven to be effective in reducing CVD risk. Approximately 86% of the physicians surveyed agreed with and supported use of the Polypill for primary prevention and 93% for secondary prevention of CVD. Both the Polypill and Standard Practice resulted in marked reductions in systolic blood pressure, total cholesterol and 10-year risk of CVD. However, the differences between the treatment groups were not statistically significant.</p> <p>Conclusions</p> <p>We successfully completed a Polypill feasibility trial in Sri Lanka. We were able to document high acceptability of the Polypill to patients and physicians. We were unable to estimate the risk factor reductions on the Polypill because the control group received similar treatment with individual drugs. The Polypill was however simpler and achieved comparable risk factor reductions, highlighting its potential usefulness in the prevention of CVD.</p> <p>Trial registration number</p> <p>ISRCTN: <a href="http://www.controlled-trials.com/NCT00567307">NCT00567307</a></p