Medication Adherence Interventions for Cardiovascular Disease in Low- and Middle-Income Countries: A Systematic Review.

Purpose: The burden of cardiovascular diseases (CVD) is high in low- and middle-income countries (LMICs). Medications are integral to the management and control of CVD; however, suboptimal adherence impacts health outcomes. This systematic review aims to critically examine interventions targeted at improving medication adherence among persons with CVD in LMICs. Methods: In this systematic review, we searched online databases PubMed, Embase, and CINAHL for studies that evaluated a medication adherence intervention for CVD, reported adherence as an outcome measure, were conducted in LMICs and reported the strategy or tool used to measure adherence. We included articles published in English, available in full text, peer-reviewed, and published between 2010 and 2020. Results: We included 45 articles in this review. The majority of the studies implemented counseling and educational interventions led by nurses, pharmacists, or community health workers. Many of the studies delivered medication-taking reminders in the form of phone calls, text messages, short message services (SMS), and in-phone calendars. Multi-component interventions were more effective than unifocal interventions. Interventions involving technology, such as mobile phone calls, electronic pillboxes, and interactive phone SMS reminders, were more effective than generic reminders. The outcomes reported in the studies varied based on the complexity and combination of strategies. When interventions were implemented at both the patient level, such as reminders, and at the provider level, such as team-based care, the effect on medication adherence was larger. Conclusion: In LMICs, medication adherence interventions among persons with CVD included a combination of patient education, reminders, fixed-dose combination therapy and team-based care approach were generally more effective than singular interventions. Among patients who had CVD, the medication adherence interventions were found to be moderately effective. Future studies focusing on improving medication adherence in LMICs should consider non-physician-led interventions and appropriately adapt the interventions to the local context

Life's Simple 7 at Midlife and Risk of Recurrent Cardiovascular Disease and Mortality after Stroke: The ARIC study

Background: Stroke is a leading cause of morbidity and mortality among adults in the U.S. Ideal levels of the Life's Simple 7 (LS7) are associated with lower cardiovascular disease (CVD) and all-cause mortality. However, the association of LS7 with CVD, recurrent stroke, and all-cause mortality after incident stroke is unknown. Methods: We used data from the ARIC study, a cohort of 13,508 adults from four US communities, 45–64 years old at baseline (1987–1989). Cardiovascular hospitalizations and mortality were ascertained in follow-up through December 31st, 2017. We defined cardiovascular health (CVH) based on AHA definitions for LS7 (range 0-14) and categorized CVH into four levels: LS7 0-3, 4-6, 7-9, and ≥10 (ideal LS7), according to prior studies. Outcomes included incident stroke, CVD, recurrent stroke, all-cause mortality, and a composite outcome including all the above. Adjusted hazard ratios (95% CI) were estimated with Cox proportional hazards regression models. Results: Median (25%-75%) follow-up for incident stroke was 28 (18.6-29.2) years. Participants with incident stroke were 55.7 (SD 5.6) years-old at baseline, 53% were women and 35% Black. Individuals with LS7 score ≥10 had 65% lower risk (HR: 0.35; 95% CI: 0.29-0.41) of incident stroke than those with LS7 4-6 (reference group). Of 1,218 participants with incident stroke, 41.2% (n=502) had composite CVD and 68.3% (n=832) died during a median (25%-75%) follow-up of 4.0 (0.76-9.95) years. Adjusted HR (95% CI) for stroke survivors with LS7≥10 at baseline were 0.74 (0.58-0.94) for the composite outcome, 0.38(0.17-0.85) for myocardial infarction, 0.60 (0.40-0.90) for heart failure, 0.63 (0.48-0.84) for all-cause mortality, and 0.65 (0.39-1.08) for recurrent stroke. Conclusions: Good and excellent midlife cardiovascular health are associated with lower risks of incident stroke and CVD after stroke. Clinicians should stress the importance of a healthy lifestyle for primary and secondary CVD prevention

Psychological Health, Well-Being, and the Mind-Heart-Body Connection A Scientific Statement From the American Heart Association

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD

Smoking-Cessation Interventions in People Living With HIV Infection: A Systematic Review

Tobacco smoking remains a prevalent behavior in people living with HIV infection (PLWHs) and is associated with impaired immune functioning, increased cardiovascular risk, and decreased response to antiretroviral therapy. This review presents a critique and synthesis of evidence on effective smoking-cessation interventions for PLWHs. A comprehensive search identified nine peer-reviewed intervention studies published between 1989 and 2012. The highest likelihood of smoking cessation (range of odds ratios 4.33-5.6) were in two randomized controlled trial interventions using cell phone technology. Clinically significant reductions in systolic blood pressure, weight gain, and increased CD4+ T-cell count were reported in participants who ceased smoking in three of the nine studies. Overall, multistrategy smoking-cessation interventions, delivered over multiple sessions, were effective. However, the most effective interventions were tailored to the unique individual needs of PLWHs, including assessment of and intervention for polysubstance abuse and mental health issues, as well as the inclusion of access-promoting elements. © 2014 Association of Nurses in AIDS Care

Improving hypertension knowledge, medication adherence, and blood pressure control: A feasibility study.

AIMS AND OBJECTIVES: To examine the feasibility of a culturally tailored education programme for Haitian immigrants diagnosed with hypertension. BACKGROUND: Hypertension is a major public health problem, impacting more than 26% of the global population. The overall prevalence of hypertension is 45.4% in the United States with nearly 80,000 deaths due to hypertension in 2015. African Americans and other Black populations living in the U.S. are disproportionally affected by hypertension. DESIGN: Pre-test and post-test feasibility study. METHODS: A convenience sample of forty-four participants who identified as Haitian immigrants was enrolled in this evidence-based education programme. The intervention included culturally tailored education focused on improving knowledge, medication adherence and blood pressure. Outcomes were measured using the Hill-Bone Medication Adherence Scale and Hypertension Knowledge Test. The SQUIRE 2.0 guidelines were used for reporting outcomes. RESULTS: Of the participants that completed the study (N=42), the mean age was 61.95 (± 9.75) years and 59% were female. Baseline systolic and diastolic blood pressures were 143 (±18.15) and 85 (±7.23), respectively. Six weeks after the intervention, there was a significant decrease in mean systolic, 126 (±12.07) and diastolic 78.50 (± 7.23) blood pressures. An increase in medication adherence and hypertension knowledge was also noted at the six-week follow-up period. CONCLUSION: The feasibility of healthcare provider implementation of a culturally tailored intervention to manage hypertension has been demonstrated. However, future research is warranted to gain a more in-depth understanding of how to approach hypertension management among Haitians and other Black immigrant communities. RELEVANCE TO CLINICAL PRACTICE: Advanced practice nurses are uniquely qualified to implement evidence-based programmes that improve patient knowledge and adherence to hypertension management. Through tailoring and adopting an evidence-based methods for educating patients about medication adherence and adequate blood pressure management, there is a potential to see improvements in patient outcomes

Heterogeneity of Cardiovascular Disease Risk Factors Among Asian Immigrants: Insights From the 2010 to 2018 National Health Interview Survey.

Background The Asian population is the fastest-growing immigrant population in the United States. Prior studies have examined the Asian immigrant population as a homogenous group. We hypothesized that there will be heterogeneity in cardiovascular disease risk factors among Asian immigrant subgroups (Indian subcontinent, Southeast Asia, Asia) compared with the non-Hispanic White population. Methods and Results A cross-sectional analysis of the 2010 to 2018 National Health Interview Survey was conducted among 508 941 adults who were born in Asian regions or were non-Hispanic White and born in the United States. Generalized linear models with Poisson distribution were fitted to compare the prevalence of self-reported hypertension, overweight/obesity, diabetes mellitus, high cholesterol, physical inactivity, and current smoking among Asian immigrants compared with White adults, adjusting for known confounders. We included 33 973 Asian immigrants from Southeast Asia (45%), Asia (29%), the Indian subcontinent (26%), and 474 968 White adults. Compared with non-Hispanic White adults, Indian subcontinent immigrants had the highest prevalence of overweight/obesity (prevalence ratio, 1.22; 95% CI, 1.19-1.25); Southeast Asian immigrants had the highest prevalence of high cholesterol (prevalence ratio, 1.16; 95% CI, 1.10-1.23); Indian subcontinent (prevalence ratio, 1.69; 95% CI, 1.49-1.93) and Southeast Asian (prevalence ratio, 1.38; 95% CI, 1.26-1.52) immigrants had a higher prevalence of diabetes. All Asian immigrant subgroups were more likely to be physically inactive and less likely to smoke than White adults. Conclusions We observed significant heterogeneity in cardiovascular disease risk factors among Asian immigrants and a varied prevalence of risk factors compared with non-Hispanic White adults. Providers caring for Asian immigrants should provide tailored and culturally informed care to improve the cardiovascular health of this diverse group

Cardiac postacute sequelae symptoms of SARS-CoV-2 in community-dwelling adults: cross-sectional study

Objective To examine risk factors for cardiac-related postacute sequelae of SARS-CoV-2 infection (PASC) in community-dwelling adults after acute COVID-19 infection. Methods We performed a cross-sectional analysis among adults who tested positive for COVID-19. Outcomes were self-reported cardiac-related PASC. We conducted stepwise multivariable logistic regression to assess association between the risk factors (existing cardiovascular disease (CVD), pre-existing conditions, days since positive test, COVID-19 hospitalisation, age, sex, education, income) and cardiac-related PASC. Results In a sample of 442 persons, mean (SD) age was 45.4 (16.2) years, 71% were women, 13% were black, 46% had pre-existing conditions, 23% had cardiovascular (CV) risk factors and 4% had CVD. Prevalence of cardiac PASC was 43% and newly diagnosed cardiac conditions were 27%. The odds for cardiac-related PASC were higher among persons with underlying pre-existing conditions (adjusted OR (aOR): 2.00, 95% CI: 1.28 to 3.10) and among those who were hospitalised (aOR: 3.03, 95% CI: 1.58 to 5.83). Conclusions More than a third of persons with COVID-19 reported cardiac-related PASC symptoms. Underlying CVD, pre-existing diseases, age and COVID-19 hospitalisation are possible risk factors for cardiac-related PASC symptoms. COVID-19 may exacerbate CV risk factors and increase risk of complications

A Multi-Site Thailand Heart Failure Snapshot Study.

BACKGROUND: The prevalence of heart failure (HF) is increasing in many low-income and middle-income countries, but the limited availability of data on patient profiles and clinical outcomes, particularly at a community level, challenges health service planning. METHODS: The Thai HF Snapshot Study was a multi-site, observational study conducted in Thailand between June 2017 to June 2019. It aimed to document demographic, clinical and sociodemographic characteristics, and to compare clinical outcomes by the level of the hospital. RESULTS: A total of 512 participants were recruited across Thailand: mean age was 64.9±15.3 years and 286 were female (55.9%). The most frequently identified admitting diagnosis was ischaemic heart disease (45.1%). Most patients (70.3%) were classified as New York Heart Association class II at discharge. Patients in university hospitals were frailer (3.2 vs 2.9; p=0.015), had more depressive symptoms (8.1 vs 5.7; p<0.001), and had lower functional status (66.2 vs 73.3; p<0.001) than those in tertiary care. CONCLUSION: Although HF patients admitted to university hospitals had access to advanced technology and health care specialists, clinical outcomes likely affected patient acuity. Interventions are urgently needed to ensure improved HF management considering the social determinants of health in Thailand