Clinical Impact of the Polypill for Cardiovascular Prevention in Latin America: A Consensus Statement of the Inter-American Society of Cardiology

The burden of cardiovascular diseases (CVD) is increasing, particularly in low-middle-income countries such as most of Latin America. This region presents specific socioeconomic characteristics, generating a high incidence of CVD despite efforts to control the problem. A consensus statement has been developed by Inter-American Society of Cardiology with the aim of answering some important questions related to CVD in this region and the role of the polypill in cardiovascular (CV) prevention as an intervention to address these issues. A multidisciplinary team composed of Latin American experts in the prevention of CVD was convened by the Inter-American Society of Cardiology and participated in the process and the formulation of statements. To characterize the prevailing situation in Latin American countries, we describe the most significant CV risk factors in the region. The barriers that impair the use of CV essential medications are also reviewed. The role of therapeutic adherence in CV prevention and how the polypill emerges as an effective strategy for optimizing adherence, accessibility, and affordability in the treatment of CVDs are discussed in detail. Clinical scenarios in which the polypill could represent an effective intervention in primary and secondary CV prevention are described. This initiative is expected to help professionals involved in the management of CVD and public health policymakers develop optimal strategies for the management of CVDs.     

The Epidemiology and Burden of COPD in Latin America and the Caribbean: Systematic Review and Meta-Analysis

Background: In the developing world, COPD continues to be an under studied, diagnosed and treated disorder. In the present study, we analyzed the prevalence, mortality and resource utilization of COPD in Latin America and the Caribbean (LAC) in order to guide future research and public policies. Methods: A systematic review and meta-analysis was performed following MOOSE and PRISMA guidance. We searched CENTRAL, MEDLINE, EMBASE, LILACS, countries’ Ministries of Health, proceedings, and doctoral theses from January 1990 to October 2012. We included studies with a validated definition of COPD that assessed the incidence, prevalence, use of health care resources or costs since 1985. Using EROS, a web-based software, pairs of reviewers independently selected, performed quality assessment (using a STROBE-based checklist) and extracted the study data. Discrepancies were resolved by consensus. Arcsine transformations and random-effects model were used for proportion meta-analyses. Results: 26 articles met entry criteria. The pooled COPD prevalence defined by GOLD criteria (11 cities, 6 countries) was 13.4% (95%CI, 10.1-17.1). Most patients suffer mild or moderate COPD and were undertreated according to international guidelines. The prevalence increased by age and was 1.75 times higher in men than women. 35 of every 1,000 hospitalizations were due to COPD, most of high economic cost, and the COPD in-hospital mortality ranged from 6.7% to 29.5%. Conclusions: COPD burden in LAC is high, especially for men and older persons; however few persons had severe disease. COPD patients often received inappropriate treatment and had high exacerbation and hospitalization rates leading to high economic costs.     

Equity and Prevention of Cardiovascular Diseases in Latin America and the Caribbean

Non-communicable diseases, particularly cardiovascular diseases, are the leading cause of decreased life expectancy and death in Latin America and the Caribbean. Although a lifestyle, which includes no tobacco use, good nutrition, and regular physical activity is touted as key to health, the environmental, racial, social and economic conditions, which underpin lifestyle are often ignored or considered only secondarily. Placing the main responsibility on a patient to change their lifestyle or to simply comply with pharmacological treatment ignores the specific conditions in which the individual lives. Furthermore, there are major disparities in access to both healthy living conditions as well as access to medical care.There is sufficient evidence to support advocating for policies that support healthy living, particularly healthy food choices. Progress is being made to improve the food environment with enactment of front of package nutritional labels. However, policies were enacted only after intense regional research and advocacy supporting their implementation.Government officials must rise above the pressures of commercial interests and support health-promoting policies or be exposed as self-interest groups themselves. Strong advocacy is required to persuade officials that all policies should take health into consideration both to improve lives and economies.     

Noncommunicable Diseases in Low- and Middle-Income Countries: A Strategic Approach to Develop a Global Implementation Research Workforce

Globally, most of the burden from noncommunicable disease is now evident in low- and middle-income countries (LMICs). At the same time, many effective noncommunicable disease interventions are now available and recommended for implementation and scale-up across LMIC health systems—yet are not being widely implemented. Understanding optimal and sustainable implementation strategies for these interventions within the LMIC context will need locally led and conducted implementation research— a research capacity which currently is lacking. The National Institutes of Health institutes, centers, and offices work with the Fogarty International Center to support biomedical research and research training across the globe. The National Heart, Lung, and Blood Institutes' Center for Translation Research and Implementation Science has a strategic focus on implementation research in global health. The Center for Translation Research and Implementation Science is considering strategies for developing research capacity and skill sets to conduct this priority research along with National Institutes of Health institutes and centers and other key global institutions that highly value implementation research. Short-term and medium-term strategies will be needed along with building on current efforts and investments and considering new efforts to address gaps. Developing and sustaining this research workforce will present many challenges and require much effort, but the returns could be transformative in advancing the prevention, treatment, and control of noncommunicable diseases within LMICs.     

Stakeholder Engagement in Planning the Design of a National Needs Assessment for Cardiovascular Disease Prevention and Management in Nepal

BackgroundThere is growing support for stakeholder engagement in health research, but the actual impact of such engagement has not been well established.ObjectivesThis paper describes the stakeholder engagement process and evaluation during the planning of the national needs assessment for cardiovascular disease in Nepal.MethodsWe used personal and professional networks to identify relevant stakeholders within the 7Ps framework (Patients and the Public, Providers, Purchasers, Payers, Public Policy Makers and Policy Advocates, Product Makers and the Principal Investigators) to develop a plan for assessing cardiovascular health needs in Nepal. We consulted 40 stakeholders through 2 meetings in small groups and a workshop in a large group to develop the study methods, conceptual framework, and stakeholder engagement process. We interviewed 33 stakeholders to receive feedback on the stakeholder engagement process.ResultsWe engaged 80% of the targeted stakeholders through small group discussions and a workshop. Three of 5 recommendations from the small group discussion were aimed at improving the stakeholder engagement process and 2 were aimed to improve the research methods. Eleven of 27 recommendations from the workshop aimed to improve the research methods, 4 aimed to improve stakeholder engagement, and 2 helped to expand the scope of dissemination. Ten were irrelevant or could not be incorporated due to resource limitation. Most stakeholders noted that the workshop provided an open platform for a multisectoral group to colearn from one another and share ideas. Others highlighted that the discussion generated insights to enhance research by incorporating expertise and ideas from different perspectives. The major challenges discussed were about committing the time for engagement.ConclusionsThe stakeholder engagement process positively affected the design of our research. This study provides important insights for future researchers that aim to engage stakeholders in national-level assessment programs in the health care system in the context of Nepal.     

Worsening of the Cardiovascular Profile in a Developing Country: The Greater Beirut Area Cardiovascular Cohort

Background

Lebanon has no established governmental noncommunicable diseases surveillance and monitoring system to permit reporting on noncommunicable diseases rates. The last World Health Organization-supported surveillance report showed worrying trends in cardiovascular disease (CVD) risk factors.

The Effect of Cardiac Rehabilitation Attendance on Sexual Activity Outcomes in Cardiovascular Disease Patients: A Systematic Review

Background

Decreased sexual activity (SA) is a common problem in patients with cardiovascular disease (CVD). Although there is evidence that cardiac rehabilitation (CR) is effective in improving physical outcomes and overall quality of life, its effects on SA remain unclear. In this systematic review we assessed the association between CR attendance and SA outcomes in adults with CVD.

Cadmium Exposure and Clinical Cardiovascular Disease: A Systematic Review

Mounting evidence supports that cadmium, a toxic metal found in tobacco, air and food, is a cardiovascular risk factor. Our objective was to conduct a systematic review of epidemiologic studies evaluating the association between cadmium exposure and cardiovascular disease. Twelve studies were identified. Overall, the pooled relative risks (95 % confidence interval) for cardiovascular disease, coronary heart disease, stroke, and peripheral arterial disease were: 1.36 (95 % CI: 1.11, 1.66), 1.30 (95 % CI: 1.12, 1.52), 1.18 (95 % CI: 0.86, 1.59), and 1.49 (95 % CI: 1.15, 1.92), respectively. The pooled relative risks for cardiovascular disease in men, women and never smokers were 1.29 (1.12, 1.48), 1.20 (0.92, 1.56) and 1.27 (0.97, 1.67), respectively. Together with experimental evidence, our review supports the association between cadmium exposure and cardiovascular disease, especially for coronary heart disease. The number of studies with stroke, heart failure (HF) and peripheral arterial disease (PAD) endpoints was small. More studies, especially studies evaluating incident endpoints, are needed.     

Cardiovascular Disease Among Women From Vulnerable Populations: A Review

On a global scale, cardiovascular disease (CVD) is the leading cause of mortality. It is also the number 1 cause of death among women, resulting in 8.6 million deaths annually and constituting one third of all deaths in women worldwide. The burden of CVD and related risk factors has taken priority in the policy development for noncommunicable diseases. However, vulnerable populations, defined here as women who are socially or economically disadvantaged (eg, low income), nonwhite (specifically South Asian and indigenous women), and those who are elderly have often been overlooked in these discussions. These additional vulnerabilities, which may exist independently or in combination, place such women at higher risk for CVD. Specifically, these vulnerabilities include low socioeconomic status, a low sense of control, high stress, South Asian or indigenous ancestry, and increased age. Thus it is vital that we initiate a multipronged approach to CVD prevention that includes rigorous monitoring of CVD risk factors in high-risk populations and the implementation of timely, accurate, and contextually tailored prevention programs, services, and treatments. Well-trained nonphysician health care workers can support the accurate monitoring and management of CVD and CVD risk factors so that groups of women who may otherwise be overlooked can receive adequate attention.