Heart failure (HF) is a global public health concern with disproportionate socioeconomic, morbidity and mortality burden on low- and middle-income countries (LMICs). This review summarises contemporary data on the demographic and clinical characteristics, aetiologies, treatment, economic burden and ...outcomes of HF in LMICs. Patients with HF in LMICs are younger than those from high-income countries (HICs) and present at advanced stages of the disease. Hypertension, ischaemic heart disease (IHD), cardiomyopathy (CMO), and rheumatic heart disease (RHD) are the leading causes of HF in LMICs. The contribution of infectious diseases to HF remains prominent in many LMICs. Most health facilities in LMICs lack adequate diagnostic tools for HF, and the use of evidence-based medical and device therapies is suboptimal. Further, HF in LMICs is associated with prolonged hospital stay and high in-hospital and one-year mortality. Finally, HF has profound economic impact on individual patients who, mostly, have no health insurance, and on societies where patients are young, comprising those who have the greatest potential to contribute to economic productivity.
more
Master important clinical skills with our award-winning online courses and case-based workshops.
On this website you can find information on high blood pressure, how to lower it and how blood pressure medicines work.
This study was aimed to ascertain the clinical profile and management of patients with ischemic heart disease (IHD) and/or peripheral artery disease (PAD). In this observational and cross-sectional study developed in 80 hospitals throughout Spain, consecutive adults with stable IHD and/or PAD were i...ncluded. A total of 1089 patients were analyzed, of whom 65.3% had only IHD, 17.8% PAD and 16.9% both. A total of 80.6% were taking only one antiplatelet agent, and 18.2% were on dual antiplatelet therapy (mainly aspirin/clopidogrel). Almost all patients were taking ≥1 lipid lowering drug, mainly moderate-to-high intensity statins. IHD patients took ezetimibe more commonly than PAD (43.9% vs. 12.9%; p < 0.001). There were more patients with IHD that achieved blood pressure targets compared to PAD (<140/90 mmHg: 67.9% vs. 43.0%; p < 0.001; <130/80 mmHg: 34.1% vs. 15.7%; p < 0.001), LDL-cholesterol (<70 mg/dL: 53.1% vs. 41.5%; p = 0.033; <55 mg/dL: 26.5% vs. 16.0%; p = 0.025), and diabetes (HbA1c < 7%, with SGLT2i/GLP1-RA: 21.7% vs. 8.8%; p = 0.032). Modifications of antihypertensive agents and lipid-lowering therapy were performed in 69.0% and 82.3% of patients, respectively, without significant differences between groups. The use of SGLT2i/GLP1-RA was low. In conclusion, cardiovascular risk factors control remains poor among patients with IHD, PAD, or both. A higher use of combined therapy is warranted.
more
Cardiovascular diseases remain the leading cause of morbidity and mortality worldwide. There are significant differences in the burden of cardiovascular disease and associated risk factors, across high-income countries and low- and middle-income countries. Cardiac imaging by echocardiography, cardia...c computed tomography, cardiac magnetic resonance imaging, single-photon emission computed tomography, and positron emission tomography myocardial perfusion imaging are well-established non-invasive tests that aid in the diagnosis, risk stratification, and management of various cardiac diseases. However, there are significant inequalities in availability and access to imaging modalities in low- and middle-income countries attributed to financial constraints, disparities in healthcare and technical infrastructure. In the post-COVID-19 pandemic era, these disparities are exaggerated by the continued technological advancements driving innovations in the field of cardiovascular (CV) imaging in high-income countries, while there is an urgent need to provide sustainable access to diagnostic imaging for patients in economically strained healthcare systems in regions like Africa. This review aims to highlight the inequalities in the burden of cardiac disease, associated risk factors, and access to diagnostic CV imaging tests, while also exploring the need for sustainable solutions to implementing CV imaging all over the world.
more
Background: Cardiovascular disease (CVD), mainly heart attack and stroke, is the
leading cause of premature mortality in low and middle income countries (LMICs).
Identifying and managing individuals at high risk of CVD is an important strategy to prevent and control CVD, in addition to multisector...al population-based interventions to reduce CVD risk factors in the entire population.
Methods: We describe key public health considerations in identifying and managing individuals at high risk of CVD in LMICs.
Results: A main objective of any strategy to identify individuals at high CVD risk is to maximize the number of CVD events averted while minimizing the numbers of
individuals needing treatment. Scores estimating the total risk of CVD (e.g. ten-year risk of fatal and non-fatal CVD) are available for LMICs, and are based on the main CVD risk factors (history of CVD, age, sex, tobacco use, blood pressure, blood cholesterol and diabetes status). Opportunistic screening of CVD risk factors enables identification of persons with high CVD risk, but this strategy can be widely applied in low resource settings only if cost effective interventions are used (e.g. the WHO Package of Essential NCD interventions for primary health care in low resource settings package) and if treatment (generally for years) can be sustained, including continued availability ofaffordable medications and funding mechanisms that allow people to purchase medications without impoverishing them (e.g. universal access to health care). Thisalso emphasises the need to re-orient health systems in LMICs towards chronic diseases management.
Conclusion: The large burden of CVD in LMICs and the fact that persons with high
CVD can be identified and managed along cost-effective interventions mean that
health systems need to be structured in a way that encourages patient registration, opportunistic screening of CVD risk factors, efficient procedures for the management of chronic conditions (e.g. task sharing) and provision of affordable treatment for those with high CVD risk. The focus needs to be in primary care because that is where most of the population can access health care and because CVD programmes can be run effectively at this level.
more
Procurement and supply management activities are fundamental to consistent and reliable access to essential medicines and health products. To reduce the impact of CVD, action needs to be taken to improve prevention, diagnosis, care and management of CVD diseases. Affordable essential medicines and t...echnologies to manage CVD disease must be available where and when they are required. Medicines and technologies need to be managed appropriately to ensure that the correct medicines are selected, procured in the right quantities, distributed to facilities in a timely manner, and handled and stored in a way that maintains their quality. This needs to be backed up by policies that enable sufficient quantities to be procured in order to reduce cost inefficiencies, ensure the reliability and security of the distribution system, and encourage the appropriate use of these health products. In order to avoid stock-outs and the disruption of treatment, all related activities need to be conducted in a timely manner, with performance continually monitored, and prompt action taken in response to problems that may arise. Additionally, medication must be dispensed correctly and used rationally by the healthcare provider and patient alike. The purpose of this guide is to explain the necessary steps.
more
In many low- and middle-income countries, there is a wide gap between evidencebased recommendations and current practice. Treatment of major CVD risk factors remains suboptimal, and only a minority of patients who are treated reach their target levels for blood pressure, blood sugar and blood choles...terol.
In other areas, overtreatment can occur with the use of non-evidence-based
protocols. The aim of using standard treatment protocols is to improve the quality
of clinical care, reduce clinical variability and simplify the treatment options,
particularly in primary health care. Standard treatment protocols can be developed by preparing new national treatment guidelines or by adapting or adopting international guidelines.
The Evidence-based protocols module uses hypertension and diabetes screening
and treatment as an entry point to control cardiovascular risk factors, prevent target organ damage, and reduce premature morbidity and mortality. A comprehensive risk- based approach for integrated management of hypertension, diabetes, and high cholesterol is included in the Risk-based CVD management module.
This module includes clinical practice points and sample protocols for:
1. hypertension detection and treatment
2. type 2 diabetes detection and treatment
3. identifying basic emergencies – care and referral.
HEARTS emphasizes adaptation, dissemination, and use of a standardized set of
simple clinical-management protocols, which should be drug- and dose-specific,
and include a core set of medications. The simpler the protocols and management tools, the more likely they are to be used correctly, and the higher the likelihood that a programme will achieve its goals.
more
Many low-resource settings have a shortage of physicians and health workers. (1) In order to provide patient-centred continuous care more effectively, primary care systems can include team-based care strategies in their clinic workflows and protocols. Team-based care uses multidisciplinary teams (wh...ich may involve new staff, or the shifting of tasks among existing staff). Teams can include patients themselves, primary care physicians, and other allied health professionals, such as nurses, pharmacists, counsellors, social workers, nutritionists, community health workers, or others. Teams reduce the burden on physicians by utilizing the skills of trained health workers. Strong evidence shows that team-based care is effective in improving hypertension control among patients in a cost-effective way. (2) Some amount of task shifting/team-based care is already taking place in many settings; this module provides further guidance on how to maximize this approach for greater impact.
more
Monitoring is a crucial element in any successful programme. It is important to
know if health care facilities – and ultimately countries – are meeting the agreed
goals and objectives for preventing and managing cardiovascular diseases (CVD).
Monitoring is the on-going collection, management ...and use of information to
assess whether an activity or programme is proceeding according to plan and/
or achieving defined targets. Not all outcomes of interest can be monitored. Clear
outcomes must be identified that relate to the most important changes expected to result from the project and to what is realistic and measurable within the timescale of the project. Once these outcomes have been articulated, indicators can be chosen that best measure whether the desired outcomes are being met.
To allow progress to be monitored, this module provides a set of indicators on
CVD management. Agreeing on a set of indicators allows countries to compare
progress in CVD management and treatment across different districts or
subnational jurisdictions, as well as at a facility level, identify where performance
can be improved, and track trends in implementation over time. Monitoring
these indicators also helps identify problems that may be encountered so that
implementation efforts can be redirected.
This module starts from the collection of data at facility level, which is then
“transferred up” the system: facility-level data are aggregated at subnational level
to produce reports that allow tracking of facility and subnational performance over time and allow for comparison among facilities. National-level data are obtained through population-based surveys.
Implementing a monitoring system requires action at many levels. At national and
subnational levels, staff can determine how best to integrate data elements into
existing data collection systems – such as the routine service-delivery data that are collected through facility-level Health Management Information Systems (HMIS).
In the facility setting, personnel must be aware of what data are needed. Sample
data-collection tools are included, recognizing that countries use different datamanagement systems for HMIS, so the CVD monitoring tools will be adapted to work with the HMIS system being used by the country, such that the indicators can be collected with minimal disruption/work to existing systems and tools
more
Webpage about Atherosclerosis, addressing symptoms, diagnosis, causes and risk factors, prevention, treatment, living with the disease.
Background: Data on burden of peripheral artery disease (PAD) and its attributable risk factors are valuable for policymaking. We aimed to estimate the burden and risk factors for PAD from 1990 to 2019.
Methods: We extracted the data on prevalence, incidence, death, years lived with disability (YLD...s), and years of life lost (YLLs) from the Global Burden of Disease Study 2019 to measure PAD burden. Moreover, the attributable burden to PAD risk factors was also estimated.
Results: Globally, in 2019, 113,443,017 people lived with PAD and 10,504,092 new cases occurred, resulting in 74,063 deaths, 500,893 YLDs, and 1,035,487 YLLs. The absolute numbers of PAD prevalent and incident cases significantly increased between 1990 and 2019, contrasting with the decline trends in age-standardized prevalence and incidence rates. However, no statistically significant changes were detected in the global age-standardized death or YLL rates. The burden of PAD and its temporal trends varied significantly by location, gender, age group, and social-demographic status. Among all potentially modifiable risk factors, age-standardized PAD deaths worldwide were primarily attributable to high fasting plasma glucose, followed by high systolic blood pressure, tobacco, kidney dysfunction, diet high in sodium, and lead exposure.
Conclusion: PAD remained a serious public health problem worldwide. More strategies aimed at implementing cost-effective interventions and addressing modifiable risk factors should be carried out, especially in regions with high or increasing burden.
more
The South African (SA) guidelines for cardiac patients for non-cardiac surgery were developed to address the need for cardiac risk assessment and risk stratification for elective non-cardiac surgical patients in SA, and more broadly in Africa.
The guidelines were developed by updating the Canadian ...Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment
and Management for Patients Who Undergo Non-cardiac Surgery, with a search of literature from African countries and recent publications. The updated proposed guidelines were then evaluated in a Delphi consensus process by SA anaesthesia and vascular surgical experts.
The recommendations in these guidelines are:
1. We suggest that elective non-cardiac surgical patients who are 45 years and older with either a history of coronary artery disease, congestive cardiac failure, stroke or transient ischaemic attack, or vascular surgical patients 18 years or older with peripheral vascular disease require further preoperative risk stratification as their predicted 30-day major adverse cardiac event (MACE) risk exceeds 5%
(conditional recommendation: moderate-quality evidence).
2. We do not recommend routine non-invasive testing for cardiovascular risk stratification prior to elective non-cardiac surgery in adults (strong recommendation: low-to-moderate-quality evidence).
3. We recommend that elective non-cardiac surgical patients who are 45 years and older with a history of coronary artery disease, or stroke or transient ischaemic attack, or congestive cardiac failure or vascular surgical patients 18 years or older with peripheral vascular disease should have preoperative natriuretic peptide (NP) screening (strong recommendation: high-quality evidence).
4. We recommend daily postoperative troponin measurements for 48 - 72 hours for non-cardiac surgical patients who are 45 years and older with a history of coronary artery disease, or stroke or transient ischaemic attack, or congestive cardiac failure or vascular surgical patients 18 years or older with peripheral vascular disease, i.e. (i) a baseline risk >5% for MACE 30 days after elective surgery (if no preoperative NP screening), or (ii) an elevated B-type natriuretic peptide (BNP)/N-terminal-prohormone B-type natriuretic peptide (NT-proBNP) measurement before elective surgery (defined as BNP >99 pg/mL or a NT-proBNP >300 pg/mL) (conditional recommendation: moderate-quality evidence).
Additional recommendations are given for the management of myocardial injury after non-cardiac surgery (MINS) and medications for comorbidities.
more
The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death... and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them.
more
Cardiovascular diseases (CVD) represent the highest burden of disease globally. Medicines are a critical intervention used to prevent and treat CVD. This review describes access to medication for CVD from a health system perspective and strategies that have been used to promote access, including pro...viding medicines at lower cost, improving medication supply, ensuring medicine quality, promoting appropriate use, and managing intellectual property issues. Using key evidence in published and gray literature and systematic reviews, we summarize advances in access to cardiovascular medicines using the 5 health system dimensions of access: availability, affordability, accessibility, acceptability, and quality of medicines. There are multiple barriers to access of CVD medicines, particularly in low- and middle-income countries. Low availability of CVD medicines has been reported in public and private healthcare facilities. When patients lack insurance and pay out of pocket to purchase medicines, medicines can be unaffordable. Accessibility and acceptability are low for medicines used in secondary prevention; increasing use is positively related to country income. Fixed-dose combinations have shown a positive effect on adherence and intermediate outcome measures such as blood pressure and cholesterol. We have a new opportunity to improve access to CVD medicines by using strategies such as efficient procurement of low-cost, quality-assured generic medicines, development of fixed-dose combination medicines, and promotion of adherence through insurance schemes that waive copayment for long-term medications. Monitoring progress at all levels, institutional, regional, national, and international, is vital to identifying gaps in access and implementing adequate policies.
more
Hypertension, also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure. Blood is carried from the heart to all parts of the body in the vessels. Each time the heart beats, it pumps blood into the vessels. Blood pressure is created by th...e force of blood pushing against the walls of blood vessels (arteries) as it is pumped by the heart. The higher the pressure, the harder the heart has to pump.
Hypertension is a serious medical condition and can increase the risk of heart, brain, kidney and other diseases. It is a major cause of premature death worldwide, with upwards of 1 in 4 men and 1 in 5 women – over a billion people – having the condition. The burden of hypertension is felt disproportionately in low- and middle-income countries, where two thirds of cases are found, largely due to increased risk factors in those populations in recent decades.
more
Non-communicable diseases (NCDs) are the second common cause of death in sub-Saharan Africa (SSA) accounting for about 35% of all deaths, after a composite of communicable, maternal, neonatal, and nutritional diseases. Despite prior perception of low NCDs mortality rates, current evidence suggests t...hat SSA is now at the dawn of the epidemiological transition with contemporary double burden of disease from NCDs and communicable diseases. In SSA, cardiovascular diseases (CVDs) are the most frequent causes of NCDs deaths, responsible for approximately 13% of all deaths and 37% of all NCDs deaths. Although ischemic heart disease (IHD) has been identified as the leading cause of CVDs mortality in SSA followed by stroke and hypertensive heart disease from statistical models, real field data suggest IHD rates are still relatively low. The neglected endemic CVDs of SSA such as endomyocardial fibrosis and rheumatic heart disease as well as congenital heart diseases remain unconquered. While the underlying aetiology of heart failure among adults in high-income countries (HIC) is IHD, in SSA the leading causes are hypertensive heart disease, cardiomyopathy, rheumatic heart disease, and congenital heart diseases. Of concern is the tendency of CVDs to occur at younger ages in SSA populations, approximately two decades earlier compared to HIC. Obstacles hampering primary and secondary prevention of CVDs in SSA include insufficient health care systems and infrastructure, scarcity of cardiac professionals, skewed budget allocation and disproportionate prioritization away from NCDs, high cost of cardiac treatments and interventions coupled with rarity of health insurance systems. This review gives an overview of the descriptive epidemiology of CVDs in SSA, while contrasting with the HIC and highlighting impediments to their management and making recommendations.
more
Background: COVID-19 is a global public health crisis that affects all sectors; studying the impact of this pandemic on the delivery of cardiology services in Africa is crucial as COVID-19-related cardiovascular complications may worsen the CVD burden in this already highly affected and resource-lim...ited continent
Methods: This was a cross-sectional e-survey study conducted amongst cardiologists in African countries. The primary outcome was the change in service delivery in African cardiology units during the on-going COVID-19 pandemic. The secondary outcomes were the satisfaction of cardiologists with regards to the workload and factors associated with this satisfaction.
Results: There was a significant reduction in working time and the number of patients consulted by week during this pandemic (p<0.001). In general, there was a decrease in the overall activities in cardiovascular care delivery. The majority of cardiology services (76.5%) and consulting programs (85%) were adjusted to the pandemic. Only half of the participants were satisfied with their workload. Reconfiguration of the consultation schedule was associated with a reduced satisfaction of participants (p=0.02).
Conclusions: COVID-19 is associated with an overall reduction in cardiology services rendered in Africa. Since the cardiovascular burdens continue to increase in this part of the World and the risk of cardiovascular complications linked to SARS COV2 remains unchanged cardiology, departments in Africa should anticipate a significant surge of cardiology services demanded by patients after the COVID-19 pandemic.
more
Introduction Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to ...accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs.
Methods A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project’s Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers.
Results The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before–after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6 months after the intervention.
Conclusion The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs.
more
The cardiovascular disease continuum begins with risk factors such as diabetes mellitus (DM), progresses to vasculopathy and myocardial dysfunction, and finally ends with cardiovascular death. Diabetes is associated with a 2- to 4-fold increased risk for heart failure (HF). Moreover, HF patients wit...h DM have a worse prognosis than those without DM. Diabetes can cause myocardial ischemia via micro- and macrovasculopathy and can directly exert deleterious effects on the myocardium. Hyperglycemia, hyperinsulinemia, and insulin resistance can cause alterations in vascular homeostasis. Then, reduced nitric oxide and increased reactive oxygen species levels favor inflammation leading to atherothrombotic progression and myocardial dysfunction. The classification, diagnosis, and treatment of HF for a patient with and without DM remain the same. Until now, drugs targeting neurohumoral and metabolic pathways improved mortality and morbidity in HF with reduced ejection fraction (HFrEF). Therefore, all HFrEF patients should receive guideline-directed medical therapy. By contrast, drugs modulating neurohumoral activity did not improve survival in HF with preserved ejection fraction (HFpEF) patients. Trials investigating whether sodium-glucose cotransporter-2 inhibitors are effective in HFpEF are on-going. This review will summarize the epidemiology, pathophysiology, and treatment of HF in diabetes.
more