Academic journal article Public Health Reviews; Rennes

Screening for Cardiovascular Disease Risk and Subsequent Management in Low and Middle Income Countries: Challenges and Opportunities

Academic journal article Public Health Reviews; Rennes

Screening for Cardiovascular Disease Risk and Subsequent Management in Low and Middle Income Countries: Challenges and Opportunities

Article excerpt

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 multisectoral 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 of affordable medications and funding mechanisms that allow people to purchase medications without impoverishing them (e.g. universal access to health care). This also 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.

Burden of cardiovascular disease and impact in LMICs

Cardiovascular disease (CVD), mainly heart attack and stroke, is the leading cause of premature mortality and morbidity worldwide [1-3]. An estimated 38 million of the 56 million deaths that occurred globally in 2012 were due to noncommunicable diseases (NCDs) (i.e. CVD, cancer, diabetes and chronic respiratory diseases), with CVD accounting for 46 % of NCD deaths. In 2008, 80 % of all deaths from NCDs occurred in low- and middle-income countries (LMICs). The good news is that premature fatal and non-fatal CVD is largely preventable, and feasible cost-effective interventions exist [4, 5], which emphasizes the need to respond to CVD and other leading NCDs in all countries. In most LMICs, the majority of people at high risk of CVD, which largely correspond to those people with hypertension, high blood cholesterol and/or diabetes, are not aware of having these conditions and do not appreciate that these are risk factors for CVD or that these conditions can be controlled with effective management [6, 7]. In addition, many people in LMICs are unaware of the lifestyle behaviours that are associated with increased risk of CVD and other NCDs, such as tobacco use, harmful use of alcohol, unhealthy diet and physical inactivity.

Strategies to prevent CVD in populations

There are two main strategies to prevent CVD: population and high-risk [8]. Advantages and disadvantages of these two strategies are summarized in Fig. 1. Population strategies involve multisectoral interventions to reduce risk factors in the population. They deploy small effects at the individual level (i.e., small reduction in risk factors) and are "good for all" (e. …

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