Ebook Prevention of cardiovascular diseases from current evidence to clinical practice: Part 1

(BQ) Part 1 book Prevention of cardiovascular diseases from current evidence to clinical practice presents the following contents: Cardiovascular disease in women - An update, risk factors in childhood and youth, genetics of cardiovascular disease, raised blood cholesterol - Preventable risk factor for cardiovascular disease, tobacco and alcohol control - Preventable risk factors,...

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Jadelson P Andrade Fausto J Pinto

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Prevention of Cardiovascular Diseases

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Jadelson P Andrade • Fausto J Pinto

Donna K Arnett

Editors

Prevention of Cardiovascular Diseases

From Current Evidence to Clinical Practice

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Originally published in Portuguese

With the title “Tratado de Prevenção Cardiovascular – Um Desaﬁ o Global”

Published by “Atheneu, 2014”

ISBN 978-3-319-22356-8 ISBN 978-3-319-22357-5 (eBook)

DOI 10.1007/978-3-319-22357-5

Library of Congress Control Number: 2015945957

Springer Cham Heidelberg New York Dordrecht London

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The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors

or omissions that may have been made

Printed on acid-free paper

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Editors

Jadelson P Andrade, M.D

Director, Hospital da Bahia

Salvador , Bahia , Brazil

Donna K Arnett, M.S.P.H., Ph.D

Professor and Chair of the Department

of Epidemiology

School of Public Health

University of Alabama School of Medicine

Birmingham , AL , USA

Fausto J Pinto, M.D., Ph.D

Head of Cardiology Department University Hospital of Santa Maria Faculty of Medicine

University of Lisbon Lisbon , Portugal

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Preface by Jadels on P Andrade

According to data released by the World Health Organization (WHO), 56.9 million deaths were reported worldwide in 2008, and of these about 17 million were caused

by cardiovascular diseases

From this alarming reported epidemiological reality, the WHO began to age all countries of the world to embrace the banner of cardiovascular prevention, proposing an alliance between the nations, governments, civil society, and private sectors to team up in your face

The WHO proposal has the primary objective to promote working together to modify these serious epidemiological data and the gloomy future outlook projected for the following 30 years

In line with the WHO global project, the Brazilian Society of Cardiology posed an international partnership with the European Society of Cardiology and the American Heart Association to prepare the book “Cardiovascular Prevention – A Global Challenge.” Three editors were invited, Jadelson P Andrade, Donna

pro-K Arnett, and Fausto J Pinto, then president and president-elect of the tioned institutions

The work was developed in 28 chapters addressing different themes of vascular prevention with the original version in Portuguese and this edition in English with the title: “Prevention of Cardiovascular Diseases: From Current Evidence to Clinical Practice.” The authors of the chapters were distributed among Brazilian, European, and American experts, all with relevant scientiﬁ c contributions

cardio-on the subject

The ultimate purpose of the editors, in line with the recent proposal from WHO,

is to make available to the international medical community a valuable reference tool for proper addressing the alarming epidemiological index

Salvador, Brazil Jadelson P Andrade, MD, FACC, FESC

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Preface by Fa usto J Pinto

Cardiovascular diseases represent the main cause of mortality worldwide, accounting for 36 % of all deaths in the European Union in 2010 according to the latest avail-able statistics published in the last OECD report They cover a range of diseases related to the circulatory system, including ischemic heart disease (IHD) and cere-bro-vascular disease, which together comprise 60 % of all cardiovascular deaths, and caused more than one-ﬁ fth of all deaths in EU member states

The occurrence of several risk factors, such as hypertension, diabetes, emia, obesity, smoking, and others, accounts for an increase in the prevalence and severity of cardiovascular disease The uprising of some of these risk factors in some regions more than other may explain partially the differences observed among the different regions in the globe and even within the same continent There are underlying risk factors, such as diet, which may explain differences in IHD mortal-ity across countries For instance, on average across EU member states, IHD mortal-ity rates in 2010 were nearly two times greater for men The disparity was greatest

dyslipid-in Cyprus, France, and Luxembourg, with male rates two-to three times higher, and least in Malta, Romania, and the Slovak Republic, at 60 % higher

The success of different strategies in the treatment of cardiovascular disease has resulted in a decrease in IHD mortality rates in nearly all countries in Europe and the USA The decline has been most remarkable in Denmark, Ireland, the Netherlands, and the United Kingdom Estonia and Norway also saw IHD mortality rates cut by one-half or more, although rates in Estonia are still high Declining tobacco consumption contributed signiﬁ cantly to reducing the incidence of IHD, and consequently to reducing mortality rates

However, the impact of treatment improvement should not undermine the lute need to improve healthy lifestyles and reduce the weight of the different risk factors, particularly the ones who can be easily prevented if appropriate steps are taken (e.g., smoking, overweight-obesity, diabetes, hypertension, dyslipidemia) The relationship of prevention strategies with cardiovascular events and death rates is clearly established through different scientiﬁ c studies Therefore, the efﬁ -cacy of primary prevention programs in patients with recognized, treatable risk fac-tors such as hypercholesterolemia, hypertension, diabetes, and smoking should be a

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priority across the different countries It is also important to recognize the need of a tailored approach considering the differences among different countries, which reinforces the importance of putting in place surveillance systems in place that may

be able to monitor properly the need and implementation of preventable measures This is of crucial importance for a successful ﬁ ght against inequalities to access

to appropriate health care among the different countries The role of scientifi c eties in the dissemination of information as well as in the promotion of different activities towards the populations as well as the decision makers can fi ll in an impor-tant gap in this regard This Book on Prevention, being a joint enterprise between the Brazilian Society of Cardiology, European Society of Cardiology and American Heart Association, will certainly fi t into this common goal of improving Prevention

soci-of Cardiovascular Disease worldwide

Cardiology Department, CCUL, CAML Fausto J Pinto, MD, PhD, FESCC, FACC University of Lisbon , Lisbon , Portugal faustopinto@medicina.ulisboa.pt

Preface by Fausto J Pinto

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Preface by Donn a K Arnett

For those of us who have devoted our lives to studying and treating cardiovascular disease (CVD), the idea that CVD prevention is critical is so obvious that further exposition on the subject may seem gratuitous It is decidedly not The successes that clinicians and public health practitioners have had in the realm of CVD preven-tion are not only reasons to exult, but also cause for redoubling our efforts with some assurance that prevention is eminently possible and further progress can be made And although some of the more alarming trends observed in some parts of the world (rising prevalence of obesity, for example) are cause for deep concern, they are also cause for increased and improved preventive action It is precisely this changing landscape of CVD and its risk factors that makes continued assessment and discussion of CVD-prevention strategies so critically important Programs in the USA such as the Centers for Disease Control and Prevention’s Million Hearts Initiative and the American Heart Association’s 2020 Impact Goal (to improve car-diovascular health by 20 % by 2020 while reducing CVD and stroke mortality by

20 %) and analogous efforts in other countries are tangible representations of lation evaluation, goal setting, policy making, and program development that drive progress in this realm Each of the chapters in this book represents a primer in CVD and its prevention With its calculated mix of CVD and risk factor fundamentals and trenchant foresight, this volume will be welcomed by all those around the globe who aim to rise to the challenge of CVD prevention

Birmingham, AL, USA Donna K Arnett, MSPH, PhD

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Value of Primordial and Primary Prevention for Cardiovascular

Diseases: A Global Perspective 21 Armin Barekatain , Sandra Weiss , and William S Weintraub

How to Estimate Cardiovascular Risk 29 Protásio L da Luz and Renata Caruso Fialdini

Tobacco and Alcohol Control: Preventable Risk Factors 41 Aloyzio Chechella Achutti

Physical Inactivity: Preventable Risk Factor

of Cardiovascular Disease 49 Evangelista Rocha

Diet and Cardiovascular Health: Global Challenges

and Opportunities 59

Cheryl A M Anderson and Amanda R Ratigan

Raised Blood Cholesterol: Preventable Risk Factor

for Cardiovascular Disease 69

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Other Determinants of Cardiovascular Diseases:

Social, Globalization, and Urbanization 109

Dalton Bertolim Précoma , Jorge Ilha Guimarães ,

and Antonio Felipe Simão

Genetics of Cardiovascular Disease 117

Steven A Claas , Stella Aslibekyan , and Donna K Arnett

Cardiovascular Disease in Women: An Update 129

Helen C Huang , Puja K Mehta , and C Noel Bairey Merz

Rheumatic Heart Disease: A Neglected Heart Disease 143

Marcia de Melo Barbosa , Maria do Carmo Pereira Nunes ,

and Regina Müller

Chagas Disease: A Neglected Disease 159

José Antonio Marin-Neto , Anis Rassi Jr , Andréa Silvestre de Sousa ,

João Carlos Pinto Dias, and Anis Rassi

Prevention and Control of Cardiovascular Diseases:

Policies, Strategies, and Interventions 183

Álvaro Avezum Jr and Gabriel Pelegrineti Targueta

Prevention and Control of Cardiovascular Diseases

Focusing on Low- and Middle- Income Countries 195

Gilson S Feitosa

Prevention and Control of Cardiovascular Diseases: What Works? 207

Dan Gaita and Laurence Sperling

Prevention and Control of Cardiovascular Diseases:

Integrated and Complimentary Strategies 219

Roberto Ferrari , Lina Marcantoni , and Gabriele Guardigli

Posttraumatic Stress Disorder and Cardiovascular Disease 227

Donald Edmondson , David Hiti , and Ian Kronish

Individual Interventions for Prevention and Control of CVDs 237

Pantaleo Giannuzzi

Social Mobilization for Cardiovascular Disease

Prevention and Control 245

Carlos Alberto Machado

Frugal Innovation: Solutions for Sustainable Global

Cardiovascular Health 251

Donna K Arnett and Steven A Claas

Atrial Fibrillation and Stroke Prevention 261

Antonio Carlos Camargo de Carvalho , Renato D Lopes ,

and Angelo A V de Paola

Contents

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Evidence for Preventing Cardiovascular Disease 301

Ian M Graham and Marie-Therese Cooney

Contents

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Advisory Board

Angelo Amato Vincenzo de Paola Full professor and chief of the discipline of Cardiology; chief of the Arrhythmia and Electrophysiology Sector – Federal University of São Paulo (UNIFESP), Brazil President of the Brazilian Society of Cardiology (2014–2015)

Antonio Carlos de Carvalho Full professor of Cardiology – Federal University of São Paulo (UNIFESP)

Luiz Alberto Piva e Mattos Coordenator of hemodynamics and Cardiovascular Intervention – Rede D’Or Hospitals, Brazil Professor of the Port-Graduate Program

in Tecnology and Intevention in Cardiology – Dante Pazzanese Cardiology Institute, São Paulo, Brazil

Marcia de Melo Barbosa Director of Ecocenter, Hospital Socor – Belo Horizonte, Brazil President of the Interamerican Society of Cardiology PhD in Cardiology by the University of São Paulo (USP), Brazil

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Research and Educational Institute from the Hospital da Bahia , Salvador , Brazil

Stella Aslibekyan , Ph.D Department of Epidemiology , University of Alabama at Birmingham , Birmingham , AL , USA

Alvaro Avezum Jr., M.D., Ph.D Instituto Dante Pazzanese of Cardiology , Sao Paulo , Brazil

University of Sao Paulo , Sao Paulo , Brazil

Population Health Research Institute, Mc Master University , Hamilton , ON , Canada

Armin Barekatain , M.D Internal Medicine , Houston , TX , USA

Steven A Claas , M.S Department of Epidemiology , School of Public Health, University of Alabama at Birmingham , Birmingham , AL , USA

Marie-Therese Cooney , MB, BCH, NUI, MRCPI, PhD Department of Related Health Care , St Vincent’s Hospital , Dublin , Ireland

Protazio L da Luz , M.D., Ph.D Cardiology—Heart Institute from the School of Medicine, University of Sao Paulo , Sao Paulo , Brazil

Antonio Carlos Camargo de Carvalho , M.D., Ph.D Paulista School of Medicine, Federal University of Sao Paulo , Sao Paulo , Brazil

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Marcia de Melo Barbosa , M.D., Ph.D ECO Center, Hospital Socor , Belo Horizonte , Brazil

Interamerican Society of Cardiology

Angelo A V de Paola , M.D., Ph.D. Paulista School of Medicine, Federal University of São Paulo , São Paulo , Brazil

Arrhythmia Department of the Paulista School of Medicine , Federal University of São Paulo , São Paulo , Brazil

Brazilian Society of Cardiology , Rio de Janeiro , Brazil

Andréa Silvestre de Sousa , M.D., Ph.D Federal University of Rio de Janeiro , Rio de Janeiro , Brazil

Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

João Carlos Pinto Dias , M.D., Ph.D School of Medicine, Federal University of Minas Gerais , Belo Horizonte , Brazil

Neglected Diseases Committee of the World Health Organization , Geneva , Switzerland

Maria do Carmo Pereira Nunes , M.D School of Medicine, Federal University of Minas Gerais , Belo Horizonte , Brazil

Donald Edmondson , M.P.H., Ph.D Center for Behavioral Cardiovascular Health, Columbia University Medical Center , New York , NY , USA

Gilson S Feitosa , M.D., Ph.D Bahia School of Medicine and Public Health , Salvador , Brazil

Hospital Santa Isabel/Santa Casa da Bahia , Salvador , Brazil

Roberto Ferrari , M.D Department of Cardiology , LTTA Centre, University Hospital of Ferrara and Maria Cecilia Hospital, GVM Care et Research, E S Health Science Foundation , Cotignola , Italy

Renata Caruso Fialdini , M.D University of Sao Paulo , Sao Paulo , Brazil

Dan Gaita , M.D Cardiology inn Romanian , Bucharest , Romania Romanian Heart Foundation , Bucharest , Romania

Pantaleo Giannuzzi , M.D. Cardiac Rehabilitation Department , Salvatori Maugeri Foundation—IRCCS, Scientiﬁ c Institute of Veruno , Veruno , Italy

Stephan Gielen , M.D. University Hospital, Martin-Luther-University of Halle/Wittenberg , Halle , Germany

Department of Internal Medicine III , University Hospital, Martin-Luther—University of Halle/Wittenberg , Halle , Germany

Contributors

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Ian M Graham , M.D Cardiovascular Medicine , Trinity College Dublin , Dublin ,

Ireland

Cardiology Emeritus , Royal College of Surgeons in Ireland , Dublin , Ireland

Gabriele Guardigli , M.D Department of Cardiology , University Hospital of Ferrara , Ferrara , Italy

Jorge Ilha Guimarães , M.D. Brazilian Society of Cardiology , Rio de Janeiro , Brazil

David Hiti , M.D. Columbia University , New York , NY , USA

Elbert S Huang , M.P.H., Ph.D. Medicine University of Chicago , Chicago , IL , USA

Helen C Huang , M.D. Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute , Los Angeles , CA , USA

Mark D Huffman , M.P.H., M.D Department of Preventive Medicine , Feinberg

of Northwestern University , Chicago , IL , USA

Ian Kronish , M.P.H., M.D. Mount Sinai School of Medicine , New York , NY , USA

Renato D Lopes , M.D., Ph.D Division of Cardiology , Duke University Medical Center , Durham , NC , USA

Paulista School of Medicine, Federal University of Sao Paulo , Sao Paulo , Brazil Brazilian Institute of Clinical Research , Sao Paulo , Brazil

Carlos Alberto Machado , M.D. Cardiovascular Health Promotion from the Brazilian Society of Cardiology , Rio de Janeiro , Brazil

José Antonio Marin-Neto , M.D., Ph.D Cardiology and Pneumology from the University of Sao Paulo, Sao Paulo , Brazil

Interventional Cardiology from the Hospital das Clinicas, Ribeirao Preto Medical School , Sao Paulo , Brazil

Luiz Alberto Mattos , M.D., Ph.D. Interventional Cardiology from Rede D’or Hospitals, Sao Paulo, Rio de Janeiro and Recife , Sao Paulo , Brazil

Puja K Mehta , M.D Cedars-Sinai Medical Center , Los Angeles , CA ,

USA Women’s Heart Center in the Division of Cardiology in the Cedars-Sinai Heart Institute , Los Angeles , CA , USA

Lina Mercantoni , M.D Department of Cardiology , University of Ferrara , Ferrara , Italy

Contributors

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C Noel Bairey Merz , M.D. Barbara Streisand Women’s Heart Center, Preventive and Rehabilitative Cardiac Center, Women’s Guild Chair in Women’s Health , Los Angeles , CA , USA

Regina Müller , M.D., Ph.D Working Group on Rheumatic Fever from the World Heart Federation , Geneva , Switzerland

National Heart Institute of Rio de Janeiro , Rio de Janeiro , Brazil

Joep Perk , M.D., Ph.D Linnaeus University , Kalmar , Sweden

Dalton Bertolim Précoma , M.D., Ph.D. Catholic University of Parana , Curitiba , Brazil

Anis Rassi , M.D., Ph.D. Faculty of Medicine , Federal University of Goias , Goiania , Goias , Brazil

Anis Rassi Jr M.D., Ph.D. Anis Rassi Hospital , Goiania , Goias , Brazil

Amanda R Ratigan , M.S Joint Doctoral Program in Public Health Epidemiology, University of California San Diego State University , San Diego , CA , USA

Department of Defense HIV/AIDS Prevention Program , Naval Research Center , San Diego , CA , USA

Master of Public Health, Epidemiology , San Diego State University , San Diego ,

Russian Society of Cardiology , Moscow , Russia

Antonio Felipe Simão , M.D. Institute of Cardiology from Santa Catarina , Florianópolis , Brazil

Sidney C Smith Jr M.D Department of Medicine , University of North Carolina

at Chapel Hill School of Medicine , Chapel Hill , USA

Laurence Sperling , M.D Emory University School of Medicine , Atlanta ,

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William S Weintraub , M.D. Center for Outcomes Research, One of Four Research Centers Comprising the Value Institute at Christiana Care Health Center , Newark , DE , USA

Sandra Weiss , M.D. Christiana Care Center for Heart et Vascular Health from the University of Chicago Medical Center , Newark , DE , USA

David A Wood , M.D., Ph.D Foundation Garﬁ eld Weston of Cardiovascular Medicine , International Centre for Circulatory Health, National Heart and Lung, Imperial College London , London , UK

Meltem Zeytinoglu , M.D Endocrinology and Metabolism , Chicago , IL , USA

Contributors

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J.P Andrade et al (eds.), Prevention of Cardiovascular Diseases,

DOI 10.1007/978-3-319-22357-5_1

Global Burden of Non-Communicable,

Chronic Diseases

Mark D Huffman and Sidney C Smith Jr

Measuring Burden of Disease

Reliable, contemporary data about the distribution, determinants, and trends in global morbidity and mortality are fundamental to understanding and improving global health The estimation of the world’s disease burden in the modern era was heralded by the publication of the Global Burden of Disease report in 1990 [ 1 ] The World Bank initially commissioned the report in collaboration with researchers

at the Harvard School of Public Health The Institute for Health Metrics and Evaluation at the University of Washington (Seattle, USA) and Imperial College London (London, UK) serve as the current host centers for the Global Burden of Disease and Metabolic Risk Factors, respectively The Global Burden of Disease

underwent periodic updates until the release of its 2010 report in a 2012 Lancet

series, which represented its most comprehensive overhaul since its inception [ 2 ] The next generation of the Global Burden of Disease aims to provide annual updates, starting with 2013 data that will be published in 2014

The study of disease burden initially led to fundamental questions about how best to measure burden Counting numbers of deaths, such as in wartime or epidemics,

or describing death rates have been common methods that are relatively ward to interpret Researchers within the Global Burden of Disease project

straightfor-have measured the cumulative effect of premature deaths through the Years of Life

M D Huffman , MD, MPH ( * )

Department of Preventive Medicine , Northwestern University Feinberg School of Medicine ,

680 North Lake Shore Drive, Suite 1400 , Chicago , IL 60611 , USA

e-mail: m-huffman@northwestern.edu

S C Smith , Jr , MD

Department of Medicine , University of North Carolina at Chapel Hill School of Medicine , CB# 7075, 6031 Burnett Womack, 160 Dental Circle , Chapel Hill , NC 27599-7075 , USA e-mail: scs@med.unc.edu

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Lost (YLL) metric, which measures differences from the same potential life length

across populations to estimate burden, usually taken as the global mean life tancy [ 3 ] However, these measures do not account for the age- and sex-characteris-tics of different countries Therefore, age-adjustment or -standardization to a global population have been basic strategies to account for a population’s age structure to improve comparability across populations Data are usually stratiﬁ ed by sex to account for differences in the proportion of men and women among different countries

However, these approaches do not account for any measure of health during the lifecourse To overcome this limitation, the Global Burden of Disease team devel-

oped the Disability Adjusted Life Year (DALY) metric, which is equal to the sum of Years of Life Lost (YLL) and Years Lived with Disability (YLD), or:

Disability Adjusted LifeYear Years of Life Lost Years Lived with D= + iisability The DALY metric was founded on the principles that: (1) everyone in the world has right to best life expectancy, and (2) differences in the rating of a death or disability should be due to age and sex and not to income, culture, location, social class

It is also important to understand how Years Lived with Disability (YLD) is defi ned, by whom, and at what time in the disease course [ 4 ] First, disability repre-sents an “objective alteration of behavior or performance at the individual level” Disability falls between impairment, which is defi ned by symptoms at an organ level, and handicap, which is defi ned by changed interactions with others at the social or environmental level due to disability To illustrate, if an individual suffers from a stroke, s/he might have symptoms of unilateral arm and leg weakness (impairment), which limits her/his ability to walk independently (disability) and her/his ability to work in a job that requires walking (handicap) Second, researchers have typically surveyed medical professionals and public health experts to rank symptom states to quantitatively estimate YLD for myriad disease states Other individuals, including but not limited to patients, families, caregivers, general pub-lic, insurance companies, and legal experts, might offer complementary perspec-tives on how YLDs should be estimated yet have not been incorporated in these estimates to date Third, YLD estimates can be sensitive to the time course of the disease, particularly for non-communicable, chronic diseases, which can have long periods of minimal to no symptoms followed by acute shocks and gradual recovery

to or near baseline In the stroke example, the immediate post-stroke disability can

be substantially different than 3, 6, or 12 months later and can be dependent upon access to rehabilitation and medical therapy As such, YLD estimates may be sus-ceptible to reporting bias by experts based on their previous clinical or health experiences

Newer estimates of disease burden incorporate costs and ﬁ nancial risk through measures such as catastrophic health spending (based on the proportion of health spending relative to non-food expenditures) and distress ﬁ nancing (based on risky

ﬁ nancial activities to pay for health, including borrowing money or selling assets) [ 5 ] These complementary measures of ﬁ nancial protection, or lack thereof, are

M.D Huffman and S.C Smith Jr.

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associated with individuals and families falling into poverty Because health systems are evaluated in terms of quality, access, and ﬁ nancial protection [ 6 ], these measures

of disease burden will likely gain more attention

Using the International Classifi cation of Diseases framework, the Global Burden of Disease project employed systematic searched published and unpub-lished data on causes of death through a variety of sources, including the World Health Organization mortality database, national vital registration systems, verbal autopsy- based sample registration systems, demographic surveillance systems, cancer registers, crime reports, mortuary data, among others [ 3 ] In the case of so-called “garbage codes” that have been deemed implausible causes of death, avail-able data were used to reclassify the causes of death [ 1 ] The project team then incorporated these best available data into advanced, multi-level statistical models and imputation methods to estimate the causes of death among all countries from

1980 through 2010

The Global Burden of Disease project is not without its critics who express cern about the complex analytic methods and frequent use of imputation to estimate data for countries that do not have accurate, updated mortality data Some fear that the Global Burden of Disease, which is largely funded by the Bill & Melinda Gates Foundation, a private non-governmental organization, may lead to reduced public investments in vital registration systems, a basic public health function that cur-rently covers less than half of the world’s population [ 7 ] Nevertheless, the Global Burden of Disease project represents the most comprehensive and accessible sum-mary of contemporary global disease burden, including providing estimates for non-communicable, chronic diseases

Global Burden of Non-Communicable, Chronic Diseases

Based on data from the Global Burden of Disease project, non-communicable, chronic diseases (NCDs) accounted for 34.5 million (65.5 % of total) deaths glob-ally in 2010, compared with 13.2 million (24.9 % of total) deaths due to maternal, neonatal, and nutritional diseases, and 5.1 (9.6 % of total) deaths due to injuries during the same year (Table 1 ) [ 3 ] While there was an increase of approximately 8 million deaths due to NCDs (30 % relative increase) since 1990, there was also a

32 % decrease in the age- and sex-speciﬁ c death rate from NCDs over the same time period from 645.9 (95 % uncertainty interval: 629.9, 662.9) per 100,000 in 1990 to 520.4 (95 % UI: 499.5, 532.0) per 100,000 in 2010 (19 % decrease) Population aging contributed substantially (39 %) to the increases in NCD deaths since 1990, which primarily explains this difference between increasing numbers of deaths and declining rates [ 3 ]

Similarly, the number of disability adjusted life years (DALYs) for all NCDs increased from 1075 million (95 % UI: 1000, 1160) DALYs in 1990 compared with

1343 million (95 % UI: 1240, 1457) in 2010, which represents a 25 % increase, while the rate of DALYs per 100,000 decreased by 3.8 % from 20,283 (95 % UI:

Global Burden of Non-Communicable, Chronic Diseases

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Table 1 All-cause and non-communicable, chronic disease (NCD)-speciﬁ c deaths and death rates

in 1990 and 2010 estimated by the Global Burden of Disease Study [ 3 ]

Table 2 Global Burden of Disease 2010 estimates of deaths and age-standardized death rates per

100,000 in 1990 and 2010 across non-communicable, chronic diseases

All ages deaths (thousands)

Age-standardized death rates per 100,000

34,539.9 (33,164.7, 35,313.0)

30.0 645.9

(629.9, 662.9)

520.4 (499.5, 532.0)

−19.4

Cardiovascular and

circulatory diseases

11,903.7 (11,329.4, 12,589.3)

15,616.1 (14,542.2, 16,315.1)

31.2 298.1

(283.9, 314.9)

234.8 (218.7, 245.2)

−21.2

(5415.9, 6201.9)

7977.9 (7337.1, 8403.8)

38.0 140.8

(131.9, 151.4)

121.4 (111.6, 127.9)

−13.8

Chronic lung

diseases

3986.3 (3914.3, 4063.8)

3776.3 (3648.2, 3934.1)

−5.3 98.2

(96.4, 100.1)

57.0 (55.1, 59.4)

−41.9

(1420.0, 1804.0)

2726.2 (2447.1, 2999.1)

76.5 36.1

(33.4, 41.6)

41.0 (36.8, 45.1)

13.8

Mental and

behavioral disorders

138.1 (95.2, 188.0)

231.9 (176.3, 329.1)

68.0 3.2 (2.2,

4.3)

3.5 (2.6, 4.9)

9.3 Musculoskeletal

disorders

69.5 (46.2, 89.6)

153.5 (110.7, 214.8)

121.0 1.7 (1.1,

2.2)

2.3 (1.7, 3.2)

37.8 Data abstracted from Lozano et al [ 3 ]

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Cardiovascular Diseases

Global cardiovascular disease deaths increased from 11.9 million (95 % UI: 11.2, 12.6) in 1990 to 15.6 million (95 % UI: 14.5, 16.3) in 2010, which represents a 31 % increase Age- and sex-adjusted rates of cardiovascular disease deaths decreased from 298.1 (95 % UI: 283.9, 314.9) per 100,000 in 1990 to 234.8 (95 % UI: 218.7, 245.2) per 100,000 in 2010, which represents a 21 % decrease [ 3 ] Ischemic heart disease was the leading cause of cardiovascular deaths during both time periods The number of deaths increased from 5.2 million (95 % UI: 5.0, 5.6) ischemic heart disease deaths in 1990 to 7.0 million (95 % UI: 6.6, 7.4), which represents a 35 % increase Age- and sex-adjusted death rates due to ischemic heart disease decreased from 131.3 (95 % UI: 126.4, 142.2) per 100,000 to 105.7 (95 % UI: 98.8, 111.9) per 100,000 in 2010, which represents a 20 % decrease

The number of disability adjusted life years (DALYs) due to cardiovascular diseases increased from 240,667 (95 % UI: 227,084, 257,718) DALYs in 1990 com-pared with 295,036 (95 % UI: 273,061, 309,562) in 2010, which represents a 23 %

Table 3 Global Burden of Disease 2010 estimates of disability adjusted life years and disability

adjusted life years lost per 100,000 in 1990 and 2010 across non-communicable, chronic diseases

All disability adjusted life years (thousands)

Disability adjusted life years per 100,000

1,343,973 (1,239,973, 1,456,773)

25.0 20,283

(18,893, 21,874)

19,502 (17,997, 21,143)

295,036 (273,061, 309,562)

22.6 4540

(4283, 4861)

4282 (3963, 4493)

−5.7

Neoplasms 148,078

(136,775, 158,256)

188,487 (174,452, 199,037)

27.3 2793

(2580, 2985)

2736 (2532, 2889)

−2.1

Chronic lung

diseases

119,153 (107,917, 132,391)

117,945 (102,924, 135,608)

−1.0 2248

(2036, 2497)

1712 (1494, 1968)

−23.8

(73,638, 102,489)

122,437 (107,437, 143,387)

43.9 1605

(1389, 1933)

1777 (1559, 2081)

185,190 (154,647, 218,496)

37.6 2539

(2115, 3005)

2668 (2245, 3171)

5.9

Musculoskeletal

disorders

116,554 (88,684, 147,285)

169,624 (129,771, 212,734)

45.5 2198

(1673, 2778)

2462 (1883, 3088)

12.0

Data abstracted from Murray et al [ 2 ]

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increase, while the rate of DALYs per 100,000 due to cardiovascular diseases decreased by 6 % from 4540 (95 % UI: 4283, 4861) per 100,000 in 1990 to 4282 (95 % UI: 3963, 4493) per 100,000 in 2010

Cancer

Global cancer deaths increased from 5.8 million (95 % UI: 5.4, 6.2) in 1990 to 8.0 lion (95 % UI: 7.3, 8.4) in 2010, which represents a 38 % increase Similar to other cardiovascular diseases, age- and sex-adjusted rates of cancer deaths decreased from 140.8 (95 % UI: 131.0, 151.5) per 100,000 in 1990 to 121.4 (95 % UI: 111.6, 127.9) per 100,000 in 2010, which represents a 14 % decrease [ 3 ] Cancers of the trachea, bronchus, and lungs were the leading cause of cancer deaths during both time periods The number of deaths increased from 1.0 million (95 % UI: 0.8, 1.3) cancers of the trachea, bronchus, and lung in 1990 to 1.5 million (95 % UI: 1.1, 1.8), which represents

mil-a 47 % incremil-ase Age- mil-and sex-mil-adjusted demil-ath rmil-ates due to cmil-ancers of the trmil-achemil-a, bronchus, and lung modestly decreased from 25.5 (95 % UI: 20.4 32.4) per 100,000 to 23.4 (95 % UI: 17.3, 27.3) per 100,000 in 2010, which represents an 8 % decrease The number of disability adjusted life years (DALYs) due to cancer increased from 148,078 (95 % UI: 136,775, 158,256) DALYs in 1990 compared with 188,487 (95 % UI: 174,452, 199,037) in 2010, which represents a 27 % increase, while the rate of DALYs per 100,000 due to cancer decreased by 2 % from 2793 (95 % UI: 2580, 2985) per 100,000 in 1990 to 2736 (95 % UI: 2532, 2889) per 100,000 in 2010

Chronic Lung Diseases

Global chronic lung disease deaths decreased from 4.0 million (95 % UI: 3.9, 4.1)

in 1990 to 3.8 million (95 % UI: 3.6, 3.9) in 2010, which represents a 5 % decrease Age- and sex-adjusted rates of chronic lung disease deaths increased from 98.2 (95 % UI: 96.4, 100.1) per 100,000 in 1990 to 57.0 (95 % UI: 55.1, 59.4) per 100,000 in 2010, which represents a 42 % decrease [ 3 ]

The number of disability adjusted life years (DALYs) due to chronic lung diseases was similar at 119,153 (95 % UI: 107,917, 132,391) DALYs in 1990 compared with 117,945 (95 % UI: 102,924, 135,608) in 2010, while the rate of DALYs per 100,000 due to chronic lung diseases decreased by 24 % from 2248 (95 % UI: 2036, 2497) per 100,000 in 1990 to 1712 (95 % UI: 1494, 1968) per 100,000 in 2010

Diabetes

Global diabetes deaths increased from 665,000 (95 % UI: 593,300, 757,500) in

1990 to 1.3 million (95 % UI: 1.1, 1.3) in 2010, which represents a 93 % increase Unlike cardiovascular diseases, cancer, and chronic lung disease, age- and

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sex- adjusted rates of diabetes deaths increased from 16.3 (95 % UI: 14.5, 18.6) per 100,000 in 1990 to 19.5 (95 % UI: 16.2, 20.5) per 100,000 in 2010, which represents a 20 % increase

The number of disability adjusted life years (DALYs) due to diabetes increased from 85,084 (95 % UI: 73,638, 102,489) DALYs in 1990 compared with 122,437 (95 % UI: 107,437, 143,387) in 2010, which represents a 44 % increase, while the rate

of DALYs per 100,000 due to diabetes increased by 11 % from 1605 (95 % UI: 1389, 1933) per 100,000 in 1990 to 1777 (95 % UI: 1559, 2081) per 100,000 in 2010

Mental and Behavioral Disorders

Global mental and behavioral disorder related deaths increased from 138,100 (95 % UI: 95,200, 188,000) in 1990 to 231,900 (95 % UI: 176,300, 329,100) in 2010, which represents a 68 % increase Age- and sex-adjusted rates of mental and behavioral disorder related deaths increased from 3.2 (95 % UI: 2.2, 4.3) per 100,000 in 1990 to 3.5 (95 % UI: 2.6, 4.9) per 100,000 in 2010, which represents a 9 % increase [ 3 ] The number of disability adjusted life years (DALYs) due to mental and behavioral disorder increased from 138.1 (95 % UI: 95.2, 188.0) DALYs in 1990 compared with 231.9 (95 % UI: 176.3, 329.1) in 2010, which represents a 68 % increase, while the rate of DALYs per 100,000 due to mental and behavioral disorder increased

by 9 % from 3.2 (95 % UI: 2.2, 4.3) per 100,000 in 1990 to 3.5 (95 % UI: 2.6, 4.9) per 100,000 in 2010

Shared Risk Factors for Non-Communicable,

Chronic Diseases

Non-communicable, chronic diseases (NCDs) share causal risk factors, which suggests that strategies to reduce the burden of these risk factors will have multipli-cative beneﬁ ts Common risk factors can be behavioral (tobacco use, unhealthy diet, and physical inactivity), physiologic (body mass index, blood pressure, blood cho-lesterol, and blood glucose), and social (stress, socioeconomic position) While these risk factors are generally considered modiﬁ able, prevention of abnormal risk factor development, also known as primordial prevention [ 8 ], leads to more favor-able health outcomes than even treatment of risk factors Prevalence estimates and attributable burdens of disease for behavioral risk factors are outlined below

Tobacco

Smoking prevalence has decreased from 41 % (95 % UI: 40, 43) in 1980 to 31 % (95 % UI: 30, 32) in 2012 for men >15 years and from 11 % (95 % UI: 10, 11) to

6 % (95 % UI: 6, 6) for women >15 years [ 9 ] However, due to population growth

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and aging as well as the inherent lag time between tobacco exposure and diseases such as cancer, the number of deaths attributable to tobacco increased from 5.3 million (95 % UI: 4.8, 6.0) in 1990 to 6.3 million (95 % UI: 5.4, 7.0) in 2010 [ 10 ]

If recent trends continue, there will be an estimated 1 billion tobacco-related deaths

in the twenty-ﬁ rst century, most of which will occur in low- and middle-income countries and half of which will occur before age 70 years [ 11 ]

Unhealthy Diet

Global increases in body mass index from 1980 to 2010 (0.4 mg/kg 2 per decade (95 % UI: 0.2, 0.6) for men and 0.5 mg/kg 2 per decade (95 % UI: 0.3, 0.7) for women) [ 12 ] suggest that access to calories has increased However, global trends

in diet quality are difﬁ cult to assess not only because of the inherent complexity in comparing different dietary patterns across the world but also because of the limita-tions in instruments for dietary data collection The Global Burden of Disease proj-ect evaluates the effects of 14 dietary variables (fruit intake, vegetable, whole grains, nuts and seeds, milk, red meat, processed meat, sugar sweetened beverages, ﬁ ber, calcium, omega-3 containing seafood, polyunsaturated fats, trans fats, and sodium) The investigators estimate the number of attributable deaths due to unhealthy diet increased from 8.5 million (95 % UI: 7.9, 9.2) in 1990 to 12.5 million (95 % UI: 11.7, 13.3) in 2010, with the greatest proportion coming from diets low in fruits (4.9 million [95 % UI: 3.8, 5.9]), low in nuts/seeds (2.5 million [95 % UI: 1.6, 3.2]), and low in vegetables (1.8 million [95 % UI: 1.2, 2.4]) [ 10 ]

Physical Inactivity

Major changes in migration, transportation, and mechanization over the past century have undoubtedly led to declines in global physical activity [ 13 ] However, like diet, global physical activity estimates and time trends are difﬁ cult to obtain because of: (1) limited number of global physical inactivity surveys; (2) limitations in survey instruments that rely upon self-reporting of physical activity; and (3) historical reli-ance on leisure-time physical activity estimates, rather than inclusion of transport, occupational, and domestic activity domains, which may overestimate physical inactivity prevalence These limitations notwithstanding, global physical inactivity prevalence in 2010 has been estimated to be 28 and 34 % for men and women, respectively [ 14 ] In 2010, the Global Burden of Disease project estimated that the number of attributable deaths due to physical inactivity was 3.2 million (95 % UI: 2.7, 3.7) [ 10 ] The Lancet’s Physical Activity Series Working Group produced

a higher estimate of deaths due to inactivity for 2008 (5.3 million, a 65 % higher estimate), which reﬂ ects the uncertainty in creating such estimates of attributable disease burden [ 15 ]

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Future Projections

Despite reductions in age-adjusted mortality from non-communicable, chronic diseases (NCDs) overall, the burden of NCDs will continue to grow in absolute terms because of the inexorable effects of population growth and aging For exam-ple, if the 2010 death rates due to cardiovascular diseases, cancer, chronic lung diseases, and diabetes remained unchanged until 2025, the annual numbers of deaths would increase from 28.3 million to 38.8 million [ 16 ] To galvanize global action and momentum in reducing the burden of NCDs, member states of the World Health Organization have adopted nine voluntary targets to reduce the burden of NCDs and their risk factors (Box) [ 17 ] The primary, equity-based target is to reduce the risk of premature death, between the ages of 30 and 69 years, from NCDs by

25 % by 2025, or the so-called “25 × 25” target

Kontis et al estimated the effect of achieving six of the eight risk factor targets (tobacco, alcohol, salt intake, obesity, raised blood pressure, raised glucose/diabetes)

on the “25 × 25” mortality target overall and on speciﬁ c NCD subtypes, stratiﬁ ed by sex and country, compared with “business as usual” trends [ 16 ] These projections suggest that, if these six risk factor targets were achieved, the risk of premature

Box: Nine Voluntary Targets Adopted by Member States of the World Health Organization to Reduce the Burden of Non-Communicable,

4 A 30 % relative reduction in mean population intake of salt/sodium

5 A 30 % relative reduction in prevalence of current tobacco use in persons aged 15+ years

6 A 25 % relative reduction in the prevalence of raised blood pressure or contain the prevalence of raised blood pressure, according to national circumstances

7 Halt the rise in diabetes and obesity

8 At least 50 % of eligible people receive drug therapy and counseling (including glycemic control) to prevent heart attacks and strokes

9 An 80 % availability of the affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases in both public and private facilities

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deaths from NCDs would decrease by 22 % for men and 19 % for women between

2010 and 2025 These estimates compare favorably with projected decreases in the risk of premature mortality from NCDs by 11 % for men and 10 % for women under the “business as usual” scenario where recent declines in NCD mortality rates con-tinue to 2025 Achieving these six risk factor targets would not only prevent or postpone 16.1 million NCD-related deaths among individuals 30–69 years old over the 15 year period (2010–2025) but would also prevent or postpone an additional 21.4 million deaths among individuals 70 years and greater The majority (70 %) of these premature deaths prevented or postponed would be from cardiovascular disease (11.4 million), followed by cancer (2.4 million), chronic lung diseases (1.2 million) and diabetes (1.1 million) Because low- and middle- income countries have a higher burden of NCD-related deaths and death rates compared with high-income countries, these countries would experience far greater progress toward the

“25 × 25” mortality target if the risk factor targets were achieved

Conclusions

Non-communicable chronic diseases (NCDs), including cardiovascular diseases, cancer, chronic lung diseases, diabetes, and mental and behavioral disorders, are the leading causes of death and disability worldwide While global age-adjusted death rates from NCDs have been falling over the past two decades, population growth and aging have led to absolute and ongoing increases in NCD-related deaths and disability adjusted life years (DALYs) Low- and middle-income countries are pro-jected to bear even greater proportions of the global burden of NCDs in the coming decades due, at least in part to their younger demographics, unless comprehensive, sustainable, and intersectoral action is taken to prevent, detect, treat, and control NCDs and their shared risk factors

References

1 Murray CJL, Lopez AD Estimating causes of death: new methods and global and regional application for 1990 In: Murray CJL, Lopez AD, editors The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors

in 1990 and projected to 2020 Boston: Harvard School of Public Health, on behalf of the World Health Organization and the World Bank; 1996 p 117–200

2 Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012;380(9859):2197–223

3 Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012;380(9859):2095–128

4 Salomon JA, Vos T, Hogan DR, Gagnon M, Naghavi M, Mokdad A, et al Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010 Lancet 2012;380(9859):2129–43

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5 Huffman MD, Rao KD, Pichon-Riviere A, Zhao D, Harikrishnan S, Ramaiya K, et al A cross- sectional study of the microeconomic impact of cardiovascular disease hospitalization in four low- and middle-income countries PLoS One 2011;6(6), e20821

6 Reinhardt UE, Cheng T-M The world health report 2000-Health systems: improving mance Bull World Health Organ 2000;78(8):1064

7 Byass P, de Courten M, Graham WJ, Laﬂ amme L, McCaw-Binns A, Sankoh OA, et al Reﬂ ections

on the Global Burden of Disease 2010 estimates PLoS Med 2013;10(7), e1001477

8 Strasser T Reﬂ ections on cardiovascular diseases Interdiscip Sci Rev 1978;3(3):225–30

9 Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer-Lindgren L, Thomson B, et al Smoking prevalence and cigarette consumption in 187 countries, 1980–2012 JAMA 2014;311(2):183

10 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clus- ters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study

13 Yusuf S, Reddy S, Ounpuu S, Anand S Global burden of cardiovascular diseases: Part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization Circulation 2001;104(22):2746–53

14 Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U, Lancet Physical Activity Series Working Group Global physical activity levels: surveillance progress, pitfalls, and prospects Lancet 2012;380(9838):247–57

15 Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, Lancet Physical Activity Series Working Group Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy Lancet 2012;380(9838):219–29

16 Kontis V, Mathers CD, Rehm J, Stevens GA, Shield KD, Bonita R, et al Contribution of six risk factors to achieving the 25 × 25 non-communicable disease mortality reduction target: a modelling study Lancet 2014;384:427–37

17 World Health Organization Global action plan for the prevention and control of nicable diseases 2013–2020 World Health Organization; 2013

noncommu-Global Burden of Non-Communicable, Chronic Diseases

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J.P Andrade et al (eds.), Prevention of Cardiovascular Diseases,

DOI 10.1007/978-3-319-22357-5_2

Cardiovascular Disease Worldwide: A Global Challenge

Jadelson P Andrade, Marianna D Andrade, and Luiz Alberto Mattos

At the beginning of this century, cardiovascular diseases (CVD) showed an epidemiological behavior very similar to those of the great endemics of past centu-ries and were responsible for high mortality rates worldwide

This current epidemiological proﬁ le of CVD is evident in data from the World Health Organization (WHO), which show that of the 56.9 million total deaths reported worldwide, approximately 30.5 % or 17 million people had CVD listed as the cause of death [ 1 2 ]

An important epidemiological fact that needs to be considered is the uneven geographic distribution of CVD deaths Lower mortality rates are observed in devel-oped countries and much of Latin America, and higher rates are observed in lower income countries, such as Eastern European countries [ 1 ]

Data released by the WHO in 2008 indicate that of the total number of CVD deaths worldwide, approximately 80.1 % occurred in low- and middle-income countries, and only 19.9 % occurred in high-income countries

If this global scenario is already alarming at the beginning of this new century, the expectations for the future are even more troubling; it is estimated that if concrete

J.P Andrade , M.D ( * )

Hospital da Bahia , Salvador , Brazil

e-mail: jadelson@hospitaldabahia.com.br

M.D Andrade , M.D., Ph.D

Intensive Care Unit from the Hospital da Bahia , Salvador , Brazil

Research and Educational Institute from the Hospital da Bahia , Salvador , Brazil

e-mail: madeway@hotmail.com

L.A Mattos , M.D., Ph.D

Interventional Cardiology from Rede D’or Hospitals, Sao Paulo,

Rio de Janeiro and Recife , Sao Paulo , Brazil

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actions are not implemented, by the year 2030, seven out of ten deaths will be due

to non-communicable diseases (NCDs), and CVD will account for the highest percentage of these deaths [ 1 3 ]

However, although the CVD mortality rates in developed countries have been declining in recent decades, as previously mentioned, the rates in most developing countries are still increasing This is due, among other factors, to the increased eco-nomic power of developing countries Rising incomes per capita have led to improvement in the health and basic living conditions of these populations, resulting

in a signiﬁ cant reduction in the incidence of and mortality from infectious and sitic diseases, with a proportional increase in the number of deaths caused by NCDs

para-In addition, the lifestyle adopted by urban populations in developing countries has signiﬁ cantly increased the prevalence of risk factors for cardiovascular diseases such as obesity, physical inactivity, tobacco use, high blood pressure, excessive salt intake, dyslipidemia, and diabetes [ 4 5 ]

Risk Factors for CVD

At the end of the 1940s, important epidemiological studies, such as the pioneering study by Framingham, began to identify predictive risk factors for the development

of CVD The primary factors listed were systemic hypertension, dyslipidemia, tobacco use, obesity, physical inactivity, excessive salt intake, and mental/emotional stress [ 6 , 7 ] The identiﬁ cation of these and other risk factors in populations in both developed and developing countries indicated the steps that should be followed to counter this epidemiological challenge

At ﬁ rst, population programs were developed and applied in developed countries, including some European countries, the USA, Canada, Australia, and Japan These programs were designed to establish some type of epidemiological control over these risk factors in their populations Analyses of the results of these programs have shown a signiﬁ cant reduction in CVD mortality rates where and when they were applied The Framingham Heart Study, the North Karelia Project, and the Stanford Project are some of the more notable programs implemented [ 5 7 8 ]

In Finland, for example, efforts to implement well-organized cardiovascular prevention programs have been rewarded with a reduction in CVD risk factors and CVD mortality rates The combined efforts of governments, health professionals, food companies, universities, and non-governmental organizations have resulted in effective actions [ 8 ] The results of these actions have led to the consumption of healthier diets with reduced levels of sodium and saturated fats and adecreased preva-lence of tobacco use and physical inactivity Between 1972 and 2007, in Finland, there was a signiﬁ cant reduction in cholesterol levels by approximately 21 %, systolic blood pressure by 10.1 mmHg, and the prevalence of tobacco use by 51 % [ 9 ]

The implementation of this program model would surely bring potential beneﬁ ts

to developing countries such as Brazil, which has a high CVD mortality rate According to data published by the Ministry of Health (Ministério da Saúde—MS)

of Brazil and obtained from a telephone survey conducted in 2010 in major Brazilian

J.P Andrade et al.

Trang 36

cities (Surveillance of Risk and Protective Factors for Chronic Diseases Telephone Survey—VIGITEL), 15 % of adults 18 years and older are smokers, only 30 % regularly consume fruits and vegetables, whereas 34 % reported consuming meat with excess fat, and only 30 % practice physical activity regularly (including leisure activities and commuting to work) [ 10 , 11 ]

According to the 2012 European Guidelines on Cardiovascular Prevention, there are eight reasons to promote cardiovascular prevention [ 12 ]:

1 Atherosclerotic CVD, especially coronary artery disease, is the leading cause of premature death worldwide;

2 CVD affects men and women equally;

3 CVD mortality rates are declining in many European countries but remain high

in Eastern Europe;

4 More than half of the observed decrease in the CVD rate is related to changes in risk factors, and 40 % is due to improved treatments;

5 Preventive efforts should be applied throughout life, from birth to old age;

6 Preventive approaches limited to high-risk individuals are less effective, and education programs for the entire population are needed;

7 Despite gaps in knowledge, there is ample evidence to justify intensive efforts related to public health and individual prevention;

8 There is still room for improvement in the control of risk factors, even in high- risk individuals

Prevention of Risk Factors, Early Diagnosis

and Treatment of CVD

The evolution and improvement of diagnostic methods and the therapeutic arsenal for CVD have created a valuable tool for reducing cardiovascular mortality Some epidemiological studies still attribute a greater impact on reducing cardiovascular morbidity and mortality to treatment rather than to prevention More recent studies, however, reveal a balance between preventive and therapeutic actions in the ﬁ ght against CVD In 2007, an epidemiological analysis was published that used the vali-dated IMPACT mortality model, and it showed a signiﬁ cant decrease in mortality rates due to coronary heart disease in both men and women in the USA between

1980 and 2000 Furthermore, the authors concluded that approximately 44 % of this decrease was due to the control of several cardiovascular risk factors, while 47 % resulted from therapeutic actions Preventive actions that contributed to this result included reductions in total cholesterol (24 %), systolic blood pressure (24 %), the prevalence of tobacco use (12 %) and physical inactivity (5 %) [ 13 , 14 ] This result was counterbalanced by the signiﬁ cant increase in the prevalence of obesity and diabetes in this population

Figure 1 summarizes the main epidemiological studies that have been published

in recent decades evaluating the impact of treatments and preventive actions on reducing cardiovascular mortality

Cardiovascular Disease Worldwide: A Global Challenge

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Global Targets for the Prevention and Control of CVD

The data presented here reinforce the importance of a new strategy for combating CVD, which will require a combination of cardiovascular prevention actions and earlier and more accurate diagnosis methods, as well as increased availability of effective treatments The balance of these actions will result in signiﬁ cant reductions

in the current epidemiological indices and also a change in future prospects During the World Health Assembly in 2012, the WHO initiated the campaign

“Unite in the Fight against NCDs,” setting a global target to reduce premature mortality rates due to NCDs by 25 % by the year 2025 [ 15 ] The campaign was based on well-deﬁ ned principles and supported by all recent scientiﬁ c evidence related to the prevention of NCDs The pillars of this campaign are the following:

• Accelerate tobacco control;

• Reduce salt intake;

• Implement appropriate treatment of high-risk CVD;

• Reduce alcohol consumption;

• Reduce physical inactivity

The WHO has encouraged all countries to unite around this banner of vascular disease prevention, proposing an alliance between the United Nations, governments, civil society, and private sectors

The goal of the WHO is to promote a collaborative effort to change the serious epidemiological reality of CVD and the future prospects that have been projected for the next 30 years [ 15 , 16 ]

Fig 1 Percent decrease in the number of deaths from coronary heart disease attributed to changes

in treatment and risk factors in different populations (Adapted from Di Chiara and Vanuzzo [ 13 ])

J.P Andrade et al.

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The Letter from Rio de Janeiro

In line with the WHO proposal, the Brazilian Society of Cardiology (Sociedade Brasileira de Cardiologia—SBC) gathered a committee formed by the presidents of

ﬁ ve of the most important cardiology societies in the world in 2013 in the city of Rio de Janeiro: the World Heart Federation, American Heart Association, European Society of Cardiology, Interamerican Society of Cardiology, and Brazilian Society

of Cardiology In conjunction with specialists in global cardiovascular prevention, a document was prepared containing targets for the prevention and control of NCDs [ 16 ] The document, called the “Letter from Rio”, was ratiﬁ ed by the presidents of the participating societies and aims to provide an overall view of CVD and propose strategic actions to reduce the prevalence of the risk factors contributing to the high CVD mortality [ 17 , 18 ] The letter conﬁ rms the global target of a 25 % reduction in early mortality due to NCDs by the year 2025 The following are included in the resolutions contained in the Letter from Rio:

• Work together in defense of global targets for achieving a 25 % reduction in mortality from NCDs by the year 2025;

• Implement public policies for the prevention and control of NCDs in the general population and speciﬁ c groups;

• Act on social determinants that contribute to the occurrence of CVD through government policies;

• Interact with health policy makers to develop cardiovascular prevention programs and methods for evaluating their results;

• Mobilize the media to continuously disseminate information on the importance

of CVD, its major risk factors, and means of prevention

Targets from the Letter from Rio for the Prevention and Control of NCDs

• 25 % reduction in mortality rates from NCDs;

• 10 % reduction in the prevalence of physical inactivity among adults;

• 25 % reduction in the prevalence of hypertension (deﬁ ned as a systolic blood pressure ≥140 mmHg and a diastolic pressure ≥90 mmHg);

• Reduction in the average intake of salt in the adult population to ≤5 g/day (2000 mg sodium);

• 30 % reduction in the prevalence of tobacco use;

• 15 % reduction in the intake of saturated fatty acids to achieve the mended level of <10 % of the daily fat requirements;

recom-• Reduction in the prevalence of obesity;

• 10 % reduction in excessive alcohol consumption;

• 20 % reduction in hypercholesterolemia;

• 50 % of eligible individuals should receive counseling and drug therapy to prevent heart attacks and strokes;

• Make available essential technologies and drugs, including generics, to 80 %

of the population suffering from NCDs in both the public and private sectors

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Conclusion

The recognition that CVD is responsible for 30 % of all deaths worldwide, together with the alarming projections for the coming years, indicate that CVD should be the target of actions against it that involve governments, trade associations, and civil society

The identifi cation of the main factors responsible for the occurrence of CVD and the signifi cant technological and scientifi c advancements in the diagnostic and therapeutic arsenal against NCDs have created valuable tools for intervention in this context An analysis of the results of cardiovascular prevention programs imple-mented in some developed countries, using the triad of reduction of cardiovascular risk factors, early diagnosis, and proper treatment, has shown signifi cant reductions

in CVD mortality and has indicated the paths to be followed in the future

References

1 WHO Statistical Information Center World Health Statistics 2009 – En-WHS 2009

2 Buttler D Un targets top killers Nature 2011;477(7364):260–1

3 Beaglehole R International trends in coronary heart disease mortality and incidence rates

J Cariovasc Risk 1999;6(2):63–8

4 Beaglehole R, Bonita R Global public health: a score-card Lancet 2008;372(9654): 1988–96

5 World Health Organization, World Heart Federation, World Stroke Organization Global atlas

on cardio-vascular disease prevention and control: policies, strategies, and interventions 2011

9 Thirty-ﬁ ve-year trends in cardiovascular risk factors in Finland Int J Epidemiol 2010; 39(2):504–18

10 Vigitel Brasil 2012: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefôni-co/Ministério da Saúde, Secretaria de Vigilância em Saúde, Departamento

de Vigilância de Doenças e AgravosnãoTransmissíveis e Promoção de Saúde Brasília: Ministério da Saúde, 2013

11 Brasil Ministério da Saúde Secretaria de Vigilância em Saúde Departamento de Análise de Situação de Saúde Plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (DCNT) no Brasil 2011-2022/Ministério da Saúde Secretaria de Vigilância em Saúde

12 Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al European Guidelines

on cardio-vascular disease prevention in clinical practice (version 2012) The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts) Eur Heart J 2012;33(13):1635–701

J.P Andrade et al.

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15 World Health Organization Revised [third] WHO discussion paper on the development of a comprehensive global monitoring framework, including indicators, and a set of voluntary global targets for the prevention and control of NCDs July 2012 http://www.who.int/nmh/ events/2012/ncd_discussion_paper/en/index.html

16 World Health Organization 65th World Health Assembly document A65/54: Second report of Committee A 25 May 2012 http://apps.who.int/gb/ebwha/pdf_ﬁ les/WHA65/A65_54-en.pdf

17 Andrade JP, Arnett DK, Pinto F, Piñeiro D, Smith Jr SC, Mattos LAP, et al Sociedade Brasileira

de Cardi-ologia – Carta do Rio de Janeiro Arq Bras Cardiol 2013;100(1):3–5

18 Simão AF, Précoma DB, Andrade JP, Correa Filho H, Saraiva JFK, Oliveira GMM, et al Sociedade Brasile-ira de Cardiologia I Diretriz Brasileira de Prevenção Cardiovascular Arq Bras Cardiol 2013:101(6 Suppl 2):1–63

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