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BACKGROUND: The World Health Assembly 2018 approved a resolution on rheumatic heart disease to strengthen programmes in countries where this condition remains a substantial public health problem. We aimed to describe the regional burden, trends, and inequalities of rheumatic heart disease in the Americas. METHODS: In this secondary analysis of the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2017, we extracted data for deaths, prevalence of cases, disability-adjusted life-years (DALYs), years lived with disability, and years of life lost (YLL) as measures of rheumatic heart disease burden using the GBD Results Tool. We analysed 1990-2017 trends in rheumatic heart disease mortality and prevalence, quantified cross-country inequalities in rheumatic heart disease mortality, and classified countries according to rheumatic heart disease mortality in 2017 and 1990-2017. FINDINGS: GBD 2017 estimated that 3â604â800 cases of rheumatic heart disease occurred overall in the Americas in 2017, with 22â437 deaths. We showed that in 2017 rheumatic heart disease mortality in the Americas was 51% (95% UI 44-59) lower (1·8 deaths per 100â000 population [95% uncertainty interval 1·7-1·9] vs 3·7 deaths per 100â000 population [3·4-3·9]) and prevalence was 30% (29-33) lower (346·4 cases per 100â000 [334·1-359·2] vs 500·6 cases per 100â000 [482·9-519·7]) than the corresponding global estimates. DALYs were half of those globally (55·7 per 100â000 [49·8-63·5] vs 118·7 per 100â000 [108·5 to 130·7]), with a 70% contribution from YLL (39·1 out of 55·7 per 100â000). A significant reduction in rheumatic heart disease mortality occurred, from a regional average of 88·4 YLL per 100â000 (95% uncertainty interval 88·2-88·6) in 1990 to 38·2 (38·1-38·4) in 2017, and a significant reduction in income-related inequality, from an excess of 191·7 YLL per 100â000 (68·6-314·8) between the poorest and richest countries in 1990 to 66·8 YLL per 100â000 (6·4-127·2) in 2017. Of the 37 countries studied, eight (22%) had both the highest level of premature rheumatic heart disease mortality in 2017 and the smallest reduction in this mortality between 1990 and 2017. INTERPRETATION: The Americas have greatly reduced premature mortality due to rheumatic heart disease since 1990. These health gains were paired with a substantial reduction in the magnitude of income-related inequalities across countries, which is consistent with overall socioeconomic and health improvements observed in the Region. Countries with less favourable rheumatic heart disease situations should be targeted for strengthening of their national programmes. FUNDING: None.
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Carga Global de Enfermedades , Cardiopatía Reumática , Américas , Salud Global , Humanos , Esperanza de Vida , Años de Vida Ajustados por Calidad de Vida , Factores SocioeconómicosRESUMEN
BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist in many low- and middle-income countries. To date, the cost-effectiveness of population-based, combined primary and secondary prevention strategies has not been assessed. In the Pinar del Rio province of Cuba, a comprehensive ARF/RHD control program was undertaken over 1986-1996. The present study analyzes the cost-effectiveness of this Cuban program. METHODS AND FINDINGS: We developed a decision tree model based on the natural history of ARF/RHD, comparing the costs and effectiveness of the 10-year Cuban program to a "do nothing" approach. Our population of interest was the cohort of children aged 5-24 years resident in Pinar del Rio in 1986. We assessed costs and health outcomes over a lifetime horizon, and we took the healthcare system perspective on costs but did not apply a discount rate. We used epidemiologic, clinical, and direct medical cost inputs that were previously collected for publications on the Cuban program. We estimated health gains as disability-adjusted life years (DALYs) averted using standard approaches developed for the Global Burden of Disease studies. Cost-effectiveness acceptability thresholds were defined by one and three times per capita gross domestic product per DALY averted. We also conducted an uncertainty analysis using Monte Carlo simulations and several scenario analyses exploring the impact of alternative assumptions about the program's effects and costs. We found that, compared to doing nothing, the Cuban program averted 5051 DALYs (1844 per 100,000 school-aged children) and saved $7,848,590 (2010 USD) despite a total program cost of $202,890 over 10 years. In the scenario analyses, the program remained cost saving when a lower level of effectiveness and a reduction in averted years of life lost were assumed. In a worst-case scenario including 20-fold higher costs, the program still had a 100% of being cost-effective and an 85% chance of being cost saving. CONCLUSIONS: A 10-year program to control ARF/RHD in Pinar del Rio, Cuba dramatically reduced morbidity and premature mortality in children and young adults and was cost saving. The results of our analysis were robust to higher program costs and more conservative assumptions about the program's effectiveness. It is possible that the program's effectiveness resulted from synergies between primary and secondary prevention strategies. The findings of this study have implications for non-communicable disease policymaking in other resource-limited settings.
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Análisis Costo-Beneficio , Atención a la Salud/economía , Cardiopatía Reumática/economía , Cardiopatía Reumática/epidemiología , Personal Administrativo , Adolescente , Niño , Preescolar , Cuba/epidemiología , Enfermedades Endémicas/economía , Femenino , Humanos , Masculino , Incertidumbre , Adulto JovenRESUMEN
INTRODUCTION: Over the last decade, total cardiovascular risk assessment and management has been recommended by cardiovascular prevention guidelines in most high-income countries and by WHO. Cardiovascular risk prediction charts have been developed based on multivariate equations of values of some well-known risk factors such as age, sex, smoking, systolic blood pressure and diabetes, including or omitting total blood cholesterol. OBJECTIVE: The objectives of this study were: to determine the distribution of cardiovascular risk in a Cuban population using the WHO/International Society of Hypertension risk prediction charts with and without cholesterol; and to assess applicability of the risk prediction tool without cholesterol in a middle-income country, by evaluating concordance between the two approaches and comparing projected drug requirements resulting from each (at risk thresholds of ≥20% and ≥30%) and for the single-risk-factor approach. METHODS: From April through December 2008, a cross-sectional study was conducted in 1287 persons (85.8% of the sample selected), aged 40-80 years living in a polyclinic catchment area of Havana, Cuba, based on the protocol and data from a WHO multinational study. The study used the two sets of the WHO and the International Society of Hypertension (WHO/ISH) risk prediction charts, with and without cholesterol. Percentages and means were calculated, as well as prevalence (%) of risk factors. The chi-square test was used to compare means (p ≤0.05). Concordance between the two prediction charts was calculated for different risk levels, using the chart with cholesterol as a reference. RESULTS: Using the risk assessment tools with and without cholesterol, 97.1% and 95.4% respectively of the study population were in the ten-year cardiovascular risk category of <20%, while 2.9% and 4.6% respectively were in the category of ≥20%. Risk categories were concordant in 88.1% of the population; overestimation was higher among the nonconcordant (136/153). When risk assessment did not include cholesterol, there was 2.6% (34/1287) overestimation of drug requirements and 0.5% (6/1287) underestimation, compared to estimates including cholesterol. CONCLUSION: Total cardiovascular risk assessment using the WHO/ISH charts without cholesterol could be a useful approach to predict cardiovascular risk in settings where cholesterol cannot be measured. This does not introduce overconsumption of drugs, but does enable better targeting of resources to those who are more likely to develop cardiovascular disease. KEYWORDS Cardiology, risk assessment, health risk appraisal, hypertension, health policy, cost savings, atherosclerosis, Cuba.
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Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/epidemiología , Colesterol/sangre , Medición de Riesgo/métodos , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/prevención & control , Estudios Transversales , Cuba/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Factores de RiesgoRESUMEN
OBJECTIVES: To determine the population distribution of cardiovascular risk in eight low- and middle-income countries and compare the cost of drug treatment based on cardiovascular risk (cardiovascular risk thresholds ≥ 30%/≥ 40%) with single risk factor cutoff levels. STUDY DESIGN AND SETTING: Using World Health Organization (WHO) and the International Society of Hypertension risk prediction charts, cardiovascular risk was categorized in a cross-sectional study of 8,625 randomly selected people aged 40-80 years (mean age, 54.6 years) from defined geographic regions of Nigeria, Iran, China, Pakistan, Georgia, Nepal, Cuba, and Sri Lanka. Cost estimates for drug therapy were calculated for three countries. RESULTS: A large fraction (90.0-98.9%) of the study population has a 10-year cardiovascular risk <20%. Only 0.2-4.8% are in the high-risk categories (≥ 30%). Adopting a total risk approach and WHO guidelines recommendations would restrict unnecessary drug treatment and reduce the drug costs significantly. CONCLUSION: Adopting a total cardiovascular risk approach instead of a single risk factor approach reduces health care expenditure by reducing drug costs. Therefore, limited resources can be more efficiently used to target high-risk people who will benefit the most. This strategy needs to be complemented with population-wide measures to shift the cardiovascular risk distribution of the whole population.
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Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/prevención & control , Países en Desarrollo/economía , Recursos en Salud/provisión & distribución , Selección de Paciente , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/economía , Enfermedades Cardiovasculares/etiología , China/epidemiología , Análisis Costo-Beneficio , Estudios Transversales , Cuba/epidemiología , Femenino , Georgia/epidemiología , Recursos en Salud/economía , Humanos , Hipercolesterolemia/epidemiología , Hipercolesterolemia/prevención & control , Hipertensión/epidemiología , Hipertensión/prevención & control , Irán/epidemiología , Masculino , Persona de Mediana Edad , Nepal/epidemiología , Nigeria/epidemiología , Pakistán/epidemiología , Medición de Riesgo , Factores de Riesgo , Sri Lanka/epidemiología , Organización Mundial de la SaludRESUMEN
OBJECTIVE: Assess capacity of health-care facilities in a low-resource setting to implement the absolute risk approach for assessment of cardiovascular risk in hypertensive patients and effective management of hypertension. DESIGN AND SETTING: A descriptive cross-sectional study in Egbeda and Oluyole local government areas of Oyo State in Nigeria in 56 randomly selected primary- (n = 42) and secondary-level (n = 2) health-care and private health-care (n = 12) facilities. PARTICIPANTS: One thousand consecutive, known hypertensives attending the selected facilities for follow-up, and health-care providers working in the above randomly selected facilities, were interviewed. RESULTS: About two-thirds of hypertensives utilized primary-care centers both for diagnosis and for follow-up. Laboratory and other investigations to exclude secondary hypertension or to assess target organ damage were not available in the majority of facilities, particularly in primary care. A considerable knowledge and awareness gap related to hypertension and its complications was found, both among patients and health-care providers. Blood pressure control rates were poor (28% with systolic blood pressure (SBP) < 140 mmHg and diastolic blood pressure (DBP) < 90 mmHg] and drug prescription patterns were not evidence based and cost effective. The majority of patients (73%) in this low socio-economic group (mean monthly income 73 US dollars) had to pay fully, out of their own pocket, for consultations and medications. CONCLUSIONS: If the absolute risk approach for assessment of risk and effective management of hypertension is to be implemented in low-resource settings, appropriate policy measures need to be taken to improve the competency of health-care providers, to provide basic laboratory facilities and to develop affordable financing mechanisms.
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Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/terapia , Recursos en Salud , Antihipertensivos/economía , Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Enfermedades Cardiovasculares/economía , Costos y Análisis de Costo/economía , Estudios Transversales , Diástole/efectos de los fármacos , Manejo de la Enfermedad , Femenino , Estudios de Seguimiento , Instituciones de Salud/economía , Instituciones de Salud/estadística & datos numéricos , Personal de Salud/economía , Personal de Salud/estadística & datos numéricos , Recursos en Salud/economía , Recursos en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/economía , Hipertensión/epidemiología , Masculino , Persona de Mediana Edad , Nigeria/epidemiología , Atención Primaria de Salud/economía , Factores de Riesgo , Factores Sexuales , Sístole/efectos de los fármacosRESUMEN
Se analizaron 966 aortas torácicas, 947 aortas abdominales y 958 arterias coronarias derechas de autopsias de niños y jóvenes de edades comprendidas entre 5 y 34 años, procedentes de 18 países de 5 continentes, como parte de una investigación multinacional organizada por la Organización Mundial de la Salud y la Federación Internacional de Sociedades de Cardiología desde 1986 a 1996. Para el estudio patomorfológico y morfométrico de las arterias se utilizó el sistema aterométrico, metodología considerada idónea para la caracterización de la lesión aterosclerótica en cualquier arteria, sector vascular o grupo de pacientes. Este sistema permitió mediante el análisis cualitativo, identificar las lesiones ateroscleróticas y mediante el cuantitativo, medir las áreas ocupadas por cada una de ellas y estimar o ponderar sus valores de obstrucción y estenosis intrarterial. Se analizaron los fallecidos según su edad y sexo. Se dividieron en 3 grupos de edades: de 5 a 14, de 15 a 24 y de 25 a 34 años. Los resultados más relevantes fueron: a) la confirmación de que la aterosclerosis progresa siempre con la edad en los 2 sexos; b) que las estrías adiposas están presentes desde la más temprana edad independientemente del país de procedencia, clima, tipo de alimentación, hábitos y estilos de vida; c) que el progreso más acelerado de las estrías adiposas se encontró entre las edades de 15 a 24 años; d) que las placas fibrosas comienzan a presentarse lentamente a partir de la segunda década de la vida y progresan notablemente a partir de la tercera; e) que las placas graves son excepcionales antes de los 30 años de edad y a partir de este momento progresan lentamente.
966 thoracic aortas, 947 abdominal aortas and 958 right coronary arteries were analyzed in autopsied children and young people aged 5 to 34 years from 18 countries in 5 continents, as part of a multinational research study from 1986 to 1996 organized by the World Health Organization and the International Societies Federation of Cardiology. The atherometric system, which is considered to be an ideal methodology to characterize the atherosclerotic lesion in any artery, vascular area or group of patients, was used for the pathomorphological and morphometric study of the arteries. This system allowed to detect the atherosclerotic lesions by a qualitative analysis and to measure the areas occupied by them and estimate/weigh their obstruction and intraarterial stenosis indices by the quantitative analysis. The deceased were examined by age and sex and divided into 3 age groups: 5 to 14, 15 to 24 and 25 to 34 years. The most relevant results which were confirmed by this study were: a) the atherosclerosis increases with rising age level in males and females alike.b) fatty steaks begin with the earliest age regardless of the country of origin, climate, type of food, habits and ways of life.c) the fastest progression in fatty streaks was found in people aged 15 to 24 years. d) fibrous plaques slowly occur during the second decade of life and remarkably progreses in the third decade of life. e) the severe plaques exceptionally occur before the 30 years-old age and from that moment on, the slowly develop.
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Se realiza un estudio de los tiempos de intervalos sistólicos (TIS) en 127 personas sanas, con edades comprendidas entre los 15 y los 44 años, las cuales fueron clasificadas en tres grupos con un intervalo de 10 años de diferencia. Se analizan los cambios de los TIS con respecto al sexo, la edad y la frecuencia cardíaca (FC), obteniéndose como resultados importantes, que la sístole electromecánica total (q-2r) se acordó significativamente en el grupo de 15 a 24 años, fundamentalmente a expensas del tiempo de eyección ventricular izquierdo (TEVI) en ambos sexos y del tiempo de contracción isovolumétrica (TCI) en los pacientes del sexo femenino de este grupo. Se comprueba una buena correlación inversa y lineal de Q-2R y TEVI con la FC (r = -0,73 y -0,68 respectivamente), siendo pobre para el período preeyectivo (PPE) (r = -0,48). Se describen otras observaciones y variaciones de los TIS y se exponen las cifras normales para esta serie estudiada (AU)
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Adolescente , Adulto , Humanos , Masculino , Femenino , Sístole , Frecuencia Cardíaca , Volumen SistólicoRESUMEN
Se realiza un estudio en 332 niños escolares y adultos (personal docente y auxiliar) de 9 aulas del centro escolar "Ciudad Libertad", Marianao, La Habana. Se utilizó en el método de interrogatorio por correspondencia a los padres de los alumnos, y a los niños se les realizó: interrogatorio, examen físico, cultivo de exudado nasal, faríngeo y título de antiestreptolisina "O" (AELO). Se observaron resultados positivos a estreptococo beta hemolítico en el 38,5 por ciento de los cultivos. El 12,6 por ciento correspondieron al grupo A; el 14,7 por ciento al C y el 11,1 por ciento al G. El título de AELO fue superior a 200 unidades Tood en el 79,5 por ciento de los alumnos. Se concluyó que el 72,5 por ciento tuvo enfermedad clínica y/o bacteriológica reciente; un 19,8 por ciento tuvo infección subclínica; un 26 por ciento eran portadores convalecientes o asintomáticos; y un 1,8 por ciento tuvo complicaciones no superadas, glomerulonefritis difusa aguda (GNDA), o fiebre reumática (FR)(AU)
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Bacterias , Fenómenos Fisiológicos Bacterianos , Métodos Epidemiológicos , Exudados y Transudados/microbiologíaRESUMEN
Se realiza un estudio de 332 niños escolares y adultos (personal docente y auxiliar) de 9 aulas del centro escolar Ciudad Libertad, Marianao. La Habana. Se utilizó el método de interrogatorio por correspondencia a los padres de los alumnos, y a los niños se les realizó: interrogatorio, examen físico, cultivo de exudado nasal, faríngeo y título de antiestreptolisina O(AELO). Se observaron resultados positivos a estreptococo beta hemolítica en el 38.5(por ciento) de los cultivos. El 12.6(por ciento) correspondió al grupo A; el 14.7(por ciento) al C y el 11.1(por ciento) al G, el título de AELO fue superior a 200 unidades Tood en el 79.5(por ciento) de los alumnos. Se concluyó que el 72.5(por ciento) tuvo enfermedad clínica o bacteriológica reciente; un 19.8(por ciento) tuvo infección subclínica; un 26(por ciento) eran portadores convalecientes o asintomáticos, y un 1.8(por ciento) tuvo complicaciones no superadas, glomerulonefritis difusa aguda (GNDA), o fiebre reumática (FR). Se ratifica la importancia de la AELO para el conocimiento de las infecciones estreptocócicas. No se observó diferencia entre los resultados de los exámenes de alumnos de aulas con infección estreptocócica conocida y aulas similares sin el antecedente, ni la relación entre los resultados observados en el personal docente y sus alumnos(AU)