RESUMO
BACKGROUND: Cardiovascular disease (CVD) imposes a significant burden on the Argentinian population. Management of its leading risk factors can significantly reduce the CVD burden in high-resource settings, but there is insufficient evidence for effective implementation of evidence-based interventions in lower-resource settings like Argentina. METHODS: In this two-arm cluster-randomized trial we seek to compare the effective implementation, of a multicomponent intervention, versus usual care, to improve the management of high CVD risk across the care continuum in three provinces of Argentina. The multicomponent intervention strategy links five primary components of the CVD care continuum to improve its management: (1) a data management system linking a digital mHealth (mobile health) screening tool used by community health workers (CHWs), (2) an electronic appointment scheduler that is integrated with the primary care center electronic appointment system, (3) point of care testing for lipid profiles, (4) a clinical decision support (CDS) system for medication initiation, and (5) a text message (SMS) reminder system to improve treatment adherence and life-style changes. The primary outcome is the mean change in Framingham laboratory-based, 10-year absolute CVD risk score between the study arms from baseline to twelve months after enrollment. CONCLUSIONS: This protocol describes the development of a multicomponent intervention to implement effective management of CVD, developed with partners at the National and provincial Departments of Health in Argentina, with the goal of understanding its effective implementation in a primary health care system strengthened by universal health coverage, provision of free health care services, and provision of free medication.
Assuntos
Doenças Cardiovasculares , Envio de Mensagens de Texto , Adulto , Humanos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Argentina , Fatores de Risco , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: The escalating prevalence of type 2 diabetes (T2DM) poses an unparalleled economic catastrophe to developing countries. Cardiovascular diseases remain the primary source of costs among individuals with T2DM, incurring expenses for medications, hospitalizations, and surgical interventions. Compelling evidence suggests that the risk of cardiovascular outcomes can be reduced by three classes of glucose-lowering therapies (GLT), including SGLT2i, GLP-1A, and pioglitazone. However, an evidence-based and cost-effective protocol is still unavailable for many countries. The objective of the current study is to compare the effectiveness and cost-effectiveness of GLT in individuals with T2DM in Brazil. METHODS: We employed Bayesian Networks to calculate the incremental cost-effectiveness ratios (ICER), expressed in international dollars (Int$) per disease-adjusted life years [DALYs] averted. To determine the effectiveness of GLT, we conducted a systematic review with network meta-analysis (NMA) to provide insights for our model. Additionally, we obtained cardiovascular outcome incidence data from two real-world cohorts comprising 851 and 1337 patients in primary and secondary prevention, respectively. Our cost analysis took into account the perspective of the Brazilian public health system, and all values were converted to Int$. RESULTS: In the NMA, SGLT2i [HR: 0.81 (95% CI 0.69-0.96)], GLP-1A [HR: 0.79 (95% CI 0.67-0.94)], and pioglitazone [HR: 0.73 (95% CI 0.59-0.91)] demonstrated reduced relative risks of non-fatal cardiovascular events. In the context of primary prevention, pioglitazone yielded 0.2339 DALYs averted, with an ICER of Int$7,082 (95% CI 4,521-10,770) per DALY averted when compared to standard care. SGLT2i and GLP-1A also increased effectiveness, resulting in 0.261 and 0.259 DALYs averted, respectively, but with higher ICERs of Int$12,061 (95% CI: 7,227-18,121) and Int$29,119 (95% CI: 23,811-35,367) per DALY averted. In the secondary prevention scenario, all three classes of treatments were deemed cost-effective at a maximum willingness-to-pay threshold of Int$26,700. Notably, pioglitazone consistently exhibited the highest probability of being cost-effective in both scenarios. CONCLUSIONS: In Brazil, pioglitazone presented a higher probability of being cost-effective both in primary and secondary prevention, followed by SGLT2i and GLP-1A. Our findings support the use of cost-effectiveness models to build optimized and hierarchical therapeutic strategy in the management of T2DM. TRIAL REGISTRATION: CRD42020194415.
RESUMO
Dear editor, Thanks for the opportunity to reply to the letter from Muñoz Laguna J and Banegas JR (1) regarding the HEARTS app (2). First, the risk score used in the HEARTS app is utterly based on the World Health Organization Cardiovascular Disease (CVD) Risk Chart Working Group study. It is, so far, the most updated, robust, and accessible CVD risk charts for the low-middle income countries globally (3). Indeed, these risk models were first derived in well-established international cohorts with baseline information on all the risk factor variables for the prediction models, had at least one year of follow-up, and provided detailed information on cause-specific mortality and non-fatal CVD events. Moreover, for the recalibration of the models, age and sex-specific incidences of myocardial infarction and stroke from each of the 21 global regions defined by the Global Burden of Disease were used. This was further completed by averaging country-specific risk factor values from the Non-Communicable Disease Risk Factor Collaboration. Therefore, Latin America and the Caribbean (LAC) regional data was used for calibration if not for the initial derivation models due to the lack of available cohort information from this Region at the study time. Finally, the models underwent external validation using individual participant data from 19 other cohorts. Although these countries did not include any from LAC, the external validation results were robust with good C indices. When available and well-established, prediction models using data from the Region may improve the score over time. The risk prediction models in the future could be further calibrated and revised according to country-specific CVD incidence. In summary, the WHO prediction models used by the HEARTS app offer a simple and reliable estimate for risk estimation for the time being. To read the complete letter, please download the manuscript using the link on the left.
Assuntos
Doenças não Transmissíveis , Doenças Cardiovasculares , Fatores de Risco de Doenças Cardíacas , Hipertensão , Aplicações da Informática Médica , Qualidade da Assistência à Saúde , AméricaRESUMO
[RESUMEN]. HEARTS en las Américas es la adaptación regional de la iniciativa Global HEARTS de la Organización Mundial de la Salud, que será el modelo para el manejo del riesgo de las enfermedades cardiovasculares (ECV) en la atención primaria de salud en la Región de las Américas para el año 2025. Ya se ha implementado en 21 países y 1045 centros de atención primaria de salud en toda América Latina y el Caribe. Se ha adoptado un enfoque de salud pública y de sistemas de salud para introducir sistemáticamente intervenciones simplificadas en el nivel de la atención primaria de salud que se centran en el control de la hipertensión como punto de entrada clínico. En este artículo se presenta una aplicación nueva y mejorada cuyo componente principal es la calculadora de riesgo de ECV y de manejo de la hipertensión. Se resume el enfoque de evaluación del riesgo y la metodología utilizada por la Organización Mundial de la Salud para actualizar sus tablas de riesgo cardiovascular del 2019; se describe la aplicación, su uso, su funcionalidad y su proceso de validación; y se presenta un conjunto de recomendaciones prácticas para optimizar el manejo del riesgo de ECV y de la hipertensión, mediante el uso de la aplicación en la práctica clínica. La aplicación HEARTS es una herramienta sólida para mejorar la calidad de la atención prestada en los centros de atención primaria. La creación y difusión de la aplicación HEARTS es un paso esencial en el camino hacia la eliminación de las ECV prevenibles en la Región de las Américas.
[ABSTRACT]. HEARTS in the Americas is the regional adaptation of the World Health Organization’s Global Hearts Initiative, which will be the model for risk management for cardiovascular disease (CVD) in primary health care in the Region of the Americas by 2025. It has already been implemented in 21 countries and 1045 primary health care centers throughout Latin America and the Caribbean. It takes a public health and health systems approach to systematically introduce simplified interventions at the primary health care level and focuses on hypertension as a clinical entry point. This paper introduces a new, improved application (app), the main component of which is the calculator for CVD risk and hypertension management. The paper summarizes the risk assessment approach and the methodology used by the World Health Organization to update its cardiovascular risk charts in 2019; describes the app, its use, functionality and validation process; and provides a set of practical recommendations for optimizing CVD risk and hypertension management by using the app in clinical practice. The HEARTS app is a powerful tool to improve the quality of care provided in primary health settings. The creation and dissemination of the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.
[RESUMO]. HEARTS nas Américas é a adaptação regional da Iniciativa Global Hearts da Organização Mundial da Saúde, que será o modelo para o gerenciamento de risco de doenças cardiovasculares (DCV) na atenção primária à saúde na Região das Américas até 2025. Ele já foi implementado em 21 países e 1045 centros de saúde primária em toda a América Latina e Caribe. Adota uma abordagem de saúde pública e sistemas de saúde para introduzir sistematicamente intervenções simplificadas no nível da atenção primária à saúde e concentra-se na hipertensão como um ponto de entrada clínica. Este documento introduz uma nova e melhor aplicação (app), cujo principal componente é a calculadora de risco de DCV e gerenciamento de hipertensão. O artigo resume a abordagem de avaliação de risco e a metodologia usada pela Organização Mundial da Saúde para atualizar seus gráficos de risco cardiovascular em 2019; descreve o aplicativo, seu uso, funcionalidade e processo de validação; e fornece um conjunto de recomendações práticas para otimizar o gerenciamento do risco de DCV e da hipertensão, usando o aplicativo na prática clínica. O aplicativo HEARTS é uma ferramenta potente para melhorar a qualidade dos cuidados prestados em ambientes de saúde primária. A criação e disseminação do aplicativo HEARTS é um passo essencial para eliminar a DCV evitável nas Américas.
Assuntos
Fatores de Risco de Doenças Cardíacas , Fatores de Risco , Hipertensão , Aplicações da Informática Médica , Fatores de Risco de Doenças Cardíacas , Fatores de Risco , Hipertensão , Aplicações da Informática Médica , Fatores de Risco de Doenças Cardíacas , Fatores de Risco , Hipertensão , Aplicações da Informática MédicaRESUMO
[ABSTRACT]. HEARTS in the Americas is the regional adaptation of the World Health Organization’s Global Hearts Initiative, which will be the model for risk management for cardiovascular disease (CVD) in primary health care in the Region of the Americas by 2025. It has already been implemented in 21 countries and 1045 primary health care centers throughout Latin America and the Caribbean. It takes a public health and health systems approach to systematically introduce simplified interventions at the primary health care level and focuses on hypertension as a clinical entry point. This paper introduces a new, improved application (app), the main component of which is the calculator for CVD risk and hypertension management. The paper summarizes the risk assessment approach and the methodology used by the World Health Organization to update its cardiovascular risk charts in 2019; describes the app, its use, functionality and validation process; and provides a set of practical recommendations for optimizing CVD risk and hypertension management by using the app in clinical practice. The HEARTS app is a powerful tool to improve the quality of care provided in primary health settings. The creation and dissemination of the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.
[RESUMEN]. HEARTS en las Américas es la adaptación regional de la Iniciativa Global Hearts de la Organización Mundial de la Salud, que será el modelo para el manejo del riesgo de la enfermedad cardiovascular (ECV) en la atención primaria de la salud en la Región de las Américas para el año 2025. Ya se ha implementado en 21 países y 1045 centros de atención primaria de salud en toda América Latina y el Caribe. Adopta un enfoque de salud pública y sistemas de salud para introducir sistemáticamente intervenciones simplificadas en el nivel de atención primaria de salud y se centra en la hipertensión como punto de entrada clínico. En este artículo se presenta una aplicación (app) nueva y mejorada cuyo componente principal es la calculadora de riesgo de ECV y de manejo de la hipertensión. Se resume el enfoque de evaluación del riesgo y la metodología utilizada por la Organización Mundial de la Salud para actualizar sus tablas de riesgo cardiovascular en 2019; se describe la app, su uso, su funcionalidad y su proceso de validación; y se proporciona un conjunto de recomendaciones prácticas para optimizar el manejo del riesgo de ECV y de la hipertensión mediante el uso de la app en la práctica clínica. La app HEARTS es una herramienta robusta para mejorar la calidad de la atención prestada en los centros de atención primaria. La creación y difusión de la aplicación HEARTS es un paso esencial en el camino hacia la eliminación de la ECV prevenible en las Américas.
[RESUMO]. HEARTS nas Américas é a adaptação regional da Iniciativa Global Hearts da Organização Mundial da Saúde, que será o modelo para o gerenciamento de risco de doenças cardiovasculares (DCV) na atenção primária à saúde na Região das Américas até 2025. Ele já foi implementado em 21 países e 1045 centros de saúde primária em toda a América Latina e Caribe. Adota uma abordagem de saúde pública e sistemas de saúde para introduzir sistematicamente intervenções simplificadas no nível da atenção primária à saúde e concentra-se na hipertensão como um ponto de entrada clínica. Este documento introduz uma nova e melhor aplicação (app), cujo principal componente é a calculadora de risco de DCV e gerenciamento de hipertensão. O artigo resume a abordagem de avaliação de risco e a metodologia usada pela Organização Mundial da Saúde para atualizar seus gráficos de risco cardiovascular em 2019; descreve o aplicativo, seu uso, funcionalidade e processo de validação; e fornece um conjunto de recomendações práticas para otimizar o gerenciamento do risco de DCV e da hipertensão, usando o aplicativo na prática clínica. O aplicativo HEARTS é uma ferramenta potente para melhorar a qualidade dos cuidados prestados em ambientes de saúde primária. A criação e disseminação do aplicativo HEARTS é um passo essencial para eliminar a DCV evitável nas Américas.
Assuntos
Fatores de Risco de Doenças Cardíacas , Hipertensão , Aplicações da Informática Médica , Fatores de Risco de Doenças Cardíacas , Fatores de Risco , Hipertensão , Aplicações da Informática Médica , Fatores de Risco de Doenças Cardíacas , Fatores de Risco , Hipertensão , Aplicações da Informática MédicaRESUMO
ABSTRACT HEARTS in the Americas is the regional adaptation of the World Health Organization's Global Hearts Initiative, which will be the model for risk management for cardiovascular disease (CVD) in primary health care in the Region of the Americas by 2025. It has already been implemented in 21 countries and 1045 primary health care centers throughout Latin America and the Caribbean. It takes a public health and health systems approach to systematically introduce simplified interventions at the primary health care level and focuses on hypertension as a clinical entry point. This paper introduces a new, improved application (app), the main component of which is the calculator for CVD risk and hypertension management. The paper summarizes the risk assessment approach and the methodology used by the World Health Organization to update its cardiovascular risk charts in 2019; describes the app, its use, functionality and validation process; and provides a set of practical recommendations for optimizing CVD risk and hypertension management by using the app in clinical practice. The HEARTS app is a powerful tool to improve the quality of care provided in primary health settings. The creation and dissemination of the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.
RESUMEN HEARTS en las Américas es la adaptación regional de la Iniciativa Global Hearts de la Organización Mundial de la Salud, que será el modelo para el manejo del riesgo de la enfermedad cardiovascular (ECV) en la atención primaria de la salud en la Región de las Américas para el año 2025. Ya se ha implementado en 21 países y 1045 centros de atención primaria de salud en toda América Latina y el Caribe. Adopta un enfoque de salud pública y sistemas de salud para introducir sistemáticamente intervenciones simplificadas en el nivel de atención primaria de salud y se centra en la hipertensión como punto de entrada clínico. En este artículo se presenta una aplicación (app) nueva y mejorada cuyo componente principal es la calculadora de riesgo de ECV y de manejo de la hipertensión. Se resume el enfoque de evaluación del riesgo y la metodología utilizada por la Organización Mundial de la Salud para actualizar sus tablas de riesgo cardiovascular en 2019; se describe la app, su uso, su funcionalidad y su proceso de validación; y se proporciona un conjunto de recomendaciones prácticas para optimizar el manejo del riesgo de ECV y de la hipertensión mediante el uso de la app en la práctica clínica. La app HEARTS es una herramienta robusta para mejorar la calidad de la atención prestada en los centros de atención primaria. La creación y difusión de la aplicación HEARTS es un paso esencial en el camino hacia la eliminación de la ECV prevenible en las Américas.
RESUMO HEARTS nas Américas é a adaptação regional da Iniciativa Global Hearts da Organização Mundial da Saúde, que será o modelo para o gerenciamento de risco de doenças cardiovasculares (DCV) na atenção primária à saúde na Região das Américas até 2025. Ele já foi implementado em 21 países e 1045 centros de saúde primária em toda a América Latina e Caribe. Adota uma abordagem de saúde pública e sistemas de saúde para introduzir sistematicamente intervenções simplificadas no nível da atenção primária à saúde e concentra-se na hipertensão como um ponto de entrada clínica. Este documento introduz uma nova e melhor aplicação (app), cujo principal componente é a calculadora de risco de DCV e gerenciamento de hipertensão. O artigo resume a abordagem de avaliação de risco e a metodologia usada pela Organização Mundial da Saúde para atualizar seus gráficos de risco cardiovascular em 2019; descreve o aplicativo, seu uso, funcionalidade e processo de validação; e fornece um conjunto de recomendações práticas para otimizar o gerenciamento do risco de DCV e da hipertensão, usando o aplicativo na prática clínica. O aplicativo HEARTS é uma ferramenta potente para melhorar a qualidade dos cuidados prestados em ambientes de saúde primária. A criação e disseminação do aplicativo HEARTS é um passo essencial para eliminar a DCV evitável nas Américas.
RESUMO
RESUMEN HEARTS en las Américas es la adaptación regional de la iniciativa Global HEARTS de la Organización Mundial de la Salud, que será el modelo para el manejo del riesgo de las enfermedades cardiovasculares (ECV) en la atención primaria de salud en la Región de las Américas para el año 2025. Ya se ha implementado en 21 países y 1045 centros de atención primaria de salud en toda América Latina y el Caribe. Se ha adoptado un enfoque de salud pública y de sistemas de salud para introducir sistemáticamente intervenciones simplificadas en el nivel de la atención primaria de salud que se centran en el control de la hipertensión como punto de entrada clínico. En este artículo se presenta una aplicación nueva y mejorada cuyo componente principal es la calculadora de riesgo de ECV y de manejo de la hipertensión. Se resume el enfoque de evaluación del riesgo y la metodología utilizada por la Organización Mundial de la Salud para actualizar sus tablas de riesgo cardiovascular del 2019; se describe la aplicación, su uso, su funcionalidad y su proceso de validación; y se presenta un conjunto de recomendaciones prácticas para optimizar el manejo del riesgo de ECV y de la hipertensión, mediante el uso de la aplicación en la práctica clínica. La aplicación HEARTS es una herramienta sólida para mejorar la calidad de la atención prestada en los centros de atención primaria. La creación y difusión de la aplicación HEARTS es un paso esencial en el camino hacia la eliminación de las ECV prevenibles en la Región de las Américas.
ABSTRACT HEARTS in the Americas is the regional adaptation of the World Health Organization's Global Hearts Initiative, which will be the model for risk management for cardiovascular disease (CVD) in primary health care in the Region of the Americas by 2025. It has already been implemented in 21 countries and 1045 primary health care centers throughout Latin America and the Caribbean. It takes a public health and health systems approach to systematically introduce simplified interventions at the primary health care level and focuses on hypertension as a clinical entry point. This paper introduces a new, improved application (app), the main component of which is the calculator for CVD risk and hypertension management. The paper summarizes the risk assessment approach and the methodology used by the World Health Organization to update its cardiovascular risk charts in 2019; describes the app, its use, functionality and validation process; and provides a set of practical recommendations for optimizing CVD risk and hypertension management by using the app in clinical practice. The HEARTS app is a powerful tool to improve the quality of care provided in primary health settings. The creation and dissemination of the HEARTS app is an essential step in the journey towards eliminating preventable CVD in the Americas.
RESUMO HEARTS nas Américas é a adaptação regional da Iniciativa Global Hearts da Organização Mundial da Saúde, que será o modelo para o gerenciamento de risco de doenças cardiovasculares (DCV) na atenção primária à saúde na Região das Américas até 2025. Ele já foi implementado em 21 países e 1045 centros de saúde primária em toda a América Latina e Caribe. Adota uma abordagem de saúde pública e sistemas de saúde para introduzir sistematicamente intervenções simplificadas no nível da atenção primária à saúde e concentra-se na hipertensão como um ponto de entrada clínica. Este documento introduz uma nova e melhor aplicação (app), cujo principal componente é a calculadora de risco de DCV e gerenciamento de hipertensão. O artigo resume a abordagem de avaliação de risco e a metodologia usada pela Organização Mundial da Saúde para atualizar seus gráficos de risco cardiovascular em 2019; descreve o aplicativo, seu uso, funcionalidade e processo de validação; e fornece um conjunto de recomendações práticas para otimizar o gerenciamento do risco de DCV e da hipertensão, usando o aplicativo na prática clínica. O aplicativo HEARTS é uma ferramenta potente para melhorar a qualidade dos cuidados prestados em ambientes de saúde primária. A criação e disseminação do aplicativo HEARTS é um passo essencial para eliminar a DCV evitável nas Américas.
RESUMO
Background Control of cardiovascular disease ( CVD ) risk factors is suboptimal in Argentina, despite the government's provision of free blood pressure and cholesterol-lowering medications for people without private insurance. We assessed whether community health workers' use of an integrated mH ealth tool encourages patients to attend visits at primary care clinics to improve CVD risk management in 2 provinces of Argentina. Methods and Results We conducted a pragmatic cluster randomized trial, with primary care clinics randomly assigned to intervention or control. Eligible people were aged 40 to 79 years, lived in the catchment area of primary care clinics, possessed a mobile phone for personal use, had public health coverage, and a 10-year CVD risk ≥10%. In the control arm, community health workers screened for CVD risk using a paper-based tool and encouraged high-risk people to present to the primary care clinics for care. In the intervention arm, community health workers used the mH ealth tool to calculate CVD risk and confirm a scheduled physician appointment. Primary outcomes were the proportion of participants who attended a baseline visit and completed at least 1 follow-up, respectively. We enrolled 755 people (376 interventions; 379 controls). Intervention participants were significantly more likely to complete baseline visits (49.4% versus 13.5%, P value 0.0008) and follow-up visits (31.9% versus 7.7%; P value 0.0041). The use of chronic medication and current smoking were significant predictors of primary outcomes. Conclusions Use of mH ealth tools identifies patients at high CVD risk in their home, increases the likelihood of participating in chronic CVD risk factor management, and strengthens referrals. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02913339.
Assuntos
Doenças Cardiovasculares/epidemiologia , Agentes Comunitários de Saúde , Acessibilidade aos Serviços de Saúde , Atenção Primária à Saúde , Telemedicina , Adulto , Idoso , Agendamento de Consultas , Argentina , Doenças Cardiovasculares/terapia , Feminino , Humanos , Seguro Saúde , Masculino , Programas de Rastreamento/métodos , Pessoas sem Cobertura de Seguro de Saúde , Pessoa de Meia-Idade , Aplicativos Móveis , Sistemas de Alerta , Risco , Envio de Mensagens de TextoRESUMO
Multiple cardiovascular risk factors are directly related to the severity of atherosclerosis, even in children and adolescents. In this context accurate assessment of risk factors at the individual level play a decisive role in cardiovascular disease (CVD) prevention. The objective of this study was to estimate the prevalence of cardiovascular risk factors, the frequency of their coexistence in individuals, and identify possible determinants associated with this coexistence in Brazilian adolescents. A cross-sectional study with 1170 students (12-17 years) from public and private schools of a large city was conducted. In addition to family history, modifiable cardiovascular risk factors were assessed including: tobacco use, alcohol consumption, sedentary lifestyle, overweight/obesity, increased waist circumference, and high blood pressure (office and home). We built a linear regression model to identify determinants associated with increasing number of modifiable risk factors. Mean study population age was 14.7±1.6 years, 67% were enrolled in public schools and 33% in private ones. The majority of the adolescents had at least two risk factors (68.9%), more than 10% had more than 4 risk factors, and in only 6.7% of the sample no risk factor was identified. Family history of CVD (ß-coefficient = 1.20; 95%CI 1.07-1.34; p<0.001), increasing age (ß-coefficient = 0.08; 95%CI 0.04-0.11; p<0.001), and being enrolled in private schools (ß-coefficient = 0.16; 95%CI 0.02-0.30; p = 0.023) were directly associated with the modifiable CV risk factors. In conclusion, the prevalence of multiple cardiovascular risk factors was high in the population of adolescents studied. School based interventions should be addressed to change this scenario.
Assuntos
Doenças Cardiovasculares/epidemiologia , Adolescente , Brasil/epidemiologia , Feminino , Humanos , Masculino , Prevalência , Fatores de Risco , Instituições AcadêmicasRESUMO
PURPOSE: Compare multiple in office BP measurements in adolescents using an oscillometric device with out-of-office blood pressure measurements (home blood pressure monitoring - HBPM). MATERIALS AND METHODS: Office measurements were performed with validated semi-automatic devices twice (3 minutes interval) in two different moments (1 week apart), with a total of four readings. These BP readings were named R1, R2, R3 and R4 (following the sequence they were performed), FDM (mean of two readings on first day) and SDM (mean of two readings on second day) and SRM (R2-R4 means). The HBPM protocol included two day-time and two evening-time measurements over 6 days. RESULTS: A total of 1024 students between 12 and 17 years were included (mean age 14.68 years; 52.4% females). The mean systolic blood pressure (SBP) values of R2, SDM and SRM were similar to HBPM values. Regarding diastolic blood pressure (DBP) HBPM value was different than R4. High SBP and DBP correlation coefficients with HBPM values were found for R2, SDM and SRM values. CONCLUSION: The second office BP measurement performed with an oscilometric device in adolescents was comparable to HBPM values, suggesting that two office readings might be suitable to rule out hypertension in this age group.
Assuntos
Determinação da Pressão Arterial/métodos , Pressão Sanguínea , Oscilometria/métodos , Adolescente , Determinação da Pressão Arterial/instrumentação , Monitorização Ambulatorial da Pressão Arterial/instrumentação , Monitorização Ambulatorial da Pressão Arterial/métodos , Criança , Estudos Transversais , Feminino , Humanos , Masculino , Oscilometria/instrumentaçãoRESUMO
BACKGROUND: Currently available tools for assessing high cardiovascular risk (HCR) often require measurements not available in resource-limited settings in low- and middle-income countries (LMIC). There is a need to assess HCR using a pragmatic evidence-based approach. OBJECTIVES: This study sought to report the prevalence of HCR in 10 LMIC areas in Africa, Asia, and South America and to investigate the profiles and correlates of HCR. METHODS: Cross-sectional analysis using data from the National Heart, Lung, and Blood Institute-UnitedHealth Group Centers of Excellence. HCR was defined as history of heart disease/heart attack, history of stroke, older age (≥50 years for men and ≥60 for women) with history of diabetes, or older age with systolic blood pressure ≥160 mm Hg. Prevalence estimates were standardized to the World Health Organization's World Standard Population. RESULTS: A total of 37,067 subjects ages ≥35 years were included; 53.7% were women and mean age was 53.5 ± 12.1 years. The overall age-standardized prevalence of HCR was 15.4% (95% confidence interval: 15.0% to 15.7%), ranging from 8.3% (India, Bangalore) to 23.4% (Bangladesh). Among men, the prevalence was 1.7% for the younger age group (35 to 49 years) and 29.1% for the older group (≥50); among women, 3.8% for the younger group (35 to 59 years) and 40.7% for the older group (≥60). Among the older group, measured systolic blood pressure ≥160 mm Hg (with or without other conditions) was the most common criterion for having HCR, followed by diabetes. The proportion of having met more than 1 criterion was nearly 20%. Age, education, and body mass index were significantly associated with HCR. Cross-site differences existed and were attenuated after adjusting for age, sex, education, smoking, and body mass index. CONCLUSIONS: The prevalence of HCR in 10 LMIC areas was generally high. This study provides a starting point to define targeted populations that may benefit from interventions combining both primary and secondary prevention strategies.
Assuntos
Países em Desenvolvimento , Diabetes Mellitus/epidemiologia , Hipertensão/epidemiologia , Infarto do Miocárdio/epidemiologia , Fumar/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , África/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Ásia/epidemiologia , Índice de Massa Corporal , Doenças Cardiovasculares/epidemiologia , Estudos Transversais , Escolaridade , Feminino , Cardiopatias/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Risco , Fatores de Risco , Fatores Sexuais , América do Sul/epidemiologia , Organização Mundial da SaúdeRESUMO
BACKGROUND: Cost-effective primary prevention of cardiovascular disease (CVD) in low- and middle-income countries requires accurate risk assessment. Laboratory-based risk tools currently used in high-income countries are relatively expensive and impractical in many settings due to lack of facilities. OBJECTIVES: This study sought to assess the correlation between a non-laboratory-based risk tool and 4 commonly used, laboratory-based risk scores in 7 countries representing nearly one-half of the world's population. METHODS: We calculated 10-year CVD risk scores for 47,466 persons with cross-sectional data collected from 16 different cohorts in 9 countries. The performance of the non-laboratory-based risk score was compared with 4 laboratory-based risk scores: Pooled Cohort Risk Equations (ASCVD [Atherosclerotic Cardiovascular Disease]), Framingham, and SCORE (Systematic Coronary Risk Evaluation) for high- and low-risk countries. Rankings of each score were compared using Spearman rank correlations. Based on these correlations, we measured concordance between individual absolute CVD risk as measured by the Harvard NHANES (National Health and Nutrition Examination Survey) risk score, and the 4 laboratory-based risk scores, using both the conventional Framingham risk thresholds of >20% and the recent ASCVD guideline threshold of >7.5%. RESULTS: The aggregate Spearman rank correlations between the non-laboratory-based risk score and the laboratory-based scores ranged from 0.915 to 0.979 for women and from 0.923 to 0.970 for men. When applying the conventional Framingham risk threshold of >20% over 10 years, 92.7% to 96.0% of women and 88.3% to 92.8% of men were equivalently characterized as "high" or "low" risk. Applying the recent ASCVD guidelines risk threshold of >7.5% resulted in risk characterization agreement for women ranging from 88.1% to 94.4% and from 89.0% to 93.7% for men. CONCLUSIONS: The correlation between non-laboratory-based and laboratory-based risk scores is very high for both men and women. Potentially large numbers of high-risk individuals could be detected with relatively simple tools.
Assuntos
Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus/epidemiologia , Dislipidemias/epidemiologia , Hipertensão/epidemiologia , Medição de Risco/métodos , Fumar/epidemiologia , Adulto , Fatores Etários , Idoso , Índice de Massa Corporal , Doenças Cardiovasculares/sangue , China , Colesterol/sangue , HDL-Colesterol/sangue , Análise Custo-Benefício , Estudos Transversais , Dislipidemias/sangue , Feminino , Saúde Global , Humanos , Hipertensão/sangue , Índia , Quênia , Masculino , Pessoa de Meia-Idade , Paquistão , Fatores Sexuais , África do Sul , América do SulRESUMO
BACKGROUND: Hypertension is the leading cause of cardiovascular disease and premature death worldwide. The prevalence of this public health problem is increasing in low- and middle-income countries (LMICs) in both urban and rural communities. OBJECTIVE: The aim of this study was to examine hypertension prevalence, awareness, treatment, and control in adults 35 to 74 years of age from urban and rural communities in LMICs in Africa, Asia, and South America. METHODS: The authors analyzed data from 7 population-based cross-sectional studies in selected communities in 9 LMICs that were conducted between 2008 and 2013. Age- and sex-standardized prevalence rates of pre-hypertension and hypertension were calculated. The prevalence rates of awareness, treatment, and control of hypertension were estimated overall and by subgroups of age, sex, and educational level. RESULTS: In selected communities, age- and sex-standardized prevalence rates of hypertension among men and women 35 to 74 years of age were 49.9% (95% confidence interval [CI]: 42.3% to 57.4%) in Kenya, 54.9% (95% CI: 51.3% to 58.4%) in South Africa, 52.5% (95% CI: 50.1% to 54.8%) in China, 32.5% (95% CI: 31.7% to 33.3%) in India, 42.3% (95% CI: 40.4% to 44.2%) in Pakistan, 45.4% (95% CI: 43.6% to 47.2%) in Argentina, 39.9% (95% CI: 37.8% to 42.1%) in Chile, 19.2% (95% CI: 17.8% to 20.5%) in Peru, and 44.1% (95% CI: 41.6% to 46.6%) in Uruguay. The proportion of awareness varied from 33.5% in India to 69.0% in Peru, the proportion of treatment among those who were aware of their hypertension varied from 70.8% in South Africa to 93.3% in Pakistan, and the proportion of blood pressure control varied from 5.3% in China to 45.9% in Peru. CONCLUSIONS: The prevalence of hypertension varies widely in different communities. The rates of awareness, treatment, and control also differ in different settings. There is a clear need to focus on increasing hypertension awareness and control in LMICs.
Assuntos
Países em Desenvolvimento , Conhecimentos, Atitudes e Prática em Saúde , Hipertensão/epidemiologia , Pré-Hipertensão/epidemiologia , Adulto , Idoso , Anti-Hipertensivos/uso terapêutico , Argentina/epidemiologia , Chile/epidemiologia , China/epidemiologia , Estudos Transversais , Feminino , Humanos , Hipertensão/tratamento farmacológico , Índia/epidemiologia , Quênia/epidemiologia , Masculino , Pessoa de Meia-Idade , National Heart, Lung, and Blood Institute (U.S.) , Paquistão/epidemiologia , Peru/epidemiologia , Prevalência , Parcerias Público-Privadas , África do Sul/epidemiologia , Estados Unidos , Uruguai/epidemiologiaRESUMO
BACKGROUND: The implications of rising obesity for cardiovascular health in middle-income countries has generated interest, in part because associations between obesity and cardiovascular health seem to vary across ethnic groups. OBJECTIVE: We assessed general and central obesity in Africa, East Asia, South America, and South Asia. We further investigated whether body mass index (BMI) and waist circumference differentially relate to cardiovascular health; and associations between obesity metrics and adverse cardiovascular health vary by region. METHODS: Using baseline anthropometric data collected between 2008 and 2012 from 7 cohorts in 9 countries, we estimated the proportion of participants with general and central obesity using BMI and waist circumference classifications, respectively, by study site. We used Poisson regression to examine the associations (prevalence ratios) of continuously measured BMI and waist circumference with prevalent diabetes and hypertension by sex. Pooled estimates across studies were computed by sex and age. RESULTS: This study analyzed data from 31,118 participants aged 20 to 79 years. General obesity was highest in South Asian cities and central obesity was highest in South America. The proportion classified with general obesity (range 11% to 50%) tended to be lower than the proportion classified as centrally obese (range 19% to 79%). Every standard deviation higher of BMI was associated with 1.65 and 1.60 times higher probability of diabetes and 1.42 and 1.28 times higher probability of hypertension, for men and women, respectively, aged 40 to 69 years. Every standard deviation higher of waist circumference was associated with 1.48 and 1.74 times higher probability of diabetes and 1.34 and 1.31 times higher probability of hypertension, for men and women, respectively, aged 40 to 69 years. Associations of obesity measures with diabetes were strongest in South Africa among men and in South America among women. Associations with hypertension were weakest in South Africa among both sexes. CONCLUSIONS: BMI and waist circumference were both reasonable predictors of prevalent diabetes and hypertension. Across diverse ethnicities and settings, BMI and waist circumference remain salient metrics of obesity that can identify those with increased cardiovascular risk.
Assuntos
Diabetes Mellitus/epidemiologia , Hipertensão/epidemiologia , Obesidade Abdominal/epidemiologia , Adulto , Idoso , Argentina/epidemiologia , Bangladesh/epidemiologia , Índice de Massa Corporal , Chile/epidemiologia , China/epidemiologia , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Paquistão/epidemiologia , Peru/epidemiologia , Prevalência , África do Sul/epidemiologia , Uruguai/epidemiologia , Circunferência da Cintura , Adulto JovemRESUMO
In low-resource settings, a physician is not always available. We recently demonstrated that community health workers-instead of physicians or nurses-can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone-based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.
Assuntos
Doenças Cardiovasculares/prevenção & controle , Agentes Comunitários de Saúde/economia , Agentes Comunitários de Saúde/estatística & dados numéricos , Análise Custo-Benefício , Programas de Rastreamento/organização & administração , Adulto , Idoso , Redução de Custos , Países em Desenvolvimento , Feminino , Guatemala , Humanos , Masculino , México , Pessoa de Meia-Idade , África do SulRESUMO
BACKGROUND: Cardiovascular disease contributes substantially to the non-communicable disease (NCD) burden in low-income and middle-income countries, which also often have substantial health personnel shortages. In this observational study we investigated whether community health workers could do community-based screenings to predict cardiovascular disease risk as effectively as could physicians or nurses, with a simple, non-invasive risk prediction indicator in low-income and middle-income countries. METHODS: This observation study was done in Bangladesh, Guatemala, Mexico, and South Africa. Each site recruited at least ten to 15 community health workers based on usual site-specific norms for required levels of education and language competency. Community health workers had to reside in the community where the screenings were done and had to be fluent in that community's predominant language. These workers were trained to calculate an absolute cardiovascular disease risk score with a previously validated simple, non-invasive screening indicator. Community health workers who successfully finished the training screened community residents aged 35-74 years without a previous diagnosis of hypertension, diabetes, or heart disease. Health professionals independently generated a second risk score with the same instrument and the two sets of scores were compared for agreement. The primary endpoint of this study was the level of direct agreement between risk scores assigned by the community health workers and the health professionals. FINDINGS: Of 68 community health worker trainees recruited between June 4, 2012, and Feb 8, 2013, 42 were deemed qualified to do fieldwork (15 in Bangladesh, eight in Guatemala, nine in Mexico, and ten in South Africa). Across all sites, 4383 community members were approached for participation and 4049 completed screening. The mean level of agreement between the two sets of risk scores was 96·8% (weighted κ=0·948, 95% CI 0·936-0·961) and community health workers showed that 263 (6%) of 4049 people had a 5-year cardiovascular disease risk of greater than 20%. INTERPRETATION: Health workers without formal professional training can be adequately trained to effectively screen for, and identify, people at high risk of cardiovascular disease. Using community health workers for this screening would free up trained health professionals in low-resource settings to do tasks that need high levels of formal, professional training.
Assuntos
Doenças Cardiovasculares/diagnóstico , Competência Clínica/normas , Agentes Comunitários de Saúde , Programas de Rastreamento/instrumentação , Adulto , Idoso , Bangladesh , Agentes Comunitários de Saúde/educação , Educação Médica/métodos , Feminino , Guatemala , Humanos , Masculino , México , Pessoa de Meia-Idade , Medição de Risco/métodos , Fatores de Risco , África do SulRESUMO
BACKGROUND: We have found that community health workers (CHWs) with appropriate training are able to accurately identify people at high cardiovascular disease (CVD) risk in the community who would benefit from the introduction of preventative management, in Bangladesh, Guatemala, Mexico, and South Africa. This paper examines the attendance pattern for those individuals who were so identified and referred to a health care facility for further assessment and management. DESIGN: Patient records from the health centres in each site were reviewed for data on diagnoses made and treatment commenced. Reasons for non-attendance were sought from participants who had not attended after being referred. Qualitative data were collected from study coordinators regarding their experiences in obtaining the records and conducting the record reviews. The perspectives of CHWs and community members, who were screened, were also obtained. RESULTS: Thirty-seven percent (96/263) of those referred attended follow-up: 36 of 52 (69%) were urgent and 60 of 211 (28.4%) were non-urgent referrals. A diagnosis of hypertension (HTN) was made in 69% of urgent referrals and 37% of non-urgent referrals with treatment instituted in all cases. Reasons for non-attendance included limited self-perception of risk, associated costs, health system obstacles, and lack of trust in CHWs to conduct CVD risk assessments and to refer community members into the health system. CONCLUSIONS: The existing barriers to referral in the health care systems negatively impact the gains to be had through screening by training CHWs in the use of a simple risk assessment tool. The new diagnoses of HTN and commencement on treatment in those that attended referrals underscores the value of having persons at the highest risk identified in the community setting and referred to a clinic for further evaluation and treatment.
Assuntos
Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/terapia , Agentes Comunitários de Saúde/organização & administração , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/estatística & dados numéricos , Bangladesh , Feminino , Guatemala , Humanos , Hipertensão/diagnóstico , Hipertensão/terapia , Masculino , México , Pobreza/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Medição de Risco/métodos , África do SulRESUMO
OBJECTIVE: To estimate individual and household economic impact of cardiovascular disease (CVD) in selected low- and middle-income countries (LMIC). BACKGROUND: Empirical evidence on the microeconomic consequences of CVD in LMIC is scarce. METHODS AND FINDINGS: We surveyed 1,657 recently hospitalized CVD patients (66% male; mean age 55.8 years) from Argentina, China, India, and Tanzania to evaluate the microeconomic and functional/productivity impact of CVD hospitalization. Respondents were stratified into three income groups. Median out-of-pocket expenditures for CVD treatment over 15 month follow-up ranged from 354 international dollars (2007 INT$, Tanzania, low-income) to INT$2,917 (India, high-income). Catastrophic health spending (CHS) was present in >50% of respondents in China, India, and Tanzania. Distress financing (DF) and lost income were more common in low-income respondents. After adjustment, lack of health insurance was associated with CHS in Argentina (OR 4.73 [2.56, 8.76], India (OR 3.93 [2.23, 6.90], and Tanzania (OR 3.68 [1.86, 7.26] with a marginal association in China (OR 2.05 [0.82, 5.11]). These economic effects were accompanied by substantial decreases in individual functional health and productivity. CONCLUSIONS: Individuals in selected LMIC bear significant financial burdens following CVD hospitalization, yet with substantial variation across and within countries. Lack of insurance may drive much of the financial stress of CVD in LMIC patients and their families.