Prevalence of Pragmatically Defined High CV Risk and its Correlates in LMIC: A Report From 10 LMIC Areas in Africa, Asia, and South America.

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.

Comparison of Nonblood-Based and Blood-Based Total CV Risk Scores in Global Populations.

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.

Hypertension Prevalence, Awareness, Treatment, and Control in Selected LMIC Communities: Results From the NHLBI/UHG Network of Centers of Excellence for Chronic Diseases.

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.

A Multiethnic Study of Pre-Diabetes and Diabetes in LMIC.

BACKGROUND: Diabetes mellitus is one of the leading causes of death and disability worldwide. Approximately three-quarters of people with diabetes live in low- and middle-income countries, and these countries are projected to experience the greatest increase in diabetes burden. OBJECTIVES: We sought to compare the prevalence, awareness, treatment, and control of diabetes in 3 urban and periurban regions: the Southern Cone of Latin America and Peru, South Asia, and South Africa. In addition, we examined the relationship between diabetes and pre-diabetes with known cardiovascular and metabolic risk factors. METHODS: A total of 26,680 participants (mean age, 47.7 ± 14.0 years; 45.9% male) were enrolled in 4 sites (Southern Cone of Latin America = 7,524; Peru = 3,601; South Asia = 11,907; South Africa = 1,099). Detailed demographic, anthropometric, and biochemical data were collected. Diabetes and pre-diabetes were defined as a fasting plasma glucose ≥126 mg/dl and 100 to 125 mg/dl, respectively. Diabetes control was defined as fasting plasma glucose <130 mg/dl. RESULTS: The prevalence of diabetes and pre-diabetes was 14.0% (95% confidence interval [CI]: 13.2% to 14.8%) and 17.8% (95% CI: 17.0% to 18.7%) in the Southern Cone of Latin America, 9.8% (95% CI: 8.8% to 10.9%) and 17.1% (95% CI: 15.9% to 18.5%) in Peru, 19.0% (95% CI: 18.4% to 19.8%) and 24.0% (95% CI: 23.2% to 24.7%) in South Asia, and 13.8% (95% CI: 11.9% to 16.0%) and 9.9% (95% CI: 8.3% to 11.8%) in South Africa. The age- and sex-specific prevalence of diabetes and pre-diabetes for all countries increased with age (p < 0.001). In the Southern Cone of Latin America, Peru, and South Africa the prevalence of pre-diabetes rose sharply at 35 to 44 years. In South Asia, the sharpest rise in pre-diabetes prevalence occurred younger at 25 to 34 years. The prevalence of diabetes rose sharply at 45 to 54 years in the Southern Cone of Latin America, Peru, and South Africa, and at 35 to 44 years in South Asia. Diabetes and pre-diabetes prevalence increased with body mass index. South Asians had the highest prevalence of diabetes and pre-diabetes for any body mass index and normal-weight South Asians had a higher prevalence of diabetes and pre-diabetes than overweight and obese individuals from other regions. Across all regions, only 79.8% of persons with diabetes were aware of their diagnosis, of these only 78.2% were receiving treatment, and only 36.6% were able to attain glycemic control. CONCLUSIONS: The prevalence of diabetes and pre-diabetes is alarmingly high among urban and periurban populations in Latin America, South Asia, and South Africa. Even more alarming is the propensity for South Asians to develop diabetes and pre-diabetes at a younger age and lower body mass index compared with individuals from other low and middle income countries. It is concerning that one-fifth of all people with diabetes were unaware of their diagnosis and that only two-thirds of those under treatment were able to attain glycemic control. Health systems and policy makers must make concerted efforts to improve diabetes prevention, detection, and control to prevent long-term consequences.

Obesity and its Relation With Diabetes and Hypertension: A Cross-Sectional Study Across 4 Geographical Regions.

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.

Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries.

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.

An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala, Mexico, and South Africa: an observational study.

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.

Referral outcomes of individuals identified at high risk of cardiovascular disease by community health workers in Bangladesh, Guatemala, Mexico, and South Africa.

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.