A Latin American Perspective on the New ACC/AHA Clinical Guidelines for Managing Atherosclerotic Cardiovascular Disease

First cardiovascular event in patients with type 2 diabetes mellitus of a cardiovascular risk management program of a poor Colombian population: a cohort study

BACKGROUND

According to several studies in population of high-income countries (HIC), patients with Type 2 diabetes mellitus (DM) have a considerably higher risk of cardiovascular morbidity and mortality. However, it is not clear if the magnitude of this association can be widespread in other populations. The objective of this study was to determine the independent association between Type 2 DM and first cardiovascular event in Colombian Caribbean poor population with no records of previous cardiovascular events reported.

METHODS

We retrospectively reviewed the individual records from the hospitalizations database of 64,668 patients of cardiovascular risk management program from July 2014 to December 2015. We used a propensity score matching cohort analysis for this study. The Kaplan-Meier curves were constructed for the cardiovascular events related endpoints and matched Cox-regression analysis to estimate associations of a history of Type 2 DM with cardiovascular outcomes during 1.5 years of follow-up. A formal sensitivity analysis using The Breslow-Day and Tarone Homogeneity tests was conducted.

RESULTS

Out of 56,351 patients with no previous cardiovascular events records, 19,368 (34.4%) patients were found to suffer Type 2 DM. Using propensity scores for Type 2 DM, we gathered a cohort of 18,449 pairs of patients with and without Type 2 DM who were balanced on 22 baseline characteristics. A first cardiovascular event occurred in 650 (3.5%) and 403 (2.1%) matched patients with and without Type 2 DM, respectively, during 1.5 years of follow-up. Type 2 DM was associated with first cardiovascular event (HR 1.69; 95% CI 1.43-2.00; p = 0.000), AMI (HR 1.79; 95% CI 1.45-2.20; p = 0.000) and stroke (HR 1.54; 95% CI 1.18-2.02; p = 0.001). Hazard ratios (95% CIs) for the association of Type 2 DM with all-cause mortality, cardiovascular mortality and all-cause hospitalization were 1.36 (1.21-1.53; p < 0.001), 1.52 (1.12-2.08; p 0.004), and 1.20 (1.21-1.53; p < 0.001), respectively.

CONCLUSION

Type 2 DM resulted to be a significant independent risk factor for first cardiovascular event in Colombian Caribbean poor population with no previous records of cardiovascular events.

Comparison of Trends in Mortality from Coronary Heart and Cerebrovascular Diseases in North and South America: 1980 to 2013

Until the past century, mortality trends from coronary heart disease (CHD) and cerebrovascular disease (CVD) were less favorable in Latin than in North America. We calculated age-standardized mortality rates using data from the World Health Organization database over the period 1980 to 2013. To identify significant changes in trends, we performed joinpoint analysis. Since the early 2000's, CHD mortality rates decreased by about 35% in the USA and Canada in both genders; similar decreases were observed in some Latin American countries (i.e., Ecuador, Puerto Rico, and Chile), whereas the decreases were smaller in the other countries. In 2011 to 2013, the highest rates were in Venezuela (114.4/100,000 men) and Colombia (86.1/100,000 men) and the lowest ones (apart from Ecuador) in Panama, Chile, and Argentina (from 41 to 46/100,000 men and 18 to 19/100,000 women). For CVD mortality, a decrease by about 30% was observed in Argentina, Panama, and Uruguay plus Colombia for women, in addition to the USA and Canada. Smaller declines were observed in the other Latin American countries (from 23% in Colombian men to 5% in Venezuelan men). Throughout the period, rates in Latin America remained appreciably higher than those in North America. The highest CVD rates were observed in Brazil (51.6/100,000 men) and the lowest ones in Canada (12.9/100,000 women). In conclusion, trends in CHD and CVD mortality continue to be less favorable in Latin America than in Canada and the USA. The marked excess of CVD mortality is partly or largely attributable to inadequate control of dyslipidemia and hypertension.

Increased statin eligibility based on ACC/AHA versus NCEP guidelines for high cholesterol management in Chile

BACKGROUND

In 2013, the American College of Cardiology and the American Heart Association (ACC/AHA) jointly released new guidelines for cardiovascular risk assessment and cholesterol management that substantially modified the previous recommendations proposed by the National Cholesterol Education Program (NCEP) in 2001. The relative impact of these new guidelines on potential statin use has not been estimated in Latin American populations.

OBJECTIVE

To estimate and compare eligibility for statin therapy based on ACC/AHA and NCEP guidelines in adult Chilean population.

METHODS

Using data from the last National Health Survey (2009-2010 NHS), we conducted a cross-sectional analysis in a ​representative sample of the Chilean adult population and calculated the proportion of individuals that would receive statins under each set of guidelines.

RESULTS

According to ACC/AHA guidelines, the population eligible for statin treatment increased from 21.7% (NCEP guidelines) to 33.2% (overall 53% increase). This effect was more pronounced among women (29.6% under ACC/AHA vs 15.6% under NCEP) and with those of advanced age (75% of the subjects >60 years of age compared with 46% under NCEP). The newly eligible group included more women and older subjects and individuals with lower LDL cholesterol levels.

CONCLUSION

Compared with NCEP recommendations, the new ACC/AHA guidelines significantly increased the number of Chilean adults eligible for statin therapy. Full implementation of the new recommendations may have important public health implications in Chile and other Latin American countries, as more women and older subjects without cardiovascular disease would qualify for statin treatment.

Medical devices and diagnostics for cardiovascular diseases in low-resource settings

Noncommunicable diseases (NCDs), including cardiovascular diseases and diabetes, have emerged as an underappreciated health threat with enormous economic and public health implications for populations in low-resource settings. In order to address these diseases, devices that are to be used in low-resource settings have to conform to requirements that are generally more challenging than those developed for traditional markets. Characteristics and issues that must be considered when working in low- and middle-income countries (LMICs) include challenging environmental conditions, a complex supply chain, sometimes inadequate operator training, and cost. Somewhat counterintuitively, devices for low-resource setting (LRS) markets need to be of at least as high quality and reliability as those for developed countries to be setting-appropriate and achieve impact. Finally, the devices need to be designed and tested for the populations in which they are to be used in order to achieve the performance that is needed. In this review, we focus on technologies for primary and secondary health-care settings and group them according to the continuum of care from prevention to treatment.

Trends and heterogeneity of cardiovascular disease and risk factors across Latin American and Caribbean countries

Aging, globalization and urbanization in Latina America and the Caribbean (LAC) have made cardiovascular disease (CVD) the number one cause of death and disability, while communicable diseases have decreased. This epidemiological transition has been more heterogeneous than in other areas of the world. While countries like Argentina, Chile, Brazil and Colombia have seen a significant decrease in CVD mortality, the rest of the countries have seen an increase, particularly Central American and Caribbean countries. These latter countries have now coexisting high prevalence of communicable and non-communicable diseases, threatening the socioeconomic development. Recent multinational cross sectional studies have provided a better perspective of the prevalence and distribution of cardiovascular risk factors in the region. While there has been a decrease in prevalence of smoking in the region, obesity, diabetes and physical inactivity continue to increase the CVD disease burden in LAC.