Cardiovascular disease in South America: current status and opportunities for prevention

Current status of nuclear cardiology practice in Latin America and the Caribbean, in the era of multimodality cardiac imaging approach: 2022 update

Cardiovascular diseases (CVDs) are the leading cause of mortality in Latin America and the Caribbean (LAC), with the risk in men being slightly higher than in women. The coronavirus disease 2019 (COVID-19) pandemic caused a significant reduction in the number of cardiac diagnostic procedures globally and in particular in LAC. Nuclear cardiology is available in the region, but there is variability in terms of existing technology, radiopharmaceuticals, and human resources. In the region, there are 2385 single photon emission computed tomography (SPECT) and 315 PET scanners, Argentina and Brazil have the largest number. There is an increasing number of new technologies such as cadmium-zinc-telluride (CZT) cardiac-dedicated gamma cameras, SPECT/computed tomography (CT), and PET/CT. All countries performed myocardial perfusion imaging studies, mainly gated-SPECT; the rest are multi-gated acquisition, mainly for cardiac toxicity; detection of viability; rest gated SPECT in patients with dilated cardiomyopathy, and bone-avid tracer cardiac scintigraphy for transthyretin cardiac amyloidosis diagnosis. Regarding other non-nuclear cardiac imaging modalities, Argentina, Colombia, and Chile have the highest ratio of CT scanners, while Brazil, Argentina, and Chile show the highest ratio of MRI scanners. The development of nuclear cardiology and other advanced imaging modalities is challenged by the high cost of equipment, lack of equipment maintenance and service, insufficient-specific training both for imaging specialists and referring clinicians, and lack of awareness of cardiologists or other referring physicians on the clinical applications of nuclear cardiology. Another important aspect to consider is the necessity of implementing cardiac imaging multimodality training. A joint work of nuclear medicine specialists, radiologists, cardiologists, and clinicians, in general, is mandatory to achieve this goal. National, regional, and international cooperation including support from scientific professional societies such as the American Society of Nuclear Cardiology and Latin American Association of Biology and Nuclear Medicine Societies, cardiological societies, and organizations such as the International Atomic Energy Agency, and Pan American Health Organization, as well as government commitment are key factors in the overall efforts to tackle the burden of cardiovascular diseases in the region.

Factores de riesgo y muerte cardiovascular en América del Sur

We present cardiovascular disease (CVD) incidence and mortality rates reported for South America stratified by country, sex, and urban/rural location in a multinational cohort included in the Population Urban Rural Epidemiological Study (PURE). This study included 24,718 participants from 51 urban and 49 rural communities in Argentina, Brazil, Chile, and Colombia and the mean follow-up was 10.3years. CVD incidence and mortality rates were calculated for the total cohort and in subpopulations. Hazard ratios and population attributable fractions (PAFs) for CVD and death were examined for 12 modifiable risk factors, grouped as metabolic (hypertension, diabetes, abdominal obesity, and high non-HDL cholesterol), behavioural (smoking, alcohol, diet quality, and physical activity) and other (education, household air pollution, strength, and depression). The leading causes of death were CVD (31.1%), cancer (30.6%), and respiratory diseases (8.6%). Approximately 72% of the PAFs for CVD and 69% of the PAFs for deaths were attributed to 12 modifiable risk factors. For CVD, the main PAFs were due to hypertension (18.7%), abdominal obesity (15.4%), smoking (13.5%), low muscle strength (5.6%), and diabetes (5.3%). For death, the main PAFs were smoking (14.4%), hypertension (12.0%), low educational level (10.5%), abdominal obesity (9.7%), and diabetes (5.5%). Cardiovascular diseases, cancer, and respiratory diseases account for more than two-thirds of deaths in South America. Men have consistently higher CVD rates and mortality than women. A large proportion of CVD and premature deaths could be avoided by controlling metabolic risk factors and smoking, which are the main risk factors in the region for both CVD and all-cause mortality.

A systematic review of cross-sectional studies on the association of sedentary behavior with cardiometabolic diseases and related biomarkers in South American adults

Introduction

Introduction: sedentary behavior (SB) has been independently associated with detrimental health outcomes in different regions worldwide. The aim of this systematic review was to examine whether domain-specific SB is associated with cardiometabolic diseases (CMD) and related biomarkers in South American adults. Methods: nine electronic databases were searched to identify all studies that analyzed the association between SB and CMD-e.g. obesity, diabetes, hypertension, metabolic syndrome (MetS) and clustering of chronic diseases (CCD)-and related biomarkers in South American adults. Two independent reviewers performed the necessary abstract/full-text screening, data abstraction, and quality assessments. The review protocol was registered in the PROSPERO database (CRD42018099319). Results: from the 1,262 articles identified in the search 262 were reviewed in full and 20 were used in the analysis in accordance to the inclusion criteria. High SB (mainly sitting and TV time) was associated with an increased likelihood of obesity (n = 8), diabetes (n = 6), and CCD (n = 3), as well as high values of BMI (n = 8), WC (n = 7), % BF (n = 4), plasma lipids (n = 4), and glycemia (n = 5). Eleven out of 20 studies were of higher quality. Conclusion: long time spent in SB, mainly sitting and TV time, was positively associated with the occurrence of CMD and related biomarkers in South American adults.

Cardiovascular Health Status Among Community-Dwelling Ecuadorian Natives Living in Neighboring Rural Communities: The Three Villages Study

Knowledge of cardiovascular health (CVH) status in rural communities is essential to implement cost-effective strategies aimed to address the growing burden of cardiovascular diseases in these settings. Here, we report on the CVH status and health metrics of 1508 community-dwellers aged ≥ 40 years in three neighboring rural villages of Coastal Ecuador (Atahualpa, El Tambo, and Prosperidad). According to the American Heart Association, a poor CVH status is designated when at least one cardiovascular health metric is in the poor range. About 70% of individuals in the villages studied had a poor CVH status, with no overall differences across villages. However, the relative prevalence of poor health metrics varied. Using Atahualpa as the referent village, a multinomial logistic regression model showed that El Tambo residents were more often smokers and had a worse diet, while Prosperidad residents had more high blood pressure but better fasting glucose levels. Probabilities of having poor health metrics were lower in Atahualpa than in El Tambo (p < 0.001), but not better than in Prosperidad (p = 0.097). Predictive estimates of having poor health metrics were significantly higher in El Tambo than in Atahualpa or in Prosperidad. This comparative study demonstrates that the CVH status of rural populations of coastal Ecuador is basically similar. However, individual health metrics in the poor range were found to vary across villages. While the three villages are generally comparable, interventions should be tailored according to local priorities. The same may occur in other rural communities, but more studies are needed to confirm our findings.

Implementation of a Multidisciplinary Inpatient Cardiology Service to Improve Heart Failure Outcomes in Guyana

BACKGROUND

Guyana is a small developing country with a high burden of cardiovascular disease and extensive barriers to optimal care delivery. We investigated the effectiveness of a newly established multidisciplinary inpatient cardiology service in this setting.

METHODS

We performed an interrupted time-series cohort study of heart failure (HF) patients admitted to the Georgetown Public Hospital Corporation from January to December 2015 and July 2016 to December 2017. The primary outcome was discharge on guideline-directed medical therapy (GDMT). Secondary outcomes included length of hospitalization and all-cause mortality.

RESULTS

We identified 740 patients, 347 (46.9%) of whom were admitted after service implementation. The postimplementation cohort was more likely to be discharged on a beta-blocker (66.6% vs 41.7%; P < .01) and mineralocorticoid receptor antagonist (31.7% vs 15.3%; P = .01). They were also more likely to undergo echocardiography (60.8% vs 40.5%; P < .01) and chest x-rays (70.6% vs 46.6%; P < .01). Hospitalization length (10.0 ± 13.1 vs 9.8 ± 10.1 days) and readmissions within 90 days (19.0% vs 19.1%) were not significantly different. There were fewer deaths in the postimplementation cohort compared with the preimplementation cohort (12/347 vs 28/393).

CONCLUSIONS

Establishment of a multidisciplinary inpatient cardiology service demonstrated increased adherence to GDMT without extending length of hospitalization.

Validation of an Open-Source Tool for Measuring Carotid Lumen Diameter and Intima-Media Thickness

In low- and middle-income regions, a relatively large number of deaths occur from cardiovascular disease or stroke. Carotid intima-media thickness (cIMT) and carotid lumen diameter (cLD) are strong indicators of cardiovascular event risk and stenosis severity, respectively. The interactive open-source software described here, Cimtool, is based on active contours for measuring these indicators in clinical practice and thus helping in preventive diagnosis and treatment. Cimtool was validated using carotid phantoms and real images obtained using ultrasound. Expert users measured cIMT and cLD in regular practice and also with Cimtool. The results obtained with Cimtool were then compared with the results for the manual approach in terms of measurement agreement, time spent on the measurements and usability. Intra-observer variability when using Cimtool was also analyzed. Statistical analysis revealed strong agreement between the manual method and Cimtool (p > 0.01 for cIMT and cLD). The correlation coefficient for both cIMT and cLD measurements was r > 0.9. Moreover, this software allowed the users to spend considerably less time on each measurement (3.5 min per study versus 50 s with Cimtool on average). An open-source, interactive, validated tool for measuring cIMT and cLD clinically was thus developed. Compared with the manual approach, Cimtool's straightforward measurement flow allows the user to spend less time per measurement and has less standard deviation. The coefficients of variation for measurements and intra-observer variability were lower than those reported for recent automated approaches, even with low-quality images.

Factores de riesgo cardiovascular en una población cafetera del Departamento de Caldas

Objetivos Determinar los factores de riesgo cardiovascular en una población caficultora del Departamento de Caldas.Materiales y Métodos Estudio transversal realizado en 2015 a 964 caficultores afiliados a la Cooperativa de Caficultores de Manizales en 6 sedes ubicadas en la zona centro y oriente del departamento. Posterior a la encuesta, se realizaron medidas antropométricas y pruebas bioquímicas. Los resultados fueron analizados en el Paquete Estadístico para las Ciencias Sociales (SPSS); versión No.18.Resultados Las Prevalencias del estudio fueron: Género masculino, 78 %; tabaquismo, 27,2 %; antecedentes de familiares fallecidos antes de los 55 años por etiología coronaria, 24 %; hipertensión arterial, 14 %; hipercolesterolemia, 56,6 %; circunferencia de la cintura para hombres 90,7 cm y para mujeres 88,1; el índice de masa corporal promedio para la población fue de 24,7 kg/m2.Conclusiones La hipercolesterolemia fue el factor de riesgo cardiovascular común y más predisponente para el desarrollo de la enfermedad cardiovascular en esta población; la detección temprana de factores de riesgo permite desarrollar estrategias de promoción y prevención con el fin de disminuir su morbilidad, mortalidad, discapacidad y costos asociados con la enfermedad cardiovascular. 

Type 2 diabetes and health care costs in Latin America: exploring the need for greater preventive medicine

BACKGROUND

Despite advances in medicine, health systems in Latin America are not coping with the challenges of chronic diseases. Incidence of disease and the economic burdens as a consequence have both increased in recent years. We have chosen Type 2 diabetes as an example to highlight the challenges posed by chronic diseases, in terms of the epidemiological transition and the economic burden of the demand for services to treat such problems.

DISCUSSION

Current health systems are not prepared to respond in a comprehensive manner to all phases of the natural history of the disease. There are new models of universal coverage, but resources and models of care are focused on programs aimed at healing/rehabilitation, and very sparsely at detection/prevention.

SUMMARY

In this scenario, chronic problems have alarmingly increased direct costs (medical care) and indirect costs (temporary disability, permanent disability and premature mortality). If more resources are not assigned to preventive medicine, these trends, in addition to not meeting the needs of the population, will financially collapse health systems and the patients' pockets. This Opinion piece outlines some possible changes that can be implemented to better prepare the health services in Latin American countries.

Door-to-door survey of cardiovascular health, stroke, and ischemic heart disease in rural coastal Ecuador--the Atahualpa Project: methodology and operational definitions

RATIONALE

Stroke and cardiovascular diseases will be the next health epidemics in Latin America due to increased life expectancy and changes in the lifestyle and dietary habits of the population. Knowledge of the cardiovascular health status of the inhabitants will allow the implementation of policies directed to reduce the burden of stroke and cardiovascular diseases in the region.

AIMS

To evaluate the cardiovascular health status of the inhabitants of Atahualpa (a rural village in coastal Ecuador) and to determine the prevalence and incidence of stroke and ischemic heart disease in the region.

DESIGN

Three-phase epidemiologic survey. During phase I, Atahualpa residents aged ≥40 years will be screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In phase II, neurologists and cardiologists will examine suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess the prevalence and incidence of these conditions. In phase III, patients with a diagnosis of stroke and ischemic heart disease will undergo complementary tests for achieving a more specific diagnosis.

DISCUSSION

Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective in improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations.

Changes in calculated coronary heart disease risk using proactive multifactorial intervention versus continued usual care in Latin-American and non-Latin-American patients enrolled in the CRUCIAL trial

OBJECTIVE

To compare the change in calculated coronary heart disease (CHD) risk using a proactive multifactorial intervention (PMI) versus usual care (UC), among Latin-American (LA) and non-LA patients enrolled in the CRUCIAL trial.

RESEARCH DESIGN AND METHODS

This is a sub-analysis of the Cluster Randomized Usual Care versus Caduet Investigation Assessing Long-term-risk (CRUCIAL) trial. CRUCIAL was a prospective, multinational, open-label, cluster-randomized trial. Eligible patients had hypertension and ≥3 additional cardiovascular risk factors, but no history of CHD and baseline total cholesterol ≤6.5 mmol/l (250 mg/dl). The PMI strategy was implemented by the inclusion of single-pill amlodipine/atorvastatin (SPAA) in the patients' treatment regimen. Overall, 20% of patients resided in the LA region.

MAIN OUTCOME MEASURE

Treatment-related change in calculated Framingham 10-year CHD risk between baseline and Week 52 in the LA and non-LA regions.

RESULTS

A greater relative reduction in calculated CHD risk after 52 weeks' follow-up was observed for patients in the PMI arm compared with UC arm in both LA (-32.8% vs. -7.5%, p = 0.003) and non-LA regions (-33.1% vs. -3.3%, p < 0.001), region interaction p = 0.316. The proportion of patients discontinuing treatment in the PMI arm due to adverse events (AEs) was low in both regions (both 5.9%).

CONCLUSIONS

The PMI approach based on the inclusion of SPAA in the patients' treatment regimen may improve the management of CHD risk among patients residing in LA and non-LA regions. Clinicians may be reassured by the low rate of AEs leading to discontinuation of SPAA in both regions.

Cardiovascular disease research in Latin America: a comparative bibliometric analysis

AIM

To investigate the number of publications in cardiovascular disease (CVD) in Latin America and the Caribbean over the last decade.

METHODS

We performed a bibliometric analysis in PubMed from 2001 to 2010 for Latin America and the Caribbean, the United States, Canada, Europe, China, and India.

RESULTS

Latin America published 4% of articles compared with 26% from the United States/Canada and 42% from Europe. In CVD, Latin America published 4% of articles vs 23% from the United States/Canada and 40% from Europe. The number of publications in CVD in Latin America increased from 41 in 2001 to 726 in 2010.

CONCLUSION

Latin America, while publishing more articles than previously, lags behind developed countries. Further advances in research infrastructure are necessary to develop prevention strategies for this region.

Comparison of risk factors of CHD in the men and women with MI

The purpose of this study is comparison of risk factors of MI in hospitalized men and women patients in CCU. The CHD is the most important cause of mortality in the industry countries. Different environmental and race in each location can affect on frequency of risk factors of MI. In this cross sectional study, comparison was done between men and women who have involved in MI. The random sampling method was used Blood sugar, cholesterol and homocystein, LPa, BMI, family history, skin color, smoking and the amount of activity were assessed with variables such as age. The data was collected via questionnaire from September until March 2004-2005. Finally the data were analyzed with using t-test, Chi square and pearson correlation. In this research 169 patients who involved in MI (114 men and 55 women) have participated. The mean of age in the men was 55.4 and in the women was 61.02. All patients had risk factors. In the men, smoking (52.6%) and family history (41.1%) were the most common risk factors of MI. In the women, hyperlipidemia (66.4%), diabetes (62%) and hypertension (58.2%) were the most common risk factors of MI. The mean of BMI in the men was 25.9 +/- 4.25 and in the women was 27.6 +/- 4.71. The mean of LPa in the men was 59.2 +/- 4.21 and in the women was 50.9 +/- 4.25. the mean of homocystein in the men was 10.7 +/- 7.67 and in the women was 8.9 +/- 14.45. Diabetes, hyperlipidemia, hypertension and smoking had significant relationship with age and sex (p < 0.001) and skin color, homocystein, LPa, job, personality type and mobility didn't have significant relationship with age and sex. In this study the most common risk factors of MI in the men were smoking and positive family history and in the women were known hyperlipidemia and diabetes.