29 Sep 2023
World Heart Day 2023: Reducing the burden of cardiovascular disease globally: beyond stents and balloons!
Global burden of Cardiovascular Disease
Cardiovascular disease (CVD) remains the lead cause of mortality for men and women globally. Our world population in 2023 is 8 billion! Of these, around 620 million people are living with heart and circulatory diseases across the world. Each year around 60 million people across the world develop a heart or circulatory disease. Globally it’s estimated that 1 in 13 people are living with a heart or circulatory disease. Heart and circulatory diseases cause around 1 in 3 deaths globally; an estimated 20.5 million deaths in 2021 - an average of 56,000 people each day or one death every 1.5 seconds (source-the British Heart Foundation).
In 2019 globally there were more women than men living with heart and circulatory diseases (around 290 million women (53%) and 260 million men).
The most common cardiovascular conditions are:
- Coronary (ischaemic) heart disease (global prevalence estimated at 200 million in 2019)
- Peripheral arterial (vascular) disease (110 million)
- Stroke (100 million)
- Atrial fibrillation (60 million).
Reducing the burden of CVD through percutaneous cardiovascular interventions
Percutaneous cardiovascular interventions have transformed the way we manage patients with CVD over the past several decades. Percutaneous interventional procedures in the form of coronary angiography, percutaneous coronary interventions (PCI), peripheral arterial interventions, stroke interventions and left atrial appendage closures play a major role in the management of the above commonly occurring cardiovascular conditions.
Primary PCI without a doubt is the biggest breakthrough in the management of myocardial infarctions worldwide in the last 2 decades. Since the first case of percutaneous coronary intervention in 1977, millions of percutaneous coronary interventions have been performed worldwide. In the management of aortic stenosis, since the first TAVI case over 20 years ago, >1.5 million TAVI procedures have been performed worldwide. Percutaneous interventions in the treatment of other valvular diseases such as those of mitral valves and tricuspid valves now provide hope to those who did not have much treatment choices in the past to improve their quality of life. Potent pharmacotherapy in the management of hypertension, diabetes, high cholesterol, antiplatelet and antithrombotic therapies/regimens help to reduce recurrent ischaemic events while reducing bleeding events.
Despite significant progress in cardiovascular care in terms of pharmacotherapy and interventional strategies, the current cardiovascular statistics are rather stark given most cardiovascular diseases are preventable!
Why is this so?
The burden of CVD has been rising due to changing lifestyles, environmental factors, rapidly ageing population, and improved survival rates from heart attacks and strokes. But there might also be other factors such as access to care and equity.
Undertreatment of women with CVD
It is puzzling why women are still under diagnosed, under treated and underrepresented in clinical studies. In the setting of acute coronary syndrome (ACS), there are reasons for the greater delay in seeking medical attention among women than men which include lack of awareness, under estimation of risk, socio-economic barriers/social determinants of health. In addition to well-established risk factors for CVD such as obesity, diabetes, hypertension, dyslipidaemia, age, inactivity, family history and smoking, risk in women is further modified by pregnancy, hormonal factors, psycho-social risks and socioeconomic factors. Obesity also has been shown to increase women’s risk of CVD more than men. In the setting of non ST elevation acute coronary syndrome diabetes mellitus had a strong association with mortality in women, but not in men. Hypertension has also been shown to have a greater population-adjusted risk of cardiovascular mortality in women than men. Lipid levels tend to fluctuate during the menstrual cycle. During pregnancy a physiological increase of LDL-cholesterol and even a larger increase in triglyceride levels are observed. Prior to menopause, oestrogen has a protective role in the development of CVD through improving lipid levels and reduced incidence of Type 2 diabetes and hypertension. However in women individual’s risk profile alters postmenopausal due to declining levels of oestrogen. In the menopausal transition, women develop a more adverse lipid profile. Worryingly, only ~25% of all patients achieve the guideline recommended LDL-C levels following an acute coronary syndrome. The Figure below shows the striking differences in cardiovascular mortality among women within the ESC countries (source European Society of Cardiology).
Source: European Society of Cardiology
The silent killer!
Hypertension, raised cholesterol, diabetes are well known risk factors for CVD in particular ischaemic heart disease stroke, heart failure, kidney damage, valvular heart disease such as aortic stenosis and many other health problems. Hypertension affects 1 in 3 adults worldwide. Yet untreated hypertension, a silent killer, alone led to 10.8 million deaths in 2021. According to a recent WHO report, approximately 4 out of every 5 people with hypertension are not adequately treated, but if countries can scale up coverage, 76 million deaths could be averted between 2023 and 2050. Concerningly, nearly half of people with hypertension globally are currently unaware of their condition! (source World Health Organisation).
Disparities in care globally…
Socioeconomic status (SE) status is a strong predictor of premature morbidity and mortality within general health. A lower socioeconomic status also has implications of increased cardiovascular disease (CVD) mortality and poorer CVD risk-factor profiles. SE status is traditionally defined by education, income and occupation, with each component having separate relationships to health. More than three-quarters of adults with hypertension live in low- and middle-income countries. In South Asian countries for example, populations may already be genetically at risk due to higher incidence of comorbidities such as diabetes, adding to the SE concerns. Studies have shown differing rates of decline in mortality from CVD between the most and the least deprived. It has been proposed that on this basis, CVD could become purely a disease of the lower SE groups by the mid 2020’s. Individuals with poor health literacy are more likely to be non-compliant with their medications.
What can be done about it?
- There is a pressing need to treat patients as a whole in addition to interventional strategies.
- To improve the cardiovascular health and well-being of our patients, it is important to pay attention to risk factors that can result in recurrent cardiovascular events.
- Guideline recommended strategies should be implemented to all patients to ensure sufficient risk factor control.
- Effective communication with general practitioners for ongoing care of patients with cardiovascular care is important.
- Raising awareness among patients and clinicians that CVD is lead cause of mortality for men and women to remove barriers to diagnosis, access and care.
- It is important to recognise that environmental factors including air pollution now play a major role in the development of CVD.
- Empowering patients to take care of their health by proactively seeking cardiovascular risk assessment including evaluation of blood pressure, lipid levels, healthy life style such as exercise, healthy diet.
- Public engagement campaigns to empower individuals to understand their health needs may improve health literacy and the concurrent CVD risk.
- Efforts to tackle socioeconomic status and CVD may aid in reducing avoidable deaths.
On this World Heart Day, now really is the time to take action to reduce the global burden of cardiovascular disease! It is everyone’s responsibility…
References
- British Heart Foundation Global Heart & Circulatory Diseases Factsheet
- https://www.who.int/news/item/19-09-2023-first-who-report-details-devastating-impact-of-hypertension-and-ways-to-stop-it
- ESC Atlas of Cardiology (escardio.org)
- Socioeconomic status and cardiovascular health in the COVID-19 pandemic. Naylor-Wardle J, Rowland B, Kunadian V.Heart. 2021 Mar;107(5):358-365.
