It Is Time for Reducing Global Cardiovascular Mortality
2019; Lippincott Williams & Wilkins; Volume: 140; Issue: 9 Linguagem: Inglês
10.1161/circulationaha.119.041653
ISSN1524-4539
AutoresLisandro D. Colantonio, Paul Muntner,
Tópico(s)Health disparities and outcomes
ResumoHomeCirculationVol. 140, No. 9It Is Time for Reducing Global Cardiovascular Mortality Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBIt Is Time for Reducing Global Cardiovascular Mortality Lisandro D. Colantonio, MD, PhD and Paul Muntner, PhD Lisandro D. ColantonioLisandro D. Colantonio Department of Epidemiology, University of Alabama at Birmingham (L.D.C., P.M.). and Paul MuntnerPaul Muntner Paul Muntner, MD, 1720 2nd Ave South, RPHB 140J, Birmingham, AL 35294-0013. Email E-mail Address: [email protected] Department of Epidemiology, University of Alabama at Birmingham (L.D.C., P.M.). Originally published26 Aug 2019https://doi.org/10.1161/CIRCULATIONAHA.119.041653Circulation. 2019;140:726–728This article is a commentary on the followingThree Public Health Interventions Could Save 94 Million Lives in 25 YearsArticle, see p 715It has been known for many decades that cardiovascular disease (CVD) is the leading cause of death in high-income countries. However, it wasn't until the 1990 GBD (Global Burden of Disease) study that it became recognized that CVD is the leading cause of death worldwide, both in high- and low-income populations.1,2 This study estimated that ischemic heart disease and cerebrovascular disease accounted for 5.7 and 4.6 million deaths worldwide, respectively, in 1990.2 These data corrected a perception that noncommunicable diseases were primarily diseases of affluent populations and stressed the need for addressing them in all world regions. After this first report, there have been subsequent waves of the GBD study that have continued to highlight a high, and growing, global burden of CVD. For example, the GBD study estimated that between 1990 and 2013, deaths attributable to ischemic heart disease and cerebrovascular disease increased by 42% and 41%, respectively, with approximately 70% of all CVD deaths worldwide in 2013 having occurred in low- or middle-income countries.2 Additionally, it has been estimated that CVD will account for >23 million deaths by 2030.3Despite being the leading cause of mortality worldwide, CVD is largely preventable through simple and inexpensive interventions. In the current issue of Circulation, Kontis et al4 report on a study that estimated the number of deaths from CVD and other non-communicable diseases between 2015 and 2040 that could be delayed worldwide through the implementation of 3 population-based interventions: (1) scaling up treatment of high blood pressure to 70%, (2) reducing sodium intake by 30%, and (3) eliminating intake of artificial trans fatty acids. The authors used global surveys to derive data on current estimates and projected trends in systolic blood pressure and intake of sodium and trans fatty acids by country. Current estimates and trends in antihypertensive treatment coverage were derived from a meta-analysis of observational studies, whereas age- and sex-specific mortality from noncommunicable diseases were obtained from the World Health Organization Global Health Estimates. The effect of the 3 interventions on mortality attributable to CVD, kidney disease, and stomach cancer were modeled based on relative risks from meta-analyses of observational studies and clinical trials, accounting for both the level of the exposure and the time since the intervention was implemented. The authors also considered the joint effect of the interventions in their analysis.Kontis et al estimated that the implementation of the 3 population-based interventions could delay 94.3 (95% CI, 85.7–102.7) million deaths by 2040, 90.7% of them from CVD. This represents 7.7% of all deaths attributable to noncommunicable diseases worldwide. Increasing the coverage of treatment for high blood pressure to 70%, achieving a 30% reduction in sodium intake, and eliminating trans fatty acids intake was estimated to delay 39.4 (95% CI, 35.9–43.0), 40.0 (95% CI, 35.1–44.6) and 14.8 (95%CI, 14.7–15.0) million deaths, respectively. The authors estimated that most of these deaths could be delayed by modest reductions in sodium intake (10% reduction) and increases in antihypertensive medication coverage (50% coverage). As expected, the most populous world regions would be expected to account for most deaths delayed, including the East Asia and Pacific (29.7 million) and the South Asia (22.6 million) regions. However, the greatest percentage of death from noncommunicable diseases delayed is expected in the North Africa and Middle East (11.3%) and in the Central and Eastern Europe and Central Asia (11.0%) regions. Sub-Saharan Africa is the region with the largest expected proportion of deaths delayed in people younger than 70 years of age (54.2%). The authors reported that the implementation of the 3 interventions would contribute to reductions in the disparities in global noncommunicable disease mortality.The choice of interventions evaluated in the current study is based on a large body of scientific evidence. Consumption of trans fatty acids increases the risk for CVD, and their elimination has been demonstrated to be feasible in several countries without changing taste or increasing the cost of food preparation.5,6 The direct association between sodium intake and blood pressure is well established. In 2003, the UK initiated a nationwide salt reduction program that was estimated to result in population reductions in blood pressure and CVD.7 Between 2003 and 2011, salt intake was reduced by 15%, systolic and diastolic blood pressure declined by 3.0 and 1.4 mm Hg, respectively, and stroke and ischemic heart disease mortality declined by 42% and 40%, respectively.7 Finally, antihypertensive medication with a goal blood pressure <140/90 mm Hg has clear CVD risk-reduction benefits. However, it has been estimated that only 37% of adults with hypertension are taking antihypertensive medication and 37% of those taking antihypertensive medication have controlled blood pressure.8Reducing mortality from noncommunicable diseases is challenging. Globally, one group that is engaged in this endeavor is the Resolve to Save Lives program (Resolve).9 Resolve is a global public health initiative aimed to delay millions of deaths from noncommunicable diseases through scalable interventions in low- and middle-income countries. Resolve is supporting global and national efforts to scale the interventions studied in the article by Kontis et al with the goal of delaying 100 million deaths.9 The study by Kontis et al demonstrates that Resolve's goal is feasible over a 25-year time horizon.4 Elimination of trans fatty acids, sodium reduction, and increased antihypertensive medication use are not the only population-based interventions for delaying deaths from noncommunicable diseases. MPOWER is a package of 6 tobacco control policies by the World Health Organization, including (1) monitoring tobacco use and prevention policies, (2) protecting people from tobacco smoke, (3) offering help to quit tobacco use, (4) warning about the dangers of tobacco, (5) enforcing bans on tobacco advertising, promotion, and sponsorship, and (6) raising taxes on tobacco.10 It has been estimated that the implementation of the MPOWER package could delay 108 million tobacco-related deaths over 15 years.11 The NOURISHING framework (nutrition label standards and regulations on the use of claims and implied claims on food, offer healthy food and set standards in public institutions and other specific settings, use economic tools to address food affordability and purchase incentives, restrict food advertising and other forms of commercial promotion, improve nutritional quality of the whole food supply, set incentives and rules to create a healthy retail and food service environment, harness food supply chain and actions across sectors to ensure coherence with health, inform people about food and nutrition through public awareness, nutrition advice and counselling in health care settings, and give nutrition education and skills) is a package of food policies in 10 key areas developed by the World Cancer Research Fund International aimed to prevent obesity and reduce diet-related noncommunicable diseases.12 It has been estimated that 1 in 5 deaths worldwide are related to poor diet, mostly attributable to CVD and cancer.13 Therefore, the NOURISHING framework has the potential to delay a large number of deaths.The study by Kontis et al provides a roadmap for delaying millions of deaths from CVD through population-based interventions worldwide. In the United States, the Department of Health and Human Services launched the Million Hearts initiative in 2012 to focus, coordinate, and enhance CVD prevention activities across the public and private sectors to prevent 1 million CVD events by 2017.14 Million Hearts is working to meet this goal by focusing its efforts on the ABCS of clinical care—aspirin for secondary CVD prevention, when appropriate; blood pressure control; cholesterol management; and smoking cessation—and in the community setting by reducing overall tobacco use, reducing sodium consumption, and eliminating artificial dietary trans fatty acids. In a preliminary report it was estimated that 115 000 fewer CVD events than expected occurred in the first 2 years after implementation of the Million Hearts program.15 There are also opportunities to scale-up proven interventions in low- and middle-income countries. For example, the US National Heart, Lung, and Blood Institute and National Institute of Neurological Disease and Stroke have announced funding for cooperative agreements to form a research alliance that will scale-up sustainable, evidence-based interventions at the population level for the prevention and management of hypertension in low- and middle-income countries. This funding will focus on 6 regions—East Asia and the Pacific, Europe and Central Asia, Latin America and the Caribbean, Middle East and North Africa, South Asia, and Sub-Saharan Africa—many of which had high potential for delaying CVD mortality in the study by Kontis et al.It is important to consider the implications of the study by Kontis et al on global health initiatives aimed at CVD and other noncommunicable disease prevention. A key take-home message from the study is that, although we know that many interventions are effective for delaying mortality, particularly from CVD, there is a great need to focus on scalable programs that can be disseminated and implemented. Also, the current study demonstrates that tens of millions of deaths could be delayed even if the goals are only partially met. However, although almost 100 million deaths can be delayed through the 3 interventions studied by Kontis et al, this accounts for <10% of all deaths from noncommunicable diseases anticipated to occur over the next 25 years. This highlights the continued need for additional prevention efforts to delay deaths from CVD and other noncommunicable diseases. In conclusion, the study by Kontis et al demonstrates the need for program implementation to delay mortality from CVD and other noncommunicable diseases and raises great interest to track the effectiveness of the Million Hearts Initiative, Resolve, and other initiatives.DisclosuresDr Muntner is a consultant for Kaiser Permanente Southern California on a project funded by Vital Strategies, for which Resolve to Save Lives is an initiative. Dr Colantonio reports no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.https://www.ahajournals.org/journal/circPaul Muntner, MD, 1720 2nd Ave South, RPHB 140J, Birmingham, AL 35294-0013. Email [email protected]eduReferences1. Murray CJ, Lopez AD, Jamison DT. The global burden of disease in 1990: summary results, sensitivity analysis and future directions.Bull World Health Organ. 1994; 72:495–509.MedlineGoogle Scholar2. 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TURAL K and KAHRAMAN A (2021) Effects of preoperative and postoperative albumin levels on postoperative arrhythmias after open heart surgeries with cardiopulmonary bypass, Journal of Surgery and Medicine, 10.28982/josam.887312, 5:6, (602-605) Liu X, Xu Y, Cheng S, Zhou X, Zhou F, He P, Hu F, Zhang L, Chen Y and Jia Y (2021) Geniposide Combined With Notoginsenoside R1 Attenuates Inflammation and Apoptosis in Atherosclerosis via the AMPK/mTOR/Nrf2 Signaling Pathway, Frontiers in Pharmacology, 10.3389/fphar.2021.687394, 12 Related articlesThree Public Health Interventions Could Save 94 Million Lives in 25 YearsVasilis Kontis, et al. Circulation. 2019;140:715-725 August 27, 2019Vol 140, Issue 9 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.041653PMID: 31449461 Originally publishedAugust 26, 2019 Keywordscardiovascular diseaseEditorialsPDF download Advertisement SubjectsEthics and Policy
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