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Abstract: If a combination of cost-effective health-care interventions and population-wide prevention interventions is implemented in a sustainable manner, a significant impact can be made on the cardiovascular disease and diabetes burden. Given the limited resources, weak health systems and competing health issues in Africa, the focus should be on interventions prioritized on the basis not only of cost effectiveness but also of affordability, feasibility and high impact. The Global Action Plan for prevention and control of noncommunicable diseases 2013–2020 identifies such a core set. Financing the effective delivery of this core set as part of the basic health care package through a strengthened health system is a pragmatic approach to address cardiovascular disease and diabetes in Africa. Cost of implementation of this core set of interventions represents an annual investment of under US$ 1 in low income countries, US$ 1.50 in lower middle income countries and US$ 3 in upper middle income countries. [Copyright &y& Elsevier]

Abstract: Objectives: To determine the population distribution of cardiovascular risk in eight low- and middle-income countries and compare the cost of drug treatment based on cardiovascular risk (cardiovascular risk thresholds ≥30%/≥40%) with single risk factor cutoff levels. Study Design and Setting: Using World Health Organization (WHO) and the International Society of Hypertension risk prediction charts, cardiovascular risk was categorized in a cross-sectional study of 8,625 randomly selected people aged 40–80 years (mean age, 54.6 years) from defined geographic regions of Nigeria, Iran, China, Pakistan, Georgia, Nepal, Cuba, and Sri Lanka. Cost estimates for drug therapy were calculated for three countries. Results: A large fraction (90.0–98.9%) of the study population has a 10-year cardiovascular risk <20%. Only 0.2–4.8% are in the high-risk categories (≥30%). Adopting a total risk approach and WHO guidelines recommendations would restrict unnecessary drug treatment and reduce the drug costs significantly. Conclusion: Adopting a total cardiovascular risk approach instead of a single risk factor approach reduces health care expenditure by reducing drug costs. Therefore, limited resources can be more efficiently used to target high-risk people who will benefit the most. This strategy needs to be complemented with population-wide measures to shift the cardiovascular risk distribution of the whole population. [Copyright &y& Elsevier]

Abstract: The Framingham Heart Study has been a trailblazer in the field of cardiovascular epidemiology. The wealth of novel scientific data that it has generated over 5 decades has made a significant contribution to cardiovascular disease (CVD) prevention in the United States and indirectly influenced global CVD prevention strategies. The Framingham Study has provided insights into the prevalence, incidence, prognosis, predisposing factors, and determinants of CVD. The now well-established risk factor concept, fundamental to prevention of CVD, originated from the Framingham study. It generated seminal findings such as the effects of tobacco use, unhealthy diet, physical inactivity, obesity, raised blood cholesterol, raised blood pressure, and diabetes on CVD. When these findings were first published, these were novel cardiovascular risk factors, now they are the major focus for global and national prevention efforts for reducing the burden of CVD and other major noncommunicable diseases. The Framingham Heart Study has also been in the forefront of the development of cardiovascular risk prediction equations for assessment of absolute risk. Further developments in this area including the development of World Health Organization/International Society of Hypertension risk prediction charts have resulted in a paradigm shift in CVD prevention strategies, from a single risk factor focus to a more cost-effective total cardiovascular risk approach, an approach recommended by the World Health Organization for CVD prevention worldwide. [Copyright &y& Elsevier]

Summary: Background: Recent improvements in the monitoring and modelling of stroke have led to more reliable estimates of stroke mortality and burden worldwide. However, little is known about the global distribution of stroke and its relations to the prevalence of cardiovascular disease risk factors and sociodemographic and economic characteristics. Methods: National estimates of stroke mortality and burden (measured in disability-adjusted life years [DALYs]) were calculated from monitoring vital statistics, a systematic review of studies that report disease surveillance, and modelling as part of the WHO Global Burden of Disease programme. Similar methods were used to generate standardised measures of the national prevalence of cardiovascular risk factors. Risk factors other than diabetes and disease burden estimates were age-adjusted and sex-adjusted to the WHO standard population. Findings: There was a ten-fold difference in rates of stroke mortality and DALY loss between the most-affected and the least-affected countries. Rates of stroke mortality and DALY loss were highest in eastern Europe, north Asia, central Africa, and the south Pacific. National per capita income was the strongest predictor of mortality and DALY loss rates (p<0·0001) even after adjustment for cardiovascular risk factors (p<0·0001). Prevalences of cardiovascular risk factors measured at a national level were generally poor predictors of national stroke mortality rates and burden, although raised mean systolic blood pressure (p=0·028) and low body-mass index (p=0·017) predicted stroke mortality, and greater prevalence of smoking predicted both stroke mortality (p=0·041) and DALY-loss rates (p=0·034). Interpretation: Rates of stroke mortality and burden vary greatly among countries, but low-income countries are the most affected. Current measures of the prevalence of cardiovascular risk factors at the population level poorly predict overall stroke mortality and burden and do not explain the greater burden in low-income countries. Funding: WHO. [Copyright &y& Elsevier]

Noncommunicable diseases (NCDs) are the most common causes of premature death and morbidity and have a major impact on health-care costs, productivity, and growth. Cardiovascular disease, cancer, diabetes, and chronic respiratory disease have been prioritized in the Global NCD Action Plan endorsed by the World Health Assembly, because they share behavioral risk factors amenable to public-health action and represent a major portion of the global NCD burden. Chronic kidney disease (CKD) is a key determinant of the poor health outcomes of major NCDs. CKD is associated with an eight- to tenfold increase in cardiovascular mortality and is a risk multiplier in patients with diabetes and hypertension. Milder CKD (often due to diabetes and hypertension) affects 5-7% of the world population and is more common in developing countries and disadvantaged and minority populations. Early detection and treatment of CKD using readily available, inexpensive therapies can slow or prevent progression to end-stage renal disease (ESRD). Interventions targeting CKD, particularly to reduce urine protein excretion, are efficacious, cost-effective methods of improving cardiovascular and renal outcomes, especially when applied to high-risk groups. Integration of these approaches within NCD programs could minimize the need for renal replacement therapy. Early detection and treatment of CKD can be implemented at minimal cost and will reduce the burden of ESRD, improve outcomes of diabetes and cardiovascular disease (including hypertension), and substantially reduce morbidity and mortality from NCDs. Prevention of CKD should be considered in planning and implementation of national NCD policy in the developed and developing world. [ABSTRACT FROM AUTHOR]

A response by the author to a letter to the editor about his article, published in previous issues, which discusses regarding the burden of Chronic Kidney Disease (CKD) is presented.

Despite numerous groundbreaking advances in the field, cardiovascular disease remains the leading cause of mortality in the United States, accounting for more than 787,000 deaths per year. Already leading the world in per capita healthcare expenditure, U.S. medical costs related to cardiovascular disease are projected to triple by 2030, to over $800 billion annually. The medical community’s traditional disproportionate focus on treating cardiovascular disease, relative to promoting cardiovascular health, is an important contributor to these expenses. To ensure continued reductions in the burden of cardiovascular disease, as well as the overall sustainability of the healthcare system, a paradigm shift that places more emphasis on cardiovascular health promotion throughout the life course is required. This review will discuss the current definitions of cardiovascular health, as well as strategies for promoting and impacting cardiovascular health at both the local and national level. [ABSTRACT FROM AUTHOR]