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CHAPTER
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G G G G Global Cardiovascular Health
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Kawkab Shishani / Erika S. Sivarajan Froelicher
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Al Alll ri ksk factors weere significannt predictors of acute myocarddial in- -
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INTRODUCTION TO fa farction (p .01). 12
GLOBAL HEALTH
CONTROLLING THE
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In In recentt years, medicine worldwide has witnessed an “epidemio-
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logic transition.” Morbidity and mortality from chronic diseases CVD EPIDEMIC
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have gradually eclipsed infectious diseases. The World Health
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Organization (WHO) has reported that chronic diseases have According to the WHO, the key modifiable lifestyle or behav-
now reached epidemic proportions. Of the 58 million deaths from ioral risk factors for CVD worldwide are smoking cessation, reg-
all causes worldwide in 2005, cardiovascular disease (CVD) ular physical activity, and diet. A systematic review of the causes
caused approximately 17.5 million deaths (Fig. 43-1), which is of mortality from CVD revealed that four factors improved prog-
three times more than those caused by infectious diseases, includ- nosis and three of them were associated with lifestyle changes:
2
ing HIV/AIDS, malaria, and tuberculosis combined. Although smoking cessation, physical activity, and dietary modification. 13
CVD is declining in developed countries, it is rising in develop- In developing countries, prevention and control measures to de-
3
ing countries. Furthermore, 80% of deaths caused by CVD oc- crease exposure to these risk factors are relatively less advanced. 14
2
cur in developing countries. The experience of developed coun- Primary and secondary prevention involving medications are not
tries in preventing CVD could slow the rapid increase in addressed in this chapter because nurses in many parts of the
lifestyle-related risks in developing countries. 4–8 world do not have prescriptive authority. The patient education
Besides the morbidity and premature mortality caused by and compliance component of medication monitoring (see
CVD, the impaired quality of life caused by the functional and Chapter 40) are contained in the chapters for hypertension (see
psychological consequences of this chronic disease poses eco- Chapter 35) and lipids (see Chapter 36). Risk reduction decreases
3
nomic and social threats to society. Thus, the impact of CVD is morbidity in patients with CVD. Thus, the guidelines of Ameri-
greatest in developing countries, where financial resources are lim- can Heart Association (AHA) for primary prevention recommend
ited and professionals with expertise in CVD prevention, treat- that risk factor assessment of diet, smoking, and physical activity
4
ment of risk factors, and rehabilitation are few. But the significant in adults should begin at age 20 years. The European Society of
burden of CVD morbidity and mortality can be prevented. 9 Cardiology (ESC) promulgated similar guidelines based on Euro-
Health care professionals in developing countries should learn pean Action to reduce morbidity and mortality in those individu-
from the risk prediction and preventive intervention standards, als at high risk and to safeguard the health of those at low risk by
5
protocols, and procedures that WHO has implemented in Eu- advocating their adoption of healthy lifestyles. Although more
rope 10 and in the Americas. 11 Furthermore, the countries that women than men die from CVD, women are less frequently as-
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participated in the Catalonia Declaration and the Victoria Dec- sessed for risk. Thus, the AHA and ESC emphasize risk assess-
7
laration have established networks of health care experts from de- ment in women with particular attention to smoking, obesity, and
veloped countries to help them develop comprehensive health the use of oral contraceptives. 5,15
policies and to ensure efficient and cost-effective public health
services. The Catalonia and Victoria Declarations also emphasized Smoking Cessation Interventions
the influential role of women in reducing CVD risk factors.
The etiology of CVD is multifactorial. Knowledge of the risk Developing countries have the largest proportion of smokers in
factors is derived mainly from the developed countries. To validate the world and rates of smoking in these countries are rising (Fig.
these findings on a global basis, the INTERHEART study, a case- 43-2). In contrast, the rates of smoking in developed countries
16
control study, compared risk factors for acute myocardial infarc- have been declining dramatically. This decline can be attributed
tion in 52 countries. In 15,152 cases and 14,820 controls, modi- to aggressive public policies that have imposed higher taxes on cig-
fiable behavioral risk factors such as smoking, regular physical arettes, increasing their cost, and laws restricting smoking in pub-
activity, dietary patterns, obesity (waist/hip ratio), alcohol con- lic places. The combination of higher costs, inconvenience, and
sumption, and blood apolipoprotein subfractions of cholesterol restrictions on the advertising and sale of cigarettes to minors has
were examined. Odds ratios (OR) were estimated for the risk fac- drastically reduced smoking rates in many areas of the world. The
tors of myocardial infarction: smoking: OR 2.87, population first international convention treaty to address health dealt with
3
attributable risk (PAR) 35.7%; regular physical activity: OR tobacco use. It is not surprising then that the burden of disease
0.86, PAR 12.2%; daily consumption of fruits and vegetables: associated with smoking is higher in developing countries than in
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OR 0.70, PAR 13.7%; and abdominal obesity: OR 1.12,
OR 0 7 0 P AR 13 7% d b d i l b i O R 11 2 developed countries. One study of several countries in the Eastern
for top versus lowest tertile and OR 1.62 for middle versus Mediterranean Region that examined the prevalence of complica-
lowest tertile, PAR 20.1% for top two tertiles versus lowest tertile. tions in patients with hypertension showed that complication
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