Growing Epidemic of Coronary Heart Disease in Low- and Middle-Income Countries

doi:10.1016/j.cpcardiol.2009.10.002

Current Problems in Cardiology

Volume 35, Issue 2, February 2010, Pages 72-115

https://doi.org/10.1016/j.cpcardiol.2009.10.002 Get rights and content

Abstract

Coronary heart disease (CHD) is the single largest cause of death in the developed countries and is one of the leading causes of disease burden in developing countries. In 2001, there were 7.3 million deaths due to CHD worldwide. Three-fourths of global deaths due to CHD occurred in the low- and middle-income countries. The rapid rise in CHD burden in most of the low- and middle-income countries is due to socio-economic changes, increase in lifespan, and acquisition of lifestyle-related risk factors. The CHD death rate, however, varies dramatically across the developing countries. The varying incidence, prevalence, and mortality rates reflect the different levels of risk factors, other competing causes of death, availability of resources to combat cardiovascular disease, and the stage of epidemiologic transition that each country or region finds itself. The economic burden of CHD is equally large but solutions exist to manage this growing burden.

Section snippets

The Epidemiologic Transition

The overall increase in the global burden and the distinct patterns in the various regions can be explained in part by the epidemiologic transition. The epidemiologic transition has been divided into 4 basic stages3, 4, 5: pestilence and famine, receding pandemics, degenerative and man-made diseases, and delayed degenerative diseases. Movement through these stages has resulted in a dramatic shift in the cause of death from infectious diseases and malnutrition in the first stage to CVD and

Differing Trends

In developed countries, despite the overall increase in CHD burden, the age-adjusted death rates for CHD are declining. This age-adjusted decline is driven largely by preventive interventions that allow people to avert disease, treatments to prevent death during an acute manifestation of disease (particularly stroke or MI), and interventions that prolong survival once CVD is manifest. Thus, the average age of death from CVD continues to climb and as a result affects a larger population in

Regional Patterns

The World Bank places countries in regions based on both geography and income level. Therefore, there are 6 low- and middle-income geographically defined regions; the remaining high-income countries are not geographically distinct. For example, the “Europe and Central Asia” region is made up of low- and middle-income countries from eastern Europe, while the wealthier western European countries are part of the “high-income” region as defined by the World Bank. Figure 1 shows the absolute numbers

Risk Factors

Table 3 displays the population attributable fraction (PAF) of deaths due to CHD for leading risk factors. Elevated levels of blood pressure and cholesterol remain the leading causes of CHD while tobacco, obesity, and physical inactivity remain important contributors. Diabetes is not listed as the GBD project lists it as a disease and not a risk factor. The PAFs sum to more than a 100% as there is interaction in the risk factors. Unique features regarding some CHD risk factors in the developing

Economic Burden

There are at least 3 ways to measure the economic burden associated with CHD and they are somewhat overlapping.⁹¹ The first source of financial burden is defined by the costs incurred in the health care system itself and is reported in “cost-of-illness” studies. In these studies, the cost of CHD includes the costs of hospitalizations for angina and MI as well as heart failure attributable to CHD. In addition, there are the costs of specific procedures related to CHD such as catheterization and

Cost-Effective Solutions

In this section, we review a series of interventions focused both at the individual level for those at with established CHD or at near-term high risk for CHD as well as the general population to reduce the future burden of CHD. This section is not exhaustive but highlights the variety of types of interventions. Much work is still needed to be done in developing countries to determine the best strategies given the limited resources but the interventions reviewed if implemented could go a long

Conclusions

CHD remains a significant and growing problem in most of the developing regions of the world. The increase in prevalence and mortality associated with the large burden of CHD is a reflection of the epidemiologic transition that has accompanied economic and social development. The challenge for developing economies, unlike developed economies, is that this economic and social transformation is occurring much more rapidly in a post industrial world with rapid globalization. Therefore, the changes

Acknowledgment

We acknowledge Gail Robinson for her tremendous support, in editing and in preparing the final document before submission.

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: Dr. Gaziano is supported by a grant from the Fogarty International Center, NIH (Grant Number 2K01TW007141-05).

: The authors have no conflicts of interest to disclose.

View full text

Growing Epidemic of Coronary Heart Disease in Low- and Middle-Income Countries

Abstract

Section snippets

The Epidemiologic Transition

Differing Trends

Regional Patterns

Risk Factors

Economic Burden

Cost-Effective Solutions

Conclusions

Acknowledgment

Lancet

Int J Cardiol

Int J Cardiol

Lancet

J Am Coll Cardiol

Lancet

Am J Cardiol

Lancet

Lancet

Lancet

Am J Clin Nutr

Soc Sci Med

Lancet

The World Health Report 2002: Reducing Risks, Promoting Healthy Life

A Race Against Time: The Challenge of Cardiovascular Disease in Developing Countries

The fourth stage of the epidemiologic transition: the age of delayed degenerative diseases

Milbank Mem Fund Q

The epidemiologic transition: a theory of the epidemiology of population change

Milbank Mem Fund Q

Global burden of cardiovascular diseases. Part I: General considerations, the epidemiologic transition, risk factors, and impact of urbanization

Circulation

Cardiovascular disease in non-Western countries

N Engl J Med

World Development Indicators

Heart disease and stroke statisticsUpdate 2004

The direct and indirect costs of cardiovascular disease in South Africa in 1991

S Afr Med J

Landlocked Developing Countries and Small Island Developing States

World Development Indicators

World Health Report 2003: Shaping the Future

Cardiovascular diseases in China

Biochem Cell Biol

Coronary heart disease in China

Heart

Burden of coronary heart disease in India

Indian Heart J

Sino-MONICA project: a collaborative study on trends and determinants in cardiovascular diseases in China. Part I: Morbidity and mortality monitoring

Circulation

Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: Randomised placebo-controlled trial

Lancet

Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial

Lancet

Oral captopril versus placebo among 13,634 patients with suspected acute myocardial infarction: interim report from the Chinese cardiac study (CCS-1)

Lancet

Long-term mortality in patients with myocardial infarction: impact of early treatment with captopril for 4 weeks

Chin Med J [Engl]

Effect of xuezhikang on cardiovascular events and mortality in elderly patients with a history of myocardial infarction: a subgroup analysis of elderly subjects from the China coronary secondary prevention study

J Am Geriatr Soc

Xuezhikang, an extract of cholestin, reduces cardiovascular events in type 2 diabetes patients with coronary heart disease: subgroup analysis of patients with type 2 diabetes from China coronary secondary prevention study (CCSPS)

J Cardiovasc Pharmacol

Trends in mortality from major diseases in Europe, 1980-1993

Eur J Epidemiol

Dynamics of cardiovascular and all-cause mortality in Western and Eastern Europe between 1970 and 2000

Eur Heart J

Coronary heart disease (CHD) epidemics: not all the same

Heart

Quality of care of patients with acute myocardial infarction in Bulgaria: a cross-sectional study

BMC Health Serv Res

Highlighting the need for better patient care in stable angina: results of the international angina treatment patterns (ATP) survey in 7074 patients

Fam Pract

World Bank Economic Indicators 2007

Economic burden of severe cardiovascular diseases in Brazil: an estimate based on secondary data

Arq Bras Cardiol

Regional Core Health Data Initiative

The costs of cardiovascular disease in Brazil: a brief economic comment

Arq Bras Cardiology

Ischemic heart diseaseHospitalization, length of stay and expenses in Brazil from 1993 to 1997

Arq Bras Cardiology

The decline in mortality from circulatory diseases in Brazil