Jadelson Andrade_ Fausto Pinto_ Donna Arnett (Eds.)-Prevention of Cardiovascular Diseases_ From...

7/26/2019 Jadelson Andrade_ Fausto Pinto_ Donna Arnett (Eds.)-Prevention of Cardiovascular Diseases_ From Current Evidenc

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Jadelson P. Andrade

Fausto J. Pinto

Donna K. Arnett

Editors

From Current Evidence

to Clinical Practice

Prevention of

CardiovascularDiseases


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Prevention of Cardiovascular Diseases


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Jadelson P. Andrade Fausto J. PintoDonna K. Arnett

Editors

Prevention of Cardiovascular

DiseasesFrom Current Evidence to Clinical Practice


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Originally published in PortugueseWith the title Tratado de Preveno Cardiovascular Um Desafio GlobalPublished by Atheneu, 2014

ISBN 978-3-319-22356-8 ISBN 978-3-319-22357-5 (eBook)DOI 10.1007/978-3-319-22357-5

Library of Congress Control Number: 2015945957

Springer Cham Heidelberg New York Dordrecht London Springer International Publishing Switzerland 2015This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part ofthe material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,broadcasting, reproduction on microfilms or in any other physical way, and transmission or informationstorage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodologynow known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in this publicationdoes not imply, even in the absence of a specific statement, that such names are exempt from the relevantprotective laws and regulations and therefore free for general use.The publisher, the authors and the editors are safe to assume that the advice and information in this bookare believed to be true and accurate at the date of publication. Neither the publisher nor the authors or theeditors give a warranty, express or implied, with respect to the material contained herein or for any errors

or omissions that may have been made.

Printed on acid-free paper

Springer International Publishing AG Switzerland is part of Springer Science+Business Media(www.springer.com)

Editors

Jadelson P. Andrade, M.D.Director, Hospital da BahiaSalvador, Bahia, Brazil

Donna K. Arnett, M.S.P.H., Ph.D.Professor and Chair of the Department

of EpidemiologySchool of Public HealthUniversity of Alabama School of MedicineBirmingham, AL, USA

Fausto J. Pinto, M.D., Ph.D.Head of Cardiology DepartmentUniversity Hospital of Santa Maria

Faculty of MedicineUniversity of LisbonLisbon, Portugal
http://www.springer.com/http://www.springer.com/


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Preface by Jadelson P. Andrade

According to data released by the World Health Organization (WHO), 56.9 milliondeaths were reported worldwide in 2008, and of these about 17 million were causedby cardiovascular diseases.

From this alarming reported epidemiological reality, the WHO began to encour-age all countries of the world to embrace the banner of cardiovascular prevention,proposing an alliance between the nations, governments, civil society, and privatesectors to team up in your face.

The WHO proposal has the primary objective to promote working together to

modify these serious epidemiological data and the gloomy future outlook projectedfor the following 30 years.

In line with the WHO global project, the Brazilian Society of Cardiology pro-posed an international partnership with the European Society of Cardiology and theAmerican Heart Association to prepare the book Cardiovascular Prevention AGlobal Challenge. Three editors were invited, Jadelson P. Andrade, DonnaK. Arnett, and Fausto J. Pinto, then president and president-elect of the aforemen-tioned institutions.

The work was developed in 28 chapters addressing different themes of cardio-

vascular prevention with the original version in Portuguese and this edition inEnglish with the title: Prevention of Cardiovascular Diseases: From CurrentEvidence to Clinical Practice. The authors of the chapters were distributed amongBrazilian, European, and American experts, all with relevant scientific contributionson the subject.

The ultimate purpose of the editors, in line with the recent proposal from WHO,is to make available to the international medical community a valuable referencetool for proper addressing the alarming epidemiological index.

Salvador, Brazil Jadelson P. Andrade, MD, FACC, FESC


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Preface by Fausto J. Pinto

Cardiovascular diseases represent the main cause of mortality worldwide, accountingfor 36 % of all deaths in the European Union in 2010 according to the latest avail-able statistics published in the last OECD report. They cover a range of diseasesrelated to the circulatory system, including ischemic heart disease (IHD) and cere-bro-vascular disease, which together comprise 60 % of all cardiovascular deaths,and caused more than one-fifth of all deaths in EU member states.

The occurrence of several risk factors, such as hypertension, diabetes, dyslipid-emia, obesity, smoking, and others, accounts for an increase in the prevalence and

severity of cardiovascular disease. The uprising of some of these risk factors insome regions more than other may explain partially the differences observed amongthe different regions in the globe and even within the same continent. There areunderlying risk factors, such as diet, which may explain differences in IHD mortal-ity across countries. For instance, on average across EU member states, IHD mortal-ity rates in 2010 were nearly two times greater for men. The disparity was greatestin Cyprus, France, and Luxembourg, with male rates two-to three times higher, andleast in Malta, Romania, and the Slovak Republic, at 60 % higher.

The success of different strategies in the treatment of cardiovascular disease has

resulted in a decrease in IHD mortality rates in nearly all countries in Europe andthe USA. The decline has been most remarkable in Denmark, Ireland, theNetherlands, and the United Kingdom. Estonia and Norway also saw IHD mortalityrates cut by one-half or more, although rates in Estonia are still high. Decliningtobacco consumption contributed significantly to reducing the incidence of IHD,and consequently to reducing mortality rates.

However, the impact of treatment improvement should not undermine the abso-lute need to improve healthy lifestyles and reduce the weight of the different riskfactors, particularly the ones who can be easily prevented if appropriate steps are

taken (e.g., smoking, overweight-obesity, diabetes, hypertension, dyslipidemia).The relationship of prevention strategies with cardiovascular events and deathrates is clearly established through different scientific studies. Therefore, the effi-cacy of primary prevention programs in patients with recognized, treatable risk fac-tors such as hypercholesterolemia, hypertension, diabetes, and smoking should be a


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priority across the different countries. It is also important to recognize the need of atailored approach considering the differences among different countries, whichreinforces the importance of putting in place surveillance systems in place that maybe able to monitor properly the need and implementation of preventable measures.

This is of crucial importance for a successful fight against inequalities to accessto appropriate health care among the different countries. The role of scientific soci-eties in the dissemination of information as well as in the promotion of differentactivities towards the populations as well as the decision makers can fill in an impor-tant gap in this regard. This Book on Prevention, being a joint enterprise betweenthe Brazilian Society of Cardiology, European Society of Cardiology and AmericanHeart Association, will certainly fit into this common goal of improving Preventionof Cardiovascular Disease worldwide.

Cardiology Department, CCUL, CAML Fausto J. Pinto, MD, PhD, FESCC, FACCUniversity of Lisbon, Lisbon, Portugal [email protected]

Preface by Fausto J. Pinto


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Preface by Donna K. Arnett

For those of us who have devoted our lives to studying and treating cardiovasculardisease (CVD), the idea that CVD prevention is critical is so obvious that furtherexposition on the subject may seem gratuitous. It is decidedly not. The successesthat clinicians and public health practitioners have had in the realm of CVD preven-tion are not only reasons to exult, but also cause for redoubling our efforts withsome assurance that prevention is eminently possible and further progress can bemade. And although some of the more alarming trends observed in some parts of theworld (rising prevalence of obesity, for example) are cause for deep concern, they

are also cause for increased and improved preventive action. It is precisely thischanging landscape of CVD and its risk factors that makes continued assessmentand discussion of CVD-prevention strategies so critically important. Programs inthe USA such as the Centers for Disease Control and Preventions Million HeartsInitiative and the American Heart Associations 2020 Impact Goal (to improve car-diovascular health by 20 % by 2020 while reducing CVD and stroke mortality by20 %) and analogous efforts in other countries are tangible representations of popu-lation evaluation, goal setting, policy making, and program development that driveprogress in this realm. Each of the chapters in this book represents a primer in CVD

and its prevention. With its calculated mix of CVD and risk factor fundamentals andtrenchant foresight, this volume will be welcomed by all those around the globewho aim to rise to the challenge of CVD prevention.

Birmingham, AL, USA Donna K. Arnett, MSPH, PhD


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Contents

Global Burden of Non-Communicable, Chronic Diseases.......................... 1Mark D. Huffman and Sidney C. Smith Jr.

Cardiovascular Disease Worldwide: A Global Challenge........................... 13Jadelson P. Andrade, Marianna D. Andrade, and Luiz Alberto Mattos

Value of Primordial and Primary Prevention for Cardiovascular

Diseases: A Global Perspective...................................................................... 21Armin Barekatain, Sandra Weiss, and William S. Weintraub

How to Estimate Cardiovascular Risk.......................................................... 29Protsio L. da Luz and Renata Caruso Fialdini

Tobacco and Alcohol Control: Preventable Risk Factors........................... 41Aloyzio Chechella Achutti

Physical Inactivity: Preventable Risk Factor

of Cardiovascular Disease.............................................................................. 49Evangelista Rocha

Diet and Cardiovascular Health: Global Challengesand Opportunities........................................................................................... 59Cheryl A.M. Anderson and Amanda R. Ratigan

Raised Blood Cholesterol: Preventable Risk Factor

for Cardiovascular Disease............................................................................. 69Lale Tokgozoglu

Hypertension: Primary Health Care Approach........................................... 81Evgeny Shlyakhto

Diabetes: A Primary Health Care Approach............................................... 91Meltem Zeytinoglu and Elbert S. Huang

Risk Factors in Childhood and Youth........................................................... 101Joep Perk


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Other Determinants of Cardiovascular Diseases:

Social, Globalization, and Urbanization....................................................... 109Dalton Bertolim Prcoma, Jorge Ilha Guimares,and Antonio Felipe Simo

Genetics of Cardiovascular Disease............................................................... 117Steven A. Claas, Stella Aslibekyan, and Donna K. Arnett

Cardiovascular Disease in Women: An Update........................................... 129Helen C. Huang, Puja K. Mehta, and C. Noel Bairey Merz

Rheumatic Heart Disease: A Neglected Heart Disease................................ 143Marcia de Melo Barbosa, Maria do Carmo Pereira Nunes,and Regina Mller

Chagas Disease: A Neglected Disease............................................................ 159Jos Antonio Marin-Neto, Anis Rassi Jr., Andra Silvestre de Sousa,Joo Carlos Pinto Dias, and Anis Rassi

Prevention and Control of Cardiovascular Diseases:

Policies, Strategies, and Interventions........................................................... 183lvaro Avezum Jr. and Gabriel Pelegrineti Targueta

Prevention and Control of Cardiovascular Diseases

Focusing on Low- and Middle-Income Countries........................................ 195

Gilson S. FeitosaPrevention and Control of Cardiovascular Diseases: What Works?......... 207Dan Gaita and Laurence Sperling

Prevention and Control of Cardiovascular Diseases:

Integrated and Complimentary Strategies................................................... 219Roberto Ferrari, Lina Marcantoni, and Gabriele Guardigli

Posttraumatic Stress Disorder and Cardiovascular Disease....................... 227Donald Edmondson, David Hiti, and Ian Kronish

Individual Interventions for Prevention and Control of CVDs.................. 237Pantaleo Giannuzzi

Social Mobilization for Cardiovascular Disease

Prevention and Control.................................................................................. 245Carlos Alberto Machado

Frugal Innovation: Solutions for Sustainable Global

Cardiovascular Health.................................................................................... 251

Donna K. Arnett and Steven A. ClaasAtrial Fibrillation and Stroke Prevention..................................................... 261Antonio Carlos Camargo de Carvalho, Renato D. Lopes,and Angelo A.V. de Paola

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A Global Alliance for Cardiovascular Disease Prevention

in Clinical Practice.......................................................................................... 277David A. Wood

Priority Areas for CVD Research.................................................................. 289Stephan Gielen

Evidence for Preventing Cardiovascular Disease........................................ 301Ian M. Graham and Marie-Therese Cooney

Contents


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Advisory Board

Angelo Amato Vincenzo de Paola Full professor and chief of the discipline ofCardiology; chief of the Arrhythmia and Electrophysiology Sector FederalUniversity of So Paulo (UNIFESP), Brazil. President of the Brazilian Society ofCardiology (20142015)

Antonio Carlos de Carvalho Full professor of Cardiology Federal University ofSo Paulo (UNIFESP)

Luiz Alberto Piva e Mattos Coordenator of hemodynamics and Cardiovascular

Intervention Rede DOr Hospitals, Brazil. Professor of the Port-Graduate Programin Tecnology and Intevention in Cardiology Dante Pazzanese Cardiology Institute,So Paulo, Brazil

Marcia de Melo Barbosa Director of Ecocenter, Hospital Socor Belo Horizonte,Brazil. President of the Interamerican Society of Cardiology. PhD in Cardiology bythe University of So Paulo (USP), Brazil


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Contributors

Aloyzio Chechella Achutti, M.D., Ph.D. School of Medicine, Federal Universityfrom Rio Grande do Sul, Porto Alegre, Brazil

Department of Social Medicine, School of Medicine, Federal University from RioGrande do Sul, Porto Alegre, Brazil

Cheryl A. M Anderson, M.P.H., Ph.D. University of California San Diego SchoolMedicine, La Jolla, CA, USA

Marianna D. Andrade, M.D., Ph.D. Intensive Care Unit from the Hospital daBahia, Salvador, Brazil

Research and Educational Institute from the Hospital da Bahia, Salvador, Brazil

Stella Aslibekyan, Ph.D. Department of Epidemiology, University of Alabama atBirmingham, Birmingham, AL, USA

Alvaro Avezum Jr., M.D., Ph.D. Instituto Dante Pazzanese of Cardiology, SaoPaulo, Brazil

University of Sao Paulo, Sao Paulo, Brazil

Population Health Research Institute, Mc Master University, Hamilton, ON, Canada

Armin Barekatain, M.D. Internal Medicine, Houston, TX, USA

Steven A. Claas, M.S. Department of Epidemiology, School of Public Health,University of Alabama at Birmingham, Birmingham, AL, USA

Marie-Therese Cooney, MB, BCH, NUI, MRCPI, PhD. Department of Age-Related Health Care, St Vincents Hospital, Dublin, Ireland

Protazio L. da Luz, M.D., Ph.D. CardiologyHeart Institute from the School ofMedicine, University of Sao Paulo, Sao Paulo, Brazil

Antonio Carlos Camargo de Carvalho, M.D., Ph.D. Paulista School of Medicine,Federal University of Sao Paulo, Sao Paulo, Brazil


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Marcia de Melo Barbosa, M.D., Ph.D. ECO Center, Hospital Socor, BeloHorizonte, Brazil

Interamerican Society of Cardiology

Angelo A. V. de Paola, M.D., Ph.D. Paulista School of Medicine, FederalUniversity of So Paulo, So Paulo, Brazil

Arrhythmia Department of the Paulista School of Medicine, Federal University ofSo Paulo, So Paulo, Brazil

Brazilian Society of Cardiology, Rio de Janeiro, Brazil

Andra Silvestre de Sousa, M.D., Ph.D. Federal University of Rio de Janeiro,Rio de Janeiro, Brazil

Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

Joo Carlos Pinto Dias, M.D., Ph.D. School of Medicine, Federal University ofMinas Gerais, Belo Horizonte, Brazil

Neglected Diseases Committee of the World Health Organization, Geneva,Switzerland

Maria do Carmo Pereira Nunes, M.D. School of Medicine, Federal University ofMinas Gerais, Belo Horizonte, Brazil

Donald Edmondson, M.P.H., Ph.D. Center for Behavioral Cardiovascular Health,Columbia University Medical Center, New York, NY, USA

Gilson S. Feitosa, M.D., Ph.D. Bahia School of Medicine and Public Health,Salvador, Brazil

Hospital Santa Isabel/Santa Casa da Bahia, Salvador, Brazil


Roberto Ferrari, M.D. Department of Cardiology, LTTA Centre, University

Hospital of Ferrara and Maria Cecilia Hospital, GVM Care et Research, E. S. HealthScience Foundation, Cotignola, Italy

Renata Caruso Fialdini, M.D. University of Sao Paulo, Sao Paulo, Brazil

Dan Gaita, M.D. Cardiology inn Romanian, Bucharest, RomaniaRomanian HeartFoundation, Bucharest, Romania

Pantaleo Giannuzzi, M.D. Cardiac Rehabilitation Department, Salvatori MaugeriFoundationIRCCS, Scientific Institute of Veruno, Veruno, Italy

Stephan Gielen, M.D. University Hospital, Martin-Luther-University of Halle/Wittenberg, Halle, Germany

Department of Internal Medicine III, University Hospital, Martin-LutherUniversity of Halle/Wittenberg, Halle, Germany

Contributors


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Ian M. Graham, M.D. Cardiovascular Medicine, Trinity College Dublin, Dublin,Ireland

Cardiology Emeritus, Royal College of Surgeons in Ireland, Dublin, Ireland

Gabriele Guardigli, M.D. Department of Cardiology, University Hospital ofFerrara, Ferrara, Italy

Jorge Ilha Guimares, M.D. Brazilian Society of Cardiology, Rio de Janeiro,Brazil

David Hiti, M.D. Columbia University, New York, NY, USA

Elbert S. Huang, M.P.H., Ph.D. Medicine University of Chicago, Chicago, IL,USA

Helen C. Huang, M.D. Barbra Streisand Womens Heart Center, Cedars-SinaiHeart Institute, Los Angeles, CA, USA

Mark D. Huffman, M.P.H., M.D. Department of Preventive Medicine, Feinbergof Northwestern University, Chicago, IL, USA

Ian Kronish, M.P.H., M.D. Mount Sinai School of Medicine, New York, NY,USA

Renato D. Lopes, M.D., Ph.D. Division of Cardiology, Duke University Medical

Center, Durham, NC, USAPaulista School of Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil

Brazilian Institute of Clinical Research, Sao Paulo, Brazil

Carlos Alberto Machado, M.D. Cardiovascular Health Promotion from theBrazilian Society of Cardiology, Rio de Janeiro, Brazil

Jos Antonio Marin-Neto, M.D., Ph.D. Cardiology and Pneumology from theUniversity of Sao Paulo, Sao Paulo, Brazil

Interventional Cardiology from the Hospital das Clinicas, Ribeirao Preto MedicalSchool, Sao Paulo, Brazil

Luiz Alberto Mattos, M.D., Ph.D. Interventional Cardiology from Rede DorHospitals, Sao Paulo, Rio de Janeiro and Recife, Sao Paulo, Brazil


Puja K. Mehta, M.D. Cedars-Sinai Medical Center, Los Angeles, CA,USAWomens Heart Center in the Division of Cardiology in the Cedars-Sinai HeartInstitute, Los Angeles, CA, USA

Lina Mercantoni, M.D. Department of Cardiology, University of Ferrara,Ferrara, Italy

Contributors


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C. Noel Bairey Merz, M.D. Barbara Streisand Womens Heart Center, Preventiveand Rehabilitative Cardiac Center, Womens Guild Chair in Womens Health,Los Angeles, CA, USA

Regina Mller, M.D., Ph.D. Working Group on Rheumatic Fever from the WorldHeart Federation, Geneva, Switzerland

National Heart Institute of Rio de Janeiro, Rio de Janeiro, Brazil

Joep Perk, M.D., Ph.D. Linnaeus University, Kalmar, Sweden

Dalton Bertolim Prcoma, M.D., Ph.D. Catholic University of Parana, Curitiba,Brazil


Anis Rassi, M.D., Ph.D. Faculty of Medicine, Federal University of Goias,Goiania, Goias, Brazil

Anis Rassi Jr. M.D., Ph.D. Anis Rassi Hospital, Goiania, Goias, Brazil

Amanda R. Ratigan, M.S. Joint Doctoral Program in Public Health Epidemiology,University of California San Diego State University, San Diego, CA, USA

Department of Defense HIV/AIDS Prevention Program, Naval Research Center,San Diego, CA, USA

Master of Public Health, Epidemiology, San Diego State University, San Diego,CA, USA

Evangelista Rocha, M.D., Ph.D. Faculty of Medicine, Institute of PreventiveMedicine and Public Health, University of Lisbon, Lisbon, Portugal

Evgeny Shlyakhto, M.D., Ph.D. Federal Almazov Medical Research Center,Saint-Petersburg, Russia

Russian Society of Cardiology, Moscow, Russia

Antonio Felipe Simo, M.D. Institute of Cardiology from Santa Catarina,Florianpolis, Brazil


Sidney C. SmithJr. M.D. Department of Medicine, University of North Carolinaat Chapel Hill School of Medicine, Chapel Hill, USA

Laurence Sperling, M.D. Emory University School of Medicine, Atlanta,GA, USA

Gabriel Pelegrineti Targueta, M.D. Instituto Dante Pazzanese of Cardiology,Federal University of Sao Paulo, Sao Paulo, Brazil

Lale Tokgzoglu, M.D. Hacettepe University in Ankara, Ankara, Turkey

Contributors


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William S. Weintraub, M.D. Center for Outcomes Research, One of FourResearch Centers Comprising the Value Institute at Christiana Care Health Center,Newark, DE, USA

Sandra Weiss, M.D. Christiana Care Center for Heart et Vascular Health from theUniversity of Chicago Medical Center, Newark, DE, USA

David A. Wood, M.D., Ph.D. Foundation Garfield Weston of CardiovascularMedicine, International Centre for Circulatory Health, National Heart and Lung,Imperial College London, London, UK

Meltem Zeytinoglu, M.D. Endocrinology and Metabolism, Chicago, IL, USA

Contributors


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1 Springer International Publishing Switzerland 2015

J.P. Andrade et al. (eds.), Prevention of Cardiovascular Diseases,

DOI 10.1007/978-3-319-22357-5_1

Global Burden of Non-Communicable,

Chronic Diseases

Mark D. Huffman and Sidney C. Smith Jr.

Measuring Burden of Disease

Reliable, contemporary data about the distribution, determinants, and trends in

global morbidity and mortality are fundamental to understanding and improving

global health. The estimation of the worlds disease burden in the modern era

was heralded by the publication of the Global Burden of Disease report in 1990 [1].

The World Bank initially commissioned the report in collaboration with researchers

at the Harvard School of Public Health. The Institute for Health Metrics and

Evaluation at the University of Washington (Seattle, USA) and Imperial College

London (London, UK) serve as the current host centers for the Global Burden of

Disease and Metabolic Risk Factors, respectively. The Global Burden of Disease

underwent periodic updates until the release of its 2010 report in a 2012 Lancet

series, which represented its most comprehensive overhaul since its inception [2].

The next generation of the Global Burden of Disease aims to provide annual updates,

starting with 2013 data that will be published in 2014.

The study of disease burden initially led to fundamental questions about how

best to measure burden. Counting numbers of deaths, such as in wartime or epidemics,

or describing death rates have been common methods that are relatively straightfor-ward to interpret. Researchers within the Global Burden of Disease project

have measured the cumulative effect of premature deaths through the Years of Life

M.D. Huffman, MD, MPH (*)

Department of Preventive Medicine, Northwestern University Feinberg School of Medicine,

680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA

e-mail: [email protected]

S.C. Smith, Jr., MD

Department of Medicine, University of North Carolina at Chapel Hill School of Medicine,

CB# 7075, 6031 Burnett Womack, 160 Dental Circle, Chapel Hill, NC 27599-7075, USA

mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Lost(YLL) metric, which measures differences from the same potential life length

across populations to estimate burden, usually taken as the global mean life expec-

tancy [3]. However, these measures do not account for the age- and sex-characteris-

tics of different countries. Therefore, age-adjustment or -standardization to a global

population have been basic strategies to account for a populations age structure to

improve comparability across populations. Data are usually stratified by sex to

account for differences in the proportion of men and women among different

countries.

However, these approaches do not account for any measure of health during the

lifecourse. To overcome this limitation, the Global Burden of Disease team devel-

oped theDisability Adjusted Life Year(DALY) metric, which is equal to the sum of

Years of Life Lost(YLL) and Years Lived with Disability(YLD), or:

Disability Adjusted LifeYear Years of Life Lost Years Lived with D= + iisability

The DALY metric was founded on the principles that: (1) everyone in the world has

right to best life expectancy, and (2) differences in the rating of a death or disability

should be due to age and sex and not to income, culture, location, social class.

It is also important to understand how Years Lived with Disability (YLD) is

defined, by whom, and at what time in the disease course [4]. First, disability repre-

sents an objective alteration of behavior or performance at the individual level.

Disability falls between impairment, which is defined by symptoms at an organ

level, and handicap, which is defined by changed interactions with others at thesocial or environmental level due to disability. To illustrate, if an individual suffers

from a stroke, s/he might have symptoms of unilateral arm and leg weakness

(impairment), which limits her/his ability to walk independently (disability) and

her/his ability to work in a job that requires walking (handicap). Second, researchers

have typically surveyed medical professionals and public health experts to rank

symptom states to quantitatively estimate YLD for myriad disease states. Other

individuals, including but not limited to patients, families, caregivers, general pub-

lic, insurance companies, and legal experts, might offer complementary perspec-

tives on how YLDs should be estimated yet have not been incorporated in theseestimates to date. Third, YLD estimates can be sensitive to the time course of the

disease, particularly for non-communicable, chronic diseases, which can have long

periods of minimal to no symptoms followed by acute shocks and gradual recovery

to or near baseline. In the stroke example, the immediate post-stroke disability can

be substantially different than 3, 6, or 12 months later and can be dependent upon

access to rehabilitation and medical therapy. As such, YLD estimates may be sus-

ceptible to reporting bias by experts based on their previous clinical or health

experiences.

Newer estimates of disease burden incorporate costs and financial risk throughmeasures such as catastrophic health spending (based on the proportion of health

spending relative to non-food expenditures) and distress financing (based on risky

financial activities to pay for health, including borrowing money or selling assets)

[5]. These complementary measures of financial protection, or lack thereof, are

M.D. Huffman and S.C. Smith Jr.


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associated with individuals and families falling into poverty. Because health systems

are evaluated in terms of quality, access, and financial protection [6], these measures

of disease burden will likely gain more attention.

Using the International Classification of Diseases framework, the Global

Burden of Disease project employed systematic searched published and unpub-

lished data on causes of death through a variety of sources, including the World

Health Organization mortality database, national vital registration systems, verbal

autopsy-based sample registration systems, demographic surveillance systems,

cancer registers, crime reports, mortuary data, among others [3]. In the case of so-

called garbage codes that have been deemed implausible causes of death, avail-

able data were used to reclassify the causes of death [1]. The project team then

incorporated these best available data into advanced, multi-level statistical models

and imputation methods to estimate the causes of death among all countries from

1980 through 2010.The Global Burden of Disease project is not without its critics who express con-

cern about the complex analytic methods and frequent use of imputation to estimate

data for countries that do not have accurate, updated mortality data. Some fear that

the Global Burden of Disease, which is largely funded by the Bill & Melinda Gates

Foundation, a private non-governmental organization, may lead to reduced public

investments in vital registration systems, a basic public health function that cur-

rently covers less than half of the worlds population [7]. Nevertheless, the Global

Burden of Disease project represents the most comprehensive and accessible sum-

mary of contemporary global disease burden, including providing estimates fornon-communicable, chronic diseases.

Global Burden of Non-Communicable, Chronic Diseases

Based on data from the Global Burden of Disease project, non-communicable,

chronic diseases (NCDs) accounted for 34.5 million (65.5 % of total) deaths glob-

ally in 2010, compared with 13.2 million (24.9 % of total) deaths due to maternal,neonatal, and nutritional diseases, and 5.1 (9.6 % of total) deaths due to injuries

during the same year (Table 1) [3]. While there was an increase of approximately 8

million deaths due to NCDs (30 % relative increase) since 1990, there was also a

32 % decrease in the age- and sex-specific death rate from NCDs over the same time

period from 645.9 (95 % uncertainty interval: 629.9, 662.9) per 100,000 in 1990 to

520.4 (95 % UI: 499.5, 532.0) per 100,000 in 2010 (19 % decrease). Population

aging contributed substantially (39 %) to the increases in NCD deaths since 1990,

which primarily explains this difference between increasing numbers of deaths and

declining rates [3].Similarly, the number of disability adjusted life years (DALYs) for all NCDs

increased from 1075 million (95 % UI: 1000, 1160) DALYs in 1990 compared with

1343 million (95 % UI: 1240, 1457) in 2010, which represents a 25 % increase,

while the rate of DALYs per 100,000 decreased by 3.8 % from 20,283 (95 % UI:



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18,893, 21,874) per 100,000 in 1990 to 19,502 (95 % UI: 17,997, 21,143) per100,000 in 2010.

The death and disability burdens of specific NCDs are outlined below with

supporting data presented in Tables 2and 3.

Table 1 All-cause and non-communicable, chronic disease (NCD)-specific deaths and death rates

in 1990 and 2010 estimated by the Global Burden of Disease Study [3]

All causes NCDs

1990 deaths 46,511,000 26,560,000

Deaths expected with 1990 population, 2010 population age structure,

1990 death rates

61,307,000 32,647,000

Deaths expected with 2010 population, 2010 population age structure,

1990 death rates

70,316,000 43,062,000

2010 deaths 52,770,000 34,540,000

Percentage change from 1990 due to population growth 31.8 % 22.9 %

Percentage change from 1990 due to population aging 19.4 % 39.2 %

Percentage change from 1990 due to change in death rates 37.7 % 32.1 %

Percentage change from 1990 to 2010 13.5 % 30.0 %

Table 2 Global Burden of Disease 2010 estimates of deaths and age-standardized death rates per

100,000 in 1990 and 2010 across non-communicable, chronic diseases

All ages deaths (thousands)

Age-standardized death rates

per 100,000

1990 2010 % change 1990 2010 % change

All non-

communicable,

chronic diseases

26,560.3

(25,843.4,

27,249.3)

34,539.9

(33,164.7,

35,313.0)

30.0 645.9

(629.9,

662.9)

520.4

(499.5,

532.0)

19.4

Cardiovascular and

circulatory diseases

11,903.7

(11,329.4,

12,589.3)

15,616.1

(14,542.2,

16,315.1)

31.2 298.1

(283.9,

314.9)

234.8

(218.7,

245.2)

21.2

Neoplasms 5779.1

(5415.9,

6201.9)

7977.9

(7337.1,

8403.8)

38.0 140.8

(131.9,

151.4)

121.4

(111.6,

127.9)

13.8

Chronic lung

diseases

3986.3

(3914.3,

4063.8)

3776.3

(3648.2,

3934.1)

5.3 98.2

(96.4,

100.1)

57.0

(55.1,

59.4)

41.9

Diabetes 1544.3

(1420.0,1804.0)

2726.2

(2447.1,2999.1)

76.5 36.1

(33.4,41.6)

41.0

(36.8,45.1)

13.8

Mental and

behavioral disorders

138.1 (95.2,

188.0)

231.9 (176.3,

329.1)

68.0 3.2 (2.2,

4.3)

3.5 (2.6,

4.9)

9.3

Musculoskeletal

disorders

69.5 (46.2,

89.6)

153.5 (110.7,

214.8)

121.0 1.7 (1.1,

2.2)

2.3 (1.7,

3.2)

37.8

Data abstracted from Lozano et al. [3]



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Cardiovascular Diseases

Global cardiovascular disease deaths increased from 11.9 million (95 % UI: 11.2,

12.6) in 1990 to 15.6 million (95 % UI: 14.5, 16.3) in 2010, which represents a 31 %increase. Age- and sex-adjusted rates of cardiovascular disease deaths decreased

from 298.1 (95 % UI: 283.9, 314.9) per 100,000 in 1990 to 234.8 (95 % UI: 218.7,

245.2) per 100,000 in 2010, which represents a 21 % decrease [ 3]. Ischemic heart

disease was the leading cause of cardiovascular deaths during both time periods.

The number of deaths increased from 5.2 million (95 % UI: 5.0, 5.6) ischemic heart

disease deaths in 1990 to 7.0 million (95 % UI: 6.6, 7.4), which represents a 35 %

increase. Age- and sex-adjusted death rates due to ischemic heart disease decreased

from 131.3 (95 % UI: 126.4, 142.2) per 100,000 to 105.7 (95 % UI: 98.8, 111.9) per

100,000 in 2010, which represents a 20 % decrease.The number of disability adjusted life years (DALYs) due to cardiovascular

diseases increased from 240,667 (95 % UI: 227,084, 257,718) DALYs in 1990 com-

pared with 295,036 (95 % UI: 273,061, 309,562) in 2010, which represents a 23 %

Table 3 Global Burden of Disease 2010 estimates of disability adjusted life years and disability

adjusted life years lost per 100,000 in 1990 and 2010 across non-communicable, chronic diseases

All disability adjusted life years

(thousands)

Disability adjusted life years per

100,000

1990 2010 % change 1990 2010 % change

All non-

communicable,

chronic diseases

1,075,297

(1,001,607,

1,159,673)

1,343,973

(1,239,973,

1,456,773)

25.0 20,283

(18,893,

21,874)

19,502

(17,997,

21,143)

3.8

Cardiovascular

and circulatory

diseases

240,667

(227,084,

257,718)

295,036

(273,061,

309,562)

22.6 4540

(4283,

4861)

4282

(3963,

4493)

5.7

Neoplasms 148,078

(136,775,

158,256)

188,487

(174,452,

199,037)

27.3 2793

(2580,

2985)

2736

(2532,

2889)

2.1

Chronic lungdiseases

119,153(107,917,

132,391)

117,945(102,924,

135,608)

1.0 2248(2036,

2497)

1712(1494,

1968)

23.8

Diabetes 85,084

(73,638,

102,489)

122,437

(107,437,

143,387)

43.9 1605

(1389,

1933)

1777

(1559,

2081)

10.7

Mental and

behavioral

disorders

134,598

(112,138,

159,316)

185,190

(154,647,

218,496)

37.6 2539

(2115,

3005)

2668

(2245,

3171)

5.9

Musculoskeletal

disorders

116,554

(88,684,147,285)

169,624

(129,771,212,734)

45.5 2198

(1673,2778)

2462

(1883,3088)

12.0

Data abstracted from Murray et al. [2]



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increase, while the rate of DALYs per 100,000 due to cardiovascular diseases

decreased by 6 % from 4540 (95 % UI: 4283, 4861) per 100,000 in 1990 to 4282

(95 % UI: 3963, 4493) per 100,000 in 2010.

Cancer

Global cancer deaths increased from 5.8 million (95 % UI: 5.4, 6.2) in 1990 to 8.0 mil-

lion (95 % UI: 7.3, 8.4) in 2010, which represents a 38 % increase. Similar to other

cardiovascular diseases, age- and sex-adjusted rates of cancer deaths decreased from

140.8 (95 % UI: 131.0, 151.5) per 100,000 in 1990 to 121.4 (95 % UI: 111.6, 127.9)

per 100,000 in 2010, which represents a 14 % decrease [3]. Cancers of the trachea,

bronchus, and lungs were the leading cause of cancer deaths during both time periods.The number of deaths increased from 1.0 million (95 % UI: 0.8, 1.3) cancers of the

trachea, bronchus, and lung in 1990 to 1.5 million (95 % UI: 1.1, 1.8), which represents

a 47 % increase. Age- and sex-adjusted death rates due to cancers of the trachea,

bronchus, and lung modestly decreased from 25.5 (95 % UI: 20.4. 32.4) per 100,000 to

23.4 (95 % UI: 17.3, 27.3) per 100,000 in 2010, which represents an 8 % decrease.

The number of disability adjusted life years (DALYs) due to cancer increased from

148,078 (95 % UI: 136,775, 158,256) DALYs in 1990 compared with 188,487 (95 %

UI: 174,452, 199,037) in 2010, which represents a 27 % increase, while the rate of

DALYs per 100,000 due to cancer decreased by 2 % from 2793 (95 % UI: 2580, 2985)per 100,000 in 1990 to 2736 (95 % UI: 2532, 2889) per 100,000 in 2010.

Chronic Lung Diseases

Global chronic lung disease deaths decreased from 4.0 million (95 % UI: 3.9, 4.1)

in 1990 to 3.8 million (95 % UI: 3.6, 3.9) in 2010, which represents a 5 % decrease.

Age- and sex-adjusted rates of chronic lung disease deaths increased from 98.2

(95 % UI: 96.4, 100.1) per 100,000 in 1990 to 57.0 (95 % UI: 55.1, 59.4) per100,000 in 2010, which represents a 42 % decrease [3].

The number of disability adjusted life years (DALYs) due to chronic lung diseases

was similar at 119,153 (95 % UI: 107,917, 132,391) DALYs in 1990 compared with

117,945 (95 % UI: 102,924, 135,608) in 2010, while the rate of DALYs per 100,000

due to chronic lung diseases decreased by 24 % from 2248 (95 % UI: 2036, 2497) per

100,000 in 1990 to 1712 (95 % UI: 1494, 1968) per 100,000 in 2010.

Diabetes

Global diabetes deaths increased from 665,000 (95 % UI: 593,300, 757,500) in

1990 to 1.3 million (95 % UI: 1.1, 1.3) in 2010, which represents a 93 % increase.

Unlike cardiovascular diseases, cancer, and chronic lung disease, age- and



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sex-adjusted rates of diabetes deaths increased from 16.3 (95 % UI: 14.5, 18.6)

per 100,000 in 1990 to 19.5 (95 % UI: 16.2, 20.5) per 100,000 in 2010, which

represents a 20 % increase.

The number of disability adjusted life years (DALYs) due to diabetes increased

from 85,084 (95 % UI: 73,638, 102,489) DALYs in 1990 compared with 122,437

(95 % UI: 107,437, 143,387) in 2010, which represents a 44 % increase, while the rate

of DALYs per 100,000 due to diabetes increased by 11 % from 1605 (95 % UI: 1389,

1933) per 100,000 in 1990 to 1777 (95 % UI: 1559, 2081) per 100,000 in 2010.

Mental and Behavioral Disorders

Global mental and behavioral disorder related deaths increased from 138,100 (95 %UI: 95,200, 188,000) in 1990 to 231,900 (95 % UI: 176,300, 329,100) in 2010, which

represents a 68 % increase. Age- and sex-adjusted rates of mental and behavioral

disorder related deaths increased from 3.2 (95 % UI: 2.2, 4.3) per 100,000 in 1990 to

3.5 (95 % UI: 2.6, 4.9) per 100,000 in 2010, which represents a 9 % increase [3].

The number of disability adjusted life years (DALYs) due to mental and behavioral

disorder increased from 138.1 (95 % UI: 95.2, 188.0) DALYs in 1990 compared

with 231.9 (95 % UI: 176.3, 329.1) in 2010, which represents a 68 % increase, while

the rate of DALYs per 100,000 due to mental and behavioral disorder increased

by 9 % from 3.2 (95 % UI: 2.2, 4.3) per 100,000 in 1990 to 3.5 (95 % UI: 2.6, 4.9)per 100,000 in 2010.

Shared Risk Factors for Non-Communicable,

Chronic Diseases

Non-communicable, chronic diseases (NCDs) share causal risk factors, which

suggests that strategies to reduce the burden of these risk factors will have multipli-

cative benefits. Common risk factors can be behavioral (tobacco use, unhealthy diet,

and physical inactivity), physiologic (body mass index, blood pressure, blood cho-

lesterol, and blood glucose), and social (stress, socioeconomic position). While

these risk factors are generally considered modifiable, prevention of abnormal risk

factor development, also known as primordial prevention [8], leads to more favor-

able health outcomes than even treatment of risk factors. Prevalence estimates and

attributable burdens of disease for behavioral risk factors are outlined below.

Tobacco

Smoking prevalence has decreased from 41 % (95 % UI: 40, 43) in 1980 to 31 %

(95 % UI: 30, 32) in 2012 for men >15 years and from 11 % (95 % UI: 10, 11) to

6 % (95 % UI: 6, 6) for women >15 years [9]. However, due to population growth



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and aging as well as the inherent lag time between tobacco exposure and diseases

such as cancer, the number of deaths attributable to tobacco increased from 5.3

million (95 % UI: 4.8, 6.0) in 1990 to 6.3 million (95 % UI: 5.4, 7.0) in 2010 [10].

If recent trends continue, there will be an estimated 1 billion tobacco-related deaths

in the twenty-first century, most of which will occur in low- and middle-income

countries and half of which will occur before age 70 years [11].

Unhealthy Diet

Global increases in body mass index from 1980 to 2010 (0.4 mg/kg 2per decade

(95 % UI: 0.2, 0.6) for men and 0.5 mg/kg2per decade (95 % UI: 0.3, 0.7) for

women) [12] suggest that access to calories has increased. However, global trendsin diet quality are difficult to assess not only because of the inherent complexity in

comparing different dietary patterns across the world but also because of the limita-

tions in instruments for dietary data collection. The Global Burden of Disease proj-

ect evaluates the effects of 14 dietary variables (fruit intake, vegetable, whole grains,

nuts and seeds, milk, red meat, processed meat, sugar sweetened beverages, fiber,

calcium, omega-3 containing seafood, polyunsaturated fats, trans fats, and sodium).

The investigators estimate the number of attributable deaths due to unhealthy diet

increased from 8.5 million (95 % UI: 7.9, 9.2) in 1990 to 12.5 million (95 % UI:

11.7, 13.3) in 2010, with the greatest proportion coming from diets low in fruits (4.9million [95 % UI: 3.8, 5.9]), low in nuts/seeds (2.5 million [95 % UI: 1.6, 3.2]), and

low in vegetables (1.8 million [95 % UI: 1.2, 2.4]) [10].

Physical Inactivity

Major changes in migration, transportation, and mechanization over the past century

have undoubtedly led to declines in global physical activity [13]. However, like diet,global physical activity estimates and time trends are difficult to obtain because of:

(1) limited number of global physical inactivity surveys; (2) limitations in survey

instruments that rely upon self-reporting of physical activity; and (3) historical reli-

ance on leisure-time physical activity estimates, rather than inclusion of transport,

occupational, and domestic activity domains, which may overestimate physical

inactivity prevalence. These limitations notwithstanding, global physical inactivity

prevalence in 2010 has been estimated to be 28 and 34 % for men and women,

respectively [14]. In 2010, the Global Burden of Disease project estimated that the

number of attributable deaths due to physical inactivity was 3.2 million (95 %UI: 2.7, 3.7) [10]. TheLancetsPhysical Activity Series Working Group produced

a higher estimate of deaths due to inactivity for 2008 (5.3 million, a 65 % higher

estimate), which reflects the uncertainty in creating such estimates of attributable

disease burden [15].



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Future Projections

Despite reductions in age-adjusted mortality from non-communicable, chronic

diseases (NCDs) overall, the burden of NCDs will continue to grow in absoluteterms because of the inexorable effects of population growth and aging. For exam-

ple, if the 2010 death rates due to cardiovascular diseases, cancer, chronic lung

diseases, and diabetes remained unchanged until 2025, the annual numbers of

deaths would increase from 28.3 million to 38.8 million [16]. To galvanize global

action and momentum in reducing the burden of NCDs, member states of the World

Health Organization have adopted nine voluntary targets to reduce the burden of

NCDs and their risk factors (Box) [17]. The primary, equity-based target is to reduce

the risk of premature death, between the ages of 30 and 69 years, from NCDs by

25 % by 2025, or the so-called 25 25 target.

Kontis et al. estimated the effect of achieving six of the eight risk factor targets

(tobacco, alcohol, salt intake, obesity, raised blood pressure, raised glucose/diabetes)on the 25 25 mortality target overall and on specific NCD subtypes, stratified by

sex and country, compared with business as usual trends [16]. These projections

suggest that, if these six risk factor targets were achieved, the risk of premature

Box: Nine Voluntary Targets Adopted by Member States of the World

Health Organization to Reduce the Burden of Non-Communicable,

Chronic Diseases [17]

1. 25 % relative reduction in risk of premature mortality from cardiovascular

diseases, cancer, diabetes, or chronic lung diseases.

2. At least 10 % relative reduction in the harmful use of alcohol, as appropri-

ate, within the national context.3. A 10 % relative reduction in the prevalence of insufficient physical

activity.

4. A 30 % relative reduction in mean population intake of salt/sodium.

5. A 30 % relative reduction in prevalence of current tobacco use in persons

aged 15+ years.

6. A 25 % relative reduction in the prevalence of raised blood pressure or

contain the prevalence of raised blood pressure, according to national

circumstances.

7. Halt the rise in diabetes and obesity.8. At least 50 % of eligible people receive drug therapy and counseling

(including glycemic control) to prevent heart attacks and strokes.

9. An 80 % availability of the affordable basic technologies and essential

medicines, including generics, required to treat major noncommunicable

diseases in both public and private facilities.



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deaths from NCDs would decrease by 22 % for men and 19 % for women between

2010 and 2025. These estimates compare favorably with projected decreases in the

risk of premature mortality from NCDs by 11 % for men and 10 % for women under

the business as usual scenario where recent declines in NCD mortality rates con-

tinue to 2025. Achieving these six risk factor targets would not only prevent or

postpone 16.1 million NCD-related deaths among individuals 3069 years old over

the 15 year period (20102025) but would also prevent or postpone an additional

21.4 million deaths among individuals 70 years and greater. The majority (70 %) of

these premature deaths prevented or postponed would be from cardiovascular

disease (11.4 million), followed by cancer (2.4 million), chronic lung diseases

(1.2 million) and diabetes (1.1 million). Because low- and middle-income countries

have a higher burden of NCD-related deaths and death rates compared with high-

income countries, these countries would experience far greater progress toward the

25 25 mortality target if the risk factor targets were achieved.

Conclusions

Non-communicable chronic diseases (NCDs), including cardiovascular diseases,

cancer, chronic lung diseases, diabetes, and mental and behavioral disorders, are the

leading causes of death and disability worldwide. While global age-adjusted death

rates from NCDs have been falling over the past two decades, population growthand aging have led to absolute and ongoing increases in NCD-related deaths and

disability adjusted life years (DALYs). Low- and middle-income countries are pro-

jected to bear even greater proportions of the global burden of NCDs in the coming

decades due, at least in part to their younger demographics, unless comprehensive,

sustainable, and intersectoral action is taken to prevent, detect, treat, and control

NCDs and their shared risk factors.

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7. Byass P, de Courten M, Graham WJ, Laflamme L, McCaw-Binns A, Sankoh OA, et al. Reflections

on the Global Burden of Disease 2010 estimates. PLoS Med. 2013;10(7), e1001477.

8. Strasser T. Reflections on cardiovascular diseases. Interdiscip Sci Rev. 1978;3(3):22530.

9. Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer-Lindgren L, Thomson B, et al.

Smoking prevalence and cigarette consumption in 187 countries, 19802012. JAMA.

2014;311(2):183.

10. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk

assessment of burden of disease and injury attributable to 67 risk factors and risk factor clus-

ters in 21 regions, 19902010: a systematic analysis for the Global Burden of Disease Study

2010. Lancet. 2012;380(9859):222460.

11. Jha P, Peto R. Global effects of smoking, of quitting, and of taxing tobacco. N Engl J Med.

2013;370(1):608.

12. Finucane M, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek C, et al. National, regional,

and global trends in body-mass index since 1980: systematic analysis of health examination

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13 Springer International Publishing Switzerland 2015

J.P. Andrade et al. (eds.), Prevention of Cardiovascular Diseases,

DOI 10.1007/978-3-319-22357-5_2

Cardiovascular Disease Worldwide: A Global

Challenge

Jadelson P. Andrade, Marianna D. Andrade, and Luiz Alberto Mattos

At the beginning of this century, cardiovascular diseases (CVD) showed an

epidemiological behavior very similar to those of the great endemics of past centu-

ries and were responsible for high mortality rates worldwide.

This current epidemiological profile of CVD is evident in data from the World

Health Organization (WHO), which show that of the 56.9 million total deaths

reported worldwide, approximately 30.5 % or 17 million people had CVD listed as

the cause of death [1, 2].

An important epidemiological fact that needs to be considered is the uneven

geographic distribution of CVD deaths. Lower mortality rates are observed in devel-oped countries and much of Latin America, and higher rates are observed in lower

income countries, such as Eastern European countries [1].

Data released by the WHO in 2008 indicate that of the total number of CVD

deaths worldwide, approximately 80.1 % occurred in low- and middle-income

countries, and only 19.9 % occurred in high-income countries.

If this global scenario is already alarming at the beginning of this new century,

the expectations for the future are even more troubling; it is estimated that if concrete

J.P. Andrade, M.D. (*)

Hospital da Bahia, Salvador, Brazil


e-mail:[email protected]

M.D. Andrade, M.D., Ph.D.

Intensive Care Unit from the Hospital da Bahia, Salvador, Brazil

Research and Educational Institute from the Hospital da Bahia, Salvador, Brazil


L.A. Mattos, M.D., Ph.D.Brazilian Society of Cardiology, Rio de Janeiro, Brazil

Interventional Cardiology from Rede Dor Hospitals, Sao Paulo,

Rio de Janeiro and Recife, Sao Paulo, Brazil
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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actions are not implemented, by the year 2030, seven out of ten deaths will be due

to non-communicable diseases (NCDs), and CVD will account for the highest

percentage of these deaths [1, 3].

However, although the CVD mortality rates in developed countries have been

declining in recent decades, as previously mentioned, the rates in most developing

countries are still increasing. This is due, among other factors, to the increased eco-

nomic power of developing countries. Rising incomes per capita have led to

improvement in the health and basic living conditions of these populations, resulting

in a significant reduction in the incidence of and mortality from infectious and para-

sitic diseases, with a proportional increase in the number of deaths caused by NCDs.

In addition, the lifestyle adopted by urban populations in developing countries has

significantly increased the prevalence of risk factors for cardiovascular diseases

such as obesity, physical inactivity, tobacco use, high blood pressure, excessive salt

intake, dyslipidemia, and diabetes [4, 5].

Risk Factors for CVD

At the end of the 1940s, important epidemiological studies, such as the pioneering

study by Framingham, began to identify predictive risk factors for the development

of CVD. The primary factors listed were systemic hypertension, dyslipidemia,

tobacco use, obesity, physical inactivity, excessive salt intake, and mental/emotionalstress [6, 7]. The identification of these and other risk factors in populations in both

developed and developing countries indicated the steps that should be followed to

counter this epidemiological challenge.

At first, population programs were developed and applied in developed countries,

including some European countries, the USA, Canada, Australia, and Japan. These

programs were designed to establish some type of epidemiological control over

these risk factors in their populations. Analyses of the results of these programs

have shown a significant reduction in CVD mortality rates where and when they

were applied. The Framingham Heart Study, the North Karelia Project, and the

Stanford Project are some of the more notable programs implemented [5, 7, 8].

In Finland, for example, efforts to implement well-organized cardiovascular

prevention programs have been rewarded with a reduction in CVD risk factors and

CVD mortality rates. The combined efforts of governments, health professionals,

food companies, universities, and non-governmental organizations have resulted in

effective actions [8]. The results of these actions have led to the consumption of

healthier diets with reduced levels of sodium and saturated fats and adecreased preva-

lence of tobacco use and physical inactivity. Between 1972 and 2007, in Finland, there

was a significant reduction in cholesterol levels by approximately 21 %, systolic blood

pressure by 10.1 mmHg, and the prevalence of tobacco use by 51 % [9].

The implementation of this program model would surely bring potential benefits

to developing countries such as Brazil, which has a high CVD mortality rate.

According to data published by the Ministry of Health (Ministrio da SadeMS)

of Brazil and obtained from a telephone survey conducted in 2010 in major Brazilian

J.P. Andrade et al.


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cities (Surveillance of Risk and Protective Factors for Chronic Diseases Telephone

SurveyVIGITEL), 15 % of adults 18 years and older are smokers, only 30 %

regularly consume fruits and vegetables, whereas 34 % reported consuming meat

with excess fat, and only 30 % practice physical activity regularly (including leisure

activities and commuting to work) [10, 11].

According to the 2012 European Guidelines on Cardiovascular Prevention, there

are eight reasons to promote cardiovascular prevention [12]:

1. Atherosclerotic CVD, especially coronary artery disease, is the leading cause of

premature death worldwide;

2. CVD affects men and women equally;

3. CVD mortality rates are declining in many European countries but remain high

in Eastern Europe;

4. More than half of the observed decrease in the CVD rate is related to changes inrisk factors, and 40 % is due to improved treatments;

5. Preventive efforts should be applied throughout life, from birth to old age;

6. Preventive approaches limited to high-risk individuals are less effective, and

education programs for the entire population are needed;

7. Despite gaps in knowledge, there is ample evidence to justify intensive efforts

related to public health and individual prevention;

8. There is still room for improvement in the control of risk factors, even in high-risk

individuals.

Prevention of Risk Factors, Early Diagnosis

and Treatment of CVD

The evolution and improvement of diagnostic methods and the therapeutic arsenal

for CVD have created a valuable tool for reducing cardiovascular mortality. Some

epidemiological studies still attribute a greater impact on reducing cardiovascular

morbidity and mortality to treatment rather than to prevention. More recent studies,however, reveal a balance between preventive and therapeutic actions in the fight

against CVD. In 2007, an epidemiological analysis was published that used the vali-

dated IMPACT mortality model, and it showed a significant decrease in mortality

rates due to coronary heart disease in both men and women in the USA between

1980 and 2000. Furthermore, the authors concluded that approximately 44 % of this

decrease was due to the control of several cardiovascular risk factors, while 47 %

resulted from therapeutic actions. Preventive actions that contributed to this result

included reductions in total cholesterol (24 %), systolic blood pressure (24 %), the

prevalence of tobacco use (12 %) and physical inactivity (5 %) [13, 14]. This result

was counterbalanced by the significant increase in the prevalence of obesity and

diabetes in this population.

Figure 1summarizes the main epidemiological studies that have been published

in recent decades evaluating the impact of treatments and preventive actions on

reducing cardiovascular mortality.

Cardiovascular Disease Worldwide: A Global Challenge


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Global Targets for the Prevention and Control of CVD

The data presented here reinforce the importance of a new strategy for combating

CVD, which will require a combination of cardiovascular prevention actions and

earlier and more accurate diagnosis methods, as well as increased availability of

effective treatments. The balance of these actions will result in significant reductions

in the current epidemiological indices and also a change in future prospects.

During the World Health Assembly in 2012, the WHO initiated the campaign

Unite in the Fight against NCDs, setting a global target to reduce premature

mortality rates due to NCDs by 25 % by the year 2025 [15]. The campaign was

based on well-defined principles and supported by all recent scientific evidencerelated to the prevention of NCDs. The pillars of this campaign are the following:

Accelerate tobacco control;

Reduce salt intake;

Implement appropriate treatment of high-risk CVD;

Reduce alcohol consumption;

Reduce physical inactivity.

The WHO has encouraged all countries to unite around this banner of cardio-

vascular disease prevention, proposing an alliance between the United Nations,governments, civil society, and private sectors.

The goal of the WHO is to promote a collaborative effort to change the serious

epidemiological reality of CVD and the future prospects that have been projected

for the next 30 years [15, 16].

Treatments Risk factors No Explication

United States 68-76 40 54 6

New Zealand 74-81 40 60

Netherlands 78-85 46 44 10

United States 80-90 43 50 7

Finland 72-92 24 76

IMPACT New Zealand 82-93 35 60 5

IMPACT Scotland 75-94 35 55 10

IMPACT England and Wales 81-00 38 52 10

IMPACT Italy 80-00 40 55 5

IMPACT United States 80-00 47 44 9

IMPACT Finland 82-97 23 53 24

IMPACT Sweden 86-02 36 55 9

0% 50% 100%

Fig. 1 Percent decrease in the number of deaths from coronary heart disease attributed to changes

in treatment and risk factors in different populations. (Adapted from Di Chiara and Vanuzzo [ 13])

J.P. Andrade et al.


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The Letter from Rio de Janeiro

In line with the WHO proposal, the Brazilian Society of Cardiology (Sociedade

Brasileira de CardiologiaSBC) gathered a committee formed by the presidents offive of the most important cardiology societies in the world in 2013 in the city of

Rio de Janeiro: the World Heart Federation, American Heart Association, European

Society of Cardiology, Interamerican Society of Cardiology, and Brazilian Society

of Cardiology. In conjunction with specialists in global cardiovascular prevention, a

document was prepared containing targets for the prevention and control of NCDs

[16]. The document, called the Letter from Rio, was ratified by the presidents of

the participating societies and aims to provide an overall view of CVD and propose

strategic actions to reduce the prevalence of the risk factors contributing to the high

CVD mortality [17, 18]. The letter confirms the global target of a 25 % reduction inearly mortality due to NCDs by the year 2025. The following are included in the

resolutions contained in the Letter from Rio:

Work together in defense of global targets for achieving a 25 % reduction in

mortality from NCDs by the year 2025;

Implement public policies for the prevention and control of NCDs in the general

population and specific groups;

Act on social determinants that contribute to the occurrence of CVD through

government policies;

Interact with health policy makers to develop cardiovascular prevention programsand methods for evaluating their results;

Mobilize the media to continuously disseminate information on the importance

of CVD, its major risk factors, and means of prevention.

Targets from the Letter from Rio for the Prevention and Control of NCDs

25 % reduction in mortality rates from NCDs;

10 % reduction in the prevalence of physical inactivity among adults;

25 % reduction in the prevalence of hypertension (defined as a systolicblood pressure 140 mmHg and a diastolic pressure 90 mmHg);

Reduction in the average intake of salt in the adult population to 5 g/day

(2000 mg sodium);

30 % reduction in the prevalence of tobacco use;

15 % reduction in the intake of saturated fatty acids to achieve the recom-

mended level of


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Conclusion

The recognition that CVD is responsible for 30 % of all deaths worldwide, together

with the alarming projections for the coming years, indicate that CVD should bethe target of actions against it that involve governments, trade associations, and

civil society.

The identification of the main factors responsible for the occurrence of CVD

and the significant technological and scientific advancements in the diagnostic and

therapeutic arsenal against NCDs have created valuable tools for intervention in this

context. An analysis of the results of cardiovascular prevention programs imple-

mented in some developed countries, using the triad of reduction of cardiovascular

risk factors, early diagnosis, and proper treatment, has shown significant reductions

in CVD mortality and has indicated the paths to be followed in the future.

References

1. WHO Statistical Information Center. World Health Statistics 2009 En-WHS 2009.

2. Buttler D. Un targets top killers. Nature. 2011;477(7364):2601.

3. Beaglehole R. International trends in coronary heart disease mortality and incidence rates.

J Cariovasc Risk. 1999;6(2):638.

4. Beaglehole R, Bonita R. Global public health: a score-card. Lancet. 2008;372(9654):198896.

5. World Health Organization, World Heart Federation, World Stroke Organization. Global atlas

on cardio-vascular disease prevention and control: policies, strategies, and interventions. 2011.

http://www.who.int/cardiovascular_dis-eases/publications/atlas_cvd/en/.

6. Dawber TR, Meadors GF, Moore Jr FE. Epidemiological approaches to heart disease: The

Framingham Study. Am J Public Health. 1951;41(3):27981.

7. Capewell S, Morrison CE, McMurray JJ. Contribution of modern cardiovascular treatment

and risk fac-tor changes to the decline in coronary heart disease mortality in Scotland between

1975 and 1994. Heart. 1999;81(4):3806.

8. Laatikainen T, Critchley J, Vartiainen E, Salomaa V, Ketonen M, Capewell S. Explaining the

decline in coronary heart disease mortality in Finland between 1982 and 1997. Am J Epidemiol.2005;162(8):76473.

9. Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol. 2010;

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10. Vigitel Brasil 2012: vigilncia de fatores de risco e proteo para doenas crnicas por

inqurito telefni-co/Ministrio da Sade, Secretaria de Vigilncia em Sade, Departamento

de Vigilncia de Doenas e AgravosnoTransmissveis e Promoo de Sade. Braslia:

Ministrio da Sade, 2013.

11. Brasil. Ministrio da Sade. Secretaria de Vigilncia em Sade. Departamento de Anlise de

Situao de Sade. Plano de aes estratgicas para o enfrentamento das doenas crnicas no

transmissveis (DCNT) no Brasil 2011-2022/Ministrio da Sade. Secretaria de Vigilncia em

Sade.12. Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines

on cardio-vascular disease prevention in clinical practice (version 2012). The Fifth Joint Task

Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease

Prevention in Clinical Practice (constituted by representatives of nine societies and by invited

experts). Eur Heart J. 2012;33(13):1635701.

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13. Di Chiara A, Vanuzzo D. Does surveillance impact on cardiovascular prevention? Eur Heart

J. 2009;30:10279.

14. Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the

decrease in U.S. deaths from coronary disease, 19802000. Explaining the decrease in U.S.

deaths from coronary disease, 19802000. N Engl J Med. 2007;356(23):238898.

15. World Health Organization. Revised [third] WHO discussion paper on the development of a

comprehensive global monitoring framework, including indicators, and a set of voluntary

global targets for the prevention and control of NCDs. July 2012. http://www.who.int/nmh/

events/2012/ncd_discussion_paper/en/index.html.

16. World Health Organization. 65th World Health Assembly document A65/54: Second report of

Committee A. 25 May 2012. http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_54-en.pdf.

17. Andrade JP, Arnett DK, Pinto F, Pieiro D, Smith Jr SC, Mattos LAP, et al. Sociedade Brasileira

de Cardi-ologia Carta do Rio de Janeiro. Arq Bras Cardiol. 2013;100(1):35.

18. Simo AF, Prcoma DB, Andrade JP, Correa Filho H, Saraiva JFK, Oliveira GMM, et al.

Sociedade Brasile-ira de Cardiologia. I Diretriz Brasileira de Preveno Cardiovascular. Arq

Bras Cardiol 2013:101(6 Suppl 2):163.

Cardiovascular Disease Worldwide: A Global Challenge
http://www.who.int/nmh/events/2012/ncd_discussion_paper/en/index.htmlhttp://www.who.int/nmh/events/2012/ncd_discussion_paper/en/index.htmlhttp://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_54-en.pdfhttp://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_54-en.pdfhttp://www.who.int/nmh/events/2012/ncd_discussion_paper/en/index.htmlhttp://www.who.int/nmh/events/2012/ncd_discussion_paper/en/index.html


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Value of Primordial and Primary Prevention

for Cardiovascular Diseases: A Global

Perspective

Armin Barekatain, Sandra Weiss, and William S. Weintraub

Global Burden of Cardiovascular Disease

Worldwide, cardiovascular disease (CVD) is estimated to be the leading cause of

death and loss of disability-adjusted life years. Although age-adjusted cardiovascular

death rates have declined in several developed countries in past decades, rates of

cardiovascular disease have risen greatly in low-income and middle-income coun-

tries [1]. CVD is now the leading cause of death in all developing regions, with the

exception of sub-Saharan Africa [1]. It causes twice as many deaths as HIV, malaria,

and tuberculosis combined. Furthermore, due to the increasing prevalence of risk

factors and lack of appropriate preventive measures, a relatively younger population

is affected by CVD in these countries [2]. This leads to the loss of many potential

years of productive life and places a huge economic burden on these countries.

Hence, efforts to produce even modest reductions in age-specific disease rates could

have a very large economic impact.

A. Barekatain, M.D. (*)Internal Medicine, Houston, Texas, USAe-mail: [email protected]

S. Weiss, M.D.Christiana Care Center for Heart et Vascular Health from the University of ChicagoMedical Center, Newark, DE, USAe-mail: [email protected]

W.S. Weintraub, M.D.Center for Outcomes Research, One of Four Research Centers Comprising the Value Institute

at Christiana Care Health Center, Newark, DE, USAe-mail: [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


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Risk Factors for Cardiovascular Disease

Epidemiologic research findings from the Framingham Heart Study and many others

have established high blood pressure, high blood cholesterol, smoking, obesity,diabetes, and physical inactivity as major risk factors for CVD [3]. These risk factors

have been shown in other studies to apply almost universally among racial and

ethnic groups [4]. In INTERHEART, a casecontrol study of 19,470 people from

52 countries, nine modifiable risk factors were found to have a globally consistent

association with myocardial infarction (MI) in both sexes and at all ages and in all

regions: abnormal lipids, smoking, hypertension, diabetes, abdominal obesity,

psychosocial factors, dietary factors, physical exercise, and alcohol consumption,

with the two most important risk factors being smoking and abnormal lipids [5].

The levels of these risk factors have increased in most non-Western countriesover the past two decades [1]. Social and economic changes have driven these

trends. The epidemiologic transition is a term used to describe the observation that

people are living longer, and those who live longer have greater exposure to risk

factors. Westernized diets and patterns of physical inactivity result in elevations in

blood pressure, body weight, blood sugar levels, and lipid concentrations. Moreover,

the global expansion of the tobacco trade has led to large increases in the rate of

smoking [6].

Is Cardiovascular Disease Preventable?

While clinical trials have provided us with evidence that treatment of people with

elevated risk factors is efficacious in preventing CVD, it is less well known that low-

ering the levels of or eliminating risk factors in communities is effective in reducing

the rate of CVD at the population level. The first line of evidence that CVD can be

prevented at the population level comes from studying its trends in several high-

income countries. For example, in the United States, the CVD mortality rate peaked

during the 1960s then reversed direction and has generally steadily fallen since then.

Reduction in the CVD mortality rate started before powerful modern medical treat-

ments entered mainstream medical practice [7]. In addition, modeling studies have

demonstrated that almost half of the decline in the rate of coronary heart disease in

the US between 1980 and 2000 is attributable to the reductions in major risk factors.

These signify that improvements in risk factors, primarily smoking, total cholesterol,

and blood pressure, were key elements to initiate the decline [8].

Another line of evidence that population-based interventions can be effective in

lowering the burden of CVD in the community comes from several epidemiologic

studies, as mentioned bellow.

The Stanford Three-Community Study began in 1972 and studied the effects of

mass-media educational campaigns to promote knowledge and awareness of

CVD and their risk factors as well as the specific measures which may reduce

A. Barekatain et al.


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risk. A statistically significant reduction of 2530 % was achieved in the com-

posite risk score for cardiovascular disease as a result of significant declines in

blood pressure, smoking, and cholesterol levels [9].

In the Stanford Five-City Project, a reduction in cholesterol level (about 2 %),

blood pressure (about 4 %), and smoking rate (13 %) was achieved in a 5-year,

low-cost, comprehensive educational and organizational programs by utilizing

about 26 h of exposure to multichannel and multifactor education. These risk

factor changes resulted in important decreases in composite total mortality risk

scores (15 %) and coronary heart disease risk scores (16 %) [10].

The North Karelia project offers a powerful lesson in successful population-

based interventions. This project was launched in 1972 to lower CVD rates by

improving the three cardinal risk factors for CHD: smoking, total cholesterol,

and blood pressure. Information was obtained about socioeconomic status, medi-

cal history, smoking, diet, alcohol consumption, physical activity, as well asheight, weight, skinfold thicknesses, blood pressure, and serum cholesterol.

Practical means were developed to modify risk factors by mass media, by train-

ing volunteers and community leaders, and through environmental changes such

as smoking restrictions, use of low-fat dairy and meat products. These interven-

tions resulted in reduced rates of smoking, high total cholesterol and high blood

pressure. As a result, the CHD mortality rate among males aged 3564 years in

North Karelia decreased by 2.9 % per year between 1969 and 1978, significantly

more than the national mortality rate (1.0 % per year) [11]. These experiences

suggest that population-based approaches to reduce risk factors could be effectiveeven in the absence of extensive medical treatments.

Primordial and Primary Prevention of Cardiovascular Disease

Primordial prevention is defined as prevention of the development of risk factors in

the first place, and primary prevention are defined as interventions designed to mod-

ify adverse levels of risk factors once present with the goal of preventing an initialCVD event. Although no multi-decade, population-based, longitudinal studies have

been conducted linking absolute levels of risk factors in childhood to incident clini-

cal CVD events in adult life, several lin

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