We are pleased to support the British Heart Foundation and the American Heart Association in raising awareness of cardiovascular disease this month. Cardiovascular disease remains the most common non-communicable disease contributing to high rates of mortality, especially in lower-middle income countries. By raising awareness of risk factors and how best to mitigate these, we hope to reduce the rates of cardiovascular mortality as part of the UN Strategic Development goals for 2030.
Senior Editor Adya Misra who handles cardiology submissions to the journal highlights our recently published noteworthy articles focusing on some of our biggest challenges in cardiology today.
Heart failure affects about 2% of the population in high income countries and individuals are at high risk of mortality, so the clinical follow-up remains crucial for patients. Conrad et al set out to investigate the medical care received by heart failure patients from the time of diagnosis until upto a year in the UK. The authors wanted to find out if physicians were following clinical guidelines for heart failure patients and if there were any notable trends in patient management such as age, sex or socioeconomic status. Among some of their pertinent findings on continuum of care, authors report that rates of heart failure diagnosis were declining in primary care and that most patients were being diagnosed in hospital.
In addition, only 17% of such patients received follow up care this rate has been declining as well. Furthermore, authors also found that women, older individuals and those with lower socioeconomic status received a diagnosis of heart failure upon hospital admission. This suggests that early signs and symptoms were missed in primary care or more worryingly, that these groups face barriers to seeking primary care. It isn’t all bad news though, as authors note that patients who were diagnosed with heart failure in primary care showed an increased rate of diagnostic investigations. In 2002, 37% patients received additional diagnostic tests in line with international guidelines compared to 82% in 2014.
Atrial Fibrillation and Ischaemic Stroke
Atrial fibrillation (AF) is an abnormality of heart rhythm which can manifest as an irregular heart beat every so often. Most individuals tend to be unaware of this abnormality and remain at risk for ischaemic stroke. Due to its irregular nature, screening in the general population is supported by cardiologists worldwide. However there is no evidence to suggest what age groups should be screened for atrial fibrillation since most of the literature is based on patients with diagnosed AF and screening everyone can be expensive. Lowres et al set out to undertake a systematic review and meta-analysis to explore which age groups should be targeted for AF screening, in order for this to be cost-effective. Crucially, they also aimed to explore how many individuals needed to be screened to detect AF in 5 year age brackets so that targeted screening can be undertaken. The authors show that the detection rate of AF increased with increasing age, along with this increasing the risk of stroke. The detection rate was 0.34% for under 60 year olds, rising to 2.73% for those over 85 years.
Following on from this, the data did not support screening individuals younger than 60 years. The authors point out that identifying one treatable person under 60 would require screening 1,089 people, which is simply not cost-effective. While these findings agree with international guidelines that recommend screening for over 65 year olds, the authors elegantly demonstrate that screening for atrial fibrillation is sensitive to age and that more screening in lower age groups is required to detect a small number of cases.
Unhealthy diets and heart disease
45% of deaths due to cardiovascular disease have been attributed to an unhealthy diet in the United States. Cardiovascular disease (CVD) puts a substantial burden on healthcare services but there is an economic impact which has been relatively less well investigated. Using a validated microsimulation model, Jardim et al investigated the economic burden of consuming an unhealthy diet in US dollars. The total cost of an unhealthy diet was $301/person/year consisting of : acute events including hospitalisation ($254), chronic costs such as primary care visits ($43), and cost of medication ($4). The authors estimate that the diet-related cost of CVD in the US is $50.4 billion per year.
Diabetes accounted for approximately 50% ($21) of the annual chronic costs, and the rest of the chronic costs were attributable to CVD. Of these, acute costs represent 84.3% of this total ($42.6 billion) and chronic costs amounting to $7.2 billion. This amount was split evenly between costs due to cardiovascular disease or diabetes. These findings provide evidence for policymakers that interventions aimed at healthy eating behaviours can save millions by mitigating chronic disease risk factors. Since these data are from the United States, authors perhaps rightly suggest that insurers can do more to subsidise healthier foods and promote high deductible plans to encourage individuals to adopt healthier lifestyles to avoid future costs.
Hypertension, or high blood pressure is a condition that increases our risk of getting a heart attack or stroke. Since there are no symptoms, it can often be difficult to catch in populations with poor access to health. Interestingly, the prevalence of hypertension has risen from 442 million in 1990 to 874 million in 2015, with a large burden in lower-middle income countries. Gamage et al designed a cluster randomised controlled trial in rural regions of India, to assess whether non physician community health workers could help in educating the population as well as monitoring hypertension in high risk individuals.
Every two weeks, community health workers educated people about hypertension and measured their blood pressure as part of this trial. The authors report that the measured blood pressure in populations receiving this education and monitoring decreased an average of 5.0/2.1mm Hg more than the populations who did not receive this. The authors discuss how a low-cost intervention such as this can be easily scaled up in rural regions where trained professionals are not always available. Training community health workers on simple tasks such as blood pressure monitoring seems to be effective in rural or remote populations and due to its low-cost, it can be implemented easily in more regions.