How to Narrow the CV Disease Care Gap Between Rich, Poor in Latin America

Marlene Busko

June 17, 2016

MEXICO CITY, MEXICO — The main barriers to effective CVD management in Latin American countries are the huge disparities between rich and poor and urban and rural dwellers, according to panelists at a session at the recent World Heart Federation's World Congress of Cardiology & Cardiovascular Health 2016 (WCC 2016)[1].

"We know that within countries we have huge inequalities" in healthcare delivery, session comoderator Dr Pablo Perel (World Heart Federation, Geneva, Switzerland) summarized. "We also know what needs to be done" for primary and secondary prevention of cardiovascular disease, he added. "Our challenge is to implement what we know," he told the audience of mainly Latin American cardiologists.

To heartwire from Medscape, he said that this discussion is also "very relevant" to the US, with the Affordable Care Act. Also, "the key American organizations, the ACC and the AHA," were involved with other international societies in developing the World Heart Federation's "road map," or strategy, for secondary prevention of CVD[2], he noted.

This road map, along with road maps for smoking cessation and hypertension, is designed to help countries around the world meet the World Heart Federation's "25 by '25" target of reducing premature mortality from cardiovascular disease and other noncommunicable diseases by 25%, compared with 2011 levels, by the year 2025.

Copayment, Transportation Barriers in Colombia

Dr Patricio Lopez-Jaramillo (Fundacion Oftalmologica de Santander, Bucaramanga, Colombia) discussed findings from a study of hypertension in participants in the Prospective Urban Rural Epidemiology (PURE) study of 17 low- to high-income countries[3]. In PURE, 10,937 patients came from four Latin American countries: Argentina, Brazil, Chile, and Colombia. Among these patients, 57.1% were aware they had hypertension and 52.8% were being treated for this, but only 18.8% had controlled hypertension, Lopez-Jaramillo pointed out.

Another study of hypertensive patients in Columbia shed light on possible reasons for uncontrolled hypertension. Patients reported that the main reasons that they were not taking antihypertensives were high copayment cost, high public-transportation cost, unavailable drugs, and poor access to specialist care. Some patients were able to overcome these obstacles with support from family members, neighbors, and social networks.

The authors concluded that healthcare practitioners need to be aware of these treatment barriers, and they should also help patients understand the importance of taking their medications and try to find ways to make it easier for patients, especially those living in rural areas, to get their medications.

Treatment Gaps, Low-Sodium Salt Experiment in Peru

Dr Jaime Miranda (CRONICAS Centre of Excellence in Chronic Diseases, Lima, Peru) said that studies in Peru of people moving from rural areas to live in crowded cities all show that "coming to the cities is bad for you."

His group found that among rural dwellers, rural to urban migrants, and urban dwellers in Peru, the prevalence of obesity was 3%, 20%, and 33%, respectively, and the prevalence of type 2 diabetes was 0.8%, 3%, and 6%, respectively[4]. About three-quarters (77%) of people living in rural areas, but only 41% of migrants and 28% of urban dwellers, had no cardiovascular risk factors.

However, poor people in rural regions are exposed to harmful high levels of smoke from cooking stoves, he noted.

Miranda noted that another study from their group, based on hypertensive patients in Lima, showed that those who were compliant with treatment were 52% less likely than others to believe that medications could be harmful; conversely, patients who were highly concerned about possible harm from medications were 41% less likely to be highly compliant with treatment.

Miranda is currently leading a study in Peru where people are being given low-sodium salt to replace their usual salt. "Stay tuned," he said.

Low Adherence to Meds in PURE, Brazilian Initiative

"We don't need to know more about risk factors for cardiovascular disease in Latin America. . . . The issue is not lack of knowledge. It is lack of implementation, said Dr Alvaro Avezum (Dante Pazzanese Institute of Cardiology, São Paulo, Brazil).

In the Latin American countries in the PURE study, after an MI, only 5% of patients received four medications (aspirin, an ACE inhibitor, a statin, and a beta-blocker) and about 30% of patients did not receive any medication. Similarly, almost 50% of patients in these countries did not receive any medication after a stroke, he reported.

Several Latin American groups are working to improve how cardiovascular disease is managed in Latin America and to overcome some roadblocks that have been identified in the World Heart Federation road maps.

For example, the Practice Innovation and Clinical Excellence (PINNACLE) Brazil registry of patients treated at ambulatory cardiology clinics is collecting data from 1000 cardiologists. The Pan American Health Organization (PAHO) is conducting a study of secondary prevention of CVD in Latin America and the Caribbean.

Diabetes in Latin America, New Educational Tools

"Diabetes really is a global emergency," said Dr Ammar Ibrahim (National Institute of Diabetes, Endocrinology and Nutrition Santo Domingo, Dominican Republic).

In 2015, in South and Central America, 9.4% of the population (29.6 million people) had diabetes and 39.0% were undiagnosed.

The prevalence of diabetes was especially high in Puerto Rico (14.2%), Cuba (12.1%), Venezuela (11.1%), and Chile (11.0%), and it was about half that in Bolivia (6.5%), Peru (6.4%), and Argentina (6.3%). Researchers estimate that by 2040, the prevalence of diabetes in South and Central American countries will increase by more than 65%.

As is well-known, diabetes that is not well controlled can lead to serious complications, Ibrahim added. For example, in one study of patients with diabetes, having a foot ulcer upped mortality risk during follow-up by 47%.

Thus, there is a need for country-specific diabetes education and prevention programs in Latin America to better inform people about risk factors, especially modifiable ones such as an unhealthy diet or abdominal obesity. New technologies such as cellphone apps may help some people manage their diabetes better. At his center, they have a gym in the waiting room that patients can use.

"We need to improve communication to better reach people with messages" about preventing CVD, Perel suggested. "The messages about cardiovascular prevention have not changed for the past 50 years," unlike advertising for consumer goods, which is tweaked every season.

The authors have no relevant financial relationships.

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