Global Cardiovascular Health
Kawkab Shishani
Erika S. Sivarajan Froelicher
INTRODUCTION TO GLOBAL HEALTHIn recent years, medicine worldwide has witnessed an “epidemiologic transition.” Morbidity and mortality from chronic diseases have gradually eclipsed infectious diseases.1 The World Health Organization (WHO) has reported that chronic diseases have now reached epidemic proportions. Of the 58 million deaths from all causes worldwide in 2005, cardiovascular disease (CVD) caused approximately 17.5 million deaths (Fig. 43-1), which is three times more than those caused by infectious diseases, including HIV/AIDS, malaria, and tuberculosis combined.2 Although CVD is declining in developed countries, it is rising in developing countries.3 Furthermore, 80% of deaths caused by CVD occur in developing countries.2 The experience of developed countries in preventing CVD could slow the rapid increase in lifestyle-related risks in developing countries.4, 5, 6, 7, 8
Besides the morbidity and premature mortality caused by CVD, the impaired quality of life caused by the functional and psychological consequences of this chronic disease poses economic and social threats to society.3 Thus, the impact of CVD is greatest in developing countries, where financial resources are limited and professionals with expertise in CVD prevention, treatment of risk factors, and rehabilitation are few. But the significant burden of CVD morbidity and mortality can be prevented.9 Health care professionals in developing countries should learn from the risk prediction and preventive intervention standards, protocols, and procedures that WHO has implemented in Europe10 and in the Americas.11 Furthermore, the countries that participated in the Catalonia Declaration6 and the Victoria Declaration7 have established networks of health care experts from developed countries to help them develop comprehensive health policies and to ensure efficient and cost-effective public health services. The Catalonia and Victoria Declarations also emphasized the influential role of women in reducing CVD risk factors.
The etiology of CVD is multifactorial. Knowledge of the risk factors is derived mainly from the developed countries. To validate these findings on a global basis, the INTERHEART study, a case-control study, compared risk factors for acute myocardial infarction in 52 countries. In 15,152 cases and 14,820 controls, modifiable behavioral risk factors such as smoking, regular physical activity, dietary patterns, obesity (waist/hip ratio), alcohol consumption, and blood apolipoprotein subfractions of cholesterol were examined. Odds ratios (OR) were estimated for the risk factors of myocardial infarction: smoking: OR = 2.87, population attributable risk (PAR) 35.7%; regular physical activity: OR = 0.86, PAR 12.2%; daily consumption of fruits and vegetables: OR = 0.70, PAR 13.7%; and abdominal obesity: OR = 1.12, for top versus lowest tertile and OR = 1.62 for middle versus lowest tertile, PAR 20.1% for top two tertiles versus lowest tertile. All risk factors were significant predictors of acute myocardial infarction (p < .01).12
CONTROLLING THE CVD EPIDEMICAccording to the WHO,2 the key modifiable lifestyle or behavioral risk factors for CVD worldwide are smoking cessation, regular physical activity, and diet. A systematic review of the causes of mortality from CVD revealed that four factors improved prognosis and three of them were associated with lifestyle changes: smoking cessation, physical activity, and dietary modification.13 In developing countries, prevention and control measures to decrease exposure to these risk factors are relatively less advanced.14 Primary and secondary prevention involving medications are not addressed in this chapter because nurses in many parts of the world do not have prescriptive authority. The patient education and compliance component of medication monitoring (see Chapter 40) are contained in the chapters for hypertension (see Chapter 35) and lipids (see Chapter 36). Risk reduction decreases morbidity in patients with CVD. Thus, the guidelines of American Heart Association (AHA) for primary prevention recommend that risk factor assessment of diet, smoking, and physical activity in adults should begin at age 20 years.4 The European Society of Cardiology (ESC) promulgated similar guidelines based on European Action to reduce morbidity and mortality in those individuals at high risk and to safeguard the health of those at low risk by advocating their adoption of healthy lifestyles.5 Although more women than men die from CVD, women are less frequently assessed for risk. Thus, the AHA and ESC emphasize risk assessment in women with particular attention to smoking, obesity, and the use of oral contraceptives.5,15
Smoking Cessation Interventions
Developing countries have the largest proportion of smokers in the world and rates of smoking in these countries are rising (Fig. 43-2). In contrast, the rates of smoking in developed countries have been declining dramatically.16 This decline can be attributed to aggressive public policies that have imposed higher taxes on cigarettes, increasing their cost, and laws restricting smoking in public places. The combination of higher costs, inconvenience, and restrictions on the advertising and sale of cigarettes to minors has drastically reduced smoking rates in many areas of the world. The first international convention treaty to address health dealt with tobacco use.3 It is not surprising then that the burden of disease associated with smoking is higher in developing countries than in developed countries. One study of several countries in the Eastern Mediterranean Region that examined the prevalence of complications in patients with hypertension showed that complication
rates were significantly higher among smokers than among nonsmokers.17 The water pipe, also known as argeela, arghileh, narghile, nargile, nargileh, hubbly-bubbly, sheesha, shisha, and goza, is a popular form of smoking that is practiced socially in many regions in the world. This activity usually involves two or more people who share the same water pipe.18 Although a common misconception persists that smoking a water pipe is not as harmful as smoking cigarettes, one episode of smoking a water pipe produces as much tar as smoking 20 cigarettes. One study found that water pipe smoke contains an abundance of chemicals known to be risk factors for cancer and CVD; the ratio of carbon monoxide to nicotine was 50:1 as compared with 16:1 for cigarettes.19 An analysis of studies done in Arab countries reveals that 31% to 57% of the population smokes a water pipe20,21 and that more women than men use tobacco in this way.22 Among the reasons for this practice is the perception that smoking a water pipe causes fewer adverse health effects and is safer than cigarettes, it is a social activity, and it is considered attractive.22 Nonetheless, this practice may have serious consequences. Women who smoke a water pipe in their homes expose their children to its fumes, which may adversely impact the health of these “passive smokers.”
rates were significantly higher among smokers than among nonsmokers.17 The water pipe, also known as argeela, arghileh, narghile, nargile, nargileh, hubbly-bubbly, sheesha, shisha, and goza, is a popular form of smoking that is practiced socially in many regions in the world. This activity usually involves two or more people who share the same water pipe.18 Although a common misconception persists that smoking a water pipe is not as harmful as smoking cigarettes, one episode of smoking a water pipe produces as much tar as smoking 20 cigarettes. One study found that water pipe smoke contains an abundance of chemicals known to be risk factors for cancer and CVD; the ratio of carbon monoxide to nicotine was 50:1 as compared with 16:1 for cigarettes.19 An analysis of studies done in Arab countries reveals that 31% to 57% of the population smokes a water pipe20,21 and that more women than men use tobacco in this way.22 Among the reasons for this practice is the perception that smoking a water pipe causes fewer adverse health effects and is safer than cigarettes, it is a social activity, and it is considered attractive.22 Nonetheless, this practice may have serious consequences. Women who smoke a water pipe in their homes expose their children to its fumes, which may adversely impact the health of these “passive smokers.”
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