Sagar Dugani

The Burden of Cardiovascular Disease in Low- and Middle-Income Countries: Epidemiology and Management.

Cardiovascular disease (CVD) is the second leading cause of mortality worldwide, accounting for 17 million deaths in 2013. More than 80% of these cases were in low- and middle-income countries (LMICs). Although the risk factors for the development of CVD are similar throughout the world, the evolving change in lifestyle and health behaviours in LMICs-including tobacco use, decreased physical activity, and obesity-are contributing to the escalating presence of CVD and mortality. Although CVD mortality is falling in high-income settings because of more effective preventive and management programs, access to evidence-based interventions for combating CVD in resource-limited settings is variable. The existing pressures on both human and financial resources impact the efforts of controlling CVD. The implementation of emerging innovative interventions to improve medication adherence, introducing m-health programs, and decentralizing the management of chronic diseases are promising methods to reduce the burden of chronic disease management on such fragile health care systems.

Despite Increased Use And Sales Of Statins In India, Per Capita Prescription Rates Remain Far Below High-Income Countries

Statin use has increased substantially in North America and Europe, with resultant reductions in cardiovascular mortality. However, little is known about statin use in lower-income countries. India is of interest because of its burden of cardiovascular disease, the unique nature of its prescription drug market, and the growing globalization of drug sales. We conducted an observational study using IMS Health data for the period February 2006-January 2010. During the period, monthly statin prescriptions increased from 45.8 to 84.1 per 1,000 patients with coronary heart disease-an increase of 0.80 prescriptions per month. The proportion of the Indian population receiving a defined daily statin dose increased from 3.35 percent to 7.78 percent. Nevertheless, only a fraction of those eligible for a statin appeared to receive the therapy, even though there were 259 distinct statin products available to Indian consumers in January 2010. Low rates of statin use in India may reflect problems with access to health care, affordability, underdiagnosis, and cultural beliefs. Because of the growing burden of cardiovascular disease in lower-income countries such as India, there is an urgent need to increase statin use and ensure access to safe products whose use is based on evidence. Policies are needed to expand insurance, increase medications affordability, educate physicians and patients, and improve regulatory oversight.

Association of Lipoproteins, Insulin Resistance, and Rosuvastatin With Incident Type 2 Diabetes Mellitus : Secondary Analysis of a Randomized Clinical Trial.

IMPORTANCEnStatins decrease levels of low-density lipoprotein (LDL) and triglycerides as well as cardiovascular events but increase the risk for a diagnosis of type 2 diabetes mellitus (T2DM). The risk factors associated with incident T2DM are incompletely characterized.nnnOBJECTIVEnTo investigate the association of lipoprotein subclasses and size and a novel lipoprotein insulin resistance (LPIR) score (a composite of 6 lipoprotein measures) with incident T2DM among individuals randomized to a high-intensity statin or placebo.nnnDESIGN, SETTING, AND PARTICIPANTSnThis secondary analysis of the JUPITER trial (a placebo-controlled randomized clinical trial) was conducted at 1315 sites in 26 countries and enrolled 17 802 men 50 years or older and women 60 years or older with LDL cholesterol levels less than 130 mg/dL, high-sensitivity C-reactive protein levels of at least 2 mg/L, and triglyceride levels less than 500 mg/dL. Those with T2DM were excluded. A prespecified secondary aim was to assess the effect of rosuvastatin calcium on T2DM. Incident T2DM was monitored for a median of 2.0 years. Data were collected from February 4, 2003, to August 20, 2008, and analyzed (intention-to-treat) from December 1, 2013, to January 21, 2016.nnnINTERVENTIONSnRosuvastatin calcium, 20 mg/d, or placebo.nnnMAIN OUTCOMES AND MEASURESnSize and concentration of lipids, apolipoproteins, and lipoproteins at baseline (11u202f918 patients with evaluable plasma samples) and 12 months after randomization (9180 patients). The LPIR score, a correlate of insulin resistance, was calculated as a weighted combination of size and concentrations of LDL, very low-density lipoprotein (VLDL), and high-density lipoprotein (HDL) particles.nnnRESULTSnAmong the 11 918 patients (4334 women [36.4%]; median [interquartile range] age, 66 [60-71] years), rosuvastatin lowered the levels of LDL particles (-39.6%; 95% CI, -49.4% to -24.6%), VLDL particles (-19.6%; 95% CI, -40.6% to 10.3%), and VLDL triglycerides (-15.2%; 95% CI, -35.9% to 11.3%) and shifted the lipoprotein subclass distribution toward smaller LDL size (-1.5%; 95% CI, -3.7% to 0.5%), larger VLDL size (2.8%; 95% CI, -5.8% to 12.7%), and lower LPIR score (-3.2%; 95% CI, -20.6% to 16.9%). In analyses adjusted for age, sex, race or ethnic origin, exercise, educational level, family history, and smoking, the hazard ratio (HR) for T2DM per SD of LPIR score in the placebo arm was 1.99 (95% CI, 1.64-2.42); in the rosuvastatin arm, 2.06 (95% CI, 1.74-2.43). After additional adjustment for systolic blood pressure, body mass index, high-sensitivity C-reactive protein, hemoglobin A1c, HDL cholesterol, LDL cholesterol, and triglycerides, the LPIR score remained associated with T2DM in the placebo arm (HR, 1.35; 95% CI, 1.03-1.76) and rosuvastatin arm (HR, 1.60; 95% CI, 1.27-2.03). Similar trends were seen at 12 months. The LPIR score improved the model likelihood ratio (χ2u2009=u200918.23; Pu2009<u2009.001) and categorical net reclassification index (0.039; 95% CI, 0.003-0.072).nnnCONCLUSIONS AND RELEVANCEnIn apparently healthy people, LPIR score was positively associated with incident T2DM, including during rosuvastatin therapy.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00239681.

25 by 25: Achieving Global Reduction in Cardiovascular Mortality

Four non-communicable diseases—cardiovascular disease, chronic respiratory disease, diabetes mellitus, and cancer—account for over 60xa0% of all deaths globally. In recognition of this significant epidemic, the United Nations set forth a target of reducing the four major NCDs by 25xa0% by 2025. Cardiovascular disease alone represents half of these deaths and is the leading cause of death globally, representing as much as 60xa0% of all deaths in regions such as Eastern Europe. In response, the WHO set specific targets on conditions and risk factors and changes in the health systems structure in order to achieve the goals. The focus was set on lifestyle risk factors—physical activity, salt-intake, and tobacco—and established conditions—obesity, hypertension, and diabetes mellitus. Health system efforts to improve medical treatment of high risk are encouraged. Efforts to achieve the goal are being promoted by leading international CVD organizations.

Development of IMAGINE: a three-pillar student initiative to promote social accountability and interprofessional education.

The evolution of medical education worldwide is marked by a focus on two important dimensions: social accountability (SA), interprofessional education (IPE) and interprofessional care (IPC). The World Health Organization mandated that medical schools should promote SA (Boelen & Heck, 1995). In Canada, the call to promote SA was echoed by Health Canada (2001) and the Association of Faculties of Medicine in Canada (2010), underscoring our responsibility and commitment towards society’s evolving needs. There is also growing evidence for the importance of IPE and IPC (Health Canada, 2001), with institutions developing strategies to incorporate IPE in their undergraduate curricula. While there is general agreement on the importance of SA, IPE and IPC, there is relatively sparse information on how to successfully create and facilitate these dimensions in undergraduate curricula. In undergraduate curricula, most examples of activities that promote SA, IPE and IPC are faculty-initiated, and the role of students in promoting these dimensions is not well understood. This report describes a student initiative which incorporates SA and IPC in addressing challenges faced by marginalized populations in Toronto. The IMAGINE (Interprofessional Medical and Allied Groups for Improving Neighbourhood Environments) initiative has three facets: health clinic, health promotion, and community awareness lecture series. The vision is to foster partnerships between students and marginalized communities to promote the delivery of holistic healthcare. Several interprofessional student initiatives have been developed to benefit diverse communities (Curran, Sharpe, Flynn, & Button, 2010; Mann et al., 2009; Moskowitz, Glasco, Johnson, & Wang, 2006). IMAGINE is the first student initiative to adopt a three-pillar approach to addressing health issues of marginalized populations using an interprofessional approach. We outline our governance model, which guides the maintenance, expansion, and evolution of IMAGINE. This model may be adapted by schools globally as they plan similar initiatives.

Cardiovascular, respiratory, and related disorders: key messages from Disease Control Priorities, 3rd edition

Cardiovascular, respiratory, and related disorders (CVRDs) are the leading causes of adult death worldwide, and substantial inequalities in care of patients with CVRDs exist between countries of high income and countries of low and middle income. Based on current trends, the UN Sustainable Development Goal to reduce premature mortality due to CVRDs by a third by 2030 will be challenging for many countries of low and middle income. We did systematic literature reviews of effectiveness and cost-effectiveness to identify priority interventions. We summarise the key findings and present a costed essential package of interventions to reduce risk of and manage CVRDs. On a population level, we recommend tobacco taxation, bans on trans fats, and compulsory reduction of salt in manufactured food products. We suggest primary health services be strengthened through the establishment of locally endorsed guidelines and ensured availability of essential medications. The policy interventions and health service delivery package we suggest could serve as the cornerstone for the management of CVRDs, and afford substantial financial risk protection for vulnerable households. We estimate that full implementation of the essential package would cost an additional US

Ischemic Heart Disease: Cost-Effective Acute Management and Secondary Prevention

21 per person in the average low-income country and

Lipoprotein insulin resistance score and risk of incident diabetes during extended follow-up of 20 years: The Women's Health Study

24 in the average lower-middle-income country. The essential package we describe could be a starting place for low-income and middle-income countries developing universal health coverage packages. Interventions could be rolled out as disease burden demands and budgets allow. Our outlined interventions provide a pathway for countries attempting to convert the UN Sustainable Development Goal commitments into tangible action.

Weighing the Anti-Ischemic Benefits and Bleeding Risks from Aspirin Therapy: a Rational Approach

Cardiovascular disease (CVD) is the single most important cause of death worldwide; in 2010, it resulted in 16 million deaths and the loss of 293 million disabilityadjusted life years (DALYs) (Lozano and others 2012; Murray and others 2012). CVD involves conditions that affect the vasculature that supplies the heart, brain, and other vital organs (Roth and others 2015). Of all of the causes of CVD, ischemic heart disease (IHD) remains the major contributor to mortality and morbidity. IHD results from delivery of insufficient oxygen to meet the demands of the heart and largely manifests as angina, acute myocardial infarction, and ischemic heart failure. Over the past two decades, although age-standardized IHD mortality has decreased in most regions, the global burden of IHD has increased by 29 percent to 29 million DALYs, in part because of a larger aging population and overall population growth (Lozano and others 2012; Moran, Forouzanfar, and others 2014a; Murray and others 2012). IHD is projected to be a major cause of death in 2030, along with unipolar depressive disorders and human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (Mathers and Loncar 2006). This chapter reviews the global burden of IHD, with a focus on lowand middle-income countries (LMICs). We review the cost-effective management of acute IHD and subsequent secondary prevention; primary prevention is discussed in chapter 22 (Jeemon and others 2017). The chapter concludes with a discussion of the challenges that IHD poses to the global community and of solutions that may help reduce attendant mortality and morbidity.

Prevalence of Cardiovascular Risk Factors among Patients Presenting with Premature Myocardial Infarction in the Middle East

BACKGROUNDnType II diabetes (T2D) is preceded by prolonged insulin resistance and relative insulin deficiency incompletely captured by glucose metabolism parameters, high-density lipoprotein (HDL) cholesterol and triglycerides.nnnOBJECTIVEnWhether lipoprotein insulin resistance (LPIR) score, a metabolomic marker, is associated with incident diabetes and improves risk reclassification over traditional markers on extended follow-up.nnnMETHODSnAmong 25,925 nondiabetic women aged 45xa0years or older, LPIR was measured by nuclear magnetic resonance spectroscopy as a weighted score of very low density lipoprotein, low-density lipoprotein, and HDL particle sizes, and their subsets concentrations. We run adjusted cox regression models for LPIR with incident T2D (20.4xa0years median follow-up).nnnRESULTSnAdjusting for demographics, body mass index, life style factors, blood pressure, and T2D family history, the LPIR hazard ratio for T2D (hazard ratio [HR] per standard deviation, 95% confidence interval) was 1.95 (1.85, 2.06). Further adjusting for HbA1c, C-reactive protein, triglycerides, HDL and low-density lipoprotein cholesterol, LPIR HR was attenuated to 1.41 (1.31, 1.53) and had the strongest association with T2D after HbA1C in mutually adjusted models. The association persisted even in those with optimal clinical profiles, adjusted HR per standard deviation 1.91 (1.17, 3.13). In participants deemed at intermediate T2D risk by the Framingham Offspring T2D score, LPIR led to a net reclassification of 0.145 (0.117, 0.175).nnnCONCLUSIONnIn middle-aged or older healthy women followed prospectively for over 20xa0years, LPIR was robustly associated with incident T2D, including among those with an optimal clinical metabolic profile. LPIR improved T2D risk classification and may guide early and targeted prevention strategies.