Cardiovascular secondary prevention in primary care setting: an immediate necessity in Brazil and worldwide

Abstract

Cardiovascular diseases (CVD) such as coronary heart disease, stroke and peripheral arterial diseases are the leading causes of death worldwide. 1 The decline in age-adjusted mortality rates observed since the late 1960s was initially attributed partially to two concomitant factors. First, case-fatality rates have decreased due to better awareness of early symptoms and introduction of pre-hospital care, coronary care units, new drugs and surgical interventions. Second, reduction in the numbers of cigarettes smoked per day (smoking has been correlated with sudden death due to cardiac arrest) and lowering of very high blood pressures (hypertension has been correlated with massive hemorrhagic stroke) have played a significant role in reducing the risk of death due to cardiovascular diseases. 2 However, in contrast to assessments on mortality data, finding information about the incidence of CVDs is not an easy task. There are few empirical population-based studies, and extrapolation from mortality data with the aim of calculating incidence is insufficient.We make the assumption that reductions in new-onset CVD cases are not occurring worldwide, or at least at the same pace observed for death rates. This assumption can be explained in terms of lifestyle changes that occurred during the 1990s. Primordial prevention (smoking bans, greater availability of healthy foods and encouragement of leisure-time physical activity) and more adequate primary prevention such as control of high blood pressure and high cholesterol became a reality. 3 However, a new factor rapidly spread worldwide: the epidemic of obesity and diabetes, which has increased the number of people prone to CVD events. 4 If the rates of new-onset cardiovascular diseases do not decline, but the case-fatality rates drop, the prevalence of people with CVD should consequently increase. The confluence of these movements (declining lethality, stable incidence and rising obesity) has increased the numbers of survivors from myocardial infarction and stroke. These individuals, together with the pool of people with angina pectoris and peripheral artery disease, are responsible for the increase in cardiovascular disease prevalence rates. Data from the 2013 Brazilian National Health Survey and the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) revealed that higher prevalence of these conditions was strongly associated with lower socioeconomic status 5-7 (Table 1).Consequently, the prevalence of individuals who can be assigned to secondary prevention is growing mainly among the poorest.Although the benefits of secondary prevention measures (lifestyle changes, blood pressure control and use of aspirin and statins) to reduce health-adverse cardiovascular events is undisputable, 8 these measures have not been adopted worldwide. In the Prospective Urban Rural Epidemiological (PURE) study, data on 153,996 adults with CVDs (aged 35-70 years) who were living in countries at different stages of economic development were analyzed. Comparing South America with North Am...

Secondary prevention of cardiovascular disease in Brazil: lessons from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

“…Previous studies in Brazil have identified the most formidable barriers preventing access to cardiac rehabilitation, which include transportation difficulties, low income, lack of insurance coverage and low educational level. [2][3][4] Regarding stroke, a previous study showed that less than 50% of patients with stroke who are attended in public hospitals and healthcare centers have any medical follow-up after their hospitalization at the time of the event. 5 Recent data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) have presented similar results.…”

Stroke prevention within primary care: management of atrial fibrillation using oral anticoagulation

“…15 However, the challenge pointed out previously in this Journal is to put cardiovascular prevention into primary care. 16 This is an action that will effectively reduce the social gap regarding mortality, 17 morbidity 18 and disability 19 due to stroke, which is still a neglected disease in Brazil. 20…”

Prevenção secundária da doença isquêmica coronariana na linha de base do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil)

“…Baixo nível socioeconômico está associado a maior prevalência de fatores de risco cardiovasculares e a pior sobrevida (Santos et al, 2015;Lotufo, 2017).…”

“…Segundo os dados do Global Burden of Disease (GBD) 2016, o número de óbitos devido a DIC aumentou 19,0% (16,2% a 22,1%) de 2006 a 2016, em razão do crescimento populacional no período, do aumento da expectativa de vida e de alguns fatores de risco, como obesidade e diabetes (GBD, 2017;Santos et al, 2015). Porém, quando padronizado por idade, houve uma redução no número de óbitos de 11,6% (9,3 a 13,6%), provavelmente em decorrência de estratégias bem-sucedidas, melhorias no tratamento hospitalar e melhores opções para a prevenção (GBD, 2017;Lotufo, 2017).…”

“…Porém, esse cenário poderá mudar no futuro devido a epidemia de obesidade e ao aumento de indivíduos com diabetes (Lotufo, 2017).…”