From the University of Rochester School of Medicine (T.A.P.), Rochester,
NY; University of North Carolina School of Medicine (S.C.S.), Chapel Hill, NC;
and National Heart and Lung Institute (P.P.-W.), London, England.
Recently available data on the
global burden of disease document, perhaps for the first time, that
cardiovascular disease (CVD) has achieved the dubious
status of the leading cause of death worldwide.1
Coronary heart disease and stroke have dominated the mortality
figures for Western Europe, North America, and Australia/New Zealand
for many decades, extending to Eastern Europe more recently. However,
the emergence of CVD as the major cause of death in the world's most
populous regions, such as China and India, along with falling death
rates from infectious and parasitic diseases in these countries are
clearly the reasons for the elevation of CVD as the leading cause of
death globally. Additional data from South and Central America, the
Middle East and North Africa, and Southeast Asia confirm these trends.
Moreover, projections of mortality based on population increases
and increased life expectancy suggest that CVD will be the leading
cause of mortality in all parts of the world by the year 2020, with the
exception of sub-Saharan Africa.2 Some of us believe that
even these estimates may be optimistic, with additional CVD occurring
due to the increase in tobacco use, obesity, sedentary lifestyle, and
an atherogenic diet in countries of increasing affluence; interaction
of these new risk factors with presently prevalent risk factors
such as hypertension; and the genetic predisposition of certain
subgroups (such as South Asians) to CVD when placed in industrial
societies.3 Indeed, conversations with colleagues from
far-flung corners of the globe confirm the rising numbers of patients
with coronary disease and stroke at relatively young ages now
populating hospital wards and intensive care units. These
cardiovascular specialists in lesser developed
countries will likely not only be faced with increasing numbers of
patients with acute and chronic manifestations of CVD but will also
lack the extensive (and expensive) resources used to combat the disease
in more affluent countries.
How should cardiovascular specialty societies
respond to this developing crisis? To address this question, a
satellite symposium was organized in conjunction with the Fourth
International Conference on Preventive Cardiology, held
in Montreal, Quebec, on June 28, 1997. The overall goal of the
symposium was to organize, coordinate, and enhance the efforts of
cardiovascular specialty societies from around the
world to improve the identification and management of
cardiovascular risk factors in patients at high risk
for vascular disease. Approximately 50 invited
representatives from all six continents and a large
number of national and international professional societies attended
the symposium. The format of the meeting was to have speakers provide
an overview on major issues, followed by reactions of a panel of
distinguished experts representing a variety of
international and professional constituencies. Three major themes were
presented: (1) the barriers and opportunities for improving
risk factor interventions, (2) the role of
cardiovascular specialty societies in improving these
risk factor management practices, and (3) the need to influence
governments to take a more active role in promoting
cardiovascular risk factor management in developing
countries.
Dr Sidney Smith (University of North Carolina School of Medicine)
discussed the array of barriers that have been identified in the United
States and Europe that make the management of risk factors difficult.
These barriers are at the level of the patient; the provider, hospital,
or clinic; and society.4 A discussion panel consisting of
Drs Ian Graham (Ireland), Jonathan A. Matenga (Zimbabwe), Salim Yusuf
(Canada), and Ingrid G. Martin (World Health Organization) then
provided their international perspectives on these barriers. A clear
problem is a lack of data on the management of CVD in many countries,
including mortality statistics, rudimentary estimates of levels of risk
factors and their associations with CVD in specific populations, the
quantification of practice patterns related to both prevention and case
management, and especially the cost-effectiveness of preventive
interventions in those specific healthcare systems. In some areas, the
gradual development of the CVD epidemic has gone unrecognized,
resulting in little change in education and practice. The education of
health professionals also continues to emphasize the treatment of acute
illness or the "reacting to illness rather than the sustaining of
health." Educational programs frequently do not provide the skills
necessary to be effective in risk factor counseling, cost-effective use
of pharmacological agents, etc. Moreover, there is a reluctance by
physicians to surrender control of preventive care to other
professionals or teams of professionals. At the same time, high
technology, whether cost-effective or not, is extremely seductive,
especially when viewed as "state of the art" by colleagues in
affluent countries. In many instances, there is little involvement of
industry in preventive care compared with acute case management. This
is compounded by a lack of clear guidelines about the use of preventive
or case management strategies or by controversial guidelines that serve
to confuse rather than inform. Finally, preventive services are often
not reimbursed by governmental funding sources, who have yet to
recognize CVD as a major local problem. Cardiovascular
specialists at these societies also lack skills as policy makers to
bring about change in reimbursement policy as the CVD epidemic
emerges.
Professor David Wood (United Kingdom) then presented his
perspectives of the potential role(s) for
cardiovascular specialty societies in overcoming these
barriers. He listed six opportunities for involvement: (1) leadership
in prevention in relation to members of the societies and to the public
at large; (2) advocacy with a dispassionate voice to review evidence
without a vested interest; (3) recommendations for guidelines that can
be adopted as professional standards and disseminated to members; (4)
evaluation of these guidelines, both in terms of their level of current
use and the barriers to their implementation; (5) education and
training in preventive strategies as required for professional
certification; and (6) research as to the basic science,
epidemiology, clinical trials, or
implementation of strategies related to risk factor management.
An expert panel responded to Dr Wood's comments. This panel included
Drs Gilles Dagenais (Canada, Canadian Society of
Cardiology), Martha Hill (United States, American Heart
Association), Antonio Bayes de Luna (Spain, International Society and
Federation of Cardiology), Edgardo Escobar (Chile,
InterAmerican Society of Cardiology), Walinjom Muna
(Cameroon, Pan African Society of Cardiology), and
Susanne Logstrup (Belgium, European Heart Network). Current activities
by the continental societies paralleled those suggested by Dr Wood.
These included educational activities, especially undergraduate, and
continuing education of their members in CVD risk-reduction skills.
Society journals may be an especially effective medium for this
purpose. International societies might promote traveling fellowships in
preventive cardiology to train future leaders in this
field. Continental and national societies should lead these training
efforts. Societies also serve as a useful means to engage industries
with vested interests in prevention, including their support for
educational programs and their involvement in consensus conferences and
advocacy groups. Cardiovascular specialty societies may
also take a lead in proposing, if not performing, research in local
cardiovascular disease control. Societies in developing
countries should lobby for studies to identify and quantify the burden
of CVD in these countries. One challenge in Africa is to raise
awareness of an emerging CVD epidemic even before its arrival. This
advocacy includes the continued presence in national, regional, and
international organizations (eg, World Health Organization) to obtain
accurate data on the burden of disease. Additional efforts may be
focused on the development of locally relevant risk factor profiles so
priorities can be set. Another important function of professional
societies in both developed and developing countries is the formulation
of standards and guidelines. There is a great need to combine the large
number of guidelines currently available on prevention. These
guidelines should remain modifiable for local conditions and emphasize
best practices and cost-effectiveness. National societies should
collaborate with continental and international societies to produce
consistent yet locally relevant guidelines for prevention.
Professional societies can also take a lead role in describing the
appropriate use of high technology, perhaps recognizing the minimal
amount of technology that is still adequate for the most cost-effective
care of the patient with vascular disease.
A final role for cardiovascular specialty societies is
in public advocacy and political activities to educate governments
about the impending burden of CVD, the importance of research, and the
need for specific governmental policies to control the epidemic.
Specialty societies can make recommendations on scientific and
professional grounds and serve as effective countermeasures to
commercial interests such as tobacco and high-fat foods, which are
increasingly effective in changing lifestyle behaviors in developing
countries.
Dr Prabhat Jha (World Bank) was the final speaker, describing the role
of governments in the control of the CVD epidemic. Many developing
countries are presently occupied with the "unfinished agenda,"
namely, the continued need to control infectious, nutritional, and
perinatal diseases. Professional societies need to alert governments
about the impending change in disease profiles so that planning and
prioritization can occur proactively rather than reactively. Research
is a key reason for increases in life expectancy around the world.
Research funded by governments can serve to stimulate local efforts.
Governments should be lobbied to establish specific policies that have
large effects on national risk factor profiles; such political activity
may be needed to counteract the influences of commercial groups
invested in disseminating atherogenic lifestyles. Examples of such
policies include taxation and control of tobacco, removal of subsidies
for meat and fat production, and reimbursement for
cost-effective behavioral lifestyle interventions.5
Finally, national science policies should support research and
development in cardiovascular
epidemiology, clinical algorithms, and
cost-effectiveness studies relevant to local health problems.
The commonality between countries or regions in terms of barriers to
preventive care and their solutions leads to the conclusion that there
is a need for a global effort to promote, coordinate, and expand
preventive cardiology efforts. Concern was expressed
about the division, duplication, or opposition of limited resources and
energies. It was concluded that a logical umbrella organization for the
coordination of these efforts was the International Society and
Federation of Cardiology (ISFC). This organization
serves as the contact for national and regional
cardiology societies and has just organized a task
force on risk factors in developing countries, which will survey and
prepare a white paper on global CVD prevention activities. Furthermore,
it will soon launch a journal, CVD Prevention. It is hoped
that this organization can engage the widest audience of interested
organizations while stimulating national societies to develop
consistently high-quality education, research, and care
programs. It is exceedingly important that the programs extend beyond
Europe, North America, and Australia/New Zealand. Professionals
concerned with the global epidemic of CVD should support and encourage
the ISFC to undertake meaningful actions in the near future.
The symposium concluded that cardiovascular specialty
societies cannot control the impending CVD epidemic by themselves.
However, unless these professionals (who know the most about CVD) take
a leadership role, any efforts by lay or governmental groups to control
the epidemic will surely lag if not fail. The lessons learned about the
CVD epidemic in developed countries should be shared with those
countries now encountering this problem. The call to action for
cardiovascular specialty societies, both national and
international, is a logical first step in a global response to an
increasingly global disease.
Acknowledgments
This symposium was supported by an unrestricted educational grant
from Merck and Co.
Footnotes
Reprint requests to Thomas A. Pearson, MD, PhD, Department of Community and Preventive Medicine, University of Rochester School of Medicine, 601 Elmwood Ave, Box 644, Rochester, NY 14642.
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© 1998 American Heart Association, Inc.
Special Report
Cardiovascular Specialty Societies and the Emerging Global Burden of Cardiovascular Disease
A Call to Action
Key Words: cardiovascular diseases • prevention • mortality • risk factors
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