Global Cardiovascular

Health
Editors

GERALD S. BLOOMFIELD
MELISSA S. BURROUGHS PEÑA

CARDIOLOGY
CLINICS
www.cardiology.theclinics.com

Consulting Editors
JORDAN M. PRUTKIN
D AV I D M . S H AV E L L E
TERRENCE D. WELCH
AUDREY H. WU

February 2017 • Volume 35 • Number 1

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 Global Cardiovascular Health

Contributors

EDITORIAL BOARD

JORDAN M. PRUTKIN, MD, MHS, FHRS TERRENCE D. WELCH, MD, FACC

Assistant Professor of Medicine, Division of Staff Cardiologist, Assistant Professor of
Cardiology/Electrophysiology, University of Medicine, Geisel School of Medicine at
Washington Medical Center, Seattle, Dartmouth, Director, Cardiac Rehabilitation
Washington Program, Dartmouth-Hitchcock Medical
Center, Lebanon, New Hampshire
DAVID M. SHAVELLE, MD, FACC, FSCAI
Associate Professor, Keck School of Medicine,
AUDREY H. WU, MD
Director, General Cardiovascular Fellowship
Assistant Professor, Internal Medicine,
Program, Director, Cardiac Catheterization
University of Michigan, Ann Arbor, Michigan
Laboratory, Los Angeles County 1 USC
Medical Center, Division of Cardiovascular
Medicine, University of Southern California,
Los Angeles, California

EDITORS

GERALD S. BLOOMFIELD, MD, MPH, FACC, MELISSA S. BURROUGHS PEÑA, MD, MS

FASE, FAHA Assistant Professor of Medicine, Division of
Assistant Professor of Medicine and Global Cardiology, Department of Medicine,
Health, Division of Cardiology, Department of University of California, San Francisco,
Medicine, Duke Clinical Research Institute, San Francisco, California
Duke Global Health Institute, Duke University,
Durham, North Carolina

AUTHORS

MARWAH ABDALLA, MD, MPH ANDREA BEATON, MD

Assistant Professor, Center for Behavioral Division of Cardiology, Children’s National
Cardiovascular Health, Division of Cardiology, Health System, Washington, DC
Department of Medicine, Columbia University
Medical Center, New York, New York CATHERINE PASTORIUS BENZIGER, MD
Cardiology Fellow, Division of Cardiology,
WILSON ARUASA, MMED University of Washington, Seattle, Washington
Moi Teaching and Referral Hospital, Eldoret,
Kenya ANDREA BERATARRECHEA, MD, MSc
South American Center of Excellence for
FELIX A. BARASA, MMED Cardiovascular Health, Institute for Clinical
Moi Teaching and Referral Hospital, Eldoret, Effectiveness and Health Policy, Buenos Aires,
Kenya Argentina
iv Contributors

ANTONIO BERNABE-ORTIZ, MD, MPH ADRIAN GARDNER, MD, MPH

CRONICAS Center of Excellence in Chronic Visiting Lecturer, Moi University School of
Diseases, Universidad Peruana Cayetano Medicine, Assistant Professor of Clinical
Heredia, Lima, Peru Medicine, Infectious Diseases, Indiana
University School of Medicine, Indianapolis,
MICHAEL BESTAWROS, MD, MPH
Indiana
Cardiac Electrophysiologist, New Mexico
Heart Institute, Albuquerque, New Mexico
JOYCE GYAMFI, MS
GERALD S. BLOOMFIELD, MD, MPH, FACC, School of Medicine, New York University,
FASE, FAHA New York, New York
Assistant Professor of Medicine and Global
Health, Division of Cardiology, Department of OMARYS I. HERASME, MPH
Medicine, Duke Clinical Research Institute, Zena and Michael A. Wiener Cardiovascular
Duke Global Health Institute, Duke University, Institute, Icahn School of Medicine at Mount
Durham, North Carolina Sinai, New York, New York

GENE BUKHMAN, MD, PhD MERINA IEREMIA, PGDHS

Division of Global Health Equity, Brigham and Samoan Ministry of Health, Apia, Samoa
Women’s Hospital, Department of Global
Health and Social Medicine, Harvard Medical VILMA IRAZOLA, MD, MSc
School, Boston, Massachusetts South American Center of Excellence for
Cardiovascular Health, Institute for Clinical
MELISSA S. BURROUGHS PEÑA, MD, MS Effectiveness and Health Policy, Buenos Aires,
Assistant Professor of Medicine, Division of Argentina
Cardiology, Department of Medicine,
CLAIRE JOHNSON, MIPH
University of California, San Francisco, San
The George Institute for Global Health,
Francisco, California
University of Sydney, Sydney,
Australia
SUSIE J. CROWE, PharmD
Purdue University College of Pharmacy, West
ROHINA JOSHI, MBBS, PhD, MPH
Lafayette, Indiana
The George Institute for Global Health,
FRANÇOIS DELAHAYE, MD, PhD University of Sydney, Sydney, Australia
Professor, Department of Cardiology,
Hospices civils de Lyon, Université Claude JEMIMA H. KAMANO, MBChB, MMed
Bernard, Lyon, France College of Health Sciences, School of
Medicine, Moi University, Eldoret,
GABRIEL ASSIS LOPES DO CARMO, Kenya
MD, PhD
Adjunct Professor, Hospital das Clı́nicas and RAKHI KARWA, PharmD, BCPS
School of Medicine, Universidade Federal de Visiting Lecturer, Moi University School of
Minas Gerais, Belo Horizonte, Minas Gerais, Medicine, Assistant Clinical Professor,
Brazil Department of Pharmacy Practice, Purdue
University College of Pharmacy, West
LYDIA FISCHER, BA Lafayette, Indiana
Department of Medicine, Indiana University
School of Medicine, Indianapolis, Indiana GENE F. KWAN, MD, MPH
Department of Global Health and Social
VALENTIN FUSTER, MD, PhD Medicine, Harvard Medical School, Section of
Zena and Michael A. Wiener Cardiovascular Cardiovascular Medicine, Boston University
Institute, Icahn School of Medicine at Mount Medical Center, Boston University School of
Sinai, New York, New York Medicine, Boston, Massachusetts
 Contributors v

MARIA LAZO-PORRAS, MD SAILESH MOHAN, MD, MPH, PhD

CRONICAS Center of Excellence in Chronic Public Health Foundation of India, New Delhi,
Diseases, Universidad Peruana Cayetano India
Heredia, Lima, Peru
DANIELA MOYANO, BSc
CLAUDIA LEUNG, BS South American Center of Excellence for
Feinberg School of Medicine, Northwestern Cardiovascular Health, Institute for Clinical
University, Chicago, Illinois Effectiveness and Health Policy, Buenos Aires,
Argentina
MARYA LIEBERMAN, PhD
Department of Chemistry and Biochemistry, ARTHUR K. MUTYABA, MBChB, MMed,
University of Notre Dame, Notre Dame, Indiana FCP(SA)
FELIX LIMBANI, MPH Division of Cardiology, Department of
Centre for Health Policy, School of Public Medicine, Groote Schuur Hospital, University
Health, University of the Witwatersrand, of Cape Town, Cape Town,
Johannesburg, South Africa South Africa

PETER LIU, MD BENSON NJUGUNA, BPharm

University of Ottawa, Ottawa, Ontario, Canada Affiliate Faculty, Department of Pharmacy
Practice, Purdue University College of
PATRICIO LOPEZ-JARAMILLO, MD, PhD Pharmacy, West Lafayette, Indiana;
Research Institute FOSCAL, Bucaramanga, Pharmacist, Department of Pharmacy,
Colombia Moi Teaching and Referral Hospital, Eldoret,
IMRAN MANJI, BPharm Kenya
Affiliate Faculty, Department of Pharmacy
MPIKO NTSEKHE, MD, PhD, FACC
Practice, Purdue University College of
Division of Cardiology, Department of
Pharmacy, West Lafayette, Indiana; Senior
Medicine, Groote Schuur Hospital, University
Pharmacist, Department of Pharmacy, Moi
of Cape Town, Cape Town, South Africa
Teaching and Referral Hospital, Eldoret, Kenya

TARA McCREADY, PhD, MBA SHANTI NULU, MD, MPH

Population Health Research Institute, Section of Cardiovascular Medicine, Yale
Hamilton, Ontario, Canada School of Medicine, New Haven, Connecticut

WALTER MENDOZA, MD OLUGBENGA OGEDEGBE, MD, MS, MPH

United Nations Population Fund, Peru Country School of Medicine, New York University,
Office, San Isidro, Lima, Peru New York, New York

TIMOTHY MERCER, MD, MPH ELIJAH S. OGOLA, MMED

Visiting Assistant Professor of Clinical Department of Clinical Medicine, College of
Medicine, Department of Medicine, Indiana Health Sciences, University of Nairobi, Nairobi,
University School of Medicine, Indianapolis, Kenya
Indiana
BRIAN OLDENBURG, PhD, MPsych
J. JAIME MIRANDA, MD, MSc, PhD School of Population and Global Health,
School of Medicine, CRONICAS Center of University of Melbourne, Melbourne,
Excellence in Chronic Diseases, Universidad Australia
Peruana Cayetano Heredia, Lima, Peru
BRUCE OVBIAGELE, MD, MSc
ANA OLGA MOCUMBI, MD, PhD Medical University of South Carolina,
Chronic and Non-Communicable Disease Charleston, South Carolina
Division, National Health Institutes and
Eduardo Mondlane University, Maputo, MAYOWA OWOLABI, MBBS, MSc, DrM
Mozambique University of Ibadan, Ibadan, Nigeria
vi Contributors

SONAK D. PASTAKIA, PharmD, BCPS, MPH AMANDA G. THRIFT, PhD

Department of Pharmacy Practice, Purdue School of Clinical Sciences at Monash Health,
University College of Pharmacy, West Monash University, Melbourne, Australia
Lafayette, Indiana
SHELDON W. TOBE, MD, MScCH
DAVID PEIRIS, MBBS, PhD, MIPH University of Toronto, Toronto, Ontario,
The George Institute for Global Health, Canada
University of Sydney, Sydney,
Australia
DAN N. TRAN, PharmD
ARTI PILLAY, PGDPH Department of Pharmacy Practice, Purdue
Pacific Research Centre for the Prevention of University College of Pharmacy, West
Obesity and Non-Communicable Diseases, Fiji Lafayette, Indiana
National University, Suva, Fiji
KATHY TRIEU, MPH
VILARMINA PONCE-LUCERO, BA The George Institute for Global Health,
CRONICAS Center of Excellence in Chronic University of Sydney, Sydney, Australia
Diseases, Universidad Peruana Cayetano
Heredia, Lima, Peru RAJESH VEDANTHAN, MD, MPH
Zena and Michael A. Wiener Cardiovascular
DEVARSETTY PRAVEEN, MBBS, MD, PhD
Institute, Icahn School of Medicine at Mount
The George Institute for Global Health,
Sinai, New York, New York
Hyderabad, India
ERIC J. VELAZQUEZ, MD
ANTONIO LUIZ PINHO RIBEIRO, MD, PhD Department of Medicine, Duke Clinical
Professor, Division of Hospital das Clı́nicas and Research Institute, Duke Global Health
School of Medicine, Department of Internal Institute, Duke University, Durham, North
Medicine and Cardiology, Universidade Carolina
Federal de Minas Gerais, Belo Horizonte,
Minas Gerais, Brazil JACQUI WEBSTER, PhD
The George Institute for Global Health,
ALLMAN ROLLINS, MD
University of Sydney, Sydney, Australia
Department of Medicine, University of
California, San Francisco, San Francisco, RUTH WEBSTER, PhD, MIPH
California The George Institute for Global Health,
ADOLFO RUBINSTEIN, MD, MSc, PhD University of Sydney, Sydney, Australia
South American Center of Excellence for RUSS WHITE, MD, MPH, FACS(ECSA)
Cardiovascular Health, Institute for Clinical Tenwek Mission Hospital, Bomet, Kenya;
Effectiveness and Health Policy, Buenos Aires, Alpert School of Medicine, Brown University,
Argentina Providence, Rhode Island
JON-DAVID SCHWALM, MD, MSc KAREN YEATES, MD, MPH
Population Health Research Institute, School of Medicine, Queens University,
Hamilton, Ontario, Canada Kingston, Ontario, Canada

WILSON K. SUGUT, MMED KHALID YUSOFF, MBBS

Moi Teaching and Referral Hospital, Eldoret, Universiti Teknologi MARA, Selangor and UCSI
Kenya University, Kuala Lumpur, Malaysia
 Global Cardiovascular Health

Contents
Preface: Five Reasons Why Global Health Matters to Cardiologists xiii
Gerald S. Bloomfield and Melissa S. Burroughs Peña

Global Shifts in Cardiovascular Disease, the Epidemiologic Transition, and Other

Contributing Factors: Toward a New Practice of Global Health Cardiology 1
Walter Mendoza and J. Jaime Miranda

One of the major drivers of change in the practice of cardiology is population

change. This article discusses the current debate about epidemiologic transition
paired with other ongoing transitions with direct relevance to cardiovascular condi-
tions. Challenges specific to patterns of risk factors over time; readiness for disease
surveillance and meeting global targets; health system, prevention, and treatment
efforts; and physiologic traits and human-environment interactions are identified.
This article concludes that a focus on the most populated regions of the world will
contribute substantially to protecting the large gains in global survival and life expec-
tancy accrued over the last decades.

mHealth Interventions to Counter Noncommunicable Diseases in Developing

Countries: Still an Uncertain Promise 13
Andrea Beratarrechea, Daniela Moyano, Vilma Irazola, and Adolfo Rubinstein

mHealth constitutes a promise for health care delivery in low- and middle-income
countries (LMICs) where health care systems are unprepared to combat the threat
of noncommunicable diseases (NCDs). This article assesses the impact of mHealth
on NCD outcomes in LMICs. A systematic review identified controlled studies eval-
uating mHealth interventions that addressed NCDs in LMICs. From the 1274 ab-
stracts retrieved, 108 articles were selected for full text review and 20 randomized
controlled trials were included from 14 LMICs. One-way SMS was the most
commonly used mobile function to deliver reminders, health education, and informa-
tion. mHealth interventions in LMICs have positive but modest effects on chronic
disease outcomes.

Chagas Cardiomyopathy: Clinical Presentation and Management in the Americas 31

Catherine Pastorius Benziger, Gabriel Assis Lopes do Carmo, and Antonio Luiz Pinho Ribeiro

The initial infection of Chagas disease is typically asymptomatic, but approximately

30% of people will progress to a chronic cardiac form. Death is often sudden due
to arrhythmias or progressive heart failure. Prevention through vector control pro-
grams and blood bank screening, along with strengthened surveillance systems
and rapid information sharing, are key to decreasing disease burden globally.
The epidemiology, diagnostic evaluation, diagnosis, and treatment of acute and
chronic Chagas cardiac disease are discussed with focus on educating the primary
care professionals and general cardiologists in nonendemic areas who have limited
experience treating this disease.
viii Contents

Electrophysiology in the Developing World: Challenges and Opportunities 49

Michael Bestawros

As a subset of the growing epidemic of cardiovascular morbidity and mortality in

low-income and middle-income countries (LMICs), the significant burdens of heart
rhythm disorders also increase. Effective diagnostic and treatment modalities exist,
but financial resources and expertise are limited. Cost-effective strategies exist to
address most of these limitations, but many surmountable barriers need to be over-
come to introduce and improve electrophysiologic care in LMICs. In this article, cur-
rent and potential solutions are offered for the diagnostic and therapeutic challenges
of managing bradyarrhythmias and tachyarrhythmias.

Cardiac Disease Associated with Human Immunodeficiency Virus Infection 59

Gerald S. Bloomfield and Claudia Leung

Over the last 2 decades human immunodeficiency virus (HIV) infection has become a
chronic disease requiring long-term management. Aging, antiretroviral therapy,
chronic inflammation, and several other factors contribute to the increased risk of
cardiovascular disease in patients infected with HIV. In low-income and middle-
income countries where antiretroviral therapy access is limited, cardiac disease is
most commonly related to opportunistic infections and end-stage manifestations
of HIV/acquired immunodeficiency syndrome, including HIV-associated cardiomy-
opathy, pericarditis, and pulmonary arterial hypertension. Cardiovascular screening,
prevention, and risk factor management are important factors in the management of
patients infected with HIV worldwide.

Environmental Exposures and Cardiovascular Disease: A Challenge for Health and

Development in Low- and Middle-Income Countries 71
Melissa S. Burroughs Peña and Allman Rollins

Environmental exposures in low- and middle-income countries lie at the intersection

of increased economic development and the rising public health burden of cardio-
vascular disease. Increasing evidence suggests an association of exposure to
ambient air pollution, household air pollution from biomass fuel, lead, arsenic, and
cadmium with multiple cardiovascular disease outcomes, including hypertension,
coronary heart disease, stroke, and cardiovascular mortality. Although populations
in low- and middle-income countries are disproportionately exposed to environ-
mental pollution, evidence linking these exposures to cardiovascular disease is
derived from populations in high-income countries. More research is needed to
further characterize the extent of environmental exposures.

Diagnosis and Management of Endomyocardial Fibrosis 87

Andrea Beaton and Ana Olga Mocumbi

Endomyocardial fibrosis (EMF) remains an important cause of restrictive cardiomy-

opathy worldwide. Patients cluster in specific geographic locations and are almost
universally living in extreme poverty. Specific etiology remains elusive and is likely
multifactorial. Untreated EMF has a very poor prognosis. Medical management
can mitigate symptoms for a time but has no curative benefit. Early surgical interven-
tions may improve survival but are not readily available in most EMF-endemic re-
gions. Increased awareness, advocacy, and research are needed to further
understand this neglected tropical cardiomyopathy and to improve survival of those
affected.
 Contents ix

Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries 99

Rajesh Vedanthan, Antonio Bernabe-Ortiz, Omarys I. Herasme, Rohina Joshi,
Patricio Lopez-Jaramillo, Amanda G. Thrift, Jacqui Webster, Ruth Webster, Karen Yeates,
Joyce Gyamfi, Merina Ieremia, Claire Johnson, Jemima H. Kamano, Maria Lazo-Porras,
Felix Limbani, Peter Liu, Tara McCready, J. Jaime Miranda, Sailesh Mohan,
Olugbenga Ogedegbe, Brian Oldenburg, Bruce Ovbiagele, Mayowa Owolabi, David Peiris,
Vilarmina Ponce-Lucero, Devarsetty Praveen, Arti Pillay, Jon-David Schwalm, Sheldon W. Tobe,
Kathy Trieu, Khalid Yusoff, and Valentin Fuster

Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure,
and stroke, is the leading global risk for mortality. Treatment and control rates are
very low in low- and middle-income countries. There is an urgent need to address
this problem. The Global Alliance for Chronic Diseases sponsored research projects
focus on controlling hypertension, including community engagement, salt reduction,
salt substitution, task redistribution, mHealth, and fixed-dose combination thera-
pies. This article reviews the rationale for each approach and summarizes the expe-
rience of some of the research teams. The studies demonstrate innovative and
practical methods for improving hypertension control.

Ambulatory Blood Pressure Monitoring: A Complementary Strategy for Hypertension

Diagnosis and Management in Low-Income and Middle-Income Countries 117
Marwah Abdalla

Ambulatory blood pressure monitoring (ABPM) can assess out-of-clinic blood pres-
sure. ABPM is an underutilized resource in low-income and middle-income coun-
tries but should be considered a complementary strategy to clinic blood pressure
measurement for the diagnosis and management of hypertension. Potential uses
for ABPM in low-income and middle-income countries include screening of high-
risk individuals who have concurrent communicable diseases, such as HIV, and in
task-shifting health care strategies.

Ensuring Patient-Centered Access to Cardiovascular Disease Medicines in Low-Income

and Middle-Income Countries Through Health-System Strengthening 125
Dan N. Tran, Benson Njuguna, Timothy Mercer, Imran Manji, Lydia Fischer, Marya Lieberman,
and Sonak D. Pastakia

Cardiovascular disease (CVD) is the leading cause of global mortality and is ex-
pected to reach 23 million deaths by 2030. Eighty percent of CVD deaths occur in
low-income and middle-income countries (LMICs). Although CVD prevention and
treatment guidelines are available, translating these into practice is hampered in
LMICs by inadequate health care systems that limit access to lifesaving medica-
tions. In this article, we describe the deficiencies in the current LMIC supply chains
that limit access to effective CVD medicines, and discuss existing solutions that are
translatable to similar settings so as to address these deficiencies.

Tuberculosis and the Heart 135

Arthur K. Mutyaba and Mpiko Ntsekhe

Video content accompanies this article at http://www.cardiology.theclinics.com.

Owing to the high prevalence of tuberculosis (TB) and human immunodeficiency

virus/AIDS, tuberculous heart disease remains an important problem in TB endemic
areas. In this article, we reiterate salient aspects of the traditional understanding and
x Contents

approach to its management, and provide important updates on the pathophysi-

ology, diagnosis, and treatment garnered over the past decade of focused clinical
and basic science research. We emphasize that, if implemented widely, these
improved evidence-based approaches to the disease can build on the early prog-
ress made in treating tuberculous heart disease and help further the goal of signifi-
cantly reducing its historically high morbidity and mortality.

Approaches to Sustainable Capacity Building for Cardiovascular Disease Care in Kenya 145
Felix A. Barasa, Rajesh Vedanthan, Sonak D. Pastakia, Susie J. Crowe, Wilson Aruasa,
Wilson K. Sugut, Russ White, Elijah S. Ogola, Gerald S. Bloomfield, and Eric J. Velazquez

Cardiovascular diseases are approaching epidemic levels in Kenya and other low-
and middle-income countries without accompanying effective preventive and thera-
peutic strategies. This is happening in the background of residual and emerging
infections and other diseases of poverty, and increasing physical injuries from traffic
accidents and noncommunicable diseases. Investments to create a skilled workforce
and health care infrastructure are needed. Improving diagnostic capacity, access to
high-quality medications, health care, appropriate legislation, and proper coordina-
tion are key components to ensuring the reversal of the epidemic and a healthy citi-
zenry. Strong partnerships with the developed countries also crucial.

Infective Endocarditis in Low- and Middle-Income Countries 153

Benson Njuguna, Adrian Gardner, Rakhi Karwa, and François Delahaye

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of

25% and significant debilitating morbidities. Although much has been reported on
contemporary IE in high-income countries, conclusions on the state of IE in low-
and middle-income countries (LMICs) are based on studies conducted before the
year 2000. Furthermore, unique challenges in the diagnosis and management of
IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting
clinical experiences from the year 2000 to 2016. Presented are the causes of IE,
management of patients with IE, and prevailing challenges in diagnosis and treat-
ment of IE in LMICs.

Rheumatic Heart Disease: The Unfinished Global Agenda 165

Shanti Nulu, Gene Bukhman, and Gene F. Kwan

Primarily affecting the young, rheumatic heart disease (RHD) is a neglected chronic
disease commonly causing premature morbidity and mortality among the global
poor. Standard clinical prevention and treatment is based on studies from the early
antimicrobial era, as research investment halted soon after the virtual eradication of
the disease from developed countries. The emergence of new global data on dis-
ease burden, new technologies, and a global health equity platform have revitalized
interest and investment in RHD. This article surveys past and current evidence for
standard RHD diagnosis and treatment, highlighting gaps in knowledge.

Index 181
 Global Cardiovascular Health xi

CARDIOLOGY CLINICS
FORTHCOMING ISSUES RECENT ISSUES
May 2017 November 2016
Hypertension: Pre-Hypertension Sports Cardiology
to Heart Failure Aaron Baggish and Andre La Gerche, Editors
Kenneth Jamerson and James Brian Byrd,
August 2016
Editors
Pulmonary Hypertension
August 2017 Ronald J. Oudiz, Editor
Aortic Diseases
May 2016
Fernando Fleischman, Editor
Cardioembolic Stroke
November 2017 Ranjan K. Thakur, Ziyad M. Hijazi, and
Pericardial Disease Andrea Natale, Editors
Jae K. Oh, William Miranda, and
Terrence D. Welch, Editors

ISSUE OF RELATED INTEREST

Heart Failure Clinics, October 2015 (Vol. 11, No. 4)
A Global Perspective/Health Inequity in Heart Failure
Pablo F. Castro, Naoki Sato, Robert J. Mentz, and Ovidiu Chioncel, Editors
Available at: http://www.heartfailure.theclinics.com

THE CLINICS ARE AVAILABLE ONLINE!

Access your subscription at:
www.theclinics.com
 Global Cardiovascular Health

P re f a c e
Fiv e Re as on s Wh y G l o ba l
H e a l t h M a t t e r s to
C a rd i o l o g i s t s

Gerald S. Bloomfield, MD, MPH, FACC, FASE, FAHA Melissa S. Burroughs Peña, MD, MS
Editors

With less and less free time to ponder the grand (Beaton A, Mocumbi AO: Diagnosis and manage-
questions in life, it can be a challenge for a prac- ment of endomyocardial fibrosis, in this issue)? In
ticing cardiologist to contemplate why global addition, the Centers for Disease Control and Pre-
health matters. Yet, it is also undeniable that we vention receives approximately 125 reports each
live in a global environment. In 2014, over three year of arriving travelers with active tuberculosis.2
billion people traveled internationally by air from The potential morbidity from tuberculous pericar-
41,000 airports around the world, and by 2030, ditis (Mutyaba AK, Ntsekhe M: Tuberculosis and
the number will increase to 5.9 billion.1 Events the heart, in this issue) and other infectious cardiac
happening in distant countries can now be broad- diseases (eg, associated with HIV) (Bloomfield GS,
cast directly to our televisions or phones in real Leung C: Cardiac disease associated with human
time. How does this global interconnectedness immunodeficiency virus infection, in this issue)
impact our practice and profession? Here we offer warrants attention to vectors that can cross bor-
five reasons global health matters, especially to ders. On the other hand, for cardiac patients trav-
cardiologists in high-income, or developed, eling to developing countries, familiarity with the
countries. cardiac services in other countries can be useful
in case of unforeseen circumstances (eg, Where
PATIENTS TRAVEL could I have my device interrogated?) (Bestawros
M: Electrophysiology in the developing world:
Cardiologists in developed countries need the challenges and opportunities, in this issue).
skills to offer health advice to patients who have
recently immigrated to developed countries. For CULTURAL SENSITIVITY
example, 13% of all people living in the United
States are foreign born, with California and New Global health requires increased sensitivity to
York having the highest portion of foreign-born cross-cultural issues. Patients’ explanatory
residents. Familiarity with cardiovascular diseases models of disease often have cultural underpin-
(CVDs) endemic to other parts of the world pre- nings, which in turn affect health care decisions
cardiology.theclinics.com

pares cardiologists to identify rare conditions. and adherence to medications. Some underrepre-
When was the last time you may have missed a sented minority patients might distrust the health
case of Chagas disease (Benzinger CP, do Carmo care system, possibly as a result of historical
GAL, Ribeiro ALP: Chagas cardiomyopathy: clin- discrimination. The same may be true of recent im-
ical presentation and management in the Ameri- migrants. The role of kin in health care decision-
cas, in this issue), or endomyocardial fibrosis making and disclosure can have cultural

Cardiol Clin 35 (2017) xiii–xv

http://dx.doi.org/10.1016/j.ccl.2016.10.001
0733-8651/17/Ó 2016 Published by Elsevier Inc.
xiv Preface

foundations, which cardiologists should be pre- issue). The persistent burden of rheumatic heart
pared to consider. disease (Nulu S, Bukhman G, Kwan GF: Rheu-
matic heart disease: the unfinished global agenda,
DISCOVERY KNOWS NO BORDERS in this issue), infective endocarditis (Njuguna B,
Gardner A, Karwa R, et al: Infective endocarditis
No country has a monopoly on talent.3 International in low- and middle-income countries, in this issue),
collaboration has been a hallmark of cardiovascu- and cardiotoxic environmental exposures in devel-
lar clinical trails going back to the GISSI4 and oping countries (Burroughs Peña MS, Rollins A:
GUSTO studies.5 Increasingly, collaboration with Environmental exposures and cardiovascular dis-
professionals from around the world informs how ease: a challenge for health and development in
we derive evidence-based medicine. To do this low- and middle-income countries, in this issue)
well, investment must be made in global research should spur those in developed countries to act
training and capacity building (Barasa FA, Vedan- whenever possible. Action to address inequalities
than R, Pastakia SD, et al: Approaches to sustain- in the upstream determinants of health outcomes
able capacity building for cardiovascular disease is always timely, and opportunities for the prac-
care in Kenya, in this issue). In turn, many recent in- ticing cardiologist to engage are increasingly
novations in cardiovascular care have roots in available.6
developing countries, including fixed-dose combi-
nation therapy and task redistribution to combat
hypertension (Vedanthan R, Bernabe-Ortiz A, Her- THE FUTURE OF OUR PROFESSION
asme OI, et al: Innovative approaches to hyperten-
The importance of global health to trainees cannot
sion control in low- and middle-income countries,
be overstated. This interest is driven by increased
in this issue), the use of mobile phones to access ru-
awareness of gross disparities between low-, mid-
ral populations and ensure that patients take their
dle-, and high-income countries. There are now
medicine (Beratarrechea A, Moyano D, Irazola V,
many examples of cardiologists and fellows-in-
et al: mHealth interventions to counter non-
training who have embraced global health as one
communicable diseases in developing countries:
of the main defining features of their practice and
still an uncertain promise, in this issue) and ambula-
research.7–10 Early clinical experiences in
tory blood pressure monitoring for hypertension
resource-limited settings usually derive a
control (Abdalla M: Ambulatory blood pressure
continuing return over one’s career. The rewards
monitoring: a complimentary strategy for hyperten-
span character development as well as clinical
sion diagnosis and management in low and middle-
expertise. As Mark Twain said, “Travel is fatal to
income countries, in this issue). If we are intentional
prejudice, bigotry, and narrow-mindedness, and
and receptive, we may find many potential solu-
many of our people need it sorely on these ac-
tions outside of our own borders.
counts. Broad wholesome, charitable views of
men and things cannot be acquired by vegetating
SUTTON’S LAW
in one little corner of the earth all one’s lifetime.”
Willie Sutton, the bank robber, is often quoted as The fourteen articles in this issue of Cardiology
responding to the question, “Why did you rob Clinics offer a contemporary compendium of
banks?,” by saying, “That’s where the money is.” global health issues of high importance to the gen-
Eighty percent of all deaths due to CVD occur in eral cardiologist. Not only does global health
low- and middle-income countries. On an interna- impact our clinical practice and daily life but also
tional level, interventions to combat CVD would globalization and interconnectedness will increas-
potentially have the greatest impact in these coun- ingly become the norm for how we train future
tries (Mendoza W, Miranda JJ: Global shifts in car- generations.
diovascular disease, the epidemiologic transition
and other contributing factors: toward a new prac- Gerald S. Bloomfield, MD, MPH, FACC, FASE,
tice of global health cardiology, in this issue). There FAHA
are untenable international disparities in the Duke Clinical Research Institute
burden of CVD and access to appropriate thera- Duke Global Health Institute
pies (Tran DN, Njuguna B, Mercer T, et al: Ensuring Department of Medicine
patient-centered access to cardiovascular dis- Duke University
ease medicines in low- and middle-income coun- 2400 Pratt Street
tries through health-system strengthening, in this Durham, NC 27705, USA
 Preface xv

Melissa S. Burroughs Peña, MD, MS 4. Maggioni AP, Franzosi MG, Fresco C, et al. GISSI tri-
Division of Cardiology als in acute myocardial infarction. Rationale, design,
Department of Medicine and results. Chest 1990;97:146S–50S.
University of California 5. The GUSTO Investigators. An international random-
505 Parnassus Avenue ized trial comparing four thrombolytic strategies for
11th Floor, Room 1180D acute myocardial infarction. The GUSTO investiga-
San Francisco, CA 94143, USA tors. N Engl J Med 1993;329:673–82.
6. Seals AA. ACC International outreach and the global
E-mail addresses: cardiovascular community. J Am Coll Cardiol 2016;
[email protected] (G.S. Bloomfield) 67:3011–3.
[email protected] (M.S. Burroughs Peña) 7. Bloomfield GS, Huffman MD. Global chronic disease
research training for fellows: perspectives, challenges,
and opportunities. Circulation 2010;121:1365–70.
REFERENCES
8. Abdalla M, Kovach N, Liu C, et al. The importance of
1. Mangili A, Vindenes T, Gendreau M. Infectious risks global health experiences in the development of new
of air travel. Microbiol Spectr 2015;3:333–44. cardiologists. J Am Coll Cardiol 2016;67(23):2789–97.
2. Centers for Disease Control and Prevention (CDC). 9. Patel A. Organizing a career in global cardiovascu-
Public health interventions involving travelers with lar health. J Am Coll Cardiol 2015;65:2144–6.
tuberculosis—U.S. ports of entry, 2007-2012. 10. Binanay CA, Akwanalo CO, Aruasa W, et al. Building
MMWR Morb Mortal Wkly Rep 2012;61:570–3. sustainable capacity for cardiovascular care at a
3. Glass RI. What the United States has to gain from public hospital in Western Kenya. J Am Coll Cardiol
global health research. JAMA 2013;310:903–4. 2015;66:2550–60.
Global Shifts in
C a rdi o v a s c u l a r D i s e a s e ,
t h e E p i d e m i o l o g i c Tr a n s i t i o n ,
and O ther Contributing Factors
Toward a New Practice of Global Health
Cardiology
Walter Mendoza, MDa, J. Jaime Miranda, MD, MSc, PhDb,c,*

KEYWORDS
 Epidemiology  Demography  Health transitions  Developing countries  Cardiology
 Global health

KEY POINTS
 Developed countries had more than a century to double or triple their populations, whereas the
same increases in population size in the developing world have occurred over decades.
 The epidemiologic transition theory is not perfect but has improved the understanding of the chang-
ing dynamics of epidemiologic profiles.
 Changes in population structures and disease profiles, cardiovascular conditions, and their asso-
ciated comorbidities will continue to challenge health care systems.
 A focus on the most populated regions of the world will contribute to protecting the large gains in
global survival and life expectancy accrued over the last decades.
 From a low-income and middle-income country perspective, current challenges provide an oppor-
tunity to redefine the agenda of global health cardiology and global cardiovascular research.

Financial Conflicts of Interest: The authors have nothing to disclose.

Funding Sources: Dr J.J. Miranda acknowledges receiving current and past support from the Alliance for
Health Policy and Systems Research (HQHSR1206660), Consejo Nacional de Ciencia, Tecnologı́a e Innovación
Tecnológica (CONCYTEC), DFID/MRC/Wellcome Global Health Trials (MR/M007405/1), Fogarty International
Center (R21TW009982), Grand Challenges Canada (0335-04), International Development Research Center
Canada (106887, 108167), Inter-American Institute for Global Change Research (IAI CRN3036), National
Heart, Lung, and Blood Institute (5U01HL114180, HHSN268200900028C), National Institute of Mental
Health (1U19MH098780), Swiss National Science Foundation (40P740-160366), UnitedHealth Foundation,
Universidad Peruana Cayetano Heredia (Fondo Concursable No. 20205071009), and the Wellcome Trust
(074833/Z/04/A, WT093541AIA, 103994/Z/14/Z).
Disclaimer: W. Mendoza is currently Program Analyst, Population and Development, at the United Nations
cardiology.theclinics.com

Population Fund in Peru, which does not necessarily endorse this contribution.
a
United Nations Population Fund, Peru Country Office, Av. Guardia Civil 1231, San Isidro, Lima 27, Peru;
b
School of Medicine, Universidad Peruana Cayetano Heredia, Av. Honorio Delgado 430, Urb. Ingenierı́a,
San Martı́n de Porres, Lima 31, Peru; c CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana
Cayetano Heredia, Av. Armendáriz 497, Miraflores, Lima 18, Peru
* Corresponding author. CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano
Heredia, Av. Armendáriz 497, Miraflores, Lima 18, Peru.
E-mail address: [email protected]

Cardiol Clin 35 (2017) 1–12

http://dx.doi.org/10.1016/j.ccl.2016.08.004
0733-8651/17/Ó 2016 Elsevier Inc. All rights reserved.
2 Mendoza & Miranda

INTRODUCTION context provides an entry point to delineate the

need for a global health cardiology practice that
As the world changes, the practice of cardiology, aligns with the major challenges in the most popu-
clinical cardiology, global health cardiology, and lated regions of the world, which bear a growing
cardiology research will follow suit. One of the ma- burden of cardiovascular diseases and conditions.
jor drivers of change in the practice of cardiology, in
both developed and developing countries, is popu- THE EPIDEMIOLOGIC TRANSITION: ITS
lation change, whose dynamics can be expressed DEFINITION AND ITS PLACE IN HISTORY
by secular epidemiologic and demographic trends,
with increasing survival and life expectancy across The epidemiologic transition theory, or model, was
all age strata. These population changes, at the coined in the early 1970s by Abdel Omran.18 Pub-
macro level, are not static or isolated but occur lished at a time when development debates were
together with many other individual-level changes influenced by fears of the so-called demographic
and adaptations, including, but not limited to, ac- explosion, in Omran’s18 view the “key difference
cess to and usage of technological changes1; between epidemiologic transition and demo-
changes in health care delivery,2,3 in medical graphic transition theories was that the former un-
training,4 and in the practice of medicine5; or even like the latter allowed for multiple pathways to a
changes within people; for example, changes in low-mortality/low-fertility population regime.”19 In
the height of populations over time,6 as well as short, Omran’s18 theory identified the 3 phases
changes within individuals, such as the recently of transition: pestilence and famine, receding pan-
shown link between microbiota and stroke out- demics, and degenerative and human created
comes.7 In this regard, over the last few years has transition. These phases were later nuanced by
become more common, and indeed necessary, to Olshansky and Ault20 who added a fourth stage:
encourage interdisciplinary dialogues to better delayed degenerative or hybristic diseases (ie,
serve medical interventions at the individual and influenced by individual behaviors and lifestyles).21
population levels. In relation to cardiovascular disease, Table 1
A long trend in the mutual interaction of technol- shows the classic stages of the epidemiologic
ogies, policies, and social movements; global de- transition. More recently, given the increase in
mographic transition; and its epidemiologic body mass index worldwide,22 some investigators
correlates continues to increase population size propose a fifth stage in the transition: the age of
across age groups, and since the early nineteenth obesity and inactivity.23,24
century it has increased by 6 times. It is projected However, from a historical point of view,
to further increase up to 10 times by the end of this Omran18 was not the first to link population
century, and by then most countries will experi- changes to epidemiologic and mortality patterns.
ence demographic aging. Life expectancy will Alternative explanations of the epidemiologic
continue to grow (it has doubled in last 2 cen- changes in patterns of mortality were described
turies), whereas female fertility will continue to a few decades before Omran’s18 views were pub-
decline. By the early nineteenth century, 70% of lished. Thomas McKeown described secular de-
women’s adult life was dedicated to bearing chil- clines in England’s mortality since the eighteenth
dren, a percentage that has now decreased to century throughout the process of industrialization
14% because of lower fertility and longer and as a consequence of better nutrition and sanitation
healthier living.8 rather than of medical interventions.25 In contrast,
Much of the transition in mortality and risk fac- Omran’s18 thesis was more optimistic about the
tors for noncommunicable diseases, including car- benefits of technology in the developing world,
diovascular diseases, has been described in detail claiming that mortality decline depended more
elsewhere,9–17 but few have been addressed to a on developing interventions oriented toward sup-
clinical audience, and in particular what do such porting national and international programs of
transitions mean for low-income and middle- health service provision and environmental con-
income settings. This article describes current de- trol.25 Subsequent analyses, based on new
bates and analyzes the pertinence and relevance methods and sources, revealed some flaws in
of the epidemiologic transition, paired with the de- the McKeown assumptions,26 as has also
mographic transition and other ongoing transitions happened to some of Omran18 claims, in relation
with direct relevance to cardiovascular conditions. to the double burden or overlapping of both
In doing so, this article emphasizes the challenges communicable and noncommunicable diseases.27
of this transition for low-income and middle- Importantly from a contextual point of view, such
income settings undergoing rapid epidemiologic debates around patterns of mortality took place by
shifts. In addition, this analysis of trends and the 1970s, after the dominance of a discourse
 Table 1
Stages of the epidemiologic transition and its global status, by region

Percentage
of the World’s
Life Dominant Form Percentage of Deaths Population in
Stage Description Expectancy of CVD Attributable to CVD This Stage Regions Affected
Pestilence Predominance of 35 RHD cardiomyopathy 5–10 11 Sub-Saharan Africa,
and famine malnutrition and caused by infection parts of all regions,
infectious diseases and malnutrition excluding high-
income regions
Receding Improved nutrition and 50 Rheumatic valvular 15–35 38 South Asia, southern
pandemics public health lead to disease, IHD, east Asia and the
increase in chronic hemorrhagic stroke Pacific, parts of Latin
diseases, America and the
hypertension Caribbean
Degenerative Increased fat and caloric 60 IHD, stroke (ischemic >50 35 Europe and central Asia,
and human intake, widespread and hemorrhagic) northern east Asia
created tobacco use, chronic and the Pacific, Latin
disease deaths exceed America and the

Global Shifts in Cardiovascular Disease

mortality from Caribbean, Middle
infections and East and North Africa,
malnutrition and urban parts of
most low-income
regions (eg, India)
Delayed CVD and cancer are 70 IHD, stroke (ischemic <50 — High-income countries,
degenerative leading causes of and hemorrhagic), parts of Latin
diseases morbidity and CHF America, and the
mortality; prevention Caribbean
and treatment avoid
death and delay
onset; age-adjusted
CVD declines

Abbreviations: CHF, congestive heart failure; CVD, cardiovascular disease; IHD, ischemic heart disease; RHD, rheumatic heart disease.
From Gaziano T, Reddy KS, Paccaud F, et al, editors. Disease control priorities in developing countries. 2nd edition. Washington, DC: World Bank and Oxford University Press. Ó
World Bank. https://openknowledge.worldbank.org/handle/10986/7242 License: CC BY 3.0 IGO.

3
4 Mendoza & Miranda

around infectious diseases, by then allegedly soon size in the developing world have occurred over
to be globally controlled, and just some years decades. Although most nations accommodate
before emerging and reemerging infectious dis- population growth, other transitions are directly
eases would recover momentum. In the last 2 de- relevant to cardiovascular health. Urbanization,
cades the concept of the epidemiologic transition nutrition and diet, food systems,30 culture, and
has gained even more attention, including its revi- technology, interplay one with another to
sionist versions28 stressing the relevance of the contribute to sustained increased survival in a
concept of societies, particularly for developing long-term shift from low to high life expectancy.31
countries together with the World Bank, and its ap- According to the demographic transition
proaches to health economics,29 showing concerns approach, in both the developing and developed
about the health of adults and chronic diseases. Far world, the longevity transition merits attention.32
from being a perfect theory to explain transitions, As Fig. 1 shows, the average remaining years to
Omran’s18 epidemiologic transition allowed for a be lived at age 60 years will continue to increase,
conversation in terms of populations and specif- with a slight advantage for women compared
ically of population health. As suggested by others, with men. This longevity transition will have
“an expanded model of transition should account different impacts across heterogeneous societies
for the immense regional variation in disease depending on how they deal with mortality de-
burden, disparities in health systems, and the clines and growing morbidity. In so doing, health
stacking of multiple kinds of epidemics within small care delivery, its workforce, organization and infra-
areas and over short periods of time.”17 structure, ethics, economics, and health financing
will be directly involved in shaping the future pat-
NOT 1 BUT SEVERAL OVERLAPPING terns of population morbidity and mortality.
TRANSITIONS In the late 1980s, Mexican researchers led by
Frenk and colleagues33 showed that in low-
The concept of transition, whether demographic or income and middle-income countries, along with
epidemiologic, is dynamic. From a global health the epidemiologic transition, there was a transition
point of view, one element merits attention: devel- in the capacity of the health care system to deal
oped countries have had more time to double or with various conditions. In unequal and heteroge-
triple their populations, usually more than 1 cen- neous countries, such as those in Latin America,
tury, whereas the same increases in population the paces of epidemiologic transition were

Fig. 1. Life expectancy at age 60 years, selected regions, 1950 to 2100. (From United Nations, Department of
Economic and Social Affairs, Population Division. World population prospects: the 2015 revision, key findings
and advance tables. 2015. Available at: http://esa.un.org/unpd/wpp/publications/files/key_findings_wpp_2015.
pdf. Accessed May 4, 2016; with permission.)