Secondary Prevention of Coronary Heart Disease: Global Perspectives

Abstract

The burden of coronary heart disease (CHD) is increasing, and most of it is related to cardiovascular risk factors. Clinical guidelines recommend that CHD patients change health behaviors and use medication to modify and control risk factors and reduce their cardiovascular risk. However, controlling risk factors remains a challenge, especially regions with low resources and in specific population groups. This thesis presents a picture of secondary prevention of CHD, with a global perspective and a focus on regions where research has been limited. The findings show that the goals defined by clinical guidelines are often not met, globally and in areas often underrepresented in research. Around half of patients participate in cardiac rehabilitation, but attendance is lower in middle-income countries compared to high-income countries. Health inequities in secondary prevention are present worldwide, as patients with lower educational level are less likely to meet the risk factor targets and participate in cardiac rehabilitation. In the Southern Cone of Latin America, women with CHD have more cardiovascular risk factors than men, and patients without private health insurance more often face to barriers to receive necessary care. Future research should prospectively address the role of awareness on risk factor control, study health inequities with an intersectional perspective, and investigate opportunities to improve risk factor information recording. Use of real-world data, study designs that combine pragmatic and in dept-approaches, and collaborative efforts can improve the impact of surveys on research, practice and policy for secondary prevention of CHD. The main results of this thesis show poor attainement of cardiovascular risk factors globally and in areas often underrepresented in research. The findings also show important health inequities in secondary prevention of coronary heart disease, as participation in cardiac rehabilitation is lower in middle-income countries than in higher-income countries and patients with lower educational level are less likely to meet risk factor targets. In the Southern Cone of Latin America, women with CHD, and especially those with lower educational level, tend to present with more cardiovascluar risk factors, and patients without private insurance are more often face barriers to access care. Future research should adress risk factor awareness prospectively, the intersectionality in health inequities, and strategies to improve risk factor registration. Use of real-world data, study designs that combine pragmatic and in dept-approaches, and collaborative efforts can improve the impact of surveys on research, practice and policy for secondary prevention of CHD.