Cad program magnitude

Worldwide, the highest number of increases in the incidence of cardiac event has been in Latin America, the Middle East and to a lesser degree, the Far East, but shows some regional variation. Although the high occurrence of CAD in China is associated with traditional risk factors, the tendency of high incidence in India has not been explained by traditional risk factors [ 7 ].

It is observed that death rates and patterns differ between developed or high income countries and low and middle income countries [ 18 ]. In Latin America, the high incidence of CAD is explained by increased sedentary lifestyle, smoking and obesity [ 7 ]. When considering racial differences, mortality from CAD is higher in black compared to whites [ 7 ]. Therefore, the differences in disease prevalence in various parts of the world are possibly due to multiple factors [ 18 ].

Firstly, various phases of the epidemiological transition in different countries are a significant determinant [ 18 ]. When a country heads away from an agrarian economy to industrialization, there will be an increased level of risk factors and also upgraded medical facilities and public health for a large percentage of the general public.

Secondly, the presence of war or infection can bind the aging population and hence CAD mortality has not increased like in other regions [ 18 ]. Thirdly, various geographical regions may have genetic predisposition for CAD risk factors such as in South Asia, metabolic syndrome is a risk factor [ 18 , 19 ]. Though it is observed that the mortality rate from CAD has decreased over the last four decades, it still accounts for almost one third of deaths in individuals older than 35 years of age [ 7 ].

Approximately half of the reduction of mortality can be credited to the upgraded management of the acute phase of ACS and related complications like acute heart failure, improved primary and secondary prevention strategies and revascularization of chronic angina [ 7 ].

Further, a gender specific pattern of risk factors has become apparent globally, with women presenting with ACS having high rate of hypertension, diabetes mellitus and obesity as opposed to men [ 21 , 22 ]. Moreover, globally there is a tendency for female patients to receive less aggressive invasive and pharmacological treatment after ACS [ 21 , 22 ]. This will help in making strategies for primary and secondary prevention of CAD and ACS according to the risk factors present and to availability of resources within the region.

Manual search of other relevant journals and references lists of primary articles was done by Udaya Ralapanawa. Reference lists of identified papers, relevant reviews and meta-analyses were scrutinized for additional articles. Then the selected articles were reassessed for relevance and duplication. Out of all studies found, the studies which do not have access to full article were excluded. The search strategy was conducted following previously published principles.

All selected articles were read by authors. Detailed notes, impressions were written down and decided on which pieces of data possess values. Data was grouped in to relevant categories and subcategories low income and high income etc. Pattern and relationship between data sets were identified and analyzed in details and interpretations were made.

Based on geography and income level, the World Bank has recognised six low and middle income regions globally and the rest of high income countries are not geographically distinct [ 18 ]. Though there is large decline in deaths of CAD in high income countries, low and middle income countries show a mixed trend [ 18 , 24 , 25 ].

Some of the other countries of the region are Pacific islands, Thailand, Laos, Colombia and Malaysia. The life expectancy of the EAP region has risen rapidly [ 18 , 26 ]. The life expectancy in China increased from 37 to 71 years in the mids to respectively [ 18 , 27 ]. This increase of life expectancy can be aligned with rapid urban modernization, a large rural to urban migration, reduced birth rates, aging of the population, major dietary changes, increased tobacco and alcohol consumption and a movement toward work involving physical inactivity which all leads to changing patterns of CAD in the region [ 6 , 18 ].

The prevalence of angina was 8. In China, among men aged 35—64 years, stroke death rate is — per , versus CAD death rate is 64— per , [ 18 , 30 ]. In China, despite the high stroke rate, CAD rate has grown speedily over the last 20 years accounting for the second leading cause of death [ 31 ].

The incidence of CAD increased annually by 2. As reported by the WHO, in in Malaysia The Malaysian burden of disease study conducted in exhibited that CAD accounts for 22, deaths or about one fifth of all deaths [ 32 , 34 ]. In the coming few decades, the prevalence of CAD will see an upsurge in the Gulf region owing to rapid urbanization and increases in the number of relatively young inhabitants [ 47 ].

Patients in the MEA present with myocardial infarction at a younger age compared to other regions [ 48 , 49 ]. High prevalence of cardiovascular risk factors like hypertension, smoking, diabetes, dyslipidaemia and sedentary lifestyle in MENA region contribute to a high prevalence of CAD in the region [ 49 ]. The latest detailed national level epidemiological data are sparse for many countries in the Middle East region and a large number of temporary emigrant workforces in the region, cultural and environment barriers in the region complicate the development of such databases [ 49 ].

It is important that Gulf countries are accounting for higher ACS complications and mortality rate in women [ 49 ]. The earliest documented case of coronary atherosclerosis in Egypt was seen in a princess who died in her early 40s and lived between and BC [ 50 ]. In , CAD accounted for Recent studies expressed that ACS patients in Egypt are relatively young mean age 57 years compared with patients living in the West mean age 66 years [ 53 — 56 ].

In line with the Cardio Risk study done across Egypt, central obesity, diabetes and hypertension were more prevalent in women with ACS and were acknowledged as major risk factors for ACS [ 50 ]. The South Asia Region SAR is one of the most heavily populated zones in the world, comprising almost one fifth of the global population [ 18 , 57 , 58 ]. Statistics in revealed that more than one fourth of global low and middle income country CVD deaths were seen in this region [ 18 ].

In , CAD accounts for South Asians have a three to five times higher risk of myocardial infarction and also present at an earlier age with more severe disease compared to Caucasians [ 57 , 59 , 60 ]. South Asian origin is a well-known independent risk factor for mortality associated with CAD mortality [ 57 , 61 , 62 ]. Firstly, inhabitants in the region have a high prevalence of traditional risk factors e.

Prevalence of hypercholesterolaemia has gone up in Asia in the course of the past few decades and the smoking rate in Asian men is much higher than the West. Secondly, novel risk factors e. Lipoprotein-a, apolipoprotein B , CRP have been identified in South Asians contributing for CAD risk which is independent of traditional risk factors [ 57 , 63 — 65 ].

CAD accounts for In India, CAD accounted for However, these figures are likely underrated when compared to the real situation due to the absence of consistent mortality data, non-accounting of silent myocardial infarctions and asymptomatic CAD deaths [ 62 , 72 ]. It was evident that in India there was a two and a sixfold increase in CAD in rural areas and in urban areas respectively from to and CAD has been considered to be of epidemic proportion in India [ 73 — 75 ].

The systematic review done by Rao et al. Moreover, they concluded that the high prevalence of CAD risk factors, treatment delays and suboptimal use of evidence based treatment when managing CADs are common in India [ 76 ]. The upsurge in CAD prevalence in India is linked to economic and social change and its after effects like changes in dietary habits, reduced physical activity and increased incidence of hypertension and diabetes [ 77 ].

Today CAD has become a key public health issue in India and it also points to enormous economic burden [ 79 ]. The situation in Sri Lanka is also not much different to India. In Sri Lanka life expectancy for females is higher than males. Also over the last few decades, life expectancy for both genders is progressively going up [ 80 , 81 ]. According to the Annual Health Bulletin of Sri Lanka in , there was a rising trend of hospitalization due to CAD, which has been the leading cause of hospital deaths since [ 82 , 83 ].

In accordance with data, CAD is the main killer and is the leading cause of premature deaths in Sri Lanka [ 80 , 84 ]. Lack of reliable health statistics, insufficient diagnostic facilities, lack of health care professionals and misguided opinions are the major obstacles in this region [ 86 , 87 ].

About million people lived in SSA region in and the most populous nation was Nigeria million [ 18 ]. The estimated death rate in SSA ranged from per , to per , in Eastern and Central Africa respectively [ 88 ]. In SSA in spite of considerable westernisation of lifestyle with increasing risk factors, CAD remains very low in occurrence [ 91 ].

In North America and Western Europe, CAD is the principle cause of acute heart failure, but in SSA acute heart failure is triggered mainly by hypertension, cardiomyopathy and rheumatic heart disease [ 92 ]. As in developed countries, CAD increases with age in SSA, but the gender difference in prevalence is not seen here like that in the West [ 90 ].

In , the World Bank classified 81 countries and territories as high income countries [ 23 ]. Among the more developed countries, the highest CAD death rates are seen in Ukraine and Russia accounting for and deaths per , population respectively, while the lowest are seen in South Korea and Japan with When we consider CAD patterns in high income regions, in the USA, CAD is the leading cause of death in adults accounting for one third of all deaths in individuals older than 35 years [ 7 , 96 , 97 ].

It is projected that nearly a half of the middle aged men and one third of the middle age women in the United State of America USA will experience some symptoms of CAD [ 7 ]. In each year, more than , individuals will have their first myocardial infarction, and approximately , patients with diagnosed CAD will have recurrence [ 98 , 99 ]. It is predicted that each year an additional , silent first myocardial infarction will occur in the USA [ ]. Overall, the incidence of CAD has declined in the USA between and cases for every , person-years of follow up [ 7 ].

As stated in a study done between and , Yoon et al. It was forecasted that in one citizen in the US will have a MI every 44 s, and almost every 1 min, someone will die of coronary event [ 7 , ].

Cardiovascular disease DALYs in men was twice as high as that in women. About 12 CVD risk factors were recognized and the largest attributable CVD burden is owing to dietary risk exposures followed by high systolic blood pressure [ 70 ]. Premature CAD mortality followed a similar pattern [ ]. Though stroke incidence is decreasing in Japan, the number of population based epidemiological studies has seen a rise in CAD incidence among men in some parts of Japan in recent decades [ ].

This rise in incidence of CAD is attributable to westernization of lifestyle since [ ]. CAD accounts for nearly a half of heart disease related deaths [ , ]. The risk of dying from CAD and its incidence among Japanese women are half or lower than in Japanese men [ ].

Even though CAD mortality and prevalence vary among countries it is the top cause of death in countries of all income groups. Estimation of the true prevalence of CAD in the population is complex [ 7 ].

As a significant number of countries have not provided data, the provision of exact figures for epidemiological data is a barrier [ 2 ]. Further, the scientific studies carried out on CAD are limited in some regions especially in low and middle income countries including Sri Lanka.

The incidence of CAD continues to fall in developed countries, but due to immigration and progressive population aging the absolute number of coronary events and as a consequence of the prevalence of CAD will not reduce but it may even go up in near the future [ 7 ].

Developing countries display considerable variability in the incidence of CAD. The globalization of Western diet and increased sedentary lifestyle will have a dramatic impact on the progressive rise in the incidence of CAD in these countries [ 7 ]. The progressive decrease in mortality from CAD in developed countries over the recent few decades may be due to both effective treatment for the acute phase and improved primary and secondary preventive measures [ 7 ].

However, ethnic difference, social inequalities, and difference in availability of effective treatment and preventive measures in different regions of the same country may affect overall outcome and this needs more studies and evaluation of different regions within the country. Economic and social transformation is occurring much more rapidly in a post-industrial world with rapid globalization and this is a major challenge to low and middle income countries, unlike developed countries.

This has led to much more rapid changes in risk factors and incidence rate compared to the development of health care facilities, human resources and the infrastructure to manage CAD. Implementing public health strategies focused on primary prevention supported by a primary care infrastructure in both low and middle income countries and in groups with low socioeconomic status in high-income countries is a way forward. Mortality from non-communicable diseases including CAD is expected to rise in the coming decades due to worsening of metabolic risk factors.

Hence, the reduction in the CAD burden will require changes at both the policy as well as at the individual levels. Stake holders should target these risk factors through public health policies and this may be the best way to interrupt this trend. Risk factor prevention campaigns and mass media campaigns promoting healthy behavior may play a significant role in overcoming this problem. Coronary artery disease mortality and prevalence vary among countries.

As a significant number of countries have not provided data, the estimation of the exact figures for epidemiological data is a barrier. While the incidence of CAD continues to fall in developed countries over the last few decades, the developing countries show considerable variability in the incidence of CAD. All countries should make an effort to provide correct epidemiological data and to conduct studies and research on CAD risk factors, prevention and new treatment windows regionally as well as globally which will help in making future strategies.

UR conceived the research idea and conducted the literature searches, collected and collated articles and drafted this paper. UR and RS commented in details on drafts and contributed to the final version of the manuscript. National Center for Biotechnology Information , U. J Epidemiol Glob Health. Author information Article notes Copyright and License information Disclaimer.

Email: moc. Received May 25; Accepted Dec 4. Published by Atlantis Press International B. This article has been cited by other articles in PMC. Keywords: Coronary artery disease, acute coronary syndrome, coronary heart disease, epidemiology. RESULTS Based on geography and income level, the World Bank has recognised six low and middle income regions globally and the rest of high income countries are not geographically distinct [ 18 ].

Open in a separate window. Figure 1. Figure 2. South Asia region The South Asia Region SAR is one of the most heavily populated zones in the world, comprising almost one fifth of the global population [ 18 , 57 , 58 ]. Global perspective on acute coronary syndrome: a burden on the young and poor. Circ Res. Int J Cardiol. Glob Heart. Singapore and coronary heart disease: a population laboratory to explore ethnic variations in the epidemiologic transition.

Eur Heart J. Burden of ischaemic heart disease and attributable risk factors in China from to findings from the global burden of disease study. BMC Cardiovasc Disord. The epidemiology of coronary heart disease. Rev Esp Cardiol Engl Ed ; 67 — Global burden of cardiovascular diseases: part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies.

Global risk of coronary heart disease: assessment and application. Am Fam Physician. Reducing the global burden of cardiovascular disease, part 1: the epidemiology and risk factors. Reducing the global burden of cardiovascular disease, part 2: prevention and treatment of cardiovascular disease. WHO; Background Paper 6. Ischaemic heart disease. Coronary artery disease in Eur Heart J Suppl. Global, regional, and national burden of cardiovascular diseases for 10 causes, to J Am Coll Cardiol.

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