Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data

Peiris D. Ghosh A. Manne-Goehler J. Jaacks L.M. Theilmann M. Marcus M.E. Zhumadilov Z. Tsabedze L. Supiyev A. Silver B.K. Sibai A.M. Norov B. Mayige M.T. Martins J.S. Lunet N. Labadarios D. Jorgensen J.M.A. Houehanou C. Guwatudde D. Gurung M.S. Damasceno A. Aryal K.K. Andall-Brereton G. Agoudavi K. McKenzie B. Webster J. Atun R. Bärnighausen T. Vollmer S. Davies J.I. Geldsetzer P.
4 March 2021 Public Library of Science

PLoS Medicine
2021 #18 Issue 3

Background Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population’s median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. Methods and findings We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%–4.2%) and 1.6% (1.3%–2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%–37.2%) for males and 41.6% (23.9%–53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%–58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. Conclusions This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.

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George Institute for Global Health, UNSW Sydney, Sydney, NSW, Australia
George Institute for Global Health, UNSW Sydney, New Delhi, India
Manipal Academy of Higher Education, Manipal, India
Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
Department of Economics, Centre for Modern Indian Studies, University of Goettingen, Goettingen, Germany
Nazarbayev University School of Medicine, Nur-Sultan, Kazakhstan
Eswatini Ministry of Health, Mbabane, Swaziland
Laboratory of Epidemiology and Public Health, Center for Life Sciences, National Laboratory Astana, Nazarbayev University, Astana, Kazakhstan
St. Francis Hospital Nsambya, Kampala, Uganda
Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
National Center for Public Health, Ulaanbaatar, Mongolia
National Institute for Medical Research, Dar es Salaam, Tanzania
Faculty of Medicine and Health Sciences, Universidade Nacional Timor Lorosa’e, Dili, Timor-Leste
Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
Department of Public Health, University of Copenhagen, Copenhagen, Denmark
Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan
Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
Monitoring Evaluation and Operational Research Project, Abt Associates, Kathmandu, Nepal
Non-Communicable Diseases, Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
Togo Ministry of Health, Lomé, Togo
Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
Medical Research Council, Wits University Rural Public Health, Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, United States

George Institute for Global Health
George Institute for Global Health
Manipal Academy of Higher Education
Heidelberg Institute of Global Health
Department of Global Health and Population
Department of Economics
Nazarbayev University School of Medicine
Eswatini Ministry of Health
Laboratory of Epidemiology and Public Health
St. Francis Hospital Nsambya
Department of Epidemiology and Population Health
National Center for Public Health
National Institute for Medical Research
Faculty of Medicine and Health Sciences
Departamento de Ciências da Saúde Pública e Forenses e Educação Médica
Faculty of Medicine and Health Sciences
Department of Public Health
Laboratory of Epidemiology of Chronic and Neurological Diseases
Department of Epidemiology and Biostatistics
Health Research and Epidemiology Unit
Faculty of Medicine
Monitoring Evaluation and Operational Research Project
Non-Communicable Diseases
Togo Ministry of Health
Institute of Applied Health Research
Centre for Global Surgery
Medical Research Council
Division of Primary Care and Population Health

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