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Congestive heart failure in Latin America: the next epidemic
Congestive heart failure in Latin America: The next epidemic Luz A. Cubillos-Garzo ´ n, MD,a Juan P. Casas, MD,b Carlos A. Morillo, MD, FRCPC,c,d and Leonelo E. Bautista, MD, MPH, DrPHe Bogota and Bucaramanga, Colombia, London, United Kingdom, Hamilton, Ontario, Canada, and Bethesda, Md
Coronary artery disease is the main cause of congestive heart failure (CHF) in all populations. Latin American countries (LAC) are undergoing the first phase of an epidemic of coronary artery disease that probably will lead to an increased incidence of CHF. The progressive implementation of successful interventions, such as early reperfusion and rehabilitation programs, should increase the survival of patients with acute myocardial infarction and the population at high risk of CHF. The increasing prevalence of risk factors, such as diabetes, hypertension, and obesity, and the ageing of the population may also contribute to a rising incidence of CHF in LAC. Moreover, infectious diseases such as Chagas disease and rheumatic heart disease, known causes of CHF, are still frequent in this population and additionally contribute to the incidence of CHF. If timely preventive interventions are not implemented, CHF could become one of the main contributors to the burden of morbidity, mortality, and health costs in LAC. Properly conducted clinical and epidemiologic studies are needed to identify, implement, and evaluate preventive strategies that are likely to succeed within the specific context of LAC. (Am Heart J 2004;147:412–7.)
See related Editorial on page 386.
In the United States, the age-adjusted cardiovascular disease mortality rate has decreased 51% in the last 3 decades.1 From 1987 to 1994, coronary artery disease (CAD) mortality rates among 34- to 74-year-olds fell by 28% in men and 31% in women.2 Between 1970 and 2000, the myocardial infarction (MI) inhospital casefatality rate declined from 38% to 13% in subjects ⱖ65 years old and from 16% to 6% in those 45 to 64 years old.1 Similar trends have been observed in other developed countries.3 Since survivors of a MI are at higher risk of congestive heart failure (CHF), the improvement in therapeutic treatment and the longer survival of patients with MI have contributed to increase the incidence of CHF in developed countries.4 In fact, from 1971 to 2000, the CHF hospitalization rate in the US population tripled, whereas the prevalence doubled.1 A higher CHF From the aHeart Failure Council, Colombian Society of Cardiology, Bogota, Colombia, the bCentre for Clinical Pharmacology, BHF Laboratories at University College London, London, United Kingdom, the cCardiovascular Research Institute, Fundacio´n Cardiovascular del Oriente Colombiano, Bucaramanga, Colombia, the dDepartment of Medicine, Cardiology Division, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, and eUniformed Services University of the Health Sciences, Bethesda, Md. Submitted February 10, 2003; accepted July 28, 2003. Reprint requests: Leonelo E. Bautista, MD, MPH, DrPH, University of Wisconsin Medical School, Department of Population Health Sciences, 610 Walnut Street, 703 WARF, Madison, WI 53726-2397. E-mail: [email protected] 0002-8703/$ - see front matter © 2004, Elsevier Inc. All rights reserved. doi:10.1016/j.ahj.2003.07.026
incidence resulted in increasing CHF age-adjusted death rate during the 1980s, even though the casefatality rate decreased from 5.6% to 2.3% in this period.1 During the 1990s, death rates leveled off, and case-fatality rate continued declining, but hospitalization rates have continued to increase. On the contrary, data from the United States National Health and Nutrition Examination Surveys have shown a considerable decline in the prevalence of cardiovascular risk factors, particularly a 38% reduction in the prevalence of hypertension among whites and 30% among blacks.1 Therefore, the growing incidence of CHF in this population is probably due to a larger pool of high-risk subjects, particularly MI survivors, rather than an increasing prevalence of cardiovascular risk factors. Latin American countries (LAC) are undergoing an epidemic of CAD that may lead to a significant increase in the incidence of CHF. In 1990, cardiovascular disorders were the main cause of death in LAC: 789,000 cardiovascular deaths, compared with 473,000 death from infectious and parasitic diseases.5 The ratio of deaths from circulatory system diseases to deaths from infectious diseases in LAC is expected to rise from 1.1 to 4.75 during the period 1985 to 2015.6 Although CAD mortality rate has decreased in some countries,7,8 it is still rising in others.6,7 The aging of the population and the rising prevalence of risk factors will contribute to increase the burden of CAD in the region.9 Unfortunately, no published data on trends of CAD incidence in LAC are currently available. However, studies on cardiovascular death and disability may help
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us to understand the current and future impact of CAD in CHF morbidity and mortality. Data on the prevalence of cardiovascular risk factors and on the prevalence of rheumatic heart disease and Chagas disease may further contribute to our understanding of the potential impact of CHF in this population. In this article, we discuss the available evidence regarding the particular characteristics that make LAC countries highly susceptible for an emerging epidemic of CHF in the near future.
Risk factors for chronic heart failure in Latin American countries Since the mid-1990s, cardiovascular diseases are the main cause of death in developing countries,10 and CAD by itself is expected to become the third cause of disability-adjusted life years by 2020.11 In fact, by 1990, 63% of all deaths and 29% of all disability-adjusted life-years attributable to cardiovascular diseases occurred in developing countries.12 By 2020, cardiovascular diseases will be responsible for 64.3 million and 18.0 million disability-adjusted life-years in developing and developed countries, respectively.11 In an analysis of Colombian mortality data, we found that CAD mortality rate in 20- to 84-year-old subjects increased from 75.9/100,000 in 1980 to 1984, to 97.3/ 100,000 in 1990 to 1996, approximately a 2.1% increase per year through the study period.13 Correspondingly, the cumulative risk of dying from CAD in the 20- to 84-year age interval rose from 16.3% to 19.9% during the same period.13 Up to 30% of this increase could be attributed to population aging.13 Further increases in CAD and CHF incidence should be expected, due to population aging. The life expectancy of the Colombian population is expected to increase from 67.8 years in 1985 to 1990 to 73.9 years in 2010 to 2015. During this period, the proportion of the population over 45 years old will triple (Figure 1).14 Similar changes are likely in most LAC. Data on survival of MI patients from LAC are scarce. However, the available information suggests an increasingly better prognosis in these patients. In a clinical trial conducted in 29 hospitals in 6 LAC, 407 unselected patients with MI were enrolled; 61.9% received reperfusion therapy (95% CI, 57.0, 66.7), with almost all receiving thrombolytic therapy (95%).15 The overall inhospital mortality rate among the 139 patients from the usual care group was 11.5% (95% CI, 6.7, 18.0).15 This case-fatality rate was very similar to that reported in a Northeastern community of the United States between 1993 and 1995 (11.7%).16 Since hospitals involved in this trial15 were able to conduct complex research, it is reasonable to assume that the 11.5% case-fatality rate corresponds to a best-case scenario. This suggests that the progressive introduction of new
Cubillos-Garzo´n et al 413
Figure 1
Changes in size of the population of Colombian men and women ⱖ45 years of age during the period 1985 to 2015.
effective interventions in the treatment of patients with MI and the increased access to medical care in LAC could result in MI case-fatality rates similar to those observed in developed countries. There is evidence to support that a significant change in MI case-fatality is already occurring in LAC. We have studied the 1-year survival probability in patients with MI from Colombia, treated in a general hospital and in an specialized cardiovascular center.17 Even though both groups had similar clinical characteristics upon arrival at the emergency room, the use of thrombolytic therapy was considerably higher in the cardiovascular center (66% vs 11.6%, P ⫽ .0001). The overall 12-month cumulative risk of death was 11.8% (95% CI, 7.5, 17.3); however, it was 3.62 times higher (95% CI, 2.29, 5.72) in patients from the general hospital than those from the cardiovascular institution (32.5% vs 5.5%; P ⬍ .001).17 This comparison between a general and an specialized hospital shows the potential for increase in the use of reperfusion therapies and for reduction in the MI case-fatality rate in the near future. In fact, a decline in the MI inhospital case-fatality rate from 13.3% in 1993 to 1995 to 10.8% in 1997 to 1998 was observed by the GEMI registry group in 37 Chilean hospitals.18 Therefore, survival of patients with MI in LAC is expected to increase progressively in the near future. Combined with a higher incidence of CAD, the improved survival of MI patients will lead to a larger pool of subjects at high risk of CHF. The prevalence of cardiovascular risk factors in many LAC is similar to that observed in developed countries, but contrary to what has been observed in the latter, the prevalence of cardiovascular risk factors in LAC appears to be increasing. This should lead to increasing incidence of MI and CHF. For example, the prevalence of hypertension in adults from LAC ranges from 8% to 40%, with an estimated average of 20% to 23%,19 close to the 24% reported in the United States20
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414 Cubillos-Garzo´ n et al
Table I. Prevalence of hypertension in the urban population of selected Latin American countries Country Argentina Brazil Chile Colombia Costa Rica Dominican Rep. Mexico Paraguay Uruguay
Age (y)
Year
Sample size
Prevalence (%)
15-99 ⬎20 ⬎15 20-69 20-59 ⱖ20 20-69 18-74 ⱖ19
1991 2002 1998 2002 1998 1993 1993 1995 1993
10,740 2314 N/A 3000 465 6184 14,657 9880 1243
24.49 24.851 20.09 14.121 14.49 22.89 32.052 30.553 17.19
N/A, Not avaible.
Table II. Prevalence of obesity (BMI ⱖ30) in the urban population of selected Latin American countries Prevalence (%) Country
Year
Age (y)
Argentina Brazil Chile Colombia Rica Dominican Rep. Mexico Paraguay Uruguay
1993 1997 1997 2002 1992 1998 1993 1995 1998
24-83 ⱖ20 25-64 20-69 20-65 ⱖ20 20-69 18-74 ⱖ18
Sample size
Women
Men
1071 10,680 3120 3000 231 6184 14,391 9880 900
16.9 12.5 23.0 16.2 39.0 16.4 25.1 26.0 18.0
16.154 6.99 15.725 8.921 21.055 23.19 14.956 25.79 17.057
Table III. Prevalence of diabetes in the urban population of selected Latin American countries
Figure 2
Country
Age-specific prevalence of hypertension.
(Table I). In fact, age-specific prevalences of hypertension are very similar in the Colombian and the US populations (Figure 2). 21 Since blood pressure increases progressively with age, and the average age in the LAC population is increasing, a corresponding increase in the prevalence of hypertension should be expected. Unfortunately, it is not possible to evaluate trends in hypertension prevalence in Latin America because no systematic surveillance efforts are underway in the region.22 A doubling in the incidence of CHF in obese subjects (body mass index ⱖ30 kg/m2) has been recently reported among members of the Framingham cohort.23 The prevalence of obesity in LAC is highly variable between countries, in rural an urban populations, and between men and women. In urban areas of a group of selected LAC, the prevalence of obesity ranged between 12% to 39% in women and from 7% to 27% in men (Table II). These figures are not far from the prevalence observed in the United States in 1988 to 1994,
Year
Sample Prevalence size (%)
Argentina 1992-94 1071 Brazil 1986-88 2051 Chile 1997 3120 Colombia 2002 3000 Costa Rica 1992 231 Dominican Rep. 1996 6184 Mexico 1992-93 14,069
8.554 7.658 4.059 4.821 4.555 4-89 7.060
Paraguay Uruguay†
6.561 8.062
1992 2000
1094 N/A
Definition Self reported WHO-1985* WHO-1985 FPG ⱖ126mg/dL FPG ⱖ140 mg/dL N/A FPG ⱖ126 or RPG ⬎200 mg/dL WHO-1985 N/A
FPG, Fasting plasma glucose; RPG, random plasma glucose *World Health Organization criteria for diabetes mellitus. †Prevalence estimated from a global projection.
25.0% in women and 19.5% in men.24 Moreover, an increasing trend in the prevalence of obesity has been observed in those countries where data is available.25–28 The risk of CHF is increased by a factor of 1.83 times in subjects with diabetes mellitus.29,30 The prevalence of diabetes in many LAC is within the range observed in developed countries. For instance, in the urban population from most LAC, the prevalence of diabetes ranges between 6% and 9%, but in some Caribbean countries it is well over 10%31,32 (Table III). In comparison, the current prevalence of diabetes in the United States is 7.3%.33 Similar to what is being observed in United States, the prevalence of diabetes has been increasing and continues to increase in LAC.31 Between 1995 to 2025, the prevalence of diabetes in LAC will increase 41%, and the absolute number of cases of diabetes will rise from 15 million to 39 million (160%).31 This will significantly increase the pool of subjects at high risk of CHF.
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Chagas and rheumatic heart disease in Latin American countries In contrast to developed countries, the incidence and prevalence of Chagas and rheumatic heart disease remain high in LAC. Chagas disease is the major cause of disability secondary to tropical diseases in young adults from Latin America. In this region, 750,000 productive life-years and $US 1200 million/year are lost due to Chagas disease; 20 million people are currently infected by Trypanosome cruzi, and 100 million are exposed to infection by the parasite.34 In Colombia, 18% of the population lives in Chagas disease– endemic areas, 1.3 million people are estimated to be infected, and 3.6 million are at high risk of becoming infected.35,36 Recent surveys among blood donors indicate that in some regions, up to 3.4% of the population is infected by T cruzi.36 CHF caused by Chagas cardiomyopathy is the most frequent and severe clinical manifestation of Chagas disease in Colombia and is associated with poor prognosis and high mortality rates when compared with CHF from other causes.37– 40 Mady et al have shown an overall survival of 66% at 1 year, 56% at 3 years, and 48% at 5 years in patients with CHF caused by Chagas cardiomyopathy.39 In many developing countries, rheumatic heart disease is the most common form of valvular heart disease and adds to the increasing burden of CHF. Indeed, rheumatic heart disease affects more than 4 million people worldwide, resulting in approximately 90,000 deaths each year.41 Although rheumatic heart disease has essentially disappeared in developed countries, in LAC 1% to 2% of school children show evidence of rheumatic valvular disease.41 A high proportion of these children will have mitral valve lesions and will progress to CHF over the next 20 to 40 years, dying at a young age, mainly as a consequence of limited access to adequate health care. In 2001 in Colombia, only 30% of the population had access to basic health care.14 A similar condition has been reported in other LAC.42,43 Thus, it is reasonable to expect that in the next 20 to 40 years, CAD, rheumatic heart disease, and Chagas disease will continue to contribute to the incidence of CHF.
Chronic heart failure in Latin American countries The organization and conduction of epidemiologic studies of CHF in developing countries is a difficult task because of the limited resources available for health research. In consequence, data on the incidence, prevalence, and prognosis of CHF is very scarce. The available data come mainly from referral centers and corresponds to a highly selected sample of
Cubillos-Garzo´ n et al 415
patients with CHF. Therefore, these data are of little use to evaluate the epidemiologic profile of CHF. CAD and hypertension appear to be the main causes of CHF in LAC, followed by valvular heart disease and Chagas disease. However, since Chagas disease is observed mainly in rural areas, its actual impact is probably underestimated in reports from specialized centers where only patients with severe CHF and access to tertiary centers are admitted.44 – 48 In Colombia, a recent retrospective study in a cardiovascular center showed that 40% of the total cardiovascular hospitalizations were due to CHF.48 In this center, CAD was the main cause of CHF (27.5% of all cases), followed by Chagas disease (18.8%) and rheumatic heart diseases (13.0%).48 In conclusion, as a consequence of the epidemiologic transition and advances in health care, the aging of the population and the prevalence of CAD, hypertension, obesity, and diabetes are increasing and will have a significant impact on the incidence of CHF in LAC. In addition, Chagas disease and rheumatic heart will remain important causes of CHF. Therefore, in a few years, the incidence and the prevalence of CHF may reach levels similar to those observed in developed countries. Timely and effective interventions should be implemented in LAC to avoid the development of a sizable epidemic of CHF.
Recommendations If appropriate preventive measures are swiftly established, LAC may be able to curtail the escalating health burden of CHF currently experienced by developed countries. The medical and socioeconomic consequences of such an epidemic could be disastrous for LAC. There is an urgent need for proper implementation of population-based studies in this population to evaluate the epidemiologic profile of CHF (risk factors, incidence, prevalence, cause, treatment) and to guide the implementation of preventive interventions. A combined strategy of appropriate treatment of CAD, combined with public health interventions aimed to lower the population mean blood pressure, may reduce the incidence of CHF by more than one third and by as much as one half in LAC.49 The widespread implementation of early reperfusion therapy, aggressive primary and secondary prevention, and reahabilitation of patients with MI should have a considerable impact on the prevention of CHF. Conventional risk factor modification, especially oriented to the treatment of diabetes, and the reduction of obesity and smoking should be also beneficial. In regions where Chagas disease is endemic, programs to control the vector and to eliminate transfusion of contaminated blood are highly desirable to halt the transmission of the disease. Additionally, large clinical trials should be
416 Cubillos-Garzo´ n et al
conducted to evaluate whether current effective therapies for CHF of ischemic cause are equally effective in patients with CHF caused by Chagas disease.50
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19. Hernandez-Hernandez R, Armas-Padilla MC, Armas-Hernandez MJ, et al. Hypertension and cardiovascular health in Venezuela and Latin American countries. J Hum Hypertens 2000;14(Suppl 1):2–5. 20. Burt VL, Whelton P, Roccella EJ, et al. Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988 –1991. Hypertension 1995;25:305–13. 21. Bautista L, Oro´ stegui M, Prada GE, et al. Prevalencia de factores de riesgo para enfermedades cro´ nicas no transmisibles en la poblacio´ n de Bucaramanga. Encuesta basal del Programa CARMEN, 2000. Bucaramanga, Colombia: Universidad Industrial de Santander; 2003. 22. Ordunez P, Silva LC, Rodriguez MP, et al. Prevalence estimates for hypertension in Latin America and the Caribbean: are they useful for surveillance? Rev Panam Salud Publica 2001;10:226 –31. 23. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med 2002;347:305–13. 24. National Heart Lung and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Washington, DC: Government Printing Office; 1998. 25. Uauy R, Albala C, Kain J. Obesity trends in Latin America: transiting from under- to overweight. J Nutr 2001;131:893S–9S. 26. Monteiro CA, D’A Benicio MH, Conde WL, et al. Shifting obesity trends in Brazil. Eur J Clin Nutr 2000;54:342– 6. 27. Martorell R, Khan LK, Hughes ML, et al. Obesity in Latin American women and children. J Nutr 1998;128:1464 –73. 28. Rivera JA, Barquera S, Campirano F, et al. Epidemiological and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity. Public Health Nutr 2002;5:113– 22. 29. He J, Ogden LG, Bazzano LA, et al. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001;161:996 –1002. 30. Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996;275:1557– 62. 31. Barcelo´ A, Rajpathak S. Incidence and prevalence of diabetes mellitus in the Americas. Rev Panam Salud Publica 2001;10: 300 – 8. 32. Aschner P. Diabetes trends in Latin America. Diabetes Metab Res Rev 2002;18(Suppl 3):S27–31. 33. Mokdad AH, Bowman BA, Ford ES, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001;286: 1195–200. 34. Schmunis GA. American trypanosomiasis as a public health problem: Chagas disease and the nervous system. Washington, DC: PAHO; 1994. p. 3–29. 35. Guhl F, Vallejo GA. Interruption of Chagas disease transmission in the Andean countries: Colombia. Mem Inst Oswaldo Cruz 1999; 94(Suppl 1):413–15. 36. Corredor A, Santacruz MM, Pa´ ez S, et al. Distribucio´ n de los triatomineos domiciliarios en Colombia. Bogota´ , Colombia: Ministerio de Salud, Instituto Nacional de Salud; 1990. 37. Bestetti RB, Muccillo G. Clinical course of Chagas heart disease: a comparison with dilated cardiomyopathy. Int J Cardiol 1997;60: 187–93. 38. Mendez GF, Cowie MR. The epidemiological features of heart failure in developing countries: a review of the literature. Int J Cardiol 2001;80:213–9.
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39. Mady C, Cardoso RH, Barretto AC, et al. Survival and predictors of survival in patients with congestive heart failure due to Chagas cardiomyopathy. Circulation 1994;90:3098 –102. 40. Rassi A Jr, Rassi A, Little WC. Chagas heart disease. Clin Cardiol 2000;23:883–9. 41. Michaud C, Trejo-Gutierrez J, Cruz C, et al. Rheumatic heart disease. In: Jamison DT, Mosley WH, Measham AR, et al, editors. Disease Control Priorities in Developing Countries. New York: Oxford University Press; 1993. p. 261– 80. 42. Musgrove P, Creese A, Preker A, et al. The World Health Report 2000. Health Systems: Improving Performance. Geneva, Switzerland: World Health Organization; 2000. p. 164 –75. 43. Muna WF. Cardiovascular disorders in Africa. World Health Stat Q 1993;46:125–33. 44. Barretto AC, Nobre MR, Wajngarten M, et al. [Heart failure at a large tertiary hospital of Sao Paulo]. Arq Bras Cardiol 1998;71: 15–20. 45. Bazzino O, Tajer C. Encuesta nacional de unidades coronarias: insuficiencia cardiaca. Rev Argent Cardiol 2003;61:9 –16. 46. Amarilla GA, Carballido R, Tacchi CD, et al. Insuficiencia cardı´aca en la Repu´ blica Argentina: Variables relacionadas con mortalidad intrahospitalaria: Resultados preliminares del protocolo CONAREC VI. Rev Argent Cardiol 1999;67:53– 62. 47. Mady C. [Heart failure. Natural history and prognosis]. Arq Bras Cardiol 1994;63:515–7. 48. Cubillos-Garzon L, Duarte E, Garcı´a R, et al. Experiencia en el manejo clı´nico de la insuficiencia cardı´aca en la Fundacio´ n Cardiovascular del Oriente Colombiano. Rev Col Cardiol 1999;9: 312. 49. Baker DW. Prevention of heart failure. J Card Fail 2002;8:333– 46. 50. Casas JP, Cubillos-Garzon LA, Morillo CA. Regional pathologies and globalization of clinical trials: has the time for regional trials arrived? Circulation 2003;107:e194. 51. Guimaraes AC. Hypertension in Brazil. J Hum Hypertens 2002; 16(Suppl 1):S7–10.
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52. Arroyo P, Fernandez V, Loria A, et al. Hypertension in urban Mexico: the 1992–93 national survey of chronic diseases. J Hum Hypertens 1999;13:671–5. 53. Ramirez MO, Pino CT, Furiasse LV, et al. Paraguayan National Blood Pressure Study: prevalence of hypertension in the general population. J Hum Hypertens 1995;9:891–7. 54. Ciruzzi M, Schargrodsky H, Rozlosnik J, et al. Frequency of family history of acute myocardial infarction in patients with acute myocardial infarction: Argentine FRICAS (Factores de Riesgo Coronario en America del Sur) Investigators. Am J Cardiol 1997;80: 122–7. 55. Campos H, Mata L, Siles X, et al. Prevalence of cardiovascular risk factors in rural and urban Costa Rica. Circulation 1992;85:648 – 58. 56. Arroyo P, Loria A, Fernandez V, et al. Prevalence of pre-obesity and obesity in urban adult Mexicans in comparison with other large surveys. Obes Res 2000;8:179 – 85. 57. Pisabarro R, Irraza´ bal E, Recalde A. Primera encuesta nacional de sobrepeso y obesidad (ENSO I). Rev Med Uruguay 2002;16: 31– 8. 58. Oliveira JE, Milech A, Franco LJ. The prevalence of diabetes in Rio de Janeiro, Brazil: the Cooperative Group for the Study of Diabetes Prevalence in Rio De Janeiro. Diabetes Care 1996;19:663– 6. 59. Jadue L, Vega J, Escobar MC, et al. [Risk factors for non communicable diseases: methods and global results of the CARMEN program basal survey]. Rev Med Chil 1999;127:1004 –13. 60. Aguilar-Salinas CA, Rojas R, Gomez-Perez FJ, et al. Prevalence and characteristics of early-onset type 2 diabetes in Mexico. Am J Med 2002;113:569 –74. 61. Jime´ nez JT, Palacios M, Canete F, et al. Prevalence of diabetes mellitus and associated cardiovascular risk factors in an adult urban population in Paraguay. Diabetes Med 1998;15:334 – 8. 62. King H, Aubert RE, Herman WH. Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21:1414 –31.
Coronary artery disease is the main cause of congestive heart failure (CHF) in all populations. Latin American countries (LAC) are undergoing the first phase of an epidemic of coronary artery disease that probably will lead to an increased incidence of CHF. The progressive implementation of successful interventions, such as early reperfusion and rehabilitation programs, should increase the survival of patients with acute myocardial infarction and the population at high risk of CHF. The increasing prevalence of risk factors, such as diabetes, hypertension, and obesity, and the ageing of the population may also contribute to a rising incidence of CHF in LAC. Moreover, infectious diseases such as Chagas disease and rheumatic heart disease, known causes of CHF, are still frequent in this population and additionally contribute to the incidence of CHF. If timely preventive interventions are not implemented, CHF could become one of the main contributors to the burden of morbidity, mortality, and health costs in LAC. Properly conducted clinical and epidemiologic studies are needed to identify, implement, and evaluate preventive strategies that are likely to succeed within the specific context of LAC. (Am Heart J 2004;147:412–7.)
See related Editorial on page 386.
In the United States, the age-adjusted cardiovascular disease mortality rate has decreased 51% in the last 3 decades.1 From 1987 to 1994, coronary artery disease (CAD) mortality rates among 34- to 74-year-olds fell by 28% in men and 31% in women.2 Between 1970 and 2000, the myocardial infarction (MI) inhospital casefatality rate declined from 38% to 13% in subjects ⱖ65 years old and from 16% to 6% in those 45 to 64 years old.1 Similar trends have been observed in other developed countries.3 Since survivors of a MI are at higher risk of congestive heart failure (CHF), the improvement in therapeutic treatment and the longer survival of patients with MI have contributed to increase the incidence of CHF in developed countries.4 In fact, from 1971 to 2000, the CHF hospitalization rate in the US population tripled, whereas the prevalence doubled.1 A higher CHF From the aHeart Failure Council, Colombian Society of Cardiology, Bogota, Colombia, the bCentre for Clinical Pharmacology, BHF Laboratories at University College London, London, United Kingdom, the cCardiovascular Research Institute, Fundacio´n Cardiovascular del Oriente Colombiano, Bucaramanga, Colombia, the dDepartment of Medicine, Cardiology Division, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, and eUniformed Services University of the Health Sciences, Bethesda, Md. Submitted February 10, 2003; accepted July 28, 2003. Reprint requests: Leonelo E. Bautista, MD, MPH, DrPH, University of Wisconsin Medical School, Department of Population Health Sciences, 610 Walnut Street, 703 WARF, Madison, WI 53726-2397. E-mail: [email protected] 0002-8703/$ - see front matter © 2004, Elsevier Inc. All rights reserved. doi:10.1016/j.ahj.2003.07.026
incidence resulted in increasing CHF age-adjusted death rate during the 1980s, even though the casefatality rate decreased from 5.6% to 2.3% in this period.1 During the 1990s, death rates leveled off, and case-fatality rate continued declining, but hospitalization rates have continued to increase. On the contrary, data from the United States National Health and Nutrition Examination Surveys have shown a considerable decline in the prevalence of cardiovascular risk factors, particularly a 38% reduction in the prevalence of hypertension among whites and 30% among blacks.1 Therefore, the growing incidence of CHF in this population is probably due to a larger pool of high-risk subjects, particularly MI survivors, rather than an increasing prevalence of cardiovascular risk factors. Latin American countries (LAC) are undergoing an epidemic of CAD that may lead to a significant increase in the incidence of CHF. In 1990, cardiovascular disorders were the main cause of death in LAC: 789,000 cardiovascular deaths, compared with 473,000 death from infectious and parasitic diseases.5 The ratio of deaths from circulatory system diseases to deaths from infectious diseases in LAC is expected to rise from 1.1 to 4.75 during the period 1985 to 2015.6 Although CAD mortality rate has decreased in some countries,7,8 it is still rising in others.6,7 The aging of the population and the rising prevalence of risk factors will contribute to increase the burden of CAD in the region.9 Unfortunately, no published data on trends of CAD incidence in LAC are currently available. However, studies on cardiovascular death and disability may help
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us to understand the current and future impact of CAD in CHF morbidity and mortality. Data on the prevalence of cardiovascular risk factors and on the prevalence of rheumatic heart disease and Chagas disease may further contribute to our understanding of the potential impact of CHF in this population. In this article, we discuss the available evidence regarding the particular characteristics that make LAC countries highly susceptible for an emerging epidemic of CHF in the near future.
Risk factors for chronic heart failure in Latin American countries Since the mid-1990s, cardiovascular diseases are the main cause of death in developing countries,10 and CAD by itself is expected to become the third cause of disability-adjusted life years by 2020.11 In fact, by 1990, 63% of all deaths and 29% of all disability-adjusted life-years attributable to cardiovascular diseases occurred in developing countries.12 By 2020, cardiovascular diseases will be responsible for 64.3 million and 18.0 million disability-adjusted life-years in developing and developed countries, respectively.11 In an analysis of Colombian mortality data, we found that CAD mortality rate in 20- to 84-year-old subjects increased from 75.9/100,000 in 1980 to 1984, to 97.3/ 100,000 in 1990 to 1996, approximately a 2.1% increase per year through the study period.13 Correspondingly, the cumulative risk of dying from CAD in the 20- to 84-year age interval rose from 16.3% to 19.9% during the same period.13 Up to 30% of this increase could be attributed to population aging.13 Further increases in CAD and CHF incidence should be expected, due to population aging. The life expectancy of the Colombian population is expected to increase from 67.8 years in 1985 to 1990 to 73.9 years in 2010 to 2015. During this period, the proportion of the population over 45 years old will triple (Figure 1).14 Similar changes are likely in most LAC. Data on survival of MI patients from LAC are scarce. However, the available information suggests an increasingly better prognosis in these patients. In a clinical trial conducted in 29 hospitals in 6 LAC, 407 unselected patients with MI were enrolled; 61.9% received reperfusion therapy (95% CI, 57.0, 66.7), with almost all receiving thrombolytic therapy (95%).15 The overall inhospital mortality rate among the 139 patients from the usual care group was 11.5% (95% CI, 6.7, 18.0).15 This case-fatality rate was very similar to that reported in a Northeastern community of the United States between 1993 and 1995 (11.7%).16 Since hospitals involved in this trial15 were able to conduct complex research, it is reasonable to assume that the 11.5% case-fatality rate corresponds to a best-case scenario. This suggests that the progressive introduction of new
Cubillos-Garzo´n et al 413
Figure 1
Changes in size of the population of Colombian men and women ⱖ45 years of age during the period 1985 to 2015.
effective interventions in the treatment of patients with MI and the increased access to medical care in LAC could result in MI case-fatality rates similar to those observed in developed countries. There is evidence to support that a significant change in MI case-fatality is already occurring in LAC. We have studied the 1-year survival probability in patients with MI from Colombia, treated in a general hospital and in an specialized cardiovascular center.17 Even though both groups had similar clinical characteristics upon arrival at the emergency room, the use of thrombolytic therapy was considerably higher in the cardiovascular center (66% vs 11.6%, P ⫽ .0001). The overall 12-month cumulative risk of death was 11.8% (95% CI, 7.5, 17.3); however, it was 3.62 times higher (95% CI, 2.29, 5.72) in patients from the general hospital than those from the cardiovascular institution (32.5% vs 5.5%; P ⬍ .001).17 This comparison between a general and an specialized hospital shows the potential for increase in the use of reperfusion therapies and for reduction in the MI case-fatality rate in the near future. In fact, a decline in the MI inhospital case-fatality rate from 13.3% in 1993 to 1995 to 10.8% in 1997 to 1998 was observed by the GEMI registry group in 37 Chilean hospitals.18 Therefore, survival of patients with MI in LAC is expected to increase progressively in the near future. Combined with a higher incidence of CAD, the improved survival of MI patients will lead to a larger pool of subjects at high risk of CHF. The prevalence of cardiovascular risk factors in many LAC is similar to that observed in developed countries, but contrary to what has been observed in the latter, the prevalence of cardiovascular risk factors in LAC appears to be increasing. This should lead to increasing incidence of MI and CHF. For example, the prevalence of hypertension in adults from LAC ranges from 8% to 40%, with an estimated average of 20% to 23%,19 close to the 24% reported in the United States20
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414 Cubillos-Garzo´ n et al
Table I. Prevalence of hypertension in the urban population of selected Latin American countries Country Argentina Brazil Chile Colombia Costa Rica Dominican Rep. Mexico Paraguay Uruguay
Age (y)
Year
Sample size
Prevalence (%)
15-99 ⬎20 ⬎15 20-69 20-59 ⱖ20 20-69 18-74 ⱖ19
1991 2002 1998 2002 1998 1993 1993 1995 1993
10,740 2314 N/A 3000 465 6184 14,657 9880 1243
24.49 24.851 20.09 14.121 14.49 22.89 32.052 30.553 17.19
N/A, Not avaible.
Table II. Prevalence of obesity (BMI ⱖ30) in the urban population of selected Latin American countries Prevalence (%) Country
Year
Age (y)
Argentina Brazil Chile Colombia Rica Dominican Rep. Mexico Paraguay Uruguay
1993 1997 1997 2002 1992 1998 1993 1995 1998
24-83 ⱖ20 25-64 20-69 20-65 ⱖ20 20-69 18-74 ⱖ18
Sample size
Women
Men
1071 10,680 3120 3000 231 6184 14,391 9880 900
16.9 12.5 23.0 16.2 39.0 16.4 25.1 26.0 18.0
16.154 6.99 15.725 8.921 21.055 23.19 14.956 25.79 17.057
Table III. Prevalence of diabetes in the urban population of selected Latin American countries
Figure 2
Country
Age-specific prevalence of hypertension.
(Table I). In fact, age-specific prevalences of hypertension are very similar in the Colombian and the US populations (Figure 2). 21 Since blood pressure increases progressively with age, and the average age in the LAC population is increasing, a corresponding increase in the prevalence of hypertension should be expected. Unfortunately, it is not possible to evaluate trends in hypertension prevalence in Latin America because no systematic surveillance efforts are underway in the region.22 A doubling in the incidence of CHF in obese subjects (body mass index ⱖ30 kg/m2) has been recently reported among members of the Framingham cohort.23 The prevalence of obesity in LAC is highly variable between countries, in rural an urban populations, and between men and women. In urban areas of a group of selected LAC, the prevalence of obesity ranged between 12% to 39% in women and from 7% to 27% in men (Table II). These figures are not far from the prevalence observed in the United States in 1988 to 1994,
Year
Sample Prevalence size (%)
Argentina 1992-94 1071 Brazil 1986-88 2051 Chile 1997 3120 Colombia 2002 3000 Costa Rica 1992 231 Dominican Rep. 1996 6184 Mexico 1992-93 14,069
8.554 7.658 4.059 4.821 4.555 4-89 7.060
Paraguay Uruguay†
6.561 8.062
1992 2000
1094 N/A
Definition Self reported WHO-1985* WHO-1985 FPG ⱖ126mg/dL FPG ⱖ140 mg/dL N/A FPG ⱖ126 or RPG ⬎200 mg/dL WHO-1985 N/A
FPG, Fasting plasma glucose; RPG, random plasma glucose *World Health Organization criteria for diabetes mellitus. †Prevalence estimated from a global projection.
25.0% in women and 19.5% in men.24 Moreover, an increasing trend in the prevalence of obesity has been observed in those countries where data is available.25–28 The risk of CHF is increased by a factor of 1.83 times in subjects with diabetes mellitus.29,30 The prevalence of diabetes in many LAC is within the range observed in developed countries. For instance, in the urban population from most LAC, the prevalence of diabetes ranges between 6% and 9%, but in some Caribbean countries it is well over 10%31,32 (Table III). In comparison, the current prevalence of diabetes in the United States is 7.3%.33 Similar to what is being observed in United States, the prevalence of diabetes has been increasing and continues to increase in LAC.31 Between 1995 to 2025, the prevalence of diabetes in LAC will increase 41%, and the absolute number of cases of diabetes will rise from 15 million to 39 million (160%).31 This will significantly increase the pool of subjects at high risk of CHF.
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Chagas and rheumatic heart disease in Latin American countries In contrast to developed countries, the incidence and prevalence of Chagas and rheumatic heart disease remain high in LAC. Chagas disease is the major cause of disability secondary to tropical diseases in young adults from Latin America. In this region, 750,000 productive life-years and $US 1200 million/year are lost due to Chagas disease; 20 million people are currently infected by Trypanosome cruzi, and 100 million are exposed to infection by the parasite.34 In Colombia, 18% of the population lives in Chagas disease– endemic areas, 1.3 million people are estimated to be infected, and 3.6 million are at high risk of becoming infected.35,36 Recent surveys among blood donors indicate that in some regions, up to 3.4% of the population is infected by T cruzi.36 CHF caused by Chagas cardiomyopathy is the most frequent and severe clinical manifestation of Chagas disease in Colombia and is associated with poor prognosis and high mortality rates when compared with CHF from other causes.37– 40 Mady et al have shown an overall survival of 66% at 1 year, 56% at 3 years, and 48% at 5 years in patients with CHF caused by Chagas cardiomyopathy.39 In many developing countries, rheumatic heart disease is the most common form of valvular heart disease and adds to the increasing burden of CHF. Indeed, rheumatic heart disease affects more than 4 million people worldwide, resulting in approximately 90,000 deaths each year.41 Although rheumatic heart disease has essentially disappeared in developed countries, in LAC 1% to 2% of school children show evidence of rheumatic valvular disease.41 A high proportion of these children will have mitral valve lesions and will progress to CHF over the next 20 to 40 years, dying at a young age, mainly as a consequence of limited access to adequate health care. In 2001 in Colombia, only 30% of the population had access to basic health care.14 A similar condition has been reported in other LAC.42,43 Thus, it is reasonable to expect that in the next 20 to 40 years, CAD, rheumatic heart disease, and Chagas disease will continue to contribute to the incidence of CHF.
Chronic heart failure in Latin American countries The organization and conduction of epidemiologic studies of CHF in developing countries is a difficult task because of the limited resources available for health research. In consequence, data on the incidence, prevalence, and prognosis of CHF is very scarce. The available data come mainly from referral centers and corresponds to a highly selected sample of
Cubillos-Garzo´ n et al 415
patients with CHF. Therefore, these data are of little use to evaluate the epidemiologic profile of CHF. CAD and hypertension appear to be the main causes of CHF in LAC, followed by valvular heart disease and Chagas disease. However, since Chagas disease is observed mainly in rural areas, its actual impact is probably underestimated in reports from specialized centers where only patients with severe CHF and access to tertiary centers are admitted.44 – 48 In Colombia, a recent retrospective study in a cardiovascular center showed that 40% of the total cardiovascular hospitalizations were due to CHF.48 In this center, CAD was the main cause of CHF (27.5% of all cases), followed by Chagas disease (18.8%) and rheumatic heart diseases (13.0%).48 In conclusion, as a consequence of the epidemiologic transition and advances in health care, the aging of the population and the prevalence of CAD, hypertension, obesity, and diabetes are increasing and will have a significant impact on the incidence of CHF in LAC. In addition, Chagas disease and rheumatic heart will remain important causes of CHF. Therefore, in a few years, the incidence and the prevalence of CHF may reach levels similar to those observed in developed countries. Timely and effective interventions should be implemented in LAC to avoid the development of a sizable epidemic of CHF.
Recommendations If appropriate preventive measures are swiftly established, LAC may be able to curtail the escalating health burden of CHF currently experienced by developed countries. The medical and socioeconomic consequences of such an epidemic could be disastrous for LAC. There is an urgent need for proper implementation of population-based studies in this population to evaluate the epidemiologic profile of CHF (risk factors, incidence, prevalence, cause, treatment) and to guide the implementation of preventive interventions. A combined strategy of appropriate treatment of CAD, combined with public health interventions aimed to lower the population mean blood pressure, may reduce the incidence of CHF by more than one third and by as much as one half in LAC.49 The widespread implementation of early reperfusion therapy, aggressive primary and secondary prevention, and reahabilitation of patients with MI should have a considerable impact on the prevention of CHF. Conventional risk factor modification, especially oriented to the treatment of diabetes, and the reduction of obesity and smoking should be also beneficial. In regions where Chagas disease is endemic, programs to control the vector and to eliminate transfusion of contaminated blood are highly desirable to halt the transmission of the disease. Additionally, large clinical trials should be
416 Cubillos-Garzo´ n et al
conducted to evaluate whether current effective therapies for CHF of ischemic cause are equally effective in patients with CHF caused by Chagas disease.50
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