174 Chapter 7 KEY FINDINGS This thesis explores secondary prevention of CHD, exemplified by findings in South America and aiming at a global perspective. The main findings of this thesis relate to secondary prevention of CHD and associated health inequities. 1. Globally and in regions underrepresented in research, CHD patients generally present with low levels of risk factor target attainment (Chapters 5 and 6). Prevalence of multiple cardiovascular risk factors is high (Chapter 4), and levels of medication use are generally high (Chapters 5 and 6) yet suboptimal in some regions (Chapters 2 and 3). Around half of CHD patients globally participate in cardiac rehabilitation, with lower rates in middleincome countries compared to high-income countries (Chapter 6). 2. There are health inequities in secondary prevention of CHD globally. Patients with a higher educational level are generally more likely to meet risk factor targets and attend cardiac rehabilitation (Chapters 4, 5, and 6), and these associations vary in lower middle-, upper-middle and high-income countries (Chapter 6). 3. In the Southern Cone of Latin America we observed health inequalities in CHD patients by sex and type of insurance coverage. Women, especially those with lower educational level, are more likely to present with multiple cardiovascular risk factors compared to men (Chapter 4). Compared to those with access to private health insurance, patients relying exclusively on public healthcare have similar levels of medication use but more often face barriers to access and afford medical care and medications (Chapter 3). Our results in context Research on secondary prevention of CHD has used several surveys to collect patient information. Notably, the international surveys EUROASPIRE and SURF CHD have been conducted in multiple rounds since 1995 and 2012 respectively, and this thesis presents the results of the latest waves of these studies (EUROASPIRE V and SURF CHD II). Some of the findings of this thesis are in line with results from previous literature. Our observations of low levels of target attainment and cardiac rehabilitation attendance, high medication use, and factors associated with hypertension control in CHD patients (Chapters 5 and 6) are consistent with previous series of EUROASPIRE and SURF CHD (24,32). Given the larger geographical coverage and inclusion of areas underrepresented in research in the studies presented in this thesis, as compared to previous studies, our results provide a broad picture of secondary prevention of CHD in clinical settings. The results on lower risk factor attainment among lower educational levels described in Chapters 4 and 6 (33) are supported by previous literature (17,34) and provide new insights, as SURF CHD II shows that the associations between educational level and risk factor attainment are heterogeneous and differ by risk factor and in high-, upper middle-, and lower-middle income countries. The findings of our systematic review (35) in Chapter 2 show that levels of medication use for secondary prevention of CHD are variable by medication class, and that the use of these medications has increased since 1993 (Chapter 2). These results are in line with previous reports in Europe, the US and China (36,37), and provide an overall picture of the
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