Chapter 8 190 SUMMARY This thesis presents a picture of the state of secondary prevention of CHD with a global perspective as well as a focus on South America. This work researches levels of risk factor target attainment, medication use and its determinants; explores health disparities based on insurance sex, educational level and health insurance coverage; and discusses the relevant aspects and opportunities to improve surveys in secondary prevention. Chapter 1 provides an overview of the burden of CHD globally. CHD is the leading cause of death, and there were 197 million prevalent cases of CHD in 2019. Existing surveys show that the level of risk factor target attainment in secondary prevention is low, that most patients use medications (with regional variations), and that there are sex and socioeconomic inequalities in secondary prevention. Most surveys reporting these results in the clinical settings have been conducted in high-income countries, mostly located in Europe, and there is a lack of evidence from other world regions with a high burden of CHD and risk factors. This chapter highlights research gaps addressed in this thesis, specifically the need of a global perspective on the state of secondary prevention and health inequalities, and the limited information on topics such as the occurrence of multiple risk factors, risk factor awareness, or the influence of insurance coverage. Chapter 2 consists of a systematic review and meta-analysis of the literature on prevalence of medication use in South America. The search in PubMed, Embase, Cochrane, LILACS and SciELO resulted in 7388 articles, from which 73 were included in the review. The pooled prevalence estimates ranged from 55.8%(95%CI 49.7%–61.8) for ACE-inhibitors/ARBs to 85.1%(95%CI 79.7%–89.3%) for aspirin. Meta-regression model results showed that the use of most medication classes significantly increased during the period 1993-2017, and that medication use was lower in studies conducted in community settings compared to academic and tertiary health centers. Chapter 3 reports the use of medication by insurance coverage among the 593 subjects with CHD and insurance coverage information the community-based CESCAS Study conducted in Argentina, Chile and Uruguay. Participants were classified as being covered exclusively by the public healthcare system or having additional health coverage. This analysis shows suboptimal levels of medication use, ranging from 24.4% of lipid lowering medications to 51.9% of antihypertensives. Multivariable analysis showed no significant differences by insurance coverage in medication use, which could explained by the provision of medication free of charge by pharmacy programs and the heterogeneity within insurance coverage categories. This chapter highlights other health inequalities, as patients covered exclusively in the public system were more likely to report facing barriers to receive care they needed and afford medications. Chapter 4 evaluates sex differences in the burden of multiple cardiovascular risk factors among the 634 participants of the CESCAS Study with a diagnosis of CHD. This study finds a high prevalence of cardiovascular risk factors (82.0% had low intake of fruit and vegetables, 76.3% were hypertensive) and multiple risk factors, as more than 80% of participants presented four or more risk factors. Poisson regression adjusted by age showed that women
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