8 Chapter 1 CORONARY HEART DISEASE BURDEN AND RISK FACTORS Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide (1). In 2019, 9.14 million people died of CHD, and it is estimated that there were 189 million prevalent CHD cases (2). The prevalence of CHD is expected to increase due to population aging and high prevalence of cardiovascular risk factors (2). Most CHD deaths and disease burden are related to cardiovascular risk factors, many of which can potentially be changed, treated, and controlled (4). Patients with established CHD are at very high cardiovascular risk (5), and are two to five times more likely to experience a recurrent cardiovascular event and die due to a cardiovascular cause compared with patients without CHD (6). During the first year after a myocardial infarction, 13-34% of CHD patients will experience a recurrent event or cardiovascular death (7–9). Risk factor control is of major importance to reduce the risks of re-occurrence of cardiovascular events and mortality. Clinical guidelines recommend that patients with CHD change health behaviors, use medication to modify and control cardiovascular risk factors, and participate in cardiac rehabilitation programs (9,10). Despite these recommendations, risk factor control in secondary prevention of CHD is poor. Several studies have shown poor attainment of the targets defined by clinical guidelines: approximately 1 in 5 CHD patients smoke tobacco, 66% do not exercise enough, more than 79% are overweight and more than 35% obese, 42-46% have high blood pressure levels, and 29% high LDL cholesterol (10,11). Recent studies show that most patients use the recommended cardioprotective medications (10,11). However, lower rates of medication use have been reported in low-and middle-income countries and community settings (12,13). PATIENT CHARACTERISTICS AND SECONDARY PREVENTION OF CHD Levels of risk factor control and medication use also differ according to patient’s characteristics, and multiple surveys have reported health inequities in secondary prevention of CHD. Women, ethnic minorities, and patients with a lower socioeconomic position generally have worse risk factor control and lower use of recommended medications (13– 18). These differences may partly be attributed to factors like educational level, income, and insurance coverage. Patients with a high educational attainment tend to have better risk factor awareness and healthy literacy (19,20), which may improve their motivation to change health behaviors and adhere to treatments (11,21,22). In some countries, having private health insurance can facilitate access to care and medications for patients with a high socioeconomic position (23). GLOBAL PERSPECTIVE Globally, the burden of CHD, risk factors and their management differs by region (10,24,25). CHD death rates and age-standardized disease burden are higher in low- and middle-income countries (LMICs) compared to high income countries (HICs). Exposure to cardiovascular risk factors have increased worldwide, but also with regional variations: HICs present the
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