9 General Introduction 1 larger increases in high blood pressure and reductions in smoking; while LMICs face larger increases of in high body mass index (BMI) and alcohol use (26). In secondary prevention, the STABILITY and SURF I studies show geographical variation in risk factor burden, with highest rates of smoking in Eastern Europe and high BMI in North America and the Middle East (10,24). Nevertheless, surveys focusing on risk factor management in secondary prevention have been conducted mainly on HICs and hence miss regions with a high burden of CHD (9). To illustrate differences and similarities between high- and lower-income settings we have focused on South America as a case example. In this region, the prevalence and mortality of CHD have increased in the past decades, and currently it is the leading cause of mortality, causing 10.2% to 19.4% of deaths (27). Cardiovascular risk factors are highly prevalent in the general population (28) and there are marked disparities in risk factors and access to care (28–30). Despite the high burden of CHD and risk factors in this region, literature on cardiovascular risk factors is limited and fragmented (31), especially for secondary prevention in clinical settings. This highlights the need for research on secondary prevention to better understand the challenges of risk factor control, and eventually design preventive strategies that are contextualized to high burden populations in this and similar regions. RATIONALE Given the variation in CHD burden and cardiovascular risk factors in different world regions, especially low resource settings, it is necessary to explore risk factor target attainment, treatment, and patient’s characteristics in secondary prevention with a wider international perspective. In addition, there is very limited evidence on the occurrence of multiple risk factors, risk factor awareness, and health inequities related to insurance coverage in the context of secondary prevention. Achieving a wide, representative picture of secondary prevention of CHD while capturing relevant information requires tools that allow research in settings with limited resources. SURF CHD II is a survey on secondary prevention with a simplified design that requires minimal staff or time to be conducted, purposely designed to facilitate its implementation in centers with limited resources. The design of surveys determines their informativeness, representativeness and quality, directly affecting the impact they have secondary prevention of CHD. The goals of this thesis are to present an overview of the state of secondary prevention of CHD, to explore determinants of risk factor control, and to discuss the challenges and opportunities of surveys in secondary prevention. We address these topics with global perspectives and with South America as a case example. Specifically, we evaluate the use of cardioprotective medication in CHD patients and its potential determinants, with a focus on insurance coverage. We further explore potential hypertension awareness, treatment and control, and assess the role of sex and educational level on cardiovascular risk factors in CHD patients. Finally, we address the content, representativeness, and quality of surveys in secondary prevention. Here, we refer to
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