Journal of Hypertension:
Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings
Modesti, Pietro A.a; Agostoni, Piergiuseppeb; Agyemang, Charlesc; Basu, Sanjayd; Benetos, Athanasee; Cappuccio, Francesco P.f; Ceriello, Antoniog; Del Prato, Stefanoh; Kalyesubula, Roberti; O’Brien, Eoinj; Kilama, Michael O.k; Perlini, Stefanol; Picano, Eugeniom; Reboldi, Gianpaolon; Remuzzi, Giuseppeo; Stuckler, Davidp; Twagirumukiza, Marcq; Van Bortel, Luc M.q; Watfa, Ghassanr; Zhao, Dongs; Parati, Gianfrancot,u; for the ESH Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings
aDepartment of Clinical and Experimental Medicine, University of Florence, Florence
bCentro Cardiologico Monzino, IRCCS, Milan, Italy
cDepartment of Public Health, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
dUniversity of California, San Francisco, California, USA
eINSERM UMR S1116, Université de Lorraine, Vandoeuvre-les-Nancy, Nancy, France
fUniversity of Warwick, Warwick Medical School, and University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
gInstitut d’Investigacions Biomèdiques August Pi i Sunyer IDIBAPS, and Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain
hSection of Metabolic Diseases and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
iMakerere University, Kampala, Uganda
jThe Conway Institute, University College Dublin, Dublin, Ireland
kBenedict Medical Center, Kampala, Uganda
lClinica Medica II, University of Pavia, Pavia
mInstitute of Clinical Physiology, CNR, Pisa
nDepartment of Internal Medicine, University of Perugia, Perugia
oIRCCS-Istituto di Ricerche Farmacologiche ‘Mario Negri’, Bergamo, Italy
pDepartment of Sociology, University of Oxford, Oxford, UK
qFaculty of Medicine and Health Sciences, Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
rDepartment of Geriatrics, CHU Nancy, Nancy, France
sBeijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
tDepartment of Health Sciences, University of Milano-Bicocca
uDepartment of Cardiology, S. Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy
Correspondence to Professor Pietro A. Modesti, (Chairman of the Working Group), Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy. Tel: +39 055 7949376; e-mail: email@example.com
Abbreviations: ACR, albuminuria to creatininuria ratio; CKD, chronic kidney disease; CVD, cardiovascular disease; ESH, European Society of Hypertension; GBD, Global Burden of Disease; LMIC, low-income and middle-income countries; STEPS, STEPwise Approach to Stroke Surveillance
This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivitives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0.
Received September 21, 2013
Accepted January 9, 2014
The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on ‘Hypertension and Cardiovascular risk in low resource settings’, which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.
HYPERTENSION IN A GLOBAL PERSPECTIVE
According to the Global Burden of Disease (GBD) 2010 study, the most comprehensive and comparable assessment of mortality and loss of health to date , cardiovascular disease (CVD) is the leading cause of death worldwide, 80% of the 16.7 million deaths due to CVD occur in low-income and middle-income countries (LMICs) and hypertension is now the leading associated risk factor [1,2]. High blood pressure (BP) accounts for 9.4 million (95% UI 8.6 million to 10.1 million) deaths and 7.0% (6.2–7.7) of global disability-adjusted life years (DALYs), more than elevated BMI, fasting plasma glucose, and total cholesterol combined .
As of 2008, almost 1 billion people have uncontrolled hypertension worldwide . The African region has the highest prevalence rate, 46% of adults aged 25 and above, whereas the Americas have the lowest prevalence, at 35%. In contrast with other CVD risks such as high BMI, the burden of hypertension is greater in lower income countries than higher income settings [3,4]. In an urban African setting, the stroke death rate (a proxy of hypertension prevalence and control) was reported to be five-fold higher than that in England [5,6]. According to WHO data, age-standardized death rate (per 100 000 population) is 141 in the African region and 93 in the European region . Multiple risk factors positively interact to exacerbate CVD risks. Hypertension, for example, combined with unhealthy diets and lack of physical activity (sodium and alcohol consumption, high BMI, and low physical activity), has a multiplicative negative effect on CVD mortality and DALYs . A substantial part of the CVD risk of death and DALYs attributable to these factors is not also exacerbated by, but also mediated through high BP . In LMICs, overweight or obesity was associated with hypertension [8–11] or progression to hypertension . Cultural aspects can also increase or decrease exposure to risk factors. The odds of obesity in LMICs is especially high for women , particularly in the Middle East and North Africa . Sex differences for abdominal obesity start at early adolescence , probably due both to a preferred body image [16–18] and to food insecurity [19–22]. Education and socioeconomic inequality seem to play a role in the development of obesity  as well as in the access to care for hypertension [10,24–30], especially in women. Sex association of obesity in adulthood was indeed lost after accounting for education and socioeconomic factors [20,31].
Hypertension is also a determinant of chronic kidney disease (CKD), a recognized marker of the poor health outcomes of hypertension and diabetes . However, growing evidence indicates that CKD is a strong cardiovascular risk factor in itself . Other causes of CKD in LMICs will be discussed later on in this article. In the general population, glomerular filtration rates (GFRs) lower than 60 ml/min/1.73 m2 and albuminuria (one of the earliest manifestations of CKD) were found to be associated with an independent risk of cardiovascular morbidity and mortality [33–36]. The fact that milder CKD affects 5–7% of the world population and is more common in LMICs and in disadvantaged and minority populations is worth noting [37,38]. Taken together, these findings underline the add-on role of CKD to the common recognized risk factors for global and cardiovascular mortality.
How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. On the one hand, according to the Disease Control Priorities Project, two prevention strategies at population level, salt reduction and tobacco control, and a multidrug strategy to treat patients with high-risk CVD meet the condition of cost-effectiveness multiple interventions in LMICs [39,40]. Population strategies supported by communication media with the concerted action of local authorities might induce cultural changes and the adoption of healthy lifestyle. On the other hand, WHO recommends identification of individuals with high-risk CVD in LMICs to make cost-effective the allocation of available resources. Cardiovascular risk stratification might, however, require facilities not easily available in LMICs. In 2011, the European Society of Hypertension established a Working Group on ’Hypertension and Cardiovascular risk in low resource settings’, which brought together cardiologists, diabetologists, nephrologists, clinical trialists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence from the Working Group and presents highlights of unmet needs for intervention and research at patient and population levels.
PREVENTION STRATEGIES AT POPULATION LEVEL
High sodium intake has effects on BP [41–43], all-cause mortality, CVD, stroke, and coronary heart disease, which have been recently quantified by the WHO Nutrition Guidance Expert Advisory Group Subgroup on Diet and Health [44–46]. When sodium intake was less than 2 g/day, SBP was reduced by 3.47 mmHg (0.76–6.18) and DBP by 1.81 mmHg (0.54– 3.08) as compared to a sodium intake ≥ 2 g/day. Increased sodium intake was associated with an increased risk of stroke (risk ratio 1.24, 95% confidence interval 1.08–1.43), stroke mortality (1.63, 1.27–2.10), and coronary heart disease mortality (1.32, 1.13–1.53) . Estimation of the effects of low-sodium vs. high-sodium intake on BP showed a greater increase in hypertensive and black populations than in normotensive individuals and whites, respectively . The 2002 joint World Health Organization/Food and Agriculture Organization of the United Nations expert consultation  and the 2007 WHO guideline  recommend a sodium intake not greater than 2 g/day. In LMICs, tobacco consumption is increasing by 3.4% per year and smoking rates are also increasing [51,52]. In developed countries, 35% of men and 22% of women smoke, whereas in LMICs, 50% of men and 9% of women are smokers. A favorable association between smoking cessation and BP decrease over time and risk to develop hypertension in an adult sample of generally healthy men has recently been reported . More than 50% of world's population now lives in urban areas where sodium consumption and tobacco use are consistently high [28,54]. Mass media campaigns have a direct impact on populations, but are expensive and require the support of local health authorities. An increasing proportion of governments in western countries have moved to ban all promotion of cigarettes and smoking via the electronic and print media . Involvement of mass media-newspapers, magazines, radio, television, and films may change cultural models and help in adopting healthy lifestyle by young people. James Bond had his last cigarette in 1989 in ‘Licence to kill’, but still drinks. Exposure to alcohol advertising is strongly associated with the likelihood of adolescents starting to drink [56,57], as well as with increased alcohol consumption among young people [58,59]. Alcohol consumption increases BP values both in hypertensive and normotensive individuals [60–62]. Attention should also probably be paid on sugar in foods and beverages, an independent risk factor in LMICs for the metabolic syndrome .
TREATMENT STRATEGY AT THE PATIENT LEVEL
The multidrug strategy to treat patients with high cardiovascular risk also meets criteria for cost-effectiveness [39,40,64,65], and WHO fully recognizes the paradigm shift from the treatment of the single risk factor in isolation to the management of total cardiovascular risk [50,66]. Identification of patients with high-risk CVD is, thus, essential.
Cardiovascular risk stratification in low-income and middle-income countries
The first limiting factor is that facilities required to assess biochemical parameters for cardiovascular risk stratification may not be easily available in LMICs. Therefore, cardiovascular risk stratification packages proposed in 2002 by WHO were based on history, BP measurement, and selective urine analysis (performed only if BP ≥140 or ≥90 mmHg) . More precisely, the WHO CVD-Risk Management Package considered three different scenarios (nonphysician health worker; medical doctor or specially trained nurse; medical doctor with access to full specialist care; Table 1) . The second limitation is that most of available equations developed to predict individual absolute risk of a cardiovascular event over a specified time period [69–76] were derived from European descent populations in high-income countries and are not necessarily valid in other populations [75,77]. Therefore, WHO/International Society of Hypertension (ISH) produced specific risk prediction charts  using population-based standardized collection and assessment of data on risk factor prevalence and relative risk (heart attacks and stroke). Data were obtained in WHO epidemiologic subregion survey from the Comparative Risk Assessment Project , and in the Asia Pacific Cohort Studies Collaboration [78–82]. These charts have the same goal as existing risk equations such as those based on Framingham and SCORE [69,72]. Absolute risk of cardiovascular events was determined by scaling individual relative risk to population incidence rates of major CVDs, estimated from the GBD study [50,65,66]. WHO/ISH charts enable cardiovascular risk assessment and prediction in LMIC populations of all WHO subregions on the basis of age, sex, SBP, type 2 diabetes mellitus, smoking status, and total serum cholesterol [50,66]. Detection of abnormalities of glucose metabolism such as impaired glucose tolerance, or the ’metabolic syndrome’ is worthwhile, because some diabetes could be prevented by focused intervention on lifestyle. Screening for diabetes is more cost-effective for people in the hypertensive and obese subgroups, the costs of screening being offset in many groups by lower future treatment costs . A third potential limitation is that easy obesity measurements (BMI or waist circumferences) are not included in the WHO/ISH charts, although there is strong evidence of the importance of obesity to guide intervention strategies aimed at reducing the incidence of type 2 diabetes. The global rise in overweight and obesity suggests that health promotion interventions at population level have not so far been effective, but improving lifestyles and increasing exercise in high-risk individuals remains a crucial issue. Therefore to include waist circumferences in the risk assessment could enhance awareness. Assessment of proteinuria is also not included in WHO charts, although recognizing that CVD risk may be higher than indicated in the chart in people with proteinuria.
Implementation of cardiovascular risk strategies and WHO/ISH Risk prediction charts in LMICs has different implications. First, this approach restricts unnecessary drug treatment to low-risk patients . This point is especially important in LMICs where much of the costs of healthcare are currently shifted directly to patients. The WHO estimates that out of pocket expenditure of more than 15–20% can lead to impoverishment; India's proportion in 2010 was 61% . Achievement of universal health coverage is a crucial step for sustainable development and for reducing poverty and social inequality, and currently represents a global goal of ‘Health for all as a human right’ . Implementation of cardiovascular risk strategies in this context might, thus, provide a way to use limited resources more efficiently . Second, the threshold of cardiovascular risk for deciding the start of drug treatment can be adjusted to suit the country context. Cost-effectiveness of an intervention indeed depends on the gross domestic product per head for the country. WHO proposed different 10-year total CVD risk thresholds for intensive intervention based on countries resource level (20% for high-resource setting; 30% for medium-resource setting; 40% for low-resource setting). Third, a little conflict with the main content may, however, exist because although cardiovascular risk stratification might be especially important for health systems of countries with very limited resources, the screening or identification of those with very high risk from the population may be much more expensive than treating only hypertension. In many LMICs, facilities available for cholesterol assay are limited, although it is often feasible to check urine sugar as a surrogate measure for diabetes. In this regard, WHO/ISH charts have a second version, for use where measurement of cholesterol level is not possible . If the resources are really limited, it is a preferred strategy to work only on hypertension and smoking and not on lipid and diabetes because a lower risk is attributed to them.
Despite drugs being a major contributor to healthcare costs, Mendis et al. found that reducing the cardiovascular risk threshold for drug treatment from 30 to 20% in LMIC populations did not substantially increase the cost of treatment. Moreover, as the cardiovascular risk threshold for drug treatment is lowered, there is a concomitant increase in health benefits .
Cardiovascular risk assessment in population surveys
When performing population surveys in LMICs, a door-to-door approach has different advantages: data collected with a door-to-door approach allow avoiding the selection bias affecting hospital data in LMICs where universal health coverage is uncommon; the use of point-of-care instruments for biochemical assays of blood glucose and lipids, the procedure suggested by WHO, limits preanalytical errors (storage, transportation, standardization of procedure) . WHO recommends the use of affordable and reliable electronic devices for BP measurement that have the option to select manual readings [89–91]. Cost of personnel is a main component of budget in population surveys. Personnel costs and the logistic difficulties connected with organizing a two-visit strategy, therefore, lead to the adoption of a single-visit strategy in the WHO STEPwise Approach to Stroke Surveillance  (STEPS) aimed at assessing cardiovascular risk in populations. Although the program allows structured between countries comparison and within country follow-up of implementation of prevention strategies, its results cannot be directly transferred to cost estimation for the plan of prevention strategies. High BP is the main factor guiding cardiovascular risk stratification and the diagnosis of hypertension requires recording BP values for several days in repeated visits [93–95]. When the estimation of hypertension prevalence based on two visits was compared with the estimation based on a single visit, the strategy adopted in the STEP program, hypertension prevalence reduced by 12% in a cohort of individuals aged 62 ± 11 years , by 35% in a cohort of individuals aged 39 ± 9 years , and by 35% in a national wide survey for the age range between 15 and 69 years (Fig. 1) . Differently from what was expected, misclassification is more common at young ages, two-thirds of men less than 30 years of age having normal BP values at the second visit . Thus, screening an individual at high cardiovascular risk at the first visit is crucial, but the panel of tests that can be included in surveys is to be seen in the perspective of costs. It is indeed unreliable to perform an echocardiogram in all participants in a national survey. However, the inclusion of a urine dipstick test for proteinuria in the test panel might be a sustainable approach. Proteinuria allows classifying a patient in the high or very high class of 10-year risk of cardiovascular mortality as defined by international guidelines for the management of hypertension [93–95,99,100]. When urine dipstick for proteinuria was added to the parameters included in a national survey based on two-visit assessments , the prevalence of individuals classified as at high or very high cardiovascular risk at the first visit remained stable at the second visit. More precisely, only 1.9% of individuals classified as at high or very high cardiovascular risk at the first visit moved to average, low or moderate cardiovascular risk categories at the second visit . With this approach, a stable estimation of individuals at high cardiovascular risk could be obtained already at the first visit.
Implications for chronic kidney disease assessment in low-income and middle-income countries
In western countries, the current debated question is ‘who should be screened to make cost-effective urine dipstick for proteinuria?’. Diabetes and hypertension are the leading causes of CKD in all developed and in many developing countries , so that current trend is to perform a ‘selective screening’ [101,102]. WHO suggests performing urine dipstick test only if clinic BP is at least 140 or at least 90 mmHg, and dipstick test for proteinuria is not included in the WHO STEP program. However, risk factors may differ in other areas of the world [103,104] because glomerulonephritis and renal diseases of unknown causes are common in Asia and sub-Saharan African countries . In China, where the prevalence of proteinuria is high , glomerulonephritis, mainly postinfectious, is the main cause of CKD  and end-stage kidney disease [107–109]. Nephrotoxic effects can also result from consumption of potentially toxic herbs, incorrect substitution of harmless herbs with toxic herbs, contamination with toxic compounds, such as heavy metals, or interactions between herbs and conventional treatments [105,107,110,111]. The use of khat in Yemen was importantly associated with kidney damage (proteinuria ≥ +1) after adjustment for several possible confounders (including hypertension and diabetes) . Data collected from Nepal, Bolivia , and Yemen [10,112] showed that more than 5% of people younger than 60 years without previous history of diabetes and hypertension had microalbuminuria or proteinuria (Fig. 2, Table 2) [112,113]. On these bases, the Asian Forum of Chronic Kidney Disease Initiative recently suggested the addition of region-specific high-risk groups for screening, such as people exposed to harmful herbal preparations  or environmental factors . In the absence of prospective studies performed in LMICs, it is impossible to infer that proteinuria, on a completely different background, should carry the same risk found in studies performed in industrialized societies. Likewise, although evidence for the benefits of CKD treatment with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in patients with albuminuria combined with diabetes or CVD is strong in high-income countries , no randomized clinical trials have been performed in LMICs. However, integration of the urine dipstick test in screening surveys opens a perspective for sustainable cardiovascular risk assessment, and may increase health awareness in countries without advanced health systems . The approach could be adapted to the conditions and socioeconomic circumstances of each nation .
The existing Manichean dualism of communicable and noncommunicable disease might lead physicians and researchers to disregard the evidence that some communicable diseases of children are the cause of cardiovascular events in adulthood. Rheumatic heart disease (RHD) is still causing most of the cardiovascular morbidity and mortality in young people in different world areas [117,118]. In China, RHD is a not negligible cause of atrial fibrillation and stroke [119–121]. If RHD is detected early, monthly penicillin injections (secondary prevention) are a cost-effective means of preventing more advanced, debilitating cardiac disease . Costs make stethoscope an essential equipment in cardiovascular risk stratification (Table 1), although screening programs including primary echocardiography revealed prevalence rates up to 10 times higher than those resulting from clinical examination alone [123–126]. In February 2012, the World Heart Federation published the first evidence-based criteria for echocardiographic diagnosis of RHD, and removed clinical examination from the diagnosis . Ultraportable, hand-held, pocket-sized imaging devices capable of producing two-dimensional and color images are now available , but in LMICs, physicians and expert sonographers are scarce. The possibility that low-cost electronic stethoscope able to reach a provisional diagnosis of cardiac valve disease might be developed to screen heart murmurs in children  is a sector of high potential interest . These devices might be accessible to unskilled personnel for screening purposes.
NEW VULNERABLE/HIGH-RISK GROUPS IN EUROPEAN UNION COUNTRIES: IMPLICATIONS FOR HEALTH SYSTEMS
In 2010, 9.4% of the total European Union populations were foreign-born . Age-standardized and sex-specific stroke mortality rates in Great Britain for 1979–1983, 1989–1993, and 1999–2003 were higher for all migrant groups in each time period compared with men born in England and Wales, men born in West Africa or Bangladesh, and women from Jamaica having the highest rates. More precisely in 1999–2003, stroke mortality was almost 200% higher among male migrants from West Africa, and almost 100% higher among those from the Caribbean . These findings bear similarities with the high stroke mortality of Surinamese and Antillean-born residents in the Netherlands . There is consensus that among people of African origin, hypertension is three-fold to four-fold more prevalent than the native European population [75,134–139]. With few exceptions, incidence and prevalence of diabetes mellitus are also much higher among migrants than among locally born residents [11,137,140,141]. In the UK, the incidence of end-stage renal failure among individuals from ethnic communities is three to five times greater than among the native population [142,143]. Should these data be confirmed in the different European countries, a future burden of cardiovascular (myocardial infarction and stroke) and renal disease (dialysis) can be expected in the next few decades with relevant implications in terms of costs for health systems of European Union member countries.
European Union recognized the need to improve data collection on migrants’ health aimed at the creation of specific prevention policies. However, many of the European Union programs have relied on the self-report of pathological conditions. This approach was useful to limit the costs of surveys, but sound data can only be obtained by directly assessing risk factors with the adoption of standardized forms to make results comparable between countries.
Migrants from LMICs usually develop cardiovascular complications in the medium-to-long term as a consequence of different environmental circumstances [77,144–147]. Cultural adaptations have great influence on the effectiveness of interventions among specific populations [148–150]. Therefore, intervention should not be focused only on the individual, but rather on the context and community; otherwise change may not be sustainable .
Policy initiatives should, thus, improve data collection, to adapt organization of health systems to cultures, and to provide information to migrants on health problems and services. Europe as a whole is often perceived as a group of wealthy countries where inclusive social protection systems provide comprehensive protection for the most vulnerable [154–156]. However, in times of financial constraint, policy discussions often circle around cutting back social protection expenditures. Only four European Union member states (Netherlands, France, Portugal, and Spain) offered undocumented migrants access to primary care [131,152,153], but recent reductions in health expenditures pose severe threats and lead to decisions limiting healthcare to migrants without sufficiently investigating the impacts on those in need . A reduction in access to primary and specialist care is indeed unlikely to be cost-effective, as use of emergency services will increase [157,158]. Current budget restrictions may also widen health inequalities, hurting other population groups in the dominant ethnic groups (lower socioeconomic groups, the unemployed who comprise a very large group in Europe at present, those with limited education, and people with mental health issues) . The drive to cost-effectiveness should, thus, be coupled with seeing health as an investment, avoiding myopic short-term savings through arbitrary healthcare cuts.
The clinical and epidemiological importance of CVD and high BP in LMICs markedly increased during the last decades and high BP is the leading risk factor. The establishment of culture of prevention in most LMICs requires the concerted action of television, radio, mass media-newspapers, and magazines, with the support of local health ministries and regulatory agencies, to limit salt intake and tobacco use.
Cost-effectiveness of prevention treatments at the patient level requires a cardiovascular risk approach. Identification of patients with high-risk CVD may indeed restrict unnecessary drug treatment to low-risk patients. The adoption of a cardiovascular risk approach in population surveys has also relevant implications for healthcare resource allocation decision-making. However, in low-resource settings, the screening or identification of those with very high risk from the population may be much more expensive than treating only hypertension. According to current evidence, some crucial points have to be considered both in surveys and patient care:
1. Hospital-based surveys have relevant selection bias, universal health coverage being uncommon in LMICs, so that a door-to-door approach is to be preferred;
2. Assessment of hypertension burden on the basis of a single visit may lead to overestimation of prevalence and healthcare requirements; thus survey strategies aimed at assessing global cardiovascular risk have to be considered;
3. Treatment gap is to be based on cardiovascular risk stratification (untreated individuals at high cardiovascular risk), rather than focusing on the single risk factors (untreated hypertensive patients);
4. Integration of urine dipstick test with cardiovascular health programs enhances the value of screening strategies;
5. Proteinuria and CKD in LMICs may result from postinfectious glomerulonephritis, or nephrotoxic agents so that the value of selective screening (diabetes and hypertension), currently adopted in high-income countries, might be limited in LMICs;
6. RHD still causes most of the cardiovascular morbidity and mortality in LMICs, so that the development of new strategies for optimization of the use of currently available devices (ultrasound), or the development of new low-cost device accessible to unskilled personnel to screen heart murmurs in children is a sector of high potential interest;
7. Global changes may have relevant implications for health systems of European countries, surveys exploring cardiovascular risk being now essential to focus prevention strategies in the setting of migrants and underserved communities living in Europe;
8. Intervention in the setting of migrants should not be focused only on the individual but rather on the context and community; otherwise change may not be sustainable.
Conflicts of interest
There are no conflicts of interest.
Reviewer's Summary Evaluation Reviewer 1
This is an interesting summary of a huge body of work and should be of interest to readers who missed the main issue of the Lancet dealing with the Global Burden of Disease early in 2013. The main limitation is that it is not novel, but it does provide an interesting European perspective.
1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet
2. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet
3. WHO. A global brief on Hypertension. Silent killer, global public health crisis
. Geneva, Switzerland: WHO; 2013. 40.
4. Ibrahim MM, Damasceno A. Hypertension in developing countries. Lancet
5. de Villiers L, Badri M, Ferreira M, Bryer A. Stroke outcomes in a socio-economically disadvantaged urban community. S Afr Med J
6. Walker RW, McLarty DG, Kitange HM, Whiting D, Masuki G, Mtasiwa DM, et al. Stroke mortality in urban and rural Tanzania. Adult Morbidity and Mortality Project. Lancet
7. Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol
8. Awoke A, Awoke T, Alemu S, Megabiaw B. Prevalence and associated factors of hypertension among adults in Gondar, Northwest Ethiopia: a community based cross-sectional study. BMC Cardiovasc Dis
9. Ibrahim MM, Rizk H, Appel LJ, el Aroussy W, Helmy S, Sharaf Y, et al. Hypertension prevalence, awareness, treatment, and control in Egypt. Results from the Egyptian National Hypertension Project (NHP). NHP Investigative Team. Hypertension
10. Modesti PA, Bamoshmoosh M, Rapi S, Massetti L, Al-Hidabi D, Al Goshae H. Epidemiology of hypertension in Yemen: effects of urbanization and geographical area. Hypertens Res
11. Cappuccio FP, Kerry SM, Adeyemo A, Luke A, Amoah AGB, Bovet P, et al. Body size and blood pressure: an analysis of Africans and the African diaspora. Epidemiology
12. Sun Z, Zheng L, Detrano R, Zhang X, Xu C, Li J, et al. Risk of progression to hypertension in a rural Chinese women population with prehypertension and normal blood pressure. Am J Hypertens
13. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet
14. Kanter R, Caballero B. Global gender disparities in obesity: a review. Adv Nutr
15. Bamoshmoosh M, Massetti L, Aklan H, Al-Karewany M, Goshae HA, Modesti PA. Central obesity in Yemeni children: a population based cross-sectional study. World J Cardiol
16. Holdsworth M, Delpeuch F, Landais E, Gartner A, Eymard-Duvernay S, Maire B. Knowledge of dietary and behaviour-related determinants of noncommunicable disease in urban Senegalese women. Public Health Nutr
17. Holdsworth M, Gartner A, Landais E, Maire B, Delpeuch F. Perceptions of healthy and desirable body size in urban Senegalese women. Int J Obes Relat Metab Disord
18. Duda RB, Jumah NA, Hill AG, Seffah J, Biritwum R. Assessment of the ideal body image of women in Accra, Ghana. Trop Doct
19. Townsend MS, Peerson J, Love B, Achterberg C, Murphy SP. Food insecurity is positively related to overweight in women. J Nutr
20. Chaput JP, Gilbert JA, Tremblay A. Relationship between food insecurity and body composition in Ugandans living in urban Kampala. J Am Diet Ass
21. Ezzati M, Vander Hoorn S, Lawes CM, Leach R, James WP, Lopez AD, et al. Rethinking the ‘diseases of affluence’ paradigm: global patterns of nutritional risks in relation to economic development. PLoS Med
22. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJ. Comparative Risk Assessment Collaborating GSelected major risk factors and global and regional burden of disease. Lancet
23. Barakat H, Barakat H, Baaj MK. CVD and obesity in transitional Syria: a perspective from the Middle East. Vasc Health Risk Manag
24. Fuentes R, Ilmaniemi N, Laurikainen E, Tuomilehto J, Nissinen A. Hypertension in developing economies: a review of population-based studies carried out from 1980 to 1998. J Hypertens
25. Pereira M, Lunet N, Azevedo A, Barros H. Differences in prevalence, awareness, treatment and control of hypertension between developing and developed countries. J Hypertens
26. Bovet P. Editorial: the cardiovascular disease epidemic: global, regional, local. Trop Med Int Health
27. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet
28. Kearney PM, Whelton M, Reynolds K, Whelton PK, He J. Worldwide prevalence of hypertension: a systematic review. J Hypertens
29. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation
30. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation
31. Duda RB, Jumah NA, Hill AG, Seffah J, Biritwum R. Interest in healthy living outweighs presumed cultural norms for obesity for Ghanaian women. Health Qual Life Outcomes
32. Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int
33. Meisinger C, Doring A, Lowel H. KORA Study GroupChronic kidney disease and risk of incident myocardial infarction and all-cause and cardiovascular disease mortality in middle-aged men and women from the general population. Eur Heart J
34. Hillege HL, Fidler V, Diercks GF, van Gilst WH, de Zeeuw D, van Veldhuisen DJ, et al. Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Circulation
35. Matsushita K, van der Velde M, Astor BC, Woodward M, Levey AS, de Jong PE, et al. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet
36. Fox CS, Matsushita K, Woodward M, Bilo HJG, Chalmers J, Heerspink HJL, et al. Associations of kidney disease measures with mortality and end-stage renal disease in individuals with and without diabetes: a meta-analysis. Lancet
37. Barsoum RS. Chronic kidney disease in the developing world. N Engl J Med
38. White SL, Chadban SJ, Jan S, Chapman JR, Cass A. How can we achieve global equity in provision of renal replacement therapy? Bull World Health Organ
39. Gaziano TA. Cardiovascular disease in the developing world and its cost-effective management. Circulation
40. Gaziano TA, Galea G, Reddy KS. Scaling up interventions for chronic disease prevention: the evidence. Lancet
41. He FJ, Jenner KH, Macgregor GA. WASH-world action on salt and health. Kidney Int
42. Modesti PA, Tamburini C, Hagi MI, Cecioni I, Migliorini A, Neri Serneri GG. Twenty-four-hour blood pressure changes in young Somalian blacks after migration to Italy. Am J Hypertens
43. Modesti PA, Hagi MI, Corsoni V, Ferraro A, Di Vincenzo E, Vanni S, Serneri GG. Impaired adaptation of cardiopulmonary receptors to western diet in normotensive black immigrants. Am J Hypertens
44. Nishida C, Uauy R, Kumanyika S, Shetty P. The joint WHO/FAO expert consultation on diet, nutrition and the prevention of chronic diseases: process, product and policy implications. Public Health Nutr
45. Matthys F, De Backer T, De Backer G, Stichele RV. Review of guidelines on primary prevention of cardiovascular disease with aspirin: how much evidence is needed to turn a tanker? Eur J Prev Cardiol
2012; [Publisher online 20 December].
46. Poole-Wilson P. The prevention of cardiovascular disease worldwide: whose task and WHO's task? Clin Med
47. Aburto NJ, Ziolkovska A, Hooper L, Elliott P, Cappuccio FP, Meerpohl JJ. Effect of lower sodium intake on health: systematic review and meta-analyses. BMJ
48. Graudal NA, Hubeck-Graudal T, Jurgens G. Effects of low-sodium diet vs. high-sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterol, and triglyceride (Cochrane Review). Am J Hypertens
49. Brown IJ, Tzoulaki I, Candeias V, Elliott P. Salt intakes around the world: implications for public health. Int J Epidemiol
50. Mendis S, Lindholm LH, Mancia G, Whitworth J, Alderman M, Lim S, Heagerty T. World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: assessment of cardiovascular risk for prevention and control of cardiovascular disease in low and middle-income countries. J Hypertens
51. Hosseinpoor AR, Bergen N, Kunst A, Harper S, Guthold R, Rekve D, et al. Socioeconomic inequalities in risk factors for non communicable diseases in low-income and middle-income countries: results from the World Health Survey. BMC Public Health
52. Giovino GA, Mirza SA, Samet JM, Gupta PC, Jarvis MJ, Bhala N, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys. Lancet
53. D’Elia L, De Palma D, Rossi G, Strazzullo V, Russo O, Iacone R, et al. Not smoking is associated with lower risk of hypertension: results of the Olivetti Heart Study. Eur J Public Health
54. Ezzati M, Hoorn SV, Rodgers A, Lopez AD, Mathers CD, Murray CJ. Comparative Risk Assessment Collaborating GEstimates of global and regional potential health gains from reducing multiple major risk factors. Lancet
55. Jamrozik K. Population strategies to prevent smoking. BMJ
56. Smith LA, Foxcroft DR. The effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: systematic review of prospective cohort studies. BMC Public Health
57. Anderson P, de Bruijn A, Angus K, Gordon R, Hastings G. Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies. Alcohol Alcohol
58. Jain A. Dunk that cola. BMJ
59. Bhaumik S. Campaign group claims that some cricketers in the Indian Premier League are breaching the rules on alcohol advertising. BMJ
60. McFadden CB, Brensinger CM, Berlin JA, Townsend RR. Systematic review of the effect of daily alcohol intake on blood pressure. Am J Hypertens
61. Koliaki C, Katsilambros N. Dietary sodium, potassium, and alcohol: key players in the pathophysiology, prevention, and treatment of human hypertension. Nutr Rev
62. Xin X, He J, Frontini MG, Ogden LG, Motsamai OI, Whelton PK. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension
63. Malhotra A. Saturated fat is not the major issue. BMJ
64. Gaziano TA, Steyn K, Cohen DJ, Weinstein MC, Opie LH. Cost-effectiveness analysis of hypertension guidelines in South Africa: absolute risk versus blood pressure level. Circulation
65. Murray CJ, Lauer JA, Hutubessy RC, Niessen L, Tomijima N, Rodgers A, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet
66. Mendis S, Lindholm LH, Anderson SG, Alwan A, Koju R, Onwubere BJC, et al. Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings. J Clin Epidemiol
67. Chalmers J. Enhancing risk stratification in hypertensive subjects: how far should we go in routine screening for target organ damage?World Health Organization International - Society of Hypertension. J Hypertens
68. WHO. WHO CVD-Risk Management Package for low- and medium-resource settings
. Geneva, Switzerland: WHO; 2002.
69. Conroy RM, Pyorala K, Fitzgerald AP, Sans S, Menotti A, De Backer G, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J
70. Sehestedt T, Jeppesen J, Hansen TW, Wachtell K, Ibsen H, Torp-Pedersen C, et al. Risk prediction is improved by adding markers of subclinical organ damage to SCORE. Eur Heart J
71. Sehestedt T, Jeppesen J, Hansen TW, Rasmussen S, Wachtell K, Ibsen H, et al. Risk stratification with the risk chart from the European Society of Hypertension compared with SCORE in the general population. J Hypertens
72. D’Agostino RB, Russell MW, Huse DM, Ellison RC, Silbershatz H, Wilson PW, Hartz SC. Primary and subsequent coronary risk appraisal: new results from the Framingham study. Am Heart J
73. Liu J, Hong Y, D’Agostino RB Sr, Wu Z, Wang W, Sun J, et al. Predictive value for the Chinese population of the Framingham CHD risk assessment tool compared with the Chinese Multi-Provincial Cohort Study. JAMA
74. Mendis S. The contribution of the Framingham Heart Study to the prevention of cardiovascular disease: a global perspective. Prog Cardiovasc Dis
75. Cappuccio FP, Oakeshott P, Strazzullo P, Kerry SM. Application of Framingham risk estimates to ethnic minorities in United Kingdom and implications for primary prevention of heart disease in general practice: cross sectional population based study. BMJ
76. Hippisley-Cox J, Coupland C, Robson J, Brindle P. Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database. BMJ
77. Brindle P, May M, Gill P, Cappuccio F, D’Agostino R Sr, Fischbacher C, Ebrahim S. Primary prevention of cardiovascular disease: a web-based risk score for seven British black and minority ethnic groups. Heart
78. Woodward M, Barzi F, Martiniuk A, Fang X, Gu DF, Imai Y, et al. Cohort profile: the Asia Pacific Cohort Studies Collaboration. Int J Epidemiol
79. Barzi F, Patel A, Gu D, Sritara P, Lam TH, Rodgers A, Woodward M. Asia Pacific Cohort Studies CollaborationCardiovascular risk prediction tools for populations in Asia. J Epidemiol Community Health
80. Lawes CM, Rodgers A, Bennett DA, Parag V, Suh I, Ueshima H, et al. Blood pressure and cardiovascular disease in the Asia Pacific region. J Hypertens
81. Zhang X, Patel A, Horibe H, Wu Z, Barzi F, Rodgers A, et al. Cholesterol, coronary heart disease, and stroke in the Asia Pacific region. Int J Epidemiol
82. Lawes CMM, Parag V, Bennett DA, Suh I, Lam TH, Whitlock G, et al. Blood glucose and risk of cardiovascular disease in the Asia Pacific region. Diabetes Care
83. Waugh N, Scotland G, McNamee P, Gillett M, Brennan A, Goyder E, et al. Screening for type 2 diabetes: literature review and economic modelling. Health Technol Assess
84. Mendis S, Lindholm LH, Anderson SG, Alwan A, Koju R, Onwubere BJ, et al. Total cardiovascular risk approach to improve efficiency of cardiovascular prevention in resource constrain settings. J Clin Epidemiol
85. Kollannur A. Will India deliver on universal health coverage? BMJ
86. Evans DB, Marten R, Etienne C. Universal health coverage is a development issue. Lancet
87. Carrin G, Evans D, Xu K. Designing health financing policy towards universal coverage. Bull World Health Organ
88. Lippi G, Chance JJ, Church S, Dazzi P, Fontana R, Giavarina D, et al. Preanalytical quality improvement: from dream to reality. Clin Chem Lab Med
89. Parati G, Mendis S, Abegunde D, Asmar R, Mieke S, Murray A, et al. Recommendations for blood pressure measuring devices for office/clinic use in low resource settings. Blood Press Monit
90. Parati G, Kilama MO, Faini A, Facelli E, Ochen K, Opira C, et al. A new solar-powered blood pressure measuring device for low-resource settings. Hypertension
91. O’Brien E, Pickering T, Asmar R, Myers M, Parati G, Staessen J, et al. Working Group on Blood Pressure Monitoring of the European Society of Hypertension International Protocol for validation of blood pressure measuring devices in adults. Blood Press Monit
92. Farooq MU, Chaudhry AH, Amin K, Majid A. The WHO STEPwise Approach to Stroke Surveillance. J Coll Physicians Surg Pak
93. Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al. 2007 Guidelines for the Management of Arterial Hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens
94. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens
95. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension
96. Figueiredo D, Azevedo A, Pereira M, de Barros H. Definition of hypertension: the impact of number of visits for blood pressure measurement. Rev Port Cardiol
97. Lang T, de Gaudemaris R, Chatellier G, Hamici L, Diene E. Prevalence and therapeutic control of hypertension in 30 000 subjects in the workplace. Hypertension
98. Modesti PA, Rapi S, Bamoshmoosh M, Baldereschi M, Massetti L, Padeletti L, et al. Impact of one or two visits strategy on hypertension burden estimation in HYDY, a population-based cross-sectional study: implications for healthcare resource allocation decision making. BMJ Open
99. Whitworth JA. World Health Organization, International Society of Hypertension Writing Group2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens
100. Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J
101. Raffle AE, Gray JAM. Screening: evidence and practice. Oxford; New York:Oxford University Press; 2007.
102. Feehally J. Chronic kidney disease: health burden of kidney disease recognized by UN. Nat Rev Nephrol
103. Perico N, Bravo RF, De Leon FR, Remuzzi G. Screening for chronic kidney disease in emerging countries: feasibility and hurdles. Nephrol Dial Transplant
104. Perico N, Remuzzi G. Chronic kidney disease: a research and public health priority. Nephrol Dial Transplant
2012; 27 (Suppl 3):iii19–iii26.
105. Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al. Chronic kidney disease: global dimension and perspectives. Lancet
106. Zhang L, Wang F, Wang L, Wang W, Liu B, Liu J, et al. Prevalence of chronic kidney disease in China: a cross-sectional survey. Lancet
107. Chen N. Chronic renal disease and dialysis in China. Bull Acad Natl Med
108. Hou F, Jiang J, Chen J, Yu X, Zhou Q, Chen P, et al. China collaborative study on dialysis: a multicenters cohort study on cardiovascular diseases in patients on maintenance dialysis. BMC Nephrol
109. Yao Q, Zhang W, Qian J. Dialysis status in China: a report from the Shanghai Dialysis Registry (2000–2005). Ethn Dis
2009; 19 (Suppl 1):S23–S26.
110. Chen N, Hsu CC, Yamagata K, Langham R. Challenging chronic kidney disease: experience from chronic kidney disease prevention programs in Shanghai, Japan, Taiwan and Australia. Nephrology
2010; 15 (Suppl 2):31–36.
111. Luyckx VA, Naicker S. Acute kidney injury associated with the use of traditional medicines. Nat Clin Pract Nephrol
112. Modesti PA, Bamoshmoosh M, Rapi S, Massetti L, Bianchi S, Al-Hidabi D, Al Goshae H. Relationship between hypertension, diabetes and proteinuria in rural and urban households in Yemen. J Hum Hypertens
113. Cravedi P, Sharma SK, Bravo RF, Islam N, Tchokhonelidze I, Ghimire M, et al. Preventing renal and cardiovascular risk by renal function assessment: insights from a cross-sectional study in low-income countries and the USA. BMJ Open
114. Li PK, Chow KM, Matsuo S, Yang CW, Jha V, Becker G, et al. Asian chronic kidney disease best practice recommendations: positional statements for early detection of chronic kidney disease from Asian Forum for Chronic Kidney Disease Initiatives (AFCKDI). Nephrology
115. Fink HA, Ishani A, Taylor BC, Greer NL, MacDonald R, Rossini D, et al. Screening for, monitoring, and treatment of chronic kidney disease stages 1 to 3: a systematic review for the U.S. Preventive Services Task Force and for an American College of Physicians Clinical Practice Guideline. Ann Intern Med
116. Luyckx VA, Naicker S, McKee M. Equity and economics of kidney disease in sub-Saharan Africa. Lancet
117. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis
118. Ralph AP, Carapetis JR. Group a streptococcal diseases and their global burden. Curr Top Microbiol Immunol
119. Zhou ZQ, Hu DY, Chen J, Zhang RH, Li KB, Zhao XL. An epidemiological survey of atrial fibrillation in China. Zhonghua Nei Ke Za Zhi
120. Zhou Z, Hu D. An epidemiological study on the prevalence of atrial fibrillation in the Chinese population of mainland China. J Epidemiol
121. Wang D, Liu M, Hao Z, Tao W, Lin S, Zhang S, et al. Features of acute ischemic stroke with rheumatic heart disease in a hospitalized Chinese population. Stroke
122. Darmawan J. World Health Organization-International League of Associations for Rheumatology Community-Oriented Program for the Control of Rheumatic DiseasesRecommendations from the Community Oriented Program for Control of Rheumatic Disease for data collection for the measurement and monitoring of health in developing countries. Clin Rheumatol
123. Beaton A, Okello E, Lwabi P, Mondo C, McCarter R, Sable C. Echocardiography screening for rheumatic heart disease in Ugandan schoolchildren. Circulation
124. Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Jani D, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med
125. Carapetis JR. Rheumatic heart disease in developing countries. N Engl J Med
126. Marijon E, Mirabel M, Celermajer DS, Jouven X. Rheumatic heart disease. Lancet
127. Remenyi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, et al. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease: an evidence-based guideline. Nat Rev Cardiol
128. Sicari R, Gargani L, Wiecek A, Covic A, Goldsmith D, Suleymanlar G, et al. The use of echocardiography in observational clinical trials: the EURECA-m registry. Nephrol Dial Transplant
129. DeGroff CG, Bhatikar S, Hertzberg J, Shandas R, Valdes-Cruz L, Mahajan RL. Artificial neural network-based method of screening heart murmurs in children. Circulation
130. Marascio G, Modesti PA. Current trends and perspectives for automated screening of cardiac murmurs. Heart Asia
131. Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet
132. Harding S, Rosato M, Teyhan A. Trends for coronary heart disease and stroke mortality among migrants in England and Wales, 1979–2003: slow declines notable for some groups. Heart
133. Stirbu I, Kunst AE, Bos V, Mackenbach JP. Differences in avoidable mortality between migrants and the native Dutch in The Netherlands. BMC Public Health
134. Cappuccio FP, Cook DG, Atkinson RW, Strazzullo P. Prevalence, detection, and management of cardiovascular risk factors in different ethnic groups in south London. Heart
135. Primatesta P, Bost L, Poulter NR. Blood pressure levels and hypertension status among ethnic groups in England. J Hum Hypertens
136. Agyemang C, Bhopal R. Is the blood pressure of people from African origin adults in the UK higher or lower than that in European origin white people? A review of cross-sectional data. J Hum Hypertens
137. Agyemang C. Trends in diabetes. Lancet
138. Agyemang C, Bhopal R. Hypertension and cardiovascular disease endpoints by ethnic group: the promise of data linkage. Heart
139. Cappuccio FP. Commentary: epidemiological transition, migration, and cardiovascular disease. Int J Epidemiol
140. Agyemang C, Kunst AE, Bhopal R, Anujuo K, Zaninotto P, Nazroo J, et al. Diabetes prevalence in populations of South Asian Indian and African origins: a comparison of England and the Netherlands. Epidemiology
141. Vandenheede H, Deboosere P, Stirbu I, Agyemang CO, Harding S, Juel K, et al. Migrant mortality from diabetes mellitus across Europe: the importance of socio-economic change. Eur J Epidemiol
142. Roderick PJ, Raleigh VS, Hallam L, Mallick NP. The need and demand for renal replacement therapy in ethnic minorities in England. J Epidemiol Comm Health
143. Lambie M, Richards N, Smith S. Ethnicity, age and incidence rates for renal replacement therapy (RRT) in Birmingham, UK: 1990–2004. Nephrol Dial Transplant
144. Agyemang C, Addo J, Bhopal R, Aikins Ade G, Stronks K. Cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe: a literature review. Global Health
145. Agyemang C, Nicolaou M, Boateng L, Dijkshoorn H, van de Born BJ, Stronks K. Prevalence, awareness, treatment, and control of hypertension among Ghanaian population in Amsterdam, the Netherlands: the GHAIA study. Eur J Prev Cardiol
146. Beune EJ, Haafkens JA, Agyemang C, Schuster JS, Willems DL. How Ghanaian, African-Surinamese and Dutch patients perceive and manage antihypertensive drug treatment: a qualitative study. J Hypertens
147. Yebei VN. Unmet needs, beliefs and treatment-seeking for infertility among migrant Ghanaian women in the Netherlands. Reprod Health Matters
148. Resnicow K, Soler R, Braithwaite RL, Ahluwalia JS, Butler J. Cultural sensitivity in substance use prevention. J Community Psychol
149. Hawthorne K, Robles Y, Cannings-John R, Edwards AG. Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev
150. Vlaar EMA, van Valkengoed IGM, Nierkens V, Nicolaou M, Middelkoop BJC, Stronks K. Feasibility and effectiveness of a targeted diabetes prevention program for 18 to 60-year-old South Asian migrants: design and methods of the DH!AAN study. BMC Public Health
151. BeLue R, Okoror TA, Iwelunmor J, Taylor KD, Degboe AN, Agyemang C, Ogedegbe G. An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective. Global Health
152. Cuadra CB. Right of access to healthcare for undocumented migrants in EU: a comparative study of national policies. Eur J Public Health
153. Greer SL, Hervey TK, Mackenbach JP, McKee M. Health law and policy in the European Union. Lancet
154. Mladovsky P. A framework for analysing migrant health policies in Europe. Health Policy (Amsterdam, Netherlands)
155. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu S, Stuckler D, et al. Financial crisis, austerity, and health in Europe. Lancet
156. MacFarlane A, O’Donnell C, Mair F, O’Reilly-de Brun M, de Brun T, Spiegel W, et al. REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings (RESTORE): study protocol. Implement Sci
157. Mladovsky P, Rechel B, Ingleby D, McKee M. Responding to diversity: an exploratory study of migrant health policies in Europe. Health Policy
158. Mladovsky P, Ingleby D, McKee M, Rechel B. Good practices in migrant health: the European experience. Clin Med
159. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet
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