Several next steps toward implementing cardiovascular disease-reduction programs include utilizing the established resources for delivering health care and developing risk assessment tools to target high-risk population groups. An efficient and central health care infrastructure is an important and sustainable solution for managing the rise in the cardiovascular epidemic. Primary care providers are critical for population-based risk factor modification, cardiovascular disease prevention, and treating chronic diseases. Economic support and resources, such as medical equipment and education pamphlets, should be made available to primary care providers who can reach large numbers of patients. Efforts should be made to pursue health programs that are affordable and accessible.

More resources and funding need to be allocated toward understanding the barriers to health care, such as the specific beliefs and practices of different cultures.

Civic and religious leaders are important allies in the public heath efforts to gain the attention and trust of their communities. Because many areas around the world have physician shortages, training of nonmedical individuals can expand substantially the workforce needed for education and screening. One example is directly observed therapy for the treatment of tuberculosis, a program in which trained nonmedical personnel monitor patients as they take every dose of medication. This program has been used worldwide with success in reducing the transmission of tuberculosis.[27]

The same concept can be applied toward establishing programs that ensure that patients have the support and reinforcement they need for the treatment of chronic disease that predispose to cardiovascular diseases.

Current recommendations for the treatment and prevention of cardiovascular disease are based on the long-term risk of myocardial infarction or death. Traditional risk factor assessment tools, such as the Framingham Risk Score, are based on a specific population and can overestimate cardiovascular risk in other ethnic groups. Efforts have been made to develop screening tools that more closely fit individual populations. For example, the Systematic Coronary Risk Evaluation Project developed a long-term risk estimation system for clinical practice in European populations.[28] Continued funding and research should focus on calibrating the risk assessment tools to fit different ethnic groups. Moreover, development of simple and inexpensive methods for screening laboratory tests as well as efficient and accurate methods for recording mortality and morbidity are needed.

CONCLUSION
Cardiovascular disease is already the major cause of death both in the developed world and is rapidly becoming a serious chronic problem in the developing world. Social, environmental, and cultural determinants of cardiovascular health, such as obesity, tobacco use, and access to health care, need to be addressed globally to reduce the incidence of cardiovascular disease. The rise in chronic diseases, in addition to the preexisting infectious disease burden, will be difficult to manage in countries that have limited economic resources. The economic problem is made worse by the fact that cardiovascular disease affects the working-age population, leading to a reduction in the available workforce,  further stymieing economic growth in the developing countries. Unless public health interventions are implemented, the combination of scarce resources and the rise in cardiovascular diseases will be catastrophic. Improving cardiovascular health care delivery infrastructures, increasing public awareness, and furthering preventive health research will be the keys to controlling the emerging worldwide epidemic in cardiovascular disease. As evidenced in the developed world, this large public health problem does not have simple solutions, and the fight against cardiovascular disease internationally will require the efforts of both individual countries and the global health community.

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Helina Kassahun, MD, and William B. Borden, MD, MBA

Helina Kassahun, MD, is a clinical cardiology fellow at New York-Presbyterian Hospital in New York City.
William B. Borden, MD, MBA, is an assistant professor of medicine and public health at the Weill Cornell Medical College in New York City and the Nanette Laitman Clinical Scholar in the department of public health. He is a practicing preventive cardiologist and health policy researcher. His current areas of research interest are in the real-world implementation of appropriate medical therapy prior to coronary interventions and in the socioeconomic equity of proposed hospital value-based purchasing programs.

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