From calculating cardiovascular risk factors in Honduras towards a universal cardiovascular risk model

Cardiovascular disease (CVD) is the most import cause of death worldwide and recent registries suggest increasing trends in CVD mortality. This increased prevalence of CVD is not confined to high-income countries in the Western world but is currently also observed in many low-and mid-income countries [1]. However, just limited data from Central American countries is available. Further, many low-and mid-income countries are undergoing epidemiological transitions with gradual adoption of Western lifestyle leading to development of new cardiovascular risk factors such as hypertension, dyslipidaemia, diabetes and obesity [2], [3]. The knowledge about local epidemiology and the exact evaluation of present potentially modifiable risk factors is important to gain awareness in the population for risk factors and risk stratification as well as to guide the decision-making process in education, public health campaigns and decisions in health care. Current international guidelines recommend risk assessment tools to predict CVD risk and outcomes to guide primary and secondary prevention programs [4]. However, these tools have been validated in predominantly Western populations and their value to predict risk in Central American populations is unclear. Increasing data about CVD prevalence and risk factor burden in low-and mid-income countries aid in the development of universal risk prediction tools and improvement of these tools in the future.

It is in this context that the work by Sanchez et al. [5] in this issue of the Journal on the prevalence of traditional risk factors of CVD in a community from Honduras is welcomed. Their study was performed in Copan, a department with almost 400.000 inhabitants in Western Honduras; a country with only 3 physicians per 10.000 inhabitants. Volunteers between 45 and 75 years of age without a history of CVD were recruited for this study in local medical institutions. By means of a questionnaire the medical history, family history, use of tabaco, use of medications, and self-reported exercise was assessed. In addition, body mass index, blood pressure, glucose, and cholesterol profile were measured. The 382 volunteers in this study were predominately women (62%), around 60 years of age, and all but one were of Hispanic/Latino descent. Only 3% of the women in this study reported to smoke, a low percentage compared to historic data about smoking in Honduras [6]. Overall, pharmacological treatment of known risk factors was quite good. Volunteers with a self-reported diagnosis of hypertension and diabetes were on medication in 91% and 96%, respectively, but many turned out to have undiagnosed hypertension (42%) or (pre)diabetes (6.7%). Only 23% of participants with increased cholesterol where on lipid lowering medication. After collecting all the traditional cardiovascular risk factors, the authors applied four different cardiovascular risk score’s in this population. The resulting risk scores appear alarming high to us as 71% of all the males and 17% of all the females had a Multi-Ethnic Study of Atherosclerosis (MESA) score of more than 7.5%.

These results provide us insights in the cardiovascular risk factors profile and burden in Honduras, albeit from a small number of individuals that may not be representative of the general population. A good infrastructure, data-network and collaboration between committed stakeholders will be key for future larger more representative cohort studies and for a successful follow-up to better determine the correlation between prevalent risk factors and resulting cardiovascular outcomes. These data will be crucial to decide whether if it is appropriate to use the existing cardiovascular risk assessment tools in this Central American populations.

This community-based cross-sectional study is the first to describe the high prevalence of cardiovascular risk factors in Honduras. Therefore, by the lack of tailored programmes, it is plausible that the higher than expected CVD prevalence likely resulted from poorly managed or untreated risk factors. Indeed, low knowledge level and awareness towards CVD risk is known to be associated with low literacy level and rural residency in Central America, consistent with the Honduran population in this study. Further epidemiological data is urgently needed to fill in the data gap on prevalent cardiovascular risk factors in Honduras including its impact on mortality and cardiovascular outcomes.

General principals in preventing CVD such as promoting a healthy diet, regular exercise and cessation of smoking are straightforward but often difficult to achieve. There is considerable uncertainty about the best ways of helping people at high CVD risk to modify their behaviour. Support by global, national and local governments and organizations is required to develop policy and implement tailored programmes. Simple solutions such as triggering healthy diet choices on schools and broad education can be effective and of low cost [7].

This study by Sanchez et al have shown us how many people have untreated hypertension, diabetes and dyslipidaemia. Approximately 17% of Hondurans do not have regular access to health services [5]. Therefore, alternative risk factor screening and management programs will be required to better control risk factors and reduce cardiovascular risk in low-and mid-income countries. One example may be programs comparable to the one recently described and tested in the “A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops.” Among black male barbershop patrons with uncontrolled hypertension, health promotion by barbers resulted in larger blood-pressure reduction when coupled with medication management in barbershops by specialty-trained pharmacists [8]. Additionally, organization and management of care via digital solutions, medical care might become more accessible in the rural areas of Central America [9]. Another example of increasing accessibility of healthcare in Latin America has been presented earlier in this Journal [10], [11].

However, the best approach for community-based interventions to control non-communicable risk factors remains unclear. Data such as these presented by Sanchez et al. provide useful information for developing targeted interventions or public health policy to curtail the growing epidemic of CVD. We hope that this epidemiologic study is the start of an effective program for the prevention of CVD. By giving this study a platform we hope to inspire this research group to continue their work and we are looking forward to the long term results.