News #6 | May/June 2009
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May, Month of the Heart – Challenges for 2009
May, Month of the Heart – Challenges for 2009
Professor Mário G. Lopes

University Cardiology Clinic, Faculty of Medicine of the University of Lisbon
And Cardiology Service I of the CHL- Santa Maria Hospital
Telephone: +351 917 287 290
mglopes@netcabo.pt


Each year we traditionally dedicate the month of May to preventing cardiovascular diseases. This year we can identify four challenges: 

1 - The main aim of the campaigns that are emerging is to continue to make patients and the population in general aware of the importance of practising healthy lifestyles and of controlling the well-known modifiable risk factors (1).  

Among these one can highlight smoking, controlling blood pressure, a varied and healthy diet avoiding (or combating) dyslipidemia, obesity and diabetes, and also regular physical exercise (such as walking for thirty minutes at least three times per week).  

However, we are confronted with non-modifiable risk factors, such as age, gender and genetic charge (family history of cardiovascular disease before 55 in men and 65 in women).  

On the other hand, clinical manifestations of atherosclerosis also occur in the population considered to be of low risk, as they do not have the well-known factors favouring the development of this pathology with an unknown aetiology and a complex physiopathology. For this reason about 50% of acute coronary syndromes or sudden deaths outside the hospital take place in patients without these risk factors (2).  

If we add ageing (currently 17% of the Portuguese population is 65 or over, and that percentage will increase to 30% in 2030) (3) we can state that when we are at an emergency unit we need to have the resources necessary to rule out or rule in one of the several cardiovascular situations with very efficient “therapeutic windows”. That is, besides the support for measures of primary and secondary prevention of cardiovascular diseases, we increasingly have to be ready to treat these patients who will lore and more often turn up in a recurring manner and generally in an emergency situation.

Pressure on the Portuguese National Health Service will increase and the classic medical spirit – permanent availability and physical and psychic resistance – will have to be promoted and mainly used as a criterion for the choice of future doctors.

2 – Unlike what was once thought, cardiovascular diseases are not exclusive to economically more wealthy societies and will continue to be the main cause of morbility and mortality throughout the world, as was demonstrated in the projections published in 2006 by Mathers and Loncar (4) (see figure).  

We are facing a public health and clinical medicine problem of enormous proportions, which demands the mobilisation of immense resources in order for us to be capable of dealing with this XXI century epidemic.

3 – The last year has revealed a grave economic and financial situation, set off by American sub-prime leases and the toxic debts that have invaded the whole planet like a pandemic with catastrophic consequences. (5,6)

The economic recession, followed by an exponential increase in unemployment, has led many patients to stop having the means to pay for treatments or to lead healthy lifestyles. This situation also affects pensioners, particularly the Portuguese OAPs, who in many cases no longer can afford the medication that, fortunately, are subsidised in Portugal (7).  

If we think that in certain clinical situations, (e.g. the cardiac patient treated with the placing of a stent) they need a long-term treatment, which is costly, we can imagine the iatrogenic pathology that may arise if this treatment is interrupted.

4 – The good news is that we are going through a period of intense innovation and technological progress and that we should see the three challenges described above as opportunities to provide more and better care (namely in the fields of cardiovascular prevention and education).  

Among other areas, I would like to call attention to the Information and Communication Technologies (TIC) applied to Medicine. It is curious to note that in the plans for economic recovery set out by the United States government, a line of credit of 19 billion US dollars was approved aimed at an Electronic Health Record which by 2012 will connect all the services that provide government-assisted health programmes (Medicaid and Medicare)(8).

One of the reasons that justify this investment has to do with the availability of the results of exams and interventions at any place and time, avoiding the waste of the repetitions we well know. The American Heart Association has a very extensive plan dedicated to supporting the cardiac patient which is intensely supported by these new IT programmes, as we summarise in the table below. (9)

We should develop equivalent programmes in Portugal, allowing the two sides of the coin: Health Promotion on the one hand and Education in Illness on the other (or ProSau/EduDo), whether articulated towards taking advantage of these tools and methodologies that make it possible to realise our long-time desire to give health care to all those who need it, using the resources created and made available in our country.

Bibliographical References:
1 - Fung G.L. Cardiovascular Risk Factor Reduction: Where Are We Going? AHA Library . 21-5-2008.
http://pt.wkhealth.com/pt/re/aha/addcontent.8281255.htm Accessed on 2009/05/11 

2 - Braunwald E. Cardiovascular Medicine at the Turn of the Millennium: Triumphs, Concerns, and Opportunities. N Engl J Med 1997; 337(19):1360-1369.
http://content.nejm.org/cgi/content/full/337/19/1360 Accessed on 2009/05/11 

3 - Instituto Nacional de Estatistica. Decréscimo e Envelhecimento da População até 20050. Instituto Nacional de Estatistica. 31-3-2004.
http://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=72193&DESTAQUESmodo=2 Accessed on 2009/05/11 

4 - Mathers CD, Loncar D. Projections of Global Mortality and Burden of Disease from 2002 to 2030. PLoS Medicine 2006; 3(11):e442.
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030442
Accessed on 2009/05/11 

5 - Aníbal S. Actual crise resulta da "corrupção ao estilo americano", diz Stiglitz. Público 10[6976], 32. 9-4-2009.
http://jornal.publico.clix.pt/main.asp?fd=NEXT&page=32&dt=20090509&c=A Accessed on 2009/05/11 

6 - Cunha IA. Europa afunda-se na pior recessão dos últimos 60 anos. Público . 5-5-2009.
http://jornal.publico.clix.pt/main.asp?fd=NEXT&page=26&dt=20090505&c=A Accessed on 2009/05/11 

7 - Cunha S. Idosos cortam nos remédios. Correio da Manhã . 15-3-2009. 

8 - Blumenthal D. Stimulating the Adoption of Health Information Technology. N Engl J Med 2009; 360(15):1477-1479.
http://content.nejm.org/cgi/content/full/360/15/1477 Accessed on 2009/05/11 

9 - Jones DW, Peterson ED, Bonow RO et al. Partnering to Reduce Risks and Improve Cardiovascular Outcomes. American Heart Association Initiatives in Action for Consumers and Patients. Circulation 2009; 119:340-350.
http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.108.191328v1 Accessed on  2009/05/11 


Figure: Worldwide projections for Group II mortalities from pathologies in the period between 2002 and 2030. Cardiovascular diseases (CVD) will continue to be the main cause of death. Adapted from Mathers and Loncar (4) 

Projecções mundiais para Mortalidade no Grupo II

Copyright: © 2006 Mathers and Loncar. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 

Chart - Initiatives carried out by the American Heart Association aimed at promoting the cardiovascular health of American patients.  Adapted from Jones et al 2009 (9) (http://www.americanheart.org/hbprisk)

1 - Heart Profilers (http://www.americanheart.org/riskassessment)
2 - HeartHub (http://www.americanheart.org/heartprofilers)
3 - HeartRx
4 - Heartsaver CPR, and Hands-Only CPR (http://www.americanheart.org/presenter.jhtml?identifier3047680 e http://handsonlycpr.eisenberginc.com/)
5 - PHR Resource Center (http://www.americanheart.org/PHR)
6 - Blood Pressure Management Center (http://www.bpmc.heart.org)
7 - Heart360 (http://www.heart360.org)
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Coordination:
Prof. Doutor J. Fernandes e Fernandes
Editorial Commitee: Prof. Doutor J. Fernandes e Fernandes, Prof. Doutor Alexandre Ribeiro, Prof. Doutor António Vaz Carneiro, Prof. Doutor João Ferreira, Dr. Luis Pereira
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