Letter by Ordunez Regarding Article, "Cardiometabolic Risk Factor Control During Times of Crises and Beyond".

To the Editor:

Dr Brooks’ article on the risk of an upcoming cardiovascular (CVD) crisis[1] is very auspicious. The friction between the pandemic and the health systems functioning, already fragile, ill-equipped, and poorly financed, is the perfect fuel for a bigger crisis. Thus, when this nightmare ends, low and low-middle income countries, already with a huge burden of noncommunicable diseases, will have accumulated more social debts and inequities, will have fewer resources for recovery, and their health systems will be completely devastated. Therefore, my letter aims to make the case for those who need the most support and solidarity in the time of coronavirus disease 2019 (COVID-19).

Certainly, the CVD crisis emerged a long time before the COVID-19. With 2 million deaths, 29% of the total deaths, CVD are the leading cause of death in the Americas. After decades of continuous reduction in mortality, between 2007 and 2017 a significant slowdown in the decline was observed, and several countries showed stagnation or a reversal in trends, including the United States.[2] This situation is a consequence of high prevalence in cardiometabolic risk factors at the population level: over 60% of overweight and obesity, 20% of raised blood pressure, 9 g of salt consumption on average, 8% of raised blood glucose, and 15% of tobacco use.[3] In parallel, our prolonged failure to provide care for peoples with noncommunicable disease is apparent. For instance, 1 in 4 adults have hypertension globally but just around 13% reach the treatment goal (<140/90 mm Hg). That occurs because half of the persons with hypertension do not aware/not diagnosed and because >50% among treated does not reach the control. Causes are multiples, but fundamental is the health system failures to diagnoses persons at risk, to secure access to quality medications, and to meet the standards of care.[4] Hence, the weather could not be more propitious for the COVID-19 perfect storm.

To complete the case, let us summarize a WHO report about the impact of COVID-19 on health services for noncommunicable disease.[5] The bottom line is that health services have been partially or completely interrupted in many countries. For CVD alone, 53% of the surveyed countries have partially or completely discontinued services for the treatment of hypertension; 49% for the treatment of diabetes and diabetes-related complications; and 31% for cardiovascular emergencies. The situation might be worse for the most vulnerable groups of the population, frequently excluded from official statistics. Fortunately, a lot of people in many places did not paralyze by the fears and uncertainty. Special recognition deserves those reacted with celerity and innovations to protect the patients and to guarantee the continuity of care at the primary health centers. Now, more than ever, primary health centers must be the health strategic front-line for the postacute phase of the pandemic for both COVID-19 and noncommunicable disease.

In this context, HEARTS, PAHO flagship program to improve CVD risk management in the Americas (https://www.paho.org/en/hearts-americas) in partnership with the US CDC and the Resolve to Save Lives, rather than postpone its interventions, is working to be part of the response and as well in the postpandemic reconstruction phase. HEARTS is implementing in 371 primary health centers from 12 countries. At the population level, priorities are public policies and regulatory actions to reduce tobacco use and the excess of salt intake and to replace the transfat. At the health system level, the target is hypertension control improvement which includes a simple and standardized treatment protocol supported by a core set of high quality and affordable medications, guided by a system for clinical monitoring and performance evaluation and managed by a primary health care team. Beyond the challenges, this double crisis offers many opportunities for change. Let us make it happen.

Disclosures

Dr Ordunez is a staff member of the Pan American Health Organization. The author alone is responsible for the views expressed in this publication, and they do not necessarily represent those of the Pan American Health Organization.