Schwalm J D, McKee Martin, Huffman Mark D, Yusuf Salim
From Population Health Research Institute and Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada (J.D.S., S.Y.); Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, United Kingdom (M.M.); and Departments of Preventive Medicine and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H.).
Circulation. 2016 Feb 23;133(8):742-55. doi: 10.1161/CIRCULATIONAHA.115.008721.
Cardiovascular disease (CVD) is the leading cause of global deaths, with the majority occurring in low- and middle-income countries. The primary and secondary prevention of CVD is suboptimal throughout the world, but the evidence-practice gaps are much more pronounced in low- and middle-income countries. Barriers at the patient, healthcare provider, and health system level prevent the implementation of optimal primary and secondary prevention. Identification of the particular barriers that exist in resource-constrained settings is necessary to inform effective strategies to reduce the identified evidence-practice gaps. Furthermore, targeting modifiable factors that contribute most significantly to the global burden of CVD, including tobacco use, hypertension, and secondary prevention for CVD, will lead to the biggest gains in mortality reduction. We review a select number of novel, resource-efficient strategies to reduce premature mortality from CVD, including (1) effective measures for tobacco control, (2) implementation of simplified screening and management algorithms for those with or at risk of CVD, (3) increasing the availability and affordability of simplified and cost-effective treatment regimens including combination CVD preventive drug therapy, and (4) simplified delivery of healthcare through task-sharing (nonphysician health workers) and optimizing self-management (treatment supporters). Developing and deploying systems of care that address barriers related to the above will lead to substantial reductions in CVD and related mortality.
心血管疾病（CVD）是全球死亡的主要原因，大多数死亡发生在低收入和中等收入国家。在全球范围内，心血管疾病的一级和二级预防都未达到最佳水平，但在低收入和中等收入国家，证据与实践之间的差距更为明显。患者、医疗服务提供者和卫生系统层面的障碍阻碍了最佳一级和二级预防措施的实施。识别资源受限环境中存在的特定障碍对于制定有效的策略以缩小已确定的证据与实践之间的差距至关重要。此外，针对对全球心血管疾病负担贡献最大的可改变因素，包括烟草使用、高血压和心血管疾病的二级预防，将在降低死亡率方面取得最大成效。我们回顾了一些新颖、资源高效的策略，以降低心血管疾病导致的过早死亡，包括（1）有效的烟草控制措施；（2）为患有心血管疾病或有心血管疾病风险的人群实施简化的筛查和管理算法；（3）提高包括联合心血管疾病预防药物治疗在内的简化且经济有效的治疗方案的可及性和可负担性；（4）通过任务分担（非医师卫生工作者）简化医疗服务提供，并优化自我管理（治疗支持者）。开发和部署能够解决上述相关障碍的医疗保健系统将大幅降低心血管疾病及相关死亡率。
