Bovet Pascal, Chiolero Arnaud, Paccaud Fred, Banatvala Nick
1Institute of Social and Preventive Medicine (IUMSP), University Hospital Centre, Rue de la Corniche 10, 2013 Lausanne, Switzerland.
2Noncommunicable Diseases and Mental Health Cluster, World Health Organization, Geneva, Switzerland.
Public Health Rev. 2015 Nov 25;36:13. doi: 10.1186/s40985-015-0013-0. eCollection 2015.
Cardiovascular disease (CVD), mainly heart attack and stroke, is the leading cause of premature mortality in low and middle income countries (LMICs). Identifying and managing individuals at high risk of CVD is an important strategy to prevent and control CVD, in addition to multisectoral population-based interventions to reduce CVD risk factors in the entire population.
We describe key public health considerations in identifying and managing individuals at high risk of CVD in LMICs.
A main objective of any strategy to identify individuals at high CVD risk is to maximize the number of CVD events averted while minimizing the numbers of individuals needing treatment. Scores estimating the total risk of CVD (e.g. ten-year risk of fatal and non-fatal CVD) are available for LMICs, and are based on the main CVD risk factors (history of CVD, age, sex, tobacco use, blood pressure, blood cholesterol and diabetes status). Opportunistic screening of CVD risk factors enables identification of persons with high CVD risk, but this strategy can be widely applied in low resource settings only if cost effective interventions are used (e.g. the WHO Package of Essential NCD interventions for primary health care in low resource settings package) and if treatment (generally for years) can be sustained, including continued availability of affordable medications and funding mechanisms that allow people to purchase medications without impoverishing them (e.g. universal access to health care). This also emphasises the need to re-orient health systems in LMICs towards chronic diseases management.
The large burden of CVD in LMICs and the fact that persons with high CVD can be identified and managed along cost-effective interventions mean that health systems need to be structured in a way that encourages patient registration, opportunistic screening of CVD risk factors, efficient procedures for the management of chronic conditions (e.g. task sharing) and provision of affordable treatment for those with high CVD risk. The focus needs to be in primary care because that is where most of the population can access health care and because CVD programmes can be run effectively at this level.
心血管疾病（CVD），主要是心脏病发作和中风，是低收入和中等收入国家（LMICs）过早死亡的主要原因。识别和管理心血管疾病高危个体是预防和控制心血管疾病的重要策略，此外还需要采取多部门基于人群的干预措施来降低整个人群的心血管疾病风险因素。
我们描述了在低收入和中等收入国家识别和管理心血管疾病高危个体时的关键公共卫生考虑因素。
识别心血管疾病高危个体的任何策略的一个主要目标是在尽量减少需要治疗的个体数量的同时，最大限度地避免心血管疾病事件的发生。低收入和中等收入国家可获得估计心血管疾病总风险的评分（例如致命和非致命心血管疾病的十年风险），这些评分基于主要的心血管疾病风险因素（心血管疾病病史、年龄、性别、烟草使用、血压、血液胆固醇和糖尿病状况）。对心血管疾病风险因素进行机会性筛查能够识别心血管疾病高危人群，但只有在使用具有成本效益的干预措施（例如世界卫生组织针对低资源环境下初级卫生保健的基本非传染性疾病干预措施包）且治疗（通常持续数年）能够持续进行的情况下，该策略才能在资源匮乏的环境中广泛应用，包括持续提供负担得起的药物以及允许人们购买药物而不至于陷入贫困的资金机制（例如全民医疗保健）。这也强调了在低收入和中等收入国家将卫生系统重新定位以应对慢性病管理的必要性。
低收入和中等收入国家心血管疾病负担沉重，且可以通过具有成本效益的干预措施识别和管理心血管疾病高危人群，这意味着卫生系统需要以鼓励患者登记、对心血管疾病风险因素进行机会性筛查、有效管理慢性病的程序（例如任务分担）以及为心血管疾病高危人群提供负担得起的治疗的方式进行构建。重点应放在初级保健上，因为大多数人可以在初级保健机构获得医疗服务，而且心血管疾病项目在这一级别可以有效开展。
