International Journal of Cardiology 179 (2015) 220–221

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Letter to the Editor

Cardiovascular disease and global health: Differences among foreign citizens admitted to a Spanish hospital Alejandro Salinas a,⁎, José M. Ramos b, Miguel Górgolas c a b c

Department of Internal Medicine, Hospital de Denia, Alicante, Spain Department of Internal Medicine, Hospital General Universitario de Alicante, Universidad Miguel Hernández, Alicante, Spain Division of Infectious Diseases, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain

a r t i c l e

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Article history: Received 29 October 2014 Accepted 4 November 2014 Available online 6 November 2014 Keywords: Cardiovascular disease Global health Foreigners Low income countries High income countries

Over the past two decades, deaths from cardiovascular disease (CVD) have been declining in high-income countries, but have increased in low and middle-income countries. There is a lack of data across European countries in relation to CVD in migrants and minority ethnic groups. As they have different ethnicity and genetic backgrounds, different personal and social habits, different exposures to infectious diseases and dietary habits and different accesses to health services and immunizations, it is expected that their CVD profile might be also different. We performed a comparative analysis of CVDs in foreign citizens (FC) admitted to a Spanish hospital in relation to the region of origin, ethnicity and income of the country. We selected patients admitted to the center from 2000 to 2012. They were divided into two groups: (1) FCs from high-income countries (FCHICs): European Union, United States, Canada, Australia and New Zealand and (2) FCs from low and middle-income countries (FCLMICs): Latin America, North Africa, SubSaharan Africa, Eastern Europe and Asia. Patients with circulatory system disease were classified according to the International Classification of Diseases, Ninth Revision, Clinical Modification (IDC-9-CM) used at the final diagnosis when the patients were discharged. The total population of the study was clasified in 8 groups: 1) valvular heart disease,

⁎ Corresponding author at: Department of Internal Medicine, Hospital de Denia, Partida Beniadlá, S/N 03700 Denia, Alicante, Spain. E-mail address: [email protected] (A. Salinas).

http://dx.doi.org/10.1016/j.ijcard.2014.11.038 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.

2) arrhythmia, 3) myocardiopathies and congestive heart failure, 4) coronary heart disease, 5) pericarditis, 6) vascular disease (arteries and vessels), 7) hypertension and 8) pulmonary hypertension and pulmonary embolism. The Committee for Security of Information and Research at the Hospital General Universitario de Alicante provided ethical approval for this study. We used IBM SPSS© 21.0 version for statistical analysis. A P value of less than 0.05 was considered statistically significant. 3728 patients had a discharge final diagnosis of CVD. 2142 patients (57.5%) were from high-income countries and 1586 (42.5%) from low and middle-income countries. The percentage of women was higher in low and middle-income countries than in highincome countries (36% vs 26.9%), being Latin American women as the majority in the first group. In high-income countries the greatest number of patients admitted was from the United Kingdom (25.2%) and in low and middle-income countries was from Morocco (10.5%). The most common diagnosis was coronary heart disease (37.3%), followed by vascular disease (25.9%), arrhythmia (13.7%), myocardiopathy and heart failure (7.9%), valvular heart disease (6.8%), hypertension (5.5%), pulmonary hypertension/pulmonary embolism (2.1%) and pericarditis (0.8%). The percentage of valvular heart disease was higher in FCLMICs than in FCHICs, as well as myocardiopathies and pericarditis, after adjusting for age and gender. (Table 1). Among FCLMICs, admissions for valvular heart disease were more frequent in North African people than in Latin American people; coronary heart disease was more frequent in Asiatic patients, vascular disease was higher in Eastern Europeans and hypertension in SubSaharan patients, compared with Latin Americans and adjusting for age and gender (Table 2). In our study, coronary heart disease was the most frequent diagnosis overall. This can be explained because a large proportion of cases was from high-income countries, where risk factors for atherosclerosis such as tobacco, stress and an unhealthy diet are much more common than in low and middle-income settings. However, it is important to note that in low and middle-income countries these risk factors are progressively growing [1], and it could have contributed to increase the total burden of CVD in our study. In recent years some studies have alerted about this problem in developing countries [2], particularly within the wealthiest population in urban areas. On the other hand, the most common CVDs in patients from low and middle-income countries were: valvular heart diseases, myocardiopathies and pericarditis.

A. Salinas et al. / International Journal of Cardiology 179 (2015) 220–221 Table 1 Cardiovascular diseases according to income. N Valvular heart disease FCHIC (N = 2142) FCLMIC (N = 1586) Arrhythmia FCHICs FCLMICs Myocardiopathies FCHICs FCLMICs CHD FCHICs FCLMICs Pericarditis FCHICs FCLMICs Vascular disease FCHICs FCLMICs HT FCHICs FCLMICs Pulmonary HT FCHICs FCLMICs

252 112 140 511 271 240 294 129 165 1391 884 507 28 6 22 967 611 356 206 97 109 79 32 47

%

221

Table 2 Cardiovascular diseases according to region. AOR

95% CI

P-value

5.2 8.8

1 1.709

1.308–2.233

b0.001

12.7 15.1

1 1.155

0.950–1.404

0.147

6 10.4

1 2.413

1.880–3.096

b0.001

41.3 32

1 0.734

0.637–0.847

b0.001

0.3 1.4

1 3.316

1.308–8.408

0.012

28.5 22.4

1 0.692

0.591–0.809

b0.001

4.5 6.9

1 1.127

0.838–1.515

0.429

1.5 3

1 1.570

0.979–2.518

0.061

FCHICs: Foreign citizens from high-income countries; FCLMICs: Foreign citizens from low and middle-income countries; CHD: coronary heart disease; HT: Hypertension, AOR: Adjusted odds ratio; CI: Confidence interval.

Valvular heart diseases have a high prevalence in Africa, particularly due to congenital heart diseases and rheumatic fever [3]. Cardiac surgery programs have been established in some developing countries to fight against these diseases [4]. The high prevalence of intravenous drug users in Central Asia and Eastern Europe in recent years could explain the higher rates of endocarditis and secondary valvular heart lesions in these regions. Within the group of myocardiopathies, it is important to remember that Chagas disease has a high prevalence in Latin America. In addition, alcoholic cardiomyopathy is an important cause of dilated cardiomyopathy in developing countries, leading to heart failure in severe cases. In Africa, endomyocardial fibrosis and hypereosinophilic syndrome are two causes of restrictive cardiomyopathy [5,6]. In some rural areas of China, selenium deficit has been associated to dilated cardiomyopathy [7]. Finally, the percentage of cases of pericarditis is especially high in FCLMICs in our study. Tuberculous pericarditis represents the main cause of pericarditis in developing countries and without treatment it is a life-threatening disease. Admissions for coronary heart disease are higher in Asian people compared to Latin Americans with statistically significant differences after adjustment for age and gender. A large study in the Asia-Pacific region showed that the Asian population had isolated low HDL levels compared with non-Asian patients, leading to an increase in the risk of coronary heart disease [8]. Genetic factors have been involved for special susceptibility in this population [9] as well as alcohol consumption [10]. In summary, differences according to region and country of origin are discovered when a large group of people is analyzed. The profile of CVDs in high-income countries and low and middle-income countries is different. When a comparative analysis is performed among regions of low and middle income countries of similar economical conditions, differences in their CVD profile can be found.

Competing interests The authors declare that they have no competing interests.

N (FCLMICs) % (region) AOR Valvular heart disease Latin America North Africa Eastern Europe Asia Sub-Saharan Africa Arrhythmia Latin America North Africa Eastern Europe Asia Sub-Saharan Africa Myocardiopathies Latin America North Africa Eastern Europe Asia Sub-Saharan Africa CHD Latin America North Africa Eastern Europe Asia Sub-Saharan Africa Pericarditis Latin America North Africa Eastern Europe Asia Sub-Saharan Africa Vascular disease Latin America North Africa Eastern Europe Asia Sub-Saharan Africa HT Latin America North Africa Eastern Europe Asia Sub-Saharan Africa Pulmonary HT Latin America North Africa Eastern Europe Asia Sub-Saharan Africa

140 48 64 12 8 8 240 94 104 28 13 1 165 59 83 13 2 8 507 205 189 64 39 10 22 9 7 2 2 2 356 152 113 67 13 11 109 53 29 10 4 13 47 30 11 4 0 2

95% CI

P-value

7.4 10.7 6 9.9 14.5

1 1.854 0.831 1.428 2.245

1.216–2.827 0.430–1.606 0.645–3.160 0.968–5.206

0.004 0.582 0.380 0.060

14.5 17.3 14 16 1.8

1 1.361 0.891 1.211 0.081

0.987–1.877 0.562–1.413 0.640–2.293 0.011–0.603

0.060 0.625 0.556 0.014

9.1 13.8 6.5 2.5 14.5

1 1.123 0.807 0.237 2.203

0.771–1.636 0.429–1.520 0.057–0.990 0.964–5.032

0.544 0.508 0.048 0.061

31.5 31.5 32 48.1 18.2

1 0.783 1.107 1.887 0.560

0.605–1.014 0.777–1.578 1.160–3.070 0.269–1.165

0.063 0.573 0.011 0.121

1.4 1.2 1 2.5 3.6

1 1.515 0.577 2.105 0.878

0.534–4.303 0.122–2.727 0.435–10.178 0.159–4.839

0.435 0.488 0.355 0.882

23.4 18.8 33.5 16 20

1 0.852 1.665 0.661 0.868

0.637–1.139 1.170–2.371 0.352–1.241 0.426–1.768

0.279 0.005 0.198 0.697

8.2 4.8 5 4.9 23.6

1 0.762 0.527 0.640 2.491

0.466–1.247 0.261–1.063 0.223–1.832 1.209–5.131

0.279 0.074 0.405 0.013

4.6 1.8 2 0 3.6

1 0.540 0.387 0.000 0.596

0.259–1.123 0.134–1.120 0.000 0.132–2.683

0.099 0.080 0.997 0.500

FCLMICs: Foreign citizens from low and middle-income countries; CHD: Coronary heart disease; HT: Hypertension, AOR: Adjusted odds ratio; CI: Confidence interval.

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Cardiovascular disease and global health: differences among foreign citizens admitted to a Spanish hospital.

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