Table Of ContentPublic Health Approach
to Cardiovascular Disease
Prevention & Management
Cardiovascular diseases (CVDs) are the number one cause of death and disability globally, being
the most important public health problem that needs to be tackled as more people die annually
from CVDs than from any other cause. Over three-quarters of CVD deaths take place in low- and
middle-income countries. This book on cardiovascular diseases provides an overview of the
global and regional challenges associated with CVDs. Coupled with case studies and theoretical
concepts, it helps the reader to contextualize CVDs in the broader public health system and the
administrative aspects of practicing CVD control approaches for improved population health in
their local setting.
Key features:
1. Covers existing and emerging issues in cardovascular disease epidemiology and prevention.
2. Has a multidisciplinary approach in content and audience.
3. Connects with health systems and relevant sustainable development goals.
4. Provides case studies enabling readers to understand and apply evidence-based solutions to
key public health issues.
5. Has inputs from globally renowned public health experts.
The book is a master piece. There are very few books that integrate public health aspects of CVD
prevention and management. The book is unique in that it addresses all the known risk factors along
with introducing emerging risk factors such as air pollution while emphasizing their role across the life
span. In terms of solutions it discusses a range of responses from health promotion at one end of the
spectrum to universal health coverage at the other end. This book will be useful not only to clinicians
but also to public health experts all over the world.
Dr V. Mohan
President & Chief of Diabetes Research, Madras Diabetes Research Foundation
Chairman & Chief Diabetologist, Dr Mohan’s Diabetes Specialities Centre
Jorge Luis Borges (1899–1986) quoted “Of the various instruments invented by man, the most
amazing is the book; all the others are extensions of the body of it…Only the book is an extension of the
imagination and memory”.
We celebrate the Publication of Public Health Approaches to Cardiovascular Disease Prevention &
Management by Prof. Prabhakaran Dorairaj, K. Srinath Reddy, and Shuchi Anand, and invite everyone
interested in cardiovascular health to the fruitful reading of it.
The book synthesizes the most modern concepts of the prevention and management of cardiovascular
diseases, particularly from the perspective of the implementation science and Public Health.
Prof Daniel Pineiro
Full Professor of Medicine, Universidad de Buenos Aires, Argentina
President-Elect, World Heart Federation, 2021–2022
Trustee, Board of Trustees, American College of Cardiology, 2018–2021
This book provides a comprehensive overview focused on one of the most pressing public health
challenges of our times. Uniquely presenting a truly global health perspective, the authors carefully
dissect the complex evidence relating to the promotion of optimal cardiovascular health across the
life course. For anyone engaged in the research or practice of public health relating to cardiovascular
conditions, especially in low- and middle-income countries, here is an ideal “one-stop-shop” for the
current state of the evidence and its practical applications.
Prof Anushka Patel
Vice-Principal Director & Chief Scientist
The George Institute for Global Health
Australia
Public Health Approach to Cardiovascular Disease Prevention and Management” flls in a needed gap
in the feld of cardiovascular literature by providing a more holistic approach to cardiovascular health,
focusing not only on management of disease but also on promotion of cardiovascular health from a
public health perspective. This very well written book will certainly be an excellent companion to all of
those interested in cardiovascular health and will be another piece contributing to achieve our common
goal of “cardiovascular health for everyone”.
Prof Fausto J Pinto
Director, Serviço de Cardiologia e Departamento Coração e
Vasos do CHULN / Head of Department
Professor Catedrático de Medicina/Cardiologia, FMUL—Full Professor
President, Centro Cardiovascular da Universidade de Lisboa (CCUL)
President, World Heart Federation (WHF) (2021–2022)
Past-President, European Society of Cardiology (ESC)
Despite cardiovascular diseases being the leading causes of premature mortality and disability
particularly in low middle income countries, policy and prevention are often neglected and this book is a
timely publication to help implement evidence based recommendations to improve population level and
patient outcomes.
Prof Kamlesh Khunti
Professor of Primary Care Diabetes and Vascular Medicine
University of Leicester, UK
Public Health Approach
to Cardiovascular Disease
Prevention & Management
Edited By
Dorairaj Prabhakaran
Public Health Foundation of India and Centre for Chronic Disease Control
Shuchi Anand
Stanford University
K. Srinath Reddy
Public Health Foundation of India
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
First edition published 2023
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2023 Taylor & Francis Group, LLC
This book contains information obtained from authentic and highly regarded sources. While all
reasonable efforts have been made to publish reliable data and information, neither the author[s]
nor the publisher can accept any legal responsibility or liability for any errors or omissions that may
be made. The publishers wish to make clear that any views or opinions expressed in this book by
individual editors, authors or contributors are personal to them and do not necessarily refect the
views/opinions of the publishers. The information or guidance contained in this book is intended
for use by medical, scientifc or health-care professionals and is provided strictly as a supplement to
the medical or other professional’s own judgement, their knowledge of the patient’s medical history,
relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the
rapid advances in medical science, any information or advice on dosages, procedures or diagnoses
should be independently verifed. The reader is strongly urged to consult the relevant national drug
formulary and the drug companies’ and device or material manufacturers’ printed instructions, and
their websites, before administering or utilizing any of the drugs, devices or materials mentioned in
this book. This book does not indicate whether a particular treatment is appropriate or suitable for
a particular individual. Ultimately it is the sole responsibility of the medical professional to make
his or her own professional judgements, so as to advise and treat patients appropriately. The authors
and publishers have also attempted to trace the copyright holders of all material reproduced in this
publication and apologize to copyright holders if permission to publish in this form has not been
obtained. If any copyright material has not been acknowledged please write and let us know so we
may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced,
transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying, microflming, and recording, or in any information
storage or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, access www.copyright.com
or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923,
978-750-8400. For works that are not available on CCC please contact mpkbookspermissions@tandf.
co.uk
Trademark notice: Product or corporate names may be trademarks or registered trademarks and are
used only for identifcation and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Prabhakaran, D., editor. | Anand, Shuchi, editor. | Srinath Reddy, K., editor.
Title: Public health approach to cardiovascular disease prevention & management / edited by
Dorairaj Prabhakaran, Shuchi Anand, K. Srinath Reddy.
Description: First edition. | Boca Raton, FL : CRC Press, 2023. | Includes bibliographical references
and index. | Summary: “This book provides an overview of the global and regional challenges
associated with CVDs. Coupled with case studies and theoretical concepts, it helps the reader to
contextualize CVDs in the broader public health system and the administrative aspects of
practicing CVD control approaches for improved population health in their local setting”—
Provided by publisher.
Identifers: LCCN 2022043142 (print) | LCCN 2022043143 (ebook) | ISBN 9781032403571 (hardback) |
ISBN 9781138483620 (paperback) | ISBN 9781003352686 (ebook)
Subjects: MESH: Cardiovascular Diseases | Public Health Practice | Health Policy
Classifcation: LCC RA645.C34 (print) | LCC RA645.C34 (ebook) | NLM WG 120 | DDC 362.1961—
dc23/eng/20221103
LC record available at https://lccn.loc.gov/2022043142
LC ebook record available at https://lccn.loc.gov/2022043143
ISBN: 978-1-032-40357-1 (hbk)
ISBN: 978-1-138-48362-0 (pbk)
ISBN: 978-1-003-35268-6 (ebk)
DOI: 10.1201/b23266
Typeset in Palatino
by Apex CoVantage, LLC
Dedicated to our students, mentees, patients and the
population-at-large from whom we have learnt a lot.
Contents
Preface. ...................................................................... ix
Acknowledgments. ........................................................... xi
About the Editors. ........................................................... xiii
List of Contributors .......................................................... xv
1 Introduction to Cardiovascular Diseases..............................................1
Dorairaj Prabhakaran
2 Cardiovascular Diseases Worldwide..................................................8
Thomas A. Gaziano
3 Concepts of Risk and Risk Factors...................................................19
Rima N. Pai and Shivani A. Patel
4 Concepts in Prevention ............................................................29
Radhika Prakash Asrani and Shivani A. Patel
5 Risk Factors ......................................................................37
5.1 Cardiovascular Disease Risk Factors.................................................38
Dorairaj Prabhakaran
5.2 Tobacco ..........................................................................43
Manu Raj Mathur and Piyu Sharma
5.3 Diet .............................................................................49
Lindsay M. Jaacks, Arun K. Chopra, and Dorairaj Prabhakaran
5.4 Physical Activity..................................................................57
Shifalika Goenka, Prarthna Mukerjee, and Greg Heath
5.5 Cardiovascular Disease, Overweight, and Obesity: Shared Strategies for
Prevention and Management.......................................................61
Johanna Ralston, Piyu Sharma, and Panniyammakal Jeemon
5.6 Alcohol..........................................................................67
Monika Arora, Neha Jain, and Sven Andreasson
5.7 Hypertension.....................................................................73
Arun Pulikkottil Jose and Neil R. Poulter
5.8 Diabetes .........................................................................83
Dorothy Lall, Ram Jagannathan, and K.M. Venkat Narayan
5.9 Lipids ...........................................................................94
Samuel S. Gidding and Arun K. Chopra
6 Emerging and Life-Course Factors in CVD..........................................102
Krithiga Shridhar, Vinita Subramanya, and Poornima Prabhakaran
7 Social Determinants of Cardiovascular Diseases..................................... 118
Panniyammakal Jeemon and K. Srinath Reddy
vii
CONTENTS
8 How Do We Frame Public Health Policies? ..........................................126
Anand Krishnan, Tilahun Haregu, and Brian Oldenburg
9 Public Health Policies for Prevention and Control of Cardiovascular Diseases ...........135
Sailesh Mohan
10 Situational Analysis of Health Policies for Cardiovascular Disease Prevention
and Control.....................................................................144
Sugitha Sureshkumar and Sailesh Mohan
11 Role of Surveillance Systems and Health Observatories for an Intelligent Public Health
Approach to Cardiovascular Diseases ..............................................157
Anand Krishnan and Lorraine Oldridge
12 Health Systems Interventions for Preventing CVD in Low- and Middle-Income
Countries....................................................................... 167
Shreya Rao, Ricardo A. Peña Silva, and Ambarish Pandey
13 Advocacy and Health Promotion...................................................183
Radhika Shrivastav, Aastha Chugh, Prachi Kathuria, and Manjusha Chatterjee
14 Digital Health and Cardiovascular Disease: Current Status and Future Directions........192
Arun Pulikkottil Jose, Devraj Jindal, and Dorairaj Prabhakaran
15 Public Health Approaches to Rheumatic Heart Disease Prevention and Management.....200
R. Krishna Kumar
16 Cost-Effectiveness Analysis: Methods, Innovations, and Applications ...................209
Kaitlin Harold, Shuchi Anand, and Rachel Nugent
17 Universal Health Coverage for Better Cardiovascular Disease Outcomes in LMICs:
Focus on Quality, Not Just Coverage ................................................215
Giridhara R. Babu, Yamuna Ana, Min Kyung Kim, Margaret E. Kruk, and Hannah H. Leslie
18 Monitoring and Evaluation of Cardiovascular Disease Prevention Programs. . . . . . . . . . . . .228
Rajmohan Panda and Abdul Ghaffar
Index ...................................................................... 239
viii
Preface
The iconic Charles Dickens novel A Tale of Two Cities opens with the sentence, “It was the best of
times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the
epoch of belief, it was the epoch of incredulity”. While this denoted the Dickensian times, it is also
applicable to the current status of cardiovascular disease (CVD) across the world. The world has
witnessed tremendous advancements in prevention and management, with an amazing decline
(of more than 50%) in CVD deaths and disability across most high-income countries of the world.
By contrast, in most low- and middle-income countries (LMICs), where the majority of the world’s
population lives, deaths due to CVD have increased in the last few decades and have replaced
pre-transitional conditions such as infections and nutritional diseases as the leading contributors
to deaths. While this is partly explained by a demographic transition that involves population
aging, a high burden of premature mortality due to CVD occurs in productive midlife years in the
LMICs. The global burden of disease estimates for 2019 calculate that CVD affected 523 million
people, almost double the fgure of two decades earlier, with one in three CVD deaths occurring
prematurely in people under 70 years of age. The majority of these premature deaths (around 90%)
are in the LMICs.
There was an air of optimism in the year 2000 when Joe Flower and colleagues, on the occasion of
50 years of American College of Cardiology, wrote “Yet we can now foresee a future in which medi-
cal science might actually defeat cardiovascular disease the way it has defeated polio, smallpox, and
other serious scourges of the past”. They emphasized the technological advances that would bring
this change in the next 50 years, where living to 100 years would be the norm. The current thinking
across the world of cardiology emphasizes the individual approach, ignoring the power of preven-
tion and public health approaches. Indeed, as a patient told one of us, “It’s not until you are lying
on the cold catheterization lab table that you refect on your life choices”, manifesting the crux of
the problem for public health: in order to realize the true value of health and engage in preventive
actions, many persons must experience a serious health event. This may be in part why the focus on
health becomes one of secondary prevention. Only once a person becomes ‘medicalized’, in other
words, only when a person becomes a patient, do they beneft from the largest share of our resources
and knowledge basis. Pharmaceutical and device industries proffer lifesaving therapies, but for a
small proportion of the world’s population: those who are patients and those who can afford them.
While competent clinical care helps to save several lives, the cumulative risk of CVD that builds
over the preceding years still snips away several years of healthy life expectancy. Many lives are
lost or shortened, despite the beneft of medical care, while some die suddenly without getting to
see their doctor. A public health approach to CVD has to combine prevention across the life course
at both population and individual levels.
This textbook shifts the focus from the patient back to the person and the population. In the frst
portion, the reader will be guided through the current clinical understanding of CVDs, in paral-
lel with key concepts and strategies that can be applied for primary and secondary prevention.
We walk through the well-recognized risk factors for its development, one of which (i.e., tobacco)
has been successfully addressed on the individual and sociocultural level, but many of which,
including diet and physical activity, remain recalcitrant—and are ripe for creative solutions.
Uniquely we acknowledge and address social determinants of cardiovascular health. The frst
portion of this book justifes the urgent need for a health systems approach, and the latter portion
puts forward a framework for such an approach. A public health-focused health system integrates
cost-e ffectiveness analyses with technology assessments, surveillance systems, and formal health
promotion strategies.
The goal of public health is not only to add life to years but add years to life, thereby ensur-
ing everyone has a full and fulsome life which embodies health and well-being. This requires a
paradigm shift from CVD to focus on cardiovascular health. Achieving cardiovascular health for
all by 2030 (the year of the Sustainable Development Goals [SDGs]) is interdependent on synergy
between people adopting patterns of healthy living and the systems that enable and support
them. This book attempts to emphasize the importance of public health approaches in achieving
cardiovascular health through promotive, preventive, and restorative approaches. This basic tenet
resonates throughout the following pages.
Dorairaj Prabhakaran
Shuchi Anand
K. Srinath Reddy
ix
