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CARdiovascular Disease: Identification of Obstacles and facilitators to MAximize secondary Prevention Policy and Strategies.
The CARDIOMAPPS project aims to identify obstacles and facilitators of the use of evidence-supported medications for the secondary prevention of CVD.
Ami is a Clinical Lecturer in Cardiovascular Medicine at the University of Birmingham and spends his time between practicing cardiology, research and teaching. After medical school at Oxford, his clinical training took him all over the UK and he eventually moved to Birmingham in 2011. Ami’s passions for cardiology and public health have led him to complete a Masters in Public Health at Harvard University, consultancy work at the Cardiovascular Diseases Division of the World Health Organisation, and a DPhil in cardiovascular epidemiology at the University of Oxford. His research has largely focused on acute coronary syndromes, atrial fibrillation, stroke and risk of future cardiovascular disease. Ami’s major global health interests are access to medicines and the burden of cardiovascular disease in India. Education has always been a keen interest, and he continues to regularly teach undergraduate and postgraduate students. Public engagement in science has also developed as an important area of his work.
By maintaining contact with clinical medicine, Ami hopes to offer a realistic, credible approach to research and policy. The Salim Yusuf Emerging Leaders Programme provides a fantastic platform to pursue his synergistic interests in research, cardiology, global health and public understanding of science.
Katherine was born in the city of Cusco in Peru. She is a nutritionist graduated from the Major National University of “San Marcos”. Katherine has done post-graduate studies at the National University of “Agraria La Molina” where she got a master’s degree in “Applied Ecology” majoring in Public Nutrition.
Katherine has also studied a second postgraduate program in Health Promotion and Prevention of non-communicable chronic diseases at the Institute of Nutrition and Food Technology (INTA) in the University of Chile; She is in the final phase of her thesis: “Environmental, Anthropometric and Family Factors associated to cardiovascular risk in Chilean adolescents”. Also, she is coordinating the research project: “Early feeding practices, growth, body composition and motor development in infants” (RLA6071/Chile). Furthermore, Katherine is part of a non-profitable association of Peru “Kausasunchis” and is directing a research project about the effect of agricultural programs in nutritional status and body composition in infants and mothers.
Her experience since college was in the field of health and healthy feeding promotion, first as a student volunteer (2003-2005) then as a worker of different institutions related to health and nutrition (2006 to now). After those experiences and also her current studies she is convinced that the promotion of health since the early years is the better way to prevent chronic diseases as cardiovascular and its risk factors.
Shweta is a trained public health nutritionist and has a doctorate in Human Nutrition from the University of Delhi as well as a second Master’s degree in Public health (distance learning) from LSHTM, UK. Shweta has also completed a 2 year NIH sponsored D43 postdoctoral fellowship (Evaluation Grade: A/Excellent) from Emory University, Atlanta and Centre for Chronic Disease (CCDC), New Delhi. At PHFI she has been leading the online academic initiative in Public Health Nutrition for the last 4 years and involved in curriculum development and teaching (Major areas: Nutrition Epidemiology, Health promotion). As a part of capacity strengthening (in nutrition) initiatives, Shweta has been the Course Director of the International Training seminar on Nutrition Epidemiology series (http://www.ccdcindia.org/nutriepitraining.php) in New Delhi for the past four years. She is also the lead for capacity building arm in nutrition as a part of the DFID-funded international project (of which PHFI is one of the 7 partner institutions) called “Transform Nutrition” (www.transformnutrition.org/). She is the recipient of Government of India, Dept of Science and Technology’s Young Scientist Award to examine the impact of prenatal Docosahexaenoic acid (DHA) supplementation on newborn anthropometry. Additionally, she has served as a co-investigator on a couple of research projects (salt intake in India, trans fats, diet and inflammation, etc).
She is a UGC-NET qualified researcher who received Junior and Senior research fellowships to complete her doctoral thesis by the Delhi University. Her thesis work revolved around analyzing the effect of dietary factors (in particular, omega 3 fatty acids and plant sterol-esters) on cardiovascular risk factors. She graduated from G.B. Pant University of Agriculture and Technology, Pantnagar and later went to the SNDT Women’s University, Mumbai where she got her Masters’ degree in Food Science and Nutrition with high academic honours.
Shweta has been conferred many prestigious awards like the “Significant Contribution Award” from the All India Institute of Medical Sciences, New Delhi (Jan 2014), Young Scientist Award 2009 in Experimental Nutrition (by the Nutrition Society of India, NIN), Dr. K.U. Naram Award for securing first rank in the M.H.Sc. in 2004-2005 from S.N.D.T. University, Mumbai, Dr. Dhirajlal Dhanjibai Shah Memorial Prize (First prize) for securing the highest G.P.A. in the Foods and Nutrition Deptt in M.H.Sc. in 2005, The Association of Scientists and Technologists (India) Bombay Chapter Prize for standing first in 2004-2005 in Post Graduate Deptt of Foods and Nutrition, S.N.D.T. University, Mumbai.
Darryl obtained his medical degree and specialist training in cardiology in Adelaide, Australia, where he subsequently completed a PhD in the refined characterization of myocardial structure and function using advanced imaging techniques. During this time Darryl simultaneously completed a Master of Public Health degree, while working part-time as a clinical cardiologist. He then undertook his first post-doctoral placement in Leiden, the Netherlands, where he acquired further experience in the conduct of observational research and advanced cardiovascular imaging. Darryl simultaneously commenced a Master of Biostatistics course by correspondence with the University of Adelaide to better understand the statistical tools used in research. From the Netherlands, he moved to take up his current post-doctoral position at the Population Health Research Institute, mcmaster University, Hamilton, Canada. He has recently accepted an in-principle offer of a position on faculty at mcmaster University and Hamilton Health Sciences in 2014. Darryl has authored >60 manuscripts in peer-reviewed journals and has received approximately 1 million dollars in competitive grant funding. His ongoing career goal is to identify innovative diagnostic and therapeutic strategies for cardiovascular disease through observational population studies with particular emphasis on cardiovascular imaging-based observation, and to test these and other novel approaches in prospective clinical trials.
Moniruzzaman obtained his Bachelor’s degree with honors in ‘Physiotherapy’ from the University of Dhaka (DU) under the Faculty of Medicine in 2007. He got his MPhil degree in ‘Noncommunicable Diseases (NCDS)’ from the same university but under the Postgraduate Medical Science and Research Faculty in collaboration with the University of Oslo, Norway in the year of 2011. Currently, he has been working as a ‘Senior Lecturer’ in NCDs program under the Dept. of Community Medicine of the Bangladesh University of Health Sciences (BUHS). He is very young in professional exercise in the field of NCDs. Besides teaching to MPH and MPhil students, he is also responsible for a wide range of project-oriented activities in the field of NCDs as a regular job in his workplace. He has worked as a Co-Investigator in six departmental research projects funded by the Govt. of Bangladesh; among those five were directly related to NCD (risk assessment of CVDs among Bangladeshi adult population, impact of educational intervention in reducing NCD risk indicators, prevalence of behavioral and biological risk factors of NCD, impact of educational booklet on cardiac rehabilitation and secondary prevention of CVDs). He attended the ‘45th Ten-Day Teaching Seminar on Cardiovascular Disease Epidemiology and Prevention’ on a fellowship awarded to a single participant from Bangladesh. He has also attended some other training relevant to his work domain.
He has got some relevant publications (08) in both national and international journals by this time and some other scientific papers have been accepted and are expected to be published by 2014. He has also got 18 abstract publications, most of which are in international scientific seminar/conference proceedings. He is an author of a book entitled ‘Physical activity levels in Bangladesh’. His fields of interest in research are cardiovascular diseases (primary), diabetes, physical activity, and physical disability. He feels more comfortable and intends to work on cardiovascular diseases, particularly risk assessment and formulation of appropriate and pragmatic prevention strategies to reduce the burden of these diseases. Now, he is mentally prepared and personally motivated for his higher education. It has become his insatiable desire to enroll in PhD fellowship.
Jose is currently a full professor of Cardiology at the School of Medicine, Pontifícia Universidade Católica do Paraná, where he practices as part of the EPIcenter, a nucleus devoted to Epidemiology research. He received his M.D. degree in 1994 at the Federal University of Parana, Brazil. He completed his Internal Medicine Residency at the Hospital das Clinicas, University of Sao Paulo (USP), and then completed a Cardiology fellowship at the Heart Institute/ USP (1995-98). At this time, he started his studies in cardiovascular risk, and in 2002 he received a Ph.D. from the University of São Paulo, presenting his thesis on the correlation of hyperhomocysteinemia and the extent of coronary artery disease. ThereafterJose went to the USA as a Post-Doc Research Fellow at the Atherosclerosis Research Center of Cedars-Sinai Medical Center, in Los Angeles, from 2002 to 2004. During his Post-Doc, he explored the role of the immune response to OxLDL in atherogenesis. In 2010, Jose broadened his area of research, starting his studies in cardiovascular epidemiology, in collaboration with the Department of Epidemiology of the Erasmus MC, Rotterdam.
Jose’s primary research interests include cardiovascular risk in a broad sense, from molecular mechanisms to epidemiological aspects. He has presented his research findings at several national and international meetings and has numerous publications in peer-reviewed journals, including Circulation, Atherosclerosis, Heart and other important journals in the field. He is currently President of the Atherosclerosis Department of the Brazilian Society of Cardiology.
José has previously worked with Prof. Cesare Sirtori, Rodolfo Paoletti, Elena Tremoli and Guido Franceschini in Milan, Italy for a stage in clinical lipidology and lipid lab work and later in Buenos Aires as the head of a Lipid Clinic and an Atherosclerosis research lab (animal models of accelerated atherosclerosis) in the Favaloro Foundation. Recently he has returned to Italy as the head of the Unit for Atherosclerosis Prevention in the Cardiologico Monzino Centre, IRCCS (a reference Center for care and research in cardiology and cardiovascular surgery) where he has been carrying out a Program for the Global Control of CV Risk aimed at patients in secondary prevention subjected to revascularization procedures in the hospital (and their first degree relatives). In recent years he has worked with others to build a cases-related DNA bank and has published several studies, which were mainly focused on oxidative stress, inflammation, non-invasive measures of atherosclerosis and effects of lipid-lowering drugs. After having organized or participated in many public meetings (World Heart Day, etc) aimed at diffusing a culture of prevention, José realized an interest in conveying heart-friendly messages to patients and public, particularly using “alternative” creative methods. In the future, he would like to put together his communication skills and passion for the prevention of disease in research projects about new strategies to fight against tobacco dependence and increased active involvement of the population in their own health care.
Aspirin, statins, ACEIs, and beta-blockers have demonstrated efficacy in the reduction of mortality when used in the secondary prevention of CVD. The PURE study has shown that in countries of all income levels, the use of these medications for CVD secondary prevention is sub-optimal. In the PURE study, the rate of use of evidence-supported secondary preventative medications ranged from 40-66.5% in high-income countries to 3.3-9.7% in low-income countries. The implication of this finding is that despite the existence of relatively inexpensive and simple measures that have been proven to reduce the burden of CVD in this high-risk population, patient care is far from ideal, and consequently, potential reductions in CVD morbidity and mortality are not being achieved.
We urgently need to identify the reasons for this gap between evidence and practice. The reasons for sub-optimal uptake of effective medications in secondary prevention are likely to be context-specific. The gradient in their use from high- to low-income countries observed in PURE supports this contention. Therefore, context-appropriate research is needed to understand the reasons behind sub-optimal use, and strategies that may be successful in increasing their uptake. For optimal utilization of these treatments, a complex series of conditions need to be met. These conditions begin at the health systems level, and involve governments, drug manufacturers and distributors, individual drug prescribers, drug dispensers, and consumers. Obstacles to drug uptake in secondary prevention may occur anywhere along this continuum. While individual obstacles have been previously studied, we believe that the urgency with which the gap between evidence and implementation needs to be bridged is of such magnitude that a paradigm shift in approach is necessary. A conventional approach to address barriers to secondary prevention might be to identify individual barriers using observational techniques, then to test possible interventions targeted at these barriers in clinical trials.
This approach is costly, slow, and can only affect change piecemeal, one intervention at a time. We propose, instead, that a policy-driven approach to aligning the conditions required for secondary prevention might offer advantages in delivering an increase in medication uptake. Policy influences a large proportion of the population in a relatively short timeframe. There is an important need to generate evidence to inform policymakers in a timely manner. However, to date, there has not been a comprehensive evaluation of obstacles and facilitators of medication use for secondary CVD prevention at multiple levels and in diverse financial and sociocultural settings. This evidence is a requisite step, however, before policy recommendations can be made, both globally and to individual governments. The World Heart Federation Emerging Leaders program offers a unique opportunity to leverage expertise and energy from researchers from around the world to be able to identify these obstacles and facilitators in a manner tailored to individual countries and settings.
This study aims at identifying obstacles to and facilitators of the use of evidence-supported medications for the secondary prevention of CVD. The overarching goal is to create context-specific tools to allow the information of evidence briefs for policymakers with respect to the optimal use of evidence-supported medications for the secondary prevention of cardiovascular disease.
This goal will be accomplished by two complementary approaches: