Addressing the challenge of cardiovascular diseases in low and middle income countries

Cardiovascular disease (CVD) is a general term for a group of disorders that affect the heart and blood vessels. They can range from arterial disease and thrombosis (blood clots) to heart attacks and strokes. Killing around 18 million people every year, CVDs are responsible for around one third of all deaths globally.

Of these deaths, three quarters are in low and middle income countries (LMICs). Poorer countries and communities are most at risk. They have more limited access to health services, and cannot afford drugs to treat high blood pressure and diabetes. These are among the key risk factors that lead to progressive cardiovascular degeneration.

In line with our commitment to address the shifting global burden of disease, NIHR has funded several Global Health Research programmes and projects that are working on CVDs in LMICs. In this feature, we highlight some of their outputs and impacts to date. A full list of NIHR awards addressing cardiovascular diseases is searchable on NIHR Open Data. We are now launching a new funding call specifically focusing on addressing CVD in LMICs.

Warfarin is a widely-used ‘blood-thinning’ medication. It helps to promote smoother circulation and reduce the risk of dangerous blood clots causing thrombosis. However, there is a lack of evidence in sub-Saharan Africa on clinical dosing algorithms. As a result, anticoagulant levels are often poorly controlled, leading to a risk of clotting.

From 2018-21, the NIHR Global Health Research Group on warfarin anticoagulation in patients with cardiovascular disease in Sub-Saharan Africa researched the effectiveness of Warfarin treatments. The Group helped develop ‘the warfarin bundle’, a new clinical pathway in Uganda and South Africa. It trained local clinicians and researchers in warfarin pharmacology and patient care. It also introduced point-of-care devices into clinics, to measure markers of anticoagulation across the population.

Professor Sir Munir Pirmohamed, the project’s director, said: “By introducing new practices and new technologies, and increasing local capacity, we hope we have made a positive difference.”

During the same period, the NIHR Global Health Research Group on Stroke investigated evidence-based methods for improving outcomes for stroke patients in Sierra Leone. Stroke is a form of cardiovascular disease which occurs either as a result of a breach in a blood vessel or a blood clot causing a blockage in the brain. In sub-Saharan Africa, stroke is a leading cause of death amongst adults of all ages, including working parents.

As part of its work in Sierra Leone, the Group set up a stroke register at the country’s main teaching hospital. This enabled changes to be implemented in the care of stroke patients at this hospital and in wider communities in Freetown.

The Group worked with local communities to improve stroke diagnosis and care. Together, they raised awareness of how lifestyle choices such as diet, activity and smoking affect the risk of CVD. They also helped reduce social stigma and empower people with the knowledge to improve their health.

The NIHR Global Health Research Unit on Diabetes and Cardiovascular Disease in South Asians is seeking to improve understanding of the mechanisms underlying diabetes and heart disease in South Asian populations. It aims to improve prevention and control of these diseases through personalised and health systems based interventions.

The team hopes to determine the health outcomes for 150,000 South Asian men and women, and identify the lifestyle, environmental, genetic and metabolic factors that drive diabetes and heart disease in South Asia. This builds on the work of a previous NIHR award, the subject of our June 2022 feature, Addressing the rise of diabetes and heart disease in South Asia.

As part of this Unit, Dr Ranjit Mohan Anjana of the Madras Diabetes Research Foundation is leading a clinical trial to evaluate the effectiveness of mobile apps for diabetes prevention.

Their results, to be published later in 2023, apparently show that participants who used the apps were able to lose weight compared to baseline and control groups in both urban and rural areas. They also claim improved diet and physical activity, and significantly lower body mass index, waist circumference, blood pressure, fasting blood sugar and total cholesterol.

Looking ahead, and upstream

Several ongoing and new NIHR-funded projects are seeking to address the causes of CVD, and to improve diagnosis, treatment and care for people affected.

For example, the NIHR Global Diet and Physical Activity Research (GDAR) Group investigates the upstream influences of CVD risk factors. These include poor diet and lack of access to healthy food and physical activity. The group’s findings are informing policies on food and active lifestyles in several countries across Africa and the Caribbean.  

Healthcare system development is also an important factor in reducing the burden of CVD. The new NIHR Global Health Research Group on Collaborative Care for Cardiometabolic Disease in Africa is working in Ghana, Kenya, and Mozambique. It works with patients, doctors, nurses, pharmacists and community leaders to identify issues and improve care pathways. Together, they hope to improve care, and reduce the burden of heart disease, diabetes, and high blood pressure.

In July 2023, NIHR is opening a new funding call focusing on addressing CVD in LMICs. The Research and Innovation for Global Health Transformation (RIGHT) call 7 will fund research to evaluate interventions that focus on early detection, effective treatment, and management of metabolic risk factors for CVD and stroke.