Canadian Journal of Cardiology

The Burden of Cardiovascular Disease in Low- and Middle-Income Countries: Epidemiology and Management

  • Ashna D.K. Bowry
    Corresponding author: Dr Ashna D.K. Bowry, Department of Community and Family Medicine, St Michael's Hospital, University of Toronto, 80 Bond Street, Toronto, Ontario M5B 1X2, Canada. Tel.: +1-416-864-3011; fax: +1-416-864-3099.
    Department of Community and Family Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
    Search for articles by this author
  • Jennifer Lewey
    Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA

    Department of Cardiology, Columbia University Medical Center, New York, New York, USA
    Search for articles by this author
  • Sagar B. Dugani
    Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
    Search for articles by this author
  • Niteesh K. Choudhry
    Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
    Search for articles by this author


      Cardiovascular disease (CVD) is the second leading cause of mortality worldwide, accounting for 17 million deaths in 2013. More than 80% of these cases were in low- and middle-income countries (LMICs). Although the risk factors for the development of CVD are similar throughout the world, the evolving change in lifestyle and health behaviours in LMICs—including tobacco use, decreased physical activity, and obesity—are contributing to the escalating presence of CVD and mortality. Although CVD mortality is falling in high-income settings because of more effective preventive and management programs, access to evidence-based interventions for combating CVD in resource-limited settings is variable. The existing pressures on both human and financial resources impact the efforts of controlling CVD. The implementation of emerging innovative interventions to improve medication adherence, introducing m-health programs, and decentralizing the management of chronic diseases are promising methods to reduce the burden of chronic disease management on such fragile health care systems.


      Deuxième cause de mortalité à l’échelle mondiale, la maladie cardiovasculaire (MCV) a occasionné 17 millions de décès en 2013. Plus de 80 % de ces décès se sont produits dans des pays à revenu faible ou intermédiaire. Même si les facteurs de risque de la MCV sont similaires partout dans le monde, les changements observés dans les pays à revenu faible ou intermédiaire au chapitre du mode de vie et des comportements liés à la santé, notamment l’usage du tabac, la diminution de l’activité physique et l’obésité, contribuent à la hausse de la prévalence de la MCV et de la mortalité. Bien que la mortalité par MCV soit en baisse dans les milieux à revenu élevé en raison de programmes de prévention et de prise en charge plus efficaces, l’accessibilité à des interventions fondées sur des preuves pour combattre la MCV dans les milieux où les ressources sont limitées demeure inégale. Les pressions exercées actuellement sur les ressources tant humaines que financières nuisent aux efforts visant à réduire l’incidence de la MCV. La mise en place de nouveaux programmes novateurs visant à améliorer l’observance thérapeutique, l’implantation de services de santé mobiles et la décentralisation de la prise en charge des maladies chroniques sont des avenues prometteuses qui pourraient réduire le fardeau que représentent les maladies chroniques pour les systèmes de santé fragilisés.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bovet P.
        • Paccaud F.
        Cardiovascular disease and the changing face of global public health: a focus on low and middle income countries.
        Public Health Rev. 2012; 33: 397-415
        • World Health Orgnaization
        The World Health Report 2003: Shaping the Future.
        World Health Organization, Geneva2003 (Available at:) (Accessed April 19, 2015)
      1. World Health Organization. Burden: mortality, morbidity and risk factors. In Alwan A, ed. Global Status Report on Noncommunicable Diseases 2010. Geneva: World Health Organization, 2011.

      2. Institute for Health Metrics and Evaluation (IHME), GBD database. Availabel at: Accessed January 10, 2015.

      3. World Health Organization. Definition of region groupings. Health statistics and information systems 2015. Available at: Accessed April 19, 2015.

        • GBD 2013 Mortality and Causes of Death Collaborators
        Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.
        Lancet. 2015; 385: 117-171
        • Lim S.S.
        • Vos T.
        • Flaxman A.D.
        • et al.
        A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2224-2260
        • Dasgupta K.
        • Padwal R.
        • Poirier L.
        • Quinn R.R.
        Managing hypertension: evidence supporting the 2013/2014 recommendations of the Canadian Hypertension Education Program.
        CMAJ. 2015; 187: 116-119
        • Robitaille C.
        • Dai S.
        • Waters C.
        • et al.
        Diagnosed hypertension in Canada: incidence, prevalence and associated mortality.
        CMAJ. 2012; 184: E49-56
        • Joffres M.
        • Falaschetti E.
        • Gillespie C.
        • et al.
        Hypertension prevalence, awareness, treatment and control in national surveys from England, the USA and Canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study.
        BMJ Open. 2013; 3: e003423
        • Danaei G.
        • Finucane M.M.
        • Lin J.K.
        • et al.
        National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants.
        Lancet. 2011; 377: 568-577
        • Lloyd-Sherlock P.
        • Beard J.
        • Minicuci N.
        • Ebrahim S.
        • Chatterji S.
        Hypertension among older adults in low- and middle-income countries: prevalence, awareness and control.
        Int J Epidemiol. 2014; 43: 116-128
        • Kearney P.M.
        • Whelton M.
        • Reynolds K.
        • et al.
        Global burden of hypertension: analysis of worldwide data.
        Lancet. 2005; 365: 217-223
        • Farzadfar F.
        • Finucane M.M.
        • Danaei G.
        • et al.
        National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants.
        Lancet. 2011; 377: 578-586
        • Mozaffarian D.
        • Abdollahi M.
        • Campos H.
        • Houshiarrad A.
        • Willett W.C.
        Consumption of trans fats and estimated effects on coronary heart disease in Iran.
        Eur J Clin Nutr. 2007; 61: 1004-1010
        • Mendez M.A.
        • Monteiro C.A.
        • Popkin B.M.
        Overweight exceeds underweight among women in most developing countries.
        Am J Clin Nutr. 2005; 81: 714-721
        • Popkin B.M.
        • Slining M.M.
        New dynamics in global obesity facing low- and middle-income countries.
        Obes Rev. 2013; 14: 11-20
        • Popkin B.M.
        • Gordon-Larsen P.
        The nutrition transition: worldwide obesity dynamics and their determinants.
        Int J Obes Relat Metab Disord. 2004; 28: S2-9
        • Poskitt E.M.
        Countries in transition: underweight to obesity non-stop?.
        Ann Trop Paediatr. 2009; 29: 1-11
        • Vorster H.H.
        • Kruger A.
        Poverty, malnutrition, underdevelopment and CVD: a South African perspective.
        Cardiovasc J Afr. 2007; 18: 321-324
        • Hu F.B.
        • Stampfer M.J.
        • Manson J.E.
        • et al.
        Dietary fat intake and the risk of coronary heart disease in women.
        N Engl J Med. 1997; 337): 1491-1499
        • Pietinen P.
        • Ascherio A.
        • Korhonen P.
        • et al.
        Intake of fatty acids and risk of coronary heart disease in a cohort of Finnish men. The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study.
        Am J Epidemiol. 1997; 145: 876-887
        • Ascherio A.
        • Katan M.B.
        • Zock P.L.
        • Stampfer M.J.
        • Willett W.C.
        Trans fatty acids and coronary heart disease.
        N Engl J Med. 1999; 340: 1994-1998
        • Oomen C.M.
        • Ocke M.C.
        • Feskens E.J.
        • et al.
        Association between trans fatty acid intake and 10-year risk of coronary heart disease in the Zutphen Elderly Study: a prospective population-based study.
        Lancet. 2001; 357: 746-751
        • Mozaffarian D.
        • Katan M.B.
        • Ascherio A.
        • Stampfer M.J.
        • Willett W.C.
        Trans fatty acids and CVD.
        N Engl J Med. 2006; 354: 1601-1613
      4. Mendis S. Puska P. Norrving B. Global atlas on cardiovascular disease prevention and control. Published by the World Health Organization in collaboration with the World Heart Federation and the World Stroke Organization. World Health Organization, Geneva2011 (Available at:) (Accessed January 30, 2015)
        • Ghafoorunissa G.
        Role of trans fatty acids in health and challenges to their reduction in Indian foods.
        Asia Pac J Clin Nutr. 2008; 7: 212-215
        • Jha P.
        • Ranson M.K.
        • Nguyen S.N.
        • Yach D.
        Estimates of global and regional smoking prevalence in 1995, by age and sex.
        Am J Public Health. 2002; 92: 1002-1006
        • Giovino G.A.
        • Mirza S.A.
        • Samet J.M.
        • et al.
        Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross-sectional household surveys.
        Lancet. 2012; 380: 668-679
        • Balbinotto S.
        The costs of CVD in Brazil: a brief economic comment.
        Arq Bras Cardiol. 2008; 91: 198-199
        • Piano M.R.
        • Benowitz N.L.
        • Fitzgerald G.A.
        • et al.
        Impact of smokeless tobacco products on CVD: implications for policy, prevention, and treatment: a policy statement from the American Heart Association.
        Circulation. 2010; 122: 1520-1544
        • Pell J.
        • Haw S.
        • Cobbe S.
        • et al.
        Smoke-free legislation and hospitalizations for acute coronary syndrome.
        N Engl J Med. 2008; 359: 482-491
        • Oberg M.
        • Jaakkola M.S.
        • Woodward A.
        • Peruga A.
        • Pruss-Ustun A.
        Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries.
        Lancet. 2011; 377: 139-146
        • Gupta R.
        • Gupta N.
        • Khedar R.S.
        Smokeless tobacco and CVD in low and middle income countries.
        Indian Heart J. 2013; 65: 369-377
        • Gaziano T.A.
        Cardiovascular disease in the developing world and its cost-effective management.
        Circulation. 2005; 112: 3547-3553
        • Gaziano T.A.
        • Bitton A.
        • Anand S.
        • Abrahams-Gessel S.
        • Murphy A.
        Growing epidemic of coronary heart disease in low- and middle-income countries.
        Curr Probl Cardiol. 2010; 35: 72-115
        • Chow C.K.
        • Teo K.K.
        • Rangarajan S.
        • et al.
        Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries.
        JAMA. 2013; 310: 959-968
        • Joshi R.
        • Jan S.
        • Wu Y.
        • MacMahon S.
        Global inequalities in access to cardiovascular health care: our greatest challenge.
        J Am Coll Cardiol. 2008; 52: 1817-1825
        • Choudhry N.K.
        • Dugani S.
        • Shrank W.H.
        • et al.
        Despite increased use and sales of statins in India, per capita prescription rates remain far below high-income countries.
        Health Aff (Millwood). 2014; 33: 273-282
        • Mendis S.
        • Lindholm L.H.
        • Mancia G.
        • et al.
        World Health Organization (WHO) and International Society of Hypertension (ISH) risk prediction charts: assessment of cardiovascular risk for prevention and control of CVD in low and middle-income countries.
        J Hypertens. 2007; 25: 1578-1582
        • Mendis S.
        • Abegunde D.
        • Yusuf S.
        • et al.
        WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE).
        Bull WHO. 2005; 83: 820-829
        • Yusuf S.
        • Islam S.
        • Chow C.K.
        • et al.
        Use of secondary prevention drugs for CVD in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey.
        Lancet. 2011; 378: 1231-1243
        • Choudhry N.K.
        • Setoguchi S.
        • Levin R.
        • Winkelmayer W.C.
        • Shrank W.H.
        Trends in adherence to secondary prevention medications in elderly post-myocardial infarction patients.
        Pharmacoepidemiol Drug Saf. 2008; 17: 1189-1196
        • Jackevicius C.A.
        • Mamdani M.
        • Tu J.V.
        Adherence with statin therapy in elderly patients with and without acute coronary syndromes.
        JAMA. 2002; 288: 462-467
        • Bowry A.D.
        • Shrank W.H.
        • Lee J.L.
        • Stedman M.
        • Choudhry N.K.
        A systematic review of adherence to cardiovascular medications in resource-limited settings.
        J Intern Med. 2011; 26: 1479-1491
        • Mills E.J.
        • Nachega J.B.
        • Bangsberg D.R.
        • et al.
        Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators.
        PLoS Med. 2006; 3: e438
        • LeBrun D.G.
        • Chackungal S.
        • Chao T.E.
        • et al.
        Prioritizing essential surgery and safe anesthesia for the Post-2015 Development Agenda: operative capacities of 78 district hospitals in 7 low- and middle-income countries.
        Surgery. 2014; 155: 365-373
        • Xavier D.
        • Pais P.
        • Devereaux P.J.
        • et al.
        Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data.
        Lancet. 2008; 371: 1435-1442
        • Powles J.
        • Fahimi S.
        • Micha R.
        • et al.
        Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide.
        BMJ Open. 2013; 3: e003733
        • He F.J.
        • Li J.
        • Macgregor G.A.
        Effect of longer-term modest salt reduction on blood pressure.
        Cochrane Database Syst Rev. 2013; 4: CD004937
        • Aburto N.J.
        • Ziolkovska A.
        • Hooper L.
        • et al.
        Effect of lower sodium intake on health: systematic review and meta-analyses.
        BMJ. 2013; 346: f1326
        • Morrison A.C.
        • Ness R.B.
        Sodium intake and CVD.
        Annu Rev Public Health. 2011; 32: 71-90
        • Lee I.M.
        • Shiroma E.J.
        • Lobelo F.
        • et al.
        Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.
        Lancet. 2012; 380: 219-229
        • Lear S.A.
        • Teo K.
        • Gasevic D.
        • et al.
        The association between ownership of common household devices and obesity and diabetes in high, middle and low income countries.
        CMAJ. 2014; 186: 258-266
        • Teo K.
        • Lear S.
        • Islam S.
        • et al.
        Prevalence of a healthy lifestyle among individuals with CVD in high-, middle- and low-income countries: the Prospective Urban Rural Epidemiology (PURE) study.
        JAMA. 2013; 309: 1613-1621
        • Popkin B.
        Will China's nutrition transition overwhelm its health care system and slow economic growth?.
        Health Aff (Millwood). 2008; 27: 1064-1076
        • Franco M.
        • Ordunez P.
        • Caballero B.
        • et al.
        Impact of energy intake, physical activity, and population-wide weight loss on CVD and diabetes mortality in Cuba, 1980-2005.
        Am J Epidemiol. 2007; 166: 1374-1380
        • Garcia-Ortiz L.
        • Recio-Rodriguez J.I.
        • Schmidt-Trucksass A.
        • et al.
        Relationship between objectively measured physical activity and cardiovascular aging in the general population—the EVIDENT trial.
        Atherosclerosis. 2014; 233: 434-440
        • Naci H.
        • Ioannidis J.P.
        Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study.
        BMJ. 2013; 347: f5577
        • Millett C.
        • Agrawal S.
        • Sullivan R.
        • et al.
        Associations between active travel to work and overweight, hypertension, and diabetes in India: a cross-sectional study.
        PLoS Med. 2013; 10: e1001459
        • Steyn K.
        • Damasceno A.
        Lifestyle and related risk factors for chronic diseases.
        in: Jamison D. Feachem R.G. Makgoba M.W. Disease and Mortality in Sub-Saharan Africa. 2nd edition. 2nd ed. World Bank, Washington, DC2006
        • Samb B.
        • Desai N.
        • Nishtar S.
        • et al.
        Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries.
        Lancet. 2010; 376: 1785-1797
        • IOM (Institute of Medicine)
        Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health.
        2010 (Washington, DC: National Academies Press,)
        • Gaziano T.A.
        • Steyn K.
        • Cohen D.J.
        • Weinstein M.C.
        • Opie L.H.
        Cost-effectiveness analysis of hypertension guidelines in South Africa: absolute risk vs blood pressure level.
        Circulation. 2005; 112: 3569-3576
        • Shillcutt S.D.
        • Walker D.G.
        • Goodman C.A.
        • Mills A.J.
        Cost effectiveness in low- and middle-income countries: a review of the debates surrounding decision rules.
        PharmacoEconomics. 2009; 27: 903-917
        • National Institute for Health and Clinical Excellence
        Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. NICE Clinical Guidelines, No. 127.
        Royal College of Physicians (UK) National Clinical Guideline Centre (UK), London2011
        • Stone N.J.
        • Robinson J.G.
        • Lichtenstein A.H.
        • et al.
        2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014; 129: S1-45
        • Gaziano T.A.
        • Opie L.H.
        • Weinstein M.C.
        Cardiovascular disease prevention with a multidrug regimen in the developing world: a cost-effectiveness analysis.
        Lancet. 2006; 368: 679-686
        • Jha P.
        • Chaloupka F.J.
        • Moore J.E.A.
        • et al.
        Tobacco addiction.
        in: Jamison D.T. Breman J.G. Measham A.R. Disease Control Priorities in Developing Countries. 2nd ed. World Bank, Washington DC2006
        • Puska P.
        • Vartiainen E.
        • Laatinkainen T.
        • Jousilahti P.
        • Paavola M.
        The North Karelia project: From North Karelia to National Action.
        Helsinki University Printing House, Helsinki2009
        • Uusitalo U.
        • Feskens E.J.
        • Tuomilehto J.
        • et al.
        Fall in total cholesterol concentration over five years in association with changes in fatty acid composition of cooking oil in Mauritius: cross sectional survey.
        BMJ. 1996; 313: 1044-1046
        • Castellano J.M.
        • Sanz G.
        • Penalvo J.L.
        • et al.
        A polypill strategy to improve adherence: results from the FOCUS project.
        J Am Coll Cardiol. 2014; 64: 2071-2082
        • Castellano J.M.
        • Sanz G.
        • Fernandez Ortiz A.
        • et al.
        A polypill strategy to improve global secondary cardiovascular prevention: from concept to reality.
        J Am Coll Cardiol. 2014; 64: 613-621
      5. Ostovaneh MR, Poustchi H, Hemming K, et al. Polypill for the prevention of cardiovascular disease (PolyIran): study design and rationale for a pragmatic cluster randomized controlled trial [Epub ahead of print]. Eur J Prev Cardiol 2014, accessed August 7, 2015.

      6. Heart Outcomes Prevention Evaluation-3 (HOPE-3). Available at: Accessed January 15, 2015.

        • Selak V.
        • Elley C.R.
        • Bullen C.
        • et al.
        Effect of fixed dose combination treatment on adherence and risk factor control among patients at high risk of CVD: randomised controlled trial in primary care.
        BMJ. 2014; 348: g3318
        • Thom S.
        • Poulter N.
        • Field J.
        • et al.
        Effects of a fixed-dose combination strategy on adherence and risk factors in patients with or at high risk of CVD: the UMPIRE randomized clinical trial.
        JAMA. 2013; 310: 918-929
        • Perry H.B.
        • Zulliger R.
        • Rogers M.M.
        Community health workers in low-, middle-, and high-income countries: an overview of their history, recent evolution, and current effectiveness.
        Annu Rev Public Health. 2014; 35: 399-421
        • Joshi R.
        • Chow C.K.
        • Raju P.K.
        • et al.
        The Rural Andhra Pradesh Cardiovascular Prevention Study (RAPCAPS).
        J Am Coll Cardiol. 2012; 59: 1188-1196
        • Kengne A.
        • Awah P.K.
        • Fezeu L.L.
        • Sobngwi E.
        • Mbanya J.C.
        Primary health care for hypertension by nurses in rural and urban Sub-Saharan Africa.
        J Clin Hypertens (Greenwich). 2009; 11: 564-572
        • Adeyemo A.
        • Tayo B.O.
        • Luke A.
        • et al.
        The Nigerian antihypertensive adherence trial: a community-based randomized trial.
        J Hypertens. 2013; 31: 201-207
        • Ogedegbe G.
        • Gyamfi J.
        • Plange-Rhule J.
        • et al.
        Task shifting interventions for cardiovascular risk reduction in low-income and middle-income countries: a systematic review of randomised controlled trials.
        BMJ Open. 2014; 4: e005983
        • Becker D.
        • Yanek L.R.
        • et al.
        Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease.
        Circulation. 2005; 111: 1298-1304
        • Brownstein J.N.
        • Chowdhury F.M.
        • Norris S.L.
        • et al.
        Effectiveness of community health workers in the care of people with hypertension.
        Am J Prev Med. 2007; 32: 435-447
      7. One Million Health Workers Campaign. Available at: Accessed January 15, 2015.

        • Beratarrechea A.
        • Lee A.G.
        • Willner J.M.
        • et al.
        The impact of mobile health interventions on chronic disease outcomes in developing countries: a systematic review.
        Telemed JE Health. 2014; 20: 75-82
        • Lester R.T.
        • Ritvo P.
        • Mills E.J.
        • et al.
        Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial.
        Lancet. 2010; 376: 1838-1845
        • Pop-Eleches C.
        • Thirumurthy H.
        • Habyarimana J.P.
        • et al.
        Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.
        AIDS. 2011; 25: 825-834
        • Shetty A.S.
        • Chamukuttan S.
        • Nanditha A.
        • Raj R.K.
        • Ramachandran A.
        Reinforcement of adherence to prescription recommendations in Asian Indian diabetes patients using short message service (SMS)—a pilot study.
        J Assoc Physicians India. 2011; 59: 711-714
        • Peiris D.
        • Devarsetty P.
        • Claire J.
        • Mogulluru K.
        Use of mHealth systems and tools for non-communicable diseases in low- and middle-income countries: a systematic review.
        J Cardiovasc Transl Res. 2014; 7: 677-691