Prevention, not cure – the fight against heart failure

Throughout the Middle East, heart disease is a major – and growing – problem. Responsible for 45% of premature deaths in the Gulf region, and affecting men and women in equal measure, cardiovascular conditions are not just for the elderly and infirm. As the prevalence of risk factors continues to rise, cardiologists have warned that the region is on the edge of an epidemic.

The statistics paint an unforgiving picture. Among the Arab Middle East population, the overall estimated prevalence of hypertension is 29.5%, rising to a startling 37.3% in the UAE. And while levels of obesity vary from country to country (averaging out at 13% for men and 24.5% for women), in Saudi Arabia, rates are as high as 30% in men and 44% in women.

To zoom in further on Saudi Arabia, 39% of men and 42% of women suffer from metabolic syndrome, a precursor to cardiovascular disease and diabetes. Considering that a quarter of adults also have diabetes – itself a risk factor for heart disease – it is clear we are dealing not so much with a single, discrete health condition, but a cluster of complex and interrelated pathologies.

Revelations at SHA24

Nowhere were the problems conveyed more starkly than at the Saudi Heart Association Conference 2013 (SHA24). Here, the consensus was clear: the rise in heart failure was tied not to issues with treatment, but with prevention.

London-based Professor David Wood said, “In Saudi Arabia, while they have world-class facilities in interventional cardiology, they do not have the comparable services in cardiovascular prevention. And that is a big gap in their national health service.”

Professor Hani Najm, vice-president of the Saudi Heart Association, added, “The prevalence of risk factors is so high in our young society that they will get cardiovascular disease early, in their 40s and 50s. We’re facing a tsunami of cardiovascular disease in the Gulf region in the coming ten to 15 years.”

The speakers discussed the need for a concerted government-led prevention programme. This would hone in on healthy behaviours – encouraging healthy diets, promoting physical activity and discouraging smoking – and target additional services toward those at the highest risks. There would also be regulatory changes, by taxing foods high in saturated fat and added sugar, for example, or subsidising public transport to reduce dependence on cars.

Nearly three years on, however, these recommendations have yet to come to fruition. As Dr Wael Al Mahmeed, chief of cardiology at Shaikh Khalifa Medical City (SKMC), explains, while there have been various prevention programmes on a smaller scale, these efforts are best described as “patchy”.

“Everybody’s doing something in their own little corner and it hasn’t been unified into one national campaign,” he says. “So I might do a little bit, and someone across the road might do a little bit, but that’s not going to have much impact.”

The wider impact

The reasons for the rise in heart disease are far from a mystery. Rates of smoking are high across the region (reaching nearly a third among some young urban populations) and levels of physical activity are low. And while some Middle Eastern diets are traditionally high in fibre and low in saturated fat, other customary foods, such as Kabsa, are rich in fat and may contribute to obesity. Moreover, recent decades have seen a creeping Westernisation of dietary habits, with a growing consumption of junk food.

Concurrently, the average age of heart disease onset is lowering. While there has been a decline in age-specific death rates from heart failure – offsetting the rise in chronic diseases you might expect from an aging population – we are seeing a spike in incidence amongst the middle-aged. Of the 850 heart attack patients admitted to Rashid Hospital in Dubai in 2013, the average age of the first heart attack was just 45: 20 years younger than the global average.

A study released earlier this year, which assessed nearly 5,000 Saudis living in urban areas, found that one in four were at risk of a heart attack within the next ten years. Considering that the majority of the study subjects were aged 20–40 years old, this effectively meant that many of today’s 30 year olds would not be active contributors to society by the time they were 50.

Evidently, this has ramifications not just for public health, but also for the region’s economy. According to the World Health Organization (WHO), it is estimated that in most low and middle-income countries, heart disease, stroke and diabetes stand to reduce GDP by 1–5%.

“Because patients with heart failure are being affected in their productive years, rather than in their elderly years, that has a major economic impact,” says Al Mahmeed. “If we don’t do something about coronary heart disease prevention, it’s going to increase the burden on the resources in the country, because heart failure is expensive and hospitalisation is long.”

But the picture is not unilaterally bleak for heart failure in the Middle East. Over the past ten to 15 years, there have been many advances in diagnosis and treatment, with the introduction of new medicines and implantable devices improving survival rates. Drugs such as angiotensin-converting enzymes inhibitors, angiotensin receptor
blockers, beta-blockers and aldosterone antagonists – all now widely used in the Middle East – have a clear positive effect on prognosis, and heart function clinics are known for providing sophisticated tertiary care.

Primary prevention programmes are sorely needed, however. And if they are to have meaningful impact, they need to be orchestrated at a national level.

The reinitialisation of heart-disease reduction

So, how can this be accomplished? The first step might be to collate more information: to date, there have been few comprehensive studies evaluating the presence of heart failure in the Middle East, and researchers are largely reliant on scattered data.

“We run a number of hospital registries in the Gulf, and one of them has been on patients who were hospitalised for heart failure,” says Al Mahmeed. “We’ve learnt quite a bit from that. We’re also going to start a study soon on heart failure in the Gulf, with seven countries involved.”

It will also be important to examine the specific sociocultural obstacles that stand in the way of improving activity levels and diet.

Currently, just 40% of men and 27% of women in the Gulf Cooperation Council region meet the recommended physical activity levels set out by WHO. This is in part due to hot temperatures and lack of facilities, but it is also tied in to cultural norms. For instance, in some Muslim-majority countries, women need to be accompanied by a male relative when outdoors, and many traditional styles of dress may not be conducive to exercise.

Policymakers will therefore need to consider how Western biomedical models can be integrated with Middle Eastern values. One 2012 study that looked into the lifestyle factors of Arabic women with heart disease living in Qatar suggested that while media campaigns were important, it was often the woman’s relationship with her doctor that was key.

“Physicians are in the best position to provide counseling and guidance to Arab women regarding weight loss, healthy diet and exercise,” said the authors, who recommended that any advice given be “contextual, realistic and practical”.

As well as educational efforts, there have also been calls for regular screening that would pinpoint those most in need of an intervention. One UAE cardiologist has advocated screening the population from the age of 20, testing their blood pressure, blood sugar, cholesterol and body mass index every two to five years. According to the Dubai Health Authority, testing after the age of 35 should occur on an annual basis.

Of course, whatever programmes are implemented, it’s important not to expect results right away. As Al Mahmeed explains, any prevention efforts should be treated as long-term investments. This might involve, for example, developing policies in line with WHO’s ‘25 by 25’ target, which seeks to reduce premature deaths from non-communicable diseases by 25% by 2025.

“People want to see results overnight, but you’re not going to for a prevention programme – it takes years to reap the benefits,” he says. “You’re looking at five-to-ten-year campaigns.”

The endgame here would be to reduce reliance on medical care – perhaps even negating the need for that care in the first place. After all, when it comes to heart failure, prevention is surely better than cure.

“Rescuing a patient with an acute evolving myocardial infarction through primary angioplasty and stenting is lifesaving, but if the underlying causes of the disease are not addressed, the risk of recurrence or dying from this disease remains the same,” said Wood. “They need to seize the opportunity of coupling their world-class interventional cardiology facilities with world-class prevention services.”