In the first population-based study to estimate the number of people with cardiovascular disease in Haiti, researchers from local health care organization GHESKIO and Weill Cornell Medicine in New York City found that 12 percent of participants in the capital, Port-au-Prince, had early-onset heart failure — more than 15 times higher than previous estimates and more than three times higher than the rate among black Americans.
Findings from the study, published in the journal Lancet Regional Health Americas, “are directly linked to improving health outcomes in Haiti and can serve as a model for similar low-income countries,” said Margaret McNairy, lead researcher on the study and a member of Weill Cornell Medicine's Center for Global Health.
Although 80% of global cardiovascular disease is predicted to affect people in low- and middle-income countries, the researchers note that prior to this study, there was little direct data from these settings to quantify how many people have these diseases, whether statistics are changing, and what the impact is on these populations.
The study found that about 15 percent of Haitian adults suffer from heart failure, stroke, heart attack or chest pain, and most of them suffer from hardening of the heart muscle.
68.5%
Among participants with heart failure, 68.5% were women.
These figures suggest that cardiovascular disease is a widespread problem for Haitians, with the most common risk factor for heart failure being high blood pressure, known as hypertension. Despite the link between the two conditions, previous studies have shown that only 13 percent of Haitian adults with high blood pressure have their blood pressure under control.
Local data are essential to “designing practical, tailored interventions for primary prevention and treatment of cardiovascular disease,” says study correspondent Lily Yang, assistant professor of medicine at Weill Cornell University. “If we can lower blood pressure even a little bit at the population level, we can reduce cardiovascular disease mortality.”
Inside the lab
From 2019 to 2021, GHESKIO community outreach workers surveyed participants in the Haiti Cardiovascular Disease Cohort, a population-based urban cohort of approximately 3,000 Port-au-Prince residents aged 18 and older. Of the participants, 58.1% were women.
All participants answered health questionnaires and underwent a comprehensive physical examination, including blood pressure measurement and blood tests, at the GHESKIO Cardiovascular Disease Clinic. They also underwent non-invasive tests such as an electrocardiogram, which measures the heart's electrical activity, and an echocardiogram, an ultrasound scan that shows how well the heart muscle and valves are functioning.
Among participants with heart failure, 68.5% were women, and the median age was 57 years, much younger than the median age of 72 years for the similar U.S. population. Researchers are investigating the reasons for the gender difference.
Heart failure is a category of cardiovascular disease. It is a chronic condition that occurs when the heart muscle cannot pump enough blood to meet the body's needs. This results in blood pooling and fluid buildup in the lungs and legs, causing shortness of breath and swelling in the legs.
Heart failure also has a very high one-year mortality rate, McNairy said. The most common subtype was heart failure with preserved ejection fraction, which was present in 80.4 percent of participants. This type of heart failure, traditionally thought of as a disease of older adults, can also affect younger patients and reduce their quality of life.
Preventing heart disease
With a focus on prevention strategies, Weill Cornell and GHESKIO are partnering with the Haitian Ministry of Health and the Haitian College of Cardiology to develop guidelines and train health care providers on proper blood pressure measurement methods, as well as to expand knowledge and services about cardiovascular disease, including community-based screening and treatment of risk factors such as hypertension.
A doctor examines an X-ray of a patient's heart at the Degando Clinic in Port-au-Prince, Haiti, on April 15, 2012. REUTERS/Swan Parker
“Prevention is the most important aspect of our work,” says Rodney Safra, chief physician at the GHESKIO Cardiovascular Diseases Clinic in Port-au-Prince. “We [that] Controlling high blood pressure is an important step in preventing heart failure and death from cardiovascular disease.” The researchers also found that heart failure was associated with obesity, chronic kidney disease, depression and stress.
Other efforts, McNairy said, aim to educate inner-city residents about the impact of excess salt on blood pressure and the importance of reducing their salt intake. She and her collaborators are also studying the effects of heavy metals and air pollution on high blood pressure and ways to reduce their exposure.
“GHESKIO, with the support of Weill Cornell Medicine, has helped treat thousands of heart failure patients across all of our clinics,” says Vanessa Rouzier, assistant professor of medicine at Weill Cornell and director of research at GHESKIO. The organization provides outpatient care and medications free of charge, and refers patients to local hospitals if inpatient care is needed, Sufulla adds.
Next steps
“For 40 years, Weill Cornell has partnered with GHESKIO to build an equitable global health partnership focused on clinical care for the most vulnerable and training and capacity building for Haitians,” McNairy said.
The concerted effort to eliminate cardiovascular disease in Haiti grew out of earlier efforts to control HIV/AIDS and tuberculosis (TB). For more than 30 years, HIV/AIDS has been the leading cause of death among adults in Haiti, says Jean Pape, executive director of GHESKIO and professor at Cornell University Medical School. GHESKIO was founded in 1982 as the first developing country to lead the fight against HIV/AIDS.
In Port-au-Prince, nearly one in three adults, including those under 30, suffer from high blood pressure.
“Our work as one of the world's first and largest HIV and TB centers has been a major factor in shifting AIDS to the seventh leading cause of death in our population,” says Papé. “Cardiovascular disease is now the number one cause of death, by a large margin. Our AIDS patients are more likely to die from cardiovascular disease than from HIV-related infections.”
In Port-au-Prince, nearly one in three adults has high blood pressure, including those under the age of 30. Haitians between the ages of 18 and 30 have about two to four times as many high blood pressure patients as young black Americans in the country.
Although 97 percent of Haitian adults are screened for high blood pressure, only 13 percent have it under control, says Mary Masterson, program director at the National Heart, Lung, and Blood Institute, part of the National Institutes of Health in Bethesda, Maryland, which funds cardiovascular disease research in Haiti.
A previous study in Haiti found that women were six times more likely to be obese than men, but another study found that this had no effect on the prevalence of heart failure between the two groups.
“Findings of this nature merit investigation and highlight the potential impact this study and others like it have on the research community,” Masterson said. “We need to better understand the mechanisms and risk factors that influence disease symptoms.”
People walk at a street market in Petionville in Haiti's capital Port-au-Prince on February 28, 2020. REUTERS/Andres Martinez Casares
Susan Clymer is a freelance medical writer based in New York City.
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