Acknowledgments
This work was supported by PI14/01841 grant from Instituto de Salud Carlos III and FONDOS FEDER.
The term Hispanic or Latino refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race according to the definition of the United States Census Bureau published in 2010. The term includes a very relevant part of the population of Latin American and Caribbean (LAC) region to which around 50 million (16%) of the U.S. population has to be added. Brazil, French Guyana, and a few Caribbean islands are also included in the term LAC region.
The LAC region is extremely diverse but exists as a continent with historic entity and cultural, linguistic, and religious liaisons among the different countries. The territory exceeds 21 million square miles and the population approaches 600 million inhabitants. Marked health care disparities within countries exist related to striking economic differences that lead to important changes in health risk coverage and outcomes between the different countries. In fact the demographic, economic and social changes observed in LAC in recent years are the main contributors to explain the growing epidemic of cardiovascular disease (CVD) in this region. At the same time, all these facts explain why the literature related to cardiovascular (CV) risk and arterial hypertension in particular in the LAC region is both sparse and confusing. In this chapter we will review the most recent literature dealing with CV risk and arterial hypertension in Latin/Hispanic population both in LAC region and in the U.S.
Cardiovascular Disease in Latin/Hispanic Population
Cardiovascular diseases account for around 30% of deaths in LAC (1.6 million) and is the leading cause of death in all countries including the lowest-income countries (Haiti, Bolivia, and Nicaragua) and around half a million deaths take place in people younger than 70 years. One-third of premature deaths arising from CVD occurs in the poorest quintile of the population whereas only 13% are in the richest one. The prevalence of CVD among Latin/Hispanic population living in the U.S. is alarming and also represents the most important cause of death in this population accounting for 31% of the total. This can be explained by a higher prevalence of obesity, diabetes mellitus, hypertension, and dyslipidemia in Latin/Hispanic than in Caucasians. As previously commented LAC region is characterized by an extreme diversity, but the great majority of countries are in the group of low to middle income countries where the CVD risk is the highest.
Table 2.1 contains the ten “level 3” risks in terms of disability-adjusted life years (DALYs) for both sexes for the following locations: global, U.S., and the LAC region. The last is divided into Andean Latin America (Bolivia, Ecuador, Peru), Caribbean (Antigua and Barbuda, Barbados, Belize, Cuba, Dominica, Dominican Republic, Grenada Guyana, Haiti, Jamaica, Saint Lucia, Saint Vincent and the Grenadines, Suriname, the Bahamas, Trinidad and Tobago), Central Latin America (Colombia, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Venezuela), Tropical Latin America (Brazil, Paraguay) and Southern Latin America (Argentina, Chile, Uruguay). As can be seen, increased levels of blood pressure (BP), body mass index and fasting plasma glucose, in agreement with global data, are the three most frequent risk factors for CVD in the Latin/Hispanic population both in the U.S. and LAC. Unlike in global data, the presence of low glomerular filtration rate (GFR) appears as a risk factor in LAC and the U.S. occupying positions from the fifth to the eighth in LAC region and the tenth in the U.S. It is well known that arterial hypertension, obesity and diabetes facilitate together with CVD the development of chronic kidney disease (CKD).
| Risk | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
|---|---|---|---|---|---|---|---|---|---|---|
| Global | Blood Pressure | Smoking | Body mass index | Childhood undernutrition | Fasting plasma glucose | Alcohol use | Household air pollution | Unsafe water | Unsafe sex | Fruit |
| United States | Body mass index | Smoking | Blood Pressure | Fasting plasma glucose | Alcohol use | Total cholesterol | Physical activity | Drug use | Fruit | Glomerular filtration |
| South Latin America | Smoking | Body mass index | Blood Pressure | Alcohol use | Fasting plasma glucose | Glomerular filtration | Total cholesterol | Fruit | Vegetables | Drug use |
| Latin America & Caribbean | Body mass index | Blood Pressure | Fasting plasma glucose | Alcohol use | Smoking | Glomerular filtration | Total cholesterol | Whole grains | Physical activity | Fruit |
| Andean Latin American | Alcohol use | Body mass index | Blood Pressure | Fasting plasma glucose | Glomerular filtration | Smoking | Childhood undernutrition | Iron deficiency | Total cholesterol | Unsafe sex |
| Caribbean | Blood Pressure | Body mass index | Fasting plasma glucose | Smoking | Unsafe sex | Childhood undernutrition | Alcohol use | Glomerular filtration | Physical activity | Whole grains |
| Central Latin America | Body mass index | Fasting plasma glucose | Blood Pressure | Alcohol use | Glomerular filtration | Smoking | Processed meat | Total cholesterol | Whole grains | Sweetened beverages |
| Tropical Latin America | Blood Pressure | Body mass index | Alcohol use | Fasting plasma glucose | Smoking | Total cholesterol | Sodium | Glomerular filtration | Fruit | Whole grains |
Global prevalence of death attributed to CVD is increasing as a consequence of population growth, the aging of populations, and epidemiologic changes in diseases. Table 2.2 contains the six different patterns of demographic and epidemiologic changes in cardiovascular mortality. As can be seen there are significant differences among the different areas in the LAC region and in the U.S. The worst prognosis for the near future corresponds to the Caribbean with a continuous increase in the number of CVD deaths. Relative increases because of population growth and aging are expected in Central, Tropical, and Andean Latin America. Large declines in CVD death rates led to a small decline in mortality.
| Change in Cardiovascular Deaths, 1990-2013 | Effect of Population Growth | Effect of Population Aging | Effect of Age-Specific Cardiovascular Death Rate | Regions Latin American and Caribbean & United States | |
|---|---|---|---|---|---|
| Category | |||||
| Increase | Large (≥20%) | Large (>30%) | Small (decline <30%) | Caribbean |
| Increase | Large (>80%) | Small (<10%) | Small (decline <30%) | — |
| Increase then decrease | Very small (<20%) | Moderate (>20%) | Very small (decline <15%) | — |
| Increase | Small (<30%) | Very large (>70%) | Large (decline >30%) | — |
| Increase | Large (>30%) | Large (>30%) | Large (decline >30%) | Central Latin America Tropical Latin America Andean Latin America |
| Small increase or decrease | Small (<40%) | Large (>30%) | Large (decline >30%) | Southern Latin America North America |
Arterial Hypertension in the Latin American and Caribbean Region and the United States
Arterial hypertension is one of the main risk factors for ischemic heart disease and the leading determinant of cerebrovascular disease, and it affects between 20% and 40% of adults in the LAC region. The increase in CVD mortality in most LAC region countries is facilitated by the frequent and growing presence of arterial hypertension; in fact, the rising incidence of high BP could contribute to explain why in LAC countries, where rates of CVD death have declined, the trend has been considerably lower than that seen in the U.S. However, recently published data reflecting that globally high BP is number one cause of deaths and burden of disease, show that the participation of the LAC region in both parameters is smaller than that observed in high-income regions, Central Asia and Eastern Europe, East and Southeast Asia and Oceania and South Asia, being comparable to the contribution of Middle East and North Africa and Sub-Saharan Africa ( Fig. 2.1 ). This relatively smaller contribution could be related to the fact that total population in LAC region represents only around 8% of the global.
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