Cardiovascular Disease in the Caribbean: Risk Factor Trends, Care and Outcomes Still Far From Expectations

Cardiovascular diseases (CVD) are a major public health concern in the Caribbean. Cardiovascular care in the Caribbean revealed encouraging improvements but still less than expectations. This study aims to gain insight into CVD and identify gaps in cardiovascular care in the Caribbean compared to high-income countries. More specifically, this review reports on the epidemiology, CVD risk factors, management practices, and patient outcomes (quality of life (QOL) and mortality). A systematic review of peer-reviewed articles was conducted to assess the CVD of individuals in the Caribbean from 1959 to 2022.Using multiple search engines and keywords, a systematic review of relevant peer-reviewed CVD articles was conducted using the necessary inclusion and exclusion criteria. Relevant data of studies were classified by title, publication year, location, type and size of samples, and results. Further analysis grouped patients by epidemiological profile, CVD risk, management, and selected outcomes (quality of life and inpatient mortality). From the initial review of 1,553 articles, 36 were analyzed from Trinidad and Tobago (20), Barbados (4), Jamaica (7), along with the Bahamas (2), British Virgin Islands (1), Bonaire (1), and one article from a Caribbean study. The social environment of fast food, sedentary jobs, and stress determinants are postulated to be precursors for an increase in CV risks. CVD in the Caribbean reveals a high prevalence of CV risks, suboptimal care, poor compliance, and high inpatient mortality compared with high-income countries. Greater efforts are required to improve CVD care at all stages, including in the social environment.


Introduction And Background
Cardiovascular disease (CVD) continues to rise at a fast pace in the Caribbean [1] presenting as myocardial ischaemia, heart failure, arrhythmias, and cardiomyopathies.By far, the commonest condition is coronary artery disease (CAD) which is responsible for the highest death rate [2].Being the leading cause of death [3], CAD has shown significant interest to all stakeholders since its development and complications are largely preventable.Increasingly, in the last decade, an increasing number of women [4] and young adults [5] are being affected which has stemmed from a change in societal and behavioral forces and influences [6].Caribbean countries have implemented numerous strategies [7], workshops [8], heads of government and ministerial meetings, and conferences [9] throughout the past two decades.Their effects are yet to be evaluated, and these investments are expected to reduce CVD prevalence, and improve risk management, care, and outcomes.The study aimed to compile the primary findings of CAD across Caribbean studies (epidemiology, CV risks, CAD or CVD, and outcomes such as quality of life (QOL) and inpatient mortality).Specifically, the epidemiologic profile of patients by age, sex, and ethnicity was to be determined, the risks for CAD of various subpopulations and variations with time, management of patients (in terms of timing and medical treatment), and determining evidence-practice gaps in CAD care.This review also identifies research gaps and recommends strategies for the treatment and prevention of CAD that would ultimately help policymakers and other stakeholders make data-driven recommendations to address the epidemic.

FIGURE 1: PRISMA 2020 flow diagram for systematic reviews
Source: [12] PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Data Extraction/Data Analysis/Interpretations
The search yielded articles based on four main themes: epidemiology (four articles) and prevalence (11 articles); cardiovascular risks (11 articles); cardiovascular management: timings (three articles), treatment (three articles), compliance and monitoring (two articles); and outcomes (quality of life and inpatient mortality) consisting of two articles.Data were collected on age, sex, and ethnic distribution of AMI; cardiovascular risks of the population, sub-populations, CAD patients, and AMI patients; management (timing of treatment: pre-hospital delay, door-to-ECG, door-to-needle thrombolytic time); pharmacological treatment (thrombolysis, primary angioplasty, and other medications); and outcome (quality of life and inpatient mortality).Relevant data were entered into a master sheet, classifying the title, year of publication, study location, study sample, objective, summary, findings, and conclusions.Informed consent was waived owing to the retrospective nature of the study.

Results
Of the initial review of 1,553 articles, 36 were accepted for analysis.These studies were mainly conducted in Trinidad and Tobago, Barbados, and Jamaica along with the Bahamas, British Virgin Islands, and Bonaire.
A strong inverse curvilinear relation between high-density lipoprotein cholesterol and coronary heart disease incidence was determined (p < 0.005) in West Indian men (n=1246) (Trinidad and Tobago, 1989) [25].
Cholesterol: High across the region, with 37.8% of Caribbean patients in 2014 having elevated levels [33].
While dietary studies are scarce, a 2023 study in Trinidad provided stark evidence: overwhelming preference for atherogenic foods high in sugar and salt among adults [35].

Management of ACS/AMI
To assess timeliness, the total time taken from symptom detection to hospitalization was measured as the mean pre-hospital delay (PHD) time.In 2018, for patients established with AMI, the mean PHD time varied from between 7.5 and 18 hours [36].The mean PHD was 7.5±6.6hours in Trinidad [36].In the Bahamas, the PHD was 18 hours, where 56% of patients present within 12 hours [37].A 2017 Trinidad study at a rural emergency department found that "the median door-to-ECG time was 10 min, with 52.5% of patients achieving a door-to-ECG time of less than 10 min.The median door-to-needle time was 70 minutes, with only 8.2% of patients having a door-to-needle time of less than 30 minutes" [38].In 2019, among AMI patients, 57.5% of patients received thrombolysis within 30 min [14].
Interestingly, Trinidad (2015) also revealed a high prevalence of complementary and alternative medicine (CAM) use (56.2%) among cardiac clinic patients, with herbal remedies being the most popular choice (85.9%) [40].A Barbados study echoed these findings, suggesting a similar reliance on CAM alongside conventional medicine.Emergency treatment for AMI patients in Trinidad followed a similar pattern: aspirin (97.2%), clopidogrel (97.2%), heparin (81.3%), and thrombolysis (70.5% for ST-elevation MI patients).However, a concerning gap emerged; none of these patients received primary angioplasty.

Outcomes
Inpatient mortality for AMI patients in Trinidad was 6.18% for men and 7.2% for women [14], while a Bahamas study reported a mortality rate of 19% [37].Fortunately, for those who survived AMI, their "overall QOL improved over time in all domains: Emotional, Physical, and Social" [44].A study among stable cardiac disease patients revealed that the prevalence of moderate to severe depression was 34.3% [95% CI (29.6-39.2)][45].

Epidemiology
This increased cardiovascular risk may be responsible for the earlier development of AMI.The incidence of AMI varies between 67 and 123 per 100,000 (Trinidad and Tobago and Barbados), compared to Japan which is 55.2-63.1 per 100,000 [61].Even when compared to other low-income countries such as Iran (73.3 per 100,000) [62], the prevalence in the Caribbean is significantly higher.The mean age is at least a decade earlier (58.6 ± 13.43 years in 2019) compared to Japan (70 ± 13 years in 2011) [61] and USA (65.6 years for men and 72.0 years for women) [63].There were more Indo-Trinidadian males than other groups: Indo-Trinidadian males (141 cases per 100,000) compared to Indo-Trinidadian females (90 cases per 100,000); Afro-Trinidadian males (81 per 100,000), and Afro-Trinidadian females (45 per 100 000).

Management of ACS/AMI
The main focus of treatment was pharmacological which varies between 42% and 97% and compares well with first world countries, varying between 44% and 89% [64][65][66][67].Evidence-based guideline goals for primary angioplasty are virtually non-existent.Furthermore, non-pharmacological treatments such as counseling and cardiac rehabilitation are poor.
Trinidad grapples with a longer pre-hospital delay (7.5 ± 6.6 hours) than that in the United Kingdom (6.1 ± 12.9 hours) [68].Pre-hospital delay is quite high, with a mean of 1 h more, which is much longer than that in the UK [68].However, the proportion of patients receiving thrombolysis (door-to-needle time) within 30 min in Trinidad and Canada was similar [69].The timing of treatment for AMI reveals poor outcomes in low-income countries (Bangladesh) which are far worse than those in high-income countries [70] with the resources available.
The Caribbean is not alone in its struggles with medication adherence.Similar concerns plague other regions, with a meager 46% compliance rate reported in Saudi Arabia [71].Adherence to treatment care and goals remain bleak, with less low-income countries attaining HBA1C targets, compared to other countries showing far better outcomes [72].In the US, non-compliance accounts for around 125,000 deaths and 10% of hospitalizations annually [73,74].

Outcomes
Depression among AMI patients in our study was found to be in 34.3% (n =388 patients) (2018) which is almost twice the reported depression prevalence in the US (18.7%) in 2017 [75].This disparity is mirrored in in-patient mortality, with our review revealing rates of 6% (males) and 7% (females), while another study reports a significantly higher value of 19% far exceeding the Netherlands' 3% [76].This may reflect the poor access to quality care for patients in the Caribbean [77].However, the quality of life of AMI survivors improves with time and may improve with proper intervention, which can be further enhanced through cardiac rehabilitation.

Limitations
Relevant potential studies may have been overlooked due to access barriers.Some abstracts provided inadequate information on their use.Variations in study designs, analyses, and information gathered, and small sample sizes may explain these inconsistencies.Further, the limited time period did not allow for detailed reporting of each study, although there may have been more relevant information.

Conclusions
This study revealed major deficit gaps in health status in terms of epidemiology, incidence and prevalence, risk factors, treatment timing, optimum management, and outcomes, in the Caribbean.There is a high prevalence of CV risks with the resulting young age of developing CAD which more commonly affects males and Indo-Trinidadians.Over the last few decades, CV diseases have increased across the Caribbean.The growing atherogenic environment and sub-optimization of risk factor management have hastened the earlier development of CAD and its complications.
We must implement a multipronged approach to bridge these care gaps.This means both robust healthcare systems and broad societal interventions, likely requiring individual efforts as well.The evidence is clear that an action plan is required that may potentially include societal interventions along with individual efforts.