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Gross national income impacts European Society of Cardiology guideline applicability

13 Feb 2023
Gross national income and cardiology guidelines

Cardiovascular disease (CVD) outcomes have improved substantially, transformed to a great extent by the availability/implementation of international cardiovascular (CV) guidelines. However, morbidity and mortality rates associated with cardiovascular disease (CVD) remain disproportionally higher in countries with lower gross national incomes (GNI). One reason may be the lack of availability of CV recommendations, e.g., the European Society of Cardiology (ESC) General CV Guidelines, in these low-to-middle income countries (LMICs). A study by van Dijk and colleagues,1 recently published in the European Heart Journal, investigated whether successful implementation of ESC guideline recommendation may be related to a country’s GNI.

The Applicability of ESC Guidelines According to GNI study investigators circulated 875 ESC guideline-recommended ‘actions’ as a survey to 102 ESC national cardiac societies (NCSs). The actions comprised, for example, the prescribing and purchasing blood-pressure–lowering medication based on the ESC CV guidelines hypertension recommendations. Respondents were asked to score these actions based on their availability in clinical practice (fully, mostly/often available, mostly/often, or fully unavailable). They were also requested to list the top three barriers limiting the recommendation actions’ national availability/ applicability. Sixty-four out of 102 NCSs (62.7%) responded.

ESC Guidelines Applicability Differs Substantially Among Countries Revealing Health Resource Levels Inequities

Study results showed that on average, many of the actions (71.6%) were fully available, with 11.8% of the actions fully unavailable, independent of a country’s GNI. However, comparing LMICs, the proportion of unavailable actions (29.4%) was substantially greater as compared in HICs (2.4%); indeed, unavailable actions were 10 times more prevalent in LMICs than in HICs.

Barriers to guideline-recommended actions involved financial issues such as lack of reimbursement, and inadequate national healthcare systems/resources. In many countries, particularly in LMICs, recommendation actions required disproportionately high cost-outlays on both national and local levels. Consequently, the lack of coverage/reimbursement for pharmaceutical interventions in LMICs limited the applicability of multiple ESC Guidelines recommendations.

Study investigators concluded international cardiology societies should consider levels of care in which services are being provided when developing guideline recommendations. ‘Context-stratifying’ guideline recommendations attuned to a country’s healthcare system/resources may make guidelines more accessible, thus improving CVD outcomes, especially in LMICs.

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Author: Saskia van Tetering

1. van Dijk WB, Schuit E, van der Graaf R, Groenwold RHH, Laurijssen S, Casadei B, et al. Applicability of European Society of Cardiology guidelines according to gross national income. Eur Heart J. 2023;44:ehac606. doi:10.1093/eurheartj/ehac606.

2. Onuma AK. The heart of the matter: adapting cardiovascular disease guidelines for low- and middle-income countries. Eur Heart J. 2022;00:1-2. doi:10.1093/eurheartj/ehac738.


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