Cardiovascular Imaging in Global Health Radiology
Cardiovascular disease (CVD) is the number one cause of death globally, and morbidity and mortality are highest in low- and middle-income countries (LMICs) due to unavailability and unaffordability of medical resources for diagnosis and management of CVD. This has led to disastrous economic consequences on the individual, household, and societal level in these regions. Cardiovascular imaging is essential to the care of patients with CVD; however, access to cardiovascular imaging is very limited in low- and middle-income countries due to expense of equipment and challenges in training healthcare personnel to correctly order, acquire, and interpret studies. The state-of-the-art tools for cardiac imaging include echocardiography, coronary angiography and left ventriculography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging. Of the available cardiac imaging modalities, echo is the most widely used in LMICs because it is safe, portable, relatively inexpensive, and able to diagnose a variety of CVDs. Additionally, inexperienced practitioners can be trained to perform a focused cardiovascular exam by echo, for example, in screening for rheumatic heart disease, in a relatively short period. Handheld or pocket-sized echo machines are particularly useful, and the images can be interpreted locally or uploaded for remote interpretation by expert cardiologists. Instituting the infrastructure for cardiovascular imaging alone is not sufficient. Clinicians in LMICs must be trained to properly refer patients and interpret the results. Additionally, patients must have access to and be able to afford necessary medicines and surgeries for treatment of CVDs. In the future, the gap to CVD treatment in LMICs may be closed further by use of telemedicine and mobile cardiovascular imaging tools as well as continued international efforts to lower infrastructure costs and train local providers in its use.
KeywordsLow- and middle-income countries Cardiovascular imaging Telemedicine Echocardiography Ultrasound
Acquired immunodeficiency disease syndrome
Coronary artery calcium scores
Coronary artery disease
Cardiac computed tomography angiography
Congenital heart disease
Cardiac magnetic resonance
Electron-beam computed tomography
Gross domestic product
Hand-carried cardiac ultrasound
Human immunodeficiency virus
International Atomic and Energy Agency
Low- and middle-income countries
Multi-detector computed tomography
Myocardial perfusion imaging
Rheumatic heart disease
Single-photon emission computed tomography
World Health Organization
- 1.WHO Global status report on noncommunicable diseases, updated 2017. Available from: http://www.who.int/mediacentre/factsheets/fs310/en/. Accessed 8 Apr 2017.
- 3.Report on the status of major health risk factors for noncommunicable diseases: WHO African Region, 2015. Available from: http://www.afro.who.int/en/noncommunicable-diseases/npc-publications.html. Accessed 8 Apr 2017.
- 4.WHO “Noncommunicable diseases” fact sheet, updated 2017. Available from: http://www.who.int/mediacentre/factsheets/fs355/en/. Accessed 8 Apr 2017.
- 5.Khatib R, McKee M, Shannon H, Chow C, Rangarajan S, Teo K, et al. Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data. Lancet. 2016;387:61–9.PubMedCrossRefGoogle Scholar
- 9.Disability-adjusted life year (DALY) rates by WHO region. Available from: http://www.who.int/gho/mortality_burden_disease/daly_rates/en/. Accessed 10 June 2017.
- 12.Nugent RA, Feigl AB. Scarce donor funding for non-communicable diseases: will it contribute to a health crisis? Washington, DC: Center for Global Development; 2010. Available at: http://www.cgdev.org/content/publications/detail/1424546. Accessed 10 June 2017.Google Scholar
- 15.Global Burden of Disease: GBD compare data visualization. Available from: https://vizhub.healthdata.org/gbd-compare/. Accessed 10 June 2017.
- 17.Sims Sanyahumbi A, Colquhoun S, Wyber R, Carapetis JR. Global disease burden of group A streptococcus. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes: basic biology to clinical manifestations. Oklahoma City: University of Oklahoma Health Sciences Center; 2016. Available at: https://www.ncbi.nlm.nih.gov/books/NBK333415/. Accessed 8 Apr 2017.Google Scholar
- 22.Akter S, Rahman MM, Abe SK, Sultana P. Prevalence of diabetes and prediabetes and their risk factors among Bangladeshi adults: a nationwide survey. Bull World Health Organ. 2014;92:204–13A. Available at: http://www.who.int/bulletin/volumes/92/3/13-128371/en/. Accessed: 8 Apr 2017.PubMedPubMedCentralCrossRefGoogle Scholar
- 23.International Diabetes Federation – seventh Edition, Regional Fact Sheet. Available at: http://www.diabetesatlas.org/resources/2015-atlas.html. Accessed: 8 Apr 2017.
- 24.Mathers C, Stevens G, Mascarenhas M, for World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization; 2009. Available from: http://www.who.int/entity/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf. Accessed 10 June 2017.
- 25.Cheitlin MD, Alpert JS, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, et al. ACC/AHA guidelines for the clinical application of echocardiography: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. J Am Coll Cardiol. 1997;29(4):862–79.PubMedCrossRefGoogle Scholar
- 26.Lang R, Badano L, Mor-Avi V, Afilalo J, Armstrong A, Ernande L. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1–39.e14.PubMedCrossRefGoogle Scholar
- 28.De Maria AN, Blanchard DG. Echocardiography. In: WR FV, Harrington RA, editors. Hurst’s the heart. 13th ed. New York: McGraw Hill; 2011. p. 411–89.Google Scholar
- 30.Hahn R, Abraham T, Adams M, Bruce C, Glas K, Lang R, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921–64.PubMedCrossRefGoogle Scholar
- 31.Goldstein S, Evangelista A, Abbara S, Arai A, Asch F, Badano L, et al. Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and the European Association of Cardiovascular Imaging: endorsed by the Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2015;28:119–82.PubMedCrossRefGoogle Scholar
- 33.Kern MJ, King SB. Cardiac catheterization, cardiac angiography, and coronary blood flow and pressure measurements. In: Fuster V, Walsh R, Harrington RA, editors. Hurst’s the heart. New York: McGraw Hill; 2011. p. 490–536.Google Scholar
- 34.Berman DS, Hayes SW, Hachamovitch R, Shaw LJ, Germano G. Nuclear Cardiology. In: WR FV, Harrington RA, editors. Hurst’s the heart. 13th ed. New York: McGraw Hill; 2011. p. 562–98.Google Scholar
- 36.Mark DB, Berman DS, Budoff MJ, Carr JJ, Gerber TC, Hecht HS, et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010;55(23):2663–99.PubMedCrossRefPubMedCentralGoogle Scholar
- 37.Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Circulation. 2010;122(21):e525–55.PubMedGoogle Scholar
- 40.Taylor AJ, Bindeman J, Feuerstein I, Cao F, Brazaitis M, O’Malley PG. Coronary calcium independently predicts incident premature coronary heart disease over measured cardiovascular risk factors: mean three-year outcomes in the Prospective Army Coronary Calcium (PACC) project. J Am Coll Cardiol. 2005;46(5):807–14.PubMedCrossRefGoogle Scholar
- 42.Kim HW, Farzaneh-Far A, Klem I, Rehwald W, Kim RJ. Magnetic Resonance of the Heart. In: Fuster V, Walsh R, Harrington RA, editors. Hurst’s the heart. 13th ed. New York: McGraw Hill; 2011. p. 631–66.Google Scholar
- 45.Schwitter J, Wacker C, van Rossum A, Lombardi M, Al-Saadi N, Ahlstrom H, et al. MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial. Eur Heart J. 2008;29:480–9.PubMedCrossRefGoogle Scholar
- 46.Schwitter J, Wacker C, Wilke N, Al-Saadi N, Sauer E, Huettle K, et al. MR-IMPACT II: Magnetic Resonance Imaging for Myocardial Perfusion Assessment in Coronary artery disease Trial: perfusion-cardiac magnetic resonance vs. single-photon emission computed tomography for the detection of coronary artery disease: a comparative multicentre, multivendor trial. Eur Heart J. 2013;34:775–81.PubMedCrossRefGoogle Scholar
- 51.Carapetis JR, Hardy M, Fakakovikaetau T, Taib R, Wilkinson L, Penny DJ, et al. Evaluation of a screening protocol using auscultation and portable echocardiography to detect asymptomatic rheumatic heart disease in Tongan schoolchildren. Nat Clin Pract Cardiovasc Med. 2008;5(7):411–7.PubMedCrossRefGoogle Scholar
- 52.Saxena A, Ramakrishnan S, Roy A, Seth S, Krishnan A, Misra P, et al. Prevalence and outcome of subclinical rheumatic heart disease in India: the RHEUMATIC (Rheumatic Heart Echo Utilisation and Monitoring Actuarial Trends in Indian Children) study. Heart. 2011;97(24):2018–22.PubMedCrossRefGoogle Scholar
- 68.Oyati IA, Danbauchi SS, Alhassan MA, Isa MS. Diastolic dysfunction in persons with hypertensive heart failure. J Nat Med Assoc. 2004;96(7):968–73.Google Scholar
- 69.Jaiyesimi F, Antia AU. Childhood rheumatic heart disease in Nigeria. Trop Geograph Med. 1981;33(1):8–13.Google Scholar
- 74.Zaidi H. Medical physics in developing countries: looking for a better world. Biomed Imaging Intervent J. 2008;4(1):e29.Google Scholar
- 79.Vitola J, Mut F, Alexánderson E, Pascual T, Mercuri M, Karthikeyan G, et al. INCAPS Investigators Group. Opportunities for improvement on current nuclear cardiology practices and radiation exposure in Latin America: Findings from the 65-country IAEA Nuclear Cardiology Protocols cross-sectional Study (INCAPS). J Nucl Cardiol. 2017;24(3):851–9.PubMedCrossRefGoogle Scholar
- 80.SonoWorld Website. Available at: http://www.sonoworld.com/. Accessed 10 June 2017.
- 87.Kwan G, Bukhman A, Miller A, Ngoga G, Mucumbitsi J, Bavuma C, et al. A simplified echocardiographic strategy for heart failure diagnosis and management within an integrated noncommunicable disease clinic at district hospital level for sub-Saharan Africa. JACC Heart Fail. 2013;1:230–6.PubMedCrossRefGoogle Scholar