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ESC Congress 2020 Register

HOPE 4 study: community-based intervention programme reduces CVD risk in low–middle income countries

ESC Congress News 2019 - Paris, France

Early detection of modifiable cardiovascular risk factors followed by lifestyle modifications and evidence-based medications can substantially reduce the risk of cardiovascular disease (CVD).

Public Health
Risk Factors and Prevention


“Hypertension is the leading cause of CVD and, despite proven medications, blood pressure remains poorly controlled around the world,” says Doctor Jon-David Schwalm (Population Health Research Institute of McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada). “We urgently need simple and scalable strategies that can be used to tackle one of the largest contributors to the global disease burden.”
To this end, the Heart Outcomes Prevention and Evaluation 4 (HOPE 4) study was conducted and results were presented by Dr. Schwalm at a Hot Line Session yesterday and simultaneously published in The Lancet.1 This 12-month, cluster randomised controlled study, undertaken in Colombia and Malaysia, looked at whether a community-based, comprehensive and integrated intervention programme, compared with usual care, could improve long-term cardiovascular risk, and focused on blood pressure and also lipids in people with newly diagnosed or poorly controlled hypertension.

The intervention package in HOPE 4 was informed by extensive health system appraisals and combined a 3-pronged approach: 1) community screening, treatment and control of CVD risk factors by non-physician health workers (in conjunction with local physicians) using mobile health tablet-based simplified management algorithms and counselling programmes; 2) provision of anti-hypertensive and cholesterol-lowering medications to eligible participants; and 3) involvement of family/friends to support the participant in medication adherence and adopting/maintaining a healthy lifestyle. A total of 1,371 people from 30 urban and rural communities (15 each in Colombia and Malaysia) were enrolled.
In contrast to previous community-based CVD intervention studies, the HOPE 4 study findings were extremely encouraging, reports Dr. Schwalm:

“We saw a greater than 40% reduction in the primary outcome of mean Framingham Risk Score 10-year CVD risk estimate among people participating in the community-based intervention vs the usual care group (-11.17% and -6.40%, respectively; p<0.0001).”

The intervention package was also associated with a change in blood pressure control status (systolic blood pressure <140 mmHg) that was more than double compared with the control group (69% vs 30%; p<0.0001). Improvements in the intervention vs control group were also seen with low-density lipoprotein cholesterol levels (mean change from baseline to 12 months -0.60 vs -0.19 mmol/L; p<0.0001).
“The latter includes increased levels of physical activity and greater consumption of fruits and vegetables, which may be largely attributable to the involvement of a participant-nominated family member/friend providing encouragement and support,” says Dr. Schwalm.

Senior author, Professor Salim Yusuf (Population Health Research Institute of McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada) explains that the HOPE 4 study design differs from previous community-based intervention packages. “At the start of the study, we conducted an extensive analysis that included systematic reviews of barriers to effective hypertension management, coupled with in-depth mixed-methods situation analyses in each country. Examples of unique barriers identified included traditional health beliefs in Malaysia and fragmentation of provision of care in Colombia.” The analyses informed the development of a strategy appropriate for these countries. “Importantly,” Prof. Yusuf continues, “the intervention approach was designed to be feasible within the existing country infrastructure. The use of locally sourced medications and task shifting with non-physician health workers contribute to a strategy that we believe is pragmatic and scalable for expansion nationally, as well as for implementation in other countries of all income levels.”

He suggests that each country identify strategies to detect and better manage hypertension based on an initial documentation of health system barriers and then develop appropriate strategies to overcome them.

Dr. Schwalm and Prof. Yusuf conclude, “HOPE 4 demonstrates the benefits of a comprehensive intervention model led by non-physician health workers in collaboration with primary care physicians and family/friends, which has resulted in a significant decrease in CVD risk among participants. With these findings, the HOPE 4 programme has the potential to make a significant impact on the global disease burden.”



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  1. Schwalm JD, et al. Lancet 2019. doi/10.1016/S0140-6736(19)31949-X

Notes to editor

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