The Global Alliance against Chronic Respiratory Diseases (GARD) is a voluntary network of national and international organizations, institutions and agencies led by the World Health Organization (WHO), working towards the vision of a world where all people breathe freely (1). GARD is supporting WHO in successfully implementing the WHO’s Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs) 2013-2020. The GARD report on GARD activities is published on a regular basis. Collaboration among GARD countries is critical for sharing experiences and providing technical assistance to developing countries based on each country’s needs (2).

Cardiovascular diseases remain the dominant cause of death worldwide. In the last decades, the remarkable advances in human genetic and genomic research, plus the now common use of genome-wide association studies, have led to the identification of numerous genetic variants associated with specific cardiovascular traits and diseases. Although the clinical applications are limited because the genetic risk of common cardiovascular disease is still unexplained, and the mechanisms of action of the genetic factor(s) are not known, these research advances have, in turn, widely opened the concept of personalized medicine. In this paper, the status and prospects of personalized medicine for cardiovascular disease will be presented. This will be followed by a discussion of issues regarding the implementation of personalized medicine.

Chest pain is one of the most common symptoms driving patients to a physician's office or the hospital's emergency department. In approximately half of the cases, chest pain is of cardiac origin, either ischemic cardiac or nonischemic cardiac disease. The other half is due to noncardiac causes, primarily esophageal disorder. Pain from either origin may occur in the same patient. In addition, psychological and psychiatric factors play a significant role in the perception and severity of the chest pain, irrespective of its cause. Chest pain of ischemic cardiac disease is called angina pectoris. Stable angina may be the prelude of ischemic cardiac disease; and for this reason, it is essential to ensure a correct diagnosis. In most cases, further testing, such as exercise testing and angiography, should be considered. The more severe form of chest pain, unstable angina, also requires a firm diagnosis because it indicates severe coronary disease and is the earliest manifestation of acute myocardial infarction. Once a diagnosis of stable or unstable angina is established, and if a decision is made not to use invasive therapy, such as coronary bypass, percutaneous transluminal coronary angioplasty, or stent insertion, effective medical treatment of associated cardiac risk factors is a must. Acute myocardial infarction occurring after a diagnosis of angina greatly increases the risk of subsequent death. Chest pain in women warrants added attention because women underestimate their likelihood to have coronary heart disease. A factor that complicates the clinical assessment of patients with chest pain (both cardiac and noncardiac in origin) is the relatively common presence of psychological and psychiatric conditions such as depression or panic disorder. These factors have been found to cause or worsen chest pain; but unfortunately, they may not be easily detected. Noncardiac chest pain represents the remaining half of all cases of chest pain. Although there are a number of causes, gastroesophageal disorders are by far the most prevalent, especially gastroesophageal reflux disease. Fortunately, this disease can be diagnosed and treated effectively by proton-pump inhibitors. The other types of non-gastroesophageal reflux disease–related noncardiac chest pain are more difficult to diagnose and treat. In conclusion, the cause of chest pain must be accurately diagnosed; and treatment must be pursued according to the cause, especially if the cause is of cardiac origin.

The author analyses global prevalence of arterial pressure and its impact on population mortality and disability, draws attention to insufficient efficacy of this disease treatment, low awareness of the population about this disease and compliance of the patients. To achieve target arterial pressure, cooperation is necessary between the physician and the patient.

Evidence supporting the association of normal and pathologically elevated blood pressure with low birth weight is presented and discussed in this article because of the overwhelming global prevalence of hypertension and its impact on individuals and nations. The findings provide strong impetus for the medical and public health communities to consider the concept of the "developmental origins of health and disease" in developing approaches to address the growing burden of hypertension worldwide.

In this article, the clinical trials that have most effectively demonstrated the effectiveness of hypertension nonpharmacologic prevention interventions are presented and discussed. Thus, data from weight reduction, dietary interventions, and lifestyle modifications are shown and discussed. It is concluded that these interventions lead to control of hypertension either by themselves or in association with pharmacologic interventions. Over the years, many controlled clinical trials have demonstrated the efficacy of pharmacologic treatment of hypertension. However, such treatment has its shortcomings. First, it usually requires a lifelong commitment to therapy because, although this approach can control hypertension and reduce its consequences, it does not cure the condition. Next, the cost of pharmacologic interventions can be very high and, thus, prohibitive for poorer individuals and nations. In addition, many patients experience problems with compliance and adherence, which almost certainly contribute to the low level of hypertension control that is so widely observed. Finally, the pharmacologic approach requires a strong commitment by public health officials for detection and treatment of hypertension if there is to be any hope of limiting this condition's impact. All of these negative considerations are compounded by the fact that the prevalence of hypertension is increasing worldwide. For all these reasons, nonpharmacologic interventions should be implemented to prevent or delay the occurrence of hypertension.

In the early 1970s, the medicine chest for an asthma physician in the United States was quite bare. A few nonspecific inhaled bronchodilators were available, along with theophylline and systemic steroids. Treatment with inhaled steroids was just coming into common use, but many physicians and most patients were either wary of their use or not convinced of their effectiveness. In 1989, when the National Asthma Education and Prevention Program promulgated the first set of treatment guidelines, the good news was that there were many more therapeutic options. The bad news was that the evidence base on how to use these treatments was small and strongly biased because the majority of the clinical data came from studies conducted by manufacturers. The National Asthma Education and Prevention Program guidelines were based mostly on “expert opinion”; what was needed was to expand the evidence base for asthma treatment through rigorous clinical trials. The only entity that had the resources and the will to do this was the National Institutes of Health, and thus a group of clinical and basic investigators backed by the leadership of the American Academy of Allergy, Asthma and Immunology approached the National Heart, Lung, and Blood Institute (NHLBI) to explore the possibility of initiating a clinical network to test the effectiveness and safety of interventions, which could then be quickly transported into practice. The reaction of the NHLBI was at first mixed. Although there were concerns, there was also strong enthusiasm about the potential of rapid and practical outcomes from which patients would surely benefit. The concerns focused on whether investigators located in several institutions would really agree to work together for the 5-year duration of the proposed network, whether they would truly be interested in designing short protocols with the goal of producing outcomes readily applicable in practice, and the cost of such a venture. Because of the novel concept under consideration, it was decided that if such a program was to be implemented, it should be subjected to the usual rigorous National Institutes of Health peer review and should be supported by set-aside funds. After much deliberation and concept review, the NHLBI decided to proceed with funding through a cooperative agreement. A request for applications was issued that required the applicants to propose 2 important clinical questions related to asthma treatment that required multicenter investigation. More than 30 applications were submitted, and the applications that received the top 5 ranking in the peer review process (based on the scientific merit of the proposed clinical questions) were selected. A separate request for applications resulted in an award for a data-coordinating center. The NHLBI selected the chair of the steering committee, Reuben Cherniack, a well-known expert who was not one of the principal investigators. Funding for the network included “core support” for the investigators to develop the protocols, but the majority of the funding was “restricted” for use during the conduct of the clinical trials; funds were made available on a cost-per-patient basis. The Asthma Clinical Research Network (ACRN; often referred to as the ACoRN) was established, and the rest of the work was up to the investigators! At the first meeting of the newly constituted ACRN, it was clear the NHLBI expected the network to tackle important problems in asthma treatment. There were 2 problems that had not been solved in such a setting before: (1) how to set up a network capable of doing multiple studies spread across the country with uniform protocols, data entry procedures, and quality control measures and (2) how to identify the right important question and then write, review, and implement an asthma treatment protocol. The problem of organizing a disaggregated network was solved by using a novel idea at the time: the Internet. Even though this information-sharing network was just getting organized, the ACRN took full advantage of it. Both clinical and lung function data were entered using Web-based protocols. A manual of procedures was adopted that codified all aspects of trial performance. This resulted in minimal measurement variance and improved the ability to detect small signals. In 1995, the fledgling Internet was taxed with large data downloads, but the technology proved robust and was essential to solving the first problem. The problem of identifying the right protocol was much more difficult. The investigators needed to identify important problems that could be solved with limited resources, both human and fiscal. To complicate matters, they were just getting to know each other, and each of them had submitted a number of sample protocols for the grant competition. Each of the 5 centers wanted their protocol to be the lead protocol, and all of them wanted the ACRN to step to the plate and hit the first pitch out of the park. Most of the first meetings were spent in debate about what was the most important question to which we could expect a clean answer. Multiple protocols were offered, some addressing treatment questions in patients with severe asthma and others addressing treatment questions in patients with mild asthma. A number of secret ballots were held, but no single idea easily emerged. In the end, we were lucky. In the early 1990s, a number of articles were published that suggested that regularly scheduled use of inhaled β2-selective agonists, when administered on a regular schedule, had adverse effects on asthma control. These inhaled asthma medications were the most commonly used asthma medications in the world. If they had adverse effects, even in a small proportion of patients, the overall negative effect could be substantial. Thus we chose a protocol to answer the research question of whether recurrent use of regularly scheduled albuterol would be associated with adverse effects on asthma control. The target population was patients with mild asthma in whom inhaled β2-agonists were most likely to be used as the only asthma medication. Peak expiratory flow was chosen as the primary outcome indicator because to power a trial on asthma exacerbations in patients with such mild disease would require more time or money than the network had available. Expiratory flow, although a surrogate marker, was robust, easy to measure, and linked to asthma control. The final trial design was straightforward. Patients with mild asthma were enrolled, and their baseline lung function was monitored during a 6-week run-in period. This was followed by a 16-week randomized treatment period and a 6-week washout period. The study was powered to detect a 25 L/min difference between the 2 treatment groups. The trial design was improved by the protocol review committee and approved by a data safety and monitoring board (both committees had been established by the NHLBI). Each center was successful in piloting the protocol through their local institutional review boards. The key aspect of the protocol was that if the recruitment goal and time guidelines could be met and if the treatment groups were balanced, then the results would be of clinical interest, regardless of the “sign” of the outcome. Timelines were met by identifying a single group to do the majority of the work in a single area; every group had a task, and everyone agreed to abide by the solutions offered to the group. The investigators soon learned that the biggest problem was to obtain placebo inhalers. Again, the investigators were lucky when senior management at Schering-Plough agreed to provide active and placebo inhalers; they had little to gain from this protocol and provided the medication as a public service. The ACRN investigators will always be grateful to these persons for their willingness to help in their first protocol, but obtaining matched drug and placebo continues to be a major obstacle for the network. The results of the first study, “Comparison of regularly scheduled with as-needed use of albuterol in mild asthma,” were published in 19961Drazen J.M. Israel E. Boushey H.A. Chinchilli V.M. Fahy J.V. Fish J.E. et al.Comparison of regularly scheduled with as-needed use of albuterol in mild asthma.N Engl J Med. 1996; 335: 841-847Crossref PubMed Scopus (324) Google Scholar and have been widely accepted by the asthma treatment community. The study demonstrated that in the population of patients with mild asthma, the regularly scheduled use of inhaled albuterol is not associated with adverse events, but it also does not provide clinical benefit. This is information that a clinician can use in daily decision making and is the hallmark of ACRN studies. Since the network was constituted (1993), the ACRN has produced more than a dozen clinical trials that have provided the basic building blocks of asthma treatment. The data have not only furthered the evidence base, they have also questioned our current thinking and provided provocative results to serve as the foundation for the next generation of asthma treatment. One of the most important questions with respect to asthma treatment has to do with the substantial among-patient variance in the treatment response and the potential genetic basis of this variance. The use of genetic information to first predict and then to tailor asthma treatment is the next frontier. The ACRN has already begun to chip away at this problem.2Israel E. Chinchilli V.M. Ford J.G. Boushey H.A. Cherniack R. Craig T.J. et al.Use of regularly scheduled albuterol treatment in asthma: genotype-stratified, randomised, placebo-controlled cross-over trial.Lancet. 2004; 364: 1505-1512Abstract Full Text Full Text PDF PubMed Scopus (548) Google Scholar They have the intellectual and patient resource capital needed to make this dream a reality. We hope that they succeed.

OBJECTIVE:High blood pressure (BP) is a leading risk factor for cardiovascular morbidity and mortality. Effective antihypertensive pharmacotherapy is available but recognition and proper management of hypertension and BP goal achievement is still poor. Therefore, it was hypothesized that physicians' attitude towards high BP, as well as patients' perception and knowledge, may influence actual management of hypertension. RESEARCH DESIGN AND METHODS:Telephone interviews were carried out with a random sample of 1259 primary care physicians in 17 countries worldwide from 12 December 2005 to 13 January 2006 using a central computer assisted telephone interview methodology (CATI). RESULTS:(1) Physicians believed that 62 +/- 21% of their patients had their BP controlled. (2) They were mostly in line with guideline recommended BP goals and 96% were aware of the elevated cardiovascular risk of hypertension, but 41% aimed to reduce BP to acceptable levels only. (3) Physicians indicated that in 41% of patients monotherapy controls BP and 71% would escalate to combination therapy after monotherapy failure. (4) 54% regard hypertension management as difficult. (5) Physicians estimated that between 60 and 70% of patients know their BP goal but thought that there was still room for improvement of hypertension management on the patient side. CONCLUSION:Although many effective treatment options for arterial hypertension exist, BP goal achievement worldwide is suboptimal, leaving patients at an unnecessary cardiovascular risk. An increase in patients' awareness and compliance together with an increased adherence of physicians to current guidelines should help in reducing the long term cardiovascular consequences of hypertension.