Brief Article
Copyright ©2011 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Cardiol. Dec 26, 2011; 3(12): 383-387
Published online Dec 26, 2011. doi: 10.4330/wjc.v3.i12.383
Adequate antiplatelet regimen in patients on chronic anti-vitamin K treatment undergoing percutaneous coronary intervention
Eiman Jahangir, Daniel Comandé, Adolfo Rubinstein
Eiman Jahangir, Daniel Comandé, Adolfo Rubinstein, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, C1414CPV, Argentina
Eiman Jahangir, Department of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, United States
Author contributions: Jahangir E, Comandé D and Rubinstein A were all involved in the development of this idea; Jahangir E and Comandé D performed the bibliometric search and analysis; all authors wrote and edited the manuscript.
Correspondence to: Dr. Eiman Jahangir, MD, Institute for Clinical Effectiveness and Health Policy, Dr. Emilio Ravignani 2024, Buenos Aires, C1414CPV, Argentina.
Telephone: +1-615-6891504 Fax: +1-615-9361872
Received: November 6, 2011
Revised: November 8, 2011
Accepted: November 15, 2011
Published online: December 26, 2011


AIM: To investigate the number of publications in cardiovascular disease (CVD) in Latin America and the Caribbean over the last decade.

METHODS: We performed a bibliometric analysis in PubMed from 2001 to 2010 for Latin America and the Caribbean, the United States, Canada, Europe, China, and India.

RESULTS: Latin America published 4% of articles compared with 26% from the United States/Canada and 42% from Europe. In CVD, Latin America published 4% of articles vs 23% from the United States/Canada and 40% from Europe. The number of publications in CVD in Latin America increased from 41 in 2001 to 726 in 2010.

CONCLUSION: Latin America, while publishing more articles than previously, lags behind developed countries. Further advances in research infrastructure are necessary to develop prevention strategies for this region.

Key Words: Cardiovascular disease, Cardiovascular risk, Epidemiology, Latin America, Research, Bibliometric analysis

Citation: Jahangir E, Comandé D, Rubinstein A. Adequate antiplatelet regimen in patients on chronic anti-vitamin K treatment undergoing percutaneous coronary intervention. World J Cardiol 2011; 3(12): 383-387

Over the last half century chronic diseases have steadily increased, accounting for 60% of the estimated 58 million people who died globally in 2005[1]. By 2030 this number is expected to increase to 69% of all deaths, partially due to a combination of increased life spans and improvement in infectious disease control[2-6]. With the majority of these deaths expected to occur in low-income and middle-income countries, chronic diseases are changing from being a problem in rich countries to the main crisis in poor countries[6]. This shift is also due to the steady decrease in certain chronic disease deaths, such as cardiovascular disease (CVD), in developed countries[7-9]. Despite this projection, it has been proposed that by decreasing the death rates from chronic diseases by 2% a year, 36 million deaths could be prevented by 2015[10].

Latin America remains one of the regions with high CV mortality rates despite advances in overall development[11]. Out of all Latin American countries only Argentina, which had high mortality rates in the 1970s, has seen a decline similar to those reported in North America (-63% between 1970-1972 and 1998-2000 in Argentina, Canada, and the United States)[11]. Despite this decline, the absolute mortality rates remain higher in Argentina compared to the United States and Canada[12]. Declines have been smaller in other countries in the region such as Brazil, Chile, and Cuba (-18%, -33% and -2%, respectively)[11]. While in recent years the rates have varied less in countries in the region, it is estimated that mortality due to CVD and stroke in Latin America will increase by 145% among men and women from 1990 to 2020 as compared to only a 28% increase for women and a 50% increase for men over the same period in developed countries[11,13].

Taking into account this increasing CVD burden, we tried to ascertain the current level of CVD research in Latin America and the Caribbean (LA&C) and whether it reflected the magnitude and extent of this epidemic, through a bibliometric analysis in PubMed. We then further evaluated the number of publications in LA&C compared to the United States, Canada, and all European countries including Russia, Western Europe, China and India.


We performed a bibliometric analysis of the National Library of Medicine and the National Institute of Health PubMed database (Bethesda, MD, United States) to describe the number of publications from LA&C during 2001-2010 on May 23, 2011. Limiting our search criteria to the years 2001-2010, we searched PubMed using MeSH terms for: (1) LA&C; (2) United States and Canada; (3) all Europe including Russia; (Table 1); (4) Western Europe; (5) China; (6) India; (7) Argentina; (8) Brazil; (9) Chile; (10) Colombia; (11) Mexico; (12) CVD, including hypertension and cerebrovascular disease; and (13) clinical, epidemiological, and public health studies articles (Appendix A available online). We then searched for studies in CVD by region and specific countries by combining MeSH terms for each region and CVDs (individually combining strategies #1-11 + #12). We assessed the total number of articles on clinical, epidemiological, and public health studies by region and country (individually combining strategies #1-11 + #13), and clinical, epidemiological, and public health studies on CVDs by region and country (individually combining strategies #1-11 + #12 + #13) (Appendix A). Finally, we evaluated the number of publications in 2001 vs 2010 by region, for total publications (strategies #1-6) and in CVDs (individually combining strategies #1-6 + #12).

Table 1 European countries included in the PubMed database analysis performed February 2011.
Western EuropeEastern Europe and Russia
FranceCzech Republic
Great BritainLatvia
LiechtensteinRepublic of Belarus
LuxembourgRepublic of Georgia
MaltaRepublic of Macedonia
San MarinoSlovenia

From January 2001 through December 2010 approximately 6.7 million articles were published in PubMed worldwide. Articles from LA&C accounted for 3.63% of the total publications (243 983 publications), and of these almost 80% came from three countries: Argentina, Brazil and Mexico (Table 2). This compared with 41.56% from Europe and 26.28% from the United States and Canada. Of the articles published from Europe, the majority came from Western Europe (2 771 953 articles of the 2 798 988 total articles). China and Indian subcontinents produced 5.73% and 2.54% of the total articles, respectively. When adjusting the number of publications by population, Western Europe produced the most articles (6679 publications/1 million persons) while India produced the least (144 publications/1 million persons). The top four Latin American countries, Argentina, Brazil, Mexico, and Chile, individually produced more articles when adjusted for population than China or India (600, 574, 414 and 728 vs 287 and 144, respectively, per million population). Interestingly Chile, which produced little more than 5% of the total publications in LA&C, had the highest population-adjusted publication rate of the region (728 publications/million persons).

Table 2 Publications in Medline and Pubmed, 2001-20101.
All publicationsPopulation2PublicationsPublications/million personsWorld total (%)
Worldwide69206 734 804973100.00
China1344  385 6142875.73
India1189 171 0831442.54
All Europe + Russia8572 798 988326641.56
All of LA&C597 243 9834083.63
Western Europe4152 771 953667941.15
United States and Canada3471 770 046510026.28
Brazil203 116 5355741.73
Mexico114  47 1804140.70
Colombia45    59431320.09
Argentina42  25 1806000.37
Chile17  12 3707280.18
Cardiovascular diseases
Worldwide6920  32 8334.8100.00
China1344    34992.610.65
India1189    12941.13.94
All Europe + Russia857  12 98515.239.55
All of LA&C597    13382.24.08
Western Europe415  12 65530.538.54
United States and Canada347    761321.923.19
Brazil203    8154.02.48
Mexico114    1641.40.50
Colombia45    290.70.09
Argentina42    1052.50.32
Chile17    694.10.21

Regarding clinical, epidemiological, and public health publications worldwide, out of 283 900 articles, the United States/Canada produced 24.6% (69 844 articles) of the total, while China produced 9.63% (27 337 articles). Europe, LA&C and India published roughly the same number of articles (15 141, 12 104 and 12 469 articles, respectively).

Worldwide, in 2001-2010 there were 32 833 publications that focused on CVD. Of these, 4.08% (1338 publications) were performed in LA&C, with Argentina, Brazil and Mexico again being the largest producers (Table 2). China produced 10.65% (3499 publications) and India 3.94% (1294 publications), while the United States/Canada produced 23.19% (7613 publications) and Europe 39.55% (12 985 publications of which 12 655 were from Western Europe). The number of articles varied markedly by country with Brazil producing approximately five times as many articles on CVDs than Mexico, the country with the second highest publication rate (815 and 164 articles, respectively). However, when adjusted for population, Brazil and Chile produced the highest number of publications (4 and 4.1, respectively, per 1 million population) in LA&C. Brazil and Chile also produced more publications per million people than China or India (2.6 and 1.1, respectively) but far less than the United States/Canada and Western Europe (21.9 and 30.5, respectively). Finally, approximately half of the articles published about CVDs were clinical, epidemiological, and public health papers regardless of the region (1338 articles in LA&C; 3436 articles in the United States and Canada; 6320 articles in Europe, 1211 articles in China, and 691 articles in India).

When evaluating the trend of total publications produced in 2001 vs 2010 in LA&C, the number has doubled (15 939 in 2001 to 36 978 in 2010). CVD publications also increased substantially from 2001 compared with 2010 (41 vs 726) in LA&C. This increase in total publications was also seen in the other regions, with the United States/Canada increasing publications from 150 705 to 229 911, in Europe from 215 401 to 409 258 (Western Europe 213 024 to 405 898), in China from 15 888 to 74 613, and in India from 10 976 to 28 635.


This bibliometric analysis describes the trend in scientific publications in LA&C, highlighting the increase in articles published over the last 10 years, particularly in CVD research. Although the number of publications remain less than 5% of all articles, there is a reassuring trend which may be due to various factors including global attention on the impact of non-communicable diseases in developing countries, increased support from national public funding agencies resulting from a local shift in the political agenda of Latin American countries, and improvement in support from other international agencies[10,11,14-18]. Furthermore, we did not take into account the impact factor of the publications, which may have widened the gap of CVD publications between developing and developed countries and regions.

Some of the recent increase may be due to the establishment of research centers such as the Collaborating Centers of Excellence which have been established with support from the National Heart, Lung, and Blood Institute with the goal of conducting research to improve the prevention and management of chronic CVDs[18]. Four of these sites are in Latin America and have already begun epidemiological research investigations such as the Centro de Excelencia en Salud Cardiovascular para el Cono Sur[19]. These centers allow for further infrastructure development and planning, furthering the research needs of Latin America.

Insufficient research funding and infrastructure are some of the largest limitations in performing and publishing research in Latin America. While agencies such as the National Institutes of Health are allocating more resources for research, the reality for local and national governments in most Latin American countries involves issues such as healthcare access and coverage, not mentioning education and housing, which are higher national priorities than health research. This is a major difference compared with developed countries such as the United States, that has a human development index of 0.902 (compared with 0.775, 0.750 and 0.699 for Argentina, Brazil, and Mexico, respectively) and is able to focus more resources towards research[20]. For instance, when comparing gross domestic product (GDP) per capita, the United States ($47 284 in international dollars) has a higher GDP per capita than Argentina ($15 854), Brazil ($11 239), or Mexico ($14 430), and the percentage of the GDP devoted to research is much higher in the United States (2.67% vs 0.51%, 1.02% and 0.5%, respectively)[21,22]. Funding is not the only issue. Another limitation is the poorly developed research network and capacity with few mentors available for training young investigators as well as no established academic career structure. These limitations are slowly being overcome with institutions such as some Centers of Excellence that have set training and infrastructure building as priorities[23]. Finally, Latin American authors may be limited in publishing in English language journals because of both a language barrier and an element of bias from journals for research that has been generated in developing countries[23].

Unlike medical teaching and skills which can help serve a small community, research leads to programs that can influence populations on a wide level, influence change at a policy level, and be applied to entire populations. Therefore, data management and research are needed as part of a multi-factorial approach to effectively control chronic diseases by improving local data acquisition, and defining resource needs in resource-limited areas, and to assess what programs work in different settings. Thus, evidence-based approaches should be the basis of all actions to ensure that the resources being devoted to a program are effectively working in the community to impact on chronic diseases[24]. There are certain steps that Latin America should take to continue improving its research capability. Initially, development of the research infrastructure and capacity needs to occur as it has been argued that strengthening research capacity is one of the most powerful, cost-effective, and sustainable means of advancing health and development[25]. Infrastructure building can be facilitated by financial, political, and resource support from both local governments, regional health agencies such as the Pan American Health Organization, and local and foreign agencies such as the Global Alliance for Chronic Disease, which combines six of the world’s foremost public health research funders (United States, United Kingdom, Canada, Australia, China and India) to fund implementation research on non-communicable diseases in developing countries[26]. Furthermore, institutions should focus on developing a career track for researchers and building mentor-mentee relationships to train young investigators. Institutional mission statements need to be developed with a focus on research and training goals as well as a strong focus on national healthcare priorities. By allocating their resources towards national health priorities, Latin American institutions can improve funding while applying research-based evidence that optimizes health benefits for their community. The success of this strategy is based on a belief that, with increased local political will, further investments can be obtained, and both of these are needed to establish an effective, sustainable, and productive research community.

Local and national support can be gained by tailoring research to the needs of the particular population as well as the priorities set in the policy agenda. These agendas should be long-term plans with sustained and reliable investment[25]. This tailored research plan is important as the habits and prevalence of risk factors can differ not only between countries within a region, but also within cities or social classes[27-30]. Therefore, epidemiologic research focusing on area-specific needs to assess the burden of disease and to identify potential prevention strategies, such as community-based interventions or lifestyle changes can lead to the support of local and national organizations. Once this has been identified, research can be focused on translating the research into the best practices and disseminating the knowledge amongst governments, universities, and agencies. While it is unclear how teaching and research impacts the prognosis of CVD, by focusing on research, infrastructure building, and disease prevention we will hopefully begin to measure and see improvements in the future of Latin America’s health and put a stop to the predicted epidemic.


We would like to thank Amber E Solivan, MPH for her assistance in reviewing and editing this article. Eiman Jahangir is currently a Fogarty International Clinical Research Fellow and is supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Eye Institute, National Heart, Blood, and Lung Institute, National Institute of Dental and Craniofacial Research, National Institute On Drug Abuse, National Institute of Mental Health, National Institute of Allergy and Infectious Diseases Health, and NIH Office of Women’s Health and Research through the International Clinical Research Scholars and Fellows Program at Vanderbilt University (R24 TW007988) and the American Relief and Recovery Act.


Over the last half century, chronic diseases have steadily increased and cardiovascular disease (CVD) now accounts for 17.7 million annual deaths worldwide, constituting 11% of estimates for the global burden of disease. With increasing life spans and improved infectious disease control, the impact of chronic diseases are estimated to grow to 69% of deaths by 2030, with 80% expected in low-middle income countries. In Latin America the mortality due to CVD and stroke is estimated to increase 145% from 1990 to 2020. Understanding the prevalence of CVD and associated risk factors is key to developing policies to combat these conditions.

Research frontiers

To ensure that measures are taken to improve the future of CVD in Latin America an expansion of research and network building needs to be initiated. Studies focusing on defining the problems and designing cost-effective, high impact strategies are necessary.

Innovations and breakthroughs

Few studies have demonstrated the level of research being produced in Latin America despite the increasing burden of CVD in this area. This study outlines the level of research being produced and provides a comparison amongst highly developed and developing countries.


By understanding the type and level of research being produced from Latin America, the authors explain how further advances in research infrastructure are necessary to develop prevention strategies for this region.


A bibliometric anaylsis is the analysis of a body of literature to reveal the pattern of publications in a field.

Peer review

The authors performed a bibliometric analysis in PubMed from 2001 to 2010 for Latin America and the Caribbean, the United States, Canada, Europe, China, and India. Through this search they discovered that, while interest in chronic diseases have improved, Latin America only produced 4% of chronic disease publications worldwide. While the number of publications in CVD in Latin America has increased significantly over the last 10 years, the studies published have not been population based prospective follow up studies and typically do not represent countrywide prevalence of disease. These results are interesting and represent areas for potential research focus.


Peer reviewers: Paul Erne, MD, Professor, Head, Department of Cardiology, Luzerner Kantonsspital, CH-6000 Luzern 16, Switzerland; Hiroyasu Ueda, MD, PhD, Department of Cardiology, Sumitomo Hospital, 5-3-20,Nakanoshima, Kita-ku, Osaka 530-0005, Japan

S- Editor Cheng JX L- Editor Cant MR E- Editor Zheng XM

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