Cardiovascular disease risk prediction in sub-Saharan African populations - Comparative analysis of risk algorithms in the RODAM study

Atherosclerotic cardiovascular disease risk among Ghanaians: A comparison of the risk assessment tools

Objectives

Risk stratification is a cornerstone for preventing atherosclerotic cardiovascular disease (ASCVD). Ghana has yet to develop a locally derived and validated ASCVD risk model. A critical first step towards this goal is assessing how the commonly available risk models perform in the Ghanaian population. This study compares the agreement and correlation between four ASCVD risk assessment models commonly used in Ghana.

Methods

The Ghana Heart Study collected data from four regions in Ghana (Ashanti, Greater Accra, Northern, and Central regions) and excluded people with a self-declared history of ASCVD. The 10-year fatal/non-fatal ASCVD risk of participants aged 40-74 was calculated using mobile-based apps for Pooled Cohort Equation (PCE), laboratory-based WHO/ISH CVD risk, laboratory-based Framingham risk (FRS), and Globorisk, categorizing them as low, intermediate, or high risk. The risk categories were compared using the Kappa statistic and Spearman correlation.

Results

A total of 615 participants were included in this analysis (median age 55 [Inter quartile range 46, 64]) years with 365 (59.3 %) females. The WHO/ISH risk score categorized 504 (82.0 %), 58 (9.4 %), and 53 (8.6 %) as low-, intermediate-, and high-risk, respectively. The PCE categorized 345 (56.1 %), 181 (29.4 %), and 89 (14.5 %) as low-, intermediate- and high-risk, respectively. The Globorisk categorized 236 (38.4 %), 273 (44.4 %), and 106 (17.2 %) as low-, intermediate-, and high-risk, respectively. Significant differences in the risk categorization by region of residence and age group were noted. There was substantial agreement between the PCE vs FRS (Kappa = 0.8, 95 % CI 0.7 - 0.8), PCE vs Globorisk (Kappa = 0.6; 95 % CI 0.6 - 0.7), and FRS vs Globorisk (Kappa = 0.6; 95 % CI 0.6 - 0.7). However, there was only fair agreement between the WHO vs Globorisk (Kappa = 0.3; 95 % CI 0.3-0.4) and moderate agreement between the WHO vs PCE and WHO vs FRS.

Conclusion

There are significant differences in the ASCVD risk prediction tools in the Ghanaian population, posing a threat to primary prevention. Therefore, there is a need for locally derived and validated tools.

Evaluation of Statin Indication and Dose Intensification Among Type 2 Diabetic Patients at a Tertiary Hospital

Background

Diabetes mellitus (DM) increases cardiovascular disease (CVD) incidence and mortality. While guidelines endorse statin use in type 2 DM (T2DM) to mitigate cardiovascular risks and mortality, challenges like statin initiation and prompt treatment adjustments affect patient outcomes. This study aimed to assess the appropriateness of indications for and dose intensification of statin therapy among T2DM patients at Tikur Anbessa Specialized Hospital (TASH).

Methodology

A hospital-based cross-sectional study was conducted from April 1 to June 30 2020. In total, 405 T2DM patients were selected using a systematic random sampling technique. The data were analyzed using SPSS version 26.0. An adjusted odds ratio (OR) was used and a 95% confidence interval (CI) and p-values of <0.05 were utilized to determine statistical significance.

Results

Of the total 405 participants, 346 (85.4%) started taking statins for primary or secondary prevention purposes. Indication for statin use was appropriate in 96.2% patients, while for 216 (62.4%) patients their doses were appropriately intensified. Predictors of the inappropriateness of statin use were an atherosclerotic cardiovascular disease (ASCVD) score of ≥7.5% (AOR=0.28; 95% CI: 0.102-0.738, p=0.01), the presence of dyslipidemia (AOR=4.48; 95% CI: 1.85-10.84; p=0.001), initiation of aspirin therapy (AOR=3.7; 95% CI: 1.522-9.144; p=0.004), and an LDL-cholesterol level of 70-189 mg/dL (AOR=0.124; 95% CI: 0.042-0.365; p=0.001). DM duration of ≥10 years (AOR=2.51; 95% CI: 1.35-4.66, p=0.004), male gender (AOR=2.04; 95% CI: 1.16-3.58, p=0.013), age ≥65 years (AOR=2.15; 95% CI: 1.23-3.75, p=0.007) and uncontrolled blood pressure (AOR=2.09; 95% CI: 1.07-4.08, p=0.031) were associated with inappropriate statin intensification.

Conclusion

The study found that indication of statins was optimal and about two-thirds of patients had their doses appropriately intensified. Monitoring is needed to avoid inappropriate intensification of statin therapy, particularly in patients with longer diabetes duration, those of male gender and advanced age, and those with uncontrolled blood pressure.

No Evidence for an Association of HIV and Antiviral Treatment With Changes in Framingham Cardiovascular Risk Score in the Ndlovu Cohort Study

BACKGROUND

HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease (CVD) risk in high-income countries. The authors studied the longitudinal association between HIV and ART and nonlaboratory Framingham Risk Score (FRS) in a middle-income country.

METHODS AND RESULTS

This longitudinal analysis of the NCS (Ndlovu Cohort Study), South Africa used baseline to 36-month follow-up data. Demographics, HIV, ART status, and cardiometabolic measures were obtained. FRS was used as a CVD risk measure. Through linear mixed models, FRS trends over time and the association with HIV were studied. Analysis included 1136 participants, with 609 (54%) having HIV, and 495 (81%) taking ART. At baseline, 9.8% of participants had a high FRS. People living with HIV (PLHIV) had a 3.2% lower FRS than HIV-negative participants (P<0.001). FRS increased similarly for both groups over time. Other factors associated with FRS were secondary and higher education (ß value: -0.075, P<0.001; ß value: -0.084, P<0.001) and alcohol consumption (ß value: 0.011, P<0.001).

CONCLUSIONS

CVD risk increased for all participants over 36 months, suggesting classic risk factors rather than HIV status or ART to be drivers of CVD risk. People living with HIV had a significantly lower FRS than their HIV-negative counterparts, possibly related to HIV itself or a more frequent interaction with healthcare services. No association of HIV and ART with changes in FRS over 36 months was observed, suggesting the need for research using clinical endpoints to elucidate the effects of HIV and ART on CVD risk. Population-based prevention of CVD risk factors in sub-Saharan Africa is warranted, regardless of HIV status.

Agreement between ten-years cardiovascular disease risk assessment tools: An application to Iranian population in Shahedieh Cohort Study

Background and aim

Cardiovascular risk-prediction models are efficient primary prevention tools to detect high-risk individuals. The study aims to use three tools to estimate the 10-year risk of developing cardiovascular disease (CVD) and investigate their agreement in an Iranian adult population.

Methods

The current cross-sectional study was carried out on 8569 adults between 35 and 70 who participated in the first phase of the Shahedieh cohort study in Yazd, Iran, and were free of CVDs (cardiac ischemia or myocardial infarction or stroke). World Health Organization/International Society of Hypertension (WHO/ISH) chart, Laboratory-Based (LB) and Non-Laboratory-Based (NLB) Framingham Risk Score (FRS) were used to predict the 10-year risk of developing CVD. The agreement across tools was determined by Kappa.

Results

WHO/ISH chart indicated the highest prevalence of low CVD risk for males (96.10%) and females (96.50%), while NLB Framingham had the highest prevalence of high CVD risk for males (19.40%) and females (5.30%). In total, there was substantial agreement between both FRS models (Kappa = o.70), while there was a slight agreement between WHO/ISH and both FRS tools. For under 60 years males and females, substantial agreements were observed between FRS methods (kappa = 0.73 and kappa = 0.68). For males and females over 60 years, this agreement was moderate and substantial, respectively (kappa = 0.54 and kappa = 0.64). WHO/ISH and LB Framingham model had substantial agreement for over 60 years females (kappa = 0.61).

Conclusions

Framingham models classified more participants in the high-risk category than WHO/ISH. Due to the lethality of CVDs, categorizing individuals based on FRS can ensure that most of the real high-risk people are detected. Remarkable agreement between FRS methods in all sex-age groups suggested using the NLB Framingham model as a primary screening tool, especially in a shortage of resources condition.

Genotype-by-socioeconomic status interaction influences heart disease risk scores and carotid artery thickness in Mexican Americans: the predominant role of education in comparison to household income and socioeconomic index

Background: Socioeconomic status (SES) is a potent environmental determinant of health. To our knowledge, no assessment of genotype-environment interaction has been conducted to consider the joint effects of socioeconomic status and genetics on risk for cardiovascular disease (CVD). We analyzed Mexican American Family Studies (MAFS) data to evaluate the hypothesis that genotype-by-environment interaction (GxE) is an important determinant of variation in CVD risk factors. Methods: We employed a linear mixed model to investigate GxE in Mexican American extended families. We studied two proxies for CVD [Pooled Cohort Equation Risk Scores/Framingham Risk Scores (FRS/PCRS) and carotid artery intima-media thickness (CA-IMT)] in relation to socioeconomic status as determined by Duncan's Socioeconomic Index (SEI), years of education, and household income. Results: We calculated heritability for FRS/PCRS and carotid artery intima-media thickness. There was evidence of GxE due to additive genetic variance heterogeneity and genetic correlation for FRS, PCRS, and CA-IMT measures for education (environment) but not for household income or SEI. Conclusion: The genetic effects underlying CVD are dynamically modulated at the lower end of the SES spectrum. There is a significant change in the genetic architecture underlying the major components of CVD in response to changes in education.

Community Health Worker-Led Cardiovascular Disease Risk Screening and Referral for Care and Further Management in Rural and Urban Communities in Rwanda

Cardiovascular disease (CVD) is a global health issue. Low- and middle-income countries (LMICs) are facing early CVD-related morbidity. Early diagnosis and treatment are an effective strategy to tackle CVD. The aim of this study was to assess the ability of community health workers (CHWs) to screen and identify persons with high risks of CVD in the communities, using a body mass index (BMI)-based CVD risk assessment tool, and to refer them to the health facility for care and follow-up. This was an action research study conducted in rural and urban communities, conveniently sampled in Rwanda. Five villages were randomly selected from each community, and one CHW per each selected village was identified and trained to conduct CVD risk screening using a BMI-based CVD risk screening tool. Each CHW was assigned to screen 100 fellow community members (CMs) for CVD risk and to refer those with CVD risk scores ≥10 (either moderate or high CVD risk) to a health facility for care and further management. Descriptive statistics with Pearson's chi-square test were used to assess any differences between rural and urban study participants vis-à-vis the key studied variables. Spearman's rank coefficient and Cohen's Kappa coefficient were mainly used to compare the CVD risk scoring from the CHWs with the CVD risk scoring from the nurses. Community members aged 35 to 74 years were included in the study. The participation rates were 99.6% and 99.4% in rural and urban communities, respectively, with female predominance (57.8% vs. 55.3% for rural and urban, p-value: 0.426). Of the participants screened, 7.4% had a high CVD risk (≥20%), with predominance in the rural community compared to the urban community (8.0% vs. 6.8%, p-value: 0.111). Furthermore, the prevalence of moderate or high CVD risk (≥10%) was higher in the rural community than in the urban community (26.7% vs. 21.1%, p-value: 0.111). There was a strong positive correlation between CHW-based CVD risk scoring and nurse-based CVD risk scoring in both rural and urban communities, 0.6215 (p-value < 0.001) vs. 0.7308 (p-value = 0.005). In regard to CVD risk characterization, the observed agreement to both the CHW-generated 10-year CVD risk assessment and the nurse-generated 10-year CVD risk assessment was characterized as "fair" in both rural and urban areas at 41.6% with the kappa statistic of 0.3275 (p-value < 001) and 43.2% with kappa statistic of 0.3229 (p-value =0.057), respectively. In Rwanda, CHWs can screen their fellow CMs for CVD risk and link those with high CVD risk to the healthcare facility for care and follow-up. CHWs could contribute to the prevention of CVDs through early diagnosis and early treatment at the bottom of the health system.

Low Subjective Cardiovascular Disease Risk Perceptions among Hypertensive Patients in Addis Ababa, Ethiopia

Background

Accurate cardiovascular disease (CVD) risk appraisal is essential for hypertensive patients to identify correctly their risk status and take efficient behavioral measures timely to avoid major adverse outcomes. However, hypertensive patients’ risk perceptions of CVD events in Ethiopia are unknown. Thus, the study aimed to compare the subjective CVD risk perception level of patients with the nonlaboratory Framingham Risk Score (nl-FRS).

Methods

A cross-sectional design was used. The Attitudes and Beliefs about Cardiovascular Disease Risk Questionnaire and the nl-FRS were used to compare subjective versus objective measures of CVD risk. Agreement between participants’ risk perceptions and the nl-FRS were examined using the kappa statistic. Bivariate chi-square test and multinomial logistic regression analyses were run to identify factors associated with risk perceptions. The statistical significance was set at a p-value < 0.05 level.

Results

Participants (n=377) had a mean age of 53.61 ± 12.80-years, range (18–82 years), 51.2% were males, 42.7% had less than high school education, 45.1% achieved target BP control, and mean HTN duration was 8.01 ± 6.07 years. The majority (58.62%) of the participants had a low subjective risk perception of CVD events (mean 17.79, 95% CI: 17.43–18.15). Approximately three-fourths (72.4%) had a moderate nl-FRS risk calculation (mean, 13.84, 95% CI: 13.36–14.33). Agreement between participants perceived-risk and the nl-FRS was poor (kappa = 0.0002, standard error = 0.023, p =0.99). Participants’ CVD risk-perception inaccuracy was also high (76%) primarily due to underestimation. Hypertension duration, frequency of physician visits, and level of diabetes control were significant predictors of CVD risk underestimation.

Conclusion

Hypertensive patients had inaccurate and low subjective risk perceptions of CVD events compared to moderate objective risks identified using the nl-FRS. Planned education on HTN and CVD risk factors is essential to improve patients’ CVD risk perception to reduce adverse CVD events.

Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys

Background

Reducing maternal mortality is a priority of Sustainable Development Goal 3.1 which requires frequent epidemiological analysis of trends and patterns of the causes of maternal deaths. We conducted two reproductive age mortality surveys to analyse the epidemiology of maternal mortality in Zimbabwe and analysed the changes in the causes of deaths between 2007-08 and 2018-19.

Methods

We performed a before and after analysis of the causes of death among women of reproductive ages (WRAs) (12-49 years), and pregnant women from the two surveys implemented in 11 districts, selected using multi-stage cluster sampling from each province of Zimbabwe (n=10); an additional district selected from Harare. We calculated mortality incidence rates and incidence rate ratios per 10000 WRAs and pregnant women (with 95% confidence intervals), in international classification of disease groups, using negative binomial models, and compared them between the two surveys. We also calculated maternal mortality ratios, per 100 000 live births, for selected causes of pregnancy-related deaths.

Results

We identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in the WRAs decreased by 82% in diseases of the respiratory system and 81% in certain infectious or parasitic diseases' groups, which include HIV/AIDS and malaria. Pregnancy-related deaths decreased by 84% in the indirect causes group and by 61% in the direct causes group, and HIV/AIDS-related deaths decreased by 91% in pregnant women. Direct causes of death still had a three-fold MMR than indirect causes (151 vs. 51 deaths per 100 000) in 2018-19.

Conclusion

Zimbabwe experienced a decline in both direct and indirect causes of pregnancy-related deaths. Deaths from indirect causes declined mainly due to a reduction in HIV/AIDS-related and malaria mortality, while deaths from direct causes declined because of a reduction in obstetric haemorrhage and pregnancy-related infections. Ongoing interventions ought to improve the coverage and quality of maternal care in Zimbabwe, to further reduce deaths from direct causes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13321-7.

Comparison of laboratory-based and non-laboratory-based WHO cardiovascular disease risk charts: a population-based study

Background

Determining the risk of Cardiovascular Disease (CVD) is a necessity for timely preventive interventions in high-risk groups. However, laboratory testing may be impractical in countries with limited resources. This study aimed at comparison and assessment of the agreement between laboratory-based and non-laboratory-based WHO risk charts models.

Methods

This study was performed using the baseline data of 8138 participants in the pars cohort study who had no history of CVD and stroke. The updated 2019 WHO model was used to determine the 10-year fatal and non-fatal CVD risks. In general, there are two types of new WHO risk prediction models for CVD. The scores were determined based on age, sex, smoking status, diabetes, Systolic Blood Pressure (SBP), and total cholesterol for the laboratory-based model and age, sex, smoking status, SBP, and Body Mass Index (BMI) for the non-laboratory-based model. The agreement of these two models was determined via kappa statistics for the classified risk (low: < 10%, moderate: 10–< 20%, high: ≥ 20%). Correlation coefficients (r) and scatter plots was used for correlation between scores.

Results

The results revealed very strong correlation coefficients for all sex and age groups (r = 0.84 for males < 60 years old, 0.93 for males ≥ 60 years old, 0.85 for females < 60 years old, and 0.88 for females ≥ 60 years old). In the laboratory-based model, low, moderate, and high risks were 76.10%, 18.17%, and 5.73%, respectively. These measures were respectively obtained as 77.00%, 18.08%, and 4.92% in the non-laboratory-based model. Based on risk classification, the agreement was substantial for males < 60 years old and for both males and females aged ≥ 60 years (kappa values: 0.79 for males < 60 years old, 0.65 for males ≥ 60 years old, and 0.66 for females ≥ 60 years old) and moderate for females < 60 years old (kappa = 0.46).

Conclusions

The non-laboratory-based risk prediction model, which is simple, inexpensive, and non-invasive, classifies individuals almost identically to the laboratory-based model. Therefore, in countries with limited resources, these two models can be used interchangeably.

Risk prediction models for atherosclerotic cardiovascular disease: A systematic assessment with particular reference to Qatar

Background: Atherosclerotic cardiovascular disease (ASCVD) is a common disease in the State of Qatar and results in considerable morbidity, impairment of quality of life and mortality. The American College of Cardiology/American Heart Association Pooled Cohort Equations (PCE) is currently used in Qatar to identify those at high risk of ASCVD. However, it is unclear if this is the optimal ASCVD risk prediction model for use in Qatar's ethnically diverse population.

Aims: This systematic review aimed to identify, assess the methodological quality of and compare the properties of established ASCVD risk prediction models for the Qatari population.

Methods: Two reviewers performed head-to-head comparisons of established ASCVD risk calculators systematically. Studies were independently screened according to predefined eligibility criteria and critically appraised using Prediction Model Risk Of Bias Assessment Tool. Data were descriptively summarized and narratively synthesized with reporting of key statistical properties of the models.

Results: We identified 20,487 studies, of which 41 studies met our eligibility criteria. We identified 16 unique risk prediction models. Overall, 50% (n = 8) of the risk prediction models were judged to be at low risk of bias. Only 13% of the studies (n = 2) were judged at low risk of bias for applicability, namely, PREDICT and QRISK3.Only the PREDICT risk calculator scored low risk in both domains.

Conclusions: There is no existing ASCVD risk calculator particularly well suited for use in Qatar's ethnically diverse population. Of the available models, PREDICT and QRISK3 appear most appropriate because of their inclusion of ethnicity. In the absence of a locally derived ASCVD for Qatar, there is merit in a formal head-to-head comparison between PCE, which is currently in use, and PREDICT and QRISK3.

Implications of weight gain with newer anti-retrovirals: 10-year predictions of cardiovascular disease and diabetes

OBJECTIVE

To evaluate the long-term risks of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) secondary to weight gain and clinical obesity associated with the initiation of integrase strand transfer inhibitors and tenofovir alafenamide (TAF) in the ADVANCE trial using validated risk equation tools.

DESIGN

Retrospective data analysis.

METHODS

In ADVANCE, 1053 treatment-naive participants in South Africa (99% black, 59% female) were randomized to 96 weeks of TAF/emtricitabine + dolutegravir (TAF/FTC + DTG), tenofovir disoproxil fumarate/FTC + DTG (TDF/FTC + DTG), or TDF/FTC + efavirenz (TDF/FTC/EFV). The 5 and 10-year risks of CVD were calculated using D:A:D, QRISK and Framingham, and T2DM risk using QDiabetes, Cambridge Diabetes and Leicester Practice Risk scores. Participants were included in this analysis if they were above 30 years old at baseline.

RESULTS

A total of 217 (TAF/FTC + DTG), 218 (TDF/FTC + DTG), and 215 (TDF/FTC/EFV) participants had 96-week data available. Weight gain was +8.1, +4.2, and +2.4 kg on TAF/FTC + DTG, TDF/FTC + DTG, and TDF/FTC/EFV, respectively. Participants on TAF/FTC + DTG had greatest risk scores for CVD (using QRISK) and T2DM, driven by weight changes. Differences were statistically significant between TAF/FTC + DTG and TDF/FTC/EFV for CVD risk using the QRISK equation, equivalent to one extra case per 1000 people treated over 10 years, and between all treatment groups for T2DM risk. Six extra T2DM cases were predicted on TAF/FTC + DTG vs. TDF/FTC + DTG using QDiabetes.

CONCLUSION

Obesity, especially with TAF/FTC + DTG, drove increased risk of T2DM, with some evidence of greater CVD risk. However, predictive tools have not been validated in the HIV-positive and black African population.

Geographic and Sociodemographic Disparities in Cardiovascular Risk in Burkina Faso: Findings from a Nationwide Cross-Sectional Survey

Background

Cardiovascular disease (CVD) risk assessment is a critical step in the current approach to the primary prevention of CVD, particularly in low-income countries such as Burkina Faso. In this study, we aimed to assess the geographic and sociodemographic disparities of the ten-year cardiovascular risk in Burkina Faso.

Methods

We conducted a secondary analysis of the data from the first nationwide survey using the World Health Organization (WHO) STEPwise approach. Ten-year cardiovascular risk was determined using the WHO 2019 updated risk chart (WHO risk) as main outcome, and the Framingham risk score (FRS) and the Globorisk chart for secondary outcomes. We performed a modified Poisson regression model using a generalized estimating equation to examine the association between CVD risk and sociodemographic characteristics.

Results

A total of 3081 participants aged 30 to 64 years were included in this analysis. The overall age and sex-standardized mean of absolute ten-year cardiovascular risk assessed using the WHO risk chart was 2.5% (95% CI: 2.4–2.6), ranging from 2.3% (95% CI: 2.2–2.4) in Centre Est to 3.0% (95% CI: 2.8–3.2) in the Centre region. It was 4.6% (95% CI: 4.4–4.8) for FRS and 4.0% (95% CI: 3.8–4.1) for Globorisk. Regarding categorized CVD risk (absolute risk ≥10%), we found out that the age and sex-standardized prevalence of elevated risk was 1.7% (95% CI: 1.3–2.1) for WHO risk, 10.4% (95% CI: 9.6–11.2) for FRS, and 5.9% (95% CI: 5.1–6.6) for Globorisk. For all of the three risk scores, elevated CVD risk was associated with increasing age, men, higher education, urban residence, and health region (Centre).

Conclusion

We found sociodemographic and geographic inequalities in the ten-year CVD risk in Burkina Faso regardless of risk score used. Therefore, population-wide interventions are needed to improve detection and management of adult in the higher CVD risk groups in Burkina Faso.

Estimating the burden of cardiovascular risk in community dwellers over 40 years old in South Africa, Kenya, Burkina Faso and Ghana

Introduction

Cardiovascular disease (CVD) risk factors are increasing in sub-Saharan Africa. The impact of these risk factors on future CVD outcomes and burden is poorly understood. We examined the magnitude of modifiable risk factors, estimated future CVD risk and compared results between three commonly used 10-year CVD risk factor algorithms and their variants in four African countries.

Methods

In the Africa-Wits-INDEPTH partnership for Genomic studies (the AWI-Gen Study), 10 349 randomly sampled individuals aged 40–60 years from six sites participated in a survey, with blood pressure, blood glucose and lipid levels measured. Using these data, 10-year CVD risk estimates using Framingham, Globorisk and WHO-CVD and their office-based variants were generated. Differences in future CVD risk and results by algorithm are described using kappa and coefficients to examine agreement and correlations, respectively.

Results

The 10-year CVD risk across all participants in all sites varied from 2.6% (95% CI: 1.6% to 4.1%) using the WHO-CVD lab algorithm to 6.5% (95% CI: 3.7% to 11.4%) using the Framingham office algorithm, with substantial differences in risk between sites. The highest risk was in South African settings (in urban Soweto: 8.9% (IQR: 5.3–15.3)). Agreement between algorithms was low to moderate (kappa from 0.03 to 0.55) and correlations ranged between 0.28 and 0.70. Depending on the algorithm used, those at high risk (defined as risk of 10-year CVD event >20%) who were under treatment for a modifiable risk factor ranged from 19.2% to 33.9%, with substantial variation by both sex and site.

Conclusion

The African sites in this study are at different stages of an ongoing epidemiological transition as evidenced by both risk factor levels and estimated 10-year CVD risk. There is low correlation and disparate levels of population risk, predicted by different risk algorithms, within sites. Validating existing risk algorithms or designing context-specific 10-year CVD risk algorithms is essential for accurately defining population risk and targeting national policies and individual CVD treatment on the African continent.

Comparison of Predicted Cardiovascular Risk Profiles by Different CVD Risk-Scoring Algorithms between HIV-1-Infected and Uninfected Adults: A Cross-Sectional Study in Tanzania

Purpose

Cardiovascular disease (CVD) risk assessment is a suitable way to differentiate between high-risk individuals requiring intervention and risk modification, and those at low risk. However, concerns have been raised when adopting a CVD-risk prediction algorithm for HIV-infected patients in sub-Saharan Africa.

Patients and Methods

We compared cardiovascular risk profiles between HIV-infected (with and without antiretroviral therapy (ART)) and HIV-uninfected adults as predicted by the American College of Cardiology/American Heart Association (ASCVD) and the Framingham cardiovascular risk score (FRS) algorithms and assessed the concordance of the algorithms in predicting 10-year CVD risk separately in HIV-infected and uninfected groups in a hospital-based cross-sectional study in Tanzania. A cross-sectional hospital-based study including 40 HIV-infected ART-naive, 64 HIV-infected on ART, and 50 HIV-uninfected adults was conducted. Traditional cardiovascular risk factors were determined by standard investigations. The primary outcome was the absolute 10-year CVD risk score based on the two algorithms.

Results

Compared to HIV-uninfected, HIV-infected adults were classified at a higher 10-year CVD risk. ASCVD algorithms predicted a higher proportion of high-risk individuals compared to FRS in both HIV-infected and uninfected groups. The concordance between ASCVD and FRS-lipid algorithms was reasonable for both HIV-infected and uninfected groups though relatively higher in the HIV-uninfected group.

Conclusion

HIV-infected individuals have a higher 10-year cardiovascular risk compared to HIV-uninfected persons. The concordance between ASCVD and FRS-lipid algorithms is reasonable in both HIV-uninfected and infected persons in Tanzania. Development of an HIV-specific algorithm is needed to accurately predict CVD risk in this population at high-risk.

Assessment of cardiovascular disease risks using Framingham risk scores (FRS) in HIV-positive and HIV-negative older adults in South Africa

The relationship between HIV and cardiovascular diseases (CVDs) remains complex. The aim of this study was to estimate the 10-year CVD risk among HIV-positive and HIV-negative people. The validated Framingham Risk Score (FRS) based on the Framingham Heart study was used to predict the CVD risk. Data for this analysis came from a 2016 cross-sectional study of South African community-dwelling older adults (≥50 years). Logistic regression models were constructed to assess the association between CVD risk and HIV. 403 respondents with a mean age 60 (SD = 6.7) years were enrolled, of whom 70% were female, 75% black African, 21.9% smokers, 77.2% never did any vigorous physical activity, and 17% were HIV-positive. The average 10-year CVD risk was 17%; significantly higher in men than women (23.2 vs 14.3%, p < 0.001). Overall, 33% had low CVD risk (FRS < 10%), 39% intermediate (FRS 10-19%) and 28% high risk (FRS ≥ 20%). Furthermore, participants who were HIV-positive were less likely than HIV-negative participants to have high CVD risk (aOR 0.27, 95% CI 0.11-0.66, p = 0.004). These findings of HIV-positive respondents having lower CVD risk than HIV-negative respondents could be due to three issues i) HIV-positive people having lesser cardio-metabolic disease risk factors; ii) possibly higher health care utilization by HIV-positive people; and/or iii) the neglect of HIV-negative people in HIV focused health systems. Periodic cardiovascular disease monitoring using tools like the Framingham Risk Scores is needed. Furthermore, studies with more robust designs are needed to further elucidate the relationship between HIV and CVD risks in HIV endemic sub-Saharan Africa.

Agreement between laboratory-based and non-laboratory-based Framingham risk score in Southern Iran

The Framingham 10-year cardiovascular disease risk is measured by laboratory-based and non-laboratory-based models. This study aimed to determine the agreement between these two models in a large population in Southern Iran. In this study, the baseline data of 8138 individuals participated in the Pars cohort study were used. The participants had no history of cardiovascular disease or stroke. For the laboratory-based risk model, scores were determined based on age, sex, current smoking, diabetes, systolic blood pressure (SBP) and treatment status, total cholesterol, and High-Density Lipoprotein. For the non-laboratory-based risk model, scores were determined based on age, sex, current smoking, diabetes, SBP and treatment status, and Body Mass Index. The agreement between these two models was determined by Bland Altman plots for agreement between the scores and kappa statistic for agreement across the risk groups. Bland Altman plots showed that the limits of agreement were reasonable for females < 60 years old (95% CI: −2.27–4.61%), but of concern for those ≥ 60 years old (95% CI: −3.45–9.67%), males < 60 years old (95% CI: −2.05–8.91%), and males ≥ 60 years old (95% CI: −3.01–15.23%). The limits of agreement were wider for males ≥ 60 years old in comparison to other age groups. According to the risk groups, the agreement was better in females than in males, which was moderate for females < 60 years old (kappa = 0.57) and those ≥ 60 years old (kappa = 0.51). The agreement was fair for the males < 60 years old (kappa = 0.39) and slight for those ≥ 60 years old (Kappa = 0.14). The results showed that in overall participants, the agreement between the two risk scores was moderate according to risk grouping. Therefore, our results suggest that the non-laboratory-based risk model can be used in resource-limited settings where individuals cannot afford laboratory tests and extensive laboratories are not available.

Associations between low HDL, sex and cardiovascular risk markers are substantially different in sub-Saharan Africa and the UK: analysis of four population studies

INTRODUCTION

Low high-density lipoprotein (HDL) is widely used as a marker of cardiovascular disease risk, although this relationship is not causal and is likely mediated through associations with other risk factors. Low HDL is extremely common in sub-Saharan African populations, and this has often been interpreted to indicate that these populations will have increased cardiovascular risk. We aimed to determine whether the association between HDL and other cardiovascular risk factors differed between populations in sub-Saharan Africa and the UK.

METHODS

We compared data from adults living in Uganda and Malawi (n=26 216) and in the UK (n=8747). We examined unadjusted and adjusted levels of HDL and applied the WHO recommended cut-offs for prevalence estimates. We used spline and linear regression to assess the relationship between HDL and other cardiovascular risk factors.

RESULTS

HDL was substantially lower in the African than in the European studies (geometric mean 0.9-1.2 mmol/L vs 1.3-1.8 mmol/L), with African prevalence of low HDL as high as 77%. Total cholesterol was also substantially lower (geometric mean 3.3-3.9 mmol/L vs 4.6-5.4 mmol/L). In comparison with European studies the relationship between HDL and adiposity (body mass index, waist to hip ratio) was greatly attenuated in African studies and the relationship with non-HDL cholesterol reversed: in African studies low HDL was associated with lower non-HDL cholesterol. The association between sex and HDL was also different; using the WHO sex-specific definitions, low HDL was substantially more common among women (69%-77%) than men (41%-59%) in Uganda/Malawi.

CONCLUSION

The relationship between HDL and sex, adiposity and non-HDL cholesterol in sub-Saharan Africa is different from European populations. In sub-Saharan Africans low HDL is a marker of low overall cholesterol and sex differences are markedly attenuated. Therefore low HDL in isolation is unlikely to indicate raised cardiovascular risk and the WHO sex-based cut-offs are inappropriate.

Differences in the Cardiovascular Risk Assessment in Cardiology Outpatients in Mali: Comparison between Framingham Body Mass Index-Based Tool and Low-Information World Health Organization Chart

Objective. This study aimed to compare 2 laborless tools, namely, the body mass index-based Framingham (bmi-Frm) and low-information WHO- (li-WHO-) based risk scores, and assess their agreement in outpatients in a cardiology department. Methodology. Data stem from a cross-sectional previous study performed from May to September 2016 in the Cardiology Department of University Hospital Gabriel Touré (UH-GT) in Bamako. All patients aged 40 and more were included in the study allowing the assessment of bmi-Frm and li-WHO prediction charts. The cardiovascular risk (CVR) was evaluated using a calculator prepared by D‘Agostino et al. for the bmi-Frm and the li-WHO chart for the Afro-D region of the WHO. The risk score for both ranged from <10 to ≥40. The data were entered in an ACCESS 2010 database, then processed by MS Excel 2010, and finally analysed using IBM SPSS Statistics 20. Continuous variables were presented as means and standard deviations, and categorical variables were presented as frequencies with percentages. $P<0.05$ was considered the statistical significance level. After sample description, the risk score was assessed using bmi-Frm and li-WHO prediction tools. Finally, a kappa test was performed to check for the interreliability of both methods. For weighted kappa, coefficients were given all five classes of risk groups in 0, 25 steps from 1 for total concordance to 0 for total discordance. Results. This study involved 793 outpatients, 63.7% being female, 35.1% of them younger than 50 years, 57.9% with no formal education, and 67.7% with no medical insurance. Means for age, body mass index (BMI), and systolic blood pressure (SBP) were, respectively, 53.81 ± 16.729 years, 25.29 ± 06.151 kg/m2, and 139.49 ± 27.110 mm Hg. Using the li-WHO prediction chart gives a much higher proportion of low-risk patients compared to bmi-Frm (83.6 vs. 37.7). Sociodemographic characteristics such as education or income level were not different in risk score neither for the bmi-Frm nor for the li-WHO risk score. The percentage of agreement between both tools was 40.4%, and agreement (kappa of 0.1 and weighted kappa of 0.2) was found to be slight. Conclusion. Using the bmi-Frm and li-WHO tool gives a similar risk estimation in younger female patients. Older patients must be evaluated using high-information tools with cholesterol, e.g., versions of the Framingham risk equation or WHO using cholesterol. These must be confirmed in further studies and compared to data from prospective studies

Poor cardiovascular health is associated with subclinical atherosclerosis in apparently healthy sub-Saharan African populations: an H3Africa AWI-Gen study

BACKGROUND

The cardiovascular health index (CVHI) introduced by the American Heart Association is a valid, accessible, simple, and translatable metric for monitoring cardiovascular health in a population. Components of the CVHI include the following seven cardiovascular risk factors (often captured as life's simple 7): smoking, dietary intake, physical activity, body mass index, blood pressure, glucose, and total cholesterol. We sought to expand the evidence for its utility to under-studied populations in sub-Saharan Africa, by determining its association with common carotid intima-media thickness (CIMT).

METHODS

We conducted a cross-sectional study involving 9011 participants drawn from Burkina Faso, Ghana, Kenya, and South Africa. We assessed established classical cardiovascular risk factors and measured carotid intima-media thickness of the left and right common carotid arteries using B-mode ultrasonography. Adjusted multilevel mixed-effect linear regression was used to determine the association of CVHI with common CIMT. In the combined population, an individual participant data meta-analyses random-effects was used to conduct pooled comparative sub-group analyses for differences between countries, sex, and socio-economic status.

RESULTS

The mean age of the study population was 51 ± 7 years and 51% were women, with a mean common CIMT of 637 ± 117 μm and CVHI score of 10.3 ± 2.0. Inverse associations were found between CVHI and common CIMT (β-coefficients [95% confidence interval]: Burkina Faso, - 6.51 [- 9.83, - 3.20] μm; Ghana, - 5.42 [- 8.90, - 1.95]; Kenya, - 6.58 [- 9.05, - 4.10]; and South Africa, - 7.85 [- 9.65, - 6.05]). Inverse relations were observed for women (- 4.44 [- 6.23, - 2.65]) and men (- 6.27 [- 7.91, - 4.64]) in the pooled sample. Smoking (p < 0.001), physical activity (p < 0.001), and hyperglycemia (p < 0.001) were related to CIMT in women only, while blood pressure and obesity were related to CIMT in both women and men (p < 0.001).

CONCLUSION

This large pan-African population study demonstrates that CVHI is a strong marker of subclinical atherosclerosis, measured by common CIMT and importantly demonstrates that primary prevention of atherosclerotic cardiovascular disease in this understudied population should target physical activity, smoking, obesity, hypertension, and hyperglycemia.

Literature review and methodological considerations for understanding circulating risk biomarkers following trauma exposure

Exposure to traumatic events is common. While many individuals recover following trauma exposure, a substantial subset develop adverse posttraumatic neuropsychiatric sequelae (APNS) such as posttraumatic stress, major depression, and regional or widespread chronic musculoskeletal pain. APNS cause substantial burden to the individual and to society, causing functional impairment and physical disability, risk for suicide, lost workdays, and increased health care costs. Contemporary treatment is limited by an inability to identify individuals at high risk of APNS in the immediate aftermath of trauma, and an inability to identify optimal treatments for individual patients. Our purpose is to provide a comprehensive review describing candidate blood-based biomarkers that may help to identify those at high risk of APNS and/or guide individual intervention decision-making. Such blood-based biomarkers include circulating biological factors such as hormones, proteins, immune molecules, neuropeptides, neurotransmitters, mRNA, and noncoding RNA expression signatures, while we do not review genetic and epigenetic biomarkers due to other recent reviews of this topic. The current state of the literature on circulating risk biomarkers of APNS is summarized, and key considerations and challenges for their discovery and translation are discussed. We also describe the AURORA study, a specific example of current scientific efforts to identify such circulating risk biomarkers and the largest study to date focused on identifying risk and prognostic factors in the aftermath of trauma exposure.

Comparative performance of pooled cohort equations and Framingham risk scores in cardiovascular disease risk classification in a slum setting in Nairobi Kenya

BACKGROUND

Cardiovascular diseases (CVD) cause 18 million deaths annually. Low- and middle-income countries (LMICs) account for 80% of the CVD burden, and the burden is expected to grow in the region in the coming years. Screening for and identification of individuals at high risk for CVD in primary care settings can be accomplished using available CVD risk scores. However, few of these scores have been validated/recalibrated for use in sub-Saharan Africa (SSA).

METHODS

Pooled cohort equations (PCE) and Framingham risk scores for 10-year CVD risk were applied on 1960 men and women aged 40 years and older from the AWI-Gen (Africa, Wits-INDEPTH Partnership for GENomic studies) study 2015. Low, moderate/intermediate or high CVD risk classifications correspond to <10%, 10-20% and >20% chance of developing CVD in 10 years respectively. Agreement between the risk scores was assessed using kappa and correlation coefficients.

RESULTS

High CVD risk was 10.3% in PCE 2013, 0.4% in PCE 2018, 2.9% in Framingham and 3.6% in Framingham non-laboratory scores. Conversely, low CVD risk was 62.2% in PCE 2013 and 95.6% in PCE 2018, 84.0% and 80.1% in Framingham and Framingham non-laboratory scores, respectively. A moderate agreement existed between the Framingham functions (kappa = 0.64, 95% CI 0.59-0.68, correlation, rs = 0.711). There was no agreement between the PCE 2013 and 2018 functions (kappa = 0.05, 95% CI 0.04-0.06).

CONCLUSIONS

Newer cohort-based data is necessary to validate and recalibrate existing CVD risk scores in order to develop appropriate functions for use in SSA.

Obesity and cardiovascular disease risk among Africans residing in Europe and Africa: the RODAM study

BACKGROUND

The association between anthropometric variables and cardiovascular disease (CVD) risk among Africans is unclear. We examined the discriminative ability of anthropometric variables and estimate cutoffs for predicting CVD risk among Africans.

METHODS

The Research on Obesity and Diabetes among African Migrants (RODAM) study was a multisite cross-sectional study of Africans in Ghana and Europe. We calculated AHA/ACC Pooled Cohort Equations (PCE) scores for 3661 participants to ascertain CVD risk, and compared a body shape index (ABSI), body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), Relative Fat Mass (RFM), and Waist to Height Ratio (WHtR). Logistic regression and receiver operating curve analyses were performed to derive cutoffs for identifying high predicted CVD risk (PCE score ≥7.5%).

RESULTS

Among men, WC (adjusted Odds Ratio (aOR): 2.25, 95% CI; 1:50-3:37) was strongly associated with CVD risk. Among women, WC (aOR: 1.69, 95% CI: 1:33-2:14) also displayed the strongest association with CVD risk in the BMI-adjusted model but WHR displayed the strongest fit. All variables were superior discriminators of high CVD risk in men (c-statistic range: 0.887-0.891) than women (c-statistic range: 0.677-0.707). The optimal WC cutoff for identifying participants at high CVD risk was 89 cm among men and identified the most cases (64%). Among women, the recommended WC cutoff of 94 cm or WHR cutoff of 0.90 identified the most cases (92%).

CONCLUSIONS

Anthropometric variables were stronger discriminators of high CVD risk in African men than women. Greater WC was associated with high CVD risk in men while WHR and WC were associated with high CVD risk in women.

Hyperuricaemia and its association with 10-year risk of cardiovascular disease among migrant and non-migrant African populations: the RODAM study

OBJECTIVE

In the advent of rapid urbanisation, migration and epidemiological transition, the extent to which serum uric acid (sUA) affects cardiovascular disease (CVD) risk among Africans is not well understood. We assessed differences in sUA levels and associations with CVD risk among migrant Ghanaians in Europe and non-migrant Ghanaians in rural and urban Ghana.

METHODS

Baseline data from 633 rural, 916 urban and 2315 migrant participants (40-70 years) from the cross-sectional RODAM study were analysed. Hyperuricaemia was defined as sUA >7 mg/dl in men and >6 mg/dl in women. The 10-year risk of atherosclerotic cardiovascular disease (ASCVD) was calculated using the American College of Cardiology (ACC)/American Heart Association (AHA) risk score which takes into account ethnic minority populations. High CVD risk was defined as ASCVD risk scores ≥7.5%. Logistic regressions were used to assess associations between hyperuricaemia and CVD risk.

RESULTS

Prevalence for hyperuricaemia in rural, urban and migrant participants was 17.4%, 19.1% and 31.7% for men, and 15.9%, 18.2% and 33.2% for women, respectively. Hyperuricaemia was positively associated with elevated CVD risk among rural residents (adjusted OR for men 3.28, 95% CI: 1.21-8.96, 6.36, 95% CI: 2.98-13.56 for women), urban residents (1.12, 95% CI: 0.45-2.81 for men, 2.11, 95% CI: 1.26-3.52 for women) and migrants (1.73, 95% CI: 1.01-2.96 for men, 4.61, 95% CI: 3.05-6.97 for women).

CONCLUSION

Our study shows variations of sUA levels in different African contexts. Hyperuricaemia is associated with elevated 10-year CVD risk in both migrants and non-migrants. Further studies should identify factors driving associations between sUA and CVD risk in Africans.

Early-life exposures and cardiovascular disease risk among Ghanaian migrant and home populations: the RODAM study

Early-life environmental and nutritional exposures are considered to contribute to the differences in cardiovascular disease (CVD) burden. Among sub-Saharan African populations, the association between markers of early-life exposures such as leg length and sitting height and CVD risk is yet to be investigated. This study assessed the association between leg length, sitting height, and estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk among Ghanaian-born populations in Europe and Ghana. We constructed sex-specific quintiles for sitting height and leg length for 3250 participants aged 40-70 years (mean age 52 years; men 39.6%; women 60.4%) in the cross-sectional multicenter Research on Diabetes and Obesity among African Migrants study. Ten-year risk of ASCVD was estimated using the Pooled Cohort Equations; risk ≥7.5% was defined as "elevated" CVD risk. Prevalence ratios (PR) were estimated to determine the associations between sitting height, leg length, and estimated 10-year ASCVD risk. For both men and women, mean sitting height and leg length were highest in Europe and lowest in rural Ghana. Sitting height was inversely associated with 10-year ASCVD risk among all women (PR for 1 standard deviation increase of sitting height: 0.75; 95% confidence interval: 0.67, 0.85). Among men, an inverse association between sitting height and 10-year ASCVD risk was significant on adjustment for study site, adult, and parental education but attenuated when further adjusted for height. No association was found between leg length and estimated 10-year ASCVD risk. Early-life and childhood exposures that influence sitting height could be the important determinants of ASCVD risk in this adult population.

Estimation of cardiovascular risk based on total cholesterol versus total cholesterol/high-density lipoprotein within different ethnic groups: The HELIUS study

Aims

European guidelines recommend estimating cardiovascular disease risk using the Systematic COronary Risk Evaluation (SCORE) algorithm. Two versions of SCORE are available: one based on the total cholesterol/high-density lipoprotein cholesterol ratio, and one based on total cholesterol alone. Cardiovascular risk classification between the two algorithms may differ, particularly among ethnic minority groups with a lipid profile different from the ethnic majority groups among whom the SCORE algorithms were validated. Thus in this study we determined whether discrepancies in cardiovascular risk classification between the two SCORE algorithms are more common in ethnic minority groups relative to the Dutch.

Methods

Using HELIUS study data (Amsterdam, The Netherlands), we obtained data from 7572 participants without self-reported prior cardiovascular disease of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan ethnic origin. For both SCORE algorithms, cardiovascular risk was estimated and used to categorise participants as low (<1%), medium (1–5%), high (5–10%) or very high (≥10%) risk. Odds of differential cardiovascular risk classification were determined by logistic regression analyses.

Results

The percentage of participants classified differently between the algorithms ranged from 8.7% to 12.4% among ethnic minority men versus 11.4% among Dutch men, and from 1.9% to 5.5% among ethnic minority women versus 6.2% among Dutch women. Relative to the Dutch, only Turkish and Moroccan women showed significantly different (lower) odds of differential cardiovascular risk classification.

Conclusion

We found no indication that discrepancies in cardiovascular risk classification between the two SCORE algorithms are consistently more common in ethnic minority groups than among ethnic majority groups.