A predominance of hypertensive heart failure in the Abuja Heart Study cohort of urban Nigerians: a prospective clinical registry of 1515 de novo cases

Hypertensive Heart Disease in the Nigerian Population: Prevalence, Phenotypes, and Cardiovascular Comorbidities

Objective There is a lack of studies on the phenotyping of hypertensive heart disease (HHD) that examine both left ventricular (LV) structure and function in patients with essential hypertension (HTN) in sub-Saharan Africa. In this study, we investigated the prevalence of HHD, its phenotypic characteristics, and associated cardiovascular (CV) comorbidities by analyzing both LV structure and function. This can significantly enhance the understanding of HHD in the Nigerian population. Methods This cross-sectional study involved 1,799 patients diagnosed with essential HTN, who were recruited from the Federal Medical Centre Abuja Hypertension Registry between 2016 and 2021. HHD was defined as the presence of abnormal LV geometry and/or LV diastolic dysfunction (LVDD), as assessed by echocardiography in accordance with the guidelines set by the American Society of Echocardiography and the European Association of CV Imaging. Abnormal LV geometry was characterized by either concentric remodeling, which is defined as a normal left ventricular mass index (LVMI) with a relative wall thickness (RWT) > 0.42, or left ventricular hypertrophy (LVH), which is indicated by an increased LVMI (> 95 g/m² in women and > 115 g/m² in men) with an RWT > 0.42. Patients with secondary HTN and those with HTN during pregnancy were excluded from the study. Results The mean age of the study participants was 55.3±13.0 years and the majority were female patients (55.9%). The prevalence of HHD, concentric LV remodeling, LVH, and LVDD was 90.8%, 38.2%, 47.4%, and 61.6%, respectively. After multivariate analysis, heart failure (adjusted odds ratio (OR): 9.71, confidence interval (CI) 6.20-15.23, p<0.001), stroke (OR: 1.59, CI 1.01-2.52, p=0.045), LVDD (OR: 2.01, CI 1.61-2.50, p<0.001), and female sex (OR: 1.47, CI 1.20-1.80, p<0.001) were independently and positively associated with LVH. Similarly, LVH (OR: 3.51, CI 2.53-4.87, p<0.001), diabetes mellitus (OR: 1.83, CI 1.37-2.44, p<0.001), concentric LV remodeling (OR: 2.18, CI 1.58-3.01, p<0.001), stroke (OR: 1.87, CI 1.06-3.32, p=0.032), and age ≥60 years (OR: 3.92, CI 3.09-4.96, p<0.001) were independently and positively associated with LVDD. Conclusion Our study showed a high prevalence of HHD with LVH and LVDD as common phenotypes in our hypertensive cohort. These findings suggest that the widespread use of echocardiography should be promoted to aid the early diagnosis of HHD.

Heart failure in low-income and middle-income countries

Heart failure (HF) is a complex syndrome which leads to significant morbidity and mortality, poor quality of life and extremely high costs to healthcare systems worldwide. Although progress in the management of HF in high-income countries is leading to an overall reduction in the incidence and mortality of HF, there is a starkly different scenario in low- and middle-income countries (LMICs). There is a substantial lack of data on HF in LMICs, as well as a scarcity of diagnostic tools, limited availability and affordability of healthcare and high burdens of cardiovascular risk factors and communicable diseases. Patients in this setting present with more advanced HF at much younger ages and are, more often, women. In this review, we aim to comprehensively describe the burden of HF from an LMIC perspective, based on the more recent available data. We summarise the major causes of HF that are endemic in these regions, including hypertension, cardiomyopathy, rheumatic heart disease, HIV-associated heart disease and endomyocardial fibrosis. Finally, we discuss the challenges faced by the least developed health systems and highlight interventions that may prove to be more efficient in changing the paradigm of HF of the more vulnerable populations.

Efficacy of beta-blockers on blood pressure control and morbidity and mortality endpoints in hypertensives of African ancestry: an individual patient data meta-analysis

Introduction

Compared with first-line antihypertensives, beta-blockers (BB) have been reported to lower the central aortic blood pressure suboptimally and are associated with increased stroke risk. This observation has not been investigated in hypertensives of African ancestry. We hypothesised that an individual patient data meta-analysis (IPD-MA) on the efficacy of second- or third-generation beta-blockers (STGBBs) in hypertensives of African descent may provide new insights.

Methods

A single-stage IPD-MA analysed the efficacy of STGBB in lowering the mean arterial blood pressure and reducing the composite outcomes: cardiovascular death, stroke, and myocardial infarction.

Results

A total of 11,860 participants from four randomised control trials were included in the analysis. Second- or third-generation beta-blockers reduced the mean arterial pressure by 1.75 mmHg [95% confidence interval (CI):1.16-2.33; P < 0.001] in all participants included in the analysis, and by 1.93 mmHg (95% CI: 0.86-3.00; P < 0.001) in hypertensive Africans. In patients with established cardiovascular disease, where the benefits of BB therapy are well established, STGBBs were associated with an adjusted odds ratio of 1.33 (95% CI: 1.06-1.65; P = 0.015) of the composite outcome, most likely due to confounding. Similarly, the risk of total myocardial infarction was 1.76 times higher (95% CI: 1.15-2.68; P = 0.008) in hypertensives of African ancestry on STGBBs.

Conclusion

The STGBBs reduced the mean arterial pressure comparably to other antihypertensives, and they were not associated with an increased risk of stroke.

Contemporary aetiology of acute heart failure in a teaching hospital in Ghana

BACKGROUND

Heart failure (HF) is recognized as a global public health disease associated with high morbidity and mortality. It is suggested that the main underlying causes of HF in developing countries differ from those identified in well-resourced countries. This study therefore presents the cardiovascular risk factors and the underlying aetiology of HF among admitted patients in a teaching Hospital in Ghana.

METHOD

The study prospectively recruited 140 consecutive patients admitted for heart failure at the Medical department of the Korle-Bu Teaching Hospital from March to October, 2014. The study evaluated the cardiovascular risk factors and the aetiologies of heart failure, and compared the risk factors and aetiologies with patient's age and gender.

RESULTS

The mean age of the study participants was 51.3 ± 16.8 years. The commonest cardiovascular risk factors observed were hypertension (46.5%), history of previous HF (40.7%), excessive alcohol use (38.6%), and family history of heart disease (29.3%); predominantly hypertension (68.3%). The major underlying aetiology of HF were dilated cardiomyopathy (38.6%), hypertensive heart disease (21.4%), ischaemic heart disease (13.6%) and valvular heart disease (12.9%). These underlying aetiology of HF were more common in patients aged 40 years and above (p = 0.004) and those presenting with multiple risk factors (p = 0.001).

CONCLUSION

The major underlying aetiology of heart failure in adults were dilated cardiomyopathy, hypertensive heart disease, ischaemic heart disease and valvular heart disease, which were significantly high among patients aged 40 years and above and those presenting multiple risk factors. Hypertension, excessive alcohol use, family history of heart disease and personal history of previous heart failure diagnosis are noted as the main cardiovascular risk factors among heart failure patients.

Hypertension and its complications are also common in low-resource specialty clinics

The spectrum of cardiovascular diseases in an outpatient low-resource rural specialty tertiary center is not well documented. The study aimed to determine the spectrum of cardiovascular diseases in this setting. We analyzed the medical records of 748 patients with complete data between June 1 and December 31, 2017. The mean age was 49.11 ± 14.47 years. The females were younger than the males (46.21 ± 14.78 vs. 53.64 ± 13.29 p value < 0.001). Hypertensive heart disease was the most common disorder (416 cases, 55.6%). Two hundred and five patients had heart failure (49.28%), while peripartum cardiomyopathy occurred in 8.33%. Seventy-five patients had valvular heart disease, 68% due to rheumatic heart disease.

Burden of atrial fibrillation among adults with heart failure in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

This study aimed to estimate the prevalence of atrial fibrillation (AF) in adults with heart failure (HF) and summarise the all-cause mortality ratio among adult patients with coexisting HF and AF in sub-Saharan Africa (SSA).

SETTING

This was a systematic review and meta-analysis of cross-sectional and cohort studies with primary data on the prevalence and incidence of AF among patients with HF and the all-cause mortality ratio among patients with HF and AF in SSA. We combined text words and MeSH terms to search MEDLINE, PubMed and Global Health Library through Ovid SP, African Journals Online and African Index Medicus from database inception to 10 November 2021. Random-effects meta-analysis was used to estimate pooled prevalence.

PRIMARY OUTCOME MEASURES

The prevalence and incidence of AF among patients with HF, and the all-cause mortality ratio among patients with HF and AF.

RESULTS

Twenty-seven of the 1902 records retrieved from database searches were included in the review, totalling 9987 patients with HF. The pooled prevalence of AF among patients with HF was 15.6% (95% CI 12.0% to 19.6%). At six months, the all-cause mortality was 18.4% (95% CI 13.1% to 23.6%) in a multinational registry and 67.7% (95% CI 51.1% to 74.3%) in one study in Tanzania. The one-year mortality was 48.6% (95% CI 32.5% to 64.7%) in a study in the Democratic Republic of Congo. We did not find any study reporting the incidence of AF in HF.

CONCLUSION

AF is common among patients with HF in SSA, and patients with AF and HF have poor survival. There is an urgent need for large-scale population-based prospective data to reliably estimate the prevalence, incidence and risk of mortality of AF among HF patients in SSA to better understand the burden of AF in patients with HF in the region.

PROSPERO REGISTRATION NUMBER

CRD42018087564.

Heart failure disease: An African perspective

Heart failure remains a health challenge in Africa, associated with significant rates of hospitalization, morbidity and mortality. The current review aims to summarize the most recent data on the epidemiology, aetiology, risk factors and management of heart failure, comparing countries in North Africa and sub-Saharan Africa. There is a paucity of data on heart failure epidemiology, aetiology and management, and on the sociodemographic characteristics of African patients with heart failure. Heart failure prevalence has been evaluated among all medical admissions or admissions to cardiac units or emergency departments in a few hospital-based studies conducted in countries in North Africa and sub-Saharan Africa. Common causes of heart failure in Africa include ischaemic heart disease, hypertensive heart disease, dilated cardiomyopathy and valvular heart disease. The aetiology of heart failure differs between countries in North Africa and sub-Saharan Africa. Diagnosing heart failure proves challenging in Africa because of a lack of basic tools and the necessary human resources. The principal drugs used frequently for heart failure therapy are lacking in sub-Saharan Africa. The clinical profile of heart failure in sub-Saharan Africa differs from that in North African countries; this is related to aetiological factors, socioeconomic status and availability of diagnostic tools. There is an evident need to establish a large multicentre registry to evaluate the heart failure burden in almost all African countries, and to highlight the major cardiovascular risk factors and co-morbidities. The present review highlights the importance of this syndrome in Africa, and calls for improvements in its early diagnosis, treatment and, possibly, prevention.

Burden of out-of-pocket payments among patients with cardiovascular disease in public and private hospitals in Ibadan, South West, Nigeria: a cross-sectional study

OBJECTIVE

Given that the mechanism for financial protection is underdeveloped in Nigeria, out-of-pocket (OOP) payment for treating cardiovascular disease could impose substantial financial burden on individuals and their families. This study estimated the burden of OOP expenditures incurred by a cohort of patients with cardiovascular disease (CVD) in Ibadan, Nigeria.

DESIGN AND SETTINGS

This study used a descriptive cross-sectional study design. A standardised survey questionnaire originally developed by Initiative for Cardiovascular Health Research in Developing Countries was used to electronically collect data from all the 744 patients with CVD who accessed healthcare between 4 November 2019 and 31 January 2020 in the cardiology departments of private and public hospitals in Ibadan, Nigeria. Baseline characteristics of respondents were presented using percentages and proportions. The OOP payments were reported as means±SDs. Costs/OOP payments were in Nigerian Naira (NGN). The average US dollar to NGN at the time of data collection was ₦362.12 per $1. All quantitative data were analysed using STATA V.15.

OUTCOME MEASURES

The burden of outpatient, inpatient and rehabilitative care OOP payments.

RESULTS

Majority of the patients with CVD were within the age range of 45-74 years and 68.55% of them were women. The diagnostic conditions reported among patients with CVD were hypertensive heart failure (84.01%), dilated cardiomyopathy (4.44%), ischaemic heart disease (3.9%) and anaemic heart failure (2.15%). Across all the hospital facilities, the annual direct and indirect outpatient costs were ₦421 595.7±₦855 962.0 ($1164.2±$2363.8) and ₦19 146.5±₦53 610.1 ($52.87±$148.05). Similarly, the average direct and indirect OOP payments per hospitalisation across all facilities were ₦182 302.4±₦249 090.4 ($503.43±$687.87) and ₦14 700.8±₦ 69 297.1 ($40.60±$191.37), respectively. The average rehabilitative cost after discharge from index hospitalisation was ₦30 012.0 ($82.88).

CONCLUSION

The burden of OOP payment among patients with CVD is enormous. There is a need to increase efforts to achieve universal health coverage in Nigeria.

Rational and design of SATRACD study: detecting subclinical anthracycline therapy related cardiac dysfunction in low income country

Background

Anthracycline therapy-related cardiac dysfunction (ATRCD) is the most notorious adverse side-effect of chemotherapy. It has become a significant cardiovascular health concern for long-term cancer survivors. With the emerging concept of subclinical ATRCD and newer diagnostictools (Speckle Tracking Echocardiography (STE) and biomarkers), detecting anthracycline cardiac toxicity at an early stage has become an important step to prevent severe cardiac dysfunction and improve the cardiovascular outcome in cancer survivors. Despite the increasing population at risk in sub-Saharan Africa (SSA), there is no contemporary data in Uganda to address the burden, pathogenesis and risk factors of subclinical ATRCD. This big gap in knowledge has led to a lack of local guidelines for monitoring and management of ATRCD.

Methods

SATRACD (Detecting Subclinical Anthracycline Therapy Related Cardiac Dysfunction In Low Income Country) study is an observational prospective cohort study. Three hundred and fifty-three anthracycline naïve cancer patients will be recruited at baseline. Patients are followed up on completion of anthracycline-based chemotherapy and at 6 months after completion of anthracycline therapy. Data on demographics, cancer profile and clinical presentation will be collected at baseline. Comprehensive cardiac assessment will be performed at each visit, including electrocardiogram, conventional echocardiography, STE, cardiac and oxidative stress markers. We will be able to determine the incidence of subclinical and clinical ATRCD at 6 months after completion of anthracycline therapy, determine whether hypertension is a major risk factor for ATRCD, evaluate the role of conventional echocardiography parameters, and biomarkers for detecting subclinical ATRCD.

Conclusion

This SATRACD study will provide contemporary data on Ugandan cancer patients who have subclinical and clinical ATRCD, help in the development of local strategies to prevent and manage ATRCD, and improve cardiovascular outcome for Ugandan cancer survivors.

Heart failure can affect everyone: the ESC Geoffrey Rose lecture

The principle of 'sick individuals vs. sick population', a concept pioneered by Geoffrey Rose 35 years ago, is particularly applicable to heart failure (HF). This perspective article summarizes and expands on the Geoffrey Rose lecture given at the European Society of Cardiology meeting held in conjunction with the World Congress of Cardiology, in Paris, 2019. This article focuses on the fact that, clearly, HF not only affects a large spectrum of the population globally, but it occurs in all ages and equally in both genders. Heart failure, in most parts of the world, is clearly not a disease of the elderly. There are multiple and complex pathways leading to HF which include various risk factors (including communicable diseases and exposure to indoor and environmental pollutants), poverty and overcrowding, as well as sub-optimal access to health care systems due to socioeconomic inequities. Reflecting on Geoffrey Rose's concept 35 years later motivates us to confront our global responsibility to address the population distribution of risk factors more effectively, instead of focusing solely on interventions that target high-risk individuals.

Risk factors of heart failure among patients with hypertension attending a tertiary hospital in Ibadan, Nigeria: The RISK-HHF case-control study

Aim

Hypertension is the leading cause of heart failure (HF) in sub-Saharan Africa. Preventive public health approach to reduce the scourge of HF must seek to understand the risk factors of HF in at-risk populations. The aim of this study was to characterize the risk factors of HF among patients with hypertension attending a cardiology clinic.

Methods and results

One hundred and one (101) case-control age- and sex-matched pairs were recruited. The study population were adults with a clinical diagnosis of hypertensive HF (cases) and individuals with systemic hypertension without HF. They were interviewed and evaluated for cardiovascular risk factors. Associations between variables were tested with chi square test, Fisher’s exact test and independent sample t test as appropriate. Logistic regression modelling was used to determine the independent risk factors of hypertensive HF (HHF) in the study population while ‘punafcc’ package in stata12 was used to calculate the population attributable fraction (PAF) of the risk factors. Suboptimal medication adherence was the strongest adverse risk factor of HHF (medium adherence aOR: 3.53, 95%CI: 1.35–9.25; low adherence aOR: 9.44, 95%CI: 3.41–26.10) with a PAF of 67% followed by dipstick proteinuria (aOR: 4.22, 95%CI: 1.62–11.02; PAF: 34%) and alcohol consumption/day per 10grams (aOR: 1.23, 95%CI: 1.02–1.49; PAF: 22%). The protective risk factors of HHF were use of calcium channel blockers (aOR 0.25, 95%CI: 0.11–0.59; PAF: 59%), then daily fruits and vegetable consumption (aOR 0.41, 95%CI: 0.17–1.01; PAF: 46%), and eGFR (aOR 0.98, 95%CI: 0.96–0.99; PAF: 5.3%).

Conclusions

The risk factors of HHF are amenable to lifestyle and dietary changes. Public health interventions and preventive cardiovascular care to improve medication adherence, promote fruit and vegetable consumption and reduce alcohol consumption among patients with hypertension are recommended. Renoprotection has utility in the prevention of HF among hypertensives.

Development and Validation of a Electrocardiographic Diagnostic Score of Heart Failure Among Patients with Hypertension Attending a Tertiary Hospital in Ibadan, Nigeria: The RISK-HHF Case-Control Study

Objectives

Hypertension is the leading cause of HF in sub-Saharan Africa. Electrocardiography (ECG) is a cheap and easily available stratification tool for the diagnosis and prognostication of individuals with hypertension. The aim of this study was to develop an ECG-based HF diagnostic score among patients with hypertension attending a specialist cardiology clinic.

Methods

One hundred and one (101) case-control age- and sex-matched pairs were recruited. The study population were adults with a clinical diagnosis of hypertensive HF failure (cases) and systemic hypertension without HF (controls). Participants underwent clinical assessment and ECG. Associations between ECG variables and HF risk were tested with chi square test. Logistic regression modelling (age- and sex adjusted) was trained on a random subset of participants and tested on the remaining participants to determine the ECG abnormalities that are diagnostic of HF and develop a HF diagnostic score. The HF diagnostic score was then validated in an independent dataset of the ECG-Hypertension Audit. Goodness of fit and c-statistics of the HF summed diagnostic score in the training, testing and validation datasets are presented. A two-sided p value of <0.05 was considered statistically significant.

Results

The independent ECG diagnostic markers of HF among hypertensive patients in this study in decreasing order of effect size were sinus tachycardia (aOR: 7.72, 95% CI: 2.31-25.85). arrhythmia (aOR: 7.14, 95% CI: 2.57-19.86), left ventricular hypertrophy (aOR: 4.47; 1.85-10.77) and conduction abnormality (aOR: 3.41, 95% CI: 1.21-9.65). The HF summed diagnostic score showed excellent calibration and discrimination in the training (Hosmer Lemeshow p = 0.90; c-statistic 0.82; 95% CI 0.76–0.89) and test samples (Hosmer Lemeshow p=0.31; c-statistic 0.73 95% CI 0.60 to 0.87) of the derivation cohort and an independent validation audit cohort (Hosmer Lemeshow p = 0.17; c-statistic 0.79 95% CI 0.74 to 0.84) respectively. The model showed high diagnostic accuracy in individuals with different intermediate pre-test probabilities of HF.

Conclusions

A ECG based HF score consisting of sinus tachycardia, arrhythmia, conduction abnormality and left ventricular hypertrophy is diagnostic of HF especially in those with intermediate pre-test probability of HF. This has clinical importance in the stratification of individuals with systemic hypertension.

Prevalence of non-communicable diseases and its risk factors among Ijegun-Isheri Osun residents in Lagos State, Nigeria: a community based cross-sectional study

BACKGROUND

The rapid epidemiologic transition of diseases has adverse implications for low-and middle-income countries (LMICs) like Nigeria due to their limited healthcare, weaker health systems and the westernization of lifestyle. There is a need to evaluate the enormity or otherwise of non-communicable diseases (NCDs) burden in such low resource settings. We performed this survey to determine the prevalence of NCDs and its risk factors among the Ijegun- Isheri Osun community residents of Lagos, Nigeria.

METHODS

A community-based cross-sectional survey was performed on 215 respondents recruited consecutively during a population preventive health campaign. Prevalence of three NCDs (hypertension, diabetes and dyslipidaemia) were calculated. Associations between each of these NCDs and selected risk factors were determined using chi square test. Multivariable logistic regression was used to estimate the risk factors of each of the three NCDs.

RESULTS

The prevalence of hypertension was 35.3% (95% CI 29.0-42.1), diabetes 4.6% (95% CI 2.2-8.4) and dyslipidaemia 47.1% (95% CI 41.1-54.8). Among the NCD risk factors, the prevalence of smoking was 41.3% (95% CI 34.2-48.6), alcohol consumption 72.5% (95% CI 65.5-78.7), and physical activity 52.9 (95% CI 45.5-60.2). The independent significant predictors of hypertension were age ≥ 60 years (aOR 4.56; 95% CI: 1.72-12.09) and dyslipidaemia (aOR 5.01; 95% CI: 2.26-11.13). Age ≥ 60 years (aOR 8.83; 95% CI: 1.88-41.55) was an independent predictor of diabetes. Age ≥ 60 years (aOR 29.32; 95% CI: 4.78-179.84), being employed (aOR 11.12; 95% CI: 3.10-39.92), smoking (aOR 2.34; 95% CI: 1.03-5.33) and physical activity (aOR 0.34; 95% CI: 0.15-0.76) were independent predictors of having dyslipidaemia.

CONCLUSIONS

The prevalence of hypertension, diabetes and dyslipidaemia and their associated risk factors are high among the respondents of Ijegun-Isheri Osun community of Lagos state, Nigeria. This highlights the need for further implementation research and policy directions to tackle NCD burden in urban communities in Nigeria. These strategies must be community specific, prioritizing the various risk factors and addressing them accordingly.

Diurnal rhythm of blood pressure among Nigerians with hypertension using 24-hour ambulatory blood pressure monitoring

Introduction

hypertension is the most common cardiac disease in Nigeria. There are very limited studies in Nigeria on the use of 24-hour ambulatory blood pressure monitoring (24-h ABPM) for evaluation of hypertensive patients. Twenty four-hour ABPM, unlike office blood pressure (OBP), can assess diurnal variation using parameters like awake blood pressure (BP), asleep (nocturnal) BP, mean 24-hour BP and dipping pattern. This can help in assessment of increased cardiovascular risk and management of hypertensive patients. We purposed to assess the diurnal rhythm of BP among Nigerians with hypertension.

Methods

this was a prospective cross-sectional study. Consecutive 77 hypertensive subjects were studied using Schiller MT-300 for 24-h ABPM.

Results

out of the 77 patients reviewed, 39 (50.6%) were females. The mean age was 50.9 years (SD 13.5). The mean awake systolic and diastolic BP were 135.6mmHg (SD 15.0) and 83.2mmHg (SD 10.0) respectively; mean asleep systolic and diastolic BP were 127.6mmHg (SD 17.9) and 76.2mmHg (SD 12.2) respectively; and mean 24-h systolic and diastolic BP were 133.6mmHg (SD 15.3) and 81.4mmHg (SD 10.2) respectively. Awake BP was elevated in 59.7% of study subjects. Elevated awake systolic BP and awake diastolic BP were present in 50.6% and 41.6% of the study population. Nocturnal (asleep) BP was elevated in 79.2%. Non-dipping pattern was the most prevalent pattern at 55.8%, followed by dipping (24.7%), reverse dipping (15.6%) and extreme dipping (3.9%).

Conclusion

a high proportion had nocturnal hypertension (79.2%) and non-dipping pattern was the most prevalent pattern (55.8%). Mean awake systolic BP, mean asleep systolic and diastolic BP and mean 24-h systolic and diastolic BP were elevated. The use of 24-h ABPM will enhance assessment of increased cardiovascular risk and management of Nigerians with hypertension.

Age-Related Characteristics and Outcomes of Patients With Heart Failure With Preserved Ejection Fraction

BACKGROUND

Although heart failure with preserved ejection fraction (HFpEF) is considered a disease of the elderly, younger patients are not spared from this syndrome.

OBJECTIVES

This study therefore investigated the associations among age, clinical characteristics, and outcomes in patients with HFpEF.

METHODS

Using data on patients with left ventricular ejection fraction ≥45% from 3 large HFpEF trials (TOPCAT [Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function], I-PRESERVE [Irbesartan in Heart Failure With Preserved Systolic Function], and CHARM Preserved [Candesartan Cilexetil in Heart Failure Assessment of Reduction in Mortality and Morbidity]), patients were categorized according to age: ≤55 years (n = 522), 56 to 64 years (n = 1,679), 65 to 74 years (n = 3,405), 75 to 84 years (n = 2,464), and ≥85 years (n = 398). This study compared clinical and echocardiographic characteristics, as well as mortality and hospitalization rates, mode of death, and quality of life across age categories.

RESULTS

Younger patients (age ≤55 years) with HFpEF were more often obese, nonwhite men, whereas older patients with HFpEF were more often white women with a higher prevalence of atrial fibrillation, hypertension, and chronic kidney disease (eGFR <60 ml/min/1.73 m²). Despite fewer comorbidities, younger patients had worse quality of life compared with older patients (age ≥85 years). Compared with patients age ≤55 years, patients age ≥85 years had higher mortality (hazard ratio: 6.9; 95% confidence interval: 4.2 to 11.4). However, among patients who died, sudden death was, proportionally, the most common mode of death (p < 0.001) in patients age ≤55 years. In contrast, older patients (age ≥85 years) died more often from noncardiovascular causes (34% vs. 20% in patients age ≤55 years; p < 0.001).

CONCLUSIONS

Compared with the elderly, younger patients with HFpEF were less likely to be white, were more frequently obese men, and died more often of cardiovascular causes, particularly sudden death. In contrast, elderly patients with HFpEF had more comorbidities and died more often from noncardiovascular causes. (Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function [TOPCAT]; NCT00094302; Irbesartan in Heart Failure With Preserved Systolic Function [I-PRESERVE]; NCT00095238; Candesartan Cilexetil in Heart Failure Assessment of Reduction in Mortality and Morbidity [CHARM Preserved]; NCT00634712).

Cardiovascular Diseases in Sub-Saharan Africa Compared to High-Income Countries: An Epidemiological Perspective

Non-communicable diseases (NCDs) are the second common cause of death in sub-Saharan Africa (SSA) accounting for about 35% of all deaths, after a composite of communicable, maternal, neonatal, and nutritional diseases. Despite prior perception of low NCDs mortality rates, current evidence suggests that SSA is now at the dawn of the epidemiological transition with contemporary double burden of disease from NCDs and communicable diseases. In SSA, cardiovascular diseases (CVDs) are the most frequent causes of NCDs deaths, responsible for approximately 13% of all deaths and 37% of all NCDs deaths. Although ischemic heart disease (IHD) has been identified as the leading cause of CVDs mortality in SSA followed by stroke and hypertensive heart disease from statistical models, real field data suggest IHD rates are still relatively low. The neglected endemic CVDs of SSA such as endomyocardial fibrosis and rheumatic heart disease as well as congenital heart diseases remain unconquered. While the underlying aetiology of heart failure among adults in high-income countries (HIC) is IHD, in SSA the leading causes are hypertensive heart disease, cardiomyopathy, rheumatic heart disease, and congenital heart diseases. Of concern is the tendency of CVDs to occur at younger ages in SSA populations, approximately two decades earlier compared to HIC. Obstacles hampering primary and secondary prevention of CVDs in SSA include insufficient health care systems and infrastructure, scarcity of cardiac professionals, skewed budget allocation and disproportionate prioritization away from NCDs, high cost of cardiac treatments and interventions coupled with rarity of health insurance systems. This review gives an overview of the descriptive epidemiology of CVDs in SSA, while contrasting with the HIC and highlighting impediments to their management and making recommendations.

Cardiac ultrasound in resource-limited settings (CURLS): towards a wider use of basic echo applications in Africa

Background

Point-of-care ultrasound is increasingly being used as a diagnostic tool in resource-limited settings. The majority of existing ultrasound protocols have been developed and implemented in high-resource settings. In sub-Saharan Africa (SSA), patients with heart failure of various etiologies commonly present late in the disease process, with a similar syndrome of dyspnea, edema and cardiomegaly on chest X-ray. The causes of heart failure in SSA differ from those in high-resource settings. Point-of-care ultrasound has the potential to identify the underlying etiology of heart failure, and lead to targeted therapy. Based on a literature review and weighted score of disease prevalence, diagnostic impact and difficulty in performing the ultrasound, we propose a context-specific cardiac ultrasound protocol to help differentiate patients presenting with heart failure in SSA.

Results

Pericardial effusion, dilated cardiomyopathy, cor pulmonale, mitral valve disease, and left ventricular hypertrophy were identified as target conditions for a focused ultrasound protocol in patients with cardiac failure and cardiomegaly in SSA. By utilizing a simplified 5-question approach with all images obtained from the subxiphoid view, the protocol is suitable for use by health care professionals with limited ultrasound experience.

Conclusions

The “Cardiac ultrasound for resource-limited settings (CURLS)” protocol is a context-specific algorithm designed to aid the clinician in diagnosing the five most clinically relevant etiologies of heart failure and cardiomegaly in SSA. The protocol has the potential to influence treatment decisions in patients who present with clinical signs of heart failure in resource-limited settings outside of the traditional referral institutions.

The spectrum of heart disease among adults at the Bamenda Regional Hospital, North west Cameroon: a semi urban setting

OBJECTIVE

We sought to determine the spectrum of heart diseases among adult patients at the Bamenda Regional Hospital in the North West Region of Cameroon. This is a chart review of echocardiographic records.

RESULTS

In total, 673 records were included in our study, of which 506 had a definite heart disease. Of the 506, 93 had mixed cardiopathies. Their ages ranged from 18 to 105 years with a median age of 64.0 (Interquartile range = 47-75) years. Females accounted for a greater proportion (55.3%) of the study population. The most common echocardiographic diagnoses were hypertensive heart disease (41.1%), valvular heart disease (22.3%) and cardiomyopathies (11.4%). The prevalence of heart failure was 17.5%, with hypertensive heart disease being the leading cause.

Hypertension and Sudden Unexpected Deaths: An Autopsy Study of Four Hundred and Seventy-Seven Brought-in-Dead in a Tertiary Health Center

Introduction

Hypertension is an important and major public health concern globally. One of the major causes of sudden death worldwide is hypertension. This study is to present the morphological pattern of deaths at autopsy of those patients who were brought-in-dead (BID) and who had hypertensive heart disease (HHD) as the underlying illness.

Materials and Methods

This is a 6-year retrospective autopsy study of BID patients as a result of HHD seen at our department between January 1, 2010, and December 31, 2015. The autopsy findings and data retrieved were analyzed using IBM Statistical Package for Social Sciences version 20. Test for statistical significance was set at P < 0.05.

Results

A total of 477 deaths (44%) as a result of HHD were recorded out of the 1016 BID during the period under study. The age ranged from 21 to 92 years with a mean age of 52 ± 14.0 years and a male to female ratio of 1.8:1. The 5^th decade of life was the most common age group encountered. The most common cause of death was acute left ventricular failure (67.8%), and myocardial infarction was the least common (1.7%).

Conclusions

Acute left ventricular heart failure was the most common cause of sudden death as a result of hypertension and was followed by intracerebral hemorrhage. In the female gender, sudden deaths were most common in the 6^th decade and in the male gender most sudden deaths were seen in the 5^th decade.

Understanding the effect of indoor air pollution on pneumonia in children under 5 in low- and middle-income countries: a systematic review of evidence

Exposure to indoor air pollution increases the risk of pneumonia in children, accounting for about a million deaths globally. This study investigates the individual effect of solid fuel, carbon monoxide (CO), black carbon (BC) and particulate matter (PM)2.5 on pneumonia in children under 5 in low- and middle-income countries. A systematic review was conducted to identify peer-reviewed and grey full-text documents without restrictions to study design, language or year of publication using nine databases (Embase, PubMed, EBSCO/CINAHL, Scopus, Web of Knowledge, WHO Library Database (WHOLIS), Integrated Regional Information Networks (IRIN), the World Meteorological Organization (WMO)-WHO and Intergovernmental Panel on Climate Change (IPCC). Exposure to solid fuel use showed a significant association to childhood pneumonia. Exposure to CO showed no association to childhood pneumonia. PM2.5 did not show any association when physically measured, whilst eight studies that used solid fuel as a proxy for PM2.5 all reported significant associations. This review highlights the need to standardise measurement of exposure and outcome variables when investigating the effect of air pollution on pneumonia in children under 5. Future studies should account for BC, PM1 and the interaction between indoor and outdoor pollution and its cumulative impact on childhood pneumonia.

Prevalence and pattern of cardiovascular-related causes of out-of- hospital deaths in Lagos, Nigeria

Background

In developed countries 50% – 75% of deaths from cardiovascular-diseases occurs out-of-hospital. In Nigeria where patronage of orthodox health facilities is low, the impact of cardiovascular-related diseases on out-of-hospital mortality has been sparsely studied.

Objectives

To determine the prevalence and pattern of cardiovascular-related causes of out-of-hospital deaths in Lagos, Nigeria.

Methods

A 5-year retrospective review of all autopsied medical decedents brought-in-dead (BID) to a Nigerian tertiary health facility to identify cardiovascular-related causes of death.

Results

A total of 90 cardiovascular-related deaths out of 176 medical BID cases were identified, giving a prevalence of 51.1%. Mean age was 65.2 ± 15.6 years. Male: Female ratio was 1.4: 1, the females were older (68.29 ± 14.89) vs (61.63 ± 15.55) years. Age group > 60 years accounted for 63.3% of deaths. Commonest primary diseases were hypertensive heart disease (48.9%) and cerebrovascular accident (24.4%). Myocardial infarction occurred in 8.9%. Heart failure, cerebral dysfunction and unspecified circulatory collapse were the causes of death in 54.4%, 23.3% and 14.4% respectively.

Conclusion

Cardiovascular-related diseases are major contributors to out-of-hospital medical deaths occurring chiefly in those >60 years. Hypertensive heart disease and heart failure are the greatest contributors to this cardiovascular-related disease mortality.

Rationale and design of the comparison of 3 combination therapies in lowering blood pressure in black Africans (CREOLE study): 2 × 3 factorial randomized single-blind multicenter trial

BACKGROUND

Current hypertension guidelines recommend the use of combination therapy as first-line treatment or early in the management of hypertensive patients. Although there are many possible combinations of blood pressure(BP)-lowering therapies, the best combination for the black population is still a subject of debate because no large randomized controlled trials have been conducted in this group to compare the efficacy of different combination therapies to address this issue.

METHODS

The comparison of 3 combination therapies in lowering BP in the black Africans (CREOLE) study is a randomized single-blind trial that will compare the efficacy of amlodipine plus hydrochlorothiazide versus amlodipine plus perindopril and versus perindopril plus hydrochlorothiazide in blacks residing in sub-Saharan Africa (SSA). Seven hundred two patients aged 30-79 years with a sitting systolic BP of 140 mm Hg and above, and less than 160 mm Hg on antihypertensive monotherapy, or sitting systolic BP of 150 mm Hg and above, and less than 180 mm Hg on no treatment, will be centrally randomized into any of the 3 arms (234 into each arm). The CREOLE study is taking place in 10 sites in SSA, and the primary outcome measure is change in ambulatory systolic BP from baseline to 6 months. The first patient was randomized in June 2017, and the trial will be concluded by 2019.

CONCLUSIONS

The CREOLE trial will provide unique information as to the most efficacious 2-drug combination in blacks residing in SSA and thereby inform the development of clinical guidelines for the treatment of hypertension in this subregion.

Data on the epidemiology of heart failure in Sub-Saharan Africa

In Sub-Saharan Africa (SSA), chronic non-communicable diseases and cardiovascular diseases in particular, are progressively taking over infectious diseases as the leading cause of morbidity and mortality. Heart failure is a major public health problem in the region. We summarize here available data on the prevalence, aetiologies, treatment, rates and predictors of mortality due to heart failure in SSA.

Clinical and Echocardiographic Predictors of Arrhythmias Detected With 24-Hour Holter Electrocardiography Among Hypertensive Heart Failure Patients in Nigeria

Background

Hypertensive heart failure (HHF) is the commonest form of heart failure in Nigeria. There is paucity of data in Nigeria on 24-hour Holter electrocardiography (24-HHECG) and important predictors of arrhythmias among HHF patients.

Objectives

To determine the 24-HHECG characteristics among HHF patients. To determine the clinical and echocardiographic predictors of arrhythmias detected using 24-HHECG among HHF patients.

Methods

A total of 100 HHF patients as well as 50 age-matched and sex-matched apparently healthy controls were prospectively recruited over a period of 1 year. They all had baseline laboratory tests, echocardiography, and 24-HHECG.

Results

Hypertensive heart failure patients had significantly higher counts of premature ventricular contractions (PVCs) than the controls (P ≤ .001). Ventricular tachycardia (VT) was recorded in 29% of HHF patients as compared with controls who had no VT on 24-HHECG. The standard deviation of all normal to normal sinus RR intervals over 24 hours (SDNN) was abnormally reduced among HHF patients when compared with controls (P = .046). There was positive correlation between atrial fibrillation (AF) and the following parameters: PVCs (r = .229, P = .015), New York Heart Association (NYHA) (r = .196, P = .033), and VT (r = .223, P = .018). Following multiple linear regression, left ventricular ejection fraction (LVEF) (P ≤ .001) and serum urea (P = .037) were predictors of PVCs among HHF patients. Serum creatinine (P ≤ .001), elevated systolic blood pressure (SBP) (P = .005), and PVCs (P ≤ .001) were important predictors of VT among HHF patients.

Conclusions

Renal dysfunction and reduced LVEF were important predictors of ventricular arrhythmias. High counts of PVCs and elevated SBP were predictive of the occurrence of VT among HHF patients. The NYHA class and ventricular arrhythmias have a significant positive correlation with AF. The SDNN is reduced in HHF patients.

A predominance of hypertensive heart disease among patients with cardiac disease in Buea, a semi-urban setting, South West Region of Cameroon

Objective

The pattern of heart disease is diverse within and among world regions. The little data on the spectrum of heart disease in Cameroon has been so far limited to major cities. We sought to describe the pattern of heart disease in Buea, the South West Region of Cameroon, a semi-urban setting. This was a descriptive cross-sectional study. Between June 2016 and April 2017 the echocardiography register of the Buea Regional Hospital was surveyed. We extracted data on the age, sex and echocardiographic diagnosis.

Results

Out of 529 patients who underwent echocardiography, 239 (45.2%) had a definite heart disease. There were 137 (57.3%) females. The mean age was 58 years (range 3–94 years). The most common echocardiographic diagnoses were hypertensive heart disease (43.2%), dilated cardiomyopathies (17.6%), ischemic heart diseases (9.6%), and cor pulmonale (8.8%). Rheumatic heart disease affected 6.7% of the patients. The most common rheumatic heart disease was mitral stenosis followed by mitral regurgitation. Congenital heart disease represented 2.1% and 5 patients (2.1%) had pulmonary hypertension. Hypertensive heart disease is the most common cardiac disease in this semi-urban region in Cameroon. Rheumatic heart disease still affects a sizable proportion of patients. Prevention of cardiac disease in our setting should focus on mass screening, the treatment and control of hypertension.

Soluble ST2 correlates with some indicators of right ventricular function in hypertensive heart failure

Purpose

ST2 receptor, which is a member of the Toll-like/interleukin-1 (IL-1) receptor family, has been found to be increased in the serum of patients 1 day after myocardial infarction. Several other studies have shown that soluble ST2 levels correlate with severity of heart failure (HF), left ventricular ejection fraction, creatinine clearance, B-type natriuretic peptide and C-reactive protein, and are predictors of mortality in HF. Most of these studies were not only limited to ischemic heart disease but also concentrated on left-sided HF. We therefore decided to study the relationship between soluble ST2 and some markers of right ventricular (RV) function in a cohort of hypertensive HF subjects.

Patients and methods

This is a prospective cohort study of hypertensive HF patients presenting to the University of Abuja Teaching Hospital, Abuja, over a 12-month period. ST2 was measured in plasma sample by the enzyme-linked immunosorbent assay (ELISA) method. Right ventricular diameters in diastole (RVDD) and right atrial area (RAA) were obtained on echocardiography, while right ventricular systolic pressure (RVSP) was estimated from echocardiography by the addition of the pressure gradient between the right ventricle and right atrium (RA) to the pressure in the RA.

Results

There was a significant correlation between RVSP and soluble ST2 (t=0.75, p<0.0001), RVDD (t=0.28, p=0.004) and RAA (t=0.46, p=0.002).

Conclusion

In a cohort of hypertensive HF subjects, soluble ST2 correlates significantly with RVSP, RVDD and RAA.

What is known about heart failure in sub-Saharan Africa: a scoping review of the English literature

We systematically reviewed and summarised existing knowledge on heart failure in sub-Saharan Africa (SSA). We searched the following databases Web of Science, EMBASE, Ovid MEDLINE, PsychINFO, Global Health, CINAHL and African Journals Online using a combination of key words: heart failure or congestive heart failure or cardiac failure. We limited our search to studies conducted in SSA and articles published 2000-2014. Twenty-seven articles met our inclusion criteria and all were quantitative studies. Existing knowledge is focused on 3 key areas: (1) epidemiology of heart failure, (2) psychological burden of heart failure, and (3) patient knowledge and compliance to treatment. SSA would benefit from longitudinal qualitative research on the experience of living with heart failure.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

Prognostic indices among hypertensive heart failure patients in Nigeria: the roles of 24-hour Holter electrocardiography and 6-minute walk test

Background

Hypertensive heart failure (HHF) is associated with a poor prognosis. There is paucity of data in Nigeria on prognosis among HHF patients elucidating the role of 24-hour Holter electrocardiogram (ECG) in concert with other risk factors.

Objective

The aim of this study was to determine the prognostic utility of 24-hour Holter ECG, the 6-minute walk test (6-MWT), echocardiography, clinical and laboratory parameters among HHF patients.

Methods

A total of 113 HHF patients were recruited and followed up for 6 months. Thirteen of these patients were lost to follow-up, and as a result only 100 HHF patients were analyzed. All the patients underwent baseline laboratory tests, echocardiography, 24-hour Holter ECG and the 6-MWT. HHF patients were analyzed as “mortality vs alive” and as “events vs no-events” based on the outcome at the end of 6 months. Events was defined as HHF patients who were rehospitalized for heart failure (HF), had prolonged hospital stay or died. No-events group was defined as HHF patients who did not meet the criteria for the events group.

Results

HHF patients in the mortality group (n = 7) had significantly higher serum urea (5.71 ± 2.07 mmol/L vs 3.93 ± 1.45 mmol/L, p = 0.003) than that in those alive. After logistic regression, high serum urea conferred increased mortality risk (p = 0.035). Significant premature ventricular complexes (PVCs) on 24-hour Holter ECG following logistic regression were also significantly higher (p = 0.015) in the mortality group than in the “alive” group (n = 93) at the end of the 6-month follow-up period. The 6-minute walk distance (6-MWD) was least among the HHF patients who died (167.26 m ± 85.24 m). However, following logistic regression, the 6-MWT was not significant (p = 0.777) for predicting adverse outcomes among HHF patients. Patients in the events group (n = 41) had significantly higher New York Heart Association (NYHA) class (p = 0.001), Holter-detected ventricular tachycardia (VT; p = 0.009), Holter-detected atrial fibrillation (AF; p = 0.028) and PVCs (p = 0.017) following logistic regression than those in the no-events group (n = 59).

Conclusion

High NYHA class, elevated serum urea, Holter ECG-detected AF and ventricular arrhythmias are predictive of a poor outcome among HHF patients. The 6-MWT was not a useful prognostic index in this study.

The heart of Africa: succeeding against the odds

South Africa and other areas of sub-Saharan Africa have in the past 20 years undergone rapid demographical changes, largely due to urbanisation and changes in lifestyle. This rapid change has led to a marked increase in specific cardiac conditions, such as hypertensive heart disease and coronary artery disease (with the highest prevalence in the middle-aged population), in conjunction with a range of other heart diseases, which are historically common in Africa-eg, rheumatic heart disease, cardiomyopathies, and unoperated congenital heart disease. The short supply of well-equipped screening facilities, late diagnosis, and inadequate care at primary, secondary, and tertiary levels have led to a large burden of patients with poorly treated heart failure. Excellent progress has been made in the understanding of the epidemiology, sociodemographical factors, effect of urbanisation, and pathophysiology of cardiac conditions, such as peripartum cardiomyopathy, rheumatic heart disease, and tuberculous pericarditis, which are common in sub-Saharan Africa. This progress has been achieved largely through several studies, such as the Heart of Soweto, THESUS, REMEDY, BA-HEF, Abeokuta-HF, and the PAPUCO studies. Studies on the suitable therapeutic management of several heart conditions have also been done or are underway. In this Lecture, I provide a personal perspective on the evolving burden of cardiac disease, as witnessed since my appointment at Chris Hani Baragwanath Hospital, in Soweto, South Africa, in 1992, which was also the year that the referendum to end apartheid in South Africa was held. Subsequently, a network of cardiologists was formed under the umbrella of the Heart of Africa Studies and the Pan African Cardiac Society. Furthermore, I summarise the major gaps in the health-care system dealing with the colliding epidemic of communicable and non-communicable heart diseases, including cardiac diseases common in peripartum women. I also touch on the fantastic opportunities available for doing meaningful research with enthusiastic colleagues and, thereby, having a large effect, despite the need to be highly innovative in finding much needed funding support.

Rehospitalization for heart failure in the elderly

Objectives:

To determine the burden of preventable rehospitalization for decompensated heart failure in the elderly.

Methods:

This was a retrospective study performed in a Nigerian University Teaching Hospital,. Demographic variables, etiology, and participants of heart failure were retrieved from data of elderly patients with heart failure admitted between January 2014 and December 2015. The participants were classified and described as either preventable, or unpreventable to determine whether the hospitalizations were preventable or not. The frequency of the groups with preventable participants (hospitalization) was derived.

Results:

Five groups of participants were preventable (55.5%), while 4 groups (44.5%) were unpreventable. The preventable participants were poor drug compliance (24 [23.4%]), uncontrolled hypertension (7 [6.9%]), infectious (34 [33.3%]), pulmonary thromboembolism (1 [1%]), and anemia (1 [1%]). The unpreventable participants include arrhythmias (19 [18.6%]), acute kidney injury (2 [2%]), acute coronary syndrome (1 [1%]), and progressive ventricular dysfunction (13 [12.7%]).

Conclusion:

Multiple rehospitalization for heart failure is a challenge for the elderly, but 55.5% of these readmissions are preventable. Poor drug compliance and pulmonary infections were the most common preventable participants. Multidisciplinary measures involving patient education, home based care, and physician training will reduce the number of hospitalizations for heart failure in the elderly.

Endemic Cardiovascular Diseases of the Poorest Billion

The poorest billion people are distributed throughout the world, though most are concentrated in rural sub-Saharan Africa and South Asia. Cardiovascular disease (CVD) data can be sparse in low- and middle-income countries beyond urban centers. Despite this urban bias, CVD registries from the poorest countries have long revealed a predominance of nonatherosclerotic stroke, hypertensive heart disease, nonischemic and Chagas cardiomyopathies, rheumatic heart disease, and congenital heart anomalies, among others. Ischemic heart disease has been relatively uncommon. Here, we summarize what is known about the epidemiology of CVDs among the world’s poorest people and evaluate the relevance of global targets for CVD control in this population. We assessed both primary data sources, and the 2013 Global Burden of Disease Study modeled estimates in the world’s 16 poorest countries where 62% of the population are among the poorest billion. We found that ischemic heart disease accounted for only 12% of the combined CVD and congenital heart anomaly disability-adjusted life years (DALYs) in the poorest countries, compared with 51% of DALYs in high-income countries. We found that as little as 53% of the combined CVD and congenital heart anomaly burden (1629/3049 DALYs per 100 000) was attributed to behavioral or metabolic risk factors in the poorest countries (eg, in Niger, 82% of the population among the poorest billion) compared with 85% of the combined CVD and congenital heart anomaly burden (4439/5199 DALYs) in high-income countries. Further, of the combined CVD and congenital heart anomaly burden, 34% was accrued in people under age 30 years in the poorest countries, while only 3% is accrued under age 30 years in high-income countries. We conclude although the current global targets for noncommunicable disease and CVD control will help diminish premature CVD death in the poorest populations, they are not sufficient. Specifically, the current framework (1) excludes deaths of people <30 years of age and deaths attributable to congenital heart anomalies, and (2) emphasizes interventions to prevent and treat conditions attributed to behavioral and metabolic risks factors. We recommend a complementary strategy for the poorest populations that targets premature death at younger ages, addresses environmental and infectious risks, and introduces broader integrated health system interventions, including cardiac surgery for congenital and rheumatic heart disease.

Right Ventricular Systolic Dysfunction Is Common in Hypertensive Heart Failure: A Prospective Study in Sub-Saharan Africa

INTRODUCTION

Right ventricular (RV) systolic dysfunction is now recognized widely as a strong and independent predictor of adverse outcomes in patients with heart failure (HF). Reduction of RV systolic function more closely predicts impaired exercise tolerance and poor survival than does left ventricular (LV) systolic function. In spite of this, there is a dearth of data on RV function in hypertensive HF which is the commonest form of HF in sub-Saharan Africa. We therefore conducted a prospective cohort study of hypertensive HF patients presenting to the University of Abuja Teaching Hospital, Abuja, Nigeria over an 8 year period.

METHODS

Each subject had transthoracic echocardiography performed on them according to the guidelines of American Society of Echocardiography. RV systolic function was defined as a tricuspid annular plane systolic excursion (TAPSE) <15 mm using M-mode echocardiography.

RESULTS

RV systolic dysfunction was identified in 272 (44.5%) of the 611 subjects that were studied. Subjects with TAPSE less than 15 mm had worse prognosis compared to those with TAPSE ≥15 mm.There was a significant correlation between TAPSE and other adverse prognostic markers including left and right atrial area, LV size, LV mass, LV ejection fraction, restrictive mitral inflow and RV systolic pressure (RVSP). However, LV ejection fraction and right atrial area were the only independent determinants of RV systolic dysfunction.

CONCLUSIONS

Hypertensive HF is a major cause of RV systolic dysfunction even in a population with a low prevalence of coronary artery disease, and RV systolic dysfunction is associated with poor prognosis in hypertensive HF. Detailed assessment of RV function should therefore be part of the echocardiography evaluation of patients with hypertensive HF.

Epidemiology and aetiology of heart failure

Heart failure (HF) is a rapidly growing public health issue with an estimated prevalence of >37.7 million individuals globally. HF is a shared chronic phase of cardiac functional impairment secondary to many aetiologies, and patients with HF experience numerous symptoms that affect their quality of life, including dyspnoea, fatigue, poor exercise tolerance, and fluid retention. Although the underlying causes of HF vary according to sex, age, ethnicity, comorbidities, and environment, the majority of cases remain preventable. HF is associated with increased morbidity and mortality, and confers a substantial burden to the health-care system. HF is a leading cause of hospitalization among adults and the elderly. In the USA, the total medical costs for patients with HF are expected to rise from US$20.9 billion in 2012 to $53.1 billion by 2030. Improvements in the medical management of risk factors and HF have stabilized the incidence of this disease in many countries. In this Review, we provide an overview of the latest epidemiological data on HF, and propose future directions for reducing the ever-increasing HF burden.

Hypertension in Sub-Saharan Africa: A Contextual View of Patterns of Disease, Best Management, and Systems Issues

Sub-Saharan Africa (SSA) bears the highest burden of both communicable and noncommunicable disease and has the weakest health systems. Much attention is directed toward a rising burden of chronic disease in the setting of epidemiologic transition and urbanization. Indeed, the highest prevalence of hypertension globally is in the World Health Organization's African region at 46% of adults aged 25 and above. And while hypertension in SSA is common, its prevalence varies significantly between urban and rural settings. Although there is evidence for epidemiologic transition in urban areas, there is also evidence of static levels of hypertension within rural areas, which comprise more than 70% of the population of SSA. Furthermore, overall cardiovascular (CV) risk in rural areas remains low. The mean age of hypertensives in SSA is approximately 30s to 40s, burdening those at peak productivity. Complications of hypertension are frequent, given the poor levels of awareness and treatment (<10%) of hypertension on the continent. Such complications include primarily stroke and hypertensive heart disease, as ischemic heart disease is uncommon. Mortality associated with these complications is high, with in-hospital mortality from 2 different sites reported as around 20%. The overall burden of hypertension is likely to be more related to poor access and availability of health systems and is representative of a looming crisis in health care delivery. The best approaches to population-wide treatment are those that utilize CV risk prediction for those with stage 1 hypertension, whereas treatment is generally indicated for all those with stage 2 or greater hypertension, especially in light of the high burden of stroke in SSA. Current guidelines recommend first-line drug therapy with a diuretic or calcium channel blocker. Despite these recommendations, the major obstacles to hypertension treatment are systemic and include the availability and cost of medications, the adequacy of health facilities and systems, and the lack of health insurance to address affordability. New and innovative systems-oriented approaches are needed to address the burden of hypertension on a platform of global equity.

The proposed role of plasma NT pro-brain natriuretic peptide in assessing cardiac remodelling in hypertensive African subjects

AIM

Although plasma NT-proBNP differentiates hypertension (HT) with or without left ventricular hypertrophy (LVH) from hypertensive heart failure (HHF), most of the published data are based on studies in Western populations. Also, most previous studies did not consider left ventricular (LV) diastolic function and right ventricular (RV) function. We therefore examined the relation between NT-proBNP on LV and RV remodelling in an African hypertensive cohort.

METHODS

Subjects were subdivided into three groups after echocardiography: hypertensives without LVH (HT) (n = 83); hypertensives with LVH (HT + LVH) (n = 50); and those with hypertensive heart failure (HHF) (n = 77).

RESULTS

Subjects with HHF had significantly higher NT-proBNP levels compared to the HT + LVH group (p < 0.0002). NT-proBNP correlated positively with right atrial area, an indirect measure of RV function.

CONCLUSIONS

NT-proBNP is proposed as a useful biomarker in differentiating hypertension with or without LVH from hypertensive heart failure in black hypertensive subjects.

Hospitalized heart failure patients with preserved vs. reduced ejection fraction in Dubai, United Arab Emirates: a prospective study

AIMS

To compare the baseline characteristics, pharmacological treatment, and in-hospital outcomes across hospitalized heart failure (HF) patients with preserved LVEF (HF-PEF) and those with reduced LVEF (HF-REF).

METHOD AND RESULTS

This was a prospective analysis of consecutive patients admitted with decompensated HF at two government hospitals in the United Arab Emirates, from 1 December 2011 to 30 November 2012. Multivariate factors of HF-PEF vs. HF-REF included elevated systolic blood pressure [odds ratio (OR) 1.02; 95% confidence interval (CI) 1.01–1.03], heart rate (OR 0.98; 95% CI 0.97–0.99), age (OR 1.02; 95% CI 1.01–1.04), female sex (OR 2.38; 95% CI 1.41–4.03), angina or myocardial infarction (OR 0.42; 95% CI 0.25–0.71), AF (OR 1.82; 95% CI 1.05–3.15), COPD or asthma (OR 2.80; 95% CI 1.47–5.35), Charlson Comorbidity Index score (OR 0.75; 95% CI 0.64–0.88), and anaemia (OR 2.97; 95% CI 1.64–5.38). In-hospital outcomes were similar between the two groups. However, patients with HF-PEF were less likely to be prescribed HF medication, and used more anticoagulants and fewer antiplatelet medications.

CONCLUSION

These results suggest that patients with HF-PEF are older, more often female, and have higher prevalence of respiratory diseases and AF. Compared with developed countries, hospitalized HF patients in the Middle East are 10 years younger and have a higher prevalence of diabetes mellitus, and the majority have HF-REF.

Risk-Factor Profile and Comorbidities in 2398 Patients With Newly Diagnosed Hypertension From the Abuja Heart Study

Risk factors, comorbidities, and end-organ damage in newly diagnosed hypertension (HT) are poorly described in larger cohorts of urban African patients undergoing epidemiological transition. We therefore decided to characterize a large cohort of hypertensive subjects presenting to a tertiary health center in sub-Saharan Africa. It is an observational cross-sectional study. We prospectively collected detailed clinical, biochemical, electrocardiography, and echocardiography data of all subjects with HT as the primary diagnosis in patients presenting at the Cardiology Unit of the University of Abuja Teaching Hospital over an 8-year period. Of 2398 subjects, 1187 patients (49.4%) were female with a mean age of 51 ± 12.8 years. Presenting symptoms and signs were most commonly palpitation in 691 (28.8%) followed by dyspnoea on exertion in 541 (22.6%), orthopnea in 532 (22.2%), pedal oedema in 468 (19.5%), paroxysmal nocturnal dyspnoea in 332 (13.8%), whereas only 31 (1.3%) presented with chest pain. Risk factors were obesity in 671 (28%); 523 (21.8%) had total cholesterol >5.2 mmol/L, diabetes mellitus was present in 201 (8.4%) and 187 (7.8%) were smokers. End-organ damage was present in form of echocardiographic left ventricular hypertrophy in 1336 (55.7%) followed by heart failure in 542 (22.6%). Arrhythmias occurred in 110 (4.6%) of cases, cerebrovascular accident in 103 (4.3%), chronic kidney disease in 26 (1.1%), hypertensive encephalopathy in 10 (0.4%), and coronary artery disease in 6 (0.26%). There were marked differences in sex as women were more obese and men presented with more advanced disease. The burden of HT and its complications in this carefully characterized African cohort is quite enormous with more than three-fourth having one form of complication. The need of effective primary and secondary preventive measures to be mapped out to tackle this problem cannot be overemphasized.

Hypertensive heart failure in Nigerian Africans: insights from the Abeokuta Heart Failure Registry

Data from the Abeokuta Heart Failure Registry were used to determine the clinical characteristics, mode of treatment, and short- and medium-term outcomes of patients with hypertensive heart failure. A total of 320 patients were consecutively studied, comprising 184 men (57.5%) and 136 women (42.5%) aged 58.4±12.4 and 60.6±14.5 years, respectively. Most patients (80%) presented with New York Heart Association functional class III or IV and around one third (35%) had preserved systolic function. Median hospital stay was 9 days (interquartile range 5-21) while intra-hospital mortality was 3.4%. The 30-day, 90-day, and 180-day mortality rates were 0.9% (95% confidence interval, -0.2 to 3.5), 3.5% (95% confidence interval, -1.7 to 7.3), and 11.7% (95% confidence interval, -7.8 to 17.5), respectively. In a multiple logistic regression analysis, only serum creatinine was an independent predictor of mortality at 180 days (adjusted odds ratio, 1.76; 95% confidence interval, -1.17 to 2.64). Hypertension is the most common etiological risk factor for heart failure in Nigeria. Most patients present in the fourth decade of life with severe heart failure and secondary valvular dysfunction and significant in-hospital mortality.

Hypertension, cardiovascular risk factors and antihypertensive medication utilisation among HIV-infected individuals in Rakai, Uganda

OBJECTIVES

To assess the prevalence of hypertension, elevated blood pressure and cardiovascular risk factors among HIV-positive individuals in rural Rakai District, Uganda.

METHODS

We assessed 426 HIV-positive individuals in Rakai, Uganda from 2007 to 2010. Prevalence of hypertension and elevated blood pressure assessed by clinical measurement was compared to clinician-recorded hypertension in case report forms. Multiple logistic regression and z-tests were used to examine the association of hypertension and elevated blood pressure with age, sex, body mass index (BMI), CD4 cell count and antiretroviral treatment (ART) use. For individuals on antihypertensives, medication utilisation was reviewed.

RESULTS

The prevalence of hypertension (two elevated blood pressure readings at different time points) was 8.0% (95% CI: 5.4-10.6%), and that of elevated blood pressure (one elevated blood pressure reading) was 26.3% (95% CI: 22.1-30.5%). Age ≥50 years and higher BMI were positively associated with elevated blood pressure. ART use, time on ART and CD4 cell count were not associated with hypertension. Eighty-three percent of subjects diagnosed with hypertension were on antihypertensive medications, most commonly beta-blockers and calcium channel blockers.

CONCLUSIONS

Hypertension is common among HIV-positive individuals in rural Uganda.

Economic burden of heart failure: investigating outpatient and inpatient costs in Abeokuta, Southwest Nigeria

Background: Heart failure (HF) is a deadly, disabling and often costly syndrome world-wide. Unfortunately, there is a paucity of data describing its economic impact in sub Saharan Africa; a region in which the number of relatively younger cases will inevitably rise.

Methods: Heath economic data were extracted from a prospective HF registry in a tertiary hospital situated in Abeokuta, southwest Nigeria. Outpatient and inpatient costs were computed from a representative cohort of 239 HF cases including personnel, diagnostic and treatment resources used for their management over a 12-month period. Indirect costs were also calculated. The annual cost per person was then calculated.

Results: Mean age of the cohort was 58.0±15.1 years and 53.1% were men. The total computed cost of care of HF in Abeokuta was 76, 288,845 Nigerian Naira (US$508, 595) translating to 319,200 Naira (US$2,128 US Dollars) per patient per year. The total cost of in-patient care (46% of total health care expenditure) was estimated as 34,996,477 Naira (about 301,230 US dollars). This comprised of 17,899,977 Naira- 50.9% ($US114,600) and 17,806,500 naira −49.1%($US118,710) for direct and in-direct costs respectively. Out-patient cost was estimated as 41,292,368 Naira ($US 275,282). The relatively high cost of outpatient care was largely due to cost of transportation for monthly follow up visits. Payments were mostly made through out-of-pocket spending.

Conclusion: The economic burden of HF in Nigeria is particularly high considering, the relatively young age of affected cases, a minimum wage of 18,000 Naira ($US120) per month and considerable component of out-of-pocket spending for those affected. Health reforms designed to mitigate the individual to societal burden imposed by the syndrome are required.