1
|
Bloomfield GS, Hill CL, Chiswell K, Cooper L, Gray S, Longenecker CT, Louzao D, Marsolo K, Meissner EG, Morse CG, Muiruri C, Thomas KL, Velazquez EJ, Vicini J, Pettit AC, Sanders G, Okeke NL. Cardiology Encounters for Underrepresented Racial and Ethnic Groups with Human Immunodeficiency Virus and Borderline Cardiovascular Disease Risk. J Racial Ethn Health Disparities 2024; 11:1509-1519. [PMID: 37160576 PMCID: PMC10632543 DOI: 10.1007/s40615-023-01627-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/27/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Underrepresented racial and ethnic groups (UREGs) with HIV have a higher risk of cardiovascular disease (CVD) compared with the general population. Referral to a cardiovascular specialist improves CVD risk factor management in high-risk individuals. However, patient and provider factors impacting the likelihood of UREGs with HIV to have an encounter with a cardiologist are unknown. METHODS We evaluated a cohort of UREGs with HIV and borderline CVD risk (10-year risk ≥ 5% by the pooled cohort equations or ≥ 7.5% by Framingham risk score). Participants received HIV-related care from 2014-2020 at four academic medical centers in the United States (U.S.). Adjusted Cox proportional hazards regression was used to estimate the association of patient and provider characteristics with time to first ambulatory cardiology encounter. RESULTS A total of 2,039 people with HIV (PWH) and borderline CVD risk were identified. The median age was 45 years (IQR: 36-50); 52% were female; and 94% were Black. Of these participants, 283 (14%) had an ambulatory visit with a cardiologist (17% of women vs. 11% of men, p < .001). In fully adjusted models, older age, higher body mass index (BMI), atrial fibrillation, multimorbidity, urban residence, and no recent insurance were associated with a greater likelihood of an encounter with a cardiologist. CONCLUSION In UREGs with HIV and borderline CVD risk, the strongest determinants of a cardiology encounter were diagnosed CVD, insurance type, and urban residence. Future research is needed to determine the extent to which these encounters impact CVD care practices and outcomes in this population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04025125.
Collapse
Affiliation(s)
- Gerald S Bloomfield
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA.
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Linda Cooper
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Shamea Gray
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Chris T Longenecker
- Division of Cardiology and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Darcy Louzao
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Keith Marsolo
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric G Meissner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Caryn G Morse
- Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | - Charles Muiruri
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kevin L Thomas
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Joseph Vicini
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - April C Pettit
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Gretchen Sanders
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Nwora Lance Okeke
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
2
|
Laddu D, Neeland IJ, Carnethon M, Stanford FC, Mongraw-Chaffin M, Barone Gibbs B, Ndumele CE, Longenecker CT, Chung ML, Rao G. Implementation of Obesity Science Into Clinical Practice: A Scientific Statement From the American Heart Association. Circulation 2024. [PMID: 38766861 DOI: 10.1161/cir.0000000000001221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Obesity is a recognized public health epidemic with a prevalence that continues to increase dramatically in nearly all populations, impeding progress in reducing incidence rates of cardiovascular disease. Over the past decade, obesity science has evolved to improve knowledge of its multifactorial causes, identifying important biological causes and sociological determinants of obesity. Treatments for obesity have also continued to develop, with more evidence-based programs for lifestyle modification, new pharmacotherapies, and robust data to support bariatric surgery. Despite these advancements, there continues to be a substantial gap between the scientific evidence and the implementation of research into clinical practice for effective obesity management. Addressing barriers to obesity science implementation requires adopting feasible methodologies and targeting multiple levels (eg, clinician, community, system, policy) to facilitate the delivery of obesity-targeted therapies and maximize the effectiveness of guideline-driven care to at-need patient populations. This scientific statement (1) describes strategies shown to be effective or promising for enhancing translation and clinical application of obesity-based research; (2) identifies key gaps in the implementation of obesity science into clinical practice; and (3) provides guidance and resources for health care professionals, health care systems, and other stakeholders to promote broader implementation and uptake of obesity science for improved population-level obesity management. In addition, advances in implementation science that hold promise to bridge the know-do gap in obesity prevention and treatment are discussed. Last, this scientific statement highlights implications for health research policy and future research to improve patient care models and optimize the delivery and sustainability of equitable obesity-related care.
Collapse
|
3
|
Amutuhaire W, Semitala FC, Kimera ID, Namugenyi C, Mulindwa F, Ssenyonjo R, Katwesigye R, Mugabe F, Mutungi G, Ssinabulya I, Schwartz JI, Katahoire AR, Musoke LS, Yendewa GA, Longenecker CT, Muddu M. Time to blood pressure control and predictors among patients receiving integrated treatment for hypertension and HIV based on an adapted WHO HEARTS implementation strategy at a large urban HIV clinic in Uganda. J Hum Hypertens 2024; 38:452-459. [PMID: 38302611 PMCID: PMC11076202 DOI: 10.1038/s41371-024-00897-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 02/03/2024]
Abstract
In this cohort study, we determined time to blood pressure (BP) control and its predictors among hypertensive PLHIV enrolled in integrated hypertension-HIV care based on the World Health Organization (WHO) HEARTS strategy at Mulago Immunosuppression Clinic in Uganda. From August 2019 to March 2020, we enrolled hypertensive PLHIV aged ≥ 18 years and initiated Amlodipine 5 mg mono-therapy for BP (140-159)/(90-99) mmHg or Amlodipine 5 mg/Valsartan 80 mg duo-therapy for BP ≥ 160/90 mmHg. Patients were followed with a treatment escalation plan until BP control, defined as BP < 140/90 mmHg. We used Cox proportional hazards models to identify predictors of time to BP control. Of 877 PLHIV enrolled (mean age 50.4 years, 62.1% female), 30% received mono-therapy and 70% received duo-therapy. In the monotherapy group, 66%, 88% and 96% attained BP control in the first, second and third months, respectively. For patients on duo-therapy, 56%, 83%, 88% and 90% achieved BP control in the first, second, third, and fourth months, respectively. In adjusted Cox proportional hazard analysis, higher systolic BP (aHR 0.995, 95% CI 0.989-0.999) and baseline ART tenofovir/lamivudine/efavirenz (aHR 0.764, 95% CI 0.637-0.917) were associated with longer time to BP control, while being on ART for >10 years was associated with a shorter time to BP control (aHR 1.456, 95% CI 1.126-1.883). The WHO HEARTS strategy was effective at achieving timely BP control among PLHIV. Additionally, monotherapy anti-hypertensive treatment for stage I hypertension is a viable option to achieve BP control and limit pill burden in resource limited HIV care settings.
Collapse
Affiliation(s)
- Willington Amutuhaire
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | | | | | | | - Frank Mulindwa
- Makerere University Infectious Diseases Institute, Kampala, Uganda
| | | | | | - Frank Mugabe
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | - Gerald Mutungi
- Department of non-communicable diseases, Uganda Ministry of Health, Kampala, Uganda
| | | | - Jeremy I Schwartz
- Yale School of Medicine, Section of General Internal Medicine, Connecticut, CT, USA
| | - Anne R Katahoire
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lewis S Musoke
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - George A Yendewa
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chris T Longenecker
- Department of Global Health and Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| |
Collapse
|
4
|
Searchinger C, Nalubwama H, Pulle J, Mehta R, Tumwbaze H, Kyarimpa R, Mwima R, Atukunda E, Bua B, Sarnacki R, Sherman MG, Oketcho M, Zimmerman M, Nakitto M, Longenecker CT, Webel A, Scheel A, Lwabi PS, Sable CA. Quality of Life in Ugandan Children and Young Adults After Surgery for Congenital Heart Disease: Mixed Methods Approach. Glob Heart 2024; 19:36. [PMID: 38638125 PMCID: PMC11025577 DOI: 10.5334/gh.1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
Background Health-related quality of life (HRQOL) is a critical issue for patients undergoing surgery for congenital heart disease (CHD) but has never been assessed in a low-income country. We conducted a cross-sectional mixed methods study with age-matched healthy siblings serving as controls at the Uganda Heart Institute. Methods One-hundred fifteen CHD pediatric and young adult patients and sibling control participants were recruited. Health-related quality of life was assessed using the Pediatric Quality of Life Inventory Version 4.0 in participants ages 5-17 and 36-Item Short Form Survey for young adults aged 18-25. A subset of 27 participants completed face-to-face interviews to supplement quantitative findings. Results Eighty-six pediatric (age 5-17) sibling and parent pairs completed Peds QOL surveys, and 29 young adult (age 18-25) sibling pairs completed SF-36 surveys. One third of patients had surgery in Uganda. Ventricular septal defects and tetralogy of Fallot were the most common diagnoses. Health-related quality of life scores in patients were lower across all domains compared to control participants in children. Reductions in physical and emotional domains of HRQOL were also statistically significant for young adults. Variables associated with lower HRQOL score on multivariate analysis in pediatric patients were younger age in the physical and emotional domains, greater number of surgeries in the physical domain and surgery outside Uganda in the school domain. The only predictor of lower HRQOL score in young adults was surgery outside Uganda in the social domain. Qualitative interviews identified a number of themes that correlated with survey results including abandonment by family, isolation from peers and community, financial hardship and social stigmatization. Conclusion Health-related quality of life was lower in Ugandan patients after CHD surgery than siblings. Younger patients and those who had surgery outside of Uganda had lower HRQOL. These data have important implications for patients undergoing CHD surgery in LMIC and have potential to inform interventions.
Collapse
Affiliation(s)
- Chloe Searchinger
- Princeton University, Princeton, NJ, USA
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | | | | | - Rittal Mehta
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | | | | | | | | | | | - Rachel Sarnacki
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | - Meredith G. Sherman
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| | | | | | | | - Chris T. Longenecker
- Division of Cardiology and Department of Global Health University of Washington School of Medicine, Seattle WA, USA
| | - Allison Webel
- University of Washington School of Nursing, Seattle WA, USA
| | - Amy Scheel
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Craig A. Sable
- Division of Cardiology and Global Health Initiative, Children’s National Hospital, Washington, DC, USA
| |
Collapse
|
5
|
Opara CC, Lan RH, Rwebembera J, Okello E, Watkins DA, Chang AY, Longenecker CT. Outcomes and care quality metrics for people living with rheumatic heart disease and atrial fibrillation in Uganda. Heart Rhythm O2 2024; 5:201-208. [PMID: 38690140 PMCID: PMC11056452 DOI: 10.1016/j.hroo.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Background Atrial fibrillation (AF) is a common complication of rheumatic heart disease (RHD) and is challenging to treat in lower-resourced settings in which RHD remains endemic. Objective We characterized demographics, treatment outcomes, and factors leading to care retention for participants with RHD and AF in Uganda. Methods We conducted a retrospective analysis of the Uganda national RHD registry between June 2009 and May 2018. Participants with AF or atrial flutter were included. Demographics, survival, and care metrics were compared with participants without AF. Multivariable logistic regression was used to identify factors associated with retention in care among participants with AF. Results A total of 1530 participants with RHD were analyzed and 293 (19%) had AF. The median age was 24 (interquartile range 14-38) years. Mortality was similar in both groups (adjusted hazard ratio 1.183, P = .77) over a median follow-up of 203 (interquartile range 98-275) days. A total of 79% of AF participants were prescribed anticoagulation, and 43% were aware of their target international normalized ratio. Retention in care was higher in participants with AF (18% vs 12%, P < .01). Factors associated with decreased retention in care include New York Heart Association functional class III/IV (adjusted odds ratio [OR] 0.48, 95% confidence interval [CI] 0.30-0.76) and distance to nearest health center (adjusted OR 0.94, 95% CI 0.90-0.99). Anticoagulation prescription was associated with enhanced care retention (adjusted OR 1.86, 95% CI 1.24-2.79). Conclusion Participants with RHD and AF in Uganda do not experience higher mortality than those without AF. Anticoagulation prescription rates are high. Although retention in care is poor among RHD participants, those with concurrent AF are more likely to be retained.
Collapse
Affiliation(s)
- Chinonso C. Opara
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
| | - Roy H. Lan
- Department of Medicine, Stanford University School of Medicine, California
| | | | - Emmy Okello
- Division of Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - David A. Watkins
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
| | - Andrew Y. Chang
- Division of Cardiology, Department of Epidemiology and Population Health, Stanford University, California
- Center for Innovation in Global Health, Stanford University, Stanford, California
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Chris T. Longenecker
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
| |
Collapse
|
6
|
Narendrula A, Brinza E, Horvat Davey C, Longenecker CT, Webel AR. Relationship between objectively measured physical activity and subclinical cardiovascular disease: a systematic review. BMJ Open Sport Exerc Med 2024; 10:e001596. [PMID: 38292295 PMCID: PMC10826575 DOI: 10.1136/bmjsem-2023-001596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
Introduction The association of physical activity (PA) with subclinical cardiovascular disease (CVD) is unclear. Clarifying this relationship may inform cardiovascular prevention strategies. Methods We performed a systematic review (CRD42021226089) using Medline, Embase, CINAHL and Cochrane (1 January 2000 to 1 September 2023). Studies published with adult populations exploring the relationship between objectively measured PA and subclinical CVD were included. Subclinical CVD was assessed using: ankle-brachial index (ABI); arterial stiffness; carotid artery disease; coronary artery atherosclerosis; endothelial function; and measures of cardiac structure and function. The Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) and Cochrane Risk of Bias tools were used for quality review. Results Of 68 included studies, most supported an inverse relationship between PA and subclinical CVD. Arterial stiffness was the most common outcome (n=40), and 33 studies suggested that less sedentary behaviour (SB), increased PA and/or higher intensity PA was associated with less arterial stiffness. Ten studies of carotid artery disease (total n=18), six of endothelial function (n=10), two of coronary artery disease (n=3) and all of ABI (n=6) suggested that PA or less SB is associated with less subclinical disease. Five studies assessing cardiac structure/function (n=6) suggested alterations in structure/function with PA. Conclusions PA reduces the risk of CVD events, and this systematic review demonstrates that some of the benefits may be mediated by an inverse association between PA and subclinical CVD. Interventions to increase PA are important for CVD prevention, so we provide a comprehensive overview of which surrogate outcome measures may be most useful to assess future CVD prevention interventions. PROSPERO registration number CRD42021226089.
Collapse
Affiliation(s)
- Aparna Narendrula
- Internal Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Ellen Brinza
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christine Horvat Davey
- Case Western Reserve University Frances Payne Bolton School of Nursing, Cleveland, Ohio, USA
| | - Chris T Longenecker
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Allison R Webel
- University of Washington School of Nursing, Seattle, Washington, USA
| |
Collapse
|
7
|
Ogungbe O, Longenecker CT, Beaton A, de Loizaga S, Brant LCC, Turkson Ocran RN, Bastani P, Sarfo FS, Commodore‐Mensah Y. Advancing Cardiovascular Health Equity Globally Through Digital Technologies. J Am Heart Assoc 2024; 13:e031237. [PMID: 38226506 PMCID: PMC10926780 DOI: 10.1161/jaha.123.031237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/30/2023] [Indexed: 01/17/2024]
Abstract
Cardiovascular diseases (CVDs) remain the leading cause of death and disability worldwide. Digital health technologies are important public health interventions for addressing the burden of cardiovascular disease. In this article, we discuss the importance of translating digital innovations in research-funded projects to low-resource settings globally to advance global cardiovascular health equity. We also discuss current global cardiovascular health inequities and the digital health divide within and between countries. We present various considerations for translating digital innovations across different settings across the globe, including reciprocal innovation, a "bidirectional, co-constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings." In this case, afferent reciprocal innovations may flow from high-income countries toward low- and middle-income countries, and efferent reciprocal innovations may be exported to high-income countries from low- and middle-income countries with adaptation. Finally, we discuss opportunities for bidirectional learning between local and global institutions and highlight examples of projects funded through the American Heart Association Health and Innovation Strategically Funded Research Network that have been adapted to lower-resource settings or have the potential to be adapted to lower-resource settings.
Collapse
Affiliation(s)
| | - Chris T. Longenecker
- Division of Cardiology and Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Andrea Beaton
- Heart Institute, Cincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
| | - Sarah de Loizaga
- Heart Institute, Cincinnati Children’s Hospital Medical CenterCincinnatiOHUSA
- University of Cincinnati College of MedicineCincinnatiOHUSA
| | - Luisa Campos Caldeira Brant
- Faculty of Medicine and Telehealth Center, Hospital das ClínicasUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Ruth‐Alma N. Turkson Ocran
- Beth Israel Deaconess Medical Center, Division of General MedicineBostonMAUSA
- Havard Medical SchoolBostonMAUSA
| | - Pouya Bastani
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Fred Stephen Sarfo
- Division of Neurology, Department of MedicineKwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Yvonne Commodore‐Mensah
- Johns Hopkins School of NursingBaltimoreMDUSA
- Department of EpidemiologyBloomberg School of Public HealthBaltimoreMDUSA
| |
Collapse
|
8
|
Azizi Z, Golbus JR, Spaulding EM, Hwang PH, Ciminelli ALA, Lacar K, Hernandez MF, Gilotra NA, Din N, Brant LCC, Au R, Beaton A, Nallamothu BK, Longenecker CT, Martin SS, Dorsch MP, Sandhu AT. Challenge of Optimizing Medical Therapy in Heart Failure: Unlocking the Potential of Digital Health and Patient Engagement. J Am Heart Assoc 2024; 13:e030952. [PMID: 38226520 PMCID: PMC10926816 DOI: 10.1161/jaha.123.030952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Affiliation(s)
- Zahra Azizi
- Center for Digital HealthStanford UniversityStanfordCA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCA
| | - Jessica R. Golbus
- Division of Cardiovascular Diseases, Department of Internal MedicineUniversity of MichiganAnn ArborMI
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP)University of MichiganAnn ArborMI
- The Center for Clinical Management and ResearchAnn Arbor VA Medical CenterAnn ArborMI
| | - Erin M. Spaulding
- Johns Hopkins University School of NursingBaltimoreMD
- mTECH Center, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Phillip H. Hwang
- Department of EpidemiologyBoston University School of Public HealthBostonMA
| | - Ana L. A. Ciminelli
- School of Medicine and Hospital das Clínicas Telehealth CenterUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Kathleen Lacar
- Center for Digital HealthStanford UniversityStanfordCA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCA
| | - Mario Funes Hernandez
- Center for Digital HealthStanford UniversityStanfordCA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCA
| | - Nisha A. Gilotra
- mTECH Center, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Natasha Din
- Center for Digital HealthStanford UniversityStanfordCA
- Veterans Affairs Palo Alto Healthcare SystemPalo AltoCA
| | - Luisa C. C. Brant
- School of Medicine and Hospital das Clínicas Telehealth CenterUniversidade Federal de Minas GeraisBelo HorizonteBrazil
| | - Rhoda Au
- Department of EpidemiologyBoston University School of Public HealthBostonMA
- Department of Anatomy and NeurobiologyBoston University School of MedicineBostonMA
| | - Andrea Beaton
- Department of PediatricsUniversity of Cincinnati School of MedicineCincinnatiOH
- Department of PediatricsThe Heart Institute at Cincinnati Children’s HospitalCincinnatiOH
| | - Brahmajee K. Nallamothu
- Division of Cardiovascular Diseases, Department of Internal MedicineUniversity of MichiganAnn ArborMI
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP)University of MichiganAnn ArborMI
- The Center for Clinical Management and ResearchAnn Arbor VA Medical CenterAnn ArborMI
| | - Chris T. Longenecker
- Division of Cardiology and Department of Global HealthUniversity of WashingtonSeattleWA
| | - Seth S. Martin
- mTECH Center, Division of Cardiology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | | | - Alexander T. Sandhu
- Center for Digital HealthStanford UniversityStanfordCA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCA
- Veterans Affairs Palo Alto Healthcare SystemPalo AltoCA
| |
Collapse
|
9
|
Azizi Z, Broadwin C, Islam S, Schenk J, Din N, Hernandez MF, Wang P, Longenecker CT, Rodriguez F, Sandhu AT. Digital Health Interventions for Heart Failure Management in Underserved Rural Areas of the United States: A Systematic Review of Randomized Trials. J Am Heart Assoc 2024; 13:e030956. [PMID: 38226517 PMCID: PMC10926837 DOI: 10.1161/jaha.123.030956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 11/17/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Heart failure disproportionately affects individuals residing in rural areas, leading to worse health outcomes. Digital health interventions have been proposed as a promising approach for improving heart failure management. This systematic review aims to identify randomized trials of digital health interventions for individuals living in underserved rural areas with heart failure. METHODS AND RESULTS We conducted a systematic review by searching 6 databases (CINAHL, EMBASE, MEDLINE, Web of Science, Scopus, and PubMed; 2000-2023). A total of 30 426 articles were identified and screened. Inclusion criteria consisted of digital health randomized trials that were conducted in underserved rural areas of the United States based on the US Census Bureau's classification. Two independent reviewers screened the studies using the National Heart, Lung, and Blood Institute tool to evaluate the risk of bias. The review included 5 trials from 6 US states, involving 870 participants (42.9% female). Each of the 5 studies employed telemedicine, 2 studies used remote monitoring, and 1 study used mobile health technology. The studies reported improvement in self-care behaviors in 4 trials, increased knowledge in 2, and decreased cardiovascular mortality in 1 study. However, 3 trials revealed no change or an increase in health care resource use, 2 showed no change in cardiac biomarkers, and 2 demonstrated an increase in anxiety. CONCLUSIONS The results suggest that digital health interventions have the potential to enhance self-care and knowledge of patients with heart failure living in underserved rural areas. However, further research is necessary to evaluate their impact on clinical outcomes, biomarkers, and health care resource use. REGISTRATION URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42022366923.
Collapse
Affiliation(s)
- Zahra Azizi
- Center for Digital HealthStanford UniversityStanfordCAUSA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | | | - Sumaiya Islam
- Center for Digital HealthStanford UniversityStanfordCAUSA
| | - Jamie Schenk
- Center for Digital HealthStanford UniversityStanfordCAUSA
| | - Natasha Din
- Center for Digital HealthStanford UniversityStanfordCAUSA
- Veterans Affairs Palo Alto Healthcare SystemPalo AltoCAUSA
| | - Mario Funes Hernandez
- Center for Digital HealthStanford UniversityStanfordCAUSA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Paul Wang
- Center for Digital HealthStanford UniversityStanfordCAUSA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Chris T. Longenecker
- Division of Cardiology and Department of Global HealthUniversity of WashingtonSeattleWAUSA
| | - Fatima Rodriguez
- Center for Digital HealthStanford UniversityStanfordCAUSA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| | - Alex T. Sandhu
- Center for Digital HealthStanford UniversityStanfordCAUSA
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of MedicineStanford UniversityStanfordCAUSA
| |
Collapse
|
10
|
Nakagaayi D, Pulle J, Otim I, Akiya OC, Otto OH, Danforth K, Longenecker CT, Ollberding N, Sarnacki R, Nakitto M, Buonfiglio S, Rwebembera J, Sable C, Sherr K, Su Y, Webel A, Beaton A, Okello E, Watkins D. A decentralized delivery program for rheumatic heart disease treatment and prevention in Uganda. Nat Med 2024; 30:12-13. [PMID: 38167934 DOI: 10.1038/s41591-023-02646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Doreen Nakagaayi
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda.
| | - Jafesi Pulle
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Isaac Otim
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | | | | | - Kristen Danforth
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Chris T Longenecker
- Department of Global Health, University of Washington, Seattle, WA, USA
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Miriam Nakitto
- Department of Research, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Samantha Buonfiglio
- Department of Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joselyn Rwebembera
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Craig Sable
- Children's National Hospital, Washington, DC, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Yanfang Su
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Allison Webel
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Andrea Beaton
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Emmy Okello
- Department of Adult Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
11
|
Davey CH, Longenecker CT, Brinza E, McCabe M, Hileman CO, Vedanthan R, Bosworth HB, Webel A. The impact of COVID-19 on cardiovascular health behaviors in people living with HIV. AIDS Care 2023; 35:1911-1918. [PMID: 36755400 PMCID: PMC10406970 DOI: 10.1080/09540121.2023.2175195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/13/2022] [Indexed: 02/10/2023]
Abstract
The COVID-19 pandemic's impact on cardiovascular health behaviors including diet, physical activity, medication adherence, and self-care among people living with HIV (PLWH) remains unknown. Using qualitative analyses, we examined the impact of the COVID-19 pandemic on cardiovascular health behaviors among PLWH. Twenty-four PLWH were enrolled in this multisite study from September to October 2020. Individuals participated in semi-structured telephone interviews that were recorded, transcribed, and coded by 4 independent coders. Codes were adjudicated and analyzed for common themes. Participants were, on average, 59.2 years old (+/-9.4), 75% African American (n = 18) and 71% male (n = 17). The pandemic altered cardiovascular disease health behaviors. PLWH changed diet based on stay-at-home orders and food access. Alterations in physical activity included transitioning from gym and group class exercise to home-based exercise. Antiretroviral adherence was maintained, even when other health behaviors wavered, suggesting resilience in PLWH that may be harnessed to maintain other health behaviors.
Collapse
Affiliation(s)
| | - Chris T. Longenecker
- Department of Medicine, Division of Cardiovascular Medicine, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Ellen Brinza
- Lerner College of Medicine, Cleveland Clinic, Cleveland, USA
| | - Madeline McCabe
- College of Medicine, Case Western Reserve University, Cleveland, USA
| | | | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, USA
| | - Hayden B. Bosworth
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, USA
- Duke University School of Nursing, Durham, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA
| | - Allison Webel
- School of Nursing, University of Washington, Seattle, USA
| |
Collapse
|
12
|
Musoke L, Bosworth HB, Dickson C, Gentry P, Strawbridge E, Subramaniam S, Gierisch J, Smith V, Woolson S, Pura J, Amutuhaire W, Naggie S, Schexnayder J, Hall K, Longenecker CT, Harris NM, Rogers C, Van Epps P. A telehealth-delivered intervention to extend the veteran HIV treatment cascade for cardiovascular disease prevention: V-EXTRA-CVD study protocol for a randomized controlled trial. HIV Res Clin Pract 2023; 24:2261747. [PMID: 37800987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Background: Veterans living with HIV have up to twice the risk of atherosclerotic cardiovascular disease (ASCVD) compared to those without HIV.Objective: Our study seeks to test a non-physician led virtual self-management implementation strategy to reduce ASCVD risk among people living with HIV (PWH). We aim to conduct a randomized control trial among PWH (n = 300) with a diagnosis of hypertension (HTN) who are enrolled in Veterans Health Administration (VHA) clinics, on suppressive antiretroviral therapy (ART), randomized 1:1 to intervention vs. education control for a 12-month duration.Methods: Using human centered design approach, we have adapted a previous 5-component telehealth focused, non-physician led intervention to a Veteran population. The education control arm receives enhanced education in addition to usual care. The primary outcome is 6 mmHg reduction in systolic BP over 12-month in the intervention arm compared to the control arm. The secondary outcome is a 12-month difference in non-HDL cholesterol. While each component of our intervention has an evidence base, they have not been tested together in an HIV context.Conclusion: The proposed multicomponent intervention has the potential to improve cardiovascular outcomes in PWH using novel virtual care methods in a patient centered care approach.
Collapse
Affiliation(s)
- Lewis Musoke
- Section of Infectious Diseases, VA Northeast Ohio Healthcare System, Case Western Reserve University, Cleveland, OH, USA
| | - Hayden B Bosworth
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
- Departments of Population Health Sciences, Medicine, Psychiatry, Nursing, Duke University Medical Center, Durham, NC, USA
| | | | - Pamela Gentry
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Elizabeth Strawbridge
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | | | - Jennifer Gierisch
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Valerie Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Sandra Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - John Pura
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | | | - Susanna Naggie
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Julie Schexnayder
- University of Alabama at Birmingham School of Nursing, Birmingham, AL, USA
| | - Karen Hall
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA
| | - Chris T Longenecker
- Division of Cardiology, Department of Global Health, University of Washington, Seattle, WA, USA
| | - Nadine M Harris
- Section of Infectious Diseases, Atlanta VA Healthcare System, Decatur, GA, USA
- Division of Infectious Diseases, Department of I Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Puja Van Epps
- Section of Infectious Diseases, VA Northeast Ohio Healthcare System, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
13
|
Rwebembera J, Chang AY, Kitooleko SM, Kaudha G, de Loizaga S, Nalule M, Ahabwe K, Zhang W, Okello E, Sinha P, Mwambu T, Sable C, Beaton A, Longenecker CT. Clinical Profile and Outcomes of Rheumatic Heart Disease Patients Undergoing Surgical Valve Procedures in Uganda. Glob Heart 2023; 18:62. [PMID: 38028964 PMCID: PMC10655755 DOI: 10.5334/gh.1260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 08/07/2023] [Indexed: 12/01/2023] Open
Abstract
Background Chronic valvular heart disease is a well-known, long-term complication of acute rheumatic fever (ARF), which remains a major public health problem in low- and middle-income countries. Access to surgical management remains limited. Outcomes of the minority proportion of patients that access surgery have not been described in Uganda. Objectives To describe the volume and type of rheumatic heart disease (RHD) valvular interventions and the outcomes of operated patients in the Uganda RHD registry. Methods We performed a retrospective cohort study of all valve surgery procedures identified in the Uganda RHD registry through December 2021. Results Three hundred and sixty-seven surgical procedures were performed among 359 patients. More than half were among young (55.9% were ≤20 years of age), female (59.9%) patients. All patients were censored at 15 years. The median (IQR) follow up period was 43 (22,79) months. Nearly half of surgeries (46.9%) included interventions on multiple valves, and most valvular operations were replacements with mechanical prostheses (96.6%). Over 70% of the procedures were sponsored by charity organizations. The overall mortality of patients who underwent surgery was 13% (47/359), with over half of the mortalities occurring within the first year following surgery (27/47; 57.4%). Fifteen-year survival or freedom from re-operation was not significantly different between those receiving valve replacements and those receiving valve repair (log-rank p = 0.76). Conclusions There has been increasing access to valve surgery among Ugandan patients with RHD. Post-operative survival is similar to regionally reported rates. The growing cohort of patients living with prosthetic valves necessitates national expansion and decentralization of post-operative care services. Major reliance on charity funding of surgery is unsustainable, thus calling for locally generated and controlled support mechanisms such as a national health insurance scheme. The central illustration (Figure 1) provides a summary of our findings and recommendations.
Collapse
Affiliation(s)
| | - Andrew Y. Chang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, USA
- Center for Innovation in Global Health, Stanford University, USA
| | | | | | - Sarah de Loizaga
- Stanford Cardiovascular Institute, Stanford University, USA
- Cincinnati Children’s Hospital Medical Center, The Heart Institute, Cincinnati, OH 45229, USA
| | | | | | | | - Emmy Okello
- Uganda Heart Institute, Kampala, Uganda
- School of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Pranava Sinha
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Craig Sable
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrea Beaton
- Stanford Cardiovascular Institute, Stanford University, USA
- Department of Internal Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Chris T. Longenecker
- Pediatric Cardiology, Children’s National Hospital, Washington, District of Columbia, USA
| |
Collapse
|
14
|
Durstenfeld MS, Wilson MP, Jankowski CM, Ditzenberger GL, Longenecker CT, Erlandson KM. Chronotropic Incompetence among People with HIV Improves with Exercise Training in the Exercise for Healthy Aging Study. medRxiv 2023:2023.11.10.23298367. [PMID: 37986954 PMCID: PMC10659453 DOI: 10.1101/2023.11.10.23298367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Background People with HIV (PWH) have lower exercise capacity compared to HIV-uninfected peers, which may be explained by chronotropic incompetence (CI), the inability to increase heart rate during exercise. Methods The Exercise for Healthy Aging Study included adults ages 50-75 with and without HIV. Participants completed 12 weeks of moderate intensity exercise, before randomization to moderate or high intensity for 12 additional weeks. We compared adjusted heart rate reserve (AHRR; CI <80%) on cardiopulmonary exercise testing by HIV serostatus, and change from baseline to 12 and 24 weeks using mixed effects models. Results Among 32 PWH and 37 controls (median age 56, 7% female, mean BMI 28 kg/m2), 28% of PWH compared to 11% of controls had CI at baseline (p=0.067). AHRR was lower among PWH (91 vs 102%; difference 11%, 95% CI 2.5-19.7; p=0.01). At week 12, AHRR normalized among PWH (+8%, 95% CI 4-11; p<0.001) and was sustained at week 24 (+5, 95%CI 1-9; p=0.008) compared to no change among controls (95%CI -4 to 4; p=0.95; pinteraction=0.004). After 24 weeks of exercise, only 15% PWH and 10% of controls had CI (p=0.70). Conclusions Chronotropic incompetence contributes to reduced exercise capacity among PWH and improves with exercise training.
Collapse
Affiliation(s)
- Matthew S. Durstenfeld
- Division of Cardiology at ZSFG and Department of Medicine, University of California, San Francisco (UCSF), USA
| | - Melissa P. Wilson
- Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Catherine M. Jankowski
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Grace L. Ditzenberger
- Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Chris T. Longenecker
- Division of Cardiology and Department of Global Health, University of Washington Medical Center, Seattle, WA, USA
| | - Kristine M. Erlandson
- Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
15
|
Minja NW, Pulle J, Rwebembera J, de Loizaga SR, Fall N, Ollberding N, Abrams J, Atala J, Kamarembo J, Oyella L, Odong F, Nalubwama H, Nakagaayi D, Sarnacki R, Su Y, Dexheimer JW, Sable C, Longenecker CT, Danforth K, Okello E, Beaton AZ, Watkins DA. Evaluating the implementation of a dynamic digital application to enable community-based decentralisation of rheumatic heart disease case management in Uganda: protocol for a hybrid type III effectiveness-implementation study. BMJ Open 2023; 13:e071540. [PMID: 37898491 PMCID: PMC10619093 DOI: 10.1136/bmjopen-2022-071540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 09/19/2023] [Indexed: 10/30/2023] Open
Abstract
INTRODUCTION Rheumatic heart disease (RHD) affects over 39 million people worldwide, the majority in low-income and middle-income countries. Secondary antibiotic prophylaxis (SAP), given every 3-4 weeks can improve outcomes, provided more than 80% of doses are received. Poor adherence is strongly correlated with the distance travelled to receive prophylaxis. Decentralising RHD care has the potential to bridge these gaps and at least maintain or potentially increase RHD prophylaxis uptake. A package of implementation strategies was developed with the aim of reducing barriers to optimum SAP uptake. METHODS AND ANALYSIS A hybrid implementation-effectiveness study type III was designed to evaluate the effectiveness of a package of implementation strategies including a digital, cloud-based application to support decentralised RHD care, integrated into the public healthcare system in Uganda. Our overarching hypothesis is that secondary prophylaxis adherence can be maintained or improved via a decentralisation strategy, compared with the centralised delivery strategy, by increasing retention in care. To evaluate this, eligible patients with RHD irrespective of their age enrolled at Lira and Gulu hospital registry sites will be consented for decentralised care at their nearest participating health centre. We estimated a sample size of 150-200 registrants. The primary outcome will be adherence to secondary prophylaxis while detailed implementation measures will be collected to understand barriers and facilitators to decentralisation, digital application tool adoption and ultimately its use and scale-up in the public healthcare system. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board (IRB) at Cincinnati Children's Hospital Medical Center (IRB 2021-0160) and Makerere University School of Medicine Research Ethics Committee (Mak-SOMREC-2021-61). Participation will be voluntary and informed consent or assent (>8 but <18) will be obtained prior to participation. At completion, study findings will be communicated to the public, key stakeholders and submitted for publication.
Collapse
Affiliation(s)
- Neema W Minja
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania, United Republic of
| | - Jafesi Pulle
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Joselyn Rwebembera
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
| | - Sarah R de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ndate Fall
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica Abrams
- Department of Pediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Reach, Cape Town, South Africa
| | - Jenifer Atala
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Jenipher Kamarembo
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Linda Oyella
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Francis Odong
- Rheumatic Heart Disease Research Collaborative, Uganda Heart Institute, Kampala, Uganda
| | - Haddy Nalubwama
- Department is Obstetrics and Gynaecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Doreen Nakagaayi
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rachel Sarnacki
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Judith W Dexheimer
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Craig Sable
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chris T Longenecker
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Kristen Danforth
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Emmy Okello
- Department of Adult Cardiology, Uganda Heart Institute Ltd, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrea Zawacki Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David A Watkins
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of General Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
16
|
Spaulding EM, Isakadze N, Molello N, Khoury SR, Gao Y, Young L, Antonsdottir IM, Azizi Z, Dorsch MP, Golbus JR, Ciminelli A, Brant LCC, Himmelfarb CR, Coresh J, Marvel FA, Longenecker CT, Commodore-Mensah Y, Gilotra NA, Sandhu A, Nallamothu B, Martin SS. Use of Human-Centered Design Methodology to Develop a Digital Toolkit to Optimize Heart Failure Guideline-Directed Medical Therapy. J Cardiovasc Nurs 2023; 39:00005082-990000000-00142. [PMID: 37855732 PMCID: PMC11026295 DOI: 10.1097/jcn.0000000000001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND Guideline-directed medical therapies (GDMTs) improve quality of life and health outcomes for patients with heart failure (HF). However, GDMT utilization is suboptimal among patients with HF. OBJECTIVE The aims of this study were to engage key stakeholders in semistructured, virtual human-centered design sessions to identify challenges in GDMT optimization posthospitalization and inform the development of a digital toolkit aimed at optimizing HF GDMTs. METHODS For the human-centered design sessions, we recruited (a) clinicians who care for patients with HF across 3 hospital systems, (b) patients with HF with reduced ejection fraction (ejection fraction ≤ 40%) discharged from the hospital within 30 days of enrollment, and (c) caregivers. All participants were 18 years or older, English speaking, with Internet access. RESULTS A total of 10 clinicians (median age, 37 years [interquartile range, 35-41], 12 years [interquartile range, 10-14] of experience caring for patients with HF, 80% women, 50% White, 50% nurse practitioners) and three patients and one caregiver (median age 57 years [IQR: 53-60], 75% men, 50% Black, 75% married) were included. Five themes emerged from the clinician sessions on challenges to GDMT optimization (eg, barriers to patient buy-in). Six themes on challenges (eg, managing medications), 4 themes on motivators (eg, regaining independence), and 3 themes on facilitators (eg, social support) to HF management arose from the patient and caregiver sessions. CONCLUSIONS The clinician, patient, and caregiver insights identified through human-centered design will inform a digital toolkit aimed at optimizing HF GDMTs, including a patient-facing smartphone application and clinician dashboard. This digital toolkit will be evaluated in a multicenter, clinical trial.
Collapse
Affiliation(s)
- Erin M. Spaulding
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Nino Isakadze
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Nancy Molello
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
| | - Shireen R. Khoury
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Yumin Gao
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Lisa Young
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | | | - Zahra Azizi
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, US
- Center for Digital Health, Stanford University, Stanford, CA, US
| | | | - Jessica R. Golbus
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI, US
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, MI, US
- The Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI, US
| | - Ana Ciminelli
- Faculdade de Medicina & Centro de Telessaúde do Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Luisa C. C. Brant
- Faculdade de Medicina & Centro de Telessaúde do Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Cheryl R. Himmelfarb
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
| | - Francoise A. Marvel
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
| | - Chris T. Longenecker
- Division of Cardiology and Department of Global Health, University of Washington, Seattle, WA, US
| | - Yvonne Commodore-Mensah
- Johns Hopkins University School of Nursing, Baltimore, MD, US
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
| | | | - Alexander Sandhu
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, US
| | - Brahmajee Nallamothu
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, MI, US
- Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), University of Michigan, MI, US
- The Center for Clinical Management and Research, Ann Arbor VA Medical Center, MI, US
| | - Seth S. Martin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, US
- Digital Health Innovation Laboratory, Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, US
- Johns Hopkins University School of Medicine, Baltimore, MD, US
- Center for Health Equity, Johns Hopkins University, Baltimore, MD, US
- Johns Hopkins University Whiting School of Engineering, Baltimore, MD, US
| |
Collapse
|
17
|
de Loizaga SR, Pulle J, Rwebembera J, Abrams J, Atala J, Chesnut E, Danforth K, Fall N, Felicelli N, Lapthorn K, Longenecker CT, Minja NW, Moore RA, Morrison R, Mwangi J, Nakagaayi D, Nakitto M, Sable C, Sanyahumbi A, Sarnacki R, Thembo J, Vincente SL, Watkins D, Zühlke L, Okello E, Beaton A, Dexheimer JW. Development and User Testing of a Dynamic Tool for Rheumatic Heart Disease Management. Appl Clin Inform 2023; 14:866-877. [PMID: 37914157 PMCID: PMC10620041 DOI: 10.1055/s-0043-1774812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 08/08/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVE Most rheumatic heart disease (RHD) registries are static and centralized, collecting epidemiological and clinical data without providing tools to improve care. We developed a dynamic cloud-based RHD case management application with the goal of improving care for patients with RHD in Uganda. METHODS The Active Community Case Management Tool (ACT) was designed to improve community-based case management for chronic disease, with RHD as the first test case. Global and local partner consultation informed selection of critical data fields and prioritization of application functionality. Multiple stages of review and revision culminated in user testing of the application at the Uganda Heart Institute. RESULTS Global and local partners provided feedback of the application via survey and interview. The application was well received, and top considerations included avenues to import existing patient data, considering a minimum data entry form, and performing a situation assessment to tailor ACT to the health system setup for each new country. Test users completed a postuse survey. Responses were favorable regarding ease of use, desire to use the application in regular practice, and ability of the application to improve RHD care in Uganda. Concerns included appropriate technical skills and supports and potential disruption of workflow. CONCLUSION Creating the ACT application was a dynamic process, incorporating iterative feedback from local and global partners. Results of the user testing will help refine and optimize the application. The ACT application showed potential for utility and integration into existing care models in Uganda.
Collapse
Affiliation(s)
- Sarah R. de Loizaga
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
| | - Jafesi Pulle
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | - Jessica Abrams
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Reach, Cape Town, South Africa
| | - Jenifer Atala
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Emily Chesnut
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Kristen Danforth
- Department of Global Health & Division of Cardiology, University of Washington, Seattle, Washington, United States
| | - Ndate Fall
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Nicholas Felicelli
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Karen Lapthorn
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Chris T. Longenecker
- Department of Global Health & Division of Cardiology, University of Washington, Seattle, Washington, United States
| | - Neema W. Minja
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Ryan A. Moore
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
| | - Riley Morrison
- Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | | | | | - Miriam Nakitto
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Craig Sable
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, United States
| | - Amy Sanyahumbi
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, United States
| | - Rachel Sarnacki
- Department of Cardiology, Children's National Medical Center, Washington, District of Columbia, United States
| | | | | | - David Watkins
- Department of Global Health & Division of Cardiology, University of Washington, Seattle, Washington, United States
| | - Liesl Zühlke
- Division of Cardiology and Paediatric Cardiology, Department of Medicine/Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - Emmy Okello
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Andrea Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
| | - Judith W. Dexheimer
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, United States
- Division of Emergency Medicine and Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| |
Collapse
|
18
|
Narendrula A, Ajani K, Lang J, Brinza E, Longenecker CT. Psychological distress and health perception in patients with a previous myocardial infarction or stroke: a national cross-sectional study. BMC Cardiovasc Disord 2023; 23:430. [PMID: 37649045 PMCID: PMC10468856 DOI: 10.1186/s12872-023-03422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND While understanding the impact of mental health on health perception improves patient-centered care, this relationship is not well-established in patients with cardiovascular disease (CVD). We examined the relationship between psychological distress and health perception in patients with a previous myocardial infarction (MI) and/or stroke. METHODS We extracted data for patients with a previous MI and/or stroke from the 2019 National Health Interview Survey (NHIS). Health perception was self-reported. Presence and severity of anxiety and depression were estimated using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-8 (PHQ-8). Binary analyses of anxiety/depression, multivariable logistic regressions controlling for confounders, and univariable analyses of confounders and anxiety/depression severity were performed. RESULTS Of 31,948 individuals for whom data on MI/stroke was available, 1235 reported a previous MI and 1203 a previous stroke. The odds of positive perceived health status were lower for individuals with anxiety/depression compared to those without anxiety/depression in both post-MI (anxiety OR 0.52, 95% CI = 0.32-0.85, P < 0.001; depression OR 0.45, 95% CI = 0.29-0.7, P < 0.001) and post-stroke groups (anxiety OR 0.61, 95% CI = 0.39-0.97, P < 0.001; depression OR 0.37, 95% CI = 0.25-0.55, P < 0.001) upon multivariable analyses. Increasing severity of anxiety/depression was also associated with worse perception of health status upon univariable analysis. CONCLUSION Among patients with a previous acute CVD event, those with psychological distress have worse perception of their health status. Understanding the range of patient health perceptions can help physicians provide more patient-centered care and encourage patient behaviors that may improve both CVD and mental health outcomes.
Collapse
Affiliation(s)
- Aparna Narendrula
- New York University Grossman School of Medicine, 550 First Avenue, NBV 16 North 30, 10016, New York, NY, USA.
| | - Kiran Ajani
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jacob Lang
- New York-Presbyterian Hospital - Weill Cornell Medicine, New York, NY, USA
| | - Ellen Brinza
- University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | | |
Collapse
|
19
|
Muddu M, Semitala FC, Kimera ID, Musimbaggo DJ, Mbuliro M, Ssennyonjo R, Kigozi SP, Katwesigye R, Ayebare F, Namugenyi C, Mugabe F, Mutungi G, Longenecker CT, Katahoire AR, Schwartz JI, Ssinabulya I. Using the RE-AIM framework to evaluate the implementation and effectiveness of a WHO HEARTS-based intervention to integrate the management of hypertension into HIV care in Uganda: a process evaluation. Implement Sci Commun 2023; 4:102. [PMID: 37626415 PMCID: PMC10463385 DOI: 10.1186/s43058-023-00488-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND World Health Organization (WHO) HEARTS packages are increasingly used to control hypertension. However, their feasibility in persons living with HIV (PLHIV) is unknown. We studied the effectiveness and implementation of a WHO HEARTS intervention to integrate the management of hypertension into HIV care. METHODS This was a mixed methods study at Uganda's largest HIV clinic. Components of the adapted WHO HEARTS intervention were lifestyle counseling, free hypertension medications, hypertension treatment protocol, task shifting, and monitoring tools. We determined the effectiveness of the intervention among PLHIV by comparing hypertension and HIV outcomes at baseline and 21 months. The RE-AIM framework was used to evaluate the implementation outcomes of the intervention at 21 months. We conducted four focus group discussions with PLHIV (n = 42), in-depth interviews with PLHIV (n = 9), healthcare providers (n = 15), and Ministry of Health (MoH) policymakers (n = 2). RESULTS Reach: Among the 15,953 adult PLHIV in the clinic, of whom 3892 (24%) had been diagnosed with hypertension, 1133(29%) initiated integrated hypertension-HIV treatment compared to 39 (1%) at baseline. Among the enrolled patients, the mean age was 51.5 ± 9.7 years and 679 (62.6%) were female. EFFECTIVENESS Among the treated patients, hypertension control improved from 9 to 72% (p < 0.001), mean systolic blood pressure (BP) from 153.2 ± 21.4 to 129.2 ± 15.2 mmHg (p < 0.001), and mean diastolic BP from 98.5 ± 13.5 to 85.1 ± 9.7 mmHg (p < 0.001). Overall, 1087 (95.9%) of patients were retained by month 21. HIV viral suppression remained high, 99.3 to 99.5% (p = 0.694). Patients who received integrated hypertension-HIV care felt healthy and saved more money. Adoption: All 48 (100%) healthcare providers in the clinic were trained and adopted the intervention. Training healthcare providers on WHO HEARTS, task shifting, and synchronizing clinic appointments for hypertension and HIV promoted adoption. IMPLEMENTATION WHO HEARTS intervention was feasible and implemented with fidelity. Maintenance: Leveraging HIV program resources and adopting WHO HEARTS protocols into national guidelines will promote sustainability. CONCLUSIONS The WHO HEARTS intervention promoted the integration of hypertension management into HIV care in the real-world setting. It was acceptable, feasible, and effective in controlling hypertension and maintaining optimal viral suppression among PLHIV. Integrating this intervention into national guidelines will promote sustainability.
Collapse
Affiliation(s)
- Martin Muddu
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda.
| | - Fred Collins Semitala
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Derick Kimera
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | - Mary Mbuliro
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Rebecca Ssennyonjo
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | - Rodgers Katwesigye
- Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | | | | | | | | | | | | | - Jeremy I Schwartz
- Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Isaac Ssinabulya
- Mulago Hospital Complex, Uganda Heart Institute, Kampala, Uganda
| |
Collapse
|
20
|
Funderburg NT, Shive CL, Chen Z, Tatsuoka C, Bowman ER, Longenecker CT, McComsey GA, Clagett BM, Dorazio D, Freeman ML, Sieg SF, Moisi D, Anthony DD, Jacobson JM, Stein SL, Calabrese LH, Landay A, Flexner C, Crawford KW, Capparelli EV, Rodriguez B, Lederman MM. Interleukin 6 Blockade With Tocilizumab Diminishes Indices of Inflammation That Are Linked to Mortality in Treated Human Immunodeficiency Virus Infection. Clin Infect Dis 2023; 77:272-279. [PMID: 37011013 PMCID: PMC10371305 DOI: 10.1093/cid/ciad199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/23/2023] [Accepted: 03/31/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND People with human immunodeficiency virus (PWH) are at increased risk for comorbidities, and plasma interleukin 6 (IL-6) levels are among the most robust predictors of these outcomes. Tocilizumab (TCZ) blocks the receptor for IL-6, inhibiting functions of this cytokine. METHODS This was a 40-week, placebo-controlled, crossover trial (NCT02049437) where PWH on stable antiretroviral therapy (ART) were randomized to receive 3 monthly doses of TCZ or matching placebo intravenously. Following a 10-week treatment period and a 12-week washout, participants were switched to the opposite treatment. The primary endpoints were safety and posttreatment levels of C-reactive protein (CRP) and CD4+ T-cell cycling. Secondary endpoints included changes in inflammatory indices and lipid levels. RESULTS There were 9 treatment-related toxicities of grade 2 or greater during TCZ administration (mostly neutropenia) and 2 during placebo administration. Thirty-one of 34 participants completed the study and were included in a modified intent-to-treat analysis. TCZ reduced levels of CRP (median decrease, 1819.9 ng/mL, P < .0001; effect size, 0.87) and reduced inflammatory markers in PWH, including D-dimer, soluble CD14, and tumor necrosis factor receptors. T-cell cycling tended to decrease in all maturation subsets after TCZ administration, but was only significant among naive CD4 T cells. Lipid levels, including lipid classes that have been related to cardiovascular disease risk, increased during TCZ treatment. CONCLUSIONS TCZ is safe and decreases inflammation in PWH; IL-6 is a key driver of the inflammatory environment that predicts morbidity and mortality in ART-treated PWH. The clinical significance of lipid elevations during TCZ treatment requires further study. Clinical Trials Registration. NCT02049437.
Collapse
Affiliation(s)
- Nicholas T Funderburg
- Division of Medical Laboratory Science, School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio, USA
| | - Carey L Shive
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Curtis Tatsuoka
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emily R Bowman
- Division of Medical Laboratory Science, School of Health and Rehabilitation Sciences, Ohio State University, Columbus, Ohio, USA
| | - Chris T Longenecker
- Department of Medicine and Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Grace A McComsey
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Pediatrics, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Brian M Clagett
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Dominic Dorazio
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Michael L Freeman
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Scott F Sieg
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Daniela Moisi
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Donald D Anthony
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Rheumatology Section, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Jeffrey M Jacobson
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sharon L Stein
- Department of Surgery, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Alan Landay
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Charles Flexner
- Divisions of Clinical Pharmacology and Infectious Diseases, School of Medicine and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Keith W Crawford
- Therapeutic Research Program, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Edmund V Capparelli
- Clinical Pediatrics and Pharmacy, University of California, San Diego, La Jolla, California, USA
| | - Benigno Rodriguez
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Michael M Lederman
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
21
|
Zidar DA, Al-Kindi S, Longenecker CT, Parikh SA, Gillombardo CB, Funderburg NT, Juchnowski S, Huntington L, Jenkins T, Nmai C, Osnard M, Shishebhor M, Filby S, Tatsuoka C, Lederman MM, Blackstone E, Attizzani G, Simon DI. Platelet and Monocyte Activation After Transcatheter Aortic Valve Replacement (POTENT-TAVR): A Mechanistic Randomized Trial of Ticagrelor Versus Clopidogrel. Struct Heart 2023; 7:100182. [PMID: 37520136 PMCID: PMC10382989 DOI: 10.1016/j.shj.2023.100182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 08/01/2023]
Abstract
Background Inflammation and thrombosis are often linked mechanistically and are associated with adverse events after transcatheter aortic valve replacement (TAVR). High residual platelet reactivity (HRPR) is especially common when clopidogrel is used in this setting, but its relevance to immune activation is unknown. We sought to determine whether residual activity at the purinergic receptor P2Y12 (P2Y12) promotes prothrombotic immune activation in the setting of TAVR. Methods This was a randomized trial of 60 patients (enrolled July 2015 through December 2018) assigned to clopidogrel (300mg load, 75mg daily) or ticagrelor (180mg load, 90 mg twice daily) before and for 30 days following TAVR. Co-primary endpoints were P2Y12-dependent platelet activity (Platelet Reactivity Units; VerifyNow) and the proportion of inflammatory (cluster of differentiation [CD] 14+/CD16+) monocytes 1 day after TAVR. Results Compared to clopidogrel, those randomized to ticagrelor had greater platelet inhibition (median Platelet Reactivity Unit [interquartile range]: (234 [170.0-282.3] vs. 128.5 [86.5-156.5], p < 0.001), but similar inflammatory monocyte proportions (22.2% [18.0%-30.2%] vs. 25.1% [22.1%-31.0%], p = 0.201) 1 day after TAVR. Circulating monocyte-platelet aggregates, soluble CD14 levels, interleukin 6 and 8 levels, and D-dimers were also similar across treatment groups. HRPR was observed in 63% of the clopidogrel arm and was associated with higher inflammatory monocyte proportions. Major bleeding events, pacemaker placement, and mortality did not differ by treatment assignment. Conclusions Residual P2Y12 activity after TAVR is common in those treated with clopidogrel but ticagrelor does not significantly alter biomarkers of prothrombotic immune activation. HRPR appears to be an indicator (not a cause) of innate immune activation in this setting.
Collapse
Affiliation(s)
- David A. Zidar
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sadeer Al-Kindi
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Chris T. Longenecker
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sahil A. Parikh
- Division of Cardiology, Center for Interventional Vascular Therapy, Columbia University Irving Medical Center, New York, New York, USA
| | - Carl B. Gillombardo
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nicholas T. Funderburg
- Division of Medical Laboratory Science, School of Health and Rehabilitations Sciences, Ohio State University, Columbus, Ohio, USA
| | - Steven Juchnowski
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Lauren Huntington
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Trevor Jenkins
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christopher Nmai
- New York University Grossman School of Medicine, New York, New York, USA
| | - Michael Osnard
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mehdi Shishebhor
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven Filby
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Curtis Tatsuoka
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michael M. Lederman
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Eugene Blackstone
- Department of Population Health and Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Guilherme Attizzani
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Daniel I. Simon
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| |
Collapse
|
22
|
Shakil SS, Temu TM, Kityo C, MMed GEMBC, Bittencourt MS, Longenecker CT. Circulating plasma NT-proBNP predicts subclinical coronary atherosclerosis on CT angiography among older adults in Uganda. BMC Res Notes 2023; 16:107. [PMID: 37337285 DOI: 10.1186/s13104-023-06385-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 06/09/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE Phenotypes and mechanisms of cardiovascular disease (CVD) may differ across global populations. In sub-Saharan Africa (SSA), distinct environmental determinants may influence development and progression of atherosclerotic coronary artery disease (CAD). METHODS We investigated associations between 6 established markers of myocardial stress and subsequent subclinical CAD (sCAD), defined as presence of any atherosclerosis on coronary CT angiography (CCTA) in a 2-year prospective cohort of Ugandan adults enriched for cardiometabolic risk factors (RFs) and HIV. Six plasma biomarkers were measured baseline among 200 participants (50% with HIV) aged ≥ 45 years with ≥ 1 cardiovascular RF. At 2-year follow-up, 132 participants (52% with HIV) who returned underwent coronary CCTA. RESULTS In logistic regression models adjusted for cardiovascular RFs (age, diabetes, hypertension, hyperlipidemia, smoking, obesity) and non-traditional RFs (HIV, chronic kidney disease), only NT-proBNP predicted subsequent subclinical CAD (p < 0.008, Bonferroni correction for multiple testing). In sensitivity analyses adjusted for ASCVD risk category (instead of individual RFs) in the baseline cohort with multiple imputation applied to missing year 2 CCTA data (n = 200), NT-proBNP remained significantly associated with subsequent CAD (p < 0.008). CONCLUSIONS NT-proBNP consistently predicted subclinical CAD in Uganda in the absence of such an association among other markers of myocardial stress, suggesting a role for NT-proBNP in atherosclerosis independently of coronary microvascular dysfunction.
Collapse
Affiliation(s)
- Saate S Shakil
- Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, USA.
| | - Tecla M Temu
- Department of Global Health, University of Washington Medical Center, Seattle, USA
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | | | - Marcio S Bittencourt
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Chris T Longenecker
- Department of Global Health, University of Washington Medical Center, Seattle, USA
| |
Collapse
|
23
|
Cárdenas JDG, Oliveira VHF, Borsari AL, Marinello PC, Longenecker CT, Deminice R. Statin protects men but not women with HIV against loss of muscle mass, strength, and physical function: a pilot study. Sci Rep 2023; 13:4693. [PMID: 36949103 PMCID: PMC10033712 DOI: 10.1038/s41598-023-31643-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/15/2023] [Indexed: 03/24/2023] Open
Abstract
Statins are cholesterol-lowering drugs commonly used among people with HIV, associated with an increased risk of myopathies. Considering that cardiovascular disease, statin therapy, and sarcopenia are independently prevalent in people with HIV, clarity on the potential benefits or harms of statin therapy on muscle health is useful to provide insight into ways to maximize skeletal muscle health and minimize CVD risk in this population. We aimed to study the effects of statin therapy on strength, muscle mass, and physical function parameters in people with HIV. This was a pilot cross-sectional study. People with HIV on continuous statin therapy (n = 52) were paired 1:1 according to age (people with HIV 53.9 ± 8.2 and people with HIV on statins 53.9 ± 8.4 years), sex, body mass index (Body mass index, people with HIV 28.6 ± 5.3 and people with HIV on statins 28.8 ± 6.3 kg/m2), and race with people with HIV not using statin (n = 52). Participants were evaluated for muscle strength (i.e. handgrip strength), lean and fat body mass (using bioelectric impedance analysis), and physical function (i.e. Short Physical Performance Battery-SPPB). Isokinetic strength and appendicular lean mass (using dual-energy X-ray absorptiometry), more accurate strength and body composition measures, were determined in 38% of the participants. Overall, statin usage does not exacerbated loss of muscle strength (32.2 ± 11.5 vs. 30.3 ± 9.6 kg, p > 0.05) muscle mass (7.6 ± 1.8 vs. 7.7 ± 1.1 kg/m2, p > 0.05), and impaired physical performance (10.1 ± 1.8 vs. 9.7 ± 2.1 points, p > 0.05) of PLWH. When analyzed by sex, men living with HIV on statins usage presented higher appendicular muscle mass (28.4 ± 3.1 vs. 26.2 ± 4.9 kg, p < 0.05) handgrip strength (42.1 ± 8.8 vs. 37.1 ± 8.3 kg, p < 0.05) and physical function through SPPB score (10.9 ± 1.3 vs. 9.5 ± 2.1, p < 0.05) than men living with HIV not on statins treatment. The same protection was not observed in women. This data was demonstrated when muscle mass and strength were determined clinically (i.e. handgrip strength and electrical impedance) and when more precise laboratory measurements of muscle mass and strength were conducted (i.e. isokinetic strength and DXA scans). Statin does not exacerbate muscle wasting, strength loss, or muscle dysfunction among people with HIV. Indeed, statins may protect men, but not woman with HIV against HIV and antiretroviral therapy-induced loss of muscle mass and strength.
Collapse
Affiliation(s)
- José David G Cárdenas
- Health Sciences Graduate Studies, State University of Londrina, Londrina, Paraná, Brazil
| | - Vitor H F Oliveira
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, Washington, USA
- Department of Physical Education, State University of Londrina, Londrina, Paraná, Brazil
| | - Ana L Borsari
- Department of Physical Education, State University of Londrina, Londrina, Paraná, Brazil
| | - Poliana C Marinello
- Biological Sciences Center, State University of Londrina, Londrina, Paraná, Brazil
| | - Chris T Longenecker
- Department of Cardiology and Global Health, University of Washington, Seattle, Washington, USA
| | - Rafael Deminice
- Health Sciences Graduate Studies, State University of Londrina, Londrina, Paraná, Brazil.
- Department of Physical Education, State University of Londrina, Londrina, Paraná, Brazil.
- Department of Physical Education, Faculty of Physical Education and Sport, State University of Londrina, Rodovia Celso Garcia Cid, Pr 445 km 380, Campus Universitário, Londrina, PR, Brazil.
| |
Collapse
|
24
|
Shakil SS, Temu TM, Kityo C, Nazzinda R, Erem G, Kentoffio K, Bittencourt M, Ntusi NAB, Zanni MV, Longenecker CT. Sex modulates the association between inflammation and coronary atherosclerosis among older Ugandan adults with and without HIV. AIDS 2023; 37:579-586. [PMID: 36730004 PMCID: PMC9974774 DOI: 10.1097/qad.0000000000003451] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Inflammation is key in the pathogenesis of atherosclerotic coronary artery disease (CAD). Distinct sex-specific inflammatory mechanisms may contribute to CAD in sub-Saharan Africa (SSA), where environmental and biological determinants of systemic inflammation may differ from those in high-income settings. APPROACH AND RESULTS We investigated sex differences in inflammatory markers and CAD in a 2-year prospective cohort of Ugandan adults enriched for cardiometabolic risk factors (RFs) and HIV. Seven plasma biomarkers were quantified at the baseline visit among 125 females and 75 males (50% with HIV) at least 45 years old at enrollment with one or more major cardiovascular RF. In year 2, coronary CT angiography (CCTA) was performed in 82 females and 50 males returning for follow-up (52% with HIV). In sex-specific models adjusted for cardiovascular RFs and HIV, tumor necrosis factor-alpha (TNF-α) RII and sCD163 predicted subsequent CAD in females, while only fibrinogen was predictive in males ( P < 0.05). Interleukin-6 (IL-6) and sCD14 were inversely associated with CAD in males ( P < 0.05). Sex modified the associations of TNF-α RII, sCD14, and sCD163 with CAD ( P < 0.05 for interaction). In multivariable multiple imputation models applied to missing year 2 CCTA data to test associations between serum biomarkers in the baseline cohort ( n = 200) and subsequent CAD, higher sCD163 was predictive in females only ( P < 0.05). CONCLUSIONS The positive link between inflammation and subclinical CAD was stronger among females than males in Uganda. Mechanisms by which sex modulates the relationship between inflammation and CAD should be further investigated in SSA.
Collapse
Affiliation(s)
- Saate S Shakil
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, USA
| | - Tecla M Temu
- Department of Global Health, University of Washington Medical Center, Seattle, USA
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | | | - Geoffrey Erem
- Department of Radiology, Makerere University, Kampala, Uganda
| | - Katherine Kentoffio
- Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, USA
| | - Marcio Bittencourt
- Departments of Medicine and Radiology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Ntobeko AB Ntusi
- Department of Medicine, Division of Cardiology, University of Cape Town, Cape Town, South Africa
- Unit on Intersection of Noncommunicable Diseases and Infectious Disease, South African Medical Research Council
| | - Markella V Zanni
- Department of Medicine, Division of Endocrinology, Massachusetts General Hospital, Boston, USA
| | - Chris T Longenecker
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, USA
| |
Collapse
|
25
|
Chang AY, Zühlke L, Ribeiro ALP, Barry M, Okello E, Longenecker CT. What We Lost in the Fire: Endemic Tropical Heart Diseases in the Time of COVID-19. Am J Trop Med Hyg 2023; 108:462-464. [PMID: 36746666 PMCID: PMC9978545 DOI: 10.4269/ajtmh.22-0514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/12/2022] [Indexed: 02/08/2023] Open
Abstract
The COVID-19 pandemic has profoundly influenced the effort to achieve global health equity. This has been particularly the case for HIV/AIDS, tuberculosis, and malaria control initiatives in low- and middle-income countries, with significant outcome setbacks seen for the first time in decades. Lost in the calls for compensatory funding increases for such programs, however, is the plight of endemic tropical heart diseases, a group of disorders that includes rheumatic heart disease, Chagas disease, and endomyocardial fibrosis. Such endemic illnesses affect millions of people around the globe and remain a source of substantial mortality, morbidity, and health disparity. Unfortunately, these conditions were already neglected before the pandemic, and thus those living with them have disproportionately suffered during the time of COVID-19. In this perspective, we briefly define endemic tropical heart diseases, summarizing their prepandemic epidemiology, funding, and control statuses. We then describe the ways in which people living with these disorders, along with the healthcare providers and researchers working to improve their outcomes, have been harmed by the ongoing COVID-19 pandemic. We conclude by proposing the path forward, including approaches we may use to leverage lessons learned from the pandemic to strengthen care systems for these neglected diseases.
Collapse
Affiliation(s)
- Andrew Y. Chang
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
- Stanford Cardiovascular Institute, Stanford University, Stanford, California
- Center for Innovation in Global Health, Stanford University, Stanford, California
| | - Liesl Zühlke
- South African Medical Research Council, Cape Town, South Africa
- Division of Paediatric Cardiology, Red Cross War Memorial Children’s Hospital, University of Cape Town, Cape Town, South Africa
- Cape Heart Institute, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Antonio Luiz P. Ribeiro
- Telehealth Center and Cardiology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Michele Barry
- Center for Innovation in Global Health, Stanford University, Stanford, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Emmy Okello
- Department of Adult and Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Chris T. Longenecker
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
| |
Collapse
|
26
|
Dirajlal-Fargo S, Zhao C, Labbato D, Sattar A, Karungi C, Longenecker CT, Nazzinda R, Funderburg N, Kityo C, Musiime V, McComsey GA. Longitudinal Changes in Subclinical Vascular Disease in Ugandan Youth With Human Immunodeficiency Virus. Clin Infect Dis 2023; 76:e599-e606. [PMID: 36004575 PMCID: PMC10169397 DOI: 10.1093/cid/ciac686] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/29/2022] [Accepted: 08/22/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Prospective investigations on the risk of cardiovascular disease among youth with perinatally acquired human immunodeficiency virus (PHIV) in sub-Saharan Africa are lacking. METHODS A prospective observational cohort study was performed in 101 youth (aged 10-18 years) with PHIV and 97 who were human immunodeficiency virus (HIV) uninfected (HIV-), from 2017 to 2021 at the Joint Clinical Research Center in Uganda. Participants with PHIV were receiving antiretroviral therapy (ART) and had HIV-1 RNA levels ≤400 copies/mL. The common carotid artery intima-media thickness (IMT) and pulse wave velocity (PWV) were evaluated at baseline and at 96 weeks. Groups were compared using unpaired t-test, and potential predictors of IMT and PWV were assessed using quantile regression. RESULTS Of the 198 participants recruited at baseline, 168 (89 with PHIV, 79 HIV-) had measurements at 96 weeks. The median age (interquartile range) age was 13 (11-15) years; 52% were female, and 85% had viral loads <50 copies/mL that remained undetectable at week 96. The baseline mean common carotid artery IMT was slightly higher in participants with PHIV compared with controls (P < .01), and PWV did not differ between groups (P = .08). At week 96, IMT decreased and PWV increased in the PHIV group (P ≤ .03); IMT increased in the HIV- group (P = .03), with no change in PWV (P = .92). In longitudinal analyses in those with PHIV, longer ART duration was associated with lower PWV (β = .008 [95% confidence interval, -.008 to .003]), and abacavir use with greater IMT (β = .043 [.012-.074]). CONCLUSIONS In healthy Ugandan youth with PHIV, virally suppressed by ART, the common carotid artery IMT did not progress over 2 years. Prolonged and early ART may prevent progression of subclinical vascular disease, while prolonged use of abacavir may increase it.
Collapse
Affiliation(s)
- Sahera Dirajlal-Fargo
- Department of Pediatrics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Chenya Zhao
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Danielle Labbato
- Department of Pediatrics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Abdus Sattar
- Case Western Reserve University, Cleveland, Ohio, USA
| | | | | | | | - Nicholas Funderburg
- Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio, USA
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda
- Makerere University, Kampala, Uganda
| | - Grace A McComsey
- Department of Pediatrics, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Rainbow Babies and Children’s Hospital, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
27
|
Shakil SS, Ojji D, Longenecker CT, Roth GA. Early Stage and Established Hypertension in Sub-Saharan Africa: Results From Population Health Surveys in 17 Countries, 2010-2017. Circ Cardiovasc Qual Outcomes 2022; 15:e009046. [PMID: 36252134 PMCID: PMC9771997 DOI: 10.1161/circoutcomes.122.009046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/19/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Multiple studies have reported a high burden of hypertension in sub-Saharan Africa, but none have examined early stage hypertension. We examined contemporary prevalence of diagnosed, treated, and controlled stage I (130-139/80-89 mm Hg) and II (≥140/90 mm Hg) hypertension in the general population of sub-Saharan Africa. METHODS We analyzed World Health Organization STEPwise Approach to Noncommunicable Disease Risk Factor Surveillance surveys from 17 sub-Saharan Africa countries including 85 371 respondents representing 85 million individuals from 2010 to 2017. We extracted demographic variables, blood pressure, self-reported hypertension diagnosis/awareness, and treatment status to estimate prevalence of stage I and II hypertension and treatment by country. We examined diagnosis and treatment trends by national sociodemographic index, a marker of development. RESULTS Stage I hypertension prevalence (regardless of diagnosis/treatment) was >25% in 13 of 17 countries, highest in Sudan (35.3% [95% CI, 33.7%-37.0%]), and lowest in Eritrea (20.2% [18.8%-21.6%]). Combined stages I and II hypertension prevalence was >50% in 13 countries; <20% were diagnosed in every country. Treatment among those diagnosed ranged from 26% to 63%, and control (<140/90 mm Hg) from 4% to 17%. In 8 of 9 countries reporting on behavioral interventions (eg, salt reduction, weight loss, exercise, and smoking cessation), <60% of diagnosed individuals received counseling. Rates of diagnosis, but not treatment, were positively associated with sociodemographic index (P=0.008), although there was substantial variation between countries even at similar levels of development. CONCLUSIONS Hypertension is common in sub-Saharan Africa but rates of diagnosis, treatment, and control markedly low. There is a large population with early stage hypertension that may benefit from behavioral counseling to prevent progression. Our analyses suggest that success in population hypertension care may be achieved independently of socioeconomic development, highlighting a need for policymakers to identify best practices in those countries that outperform similar or more developed countries.
Collapse
Affiliation(s)
- Saate S Shakil
- Division of Cardiology, Department of Medicine (S.S.S., C.T.L., G.A.R.), University of Washington, Seattle
- Institute for Health Metrics and Evaluation (S.S.S., G.A.R.), University of Washington, Seattle
| | - Dike Ojji
- Department of Medicine, Faculty of Clinical Sciences, University of Abuja, Nigeria (D.O.)
- University of Abuja Teaching Hospital, Gwagwalada, Nigeria (D.O.)
| | - Chris T Longenecker
- Division of Cardiology, Department of Medicine (S.S.S., C.T.L., G.A.R.), University of Washington, Seattle
- Department of Global Health (C.T.L.), University of Washington, Seattle
| | - Gregory A Roth
- Division of Cardiology, Department of Medicine (S.S.S., C.T.L., G.A.R.), University of Washington, Seattle
- Institute for Health Metrics and Evaluation (S.S.S., G.A.R.), University of Washington, Seattle
| |
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW To synthesize current evidence on the impact of cardiovascular disease among women living with HIV (WLWH) with a particular focus on disease prevalence, mechanisms and prevention. RECENT FINDINGS HIV-related cardiovascular disease risk is 1.5-fold to 2-fold higher for women than for men. Mechanisms of enhanced risk are multifactorial and include reinforcing pathways between traditional risk factors, metabolic dysregulation, early reproductive aging and chronic immune activation. These pathways influence both the presentation of overt syndromes of myocardial infarction, stroke and heart failure, as well as subclinical disease, such as microvascular dysfunction and cardiac fibrosis. Cardiovascular disease, therefore, remains a consistent threat to healthy aging among WLWH. SUMMARY Although no specific prevention strategies exist, patient-centered risk mitigation approaches that are adaptable to the needs of aging individuals are essential to combat disparities in cardiovascular outcomes among WLWH. Further research into the optimal prevention approach for CVD among WLWH, particularly for women living in under-resourced health systems, is needed.
Collapse
Affiliation(s)
- Katherine Kentoffio
- Department of Medicine, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Tecla M Temu
- Department of Global Health, University of Washington School of Medicine, Seattle, WA, USA
| | - Saate S Shakil
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Markella V. Zanni
- Department of Medicine, Division of Endocrinology, Massachusetts General Hospital, Boston, MA, USA
| | - Chris T. Longenecker
- Department of Global Health, University of Washington School of Medicine, Seattle, WA, USA
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, WA, USA
| |
Collapse
|
29
|
Kentoffio K, Durstenfeld MS, Siedner MJ, Kityo C, Erem G, Ssinabulya I, Ghoshhajra B, Bittencourt MS, Longenecker CT. Sex-specific performance of the ASCVD pooled cohort equation risk calculator as a correlate of coronary artery calcium in Kampala, Uganda. International Journal of Cardiology Cardiovascular Risk and Prevention 2022; 14:200136. [PMID: 36060290 PMCID: PMC9434411 DOI: 10.1016/j.ijcrp.2022.200136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/03/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022]
Abstract
Introduction: The prevalence of cardiovascular disease (CVD) is rising in Sub-Saharan Africa, but it is not known whether current risk assessment tools predict coronary atherosclerosis in the region. Furthermore, sex-specific performance and interaction with HIV serostatus has not been well studied. Methods: This cross-sectional study compared ASCVD risk scores and detectable coronary artery calcium (CAC>0) by sex in Kampala, Uganda (n = 200). The cohort was enriched for persons living with HIV, and all participants had at least one CVD risk factor. We fit log binomial regression models and constructed ROC curves to assess the correlation between ASCVD scores and CAC>0. Results: The mean age was 56. 62% were female and 50% of both men and women were living with HIV. The median 10-year ASCVD risk score was significantly higher in men (11.0%, IQR 7.6–19.4%) than in women (5.1%, IQR 3.2–8.7%), although the prevalence of CAC>0 was similar (8.1 vs 10.5%, p = 0.63). Each 10% increase in ASCVD risk was associated with increased risk of CAC>0 in men (PR 1.59, 95% CI 1.00–2.55, p = 0.05) but not women (PR 1.15, 95% CI 0.44–3.00, p = 0.77). ROC curves demonstrated an AUC of 0.57 for women vs 0.70 for men. Adjustment for HIV serostatus improved the predictive value of ASCVD in women only (AUC 0.78, p = 0.02). Conclusions: ASCVD risk score did not correlate with the presence of CAC in women. When HIV status was added to the ASCVD risk score, correlation with CAC was improved in women but not in men.
Collapse
Affiliation(s)
- Katherine Kentoffio
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew S. Durstenfeld
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Mark J. Siedner
- Massachusetts General Hospital, Center for Global Health, Boston, MA, USA
- Mbarara University of Science and Technology, Mbarara, Uganda
- Harvard Medical School, Boston, MA, USA
| | - Cissy Kityo
- HIV Medicine, Joint Clinical Research Centre, Kampala, Uganda
| | - Geoffrey Erem
- Department of Radiology, St Francis Hospital Nsambya, Kampala, Uganda
- Departments of Radiology and Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Ssinabulya
- Departments of Radiology and Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Brian Ghoshhajra
- Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Marcio S. Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Chris T. Longenecker
- Department of Global Health and Division of Cardiology, University of Washington, Seattle, WA, USA
- Corresponding author. Global Cardiovascular Health Program, University of Washington School of Medicine, Department of Global Health, Hans Rosling Center Room 721, Guthrie Annex 3, Seattle, WA, 98105, USA.
| |
Collapse
|
30
|
Muddu M, Semitala FC, Kimera I, Mbuliro M, Ssennyonjo R, Kigozi SP, Katwesigye R, Ayebare F, Namugenyi C, Mugabe F, Mutungi G, Longenecker CT, Katahoire AR, Ssinabulya I, Schwartz JI. Improved hypertension control at six months using an adapted WHO HEARTS-based implementation strategy at a large urban HIV clinic in Uganda. BMC Health Serv Res 2022; 22:699. [PMID: 35610717 PMCID: PMC9131679 DOI: 10.1186/s12913-022-08045-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 05/05/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To adapt a World Health Organization HEARTS-based implementation strategy for hypertension (HTN) control at a large urban HIV clinic in Uganda and determine six-month HTN and HIV outcomes among a cohort of adult persons living with HIV (PLHIV). METHODS Our implementation strategy included six elements: health education, medication adherence, and lifestyle counseling; routine HTN screening; task shifting of HTN treatment; evidence-based HTN treatment protocol; consistent supply of HTN medicines free to patients; and inclusion of HTN-specific monitoring and evaluation tools. We conducted a pre-post study from October 2019 to March 2020 to determine the effect of this strategy on HTN and HIV outcomes at baseline and six months. Our cohort comprised adult PLHIV diagnosed with HTN who made at least one clinic visit within two months prior to study onset. FINDINGS We enrolled 1,015 hypertensive PLHIV. The mean age was 50.1 ± 9.5 years and 62.6% were female. HTN outcomes improved between baseline and six months: mean systolic BP (154.3 ± 20.0 to 132.3 ± 13.8 mmHg, p < 0.001); mean diastolic BP (97.7 ± 13.1 to 85.3 ± 9.5 mmHg, p < 0.001) and proportion of patients with controlled HTN (9.3% to 74.1%, p < 0.001). The HTN care cascade also improved: treatment initiation (13.4% to 100%), retention in care (16.2% to 98.5%), monitoring (16.2% to 98.5%), and BP control among those initiated on HTN treatment (2.2% to 75.2%). HIV cascade steps remained high (> 95% at baseline and six months) and viral suppression was unchanged (98.7% to 99.2%, p = 0.712). Taking ART for more than two years and HIV viral suppression were independent predictors of HTN control at six months. CONCLUSIONS A HEARTS-based implementation strategy at a large, urban HIV center facilitates integration of HTN and HIV care and improves HTN outcomes while sustaining HIV control. Further implementation research is needed to study HTN/HIV integration in varied clinical settings among diverse populations.
Collapse
Affiliation(s)
- Martin Muddu
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Fred C. Semitala
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Kimera
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Mary Mbuliro
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Rebecca Ssennyonjo
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Simon P. Kigozi
- grid.463352.50000 0004 8340 3103Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - Rodgers Katwesigye
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Florence Ayebare
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Christabellah Namugenyi
- grid.11194.3c0000 0004 0620 0548Makerere University Joint AIDS Program (MJAP), P.O. Box 7072, Kampala, Uganda
| | - Frank Mugabe
- grid.415705.2Ministry of Health, Kampala, Uganda
| | | | - Chris T. Longenecker
- grid.67105.350000 0001 2164 3847Case Western Reserve University School of Medicine, Cleveland, OH USA
| | - Anne R. Katahoire
- grid.11194.3c0000 0004 0620 0548Makerere University College of Health Sciences, Kampala, Uganda
| | - Isaac Ssinabulya
- grid.416252.60000 0000 9634 2734Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Jeremy I. Schwartz
- grid.47100.320000000419368710Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| |
Collapse
|
31
|
Muiruri C, Corneli A, Cooper L, Dombeck C, Gray S, Longenecker CT, Meissner EG, Okeke NL, Pettit AC, Swezey T, Vicini J, Bloomfield GS. Perspectives of HIV specialists and cardiologists on the specialty referral process for people living with HIV: a qualitative descriptive study. BMC Health Serv Res 2022; 22:623. [PMID: 35534889 PMCID: PMC9082896 DOI: 10.1186/s12913-022-08015-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background Cardiology care may be beneficial for risk factor management in people living with HIV (PLWH), yet limited information is available about the referral process from the perspectives of HIV specialists and cardiologists. Methods We conducted 28 qualitative interviews at academic medical centers in the United States from December 2019 to February 2020 using components of the Specialty Referral Process Framework: referral decision, entry into referral care, and care integration. We analyzed the data using applied thematic analysis. Results Reasons for cardiology referral most commonly included secondary prevention, uncontrolled risk factors, cardiac symptoms, and medication management. Facilitators in the referral process included ease of referral, personal relationships between HIV specialists and cardiologists, and close proximity of the clinic to the patient’s home. Barriers included lack of transportation, transportation costs, insurance coverage gaps, stigma, and patient reluctance. Conclusions Our results will inform future studies on implementation strategies aimed at improving the specialty referral process for PLWH. Trial Registration ClinicalTrials.gov Identifier: NCT04025125. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08015-0.
Collapse
Affiliation(s)
- Charles Muiruri
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Suite 210, Durham, NC, 27701, USA. .,Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Amy Corneli
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Suite 210, Durham, NC, 27701, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Linda Cooper
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC, USA
| | - Carrie Dombeck
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Suite 210, Durham, NC, 27701, USA
| | - Shamea Gray
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Chris T Longenecker
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Eric G Meissner
- Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC, USA
| | - Nwora Lance Okeke
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - April C Pettit
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Teresa Swezey
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St., Suite 210, Durham, NC, 27701, USA
| | - Joseph Vicini
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
32
|
Ndagire E, Ollberding N, Sarnacki R, Meghna M, Pulle J, Atala J, Agaba C, Kansiime R, Bowen A, Longenecker CT, Oyella L, Rwebembera J, Okello E, Parks T, Zang H, Carapetis J, Sable C, Beaton AZ. Modelling study of the ability to diagnose acute rheumatic fever at different levels of the Ugandan healthcare system. BMJ Open 2022; 12:e050478. [PMID: 35318227 PMCID: PMC8943770 DOI: 10.1136/bmjopen-2021-050478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 01/28/2022] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the ability to accurately diagnose acute rheumatic fever (ARF) given the resources available at three levels of the Ugandan healthcare system. METHODS Using data obtained from a large epidemiological database on ARF conducted in three districts of Uganda, we selected variables that might positively or negatively predict rheumatic fever based on diagnostic capacity at three levels/tiers of the Ugandan healthcare system. Variables were put into three statistical models that were built sequentially. Multiple logistic regression was used to estimate ORs and 95% CI of predictors of ARF. Performance of the models was determined using Akaike information criterion, adjusted R2, concordance C statistic, Brier score and adequacy index. RESULTS A model with clinical predictor variables available at a lower-level health centre (tier 1) predicted ARF with an optimism corrected area under the curve (AUC) (c-statistic) of 0.69. Adding tests available at the district level (tier 2, ECG, complete blood count and malaria testing) increased the AUC to 0.76. A model that additionally included diagnostic tests available at the national referral hospital (tier 3, echocardiography, anti-streptolysin O titres, erythrocyte sedimentation rate/C-reactive protein) had the best performance with an AUC of 0.91. CONCLUSIONS Reducing the burden of rheumatic heart disease in low and middle-income countries requires overcoming challenges of ARF diagnosis. Ensuring that possible cases can be evaluated using electrocardiography and relatively simple blood tests will improve diagnostic accuracy somewhat, but access to echocardiography and tests to confirm recent streptococcal infection will have the greatest impact.
Collapse
Affiliation(s)
- Emma Ndagire
- Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Nicholas Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rachel Sarnacki
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Murali Meghna
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Jafesi Pulle
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | - Jenifer Atala
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | - Collins Agaba
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | | | - Asha Bowen
- Telethon Kids Institute, Perth, Western Australia, Australia
| | | | - Linda Oyella
- Department of RHD Research, Uganda Heart Institute, Kampala, Uganda
| | | | - Emmy Okello
- Division of Adult Cardiology, Uganda Heart Institute, Kampala, Uganda
| | - Tom Parks
- London School of Hygiene & Tropical Medicine, London, UK
| | - Huaiyu Zang
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | | | - Craig Sable
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Andrea Z Beaton
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Cardiology, The Heart Institute, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| |
Collapse
|
33
|
Zhang B, Huaman MA, Fichtenbaum CJ, Longenecker CT. Reply to Chu et al. Clin Infect Dis 2022; 74:944-945. [PMID: 34181726 PMCID: PMC8906752 DOI: 10.1093/cid/ciab592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Medical Center, Cincinnati, Ohio, USA
| | - Moises A Huaman
- Department of Internal Medicine, Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Carl J Fichtenbaum
- Department of Internal Medicine, Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Chris T Longenecker
- Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
34
|
Dong T, Rana MN, Longenecker CT, Rajagopalan S, Kim CH, Al-Kindi SG. Machine Learning Estimation of Low-Density Lipoprotein Cholesterol in Women With and Without HIV. J Acquir Immune Defic Syndr 2022; 89:318-323. [PMID: 34813572 DOI: 10.1097/qai.0000000000002869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Low-density lipoprotein cholesterol (LDL-C) is typically estimated from total cholesterol, high-density lipoprotein cholesterol, and triglycerides. The Friedewald, Martin-Hopkins, and National Institutes of Health equations are widely used but may estimate LDL-C inaccurately in certain patient populations, such as those with HIV. We sought to investigate the utility of machine learning for LDL-C estimation in a large cohort of women with and without HIV. METHODS We identified 7397 direct LDL-C measurements (5219 from HIV-infected individuals, 2127 from uninfected controls, and 51 from seroconvertors) from 2414 participants (age 39.4 ± 9.3 years) in the Women's Interagency HIV Study and estimated LDL-C using the Friedewald, Martin-Hopkins, and National Institutes of Health equations. We also optimized 5 machine learning methods [linear regression, random forest, gradient boosting, support vector machine (SVM), and neural network] using 80% of the data (training set). We compared the performance of each method using root mean square error, mean absolute error, and coefficient of determination (R2) in the holdout (20%) set. RESULTS SVM outperformed all 3 existing equations and other machine learning methods, achieving the lowest root mean square error and mean absolute error, and the highest R2 (11.79 and 7.98 mg/dL, 0.87, respectively, compared with those obtained using the Friedewald equation: 12.45 and 9.14 mg/dL, 0.87). SVM performance remained superior in subgroups with and without HIV, with nonfasting measurements, in LDL <70 mg/dL and triglycerides > 400 mg/dL. CONCLUSIONS In this proof-of-concept study, SVM is a robust method that predicts directly measured LDL-C more accurately than clinically used methods in women with and without HIV. Further studies should explore the utility in broader populations.
Collapse
Affiliation(s)
- Tony Dong
- Department of Internal Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH
| | - Mariam N Rana
- Department of Internal Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH
| | - Chris T Longenecker
- Division of Cardiovascular Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH; and
| | - Sanjay Rajagopalan
- Division of Cardiovascular Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH; and
| | - Chang H Kim
- Department of Medicine, MetroHealth Medical Center/Case Western Reserve University, Cleveland, OH
| | - Sadeer G Al-Kindi
- Division of Cardiovascular Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH; and
| |
Collapse
|
35
|
Davey CH, Trinh V, Schexnayder J, Longenecker CT, Webel A. Comparison of diet, muscle strength, steps per day and symptoms in people with HIV and HIV-negative peers. Res Nurs Health 2022; 45:123-133. [PMID: 34888899 PMCID: PMC8792302 DOI: 10.1002/nur.22202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/03/2021] [Accepted: 11/27/2021] [Indexed: 02/03/2023]
Abstract
People with HIV (PWH) experience a high frequency of symptoms that are associated with poor clinical outcomes. We conducted a secondary analysis of data from an observational study to examine whether diet, muscle strength, or physical activity were associated with symptoms among PWH and their HIV-uninfected peers. One-hundred ninety-one individuals (105 PWH and 86 HIV uninfected) with similar age and race were included. Symptoms were examined using the Patient-Reported Outcomes Measurement Information System (PROMIS-29) questionnaire, for which lower scores indicate higher function or fewer symptoms. The total healthy eating index score and carbohydrates, sugar sweet beverages, alcohol, and fiber consumption per day were obtained through 24-hour dietary recalls. A dynamometer was used to determine muscle strength. Steps per day were examined through 7 days of actigraphy. Linear regression analyses were used to determine the relationship between symptoms and diet, muscle strength, and steps per day. Participants were, on average, 54 years, 83% were African American, and 58% were male. In PWH, less healthy eating, fiber intake, and muscle strength were associated with poorer physical function; more steps per day were associated with fatigue; less daily carbohydrate consumption was associated with more pain. HIV-uninfected individuals demonstrated an association between fewer steps per day and poorer physical function and more pain, and less carbohydrate intake and more sleep disturbance. The relationships between diet, muscle strength, steps per day and PROMIS-29 health domains differed by HIV status.
Collapse
Affiliation(s)
| | - Vinh Trinh
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, USA
| | | | - Chris T. Longenecker
- Case Western Reserve University School of Medicine and University Hospitals, Cleveland, USA
| | - Allison Webel
- University of Washington, School of Nursing, Seattle, USA
| |
Collapse
|
36
|
Chang AY, Barry M, Bendavid E, Watkins D, Beaton AZ, Lwabi P, Ssinabulya I, Longenecker CT, Okello E. Mortality Along the Rheumatic Heart Disease Cascade of Care in Uganda. Circ Cardiovasc Qual Outcomes 2022; 15:e008445. [PMID: 35041475 DOI: 10.1161/circoutcomes.121.008445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew Y Chang
- Department of Epidemiology and Population Health (A.Y.C.), Stanford University, CA.,Department of Medicine (A.Y.C., M.B., E.B.), Stanford University, CA.,Center for Innovation in Global Health (A.Y.C., M.B.), Stanford University, CA
| | - Michele Barry
- Department of Medicine (A.Y.C., M.B., E.B.), Stanford University, CA.,Center for Innovation in Global Health (A.Y.C., M.B.), Stanford University, CA
| | - Eran Bendavid
- Department of Medicine (A.Y.C., M.B., E.B.), Stanford University, CA.,Division of Primary Care & Population Health (E.B.), Stanford University, CA
| | - David Watkins
- Department of Medicine (D.W.), University of Washington, Seattle.,Department of Global Health (D.W.), University of Washington, Seattle
| | - Andrea Z Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center & The University of Cincinnati School of Medicine, OH (A.Z.B.)
| | - Peter Lwabi
- Uganda Heart Institute, Mulago Hospital, Kampala (P.L., I.S., E.O.)
| | - Isaac Ssinabulya
- Uganda Heart Institute, Mulago Hospital, Kampala (P.L., I.S., E.O.)
| | - Chris T Longenecker
- University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland (C.T.L.)
| | - Emmy Okello
- Uganda Heart Institute, Mulago Hospital, Kampala (P.L., I.S., E.O.)
| |
Collapse
|
37
|
Longenecker CT, Bogorodskaya M, Margevicius S, Nazzinda R, Bittencourt MS, Erem G, Nalukwago S, Huaman MA, Ghoshhajra BB, Siedner MJ, Juchnowski SM, Zidar DA, McComsey GA, Kityo C. Sex modifies the association between HIV and coronary artery disease among older adults in Uganda. J Int AIDS Soc 2022; 25:e25868. [PMID: 34995413 PMCID: PMC8741262 DOI: 10.1002/jia2.25868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Little is known about the epidemiology of coronary artery disease (CAD) in sub-Saharan Africa, where the majority of people living with HIV (PLHIV) live. We assessed the association of HIV with CAD and explored relationships with monocyte activation in sex-stratified analyses of older PLHIV and people without HIV (PWOH) in Uganda. METHODS The Ugandan Study of HIV effects on the Myocardium and Atherosclerosis (mUTIMA) follows 100 PLHIV on antiretroviral therapy (ART) and 100 age- and sex-matched PWOH controls in Kampala, Uganda; all >45 years of age with >1 cardiovascular disease risk factor. At the year 2 exam (2017-2019), 189 participants had available coronary calcium score and 165 had coronary CT angiography (CCTA) for this analysis. A subset of participants (n = 107) had both CCTA and fresh whole blood flow cytometry for monocyte phenotyping. RESULTS Median age was 57.8 years and 63% were females. Overall, 88% had hypertension, 37% had diabetes and 4% were smokers. Atherosclerotic cardiovascular disease (ASCVD) risk was modestly higher for PWOH, but not statistically significant (median 10-year ASCVD risk 7.2% for PLHIV vs. 8.6% for PWOH, p = 0.09). Median duration of ART was 12.7 years and 86% had suppressed viral load. Despite a high prevalence of risk factors, only 34/165 (21%, 95% CI 15-28%) had any coronary plaque. After adjustment for ASCVD risk score, HIV status was not associated with CAD (OR 0.55, 95% CI 0.23-1.30) but was associated with more severe CAD (segment severity score>3) among those with disease (OR 10.9, 95% CI 1.67-70.45). Females had a trend towards higher odds of CAD among PLHIV (OR 4.1, 95% CI 0.4-44.9), but a trend towards lower odds of CAD among PWOH (OR 0.30; 95% CI 0.07-1.3; HIV*sex interaction p = 0.019). CAD was positively correlated with classical monocytes (r = 0.3, p = 0.012) and negatively correlated with CX3CR1 expression (r = -0.31, p = 0.011) in PLHIV and negatively correlated with patrolling monocytes (r = -0.36, p = 0.031) and tissue factor expression (r = -0.39, p = 0.017) in PWOH. CONCLUSIONS Our results suggest that HIV may be associated more with severity rather than the presence of CAD in Uganda. Sex differences in the HIV effect suggest that tailored CAD prevention strategies may be required in this setting.
Collapse
Affiliation(s)
- Chris T. Longenecker
- University Hospitals of ClevelandClevelandOhioUSA
- Case Western Reserve UniversityClevelandOhioUSA
| | - Milana Bogorodskaya
- Case Western Reserve UniversityClevelandOhioUSA
- MetroHealth Medical CenterClevelandOhioUSA
| | | | | | | | - Geoffrey Erem
- St. Francis Hospital NsambyaKampalaUganda
- Makerere University School of MedicineKampalaUganda
| | | | | | | | | | | | - David A. Zidar
- Case Western Reserve UniversityClevelandOhioUSA
- Louis Stokes Cleveland Veterans Affairs Medical CenterClevelandOhioUSA
| | - Grace A. McComsey
- University Hospitals of ClevelandClevelandOhioUSA
- Case Western Reserve UniversityClevelandOhioUSA
| | | |
Collapse
|
38
|
Wright CH, Longenecker CT, Nazzindah R, Kityo C, Najjuuko T, Taylor K, Rentrope CR, Webel A. A Mixed Methods, Observational Investigation of Physical Activity, Exercise, and Diet Among Older Ugandans Living With and Without Chronic HIV Infection. J Assoc Nurses AIDS Care 2021; 32:640-651. [PMID: 33273157 DOI: 10.1097/jnc.0000000000000221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT People living with HIV (PLWH) are at increased risk for cardiovascular disease. Physical activity, exercise, and controlled diet can mitigate this risk, yet these behaviors are understudied in sub-Saharan Africa. Our objective was to describe and compare the meaning, value, and patterns of physical activity, exercise, and diet among PLWH and older adults without HIV in Uganda. This mixed methods, observational study included 30 adult PLWH and 29 adults without HIV who (a) wore an accelerometer to measure physical activity; (b) had weight, height, and waist and hip circumference measured; (c) completed physical fitness measures; and (d) used digital cameras to record photographs and videos of their typical diet and physical activities. Participants were approximately 58 years old and 68% female. Approximately 20% of PLWH and 40% of adults without HIV met physical activity guidelines (p > .05). Qualitative themes included engaging in a variety of exercise, structural barriers to exercising, and typical meals. Older adults in Uganda have low levels of physical activity and homogenous diets, increasing their risk for cardiovascular disease.
Collapse
Affiliation(s)
- Chelsea H Wright
- Chelsea H. Wright, MD, is a Family Medicine Resident, MetroHealth Medical Center, Cleveland, Ohio, USA. Chris T. Longenecker, MD, FAHA, is an Associate Professor of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA. Rashidah Nazzindah, MBChB, PhD, is a Physician, Joint Clinical Research Center, Kampala, Uganda. Cissy Kityo, MBChB, PhD, is a Director, Joint Clinical Research Center, Kampala, Uganda. Theresa Najjuuko, BSN, is a Research Nurse, Joint Clinical Research Center, Kampala, Uganda. Kirsten Taylor, is an Undergraduate Student, Case Western Reserve University College of Arts and Sciences, Cleveland, Ohio, USA. Cynthia Robin Rentrope, MSSA, MPH, LSW, is a Research Assistant IV, Case Western Reserve University, Cleveland, Ohio, USA. Allison Webel, RN, PhD, FAAN, is an Associate Professor of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Huaman MA, Feria MG, Kityo C, Nalukwago S, Nazzinda R, Zidar DA, Zanni MV, Siedner MJ, Grinspoon SK, Longenecker CT. A Sex-Stratified Analysis of Monocyte Phenotypes Associated with HIV Infection in Uganda. Viruses 2021; 13:v13112135. [PMID: 34834941 PMCID: PMC8620269 DOI: 10.3390/v13112135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 12/02/2022] Open
Abstract
Women with HIV may experience higher rates of non-AIDS comorbidities compared to men with HIV, but the underlying mechanisms are not well understood. We investigated sex-related differences in the effects of HIV on monocyte phenotypes within the Ugandan Study of HIV effects on the Myocardium and Atherosclerosis (mUTIMA). Of 133 participants who provided blood for flow cytometry assays, 86 (65%) were women and 91 (68%) were persons living with HIV (PLWH) on antiretroviral therapy. The median age was 57 (interquartile range, 52–63) years. PLWH exhibited a lower proportion of circulating CD14+CD16- classical monocytes (66.3% vs. 75.1%; p < 0.001), and higher proportion of CD14+CD16+ inflammatory monocytes (17% vs. 11.7%; p = 0.005) compared to HIV-uninfected participants. PLWH had an increased expression of the chemokine receptor CX3CR1 in total monocytes (CX3CR1+ monocytes, 24.5% vs. 4.7%; p < 0.001) and monocyte subsets. These findings were generally similar when analyzed by sex, with no significant interactions between sex and HIV status in adjusted models. Our data show that the inflammatory monocyte subset is expanded and monocyte CX3CR1 chemokine receptor expression is enhanced among PLWH, regardless of sex. Whether these parameters differentially affect risk for non-AIDS comorbidities and clinical outcomes in women with HIV requires additional investigation.
Collapse
Affiliation(s)
- Moises A. Huaman
- Division of Infectious Diseases, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA;
- Correspondence:
| | - Manuel G. Feria
- Division of Infectious Diseases, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA;
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala P.O. Box 10005, Uganda; (C.K.); (S.N.); (R.N.)
| | - Sophie Nalukwago
- Joint Clinical Research Centre, Kampala P.O. Box 10005, Uganda; (C.K.); (S.N.); (R.N.)
| | - Rashidah Nazzinda
- Joint Clinical Research Centre, Kampala P.O. Box 10005, Uganda; (C.K.); (S.N.); (R.N.)
| | - David A. Zidar
- Division of Cardiology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA; (D.A.Z.); (C.T.L.)
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH 44106, USA
| | - Markella V. Zanni
- Divisions of Infectious Diseases and Endocrinology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; (M.V.Z.); (M.J.S.); (S.K.G.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Mark J. Siedner
- Divisions of Infectious Diseases and Endocrinology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; (M.V.Z.); (M.J.S.); (S.K.G.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Steven K. Grinspoon
- Divisions of Infectious Diseases and Endocrinology, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; (M.V.Z.); (M.J.S.); (S.K.G.)
- Harvard Medical School, Boston, MA 02115, USA
| | - Chris T. Longenecker
- Division of Cardiology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA; (D.A.Z.); (C.T.L.)
- University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| |
Collapse
|
40
|
Muddu M, Ssinabulya I, Kigozi SP, Ssennyonjo R, Ayebare F, Katwesigye R, Mbuliro M, Kimera I, Longenecker CT, Kamya MR, Schwartz JI, Katahoire AR, Semitala FC. Hypertension care cascade at a large urban HIV clinic in Uganda: a mixed methods study using the Capability, Opportunity, Motivation for Behavior change (COM-B) model. Implement Sci Commun 2021; 2:121. [PMID: 34670624 PMCID: PMC8690902 DOI: 10.1186/s43058-021-00223-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/30/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Persons living with HIV (PLHIV) receiving antiretroviral therapy (ART) have a high prevalence of hypertension (HTN) and increased risk of mortality from cardiovascular diseases. HTN and HIV care integration is recommended in Uganda, though its implementation has lagged. In this study, we sought to analyze the HTN and HIV care cascades and explore barriers and facilitators of HTN/HIV integration within a large HIV clinic in urban Uganda. METHODS We conducted an explanatory sequential mixed methods study at Mulago ISS clinic in Kampala, Uganda. We determined proportions of patients in HTN and HIV care cascade steps of screened, diagnosed, initiated on treatment, retained, and controlled. Guided by the Capability, Opportunity, Motivation and Behavior (COM-B) model, we then conducted semi-structured interviews and focus group discussions with healthcare providers (n = 13) and hypertensive PLHIV (n = 32). We coded the qualitative data deductively and analyzed the data thematically categorizing them as themes that influenced HTN care positively or negatively. These denoted barriers and facilitators, respectively. RESULTS Of 15,953 adult PLHIV, 99.1% were initiated on ART, 89.5% were retained in care, and 98.0% achieved control (viral suppression) at 1 year. All 15,953 (100%) participants were screened for HTN, of whom 24.3% had HTN. HTN treatment initiation, 1-year retention, and control were low at 1.0%, 15.4%, and 5.0%, respectively. Barriers and facilitators of HTN/HIV integration appeared in all three COM-B domains. Barriers included low patient knowledge of HTN complications, less priority by patients for HTN treatment compared to ART, sub-optimal provider knowledge of HTN treatment, lack of HTN treatment protocols, inadequate supply of anti-hypertensive medicines, and lack of HTN care performance targets. Facilitators included patients' and providers' interest in HTN/HIV integration, patients' interest in PLHIV peer support, providers' knowledge and skills for HTN screening, optimal ART adherence counseling, and availability of automated BP machines. CONCLUSION The prevalence of HTN among PLHIV is high, but the HTN care cascade is sub-optimal in this successful HIV clinic. To close these gaps, models of integrated HTN/HIV care are urgently needed. These findings provide a basis for designing contextually appropriate interventions for HTN/HIV integration in Uganda and other low- and middle-income countries.
Collapse
Affiliation(s)
- Martin Muddu
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
| | - Isaac Ssinabulya
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Simon P. Kigozi
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | | | - Florence Ayebare
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Mary Mbuliro
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Isaac Kimera
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | | | - Moses R. Kamya
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| | - Jeremy I. Schwartz
- Uganda Initiative for Integrated Management of Non-Communicable Diseases (UINCD), Kampala, Uganda
- Section of General Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06511 USA
| | - Anne R. Katahoire
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Fred C. Semitala
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
- Department of Internal Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
- Infectious Disease Research Collaboration (IDRC), Kampala, Uganda
| |
Collapse
|
41
|
Okello E, Ndagire E, Muhamed B, Sarnacki R, Murali M, Pulle J, Atala J, Bowen AC, DiFazio MP, Nakitto MG, Harik NS, Kansiime R, Longenecker CT, Lwabi P, Agaba C, Norton SA, Omara IO, Oyella LM, Parks T, Rwebembera J, Spurney CF, Stein E, Tochen L, Watkins D, Zimmerman M, Carapetis JR, Sable CA, Beaton A. Incidence of acute rheumatic fever in northern and western Uganda: a prospective, population-based study. Lancet Glob Health 2021; 9:e1423-e1430. [PMID: 34419237 DOI: 10.1016/s2214-109x(21)00288-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/24/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Acute rheumatic fever is infrequently diagnosed in sub-Saharan African countries despite the high prevalence of rheumatic heart disease. We aimed to determine the incidence of acute rheumatic fever in northern and western Uganda. METHODS For our prospective epidemiological study, we established acute rheumatic fever clinics at two regional hospitals in the north (Lira district) and west (Mbarara district) of Uganda and instituted a comprehensive acute rheumatic fever health messaging campaign. Communities and health-care workers were encouraged to refer children aged 3-17 years, with suspected acute rheumatic fever, for a definitive diagnosis using the Jones Criteria. Children were referred if they presented with any of the following: (1) history of fever within the past 48 h in combination with any joint complaint, (2) suspicion of acute rheumatic carditis, or (3) suspicion of chorea. We excluded children with a confirmed alternative diagnosis. We estimated incidence rates among children aged 5-14 years and characterised clinical features of definite and possible acute rheumatic fever cases. FINDINGS Data were collected between Jan 17, 2018, and Dec 30, 2018, in Lira district and between June 5, 2019, and Feb 28, 2020, in Mbarara district. Of 1075 children referred for evaluation, 410 (38%) met the inclusion criteria; of these, 90 (22%) had definite acute rheumatic fever, 82 (20·0%) had possible acute rheumatic fever, and 24 (6%) had rheumatic heart disease without evidence of acute rheumatic fever. Additionally, 108 (26%) children had confirmed alternative diagnoses and 106 (26%) had an unknown alternative diagnosis. We estimated the incidence of definite acute rheumatic fever among children aged 5-14 years as 25 cases (95% CI 13·7-30·3) per 100 000 person-years in Lira district (north) and 13 cases (7·1-21·0) per 100 000 person-years in Mbarara district (west). INTERPRETATION To the best of our knowledge, this is the first population-based study to estimate the incidence of acute rheumatic fever in sub-Saharan Africa. Given the known rheumatic heart disease burden, it is likely that only a proportion of children with acute rheumatic fever were diagnosed. These data dispel the long-held hypothesis that the condition does not exist in sub-Saharan Africa and compel investment in improving prevention, recognition, and diagnosis of acute rheumatic fever. FUNDING American Heart Association Children's Strategically Focused Research Network Grant, THRiVE-2, General Electric, and Cincinnati Children's Heart Institute Research Core.
Collapse
Affiliation(s)
- Emmy Okello
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda; Department of Medicine, Makerere University, Kampala, Uganda
| | - Emma Ndagire
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Babu Muhamed
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - Rachel Sarnacki
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - Meghna Murali
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - Jafesi Pulle
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Jenifer Atala
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Asha C Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, and Department of Infectious Diseases, Perth Children's Hospital, Nedlands, WA, Australia
| | - Marc P DiFazio
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - M G Nakitto
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Nada S Harik
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - Rosemary Kansiime
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Chris T Longenecker
- Case Western Reserve University, Health Education Campus, Cleveland, OH, USA
| | - Peter Lwabi
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Collins Agaba
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Scott A Norton
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Isaac Otim Omara
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Linda Mary Oyella
- The Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Tom Parks
- Wellcome Center for Human Genetics, The London School of Tropical Medicine and Hygiene, London, UK
| | | | - Christopher F Spurney
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - Elizabeth Stein
- University of Washington School of Medicine, Seattle, WA, USA
| | - Laura Tochen
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - David Watkins
- Department of Medicine and Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, and Department of Infectious Diseases, Perth Children's Hospital, Nedlands, WA, Australia
| | - Craig A Sable
- Makerere School of Health Sciences, Children's National Hospital, Washington DC, USA
| | - Andrea Beaton
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; The University of Cincinnati School of Medicine, Cincinnati, OH, USA.
| |
Collapse
|
42
|
Chang AY, Rwebembera J, Bendavid E, Okello E, Barry M, Beaton AZ, Haeffele C, Webel AR, Kityo C, Longenecker CT. Clinical Outcomes, Echocardiographic Findings, and Care Quality Metrics for People Living with HIV and Rheumatic Heart Disease in Uganda. Clin Infect Dis 2021; 74:1543-1548. [PMID: 34382644 DOI: 10.1093/cid/ciab681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rheumatic Heart Disease (RHD) affects 41 million people worldwide, mostly in low- and middle-income countries, where it is co-endemic with HIV. HIV is also a chronic inflammatory disorder associated with cardiovascular complications, yet the epidemiology of patients affected by both diseases is poorly understood. METHODS Utilizing the Uganda National RHD Registry, we described the echocardiographic findings, clinical characteristics, medication prescription rates, and outcomes of all 73 people carrying concurrent diagnoses of HIV and RHD between 2009 and 2018. These individuals were compared to an age- and sex-matched cohort of 365 subjects with RHD only. RESULTS The median age of the HIV-RHD group was 36 years (IQR 15) and 86% were women. The HIV-RHD cohort had higher rates of prior stroke/transient ischemic attack (12% vs 5%, p=0.02) than the RHD-only group, with this association persisting following multivariable adjustment (OR 3.08, p=0.03). Prevalence of other comorbidities, echocardiographic findings, prophylactic penicillin prescription rates, retention in clinical care, and mortality were similar between the two groups. CONCLUSIONS Patients living with RHD and HIV in Uganda are a relatively young, predominantly female group. Although RHD-HIV comorbid individuals have higher rates of stroke, their similar all-cause mortality and RHD care quality metrics (such as retention in care) compared to those with RHD alone suggest rheumatic heart disease defines their clinical outcome more than HIV does. We believe this study to be one of the first reports of the epidemiologic profile and longitudinal outcomes of patients who carry diagnoses of both conditions.
Collapse
Affiliation(s)
- Andrew Y Chang
- Stanford Cardiovascular Institue, Stanford University, Stanford, CA, USA.,Department of Medicine, Stanford University, Stanford, CA, USA.,Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA
| | | | - Eran Bendavid
- Department of Medicine, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA
| | - Emmy Okello
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Michele Barry
- Department of Medicine, Stanford University, Stanford, CA, USA.,Center for Innovation in Global Health, Stanford University, Stanford, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Andrea Z Beaton
- The Heart Institute, Cincinnati Children's Hospital Medical Center & The University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Christiane Haeffele
- Stanford Cardiovascular Institue, Stanford University, Stanford, CA, USA.,Department of Medicine, Stanford University, Stanford, CA, USA
| | - Allison R Webel
- Department of Child, Family and Population Health Nursing, University of Washington, Seattle, WA, USA
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Chris T Longenecker
- University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| |
Collapse
|
43
|
Jan YT, Tsai PS, Longenecker CT, Lin DC, Yun CH, Sung KT, Liu CC, Kuo JY, Hung CL, Wu TH, Lin JL, Hou CJY, Tsai CT, Chien CY, So A. Thoracic Aortic Calcification and Pre-Clinical Hypertension by New 2017 ACC/AHA Hypertension Guidelines. Diagnostics (Basel) 2021; 11:diagnostics11061027. [PMID: 34205037 PMCID: PMC8226485 DOI: 10.3390/diagnostics11061027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/06/2021] [Accepted: 05/31/2021] [Indexed: 01/19/2023] Open
Abstract
The recently revised 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension (HTN) guidelines employ a lower blood pressure threshold to define HTN, aiming for earlier prevention of HTN-related cardiovascular diseases (CVD). Thoracic aortic calcification (TAC), a new surrogate marker of aging and aortic medial layer degeneration, and different stages of HTN, according to the 2017 ACC/AHA HTN guidelines, remain unknown. We classified 3022 consecutive asymptomatic individuals enrolled into four HTN categories using the revised 2017 ACC/AHA guidelines: normal blood pressure (NBP), elevated blood pressure (EBP), and stage 1 (S1) and stage 2 (S2) HTN. The coronary artery calcification score and TAC metrics (total Agaston TAC score, total plaque volume (mm3), and mean density (Hounsfield units, HU)) were measured using multi-detector computed tomography. Compared to NBP, a graded and significant increase in the TAC metrics was observed starting from EBP and S1 and S2 HTN, using the new 2017 ACC/AHA guidelines (NBP as reference; all trends: p < 0.001). These differences remained consistent after being fully adjusted. Older age (>50 years), S1 and S2 HTN, prevalent diabetes, and chronic kidney disease (<60 mL/min/1.73 m2) are all independently contributing factors to higher TAC risk using multivariate stepwise logistic regressions (all p ≤ 0.001). The optimal cutoff values of systolic blood pressure, diastolic blood pressure, and pulse pressure were 121, 74, and 45 mmHg, respectively, for the presence of TAC after excluding subjects with known CVD and ongoing HTN medication treatment. Our data showed that the presence of TAC starts at a stage of elevated blood pressure not categorized as HTN from the updated 2017 ACC/AHA hypertension guidelines.
Collapse
Affiliation(s)
- Ya-Ting Jan
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (Y.-T.J.); (P.-S.T.); (K.-T.S.)
- Department of Radiology, MacKay Memorial Hospital, Taipei 104, Taiwan;
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Mackay Junior College of Medicine, Nursing and Management, New Taipei City 112, Taiwan
| | - Pei-Shan Tsai
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (Y.-T.J.); (P.-S.T.); (K.-T.S.)
- Department of Radiology, MacKay Memorial Hospital, Taipei 104, Taiwan;
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Mackay Junior College of Medicine, Nursing and Management, New Taipei City 112, Taiwan
| | | | - Dao-Chen Lin
- Division of Endocrine and metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan;
- Department of Radiology, Taipei Veterans General Hospital, Taipei 112, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chun-Ho Yun
- Department of Radiology, MacKay Memorial Hospital, Taipei 104, Taiwan;
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Mackay Junior College of Medicine, Nursing and Management, New Taipei City 112, Taiwan
| | - Kuo-Tzu Sung
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (Y.-T.J.); (P.-S.T.); (K.-T.S.)
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan
| | - Chuan-Chuan Liu
- Graduate Institute of Health Care Organization Administration, College of Public Health National Taiwan University, Taipei 100, Taiwan;
- Health Evaluation Center, MacKay Memorial Hospital, Taipei 104, Taiwan
- Department of Medical Technology, Yuanpei University of Science and Technology, Hsin-Chu City 306, Taiwan
| | - Jen-Yuan Kuo
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan
| | - Chung-Lieh Hung
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan
- Graduate Institute of Health Care Organization Administration, College of Public Health National Taiwan University, Taipei 100, Taiwan;
| | - Tung-Hsin Wu
- Department of Biomedical Imaging and Radiological Sciences, National Yang Ming Chiao Tung University, Taipei 112, Taiwan; (Y.-T.J.); (P.-S.T.); (K.-T.S.)
- Correspondence: (T.-H.W.); (C.-Y.C.)
| | - Jiun-Lu Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan;
| | - Charles Jia-Yin Hou
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan
| | - Cheng-Ting Tsai
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104, Taiwan
| | - Chen-Yen Chien
- Department of Medicine, Mackay Medical College, New Taipei City 252, Taiwan; (J.-Y.K.); (C.-L.H.); (C.J.-Y.H.); (C.-T.T.)
- Mackay Junior College of Medicine, Nursing and Management, New Taipei City 112, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, MacKay Memorial Hospital, Taipei 104, Taiwan
- Correspondence: (T.-H.W.); (C.-Y.C.)
| | - Aaron So
- Imaging Program, Lawson Health Research Institute, London, ON N6C 2R5, Canada;
- Department of Medical Biophysics, University of Western Ontario, London, ON N6A 3K7, Canada
| |
Collapse
|
44
|
Kipke J, Margevicius S, Kityo C, Mirembe G, Buggey J, Yun C, Hung C, McComsey GA, Longenecker CT. Sex, HIV Status, and Measures of Cardiac Stress and Fibrosis in Uganda. J Am Heart Assoc 2021; 10:e018767. [PMID: 33998251 PMCID: PMC8483535 DOI: 10.1161/jaha.120.018767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Biomarkers of myocardial stress and fibrosis are elevated in people living with HIV and are associated with cardiac dysfunction. It is unknown whether sex influences these markers of heart failure risk in sub‐Saharan Africa, where HIV burden is high and where the vast majority of women with HIV live. Methods and Results Echocardiograms and 6 plasma biomarkers (suppression of tumorigenicity‐2, growth differentiation factor 15, galectin 3, soluble fms‐like tyrosine kinase‐1, NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], and cystatin C) were obtained from 100 people living with HIV on antiretroviral therapy and 100 HIV‐negative controls in Uganda. All participants were ≥45 years old with ≥1 major cardiovascular risk factor. Multivariable linear and logistic regression models were used to assess associations between biomarkers, echocardiographic variables, HIV status, and sex, and to assess whether sex modified these associations. Overall, mean age was 56 years and 62% were women. Suppression of tumorigenicity‐2 was higher in men versus women (P<0.001), and growth differentiation factor 15 was higher in people living with HIV versus controls (P<0.001). Sex modified the HIV effect on cystatin C and NT‐proBNP (both P for interaction <0.025). Women had more diastolic dysfunction than men (P=0.02), but there was no evidence of sex‐modifying HIV effects on cardiac structure and function. Cardiac biomarkers were more strongly associated with left ventricular mass index in men compared with women. Conclusions There are prominent differences in biomarkers of cardiac fibrosis and stress by sex and HIV status in Uganda. The predictive value of cardiac biomarkers for heart failure in people living with HIV in sub‐Saharan Africa should be examined, and novel risk markers for women should be further explored.
Collapse
Affiliation(s)
- Jasmine Kipke
- Case Western Reserve University School of MedicineClevelandOH
| | | | | | | | | | | | | | - Grace A. McComsey
- Case Western Reserve University School of MedicineClevelandOH
- University Hospitals Cleveland Medical CenterClevelandOH
| | - Chris T. Longenecker
- Case Western Reserve University School of MedicineClevelandOH
- University Hospitals Cleveland Medical CenterClevelandOH
| |
Collapse
|
45
|
Rana MN, Kim CH, Sullivan CE, Longenecker CT, Al-Kindi SG. Performance of Methods to Estimate Low-Density Lipoprotein Cholesterol in Women With and Without HIV Infection. J Acquir Immune Defic Syndr 2021; 87:750-754. [PMID: 33470728 DOI: 10.1097/qai.0000000000002631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Low-density lipoprotein cholesterol (LDL-C) is estimated from total cholesterol, high-density lipoprotein cholesterol and triglycerides using predefined equations which assume fixed or varying relationships between these parameters and may underestimate or overestimate LDL-C. Data on the performance of these equations in persons with HIV are limited. We sought to investigate the utility of the 3 most widely used methods (Friedewald, Hopkins, and the recently proposed NIH equation) to predict LDL-C in persons with HIV. METHODS We identified 7397 direct LDL-C (5219 HIV, 2127 uninfected controls, 51 seroconvertors) measurements in the Women's Interagency HIV Study, and used the 3 equations (Friedewald, Hopkins, and NIH) to calculate LDL-C. We compared the performance of the 3 equations using root mean square error and coefficient of determination (R2). RESULTS Overall, the Friedewald equation had the best performance characteristics, outperforming Hopkins and NIH methods with lower root mean square error and higher R2 at lower triglyceride levels. However, this association did not hold true at higher triglyceride levels (quartiles 3 and 4), whereas the Hopkins equation had better performance characteristics in quartile 3, none of the 3 equations were optimal in quartile 4. After adjusting for fasting status and triglycerides levels, HIV+ had larger mean difference compared with directly measured LDL using all 3 methods. CONCLUSIONS All 3 methods have lower accuracy in HIV+ vs HIV- women, even after adjusting for triglyceride levels and fasting status. Further research should focus on identifying methods to estimate LDL-C in HIV.
Collapse
Affiliation(s)
- Mariam N Rana
- Department of Internal Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH
| | - Chang H Kim
- Department of Internal Medicine, MetroHealth/Case Western Reserve University, Cleveland, OH; and
| | - Claire E Sullivan
- Division of Cardiovascular Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH
| | - Chris T Longenecker
- Division of Cardiovascular Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH
| | - Sadeer G Al-Kindi
- Division of Cardiovascular Medicine, University Hospitals/Case Western Reserve University, Cleveland, OH
| |
Collapse
|
46
|
Dirajlal-Fargo S, Albar Z, Bowman E, Labbato D, Sattar A, Karungi C, Longenecker CT, Nazzinda R, Funderburg N, Kityo C, Musiime V, McComsey GA. Subclinical Vascular Disease in Children With Human Immunodeficiency Virus in Uganda Is Associated With Intestinal Barrier Dysfunction. Clin Infect Dis 2021; 71:3025-3032. [PMID: 31807748 DOI: 10.1093/cid/ciz1141] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 12/04/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The risk of cardiovascular disease (CVD) and its mechanisms in children living with perinatally acquired HIV (PHIV) in sub-Saharan Africa has been understudied. METHODS Mean common carotid artery intima-media thickness (IMT) and pulse-wave velocity (PWV) were evaluated in 101 PHIV and 96 HIV-negative (HIV-) children. PHIV were on ART, with HIV-1 RNA levels ≤400 copies/mL. We measured plasma and cellular markers of monocyte activation, T-cell activation, oxidized lipids, and gut integrity. RESULTS Overall median (interquartile range, Q1-Q3) age was 13 (11-15) years and 52% were females. Groups were similar by age, sex, and BMI. Median ART duration was 10 (8-11) years. PHIV had higher waist-hip ratio, triglycerides, and insulin resistance (P ≤ .03). Median IMT was slightly thicker in PHIVs than HIV- children (1.05 vs 1.02 mm for mean IMT and 1.25 vs 1.21 mm for max IMT; P < .05), while PWV did not differ between groups (P = .06). In univariate analyses, lower BMI and oxidized LDL, and higher waist-hip ratio, hsCRP, and zonulin correlated with thicker IMT in PHIV (P ≤ .05). After adjustment for age, BMI, sex, CD4 cell count, triglycerides, and separately adding sCD163, sCD14, and hsCRP, higher levels of intestinal permeability as measured by zonulin remained associated with IMT (β = 0.03 and 0.02, respectively; P ≤ .03). CONCLUSIONS Our study shows that African PHIV have evidence of CVD risk and structural vascular changes despite viral suppression. Intestinal intestinal barrier dysfunction may be involved in the pathogenesis of subclinical vascular disease in this population.
Collapse
Affiliation(s)
- Sahera Dirajlal-Fargo
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University, Cleveland, Ohio, USA
| | - Zainab Albar
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Emily Bowman
- Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio, USA
| | - Danielle Labbato
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Abdus Sattar
- Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Chris T Longenecker
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Nicholas Funderburg
- Ohio State University School of Health and Rehabilitation Sciences, Columbus, Ohio, USA
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - Victor Musiime
- Joint Clinical Research Centre, Kampala, Uganda.,Makerere University, Kampala, Uganda
| | - Grace A McComsey
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
47
|
Huaman MA, Juchnowski SM, Zidar DA, Kityo CM, Nalukwago S, Nazzinda R, Fichtenbaum CJ, Longenecker CT. Monocyte activation in persons living with HIV and tuberculosis coinfection. AIDS 2021; 35:447-452. [PMID: 33252496 PMCID: PMC7855758 DOI: 10.1097/qad.0000000000002766] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To characterize monocyte subsets and activation in persons living with HIV (PLWH) with tuberculosis coinfection. DESIGN Cross-sectional study within a cohort of PLWH and HIV-uninfected participants at the Joint Clinical Research Centre in Kampala, Uganda. METHODS Participants were at least 45 years old with at least one cardiovascular risk factor. PLWH had an HIV viral load 1000 copies/ml or less on stable antiretroviral therapy prior to cohort entry. QuantiFERON-TB testing was performed to define latent tuberculosis infection (LTBI). Prior active TB was defined by self-report and verified by medical records. Blood was stained with monocyte subset markers (CD14+, CD16), CD62p, CD69, CX3CR1, HLA-DR, and tissue factor, and examined with flow cytometry. RESULTS One hundred and twenty-five participants (83 PLWH and 42 without HIV) were included. Median CD4+ count was 582 cells/μl in PLWH. PLWH had a higher frequency of total monocytes (4.3% vs. 3.2%; P < 0.001) and inflammatory monocyte subset (15.5% vs. 11.7%; P = 0.016) compared with HIV-uninfected individuals. No differences in the frequency of monocyte subsets were observed by TB status. Among PLWH, prior active TB was associated with increased frequency of total monocytes compared with LTBI (5.1% vs. 3.7%; P = 0.013). HLA-DR density on monocytes was three-fold higher in PLWH with LTBI or prior TB compared with PLWH without LTBI (P = 0.002). In multivariate analysis, a higher monocyte HLA-DR density remained associated with LTBI or prior TB in PLWH (log-MFI; b = 1.17; P < 0.001). CONCLUSION Our findings indicate enhanced monocyte activation in PLWH with LTBI or prior active TB, which may contribute to the pathogenesis of noncommunicable diseases in HIV.
Collapse
Affiliation(s)
- Moises A Huaman
- Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati
| | | | - David A Zidar
- Case Western Reserve University School of Medicine
- Louis Stokes Cleveland Veterans Affairs Medical Center
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, Ohio, USA
| | | | | | | | - Carl J Fichtenbaum
- Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati
| | - Chris T Longenecker
- Case Western Reserve University School of Medicine
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, Ohio, USA
| |
Collapse
|
48
|
Schexnayder J, Longenecker CT, Muiruri C, Bosworth HB, Gebhardt D, Gonzales SE, Hanson JE, Hileman CO, Okeke NL, Sico IP, Vedanthan R, Webel AR. Understanding constraints on integrated care for people with HIV and multimorbid cardiovascular conditions: an application of the Theoretical Domains Framework. Implement Sci Commun 2021; 2:17. [PMID: 33579396 PMCID: PMC7881687 DOI: 10.1186/s43058-021-00114-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/22/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND People with HIV (PWH) experience increased cardiovascular disease (CVD) risk. Many PWH in the USA receive their primary medical care from infectious disease specialists in HIV clinics. HIV care teams may not be fully prepared to provide evidence-based CVD care. We sought to describe local context for HIV clinics participating in an NIH-funded implementation trial and to identify facilitators and barriers to integrated CVD preventive care for PWH. METHODS Data were collected in semi-structured interviews and focus groups with PWH and multidisciplinary healthcare providers at three academic medical centers. We used template analysis to identify barriers and facilitators of CVD preventive care in three HIV specialty clinics using the Theoretical Domains Framework (TDF). RESULTS Six focus groups were conducted with 37 PWH. Individual interviews were conducted with 34 healthcare providers and 14 PWH. Major themes were captured in seven TDF domains. Within those themes, we identified nine facilitators and 11 barriers to CVD preventive care. Knowledge gaps contributed to inaccurate CVD risk perceptions and ineffective self-management practices in PWH. Exclusive prioritization of HIV over CVD-related conditions was common in PWH and their providers. HIV care providers assumed inconsistent roles in CVD prevention, including for PWH with primary care providers. HIV providers were knowledgeable of HIV-related CVD risks and co-located health resources were consistently available to support PWH with limited resources in health behavior change. However, infrequent medical visits, perceptions of CVD prevention as a primary care service, and multiple co-location of support programs introduced local challenges to engaging in CVD preventive care. CONCLUSIONS Barriers to screening and treatment of cardiovascular conditions are common in HIV care settings and highlight a need for greater primary care integration. Improving long-term cardiovascular outcomes of PWH will likely require multi-level interventions supporting HIV providers to expand their scope of practice, addressing patient preferences for co-located CVD preventive care, changing clinic cultures that focus only on HIV to the exclusion of non-AIDS multimorbidity, and managing constraints associated with multiple services co-location. TRIAL REGISTRATION ClinicalTrials.gov , NCT03643705.
Collapse
Affiliation(s)
- Julie Schexnayder
- grid.67105.350000 0001 2164 3847Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-7343 USA
| | - Chris T. Longenecker
- grid.67105.350000 0001 2164 3847Case Western Reserve University School of Medicine, Cleveland, OH USA ,grid.241104.20000 0004 0452 4020University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH USA
| | - Charles Muiruri
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Durham, NC USA
| | - Hayden B. Bosworth
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Durham, NC USA
| | - Daniel Gebhardt
- grid.411931.f0000 0001 0035 4528MetroHealth Medical Center, Cleveland, OH USA
| | - Sarah E. Gonzales
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Durham, NC USA
| | - Jan E. Hanson
- grid.67105.350000 0001 2164 3847Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-7343 USA
| | | | - Nwora Lance Okeke
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Durham, NC USA
| | - Isabelle P. Sico
- grid.26009.3d0000 0004 1936 7961Duke University School of Medicine, Durham, NC USA
| | - Rajesh Vedanthan
- grid.137628.90000 0004 1936 8753New York University Grossman School of Medicine, New York, NY USA
| | - Allison R. Webel
- grid.67105.350000 0001 2164 3847Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-7343 USA
| |
Collapse
|
49
|
Huaman MA, De Cecco CN, Bittencourt MS, Ticona E, Kityo C, Ballena I, Nalukwago S, Nazzinda R, Ticona C, Azañero R, Zhang B, Farquhar C, Hawn TR, Sterling TR, Fichtenbaum CJ, Longenecker CT. Latent Tuberculosis Infection and Subclinical Coronary Atherosclerosis in Peru and Uganda. Clin Infect Dis 2021; 73:e3384-e3390. [PMID: 33388766 DOI: 10.1093/cid/ciaa1934] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Tuberculosis has been linked to an increased risk of atherosclerotic cardiovascular disease (ASCVD). We assessed whether latent tuberculosis infection (LTBI) is associated with subclinical coronary atherosclerosis in two TB-prevalent areas. METHODS We analyzed cross-sectional data from studies conducted in Lima, Peru, and Kampala, Uganda. Individuals ≥40 years old were included. We excluded persons with known history of ASCVD events or active TB. Participants underwent QuantiFERON®-TB (QFT) testing to define LTBI, and computed tomography angiography to examine coronary atherosclerosis. A Coronary Artery Disease-Reporting Data System (CAD-RADS) score ≥3 defined obstructive CAD (plaque causing ≥50% stenosis). RESULTS 113 persons with LTBI and 91 persons without LTBI were included. There were no significant differences between LTBI and non-LTBI participants in terms of age (median [interquartile range]; 56 [51-62] vs. 55 [49-64], p=0.829), male sex (38% vs. 42%; p=0.519), or 10-year ASCVD risk scores (7.1 [3.2-11.7] vs. 6.1 [2.8-10.8]; p=0.533). CAD prevalence (any plaque) was similar between groups (29% vs. 24%; p=0.421). Obstructive CAD was present in 9% of LTBI and 3% of non-LTBI individuals; p=0.095. LTBI was associated with obstructive CAD after adjusting for ASCVD risk score, HIV status, and study site (adjusted odds ratio, 4.96, 95% CI 1.05-23.44; p=0.043). Quantitative QFT TB antigen minus nil interferon-gamma responses were associated with obstructive CAD (adjusted odds ratio, 1.2, 95% CI 1.03-1.41; p=0.022). CONCLUSIONS LTBI was independently associated with an increased likelihood of subclinical obstructive CAD. Our data indicates that LTBI is a non-traditional correlate of ASCVD risk.
Collapse
Affiliation(s)
- Moises A Huaman
- Department of Internal Medicine, Division of Infectious Diseases, University of Cincinnati College of Medicine, Ohio, United States of America
| | - Carlo N De Cecco
- Division of Cardiothoracic Imaging, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
| | | | - Eduardo Ticona
- Hospital Nacional Dos de Mayo, Lima, Peru.,Department of Internal Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | | | | | | | | | | | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, Ohio, United States of America
| | - Carey Farquhar
- Departments of Medicine and Global Health, University of Washington School of Medicine, Seattle, United States of America
| | - Thomas R Hawn
- Departments of Medicine and Global Health, University of Washington School of Medicine, Seattle, United States of America
| | - Timothy R Sterling
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, United States of America
| | - Carl J Fichtenbaum
- Department of Internal Medicine, Division of Infectious Diseases, University of Cincinnati College of Medicine, Ohio, United States of America
| | - Chris T Longenecker
- Harrington Heart & Vascular Institute, Case Western Reserve University School of Medicine, Ohio, United States of America
| |
Collapse
|
50
|
Lipinski J, Margevicius S, Schluchter MD, Wilson DL, McComsey GA, Longenecker CT. Statin effect on coronary calcium distribution, mass and volume scores and associations with immune activation among HIV+ persons on antiretroviral therapy. Antivir Ther 2021; 25:419-427. [PMID: 33901017 DOI: 10.3851/imp3389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND Inflammation has been associated with whole heart coronary artery calcification (CAC) among people with HIV (PWH) on antiretroviral therapy (ART); however, prior studies have not evaluated the distribution of calcium or separated mass versus volume scores, which are differentially associated with clinical events in the general population. Statins may also have a greater effect on CAC mass compared with volume. METHODS 147 PWH were randomized 1:1 to rosuvastatin 10 mg or placebo and followed for 96 weeks. We re-analysed coronary calcium scans from 0, 48 and 96 weeks to determine mass and volume scores and measures of CAC diffusivity. Mixed effects models and generalized estimating equations were used to examine longitudinal associations of CAC with treatment and biomarkers. RESULTS Median age at study entry was 46 years; 78% were male and 68% African American. Median CD4+ was 613 and half were on protease inhibitors. Randomization to statin therapy was not associated with a change in mass score, volume score, number of involved vessels or diffusivity index (all P>0.1). Soluble CD14 was associated with the presence of CAC (P=0.05) and borderline associated with number of involved vessels (P=0.07) across all three time points. CONCLUSIONS In PWH on ART, moderate intensity rosuvastatin does not appear to have a significant effect on volume, mass or regional distribution of CAC over 96 weeks. We extend previous cross-sectional observations to show that soluble CD14 is associated with whole heart CAC over time and independently of age and systolic blood pressure.
Collapse
Affiliation(s)
- Jerry Lipinski
- Department of Internal Medicine, University of California, San Diego, San Diego, CA, USA
| | | | - Mark D Schluchter
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David L Wilson
- Case Western Reserve University School of Engineering, Cleveland, OH, USA
| | - Grace A McComsey
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Chris T Longenecker
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| |
Collapse
|