Detection and characteristics of hypertension patients admitted in 37 cardiology departments from 17 Sub-Saharan African countries

Background

High blood pressure (BP) is a major risk factor for several common cardiovascular (CV) disease such as stroke, heart failure or chronic kidney disease. The Sub-Saharan Africa (SSA) should face the highest rate of hypertension worldwide with an overall prevalence estimation of 46%. Due to scarce resources and inadequate healthcare provision, SSA have scarce hard data on treatment and control of high BP.

Purpose

To assess the detection and characteristics of hypertension patients admitted in hospitalizations 17 SSA countries

Methods

We conducted a transversal and longitudinal study in CV department of 37 hospitals from 23 cities in 17 SSA countries (10 low income: Niger, Guinea, Benin, Mali, Democratic Republic of the Congo, Tchad, Burkina Faso, Togo, Burundi, Ethiopia and 7 middle income: Cote d'Ivoire, Senegal, Cameroon, Congo, Soudan, Mauritania, Gabon). The February study was designed by a multidisciplinary collaborative team of epidemiologists, pharmacists and cardiologists from Africa and France. This ongoing observatory included all inpatients in February from each year since 2016. Data including socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, treatments, length of stay and discharge diagnosis were collected by the investigating physicians. Hypertension and severity of hypertension were defined according to 2018 ESC/ESH guidelines and BP was measured twice using standardized method. All analyses were performed through scripts developed in the R software (4.0.3 (2020-10-10))

Results

The study involved 4360 patients. Hypertension was measured on 1906 (43.7%) patients at admission. Proportion of patients with high BP in hospital increased from 42.2% in 2016 to 52.2% in 2021 (p<0.05) and differed significantly across countries from 77.6% in Niger to 100% in Chad. Among hypertensive patients, men represented 59.6% of patients and mean of age was 59±15.1 years. Overall, 61.4% of patients were from low income countries. The mains causes of admission among hypertensive patients were heart failure (37.8%) and stroke (18.9%). Average of systolic BP was 159±29.3 mmHg and average of diastolic BP was 96.7±16mmHg. Overall, 760 (40.3%), 525 (27.8%) and 602 (31.9%) had grade 1, grade 2 and grade 3 hypertension respectively. History of CV disease was observed in 51.5% of patients. Thus, 70.4% of patients had at least one CV risk factor other than hypertension. Angiotensin converting enzyme inhibitors and diuretics was prescribed in 56.9% and 55.8% of patients respectively. The average amount of antihypertensive drugs prescribed in hospital was 2.09±1.18. Overall, 237 (12.4%), 295 (15.5%), 640 (33.6%) and 734 (38.5%) received respectively no drug, monotherapy, two-drug strategies and three and more drug strategies.

Conclusion

In patients admitted in cardiology departments, hypertension is a huge burden in SSA.

Funding Acknowledgement

Type of funding sources: None.

Stroke care in 17 Sub-Saharan African countries: the FEBRUARY study (2016–2021) from African research network

Background

Stroke is one of the leading causes of morbidity and mortality worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability would occur in low- and middle-income countries. Between 2002 and 2020, estimation stroke mortality in Sub-Saharan Africa (SSA) was tripled. There is scarce data on management of stroke in SSA.

Purpose

To describe stroke care in cardiology departments in 17 SSA countries

Methods

We conducted a transversal and longitudinal study in CV department of 37 hospitals from 23 cities in 17 SSA countries (10 low income: Niger, Guinea, Benin, Mali, Democratic Republic of the Congo (DCR), Tchad, Burkina Faso, Togo, Burundi, Ethiopia and 7 middle income: Cote d'Ivoire, Senegal, Cameroon, Congo, Soudan, Mauritania, Gabon). The FEBRUARY study was designed by a multidisciplinary collaborative team of epidemiologists, pharmacists and cardiologists from Africa and France. This ongoing observatory included all inpatients in February from each year since 2016. Data including socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, treatments, length of stay and discharge diagnosis were collected by the investigating physicians. All analyses were performed through scripts developed in the R software (4.0.3 (2020-10-10)).

Results

Overall, 4360 patients were admitted to hospital over the 6 years of the study. Stroke was the third cause of hospitalization with 477 (11%) patients admitted. Proportions of patients admitted for stroke varied across countries from 0% in Ethiopia to 52% in DRC (p<0.01) (figure) and over the years from 11% in 2016 to 16.5% in 2021. Men represented 60.1% of stroke patients. Mean of age was 62.5±13.4 years. Overall, 300 patients (62.9%) were from low-income countries and 177 patients (37.1%) from middle-income countries. A majority of patients were living in urban areas (N=387; 82.9%) compared to rural areas (N=80; 17.1%). Individual wealth index was low, middle and high in 105 (23.2%), 152 (33.6%) and 196 (43.3%) patients respectively. Among stroke patients, 413 (89.8%) had a computed tomography. Ischemic stroke represented 71.8% of patients with stroke. Among CV risk factors, high blood pressure was identified in 81.9% of patients. In-hospital antithrombotic therapy was prescribed for 2 patients (0.42%). Anticoagulant therapy and antiplatelet therapy were prescribed for 26.4% and 53.5% of patients respectively. Proportions of patients treated with antiplatelet therapy varied across countries (p<0.05). At discharge, 8% and 44.4% of patients received anticoagulant therapy or antiplatelet therapy respectively. Mean of length of stay was 12.4±18.4 days. Stroke represent the second cause of mortality (18.7%) and did not vary significantly across countries.

Conclusion

Stroke was the third cause of admission with more than 1/10 patients and the second cause of mortality with almost 1/5 patients in cardiology departments in SSA.

Funding Acknowledgement

Type of funding sources: None.

Healthy sleep score and incident cardiovascular diseases: the Paris Prospective Study III (PPS3)

Background/Introduction

Most studies on the association between sleep habits and cardiovascular disease (CVD) have focused on one single sleep dimension, essentially sleep duration and sleep apnea.

Purpose

To examine the joint effect of several dimensions of sleep habits with incident CVD in a community-based prospective cohort.

Methods

Between 2008 and 2011, 10,157 men and women aged 50 to 75 years were recruited in a preventive medical center. They underwent a standard physical examination coupled with standard biological tests, and provided information related to lifestyle, personal and family medical history, current health status, and medication use on questionnaires. Sleep habits were self-reported on validated questionnaires that assess sleep duration and insomnia complaints (Pittsburg questionnaire), early chronotype, sleep apnea (Berlin questionnaire) and subjective daytime sleepiness (Epworth questionnaire). Each sleep dimension was assigned 1 point if optimal and 0 point otherwise. A healthy sleep score ranging from 0 to 5 (the higher the better) and reflecting the number of optimal sleep dimensions was computed: early chronotype, sleep duration of 7–8 h/day, never/rarely insomnia, no sleep apnea, and no frequent excessive daytime sleepiness. The occurrence of incident CVD events including coronary heart disease and stroke was followed every two years up to September 2020, and events were validated after review of the medical records. The multivariable association between higher healthy sleep score and CVD events was examined in proportional hazard Cox regression analysis. Population-attributable fractions were calculated to estimate the proportion of CVD cases that could be prevented by healthier sleep habits.

Results

This study included 7203 participants (62% of men, mean age: 59.7 years±6.2) who were free of CVD at baseline and had complete data on sleep habits and covariates. Among them, 6.9% had a poor sleep score (healthy sleep score of 0 or 1), and 10.4% had an optimal sleep score (score= 5). After a median follow-up of 8 years, 275 participants had incident CVD events. After adjustment for age, sex, total alcohol consumption, socioprofessional categories, smoking status, body mass index, physical activity, family history of heart diseases, LDL and HDL cholesterol, and diabetes status, the risk of CVD decreased by 22% (HR=0.78 [95% CI: 0.71–0.86]) per 1 point increment in the healthy sleep score, and there was a 74% risk reduction in CVD risk (HR=0.26 [0.13–0.51]) between participants with the highest (score of 5) and those with the lowest (score of 0–1) healthy sleep score (Table 1). Under the hypothesis that all the participants would achieve an optimal sleep score of 5, 70.8% of incident CVD could be potentially avoided each year.

Conclusion(s)

In this community-based prospective cohort, a higher healthy sleep score combining 5 sleep dimensions was associated with a lower risk of CHD or stroke.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The National Research Agency (ANR), The Region Ile de France (Domaine d'Intérêt Majeur)

Causes of admission and mortality among patients admitted in 37 cardiology departments in 17 Sub-Saharan African countries: the FEBRUARY observatory (2016–2021) from African Research Network

Background

Cardiovascular disease (CVD) is a major cause of death worldwide. At least two-third of CVD death occurs in low- (LIC) and middle-income (MIC) countries. An estimated 1 million deaths were attributable to CVD in sub-Saharan Africa (SSA) alone. Scarce data are available about the admission for CVD and outcome in cardiology department in SSA.

Purpose

To describe admission for CVD and outcome of hospitalization in 17 in SSA countries.

Methods

We conducted a transversal and longitudinal study in CV department of 37 hospitals from 23 cities in 17 SSA countries (10 low income: Niger, Guinea, Benin, Mali, Democratic Republic of the Congo, Tchad, Burkina Faso, Togo, Burundi, Ethiopia and 7 middle income: Cote d'Ivoire, Senegal, Cameroon, Congo, Soudan, Mauritania, Gabon). The February study was designed by a multidisciplinary collaborative team of epidemiologists, pharmacists and cardiologists from Africa and France. This ongoing observatory included all inpatients in February from each year since 2016.Data including socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, treatments, length of stay and discharge diagnosis were collected by the investigating physicians. All analyses were performed through scripts developed in the R software (4.0.3 (2020-10-10))

Results

Overall, 4360 patients were included in the February study. Men represented 56.4%. Mean of age was 56.7±16.8 years. The main cause of admission was heart failure (41.5%) followed by acute coronary syndrome (11.9%) and stroke (11%). Cause of admission varied significantly across countries (p<0.01) and over the years (p<0.01). Proportions of admission for heart failure varied from 20% in Ethiopia to 62% in Guinea. Mean of length of stay was 9.95±22.4 days. All causes of admission confounded, in-hospital mortality rate was 11% (N=423). Mortality rate differed significantly according to causes of admission (p<0.01).Mortality rate among patients admitted for stroke, heart failure and acute coronary syndrome was respectively 18%, 12.3% and 9.5%. Overall, 31 (0.7%) were admitted for endocarditis and mortality rate among them was 20.8% (figure). Overall, mortality rate did not vary according to gender or over the years but was significantly different according to patient wealth index (p<0.05), countries (p<0.01) and level income countries (p<0.01). Mortality rate was significantly higher in LIC.

Conclusion

Heart failure, acute coronary syndrome and stroke represent the two-third of causes of admission. Overall, mortality rate in cardiology departments in SSA reached 11%.

Funding Acknowledgement

Type of funding sources: None.

Identification of risk loci for primary aldosteronism in genome-wide association studies

Primary aldosteronism affects up to 10% of hypertensive patients and is responsible for treatment resistance and increased cardiovascular risk. Here we perform a genome-wide association study in a discovery cohort of 562 cases and 950 controls and identify three main loci on chromosomes 1, 13 and X; associations on chromosome 1 and 13 are replicated in a second cohort and confirmed by a meta-analysis involving 1162 cases and 3296 controls. The association on chromosome 13 is specific to men and stronger in bilateral adrenal hyperplasia than aldosterone producing adenoma. Candidate genes located within the two loci, CASZ1 and RXFP2, are expressed in human and mouse adrenals in different cell clusters. Their overexpression in adrenocortical cells suppresses mineralocorticoid output under basal and stimulated conditions, without affecting cortisol biosynthesis. Our study identifies the first risk loci for primary aldosteronism and highlights new mechanisms for the development of aldosterone excess.

Characteristics and factors associated to patients discharging from hospital without an implantable cardioverter defibrillator after out-of-hospital cardiac arrest

AIMS

Guidelines recommend that in the absence of reversible cause for sudden cardiac arrest (SCA), implantable cardioverter defibrillator (ICD) should be performed to prevent further fatal event. We sought to describe the frequency and characteristics of patients discharged from the hospital without ICD after the SCA in the daily practice.

METHODS AND RESULTS

From 2011 to 2018, all SCAs related to a cardiac cause admitted alive across the 48 hospitals of Great Paris Area were prospectively enrolled. Two investigators thoroughly reviewed each medical report to ensure accuracy of the assigned diagnosis towards identifying the cause of SCA and ICD implantation. Out of the 4314 SCA admitted alive at hospital admission, 1064 cardiac-related SCA survivors were discharged alive from hospital, including 356 patients (33.5%) with an ICD and 708 (66.5%) without. The principal underlying cause of SCA among those discharged without an ICD was acute coronary syndrome (ACS; 602, 85%), chronic coronary artery disease (41, 5.8%), structural non-ischaemic heart disease (48, 6.8%), and non-structural heart disease (17, 2.4%). Among ACS-related SCA, 93.8% (602/642) discharged without an ICD. The unique factor associated with non-ICD implantation in the setting of ACS was immediate coronary angioplasty (odds ratio 4.22, 95% confidence interval 1.86-9.30, P < 0.001).

CONCLUSION

Two-thirds of SCA survivors were discharged without an ICD, mainly in the setting of ACS. The unique factor associated with non-ICD implantation among ACS was immediate coronary angioplasty emphasizing the fact that ACS definition must be precise since associated with ICD implantation or not.

Gender gap in annual preventive care services in France

BACKGROUND

In France, screening for cardiovascular risk factors is recommended during annual preventive visits. However, data are lacking on the temporal trend in women's uptake to preventive care services, and in cardiovascular and mortality outcomes. The aim of the study was to investigate the participation and mortality of women in annual preventive care services in a major preventive medicine center in France.

METHOD

Ee conducted repeated cross-sectional studies including a total of 366,270 individuals who had a first examination at the Centre d'Investigations Préventives et Cliniques, France, between January 1992 and December 2011.

FINDINGS

Women's participation was low below 50 years of age, then increases from 50 to 70 years, and is lower for women older than 70 years. The gap in female participation was more pronounced among individuals with high education, low social deprivation, and no depressive symptoms. Compared with the general population, the screened population had significantly lower standardized mortality ratios (SMRs) among both men and women, for all age ranges. Screened women aged 18-49 years showed a lower mortality gain compared with men of the same age; SMRs did not differ significantly by sex for individuals over 50 years.

INTERPRETATION

In this community-based sample, compared with men, women's participation to annual preventive care services was lower, and screened women had a lower mortality gain. Despite the demonstrated benefit of annual check-ups on health, there is a gender gap in adherence to preventive programs and in efficiency of screening programs, especially in the young age range. This gap in cardiovascular disease prevention may result in poorer cardiovascular health in women. Urgent adaptations to overcome this gender gap in preventive screening in France are warranted.

FUNDING

Bamba Gaye is supported by the Fondation Recherche Médicale grant.

Lack of Early Etiologic Investigations in Young Sudden Cardiac Death

BACKGROUND

Since majority of sudden cardiac arrest (SCA) victims die in the intensive care unit (ICU), early etiologic investigations may improve understanding of SCA and targeted prevention.

METHODS

In this prospective, population-based registry all SCA admitted alive across the 48 hospitals of the Paris area were enrolled. We investigated the extent of early etiologic work-up among young SCD cases (<45 years) eventually dying within the ICU.

RESULTS

From May 2011 to May 2018, 4,314 SCA patients were admitted alive. Among them, 3,044 died in ICU, including 484 (15.9%) young patients. SCA etiology was established in 233 (48.1%) and remained unexplained in 251 (51.9%). Among unexplained (compared to explained) cases, coronary angiography (17.9 vs. 49.4%, P<0.001), computed tomography scan (24.7 vs. 46.8%, P<0.001) and trans-thoracic echocardiography (31.1 vs. 56.7%, P<0.001) were less frequently performed. Only 22 (8.8%) patients with unexplained SCD underwent all three investigations. SCDs with unexplained status decreased significantly over the 7 years of the study period (from 62.9 to 35.2%, P=0.005). While specialized TTE and CT scan performances have increased significantly, performance of early coronary angiography did not change. Autopsy, genetic analysis and family screening were performed in only 48 (9.9%), 5 (1.0%) and 14 cases (2.9%) respectively.

CONCLUSIONS

More than half of young SCD dying in ICU remained etiologically unexplained; this was associated with a lack of early investigations. Improving early diagnosis may enhance both SCA understanding and prevention, including for relatives. Failure to identify familial conditions may result in other preventable deaths within these families.

Does age influence out-of-hospital cardiac arrest incidence and outcomes among women? Insights from the Paris SDEC

AIMS

Age and sex disparities in out-of-hospital cardiac arrest (OHCA) have been described. Reproductive age may have a protected effect on females vs. males, although results are conflicting. We aimed to clarify this using the Paris Sudden Death Expertise Centre (SDEC) registry.

METHODS AND RESULTS

The Paris SDEC registry collects OHCAs occurring in the Greater Paris Area. We included all OHCAs of presumed cardiac causes occurring between 2013 and 2018. Patients were divided into age groups: 1-13, 13-50, 50-75, and >75 years. Sex and age disparities in OHCA incidence and outcomes were analysed using multivariable negative binomial and logistic regression models. There were 19 782 OHCAs meeting inclusion criteria: 0.37% aged 1-13 years, 12.4% aged 13-50 years, 40.4% aged 50-75 years, and 46.9% aged >75 years. Adjusted incidence rate ratios (IRRs) in females vs. males were for the youngest to the older age groups: 1.29 [95% confidence interval (CI) 0.78-2.13], 0.54 [0.49-0.59], 0.60 [0.56-0.64], and 0.75 [0.67-0.84]. At reproductive age, females were more likely than males to have a return of spontaneous circulation [adjusted odds ratio (OR) 1.60 (1.27-2.02)], to be alive at hospital admission [OR: 1.49 (1.18-1.89)]. In both sexes, patients aged 13-50 years were more likely to survive at hospital discharge than those aged 50-75 years [males: OR 1.81 (1.49-2.20), females: 2.24 (1.54-3.25)]. However, at reproductive age, no sex disparity was observed in survival at hospital discharge [OR: 1.16 (0.75-1.80)].

CONCLUSION

Incidence rate ratios were similar between pre- and post-menopausal aged patients. At reproductive age, no sex disparity in survival at hospital discharge was observed, suggesting that menopausal status may not influence OHCA occurrence and prognosis.

Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center

BACKGROUND

Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Here, our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area.

METHODS

We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated, but died in intensive care units in the Paris region in 2011-2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. One-year graft survival was assessed using Cox and log-rank tests.

RESULTS

Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e., 28% of the patients with brain death. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, factors associated with organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6-27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1-1.6], P < 0.001); older age was negatively associated with donation (OR/10-year increase, 0.7 [0.6-0.8], P < 0.001). In patients without post-resuscitation shock, the factor associated with donation was neurological cause of OHCA (OR, 6.9 [3.0-15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7-1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2-0.7], P = 0.006) were negatively associated with organ donation. One-year graft survival did not differ according to Utstein characteristics of the donor.

CONCLUSIONS

4% of patients who died in ICU after OHCA led to organ donation. Patients with OHCA constitute a valuable source of donated organs, and special attention should be paid to young patients with OHCA of neurological cause.

Use of traditional medicine and control of hypertension in 12 African countries

Background

Use of traditional medicine (TM) is widespread in sub-Saharan Africa as a treatment option for a wide range of disease. We aimed to describe main characteristics of TM users and estimate the association of TM use with control of hypertension.

Methods

We used data on 2128 hypertensive patients of a cross-sectional study (convenience sampling), who attended cardiology departments of 12 sub-Saharan African countries (Benin, Cameroon, Congo, Democratic Republic of the Congo, Gabon, Guinea, Côte d’Ivoire, Mauritania, Mozambique, Niger, Senegal, Togo). To model association of TM use with odds of uncontrolled, severe and complicated hypertension, we used multivariable mixed logistic regressions, and to model the association with blood pressure (systolic (SBP) and diastolic (DBP)) we used mixed linear models. All models were adjusted for age, sex, wealth, adherence to hypertension conventional treatment and country (random effect).

Results

A total of 512 (24%) participants reported using TM, varying across countries from 10% in the Congo to 48% in Guinea. TM users were more likely to be men, living in rural area, poorly adhere to prescribed medication (frequently due to its cost). Use of TM was associated with a 3.87 (95% CI 1.52 to 6.22)/1.75 (0.34 to 3.16) mm Hg higher SBP/DBP compared with no use; and with greater odds of severe hypertension (OR=1.34; 95% CI 1.04 to 1.74) and of any hypertension complication (OR=1.27; 95% CI 1.01 to 1.60), mainly driven by renal complication (OR=1.57; 95% CI 1.07 to 2.29) after adjustment for measured confounders.

Conclusions

The use of TM was associated with higher blood pressure, more severe hypertension and more complications in Sub-Saharan African countries. The widespread use of TM needs to be acknowledged and worked out to integrate TM safely within the conventional healthcare.

Prevalence of Hearing Loss and Hearing Aid Use Among Adults in France in the CONSTANCES Study

IMPORTANCE

Although hearing loss is common in the population worldwide, the prevalence of hearing loss and hearing aid use is not known.

OBJECTIVE

To estimate the prevalence of hearing loss and hearing aid use in the adult French population.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the CONSTANCES cohort, a representative sample of the French population. Volunteers aged 18 to 75 years were recruited at 21 preventive health centers between January 1, 2012, and December 31, 2019. The present study included participants with audiometric data.

MAIN OUTCOMES AND MEASURES

The main outcomes were prevalence of hearing loss and disabling hearing loss overall and by sex and age group and prevalence of self-reported hearing aid use among those with disabling hearing loss. Hearing loss was defined as a pure-tone average (PTA) in the better ear of 20 dB or higher, and disabling hearing loss was defined as a PTA in the better ear of 35 dB or higher.

RESULTS

Of 200 870 participants in the CONSTANCES study, 186 460 had full audiometric data and were included in this study (mean [SD] age, 47.1 [13.5] years); 100 330 (53.8%) were female, and 86 130 (46.2%) were male. Of these participants, 24.8% (95% CI, 24.6%-25.0%) had hearing loss and 4.3% (95% CI, 4.2%-4.4%) had disabling hearing loss. The prevalence rates of hearing loss increased from 3.4% (95% CI, 2.8%-3.9%) at age 18 to 25 years to 73.3% (95% CI, 69.5%-77.2%) at age 71 to 75 years among men and from 4.4% (95% CI, 3.9%-5.0%) at age 18 to 25 years to 64.1% (95% CI, 59.7%-68.4%) at age 71 to 75 years among women. The prevalence of disabling hearing loss increased from 0.3% (95% CI, 0.2%-0.4%) among participants aged 18 to 25 years to 23.3% (95% CI, 20.7%-26.0%) among participants aged 71 to 75 years. Among the 8050 participants with disabling hearing loss, 36.8% (95% CI, 35.8%-37.9%) reported using hearing aids, including 56.7% (95% CI, 38.9%-74.4%) aged 18 to 25 years and 32.9% (95% CI, 26.8%-39.2%) aged 71 to 75 years.

CONCLUSIONS AND RELEVANCE

In this cohort study, hearing loss was prevalent in France, and the prevalence of hearing loss increased with age among both men and women. Hearing aids were underused, particularly among older individuals. These findings suggest that hearing loss prevention and screening in the French population are needed.

Use of traditional medicine and control of hypertension in 12 Sub-Saharan African countries: the EIGHT cross-sectional study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Camille Lassale is supported by a fellowship from “La Caixa” Foundation (ID 100010434). The fellowship code is LCF/BQ/PR21/11840003

Background

Use of traditional medicine (TM), is widespread in Sub-Saharan Africa as treatment option for a wide range of disease. We aimed to describe the profile of TM users and estimate the association with blood pressure (BP) and control of hypertension among hypertensive patients in a pan-African study.

Methods

We included 2128 participants in the cross-sectional EIGHT study, who attended an outpatient consultation in the cardiology departments of 12 Sub-Saharan African countries (Benin, Cameroon, Congo, Democratic Republic of the Congo, Gabon, Guinea, Côte d’Ivoire, Mauritania, Mozambique, Niger, Senegal, Togo). We describe patients’ characteristics according to TM use. We modelled the odds of uncontrolled hypertension, severe hypertension, and complications of hypertension by multivariable mixed logistic regression, and the linear association with systolic and diastolic BP by linear regression, all adjusted for age, sex, individual wealth index, adherence to hypertension conventional treatment, and country.

Results

A total of 512 (24%) of participants reported using TM, and this percentage varied drastically across countries from 10% in the Congo to 48% in Guinea. TM users were more likely to be male, with poor treatment adherence, reporting missing treatment because it is too expensive, and presenting any complication of hypertension. TM use was associated with greater odds of hypertension (OR=1.30; 95% confidence interval: 0.99, 1.70), severe hypertension (OR=1.34; 1.04, 1.74) and of any complication of hypertension (OR=1.27; 1.01, 1.60), driven by renal complication (OR=1.57; 1.07, 2.29). Use of TM was associated with a 3.87 mmHg higher systolic BP and 1.75 mm Hg higher diastolic BP compared to no use.

Conclusions

In this cross-sectional study of patients with hypertension in 12 Sub-Saharan African countries, we identified that the use of traditional medicine was associated with a poorer control of hypertension and more complications.

Incidence of Sudden Cardiac Death in the European Union

BACKGROUND

Although sudden cardiac death (SCD) is recognized as a high-priority public health topic, reliable estimates of the incidence of SCD or, more broadly, out-of-hospital cardiac arrest (OHCA), in the population are scarce, especially in the European Union.

OBJECTIVES

The study objective was to determine the incidence of SCD and OHCA in the European Union.

METHODS

The study examined 4 large (ie, >2 million inhabitants) European population-based prospective registries collecting emergency medical services (EMS)-attended (ie, with attempted resuscitation) OHCA and SCD (OHCA without obvious extracardiac causes) for >5 consecutive years from January 2012 to December 2017 in the Paris region (France), the North Holland region (the Netherlands), the Stockholm region (Sweden), and in all of Denmark.

RESULTS

The average annual incidence of SCD in the 4 registries ranged from 36.8 per 100,000 (95% CI: 23.5-50.1 per 100,000) to 39.7 per 100,000 (95% CI: 32.6-46.8 per 100,000). When extrapolating to each European country and accounting for age and sex, this yields to 249,538 SCD cases per year (95% CI: 155,377-343,719 SCD cases per year). The average annual incidence of OHCA in the 4 registries ranged from 47.8 per 100,000 (95% CI: 21.2-74.4 per 100,000) to 57.9 per 100,000 (95% CI: 19.6-96.3 per 100,000), corresponding to 343,496 OHCA cases per year (95% CI: 216,472-464,922 OHCA cases per year) in the European Union. Incidence rates of SCD and OHCA increased with age and were systematically higher in men compared with women.

CONCLUSIONS

By combining data from 4 large, population-based registries with at least 5 years of data collection, this study provided an estimate of the incidence of SCD and OHCA in the European Union.

Sex differences in aortopathy and valve diseases among patients undergoing cardiac surgery

BACKGROUND

We aimed to study sex differences in aortopathy and valve disease among patients undergoing aortic valve replacement and/or surgery for ascending aortic aneurysm, and assess whether differences are specific for patients with bicuspid (BAV) compared to patients with tricuspid aortic valve (TAV).

METHODS

We used a single-center and observational cohort including 1,045 patients undergoing elective open-heart surgery for aortic valve disease and/or ascending aortic aneurysm at the Karolinska Hospital (Sweden).

RESULTS

Women (33.0%) were older than men (mean [SD]; 67.9 [11] years vs 62.5 [13] years for men; P < 0.001). No significant sex difference in prevalence of ascending aortic aneurysm was found according to absolute measures (P = 0.19), however, women had a greater dilation of the ascending aorta when normalized for body surface area (mean [SD], 21.8 [6.3] mm/m² vs 19.3 [4.4] mm/m² for men; P < 0.001). Among the 560 patients with BAV, women had significantly more AS (adjusted OR, 2.23; 95% CI, 1.19-4.20; P = 0.013) and less AI (adjusted OR 0.42; 95% CI, 0.23-0.78; P < 0.01); whereas no sex difference was found among patients with TAV.

CONCLUSIONS

In this large study of patients undergoing cardiac surgery, we found greater degree of aortic dilation in women compared to men suggesting a need for earlier monitoring of women. Moreover, women with BAV had a significantly higher prevalence of AS compared to men. These results describe the aorta and valvular characteristics of patients by sex and provide guidance regarding which patients might benefit from closer surveillance.

Harmonization of the definition of sudden cardiac death in longitudinal cohorts of the European Sudden Cardiac Arrest network - towards Prevention, Education, and New Effective Treatments (ESCAPE-NET) consortium

BACKGROUND

The burden of sudden cardiac death (SCD) in the general population is substantial and SCD frequently occurs among people with few or no known risk factors for cardiac disease. Reported incidences of SCD vary due to differences in definitions and methodology between cohorts. This study aimed to develop a method for adjudicating SCD cases in research settings and to describe uniform case definitions of SCD in an international consortium harmonizing multiple longitudinal study cohorts.

METHODS

The harmonized SCD definitions include both case definitions using data from multiple sources (eg, autopsy reports, medical history, eyewitnesses) as well as a method using only information from registers (eg, cause of death registers, ICD-10 codes). Validation of the register-based method was done within the consortium using the multiple sources definition as gold standard and presenting sensitivity, specificity, accuracy and positive predictive value.

RESULTS

Consensus definitions of "definite," "possible" and "probable" SCD for longitudinal study cohorts were reached. The definitions are based on a stratified approach to reflect the level of certainty of diagnosis and degree of information. The definitions can be applied to both multisource and register-based methods. Validation of the method using register-information in a cohort comprising 1335 cases yielded a sensitivity of 74%, specificity of 88%, accuracy of 86%, and positive predictive value of 54%.

CONCLUSIONS

This study demonstrated that a harmonization of SCD classification across different methodological approaches is feasible. The developed classification can be used to study SCD in longitudinal cohorts and to merge cohorts with different levels of information.

OUP accepted manuscript

More than 40 years after the first implantable cardioverter-defibrillator (ICD) implantation, sudden cardiac death (SCD) still accounts for more than five million deaths worldwide every year. Huge efforts in the field notwithstanding, it is now increasingly evident that the current strategy of long-term prevention based on left ventricular ejection fraction as the key selection criterion is actually of very limited impact, also because the largest absolute numbers of SCD are encountered in the general population not known to be at risk. It has been recently reemphasized that SCD is often not so sudden, with almost half of the victims experiencing typical warning symptoms preceding the event. Importantly, heeded and prompt medical attention can dramatically improve survival. Essentially, such timely action increases the chances of the SCD event being witnessed by emergency medical services and provides the opportunity for early intervention. In addition, newer technologies incorporating digital data acquisition, transfer between interconnected devices, and artificial intelligence, should allow dynamic, real-time monitoring of diverse parameters and therefore better identification of subjects at short-term SCD risk. Along with warning symptoms, these developments allow a new approach of near-term prevention based on the hours and minutes preceding SCD. In the present review, we challenge the current paradigm of mid- and long-term prevention using ICD in patients at the highest risk of SCD, and introduce a complementary concept applicable to the entire population that would aim to pre-empt SCD by timely detection and intervention within the minutes or hours prior to the event.

Cardiovascular Health at Age 5 Years: Distribution, Determinants, and Association With Neurodevelopment

BACKGROUND

Early childhood may represent an opportune time to commence primordial prevention of cardiovascular disease (CVD, i.e., prevention of risk factors onset), but epidemiological evidence is scarce. We aimed to examine the distribution and parental and early life determinants of ideal cardiovascular health (CVH) in children up to 5 years and to compare the level of cognitive development between children with and without ideal CVH at age 5 years.

METHODS

Using data from the Etude sur les déterminants pré et post natals précoces du Développement psychomoteur et de la santé de l'Enfant (EDEN) study, a French population-based mother-child cohort study, CVH was examined in children at 5 years of age based on the American Heart Association CVH metrics (ideal body mass index, physical activity, diet, blood pressure, cholesterol and glucose levels, and passive smoking, considered in sensitivity analysis only). Children were categorized as having ideal (five to six ideal metrics) or non-ideal CVH (<5 ideal metrics). Intelligence quotient (IQ) at age 5 years was assessed using the French version of the Wechsler Preschool and Primary Scale of Intelligence.

RESULTS

Among the 566 children (55% boys), only 34% had ideal CVH. In fully adjusted logistic regression, boys compared to girls (OR = 1.77, 95% CI 1.13-2.78), children with intermediate (1.77, 1.05-2.98) or ideal (2.58, 1.38-4.82) behavioral CVH at age 3 years and children who spent < 30 min/day watching television (1.91, 1.09-3.34) at age 3 years were more likely to have ideal CVH at age 5 years. At age 5 years, there was a significant 2.98-point difference (95% CI 0.64-5.32) in IQ between children with and without ideal biological CVH after adjusting for confounders.

CONCLUSION

This study highlights that only a third of children aged 5 years had ideal CVH and identified modifiable determinants of ideal CVH and is suggestive of an association between CVH and neurodevelopment at a young age.

Oral Condition and Incident Coronary Heart Disease: A Clustering Analysis

Poor oral health has been linked to coronary heart disease (CHD). Clustering clinical oral conditions routinely recorded in adults may identify their CHD risk profile. Participants from the Paris Prospective Study 3 received, between 2008 and 2012, a baseline routine full-mouth clinical examination and an extensive physical examination and were thereafter followed up every 2 y until September 2020. Three axes defined oral health conditions: 1) healthy, missing, filled, and decayed teeth; 2) masticatory capacity denoted by functional masticatory units; and 3) gingival inflammation and dental plaque. Hierarchical cluster analysis was performed with multivariate Cox proportional hazards regression models and adjusted for age, sex, smoking, body mass index, education, deprivation (EPICES score; Evaluation of Deprivation and Inequalities in Health Examination Centres), hypertension, type 2 diabetes, LDL and HDL serum cholesterol (low- and high-density lipoprotein), triglycerides, lipid-lowering medications, NT-proBNP and IL-6 serum level. A sample of 5,294 participants (age, 50 to 75 y; 37.10% women) were included in the study. Cluster analysis identified 3,688 (69.66%) participants with optimal oral health and preserved masticatory capacity (cluster 1), 1,356 (25.61%) with moderate oral health and moderately impaired masticatory capacity (cluster 2), and 250 (4.72%) with poor oral health and severely impaired masticatory capacity (cluster 3). After a median follow-up of 8.32 y (interquartile range, 8.00 to 10.05), 128 nonfatal incident CHD events occurred. As compared with cluster 1, the risk of CHD progressively increased from cluster 2 (hazard ratio, 1.45; 95% CI, 0.98 to 2.15) to cluster 3 (hazard ratio, 2.47; 95% CI, 1.34 to 4.57; P < 0.05 for trend). To conclude, middle-aged individuals with poor oral health and severely impaired masticatory capacity have more than twice the risk of incident CHD than those with optimal oral health and preserved masticatory capacity (ClinicalTrials.gov NCT00741728).

Blood pressure-lowering medicines implemented in 12 African countries: the cross-sectional multination EIGHT study

OBJECTIVE

In Africa, the number of patients with hypertension is expected to reach 216.8 million by 2030. Large-scale data on antihypertensive medications used in Sub-Saharan Africa (SSA) are scarce.Here, we describe antihypertensive drug strategies and identify treatment factors associated with blood pressure (BP) control in 12 Sub-Saharan countries.

SETTING

Outpatient consultations for hypertension in urban tertiary cardiology centres of 29 hospitals from 17 cities across 12 SSA countries between January 2014 and November 2015.

PARTICIPANTS

Patients ≥18 years of age with hypertension were enrolled at any visit during outpatient consultations in the cardiology departments MAIN OUTCOME MEASURE: We collected BP levels, demographic characteristics and antihypertensive treatment use (including traditional medicine) of patients with hypertension attending outpatient visits. BP control was defined as seated office BP <140/90 mm Hg. We used logistic regression with a random effect on countries to assess factors of BP control.

RESULTS

Overall, 2198 hypertensive patients were included and a total of 96.6% (n=2123) were on antihypertensive medications. Among treated patients, 653 (30.8%) patients received a monotherapy by calcium channel blocker (n=324, 49.6%), renin-angiotensin system blocker (RAS) (n=126, 19.3%) or diuretic (n=122, 18.7%). Two-drug strategies were prescribed in 927 (43.6%) patients including mainly diuretics and RAS (n=327, 42% of two-drug strategies). Prescriptions of three-drugs or more were used in 543 (25.6%) patients. Overall, among treated patients, 1630 (76.7%) had uncontrolled BP, of whom 462 (28.3%) had BP levels ≥180/110 mm Hg, mainly in those on monotherapy. After adjustment for sociodemographic factors, the use of traditional medicine was the only factor significantly associated with uncontrolled BP (OR 1.72 (1.19 to 2.49) p<0.01).

CONCLUSION

Our study provided large-scale data on antihypertensive prescriptions in the African continent. Among patients declared adherent to drugs, poor BP control was significantly associated with the use of traditional medicine.