Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study

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

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

Conceptual framework for establishing the African Stroke Organization

Africa is the world's most genetically diverse, second largest, and second most populous continent, with over one billion people distributed across 54 countries. With a 23% lifetime risk of stroke, Africa has some of the highest rates of stroke worldwide and many occur in the prime of life with huge economic losses and grave implications for the individual, family, and the society in terms of mental capital, productivity, and socioeconomic progress. Tackling the escalating burden of stroke in Africa requires prioritized, multipronged, and inter-sectoral strategies tailored to the unique African epidemiological, cultural, socioeconomic, and lifestyle landscape. The African Stroke Organization (ASO) is a new pan-African coalition that brings together stroke researchers, clinicians, and other health-care professionals with participation of national and regional stroke societies and stroke support organizations. With a vision to reduce the rapidly increasing burden of stroke in Africa, the ASO has a four-pronged focus on (1) research, (2) capacity building, (3) development of stroke services, and (4) collaboration with all stakeholders. This will be delivered through advocacy, awareness, and empowerment initiatives to bring about people-focused changes in policy, clinical practice, and public education. In the spirit of the African philosophy of Ubuntu "I am because we are," the ASO will harness the power of diversity, inclusiveness, togetherness, and team work to build a strong, enduring, and impactful platform for tackling stroke in Africa.

Differential Impact of Risk Factors on Stroke Occurrence Among Men Versus Women in West Africa

Background and Purpose- The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods- SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results- Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49-71.77) versus 16.1 0(9.19-28.19)], dyslipidemia [2.08 (1.42-3.06) versus 1.83 (1.29-2.59)], diabetes mellitus [3.18 (2.11-4.78) versus 2.19 (1.53-3.15)], stress [2.34 (1.48-3.67) versus 1.61 (1.07-2.43)], and low consumption of green leafy vegetables [2.92 (1.89-4.50) versus 2.00 (1.33-3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%-99.6%) among females with 9 factors accounting for 97.2% (94.9%-98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions- Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.

Randomized Trial of an Intervention to Improve Blood Pressure Control in Stroke Survivors

BACKGROUND

We conducted the first-of-its kind randomized stroke trial in Africa to test whether a THRIVES (Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke) intervention improved blood pressure (BP) control among patients with stroke.

METHODS AND RESULTS

Intervention comprised a patient global risk factor control report card, personalized phone text-messaging, and educational video. Four hundred patients recruited from 4 distinct medical facilities in Nigeria, aged ≥18 years with stroke-onset within one-year, were randomized to THRIVES intervention and control group. The control group also received text messages, and both groups received modest financial incentives. The primary outcome was mean change in systolic BP (SBP) at 12 months. There were 36.5% females, 72.3% with ischemic stroke; mean age was 57.2±11.7 years; 93.5% had hypertension and mean SBP was 138.33 (23.64) mm Hg. At 12 months, there was no significant difference in SBP reduction from baseline in the THRIVES versus control group (2.32 versus 2.01 mm Hg, P=0.82). In an exploratory analysis of subjects with baseline BP >140/90 mm Hg (n=168), THRIVES showed a significant mean SBP (diastolic BP) decrease of 11.7 (7.0) mm Hg while control group showed a significant mean SBP (diastolic BP) decrease of 11.2 (7.9) mm Hg at 12 months.

CONCLUSIONS

THRIVES intervention did not significantly reduce SBP compared with controls. However, there was similar significant decrease in mean BP in both treatment arms in the subgroup with baseline hypertension. As text-messaging and a modest financial incentive were the common elements between both treatment arms, further research is required to establish whether these measures alone can improve BP control among stroke survivors.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01900756.

Post-intervention qualitative assessment of mobile health technology to manage hypertension among Ghanaian stroke survivors

Stroke is a leading cause of death in Africa and a key modifiable risk factor for the index and recurrent stroke is through the adequate management of blood pressure. Recent guidelines encourage management beyond clinic settings, yet implementation of these guidelines can be challenging, especially in resource constrained regions, such as in Sub-Saharan Africa. Mobile health technology may offer an innovative and cost-effective approach to improve BP monitoring and facilitate adherence to antihypertensive medications. Stroke survivors (n = 16) and their caregivers (n = 8) who participated in a 3-month feasibility study were invited to share post-intervention insights via focus groups (n = 3). Clinician (n = 7) input on intervention delivery and clinical impressions was also obtained via a separate focus group (n = 1). Four major themes emerged highlighting the ability to self-monitor, the use of technology as an interventional tool, training and support, and post-intervention adherence. Overwhelming receptivity toward home blood pressure monitoring and the use of mobile health (mHealth) was noted. Feedback indicated benefits in having access to equipment and that message prompts facilitated adherence. Post-intervention adherence declined following study intervention, indicating a need for increased exposure to facilitate long-term behavioral change, although participants conveyed a heightened awareness of the importance of BP monitoring and lifestyle changes needed.

Temporal trend analysis of stroke and salt intake: a 15-year population-based study

Objectives: The aim of this study was to evaluate temporal trends of salt intake with stroke incidence, stroke subtypes, and blood pressure in an adult population.Methods: Data were extracted from Isfahan Salt Study. The stroke incidence rate, average salt intake, systolic and diastolic blood pressure in adults, aged over 18 years were considered from 2000 to 2014. The Average Annual Percent Changes (AAPC), parallelism, and the coincidence of trends were estimated, using a permutation test.Results: The trend of salt intake was increased from 2010 to 2014 (AAPC = +1.59, P-value = 0.004). The trend of the stroke incidence rate was nonlinear with two change points in 2003 and 2009. The overall stroke incidence rate increased by 6.65% per year (95% CI: 1.66, 11.8, P-value = 0.015). The temporal trend changes of stroke incidence rate were steeper in patients who aged 40-45 and over 50 years (+6 to +11.5%) than in patients who aged 19-40 and 45-50 (range: -3.3% to 0). The parallelism hypothesis of longitudinal changes between salt intake and ischemic stroke was accepted in patients, aged <50 years (P-value = 0.871).Conclusions: The average salt intake and its cone-shaped variance over 15 years of the study, indicated that salt intake reduction programs and policies were effective to stop associating intake increase until 2007, however, associated intake was increased since that time, which necessitates performing preventive programs. More importantly, the trend of salt intake and ischemic stroke was similar in patients who aged <50 years, regardless of considering their blood pressure.

Differential pricing of medicines to improve access to medicines for hypertension and diabetes control in Ghana: The Ghana Access and Affordability Program, a multi-center prospective trial

Background: Access to medicines for hypertension and diabetes mellitus (DM) management is challenging in resource-limited countries. We sought to assess whether differential pricing of medicines based on socio-economic status would improve affordability of antihypertensive and anti-diabetic medications. A quasi-experimental, prospective cohort study was implemented at five Ghanaian health facilities, using medicines differentially priced by three pharmaceutical companies. Methods: Adult patients ≥18 years with hypertension or DM were enrolled and assigned to a lower tiered differential price (DP arm) or market price (MP arm) based on minimum wage earning or a score >6/18 on a multi-dimensional poverty index scale. Study medicines were purchased at either the DP or MP when prescribed. Participants were followed for 18 months to assess blood pressure (BP) and glycemic control. Predictors of ability to purchase study medicines were assessed using parsimonious logistic regression models. Results: 3,296 participants were enrolled with mean age of 57±12.7 years, 76.6% females. 1,869 (56.7%) had hypertension, 422 (12.8%) had DM, and 1,005 (30.5%) with both hypertension and DM. Average follow-up was 14 months. There were prescriptions of study medications for 526 participants of which 238 (45.2%) were able to make purchases at DP 60.9% versus MP 39.1%. Independent predictors of purchasing ability were higher income, MP arm, willingness to purchase additional medicines, and being at tertiary level institution. Conclusions: Approximately 45% of Ghanaians could afford prescribed study medicines provided at a differential pricing mechanism albeit at an unsustainable basis. Further price reductions are expected to enhance access to medicines for hypertension and DM control.

Risk factors, clinical presentations and predictors of stroke among adult patients admitted to stroke unit of Jimma university medical center, south west Ethiopia: prospective observational study

Background

Stroke is the second-leading global cause of death behind heart disease in 2013 and is a major cause of permanent disability. The burden of stroke in terms of mortality, morbidity and disability is increasing across the world. It is currently observed to be one of the commonest reasons of admission in many health care setups and becoming an alarming serious public health problem in our country Ethiopia. Despite the high burden of strokes globally, there is insufficient information on the current clinical profile of stroke in low and middle income countries (LMICs) including Ethiopia. So, this study was aimed to assess risk factors, clinical presentations and predictors of stroke subtypes among adult patients admitted to stroke unit of Jimma university medical center (JUMC).

Methods

Prospective observational study design was carried out at stroke unit (SU) of JUMC for 4 consecutive months from March 10–July 10, 2017. A standardized data extraction checklist and patient interview was used to collect data. Data was entered into Epi data version 3.1 and analyzed using SPSS version 20. Multivariable logistic regression was used to identify the predictors of stroke subtypes.

Result

A total of 116 eligible stroke patients were recruited during the study period. The mean age of the patients was 55.1 ± 14.0 years and males comprised 62.9%. According to world health organization (WHO) criteria of stroke diagnosis, 51.7% of patients had ischemic while 48.3% had hemorrhagic stroke. The most common risk factor identified was hypertension (75.9%) followed by family history (33.6%), alcohol intake (22.4%), smoking (17.2%) and heart failure (17.2%). The most common clinical presentation was headache complained by 75.0% of the patients followed by aphasia 60.3% and hemiparesis 53.4%. Atrial fibrillation was the independent predictor of hemorrhagic stroke (AOR: 0.08, 95% CI: 0.01–0.68).

Conclusion

The clinical characteristics of stroke in this set up were similar to other low- and middle-resource countries. As stroke is a high priority chronic disease, large-scale public health campaign should be launched focusing on public education regarding stroke risk factors and necessary interventions.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1409-0) contains supplementary material, which is available to authorized users.

Minimal Setting Stroke Unit in a Sub-Saharan African Public Hospital

Introduction: Sub-Saharan Africa (SSA) has the highest stroke prevalence along with a case fatality that amounts to 40%. We aimed to assess the effect of a minimal setting stroke unit in SSA Public hospital on stroke mortality and main medical complications.

Materials and Methods: The study was set in Conakry, Guinea, Ignace Deen public referral hospital. Clinical characteristics, hospital mortality and main medical stroke complications rates (pneumonia, urinary tract infections, sores and venous thromboembolism) of admitted stroke patients after the installation of a minimal stroke unit equipped with heart rate, blood pressure and blood oxygen saturation monitoring and portable oxygen concentrator (POST) were compared to a similar number of stroke patients admitted before the stroke unit creation (PRE).

Results: PRE (n = 318) and POST (n = 361) stroke, patients were comparable in term of age (61 ± 14 vs. 60 ± 14.8 years, p = 0.24), sex (56 vs. 50% males, p = 0.09), High blood pressure rate (76.7 vs. 79%, p = 0.44), stroke subtype (ischemic in 72 vs. 78% of cases, p = 0.05) and NIHSS (11 ± 4 vs. 11 ± 4, p = 0.85). Diabetes was more frequent in the PRE group (19 vs. 9%, p < 0.001). Mortality was significantly lower in the POST group (7.2 vs. 22.3%, p < 0.0001) as well as medical complications (4.1 vs. 27.7%, p < 0.001) and lower pneumonia rate (3.3 vs. 14.5%, p < 0.001).

Conclusions: Minimally equipped stroke units significantly reduce stroke mortality and main medical complications in SSA.

Risk factors, clinical presentations and predictors of stroke among adult patients admitted to stroke unit of Jimma university medical center, south west Ethiopia: prospective observational study

Background

Stroke is the second-leading global cause of death behind heart disease in 2013 and is a major cause of permanent disability. The burden of stroke in terms of mortality, morbidity and disability is increasing across the world. It is currently observed to be one of the commonest reasons of admission in many health care setups and becoming an alarming serious public health problem in our country Ethiopia. Despite the high burden of strokes globally, there is insufficient information on the current clinical profile of stroke in low and middle income countries (LMICs) including Ethiopia. So, this study was aimed to assess risk factors, clinical presentations and predictors of stroke subtypes among adult patients admitted to stroke unit of Jimma university medical center (JUMC).

Methods

Prospective observational study design was carried out at stroke unit (SU) of JUMC for 4 consecutive months from March 10–July 10, 2017. A standardized data extraction checklist and patient interview was used to collect data. Data was entered into Epi data version 3.1 and analyzed using SPSS version 20. Multivariable logistic regression was used to identify the predictors of stroke subtypes.

Result

A total of 116 eligible stroke patients were recruited during the study period. The mean age of the patients was 55.1 ± 14.0 years and males comprised 62.9%. According to world health organization (WHO) criteria of stroke diagnosis, 51.7% of patients had ischemic while 48.3% had hemorrhagic stroke. The most common risk factor identified was hypertension (75.9%) followed by family history (33.6%), alcohol intake (22.4%), smoking (17.2%) and heart failure (17.2%). The most common clinical presentation was headache complained by 75.0% of the patients followed by aphasia 60.3% and hemiparesis 53.4%. Atrial fibrillation was the independent predictor of hemorrhagic stroke (AOR: 0.08, 95% CI: 0.01–0.68).

Conclusion

The clinical characteristics of stroke in this set up were similar to other low- and middle-resource countries. As stroke is a high priority chronic disease, large-scale public health campaign should be launched focusing on public education regarding stroke risk factors and necessary interventions.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1412-5) contains supplementary material, which is available to authorized users.

The dynamics of Poststroke depression among Ghanaians

OBJECTIVE

The very few published data on post-stroke depression (PSD) among indigenous Africans have covered its prevalence and predictors. We sought to evaluate the dynamics of PSD in a cohort of Ghanaian stroke survivors followed for 9 months after an acute stroke.

METHODS

Stroke survivors in this prospective cohort were adults aged >18 years with CT scan confirmed stroke, recruited into a randomized controlled trial to assess the feasibility of an mHealth technology-enabled, nurse guided intervention for blood pressure control. PSD was assessed a secondary outcome measure using the Hamilton Depression Rating Scale (HDRS) at enrollment, months 3, 6, and 9. Those with a score of >7 points on HDRS were categorized as depressed. A multivariate logistic regression analysis was performed to identify independent predictors of PSF.

RESULTS

Mean age of study participants was 55.1 ± 12.7 years with 65% being males. Ischemic strokes comprised 76.6% of study population. Prevalence of PSD at baseline was 78.6%, 43.6% at month 3, 41.1% at month 6 and 18.2% at month 9 (p < .0001). Factors significantly associated with PSD at baseline were higher NIH Stoke Scale score (adjusted OR 1.51, 95% CI: 1.03-2.23) and pain (adjusted OR 7.18, 95% CI: 1.52-33.89). NIHSS score (adjusted OR, 1.99, 95% CI: 1.12-3.52) as associated with PSD at month 9.

CONCLUSION

80% Ghanaian stroke survivors have early PSD declining to 20% at month 9. Stroke severity is the persistent factor associated with PSD at baseline and follow-up, and good be a target for screening and promptly treating PSD.

Echocardiographic Abnormalities and Determinants of 1-Month Outcome of Stroke Among West Africans in the SIREN Study

Background

Little is known about the relationship between echocardiographic abnormalities and outcome among patients with acute stroke. We investigated the pattern and association of baseline echocardiographic variables with 1‐month disability and mortality among patients with stroke in the SIREN (Stroke Investigative Research and Education Network) study.

Methods and Results

We enrolled and followed up consecutive 1020 adult patients with acute stroke with baseline transthoracic echocardiography from west Africa. To explore the relationship between echocardiographic variables and 1‐month disability (using modified Rankin scale >3) and fatality, regression models were fitted. Relative risks were computed with 95% CIs. The participants comprised 60% men with a mean age of 59.2±14.6 years. Ischemic stroke was associated with smaller aortic root diameter (30.2 versus 32.5, P=0.018) and septal (16.8 versus 19.1, P<0.001) and posterior wall thickness at systole (18.9 versus 21.5, P=0.004). Over 90% of patients with stroke had abnormal left ventricular (LV) geometry with eccentric hypertrophy predominating (56.1%). Of 13 candidate variables investigated, only baseline abnormal LV geometry (concentric hypertrophy) was weakly associated with 1‐month disability (unadjusted relative risk, 1.80; 95% CI, 0.97–5.73). Severe LV systolic dysfunction was significantly associated with increased 1‐month mortality (unadjusted relative risk, 3.05; 95% CI, 1.36–6.83).

Conclusions

Nine of 10 patients with acute stroke had abnormal LV geometry and a third had systolic dysfunction. Severe LV systolic dysfunction was significantly associated with 1 month mortality. Larger studies are required to establish the independent effect and unravel predictive accuracy of this association.

Characteristics of hypertension among people living with HIV in Ghana: Impact of new hypertension guideline

Data on the burden of hypertension among people living with HIV (PLWH) in Africa are limited, especially after new expert consensus hypertension guidelines were published in 2017. The authors sought to assess the prevalence and factors associated with hypertension among PLWH. This is a cross-sectional study involving PLWH on combination antiretroviral therapy (cART) (n = 250) compared with sex-matched cART-naïve PLWH (n = 201) in Ghana. Hypertension was defined as blood pressure ≥ 140/90 mm Hg or use of antihypertensive drugs. The authors also assessed the prevalence and predictors associated with hypertension using the recent guideline recommended cutoff BP ≥ 130/80 mm Hg. Multivariate logistic regression models were fitted to identify factors associated with hypertension among PLWH. The mean age of PLWH on cART was 45.7 ± 8.6 years, and 42.9 ± 8.8 years among PLWH cART-naive with 81% of study participants being women. The prevalence of hypertension among PLWH on cART and PLWH cART-naïve was 36.9% and 23.4%, P = 0.002 at BP ≥ 140/90 mm Hg and 57.2% and 42.3%, respectively, P = 0.0009, at BP ≥ 130/80 mm Hg. Factors associated with hypertension at BP ≥ 140/90 mm Hg in the PLWH group with adjusted odds ratio (95% CI) were increasing age, 2.08 (1.60-2.71) per 10 years, and body mass index, 1.53 (1.24-1.88) per 5 kg/m² rise. At BP ≥ 130/80 mm Hg, cART exposure, aOR of 1.77 (95% CI: 1.20-2.63), family history of hypertension, aOR of 1.43 (1.12-1.83), and hypertriglyceridemia, aOR of 0.54 (0.31-0.93), were associated with hypertension. Among PLWH, cART exposure was associated with higher prevalence of hypertension per the new guideline definition, a finding which warrants further investigation and possible mitigation.

Evaluation of Vascular Event Risk while on Long-term Anti-retroviral Suppressive Therapy [EVERLAST]: Protocol for a prospective observational study

Background & objective

Cardiovascular disease (CVD) risk among the HIV population is high due to a combination of accelerated atherosclerosis from the pro-inflammatory milieu created by chronic HIV infection and the potentially adverse metabolic side effects from cART (combination antiretroviral therapy) medications. Although sub-Saharan Africa (SSA) bears 70% of the global burden of HIV disease, there is a relative paucity of studies comprehensively assessing CVD risk among people living with HIV on the continent. The overarching objective of the Evaluation of Vascular Event Risk while on Long-term Anti-retroviral Suppressive Therapy (EVERLAST) Study is to characterize the burden of CVD among HIV patients on ART in Ghana, and explore factors influencing it.

Methods

The EVERLAST study incorporates prospective CVD risk assessments and a convergent mixed methods approach. This prospective study will evaluate CVD risk by measuring Carotid Intimal Media Thickness (CIMT) and presence of traditional medical and lifestyle vascular risk among 240 Ghanaian HIV patients on antiretroviral therapy compared with age- and sex-matched HIV uninfected (n = 240) and HIV positive ART naïve controls (n = 240). A contextual qualitative analysis will also be conducted to determine attitudes/perceptions of various key local stakeholders about CVD risk among HIV patients. The primary outcome measure will be CIMT measured cross-sectionally and prospectively among the three groups. A host of secondary outcome variables including CVD risk factors, CVD risk equations, HIV associated neurocognitive dysfunction and psychological well-being will also be assessed.

Conclusion

EVERLAST will provide crucial insights into the unique contributions of ART exposure and environmental factors such as lifestyle, traditional beliefs, and socio-economic indicators to CVD risk among HIV patients in a resource-limited setting. Ultimately, findings from our study will be utilized to develop interventions that will be tested in a randomized controlled trial to provide evidence to guide CVD risk management in SSA.

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EVERLAST seeks to assess the burden and determinants of cardiovascular risk among Ghanaian HIV patients

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A mixed methods study with prospective analyses of CVD risk factors among HIV patients and HIV-negative controls over 12 months

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Primary outcome measure is sub-clinical carotid atherosclerosis measured using B-mode ultrasound.

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Secondary outcome measures include neurocognitive dysfunction, and CVD events.

The Sub-Saharan Africa Conference on Stroke (SSACS): An idea whose time has come

Stroke is a leading cause of global morbidity and mortality. Sub-Saharan Africa (SSA), where an unprecedented rise in stroke burden is currently raging, has the highest age-standardized stroke incidence, stroke prevalence, and stroke mortality rates. This is in sharp contrast to the relative decline in stroke incidence in high-income countries over the past four decades through better awareness and control of vascular risk factors. Compared to other groups, Africans tend to have a higher risk of stroke, higher percentage of the hemorrhagic type and much poorer outcomes. Indeed, stroke levies a heavy toll on the developing SSA economy by affecting a relatively younger age group. In this commentary, we examine the disproportionately high burden of stroke in the setting of grossly inadequate resources and evidence-based interventions. We propose an annual pan-regional stroke conference (starting in 2020) to harness global resources and local talent with the goal of galvanizing action to tackle this escalating burden. We anticipate that a successful conference series could become a rallying point for the eventual establishment of an African Stroke Organization.

Prevalence and correlates of stroke among older adults in Ghana: Evidence from the Study on Global AGEing and adult health (SAGE)

This study examines the prevalence and correlates of stroke among older adults in Ghana. This cross-sectional study retrieved data from Wave 1 of the World Health Organization (WHO) Survey on Global Ageing and Adult Health (SAGE) conducted between 2007 and 2008. The sample, comprising 4,279 respondents aged 50 years and above, was analysed using descriptive statistics, cross tabulations and Chi-Square tests, and a multivariable binary logistic regression. Respondents ranged in age from 50 to 114 years, with a median age of 62 years. Stroke prevalence was 2.6%, with the correlates being marital status, level of education, employment status, and living with hypertension or diabetes. The results showed that being separated/divorced, having primary and secondary education, being unemployed and living with hypertension and diabetes, significantly increased the odds of stroke prevalence in this population. The results suggest that interventions to reduce stroke prevalence and impact must be developed alongside interventions for hypertension, diabetes and sociodemographic/economic factors such as marital status, level of education, and employment status.

Longer-term effectiveness of protease-inhibitor-based second line antiretroviral therapy in four large sub-Saharan African clinics

OBJECTIVES

Data on the longer-term effectiveness of second line combination antiretroviral therapy (ART) in sub-Saharan Africa (SSA) are lacking. We sought to assess the probability and determinants of 2nd line ART failure in SSA.

METHODS

A retrospective, multi-center study of 2nd line ART initiated between 2005 and 2017 at four ART centers in Ethiopia, Ghana and Uganda. Main outcome measure was virologic failure (VF) defined as VL>1000 copies/ml after >6 months on 2nd line therapy. Predictors of VF and virologic re-suppression on 2nd line were evaluated using Cox Proportional Hazards and multivariable logistic regression models, respectively.

RESULTS

2191 subjects started 2nd line therapy, 61.5% females. Switching from 1st line (56.4% NVP-based, 70.3% including thymidine-analogues) to 2nd line therapy occurred after mean of 4.1 years. 98.9% of patients started boosted PI with NRTI backbone (TDF+3TC/FTC 67.3%, AZT+3TC 18.5%, others 14.2%). There were 267 (12.0%) VF with a 5-year estimated probability of 15.0% (95% CI 13.2-16.9). Key determinants of VF were concomitant rifampicin use (aHR 2.50 [95% CI 1.54-4.05]) and clinical/immunological failure versus virologic failure as reason for switching therapy (aHR, 0.53 [0.33-0.86]). 138 of 267 (51.7%) subsequently achieved virologic re-suppression and predictors included HIV RNA levels at 2nd-line failure: +1 log higher aOR 0.59 [0.43-0.80], experiencing change within 2nd line ART before VF: aOR 0.17 [0.05-0.56], and more recent calendar year of 2nd line initiation: aOR 0.85 [0.75-0.94].

CONCLUSIONS

The effectiveness of current 2nd line ART regimens in SSA is good but challenged by interactions with TB therapy.

Prevalence, Trajectory, and Predictors of Poststroke Fatigue among Ghanaians

BACKGROUND AND PURPOSE

Poststroke fatigue (PSF) is rife among stroke survivors and it exerts a detrimental toll on recovery from functional deficits. The burden of PSF is unknown in sub-Saharan Africa. We have assessed the prevalence, trajectory, and predictors of PSF among 60 recent Ghanaian stroke patients.

METHODS

Study participants in this prospective cohort (recruited between January 2017 and June 2017) were stroke survivors, aged greater than 18 years, with CT scan confirmed stroke of less than 1-month onset. PSF was assessed using the Fatigue Severity Scale (FSS) at enrollment, months 3, 6, and 9. Those with a score of greater than or equal to 4 points on FSS were categorized as "fatigued." A multivariate logistic regression analysis was performed to identify independent predictors of PSF at enrollment and at month 9.

RESULTS

Sixty-five percent (65%) of our sample were males with a mean age of 55.1 ± 12.7 years. In addition to all participants having hypertension, 85% had dyslipidemia and 25% had diabetes mellitus. Ischemic strokes comprised 76.6% of the study population. The prevalence of PSF was 58.9% at baseline and declined to 23.6% at month 9, P = .0002. Diabetes mellitus was significantly associated with PSF at baseline with an adjusted odds ratio of 15.12 (95% CI: 1.70-134.30), P = .01. However, at month 9, age greater than or equal to 65 years, adjusted odds ratio (aOR) of 7.02 (95% CI: 1.16-42.52); female sex, aOR of 8.52 (1.23-59.16), and depression, aOR of 8.86 (1.19-65.88) were independently associated with PSF.

CONCLUSIONS

Approximately 6 out of 10 Ghanaian stroke survivors experience PSF within the first month of stroke onset. PSF persists in approximately 1 out of 4 stroke survivors at 10 months after the index stroke. Further studies to elucidate the underlying mechanisms for PSF are required and adequately powered interventional multicenter trials are eagerly awaited to provide solid evidence base for the clinical management of PSF.

Trends in cerebrovascular diseases mortality in Serbia, 1997-2016: a nationwide descriptive study

OBJECTIVES

Over the last decades, mortality from cerebrovascular diseases (CVDs) has decreased in many countries. The aim of this study was to assess the trends of CVDs mortality in Serbia.

METHODS

Descriptive epidemiological study. Age-standardised rates (ASRs) for CVDs mortality were assessed by joinpoint regression analysis to identify significant changes in trends and estimate annual per cent changes with 95% CI. The age-period-cohort analysis has been used to describe variations in mortality.

RESULTS

Over this 20-year period, there were 312 847 deaths from CVDs, with the overall average annual ASR of 148.4 per 100 000. The trend of ASRs from CVDs mortality in males in Serbia showed a significant joinpoint: rates insignificantly decreased from 1997 to 2005 by -0.8% per year (95% CI -1.7% to 0.2%) and thereafter rapidly decreased by -5.0% per year (95% CI -5.6% to -4.5%). A joinpoint for females was found in 2006: the mortality trend was first significantly decreasing by -1.0% per year (95% CI -1.9% to -0.0%) and then sharply falling down by -6.0% per year (95% CI -6.8% to -5.3%). Results of age-period-cohort analysis indicated that the relative risk for CVDs mortality showed statistically significant (p<0.05) cohort and period effects, as well as the net drift and local drifts in Serbian population. The trends in mortality for all subtypes of CVDs were similar in both sexes: trends significantly decreased for most subtypes, with the exception of a significant increase for cerebral infarction.

CONCLUSIONS

After a decade of increase, CVDs mortality rates are declining in last decade in Serbia. However, mortality rates from CVDs remain exceedingly high in Serbia. Differences in mortality trends of the stroke subtypes should be taken into account in the creation of both prevention and treatment guidelines.

Recurrent Stroke in a Ghanaian Patient With Polycythemia

BACKGROUND

Polycythemia is a rare but important preventable cause of stroke with potential for recurrence when not identified and appropriately managed.

CASE PRESENTATION

This is a case of a 55-year-old Ghanaian who presented to our tertiary facility after a 2-month delay with a history of sudden onset of right-sided hemiparesis and expressive aphasia. He had suffered a previous stroke with left hemiparesis 2 years previously where hypertension and polycythemia were identified and treatment initiated. However, patient defaulted treatment for 18 months prior to the onset of recurrent stroke. A cranial CT scan revealed chronic right and subacute left middle cerebral artery territorial infarcts. Presenting hematocrit was 71%. Treatments initiated included high dose hydroxyurea, venesections, and dual antiplatelet therapy of Aspirin and Clopidogrel. He has since been discharged and remains stable under follow-up with moderate functional deficits- Modified Rankin score of 3/6 and the hematocrit of 54% at 3 months postdischarge.

CONCLUSIONS

Default of therapy for polycythemia is associated with a profound risk of recurrent strokes requiring patient education and support to prevent the devastating consequence of this modifiable but rare cause of stroke. This case report highlights the challenges of instituting secondary prevention for stroke in resource-limited settings.

Burden of subclinical carotid atherosclerosis and vascular risk factors among people living with HIV in Ghana

BACKGROUND

The burden of cardiovascular disease (CVD) among people living with HIV (PLWH) in sub-Saharan Africa is projected to rise due to a rapid epidemiological transition and improved treatment of HIV infection on the sub-continent.

OBJECTIVE

The Evaluation of Vascular Event Risk while on Long-term Anti-retroviral Suppressive Therapy (EVERLAST) Study sought to assess the extent of subclinical atherosclerosis and characterize the nature of CVD risk factors among HIV patients on Antiretroviral therapy (ART) in Ghana.

METHODS

We conducted a cross-sectional study involving HIV patients on antiretroviral therapy (n = 250) in comparison with HIV positive ART naïve (n = 201), and HIV uninfected controls (n = 250). We assessed prevalence of hypertension, dyslipidemia, diabetes mellitus, central obesity, and carotid atherosclerosis using B-mode carotid Doppler ultrasonography. We assessed factors associated with subclinical atherosclerosis defined by a carotid intimal media thickness (CIMT) cut-off of ≥0.78 mm among PLWH using a logistic regression model.

RESULTS

Mean age of PLWH on combination ART (cART) was 45.7 ± 8.6 years, 42.9 ± 8.8 years among PLWH not on cART, and 44.9 ± 9.5 years among HIV negative controls of which 81.2%, 81.6% and 81.1% respectively were females. Prevalence of subclinical atherosclerosis at the common carotid artery in the three groups was 67.6%, 66.7% and 62.4%, p = 0.43. Among PLWH, raised serum total cholesterol (OR 1.16, 95% CI: 1.00-1.35) and triglycerides (OR 1.32, 95% CI: 1.01-1.73) were significantly associated with subclinical atherosclerosis. Prevalence of vascular risk factors among PLWH on cART, PLWH cART naïve, and HIV negative controls respectively were as follows: dyslipidemia- 79.5%, 83.1%, and 73.5%, p = 0.04; hypertension- 40.2%, 23.4%, and 44.9%, p < 0.0001; central obesity-61.8%, 66.7%, and 78.2%, p < 0.0001; diabetes mellitus-6.8%, 5.5% and 4.9%, p = 0.53.

CONCLUSION

Overall while there is a high baseline prevalence of CVD risk factors in the Ghanaian population, serum lipid derangements appear to be more prevalent among HIV infected patients, and are linked to sub-clinical atherosclerosis. Future studies need to confirm these findings, explore the underlying pathophysiology, and optimize treatment strategies to avert untoward CVD outcomes.

Phone-based intervention for blood pressure control among Ghanaian stroke survivors: A pilot randomized controlled trial

BACKGROUND

The potential of mobile-health (mHealth) technology for the management of hypertension among stroke survivors in Africa remains unexplored. We assessed whether an mHealth technology-enabled, nurse-guided intervention initiated among stroke patients within one month of symptom onset is effective in improving their blood pressure (BP) control.

METHODS

A two-arm pilot cluster randomized controlled trial involving 60 stroke survivors, ≥18 years, with BP ≥140/90 mmHg at screening/enrollment visit at a medical center in Ghana. Participants in the intervention arm (n = 30) received a Blue-toothed BP device and smartphone with an App for monitoring BP measurements and medication intake under nurse guidance for three months after which intervention was withdrawn. Control arm (n = 30) received usual care. Primary outcome measure was proportion with clinic BP < 140/90 mmHg at month 9; secondary outcomes included medication adherence.

FINDINGS

Mean ± SD age was 55 ± 13 years, 65% males. Two participants on intervention and three in control group were lost to follow-up. At month 9, proportion on the intervention versus controls with BP < 140/90 mmHg was 14/30 (46.7%) versus 12/30 (40.0%), p = 0.79 by intention-to-treat; systolic BP < 140 mmHg was 22/30 (73.3%) versus 13/30 (43.3%), p = 0.035. Mean ± SD medication possession ratio was 0.95 ± 0.16 on intervention versus 0.98 ± 0.24 in the control arm, p = 0.56.

INTERPRETATION

We demonstrate feasibility and signal of improvement in BP control among stroke survivors in a resource-limited setting via an mHealth intervention. Larger scale studies are warranted.

TRIAL REGISTRATION

NCT02568137. Registered on 13 July 2015 at ClinicalTrials.gov.

Knowledge, attitudes and practices related to stroke in Ghana and Nigeria: A SIREN call to action

INTRODUCTION

Stroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA.

PURPOSE

In this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education.

METHODS

Stroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman's Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes.

RESULTS AND DISCUSSION

The major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana.

Estimated glomerular filtration rate predicts incident stroke among Ghanaians with diabetes and hypertension

Background

Sub-Saharan Africa is currently experiencing a high burden of both chronic kidney disease (CKD) and stroke as a result of a rapid rise in shared common vascular risk factors such as hypertension and diabetes mellitus. However, no previous study has prospectively explored independent associations between CKD and incident stroke occurrence among indigenous Africans. This study sought to fill this knowledge gap.

Methods

A prospective cohort study involving Ghanaians adults with hypertension or type II diabetes mellitus from 5 public hospitals. Patients were followed every 2 months in clinic for 18 months and assessed clinically for first ever stroke by physicians. Serum creatinine derived estimated glomerular filtration rates (eGFR) were determined at baseline for 2631 (81.7%) out of 3296 participants. We assessed associations between eGFR and incident stroke using a multivariate Cox Proportional Hazards regression model.

Results

Stroke incidence rates (95% CI) increased with decreasing eGFR categories of 89, 60–88, 30–59 and <29 ml/min corresponding to incidence rates of 7.58 (3.58–13.51), 14.45 (9.07–21.92), 29.43 (15.95–50.04) and 66.23 (16.85–180.20)/1000 person-years respectively. Adjusted hazard ratios (95%CI) for stroke occurrence according to eGFR were 1.42 (0.63–3.21) for eGFR of 60-89 ml/min, 1.88 (1.17–3.02) for 30-59 ml/min and 1.52 (0.93–2.43) for <30 ml/min compared with eGFR of >89 ml/min. Adjusted HR for stroke occurrence among patients with hypertension with eGFR<60 ml/min was 3.69 (1.49–9.13), p = .0047 and among those with diabetes was 1.50 (0.56–3.98), p = .42.

Conclusion

CKD is dose-dependently associated with occurrence of incident strokes among Ghanaians with hypertension and diabetes mellitus. Further studies are warranted to explore interventions that could attenuate the risk of stroke attributable to renal disease among patients with hypertension in SSA.

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We assessed association between incident stroke and estimated glomerular filtration rate.

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2631 participants stroke-free Ghanaian adults with hypertension or diabetes were followed for 14 months.

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There were 45 incident strokes.

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Incident stroke risk independently increased with declining eGFR.

Risk factors for stroke occurrence in a low HIV endemic West African country: A case-control study

BACKGROUND

HIV infection is an emerging vascular risk factor associated with stroke occurrence. The weight of evidence from sub-Saharan Africa in support of this has accrued from countries with high HIV prevalence. Our objective was to assess the contribution of HIV sero-positivity to the occurrence and outcomes of stroke in a West African country with low HIV prevalence.

METHODS

A case-control study design conducted at a tertiary medical center in Ghana involved in the Stroke Investigative Research & Educational Networks (SIREN) epidemiological study. Stroke cases were adults (aged ≥18 years) with CT or MRI confirmed stroke and stroke-free controls were age-matched and recruited from communities in the catchment areas of cases. Standard instruments were used to assess vascular and lifestyle factors and serological screening for HIV antibodies was conducted for all study participants. Stroke patients were followed for in-patient mortality outcomes. Associations between HIV, demographic and vascular risk factors and stroke occurrence and outcomes were assessed using logistic regression analysis.

RESULTS

We enrolled 540 stroke cases and 540 control subjects with a mean (± SD) age of 60.8 ± 15.5 years (cases) and 60.0 ± 15.5 (controls). Among stroke cases, the frequency of HIV was 12/540 (2.2%, 95% CI: 1.3% - 3.6%) versus 15/540 (2.8%, 95% CI: 1.7% - 4.6%) among stroke-free controls, p = .70. However, the median (IQR) age of Persons Living with HIV (PLWH) with stroke was significantly lower at 46.5 (40-65.3) years versus 61.0 (50-74) years, p = .03 among HIV- stroke patients. Stroke among PLWHA was predominantly hemorrhagic in 7 out of 12 cases and ischemic in 5 of 12 with notable clustering of established factors such as hypertension, (100%), dyslipidemia, 83.3%, central obesity, 50.0%, diabetes mellitus, 33.3%, cardiac diseases, 8.3% in this group. None of the PLWH with stroke were receiving antiretroviral therapy.

CONCLUSION

We found no associations between HIV infection and stroke occurrence among Ghanaians. However a clustering of cardio-metabolic factors in the context of HIV may promote stroke occurrence in younger individuals.

Incident stroke among Ghanaians with hypertension and diabetes: A multicenter, prospective cohort study

Background

The burden of stroke among hypertensive and diabetic population in sub-Saharan Africa remains high. We sought to identify the risk factors associated with stroke occurrence in these high-risk population groups.

Methods

A prospective cohort study involving adults with hypertension and or type II diabetes mellitus at 5 public hospitals in Ghana who were stroke-free at enrollment. Patients were followed every 2 months at clinic for 18 months and assessed clinically for first ever stroke by physicians. We calculated crude incidence rates for stroke and assessed the factors associated with stroke occurrence using a multivariate Cox Proportional Hazards regression models.

Results

Of 3220 eligible participants with 3805 person-years of follow-up, there were 54 clinically confirmed new strokes. Incidence rate of stroke was 14.19 events per 1000 person-years [95% CI: 10.77–18.38], with rates among diabetics with hypertension being 16.64 [10.58–25.00], hypertension of 13.77 [9.33–19.64] and diabetes was 9.81 [3.59–21.74]. Two factors independently associated with stroke occurrence were previous cigarette smoking with adjusted HR (95% CI) of 2.59 (1.18–5.67) and physical inactivity, 1.81 (1.06–3.10). In secondary analysis, stage II hypertension compared with optimal BP was associated with aHR of 3.04 (1.00–9.27), p = .05 for stroke occurrence.

Conclusion

Incident stroke among Ghanaians with hypertension and diabetes is quite high. Stricter control of blood pressure and engaging in regular physical activities are strongly recommended to reduce the risk of strokes.

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The first prospective cohort study to assess factors associated with incident strokes among Ghanaians

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3220 participants stroke free adults with hypertension or diabetes were followed for an average of 14 months

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There were 54 strokes with incidence rate of 14.19 events per 1000 person-years

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Patients with both diabetes with hypertension had highest stroke rates

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Previous cigarette smoking and physical inactivity were independently associated with incident strokes

Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature

BACKGROUND

Tele-rehabilitation for stroke survivors has emerged as a promising intervention for remotely supervised administration of physical, occupational, speech, and other forms of therapies aimed at improving motor, cognitive, and neuropsychiatric deficits from stroke.

OBJECTIVE

We aimed to provide an updated systematic review on the efficacy of tele-rehabilitation interventions for recovery from motor, higher cortical dysfunction, and poststroke depression among stroke survivors.

METHODS

We searched PubMed and Cochrane library from January 1, 1980 to July 15, 2017 using the following keywords: "Telerehabilitation stroke," "Mobile health rehabilitation," "Telemedicine stroke rehabilitation," and "Telerehabilitation." Our inclusion criteria were randomized controlled trials, pilot trials, or feasibility trials that included an intervention group that received any tele-rehabilitation therapy for stroke survivors compared with a control group on usual or standard of care.

RESULTS

This search yielded 49 abstracts. By consensus between 2 investigators, 22 publications met the criteria for inclusion and further review. Tele-rehabilitation interventions focused on motor recovery (n = 18), depression, or caregiver strain (n = 2) and higher cortical dysfunction (n = 2). Overall, tele-rehabilitation interventions were associated with significant improvements in recovery from motor deficits, higher cortical dysfunction, and depression in the intervention groups in all studies assessed, but significant differences between intervention versus control groups were reported in 8 of 22 studies in favor of tele-rehabilitation group while the remaining studies reported nonsignificant differences.

CONCLUSION

This updated systematic review provides evidence to suggest that tele-rehabilitation interventions have either better or equal salutary effects on motor, higher cortical, and mood disorders compared with conventional face-to-face therapy.

Stroke, cerebrovascular diseases and vascular cognitive impairment in Africa

With increased numbers of older people a higher burden of neurological disorders worldwide is predicted. Stroke and other cerebrovascular diseases do not necessarily present with different phenotypes in Africa but their incidence is rising in tandem with the demographic change in the population. Age remains the strongest irreversible risk factor for stroke and cognitive impairment. Modifiable factors relating to vascular disease risk, diet, lifestyle, physical activity and psychosocial status play a key role in shaping the current spate of stroke related diseases in Africa. Hypertension is the strongest modifiable risk factor for stroke but is also likely associated with co-inheritance of genetic traits among Africans. Somewhat different from high-income countries, strokes attributed to cerebral small vessel disease (SVD) are higher >30% among sub-Saharan Africans. Raised blood pressure may explain most of the incidence of SVD-related strokes but there are likely other contributing factors including dyslipidaemia and diabetes in some sectors of Africa. However, atherosclerotic and cardioembolic diseases combined also appear to be common subtypes as causes of strokes. Significant proportions of cerebrovascular diseases are ascribed to various forms of infectious disease including complications of human immunodeficiency virus. Cerebral SVD leads to several clinical manifestations including gait disturbance, autonomic dysfunction and depression. Pathological processes are characterized by arteriolosclerosis, lacunar infarcts, perivascular spaces, microinfarcts and diffuse white matter changes, which can now all be detected on neuroimaging. Except for isolated cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy or CADASIL, hereditary arteriopathies have so far not been reported in Africa. Prevalence estimates of vascular dementia (2-3%), delayed dementia after stroke (10-20%) and vascular cognitive impairment (30-40%) do not appear to be vastly different from those in other parts of the world. However, given the current demographic transition in both urban and rural settings these figures will likely rise. Wider application of neuroimaging modalities and implementation of stroke care in Africa will enable better estimates of SVD and other subtypes of stroke. Stroke survivors with SVD type pathology are likely to have low mortality and therefore portend increased incidence of dementia.

ADRB3 Gene Trp64Arg Polymorphism and Essential Hypertension: A Meta-Analysis Including 9,555 Subjects

Background: Presence of the β3-Adrenergic receptor (ADRB3) gene Trp64Arg (T64A) polymorphism may be associated with an increased susceptibility for essential hypertension (EH). A clear consensus, however, has yet to be reached.

Objective and methods: To further elucidate the relationship between the ADRB3 gene Trp64Arg polymorphism and EH, a meta-analysis of 9,555 subjects aggregated from 16 individual studies was performed. The combined odds ratios (ORs) and their corresponding 95% confidence intervals (CI) were evaluated using either a random or fixed effect model.

Results: We found a marginally significant association between ADRB3 gene Trp64Arg polymorphism and EH in the whole population under the additive genetic model (OR: 1.200, 95% CI: 1.00–1.43, P = 0.049). Association within the Chinese subgroup, however, was significant under allelic (OR: 1.150, 95% CI: 1.002–1.320, P = 0.046), dominant (OR: 1.213, 95% CI: 1.005–1.464, P = 0.044), heterozygous (OR: 1.430, 95% CI:1.040–1.970, P = 0.03), and additive genetic models (OR: 1.280, 95% CI: 1.030–1.580, P = 0.02). A significant association was also found in the Caucasian subgroup under allelic (OR: 1.850, 95% CI: 1. 260–2.720, P = 0.002), dominant (OR: 2.004, 95% CI: 1.316–3.052, P = 0.001), heterozygous (OR: 2.220, 95% CI: 1.450–3.400, P = 0.0002), and additive genetic models (OR: 2.000, 95% CI: 1. 330–3.010, P = 0.0009).

Conclusions: The presence of the ADRB3 gene Trp64Arg polymorphism is positively associated with EH, especially in the Chinese and Caucasian population. The Arg allele carriers of ADRB3 gene Trp64Arg polymorphism may be at an increased risk for developing EH.