Acute cardiovascular effects of the Wenchuan earthquake: ambulatory blood pressure monitoring of hypertensive patients

Activities of the hypothalamo-pituitary-adrenal axis and autonomic nervous system following a strong earthquake

This study aimed to investigate the effects of post-traumatic stress, caused by a strong earthquake, on the hypothalamo-pituitary-adrenal axis (HPA) and autonomous nervous system activity (ANS). Activities of the HPA (as salivary cortisol) and ANS (as heart-rate variability [HRV]) were measured following the 2020 Elazig (Türkiye) earthquake (6.8 Richter Scale, classified as strong). A total of 227 participants (103 men (45%) and 124 women (%55)) provided saliva samples twice, namely, 1 week and 6 weeks after the earthquake. Of these participants, HRV was measured in 51 participants by 5 min continuous electrocardiogram (ECG) recording. Frequency- and time-domain parameters of the HRV were calculated to assess the activity of ANS and low/high frequency (LF/HF) ratio was used as surrogate for sympathovagal balance. Salivary cortisol levels decreased from week 1 towards week 6 (17.40 ± 1.48 and 15.32 ± 1.37 ng/mL, respectively, p < 0.05). There were no gender differences (17.99 ± 2.63 and 16.90 ± 1.60 ng/mL, respectively for females and males, p > 0.05) for salivary cortisol levels. There were no differences in time- and frequency domain parameters of the HRV including LF/HF ratio (2.95 ± 0.38 ms2 and 3.60 ± 0.70 ms2 , respectively for week 1 and 6, p > 0.05). The data show that HPA axis activity, but not that of the ANS, remains higher 1 week after the earthquake but decreases afterwards towards the sixth week, suggesting that the HPA axis might be responsible for the long-term effects of a traumatic event like a strong earthquake.

Systematic review on chronic non-communicable disease in disaster settings

BACKGROUND

Non-communicable diseases (NCDs) constitute the leading cause of mortality globally. Low and middle-income countries (LMICs) not only experience the largest burden of humanitarian emergencies but are also disproportionately affected by NCDs, yet primary focus on the topic is lagging. We conducted a systematic review on the effect of humanitarian disasters on NCDs in LMICs assessing epidemiology, interventions, and treatment.

METHODS

A systematic search in MEDLINE, MEDLINE (PubMed, for in-process and non-indexed citations), Social Science Citation Index, and Global Health (EBSCO) for indexed articles published before December 11, 2017 was conducted, and publications reporting on NCDs and humanitarian emergencies in LMICs were included. We extracted and synthesized results using a thematic analysis approach and present the results by disease type. The study is registered at PROSPERO (CRD42018088769).

RESULTS

Of the 85 included publications, most reported on observational research studies and almost half (48.9%) reported on studies in the Eastern Mediterranean Region (EMRO), with scant studies reporting on the African and Americas regions. NCDs represented a significant burden for populations affected by humanitarian crises in our findings, despite a dearth of data from particular regions and disease categories. The majority of studies included in our review presented epidemiologic evidence for the burden of disease, while few studies addressed clinical management or intervention delivery. Commonly cited barriers to healthcare access in all phases of disaster and major disease diagnoses studied included: low levels of education, financial difficulties, displacement, illiteracy, lack of access to medications, affordability of treatment and monitoring devices, and centralized healthcare infrastructure for NCDs. Screening and prevention for NCDs in disaster-prone settings was supported. Refugee status was independently identified both as a risk factor for diagnosis with an NCD and conferring worse morbidity.

CONCLUSIONS

An increased focus on the effects of, and mitigating factors for, NCDs occurring in disaster-afflicted LMICs is needed. While the majority of studies included in our review presented epidemiologic evidence for the burden of disease, research is needed to address contributing factors, interventions, and means of managing disease during humanitarian emergencies in LMICs.

Cardiovascular Diseases in Natural Disasters; a Systematic Review

Introduction:

As a result of destruction and lack of access to vital infrastructures and mental stress, disasters intensify cardiovascular diseases (CVDs) and hence management of CVDs becomes more challenging. The aim of this study is investigating incidence and prevalence of CVDs, morbidity and mortality of CVDs, treatment and management of CVDs at the time of natural disasters.

Methods:

In the present systematic review, the articles published in English language until 28. 11. 2020, which studied CVDs in natural disasters were included. The inclusion criteria were CVDs such as myocardial infarction (MI), acute coronary syndrome (ACS), hypertension (HTN), pulmonary edema, and heart failure (HF) in natural disasters such as earthquake, flood, storm, hurricane, cyclone, typhoon, and tornado.

Result:

The search led to accessing 4426 non-duplicate records. Finally, the data of 104 articles were included in quality appraisal. We managed to find 4, 21 and 79 full text articles, which considered cardiovascular diseases at the time of flood, storm, and earthquake, respectively.

Conclusion:

Prevalence of CVD increases after disasters. Lack of access to medication or lack of medication adjustment, losing home blood pressure monitor as a result of destruction and physical and mental stress after disasters are of the most significant challenges of controlling and managing CVDs. By means of quick establishment of health clinics, quick access to appropriate diagnosis and treatment, providing and access to medication, self-management, and self-care incentives along with appropriate medication and non-medication measures to control stress, we can better manage and control cardiovascular diseases, particularly hypertension.

Disaster hypertension and cardiovascular events in disaster and COVID-19 pandemic

The incidence of large disasters has been increasing worldwide. This has led to a growing interest in disaster medicine. In this review, we report current evidence related to disasters and coronavirus disease‐2019 (COVID‐19) pandemic, such as cardiovascular diseases during disasters, management of disaster hypertension, and cardiovascular diseases associated with COVID‐19. This review summarizes the time course and mechanisms of disaster‐related diseases. It also discusses the use of information and communication technology (ICT) as a cardiovascular risk management strategy to prevent cardiovascular events. During the 2011 Great East Japan Earthquake, we used the “Disaster Cardiovascular Prevention” system that was employed for blood pressure (BP) monitoring and risk management using ICT. We introduced an ICT‐based BP monitoring device at evacuation centers and shared patients’ BP values in the database to support BP management by remote monitoring, which led to improved BP control. Effective use of telemedicine using ICT is important for risk management of cardiovascular diseases during disasters and pandemics in the future.

Chronological Impact of Earthquakes on Blood Pressure: A Literature Review and Retrospective Study of Hypertension in Haiti Before and After the 2010 Earthquake

Objective: We review prior studies on the incidence of hypertension (HTN) after earthquakes and present a retrospective analysis of HTN after the 2010 earthquake in Haiti. Methods: Prior reports on HTN incidence were reviewed and a retrospective chart review for diagnosis of HTN in 4,308 patient charts was performed over a 7 year period (five clinics). A retrospective cohort study (RCS) was then performed on 11 patients with linear follow-up. Results: The Literature review revealed a significant increase in acute and subacute HTN following earthquakes. However, the chronic effects of earthquakes varied. Our chart review uncovered no significant difference in diagnosed HTN in a Fort-Liberté clinic 128 kilometers (km) distant and 4 weeks post-event. A secondary linear RCS for 11 individuals, prior to and after the earthquake, also did not detect a significant change in HTN prevalence. Conclusion: Prior studies demonstrate acute and subacute, increases in HTN after earthquakes, but late changes have varied. Retrospective studies in the Fort-Liberté clinic, 128 km distant and 4 weeks post-event, revealed no significant change in HTN, confirming prior findings that changes in HTN after earthquakes are early and local events. Further work examining HTN after earthquakes is needed to improve early health care after natural disasters.

Lessons learned about stress and the heart after major earthquakes

There is evidence that certain stressors can trigger cardiovascular events. Several studies have now demonstrated an increase in major adverse cardiac events associated with natural disasters such as an earthquake. The purpose of this paper is to review the literature on earthquakes and cardiovascular events. Reports from 13 major quakes were reported. Earthquakes have been associated with a number of cardiac events including sudden cardiac death, fatal myocardial infarction (MI), myocardial infarction, stress cardiomyopathy, heart failure, stroke, arrhythmias, hypertension and pulmonary embolism. Most reports were associated with earthquakes of magnitude 6.0 or greater. Cardiac events were reported within hours of the quakes. In some reports there was a sharp spike in cardiac events followed by a decrease; but in other quakes the increases in cardiac events lasted weeks, months and even years. There often was an association between the cardiac events and amount of personal property loss. The Great East Japan Earthquake was an unusual event in that it was associated with a major tsunami and cardiac events appeared worse in inundated areas due to flooding. Some but not all reports suggested more MIs associated with early morning earthquakes that woke up the population. Hospitals in earthquake-prone areas should consider developing plans for handling increases in myocardial infarctions and other cardiac events that are associated with earthquakes.

Echoes from Gaea, Poseidon, Hephaestus, and Prometheus: environmental risk factors for high blood pressure

High blood pressure (BP) affects over one billion people and is the leading risk factor for global mortality. While many lifestyle and genetic risk factors are well-accepted to increase BP, the role of the external environment is typically overlooked. Mounting evidence now supports that numerous environmental factors can promote an elevation in BP. Broadly speaking these include aspects of the natural environment (e.g., cold temperatures, higher altitude, and winter season), natural disasters (e.g., earthquakes, volcanic eruptions), and man-made exposures (e.g., noise, air pollutants, and toxins/chemicals). This is important for health care providers to recognize as one (or several) of these environmental factors could be playing a clinically meaningful role in elevating BP or disrupting hypertension control among their patients. At the population level, certain environmental exposures may even be contributing to the growing pandemic of hypertension. Here we provide an updated review of the literature linking environment exposures with high BP and outline practical recommendations for clinicians.

YaAn earthquake increases blood pressure among hospitalized patients

BACKGROUND

YaAn, a city in Sichuan province, China, was struck by a major earthquake measuring 7.0 on the Richter scale on April 20, 2013. This study sought to investigate the impact of YaAn earthquake on the blood pressure (BP) among hospitalized patients in the department of cardiology.

METHODS

We enrolled 52 hospitalized patients who were admitted to our hospital at least three days before the day of earthquake in 2013 (disaster group) as compared with 52 patients during April 20, 2014 (nondisaster group). BP was measured three times per day and the prescription of antihypertensive medicine was recorded.

RESULTS

The earthquake induced a 3.3 mm Hg significant increase in the mean postdisaster systolic blood pressure (SBP) in the disaster group as compared with the nondisaster group. SBP at admission was positively associated with the elevated SBP in the logistic regression model (odds ratio (OR) = 1.09, 95% confidence interval (CI):1.016-1.168, p = 0.015), but not other potential influencing factors, including antihypertensive medicine, sex, age, and body weight, excluding β-blockers. Patients with β-blockers prescription at the time of earthquake showed a blunt response to earthquake-induced SBP elevation than those who were taking other antihypertensive drugs (OR = 0.128, 95% CI: 0.019-0.876, p = 0.036).

CONCLUSION

The YaAn earthquake induced significant increase in SBP even at a distance from the epicenter among hospitalized patients. The findings demonstrate that pure psychological components seem to be a cause of the pressor response and β-blockers might be better in controlling disaster-induced hypertension.

Prolonged Living as a Refugee from the Area Around a Stricken Nuclear Power Plant Increases the Risk of Death

Although it is well known that the Great East Japan Earthquake (March 11, 2011) resulted in a large number of disaster-related deaths, it is not common knowledge that the number of disaster-related deaths continues to increase, even four years after the earthquake, in Fukushima Prefecture, where the nuclear power plant accident occurred. There has been a lack of a minute and critical analysis for the causes for this continuous increase. In this report, the causes for the increase in disaster-related deaths in Fukushima Prefecture were analyzed by aggregating and comparing multiple data released by public organizations (the Reconstruction Agency, the National Police Agency, and Fukushima Prefecture), which may also have implications for developing response strategies to other disasters. The disaster-related death rate, the dead or missing rate, and the refugee rate (the number of disaster-related deaths, dead or missing persons, and refugees per 1,000 people) in each prefecture in stricken areas, and also each city, county, town, and village in Fukushima Prefecture, were calculated and compared with each other. The populations which were used for the calculation of each death rate in the area were based on the number of dead victims who had lived in the area when the earthquake occurred, regardless of where they were at the time of their death. The disaster-related death rate was higher than the dead or missing rate in the area around a stricken nuclear power plant in Fukushima Prefecture. These areas coincide exactly with the Areas under Evacuation Orders because of unsafe radiation levels. The external and internal radiation doses of most of the victims of the Great East Japan Earthquake have appeared not to be so high to harm their health, until now. The psychological stress associated with being displaced from one's home for a long time with an uncertain future may be the cause for these disaster-related deaths. There is an urgent need to recognize refugees' stressful situations, which could even cause death, and to provide them with high-quality medical treatment, including care for their long-term mental health

Aftershock Triggers Augmented Pressor Effects in Survivors: Follow-Up of the Great East Japan Earthquake

BACKGROUND

Previous reports focused on the significant acute effects immediately after an earthquake on an increase in blood pressure (BP) assessed by ambulatory BP monitoring. However, there have been no data on the impact of environmental triggers on the long-term response to earthquake.

METHODS

We analyzed the ambulatory BP monitoring data of 8 patients who lived in the disaster area of the 11 March 2011 Great East Japan Earthquake on the day of the largest aftershock with a first tsunami warming (sirens) on 7 December 2012.

RESULTS

There was no significant difference in the BP in either the period 1 hour before (median (range): 126.5 (121.5-138.0) vs. 137.8 (129.5-177.0) mm Hg, P = 0.07) or that 1 hour after (139.3 (113.0-143.5) vs. 137.5 (125.0-192.0) mm Hg, P = 0.27) the aftershock between those living at home and those who had been living in temporary housing. After the time of aftershock, the systolic BP levels at that night (124.9 (113.2-137.9) vs. 107.0 (101.9-110.1) mm Hg, P = 0.021) and systolic BP levels at the following morning (149.3 (131.0-196.2) vs. 129.5 (128.8-131.0) mm Hg, P = 0.029) were also significantly higher in those living in temporary housing at the time compared to those living in their own homes.

CONCLUSION

Our data suggest that the stress of a change in living conditions following the disaster might have contributed an increased risk of cardiovascular events.

Long-term blood pressure changes induced by the 2009 L'Aquila earthquake: assessment by 24 h ambulatory monitoring

An increased rate of cardiovascular and cerebrovascular events has been described during and immediately after earthquakes. In this regard, few data are available on long-term blood pressure control in hypertensive outpatients after an earthquake. We evaluated the long-term effects of the April 2009 L'Aquila earthquake on blood pressure levels, as detected by 24 h ambulatory blood pressure monitoring. Before/after (mean±s.d. 6.9±4.5/14.2±5.1 months, respectively) the earthquake, the available 24 h ambulatory blood pressure monitoring data for the same patients were extracted from our database. Quake-related daily life discomforts were evaluated through interviews. We enrolled 47 patients (25 female, age 52±14 years), divided into three groups according to antihypertensive therapy changes after versus before the earthquake: unchanged therapy (n=24), increased therapy (n=17) and reduced therapy (n=6). Compared with before the quake, in the unchanged therapy group marked increases in 24 h (P=0.004), daytime (P=0.01) and nighttime (P=0.02) systolic blood pressure were observed after the quake. Corresponding changes in 24 h (P=0.005), daytime (P=0.01) and nighttime (P=0.009) diastolic blood pressure were observed. Daily life discomforts were reported more frequently in the unchanged therapy and increased therapy groups than the reduced therapy group (P=0.025 and P=0.018, respectively). In conclusion, this study shows that patients with unchanged therapy display marked blood pressure increments up to more than 1 year after an earthquake, as well as long-term quake-related discomfort. Our data suggest that particular attention to blood pressure levels and adequate therapy modifications should be considered after an earthquake, not only early after the event but also months later.

Disaster hypertension - its characteristics, mechanism, and management -

The devastating Great East Japan Earthquake, which was 9.0 on the Richter scale, occurred on March 11, 2011. Japan experienced the Great Hanshin-Awaji Earthquake 16 years ago, and I was working at the epicenter, and reported the characteristics of the earthquake-associated cardiovascular risk and high blood pressure (BP) found during the continuous practice and clinical studies of Tsuna Medical Association before and after the quake. A major disaster increases thrombophilic tendency and BP, both of which trigger disaster-induced cardiovascular events such as stroke, cardiac events, etc. The high salt intake and the increased salt sensitivity caused by disrupted circadian rhythms are the 2 major leading causes of disaster hypertension (HT) through neurohumoral activation under stressful conditions. To better assess and reduce the risks for disaster-associated cardiovascular events, we introduced the web-based Disaster Cardiovascular Prevention (DCAP) network (which consists of DCAP risk and prevention score assessment, and self-measured BP monitoring at both the shelter and the home) to the survivors of the 2011 disaster, and frequently found newly developed HT. Here I review the recent evidence, possible mechanism and the management of "disaster HT" for effective prevention of disaster-induced cardiovascular events.