Incidence of stroke and its predictors among hypertensive patients in Felege Hiwot comprehensive specialized hospital, Bahir Dar, Ethiopia, a retrospective follow-up study

BACKGROUND

Globally, one in three adults has hypertension, a condition that causes 51% of all deaths from stroke. Stroke is becoming a major public health problem and the most common cause of morbidity and mortality among non-communicable diseases in the world and Ethiopia. Therefore, this study assesses the incidence of stroke and its predictors among hypertensive patients in Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia 2021.

METHODS

A hospital-based retrospective follow-up study design was used, simple random sampling technique was used to select 583 hypertensive patients that had follow-up registration between January 2018 and December 30th, 2020. Data were entered into Epi-data version 3.1 and exported to STATA version 14. The adjusted hazard ratio for each predictor with a 95% confidence interval was calculated using the Cox proportional hazards regression model, and a P-value ≤  0.05 was used to denote statistical significance.

RESULTS

From 583 hypertensive patients 106(18.18%) [95% CI 15-20] were developed stroke. The overall incidence rate was 1 per 100 person-years (95% CI 0.79-1.19). Comorbidities (Adjusted hazard ratio(AHR): 1.88, 95% CI 1.0-3.5), stage two hypertension (AHR = 5.21, 95%CI 2.75-9.8), uncontrolled systolic blood pressure (AHR: 2, 95% CI 1.21-354), uncontrolled diastolic blood pressure (AHR:1.9, 95% CI 1.1-3.57), alcohol consumption (AHR = 2.04, 95%CI 1.2-3.49), age 45-65 (AHR = 10.25, 95%CI 7.47-11.1); and drug discontinuation (AHR = 2.05,95% CI 1.26-3.35) were independent predictors for the incidence of stroke among hypertensive patients.

CONCLUSION

The incidence of stroke among hypertensive patients was high and various modifiable and non-modifiable risk factors highly contributed to its incidence. This study recommends early screening of blood pressure, giving priority to comorbid patients and patients with advanced stage hypertension, and giving health education about behavioral risks and drug adherence.

Ethnicity affects the risk factors of acute myocardial infarction and should be considered in educational programs

Acute Myocardial infarction is a non-communicable disease representing the leading cause of death in Saudi Arabia. Studying the ethnicity in its risk factors has been poorly investigated.

Early-onset burdensome multimorbidity: an exploratory analysis of sentinel conditions, condition accrual sequence and duration of three long-term conditions using the 1970 British Cohort Study

OBJECTIVES

The prevalence of multiple long-term condition (LTC) multimorbidity is increasing with younger onset among socioeconomically deprived populations. Research on life course trajectories towards multimorbidity is limited and early-onset multimorbidity poorly characterised. Understanding sentinel conditions (the first LTC occurring in the life course), the sequence of LTC accrual and the permanency of the reporting of LTCs may help identify time points for prevention efforts. We used a longitudinal birth cohort to estimate the prevalence of a common three-condition early-onset multimorbidity (multiple long-term condition multimorbidity (MLTC-M)) group at midlife, describe the frequency of sentinel conditions, the sequence of LTC accrual and explore the permanency of one of these conditions: psychological distress.

SETTING

1970 British Cohort Study (BCS70).

PARTICIPANTS

17 196 cohort members born in 1970.

OUTCOME MEASURES

Prevalence of the most common three-condition multimorbidity group at age 46. The nature and timing of sentinel conditions, the sequencing patterns of subsequent LTC accrual and the permanency of the reporting of psychological distress.

RESULTS

At age 46 high blood pressure, psychological distress and back pain were the most common three-condition MLTC-M group, (4.3%, n=370). A subgroup of 164 (44.3%) people provided complete information on LTC across all time points. Psychological distress measured by the Malaise Index was the most common sentinel condition, occurring in 25.0% (n=41), followed by back pain (22%, n=36). At age 26, 45.1% (75/164) reported their sentinel condition. The most common sequence of LTC accrual was the co-reporting of psychological distress and back pain followed by high blood pressure. Almost one-third (30.5%, n=50) reported a variation of psychological distress across the adult life course.

CONCLUSION

In these exploratory analyses, psychological distress and back pain were the most common sentinel conditions, and along with high blood pressure these three conditions represented the most common three-condition MLTC-M group. These analyses suggest that birth cohorts, like the BCS70, may usefully inform life course-multimorbidity research.

The mediating pathways between parental separation in childhood and offspring hypertension at midlife

Social life course determinants of adult hypertension are relatively unknown. This paper examines how parental separation before age 10 relates to hypertension at age 46. Adjusting for parental confounders and considering the role of adult mediators, we aim to quantify unexplored mediating pathways in childhood using prospectively collected data. Data from the 1970 British Birth Cohort Study are utilised. Hypertension is measured by health care professionals at age 46. Potential mediating pathways in childhood include body mass index (BMI), systolic and diastolic blood pressure, illness, disability, family socioeconomic status (SES) and cognitive and developmental indicators at age 10. Additionally, we explore to what extent childhood mediators operate through adult mediators, including health behaviours, family SES, BMI and mental wellbeing. We also test for effect modification of the relationship between parental separation and hypertension by gender. Nested logistic regression models test the significance of potential mediating variables. Formal mediation analysis utilising Karlson Holm and Breen (KHB) method quantify the direct and indirect effect of parental separation on offspring hypertension at midlife. There was an association between parental separation and hypertension in mid-life in women but not men. For women, family SES and cognitive and behavioural development indicators at age 10 partly mediate the relationship between parental separation and hypertension at age 46. When adult mediators including, health behaviours, family SES, BMI and mental wellbeing are included, the associations between the childhood predictors and adult hypertension are attenuated, suggesting that these childhood mediators in turn may work through adult mediators to affect the risk of hypertension in midlife. We found family SES in childhood, cognitive and behaviour development indicators at age 10, including disruptive behaviour, coordination and locus of control in childhood, to be important mediators of the relationship between parental separation and midlife hypertension suggesting that intervening in childhood may modify adult hypertension risk.

Nocturnal hypertension: a common phenotype in a tertiary clinical setting associated with increased arterial stiffness and central blood pressure

OBJECTIVE

Although the detrimental effect of increased mean blood pressure (BP) is well established, the role of the dynamic and circadian features of BP is less well defined but may be similarly important. In this prospective analysis of hypertensive patients from a tertiary hospital hypertension clinic, we investigated whether the presence of night-time systolic hypertension is associated with more pronounced end-organ damage as assessed by measures of pulse wave analysis (PWA) and pulse wave velocity (PWV).

METHODS

A cohort of 222 consecutive hypertensive patients underwent ambulatory blood pressure measurements, PWA, PWV testing and collection of routine clinical data. Group differences and group-effects of daytime and night-time hypertension on target organ damage and cardiovascular risk parameters were analysed.

RESULTS

Nocturnal hypertension was evident in more than half of the study population. PWV, central systolic, mean arterial and pulse pressure were higher in patients with nocturnal hypertension. Stratification into four groups according to daytime and night-time hypertension status revealed group differences in all outcome parameters. Posthoc testing for individual group differences demonstrated significant differences between fully controlled individuals and the group with high daytime and night-time BP. In a regression analysis for independent effects of categorical night-time and daytime hypertension, nocturnal hypertension was a significant predictor for all PWA and PWV outcomes.

CONCLUSION

Nocturnal hypertension was a highly prevalent phenotype in this population and associated with increased central BP and more pronounced target organ damage as indicated by elevated PWV. Regression analysis confirmed the role of night-time hypertension as an independent explanatory variable for elevated PWV.

Association of hypertension cut-off values with 10-year cardiovascular mortality and clinical consequences: a real-world perspective from the prospective MONICA/KORA study

AIMS

To investigate the clinical value of a lower blood pressure (BP) cut-off for Stage 1 (S1) hypertension (130-139 mmHg systolic or 80-89 mmHg diastolic) in comparison to the currently established Stage 2 (S2) cut-off (≥140/90 mmHg) in a population-based cohort.

METHODS AND RESULTS

We assessed the hypertension prevalence and associated cardiovascular disease (CVD) events in a sample of 11 603 participants (52% men, 48% women; mean 47.6 years) from the MONICA/KORA prospective study. The implementation of the new S1 cut-off increased the prevalence of hypertension from 34% to 63%. Only 24% of S2 hypertension patients were under treatment. Within a follow-up period of 10 years (70 148 person-years), 370 fatal CVD events were observed. The adjusted CVD-specific mortality rate per 1000 persons was 1.61 [95% confidence interval (CI) 1.10-2.25] cases in S2 and 1.07 (95% CI 0.71-1.64) cases in S1 hypertension in comparison to normal BP. Cox proportional regression models were significant for the association of S2 and CVD mortality (1.54, 95% CI 1.04-2.28, P = 0.03), also in the presence of competing risks (1.47, P = 0.05). However, statistical significance for S1 hypertension was not reached (0.93, 95% CI 0.61-1.44, P = 0.76). Among S2 participants, there was a significantly higher prevalence of depressed-mood in treated patients (47%) in comparison to non-treated patients (33%) (P < 0.0001).

CONCLUSION

The lower BP cut-off substantially increased hypertension prevalence, while capturing a population with lower CVD mortality. Additionally, participants under treatment were more likely to have depressed-mood in comparison to non-treated participants, which might reflect a negative labelling effect.

Fibrinogen/Albumin ratio: A more powerful prognostic index for patients with end-stage renal disease

BACKGROUND

Microinflammation is linked to an increased risk of death due to cardiovascular disease (CVD) in patients with end-stage renal disease (ESRD). Although the fibrinogen/albumin ratio (FAR), a novel inflammatory marker, has been shown to predict mortality in various diseases, limited evidence is available for its role in ESRD. The purpose of this study is to explore the prognostic value of the FAR in ESRD patients on peritoneal dialysis (PD).

METHODS

In this retrospective observational study, we enrolled patients with ESRD who underwent PD therapy in our hospital between 1 January 2011 and 31 December 2017. The Kaplan-Meier method and Cox proportional hazards models were used to determine the contact between the FAR level and mortality.

RESULTS

A total of 562 patients were enrolled in our research. The median FAR was 0.12, and patients were divided into two groups (low FAR group: FAR < 0.12, n = 250, and high FAR group: FAR ≥ 0.12, n = 312) according to the median FAR. Kaplan-Meier curves showed that the cumulative incidences of both all-cause mortality and CVD mortality were significantly higher in patients with FAR ≥ 0.12 (both P < .001). In multivariable analysis, the high FAR group had an important increased risk of all-cause and CVD mortality (HR: 1.80; 95% CI: 1.03-3.14, P = .038 and HR: 2.31; 95% CI: 1.17-4.59, P = .016, respectively).

CONCLUSIONS

Our results suggest that a high baseline FAR value is an independent prognostic factor in ESRD patients on PD.

Does Incident Solar Ultraviolet Radiation Lower Blood Pressure?

Background Hypertension remains a leading global cause for premature death and disease. Most treatment guidelines emphasize the importance of risk factors, but not all are known, modifiable, or easily avoided. Population blood pressure correlates with latitude and is lower in summer than winter. Seasonal variations in sunlight exposure account for these differences, with temperature believed to be the main contributor. Recent research indicates that UV light enhances nitric oxide availability by mobilizing storage forms in the skin, suggesting incident solar UV radiation may lower blood pressure. We tested this hypothesis by exploring the association between environmental UV exposure and systolic blood pressure (SBP) in a large cohort of chronic hemodialysis patients in whom SBP is determined regularly. Methods and Results We studied 342 457 patients (36% black, 64% white) at 2178 US dialysis centers over 3 years. Incident UV radiation and temperature data for each clinic location were retrieved from the National Oceanic and Atmospheric Administration database. Linear mixed effects models with adjustment for ambient temperature, sex/age, body mass index, serum Na+/K+ and other covariates were fitted to each location and combined estimates of associations calculated using the DerSimonian and Laird procedure. Pre-dialysis SBP varied by season and was ≈4 mm Hg higher in black patients. Temperature, UVA and UVB were all linearly and inversely associated with SBP. This relationship remained statistically significant after correcting for temperature. Conclusions In hemodialysis patients, in addition to environmental temperature, incident solar UV radiation is associated with lower SBP. This raises the possibility that insufficient sunlight is a new risk factor for hypertension, perhaps even in the general population.

Proteinuria as an independent predictor of stroke: Systematic review and meta-analysis

Background

Proteinuria has emerged as an important vascular risk factor for adverse cardiovascular events including stroke. Hypertension has been proposed as the principal confounder of this relationship but its role has not been systematically examined.

Aim

We aimed to determine if proteinuria remains an independent predictor of stroke after more complete adjustment for blood pressure.

Summary of review

We performed a systematic review, searching MEDLINE and EMBASE (to February 2018) for cohort studies or randomized controlled trials that reported stroke incidence in adults according to baseline proteinuria ± glomerular filtration rate. Study and participant characteristics and relative risks were extracted. Estimates were combined using a random effects model. Heterogeneity was assessed by χ² statistics and I², and by subgroup strata and meta-regression, with a particular focus on the impact of more complete adjustment for blood pressure on the association. The quality of cohort studies and post hoc analyses was assessed using the Newcastle–Ottawa Scale. We identified 38 studies comprising 1,735,390 participants with 26,405 stroke events. Overall, the presence of any level of proteinuria was associated with greater stroke risk (18 studies; pooled crude relative risk 2.00, 95%CI 1.63–2.46; p < 0.001) even after adjustment for established cardiovascular risk factors (33 studies; pooled adjusted relative risk 1.72, 1.51–1.95; p < 0.001), albeit with considerable heterogeneity between studies (p < 0.001; I²= 77.3%). Moreover, the association did not substantially attenuate with more thorough adjustment for hypertension: single baseline blood pressure measure (10 studies; pooled adjusted relative risk = 1.92, 1.39–2.66; p < 0.001); history or treated hypertension (four studies; pooled adjusted relative risk = 1.76, 1.13–2.75, p = 0.013); multiple blood pressure measurements over months to years (four studies; relative risk = 1.68, 1.33–2.14; p < 0.001).

Conclusions

Even after extensive adjustment for hypertension, proteinuria is strongly and independently associated with incident stroke risk, possibly indicating a shared renal and cerebral susceptibility to vascular injury that is not fully explained by traditional vascular risk factors.

[Epidemiology of Arterial Hypertension in Russian Federation - Importance of Choice of Criteria of Diagnosis]

PURPOSE

Assessment of prevalence of arterial hypertension (AH), need for prescription of antihypertensive therapy (AHT), and efficacy of AHT in Russian population in accordance with novel guideline of the American College of Cardiology/American Heart Association ("American recommendations") on diagnosis and treatment of AH (2017).

MATERIALS AND METHODS

Epidemiological study ESSE-RF (ЭССЕ-РФ) was carried out in 12 regions of Russian Federation (RF) with different climatic-geographic characteristics. Number of examined residents of RF aged 25-65 years was 20 652. The sample was stratified by  gender and age. Examination included anthropometry, laboratory tests, blood pressure (BP) measurement with the OMRON tonometer. The SCORE scale was used for evaluation of risk of development of cardiovascular diseases (CVD). In  American recommendations AH was defined as  follows: 1-st degree  - systolic BP (SBP) 130-139  and/or diastolic BP (DBP) 80-89 mm Hg, 2-nd degree - BP ≥140/90 mm Hg and/or presence of AHT. In recommendations of the European Society of Cardiology (2013, 2018) ("European recommendations") AH was defined as BP ≥140/90 mm Hg and/or presence of AHT.

RESULTS

We analyzed data of examination of  20 607  participants - 7806 men (37.9%) and 12 801  women (62.1%). According to  European recommendations AH was diagnosed in 10 347  persons (50.2%)  - 3987 men (51.1%) men and 6 360 women (49.7%). According to American recommendations AH was registered in 14 853 persons (72.1%) - 6 059 men (77.6%) and 8 794 women (68.7%). AHT received 6324 persons (61.1% of those with AH); according to American recommendations, the onset of AHT was indicated to additional 620 persons with 1-st degree AH because of high CVD risk. Among all participants with AH (on and without AHT) strengthening of AHT for achievement of target BP level was required in 77.8 and 92.6% of patients according to European and American recommendations, respectively.

CONCLUSION

Application of novel criteria of AH diagnosis from 2017 ACC/AHA guideline to Russian population would increase prevalence of AH up to 72.1%. Onset of AHT would be indicated in 13.8% of patients with 1-st degree AH, while in 93% of patients receiving AHT its strengthening would be required.

Blood pressure in athletic preparticipation evaluation and the implication for cardiac remodelling

OBJECTIVES

To explore blood pressure (BP) in athletes at preparticipation evaluation (PPE) in the context of recently updated US and European hypertension guidelines, and to determine the relationship between BP and left ventricular (LV) remodelling.

METHODS

In this retrospective study, athletes aged 13-35 years who underwent PPE facilitated by the Stanford Sports Cardiology programme were considered. Resting BP was measured in both arms; repeated once if ≥140/90 mm Hg. Athletes with abnormal ECGs or known hypertension were excluded. BP was categorised per US/European hypertension guidelines. In a separate cohort of athletes undergoing routine PPE echocardiography, we explored the relationship between BP and LV remodelling (LV mass, mass/volume ratio, sphericity index) and LV function.

RESULTS

In cohort 1 (n=2733, 65.5% male), 34.3% of athletes exceeded US hypertension thresholds. Male sex (B=3.17, p<0.001), body mass index (BMI) (B=0.80, p<0.001) and height (B=0.25, p<0.001) were the strongest independent correlates of systolic BP. In the second cohort (n=304, ages 17-26), systolic BP was an independent correlate of LV mass/volume ratio (B=0.002, p=0.001). LV longitudinal strain was similar across BP categories, while higher BP was associated with slower early diastolic relaxation.

CONCLUSION

In a large contemporary cohort of athletes, one-third presented with BP levels above the current US guidelines' thresholds for hypertension, highlighting that lowering the BP thresholds at PPE warrants careful consideration as well as efforts to standardise measurements. Higher systolic BP was associated with male sex, BMI and height and with LV remodelling and diastolic function, suggesting elevated BP in athletes during PPE may signify a clinically relevant condition.

Fallacies of Evidence-Based Medicine in Cardiovascular Medicine

Evidence-based medicine (EBM) has gained a dominant role as the backbone of modern medical activities since its definition about 20 years ago. It serves the purpose to unify and optimize patient management and minimize scientific bias and fraud. The article looks, in the realm of cardiovascular medicine, at the banes of overly rigorous application of EBM with insufficient counterbalancing of other decision criteria. It exemplifies based on fictitious and real trials where EBM does not make sense, can be misleading, or has been inappropriately applied. Closure of the patent foramen ovale and percutaneous coronary intervention are focused upon as 2 major examples. Without abrogating the merits of EBM, concern has to be raised about the risk of increasingly putting EBM first. Neglecting experience and common sense in patient-management as a consequence is not in the interest of mankind.