Longitudinal control of blood pressure among a cohort of Ghanaians with hypertension: A multicenter, hospital‐based study

High rate of uncontrolled hypertension among adults receiving integrated HIV and hypertension care with aligned multi-month dispensing in Malawi: results from a cross-sectional survey and retrospective chart review

INTRODUCTION

People living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication.

METHODS

We conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year.

RESULTS

We surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year.

CONCLUSIONS

Uncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.

Exploring patient-, provider-, and health facility-level determinants of blood pressure among patients with hypertension: A multicenter study in Ghana

Optimal blood pressure (BP) control is essential in averting cardiovascular disease and associated complications, yet multiple factors influence the achievement of BP targets. We explored patient-, provider-, and health facility-level factors of systolic and diastolic BP and controlled BP status among patients with hypertension in Ghana. Using a cross-sectional design, we recruited 15 health facilities, and from each facility, we recruited four healthcare providers involved in managing hypertension and 15 patients diagnosed with hypertension. The primary outcome of interest was systolic and diastolic BP; the secondary outcome was BP control (<140/90 mmHg) in compliance with Ghana's national standard treatment guidelines. We used mixed-effects regression models to explore the patient- and facility-level predictors of the outcomes. Two hundred twenty-four patients and 67 healthcare providers were sampled across 15 health facilities. The mean (SD) age of providers and patients was 32 (7) and 61 (13) years, respectively. Most (182 [81%]) of the patient participants were female, and almost half (109 [49%]) had controlled BP. At the patient level, traveling for 30 minutes to one hour to the health facility was associated with higher diastolic BP (Coeff.:3.75, 95% CI: 0.12, 7.38) and lower odds of BP control (OR: 0.51, 95% CI: 0.28, 0.92) compared to traveling for less than 30 minutes. Receiving hypertension care at government health facilities than at private health facilities was associated with lower systolic BP (Coeff.: -13.89; 95% CI: -23.99, -3.79). A higher patient-to-physician or physician-assistant ratio was associated with elevated systolic BP (Coeff.: 21.34; 95% CI: 8.94, 33.74) and lower odds of controlled BP (OR: 0.19, 95% CI: 0.05, 0.72). Along with addressing the patient-level factors influencing BP outcomes in Ghana, there is a need for public health and policy interventions addressing the inaccessibility of hypertension services, the shortage of clinical care providers, and the underperformance of private health facilities.

Healthcare system barriers and facilitators to hypertension management in Ghana

Background: Hypertension continues to pose a significant burden on the health systems in Sub-Saharan Africa (SSA). Multiple challenges at the health systems level could impact patients' blood pressure outcomes. There is a need to understand the gaps in health systems to improve their readiness to manage the rising burden of hypertension Objective: To explore health system barriers and opportunities for improved management of hypertension in Ghana, West Africa. Methods: We conducted 5 focus group discussions involving 9 health facility leaders and 24 clinicians involved in hypertension treatment at 15 primary-level health facilities in Kumasi, Ghana. We held discussions remotely over Zoom and used thematic analysis methods. Results: Four themes emerged from the focus group discussions: (1) financial and geographic inaccessibility of hypertension services; (2) facilities' struggle to maintain the supply of antihypertensive medications and providers' perceptions of suboptimal quality of insured medications; (3) shortage of healthcare providers, especially physicians; and (4) patients' negative self-management practices. Facilitators identified included presence of wellness and hypertension clinics for screening and management of hypertension at some health facilities, nurses' request for additional roles in hypertension management, and the rising positive practice of patient home blood pressure monitoring. Conclusion: Our findings highlight critical barriers to hypertension service delivery and providers' abilities to provide quality services. Health facilities should build on ongoing innovations in hypertension screening, task-shifting strategies, and patient self-management to improve hypertension control. In Ghana and other countries, policies to equip healthcare systems with the resources needed for hypertension management could lead to a high improvement in hypertension outcomes among patients.

Determinants of visit-to-visit systolic blood pressure variability among Ghanaians with hypertension and diabetes mellitus

Objective

To identify the determinants of systolic blood pressure variability (SBPV) among Ghanaians.

Design

We undertook a secondary analysis of data collected in a prospective study.

Setting

The study involved patients with hypertension and or diabetes receiving care in five hospitals in Ghana.

Main outcome measures

We assessed determinants of SBPV among 2,785 Ghanaian patients. We calculated the standard deviation (SD) of systolic BP recordings of 3 to 10 visits per patient over 18 months as a measure of SBPV. A multivariate linear regression analysis was fitted to identify factors independently associated with risk visit-to-visit SBP standard deviation.

Results

The mean SD of individual patient visit-to-visit SBP overall was 14.8± 6.3 mm Hg. Those with hypertension and diabetes had the highest SD of 15.4 ±6.2 mm Hg followed by 15.2 ±6.5 mm Hg among those with hypertension only and then 12.0 ± 5.2 mm Hg among those with diabetes only, p<0.0001. Factors independently associated with SBPV with adjusted β coefficients (95% CI) included age: 0.06 (0.03 - 0.08) for each year rise in age, eGFR -0.03 (-0.05 - -0.02) for each ml/min rise, low monthly income of <210 Ghana cedis 1.45 (0.43-2.46), and secondary level of education -1.10 (-1.69, -0.50). Antihypertensive classes were associated with SBPV, the strongest associations being hydralazine 2.35 (0.03 - 4.68) and Methyldopa 3.08 (2.39 - 3.77).

Conclusion

Several socio-demographic and clinical factors are associated with SBPV. Future studies should assess the contribution of SBPV to CVD outcomes among indigenous Africans and identify actionable targets.

Funding

Funding for this study was provided by MSD, Novartis, Pfizer, Sanofi (each a Participant Company) and the Bill and Melinda Gates Foundation (collectively, the Funders) through the New Venture Fund (NVF). FSS and BO are also supported by funding from the National Heart, Lung, and Blood Institute (R01HL152188).

Global burden of atrial fibrillation/flutter due to high systolic blood pressure from 1990 to 2019: estimates from the global burden of disease study 2019

Atrial fibrillation/atrial flutter (AF/AFL) has progressed to be a public health concern, and high systolic blood pressure (HSBP) remains the leading risk factor for AF/AFL. This study estimated the HSBP attributable AF/AFL burden based on the data from the Global Burden of Disease (GBD) study 2019. Numbers, age-standardized rates (ASR) of deaths, disability-adjusted life years (DALYs), and corresponding estimated annual percentage change (EAPC) were analyzed by age, sex, sociodemographic index (SDI), and locations. Gini coefficient was calculated to evaluate health inequality. Globally, HSBP-related AF/AFL caused 107 091 deaths and 3 337 876 DALYs in 2019, an increase of 142.5% and 105.9% from 1990, respectively. The corresponding mortality and DALYs ASR declined by 5.8% and 7.7%. High-income Asia Pacific experienced the greatest decrease in mortality and DALYs ASR, whereas the largest increase was observed in Andean Latin America. Almost half of the HSBP-related AF/AFL burden was carried by high and high-middle SDI regions, and it was experiencing a shift to lower SDI regions. A negative correlation was detected between EAPC and SDI. Females and elderly people tended to have a higher AF/AFL burden, whereas young adults (30-49 years old) experienced an annual increase in AF/AFL burden. The Gini index of DALYs rate decreased from 0.224 in 1990 to 0.183 in 2019. Despite improved inequality having been observed over the past decades, the HSBP-related AF/AFL burden varied across regions, sexes, and ages. Cost-effective preventive, diagnostic, and therapeutic tools are required to be implemented in less developed regions.

Blood pressure control status of patients with hypertension on treatment in Dessie City Northeast Ethiopia

INTRODUCTION

Uncontrolled blood pressure contributes a huge contribution to many hypertension-related complications and it is one of the unbeaten problems for patients taking antihypertensive drugs. The association of social support and other factors with uncontrolled blood pressure during the covid-19 pandemic is not well investigated. Therefore, this study explored the determinants of blood pressure control status during the COVID-19 pandemic among patients with hypertension who were on an antihypertensive treatment.

METHOD

A cross-sectional study was done from March to May 2021 among adults aged 18 or more patients with hypertension for three months or more on treatment in Dessie City. An interview-administered questionnaire was done using simple random sampling from hypertension follow-up register for 380 patients with hypertension. Blood pressure measurement was taken from their arm using a stethoscope and mercury sphygmomanometer at a sitting position with 90-degree back support. Uncontrolled blood pressure was also computed either the systolic or diastolic blood pressure greater than or less than the limit of uncontrolled blood pressure with regarding the age and diabetic status of patients. The perceived social support-related questionnaire was adopted from the Multidimensional Scale of Perceived Social Support (MSPSS) -12 item checklist. It was sum-up and transformed into three categories using tertile of their computed raw scores. The adjusted prevalence ratio with a 95 percent confidence interval (CI) was used to calculate the strength of the association between uncontrolled blood pressure and independent predictors using log-binomial regression analysis. A P-value less than 0.05 was declared as statistically significant in multivariable log-binomial regression analysis.

RESULT

A total of 360 study participants were included in this study. The prevalence of uncontrolled blood measures in patients with hypertension with a 95% CI was 55.8(50.7, 61.0). In a multivariable analysis adjusted prevalence ratio with 95% CI for poor medication adherence 1.86(1.59,2.19), being male 1.35(1.11,1.64), secondary education 0.52(0.35,0.77), and low social support 1.24(1.01, 1.54) were the predictors of uncontrolled blood pressure.

CONCLUSION

Uncontrolled blood pressure for patients with hypertension on treatment is higher during the COVID-19 pandemic. Being male, poor medication adherence, educational status and low social support are factors that contribute to uncontrolled blood pressure.

High Rates of Uncontrolled Blood Pressure in Malawian Adults Living with HIV and Hypertension

Background

Hypertension is among the most commonly diagnosed non-communicable diseases in Africa, and studies have demonstrated a high prevalence of hypertension among individuals with HIV. Despite high prevalence, there has been limited attention on the clinical outcomes of hypertension treatment in this population.

Objective

We sought to characterize rates of and factors associated with blood pressure control over one year among individuals on antiretroviral therapy (ART) and antihypertensive medications.

Methods

We performed a prospective observational cohort study at an HIV clinic in Malawi. We defined uncontrolled hypertension as a systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg at two or more follow-up visits during the year, while controlled hypertension was defined as <140 mm Hg systolic and <90 mm Hg diastolic at all visits, or at all but one visit. We calculated an antihypertensive non-adherence score based on self-report of missed doses at each visit (higher score = worse adherence) and used rank sum and chi-square tests to compare sociodemographic and clinical factors (including adherence) associated with blood pressure control over the year.

Results

At study entry, 158 participants (23.5%) were on antihypertensive medication; participants had a median age of 51.0 years, were 66.5% female, and had a median of 6.9 years on ART. 19.0% (n = 30) achieved blood pressure control over the year of follow-up. Self-reported non-adherence to hypertension medications was the only factor significantly associated with uncontrolled blood pressure. The average non-adherence score for those with controlled blood pressure was 0.22, and for those with uncontrolled blood pressure was 0.61 (p = 0.009).

Conclusions

Adults living with HIV and hypertension in our cohort had low rates of blood pressure control over one year associated with self-reported non-adherence to antihypertensive medications. Given the high prevalence and incidence of hypertension, interventions to improve blood pressure control are needed to prevent associated long-term cardio- and cerebrovascular morbidity and mortality.

Factors associated with incidence of stroke and heart failure among people living with HIV in Ghana: Evaluating Vascular Event Risk while on Long-Term Antiretroviral Suppressive Therapy (EVERLAST) Study

People living with HIV (PLWH) have a two‐fold higher risk of cardiovascular diseases (CVDs) compared with HIV‐negative populations. Although 70% of the global HIV population reside in Africa, data on CVD outcomes among PLWH are scarce. We seek to evaluate factors associated with incidence of stroke and heart failure in a prospective cohort of Ghanaian PLWH. We followed up a cohort of PLWH on antiretroviral therapy for 12 months to assess rates of clinically adjudicated stroke, and heart failure. We calculated incidence rates of events/1000 person‐years and fitted Cox proportional hazards regression models to identify factors associated with incident stroke and heart failure as a combined outcome measure and as separate outcome measures. Among 255 participants, the mean age was 46 years and 211 (82.7%) were female. The participants contributed 245 years of follow‐up data with mean follow‐up duration of 11.5 months. There were three incident strokes giving an incidence rate of 12.24 per 1000 person‐years (95% CI: 3.13–33.33) and two heart failure events with an incidence rate of 8.16 (95%CI: 1.37–26.97) per 1000 py. The combined event rate was 20.41 (95% CI: 7.48–45.24) per 1000 py. Being hypertensive was associated with aHR of 8.61 (1.32–56.04) of the combined outcome while each 100 cells/mm³ rise in CD4 count was associated with aHR of 0.56 (0.35–0.88). Carotid bulb intimal media thickness was independently associated with stroke occurrence with aHR of 12.23 (1.28–117.07). People living with HIV on long‐term cART in this Ghanaian sample have high rates of clinically adjudicated cardiovascular diseases driven by uncontrolled hypertension and persisting immunosuppression. Integration of CVD care into routine HIV management may help alleviate this untoward confluence of rising CVDs among PLWH.

Atherosclerotic event risk and risk reduction therapies among Ghanaian hemorrhagic stroke survivors

BACKGROUND

Intracerebral hemorrhage (ICH) stroke constitute up to 40% of incident strokes in Africa. While ICH patients are at high risk for atherosclerotic events, the risk-benefit of anti-atherosclerotic therapies in this patient population is uncertain.

PURPOSE

To assess whether utility of statins and/or antithrombotic agents after surviving an ICH correlates with atherosclerotic risk of an observational cohort.

METHODS

We analyzed data in a stroke registry prospectively collected on consecutively encountered stroke survivors seen at an out-patient clinic in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details, including diagnosis of ICH, co-morbidities, and key atherosclerotic risk reduction therapies (statins and anti-platelet drugs). We computed ischemic vascular risk using the Framingham Risk Score (FRS) to classify patients into low, intermediate and high vascular risk.

RESULTS

Of 1101 stroke survivors seen during the period, 244 (22.2%) had ICH. Vascular risk profiles were low (n = 86; 35.2%), intermediate (n = 71; 29.1%) and high (n = 87; 35.7%). Utility of statin use was 76.7% (low risk), 84.5% (intermediate risk), and 87.4% (high risk), p = 0.16 while antiplatelet use trended with atherosclerotic risk being 9.3% (low risk), 25.4% (intermediate risk), and high risk (34.5%), p = 0.0004. Independent factors associated with statin use were hypertension (OR 8.80; 95% CI: 2.34-33.11) and cigarette smoking (OR 0.29; 95% CI: 0.09-0.89) while antiplatelet drug use was associated with age (OR 1.43; 95% CI: 1.06-1.92) and time from index stroke (OR: 1.02; 95% CI: 1.01-1.02).

CONCLUSION

Approximately two-thirds of ICH survivors in this African sample had intermediate to high risk of future atherosclerotic events. Clinical trials on the timing, safety, and efficacy of statins and antiplatelet drugs among ICH survivors could help better guide risk mitigation in this population.

Prevalence and predictors of post-stroke epilepsy among Ghanaian stroke survivors

BACKGROUND

Post-stroke epilepsy (PSE) is associated with poorer quality of life, higher mortality, and greater health expenditures. We are unaware of any published reports on the frequency of and factors associated with PSE in Africa.

PURPOSE

To assess the frequency and factors associated with PSE among Ghanaian stroke survivors.

METHODS

We conducted a cross-sectional study of consecutive stroke survivors seen at an out-patient Neurology clinic enrolled into a stroke registry at a tertiary medical center in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details including diagnosis of post-stroke epilepsy, anti-epileptic medications, presence, treatment and control of vascular risk factors. Multivariate logistic regression models were constructed to identify factors associated with PSE.

RESULTS

Of 1101 stroke patients encountered, 126 had PSE (frequency of 11.4%; 95% CI of 9.6-13.5%). Mean (± SD) age among PSE vs. non-PSE patients was 57.7 (± 15.2) vs. 58.7 (± 13.9) years. Factors independently associated with PSE were being male (aOR 1.94; 95% CI: 1.32-2.86), cortical ischemic strokes (1.79; 1.12-2.87), blood pressure > 130/80 mmHg (OR 2.26; 1.06-4.79), use of antihypertensive treatment (OR 0.43; 0.23-0.79). There was an inverted J-shaped curve association between number of classes of antihypertensive drugs prescribed and occurrence of PSE, with the lowest inflection point at 3 classes (OR 0.34; 0.17-0.68).

CONCLUSION

In this convenience sample of ambulatory Ghanaian stroke survivors, one in ten had PSE. Further investigations to confirm and clarify the associations between the identified demographic and clinical characteristics are warranted.

Frequency and factors linked to refractory hypertension among stroke survivors in Ghana

BACKGROUND

Refractory hypertension (RfH) is a rare, severe phenotype of resistant hypertension, linked to higher risk of adverse cardiovascular outcomes. Little is known about the association of RfH with stroke type and subtype.

OBJECTIVE

To determine the prevalence and predictors of RfH among stroke survivors in Ghana.

METHODS

We interrogated the dataset of a prospectively collected registry of hypertensive patients seen between July 2015 and June 2019, at five hospitals in Ghana. We compared stroke survivors to stroke-free controls. Clinic-based blood pressure was measured using a standardized protocol and antihypertensive medications were assessed via review of medical records and inspection of pills. Refractory hypertension was defined as office BP ≥140/90 mmHg on ≥5 classes of antihypertensive medications. Multivariate logistic regression models were constructed to assess factors associated with RfH.

RESULTS

Of 3927 hypertensive patients (1169 stroke survivors, 2758 controls), 86 had RfH for an overall prevalence of 2.2% (95% CI: 1.8-2.7%). Among patients with RfH, 5.8% (4.5-7.3%) were stroke survivors vs. 0.7% (0.4-1.0%) were stroke-free (p < .0001). Adjusted odds ratio (95% CI) for factors associated with RfH were being male (1.81, 1.15-2.85), age < 60 years (2.64, 1.59-4.40), chronic kidney disease (2.09, 1.21-3.60), and known stroke (7.53, 4.35-13.04). RfH was associated with intracerebral hemorrhage, (11.43, 5.65-23.14), ischemic stroke (9.76, 5.47-17.42), lacunar stroke (13.58, 6.45-28.61), and non-lacunar ischemic stroke (3.67, 1.04-13.02).

CONCLUSION

Presence of RfH is significantly accentuated among stroke survivors. Intensified efforts are warranted to identify and aggressively address barriers to control in these patients to avert subsequent vascular events.