Ideal Cardiovascular Health Index and Its Determinants in a Rural South African Population

No Evidence for an Association of HIV and Antiviral Treatment With Changes in Framingham Cardiovascular Risk Score in the Ndlovu Cohort Study

BACKGROUND

HIV and antiretroviral therapy (ART) have been associated with increased cardiovascular disease (CVD) risk in high-income countries. The authors studied the longitudinal association between HIV and ART and nonlaboratory Framingham Risk Score (FRS) in a middle-income country.

METHODS AND RESULTS

This longitudinal analysis of the NCS (Ndlovu Cohort Study), South Africa used baseline to 36-month follow-up data. Demographics, HIV, ART status, and cardiometabolic measures were obtained. FRS was used as a CVD risk measure. Through linear mixed models, FRS trends over time and the association with HIV were studied. Analysis included 1136 participants, with 609 (54%) having HIV, and 495 (81%) taking ART. At baseline, 9.8% of participants had a high FRS. People living with HIV (PLHIV) had a 3.2% lower FRS than HIV-negative participants (P<0.001). FRS increased similarly for both groups over time. Other factors associated with FRS were secondary and higher education (ß value: -0.075, P<0.001; ß value: -0.084, P<0.001) and alcohol consumption (ß value: 0.011, P<0.001).

CONCLUSIONS

CVD risk increased for all participants over 36 months, suggesting classic risk factors rather than HIV status or ART to be drivers of CVD risk. People living with HIV had a significantly lower FRS than their HIV-negative counterparts, possibly related to HIV itself or a more frequent interaction with healthcare services. No association of HIV and ART with changes in FRS over 36 months was observed, suggesting the need for research using clinical endpoints to elucidate the effects of HIV and ART on CVD risk. Population-based prevention of CVD risk factors in sub-Saharan Africa is warranted, regardless of HIV status.

Association between Physical Fitness and Cardiovascular Health in Firefighters

Firefighters perform strenuous work in dangerous and unpredictable environments requiring optimal physical conditioning. The aim of this study was to investigate the association between physical fitness and cardiovascular health (CVH) in firefighters. This cross-sectional study systematically recruited 309 full-time male and female firefighters between the ages of 20 to 65 years in Cape Town, South Africa. Physical fitness was assessed using absolute (abV̇O2max) and relative oxygen consumption (relVO2max), grip and leg strength, push-ups and sit-ups, sit-and-reach for flexibility and lean body mass (LBM). CVH encompassed age, smoking, blood pressure (BP), blood glucose, lipid profile, body mass index, body fat percentage (BF%), and waist circumference. Linear regressions and logistic regressions were applied. Multivariable analysis indicated that relVO2max was associated with systolic BP (p < 0.001), diastolic BP (p < 0.001), non-fasting blood glucose (p < 0.001), and total cholesterol (p = 0.037). Poor CVH index was negatively associated with relV̇O2max (p < 0.001), leg strength (p = 0.019), and push-ups (p = 0.012). Furthermore, age was inversely associated with V̇O2max (p < 0.001), push-up and sit-up capacity (p < 0.001), and sit-and-reach (p < 0.001). BF% was negatively associated with abV̇O2max (p < 0.001), grip and leg strength (p < 0.001), push-ups (p = 0.008), sit-ups (p < 0.001), and LBM (p < 0.001). Cardiorespiratory fitness, muscular strength, and muscular endurance were significantly associated with a better overall CVH profile.

Changes in ideal cardiovascular health among Malawian adults from 2009 to 2017

Ideal Cardiovascular Health (CVH) is a concept defined by the American Heart Association (AHA) as part of its 2020 Impact Goals. Until now, changes in ideal CVH have been poorly evaluated in Sub-Saharan African populations. We aimed to investigate changes in the prevalence of ideal CVH and its components in a population of Malawian adults. Secondary analysis was done on cross-sectional data from 2009 to 2017, obtained from the Malawi STEPS surveys which included 5730 participants aged 25-64 years. CVH metrics categorized into "ideal (6-7 ideal metrics)", "intermediate (3-5 ideal metrics)" and "poor (0-2 ideal metrics)" were computed using blood pressure, body mass index (BMI), fasting glycaemia, fruit and vegetable intake, physical activity, smoking, and total cholesterol. Sampling weights were used to account for the sampling design, and all estimates were standardised by age and sex using the direct method. The mean participant age across both periods was 40.1 ± 12.4 years. The prevalence of meeting ≥ 6 ideal CVH metrics increased substantially from 9.4% in 2009 to 33.3% in 2017, whereas having ≤ 2 ideal CVH metrics decreased from 7.6% to 0.5% over this time. For the individual metrics, desirable levels of smoking, fruit and vegetable intake, physical activity, blood pressure (BP), total cholesterol and fasting glucose all increased during the study period whilst achievable levels of BMI (< 25 kg/m²) declined. From 2009 to 2017, the mean number of ideal CVH metrics was higher in women compared to men (from 2.1% to 5.1% vs 2.0% to 5.0%). However, poor levels of smoking and fruit and vegetable intake were higher in men compared to women (from 27.9% to 23.6% vs. 7.4%% to 1.9% , and from 33.7% to 42.9% vs 30.8% to 34.6%, respectively). Also, whilst achievable levels of BMI rose in men (from 84.4% to 86.2%) the proportion reduced in women (from 72.1% to 67.5% ). Overall, CVH improved in Malawian adults from 2009 to 2017 and was highest in women. However, the prevalence of poor fruit and vegetable intake, and poor smoking remained high in men whilst optimal levels of BMI was declined in women. To improve this situation, individual and population-based strategies that address body mass, smoking and fruit and vegetable intake are warranted for maximal health gains in stemming the development of cardiovascular events.

The social determinants of ideal cardiovascular health: A global systematic review

This systematic review synthesizes research published from January 2010-July 2022 on the social determinants of ideal cardiovascular health (CVH) carried out around the world and compares trends in high-income countries (HICs) to those in low- and middle-income countries (LMICs). 41 studies met inclusion criteria (n = 28 HICs, n = 13 LMICs). Most were from the United States (n = 22) and cross-sectional (n = 33), and nearly all evaluated associations among adults. Among studies conducted in LMICs, nearly all were from middle-income countries and only one was carried out in low-income country. Education (n = 24) and income/wealth (n = 17) were the most frequently examined social determinants in both HICs and LMICs. Although most studies assessed ideal CVH using reliable and valid methods (n = 24), only 7 used criteria pre-defined by the American Heart Association to characterize ideal levels of each CVH metric. Despite heterogeneity in how outcome measures were derived and analyzed, consistent associations were evident between multiple markers of higher social status (i.e. greater education, income/wealth, socioeconomic status, racial/ethnic majority status) and greater levels of ideal CVH across both country contexts. Gaps in the literature include evidence from LMICs and HICs other than the United States, longitudinal research, and investigations of a wider array of social determinants beyond education and income/wealth.

National levels, changes and correlates of ideal cardiovascular health among Beninese adults: evidence from the 2008 to 2015 STEPS surveys

Introduction

A higher number of ideal cardiovascular health (CVH) metrics is associated with a lower risk of cardiovascular-related and all-cause mortality. However, the change in CVH metrics has rarely been studied in sub-Saharan Africa. We investigated the level and changes of CVH metrics and their correlates among Beninese adults between 2008 and 2015.

Methods

Secondary analysis was performed on data obtained from Benin's 2008 and 2015 WHO Stepwise surveys (STEPS). In total, 3617 and 3768 participants aged 25-64 years were included from both surveys, respectively. CVH metrics were assessed using the American Heart Association definition, which categorised smoking, fruit and vegetable consumption, physical activity, body mass index (BMI), blood pressure (BP), total cholesterol (TC) and glycaemia into 'ideal', 'intermediate' and 'poor' CVH. The prevalence of ideal CVH metrics was standardised using the age and sex structure of the 2013 population census.

Results

Few participants met all seven ideal CVH metrics, and ideal CVH significantly declined between 2008 and 2015 (7.1% (95% CI 6.1% to 8.1%) and 1.2% (95% CI 0.8% to 1.5%), respectively). The level of poor smoking (8.0% (95% CI 7.1% to 8.9%) and 5.6% (95% CI 4.8% to 6.3%)) had decreased, whereas that of poor BP (25.9% (95% CI 24.5% to 27.4%) and 32.0% (95% CI 30.0% to 33.5%)), poor total cholesterol (1.5% (95% CI 1.0% to 1.9%) and 5.5% (95% CI 4.8% to 6.2%)) and poor fruit and vegetable consumption (34.2% (95% CI 32.4% to 35.9%) and 51.4% (95% CI 49.8% to 53.0%)) significantly increased. Rural residents and young adults (25-34 years) had better CVH metrics.

Conclusion

The proportion of adults with ideal CVH status was low and declined significantly between 2008 and 2015 in Benin, emphasising the need for primordial prevention targeting urban areas and older people to reduce the burden of cardiovascular disease risk factors.

Cardiovascular Disease Risk Factors, Musculoskeletal Health, Physical Fitness, and Occupational Performance in Firefighters: A Narrative Review

Introduction

Firefighting is a strenuous occupation that requires firefighters to be in peak physical condition. However, many firefighters have risk factors for cardiovascular disease, impaired musculoskeletal health, and are not physically fit for duty, which all negatively impact their occupational performance. Therefore, the aim of this review is to determine the relationship between cardiovascular disease risk factors, musculoskeletal health, physical fitness, and occupational performance in firefighters.

Methods

The electronic databases PubMed, SCOPUS, and Web of Science were searched online via the library portal of the University of the Western Cape. Publications and grey literature between the years 2000 to present were used. In total, 2607 articles were identified; after the removal of duplicates 1188 articles were then screened, and were excluded for not meeting initial screening criteria. The remaining 209 full-text articles were screened based on the inclusion and exclusion criteria, where 163 articles were excluded. Only studies that were quantitative were included. This left 46 articles that were then finally included in the current narrative review.

Results

The current literature indicated that significant relationships existed between cardiovascular risk factors, musculoskeletal health, physical fitness, and occupational performance. The results indicated firefighters who were aged, obese, physically inactive, cigarette smokers, and unfit were at the highest risk for cardiovascular and musculoskeletal health complications, and unsatisfactory occupational performance. Musculoskeletal health complications significantly affected occupational performance and work ability and were related to physical fitness of firefighters. Most cardiovascular risk factors were related to physical fitness, and all physical fitness parameters were related to occupational performance in firefighters.

Conclusion

The overwhelming evidence in the current review established that physical fitness is related to occupational performance. However, the relationship between cardiovascular risk factors and musculoskeletal health in relation to occupational performance is less clear and still understudied. Significant gaps remain in the literature.

Cardiovascular disease risk in women living with HIV

PURPOSE OF REVIEW

To synthesize current evidence on the impact of cardiovascular disease among women living with HIV (WLWH) with a particular focus on disease prevalence, mechanisms and prevention.

RECENT FINDINGS

HIV-related cardiovascular disease risk is 1.5-fold to 2-fold higher for women than for men. Mechanisms of enhanced risk are multifactorial and include reinforcing pathways between traditional risk factors, metabolic dysregulation, early reproductive aging and chronic immune activation. These pathways influence both the presentation of overt syndromes of myocardial infarction, stroke and heart failure, as well as subclinical disease, such as microvascular dysfunction and cardiac fibrosis. Cardiovascular disease, therefore, remains a consistent threat to healthy aging among WLWH.

SUMMARY

Although no specific prevention strategies exist, patient-centered risk mitigation approaches that are adaptable to the needs of aging individuals are essential to combat disparities in cardiovascular outcomes among WLWH. Further research into the optimal prevention approach for CVD among WLWH, particularly for women living in under-resourced health systems, is needed.

Ideal Cardiovascular Health: Distribution, Determinants and Relationship with Health Status among People Living with HIV in Urban Tanzania

Background

Ageing adults living with HIV (ALHIV) have increased risk of cardiovascular diseases as a result of HIV-infection-related chronic immune activation and inflammatory responses. Cardiovascular health index (CVHI) is a valid and relatively simple index for assessing the cardiovascular health (CVH) of the general population. Use of this index among ALHIV in Sub Saharan Africa, a resource-restricted setting where it could be mostly beneficial, remains limited. Understanding of the distribution and associated factors may inform the design of optimal interventions to improve CVH of ALHIV.

Objective

We aimed to assess the distribution and factors associated with CVHI scores among ALHIV in an urban setting in Tanzania.

Methods

A cross-sectional study was conducted among ALHIV on antiretroviral therapy at six HIV clinics in Dar-es-Salaam, Tanzania. We summed the score of each of the seven CVHI metric to obtain the overall CVHI score and assessed the distribution of the score by sex. We then categorized the overall score into ideal (5-7), intermediate (3-4) and poor (<3) CVH categories and performed ordinal regression to identify CVHI score associated factors.

Results

In all, 629 ALHIV [mean age of 43.5(SD ± 11.2) years] were enrolled. Most had ideal levels of blood glucose (96.2%) and smoking status (83.4%) while less than half had ideal BMI (48.1%), blood pressure (BP) (43.9%) and dietary intake (7.8%). Less than half (47.6%) showed ideal CVH, while less than 1% had all seven metrics at ideal level. Older age (0.96(95%CI:0.95-0.97), p-value < 0.001), being retired/unemployed (0.59(95%CI:0.43-0.81), p-value < 0.01), being employed (0.76(95%CI:0.62-0.94), p-value = 0.01) alcohol use (0.41(95%CI:0.21-0.80), p-value = 0.01) and presence of non-communicable disease comorbidities (0.68(95%CI:0.48-0.97), p-value = 0.04) had significant lower odds of ideal CVH.

Conclusion

Based on our findings, interventions to improve CVH of ALHIV should target BP management, health education on diet for BMI control and reduction in alcohol consumption, particularly among ageing ALHIV with comorbidities.

Ideal Cardiovascular Health in a Nationally Representative Population-Based Sample of Adults in Malawi

Background:

Ideal cardiovascular health (ICH) measures four ideal health behaviours (non-smoking, body mass index <25 kg/m², healthy diet, and physical activity) and three health factors (total cholesterol <200 mg/dL, blood pressure <120/<80 mmHg, and fasting blood glucose <100 mg/dL).

Objective:

This study aimed to determine the prevalence, distribution, and correlates of ICH among adults in Malawi.

Methods:

National cross-sectional survey data of 3,441 persons aged 18–69 years with complete ICH measurements in Malawi in 2017 were analysed.

Results:

Almost one in ten (7.4%) of respondents had 0–2 ICH metric), 21.2% 3–4 ICH metrics, and 71.5% 5–7 ICH metrics). Only 3.3% had all seven ICH metrics, 15.3% had intermediate ICH (≥1 metric in the intermediate category and none in the poor category), and 81.5% poor ICH (≥1 metric in poor category). In adjusted logistic regression analysis, older age (50–69 years) (Adjusted Odds Ratio-AOR: 0.25, 95% Confidence Interval-CI: 0.17–0.36) and urban residence (AOR: 0.56, 95% CI: 0.40–0.78) were negatively associated with meeting 5–7 ICH metrics. In addition, in unadjusted analysis, higher education was positively associated with meeting 5–7 ICH metrics.

Conclusion:

The proportion of meeting 5–7 ICH metrics was high in Malawian adults. Both high-risk and population-wide intervention programmes targeting older adults and urban residents should be implemented in aiding to improve cardiovascular health in Malawi.

Highlights

Poor cardiovascular health is associated with subclinical atherosclerosis in apparently healthy sub-Saharan African populations: an H3Africa AWI-Gen study

BACKGROUND

The cardiovascular health index (CVHI) introduced by the American Heart Association is a valid, accessible, simple, and translatable metric for monitoring cardiovascular health in a population. Components of the CVHI include the following seven cardiovascular risk factors (often captured as life's simple 7): smoking, dietary intake, physical activity, body mass index, blood pressure, glucose, and total cholesterol. We sought to expand the evidence for its utility to under-studied populations in sub-Saharan Africa, by determining its association with common carotid intima-media thickness (CIMT).

METHODS

We conducted a cross-sectional study involving 9011 participants drawn from Burkina Faso, Ghana, Kenya, and South Africa. We assessed established classical cardiovascular risk factors and measured carotid intima-media thickness of the left and right common carotid arteries using B-mode ultrasonography. Adjusted multilevel mixed-effect linear regression was used to determine the association of CVHI with common CIMT. In the combined population, an individual participant data meta-analyses random-effects was used to conduct pooled comparative sub-group analyses for differences between countries, sex, and socio-economic status.

RESULTS

The mean age of the study population was 51 ± 7 years and 51% were women, with a mean common CIMT of 637 ± 117 μm and CVHI score of 10.3 ± 2.0. Inverse associations were found between CVHI and common CIMT (β-coefficients [95% confidence interval]: Burkina Faso, - 6.51 [- 9.83, - 3.20] μm; Ghana, - 5.42 [- 8.90, - 1.95]; Kenya, - 6.58 [- 9.05, - 4.10]; and South Africa, - 7.85 [- 9.65, - 6.05]). Inverse relations were observed for women (- 4.44 [- 6.23, - 2.65]) and men (- 6.27 [- 7.91, - 4.64]) in the pooled sample. Smoking (p < 0.001), physical activity (p < 0.001), and hyperglycemia (p < 0.001) were related to CIMT in women only, while blood pressure and obesity were related to CIMT in both women and men (p < 0.001).

CONCLUSION

This large pan-African population study demonstrates that CVHI is a strong marker of subclinical atherosclerosis, measured by common CIMT and importantly demonstrates that primary prevention of atherosclerotic cardiovascular disease in this understudied population should target physical activity, smoking, obesity, hypertension, and hyperglycemia.