Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study

Background

Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels.

Methods

The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined).

Findings

Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50).

Interpretation

There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke.

Funding

The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.

Anticoagulation control among patients on vitamin K antagonists in nine countries in Sub-Saharan Africa

Vitamin K antagonists (VKA) is the primary anticoagulant in most settings of Sub-Saharan Africa. Understanding the quality of anticoagulation services in the continent is vital in optimising the intended benefits. This study assessed the quality of anticoagulation and associated factors among VKA-treated patients in nine SSA countries. We conducted a retrospective cohort study of randomly selected patients on anticoagulation from 20 clinics in Botswana, the Democratic Republic of Congo, Ethiopia, Gambia, Ghana, Mozambique, Nigeria, Tanzania, and South Africa. Eligible participants were those on VKAs for at least three months and with at least four international normalised ratios (INR) results in 2019-2021. We report the proportion of INR values in the therapeutic range, time-in-therapeutic range (TTR) using the Rosendaal method, and the proportion of patients with TTR ≥ 65% (optimal anticoagulation). The mean age was 51.1(16.1) years, and 64.2% were women. The most common indications for VKA included venous thromboembolism (29.6%), prosthetic valves (26.7%) and atrial fibrillation/flutter (30.1%). We analysed 6743 INR tests from 1011 participants, and of these, 48.5% were sub-therapeutic, 34.1% therapeutic, and 17.4% were supratherapeutic relative to disease-specific reference ranges. TTR was calculated for 660 patients using 4927 INR measurements. The median (interquartile range [IQR]) TTR was 35.8(15.9,57.2) %. Optimal anticoagulation control was evident in 19.2% of participants, varying from 2.7% in Tanzania to 23.1% in Ethiopia. The proportion of patients with TTR ≥ 65% was 15,4% for prosthetic heart valves, 21.1% for venous thromboembolism and 23.7% for atrial fibrillation or flutter. Countries with universal health coverage had higher odds of optimal anticoagulation control (adjusted odds ratio (aOR) 1.79, 95% confidence interval [CI], 1.15- 2.81, p = 0.01). Patients on VKAs for different therapeutic indications in SSA had suboptimal TTR. Universal health coverage increased the odds of achieving TTR by 79%. The evidence calls for more intensive warfarin management strategies in SSA, including providing VKA services without out-of-pocket payments.

Dietary patterns associated with hypertension among stroke-free indigenous Africans: insights from the Stroke Investigative Research and Educational Network study

BACKGROUND

The dietary factors associated with the high burden of hypertension among indigenous Africans remain poorly understood. We assessed the relationship between dietary patterns and hypertension among indigenous Africans.

METHOD

In this study, 1550 participants with hypertension matched (for age: ± 5 years, sex and ethnicity) with 1550 participants without hypertension were identified from the stroke-free population in the Stroke Investigative Research and Educational Network study in Ghana and Nigeria. Food consumption was assessed using a food frequency questionnaire, and dietary information was summarized using principal component analysis to identify seven dietary patterns. Conditional logistic regression was applied to compute the odds ratio (OR) and 95% confidence interval (CI) for the risk of hypertension by tertiles of dietary patterns adjusting for age, education, income, smoking, alcohol use, physical inactivity, family history of cardiovascular diseases, obesity and salt intake at a two-sided P less than 0.05.

RESULTS

Multivariable-adjusted OR [95% confidence interval (CI)] for risk of hypertension by second and third tertiles [using the lowest (first) tertile as reference] of dietary patterns were 0.62 (0.48-0.80), 0.70 (0.54-0.90) for whole grains and fruit drinks; 0.87 (0.68-1.12), 0.83 (0.64-1.08) for fruits; 0.85 (0.65-1.10), 0.97 (0.75-1.26) for vegetables, legumes and potatoes; 0.78 (0.60-1.00), 0.84 (0.65-1.08) for fried foods and sweetened drinks; 1.13 (0.88-1.45), 0.80 (0.62-1.03) for poultry product and organ meat; 1.11 (0.86-1.43), 0.88 (0.68-1.14) for red meat; and 1.14 (0.88-1.48), 1.09 (0.84-1.43) for processed foods ( P  < 0.05).

CONCLUSION

A higher adherence to dietary consumption of whole grains and fruits was inversely associated with low odds of hypertension in this population.

ACHIEVE conference proceedings: implementing action plans to reduce and control hypertension burden in Africa

The prevalence of hypertension, the commonest risk factor for preventable disability and premature deaths, is rapidly increasing in Africa. The African Control of Hypertension through Innovative Epidemiology, and a Vibrant Ecosystem [ACHIEVE] conference was convened to discuss and initiate the co-implementation of the strategic solutions to tame this burden toward achieving a target of 80% for awareness, treatment, and control by the year 2030. Experts, including the academia, policymakers, patients, the WHO, and representatives of various hypertension and cardiology societies generated a 12-item communique for implementation by the stakeholders of the ACHIEVE ecosystem at the continental, national, sub-national, and local (primary) healthcare levels.

Novel functional insights into ischemic stroke biology provided by the first genome-wide association study of stroke in indigenous Africans

BACKGROUND

African ancestry populations have the highest burden of stroke worldwide, yet the genetic basis of stroke in these populations is obscure. The Stroke Investigative Research and Educational Network (SIREN) is a multicenter study involving 16 sites in West Africa. We conducted the first-ever genome-wide association study (GWAS) of stroke in indigenous Africans.

METHODS

Cases were consecutively recruited consenting adults (aged > 18 years) with neuroimaging-confirmed ischemic stroke. Stroke-free controls were ascertained using a locally validated Questionnaire for Verifying Stroke-Free Status. DNA genotyping with the H3Africa array was performed, and following initial quality control, GWAS datasets were imputed into the NIH Trans-Omics for Precision Medicine (TOPMed) release2 from BioData Catalyst. Furthermore, we performed fine-mapping, trans-ethnic meta-analysis, and in silico functional characterization to identify likely causal variants with a functional interpretation.

RESULTS

We observed genome-wide significant (P-value < 5.0E-8) SNPs associations near AADACL2 and miRNA (MIR5186) genes in chromosome 3 after adjusting for hypertension, diabetes, dyslipidemia, and cardiac status in the base model as covariates. SNPs near the miRNA (MIR4458) gene in chromosome 5 were also associated with stroke (P-value < 1.0E-6). The putative genes near AADACL2, MIR5186, and MIR4458 genes were protective and novel. SNPs associations with stroke in chromosome 2 were more than 77 kb from the closest gene LINC01854 and SNPs in chromosome 7 were more than 116 kb to the closest gene LINC01446 (P-value < 1.0E-6). In addition, we observed SNPs in genes STXBP5-AS1 (chromosome 6), GALTN9 (chromosome 12), FANCA (chromosome 16), and DLGAP1 (chromosome 18) (P-value < 1.0E-6). Both genomic regions near genes AADACL2 and MIR4458 remained significant following fine mapping.

CONCLUSIONS

Our findings identify potential roles of regulatory miRNA, intergenic non-coding DNA, and intronic non-coding RNA in the biology of ischemic stroke. These findings reveal new molecular targets that promise to help close the current gaps in accurate African ancestry-based genetic stroke's risk prediction and development of new targeted interventions to prevent or treat stroke.

Differential Clubbing and a Triad of Patent Ductus Arteriosus, Ventricular Septal Defect and Supravalvular Ring Mitral Stenosis: A Case Report

It is not uncommon for congenital heart defects to occur in clusters. Those involving a right to left heart shunt commonly cause cyanosis and finger clubbing. Differential clubbing involving only the lower limb digits is a strong pointer to the presence of patent ductus arteriosus with reversal of shunt. We report a case of 25-year-old man with effort intolerance and differential clubbing. He was found to have the uncommon triad of patent ductus arteriosus, ventricular septal defect and supravalvular ring mitral stenosis. The presence of differential clubbing on a background of patent ductus arteriosus usually indicates a reversal of shunt and negates surgical intervention. This general rule may however not apply with co-existing mitral stenosis as the elevated pulmonary pressure may be predominantly post-capillary. The finding of mitral stenosis in a patient with patent ductus arteriosus and differential limb clubbing may signify a good prognostic surgical outcome.

Clinical and neuroimaging factors associated with 30-day fatality among indigenous West Africans with spontaneous intracerebral hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is associated with a high case fatality rate in resource-limited settings. The independent predictors of poor outcome after ICH in sub-Saharan Africa remains to be characterized in large epidemiological studies. We aimed to determine factors associated with 30-day fatality among West African patients with ICH.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study conducted at 15 sites in Nigeria and Ghana. Adults aged ≥18 years with spontaneous ICH confirmed with neuroimaging. Demographic, cardiovascular risk factors, clinical features and neuroimaging markers of severity were assessed. The independent risk factors for 30-day mortality were determined using a multivariate logistic regression analysis with an adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Among 964 patients with ICH, 590 (61.2%) were males with a mean age (SD) of 54.3(13.6) years and a case fatality of 34.3%. Factors associated with 30-day mortality among ICH patients include: Elevated mean National Institute of Health Stroke Scale(mNIHSS);(OR 1.06; 95% CI 1.02-1.11), aspiration pneumonitis; (OR 7.17; 95% CI 2.82-18.24), ICH volume > 30mls; OR 2.68; 95% CI 1.02-7.00)) low consumption of leafy vegetables (OR 0.36; 95% CI 0.15-0.85).

CONCLUSION

This study identified risk and protective factors associated with 30-day mortality among West Africans with spontaneous ICH. These factors should be further investigated in other populations in Africa to enable the development of ICH mortality predictions models among indigenous Africans.

Risk Assessment Score and Chi-Square Automatic Interaction Detection Algorithm for Hypertension Among Africans: Models From the SIREN Study

BACKGROUND

This study aimed to develop a risk-scoring model for hypertension among Africans.

METHODS

In this study, 4413 stroke-free controls were used to develop the risk-scoring model for hypertension. Logistic regression models were applied to 13 risk factors. We randomly split the dataset into training and testing data at a ratio of 80:20. Constant and standardized weights were assigned to factors significantly associated with hypertension in the regression model to develop a probability risk score on a scale of 0 to 1 using a logistic regression model. The model accuracy was assessed to estimate the cutoff score for discriminating hypertensives.

RESULTS

Mean age was 59.9±13.3 years, 56.0% were hypertensives, and 8 factors, including diabetes, age ≥65 years, higher waist circumference, (BMI) ≥30 kg/m2, lack of formal education, living in urban residence, family history of cardiovascular diseases, and dyslipidemia use were associated with hypertension. Cohen κ was maximal at ≥0.28, and a total probability risk score of ≥0.60 was adopted for both statistical weighting for risk quantification of hypertension in both datasets. The probability risk score presented a good performance-receiver operating characteristic: 64% (95% CI, 61.0-68.0), a sensitivity of 55.1%, specificity of 71.5%, positive predicted value of 70.9%, and negative predicted value of 55.8%, in the test dataset. Similarly, decision tree had a predictive accuracy of 67.7% (95% CI, 66.1-69.3) for the training set and 64.6% (95% CI, 61.0-68.0) for the testing dataset.

CONCLUSIONS

The novel risk-scoring model discriminated hypertensives with good accuracy and will be helpful in the early identification of community-based Africans vulnerable to hypertension for its primary prevention.

Frailty and outcomes in heart failure patients from high-, middle-, and low-income countries

BACKGROUND AND AIMS

There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels.

METHODS

A total of 3429 adults with HF (age 61 ± 14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss, and self-reported exhaustion. Mean left ventricular ejection fraction was 39 ± 14% and 26% had New York Heart Association Class III/IV symptoms. Participants were followed for a median (25th to 75th percentile) of 3.1 (2.0-4.3) years. Cox proportional hazard models for death and HF hospitalization adjusted for country income level; age; sex; education; HF aetiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; New York Heart Association functional class; HF medication use; blood pressure; and haemoglobin, sodium, and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve.

RESULTS

At baseline, 18% of participants were robust, 61% pre-frail, and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios (95% confidence interval) for death among the pre-frail and frail were 1.59 (1.12-2.26) and 2.92 (1.99-4.27). Respective adjusted hazard ratios (95% confidence interval) for HF hospitalization were 1.32 (0.93-1.87) and 1.97 (1.33-2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization.

CONCLUSIONS

Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.

Childhood and Infant exposure to famine in the Biafran war is associated with hypertension in later life: the Abia NCDS study

There are very few studies in Africans investigating the association between early life exposure to malnutrition and subsequent hypertension in adulthood. We set out to investigate this potential association within an adult cohort who were born around the time of the Biafran War (1968-1970) and subsequent famine in Nigeria. This was a retrospective analysis of Abia State Non-Communicable Diseases and Cardiovascular Risk Factors (AS-NCD-CRF) Survey, a community-based, cross-sectional study that profiled 386 adults (47.4% men) of Igbo ethnicity born in the decade between January 1965 and December 1974. Based on their date of birth and the timing of the famine, participants were grouped according to their exposure to famine as children (Child-Fam) or in-utero fetus/infant (Fet-Inf-Fam) or no exposure (No-Fam). Binomial logit regression models were fitted to determine the association between famine exposure and hypertension in adulthood. Overall, 130 participants had hypertension (33.7%). Compared to the No-Fam group (24.4%), the prevalence of hypertension was significantly elevated in both the Child-Fam (43% - adjusted OR 2.47, 95% CI 1.14-5.36) and Fet-Inf-Fam (44.6% - adjusted OR 2.54, 95% CI 1.33-4.86) groups. The risk of hypertension in adulthood was highest among females within the Child-Fam group. However, within the Fet-Inf-Fam group males had a equivalently higher risk than females. These data suggest that early life exposure to famine and malnutrition in Africa is associated with a markedly increased risk of hypertension in adulthood; with sex-based differences evident. Thus, the importance of avoiding armed conflicts and food in-security in the region cannot be overstated. The legacy effects of the Biafran War clearly show the wider need for ongoing programs that support the nutritional needs of African mothers, infants and children as well as proactive surveillance programs for the early signs of hypertension in young Africans.

The Pandemic of Coronary Artery Disease in the Sub-Saharan Africa: What Clinicians Need to Know

PURPOSE OF REVIEW

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality globally with an accelerated increase in CVD‑related death in Africa and other low‑middle‑income countries. This review is aimed at highlighting the burden of coronary artery disease CAD, its peculiarities as well as challenges of management in sub-Saharan Africa.

RECENT FINDINGS

Recent data revealed a shift from high incidence of CVDs associated with poverty and malnutrition (such as rheumatic heart disease) initially, which are now falling, to rising incidence of other non-communicable CVDs (such as hypertension, coronary artery disease (CAD), and heart failure). Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide, which is projected to supersede communicable diseases in the future. Previous studies have shown that CAD was rare among Africans. Those studies conducted in Africa in the 1940s-1960s reported that Black Africans were almost immune to developing CAD and were even thought to have specific genetic make-up protecting them from CAD. However, the continent is now experiencing a steady rise in the prevalence of CAD associated with severe disease burden, compared to other regions of the world. The changes seen have been attributed to the current epidemiological transition with increase in CVD risk factors that are poorly controlled, lack of awareness as well as the poor health facilities to tackle the menace of the disease. The Global Burden of Disease (GBD) estimates have also shown that over the past three decades the highest contribution to CVD burden in Africa is attributed to atherosclerotic diseases, with 71.4, 37.7, and 154% increases in the burden of ischemic heart disease, stroke, and peripheral artery disease respectively. There is a steady increase of CAD prevalence in Africa as a result of increase in CV risk factors. Hypertension, obesity, diabetes, dyslipidemia, and cigarette smoking are the rapidly rising risk factors for CAD on the continent. Africa also faces challenges in diagnosis and management of CAD. There is need for increased public and health personnel awareness on prevention and control of commonly identifiable risk factors, provision of prehospital emergency services, and provision of modern therapeutic facilities for treatment of CAD including reperfusion therapy. These are priority areas where efforts could be intensified in the future with potential to improve the current rate of progress of the disease on the continent.

DEMOGRAPHICS OF COLLABORATORS INVESTIGATING THE NIGERIAN MEDICAL AND DENTAL INTERNS: A MEDICAL INTERNSHIP TRAINING IN NIGERIA (MINTING) STUDY COLLABORATION

Introduction

The internship period is a peculiar time in a doctor's career, and some have described it as a "nuisance year" during which the junior doctor assumes many roles at the same time. Junior doctors especially house officers are faced with many unique challenges; this is even more pronounced in poor resource settings like Nigeria. This study aimed to unravel and improve understanding of the challenges faced by medical and dental interns in Nigeria.

Methodology

A nine-member House officers Research and Statistics Committee (HRSC) was immediately set up to include three senior colleagues - Senior Registrars and Registrar. To carry out her responsibility efficiently the committee created the House Officers Research Collaboration Network (HRCN), a 103- member team comprising medical and dental interns from across Nigeria under a collaborative - Medical INternship Training in Nigeria (MINTING) study.

Results

Out of a total of the 103 House Officers Research Collaboration Network, 80 of them participated in this survey giving a 78% response rate. Ten of the intern Collaborators had additional qualification and seven of them had BSc as an initial degree. About 66 % of the Collaborators have never authored any publication. Of the 27 that have published an article; three collaborators are said to have published 15, 13, 16 articles respectively. Male collaborators where more likely to have published at least one article in the past. Thirty one of the 80 Collaborators have never been in a research collaborative group prior to this MINTING collaborative.

Conclusion

This commentary is set out to describe in detail Nigerian House Officers initiative in terms of the structure, functions, operational modalities, and to investigate the demographics of the HRCN collaborators which showed that over two third of collaborators have never authored any publication and about a third of them have never been involved in collaborative research. We also believe the findings will serve as policy guide and benchmark in training the critical medical health force.

Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study

Background Baseline stroke severity is probably partly responsible for poor stroke outcomes in sub-Saharan Africa. However, there is a paucity of information on determinants of stroke severity among indigenous Africans. We sought to identify the factors associated with stroke severity among West Africans in the SIREN (Stroke Investigative Research and Educational Networks) study. Methods and Results Stroke was diagnosed clinically and confirmed with brain neuroimaging. Severe stroke was defined as a Stroke Levity Scale score of ≤5. A multivariate logistic regression model was constructed to identify factors associated with stroke severity at 95% CI and a nominal cutoff of 5% type 1 error. A total of 3660 stroke cases were included. Overall, 50.7%% had severe stroke, including 47.6% of all ischemic strokes and 56.1% of intracerebral hemorrhage. Factors independently associated with severe stroke were meat consumption (adjusted odds ratio [aOR], 1.97 [95% CI, 1.43-2.73]), low vegetable consumption (aOR, 2.45 [95% CI, 1.93-3.12]), and lesion volume, with an aOR of 1.67 (95% CI, 1.03-2.72) for lesion volume of 10 to 30 cm³ and aOR of 3.88 (95% CI, 1.93-7.81) for lesion volume >30 cm³. Severe ischemic stroke was independently associated with total anterior circulation infarction (aOR, 3.1 [95% CI, 1.5-6.9]), posterior circulation infarction (aOR, 2.2 [95% CI, 1.1-4.2]), and partial anterior circulation infarction (aOR, 2.0 [95% CI, 1.2-3.3]) compared with lacunar stroke. Increasing age (aOR, 2.6 [95% CI, 1.3-5.2]) and lesion volume >30 cm³ (aOR, 6.2 [95% CI, 2.0-19.3]) were independently associated with severe intracerebral hemorrhage. Conclusions Severe stroke is common among indigenous West Africans, where modifiable dietary factors are independently associated with it. These factors could be targeted to reduce the burden of severe stroke.

Heart failure in Nigeria: protocol for a systematic review and meta-analysis

Background

Heart failure is now a significant contributor to the burden of non-communicable diseases in developing countries like Nigeria which is experiencing epidemiologic and demographic transition. The epidemiology of heart failure in this country is poorly characterized. The aim of the review is to determine the prevalence of heart failure, the associated risk factors, the aetiology, management, and outcomes of the condition in the country.

Methods

Relevant databases such as PubMed /Medline, EMBASE, Web of Science, Google Scholar, African Index Medicus, and African journal online would be searched for articles published in English from January 2000 to December 2021. The analysis will include observational studies conducted among Nigerian adults aged 12 years and above. Article selection shall be conducted by pairs of independent reviewers. Data extraction shall be done by 2 independent reviewers.

Results

The primary outcome would be the pooled prevalence of heart failure while the secondary outcomes would be to identify the risk factors and management of heart failure in Nigeria.

Conclusion

This will be the first systematic review and meta-analysis of heart failure epidemiology in Nigeria which will hopefully identify gaps for future research and guidance for policy interventions.

Improving cardiovascular outcomes for patients with heart failure in sub-Saharan Africa: conference proceedings of the 2022 Nigerian Cardiovascular Symposium

The Nigerian Cardiovascular Symposium is an annual conference held in partnership with cardiologists in Nigeria and the diaspora to provide updates in cardiovascular medicine and cardiothoracic surgery with the aim of optimising cardiovascular care for the Nigerian population. This virtual conference (due to the COVID-19 pandemic) has created an opportunity for effective capacity building of the Nigerian cardiology workforce. The objective of the conference was for experts to provide updates on current trends, clinical trials and innovations in heart failure, selected cardiomyopathies such as hypertrophic cardiomyopathy and cardiac amyloidosis, pulmonary hypertension, cardiogenic shock, left ventricular assist devices and heart transplantation. Furthermore, the conference aimed to equip the Nigerian cardiovascular workforce with skills and knowledge to optimise the delivery of effective cardiovascular care, with the hope of curbing 'medical tourism' and the current 'brain drain' in Nigeria. Challenges to optimal cardiovascular care in Nigeria include workforce shortage, limited capacity of intensive care units, and availability of medications. This partnership represents a key first step in addressing these challenges. Future action items include enhanced collaboration between cardiologists in Nigeria and the diaspora, advancing participation and enrollment of African patients in global heart failure clinical trials, and the urgent need to develop heart failure clinical practice guidelines for Nigerian patients.

Premature Atherosclerotic Cardiovascular Disease: A Case of Myocardial Infarction Seven Years after Bentall Procedure in a Nigerian Man

Surgical procedures often carry varying risk of post-procedural complications. The Bentall procedure for managing aortic root diseases has known complications including graft infection, pseudoaneurysm of the aorta or coronary arteries, embolisation and coronary insufficiency. The last three complications can cause myocardial infarction, are evaluated with coronary angiography and have been well described in the literature. Surprisingly, none of these possible complications was found in our patient. This case report describes a young Nigerian man with atherosclerotic coronary artery disease seven years after Bentall procedure.

African Control of Hypertension through Innovative Epidemiology and a Vibrant Ecosystem (ACHIEVE): novel strategies for accelerating hypertension control in Africa

Hypertension is a leading preventable and controllable risk factor for cardiovascular and cerebrovascular diseases and the leading preventable risk for death globally. With a prevalence of nearly 50% and 93% of cases uncontrolled, very little progress has been made in detecting, treating, and controlling hypertension in Africa over the past thirty years. We propose the African Control of Hypertension through Innovative Epidemiology and a Vibrant Ecosystem (ACHIEVE) to implement the HEARTS package for improved surveillance, prevention, treatment/acute care of hypertension, and rehabilitation of those with hypertension complications across the life course. The ecosystem will apply the principles of an iterative implementation cycle by developing and deploying pragmatic solutions through the contextualization of interventions tailored to navigate barriers and enhance facilitators to deliver maximum impact through effective communication and active participation of all stakeholders in the implementation environment. Ten key strategic actions are proposed for implementation to reduce the burden of hypertension in Africa.

Patient-level and system-level determinants of stroke fatality across 16 large hospitals in Ghana and Nigeria: a prospective cohort study

BACKGROUND

Every minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs.

FINDINGS

Overall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07-1·33); systolic blood pressure, 1·02 (1·01-1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm3, 1·48 (1·22-1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13-1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31-2·33); and aspiration pneumonia, 1·79 (1·16-2·77).

INTERPRETATION

Studies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted.

FUNDING

US National Institutes of Health.

TRANSLATIONS

For the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.

Clinical Characteristics, Management, and Six-Month Outcomes after Discharge of Patients Admitted for Acute Heart Failure in Ibadan, Nigeria

BACKGROUND

The burden of acute heart failure (AHF) is on the increase globally however, there are few studies on AHF in Nigeria and among black populations.

OBJECTIVE

This study described the clinical profile, conventional management and six-months outcome after discharge of patients admitted for acute heart failure at the University College Hospital, Ibadan, Nigeria.

METHODS

The study was a prospective study of 160 consecutive AHF patients. Socio-demographic details, clinical history, basic laboratory parameters electrocardiographic and echocardiographic parameters were assessed. They were followed-up for six-months after discharge to ascertain death or readmission.

RESULTS

The mean ± standard deviation (SD) age of all the patients was 58.0 ±15.1 years. Those aged 60 years and above constituted about half of the participants. Males comprised 59.3% and hypertension was the most common risk factor (77.5%). One hundred and thirty-four subjects (83.8%) were in New York Heart Association functional classes III or IV. The most common AHF type was heart failure with reduced ejection fraction and mostly presented de novo. The mean duration of admission was 11 days while intrahospital mortality and mortality at 6 months after discharge were 6.3% and 25.6% respectively.

CONCLUSION

This study provided a real-world data of AHF at UCH, Ibadan, Nigeria. It showed AHF was predominantly associated with hypertension. There was high mortality among these AHF subjects. There is a need for more strategy in our environment for preventing AHF and its adverse outcomes.

Influence of systolic blood pressure on outcomes in Nigerians with peripartum cardiomyopathy

BACKGROUND

The relationship between blood pressure (BP) trajectories and outcomes in patients with peripartum cardiomyopathy (PPCM) is not clear. Aim: The study aimed to assess the clinical features and outcomes (all-cause mortality and unrecovered left ventricular [LV] systolic function) of PPCM patients grouped according to their baseline systolic BP (SBP).

PATIENTS AND METHODS

PPCM patients presenting to 14 tertiary hospitals in Nigeria were consecutively recruited between June 2017 and March 2018 and then followed up till March 2019. SBP at first presentation was used to categorize the patients into seven groups: <90, 90-99, 100-109, 110-119, 120-129, 130-139, and ≥140 mmHg. Unrecovered LV systolic function was defined as echocardiographic LV ejection fraction (LVEF) below 55% at the last profiling.

RESULTS

Two hundred and twenty-seven patients were recruited and followed up for a median of 18 months. Of these, 4.0% had <90 mmHg, 16.3% had 90-99 mmHg, 24.7% had 100-109 mmHg, 24.7% had 110-119 mmHg, 18.5% had 120-129 mmHg, 7.5% had 130-139 mmHg, and 4.4% had ≥140 mmHg of SBP at presentation. The highest frequency of all-cause mortality was recorded among patients with SBP ≤90 mmHg (30.8%) followed by those with 90-99 mmHg (20.5%) (P = 0.076), while unrecovered LV systolic function did not differ significantly between the groups (P = 0.659). In a Cox proportional regression model for all-cause mortality, SBP <90 mmHg had a hazard ratio (HR) of 4.00 (95% confidence interval [CI] 1.49-10.78, P = 0.006), LVEF had an HR of 0.94 (95% CI 0.91-0.98, P = 0.003, B = 0.06%), and use of angiotensin-converting enzyme or angiotensin receptor and/or β-receptor blockers had an HR of 1.71 (95% CI 0.93-3.16, P = 0.085). However, SBP was not associated with LV function recovery.

CONCLUSION

In our cohort of PPCM patients, one-fifth was hypotensive at presentation. SBP <90 mmHg at presentation was associated with a four-fold higher risk of all-cause mortality during a median follow-up of 18 months.

THE EARLY PHYSICIANS OF IBADAN MEDICAL SCHOOL: PROFESSOR ALEXANDER BROWN

The paper chronicles the life and times of Professor Alexander Brown, the Foundation Professor and Head of the Department of Medicine at the University of Ibadan. The official opening of the University College Ibadan, Nigeria on 20 November 1957 as well as the graduation of the first set of clinical students in 1960 were glorious moments for Alexander Brown who laboured for 12years to witness these. He was also instrumental to the creation of the Department of Paediatrics (1962), Department of Radiology (1963) and the Medical Illustration unit of the hospital. Paediatrics and Radiology were initially units in the Department of Medicine. He played significant role in the development of postgraduate programmes in Cardiology, neuropsychiatry and nephrology units of the hospital and substantial role in the development of nursing education in the hospital. He was the brain behind the famous Ibarapa Community Health Project.

Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation

BACKGROUND

Testing of factor Xa inhibitors for the prevention of cardiovascular events in patients with rheumatic heart disease-associated atrial fibrillation has been limited.

METHODS

We enrolled patients with atrial fibrillation and echocardiographically documented rheumatic heart disease who had any of the following: a CHA2DS2VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating a higher risk of stroke), a mitral-valve area of no more than 2 cm2, left atrial spontaneous echo contrast, or left atrial thrombus. Patients were randomly assigned to receive standard doses of rivaroxaban or dose-adjusted vitamin K antagonist. The primary efficacy outcome was a composite of stroke, systemic embolism, myocardial infarction, or death from vascular (cardiac or noncardiac) or unknown causes. We hypothesized that rivaroxaban therapy would be noninferior to vitamin K antagonist therapy. The primary safety outcome was major bleeding according to the International Society of Thrombosis and Hemostasis.

RESULTS

Of 4565 enrolled patients, 4531 were included in the final analysis. The mean age of the patients was 50.5 years, and 72.3% were women. Permanent discontinuation of trial medication was more common with rivaroxaban than with vitamin K antagonist therapy at all visits. In the intention-to-treat analysis, 560 patients in the rivaroxaban group and 446 in the vitamin K antagonist group had a primary-outcome event. Survival curves were nonproportional. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the vitamin K antagonist group (difference, -76 days; 95% confidence interval [CI], -121 to -31; P<0.001). A higher incidence of death occurred in the rivaroxaban group than in the vitamin K antagonist group (restricted mean survival time, 1608 days vs. 1680 days; difference, -72 days; 95% CI, -117 to -28). No significant between-group difference in the rate of major bleeding was noted.

CONCLUSIONS

Among patients with rheumatic heart disease-associated atrial fibrillation, vitamin K antagonist therapy led to a lower rate of a composite of cardiovascular events or death than rivaroxaban therapy, without a higher rate of bleeding. (Funded by Bayer; INVICTUS ClinicalTrials.gov number, NCT02832544.).

A Differential Response to Antihypertensive Therapy in African Men and Women: Insights From the CREOLE Trial

BACKGROUND

We sought to address the paucity of data to support the evidence-based management of hypertension to achieve optimal blood pressure (BP) control on a sex-specific basis in Africa.

METHODS

We undertook a post hoc analysis of the multicenter, randomized CREOLE (Comparison of Three Combination Therapies in Lowering Blood Pressure in Black Africans) Trial to test the hypothesis that there would be clinically important differences in office BP control between African men and women. We compared the BP levels of 397 and 238 hypertensive women (63%, 50.9 ± 10.5 years) and men (51.2 ± 11.3 years) from 10 sites across sub-Saharan Africa who completed baseline and 6-month profiling according to their randomly allocated antihypertensive treatment.

RESULTS

Overall, 442/635 (69.6%) participants achieved an office BP target of <140/90 mm Hg at 6 months; comprising more women (286/72.0%) than men (156/65.5%) (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 1.07-2.39; P = 0.023). Women randomized to amlodipine-hydrochlorothiazide (HCTZ) (adjusted OR 3.03, 95% CI 1.71-5.35; P < 0.001) or amlodipine-perindopril (adjusted OR 2.62, 95% CI 1.49-4.58; P = 0.01) were more likely to achieve this target compared with perindopril-HCTZ. Among men, there were no equivalent treatment differences-amlodipine-HCTZ (OR 1.54, 95% CI 0.76-3.12; P = 0.23) or amlodipine-perindopril (OR 1.32, 95% CI 0.65-2.67; P = 0.44) vs. perindopril-HCTZ. Among the 613 participants (97%) with 24-hour ambulatory BP monitoring, women had significantly lower systolic (124.1 ± 18.1 vs. 127.3 ± 16.9; P = 0.028) and diastolic (72.7 ± 10.4 vs. 75.1 ± 10.5; P = 0.007) BP levels at 6 months compared with men.

CONCLUSIONS

These data suggest clinically important differences in the therapeutic response to antihypertensive combination therapy among African women compared with African men.

Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE)

Background and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes.Methods Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH).Results Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (<i>P</i><0.0001). Conclusions The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.

Development and evaluation of a package to improve hypertension control in Nigeria [DEPIHCON]: a cluster-randomized controlled trial

Background

Nigeria’s healthcare system capacity to stem the increasing trend in hypertension is limited in coverage, scope and manpower. Use of trained community-based care providers demonstrated to be an effective complement in improving access to, and supporting healthcare delivery has not been adequately examined for hypertension care in Nigeria. This study is proposed to evaluate the effectiveness of using trained community-oriented resource persons (CORPs) to improve hypertension control in Nigeria.

Methods

An intervention study will be conducted in three states using a mixed method design. First is a baseline survey using a semi-structured pre-tested questionnaire to collect information on demographics, clinical data, knowledge, occurrence and risk factors of hypertension among 1704 adults ≥18 years. Focus group discussions (FGD) and key informant interviews (KII) will be conducted to explore a community’s experience of hypertension, challenges with hypertension management and support required to improve control in 10 selected communities in each state. The second is a cluster-randomized controlled trial to evaluate effect of a package on reduction of blood pressure (BP) and prevention of cardiovascular (CVD) risk factors among 200 hypertensive patients to be followed up in intervention and control arms over a 6-month period in each state. The package will include trained CORPs conducting community-based screening of BP and referral, diagnosis confirmation and initial treatment in the health facility, followed by monthly home-based follow-up care and provision of health education on hypertension control and healthy lifestyle enhanced by phone voice message reminders. In the control arm, the usual care (diagnosis, treatment and follow-up care in hospital of a patient’s choice) will continue. Third, an endline survey will be conducted in both intervention and control communities to evaluate changes in mean BP, control, knowledge and proportion of other CVD risk factors. In addition, FGD and KII will be used to assess participants’ perceived quality and acceptability of the interventions as delivered by CORPs.

Discussion

This research is expected to create awareness, improve knowledge, perception, behaviours, attitude and practices that will reduce hypertension in Nigeria. Advocacy for buy-in and scale up of using CORPs in hypertension care by the government is key if found to be effective.

Trial registration

PACTR Registry PACTR202107530985857. Registered on 26 July 2021.

Association between Height and Blood Pressure in Middle Age and Older Adults in Southeast Nigeria

BACKGROUND

This study was carried out in Abia State, Southeast Nigeria, to determine the association between height and blood pressure in middle age and elderly adults.

MATERIALS AND METHODS

This was a cross-sectional study carried out in Abia State, Southeast Nigeria, between August 2011 and March 2012. The participants were residents in the state and were recruited from the three senatorial zones of the state. The total number of participants that took part in the study was 2,487 adults. The World Health Organisation STEPwise approach to surveillance of chronic disease risk factors was used. Information collected included blood pressure and anthropometric measurements. The association between height and blood pressure was determined.

RESULTS

A total of 1,363 participants that took part in the study were >40 years old. Six hundred and fifty-five participants (48.1%) were males and 708 participants (51.9%) were females. There was no significant inverse relationship between height and blood pressure components ( Systolic Blood Pressure Diastolic Blood Pressure, and Pulse Pressure ) among the males. Among the females there was a high inverse relationship between height and blood pressure components. However, this relationship was not statistically significant. In addition, among the males there was no relationship between height and hypertension. Among the females, there was some degree of inverse relationship between height and hypertension, although multivariate regression analysis showed that this was not significant.

CONCLUSION

There was an inverse but non-significant relationship between height and blood pressure components/ hypertension among males and females in Southeast Nigeria in this study.

Vitamin K-dependent anticoagulant use and level of anticoagulation control in sub-Saharan Africa: protocol for a retrospective cohort study

BACKGROUND

Given that vitamin K-dependent anticoagulants (VKAs) will continue to be the primary anticoagulant in Africa for a long time, understanding the quality of anticoagulation services in the continent is vital for optimising the intended benefits. Notably, a few small studies have assessed the quality of anticoagulation in sub-Saharan Africa (SSA) countries. This study will describe the current VKA use and anticoagulation control among patients in selected SSA countries.

METHODS AND ANALYSIS

We plan to review the 2019 anticoagulation data of a cohort of 800 random patients from 19 selected clinics in Botswana, the Democratic Republic of Congo, Ethiopia, Gambia, Ghana, Mozambique, Nigeria, Tanzania and South Africa. We expect at least one participating site to enrol 100 participants in each country. Eligible participants will be those on VKAs for at least 3 months and with at least four international normalised ratio (INR) results. We will document the indications, type and duration of VKA use, sociodemographic factors, coexisting medical conditions, concurrent use of drugs that interact with warfarin and alcohol and tobacco products. The level of anticoagulation control will be determined by calculating the time-in-therapeutic range (TTR) using the Rosendaal and the Percent of INR in TTR methods. A TTR of less than 65% will define a suboptimal anticoagulation control.

ETHICS AND DISSEMINATION

This study was approved by the Ministry of Health and Wellness Ethics Committee (HPDME13/8/1) in Botswana and local research ethics committees or institutional review boards of all participating sites. As the study collects data from existing records, sites applied for waivers of consent. We will disseminate research findings through peer-reviewed scientific publications.

Risk Factor Characterization of Ischemic Stroke Subtypes Among West Africans

BACKGROUND AND PURPOSE

To identify the qualitative and quantitative contributions of conventional risk factors for occurrence of ischemic stroke and its key pathophysiologic subtypes among West Africans.

METHODS

The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with ischemic stroke who were etiologically subtyped using the A-S-C-O-D classification into atherosclerosis, small-vessel occlusion, cardiac pathology, other causes, and dissection. Controls were age- and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle, and psychosocial factors were performed. We used conditional logistic regression to estimate adjusted odds ratios with 95% CI.

RESULTS

There were 2431 ischemic stroke case and stroke-free control pairs with respective mean ages of 62.2±14.0 versus 60.9±13.7 years. There were 1024 (42.1%) small vessel occlusions, 427 (17.6%) large-artery atherosclerosis, 258 (10.6%) cardio-embolic, 3 (0.1%) carotid dissections, and 719 (29.6%) undetermined/other causes. The adjusted odds ratio (95% CI) for the 8 dominant risk factors for ischemic stroke were hypertension, 10.34 (6.91-15.45); dyslipidemia, 5.16 (3.78-7.03); diabetes, 3.44 (2.60-4.56); low green vegetable consumption, 1.89 (1.45-2.46); red meat consumption, 1.89 (1.45-2.46); cardiac disease, 1.88 (1.22-2.90); monthly income $100 or more, 1.72 (1.24-2.39); and psychosocial stress, 1.62 (1.18-2.21). Hypertension, dyslipidemia, diabetes were confluent factors shared by small-vessel, large-vessel and cardio-embolic subtypes. Stroke cases and stroke-free controls had a mean of 5.3±1.5 versus 3.2±1.0 adverse cardio-metabolic risk factors respectively (P<0.0001).

CONCLUSIONS

Traditional vascular risk factors demonstrate important differential effect sizes with pathophysiologic, clinical and preventative implications on the occurrence of ischemic stroke among indigenous West Africans.

Cardiovascular Risk Factors and Clinical Outcomes among Patients Hospitalized with COVID-19: Findings from the World Heart Federation COVID-19 Study

BACKGROUND AND AIMS

Limited data exist on the cardiovascular manifestations and risk factors in people hospitalized with COVID-19 from low- and middle-income countries. This study aims to describe cardiovascular risk factors, clinical manifestations, and outcomes among patients hospitalized with COVID-19 in low, lower-middle, upper-middle- and high-income countries (LIC, LMIC, UMIC, HIC).

METHODS

Through a prospective cohort study, data on demographics and pre-existing conditions at hospital admission, clinical outcomes at hospital discharge (death, major adverse cardiovascular events (MACE), renal failure, neurological events, and pulmonary outcomes), 30-day vital status, and re-hospitalization were collected. Descriptive analyses and multivariable log-binomial regression models, adjusted for age, sex, ethnicity/income groups, and clinical characteristics, were performed.

RESULTS

Forty hospitals from 23 countries recruited 5,313 patients with COVID-19 (LIC = 7.1%, LMIC = 47.5%, UMIC = 19.6%, HIC = 25.7%). Mean age was 57.0 (±16.1) years, male 59.4%, pre-existing conditions included: hypertension 47.3%, diabetes 32.0%, coronary heart disease 10.9%, and heart failure 5.5%. The most frequently reported cardiovascular discharge diagnoses were cardiac arrest (5.5%), acute heart failure (3.8%), and myocardial infarction (1.6%). The rate of in-hospital deaths was 12.9% (N = 683), and post-discharge 30 days deaths was 2.6% (N = 118) (overall death rate 15.1%). The most common causes of death were respiratory failure (39.3%) and sudden cardiac death (20.0%). The predictors of overall mortality included older age (≥60 years), male sex, pre-existing coronary heart disease, renal disease, diabetes, ICU admission, oxygen therapy, and higher respiratory rates (p < 0.001 for each). Compared to Caucasians, Asians, Blacks, and Hispanics had almost 2-4 times higher risk of death. Further, patients from LIC, LMIC, UMIC versus. HIC had 2-3 times increased risk of death.

CONCLUSIONS

The LIC, LMIC, and UMIC's have sparse data on COVID-19. We provide robust evidence on COVID-19 outcomes in these countries. This study can help guide future health care planning for the pandemic globally.

Differences in socio-demographic and risk factor profile, clinical presentation, and outcomes between patients with and without RHD heart failure in Sub-Saharan Africa: results from the THESUS-HF registry

Background

Rheumatic heart disease (RHD) was found in the THESUS-HF registry to be the third most common cause of acute heart failure (AHF) in Sub-Saharan Africa.

Methods

One thousand six patients with AHF from 9 Sub-Saharan African countries were recruited in THESUS-HF, of which 143 (14.3%) had RHD-AHF. Clinical characteristics and outcomes in patients with RHD-AHF and non-RHD-AHF were compared. Kaplan-Meier plots for time to all-cause death and/or HF readmission according to the presence of RHD-AHF and non-RHD-AHF were performed and survival distributions compared using the log-rank test. Cox regression was used to determine the hazard ratio of death to day 180 and death or readmission to day 60 after adjusting for confounders.

Results

Patients with RHD-AHF were younger, more often females, had higher rates of atrial fibrillation, had less hypertension, hyperlipidemia and diabetes, had lower BP, and higher pulse rate and better kidney function and echocardiographic higher ejection fraction larger left atria and more diastolic dysfunction. Patients with RHD-AHF had a numerically longer mean stay in the hospital (10.5 vs. 8.8 days) and significantly higher initial hospitalization mortality (9.1% vs. 3.4%).

Conclusions

In conclusion, patients with HF related to RHD were younger, have higher rate of atrial fibrillation and have a worse short-term outcome compared to HF related to other etiologies in Sub-Saharan Africa.

A Novel Afrocentric Stroke Risk Assessment Score: Models from the Siren Study

BACKGROUND

Stroke risk can be quantified using risk factors whose effect sizes vary by geography and race. No stroke risk assessment tool exists to estimate aggregate stroke risk for indigenous African.

OBJECTIVES

To develop Afrocentric risk-scoring models for stroke occurrence.

MATERIALS AND METHODS

We evaluated 3533 radiologically confirmed West African stroke cases paired 1:1 with age-, and sex-matched stroke-free controls in the SIREN study. The 7,066 subjects were randomly split into a training and testing set at the ratio of 85:15. Conditional logistic regression models were constructed by including 17 putative factors linked to stroke occurrence using the training set. Significant risk factors were assigned constant and standardized statistical weights based on regression coefficients (β) to develop an additive risk scoring system on a scale of 0-100%. Using the testing set, Receiver Operating Characteristics (ROC) curves were constructed to obtain a total score to serve as cut-off to discriminate between cases and controls. We calculated sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) at this cut-off.

RESULTS

For stroke occurrence, we identified 15 traditional vascular factors. Cohen's kappa for validity was maximal at a total risk score of 56% using both statistical weighting approaches to risk quantification and in both datasets. The risk score had a predictive accuracy of 76% (95%CI: 74-79%), sensitivity of 80.3%, specificity of 63.0%, PPV of 68.5% and NPV of 76.2% in the test dataset. For ischemic strokes, 12 risk factors had predictive accuracy of 78% (95%CI: 74-81%). For hemorrhagic strokes, 7 factors had a predictive accuracy of 79% (95%CI: 73-84%).

CONCLUSIONS

The SIREN models quantify aggregate stroke risk in indigenous West Africans with good accuracy. Prospective studies are needed to validate this instrument for stroke prevention.

Pregnancy-associated Acute Myocardial Infarction (PAMI): Case Report

Cardiovascular diseases are recognised complications of pregnancy, however, pregnancy-associated acute myocardial infarction (PAMI) is uncommon. Pregnancy is known to increase risk of myocardial infarction even in the absence of traditional risk factors for atherosclerotic vascular disease. Our patient presented with acute chest pain two weeks after delivery and her electrocardiogram was in keeping with STelevation myocardial infarction (STEMI). Coronary angiography revealed coronary artery dissection and she was managed conservatively. Various pathophysiological mechanisms of PAMI have been described in literature including spontaneous coronary artery dissection (SCAD) found in our case. The diagnosis is often missed and earlier reported cases were diagnosed at autopsy. Therefore, we report this case as a learning tool. Also, there is a need for a high index of suspicion in pregnant patients presenting with features suggestive of aortic dissection, and its diagnosis should be thought of in peripartum women presenting with acute chest pain.

Disparities in clinical features and outcomes of peripartum cardiomyopathy in high versus low prevalent regions in Nigeria

Aims

The prospective, multicentre Peripartum Cardiomyopathy in Nigeria (PEACE) registry originally demonstrated a high prevalence of peripartum cardiomyopathy (PPCM) among patients originating from Kano, North‐West Nigeria. In a post hoc analysis, we sought to determine if this phenomenon was characterized by a differential case profile and outcome among PPCM cases originating elsewhere.

Methods and results

Overall, 199 (81.6%) of a total 244 PPCM patients were recruited from three sites in Kano, compared with 45 patients (18.4%) from 11 widely dispersed centres across Nigeria. Presence and extent of ventricular myocardial remodelling during follow‐up, relative to baseline status, were assessed by echocardiography. During median 17 months follow‐up, Kano patients demonstrated significantly better myocardial reverse remodelling than patients from other sites. Overall, 50.6% of patients from Kano versus 28.6% from other regions were asymptomatic (P = 0.029) at study completion, with an accompanying difference in all‐cause mortality (17.6% vs. 22.2% respectively, P = 0.523) not reaching statistical significance. Alternatively, 135/191 (84.9%) of Kano patients had selenium deficiency (<70 μg/L), and 46/135 (34.1%) of them received oral selenium supplementation. Critically, those that received selenium supplementation demonstrated better survival (6.5% vs. 21.2%; P = 0.025), but the supplement did not have significant impact on myocardial remodelling.

Conclusions

This study has shown important non‐racial regional disparities in the clinical features and outcomes of PPCM patients in Nigeria, that might partly be explained by selenium supplementation.

High prevalence of non-dipping patterns among Black Africans with uncontrolled hypertension: a secondary analysis of the CREOLE trial

BACKGROUND

Dipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of antihypertensive therapy, and intensifying salt restriction.

OBJECTIVES

To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of 6 months of three antihypertensive regimens on the dipping pattern among Black African hypertensive patients.

METHODS

This was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-h ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures.

RESULTS

The prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium > 140 mmol/l (OR = 1.72, 95% CI 1.17-2.51, p-value 0.005), a higher office systolic BP (OR = 1.03, 95% CI 1.01-1.05, p-value 0.003) and a lower office diastolic BP (OR = 0.97, 95% CI 0.95-0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar's Chi2 0.71, p-value 0.40).

CONCLUSION

There was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes. Trial registration ClinicalTrials.gov (NCT02742467).

Urinary Sodium and Potassium, and Risk of Ischemic and Hemorrhagic Stroke (INTERSTROKE): A Case-Control Study

BACKGROUND

Although low sodium intake (<2 g/day) and high potassium intake (>3.5 g/day) are proposed as public health interventions to reduce stroke risk, there is uncertainty about the benefit and feasibility of this combined recommendation on prevention of stroke.

METHODS

We obtained random urine samples from 9,275 cases of acute first stroke and 9,726 matched controls from 27 countries and estimated the 24-hour sodium and potassium excretion, a surrogate for intake, using the Tanaka formula. Using multivariable conditional logistic regression, we determined the associations of estimated 24-hour urinary sodium and potassium excretion with stroke and its subtypes.

RESULTS

Compared with an estimated urinary sodium excretion of 2.8-3.5 g/day (reference), higher (>4.26 g/day) (odds ratio [OR] 1.81; 95% confidence interval [CI], 1.65-2.00) and lower (<2.8 g/day) sodium excretion (OR 1.39; 95% CI, 1.26-1.53) were significantly associated with increased risk of stroke. The stroke risk associated with the highest quartile of sodium intake (sodium excretion >4.26 g/day) was significantly greater (P < 0.001) for intracerebral hemorrhage (ICH) (OR 2.38; 95% CI, 1.93-2.92) than for ischemic stroke (OR 1.67; 95% CI, 1.50-1.87). Urinary potassium was inversely and linearly associated with risk of stroke, and stronger for ischemic stroke than ICH (P = 0.026). In an analysis of combined sodium and potassium excretion, the combination of high potassium intake (>1.58 g/day) and moderate sodium intake (2.8-3.5 g/day) was associated with the lowest risk of stroke.

CONCLUSIONS

The association of sodium intake and stroke is J-shaped, with high sodium intake a stronger risk factor for ICH than ischemic stroke. Our data suggest that moderate sodium intake-rather than low sodium intake-combined with high potassium intake may be associated with the lowest risk of stroke and expected to be a more feasible combined dietary target.

SARS-CoV 2 Infection (Covid-19) and Cardiovascular Disease in Africa: Health Care and Socio-Economic Implications

The current pandemic of SARS-COV 2 infection (Covid-19) is challenging health systems and communities worldwide. At the individual level, the main biological system involved in Covid-19 is the respiratory system. Respiratory complications range from mild flu-like illness symptoms to a fatal respiratory distress syndrome or a severe and fulminant pneumonia. Critically, the presence of a pre-existing cardiovascular disease or its risk factors, such as hypertension or type II diabetes mellitus, increases the chance of having severe complications (including death) if infected by the virus. In addition, the infection can worsen an existing cardiovascular disease or precipitate new ones. This paper presents a contemporary review of cardiovascular complications of Covid-19. It also specifically examines the impact of the disease on those already vulnerable and on the poorly resourced health systems of Africa as well as the potential broader consequences on the socio-economic health of this region.

Prevalence, awareness, treatment, and control of hypertension in Nigeria in 1995 and 2020: A systematic analysis of current evidence

Improved understanding of the current burden of hypertension, including awareness, treatment, and control, is needed to guide relevant preventative measures in Nigeria. A systematic search of studies on the epidemiology of hypertension in Nigeria, published on or after January 1990, was conducted. The authors employed random‐effects meta‐analysis on extracted crude hypertension prevalence, and awareness, treatment, and control rates. Using a meta‐regression model, overall hypertension cases in Nigeria in 1995 and 2020 were estimated. Fifty‐three studies (n = 78 949) met our selection criteria. Estimated crude prevalence of pre‐hypertension (120‐139/80‐89 mmHg) in Nigeria was 30.9% (95% confidence interval [CI]: 22.0%‐39.7%), and the crude prevalence of hypertension (≥140/90 mmHg) was 30.6% (95% CI: 27.3%‐34.0%). When adjusted for age, study period, and sample, absolute cases of hypertension increased by 540% among individuals aged ≥20 years from approximately 4.3 million individuals in 1995 (age‐adjusted prevalence 8.6%, 95% CI: 6.5‐10.7) to 27.5 million individuals with hypertension in 2020 (age‐adjusted prevalence 32.5%, 95% CI: 29.8‐35.3). The age‐adjusted prevalence was only significantly higher among men in 1995, with the gap between both sexes considerably narrowed in 2020. Only 29.0% of cases (95% CI: 19.7‐38.3) were aware of their hypertension, 12.0% (95% CI: 2.7‐21.2) were on treatment, and 2.8% (95% CI: 0.1‐5.7) had at‐goal blood pressure in 2020. Our study suggests that hypertension prevalence has substantially increased in Nigeria over the last two decades. Although more persons are aware of their hypertension status, clinical treatment and control rates, however, remain low. These estimates are relevant for clinical care, population, and policy response in Nigeria and across Africa.

Clinical characteristics and outcomes of black African heart failure patients with preserved, mid‐range, and reduced ejection fraction: a post hoc analysis of the THESUS‐HF registry

Aims

Limited data are available on clinical characteristics and prognosis of heart failure (HF) in black African populations especially with respect to current classifications and HF management guidelines.

Methods and results

In this post hoc analysis, African patients admitted with acute HF and enrolled in the THESUS‐HF registry in one of 12 hospitals in 9 countries were classified as having preserved left ventricular ejection fraction (LVEF) (HFpEF), mid‐range LVEF (HFmrEF), and reduced LVEF (HFrEF) based on echocardiography performed close to the time of admission. Sociodemographic and clinical characteristics, management, and 60 and 180 day outcomes were compared between the groups. Of 888 patients with LVEF available, there were 472 (53.2%) with HFrEF, 174 (19.6%) with HFmrEF, and 243 (27.3%) with HFpEF. History of atrial fibrillation was higher in patients with HFmrEF (28.5%) than in patients with HFrEF (14.5%). Patients with HFrEF had a larger mean LV systolic diameter (54.1 ± 9.67 mm) than patients with HFmrEF (42.9 ± 8.47 mm), who had a larger mean LV diameter than patients with HFpEF (32.6 ± 8.64 mm); a similar pattern with LV diastolic diameter was observed. The mean posterior diastolic wall thickness (10.2 ± 2.94 mm) was lower in patients with HFrEF than in those with HFmrEF (11.1 ± 2.59 mm) and HFpEF (11.2 ± 2.90 mm). Patients with HFpEF were less likely to use angiotensin‐converting enzyme inhibitor/angiotensin receptor blockers, and aldosterone inhibitors, and more likely to use beta‐blockers than those with HFrEF at either admission or discharge/Day 7. Death or readmission rates through Day 60 and 180 day death rates did not differ significantly among the groups; unadjusted hazard ratios relative to patients with HFrEF were 1.32 [95% confidence interval (CI) 0.84–2.08] and 1.24 (95% CI 0.82–1.89) for 60 day death or readmission and 0.92 (95% CI 0.59–1.43) and 0.78 (95% CI 0.51–1.20) for 180 day death in patients with HFmrEF and HFpEF, respectively.

Conclusions

Classification by LVEF according to European Society of Cardiology guidelines revealed some differences in clinical presentation but similar mortality and rehospitalization rates across all EF groups in Africans admitted for HF.

Development and Validation of a Electrocardiographic Diagnostic Score of Heart Failure Among Patients with Hypertension Attending a Tertiary Hospital in Ibadan, Nigeria: The RISK-HHF Case-Control Study

Objectives

Hypertension is the leading cause of HF in sub-Saharan Africa. Electrocardiography (ECG) is a cheap and easily available stratification tool for the diagnosis and prognostication of individuals with hypertension. The aim of this study was to develop an ECG-based HF diagnostic score among patients with hypertension attending a specialist cardiology clinic.

Methods

One hundred and one (101) case-control age- and sex-matched pairs were recruited. The study population were adults with a clinical diagnosis of hypertensive HF failure (cases) and systemic hypertension without HF (controls). Participants underwent clinical assessment and ECG. Associations between ECG variables and HF risk were tested with chi square test. Logistic regression modelling (age- and sex adjusted) was trained on a random subset of participants and tested on the remaining participants to determine the ECG abnormalities that are diagnostic of HF and develop a HF diagnostic score. The HF diagnostic score was then validated in an independent dataset of the ECG-Hypertension Audit. Goodness of fit and c-statistics of the HF summed diagnostic score in the training, testing and validation datasets are presented. A two-sided p value of <0.05 was considered statistically significant.

Results

The independent ECG diagnostic markers of HF among hypertensive patients in this study in decreasing order of effect size were sinus tachycardia (aOR: 7.72, 95% CI: 2.31-25.85). arrhythmia (aOR: 7.14, 95% CI: 2.57-19.86), left ventricular hypertrophy (aOR: 4.47; 1.85-10.77) and conduction abnormality (aOR: 3.41, 95% CI: 1.21-9.65). The HF summed diagnostic score showed excellent calibration and discrimination in the training (Hosmer Lemeshow p = 0.90; c-statistic 0.82; 95% CI 0.76–0.89) and test samples (Hosmer Lemeshow p=0.31; c-statistic 0.73 95% CI 0.60 to 0.87) of the derivation cohort and an independent validation audit cohort (Hosmer Lemeshow p = 0.17; c-statistic 0.79 95% CI 0.74 to 0.84) respectively. The model showed high diagnostic accuracy in individuals with different intermediate pre-test probabilities of HF.

Conclusions

A ECG based HF score consisting of sinus tachycardia, arrhythmia, conduction abnormality and left ventricular hypertrophy is diagnostic of HF especially in those with intermediate pre-test probability of HF. This has clinical importance in the stratification of individuals with systemic hypertension.

Impaired Renal Function and its Predictors among Treatment-Naive HIV-seropositive Patients in a Tertiary Institution in South-East Nigeria

BACKGROUND

Renal impairment is a significant independent risk factor for mortality among HIV-infected patients. Some antiretroviral drugs are nephrotoxic, especially to the tubules, and their dosage need to be modified in the presence of renal impairment to avoid progression to chronic kidney disease.

AIM

To determine the prevalence and predictors of renal impairment among treatment-naïve HIV sero-positive patients seen at Federal Medical Centre, Umuahia, Abia state.

MATERIALS AND METHODS

This was a cross-sectional study involving 115 HIV-seropositive treatment-naïve cases and 115 seronegative controls. Questionnaires were administered and history regarding health status was obtained. Participants had biophysical profile measured. Blood and urine specimens were analyzed in the laboratory. The re-expressed modification of diet in renal disease (MDRD) was used to determine estimated Glomerular Filtration Rate (eGFR). Factors found to be associated with renal impairment were subjected to binary logistic regression analysis to determine the predictors of renal impairment.

RESULTS

The prevalence of renal impairment among the cases was 27.8%. Factors associated with renal impairment included duration of HIV diagnosis of 12 months and above, significant intake of herbal remedies, hypertension, significant proteinuria, WHO clinical stage 3 or 4, anaemia and CD4 count less than 350cells/µL. Predictors of renal impairment were hypertension, WHO clinical stage 3 or 4 disease, significant proteinuria and significant intake of herbal remedies.

CONCLUSION

Renal impairment was prevalent in this sample. Concerted efforts should be directed to early diagnosis of renal impairment among these patients. Reno-protective measures need to be instituted early to avoid deleterious outcomes.

Knowledge and practices of blood pressure measurement among final year students, house officers, and resident dental surgeons in a dental hospital, South West Nigeria

Objectives

To assess the knowledge and practices of blood pressure measurement (BPM) among final year students, house officers, and resident dental surgeons.

Materials and Methods

A cross-sectional study consisting of a convenience sample of all final year students, house officers, and resident dental surgeons in a dental hospital in South West Nigeria was conducted. All participants were requested to complete a 16-item questionnaire about their knowledge of accurate BPM. After completing the questionnaire, the participants were observed by a single research associate as they measured the blood pressure (BP) of patients using a checklist prepared according to the World Health Organization and the American Heart Association (AHA) guidelines for measuring BP. The performance score was based on a 25-element skillset on BP measurement. Data were entered into Statistical Package for the Social Sciences (SPSS) Version 22. Frequencies and means were generated and independent Student's t-tests and Pearson's Chi-square tests were used to test the association between continuous and categorical variables, respectively at P value < 0.05.

Results

In total, 139 questionnaires were returned by 59 final year dental nursing students, 29 final year dental students, 14 house officers, 18 registrars, and 19 senior registrars. Overall, 46.0% of the participants had poor knowledge of accurate BPM. The mean [standard deviation (SD)] BPM knowledge score was 5.8 (2.0), dental nursing students had the least 4.8 (1.5) score, and dental students had the highest 6.9 (2.0) score (P < 0.0001). Overall, the mean (SD) BPM knowledge scores for students and dentists were 5.5 (1.9) and 6.4 (1.9), respectively (P = 0.01). One-hundred and thirty-seven (98.6%) participants performed BPM inaccurately. There was a weak positive non-statistically significant correlation between knowledge and performance scores (r = 0.03; P = 0.75).

Conclusions

Overall, 46.0% of participants had poor knowledge of accurate BPM while 98.6% performed BPM inadequately. These findings suggest the need for curriculum review on accurate BPM.

Incidence, clinical characteristics, and risk factors of peripartum cardiomyopathy in Nigeria: results from the PEACE Registry

Aims

The aim of this study was to describe the incidence, clinical characteristics and risk factors of peripartum cardiomyopathy (PPCM) in Nigeria.

Methods and Results

The study was conducted in 22 hospitals in Nigeria, and PPCM patients were consecutively recruited between June 2017 and March 2018. To determine factors associated with PPCM, the patients were compared with apparently healthy women who recently delivered, as controls. Four hundred six patients were compared with 99 controls. The incidence and disease burden (based on the rate of consecutive recruitment of subjects) varied widely between the six geographical zones of Nigeria. From the North–West zone, 72.3% of the patients was recruited, where an incidence as high as 1 per 96 live births was obtained in a centre, while the disease was uncommon (7.6% of all recruited patients) in the South. Majority of the patients (76.6%) and controls (74.8%) (p = 0.694) were of Hausa–Fulani ethnic group. Atrial fibrillation, intracardiac thrombus, stroke, and right ventricular systolic dysfunction were found in 1.7%, 6.4%, 2.2%, and 54.9% of the patients, respectively. Lack of formal education (odds ratio [OR] 3.08, 95% confidence interval [1.71, 5.53]; P < 0.001), unemployment (OR: 3.28 [2.05, 5.24]; P < 0.001), underweight (OR: 13.43 [4.17, 43.21]; P < 0.001) and history of pre‐eclampsia (OR: 9.01 [2.18, 37.75]; P = 0.002) emerged as independent PPCM risk factors using regression models. Customary hot baths (OR: 1.24 [0.80, 1.93]; P = 0.344), pap enriched with dried lake salt (OR: 1.20 [0.74, 1.94]; P = 0.451), and Hausa–Fulani ethnicity (OR: 1.11 [0.67, 1.84]; P = 0.698) did not achieve significance as PPCM risk factors.

Conclusions

In Nigeria, the burden of PPCM was greatest in the North–West zone, which has the highest known incidence. PPCM was predicted by sociodemographic factors and pre‐eclampsia, which should be considered in its control at population level. Postpartum customary birth practices and Hausa–Fulani ethnicity were not associated with PPCM in Nigeria.

Prevalence and Risk Factors for Diabetes Mellitus in A State in South East Nigeria: Results of a Population Based House to House Survey

BACKGROUND

Population based studies on diabetes mellitus (DM) are scarce in Nigeria.

INTRODUCTION

This was a population-based house to house survey aimed at determining the prevalence of DM and assessing the risk factors associated with DM in a state in Southeast Nigeria.

METHODS

This was a cross-sectional observational study in which 1680 adults were recruited using a multistage sampling method to randomly select not more than two suitable participants of both sex in each household from four enumeration areas (EAs) in each local government area (LGA) and the three senatorial zones in the state. A modified World Health Organization (WHO) Stepwise Approach to Surveillance questionnaire was used for data collection and random blood glucose (RBG) was measured after anthropometric assessment. Test statistics used were chi-square, t-test, and logistic regression.

RESULTS

The overall prevalence of DM in this study was 3.3%. A positive family history of DM was significantly higher in patients with diabetes: 18.2% vs. 9.6% (p=0.036). The mean (SD) of weight, body mass index (BMI), hip circumference (HC) and waist circumference (WC) were significantly higher in patients with DM(p=0.001,<0.001,<0.001,<0.001, respectively).The odd ratio (95% CI) of a person>35years developing DM was 3.89(1.11-13.60). The OR (95% CI) for waist-hip ratio (WHR) was 3.04 (1.02-9.03) and family history of DM had an OR of 2.62(0.88-6.50). The odd of developing DM is positively associated with age>35years, increased WHR, WC, family history of DM, BMI>25Kg/m2, and HC. The odd of developing DM was negatively associated with smoking.

CONCLUSION

The prevalence of DM in this study was 3.3%. A BMI>25 kg/m2, WHR >0.85, family history of DM, HC, and older age were associated with significantly higher prevalence.

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.

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.

Anaemia and iron deficiency in heart failure: epidemiological gaps, diagnostic challenges and therapeutic barriers in sub-Saharan Africa

Anaemia and iron deficiency (ID) are common and of prognostic importance in heart failure (HF). In both conditions the epidemiology, diagnosis and therapies have been extensively studied in high-income countries but are still largely unexplored in sub-Saharan Africa (SSA). The lack of adequate and robust epidemiological data in SSA makes it difficult to recognise the significance of anaemia and ID in HF. From a clinical perspective, less attention is paid by clinicians to screening for anaemia in HF, and as far as interventions are concerned, there are no clinical trials in SSA that provide guidance on the appropriate interventional approach. Therefore studies are needed to provide more insight into the burden and peculiarities of and intervention for anaemia and ID in HF in SSA, where the pathophysiology might be different from that in high-income countries. There is increasing appreciation that targeting ID may serve as a useful additional treatment strategy for patients with chronic HF in high-income countries. However, there is limited information on the diagnosis of and therapy for ID in HF in SSA, where infections and malnutrition are more likely to influence the situation. This article reviews the present epidemiological gap in knowledge about anaemia and ID in HF, as well as the diagnostic and therapeutic challenges in SSA.

Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study

BACKGROUND

Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels.

METHODS

We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month.

FINDINGS

We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14-1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12-1·72) irrespective of other patient and service characteristics.

INTERPRETATION

Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes.

FUNDING

Chest, Heart and Stroke Scotland.

Rationale and Design for the Peripartum Cardiomyopathy in Nigeria (PEACE) Registry

Background: Nigeria probably has the highest burden of Peripartum Cardiomyopathy (PPCM) in the world. The primary objective is to describe the burden, ventricular remodelling and outcomes (rehospitalisation rate, cardio-embolic events and survival) of PPCM in Nigeria. In the sub-studies, we aim to describe the relationship between selenium deficiency, oxidative stress and PPCM, the impact of sodium selenite supplementation on cardiac function in PPCM, and the prevalence of selenium deficiency and its relationship with cardiac function in apparently healthy pregnant women.Methods: The main Registry and the first sub-study are prospective longitudinal studies, while the second sub-study is an open-label randomised trial. 36 study centres across Nigeria have been registered and 10 of them are already recruiting subjects. Patients will be recruited from June to December 2017 and followed up till December 2018. Serum selenium and glutathione peroxidase will be assayed at recruitment for consecutive PPCM patients with LV ejection fraction (LVEF) <45% at 6 months postpartum. 200 subjects with selenium deficiency will be randomised into treatment (Selenium Selenite 200µg tablets daily for 3 months) and control arms. In the second sub-study, 120 apparently healthy pregnant women will be recruited at 28-38 weeks of gestation and reviewed at 6-8 weeks postpartum, and their serum selenium and GPO levels will be measured at recruitment.Conclusion: This will be the largest systematic evaluation of PPCM in Nigeria, and it is hoped that the information will assist in developing locally applicable treatment guidelines and policies for the disease.