Causes of admission and mortality among patients admitted in 37 cardiology departments in 17 Sub-Saharan African countries: the FEBRUARY observatory (2016–2021) from African Research Network

Background

Cardiovascular disease (CVD) is a major cause of death worldwide. At least two-third of CVD death occurs in low- (LIC) and middle-income (MIC) countries. An estimated 1 million deaths were attributable to CVD in sub-Saharan Africa (SSA) alone. Scarce data are available about the admission for CVD and outcome in cardiology department in SSA.

Purpose

To describe admission for CVD and outcome of hospitalization in 17 in SSA countries.

Methods

We conducted a transversal and longitudinal study in CV department of 37 hospitals from 23 cities in 17 SSA countries (10 low income: Niger, Guinea, Benin, Mali, Democratic Republic of the Congo, Tchad, Burkina Faso, Togo, Burundi, Ethiopia and 7 middle income: Cote d'Ivoire, Senegal, Cameroon, Congo, Soudan, Mauritania, Gabon). The February study was designed by a multidisciplinary collaborative team of epidemiologists, pharmacists and cardiologists from Africa and France. This ongoing observatory included all inpatients in February from each year since 2016.Data including socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, treatments, length of stay and discharge diagnosis were collected by the investigating physicians. All analyses were performed through scripts developed in the R software (4.0.3 (2020-10-10))

Results

Overall, 4360 patients were included in the February study. Men represented 56.4%. Mean of age was 56.7±16.8 years. The main cause of admission was heart failure (41.5%) followed by acute coronary syndrome (11.9%) and stroke (11%). Cause of admission varied significantly across countries (p<0.01) and over the years (p<0.01). Proportions of admission for heart failure varied from 20% in Ethiopia to 62% in Guinea. Mean of length of stay was 9.95±22.4 days. All causes of admission confounded, in-hospital mortality rate was 11% (N=423). Mortality rate differed significantly according to causes of admission (p<0.01).Mortality rate among patients admitted for stroke, heart failure and acute coronary syndrome was respectively 18%, 12.3% and 9.5%. Overall, 31 (0.7%) were admitted for endocarditis and mortality rate among them was 20.8% (figure). Overall, mortality rate did not vary according to gender or over the years but was significantly different according to patient wealth index (p<0.05), countries (p<0.01) and level income countries (p<0.01). Mortality rate was significantly higher in LIC.

Conclusion

Heart failure, acute coronary syndrome and stroke represent the two-third of causes of admission. Overall, mortality rate in cardiology departments in SSA reached 11%.

Funding Acknowledgement

Type of funding sources: None.

Use of traditional medicine and control of hypertension in 12 Sub-Saharan African countries: the EIGHT cross-sectional study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Camille Lassale is supported by a fellowship from “La Caixa” Foundation (ID 100010434). The fellowship code is LCF/BQ/PR21/11840003

Background

Use of traditional medicine (TM), is widespread in Sub-Saharan Africa as treatment option for a wide range of disease. We aimed to describe the profile of TM users and estimate the association with blood pressure (BP) and control of hypertension among hypertensive patients in a pan-African study.

Methods

We included 2128 participants in the cross-sectional EIGHT study, who attended an outpatient consultation in the cardiology departments of 12 Sub-Saharan African countries (Benin, Cameroon, Congo, Democratic Republic of the Congo, Gabon, Guinea, Côte d’Ivoire, Mauritania, Mozambique, Niger, Senegal, Togo). We describe patients’ characteristics according to TM use. We modelled the odds of uncontrolled hypertension, severe hypertension, and complications of hypertension by multivariable mixed logistic regression, and the linear association with systolic and diastolic BP by linear regression, all adjusted for age, sex, individual wealth index, adherence to hypertension conventional treatment, and country.

Results

A total of 512 (24%) of participants reported using TM, and this percentage varied drastically across countries from 10% in the Congo to 48% in Guinea. TM users were more likely to be male, with poor treatment adherence, reporting missing treatment because it is too expensive, and presenting any complication of hypertension. TM use was associated with greater odds of hypertension (OR=1.30; 95% confidence interval: 0.99, 1.70), severe hypertension (OR=1.34; 1.04, 1.74) and of any complication of hypertension (OR=1.27; 1.01, 1.60), driven by renal complication (OR=1.57; 1.07, 2.29). Use of TM was associated with a 3.87 mmHg higher systolic BP and 1.75 mm Hg higher diastolic BP compared to no use.

Conclusions

In this cross-sectional study of patients with hypertension in 12 Sub-Saharan African countries, we identified that the use of traditional medicine was associated with a poorer control of hypertension and more complications.

P1802Management and outcomes of infective endocarditis in adults with congenital heart disease

Background

Causes, epidemiology and microbiology of infective endocarditis (IE) have evolved in recent decades. Although novel tools for the diagnosis and therapeutic strategies have emerged, mortality and morbidity remain high. These trends may particularly concern the growing population of adults with congenital heart disease (CHD) who are at increased risk for IE.

Purpose

We aimed to characterize IE in CHD patients and describe management and outcome in this setting. We also sought to determine the risk factors associated with in-hospital death in CHD patients.

Methods

From January 2000 to June 2018, 666 consecutive episodes of IE in adults were recorded in our center. Among them, 143 concerned CHD, including 5 implantable cardiac electronic devices-lead infections, all managed by an IE team including CHD specialists. Cases were classified according to modified Duke criteria.

Results

CHD patients were significantly younger (37 years IQR [26–52]), with a more common history of cardiac reoperations (numbers of sternotomies≥2 in 35.7%) and infective endocarditis (19.7%, p<0.01) compared to non-CHD patients. There were more infections of valve-containing prosthetics (44% vs. 30%, p<0.04), and the right heart side (41.5%, p<0.01) in CHD patients. Forty-nine percent of them had a simple CHD, 12.7% a moderate, and 36.4% a complex. A predisposing event could be identified in only 34% of cases. Oral streptococci/Streptococci bovis and Staphylococcus aureus were the most frequently microorganisms isolated (32.4% and 20.4%, respectively). Surgery was performed in 90 episodes (62%), and was selected in emergency (<24h) in 61% (figure 1). In-hospital mortality was 12.7% and was directly related to IE in 10/18 cases. CHD patients had a significant lower risk of death compared to non-CHD patients (OR=0.47, p=0.026, p<0.01), even after adjustment for age, and the infected heart side. On multivariate analysis the complexity of CHD (if simple CHD: OR=0.07 IQR [0.01 to 0.44], p<0.01) and the white blood cell count (OR=1.18 IQR [1.04 to 1.33], p=0.01) were the strongest predictive factors of in-hospital death in the CHD group.

Conclusions

Mortality associated with IE in CHD patients is lower than in acquired heart disease. The multidisciplinary approach by IE team and CHD specialists may have improved management and outcome in this setting. However, risk for death remains high in complex lesions. Larger prospective studies on IE in adults with CHD are needed to develop guidelines in these complex patients.

P1586Research network in Africa (RNA): antihypertensive drugs strategies in 12 African countries

Background

High Blood Pressure is the worldwide leading global burden of disease risk factor. In Sub-Saharan Africa, the number of adults with raised blood pressure has alarmingly increased from 0.59 to 1.13 billion between 1975 and 2015. Blood pressure-lowering medicines are cornerstone of cardiovascular risk reduction. Data on management of anti-hypertensive drugs in sub-Saharan Africa are squarce.

Purpose

Our study aims to describe antihypertensive drugs strategies in Africa.

Methods

We conducted a cross-sectional survey in urban clinics during outpatient consultation specialized in hypertension cardiology departments of 29 medical centers from 17 cities across 12 African countries (Benin, Cameroon, Congo, Democratic Republic of Congo, Gabon, Guinea, Ivory Coast, Mauritania, Mozambic, Niger, Senegal, Togo). Data were collected on demographics, treatment and standardized BP measures were made among the hypertensive patients attending the clinics. Country income was retrieved from the World Bank database. All analyses were performed through scripts developed in the R software (3.4.1 (2017–06–30)).

Results

A total of 2198 hypertensive patients (58.4±11.8 years; 39.9% male) were included. Among whom 2123 (96.6%) had at least one antihypertensive drug. Overall, 30.8% (n=653) received monotherapy and calcium-channel blockers (49.6%) were the most common monotherapy prescribed follow by diuretics (18.7%). Two-drug strategies were prescribed for 927 patients (43.6%). Diuretics and Angiotensin-converting enzyme inhibitors was the combination most frequently prescribed (33.7%). Combination of three drugs or more was used in 25.6% (n=543) of patients. The proportion of drugs strategies differed significantly according to countries (p<0.001), monotherapy ranged from 12.7% in Niger to 47.1% in Democratic Republic of the Congo (figure). Furthermore we observed a significantly difference of strategies between low and middle income countries (55.3% and 44.7% of monotherapy respectively) (p<0.001). According to hypertension grades 1, 2 and 3, the proportion of three-drugs or more combination was 25%, 28% and 34% in middle-income and lower in low-income countries (18%, 19% and 25%). Furthermore, Grade 3 hypertension in low income countries was still treated with monotherapy (36%) instead of 19% in middle income countries (p<0.01).

Antihypertensive strategies by country

Conclusion

Our study described antihypertensive drugs use across 12 sub-Saharan countries, and identified disparities specific to the income context. Inequity in access to drugs combination is a serious barrier to tackle the burden of hypertension in Africa.

P6369Prevalence of severe hypertension in a sub-Saharan African community

Background

Individuals with SH have high 10-year risk of cardiovascular disease, especially when additional risk factors or target organ damage are present. Though some data from in-hospital or selected populations are available, there are no studies reporting community-level prevalence of Severe Hypertension (SH) in sub-Saharan Africa.

Purpose

Using a cross-sectional design in Abidjan (Ivory Coast), we assessed prevalence of Severe Hypertension among adults.

Methods

Study participants were recruited within the framework of The Heart Fund's global health initiative. Data were collected in August 2016 from 6 randomly selected sites, ensuring representativeness of both urban and rural areas. Blood pressure (BP) was measured twice, 10 minutes apart, after optimal resting time. Blood pressure measurement were standardized between sites and SH was defined as systolic blood pressure ≥180 and/or diastolic blood pressure ≥110 mmHg at both readings. Demographics and data on cardiovascular history/risk factors were collected in the field. Ethics approval for the study was obtained from the National Ethical Committee of Côte d'Ivoire and written informed consent was obtained from all adult patients.

Results

Among 1,785 subjects examined, 1,182 aged between 18 and 75 years were included in this analysis. The prevalence of SH was 14.1% (12.5% females vs 17.0% males; P=0.03) (Figure). Among participants with severe hypertension, 28.9% were either undiagnosed or untreated. Alarmingly, subjects at high cardiovascular risk (age ≥60 years and/or obese) had even higher prevalence of overall SH (29.6% and 24.9%, respectively) as well as undiagnosed/untreated SH (29.4% and 24.6%). SH prevalence was almost double in urban compared to rural areas (17.0% vs. 9.2%, P=0.02); however, conversely, undiagnosed/untreated SH was significantly higher in rural areas (50.4% vs 21.9%). Compared to normal bodyweight, those who were overweight and obese had a 1.95-fold (95% CI, 1.30–2.93; P<0.001)and 4.24-fold (95% CI, 2.68–6.74; P<0.001)increased odds of SH (adjusting for age and sex), respectively. Similarly, participants ≥60 years had a 6.04-fold (95% CI, 3.93–9.36; P<0.001)increased risk of undiagnosed SH compared to under 50 years. Finally, men had higher odds of SH compared to women (OR 1.71, 95% CI, 1.19–2.47; P=0.004).

Figure 1

Conclusion(s)

Our community-based study revealed very high prevalence of SH among adults in Abidjan area, with almost one out of every seven having SH. This underscores SH as a growing public health problemin sub-Saharan Africa.More concerning, a significant (almost one third) proportion of them were either undiagnosed or untreated.

Cross-sectional analysis of deprivation and ideal cardiovascular health in the Paris Prospective Study 3

AIMS

We hypothesised that deprivation might represent a barrier to attain an ideal cardiovascular health (CVH) as defined by the American Heart Association (AHA).

METHODS AND RESULTS

The baseline data of 8916 participants of the Paris Prospective Study 3, an observational cohort on novel markers for future cardiovascular disease, were used. The AHA 7-item tool includes four health behaviours (smoking, body weight, physical activity and optimal diet) and three biological measures (blood cholesterol, blood glucose and blood pressure). A validated 11-item score of individual material and psychosocial deprivation, the Evaluation de la Précarité et des Inégalités dans les Centres d'Examens de Santé-Evaluation of Deprivation and Inequalities in Health Examination centres (EPICES) score was used. The mean age was 59.5 years (standard deviation 6.2), 61.2% were men and 9.98% had an ideal CVH. In sex-specific multivariable polytomous logistic regression, the odds ratio (OR) for ideal behavioural CVH progressively decreased with quartile of increasing deprivation, from 0.54 (95% CI 0.41 to 0.72) to 0.49 (0.37 to 0.65) in women and from 0.61 (0.50 to 0.76) to 0.57 (0.46 to 0.71) in men. Associations with ideal biological CVH were confined to the most deprived women (OR=0.60; 95% CI 0.37 to 0.99), whereas in men, greater deprivation was related to higher OR of intermediate biological CVH (OR=1.28; 95% CI 1.05 to 1.57 for the third quartile vs the first quartile).

CONCLUSIONS

Higher material and psychosocial deprivation may represent a barrier to reach an ideal CVH.

TRIAL REGISTRATION NUMBER

NCT00741728.

High level of depressive symptoms as a barrier to reach an ideal cardiovascular health. The Paris Prospective Study III

We hypothesized that depression might represent a barrier to reach an ideal cardiovascular health (CVH) as estimated by the 7-item tool proposed by the American Heart Association. Between 2008 and 2012, 9,417 subjects 50-75 years of age were examined in a large health center and enrolled in the Paris Prospective Study III (PPS3). Participants with 0-2, 3-4 and 5-7 health metrics at the ideal level were categorized as having poor, intermediate and ideal CVH, respectively. Participants with a score ≥ 7 on the 13-item Questionnaire of Depression 2nd version, Abridged or who were on antidepressants were referred as having high level of depressive symptoms (HLDS). The mean age of the 9417 study participants was 59.57 (SD 6.28) years and 61.16% were males. A total of 9.55% had HLDS. Poor, intermediate and ideal CVH was present in 40.38%, 49.52% and 10.10% of the participants. In multivariate polytomous logistic regression analysis, HLDS was inversely associated with ideal CVH (odds ratio = 0.70; 95% CI: 0.55;0.90). This was driven by an association with the behavioural component of the CVH. Participants with HLDS had a substantial reduced chance of reaching an ideal CVH.