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 anti-hypertensive therapy, and intensifying salt restriction.

Objectives

To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of three 6-months anti-hypertensive 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-hour 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 >140mmol/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 χ2 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.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Fogarty International Center and the National Institutes of Health of the United States of America Figure 1

Correlation between Echocardiographic Left Ventricular Hypertrophy and various Electrocardiographic Criteria of Left Ventricular Hypertrophy among Black Hypertensives

BACKGROUND

Systemic hypertension remains an important risk factor for cardiovascular diseases and a major global public health problem. Left ventricular hypertrophy (LVH) is a recognized complication of systemic hypertension and strongly predicts cardiovascular morbidity and mortality. In Nigeria, few studies have evaluated the correlation of ECG criteria in the diagnosis of left ventricular hypertrophy among hypertensives and almost all the previous studies on ECG LVH used only one or two criteria. This study sets out to determine the correlations between various ECG criteria of LVH and echocardiographic LVH among patients with hypertension using six ECG LVH criteria.

METHODS

One hundred and seventy-eight hypertensives and eighty- nine age and sex matched controls were recruited consecutively into the study. All participants including hypertensives and control subjects had echocardiography whereas only hypertensive subjects had both echocardiography and ECG. ECG LVH was determined using Sokolow-Lyon, Cornell voltage, Goldberger, Massoleini, Romhilt-Estes and Cornell duration product ECG criteria.

RESULTS

Sokolow-Lyon and Cornell voltage criteria had significant positive correlation with echocardiographic LVH (p=0.001 and 0.003, respectively). Although Goldberger and Massoleini criteria had positive correlation coefficients, these were not statistically significant.

CONCLUSION

There are significant correlations between echocardiographic LVH and ECG LVH determined by Cornell voltage and Sokolow-Lyon criteria.

Status of cardiac arrhythmia services in Africa in 2018: a PASCAR Sudden Cardiac Death Task Force report

Background

There is limited information on the availability of health services to treat cardiac arrhythmias in Africa.

Methods

The Pan–African Society of Cardiology (PASCAR) Sudden Cardiac Death Task Force conducted a survey of the burden of cardiac arrhythmias and related services over two months (15 October to 15 December) in 2017. An electronic questionnaire was completed by general cardiologists and electrophysiologists working in African countries. The questionnaire focused on availability of human resources, diagnostic tools and treatment modalities in each country.

Results

We received responses from physicians in 33 out of 55 (60%) African countries. Limited use of basic cardiovascular drugs such as anti–arrhythmics and anticoagulants prevails. Non–vitamin K–dependent oral anticoagulants (NOACs) are not widely used on the continent, even in North Africa. Six (18%) of the sub–Saharan African (SSA) countries do not have a registered cardiologist and about one–third do not have pacemaker services. The median pacemaker implantation rate was 2.66 per million population per country, which is 200–fold lower than in Europe. The density of pacemaker facilities and operators in Africa is quite low, with a median of 0.14 (0.03–6.36) centres and 0.10 (0.05–9.49) operators per million population. Less than half of the African countries have a functional catheter laboratory with only South Africa providing the full complement of services for cardiac arrhythmia in SSA. Overall, countries in North Africa have better coverage, leaving more than 110 million people in SSA without access to effective basic treatment for cardiac conduction disturbances.

Conclusion

The lack of diagnostic and treatment services for cardiac arrhythmias is a common scenario in the majority of SSA countries, resulting in sub–optimal care and a subsequent high burden of premature cardiac death. There is a need to improve the standard of care by providing essential services such as cardiac pacemaker implantation.

HIV treatment is associated with a two-fold higher probability of raised triglycerides: Pooled Analyses in 21 023 individuals in sub-Saharan Africa

BACKGROUND

Anti-retroviral therapy (ART) regimes for HIV are associated with raised levels of circulating triglycerides (TG) in western populations. However, there are limited data on the impact of ART on cardiometabolic risk in sub-Saharan African (SSA) populations.

METHODS

Pooled analyses of 14 studies comprising 21 023 individuals, on whom relevant cardiometabolic risk factors (including TG), HIV and ART status were assessed between 2003 and 2014, in SSA. The association between ART and raised TG (>2.3 mmol/L) was analysed using regression models.

FINDINGS

Among 10 615 individuals, ART was associated with a two-fold higher probability of raised TG (RR 2.05, 95% CI 1.51-2.77, I2=45.2%). The associations between ART and raised blood pressure, glucose, HbA1c, and other lipids were inconsistent across studies.

INTERPRETATION

Evidence from this study confirms the association of ART with raised TG in SSA populations. Given the possible causal effect of raised TG on cardiovascular disease (CVD), the evidence highlights the need for prospective studies to clarify the impact of long term ART on CVD outcomes in SSA.

Idiopathic scrotal calcinosis; a rare scrotal tumour: a case report and review of literature

Idiopathic scrotal calcinosis is a rare benign disease characterized by multiple, asymptomatic and painless nodules on the scrotum. We herein report this rare disease in a Nigerian adult male and briefly review the relevant literature.

Anaemia and its response to treatment with recombinant human erythropoietin in chronic kidney disease patients

BACKGROUND

The introduction of erythropoietin has transformed the management of anaemia in CKD, with considerable benefits which includes enhanced quality of life, increased exercise capacity and improved cardiac function. There is paucity of data on the beneficial effects of this treatment from this environment.

OBJECTIVE

The aim of this work was to study the pattern and response of anaemia and its response to treatment with recombinant human erythropoietin(r-HuEpo) in CKD patients in Nigeria.

METHODS

This was a prospective study in which 20 CKD patients who satisfied the inclusion criteria were recruited consecutively. Subcutaneous r-HuEpo was administered to each of the study patients, starting with a weekly dose of 50 iu per kg and titrated according to haemoglobin (Hb) response, which was monitored fortnightly throughout the study period with the aim of achieving a target Hb of 11g per dl.

RESULTS

The patients studied were anaemic with mean Hb of 7.36(1.05) g/dl. The anemia was normocytic normochromic in 85% of the patients. All the patients responded to treatment with r-HuEpo with the mean Hb rising from 6.74(0.70)g per dl to 11.64(0.37) g/dl and 7.64(1.19) to 11.98(0.45) g/dl in those on maintenance haemodialysis and pre-dialysis patients respectively. The patients reached the target Hb of 11g/dl within 8 weeks in predialytic CKD patients and within 10 weeks in those on maintenance haemodialysis.

CONCLUSION

Anaemia is mostly normocytic normochromic in CKD patients in our environment and r-HuEpo therapy is effective in correcting the anaemia.

Krukenberg's tumour

BACKGROUND

Krukenburg's tumour, a metastatic cancer to the ovary can pose difficulties in early diagnosis. The paucity of reports from our environment coupled with the difficulties we encountered makes it imperative that we report this case.

METHODS

We present a 32-year-old lady who presented with mucoid and bloody diarrhoea associated with menstrual irregularity, weight loss and lower abdominal pains 2 years after surgical treatment for gastric cancer. Literature on Krukenburg's tumour was also reviewed.

RESULTS

While serum level of CEA was found to be elevated and colonoscopy showed an ulcerated mass obliterating the lumen of the sigmoid colon, abdominal CT scan revealed bilateral adnexal masses. The histology of the colonic lesion showed signet ring carcinoma while the enlarged ovaries turned out to have evidence of metastatic adenocarcinoma.

CONCLUSION

Early diagnosis of KT can be difficult. Periodic surveillance is, therefore, essential especially in those who have had a gastrointestinal malignancy.

Blood pressure control among treated hypertensives in a tertiary health institution

BACKGROUND

Goal blood pressure (BP) was defined by the JNC VI and the World Health Organization-International Society of Hypertension (WHO/ISH) as <140 mm Hg systolic and <90 mm Hg diastolic for the general and <130 mm Hg systolic and <85 mm Hg diastolic for special high-risk populations. It is well established that adequate BP control characterizes only a fraction of treated hypertensive patients. The importance of tight BP control has been established in preventing cardiovascular morbidity and mortality

METHODS

We performed cross-sectional studies on the current status of BP control among treated hypertensive in our center. One hundred consecutive patients with essential hypertension who have been attending the out patient hypertension clinic and have been on treatment for at least 6 months were recruited. The pre treatment BP and BP records in the previous 2 visits were noted. Patients were said to have good BP control if their BPs are < 140/90 mmHg (<130/80 mmHg for high risk patients) at the time of the study and in the last visit.

RESULTS

There were 49 males and 51 female (M: F; 1:1), aged 26 to 85 (mean 52.33 +/- 12.29) years. The duration of hypertension ranged 6 months to 30 (mean 7.37 +/- 7.1) years. The duration of treatment in our centre was 6 months to 10 (mean 3.22 +/- 2.23) years. Blood pressure was controlled in 33 (33%) of the patients. Pre-treatment mean blood pressure was significantly higher than the BP value at the time of the study (155.87 +/- 26.02/97.81 +/- 11.89 mmHg versus 143.40 +/- 24.14/86.53 +/- 12.71 mmHg) (p<0.05). Diuretics were the commonest antihypertensive prescribed either alone or in combination (69%), followed by a calcium antagonist (56%) and centrally acting drugs (38%). Twenty seven were on single antihypertensive, 43 (43%) on 2, 25(25%) on 3 and 5 (5%) on 4 classes of antihypertensive. Blood pressure control was associated with taking more than one antihypertensive medication and compliance.

CONCLUSION

Control of BP in patients receiving antihypertensive drugs is still far from optimal in the study population in Nigeria just as in other countries. Many patients had multiple cardiovascular risk factors. Adherence to medication should be encouraged.

The impact of income on the echocardiographic pattern of heart diseases in Kano, Nigeria

BACKGROUND

The aims of the present study were to assess the echocardiographic pattern of heart diseases, and to compare the pattern seen in a private echocardiography centre patronized by high income earners (group 1), with that in Murtala Mohammed Specialist Hospital patronized by low income earners (group 2), in Kano, Nigeria.

METHODS

the study was retrospective in design. The records of patients aged > or =15 years for a one year period (July 2006-June 2007) were reviewed.

RESULTS

Hypertensive heart disease (in 56.7%) was the most common heart disease, more common among group 1 patients (p=0.027). Dilated cardiomyopathy was the 2nd most common heart disease (in 15.2%), more common among group 2 patients (p=0.037). Ischemic Heart Disease (IHD) was the 3rd most common (in 8.7%) heart disease in the study, more common than rheumatic heart disease (in 8.3%). Peripartum cardiomyopathy was exclusively found among group 2 patients (4.3%).

CONCLUSION

The pattern of heart diseases in Kano differs between low and higher income earners. HHD was the commonest heart disease among both low income and higher income earners. The relatively high frequency of IHD might be a demonstration of the advanced stage of epidemiologic transition in Kano Nigeria.

A three-year review of mortality patterns in the medical wards of Aminu Kano Teaching Hospital, Kano, Nigeria

BACKGROUND

The pattern of morbidity and mortality reflects the burden of disease in a particular community. This pattern shows geographic variations between communities and countries. The knowledge of the pattern of diseases and their contribution to mortality in a given country is very important in evaluating its health care delivery system. Such knowledge is important for health planning and for improving the healthcare services in that particular nation. We set out to study the mortality pattern in our medical wards.

MATERIALS AND METHODS

This is a retrospective study that reviewed the causes of death in the medical wards of Aminu Kano Teaching Hospital (AKTH) Kano between January 2001 and December 2003 (three years). The data were obtained from the admission and discharge/death register, patients' case records, the weekly as well as quarterly mortality reviews. The SPSS version 10 was used to analyse the data.

RESULTS

A total of 3369 patients were admitted over the 3 year study period. Of these 2518 (74.7%) were discharged or referred and 851 patients died, giving an overall mortality rate of 25.3%. The male to female admission ratio was 1.6:1. Majority of deaths, 714 (83.9%) occurred after 24 hours of admission. The most important causes of death were infectious diseases other than HIV/AIDS (17.9%), cerebrovascular disease (17%), HIV/AIDS (13.6%), chronic renal failure (12.5%) and diseases of the circulatory system (11.9%).

CONCLUSION

Mortality in the medical wards reflects the emerging trend of mixed disease spectrum burden comprising communicable and non communicable diseases. Public health education, raising the socio-economic status of our people as well as improving the standards of our health care facilities and personnel would prevent a large proportion of deaths from medical wards.

Cardiac morbidity in subjects referred for echocardiographic assessment at a tertiary medical institution in the Nigerian savanna zone

Cardiovascular diseases constitute a major public health problem both in the developed and developing countries. The profile of morbidity and mortality however, varies between regions and countries and even within countries. The importance of recognizing the cardiovascular conditions that prevail in a particular area is very important in health planning and for improving healthcare services. We therefore set out to describe the cardiac morbidity pattern from our echocardiographic data. Between August 2002 and September 2004 (24 months), we reviewed the echocardiographic diagnosis of all patients aged 15 years referred for echocardiography. Information obtained from the records included age, gender, names of referring hospital/physician, clinical diagnosis and echocardiogram findings. Data was analyzed using SPSS version 10.0 software. A total of 594 persons were referred for echocardiographic examination in the 2 year study period. Of these, 489 (82.3%) had an abnormal echocardiogram. We analyzed those with abnormal echocardiograms. There were 272 males and 217 females. The male to female ratio was 1.3:1. Hypertensive heart disease was the commonest echocardiographic diagnosis, present in 228 (46.6%) of the patients. This is followed by dilated cardiomyopathy seen in 82 (16.8%) and then rheumatic heart disease in 55 (11.2%). Other findings were Non dilated cardiomyopathy (6.1%), Hypertrophic cardiomyopathy (5.7%), pericardial diseases (3.7%), Ischemic heart disease (4.7%), Cor pulmonale (1.4%) and Endomyocardial fibrosis (0.4%) of patients. It was noted that majority of the cases were advanced with irreversible myocardial damage. Systemic hypertension remains the most important cause of CVD morbidity in savanna region of Nigeria. Addressing the major cardiovascular risk factors especially systemic hypertension will go a long way in reducing the burden of cardiovascular diseases.

Physical exercise and health: a review

BACKGROUND

Physical activity results in increased exercise capacity and physical fitness, which may lead to many health benefits. Individuals who are more physically active appear to have lower rates of all-cause mortality, probably due to a decrease in chronic diseases including coronary artery disease (CAD). This may result from an improvement in cardiovascular risk factors in addition to enhanced fibrinolysis, improved endothelial function, decreased sympathetic tone, and other yet undetermined factors.

METHODS

We reviewed the literature on physical activity and health with particular reference to the benefits derivable by engaging in regular physical activity. The MEDLINE/PUBMED and bibliographic searches for English language studies were used.

RESULTS

Physical inactivity is now considered a risk factor for Cardiovascular diseases (CVD). Regular exercise results in an increase in exercise capacity and lower myocardial oxygen demand leading to cardiovascular benefits, including lower mortality rates. Physically active individuals suffer from fewer ailments than do less-active individuals. Physical activity reduces cardiovascular risk through lowering of blood pressure, improved glucose tolerance, reduced obesity, improvement in lipid profile, enhanced fibrinolysis, improved endothelial function and enhanced parasympathetic autonomic tone.

CONCLUSION

Physical exercise has many health benefits and the evidence for this continues to accumulate. Health care professionals should incorporate counselling to patients for physical exercise in their daily clinical practice, while health policy makers and community physicians should see to implementation of this at the community level.

Heart disease in HIV/AIDS. How much is due to cachexia?

HIV/AIDS affects the heart through different mechanisms. Before the advent of HIV/AIDS, cachexia had been established as a cause of cardiac morbidity. Interestingly when HIV/AIDS affects the heart, not much role is ascribed to cachexia; one of the major criteria for diagnosis. As most electrocardiographic (ECG) changes in HIV/AIDS are also seen in cachexia, it became necessary to look at the ECG changes in HIV/AIDS in relation to body mass index (BMI). This was to see if any relationship existed. One hundred, 78 and 80 full blown AIDS, HIV positive asymptomatic and HIV negative subjects underwent 12 lead resting ECG respectively. Their BMI were determined from the heights and weights. BMI was least in the first group and highest in the last group. The mean differences achieved statistical significance. Systolic and diastolic blood pressures significantly fell from HIV negative to the AIDS patients. This was as BMI fell. Systolic and diastolic blood pressures fall significantly with cachexia. The following indices on ECG: heart rate, corrected QT interval, ST segment depression and T wave inversion increased from the HIV negative to the full blown AIDS patients. This was also the direction of reduction in BMI. Since these ECG changes have long been known with cachexia, it is being suggested that the cachexia associated with HIV/AIDS contributes to the heart disease in them.

Ischaemic heart disease in Aminu Kano Teaching Hospital, Kano, Nigeria: a 5 year review

BACKGROUND

Socio-economic changes and rural urban migration have led to emergence of non-communicable disease including ischaemic heart disease (IHD) and many others. The actual prevalence of IHD in Nigeria is not known. The non communicable disease (NCD) survey sought to determine the prevalence of major risk factors, rather than the prevalence of the disease itself. The prevalence is generally considered low in Nigeria but the current impression about its importance stems mostly from anecdotal reports. We therefore set out to describe the prevalence as well as the spectrum of IHD at Aminu Kano Teaching Hospital, Kano.

METHOD

Between July 2000 and June 2005, we reviewed the prevalence as well as the spectrum of presentation of IHD in Aminu Kano Teaching Hospital. Information was obtained from the medical records of patients in the medical unit of the hospital. Age, sex, diagnosis, risk factors for IHD, other relevant clinical and laboratory data and outcome of patients for myocardial infarction (MI) were extracted from the records. Data was analyzed using SPSS version 10.0 software.

RESULTS

There were 5124 medical patients admitted over the period under review, out of which 1347 had cardiovascular diseases. Forty six patients were diagnosed to have IHD giving it a prevalence of 0.9% of medical conditions and 3.4% of all cardiovascular cases. There were 33 males and 13 females (M : F = 2.5:1). Twenty two patients (47.8%) had myocardial infarction, 14 (30.4%) had ischemic cardiomyopathy and 10 (21.7%) had angina. The patients consist of 41 (89.1%) Nigerians, 3 (6.5%) Lebanese, 1 (2.2%) Indian and 1 (2.2%) Pakistani. The risk factors found were Hypertension in 37 (80.4%) of patients, diabetes in 16 (34.8%), and Dyslipidaemia in 20 (43.5%). Others were cigarette smoking and obesity.

CONCLUSION

IHD is an important cause of morbidity and mortality in our population. There is need for us to be on the alert and prepare ourselves to manage these cases. Focus should be on preventive cardiology.

Structural heart diseases in Nigerian children

BACKGROUND

Cardiovascular diseases both in adults and children constitute a major public health problem and structural heart diseases are an important group of disorders in children worldwide. The pattern of this group of disorders however, varies between regions and countries and even within countries. Recognizing the structural cardiac conditions that prevail in a particular area is important in health planning and for improving health care services. The present survey sets out to describe the pattern of structural heart diseases among children in Aminu Kano Teaching Hospital, Kano from our echocardiography data.

METHODS

The echocardiographic reports of all children seen in Aminu Kano Teaching Hospital, Kano between August 2002 and September 2004 (24 months) were reviewed. Information obtained from the records includes age, gender, clinical diagnosis and echocardiographic findings. Data was analyzed using SPSS version 10.0 software.

RESULTS

A total of 108 children, aged between two weeks and eighteen years, were referred for echocardiographic examination in the 2-year study period. Of these, 88 had an abnormal echocardiogram. There were 55 boys and 31 girls, giving a male and female ratio of 1.8:1. Congenital heart diseases accounted for 55 (62.5%) of the studied subjects while acquired heart diseases were responsible for 33 (37.5%). Isolated ventricular septal defect (VSD) was the commonest congenital heart disease. Rheumatic valvular heart diseases were the commonest acquired structural heart disease.

CONCLUSION

With the establishment of tertiary healthcare institutions in Nigeria, availability of echocardiographic facilities as well as increasing number of paediatric cardiologists, more of these cases are likely to be seen in the future. There is an urgent need for the government to establish a well equipped cardiothoracic surgical centre to cater for these patients either free or at highly subsidized rates.

Post transplant Kaposi's sarcoma among Nigerians: a report of two cases

With the establishment of kidney transplant centres in Nigeria and increase in the number of kidney transplant recipients returning home for follow up after successful transplant abroad, an increasing number of patients with post transplant complications are likely to be seen. There is the need for physicians vested with the care of these patients to be aware of the post transplant complications so that early diagnosis and effective treatment can be instituted so as to save both the patient and the allograft. Two out of seventeen renal transplant recipients followed up in our unit had post renal transplant Kaposi's sarcoma. Both were successfully treated with withdrawal of cyclosporin, reduction of other immunosuppressives and introduction of low dose Mycophenolate Mofetil (MMF). One had a course of radiotherapy followed by weekly intravenous vincristine and the other only had vincristine with complete remission of the lesions in both patients. Post transplant Kaposi's sarcoma occurs in Nigerian transplant patients and this report highlights the need for increased awareness and high index of suspicion of post transplant Kaposi's sarcoma among kidney transplant recipients.

Epidemiology and pathogenesis of human immunodeficiency virus (HIV) related heart disease: a review

BACKGROUND

There is a clear and growing body of evidence for cardiac dysfunction in a significant portion of patients with HIV disease. An increased number of HIV-infected individuals may present with cardiac complications in the future as more patients with this disease survive longer because of modern therapy. Heart involvement in AIDS may be well characterized cardiac disease occurring coincidentally in AIDS patients, a complication of the disease or its treatment or possibly a direct insult to the heart by the HIV itself.

METHODS

We reviewed the literature on heart disease in HIV infection and AIDS with particular reference to epidemiology and pathogenetic mechanisms that may play a role in diagnosis, management, and therapy of these complications. The MEDLINE/PUBMED and bibliographic searches forEnglish language studies were used.

RESULTS

A variety of potential aetiologies have been postulated in HIV-related heart disease, including myocardial invasion with HIV itself, opportunistic infections, viral infections, autoimmune response to viral infection, drug-related cardiac toxicity, nutritional deficiencies, and prolonged immunosuppression.

CONCLUSION

An increased number of HIV-infected individuals present with cardiac complications as chronic viral infection, co-infections, drug therapy, and immunosuppression. Understanding the nature and course of cardiac illness related to HIV infection may allow appropriate monitoring, early intervention and therapy