Barriers and challenges for primary and secondary prevention of heart disease in sub-Saharan Africa

The diverse people of sub-Saharan Africa face a number of paradoxical challenges arising from economic development and urbanisation, including an increasing prevalence of noncommunicable forms of heart disease. Prevention programmes designed not only to detect those with established and often disabling forms of heart disease, but prevent disease progression and a premature death, are an obvious priority in this setting. This review article reflects on the barriers and challenges to effective primary and secondary prevention of heart disease in sub-Saharan Africa by (a) examining what residual issues challenge effective prevention in high-income countries? (b) what are the key ingredients to an integrated programme of primary and secondary prevention across the lifespan (from the population to individual)? and (c) considering the first two points, what are the barriers and challenges in sub-Saharan Africa to implementing cost-effective primary and secondary prevention using a systematic approach to “who, what and how”

Is there an association between sleeping patterns and other environmental factors with obesity and blood pressure in an urban African population?

Beyond changing dietary patterns, there is a paucity of data to fully explain the high prevalence of obesity and hypertension in urban African populations. The aim of this study was to determine whether other environmental factors (including sleep duration, smoking and physical activity) are related to body anthropometry and blood pressure (BP). Data were collected on 1311 subjects, attending two primary health care clinics in Soweto, South Africa. Questionnaires were used to obtain data on education, employment, exercise, smoking and sleep duration. Anthropometric and BP measurements were taken. Subjects comprised 862 women (mean age 41 ± 16 years and mean BMI 29.9 ± 9.2 kg/m 2 ) and 449 men (38 ± 14 years and 24.8 ± 8.3 kg/m 2 ). In females, ANOVA showed that former smokers had a higher BMI (p 30 minutes was related to a lower BMI (β = -0.04, p30 minutes/day was related to lower systolic (β = -0.02, p<0.05) and lower diastolic BP (β = -0.02, p = 0.05). Longer night time sleep duration was associated with higher diastolic (β = 0.005, p<0.01) and systolic BP (β = 0.003, p<0.05) in females. No health benefits were noted for physical activity. These data suggest that environmental factors rarely collected in African populations are related, in gender-specific ways, to body anthropometry and blood pressure. Further research is required to fully elucidate these associations and how they might be translated into public health programs to combat high levels of obesity and hypertension

Women versus men with chronic atrial fibrillation: insights from the Standard versus Atrial Fibrillation spEcific managemenT studY (SAFETY)

BACKGROUND: Gender-based clinical differences are increasingly being identified as having significant influence on the outcomes of patients with cardiovascular disease (CVD), including atrial fibrillation (AF). OBJECTIVE: To perform detailed clinical phenotyping on a cohort of hospitalised patients with chronic forms of AF to understand if gender-based differences exist in the clinical presentation, thrombo-embolic risk and therapeutic management of high risk patients hospitalised with chronic AF. METHODS: We are undertaking the Standard versus Atrial Fibrillation spEcific managemenT studY (SAFETY) - a multi-centre, randomised controlled trial of an AF-specific management intervention versus usual care. Extensive baseline profiling of recruited patients was undertaken to identify gender-specific differences for risk delineation. RESULTS: We screened 2,438 patients with AF and recruited 335 into SAFETY. Of these, 48.1% were women who were, on average, 5 years older than their male counterparts. Women and men displayed divergent antecedent profiles, with women having a higher thrombo-embolic risk but being prescribed similar treatment regimens. More women than men presented to hospital with co-morbid thyroid dysfunction, depression, renal impairment and obesity. In contrast, more men presented with coronary artery disease (CAD) and/or chronic obstructive pulmonary disease (COPD). Even when data was age-adjusted, women were more likely to live alone (odds ratio [OR] 2.33; 95% confidence interval [CI] 1.47 to 3.69), have non-tertiary education (OR 2.69; 95% CI 1.61 to 4.48) and be symptomatic (OR 1.93; 95% CI 1.06 to 3.52). CONCLUSION: Health care providers should be cognisant of gender-specific differences in an attempt to individualise and, hence, optimise the management of patients with chronic AF and reduce potential morbidity and mortality.Jocasta Ball, Melinda J. Carrington, Kathryn A. Wood, Simon Stewart (the SAFETY Investigators

Establishing a Pragmatic Framework to Optimise Health Outcomes in Heart Failure and Multimorbidity (ARISE-HF): A Multidisciplinary Position Statement

Background Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide. Methods To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population. Results We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol — adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals. Conclusions We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF

Patient preferences and willingness-to-pay for a home or clinic based program of chronic heart failure management: findings from the which? trial

BACKGROUND Beyond examining their overall cost-effectiveness and mechanisms of effect, it is important to understand patient preferences for the delivery of different modes of chronic heart failure management programs (CHF-MPs). We elicited patient preferences around the characteristics and willingness-to-pay (WTP) for a clinic or home-based CHF-MP. METHODOLOGY/PRINCIPAL FINDINGS A Discrete Choice Experiment was completed by a sub-set of patients (n = 91) enrolled in the WHICH? trial comparing home versus clinic-based CHF-MP. Participants provided 5 choices between hypothetical clinic and home-based programs varying by frequency of nurse consultations, nurse continuity, patient costs, and availability of telephone or education support. Participants (aged 71±13 yrs, 72.5% male, 25.3% NYHA class III/IV) displayed two distinct preference classes. A latent class model of the choice data indicated 56% of participants preferred clinic delivery, access to group CHF education classes, and lower cost programs (p<0.05). The remainder preferred home-based CHF-MPs, monthly rather than weekly visits, and access to a phone advice service (p<0.05). Continuity of nurse contact was consistently important. No significant association was observed between program preference and participant allocation in the parent trial. WTP was estimated from the model and a dichotomous bidding technique. For those preferring clinic, estimated WTP was ≈AU$9-20 per visit; however for those preferring home-based programs, WTP varied widely (AU$15-105). CONCLUSIONS/SIGNIFICANCE Patient preferences for CHF-MPs were dichotomised between a home-based model which is more likely to suit older patients, those who live alone, and those with a lower household income; and a clinic-based model which is more likely to suit those who are more socially active and wealthier. To optimise the delivery of CHF-MPs, health care services should consider their patients’ preferences when designing CHF-MPs.Jennifer A. Whitty, Simon Stewart, Melinda J. Carrington, Alicia Calderone, Thomas Marwick, John D. Horowitz, Henry Krum, Patricia M. Davidson, Peter S. Macdonald, Christopher Reid, Paul A. Scuffha

May Measurement Month 2018: a pragmatic global screening campaign to raise awareness of blood pressure by the International Society of Hypertension

Aims Raised blood pressure (BP) is the biggest contributor to mortality and disease burden worldwide and fewer than half of those with hypertension are aware of it. May Measurement Month (MMM) is a global campaign set up in 2017, to raise awareness of high BP and as a pragmatic solution to a lack of formal screening worldwide. The 2018 campaign was expanded, aiming to include more participants and countries. Methods and results Eighty-nine countries participated in MMM 2018. Volunteers (≥18 years) were recruited through opportunistic sampling at a variety of screening sites. Each participant had three BP measurements and completed a questionnaire on demographic, lifestyle, and environmental factors. Hypertension was defined as a systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, or taking antihypertensive medication. In total, 74.9% of screenees provided three BP readings. Multiple imputation using chained equations was used to impute missing readings. 1 504 963 individuals (mean age 45.3 years; 52.4% female) were screened. After multiple imputation, 502 079 (33.4%) individuals had hypertension, of whom 59.5% were aware of their diagnosis and 55.3% were taking antihypertensive medication. Of those on medication, 60.0% were controlled and of all hypertensives, 33.2% were controlled. We detected 224 285 individuals with untreated hypertension and 111 214 individuals with inadequately treated (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) hypertension. Conclusion May Measurement Month expanded significantly compared with 2017, including more participants in more countries. The campaign identified over 335 000 adults with untreated or inadequately treated hypertension. In the absence of systematic screening programmes, MMM was effective at raising awareness at least among these individuals at risk

Blood Pressure and Heart Rate During Continuous Experimental Sleep Fragmentation in Healthy Adults

Study Objectives: This paper aims to determine whether experimental arousals from sleep delay the sleep related fall in cardiovascular activity in healthy adults. Design: We report the results of 2 studies. The first experiment manipulated arousals from sleep in young adults. The second compared the effect of frequent arousals on young and middle-aged adults. The influence of arousals were assessed in 2 ways; (1) the fall in cardiovascular activity over sleep onset and the early sleep period, and (2) the underlying sleep levels during the sleep periods in between arousals. Setting: Both experiments were conducted in the sleep laboratory of the Department of Psychology, The University of Melbourne, Australia. Participants: There were 5 male and 5 female healthy individuals in each experiment between the ages of 18–25 years (Experiment 1) and 38–55 years (Experiment 2). Interventions: Participants in Experiment 1 were aroused by auditory stimuli every (i) 2 min, (ii) 1 min, and (iii) 30 sec of sleep for 90 min after the first indication of sleep. In a control condition, participants slept undisturbed for one NREM sleep cycle. Experiment 2 compared the control with the 30-sec condition in the young adults and in an additional group of middle-aged adults. Measurements and Results: The dependent variables were blood pressure (BP) and heart rate (HR). In Experiment 1, sleep fragmentation at higher frequencies retarded the fall in BP over sleep onset but did not affect the underlying sleep levels. Experiment 2 showed that there were no age differences on the effect of arousals on changes in BP and HR during sleep. Conclusions: This paper supports the hypothesis that repetitive arousals from sleep independently contribute to elevations in BP at night

Bridging the gap in heart failure prevention: Rationale and design of the Nurse-led intervention for Less Chronic Heart Failure (NiL-CHF) Study

Aims The primary objective of the Nurse-led Intervention for Less Chronic Heart Failure (NIL-CHF) Study is to develop a programme of care that cost-effectively prevents the development of chronic heart failure (CHF). Methods NIL-CHF is a randomized controlled trial of a hybrid, home- and clinic-based, nurse-led multidisciplinary intervention targeting hospitalized patients at risk of developing CHF. A target of 750 patients aged ≥45 years will be exposed to usual post-discharge care or the NIL-CHF intervention. The composite primary endpoint is all-cause mortality or CHF-related admission during 3–5 years of follow-up. After 12 months recruitment, ∼300 eligible patients (40% of target) have been randomized. Overall, 73% are male and the mean age is 65 ± 10 years. The most common antecedents for CHF thus far are hypertension (70%, 95% CI, 64–75%), coronary artery disease (51%, 95% CI, 31–41%), and type 2 diabetes (26%, 95% CI, 21–31%), whereas 76% (95% CI, 69–82%) of patients have diastolic dysfunction, 29% (95% CI, 23–36%) left ventricular hypertrophy, 71% (95% CI, 64–78%) mitral valve dysfunction, and 7% (95% CI, 4–12%) have a left ventricular ejection fraction ≤45%. Conclusion As one of the largest randomized studies of its kind, NIL-CHF will ultimately provide important insights into the potential to prevent CHF via prolonged and intensive disease management