Basil N. Okeahialam

Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study)

AIMS Rheumatic heart disease (RHD) accounts for over a million premature deaths annually; however, there is little contemporary information on presentation, complications, and treatment. METHODS AND RESULTS This prospective registry enrolled 3343 patients (median age 28 years, 66.2% female) presenting with RHD at 25 hospitals in 12 African countries, India, and Yemen between January 2010 and November 2012. The majority (63.9%) had moderate-to-severe multivalvular disease complicated by congestive heart failure (33.4%), pulmonary hypertension (28.8%), atrial fibrillation (AF) (21.8%), stroke (7.1%), infective endocarditis (4%), and major bleeding (2.7%). One-quarter of adults and 5.3% of children had decreased left ventricular (LV) systolic function; 23% of adults and 14.1% of children had dilated LVs. Fifty-five percent (n = 1761) of patients were on secondary antibiotic prophylaxis. Oral anti-coagulants were prescribed in 69.5% (n = 946) of patients with mechanical valves (n = 501), AF (n = 397), and high-risk mitral stenosis in sinus rhythm (n = 48). However, only 28.3% (n = 269) had a therapeutic international normalized ratio. Among 1825 women of childbearing age (12-51 years), only 3.6% (n = 65) were on contraception. The utilization of valvuloplasty and valve surgery was higher in upper-middle compared with lower-income countries. CONCLUSION Rheumatic heart disease patients were young, predominantly female, and had high prevalence of major cardiovascular complications. There is suboptimal utilization of secondary antibiotic prophylaxis, oral anti-coagulation, and contraception, and variations in the use of percutaneous and surgical interventions by country income level.

Clinical Outcomes in 3343 Children and Adults with Rheumatic Heart Disease from 14 Low and Middle Income Countries: 2-Year Follow-up of the Global Rheumatic Heart Disease Registry (the REMEDY study)

Background: There are few contemporary data on the mortality and morbidity associated with rheumatic heart disease or information on their predictors. We report the 2-year follow-up of individuals with rheumatic heart disease from 14 low- and middle-income countries in Africa and Asia. Methods: Between January 2010 and November 2012, we enrolled 3343 patients from 25 centers in 14 countries and followed them for 2 years to assess mortality, congestive heart failure, stroke or transient ischemic attack, recurrent acute rheumatic fever, and infective endocarditis. Results: Vital status at 24 months was known for 2960 (88.5%) patients. Two-thirds were female. Although patients were young (median age, 28 years; interquartile range, 18–40), the 2-year case fatality rate was high (500 deaths, 16.9%). Mortality rate was 116.3/1000 patient-years in the first year and 65.4/1000 patient-years in the second year. Median age at death was 28.7 years. Independent predictors of death were severe valve disease (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.80–3.11), congestive heart failure (HR, 2.16; 95% CI, 1.70–2.72), New York Heart Association functional class III/IV (HR, 1.67; 95% CI, 1.32–2.10), atrial fibrillation (HR, 1.40; 95% CI, 1.10–1.78), and older age (HR, 1.02; 95% CI, 1.01–1.02 per year increase) at enrollment. Postprimary education (HR, 0.67; 95% CI, 0.54–0.85) and female sex (HR, 0.65; 95% CI, 0.52–0.80) were associated with lower risk of death. Two hundred and four (6.9%) patients had new congestive heart failure (incidence, 38.42/1000 patient-years), 46 (1.6%) had a stroke or transient ischemic attack (8.45/1000 patient-years), 19 (0.6%) had recurrent acute rheumatic fever (3.49/1000 patient-years), and 20 (0.7%) had infective endocarditis (3.65/1000 patient-years). Previous stroke and older age were independent predictors of stroke/transient ischemic attack or systemic embolism. Patients from low- and lower-middle–income countries had significantly higher age- and sex-adjusted mortality than patients from upper-middle–income countries. Valve surgery was significantly more common in upper-middle–income than in lower-middle– or low-income countries. Conclusions: Patients with clinical rheumatic heart disease have high mortality and morbidity despite being young; those from low- and lower-middle–income countries had a poorer prognosis associated with advanced disease and low education. Programs focused on early detection and the treatment of clinical rheumatic heart disease are required to improve outcomes.

Human immunodeficiency virus (HIV) related heart disease: a review.

SummaryRecent advances in the knowledge of human immunodeficiency virus (HIV) replication and transmission as well as the emergence of effective antiretroviral therapies are leading to longer survival times for HIV- infected individuals. As a result, organ-related manifestations of late-stage HIV infection, including HIV-related heart diseases have emerged. It is now clear that cardiac involvement in HIV seropositive patients is relatively common and is associated with increased morbidity and mortality. Cardiac involvement in HIV infection is multifactorial. The epidemiology has changed dramatically since the introduction of highly active antiretroviral therapy (HAART), but studies carried out before the introduction of HAART remain relevant because of limited access to this treatment in many areas of the world. A variety of cardiac lesions have been reported in HIV infection and AIDS, including pericardial disease with effusion and tamponade, nonspecific or infectious myocarditis, dilated cardiomyopathy with global left ventricular dysfunction, endocardial valvular disease due to marantic or infective endocarditis, arrhythmias, pulmonary hypertension and neoplastic invasion. In the post HAART-era, coronary artery disease and dyslipidaemia, drug-related cardiotoxicity and cardiac autonomic dysfunction are becoming increasingly prevalent. In this review, we highlight the importance of cardiac complications in HIV disease and discuss measures that can be taken to improve survival.

Cardiovascular disease risk factors among HIV-infected Nigerians receiving highly active antiretroviral therapy

Background: Highly active antiretroviral therapy (HAART) has become more accessible to Human immunodeficiency virus infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) patients worldwide. There is growing concern that the metabolic complications associated with HIV and HAART may increase cardiovascular risk and lead to cardiovascular diseases. We, therefore, set out to describe the cardiovascular risk profile of HIV/AIDS patients receiving HAART at a health facility in northern part of Nigeria. Materials and Methods: This cross-sectional study was conducted at the Aminu Kano Teaching Hospital, Kano, Nigeria. Consenting patients, who had been receiving HAART, were compared with age and sex matched HAART-naive subjects. Questionnaire interview, electrocardiography, anthropometric and blood pressure measurements were conducted under standard conditions. Blood samples were obtained for the determination of plasma glucose, uric acid and lipid levels. Results: Two hundred subjects were studied, 100 were on HAART (group 1) and the other 100 (group 2) were HAART-naive. Subjects’ mean age for all the participants was 32.5 (7.6) years. The prevalence of hypertension was 17% in group 1 and 2% in group 2 (P < 0.001). Similarly, 11% and 21% of group 1 subjects were obese or had metabolic syndrome compared with 2% and 9% of group 2 patients (P < 0.05 for both). Conclusion: HAART treatment was associated with significantly higher prevalences of hypertension, obesity and metabolic syndrome.

Carotid intima media thickness as a measure of cardiovascular disease burden in nigerian africans with hypertension and diabetes mellitus.

As part of a larger study of cardiovascular risk factors in nonhypertensive type 2 diabetes patients, we subjected a cohort of diabetics to B mode ultrasonography of the carotid artery to measure the intima media thickness (IMT) and compared it with values in hypertensives and apparently normal controls matched reasonably for gender and age. All groups were comparable in terms of age and gender representation. The mean (SD) of carotid IMT right and left was 0.94 mm (0.12), 0.94 mm (0.16); 0.93 mm (0.21), 0.93 mm (0.15); 0.91 mm (0.17), 0.91 mm (0.13) for diabetic, hypertensive, and normal groups, respectively. There was a nonsignificant tendency to raised IMT for the disease groups from the normal ones. Diabetic and hypertensive Nigerians are equally burdened by cardiovascular disease risk factors. Apparently normal subjects have a reasonable degree of burden suggesting the need to evaluate them for other traditional and emerging risk factors.

Prevalence of dyslipidemia among human immunodeficiency virus infected Nigerians

BACKGROUND Dyslipidemia is a significant risk factor for premature cardiovascular disease. People infected with human immunodeficiency virus (HIV) have been shown to develop alterations in body composition, lipid and glucose metabolism, which predisposes them to cardiovascular disease. Human immunodeficiency virus (HIV) infection and its therapies may contribute to these changes. These metabolic changes in addition to the other traditional risk factors may contribute to the excess cardiovascular disease (CVD) morbidity and mortality observed in HIV-infected individuals. We, therefore set out to describe the prevalence of dyslipidemia among HIV infected Nigerians. MATERIALS AND METHODS This is a cross sectional study, was conducted in HIV specialty clinic of Aminu Kano Teaching Hospital (AKTH) between May and August 2009. HIV infected patients were recruited. Half of them were on HAART for 6 months and above while the other half were HAART naïve. Patients who satisfied inclusion criteria were recruited consecutively until the required sample size was obtained. Data were collected using the pre-tested interviewer administered questionnaire. Socio-demographic information, anthropometric measurements and blood pressure were obtained from the subjects in a standardized manner. Venous samples were collected for necessary investigations and analyzed at the hospital central laboratory. RESULTS Two hundred subjects were studied, the mean age for all the participants was 32.5 ± 7.55 years. The age ranged from 20 to 50 years, 64% of the respondents (128) were aged between 20 and 34 years. Forty three (21.5%) of them were above the age of 40 years. Fifty percent were on HAART and the other 50% were HAART naïve. The duration of HAART treatment ranged from 6-84 months. The mean CD4 cell counts was higher for subjects on HAART compared to HAART naive 376.33±215.66 and 261.09 ±195.64, respectively (P < 0.001). High TC (31% vs. 7%, P ≤ 0.001), low HDL-C (61% vs. 76%, P = 0.022), high LDL (36% vs. 26%, P = 0.126), high TG (19% vs. 13%, P = 0.247). CONCLUSION HIV infected patients on HAART demonstrated higher prevalence of high TC while HAART naïve subject showed higher prevalence of low HDL.

Statin Related Memory Dysfunction in a Nigerian Woman: A Case Report

Statins are useful in the treatment of dyslipidemia commonly associated with hypertension and diabetes mellitus. They are not devoid of side effects chief of which are musculo-skeletal.Memory impairment as a side effect is not common; and has not been reported in Nigeria to authors knowledge. This case report is on a woman who with Simvastatin developed memory deficits which adversely affected activities of daily living. Clinicians are enjoined to be on the alert for this, and should respond appropriately when it arises.

Plasma lipid profile in Nigerians with high - normal blood pressure

BackgroundHigh blood pressure levels have been associated with elevated atherogenic blood lipid fraction, but epidemiological surveys often give inconsistent results across population sub-groups. To determine the extent to which there are differences in lipid profile based on blood pressure levels, we assessed lipid profile of subjects with high-normal blood pressure and compared with those of hypertensives and optimally normal blood pressure.MethodsThe study was a cross–sectional comparative study conducted at Aminu Kano Teaching Hospital, Kano, Nigeria. Fasting lipid levels were examined among randomly selected patients with optimally normal blood pressure (group 1), high – normal blood pressure (group 2) and those with hypertension (group 3). Optimal blood pressure was defined as systolic blood pressure (SBP) of < 120 mmHg/or diastolic blood pressure (DBP) of < 80 mmHg; and high- normal blood pressure as SBP of 130 – 139 mmHg and/or DBP of 85 – 89 mmHg.ResultsA total of 300 subjects were studied, 100 in each group. The mean age of subjects in group 1 was 27.32 ± 8.20 years and 60% were female, while that of group 2 was 34.04 ± 6.25 years, and 53% were female, and that for group 3 was 52.81 ± 13.3 years and 56% were female. The mean total cholesterol (TC) for subjects in group1 (3.96 ± 0.40 mmol/L) was significantly lower than levels in group2 (4.55 ± 1.01 mmol/L); P = <0.001. Subjects in group 3 (5.20 ± 1.88 mmol/L), however had statistically significant higher mean TC when compared with group 2; (P = 0.03). The difference between the groups for low density lipoprotein cholesterol (LDL-C) and triglycerides (TG) followed the same pattern as that of TC, with statistically significant increasing trend across the blood pressure categories. Levels of high density lipoprotein cholesterol (HDL-C) were however similar across the three groups (group 2 versus group 1; P = 0.49, group 2 versus group 3; P = 0.9). Increased TC (>5.2 mmol/L) was absent in group1, but found among 11% of group2 subjects and 40% of those in group 3 (P-value for trend <0.001). Mean fasting plasma glucose (FPG) was 3.8 ± 0.4 mmol/L, 4.7 ± 1.1 mmol/L, 5.1 ± 1.9 mmol/L and for subjects in groups 1, 2 and 3 respectively (p > 0.05 for groups 2 Vs 1 and p <0.001 for groups 2 Vs 3). The differences in mean body mass index (BMI) between the groups followed a similar trend as that of FPG. Multivariate logistic regression analysis showed that FPG, TG and BMI were the strongest predictors of prehypertension [odds ratio (OR) 10.14, 95% CI (confidence interval) 3.63 – 28.33, P = 0.000; OR 5.75, 95% CI 2.20 – 15.05, P = 0.000; and OR 2.03, 95% CI 1.57 – 2.62, P = 0.000 respectively].ConclusionThe study has shown a significant increase in plasma TC, LDL-C and TG values as blood pressure levels increased from optimally normal, across high-normal to hypertensive levels. There was a similar trend for FPG and BMI, demonstrating the central role that blood pressure plays in these metabolic disorders in Nigerians. These findings are relevant in terms of both prevention and treatment of cardiovascular morbidities and mortality.

Twelve Month Follow-Up Audit of Nigerian Hypertensives on Back Titration

Introduction: An audit of a hypertension service in Jos, Nigeria revealed the possibility of back titration of antihypertensive therapy without untoward effect. The impact was reduction of disease economic burden. Consequently a deliberate policy of back- titration was adopted in those who have remained well controlled for >12 months. Objective: To see how low dosages could go without compromising control. Methods: All consenting hypertensive clients in this specialist hypertension clinic who had been controlled for 12 months or longer on regular follow-up(between July and September 2011); with no heart failure, renal failure, stroke or myocardial infarction (<6 months) were enrolled. Drugs were sequentially back-titrated starting with 1 drug in those on multiple drugs. Follow up continued in the usual manner, and if controlled by the next visit a further dose lowering was advised until loss of control when dose was promptly returned to the lowest maintaining control. Results: There were 41 patients initially. 2 did not follow up after the first back-titration visit leaving 39 as the subject of this analysis; 14 of whom were males. Their ages ranged from 40 to 91 years and they had been consistently controlled (BP <140/90 mmHg) for between 12 to 95 months. 18 remained normal at various stages of back-titration; in 5 (3F, 2M) all drugs had been completely withdrawn. In 21, control was lost in the course of backtitration and promptly recovered by returning to previous dose that controlled BP. Those who were successfully back-titrated to no drug were mostly on one drug at low doses. Conclusion: After a minimum of 12 months of sustained BP control, it is possible to back-titrate drug dosages in about 50% of this hypertensive cohort, a quarter of whom went completely without drugs for 1 year. The exact mechanism is unknown, but the benefit is in the psychological relief of lower pill burden and reduced cost of treatment. This observation should be extended to other cohorts to prove its applicability; advisedly only under expert care.

OS 37-02 HYPERTENSION IN HIV-INFECTED ADULTS IN NORTH-CENTRAL NIGERIA: PREVALENCE, ASSOCIATED RISK FACTORS AND ASSESSMENT OF RISK USING THE FRAMINGHAM RISK SCORE.

Objective: To evaluate the prevalence of Hypertension and associated risk factors in HIV+ adults and assessment of these risks using the Framingham risk score ‘FRS’. Design and Method: A cross-sectional analytical study. One hundred and fifty consecutive HIV+ adults presenting at the HIV clinic of Jos University Teaching Hospital (90 on HAART) with 50 HIV- as controls were recruited. Relevant history, physical examination (including blood pressure measured according to standard guidelines), laboratory specimen (fasting plasma sugar and lipids, CD4 count and viral load) and electrocardiogram were obtained from the participants. The prevalence of hypertension and associated risk factors was determined and the FRS for each participant was calculated and interpreted to assess cardiovascular risk. Data was analyzed using Epi info version 7 statistical software; p value < 0.05 was considered significant. Results: There were 94 females and 30 females among the HIV+ and HIV- respectively. The mean ages of HIV+ and HIV- were 41 ± 7 and 40 ± 8 years respectively (p = 0.77). The prevalence of hypertension in the HIV+ and HIV- was 46.0% and 10.0% respectively, p < 0.01. Among the HIV+, 123 (82%) had at least 1 risk factor while 37 (25%) had at least 4 compared to 31 (62%) and 0 (0%) respectively in the HIV-, p < 0.01. The use of HAART was associated with higher prevalence of hypertension, dyslipidaemia, diabetes mellitus and obesity among the HIV+ (Data not shown). The mean FRS of those on HAART (4.8 ± 0.6) and those not on HAART (3.3 ± 0.6) were significantly higher than that of the controls (2.5 ± 1.0); p = 0.04. Furthermore, those on HAART had significantly higher mean FRS compared to those not on HAART, p < 0.01. The use of protease inhibitor based regimen predisposed to higher mean FRS 7.9 ± 2.0 versus 3.2 ± 0.7, p < 0.01. Conclusions: Hypertension and associated risk factors are common in HIV+ persons. Early diagnosis with prompt treatment will significantly reduce morbidity and mortality in these patients.