Khawar Kazmi

Prevalence, Awareness, Treatment, and Control of Hypertension in Rural and Urban Communities in High-, Middle-, and Low-Income Countries

IMPORTANCE Hypertension is the most important preventable cause of morbidity and mortality globally, yet there are relatively few data collected using standardized methods. OBJECTIVE To examine hypertension prevalence, awareness, treatment, and control in participants at baseline in the Prospective Urban Rural Epidemiology (PURE) study. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of 153,996 adults (complete data for this analysis on 142,042) aged 35 to 70 years, recruited between January 2003 and December 2009. Participants were from 628 communities in 3 high-income countries (HIC), 10 upper-middle-income and low-middle-income countries (UMIC and LMIC), and 4 low-income countries (LIC). MAIN OUTCOMES AND MEASURES Hypertension was defined as individuals with self-reported treated hypertension or with an average of 2 blood pressure measurements of at least 140/90 mm Hg using an automated digital device. Awareness was based on self-reports, treatment was based on the regular use of blood pressure-lowering medications, and control was defined as individuals with blood pressure lower than 140/90 mm Hg. RESULTS Among the 142,042 participants, 57,840 (40.8%; 95% CI, 40.5%-41.0%) had hypertension and 26,877 (46.5%; 95% CI, 46.1%-46.9%) were aware of the diagnosis. Of those who were aware of the diagnosis, the majority (23,510 [87.5%; 95% CI, 87.1%-87.9%] of those who were aware) were receiving pharmacological treatments, but only a minority of those receiving treatment were controlled (7634 [32.5%; 95% CI, 31.9%-33.1%]). Overall, 30.8%, 95% CI, 30.2%-31.4% of treated patients were taking 2 or more types of blood pressure-lowering medications. The percentages aware (49.0% [95% CI, 47.8%-50.3%] in HICs, 52.5% [95% CI, 51.8%-53.2%] in UMICs, 43.6% [95% CI, 42.9%-44.2%] in LMICs, and 40.8% [95% CI, 39.9%-41.8%] in LICs) and treated (46.7% [95% CI, 45.5%-47.9%] in HICs, 48.3%, [95% CI, 47.6%-49.1%] in UMICs, 36.9%, [95% CI, 36.3%-37.6%] in LMICs, and 31.7% [95% CI, 30.8%-32.6%] in LICs) were lower in LICs compared with all other countries for awareness (P <.001) and treatment (P <.001). Awareness, treatment, and control of hypertension were higher in urban communities compared with rural ones in LICs (urban vs rural, P <.001) and LMICs (urban vs rural, P <.001), but similar for other countries. Low education was associated with lower rates of awareness, treatment, and control in LICs, but not in other countries. CONCLUSIONS AND RELEVANCE Among a multinational study population, 46.5% of participants with hypertension were aware of the diagnosis, with blood pressure control among 32.5% of those being treated. These findings suggest substantial room for improvement in hypertension diagnosis and treatment.

Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data

BACKGROUND WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability. METHODS We analysed information about availability and costs of cardiovascular disease medicines (aspirin, β blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry. FINDINGS Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55). INTERPRETATION Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHOs targets of 50% use of key medicines by 2025. FUNDING Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

Education and risk for acute myocardial infarction in 52 high, middle and low income countries. INTERHEART case-control study

Objective: To determine the effect of education and other measures of socioeconomic status (SES) on risk of acute myocardial infarction (AMI) in patients and controls from countries with diverse economic circumstances (high, middle, and low income countries). Design: Case-control study. Setting: 52 countries from all inhabited regions of the world. Participants: 12242 cases and 14622 controls. Main outcome measures: First non-fatal AMI. Results: SES was measured using education, family income, possessions in the household and occupation. Low levels of education (⩽8 years) were more common in cases compared to controls (45.0% and 38.1%; p<0.0001). The odds ratio (OR) for low education adjusted for age, sex and region was 1.56 (95% confidence interval 1.47 to 1.66). After further adjustment for psychosocial, lifestyle, other factors and mutually for other socioeconomic factors, the OR associated with education ⩽8 years was 1.31 (1.20 to 1.44) (p<0.0001). Modifiable lifestyle factors (smoking, exercise, consumption of vegetables and fruits, alcohol and abdominal obesity) explained about half of the socioeconomic gradient. Family income, numbers of possessions and non-professional occupation were only weakly or not at all independently related to AMI. In high-income countries (World Bank Classification), the risk factor adjusted OR associated with low education was 1.61 (1.33 to 1.94), whereas it was substantially lower in low-income and middle-income countries: 1.25 (1.14 to 1.37) (p for interaction 0.045). Conclusion: Of the SES measures we studied, low education was the marker most consistently associated with increased risk for AMI globally, most markedly in high-income countries.

Glucose levels compared with diabetes history in the risk assessment of patients with acute myocardial infarction

BACKGROUND Both a history of diabetes mellitus and elevated inhospital glucose levels predict death after acute myocardial infarction (AMI). However, only diabetes history (and not glucose levels) is routinely considered in AMI risk assessment. METHODS We conducted a post hoc analysis of 2 randomized controlled trials of AMI with ST-segment elevation to compare the prognostic value of inhospital glucose levels with diabetes history in 30,536 subjects. Average inhospital glucose (mean of glucose levels at admission, 6 hours, and 24 hours), diabetes history, and death at 30 days (occurring in 2,808 subjects) were documented. RESULTS Average glucose predicted 30-day death (OR 1.10 per 1-mmol/L [18-mg/dL] increase, 95% CI 1.09-1.11, P < .0001); this was unchanged after adjusting for diabetes history. In contrast, diabetes history alone predicted 30-day death (OR 1.63, 95% CI 1.48-1.78, P < .0001), but not after adjusting for average glucose (OR 0.98, 95% CI 0.88-1.09, P = .72). The C-indices (areas under the receiver operating characteristic curves) for 30-day death were 0.54 for diabetes history alone, 0.64 for average glucose alone, and 0.64 for glucose plus diabetes. Higher glucose levels predicted death in patients with and without diabetes history, but this relationship was more steep in nondiabetic subjects such that their rate of 30-day death (13.2%) matched that of diabetic patients (13.7%) when average glucose was > or =144 mg/dL (8 mmol/L) (P = .55 after multivariable adjustment). CONCLUSIONS Although diabetes history is routinely considered in the risk stratification of AMI patients, inhospital glucose levels are a much stronger predictor of death and should be incorporated in their risk assessment. Patients with AMI with inhospital glucose > or =144 mg/dL have a very high risk of death regardless of diabetes history.

Association of Household Wealth Index, Educational Status, and Social Capital with Hypertension Awareness, Treatment, and Control in South Asia.

OBJECTIVE Hypertension control rates are low in South Asia. To determine association of measures of socioeconomic status (wealth, education, and social capital) with hypertension awareness, treatment, and control among urban and rural subjects in these countries we performed the present study. METHODS We enrolled 33,423 subjects aged 35‐70 years (women 56%, rural 53%, low‐education status 51%, low household wealth 25%, low‐social capital 33%) in 150 communities in India, Pakistan, and Bangladesh during 2003‐2009. Prevalence of hypertension and its awareness, treatment, and control status and their association with wealth, education, and social capital were determined. RESULTS Age‐, sex‐, and location‐adjusted prevalence of hypertension in men was 31.5% (23.9‐40.2%) and women was 32.6% (24.9‐41.5%) with variations in prevalence across study sites (urban 30‐56%, rural 11‐43%). Prevalence was significantly greater in urban locations, older subjects, and participants with more wealth, greater education, and lower social capital index. Hypertension awareness was in 40.4% (urban 45.9, rural 32.5), treatment in 31.9% (urban 37.6, rural 23.6), and control in 12.9% (urban 15.4, rural 9.3). Control was lower in men and younger subjects. Hypertension awareness, treatment, and control were significantly lower, respectively, in lowest vs. highest wealth index tertile (26.2 vs. 50.6%, 16.9 vs. 44.0%, and 6.9 vs. 17.3%, P < 0.001) and lowest vs. highest educational status tertile (31.2 vs. 48.4%, 21.8 vs. 42.1%, and 7.8 vs. 19.2%, P < 0.001) while insignificant differences were observed in lowest vs. highest social capital index (38.2 vs. 36.1%, 35.1 vs. 27.8%, and 12.5 vs. 9.1%). CONCLUSIONS This study shows low hypertension awareness, treatment, and control in South Asia. Lower wealth and educational status are important in low hypertension awareness, treatment, and control.

N-acetyl-beta-D-glucosaminidase in acute myocardial infarction.

The objective of the study was to investigate whether the lysosomal enzyme, N-Acetyl-β-D-glucosaminidase (NAG) activity is increased in plasma of patients with acute myocardial infarction (AMI) and to determine if there is any association between plasma levels of NAG and severity of myocardial infarction (MI). NAG activity in plasma was monitored in 69 patients with AMI and 135 normal healthy subjects using a spectrofluorimetric method. A modified Aldrich ST elevation score was used to gauge the severity of MI in terms of size of the infarct. Plasma NAG levels in AMI patients and normal healthy subjects were found to be 10.92±7.5 U/l and 6.8±2.2 U/l, respectively. These two mean value when compared by Students t-test were significantly different P = 0.0001. No statistically significant differences in NAG activity were observed in patients in terms of gender, age, location of infarct, time from onset of chest pain to blood sampling in the hospital and size of the infarct.

Spontaneous coronary artery dissection: a rare cause of acute coronary syndrome

We present a case of a 71-year-old man, with a history of hypertension and dyslipidaemia, who presented with typical cardiac chest pain and palpitations of 2 h duration. The examination revealed irregular pulse of 138 bpm, blood pressure 115/75 mm Hg, variable first and normal second heart sounds. The lungs were clear to auscultation. The ECG showed atrial fibrillation with a rapid ventricular rate. His heart rate was controlled with β blockers and the acute coronary syndrome treatment protocol was initiated. His baseline blood reports were within normal limits and two serial troponin I tests were negative. Coronary angiogram showed dissection in the left coronary system extending into the branch vessels and 30–40% stenosis in the right coronary artery. The patient underwent coronary artery bypass graft as an emergent case. He suffered a mild stroke postsurgery with complete functional recovery. He is being followed up in the clinic and has performed well.

Myocardial infarction during factor IX infusion in hemophilia B: case report and review of the literature

There are very few reports in the literature of acute myocardial infarction (MI) occurring during infusion of factor concentrates, particularly cryosupernatant in patients with hemophilia B. We describe a case of a 61-year-old man with hemophilia B who suffered an acute MI while receiving cryosupernatant infusion as factor replacement therapy. Cryosupernatant is rich in coagulation factor IX and contains low levels of fibrinogen and von Willebrand’s factor. Factor IX and other factors present in cryosupernatant can possibly become activated during the manufacturing process causing thrombus formation in patients who are prone to it.

N-acetyl-beta-D-glucosaminidase--a marker of reperfusion and a prognostic indicator in patients with acute myocardial infarction.

Objective — N-acetyl--D-glucosaminidase (NAG) is a lysosomal enzyme of which the activity in plasma is increased in a number of conditions including myocardial infarction. Plasma levels of cardiac proteins, such as myoglobin, troponin and creatine kinase, have been used as markers of myocardial reperfusion as well as for the prognosis of the disease.The aim of this study is to investigate whether NAG could be used as an additional biochemical marker to predict myocardial reperfusion and to find out if its release following thrombolysis has a prognostic value as well. Method — Streptokinase (SK) in a dose of 1.5 million units was administered intravenously to 75 patients with acute myocardial infarction (AMI) and the response to SK was assessed over a period of 90 minutes. Plasma NAG activity was monitored before (0 min) and 90 min after SK treatment. Results — The mean NAG activity values were found to be 8.6 ± 4.8 U/l and 10.95 ± 7.3 U/l, respectively, and when compared using paired samples t-test revealed a significant increase (p = 0.0001) following thrombolytic therapy. The increase appears perfusion related as rabbits injected with SK failed to show any increase in plasma NAG activity.There was an association between plasma NAG activity and clinical response to SK treatment (p = 0.045). A follow-up of 66 patients over a period of 18 months, revealed increased survival in AMI patients having significantly more activity/release of plasma NAG after thrombolytic treatment (p = 0.001). Conclusion — NAG appears to be another potential biochemical marker of reperfusion. Moreover, NAG release profile during thrombolysis could be of value in predicting prognosis of the disease.

Admission troponin T as a prognostic marker and it relationship to streptokinase treatment patients with acute myocardial infarction.

The relationship between the admission troponin T (TnT) level and the response to streptokinase (SK) was examined in 76 patients with acute myocardial infarction (AMI). Of 27 TnT positive patients, 10 (37%) showed a response to SK as suggested by a non-invasive criterion for reperfusion, while 24 (49%) were ‘responders’ among 49 TnT negative patients. There appeared to be a trend towards a better response to SK in the TnT negative group but the difference lacked statistical power due to the small sample size. The mean time-interval between the onset of symptoms and thrombolytic treatment among TnT positive ‘non-responders’ was significantly (P <0.005) higher than the TnT negative ‘non-responders’ (5.23 ±3.42 h versus 2.38 ± 1.37 h). An 18 month follow up on 61 patients revealed a higher mortality (33%) among TnT positive patients than TnT negative patients (10%). Mortality among TnT positive ‘non-responders’ was significantly higher (P=0.0494) than mortality among TnT-negative ‘non-responders’ (43% versus 9%), indicating that TnT positive patients, non-responsive to SK were at a greater risk of cardiac death. The data suggest that the admission TnT level can be of value in risk stratification of patients with AMI.