Age and healthy lifestyle behavior's disparities and similarities on knowledge of myocardial infarction symptoms and risk factors among public and outpatients in a resource-limited setting, cross-sectional study in greater Gaborone, Botswana.

OBJECTIVES: In this cross-sectional study from Botswana, we investigated knowledge of myocardial infarction (MI) symptoms and risk factors among the general public and outpatients with MI risk factors based on age and lifestyle behaviors, in addition to assessing associations with sociodemographic and MI risk factors. METHOD: Open-ended questionnaires about 8 MI symptoms and 10 risk factors, were administered by research assistants to a representative selection of outpatients (n = 525) and the public (n = 2248). Weight and height were measured in all participants and BMI was calculated. Knowledge scores were compared between the two groups. We examined whether sociodemographic and MI risk factors had impact on the scores. Analyses were further adjusted for lifestyle behavior (smoking status, dietary status and physical activities). RESULTS: The valid response rate was 97.9% comprising 97.8% for the public (n = 2199) and 98.1% for outpatients (n = 515). Public respondents (35.2 ± 12.3 years) were younger than outpatients (38.5 ± 12.6 years). The public comprised 56.9% females while outpatients 54.6%. In general, outpatients had higher knowledge of MI symptoms than the public, with mean scores ± SD of 3.49 ± 2.84 vs 2.80 ± 2.54. Outpatients also had higher knowledge score of MI risk factors than the public, with mean scores, 5.33 ± 3.22 vs 3.82 ± 3.07. For MI symptoms, outpatients were more aware than the public for chest pains among all ages, for arm pain/ numbness, neck/ jaw pain radiating to/ from chest, and feeling sick or looking pallor on the skin among those aged 35-49 years. Among both the public and outpatients, lower knowledge of both MI symptoms and risk factors was associated with primary education, not residing/working together, history of hypertension, no history of heart disease/stroke, and obesity. There were similarities and disparities on MI knowledge among respondents with various numbers of healthy lifestyle behaviours. CONCLUSION: Results call for urgent educational campaigns on awareness and knowledge of MI and using strategies based on age and lifestyle behavior.

Public and outpatients' awareness of calling emergency medical services immediately by acute stroke in an upper middle-income country: a cross-sectional questionnaire study in greater Gaborone, Botswana.

OBJECTIVES: In this cross-sectional study from Botswana, we investigated awareness of calling emergency medical services (EMS) and seeking immediate medical assistance by acute stroke among stroke risk outpatients and public. METHOD: Closed-ended questionnaires on awareness of calling EMS and seeking immediate medical assistance by acute stroke, were administered by research assistants to a representative selection of outpatients and public. RESULTS: The response rate was 96.0% (93.0% for public (2013) and 96.6% for outpatients (795)). Public respondents had mean age of 36.1 ± 14.5 years (age range 18-90 years) and 54.5% were females, while outpatients had mean age of 37.4 ± 12.7 years (age range 18-80 years) and 58.1% were females. Awareness of calling EMS (78.3%), and of seeking immediate medical assistance (93.1%) by stroke attack was adequate. For calling EMS by acute stroke, outpatients had higher awareness than the public (p < 0.05) among those with unhealthy diet (90.9% vs 71.1%), family history of both stroke and heart diseases (90.7% vs 61.2%), no history of psychiatric diseases (93.2% vs 76.0%) and sedentary lifestyle (87.5% vs 74.8%). Predictors of low awareness of both calling EMS and seeking immediate medical assistance were no medical insurance, residing/working together, history of psychiatric diseases, and normal weight. Male gender, ≥50 years age, primary education, family history of both stroke and heart diseases, current smoking, no history of HIV/AIDS, and light physical activity were predictors of low awareness of need for calling EMS. CONCLUSION: Results call for educational campaigns on awareness of calling EMS and seeking immediate medical assistance among those with high risk factor levels.

Healthcare professionals' knowledge of modifiable stroke risk factors: A cross-sectional questionnaire survey in greater Gaborone, Botswana.

BACKGROUND: Stroke remains the second leading cause of deaths and disability globally, with highest mortality in Africa (low- and middle-income countries). It is crucial for healthcare professionals to have sufficient stroke risk factors' knowledge in order to reduce the stroke burden. AIMS: We investigated healthcare professionals' knowledge of modifiable stroke risk factors, and identified demographic factors influencing this knowledge. METHODS: In this cross-sectional survey study from Botswana (upper middle-income country), structured questionnaires reflecting recent stroke guidelines were administered to a representative selection of healthcare workers in greater Gaborone. The response rate was 61.4%, comprising 84 doctors, 227 nurses and 33 paramedics. Categorical data were described using percentages and Chi-square tests. Associations between stroke risk factors' knowledge and demographic factors were analyzed with one-way ANOVA using SPSS 25 statistical software. RESULTS: Awareness rate of individual stroke risk factors was highest for hypertension (96.5%), followed by obesity (93.3%), smoking (91.9%), elevated total cholesterol (91.0%), physical inactivity (83.4%), elevated low-density lipoprotein (LDL) cholesterol (81.1%), excessive alcohol drinking (77.0%), and lowest for diabetes (73.3%). For all-8 risk factors, doctors had the highest knowledge, followed by nurses and paramedics lowest (7.11 vs 6.85 vs 6.06, P < 0.05). CONCLUSION: In Botswana, specific healthcare professionals' subgroups need to be targeted for continuing education on stroke risk factors for improving stroke prevention and reducing stroke-related disability and mortality.

Brain amyloid and vascular risk are related to distinct white matter hyperintensity patterns.

White matter hyperintensities (WMHs) are associated with vascular risk and Alzheimer's disease. In this study, we examined relations between WMH load and distribution, amyloid pathology and vascular risk in 339 controls and cases with either subjective (SCD) or mild cognitive impairment (MCI). Regional deep (DWMH) and periventricular (PWMH) WMH loads were determined using an automated algorithm. We stratified on Aß1-42 pathology (Aß+/-) and analyzed group differences, as well as associations with Framingham Risk Score for cardiovascular disease (FRS-CVD) and age. Occipital PWMH (p = 0.001) and occipital DWMH (p = 0.003) loads were increased in SCD-Aß+ compared with Aß- controls. In MCI-Aß+ compared with Aß- controls, there were differences in global WMH (p = 0.003), as well as occipital DWMH (p = 0.001) and temporal DWMH (p = 0.002) loads. FRS-CVD was associated with frontal PWMHs (p = 0.003) and frontal DWMHs (p = 0.005), after adjusting for age. There were associations between global and all regional WMH loads and age. In summary, posterior WMH loads were increased in SCD-Aß+ and MCI-Aß+ cases, whereas frontal WMHs were associated with vascular risk. The differences in WMH topography support the use of regional WMH load as an early-stage marker of etiology.

Inflammatory markers and extent and progression of early atherosclerosis: Meta-analysis of individual-participant-data from 20 prospective studies of the PROG-IMT collaboration.

BACKGROUND: Large-scale epidemiological evidence on the role of inflammation in early atherosclerosis, assessed by carotid ultrasound, is lacking. We aimed to quantify cross-sectional and longitudinal associations of inflammatory markers with common-carotid-artery intima-media thickness (CCA-IMT) in the general population. METHODS: Information on high-sensitivity C-reactive protein, fibrinogen, leucocyte count and CCA-IMT was available in 20 prospective cohort studies of the PROG-IMT collaboration involving 49,097 participants free of pre-existing cardiovascular disease. Estimates of associations were calculated within each study and then combined using random-effects meta-analyses. RESULTS: Mean baseline CCA-IMT amounted to 0.74 mm (SD = 0.18) and mean CCA-IMT progression over a mean of 3.9 years to 0.011 mm/year (SD = 0.039). Cross-sectional analyses showed positive linear associations between inflammatory markers and baseline CCA-IMT. After adjustment for traditional cardiovascular risk factors, mean differences in baseline CCA-IMT per one-SD higher inflammatory marker were: 0.0082 mm for high-sensitivity C-reactive protein (p < 0.001); 0.0072 mm for fibrinogen (p < 0.001); and 0.0025 mm for leucocyte count (p = 0.033). 'Inflammatory load', defined as the number of elevated inflammatory markers (i.e. in upper two quintiles), showed a positive linear association with baseline CCA-IMT (p < 0.001). Longitudinal associations of baseline inflammatory markers and changes therein with CCA-IMT progression were null or at most weak. Participants with the highest 'inflammatory load' had a greater CCA-IMT progression (p = 0.015). CONCLUSION: Inflammation was independently associated with CCA-IMT cross-sectionally. The lack of clear associations with CCA-IMT progression may be explained by imprecision in its assessment within a limited time period. Our findings for 'inflammatory load' suggest important combined effects of the three inflammatory markers on early atherosclerosis.

Full Implementation of Screening for Nutritional Risk and Dysphagia in an Acute Stroke Unit: A Clinical Audit.

BACKGROUND AND PURPOSE: In patients with acute stroke, undernutrition and aspiration pneumonia are associated with increased mortality and length of hospital stay. Formal screening for nutritional risk and dysphagia helps to ensure optimal nutritional management in all patients with stroke and to reduce the risk of aspiration in patients with dysphagia. We developed a national guideline for nutritional and dysphagia screening in acute stroke, which was introduced in our stroke unit on June 1, 2012. The primary objective was to audit adherence to the guideline and to achieve full implementation. Second, we assessed the prevalence of nutritional risk and dysphagia. METHODS: We performed a chart review to assess performance of screening for nutritional risk and dysphagia in all patients with stroke hospitalized for ≥48 hours between June 1, 2012, and May 31, 2013. Next we applied a "clinical microsystems approach" with rapid improvement cycles and audits over a 6-month period to achieve full implementation. RESULTS: The chart review showed that nutritional risk screening was performed in 65% and swallow testing in 91% of eligible patients (n = 185). Proactive implementation resulted in >95% patients screened (n = 79). The overall prevalence of nutritional risk was 29%, and 23% of the patients failed the initial swallow test. CONCLUSIONS: Proactive implementation is required to obtain high screening rates for nutritional risk and swallowing difficulties using validated screening tools. The proportion of patients at nutritional risk and the prevalence of dysphagia at initial swallow test were in the lower range of previous reports.

Creatine kinase as predictor of blood pressure and hypertension. Is it all about body mass index? A follow-up study of 250 patients.

The correlation between creatine kinase (CK) and blood pressure (BP) was examined prospectively in 120 patients with persistent high CK and 130 individuals with normal CK. Hypertension was defined as systolic BP (SBP) ≥ 140 mm Hg or diastolic BP (DBP) ≥ 90 mm Hg or current use of antihypertensive medication. Baseline CK was weakly correlated with SBP (r = 0.11, P = .07) and DBP (r = 0.16, P = .01) at follow-up. Persons with persistent high CK had higher SBP (140.8 mm Hg vs 138.2 mm Hg) and DBP (83.2 mm Hg vs 81.0 mm Hg, P = .06) values and were more likely to have hypertension (66.7% vs 55.5%, P = .05) than individuals with normal CK. In age- and sex-adjusted analysis, a 1-unit change in logCK was associated with a 4.9-mm Hg higher SBP, a 3.3-mm Hg higher DBP, and a 2.2-higher odds for having hypertension at follow-up (P = .1, .07, and .06, respectively). When including body mass index (BMI) to the model, BMI was a strong and independent predictor for SBP, DBP, and hypertension at follow-up and the CK effect on blood pressure was substantially attenuated. This study showed that the CK effect on blood pressure is clearly modified by BMI.

Clinical impact of persistent hyperCKemia in a Norwegian general population: a case-control study.

In this case-control study we assessed the clinical impact of persistent hyperCKemia in a Norwegian general population. HyperCKemia was defined according to the NORIP- references (women 35-210 U/L, men <50 years 50-400 U/L, and men ≥50 years 40-280 U/L). We compared the frequency of muscular symptoms and function, neuromuscular diseases and risk factors between 120 cases with persistent hyperCKemia and 130 age- and sex-matched controls with normal CK values, all recruited from the single-centre, population-based prospective Tromsø Study. The participants underwent a standardized interview assessing muscle symptoms, physical activity, use of statins and presence of other CK risk factors, prior to clinical neurological and neurophysiological examination. Knee extensor muscle strength (Cybex NORM dynamometer) and dominant hand grip strength (Martin Vigorimeter) was assessed. A total of 85 cases (71%) reported either muscle pain, muscle stiffness or cramps, compared to 70 controls (54%) (p=0.017) There were no differences in muscle strength between the groups. In men, weight, Body Mass Index and muscle symptoms were significantly higher in the group with persistent hyperCKemia. In women, no differences between the groups were detected. Use of statins was similar in cases and controls. We diagnosed 3 women with previously unknown myopathy, all in the group with persistent hyperCKemia. This study support that CK may be used as a marker of muscular symptoms in the general population.

Recurrence and long-term maternal health risks of hypertensive disorders of pregnancy: a population-based study.

OBJECTIVE: The purpose of this study was to investigate the recurrence risk of hypertensive disorders in subsequent pregnancies and to explore the associations among hypertensive disorders of pregnancy and maternal cardiovascular risk factor profile and the development of cardiovascular diseases later in life. STUDY DESIGN: We used population-based, cross-sectional data from the fourth survey of the Tromsø Study. RESULTS: Preeclampsia in the first pregnancy increased the risk of recurrence in later pregnancies (relative risk, 6.6; 95% confidence interval, 5.5-7.9) compared with a normotensive first pregnancy. Women with a history of preeclampsia or nonproteinuric hypertension had an unfavorable cardiovascular risk profile. Hypertension was prevalent in 25% and 28% of the women, respectively. The carotid artery intima-media thickness and total carotid plaque area were significantly larger in women with previous preeclampsia. CONCLUSION: A strong association between hypertensive disorders of pregnancy and an increased risk of atherosclerosis and cardiovascular diseases was demonstrated by the assessment of risk factors that can be potentially modified.

Variation of serum creatine kinase (CK) levels and prevalence of persistent hyperCKemia in a Norwegian normal population. The Tromsø Study.

In this cross-sectional study we assessed the prevalence of hyperCKemia, defined as persistent CK values ≥210 U/L in women, ≥400 U/L in men <50 years and ≥280 U/L in men ≥50 years (reference values according to the Nordic Reference Interval Project). Blood samples were obtained from 12,828 participants in the 6th survey of The Tromsø Study. We identified 686 (5.3%) individuals with incidentally elevated CK. After a standardized control test, 169 persons (1.3%) had persistent hyperCKemia, i.e. 69.9% normalization. Use of statins or other causes of hyperCKemia were detected in 78 individuals (46.2%), giving a prevalence of "idiopathic hyperCKemia" of 0.71%. CK variation was highest in younger men and in females between 60 and 69 years. This study has identified persistent hyperCKemia in 1.3% of the normal population, and demonstrates the importance of performing controlled CK analyses, also in those with identified risk factors.

Creatine kinase activity and blood pressure in a normal population: the Tromsø study.

OBJECTIVES: In the vast majority of cases the cause for hypertension is not known. On the basis of observations from black and multiethnic populations, it has been hypothesized that a genetically high tissue creatine kinase activity may be an independent factor responsible for primary hypertension. If the relation between creatine kinase and blood pressure is causal, it is reasonable to believe that it will be independent of ethnicity and present in different populations. In this cross-sectional study, we examined whether creatine kinase was associated with blood pressure in a large Caucasian normal population. METHODS AND RESULTS: Data on creatine kinase and blood pressure were analyzed in a random sample of 12 776 men and women (65% of those eligible), aged 30-87 years from a normal population in the municipality of Tromsø, Norway. We used linear regression to model the association between creatine kinase and blood pressure. Creatine kinase was independently associated with blood pressure. A one unit increase in log CK was associated with a 3.3 (95% CI 1.4-5.2) mmHg increase in systolic blood pressure and a 1.3 (95% CI 0.3-2.3) mmHg increase in diastolic blood pressure, after adjustment for age, sex, body mass index, s-glucose, s-creatinine, physical activity and alcohol consumption. The creatine kinase effect on blood pressure was independent of antihypertensive medication, and no difference in creatine kinase level was found between those with controlled and uncontrolled hypertension (geometric mean 101 vs. 104 IU/l, P = 0.1). CONCLUSION: Creatine kinase was associated with blood pressure in this population.

The association between inflammatory markers and carotid atherosclerosis is sex dependent: the Tromsø Study.

BACKGROUND: The presence of echolucent artery plaques is associated with increased risk of cardiovascular events as compared to echogenic plaques. Whether inflammatory markers are associated with carotid plaque morphology is questioned. METHODS: 5,341 individuals were examined with ultrasonography of the right carotid artery. Of these, 3,205 had carotid plaque(s), in whom plaque area (mm(2)) and plaque echogenicity, expressed as the computer-assisted gray scale median (GSM), were determined. White blood cell count (WBC), fibrinogen and C-reactive protein (CRP) were analyzed, as well as other cardiovascular risk factors. In multiple linear and logistic regression models, we determined the relationship between plaque area and echogenicity, and inflammatory markers. RESULTS: Women and men with carotid plaque(s) had significantly elevated levels of WBC and fibrinogen, but not CRP, as compared to subjects without plaques. All inflammatory markers were significantly associated with plaque area in men. WBC was significantly associated with plaque echogenicity in women, whereas no association was found between fibrinogen and CRP and plaque echogenicity in either gender. CONCLUSIONS: This cross-sectional study showed sex-dependent differences in associations between measures of carotid atherosclerosis and inflammatory markers. CRP did not discriminate echolucent from echogenic carotid plaques in either gender. Our data highlight the importance of sex-specific analyses in future studies.