Atherosclerotic cardiovascular disease risk among Ghanaians: A comparison of the risk assessment tools.

Objectives: Risk stratification is a cornerstone for preventing atherosclerotic cardiovascular disease (ASCVD). Ghana has yet to develop a locally derived and validated ASCVD risk model. A critical first step towards this goal is assessing how the commonly available risk models perform in the Ghanaian population. This study compares the agreement and correlation between four ASCVD risk assessment models commonly used in Ghana. Methods: The Ghana Heart Study collected data from four regions in Ghana (Ashanti, Greater Accra, Northern, and Central regions) and excluded people with a self-declared history of ASCVD. The 10-year fatal/non-fatal ASCVD risk of participants aged 40-74 was calculated using mobile-based apps for Pooled Cohort Equation (PCE), laboratory-based WHO/ISH CVD risk, laboratory-based Framingham risk (FRS), and Globorisk, categorizing them as low, intermediate, or high risk. The risk categories were compared using the Kappa statistic and Spearman correlation. Results: A total of 615 participants were included in this analysis (median age 55 [Inter quartile range 46, 64]) years with 365 (59.3 %) females. The WHO/ISH risk score categorized 504 (82.0 %), 58 (9.4 %), and 53 (8.6 %) as low-, intermediate-, and high-risk, respectively. The PCE categorized 345 (56.1 %), 181 (29.4 %), and 89 (14.5 %) as low-, intermediate- and high-risk, respectively. The Globorisk categorized 236 (38.4 %), 273 (44.4 %), and 106 (17.2 %) as low-, intermediate-, and high-risk, respectively. Significant differences in the risk categorization by region of residence and age group were noted. There was substantial agreement between the PCE vs FRS (Kappa = 0.8, 95 % CI 0.7 - 0.8), PCE vs Globorisk (Kappa = 0.6; 95 % CI 0.6 - 0.7), and FRS vs Globorisk (Kappa = 0.6; 95 % CI 0.6 - 0.7). However, there was only fair agreement between the WHO vs Globorisk (Kappa = 0.3; 95 % CI 0.3-0.4) and moderate agreement between the WHO vs PCE and WHO vs FRS. Conclusion: There are significant differences in the ASCVD risk prediction tools in the Ghanaian population, posing a threat to primary prevention. Therefore, there is a need for locally derived and validated tools.

Behavioural and nutritional risk factors for cardiovascular diseases among the Ghanaian population- a cross-sectional study.

BACKGROUND: Lifestyle behavioural risk factors have been linked to increased cardiovascular disease. Recent data have shown increased atherosclerotic cardiovascular disease (ASCVD) burden in Ghana. This study aimed to describe the behavioural and nutritional risk factors for ASCVD among Ghanaians, and how these risk factors vary by ethnicity, demography and residence. METHODS: We used data from the Ghana Heart Study, a community-based cross-sectional study that recruited participants from eight communities from four regions using a multi-stage sampling technique. Information about various lifestyle behaviours (LBs), including cigarette smoking, alcohol intake, physical inactivity, and fruit and vegetable intake, was obtained using a questionnaire. Data was analysed using IBM SPSS statistics 25. Univariate and multivariate analysis was used to test associations between demographic characteristics and various LBs. RESULTS: The participants' median (interquartile) age was 46.0 (27.0) years. Of the 1,106 participants (58% females, 80.4% urban dwellers), 8.6% reported using tobacco, 48.9% alcohol, 83.7% physically inactive, 81.4% and 84.9% inadequate fruit and vegetable intake, respectively. Age, sex, ethnicity, and religion were associated with tobacco use, whereas age, sex, educational level, marital status, ethnicity, employment status, and region of residence were associated with physical inactivity. Similarly, ethnicity, employment status, and residence region were associated with inadequate fruit and vegetable intake. Rural dwellers were more likely to be physically inactive and consume inadequate fruits and vegetables. Almost 92% had a combination of two or more LBs. The main predictors of two or more LBs for ASCVD were educational level, marital status, ethnicity, and employment status. CONCLUSION: Lifestyle risk factors for ASCVD were highly prevalent in Ghana, with significant age, sex, ethnic, and regional differences. These risky lifestyle behaviors tend to occur together and must be considered in tailoring public health education. TRIAL REGISTRATION: The study was registered at http://www.chictr.org.cn as ChiCTR1800017374.

Frequency & factors associated with elevated lipoprotein-a among Ghanaian stroke survivors.

BACKGROUND: Indigenous Africans are genetically predisposed to elevated lipoprotein-a (Lp(a)), a veritable risk factor for ischemic stroke. Recent studies have demonstrated the promising efficacy of therapeutic interventions for addressing elevated Lp(a) among patients at high risk of atherosclerotic cardiovascular events. It is important to assess the burden of elevated Lp(a) among stroke survivors of African ancestry aimed at addressing potential unmet therapeutic gaps for optimal secondary prevention. PURPOSE: To assess the frequency of elevated lipoprotein-a among Ghanaian stroke survivors and factors associated with it. METHODS: A prospective study conducted at the Neurology clinic of the Komfo Anokye Teaching Hospital among ischemic stroke survivors aged ≥18 years. Serum lipoprotein-a concentrations were measured using ELISA kits. A multivariate regression analysis was fitted to identify factors independently associated with elevated lipoprotein-a concentration > 30 mg/dl. RESULTS: Among 116 stroke survivors, 35 (30.2%) had elevated Lp(a). The adjusted odds ratio (95% CI) of factors associated with elevated Lp(a) were female sex 3.09 (1.05-9.12), p = 0.04, diabetes mellitus 3.52 (1.32-9.40), p = 0.01, urban dwelling 4.64 (1.61-13.39), p = 0.005 and total cholesterol 1.85 (1.28-2.67), p = 0.001. Whereas the LDL cholesterol significantly decreased from baseline to month 12 among a subset of participants, the Lp(a) levels significantly increased from a baseline value of 29.38 ± 15.32 mg/dl to 40.97 ± 29.72 mg/dl, p = 0.032. CONCLUSION: Approximately 1 in 3 Ghanaian ischemic stroke survivors harbor an elevated Lp(a) associated with female sex, urban residence, diabetes mellitus and raised cholesterol. This burden highlights an unmet therapeutic gap in secondary risk reduction in this resource-limited setting.

Determinants of visit-to-visit systolic blood pressure variability among Ghanaians with hypertension and diabetes mellitus.

Objective: To identify the determinants of systolic blood pressure variability (SBPV) among Ghanaians. Design: We undertook a secondary analysis of data collected in a prospective study. Setting: The study involved patients with hypertension and or diabetes receiving care in five hospitals in Ghana. Main outcome measures: We assessed determinants of SBPV among 2,785 Ghanaian patients. We calculated the standard deviation (SD) of systolic BP recordings of 3 to 10 visits per patient over 18 months as a measure of SBPV. A multivariate linear regression analysis was fitted to identify factors independently associated with risk visit-to-visit SBP standard deviation. Results: The mean SD of individual patient visit-to-visit SBP overall was 14.8± 6.3 mm Hg. Those with hypertension and diabetes had the highest SD of 15.4 ±6.2 mm Hg followed by 15.2 ±6.5 mm Hg among those with hypertension only and then 12.0 ± 5.2 mm Hg among those with diabetes only, p<0.0001. Factors independently associated with SBPV with adjusted ß coefficients (95% CI) included age: 0.06 (0.03 - 0.08) for each year rise in age, eGFR -0.03 (-0.05 - -0.02) for each ml/min rise, low monthly income of <210 Ghana cedis 1.45 (0.43-2.46), and secondary level of education -1.10 (-1.69, -0.50). Antihypertensive classes were associated with SBPV, the strongest associations being hydralazine 2.35 (0.03 - 4.68) and Methyldopa 3.08 (2.39 - 3.77). Conclusion: Several socio-demographic and clinical factors are associated with SBPV. Future studies should assess the contribution of SBPV to CVD outcomes among indigenous Africans and identify actionable targets. Funding: Funding for this study was provided by MSD, Novartis, Pfizer, Sanofi (each a Participant Company) and the Bill and Melinda Gates Foundation (collectively, the Funders) through the New Venture Fund (NVF). FSS and BO are also supported by funding from the National Heart, Lung, and Blood Institute (R01HL152188).

Undiagnosed sub-valvular aortic stenosis with an associated Ventricular Septal Defect (VSD) presenting late in a multi-parous woman.

BACKGROUND: Sub-valvular aortic stenosis is a rare disorder that has a prevalence of 6.5% of all adult congenital heart diseases. The hemodynamic changes that occur in pregnancy with the resultant increase in cardiac output may not well be tolerated by a pregnant woman with sub-valvular aortic stenosis. CASE PRESENTATION: We report the case of a 34-year-old para 7 (6 alive + 1 dead) who has been experiencing intermittent episodes of easy fatigability on moderate exertion since childhood and had survived 6 prior pregnancies. During her last pregnancy, she started experiencing chest pain, palpitations, dyspnea, orthopnea, and pre-syncope at 36 weeks and had a caesarean section at 37 weeks on account of fetal distress. The post-delivery cardiac evaluation showed severe sub-valvular Aortic stenosis and a ventricular septal defect. CONCLUSION: Sub-valvular Aortic stenosis may progress slowly in adults and may be tolerated during pregnancy. Despite the rare presentation and contraindication of pregnancy in such a patient, she extraordinarily survived the pregnancy with a healthy baby. Routine cardiovascular assessment during prenatal, ante-natal and post-natal care is highly advocated particularly so in resource-poor settings.

Lutembacher syndrome in a middle-aged woman in Ghana with an extremely large atrial septal defect.

Lutembacher syndrome (LS) is a rare heart disorder characterized by a congenital or acquired combination of the atrial septal defect (ASD) and mitral stenosis. In LS, patients may be asymptomatic for years, but early detection and treatment result in a better prognosis. In contrast, the prognosis is usually poor, with conservative treatment if the diagnosis is late and the patient develops heart failure and pulmonary hypertension. Although rheumatic heart disease (RHD) and congenital heart disease are prevalent in Ghana, cases of LS are not reported. Here, we report the case of a 45-year-old woman with rheumatic mitral valve stenosis and an exceptionally large ASD with bidirectional flow who was diagnosed with LS and treated conservatively for heart failure at a cardiology clinic in Ghana.

Prevalence of Hypertension in Ghana: Analysis of an Awareness and Screening Campaign in 2019.

Introduction: Hypertension is an important public health menace globally and in sub-Saharan Africa. The prevalence of hypertension is on the rise in low- and lower-middle-income countries (LMIC) such as Ghana. This rise led to the adoption of the May Measurement Month (MMM) initiative, a global blood pressure screening campaign. We aimed to create awareness and present the findings of the 2019 MMM screening campaign in the Ashanti region of Ghana. Methods: Ghana was 1 of 92 countries that participated in this global community-based cross-sectional study in May 2019. Participants (⩾18 years) were recruited by opportunistic sampling. The blood pressures of participants were measured 3 times and the mean of the last 2 was used for the analysis. Summary statistics were used to describe the data. Simple and multiple logistic regression models were used to determine the predictors of hypertension. Results: We screened 3080 participants with a mean age of 39.8 ± 16.8 years. The prevalence of hypertension was 27.3% among participants. Two-thirds of the hypertensives were unaware of their condition and only 49.5% of participants with a history of hypertension on medication were controlled. Predictors of hypertension in a multiple logistic regression were increasing age (OR = 1.05 (CI 1.04-1.06), P < .001) and high body mass index (OR = 1.06 (1.02-1.10), P = .005). Conclusion: The MMM initiative is highly commendable and of huge public health importance in LMICs like Ghana. Population-based health programs such as the MMM initiative is encouraged to shape appropriate public health policies to reduce the prevalence of hypertension.

Burden of hypertension in Ghana - Analysis of awareness and screening campaign in the Ashanti Region of Ghana.

OBJECTIVES: Hypertension is a major risk factor for cardiovascular mortality globally and in Ghana. May Measurement Month (MMM) is a global awareness and screening campaign initiated by the International Society of Hypertension. METHODS: Participants were recruited by opportunist sampling in the Ashanti region of Ghana. The blood pressures of participants were measured three times and the mean of the last two readings was used for the analysis. Simple and multiple logistic regression was used to determine the predictors of hypertension. RESULTS: The MMM 2018 awareness and screening campaign enrolled 5054 participants with a mean age of 39.4 ± 14.7 years. There were 2553 (50.6%) males, 987 (20.1%) of respondents had never checked their blood pressure and 676 (13.9%) had a prior history of hypertension. The prevalence of hypertension was 37.4%. We found that 589(66.8%) of 822 respondents with high blood pressure did not have a history of hypertension. Respondents with a known history of hypertension on medication were 442 (65.9%) and 219(68.0%) of 322 respondents on medication had uncontrolled hypertension. The predictors of high blood pressure in a multiple logistic regression were increasing age (OR = 1.05 CI 1.05-1.06, p < 0.001), history of alcohol intake (OR = 1.33 CI 1.04 -1.70, p = 0.02), overweight (OR = 1.4 CI 1.14-1.76, p = 0.001) and obesity (OR = 1.32, CI 1.01-1.74, p = 0.047). CONCLUSION: There is a high prevalence of hypertension in the Ashanti region in Ghana. Most participants with hypertension were not aware and the majority of those with hypertension on medications were uncontrolled. This calls for more education and screening of hypertension to decrease cardiovascular mortality.

May Measurement Month 2019: an analysis of blood pressure screening results from Ghana-Sub-Saharan Africa.

Raised blood pressure (BP) remains the biggest single risk factor contributing to the global burden of disease and to global mortality. Although a substantial number of people who have hypertension are either oblivious of it, not treated, or being managed but remain uncontrolled. May Measurement Month (MMM) is a global initiative led by the International Society of Hypertension (ISH) with the goal of increasing awareness of high BP and serving as a spur to establish screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2019. Measurement of BP and collection of relevant health information were performed according to a standardized protocol for MMM. Screening sites were set up in churches, mosques, health facilities, pharmacies, recreational parks, sports facilities, shopping centres, marketplaces, universities, workplaces, and community centres across four regions of Ghana. A total of 7102 participants gave their consent and were screened during MMM 2019. After multiple imputation, of all 7102 participants 1836 (25.9%) had hypertension. Of all 1836 participants with hypertension, 36.5% were aware of their status and 30.0% were on anti-hypertensive medication. Of 550 participants on antihypertensive medications, 46.1% had controlled BP (systolic BP <140 mmHg and diastolic BP <90 mmHg). Also, of all 1836 participants with hypertension, 13.8% had their BP controlled. Again, the proportion of participants with hypertension of those not receiving anti-hypertensive treatment was 1286 (19.6%). Data obtained from this project demonstrates that there is still a significant number of people with hypertension who are unaware of having it, are untreated, or are on treatment but remain uncontrolled. It also highlights the significance of BP screening campaigns as a tool to identify persons with elevated BP.

Cardiometabolic Risk Factors and Preclinical Target Organ Damage Among Adults in Ghana: Findings From a National Study.

Background Although sub-Saharan Africa has a high prevalence of cardiovascular diseases (CVDs), there remains a lack of systematic and comprehensive assessment of risk factors and early CVD outcomes in adults in sub-Saharan Africa. Methods and Results Using a stratified multistage random sampling method, we recruited 1106 men and women, aged >18 years, from the general population in Ghana to participate in a national health survey from 2016 to 2017. In Ghanaian adults, the age-standardized prevalence of known CVD risk factors was 15.1% (95% CI, 12.9%-17.3%) for obesity, 6.8% (95% CI, 5.1%-8.5%) for diabetes mellitus, 26.1% (95% CI, 22.9%-29.4%) for hypertension, and 9.3% (95% CI, 7.1%-11.5%) for hyperuricemia. In addition, 10.1% (95% CI, 7.0%-13.2%) of adults had peripheral artery disease, 8.3% (95% CI, 6.7%-10.0%) had carotid thickening, 4.1% (95% CI, 2.9%-5.2%) had left ventricular hypertrophy, and 2.5% (95% CI, 1.5%-3.4%) had chronic kidney disease. Three CVD risk factors appeared to play prominent roles in the development of target organ damage, including obesity for peripheral artery disease (odds ratio [OR], 2.22; 95% CI, 1.35-3.63), hypertension for carotid thickening (OR, 1.92; 95% CI, 1.22-3.08), and left ventricular hypertrophy (OR, 5.28; 95% CI, 2.55-12.11) and hyperuricemia for chronic kidney disease (OR, 5.49; 95% CI, 2.84-10.65). Conclusions This comprehensive health survey characterized the baseline conditions of a national cohort of adults while confirming the prevalence of CVD risk factors, and early CVD outcomes have reached epidemic proportions in Ghana. The distinct patterns of risk factors in the development of target organ damage present important challenges and opportunities for interventions to improve cardiometabolic health among adults in Ghana.

May Measurement Month 2018: an analysis of blood pressure screening results from Ghana.

Elevated blood pressure (BP) is one of the leading risk factors for death and disability globally. It is also an important global health challenge because of its high prevalence and resulting morbidities. Albeit, a substantial number of people who have hypertension are either oblivious of it, not treated, or being managed but remain uncontrolled. May Measurement Month (MMM) is a global initiative led by the International Society of Hypertension (ISH) with the goal of increasing awareness of high BP and serving as a spur to establish screening programmes worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2018. Measurement of BP and collection of relevant health information were performed according to a standardized protocol for MMM. Screening sites were set up in churches, mosques, health facilities, pharmacies, recreational parks, sports facilities, shopping centres, marketplaces, universities, workplaces, and community centres across four regions of Ghana. A total of 6907 participants were screened during MMM 2018. After multiple imputation, 2354 (34.1%) had hypertension. Of individuals not taking antihypertensive medications 1526 (25.1%) were hypertensive of whom 48.4% were aware of having it. Also, of individuals taking antihypertensive medications 432 (52.2%) had uncontrolled BP. Data obtained from this project demonstrates that a significant number of people with hypertension are unaware of having it, are untreated, or are on treatment but remain uncontrolled. It also highlights the effectiveness of BP screening campaigns as a tool to identify persons with elevated BP.