Going from Primary to Primordial Prevention: Is the Juice Worth the Squeeze?

PURPOSE OF REVIEW: While primary prevention strategies target individuals who are at high risk of cardiovascular disease, there is rising interest towards primordial prevention that focuses on preventing the development of risk factors upstream of disease detection. Therefore, we review the advantages of primordial prevention interventions on minimizing future cardiovascular events. RECENT FINDINGS: Primordial prevention of atherosclerotic cardiovascular disease involves behavioral, genetic, and environmental strategies, starting from fetal/infant health and continuing throughout childhood and young adulthood. Early interventions focusing on modifiable risk factors such as physical inactivity, non-ideal body weight, smoking, and environmental pollutants are important towards preventing the initial occurrence of risk factors such as hypertension, dyslipidemia, and diabetes to ultimately reduce cardiovascular disease. Implementing primordial prevention strategies early on in life can minimize cardiovascular events and lead to healthy aging in the population. Future studies can further evaluate the effectiveness of various primordial prevention strategies.

Global Cardiovascular Research: Gaps and Opportunities.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. CVDs contribute to a large health and economic burden on a global scale. We aim to describe the current landscape of global cardiovascular research, highlight significant findings, and identify potential opportunities for further studies. RECENT FINDINGS: There has been remarkable research output regarding cardiovascular health in recent decades. Large-scale collaborative studies have made impactful strides in identifying modifiable risk factors and forming evidence-based guidelines to facilitate improved cardiovascular care and outcomes. However, there are significant CVD disparities between high- and low- income countries which require interventions to mitigate these inequalities. Encouraging collaborative partnerships, strengthening research capacity in low-resource settings, and promoting equity in research are fundamental strategic approaches to help improve global cardiovascular research.

Patient-related factors associated with severe heat-related illnesses in Karachi: A hospital perspective.

In 2015, Karachi saw its first ever epidemic of severe heatrelated illnesses that resulted in an extraordinary number of hospital admissions, especially in the intensive care, for fatal heat stroke within-hospital mortality of 3.7%.We conducted this study to elucidate the patient-related factors that lead to an increase in hospital admissions with heat-related illnesses in a tertiary care hospital. It was a descriptive case series conducted in the department of medicine at the Aga Khan University in June 2015. A total of 134 patients were admitted with heat-related illnesses of which 76(56.7%) were males. The mean age of the patients was 66 ±14.5 years. Heatstroke was present in 86 (64.2%) patients, followed by heat exhaustion in 48 (35.8%) and in-hospital mortality from heat-related illnesses was 5(3.7%). Hypertension (OR 2(95 % CI 1.0, 3.6) and insufficient sleep or food or water intake (OR 1.7(95 % CI 0.8, 3.8) was associated with severe heat-related illnesses. The effects remained even after adjusting for type and area of residence.

Does depressed persons with non-cardiovascular morbidity have a higher risk of CVD? A population-based cohort study in Sweden.

BACKGROUND: Depression often co-exists with non-cardiovascular morbid conditions. Whether this comorbidity increases the risk of cardiovascular disease has so far not been studied. Thus, the aim of this study was to determine if non-cardiovascular morbidity modifies the effect of depression on future risk of CVD. METHODS: Data was derived from the PART study (acronym in Swedish for: Psykisk hälsa, Arbete och RelaTioner: Mental Health, Work and Relationships), a longitudinal cohort study on mental health, work and relations, including 10,443 adults (aged 20-64 years). Depression was assessed using the Major Depression Inventory (MDI) and self-reported data on non-cardiovascular morbidity was assessed in 1998-2000. Outcomes of CVD were assessed using the National Patient Register during 2001-2014. RESULTS: Both depression (HR 1.5 (95% CI, 1.1, 2.0)) and non-cardiovascular morbidity (HR 2.0 (95% CI, 1.8, 2.6)) were associated with an increased future risk of CVD. The combined effect of depression and non-cardiovascular comorbidity on future CVD was HR 2.1 (95%, CI 1.3, 3.4) after adjusting for age, gender and socioeconomic position. Rather similar associations were seen after further adjustment for hypertension, diabetes and unhealthy lifestyle factors. CONCLUSION: Persons affected by depression in combination with non-cardiovascular morbidity had a higher risk of CVD compared to those without non-cardiovascular morbidity or depression alone.

Severity of depression, anxious distress and the risk of type 2 diabetes - a population-based cohort study in Sweden.

BACKGROUND: Previous studies assessing the relationship between depression and diabetes mellitus did not consider the severity of depression. In the present study we assessed the risk of developing type 2 diabetes mellitus (T2DM) among people with various severity of depression. METHODS: This prospective longitudinal cohort study included 9,936 individuals residing in Stockholm County, Sweden who responded to the baseline questionnaire in 1998-2000. The participants were followed from 1 year after the baseline up to 2015 for the occurrence of T2DM, using the National Patient Register, Swedish Prescribed Drug Registers, and Cause of Death Register. Depression and anxious distress were assessed using psychiatric rating scales and defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). RESULTS: Depression was associated with a statistically significant increased risk of T2DM after adjusting for potential confounders (OR 1.48, CI 1.10, 1.99). The strongest association was observed for severe depression (OR 1.72, CI 1.15, 2.59). Further, those with depression, regardless of severity, and with concurrent moderate/severe anxious distress had an increased risk of T2DM (OR 1.73, CI 1.13, 2.63) compared to those with neither depression nor anxious distress. CONCLUSIONS: The study adds evidence that depression is associated with a higher risk for developing T2DM, and the association is stronger among people with severe depression.

Correction to: Severity of depression, anxious distress and the risk of type 2 diabetes - a population-based cohort study in Sweden.

It was highlighted that the original article [1] contained an error in the flow chart in Fig. 1.

Frequency of Peri-operative Hypertension in a tertiary care hospital in Karachi, Pakistan.

This study aims to determine the frequency of perioperative hypertension and its types (pre, intra and post-operative) hypertension in patients admitted for surgical procedures. This was a cross-sectional study conducted between the years 2012-2013 at the Aga Khan University Hospital, Karachi. Patients admitted for any surgical procedure during this time were included. Perioperative hypertension has been defined as systolic blood pressure of >140 mm Hg or a diastolic blood pressure of >90 mm Hg or whose blood pressure increased by 20% during surgery. A total of 428 surgical procedures were reviewed for the study. Overall perioperative hypertension was present in 231 (54%) of the patients. In the sample, 91 (21.7%) had pre-operative hypertension, 126(29.4%) reported pre-surgery hypertension, 24(5.6%) had intra-operative hypertension and 63(14.7%) had post-operative hypertension. Mean pain score was 1.43(1.4) v 1.25(1.2) in those with postoperative hypertension v no post-operative hypertension (p value 0.009).

Association of Catechol-O-methyltransferase (COMT Val158Met) with future risk of cardiovascular disease in depressed individuals - a Swedish population-based cohort study.

BACKGROUND: Catechol-O-methyltransferase (COMT Val158Met) has been implicated in both depression and cardiovascular disease. The purpose of this study was to assess if COMT Val158Met, which influences the COMT enzyme activity, has an effect on the risk of cardiovascular disease (CVD) in individuals with a history of depression and also to determine if the risk differs depending on gender. METHODS: Data from a longitudinal cohort study of mental health among Swedish adults was used. Depression was assessed twice 3 years apart for each participant, in 1998-2001 and 2001-2003. Saliva DNA was contributed by 4349 (41.7%) of the participants and 3525 was successfully genotyped for COMT Val158Met. Participants were followed up until December 2014 from the National Patient register with regard to cardiovascular outcomes (hypertensive or ischemic heart disease, and stroke). RESULTS: Those with depression and the high COMT enzyme activity genotype (Val/Val) had almost a three-fold increased risk of later CVD (OR 3.6; 95% CI: 2.0-6.6) compared to those non-depressed carrying the Val/Val allele. This effect on risk for CVD was higher in women compared to men (OR 7.0; 95% CI: 3.0-14.0 versus OR 2.1; 95% CI: 1.0-6.8). Both additive interaction (attributable proportion (AP) = 0.56; 95% CI: 0.24-0.90 and synergy index (SI) = 4.39; 1.0-18.7) and multiplicative interaction (log likelihood test p = 0.1) was present between depression and COMT Val158Met in predicting risk of later CVD. CONCLUSION: High COMT activity genotype Val158Met increased the risk of CVD in depressed persons. The risk was higher in women compared to men.

Effect of neuroticism on risk of cardiovascular disease in depressed persons - a Swedish population-based cohort study.

BACKGROUND: The relationship between neuroticism, depression and cardiovascular disease (CVD) is complex and has so far not been studied in depth. The aim of this study was to determine if neuroticism is an effect-modifier in the association between depression and CVD. Data derived from a longitudinal cohort study on mental health, work and relations among adults (20-64 years), including 10,443 individuals. Depression was assessed using the Major Depression Inventory (MDI) and neuroticism by the Swedish Scale of Personality (SSP). Outcomes of cardiovascular disease were register-based from the National inpatient register. RESULTS: Both depression (OR 1.9 (95%CI 1.4, 2.5)) and high levels of neuroticism (OR 1.2 (95%CI 1.1-1.3)) were associated with increased risk of CVD. The combined effect of depression and neuroticism on the risk of CVD revealed HRs ranging from 1.0 to 1.9 after adjusting for age and gender, socioeconomic position, prevalent hypertension and diabetes. Almost similar associations were seen after further adjustment for lifestyle factors. CONCLUSION: Neuroticism increased the risk of CVD in depressed persons. We found synergistic interaction between neuroticism and depression status in predicting future risk of CVD.

Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.

BACKGROUND: In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient's autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown. AIM: To determine the barriers and perceptions in discussion of code status by physicians. DESIGN: Questionnaire-based cross-sectional study. SETTING AND PARTICIPANTS: This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included. RESULTS: A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians. CONCLUSION: Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries.

Women with pregnancy induced hypertension have a higher risk of developing essential hypertension - a case control study from a tertiary care center in Pakistan.

OBJECTIVE: To determine the association of essential hypertension with pregnancy-induced hypertension in women. METHODS: The case-control study was conducted at Aga Khan University Hospital, Karachi, from January 2012 to March 2013, and comprised on hypertensive female patients who visited the outpatient medicine clinics. The patients were aged 18-65 years and had been pregnant atleast once. Cases were women diagnosed as hypertensive or pre-hypertensive and the controls were normotensive women. The primary outcome was essential hypertension and the main exposure was pregnancy-induced hypertension. RESULTS: Of the 258 subjects, 175(49.7%) were cases and 177(50.3%) were controls. The overall mean age was 44.6±13.3 years. Odds Ratio (95% Confidence interval) for pregnancy-induced hypertension for the outcome of essential hypertension was 1.6 (0.88, 3.0). The odds ratio increased further to 2.5(1.2, 5.2) after adjustment for age, family history of hypertension and physical activity. The association remained after further adjusting for body mass index in the final model; 2.20 (1.06, 4.57). CONCLUSIONS: Women who develop hypertension in pregnancy are at higher risk of developing essential hypertension later in life.

Depression is linked to uncontrolled hypertension: a case-control study from Karachi, Pakistan.

BACKGROUND: High blood pressure is an important risk factor for cardiovascular disease and may be more prevalent in persons with psychopathology. OBJECTIVE: To determine the association between uncontrolled hypertension with depressive and anxiety disorders in two tertiary care centers in Karachi. METHODS: It was a case-control study conducted in two hospitals in Karachi. Cases were patients with uncontrolled hypertension and controls were patients with controlled hypertension. History of anxiety or depression as measured by Hospital Anxiety and Depression Scale (HADS) was the exposure. HADS of >8 was suggestive of having anxiety or depression. RESULTS: A total of 700 participants were approached, out of whom 590 fulfilled the inclusion criteria and consented to participate, 323 (54.7%) participants were enrolled as cases and 267 (45.3%) as controls. Mean (SD) age was 54.98 (12.38) years, 229 (38%) were males. Odds ratio (OR) (95% CI) of having uncontrolled hypertension and being depressed (HADS-D > 8) was 2.02 (1.44-2.83), p value ≤ 0.001. The association remained significant even after adjusting for age and gender in Model 1 OR (95% CI): 1.82 (1.27-2.60), p value = 0.001, ethinicity and education in Model 2 OR (95% CI): 1.87 (1.29-2.71), p value = 0.001 and comorbids, history of hospitalization body mass index in Model 3 OR (95% CI): 1.94 (1.31-2.85), p value = 0.001. CONCLUSION: There is association between uncontrolled hypertension and depression that is independent of sociodemographic factors, comorbids and history of hospitalization.

Comparison of Critical Illness Score in Patients Admitted to Intermediate Care Units of a Tertiary Care Hospital: A Comparative Cross-Sectional Study from Karachi, Pakistan.

Introduction: Intermediate care units (IMCUs) serve as step-up units for emergency department patients and as step-down units for critically ill patients transferred from intensive care units. This study compares four critical illness scores for assessment of acutely ill patients and their accuracy in predicting mortality in patients admitted to IMCU. Methods: A comparative cross-sectional study on patients aged ≥18 admitted to IMCU of Aga Khan University Hospital from 2017 to 2019. All patients admitted to IMCU from the emergency room were included in the study. Patient's record were reviewed for demographic data, physiological and laboratory parameters. Critical illness scores were calculated from these variables for each patient. Results: A total of 1192 patients were admitted to the IMCU, of which 923 (77.4%) medical records were finally analyzed. The mean (SD) age of participants was 62 years (± 16.5) and 469 (50.8%) were women. The overall hospital mortality rate of patients managed in IMCU was 6.4% (59/923 patients). The median scores of APACHE II, SOFA, SAPS II and MEWS were 16 (IQR 11-21), 4 (IQR 2-6), 36 (IQR 30-53) and 3 (IQR 2-4) points respectively. AUC for SAPS II was 0.763 (95% CI: 0.71-0.81), SOFA score was 0.735 (95% CI: 0.68-0.79) and MEWS score was 0.714 (95% CI: 0.66-0.77). The lowest ROC curve was 0.584 (95% CI: 0.52-0.64) for APACHE II. Conclusion: In conclusion, our study found that SAPS II, followed by SOFA and MEWS scores, provided better discrimination in stratifying critical illness in patients admitted to IMCU of a tertiary care hospital in Pakistan.

Obesity and risk of hypertension in preadolescent urban school children: insights from Pakistan.

BACKGROUND: Childhood obesity and hypertension are growing concerns globally, especially in developing countries. This study investigated the association between overall and central obesity at baseline, and prehypertension or hypertension at follow-up among preadolescent school children in urban Karachi, Pakistan. METHODS: This is a sub study with cohort design embedded within a feasibility trial on School Health Education Program in Pakistan (SHEPP) in preadolescents aged 6-11 years, attending two private schools conducted from 2017 to 2019. Hypertension or prehypertension at follow-up were the outcomes and obesity or central obesity at baseline were the exposure variables. Hypertension was defined as systolic blood pressure and/or diastolic blood pressure ≥ 95th percentile for age, sex, and height. Obesity was defined as body mass index for-age and sex ≥ 95th percentile, whereas central obesity was determined by waist circumference measurements ≥ 85th percentile of age, sex, and height specific cut-offs. Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to identify risk factors for hypertension and prehypertension. RESULTS: Analysis was conducted for 908 participants, evenly distributed with 454 boys and 454 girls. Hypertension was observed in 19.8% of the preadolescents, with rates of 18.5% in boys and 21.0% in girls. Prehypertension was found in 16.8% of preadolescents, with 18% among boys and 16% among girls. Additionally, 12.8% of preadolescents were classified as obese and 29.8% had central obesity. Obesity at baseline was associated with hypertension at followup (OR 8.7, 95% CI 3.5, 20.4) in the final model after adjusting for age, gender, physical activity, sedentary behavior, fruits, vegetable intake and hypertension at baseline. Central obesity at baseline also yielded high odds, with prehypertension (OR 1.9, 95% CI 1.4, 2.8) and hypertension (OR 2.7, 95% CI 1.9, 3.9) at follow up in the final model. CONCLUSION: This study highlights a concerning prevalence of hypertension and prehypertension among preadolescent school-going children. Obesity and central obesity at baseline emerged as significant predictive factors for hypertension or prehypertension at followup within this cohort. The findings emphasize the urgency of implementing comprehensive school health education programs aimed at early detection and effective management of hypertension during childhood and adolescence in school settings.

Obesity and Risk of Hypertension in Preadolescent Urban School Children: Insights from a Developing Country.

Background: Childhood obesity and hypertension are growing concerns globally, especially in developing countries. This study investigated the association between overall and central obesity at baseline, and prehypertension or hypertension at follow-up among preadolescent school children in Karachi, Pakistan. Methods: This is a sub study with cohort design embedded within a feasibility trial on School Health Education Program in Pakistan (SHEPP) in preadolescent aged 6-11 years, attending two private schools, were enrolled from 2017 to 2019. Hypertension or prehypertension at follow-up were the outcomes and obesity or central obesity at baseline were the exposure variables. Hypertension was defined as systolic blood pressure and/or diastolic blood pressure ≥ 95th percentile for age, sex, and height. Obesity was defined as body mass index for-age and sex ≥ 95th percentile, whereas central obesity was determined by waist circumference measurements ≥ 85th percentile of age, sex, and height specific cut-offs. Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to identify risk factors for hypertension and prehypertension. Results: Analysis was conducted for 908 participants, evenly distributed with 454 boys and 454 girls. Hypertension was observed in 19.8% of the preadolescents, with rates of 18.5% in boys and 21.0% in girls. Prehypertension was found in 16.8% of preadolescents, with 18% among boys and 16% among girls. Additionally, 12.8% of preadolescents were classified as obese and 29.8% had central obesity. Obesity at baseline was associated with hypertension (OR 8.7, 95% CI 3.5, 20.4) in the final model after adjusting for age, gender, physical activity, sedentary behavior, fruits, vegetable intake and hypertension at baseline. Central obesity at baseline also yielded high odds, with prehypertension (OR 1.9, 95% CI 1.4, 2.8) and hypertension (OR 2.7, 95% CI 1.9, 3.9) in the final model. Conclusion: This study highlights a concerning prevalence of hypertension and prehypertension among preadolescent school-going children. Obesity and central obesity at baseline emerged as significant predictive factors for hypertension within this cohort. The findings emphasize the urgency of implementing comprehensive school health education programs aimed at early detection and effective management of hypertension during childhood and adolescence in school settings.

Comparison of Physical Activity Measured by Self-Reported Physical Activity and Wearable Device Xiaomi MI2 Band in Preadolescent School Children - A Pilot Cross-Sectional Study.

The purpose of this study is to compare physical activity measured by the wearable device Xiaomi Mi2 Band and self-reported physical activity by YPAQ in preadolescent school children. A pilot cross-sectional study was performed on a subsample (5%=n=60) of preadolescent children within a parallel-group feasibility intervention trial (n=1000). All children aged 9-11 years enrolled in the schools were included in the study and children with any physical disability were excluded. Self-reported physical activity was recorded through the modified version of the Youth Physical Activity Questionnaire (YPAQ) and automatic physical activity was measured by the Xiaomi Mi2 band over 7 days. Data from the Xiaomi Mi2 band was synchronized with its mobile application from where data was transferred to an excel sheet. Data on 7-day total physical activity in minutes and 7-day total step count were recorded by the Xiaomi Mi2 band. Student's t-tests were used to determine whether significant differences were present between self-reported physical activity and by Xiaomi Mi2 band. A Bland-Altman method was also used to assess the degree of agreement between the two methods of measuring physical activity. Mean ± SD age of the children was 9.6 (± 1.0) years and 31 (51.7 %) were boys. The mean ± SD time spent in physical activity reported by YPAQ was 457.5 (± 136) minutes and by the Xiaomi Mi2 band was 594.7 (± 183) minutes. The Bland-Altman plot identified a mean bias between the methods (YPAQ and Xiaomi Mi2 band) of -157.6 (95% CI: 296.3, -611.0) minutes of 7-day physical activity. Physical activity measured by a wearable device, the Xiaomi Mi2 band can give overestimated values of physical activity compared to self-reported physical activity in preadolescent school children. However, when PA is measured through step counts by the Xiaomi Mi2 band converted to minutes, it is comparable to PA measured by YPAQ.

School Health Education Program in Pakistan (SHEPP): findings from a feasibility trial in pre-adolescent school children from a lower middle-income country.

BACKGROUND: The school environment plays an essential role in promoting health education and physical activity for children and adolescents. We aim to assess the feasibility of threefold health education program in children and its potential efficacy on physical activity and diet and cardiometabolic risk factors including blood pressure, body mass index (BMI), and waist circumference. METHODS: The SHEPP was a parallel group feasibility intervention trial conducted in two schools over 23 months. All children aged 9-11 years enrolled in the schools were included. The SHEPP intervention comprised of health education on healthy lifestyle and physical activity sessions for children, training of teachers, and awareness sessions for parents conducted over 10 months. One school received the intervention of SHEPP while the other school continued routine activity. The primary outcome was the feasibility of SHEPP in terms of recruitment, retention, and treatment fidelity. Secondary outcomes were physical activity levels, dietary intake (of fruits and vegetables), and cardiometabolic risk factors (blood pressure, BMI, and waist circumference (WC)). RESULTS: A total of 1280 preadolescent children were assessed for eligibility and 1191 were found eligible. The overall recruitment n (%) was 982/1191(82.5%) with 505(51.4) from SHEPP intervention school and 477(48.6) in routine activity school. The overall retention rate n (%) at 10-month follow-up was 912/982(92.8), with 465/505(92) in SHEPP intervention school and 447/477(93.7) in routine activity school. In treatment fidelity, 132/144(92) %). Physical activity sessions and all (100%) health education sessions were conducted for each of the twelve classes. Mean (SD) Seven-day Physical activity increased by 134 (196) min in the SHEPP intervention school v 29.8(177) in the routine activity school (P value < 0.001) from baseline to follow-up. Overall, there was an increase in vegetable intake (> 3 serving /day) in SHEPP intervention school of 5.5 to 21.4% from baseline to follow-up compared to 7.5 to 14.9% in routine activity school. The mean change (SD) in systolic blood pressure was 1.3(12) mmHg, 2.2(19.0) mm Hg in in diastolic blood pressure, - 0.09(5.4) kg/m2 in BMI and 6.2 cm in waist circumference in the intervention arm versus - 3.4(11.1) mm Hg in SBP, - 4.3(9.9) mm Hg in DBP, - 0.04((4.6) kg/m2 in BMI, and 3.8 cm in WC in the control arm. CONCLUSION: We found that intervention using SHEPP is feasible in schools and may help children to adopt a healthy lifestyle as they age by increasing physical activity. However, the potentially beneficial effect on diet, MI, and BP needs further exploration and a longer follow-up, more specifically at the juncture of teenage and adulthood. TRIAL REGISTRATION: NCT03303287.

Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan.

Background: Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality. Methods: A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses. Results: Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]). Conclusions: Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.

Medication Adherence in Patients With Uncontrolled Hypertension & Hypertensive Crisis Presenting to a Hospital Setting in Karachi, Pakistan.

BACKGROUND: Hypertension is an established risk factor for cardiovascular disease. Non-adherence to antihypertensive medications contributes to poorly controlled hypertension while also increasing the risk of hypertensive crisis. The aim of our study was thus to estimate the frequency of adherence to antihypertensive medications in our population and also see if an association exists between adherence and the development of a hypertensive crisis. METHODS: This cross-sectional study was undertaken on patients admitted to Aga Khan University Hospital, Karachi, Pakistan, between July 2020 and March 2022. All patients with uncontrolled hypertension with systolic blood pressure >140 and diastolic blood pressure >90 who were admitted through the emergency department were included. A systolic blood pressure over 180mmHg or diastolic blood pressure over 120mmHg, with or without end-organ damage was used to define a hypertensive crisis. Adherence to medications was assessed using the 4-item Morisky Green Levine (MGL) scale. Each item was scored as 1 and then added together to get a final score out of 4 with a score of ≥3 signifying adherence while a cumulative score of 0, 1, or 2 was classified as non-adherence. RESULTS: We found that 64% of the cohort were adherent to their medications while 93 (36%) were non-adherent. The most common comorbid condition was found to be diabetes mellitus (54.8%). Around 146 (64.6%) patients were on a single anti-hypertensive agent. Depression as calculated according to the hospital anxiety and depression scale (HADS) was seen in 133 (51.2%) of our cohort while 147 (56.5%) had anxiety. Similar rates of adherence were seen amongst males (49.1%) and females (50.9%). The highest level of adherence was seen in the 61 to 75 years age group (34.9%) and in those with university-level education (30.6%). We also found a statistically significant association between adherence to antihypertensive medications with anxiety (p-value=0.048). Moreover, in the hypertensive crisis group, 40.7% of the patients were adherent to their antihypertensive medications while 54.8% were found to be non-adherent, with the p-value reaching statistical significance (p-value=0.028). CONCLUSION: We found a higher rate of adherence (64%) in this inpatient hypertensive population as compared to previous studies in our population. We also found that non-adherence is a risk factor for the development of a hypertensive crisis. Therefore, at clinic visits, physicians should assess their patient's adherence to antihypertensive medications to prevent the development of a hypertensive crisis.