May Measurement Month 2021: an analysis of blood pressure screening results from Nigeria.

There is a need to constantly assess the awareness, treatment, and control of hypertension in Nigeria. This study determined the frequency of undiagnosed hypertension across the six geopolitical zones of Nigeria. We conducted an opportunistic screening of adults aged at least 18 years in the month of May 2021. Participants were recruited by trained volunteers using the May Measurement Month protocol. Blood pressure (BP) was measured using validated digital sphygmomanometers. We defined hypertension as systolic BP ≥ 140 and/or diastolic BP ≥ 90 mmHg and/or the use of BP-lowering medications. A total of 9361 participants (51.5% females) with a mean age of 40.7 ± 15.5 years were screened. Hypertension was present in 3192 (34.1%) of the participants. About half (1491, 46.7%) of the hypertensives were unaware of the diagnosis. Among the 3192 participants with hypertension, less than half (1540, 48.2%) were on antihypertensive medications, while only 36.4% of those on antihypertensive medications had their BP controlled (<140/90 mmHg). About one-third of Nigerians in this opportunistic screening had hypertension, with about half of them being unaware of their diagnosis while only about two out of every five on antihypertensive medications had controlled BP. Urgent health actions are needed in Nigeria to reduce the burden of hypertension and its complications.

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

Hypertension remains the dominant cardiovascular risk factor worldwide. May Measurement Month (MMM) is an annual global programme of the International Society of Hypertension aimed at screening for undetected hypertension in the general population. We report the outcome of MMM 2018 in Nigeria. An opportunistic screening of adults aged at least 18 years was conducted in the six geopolitical zones of Nigeria in the month of May, 2018. Screening for hypertension was done by trained volunteers with the use of validated digital and mercury sphygmomanometers following the MMM protocol. Hypertension was defined as blood pressure (BP) ≥140/90 mmHg or the use of BP-lowering medication. There were 6398 participants (53.0% female) with a mean (SD) age of 41.7 (15.0) years. Hypertension was present in 36.4% of the participants with 51.1% of the hypertensives aware of their status, 41.8% on medication, of whom 43.1% were controlled. Overall, only 18.0% of all hypertensive participants had their BP under control. The proportion with hypertension is high, and awareness, treatment, and control rates are low. Concerted efforts are needed to improve awareness and treatment of hypertension in Nigeria in order to reduce the high rate of complications associated with uncontrolled BP.

Removing the mask on hypertension (REMAH) study: Design; quality of blood pressure phenotypes and characteristics of the first 490 participants.

Purpose: Previous studies that evaluated the prevalence of hypertension in Nigeria were either clinic based, non-standardized or did not include out-of-clinic blood pressure (BP) measurement. Materials and Methods: We selected a rural and an urban community in one state in each of the 6 geopolitical zones of Nigeria. Five consecutive BP of adults older than 18 years were measured in the clinic following which, each participant was provided with a home BP device to obtain duplicate morning and evening BP for 3 days. Result: Out of 556 invited from Anambra State, South-East Nigeria, 490 (88%) consented. Overall, more women participated in both rural (115 vs 61, p < .0001) and urban (213 vs 101; p < .0001) sites. About 35.9% of participants had their home BP monitored. Of the 4890 clinic BP readings, 29.8%, 16.3%, 16.6%, 16.4% and 20.8% ended in 0,2,4,6 and 8 digits respectively. Only 0.8% ended in odd numbers. Of the identical BP readings,5 (0.20%), 6 (0.25%), 56 (2.30%) and 316 (12.9%) SBP and 8 (0.33%), 17 (0.70%), 93 (3.80%), 319 (13.1%) DBP had no difference in five, four, three and two values of the five consecutive readings. Conclusion: REMAH is feasible and the quality of BP will ensure that the final results are robust.

Rationale and design of the comparison of 3 combination therapies in lowering blood pressure in black Africans (CREOLE study): 2 × 3 factorial randomized single-blind multicenter trial.

BACKGROUND: Current hypertension guidelines recommend the use of combination therapy as first-line treatment or early in the management of hypertensive patients. Although there are many possible combinations of blood pressure(BP)-lowering therapies, the best combination for the black population is still a subject of debate because no large randomized controlled trials have been conducted in this group to compare the efficacy of different combination therapies to address this issue. METHODS: The comparison of 3 combination therapies in lowering BP in the black Africans (CREOLE) study is a randomized single-blind trial that will compare the efficacy of amlodipine plus hydrochlorothiazide versus amlodipine plus perindopril and versus perindopril plus hydrochlorothiazide in blacks residing in sub-Saharan Africa (SSA). Seven hundred two patients aged 30-79 years with a sitting systolic BP of 140 mm Hg and above, and less than 160 mm Hg on antihypertensive monotherapy, or sitting systolic BP of 150 mm Hg and above, and less than 180 mm Hg on no treatment, will be centrally randomized into any of the 3 arms (234 into each arm). The CREOLE study is taking place in 10 sites in SSA, and the primary outcome measure is change in ambulatory systolic BP from baseline to 6 months. The first patient was randomized in June 2017, and the trial will be concluded by 2019. CONCLUSIONS: The CREOLE trial will provide unique information as to the most efficacious 2-drug combination in blacks residing in SSA and thereby inform the development of clinical guidelines for the treatment of hypertension in this subregion.

Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation: a cohort study.

BACKGROUND: Atrial fibrillation is an important cause of morbidity and mortality worldwide, but scant data are available for long-term outcomes in individuals outside North America or Europe, especially in primary care settings. METHODS: We did a cohort study using a prospective registry of patients in 47 countries who presented to a hospital emergency department with atrial fibrillation or atrial flutter as a primary or secondary diagnosis. 15 400 individuals were enrolled to determine the occurrence of death and strokes (the primary outcomes) in this cohort over eight geographical regions (North America, western Europe, and Australia; South America; eastern Europe; the Middle East and Mediterranean crescent; sub-Saharan Africa; India; China; and southeast Asia) 1 year after attending the emergency department. Patients from North America, western Europe, and Australia were used as the reference population, and compared with patients from the other seven regions FINDINGS: Between Dec 24, 2007, and Oct 21, 2011, we enrolled 15 400 individuals to the registry. Follow-up was complete for 15 361 (99·7%), of whom 1758 (11%) died within 1 year. Fewer deaths occurred among patients presenting to the emergency department with a primary diagnosis of atrial fibrillation compared with patients who had atrial fibrillation as a secondary diagnosis (377 [6%] of 6825 patients vs 1381 [16%] of 8536, p<0·0001). Twice as many patients had died by 1 year in South America (192 [17%] of 1132) and Africa (225 [20%] of 1137) compared with North America, western Europe, and Australia (366 [10%] of 3800, p<0·0001). Heart failure was the most common cause of death (519 [30%] of 1758); stroke caused 148 (8%) deaths. 604 (4%) of 15361 patients had had a stroke by 1 year; 170 (3%) of 6825 for whom atrial fibrillation was a primary diagnosis and 434 (5%) of 8536 for whom it was a secondary diagnosis (p<0·0001). The highest number of strokes occurred in patients in Africa (89 [8%] of 1137), China (143 [7%] of 2023), and southeast Asia (88 [7%] of 1331) and the lowest occurred in India (20 [<1%] of 2536). 94 (3%) of 3800 patients in North America, western Europe, and Australia had a stroke. INTERPRETATION: Marked unexplained inter-regional variations in the occurrence of stroke and mortality suggest that factors other than clinical variables might be important. Prevention of death from heart failure should be a major priority in the treatment of atrial fibrillation. FUNDING: Boehringer Ingelheim.

Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis.

BACKGROUND: Tuberculous pericarditis is associated with high morbidity and mortality even if antituberculosis therapy is administered. We evaluated the effects of adjunctive glucocorticoid therapy and Mycobacterium indicus pranii immunotherapy in patients with tuberculous pericarditis. METHODS: Using a 2-by-2 factorial design, we randomly assigned 1400 adults with definite or probable tuberculous pericarditis to either prednisolone or placebo for 6 weeks and to either M. indicus pranii or placebo, administered in five injections over the course of 3 months. Two thirds of the participants had concomitant human immunodeficiency virus (HIV) infection. The primary efficacy outcome was a composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. RESULTS: There was no significant difference in the primary outcome between patients who received prednisolone and those who received placebo (23.8% and 24.5%, respectively; hazard ratio, 0.95; 95% confidence interval [CI], 0.77 to 1.18; P=0.66) or between those who received M. indicus pranii immunotherapy and those who received placebo (25.0% and 24.3%, respectively; hazard ratio, 1.03; 95% CI, 0.82 to 1.29; P=0.81). Prednisolone therapy, as compared with placebo, was associated with significant reductions in the incidence of constrictive pericarditis (4.4% vs. 7.8%; hazard ratio, 0.56; 95% CI, 0.36 to 0.87; P=0.009) and hospitalization (20.7% vs. 25.2%; hazard ratio, 0.79; 95% CI, 0.63 to 0.99; P=0.04). Both prednisolone and M. indicus pranii, each as compared with placebo, were associated with a significant increase in the incidence of cancer (1.8% vs. 0.6%; hazard ratio, 3.27; 95% CI, 1.07 to 10.03; P=0.03, and 1.8% vs. 0.5%; hazard ratio, 3.69; 95% CI, 1.03 to 13.24; P=0.03, respectively), owing mainly to an increase in HIV-associated cancer. CONCLUSIONS: In patients with tuberculous pericarditis, neither prednisolone nor M. indicus pranii had a significant effect on the composite of death, cardiac tamponade requiring pericardiocentesis, or constrictive pericarditis. (Funded by the Canadian Institutes of Health Research and others; IMPI ClinicalTrials.gov number, NCT00810849.).

Non-invasive estimation of pulmonary artery pressures in patients with sickle cell anaemia in Ibadan, Nigeria: an echocardiographic study.

INTRODUCTION: Pulmonary hypertension is emerging as one of the causes of morbidity and mortality in adults with sickle cell disease. The prevalence of pulmonary hypertension in Nigerian adults with sickle cell anaemia is unknown. We decided to estimate the pulmonary artery systolic and diastolic pressures in subjects with sickle cell anaemia seen at the University College Hospital, Ibadan, Nigeria, and to determine the frequency of pulmonary hypertension among them. METHODS: Ninety patients (38 males and 52 females) with sickle cell anaemia in steady state and comparable age- and sex-matched normal controls had a clinical evaluation and echocardiographic examination. RESULTS: The mean age of the subjects with sickle cell anaemia was 24.0 (9.00) years while the mean age for the control group was 24.0 (7.00) years. The frequency of pulmonary hypertension as assessed by a tricuspid regurgitant jet velocity of > 2.5 m/s in this study was 12.2%. Larger left ventricular dimensions and volumes, higher stroke volume and increased left ventricular mass indexed by body surface area were found to be associated with pulmonary hypertension. A multivariate analysis of the potential predictors of pulmonary hypertension in this study showed that male sex and lower packed cell volume (PCV) were independent predictors of pulmonary hypertension in patients with sickle cell anaemia. CONCLUSION: We conclude that pulmonary artery systolic and diastolic pressures are higher in subjects with sickle cell disease than normal controls. Male sex and low PCV are independent determinants of pulmonary arterial pressure in subjects with sickle cell anaemia in Nigeria.

Evaluating the Effectiveness of African School of Hypertension for Non-Physician Health Workers, a Qualitative Study: QuASH Hypertension Study.

Background: The implementation of task sharing and shifting (TSTS) policy as a way of addressing the shortage of physicians and reducing the burden of hypertension in Africa birthed the idea of the African School of Hypertension (ASH). The ASH is saddled with the responsibility of training non-physician health workers across Africa continent in the management of uncomplicated hypertension. Aim: To get feedback from some faculty members and students who participated in the first ASH programme. Methods: This was a cross-sectional exploratory qualitative study conducted among eight students and eight faculty members. Feedback from the program was obtained by conducting in-depth interviews centred on description of course content; expectations and knowledge acquired from ASH; level of interaction between students and faculty members; challenges faced during the ASH; level of implementation of acquired training; and suggestions to improve subsequent ASH programs. Results: The course content of the ASH was described as simple, appropriate and adequate while interaction between students and faculty members were highly cordial and engaging. New knowledge about hypertension management was acquired by the students with different levels of implementation post-graduation. Some identified challenges with the ASH program were poor internet connectivity during lectures, non-uniformity of TSTS policies and hypertension management guidelines across Africa, technical problems with hypertension management app and low participation from other African countries apart from Nigeria. Some recommendations to improve ASH program were development of a uniform hypertension management guideline for Africans, wider publicity of the ASH, interpretation of lectures into French and Portuguese languages and improvement of internet connectivity. Conclusion: The ASH programme has largely achieved its objectives with the very encouraging feedback received from both faculty members and the students. Steps should be taken to address the identified challenges and implement the suggested recommendations in subsequent ASH program to sustain this success.

Rationale and design of the Investigation of the Management of Pericarditis (IMPI) trial: a 2 × 2 factorial randomized double-blind multicenter trial of adjunctive prednisolone and Mycobacterium w immunotherapy in tuberculous pericarditis.

BACKGROUND: In spite of antituberculosis chemotherapy, tuberculous (TB) pericarditis causes death or disability in nearly half of those affected. Attenuation of the inflammatory response in TB pericarditis may improve outcome by reducing cardiac tamponade and pericardial constriction, but there is uncertainty as to whether adjunctive immunomodulation with corticosteroids and Mycobacterium w (M. w) can safely reduce mortality and morbidity. OBJECTIVES: The primary objective of the IMPI Trial is to assess the effectiveness and safety of prednisolone and M. w immunotherapy in reducing the composite outcome of death, constriction, or cardiac tamponade requiring pericardial drainage in 1,400 patients with TB pericardial effusion. DESIGN: The IMPI trial is a multicenter international randomized double-blind placebo-controlled 2 × 2 factorial study. Eligible patients are randomly assigned to receive oral prednisolone or placebo for 6 weeks and M. w injection or placebo for 3 months. Patients are followed up at weeks 2, 4, and 6 and months 3 and 6 during the intervention period and 6-monthly thereafter for up to 4 years. The primary outcome is the first occurrence of death, pericardial constriction, or cardiac tamponade requiring pericardiocentesis. The secondary outcome is safety of immunomodulatory treatment measured by effect on opportunistic infections (eg, herpes zoster) and malignancy (eg, Kaposi sarcoma) and impact on measures of immunosuppression and the incidence of immune reconstitution disease. CONCLUSIONS: IMPI is the largest trial yet conducted comparing adjunctive immunotherapy in pericarditis. Its results will define the role of adjunctive corticosteroids and M. w immunotherapy in patients with TB pericardial effusion.

Left ventricular noncompaction in Ibadan, Nigeria.

BACKGROUND: There has been an increase in the reporting of cases of left ventricular noncompaction (LVNC) cardiomyopathy in medical literature due to advances in medical imaging. Patients with LVNC may be asymptomatic or may present with arrhythmias, heart failure, thromboembolism or sudden death. LVNC is typically diagnosed by echocardiography, although there are higher-resolution cardiac imaging techniques such as cardiac magnetic resonance imaging (MRI) to make the diagnosis. The objective of the study is to report on a series of 9 cases of LVNC cardiomyopathy seen at the University College Hospital, Ibadan. Cases of LVNC seen between September 1, 2015 and July 31, 2022 in our echocardiography service  is being reported. RESULTS: There were a total of 6 men and 3 women. Mean age at presentation was 52.89 ± 15.02 years. The most common mode of presentation was heart failure (6 patients). Hypertension was the most common comorbidity (6 patients). Three patients had an ejection fraction of less than 40% and the mean ratio of noncompacted to compacted segment at end-systole was 2.80 ± 0.48. The most common areas of trabecular localization were the LV lateral wall and the apex. Beta blockers were highly useful in the management of the patients. CONCLUSIONS: LVNC cardiomyopathy is not uncommon in our environment and a high index of suspicion is often required.

Left ventricular geometry and electrocardiographic criteria in assessing left ventricular hypertrophy in sickle cell anemia patients.

BACKGROUND: Left ventricular hypertrophy (LVH) is recognized as a cardiovascular risk factor and is a known consequence of sickle cell anemia (SCA). Abnormal left ventricular geometric patterns have been described but the determinants have not been well elucidated. METHOD: Electrocardiography (ECG) and Echocardiography (ECHO) was done on subjects with SCA and hemoglobin A(HBA). Those with systemic hypertension were excluded. Voltages, durations, and intervals were measured as appropriate and recorded in a standard proforma. Analysis was made using a standard statistical software. RESULTS: Eighty four people with SCA and 91 with HBA were recruited as cases and controls respectively. Subjects with SCA have more abnormal LV geometric patterns than those with HBA(p=0.000). Eccentric LVH(p=0.000) was more in SCA subjects while concentric LVH(p=0.054) and concentric remodeling(p=0.319) were not. Forty-one and fifty-two subjects with SCA and HBA respectively did ECGs. . Subjects with eccentric LVH had lower hip circumference, higher left atrial diameter, right atrial area, higher sokolow-lyon voltage sum, stroke volume and cardiac output. The Sokolow-Lyon voltage criteria at the traditional cut off point was not different between those with and without eccentric LVH. However, Sokolow-Lyon voltage criteria at a cut-off of ≥4.7mV detected eccentric LVH with a sensitivity of 60% and specificity of 83.3%.While Sokolow-Lyon voltage sum, stroke volume, right atrial area, and left atrial diameter correlated positively, pulse rate and hip circumference correlated inversely with eccentric LVH. Sokolow Lyon voltage sum was the independent determinant of eccentric LVH in this study. CONCLUSION: Sickle cell anemia predisposes to abnormal LV geometric patterns, especially eccentric LVH. There may be a need to review the electrocardiographic cut off points for defining eccentric LVH in the SCA populace.

Integrated Primary Palliative Care in Nigeria- Perspectives of Patients, Families and Providers.

BACKGROUND: Palliative care should be integrated into primary healthcare systems within low- and middle-income countries to achieve Universal Health Coverage goals. We aimed to identify preferences and expectations for primary palliative care among people living with serious illness and their families and the readiness of primary healthcare providers to deliver primary palliative care in Nigeria. METHODS: Qualitative descriptive interview study with 48 participants: people living with serious illness (n=21) and their family caregivers (n=15), healthcare providers (n=12). Data were analysed using thematic analysis. RESULTS: Three major themes were identified. 1.) Engaging patients and families. 2.) Managing patients and families' expectations and preferences. 3.) Addressing staffing-related issues. Patients and families have existing trust and bonds from using primary healthcare but lack individual agency necessary for person-centered care decisions. They expect an easily accessible service, opportunities for social interaction and adequate communication. Development of healthcare providers is needed to ensure an appropriate clinical response, manage interprofessional trust and ensure clear role delineation. CONCLUSIONS: Our findings have identified specific approaches to implement the WHO policy on integrated primary palliative care. Palliative care integration within primary healthcare in Nigeria can be achieved through building information and communication skills of healthcare providers, engaging and empowering patients to exercise their agency in care decisions, and adequately delineating healthcare providers' roles to ensure staff work within their competencies and training.

Prevalence, patterns and predictors of dyslipidaemia in Nigeria: a report from the REMAH study.

AIM: The aim of this study was to determine the prevalence and predictors of dyslipidaemia in adults in Nigeria. METHODS: Using the WHO criteria, we determined dyslipidaemia using serum lipid levels of 3 211 adult Nigerians, aged at least 18 years, obtained between March 2017 and February 2018 from two communities (rural and urban) in a state from each of the six geopolitical zones of Nigeria. RESULTS: The overall prevalence of low high-density lipoprotein cholesterol (l-HDL), elevated low-density lipoprotein cholesterol (e-LDL), hypertriglyceridaemia (h-TG) and hypercholesterolaemia (h-CHL) were 72.5,13.6, 21.4 and 7.5%, respectively. The adjusted odds of h-CHL [odds ratio (95% confidence interval) 1.47 (1.10-1.95)], h-TG [1.89 (1.48-2.41)] and e-LDL [1.51 (1.03-2.15)] increased with obesity. Being a rural dweller increased the odds of h-TG [1.55 (1.29-1.85)], e-LDL [1.38 (1.10-1.73)] and l-HDL [1.34 (1.14-1.58)]. The odds of h-CHL [2.16 (1.59-2.95)], h-TG [1.21 (1.01-1.47)], e-LDL [1.42 (1.13-1.80)] and l-HDL [0.78 (0.65-0.93)] increased with hypertension. Diabetes mellitus doubled only the odds of h-TG [2.04(1.36-3.03)]. CONCLUSION: The prevalence of dyslipidaemia, particularly low HDL-C, is high among adult Nigerians.

A Differential Response to Antihypertensive Therapy in African Men and Women: Insights From the CREOLE Trial.

BACKGROUND: We sought to address the paucity of data to support the evidence-based management of hypertension to achieve optimal blood pressure (BP) control on a sex-specific basis in Africa. METHODS: We undertook a post hoc analysis of the multicenter, randomized CREOLE (Comparison of Three Combination Therapies in Lowering Blood Pressure in Black Africans) Trial to test the hypothesis that there would be clinically important differences in office BP control between African men and women. We compared the BP levels of 397 and 238 hypertensive women (63%, 50.9 ± 10.5 years) and men (51.2 ± 11.3 years) from 10 sites across sub-Saharan Africa who completed baseline and 6-month profiling according to their randomly allocated antihypertensive treatment. RESULTS: Overall, 442/635 (69.6%) participants achieved an office BP target of <140/90 mm Hg at 6 months; comprising more women (286/72.0%) than men (156/65.5%) (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 1.07-2.39; P = 0.023). Women randomized to amlodipine-hydrochlorothiazide (HCTZ) (adjusted OR 3.03, 95% CI 1.71-5.35; P < 0.001) or amlodipine-perindopril (adjusted OR 2.62, 95% CI 1.49-4.58; P = 0.01) were more likely to achieve this target compared with perindopril-HCTZ. Among men, there were no equivalent treatment differences-amlodipine-HCTZ (OR 1.54, 95% CI 0.76-3.12; P = 0.23) or amlodipine-perindopril (OR 1.32, 95% CI 0.65-2.67; P = 0.44) vs. perindopril-HCTZ. Among the 613 participants (97%) with 24-hour ambulatory BP monitoring, women had significantly lower systolic (124.1 ± 18.1 vs. 127.3 ± 16.9; P = 0.028) and diastolic (72.7 ± 10.4 vs. 75.1 ± 10.5; P = 0.007) BP levels at 6 months compared with men. CONCLUSIONS: These data suggest clinically important differences in the therapeutic response to antihypertensive combination therapy among African women compared with African men.

Registry for Acute Coronary Events in Nigeria (RACE-Nigeria): Clinical Characterization, Management, and Outcome.

Background Coronary artery disease was hitherto a rarity in Africa. Acute coronary syndrome (ACS) accounts for coronary artery disease-related morbidity and mortality. Reports on ACS in Africa are few. Methods and Results We enrolled 1072 indigenous Nigerian people 59.2±12.4 years old (men, 66.8%) with ACS in an observational multicentered national registry (2013-2018). Outcome measures included incidence, intervention times, reperfusion rates, and 1-year mortality. The incidence of ACS was 59.1 people per 100 000 hospitalized adults per year, and comprised ST-segment-elevation myocardial infarction (48.7%), non-ST-segment-elevation myocardial infarction (24.5%), and unstable angina (26.8%). ACS frequency peaked 10 years earlier in men than women. Patients were predominantly from urban settings (87.3%). Median time from onset of symptoms to first medical contact (patients with ST-segment-elevation myocardial infarction) was 6 hours (interquartile range, 20.1 hours), and only 11.9% presented within a 12-hour time window. Traditional risk factors of coronary artery disease were observed. The coronary angiography rate was 42.4%. Reperfusion therapies included thrombolysis (17.1%), percutaneous coronary intervention (28.6%), and coronary artery bypass graft (11.2%). Guideline-based pharmacotherapy was adequate. Major adverse cardiac events were 30.8%, and in-hospital mortality was 8.1%. Mortality rates at 30 days, 3 months, 6 months, and 1 year were 8.7%, 9.9%, 10.9%, and 13.3%, respectively. Predictors of mortality included resuscitated cardiac arrest (odds ratio [OR], 50.0; 95% CI, 0.010-0.081), nonreperfusion (OR, 34.5; 95% CI, 0.004-0.221), pulmonary edema (OR, 11.1; 95% CI, 0.020-0.363), left ventricular diastolic dysfunction (OR, 4.1; 95% CI, 0.091-0.570), and left ventricular systolic dysfunction (OR, 2.1; 95% CI, 1.302-3.367). Conclusions ACS burden is rising in Nigeria, and patients are relatively young and from an urban setting. The system of care is evolving and is characterized by lack of capacity and low patient eligibility for reperfusion. We recommend preventive strategies and health care infrastructure-appropriate management guidelines.

Prevalence and Determinants of Masked Hypertension in Nigeria: The REMAH Study.

BACKGROUND: Estimating the burden of hypertension in Nigeria hitherto relied on clinic blood pressure (BP) measurement alone. This excludes individuals with masked hypertension (MH), i.e., normotensive clinic but hypertensive out-of-clinic BP. METHODS: In a nationally representative sample of adult Nigerians, we obtained clinic BP using auscultatory method and out-of-clinic BP by self-measured home BP with semi-automated oscillometric device. Clinic BP was average of 5 consecutive measurements and home BP was average of 3 days duplicate morning and evening readings. MH was clinic BP <140 mm Hg systolic and 90 mm Hg diastolic and home BP ≥135 mm Hg systolic and/or 85 mm Hg diastolic. RESULTS: Among 933 participants, the prevalence of sustained hypertension, MH, and white-coat hypertension was 28.3%, 7.9%, and 11.9%, respectively. Among subjects whose clinic BP were in the normotensive range (n = 558), the prevalence of MH was 13%; 12% among untreated and 27% among treated individuals. The mutually adjusted odds ratios of having MH among all participants with normotensive clinic BP were 1.33 (95% confidence interval, 1.10-1.60) for a 10-year higher age, 1.59 (1.09-2.40) for a 10 mm Hg increment in systolic clinic BP, and 1.16 (1.08-1.28) for a 10 mg/dl higher random blood glucose. The corresponding estimates in the untreated population were 1.24 (1.03-1.51), 1.56 (1.04-2.44), and 1.16 (1.08-1.29), respectively. CONCLUSIONS: MH is common in Nigeria and increasing age, clinic systolic BP, and random blood glucose are the risk factors.

Impact of relative systemic hypertension on the heart in sickle cell anaemia.

Sickle cell anaemia (SCA) is associated with macrovascular complications at relatively normal blood pressures. This has led to the development of the term 'relative systemic hypertension' (RSH). The electrocardiography (ECG) and echocardiography (ECHO) findings in these people has not been well highlighted. Patients with SCA in steady state were consecutively recruited. History, physical examination, ECG and ECHO information were obtained from all participants after informed consent was obtained. Eighty-three people were recruited in all- 15 of which had RSH, giving a prevalence of 18.1%. Those with RSH had higher packed cell volumes (PCV), smaller right atria area, lower tricuspid regurgitant velocities, lower incidence of early satiety, longer QTc and higher frequency of a history of vaso-occlusive crises. The indices of right and left ventricular function were normal in both groups. Right atrial area was the only significant determinant of RSH in this study. RSH is associated with higher PCV, longer QTc and smaller right atrial area in SCA patients. More studies to evaluate sympathetic output in SCA with RSH is required.

Development and Validation of a Electrocardiographic Diagnostic Score of Heart Failure Among Patients with Hypertension Attending a Tertiary Hospital in Ibadan, Nigeria: The RISK-HHF Case-Control Study.

OBJECTIVES: Hypertension is the leading cause of HF in sub-Saharan Africa. Electrocardiography (ECG) is a cheap and easily available stratification tool for the diagnosis and prognostication of individuals with hypertension. The aim of this study was to develop an ECG-based HF diagnostic score among patients with hypertension attending a specialist cardiology clinic. METHODS: One hundred and one (101) case-control age- and sex-matched pairs were recruited. The study population were adults with a clinical diagnosis of hypertensive HF failure (cases) and systemic hypertension without HF (controls). Participants underwent clinical assessment and ECG. Associations between ECG variables and HF risk were tested with chi square test. Logistic regression modelling (age- and sex adjusted) was trained on a random subset of participants and tested on the remaining participants to determine the ECG abnormalities that are diagnostic of HF and develop a HF diagnostic score. The HF diagnostic score was then validated in an independent dataset of the ECG-Hypertension Audit. Goodness of fit and c-statistics of the HF summed diagnostic score in the training, testing and validation datasets are presented. A two-sided p value of <0.05 was considered statistically significant. RESULTS: The independent ECG diagnostic markers of HF among hypertensive patients in this study in decreasing order of effect size were sinus tachycardia (aOR: 7.72, 95% CI: 2.31-25.85). arrhythmia (aOR: 7.14, 95% CI: 2.57-19.86), left ventricular hypertrophy (aOR: 4.47; 1.85-10.77) and conduction abnormality (aOR: 3.41, 95% CI: 1.21-9.65). The HF summed diagnostic score showed excellent calibration and discrimination in the training (Hosmer Lemeshow p = 0.90; c-statistic 0.82; 95% CI 0.76-0.89) and test samples (Hosmer Lemeshow p=0.31; c-statistic 0.73 95% CI 0.60 to 0.87) of the derivation cohort and an independent validation audit cohort (Hosmer Lemeshow p = 0.17; c-statistic 0.79 95% CI 0.74 to 0.84) respectively. The model showed high diagnostic accuracy in individuals with different intermediate pre-test probabilities of HF. CONCLUSIONS: A ECG based HF score consisting of sinus tachycardia, arrhythmia, conduction abnormality and left ventricular hypertrophy is diagnostic of HF especially in those with intermediate pre-test probability of HF. This has clinical importance in the stratification of individuals with systemic hypertension.

Urinary sodium excretion and its association with blood pressure in Nigeria: A nationwide population survey.

Assessment of level of salt intake in a population is the first step toward planning strategies aimed at salt reduction. As a surrogate of salt intake, we measured a single 24-hour urine sodium (uNa) of free-living 2503 adults in a nationally representative sample of Nigerians drawn from 12 rural and urban communities; and evaluated the community-level association of uNa with blood pressure (BP). Overall, the median (interquartile range (IQR)) of uNa was 99 (105) mmol, ranging from 23.8 (32.4) in rural north-central to 172.8 (131.0) mmol in urban northwestern region. Daily uNa was significantly higher (p < .001) in men compared to women (107.1 vs 93.9 mmol); and urban compared to rural dwellers (114.9 vs 86.0mmol). About one-half of participants excreted uNa in excess of recommended daily maximum value (86mmol). In a model adjusted for age, sex, body mass index (BMI), level of education, place of residence, and use of antihypertensive medication; being a man (odds ratio, OR 1.69, 95% confidence Interval CI, 1.21-2.37, p = .002) and being < 60 years of age (OR 1.74, 95% CI 1.23-2.45, p = .002), were associated with excreting higher than recommended uNa. In a fully adjusted model of the community-level analysis, urinary sodium, potassium, and sodium-to-potassium ratio each showed no significant independent association with both systolic and diastolic BPs. Among adult Nigerians, the median daily uNa excretion was 99 mmol and it had no significant association with blood pressure indices.

Prevalence, Awareness, Treatment and Control of Hypertension in Nigeria: Data from a Nationwide Survey 2017.

Background: Previous studies that evaluated the prevalence, awareness and treatment of hypertension in Nigeria were either localized to some specific regions of the country or non-standardized thereby making evaluation of trend in hypertension care difficult. Methods: We used the World Health Organization (WHO) STEPwise approach to chronic disease risk factor surveillance to evaluate in a nationally representative sample of 4192 adult Nigerians selected from a rural and an urban community in one state in each of the six geo-political zones of the country. Results: The overall age-standardized prevalence of hypertension was 38.1% and this varied across the geo-political zones as follows: North-Central, 20.9%; North-East, 27.5%; North-West, 26.8%; South-East, 52.8%; South-South, 44.6%; and South-West, 42.1%. Prevalence rate did not differ significantly (p > 0.05) according to place of residence; 39.2% versus 37.5 %; urban vs rural. Prevalence of hypertension increased from 6.8% among subjects less than 30 years to 63.0% among those aged 70 years and above. Awareness was better (62.2% vs. 56.6%; P = 0.0272); treatment rate significantly higher (40.9 % vs. 30.8%; P < 0.0001) and control similar (14 vs. 10.8%) among urban compared to rural residents. Women were more aware of (63.3% vs. 52.8%; P < 0.0001); had similar (P > 0.05) treatment (36.7 vs. 34.3%) and control (33.9% vs. 35.5%) rates of hypertension compared to men. Conclusion: Our results suggest a large burden of hypertension in Nigeria and a closing up of the rural-urban gap previously reported. This calls for a change in public health policies anchored on a primary health care system to address the emerging disease burden occasioned by hypertension.