The association of blood pressure, body mass index and carotid intima-media thickness as childhood predictors of cardiovascular disease risk: A systematic review and meta-analysis.

Background and Aims: Blood pressure, body mass index (BMI), and carotid intima-media thickness (CIMT) are well-known independent predictors of cardiovascular disease especially in adulthood. However, there is insufficient evidence regarding the statistical significance of the relationship between childhood CIMT, blood pressure and BMI. This systematic review and meta-analysis was therefore conducted to ascertain the relationship. Methods: This systematic review and meta-analysis was reported in accordance with the PRISMA statement. Three electronic databases were searched, namely EMBASE, MEDLINE and the Cochrane Library. Data were extracted independently by two review authors. Quantitative data were analyzed using Review Manager. Results: The meta-analysis was conducted using a random effects model and standard mean difference. The results of the meta-analysis indicated a statistically significant difference in CIMT of 0.86 (95% CI: 0.41-1.31) between normotensive versus hypertensive children. Again, overweight and moderately obese children had higher CIMT values as compared to normal weight children with a pooled standard mean difference of 0.72 (95% CI: 0.24-1.20) and 2.75 (95% CI: 0.73-4.77) respectively. The pooled standard mean difference of systolic and diastolic blood pressures was found to be 2.44 (95% CI: 1.69-3.19) and 1.28 (95% CI: 0.65-1.92) respectively between normal weight and overweight/obese children. Conclusion: The meta-analysis found a significant difference in CIMT between normotensive and hypertensive children, with overweight and moderately obese children having higher CIMT values. Thus, conducting CIMT screening for obese or overweight children and children with increased blood pressure can provide valuable information about their cardiovascular disease risk.

Effect of a Cardiovascular Polypill on Poststroke Cognition Among Ghanaians: Secondary Analysis of a Randomized Clinical Trial.

BACKGROUND: Poststroke cognitive impairment is prevalent worldwide, with no satisfactory preventative therapeutic strategies. We report on the effect of a cardiovascular polypill on cognitive performance among recent stroke survivors. METHODS AND RESULTS: The SMAART (Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment) trial was a phase II randomized trial primarily assessing the polypill versus usual care for secondary prevention after a recent ischemic stroke. Participants allocated to the experimental arm were provided 2 Polycaps taken orally once a day for 12 months. A capsule of Polycap contained aspirin 100 mg, simvastatin 20 mg, hydrochlorothiazide 12.5 mg, ramipril 5 mg, and atenolol 50 mg. Participants in the usual care arm received standard secondary prevention therapy. We compared slopes of the trajectory of raw scores in the executive, language, memory, and visuospatial cognitive domains and aggregated cognitive scores over 12 months via a linear mixed-effects model. We enrolled 148 eligible participants (n=74 in each arm) and 59 versus 64 participants in the polypill and usual care arms, respectively, at month 12. Compared with the usual care arm, the slopes of cognitive performance over 12 months in the polypill arm were steeper by 2.02 units (95% CI, 0.52-3.53), P=0.009 in executive domain, 1.88 units (95% CI, 0.42-3.34), P=0.012 in language domain, 2.60 (0.03-5.17), P=0.049 in memory domain, 0.55 (-0.80 to 1.91), P=0.42 in the visuospatial domain, and global cognitive performance 6.87 units (95% CI, 1.44-12.30), P=0.013. CONCLUSIONS: The cardiovascular polypill is associated with a signal of better cognitive performance over 12 months among stroke survivors. Further definitive trials are warranted. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03329599.

Successful conservative management of a large 12-week-old cervical ectopic pregnancy in a nulliparous woman: a case report.

Cervical ectopic pregnancy (CEP) accounts for less than 0.1% of all ectopic pregnancies. CEP is associated with high morbidity and mortality potential due to the associated life-threatening hemorrhage. When it is large, detected late, and occurs in a nulliparous woman, management is more challenging as it requires the need to preserve the uterus. We present a case of a 33-year-old nulliparous woman with a large live cervical ectopic pregnancy at 12 weeks + 1 day gestation and a very high serum ß-HCG of 126,750 Miu/ml. She was successfully managed with suction curettage and cervical encerclage tamponade in order to preserve the uterus. The treatment was associated with significant hemorrhage and a prolonged period of follow-up. In low-resource settings, uterine-conserving management of CEP can be challenging, and curettage with cervical encerclage tamponade can be a cost-effective treatment modality even though it is associated with significant haemorrhage and prolonged treatment period.

A cardiovascular polypill for secondary stroke prevention in a tertiary centre in Ghana (SMAART): a phase 2 randomised clinical trial.

BACKGROUND: A cardiovascular polypill containing generic drugs might facilitate sustained implementation of and adherence to evidence-based treatments, especially in resource-limited settings. However, the impact of a cardiovascular polypill in mitigating atherosclerotic risk among stroke survivors has not been assessed. We aimed to compare a polypill regimen with usual care on carotid intima-media thickness (CIMT) regression after ischaemic stroke. METHODS: In SMAART, a phase 2 parallel, open-label, assessor-masked, randomised clinical trial, we randomly allocated individuals (aged ≥18 years) who had an ischaemic stroke within the previous 2 months, using a computer-generated randomisation sequence (1:1), to either a polypill or usual care group at a tertiary centre in Ghana. The polypill regimen was a fixed-dose pill containing 5 mg ramipril, 50 mg atenolol, 12·5 mg hydrochlorothiazide, 20 mg simvastatin, and 100 mg aspirin administered as two capsules once per day for 12 months. Usual care was tailored guideline-recommended secondary prevention medications. The primary outcome was the change in CIMT over 12 months with adjustment for baseline values, compared using ANCOVA in all participants with complete data at month 12. Safety was analysed in all randomly assigned participants. This trial is registered at ClinicalTrials.gov, NCT03329599, and is completed. FINDINGS: Between Feb 12, 2019, and Dec 4, 2020, we randomly assigned 148 participants (74 to the usual care group and 74 to the polypill group), 74 (50%) of whom were male and 74 (50%) female. CIMT was assessed in 62 (84%) of 74 participants in the usual care group and 59 (80%) of 74 participants in the polypill group; the main reason for loss to follow-up was participants not completing the study. The mean CIMT change at month 12 was -0·092 mm (95% CI -0·130 to -0·051) in the usual care group versus -0·017 mm (-0·067 to 0·034) in the polypill group, with an adjusted mean difference of 0·049 (-0·008 to 0·109; p=0·11). Serious adverse events occurred among two (3%) participants in the usual care group, and eight (11%) participants in the polypill group (p=0·049). INTERPRETATION: The polypill regimen resulted in similar regression in subclinical atherosclerosis and many secondary and tertiary outcome measures as the tailored drug regimen, but with more serious adverse events. Larger, longer-term, event-based studies, including patients with stroke in primary care settings, are warranted. FUNDING: US National Institutes of Health. TRANSLATION: For the Akan (Twi) translation of the abstract see Supplementary Materials section.

Burden of subclinical carotid atherosclerosis and vascular risk factors among people living with HIV in Ghana.

BACKGROUND: The burden of cardiovascular disease (CVD) among people living with HIV (PLWH) in sub-Saharan Africa is projected to rise due to a rapid epidemiological transition and improved treatment of HIV infection on the sub-continent. OBJECTIVE: The Evaluation of Vascular Event Risk while on Long-term Anti-retroviral Suppressive Therapy (EVERLAST) Study sought to assess the extent of subclinical atherosclerosis and characterize the nature of CVD risk factors among HIV patients on Antiretroviral therapy (ART) in Ghana. METHODS: We conducted a cross-sectional study involving HIV patients on antiretroviral therapy (n = 250) in comparison with HIV positive ART naïve (n = 201), and HIV uninfected controls (n = 250). We assessed prevalence of hypertension, dyslipidemia, diabetes mellitus, central obesity, and carotid atherosclerosis using B-mode carotid Doppler ultrasonography. We assessed factors associated with subclinical atherosclerosis defined by a carotid intimal media thickness (CIMT) cut-off of ≥0.78 mm among PLWH using a logistic regression model. RESULTS: Mean age of PLWH on combination ART (cART) was 45.7 ±â€¯8.6 years, 42.9 ±â€¯8.8 years among PLWH not on cART, and 44.9 ±â€¯9.5 years among HIV negative controls of which 81.2%, 81.6% and 81.1% respectively were females. Prevalence of subclinical atherosclerosis at the common carotid artery in the three groups was 67.6%, 66.7% and 62.4%, p = 0.43. Among PLWH, raised serum total cholesterol (OR 1.16, 95% CI: 1.00-1.35) and triglycerides (OR 1.32, 95% CI: 1.01-1.73) were significantly associated with subclinical atherosclerosis. Prevalence of vascular risk factors among PLWH on cART, PLWH cART naïve, and HIV negative controls respectively were as follows: dyslipidemia- 79.5%, 83.1%, and 73.5%, p = 0.04; hypertension- 40.2%, 23.4%, and 44.9%, p < 0.0001; central obesity-61.8%, 66.7%, and 78.2%, p < 0.0001; diabetes mellitus-6.8%, 5.5% and 4.9%, p = 0.53. CONCLUSION: Overall while there is a high baseline prevalence of CVD risk factors in the Ghanaian population, serum lipid derangements appear to be more prevalent among HIV infected patients, and are linked to sub-clinical atherosclerosis. Future studies need to confirm these findings, explore the underlying pathophysiology, and optimize treatment strategies to avert untoward CVD outcomes.