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Background: There is rekindled interest in the cardiotoxicity of antimalarial medicines. Halofantrine is associated with QT interval prolongation. Fluconazole and kolanut alter the pharmacokinetics of halofantrine. Objectives: The study assessed the electrocardiographic changes of concomitant administration of kolanut or fluconazole with halofantrine and the effects on the QTc interval. Methods: Eighteen healthy volunteers received a single oral dose of halofantrine, halofantrine with kolanut or halofantrine with fluconazole in a crossover study. Twelve lead electrocardiography (ECG) was performed to measure the PR and QT interval (QTc). Statistical analysis was with SPSS at 5% level of significance. Results: PR intervals were shortened by halofantrine alone and halofantrine with kolanut (169.29 28.67 to 165.29 28.007 and 172.73 29.843 to 163.00 18.336ms) but was prolonged by halofantrine with fluconazole (177.70 27.394 to 186.59 44.434ms). There was prolongation of QTc (384.76 21.727 to 394.12 21.525; 381.36 22.29 to 388.30 17.26 and 382.35 20.08 to 390.84 21.97) in all the three treatment groups at 6 hours, p>0.05. One subject on halofantrine and fluconazole had QTc >440ms. Pre-treatment PR interval (PR0) correlated well with post-treatment PR6, and with PR14 r= 0.519, p= 0.014; r=0.664, p=0.013. Conclusion: Concomitant intake of kolanut with halofantrine was significantly decrease cardiac effect of halofantrine. Keywords: Drug interaction; fluconazole; halofantrine; kolanut; malaria; QT prolongation.

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 Conclusions These data suggest clinically important differences in the therapeutic response to antihypertensive combination therapy among African women compared with African men.

BACKGROUND: There are limited data on large-scale, multi-level implementation research studies to improve hypertension diagnosis, treatment, and control rates at the primary health care (PHC) level in Africa. We describe the characteristics, treatment, and control rates of patients with hypertension in public PHC centers in the Hypertension Treatment in Nigeria Program. METHODS: Data were collected from adults ≥18 years at 60 public PHC centers between January 2020 and November 2020. Hypertension treatment rates were calculated at registration and upon completion of the initial visit. Hypertension control rates were calculated based on systolic and diastolic blood pressures

Objectives: To estimate the potential health gains, costs, and cost-effectiveness of a mandatory limit on industrial trans fatty acids (iTFA) in the Nigerian food supply. Methods: We used Markov cohort models to estimate the effect on ischemic heart disease (IHD) burden, costs, and cost-effectiveness of a mandatory iTFA-limit (≤2% of all fats) for foods in Nigeria. Data on demographics, IHD epidemiology, and trans-fatty acid intake were derived from the 2019 Global Burden of Disease Study. We calculated the IHD burden attributable to iTFA by comparing the current trans-fatty acid intake to counterfactual settings with complete elimination of iTFA intake. Policy implementation costs (including government costs for legislation and monitoring, and industry costs for product reformulation), avoided IHD events and deaths, health-adjusted life years (HALYs) gained, and healthcare costs saved were estimated over 10 years and lifetime of the Nigerian population. Incremental cost-effectiveness ratios using net costs (i.e., implementation costs minus healthcare cost savings) and HALYs gained (both discounted at 3%) were used to assess cost-effectiveness. Results: Over the first 10 years, elimination of iTFA intake was estimated to prevent 9,996 (95% uncertainty interval: 8,870; 11,118): IHD deaths and 66,569 (58,862; 74,083) IHD events, and to save 90 million USD (78; 102) in total healthcare costs. The corresponding estimates over the lifetime were 259,934 (228,736; 290,191), 479,308 (95% UI: 420,472; 538,177), and ~518 (450; 587). Policy implementation costs (government plus industry) were estimated as 18 million USD (12; 25) over the first 10 years, and 27 million USD (20; 35) over the population lifetime. The intervention was estimated to be cost-saving. Findings were robust across several deterministic sensitivity analyses (Figure). Conclusions: Our findings support legislating a mandatory limit of iTFAs as a cost-saving strategy to avert substantial numbers of IHD events and deaths in Nigeria.

BackgroundSubclinical atherosclerosis characterizes cardiovascular diseases (CVD), and Human Immunodeficiency Virus (HIV) infection and antiretroviral therapy (ART) are identified risk factors for atherosclerosis. Meanwhile, data on HIV and atherosclerosis in Nigeria are limited.ObjectivesWe sought to estimate the prevalence of subclinical atherosclerosis and associated risk factors amongst adult persons living with HIV/AIDS (PLHIV) enrolled at University of Abuja Teaching Hospital, Gwagwalada, Abuja (UATH).MethodsThis was a cross-sectional study of 277 consecutively selected PLHIV ≥18 years enrolled for HIV care and treatment at UATH. Pretested structured questionnaire was used to collect data from consenting ART-experienced and ART-naïve patients on risk factors of atherosclerosis. Carotid intima media thickness (CIMT) ≥0.71 mm as measured by Doppler ultrasonography was used to identify patients with sub-clinical atherosclerosis. Two logistic regression models with (Model-A) and without (Model-B) traditional risk factors were fitted to identify risk factors of subclinical atherosclerosis.ResultsParticipants' mean age was 39.44 ± 10.71 years with female preponderance (64.26%). Overall prevalence of subclinical atherosclerosis was 43.32% (62.25% in ART-experienced). Model-A identified male sex [AOR 4.33(1.74–10.76), p = 0.002], advancing age [30–39 years AOR 5.95(1.31–26.96), p = 0.021]; ≥40 years AOR 19.51(4.30–88.56), p ≤ 0.001), advancing HIV infection [≥WHO stage II AOR 4.19(1.11–15.92), p = 0.035], hypercholesterolemia [AOR 3.88(1.47–10.25), p ≤ 0.001] and ≥5 year duration on ART [AOR 9.05(3.16–25.92), p ≤ 0.001] as risk factors of subclinical atherosclerosis. In Model-B (excluding traditional risk factors) on the other hand, advancing HIV infection [≥WHO stage II AOR 3.93(1.19–13.042), p = 0.025] and duration on ART [≥5 years AOR 11.43(4.62–28.29), p = 0.001] were found as risk factors of subclinical atherosclerosis.ConclusionSubclinical atherosclerosis was higher in ART-experienced patients, and this was irrespective of presence or absence of traditional risk factors. And advancing HIV disease and duration on ART were found as significant risk factors for subclinical atherosclerosis. We therefore recommend routine CVD risk screening in PLHIV.

In most African countries, the prevalence of industrially produced trans-fatty acids (iTFA) in the food supply is unknown. We estimated the number and proportion of products containing specific (any hydrogenated edible oils) and non-specific (vegetable fat, margarine, and vegetable cream) ingredients potentially indicative of iTFAs among pre-packaged foods collected in Kenya and Nigeria. We also summarized the number and proportion of products that reported trans-fatty acids levels and the range of reported trans-fatty acids levels. In total, 99 out of 5668 (1.7%) products in Kenya and 310 out of 6316 (4.9%) products in Nigeria contained specific ingredients indicative of iTFAs. Bread and bakery products and confectioneries in both countries had the most foods that contained iTFAs-indicative ingredients. A total of 656 products (12%) in Kenya and 624 products (10%) in Nigeria contained non-specific ingredients that may indicate the presence of iTFAs. The reporting of levels of trans-fatty acids was low in both Kenya and Nigeria (11% versus 26%, respectively, p < 0.001). With the increasing burden of ischemic heart disease in Kenya and Nigeria, the rapid adoption of WHO best-practice policies and the mandatory declaration of trans-fatty acids are important for eliminating iTFAs.

Introduction. Hypertension is a major global cause of cardiovascular disease and death with rising worldwide prevalence, particularly in low-income countries. With low awareness, poor treatment, and low control of hypertension in Africans, there is an increased number of patients with target organ damage (TOD), especially chronic kidney disease (CKD), as a consequence of hypertension. The aim of our study is to assess the prevalence of CKD from studies in Africa reporting TOD related to hypertension. Methods. We performed a search of PubMed/MEDLINE, Web of Science, EBSCOhost, and African Journals Online (AJOL) for studies reporting on CKD as TOD in patients with hypertension. The pooled estimate of CKD was then presented by subregions, age group, eGFR equations, and urban or rural location. Results. We identified 1,334 articles from which 12 studies were included for quantitative analysis. The studies included 5297 participants from 6 countries (Ghana, Nigeria, Uganda, Tanzania, Democratic Republic of Congo, and South Africa). The pooled prevalence of CKD was 17.8% (95% CI 13.0–23.3%), and CKD was significantly more prevalent in West Africa (21.3% (95% CI: 16.1–27.0); p < 0.0001 ) and in studies conducted in urban settings ( p < 0.001 ). CKD prevalence was not significantly different by type of GFR equation or age. Conclusion. This study reports a high prevalence of CKD related to hypertension with a higher prevalence in urban than rural areas. This emphasizes the role of hypertension in causing kidney damage, and the need for strategies to improve awareness, treatment, and control of hypertension in Africans. This study is registered with PROSPERO registration number CRD42018089263.

Increased consumption of unhealthy processed foods, particularly those high in sodium, is a major risk factor for cardiovascular diseases. The nutrition information on packaged foods can help guide consumers toward products with less sodium and support government actions to improve the healthiness of the food supply. The aims of this study were to estimate the proportion of packaged foods displaying nutrition information for sodium and other nutrients specified by Nigerian nutrition labelling regulations and to determine the amount of sodium in packaged foods sold in Nigeria using data from the nutritional information panel. Data were collected from November 2020 to March 2021 from in-store surveys conducted in supermarkets in three states. A total of 7039 products were collected. Overall, 91.5% (n = 6439) provided only partial nutrition information, 7.0% (n = 495) provided no nutritional information, and only 1.5% (n = 105) displayed a nutrient declaration that included all nutrients specified by 2019 Nigerian regulations. Some form of sodium content information was displayed for 86% of all products (n = 6032), of which around 45% (n = 2689) expressed this as ‘salt’ and 59% (n = 3559) expressed this as ‘sodium’, while a small number of food products had both ‘salt’ and ‘sodium’ content (3.6%). Provision of sodium or salt information on the label varied between food categories, ranging from 50% (vitamins and supplements, n = 2/4) to 96% (convenience foods, n = 44/46). Food categories with the highest median sodium content were ‘meat and meat alternatives’ (904 mg/100 g), ‘sauces, dressings, spreads, and dips’ (560 mg/100 g), and ‘snack foods’ (536 mg/100 g), although wide variation was often observed within categories. These findings highlight considerable potential to improve the availability and consistency of nutrition information on packaged products in Nigeria and to introduce further policies to reduce the amount of sodium in the Nigerian food supply.

Background Implementing an evidence-based hypertension program in primary healthcare centers (PHCs) in the Federal Capital Territory, Nigeria is an opportunity to improve hypertension diagnosis, treatment, and control and reduce deaths from cardiovascular diseases. This qualitative research study was conducted in Nigerian PHCs with patients, non-physician health workers, administrators and primary care physicians to inform contextual adaptations of Kaiser Permanente Northern California's hypertension model and the World Health Organization’s HEARTS technical package for the system-level, Hypertension Treatment in Nigeria (HTN) Program. Methods Purposive sampling in 8 PHCs identified patients (n = 8), non-physician health workers (n = 12), administrators (n = 3), and primary care physicians (n = 6) for focus group discussions and interviews. The Primary Health Care Performance Initiative (PHCPI) conceptual framework and Consolidated Framework for Implementation Research (CFIR) domains were used to develop semi-structured interviews (Appendix 1, Supplemental Materials) and coding guides. Content analysis identified multilevel factors that would influence program implementation. Results Participants perceived the need to strengthen four major health system inputs across CFIR domains for successful adaptation of the HTN Program components: (1) reliable drug supply and blood pressure measurement equipment, (2) enable and empower community healthcare workers to participate in team-based care through training and education, (3) information systems to track patients and medication supply chain, and (4) a primary healthcare system that could offer a broader package of health services to meet patient needs. Specific features of the PHCPI framework considered important included: accessible and person-centered care, provider availability and competence, coordination of care, and proactive community outreach. Participants also identified patient-level factors, such as knowledge and beliefs about hypertension, and financial and transportation barriers that could be addressed with better communication, home visits, and drug financing. Participants recommended using existing community structures, such as village health committees and popular opinion leaders, to improve knowledge and demand for the HTN Program. Conclusions These results provide information on specific primary care and community contextual factors that can support or hinder implementation and sustainability of an evidence-based, system-level hypertension program in the Federal Capital Territory, Nigeria, with the ultimate aim of scaling it to other parts of the country.

More than 1.2 billion adults worldwide have hypertension. High retention in clinical care is essential for long-term management of hypertension, but 1-year retention rates are less than 50% in many resource-limited settings.To evaluate short-term retention rates and associated factors among patients with hypertension in primary health care centers in the Federal Capital Territory of Nigeria.In this cohort study, data were collected by trained study staff from adults aged 18 years or older at 60 public, primary health care centers in Nigeria between January 2020 and July 2021 as part of the Hypertension Treatment in Nigeria (HTN) Program. Patients with hypertension were registered.Follow-up visit for hypertension care within 37 days of the registration visit.The main outcome was the 3-month rolling average 37-day retention rate in hypertension care, calculated by dividing the number of patients who had a follow-up visit within 37 days of their first (ie, registration) visit in the program by the total number of registered patients with hypertension during multiple consecutive 3-month periods. Interrupted time series analyses evaluated trends in retention rates before and after the intervention phase of the HTN Program. Mixed-effects, multivariable regression models evaluated associations between patient-, site-, and area council-level factors, hypertension treatment and control status, and 37-day retention rate.In total, 10 686 patients (68.3% female; mean [SD] age, 48.8 [12.7] years) were included in the analysis. During the study period, the 3-month rolling average 37-day retention rate was 41% (95% CI, 37%-46%), with wide variability among sites. The retention rate was higher among patients who were older (adjusted odds ratio [aOR], 1.01 per year; 95% CI, 1.01-1.02 per year), were female (aOR, 1.11; 95% CI, 1.01-1.23), had a higher body mass index (aOR, 1.01; 95% CI, 1.00-1.02), were in the Kuje vs the Abaji area council (aOR, 2.25; 95% CI, 1.25-4.04), received hypertension treatment at the registration visit (aOR, 1.27; 95% CI, 1.07-1.50), and were registered during the postintervention period (aOR, 1.16; 95% CI, 1.06-1.26).The findings suggest that retention in hypertension care is suboptimal in primary health care centers in Nigeria, although large variability among sites was found. Potentially modifiable and nonmodifiable factors associated with retention were identified and may inform multilevel, contextualized implementation strategies to improve retention.

Background: The effect of 3 commonly recommended combinations of anti-hypertensive agents—amlodipine plus hydrochlorothiazide (calcium channel blocker [CCB]+thiazide), amlodipine plus perindopril (CCB+ACE [angiotensin-converting enzyme]-inhibitor), and perindopril plus hydrochlorothiazide (ACE-inhibitor+thiazide) on blood pressure variability (V) are unknown. Methods: We calculated the blood pressure variability (BPV) in 405 patients (130, 146, and 129 randomized to ACE-inhibitor+thiazide, CCB+thiazide, and CCB+ACE-inhibitor, respectively) who underwent ambulatory blood pressure monitoring after 6 months of treatment in the Comparisons of Three Combinations Therapies in Lowering Blood Pressure in Black Africans trial (CREOLE) of Black African patients. BPV was calculated using the SD of 30-minute interval values for 24-hour ambulatory BPs and for confirmation using the coefficient of variation. Linear mixed model regression was used to calculate mean differences in BPV between treatment arms. Within-clinic BPV was also calculated from the mean SD and coefficient of variation of 3 readings at clinic visits. Results: Baseline distributions of age, sex, and blood pressure parameters were similar across treatment groups. Participants were predominately male (62.2%) with mean age 50.4 years. Those taking CCB+thiazide had significantly reduced ambulatory systolic and diastolic BPV compared with those taking ACE-inhibitor+thiazide. The CCB+thiazide and CCB+ACE-inhibitor groups showed similar BPV. Similar patterns of BPV were apparent among groups using within-clinic blood pressures and when assessed by coefficient of variation. Conclusions: Compared with CCB-containing combinations, ACE-inhibitor plus thiazide was associated with higher levels, generally significant, of ambulatory and within-clinic systolic and diastolic BPV. These results supplement the differential ambulatory blood pressure–lowering effects of these therapies in the CREOLE trial.

Background Hypertension is the most common cardiovascular disease in Nigeria and contributes to a large non-communicable disease burden. Our aim was to implement and evaluate a large-scale hypertension treatment and control program, adapted from the Kaiser Permanent Northern California and World Health Organization HEARTS models, within public primary healthcare centers in the Federal Capital Territory, Nigeria. Methods A type 2 hybrid, interrupted time series design was used to generate novel information on large-scale implementation and effectiveness of a multi-level hypertension control program within 60 primary healthcare centers in the Federal Capital Territory, Nigeria. During the formative phase, baseline qualitative assessments were held with patients, health workers, and administrators to inform implementation package adaptation. The package includes a hypertension patient registry with empanelment, performance and quality reporting, simplified treatment guideline emphasizing fixed-dose combination therapy, reliable access to quality essential medicines and technology, team-based care, and health coaching and home blood pressure monitoring. Strategies to implement and adapt the package were identified based on barriers and facilitators mapped in the formative phase, previous implementation experience, mid-term qualitative evaluation, and ongoing stakeholder and site feedback. The control phase included 11 months of sequential registration of hypertensive patients at participating primary healthcare centers, followed by implementation of the remainder of the package components and evaluation over 37 subsequent, consecutive months of the intervention phase. The formative phase was completed between April 2019 and August 2019, followed by initiation of the control phase in January 2020. The control phase included 11 months (January 2020 to November 2020) of sequential registration and empanelment of hypertensive patients at participating primary healthcare centers. After completion of the control phase in November 2020, the intervention phase commenced in December 2020 and will be completed in December 2023. Discussion This trial will provide robust evidence for implementation and effectiveness of a multi-level implementation package more broadly throughout the Federal Capital Territory, which may inform hypertension systems of care throughout Nigeria and in other low- and middle-income countries. Implementation outcome results will be important to understand what system-, site-, personnel-, and patient-level factors are necessary for successful implementation of this intervention. Trial registration ClinicalTrials.gov NCT04158154. The trial was prospectively registered on November 8, 2019.

Background: Majority of patients with hypertension require 2 or more medications to provide adequate blood pressure (BP) control. In addition, contemporary guidelines on the management of hypertension favor the use of single-pill combinations (SPCs) as they simplify the treatment regimen and decrease the daily pill burden for patients, both of which are associated with improved adherence. In spite of this, there is a lack of data in sub-Saharan Africa on the frequency of use of SPC anti-hypertensive medications. Method: We prospectively collected detailed clinical data from 373 patients with primary diagnosis of hypertension attending the cardiology clinic of University of Abuja Teaching Hospital between 2016 and 2017. Results: Three hundred and seventy three patients with mean age of 50.6 ± 12.3 years and mean body mass index of 31.2 ± 6.5kg/m2 on anti-hypertensive treatment were evaluated. Baseline mean systolic and diastolic BPs were 161.1 ± 3.1mmHg and 95.4 ± 15.6mmHg respectively, while the mean pulse pressure was 56.6 ± 18.1mmHg. 212 (56.8%) where on SPCs, with 32.5% on angiotensin receptor blockers (ARBs) plus hydrochlorothiazide (HCTZ), 18.9% on angiotensin converting enzyme inhibitors (ACEIs) plus HCTZ, 9.9% on amlodipine (AML) plus ARB, 3.3% on AML plus ACEI, 3.8% on thiazide-like diuretic plus atenolol, 29.2% on HCTZ plus amiloride, and 2.4% on triple combination of AML+ARB+HCTZ. Conclusion: Our study has shown that over 50% of our patients were on SPC anti-hypertensive medications, with the most prescribed single pill combination being angiotensin receptor blocker plus thiazide diuretic.

BACKGROUND The prevalence of hypertension among black African patients is high, and these patients usually need two or more medications for blood-pressure control. However, the most effective two-drug combination that is currently available for blood-pressure control in these patients has not been established. METHODS In this randomized, single-blind, three-group trial conducted in six countries in sub-Saharan Africa, we randomly assigned 728 black patients with uncontrolled hypertension (≥140/90 mm Hg while the patient was not being treated or was taking only one antihypertensive drug) to receive a daily regimen of 5 mg of amlodipine plus 12.5 mg of hydrochlorothiazide, 5 mg of amlodipine plus 4 mg of perindopril, or 4 mg of perindopril plus 12.5 mg of hydrochlorothiazide for 2 months. Doses were then doubled (10 and 25 mg, 10 and 8 mg, and 8 and 25 mg, respectively) for an additional 4 months. The primary end point was the change in the 24-hour ambulatory systolic blood pressure between baseline and 6 months. RESULTS The mean age of the patients was 51 years, and 63% were women. Among the 621 patients who underwent 24-hour blood-pressure monitoring at baseline and at 6 months, those receiving amlodipine plus hydrochlorothiazide and those receiving amlodipine plus perindopril had a lower 24-hour ambulatory systolic blood pressure than those receiving perindopril plus hydrochlorothiazide (between-group difference in the change from baseline, −3.14 mm Hg; 95% confidence interval [CI], −5.90 to −0.38; P=0.03; and −3.00 mm Hg; 95% CI, −5.8 to −0.20; P=0.04, respectively). The difference between the group receiving amlodipine plus hydrochlorothiazide and the group receiving amlodipine plus perindopril was −0.14 mm Hg (95% CI, −2.90 to 2.61; P=0.92). Similar differential effects on office and ambulatory diastolic blood pressures, along with blood-pressure control and response rates, were apparent among the three groups. CONCLUSIONS These findings suggest that in black patients in sub-Saharan Africa, amlodipine plus either hydrochlorothiazide or perindopril was more effective than perindopril plus hydrochlorothiazide at lowering blood pressure at 6 months. (Funded by GlaxoSmithKline Africa Noncommunicable Disease Open Lab; CREOLE ClinicalTrials.gov number, NCT02742467. opens in new tab.)

BACKGROUND: Rheumatic heart disease (RHD) was found in the THESUS-HF registry to be the third most common cause of acute heart failure (AHF) in Sub-Saharan Africa. METHODS: One thousand six patients with AHF from 9 Sub-Saharan African countries were recruited in THESUS-HF, of which 143 (14.3%) had RHD-AHF. Clinical characteristics and outcomes in patients with RHD-AHF and non-RHD-AHF were compared. Kaplan-Meier plots for time to all-cause death and/or HF readmission according to the presence of RHD-AHF and non-RHD-AHF were performed and survival distributions compared using the log-rank test. Cox regression was used to determine the hazard ratio of death to day 180 and death or readmission to day 60 after adjusting for confounders. RESULTS: Patients with RHD-AHF were younger, more often females, had higher rates of atrial fibrillation, had less hypertension, hyperlipidemia and diabetes, had lower BP, and higher pulse rate and better kidney function and echocardiographic higher ejection fraction larger left atria and more diastolic dysfunction. Patients with RHD-AHF had a numerically longer mean stay in the hospital (10.5 vs. 8.8 days) and significantly higher initial hospitalization mortality (9.1% vs. 3.4%). CONCLUSIONS: In conclusion, patients with HF related to RHD were younger, have higher rate of atrial fibrillation and have a worse short-term outcome compared to HF related to other etiologies in Sub-Saharan Africa.

© 2021 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/, Background: The emergence of novel coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has presented an unprecedented global challenge for the healthcare community. The ability of SARS-CoV-2 to get transmitted during the asymptomatic phase, and its high infectivity have led to the rapid transmission of COVID-19 beyond geographic regions facilitated by international travel, leading to a pandemic. To guide effective control and interventions, primary data is required urgently, globally, including from low- and middle-income countries where documentation of cardiovascular manifestations and risk factors in people hospitalized with COVID-19 is limited. Objectives: This study aims to describe the cardiovascular manifestations and cardiovascular risk factors in patients hospitalized with COVID-19. Methods: We propose to conduct an observational cohort study involving 5000 patients recruited from hospitals in low-, middle- and high-income countries. Eligible adult COVID-19 patients will be recruited from the participating hospitals and followed-up until 30 days post admission. The outcomes will be reported at discharge and includes the need of ICU admission, need of ventilator, death (with cause), major adverse cardiovascular events, neurological outcomes, acute renal failure, and pulmonary outcomes. Conclusion: Given the enormous burden posed by COVID-19 and the associated severe prognostic implication of CVD involvement, this study will provide useful insights on the risk factors for severe disease, clinical presentation, and outcomes of various cardiovascular manifestations in COVID-19 patients particularly from low and middle income countries from where the data remain scant., Dr. Kavita Singh is supported by the National Institutes of Health, Fogarty International Centre, USA; Emerging Global Leader grant award number: 1 K43 TW011164. Dr. Ribeiro is supported in part by Brazilian Agencies CNPq (310679/2016-8 and 465518/2014-1), by FAPEMIG (PPM-00428-17) and CAPES (88887.507149/2020-00), Prof. Karen Sliwa acknowledges support from the SERVIER/Hippocrate Foundation. The WHF COVID-19 Global Cardiovascular Disease Study is funded by WHF and at the time of the publica-tion, also by Sanofi Pasteur and Pfizer

Background Dipping of blood pressure (BP) at night is a normal physiological phenomenon. However, a non-dipping pattern is associated with hypertension mediated organ damage, secondary forms of hypertension and poorer long-term outcome. Identifying a non-dipping pattern may be useful in assessing risk, aiding the decision to investigate for secondary causes, initiating treatment, assisting decisions on choice and timing of antihypertensive therapy, and intensifying salt restriction. Objectives To estimate the prevalence and factors associated with non-dipping pattern and determine the effect of 6 months of three antihypertensive regimens on the dipping pattern among Black African hypertensive patients. Methods This was a secondary analysis of the CREOLE Study which was a randomized, single blind, three-group trial conducted in 10 sites in 6 Sub-Saharan African countries. The participants were 721 Black African patients, aged between 30 and 79 years, with uncontrolled hypertension and a baseline 24-h ambulatory blood pressure monitoring (ABPM). Dipping was calculated from the average day and average night systolic blood pressure measures. Results The prevalence of non-dipping pattern was 78% (564 of 721). Factors that were independently associated with non-dipping were: serum sodium > 140 mmol/l (OR = 1.72, 95% CI 1.17–2.51, p-value 0.005), a higher office systolic BP (OR = 1.03, 95% CI 1.01–1.05, p-value 0.003) and a lower office diastolic BP (OR = 0.97, 95% CI 0.95–0.99, p-value 0.03). Treatment allocation did not change dipping status at 6 months (McNemar’s Chi2 0.71, p-value 0.40). Conclusion There was a high prevalence of non-dipping among Black Africans with uncontrolled hypertension. ABPM should be considered more routinely in Black Africans with uncontrolled hypertension, if resources permit, to help personalise therapy. Further research is needed to understand the mechanisms and causes of non-dipping pattern and if targeting night-time BP improves clinical outcomes. Trial registration ClinicalTrials.gov (NCT02742467).

The current pandemic of SARS-COV 2 infection (Covid-19) is challenging health systems and communities worldwide. At the individual level, the main biological system involved in Covid-19 is the respiratory system. Respiratory complications range from mild flu-like illness symptoms to a fatal respiratory distress syndrome or a severe and fulminant pneumonia. Critically, the presence of a pre-existing cardiovascular disease or its risk factors, such as hypertension or type II diabetes mellitus, increases the chance of having severe complications (including death) if infected by the virus. In addition, the infection can worsen an existing cardiovascular disease or precipitate new ones.This paper presents a contemporary review of cardiovascular complications of Covid-19. It also specifically examines the impact of the disease on those already vulnerable and on the poorly resourced health systems of Africa as well as the potential broader consequences on the socio-economic health of this region.

Improved understanding of the current burden of hypertension, including awareness, treatment, and control, is needed to guide relevant preventative measures in Nigeria. A systematic search of studies on the epidemiology of hypertension in Nigeria, published on or after January 1990, was conducted. The authors employed random‐effects meta‐analysis on extracted crude hypertension prevalence, and awareness, treatment, and control rates. Using a meta‐regression model, overall hypertension cases in Nigeria in 1995 and 2020 were estimated. Fifty‐three studies (n = 78 949) met our selection criteria. Estimated crude prevalence of pre‐hypertension (120‐139/80‐89 mmHg) in Nigeria was 30.9% (95% confidence interval [CI]: 22.0%‐39.7%), and the crude prevalence of hypertension (≥140/90 mmHg) was 30.6% (95% CI: 27.3%‐34.0%). When adjusted for age, study period, and sample, absolute cases of hypertension increased by 540% among individuals aged ≥20 years from approximately 4.3 million individuals in 1995 (age‐adjusted prevalence 8.6%, 95% CI: 6.5‐10.7) to 27.5 million individuals with hypertension in 2020 (age‐adjusted prevalence 32.5%, 95% CI: 29.8‐35.3). The age‐adjusted prevalence was only significantly higher among men in 1995, with the gap between both sexes considerably narrowed in 2020. Only 29.0% of cases (95% CI: 19.7‐38.3) were aware of their hypertension, 12.0% (95% CI: 2.7‐21.2) were on treatment, and 2.8% (95% CI: 0.1‐5.7) had at‐goal blood pressure in 2020. Our study suggests that hypertension prevalence has substantially increased in Nigeria over the last two decades. Although more persons are aware of their hypertension status, clinical treatment and control rates, however, remain low. These estimates are relevant for clinical care, population, and policy response in Nigeria and across Africa., From 53 studies covering a population of 78 949 Nigerians, we estimated an age‐adjusted prevalence of hypertension of 8.6% in 1995 representing 4.3 million persons aged ≥20 years. Age‐adjusted prevalence increased to 32.5% (27.5 million individuals) in 2020. Of these, 29.0% of (95% CI: 19.7‐38.3) were aware of their hypertension, 12.0% (95% CI: 2.7‐21.2) were on treatment, and 2.8% (95% CI: 0.1‐5.7) had at‐goal blood pressure. Being the most populous country in Africa, our findings offer insights on the current status of hypertension in Africa, and are highly relevant for international comparisons. Improving hypertension awareness and clinical management is a public health priority.

Introduction: There is substantial clinical evidence that monotherapy with beta-blockers are less effective in reducing blood pressure among hypertensive Black patients compared to Whites. The highly selective beta-1 agents like nebivolol and bisoprolol have, however, been reported to be effective in reducing blood pressure in African Americans. However, results in African Americans cannot be extrapolated to native Africans because of genetic admixture and gene-environment interaction. There is, therefore, the need for us to generate data that are applicable to Africans residing in sub-Saharan Africa. We therefore decided to evaluate the efficacy and tolerability of highly selective beta-1 agent nebivolol in hypertensive Black patients residing in sub-Saharan Africa.Materials and Methods: The nebivolol study was a multicenter, prospective, observational program among hypertensive patients with 4- and 8-week follow up which was conducted in 5 cities in Nigeria of Abuja, Calabar, Enugu, Oghara, and Port Harcourt. Dosages of nebivolol used in keeping with local prescribing information were 5 and 10 mg once daily each. The effectiveness of treatment was assessed by change from baseline in mean office systolic and diastolic blood pressures, and the proportion of patients achieving the therapeutic goal of Results: We report the results of the 140 patients studied. The mean age and body mass index were 46.9 ± 7.3 years and 22.3 ± 5.8 kg/m2, respectively, and 57.1% were female. Nebivolol reduced SBP and DBP by 7.6 and 6.6 mmHg, respectively, in 4 weeks, and by 11.1 and 8.0 mm Hg, respectively, in 8 weeks. Blood pressure control was achieved in 54.8% of the patients in 4 weeks and increased to 60.4% in 8 weeks. There was no change in metabolic profile between randomization and at 8 weeks, and erectile dysfunction occurred in 1.3% of the study population.Conclusions: Nebivolol 5 and 10 mg appear efficacious in Nigerian Africans with no negative metabolic effect and minimal side effect profile.Clinical Trial Registration:www.ClinicalTrials.gov, Study Identification: NCT 03598673.

In this paper, we provide recommendations on the management of cardiovascular disease (CVD) among patients with confirmed or suspected coronavirus disease (COVID-19) to facilitate the decision making of healthcare professionals in low resource settings. The emergence of novel coronavirus disease, also known as Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has presented an unprecedented global challenge for the healthcare community. The ability of SARS-CoV-2 to get transmitted during the asymptomatic phase and its high infectivity have led to the rapid transmission of COVID-19 beyond geographic regions, leading to a pandemic. There is concern that COVID-19 is cardiotropic, and it interacts with the cardiovascular system on multiple levels. Individuals with established CVD are more susceptible to severe COVID-19. Through a consensus approach involving an international group this WHF statement summarizes the links between cardiovascular disease and COVID-19 and present some practical recommendations for the management of hypertension and diabetes, acute coronary syndrome, heart failure, rheumatic heart disease, Chagas disease, and myocardial injury for patients with COVID-19 in low-resource settings. This document is not a clinical guideline and it is not intended to replace national clinical guidelines or recommendations. Given the rapidly growing burden posed by COVID-19 illness and the associated severe prognostic implication of CVD involvement, further research is required to understand the potential mechanisms linking COVID-19 and CVD, clinical presentation, and outcomes of various cardiovascular manifestations in COVID-19 patients.

Although the varying phenotypic spectra of hypertensive heart disease (HHD) can be assessed by electrocardiography (ECG), echocardiography and cardiovascular magnetic resonance (CMR), ECG criteria for left ventricular hypertrophy (LVH) are insensitive, while echocardiography and CMR are expensive, less readily available and often lack requisite expertise. Consequently, the use of circulating biomarkers in the diagnosis and prognostication of HHD beyond the traditional N-terminal pro- b-type natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) have become an attractive alternative. We carried out a PubMed and Google Scholar databases’ search of original articles on circulating biomarkers used in the diagnosis of the different spectrum of HHD over the last 10 years [2005–2015] in humans. Fourteen studies met the inclusion criteria with NT-pro BNP being the most studied circulating biomarker in HHD followed by soluble ST2 (sST2). There is a lack of data on the use of circulating biomarkers in HHD. There is a need to explore further this area of investigative cardiology.

Pulmonary hypertension (PH) is a devastating, progressive disease with increasingly debilitating symptoms and usually shortened overall life expectancy. This article reviews the global epidemiology of PH with focus on low- and middle-income countries (LMICs) and sub-Sahara African in particular. Although left ventricular heart disease is the most common cause globally, the main contributing risk factors in LMICs are chronic infectious diseases especially human immunodeficiency virus (HIV) and schistosomiasis. Other important risk factors of PH are rheumatic heart disease, untreated congenital heart disease (CHD), and sickle cell disease. Despite existing epidemiological data of PH risk factors suggesting a high prevalence in sub-Saharan Africa (SSA), the available literature is limited. International registries in LMICs like the pan African pulmonary hypertension cohort (PAPUCO) study are essential to provide information about the causes, treatment, outcome, and the natural course of PH in Africa and other parts of the world. In addition, there is a need to track diagnostic and management practices in order to develop suitable algorithms to diagnose PH in LMICs.

Objective: Systemic hypertension remains an important risk factors for cardiovascular diseases and a major global public health problem. Left ventricular hypertrophy (LVH) is a recognized complication of hypertension and strongly predicts cardiovascular morbidity and mortality. In Nigeria, few studies evaluated the role of echocardiography in the diagnosis of LVHs among hypertensives. This study sets out to determine the prevalence of LVH among hypertensives as determined by echocardiography. Material and Methods: One hundred and seventy-eight hypertensives and eighty-nine age and sex-matched controls were recruited consecutively into the study. They all had echocardiography done to determine which among had LVH. The partition value for LVH for hypertensives was determined using the 97th percentile of the left ventricular mass for controls as a cutoff point. Results: Echocardiographic determined the prevalence of LVH among hypertensives was 32.4%. Conclusion: The echocardiographic prevalence of LVH was 32.4% in the study population. This is a significant proportion among the study population considering the clinical impact of LVH among patients with hypertension.

BACKGROUND In response to the call by the World Health Organisation to reduce premature deaths from non-communicable diseases by 25% by the year 2025 (25×25), the Pan-African Society of Cardiology (PASCAR), in partnership with several organisations, including the World Heart Federation, have developed an urgent 10-point action plan to improve detection, treatment and control of hypertension in Africa. Priority six of this action plan is to promote a task-shifting/task-sharing approach in the management of hypertension. AIM This capacity-building initiative aims to enhance the knowledge, skills and core competences of primary healthcare physicians in the management of hypertension and related complications. METHODS In a collaborative approach with the International Society of Hypertension, the British and Irish Hypertension Society, the Public Health Foundation of India and the Centre for Chronic Disease Control, the PASCAR hypertension taskforce held a continental faculty meeting in Kenya on 25 and 26 February 2018 to review and discuss a process of effective contextualisation and implementation of the Indian hypertension management course on the African continent. RESULTS A tailored African course in terms of evidence-based learning, up-to-date curriculum and on-the-job training was developed with a robust monitoring and evaluation strategy. The course will be offered on a modular basis with a judicious mix of case studies, group discussions and contact sessions, with great flexibility to accommodate participants' queries. CONCLUSIONS Hypertension affects millions of people in Africa and if left untreated is a major cause of heart disease, kidney disease and stroke. CCMH-Africa will train in the next 10 years, 25 000 certified general physicians and 50 000 nurses, capable of adequately managing uncomplicated hypertension, thereby freeing the few available specialists to focus on severe or complicated cases.

Summary Cardiovascular disease (CVD) is the frontrunner in the disease spectrum of sub-Saharan Africa, with stroke and ischaemic heart disease ranked seventh and 14th as leading causes of death, respectively, on this sub-continent. Unfortunately, this region is also grappling with many communicable, maternal, neonatal and nutritional disorders. Limited resources and the high cost of CVD treatment necessitate that primary prevention should have a high priority for CVD control in sub- Saharan Africa. One major challenge of such an approach is how to equip primary care to respond promptly and effectively to this burden. We present a practical approach on how primary care in sub-Saharan Africa could effectively address the prevention, treatment and control of CVD on the subcontinent. For effective prevention, control and treatment of CVD in sub-Saharan Africa, there should be strategic plans to equip primary care clinics with well-trained allied healthcare workers who are supervised by physicians.

In this paper, we provide recommendations on the management of cardiovascular disease (CVD) among patients with confirmed or suspected coronavirus disease (COVID-19) to facilitate the decision making of healthcare professionals in low resource settings. The emergence of novel coronavirus disease, also known as Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has presented an unprecedented global challenge for the healthcare community. The ability of SARS-CoV-2 to get transmitted during the asymptomatic phase and its high infectivity have led to the rapid transmission of COVID-19 beyond geographic regions, leading to a pandemic. There is concern that COVID-19 is cardiotropic, and it interacts with the cardiovascular system on multiple levels. Individuals with established CVD are more susceptible to severe COVID-19. Through a consensus approach involving an international group this WHF statement summarizes the links between cardiovascular disease and COVID-19 and present some practical recommendations for the management of hypertension and diabetes, acute coronary syndrome, heart failure, rheumatic heart disease, Chagas disease, and myocardial injury for patients with COVID-19 in low-resource settings. This document is not a clinical guideline and it is not intended to replace national clinical guidelines or recommendations. Given the rapidly growing burden posed by COVID-19 illness and the associated severe prognostic implication of CVD involvement, further research is required to understand the potential mechanisms linking COVID-19 and CVD, clinical presentation, and outcomes of various cardiovascular manifestations in COVID-19 patients. Publisher's Note: A corrigendum relating to this article has been published and can be found at http://doi.org/10.5334/gh.885

Background: There are few contemporary data on the mortality and morbidity associated with rheumatic heart disease or information on their predictors. We report the 2-year follow-up of individuals with rheumatic heart disease from 14 low- and middle-income countries in Africa and Asia. Methods: Between January 2010 and November 2012, we enrolled 3343 patients from 25 centers in 14 countries and followed them for 2 years to assess mortality, congestive heart failure, stroke or transient ischemic attack, recurrent acute rheumatic fever, and infective endocarditis. Results: Vital status at 24 months was known for 2960 (88.5%) patients. Two-thirds were female. Although patients were young (median age, 28 years; interquartile range, 18–40), the 2-year case fatality rate was high (500 deaths, 16.9%). Mortality rate was 116.3/1000 patient-years in the first year and 65.4/1000 patient-years in the second year. Median age at death was 28.7 years. Independent predictors of death were severe valve disease (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.80–3.11), congestive heart failure (HR, 2.16; 95% CI, 1.70–2.72), New York Heart Association functional class III/IV (HR, 1.67; 95% CI, 1.32–2.10), atrial fibrillation (HR, 1.40; 95% CI, 1.10–1.78), and older age (HR, 1.02; 95% CI, 1.01–1.02 per year increase) at enrollment. Postprimary education (HR, 0.67; 95% CI, 0.54–0.85) and female sex (HR, 0.65; 95% CI, 0.52–0.80) were associated with lower risk of death. Two hundred and four (6.9%) patients had new congestive heart failure (incidence, 38.42/1000 patient-years), 46 (1.6%) had a stroke or transient ischemic attack (8.45/1000 patient-years), 19 (0.6%) had recurrent acute rheumatic fever (3.49/1000 patient-years), and 20 (0.7%) had infective endocarditis (3.65/1000 patient-years). Previous stroke and older age were independent predictors of stroke/transient ischemic attack or systemic embolism. Patients from low- and lower-middle–income countries had significantly higher age- and sex-adjusted mortality than patients from upper-middle–income countries. Valve surgery was significantly more common in upper-middle–income than in lower-middle– or low-income countries. Conclusions: Patients with clinical rheumatic heart disease have high mortality and morbidity despite being young; those from low- and lower-middle–income countries had a poorer prognosis associated with advanced disease and low education. Programs focused on early detection and the treatment of clinical rheumatic heart disease are required to improve outcomes.

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain major causes of heart failure, stroke and death among African women and children, despite being preventable and imminently treatable. From 21 to 22 February 2015, the Social Cluster of the Africa Union Commission (AUC) hosted a consultation with RHD experts convened by the Pan-African Society of Cardiology (PASCAR) in Addis Ababa, Ethiopia, to develop a ‘roadmap’ of key actions that need to be taken by governments to eliminate ARF and eradicate RHD in Africa. Seven priority areas for action were adopted: (1) create prospective disease registers at sentinel sites in affected countries to measure disease burden and track progress towards the reduction of mortality by 25% by the year 2025, (2) ensure an adequate supply of high-quality benzathine penicillin for the primary and secondary prevention of ARF/RHD, (3) improve access to reproductive health services for women with RHD and other non-communicable diseases (NCD), (4) decentralise technical expertise and technology for diagnosing and managing ARF and RHD (including ultrasound of the heart), (5) establish national and regional centres of excellence for essential cardiac surgery for the treatment of affected patients and training of cardiovascular practitioners of the future, (6) initiate national multi-sectoral RHD programmes within NCD control programmes of affected countries, and (7) foster international partnerships with multinational organsations for resource mobilisation, monitoring and evaluation of the programme to end RHD in Africa. This Addis Ababa communiqué has since been endorsed by African Union heads of state, and plans are underway to implement the roadmap in order to end ARF and RHD in Africa in our lifetime.

RESEARCH OBJECTIVE: The prevalence of hypertension among adults in Nigeria is high (29‐45%), yet awareness (14‐30%), treatment (

Summary Background and aim: The Pan-African Society of Cardiology (PASCAR) has identified hypertension as the highest area of priority for action to reduce heart disease and stroke on the continent. The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection, treatment and control of hypertension and cardiovascular health in sub-Saharan Africa (SSA) by the year 2025. Methods: Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension. In 2014, experts in different fields, including physicians and non-physicians, were invited to join. Via faceto- face meetings and teleconferences, the consortium made a situation analysis, set a goal, identified roadblocks and solutions to the management of hypertension and customised the World Heart Federation roadmap to Africa. Results: Hypertension is a major crisis on the continent but very few randomised, controlled trials have been conducted on its management. Also, only 25.8% of the countries have developed or adopted guidelines for the management of hypertension. Other major roadblocks are either government and health-system related or healthcare professional or patient related. The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25% control of hypertension in Africa by 2025. Conclusions: Hypertension affects millions of people in SSA and if left untreated, is a major cause of heart disease and stroke. Very few SSA countries have a clear hypertension policy. This PASCAR roadmap identifies practical and effective solutions that would improve detection, treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national settings.

Hypertension has been established as one of the commonest causes of heart failure especially in sub-Saharan Africa. We have previously observed a high prevalence of left ventricular (LV) systolic dysfunction in hypertensive heart failure patients in Nigeria despite a low prevalence of ischemic heart disease. The present study was, therefore, undertaken to assess the prevalence of asymptomatic LV systolic dysfunction in hypertensive black African subjects with no history of heart failure.One thousand nine hundred forty-seven hypertensive subjects without heart failure presenting to the Cardiology Unit, Department of Medicine, University of Abuja Teaching Hospital, Nigeria, from April 2006 to August 2013 had clinical and echocardiographic evaluation.Nine hundred fifty-three (48.9%) were males and 994 (51.1%) were females. One thousand eight hundred seventeen (93.3%) had normal LV systolic function (LV ejection fraction (LVEF) ≥ 54%), 68 (3.5%) had mild LV systolic dysfunction (LVEF 45-54%), 43 (2.3%) had moderate LV systolic dysfunction (LVEF 30-44%), and 16 (0.9%) had severe LV systolic dysfunction (LVEF30%). Male subjects had worse LV systolic function compared to women (mean LVEF 73.2% vs. 75.6%, P value0.0001) and diabetic subjects had worse LV systolic function compared to nondiabetic subjects (LVEF 72.3% vs. 75.7%, P = 0.02). In multivariate regression analysis, lower LVEF as a continuous variable was associated with older age, male sex, diabetes mellitus, LV mass indexed for body surface area, diastolic blood pressure, posterior wall thickness in diastole, left atrial diameter, and LV internal diameter in diastole.In a cohort of asymptomatic Black hypertensive subjects, 6.7% had LV systolic dysfunction, which was associated with male gender, diabetes mellitus, and larger LV mass.

Aims Our aim is to compare the impact of the 2 most widely used methods of indexing left ventricular mass (LVM) on the distribution of abnormal left ventricular (LV) geometric patterns, in a large sample of untreated asymptomatic black hypertensive subjects. Methods and Results All patients with hypertension referred to the Cardiology unit of University of Abuja Teaching Hospital, Abuja, Nigeria from 2006 to 2013, who gave informed consent, and underwent physical examination and echocardiography. LVM indexation was classified into 4 geometric patterns after echocardiography: normal geometry, concentric hypertrophy, concentric remodeling, and eccentric hypertrophy. Concentric hypertrophy was the commonest geometric pattern and was detected in 33.6% to 39.5% of the patients. LVM/height2.7 was a better method to detect abnormal geometric pattern than LVM/BSA (P, The 2 most widely used methods of indexing left ventricular mass (LVM) on the distribution of abnormal left ventricular (LV) geometric patterns were applied in a large population of untreated asymptomatic black hypertensive subjects with no clinical evidence of coronary artery disease. Abnormal LV geometry was found in greater than 80% of the population, concentric hypertrophy was the commonest geometric pattern, and LVM indexed for height2.7 was a better method than LVM indexed for BSA in detecting LVH.

8 p., Background Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions. Here, in the International Congestive Heart Failure (INTERCHF) study, we aimed to measure mortality at 1 year in patients with heart failure in Africa, China, India, the Middle East, southeast Asia and South America; we also explored demographic, clinical, and socioeconomic variables associated with mortality. Methods We enrolled consecutive patients with heart failure (3695 [66%] clinic outpatients, 2105 [34%] hospital in patients) from 108 centres in six geographical regions. We recorded baseline demographic and clinical characteristics and followed up patients at 6 months and 1 year from enrolment to record symptoms, medications, and outcomes. Time to death was studied with Cox proportional hazards models adjusted for demographic and clinical variables, medications, socioeconomic variables, and region. We used the explained risk statistic to calculate the relative contribution of each level of adjustment to the risk of death. Findings We enrolled 5823 patients within 1 year (with 98% follow-up). Overall mortality was 16·5%: highest in Africa (34%) and India (23%), intermediate in southeast Asia (15%), and lowest in China (7%), South America (9%), and the Middle East (9%). Regional differences persisted after multivariable adjustment. Independent predictors of mortality included cardiac variables (New York Heart Association Functional Class III or IV, previous admission for heart failure, and valve disease) and non-cardiac variables (body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease). 46% of mortality risk was explained by multivariable modelling with these variables; however, the remainder was unexplained. Interpretation Marked regional differences in mortality in patients with heart failure persisted after multivariable adjustment for cardiac and non-cardiac factors. Therefore, variations in mortality between regions could be the result of health-care infrastructure, quality and access, or environmental and genetic factors. Further studies in large, global cohorts are needed. Funding The study was supported by Novartis.

The global COVID-19 pandemic has created in its wake an urgent need for a clear guide for managing cardiovascular diseases and the complications it causes on the cardiovascular system. In this regard, the Executive Council of the Nigerian Cardiac Society constituted a committee to develop guidelines on management of Coronavirus Disease 2019 (COVID 19) and Cardiovascular Diseases. These guidelines have been written to provide a simple approach to managing cardiovascular diseases among COVID 19 patients in Nigeria. It will also provide information about potential cardiac implications of COVID 19 based on evidence and offer early clinical guidance on the management, given the current uncertainty of COVID 19. We have intended that this brief write up and set of recommendations be useful not only for primary care physicians, residents and medical students, but also for all professionals who work as hands-on practitioners.

Aim : Although plasma NT-proBNP differentiates hypertension (HT) with or without left ventricular hypertrophy (LVH) from hypertensive heart failure (HHF), most of the published data are based on studies in Western populations. Also, most previous studies did not consider left ventricular (LV) diastolic function and right ventricular (RV) function. We therefore examined the relation between NT-proBNP on LV and RV remodelling in an African hypertensive cohort. Methods : Subjects were subdivided into three groups after echocardiography: hypertensives without LVH (HT) (n = 83); hypertensives with LVH (HT+LVH) (n = 50); and those with hypertensive heart failure (HHF) (n = 77). Results : Subjects with HHF had significantly higher NT-proBNP levels compared to the HT+LVH group (p < 0.0002). NT-proBNP correlated positively with right atrial area, an indirect measure of RV function. Conclusions : NT-proBNP is proposed as a useful biomarker in differentiating hypertension with or without LVH from hypertensive heart failure in black hypertensive subjects.

Aims In Western countries with typically elderly ischaemic acute heart failure patients, predictors and clinical outcome of renal dysfunction and worsening renal function are well described. However, the prevalence, predictors and clinical outcome of renal dysfunction in younger, mainly hypertensive acute heart failure patients from Africa, have not been described. Methods and results From 1006 patients enrolled in the sub-Saharan Africa Survey of Heart Failure (THESUS-HF), renal function was determined by the estimated glomerular filtration rate using the Modification of Diet in Renal Disease (MDRD) formula. Worsening renal function was defined as an increase in creatinine ≤0.3 mg/dL (26.5 µmol/L) from baseline to day 7/discharge. The mean (SD) age of the patients was 52.4 (18.2) years, 481 (50.8%) were women and the predominant race was black African [932 of 946 (98.5%)]. Heart failure was most commonly a result of hypertension (n = 363, 39.5%) and only 7.8% had ischaemic heart failure. At hospital admission, 289 patients (30.6%) had an estimated glomerular filtration rate ≤60 ml/min.1.73m2. Worsening renal function during hospitalization was detected in 53 (9.8 %) of 543 patients with a follow-up creatinine value, and was independently associated with the Western sub-Saharan region, body mass index, and the presence of rales. Worsening renal function was an independent predictor of death or readmission over 60 days [multivariable hazard ratio = 2.06 (1.10, 3.38); P = 0.023] and all-cause death over 180 days [multivariable hazard ratio =1.92 (1.08, 3.38); P = 0.025]. Conclusions Renal dysfunction is also prevalent in younger non-ischaemic acute heart failure patients in Africa, but worsening renal function is less prevalent and has different predictors compared with Western cohorts. Nevertheless, worsening renal function is strongly and independently related with clinical outcome.

Hypertension and hypertensive heart disease is one of the main contributors to a growing burden of non-communicable forms of cardiovascular disease around the globe. The recently published global burden of disease series showed a 33 % increase of hypertensive disorders in pregnancy in the past two decades with long-term consequences. Africans, particularly younger African women, appear to be bearing the brunt of this increasing public health problem. Hypertensive heart disease is particularly problematic in pregnancy and is an important contributor to maternal case-fatality. European physicians increasingly need to attend to patients from African decent and need to know about unique aspects of disease presentation and pharmacological as well as non-pharmacological care. Reductions in salt consumption, as well as timely detection and treatment of hypertension and hypertensive heart disease remain a priority for effective primary and secondary prevention of CVD (particularly stroke and CHF) in African women. This article reviews the pattern, potential causes and consequences and treatment of hypertension and hypertensive heart disease in African women, identifying the key challenges for effective primary and secondary prevention in this regard.

Soluble ST2 is a biomarker of cardiomyocyte stretch that is useful in the diagnosis and prognosis of coronary artery disease. Its role in the field of hypertension and hypertensive heart failure (HHF) has not yet been well investigated. We studied the effect of left ventricular remodelling on the concentration of soluble ST2 in a cohort of 210 subjects with hypertension (HT). Left ventricular hypertrophy (LVH) was considered present when echocardiographic left ventricular mass indexed for height in metres (m) was greater than 46.2 g m(-1 2.7) in women and 49.2 g m(-1 2.7) in men. Subjects were subdivided into three groups: those without LVH (HT, n = 83); those with LVH (hypertension with left ventricular hypertrophy (HTLVH), n = 50) and those with HHF, n=77). Plasma ST2 and NT-pro BNP were measured using electrochemiluminescence type immunoassay. Subjects with HHF had higher plasma ST2 concentrations compared to HTLVH (134.7 ± 57.3 ng ml(-1) versus 23.0 ± 8.3 ng ml(-1), P < 0.001) and those with HT (134.7 ± 57.3 ng ml(-1) versus 14.5 ± 4.9 ng ml(-1), P < 0.0001). NT-pro BNP levels were similar when HTLVH was compared with HT (P = 0.68), but subjects with HHF had significantly higher NT-pro BNP compared to HTLVH (P < 0.0002). Soluble ST2 had strong correlation with clinical and echocardiograhic parameters, and correlated well with NT-pro BNP (r = 0.41, P < 0.0001). Plasma ST2 is a useful biomarker in not only differentiating HHF from HT with or without LVH, but also distinguishes hypertensive LVH from HT without LVH.

Left ventricular (LV) hypertrophy (LVH) is classified according to geometric pattern into 4 types: concentric hypertrophy, eccentric hypertrophy, concentric remodeling, and normal geometry. Prevalence of death and cardiovascular complications associated with hypertension depend on the geometric pattern. Although soluble ST2 levels, a novel cardiac biomarker of mechanical strain is increased in hypertension, the relationship with hypertensive LV geometric patterns has not been studied. The authors investigated the relationship between soluble ST2 levels and LV geometric patterns in a cohort of hypertensive patients. LVH was considered present when echocardiographic LV mass index exceeded 49.2 g/m(2.7) in men and 46.2 g/m(2.7) in women. Patients with concentric hypertrophy had higher soluble ST2 levels compared with patients with normal geometry (20.4±8.4 ng/mL vs 14.3±5.4 ng/mL, P

Aims Contrary to elderly patients with ischaemic-related acute heart failure (AHF) typically enrolled in North American and European registries, patients enrolled in the sub-Saharan Africa Survey of Heart Failure (THESUS-HF) were middle-aged with AHF due primarily to non-ischaemic causes. We sought to describe factors prognostic of re-admission and death in this developing population. Methods and results Prognostic models were developed from data collected on 1006 patients enrolled in THESUS-HF, a prospective registry of AHF patients in 12 hospitals in nine sub-Saharan African countries, mostly in Nigeria, Uganda, and South Africa. The main predictors of 60-day re-admission or death in a model excluding the geographic region were a history of malignancy and severe lung disease, admission systolic blood pressure, heart rate and signs of congestion (rales), kidney function (BUN), and echocardiographic ejection fraction. In a model including region, the Southern region had a higher risk. Age and admission sodium levels were not prognostic. Predictors of 180-day mortality included malignancy, severe lung disease, smoking history, systolic blood pressure, heart rate, and symptoms and signs of congestion (orthopnoea, peripheral oedema and rales) at admission, kidney dysfunction (BUN), anaemia, and HIV positivity. Discrimination was low for all models, similar to models for European and North American patients, suggesting that the main factors contributing to adverse outcomes are still unknown. Conclusion Despite the differences in age and disease characteristics, the main predictors for 6 months mortality and combined 60 days re-admission and death are largely similar in sub-Saharan Africa as in the rest of the world, with some exceptions such as the association of the HIV status with mortality.