COVID-19 complications in a small-town hospital in South Africa

South Africa has experienced three deadly waves of the COVID-19 pandemic with devastating consequences, but little is known about the experiences in small-town hospitals in the country. Between May 2020 and June 2021, author GC treated ~100 confirmed COVID-19 cases. This retrospective case series report describes 10 of these cases, 7 with unusual complications and 3 with sudden death.

Hypertension in pregnancy: a future risk for chronic kidney disease in South Africa

Background. Hypertension in pregnancy is a risk factor for end-stage chronic kidney disease (ESKD) and is particularly common in South Africa (SA). There are no data for the risk of developing chronic kidney disease (CKD).Objectives. To conduct a study of all female patients who presented to the renal replacement programme at Groote Schuur Hospital, Cape Town, SA.Methods. This was a retrospective study of female patients with ESKD who were presented to renal replacement meetings between 2007 and 2017. For each patient who was assessed, there was a comprehensive letter detailing patient demographics, as well as psychosocial and medical history, which served as the source data. Patients with a history of hypertension in pregnancy were identified as the case group and those without the condition were the control group. Patient demographics, causes of CKD, kidney function and outcome of the meeting were documented.Results. Of the 415 female patients with ESKD, 70 (16.9%) had a history of hypertension in pregnancy. The ethnic breakdown was as follows: 132 (42.44%) black, 172 (55.3%) mixed ancestry and 7 (2.25%) white. Compared with the control group, the patients were younger, with a median age of 33 v. 41 years (p<0.001), higher serum creatinine 1 045 v. 751 µmol/L (p=0.017) and lower estimated glomerular filtration rate (eGFR) 4.0 v. 5.1 mL/min (p=0.029). Patients were more likely to abuse methamphetamine (5.7 v. 1.7%; p=0.049), and less likely to be diabetic (1.4 v. 20.9%; p<0.001) or HIV-positive (2.9 v. 12.5%; p=0.019). There were no ethnic differences between patients and controls. Underlying causes of renal disease showed significant differences, as patients were more likely to have hypertensive nephropathy (57.1 v. 22.9%; p<0.0001), and less likely to have diabetic kidney disease (1.4 v. 20.4%; p<0.001), HIV-associated nephropathy (HIVAN) (1.4 v. 6.4%) or polycystic kidney disease (1.4 v. 7.0%). There was no difference in acceptance to the dialysis and transplant programme (53 v. 47%).Conclusions. This study suggests an important link between hypertension in pregnancy and ESKD. The patients were significantly younger, presented later and were more likely to have hypertensive nephropathy. Methamphetamine abuse appears to be a risk factor. The study suggests that all women with hypertensive disorders during pregnancy need further evaluation and follow-up postpartum

Therapeutic drug monitoring of amlodipine and the Z-FHL/HHL ratio: Adherence tools in patients referred for apparent treatment-resistant hypertension

Background. Non-adherence to antihypertensives is a cause of 'pseudo-treatment-resistant' hypertension.Objective. To determine whether monitoring plasma amlodipine concentrations and inhibition of angiotensin-converting enzyme (ACE) can be adjunct adherence tools.Methods. Patients with hypertension who were prescribed enalapril and amlodipine were enrolled. Blood pressures (BPs) were monitored and an adherence questionnaire was completed. Steady-state amlodipine was assayed using liquid chromatography-mass spectrometry and degree of ACE inhibition using the Z-FHL/HHL (z-phenylalanine-histidine-leucine/hippuryl-histidine-leucine) ratio.Results. One hundred patients (mean (standard deviation) age 50.5 (12) years, 46% male) were enrolled. Based on plasma assays, 26/97 patients (26.8%) were unsuppressed by enalapril and 20/100 (20%) were sub-therapeutic for amlodipine. There were significant BP differences based on plasma levels of the medication: 21/20 mmHg lower in the group with suppressed ACE and 26/20 mmHg in the group with steady-state amlodipine concentrations.Conclusions. Monitoring antihypertensive adherence by assaying plasma medication concentrations is a feasible option for evaluating true v. pseudo-resistant hypertension

Evaluation and Management of Patients Referred to a Tertiary-Level Hypertension Clinic in Cape Town; South Africa

Background. Hypertension remains a global health burden; with a high incidence of long-term morbidity and mortality.Objective. To evaluate blood pressure (BP) control; factors associated with poor BP control; target organ damage (TOD); white-coat hypertension; treatment-resistant hypertension and secondary hypertension in patients referred to a tertiary-level hypertension clinic.Method. This was a prospective case-control study of patients referred for specialist hypertension management. Patient parameters recorded included age; gender; body mass index; uric acid; cholesterol; screening BP; follow-up BP; TOD and medications. We also recorded causes of secondary hypertension. Net BP change and the percentage achieving target BP were calculated in all patients followed up.Results. A total of 175 patients were sampled (72 males and 103 females; mean age 46.5 years). Of the patients 16.6% had a normal screening BP; 62.9% of patients were followed up; and 43.6% of these achieved BP control. After intervention; there was a net drop of 13.2 mmHg (range 7.9 - 18.4) in systolic BP and of 3.8 mmHg (4.4 - 12.0) in diastolic BP. Of all the patients; 12.6% had resistant hypertension; 49.1% had evidence of left ventricular hypertrophy and 18.3% had microalbuminuria; 13.1% of the patients were diagnosed with secondary hypertension. Conclusion. Specialist intervention was useful in identifying patients with white-coat and secondary hypertension; as well as in improving hypertension control in patients with apparent treatment-resistant hypertension. However; a significant percentage of patients did not reach target BP; and further efforts are required to identify the underlying causes for this

South African Hypertension Practice Guideline 2014 : Review Article

Outcomes : Extensive data from many randomised; controlled trials have shown the benefit of treating hypertension (HTN). The target blood pressure (BP) for antihypertensive management is systolic 140 mmHg and diastolic 90 mmHg; with minimal or no drug side effects. Lower targets are no longer recommended. The reduction of BP in the elderly should be achieved gradually over one month. Co-existent cardiovascular (CV) risk factors should also be controlled. Benefits : Reduction in risk of stroke; cardiac failure; chronic kidney disease and coronary artery disease. Recommendations : Correct BP measurement procedure is described. Evaluation of cardiovascular risk factors and recommendations for antihypertensive therapy are stipulated. Lifestyle modification and patient education are cornerstones of management. The major indications; precautions and contra-indications are listed for each antihypertensive drug recommended. Drug therapy for the patient with uncomplicated HTN is either mono- or combination therapy with a low-dose diuretic; calcium channel blocker (CCB) and an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB). Combination therapy should be considered ab initio if the BP is ? 160/100 mmHg. In black patients; either a diuretic and/or a CCB is recommended initially because the response rate is better compared to an ACEI. In resistant hypertension; add an alpha-blocker; spironolactone; vasodilator or ?-blocker

A Cross-Sectional Study of Blood Pressure Control in Hypertensive Patients in General Practice (the I-TARGET Study) : Cardiovascular Topics

Introduction: Despite the availability of multiple effective antihypertensive drugs; hypertension control rates remain poor. The reasons for this are complex; but increasingly; physician inertia has been identified as a crucial factor. In this study we attempted to define the level of blood pressure (BP) control and reasons for not achieving control in a survey of selected general practices within South Africa. Methods: This was a multi-centre; cross-sectional disease study involving 15 selected general practices throughout South Africa. Treated hypertensive patients over 18 years old were eligible for inclusion. The study was approved by Pharma Ethics; and after informed consent; consecutive hypertensive patients at the participating general practice centres were included; with each centre enrolling 30 patients. Results: A total of 451 patients; from 15 sites in South Africa; were entered in the study. The mean age of the patients was 60.7 years; 56.3were female and 15.7were current smokers. The BP was reduced by 26.4/17.6 mmHg (p 0.001) in 220 patients with a documented initial BP. Co-morbidities were present in 322 (71.4) patients and overall; 37.9had more than one co-morbidity. Lifestyle modification was not uniformly applied; with only 46.1; 59.6 and 56.8receiving advice about weight loss; exercise and diet; respectively. Less than a third (30.7) of patients were on monotherapy; 42.8were on two drugs (25.9on fixed-drug combination and 16.9on free combination) and 26.5were on more than two agents. Most (86.9) practitioners used either international or local guidelines to determine target BP. Overall; 61.2of patients were at goal (BP 140/90 mmHg). If a stricter target BP (BP ? 130/80 mmHg) is applied to patients with co-morbidities; as recommended by the guidelines; 60.6of patients did not reach goal. Of the 175 patients not at target BP; there was no action plan in 22.9; while 39.4were advised to undertake lifestyle changes only. Conclusions: Control rates were quite good in comparison with other surveys within and outside South Africa. However we were able to define several important deficiencies: there was evidence of physician inertia and also practitioners need to be more cognisant of local and international guidelines to optimise treatment