Undiagnosed and diagnosed diabetes mellitus among hospitalised acute heart failure patients in Botswana.

OBJECTIVE: The objective of this study was to determine the burden of diagnosed and undiagnosed type 2 diabetes mellitus among patients hospitalised with acute heart failure in Botswana. METHODS: The study enrolled 193 consecutive patients admitted with acute heart failure to the medical wards at Princess Marina Hospital in Gaborone. Patients were classified as previously known diabetics, undiagnosed diabetics (glycated haemoglobin ≥ 6.5%) or as non-diabetics (glycated haemoglobin < 6.5%). Data on other comorbid conditions such as hypertension, atrial fibrillation, ischaemic heart disease, stroke, and renal failure were also collected. RESULTS: The mean (SD) age of the participants was 54.2 (17.1) years and 53.9% were men. The percentage of known and undiagnosed diabetes mellitus was 15.5% and 12.4%, respectively. Diabetic patients were significantly more likely to have hypertension (77.8% vs 46.0%, p < 0.001), ischaemic heart disease (20.4% vs 5.0%, p < 0.001), chronic kidney disease (51.3% vs 23.0%, p < 0.001), and stroke (20.4% vs 5.8%, p < 0.01). In addition, diabetics were older than non-diabetics (61.0 years vs 51.6 years, p < 0.001). CONCLUSION: About 27.9% of patients admitted with acute heart failure in Botswana had diabetes, and almost half of them presented with undiagnosed diabetes. These findings indicate that all hospitalised patients should be screened for diabetes.

Presentation and mortality of patients hospitalised with acute heart failure in Botswana.

INTRODUCTION: Heart failure is a common cause of hospitalisation and therefore contributes to in-hospital outcomes such as mortality. In this study we describe patient characteristics and outcomes of acute heart failure (AHF) in Botswana. METHODS: Socio-demographic, clinical and laboratory data were collected from 193 consecutive patients admitted with AHF at Princess Marina Hospital in Gaborone between February 2014 and February 2015. The length of hospital stay and 30-, 90- and 180-day in-hospital mortality rates were assessed. RESULTS: The mean age was 54 ± 17.1 years, and 53.9% of the patients were male. All patients were symptomatic (77.5% in NYHA functional class III or IV) and the majority (64.8%) presented with significant left ventricular dysfunction. The most common concomitant medical conditions were hypertension (54.9%), human immuno-deficiency virus (HIV) (33.9%), anaemia (23.3%) and prior diabetes mellitus (15.5%). Moderate to severe renal dysfunction was detected in 60 (31.1%) patients. Peripartum cardiomyopathy was one of the important causes of heart failure in female patients. The most commonly used treatment included furosemide (86%), beta-blockers (72.1%), angiotensin converting enzyme inhibitors (67.4%), spironolactone (59.9%), digoxin (22.1%), angiotensin receptor blockers (5.8%), nitrates (4.7%) and hydralazine (1.7%). The median length of stay was nine days, and the in-hospital mortality rate was 10.9%. Thirty-, 90- and 180-day case fatality rates were 14.7, 25.8 and 30.8%, respectively. Mortality at 180 days was significantly associated with increasing age, lower haemoglobin level, lower glomerular filtration rate, hyponatraemia, higher N-terminal pro-brain natriuretic peptide levels, and prolonged hospital stay. CONCLUSIONS: AHF is a major public health problem in Botswana, with high in-hospital and post-discharge mortality rates and prolonged hospital stays. Late and symptomatic presentation is common, and the most common aetiologies are preventable and/or treatable co-morbidities, including hypertension, diabetes mellitus, renal failure and HIV.

Rates and predictors of three-year mortality in older people in rural Tanzania.

BACKGROUND: There are few data on mortality rates in the general elderly living in sub-Saharan Africa. We aimed to detail three-year mortality rates in a population of rural community-dwelling older adults in northern Tanzania. METHODS: We performed a community-based study of 2232 people aged 70 years and over living in Hai district, Tanzania. At baseline, participants underwent clinical assessment for disability, neurological disorders, hypertension, atrial fibrillation and memory problems. At three-year follow-up mortality data were collected. Mortality rates were compared to UK estimates. RESULTS: At follow-up, data were available for 1873 subjects (83.9%). Of those, 208 (11.1%, 95% CI 9.7-12.5) had died. The age-standardised mortality rate was 10.2% (95% CI 8.8-11.6). Age-standardised mortality rates were lower than estimated for the UK (13.9%). In Cox regression analysis, greater age, higher levels of functional disability, use of a walking aid, subjective report of memory problems, being severely underweight and being normotensive were significant predictors of mortality. CONCLUSIONS: Those who survive to old age in Tanzania appear to have relatively low mortality rates. Physical and cognitive disabilities were strongly associated with mortality risk in this elderly community-dwelling population. The association between blood pressure and mortality merits further study.

Ambulatory blood pressure monitoring to assess the white-coat effect in an elderly East African population.

The authors hypothesized that published hypertension rates in Tanzania were influenced by the physiological response of individuals to blood pressure (BP) testing, known as the white-coat effect (WCE). To test this, a representative sample of 79 participants from a baseline cohort of 2322 people aged 70 years and older were followed to assess BP using conventional BP measurement (CBPM) and ambulatory BP monitoring (ABPM). There was a significant difference between daytime ABPM and CBPM for both systolic BP (mean difference 29.7 mm Hg) and diastolic BP (mean difference 7.4 mm Hg). Rates of hypertension were significantly lower when measured by 24-hour ABPM (55.7%) than by CBPM (78.4%). The WCE was observed in 54 participants (68.4%). The WCE was responsible for an increase in recorded BP. Accurate identification of individuals in need of antihypertensive medication is important if resources are to be used efficiently, especially in resource-poor settings.

Electrocardiographic reference values for a population of older adults in sub-Saharan Africa.

BACKGROUND/OBJECTIVES: Older adults in sub-Saharan Africa (SSA) are at greatest risk of an impending noncommunicable diseases epidemic, of which cardiac disease is the most prevalent contributor. Thus, it is essential to establish electrocardiographic reference values for a population that is likely to differ genetically and environmentally from others where reference values are established. METHODS: Two thousand two hundred thirty-two apparently healthy community-based participants without known cardiac disease aged 70+ in rural Tanzania underwent 12-lead electrocardiography. Electrocardiograms were digitally analyzed and gender-specific reference values for P duration (PD), P amplitude (PAMP), P area (PAREA), P terminal negative force (V1) (PTNF), PR interval, QRS duration (QRSD), QT/QTc, R amplitude (II, V5) (RAMP) LVH index (LVHI), R axis and R/S ratio (V1) reported, following univariate analysis of covariance using a multiple linear regression model, adjusting for age, systolic blood pressure (SBP), body mass index (BMI), and RR interval. RESULTS: Data from 1824 subjects were suitable for analysis. Adjusted mean values for men/women were: PD 115/110 ms, PAMP (avg) 123/114 µV, PAMP (II) 203/190 µV, PAREA (avg) 5.3/4.6 mV*s, PAREA (II) 9.3/8.1 mV*s, PTNF 1.7/1.4 mV*s, PR 158/152 ms, QRSD 89/84 ms, QT 370/375 ms, QTc 421/427 ms, RAMP (II) 805/854 µV, (V5) 2022/1742 µV, LVHI 3.0/2.8 mV (Sokolow-Lyon), 1.293/1.146 mV (Cornell), R axis 51/49°, R/S 0.2/0.2. Excluding PTNF , R axis and R/S ratio, all gender differences were significant (P < 0.001 apart from LVHI [Sokolow-Lyon; P < 0.005)] and RAMP (II) [P < 0.05]) following adjustment for age, SBP, BMI, and RR interval. CONCLUSIONS: Our description of comprehensive electrocardiographic parameters establishes reference values in this genetically and environmentally diverse SSA population thereby allowing identification of "outliers" with potential cardiac disease.

Current Evidence and Recommendations for Cardiac Resynchronisation Therapy.

The number of people in Europe living with symptomatic heart failure is increasing. Since its advent in the 1990s, cardiac resynchronisation therapy (CRT) has proven beneficial in terms of morbidity and mortality in selected heart failure (HF) patient populations, when combined with optimal pharmacological therapy. We review the evidence for CRT and the populations of HF patients it is currently shown to benefit, and those in which more research needs to be performed.

Strikingly low prevalence of atrial fibrillation in elderly Tanzanians.

OBJECTIVES: To determine the prevalence of atrial fibrillation (AF) in individuals aged 70 and older in a rural African community. DESIGN: Community-based cross-sectional survey. SETTING: A demographic surveillance site (DSS) within the rural Hai district of northern Tanzania. PARTICIPANTS: Approximately one-quarter (N = 2,232) of the population aged 70 and older of the DSS. MEASUREMENTS: Participants were screened for AF using 12-lead electrocardiography; demographic and 1-year mortality data were collected; and functional status, body mass index, and blood pressure were recorded. The sex-specific prevalence of AF in each 5-year age band was determined. RESULTS: Fifteen of 2,232 participants (12 women, 3 men) had AF, giving a crude prevalence rate of 0.67% (95% confidence interval (CI) = 0.33-1.01) and an age-adjusted prevalence of 0.64% (95% CI = 0.31-0.97). Prevalence was 0.96% (95% CI = 0.42-1.49) in women and 0.31% (95% CI = -0.04 to 1.24) in men. Prevalence increased with age, from 0.46% (95% CI = 0.01-0.90) in those aged 70-74-1.30% (95% CI = 0.17-2.42) in those aged 85 and older. One-year mortality was 50% in women and 66.6% in men. CONCLUSIONS: This is the first published community-based AF prevalence study from sub-Saharan Africa. The prevalence rate of AF is strikingly lower than in other elderly populations studied, yet the 1-year mortality rate was exceedingly high.

The prevalence of disability in older people in Hai, Tanzania.

BACKGROUND: the World Health Organization estimates that more than one billion of the world's population are disabled. Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability among the elderly in low-income countries. The aim of this study was to accurately document the prevalence of disability in those aged 70 years and over in a community-based setting in sub-Saharan Africa. METHODS: we performed a community-based study of people aged 70 years and over in Hai, Tanzania. Participants underwent disability assessment using the culturally non-specific Barthel index (BI), and also clinical assessment for neurological disorders and memory problems. RESULTS: in 2,232 participants, the age-adjusted prevalence of severe disability (BI<15) was 3.7% (95% CI: 2.9-4.5) and the age-adjusted prevalence of moderate disability (BI: 15-18) was 6.2% [95% confidence interval (CI): 5.2-7.2]. Increasing age, female gender, memory problems and the presence of neurological disorders were all independent predictors of the presence of disability. CONCLUSION: in this study, the average disability level was lower than seen in most high-income countries. This may reflect increased mortality from disabling disease in low-income countries. Disability is likely to increase as the population of low-income countries ages and disease survival improves.

Neurological disorder screening in the elderly in low-income countries.

There are few data on neurological disorder prevalence from developing countries, particularly in the elderly in sub-Saharan Africa (SSA). This is in part due to the lack of a feasible and valid screening instrument. We aimed to develop (and pilot) a brief screening instrument for neurological disorders in an elderly population in SSA. Our study population of 2,232 was selected at random from the entire 70 years and over population of a demographic surveillance site in rural Tanzania. One village, with a population of 277, was randomly selected as a pilot site prior to screening the rest of the study population. We designed a screening questionnaire based on the neurological section of the WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision for use by non-medical interviewers (NMI). Of the 277 participants aged 70 years and over in the pilot village, 82 had neurological disorders, with a further 267 identified as having neurological disorders during the study extension to the remaining study population of 1955. The questionnaire was practical, acceptable to recipients, and easily performed by an NMI. The sensitivity and specificity of the questionnaire were 87.8 and 94.9 %, respectively, in the pilot and 97.0 and 90.4 %, respectively, in the extension. This is the first published screening instrument for measuring the prevalence of neurological disorders in a developing country, which is dedicated to the elderly population. It is feasible to use and has high sensitivity and specificity.

Rates of diagnosis and treatment of neurological disorders within a prevalent population of community-dwelling elderly people in sub-Saharan Africa.

BACKGROUND: The prevalence of neurological disorders in those aged 70years and over in the Hai district of Tanzania has been previously reported. The following research reports rates of patient's: treatment seeking, diagnosis and treatment within this prevalent population. METHODS: All people identified as having at least one neurological disorder in the prevalence study were questioned regarding whether they had sought treatment for their disorder, whether they had had a previous correct diagnosis and whether they were being currently treated. RESULTS: From a background population of 2232 people, 349 people had neurological disorders, of whom 225 (64.5%) had sought treatment for their symptoms. Of the 384 disorders identified in these 349 people, only 14.6% had been diagnosed and only 9.9% were receiving appropriate treatment. Males were significantly more likely to have been diagnosed and were more likely to have been treated appropriately. CONCLUSIONS: Levels of diagnosis and treatment were low, with some gender inequality. Reasons for this may include a lack of recognition of the condition within the local population and lack of access to appropriate services. In the absence of effective primary and secondary preventative measures, and effective treatment, the burden of neurological disorders is likely to increase with further demographic ageing.