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Coronary Heart Disease and Associated Risk Factors in Sub-Saharan Africans

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Coronary Heart Disease and Associated Risk Factors in Sub-Saharan Africans Journal of Human Hypertension (2007) 21, 411–414 & 2007 Nature Publishing Group All rights reserved 0950-9240/07 $30.00 www.nature.com/jhh RESEARCH LETTER Coronary heart disease and associated risk factors in sub-Saharan Africans Journal of Human Hypertension (2007) 21, 411–414. for each ethnic group by the direct method using all doi:10.1038/sj.jhh.1002146; published online 8 February 2007 patients as the standard population and by 15-year age bands. Proportions were compared between the four groups using w2-square testing. When the Documented information on the prevalence of ANOVA result between groups was significant, this coronary heart disease (CHD) and coronary risk was followed by pairwise comparisons between factor (CRF) in developing countries is scarce, but groups using the Tukey multiple comparisons there is sufficient data to suggest a CHD epidemic. procedure. Results were deemed significant when Experience in the developed world has shown that the calculated q value was greater than or equal to significant reduction in CHD prevalence can be the critical value q0.05,N,4 ¼ 3.633 (i.e., where achieved via primary and secondary prevention; Po0.05). All analyses were performed using SAS recognizing ethnic disparities in CRF is the first software v8.2. step to implement targeted prevention programmes. We included 179 consecutive patients: 37 black, An epidemiological transition is now occurring 44 European, 51 South Asian and 47 coloured in the developing world where the major causes of Africans. Baseline characteristics are presented death are changing from infectious to non-commu- and compared in Table 1. Patients were aged nicable diseases such as CHD. CHD is still relatively between 33 and 86 years at the time of diagnosis of uncommon in Africa, in comparison with valvular their CHD; mean age differed significantly across and hypertensive cardiopathies.1 However, although ethnic groups, with younger patients in the South the decline in the prevalence of CRF in developed Asian group. There were fewer men with CHD nations has been well documented,2,3 recent life- among the coloured Africans, compared with either style changes in developing countries have resulted the European or South Asian Africans. Black in the view that CHD will become the leading cause Africans had more systemic hypertension (97.9%) of death worldwide over the next 15 years.4 Until than coloured (79.9%, q ¼ 5.13), European (70.7%, recently, ethnic variations in CHD have mainly been q ¼ 3.74) and South Asian (66.2%, q ¼ 5.84) Afri- examined in North America and Europe.5–8 cans. Black Africans were also less likely to have Data from developing countries are scarce.1 In more than one other CRF (57.6%) than coloured addition, owing to lack of medical facilities, cor- (90.2%, q ¼ 4.92), European (85.9%, q ¼ 4.02) or onary angiograms are rarely performed in most sub- South Asian (84.7%, q ¼ 3.97) Africans. There was Saharan African medical centres, the only exception also evidence that black Africans had more single being the republic of South Africa.9 The aim of this vessel disease (56.8%) compared with coloured study is to identify and compare CRF and clinical (21.3%, q ¼ 4.72), European (31.8%, q ¼ 3.84) and presentation in different ethnic groups in Mozambi- South Asian (13.7%, q ¼ 6.09) Africans. Clinical que, in patients with angiographically documented presentation differed between the four ethnic significant CHD. groups, with significantly more myocardial infarc- A retrospective study was conducted using the tions (MI) in South Asians, when compared to other computerized database of the cardiac catheterization ethnic African groups (overall P ¼ 0.02). laboratory at the Maputo Heart Institute. From July The Mozambican population is a mosaic of ethnic 2003 to October 2005, we reviewed the records of groups with a predominant black Africans, few consecutive patients with angiographically docu- European people of Portuguese descent and South mented CHD from four ethnic groups in Mozambi- Asian people who came to south east Africa from que: black, European, South Asian and coloured the Indian subcontinent more than a century ago. Africans. Detailed information concerning demo- The Maputo Heart Institute (Instituto do Corac¸a˜o, graphics, previous coronary events, CRF, coronary Maputo), a public non-profitable association, is the syndrome type, angiographic and echocardiographic only medical centre in Mozambique (19 million data were collected. Patient characteristics are inhabitants) performing coronary angiography and presented as means7s.d. or proportions, as appro- cardiac catheterism. Help from European non- priate. Continuous variables were compared governmental organizations and medical fees paid between groups using analysis of variance (ANOVA) by patients who can afford to pay for their treatment or Kruskal–Wallis tests, for normally or non- allow us to treat and operate upon poor children normally distributed variables, respectively. Age- and who suffer mainly from severe rheumatic heart sex-standardized proportions of CRF were derived disease or endomyocardial fibrosis. Research Letter 412 Table 1 Baseline patients characteristics. Pairwise comparisons were reported in the lower part of the table (%)** Variables Black Africans Coloured European South Asian Over P-value Africans Africans Africans Number 37 47 44 51 Age (years)a 61.8711.5 62.0710.9 64.179.7 56.179.9 0.002 Male 28 (75.7) 27 (57.4) 37 (84.1) 47 (92.2) o0.001 Coronary risk factorsb,c Systemic hypertension 36 (97.9) 37 (70.7) 35 (79.9) 34 (66.2) 0.003 Hypercholesterolaemia 5 (9.9) 23 (46.9) 23 (54.4) 26 (42.2) o0.001 Diabetes mellitus 8 (17.9) 20 (44.5) 14 (25.8) 19 (32.2) 0.05 Smoking 4 (13.9) 20 (44.3) 35 (82.5) 31 (47.8) o0.001 Obesity 10 (23.7) 12 (21.5) 13 (30.3) 17 (38.3) 0.27 Family history 6 (15.6) 38 (83.0) 20 (50.3) 32 (60.8) o0.001 Two or more CRF 22 (57.6) 43 (90.2) 37 (85.9) 46 (84.7) o0.001 Clinical presentationd Stable angina 16 (43.2) 27 (57.4) 18 (40.9) 16 (31.4) Unstable angina 8 (21.6) 10 (21.3) 14 (31.8) 8 (15.7) 0.023 MI 13 (35.1) 7 (14.9) 9 (20.5) 21 (41.2) Others 0 (0) 3 (6.4) 3 (6.8) 6 (11.8) Coronary lesione One vessel 21 (56.8) 10 (21.3) 14 (31.8) 7 (13.7) Two vessels 6 (16.2) 18 (38.3) 12 (27.3) 17 (33.3) 0.0011 Three vessels 10 (27.0) 19 (40.4) 18 (40.9) 27 (52.9) LVEF (%)f 60713 55712 56714 52712 0.14 Variables Black vs Black vs Black vs South Coloured vs Coloured vs European vs Coloured European Asian European South Asian South Asian Age (years)a NS NS NS NS o0.05 o0.05 Male NS NS NS o0.05 o0.05 NS Coronary risk factorsb,c Systemic hypertension o0.05 o0.05 o0.05 NS NS NS Hypercholesterolaemia o0.05 o0.05 o0.05 NS NS NS Diabetes mellitus o0.05 NS NS NS NS NS Smoking o0.05 o0.05 o0.05 o0.05 NS o0.05 Obesity — — — — — — Family history o0.05 o0.05 o0.05 o0.05 NS NS Two or more CRF o0.05 o0.05 o0.05 NS NS NS Abbreviations: CRF, coronary risk factor; MI, myocardial infarction; NS, not significant. aMean7s.d. bAge- and sex-standardized proportions. cSystemic hypertension: systolic blood pressure 4140 mm Hg and/or diastolic blood pressure 490 mmHg, or on antihypertensive medication; diabetes mellitus: fasting blood glucose 41.26 g/l (7 mmol/l); smoking: current or old smoker less than 3 years after quitting smoking; hypercholesterolaemia: repeated total fasting serum cholesterol 42.3 mg/ml (6.7 mmol/l) within 24 h of admission, or previous treatment for elevated cholesterol by a physician; obesity: body mass index 428 kg/m2; family history of premature CAD: MI or sudden death before the age of 55 in father or other male first-degree relative, or before the age of 65 in mother or other female first-degree relative. dChronic stable angina: typical exercise chest discomfort (having started 4 or more weeks ago) and/or a positive exercise test; unstable angina: acute coronary syndrome with rest chest pain or exercise pain (having started 4 or less weeks ago), without criteria of myocardial infarction; myocardial infarction: typical chest pain, not relieved by rest and nitroglycerin, lasting for more than 20 min with ST segment elevation of at least 2 mm in two or more contiguous leads, associated with a serum enzyme elevation of total creatine kinase 42 times normal and/or creatine kinase- MB 45% of total creatine kinase. eDefinition of coronary angiographic and echographic data: coronary stenosis was considered significant above 70% narrowing concerning any of the three main coronary vessels or their collaterals (left descending artery, circumflex artery and right coronary artery) and 50% for the left main stem. fEchocardiographic ejection fraction (LVEF) was estimated using the bidimensional Simpson method, mean EF7s.d. **Tukey-type multiple comparison procedure. The black African profile of CHD sufferers differs in the INTERHEART Africa study,10 the authors significantly from the other ethnic groups reported reported that systemic hypertension is the most here. This particular profile of black Africans is not important cardiovascular risk factor for the devel- similar to that of Afro-Americans, who reportedly opment of MI in black Africans. In their study, the have three or four simultaneous CRFs.5,6 Recently, most frequent CRFs in black Africans were abdom- Journal of Human Hypertension Research Letter 413 inal obesity and elevated ApoB/ApoA-1 ratio.
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