Cardiovascular Journal of Africa: Vol 32 No 5 (SEPTEMBER/OCTOBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 240 AFRICA Fig. 1 outlines the spectrum of CVD and the proportions. The three most common primary diagnoses were strokes (38.42%), hypertensive heart disease with heart failure (33.28%), and hypertensive emergency/urgency (18.04%). These were more frequent in women than in men (Figs 2, 3). One hundred and seventy-four of the 1 325 patients with a CVD diagnosis died before discharge, with an in-hospital mortality rate of 13.1%. This was comparable to the in-hospital mortality rate in the non-CVD group. Strokes accounted for the majority of cardiovascular deaths (70.7%), followed by hypertensive heart disease and heart failure (23%) (Fig. 4). One hundred and thirty-eight of the CVD patients were HIV infected, representing 10.4% of the CVD group (Table 1). In this group, hypertensive heart disease with heart failure (34.8%) was the main CVD diagnosis, followed by stroke (27.5%) (Table 2). Discussion The major findings of this retrospective study are: (1) CVD accounted for a significant proportion of the hospital admissions at 27%; (2) strokes were the predominant manifestation of CVD, at 38% of the CVD admissions and 70% of the in-hospital mortality; (3) hypertensive heart disease-related heart failure and hypertensive emergency/urgency were the second and third most common primary reasons for admission. Additional significant findings included the observations that 32.4% of the patient population with CVD was young (age < 55 years), 94% had hypertension and 30% had diabetes mellitus. Should these findings be representative of similar hospitals nationwide, they may have important clinical, socio-economic and public health implications for the country and the region. Although the retrospective design of the study was not optimal, prior to this, few if any studies have been published to document the significant burden of CVD-related morbidity and mortality as experienced in semi-rural hospital settings. CVD are the largest contributor to global mortality, accounting for up to 45% of the 39.8 million deaths due to NCD. 10 Most alarmingly, more than 75% of cardiovascular deaths occur in low- and middle-income countries including sub-Saharan Africa, 14 and to date, there has not been a comprehensive effective programme or plan on the scale or magnitude required to change the trajectory of the growing burden of CVD in the country. South Africa is rapidly undergoing epidemiological transition and is saddled with a quadruple burden of disease. This transition and burden are marked by increasing prevalence of NCD, and a persistent epidemic of infectious disease, trauma and high perinatal and maternal morbidity. 4 It has been postulated that socio-economic and demographic development could have played a major role in this health transition. 15 Additionally, a high prevalence of cardiovascular risk factors has historically been well reported in poor rural and township communities in South Africa. 1,16-18 Cross-sectional studies in Limpopo, Free State and the Western Cape reported a prevalence of systemic hypertension of 14 to 41%, diabetes mellitus of 4.8 to 8.6%, tobacco smoking of 13 to 54%, and female obesity of up to 51%. 1,2,16-18 Systemic hypertension is a significant risk factor for CVD in black people. At least 56% of patients presenting for the first time with heart disease in the Heart of Soweto study had systemic hypertension. 6 Of major concern, the age-standardised prevalence of systemic hypertension increased by 7.7% in low-income countries, compared to a decrease of 2.6% in high-income countries. 19 Furthermore, there are lower rates of hypertension awareness and receipt or use of therapies in low- compared to high-income countries. 19 Our study findings of 94% prevalence of systemic hypertension among admitted patients highlight the potential importance of prioritising NCD prevention and treatment at the scale of the very successful government HIV anti-retroviral programme. It is of interest that the contribution of coronary heart disease-related complications to the burden of admissions and in-hospital mortality was as low as 4.5%. This corroborates information from global bodies such as the WHO, that sub-Saharan Africa remains the only region of the world where CAD is not the major manifestation of CVD globally. 14 However, risk factors for atherosclerotic disease in South African black people are increasing. In the Agricout cross-sectional study, 12% of the individuals had an ankle brachial index less than 0.9, suggestive of occult atherosclerosis. 20 Additionally, the INTERHEART study identified five risk factors for myocardial infarction in an African population presenting for the first time with acute myocardial infarction (history of smoking, diabetes and hypertension, abdominal obesity, and ratio of apolipoprotein B to apolipoprotein A-1). 21 Interestingly, there was a socio-economic disparity in the prevalence of risk factors for CVD between South African ethnic groups; a higher socio-economic class and education level was associated with increased prevalence of acute myocardial infarction Table 2. CVD as a primary diagnosis in HIV-infected patients, n = 138 Variable Number Percentage Stroke 38 27.5 Acute coronary syndrome 2 1.4 Rheumatic heart disease 8 5.8 Hypertensive urgency or emergency 22 15.9 Hypertensive heart disease in heart failure 48 34.8 TB pericarditis 14 10.1 Peripartum cardiomyopathy 4 2.9 Pulmonary hypertension 1 0.7 Congenital heart defects 1 0.7 Percentage 0 20 40 60 80 Hypertensive urgency or emergency Hypertensive heart disease in heart failure RHD ACS Stroke 70.7 1.7 0.6 2.9 23.0 1.1 Peripartum cardiomyopathy Fig. 4. Frequency of CVD as a cause of death at Dora Nginza Hospital for 1 April 2016 to 31 October 2016. TB, tuber- culosis; RHD, rheumatic heart disease; ACS, acute coronary syndrome.