CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 314 AFRICA drug strategies beyond triple combinations. BP control was highly variable from one country to another (range: 16.4–61.2%). The description of patients’ cardiovascular risk factors or co-morbidities was heterogeneous and not precisely described. Diabetesmellituswas themost common cardiovascular risk factor reported. The other cardiovascular risk factors were scarcely described, especially obesity and dyslipidaemia. Moreover, the proportion of patients with associated cardiovascular risk factors varied widely across studies. In Africa, 130.2 million people suffer from hypertension, a figure that is expected to reach 216.8million by 2030.50 The highest prevalence of hypertension in the world is in SSA.4 In highincome countries, improvements in hypertension control have led to considerable reduction in overall morbidity and mortality rates over the last 50 years.51 Several international guidelines combining lifestyle modification and BP-lowering medications were elaborated on and contained specific recommendations for black adults living mostly in high-income countries outside of Africa.6 Those guidelines were mentioned in most of the articles in the review, however, it was difficult to conclude whether guidelines were sufficiently followed. Lifestyle measures were only mentioned in a quarter of the articles. Surprisingly, RAS blockers were the most commonly prescribed BP-lowering drugs, even though CCB and diuretics are recommended in black African-Americans or AfricanEuropeans, according to guidelines. It was impossible to know whether RAS blockers were prescribed in a valid indication because of the numerous non-reported patients’ co-morbidities. Therefore, diuretics should be considered, particularly due to their low cost.25 RAS blockers, CCB and diuretics were also the most frequent antihypertensive drug classes prescribed in France over the 2000–2015 period.52 The antihypertensive medication used in monotherapy or in combination appeared to be insufficiently effective regarding high proportions of patients with uncontrolled BP. BP control varied widely across studies and hypertension severity was underestimated. Adherence to medication was poorly evaluated, even though it is an important determinant in BP control.53 Many other underestimated physician- and patient-related factors may have contributed to poor BP control. These include (1) physician therapeutic inertia, as suggested by the low proportion of patients with combination therapy despite poor BP control,54 Table 5. Risk-of-bias assessment CK1 CK 2 CK 3 CK 4 CK 5 CK 6 CK 7 CK 8 CK 9 CK 10 CK 11 CK 12 CK 13 CK 14 Quality Adigun et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Hesse et al. Yes Yes NR Yes No No No NA Yes Yes Yes NA NR No Fair Yusuff et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Yusuff et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Etuk et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Pillay et al. Yes Yes NR No Yes No No NA No Yes Yes NA NA No Fair Rayner et al. Yes Yes NR No Yes No No NA No No Yes NA NA No Poor Olanrewaju et al. Yes Yes NR Yes No No No NA No No Yes NA NA No Poor Ga et al.niyu Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Ilesanmi et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Konin et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Kramoh et al. Yes Yes NR Yes No No No NA Yes Yes Yes NA NA No Fair Omole et al. Yes Yes NR Yes No No No NA No No Yes NA NA No Poor Tamuno et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Ukwe et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Ojji et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Shoba- et al. Yes Yes NR Yes No No No NA No No Yes NA NA No Poor Yaméogo et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA Yes Fair Mutua et al. Yes Yes NR Yes Yes No No NA Yes No Yes NA NA Yes Fair Ikama et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA NR Fair Shukrala et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Bakare et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA No Fair Busser et al. Yes Yes NR Yes No No No NA No No Yes NA NA No Poor Kika et al. Yes Yes NR Yes No No No NA Yes No Yes NA NA Yes Fair Ssianulya et al. Yes Yes NR Yes No No No NA No No Yes NA NA No Poor Adejumo et al. Yes Yes NR Yes Yes No No NA Yes No Yes NA NA No Fair Berhe et al. Yes Yes NR Yes Yes No No NA Yes Yes Yes NA Yes Yes Good Mbui et al. Yes Yes No Yes Yes No No NA Yes No Yes NA NA Yes Fair Olowofela et al. Yes Yes NR Yes Yes No No NA Yes No Yes NA NA No Fair Teshome et al. Yes Yes NR Yes Yes No No NA Yes No Yes NA NA Yes Fair CK 1: Was the research question or objective in this article clearly stated? CK 2: Was the study population clearly specified and defined? CK 3: Was the participation rate of eligible persons at least 50%? CK 4: Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants? CK 5: Was a sample size justification, power description, or variance and effect estimates provided? CK 6: For the analyses in this article, were the exposure(s) of interest measured prior to the outcome(s) being measured? CK 7: Was the time frame sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed? CK 8: For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g. categories of exposure, or exposure measured as continuous variable)? CK 9: Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? CK 10: Was the exposure(s) assessed more than once over time? CK 11: Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants? CK 12: Were the outcome assessors blinded to the exposure status of participants? CK 13: Was loss to follow up after baseline 20% or less? CK 14: Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)? NA, not applicable; NR, not reported.
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