Heart Rate Variability, HIV and the Risk of Cardiovascular Diseases in
                        Rural South Africa

Background: Sub-Saharan Africa is undergoing an epidemiological transition fueled by the interaction between infectious and cardiovascular diseases. Our cross-sectional study aimed to characterize the spectrum of abnormalities suggesting end-organ damage on ECG and transthoracic echocardiograms (TTE) among older adults with cardiovascular diseases in rural South Africa. Methods: The prevalence of ECG and TTE abnormalities was estimated; χ 2 analyses and multivariable logistic regressions were performed to test their association with sex, hypertension, and other selected comorbidities. Results: Overall, 729 ECGs and 155 TTEs were completed, with 74 participants completing both. ECG evaluation showed high rates of left ventricular hypertrophy (LVH, 36.5%) and T wave abnormalities (13.6%). TTE evaluation showed high rates of concentric LVH (31.6%), with moderate-severe (56.8%) diastolic dysfunction. Participants with hypertension showed more cardiac remodeling on ECG by LVH (45.4% versus 22.1%, P <0.01), and TTE by concentric LVH (42.5% versus 8.2%, P <0.01) and increased left ventricular mass (58.5% versus 20.4%, P <0.0001). In multivariable logistic regression, systolic blood pressure remained significantly associated with LVH on ECG (adjusted odds ratio, 1.03 per mm Hg [95% CI, 1.03–1.04], P <0.0001) and increased left ventricular mass on TTE (adjusted odds ratio, 1.04 per mm Hg [95% CI, 1.01–1.06], P =0.001). Male participants (n=326, 40.2%) were more likely than females (n=484, 59.8%) to show ECG abnormalities like LVH (45% versus 30.8%, P <0.01), whereas females were more likely to show TTE abnormalities like concentric LVH (40.8% versus 13.5%, P <0.01) and increased left ventricular mass (58.4% versus 23.1%, P <0.0001). Similar results were confirmed in multivariable models. Conclusions: Our findings suggest that cardiovascular diseases are widespread in rural South Africa, with a larger burden of hypertensive heart disease than previously appreciated, and define the severity of end-organ damage that is already underway. Local health systems must adapt to face the growing burden of hypertension, as suboptimal rates of hypertension diagnosis and treatment may dramatically increase the heart failure burden.

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Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data

BMJ Open ◽

10.1136/bmjopen-2020-048592 ◽

2021 ◽

Vol 11 (6) ◽

pp. e048592

Author(s):

Jessica Newberry Le Vay ◽

Andrew Fraser ◽

Peter Byass ◽

Stephen Tollman ◽

Kathleen Kahn ◽

...

Keyword(s):

South Africa ◽

Cardiovascular Disease ◽

Cardiovascular Diseases ◽

Mortality Rate ◽

Verbal Autopsy ◽

Rural South ◽

Cardiovascular Disease Mortality ◽

Disease Mortality ◽

Autopsy Data ◽

Rural South Africa

ObjectivesCardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data.DesignA mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts.SettingThis study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa.ParticipantsDeaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data.ResultsBetween 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391).ConclusionsThe temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.

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