Faculty Bibliography

Cardiovascular disease (CVD) is the leading cause of mortality worldwide and also exerts a significant economic burden, especially in low- and middle-income countries (LMICs). Detection of subclinical CVD, before an individual experiences a major event, may therefore offer the potential to prevent or delay morbidity and mortality, if combined with an appropriate care response. In this review, we discuss imaging technologies that can be used to detect subclinical atherosclerotic CVD (carotid ultrasound, coronary artery calcification) and nonatherosclerotic CVD (echocardiography). We review these imaging modalities, including aspects such as rationale, relevance, feasibility, utilization, and access in LMICs. The potential gains in detecting subclinical CVD may be substantial in LMICs, if earlier detection leads to earlier engagement with the health care system to prevent or delay cardiac events, morbidity, and premature mortality. Thus, dedicated studies examining the feasibility, utility, and cost-effectiveness of detecting subclinical CVD in LMICs are warranted.

BACKGROUND:Mobile health (mHealth) approaches for non-communicable disease (NCD) care seem particularly applicable to sub-Saharan Africa given the penetration of mobile phones in the region. The evidence to support its implementation has not been critically reviewed. METHODS:We systematically searched PubMed, Embase, Web of Science, Cochrane Central Register of Clinical Trials, a number of other databases, and grey literature for studies reported between 1992 and 2012 published in English or with an English abstract available. We extracted data using a standard form in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS:Our search yielded 475 citations of which eleven were reviewed in full after applying exclusion criteria. Five of those studies met the inclusion criteria of using a mobile phone for non-communicable disease care in sub-Saharan Africa. Most studies lacked comparator arms, clinical endpoints, or were of short duration. mHealth for NCDs in sub-Saharan Africa appears feasible for follow-up and retention of patients, can support peer support networks, and uses a variety of mHealth modalities. Whether mHealth is associated with any adverse effect has not been systematically studied. Only a small number of mHealth strategies for NCDs have been studied in sub-Saharan Africa. CONCLUSIONS:There is insufficient evidence to support the effectiveness of mHealth for NCD care in sub-Saharan Africa. We present a framework for cataloging evidence on mHealth strategies that incorporates health system challenges and stages of NCD care. This framework can guide approaches to fill evidence gaps in this area. Systematic review registration: PROSPERO CRD42014007527.

Ischemic heart disease (IHD) is the greatest single cause of mortality and loss of disability-adjusted life years worldwide, and a substantial portion of this burden falls on low- and middle-income countries (LMICs). Deaths from IHD and acute coronary syndrome (ACS) occur, on average, at younger ages in LMICs than in high-income countries, often at economically productive ages, and likewise frequently affect the poor within LMICs. Although data about ACS in LMICs are limited, there is a growing literature in this area and the research gaps are being steadily filled. In high-income countries, decades of investigation into the risk factors for ACS and development of behavioral programs, medications, interventional procedures, and guidelines have provided us with the tools to prevent and treat events. Although similar tools can be, and in fact have been, implemented in many LMICs, challenges remain in the development and implementation of cardiovascular health promotion activities across the entire life course, as well as in access to treatment for ACS and IHD. Intersectoral policy initiatives and global coordination are critical elements of ACS and IHD control strategies. Addressing the hurdles and scaling successful health promotion, clinical and policy efforts in LMICs are necessary to adequately address the global burden of ACS and IHD.

Background: ED patients with acute drug overdose have been shown to suffer adverse cardiovascular events, but prediction of these events is difficult. Objectives: To validate previously derived features of the initial ECG associated with adverse cardiovascular events in this population. Methods: We performed a prospective validation cohort study to evaluate adult ED patients with acute drug overdose at two urban university hospitals over 5 years in whom ED admission ECGs were performed. Excluded were patients with alternate diagnoses, anaphylaxis, chronic drug toxicity, and missing outcome data. Adverse cardiovascular events were defined as any of the following: shock (vasopressor requirement), myocardial injury (MI, elevated troponin), ventricular dysrythmia, or cardiac arrest (pulseless). Blinded cardiologists interpreted ECGs for rhythm, intervals, QT dispersion, ischemia (T wave inversion, ST depression), and infarction (ST elevation, Q waves). Diagnostic test characteristics of the previously derived ECG rule (ectopy, non-sinus rhythm, QTc), as well as univariate statistics, odds ratios (OR), and 95% confidence intervals (CI) were calculated. Assuming 10% prevalence of predictor variables and baseline 8% adverse cardiovascular event rate in the population, we calculated the need to enroll 552 patients to show three-fold increased risk per factor with 80% power and 5% alpha. Results: Of 589 acute drug overdose patients who met inclusion criteria (48% male, mean age 42), there were 95 adverse cardiovascular events (39 shock, 64 MI, 26 dysrhythmia, 16 cardiac arrest). The most common drug exposures were benzodiazepines, opioids, and acetaminophen. All previously derived criteria were highly predictive of adverse events, with QTc >500 ms the highest risk feature associated with over 10-fold increased adverse cardiovascular event risk (OR 11.2, CI 4.6-27). All high-risk ECG features as well as diagnostic test characteristics of the ECG rule are presented in Table 217. Conclusion: This study val!

BACKGROUND:Hypertension is the leading global risk factor for mortality. Hypertension treatment and control rates are low worldwide, and delays in seeking care are associated with increased mortality. Thus, a critical component of hypertension management is to optimize linkage and retention to care. METHODS/DESIGN/METHODS:This study investigates whether community health workers, equipped with a tailored behavioral communication strategy and smartphone technology, can increase linkage and retention of hypertensive individuals to a hypertension care program and significantly reduce blood pressure among them. The study will be conducted in the Kosirai and Turbo Divisions of western Kenya. An initial phase of qualitative inquiry will assess facilitators and barriers of linkage and retention to care using a modified Health Belief Model as a conceptual framework. Subsequently, we will conduct a cluster randomized controlled trial with three arms: 1) usual care (community health workers with the standard level of hypertension care training); 2) community health workers with an additional tailored behavioral communication strategy; and 3) community health workers with a tailored behavioral communication strategy who are also equipped with smartphone technology. The co-primary outcome measures are: 1) linkage to hypertension care, and 2) one-year change in systolic blood pressure among hypertensive individuals. Cost-effectiveness analysis will be conducted in terms of costs per unit decrease in blood pressure and costs per disability-adjusted life year gained. DISCUSSION/CONCLUSIONS:This study will provide evidence regarding the effectiveness and cost-effectiveness of strategies to optimize linkage and retention to hypertension care that can be applicable to non-communicable disease management in low- and middle-income countries. TRIAL REGISTRATION/BACKGROUND:This trial is registered with (NCT01844596) on 30 April 2013.

BACKGROUND:Hypertension is the leading global risk factor for mortality. Hypertension treatment and control rates are low worldwide, and insufficient human resource capacity is among the contributing factors. Thus, a critical component of hypertension management is to develop novel and effective solutions to the human resources challenge. One potential solution is task redistribution and nurse management of hypertension in these settings. OBJECTIVES/OBJECTIVE:The aim of this study is to investigate whether nurses can effectively reduce blood pressure in hypertensive patients in rural western Kenya and, by extension, throughout sub-Saharan Africa. METHODS:An initial phase of qualitative inquiry will assess facilitators and barriers of nurse management of hypertension. In addition, we will perform usability and feasibility testing of a novel, electronic tablet-based integrated decision-support and record-keeping tool for the nurses. An impact evaluation of a pilot program for nurse-based management of hypertension will be performed. Finally, a needs-based workforce estimation model will be used to estimate the nurse workforce requirements for stable, long-term treatment of hypertension throughout western Kenya. FINDINGS/RESULTS:The primary outcome measure of the impact evaluation will be the change in systolic blood pressure of hypertensive individuals assigned to nurse-based management after 1 year of follow-up. The workforce estimation modeling output will be the full-time equivalents of nurses. CONCLUSIONS:This study will provide evidence regarding the effectiveness of strategies to optimize task redistribution and nurse-based management of hypertension that can be applicable to noncommunicable disease management in low- and middle-income countries.