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Meta-Analysis
. 2021 Feb 10;19(1):30.
doi: 10.1186/s12916-021-01909-6.

Poor cardiovascular health is associated with subclinical atherosclerosis in apparently healthy sub-Saharan African populations: an H3Africa AWI-Gen study

Engelbert A Nonterah  1   2 , Nigel J Crowther  3 , Abraham Oduro  4 , Godfred Agongo  4 , Lisa K Micklesfield  5 , Palwendé R Boua  6 , Solomon S R Choma  7 , Shukri F Mohamed  8 , Herman Sorgho  6 , Stephen M Tollman  9 , Shane A Norris  5 , Frederick J Raal  10 , Diederick E Grobbee  11 , Michelé Ramsay  12 , Michiel L Bots  11 , Kerstin Klipstein-Grobusch  11   13 ; as part of the H3Africa AWI-Gen study
Affiliations
Meta-Analysis

Poor cardiovascular health is associated with subclinical atherosclerosis in apparently healthy sub-Saharan African populations: an H3Africa AWI-Gen study

Engelbert A Nonterah et al. BMC Med. .

Abstract

Background: The cardiovascular health index (CVHI) introduced by the American Heart Association is a valid, accessible, simple, and translatable metric for monitoring cardiovascular health in a population. Components of the CVHI include the following seven cardiovascular risk factors (often captured as life's simple 7): smoking, dietary intake, physical activity, body mass index, blood pressure, glucose, and total cholesterol. We sought to expand the evidence for its utility to under-studied populations in sub-Saharan Africa, by determining its association with common carotid intima-media thickness (CIMT).

Methods: We conducted a cross-sectional study involving 9011 participants drawn from Burkina Faso, Ghana, Kenya, and South Africa. We assessed established classical cardiovascular risk factors and measured carotid intima-media thickness of the left and right common carotid arteries using B-mode ultrasonography. Adjusted multilevel mixed-effect linear regression was used to determine the association of CVHI with common CIMT. In the combined population, an individual participant data meta-analyses random-effects was used to conduct pooled comparative sub-group analyses for differences between countries, sex, and socio-economic status.

Results: The mean age of the study population was 51 ± 7 years and 51% were women, with a mean common CIMT of 637 ± 117 μm and CVHI score of 10.3 ± 2.0. Inverse associations were found between CVHI and common CIMT (β-coefficients [95% confidence interval]: Burkina Faso, - 6.51 [- 9.83, - 3.20] μm; Ghana, - 5.42 [- 8.90, - 1.95]; Kenya, - 6.58 [- 9.05, - 4.10]; and South Africa, - 7.85 [- 9.65, - 6.05]). Inverse relations were observed for women (- 4.44 [- 6.23, - 2.65]) and men (- 6.27 [- 7.91, - 4.64]) in the pooled sample. Smoking (p < 0.001), physical activity (p < 0.001), and hyperglycemia (p < 0.001) were related to CIMT in women only, while blood pressure and obesity were related to CIMT in both women and men (p < 0.001).

Conclusion: This large pan-African population study demonstrates that CVHI is a strong marker of subclinical atherosclerosis, measured by common CIMT and importantly demonstrates that primary prevention of atherosclerotic cardiovascular disease in this understudied population should target physical activity, smoking, obesity, hypertension, and hyperglycemia.

Keywords: Cardiovascular diseases; Cardiovascular health index; Carotid intima-media thickness; Primary prevention; Screening; Sub-Saharan Africa; Subclinical atherosclerosis; Understudied populations.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Map of Africa showing the prevalence of levels of cardiovascular health (CVH) for the various countries of the AWI-Gen study and according to sex, AWI-Gen population is the combined participant analysis. p values denote differences between women and men
Fig. 2
Fig. 2
Adjusted association of cardiovascular health index (CVHI) score with common carotid intima-media thickness (CIMT in μm) in the combined AWI-Gen population stratified by country, sex, and socio-economic status (SES) subgroups. Effect is represented by β-coefficients and is a change in mean CIMT (in micrometers) with each unit increase in the CVHI score (0–14). Wealth quintile defined as Q1 = poorest, Q2 = poorer, Q3 = poor, Q4 less poor, and Q5 = least poor. Adjusted for age, educational status, household SES, HIV + ART, self-reported history of stroke, heart attack, congestive heart failure, and chronic kidney disease
Fig. 3
Fig. 3
Adjusted association of cardiovascular health index (CVHI) score with common carotid intima-media thickness (CIMT in μm) in women stratified by country and socio-economic status (SES). Effect is represented by β-coefficients and is a change in mean CIMT (in micrometers) with each unit increase in the CVHI score (0–14). Wealth quintile defined as Q1 = poorest, Q2 = poorer, Q3 = poor, Q4 less poor, and Q5 = least poor. Adjusted for age, educational status, household SES, HIV + ART, self-reported history of stroke, heart attack, congestive heart failure, and chronic kidney disease
Fig. 4
Fig. 4
Adjusted association of cardiovascular health index (CVHI) score with common carotid intima-media thickness (CIMT in micrometers) in men stratified by country and socio-economic status (SES). Effect is represented by β-coefficients and is a change in mean CIMT (in μm) with each unit increase in the CVHI score (0–14). Wealth quintile defined as Q1 = poorest, Q2 = poorer, Q3 = poor, Q4 less poor, and Q5 = least poor. Adjusted for age, educational status, household SES, HIV + ART, self-reported history of stroke, heart attack, congestive heart failure, and chronic kidney disease
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