Cardiovascular Disease in Sub-Saharan Africa
2005; Lippincott Williams & Wilkins; Volume: 112; Issue: 23 Linguagem: Inglês
10.1161/circulationaha.105.597765
ISSN1524-4539
AutoresLionel H. Opie, Bongani M. Mayosi,
Tópico(s)Birth, Development, and Health
ResumoHomeCirculationVol. 112, No. 23Cardiovascular Disease in Sub-Saharan Africa Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBCardiovascular Disease in Sub-Saharan Africa Lionel H. Opie and Bongani M. Mayosi Lionel H. OpieLionel H. Opie From the Hatter Institute for Heart Research, Cape Heart Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa (L.H.O.), and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Observatory, Cape Town, South Africa (B.M.M.). and Bongani M. MayosiBongani M. Mayosi From the Hatter Institute for Heart Research, Cape Heart Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa (L.H.O.), and the Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Observatory, Cape Town, South Africa (B.M.M.). Originally published6 Dec 2005https://doi.org/10.1161/CIRCULATIONAHA.105.597765Circulation. 2005;112:3536–3540"I speak of Africa and golden joys."— —Shakespeare, Henry IV part 2"The wind of change is blowing through this continent."— —Harold McMillan, former Prime Minister of the United KingdomOpen your eyes to Africa. It is big, complex and confounding," says the British Medical Journal of October 1, 2005.1 It has some of world's richest natural resources in minerals and oil. Yet 34 of the world's 41 indebted poor countries are in Africa, and only 37% of Africa's children attend secondary school. Africa, with one sixth of the world's population, accounts for one fiftieth of the global trade. We also read of wars, civil disturbances, and devastating chronic diseases such as malnutrition, HIV/AIDS, tuberculosis, and malaria. The problems seem insuperable. "Who takes responsibility for Zimbabwe?" asked The Lancet in despair in a recent editorial.2Sub-Saharan Africa, the Cradle of HumankindWhy is the focus of the present series of articles on Africa in this issue of Circulation on sub-Saharan Africa? Linguistic maps of Africa show that the Sahara divides northern peri-Mediterranean Africa and some adjoining areas from sub-Saharan Africa. The language of the north is Hamito-Semitic and Arab, whereas the sub-Saharan is covered almost entirely by the Niger-Congo Bantu languages, with 2 exceptions: the Khoisan language in the Kalahari desert, lying in what is now Namibia and Botswana, and parts of South Africa in which the Indo-European languages are prominent. Thus, Sub-Saharan Africa differs linguistically and culturally from Northern Africa. Sub-Saharan Africa is also the putative cradle of humankind (Figure). Download figureDownload PowerPointLinguistic map of Africa, showing the marked division between the northern and sub-Saharan areas. Upward arrows indicate possible evolution of humankind, from the sites in South Africa and elsewhere as hominids about 3 million years ago, then from the East African site as Homo sapiens about 160 000 years ago. The latter is often referred to as the "Out of Africa" hypothesis for the origin of modern humans. First spread from Africa was to western Asia, thence to Europe, and much more recently to North America and then to South America via Alaska. Map courtesy of Creative Commons, created by Mark Dingemanse. Accessed on October 26, 2005, at: http://commons.wikimedia.org/wiki/Image:African_language_families.pngIn 1871, Charles Darwin predicted that human ancestors would be found in Africa.3 "Both the genetic antiquity and impact of the African contribution to the modern Homo sapiens are so great as to view Africa as a central place of human evolution."4 Many researchers now support the "out-of-Africa" model,5 whence came "Eve," the postulated common ancestor to all modern humans. But, from where in Africa? The "out-of-Ethiopia" hypothesis gives an estimated age of ancestors more human than ape (Homo sapiens) in Ethiopia about 160 000 years ago,5 on the basis of mitochondrial footprints.6 There are also some ancient Homo sapiens remains in South Africa, although not quite as old. "But all that refers only to the recent stages in human evolution" (P.V. Tobias, DSc, FRS, e-mail communication, on human evolution, October 25, 2005). With regard to the origin of the hominids, which occurred at an even earlier stage of evolution, the oldest South African sites at Sterkfontein, west of Johannesburg, contain fossils that go back about 3.3 million years (ibid). There are even older remains of these early hominids from Kenya, Ethiopia, and especially the Chad Republic (ibid). Flat-faced fossils between 3.2 and 3.5 million years old were found in the Olduvai Gorge in Kenya.7 Overall, we can safely say that "out of Africa" is the cradle of humankind without being able to pinpoint the exact area. Multiple sites of origin cannot be excluded.What about subsequent expansion? How did the population escape from the cradle(s) to become "Pan-African" and sub-Saharan, which is the scope of this focused issue of Circulation? Within Africa, the oldest detectable major migrations occurred about 60 000 to 77 000 years ago,6 expanding to Southern Africa, becoming the Khoisan people (and more about them later), and into Eastern, Central, and Western Africa.6 There might even have been earlier "upstream" flows into central Africa from the Khoisan about 150 000 years ago.8 Similar techniques, with DNA patterns, have been used to trace the expansion from Africa to all parts of the globe, presumably spreading upward along the great lakes and Nile River to Egypt, and thence into Asia about 60 000 years ago (Figure). Spread from Africa to Europe occurred about 45 000 years ago. Further emigration from Asia to America occurred via Alaska about 7000 to 35 000 years ago.The First Drawing of a Human Heart?Now we take a big jump in time and briefly deviate via Egypt. The origins of the ancient Egyptians are not too well defined but could have occurred from those emigrants en route from Africa to Asia who saw their future in the rich waters of the Nile delta, or from Eurasians who had returned to Mediterranean Africa or from a separate origin in the near Middle East. In time, Egypt became the source of a thriving civilization where, among other things, they were obsessed with death and the afterlife. The Egyptian Book of the Dead was a collection of papyrus rolls placed in Egyptian tombs. The heart, the organ of conscience and understanding, had to be weighed against the feather, which symbolized order, truth, and justice. A heavy heart was a bad heart, and the heart had to be lighter than the feather for its previous bearer to pass beneficially into the afterlife. The Book of the Dead, circa 1370 BC, illustrates these small hearts, probably among the first ever drawn. Those with overweight and functionally inadequate hearts failed the test. To put it simply in current terms: A big heart is a bad heart.Early Tribal LifeAt about the same time, the early tribesmen of sub-Saharan Africa were hunter-gatherers, living far from the complexity of current modern "civilization." One of the oldest of these indigenous groups were the Khoisan nomadic hunters, peaceful tribes with a rich tradition and language but now barely surviving the onslaught of modern life and, alas, governments. "The last stand of the Kalahari Bushmen ends in dispossession, defeat and despair."9 What of their cardiovascular health while they were still hunter-gatherers? An important article in Circulation describes the blood pressure (BP) patterns of this group in 1960.10 Quite differently from the pattern in most Western persons, the BP did not rise with age. This poses the repetitive problem, do the differences lie in the genes or the environment? A key phrase in the Methods section of the report by Kaminer and Lutz10 is, "Each nomadic group was a completely self-contained socioeconomic unit." This description could probably also be applied to the early tribal groups of East Africa, as first recorded in Kenya by Donnison in 192911 and confirmed in Uganda by Williams in 1941.12 These tribesmen did not suffer from the steady rise in BP as in "the people of Europe and North America."12 Is it a coincidence that another "self-contained socioeconomic group," this time white and female, showed no BP increase over 30 years?13 What could be the common factor to these 3 very diverse groups? Clearly not external genetic similarities, nor diet, nor the level of physical exercise, nor lack of stress (imagine the daily lives of early tribesmen), but rather the socioeconomic independence from "Western civilization." These observations show how lifestyle can affect BP and, hence, cardiovascular outcome. If we could pinpoint the secret of the flat BP in these 3 rather disparate groups, this could contribute to solving a major public health problem in Western societies in which even those who are normotensive at 55 years of age have a 90% lifetime risk of developing hypertension.14Epidemiological Factors and Cardiovascular RiskCurrently, there are strong economic forces propelling previously isolated rural groups into the periurban and urban areas. Much of Africa is undergoing an epidemiological transition.15 Cardiovascular disease (CVD) is the leading worldwide cause of death in all developing regions with the exception of sub-Saharan Africa. There, the first phase of this transition, that is, the phase of pestilence and famine, is still dominant.16 However, in the next phase, that of receding pandemics, CVD becomes more prominent, and in the third phase of degenerative and man-made disease, CVD is the leading cause of death. As "civilization" spreads, so does CVD become an increasing health burden that requires skillful, cost-effective management.16 As shown in the INTERHEART study, hypertension is a strong contributor to the hazards of CVD in black Africans, with an OR of 7.0 versus 2.3 to 3.9 in other ethnic groups, with P<0.0002.17 Hypertension is eminently treatable and to some extent preventable.18Poverty and affluence may both bring disease. According to the "fetal" origins of adult disease, as put forward by Barker, environmental factors and particularly poor maternal nutrition during pregnancy may program risks for adverse health that appear only later in adult life.19 Specifically, there is an inverse relation between birth weight and CVD in later life, as shown in a longitudinal study from Scotland.20 Affluence, too, has its problems. Higher-income black Africans are more susceptible to myocardial infarction than high-income white or other nonblack Africans, hypothetically because different stages of the epidemiological transition are at work.17 Besides hypertension, another major cardiovascular disease susceptible to the changing environment in Africa is diabetes mellitus,21 also a prominent risk factor for myocardial infarction in black Africans.17 Other major cardiovascular diseases in Africa include the consequences of HIV/AIDS (often manifesting as tuberculous pericarditis), rheumatic valvular disease, and cardiomyopathy, each of which has at least some environmental component and each of which is discussed in different articles in this issue of Circulation.Toward Practical SolutionsIn a continent where poverty is rife, despite the burgeoning wealth of upper-income groups in countries such as Nigeria and South Africa, how can effective cardiovascular therapy be sustained financially? This question is tackled by Gaziano et al in an important article selected for the Editor's pick of this week.22 The answer is that major improvements could be achieved with not much expenditure but much application of policy. Furthermore, by judicious selection of high-risk hypertensive patients, those who need more urgent treatment can be selected by risk factor calculation.22 Such scientific knowledge must be matched by the political will to apply these policies. This is where the nongovernmental organizations come in, a large number of which are active in sub-Saharan Africa (Table). Cardiovascular Health Organizations of Sub-Saharan AfricaCountry/RegionOrganizationMissionWeb or E-Mail Address (Where Available)ContinentalAfrica Heart Network (AHN)Umbrella organization for national heart foundationshttp://www.worldheart.org/members-foundations-ahn.phpInternational Forum for Hypertension Control and Cardiovascular Disease Prevention in Africa (IFHA)Umbrella organization for individuals and national societies[email protected]Pan African Society of Cardiology (PASCAR)Umbrella organization for national professional associations of cardiovascular practitionershttp://www.pascar.org/BeninBenin Heart FoundationNonprofit NGO established to reduce the incidence of CVD through public education and support of researchhttp://www.worldheart.org/members-foundations-ahn.phpCameroonCameroon Cardiac SocietyProfessional association of cardiovascular health practitionersCameroon Heart Foundation (CAMEHF)Nonprofit NGO established to reduce the incidence of CVD through public education and support of researchhttp://www.worldheart.org/members-foundations-ahn.phpCongoHeart Foundation of Congo Brazzaville ("Un coeur pour la vie")Nonprofit NGO established to reduce the incidence of CVD through public education and support of researchhttp://www.worldheart.org/members-foundations-ahn.phpGhanaGhana Heart FoundationNonprofit NGO established to reduce the incidence of CVD through public education and support of researchhttp://www.worldheart.org/members-foundations-ahn.phpGhana Society of Hypertension & CardiologyProfessional association of cardiovascular health practitioners[email protected]KenyaHeart Association of KenyaNonprofit NGO established to reduce the incidence of CVD through public education and support of research[email protected]Kenya Cardiac SocietyProfessional association of cardiovascular health practitionerswww.kenyacardiacs.comKenya Hypertension LeagueProfessional association of cardiovascular health practitionershttp://www.meduohio.edu/whl/africa.htmlMauritiusMauritius Heart FoundationNonprofit NGO established to reduce the incidence of CVD through public education and support of research[email protected]MozambiqueHeart Association of MozambiqueNonprofit NGO established to reduce the incidence of CVD through public education and support of researchhttp://www.worldheart.org/members-globalreach.phpNigeriaNigerian Heart FoundationNonprofit NGO established to reduce the incidence of CVD through public education and support of research[email protected]Nigerian Hypertension SocietyProfessional association of cardiovascular health practitionershttp://www.meduohio.edu/whl/africa.htmlNigerian Cardiac SocietyProfessional association of cardiovascular health practitioners[email protected]ContinuedCountry/RegionOrganizationMissionWeb or E-Mail Address (Where Available)NGO indicates nongovernmental organization.SenegalSenegal Heart Hypertension FoundationProfessional association of cardiovascular health practitionershttp://www.meduohio.edu/whl/africa.htmlSouth AfricaSouth African Heart Association (with the following interest groups: Cardiac Arrhythmia Society of South Africa; Paediatric Cardiology Society of South Africa; Nuclear Cardiology Group; Society of Cardiothoracic Surgery; Society for Interventional Cardiology; Lipid and Atherosclerosis Society of South Africa)Professional association of cardiovascular health practitionerswww.saheart.orgStroke Association of South AfricaProfessional association of health practitioners with an interest in stroke medicineSouthern African Hypertension SocietyProfessional association of physicianshttp://www.hypertension.org.za/Heart Foundation of South AfricaNonprofit NGO established to reduce the incidence of CVD through public education and support of researchwww.heartfoundation.co.zaSociety for Endocrinology, Metabolism, and Diabetes of South Africa (SEMDSA)Professional association of physicianshttp://www.semdsa.org.za/SudanSudan Heart InstituteNonprofit NGO established to reduce the incidence of CVD through public education and support of researchhttp://www.worldheart.org/members-foundations-ahn.phpZimbabweZimbabwe Hypertension SocietyProfessional association of physicians with an interest in hypertensionhttp://www.meduohio.edu/whl/africa.htmlThe ingredients for success in the struggle against cardiovascular diseases include governmental will-power, vigorous nongovernmental organizations, dedicated physicians, and fully trained nurses with technical support. An important issue is keeping trained personnel in Africa, as brought to the fore in ProCOR by Nobel Prize winner Bernard Lown, a renowned cardiologist.23 The "brain drain" deprives Africa of doctors, nurses, technicians, and others who, together, could help to fight the growing CVD epidemic. Dr Lown emphasizes that wealthy Western countries should only with reluctance permanently take on those from Africa. An exception would be refugees from those African regimes that make it impossible for such qualified people to continue to practice in their home country. Promoting a strong research base indirectly helps to keep "good brains" in their home countries, in addition to enhancing patient care. "Inequalities in health research contribute to inequalities in health."24On the positive side, a web of medical and cardiovascular societies is spreading across Africa, including active nongovernmental organizations such as the Heart Foundations (Table). For example, there is a very active Heart Foundation in Nigeria that strongly supports a World Health Organization report on preventing chronic diseases, released on October 5, 2005. Dr K. Akinroye, Vice President of the Nigerian Heart Foundation, reports that Nigerian President Olusegun Obasanjo has lent his support to the goal of reducing death from chronic disease as follows: "Governments have a responsibility to support their citizens in their pursuit of a healthy, long life. It is not enough to say, we have told them not to smoke, we have told them to eat fruit and vegetables, we have told them to take regular exercise. We must create communities, schools and workplaces and markets that make these healthy choices possible. We must tackle this problem step by step and we must start now."25ConclusionsIn Africa, the dominant factors driving (or limiting) success are the will to deliver first-class cardiovascular care within the limits of cost-effectiveness and the need to build a suitable infrastructure, including those doctors, nurses, and others who should be kept in Africa. Many major cardiovascular drugs are no longer prohibitively expensive. The real challenge is how best to deliver the drugs to those who need them. We are deeply appreciative of the opportunity of presenting this group of articles in Circulation, a shining example of the application of first-world concepts and rigor of scientific method, including thorough review processes, to help heal the cardiovascular problems of sub-Saharan Africa.The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.DisclosuresNone.FootnotesCorrespondence to Dr Lionel Opie, Hatter Institute, University of Cape Town Faculty of Health Sciences, Anzio Rd, Observatory 7925, South Africa. E-mail [email protected] References 1 Clark J. Open your eyes to Africa: it is big, complex and confounding. BMJ. 2005; 331. Editorial.Google Scholar2 Editorial. Who takes responsibility for Zimbabwe? Lancet. 2005; 366: 1138.Google Scholar3 Darwin C. The Descent of Man. 1871. Reprinted in Penguin Classics Series; New York, NY: 2004.Google Scholar4 Satta Y, Takahata N. Out of Africa with regional interbreeding? Modern human origins. Bioessays. 2002; 24: 871–875.CrossrefMedlineGoogle Scholar5 Stringer C. Human evolution: out of Ethiopia. Nature. 2003; 423: 692–693, 695.MedlineGoogle Scholar6 Watson E, Forster P, Richards M, Bandelt HJ. Mitochondrial footprints of human expansions in Africa. Am J Hum Genet. 1997; 61: 691–704.CrossrefMedlineGoogle Scholar7 Thackeray F. "Mrs Ples" and our distant relatives. Science in Africa. May 2001. Available at: www.scienceinafrica.co.za/2001/may/ples.htm. Accessed October 20, 2005.Google Scholar8 Southern African Eve. Science. 1999; 286: 229. Editorial.Google Scholar9 The last stand of the Kalahari Bushmen ends in dispossession, defeat and despair. Washington Post. October 2005. Cited by: Sunday Independent, Johannesburg, South Africa. October 23, 2005; p 3.Google Scholar10 Kaminer B, Lutz WP. Blood pressure in Bushmen of the Kalahari Desert. Circulation. 1960; 22: 289–295.CrossrefMedlineGoogle Scholar11 Donnison C. Blood pressure in the African natives: its bearing upon aetiology of hyperpiesia and arteriosclerosis. Lancet. 1929; 1: 6–7.CrossrefGoogle Scholar12 Williams AW. The blood pressure of Africans. East Afr Med J. 1941; 21: 368.Google Scholar13 Timio M, Lippi G, Venanzi S, Gentili S, Quintaliani G, Verdura C, Monarca C, Saronio P, Timio F. Blood pressure trend and cardiovascular events in nuns in a secluded order: a 30-year follow-up study. Blood Press. 1997; 6: 81–87.CrossrefMedlineGoogle Scholar14 JNC VII. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil S, Wright Jr JT, Roccella EJ. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. JAMA. 2003; 289: 2560–2572.CrossrefMedlineGoogle Scholar15 Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001; 104: 2746–2753.CrossrefMedlineGoogle Scholar16 Gaziano TA. Cardiovascular disease in the developing world and its cost-effective management. Circulation. 2005; 112: 3547–3553.LinkGoogle Scholar17 Steyn K, Sliwa K, Hawken S, Commerford P, Onen C, Damasceno A, Ounpuu S, Yusuf S. Risk factors associated with myocardial infarction in Africa: the INTERHEART Africa Study. Circulation. 2005; 112: 3554–3561.LinkGoogle Scholar18 Opie LH, Seedat YK. Hypertension in sub-Saharan African populations. Circulation. 2005; 112: 3562–3568.LinkGoogle Scholar19 McMillen IC, Robinson JS. Developmental origins of the metabolic syndrome: prediction, plasticity, and programming. Physiol Rev. 2005; 85: 571–633.CrossrefMedlineGoogle Scholar20 Lawlor DA, Ronalds G, Clark H, Smith GD, Leon DA. Birth weight is inversely associated with incident coronary heart disease and stroke among individuals born in the 1950s: findings from the Aberdeen Children of the 1950s prospective cohort study. Circulation. 2005; 112: 1414–1418.LinkGoogle Scholar21 Kengne AP, Amoah AGB, Mbanya J-C. Cardiovascular complications of diabetes mellitus in Africa. Circulation. 2005; 112: 3592–3601.LinkGoogle Scholar22 Gaziano TA, Steyn K, Cohen DJ, Weinstein MC, Opie LH. Cost-effectiveness analysis of hypertension guidelines in South Africa: absolute risk versus blood pressure level. Circulation. 2005; 112: 3569–3576.LinkGoogle Scholar23 Lown B. The brain drain. ProCOR 26 July, 2005. [email protected]Google Scholar24 Volmink J, Dare L. Addressing inequalities in research capacity in Africa. BMJ. 2005; 331: 705–706.MedlineGoogle Scholar25 Obasanjo O. Quoted by: Akinroye KK. Nigerian Heart Foundation Welcomes WHO Report on Preventing Chronic Diseases Released 5th October 2005. ProCOR Web Site. Available at: http://www.procor.org/discussion/displaymsg.asp?ref=2277&cate=ProCOR+Dialogue. Accessed October 5, 2005.Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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Dzudie A, Ngongang Ouankou C, Nganhyim L, Mouliom S, Ba H, Kamdem F, Ndjebet J, Nzali A, Tantchou C, Nkoke C, Barche B, Abanda M, Metogo Mbengono U, Hentchoya R, Petipe Nkappe C, Ouankou M, Kouam Kouam C, Mintom P, Boombhi J, Kuate Mfeukeu L, Ngatchou W, Kingue S and Ngowe Ngowe M (2021) Long-term prognosis of patients with permanent cardiac pacemaker indication in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry, Annales de Cardiologie et d'Angéiologie, 10.1016/j.ancard.2020.07.005, 70:1, (18-24), Online publication date: 1-Feb-2021. Ale O, Braimoh R, Adebiyi A and Ajuluchukwu J (2020) Lifestyle modification and hypertension: prescription patterns of Nigerian general practitioners, Pan African Medical Journal, 10.11604/pamj.2020.35.130.19278, 35 Raal F, Alsheikh-Ali A, Omar M, Rashed W, Hamoui O, Kane A, Alami M, Abreu P and Mashhoud W (2018) Cardiovascular risk factor burden in Africa and the Middle East across country income categories: a post hoc analysis of the cross-sectional Africa Middle East Cardiovascular Epidemiological (ACE) study, Archives of Public Health, 10.1186/s13690-018-0257-5, 76:1, Online publication date: 1-Dec-2018. May J (2018) Keystones affecting sub-Saharan Africa's prospects for achieving food security through balanced diets, Food Research International, 10.1016/j.foodres.2017.06.062, 104, (4-13), Online publication date: 1-Feb-2018. Akintunde A and Oloyede T (2017) Metabolic syndrome and occupation: Any association? Prevalence among auto technicians and school teachers in South West Nigeria, Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 10.1016/j.dsx.2016.12.035, 11, (S223-S227), Online publication date: 1-Nov-2017. Bloomfield G, Narayan K, Sampson U and Narula J (2016) What Defines a Valuable Investment in Global Health Research?, Global Heart, 10.1016/j.gheart.2015.12.007, 11:1, (1) Awaad M and Darahim K (2015) Anxiety and depression in the caregivers of children with congenital heart disease, Middle East Current Psychiatry, 10.1097/01.XME.0000471465.50470.5f, 22:4, (179-185), Online publication date: 1-Oct-2015. Venter P, Malan L and Schutte A (2014) Psychosocial stress but not hypertensive status associated with angiogenesis in Africans, Blood Pressure, 10.3109/08037051.2014.901008, 23:5, (307-314), Online publication date: 1-Oct-2014. Adeloye D, Basquill C and Schnabel R (2014) Estimating the Prevalence and Awareness Rates of Hypertension in Africa: A Systematic Analysis, PLoS ONE, 10.1371/journal.pone.0104300, 9:8, (e104300) Alsheikh-Ali A, Omar M, Raal F, Rashed W, Hamoui O, Kane A, Alami M, Abreu P, Mashhoud W and Nugent R (2014) Cardiovascular Risk Factor Burden in Africa and the Middle East: The Africa Middle East Cardiovascular Epidemiological (ACE) Study, PLoS ONE, 10.1371/journal.pone.0102830, 9:8, (e102830) Davidson P and Himmelfarb C (2013) Population Health Studies – What Do They Tell Us?, Heart, Lung and Circulation, 10.1016/j.hlc.2013.08.014, 22:11, (885-886), Online publication date: 1-Nov-2013. Gama H, Damasceno A, Silva-Matos C, Diogo D, Azevedo A and Lunet N (2013) Low prevalence of hypertension with pharmacological treatments and associated factors, Revista de Saúde Pública, 10.1590/S0034-910.2013047004328, 47:2, (301-308), Online publication date: 1-Jun-2013. Dewhurst M, Dewhurst F, Gray W, Chaote P, Orega G and Walker R (2012) The high prevalence of hypertension in rural-dwelling Tanzanian older adults and the disparity between detection, treatment and control: a rule of sixths?, Journal of Human Hypertension, 10.1038/jhh.2012.59, 27:6, (374-380), Online publication date: 1-Jun-2013. OPIE L, KRUM H, VICTOR R and KAPLAN N (2013) Antihypertensive therapies Drugs for the Heart, 10.1016/B978-1-4557-3322-4.00016-8, (224-271), . Mayosi B and Forrester T (2012) Commentary: 'Serum-cholesterol, diet, and coronary heart-disease in Africans and Asians in Uganda' by AG Shaper and KW Jones, International Journal of Epidemiology, 10.1093/ije/dys169, 41:5, (1233-1235), Online publication date: 1-Oct-2012. Ngoungou E, Aboyans V, Kouna P, Makandja R, Ecke Nzengue J, Allogho C, Laskar M, Preux P and Lacroix P (2012) Prevalence of cardiovascular disease in Gabon: A population study, Archives of Cardiovascular Diseases, 10.1016/j.acvd.2011.12.005, 105:2, (77-83), Online publication date: 1-Feb-2012. Grace J and Semple S The prevalence of cardiovascular disease risk factors in normotensive, pre-hypertensive and hypertensive South African colliery executives, International Journal of Occupational Medicine and Environmental Health, 10.2478/s13382-012-0045-3, 25:4 Die-Kacou H, Kakou A, Kamagaté M, Yavo J, Bamba-Kamagaté D, Balayssac E, Daubret-Potey T and Vamy M (2011) Sodium and Blood Pressure in Africa, Therapies, 10.2515/therapie/2011066, 66:6, (541-544), Online publication date: 1-Nov-2011. Vorster H, Kruger A and Margetts B (2011) The Nutrition Transition in Africa: Can It Be Steered into a More Positive Direction?, Nutrients, 10.3390/nu3040429, 3:4, (429-441) Maher D, Waswa L, Baisley K, Karabarinde A, Unwin N and Grosskurth H (2010) Distribution of hyperglycaemia and related cardiovascular disease risk factors in low-income countries: a cross-sectional population-based survey in rural Uganda, International Journal of Epidemiology, 10.1093/ije/dyq156, 40:1, (160-171), Online publication date: 1-Feb-2011. Mayosi B, Flisher A, Lalloo U, Sitas F, Tollman S and Bradshaw D (2009) The burden of non-communicable diseases in South Africa, The Lancet, 10.1016/S0140-6736(09)61087-4, 374:9693, (934-947), Online publication date: 1-Sep-2009. Rodseth R and Biccard B (2014) Living longer as an anaesthetist: The 'magic' lifestyle or the 'lifestyle polypill', Southern African Journal of Anaesthesia and Analgesia, 10.1080/22201173.2009.10872610, 15:4, (5-10), Online publication date: 1-Aug-2009. Onwuchewa A, BellGam H and Asekomeh G (2009) Stroke at the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria, Tropical Doctor, 10.1258/td.2008.080285, 39:3, (150-152), Online publication date: 1-Jul-2009. KAPLAN N and OPIE L (2009) Antihypertensive Drugs Drugs for the Heart, 10.1016/B978-1-4160-6158-8.50012-5, (198-234), . Ntim W, Johnson T, Mount D and Kong B (2008) International Outreach Programs Are Laudable and Timely, Journal of the American College of Cardiology, 10.1016/j.jacc.2008.07.059, 52:21, (1747), Online publication date: 1-Nov-2008. Biccard B (2014) Anaesthesia for vascular procedures: How do South African patients differ? , Southern African Journal of Anaesthesia and Analgesia, 10.1080/22201173.2008.10872536, 14:1, (109-115), Online publication date: 1-Jan-2008. Syed F and Mayosi B (2007) A Modern Approach to Tuberculous Pericarditis, Progress in Cardiovascular Diseases, 10.1016/j.pcad.2007.03.002, 50:3, (218-236), Online publication date: 1-Nov-2007. Fuster V, Voute J, Hunn M and Smith S (2007) Low Priority of Cardiovascular and Chronic Diseases on the Global Health Agenda, Circulation, 116:17, (1966-1970), Online publication date: 23-Oct-2007. December 6, 2005Vol 112, Issue 23 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.105.597765PMID: 16330692 Originally publishedDecember 6, 2005 Keywordsmyocardial infarctionEditorialsdiabetes mellitusAfricahypertensionPDF download Advertisement SubjectsChronic Ischemic Heart DiseaseClinical StudiesEpidemiologyMyocardial Infarction
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