Communique: Key Takeaways From Scientific Plenaries
- Stroke still remains the commonest cause of death in neurologic patients in Nigeria.
- Emergency response should apply caution in lowering the blood pressure early in management with careful assessment. If blood pressure is ≤180/100, please do not lower.
- Initial stroke assessment should involve use of stroke severity scale (Lyden et al 1994).
- All patients admitted to hospital with suspected acute stroke should have non-contrast CT brain imaging on arrival to hospital within 20 minutes.
- Ischaemic strokes can be improved upon with use of tissue plasminogen activator (Intravenous Alteplase) for conservative management.
- Only the assessment of blood glucose must precede any intervention.
- Time is brain. 32000 brain cells are lost every 8.7 seconds.
- During stroke, 1.2 billion cells are lost, leading to ageing and degeneration equivalent to 36 years per lifetime.
- Challenges in stroke management in Nigeria include delayed average presentation time for CT imaging following stroke onset to be 70 hours. (Ogbole et al).
- 46% of sufferers do not present within 24 hours of onset as warning signs in only one in three stroke events are identified.
- Awareness is still very poor and there is a strong need for advocacy for stroke units in hospitals.
- Elevated systolic blood pressure is the leading preventable cause of premature deaths globally (11 million) with over 200 million daily adjusted life years (DALY).
- Definition of hypertension is beyond Systolic BP/Diastolic BP values as it should be defined in terms of Blood pressure levels above which investigations and treatment should do more good than harm (Rose et al 1971).
- Advocacy for wider use of out-of-office measurement with home blood pressure monitoring as an option to confirm diagnosis detect white-coat and masked hypertension as well as monitor control.
- Even with well-defined treatment protocols, percentage of patients treated is still very low globally (30%) with controlled rate (13%) – (Chow et al 2013).
- Screening programs should be done every 5 years in subjects with optimal blood pressure, every 3 years in subjects with normal BP and annually in those with high normal pressure.
- Local community-setting statistics show prevalence – 42%, awareness – 29%, treated – 13%, control – less than 8% (Chijioke et al 2016).
- Strategies aimed at blood pressure control should be both physician-oriented (patient education, avoid inertia and patient monitoring) and patient-oriented (lifestyle modifications, home BP measurement, treatment adherence).
III. Heart Failure – Part 1
- At least 37 million people with heart failure (HF) worldwide with over a million new cases every year.
- 1 in 5 adults over 40 years will have heart failure in their lifetime.
- All heart failure patients, regardless of their symptoms, are all at high risk of dying because of the silent progression of the disease.
- It is deadlier than almost all cancers. 1 in 5 heart failure patients die within 1 year of diagnosis, while 50% of all confirmed subjects would have died within 5 years.
- 6- to 9-fold increase in sudden death in heart failure compared to the normal population and characterized by frequent hospitalization.
- Guideline treatment goals in heart failure are to improve clinical status, functional capacity and quality of life, reduce hospitalizations and reduce death.
- Critical platform to achieve this beyond drug therapy is the institution of heart failure networks in specialist health centres in Nigeria.
- Heart failure networks at point of care consist of HF clinics and HF patient support/advocacy groups.
- The HF networks should involve a multi-disciplinary team approach by all stakeholders (doctors, nurses, pharmacists, HMOs, Ministry of Health, social workers, health NGOs) to which the patient is most central and most important figure.
- There is also critical need for more public awareness by all stakeholders to enlighten people on HF disease burden and symptoms recognition.
IV. Heart Failure – Part 2
- Compared to Enalapril, Sacubitril/Valsartan showed better results in preventing recurrent hospitalizations, improved quality of life and reduced death.
- Post discharge, the patients do not truly stay out of hospital as the re-admission rate is still very high – 1 in every 4 patients within 30 days of discharge.
- Over 44% of heart failure patients would be re-hospitalized at least twice in a year.
- Sudden cardiac death accounts for approximately half of deaths in patients with heart failure.
- Pioneer trial done in post-acute heart failure patients in a hospital setting following an acute decompensation with Sacubitril/Valsartan use showed remarkable improvement in hospitalization and death reduction, especially in the vulnerable phase of the first 30 days post discharge.
- Transition study showed an equal safety and tolerability profile with Sacubitril/Valsartan pre-discharge initiation compared to post-discharge.
- Rationale for the Pioneer trial was borne out of the contrast of evidence in previous heart failure trials done in ambulatory and non-hospitalized patients.
- Pioneer trials showed 29% greater reduction with Sacubitril/Valsartan compared to Enalapril in NT pro BNP levels, reflective of the reduction in the heart failure severity and patient improvement.
V. Diabetes – Part 1
- If people with Diabetes Mellitus (DM) were asked to live together in a place, they will constitute the 3rd largest country in the World…the country of DIABETES!
- Diabetes Mellitus is the fastest growing epidemic in the World today as 630 million people today are suffering from it.
- Number of deaths from Diabetes Mellitus, averaging about 5 million per year, is more than the combined totality of deaths from HIV/TB and Malaria put together (3.7 million) – IDF 2015.
- Poor outcomes are due to the error of clinically focusing on symptomatic treatment and glycaemic control alone.
- A new class of anti-diabetic medication, the DDP4 inhibitors (e.g Vildagliptin), help to address these multifactorial mechanisms.
- Vildagliptin has shown greater efficacy as an add-on to Metformin when compared to other classes of DDP4 inhibitors (Bosi et al 2009).
- The DDP4 inhibitors show similar HBA1c reduction compared to S/Us with no weight gain and extremely few hypoglycaemic events.
- The DDP4 inhibitors show similar levels of blood sugar control (as measured by glycosylated haemoglobin, the gold standard of diabetes assessment).
- The use of DDP4 Inhibitors addresses 7 out of the 8 ominous causes implicated in the pathogenesis of Diabetes Mellitus.
- Modification of CV risk should be a multifactorial approach, not just glycaemic control. It involves:
- Lifestyle modification
- Blood Pressure control
- Lipid management
VI. Diabetes – Part 2
- Community-based prevalence in Nigeria shows rural preponderance of 1-2% and 6-10% in urban population translating to 5 million people.
- Less than 30% of all DM patients in Africa have glycosylated haemoglobin of less than 7%.
- Many DM patients in Nigeria present with very high levels of glycosylated haemoglobin, hence there is very little room for monotherapy in management.
- The disease has also progressed remarkably, with silent deterioration in haemodynamic function, leading to heightened cardiovascular risk at the time of diagnosis.
- This underscores the need for early intensification.
- Core defects in Diabetes Mellitus are impaired insulin production and end-organ insulin resistance.
- DDP4 inhibitors slow down Islet cell decline through reverse remodelling and repair, as well as improving insulin resistance.
- International estimates of Chronic Kidney Disease (CKD) are consistent ~ 10-16% occurrence in adults globally (Lancet 2010).
- Estimates from the Global Burden of Disease Studies (2017) show CKD as the 12th leading cause of death, ahead of Tuberculosis (13th), HIV (14th), Malaria (21st).
- It was also the 6th fastest-growing cause of death between 1990 – 2017.
- One-third of the global population is at increased risk of CKD.
- The risk for the development of diabetic nephropathy has a genetic component that is likely polygenetic, of which Africans have a high genetic risk (ADA 2012).
- Among all Africans, West Africans have an over 40% higher risk (Freedmann et al 2010).
- Diabetic Nephropathy is the leading cause of end-stage kidney disease. This is seen in 30 – 40% of patients.
- Detection and quantification of protein excretion in urine has diagnostic and therapeutic/prognostic significance, and screening should be performed yearly.
- Specific treatment of patients with diabetic nephropathy can be divided into 4 major areas:
- Cardiovascular risk reduction
- Glycemic control – Declining renal function increases risk of severe hypoglycaemia
- Blood pressure control – Target blood pressure in diabetics should be less than 130/80
- Inhibition of the renin-angiotensin system (RAS) – significant additional benefit/ treats microalbuminuria – N Engl J Med 2001.
Breakout Sessions – Driving Advocacy for Health Sector
Following extensive plenary lectures, workshops, discussions and debates, the summit made the following recommendations:
- Advocate for the change in government policy towards non-communicable diseases (NCDs) especially the cardiometabolic disorders.
- The need for increased investment in the health sector which can be achieved through increased budgetary allocation and the establishment of levy/tax on sugar-containing products and beverages, which can, in turn, be ploughed back into the health system for prevention and control of NCDs.
- To ensure that all stakeholders in the health sector will need to come together to actualize the full implementation of the National Health Act as this would help in tackling the burden of cardiovascular diseases.
- Ensuring that there are laws to censor/regulate the dissemination of information about cardiovascular disease and cardiometabolic disorders.
- Coordination of involvement of professional groups – NCS (Nigerian Cardiac Society), EMSON (Endocrine and Metabolism Society of Nigeria), NSN (Nigerian Society of Nephrology) and other professional groups – towards advocating for NCDs.
- The need for a National Diabetes/NCDs survey to generate baseline data planning and implementation of programs.
- Work towards increasing access to care, drugs and consumables for NCDs (including subsidies).
- Development and dissemination of clinical practice guidelines for all NCDs.
- Collaborative efforts in advocating for prevention strategies for NCDs
- Capacity-building in order to improve the care and support for people living with NCDs.
- Engaging key health decision makers (Ministry of Health, National Health Council, Governors forum, National Assembly, etc.).
- The need to reach out to advocacy partners in the health sectors (pharmaceutical companies, NGOs, civil society groups, community and faith-based organizations) and donor agencies.
Emeritus Prof. Ayodele Olajide Falase
MB, BS (Ib), MRCP(UK), MD, FWACP, FNPMCN, FRCP(Lond), NNOM
Chairman, 5th Novartis International Cardiovascular Summit
5th Novartis International Cardiovascular Summit: This summit titled 5th Novartis International Cardiovascular Summit held on April 17, 2019 at Sheraton Hotels, Ikeja, Lagos – Nigeria. Key Takeaways From 5th Novartis International Cardiovascular Summit was centred on neurology, hypertension, heart failure, diabetes and nephrology.