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VOLUME 13 NUMBER 2 • DECEMBER 2016

93

SA JOURNAL OF DIABETES & VASCULAR DISEASE

REVIEW

from chronic gastroenteritis, hypoadrenalism and shortened life

expectancy associated with advanced AIDS.

Despite the scarcity of data from SSA, there are some indications

of overall excess CVD risk factors in HIV-infected patients. Situation

analysis in 2008 of 501 HIV-infected patients from Botswana using

the database of the Botswana Medical Aid Scheme combined with

data from the Centre for Chronic Diseases revealed impressive

clustering of hypertension, dyslipidaemia, obesity, dysglycaemia

and smoking (Fig. 2). The peak age range for the occurrence of

CVD risk factors was about a decade after the peak age for HIV

infection in Botswana.

Given the difficulty of determining whether the observed

increase in CVD risks were due to HIV itself, treatment with HAART

or merely a factor of improved longevity, it would be ideal to

perform case–control studies on the prevalence of CVD risk factors

and the prevalence of arteriosclerotic cardiovascular endpoints such

as IHD, stroke, and peripheral arterial disease in HIV-infected versus

age- and gender-matched non-HIV-infected individuals. Also, a

comparison of pre-HAART and on-HAART HIV-infected patients

would shed light on this grey area. It is important to remember

that the enormous impact of HIV/AIDS does not appear to have

diminished the impact of chronic cardiovascular diseases on

mortality in SSA.

49

Reports on IHD in SSA

There are a few scattered reports of IHD in SSA. Kengne and

colleagues

50

collated a total of 356 cases of SSA patients with

coronary heart disease (CHD) from four selected countries (Ghana,

Cameroon, Senegal and Kenya). They reported a high prevalence

of CHD risk factors, which was not surprising in this selected

population of patients with established CHD. Males outnumbered

females by ratios ranging from 1.3:1 to 6:1, with hypertension in

up to two-thirds of the patients. The report highlighted the fact

that IHD was by no means rare in these African populations.

The African arm of the INTERHEART study showed that

dyslipidaemia, abdominal obesity and tobacco use accounted for

greater population-attributable risk in the overall African population,

whereas hypertension and diabetes were less prominent risk

factors.

51

However, in black Africans, dyslipidaemia was followed by

hypertension, abdominal obesity, diabetes and then tobacco use.

The INTERHEART African study cast doubt on the notion of

protective lipid profiles in blacks, as one reason for implicitly low IHD

prevalence in Africa. High HDL cholesterol levels in black Africans

might be dysfunctional and less protective than generally believed.

However, the findings of the INTERHEART African study were at

slight variance with reports by Ezzati and colleagues who showed

that hypertension, low intake of fruits and vegetables and physical

inactivity accounted for population-attributable fractions for

ischaemic heart disease mortality of 43, 25 and 20%, respectively, in

the Africa region. These were all above the population-attributable

fraction of 15% for high cholesterol.

52

Limitations in diagnostic evaluation of patients with possible IHD

might explain, at least in part, the apparent rarity of IHD in SSA.

This is illustrated by the study on black South Africans by Joubert

and colleagues using data from the Medical University of South

Africa (MEDUNSA) stroke data bank. The study showed increased

prevalence of CHD with improved diagnostic tools.

53

History of angina pectoris or myocardial infarction using the

Rose questionnaire yielded a prevalence of only 0.7% in 741

black patients with stroke, 71% of whom had cerebral infarction.

Resting 12-lead electrocardiography was analysed for the presence

of poor R-wave progression in the precordial leads, the presence of

pathological Q waves and ST–T wave changes using the Minnesota

Fig. 2.

Cardiovascular disease risk factors in HIV-infected patients in Botswana.

Table 5.

Top 10 causes of morality in South African men and women > 60 years in 2000.

COPD = chronic obstructive pulmonary disease.

Cause of death

Percentage (%) in males aged >

60 years [

n

= 71 641]

Cause of death

Percentage (%) in females aged >

60 years [

n

= 73 474]

Ischaemic heart disease

17.2

Stroke

17.7

Stroke

12.2

Ischaemic heart disease

16.0

COPD

8.0

Hypertensive heart disease

9.8

Tuberculosis

6.4

Diabetes mellitus

7.3

Lower respiratory tract infection

5.1

Lower respiratory tract infection

5.3

Hypertensive heart disease

4.2

COPD

4.4

Cancer of airways

4.1

Nephritis

2.8

Diabetes mellitus

4.0

Tuberculosis

2.7

Cancer of prostate

3.1

Asthma

2.4

Cancer of oesophagus

2.8

Cancer of the breast

1.9