Congrès National de Cardiologie et de Chirurgie Cardiovasculaire

Tabarka du 25 au 27 Octobre 2018.

« HTA non contrôlée : Session Africaine »

Que disent les recommandations de la PASCAR ?

Prof Anastase DZUDIE. MD, PhD, FESC

Unité de Cardiologie et stimulation cardiaque, Hôpital Général de Douala, Cameroun

Président du Groupe de travail Hypertension, Pan African Society of Cardiology

Faculté de Médecine et des Sciences Biomédicales (FMSB), Université de Yaoundé 1,

Cameroun

Clinical Research Education, Networking and Consultancy (CRENC),

Douala, Cameroun

Hypertension

in Africa

Why thisquestion isrelevant?

2. Hypertension

in Africa today:

Challenges &

opportunities

4. Ten pillars

& our key next steps

Conclusion

WHAT WE WILL COVER

1. Classification of BP & definition of hypertension

COR LOE Recommendation for Definition of High BP

I B-NRBP should be categorized as normal, elevated, or stage 1 or

2 hypertension to prevent and treat high BP.

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category.

BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions, as

detailed in DBP, diastolic blood pressure; and SBP systolic blood pressure.

BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm Hg and <80 mm Hg

Hypertension

Stage 1 130–139 mm Hg or 80–89 mm Hg

Stage 2 ≥140 mm Hg or ≥90 mm Hg

COR LOE HF in Adults With Hypertension

I

SBP:

B-R

In adults at increased risk of Heart Failure, the optimal BP in

those with hypertension should be less than 130/80 mm Hg.

DBP: C-

EO

IAdults with hypertension and Chronic Kidney Disease

should be treated to a BP goal of less than 130/80 mm Hg.DBP:

C-EO

COR LOE Hypertension in Patients With Diabetes Mellitus

I

SBP:

B-RSR

In adults with DM and hypertension, antihypertensive drug

treatment should be initiated at a BP of 130/80 mm Hg or higher

with a treatment goal of less than 130/80 mm Hg.

I

SBP:

B-RSR

For adults with confirmed hypertension and known CVD or

10-year ASCVD event risk of 10% or higher a BP target of

less than 130/80 mm Hg is recommended.

ACC/AHA: BP Goal for Patients With Hypertension

X

Roadmap to achieve 25% hypertension in Africa by 2025

Anastase Dzudie, Brian Rayner, Dike Ojji, Aletta E Schutte, Marc Twagirumukiza, Albertino Damasceno, Seringe Abdou Ba, Abdoul Kane, Euloge Kramoh, Jean Baptiste Anzouan Kacou, Basden Onwubere, Ruth Cornick, Karen Sliwa, Benedict Anisiuba, Ana Olga Mocumbi, Elijah Ogola, Mohamed Awad, George Nel, Harun Otieno, Ali Ibrahim Toure, Samuel Kingue, Andre Pascal Kengne, Pablo Perel, Alma Adler, Neil Poulter, Bongani Mayosi, on behalf of the PASCAR task force on hypertension.

CARDIOVASCULAR JOURNAL OF AFRICA, Volume 28, No 4, July/August 2017

Glob Heart. 2017 Oct 14. pii: S2211-8160(17)30054-6.

PASCAR ROADMAP ON HYPERTENSION:

AFR=African Region, AMR=Region of the Americas, SEAR =South-East Asia Region, EUR=European Region, EMR=Eastern

Mediterranean Region, WPR=Western Pacific Region

•The global prevalence is ≈22%.

Hypertension: WHO Estimates

Global Status Report, 2014. Apps.WHO.int.

Between 1990 and 2010, hypertension caused over 500,000 deaths in Africa!

1. Alain Menanga (CMR), apmcbl@hotmail.com2. Alma Adler (WHF), Alma.Adler@worldheart.org3. AP Kengne (SAMRC), Andre.Kengne@mrc.ac.za4. Anisiuba, Benedict

(Nigeria),banisiuba@yahoo.co.uk5. Armel Djomou (CMR), drdjomouarmel@yahoo.fr6. BA, Serigne (Senegal), saba@refer.sn7. Bertrand Mbolla (Congo), fikabertrand@yahoo.fr8. Christ N Nganou (CMR), cn_nganou@yahoo.fr9. Cornick, Ruth, (South Africa),

ruth.cornick@uct.ac.za10.Dadier Balde (Guinee Conakry), drdadhi@yahoo.fr11.Damasceno, Albertino (Mozambique),

tino_7117@hotmail.com12.Dzudie, Anastase (CMR), aitdzudie@yahoo.com13.Euloge Kramoh (Cote d’Ivoire),

krakoueul@yahoo.fr14.Gamra, Habib (Tunisia), hgamra03@yahoo.com15.Houenassi (Benin), houenassi_m@yahoo.fr16.Jean Baptiste Anzouan Kacou (Cote d’Ivoire),

jb_anzouan@yahoo.fr17.Jean Bruno MIPINDA (Gabon),

jbmipinda@yahoo.fr18.Jean Marie Damourou (Togo), jdamoro@yahoo.fr19.Jolis Nzisabira (Burundi), nzisajol@yahoo.fr20.Kane, Abdoul (Senegal),

abdoulkane.cardio@gmail.com21.Latif, Mousse (Benin), victorymousse@yahoo.fr22.Leopold, Aminde (CMR), amindeln@gmail.com23.Liliane Mfeukeu Kuate (CMR),

mfeukeuliliane@yahoo.fr24.Lucie Nebie (Burkina Faso),

lucie_v_a_nebie@yahoo.fr

25.Lucien Allawaye (Chad), lucienallawaye14@gmail.com

26.Mayosi, Bongani (SA), Bongani.mayosi@uct.ac.za27.Mahmoud, Sani (Nigeria),

sanimahmoud@gmail.com28.Mocumbi, Ana-Olga (Mozambique),

amucumbi@yahoo.com29.Mohamed, Awad (Sudan), awad90000@gmail.com30.Nel, George (SA), george@medsoc.co.za31.Ogah, Okechukwu

(Nigeria),Osogah56156@yahoo.com32.Ogola, Elijah (Kenya), elijah.ogola@uonbi.ac.ke33.Ojji, Dike (Nigeria), dikeojji@yahoo.co.uk34.Omokhodion, Samuel (Nigeria),

samuel_odion@hotmail.com35.Onwubere, Basden (Nigeria),

basden.onwubere@unn.edu.ng36.Otieno, Harun (Kenya), africaheartmd@gmail.com37.Ouane Nouhom (Mali),

nouhoumouane@hotmail.com38.Pablo Perel (WHF), Pablo.Perel@worldheart.org39.Pascal Bovet (Seychelles), Pascal.Bovet@chuv.ch40.Poulter, Neil (ISH, United Kingdom);

n.poulter@imperial.ac.uk41.Rayner, Brian (SA), Brian.rayner@uct.ac.za42.Salim, Yusuf (WHF), Salim.Yusuf@phri.ca43.Samuel KINGUE ( CMR), samuel_kingue@yahoo.fr44.Schutte, Aletta E. (SA), Alta.Schutte@nwu.ac.za45.Sliwa, Karen (SA), Karen.Sliwa-Hahnle@uct.ac.za46.Subahi, Saad (Sudan), sasubahi@yahoo.com47.Toure Ali, Ibrahim (Niger), pr_toure@yahoo.fr48.Twagirumukiza, Marc (Rwanda),

twamarc@yahoo.fr; twamarc@gmail.com

PASCAR WORKING GROUP ON HYPERTENSION

Expertise and leadership: clinicians (cardiologists, nephrologists), public health physicians, researchers (including clinical trialists), nurses, pharmacologists, evidence-based medicine specialists and guideline developers; 95% responded +

May 14

London

Oct 14 Nairobi

Aug 15

Sep 15

Feb 14

Consolidate the taskforce

Planning the meeting

Recruitment of task force Members

Appointment of chair Build Task force

Apr 15

1rst taskforce meeting. Hypertension as a priority action area Review of previous relevant hypertension programs and guidelines and plan the Africa roadmap

Warehouse - WHF Internal survey – Identification of a Ware house developer – Work with WHF on roadmap

Nov 14 Publication of the 1st meeting proceedings with conclusions from the task force

Discuss the 1st draft of Africa roadmap with National cardiac and hypertension societies

Feedback from members and how to customize the WHF roadmap for Africa

Draft of roadmap by PASCAR & WHF experts

Oct 15

April 16

May 16

Draft of roadmap

Mauritius

Task force review and agree on a second version of draft roadmap by emails

Submission of roadmap for external peer review (hypertension expert & public health specialists) Validation

Task force collect and summarize external peer review comments June16

Jun 16

Month

Mexico Task force review external peer review comments - updates needed on algorithm

May 17 Task force review and agree on the final version of evidence report and recommendations by emails

Publication by in Cardiovascular Journal of Africa and Global HeartSep 17

Main Activities

Description

Discuss the 1st draft of Africa roadmap with French National cardiac and hypertension societies

March 16

Yaounde

CONFERENCE PROCEEDINGS

1.Need for a clear continental policy program!

2.Need for research: outcome data & RCTs!

Controlled*7 % (5-8%)

Uncontrolled93 % * BP < 140/90 mmHg

Treated18 % (14-22%)

Untreated82 %

Awareness27 % (7-56%)

Not aware73 %

Prevalence30 %

(27-34%)

THE CRISIS & OUR TARGET TO ACHIEVE IN 2025

Anastase DZUDIE et al; CVJA, Volume 28, No 4, July/August 2017Numbers are from Feven Ataklte et al; Hypertension. 2015, DOI: 10.1161/HYPERTENSIONAHA.114.04394

Controlled*25 %

150 millions people

Roadblocks Solutions

Shortage of healthcare

professionals &

legislation

1. Use task sharing / shifting

2. Influence prescription legislation

(eg Mozambique)

MedicineImprove availability & affordability

of high quality medications

Unavailable or complex

guidelines

Write or adopt simple and

practical guidelines

10 PRIORITY ACTIONS TO REDUCE THE BURDEN OF HYPERTENSION IN AFRICA BY 2025

2015 map of African countries (coloured blue) with traceable guidelines for the management of hypertension

Dzudie et al. CARDIOVASCULAR JOURNAL OF AFRICA, Volume 28, No 4, July/August 2017

MMM in Africa: > 130 000 people screened in 2017!

> 140 000 in 2018!!!

MAURITANIA

MALINIGER

CHAD

Mediterranean Sea

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

SOMALIA

KENYA

TANZANIA

DEMOCRATIC

(ZAIRE)

CENTRAL

RWANDA

GABON

EQUATORIAL GUINEA

ANGOLA

CONGO

NIGERIABENIN

DTVOIRESIERRA

SENEGAL

GHANA

THE

GUINEA

LIBERIACAMEROON

SOUTH AFRICA

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCAR

ZIMBABWE

BOTSWANA

SWAZILAND

Indian

Ocean

Indian

Ocean

LESOTHO

NAMIBIA

ANGOLA

Atlantic

Ocean

Red

Sea

UGANDA

OF THE CONGO

REPUBLIC

BURUNDI

SAO TOME

REP. OF

TOGOCOTE

BURKINA

GUINEA

LEONE

GAMBIA

BISSAU

Walvis Bay

SOUTH

REPUBLIC

AFRICAN

THE

AFRICA

MAURITIUS

REUNION ISLAND

SEYCHELLES

COMOROS

MAYOTTE

GLORIOSO ISLANDS

TUNISIA

MOROCCO

SAHARA

ALGERIALIBYA EGYPT

WESTERN

Map of African countries with evidence of existence of Clinical practice guidelines for hypertension management

Dzudie et al. European Heart Journal

CREOLE: What is the best dual combination to initiate the treatment of hypertension in Africa?

Eligiblepatients

Randomized(Blinded)

Visit1

Arm1(n=234)

Amlodipine/

Hydrochlorothiazide

Arm2(n=234)

Amlodipine/

Perindopril

Arm3(n=234)

Perindopril/

Hydrochlorothiazide

Visit 2

2 months

Visit 3

4 months

Visit 4 (Final)

6 months

25% of African Countries have traceableguidelines for hypertension.

What is the best dual combinationto initiate the treatment ofhypertension in Africa?

ACEI + Diu?

Diu + CCB?

ACEI + CCBs?

Thiazide

Diuret ics

ACE

inhibi tors

Calcium

Antagonists

Angiotensin

ReceptorBlockers

b-blockers

Other

• Relevant

• Antihypertensive effect

• CV Protection

• Optimal tolerability

ESH / ESC 2013 Guidelines Recommendations

Preferred

Useful

Possible

Not recommended

2013 ESH/ESC Guidelines. J Hyper tens 2013; 31: 1281–

13572013 ESH/ESC Guidelines. Eur Hear t J 2013; 34: 2159-2219

MAURITANIA

MALINIGER

CHAD

Mediterranean Sea

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

SOMALIA

KENYA

TANZANIA

DEMOCRATIC

(ZAIRE)

CENTRAL

RWANDA

GABON

EQUATORIAL GUINEA

ANGOLA

CONGO

NIGERIABENIN

DTVOIRESIERRA

SENEGAL

GHANA

THE

GUINEA

LIBERIACAMEROON

SOUTH AFRICA

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCAR

ZIMBABWE

BOTSWANA

SWAZILAND

Indian

Ocean

Indian

Ocean

LESOTHO

NAMIBIA

ANGOLA

Atlantic

Ocean

Red Sea

UGANDA

OF THE CONGO

REPUBLIC

BURUNDI

SAO TOME

REP. OF

TOGOCOTE

BURKINA

GUINEA

LEONE

GAMBIA

BISSAU

Walv is Bay

SOUTH

REPUBLIC

AFRICAN

THE

AFRICA

MAURITIUS

REUNION ISLAND

SEYCHELLES

COMOROS

MAYOTTE

GLORIOSO ISLANDS

TUNISIA

MOROCCO

SAHARA

ALGERIALIBYA EGYPT

WESTERN

Primary outcome: A reduction in SBP (ABPM)17

Availability medicines across PHC facilities in the South west Region,

Cameroon.

Dzudie et al, 2015, submitted

Public; % (n) Confessional Private Private community Urban; %,n Suburban Rural; % (n)

Medicines for IHD/Stroke, Diabetes and Hypertension vs HIV (ARVs) and Tuberculosis

Aspirin 41.7 (10) 81.8 (9) 61.1 (11) 100.0 (10) 82.4 (14) 64.0 (16) 47.6 (10)

Statin 0.0 (0) 0.0 (0) 0.0 (0) 20.0 (2) 5.9 (1) 4.0 (1) 0.0 (0)

Metformin 79.2 (19) 100.0 (11) 56.6 (10) 100.0 (10) 82.4 (14) 84.0 (21) 71.4 (15)

Insulin 79.2 (19) 81.8 (9) 50.0 (9) 100.0 (10) 91.4 (16) 72.0 (18) 61.9 (13)

Amlodipine 16.7 (4) 36.4 (4) 5.6 (1) 90.0 (9) 47.1 (8) 32.0 (8) 9.5 (2)

ACEI 0.0 (0) 81.8 (9) 5.6 (1) 50.0 (5) 29 .4 (5) 28.0(7) 14.3 (3)

HCT 79.2 (19) 90.9 (10) 72.2 (13) 100.0 (0) 88.2 (15) 84.0 (21) 76.2 (16)

ARVs 100 (8) 100 (4) NA NA 100 (3) 100 (6) 100 (4)

GAZON

30% of fake medicine

Shift of paradigm

Promote task sharing / shifting in the detection of hypertension by adequately trained community health workers (3) and in the management by nurses and GPs

6/10

Gaziano TA, Abrahams-Gessel S, Denman CA, Montano CM, Khanam M, Puoane T, et al. An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala,

Mexico, and South Africa: an observational study. The Lancet Global health. [Observational Study]

CAPACITY OF HEALTH CARE EXPERTS TO MANAGE HYPERTENSION IN CAMEROON

Hypertensionorganizations and experts

PEOPLE WITH HYPERTENSIONCameroon: 23 millions inhabitants

with *4,7 million living with HT in 2015

Primary care * 20000 nurses and

midwives

Specialists in cardiovascular

Medicine

Dzudie et al. Unpublished

* 3000 GPs

* 90

~ 6,3 millions in 2025

African Certificate Course in Management of Hypertension

TRAINING!!!!!!!

25 000 certified general physicians and 50 000 nurses!!!

IN 10 Years.

6/10

Gaziano TA, Abrahams-Gessel S, Denman CA, Montano CM, Khanam M, Puoane T, et al. An assessment of community health workers' ability to screen for cardiovascular disease risk with a simple, non-invasive risk assessment instrument in Bangladesh, Guatemala,

Mexico, and South Africa: an observational study. The Lancet Global health. [Observational Study]

Task shifting / Task sharing

African Certificate Course in Management of Hypertension (CCMH-Africa)

PASCAR High Impact Meetings [T3] x 3 trainers per country aligned per region

French Africa Local Language

Adaptation

Portuguese

AfricaArabic Africa English Africa

Country High Impact Course [T3]

Train the Trainer at “Regional and National Congresses”

In Country: Full Prescriber Certificate Courses - 10 contacts over 10 month

National Trainers train Prescriber (GP)

Full Non-Prescriber Course – 5 contact over 5 months

GP train referral Non-Prescribers such as sisters

24

Partners: PASCAR, PHFI, BIHS, ISH, Ministries of Public Health and Faculties of Medicine

Continental Meeting: High Impact Train The

Trainer [T3]

Nairobi, 25 february 2018

PASCAR

ISH

PHFI

BIHS

Population level interventions

1. Policy dialogues

2. Implementation

PASCARTask force on Hypertension

KEY NEXT STEPS: PURSUIT IN POLICY DIALOGUES

ALL PROFESSIONAL & LAY GROUPS

TRAINING INSTITUTIONS IN AFRICA

HYPERTENSION TRAINING COURSES

NATIONAL CARDIAC SOCIETIES

AFRICAN HEART NETWORK

NATIONAL HEART FOUNDATIONS

IFHA & NATIONAL HYPERTENSION

SOCIETIES

AFRICAN UNION

HEALTH COMMISSION

WHO & OTHER UN AGENCIES

AFRICAN MINISTRIES OF HEALTH

Challenges

Advocacy, Team efforts & Partnerships

Conclusion

• Hypertension our first ennemy continental coalition

• Aim a 25% control rate of hypertension by 2025

Background and Aim

• Ten pillars are necessary to achieve this goal.

• All stakeholders (we, the government, the private sector, academia, and community organizations should work together)

Priority actions

• Policy dialogue (WHO, AU) to ensure implementation

• Key role of Regional and National champions via Cardiac societies

Future steps

" Africa should walk before it can SPRINT”

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Acknowledgements

Shaping the future of Hypertension in Africa

TEAM: Together Everyone Achieve More

All & Everyone !!!!!!

PASCAR task force on hypertension, WHF, ISH, .. and all other partners