Arrhythmia care in Africa

Using Technology to Deliver Cardiovascular Care in African Countries

PURPOSE OF REVIEW

This review aims to explore the applications of digital technology in cardiovascular care across African countries. It highlights the opportunities and challenges associated with leveraging technology to enhance patient self-monitoring, remote patient-clinician interactions, telemedicine, clinician and patient education, and research facilitation. The purpose is to highlight how technology can transform cardiovascular care in Africa.

RECENT FINDINGS

Recent findings indicate that the increasing penetration of mobile phones and internet connectivity in Africa offers a unique opportunity to improve cardiovascular care. Smartphone-based applications and text messaging services have been employed to promote self-monitoring and lifestyle management, although challenges related to smartphone ownership and digital literacy persist. Remote monitoring of patients by clinicians using home-based devices and wearables shows promise but requires greater accessibility and validation studies in African populations. Telemedicine diagnosis and management of cardiovascular conditions demonstrates significant potential but faces adoption challenges. Investing in targeted clinician and patient education on novel digital technology and devices as well as promoting technology-assisted research for participant recruitment and data collection can facilitate cardiovascular care advancements in Africa. Technology has the potential to revolutionize cardiovascular care in Africa by improving access, efficiency, and patient outcomes. However, barriers related to limited resources, supportive infrastructure, digital literacy, and access to devices must be addressed. Strategic actions, including investment in digital infrastructure, training programs, community collaboration, and policy advocacy, are crucial to ensuring equitable integration of digital health solutions.

Types and Outcomes of Arrhythmias in a Cardiac Care Unit in Western Kenya: A Prospective Study

Background

Sustained arrhythmias are frequently encountered in cardiac care units (CCU), but their types and outcomes in Africa are unknown. Studies from high-income countries suggest arrhythmias are associated with worse outcomes.

Objectives

To determine the types and proportion of cardiac arrhythmias among patients admitted to the CCU at Moi Teaching and Referral Hospital (MTRH), and to compare 30-day outcomes between patients with and without arrhythmias at the time of CCU admission.

Methods

We conducted a prospective study of a cohort of all patients admitted to MTRH-CCU between March and December 2021. They were stratified on the presence or absence of arrhythmia at the time of CCU admission, irrespective of whether it was the primary indication for CCU care or not. Clinical characteristics were collected using a structured questionnaire. Participants were followed up for 30 days. The primary outcome of interest was 30-day all-cause mortality. Secondary outcomes were 30-day all-cause readmission and length of hospital stay. The 30-day outcomes were compared between the patients with and without arrhythmia, with a p value < 0.05 being considered statistically significant.

Results

We enrolled 160 participants. The median age was 46 years (IQR 31, 68), and 95 (59.4%) were female. Seventy (43.8%) had a diagnosis of arrhythmia at admission, of whom 62 (88.6%) had supraventricular tachyarrhythmias, five (7.1%) had ventricular tachyarrhythmias, and three (4.3%) had bradyarrhythmia. Atrial fibrillation was the most common supraventricular tachyarrhythmia (82.3%). There was no statistically significant difference in the primary outcome of 30-day mortality between those who had arrhythmia at admission versus those without: 32.9% versus 30.0%, respectively (p = 0.64).

Conclusion

Supraventricular tachyarrhythmias were common in critically hospitalized cardiac patients in Western Kenya, with atrial fibrillation being the most common. Thirty-day all-cause mortality did not differ significantly between the group admitted with a diagnosis of arrhythmia and those without.

Electrical storm in a middle-aged man

Electrical storm (ES) refers to a life-threatening condition characterised by three or more episodes of ventricular tachycardia (VT), ventricular fibrillation (VF), or appropriate implantable cardioverter defibrillator (ICD) shocks in 24 hours. We report a case of a 58-year-old man who suffered recurrent episodes of sustained VT despite appropriate defibrillation and antiarrhythmic drug therapy. On stepwise evaluation, arrhythmogenic right ventricular cardiomyopathy (ARVC) was considered the most likely substrate for his dysrhythmia. He was managed conservatively on antiarrhythmic drugs with no further clinical episodes of VT, and ICD implantation for secondary prophylaxis was recommended.

Funding

None declared.

Nurses' Knowledge, Attitudes, and Practice of Cardiopulmonary Resuscitation at a Selected Training Hospital in Namibia: A Cross-Sectional Survey

Background

Nurses play a key role in cases of cardiopulmonary arrest by promptly attending to and initiating cardiopulmonary resuscitation. Effective cardiopulmonary resuscitation thus requires nurses to possess appropriate attitudes, competencies, and adherence to the best nursing practice. Cardiac arrests are a prevalent cause of fatalities, being responsible for approximately 30% of deaths worldwide. Despite this statistic, however, research in this specific field is lacking in Namibia.

Objective

The objective of this research was to examine registered nurses' knowledge, attitudes toward, and practice with regard to cardiopulmonary resuscitation at a selected teaching hospital in Namibia.

Methods

A cross-sectional survey design using a self-administered questionnaire was utilized to purposively recruit 158 registered nurses from the inpatient and outpatient departments of a teaching hospital in Namibia. Descriptive and chi-square tests were performed using SPSSv26.

Results

The results of the study indicate that a significant percentage of nurses have limited knowledge (14.7 ± 1.50), negative attitudes (36.2 ± 4.8), and poor practice (11.16 ± 1.18) when it comes to cardiopulmonary resuscitation. Their poor knowledge is strongly associated with poor practice (χ2 = 9.162, P = .002). The study further revealed a significant correlation between the departments in which the nurses worked and their practice of cardiopulmonary resuscitation, suggesting that the work environment is a crucial factor in determining a nurse's approach to emergency care.

Conclusion

The findings of study indicate that the cardiopulmonary resuscitation practice in the selected hospital is unsafe due to the registered nurses' poor knowledge and negative attitudes. It is strongly recommended that hospital managers and policy-makers take steps to formulate guidelines that mandate regular cardiopulmonary resuscitation training at predetermined times.

Prevalence and risk factors for atrial fibrillation in a semi-rural sub-Saharan African population: The hEart oF ethiopia: Focus on Atrial Fibrillation (TEFF-AF) Study

Background

There is a scarcity of reported data on the prevalence of atrial fibrillation (AF) in sub-Saharan Africa.

Objectives

To undertake AF screening in semi-rural Ethiopia.

Methods

The TEFF-AF (The hEart oF Ethiopia: Focus on Atrial Fibrillation) study conducted AF screening using a single-lead electrocardiogram device (KardiaMobile) on willing community participants at the Soddo Christian Hospital, Ethiopia. Participants' clinical parameters and medical history were obtained to characterize their risk factor profile, including calculation of CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation) score.

Results

A total of 3000 Ethiopians (median 31 [interquartile range 25-41] years of age; 65% men) were screened. The participants were generally well educated, from the local region and with a low burden of cardiovascular risk factors. A total of 50 participants had a CHARGE-AF score (5-year AF risk) of ≥2%. AF was detected in 13 (0.43%) individuals (median 50 [interquartile range 36-60] years of age; n = 7 men). The prevalence among participants over 40 years of age was 1% (n = 9 of 930). AF prevalence was higher for older age groups, with ≥70 years of age reaching 6.67% (n = 3 of 45). Population prevalence was estimated to be 234 (95% confidence interval 7-460) per 10,000 persons for ≥60 years of age. Four (31%) of the 13 participants with AF had a CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score of ≥2, and others likely had rheumatic valvular AF, but only 2 of the 13 participants with AF were on oral anticoagulation therapy.

Conclusion

In this semi-rural Ethiopian community of relatively younger participants, AF prevalence was found to be low but increased with increasing age. Mobile single-lead electrocardiogram technology can be used effectively for AF screening in low-resource settings.

A Systematic Review of the Spectrum of Cardiac Arrhythmias in Sub-Saharan Africa

Major structural cardiovascular diseases are associated with cardiac arrhythmias, but their full spectrum remains unknown in sub-Saharan Africa (SSA), which we addressed in this systematic review. Atrial fibrillation/atrial flutter (AF/AFL) prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, but <1% in the general population. Use of oral anticoagulation is heterogenous (9-79%) across SSA. The epidemiology of sudden cardiac arrest/death is less characterized in SSA. Cardiopulmonary resuscitation is challenging, owing to low awareness and lack of equipment for life-support. About 18% of SSA countries have no cardiac implantable electronic devices services, leaving hundreds of millions of people without any access to treatment for advanced bradyarrhythmias, and implant rates are more than 200-fold lower than in the western world. Management of tachyarrhythmias is largely non-invasive (about 80% AF/AFL via rate-controlled strategy only), as electrophysiological study and catheter ablation centers are almost non-existent in most countries.

Highlights

- Atrial fibrillation/flutter prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, and <1% in the general population in sub-Saharan Africa (SSA).- Rates of oral anticoagulation use for CHA2DS2VASC score ≥2 are very diverse (9-79%) across SSA countries.- Data on sudden cardiac arrest are scant in SSA with low cardiopulmonary resuscitation awareness.- Low rates of cardiac implantable electronic devices insertions and rarity of invasive arrhythmia treatment centers are seen in SSA, relative to the high-income countries.