Symptoms and Signs of Heart Failure at Admission and Discharge and Outcomes in the Sub-Saharan Acute Heart Failure (THESUS-HF) Registry

Rivaroxaban in Valvular Atrial Fibrillation - a Critical Appraisal of the INVICTUS Trial

PURPOSE

The efficacy of factor Xa inhibitors in patients with atrial fibrillation (AF) and rheumatic heart disease (RHD) is unknown.

METHODS/RESULTS

The objective of this article was to conduct a comprehensive evaluation of the INVICTUS trial, an open-label randomized controlled study that compared vitamin K antagonists (VKA) to rivaroxaban in patients with AF and RHD while also considering the existing evidence from literature in this particular area of research.

CONCLUSION

The findings of the INVICTUS trial indicated that rivaroxaban was found to be inferior in efficacy to VKA. However, it is important to note that the primary outcome of the trial was driven by sudden death and death caused by mechanical pump failure. As a result, it is necessary to approach the data from this study with caution, and it would be inappropriate to draw parallel conclusions for other causes of valvular AF. Particularly, the perplexing issue of how rivaroxaban could have contributed to both pump failure and sudden cardiac death requires further explanation. Additional data regarding changes in heart failure medication and ventricular function would be essential for proper interpretation.

Pattern of cardiovascular diseases at a teaching hospital in Addis Ababa, Ethiopia: An echocardiographic study of 1500 patients

Cardiovascular diseases (CVD) represent a significant global health problem. They account for nearly one third of deaths worldwide. With improvements in diagnostic modalities, their prevalence in sub-Saharan Africa (SSA) is rising. Disease pattens vary in different regions and communities and the pattern in our setting is not known. Echocardiography is a noninvasive diagnostic tool that essential for structural and hemodynamic assessment of the heart. It stands at the far front for comprehensive evaluation of the heart because of its relative low cost and wide availability. The aim of this study was to assess pattern of CVDs among patients who had echocardiography done at a teaching Hospital in Addis Ababa, Ethiopia. A retrospective review of 1500 echocardiograms of patients referred to the echocardiography laboratory of St. Paul Hospital Millennium Medical College (SPHMMC) for cardiac evaluation from January 1, 2018 to June 30, 2019 was performed. All subjects had standard transthoracic echocardiography performed by cardiologists using General Electric Vivid E9 and E95 machines. Demographic parameters and echocardiographic findings were collected using a structured checklist from the echocardiography register. Descriptive statistics were used to assess the echocardiographic findings. The mean age of subjects was 48.2 (SD of 18.2) and ranged between 14 and 100 years of age. Both males and females were nearly equally distributed with males accounting for 48.3%. Most (77.9%) of the subjects had an abnormal echocardiographic report; only 332 (22.1%) had a normal study. Diastolic dysfunction (DD) (33.4%), valvular heart disease (18.4%), and left ventricular hypertrophy (LVH) (13.7%) were the most common findings in our hospital. Among patients with DD, Grade 1 dysfunction accounted for the majority (79.8%), of which 41% had associated LVH. Pulmonary hypertension (PH), cardiomyopathy and ischemic heart disease were also not uncommon. Abnormal echocardiographic findings are common in patients referred to our hospital for transthoracic echo. The commonest echocardiographic abnormalities were DD, Valvular heart disease (both rheumatic and calcific valves) and LVH.

Developing a Sustainable Cardiovascular Disease Research Strategy in Tanzania Through Training: Leveraging From the East African Centre of Excellence in Cardiovascular Sciences Project

Introduction

Cardiovascular disease (CVD) contribute the largest mortality burden globally, with most of the deaths (80% of all deaths) occurring in low and middle-income countries (LMICs), including Tanzania. Despite the increasing burden, to date, CVD research output is still limited in Tanzania, as it is for many sub-Saharan Africa (SSA) countries. This trend hinders the establishment of locally informed CVD management and policy changes. Here, we aim to review the existing gaps while highlighting the available opportunities for a sustainable CVD research strategy in Tanzania.

Methods

A rapid review of available literature on CVD research in SSA was conducted, with emphasis on the contribution of Tanzania in the world literature of CVD. Through available literature, we identify strategic CVD research priorities in Tanzania and highlight challenges and opportunities for sustainable CVD research output.

Findings

Shortage of skilled researchers, inadequate research infrastructure, limited funding, and lack of organized research strategies at different levels (regional, country, and institutional) are among the existing key bottlenecks contributing to the low output of CVD research in Tanzania. There is generally strong global, regional and local political will to address the CVD epidemic. The establishment of the East African Centre of Excellence in Cardiovascular Sciences (EACoECVS) offers a unique opportunity for setting strategies and coordinating CVD research and training for Tanzania and the East African region.

Conclusion

There is a light of hope for long-term sustainable CVD research output from Tanzania, taking advantage of the ongoing activities and plans for the evolving EACoECVS. The Tanzanian experience can be taken as a lesson for other SSA countries.

Congestive Heart Failure Patients’ Pulse Rate Progression and Time to Death at Debre Tabor Referral Hospital, Ethiopia

Background. Heart failure is a progressive condition marked by worsening symptoms such as shortness of breath, coughing, exhaustion and lethargy, fluid retention with swelling of the legs and abdomen, and a reduced ability to exercise. As a result, this study aims to use a joint model application to determine the joint risk factors of longitudinal change in pulse rate and time to death of congestive heart failure patients and their association admitted to a hospital. Methods. A retrospective study was undertaken on congestive heart failure patients admitted to the Debre Tabor Referral Hospital from January 2016 to December 2019. A statistical joint modeling strategy was employed to match the repeated biomarker pulse rate and a survival outcome at the same time. A total of 271 patients with congestive heart failure were chosen. Data were analyzed with R statistical software via joineRML. Results. According to the findings, the association between longitudinal changes in pulse rate and time to death in heart failure patients is statistically significant. Sex, residence, left ventricular injection fraction, New York Heart Association class, and diabetes mellitus were all found to be significant risk factors for congestive heart failure patients’ short survival time to death. Age, sex, residence, hypertension, left ventricular injection fraction, congestive heart failure, diabetes mellitus, tuberculosis, and etiology were all significant contributors in pulse rate progression. Conclusion. The computed association parameters revealed subject-specific values. The subject-specific linear time slope of PR measurement was positively related to the hazard rate of time to death of CHF patients in the study area. To reduce the risk level of CHF, health professionals, governmental organizations, and nongovernmental organizations must promote and allocate a suitable amount of budget for the treatment of CHF patients.

The V-RAMP Program: Building Research Administration and Management Capacity in Nigeria

The increasing volume and complexity of research activities in Nigeria necessitates urgent measures to improve research infrastructure in grants administration and management. The Vanderbilt-Nigeria Research Administration and Management Training Program (V-RAMP) seeks to build infrastructure capacity in research administration and management and research ethics at a major teaching hospital in Nigeria. We will perform a mixed methods needs assessment of the administrative and management environment and develop an action plan to address infrastructure needs, prioritize processes, and guide program implementation. We will capacitate a newly established Office of Research Administration and improve the knowledge and skills of research administrators and grant managers via short term in-person trainings in Nashville, Tennessee and in Kano, Nigeria and through remote learning opportunities. We will enhance local administrative efficiency and performance of research ethics operations through training and mentoring of members and staff of the ethics review committee. Systematic processes to streamline protocols, including a REDCap protocol tracking database and standard operating procedures in the responsible conduct of research and rigor and reproducibility will also be developed. V-RAMP will enable the creation of a high-quality research administration environment that is knowledgeable, efficient, and compliant regarding the fiscal, management and ethical standards of sponsored research.

Oxygen delivery systems for adults in Sub-Saharan Africa: A scoping review

Background

Respiratory diseases are the leading cause of death and disability worldwide. Oxygen is an essential medicine used to treat hypoxemia from respiratory diseases. However, the availability and utilization of oxygen delivery systems for adults in sub-Saharan Africa is not well-described. We aim to identify and describe existing data around oxygen availability and provision for adults in sub-Saharan Africa, determine knowledge or research gaps, and make recommendations for future research and capacity building.

Methods

We systematically searched four databases for articles on April 22, 2020, for variations of keywords related to oxygen with a focus on countries in sub-Saharan Africa. Inclusion criteria were studies that included adults and addressed hypoxemia assessment or outcome, oxygen delivery mechanisms, oxygen availability, oxygen provision infrastructure, and oxygen therapy and outcomes.

Results

35 studies representing 22 countries met inclusion criteria. Availability of oxygen delivery systems ranged from 42%-94% between facilities, with wide variability in the consistency of availability. There was also wide reported prevalence of hypoxemia, with most studies focusing on specific populations. In facilities where oxygen is available, health care workers are ill-equipped to identify adult patients with hypoxemia, provide oxygen to those who need it, and titrate or discontinue oxygen appropriately. Oxygen concentrators were shown to be the most cost-effective delivery system in areas where power is readily available.

Conclusions

There is a substantial need for building capacity for oxygen delivery throughout sub-Saharan Africa. Addressing this critical issue will require innovation and a multi-faceted approach of developing infrastructure, better equipping facilities, and health care worker training.

Clinical characteristics and outcomes of black African heart failure patients with preserved, mid‐range, and reduced ejection fraction: a post hoc analysis of the THESUS‐HF registry

Aims

Limited data are available on clinical characteristics and prognosis of heart failure (HF) in black African populations especially with respect to current classifications and HF management guidelines.

Methods and results

In this post hoc analysis, African patients admitted with acute HF and enrolled in the THESUS‐HF registry in one of 12 hospitals in 9 countries were classified as having preserved left ventricular ejection fraction (LVEF) (HFpEF), mid‐range LVEF (HFmrEF), and reduced LVEF (HFrEF) based on echocardiography performed close to the time of admission. Sociodemographic and clinical characteristics, management, and 60 and 180 day outcomes were compared between the groups. Of 888 patients with LVEF available, there were 472 (53.2%) with HFrEF, 174 (19.6%) with HFmrEF, and 243 (27.3%) with HFpEF. History of atrial fibrillation was higher in patients with HFmrEF (28.5%) than in patients with HFrEF (14.5%). Patients with HFrEF had a larger mean LV systolic diameter (54.1 ± 9.67 mm) than patients with HFmrEF (42.9 ± 8.47 mm), who had a larger mean LV diameter than patients with HFpEF (32.6 ± 8.64 mm); a similar pattern with LV diastolic diameter was observed. The mean posterior diastolic wall thickness (10.2 ± 2.94 mm) was lower in patients with HFrEF than in those with HFmrEF (11.1 ± 2.59 mm) and HFpEF (11.2 ± 2.90 mm). Patients with HFpEF were less likely to use angiotensin‐converting enzyme inhibitor/angiotensin receptor blockers, and aldosterone inhibitors, and more likely to use beta‐blockers than those with HFrEF at either admission or discharge/Day 7. Death or readmission rates through Day 60 and 180 day death rates did not differ significantly among the groups; unadjusted hazard ratios relative to patients with HFrEF were 1.32 [95% confidence interval (CI) 0.84–2.08] and 1.24 (95% CI 0.82–1.89) for 60 day death or readmission and 0.92 (95% CI 0.59–1.43) and 0.78 (95% CI 0.51–1.20) for 180 day death in patients with HFmrEF and HFpEF, respectively.

Conclusions

Classification by LVEF according to European Society of Cardiology guidelines revealed some differences in clinical presentation but similar mortality and rehospitalization rates across all EF groups in Africans admitted for HF.

Persistent Heart Failure Symptoms at Hospital Discharge Predicts 30-Day Clinical Events

Background

The relationship between heart failure (HF) symptoms at hospital discharge and 30-day clinical events is unknown. Variability in HF symptom assessment may affect ability to predict readmission risk.

Objective

The aim of this study was to describe HF symptom profiles and burden at hospital discharge. A secondary aim was to examine the relationship between symptom burden at discharge and 30-day clinical events.

Methods

An exploratory descriptive design was used. Patients with HF (n = 186) were enrolled 24 to 48 hours pre hospital discharge. The HF Somatic Perception Scale quantified 18 HF physical signs and symptoms. Scores were divided into tertiles (0-10, 11-19, and 20 and higher). The Patient Health Questionnaire-9 quantified depressive symptoms. Self-assessed health, comorbid illnesses, and 30-day clinical events were documented. Chi-square and logistic regression were used to examine clinical events.

Results

The sample (n = 186) was predominantly White (87.6%), male (59.1%), elderly (mean [SD], 74.2 [12.5]), and symptomatic (92.5%) at discharge. Heart Failure Somatic Perception Scale scores ranged from 0 to 53, with a mean (SD) of 13.7 (10.1). Symptoms reported most frequently were fatigue (67%), nocturia (62%), need to rest (53%), and inability to do usual activities due to shortness of breath (52%). Thirty-day event rate was 28%, with significant differences between Heart Failure Somatic Perception Scale tertiles (9.4% vs 37.7% in the second and third tertiles, respectively; [chi]22(N = 186) = 16.73, P < .001). Heart Failure Somatic Perception Scale tertile 2 or 3 (odds ratio [OR], 5.7; P = .003; and OR, 4.3; P = .021), self-assessed health (OR, 2.6; P = .029), and being in a relationship predicted clinical events.

Conclusions

Heart failure symptom burden at discharge predicted 30-day clinical events. Comprehensive symptom assessment is important when determining readmission risk.

Characteristics and Outcomes of Super-Elderly Patients (Aged ≥90 Years) Hospitalized for Heart Failure - Analysis of a Nationwide Inpatient Database

Background: Although the aged population is increasing in developed countries, clinical evidence on super-elderly heart failure (HF) patients is scarce. This study determined the characteristics and outcomes of Japanese hospitalized super-elderly HF patients (aged ≥90 years) using a nationwide inpatient database.

Methods and Results: A comprehensive analysis was performed of 447,818 HF patients in the Diagnosis Procedure Combination database who were hospitalized and discharged between January 2010 and March 2018. Among the study population, 243,028 patients (54.3%) were aged ≥80 years and 64,628 patients (14.4%) were aged ≥90 years. The percentage of elderly patients increased over time. Elderly patients were more likely to be female and had a higher New York Heart Association functional class at admission. Invasive and advanced procedures were rarely performed, whereas infectious complications were more common in patients with older age. Length of hospital stay and in-hospital mortality increased with age. Multivariable logistic regression analysis fitted with a generalized estimating equation showed higher in-hospital mortality in patients aged ≥80 and ≥90 years (odds ratios 1.99 and 3.23, respectively) compared with those aged <80 years.

Conclusions: The number of hospitalized super-elderly HF patients has increased, and these patients are associated with worse clinical outcomes. The results of this study may be useful in establishing an optimal management strategy for super-elderly HF patients in the era of HF pandemic.

Prevalence and correlates of chronic obstructive pulmonary disease and chronic respiratory symptoms in rural southwestern Uganda: a cross-sectional, population-based study

Background

The global burden of chronic obstructive pulmonary disease (COPD) disproportionately affects resource-limited settings such as sub-Saharan Africa (SSA), but population-based prevalence estimates in SSA are rare. We aimed to estimate the population prevalence of COPD and chronic respiratory symptoms in rural southwestern Uganda.

Methods

Adults at least 18 years of age who participated in a population-wide census in rural southwestern Uganda completed respiratory questionnaires and lung function testing with bronchodilator challenge at health screening events in June 2015. We defined COPD as post-bronchodilator forced expiratory volume in one second to forced vital capacity ratio less than the lower limit of normal. We fit multivariable linear and log binomial regression models to estimate correlates of abnormal lung function and respiratory symptoms, respectively. We included inverse probability of sampling weights in models to facilitate population-level estimates.

Results

Forty-six percent of census participants (843/1814) completed respiratory questionnaires and spirometry, of which 565 (67%) met acceptability standards. COPD and respiratory symptom population prevalence were 2% (95% confidence interval (CI)  = 1%-3%) and 30% (95% CI = 25%-36%), respectively. Respiratory symptoms were more prevalent and lung function was lower among women and ever-smokers (P < 0.05). HIV serostatus was associated with neither respiratory symptoms nor lung function.

Conclusions

COPD population prevalence was low despite prevalent respiratory symptoms. This work adds to the growing body of literature depicting lower-than-expected COPD prevalence estimates in SSA and raises questions about whether the high respiratory symptom burden in rural southwestern Uganda represents underlying structural lung disease not identified by screening spirometry.

Understanding the Etiology of Heart Failure Among the Rural Poor in Sub-Saharan Africa: A 10-Year Experience From District Hospitals in Rwanda

BACKGROUND

Heart failure is a significant cause of morbidity and mortality in sub-Saharan Africa. Our understanding of the heart failure burden in this region has been limited mainly to registries from urban referral centers. Starting in 2006, a nurse-driven strategy was initiated to provide echocardiography and decentralized heart failure care within noncommunicable disease (NCD) clinics in rural district hospitals in Rwanda.

METHODS AND RESULTS

We conducted a retrospective review of patients with cardiologist-confirmed heart failure treated at 3 district hospital NCD clinics in Rwanda from 2006 to 2017 to determine patient clinical characteristics and disease distribution. Over 10 years, 719 patients with confirmed heart failure were identified. Median age was 27 years overall, and 42 years in adults. Thirty-six percent were children (age <18 years), 68% were female, and 78% of adults were farmers. At entry, 39% were in New York Heart Association functional class III-IV. Among children, congenital heart disease (52%) and rheumatic heart disease (36%) were most common. In adults, cardiomyopathy (40%), rheumatic heart disease (27%), and hypertensive heart disease (13%) were most common. No patients were diagnosed with ischemic cardiomyopathy.

CONCLUSIONS

The results of the largest single-country heart failure cohort from rural sub-Saharan Africa demonstrate a persistent burden of rheumatic disease and nonischemic cardiomyopathies.

Heart Failure in Sub-Saharan Africa

Heart failure is a growing problem in sub-Saharan Africa. This arises as the prevalence of risk factors for cardiovascular disease rises, life expectancy increases and causes of heart failure more common in Africa, such as rheumatic heart disease and endomyocardial fibrosis, continue to be a significant issue. Lack of access to diagnostics is an issue with the expense and technical expertise required for echocardiography limiting access. Biomarker strategies may play a role here. Access to essential medicines is also limited and requires a renewed focus by the international community to ensure that appropriate medications are readily available, similar to that which has been implemented for HIV and malaria.