Cardiac Pacing Training in Africa

Improving implant training for physicians and their teams in under-represented regions

The burden of cardiovascular disease is increasing globally, with low- and middle-income countries (LMICs) absorbing most of the burden while lacking the necessary healthcare infrastructure to combat the increase. In particular, the disparity in pacemaker implants between high-income countries and LMICs is glaring, partially spurned by reduced numbers of physicians and supporting staff who are trained in pacemaker implant technique. Herein, we will discuss current pacemaker implant training models, outline training frameworks that can be applied to underserved regions, and review adjunctive training techniques that can help supplement traditional training models in LMICs.

Advancing global equity in cardiac care as cardiac implantable electronic device reuse comes of age

A nation's health and economic development are inextricably and synergistically connected. Stark differences exist between wealthy and developing nations in the use of cardiac implantable electronic devices (CIEDs). Cardiovascular disease is now the leading cause of death in low- and middle-income countries (LMIC), with a significant burden from rhythm-related diseases. As science, technology, education, and regulatory frameworks have improved, CIED recycling for exportation and reuse in LMIC has become possible and primed for widespread adoption. In our manuscript, we outline the science and regulatory pathways regarding CIED reuse. We propose a pathway to advance this technology that includes creating a task force to establish standards for CIED reuse, leveraging professional organizations in areas of need to foster the professional skills for CIED reuse, collaborating with regulatory agencies to create more efficient regulatory expectations and bring the concept to scale, and establishing a global CIED reuse registry for quality assurance and future science.

Cardiovascular diseases in Africa in the twenty-first century: Gaps and priorities going forward

In 2015, the United Nations set important targets to reduce premature cardiovascular disease (CVD) deaths by 33% by 2030. Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide. There is currently an epidemiological transition on the continent, where NCDs is projected to outpace communicable diseases within the current decade. Unchecked increases in CVD risk factors have contributed to the growing burden of three major CVDs-hypertension, cardiomyopathies, and atherosclerotic diseases- leading to devastating rates of stroke and heart failure. The highest age standardized disability-adjusted life years (DALYs) due to hypertensive heart disease (HHD) were recorded in Africa. The contributory causes of heart failure are changing-whilst HHD and cardiomyopathies still dominate, ischemic heart disease is rapidly becoming a significant contributor, whilst rheumatic heart disease (RHD) has shown a gradual decline. In a continent where health systems are traditionally geared toward addressing communicable diseases, several gaps exist to adequately meet the growing demand imposed by CVDs. Among these, high-quality research to inform interventions, underfunded health systems with high out-of-pocket costs, limited accessibility and affordability of essential medicines, CVD preventive services, and skill shortages. Overall, the African continent progress toward a third reduction in premature mortality come 2030 is lagging behind. More can be done in the arena of effective policy implementation for risk factor reduction and CVD prevention, increasing health financing and focusing on strengthening primary health care services for prevention and treatment of CVDs, whilst ensuring availability and affordability of quality medicines. Further, investing in systematic country data collection and research outputs will improve the accuracy of the burden of disease data and inform policy adoption on interventions. This review summarizes the current CVD burden, important gaps in cardiovascular medicine in Africa, and further highlights priority areas where efforts could be intensified in the next decade with potential to improve the current rate of progress toward achieving a 33% reduction in CVD mortality.

Clinical validation and evaluation of a novel six-lead handheld electrocardiogram recorder compared to the 12-lead electrocardiogram in unselected cardiology patients (EVALECG Cardio)

Aims

Handheld electrocardiogram (ECG) monitors are increasingly used by both healthcare workers and patients to diagnose cardiac arrhythmias. There is a lack of studies validating the use of handheld devices against the standard 12-lead ECG. The Kardia 6L is a novel handheld ECG monitor which can produce a 6-lead ECG. In this study, we compare the 6L ECG against the 12-lead ECG.

Methods and results

A prospective study consisting of unselected cardiac inpatients and outpatients at Leeds Teaching Hospital NHS Trust. All participants had a 12- and 6-lead ECGs. All ECG parameters were analysed by using a standard method template for consistency between independent observers. Electrocardiograms from the recorders were compared by the following statistical methods: linear regression, Bland-Altman, receiver operator curve, and kappa analysis. There were 1015 patients recruited. The mean differences between recorders were small for PR, QRS, cardiac axis, with receiver operator analysis area under the curve (AUC) of >80%. Mean differences for QT and QTc (between recorders) were also small, with AUCs for QT leads of >75% and AUCs for QTc leads of >60%. Key findings from Bland-Altman analysis demonstrate overall an acceptable agreement with few outliers instances (<6%, Bland-Altman analysis).

Conclusion

Several parameters recorded by the Kardia 6L (QT interval in all six leads, rhythm detection, PR interval, QRS duration, and cardiac axis) perform closely to the gold standard 12-lead ECG. However, that consistency weakens for left ventricular hypertrophy, QRS amplitudes (Lead I and AVL), and ischaemic changes.

[Characteristic and evolution of pacemaker complications in a Subsaharan Africa Heart Centre]

AIM OF THE STUDY

The working environment and the low rate of pacemaker insertions increase the risk of complications in sub-Saharan Africa. The objective of our work was to assess the impact of specific preventive measures on these complications over the long term.

PATIENT AND METHODS

We conducted a retrospective study of all pacemaker implantations from June 2006 to June 2016 at the Abidjan Heart Institute. We evaluated the incidence of pacemaker complications, their risks factors and their impact on the overall prognosis of patients.

RESULTS

Three hundred and two procedures were performed in 286 patients (49% male, mean age: 67±12 years), with a predominance of primary implantation (82.8%) of single-chamber ventricular pacemakers (66.6%). Twenty-five major complications (8.27%) and 14 minor (4.6%) occurred with a predominance of lead displacements (3.64%). The major complications were favored by the subclavian approach (P=0.018; OR=2.34; 95% CI [1.16-4.75]) and intraoperative incidents (P=0.02; OR=2.17; 95% CI [1.16-4.75]. The preventive measures taken made it possible to achieve a significant (P=0.017) and linear (P=0.009) reduction of these complications, with no effect the patients prognosis (Log-Rank=0.217; P=0.64).

CONCLUSION

Quality cardiac stimulation is possible in Sub-Saharan Africa with preventive measures adapted to the environment.

A simple adaptation of a handheld ECG recorder to obtain chest lead equivalents

Hand held ECG recorders are transforming the way we detect and diagnose heart rhythm disorders. The Kardia 6 L was launched in 2019 to detect and diagnose heart rhythm disorders recording a six lead (limb lead) ECG. Recording and analysis of precordial leads are currently not supported by the Kardia 6 L. In this study we aim to assess if reliable chest lead data can be obtained using a simple modification to the recording system.

Incidence of recreational sports-related sudden cardiac arrest in participants over age 12 in a general African population

Background

The incidence of sports-related sudden cardiac arrest (SrSCA) in sub-Saharan Africa is unknown.

Objective

To determine the incidence of sudden cardiac arrest (SCA) in non-competitive athletes in an urban population of Cameroon, a country in sub-Saharan Africa.

Methods

Two study populations in Cameroon were used. A 12-month, multisource surveillance system of 86 189 inhabitants over 12 years old recorded all deaths in two administrative districts of Douala City. All fields of sports, emergency medical service, local medical examiners and district hospital mortuaries were surveyed. Two blinded cardiologists used a verbal autopsy protocol to determine the cause of death. SCA was identified for all deaths occurring within 1 hour of onset of symptoms. A cross-sectional study was conducted among 793 persons in Yaoundé City, which is the second study population aimed at determining the proportion of people who are physically active.

Results

The mean age in the cross-sectional study was 27.3±10.7, with more men (56.2%). The cross-sectional study showed that 69.0% (95% CI 65.8 to 72.2) of the population could be considered to have at least 3 hours of physical activity per week. The surveillance found that among 288 all-cause deaths, 27 (9.4%) were due to SCA. One SrSCA was registered in a 35-year-old woman while running. Merging both sources revealed an SrSCA incidence of 1.7 (95% CI 0.2 to 12.0) cases per 100 000 athletes per year.

Conclusion

This pioneer study reports the incidence estimates of SrSCA in a sub-Saharan African general population and should be regarded as a first step to a big problem.