A review of the epidemiology of atrial fibrillation in sub-Saharan Africa

[Antithrombotiques oraux et pronostic après un an des patients atteints de fibrillation auriculaire dans un milieu à ressources limitées]

BACKGROUND

Atrial fibrillation is associated with increased risk of morbidity and mortality. There's limited data on the outcomes of atrial fibrillation patients in Africa. We aimed at evaluating the clinical outcomes and their associated factors in patients with atrial fibrillation on antithrombotic therapy in Douala.

METHODS

The Douala atrial fibrillation registry is a prospective, observational cohort study of patients with atrial fibrillation followed by cardiovascular specialists in 3 specialized care centres. From January to April 2018, all patients with electrocardiographic diagnosis of atrial fibrillation, aged 21 years or older, were included in the registry provided their consent. The composite endpoint of heart failure, stroke, major bleeding, hospitalisation and mortality as well as their individual occurrence were assessed at 12 months.

RESULTS

Of 113 participants that were included, 6(5.3%) were lost to follow-up. The mean age was 70 ± 12 years, with a female predominance (68%). After a mean follow-up time of 12.2 ± 0.7 months, 51 patients (47.7%) had at least one outcome. Hospitalisation, all-cause mortality, heart failure, stroke and major bleeding rates were 33.3%, 16.8%, 15.2%, 4.8% and 2.9% respectively. There was no significant difference in the composite outcome and mortality according to the antithrombotic treatment. Previous heart failure [aHR = 3.07, 95% CI (1.48-6.36) p = 0.003], new onset atrial fibrillation [aHR= 4.00, 95% CI (0.96-8.19) p < 0.001] and paroxystic atrial fibrillation [aHR= 3.74, 95% CI (1.33-10.53) p = 0.013] were significant predictors of outcome.

CONCLUSION

Half of patients with atrial fibrillation in this registry developed an outcome after one year of follow-up, with heart failure, new onset and paroxystic atrial fibrillation being the main predicting factors. Diagnosing and managing atrial fibrillation in patients with heart disease should therefore be considered as a key priority.

The Budget Impact Analysis of Adopting Direct Oral Anticoagulants for Stroke Prevention in Nonvalvular Atrial Fibrillation Patients in Malawi

OBJECTIVES

This study aimed to estimate the budget impact of adopting direct oral anticoagulants (DOACs) for stroke prevention in patients with nonvalvular atrial fibrillation in Malawi after the inclusion of DOACs in the World Health Organization's essential medicine list.

METHODS

A model was developed in Microsoft Excel. An eligible population of 201 491 was adjusted with 0.05 % incidence rate and mortality rates yearly according to the treatments. The model estimated the implication of supplementing rivaroxaban or apixaban to the standard treatment mix (also the comparator), thus warfarin and aspirin. The current market share of 43% aspirin and 57% warfarin was adjusted proportionally with 10% DOAC uptake in the first year and 5% annually over the subsequent 4 years. Clinical events of stroke and major bleeding from the ROCKET-AF and ARISTOTLE trials were used because health outcome indicators affect resource utilization. The analysis was conducted solely from the Malawi Ministry of Health perspective and it considered direct costs over 5 years. The sensitivity analysis involved varying drug costs, population, and care costs from both public and private sectors.

RESULTS

The research suggests that despite potential savings of $6 644 141 to $6 930 812 in stroke care because of fewer stroke events, the total Ministry of Health healthcare budget (approximately $260 400 000) may increase by between $42 488 342 to $101 633 644 in 5 years because drug acquisition costs are greater than savings.

CONCLUSIONS

With a fixed budget and current DOACs prices, Malawi can consider using DOACs in patients at the highest risk while waiting for cheaper generic versions.

Global disparities in arrhythmia care: Mind the gap

Delivery of comprehensive arrhythmia care requires the simultaneous presence of many resources. These include complex hospital infrastructure, expensive implantable equipment, and expert personnel. In many low- and middle-income countries (LMICs), at least 1 of these components is often missing, resulting in a gap between the demand for arrhythmia care and the capacity to supply care. In addition to this treatment gap, there exists a training gap, as many clinicians in LMICs have limited access to formal training in cardiac electrophysiology. Given the progressive increase in the burden of cardiovascular diseases in LMICs, these patient care and clinical training gaps will widen unless further actions are taken to build capacity. Several strategies for building arrhythmia care capacity in LMICs have been described. Medical missions can provide donations of both equipment and clinical expertise but are only intermittently present and therefore are not optimized to provide the longitudinal support needed to create self-sustaining infrastructure. Use of donated or reprocessed equipment (eg, cardiac implantable electronic devices) can reduce procedural costs but does not address the need for infrastructure, including diagnostics and expert personnel. Collaborative efforts involving multiple stakeholders (eg, professional organizations, government agencies, hospitals, and educational institutions) have the potential to provide longitudinal support of both patient care and clinician education in LMICs.

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.

Global, regional, and national burden of disease study of atrial fibrillation/flutter, 1990-2019: results from a global burden of disease study, 2019

Background

Data from the Global Burden of Disease, Injury, and Risk Factor Study 2019 (GBD 2019) was used to assess the burden and change in prevalence, incidence, deaths, disability-adjusted life years, and risk factors for atrial fibrillation/flutter in 204 countries and territories between 1990 and 2019.

Methods

Incidence, prevalence, deaths, disability-adjusted life years (DALYs), and their age-standardized rates of AF/AFL were analyzed by age, sex, socio-demographic index (SDI), and human development index (HDI) using the Global Burden of Disease study 2019 (GBD2019) results，and risk factors for AF/AFL (mainly high systolic blood pressure, high body-mass index, alcohol use, smoking and diet high in sodium) were differentially analyzed.

Results

There are 59.70 million (95% uncertainty interval (UI) 45.73–75.29 million) AF/AFL patients worldwide in 2019, with 4.72 million (95% uncertainty interval (UI) 3.64–5.96 million) new cases and 0.315 million deaths (95% uncertainty interval (UI) 0.268–0.361 million) and 8.39 million disability-adjusted years (95% uncertainty interval (UI) 6.69–10.54 million). The highest risk factor for deaths, DALYs attributable to AF/AFL in 2019 was high systolic blood pressure, high body-mass index, alcohol use, smoking, and diet high in sodium. It is estimated that between 2030 and 2034, the total incidence of male AF/ AFL will be 16.08 million, and the total number of deaths will be 1.01 million. For females, the total number of incidence is 16.85 million, and the total number of deaths is 1.49 million.

Conclusions

AF/AFL remains a major global public health problem, although the ASR of prevalence, incidence, and DALY at the worldwide level showed a decreasing trend from 1990 to 2019(the ASR of deaths increased slightly). However, the unfavorable trend observed in this study in countries with lower SDI suggests that current prevention and treatment strategies should be reoriented. Some countries should develop more targeted and specific strategies to prevent the increase of AF/AFL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14403-2.

Burden of atrial fibrillation among adults with heart failure in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

This study aimed to estimate the prevalence of atrial fibrillation (AF) in adults with heart failure (HF) and summarise the all-cause mortality ratio among adult patients with coexisting HF and AF in sub-Saharan Africa (SSA).

SETTING

This was a systematic review and meta-analysis of cross-sectional and cohort studies with primary data on the prevalence and incidence of AF among patients with HF and the all-cause mortality ratio among patients with HF and AF in SSA. We combined text words and MeSH terms to search MEDLINE, PubMed and Global Health Library through Ovid SP, African Journals Online and African Index Medicus from database inception to 10 November 2021. Random-effects meta-analysis was used to estimate pooled prevalence.

PRIMARY OUTCOME MEASURES

The prevalence and incidence of AF among patients with HF, and the all-cause mortality ratio among patients with HF and AF.

RESULTS

Twenty-seven of the 1902 records retrieved from database searches were included in the review, totalling 9987 patients with HF. The pooled prevalence of AF among patients with HF was 15.6% (95% CI 12.0% to 19.6%). At six months, the all-cause mortality was 18.4% (95% CI 13.1% to 23.6%) in a multinational registry and 67.7% (95% CI 51.1% to 74.3%) in one study in Tanzania. The one-year mortality was 48.6% (95% CI 32.5% to 64.7%) in a study in the Democratic Republic of Congo. We did not find any study reporting the incidence of AF in HF.

CONCLUSION

AF is common among patients with HF in SSA, and patients with AF and HF have poor survival. There is an urgent need for large-scale population-based prospective data to reliably estimate the prevalence, incidence and risk of mortality of AF among HF patients in SSA to better understand the burden of AF in patients with HF in the region.

PROSPERO REGISTRATION NUMBER

CRD42018087564.

The prevalence, management, and thirty-day outcomes of symptomatic atrial fibrillation in a Tanzanian emergency department

Introduction

Data describing atrial fibrillation (AF) care in emergency centres (ECs) in sub-Saharan Africa is lacking. We sought to describe the prevalence and outcomes of AF in a Tanzanian EC.

Methods

In a prospective, observational study, adults presenting with chest pain or shortness of breath to a Tanzanian EC were enrolled from January through October 2019. Participants underwent electrocardiogram testing which were reviewed by two independent physician judges to determine presence of AF. Participants were asked about their medical history and medication use at enrollment, and a follow-up questionnaire was administered via telephone thirty days later to assess mortality, interim stroke, and medication use.

Results

Of 681 enrolled patients, 53 (7.8%) had AF. The mean age of participants with AF was 68.1, with a standard deviation (sd) of 21.1 years, and 23 of the 53 (43.4%) being male. On presentation, none of the participants found to have AF reported a previous history of AF. The median CHADS-VASC score among participants was 4 with an interquartile range (IQR) of 2-4. No participants were taking an anticoagulant at baseline. On index presentation, 49 (92.5%) participants with AF were hospitalised with 52 (98.1%) participants completing 30-day follow-up. 18 (34%) participants died, and 5 (9.6%) suffered a stroke. Of the surviving 31 participants with AF and a CHADS-VASC score ≥ 2, none were taking other anti-coagulants at 30 days. Compared to participants without AF, participants with AF were more likely to be hospitalised (OR 5.25, 95% CI 2.10-17.95, p < 0.001), more likely to die within thirty days (OR 1.93, 95% CI 1.03-3.50, p = 0.031), and more likely to suffer a stroke within thirty days (OR 5.91, 95% CI 1.76-17.28, p < 0.001).

Discussion

AF is common in a Tanzanian EC, with thirty-day mortality being high, but use of evidence-based therapies is rare. There is an opportunity to improve AF care and outcomes in Tanzania.

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In a Tanzanian emergency centre, atrial fibrillation was common but patient awareness of their condition was low

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Use of anticoagulants among patients with atrial fibrillation was rare both before and after hospital presentation

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Following hospital presentation, thirty-day mortality and stroke rates among patients with atrial fibrillation were high

Atrial fibrillation and obstructive sleep apnea in African populations: uncovering a neglected association

Atrial fibrillation (AF), the most common sustained arrhythmia, is one of the risk factors with the largest relative increase in attributed cardiovascular mortality in Africa. There are important knowledge gaps in the epidemiology of AF in Africa, along with inadequate service provision for cardiac arrhythmias including AF. This paper comments on the available data on the prevalence and correlates of obstructive sleep apnea (OSA) in patients with AF in Africa. Two studies from Tunisia revealed a high prevalence of OSA based on polysomnography (77% and 90%) among patients with AF. Patients with OSA were more likely to report snoring, were older and had longer AF duration compared to those without OSA. The implications of these findings are discussed. Furthermore, key points on the mechanisms underlying the association between AF and OSA, the impact of OSA on AF-related outcomes and the screening and management of OSA in patients with AF are highlighted.

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.

Improving anticoagulation in sub-Saharan Africa: What are the challenges and how can we overcome them?

Patients in sub-Saharan Africa generally have poor anticoagulation control. We review the potential reasons for this poor control, as well as the potential solutions. Challenges include the affordability and centralisation of anticoagulation care, problems with access to medicines and international normalised ratio monitoring, the lack of locally validated standardized dosing protocols, and low levels of anticoagulation knowledge among healthcare workers and patients. Increasing numbers of patients will need anticoagulation in the future because of the increasing burden of noncommunicable disease in the region. We propose that locally developed "warfarin care bundles" which address multiple anticoagulation challenges in combination may be the most appropriate solution in this setting currently.

[Observational study of the prevalence of non-valvular atrial fibrillation and ischemic stroke and the factors associated with non-valvular atrial fibrillation in hypertensive patients: about 2887 cases]

Introduction

high blood pressure (HBP), atrial fibrillation (AF) and ischemic stroke are three public health problems. The purpose of this study was to determine the prevalence of AF and ischemic stroke in hypertensive patients and the factors associated with the occurrence of non-valvular AF in these patients.

Methods

we used data collected in the Department of Cardiology at the University Hospital of Sfax as a part of National Tunisian Registry of Hypertension. We examined the associations between different socio-demographic, clinical, paraclinical, and therapeutic variables and AF in hypertensive patients using logistic regression models.

Results

our sample consisted of 2887 patients with a sex ratio of 0.95. The average age of patients was 65 years (±11). AF was found in 230 patients (8%), while ischemic stroke was found in 152 patients (5.3%). Multivariate analysis highlighted that independent factors associated with an increase in the prevalence of AF were: advanced age (p = 0,001, Odds Ratio (OR) = 1,647, 95% confidence interval ( CI): 1,1227-2,213), the detection of left ventricular hypertrophy (LVH) on cardiac ultrasound (p= 0,004, OR= 2,140, 5%CI 9: 1,281-3,576), and left ventricular ejection fraction (LVEF) < 50% (p<0,001, OR=4,677, 95% CI: 2,715 and 8.057).

Conclusion

this study confirms that there is a direct and independent relationship between high blood pressure, advanced age, LVH and AF. AF in patients with high blood pressure is a disease progression leading to an increased risk of ischemic stroke. Optimal high blood pressure control is a priority in hypertensive patients, especially in the elderly, aiming at preventing the risk of AF and ischemic stroke.

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.