Heart Failure in the Urban African Enclave of Soweto

Acute decompensated heart failure - treatments and challenges -

Acute decompensated heart failure (ADHF) is a major public health problem throughout the world and its importance is continuing to grow. This article reviews the epidemiology of ADHF and the profile of patients suffering from this condition. It describes factors used in assessing prognosis and presents treatment options. Although no currently available treatments have been shown to favorably affect long-term outcomes, there are a variety of strategies and approaches to management that are expected to reduce morbidity and mortality following discharge after ADHF hospitalization. In particular, the clinician is alerted to the need to identify factors that trigger decompensation as well as to optimize treatments for chronic heart failure. The importance of the transition from hospital to the outpatient setting is described. Particular attention should be focused on providing health education to the patient and their family at an appropriate level of medical literacy as well as ensuring early follow-up evaluation after hospital discharge.

Coronary artery disease in Africa and the Middle East

Countries in Africa and the Middle East bear a heavy burden from cardiovascular disease. The prevalence of coronary heart disease is promoted in turn by a high prevalence of cardiovascular risk factors, particularly smoking, hypertension, dyslipidemia, diabetes, and sedentary lifestyles. Patients in Africa and the Middle East present with myocardial infarction at a younger age, on average, compared with patients elsewhere. The projected future burden of mortality from coronary heart disease in Africa and the Middle East is set to outstrip that observed in other geographical regions. Recent detailed nationally representative epidemiological data are lacking for many countries, and high proportions of transient expatriate workers in countries such as Saudi Arabia and the United Arab Emirates complicate the construction of such datasets. However, the development of national registries in some countries is beginning to reveal the nature of coronary heart disease. Improving lifestyles (reducing calorie intake and increasing physical activity) in patients in the region will be essential, although cultural and environmental barriers will render this difficult. Appropriate prescribing of pharmacologic treatments is essential in the prevention and management of cardiovascular disease. In particular, recent controversies relating to the therapeutic profile of beta-blockers may have reduced their use. The current evidence base suggests that beta-blockers are as effective as other therapies in preventing cardiovascular disease and that concerns relating to their use in hypertension and cardiovascular disease have been overstated.

A rare case of cor pulmonale secondary to idiopathic pulmonary fibrosis in Nigeria

Idiopathic pulmonary fibrosis (IPF) is a rarely reported disease in Nigeria. Cor pulmonale, one of the complications of this type of diffuse parenchymal lung disease is even rarer. The authors present a Nigerian patient with IPF with a classical high-resolution CT features, managed in our centre together with associated problems.

Hypertension and its management in countries in Africa and the Middle East, with special reference to the place of β-blockade

BACKGROUND

The prevalence and clinical consequences of hypertension in countries in Africa and the Middle East have not been studied as well as in other regions.

SCOPE

We have reviewed the literature on the epidemiology and management of hypertension and related cardiovascular complications in countries within Africa and the Middle East. A PubMed search for countries in the region and 'hypertension' was supplemented by articles identified from reviews, and by literature suggested by the authors.

FINDINGS

The prevalence of hypertension is >20% in some countries in the Middle East and Africa, despite an average population age that is some 10-15 years lower than those of developed countries. Hypertension in these countries is associated with an increased risk of cardiovascular risk factors and cardiovascular disease, as elsewhere. Awareness rates of hypertension are low. Hypertension and its complications are undertreated, and mortality rates from cardiovascular disease are higher than in developed countries.

CONCLUSION

Available resources should be brought to bear on the management of hypertension in these countries. In particular, a recent downgrading of the importance of β-blockers in hypertension management guidelines needs to be reassessed. These agents are as effective as other antihypertensive classes both on blood pressures and on cardiovascular event rates. General concerns over an increased rate of new-onset diabetes with β-blockers have been overstated, although these agents should be avoided in metabolic syndrome.

Standing at the crossroads between new and historically prevalent heart disease: effects of migration and socio-economic factors in the Heart of Soweto cohort study

AIMS

Migration, urbanization, and change in socio-economic factors have potentially profound effects on heart disease in low-to-middle income countries.

METHODS AND RESULTS

Chris Hani Baragwanath Hospital in Soweto, South Africa, provides health care to >1 million Africans. We systematically captured data from all de novo presentations of suspected heart disease (focusing on 'new' vs. historically prevalent forms) during 2006-2008. There were 3168 female (52 ± 18 years) vs. 2160 male (53 ± 17 years) cases. Overall, 999 (19%) presented with uncomplicated hypertension (n = 988) or type II diabetes, 1862 cases (35%) 'new' heart disease (1146 and 581 cases of hypertensive heart failure and coronary artery disease), and 2092 cases (39%) of historically prevalent heart disease (including 724 with primary valve disease and 502 idiopathic dilated cardiomyopathies). Level of education and non-communicable risk factors were important correlates of advanced disease. The rate of historically prevalent cases was higher in those aged 20-49 years (19-60 cases/100,000 population/annum) whilst being higher for "new" heart disease in those aged >50 years (155-343 cases/population/annum). Historically prevalent heart disease cases were younger [adjusted odds ratio (OR) 0.98, 95% 0.97-0.99 per year], more likely to be African (OR 4.59, 95% 2.76-7.60) while being less likely to originate from Soweto (OR 0.87, 95% 0.75-1.00) and be female (OR 0.67, 95% 0.49-0.92).

CONCLUSION

Dynamic socio-economic and lifestyle factors characteristic of epidemiological transition appear to have positioned the urban, mainly African community of Soweto at the crossroads between historically prevalent and 'new' forms of heart disease.