Occurrence, aetiology and challenges in the management of congestive heart failure in sub-Saharan Africa: experience of the Cardiac Centre in Shisong, Cameroon

Undernutrition in young children with congenital heart disease undergoing cardiac surgery in a low-income environment

BACKGROUND

Malnutrition (undernutrition) in children with congenital disease (CHD) is a notable concern, with preoperative and persistent growth failure post-cardiac surgery contributing to poorer outcomes. Poor growth in children with CHD in low-income environments is exacerbated by feeding difficulties, poverty, delayed diagnosis, and late corrective surgery. This study describes and compares the growth of young children with CHD undergoing cardiac surgery in central South Africa from before to 6-months after cardiac surgery.

METHODS

Children 30 months and younger, with their mothers, were included in this prospective observational descriptive study. Weight- height-, and head circumference-for-age z-scores were used to identify children who were underweight, stunted and microcephalic. Z-scores for growth indices were compared from baseline to 3-months and 6-months post-cardiac surgery. Changes in growth over time were calculated using a 95% confidence interval on the difference between means. Linear regression was used to determine the association between growth and development, health-related quality of life and parenting stress respectively.

RESULTS

Forty mother-child pairs were included at baseline. Most children (n = 30) had moderate disease severity, with eight children having cyanotic defects. A quarter of the children had Down syndrome (DS). Twenty-eight children underwent corrective cardiac surgery at a median age of 7.4 months. Most children (n = 27) were underweight before cardiac surgery [mean z-score - 2.5 (±1.5)], and many (n = 18) were stunted [mean z-score - 2.2 (±2.5)]. A quarter (n = 10) of the children had feeding difficulties. By 6-months post-cardiac surgery there were significant improvements in weight (p = 0.04) and head circumference (p = 0.02), but complete catch-up growth had not yet occurred. Malnutrition (undernutrition) was strongly associated (p = 0.04) with poorer motor development [Mean Bayley-III motor score 79.5 (±17.5)] before cardiac surgery. Growth in children with cyanotic and acyanotic defects, and those with and without DS were comparable.

CONCLUSION

Malnutrition (undernutrition) is common in children with CHD in central South Africa, a low-income environment, both before and after cardiac surgery, and is associated with poor motor development before cardiac surgery. A diagnosis of CHD warrants regular growth monitoring and assessment of feeding ability. Early referral for nutritional support and speech therapy will improve growth outcomes.

Lived Experience of Adult With Heart Failure at Tibebe Ghion Specialized Teaching Hospital Northwest Ethiopia, Qualitative Phenomenological Study

Background

Heart failure is major public health problem that affects many people worldwide. It affects all aspects of patients' lives, leading to extreme physical, social, and functional restriction and increasing psychological distress. The purpose of this study was to explore the lived experience of adult patient with heart failure at Tibebe Ghion Specialize Hospital, Ethiopia, 2022.

Method

Qualitative Phenomenological study design was conducted at Tibebe Ghion Specialized Referral Hospital, from November 10 to December 15, 2022. Heterogenous purposive sampling technique was used to select 11 study participants. Data were collected through in-depth interviews guides and observational checklist. The rigor and trustworthiness of the study were maintained by transferability, dependability, credibility, and conformability. Thematic analysis method was used for the development of codes and themes using ATLAS. ti.7 software for analysis.

Result

Five main themes and eleven subthemes were developed that explore the lived experience of adults with heart failure. Impact of heart failure on daily life, psychological and spiritual experiences, financial experiences, experiences related to hospital service, and challenges to getting treatment are major themes. Unavailability of medicine, lab investigations, and the inaccessibility of cardiac centers were the main challenges during their treatment.

Conclusion

This study explored that lived experience of adult HF patients were addressed in in terms of Physical, Psychological and Spiritual, financial, hospital service and challenges to get treatment. Therefore, we recommended providing psychological and economical support for HF patients and in addition to accessing medication and medical care centers.

Survival time to complications of congestive heart failure patients at Felege Hiwot comprehensive specialized referral hospital, Bahir Dar, Ethiopia

BACKGROUNDS

Congestive heart failure is a serious chronic condition when the heart's muscles become too damaged and a condition in which one or both ventricles cannot pump sufficient blood to meet the metabolic needs of the body. This study aimed to identify factors affecting the complications time of congestive heart failure patients treated from January 2016 to December 2019 at Felege Hiwot comprehensive specialized referral hospital in Bahir Dar, Ethiopia.

METHODS

A hospital-based retrospective data collection was collected from the medical charts of 218 randomly selected congestive heart failure patients. The Kaplan-Meier curve and the Cox proportional hazards model were used to compare and identify the factors associated with time to complication in patients with congestive heart failure.

RESULTS

The median complication time of congestive heart failure patients was 22 months [95% CI: 21.98-28.01]. About 194 (88.99%) of the patients were complicated. The Kaplan-Meier curve depicts the survival probability of complicated patients decreasing as the complication time increases. The hazard ratios for serum sodium concentration, left ventricular ejection fraction, patients from rural areas, age of patients, serum hemoglobin concentration, and New York heart association classes I, II, and III were given 0.94 [95% CI: 0.90-1.00], 0.74 [95% CI: 0.65-0.85], 0.75 [95% CI: 0.68-0.84], 1.28 [95% CI: 1.12-1.46], 0.89 [95% CI: 0.85-0.94], 0.44 [95% CI: 0.36-0.53], 0.54 [95% CI: 0.47-0.62] and 0.73 [95% CI: 0.65-0.81] respectively, and they are statistically associated with the complication time of congestive heart failure patients.

CONCLUSIONS

The median complication time of congestive heart failure patients was 22 months. This study strongly suggests that healthcare awareness should be strengthened earlier about the potential complications for patients with lower serum sodium concentrations below the threshold and aged congestive heart failure patients to reduce the risk of developing complications.

Prevalence, correlates and in-hospital outcomes of kidney dysfunction in hospitalized patients with heart failure in Buea-Cameroon

Background

Kidney dysfunction is common in patients with heart failure (HF) and has been associated with poor outcomes. This study aimed to determine the prevalence, correlates, and prognosis of kidney dysfunction in patients with HF in Cameroon, an understudied population.

Methods

We conducted a cross-sectional study in consecutive patients hospitalized with HF between June 2016 and November 2017 in the Buea Regional Hospital, Cameroon. Kidney dysfunction was defined as an estimated glomerular filtration rate < 60 ml/min/1.73m². Prognostic outcomes included death and prolonged hospital stay (> 7 days). We also performed a sensitivity analysis excluding racial considerations.

Results

Seventy four patients (86.1% of those eligible) were included. Their median age was 60 (interquartile range: 44–72) years and 46.0% (n = 34) were males. Half of patients (n = 37) had kidney dysfunction. Correlates of kidney dysfunction included previous diagnosis of HF (adjusted odds ratio [aOR]4.3, 95% CI: 1.1–17.5) and left ventricular hypertrophy (aOR3.4, 95% CI: 1.1–9.9). Thirty-six (48.9%) had prolonged hospital stay, and seven (9.5%) patients died in hospital. Kidney dysfunction was not associated with in-hospital death (aOR 0.4, 95% CI: 0.1–2) nor prolonged hospital stay (aOR 2.04, 0.8–5.3). In sensitivity analysis (excluding racial consideration), factors associated with Kidney dysfunction in HF were; anemia (aOR: 3.0, 95% CI: 1.1–8.5), chronic heart failure (aOR: 4.7, 95% CI: 0.9–24.6), heart rate on admission < 90 bpm (aOR: 3.4, 95% CI: 1.1–9.1), left atrial dilation (aOR: 3.2, 95% CI: 1.04–10), and hypertensive heart disease (aOR: 3.1, 95% CI: 1.2–8.4). Kidney dysfunction in HF was associated with hospital stay > 7 days (OR: 2.6, 95% CI: 1–6.8).

Conclusion

Moderate-to-severe kidney dysfunction was seen in half of the patients hospitalized with HF in our setting, and this was associated with a previous diagnosis of HF and left ventricular hypertrophy. Kidney dysfunction might not be the main driver of poor HF outcomes in this population. In sensitivity analysis, this was associated with anemia, chronic heart failure, heart rate on admission less than 90 bpm, left atrial dilatation, and hypertensive heart disease. Kidney dysfunction was associated with hospital stay > 7 days.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02641-2.

Pattern of congenital heart disease among children presenting to the Uganda Heart Institute, Mulago Hospital: a 7-year review

BACKGROUND

Congenital heart disease (CHD) is the most common congenital anomaly in children. Over half of the deaths due to CHD occur in the neonatal period. Most children with unrepaired complex heart lesions do not live to celebrate their first birthday. We describe the spectrum of congenital heart disease in Uganda.

METHODS

We retrospectively reviewed the data of children with CHD who presented to the Uganda Heart Institute (UHI), Mulago Hospital Complex from 2007 to 2014.

RESULTS

A total of 4621 children were seen at the UHI during the study period. Of these, 3526 (76.3%) had CHD; 1941(55%) were females. Isolated ventricular septal defect (VSD) was the most common CHD seen in 923 (27.2%) children followed by Patent ductus arteriosus (PDA) 760 (22%) and atrial septal defects (ASD) 332 (9.4%). Tetralogy of Fallot (TOF) and Truncus arteriosus were the most common cyanotic heart defects (7% and 5% respectively). Dysmorphic features were diagnosed in 185 children, of which 61 underwent genetic testing (Down syndrome=24, 22q11.2 deletion syndrome n=10). Children with confirmed 22q11.2 deletion had conotruncal abnormalities.

CONCLUSION

Isolated VSD and Tetralogy of Fallot are the most common acyanotic and cyanotic congenital heart defects. We report an unusually high occurrence of Truncus arteriosus.

[Heart Failure in Africa]

Heart Failure in Africa Abstract. In Africa, mortality due to heart failure is twice as high as in other low- to middle-income countries and five times as high as in high-income countries. Arterial hypertension is by far the most common cause of heart failure, followed by cardiomyopathies and rheumatic heart diseases. At diagnosis, most patients suffer already from an advanced disease stage. Only a few patients are aware of arterial hypertension, and few are treated and have their hypertension well controlled. Only a minority of patients have a well-controlled hypertension. The neglect of chronic non-communicable diseases on the health agenda leads to poor awareness, poor diagnostic resources, preventions strategies and treatment options. International guidelines cannot be properly followed in these circumstances. Information at community level and in healthcare facilities is urgently needed as well as training of healthcare staff, implementation of improved diagnostics and treatment of arterial hypertension and heart failure.

Diagnosis and Management of Acute Heart Failure in Sub-Saharan Africa

PURPOSE OF REVIEW

Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present.

RECENT FINDINGS

AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.

Short-term rehospitalisation or death and determinants after admission for acute heart failure in a cohort of African patients in Port Harcourt, southern Nigeria

BACKGROUND

Heart failure (HF) is a major health burden globally and contributes significantly to morbidity and mortality related to cardiovascular disease. The aim of this study was to determine the outcome, and factors determining these outcomes in patients admitted for acute HF and followed up for six months.

METHOD

This was a hospital-based, prospective study. Subjects included consecutive patients with a confirmed diagnosis of acute HF admitted to the medical wards of the University of Port Harcourt Teaching Hospital (UPTH) in Nigeria over one year. All had a full physical examination and relevant investigations, including echocardiography. Subjects were followed up for six months and reassessed for outcome/endpoint, which was rehospitalisation or death. Factors that predicted these outcomes were also determined.

RESULTS

There were 160 subjects, 84 females and 76 males, age range 20 to 87 years, mean age 52.49 ± 13.89 years. Sixteen subjects (10.0%) were lost to follow up, 66 (41.3%) showed clinical improvement, 57 (35.6%) were rehospitalised, while 21 (13.1%) died. Determinants of rehospitalisation were New York Heart Association (NYHA) class, heart failure type, haemoglobin level at presentation and estimated glomerular filtration rate (eGFR). Determinants of mortality were NYHA class and haemoglobin level at presentation.

CONCLUSION

Heart failure rehospitalisation and mortality rates of 35.6 and 13.1%, respectively, were high compared to developed countries.

Heart diseases and echocardiography in rural Tanzania: Occurrence, characteristics, and etiologies of underappreciated cardiac pathologies

BACKGROUND

Little is known about heart diseases and their treatment in rural sub-Saharan Africa. This study aimed to describe the occurrence, characteristics, and etiologies of heart diseases, and the medication taken before and prescribed after echocardiography in a rural referral Hospital in Tanzania.

METHODS

This prospective descriptive cohort study included all adults and children referred for echocardiography. Clinical and echocardiographic data were collated for analysis.

RESULTS

From December 2015 to October 2017, a total of 1'243 echocardiograms were performed. A total of 815 adults and 59 children ≤15 years had abnormal echocardiographic findings; in adults 537/815 (66%) had hypertension, with 230/537(43%) on antihypertensive drugs, and 506/815 (62%) were not on regular cardiac medication; 346/815 (42%) had severe eccentric or concentric left ventricular hypertrophy, and 182/815 (22%) had severe systolic heart failure. Only 44% demonstrated normal left ventricular systolic function. The most frequent heart diseases were hypertensive heart disease (41%), valvular heart disease (18%), coronary heart disease (18%), peripartum cardiomyopathy (7%), and other non-hypertensive dilated cardiomyopathies (6%) in adults, and congenital heart disease (34%) in children. Following echocardiography, 802/815 (98%) adults and 40/59 (68%) children had an indication for cardiac medication, 70/815 (9%) and 2/59 (3%) for oral anticoagulation, and 35/815 (4%) and 23/59 (39%) for cardiac surgery, respectively.

CONCLUSION

Hypertension is the leading etiology of heart diseases in rural Tanzania. Most patients present with advanced stages of heart disease, and the majority are not treated before echocardiography. There is an urgent need for increased awareness, expertise and infrastructure to detect and treat hypertension and heart failure in rural Africa.

Validation of heart failure quality of life tool and usage to predict all-cause mortality in acute heart failure in Uganda: the Mbarara heart failure registry (MAHFER)

BACKGROUND

The health-related quality of life (HRQoL) is an important treatment goal that could serve as low-cost prognostication tool in resource poor settings. We sought to validate the Kansas City Cardiomyopathy Questionnaire (KCCQ) and evaluate its use as a predictor of 3 months all-cause mortality among heart failure participants in rural Uganda.

METHODS

The Mbarara Heart Failure Registry Cohort study observes heart failure patients during hospital stay and in the community in rural Uganda. Participants completed health failure evaluations and HRQoL questionnaires at enrollment, 1 and 3 months of follow-up. We used Cronbach's alpha coefficients to define internal consistency, intraclass correlation coefficients as a reliability coefficient, and Cox proportional hazard models to predict the risk of 3 months all-cause mortality.

RESULTS

Among the 195 participants who completed HRQoL questionnaires, the mean age was 52 (standard deviation (SD) 21.4) years, 68% were women and 29% reported history of hypertension. The KCCQ had excellent internal consistency (87% Cronbach alpha) but poor reliability. Independent predictors of all-cause mortality within 3 months included: worse overall KCCQ score (Adjusted Hazard ratio (AHR) 2.9, 95% confidence interval (CI) 1.1, 8.1), highest asset ownership (AHR 3.6, 95% CI 1.2, 10.8), alcoholic drinks per sitting (AHR per 1 drink 1.4, 95% CI 1.0, 1.9), New York Heart Association (NYHA) functional class IV heart failure (AHR 2.6, 95% CI 1.3, 5.4), estimated glomerular filtration rate (eGFR) 30 to 59 ml/min/1.73 m2 (AHR 3.4, 95% CI 1.1, 10.8), and eGFR less than 15 ml/min/1.73 m2 (AHR 2.7, 95% CI 1.0, 7.1), each 1 pg/mL increase in Brain Natriuretic Peptide (BNP) (AHR, 1.0, 95% CI 1.0, 1.0), and each 1 ng/mL increase in Creatine-Kinase MB isomer (CKMB) (AHR 1.0, 95% CI 1.0, 1.1).

CONCLUSION

The KCCQ showed excellent internal consistency. Worse overall KCCQ score, highest asset ownership, increasing alcoholic drink per sitting, NYHA class IV, decreased estimated glomerular filtration rate, BNP, and CKMB predicted all-cause mortality at 3 months. The KCCQ could be an additional low-cost tool to aid in the prognostication of acute heart failure patients.

Incidence and predictors of 6 months mortality after an acute heart failure event in rural Uganda: The Mbarara Heart Failure Registry (MAHFER)

OBJECTIVE

We sought to estimate the incidence and predictors of all-cause mortality 6 months after heart failure hospitalization in Uganda.

METHODS

Mbarara Heart Failure Registry is a cohort of patients hospitalized with a clinical diagnosis of heart failure at Mbarara Regional Referral Hospital, Uganda. We measured serum electrolytes, cardiac markers, and echocardiograms. All participants were followed until death or end of 6 months. We used Fine and Gray models to estimate the incidence and predictors all-cause mortality.

RESULTS

A total of 215 participants were enrolled, 141 (66%) were women, and mean age 53 (standard deviation 22) years. Nineteen (9%) had diabetes, 40 (19%) had HIV, and 119 (55%) had hypertension. The overall incidence of all-cause mortality was 3.58 (95% CI 2.92, 4.38) per 1000 person-days. Men had higher incidence of death compared to women (4.02 vs 3.37 per 1000 person-days). The incidence of all-cause mortality during hospitalization was almost twice that of in the community (27.5 vs 14.77 per 1000 person-days). In adjusted analysis, increasing age, NYHA class IV, decreasing renal function, smoking, each unit increase in serum levels of Potassium, BNP, and Creatine kinase-MB predicted increased incidence of 6 months all-cause death whereas taking beta-blockers and having an index admission on a weekend compared to a week day predicted survival.

CONCLUSIONS AND INTERPRETATION

There is a high incidence of all-cause mortality occurring in-hospital among patients hospitalized with heart failure in rural Uganda. Heart failure directed therapies should be instituted to curb heart failure-related mortality.

Human Immunodeficiency Virus and Heart Failure in Low- and Middle-Income Countries

Successful combination therapy for human immunodeficiency virus (HIV) has transformed this disease from a short-lived infection with high mortality to a chronic disease associated with increasing life expectancy. This is true for high- as well as low- and middle-income countries. As a result of this increased life expectancy, people living with HIV are now at risk of developing other chronic diseases associated with aging. Heart failure has been common among people living with HIV in the eras of pre- and post- availability of antiretroviral therapy; however, our current understanding of the pathogenesis and approaches to management have not been systematically addressed. HIV may cause heart failure through direct (e.g., viral replication, mitochondrial dysfunction, cardiac autoimmunity, autonomic dysfunction) and indirect (e.g., opportunistic infections, antiretroviral therapy, alcohol abuse, micronutrient deficiency, tobacco use) pathways. In low- and middle-income countries, 2 large observational studies have recently reported clinical characteristics and outcomes in these patients. HIV-associated heart failure remains a common cardiac diagnosis in people living with heart failure, yet a unifying set of diagnostic criteria is lacking. Treatment patterns for heart failure fall short of society guidelines. Although there may be promise in cardiac glycosides for treating heart failure in people living with HIV, clinical studies are needed to validate in vitro findings. Owing to the burden of HIV in low- and middle-income countries and the concurrent rise of traditional cardiovascular risk factors, strategic and concerted efforts in this area are likely to impact the care of people living with HIV around the globe.

Prevalence of rheumatic heart disease in Senegalese school children: a clinical and echocardiographic screening

OBJECTIVE

To study the prevalence of rheumatic heart disease (RHD) in schools (locally referred to as 'daaras') located in the city of Dakar and its suburbs using both clinical examination and echocardiography.

METHODS

This is a cross-sectional study conducted from 9 August to 24 December 2011 involving 2019 pupils, aged between 5 and 18 years selected from the 16 'daaras' of the Academic Inspectorate (Inspection d'Académie) of the city of Dakar and its suburbs. Anamnestic, clinical and echocardiographic data were collected and entered into a questionnaire designed for the study. The World Heart Federation criteria for echocardiographic diagnosis were used to diagnose RHD. p<0.05 was considered statistically significant in bivariate analysis.

RESULTS

About 60.1% of the pupils were men and the mean age was 9.7±3.3 years. 10 cases of definite RHD were detected, prevalence being 4.96 per 1000 (95% CI 2.4 to 9.1). This prevalence was five times higher with echocardiographic screening compared with clinical screening. 23 cases (11.4 per 1000) of borderline forms were detected. The populations at risk of definite RHD identified in our study were children over 14 years (p<0.001), those with recurrent sore throat (p=0.003) and those residing in the suburbs of the city of Dakar (p<0.001).

CONCLUSION

Our study shows a relatively high prevalence of RHD. Reducing its prevalence should focus on the implementation of appropriate policies, targeting at-risk populations and focusing on raising awareness and early detection.

Cardiac surgery for patients with heart failure due to structural heart disease in Uganda: access to surgery and outcomes

OBJECTIVE

Few data are available on heart failure (HF) in sub-Saharan Africa. We aimed to provide a current picture of HF aetiologies in urban Uganda, access to heart surgery, and outcomes.

METHODS

We prospectively collected clinical and echocardiographic data from 272 consecutive patients referred for suspected heart disease to a tertiary hospital in Kampala during seven non-governmental organisation (NGO) missions from 2009 to 2013. We focused the analysis on 140 patients who fulfilled standardised criteria of HF by echocardiography.

RESULTS

Rheumatic heart disease (RHD) was the leading cause of HF in 44 (31%) patients. Among the 50 children included (age ≤ 16 years), congenital heart disease (CHD) was the first cause of HF (30 patients, 60%), followed by RHD (16 patients, 32%). RHD was the main cause of HF (30%) among the 90 adults. All 85 patients with RHD and CHD presented with an indication for heart surgery, of which 74 patients were deemed fit for intervention. Surgery was scheduled in 38 patients with RHD [86%, median age 19 years (IQR: 12-31)] and in 36 patients with CHD [88%, median age 4 years (IQR 1-5)]. Twenty-seven candidates (32%) were operated on after a median waiting time of 10 months (IQR 6-21). Sixteen (19%) had died after a median of 38 months (IQR 5-52); 19 (22%) were lost to follow up.

CONCLUSION

RHD still represents the leading cause of HF in Uganda, in spite of cost-efficient prevention strategies. The majority of surgical candidates, albeit young, do not have access to treatment and present high mortality rates.

HIV and noncommunicable cardiovascular and pulmonary diseases in low- and middle-income countries in the ART era: what we know and best directions for future research

With the advent of effective antiretroviral therapy (ART), HIV is becoming a chronic disease. HIV-seropositive (+) patients on ART can expect to live longer and, as a result, they are at risk of developing chronic noncommunicable diseases related to factors, such as aging, lifestyle, long-term HIV infection, and the potential adverse effects of ART. Although data are incomplete, evidence suggests that even in low- and middle-income countries (LMICs), chronic cardiovascular and pulmonary diseases are increasing in HIV-positive patients. This review summarizes evidence-linking HIV infection to the most commonly cited chronic cardiovascular and pulmonary conditions in LMICs: heart failure, hypertension, coronary artery disease/myocardial infarction, stroke, obstructive lung diseases, and pulmonary arterial hypertension. We describe the observed epidemiology of these conditions, factors affecting expression in LMICs, and key populations that may be at higher risk (ie, illicit drug users and children), and finally, we suggest that strategic areas of research and training intended to counter these conditions effectively. As access to ART in LMICs increases, long-term outcomes among HIV-positive persons will increasingly be determined by a range of associated chronic cardiovascular and pulmonary complications. Actions taken now to identify those conditions that contribute to long-term morbidity and mortality optimize early recognition and diagnosis and implement effective prevention strategies and/or disease interventions are likely to have the greatest impact on limiting cardiovascular and pulmonary disease comorbidity and improving population health among HIV-positive patients in LMICs.

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs.

METHODS AND FINDINGS

Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%-64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%-41%) with beta-blockers, and 32% (95% CI: 25%-39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%-7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%-10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified.

CONCLUSIONS

The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary.

Lack of focus on cardiovascular disease in sub-Saharan Africa

Research into cardiovascular disease in Sub-Saharan Africa has been hampered by lack of funding and expertise. However, hospital- and community-based data reveal high economic and social costs of these diseases to the national health services and the communities, with the region facing a mixed burden of diseases related to poverty and infections, emergence of risk factors and diseases of affluence, as well as new cardiovascular problems caused by the HIV/AIDS epidemics. The availability of echocardiography has raised the profile of these conditions in sub-Saharan Africa, stimulating several projects led by local cardiologists under the umbrella of the Pan-African Society of Cardiology. This research may help to overcome the lack of focus on cardiovascular diseases in Sub-Saharan Africa, as well as increase the awareness of the public and policymakers on the burden of cardiovascular diseases.

Congenital heart disease and rheumatic heart disease in Africa: recent advances and current priorities

Africa has one of the highest prevalence of heart diseases in children and young adults, including congenital heart disease (CHD) and rheumatic heart disease (RHD). We present here an extensive review of recent data from the African continent highlighting key studies and information regarding progress in CHD and RHD since 2005. Main findings include evidence that the CHD burden is underestimated mainly due to the poor outcome of African children with CHD. The interest in primary prevention for RHD has been recently re-emphasised, and new data are available regarding echocardiographic screening for subclinical RHD and initiation of secondary prevention. There is an urgent need for comprehensive service frameworks to improve access and level of care and services for patients, educational programmes to reinforce the importance of prevention and early diagnosis and a relevant research agenda focusing on the African context.

The spectrum of cardiac disease in the West Region of Cameroon: a hospital-based cross-sectional study

BACKGROUND

Cardiovascular disease is a growing public health problem in Africa. The extent of heart disease in Cameroon remains largely unknown. This study aimed at reporting the etiology of cardiac disease in a cardiologic clinic situated in a semi-urban area in the West region of Cameroon.

METHODS

This is an analysis of echocardiographic diagnosis of cardiac disease done between July 2008 and October 2010 at the "Centre Medical de la Trinité" in the West region of Cameroon. Data included age, sex and echocardiographic findings.

RESULTS

A total of 1252 patients presented with abnormal echocardiograms, 60.4% (n = 756) being female and 85.8% (n = 1074) aged over 50 years. Overall, the most important conditions were hypertensive heart disease (41.5%, n = 520) and cardiomyopathies (30.5%, n = 382). Among patients aged less than 10 years, congenital heart diseases were the most frequent (52.4%, n = 22), and rheumatic heart disease was the most important cardiac condition in patients aged 10 to 19 years (62.1%, n = 18) and those aged 20 to 39 years (53.3%, n = 8). Congenital heart diseases included persistent ductus arteriosus (27.6%, n = 8), tetralogy of Fallot (20.7%, n = 6) and inter-atria/interventricular communication (20.7%, n = 6).

CONCLUSION

Hypertension is the leading cause of cardiac disease among the elderly in our setting, emphasizing the necessity to strengthen the preventive strategies against hypertension in Cameroon. Rheumatic heart disease and congenital heart disease frequent in children and youths highlight the need of early detection and treatment of throat infections, and of routine cardiac surgery services in Cameroon.

Heart failure in sub-Saharan Africa

The heart failure syndrome has been recognized as a significant contributor to cardiovascular disease burden in sub-Saharan African for many decades. Seminal knowledge regarding heart failure in the region came from case reports and case series of the early 20th century which identified infectious, nutritional and idiopathic causes as the most common. With increasing urbanization, changes in lifestyle habits, and ageing of the population, the spectrum of causes of HF has also expanded resulting in a significant burden of both communicable and non-communicable etiologies. Heart failure in sub-Saharan Africa is notable for the range of etiologies that concurrently exist as well as the healthcare environment marked by limited resources, weak national healthcare systems and a paucity of national level data on disease trends. With the recent publication of the first and largest multinational prospective registry of acute heart failure in sub-Saharan Africa, it is timely to review the state of knowledge to date and describe the myriad forms of heart failure in the region. This review discusses several forms of heart failure that are common in sub-Saharan Africa (e.g., rheumatic heart disease, hypertensive heart disease, pericardial disease, various dilated cardiomyopathies, HIV cardiomyopathy, hypertrophic cardiomyopathy, endomyocardial fibrosis, ischemic heart disease, cor pulmonale) and presents each form with regard to epidemiology, natural history, clinical characteristics, diagnostic considerations and therapies. Areas and approaches to fill the remaining gaps in knowledge are also offered herein highlighting the need for research that is driven by regional disease burden and needs.