Status of cardiac arrhythmia services in Africa in 2018: a PASCAR Sudden Cardiac Death Task Force report

Appropriate application of diagnostics for identifying patients in need of pacemaker therapy

Pacemaker therapy is the cornerstone in treatment of bradycardia and conduction disorders. Several diagnostic tools are utilized to diagnose and guide the physicians for appropriate management and accordingly proper utilization of pacemaker therapy. The current article is discussing the different diagnostics used for appropriate evaluation and diagnosis of bradyarrhythmias and the suggested solutions to improve bradycardia diagnosis and pacemaker therapy utilization in underpenetrated areas.

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.

Regional expert opinion: Management of heart failure with preserved ejection fraction in the Middle East, North Africa and Turkey

Although epidemiological data on heart failure (HF) with preserved ejection fraction (HFpEF) are scarce in the Middle East, North Africa and Turkey (MENAT) region, Lancet Global Burden of Disease estimated the prevalence of HF in the MENAT region in 2019 to be 0.78%, versus 0.71% globally. There is also a high incidence of HFpEF risk factors and co-morbidities in the region, including coronary artery disease, diabetes, obesity, hypertension, anaemia and chronic kidney disease. For instance, 14.5-16.2% of adults in the region reportedly have diabetes, versus 7.0% in Europe. Together with increasing life expectancy, this may contribute towards a higher burden of HFpEF in the region than currently reported. This paper aims to describe the epidemiology and burden of HFpEF in the MENAT region, including unique risk factors and co-morbidities. It highlights challenges with diagnosing HFpEF, such as the prioritization of HF with reduced ejection fraction (HFrEF), the specific profile of HFpEF patients in the region and barriers to effective management associated with the healthcare system. Guidance is given on the diagnosis, prevention and management of HFpEF, including the emerging role of sodium-glucose co-transporter-2 inhibitors. Given the high burden of HFpEF coupled with the fact that its prevalence is likely to be underestimated, healthcare professionals need to be alert to its signs and symptoms and to manage patients accordingly. Historically, HFpEF treatments have focused on managing co-morbidities and symptoms, but new agents are now available with proven effects on outcomes in patients with HFpEF.

Advancing the Cardiovascular Workforce in Africa to Tackle the Epidemic of Cardiovascular Disease: The Time is Now

The African region is experiencing an epidemic of cardiovascular disease with dire consequences of increasing morbidity and mortality. Compared with high-income countries where older populations are most affected, the burden of CVD in Africa is higher in the younger populations, which hampers regional socioeconomic development. Strategies to increase and advance the cardiovascular workforce are urgently needed to help address this problem. This commentary highlights the critical lack of skilled cardiovascular healthcare professionals, including cardiologists, cardiac surgeons, and cardiovascular nurses in the African region. Multilevel viable solutions to advance the cardiovascular workforce in Africa based on successful models in Africa are also presented.

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.

Heart failure disease: An African perspective

Heart failure remains a health challenge in Africa, associated with significant rates of hospitalization, morbidity and mortality. The current review aims to summarize the most recent data on the epidemiology, aetiology, risk factors and management of heart failure, comparing countries in North Africa and sub-Saharan Africa. There is a paucity of data on heart failure epidemiology, aetiology and management, and on the sociodemographic characteristics of African patients with heart failure. Heart failure prevalence has been evaluated among all medical admissions or admissions to cardiac units or emergency departments in a few hospital-based studies conducted in countries in North Africa and sub-Saharan Africa. Common causes of heart failure in Africa include ischaemic heart disease, hypertensive heart disease, dilated cardiomyopathy and valvular heart disease. The aetiology of heart failure differs between countries in North Africa and sub-Saharan Africa. Diagnosing heart failure proves challenging in Africa because of a lack of basic tools and the necessary human resources. The principal drugs used frequently for heart failure therapy are lacking in sub-Saharan Africa. The clinical profile of heart failure in sub-Saharan Africa differs from that in North African countries; this is related to aetiological factors, socioeconomic status and availability of diagnostic tools. There is an evident need to establish a large multicentre registry to evaluate the heart failure burden in almost all African countries, and to highlight the major cardiovascular risk factors and co-morbidities. The present review highlights the importance of this syndrome in Africa, and calls for improvements in its early diagnosis, treatment and, possibly, prevention.

African particularities of sudden adult death in Togo on autopsy cases

Background

The purpose of the study was to determine the circumstances of occurrence of these sudden deaths, risk factors, to identify the causes of sudden death in adults at autopsy, with a view to improving prevention.

Methods

This is a retrospective study of the cases of sudden death that were the subject of an autopsy in the pathology anatomy department of the University Hospital Sylvanus Olympio in Lomé from 2009 to 2018.

Results

A total of 318 sudden death cases were recorded. The sex ratio (M/F) was 1.8, and the mean age was 43 ± 0.36 years. Sudden deaths were the second most common reason for autopsies after traffic accidents. The place of death was home in 76.7% of cases and in hospitals in 23.3%. Obesity was noted in 59.4%, with an umbilical adipose panicle varying between 7 and 12 cm thick. Cardiovascular causes excluding cerebral involvement (n = 173 cases, 54.40%) followed by pulmonary causes (n = 100 cases, 31.44%) were the most common cause of sudden death. The predominant cardiac pathology was infarction accounting for 32.07% of all causes of sudden death, and pulmonary embolism with 19.49% was the leading cause at the pulmonary level.

Conclusion

The victims of sudden death in Togo are relatively young, predominantly male and predominantly obese. The main causes of sudden death were myocardial infarction followed by pulmonary embolism. The prevention of sudden death remains paramount, especially in the African context, where pre-hospital care is often inadequate.

Cardiac arrhythmia services in Africa from 2011 to 2018: the second report from the Pan African Society of Cardiology working group on cardiac arrhythmias and pacing

AIMS

Cardiac arrhythmia services are a neglected field of cardiology in Africa. To provide comprehensive contemporary information on the access and use of cardiac arrhythmia services in Africa.

METHODS AND RESULTS

Data on human resources, drug availability, cardiac implantable electronic devices (CIED), and ablation procedures were sought from member countries of Pan African Society of Cardiology. Data were received from 23 out of 31 countries. In most countries, healthcare services are primarily supported by household incomes. Vitamin K antagonists (VKAs), digoxin, and amiodarone were available in all countries, while the availability of other drugs varied widely. Non-VKA oral anticoagulants (NOACs) were unequally present in the African markets, while International Normalized Ratio monitoring was challenging. Four countries (18%) did not provide pacemaker implantations while, where available, the implantation and operator rates were 2.79 and 0.772 per million population, respectively. The countries with the highest pacemaker implantation rate/million population in descending order were Tunisia, Mauritius, South Africa, Algeria, and Morocco. Implantable cardioverter-defibrillator and cardiac resynchronization therapy (CRT) were performed in 15 (65%) and 12 (52%) countries, respectively. Reconditioned CIED were used in 5 (22%) countries. Electrophysiology was performed in 8 (35%) countries, but complex ablations only in countries from the Maghreb and South Africa. Marked variation in costs of CIED that severely mismatched the gross domestic product per capita was observed in Africa. From the first report, three countries have started performing simple ablations.

CONCLUSION

The access to arrhythmia treatments varied widely in Africa where hundreds of millions of people remain at risk of dying from heart block. Increased economic and human resources as well as infrastructures are the critical targets for improving arrhythmia services in Africa.

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.

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.

HIV and cardiovascular disease

HIV-related cardiovascular disease research is predominantly from Europe and North America. Of the estimated 37·9 million people living with HIV worldwide, 25·6 million live in sub-Saharan Africa. Although mechanisms for HIV-related cardiovascular disease might be the same in all people with HIV, the distribution of cardiovascular disease risk factors varies by geographical location. Sub-Saharan Africa has a younger population, higher prevalence of elevated blood pressure, lower smoking rates, and lower prevalence of elevated cholesterol than western Europe and North America. These variations mean that the profile of cardiovascular disease differs between low-income and high-income countries. Research in, implementation of, and advocacy for risk reduction of cardiovascular disease in the global context of HIV should account for differences in the distribution of traditional cardiovascular disease risk factors (eg, hypertension, smoking), consider non-traditional cardiovascular disease risk factors (eg, access to antiretroviral therapy with more benign cardiovascular disease side effect profiles, indoor air pollution), and encourage the inclusion of relevant risk reduction approaches for cardiovascular disease in HIV-care guidelines. Future research priorities include implementation science to scale up and expand integrated HIV and cardiovascular disease care models, which have shown promise in sub-Saharan Africa; HIV and cardiovascular disease epidemiology and mechanisms in women; and tobacco cessation for people living with HIV.

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.

Cardiac arrhythmias in low- and middle-income countries

Many low- and middle-income countries (LMICs) are undergoing an epidemiological transition. With an improvement in socioeconomic conditions and an aging population, cardiovascular diseases (CVDs), like cardiac arrhythmias, are expected to increase in these countries. However, there are limited studies on the epidemiology and management of cardiac arrhythmias in LMICs. This review will highlight the unique challenges and opportunities that these countries face when managing cardiac arrhythmias.

Cardiovascular Diseases in Sub-Saharan Africa Compared to High-Income Countries: An Epidemiological Perspective

Non-communicable diseases (NCDs) are the second common cause of death in sub-Saharan Africa (SSA) accounting for about 35% of all deaths, after a composite of communicable, maternal, neonatal, and nutritional diseases. Despite prior perception of low NCDs mortality rates, current evidence suggests that SSA is now at the dawn of the epidemiological transition with contemporary double burden of disease from NCDs and communicable diseases. In SSA, cardiovascular diseases (CVDs) are the most frequent causes of NCDs deaths, responsible for approximately 13% of all deaths and 37% of all NCDs deaths. Although ischemic heart disease (IHD) has been identified as the leading cause of CVDs mortality in SSA followed by stroke and hypertensive heart disease from statistical models, real field data suggest IHD rates are still relatively low. The neglected endemic CVDs of SSA such as endomyocardial fibrosis and rheumatic heart disease as well as congenital heart diseases remain unconquered. While the underlying aetiology of heart failure among adults in high-income countries (HIC) is IHD, in SSA the leading causes are hypertensive heart disease, cardiomyopathy, rheumatic heart disease, and congenital heart diseases. Of concern is the tendency of CVDs to occur at younger ages in SSA populations, approximately two decades earlier compared to HIC. Obstacles hampering primary and secondary prevention of CVDs in SSA include insufficient health care systems and infrastructure, scarcity of cardiac professionals, skewed budget allocation and disproportionate prioritization away from NCDs, high cost of cardiac treatments and interventions coupled with rarity of health insurance systems. This review gives an overview of the descriptive epidemiology of CVDs in SSA, while contrasting with the HIC and highlighting impediments to their management and making recommendations.

Hypertrophic Cardiomyopathy and Wolff-Parkinson-White Syndrome in a Young African Soldier with Recurrent Syncope

Syncope is a common manifestation of both hypertrophic cardiomyopathy (HCM) and Wolff-Parkinson-White (WPW) syndrome. The most common arrhythmia in HCM is ventricular tachycardia (VT) and atrial fibrillation (AF). While preexcitation provides the substrate for reentry and supraventricular tachycardia (SVT), AF is more common in patients with preexcitation than the general population. Concurrence of HCM and WPW has been reported in many cases, but whether the prognosis or severity of arrhythmia is different compared to the individual disorders remains unsettled. We report a case of HCM and Wolff-Parkinson-White (WPW) syndrome in a 28-year-old male Nigerian soldier presenting with recurrent syncope and lichen planus.

Cardiac Arrhythmias in Africa: Epidemiology, Management Challenges, and Perspectives

Africa is experiencing an increasing burden of cardiac arrhythmias. Unfortunately, the expanding need for appropriate care remains largely unmet because of inadequate funding, shortage of essential medical expertise, and the high cost of diagnostic equipment and treatment modalities. Thus, patients receive suboptimal care. A total of 5 of 34 countries (15%) in Sub-Saharan Africa (SSA) lack a single trained cardiologist to provide basic cardiac care. One-third of the SSA countries do not have a single pacemaker center, and more than one-half do not have a coronary catheterization laboratory. Only South Africa and several North African countries provide complete services for cardiac arrhythmias, leaving more than hundreds of millions of people in SSA without access to arrhythmia care considered standard in other parts of the world. Key strategies to improve arrhythmia care in Africa include greater government health care funding, increased emphasis on personnel training through fellowship programs, and greater focus on preventive care.

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

This systematic review summarizes the data on the prevalence, risk factors, complications, and management of atrial fibrillation (AF) in sub-Saharan Africa (SSA). Bibliographic databases were searched from inception to 31 May 2019, to identify all published studies providing data on AF in populations living in SSA. A total of 72 studies were included. The community-based prevalence of AF was 4.3% and 0.7% in individuals aged ≥40 years and aged ≥70 years, respectively. The prevalence of AF ranged between 6.7% and 34.8% in patients with ischemic stroke, between 9.5% and 46.8% in those with rheumatic heart disease (RHD), between 5% and 31.5% in patients with dilated cardiomyopathy. The main risk factors for AF were hypertension, affecting at least one-third of patients with AF, and valvular heart disease (12.3%-44.4%) and cardiomyopathy (~20%). Complications of AF included heart failure in about two thirds and stroke in 10% to 15% of cases. The use of anticoagulation for stroke prevention was suboptimal. Rate control was the most frequent therapeutic strategy, used in approximately 65% to 95% of AF patients, with approximately 80% of them achieving rate control. The management of AF was associated with exorbitant cost. In conclusion, AF seems to have a higher prevalence in the general population than previously thought and is mostly associated with hypertension, cardiomyopathy, and RHD in SSA. It is associated with a high incidence of heart failure and stroke. The management of AF is suboptimal in SSA, especially with a low uptake of oral anticoagulation.