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Hahnle L, Mennen M, Gumedze F, Mutithu D, Adriaanse M, Egan D, Mazondwa S, Walters R, Appiah LT, Inofomoh F, Ogah O, Adekanmbi O, Goma F, Ogola E, Mwazo K, Suliman A, Singh K, Raspail L, Prabhakaran D, Perel P, Sliwa K, Ntusi NAB. Greater Disease Severity and Worse Clinical Outcomes in Patients Hospitalised with COVID-19 in Africa. Glob Heart 2024; 19:34. [PMID: 38638124 PMCID: PMC11025574 DOI: 10.5334/gh.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/27/2024] [Indexed: 04/20/2024] Open
Abstract
Background COVID-19 cardiovascular research from Africa is limited. This study describes cardiovascular risk factors, manifestations, and outcomes of patients hospitalised with COVID-19 in the African region, with an overarching goal to investigate whether important differences exist between African and other populations, which may inform health policies. Methods A multinational prospective cohort study was conducted on adults hospitalised with confirmed COVID-19, consecutively admitted to 40 hospitals across 23 countries, 6 of which were African countries. Of the 5,313 participants enrolled globally, 948 were from African sites (n = 9). Data on demographics, pre-existing conditions, clinical outcomes in hospital (major adverse cardiovascular events (MACE), renal failure, neurological events, pulmonary outcomes, and death), 30-day vitality status and re-hospitalization were assessed, comparing African to non-African participants. Results Access to specialist care at African sites was significantly lower than the global average (71% vs. 95%), as were ICU admissions (19.4% vs. 34.0%) and COVID-19 vaccination rates (0.6% vs. 7.4%). The African cohort was slightly younger than the non-African cohort (55.0 vs. 57.5 years), with higher rates of hypertension (48.8% vs. 46.9%), HIV (5.9% vs. 0.3%), and Tuberculosis (3.6% vs. 0.3%). In African sites, a higher proportion of patients suffered cardiac arrest (7.5% vs. 5.1%) and acute kidney injury (12.7% vs. 7.2%), with acute kidney injury (AKI) appearing to be one of the strongest predictors of MACE and death in African populations compared to other populations. The overall mortality rate was significantly higher among African participants (18.2% vs. 14.2%). Conclusions Overall, hospitalised African patients with COVID-19 had a higher mortality despite a lower mean age, contradicting literature that had previously reported a lower mortality attributed to COVID-19 in Africa. African sites had lower COVID-19 vaccination rates and higher AKI rates, which were positively associated with increased mortality. In conclusion, African patients were hospitalized with more severe COVID-19 cases and had poorer outcomes.
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Affiliation(s)
- Lina Hahnle
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Mathilda Mennen
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Freedom Gumedze
- Department of Statistical Sciences, University of Cape Town, South Africa
| | - Daniel Mutithu
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
- Cape Heart Institute, University of Cape Town, South Africa
| | - Marguerite Adriaanse
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Daniel Egan
- Department of Medicine, University of Cape Town, South Africa
| | | | - Rochelle Walters
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- ARUA/GUILD Cluster of Research Excellence on Noncommunicable Diseases and associated multimorbidities, South Africa
| | - Lambert Tetteh Appiah
- Department of Medicine, Kwame Nkrumah University of Science & Technology (KNUST) and Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Francisca Inofomoh
- Internal Medicine Department, Olabisi Onabanjo University Teaching Hospital, Nigeria
| | - Okechukwu Ogah
- Department of Medicine, College of Medicine, University of Ibadan, and University College Hospital Ibadan, Nigeria
| | | | - Fastone Goma
- Centre for Primary Care Research, Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia
| | | | - Kieran Mwazo
- Department of Medicine, Coast General Teaching and Referral Hospital, Mombasa, Kenya
| | | | - Kavita Singh
- Public Health Foundation of India, Gurugram, Haryana and Centre for Chronic Disease Control, New Delhi, IN
- Heidelberg Institute of Global Health, University of Heidelberg, Germany
| | | | - Dorairaj Prabhakaran
- Public Health Foundation India, Centre for Chronic Disease Control, IN
- World Heart Federation, CH
- London School of Hygiene & Tropical Medicine, GB
| | - Pablo Perel
- World Heart Federation, CH
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, GB
| | - Karen Sliwa
- World Heart Federation, CH
- Cape Heart Institute, Department of Medicine & Cardiology, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Ntobeko A. B. Ntusi
- Department of Medicine, University of Cape Town, South Africa
- UCT/SAMRC Extramural Unit on Intersection of Noncommunicable Diseases and Infectious Diseases, South Africa
- World Heart Federation, CH
- J46 (J floor) Old Main Building, Groote Schuur Hospital Observatory, 7925, Cape Town, South Africa
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Benede N, Tincho MB, Walters A, Subbiah V, Ngomti A, Baguma R, Butters C, Hahnle L, Mennen M, Skelem S, Adriaanse M, Facey-Thomas H, Scott C, Day J, Spracklen TF, van Graan S, Balla SR, Moyo-Gwete T, Moore PL, MacGinty R, Botha M, Workman L, Johnson M, Goldblatt D, Zar HJ, Ntusi NA, Zühlke L, Webb K, Riou C, Burgers WA, Keeton RS. Distinct T cell polyfunctional profile in SARS-CoV-2 seronegative children associated with endemic human coronavirus cross-reactivity. iScience 2024; 27:108728. [PMID: 38235336 PMCID: PMC10792240 DOI: 10.1016/j.isci.2023.108728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/19/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
SARS-CoV-2 infection in children typically results in asymptomatic or mild disease. There is a paucity of studies on SARS-CoV-2 antiviral immunity in African children. We investigated SARS-CoV-2-specific T cell responses in 71 unvaccinated asymptomatic South African children who were seropositive or seronegative for SARS-CoV-2. SARS-CoV-2-specific CD4+ T cell responses were detectable in 83% of seropositive and 60% of seronegative children. Although the magnitude of the CD4+ T cell response did not differ significantly between the two groups, their functional profiles were distinct, with SARS-CoV-2 seropositive children exhibiting a higher proportion of polyfunctional T cells compared to their seronegative counterparts. The frequency of SARS-CoV-2-specific CD4+ T cells in seronegative children was associated with the endemic human coronavirus (HCoV) HKU1 IgG response. Overall, the presence of SARS-CoV-2-responding T cells in seronegative children may result from cross-reactivity to endemic coronaviruses and could contribute to the relative protection from disease observed in SARS-CoV-2-infected children.
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Affiliation(s)
- Ntombi Benede
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
| | - Marius B. Tincho
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
| | - Avril Walters
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
| | - Vennesa Subbiah
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
| | - Amkele Ngomti
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
| | - Richard Baguma
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
| | - Claire Butters
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Observatory, South Africa
| | - Lina Hahnle
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory, South Africa
| | - Mathilda Mennen
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory, South Africa
| | - Sango Skelem
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory, South Africa
| | - Marguerite Adriaanse
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory, South Africa
| | - Heidi Facey-Thomas
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Christiaan Scott
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Observatory, South Africa
| | - Jonathan Day
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Observatory, South Africa
| | - Timothy F. Spracklen
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- South African Medical Research Council, Francie Van Zijl Drive, Parow Cape Town, South Africa
| | - Strauss van Graan
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- SA MRC Antibody Immunity Research Unit, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Sashkia R. Balla
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- SA MRC Antibody Immunity Research Unit, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Thandeka Moyo-Gwete
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- SA MRC Antibody Immunity Research Unit, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Penny L. Moore
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg, South Africa
- SA MRC Antibody Immunity Research Unit, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Rae MacGinty
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Medical Research Council (MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Maresa Botha
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Medical Research Council (MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Lesley Workman
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Medical Research Council (MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Marina Johnson
- Great Ormond Street Institute of Child Health Biomedical Research Centre, University College London, London, UK
| | - David Goldblatt
- Great Ormond Street Institute of Child Health Biomedical Research Centre, University College London, London, UK
| | - Heather J. Zar
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Medical Research Council (MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, South Africa
| | - Ntobeko A.B. Ntusi
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Observatory, South Africa
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, South Africa
| | - Liesl Zühlke
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Observatory, South Africa
- South African Medical Research Council, Francie Van Zijl Drive, Parow Cape Town, South Africa
| | - Kate Webb
- Division of Paediatric Rheumatology, Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, Observatory, South Africa
- Crick African Network, The Francis Crick Institute, London, UK
| | - Catherine Riou
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, South Africa
| | - Wendy A. Burgers
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, University of Cape Town, Observatory, South Africa
| | - Roanne S. Keeton
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, South Africa
- Division of Medical Virology, Department of Pathology, University of Cape Town, Observatory, South Africa
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Bedwell GJ, Dias P, Hahnle L, Anaeli A, Baker T, Beane A, Biccard BM, Bulamba F, Delgado-Ramirez MB, Dullewe NP, Echeverri-Mallarino V, Haniffa R, Hewitt-Smith A, Hoyos AS, Mboya EA, Nanimambi J, Pearse R, Pratheepan AP, Sunguya B, Tolppa T, Uruthirakumar P, Vengadasalam S, Vindrola-Padros C, Stephens TJ. Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study. Anesth Analg 2022; 135:1217-1232. [PMID: 36005395 DOI: 10.1213/ane.0000000000006113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Provision of timely, safe, and affordable surgical care is an essential component of any high-quality health system. Increasingly, it is recognized that poor quality of care in the perioperative period (before, during, and after surgery) may contribute to significant excess mortality and morbidity. Therefore, improving access to surgical procedures alone will not address the disparities in surgical outcomes globally until the quality of perioperative care is addressed. We aimed to identify key barriers to quality perioperative care delivery for 3 "Bellwether" procedures (cesarean delivery, emergency laparotomy, and long-bone fracture fixation) in 5 low- and middle-income countries (LMICs). METHODS Ten hospitals representing secondary and tertiary facilities from 5 LMICs were purposefully selected: 2 upper-middle income (Colombia and South Africa); 2 lower-middle income (Sri Lanka and Tanzania); and 1 lower income (Uganda). We used a rapid appraisal design (pathway mapping, ethnography, and interviews) to map out and explore the complexities of the perioperative pathway and care delivery for the Bellwether procedures. The framework approach was used for data analysis, with triangulation across different data sources to identify barriers in the country and pattern matching to identify common barriers across the 5 LMICs. RESULTS We developed 25 pathway maps, undertook >30 periods of observation, and held >40 interviews with patients and clinical staff. Although the extent and impact of the barriers varied across the LMIC settings, 4 key common barriers to safe and effective perioperative care were identified: (1) the fragmented nature of the care pathways, (2) the limited human and structural resources available for the provision of care, (3) the direct and indirect costs of care for patients (even in health systems for which care is ostensibly free of charge), and (4) patients' low expectations of care. CONCLUSIONS We identified key barriers to effective perioperative care in LMICs. Addressing these barriers is important if LMIC health systems are to provide safe, timely, and affordable provision of the Bellwether procedures.
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Affiliation(s)
- Gillian J Bedwell
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Priyanthi Dias
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Lina Hahnle
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Tim Baker
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Abi Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Fred Bulamba
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Martha B Delgado-Ramirez
- Departments of Clinical Epidemiology and Biostatistics.,Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Nilmini P Dullewe
- Post Basic School of Nursing, Colombo, Sri Lanka.,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | | | - Rashan Haniffa
- Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Adam Hewitt-Smith
- Elgon Centre for Health, Research and Innovation, Mbale' Uganda.,Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Alejandra Sanin Hoyos
- Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Erick A Mboya
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juliana Nanimambi
- Department of Anaesthesia and Critical Care, Faculty of Health Sciences, Busitema University, Mbale, Uganda.,Elgon Centre for Health, Research and Innovation, Mbale' Uganda
| | - Rupert Pearse
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Anton Premadas Pratheepan
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Jaffna Teaching Hospital, Jaffna, Sri Lanka
| | - Bruno Sunguya
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Timo Tolppa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Powsiga Uruthirakumar
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | | | | | - Timothy J Stephens
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Hoevelmann J, Viljoen CA, Manning K, Baard J, Hahnle L, Ntsekhe M, Bauersachs J, Sliwa K. The prognostic significance of the 12-lead ECG in peripartum cardiomyopathy. Int J Cardiol 2018; 276:177-184. [PMID: 30497895 DOI: 10.1016/j.ijcard.2018.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 10/24/2018] [Accepted: 11/05/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is an important cause of pregnancy-associated heart failure, which appears in previously healthy women towards the end of pregnancy or within five months following delivery. Although the ECG is widely used in clinical practice, its prognostic value has not been established in PPCM. METHODS We analysed 12-lead ECGs of patients with PPCM, taken at index presentation and follow-up visits at 6 and 12 months. Poor outcome was determined by the composite endpoint of death, readmission, NYHA functional class III/IV or left ventricular ejection fraction (LVEF) of ≤35% at follow-up. RESULTS This cohort of 66 patients had a median age of 28.59 (IQR 25.43-32.19). The median LVEF at presentation (33%, IQR 25-40) improved significantly at follow-up (LVEF 49%, IQR 38-55, P < 0.001 at 6 months; 52% IQR 38-57, P = 0.001 at 12 months). Poor outcome occurred in 27.91% at 6 months and 41.18% at 1 year. Whereas sinus tachycardia at baseline was an independent predictor of poor outcome at 12 months (OR 6.56, 95% CI 1.17-20.41, P = 0.030), sinus arrhythmia was associated with event free survival (log rank P = 0.013). T wave inversion was associated with an LVEF ≤35% at presentation (P = 0.038), but did not predict poor outcome. A prolonged QTc interval at presentation (found in almost half of the cohort) was an independent predictor of poor outcome at 6 months (OR 6.34, 95% CI 1.06-37.80, P = 0.043). CONCLUSION(S) A prolonged QTc and sinus tachycardia at baseline were independent predictors of poor outcome in PPCM at 6 months and 1 year respectively.
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Affiliation(s)
- J Hoevelmann
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - C A Viljoen
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - K Manning
- University of Cape Town, Department of Medicine, Cape Town, South Africa
| | - J Baard
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa
| | - L Hahnle
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa; University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - M Ntsekhe
- University of Cape Town, Division of Cardiology, Cape Town, South Africa
| | - J Bauersachs
- Hannover Medical School, Department of Cardiology and Angiology, Hannover, Germany
| | - K Sliwa
- University of Cape Town, Hatter Institute for Cardiovascular Research in Africa, Cape Town, South Africa.
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