Heart Disease In sub-Saharan Africa Research Articles

Adapted echocardiography screening methods for prevention of rheumatic heart disease in Sub-Saharan Africa: a systematic review

Echocardiography is the current gold standard used in diagnosing rheumatic heart disease and its associated sequelae, but utilization is currently limited in resource-poor settings. Decentralized diagnostic methods in these areas are crucial to improving cardiac health outcomes. A systematic review was undertaken to evaluate the diagnostic performance of adapted echocardiography screening methods in countries of sub-Saharan Africa. A literature search was conducted via the PubMed, Embase, and African Healthline databases. Studies were included in the review if they assessed the diagnostic accuracy of an adapted screening method as compared to the reference standard of hospital-based echocardiogram by trained cardiologists. Diagnostic performances of handheld echocardiography and task-shifting to non-physician roles, were assessed. For HAND techniques, the pooled sensitivity, specificity and diagnostic odds ratio was 81.2%, 91.7%, and 48.01% respectively. Task-shifting and simplified protocol diagnostic performance was also analyzed; pooled sensitivity, specificity and diagnostic OR was 74.8%, 89.5%, and 25.37% respectively. This review demonstrates strong specificity with moderate sensitivity among both methods of adapted screening. HAND methods using the standard prescribed WHO protocol had stronger diagnostic performance overall. These studies present a first step towards validating current echocardiographic screening criteria using hand-held machines and establishing training of non-physicians to conduct screening in low-resource settings.

Treating Children With Advanced Rheumatic Heart Disease in Sub-Saharan Africa: The NGO EMERGENCY's Project at the Salam Centre for Cardiac Surgery in Sudan

Rheumatic heart disease is endemic in Sub-Saharan Africa and while efforts are under way to boost prophylaxis and early diagnosis, access to cardiac surgery is rarely affordable. In this article, we report on a humanitarian project by the NGO EMERGENCY, to build and run the Salam Centre for Cardiac Surgery in Sudan. This hospital is a center of excellence offering free-of-charge, high-quality treatment to patients needing open-heart surgery for advanced rheumatic and congenital heart disease. Since it opened in 2007, more than 8,000 patients have undergone surgery there; most of them Sudanese, but ~20% were admitted from other countries, an example of inter-African cooperation. The program is not limited to surgical procedures. It guarantees long-term follow-up and anticoagulant treatment, where necessary. By way of example, we report clinical features and outcome data for the pediatric cohort: 1,318 children under the age of 15, operated on for advanced rheumatic heart disease between 2007 and 2019. The overall 5-year survival rate was 85.0% (95% CI 82.7–87.3). The outcomes for patients with mitral valves repaired and with mitral valves replaced are not statistically different. Nevertheless, observing the trend of patients undergoing valve repair, a better outcome for this category might be assumed. RHD in children is an indicator of poor socio-economic conditions and an inadequate health system, which clearly will not be cured by cardiac surgery alone. Nevertheless, the results achieved by EMERGENCY, with the crucial involvement and participation of the Sudanese government over the years, show that building a hospital, introducing free cardiac surgery, and offering long-term post-operative care may help spread belief in positive change in the future.

Prevalence and Impact of Metabolic Syndrome on Short-Term Prognosis in Patients with Acute Coronary Syndrome: Prospective Cohort Study

PurposeDespite the increasing burden of metabolic syndrome (MS) and ischemic heart disease in sub-Saharan Africa, data on the prevalence of MS among patients with acute coronary syndrome (ACS) from the regions are limited. Hence, this study is aimed to evaluate the prevalence and impact of MS on 30-day all-cause mortality in patients hospitalized with ACS.Patients and MethodsWe prospectively assessed 176 ACS patients, who were admitted to two tertiary hospitals in Ethiopia. MS was diagnosed based on a harmonized definition of MS. In-hospital major adverse cardiovascular events (MACE) and 30-day mortality were recorded. Multivariable cox-regression was used to identify predictors of 30-day mortality.ResultsAmong 176 ACS patients enrolled, 62 (35.2%) had MS. Majority of the patients (62.5%) were male with the mean age of 56±11.9 years. ACS patients with MS were older, presented with atypical symptoms, and they had history of hypertension, diabetes, dyslipidemia and coronary artery disease compared to those without MS. MS was also significantly associated with in-hospital MACE (30.6% vs 17.5%; p= 0.046) and 30-day mortality [adjusted hazard ratio (AHR) = 3.25, 95% CI=1.72–6.15]. The other significant predictors of 30-day mortality were pre-hospital delay >12h (HR= 4.32, 95% CI=1.68–11.100), killip class ≥2 (HR=10.7, 95% CI= 2.54–44.95), and ejection fraction <40 (HR= 2.59 95% CI=1.39–4.84).ConclusionThe prevalence of MS among patients with ACS in Ethiopia is high. MS was significantly associated with high in-hospital MACE and it was an independent predictor of 30-day mortality. Initiating appropriate strategies on MS prevention and timely diagnosis of MS components could decrease the burden of ACS and improve patient’s outcome.

Exome Sequencing and Congenital Heart Disease in Sub-Saharan Africa.

Congenital heart disease (CHD) is the most common birth defect and affects roughly 1% of the global population. There have been many large CHD sequencing projects in developing countries but none in sub-Saharan Africa. In this exome sequencing study, we recruited families from Lagos, Nigeria, affected by structural heart disease. Ninety-eight participants with CHD and an average age of 3.6 years were recruited from Lagos, Nigeria. Exome sequencing was performed on probands and parents when available. For genes of high interest, we conducted functional studies in Drosophila using a cardiac-specific RNA interference-based gene silencing system. The 3 most common CHDs were tetralogy of Fallot (20%), isolated ventricular septal defect (14%), and transposition of the great arteries (8%). Ten percent of the cohort had pathogenic or likely pathogenic variants in genes known to cause CHD. In 64 complete trios, we found 34 de novo variants that were not present in the African population in the Genome Aggregation Database (v3). Nineteen loss of function variants were identified using the genome-wide distribution of selection effects for heterozygous protein-truncating variants (shet). Nine genes caused a significant mortality when silenced in the Drosophila heart, including 4 novel disease genes not previously associated with CHD (UBB, EIF4G3, SREBF1, and METTL23). This study identifies novel candidate genes and variants for CHD and facilitates comparisons with previous CHD sequencing studies in predominantly European cohorts. The study represents an important first step in genomic studies of CHD in understudied populations. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01952171.

Contemporary outcomes of aortic and mitral valve surgery for rheumatic heart disease in sub-Saharan Africa

ObjectivesRheumatic heart disease is endemic in sub-Saharan Africa. There is a paucity of data on the outcomes of valvular surgery for rheumatic heart disease in the developing world. The objective of this study was to evaluate the outcomes of aortic and mitral valve surgery for rheumatic heart disease in Ethiopia. MethodsBetween 2009 and 2017, 240 consecutive patients with rheumatic heart disease underwent aortic and/or mitral surgery at the Cardiac Center of Ethiopia in Addis Ababa. These surgeries were performed in the context of 22 international humanitarian missions. Median follow-up was 2.3 (interquartile range, 0.5-4.0) years and 96% complete. Outcomes were compared between patients who underwent mechanical valve implantation (n = 90, 38%), bioprosthetic valve implantation (n = 58, 24%), and valve repair (n = 92, 38%). ResultsMean age of patients was 19 ± 8 years, and 136 patients (57%) were female. Operative mortality occurred in 5 patients (2.1%) and was not significantly different between the groups. Eleven additional patients (5%) died at follow-up, and 55 patients (23%) had at least 1 major adverse valve-related event. Propensity score–adjusted Cox regression analysis demonstrated higher rates of death in the bioprosthetic group compared with the mechanical group (hazard ratio, 8.82; 95% confidence interval, 1.64-47.39; P = .011). Survival was not significantly different between the repair and mechanical groups (hazard ratio, 1.09; 95% confidence interval, 0.17-7.16; P = .93). Likewise, rates of major adverse valve-related event were higher in the bioprosthetic group compared with the mechanical group (hazard ratio, 2.71; 995% confidence interval, 1.13-6.49; P = .025), but not significantly different between the repair and mechanical groups (hazard ratio, 1.98; 95% confidence interval, 0.89-4.39; P = .092). ConclusionsLeft-sided valve surgery for rheumatic heart disease in sub-Saharan Africa is associated with acceptable perioperative outcomes, but a high incidence of major adverse valve-related event at follow-up. The use of bioprosthetic valves is associated with poor outcomes in this patient population.

Contemporary Outcomes of Aortic and Mitral Valve Surgery for Rheumatic Heart Disease in Sub-Saharan Africa

Contemporary Outcomes of Aortic and Mitral Valve Surgery for Rheumatic Heart Disease in Sub-Saharan Africa

Barriers and challenges for primary and secondary prevention of heart disease in sub-Saharan Africa

The diverse people of sub-Saharan Africa face a number of paradoxical challenges arising from economic development and urbanisation, including an increasing prevalence of noncommunicable forms of heart disease. Prevention programmes designed not only to detect those with established and often disabling forms of heart disease, but prevent disease progression and a premature death, are an obvious priority in this setting. This review article reflects on the barriers and challenges to effective primary and secondary prevention of heart disease in sub-Saharan Africa by (a) examining what residual issues challenge effective prevention in high-income countries? (b) what are the key ingredients to an integrated programme of primary and secondary prevention across the lifespan (from the population to individual)? and (c) considering the first two points, what are the barriers and challenges in sub-Saharan Africa to implementing cost-effective primary and secondary prevention using a systematic approach to “who, what and how”?

Children’s heart disease in sub-Saharan Africa: Challenging the burden of disease

Children with heart disease in Africa have little or no access to treatment of any kind, and cardiac surgical services are virtually absent outside a handful of centres in a few of the wealthier nations. There is little reliable data concerning the prevalence of congenital or acquired heart disease in African children, but there is sufficient information to indicate that the burden of cardiac disease is vast. This major non-communicable disease is largely hidden, overshadowed by the incidence of communicable diseases. There is as yet little evidence of the hoped-for epidemiological transition toward non-communicable diseases amongst children in Africa. The burden of congenital heart disease is only part of the problem, with rheumatic heart disease (RHD) remaining the commonest cardiac problem, related to poor socioeconomic conditions. RHD is the most preventable form of cardiac disease, yet there is little preventive work being done. The many obstacles to developing paediatric cardiac care are discussed, and some possible ways forward are proposed.

Interventions addressing risk factors of ischaemic heart disease in sub-Saharan Africa: a systematic review

BackgroundIschaemic heart disease (IHD) is currently ranked eighth among the leading causes of deaths in sub-Saharan Africa (sSA). Yet, effective population-wide preventive measures targeting risks in the region are still...

Coronary heart disease in sub-Saharan Africa: still rare, misdiagnosed or underdiagnosed?

Coronary heart disease (CHD) is the leading cause of death in developed countries, but it has generally been considered to be rare in sub-Saharan Africa (SSA). SSA is undergoing rapid epidemiological transition with an increasing prevalence of major cardiovascular risk factors and consequential cardiovascular diseases such as stroke. However, CHD including myocardial infarction has generally been considered to be rare despite this deterioration in the risk factors profile. There is an urgent need to raise awareness about CHD both in the general population and healthcare professionals while making available simple, inexpensive screening and diagnostic tools in sub-Saharan African countries.

Cardiovascular risk factors in sub-Saharan Africa: a review

Ischemic heart disease is increasing dramatically in the Sub-Saharan Africa (SSA), despite an increasing prevalence of risk factors, and some characteristics of the African people that make the African population subject to the effects of major cardiovascular risk factors. The pace and direction of economic development, rates of urbanization, the changes in life expectancy, associated with different pathophysiological factors are causing an increased rate of atherosclerotic disease in these countries. The prevalence of ischemic heart disease in SSA has shown a significant rise in the next two following decades due to the rising prevalence of risk factors, especially hypertension, diabetes, overweight and obesity, physical inactivity, tobacco use and the dyslipidemia, mainly due to an increase in urbanization. Moreover, thanks to new knowledge, it has been pointed out the difference of individual risk factors in the African population and other populations due to genetic differences. It is estimated that age-standardized approach for ischemic heart disease mortality rates will rise by 27% in African men and 25% in women by 2015 and by 70 and 74%, respectively by 2030. More research is needed in Africa to provide evidence for cardiovascular prevention and treatment to mitigate the oncoming epidemic. Health interventions are needed for preventing or reducing the morbidity/ mortality and should be addressed to both children and adults, including score of the risk stratification modified, starting early and aggressive therapy, if necessary.

Strategies for prevention and control of rheumatic fever and rheumatic heart disease in Sub-Saharan Africa: a preliminary cost-effectiveness analysis

Strategies for prevention and control of rheumatic fever and rheumatic heart disease in Sub-Saharan Africa: a preliminary cost-effectiveness analysis

Partnership for sustainability in cardiac surgery to address critical rheumatic heart disease in sub-Saharan Africa: the experience from Rwanda.

Rheumatic heart disease (RHD) in the developing world results in critical disability among children, adolescents, and young adults-marginalizing a key population at its peak age of productivity. Few regions in sub-Saharan Africa have independently created an effective strategy to detect and treat streptococcal infection and mitigate its progression to RHD. We describe a unique collaboration, where the Rwanda Ministry of Health, the Rwanda Heart Foundation, and an expatriate humanitarian cardiac surgery program have together leveraged an innovative partnership as a means to expand Rwanda's current capacity to address screening and primary prevention, as well as provide life-saving cardiac surgery for patients with critical RHD. Interviews with key personnel and review of administrative records were conducted to obtain qualitative and quantitative data on the recruitment of clinical personnel, procurement of equipment, and program finances. The number of surgical cases completed and the resultant clinical outcomes are reviewed. From 2008 to 2013, six annual visits were completed. A total of 128 prosthetic valves have been implanted in 86 complex patients in New York Heart Association (NYHA) class III or IV heart failure, with excellent clinical outcomes (5 % 30-day mortality). Postoperative complications included a cerebrovascular accident (n = 1) and hemorrhage, requiring reoperation (n = 2). All procedures were performed with participation of local personnel. This strategy provides a reliable and consistent model of sophisticated specialty care delivery; inclusive of patient-centered cardiac surgery, mentorship, didactics, skill transfer, and investment in a sustainable cardiac program to address critical RHD in sub-Saharan Africa.

Epidemiology of ischaemic heart disease in sub-Saharan Africa.

The epidemiology of ischaemic heart disease (IHD) in sub-Saharan Africa (SSA) remains largely enigmatic. Major obstacles to our understanding of the condition include lack of reliable health statistics, particularly cause-specific mortality data, inadequate diagnostic capabilities, shortage of physicians and cardiologists, and misguided opinions. This review of the epidemiology of ischaemic heart disease in sub-Saharan Africa involved a systematic bibliographic MEDLINE search of published data on IHD in SSA over the past century. Search words included epidemiology, ischaemic (coronary) heart disease, myocardial infarction, cardiovascular risk factors and sub-Saharan Africa. Selected data are presented on the prevalence of cardiovascular risk factors and mortality from ischaemic heart disease from different countries representing the main regions of the continent. Although IHD in SSA remains relatively uncommon, its prevalence is predicted to rise in the next two decades due to the rising prevalence of risk factors, especially hypertension, diabetes, overweight and obesity, physical inactivity, increased tobacco use and dyslipidaemia. It is estimated that age-standardised mortality rates for IHD will rise by 27% in African men and 25% in women by 2015, and by 70 and 74%, respectively by 2030. Ischaemic heart disease remains relatively uncommon in SSA, despite an increasing prevalence of risk factors, but its incidence is rising. The pace and direction of economic development, rates of urbanisation, and changes in life expectancy resulting from the impact of pre-transitional diseases and violence will be major determinants of the IHD epidemic in SSA. The best window of opportunity for prevention of the emerging epidemic of ischaemic heart disease in sub-Saharan Africa is now.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Pregnancy in women with heart disease in sub-Saharan Africa

Although previous studies showed that pregnancy with heart disease is associated with significant complications, few focused on patients with valvular heart disease in sub-Saharan Africa. We report maternal and foetal outcomes in 50 pregnant women with heart disease admitted to the Department of Cardiology of the University of Dakar, during an 8-year period. Rheumatic heart disease was observed in 46 women, seven of whom had previously been operated on. Among the remaining 39, 32 had mitral stenosis (isolated or associated with other valvular lesions). At admission, 36 women presented with pulmonary oedema, two with pulmonary embolism and 18 with arrhythmia. There were 17 maternal deaths (34%). Maternal death was associated with: mitral stenosis (P=0.03); severe tricuspid regurgitation (P=0.001); New York Heart Association functional class III or IV (P=0.001); symptoms of heart failure (P<0.001). A favourable maternal outcome was associated with: prior cardiac events (P<0.001); prior surgical valve replacement (P=0.03); cardiac prosthetic valve (P=0.03). There were 30 live births, six foetal deaths and five therapeutic abortions; nine women were lost to follow-up. Delivery was vaginal in 19 out of 30 cases and by caesarean section in 11 cases. Median gestational age at delivery was 28weeks (range, 8-38weeks). Five births occurred preterm. There were four stillbirths (neonatal mortality, 7.6%). Heart disease severely impacts maternal and foetal outcome in our study. Pregnant women who underwent appropriate valve replacement before pregnancy had a better prognosis.

Pregnancy-related cardiac complications: A consequence of the burden of rheumatic heart disease in sub-Saharan Africa

Pregnancy-related cardiac complications: A consequence of the burden of rheumatic heart disease in sub-Saharan Africa

Strategies for heart disease in sub-Saharan Africa

The commonest forms of heart disease in sub-Saharan Africa are chronic rheumatic heart disease, dilated cardiomyopathy, pulmonary heart disease, infectious forms of heart disease including chronic, constrictive and infective endocarditis,...