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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015
AFRICA
151
In this issue of the Journal, Seedat (page 193) asks why the
control of hypertension in sub-Saharan Africa is as bad as it
is. Citing the importance of the disease as a cause of death and
disability, he concludes that both the prevalence of hypertension
and the failure to control it properly is driven by the poverty
of the population of the region, the cost of pharmaceuticals,
and a lack of medical resources. He finishes with a rousing call,
echoing the late iconic President Mandela, to all of us to find
African solutions to African problems.
In an editorial comment, Campbell and Legoum (page 152)
re-iterate the size of the problem of hypertension in the region,
and remind us that this was not always the case. Mechanisms we
do not always fully understand, but which are almost certainly
driven by urbanisation and poverty, are probably driving the
epidemic. Furthermore, they point out that recognition and
acknowledgement of the size and importance of the problem
is an important first step to finding a resolution. Crucially,
they discuss that at recent meetings in Africa, local leaders and
champions have emerged who can spearhead an offensive on this
scourge. They also list a number of organisations committed to
the project. All involved in treatment and control of hypertension
in Africa need to read the contributions of Seedat and Campbell.
In one of those happy moments of editorial serendipity,
we are able to publish the literature review of Pinchevsky
and co-authors in this same issue (page 188). These authors
investigated the published results of the success of guideline-
directed control of a number of important risk factors (including
blood pressure) in patients with diabetes. Only 35.2% (range
7.4–66.3%) of patients achieved a target blood pressure of
130/80 mmHg (or less), and targets for glycaemic and lipid
control were not much better. It is interesting to note that
even in well-resourced countries, achievement of targets in this
vulnerable population were most unsatisfactory. Perhaps we need
to re-think traditional methods of management and reflect on
why we are so unsuccessful in our usual management strategies.
It may be time for the world to look more closely at a polypill or
alternative novel approach.
Permanent pacemaker implantation (PPMI) is a very effective
tool to treat bradyarrhythmias, particularly complete heart
block. The sad fact is that many patients who should receive
PPMI in many parts of Africa (and I assume other similarly
poorly resourced countries) do not receive the life-saving
benefit and dramatic symptomatic improvement that PPMI
offers. Pacemaker implantation is simple, at least for the basic
ventricular-paced, ventricular-inhibited (VVI) systems that most
patients with complete heart block require. The technique can be
learned in a few months, it requires basic surgical skills, which
most doctors possess, and access to fluoroscopy.
The challenge with pacemakers is the cost of the necessary
hardware. A pacemaker generator, in its most basic form, costs
US$2 500–3 000 and the leads cost US$800–1 000. The high cost
of pacemakers results in limited access for deserving patients
in under-resourced countries to these dramatic improvements
in both quality of life and life expectancy. As outlined by Jama
and colleagues (page 181), re-use of such devices is both feasible
and clinically safe, provided the necessary skills for re-testing
and sterilisation of the devices are available. Such programmes
have been available and in place in parts of Africa for years
but have not been subjected to the sort of post-implantation
examination performed by Jama and co-authors, and they are to
be congratulated for that.
I have purposefully not addressed implantable cardioverter
defibrillator (ICD) re-use, which they also discuss. I believe that
we in Africa need to be able to address the relatively simple issue
of pacing for complete heart block, ensure that it is relatively
easily available to all who need it, and work towards simple
pacemaker availability before worrying about more complex
devices, which while undoubtedly effective, offer marginal
benefit compared to the wonderful benefit of VVI pacing for
symptomatic complete heart block.
PJ Commerford
Editor in Chief
From the Editor’s Desk
Professor PJ Commerford