50 / 88
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 4, July/August 2017
252
AFRICA
sub-continent are designed to treat mostly acute communicable
diseases, while neglecting the treatment and prevention of
non-communicable diseases, especially CVD.
6
This is partially due
to lack of resources, as the healthcare system in this part of the
world is often challenged by lack of sufficient resources and up-to-
date practical information for healthcare providers.
7-9
Another major challenge to treating and controlling CVD
is the large rural population, as there are few providers to serve
that population, and distances to the facilities are large, thereby
increasing transportation costs.
10
This is of great concern since
the majority of the populace in sub-Saharan Africa resides in
rural settings.
Therefore, for there to be any meaningful effect in the
treatment and control of diabetes and CVD in sub-Saharan
Africa, healthcare must be brought closer to the people. The best
way to achieve this is to employ a primary care approach, which
should not only be involved in prevention and control but also
in treatment of patients. For this type of approach to succeed in
sub-Saharan Africa where there is a dearth of physicians, it has
to be built around a non-physician workforce, including nurses,
community health workers and other allied health professionals
in the primary care setting.
11
In the next section of this review we will discuss the role of
the non-physician workforce in this primary care approach.
We will also address how the primary care setting can be used
to recognise common cardiac problems, such as chest pain,
breathlessness on exertion, oedema, palpitations and syncope.
The importance of a thorough physical examination as well as
relatively simple non-invasive investigations, such as a blood
sugar test with a glucometer will be discussed. Furthermore,
we will highlight how basic approaches to cardiovascular risk
assessment, as developed by the WHO, health professional
societies and other expert bodies can be used in the primary care
setting. A section of the review will also tackle the important
issue of age-appropriate screening for major risk factors, such as
hypertension, diabetes mellitus and dyslipidaemia, and address
the issue of speciality care referral and long-term primary care
management of patients with established CVD and diabetes,
using the Seychelles success story.
Non-physician workforce in primary care
management of CVD
Non-physician health workers can be trained in the simple skills
of taking a detailed history from patients and good physical
examination with the aid of WHO pocket guidelines for the
assessment and management of cardiovascular risk.
11
They
should be trained on how to use the WHO pocket guide to
recognise people with risk factors who have not yet developed
clinically manifest cerebrovascular disease. The effectiveness of
this type of model has been demonstrated in Rwanda, where
non-communicable disease clinics are run at district level, with
such clinics staffed by two or three nurses who see 10 to 20
patients each day.
12
For effective utilisation of non-physician healthcare workers,
they should be trained in the accurate use of basic instruments
such as stethoscopes, blood pressure devices, measuring tapes
and weighing scales. They should also be able to carry out basic
non-invasive investigations such as testing for glucose using
a glucometer, testing for albumin in urine using albustix, and
blood cholesterol testing using strips. In Rwanda and some other
sub-Saharan African countries,
12
such training is provided at
the district level where district hospital leaders, working closely
with the staff of healthcare centres, provide in-service training,
clinical mentorship and evaluation. Nurses are also trained at
district clinics through daily direct patient management while
working with physicians.
Another model adopted in this training, which has also
been used in Rwanda, involves the use of programme leaders
in non-communicable diseases (NCDs), neuropsychiatry and
infectious diseases (HIV and TB), who form a chronic care team
that trains and mentors a group of healthcare centre clinicians
in the basic management of non-infectious diseases.
12
The
main advantage of the use of the programme leader approach
is cost effectiveness. In settings such as Rwanda, where there
has been success in these training models, training has been
formalised into a three-month curriculum in advanced chronic
disease management. The effectiveness of such training has
been demonstrated in Rwanda where nurses have been trained at
the community and district level, not only in basic clinical and
laboratory skills, but also in echocardiography for the evaluation
of heart failure patients.
12
The non-physician healthcare worker should also be trained
in how to initiate medications such as thiazide diuretics, beta-
blockers, angiotensin converting enzymes inhibitors, calcium
channel blockers, aspirin, metformin, statins and insulin. For
example, in a model in Rwanda, heart failure treatment initially
takes place in district level NCD clinics with non-physicians
using algorithms to make the diagnosis and initiate treatments
such as frusemide, spironolactone and angiotensin converting
enzyme inhibitors.
13
However, in the use of these medications,
the place of regular supervision by a trained physician cannot be
over-emphasised. For example, in non-physician-based care of
heart failure patients in Rwanda, the role of the cardiologist is
restricted to supervision and mentoring of district level clinicians,
and evaluation of patients who are potential surgery candidates.
14
Non-physician clinicians should also be trained to identify
serious clinical features in a patient, such as pedal oedema, severe
chest pain, and breathlessness on mild exertion and at rest, which
are pointers to patients needing referral to secondary and tertiary
centres. For example, they should be taught to refer if there are
clinical features suggestive of the following: acute cardiovascular
events such as heart attack, angina, heart failure, arrhythmias,
stroke and transient ischaemic attack, secondary or malignant
hypertension, newly diagnosed or uncontrolled diabetes mellitus,
and established CVD such as stroke and heart failure.
The non-physician can play a large role in the prevention
of CVD and diabetes by using the WHO/ISH risk-prediction
charts.
11
These charts are designed for 14 WHO epidemiological
sub-regions and indicate 10-year risk of fatal or non-fatal major
cardiovascular events, such as stroke and myocardial infarction,
according to age, gender, blood pressure, smoking status, total
blood cholesterol level and presence or absence of diabetes
mellitus. There are two sets of charts: one set of 14 charts can
be used in settings where cholesterol can be measured, while the
second set of 14 is for settings where blood cholesterol cannot
be measured. Each chart can be used only in countries in the
specific WHO epidemiological sub-region.
Before the non-physician health worker applies the WHO risk-
stratification chart, he/she must select the appropriate chart for