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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 3, May/June 2020
AFRICA
113
Cardiovascular care in sub-Saharan Africa during the
COVID-19 crisis: lessons from the global experience
Kishal Lukhna, Blanche Cupido, Jens Hitzeroth, Ashley Chin, Mpiko Ntsekhe
‘by 3 methods we may learn wisdom: first by reflection, which is
noblest; second is by imitation, which is easiest; and the third is by
experience, which is the most bitter
Confucius
Sub-Saharan Africa (SSA) stands on the verge of an
unprecedented challenge to its healthcare infrastructure and
systems due to a novel infectious disease that has overwhelmed
the greatest of healthcare services worldwide. Coronavirus
disease 2019 (COVID-19), the clinical disease caused by SARS-
CoV-2, was classified by the World Health Organisation (WHO)
as an international public health emergency in late January and
has increased exponentially to pandemic proportions since then.
1
There are currently over four million confirmed cases and 302
059 deaths documented worldwide.
2
South Africa has become the
epicentre of COVID-19 infections in Africa, with approximately
13 524 cases and 247 deaths at the time of writing.
2
COVID-19 is a viral syndrome with a predilection for the
upper respiratory tract and lungs, which can cause severe
dysfunction of multiple organs, including the cardiovascular
system.
3,4
Analysis of the large number of COVID-19-related
fatalities in New York, China and Italy suggests that male
patients with advanced age, hypertension, diabetes, obesity and
established cardiovascular disease are at highest risk of mortality
from COVID-19.
5-9
New and decompensated heart failure,
myocarditis, cardiac arrhythmias, pericarditis with or without
tamponade, acute pulmonary embolus and acute myocardial
infarction (MI) have all been described as the initial presenting
manifestation of COVID-19 and as complications in those with
established disease.
10,11
Complicating the picture is the fact that
biomarkers of cardiac injury and haemodynamic strain are
elevated in up to 30% of patients, even where there is no overt
evidence of cardiac involvement.
12
Despite much goodwill and great effort, factors such as
overcrowding and limited testing capacity have meant that the
continent’s goal of prevention, control and containment of the
virus has had variable and limited success across countries. As we
brace ourselves for the impending COVID-19 medical onslaught,
we set out to explore the published experience from geographies
that have seen the worst of the pandemic and highlight a few
important lessons shared in those reports with relevance for
cardiovascular disease clinicians in Africa.
Lesson 1: ‘Don’t wait for the rain to prepare
the umbrella’
Malaysian proverb
The preparation and re-organisation of healthcare services to
deal adequately and appropriately with the burden of both
non-COVID-19 and COVID-19 patients with cardiovascular
disease should be prioritised. This will be even more important
here in SSA where our healthcare systems are already strained
with the current COVID-19-free burden of non-communicable
and communicable diseases.
Given the vast diversity and heterogeneity of health
infrastructure, resources and disease burden, no single effective
plan can be recommended or applied throughout Africa.
However, there is little doubt that those countries in Europe, Asia
and North America that were best prepared fared much better
than those who ignored the writing on the wall, confirming that
failure to prepare is almost certainly preparation for failure.
Lesson 2: ‘If you hear hooves think horses not
zebras’
The vast majority of patients presenting with symptoms and
signs of acute cardiac disease will indeed have acute cardiac
disease and should be treated as such.
Although the finding that the prevalence of hypertension,
diabetes, obesity and cardiovascular disease among those
presenting with symptomatic COVID-19 is high, this does
not mean that the corollary is also true (that among those
presenting with cardiovascular syndromes, COVID-19 is high).
In fact, the opposite is true: (1) the vast majority of patients
presenting with acute cardiac disorders as their primary
presentation will be COVID-19 free, and; (2) the vast majority
of patients with COVID-19 do not have cardiovascular
complications.
3
This is important because the temptation to delay the
diagnostic work-up and treatment of acute cardiac syndromes
until patients have been tested and the disease has been excluded
has major consequences and should be avoided. The outcomes
of most acute cardiac disorders such as acute MI are time-
sensitive and time-dependent. So if you need to test patients for
COVID-19, do so, but don’t ignore the obvious in front of you.
The Cardiac Clinic, Groote Schuur Hospital and University
of Cape Town, South Africa
Kishal Lukhna, MB ChB, MMed, FCP (SA)
Blanche Cupido, MB ChB, FCP (SA), MPhil (UCT), Cert Cardio (SA)
Jens Hitzeroth, MB ChB, FCP (SA), Cert Cardio (SA)
Ashley Chin, MB ChB, MPhil
The Cardiac Clinic, Groote Schuur Hospital and University
of Cape Town, South Africa
Mpiko Ntsekhe, MD, PhD, FACC,
mpiko.ntsekhe@uct.ac.zaEditorial