Cardiovascular Journal of Africa: Vol 25 No 5 (September/October 2014)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 5, September/October 2014 AFRICA 209
disease in sub-Saharan Africa, as robust echo-based data are
limited,5,15-17 and surgical outcomes seldom depicted.
Regarding the aetiology of HF, our findings are consistent
with those of other sub-Saharan countries, as illustrated in Table
3.4,5,7,15-17 In Uganda, RHD remains the leading cause of HF
in young adults and the second cause in children. As in other
series, we found that RHD affected mostly young women in the
third decade of life, and that mitral regurgitation was the most
common presentation.18 Diagnosis was often made when left
ventricular function was already impaired, requiring intervention.
Our study underscores the need for preventive strategies
in order to lessen the burden of RHD in Africa. RHD is a
preventable disease provided patients receive penicillin for Group
A streptococcal pharyngitis (primary prevention) or after a
first attack of acute rheumatic fever (secondary prevention).
Notwithstanding, RHD remains a major burden in low-income
countries, affecting 15 million people and leading to at least 200
000 deaths per annum worldwide.19,20
Diagnosis is often made when costly interventions are
required, leaving most sub-Saharan African patients to the
natural course of the disease. Comprehensive programmes
focusing on secondary prophylaxis are cost-efficient and could
avoid progression to irreversible valve damage. Our study
advocates launching preventive strategies in Uganda. The role
of echocardiography-based screening in endemic areas is still a
matter of controversy.21-24
In our study, CHD was the main cause of HF among children
and accounted for up to 9% of HF among adults, suggesting
the need for diagnostic expertise in echocardiography and for
cardiac surgery facilities.9 While in developed countries prenatal
diagnosis is currently used to detect CHD, access to diagnosis and
treatment are limited in low-income countries.25 Furthermore,
simple CHD may be cured by timely surgical or percutaneous
treatment, whereas a delayed diagnosis increases morbidity and
mortality rates. Efforts should focus on early detection of CHD
and on building a referral system for diagnosis, management and
follow up of patients in a resource-deprived setting.25
In contrast with previous reports, 3,26 endomyocardial fibrosis
in the urban area of Kampala no longer seems to be the
main cause of HF. That could be ascribed to improved socio-
economic conditions. It must be stressed that the nationwide
prevalence of the disease could be higher, as suggested by an
echocardiography-based screening study performed in rural
Mozambique.27 Urban Uganda seems to follow the trend of the
epidemiological transition witnessed in many African countries,
with the emergence of hypertensive cardiomyopathy and IHD as
major causes of HF in adults.4,7,16
The progression to hypertensive cardiomyopathy could be
halted through early diagnosis and appropriate treatment,
including the reduction of salt intake. Raising awareness among
the general population and health workers should therefore
become a priority in African countries,28 and could be achieved
by training primary healthcare practitioners to use simple
algorithms to score cardiovascular risk and initiate treatment
when needed.
We found that right ventricular failure due to PH was
relatively common in adults, in agreement with the results from
other African studies.4,5,7,16-18 Unlike a recent multinational survey
including nine countries, we did not diagnose patients with post-
tuberculosis or HIV-related cardiomyopathy, and we found only
one case of post-partum cardiomyopathy.7 We encountered no
cases of cor pulmonale due to post-tuberculosis lung damage,
tuberculosis-related pericarditis or HIV-related cardiomyopathy
in spite of HIV being endemic in Uganda
en/dataanalysis/knowyourepidemic/epidemiologicalfactsheets/).
Although the epidemiology of cardiovascular diseases is
usually treated in African countries as a whole,8 differences in
climate, diet and income may explain apparent discrepancies
between regions. The fact that our study was conducted in an
urban area may also account for these conflicting results.
As outlined by our series in which only 36% of surgical
candidates had access to treatment and 18% died on the
waiting list, there is an urgent need for comprehensive service
frameworks to improve level of care, and services by NGOs
are insufficient to treat all patients in need of treatment. With
the exception of South Africa, access to cardiac expertise and
heart surgery remains extremely limited in most sub-Saharan
countries.9 The absence of trained physicians is a barrier to
tackling the burden of cardiovascular disease, a growing public
health issue in Africa.29
Table 3. Echo-based diagnosis of heart failure in sub-Saharan Africa.
Uganda Nigeria16 South Africa5 Ghana4 Malawi17* Cameroon15 THESUS-HF7§
Inclusion period 2009–2013 2002–2006 2006 1992–1995 2001–2005 2002–2008 2007–2010
Settings Kampala Abuja Soweto Accra Mzuzu Kumbo 9 nations
Total sample size 272 – 1960 8121
Population with CVD 190 – 3908*
Sample size with HF 140 340 844 (de novo) 572 – 462 1006
Age 40 (14–66) 51 ± 15 55 ± 16 42 ± 1 40 ± 32 43 ± 18 52 ± 18
Females,n (%) 59 49 57 45 59 43 51
Causes of HF
First aetiology RHD HCMP HCMP HCMP RHD RHD HCMP
Second aetiology CHD DCMP DCMP RHD HCMP DCMP DCMP
Third aetiology HCMP RHD Right HF DCMP DCMP HCMP RHD
CVD = cardiovascular disease, HF = heart failure, RHD = rheumatic heart disease, HCMP = hypertensive cardiomyopathy, DCMP = dilated
cardiomyopathy.
*Data from these studies are presented as mean ± SD or median (IQR) as available. In the study by EZ Soliman, the registry did not specifically
address the causes of HF, but the main causes of cardiovascular disease.
§THESUS-HF = THE SUb-Saharan Africa survey of Heart Failure was a prospective survey of patients with acute HF admitted to 12 university
hospitals in nine sub-Saharan countries: South Africa, Mozambique, Uganda (n = 154), Kenya, Ethiopia, Sudan, Senegal, Nigeria and Cameroon.