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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 5, September/October 2014
210
AFRICA
Efforts to overcome these hurdles have resulted in two types
of humanitarian projects: the creation of well-equipped, on-site
healthcare structures, and the transfer of patients, mainly
children, with complex diseases to receive highly specialised
care abroad. Our programme was based on providing surgery in
European centres. However, prospective studies with long-term
follow up to clearly define whether these strategies are effective
in reducing infant and young adult mortality in the sub-Saharan
socio-economic background are warranted.
Strengths and limitations
The study was conducted by skilled cardiologists who are
experienced in the assessment of valvular heart disease, in
collaboration with local medical staff who were previously
involved in other studies on the causes of HF in Uganda.
3,12
The
diagnosis was therefore robust. The prospective nature of the
study has enabled us to form a cohort of patients with structural
heart disease and to organise follow up. We provide here original
and scarce data on the selection and outcomes of heart surgery
candidates in a poorly resourced country.
Our results appear to be in agreement with previous data
from other sub-Saharan hospital-based registries, with the
exception of tuberculosis and HIV-related heart disorders. Our
study was based on a prospectively collected patient cohort
from a tertiary teaching hospital, which does not allow us to
draw conclusions on the prevalence of HF and its associated
echocardiographic patterns in the general population. IHD
diagnosis was only presumptive because at the time of the study
coronary angiography was not available in Uganda.
Finally, the sample size was relatively modest due to the
limited time period of the NGO missions and we acknowledge
high rates of loss to follow up. Also, we decided not to analyse
outcomes according to treatment in RHD and CHD patients,
due to methodological constraints (high rate of lost to follow
up in a country with no nationwide mortality register, survivor
treatment selection bias). Although descriptive, our study
complies with the STROBE guidelines.
30
We attempted to contact
every patient, however, remoteness, frequent changes of mobile
phones, and cultural boundaries may explain the difficulties in
contacting all patients or their next of kin.
Conclusions
Rheumatic heart disease prevails as the leading cause of heart
failure in urban Uganda, and CHD represents an increasing
challenge for African practitioners, whereas hypertensive and
ischaemic heart disease emerge among elderly adults. Only a
minority of young surgical candidates with RHD and CHD have
access to treatment. Mortality rate remains high. Cost-effective
preventive strategies for RHD and hypertension, rational referral
services for early diagnosis, and north–south transfer of skills may
lessen the growing burden of cardiovascular diseases in Africa.
We thank Dr Martin Nsubuga, medical superintendent of the St Raphael of
St Francis Nsambya Hospital, and Drs Renato Corrado, Elena Balducci and
Federico Chiodi Daelli who conduct AISPO activities at the San Raffaele
Scientific Institute in Italy. We are grateful to the staff of the Emergency
Salam Centre for Cardiac Surgery in Khartoum, Sudan for interventions.
The Ministry of Foreign Affairs, Italy (MAE) in the context of the
MAE–Italian co-operation project supported this study (AID 8572/AISPO/
UGANDA), aimed at the functional expansion of St Francis, Nsambya
Hospital, archdiocese of Kampala. The funding sources had no involvement
in the study design, data collection, analysis, interpretation, report writing or
publication. The authors had full access to all data and accept full responsibil-
ity for the content of this report.
References
1.
Celermajer DS, Chow CK, Marijon E,
et al.
Cardiovascular disease in
the developing world: prevalences, patterns, and the potential of early
disease detection.
J Am Coll Cardiol
2012;
60
: 1207–1216.
2.
Sliwa K, Wilkinson D, Hansen C,
et al
. Spectrum of heart disease and
risk factors in a black urban population in South Africa (the Heart of
Soweto Study): a cohort study.
Lancet
2008;
371
: 915–922.
3.
D’Arbela PG, Kanyerezi RB, Tulloch JA. A study of heart disease in
the Mulago hospital, Kampala, Uganda.
Trans R Soc Trop Med Hyg
1966;
60
: 782–790.
4.
Amoah AG, Kallen C. Aetiology of heart failure as seen from a
National Cardiac Referral Centre in Africa.
Cardiology
2000;
93
: 11–18.
5.
Stewart S, Wilkinson D, Hansen C,
et al
. Predominance of heart failure
in the Heart of Soweto Study cohort: emerging challenges for urban
African communities.
Circulation
2008;
118
: 2360–2367.
6.
Mayosi BM. Contemporary trends in the epidemiology and manage-
ment of cardiomyopathy and pericarditis in sub-Saharan Africa.
Heart
2007;
93
: 1176–1183.
7.
Damasceno A, Mayosi BM, Sani M,
et al
. The causes, treatment, and
outcome of acute heart failure in 1006 Africans from 9 countries: results
of the sub-Saharan Africa survey of heart failure.
Arch Intern Med
2012;
3
: 1–9.
8.
Mocumbi AO, Sliwa K. Women’s cardiovascular health in Africa.
Heart
2012;
98
: 450–455.
9.
Zühlke L, Mirabel M, Marijon E. Congenital heart disease and rheu-
matic heart disease in Africa: recent advances and current priorities.
Heart
2013;
99
: 1554–1561.
10. Beaton A, Okello E, Lwabi P,
et al
. Echocardiography screening for
rheumatic heart disease in ugandan schoolchildren.
Circulation
2012;
125
: 3127–3132.
11. Tibazarwa K, Ntyintyane L, Sliwa K,
et al
. A time bomb of cardio-
vascular risk factors in South Africa: results from the Heart of Soweto
Study ‘Heart Awareness Days’.
Int J Cardiol
2009;
132
: 233–239.
12. Freers J, Mayanja-Kizza H, Ziegler JL,
et al.
Echocardiographic diagno-
sis of heart disease in Uganda.
Trop Doct
1996;
26
: 125–128.
13. McMurray JJ, Adamopoulos S, Anker SD,
et al
. ESC Guidelines for
the diagnosis and treatment of acute and chronic heart failure 2012:
The Task Force for the Diagnosis and Treatment of Acute and Chronic
Heart Failure 2012 of the European Society of Cardiology. Developed
in collaboration with the Heart Failure Association (HFA) of the ESC.
Eur Heart J
2012;
33
: 1787–1847
14. Bonow RO, Carabello BA, Chatterjee K,
et al
. 2008 focused update
incorporated into the ACC/AHA 2006 guidelines for the management
of patients with valvular heart disease: a report of the American College
of Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing committee to revise the 1998 guidelines for the
management of patients with valvular heart disease). Endorsed by the
Society of Cardiovascular Anesthesiologists, Society for Cardiovascular
Angiography and Interventions, and Society of Thoracic Surgeons.
J
Am Coll Cardiol
2008;
52
: e1–142.
15. Tantchou Tchoumi JC, Ambassa JC, Kingue S,
et al
. Occurrence,