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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 3, May/June 2016
AFRICA
127
From the Editor’s Desk
This issue carries several important messages for those interested
in cardiovascular heath in Africa. In the landmark Addis Ababa
communiqué, Watkins and colleagues (page 184) describe seven
essential actions aimed at eliminating rheumatic heart disease
(RHD) in Africa. The distinguished group of authors are widely
representative of Africans knowledgeable and active in both
research and clinical service in this field and they are supported
by international experts. Most importantly, this third All-Africa
Workshop on Acute Rheumatic Fever and Rheumatic Heart
Disease was hosted by the social cluster of the African Union
Commission, and the communiqué has since been endorsed
by African Union heads of state. Therefore the political will
and support so necessary for successful implementation seems
to be available and will be essential in the years ahead. The
communiqué identifies that one of the barriers to eradicating
RHD in Africa is that there are few centres capable of providing
cardiac surgery, and action five aims to ‘Establish centres of
excellence for cardiac surgery, which will sustainably deliver
state-of-the-art surgical care, train the next generation of
African cardiac practitioners, and conduct research on endemic
cardiovascular diseases, including RHD’.
Against the background of that statement it is disturbing to
read the position paper of the South African Heart Association
by Sliwa and colleagues (page 188) on training in cardiology
and cardiothoracic surgery in South Africa. The authors, all
experienced in their fields of expertise and many are responsible
for providing training in these fields, document the lack of
training opportunities, the lack of adequate facilities and the
failure of the state to expand and enlarge facilities so as to keep
up with the population expansion. For the majority of South
Africans who lack medical insurance or the funds to access
private healthcare and who have heart disease, the situation
has worsened over the last decade, with longer waiting lists for
cardiac surgery at some tertiary centres than were seen previously,
and a lack of simple monitoring tools such as echocardiography
at many secondary level facilities. As the authors point out,
clinicians have limited powers to alter the situation, and urgent
action at government level is needed.
So we have the paradoxical situation where we publish
two conflicting statements on the state of cardiovascular care
in Africa. One is an encouraging, visionary message that the
need for improved facilities for such care is recognised by both
healthcare professionals and politicians, the other sketches
the existing situation in South Africa where there has been no
progression and in fact retrogression in provision of such care
for the majority of the population. Which of the two scenarios
play out in the future will depend on the continued involvement
of the cardiovascular healthcare community and its active and
successful interaction with politicians and governments.
An interesting review of research output in sub-Saharan
Africa (SSA) and international collaboration in that research is
provided by Ettarh (page 194). This study provides a picture over
10 years of the volume and scientific impact of international
collaboration in cardiovascular research in SSA. This may be
the first study of its kind and encouragingly demonstrates that
research output is increasing and collaboration appears to be
improving. Unfortunately, the extent of collaboration within
SSA is very limited compared to the level of collaboration with
other non-SSA countries. This pattern has been observed with
data for all of the scientific output of the region. The potential
benefits of increased collaboration in the region are described
and should be an encouragement to junior researchers to widen
collaboration in SSA.
Research into ethnic differences in risk factors for cardiac
and other non-communicable diseases may provide insight
into possible strategies to stem the predicted increase in these
diseases in Africa. Keswell and co-authors (page 177) examined
associations between body fat distribution, insulin resistance and
dyslipidaemia in black and white South African women. The
novel finding of this study was that central and peripheral fat
depositions were independently associated with insulin resistance
in both black and white women, and with triglyceride levels in
the black women. By contrast, fasting glucose concentrations
were associated with centralisation of body fat in black, but
not white women, whereas total cholesterol and low-density
lipoprotein cholesterol concentrations were associated with
centralisation of body fat in white, but not black women.
Hypertrophic cardiomyopathy (HCM) was historically
thought to be rare among Africans but as Ntusi and colleagues
point out (page 152), recent echocardiographic studies from the
continent have dispelled that myth. They examined a consecutive
series of patients with HCM (30.2% black African), prospectively
enrolled from a tertiary referral centre and characterised them
clinically, echocardiographically and genetically. They found
HCM to occur more in men, and with a younger age of onset.
Major symptoms and complications were similar to those
reported in North American, Middle Eastern and Asian studies.
Known and novel disease-causing mutations were identified in
the
MYH7
and
MYBPC3
genes, with a lower yield of mutation
screening of about 30%, compared to the expected 40 to 70%
found elsewhere. The mortality rate in this contemporary African
HCM series was, however, higher than reported elsewhere,
although comparable to age- and gender-matched members of
the South African population. Survival was predicted by NYHA
functional class at last clinic visit.
Balloon mitral valvuloplasty (BMV) revolutionised the
management of many patients with rheumatic mitral stenosis,
and the advent of the innovative Inoue balloon in the early
eighties further popularised the technique, which was remarkably
successful in alleviating symptoms and improving the mitral
valve area. The method of selecting the size of balloon to use,
based on the height of the patient, always seemed unusual, to
say the least, but produced good results. Tastan and co-workers
(page 147) describe the use of echocardiography to select balloon
size and their results seem to indicate that this may be a more
preferable method.
PJ Commerford
Editor-in-Chief