Cardiovascular Journal of Africa: Vol 28 No 2 (March/April 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 2, March/April 2017 116 AFRICA
and non-availability of advanced HF treatments such as
cardiac resynchronisation therapy and assist devices, which are
commonly used in the developed world. The high mortality rates
in the current study and other African studies should therefore
be taken as a call for improvement in the care of patients with
HF in sub-Saharan Africa.
The LOS is another measure of quality of in-hospital care of
HF and is directly related to cost.32 The median LOS of nine days
in our cohort is similar to previous studies in Africa and Europe,
but more than twice that reported in North America.7,21,24,31 The
LOS found in our study and probably other African studies
may be explained by multiple factors that include a significant
coexistence of other acute or chronic medical conditions,
occasional interruption of treatment due to unavailability of
medication at hospitals, non-compliance, low rates of intensive
care admission, and patients’ non-medical problems requiring
intervention. Being a tertiary hospital in Botswana, PMH
receives patients with severe forms of HF, including patients
referred from distant hospitals, whose hospital stays may be
prolonged by lack of timely transport back to their referring
hospitals or residence.
After discharge, case fatality rates among those with HF are
reported to be high, with up to 40% of those with severe HF
dying within one year.7,8 In our study, about a third (30.9%)
of patients died within six months of admission, a rate that is
significantly higher than the 180-day mortality rate of 17.8%
reported in the large THESUS-HF study.5 The difference in
mortality rates may partly be explained by the fact that the
THESUS-HF study was performed in different settings with
variable patient presentations and mortality rates.7
Several co-morbidities that were prevalent among our
patients, and are known to independently increase the risk of
mortality among HF patients were hypertension, diabetes, renal
failure and anaemia.28 Overall, our study showed that in-hospital
and post-discharge mortality rates were higher in patients who
had longer lengths of hospital stay, hyponatraemia, older age,
lower haemoglobin level, higher NT-proBNP level, and lower
eGFR. These poor prognostic factors have also been reported
in other studies.28
This study was undertaken in a small town and hence is
limited by the relatively small number of patients. However it
provides useful findings, opening new avenues for future studies
on HF. Because our cohort was selected from a tertiary hospital,
it is likely to over-represent those with severe HF. For various
reasons, we could not follow up all our patients at our clinic
after discharge, and it was not possible to gather information
on their treatment. Therefore, the influence of the differences in
out-patient care on patients’ outcomes could not be assessed. All
deaths were assumed to be attributable to HF, which is also likely
to be an overestimation because of other significant medical
co-morbidities that were prevalent in our patients.
Conclusion
This study has demonstrated high morbidity and mortality rates
among patients admitted to a tertiary hospital in Botswana for
AHF. Both non-communicable (hypertension) and infectious
diseases (HIV) are common among HF patients and often
coexist. As mortality rates among HF patient remain high after
admission, efforts should be made to improve HF management,
both on an in-patient basis and in the community following
discharge, in order to help improve prognosis.
We thank the patients and their relatives for their cooperation. We acknowl-
edge the nursing staff at the medical wards and cardiac clinic for their
assistance with the study. Lastly, we thank Dr Daniel Baxter for his critical
comments on the manuscript. This study was supported by a grant from the
University of Botswana; Round 25.
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