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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 2, March/April 2018
AFRICA
119
Non-vitamin K-dependent oral anticoagulants (NOACs)
were not available in the majority of countries, including North-
African countries such as Tunisia (Table 4).
Invasive treatment: considerable heterogeneity in the access to
invasive arrhythmia treatment was observed across Africa (Fig.
1). About one-third of the PASCAR countries did not perform
pacemaker implantations: Burundi, Central African Republic,
Chad, Equatorial Guinea, Guinea Conakry, Liberia, Malawi,
Niger, Republic of Congo, Sao Tome et Principe, Swaziland
and Somalia. In 2014, the median pacemaker implantation
rate was 2.66 per million population per country.
7
The 2017
PASCAR survey showed that the density of pacemaker facilities
and operators in SSA was quite low, with a median of 0.14
centres per million population and 0.10 operators per million
population.
7
Implantable cardioverter-defibrillator (ICD) and
cardiac resynchronisation therapy (CRT) were performed in
11/33 (33.3%) and 10/33 (30%) of the countries respectively.
7
Electrophysiological studies and ablation techniques were
unavailable in all SSA areas, apart from South Africa. Here
complex ablations requiring three-dimensional mapping were
routinely carried out, as in countries of the Maghreb (Table 5).
Marked variation in cost (up to 1 000-fold) was observed
across countries, with an inverse correlation between implant
rates and the procedural fees standardised to the gross domestic
product (GDP) per capita.
7
Poverty, lack of facilities/equipment,
prohibitive costs of procedures, paucity of trained health
professionnals, and non-existent fellowship programmes were
the main drivers of under-utilisation of interventional cardiac
arrhythmia care.
Discussion
The paradigm shift in the epidemiology of disease burden in
Africa towards the predominance of non-communicable diseases
(NCDs) emphasises the need for appropriate health policies to
address the changing pattern of diseases. The steady increase
in the incidence of heart diseases and their risk factors, such
as hypertension, ischaemic heart disease, diabetes and heart
failure mechanistically impact significantly on the burden of
Table 2. Routine diagnostic techniques available
in the various African countries
Countries
ECG
SA-ECG
Holter ECG
2D echo
Tilt-table testing
Exercise testing
South Africa
x x x x x x
Sudan
x x x x x x
Algeria
x x x x x x
Tunisia
x x x x
x
Senegal
x
x x x x
Côte d’ivoire
x
x x x x
Kenya
x
x x x x
Nigeria
x
x x
x
Mauritius
x
x x
x
Cameroon
x
x x
x
Angola
x
x x
x
Tanzania
x
x x
x
Mozambique
x
x x
x
Sierra Leone
x
x x
x
Burkina Faso
x
x x
x
Zimbabwe
x
x x
x
Burundi
x
x x
x
Uganda
x
x x
x
Benin
x
x x
x
Gabon
x
x x
x
Chad
x
x x
Congo Republic
x
x x
Mali
x
x x
Togo
x
x x
Mauritania
x
x x
Equatorial Guinea
x
x
Guinea Conakry
x
x
Somalia
x
x
Niger
x
x
Malawi
x
Swaziland
x
Liberia
x
Central Africa Republic
x
SA-ECG and tilt-table test are available in a minority. ECG = electrocardiogra-
phy ; SA-ECG = signal-averaged electrocardiography; 2D echo = two-dimen-
tional echocardiography.
Table 3. Availability of various anti-arrhythmic drugs
in various African countries
Country
Digoxine
Amiodarone
Beta-blockers
Flecainide
Xylocaïne iv
Procainamide iv
Hydroquinidine
South Africa
x x x
x x
x
Tunisia
x x x x
x
Sudan
x x x
x x
Côte d’ivoire
x x x
x x
Algeria
x x x
x x
Burkina Faso
x x x
x x
Kenya
x x x
x x
Gabon
x x x x
Uganda
x x x x
Tanzania
x x x
Sierra Leone
x x x
Angola
x x x
x
Nigeria
x x x
x
Senegal
x x x
x
x
Niger
x x x
Zimbabwe
x x
x x
Mauritius
x x
x
Mozambique
x x
x
Burundi
x x
Mauritania
x x
Benin
x x
Cameroon
x
x
Guinea Conakry
x
Congo Republic
x
Mali
x
Togo
x
Liberia
x
Chad
x
Equatorial Guinea
Somalia
Malawi
Swaziland
Central Africa Republic
Procainamide and hydroquinidine are largely unavailable; iv = intravenous.