CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 2, May/June 2023 122 AFRICA Heart failure (HF) is the final common pathway for many cardiovascular disorders and remains a significant global problem. In Nigeria and the rest of sub-Saharan Africa (SSA), HF care and research is plagued by limited population or registry-based data, limited training of the cardiovascular (CV) workforce, and the ‘brain drain’. This is further compounded by inadequate availability of medications, and CV diagnostic and therapeutic resources. Additionally, the population afflicted by HF in SSA tends to be younger than in other parts of the world. A report from the SSA survey of HF revealed that acute HF in SSA affects younger patients (mean age 52.3 years), mainly due to preventable/treatable aetiologies such as hypertension (43.9%), rheumatic heart disease (RHD) (15%) and dilated cardiomyopathy (19.5%).1,2 Despite advancements in medical, device-based and surgical management of HF, disparities in treatment patterns and outcomes persist, even in Western countries,3 and these advances may not be readily accessible to patients with HF in SSA. Moreover, clinical practice guidelines are routinely developed in the United States and Western Europe, based on clinical trials that may not be reflective of the reality of the African patient with HF.4 In order to develop relevant SSA HF clinical practice guidelines, the continental variation in aetiopathogenesis of HF, access to CV diagnostics, and timely initiation of evidencebased HF therapeutics must be considered. Other considerations include the younger HF population in Africa, and lack of funds and credible health insurance policies, which may lead to poor adherence to medications. To bridge these treatment disparities, the Cardiovascular Education Foundation (a US-based non-profit organisation) has organised the Nigerian Cardiovascular Symposium in collaboration with the Nigerian Cardiac Society. This symposium is a series of hybrid didactic (virtual) lectures over four weekends and practicum sessions where the diaspora-based faculty spend one to two weeks in Nigeria training and performing diagnostic and interventional procedures (percutaenous interventions and electrophysiology procedures) with Nigerian colleagues. The aim of the symposium is to educate the CV workforce, facilitate capacity building and teach advanced CV diagnostic and interventional skills to the cardiovascular workforce in Nigeria. The purpose of this article is to highlight a summary of the pivotal points presented at the HF and cardiomyopathies session of the annual Nigerian Cardiovascular Symposium, which took place virtually on 11 September 2022. The session covered a wide range of topics: diagnosis and management of HF with reduced ejection fraction (HFrEF) and HF with preserved ejection (HFpEF), cardiomyopathies and pulmonary hypertension (PH). The symposium concluded with the care of the critically ill cardiac patient with advanced HF or cardiogenic shock (CS) who may benefit from left ventricular assist devices (LVAD) and/ or heart transplantation (HT). The American College of Cardiology (ACC)/ American Heart Association (AHA) 2022 HF guidelines: applicability to the Nigerian patient with HF The presentation started by highlighting the significant HF burden in SSA due to a younger population being affected. HF hospitalisation is a marker for poor outcomes where rates of rehospitalisation remain high, about 30% within 60 to 90 days of discharge.5 The definition of HF, which emphasises the symptoms/signs of HF caused by a structural and/or functional cardiac abnormality corroborated by elevated natriuretic peptide levels or evidence of cardiogenic pulmonary or systemic congestion was highlighted.6 The stages in the development/ progression of HF from stage A (at risk for HF), stage B (pre-HF), stage C (symptomatic HF) to stage D (advanced HF) were emphasised.4 In addition, left ventricular (LV) ejection fraction (EF) categories were reviewed: HF with mildly reduced EF (HFmrEF) (LVEF 41–49%) and HF with improved EF (HFimpEF), a baseline LVEF of ≤ 40%, a ≥ 10-point increase from baseline LVEF, and a second measurement of LVEF > 40%.6 The top 10 take-home messages are: (1) guidelinedirected medical therapy (GDMT) for HFrEF includes four medication classes that include sodium-glucose co-transporter-2 inhibitors (SGLT2i), angiotensin receptor neprilysin inhibitor (ARNI), angiotensin converting enzyme inhibitor (ACEI)/ angiotensin receptor blocker (ARB), beta-blocker (BB) and mineralocorticoid receptor antagonist (MRA), (2) SGLT2i are highly recommended in HFmrEF over other GDMT, (3) recommendations for SGLT2i, MRA and ARNI in HFpEF (2b recommendation), (4) improved LVEF refers to HFrEF where LVEF is now > 40%; these patients should continue HFrEF treatment, (5) value statements for recommendations for interventions/therapies with published high-quality, costeffectiveness studies, (6) recommendations for amyloid heart disease treatment, (7) evidence supporting the importance of increased filling pressures for diagnosis of HF if LVEF > 40%, (8) recommendation for palliative care or advanced HF therapies for patients with advanced HF who wish to prolong survival, (9) primary prevention of HF was emphasised by restaging HF as those at risk for HF (stage A) or pre-HF (stage B), (10) recommendations are provided for patients with HF and iron deficiency anaemia, hypertension, sleep disorders, type 2 diabetes mellitus, atrial fibrillation (AF), coronary artery disease (CAD) and malignancy. African patients are almost non-existent in HF clinical trials, whichmay limit generalisability inNigerian patients. Furthermore, cost and access may be a barrier to adequate evidence-based guideline-directed quadruple HF therapy. Ajuluchukwu et al. reported that BB and MRA were under-prescribed and that physician adherence to GDMT was influenced by the patient’s age.7 HF with preserved EF: much commoner than we think The conference emphasised that, despite having a younger population, HFpEF is common in Africa, as was seen in the INTER-CHF trial where 28.8% of patients had EF > 50%.8 HFpEF accounts for HF in 50% of the US population and is primarily a disease of aging. It is estimated that > 70% of patients with HF over 65 years have HFpEF.9 The five-year mortality of HFpEF is approximately 75%, similar to that of HFrEF.10 Diagnosis of HFpEF entails having a high pretest probability corroborated by physical examination. Cardiac tests such as natriuretic peptides (may be low due to smaller LV size, increased clearance by adipocytes), electrocardiogram, echocardiogramand
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