CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 2, May/June 2023 AFRICA 71 Dzudie et al. found atrial fibrillation present in HF patients, with a frequency ranging from 23 to 40%.11 It was observed in 41% of patients in our study. Yancy et al. found left bundle branch block in up to 30% of patients with HF in their study,12 and it was found in 40.6% in the study by Bouqat et al.13 We found a comparable rate of left bundle branch block in our study (36%). Determining the decompensation factors of HF should be systematic in order to reduce the risk of rehospitalisation and improve the management of HF.14 Berkovitch,14 in his study including 2 212 patients, found several factors, including infection (21%), non-compliance (17%), renal dysfunction (13%) and other miscellaneous factors (49%). Our results were similar to this study. In our study, the aetiology of HF was mainly ischaemic. In European and American studies,1,2 hypertension represents the leading cause of HF among African adults.15 The increase in incidence of ischaemic heart disease in Tunisia can be explained by a better diagnostic approach and an increase in coronary disease due to changing lifestyles. Valvular disease is a cause of left ventricular (LV) dysfunction in our country. It was observed in 23% of cases and its frequency was 24% in a Moroccan study.1 This was mainly due to frequent rheumatic valvulopathy, in contrast to developed countries where valvulopathies were mainly dystrophic. The relative decline of rheumatic valvulopathies is due to the widespread use of antibiotics and an improvement in general hygiene.13 Over the last 20 years, HF management has been codified thanks to recent updates of European recommendations.16 In our study, the most commonly used drugs were diuretics (mainly furosemide), ACEI, BB and MRA. Data from our study suggest, however, that the prescription of drugs for HF was not optimal. Various factors influencing requirements have been identified, including age, gender and co-morbidities, especially renal insufficiency. Indeed, the triple combination (ACEI, BB and MRA) was prescribed in only 35% of cases in some series17 and the number of patients treated with appropriate doses was low. Our medical prescription included a triple combination in 45% of patients. However, the recommended optimal doses for each class were achieved in only 11% for ACEI, in 15% for BB and in 12% for MRA. Non-pharmacological treatment that can improve the prognosis of HF, such as resynchronisation therapy and defibrillation, remains weak.13,14,16 Indeed, in our study cardiac resynchronisation was performed in only 30 patients (9%) and an implantable cardioverter defibrillator was placed in 15 patients. The explanation for the non-implementation of these devices were: patient’s refusal, problem with logistics and cost, and low percentage of patients eligible for resynchronisation. Cardiac transplantation is not often performed due to its high economic cost and its logistical problem. No case of transplantation is reported in our study. Despite recent advances in treatment, HF remains a serious disease linked to high mortality rates, with a particularly somber, long-term prognosis. Mortality rates ranged across different regions from 6.9 to 15.6% for chronic HF in the study by CrespoLeiro et al.17 Our study revealed that in-hospital mortality was around 10%. This is similar to the report by Savarese and Lars18 and comparatively higher than that reported in other registers,19 which varied from 4 to 7%. Higher rates for six-month mortality from HF were observed in Morocco and ranged from 15 to 35%, depending on the studies.14,20 According to our results, the six-month mortality rate was 16%. It is also noteworthy that the HF mortality rate is higher than that from myocardial infarction and several cancers.19 Hospital re-admissions remain a big challenge for the care of the HF patient. Despite the remarkable progress that has been made over the past five years, more than 20% of patients are re-admitted within 30 days and up to 50% within six months.20 Our study found that the six-month re-admission rate was 36%. Prognostic models provide a means of assessing a patient’s risk of adverse clinical outcomes and may influence clinical management. Several studies used multivariate logistic regression to derive predictive models.21,22 In our study, ischaemic HF was independently predictive of mortality [hazard ratio (HR) = 1.63]. Several studies have corroborated our results.21-23 The independent prognostic value of age of death from any cause was confirmed by the study by Wedel et al.,24 which involved patients from the CORONA trial (HR 1.26 per each 10-year increase; p < 0.0001). The study by Allen et al.25 was conducted on patients from the CHARM trial (HR = 1.32 per each 10 years over the age of 60 years; p = 0.0001) in a follow-up period of 38 months. Wedel et al. found diabetes to be an important precursor to the development of HF and it was associated with an increased mortality rate.24 This confirms our results of a 10% risk of mortality. The use of BB was found to be an independent protective factor in the MAGGIC meta-analysis,26 which included individual data of 3 372 patients with reduced LVEF. Our study showed similar results. As is any research, our study is subject to certain limitations, the most important one being the limited number of patients. This was a major setback while concluding our results. However, it should encourage us to establish a national HF registry that will enable better statistical analysis and lead to more relevant conclusions. Despite these limitations, the study highlighted some limits in the current management system of HF in Tunisia, including non-optimal medication management, poorly supported terminal HF (no transplantation), and very limited recourse to cardiac rehabilitation. Conclusion This study highlighted the epidemiological and clinical features of HF in Tunisia and revealed the deficiencies in patient care. These results should be an incentive to treat HF patients more effectively and to take further preventative measures to improve HF prognosis. The authors thank the managers of the factories, all data collectors and study participants for sharing their precious time and information while collecting data. References 1. Maggioni AD. Epidemiology of heart failure in Europe. Heart Fail Clin 2015; 11: 625–635. 2. Buja A, Solinas G, Visca M, et al. Prevalence of heart failure and adherence to process indicators: which sociodemographic determinants are involved? Int J Environ Res Public Health 2016; 13: 238.
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