Heart failure prevention and management requires a context-driven approach in African countries where it is an evolving syndrome with changing predictive risk factors, and where investment in research is scarce and, consequently, there is a lack of data, experts say.
There is a need to to tackle context-specific barriers for HF care, they said, with improvements starting at primary care level and common precursors, such as hypertension, being identified early.
For example, in South Africa, with half of the adult population overweight or obese, and maternal deaths at 88 per 100 000 population, detecting cardiovascular risk factors among pregnant women – and those planning to have children – is now a top priority, reports Chris Bateman for MedicalBrief.
Professor Karen Sliwa, director of the Cape Heart Institute at the University of Cape Town, speaking at the recent SA Heart Association Annual Congress in Johannesburg, on the management of cardiovascular risk factors during pregnancy said that SA’s maternal mortality rate was 10 times that of France, with obesity being the primary driver of both hypertension and diabetes.
Sliwa adds that predictive risk factors among pregnant women have changed with rheumatic heart disease (RHD) now leading the field, causing 50% of all maternal deaths.
“Then we also have a condition called Peripartum Cardiomyopathy. Women who were previously healthy develop a weak heart muscle which leads to heart failure and possibly death. This condition occurs in one of every 1 000 women in South Africa.”
Sliwa’s advice for both healthcare providers and patients in preventing heart problems among pregnant women is to control the main risk factors namely: diabetes, hypertension, smoking, and weight. Healthcare professionals seeing shortness of breath or chest pain amongst pregnant women should first and foremost look at the possibility of an underlying heart problem. “It’s extremely easy to put these symptoms down to pregnancy itself as we tend to think its only men that have heart problems,” said Sliwa.
Another big driver of cardiac problems among pregnant women was late referral, with ignorance of potential heart problems widespread among doctors and nurses. She advised healthcare professionals not to hesitate to refer a patient when in doubt. Management by a multi-disciplinary team was optimal, she said.
At-risk pregnant women can be divided into three main categories, including:
- Known pre-existing heart disease such as congenital heart disease (one or more problems with the heart's structure that exist since birth), Marfans cardiomyopathy (a genetic disorder of the connective tissue), rheumatic heart disease (a condition in which the heart valves have been permanently damaged by rheumatic fever, and the most commonly acquired heart disease in people under age 25), and valve prosthesis (Prosthetic heart valves designed to replicate the function of native valves by maintaining unidirectional blood flow);
- Newly diagnosed heart disease unmasked by pregnancy, familial cardiomyopathy (an inherited disease that affects the heart muscle), undiagnosed rheumatic heart disease and undiagnosed congenital heart disease; and
Newly developed cardiovascular disease, such as peripartum cardiomyopathy (new onset heart failure between the last month of pregnancy and 5 months post-delivery with no determinable cause), and gestational hypertension (abnormal blood pressure after 20 weeks of pregnancy), and preeclampsia (a condition in pregnancy characterized by high blood pressure, sometimes with fluid retention and elevated protein in the urine)
Once comorbidity was established and potential heart failure diagnosed, action would depend on how many weeks into gestation the woman was. Over sixteen weeks begged the question of whether the woman could be stabilised, what intervention was required and whether an early delivery was possible. Under sixteen weeks required balancing how badly the pregnancy was desired with the woman’s condition and the possibility of termination of pregnancy.
Any preconception evaluation, especially for women with cardiovascular disease risk factors, should include an echocardiogram to assess left and right ventricular valve function, and an exercise test.
Separately, Silwa, together with colleagues Neusa Jessen and Ana Olga Mocumbi, writes in the latest issue of the European Heart Journal, that unlike in developed countries, where echocardiographic-based studies suggest that the true prevalence of heart failure is double the 1%-2% generally found in the adult population, the situation in Africa is different.
In Africa, hospital-based studies highlight the importance of the problem but the real scenario is obscure given the lack of population-based studies.
Distinctive antecedents, presentation and weight
The Sub-Saharan Africa Survey of Heart Failure (THESUS-HF), conducted a decade ago, raised, for the first time, evidence regarding aetiology, treatment, and outcomes of acute HF in African populations, unveiling surprising features: patients were very young (mean age of 52 years); women were slightly more affected than men; causes were diverse and predominantly non-ischaemic, mainly hypertensive (45.4%) and rheumatic heart disease (RHD, 14.3%).
Endemic cardiomyopathies (i.e, idiopathic dilated cardiomyopathy, peripartum cardiomyopathy, and endomyocardial fibrosis) and infectious causes were also important.
Comorbidities were common, including atrial fibrillation (18.3%), anaemia (15.2%), diabetes mellitus (11.4%), and renal dysfunction (7.7%). These findings have been confirmed in recent studies.
The INTERnational Congestive Heart Failure (INTER-CHF) study that enrolled 1 294 African adult patients, including ambulatory, highlighted regional variations in the antecedents, presentation and treatment of HF and the importance of social inequities as an igniter and booster for this public health problem.
Compared with Asia, Middle-East, and South America, African patients were younger, more economically disadvantaged, in worse clinical states and undertreated. Hypertensive heart disease (35%) was the most prevalent cause, but ischaemic heart disease appeared in second (20%), while RHD and infectious causes were less common, depicting the ongoing epidemiologic transition.
Nevertheless, the African continent is markedly diverse, and this transition is occurring at different paces between regions. More affluent regions already present considerable proportions of non-communicable causes of HF.
Independent of place of residence, socio-economic factors influence behaviour and risk.
Without changes, communicable causes will persist alongside the rising non-communicable risks, stretching the weak health systems. Acute HF adds to the burden with prolonged hospital stays, readmissions, and mortality and lays a huge economic weight for families as it affects young man and woman that instead of providing, bring additional expenditures to their families.
Struggles for diagnosing, managing
RHD and endomyocardial fibrosis may remain asymptomatic until later stages or be unmasked by pregnancy. Echocardiography is fundamental for diagnosis and management, particularly at early stages of RHD, when it is possible to prevent progression.
Unfortunately, access to diagnostic tools for cardiovascular disease (CVD) is scarce in most African countries, particularly in the poorer communities.
This was shown by Jessen et al in Mozambique, where availability of CVD diagnostic tests and tools was much lower in public (below 60%) than in private sector (around 90%) where prices are high.
Other factors that hamper HF diagnosis are low financial power, poor health literacy, low coverage of health services, and lack of in-job training.
Managing HF is equally challenging in many African countries, both from the health professionals and from the patient and caregivers’ perspective. Access to guideline-directed medical therapy, crucial for improving survival in HF – particularly with reduced ejection fraction – is usually low.
Dramatic cases are common, such as young women with peripartum cardiomyopathy, a major contributor to mortality (5%-25% at one year).
In the study conducted in Maputo, data on availability and price of 14 World Health Organisation (WHO) core essential medicines (EMs) and 35 CVD EMs were collected from all six public and six private hospitals and 30 private-retail pharmacies.
Overall, mean availability of cardiovascular EMs was low (20.7% in public sector, 21.5% in private-retail pharmacies, 22.2% in private hospitals), while availability of other EMs of the WHO core list was better (52.6% in public, 59.8% in private-retail pharmacies, and 50.0% in private hospitals).
The median price of the lowest priced and most sold generic versions of cardiovascular medicines was 4.51 and 5.37 times the international reference price, respectively, much higher than the median price of WHO core EMs (2.93).
A lowest paid government worker would spend on average two to 15 days’ wage monthly to undergo private-sector interventions for primary prevention and 14.0–17.8 days’ wage monthly to undergo clinical CVD interventions for secondary prevention.
Collaboration
Key projects have been created and are fostering regional collaboration. One example is the South–South Partnership in Cardiovascular Research in Africa, initiated by Professor Karen Sliwa, director of the Cape Heart Institute at the University of Cape Town, and Professor Ana Mocumbi, vice-president of the Mozambican Institute for Health Education and Research, which aims to build local capacity and promote regional and global partnerships for research.
Through various initiatives, this project is empowering the next generation of cardiovascular clinicians and researchers, with particular emphasis on females.
In addition, the THESUS II survey is currently in planning – all society members of the Pan African Society of Cardiology were contacted, and a positive response was obtained from all regions of Africa.
A global network could collaborate in research, facilitate national stakeholder discussions and development of national scorecards.
The World Heart Federation has provided a ‘Roadmap for Heart Failure’, a guidance for national NCD programmes to identify and overcome roadblocks in the process of dealing with HF.
Conclusions and way forward
Africa is characterised by a high socio-economic, demographic and cultural heterogeneity among its different regions and populations.
As clearly presented by Sliwa at the European Society of Cardiology’s joint session with JAMA Cardiology: ‘Achieving Global Health Equity: A New Challenge in Heart Failure’, at the 2023 Congress, Africa faces several challenges that need better understanding by acquisition of proper data that can drive the implementation of effective solutions for prevention and management of HF in the different contexts.
Access to affordable medical therapy is crucial to improve survival of the many patients facing HF. The continent needs innovative approaches to address inequalities in education, low access to health care and the profound shortage of health care providers.
Development of local capacity by research training and funding of projects is fundamental. Regional and international partnerships are crucial for proper and expedite advancement.
Study details
Access to Essential Medicines and Diagnostic Tests for Cardiovascular Diseases in Maputo, Mozambique
Neusa Jessen, Abhishek Sharma, Ana Olga Mocumbi, et al.
Published in Global Heart Journal on 28 February 2023
Abstract
Background
To tackle the increasing burden of non-communicable diseases (NCDs) and reduce premature cardiovascular (CV) mortality by a third by the year 2030, countries must achieve 80% availability of affordable essential medicines (EMs) and technologies in all health facilities.
Methods
Using a modified version of World Health Organization (WHO)/Health Action International (HAI) methodology, we collected data on availability and price of 14 WHO Core EMs and 35 CV EMs in all 6 public-sector hospitals, 6 private-sector hospitals, and 30 private-retail pharmacies. Data on 19 tests and 17 devices were collected from hospitals. Medicine prices were compared with international reference prices (IRPs). Medicines were considered unaffordable if the lowest paid worker had to spend more than one day’s wage to purchase a monthly supply.
Results
Mean availability of CV EMs was lower than that of WHO Core EMs in both public (hospitals: 20.7% vs. 52.6%) and private sectors (retail pharmacies: 21.5% vs. 59.8%; hospitals: 22.2% vs. 50.0%). Mean availability of CV diagnostic tests and devices was lower in public (55.6% and 58.3%, respectively) compared to private sector (89.5% and 91.7%, respectively). Across WHO Core and CV EMs, the median price of lowest priced generic (LPG) and most sold generic (MSG) versions were 4.43 and 3.20 times the IRP, respectively. Relative to the IRP, median price of CV medicines was higher than that of Core EMs (LPG: 4.51 vs. 2.93). The lowest paid worker would spend 14.0 to 17.8 days’ wage monthly to undergo secondary prevention.
Conclusion
Access to CV EMs is limited in Maputo City owing to low availability and poor affordability. Public-sector hospitals are not well equipped with essential CV diagnostics. This data could inform evidence-based policies for improving access to CV care in Mozambique.
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