Heart failure disease: An African perspective

Determinants of readmission amongst hospitalized patients with heart failure in Ghana and Nigeria: a prospective cohort study

BACKGROUND

Readmission following hospitalization for acute heart failure (HF) is an adverse prognostic event. Readmission rates for HF in African countries are variable, ranging from 1.53 to 25% in the first 30 days, and 12.2% to over 50% at 180 days. Few studies done in the African region have identified several determinants of HF readmission including New York Heart Association functional class, heart failure phenotype, older age, amongst others. This study sought to explore determinants of readmission amongst a contemporary cohort of adult patients hospitalized with HF in Ghana and Nigeria.

METHODS

This was a multicenter prospective cohort study, with 30- and 90-day follow-up after recruitment, conducted from June 2021 to April 2022, in two tertiary teaching hospitals in Ghana and Nigeria. A total of 201 adult patients who presented with acute heart failure at the two study sites were consecutively enrolled.

RESULTS

In this cohort of 201 patients (mean age (SD) 58.8 (15.6) years, 44.3% women), 8.0% and 13.9% were readmitted at 30- and 90-days, respectively. The odds of readmission at 30-days were higher in participants from Nigeria (OR = 4.3, 95% CI - 0.02-0.75, p = 0.039) and those with duration of heart failure diagnosis of 1 month to < 1 year (sub-acute HF) (OR = 4.0, 95% CI - -0.00-0.27, p = 0.045). Every unit increase in pulse rate was associated with almost 5-fold higher odds of readmission at 30-days (OR = 4.7, 95% CI - 0.00-0.01, p = 0.031). The odds of 90-day readmission were higher in participants with New York Heart Association functional class III-IV at discharge (OR = 5.1, 95% CI - -0.03-0.42, p = 0.025).

CONCLUSION

Heart failure patients with sub-acute HF, higher pulse rates at baseline and higher NYHA functional class at discharge, may represent a vulnerable group at high risk of readmission in Ghana and Nigeria. Future studies should explore the mechanisms underlying this observation and consider interventions to reduce the risk of readmission amongst this unique patient population.

CLINICAL TRIAL NUMBER

Not applicable.

Primary Causes and Direct Medical Cost of Heart Failure Among Adults Admitted with Acute Decompensated Heart Failure in a Public Tertiary Hospital, Kenya

Background

Heart failure (HF) is a major contributor to cardiovascular morbidity and mortality. Adversely impacting health outcomes in Kenya and other developing countries, data on the direct medical cost of HF hospitalization remain limited.

Methods

This was a prospective study conducted at Moi Teaching and Referral Hospital. Patients with HF were identified by sequential medical chart abstraction. Primary causes were extracted from echocardiogram reports and adjudicated by a cardiologist. Direct medical cost of hospitalization was derived using activity-based and micro-costing methods, adopting payers' system perspective. Drivers of overall cost were explored using linear regression models.

Results

142 participants were consecutively recruited from September to November 2022. 51.4% were females, and the mean age was 54 (SD 20). The leading primary causes were cor pulmonale (CP), 28.9%; dilated cardiomyopathy (DCM), 26.1%; rheumatic heart disease (RHD), 19.7%; hypertensive heart disease (HHD), 16.9%; ischaemic heart disease (IHD), 6.3%; and pericardial disease (PD), 2.1%. Overall direct cost of HF hospitalization was KES 11,470.94 (SD 8,289.57) [USD 93.49 (67.56)] per patient per day, with the mean length of hospital stay of 10.1 (SD 7.1). RHD incurred the highest costs, KES 15,299.08 (SD 13,196.89) [USD 124.70 (107.56)] per patient per day; IHD, KES 12,966.47 (SD 6656.49) [USD 105.68 (54.25)]; and DCM, KES 12,268.08 (SD 7,816.12) [USD 99.99 (63.71)]. The cost of medications was the leading driver, β = 0.56 (0.55 - 0.56), followed by inpatient fees, β = 0.27 (0.27 - 0.28), and laboratory investigations, β = 0.19 (0.18 - 0.19).

Conclusion

Cor pulmonale, CM, RHD, and HHD were the major causes of HF. The overall direct medical cost of hospitalization was extremely expensive compared with the Kenyan average monthly household income per capita. Widespread comprehensive health insurance coverage is therefore recommended to cushion families against such catastrophic health expenditures besides public health measures aimed at addressing primary causes of HF.

Heart failure outcomes in Sub-Saharan Africa: a scoping review of recent studies conducted after the 2022 AHA/ACC/HFSA guideline release

BACKGROUND

Heart failure (HF) in Sub-Saharan Africa (SSA) presents unique challenges, with high prevalence and distinct epidemiological features compared to high-income settings. Despite its burden, recent comprehensive data are lacking, especially amidst recent 2022 AHA/ACC/HFSA guideline release. This scoping review aims to map the literature on HF in SSA, focusing on aetiologies, structural abnormalities, management practices, and outcomes to identify research gaps and inform clinical practice.

METHODS

Studies from 2022-2024 published in English or French were included, covering adult patients > 18 years, all study designs except case reports. Studies not reporting any outcomes or focusing solely on one HF subtype were excluded. Literature from all SSA countries was searched using a FACET approach in databases including PubMed, Google Scholar, Cochrane and Scopus.

RESULTS

Ten studies, evaluating 2039 patients, were analysed. Dilated cardiomyopathy (DCM), and Hypertensive cardiomyopathy (HCM) emerged as prominent aetiologies. Rheumatic heart disease was reported in only four studies. Common issues included high rates of electrolyte disturbances and anemia, which influenced patient outcomes. Guideline adherence exhibited significant deficiencies, notably with a suboptimal prescription rate of SGLT2 inhibitors (8.3-24.7%). Mortality rates ranged from 3.7% to 19%, linked to factors like low blood pressure and electrolyte imbalances. Hospital stays were variable but significant rehospitalization were common within 8-15 days post discharge and associated with non-compliance and lifestyle factors.

CONCLUSION

HCM and DCM are prevalent heart failure aetiologies in SSA. Longitudinal studies are recommended to contextualise aetiological diagnosis and validate prognostic tools amidst limited resources. Enhanced guideline adherence, hypertension control and efficient post-discharge care are essential to reduce morbidity and mortality.

Regulatory effect of rapamycin on recruitment and function of myeloid-derived suppressor cells in heart failure

BACKGROUND

Immune response and inflammation play important roles in the physiological and pathophysiological processes of heart failure (HF). In our previous study, myeloid-derived suppressor cells (MDSCs), a heterogeneous group of immature myeloid cells with anti-inflammatory and immunosuppressive functions, were shown to exert cardioprotective effects in HF. The pharmacological targeting of MDSCs using rapamycin may emerge as a promising strategy for the prevention and treatment of HF. However, the specific mechanisms underlying rapamycin-induced MDSC accumulation remain unclear. Our study aimed to clarify the effects of rapamycin on the recruitment and function of MDSCs in HF, exploring new therapeutic options for the prevention and treatment of HF.

METHODS

We used transverse aortic constriction surgery and isoproterenol injection to establish HF models. Flow cytometry, reverse transcription polymerase chain reaction, transcriptomics and western blot were used to explore the regulation of rapamycin on recruitment and function of MDSCs in HF. Furthermore, rapamycin and granulocyte-macrophage colony-stimulating factor (GM-CSF) were combined to induce exogenous MDSCs from bone marrow cells.

RESULTS

Rapamycin promotes the recruitment of MDSCs by inhibiting their maturation and differentiation via suppression of the Wnt signaling in HF mice and enhanced the immunosuppressive function of MDSCs via the NF-κB signaling. Furthermore, exogenous MDSCs induced by rapamycin and GM-CSF can significantly alleviate transverse aortic constriction-induced cardiac dysfunction.

CONCLUSIONS

The pharmacological targeting of MDSCs using rapamycin is a promising strategy for the prevention and treatment of HF.

An audit of the establishment of a cardiac magnetic resonance imaging service in a public tertiary hospital setting in the Western Cape Province of South Africa

Introduction

cardiovascular magnetic resonance imaging is considered the standard of care for many clinical cardiovascular applications. Magnetic resonance imaging is a scarce resource in sub-Saharan Africa, with a paucity of cardiac magnetic resonance imaging clinical services and research. The aim of this audit was to review the cardiac magnetic resonance imaging service provided at a public tertiary hospital in Cape Town, Western Cape Province, South Africa.

Methods

a retrospective, descriptive audit via quantitative record review of Tygerberg Hospital´s cardiovascular magnetic resonance imaging service was conducted from the inception thereof on 1st April 2015 up to 31st October 2022.

Results

a total of 1,403 cardiovascular magnetic resonance imaging scans met the inclusion criteria. The mean age of the study population was 43 years, and 52% were female. The most common patient comorbidities were modifiable cardiovascular risk factors, including hypertension (22%; n=306), cigarette smoking (9.6%; n=134), diabetes mellitus type II (6.7%; n=94) and dyslipidaemia (4.4%; n=62). Sixty-three percent (n=888) of scans were performed after hours. In 93% of scans, intravenous gadolinium-based contrast agents were administered. Nonischaemic cardiomyopathy dominated the indications (56.7%; n=976) and final diagnosis (42%; n=589). The most common incidental extracardiac finding was hilar or mediastinal lymphadenopathy (6%; n=82).

Conclusion

the recently established, functional cardiovascular magnetic resonance imaging service at Tygerberg Hospital serves a unique patient population with a comparatively differently distributed cardiac disease spectrum, contributing to research diversity.

Burden of heart failure in Asia, 1990-2019: findings from the Global Burden of Disease Study 2019

OBJECTIVES

Heart failure (HF) is on the rise as a global health problem, but information on its burden in Asia is limited. This study aimed to assess the burden, trends, and underlying causes of HF in the Asian region.

STUDY DESIGN AND METHODS

Data on HF in Asia from 1990 to 2019, including prevalence, years lived with disability (YLD), and underlying causes, were extracted from the Global Burden of Diseases 2019. The cases, the age-standardized prevalence, and the YLD were compared between the age groups, the sexes, the sociodemographic index, and the locations. The proportion of age-standardized prevalence rates of HF attributable to 16 underlying causes was also analyzed.

RESULTS

In 2019, the age-standardized prevalence rate of HF per 100,000 persons in Asia was 722.45 (95% uncertainty interval [UI]: 591.97-891.64), with an estimated 31.89 million cases (95% UI: 25.94-39.25). From 1990 to 2019, the prevalence of age-standardized HF in Asia decreased by 4.51%, reflecting the global trend (-7.06%). Age-standardized YLD rates of HF exhibited patterns similar to prevalence rates. Among Asian countries, China had the highest age-standardized prevalence rate, followed by Kuwait and Jordan. Hypertensive heart disease was the leading cause of HF, followed by ischemic heart disease and rheumatic heart disease.

CONCLUSIONS

Although the burden of HF in Asia showed a gradual decline between 1990 and 2019, it remains a significant health challenge that requires increased attention. Regional disparities in HF burden are evident, emphasizing the need for urgent prevention and control measures at the regional and national levels.

Comorbid depression among adults with heart failure in Ethiopia: a hospital-based cross-sectional study

BACKGROUND

Depression is a common comorbidity in adults with heart failure. It is associated with poor clinical outcomes, including decreased health-related quality of life and increased morbidity and mortality. There is a lack of data concerning the extent of this issue in Ethiopia. Consequently, this study aimed to assess the prevalence of comorbid depression and associated factors among adults living with heart failure in Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted at the cardiac outpatient clinics of two selected specialist public hospitals in Addis Ababa, Ethiopia: St. Paul's Hospital Millennium Medical College and St. Peter Specialized Hospital. An interviewer-administered questionnaire was used to collect data from 383 adults with heart failure who attended the clinics and met the inclusion criteria. Depression was measured using the Patient Health Questionnaire (PHQ-9). A binary logistic regression model was fitted to identify factors associated with depression. All statistical analyses were conducted using STATA version 17 software.

RESULTS

The mean age of the participants was 55 years. On average, participants had moderate depression, as indicated by the mean PHQ-9 score of 11.02 ± 6.14, and 217 (56.6%, 95%CI 51.53-61.68) had comorbid depression. Significant associations with depression were observed among participants who were female (AOR: 2.31, 95%CI:1.30-4.08), had comorbid diabetes mellitus (AOR: 3.16, 95%CI: 1.47-6.82), were classified as New York Heart Association (NYHA) class IV (AOR: 3.59, 95%CI: 1.05-12.30), reported poor levels of social support (AOR: 6.04, 95%CI: 2.97-12.32), and took more than five medications per day (AOR: 5.26, 95%CI: 2.72-10.18).

CONCLUSIONS

This study indicates that over half of all adults with heart failure in Ethiopia have comorbid depression, influenced by several factors. The findings have significant implications in terms of treatment outcomes and quality of life. More research in the area, including interventional and qualitative studies, and consideration of multifaceted approaches, such as psychosocial interventions, are needed to reduce the burden of comorbid depression in this population.

Assessing and Improving the Care of Patients With Heart Failure in Ghana: Protocol for a Prospective Observational Study and the Ghana Heart Initiative-Heart Failure Registry

BACKGROUND

Heart failure (HF) is a leading cause of morbidity and mortality globally, with a high disease burden. The prevalence of HF in Ghana is increasing rapidly, but epidemiological profiles, treatment patterns, and survival data are scarce. The national capacity to diagnose and manage HF appropriately is also limited. To address the growing epidemic of HF, it is crucial to recognize the epidemiological characteristics and medium-term outcomes of HF in Ghana and improve the capability to identify and manage HF promptly and effectively at all levels of care.

OBJECTIVE

This study aims to determine the epidemiological characteristics and medium-term HF outcomes in Ghana.

METHODS

We conducted a prospective, multicenter, multilevel cross-sectional observational study of patients with HF from January to December 2023. Approximately 5000 patients presenting with HF to 9 hospitals, including teaching, regional, and municipal hospitals, will be recruited and evaluated according to a standardized protocol, including the use of an echocardiogram and an N-terminal pro-brain natriuretic peptide (NT-proBNP) test. Guideline-directed medical treatment of HF will be initiated for 6 months, and the medium-term outcomes of interventions, including rehospitalization and mortality, will be assessed. Patient data will be collated into a HF registry for continuous assessment and monitoring.

RESULTS

This intervention will generate the necessary information on the etiology of HF, clinical presentations, the diagnostic yield of various tools, and management outcomes. In addition, it will build the necessary capacity and support for HF management in Ghana. As of July 30, 2023, the training and onboarding of all 9 centers had been completed. Preliminary analyses will be conducted by the end of the second quarter of 2024, and results are expected to be publicly available by the middle of 2024.

CONCLUSIONS

This study will provide the necessary data on HF, which will inform decisions on the prevention and management of HF and form the basis for future research.

TRIAL REGISTRATION

ISRCTN Registry (United Kingdom) ISRCTN18216214; https:www.isrctn.com/ISRCTN18216214.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52616.

Hypertension Related Co-Morbidities and Complications in Women of Sub-Saharan Africa: A Brief Review

Hypertension is the leading cause of cardiovascular disease in women, and sub-Saharan African (SSA) countries have some of the highest rates of hypertension in the world. Expanding knowledge of causes, management, and awareness of hypertension and its co-morbidities worldwide is an effective strategy to mitigate its harms, decrease morbidities and mortality, and improve individual quality of life. Hypertensive disorders of pregnancy (HDPs) are a particularly important subset of hypertension, as pregnancy is a major stress test of the cardiovascular system and can be the first instance in which cardiovascular disease is clinically apparent. In SSA, women experience a higher incidence of HDP compared with other African regions. However, the region has yet to adopt treatment and preventative strategies for HDP. This delay stems from insufficient awareness, lack of clinical screening for hypertension, and lack of prevention programs. In this brief literature review, we will address the long-term consequences of hypertension and HDP in women. We evaluate the effects of uncontrolled hypertension in SSA by including research on heart disease, stroke, kidney disease, peripheral arterial disease, and HDP. Limitations exist in the number of studies from SSA; therefore, we will use data from countries across the globe, comparing and contrasting approaches in similar and dissimilar populations. Our review highlights an urgent need to prioritize public health, clinical, and bench research to discover cost-effective preventative and treatment strategies that will improve the lives of women living with hypertension in SSA.

Self-care behaviour and associated factors among heart failure patients in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

This study aimed to estimate the pooled level of self-care behaviour among heart failure patients in Ethiopia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed/MEDLINE, HINARI, Web of Sciences, Scopus, Google Scholar, Science Direct, African journals online and University repositories were searched from 1 January 2000 to 1 November 2023.

ELIGIBILITY CRITERIA

We include studies that examined self-care behaviour among heart failure patients, studies that report factors associated with self-care behaviour and observational studies (cross-sectional, case-control and cohort) with full text available.

DATA EXTRACTION AND SYNTHESIS

The data were extracted with Microsoft Excel and analysed by using STATA V.11 software. The weighted inverse variance random-effects model at 95% CI was used to estimate the pooled level of self-care behaviour and its associated factors among heart failure patients. Tests of heterogeneity, test of publication bias and subgroup analyses were also employed.

RESULTS

Thirteen cross-sectional studies with 4321 study participants were included; and the pooled level of good self-care behaviour among heart failure patients in Ethiopia was found to be 38.3% (95% CI 31.46 to 45.13). Only 68.8% of heart failure patients were knowledgeable about heart failure. Knowledge about heart failure (Adjusted Odds Ratio (AOR)=3.39; 95% CI 2.42 to 4.74) and absence of comorbidity (AOR=2.69; 95% CI 1.35 to 5.37) were significantly associated with good self-care behaviour among heart failure patients in Ethiopia.

CONCLUSION

The majority of heart failure patients in Ethiopia did not adhere to the recommended self-care behaviours. Nearly one-third of heart failure patients were not knowledgeable about heart failure. Knowledge about heart failure and the absence of comorbidities were significantly associated with good self-care behaviour. Therefore, efforts should be devoted to increasing knowledge and preventing comorbidities among heart failure patients.

PROSPERO REGISTRATION NUMBER

CRD42023394373.

Comparing Machine Learning Classifiers for Predicting Hospital Readmission of Heart Failure Patients in Rwanda

High rates of hospital readmission and the cost of treating heart failure (HF) are significant public health issues globally and in Rwanda. Using machine learning (ML) to predict which patients are at high risk for HF hospital readmission 20 days after their discharge has the potential to improve HF management by enabling early interventions and individualized treatment approaches. In this paper, we compared six different ML models for this task, including multi-layer perceptron (MLP), K-nearest neighbors (KNN), logistic regression (LR), decision trees (DT), random forests (RF), and support vector machines (SVM) with both linear and radial basis kernels. The outputs of the classifiers are compared using performance metrics including the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. We found that RF outperforms all the remaining models with an AUC of 94% while SVM, MLP, and KNN all yield 88% AUC. In contrast, DT performs poorly, with an AUC value of 57%. Hence, hospitals in Rwanda can benefit from using the RF classifier to determine which HF patients are at high risk of hospital readmission.

Oxidative stress markers-driven prognostic model to predict post-discharge mortality in heart failure with reduced ejection fraction

Background

Current predictive models based on biomarkers reflective of different pathways of heart failure with reduced ejection fraction (HFrEF) pathogenesis constitute a useful tool for predicting death risk among HFrEF patients. The purpose of the study was to develop a new predictive model for post-discharge mortality risk among HFrEF patients, based on a combination of clinical patients’ characteristics, N-terminal pro-B-type Natriuretic peptide (NT-proBNP) and oxidative stress markers as a potentially valuable tool for routine clinical practice.

Methods

116 patients with stable HFrEF were recruited in a prospective single-center study. Plasma levels of NT-proBNP and oxidative stress markers [superoxide dismutase (SOD), glutathione peroxidase (GPX), uric acid (UA), total bilirubin (TB), gamma-glutamyl transferase (GGT) and total antioxidant capacity (TAC)] were measured in the stable predischarge condition. Generalized linear model (GLM), random forest and extreme gradient boosting models were developed to predict post-discharge mortality risk using clinical and laboratory data. Through comprehensive evaluation, the most performant model was selected.

Results

During a median follow-up of 525 days (7–930), 33 (28%) patients died. Among the three created models, the GLM presented the best performance for post-discharge death prediction in HFrEF. The predictors included in the GLM model were age, female sex, beta blockers, NT-proBNP, left ventricular ejection fraction (LVEF), TAC levels, admission systolic blood pressure (SBP), angiotensin-converting enzyme inhibitors/angiotensin receptor II blockers (ACEI/ARBs) and UA levels. Our model had a good discriminatory power for post-discharge mortality [The area under the curve (AUC) = 74.5%]. Based on the retained model, an online calculator was developed to allow the identification of patients with heightened post-discharge death risk.

Conclusion

In conclusion, we created a new and simple tool that may allow the identification of patients at heightened post-discharge mortality risk and could assist the treatment decision-making.