Contemporary trends in the epidemiology and management of cardiomyopathy and pericarditis in sub-Saharan Africa

Addressing Cardiometabolic Challenges in HIV: Insights, Impact, and Best Practices for Optimal Management-A Narrative Review

Introduction

Since the advent of highly active antiretroviral therapy (HAART), morbidity and mortality rates associated with human immunodeficiency virus (HIV) have significantly decreased leading to prolonged life span of Individuals living with HIV due to the effectiveness of antiretroviral therapy. However, this prolonged lifespan alone does not fully account for the increased incidence of cardiometabolic complications. These complications result from a complex interplay of factors such as chronic inflammation, immune activation, ART-related metabolic effects, and lifestyle changes. which contribute to elevated morbidity and mortality rates, therefore requiring a deeper understanding and setting effective management strategies. This review aims at providing insights and a nuanced understanding of the relationship between HIV and cardiometabolic disorders, explore their clinical implications and adapt optimal management strategies to address the multifaceted challenges at the intersection of HIV and cardiometabolic health, ultimately enhancing patient outcomes and quality of life.

Methods

Data retrieval was conducted using a predetermined search strategy from medical journals that were published in bibliographical databases like PubMed, Science Direct and Embase. This review systematically considered and synthesized current literature on the association between cardiometabolic challenges and HIV.

Results

This review provides a detailed exploration of the interrelationship between HIV and cardiometabolic challenges, with an emphasis on insights, impact, and best practices for optimal management. It underscores the high risk of cardiovascular disease, insulin resistance, dyslipidemia, and lipodystrophy in people living with HIV. Recommendations include evidence-based approaches such as routine cardiometabolic risk. Prevention, screening, management, lifestyle interventions (diet and exercise), and optimizing ART regimens to reduce the negative health outcomes experienced by people living with HIV and to direct clinical practice. To reduce health issues, enhance clinical results, and improve the long-term quality of life for people living with HIV, it is important to early identify cardiovascular risk factors and to follow customized prevention and management methods.

Conclusion

This review shows that early detection through regular screening is pivotal through collaboration between healthcare providers, researchers, and policymakers which will allow for timely interventions and drive innovation and address evolving challenges to enhancing the quality of life for individuals living with HIV. Continuing to do research and advocacy efforts, will not only advance knowledge but also optimize the long-term health outcomes for people living with HIV.

Fungal Pericarditis-A Systematic Review of 101 Cases

Fungal pericarditis is a rare disease but its incidence has risen in parallel with the global increase in invasive fungal infections. This systematic review analyzes data from previously reported cases of fungal pericarditis to provide an improved understanding of the etiology, clinical presentation, management, and outcomes of this rare disease. We reviewed Medline and Scopus databases from 1 January 1990 to 29 January 2024 for case reports that documented the isolation of a fungal pathogen from pericardial fluid or tissue. Of the 2330 articles screened, 101 cases met the inclusion criteria. Patients with fungal pericarditis and the involvement of at least one other organ-usually the lungs, brain, or kidney-had worse outcomes than patients with isolated pericardial disease. Immunosuppression was reported in 50% of cases and was associated with worse outcomes in adults. Patients who presented with chest pain, received adequate empiric antifungal therapy, and underwent pericardiocentesis and pericardiectomy had improved survival. The most common isolated pathogens were Candida spp., followed by Aspergillus spp. and Mucor spp., with the latter two linked to worse outcomes. Only 35% of patients received empiric antifungal medications before the causative pathogen was identified, and mortality was associated with a delay in appropriate therapy. Immunosuppression, disseminated disease, and presence of shock/multiorgan failure were additional risk factors associated with death. Fungal pericarditis carries a mortality rate of up to 50%, with nearly half of patients being immunocompromised. Clinicians frequently do not consider fungal pericarditis in the differential diagnoses, which leads to delays in treatment and poorer outcomes. Further prospective multicenter studies are urgently needed to better understand the epidemiology, improve diagnostic testing and management, and decrease unacceptably high mortality in patients with fungal pericarditis.

Impact of hypertension on mortality in adults in Moramanga, Madagascar: a retrospective cohort study in the community

BACKGROUND

Hypertension remains a global public health problem. This study aimed to evaluate the impact of hypertension on premature mortality among people living in Moramanga, Madagascar.

METHODS

Three communes of Moramanga district have been monitored since 2012 as part of the MHURAM project (Moramanga Health Survey in Urban and Rural Areas in Madagascar). In 2013, individuals aged 15 years and above were surveyed to estimate the prevalence of hypertension and identify risk factors. A follow-up survey was conducted in 2016-2017 to record deaths; causes of death were assessed through verbal autopsy (VA). The occurrence of premature death was evaluated using a retrospective cohort study design applied to data collected from adults aged 30 to 70 who participated in the hypertension survey. Mortality rates and partial life expectancy by sex and hypertension status were estimated using survival analysis; covariates associated with premature risk of mortality were identified using a Cox proportional hazards model. The contribution of causes of death to the difference in partial life expectancy between hypertensive and non-hypertensive individuals was evaluated using a decomposition analysis.

RESULTS

There were 4,472 participants in the hypertension survey aged between 30 and 70 during the follow-up. The average follow-up was 2.7 years per individual, resulting in 11,892 person-years in total with 117 deaths reported giving a mortality rate of 9.8‰ (13.1‰ for males and 7.1‰ for females). An estimated 3.2 years of life was lost among those diagnosed with hypertension compared to normotensive (32.0 years and 35.2 years respectively). Adjusted for gender, smoking habit, sedentary lifestyle, and wealth index, hypertension is a risk factor for premature death [HR = 1.58 95%CI (1.07-2.36)]. Hypertensive individuals also experienced higher all-cause and communicable disease mortality in people aged between 30 and 39 years.

CONCLUSION

Hypertension is associated with higher risks of premature death in the community of Moramanga. In addition, hypertension contributes not only to mortality via cardiovascular diseases, but also through all causes combined. The health system should enhance prevention efforts, particularly for young hypertensive patients, when risk is most pronounced.

Cardiovascular Involvement in Tuberculosis Patients Treated in Southern Africa

Background

Tuberculosis (TB) is the leading cause of death among people with HIV and a major global health challenge. Subclinical cardiovascular manifestations of TB are poorly documented in high TB and HIV burden countries.

Objectives

The purpose of this study was to quantify the prevalence of cardiovascular involvement in TB patients and investigate changes after completion of anti-TB treatment.

Methods

HIV-positive and HIV-negative patients diagnosed with pulmonary TB between October 2022 and November 2023 were enrolled from 2 tertiary care hospitals in Zambia and South Africa. Standardized transthoracic echocardiography (TTE) was conducted at TB diagnosis and after 6 months of anti-TB treatment. Cross-sectional and longitudinal analyses assessed pericardial effusion, thickening, or calcification, with and without signs of pericardial constriction.

Results

A total of 286 TB patients (218 [76%] men, 109 [38%] people with HIV, median age 35 years) underwent TTE at TB diagnosis, of whom 105 participants had a second TTE after completion of treatment. At TB diagnosis, 134 (47%) had pericardial effusions, 86 (30%) thickening, 7 (2%) calcifications, 103 (42%) signs of constriction, and 13 (12%) had definite diagnosis of constriction. After TB treatment, pericardial effusions (47% vs 16%, P < 0.001) and pericardial thickenings (30% vs 15%, P = 0.002) became less prevalent. Pericardial calcifications (2% vs 1%, P = 0.4), signs of constrictions (42% vs 38%, P = 0.4), and definite diagnosis of constriction (12% vs 14%, P = 0.8) were similar.

Conclusions

Cardiac involvement is frequent in newly diagnosed TB patients. Early pericardial changes may be reversed with anti-TB treatment. Echocardiographic screening facilitates early detection and timely management of cardiovascular involvement in TB patients.

Severe calcification in chronic constrictive pericarditis of tuberculous-related a case report and literature review

Chronic constrictive pericarditis is a pericardial affection that causes a severe impairment of myocardial compliance. Among its many etiologies, tuberculosis is the most common cause, mainly in developing countries. Multimodal imaging methods are essential tools for guiding diagnosis. We present the case of a 64-year-old man with no past medical history who presented with dyspnea stage II of NYHA and right heart failure. At admission, he was stable, with normal blood pressure and a normal heart rate. His ECG showed a low voltage of QRS complexes. Transthoracic echocardiography revealed significant pericardial thickening enveloping the ventricles, with significant respiratory flow variation. A thoracic CT scan and cardiac MRI confirmed the presence of pericardial thickening and calcifications. The patient underwent beat-heart pericardial decortication. The anatomopathological examination of the surgical piece revealed Mycobacterium tuberculosis. The postoperative check-up after 6 months showed good clinical and echocardiographic evolution.

Survival and predictors of mortality in patients with heart failure in the cardiology department of the Center Hospitalier Basse Terre in Guadeloupe: historical cohort study

BACKGROUND

Despite the progress made in recent years in the treatment of Acute Heart Failure (AHF), its prognosis remains poor in the developing country. The objective of this study is to analyze the survival and predictors of mortality of patients with acute heart failure in the cardiology department of the Basse Terre Hospital Center in Guadeloupe.

METHODS

this was a historical cohort study carried out over a period from June 2021 to June 2022, targeting all acute heart failure patients undergoing cardiac monitoring in the cardiology department of the Basse Terre Hospital Center in Guadeloupe. Sociodemographic, clinical, biological characteristics and outcome (recovery or death) were studied. Survival was described using the Kaplan Meier method α = 5%.

RESULTS

this study involved 242 acute heart failure patients whose median age was 75 years and the majority were male (sex ratio 2 M/1F). Among these patients, 14.9% died, the most common cause of death was cardiogenic shock (52.8%). After adjustment, tobacco consumption (aHR: 2.90; 95% CI: 1.36-8.09), Chronic Kidney Disease (aHR: 2.52; 95% CI: 1.22-5.20), infection (aHR: 2.14; 95CI %: 1.99-4.58), hyponatremia (aHR: 1.90; 95% CI: 1.10-2.86), mitral regurgitation (aHR: 3.04; 95% CI: 1.98-9.47) and N-terminal pro Brain Natriuretic Peptide > 10000ng/ml (aHR: 2.57; 95% CI: 1.21-5.49) were independently associated with the risk of death in heart failure patients.

CONCLUSION

Acute heart failure leads to high mortality, mainly due to cardiogenic shock and factors of multiple organ failure.

Recurrent Pericarditis and Paradigm Shift in Cardiovascular Imaging and Targeted Therapeutics

Recurrent pericarditis poses a significant challenge to patients and clinicians given its high morbidity and health care burden. Since the last iteration of European Society of Cardiology Guidelines in 2015, further insights have been gained into the pathophysiology, multimodality imaging assessment, and treatment of this condition. The purpose of this review is to discuss each of these aspects and highlight the role of imaging-guided therapy and interleukin-1 inhibitors in autoinflammatory phenotypes that together have transformed the care of these patients. Although future investigations are needed to optimize diagnostic surveillance and timing of therapy, recent evidence points at an encouraging paradigm shift in the treatment of recurrent pericarditis.

Asymptomatic Chronic Large Pericardial Effusions: To Drain or to Observe?

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments.

Cardiac Tuberculosis: A Case Series from Ethiopia, Italy, and Uganda and a Literature Review

Extrapulmonary tuberculosis (TB) is estimated to account for up to 20% of active cases of TB disease, but its prevalence is difficult to ascertain because of the difficulty of diagnosis. Involvement of the heart is uncommon, with constrictive pericarditis being the most common cardiac manifestation. Diagnostic research for cardiac disease is frequently lacking, resulting in a high mortality rate. In addition to direct cardiac involvement, instances of cardiac events during antitubercular therapy are described. This case series describes five cases of TB affecting the heart (cardiac TB) from Italy and high-burden, low-income countries (Ethiopia and Uganda), including a case of Loeffler syndrome manifesting as myocarditis in a patient receiving antitubercular therapy. Our study emphasizes how cardiac TB, rare but important in high-burden areas, is a leading cause of pericardial effusion or pericarditis. Timely diagnosis and a comprehensive approach, including imaging and microbiological tools, are crucial. Implementing high-sensitivity methods and investigating alternative samples, such as detection of tuberculosis lipoarabinomannan or use of the GeneXpert assay with stool, is recommended in TB control programs.

Novel role of cardiovascular MRI to contextualise tuberculous pericardial inflammation and oedema as predictors of constrictive pericarditis

Tuberculosis (TB) and human immunodeficiency virus/acquired immunodeficiency syndrome have reached epidemic proportions, particularly affecting vulnerable populations in low- and middle-income countries of sub-Saharan Africa. TB pericarditis is the commonest cardiac manifestation of TB and is the leading cause of constrictive pericarditis, a reversible (by surgical pericardiectomy) cause of diastolic heart failure in endemic areas. Unpacking the complex mechanisms underpinning constrictive haemodynamics in TB pericarditis has proven challenging, leaving various basic and clinical research questions unanswered. Subsequently, risk stratification strategies for constrictive outcomes have remained unsatisfactory. Unique pericardial tissue characteristics, as identified on cardiovascular magnetic resonance imaging, enable us to stage and quantify pericardial inflammation and may assist in identifying patients at higher risk of tissue remodelling and pericardial constriction, as well as predict the degree of disease reversibility, tailor medical therapy, and determine the ideal timing for surgical pericardiectomy.

Pericardial effusion in children at tertiary national referral hospital, Addis Ababa, Ethiopia: a 7-year institution based review

BACKGROUND

Pericardial effusion (PE) is a rare yet an important cause of child mortality due to collection of excess fluid in pericardial space. The study aimed to describe the PE profile in the national cardiac referral hospital, Addis Ababa, Ethiopia.

METHODS

The study employed cross-sectional study design for a 7-year review of childhood PE in Tikur Anbessa Specialized Hospital. Descriptive and analytic statistics were applied.

RESULTS

There were 17,386 pediatric emergency/ER admissions during the study period, and PE contributed to 0.47% of ER admissions. From 71 included subjects, 59% (42) were males with mean age of 7.8 ± 3.3 years. Cough or shortness of breath,73.2% (52) and fever or fast breathing, 26.7% (19), were the common presenting symptoms. The median duration of an illness before presentation was 14days (IQR: 8-20). The etiologies for pericardial effusion were infective (culture positive-23.9%, culture negative-43.6%, tuberculous-4.2%), hypothyroidism (4.2%), inflammatory (12.7%), malignancy (7%) or secondary to chronic kidney disease (1. 4%). Staphylococcus aureus was the most common isolated bacteria on blood culture, 12.7% (9) while the rest were pseudomonas, 7% (5) and klebsiella, 4.2% (3). Mild, moderate and severe pericardial effusion was documented in 22.5% (16), 46.5% (33), and 31% (22) of study subjects, respectively. Pericardial tamponade was reported in 50.7% (36) of subjects. Pericardial drainage procedure (pericardiocentesis, window or pericardiotomy) was performed for 52.1% (37) PE cases. The case fatality of PE was 12.7% (9). Pericardial drainage procedure was inversely related to mortality, adjusted odds ratio 0.11(0.01-0.99), p 0.049).

CONCLUSION

PE contributed to 0.47% of ER admissions. The commonest PE presentation was respiratory symptoms of around two weeks duration. Purulent pericarditis of staphylococcal etiology was the commonest cause of PE and the case fatality rate was 12.7%. Pericardial drainage procedures contributed to reduction in mortality. All PE cases should be assessed for pericardial drainage procedure to avoid mortality.

Predictors of Coronary Artery Disease in Heart Failure with Reduced Ejection Fraction at the Aga Khan University Hospital in Nairobi

There appears to be an epidemiological transition in the etiology of heart failure in sub-Saharan Africa (SSA) in parallel with a steady increase in risk factors for coronary artery disease (CAD). SSA has limited access to heart failure and CAD diagnostics, limiting the number of patients who receive optimal care. Our objectives were to study the predictors of coronary artery disease among patients with heart failure with reduced ejection fraction (HFrEF) and develop a model to assist clinicians in determining the likelihood of CAD before cardiac catheterization.

Methodology

This was a retrospective study at the Aga Khan University Hospital, Nairobi, which is equipped with diagnostic capabilities for heart failure and coronary artery assessment. We evaluated patients with HFrEF based on echocardiographic data over a 12-year period. Patients with coronary anatomical evaluation data were included. A multivariable model of CAD was generated using stepwise logistic regression.

Results

Of the 1329 patients screened, 514 met the inclusion criteria. The mean age was 61.0 ± 12.8 years. There were 381 male cases (75.2%), and the predominant race was African, numbering 386 (75.2%). Most patients, 97%, were evaluated through conventional coronary angiography. Further, 310 (60.3%) cases had significant CAD. The prevalence of CAD in HFrEF was 52.3% in Africans, 85% in Asians, and 79% in Caucasians. In the multivariable logistic regression, the odds of having significant CAD was higher among participants with diabetes mellitus (aOR: 1.86; 95%CI: 1.15-3.03), Q waves (aOR: 2.12; 95%CI: 1.12-4.10), significant ST segment deviation (aOR: 4.14; 95%CI: 2.23-8.03), and regional wall motion abnormalities on echocardiogram (aOR: 6.53; 95%CI: 3.94-11.06).

Conclusion

In this population, CAD was a major etiology in HFrEF among the African population. The most powerful predictors of CAD were type 2 diabetes, the presence of pathological Q waves, or ST segment shift on a 12-lead electrocardiogram, and regional wall motion abnormality on 2D echocardiogram.

Highlights

There is an epidemiological transition in the cause of heart failure in sub-Saharan Africa (SSA) in keeping with the steady increase in cardiovascular risk factors for coronary artery disease (CAD).The prevalence of CAD in African patients with heart failure with reduced ejection fraction (HFrEF) was 52.3%.In the multivariable logistic regression, diabetic mellitus, pathological Q waves, significant ST segment deviation, and regional wall motion abnormalities were significantly associated with CAD.

The Pandemic of Coronary Artery Disease in the Sub-Saharan Africa: What Clinicians Need to Know

PURPOSE OF REVIEW

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality globally with an accelerated increase in CVD‑related death in Africa and other low‑middle‑income countries. This review is aimed at highlighting the burden of coronary artery disease CAD, its peculiarities as well as challenges of management in sub-Saharan Africa.

RECENT FINDINGS

Recent data revealed a shift from high incidence of CVDs associated with poverty and malnutrition (such as rheumatic heart disease) initially, which are now falling, to rising incidence of other non-communicable CVDs (such as hypertension, coronary artery disease (CAD), and heart failure). Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide, which is projected to supersede communicable diseases in the future. Previous studies have shown that CAD was rare among Africans. Those studies conducted in Africa in the 1940s-1960s reported that Black Africans were almost immune to developing CAD and were even thought to have specific genetic make-up protecting them from CAD. However, the continent is now experiencing a steady rise in the prevalence of CAD associated with severe disease burden, compared to other regions of the world. The changes seen have been attributed to the current epidemiological transition with increase in CVD risk factors that are poorly controlled, lack of awareness as well as the poor health facilities to tackle the menace of the disease. The Global Burden of Disease (GBD) estimates have also shown that over the past three decades the highest contribution to CVD burden in Africa is attributed to atherosclerotic diseases, with 71.4, 37.7, and 154% increases in the burden of ischemic heart disease, stroke, and peripheral artery disease respectively. There is a steady increase of CAD prevalence in Africa as a result of increase in CV risk factors. Hypertension, obesity, diabetes, dyslipidemia, and cigarette smoking are the rapidly rising risk factors for CAD on the continent. Africa also faces challenges in diagnosis and management of CAD. There is need for increased public and health personnel awareness on prevention and control of commonly identifiable risk factors, provision of prehospital emergency services, and provision of modern therapeutic facilities for treatment of CAD including reperfusion therapy. These are priority areas where efforts could be intensified in the future with potential to improve the current rate of progress of the disease on the continent.

Assessment of non-tuberculosis abnormalities on digital chest x-rays with high CAD4TB scores from a tuberculosis prevalence survey in Zambia and South Africa

BACKGROUND

Chest X-rays (CXRs) have traditionally been used to aid the diagnosis of TB-suggestive abnormalities. Using Computer-Aided Detection (CAD) algorithms, TB risk is quantified to assist with diagnostics. However, CXRs capture all other structural abnormalities. Identification of non-TB abnormalities in individuals with CXRs that have high CAD scores but don't have bacteriologically confirmed TB is unknown. This presents a missed opportunity of extending novel CAD systems' potential to simultaneously provide information on other non-TB abnormalities alongside TB. This study aimed to characterize and estimate the prevalence of non-TB abnormalities on digital CXRs with high CAD4TB scores from a TB prevalence survey in Zambia and South Africa.

METHODOLOGY

This was a cross-sectional analysis of clinical data of participants from the TREATS TB prevalence survey conducted in 21 communities in Zambia and South Africa. The study included individuals aged ≥ 15 years who had high CAD4TB scores (score ≥ 70), but had no bacteriologically confirmed TB in any of the samples submitted, were not on TB treatment, and had no history of TB. Two consultant radiologists reviewed the images for non-TB abnormalities.

RESULTS

Of the 525 CXRs reviewed, 46.7% (245/525) images were reported to have non-TB abnormalities. About 11.43% (28/245) images had multiple non-TB abnormalities, while 88.67% (217/245) had a single non-TB abnormality. The readers had a fair inter-rater agreement (r = 0.40). Based on anatomical location, non-TB abnormalities in the lung parenchyma (19%) were the most prevalent, followed by Pleura (15.4%), then heart & great vessels (6.1%) abnormalities. Pleural effusion/thickening/calcification (8.8%) and cardiomegaly (5%) were the most prevalent non-TB abnormalities. Prevalence of (2.7%) for pneumonia not typical of pulmonary TB and (2.1%) mass/nodules (benign/ malignant) were also reported.

CONCLUSION

A wide range of non-TB abnormalities can be identified on digital CXRs among individuals with high CAD4TB scores but don't have bacteriologically confirmed TB. Adaptation of AI systems like CAD4TB as a tool to simultaneously identify other causes of abnormal CXRs alongside TB can be interesting and useful in non-faculty-based screening programs to better link cases to appropriate care.

Pericardial Disease in the Developing World

Pericardial disease in the developing world is dominated primarily by effusive and constrictive syndromes and contributes to the acute and chronic heart failure burden in many regions. The confluence of geography (location in the tropics), a significant burden of diseases of poverty and neglect, and a significant contribution of communicable diseases to the general burden of disease is reflected in the wide etiological spectrum of causes of pericardial disease. The prevalence of Mycobacterium tuberculosis in particular, is high throughout much of the developing world where it is the most frequent and important cause of pericarditis and is associated with significant morbidity and mortality. Acute viral/idiopathic pericarditis, which is the primary manifestation of pericardial disease in the developed world is believed to occur significantly less frequently in the developing world. Although diagnostic approaches and criteria to establish the diagnosis of pericardial disease are similar throughout the globe, resource constraints such as access to multimodality imaging and hemodynamic assessment are a major limitation in much of the developing world. These important considerations significantly influence the diagnostic and treatment approaches, and outcomes related to pericardial disease.

The Evolving Etiologic and Epidemiologic Portrait of Pericardial Disease

Pericardial disease includes a variety of conditions, including inflammatory pericarditis, pericardial effusions, constrictive pericarditis, pericardial cysts, and primary and secondary pericardial neoplasms. The true incidence of this varied condition is not well established, and the causes vary greatly across the world. This review aims to describe the changing pattern of epidemiology of pericardial disease and to provide an overview of causative etiologies. Idiopathic pericarditis (assumed most often to be viral) remains the most common etiology for pericardial disease globally, with tuberculous pericarditis being most common in developing countries. Other important etiologies include fungal, autoimmune, autoinflammatory, neoplastic (both benign and malignant), immunotherapy-related, radiation therapy-induced, metabolic, postcardiac injury, postoperative, and postprocedural causes. Improved understanding of the immune pathophysiological pathways has led to identification and reclassification of some idiopathic pericarditis cases into autoinflammatory etiologies, including immunoglobulin G (IgG)4-related pericarditis, tumour necrosis factor receptor-associated periodic syndrome (TRAPS), and familial Mediterranean fever in the current era. Contemporary advances in percutaneous cardiac interventions and the recent COVID-19 pandemic have also resulted in changes in the epidemiology of pericardial diseases. Further research is needed to improve our understanding of the etiologies of pericarditis, using the assistance of contemporary advanced imaging techniques and laboratory testing. Careful consideration of the range of potential causes and local epidemiologic patterns of causality are important for the optimization of diagnostic and therapeutic approaches.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Heart Diseases of Uncertain Etiology: A New Definition of Heart Failure for Epidemiological Studies

It has been a long time since, in the spectrum of ischemic (IHD) or coronary (CHD) heart diseases, a differentiation was performed between the forms presenting with and those without pain [...].

Infections and Cardiovascular Disease: JACC Focus Seminar 1/4

The burden of cardiovascular diseases is sharply rising in low- and middle-income countries (LMICs). Along with the increasing rates of cardiovascular risk factors in these regions, there is a growing recognition of the contribution of neglected tropical diseases and other infections. Several cardiac implications of these infections have been reported but have not yet been validated by robust population data. This is in part due to limited access to health care and insufficient data collection infrastructure in many LMICs. Therefore, the true impact of these infections on the cardiovascular system may be underestimated, because of both underdiagnosis and underreporting bias. There is an urgent need to thoroughly delineate the cardiac impact of these conditions with elevated prevalence in LMICs and to propose strategies to reduce the negative consequences of these diseases in health systems with limited resources.

Pediatric Pericarditis: Update

PURPOSE OF REVIEW

While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis.

RECENT FINDINGS

We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis.  Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis.

CASE VIGNETTE

A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.

Cardiac dysfunction in active pulmonary tuberculosis: Mysterious facts of TB’s pandora

<b>Introduction</b>: Cardiac dysfunction in pulmonary tuberculosis is relatively more common and underestimated due to lack of suspicion. We have studied prevalence of cardiac dysfunction in pulmonary tuberculosis with special emphasis on echocardiography, serum cortisol and its correlation in cases with unstable cardiorespiratory parameters.<br /> <b>Methods:</b> Prospective, observational, complete workup, and one year follow up study conducted during January 2016 to December 2020 included 800 cases of active pulmonary tuberculosis with specified inclusion criteria of disproportionate tachycardia, tachypnea with or without hypoxia and shock. Cases with known risk factor for cardiac disease and taking cardiac medicines, and cases with pericardial effusion were excluded from study. All study cases were undergone protocolized analysis such as chest radiograph, pulse oximetry, ECG, sputum examination, cardiac enzymes (CPK-MB, NT-Pro-BNP, and cardiac troponins), serum cortisol, and echocardiography at entry point, at two and six months of treatment with anti-tuberculosis medicines as per NTEP. Statistical analysis was carried out by Chi-square test.<br /> <b>Observations and analysis: </b>In a study of 800 pulmonary tuberculosis cases, 56.00% (448/800) cases were males, and 44.00% (352/800) cases were females. Cases with BMI&lt;18 was 41.62% (333/800) and BMI&gt;18 was 58.37% (467/800). Radiological patterns as unilateral disease in 33.62% (269/800) &amp; bilateral disease in 66.37% (531/800). Hemoglobin less than 10 gm% were documented in 85.12% (681/800) and above 10 gm% were in 14.87% (119/800) cases. Serum albumin less than 3.5 gm% and more than 3.5 gm% were observed in 48.12% (385/800) and 51.12% (415/800) cases respectively. Hypoxia was documented 26.12% (209/800) cases and normal oxygen saturation in 73.87% (591/800) cases. cases with normal and abnormal serum cortisol were 61.37% (491/800) &amp; 38.62% (309/800) respectively. Sputum examination for AFB observed in 30.00% (240/800) and gene Xpert MTB/RIF documented in 51.37% (411/800) cases respectively. Bronchoscopy guided techniques were used in 149 cases and BAL smear AFB in 44.96% (67/149) cases, gene Xpert MTB/RIF in 97.31% (145/149) cases and MGIT culture in four cases (positive in 100% cases subjected to MGIT culture). We have observed global hypokinesia is predominant cardiac dysfunction documented in 82.21% (171/208) cases, followed by left heart systolic dysfunction in 16.34% (34/208) cases and left heart diastolic dysfunction in 75% (156/208) cases. Right heart dysfunction as dilated right atrium and right ventricle documented in 52.88% (110/208) cases and pulmonary hypertension in 40.38% (84/208) cases. Covariates such as age, gender, hemoglobin, BMI, serum cortisol, serum albumin, oxygen saturation and radiological involvement has significant association with cardiac dysfunction. (p&lt;0.00001) Response to treatment with antituberculosis medicines and steroids has documented as improved in 77.40% cases (161/208) cases, persistent in 13.46% (28/2028) cases and progressive in 9.13% (19/208) cases. Final outcome of cardiac dysfunction in Pulmonary tuberculosis cases has significant association with serum cortisol level (p&lt;0.00086).<br /> <b>Conclusion:</b> Cardiac dysfunction is active pulmonary tuberculosis needs prompt workup in presence of disproportionate tachypnea, tachycardia with or without hypoxia and shock. Echocardiography is basic tool to evaluate these cases and global hypokinesis is most common abnormality. Serum cortisol abnormality documented in fair number of cases and very well correlated with left ventricular dysfunction abnormalities. Steroids with antituberculosis treatment backup is mainstay protocol during management of these cases. Cardiac dysfunction is reversible in majority of cases and proportionate number shown complete improvement in cardiac dysfunction.

Pulmonary tuberculosis with cardiac dysfunction: An ignored combination!

Cardiovascular involvement is rare in tuberculosis &amp; high index of suspicion is must in diagnosing these cases in high burden setting to have successful treatment outcome. In this case report, 26-year male, presented with constitutional symptoms for three months duration with acute deterioration with tachycardia and tachypnea with hypoxia. Radiological investigations documented conglomerated miliary tuberculosis and confirmed by sputum smear microscopy. Cardiac investigations revealed sinus tachycardia in ECG, raised cardiac enzymes, and echocardiography as ‘global left ventricular hypokinesia’ with reduced ejection fraction. Treatment initiated with steroids with anti-tuberculosis and recorded near complete radiological resolution, bacteriological cure and restored cardiac function after six months with good compliance. We recommend cardiac workup in all pulmonary tuberculosis cases with disproportionate tachycardia.

Two decades of implantable cardioverter defibrillator implantation and follow-up at a South African referral centre: trends, indications and long-term outcomes in a resource-limited setting

Background

More than two-thirds of cardiovascular deaths occur in low- and middle-income countries. Sudden cardiac deaths (SCD) from ventricular arrhythmias are an important cause of cardiovascular deaths. Implantable cardioverter defibrillators (ICD) are an important therapeutic strategy for detecting and terminating ventricular arrhythmias in patients at risk of SCD. The profile of patients treated with ICDs in South Africa is unknown. Further, with changing lines of evidence, the implantation trends are undetermined. The objectives of this study were to determine the profile of ICD recipients and implantation trends in a South African quaternary hospital.

Methods

This was a retrospective review of all patients implanted with ICDs at Groote Schuur Hospital from 01 January 1998 to 31 December 2020. A standardised data collection form was used to collect baseline demographic data, information on clinical presentation and ICD follow-up data for the history of ICD shock therapies.

Results

A total of 253 ICDs were implanted; 75% for secondary prevention and 25% for primary prevention. 67.2% of the implanted ICDs were single-chamber ICDs, dual-chamber ICDs were implanted in 12.3% and Cardiac resynchronisation with a defibrillator (CRT-D) in 20.6%. There was an upward trajectory of ICD implantations during the study period. Increasing numbers of dual-chamber devices and CRT-D were implanted over time. ICD recipients had a mean (standard deviation) age of 50 (14) years and were predominantly male (69%). Primary prevention ICD recipients were younger than secondary prevention recipients, with a mean (SD) age of 46 (14) years versus 51 (14) years, p = 0.019. The secondary prevention group presented with ventricular tachycardia in 81%, ventricular fibrillation in 13% and cardiopulmonary resuscitation without documented heart rhythm in 5.3% (10/190). After a median (interquartile range) follow-up of 44 (15; 93) months, there was an overall mortality rate of 16.2%, with no mortality difference between the primary and secondary prevention patient groups.

Conclusion

There is an increase in the annual number of ICDs implanted at a South African referral centre. ICDs are predominantly implanted for secondary prevention. However, over time the number of devices implanted for primary prevention is steadily increased. During follow-up, there was no mortality difference between the primary prevention and the secondary prevention groups.

Cardiovascular diseases in Africa in the twenty-first century: Gaps and priorities going forward

In 2015, the United Nations set important targets to reduce premature cardiovascular disease (CVD) deaths by 33% by 2030. Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide. There is currently an epidemiological transition on the continent, where NCDs is projected to outpace communicable diseases within the current decade. Unchecked increases in CVD risk factors have contributed to the growing burden of three major CVDs-hypertension, cardiomyopathies, and atherosclerotic diseases- leading to devastating rates of stroke and heart failure. The highest age standardized disability-adjusted life years (DALYs) due to hypertensive heart disease (HHD) were recorded in Africa. The contributory causes of heart failure are changing-whilst HHD and cardiomyopathies still dominate, ischemic heart disease is rapidly becoming a significant contributor, whilst rheumatic heart disease (RHD) has shown a gradual decline. In a continent where health systems are traditionally geared toward addressing communicable diseases, several gaps exist to adequately meet the growing demand imposed by CVDs. Among these, high-quality research to inform interventions, underfunded health systems with high out-of-pocket costs, limited accessibility and affordability of essential medicines, CVD preventive services, and skill shortages. Overall, the African continent progress toward a third reduction in premature mortality come 2030 is lagging behind. More can be done in the arena of effective policy implementation for risk factor reduction and CVD prevention, increasing health financing and focusing on strengthening primary health care services for prevention and treatment of CVDs, whilst ensuring availability and affordability of quality medicines. Further, investing in systematic country data collection and research outputs will improve the accuracy of the burden of disease data and inform policy adoption on interventions. This review summarizes the current CVD burden, important gaps in cardiovascular medicine in Africa, and further highlights priority areas where efforts could be intensified in the next decade with potential to improve the current rate of progress toward achieving a 33% reduction in CVD mortality.

[Évaluation de la qualité de vie et description des facteurs associés, chez les patients en insuffisance cardiaque chronique vivant dans un pays d'Afrique de l'Ouest à faible revenu]

OBJECTIVE

To assess the quality of life (QOL) and describe associated factors in patients with chronic heart failure (HF) living in a low-income population in West Africa.

METHODS

This is was a cross-sectional study conducted from January 2017 to June 2018, in the department of cardiology of the University Teaching Hospital (CHU-Campus) in Lomé (Togo). Enrolled patients had stable chronic HF and have been hospitalized in the past 6 months; QOL was assessed using the Minnesota Living with Heart Failure questionnaire (MLHFQ).

RESULTS

171 patients were included (women = 40.9%, 33% unschooled, 75% without health insurance; 46.8% in NYHA class II). The prevalence of depression was 62%. The mean total score of MLHFQ was 37.2 ± 22.3. In univariate analysis, there was a positive correlation between the total score and the following factors: age (r= 0.33, p ˂0.0001), NYHA classes (r= 0.67, p ˂0.0001), number of rehospitalizations (r= 0.61, p ˂0.0001), number of comorbidities (r= 0.43, p ˂0.0001), and the depression score (r= 0.67, p ˂0.0001). After adjustments, positive correlation persisted with NYHA classes (p ˂0.0001), number of rehospitalizations (p= 0.02), and depression (p ˂0.0001).

CONCLUSION

The QOL of HF patients was moderately impaired and was comparable to values reported among high-income populations. Factors associated with poor quality of life were advanced NYHA classes, number of rehospitalizations, and depression.

Advances in Imaging and Targeted Therapies for Recurrent Pericarditis: A Review

Importance

Pericarditis is the most common form of pericardial disease. Recurrence of pericarditis affects 15% to 30% of patients after the initial episode of pericarditis. Up to 50% of patients with the first recurrence have additional recurrences. These patients often progress to have colchicine-resistant and corticosteroid-dependent disease. Rapidly evolving cardiac magnetic resonance imaging techniques and novel targeted therapies have paved the way for imaging-guided therapy for recurrent pericarditis. However, the optimal application of these recent advances remains unclear.

Observations

A search was conducted using the PubMed and Cochrane databases for English-language studies, management guidelines, meta-analyses, and review articles published until April 2022 on recurrent pericarditis. Following the 2015 European Society of Cardiology guidelines for the diagnosis and management of pericardial diseases, new clinical trials and registry data have emerged that demonstrate the efficacy of interleukin-1 blockers in recurrent pericarditis. In addition, new observational data have come to light supporting the use of cardiac magnetic resonance imaging in the diagnosis, risk stratification, and management of such patients.

Conclusions and Relevance

Advances in imaging and targeted therapies have led to a paradigm shift in the management of recurrent pericarditis. This narrative review summarizes the established and emerging data on the diagnosis and treatment of recurrent pericarditis with special emphasis on the role of cardiac magnetic resonance imaging and interleukin-1 blockers in the current era of tailored therapy for recurrent pericarditis.

Large Pericardial Effusion—Diagnostic and Therapeutic Options, with a Special Attention to the Role of Prolonged Pericardial Fluid Drainage

Background: Large pericardial effusion (LPE) is associated with high mortality. In patients with cardiac tamponade or with suspected bacterial etiology of pericardial effusion, urgent pericardial decompression is necessary. Aim: The aim of the present retrospective study was to assess the short-term results of pericardial decompression combined with prolonged drainage in LPE. Material: This study included consecutive patients with LPE who had been treated with pericardial fluid drainage between 2007 and 2017 in the National Tuberculosis and Lung Diseases Research Institute. Methods: Echocardiographic examination was used to confirm LPE and the signs of cardiac tamponade. Pericardiocentesis or surgical decompression were combined with pericardial fluid (PF) drainage. Short-term effectiveness of therapy was defined as less than 5 mm of fluid behind the left ventricular posterior wall in echocardiography. Results: The analysis included 74 patients treated with pericardial fluid drainage (33 female and 41 male), mean age 58 years, who underwent pericardial decompression. Out of 74 patients, 26 presented with cardiac tamponade symptoms. Pericardiocentesis was performed in 18 patients and pericardiotomy in 56 patients. Median PF drainage duration was 13 days. In 17 out of 25 patients with neoplastic PF, intrapericardial cisplatin therapy was implemented. In 4 out of 49 patients with non-malignant PF, purulent pericarditis was recognized and intrapericardial fibrinolysis was used. Short-term effectiveness of the therapy was obtained in all of patients. Non-infective complications were noted in 16% of patients and infective ones in 10%. Conclusion: Pericardial decompression combined with prolonged PF drainage was safe and efficient method of LPE treatment.

Tuberculous Pericarditis—Own Experiences and Recent Recommendations

Tuberculous pericarditis (TBP) accounts for 1% of all forms of tuberculosis and for 1–2% of extrapulmonary tuberculosis. In endemic regions, TBP accounts for 50–90% of effusive pericarditis; in non-endemic, it only accounts for 4%. In the absence of prompt and effective treatment, TBP can lead to very serious sequelae, such as cardiac tamponade, constrictive pericarditis, and death. Early diagnosis of TBP is a cornerstone of effective treatment. The present article summarises the authors’ own experiences and highlights the current status of knowledge concerning the diagnostic and therapeutic algorithm of TBP. Special attention is drawn to new, emerging molecular methods used for confirmation of M. tuberculosis infection as a cause of pericarditis.

Surgical Treatment of Valvular Heart Disease in Nigeria: A 6-Year Experience

Surgical treatment of valvular heart disease in Nigeria, the most populous country in sub-Saharan Africa, is adversely affected by socioeconomic factors such as poverty and ignorance. To evaluate our experience in this context, we identified all patients who underwent surgery for acquired or congenital valvular heart disease at our Nigerian center from February 2013 through January 2019. We collected data from their medical records, including patient age and sex, pathophysiologic causes and types of valvular disease, surgical treatment, and outcomes. Ninety-three patients (43 males [46.2%]; mean age, 38.9 ± 10.0 yr [range, 11-80 yr]) underwent surgical treatment of a total of 122 diseased valves, including 72 (59.0%) mitral, 26 (21.3%) aortic, 21 (17.2%) tricuspid, and 3 (2.5%) pulmonary. The most prevalent pathophysiologic cause of disease was rheumatic (87 valves [71.3%]), followed by functional (20 [16.4%]), congenital (8 [6.6%]), degenerative (5 [4.1%]), and endocarditic (2 [1.6%]). All 3 diseased pulmonary valves had annular defects associated with congenital disease. Surgical treatment included mechanical prosthetic replacement of 92 valves (75.4%), surgical repair of 29 (23.8%), and bioprosthetic replacement of 1 (0.8%). We conclude that, in Nigeria, valvular disease is mainly rheumatic, affects mostly younger to middle-aged individuals, and is usually treated with prosthetic replacement.

Impact of pericardial fluid glucose level and computed tomography attenuation values on diagnosis of malignancy-related pericardial effusion

Background

We evaluated malignancy according to the characteristics of pericardial fluid in symptomatic Japanese patients undergoing pericardiocentesis and computed tomography (CT).

Methods

This was a retrospective, single-center, observational study of 125 symptomatic patients undergoing pericardiocentesis. The patients were classified into two groups: a malignancy group and a non-malignancy group, according to the primary disease and cytology of the pericardial effusion (PE). We compared the pericardial fluid sample and CT measurements between both groups.

Results

All patients were diagnosed as having exudative PE by Light’s criteria. PE with malignant cells was demonstrated in 76.8% of the malignancy group patients. Pericardial to serum lactate dehydrogenase (LDH) ratio > 0.6, as one of Light’s criteria, was associated with malignancy (p = 0.017). Lower serum brain natriuretic peptide (BNP) concentration was also associated with malignancy (BNP: 126.9 ± 89.8 pg/ml vs 409.2 ± 97.7 pg/ml, malignancy vs non-malignancy groups, respectively; p = 0.037). A significant difference was observed in pericardial fluid glucose level between the malignancy and non-malignancy groups (pericardial fluid glucose: 78.24 ± 48.29 mg/dl vs 98.41 ± 44.85, respectively; p = 0.048). Moreover, CT attenuation values (Hounsfield units (HU)) tended to be higher in the malignancy group vs the non-malignancy group (22.7 [interquartile range (IQR), 17.4–26.0] vs 17.4 [IQR, 13.7–26.4], respectively; p = 0.08). The sensitivity and specificity of pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were 40.9% and 89.6%, respectively, in the malignancy group. The positive- and negative predictive values of pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were 85.7% and 50.0%, respectively, in the malignancy group. Pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were cutoff values associated with malignancy (p = 0.012).

Conclusions

Lower pericardial fluid glucose level with higher CT attenuation values may suggest malignancy-related PE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02091-6.

Background and design of a 5-year ST Elevation Myocardial Infarction Cohort in Isfahan, Iran: SEMI-CI study

BACKGROUND

Cardiovascular disease (CVD) is one of the most important causes of mortality and morbidity in Iran. Secondary prevention of acute myocardial infarction (AMI) is necessary. The main aim of this cohort is evaluating clinical, paraclinical, management, and 5-year major events of the participants in Isfahan, Iran.

METHODS

All consecutive patients with AMI hospitalized in Chamran Hospital, Isfahan, during 1 year from march 2015 were recruited and followed for 5 years. ST-Elevation Myocardial Infarction Cohort Study (SEMI-CI) has been initiated as a longitudinal study to evaluate course of patients with AMI in Iran, adherence to evidence-based secondary prevention drug, and five-year events such as death, re-myocardial infarction (REMI), re-hospitalization, congestive heart failure (CHF), and referring to another procedure [percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and resynchronization therapy].

RESULTS

A total of 867 patients with ST-elevation myocardial infarction (STEMI) with mean age of 60.91 ± 12.76 years were recruited. 705 (81.3%) subjects were men with mean age of 59.63 ± 12.59 years. 470 (54.2%) patients had anterior AMI (ant-AMI) and the rest had other types of AMI. The ejection fraction (EF) mean was 37.80 ± 11.74 percent. A total of 30 (3.5%) cases of AMI had not received reperfusion. 445 (51.4%) had primary PCI and 392 (45.2%) had thrombolysis at first revascularization strategy. In-hospital death occurred in 72 participants (8.3%). Drug during hospital included: at discharge, 767 (88.5%) received aspirin, 787 (90.7%) statin, 697 (80.4%) beta-blocker, and 480 (55.4%) angiotensin-converting enzyme (ACE) inhibitor.

CONCLUSION

According to the best of our knowledge, it is among few cohorts in Eastern Mediterranean Region (EMR) in patients with AMI. This paper showed methodology of this study in patients with STEMI and its follow-up protocol. We can use this result in policy-making for improving secondary prevention strategies.

Tuberculosis and the Heart

Acquired tuberculosis continues to be a challenge worldwide. Although tuberculosis has been considered a global public health emergency, it remains poorly controlled in many countries. Despite being primarily a pulmonary disease, tuberculosis could involve the heart. This systematic review is part of the "Neglected Tropical Diseases and Other Infectious Diseases Involving the Heart" (the NET-Heart Project) initiative from the Interamerican Society of Cardiology. This project aims to review the cardiovascular involvement of these heterogeneous diseases, advancing original algorithms to help healthcare providers diagnose and manage cardiovascular complications. In tuberculosis, pericardium involvement is relatively common, especially in AIDS, and tuberculosis is the most common cause of constrictive pericarditis in endemic countries. Myocarditis and aortitis by tuberculosis are rare. Clinical manifestations of cardiovascular involvement by tuberculosis differ from those typically found for bacteria or viruses. Prevailing systemic symptoms and the pericarditis diagnostic index should be taken into account. An echocardiogram is the first step for diagnosing cardiovascular involvement; however, several image modalities can be used, depending on the suspected site of infection. Adenosine deaminase levels, gamma interferon, or polymerase chain reaction testing could be used to confirm tuberculosis infection; each has a high diagnostic performance. Antituberculosis chemotherapy and corticosteroids are treatment mainstays that significantly reduce mortality, constriction, and hospitalizations, especially in patients with HIV. In conclusion, tuberculosis cardiac involvement is frequent and could lead to heart failure, constrictive pericarditis, or death. Early detection of complications should be a cornerstone of overall management.

Management of acute and recurrent pericarditis in pregnancy

This review summarizes the currently available evidence on the management of acute and recurrent pericarditis during pregnancy, focusing on the safety of diagnostic procedures and treatment options for the mother and foetus. Family planning should be addressed in women with recurrent pericarditis of reproductive age and adjustment of therapy should be considered before a planned pregnancy. The treatment of pericarditis in pregnancy is similar to that for non-pregnant women but considers current knowledge on drug safety during pregnancy and lactation. The largest case series on this topic described 21 pregnancies with idiopathic recurrent pericarditis. Pregnancy should be planned in a phase of disease quiescence. Non-steroidal anti-inflammatory drugs can be used at high dosages until the 20th week of gestation (except low-dose aspirin 100 mg/die). Colchicine is allowed until gravindex positivity; after this period, administration of this drug during pregnancy and lactation should be discussed with the mother if its use is important to control recurrent pericarditis. Prednisone is safe if used at low-medium doses (2,5 - 10 mg/die). General outcomes of pregnancy in patients with pericarditis are good when the mothers are followed by a multidisciplinary team with experience in the field.

Epidemiological Impact of Myocarditis

Myocarditis is an inflammatory disease of the heart muscle with a wide range of potential etiological factors and consequently varying clinical patterns across the world. In this review, we address the epidemiology of myocarditis. Myocarditis was considered a rare disease until intensified research efforts in recent decades revealed its true epidemiological importance. While it remains a challenge to determine the true prevalence of myocarditis, studies are underway to obtain better approximations of the proportions of this disease. Nowadays, the prevalence of myocarditis has been reported from 10.2 to 105.6 per 100,000 worldwide, and its annual occurrence is estimated at about 1.8 million cases. This wide range of reported cases reflects the uncertainty surrounding the true prevalence and a potential underdiagnosis of this disease. Since myocarditis continues to be a significant public health issue, particularly in young adults in whom myocarditis is among the most common causes of sudden cardiac death, improved diagnostic and therapeutic procedures are necessary. This manuscript aims to summarize the current knowledge on the epidemiology of myocarditis, new diagnostic approaches and the current epidemiological impact of the COVID-19 pandemic.

Effusive-Constrictive Pericarditis due to Immune Reconstitution Inflammatory Syndrome following Tuberculous Pericarditis

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Tuberculous pericarditis is the most common cause of pericarditis worldwide.

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Consider the possibility of TB-IRIS in patients with tuberculous pericarditis.

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Corticosteroids might be necessary, but there are several caveats to consider.

Neurologic complications of myocarditis

Myocarditis, a nonischemic acquired cardiomyopathy, is an uncommon condition with multiple presentation patterns which may be initially difficult to recognize and may simulate other conditions such as acute myocardial infarction, pericarditis, septicemia, etc. There are four distinct clinical presentation patterns that include: (1) low-grade nonspecific symptoms such as fatigue; (2) symptoms that resemble an acute myocardial infarction, especially in younger individuals; (3) a heart failure presentation which may be acute, subacute, or chronic and may be associated with cardiac conduction system defects and arrhythmias; and (4) an arrhythmia presentation that may produce sudden cardiac death, especially in young athletes with minimal or no prodromal symptoms. This chapter will provide a brief overview of various myocarditis etiologies and diagnostic modalities. The ultimate focus will be directed toward neurologic manifestations of myocarditis and its subtypes, complications of specific therapies including extracorporeal membrane oxygenation (ECMO) for refractory heart failure, and review the current literature regarding the appropriate use of therapeutic anticoagulation in myocarditis and heart failure for stroke prevention. Covid-19 infection has been discovered to cause myocarditis. The emerging science will be discussed. Nuances of brain death (BD) determination in patients receiving venoarterial ECMO for heart failure refractory to standard medical therapies will be discussed.

Prevalence of cardiometabolic syndrome in HIV-infected persons: a systematic review

INTRODUCTION

HIV infected persons are twofold likely to experience a heart attack, stroke, and other forms of Cardiometabolic Syndrome (CMetS).

METHODS

Electronic searches of databases (MEDLINE and Google Scholar) were queried for articles written in English from 2000 to 2019.

RESULTS

In this review (16 publications), a total of 14,002 participants from 8 countries were included. Two continents contributed to 62.5% of the CMetS studies while 38.1% from Latin America and 24.4% from North America. The studies were conducted in 113 different centers, with an average study length of 2.8 years. The majority of the study designs were cross-sectional (62%) followed by a cohort study (25%) and clinical trials (12.5%). The mean age of the population enrolled was 41.9 years and 54.6% of the participants were males. The overall prevalence of CMetS using the National Cholesterol Education Adult Treatment Panel definition was 20.6%. Only 31.3% of the studies were reported using the International Diabetes Federation definition. Smoking and high blood pressure were reported as a risk factor in 62.5% of the studies, while diabetes (31.3%), family history of CMetS (25%), and cardiac vascular and cancer diseases were reported in 12.5% of the studies. The average duration of stay with HIV after confirmation was 5.23 + 1.4 (years + SD) and the median duration on HAART was 4.5 + 2.3 (years + SD).

CONCLUSIONS

CMetS was a common problem among HIV infected persons. Several RFs can contribute to the development of CMetS with smoking and hypertension highly interrelated.

PROSPERO-NUMBER

CRD42018107187.

The role of cardiac imaging in the management of non-ischemic cardiovascular diseases in human immunodeficiency virus infection

Infection with human immunodeficiency virus (HIV) has become the pandemic of the new century. About 36.9 million people are living with HIV worldwide. The introduction of antiretroviral therapy in 1996 has dramatically changed the global landscape of HIV care, resulting in significantly improved survival and changing HIV to a chronic disease. With near-normal life expectancy, contemporary cardiac care faces multiple challenges of cardiovascular diseases, disorders specific to HIV/AIDS, and those related to aging and higher prevalence of traditional risk factors. Non-ischemic cardiovascular diseases are major components of cardiovascular morbidity and mortality in HIV/AIDS. Non-invasive cardiac imaging plays a pivotal role in the management of these diseases. This review summarizes the non-ischemic presentation of the HIV cardiovascular spectrum focusing on the role of cardiac imaging in the management of these disorders.

Tuberculous pericardial disease: a focused update on diagnosis, therapy and prevention of complications

Tuberculous pericarditis (TBP) is the most important manifestation of tuberculous heart disease and is still associated with a significant morbidity and mortality in TB endemic areas. The high prevalence of the disorder over the last 3 decades has been fueled by the human immunodeficiency virus/AIDS (HIV/AIDS) pandemic in these areas. The objective of this review is to provide a focused update on developments in the diagnosis and therapy of this condition, prevention of its complications, as well as future novel therapies. The definitive diagnosis of a tuberculous etiology in patients with suspected TBP continues to pose a challenge for clinicians. Clinical prediction scores, although never formally validated have been used with some success. However, they may be prone to both over and underdiagnosis due to lack of pericardial fluid analysis. Recent studies evaluating Xpert MTB/RIF, suggest that this advanced polymerase chain reaction (PCR) based technology does not provide increased accuracy compared to earlier iterations. However a combined two test approach starting with Xpert MTB/RIF followed by either adenosine deaminase (ADA) or interferon gamma (IFN-γ) may provide for significantly enhanced specificity and sensitivity cost permitting. Pericardiocentesis remains the gold standard for managing the compressive pericardial fluid and its adverse hemodynamic sequelae. A four drug anti-TB drug regimen at standard doses and duration is recommended. However recent evidence suggests that these drugs penetrate the pericardium very poorly potentially explaining the high mortality observed particularly in those who are culture positive with a high bacillary load. Constrictive pericarditis is the main long-term complication of TBP and is still a significant cause of heart failure in Sub-Saharan Africa. This is important because access to definitive surgical therapy where TBP is prevalent continues to be low, highlighting the need to develop strategies or interventions to prevent fibrosis and constriction. Recent detailed advanced studies of pericardial fluid in TBP have revealed a strong profibrotic transcriptomic profile, with high amounts of pro-inflammatory cytokines and low levels of the anti-fibrotic tetrapeptide N-Acetyl-Seryl-Aspartyl-Lysyl-Proline (Ac-SDKP). These new insights may explain in part the high propensity to fibrosis associated with the condition and offer hope for the future use of targeted therapy to interrupt pathways and mediators of tissue damage and subsequent maladaptive healing and fibrosis. The value of effective pericardiocentesis in reducing these pro-inflammatory and pro-fibrotic cytokines and peptides in an attempt to prevent pericardial constriction has yet to be established but has generated hypotheses for ongoing and future research.

Treatment outcome and its predictors among patients of acute heart failure at a tertiary care hospital in Ethiopia: a prospective observational study

Background

Acute heart failure is a rapid onset of new or worsening of signs and symptoms of heart failure that requires hospitalization or a visit to the emergency department. The aim of this study was to evaluate treatment outcome and determine factors that predict a poor treatment outcome in acute heart failure patients at a Tertiary Care Hospital in Ethiopia.

Methods

A prospective observational study design was used. Data were collected using a structured questionnaire as a tool. Outcome variables were assessed at the time of discharge from the hospital. Bivariate and multivariate logistic regression analyses were used to determine factors that predict in-hospital mortality. A p-value ≤0.05 was considered as statistically significant.

Results

Out of the 169 patients, the median age of patients with acute heart failure was 34 years (IQR = 23 to 50) and median hospital stay was 4.0 days (IQR = 3.0 to 6.0). The leading precipitating factor and underlying disease at the time of admission were pneumonia (47.5%) and chronic rheumatic heart disease (48.5%), respectively. The in-hospital mortality was found to be 17.2%. Smoking (adjusted odds ratio (AOR) = 8.7, p = 0.006), diabetes mellitus (AOR = 10.2, p = 0.005), pulmonary hypertension (AOR = 4.3, p = 0.016), and the presence of adverse drug events (AOR = 4.2, p = 0.003) were predictors of in-hospital mortality.

Conclusion

High in-hospital mortality was observed among acute heart failure patients admitted to a Tertiary Care Hospital in Ethiopia. Smoking, diabetes mellitus, pulmonary hypertension and the presence of adverse drug events were predictors of in-hospital mortality.

Management of Acute and Recurrent Pericarditis: JACC State-of-the-Art Review

Pericarditis refers to the inflammation of the pericardial layers, resulting from a variety of stimuli triggering a stereotyped immune response, and characterized by chest pain associated often with peculiar electrocardiographic changes and, at times, accompanied by pericardial effusion. Acute pericarditis is generally self-limited and not life-threatening; yet, it may cause significant short-term disability, be complicated by either a large pericardial effusion or tamponade, and carry a significant risk of recurrence. The mainstay of treatment of pericarditis is represented by anti-inflammatory drugs. Anti-inflammatory treatments vary, however, in both effectiveness and side-effect profile. The objective of this review is to summarize the up-to-date management of acute and recurrent pericarditis.

Cardiac ultrasound in resource-limited settings (CURLS): towards a wider use of basic echo applications in Africa

Background

Point-of-care ultrasound is increasingly being used as a diagnostic tool in resource-limited settings. The majority of existing ultrasound protocols have been developed and implemented in high-resource settings. In sub-Saharan Africa (SSA), patients with heart failure of various etiologies commonly present late in the disease process, with a similar syndrome of dyspnea, edema and cardiomegaly on chest X-ray. The causes of heart failure in SSA differ from those in high-resource settings. Point-of-care ultrasound has the potential to identify the underlying etiology of heart failure, and lead to targeted therapy. Based on a literature review and weighted score of disease prevalence, diagnostic impact and difficulty in performing the ultrasound, we propose a context-specific cardiac ultrasound protocol to help differentiate patients presenting with heart failure in SSA.

Results

Pericardial effusion, dilated cardiomyopathy, cor pulmonale, mitral valve disease, and left ventricular hypertrophy were identified as target conditions for a focused ultrasound protocol in patients with cardiac failure and cardiomegaly in SSA. By utilizing a simplified 5-question approach with all images obtained from the subxiphoid view, the protocol is suitable for use by health care professionals with limited ultrasound experience.

Conclusions

The “Cardiac ultrasound for resource-limited settings (CURLS)” protocol is a context-specific algorithm designed to aid the clinician in diagnosing the five most clinically relevant etiologies of heart failure and cardiomegaly in SSA. The protocol has the potential to influence treatment decisions in patients who present with clinical signs of heart failure in resource-limited settings outside of the traditional referral institutions.

The burden of acute coronary syndrome, heart failure, and stroke among emergency department admissions in Tanzania: A retrospective observational study

Introduction

The prevalence of cardiovascular disease in sub-Saharan Africa is substantial and growing. Much remains to be learned about the relative burden of acute coronary syndrome (ACS), heart failure, and stroke on emergency departments and hospital admissions.

Methods

A retrospective chart review of admissions from September 2017 through March 2018 was conducted at the emergency department of a tertiary care center in northern Tanzania. Stroke admission volume was compared to previously published data from the same hospital and adjusted for population growth.

Results

Of 2418 adult admissions, heart failure and stroke were the two most common admission diagnoses, accounting for 294 (12.2%) and 204 (8.4%) admissions, respectively. ACS was uncommon, accounting for 9 (0.3%) admissions. Of patients admitted for heart failure, uncontrolled hypertension was the most commonly identified etiology of heart failure, cited in 124 (42.2%) cases. Ischemic heart disease was cited as the etiology in only 1 (0.3%) case. Adjusting for population growth, the annual volume of stroke admissions increased 70-fold in 43 years, from 2.9 admissions per 100,000 population in 1974 to 202.2 admissions per 100,000 in 2017.

Conclusions

The burden of heart failure and stroke on hospital admissions in Tanzania is substantial, and the volume of stroke admissions is rising precipitously. ACS is a rare diagnosis, and the distribution of cardiovascular disease phenotypes in Tanzania differs from what has been observed outside of Africa. Further research is needed to ascertain the reasons for these differences.

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In northern Tanzania, acute coronary syndrome is a rare admission diagnosis

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Heart failure and stroke are the most common admission diagnoses

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The burden of stroke admissions in this community is rising rapidly

[Epidemioclinical and evolutionary profile of dilated cardiomyopathies at the University Hospital in Brazzaville, Congo]

L'objectif de cette étude est de contribuer à l'amélioration de la prise en charge des patients porteurs de cardiomyopathies dilatées (CMD) à Brazzaville. Cette étude, prospective et analytique, a été réalisée au CHU de Brazzaville entre le 1^er Janvier 2014 et le 30 Juin 2015. Elle a inclus les patients hospitalisés dans le service de cardiologie pour une insuffisance cardiaque (IC) en rapport avec une CMD. L'étude a porté sur 100 patients. La fréquence hospitalière de la CMD était de 32,1%. Il s'agissait de 38 hommes (38%) et 62 femmes (62%), âgés en moyenne de 52,9 ± 17,1 ans. L'IC était globale dans 72 cas (72%). L'ECG s'inscrivait en rythme sinusal (95%), et objectivait une hypertrophie ventriculaire gauche (40%), un bloc de branche gauche (16%), et une fibrillation auriculaire (5%). La fraction d'éjection du ventricule gauche (VG) était en moyenne de 33,4 ± 6,8%, et le diamètre télédiastolique du VG de 65,5 ± 7,0 mm. Le traitement comportait un diurétique de l'anse (100%), un IEC/ARA2 (100%), un bêtabloquant (38%), un digitalique (30%), un anti-aldostérone (16%), et un anti-vitamine K (11%). Au terme d'un suivi de 12 mois, le taux de létalité globale était de 9%, le taux de réhospitalisation de 12%, et le taux de perdus de vue de 41%. Cette étude a montré que la CMD est une affection fréquente, et une des principales causes d'insuffisance cardiaque. La durée de suivi brève et le nombre important de perdus de vue ne permettent pas d'en évaluer la survie dans notre contexte.

Epidemiology of pericardial diseases in Africa: a systematic scoping review

OBJECTIVES

This scoping review sought to summarise available data on the prevalence, aetiology, diagnosis, treatment and outcome of pericardial disease in Africa.

METHODS

We searched PubMed, Scopus and African Journals Online from 1 January 1967 to 30 July 2017 to identify all studies published on the prevalence, aetiologies, diagnosis, treatment and outcomes of pericardial diseases in adults residing in Africa.

RESULTS

36 studies were included. The prevalence of pericardial diseases varies widely according to the population of interest: about 1.1% among people with cardiac complaints, between 3.3% and 6.8% among two large cohorts of patients with heart failure and up to 46.5% in an HIV-infected population with cardiac symptoms. Tuberculosis is the most frequent cause of pericardial diseases in both HIV-uninfected and HIV-infected populations. Patients with tuberculous pericarditis present mostly with effusive pericarditis (79.5%), effusive constrictive pericarditis (15.1%) and myopericarditis (13%); a large proportion of them (up to 20%) present in cardiac tamponade. The aetiological diagnosis of pericardial diseases is challenging in African resource-limited settings, especially for tuberculous pericarditis for which the diagnosis is not definite in many cases. The outcome of these diseases remains poor, with mortality rates between 18% and 25% despite seemingly appropriate treatment approaches. Mortality is highest among patients with tuberculous pericarditis especially those coinfected with HIV.

CONCLUSION

Pericardial diseases are a significant cause of morbidity and mortality in Africa, especially in HIV-infected individuals. Tuberculosis is the most frequent cause of pericardial diseases, and it is associated with poor outcomes.

Validation of heart failure quality of life tool and usage to predict all-cause mortality in acute heart failure in Uganda: the Mbarara heart failure registry (MAHFER)

BACKGROUND

The health-related quality of life (HRQoL) is an important treatment goal that could serve as low-cost prognostication tool in resource poor settings. We sought to validate the Kansas City Cardiomyopathy Questionnaire (KCCQ) and evaluate its use as a predictor of 3 months all-cause mortality among heart failure participants in rural Uganda.

METHODS

The Mbarara Heart Failure Registry Cohort study observes heart failure patients during hospital stay and in the community in rural Uganda. Participants completed health failure evaluations and HRQoL questionnaires at enrollment, 1 and 3 months of follow-up. We used Cronbach's alpha coefficients to define internal consistency, intraclass correlation coefficients as a reliability coefficient, and Cox proportional hazard models to predict the risk of 3 months all-cause mortality.

RESULTS

Among the 195 participants who completed HRQoL questionnaires, the mean age was 52 (standard deviation (SD) 21.4) years, 68% were women and 29% reported history of hypertension. The KCCQ had excellent internal consistency (87% Cronbach alpha) but poor reliability. Independent predictors of all-cause mortality within 3 months included: worse overall KCCQ score (Adjusted Hazard ratio (AHR) 2.9, 95% confidence interval (CI) 1.1, 8.1), highest asset ownership (AHR 3.6, 95% CI 1.2, 10.8), alcoholic drinks per sitting (AHR per 1 drink 1.4, 95% CI 1.0, 1.9), New York Heart Association (NYHA) functional class IV heart failure (AHR 2.6, 95% CI 1.3, 5.4), estimated glomerular filtration rate (eGFR) 30 to 59 ml/min/1.73 m2 (AHR 3.4, 95% CI 1.1, 10.8), and eGFR less than 15 ml/min/1.73 m2 (AHR 2.7, 95% CI 1.0, 7.1), each 1 pg/mL increase in Brain Natriuretic Peptide (BNP) (AHR, 1.0, 95% CI 1.0, 1.0), and each 1 ng/mL increase in Creatine-Kinase MB isomer (CKMB) (AHR 1.0, 95% CI 1.0, 1.1).

CONCLUSION

The KCCQ showed excellent internal consistency. Worse overall KCCQ score, highest asset ownership, increasing alcoholic drink per sitting, NYHA class IV, decreased estimated glomerular filtration rate, BNP, and CKMB predicted all-cause mortality at 3 months. The KCCQ could be an additional low-cost tool to aid in the prognostication of acute heart failure patients.