The burden of cardiac diseases in Sub-Saharan Africa

It is widely acknowledged that sub-Saharan Africa faces a double burden of diseases. On the one hand are the communicable diseases of HIV, tuberculosis and malaria and the other, cardiovascular disease, respectively the commonest and second most common causes of death and disability on the continent

Time to end Rheumatic Heart Disease: Lessons and opportunities from observational registries

The fight against Rheumatic Heart Disease (RHD) is at a critical juncture. Despite the adoption of a global resolution by the World Health Assembly against RHD in May 2018, practitioners working in countries where RHD is endemic continue to be faced with an overwhelming clinical burden, lack of surgical and interventional resources, and insufficient opportunities and funding for research. Recent years have seen the publication of several observational registries, most of which were investigator-initiated, not supported by larger research funders, and coordinated by small teams using paper-based infrastructure. This commentary reflects on the lessons and opportunities that these registries have afforded the field and suggests some areas for further investigation

Quantification of echodensities in tuberculous pericardial effusion using fractal geometry: a proof of concept study

BACKGROUND:The purpose of this study was to quantify the heterogeneous distribution of echodensities in the pericardial fluid of patients with tuberculous pericarditis using echocardiography and fractal analysis, and to determine whether there were differences in the fractal dimensions of effusive-constrictive and effusive non-constrictive disease. METHODS: We used fractal geometry to quantify the echocardiographic densities in patients who were enrolled in the Investigation of the Management of Pericarditis in Africa (IMPI Africa) Registry. Sub-costal and four chamber images were included in the analysis if a minimum of two clearly identified fibrin strands were present and the quality of the images were of a standard which allowed for accurate measurement of the fractal dimension. The fractal dimension was calculated as follows: Df=limlog N(s)/[log (l/s)], where Df is the box counting fractal dimension of the fibrin strand, s is the side length of the box and N(s) is the smallest number of boxes of side length s to cover the outline of the object being measured. We compared the fractal dimension of echocardiographic findings in patients with effusive constrictive pericarditis to effusive non-constrictive pericardial effusion using the non-parametric Mann-Whitney test. RESULTS: Of the 14 echocardiographs from 14 participants that were selected for the study, 42.8% (6/14) of images were subcostal views while 57.1% (8/14) were 4-chamber views. Eight of the patients had tuberculous effusive constrictive pericarditis while 6 had tuberculous effusive non-constrictive pericarditis. The mean fractal dimension Df was 1.325 with a standard deviation (SD) of 0.146. The measured fibrin strand dimension exceeded the topological dimension in all the images over the entire range of grid scales with a correlation coefficient (r2) greater than 0.8 in the majority. The fractal dimension of echodensities was 1.359+/-0.199 in effusive constrictive pericarditis compared to 1.330+/-0.166 in effusive non-constrictive pericarditis (p=0.595). CONCLUSIONS: The echocardiographic densities in tuberculous pericardial effusion have a fractal geometrical dimension which is similar in pure effusive and effusive constrictive disease

COVID-19 and heart failure

Acute and chronic heart failure patients have a 2- to 3-fold increased risk of complicating with severe COVID-19, and these patients tend to have multiple comorbidities which are the primary aetiologies for the heart failure clinical syndrome. Furthermore, the incidence and prevalence of heart failure increases with advanced age, and advanced age is an independent risk factor for poor prognosis and mortality. The SARSCoV-2 infection also has multiple mechanisms that cause acute heart failure and precipitate acutely decompensated chronic heart failure. Additionally, the optimal management of these patients has been marred with the controversy around the use of the renin-angiotensin-aldosterone system blockers. This review provides an update on how heart failure patients should be managed during COVID-19 and summarises the existing evidence, focusing on heart failure

Effectiveness of implantable loop recorder and Holter electrocardiographic monitoring for the detection of arrhythmias in patients with peripartum cardiomyopathy

Background Patients with peripartum cardiomyopathy (PPCM) are at increased risk of sudden cardiac death (SCD). However, the exact underlying mechanisms of SCD in PPCM remain unknown. By means of extended electrocardiographic monitoring, we aimed to systematically characterize the burden of arrhythmias occurring in patients with newly diagnosed PPCM. Methods and results Twenty-five consecutive women with PPCM were included in this single-centre, prospective clinical trial and randomised to receiving either 24 h-Holter ECG monitoring followed by implantable loop recorder implantation (ILR; REVEAL XT, Medtronic®) or 24 h-Holter ECG monitoring alone. ILR + 24 h-Holter monitoring had a higher yield of arrhythmic events compared to 24 h-Holter monitoring alone (40% vs 6.7%, p = 0.041). Non-sustained ventricular tachycardia (NSVT) occurred in four patients (16%, in three patients detected by 24 h-Holter, and multiple episodes detected by ILR in one patient). One patient deceased from third-degree AV block with an escape rhythm that failed. All arrhythmic events occurred in patients with a severely impaired LV systolic function. Conclusions We found a high prevalence of potentially life-threatening arrhythmic events in patients with newly diagnosed PPCM. These included both brady- and tachyarrhythmias. Our results highlight the importance of extended electrocardiographic monitoring, especially in those with severely impaired LV systolic function. In this regard, ILR in addition to 24 h-Holter monitoring had a higher yield of VAs as compared to 24 h-Holter monitoring alone. In settings where WCDs are not readily available, ILR monitoring should be considered in patients with severely impaired LV systolic dysfunction, especially after uneventful 24 h-Holter monitoring

Interventional cardiology during the COVID-19 epidemic

The impact of the COVID-19 pandemic on our lives is unprecedented and major adjustments to our practices as physicians are required. Although our comments are applicable at the time of writing, the situation changes daily and the content of this article should be adjusted accordingly.Cath lab: An unambiguous cath lab protocol should be drawn up for each facility, appropriate to local circumstances. This should include standard procedures in preparation for arrival at the lab, in the performance of procedures, and, importantly, in maintaining due diligence when removing protective gear. All team members should be well trained in these procedures.Acute coronary syndromes: Standard timing for the invasive management of patients should not change during the pandemic. Due to delays often unavoidable during the pandemic, alternative strategies such as thrombolysis may be more readily available and therefore more appropriate.Drugs: The sick COVID-19 patient often represents a pro-thrombotic state and operators should ensure adequate anti-thrombotic therapy. Knowledge of interactions between cardiac drugs and investigational antiviral treatments is important.Elective procedures: Patients with chronic cardiac conditions are at high risk and may require non-urgent procedures to avert major complications. Selecting these cases requires consideration of multiple risks and benefits

Advancing global health through cardiovascular research, mentorship, and capacity building: in memoriam, professor Bongani Mayosi (1967–2018)

We are deeply saddened by the passing of Professor Bongani Mayosi. Bongani was one of the inaugural board members of Pilot and Feasibility Studies. He contributed greatly to the design and conduct of pilot and feasibility studies in cardiovascular research. Before his untimely death on Friday, July 27, 2018, he rose rapidly through the ranks to become a top cardiologist and one of the premier medical researchers in South Africa, Africa and the World Born in Mthatha, Eastern Cape Province on January 28, 1967, Bongani Mawethu Mayosi followed in his father’s footsteps to become a doctor. He trained at the now Nelson R. Mandela School of Medicine at University of KwaZulu-Natal, where he received his M.B., Ch.B. (Cum Laude) in 1989 and also met his wife, Professor and Head of Dermatology, Nonhlanhla Khumalo, in their first week of medical school. In 1990, the pair made their way to Port Elizabeth to work at the Livingstone Hospital as interns, before moving to Cape Town to establish long-term careers. After completing his specialist training in internal medicine and cardiology at the University of Cape Town (UCT), Professor Mayosi moved to Oxford University, UK, on a prestigious Nuffield Medical Fellowship where he completed a D.Phil. in cardiovascular genetics at the Wellcome Trust Centre for Human Genetics

Cardio-thoracic ratio is stable, reproducible and has potential as a screening tool for HIV-1 related cardiac disorders in resource poor settings

BACKGROUND: Cardiovascular disorders are common in HIV-1 infected persons in Africa and presentation is often insidious. Development of screening algorithms for cardiovascular disorders appropriate to a resource-constrained setting could facilitate timely referral. Cardiothoracic ratio (CTR) on chest radiograph (CXR) has been suggested as a potential screening tool but little is known about its reproducibility and stability. Our primary aim was to evaluate the stability and the inter-observer variability of CTR in HIV-1 infected outpatients. We further evaluated the prevalence of cardiomegaly (CTR≥0.5) and its relationship with other risk factors in this population. METHODOLOGY: HIV-1 infected participants were identified during screening for a tuberculosis vaccine trial in Khayelitsha, South Africa between August 2011 and April 2012. Participants had a digital posterior-anterior CXR performed as well as history, examination and baseline observations. CXRs were viewed using OsiriX software and CTR calculated using digital callipers. RESULTS: 450 HIV-1-infected adults were evaluated, median age 34 years (IQR 30-40) with a CD4 count 566/mm 3 (IQR 443-724), 70% on antiretroviral therapy (ART). The prevalence of cardiomegaly was 12.7% (95% C.I. 9.6%-15.8%). CTR was calculated by a 2 nd reader for 113 participants, measurements were highly correlated r = 0.95 (95% C.I. 0.93-0.97) and agreement of cardiomegaly substantial κ = 0.78 (95% C.I 0.61-0.95). CXR were repeated in 51 participants at 4-12 weeks, CTR measurements between the 2 time points were highly correlated r = 0.77 (95% C.I 0.68-0.88) and agreement of cardiomegaly excellent κ = 0.92 (95% C.I. 0.77-1). Participants with cardiomegaly had a higher median BMI (31.3; IQR 27.4-37.4) versus 26.9; IQR 23.2-32.4); p<0.0001) and median systolic blood pressure (130; IQR 121-141 versus 125; IQR 117-135; p = 0.01). CONCLUSION: CTR is a robust measurement, stable over time with substantial inter-observer agreement. A prospective study evaluating utility of CXR to identify cardiovascular disorder in this population is warranted