Variation in Secondary Prevention of Coronary Heart Disease: The INTERASPIRE Study.

BACKGROUND AND AIMS: INTERASPIRE is an international study of coronary heart disease (CHD) patients, designed to measure if guideline standards for secondary prevention and cardiac rehabilitation are being achieved in a timely manner. METHODS: Between 2020-2023, adults hospitalized in the preceding 6-24 months with incident or recurrent CHD were sampled in 14 countries from all 6 World Health Organization regions and invited for a standardized interview and examination. Direct age and sex standardization was used for country-level prevalence estimation. RESULTS: Overall, 4548 (21.1% female) CHD patients were interviewed a median of 1.05 (interquartile range 0.76-1.45) years after index hospitalization. Among all participants, 24% were obese (40% centrally). Only 38.5% achieved a blood pressure (BP) <130/80 mmHg and 19.2% a low-density lipoprotein cholesterol (LDL-C) of <1.4 mmol/l. Of those smoking at hospitalization, 48% persisted at interview. Of those with known diabetes, 56% achieved glycated hemoglobin (HbA1c) of <7.0%. A further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. Females were less likely to achieve targets: BP (females 37.4% males 38.6%), LDL-C (females 13.7% males 18.6%) and HbA1c in diabetes (females 47.7% males 57.5%). Overall, just 9.0% (inter-country range 3.8%-20.0%) reported attending cardiac rehabilitation and 1.0% (inter-country range 0.0%-2.4%) achieved the study definition of optimal guideline adherence. CONCLUSIONS: INTERASPIRE demonstrates inadequate and heterogeneous international implementation of guideline standards for secondary prevention in the first year after CHD hospitalization, with geographic and sex disparity. Investment aimed at reducing between-country and between-individual variability in secondary prevention will promote equity in global efforts to reduce the burden of CHD.

Clinical presentation, management, and 6-month outcomes in women with peripartum cardiomyopathy: an ESC EORP registry.

AIMS: We sought to describe the clinical presentation, management, and 6-month outcomes in women with peripartum cardiomyopathy (PPCM) globally. METHODS AND RESULTS: In 2011, >100 national and affiliated member cardiac societies of the European Society of Cardiology (ESC) were contacted to contribute to a global registry on PPCM, under the auspices of the ESC EURObservational Research Programme. These societies were tasked with identifying centres who could participate in this registry. In low-income countries, e.g. Mozambique or Burkina Faso, where there are no national societies due to a shortage of cardiologists, we identified potential participants through abstracts and publications and encouraged participation into the study. Seven hundred and thirty-nine women were enrolled in 49 countries in Europe (33%), Africa (29%), Asia-Pacific (15%), and the Middle East (22%). Mean age was 31 ± 6 years, mean left ventricular ejection fraction (LVEF) was 31 ± 10%, and 10% had a previous pregnancy complicated by PPCM. Symptom-onset occurred most often within 1 month of delivery (44%). At diagnosis, 67% of patients had severe (NYHA III/IV) symptoms and 67% had a LVEF ≤35%. Fifteen percent received bromocriptine with significant regional variation (Europe 15%, Africa 26%, Asia-Pacific 8%, the Middle East 4%, P < 0.001). Follow-up was available for 598 (81%) women. Six-month mortality was 6% overall, lowest in Europe (4%), and highest in the Middle East (10%). Most deaths were due to heart failure (42%) or sudden (30%). Re-admission for any reason occurred in 10% (with just over half of these for heart failure) and thromboembolic events in 7%. Myocardial recovery (LVEF > 50%) occurred only in 46%, most commonly in Asia-Pacific (62%), and least commonly in the Middle East (25%). Neonatal death occurred in 5% with marked regional variation (Europe 2%, the Middle East 9%). CONCLUSION: Peripartum cardiomyopathy is a global disease, but clinical presentation and outcomes vary by region. Just under half of women experience myocardial recovery. Peripartum cardiomyopathy is a disease with substantial maternal and neonatal morbidity and mortality.

Prevalence of positive chronic kidney Disease screening in professional male long haul drivers at risk of cardiovascular Disease in Lagos, Nigeria: a cross-section study.

BACKGROUND: Professional drivers are known to be at high risk for cardiovascular disease (CVD) on account of the higher prevalence co-occurring risk factors they harbour. Chronic kidney disease (CKD) and CVD share similar risk factors. Both impact each other adversely. The renal profile of professional drivers in Nigeria is not well characterised. We decided to study the prevalence of positive CKD screening amongst professional male long distance drivers in Lagos, Southwest Nigeria so as to quantify the burden and its predictors. METHODS: Two hundred and ninety-three drivers were recruited. Details of their socio-demographic characteristics were obtained. Their anthropometric indices, blood pressure, fasting plasma blood glucose and lipid profile were measured. Serum creatinine was measured and estimated glomerular filtration rate, eGFR, was calculated with Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Urinary Albumin Creatinine Ratio (UACR) was determined. A 10 year CVD risk of the subjects was calculated with the Framingham Risk Score (FRS). RESULTS: Mean age of the study population was 44.8 + 9.7 years. The prevalence of alcohol use and smoking were 71.0 and 19.5% respectively. One hundred and twenty-one (62.8%) of the subjects were either overweight or obese while 70(24.1%) had abdominal obesity. The prevalence of hypertension and diabetes were 39.7 and 13.9% respectively. Prevalence of CKD by eGFR< 60 ml/min/1.73m2 or UACR > 30 mg/g was 51.7% (95% CI; 46.0-57.5). The odds for CKD increased with lower HDL-c levels; OR 3.5 (95% CI, 1.1-11.2; p = 0.03) and longer duration of professional driving > 20 years; OR 2.4(95% CI, 1.5-4.0). CONCLUSION: Professional male long distance drivers in addition to having very high prevalence of clustering of both CVD and CKD risk factors have a significant burden of asymptomatic CKD. UACR appears to be an earlier marker of CKD in this population. Health awareness promotion and aggressive risk factor reduction are advocated as ways to reduce this burden.

May Measurement Month 2017: screening for hypertension in Nigeria-Sub-Saharan Africa.

Hypertension and its complications are now responsible for about a quarter of emergency medical admissions in urban hospitals in Nigeria. It is the commonest risk factor for stroke, heart failure, chronic kidney disease, and dementia. Furthermore, high blood pressure is the commonest cause of sudden unexpected natural death in the country. Regrettably, the rate of awareness, treatment, and control is abysmally low in the country and in many parts of the world. May Measurement Month (MMM) is a global initiative of the International Society of Hypertension aimed at raising awareness of high blood pressure (BP) and to act as a temporary solution to the lack of screening programs worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 years was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. A total of 19 904 individuals with a mean age of 40.9 years, were screened during MMM17. After multiple imputation, 6709 (36.2%) had hypertension. Of individuals not receiving anti-hypertensive medication, 4140 (25.9%) were found to have hypertension. Of individuals receiving anti-hypertensive medication, 1449 (58.8%) had uncontrolled BP. MMM17 was one of the largest BP screening campaigns undertaken in Nigeria. A significant number of the participants were identified with hypertension (but not on any treatment) and uncontrolled BP despite being treated. These results suggest that opportunistic screening can identify significant numbers with raised BP.

Statistics on the use of cardiac electronic devices and interventional electrophysiological procedures in Africa from 2011 to 2016: report of the Pan African Society of Cardiology (PASCAR) Cardiac Arrhythmias and Pacing Task Forces.

Aims: To provide comprehensive information on the access and use of cardiac implantable electronic devices (CIED) and catheter ablation procedures in Africa. Methods and results: The Pan-African Society of Cardiology (PASCAR) collected data on invasive management of cardiac arrhythmias from 2011 to 2016 from 31 African countries. A specific template was completed by physicians, and additional information obtained from industry. Information on health care systems, demographics, economics, procedure rates, and specific training programs was collected. Considerable heterogeneity in the access to arrhythmia care was observed across Africa. Eight of the 31 countries surveyed (26%) did not perform pacemaker implantations. The median pacemaker implantation rate was 2.66 per million population per country (range: 0.14-233 per million population). Implantable cardioverter-defibrillator and cardiac resynchronization therapy were performed in 12/31 (39%) and 15/31 (48%) countries respectively, mostly by visiting teams. Electrophysiological studies, including complex catheter ablations were performed in all countries from Maghreb, but only one sub-Saharan African country (South Africa). Marked variation in cost (up to 1000-fold) was observed across countries with an inverse correlation between implant rates and the procedure fees standardized to the gross domestic product per capita. Lack of economic resources and facilities, high cost of procedures, deficiency of trained physicians, and non-existent fellowship programs were the main drivers of under-utilization of interventional cardiac arrhythmia care. Conclusion: There is limited access to CIED and ablation procedures in Africa. A quarter of countries did not have pacemaker implantation services, and catheter ablations were only available in one country in sub-Saharan Africa.

Socio-economic factors determine maternal and neonatal outcomes in women with peripartum cardiomyopathy: A study of the ESC EORP PPCM registry.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is a global disease with substantial morbidity and mortality. The aim of this study was to analyze to what extent socioeconomic factors were associated with maternal and neonatal outcomes. METHODS: In 2011, >100 national and affiliated member cardiac societies of the European Society of Cardiology (ESC) were contacted to contribute to a global PPCM registry, under the auspices of the ESC EORP Programme. We investigated the characteristics and outcomes of women with PPCM and their babies according to individual and country-level sociodemographic factors (Gini index coefficient [GINI index], health expenditure [HE] and human developmental index [HDI]). RESULTS: 739 women from 49 countries (Europe [33%], Africa [29%], Asia-Pacific [15%], Middle East [22%]) were enrolled. Low HDI was associated with greater left ventricular (LV) dilatation at time of diagnosis. However, baseline LV ejection fraction did not differ according to sociodemographic factors. Countries with low HE prescribed guideline-directed heart failure therapy less frequently. Six-month mortality was higher in countries with low HE; and LV non-recovery in those with low HDI, low HE and lower levels of education. Maternal outcome (death, re-hospitalization, or persistent LV dysfunction) was independently associated with income. Neonatal death was significantly more common in countries with low HE and low HDI, but was not influenced by maternal income or education attainment. CONCLUSIONS: Maternal and neonatal outcomes depend on country-specific socioeconomic characteristics. Attempts should therefore be made to allocate adequate resources to health and education, to improve maternal and fetal outcomes in PPCM.

Living with peripartum cardiomyopathy: A statement from the Heart Failure Association and the Association of Cardiovascular Nursing and Allied Professions of the European Society of Cardiology.

This statement focuses on the fact that women with peripartum cardiomyopathy (PPCM) have a substantial mortality and morbidity rate. Less than 50% of patients have full recovery of their cardiac function within 6 months of diagnosis. Also, patients with recovered cardiac function often suffer from comorbidities, such as hypertension or arrhythmias, which require long-term treatment. This has major implications which extend beyond the life of the patient, as it may also substantially impact her family. Women with a new diagnosis of PPCM should be involved in the decision-making processes regarding therapies, e.g. the recommendation to abstain from breastfeeding, or the use of cardiac implantable electronic devices. Women living with PPCM face the uncertainty of not knowing for some time whether their cardiac function will recover to allow them a near-to-normal life expectancy. This not only impacts their ability to work, which may have financial implications, but may also affect mental health and quality of life for the extended family. Women living with PPCM must be informed that a future pregnancy always carries a substantial risk and, in case of poor cardiac recovery, is associated with a high morbidity and mortality. Patients with PPCM are best managed by an interdisciplinary and multiprofessional approach including e.g. a cardiologist, a gynaecologist, nurses, a psychologist, and social workers. The scope of this document encompasses contemporary challenges and approaches for the management of women diagnosed with PPCM.

Cardiovascular toxicities of immune therapies for cancer - a scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Council of Cardio-Oncology.

The advent of immunological therapies has revolutionized the treatment of solid and haematological cancers over the last decade. Licensed therapies which activate the immune system to target cancer cells can be broadly divided into two classes. The first class are antibodies that inhibit immune checkpoint signalling, known as immune checkpoint inhibitors (ICIs). The second class are cell-based immune therapies including chimeric antigen receptor T lymphocyte (CAR-T) cell therapies, natural killer (NK) cell therapies, and tumour infiltrating lymphocyte (TIL) therapies. The clinical efficacy of all these treatments generally outweighs the risks, but there is a high rate of immune-related adverse events (irAEs), which are often unpredictable in timing with clinical sequalae ranging from mild (e.g. rash) to severe or even fatal (e.g. myocarditis, cytokine release syndrome) and reversible to permanent (e.g. endocrinopathies).The mechanisms underpinning irAE pathology vary across different irAE complications and syndromes, reflecting the broad clinical phenotypes observed and the variability of different individual immune responses, and are poorly understood overall. Immune-related cardiovascular toxicities have emerged, and our understanding has evolved from focussing initially on rare but fatal ICI-related myocarditis with cardiogenic shock to more common complications including less severe ICI-related myocarditis, pericarditis, arrhythmias, including conduction system disease and heart block, non-inflammatory heart failure, takotsubo syndrome and coronary artery disease. In this scientific statement on the cardiovascular toxicities of immune therapies for cancer, we summarize the pathophysiology, epidemiology, diagnosis, and management of ICI, CAR-T, NK, and TIL therapies. We also highlight gaps in the literature and where future research should focus.

Artificial intelligence guided screening for cardiomyopathies in an obstetric population: a pragmatic randomized clinical trial.

Nigeria has the highest reported incidence of peripartum cardiomyopathy worldwide. This open-label, pragmatic clinical trial randomized pregnant and postpartum women to usual care or artificial intelligence (AI)-guided screening to assess its impact on the diagnosis left ventricular systolic dysfunction (LVSD) in the perinatal period. The study intervention included digital stethoscope recordings with point of-care AI predictions and a 12-lead electrocardiogram with asynchronous AI predictions for LVSD. The primary end point was identification of LVSD during the study period. In the intervention arm, the primary end point was defined as the number of identified participants with LVSD as determined by a positive AI screen, confirmed by echocardiography. In the control arm, this was the number of participants with clinical recognition and documentation of LVSD on echocardiography in keeping with current standard of care. Participants in the intervention arm had a confirmatory echocardiogram at baseline for AI model validation. A total of 1,232 (616 in each arm) participants were randomized and 1,195 participants (587 intervention arm and 608 control arm) completed the baseline visit at 6 hospitals in Nigeria between August 2022 and September 2023 with follow-up through May 2024. Using the AI-enabled digital stethoscope, the primary study end point was met with detection of 24 out of 587 (4.1%) versus 12 out of 608 (2.0%) patients with LVSD (intervention versus control odds ratio 2.12, 95% CI 1.05-4.27; P = 0.032). With the 12-lead AI-electrocardiogram model, the primary end point was detected in 20 out of 587 (3.4%) versus 12 out of 608 (2.0%) patients (odds ratio 1.75, 95% CI 0.85-3.62; P = 0.125). A similar direction of effect was observed in prespecified subgroup analysis. There were no serious adverse events related to study participation. In pregnant and postpartum women, AI-guided screening using a digital stethoscope improved the diagnosis of pregnancy-related cardiomyopathy. ClinicalTrials.gov registration: NCT05438576.

Trends and outcomes of cardiovascular disease admissions in Lagos, Nigeria: a 16-year review.

BACKGROUND: Cardiovascular disease (CVD)-related admissions are on the increase in Nigeria and the rest of Africa. This study was carried out to highlight the burden, patterns and outcomes of CVD admissions in a tertiary hospital over a 16-year period in Lagos, Nigeria. METHODS: Admissions records of patients admitted into the medical wards within the study period (January 2002 to December 2017) were reviewed and relevant information pertaining to the study objectives was retrieved for analysis. RESULTS: There were a total of 21 369 medical admissions and 4 456 (20.8%) CVD-related admissions. A total of 3 582 medical deaths were recorded and 1 090 (30.4%) CVD-related deaths. The median age of the patients was 56.6 (46.0-68.0) years and 51.4% of these were males. Stroke, heart failure, hypertensive disease and acute coronary syndrome constituted 51.2, 36.2, 11.3 and 1.6% of all CVD admissions, respectively. There was a cumulative increase in the number of CVD admissions and deaths (p < 0.001, respectively) during the period under review. CONCLUSIONS: CVD admissions are not only common in Nigeria, but there was also a temporal exponential increase in both the admission and death rates, most likely reflecting the epidemiological transition in Nigeria.

Assessing Iron Status in Chronic Heart Failure Patients by Using Serum Ferritin and Transferrin Saturation Levels: A Cross-Sectional Descriptive Study.

Background and objective Chronic heart failure (HF) is a major medical condition worldwide and is associated with significant morbidity and mortality. Chronic HF could be complicated by iron deficiency (ID), and in severe cases, ID anemia, leading to negative HF outcomes even in people on optimal HF treatments. ID has been reported to be the most common nutritional deficiency in chronic HF. It is therefore important to study and analyze the relationship between these two variables. Identifying and treating the comorbidity of ID in chronic HF may help improve the treatment outcomes of chronic HF. In this study, we aimed to determine the iron status of chronic HF patients by using serum ferritin (SF) and transferrin saturation (TSAT). Materials and methods A cross-sectional descriptive study was conducted involving 88 Nigerian patients with chronic HF at the Lagos University Teaching Hospital (LUTH). The participants were evaluated based on their laboratory findings. Results ID was found in 34% of chronic HF patients. Of them, 17% had absolute ID while 17% had functional ID. Conclusion ID was present in about one-third of the chronic HF patients. It was more common and worse in patients belonging to advanced HF functional classes.

Acute Rheumatic Fever and Rheumatic Heart Disease: Highlighting the Role of Group A Streptococcus in the Global Burden of Cardiovascular Disease.

Group A Streptococcus (GAS) causes superficial and invasive infections and immune mediated post-infectious sequalae (including acute rheumatic fever/rheumatic heart disease). Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are important determinants of global cardiovascular morbidity and mortality. ARF is a multiorgan inflammatory disease that is triggered by GAS infection that activates the innate immune system. In susceptible hosts the response against GAS elicits autoimmune reactions targeting the heart, joints, brain, skin, and subcutaneous tissue. Repeated episodes of ARF-undetected, subclinical, or diagnosed-may progressively lead to RHD, unless prevented by periodic administration of penicillin. The recently modified Duckett Jones criteria with stratification by population risk remains relevant for the diagnosis of ARF and includes subclinical carditis detected by echocardiography as a major criterion. Chronic RHD is defined by valve regurgitation and/or stenosis that presents with complications such as arrhythmias, systemic embolism, infective endocarditis, pulmonary hypertension, heart failure, and death. RHD predominantly affects children, adolescents, and young adults in LMICs. National programs with compulsory notification of ARF/RHD are needed to highlight the role of GAS in the global burden of cardiovascular disease and to allow prioritisation of these diseases aimed at reducing health inequalities and to achieve universal health coverage.

Effects of pregnancy on cardiac structure and function in women with sickle cell anemia: a longitudinal comparative study.

BACKGROUND: Sickle cell anemia is the commonest hemoglobinopathy in pregnant Nigerian women, and cardiac manifestations are a significant feature of the disease especially in pregnancy. Pregnant women with sickle cell anemia are at high risk of morbidity and mortality and cardiac dysfunction in them increases this risk and may compromise their post-partum health. OBJECTIVE: To evaluate the cardiac size and function in women with sickle cell anemia (HbSS) during late pregnancy and postpartum. METHODOLOGY: This was a longitudinal comparative study in which 40 women, consisting of 20 pregnant HBSS and 20 pregnant HBAA women controls, were recruited. Echocardiography was performed in the third trimester of pregnancy and 6 weeks postpartum. RESULTS: There was a decrease in the mean left atrial diameter (p < .001), left ventricular diameter in diastole (p = .041), and left ventricular mass (p = .004) of HBSS women in the postpartum period compared to their antepartum state. In contrast, there was no significant difference in most cardiac dimensions of pregnant vs postpartum HBAA women. There was no significant change in cardiac function in the pregnant vs postpartum states in both study groups. There were significant differences in cardiac size but not function when comparing HBSS and HBAA women in pregnancy and postpartum. CONCLUSION: Changes in cardiac size of sickle cell women in pregnancy does not appear to affect cardiac function during pregnancy and in the puerperium, suggesting that the increased size may purely be a response to their chronic anemic state. Studies following women up for longer periods including those with co-morbidities are recommended.

Prevalence, patterns and predictors of metabolic abnormalities in Nigerian hypertensives with hypertriglyceridemic waist phenotype: A cross sectional study.

BACKGROUND: Simultaneous presence of elevated waist circumference and hypertriglyceridemia (HTGW) is a simple and low-cost measure of visceral obesity, and it is associated with a plethora of cardio-metabolic abnormalities that can increase the risk of cardiovascular diseases and incident Type 2 diabetes mellitus. We decided to study the prevalence, patterns, and predictors of metabolic abnormalities in Nigerian hypertensives with the HTGW phenotype. METHODS: The medical records of 582 hypertensives with complete data of interest were retrieved and analyzed for the study. Their socio-demographic data, anthropometric data, and booking blood pressure values were retrieved. The results of their fasting plasma glucose, lipid profile, uric acid and serum creatinine were also retrieved for analysis. RESULTS: The mean age of the study population was 56.2 ±13.6, with 53.1% being males. The prevalence of smoking and use of alcohol was 4.3% and 26.5% respectively. The prevalence of the HTGW phenotype was 23.4% and were predominantly males (61%). Subjects with the HTGW phenotype were more obese assessed by waist circumference (WC) and body mass index (BMI). Mean serum total cholesterol, triglyceride, very low-density lipoprotein, uric acid, and creatinine were significantly higher in the HTGW phenotype (p = 0.003; <0.001; <0.001; 0.002 and <0.001 respectively). The prevalence of newly diagnosed Type 2 diabetes was 28.7%. There was also a preponderance of cardio-metabolic abnormalities (obesity, dyslipidaemia, hyperuricemia) in the HTGW phenotype. In both males and females, the HGTW phenotype was significantly associated with elevated Tc, TG, VLDL, hyperuricemia and atherogenic index of plasma. CONCLUSION: The HTGW phenotype is common amongst Nigerian hypertensives, and it is associated with metabolic abnormalities.

Registry for Acute Coronary Events in Nigeria (RACE-Nigeria): Clinical Characterization, Management, and Outcome.

Background Coronary artery disease was hitherto a rarity in Africa. Acute coronary syndrome (ACS) accounts for coronary artery disease-related morbidity and mortality. Reports on ACS in Africa are few. Methods and Results We enrolled 1072 indigenous Nigerian people 59.2±12.4 years old (men, 66.8%) with ACS in an observational multicentered national registry (2013-2018). Outcome measures included incidence, intervention times, reperfusion rates, and 1-year mortality. The incidence of ACS was 59.1 people per 100 000 hospitalized adults per year, and comprised ST-segment-elevation myocardial infarction (48.7%), non-ST-segment-elevation myocardial infarction (24.5%), and unstable angina (26.8%). ACS frequency peaked 10 years earlier in men than women. Patients were predominantly from urban settings (87.3%). Median time from onset of symptoms to first medical contact (patients with ST-segment-elevation myocardial infarction) was 6 hours (interquartile range, 20.1 hours), and only 11.9% presented within a 12-hour time window. Traditional risk factors of coronary artery disease were observed. The coronary angiography rate was 42.4%. Reperfusion therapies included thrombolysis (17.1%), percutaneous coronary intervention (28.6%), and coronary artery bypass graft (11.2%). Guideline-based pharmacotherapy was adequate. Major adverse cardiac events were 30.8%, and in-hospital mortality was 8.1%. Mortality rates at 30 days, 3 months, 6 months, and 1 year were 8.7%, 9.9%, 10.9%, and 13.3%, respectively. Predictors of mortality included resuscitated cardiac arrest (odds ratio [OR], 50.0; 95% CI, 0.010-0.081), nonreperfusion (OR, 34.5; 95% CI, 0.004-0.221), pulmonary edema (OR, 11.1; 95% CI, 0.020-0.363), left ventricular diastolic dysfunction (OR, 4.1; 95% CI, 0.091-0.570), and left ventricular systolic dysfunction (OR, 2.1; 95% CI, 1.302-3.367). Conclusions ACS burden is rising in Nigeria, and patients are relatively young and from an urban setting. The system of care is evolving and is characterized by lack of capacity and low patient eligibility for reperfusion. We recommend preventive strategies and health care infrastructure-appropriate management guidelines.

SARS-CoV 2 Infection (Covid-19) and Cardiovascular Disease in Africa: Health Care and Socio-Economic Implications.

The current pandemic of SARS-COV 2 infection (Covid-19) is challenging health systems and communities worldwide. At the individual level, the main biological system involved in Covid-19 is the respiratory system. Respiratory complications range from mild flu-like illness symptoms to a fatal respiratory distress syndrome or a severe and fulminant pneumonia. Critically, the presence of a pre-existing cardiovascular disease or its risk factors, such as hypertension or type II diabetes mellitus, increases the chance of having severe complications (including death) if infected by the virus. In addition, the infection can worsen an existing cardiovascular disease or precipitate new ones. This paper presents a contemporary review of cardiovascular complications of Covid-19. It also specifically examines the impact of the disease on those already vulnerable and on the poorly resourced health systems of Africa as well as the potential broader consequences on the socio-economic health of this region.

Electrocardiographic features and their echocardiographic correlates in peripartum cardiomyopathy: results from the ESC EORP PPCM registry.

AIMS: In peripartum cardiomyopathy (PPCM), electrocardiography (ECG) and its relationship to echocardiography have not yet been investigated in large multi-centre and multi-ethnic studies. We aimed to identify ECG abnormalities associated with PPCM, including regional and ethnic differences, and their correlation with echocardiographic features. METHODS AND RESULTS: We studied 411 patients from the EURObservational PPCM registry. Baseline demographic, clinical, and echocardiographic data were collected. ECGs were analysed for rate, rhythm, QRS width and morphology, and QTc interval. The median age was 31 [interquartile range (IQR) 26-35] years. The ECG was abnormal in > 95% of PPCM patients. Sinus tachycardia (heart rate > 100 b.p.m.) was common (51%), but atrial fibrillation was rare (2.27%). Median QRS width was 82 ms [IQR 80-97]. Left bundle branch block (LBBB) was reported in 9.30%. Left ventricular (LV) hypertrophy (LVH), as per ECG criteria, was more prevalent amongst Africans (59.62%) and Asians (23.17%) than Caucasians (7.63%, P < 0.001) but did not correlate with LVH on echocardiography. Median LV end-diastolic diameter (LVEDD) was 60 mm [IQR 55-65] and LV ejection fraction (LVEF) 32.5% [IQR 25-39], with no significant regional or ethnic differences. Sinus tachycardia was associated with an LVEF < 35% (OR 1.85 [95% CI 1.20-2.85], P = 0.006). ECG features that predicted an LVEDD > 55 mm included a QRS complex > 120 ms (OR 11.32 [95% CI 1.52-84.84], P = 0.018), LBBB (OR 4.35 [95% CI 1.30-14.53], P = 0.017), and LVH (OR 2.03 [95% CI 1.13-3.64], P = 0.017). CONCLUSIONS: PPCM patients often have ECG abnormalities. Sinus tachycardia predicted poor systolic function, whereas wide QRS, LBBB, and LVH were associated with LV dilatation.

Disparities in clinical features and outcomes of peripartum cardiomyopathy in high versus low prevalent regions in Nigeria.

AIMS: The prospective, multicentre Peripartum Cardiomyopathy in Nigeria (PEACE) registry originally demonstrated a high prevalence of peripartum cardiomyopathy (PPCM) among patients originating from Kano, North-West Nigeria. In a post hoc analysis, we sought to determine if this phenomenon was characterized by a differential case profile and outcome among PPCM cases originating elsewhere. METHODS AND RESULTS: Overall, 199 (81.6%) of a total 244 PPCM patients were recruited from three sites in Kano, compared with 45 patients (18.4%) from 11 widely dispersed centres across Nigeria. Presence and extent of ventricular myocardial remodelling during follow-up, relative to baseline status, were assessed by echocardiography. During median 17 months follow-up, Kano patients demonstrated significantly better myocardial reverse remodelling than patients from other sites. Overall, 50.6% of patients from Kano versus 28.6% from other regions were asymptomatic (P = 0.029) at study completion, with an accompanying difference in all-cause mortality (17.6% vs. 22.2% respectively, P = 0.523) not reaching statistical significance. Alternatively, 135/191 (84.9%) of Kano patients had selenium deficiency (<70 µg/L), and 46/135 (34.1%) of them received oral selenium supplementation. Critically, those that received selenium supplementation demonstrated better survival (6.5% vs. 21.2%; P = 0.025), but the supplement did not have significant impact on myocardial remodelling. CONCLUSIONS: This study has shown important non-racial regional disparities in the clinical features and outcomes of PPCM patients in Nigeria, that might partly be explained by selenium supplementation.

Hypertensive disorders in women with peripartum cardiomyopathy: insights from the ESC EORP PPCM Registry.

AIMS: Hypertensive disorders occur in women with peripartum cardiomyopathy (PPCM). How often hypertensive disorders co-exist, and to what extent they impact outcomes, is less clear. We describe differences in phenotype and outcomes in women with PPCM with and without hypertensive disorders during pregnancy. METHODS AND RESULTS: The European Society of Cardiology EURObservational Research Programme PPCM Registry enrolled women with PPCM from 2012-2018. Three groups were examined: (i) women without hypertension (PPCM-noHTN); (ii) women with hypertension but without pre-eclampsia (PPCM-HTN); (iii) women with pre-eclampsia (PPCM-PE). Maternal (6-month) and neonatal outcomes were compared. Of 735 women included, 452 (61.5%) had PPCM-noHTN, 99 (13.5%) had PPCM-HTN and 184 (25.0%) had PPCM-PE. Compared to women with PPCM-noHTN, women with PPCM-PE had more severe symptoms (New York Heart Association class IV in 44.4% vs. 29.9%, P < 0.001), more frequent signs of heart failure (pulmonary rales in 70.7% vs. 55.4%, P = 0.002), a higher baseline left ventricular ejection fraction (LVEF) (32.7% vs. 30.7%, P = 0.005) and a smaller left ventricular end-diastolic diameter (57.4 ± 6.7 mm vs. 59.8 ± 8.1 mm, P = 0.001). There were no differences in the frequencies of death from any cause, rehospitalization for any cause, stroke, or thromboembolic events. Compared to women with PPCM-noHTN, women with PPCM-PE had a greater likelihood of left ventricular recovery (LVEF ≥ 50%) (adjusted odds ratio 2.08, 95% confidence interval 1.21-3.57) and an adverse neonatal outcome (composite of termination, miscarriage, low birth weight or neonatal death) (adjusted odds ratio 2.84, 95% confidence interval 1.66-4.87). CONCLUSION: Differences exist in phenotype, recovery of cardiac function and neonatal outcomes according to hypertensive status in women with PPCM.

Risk stratification and management of women with cardiomyopathy/heart failure planning pregnancy or presenting during/after pregnancy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy.

This position paper focusses on the pathophysiology, diagnosis and management of women diagnosed with a cardiomyopathy, or at risk of heart failure (HF), who are planning to conceive or present with (de novo or previously unknown) HF during or after pregnancy. This includes the heterogeneous group of heart muscle diseases such as hypertrophic, dilated, arrhythmogenic right ventricular and non-classified cardiomyopathies, left ventricular non-compaction, peripartum cardiomyopathy, Takotsubo syndrome, adult congenital heart disease with HF, and patients with right HF. Also, patients with a history of chemo-/radiotherapy for cancer or haematological malignancies need specific pre-, during and post-pregnancy assessment and counselling. We summarize the current knowledge about pathophysiological mechanisms, including gene mutations, clinical presentation, diagnosis, and medical and device management, as well as risk stratification. Women with a known diagnosis of a cardiomyopathy will often require continuation of drug therapy, which has the potential to exert negative effects on the foetus. This position paper assists in balancing benefits and detrimental effects.