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.

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.

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.

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.

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.

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.

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update.

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world's population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.

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.

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.

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.

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.

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.

Clinical Features and Outcomes of Peripartum Cardiomyopathy in Nigeria.

BACKGROUND: Nigeria has the highest incidence of peripartum cardiomyopathy (PPCM) in the world. However, data on PPCM-related outcomes are limited. OBJECTIVES: The purpose of this study was to examine the clinical profile, myocardial remodeling, and survival of patients with PPCM in Nigeria. METHODS: This study consecutively recruited 244 PPCM patients (median 7 months postpartum) at 14 sites in Nigeria and applied structured follow-up for a median of 17 months (interquartile range: 14 to 20 months). Left ventricular reverse remodeling (LVRR) was defined as the composite of left ventricular (LV) end-diastolic dimension <33 mm/m2 and absolute increase in left ventricular ejection fraction (LVEF) ≥10%. LV full recovery was defined as LVEF ≥55%. RESULTS: Overall, 45 (18.7%) patients died during follow-up. Maternal age <20 years (hazard ratio [HR]: 2.40; 95% confidence interval (CI): 1.27 to 4.54), hypotension (HR: 1.87; 95% CI: 1.02 to 3.43), tachycardia (HR: 2.38; 95% CI: 1.05 to 5.43), and LVEF <25% at baseline (HR: 2.11; 95% CI: 1.12 to 3.95) independently predicted mortality. Obesity (HR: 0.16; 95% CI: 0.04 to 0.55) and regular use of beta-blockers at 6-month follow-up (HR: 0.20; 95% CI: 0.09 to 0.41) were independently associated with reduced risk for mortality. In total, 48 patients (24.1%) achieved LVRR and 45 (22.6%) achieved LV full recovery. LVEF <25% at baseline (HR: 0.66; 95% CI: 0.47 to 0.92) and regular use of beta-blockers at 6-month follow-up (HR: 1.62; 95% CI: 1.17 to 2.25) independently determined the risk for LV full recovery. Progressive reverse remodeling of all cardiac chambers was observed. In total, 18 patients (7.4%) were hospitalized during the study. CONCLUSIONS: This is the largest study of PPCM in Africa. Consistent with late presentations, the mortality rate was high, whereas frequencies of LVRR and LV full recovery were low. Several variables predicted poor outcomes, and regular use of beta-blockers correlated with late survival and LV functional recovery.

Opportunistic screening of cardiovascular disease risk factors in community pharmacies in Nigeria: a cross-sectional study.

Background Early identification and treatment of cardiovascular disease (CVD) risk factors through screening are crucial in the primary prevention of CVD and reduction in healthcare-related costs. Use of Non-Physician Healthcare-workers including Community Pharmacists has been advocated as an effective and cost-efficient model of healthcare delivery. In Nigeria the use of community pharmacists for mass screening of CVD risk factors has not been explored. Objective We sought to investigate the possibility of mass CVD risk factor screening in community pharmacies by pharmacists. Setting Lagos, Nigeria. Methods Between October and December 2018 eight hundred and eighty-nine apparently healthy participants were screened for obesity, hypertension, diabetes and hypercholesterolaemia in ten community pharmacies. Diabetes and hypercholesterolaemia were screened for using point-of-care testing modalities. A structured questionnaire was used to obtain the socio-demographic data of the participants. Main outcome measures Prevalence of overweight/obesity, hypertension, diabetes, hypercholesterolaemia, smoking and alcohol intake. Results Mean age of the subjects was 56.8 ± 21.1 years. Majority (57.4%) were females. Prevalence of smoking and alcohol intake were 4.3% and 26.7% respectively. 59.7% and 71.5% of males and females were either overweight (BMI ≥ 25 kg/m2) or obese (BMI ≥ 30 kg/m2) respectively. Prevalence of hypertension was 28.2% in all subjects, 30.9% in males and 26.3% in females, p < 0.001. Using BP > 130/80 mmHg prevalence of hypertension was 55.1%. Diabetes was detected in 3% of the subjects while 45.3% had hypercholesterolaemia. In total, 64.1% of the subjects were diagnosed with CVD risk factors for the first time. Conclusion Opportunistic screening for CVD risk factors is possible in community pharmacies and has the ability to detect previously undiagnosed risk factors. This community pharmacy based model could serve as a cost-effective approach to primary prevention of CVD.

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.

Cardiac Pacing Training in Africa: Endorsed by the Africa Heart Rhythm Association (AFHRA): JACC International.

The field of pacing in Africa has evolved in an uncoordinated way across the continent with significant variation in local expertise, cost, and utilization. There are many countries where pacemaker services do not meet one-hundredth of the national demand. Regional, national, and institutional standards for pacemaker qualification and credentials are lacking. This paper reviews the current needs for bradycardia pacing and evaluates what standards should be set to develop pacemaker services in a resource-constrained continent, including the challenges and opportunities of capacity building and training as well as standards for training programs (training prerequisites, case volumes, program content, and evaluation).

The inaugural meeting of the Africa Heart Rhythm Association (AFHRA).

Cardiorhythm Africa, the inaugural conference of AFHRA, was conceived during the biennial PASCAR congress held in Johannesburg in November 2019, with the ambition to be the largest ever pan-African conference focused purely on arrhythmia. Significant aims were to (1) bring together arrhythmia specialists from across Africa and from the diaspora; and (2) announce the newly formed African Heart Rhythm Association (AFHRA), an affiliate organisation of PASCAR formed from the amalgamation of the Cardiac Pacing and Arrhythmias taskforces. The meeting held in Nairobi (29-31 January 2020) was organised to provide a focus on resource-constrained arrhythmia management within the African context and novel/advanced and potentially home-grown solutions. There was full representation from all five PASCAR regions (North, East, West, Central and Southern Africa). This report summarises the scope and perspective of the first Cardiorhythm Africa meeting and presents the future directions for this annual meeting.

Correction to: Knowledge of cardiovascular disease risk factors and practice of primary prevention of cardiovascular disease by Community Pharmacists in Nigeria: a cross-sectional study.

The article Knowledge of cardiovascular disease risk factors and practice of primary prevention of cardiovascular disease by Community Pharmacists in Nigeria: a cross-sectional study.

The inaugural meeting of the Africa Heart Rhythm Association (AFHRA)

Cardiorhythm Africa, the inaugural conference of AFHRA, was conceived during the biennial PASCAR congress held in Johannesburg in November 2019, with the ambition to be the largest ever pan-African conference focused purely on arrhythmia. Significant aims were to (1) bring together arrhythmia specialists from across Africa and from the diaspora; and (2) announce the newly formed African Heart Rhythm Association (AFHRA), an affiliate organisation of PASCAR formed from the amalgamation of the Cardiac Pacing and Arrhythmias taskforces. The meeting held in Nairobi (29­31 January 2020) was organised to provide a focus on resource-constrained arrhythmia management within the African context and novel/advanced and potentially home-grown solutions. There was full representation from all five PASCAR regions (North, East, West, Central and Southern Africa). This report summarises the scope and perspective of the first Cardiorhythm Africa meeting and presents the future directions for this annual meeting