What's Actually Causing Heart Failure in Africa: Hypertension, Rheumatic Disease, HIV and TB

It should be started at the lowest possible dose — half a tablet, 25mg once daily, titrated over a week to 50mg, then 100mg, not typically exceeding 100mg once daily or 50mg twice daily. The primary indication is ejection fraction below 45% with elevated NT-proBNP. In a patient with ejection fraction below 35% and high NT-proBNP, it should be initiated at the lowest dose and titrated carefully upward.

In Africans and Asians, coronary artery disease is largely driven by genetic predisposition. In Caucasians, the predominant driver is sedentary lifestyle combined with diet — high-fat foods, alcohol, physical inactivity — which more than compensates for their lesser genetic predisposition. Surgical outcomes are comparable worldwide, with success rates upward of 90% and combined morbidity and mortality after CABG around 5 to 7% regardless of country. But the numbers in Asia and Africa are hugely underrepresented — if one million cardiac deaths annually in sub-Saharan Africa is the current reported figure, the true number with adequate diagnostic infrastructure would likely be closer to three million.

The traditional Indian vegetarian population was genuinely following something close to this diet. What changed was cooking oil. Industrial cooking oils were repackaged and marketed under omega fatty acid branding — omega-3, then omega-6, now omega-9 — persuading consumers to abandon traditional cooking fats like mustard oil and olive oil for artificially processed, packaged products whose health claims aren't supported by meaningful clinical evidence. If the population simply returned to traditional cooking oils, it would likely cut the cardiac disease burden significantly. The pyramid isn't the problem; the oil in the pan is.

No, it does not. Gyms typically require only a basic medical certificate, not triglyceride, homocysteine or CRP levels. The supplement industry is enormous, largely unregulated and mostly not FDA-approved. And building muscle mass ignores that the heart is also a muscle — when it hypertrophies beyond physiological bounds, that's called hypertrophic cardiomyopathy, not fitness. The footballer Christian Eriksen is instructive: he had a cardiac event at Euro 2020, received an ICD, returned to professional football, and years later the ICD detected and treated an arrhythmic episode with a single defibrillation — he felt dizzy, walked off, and was alive. Shane Warne's death, by contrast, fit the classic pattern: lifelong smoking, crash diets, and heavy alcohol.

For patients above 55, LVADs have to a reasonable extent already replaced transplantation as destination therapy — they can run fifteen years without complications on antiplatelet and anticoagulant therapy alone, with no immunosuppression needed. Three developments will transform deceased-donor transplant over the next decade: donation after circulatory death, which could roughly double the donor pool; ex vivo machine perfusion devices like the TransMedics Organ Care System, which keep a donor heart beating outside the body for twelve to twenty-four hours or more, making cross-continental transport feasible; and xenotransplantation, with genetically modified pig hearts already transplanted into two human recipients. It's unlikely any engineered device will fully replicate a natural heart, though — transplantation will stay relevant for at least the next fifteen to twenty-five years.

Hypertensive heart disease, driven by poor blood pressure monitoring, inadequate drug access, and incorrect prescriptions for the population being treated.

Very prevalent, described by Dr. William Boyd's line that rheumatic fever licks the joints but bites the heart.

Both are described as a significant and often under-acknowledged contributor, a global threat in the context of cardiomyopathy in the African population today.

Roughly 10.8% in Tunisia, about 30% in Cameroon, and over 50% in East Africa, according to a 2020 meta-analysis of thirteen African registry studies.