Heart Failure and Coronary Artery Disease in Africa: A Guide

Heart failure and coronary artery disease in Africa strike younger patients, are diagnosed later and are recorded less completely than in most other regions. Heart failure often begins in the 30s and 40s, driven above all by hypertensive heart disease, followed by cardiomyopathy, rheumatic heart disease, HIV and tuberculosis. Both conditions are among the most common, and largely preventable, causes of death across the continent.

Dr. Biswarup Purkayastha, Consultant – Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurugram, India, frames the problem as a paradox: a continent that supplies the world with diamonds, minerals and wildlife still leaves many of its own patients struggling to obtain a decent echocardiogram or a reliable supply of basic cardiac medicines. Services that have been routine elsewhere for 30 to 35 years remain scarce in much of the region, and in some countries quality care is concentrated in a handful of private clinics.

The disease pattern differs from the rest of the world in its causes, its timing and its true scale, and he argues that a handful of system-level changes would bend the curve. Three companion articles, mapped at the end of this guide, cover drug therapy, surgery and devices, and coronary treatment in depth.

Why heart failure in Africa is different

Heart failure in Africa differs from the pattern elsewhere in four ways: earlier onset, later presentation, thin diagnostic infrastructure and haphazard treatment. Dr. Purkayastha identifies this cluster of features as what makes the burden starker than in most other regions.

Earlier onset. Patients often develop heart failure in their 30s and 40s; in the largest African registry the mean age was about 52, two decades younger than in Europe or North America. Hypertensive heart disease, rheumatic heart disease and coronary artery disease in younger adults all contribute.

Later presentation. Patients often arrive with valvular disease so advanced that it has progressed to intractable heart failure. At that point the condition no longer has a medical answer, and frequently no conventional surgical answer either: repairing or replacing the valve will not recover the heart. The options narrow to implantable device therapy or heart transplantation, both far more resource-intensive than an operation performed a few years earlier would have been.

Thin diagnostic infrastructure. Many patients struggle to access a transoesophageal echocardiogram (an ultrasound of the heart taken from inside the gullet), or even a good-quality transthoracic study, which is a routine outpatient tool in cardiology clinics almost everywhere. He draws the comparison with Asia, where a cardiac outpatient clinic commonly runs three to four echocardiography machines.

Haphazard treatment. Patients referred with advanced heart failure or coronary disease are often on medications that do not suit their condition. In his view, keeping heart failure patients on archaic regimens such as digoxin or older non-specific beta blockers does little for them and consumes time that should have gone into referral.

A fifth, structural issue compounds the others: the problem is underrepresented in the literature, in clinical studies and in registries, partly because the region has received less research attention.

What causes heart failure in Africa?

Hypertensive heart disease is the leading cause of heart failure in Africa, followed by cardiomyopathy. Rheumatic heart disease is significant in some regions, and HIV, tuberculosis and the lifestyle change that follows urban migration add to the toll.

Hypertensive heart disease leads almost everywhere

The single largest cause is hypertensive heart disease, the damage that long-standing high blood pressure does to the heart muscle. Dr. Purkayastha attributes its prevalence to a chain of system failures rather than biology alone: poor medical access, blood pressure that is not consistently recorded in outpatient clinics, inadequate availability of drugs, inadequate prescriptions, and medicines that are not matched to the population being treated.

He anchors this in a 2020 review from Tunisia that pooled 13 African heart failure registries across North Africa, sub-Saharan Africa, West Africa and East Africa over a ten-year period. Hypertensive heart disease emerged as the leading cause of heart failure in almost every country studied. Cardiomyopathy followed. Rheumatic heart disease was significant in some regions but ranked lower in many others.

Rheumatic heart disease

Rheumatic heart disease is lasting damage to the heart valves left by rheumatic fever, an immune reaction to a streptococcal throat infection. It remains highly prevalent in sub-Saharan Africa. As the old clinical aphorism puts it, rheumatic fever licks the joints but bites the heart. Because rheumatic mitral stenosis is still among the most common causes of heart failure in resource-limited settings, it shapes much of the surgical workload described in the companion article on valve surgery and devices.

Cardiomyopathies

Cardiomyopathy is disease of the heart muscle itself. Several forms are common, some of genetic origin and some reflecting a genetic predisposition in the population. He is also clear on one modifiable contributor: multiple studies have established that any form of alcohol predisposes to cardiac dysfunction, traditional brews included, and the belief that red wine protects the heart was debunked long ago. Chronic consumption, in his words, will only damage the heart.

The double burden of HIV and tuberculosis

Dr. Purkayastha calls tuberculosis and HIV the "double trouble" and argues for discussing them openly rather than avoiding the subject. Both are present in large numbers across the region and both contribute to cardiomyopathy. Their interaction with cardiac drugs, and the limited options when a patient with HIV and tuberculosis develops end-stage failure, are covered in the article on drug therapy.

Urban migration and atherosclerosis

The final driver is demographic. As younger people move to larger cities, they acquire the same lifestyle-driven diseases as Western populations, above all atherosclerotic coronary artery disease. Underreported and diagnosed late, that coronary disease progresses to frank, full-blown heart failure.

How common are heart failure and coronary artery disease in Africa?

Heart failure accounts for from about 10.8% to more than half of cardiology admissions, depending on the region, and coronary artery disease causes about 1 million deaths a year in sub-Saharan Africa.

The proportion of cardiology admissions caused by heart failure varies widely across the continent. In the data Dr. Purkayastha presented, heart failure accounted for about 10.8% of cardiology admissions in Tunisia, about 30% in Cameroon, and more than half in East Africa.

Coronary artery disease carries its own toll. It causes about 1 million deaths a year in sub-Saharan Africa, roughly 13% of all deaths in the region. Citing a review on the pandemic of coronary artery disease in sub-Saharan Africa, Dr. Purkayastha set that against cancer, which accounts for about half as many deaths: a largely preventable disease is killing twice as many people each year.

He considers even these figures an undercount. Because quality diagnostic and imaging facilities are not widely available, cases go undetected and unrecorded. If the right investigative modalities were in place, he estimates the reported 1 million deaths would probably rise to about 3 million.

Is coronary artery disease in Africa genetic or lifestyle-driven?

Coronary artery disease in African, Asian and Caucasian populations is driven largely by the same modifiable risk factors, which together account for about 90% of heart attack risk in every region studied.

Asked how coronary artery disease differs between African, Asian and Caucasian populations, Dr. Purkayastha separates two questions that are often conflated: why the disease occurs, and how often it is detected.

On cause, high blood pressure, smoking, diabetes, abnormal lipids, abdominal obesity, poor diet and inactivity explain most heart attack risk in every population, including African and Asian ones; South Asians tend to develop the disease about a decade earlier. He adds that heavy meat consumption in parts of the African population, and in some Asian populations, increases risk further. On occurrence, the reported numbers in Africa and Asia are, in his view, hugely understated for the diagnostic reasons above.

Outcomes of coronary surgery, by contrast, do not differ meaningfully by population; the figures are set out in the article on coronary treatment. Clinicians' questions on alcohol and cardiomyopathy, and on coronary disease across African, Asian and Caucasian populations, are answered in the Live Discussion from the masterclass.

Recognising a heart attack: men, women and diabetics

Men usually have classic heart attack symptoms, while women and diabetic patients often have subtle ones, such as indigestion, reflux or a flu-like illness, so the diagnosis has to be pursued with a much higher index of suspicion.

Late presentation starts with missed symptoms, and Dr. Purkayastha directs this point at general practitioners and physicians in particular.

In men, a heart attack usually announces itself conventionally:

• heavy, painful chest
• cold sweats
• pain in the neck or left arm
• sudden nausea
• shortness of breath
• extreme lethargy

In women the picture may be far more subtle. A flu-like illness, a mild fever, indigestion or a sensation of reflux may be the only signs. Symptoms can be present subacutely, sometimes for several days, and are often misread as heartburn. Coronary symptoms in diabetic patients are similarly muted. In both groups, he advises, the diagnosis has to be pursued with a much higher index of suspicion. Any unexplained breathlessness, fatigue, chest pain, nausea or vomiting should raise the question of a heart attack.

How to reduce heart failure in Africa: six levers

Dr. Purkayastha proposes six levers for health systems and clinicians, from routine blood pressure monitoring to newer drugs, and he names early referral as the key.

1. Routine, standardised blood pressure monitoring, with good-quality care at the general practice level, to attack the leading cause at its source.
2. Remote heart failure clinics run as telehealth services, extending specialist oversight to patients who cannot easily reach a cardiac centre.
3. Introduction of the newer guideline-directed drugs for heart failure in place of outdated regimens.
4. Better lipid control, including newer agents such as PCSK9 inhibitors (injectable cholesterol-lowering drugs), given the predominantly non-vegetarian diet and heavy meat consumption in parts of the population.
5. Good-quality echocardiography at the outpatient level, so that valve disease and falling heart function are caught while they can still be treated conventionally.
6. Early referral, which he describes as the key.

On the last point he is emphatic. In his experience an early referral can sometimes spare a patient an entire operation, and he says he has never measured his practice by the number of procedures performed. The cost of delay is concrete: valve disease that could have been repaired becomes heart failure that only a device or a transplant can address.

The heart team approach to heart failure

A heart team is a group of at least six specialties that decide a patient's treatment together. It is the organising principle behind all of Dr. Purkayastha's treatment recommendations. Heart failure, he argues, cannot be managed by a cardiologist alone, a cardiac surgeon alone, a physician alone or an intensivist alone. At least six specialties need to sit down together:

• cardiologists
• cardiothoracic surgeons
• respiratory physicians
• intensivists
• general physicians
• a family medicine or preventive medicine physician

He expects this group to debate, argue and at times fight each other in order to arrive at the right therapy. The reason is that the same disease can warrant very different responses depending on the patient. His illustration: at 43, a patient might be offered open-chest, total arterial coronary artery bypass grafting. At 73, the same disease might call for a completely different therapy. At 83, the right answer may be tender loving care, good-quality medicine and a better quality of remaining life.

How heart failure and coronary artery disease are treated

Treatment spans four categories: medicines, valve procedures, devices and transplantation, and coronary revascularisation with prevention. Each is covered in depth in a companion article:

• Medicines. Heart failure pharmacology has changed substantially in recent years, with SGLT2 inhibitors, angiotensin receptor-neprilysin inhibitors, non-steroidal mineralocorticoid antagonists and soluble guanylate cyclase stimulators. Dosing, ejection fraction thresholds and management in patients with HIV and tuberculosis are covered in new heart failure drugs, from SGLT2 inhibitors to ARNIs.
• Valve procedures. Balloon mitral valvotomy, valve repair and valve replacement, with Dr. Purkayastha's views on when replacement outlasts repair, are covered in heart failure surgery: valve repair, LVADs and transplant.
• Devices and transplant. ICDs, left ventricular assist devices and heart transplantation, including the developments he expects to reshape donor supply over the coming decade, are covered in the same article.
• Coronary revascularisation and prevention. Emergency management where no catheterisation laboratory is available, the evidence comparing stenting with bypass surgery, and his views on diet and fitness are covered in PCI vs CABG: the trial evidence, emergency heart attack care and prevention.