The Causes, Treatment, and Outcome of Acute Heart Failure in 1006 Africans From 9 Countries: Results of the Sub-Saharan Africa Survey of Heart Failure

Study Questions:

What is the impact of acute heart failure (AHF) in sub-Saharan Africa?


This was a multicenter, prospective, observational study of patients admitted with a chief complaint of dyspnea to 1 of 12 hospitals in sub-Saharan Africa with a confirmed diagnosis of AHF. All patients underwent echocardiography, and those with acute myocardial infarctions or severe renal failure (creatinine >4 mg/dl or dialysis) were excluded. AHF was classified as endemic (e.g., infective causes, rheumatic heart disease, human immunodeficiency virus [HIV]-associated cardiomyopathy) or emerging (e.g., hypertension, ischemic heart disease) etiologies. Follow-up occurred at 1 and 6 months. Vital status, readmission frequency, and laboratories were tallied at follow-up. Patients who did not follow-up were called for information collection. Patients lost completely to follow-up were censored.


There were 1,006 AHF patients enrolled, and follow-up was complete in 57.5% (n = 578) at 1 month and 45.8% (n = 461) at 6 months. An additional 31.4 % (n = 316) of patients had a last date known alive. Complete loss of follow-up occurred in 7% (n = 70). The median [interquartile range] patient age was 55 [39-67] years, 50.8% were female, 13% (65 of 500 tested) were seropositive for HIV, 9.8% smoked, and 11% were known diabetics. The median left ventricular ejection fraction (LVEF) was 37% [26-50%]. The most common causes of AHF were hypertension (n = 453, 45%), idiopathic cardiomyopathy (n = 188, 19%), rheumatic heart disease (n = 143, 14%), and ischemic heart disease (n = 77, 7.7%). Overall, 506 cases (52%) of AHF were classified as having an “emerging” cause, and only 2.6% were attributed to HIV. Index admission length of stay was 7 [5-10] median days, with a 4.2% in-hospital mortality. The rate of readmission and death at 60 days was 9.1% and 10.6%, respectively. Death occurred in 17.8% (95% confidence interval, 15.4-20.6%) at 6 months. At 6 months, approximately 50% of patients were on a beta-blocker, 82% were on an angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker, and 62% were on an aldosterone antagonist.


The authors concluded that in Africa, HF is predominantly nonischemic in etiology, and is often associated with etiologies encountered in developed countries.


This registry provides information on the incidence, treatment, and outcome of patients in sub-Saharan Africa. The study weaknesses included incomplete data collection on several variables, a low clinic follow-up at 6 months, and a somewhat vague definition of HF for study inclusion. However, the first two weaknesses highlight difficulties (e.g., poor access to care, lack of telephones, migratory lifestyle) that will be encountered in managing HF in Africa. Additional concerns highlighted are the relatively low rate of beta-blocker use and high mortality at 6 months in a patient cohort with a median LVEF of 37%. Finally, the authors raise concern that ‘emerging diseases’ (i.e., hypertension, ischemic heart disease) may become more prevalent with socioeconomic advancement of patients in sub-Saharan Africa.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Acute Heart Failure, Echocardiography/Ultrasound, Hypertension

Keywords: Rheumatic Heart Disease, Follow-Up Studies, Mineralocorticoid Receptor Antagonists, Creatinine, Prevalence, Renal Dialysis, Registries, Smoke, Cardiomyopathies, Stroke Volume, Confidence Intervals, Hypertension, Echocardiography, Myocardial Infarction, Myocardial Ischemia, Hospital Mortality, Dyspnea, Renal Insufficiency, Heart Failure, Diabetes Mellitus

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