Figure 1
Map of Malawi illustrating the location of Neno district in relation to the two major urban areas and Neno’s two major health facilities where PEN-Plus clinics are located.
Figure 2
Heart failure protocol for initial diagnosis and management used by non-physician providers in PEN-Plus clinic in Neno, Malawi. Providers use focused cardiac ultrasound and follow the flow on the left-hand side of the protocol to determine a diagnostic category and management. The right-sided boxes guide management based on the diagnosis made.
Table 1
Patient Sociodemographic and clinical profiles.
| CHARACTERISTIC | TOTAL POPULATION | MALE | FEMALE |
|---|---|---|---|
| N (%) | 178 | 75 (42) | 103(58) |
| Median age at enrollment to the clinic – Years (n = 176)* | 67 (IQR 44 –75) | 71 | 60 |
| Mean duration of enrollment (months) | 11.5 (IQR 5.1–16.5) | 11.0 | 11.5 |
| Median number of visits throughout the enrollment duration | 5 (IQR 3–9) | 4 | 6 |
| Median BMI (kg/m2) (n = 153) | 20.4 (IQR 18.2–23.8) | 19.8 | 20.2 |
| Smoking status* (n = 174) | 35 (20) | 27 (77.1) | 8 (22.9) |
| Alcohol* consumption (n = 174) | 48 (28) | 32 (66.7) | 16 (33.3) |
| HIV (n = 131) | 14 (11) | 1 (7.1) | 13 (92.9) |
| Hypertension (n = 178) | 78 (44) | 33 (42.3) | 45 (57.7) |
| Diabetes (n = 178) | 5 (3) | 3 (60) | 2 (40) |
[i] BMI: Body Mass Index; HIV: Human Immunodeficiency Virus.
*Smoking status defined as actively smoking or stopped within past 12 months. Alcohol consumption defined as actively using alcohol at the time of enrollment.
Table 2
Clinical profile at enrollment and follow-up N (%).
| CHARACTERISTIC | ENROLLMENT | FOLLOW UP | P-VALUE* |
|---|---|---|---|
| Orthopnea | n = 127 | n = 138 | |
| Yes | 93 (73) | 12 (8) | 0.010 |
| Cough | n = 172 | n = 136 | |
| Yes | 79 (46) | 7 (5) | 0.238 |
| Fatigue | n = 172 | n = 145 | |
| Yes | 83 (48) | 9 (6) | 0.001 |
| Chest Pain | n = 172 | n = 129 | |
| Yes | 66 (38) | 3 (2) | 0.072 |
| Peripheral Edema | n = 176 | n = 135 | |
| Yes | 66 (38) | 12 (9) | 0.001 |
| Bibasilar crackles | n = 175 | n = 133 | |
| Yes | 15(9) | 5(4) | 0.029 |
| JVP elevated | n = 175 | n = 125 | |
| Yes | 18 (10) | 5 (4) | |
| Volume status | n = 157 | n = 111 | 0.047 |
| Hypovolemic | 1 (1) | 1 (1) | |
| Euvolemic | 99 (63) | 101 (91) | |
| Hypervolemic | 57 (36) | 9 (8) | |
| NYHA class | n = 159 | n = 130 | 0.001 |
| NYHA I | 37 (23) | 65 (50) | |
| NYHA II | 101 (64) | 61 (47) | |
| NYHA III | 18 (11) | 3 (2) | |
| NYHA IV | 3 (2) | 1 (1) |
[i] JVP: jugular venous pressure; NYHA: New York Heart Association.
*We computed and compared proportions for each symptom at enrollment and follow-up using chi-square and Fisher’s test.
Table 3
Heart failure diagnostic categories (n = 154).
| DIAGNOSTIC CATEGORY | N (%) | MEAN AGE (SD) | PEDIATRIC PATIENTS <18, (N-15)% |
|---|---|---|---|
| Hypertensive Heart Disease | 56 (36.4) | 70.4 (12.0) | 0 |
| Cardiomyopathy | 40 (26.0) | 53.0 (20.2) | 2 |
| Rheumatic Mitral stenosis | 11 (7.1) | 28.8 (16.5) | 4 |
| Other Valvular or Congenital Heart Disease | 8 (5.2) | 15.3 (25.2) | 6 |
| Right HF | 5 (3.3) | 65.8 (20.2) | 0 |
| Normal-focused cardiac ultrasound | 9 (5.8) | 57.9 (14.8) | 0 |
| Other/could not be classified | 25 (16.2) | 50.9 (23.5) | 3 |
Figure 3
Central Illustration: Retention in care, New York Heart Association (NYHA) class improvement, and HF categories among patients managed by non-physician clinicians in Neno, rural Malawi.