Figure 1
Systematic search for atrial arrhythmias, sudden cardiac arrest/sudden cardiac death & ventricular arrhythmias, bradycardia, and cardiac implantable electronic devices in sub-Saharan Africa.
AF/AFL (atrial fibrillation/atrial flutter); AJOL (African Journals Online); ICD (implantable cardioverter defibrillator); PPM (permanent pacemaker); SVTs (supraventricular tachycardias); SCA (sudden cardiac arrest); SCD (sudden cardiac death); SSA (sub-Saharan Africa); VT (ventricular tachycardia); VF (ventricular fibrillation). Initial search restricted to human studies published up to March 31st, 2019. *Studies not included in tables had relevant findings, but were too heterogenous to fit into a table.
Table 1
Atrial fibrillation studies in sub-Saharan Africa.
| Author, Year & Country | Mean age in years | Study size & population | Gender | Prevalence of AF | Comorbidities | AAM or rate-control medication | CHADS2 ≥ 1 or CHA2DS2 VASC ≥ 2, mean or median | OAC* | FU & Mortality |
|---|---|---|---|---|---|---|---|---|---|
| Mwita [49] 2019 Botswana | 66.7 | 138; Tertiary hospital | Females 63.8% Males 36.2% | – | HTN 59% RHD 38% HF 36% CVA/TIA 22% DM 8% Obesity 35% | Digoxin 32% BB 70% Amiodarone 0% CCB 0% | Mean CHA2DS2 VASC 3.6 | 73.8% (Warfarin 69%) in CHA2DS2 VASC ≥ 2 | 12 months mortality 14.5% |
| THESUS-HF Registry [22] 2018 Multinational (9 SSA countries) | 57 | 206/1006; Heart failure | Females 53.1% Males 46.9% | 21.8% | HTN 52% HF 100% VHD 44% CM 38% CAD 5.3% CVA 3.4% | – | – | Admission 52.2% 6 months FU 21.8% | 16% rehospitalization or death at 60 days follow-up |
| Thomas [50] 2018 South Africa | – | 42; Tertiary Hospital | Females 43.0% Males 57.0% | Paroxysmal 50% Persistent 29% Permanent 12% Atrial flutter 17% | – | – | – | – | 5.8 years CVA 10% CM 17% |
| Muthalaly [51] 2018 Uganda | 42 | 0/856; Rural community | Females 62.5% Males 37.5% | 0% | HTN 11.6% DM 3.4% CAD/HF 5.6% CVA 2.7% | – | – | – | – |
| Temu [48] 2017 Kenya | 37 NVAF 69 VAF | 77 VAF/69 NAVF; Clinic and hospitalized patients | Females 67.1% Males 32.9% | - | VAF/NVAF HTN 29%/73% HF 10%/49% RHD 100%/0% CVA 23%/26% DM 1%/8.7% | BB 49% Digoxin 36% | Mean CHADS2 score 2.2 for NVAF | 79% for NVAF TTR 52% VAF, 56% NVAF | 12 months mortality 10% VAF, 15% NVAF |
| Greffie [52] 2016 Ethiopia | 67.4 | 94; Stroke patients | Females 53.1% Males 46.9% | 28.7% (Ischemic 34% Hemorrhagic 14%) | – | – | – | – | Hospital case fatality with AF 22.2% & without AF 8%. 12 months mortality 14.5% |
| Lugero [43] 2016 Uganda | 52 | 102, Cardiology Unit | Females 56.9% Males 43.1% | – | HTN 50% HF 50% RHD 32% Obesity 10% ICVA 12.8% | – | 74.5% | – | In hospital mortality 9.8% |
| Yameogo [45] 2016 Burkina Faso | 65 | 103/970; Cardiology department | Females 44.6% Males 55.4% | 10.6% NVAF 66% Paroxysmal 11.8% Persistent 70.6% Permanent 17.6% | HTN 66.2% HF 86.8% ICVA/TIA 33.8% VD 20.6% DM 20.6% ↑TSH 10.3% | – | 97% Median CHA2DS2VASC score = 3.9 | 35.3% | – |
| Ajayi [53] 2016 Nigeria | 67 | 55/1462; Tertiary referrals | Females 47.3% Males 52.7% | 3.8% | HTN 87.3% HHD 65.5% DCM 16.4% CVA 40% COPD 25% DM 18% ↑TSH 4.4% | – | 65.5% | – | – |
| Akpa [44] 2015 Nigeria | 60 | 68/228 cardiology unit/clinic | Females 42.6% Males 57.4% | 28.9% VAF 14.7% NVAF 85.3% | HHD 58.8% DCM 19.2% RHD 14.7% | Digoxin 92.6% Amiodarone 6% | 100% | 8.8% | - |
| Mandi [40] 2015 Burkina Faso | 63 | 69 NVAF/159 ICVA patients | Females 62.3% Males 37.7% | 43.3% Paroxysmal 13% Persistent 52% Permanent 35% | HTN 85% DM 21.7% Prior ICVA 17.4% | Digoxin 7.3% BB 27.5% Amiodarone 20.3% | 100% Mean CHA2DS2VASC score = 4.7 | 52% | 21.7% in-hospital mortality |
| RE-LY Registry [41] (baseline data) 2014 Multinational (included 10 SSA countries) | 57 | 1137 (SSA only); Emergency presentations | Females 53.1% Males 46.9% | Paroxysmal 8.9% Persistent 9.6% Permanent 81.4% | HF 63.8% HTN 54% All VHD 32.6% RHD 21.5% CAD 5.5% DM 14% CVA/TIA 14.1% | BB 21.7% Digoxin 34.5% CCB 2.0% Amiodarone 3.3% | Mean CHADS2 score 1.8 | 19.4% TTR 32.7% | – |
| Jardine [39] 2014 South Africa | 67 | 302; National Registry | Females 40.1% Males 59.9% | Paroxysmal 32.1% Persistent 21.2% Permanent 46.7% | HTN 65.9% HF 32.5% VHD 27.5% CAD 26.8% DM 15% ICVA/TIA 13.6% | Rate-control 63.9% Rhythm-control 36.1% BB 59.6% CCB 13% Class IC 3% Class III 33.8% DCCV 13.2% Catheter ablation 4.2% | Mean CHA2DS2VASC score = 3.08 | 75.2% | – |
| REMEDEY [24] 2016 Multinational (included 11 SSA countries) | 28 | 586/3343 (all study population); RHD | Females 66.1% Males 33.9% | 18–28% depending on income-level | RHD 100% | – | 40.7% | 69.5% TTR 27.4% | 2 years mortality 16.9% |
| Koopman [15] 2014 Ghana | 66 | 924; Rural population | Females 48.1% Males 51.9% | 0.3% | HTN 24% CAD 1.2% | – | – | – | – |
| Shavada [37] 2013 Kenya | 67 | 162; Discharge diagnosis | Females 44.0% Males 56.0% | Paroxysmal 40% Persistent 20% Permanent 40% | HTN 68% HF 38% DM 33% CAD19% VHD 12% | Rate-control 78% Rhythm-control 22% BB 46% Digoxin 44% CCB 9% Amiodarone 10% DCCV 8% | 78% | 72% | 6months mortality 6.5% |
| Coulibaly [20] 2013 Mali | 55 | 111/3964; cardiac admissions | Females 48.0% Males 52.0% | 2.8% Permanent 73% | HHD 33% VAF 33% CAD 12.5% CVA 20% | Digoxin 21% BB 51% CCB 1% Amiodarone 13% DCCV 0% | 78.6% | 22.9% | |
| Dewhurst [16] 2012 Tanzania | 78 | 15/2232; Community | Females 56.3% Males 43.7% | 0.67% | – | – | – | – | One-year mortality 53% |
| Ntep-Gweth [38] 2010 Cameroon | 66 | 172; Office visit | Females 56.4% Males 43.6% | Paroxysmal 23% Persistent 22% Permanent 56% | HTN 65% HF 58% HHD 48% RHD 26% CM 16% DM 10% CAD 6% ICVA 16.1% | Rate-control 84% Rhythm control 16% BB 11% Digoxin 62% CCB 9% Amiodarone 29% DCCV 2.3% | 91.9% | 34.2% | 29.5% died during 11 months of follow-up; 16.1% CVA |
| Sliwa [18] 2010 South Africa | 59 | 246/5328; Cardiac admissions | Females 44.0% Males 56.0% | 4.6% | HF 56% HTN 60% HHD 47% VHD 44% RHD 21% CM 15% CAD 6.5% Alcohol 48% | BB 36% Digoxin 24% Amiodarone 7.3% | – | 33% | – |
| Mbaye [19] 2010 Senegal | 57 | 150; Cardiac admissions | Females 68.7% Males 31.3% | 5,4% | HHD 41% VHD 37% CM 4.7% ICVA 14.7% CAD 2.7% | Rate-control 87% Amiodarone 7% DCCV 1.3% | – | 62% | – |
| Coulibaly [17] 2010 Ivory Coast | 59 | 217/3908; Cardiac admissions | Females 64.8% Males 35.2% | 5.5% | HF 63% HHD 48% RHD 28% | – | 47% | – | – |
| Bhagat [54] 1999 Zimbabwe | 200; Cardiology clinic | – | – | – | – | 79% urban 83% rural | 38% urban 19% rural | – |
[i] AAM (antiarrhythmic medication); BB (betablocker); CAD (coronary artery disease); CCB (non-dihydropyridine calcium channel blocker); CM (cardiomyopathy); COPD (chronic obstructive pulmonary disease); CVA (cerebrovascular accident); DCCV (direct current cardioversion); DM (Diabetes mellitus); FU (follow-up); HF (heart failure); HHD (hypertensive heart disease); HTN (hypertension); ICVA (ischemic cerebrovascular accident); NVAF (non-valvular atrial fibrillation); OAC (oral anticoagulation); RHD (rheumatic heart disease); TIA (transient ischemic attack); ↑TSH (hyperthyroidism); TTR (time in therapeutic range); VAF (valvular atrial fibrillation); VD (vascular disease); VHD (valvular heart disease). * Percentage of patients with CHADS2 ≥ 1 or CHA2DS2VASC ≥ 2 who were anticoagulated.
Figure 2
Trend of publications on cardiac arrhythmias from 1980 to March 31st, 2019 in sub-Saharan Africa.
Table 2
Sudden cardiac death/sudden cardiac arrest studies in sub-Saharan Africa.
| Author, Year, country | Mean age in years or age range | Sample size | Gender | Study population | CPR attempted | Rhythm of arrest | ROSC | Etiologies & Comorbidities | Survival to discharge |
|---|---|---|---|---|---|---|---|---|---|
| Edwards-Jackson et al [57], 2019, Malawi | 30 days to 13 years | 135 | – | Paediatric population IHCA | 100% | – | 6% | Malaria 51% | 0% (100% mortality) |
| Ngunga et al [58], 2018, Kenya | 61 | 353 | Females 46.5% Males 53.5% | IHCA | Not mentioned | Asystole 47.6%, PEA 38.2%, VT/VF 5.4%, Unknown 8.8% | Asystole patients 17.3%, PEA 40.7%, VT/VF 57.9%, Unknown 25.8%. Mean time to ROSC 5.3 mins | Heart Failure 9.1% HTN 39.7% DM 25.5% CAD 6.0% CVA 4.9% Cancer 9.1% HIV/AIDS 14.5% Sepsis 19% | 4.2% |
| Bonny et al [59], 2017, Cameroon | Men 36 Women 35 | 27/288 Incidence of SCD 33.6 per 100 000 person-years | Females 48.1% Males 51.9% | OHCA 63% | 3.7% | – | – | Heart failure 14.8% HTN 22.2% DM 11.1% CAD 7.4% HIV 7.4% Tropical disease 3.7% | – |
| Adekola et al [60], 2016, Nigeria | 1–18 years 23.33% >18years 77.67% | 60/4,229 cases | Females 55.0% Males 45.0% | Perioperative cardiac arrests | 100% | - | 56.7% | No co-existing disease 81.2% HTN 13.3% DM 8.3% Sickle cell 1.6% Incidence in ASA III/IV/V >ASA I/II | 20.6% |
| Talle et al [61], 2015, Nigeria | 49 all patients, 39 years SCD patients | Total 388 cardiac admissions, 56 deaths, 23 (41.1%) SCD | Females 52.2% Males 47.8% | Cardiac admissions | 52.1% | – | 8.3% | Heart failure 82.6% CAD 39.1% Peripartum CM 21.7% DCM 17.4% RHD 17.4% HTN 47% DM 21% PHTN 4.3% | – |
| Akinwusi et al [62], 2013, Nigeria | 46 | 29/718 (4%) | Females 13.8% Males 86.2% | Adult medical deaths | – | – | – | CVD 51.7% (HHD 86.7%, HF 80%) Respiratory 20.7% PE 10.4% CNS disease 13.8% GI 13.0% Chemical/drug 13.8% HTN 48.3% | – |
| Tiemensma et al [64], 2012, South Africa | 42.6 | 816 | Females 31.0% Males 69.0% | Sudden and unexpected adult deaths | – | – | – | CVD 17.2% (CAD 75.7%) Respiratory 15.0% CNS 7.5% GI 2.9% GU 1.2% | |
| Kwari et al [63], 2010, Nigeria | – | 14/4,015 | – | Perioperative cardiac arrest | – | – | – | Patients with ASA class III/IV risk status suffered more arrest than ASA I/II | 14% |
| Stein et al [65], 2009, South Africa | Adults | 510 | – | OHCA | 40% (By-stander 36%) Median response time 9 minutes | VT/VF 23%. Only predictor of ROSC was shockable rhythm | 18% | Cardiac causes 75% | – |
| Olotu et al [66], 2009, Kenya | 28 months | 114 | Females 40.0% Males 60.0% | IHCA Pediatric patients | 100% | – | 26% | Malaria Septicemia Severe malnutrition | 16% |
| Rotimi et al [67], 2004, Nigeria | Men 53.7 Women 52.2 | 79 | Females 25.3% Males 74.7% | Medico-legal autopsies | – | – | – | HHD 83.5% CAD 6.3% | – |
| Schneider et al [69], 2001, Ethiopia | – | 92 | – | Sudden unexpected deaths based on police reports | – | – | – | CAD 47.8% RHD 7.6% | – |
| Rotimi et al [68], 1998, Nigeria | 28–80 years | 50 | Females 30.0% Males 70.0% | Coroner’s autopsies | – | – | – | HTN 82% Heart failure 68% CAD 4% | – |
| Arthur et al [70], 1995, Ghana | – | 16 | – | Pediatric patients | – | – | – | Cardiac disease 50% Sickle cell 6.25% Tuberculosis 6.25% No chronic disease 37.5% | – |
[i] ASA (American Society of Anesthesiologists); CAD (coronary artery disease); CNS (central nervous system); CPR (cardiopulmonary resuscitation); CVD (cardiovascular disease); DCM (dilated cardiomyopathy); DM (diabetes mellitus); GI (gastrointestinal); GU (genitourinary); HHD (hypertensive heart disease); HIV (human immunodeficiency virus); HTN (hypertension); IHCA (in-hospital cardiac arrest); OHCA (out-of-hospital cardiac arrest); PE (pulmonary embolism); PEA (pulseless electrical activity); PHTN (pulmonary hypertension); RHD (rheumatic heart disease); ROSC (return of spontaneous circulation); SCD (sudden cardiac death); VT/VF (Ventricular tachycardia/ventricular fibrillation).
Table 3
Reported underlying etiologies of sudden cardiac arrest/sudden cardiac death among adults in sub-Saharan Africa.
| Cardiomyopathies [58, 61] |
| Hypertensive heart disease [58, 62, 67] |
| Coronary artery disease [58, 59, 61, 64, 69] |
| Rheumatic heart disease [61, 69] |
| Congenital heart disease [96] |
| Arrhythmogenic right ventricular cardiomyopathy [76, 77] |
| Hypertrophic cardiomyopathy [74, 75] |
| Brugada syndrome [78, 79] |
| Congenital Long QT syndrome (seen only in non-Black populations) [74, 88, 101] |
| Ventricular non-compaction [84] |
| Pulmonary embolism [62, 91] |
| Endomyocardial fibrosis [95] |
| Pulmonary hypertension [61] |
| Pericarditis (mainly tuberculous) [92] |
| Aortic dissection/rupture [64] |
| Endemic parasitic infections like trypanosomiasis & schistosomiasis [9, 59, 93] |
| Sarcoidosis [102, 103, 104] |
| Respiratory disease [58, 62, 64] |
| Septicemia [58, 66] |
| HIV/AIDS [58, 59] |
| Cancer [58] |
| Tuberculosis [58, 64, 70] |
| Renal disease [58, 64] |
| Liver disease [58, 64] |
[i] N/B: Detailed investigations for the cause of SCA/SCD are sparse in SSA. Therefore, uncertainty remains about the relative frequencies of these underlying etiologies.
Table 4
Cardiac implantable electronic devices in sub-Saharan Africa.
| Author, Year, country | Mean age in years | Sample size | Gender | Indication | Types of CIEDs | Chamber of implantation | Complications |
|---|---|---|---|---|---|---|---|
| Tchoumi et al [108], 2019, Cameroon | 62 | 130 | Females 40.0% Males 60.0% | SSS 29.1% AVB 88 70.9% | PPM 124 ICD 4 CRT 2 | VVI 17.0% DDD 81.5% CRT 1.5% | - Pocket infection 4 (3.1%) - Lead displacement 4 (3.1%) - Pneumothorax 2 (1.5%) - Hemothorax 2 (1.5%) |
| Adoubi et al [109], 2018, Ivory Coast | 67 | 283 | Females 50.9% Males 49.1% | SSS 17% AVB 83% | PPM | – | – |
| Jouven et al [110], 2016, 14 SSA countries | – | 502 during 16 missions to SSA | – | – | PPM | – | - No periprocedural complications - 52% of patients initially listed as suitable died before the missions arrived |
| Jama et al [107], 2015, South Africa | - | 126 | Females 52.9% Males 47.1% | PPM SSA 12.8% AVB 79.4% Others 7.8% ICD Secondary prevention 79.2% Others 20.8% | PPM 102 New 50% Recycled 50% ICD 24 New 50% Recycled 50% | PPM VVI 79.5% DDD 17.6% Others 2.9% ICD VVI 100% | - No device infection, malfunction, early battery depletion or device removal in either the re-used or new devices groups |
| Ikama et al [111], 2015, Congo | 70 | 8/20 implanted | Females 50.0% Males 50.0% | AVB 100% | PPM | – | - No complications - 8 patients (40%) of the initial 20 died before mission arrived |
| Falase B et al [112], 2013, Nigeria | 68 | 51 | Females 43.1% Males 56.9% | SSS 9.8% AVB 90.2% | PPM | VVI 56.9% DDD 43.1% | - Infection 3 (5.9%) - Lead displacement 3 (5.9%) - Pocket erosion 2 (3.9%) - Death 1 (2%) |
| Kane et al [113], 2012, Senegal | 66 | 107 | – | – | PPM | – | - Infection 5.6% |
| Ekpe et al [119], 2008, Nigeria | 70 | 23 | Females 48.0% Males 52.0% | SSS 0% AVB 100% | PPM | Endocardial 65% Epicardial 35% | – |
| Thiam et al [116], 2003, Ivory Coast | – | 92 | Females 48.9% Males 51.1% | – | PPM New 47% Recycled 53% | VVI 87% DDD 23% | - Infection 5 (5.4%) - Lead displacement 3 (3.3%) - Pacemaker syndrome 1 (1.1%) - Death 1 (1.1%) |
| Millar et al [114], 2001, South Africa | – | 1643 | – | Public hospitals SSS 16.2% AVB 75.3% AVNA 3% Others 6.3% Private hospitals SSS 34.9% AVB 45.3% AVNA 13.6% Others 7.6% | PPM | Public hospitals AAI 0.4% VVI 73% VDD 14.5% DDD 12.1% Private hospitals AAI 0.4% VVI 53.3% VDD 10.9% DDD 42.3% | – |
| Diop et al [117], 2000, Senegal | 54 | 12 | Females 41.7% Males 58.3% | – | PPM | VVI 41.7% DDD 58.3% | - Pocket infection 2 (16.0%) |
| Mayosi et al [115], 1999, South Africa | 21–50 | 232 | Females 41.8% Males 58.2% | SSS 25% AVB 62% Others 13% | PPM | VVI 65% DDD 35% | – |
| Dos Santos et al [118], 1982, South Africa | 17–78 | 57 | Females 61.0% Males 39.0% | SSS 4% AVB 91% SSS + AVB 5% | PPM | VVI 98.3% DDD 1.7% | - Infection 2 (3.5%) - Lead displacement 2 (3.5%) - Erosion 3 (5.3%) |
[i] AAI (single chamber atrial pacemaker); AVB (atrioventricular block); AVNA (atrioventricular node ablation); CIEDs (cardiac implantable electronic devices); CRT (cardiac resynchronization therapy); DDD (dual chamber pacemaker); ICD (implantable cardioverter defibrillator); LVEF (left ventricular ejection fraction); PPM (permanent pacemaker); SSA (sub-Saharan Africa); SSS (sick sinus syndrome); VDD (dual chamber sensing, ventricular pacing pacemaker); VVI (single chamber ventricular pacemaker).
Figure 3
Central illustration of cardiac arrhythmias in sub-Saharan Africa.
CIEDs (cardiac implantable electronic devices); CPR (cardiopulmonary resuscitation); CRT (cardiac resynchronization therapy); ICD (implantable cardioverter defibrillator); IHCA (in-hospital cardiac arrest); PPM (permanent pacemaker); OHCA (out-of-hospital cardiac arrest); ROSC (return of spontaneous circulation); SSA (sub-Saharan Africa); VT/VF (ventricular tachycardia/ventricular fibrillation).