Clovis Nkoke

Coronary heart disease in sub-Saharan Africa: still rare, misdiagnosed or underdiagnosed?

Coronary heart disease (CHD) is the leading cause of death in developed countries, but it has generally been considered to be rare in sub-Saharan Africa (SSA). SSA is undergoing rapid epidemiological transition with an increasing prevalence of major cardiovascular risk factors and consequential cardiovascular diseases such as stroke. However, CHD including myocardial infarction has generally been considered to be rare despite this deterioration in the risk factors profile. There is an urgent need to raise awareness about CHD both in the general population and healthcare professionals while making available simple, inexpensive screening and diagnostic tools in sub-Saharan African countries.

UNAIDS 90–90–90 targets to end the AIDS epidemic by 2020 are not realistic: comment on “Can the UNAIDS 90–90–90 target be achieved? A systematic analysis of national HIV treatment cascades”

### Summary box There is indisputable evidence regarding the remarkable success over the past two decades in reducing HIV associated morbidity, mortality, transmission, stigma and improving the quality of life of people living with HIV.1 In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched the 90–90–90 targets; the aim was to diagnose 90% of all HIV-positive persons, provide antiretroviral therapy (ART) for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020. This is estimated to result in 73% of people with HIV achieving viral suppression, a crucial step in ending the AIDS epidemic by 2030.2 However, 36.9 million people are living with HIV today and about 2.1 million new infections were recorded in 2015.3 This high rate of new infections continues to fuel the epidemic. Reports from national HIV programmes …

Rheumatic heart disease awareness in the South West region of Cameroon : A hospital based survey in a Sub-Saharan African setting

Background Early diagnosis and adequate treatment of Group A streptococcal throat infection is an important initial stage in the primary prevention of acute rheumatic fever and rheumatic heart disease. This preventable condition associated with high mortality rates mandates a thorough understanding by the general public and the health. Objective The aim of the study was to assess the level of awareness about different aspects of rheumatic heart disease in patients coming to the outpatient department of the Buea regional Hospital, South West region of Cameroon. Methods This was a cross-sectional descriptive study carried in the outpatient department of the Buea Regional Hospital, Cameroon. The study population was adults and children aged 9 years and above. Data collection was done by using a self-administered questionnaire addressed to assess awareness on rheumatic heart disease. Results A total of 256 participants were interviewed, of which 70 (27.3%) were males. Their mean age was 34.4 ± 11.9 years (males: 36.2 ± 12.7 years versus females: 33.7 ± 11.6 years, p = 0.129). Most of the participants were in the 20 to 29 year old group (37.9%). More than two thirds (71.1%) of the participants reported having had sore throat at least once. The disease was treated with antibiotics in only 45.4%, with the treatment prescribed by a health care professional in 35.8% of the cases. About 73% of the respondents did not know what causes sore throat, and most (71.1%) were unaware of any complications that could arise from poorly treated sore throat. More than 70% of the participants did not know that sore throat can be associated with heart disease. Rheumatic heart disease was unknown to 82% of the participants and 95% of them did not know what causes RHD. Only 5.1% percent of the participants had an adequate knowledge of RHD. Age ≤ 35 years, post-secondary level of education, and having heard of RHD were significantly associated with an adequate knowledge. After adjusting for age, post-secondary education (aOR: 9, [95% C: 1.2–67.5], p = 0.019), and having heard of RHD (aOR: 18.1, [95% CI: 4.7–70.3], p<0.001) were still associated with a fair knowledge. Conclusions Levels of knowledge and awareness on rheumatic heart disease is low. This study provides important insight into the perception and practices related to sore throat that can be used in the design of awareness activities aimed reducing the risk of RHD in Cameroon. The appropriateness of antibiotics prescribed, and the health care provider awareness and knowledge levels regarding RHD in Cameroon has not been reported yet in the literature. This grey area deserves more research.

Trends in pediatric echocardiography and the yield for congenital heart disease in a major cardiac referral hospital in Cameroon

BACKGROUND Congenital heart disease (CHD) is a common condition in children in Sub-Saharan Africa (SSA), where it is associated with poor outcomes. Diagnosis of CHD in SSA depends essentially on echocardiography, which is available only in few urban referral centers. Our aim was to assess time changes in the pattern of referral for pediatric echocardiography and the subsequent diagnosis of structural CHD in a major SSA city. METHODS All pediatric echocardiography performed between 2004 and 2013 at the echocardiography laboratory of the Yaounde General Hospital were reviewed. The primary indication of the study and the presence of structural CHD were recorded. RESULTS Between 2004 and 2013, 9,390 echocardiograms were performed and 834 (8.9%) children aged 1 day to 15 years underwent echocardiography at the center, and 227 (27.2%) cases of definite structural CHD were diagnosed, with 123 (54.2%) in boys. The most frequent indications for echocardiography were heart murmurs (40%) and the suspicion of CHD (37.4%). The commonest CHD was ventricular septal defect (VSD) (30%) with tetralogy of Fallot being the most frequent cyanotic heart lesion (5.3%). The proportion of pediatric echocardiography decreased from 13.3% in 2004-2005 to 6.1% in 2012-2013 (P=0.001) but not in a linear fashion (P=0.072 for linear trend).The diagnosis of structural CHD increased from 25.1% in 2004-2005 to 27.1% in 2012-2013. This increase however was non-significant (P=0.523) and did not follow a linear trend (P=0.230). CONCLUSIONS The pattern of referral for pediatric echocardiography at this center has changed over time, but diagnosis of structural CHD has remained the same. Improving access to this diagnostic procedure and subsequent treatment of diagnosed CHD will help improving the outcome of the disease in this setting.

A new look at human immunodeficiency virus infection and stroke in Sub-Saharan Africa

Stroke and human immunodeficiency virus (HIV) infection are major causes of morbidity and mortality in Sub-Saharan Africa (SSA), with disease burdens being amongst the highest worldwide. HIV infection has emerged as an important risk factor for stroke. The remarkable development in the treatment of HIV infection which occurred in recent decades has allowed the survival of a large number of patients. This therapeutic success which allows patients to live longer has facilitated the emergence of a new population of adults with increased risk for cardiovascular disease including stroke due to aging, the direct effects of HIV infection and combined anti-retroviral therapy (cART). Preventive strategies to decrease the burden of stroke amongst this specific patient population remain understudied in this region of the world. Lack of early diagnosis (CT scans) and poor record keeping make appreciation of the burden difficult. There is indisputable evidence that early diagnosis and early placement on cART therapy reduce HIV associated morbidity and mortality in this region of the world. However, the emergence of a new population of patients at risk for developing stroke (HIV patients) who fortunately live longer deserves a keener attention. Long term effects of cART regimens on cardiovascular and metabolic profiles remain uncertain, and specific cohort studies to properly ascertain its consequences are needed. The evidence and specific guidelines with regards to anti-platelet therapies and statin use, though potentially beneficial, in this patient sub group remains scarce. African specific cohort studies including HIV positive patients in our opinion should constitute a top research priority, to properly ascertain the potential roles of anti-platelet therapies and statins with regards to primary and secondary prevention of stroke, as well as long term effects of cART on their cardiovascular and metabolic profiles.

A new look at acquired heart diseases in a contemporary sub-Saharan African pediatric population: the case of Yaoundé, Cameroon

BACKGROUND Acquired heart diseases (AHD) in children cause significant morbidity and mortality especially in low resource settings. There is limited description of acquired childhood heart diseases in Cameroon, making it difficult to estimate its current contribution to childhood morbidity and mortality. Echocardiography is the main diagnostic modality in low resource settings and has a key role in the characterization and management of these disorders. We aimed to determine the prevalence and spectrum of AHD in children in Yaoundé-Cameroon, in an era of echocardiography. These data are needed for health service and policy formulation. METHODS Echocardiography records from August 2003 to December 2013 were reviewed. Echocardiography records of children ≤18 years with an echocardiographic diagnosis of a definite AHD were identified and relevant data extracted from their records. RESULTS One hundred and fifty eight children (13.4%) ≤18 years had an AHD. The mean [± standard deviations (SD)] age was 11.9 (±4.4) years .The most common affected age group was 15-18 years (36.1%). Heart failure (20.3%), suspicion of rheumatic heart disease (RHD) (12.0%) and the presence of a heart murmur (8.9%) were the most common indications for echocardiography. RHD (41.1%), pericardial disease (25.3%), dilated cardiomyopathy (DCM) (15.8%) and endomyocardial fibrosis (EMF) (13.9%) were the most common AHD. Cor pulmonale was rare (1.3%). Fifty-seven (87.7%) children with RHD had mitral regurgitation alone or in combination with other heart valve lesions and 63.3% of the lesions were severe. CONCLUSIONS RHD remains the most common AHD in children in this setting and is frequently severe. Multicenter collaborative studies will help to better describe the pattern of AHD and there should be a renewed focus on the prevention of RHD.

Post-stroke care: an alternative model to reduce stroke related morbidity in sub-Saharan Africa

Stroke is a leading cause of death and disability in adults in sub-Saharan Africa (SSA). Despite its considerable burden, there has been limited progress to properly cater for and rehabilitate stroke survivors. Scarcity of rehabilitation services and grossly inadequate skilled personnel for post stroke care are distressing realities for stroke victims in SSA. There is growing evidence suggesting that home-based rehabilitation for stroke can have functional outcomes similar to patients who receive inpatient neuro-rehabilitation. The acute phase of treatment during hospitalization could be an opportunity to educate families and caregivers on how to care for stroke victims at home and provide home-based rehabilitation and care tailored to their disability. Interventions to vulgarize home-based post-stroke care could be more acceptable, affordable and accessible for victims and families. This could go a long way to palliate to the scarcity of rehabilitation services and reduce stroke related morbidity. We suggest that further research be carried out to ascertain the feasibility of this model in SSA settings, with greater emphasis on the cost effectiveness and sustainability arms of such an intervention.