Ntobeko A.B. Ntusi

Severe disseminated hydatid disease successfully treated medically with prolonged administration of albendazole.

A 19-year old gentleman presented to our medical department, referred by a GP with an assessment of minor stroke. The patient had a pneumonectomy for a hydatid cyst of the right lung 4 years previously. After refusing repeat surgery for excision of hepatic hydatid cysts, he was lost to follow-up. On this occasion, he complained of right sided weakness with decreased visual acuity bilaterally for 3 days. The neurological deficit had been improving since the onset (and resolved completely 2 days later). There was a history of a single generalized tonic-clonic seizure about 2 months previously and, also, episodes of syncope associated with impairment of the level of consciousness, but with no abnormal movements noted, followed by confusion on waking. …

Heart failure in sub-Saharan Africa: A contemporaneous systematic review and meta-analysis

OBJECTIVE To summarise available data on the prevalence, aetiology, treatment and prognosis of heart failure (HF) in sub-Saharan Africa (SSA). SETTING This systematic review and meta-analysis included data from individuals recruited in primary to tertiary health facilities in SSA. PARTICIPANTS All published and unpublished literatures between January 1, 1996 and June 23, 2017, of individuals aged 12years and older and residing in sub-Saharan Africa. They must be of African descent. OUTCOME Number of heart failure admissions into general wards or HF clinics; number of cases of the different aetiologies of HF; number of participants on the different medications for HF; number of cases of all-cause mortality in participants with HF, and the predictors of all-cause mortality. Due to a limited word count, only results on the aetiologies of HF will be presented in the abstract. RESULTS Thirty five full text articles were selected after screening of an initial 3785 titles and abstract. Hypertensive heart disease (HHD) (39.2% [95% CI=32.6-45.9]) was the commonest cause of HF in SSA, followed by cardiomyopathies (CMO) (21.4% [95% CI=16.0-27.2]) and rheumatic heart disease (RHD) (14.1% [95% CI=10.0-18.8]). Ischaemic heart disease (7.2% [95% CI=4.1-11.0]) was rare. CONCLUSION HHD, CMO and RHD are the most common causes of HF in SSA, with HHD and CMO responsible for over 50% of the cases. Also, the last two decades have witnessed a relative reduction in the prevalence of RHD below 15.0%.

Diagnosing cardiac disease during pregnancy: imaging modalities.

Abstract Pregnant women with known or suspected cardiovascular disease (CVD) often require cardiovascular imaging during pregnancy. The accepted maximum limit of ionising radiation exposure to the foetus during pregnancy is a cumulative dose of 5 rad. Concerns related to imaging modalities that involve ionising radiation include teratogenesis, mutagenesis and childhood malignancy. Importantly, no single imaging study approaches this cautionary dose of 5 rad (50 mSv or 50 mGy). Diagnostic imaging procedures that may be used in pregnancy include chest radiography, fluoroscopy, echocardiography, invasive angiography, cardiovascular computed tomography, computed tomographic pulmonary angiography, cardiovascular magnetic resonance (CMR) and nuclear techniques. Echocardiography and CMR appear to be completely safe in pregnancy and are not associated with any adverse foetal effects, provided there are no general contra-indications to MR imaging. Concerns related to safety of imaging tests must be balanced against the importance of accurate diagnosis and thorough assessment of the pathological condition. Decisions about imaging in pregnancy are premised on understanding the physiology of pregnancy, understanding basic concepts of ionising radiation, the clinical manifestations of existent CVD in pregnancy and features of new CVD. The cardiologist/physician must understand the indications for and limitations of, and the potential harmful effects of each test during pregnancy. Current evidence suggests that a single cardiovascular radiological study during pregnancy is safe and should be undertaken at all times when clinically justified. In this article, the different imaging modalities are reviewed in terms of how they work, how safe they are and what their clinical utility in pregnancy is. Furthermore, the safety of contrast agents in pregnancy is also reviewed.

An approach to the clinical assessment and management of syncope in adults

Syncope, defined as a brief loss of consciousness due to an abrupt fall in cerebral perfusion, remains a frequent reason for medical presentation. The goals of the clinical assessment of a patient with syncope are twofold: (i) to identify the precise cause in order to implement a mechanism-specific and effective therapeutic strategy; and (ii) to quantify the risk to the patient, which depends on the underlying disease,rather than the mechanism of the syncope. Hence, a structured approach to the patient with syncope is required. History-taking remains the most important aspect of the clinical assessment. The classification of syncope is based on the underlying pathophysiological mechanism causing the event, and includes cardiac, orthostatic and reflex (neurally mediated) mechanisms. Reflex syncope can be categorised into vasovagal syncope (from emotional or orthostatic stress), situational syncope (due to specific situational stressors), carotid sinus syncope(from pressure on the carotid sinus, e.g. shaving or a tight collar), and atypical reflex syncope (episodes of syncope or reflex syncope that cannot be attributed to a specific trigger or syncope with an atypical presentation). Cardiovascular causes of syncope may be structural(mechanical) or electrical. Orthostatic hypotension is caused by an abnormal drop in systolic blood pressure upon standing, and is defined asa decrease of >20 mmHg in systolic blood pressure or a reflex tachycardia of >20 beats/minute within 3 minutes of standing. The main causes of orthostatic hypotension are autonomic nervous system failure and hypovolaemia. Patients with life-threatening causes of syncope should be managed urgently and appropriately. In patients with reflex or orthostatic syncope it is important to address any exacerbating medication and provide general measures to increase blood pressure, such as physical counter-pressure manoeuvres. Where heart disease is found to bet he cause of the syncope, a specialist opinion is warranted and where possible the problem should be corrected. It is important to remember that in any patient presenting with syncope the main objectives of management are to prolong survival, limit physical injuries and prevent recurrences. This can only be done if a patient is appropriately assessed at presentation, investigated as clinically indicated, and subsequently referred to a cardiologist for appropriate management.

Data on the epidemiology of heart failure in Sub-Saharan Africa

In Sub-Saharan Africa (SSA), chronic non-communicable diseases and cardiovascular diseases in particular, are progressively taking over infectious diseases as the leading cause of morbidity and mortality. Heart failure is a major public health problem in the region. We summarize here available data on the prevalence, aetiologies, treatment, rates and predictors of mortality due to heart failure in SSA.

Human immunodeficiency virus-associated heart failure in sub-Saharan Africa: evolution in the epidemiology, pathophysiology, and clinical manifestations in the antiretroviral era

The survival of patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) who have access to highly active antiretroviral therapy (ART) has dramatically increased in recent times. This review focuses on HIV‐associated heart failure in sub‐Saharan Africa (SSA). In HIV infected persons, heart failure may be related to pathology of the pericardium, the myocardium, the valves, the conduction system, or the coronary and pulmonary vasculature. HIV‐associated heart failure can be because of direct consequences of HIV infection, autoimmune reactions, pro‐inflammatory cytokines, opportunistic infections (OIs) or neoplasms, use of ART or therapy for OIs and presence of traditional cardiovascular risk factors. Myocardial involvement includes diastolic dysfunction, asymptomatic left ventricular dysfunction, cardiomyopathy, myocarditis, fibrosis, and steatosis. Pericardial diseases include pericarditis, pericardial effusions (rarely causing tamponade), pericardial constriction, and effusive‐constrictive syndromes. Coronary artery disease is commonly reported in industrial nations, although its prevalence is thought to be low in HIV‐infected persons from SSA.

Cardiovascular magnetic resonance characterisation of pericardial and myocardial involvement in patients with tuberculous pericardial constriction with and without HIV co-infection

Background Tuberculosis pericarditis (TBP) is the most common cause of a large pericardial effusion in the developing world, accounting for 70% of effusions in a case series from South Africa; and has a high mortality related to pericardial tamponade, constrictive pericarditis, arrhythmias and heart failure. Manifestations of TBP include pericarditis with pericardial effusion, effusive-constrictive and constrictive pericarditis. There has been a dramatic resurgence in TBP in the context of co-infection with the human immunodeficiency virus (HIV). Almost 100% of pericardial effusions in those infected with HIV in sub-Saharan Africa are due to tuberculosis, compared with 50-70% in those HIV-uninfected and less than 5% in industrial nations. In patients with TBP, co-infection with HIV is associated with increased heart failure, haemodynamic instability, electrocardiographic (ECG) ST elevation and mortality, suggesting an aggressive myopericarditis in the context of HIV co-infection. However, little is known about myocardial involvement in patients with TBP. Cardiovascular magnetic resonance (CMR) can assess non-invasively cardiac function, myocardial oedema, inflammation and fibrosis. We hypothesised that HIV co-infection would be associated with increased myocardial pathology on CMR in patients with TBP.

Bongani Mawethu Mayosi

cardiologist in Africa, known by many for his visionary, altruistic, and collaborative approach to dealing with the continent’s fundamental health issues. On 27 July 2018, he died by suicide, following a diagnosis of depression. His enduring legacy will be one of research excellence, academic development, and the transforming effect he had on individual lives, institutions, and countries, particularly on the African continent. Bongani Mayosi was born on 28 January 1967 in Umthatha, South Africa, the second son of Dr George Mayosi and Mrs Nontle Mayosi. He completed high school, passing six subjects with distinction, aged 15. His first two degrees were a BMedSci completed in 1986 and concurrently an MBChB in 1989, at the University of Natal, South Africa, both obtained cum laude and at the top of his class. He was a medical intern at Livingstone Hospital, Port Elizabeth. Moving to Cape Town the following year, he worked at Groote Schuur Hospital (GSH) and the University of Cape Town (UCT). Within 3 years, he had been admitted to the Fellowship of the College of Physicians of South Africa. Immediately after, he was awarded the prestigious Oxford Nuffield Medical Scholarship, allowing him to read for a DPhil in Cardiovascular Medicine at the University of Oxford, UK. He returned home to complete his clinical training in cardiology at GSH and UCT. He was appointed as the 7th Chair and Head of the Department of Medicine at UCT and GSH in 2006, at the age of only 38 years. Following an illustrious tenure, during which he transformed the Department of Medicine, growing it to be the largest and leading medicine department on the African continent, he was appointed as the dean of the Faculty of Health Sciences at UCT and occupied this position until his untimely death. His research focused on cardiomyopathy, heart failure, rheumatic heart disease (RHD), tuberculous pericarditis, HIVassociated heart the National Research Foundation. He was a member of the Academy of Science of South Africa and president of the College of Physicians of South Africa, and in 2017 he was elected to the US National Academy of Medicine. Bongani was a longserving member of Nature Reviews Cardiology’s Advisory Board and was instrumental in fostering a working relationship between the journal and the PanAfrican Society of Cardiology, of which he served as president. Bongani’s character was one of outstanding integrity, humility, intelligence, and passion for the pursuit of knowledge. He will be remembered as the consummate professional and an exemplary leader. He imagined an Africa capable of driving its own agenda, using science to improve the health of its nations. He will be remembered for his love of the UCT students and his unwavering belief in the potential of others, for his excellence in research and translation of that research into work with a meaningful effect, and for his absolute love of his family. He was a devoted husband and father and never missed an opportunity to share how much his family meant to him. He spoke of the gratitude he had for the support of his wife and the love of his daughters, whom he referred to as his pride and joy.

Cardiac Magnetic Resonance in Stable Coronary Artery Disease: Added Prognostic Value to Conventional Risk Profiling

Aims Cardiovascular magnetic resonance (CMR) permits a comprehensive evaluation of stable coronary artery disease (CAD). We sought to assess whether, in a large contemporaneous population receiving optimal medical therapy, CMR independently predicts prognosis beyond conventional cardiovascular risk factors (RF). Methods We performed a single centre, observational prospective study that enrolled 465 CAD patients (80% males; 63±11 years), optimally treated with ACE-inhibitors/ARB, aspirin, and statins (76-85%). Assessments included conventional evaluation (clinical history, atherosclerosis RF, electrocardiography, and echocardiography) and a comprehensive CMR with LV dimensions/function, late gadolinium enhancement (LGE), and stress perfusion CMR (SPCMR). Results During a median follow-up of 62 months (IQR 23-74) there were 50 deaths and 92 major adverse cardiovascular events (MACE). CMR variables improved multivariate model prediction power of mortality and MACE over traditional RF alone (F-test p<0.05 and p<0.001, respectively). LGE was an independent prognostic factor of mortality (hazard ratio [95% CI]: 3.4 [1.3−8.8]); moreover, LGE (3.3 [1.7−6.3]) and SPCMR (2.1 [1.4−3.2]) were the best predictors of MACE. Conclusion LGE is an independent noninvasive marker of mortality in the long term in patients with stable CAD and optimized medical therapy. Furthermore, LGE and SPCMR independently predict MACE beyond conventional risk stratification.

Fits, faints and funny turns : CME - guest editorial

Fits, faints and funny turns represent a common reason for presentation - either to the general practitioner or to the emergency department. In many cases, the consultation is dissatisfying for the doctor and the patient, as such patients frequently present a diagnostic dilemma for the clinician. Frequently, the key to a satisfactory evaluation is a structured approach, premised on a clear and comprehensive history focused on prior comorbidities and the episode - its context, precipitating factors, prior situational factors, onset and evolution, and events occurring afterwards. A detailed and carefully elicited medical history allows the clinician to confirm the diagnosis, delineate the underlying mechanism, and identify features that may suggest high risk of recurrence, injury or death.