Tackling heart failure in sub-Saharan Africa: the imperious need for hypertension prevention and control
Jean Jacques Noubiap1,&
1Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
Jean Jacques Noubiap, Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
Heart failure (HF) is a leading contributor to the global burden of disease, affecting about 26 million people worldwide . It is associated with high morbidity, recurrent and prolonged hospitalization, poor quality of life, premature death and massive economic loss [1, 2]. Sub-Saharan African (SSA) populations are disproportionally affected. According to the International Congestive Heart Failure (INTER-CHF) prospective cohort study, patients with HF in Sub-Saharan Africa (SSA) have the highest mortality rate, with a third of them who die within a year . The excess HF-related mortality in the region is mostly attributed to weak health care systems that are already overwhelmed with the burden of infectious diseases, and to poor access to guideline-directed medical treatment [2, 3]. Furthermore, HF in SSA occurs at a much younger age, mostly in professionally active adults, leading to significant loss of economic productivity [4-6].
Largely unknown about two decades ago, the epidemiology of HF in SSA has been increasingly studied in the recent years. The Sub-Saharan Africa Survey of Heart Failure (THESUS-HF) was pioneer to prospectively investigate the causes, clinical features, treatment, and outcomes of patients admitted with acute HF in academic hospitals in SSA . THESUS-HF along with several other reports have revealed that, in a stark contrast with data from most European and North American populations, HF in SSA populations is predominantly non-ischemic and most commonly due to hypertension. This is corroborated by the findings from the study by Mandi et al. published in this volume of the Pan African Medical Journal .
Mandi et al. conducted a prospective cohort study at the Regional Hospital Center of Tenkodogo, a tertiary hospital in the eastern region of Burkina Faso. They found that 17.6% of patients who attended the cardiology unit had acute HF, mostly de novo cases (80.2%). Importantly, hypertensive heart disease accounted for up to half of all cases of HF. Other key information is the young age of patients, with an average of 58 years; the high mortality of up to 31 per 100 patient-years of follow-up; a strikingly low use of beta-blockers (18.8%) that are pivotal in guideline-directed medical treatment of HF; and a high frequency of atrial fibrillation (29.5%), one of the highest reported in HF patients in the region .
The most salient message from the study by Mandi et al., although not surprising, is the high burden of hypertensive heart disease. This aligns with a recent comprehensive review of the epidemiology of heart failure in SSA which showed that four in ten cases of heart failure in the region are directly attributed to hypertension . This reminds us about the ongoing disaster caused by hypertension in SSA. Indeed, unlike many countries in other parts of the globe where the prevalence of hypertension is steadily decreasing, in SSA countries, this prevalence is rising . It is estimated that more than 30% of adults in SSA have hypertension, compared to less than 20% about 30 years ago [10, 11]. More worrisome, this high prevalence of hypertension is associated with low awareness, treatment and control rates, with only 27% of affected people who are aware of their condition, 18% who are on treatment, and 7% who achieve controlled blood pressure (BP) in the region . As a result, in 2017, hypertension was a leading risk for death and disability, accounting for ~ 580,000 deaths and ~14 million disability-adjusted life years in SSA .
The surge in hypertension prevalence in SSA over the last two decades is part of the epidemiologic transition that is occurring in region, driven by socioeconomic and cultural changes characterized by reduced physical activity, elevated stress, unhealthy dietary patterns with high saturated fat and salt consumption, and alcohol abuse . All these environmental factors play on a permissive genetic background that predisposes African populations to be more sensitive to salt, i.e., to be more susceptible to sodium-related increase in blood pressure . The major contribution of modifiable environmental factors on the incidence of hypertension suggests that it can be prevented to a large extent. Furthermore, considering the huge economic burden imposed by hypertension on health care systems and individuals in SSA, with an estimated 7.3% of total health care spending directly related to hypertension and its complications, prevention of hypertension should be an imperious priority in the region .
The prevention of hypertension should be integrated in an umbrella of interventions for primordial prevention of cardiovascular disease in general. This starts with educating populations on hypertension and other cardiovascular risk factors, and measures to prevent them. Population-wide interventions should be implemented to promote healthy diet, by reducing saturated and trans fat, sugar and salt intake, by increasing potassium and fruits consumption ; and by encouraging physical activity and a healthy living and working environment. The food industry should contribute to these efforts by selling healthy products, within a well-established legislation framework to mandate food labelling and compliance to recommended levels of dietary salt and sugar.
The next step is to scale up hypertension screening and effective management, especially in the context of unacceptably high rates of undiagnosed, untreated and poorly controlled disease in SSA . Systematic blood pressure measurement is pivotal to ensure that no adult who encounters a health facility misses the opportunity to be screened for hypertension, but bearing in mind the significant proportion of white coat hypertension . Community blood pressure screening should also be encouraged through the provision of blood pressure devices at the workplace and churches, for instance. Regarding treatment, approaches to achieve a global cardiovascular risk reduction are the most effective . Hence, a cardiovascular risk assessment should be performed, looking for other potential risk factors such as obesity, diabetes and dyslipidaemia, and target organ damage including left ventricular dysfunction, cerebrovascular disease and renal dysfunction that should be comprehensively addressed. It is essential that good quality generic cardiovascular medications are provided to patients at low cost, and ultimately, that universal health coverage is implemented to ensure that the large majority of the population have access to effective health care . Home blood pressure monitoring (HBPM) should be scaled up to improve blood pressure control. When combined with appropriate patient education, lifestyle modification and adherence to medications, HBPM stands out as a valuable tool in the treatment of hypertension . Furthermore, health care workers should be trained to appropriately manage hypertension, and be provided with contextualized national guidelines for the diagnosis and treatment of cardiovascular risk factors and diseases. Task sharing or shifting strategies should be considered for implementation at the primary care level to enhance access to health care .
All these strategic components for the prevention and control of hypertension require a constant implication and a strong collaboration between national governments and health organizations, international agencies and scientific societies such as the World Health Organization (WHO), the World Heart Federation and the International Society of Hypertension, and international aid and health funding bodies. In May 2013, the 66th World Health Assembly endorsed the WHO Global Action Plan for the Prevention and Control of Noncommunicable diseases 2013-2020. This global initiative provides a road map and a menu of policy options to be implemented collectively between 2013 and 2020 by WHO Member States and various organizations, in order to achieve nine global targets including a 30% reduction in mean population salt intake; a 25% reduction in the prevalence of raised blood pressure; and a 25% relative reduction in premature mortality from noncommunicable diseases by 2025. Considering the current trends in the burden of hypertension and other NCDs , it is very unlikely that these targets will be attained in SSA by 2025. However, SSA countries should build on the progress made and capitalize the experience gained to develop and deploy more feasible and effective local policies and plans to curb the burden of hypertension and other NCDs.
Disclosures: Dr Noubiap is supported by a Postgraduate Scholarship from the University of Adelaide.
The author declare no competing interests.
- Ambrosy AP, Fonarow GC, Butler J, Chioncel O, Greene SJ, Vaduganathan M et al. The global health and economic burden of hospitalizations for heart failure: lessons learned from hospitalized heart failure registries. J Am Coll Cardiol. 2014;63(12):1123-1133. PubMed | Google Scholar
- Dokainish H, Teo K, Zhu J, Roy A, AlHabibFJ, ElSayed A et al. Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study [published correction appears in Lancet Glob Health]. Lancet Glob Health. 2017;5(7):e665-e67. PubMed | Google Scholar
- Tromp J, Bamadhaj S, Cleland JGF,Angermann CE, Dahlstrom U, Ouwerkerk W et al. Post-discharge prognosis of patients admitted to hospital for heart failure by world region, and national level of income and income disparity (REPORT-HF): a cohort study. Lancet Glob Health. 2020;8(3):e411-e422. PubMed | Google Scholar
- Agbor VN, Essouma M, Ntusi NAB, Nyaga UF, Bigna JJ, Noubiap JJ. Heart failure in sub-Saharan Africa: A contemporaneous systematic review and meta-analysis. Int J Cardiol. 2018;257:207-215. PubMed | Google Scholar
- Nyaga UF, Bigna JJ, Agbor VN, Essouma M, Ntusi NAB, Noubiap JJ. Data on the epidemiology of heart failure in Sub-Saharan Africa. Data Brief. 2018;17:1218-1239. PubMed | Google Scholar
- Agbor VN, Ntusi NAB, Noubiap JJ. An overview of heart failure in low- and middle-income countries. Cardiovasc Diagn Ther. 2020;10(2):244-251. PubMed | Google Scholar
- Damasceno A, Mayosi BM, Sani M, Ogah OS, Mondo C, Ojji D et al. The causes, treatment, and outcome of acute heart failure in 1006 Africans from 9 countries. Arch Intern Med. 2012;172(18):1386-1394. PubMed | Google Scholar
- Mandi DG, Bamouni J, Yaméogo RA, Naïbé DT, Kaboré E, Kambiré Y et al. Spectrum of heart failure in sub-Saharan Africa: data from a tertiary hospital-based registry in the eastern center of Burkina Faso. Pan Afr Med J. 2020;36(30). PubMed | Google Scholar
- Noubiap JJ, Nyaga UF. A review of the epidemiology of atrial fibrillation in sub-Saharan Africa. J Cardiovasc Electrophysiol. 2019;30(12):3006-3016. PubMed | Google Scholar
- Mills KT, Stefanescu A, He J. The global epidemiology of hypertension. Nat Rev Nephrol. 2020;16(4):223-237. PubMed | Google Scholar
- Ataklte F, Erqou S, Kaptoge S, Taye B, Echouffo-Tcheugui JB, Kengne AP. Burden of undiagnosed hypertension in sub-saharan Africa: a systematic review and meta-analysis. Hypertension. 2015;65(2):291-298. PubMed | Google Scholar
- Institute for Health Metrics and Evaluation . Global both sex, all ages, 2017, Dalys. 2020. Cited 2020 23 June.
- Opie LH, Seedat YK. Hypertension in sub-Saharan African populations. Circulation. 2005;112(23):3562-3568. PubMed | Google Scholar
- Luft FC, Miller JZ, Grim CE, Christian JC, Daugherty SA, Weinberger MH et al. Salt sensitivity and resistance of blood pressure. Age and race as factors in physiological responses. Hypertension. 1991;17(1 Suppl):I102-I108. PubMed | Google Scholar
- Gaziano TA, Bitton A, Anand S, Weinstein MC; International Society of Hypertension. The global cost of nonoptimal blood pressure. J Hypertens. 2009;27(7):1472-1477. PubMed | Google Scholar
- Noubiap JJ, Bigna JJ, Nansseu JR. Low sodium and high potassium intake for cardiovascular prevention: evidence revisited with emphasis on challenges in sub-Saharan Africa. J Clin Hypertens (Greenwich). 2015;17(1):81-83. PubMed | Google Scholar
- Noubiap JJ, Nansseu JR, Nkeck JR, Nyaga UF, Bigna JJ. Prevalence of white coat and masked hypertension in Africa: A systematic review and meta-analysis [published online ahead of print, 2018 Jul 9]. J Clin Hypertens (Greenwich). 2018;10.1111/jch.13321. PubMed | Google Scholar
- Campbell NR, Bovet P, Schutte AE, Lemogoum D, Nkwescheu AS. High Blood Pressure in Sub-Saharan Africa: Why Prevention, Detection, and Control are Urgent and Important. J Clin Hypertens (Greenwich). 2015;17(9):663-667. PubMed | Google Scholar
- Ndip Agbor V, Temgoua MN, Noubiap JJ. Scaling up the use of home blood pressure monitoring in the management of hypertension in low-income countries: A step towards curbing the burden of hypertension. J Clin Hypertens (Greenwich). 2017;19(8):786-789. PubMed | Google Scholar