It has been suggested that the prevalence of coronary artery disease (CAD) is steadily increasing in sub-Saharan Africa. To address this issue, we conducted a Medline search of English language articles on cardiovascular diseases-and specifically CAD in Africa- from 1966 to 1997. The prevalence of CAD and related complications is relatively low in most regions in Africa compared to that obtained in the economically developed countries, although the situation is rapidly changing due to trends in urbanization, changes in lifestyle, acquisition of technology and the increasing numbers of tertiary care institutions. There are variations in reported prevalence rates within the different regions, but there is an upward trend in all the regions of the sub-Saharan Africa. This trend is believed to be related to the increasing frequencies of CAD risk factors in the subcontinent.

Trends in Coronary Artery Disease and Associated Risk Factors in sub-Saharan Africans

Endomyocardial fibrosis is a relatively common form of heart disease in Uganda (Davies, 1948; Shaper and Williams, 1960) and accounts for some 10 per cent of heart disease seen at necropsy in Kampala (Davies, 1961). It is characterized in the established condition by fibrosis in the endocardium and subjacent myocardium affecting particularly the inflow tract and the apex of one or both ventricles. The aetiology of this disorder is not known, and hypotheses have been put forward in attempts to incriminate virus or filarial infections, plantain diets, and rheumatic heart disease. The disorder has also been described in West Africa, Ceylon, South India, and Central Africa, and wellauthenticated cases have been seen in Europeans resident in tropical areas (Brockington, Olsen, and Goodwin, 1967). Mulago Hospital, Kampala, is situated in Buganda, the largest province of Uganda, and about half the patients admitted to the hospital belong to the local Ganda tribe (Fig. 1). There is also a large immigrant population in Buganda, coming in particular from Rwanda and Burundi (herein referred to as 'Rwandans') and from the Western Province of Uganda (Kigezi, Ankole, Toro, and Bunyoro districts). An analysis of the tribal origins of cases of endomyocardial fibrosis coming to necropsy at Mulago Hospital in the period 19501961 showed a preponderance of this condition among those groups immigrant to Buganda, in particular those originating from Rwanda and Burundi. The condition was far less common than expected among the indigenous Ganda people (Shaper and Coles, 1965). This analysis of the tribal origins of subjects with endomyocardial fibrosis has now been extended to cover the period 1950-1965, and a similar analysis

https://heart.bmj.com/content/heartjnl/30/3/391.full.pdf

Necropsy study of endomyocardial fibrosis and rheumatic heart disease in Uganda 1950-1965.

Hypertension and related complications appear, from clinical impression, to be increasing problems in urban Ghanaians. In early 1973 we conducted a blood pressure survey in 20 rural Ghanaian villages to determine the prevalence of hypertension, in comparison with studies done in Accra residents and black Americans. Rural Ghanaians had mean systolic and diastolic blood pressures which were lower at all ages than the urban groups. 2·5% of the subjects aged 16 to 54 years had diastolic blood pressures of 95 or higher mm Hg. These findings are discussed in view of the proposed hypertension control programme in Accra. We conclude that hypertension is not a significant health problem in rural Ghanaians and that large-scale hypertension case-finding and intervention programmes should be confined to urban populations.

Blood pressure distribution in a rural Ghanaian population

Of 880 patients who attended the paediatric cardiology unit, University College Hospital, Ibadan, during a ten-year period, 635 (72.2%) had congenital cardiac malformations. Ventricular septal defects were the commonest lesions (35% of the 635 cases), followed by patent ductus arteriosus (22%), Fallot's tetralogy (10%), pulmonary stenosis (9%) and atrial septal defects (7.5%). Coarctation of the aorta was uncommon (2%) and aortic stenosis rare (0.6%). The overall sex incidence was even. Aetiological factors were ascertained in 72 cases (11%). In 60% of these cases intra-uterine rubella was responsible and in 18% perinatal asphyxia. In most patients the cardiac malformation was detected late; consequently complications, such as heart failure, pulmonary hypertension, and polycythaemia were common, even in new patients. Sixty-seven patients (11%) died in hospital, mostly from surgical intervention, heart failure, hypoxaemia, bronchopneumonia and associated extracardiac defects. It is suspected that hypocalcaemia, resulting from vitamin D deficiency may be a cause of the observed low prevalence of obstructive aortic lesions. We suggest that cardiac evaluation be performed at birth in postnatal clinics and in immunization centres, in order to facilitate early detection and treatment of congenital heart disease.

Congenital heart disease in Nigeria: a ten-year experience at UCH, Ibadan.

Objective : Few data are available on heart failure (HF) in sub-Saharan Africa. We aimed to provide a current picture of HF aetiologies in urban Uganda, access to heart surgery, and outcomes.
Methods : We prospectively collected clinical and echocardiographic data from 272 consecutive patients referred for suspected heart disease to a tertiary hospital in Kampala during seven non-governmental organisation (NGO) missions from 2009 to 2013. We focused the analysis on 140 patients who fulfilled standardised criteria of HF by echocardiography.
Results : Rheumatic heart disease (RHD) was the leading cause of HF in 44 (31%) patients. Among the 50 children included (age ≤ 16 years), congenital heart disease (CHD) was the first cause of HF (30 patients, 60%), followed by RHD (16 patients, 32%). RHD was the main cause of HF (30%) among the 90 adults. All 85 patients with RHD and CHD presented with an indication for heart surgery, of which 74 patients were deemed fit for intervention. Surgery was scheduled in 38 patients with RHD [86%, median age 19 years (IQR: 12-31)] and in 36 patients with CHD [88%, median age 4 years (IQR 1-5)]. Twenty-seven candidates (32%) were operated on after a median waiting time of 10 months (IQR 6-21). Sixteen (19%) had died after a median of 38 months (IQR 5-52); 19 (22%) were lost to follow up.
Conclusions : RHD still represents the leading cause of HF in Uganda, in spite of cost-efficient prevention strategies. The majority of surgical candidates, albeit young, do not have access to treatment and present high mortality rates.

/pdf/cardiac-surgery-for-patients-with-heart-failure-due-to-2y7rcg4k29.pdf

Cardiac surgery for patients with heart failure due to structural heart disease in Uganda: access to surgery and outcomes.

449 patients with heart disease were admitted to the Mulago Hospital, Kampala, each patient for the first time, during the 12 months from 1 October 1962. In order of importance the common disorders were rheumatic heart disease, hypertension or acute nephritis with heart failure, idiopathic cardiomegaly, endomyocardial fibrosis, and syphilitic heart disease. Less common were cor pulmonale, anaemia with heart failure, congenital heart disease and pericardial disease. Patients with endomyocardial fibrosis were mainly immigrants from Rwanda and Burundi or from the adjoining tribes. No other disease showed a particular tribal incidence. The importance of cardiac disease as a cause of admission to the Mulago Hospital has not changed over 5 years but the pattern of disease shows a decrease in syphilitic heart disease and an increase in cor pulmonale. Heart disease is of equal importance as a hospital problem in Uganda, Kenya, Nigeria and Rhodesia, but the incidence of the separate diseases differs in these areas.

A study of heart disease in the Mulago Hospital, Kampala, Uganda

18 subjects in heart failure due to idiopathic cardiomegaly were admitted to a trial to test the value of prolonged complete bed rest, coupled with a high protein diet, vitamin supplements and standard measures of treatment of heart failure. 10 completed 6 months or more in bed and 5 showed a reduction in heart size. 4 demanded discharge before 6 months in hospital had been completed, and of these 1 showed a reduction in heart size. 5 died in hospital. The relationship of improvement to mode of onset and clinical findings on admission is discussed.

R.B. Kanyerezi

Papers

A study of heart disease in the Mulago Hospital, Kampala, Uganda

Prolonged bed rest in the treatment of idiopathic cardiomegaly