Heart failure (HF) is a rapidly growing public health issue with an estimated prevalence of >37.7 million individuals globally. HF is a shared chronic phase of cardiac functional impairment secondary to many aetiologies, and patients with HF experience numerous symptoms that affect their quality of life, including dyspnoea, fatigue, poor exercise tolerance, and fluid retention. Although the underlying causes of HF vary according to sex, age, ethnicity, comorbidities, and environment, the majority of cases remain preventable. HF is associated with increased morbidity and mortality, and confers a substantial burden to the health-care system. HF is a leading cause of hospitalization among adults and the elderly. In the USA, the total medical costs for patients with HF are expected to rise from US$20.9 billion in 2012 to $53.1 billion by 2030. Improvements in the medical management of risk factors and HF have stabilized the incidence of this disease in many countries. In this Review, we provide an overview of the latest epidemiological data on HF, and propose future directions for reducing the ever-increasing HF burden.

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Epidemiology and aetiology of heart failure

Heart failure (HF) is a public health problem of global proportions afflicting more than 25 million patients worldwide. Despite stable or declining per capita hospitalization rates in the USA and several European countries, there are over one million hospitalizations for HF annually in the USA, with similar numbers in Europe, accounting for 6.5 million hospital days and the majority of the approximately $40 billion spent each year on HF-related care. Moreover, clinical trial data suggest that post-discharge survival and readmissions have largely remained unchanged. Thus, understanding geographic and ethnic variations in HF is essential to formulating public policy at the local, national, regional, and international levels and setting the agenda for basic, translational, and clinical research endeavors. This paper aims to describe regional and ethnic variations in patient characteristics, management, and outcomes in hospitalized HF.

Global Perspectives in Hospitalized Heart Failure: Regional and Ethnic Variation in Patient Characteristics, Management, and Outcomes

Purpose of reviewDespite the rising prevalence of heart failure in Africa, it remains unclear what supportive and palliative care services are required to meet patient needs. This review highlights recent contributions to knowledge of the supportive and palliative care needs of heart failure patient

Palliative and supportive care needs of heart failure patients in Africa: a review of recent developments.

Background: Right ventricular (RV) function is an important entity in heart failure. Patients with RV dysfunction (RVD) have poorer prognosis and exercise tolerance than those with preserved RV systolic function. Tricuspid annular plane systolic excursion (TAPSE) has been proposed as a simple and reproducible parameter for the qualitative assessment of RV systolic function/ejection fraction (EF). This study aims at describing RV function/RVD among heart failure patients in a specialized cardiac facility in Southwestern Nigeria. Materials and Methods: One hundred and thirty-two patients with clinical diagnosis of heart failure were recruited into the study between June 2011 and December 2014. Baseline data, laboratory investigations, electrocardiography, and echocardiography were taken for the participants. RV function was assessed with TAPSE. Statistical analysis was done using Statistical Package for Social Sciences 16.0 (Chicago Ill. USA). P < 0.05 was considered statistically significant. Results: The mean age of study participants was 62.1 ± 14.2 years. RV systolic dysfunction (TAPSE <20 mm) was found in 86 (65.2%) of all patients while moderate-to-severe RVD (TAPSE <15 mm) was found in 26 (19.7%) patients. Those with RVD are more likely to be older and had a larger left ventricular internal diastolic dimension than those without RVD. Systolic blood pressure, diastolic blood pressure, and EF were significantly lower among patients with RVD than those with normal RV function. Conclusion: RVD is common and is associated with more advanced heart failure and possibly worse prognosis among Nigerians with heart failure. Screening for RVD is encouraged to identify and aggressively treat to reduce the associated increased mortality.

Right ventricular function in patients with heart failure in a cardiac clinic in Southwest Nigeria

............................................................................................................................... 8 Acknowledgements ............................................................................................................... 9 Index of Tables .................................................................................................................... 10 Index of Figures ................................................................................................................... 12 Abbreviations used in the text............................................................................................. 14 Preface ................................................................................................................................ 16 Summary of Chapters ...................................................................................................... 16 Author’s contribution ...................................................................................................... 19 Chapter 1. Background of the Thesis ............................................................................... 20 1.1. Conceptual definition and historical perspectives on pulmonary hypertension ..... 20 1.2. Operational definitions of pulmonary hypertension .............................................. 21 1.3. Diagnostic strategy and clinical classification of pulmonary hypertension ............. 23 1.3.1. Detection of a predisposing condition ............................................................ 23 1.3.2. Uncovering the presence of PH ...................................................................... 24 1.3.3. Classification of the type of Pulmonary Hypertension .................................... 35 1.3.4. Confirmation of the presence of pulmonary hypertension ............................. 39 1.3.5. Echocardiography versus right heart catheterization in the diagnosis of pulmonary hypertension ............................................................................................. 39 1.4. The burden of pulmonary hypertension in left heart diseases ............................... 39 1.4.1. Incidence of pulmonary hypertension in left heart disease ............................ 40

Predicting pulmonary hypertension and outcomes in patients with left heart disease

Over the last few years, the focus of the international health community has shifted from communicable diseases as the main cause of morbidity and mortality in Africa (and indeed in the world in general) to non-communicable diseases. Relatively scant recent research suggests that in Africa cardiovascular (CV) diseases are a leading cause of morbidity and mortality, where up to 25% of admissions to hospitals are for CV disease, including hypertension (HTN). 14 Heart failure (HF) is the most common CV disorder and the main driver of CV adverse morbidity and mortality. 15 In this respect, the study by Ojji et al. in this month’s issue of the journal is a welcomed addition. In this hospital-based study, the authors report on the current spectrum of (CV) diseases in Abuja—the new and modern capital of the Federal Republic of Nigeria. The data from Abuja were compared with the findings in Soweto, a predominantly Black community in South Africa. The findings suggest that CV diseases in Abuja, Nigeria are mainly nonischaemic in origin and occur mainly in a younger and productive age group. Hypertension was found to be the most common cause, followed by dilated cardiomyopathies and rheumatic heart disease. The authors noted some subtle differences in the heart disease pattern in Abuja and Soweto. While there are higher rates of HTN and hypertensive HF in Abuja, ischaemic heart disease and right HF were more common in the Soweto study. As noted by the authors, this may be related to a higher burden of CAD and lung disease risk factors such as cigarette smoking, obesity, dyslipidaemia, and diabetes in Soweto compared with Abuja. Furthermore, peripartum cardiomyopathy is not as common a cause of CV disease and HF as expected. Given this relative lack of published data, putting the results of Ojji et al. into perspective is difficult. However, previous studies have found similar trends in different African countries and communities. 15 In most studies, HTN is followed by other disease entities that are less common outside of Africa, such as idiopathic dilated cardiomyopathy and rheumatic heart diseases. The Heart of Soweto registry from the Soweto township in South Africa, which is also described in the manuscript itself, found similar, although not identical trends (see above). In a registryof 2908 patients presenting for CV diseases to a clinic in Mzuzu central hospital in Malawi during a 5-year period, the most common causes of CV morbidity were rheumatic (34%), HTN (24%), cardiomyopathies (most commonly idiopathic dilated; 19%), and pericardial disease (14%). Atherosclerosis represented only 1–4% of cases. These trends are observed everywhere in Africa—in published and unpublished data, such as those depicted in a poster in the waiting area of a county hospital in Tzaneen; the Northern Province of South Africa (Figure 1). Indeed, similar results were published in studies from Nigeria 7 summarized in detail in the review by Ogah et al. These studies show that the prevalence of HTN in the general Nigerian population ranges from 8% to 46.4%. More importantly, it seems that the prevalence of HTN is increasing—from 8.6% reported in the only population-based study during the period from 1970 to 1979 to 22.55% during the period 2000–2011. HTN-related complications such as stroke, hypertensive heart disease (including hypertensive HF), andchronic kidneydisease is common andoften severe inhypertensive Nigerians. Late presentation is also common. Awareness, treatment, and control of HTN are low, as in many developing countries of the world. Regarding admissions for HF, in a smaller study from the Yaounde general hospital in Cameroon, the main causes of HF admissions were HTN (54%), cardiomyopathies (26%), and valvular heart diseases (24%). Ischaemic heart diseasewas the fifth most common aetiology (2.4%). In a registry of 1000 patients admitted for HF and followed prospectively by Damasceno et al., the most common causes of HF were HTN (45%) and rheumatic heart disease (14%), while ischaemic heart disease (8%) was not a common cause for HF. The study by Ojji et al., besides being one of the largest registries of CV diseases and HF in Africa, emphasizes two additional important aspects of CV diseases and HF and their treatment. First, the age of the patients affected is younger than in other world regions. Damasceno et al., Stewart et al., and Sliwa et al. have shown that CV diseases and HF occur in Africa at a younger age than outside Africa. In the series from Malawi, Soliman et al. found that the average age of patients presenting with CV diseases is as low as 40 years. Other studies describing CV admissions in Nigeria found the age of admission to be 50–55 years. 7,10 In the study of Ojji et al. the

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The burden of heart failure in Africa

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The burden of heart failure in Africa