About 1.1 billion people live in 49 countries of sub-Saharan Africa (SSA) accounting for approximately 15% of the world population . Historically, the leading causes of mortality in SSA have been communicable diseases, and non-communicable diseases (NCDs) were not considered to be a public health priority [2, 3]. However, it is now clear that the burden of NCDs has long been an endemic problem in SSA [3, 4, 5, 6]. NCDs are projected to overtake infectious diseases and account for more than half of all deaths by 2030 in SSA . Among NCDs, cardiovascular diseases (CVDs) are the leading cause of death accounting for 37% of all NCDs deaths and approximately 13% of all deaths in SSA . Approximately 32 million people in SSA are currently living with some form of diagnosed CVD and it is estimated that there are many more living with undiagnosed CVD, and 3.6 million incident cases are reported annually [2, 3].
All major structural CVDs are associated with cardiac arrhythmia. Therefore, it is likely that the growing burden of CVDs in SSA also reflects the growing burden of cardiac arrhythmias, though the full spectrum is poorly characterized. Prior reviews have described the epidemiology of atrial fibrillation in Africa . However, it remains uncertain as to whether atrial fibrillation/atrial flutter (AF/AFL), supraventricular tachycardias (SVTs), significant bradyarrhythmias, ventricular tachycardia/ventricular fibrillation (VT/VF), as well as sudden cardiac arrest/sudden cardiac death (SCA/SCD) are regularly diagnosed and treated in SSA. Ascription of SCD among some SSA populations to non-medical causes like witchcraft is not uncommon . Nonetheless, arrhythmias are probably underdiagnosed in SSA due to lack of equipment and expertise . Few informative surveys and reviews on the status of arrhythmia services in Africa have revealed severe deficiencies in healthcare systems and arrhythmia specialists [9, 11, 12, 13, 14]. However, a detailed description of clinical arrythmia entities in SSA is lacking. This systematic review will therefore assess the distribution, etiologies, diagnosis, and treatment of arrhythmias in tandem arrythmia services in SSA. It will also compare these with high-income countries (HIC) of Western Europe and North America, identify possible contributors to any under-diagnosis and under-treatment, and provide some recommendations.
We systematically searched the PubMed/MEDLINE, Excerpta Medica Database (EMBASE), and African Journals Online (AJOL), to identify all relevant studies published until March 31st, 2019 and restricted to humans, reporting on cardiac arrhythmias in SSA, without language restriction. The search strategy and terms used were as follows: 1) Atrial fibrillation OR atrial flutter AND Africa; 2) supraventricular tachycardia OR atrioventricular nodal reentry tachycardia OR atrial tachycardia OR atrioventricular reentry tachycardia OR Wolff-Parkinson-White syndrome AND Africa; 3) sudden cardiac arrest OR sudden cardiac death OR ventricular arrhythmia OR ventricular tachycardia OR ventricular fibrillation AND Africa; and 4) bradycardia OR pacemaker OR defibrillator OR cardiac implantable electronic devices AND Africa. Sub-Saharan African studies were then filtered from the identified studies. Inclusion criteria for AF/AFL and SVTs were studies reporting prevalence, risk factors, arrhythmia treatment, oral anticoagulation, and follow-up outcome. Inclusion criteria for SCA/SCD were studies reporting out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA), attempted cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and survival. Manual searches of references of published articles were also undertaken. We excluded editorials, commentaries, letter, notes, conference abstracts without full published articles, and narrative reviews (See Figure 1). Data extraction and quality assessment were meticulously done according to set criteria by two authors (MFY & MN) independently. The marked heterogeneity of studies among specific arrhythmia entities precluded any meta-analysis.
As shown in Figure 1, the initial PubMed/Medline, EMBASE, and AJOL search restricted to humans till March 31st, 2019 and manual searches of references of published articles for AF/AFL, revealed 1,036 citations. When narrowed to SSA with exclusion of duplicates, editorials, letters, reviews, conference abstracts without full article publications, and commentaries, they were 343 remaining abstracts to screen, of which 43 made the inclusion criteria and 23 studies had compatible data to be entered in Table 1. For SVTs, the final number of abstracts reviewed was 20, and only two studies were suitable. The search for SCA, SCD, and ventricular arrhythmias, revealed 1,268 citations. After applying the exclusion criteria, there were 299 abstracts left to screen, of which 49 made the inclusion criteria, and 14 studies had compatible data to be entered in Table 2. The search for articles on bradycardia and cardiac implantable electronic devices (CIEDs) revealed 1,450 citations, which were narrowed down to 239 abstracts via exclusion criteria (Figure 1). After a detailed review, 17 studies met inclusion criteria and 13 of these studies had compatible data which was entered in Table 4.
|Author, Year & Country||Mean age in years||Study size & population||Gender||Prevalence of AF||Comorbidities||AAM or rate-control medication||CHADS2 ≥ 1 or CHA2DS2 VASC ≥ 2, mean or median||OAC*||FU & Mortality|
|66.7||138; Tertiary hospital||Females 63.8%
(Warfarin 69%) in CHA2DS2
VASC ≥ 2
|12 months mortality 14.5%|
(9 SSA countries)
|57||206/1006; Heart failure||Females 53.1%
6 months FU 21.8%
|16% rehospitalization or death at 60 days follow-up|
|–||42; Tertiary Hospital||Females 43.0%
Atrial flutter 17%
|42||0/856; Rural community||Females 62.5%
|77 VAF/69 NAVF; Clinic and hospitalized patients||Females 67.1%
|Mean CHADS2 score 2.2 for NVAF||79% for NVAF
TTR 52% VAF, 56% NVAF
|12 months mortality 10% VAF, 15% NVAF|
|67.4||94; Stroke patients||Females 53.1%
|–||–||–||–||Hospital case fatality with AF 22.2% & without AF 8%. 12 months mortality 14.5%|
|52||102, Cardiology Unit||Females 56.9%
|–||74.5%||–||In hospital mortality 9.8%|
|65||103/970; Cardiology department||Females 44.6%
Median CHA2DS2VASC score = 3.9
|60||68/228 cardiology unit/clinic||Females 42.6%
|63||69 NVAF/159 ICVA patients||Females 62.3%
Prior ICVA 17.4%
Mean CHA2DS2VASC score = 4.7
|52%||21.7% in-hospital mortality|
RE-LY Registry  (baseline data)
(included 10 SSA countries)
|57||1137 (SSA only); Emergency presentations||Females 53.1%
All VHD 32.6%
|Mean CHADS2 score 1.8||19.4%
|67||302; National Registry||Females 40.1%
Class IC 3%
Class III 33.8%
Catheter ablation 4.2%
|Mean CHA2DS2VASC score = 3.08||75.2%||–|
Multinational (included 11 SSA countries)
|28||586/3343 (all study population); RHD||Females 66.1%
|18–28% depending on income-level||RHD 100%||–||40.7%||69.5%
|2 years mortality 16.9%|
|66||924; Rural population||Females 48.1%
|67||162; Discharge diagnosis||Females 44.0%
|78%||72%||6months mortality 6.5%|
Coulibaly  2013
|55||111/3964; cardiac admissions||Females 48.0%
|78||15/2232; Community||Females 56.3%
|0.67%||–||–||–||–||One-year mortality 53%|
|66||172; Office visit||Females 56.4%
Rhythm control 16%
|91.9%||34.2%||29.5% died during 11 months of follow-up; 16.1% CVA|
|59||246/5328; Cardiac admissions||Females 44.0%
Digoxin 24% Amiodarone 7.3%
|57||150; Cardiac admissions||Females 68.7%
Coulibaly  2010
|59||217/3908; Cardiac admissions||Females 64.8%
|200; Cardiology clinic||–||–||–||–||79% urban
Figure 2 shows an encouraging increasing trend of publications on cardiac arrhythmias in SSA over the past four decades, based on the studies identified for this systematic review.
Table 1 summarizes key findings from hospital-based and community-based AF/AFL studies in SSA. AF prevalence is low in the general population of SSA at <1% and increases with age [3, 15, 16], 3–7% in hospital cardiology admissions or newly diagnosed cardiovascular diseases [17, 18, 19, 20, 21], 16–22% in heart failure patients [22, 23], 10–14% in newly diagnosed and 18–28% in established rheumatic heart disease (RHD) patients [24, 25, 26], 25% in patients with tuberculous pericarditis , 6% de novo cases post-cardiac surgery , 9.5% in pregnant women with structural heart disease , 2–10% of de novo stroke patients [30, 31, 32, 33], and varies between 25–65% in patients attending oral anti-coagulation clinics in SSA [34, 35, 36]. In SSA there is a high proportion of permanent AF (12–81.4% across studies) and persistent AF (9.6–70.6%), compared to prevalence of paroxysmal AF (8.9–50%) [20, 37, 38, 39, 40, 41] as shown in Table 1. Prominent risk factors or comorbidities associated with AF/AFL in SSA are hypertension, which is observed in 50–87% of cases, heart failure 32–64%, diabetes 4–63%, RHD 15–38%, dilated cardiomyopathy 16–38%, stroke 3–40%, and CAD 1.2–26% of AF/AFL patients (Table 1). Other AF risk factors include non-rheumatic valvular diseases, smoking, obesity, obstructive sleep apnea, hyperthyroidism, COPD, congenital heart disease, and increased alcohol intake [15, 18, 19, 20, 28, 37, 38, 41, 42, 43, 44, 45]. There appears to be a female preponderance of AF/AFL in SSA with studies showing 40–69% of patients being females versus 31–60% males (Table 1). Studies in this region have shown that the presence of AF/AFL is associated prospectively with significantly high mortality (15–53%), increased rates of heart failure hospitalization, and non-fatal cardioembolic strokes during follow-up (10–15%) [19, 38, 46, 47].
Use of oral anticoagulation (OAC) in AF/AFL patients in SSA was noted to be very variable from 9–79% in patients with CHA2DS2VASC score ≥2 or CHADS2 score of ≥1 across studies, as shown in Table 1. In patients from SAA who were anticoagulated with Vitamin K antagonists, average time in therapeutic range (TTR) calculated by the Rosendaal method was noted to be generally low at 27–56% [24, 41, 48]. Vitamin K antagonist (VKA) oral anticoagulant were available in all countries surveyed recently by Pan African Society of Cardiology (PASCAR), while non-VKA oral anticoagulants (NOACs) were less available as follows: rivaroxaban (available in 90% of countries), dagibatran (45%), apixaban (22%), and endoxaban (0%) .
From the initial citations for SVTs, only two studies all from South Africa met inclusion criteria as shown in Figure 1 [55, 56]. Among a pediatric population, the differential diagnoses of SVT were atrioventricular nodal reentrant tachycardia (AVNRT) 51%, atrioventricular reentrant tachycardias (AVRT) 24%, atrial tachycardia (AT) 22%, and junctional ectopic tachycardia 3% . In the other study, nine patients with Wolff-Parkinson-White syndrome and symptomatic paroxysmal SVTs had their accessory pathways successfully surgically divided without complications or recurrence (four posteroseptal, three left free wall, and two right free wall accessory pathways) .
The key finding of this systematic review is the sparsity of studies on SCA/SCD in this region. Table 2 depicts the few studies on SCA/SCD in SSA [57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70]. From the published studies, one of the salient findings is the low mean age of SCA/SCD with a range of 35–60 years across studies among adults, with higher rates in males compared to females in majority of studies. The reported incidences of OHCA range from 6–34 per 100,000 inhabitants in SSA  . The incidence of IHCA among cardiology admissions is approximately 6% in this region . The most common underlying rhythm of SCA/SCD in SSA is asystole, followed by pulseless electrical activity (PEA), then VT/VF, and unknown [58, 65].
|Author, Year, country||Mean age in years or age range||Sample size||Gender||Study population||CPR attempted||Rhythm of arrest||ROSC||Etiologies & Comorbidities||Survival to discharge|
|Edwards-Jackson et al , 2019, Malawi||30 days to 13 years||135||–||Paediatric population IHCA||100%||–||6%||Malaria 51%||0% (100% mortality)|
|Ngunga et al , 2018, Kenya||61||353||Females 46.5%
|IHCA||Not mentioned||Asystole 47.6%, PEA 38.2%,
VT/VF 5.4%, Unknown 8.8%
|Asystole patients 17.3%, PEA 40.7%, VT/VF 57.9%, Unknown 25.8%. Mean time to ROSC 5.3 mins||Heart Failure 9.1%
|Bonny et al , 2017, Cameroon||Men 36
Incidence of SCD
33.6 per 100 000
|OHCA 63%||3.7%||–||–||Heart failure 14.8%
Tropical disease 3.7%
Adekola et al , 2016,
|1–18 years 23.33%
|60/4,229 cases||Females 55.0%
|Perioperative cardiac arrests||100%||-||56.7%||No co-existing disease 81.2%
Sickle cell 1.6%
Incidence in ASA III/IV/V >ASA I/II
Talle et al , 2015,
|49 all patients,
39 years SCD patients
|Total 388 cardiac admissions, 56 deaths, 23 (41.1%) SCD||Females 52.2%
|Cardiac admissions||52.1%||–||8.3%||Heart failure 82.6%
Peripartum CM 21.7%
|Akinwusi et al , 2013, Nigeria||46||29/718 (4%)||Females 13.8%
|Adult medical deaths||–||–||–||CVD 51.7% (HHD 86.7%, HF 80%)
CNS disease 13.8%
Tiemensma et al , 2012,
|Sudden and unexpected adult deaths||–||–||–||CVD 17.2% (CAD 75.7%)
Kwari et al , 2010,
|–||14/4,015||–||Perioperative cardiac arrest||–||–||–||Patients with ASA class III/IV risk status suffered more arrest than ASA I/II||14%|
Stein et al , 2009,
Median response time 9 minutes
|VT/VF 23%. Only predictor of ROSC was shockable rhythm||18%||Cardiac causes 75%||–|
Olotu et al , 2009,
|28 months||114||Females 40.0%
Rotimi et al , 2004,
|Medico-legal autopsies||–||–||–||HHD 83.5%
|Schneider et al , 2001, Ethiopia||–||92||–||Sudden unexpected deaths based on police reports||–||–||–||CAD 47.8%
Rotimi et al , 1998,
|28–80 years||50||Females 30.0%
|Coroner’s autopsies||–||–||–||HTN 82%
Heart failure 68%
Arthur et al , 1995,
|–||–||–||Cardiac disease 50%
Sickle cell 6.25%
No chronic disease 37.5%
The reported underlying etiologies of SCA/SCD and ventricular arrhythmias in SSA are shown in Table 3. Studies have identified hypertensive heart disease, coronary disease, cardiomyopathy, and valvular heart disease, especially rheumatic heart disease, in heterogeneous orders, as the most common causes of SCA/SCD among adults in SSA [61, 64, 67, 69, 71, 72, 73], while malaria was the prominent cause among the pediatric victims [57, 66]. Malignant arrhythmogenic inherited diseases have been identified in Blacks in SSA. Cases of hypertrophic cardiomyopathy have been reported in Black Africans [74, 75]. Little was known about arrhythmogenic right ventricular cardiomyopathy (ARVC) in SSA, but registry data from South Africa revealed similar clinical presentation and an annual SCA/SCD rate comparable to other large registries from the Western World [76, 77]. Brugada syndrome is associated with SCD [78, 79]. Loss-of-function CACNA1C variant, Cavα1c-T1787M, present in 0.8% of the Black African population, has recently been identified as a new risk factor for ventricular arrhythmias . Although electrocardiographic patterns of early repolarization (ER) have been reported in a Black African population , their correlation with malignant arrythmias or SCA/SCD have not been studied in SSA. Notwithstanding, studies in African Americans have shown that the relatively high prevalence of ER in this population is not independently predictive of adverse outcomes [82, 83]. Ventricular non-compaction, a prominent cause of VT/VF, has been identified in patients of African ancestry with the prevalence of 6.9% in one cardiomyopathy clinic in South Africa , and in other SSA studies [85, 86]. Apart from one case report in a black infant , no other studies have documented congenital long QT syndrome in Black Africans. For example, a congenital long QT series of 41 patients in South Africa had Blacks (0%), Whites (87.8%), mixed race (9.8%), and Indian (2.5%) , and one other study still in South Africa did not mention ethnicity . Acquired long-QT syndrome in heart failure cohorts has been associated with excess mortality [89, 90]. In patients with peripartum cardiomyopathy, prolonged corrected non-congenital QT interval and sinus tachycardia on baseline ECG were independent predictors of poor composite outcome which included death during follow-up .
|Cardiomyopathies [58, 61]|
|Hypertensive heart disease [58, 62, 67]|
|Coronary artery disease [58, 59, 61, 64, 69]|
|Rheumatic heart disease [61, 69]|
|Congenital heart disease |
|Arrhythmogenic right ventricular cardiomyopathy [76, 77]|
|Hypertrophic cardiomyopathy [74, 75]|
|Brugada syndrome [78, 79]|
|Congenital Long QT syndrome (seen only in non-Black populations) [74, 88, 101]|
|Ventricular non-compaction |
|Pulmonary embolism [62, 91]|
|Endomyocardial fibrosis |
|Pulmonary hypertension |
|Pericarditis (mainly tuberculous) |
|Aortic dissection/rupture |
|Endemic parasitic infections like trypanosomiasis & schistosomiasis [9, 59, 93]|
|Sarcoidosis [102, 103, 104]|
|Respiratory disease [58, 62, 64]|
|Septicemia [58, 66]|
|HIV/AIDS [58, 59]|
|Tuberculosis [58, 64, 70]|
|Renal disease [58, 64]|
|Liver disease [58, 64]|
Reports of SCA/SCD due to pulmonary embolism [62, 91], pulmonary hypertension , and aortic dissection/rupture  are seen. Pericarditis, especially tuberculous which accounts for about 65–91% of all pericarditis cases in SSA, is associated with premature death . Some endemic parasitic infections have been identified as potential causes of arrhythmias and conduction abnormalities. These include trypanosomiasis-induced cardiomyopathy through chronic pan-carditis (Trypanosoma brucei which is of the same genus as Trypanosoma cruzi which causes Chagas disease in Latin America), and schistosomiasis-induced pulmonary hypertension leading to right sided cardiomyopathy plus arrhythmias, amebiasis, toxoplasmosis, among others [9, 93]. There have been case reports of SCA/SCD events with use of an antimalarial, halofantrine . Endomyocardial fibrosis which is endemic in SSA has very poor prognosis with survival after diagnosis reported to be two years due to malignant arrhythmias, heart failure, and thromboembolism . SCA/SCD due to congenital heart disease has been reported in SSA . Short QT syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), and other VTs forms have not been observed in the SSA literature.
As shown in Table 2, there is an alarming observed gross lack of CPR awareness among the SSA populations. CPR was only attempted in 3.7–40% of OHCA and only attempted in about 50% of IHCA cases among adults [59, 61, 65], in non-perioperative studies. Excluding perioperative cardiac arrest, ROSC was achieved in <20% of adult SCA cases and survival to discharge was low at <5%. The best predictor of ROSC was a shockable rhythm (VT/VF), followed by PEA, with asystole having the worse outcomes [58, 65]. Multiple surveys in SSA have demonstrated that even clinicians including physicians do not have adequate basic life support (BLS) and advanced cardiac life support (ACLS) training (about half of those surveyed), and the majority are unable to operate an automated external defibrillator (AED) [13, 97, 98]. In South Africa where EMS services are available, overall knowledge and skill performance of CPR is still well below standard by EMS personal with only 25% of the required standards met . In addition to lack of optimal resuscitative measures, quality improvement schemes are also deficient in SSA. A survey of 17 hospitals in SSA found that only 20% of these had a cardiac arrest response team system, only 21% documented CPR events, and only 21% reviewed such events for education and quality improvement .
Seventeen studies on bradyarrhythmias and CIEDs in SSA were identified through the systematic search [9, 11, 12, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119] (Figure 1). Table 4 depicts 13 of these studies with some uniform data that could be organized into one table. The commonest indication for permanent pacing in SSA is atrioventricular block (AVB) accounting for 45–100% of all cases across studies, compared to sick sinus syndrome at 0–35%, and others (atrioventricular node ablation, cardiac re-synchronization therapy, etc) 0–20%. Single chamber ventricular (VVI) pacemakers are the most frequently implanted (17–87%), compared to dual chamber (12–82%), and others like atrial-sensed ventricular-paced (VDD) (0–15%) [107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 120]. Cost constraints have been identified as the reason for high implant percentage of VVI compared to DDD .
|Author, Year, country||Mean age in years||Sample size||Gender||Indication||Types of CIEDs||Chamber of implantation||Complications|
|Tchoumi et al , 2019, Cameroon||62||130||Females 40.0%
AVB 88 70.9%
|- Pocket infection 4 (3.1%)
- Lead displacement 4 (3.1%)
- Pneumothorax 2 (1.5%)
- Hemothorax 2 (1.5%)
|Adoubi et al , 2018, Ivory Coast||67||283||Females 50.9%
Jouven et al , 2016,
14 SSA countries
|–||502 during 16 missions to SSA||–||–||PPM||–||- No periprocedural complications
- 52% of patients initially listed as suitable died before the missions arrived
|Jama et al , 2015, South Africa||-||126||Females 52.9%
Secondary prevention 79.2%
|- No device infection,
malfunction, early battery depletion or device removal
in either the re-used or new devices groups
|Ikama et al , 2015, Congo||70||8/20 implanted||Females 50.0%
|AVB 100%||PPM||–||- No complications
- 8 patients (40%) of the initial 20 died before mission arrived
|Falase B et al , 2013, Nigeria||68||51||Females 43.1%
|- Infection 3 (5.9%)
- Lead displacement 3 (5.9%)
- Pocket erosion 2 (3.9%)
- Death 1 (2%)
|Kane et al , 2012, Senegal||66||107||–||–||PPM||–||- Infection 5.6%|
|Ekpe et al , 2008, Nigeria||70||23||Females 48.0%
|Thiam et al , 2003, Ivory Coast||–||92||Females 48.9%
|- Infection 5 (5.4%)
- Lead displacement 3 (3.3%)
- Pacemaker syndrome 1 (1.1%)
- Death 1 (1.1%)
|Millar et al , 2001, South Africa||–||1643||–||
|Diop et al , 2000, Senegal||54||12||Females 41.7%
|- Pocket infection 2 (16.0%)|
|Mayosi et al , 1999, South Africa||21–50||232||Females 41.8%
|Dos Santos et al , 1982, South Africa||17–78||57||Females 61.0%
SSS + AVB 5%
|- Infection 2 (3.5%)
- Lead displacement 2 (3.5%)
- Erosion 3 (5.3%)
Epidemiological survey data emanating from SSA indicate that there are still countries without a CIEDs implanting center, and a patchy presence in others. The first report of the PASCAR on the statistics of the use of CIEDs and ablation procedures revealed that 26% of the 31 countries surveyed did not perform any permanent pacemaker (PPM) implantations. The median pacemaker implantation rate was 2.66 per million population per country, median number of PPM implantation centers was 0.14 per million inhabitants and 0.10 operators per million population. Implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) were performed in 39% and 48% countries respectively, mostly by humanitarian visiting cardiac teams from abroad. Rates of centers performing ICD and CRT were similar and ranged from 0.02 to 1.59 per million population [11, 12]. In a more recent second report of PASCAR survey (2011–2018), 18% of countries in this region still did not perform PPM implantations, and implantation and operator rates rate were 2.79 and 0.772 per million population respectively in implanting countries. ICD and CRT were performed in 65% and 52% countries respectively, while reconditioned CIEDs were used in 22% countries . In a study with long-term survival data after permanent pacing in SSA, there was a 17% mortality after a median follow-up time of about nine years . Complications of pacing across studies are infections (0–6%), lead displacements (0–6%), pneumothorax (0–1.5%), hemothorax (0–1.5%), erosions (0–5.3%%), and death (0–2%) [107, 108, 109, 110, 111, 112, 113, 114, 115, 120].
Electrocardiography (ECG) is available in all SSA countries, 2-D echocardiography in 87%, Holter ambulatory cardiac monitoring in 74%, exercise tolerance test in 52%, tilt table test in 13%, cardiac computed tomography and cardiac magnetic resonance imaging available in <25% of countries, and signal average ECG is done only in South Africa [9, 11]. Electrical cardioversions are only done in 45% of SSA countries .
Recent survey of countries in Africa by PASCAR showed that digoxin and amiodarone were available in all surveyed countries, flecainide (80% of countries), sotalol (75%), propafenone (22%), quinidine (17%), and mexiletine (4% of countries) , and prior surveys showed that atropine and intravenous lidocaine were also present in some African countries [9, 11]. These findings were also observed in individual AF/AFL studies where betablockers and non-dihydropyridine calcium channel blockers are prescribed and dispensed in this region [18, 20, 37, 38, 39, 41, 44, 48]. There is no available information about use of adenosine to manage acute SVTs in this region.
Management of arrhythmias in SSA is largely non-invasive as electrophysiological (EP) study and catheter ablation centers are almost inexistent or patchy in SSA. South Africa is the only country in this region where complex ablations requiring 3-D mapping and transseptal puncture are performed [11, 12, 14]. Even in South Africa, national AF registry data showed that only 4.2% of AF patients underwent catheter ablations . About 80% of AF/AFL patients are managed with rate control strategy across studies in SSA [18, 20, 37, 38, 41, 44]. Figure 3 summarizes cardiac arrhythmias in SSA.
We observed that the prevalence of AF/AFL is <1% in the general population in sub-Saharan Africa. There are estimated 1.3 million people with AF/AFL in SSA and according to the 2017 Global burden of Disease Study, this region has one of the lowest prevalence rates of AF/AFL at 0.13%, compared to ~1.5% in the high-income countries (HIC) of Western Europe and North America, but does increase with age . Given lack of resources including ECG and ambulatory cardiac monitoring as well as the high prevalence of ‘highly arrhythmogenic’ conditions/risk factors/circumstances (e.g. RHD, cardiomyopathies, pericardial disease, unavailability of surgery, etc…), this low prevalence in SSA could represent an under-estimate. Other important factors include lack of healthcare access and survivorship bias i.e. lower life expectancy with communicable diseases. AF/AFL occurs at younger ages in SSA as seen in the RE-LY global registry, where many patients from SSA were younger (average age 57 years) compared to Western World (70 years) . Risk factors of AF are similar in SSA compared to HIC, except the significantly higher prevalence of rheumatic heart disease in SSA (22%) vs HIC (~2%) in AF patients observed in one large registry, as well as lower rates of ischemic heart disease in SSA (6%) vs HIC (~18%) , and high AF prevalence 25% in pericarditis in SSA vs 4.3% seen in pericarditis in HIC . The findings of this systematic review are similar to those of prior reviews in Africa with respect to AF prevalences rates, risk factors, and co-morbidities [8, 122].
Despite the relatively lower prevalence of AF in people of African descent, the presence of AF is associated with higher rates of strokes, heart failure, and mortality compared to Caucasians, and Black patients with AF are much younger than patients of other races . Atrial fibrillation was seen in 43–82% of patients with cardio-embolic strokes in SSA [40, 46]. Uncontrolled hypertension, low use of anticoagulation due less access and high costs (especially non-vitamin K-dependent oral anticoagulants) and poor time in the therapeutic range among patients on vitamin K-dependent oral anticoagulants, low use of heart failure medication, and late presentation with complications are plausible reasons for this increased risk of adverse outcomes. While anticoagulation has been shown to reduce strokes and systemic embolism as well as improve survival in AF/AFL patients [124, 125], its underuse is a worldwide problem [41, 126], which is even more pronounced in many regions of SSA [18, 20, 38, 44]. Permanent and persistent AF are more common in SSA while paroxysmal AF is most frequent in HIC of the Western World, suggesting that patients are presenting late in the natural history of the possible underlying AF-causing cardiovascular diseases in SSA .
This systematic review has shown that about four in five of all AF are managed via rate-control strategy. These findings are similar to those of one other AF review in this region . This demonstrates that evidenced-based AF rhythm-control strategies with catheter ablations which have been shown to have a survival benefit in AF patients with heart failure as in the CASTLE AF trial and others in a systematic review  are unlikely to become routine practice soon in this region. The same goes for VT ablations which are associated with significant morbidity, though not mortality, benefit .
Adult studies on SVTs in SSA remain largely non-existent except for one surgical case series on Wolff-Parkinson-White syndrome, with no palpable epidemiological data on AVNRT, pre-excitation syndromes with their associated orthodromic and antidromic AVRT, atrial tachycardia, inappropriate sinus tachycardia, and postural orthostatic tachycardia syndrome (POTS). The lack of electrophysiological expertise in almost all SSA countries except in South Africa, underscores this non-existent literature of SVTs. In Western World clinical studies, AVNRT accounts for about 55–60% of all SVTs, AVRT 25–30%, and AT 10–17% [123, 129], which is similar to what was seen in the only study in SSA. Most SVTs are very responsive to beta-blockers and non-dihydropyridine calcium channel blockers which are generically cheap in SSA and will be useful once the diagnosis is confirmed. SVTs can lead to tachycardia-induced cardiomyopathy, atrial fibrillation, and SCD especially if people with pre-excitation develop AF/AFL [123, 130], and it is not unreasonable to speculate this as the etiology of some of the SCD seen in SSA. Emphasis on teaching, recognition, diagnosis, management, clinical relevance, and awareness of these SVTs and other cardiac arrhythmias need to be enforced in medical schools and allied medical training programs across SSA.
Given sparsity of structured Emergency Medical Services (EMS) and registries, the epidemiology of SCA/SCD is less characterized in SSA, apart from few data without supporting background for establishing reliable incidence estimates and etiologies. Both the internal and external validity of study results are affected by ascertainment of SCA/SCD cases. Data are more likely to reflect reality in the HIC with well-structured and readily available EMS of within a few minutes from the cardiac arrest, compared to poorer regions of SSA where these services are only present in patches in some urban areas, but remain largely inexistent in rural areas. Thus reported incidences of OHCA in SSA of 6–34 cases per 100,000 inhabitants are lower than in Europe and North America, where incidences of EMS-assessed and EMS-treated OHCA are about 86–110 per 100,000 and 40–57 per 100,000 respectively, and the presence of shockable rhythm (VT/VF) is seen in 20–35% of OHCA cases in adults and about 7% in children. In these regions, the incidence of IHCA varies from 0.6–1.6 per 1000 inpatient bed-days (VT/VF 16.1%, PEA 52.3%, asystole 23.6%, unknown 8% in adults, while VT/VF was 10.7% in children) [123, 131].
This review identified underlying etiologies of SCA/SCD and ventricular arrhythmias in SSA, with hypertensive heart disease, coronary disease, cardiomyopathy, including peripartum cardiomyopathy, and valvular heart disease, especially rheumatic heart disease being the most common causes of SCA/SCD among adults [61, 64, 67, 69, 71, 72, 73, 90]. Others include malignant arrhythmogenic inherited diseases [74, 75, 76, 77, 78, 79, 80, 81, 84, 85, 86, 87, 88, 102, 103, 104], pericarditis , endemic parasitic infections [9, 93], pulmonary embolism [62, 91], endomyocardial fibrosis , congenital heart disease , pulmonary embolism [62, 91], pulmonary hypertension , and aortic dissection/rupture . Despite sarcoidosis being prevalent in SSA where approximately one in five cases is often mis-diagnosed as tuberculosis, studies on cardiac manifestations of sarcoidosis are lacking in this region [102, 103, 104]. However, it is known that African Americans in USA have a higher sarcoid incidence and >10 folds higher mortality including SCD and heart failure death compared to Caucasians . Also, 5% of patients with sarcoidosis are known to have clinically manifest cardiac involvement and another 20–25% have asymptomatic cardiac involvement, and these manifestations include cardiomyopathy leading to heart failure, VT/VF, and cardiac conduction disease . In HIC, the most frequent cause of OHCA is CAD accounting for more than 50% of SCA/SCD cases , with autopsy studies showing 80% of adults who suffer SCD have severe CAD , and in 61% of OHCA, at least one significant coronary lesion deemed responsible for the OHCA was seen on angiography in adults . Autopsy studies of SCD also show that 10–15% have dilated or hypertrophic cardiomyopathy, and 5–10% have structurally normal hearts. About 30–50% of heart failure patients will die from SCD .
This review identified very low CPR awareness even among physicians and low rates of CPR initiation in SSA. Compare this to HIC of Western Europe and North America where 40–45% of OHCA victims received bystander CPR, and where >60% of the general population are trained to perform CPR, and where all IHCA victims without prior ‘do not resuscitate’ (DNR) code are expected to have full attempt at resuscitation via CPR and advanced cardiac life support . The critical importance of quality CPR on survival in SCA victims have been demonstrated , and 12.6% with versus 7.6% without bystander CPR survive to discharge in large Western World registries . For every minute that passes between collapse and defibrillation, survival from witnessed VF SCA falls 7% to 10% if no CPR is provided and when bystander CPR is provided, the fall in survival is more gradual and averages 3% to 4% . Pre-emptive strides to inculcate at least chest-compression and rescue breathing CPR to the masses, as well as setting-up EMS and maintaining acceptable standards, alongside building new or improving existing recipient hospitals in terms of cardiac professional expertise and cardiac equipment, should become priority in eyes of policy makers and stakeholders within the health sector in SSA.
It is estimated that 1 million patients worldwide die annually because of a lack of bradyarrhythmia device therapy , and with low implant rates in SSA, it is less doubtful that this region is contributing abundantly to this death pool. The rates of CIEDs implants in SSA are abysmally rock-bottom. For instance, Nigeria offers 0.2 implants per million population, which is >4000 times less than in Germany [12, 14, 139]. This means that many patients in this region with advanced bradyarrhythmias requiring pacemaker implantation are at the mercy of either succumbing to unbidden recurrent presyncope/syncope or premature sudden cardiac death. More than half (52%) of the patients identified as having an indication for pacing by visiting humanitarian pacing missions across 14 countries in SSA died before the missions arrived . CAD and age-related degenerative conduction disease are the most common causes of AV block and SSS in HIC. The relatively low rates of CAD in SSA coupled with deaths from competitive causes at relatively younger age in SSA, could account for some of the low rates of pacemaker implantations in SSA. However, the approximately more than 200-fold lower rate of cardiac device implants compared to HIC of Western Europe and North America might not be fully explained by these alone [11, 12]. That said, data from a few observational studies in the USA suggest lower risk of sick sinus syndrome in African Americans compared to Caucasians .
Three identified main barriers to pacemaker and ICD implantation in SSA are reduced availability of implanting facilities with appropriate equipment, deficits in trained clinical specialists, and high cost of the devices and their accessories in the setting of high pay-out-of-pocket policies [9, 12, 106, 107, 141]. An interim solution to the high cost of cardiac devices is the re-use of previously implanted and explanted devices donated from the developed world, the so-called postmortem pacemakers and defibrillators, which have been shown to be safe in SSA [107, 116, 141, 142] and worldwide [138, 143], and their use has been backed by electrophysiology specialists . Despite earlier observation of underuse of these recycled cardiac devices in SSA , growing partnerships between PASCAR and My Heart Your Heart (University of Michigan, USA) as well as Pace 4 Life (UK-based charity organisation) are now helping to bring more of these reconditioned CIEDs to SSA [9, 141]. Given the palpable clear life-saving contribution of CIEDS, fostering partnerships and encouraging the re-use of CIEDS donated from the developed countries, plus initiatives aimed at building acceptable implanting centers and training specialists even through short and tailored fellowships , are of paramount importance and urgency.
Encouraging member States of the African Region of the World Health Organization to meet the prescribed target of 15% of annual expenditure on health under the Abuja Declaration, as majority are still falling short, will help . Also, balancing the currently skewed budget allocations appropriately between communicable disease and NCDs will be helpful [145, 146].
This review has observed deficiencies in health care systems and specialist cardiac services to manage CVDs [11, 12, 147, 148]. Therefore, patients who survive OHCA, for example, and reach hospitals in SSA have lower chances of survival compared to their high-income country counterparts where invasive investigations and treatments are now routine practice. Every country in SSA should strive to have at least one large tertiary referral academic center for treatment of CVDs and invasive treatment of arrhythmias. The development of cardiac arrhythmia services with available ECG machines, built-in cardiac rhythm monitoring systems and devices like Holter monitors, external loop and patch recorders, mobile cardiac telemetry (MCT), and implantable loop recorders, as well as trained professionals to interpret their findings are warranted in order to diagnose arrhythmias in SSA.
There is a very low proportion of physicians to population, with majority of SSA countries having <5 physicians per 10,000 people , and 18% of the sub-Saharan African countries in a survey did not have a registered cardiologist, let alone a cardiac electrophysiologist [11, 12]. The paucity of good training programs for cardiologists in SSA is compounded by the difficulty of African-trained physicians to get into good cardiology training fellowship programs in the western world, as cardiology is a highly attractive sub-specialty for which entry is usually fairly competitive even for western-trained physicians within their own respective countries. International and regional training partnerships should be fostered, like the PASCAR Fellowship in cardiac pacing which has already trained some fellows from countries where no pacing was present, and other regional initiatives .
Management of CVDs can very expensive . CIEDs are very costly and unfordable by majority of the population in SSA, where direct out-of-pocket payments as a share of total health expenditure are still >40%, often leading to impoverishment . This is compounded by the rarity of national health insurance systems, available in only about 15% of 55 African countries . Development of these insurance systems should be encouraged and should become salient schemes in public health and financial planning within countries. An inclusive universal healthcare system with national-level health insurance scheme is probably better as it will avoid the poorer population from being left behind.
This review has noted very sparse data on SVTs, ventricular arrhythmias, and bradyarrhythmias. Poor ascertainment and capture of the true burden and trends of arrythmias and other CVDs might lead to underestimated disease rates and distort public health planning. Efforts should be made by governments and academic institutions through funding to remedy this handicap.
As recommended in PRISMA-P guidelines, classical publication databases such as PubMed/MEDLINE and EMBASE were used to retrieve the information. The databases used were supplemented by a database focused on African publication (AJOL). Furthermore, in order to capture any grey publication, some manual searches were conducted on internet and bibliography of published articles. Although, this wide variety of sources provide an accurate picture of the cardiac arrhythmias in sub-Saharan Africa, it comes with several challenges. Firstly, the clinical heterogeneity materialized, for instance, by marked differences observed in how studies were designed, differences in participants (age), comorbidities assessed, and treatment availability (Tables 1, 2, and 4). Secondly, the statistical heterogeneity characterized by how findings were reported precluded a meta-analysis. Although search criteria which combine the names of all sub-Saharan African countries was an option, we believe relevant arrhythmia studies in this region were not missed with the criteria used.
The SSA region appears unprepared for the growing burden of arrhythmias, which appear to be under-diagnosed and undertreated. While victims of OHCA arrest in this region have low chances of ROSC and survival due to lack of CPR awareness and shortage of EMS, survivors to hospital also have lower survival rates due to sparsity of invasive cardiac procedures like coronary angiography, primary PCI, pacemakers, defibrillators, and antiarrhythmic medications. On the other hand, the majority of the tachyarrhythmias are managed conservatively due to low rates of invasive cardiac electrophysiological procedures in SSA, as setting-up health systems for their management is usually very expensive. Thus, to reduce morbidity and mortality from arrhythmias, high level strategic planning is needed, involving governmental, non-governmental organizations, international organizations, societies and associations, and local stakeholders.
AF/AFL: Atrial fibrillation/atrial flutter
CIEDs: Cardiac implantable electronic devices
CPR: Cardiopulmonary resuscitation
CRT: Cardiac resynchronization therapy
CVDs: Cardiovascular diseases
HIC: High-Income Countries
GBD: Global burden of disease
ICD: Implantable cardioverter defibrillator
IHCA: In-hospital cardiac arrest
NCDs: Non-communicable disease
PEA: Pulseless electrical activity
PPM: Permanent pacemaker
OHCA: Out-of-hospital cardiac arrest
RHD: Rheumatic heart disease
ROSC: Return of spontaneous circulation
SVTs: Supraventricular tachycardias
SCA: Sudden cardiac arrest
SCD: Sudden cardiac death
SSA: Sub-Saharan Africa
VT: Ventricular tachycardia
VF: Ventricular fibrillation
We most fervently acknowledge the Pan-African Society of Cardiology (PASCAR) and its various ensuing task forces which have helped to galvanize CVDs research, raise awareness, and given the fight against CVDs new purpose and impetus in this region. We are especially grateful to Cardiac Arrhythmias and Pacing Task Force of PASCAR for the very informative surveys conducted, the findings of which we have cited many times in this review, as well as the Task Force on Sudden Cardiac Death.
The authors have no competing interests to declare.
United Nations. World population prospects. The 2017 Revision 2017. https://esa.un.org/unpd/wpp/Publications/Files/WPP2017_KeyFindings.pdf.
World Health Organization. Global health estimates 2016: Deaths by cause, age, sex, by country, and by region, 2000–2016 2018. https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html.
A systematic analysis for the Global Burden of Disease Study 2017. Default results are deaths and DALYs for 2017 with trends since 1990 2017. http://ghdx.healthdata.org/gbd-results-tool (accessed 20 March 2019).
Mensah GA, Roth GA, Sampson UK, Moran AE, Feigin VL, Forouzanfar MH, et al. Mortality from cardiovascular diseases in sub-Saharan Africa, 1990–2013: A systematic analysis of data from the Global Burden of Disease Study 2013. Cardiovascular Journal of Africa. 2015; 26(2 Suppl 1): S6–10. DOI: https://doi.org/10.5830/CVJA-2015-036
Keates AK, Mocumbi AO, Ntsekhe M, Sliwa K, Stewart S. Cardiovascular disease in Africa: Epidemiological profile and challenges. Nature reviews Cardiology. 2017; 14(5): 273–93. DOI: https://doi.org/10.1038/nrcardio.2017.19
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS medicine. 2006; 3(11): e442. DOI: https://doi.org/10.1371/journal.pmed.0030442
Jacobs MS, van Hulst M, Adeoye AM, Tieleman RG, Postma MJ, Owolabi MO. Atrial fibrillation in Africa—An under-reported and unrecognized risk factor for stroke: A systematic review. Global Heart. 2019; 14(3): 269–79. DOI: https://doi.org/10.1016/j.gheart.2019.04.003
Bonny A, Ngantcha M, Scholtz W, Chin A, Nel G, Anzouan-Kacou JB, et al. Cardiac arrhythmias in Africa: Epidemiology, management challenges, and perspectives. Journal of the American College of Cardiology. 2019; 73(1): 100–9. DOI: https://doi.org/10.1016/j.jacc.2018.09.084
Bestawros M. Electrophysiology in the developing world: Challenges and opportunities. Cardiology Clinics. 2017; 35(1): 49–58. DOI: https://doi.org/10.1016/j.ccl.2016.09.002
Talle MA, Bonny A, Scholtz W, Chin A, Nel G, Karaye KM, et al. Status of cardiac arrhythmia services in Africa in 2018: A PASCAR Sudden Cardiac Death Task Force report. Cardiovascular Journal of Africa. 2018; 29(2): 115–21. DOI: https://doi.org/10.5830/CVJA-2018-027
Bonny A, Ngantcha M, Jeilan M, Okello E, Kaviraj B, Talle MA, et al. Statistics on the use of cardiac electronic devices and interventional electrophysiological procedures in Africa from 2011 to 2016: Report of the Pan African Society of Cardiology (PASCAR) Cardiac Arrhythmias and Pacing Task Forces. Europace: European pacing, arrhythmias, and cardiac electrophysiology. Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology. 2018; 20(9): 1513–26. DOI: https://doi.org/10.1093/europace/eux353
Adedinsewo D, Omole O, Oluleye O, Ajuyah I, Kusumoto F. Arrhythmia care in Africa. Journal of Interventional Cardiac Electrophysiology: An International Journal of Arrhythmias and Pacing; 2018. DOI: https://doi.org/10.1007/s10840-018-0398-z
Bonny A, Ngantcha M, Yuyun MF, Scholtz W, Karaye KM, Suliman A, et al. Cardiac arrhythmia services in Africa from 2011 to 2018: The second report from the Pan African Society of Cardiology working group on cardiac arrhythmias and pacing. Paris: ESC World Cardiology Congress; 2019. DOI: https://doi.org/10.1093/europace/euz354
Koopman JJ, van Bodegom D, Westendorp RG, Jukema JW. Scarcity of atrial fibrillation in a traditional African population: A community-based study. BMC cardiovascular disorders. 2014; 14: 87. DOI: https://doi.org/10.1186/1471-2261-14-87
Dewhurst MJ, Adams PC, Gray WK, Dewhurst F, Orega GP, Chaote P, et al. Strikingly low prevalence of atrial fibrillation in elderly Tanzanians. Journal of the American Geriatrics Society. 2012; 60(6): 1135–40. DOI: https://doi.org/10.1111/j.1532-5415.2012.03963.x
Coulibaly I, Anzouan-Kacou JB, Konin KC, Kouadio SC, Abouo-N’Dori R. Medecine tropicale: Revue du Corps de sante colonial. Atrial fibrillation: Epidemiological data from the Cardiology Institute in Abidjan, Cote d’Ivoire. 2010; 70(4): 371–4.
Sliwa K, Carrington MJ, Klug E, Opie L, Lee G, Ball J, et al. Predisposing factors and incidence of newly diagnosed atrial fibrillation in an urban African community: Insights from the Heart of Soweto Study. Heart (British Cardiac Society). 2010; 96(23): 1878–82. DOI: https://doi.org/10.1136/hrt.2010.206938
Mbaye A, Pessinaba S, Bodian M, Mouhamadou BN, Mbaye F, Kane A, et al. Atrial fibrillation, frequency, etiologic factors, evolution and treatment in a cardiology department in Dakar, Senegal. The Pan African Medical Journal. 2010; 6: 16.
Coulibaly S, Diall IB, Menta I, Diakité M, Ba HO, Sibibé S, et al. Fibrillation atriale dans le service de Cardiologie du CHU du Point G: Clinique, facteurs etiologiques et evolution naturelle. [Atrial fibrillation in Cardiology Service of Point G Training Hospital: Clinical, etiologic factors, and natural evolution]. Cardiologie Tropicale; 2013.
Sliwa K, Wilkinson D, Hansen C, Ntyintyane L, Tibazarwa K, Becker A, et al. Spectrum of heart disease and risk factors in a black urban population in South Africa (the Heart of Soweto Study): A cohort study. Lancet (London, England). 2008; 371(9616): 915–22. DOI: https://doi.org/10.1016/S0140-6736(08)60417-1
Sani MU, Davison BA, Cotter G, Mayosi BM, Edwards C, Ogah OS, et al. Prevalence, clinical characteristics, and outcomes of valvular atrial fibrillation in a cohort of African patients with acute heart failure: Insights from the THESUS-HF registry. Cardiovascular Journal of Africa. 2018; 29(3): 139–45. DOI: https://doi.org/10.5830/CVJA-2017-051
Makubi A, Hage C, Lwakatare J, Kisenge P, Makani J, Ryden L, et al. Contemporary aetiology, clinical characteristics, and prognosis of adults with heart failure observed in a tertiary hospital in Tanzania: The prospective Tanzania Heart Failure (TaHeF) study. Heart (British Cardiac Society). 2014; 100(16): 1235–41. DOI: https://doi.org/10.1136/heartjnl-2014-305599
Zuhlke L, Karthikeyan G, Engel ME, Rangarajan S, Mackie P, Cupido-Katya Mauff B, et al. Clinical outcomes in 3,343 children and adults with rheumatic heart disease from 14 low- and middle-income countries: Two-year follow-up of the Global Rheumatic Heart Disease Registry (the REMEDY Study). Circulation. 2016; 134(19): 1456–66. DOI: https://doi.org/10.1161/CIRCULATIONAHA.116.024769
Okello E, Longenecker CT, Beaton A, Kamya MR, Lwabi P. Rheumatic heart disease in Uganda: Predictors of morbidity and mortality one year after presentation. BMC Cardiovascular Disorders. 2017; 17(1): 20. DOI: https://doi.org/10.1186/s12872-016-0451-8
Sliwa K, Carrington M, Mayosi BM, Zigiriadis E, Mvungi R, Stewart S. Incidence and characteristics of newly diagnosed rheumatic heart disease in urban African adults: Insights from the heart of Soweto study. European Heart Journal. 2010; 31(6): 719–27. DOI: https://doi.org/10.1093/eurheartj/ehp530
Syed FF, Ntsekhe M, Wiysonge CS, Badri M, Oh JK, Mayosi BM. Atrial fibrillation as a consequence of tuberculous pericardial effusion. International Journal of Cardiology. 2012; 158(1): 152–4. DOI: https://doi.org/10.1016/j.ijcard.2012.04.075
Mansoor E. De novo atrial fibrillation post cardiac surgery: The Durban experience. Cardiovascular Journal of Africa. 2014; 25(6): 282–7. DOI: https://doi.org/10.5830/CVJA-2014-067
Alkali NH, Bwala SA, Akano AO, Osi-Ogbu O, Alabi P, Ayeni OA. Stroke risk factors, subtypes, and 30-day case fatality in Abuja, Nigeria. Nigerian Medical Journal: Journal of the Nigeria Medical Association. 2013; 54(2): 129–35. DOI: https://doi.org/10.4103/0300-1652.110051
Walker RW, Dewhurst M, Gray WK, Jusabani A, Aris E, Unwin N, et al. Electrocardiographic assessment of coronary artery disease and stroke risk factors in rural and urban Tanzania: A case-control study. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association. 2014; 23(2): 315–20. DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2013.03.002
Lekoubou A, Nkoke C, Dzudie A, Kengne AP. Recurrent stroke and early mortality in an urban medical unit in Cameroon. Journal of Stroke and Cerebrovascular Diseases: The Official Journal of National Stroke Association. 2017; 26(8): 1689–94. DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.03.031
Adeoye AM, Ogah OS, Ovbiagele B, Akinyemi R, Shidali V, Agyekum F, et al. Prevalence and prognostic features of ECG abnormalities in acute stroke: Findings from the SIREN Study Among Africans. Global Heart. 2017; 12(2): 99–105. DOI: https://doi.org/10.1016/j.gheart.2017.01.002
Ebrahim I, Bryer A, Cohen K, Mouton JP, Msemburi W, Blockman M. Poor anticoagulation control in patients taking warfarin at a tertiary and district-level prothrombin clinic in Cape Town, South Africa. Suid-Afrikaanse tydskrif vir geneeskunde. [South African Medical Journal]. 2018; 108(6): 490–4. DOI: https://doi.org/10.7196/SAMJ.2018.v108i6.13062
Anakwue R, Ocheni S, Madu A. Utilization of oral anticoagulation in a teaching hospital in Nigeria. Annals of Medical and Health Sciences Research. 2014; 4(Suppl 3): S286–90. DOI: https://doi.org/10.4103/2141-9248.141973
Sonuga BO, Hellenberg DA, Cupido CS, Jaeger C. Profile and anticoagulation outcomes of patients on warfarin therapy in an urban hospital in Cape Town, South Africa. African Journal of Primary Health Care & Family Medicine. 2016; 8(1): e1–8. DOI: https://doi.org/10.4102/phcfm.v8i1.1032
Shavadia J, Yonga G, Mwanzi S, Jinah A, Moriasi A, Otieno H. Clinical characteristics and outcomes of atrial fibrillation and flutter at the Aga Khan University Hospital, Nairobi. Cardiovascular Journal of Africa. 2013; 24(2): 6–9. DOI: https://doi.org/10.5830/CVJA-2012-064
Ntep-Gweth M, Zimmermann M, Meiltz A, Kingue S, Ndobo P, Urban P, et al. Atrial fibrillation in Africa: Clinical characteristics, prognosis, and adherence to guidelines in Cameroon. Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology. 2010; 12(4): 482–7. DOI: https://doi.org/10.1093/europace/euq006
Jardine RM, Fine J, Obel IW. A survey on the treatment of atrial fibrillation in South Africa. Suid-Afrikaanse tydskrif vir geneeskunde. [South African medical journal]. 2014; 104(9): 623–7. DOI: https://doi.org/10.7196/SAMJ.8111
Mandi DG, Samadoulougou AK, Yameogo RA, Millogo GRC, Naibe DT, Hervé KPK, et al. Non valvular atrial fibrillation related ischaemic stroke at the Teaching Hospital of Yalgado Ouédraogo, Burkina Faso. N J Vasc Med Surg. 2015; 3. DOI: https://doi.org/10.4172/2329-6925.1000171
Oldgren J, Healey JS, Ezekowitz M, Commerford P, Avezum A, Pais P, et al. Variations in cause and management of atrial fibrillation in a prospective registry of 15,400 emergency department patients in 46 countries: The RE-LY Atrial Fibrillation Registry. Circulation. 2014; 129(15): 1568–76. DOI: https://doi.org/10.1161/CIRCULATIONAHA.113.005451
Lugero C, Kibirige D, Kayima J, Mondo CK, Freers J. Atrial fibrillation among the black population in a Ugandan tertiary hospital. International Journal of General Medicine. 2016; 9: 191–8. DOI: https://doi.org/10.2147/IJGM.S100637
Yameogo AR, Kologo JK, Mandi G, Kabore HP, Millogo GR, Seghda AA, et al. Use of Vitamins K antagonists in non-valvular atrial fibrillation thromboembolic risk prevention in Burkina Faso. The Pan African Medical Journal. 2016; 24: 108. DOI: https://doi.org/10.11604/pamj.2016.24.108.7100
Mapoure YN, Kamdem F, Akeyeh FJ, Dzudie A, Mouliom S, Mouelle AS, et al. Cardio-embolic stroke: Lessons from a single centre in sub-Saharan Africa. Revue Neurologique; 2019. DOI: https://doi.org/10.1016/j.neurol.2019.02.004
Healey JS, Oldgren J, Ezekowitz M, Zhu J, Pais P, Wang J, et al. Occurrence of death and stroke in patients in 47 countries 1 year after presenting with atrial fibrillation: A cohort study. Lancet (London, England). 2016; 388(10050): 1161–9. DOI: https://doi.org/10.1016/S0140-6736(16)30968-0
Temu TM, Lane KA, Shen C, Ng’ang’a L, Akwanalo CO, Chen PS, et al. Clinical characteristics and 12-month outcomes of patients with valvular and non-valvular atrial fibrillation in Kenya. PloS One. 2017; 12(9): e0185204. DOI: https://doi.org/10.1371/journal.pone.0185204
Mwita JC, Ocampo C, Molefe-Baikai OJ, Goepamang M, Botsile E, Tshikuka JG. Characteristics and 12-month outcome of patients with atrial fibrillation at a tertiary hospital in Botswana. Cardiovascular Journal of Africa. 2019; 30: 1–7. DOI: https://doi.org/10.5830/CVJA-2019-013
Thomas V, Schulein S, Millar RN, Mayosi BM. Clinical characteristics and outcome of lone atrial fibrillation at a tertiary referral centre: The Groote Schuur Hospital experience. Cardiovascular Journal of Africa. 2018; 29(5): 268–72. DOI: https://doi.org/10.5830/CVJA-2018-005
Muthalaly RG, Koplan BA, Albano A, North C, Campbell JI, Kakuhikire B, et al. Low population prevalence of atrial fibrillation in rural Uganda: A community-based cross-sectional study. International Journal of Cardiology. 2018; 271: 87–91. DOI: https://doi.org/10.1016/j.ijcard.2018.05.074
Greffie ES, Mitiku T, Getahun S. High prevalence of atrial fibrillation in stroke patients admitted to University of Gondar Hospital, Northwest Ethiopia. Ethiopian Medical Journal. 2016; 54(4): 207–12.
Bhagat K, Tisocki K. Prescribing patterns for the use of antithrombotics in the management of atrial fibrillation in Zimbabwe. The Central African Journal of Medicine. 1999; 45(11): 287–90. DOI: https://doi.org/10.4314/cajm.v45i11.8501
Van der Merwe DM, Van der Merwe PL. Supraventricular tachycardia in children. Cardiovascular Journal of South Africa: Official Journal for Southern Africa Cardiac Society [and] South African Society of Cardiac Practitioners. 2004; 15(2): 64–9.
Millar RN, Milne DA, von Oppell UO, Reichart B. Surgery for the Wolff-Parkinson-White syndrome. The Groote Schuur Hospital experience. Suid-Afrikaanse tydskrif vir geneeskunde. [South African Medical Journal]. 1991; 79(10): 583–7.
Edwards-Jackson N, North K, Chiume M, Nakanga W, Schubert C, Hathcock A, et al. Outcomes of in-hospital paediatric cardiac arrest from a tertiary hospital in a low-income African country. Paediatrics and International Child Health. 2019: 1–5. DOI: https://doi.org/10.1080/20469047.2019.1570443
Ngunga LM, Yonga G, Wachira B, Ezekowitz JA. Initial rhythm and resuscitation outcomes for patients developing cardiac arrest in hospital: Data from low-middle income country. Global Heart. 2018; 13(4): 255–60. DOI: https://doi.org/10.1016/j.gheart.2018.07.001
Bonny A, Tibazarwa K, Mbouh S, Wa J, Fonga R, Saka C, et al. Epidemiology of sudden cardiac death in Cameroon: The first population-based cohort survey in sub-Saharan Africa. International Journal of Epidemiology. 2017; 46(4): 1230–8. DOI: https://doi.org/10.1093/ije/dyx043
Adekola OO, Asiyanbi GK, Desalu I, Olatosi JO, Kushimo OT. The outcome of anaesthesia related cardiac arrest in a sub-Saharan tertiary hospital. Egyptian Journal of Anaesthesia. 2016; 32(3): 315–21. DOI: https://doi.org/10.1016/j.egja.2016.04.002
Talle MA, Bonny A, Bakki B, Buba F, Anjorin CO, Yusuph H, et al. Sudden cardiac death: Clinical perspectives from the University of Maiduguri Teaching Hospital, Nigeria. World Journal of Cardiovascular Diseases. 2015; 5: 95–106. DOI: https://doi.org/10.4236/wjcd.2015.55013
Akinwusi PO, Komolafe AO, Olayemi OO, Adeomi AA. Pattern of sudden death at Ladoke Akintola University of Technology Teaching Hospital, Osogbo, South West Nigeria. Vascular Health and Risk Management. 2013; 9: 333–9. DOI: https://doi.org/10.2147/VHRM.S44923
Kwari YD, Bello MR, Eni UE. Pattern of perioperative cardiac arrests at University of Maiduguri Teaching Hospital. Nigerian Journal of Medicine: Journal of the National Association of Resident Doctors of Nigeria. 2010; 19(2): 173–6. DOI: https://doi.org/10.4314/njm.v19i2.56514
Tiemensma M, Burger EH. Sudden and unexpected deaths in an adult population, Cape Town, South Africa, 2001–2005. Suid-Afrikaanse tydskrif vir geneeskunde. [South African medical journal]. 2012; 102(2): 90–4. DOI: https://doi.org/10.7196/SAMJ.5363
Stein C. Out-of-hospital cardiac arrest cases in Johannesburg, South Africa: A first glimpse of short-term outcomes from a paramedic clinical learning database. Emergency Medicine Journal: EMJ. 2009; 26(9): 670–4. DOI: https://doi.org/10.1136/emj.2008.066084
Olotu A, Ndiritu M, Ismael M, Mohammed S, Mithwani S, Maitland K, et al. Characteristics and outcome of cardiopulmonary resuscitation in hospitalised African children. Resuscitation. 2009; 80(1): 69–72. DOI: https://doi.org/10.1016/j.resuscitation.2008.09.019
Rotimi O, Fatusi AO, Odesanmi WO. Sudden cardiac death in Nigerians—The Ile-Ife experience. West African Journal of Medicine. 2004; 23(1): 27–31. DOI: https://doi.org/10.4314/wajm.v23i1.28076
Rotimi O, Ajayi AA, Odesanmi WO. Sudden unexpected death from cardiac causes in Nigerians: A review of 50 autopsied cases. International Journal of Cardiology. 1998; 63(2): 111–5. DOI: https://doi.org/10.1016/S0167-5273(97)00274-X
Vedanthan R, Fuster V, Fischer A. Sudden cardiac death in low- and middle-income countries. Global Heart. 2012; 7(4): 353–60. DOI: https://doi.org/10.1016/j.gheart.2012.10.002
Mene-Afejuku TO, Balogun MO, Akintomide AO, Adebayo RA, Ajayi OE, Amadi VN, et al. Clinical and echocardiographic predictors of arrhythmias detected with 24-hour holter electrocardiography among hypertensive heart failure patients in Nigeria. Clinical Medicine Insights Cardiology. 2017; 11: 1179546817746632. DOI: https://doi.org/10.1177/1179546817746632
Heradien M, Goosen A, Moolman-Smook JC, Brink PA. Race and gender representation of hypertrophic cardiomyopathy or long QT syndrome cases in a South African research setting. Cardiovascular Journal of Africa. 2007; 18(5): 312–5.
Cabral TT, Budzee A, Butera G. The first cardioverter defibrillator implanted in Central Africa. The Pan African Medical Journal. 2016; 23: 115. DOI: https://doi.org/10.11604/pamj.2016.23.115.3822
Watkins DA, Hendricks N, Shaboodien G, Mbele M, Parker M, Vezi BZ, et al. Clinical features, survival experience, and profile of plakophylin-2 gene mutations in participants of the arrhythmogenic right ventricular cardiomyopathy registry of South Africa. Heart Rhythm. 2009; 6(11 Suppl): S10–7. DOI: https://doi.org/10.1016/j.hrthm.2009.08.018
Mayosi BM, Fish M, Shaboodien G, Mastantuono E, Kraus S, Wieland T, et al. Identification of Cadherin 2 (CDH2) mutations in arrhythmogenic right ventricular cardiomyopathy. Circulation Cardiovascular Genetics. 2017; 10(2). DOI: https://doi.org/10.1161/CIRCGENETICS.116.001605
Bonny A, Tonet J, Fontaine G, Lacotte J, Coignard E, Duthoit G, et al. Brugada syndrome in pure black Africans. Journal of Cardiovascular Electrophysiology. 2008; 19(4): 421–6. DOI: https://doi.org/10.1111/j.1540-8167.2007.01041.x
Aba YT, Fresard A, Gagneux-Brunon A, Lutz MF, Cazorla C, Lucht F, et al. Brugada syndrome revealed by intestinal shigellosis in a patient from Benin at the University Hospital of Saint-Etienne. Bulletin de la Societe de pathologie exotique (1990). 2017; 110(4): 250–3. DOI: https://doi.org/10.1007/s13149-017-0575-9
Blancard M, Debbiche A, Kato K, Cardin C, Sabrina G, Gandjbakhch E, et al. An African loss-of-function CACNA1C variant p.T1787M associated with a risk of ventricular fibrillation. Scientific Reports. 2018; 8(1): 14619. DOI: https://doi.org/10.1038/s41598-018-32867-4
Bonny A, Noah DN, Amougou SN, Saka C. Prevalence and significance of early repolarisation in a black African population: Data of 246 individuals with cardiovascular morbidity. Cardiovascular Journal of Africa. 2013; 24(7): 280–5. DOI: https://doi.org/10.5830/CVJA-2013-063
Ilkhanoff L, Soliman EZ, Prineas RJ, Walsh JA, 3rd, Ning H, Liu K, et al. Clinical characteristics and outcomes associated with the natural history of early repolarization in a young, biracial cohort followed to middle age: The Coronary Artery Risk Development in Young Adults (CARDIA) study. Circulation Arrhythmia and Electrophysiology. 2014; 7(3): 392–9. DOI: https://doi.org/10.1161/CIRCEP.113.000874
Peters F, Khandheria BK, dos Santos C, Matioda H, Maharaj N, Libhaber E, et al. Isolated left ventricular noncompaction in sub-Saharan Africa: A clinical and echocardiographic perspective. Circulation Cardiovascular Imaging. 2012; 5(2): 187–93. DOI: https://doi.org/10.1161/CIRCIMAGING.111.966937
Gaye ND, Ngaide AA, Bah MB, Babaka K, Mbaye A, Abdoul K. Non-compaction of left ventricular myocardium in sub-Saharan African adults. Heart Asia. 2017; 9(2): e010884. DOI: https://doi.org/10.1136/heartasia-2017-010884
Paule P, Braem L, Mioulet D, Jop B, Theron A, Gil JM, et al. Left ventricular noncompaction: A cardiomyopathy in young individuals. Description of first cases in Africa. Medecine Tropicale: Revue du Corps de sante colonial. 2007; 67(6): 587–93.
Hedley PL, Durrheim GA, Hendricks F, Goosen A, Jespersgaard C, Stovring B, et al. Long QT syndrome in South Africa: The results of comprehensive genetic screening. Cardiovascular Journal of Africa. 2013; 24(6): 231–7. DOI: https://doi.org/10.5830/CVJA-2013-032
Kolo PM, Opadijo OG, Omotoso AB, Katibi IA, Balogun MO, Araoye MA. Prognostic significance of QT interval prolongation in adult Nigerians with chronic heart failure. Nigerian Journal of Clinical Practice. 2008; 11(4): 336–41.
Hoevelmann J, Viljoen CA, Manning K, Baard J, Hahnle L, Ntsekhe M, et al. The prognostic significance of the 12-lead ECG in peripartum cardiomyopathy. International Journal of Cardiology. 2019; 276: 177–84. DOI: https://doi.org/10.1016/j.ijcard.2018.11.008
Laher AE, Moolla M, Motara F, Paruk F, Richards G. Survival after cardiac arrest secondary to massive pulmonary embolism. Case Reports in Emergency Medicine. 2018; 2018: 8076808. DOI: https://doi.org/10.1155/2018/8076808
Mayosi BM, Ntsekhe M, Bosch J, Pandie S, Jung H, Gumedze F, et al. Prednisolone and Mycobacterium indicus pranii in tuberculous pericarditis. The New England Journal of Medicine. 2014; 371(12): 1121–30. DOI: https://doi.org/10.1056/NEJMoa1407380
Hidron A, Vogenthaler N, Santos-Preciado JI, Rodriguez-Morales AJ, Franco-Paredes C, Rassi A Jr. Cardiac involvement with parasitic infections. Clinical Microbiology Reviews. 2010; 23(2): 324–49. DOI: https://doi.org/10.1128/CMR.00054-09
Malvy D, Receveur MC, Ozon P, Djossou F, Le Metayer P, Touze JE, et al. Fatal cardiac incident after use of halofantrine. Journal of Travel Medicine. 2000; 7(4): 215–6. DOI: https://doi.org/10.2310/7060.2000.00065
Mocumbi AO, Falase AO. Recent advances in the epidemiology, diagnosis, and treatment of endomyocardial fibrosis in Africa. Heart (British Cardiac Society). 2013; 99(20): 1481–7. DOI: https://doi.org/10.1136/heartjnl-2012-303193
Tantchou Tchoumi JC, Butera G, Giamberti A, Ambassa JC, Sadeu JC. Occurrence and pattern of congenital heart diseases in a rural area of sub-Saharan Africa. Cardiovascular Journal of Africa. 2011; 22(2): 63–6. DOI: https://doi.org/10.5830/CVJA-2010-046
Olajumoke TO, Afolayan JM, Raji SA, Adekunle MA. Cardiopulmonry resuscitation—Knowledge, attitude & pratices in Osun State, Nigeira. Journal of the West African College of Surgeons. 2012; 2(2): 23–32.
Sadoh WE, Osariogiagbon W. Knowledge and practice of cardiopulmonary resuscitation amongst doctors and nurses in Benin City, Nigeria. Nigerian Hospital Practice. 2009; 3: 1–2. DOI: https://doi.org/10.4314/nhp.v3i1-2.45616
Veronese JP, Wallis L, Allgaier R, Botha R. Cardiopulmonary resuscitation by Emergency Medical Services in South Africa: Barriers to achieving high quality performance. Revue africaine de la medecine d’urgence. [African Journal of Emergency Medicine]. 2018; 8(1): 6–11. DOI: https://doi.org/10.1016/j.afjem.2017.08.005
Zha Y, Ariyo M, Olaniran O, Ariyo P, Lyon C, Kalu Q, et al. Cardiopulmonary resuscitation capacity in referral hospitals in Nigeria: Understanding the global health disparity in resuscitation medicine. Journal of the National Medical Association. 2018; 110(4): 407–13. DOI: https://doi.org/10.1016/j.jnma.2017.09.002
Brink PA, Crotti L, Corfield V, Goosen A, Durrheim G, Hedley P, et al. Phenotypic variability and unusual clinical severity of congenital long-QT syndrome in a founder population. Circulation. 2005; 112(17): 2602–10. DOI: https://doi.org/10.1161/CIRCULATIONAHA.105.572453
Smith C, Feldman C, Reyneke J, Promnitz DA, Kallenbach JM, Zwi S. Sarcoidosis in Johannesburg—A comparative study of black and white patients. Suid-Afrikaanse tydskrif vir geneeskunde. [South African Medical Journal]. 1991; 80(9): 423–7.
Morar R, Feldman C. Sarcoidosis in Johannesburg, South Africa: A retrospective study. European Respiratory Journal. 2015; 46(suppl 59): PA841. DOI: https://doi.org/10.1183/13993003.congress-2015.PA841
Awotedu AA, George AO, Oluboyo PO, Alabi GO, Onadeko BO, Ogunseyinde O, et al. Sarcoidosis in Africans: 12 cases with histological confirmation from Nigeria. Transactions of the Royal Society of Tropical Medicine and Hygiene. 1987; 81(6): 1027–9. DOI: https://doi.org/10.1016/0035-9203(87)90387-7
Mond HG, Proclemer A. The 11th world survey of cardiac pacing and implantable cardioverter-defibrillators: Calendar year 2009—A World Society of Arrhythmia’s project. Pacing and Clinical Electrophysiology: PACE. 2011; 34(8): 1013–27. DOI: https://doi.org/10.1111/j.1540-8159.2011.03150.x
Sani MU, Mayosi BM. The Pacemaker and ICD Reuse Programme of the Pan-African Society of Cardiology. Heart (British Cardiac Society). 2017; 103(23): 1844–5. DOI: https://doi.org/10.1136/heartjnl-2017-311462
Jama ZV, Chin A, Badri M, Mayosi BM. Performance of re-used pacemakers and implantable cardioverter defibrillators compared with new devices at Groote Schuur Hospital in Cape Town, South Africa. Cardiovascular Journal of Africa. 2015; 26(4): 181–7. DOI: https://doi.org/10.5830/CVJA-2015-048
Tchoumi JT, Ambassa JC, Mvondo C, Butera G. Challenges in cardiac pacing activities in a subsaharan tertiairy centre. Archives of Cardiovascular Diseases Supplements. 2019; 11(1): 33–4. DOI: https://doi.org/10.1016/j.acvdsp.2018.10.068
Adoubi AK, Diby F, Ndjessan JJ, Gnaba A, Yangni-Angaté HK. Prognosis of heart failure in patients with conventional cardiac pacing. A monocentric study in sub-Saharan Africa. Global Heart. 2018; 13(4): 398. DOI: https://doi.org/10.1016/j.gheart.2018.09.080
Jouven X, Sagnol P, Marijon E. Cardiac pacing in sub-Saharan Africa—Cardiology and development experience. Sang Thrombose Vaisseaux. 2016; 28(5): 225–30. DOI: https://doi.org/10.1684/stv.2016.0952
Ikama SM, Makani J, Jouven X, Kimbally-Kaky G. Permanent cardiac pacing: First Congolese experiment. The Pan African Medical Journal. 2015; 20: 381. DOI: https://doi.org/10.11604/pamj.2015.20.381.5803
Falase B, Sanusi M, Johnson A, Akinrinlola F, Ajayi R, Oke D. Analysis of a five year experience of permanent pacemaker implantation at a Nigerian Teaching Hospital: Need for a national database. The Pan African Medical Journal. 2013; 16: 16. DOI: https://doi.org/10.11604/pamj.2013.16.16.2644
Kane AD, Ndiaye MB, Pessinaba S, Mbaye A, Bodian M, Driouch ME, et al. Infections secondary to pacemaker implantation: A synopsis of six cases. Cardiovascular Journal of Africa. 2012; 23(10): e1–4. DOI: https://doi.org/10.5830/CVJA-2012-035
Millar RN. 1998 survey of cardiac pacing in South Africa—Report of the working group on registries of the cardiac arrhythmia society of South Africa (CASSA). Suid-Afrikaanse tydskrif vir geneeskunde. [South African Medical Journal]. 2001; 91(10): 873–6.
Mayosi BM, Little F, Millar RN. Long-term survival after permanent pacemaker implantation in young adults: 30 year experience. Pacing and Clinical Electrophysiology: PACE. 1999; 22(3): 407–12. DOI: https://doi.org/10.1111/j.1540-8159.1999.tb00468.x
Thiam M, Fall PD, Gning SB, Ott D, Gueye PM, Wade B, et al. Annales de cardiologie et d’angeiologie. Cardiac pacing in West Africa: Feasibility, problems, and perspectives. 2003; 52(4): 212–4. DOI: https://doi.org/10.1016/S0003-3928(02)00189-0
Ekpe EE, Aghaji MA, Edaigbini SA, Onwuta CN. Cardiac pacemaker treatment of heart block in Enugu a 5-year review. Nigerian Journal of Medicine: Journal of the National Association of Resident Doctors of Nigeria. 2008; 17(1): 7–12. DOI: https://doi.org/10.4314/njm.v17i1.37346
Varwani MH, Jeilan M. ICD implantation in post MI LV dysfunction: A sub Saharan Centre experience. Cardiovascular Journal of Africa. 2018; 29: 12. DOI: https://doi.org/10.5830/CVJA-2018-066
Imazio M, Gaita F, LeWinter M. Evaluation and treatment of pericarditis: A systematic review. Jama. 2015; 314(14): 1498–506. DOI: https://doi.org/10.1001/jama.2015.12763
Noubiap JJ, Nyaga UF. A review of the epidemiology of atrial fibrillation in sub-Saharan Africa. Journal of Cardiovascular Electrophysiology. 2019; 30(12): 3006–16. DOI: https://doi.org/10.1111/jce.14222
Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. Heart disease and stroke statistics—2018 Update: A report from the American Heart Association. Circulation. 2018; 137(12): e67–e492. DOI: https://doi.org/10.1161/CIR.0000000000000573
Hart RG, Pearce LA, Aguilar MI. Meta-analysis: Antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Annals of Internal Medicine. 2007; 146(12): 857–67. DOI: https://doi.org/10.7326/0003-4819-146-12-200706190-00007
Wallentin L, Lopes RD, Hanna M, Thomas L, Hellkamp A, Nepal S, et al. Efficacy and safety of apixaban compared with warfarin at different levels of predicted international normalized ratio control for stroke prevention in atrial fibrillation. Circulation. 2013; 127(22): 2166–76. DOI: https://doi.org/10.1161/CIRCULATIONAHA.112.142158
Kakkar AK, Mueller I, Bassand JP, Fitzmaurice DA, Goldhaber SZ, Goto S, et al. Risk profiles and antithrombotic treatment of patients newly diagnosed with atrial fibrillation at risk of stroke: Perspectives from the international, observational, prospective GARFIELD registry. PloS One. 2013; 8(5): e63479. DOI: https://doi.org/10.1371/journal.pone.0063479
AlTurki A, Proietti R, Dawas A, Alturki H, Huynh T, Essebag V. Catheter ablation for atrial fibrillation in heart failure with reduced ejection fraction: A systematic review and meta-analysis of randomized controlled trials. BMC Cardiovascular Disorders. 2019; 19(1): 18. DOI: https://doi.org/10.1186/s12872-019-0998-2
Patel D, Hasselblad V, Jackson KP, Pokorney SD, Daubert JP, Al-Khatib SM. Catheter ablation for ventricular tachycardia (VT) in patients with ischemic heart disease: A systematic review and a meta-analysis of randomized controlled trials. Journal of Interventional Cardiac Electrophysiology: An International Journal of Arrhythmias and Pacing. 2016; 45(2): 111–7. DOI: https://doi.org/10.1007/s10840-015-0083-4
Porter MJ, Morton JB, Denman R, Lin AC, Tierney S, Santucci PA, et al. Influence of age and gender on the mechanism of supraventricular tachycardia. Heart Rhythm. 2004; 1(4): 393–6. DOI: https://doi.org/10.1016/j.hrthm.2004.05.007
Page Richard L, Joglar José A, Caldwell Mary A, Calkins H, Conti Jamie B, Deal Barbara J, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Circulation. 2016; 133(14): e506–e74.
Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: Systematic review of 67 prospective studies. Resuscitation. 2010; 81(11): 1479–87. DOI: https://doi.org/10.1016/j.resuscitation.2010.08.006
Mirsaeidi M, Machado RF, Schraufnagel D, Sweiss NJ, Baughman RP. Racial difference in sarcoidosis mortality in the United States. Chest. 2015; 147(2): 438–49. DOI: https://doi.org/10.1378/chest.14-1120
Adabag AS, Luepker RV, Roger VL, Gersh BJ. Sudden cardiac death: Epidemiology and risk factors. Nature Reviews Cardiology. 2010; 7(4): 216–25. DOI: https://doi.org/10.1038/nrcardio.2010.3
Chelly J, Mongardon N, Dumas F, Varenne O, Spaulding C, Vignaux O, et al. Benefit of an early and systematic imaging procedure after cardiac arrest: Insights from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry. Resuscitation. 2012; 83(12): 1444–50. DOI: https://doi.org/10.1016/j.resuscitation.2012.08.321
Olasveengen TM, de Caen AR, Mancini ME, Maconochie IK, Aickin R, Atkins DL, et al. 2017 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations summary. Circulation. 2017; 136(23): e424–e40. DOI: https://doi.org/10.1161/CIR.0000000000000553
Hazinski MF, Idris AH, Kerber RE, Epstein A, Atkins D, Tang W, et al. Lay rescuer automated external defibrillator (“public access defibrillation”) programs: Lessons learned from an international multicenter trial: Advisory statement from the American Heart Association Emergency Cardiovascular Committee; The Council on Cardiopulmonary, Perioperative, and Critical Care; and the Council on Clinical Cardiology. Circulation. 2005; 111(24): 3336–40. DOI: https://doi.org/10.1161/CIRCULATIONAHA.105.165674
Runge MW, Baman TS, Davis S, Weatherwax K, Goldman E, Eagle KA, et al. Pacemaker recycling: A notion whose time has come. World Journal of Cardiology. 2017; 9(4): 296–303. DOI: https://doi.org/10.4330/wjc.v9.i4.296
Raatikainen MJP, Arnar DO, Merkely B, Nielsen JC, Hindricks G, Heidbuchel H, et al. A decade of information on the use of cardiac implantable electronic devices and interventional electrophysiological procedures in the European society of cardiology countries: 2017 report from the European Heart Rhythm Association. Europace: European Pacing, Arrhythmias, and Cardiac Electrophysiology: Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology. 2017; 19(suppl_2): ii1–ii90. DOI: https://doi.org/10.1093/europace/eux258
Jensen PN, Gronroos NN, Chen LY, Folsom AR, deFilippi C, Heckbert SR, et al. Incidence of and risk factors for sick sinus syndrome in the general population. Journal of the American College of Cardiology. 2014; 64(6): 531–8. DOI: https://doi.org/10.1016/j.jacc.2014.03.056
Wunderly K, Yousef Z, Bonny A, Weatherwax KJ, Lavan B, Allmendinger C, et al. Using reconditioned pacemakers to treat bradycardia in Africa. Nature Reviews Cardiology. 2018; 15(12): 725–6. DOI: https://doi.org/10.1038/s41569-018-0076-y
Ochasi A, Clark P. Reuse of pacemakers in Ghana and Nigeria: Medical, legal, cultural, and ethical perspectives. Developing World Bioethics. 2015; 15(3): 125–33. DOI: https://doi.org/10.1111/dewb.12047
Baman TS, Meier P, Romero J, Gakenheimer L, Kirkpatrick JN, Sovitch P, et al. Safety of pacemaker reuse: A meta-analysis with implications for underserved nations. Circulation Arrhythmia and Electrophysiology. 2011; 4(3): 318–23. DOI: https://doi.org/10.1161/CIRCEP.110.960112
Hughey AB, Desai N, Baman TS, Gakenheimer L, Hagan L, Kirkpatrick JN, et al. Heart Rhythm Society members’ views on pacemaker and implantable cardioverter-defibrillator reuse. Pacing and Clinical Electrophysiology: PACE. 2014; 37(8): 969–77. DOI: https://doi.org/10.1111/pace.12418
World Health Organization. Public financing for health in Africa: From Abuja to the SDGs 2016. https://www.who.int/health_financing/documents/public-financing-africa/en/.
World Health Organization. State of health financing in the African region. Brazzaville: WHO Africa 2013. https://www.afro.who.int/sites/default/files/2017-06/state-of-health-financing-afro.pdf.
Kakou-Guikahue M, N’Guetta R, Anzouan-Kacou JB, Kramoh E, N’Dori R, Ba SA, et al. Optimizing the management of acute coronary syndromes in sub-Saharan Africa: A statement from the AFRICARDIO 2015 Consensus Team. Archives of Cardiovascular Diseases. 2016; 109(6–7): 376–83. DOI: https://doi.org/10.1016/j.acvd.2015.12.005
Carlson S, Duber HC, Achan J, Ikilezi G, Mokdad AH, Stergachis A, et al. Capacity for diagnosis and treatment of heart failure in sub-Saharan Africa. Heart (British Cardiac Society). 2017; 103(23): 1874–9. DOI: https://doi.org/10.1136/heartjnl-2016-310913
Agyepong IA, Sewankambo N, Binagwaho A, Coll-Seck AM, Corrah T, Ezeh A, et al. The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa. Lancet (London, England). 2018; 390(10114): 2803–59. DOI: https://doi.org/10.1016/S0140-6736(17)31509-X
Sliwa K, Zuhlke L, Kleinloog R, Doubell A, Ebrahim I, Essop M, et al. Cardiology-cardiothoracic subspeciality training in South Africa: A position paper of the South Africa Heart Association. Cardiovascular Journal of Africa. 2016; 27(3): 188–93. DOI: https://doi.org/10.5830/CVJA-2016-063