Cardiovascular Disease in Africa and Beyond

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1 Global Health and Disasters course 21 October 2016 Cardiovascular Disease in Africa and Beyond Ed Havranek, MD Denver Health Medical Center University of Colorado School of Medicine

2 Medical Education Partnership Initiative (MEPI) Ethiopia Nigeria Uganda Zambia Botswana Kenya Tanzania Mozambique Zimbabwe South Africa

3 Clinical Epidemiology 1 st 10 general medical admissions 4/7/15 Age Gender Diagnosis Underlying Condition(s) 1 42 M Stroke Hypertension 2 24 F GI Bleed Jaundice/hepatitis 3 46 F Subacute meningitis HIV, DM 4 79 F Heart failure Hypertension 5 36 M Nephrotic syndrome HIV 6 33 F Dyspnea at rest 2 wks post partum 7 40 M Mitral stenosis, new AF HIV 8 59 M Myocardial infarction Hypertension 9 20 F? sepsis HIV M TTP HIV

4 Clinical Epidemiology 1 st 10 general medical admissions 4/7/15 Age Gender Diagnosis Underlying Condition(s) 1 42 M Stroke Hypertension 2 24 F GI Bleed Jaundice/hepatitis 3 46 F Subacute meningitis HIV, DM 4 79 F Heart failure Hypertension 5 36 M Nephrotic syndrome HIV 6 33 F Dyspnea at rest 2 wks post partum 7 40 M Mitral stenosis, new AF HIV 8 59 M Myocardial infarction Hypertension 9 20 F? sepsis HIV M TTP HIV

5 Contribution of Changes in Population Growth, Population Aging, and Rates of Age-Specific Cardiovascular Death to Changes in Cardiovascular Mortality, Roth GA et al. N Engl J Med 2015;372:

6 Contribution of Changes in Population Growth, Population Aging, and Rates of Age-Specific Cardiovascular Death to Changes in Cardiovascular Mortality, Roth GA et al. N Engl J Med 2015;372:

7 Figure 7 Regions sized by burden of disease Regions sized by healthcare workforce The Lancet 2010; 376:

8 Rheumatic Fever Occurs following pharyngitis caused by certain strains of group A streptococcus after a latency period of 3 weeks. Children and those exposed to them are at higher risk Outbreaks may occur in crowded conditions

9 Rheumatic Fever clinical features 2 major or 1 major + 2 minor and evidence of prior Strep infection: Major criteria: carditis polyarthritis chorea erythema marginatum subcutaneous nodules Minor criteria: arthralgia fever prolonged PR interval elevated ESR or CRP Prior Strep infection: (+) throat culture, (+) rapid antigen test, elevated ASO JAMA 1992; 268: 2069

10 Rheumatic Heart Disease clinical features A well known cause of valvular heart disease Mitral stenosis present in ~65% Aortic regurgitation Mitral regurgitation Aortic stenosis isolated AV disease ~2 5% Tricuspid and pulmonic involvement less common Not thought to cause constrictive pericarditis Not thought to cause cardiomyopathy

11 Rheumatic Heart Disease A Three pronged approach 1. Primary prevention: treat Strep pharyngitis 2. Secondary prevention: prophylactic abx after RF 3. Treatment of valvular disease: medical, surgical, percutaneous

12 Zimbabwe Historical Context The British Empire Rhodesia Robert Mugabe

13 Zimbabwe Historical Context 2000 Land redistribution begins. Inflation Economic downturn accelerates Contested election. Power sharing Hyperinflation. Cholera epidemic Zimbabwean dollar withdrawn

14 Zimbabwe Historical Context First 10 Medical Schools Senegal 1918 South Africa Uganda 1923 Nigeria 1948 Cote d Ivoire 1962 Zimbabwe 1963 Angola 1963 Adult Literacy Rates Zimbabwe 84.5% Lesotho 79.4% Cameroon 62.5% Uganda 58.4% Nigeria 54.9% Benin 32.6% Burkina Faso 17.6% Niger 13.2%

15 Cardiology Education in Zimbabwe Objective: develop a small group of junior faculty with basic region specific qualifications in cardiology

16 Cardiology Education in Zimbabwe More intensive mentoring of selected postgraduates Clinical skills Research skills

17 Cardiology Education in Zimbabwe Clinical skills Echocardiography ECG and arrhythmia detection Pacemaker implantation Outpatient management

18 Cardiology Education in Zimbabwe Research skills Patient registries o Inpatient stroke o Pediatric RHD o Peripartum cardiomyopathy o Inpatient CHF 30 d mortality Atrial fibrillation Ventricular arrhythmias

19 Cardiology Education in Zimbabwe Cardiovascular physiology lectures for 2d year medical students Clinical cardiology lectures for 5 th year medical students

20 Cardiovascular Disease in Africa and Beyond Be respectful The agenda should be driven by the community being served. Listen twice before acting once

21 Cardiovascular Disease in Africa and Beyond Plant trees Seek sustainable growth. Create things that will outlast you. Persevere.

22 Acknowledgments Zimbabwe: James Hakim, Jonathan Matenga Colorado: Tom Campbell, Larry Allen, Tom Maddox, Joe Schuller, David Katz, David Kao, Dan Bessesen, Alex Benson