THe Sub-Saharan Africa Survey of Heart Failure (THESUS-HF II): management and in-hospital outcome

Abstract Background Heart failure (HF) affects 64.3 million people globally. Despite advances in understanding HF in Africa, epidemiological data remain outdated, and medication availability and affordability are poorly documented. These challenges hinder patient management and healthcare planning, particularly as Africa faces a shifting disease burden. Purpose The THESUS II study aimed to provide updated, comprehensive data on acute HF in Africa, describing aetiology, clinical characteristics, management, and in-hospital outcomes. Methods This ongoing multi-country, multi-centre prospective study enrolled 1,163 patients from 45 hospitals across 16 PASCAR member countries over seven consecutive 24-hour periods. Data included demographics, clinical presentation, electrocardiographic and echocardiographic findings, treatments, and outcomes. Results The median age was 54.1 years (IQR 36.6–67.2), and 50.2% were male. A prior HF diagnosis was present in 39%. As shown in Figure 1, the main causes were pressure overload (31.5%, mostly hypertensive heart disease) and ischemic cardiomyopathy (27.4%). Valvular/congenital cardiomyopathies (11.9%), other cardiomyopathies (11.9%), primary myocardial disease (4.8%), and toxic cardiomyopathy (2.1%) were also noted. Pulmonary heart disease (3.3%) was linked to pulmonary hypertension and COPD, and infectious cases (1.2%) were all due to endocarditis. Stress-related and high-output cardiomyopathies (1.5%) were associated with atrial fibrillation and thyroid disorders, while volume overload syndromes (0.8%) were primarily due to chronic kidney disease. At admission, most patients were in NYHA class III (25.8%) or IV (59.2%), with valvular/congenital disease groups being the most symptomatic (Table 1). Echocardiography showed median LVEDD 58mm (IQR 49–64.9) and LVEF 38% (IQR 29–54.4), with the cardiomyopathy group having the lowest LVEF (median 32.0%, IQR 26–39, p0.001). ECG findings showed sinus rhythm (71.2%) and atrial fibrillation (20.4%). The median emergency unit stay was 17 hours (IQR 4–40.5). 90.0% were admitted to the general ward (median 5 days, IQR 2–9), while 10.2% required ICU admission (median 3 days, IQR 2–4). Patients with hypertensive heart disease and cardiomyopathy had the longest hospital stays (7.0 and 6.5 days, respectively). Regarding treatment, 95.8% received loop diuretics, 66.8% beta-blockers, 43.2% ACE inhibitors, and 31.2% ARBs. ARNIs were used in 7.3%, MRAs in 72.1%, SGLT2 inhibitors in 54.8%, and digoxin in 31.6%. At discharge, 93.0% were alive, 5.9% had died, and 1.1% had unknown outcomes, with no significant differences across HF causes. Conclusion Since THESUS I (2008–2010), the HF landscape in Africa has changed significantly. The THESUS II study highlights hypertensive and ischemic heart disease as key targets for prevention and management. The findings emphasize high morbidity and mortality and underscore the urgent need for improved HF management strategies across Africa.