Improving heart failure care in rural Africa: overcoming implementation barriers

In this narrative review, we present the most important heart diseases causing heart failure in sub-Saharan Africa, discuss challenges, uncertainties and research gaps, and suggest strategies to lower the burden of disease. Hypertensive heart disease is the most common cause for heart failure in Africa causing the largest burden of disease. Only a small minority of hypertensive people achieve guideline-recommended blood pressure values. For rheumatic heart disease, current guidelines recommend screening programs with handheld ultrasound devices performed by trained non-experts to detect children with a mild stage of the disease, because secondary prophylaxis with penicillin lowers the progression of the disease. Women with peripartum cardiomyopathy need access to specialized care and follow-up, to fully recover their left ventricular function. Tuberculosis is the main cause for pericarditis and pericardial tamponade, and health care personnel requires training in diagnosis and therapy, including pericardiocentesis. Coronary heart disease is less prevalent in sub-Saharan Africa than elsewhere but also underdiagnosed because of lack of diagnostic tools. In those with an indication for anticoagulation, only a minority receives oral anticoagulation. Programs are needed to increase awareness for hypertension and heart failure, to implement referral systems, to ameliorate access to diagnostic equipment, medication, and specialized care including cardiac surgery, and to increase the availability of health insurance.