Figure 1
(a) INTER-CHF study sites. (b) Common etiologies of Heart Failure in the 5 African countries.
a) Legend: African countries involved in INTER-CHF with recruitment numbers: Nigeria (383 patients), South Africa (169 patients), Sudan (501 patients), Uganda (151 patients), and Mozambique (90 patients). Total recruitment (1,294 patients).
b) Legend: Prevalence of common etiologies of heart failure in the five African countries in INTER-CHJF study. It shows that hypertensive heart disease (HD) was the most common etiology in Nigeria, Uganda, Mozambique and overall, while ischemic HD was the most common in South Africa and Sudan.
Table 1
Baseline characteristics and treatments.
| Variables | Overall Mean(SE)or n(%) N = 5823 | Africa Overall Mean(SE)or n(%) N = 1294 | Nigeria Mean(SE)or n(%) N = 383 | SouthAfrica Mean(SE)or(%) N = 169 | Sudan Mean(SE)or n(%) N = 501 | Uganda Mean(SE)or n(%) N = 151 | Mozambique Mean(SE) or n(%) N = 90 |
|---|---|---|---|---|---|---|---|
| Demographic characteristics | |||||||
| Age, years | 59.3(0.2) | 53.4(0.4) | 50.8(0.8) | 53.3(1.2) | 56.8(0.7) | 52.3(1.3) | 46.2(1.7) |
| Males | 3495(60.7) | 662(51.9) | 203(54.3) | 95(56.2) | 290(56.1) | 41(27.5) | 33(40.1) |
| Employed Status | 1480(16.8) | 426(21) | 176(41.8) | 75(41.6) | 103(18.5) | 32(20.9) | 40(41) |
| Illiterate | 1319(14.8) | 495(42.9) | 113(29.9) | 4(1.87) | 279(55.3) | 79(46.9) | 20(22.2) |
| No Health Insurance | 2477(38.5) | 878(66.9) | 372(97.1) | 40(22.8) | 227(45.3) | 150(99.4) | 89(98.9) |
| In-patient status at recruitment | 2105(34.3) | 616(48.6) | 119(30.5) | 24(13.9) | 423(84.5) | 39(26.6) | 11(12) |
| Clinical characteristics | |||||||
| NYHA class 1 | 802(11.9) | 105(7.23) | 14(3.5) | 43(24.9) | 27(5.35) | 7(4.77) | 14(15.1) |
| NYHA class 2 | 2548(44.6) | 487(37.1) | 134(34.5) | 67(40) | 202(41.5) | 28(17.3) | 56(59.9) |
| NYHA class 3 | 1756(28.80 | 440(35.3) | 152(40) | 39(23) | 171(33.5) | 60(40.2) | 18(20.9) |
| NYHA class 4 | 714(8.95) | 262(20.6) | 83(21.7) | 20(11.6) | 101(19.4) | 56(38.4) | 2(2.38) |
| BMI, Kg/m2 | 26.2(0.08) | 25.5(0.17) | 25.1(0.29) | 30.1(0.45) | 25.3(0.26) | 21.8(0.47) | 24.9(0.61) |
| SBP, mmHg | 125(0.3) | 124(0.6) | 122(1.2) | 129(1.8) | 119(1.1) | 129(2.0) | 121(2.5) |
| DBP, mmHg | 75.7(0.18) | 78.6(0.38) | 78.8(0.79) | 82.0(1.19) | 75.9(0.70) | 84.9(1.27) | 74.5(1.64) |
| Pulse Rate/min | 80.3(0.22) | 87.6(0.46) | 88.0(0.91) | 81.2(1.36) | 90.4(0.80) | 94.6(1.46) | 82.3(1.89) |
| Time of HF diagnosis <1 year | 2385(40.5) | 715(53.9) | 217(56.3) | 79(47.3) | 263(55.4) | 110(71.90) | 46(48.3) |
| Hypertension | 3549(64.2) | 690(62.1) | 252(71.5) | 100(60.5) | 207(36.9) | 104(76.7) | 27(39.4) |
| Diabetes mellitus | 1728(28.7) | 201(17.2) | 41(10.5) | 34(18.9) | 113(19.8) | 12(8.01) | 1(1.24) |
| Dyslipidemia | 1812(31.2) | 207(21) | 59(19.7) | 63(36.8) | 69(12.2) | 11(13.40) | 5(6.5) |
| Chronic Kidney Disease | 487(7.12) | 45(3.81) | 17(4.84) | 14(7.98) | 11(1.98) | 3(2.72) | 0(0) |
| Current Tobacco | 554(5.54) | 78(3.55) | 10(1.83) | 29(13.1) | 31(4.45) | 6(3.99) | 2(1.89) |
| Alcohol | 798(7.87) | 194(10.6) | 61(12.4) | 60(30.4) | 19(2.36) | 25(20) | 29(36.9) |
| Prior Stroke | 405(5.88) | 55(4.97) | 9(2.45) | 13(7.73) | 28(5.62) | 3(2.48) | 2(2.69) |
| Previous MI | 1114(17.7) | 97(8.26) | 4(0.95) | 41(23.6) | 46(7.93) | 6(8.97) | 0(0) |
| HF Hospitalization in Past year | 1567(25.2) | 420(32.3) | 94(24.5) | 60(35) | 201(39.1) | 24(16.7) | 41(47.5) |
| History of COPD | 450(6.05) | 26(2.22) | 5(1.41) | 18(10.2) | 2(0.34) | 1(0.63) | 0(0) |
| MOCA | 20.5(0.09) | 17.7(0.21) | 21.7(0.29) | 23.0(0.46) | 13.6(0.29) | 24.3(1.08) | 18.5(0.64) |
| Treatments | |||||||
| BetaBlockers | 3768(66.5) | 634(48.4) | 112(29.1) | 108(63.8) | 267(51.9) | 105(71.8) | 42(49.3) |
| ACE or ARB | 4322(74) | 990(77.7) | 316(83.3) | 127(75.4) | 343(67) | 124(84.3) | 80(90.7) |
| Aldosterone antagonists | 2913(48) | 787(59.1) | 343(89.4) | 81(47.6) | 331(66.4) | 26(17.8) | 6(6.4) |
| Diuretics | 4414(78) | 1214(93.7) | 360(94) | 141(83.8) | 489(97.8) | 140(93) | 84(92.7) |
| Digoxin | 1550(26) | 443(31.8) | 264(68.5) | 32(18.9) | 72(14.9) | 38(24.3) | 37(38.5) |
| Warfarin | 858(14) | 222(16.7) | 112(29.1) | 32(18.6) | 66(12.70) | 4(2.82) | 8(9.32) |
| Investigations | |||||||
| Creatinine, μmol/L | 112(1.15) | 129(2.57) | 111(5.73) | 104(9.98) | 139(5.63) | 175(14.0) | 130(11.4) |
| Hemoglobin, g/dL | 125(0.33) | 119(0.77) | 119(1.70) | 128(2.40) | 117(1.27) | 129(3.46) | 124(2.50) |
| Sinus Rhythm | 3699(75.7) | 728(75.2) | 239(74.7) | 102(81.7) | 255(73.6) | 60(79) | 72(83.1) |
| Atrial Fibrillation | 850(17.3) | 154(16.6) | 50(15.5) | 8(6.23) | 74(21.4) | 10(10.6) | 12(12.4) |
[i] Key: SE, standard error; n, number of patients; NYHA, New York Heart Association; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; HF, heart failure; MI, myocardial infarction; HF, heart failure; COPD, chronic obstructive airway disease; MoCA, Montreal Cognitive Assessment; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin II receptor blocker; normal ranges: serum creatinine 30–111 μmol/L; hemoglobin 13.7–16.7 g/dL.
Table 2
Etiologies of Heart Failure.
| Variables | Africa Overall N = 1294 | Nigeria N = 383 | South Africa N = 169 | Sudan N = 501 | Uganda N = 151 | Mozambique N = 90 |
|---|---|---|---|---|---|---|
| Hypertensive HD | 35 | 65.1 | 13.6 | 11.7 | 46.9 | 24.7 |
| Ischemic HD | 20 | 3.01 | 44.9 | 25.3 | 1.09 | 1.27 |
| Idiopathic – DCM | 14.1 | 10.6 | 8.61 | 20.9 | 22.2 | 18.3 |
| Rheumatic HD | 7.2 | 5.3 | 3.3 | 16.8 | 13 | 19.3 |
| Valvular Non-Rheumatic HD | 2.3 | 2.0 | 2.2 | 1.3 | 7.8 | 2.4 |
| HIV Cardiomyopathy | 0.7 | 0.2 | 3.3 | 0 | 0.83 | 3.8 |
| Alcohol/Drug induced CMP | 0.66 | 0.68 | 1.1 | 0.43 | 0 | 2.4 |
| EMF | 0.26 | 0 | 0.45 | 0 | 1.8 | 2.2 |
| PPCM | 0.14 | 0.58 | 0.60 | 0.17 | 0 | 0.38 |
| Post Chemotherapy HD | 0.12 | 0 | 0.69 | 0 | 0 | 0 |
| Tuberculosis related HD | 0.09 | 0 | 0.51 | 0 | 0 | 0.82 |
| Congenital HD | 0.08 | 0.26 | 0 | 0.17 | 0.58 | 0 |
| Endocrine/Metabolic | 5.4 | 0.73 | 3.5 | 11 | 1.9 | 0.9 |
| Other causes | 13.3 | 11.6 | 16.2 | 11.4 | 3.9 | 23.5 |
| Unknown etiology | 0.6 | 0 | 1.1 | 0.87 | 0 | 0 |
[i] Key: HD, heart disease; DCM, dilated cardiomyopathy; HIV, human immunodeficiency virus; CMP, cardiomyopathy; EMF, endomyocardial fibrosis; PPCM, peripartum cardiomyopathy. Values are expressed as proportions in percentages.
Figure 2
Kaplan Meir curves: (2a) Death outcome by Region. (2b) Death outcome by Sex.
Legend: Kaplan Meier survival cures describing mortality pattern in the five African countries (Figure 2a) and in males and females (Figure 2b), over one year.
Table 3
Outcomes.
| Variables | Overall Africa N = 1294 | Nigeria N = 383 | South Africa N = 169 | Sudan N = 501 | Uganda N = 151 | Mozambique N = 90 | P-VALUE |
|---|---|---|---|---|---|---|---|
| Death at Year 1 | 26.4 | 12.3 | 11.8 | 42.7 | 32.5 | 13.3 | <0.0001* |
| Hospitalization at Year 1 | 24.3 | 20.6 | 16.6 | 37.3 | 6.0 | 13.3 | <0.0001* |
| Death or Hospitalization at Year 1 | 39 | 25.3 | 21.9 | 59.7 | 35.1 | 21.1 | <0.0001* |
| Cardiac Death at Year 1 | 9.0 | 7.3 | 7.1 | 13.6 | 0.7 | 7.8 | <0.0001* |
| Non-Cardiac Death at Year 1 | 2.9 | 1.6 | 3.6 | 4.4 | 0 | 3.3 | 0.0038* |
| Unknown Death at Year 1 | 14.6 | 3.4 | 1.2 | 24.8 | 31.8 | 2.2 | <0.0001* |
[i] Key: Values are expressed as proportions in percentages; * p-value statistically significant.
Table 4
Correlates of mortality.
| Variables | Unadjusted HR (95% CI) | P-value | Adjusted HR (95% CI) | P-Value |
|---|---|---|---|---|
| Model 1 | ||||
| Age (Unit = 10), years | 1.10 (1.03–1.17) | 0.007* | 1.10 (1.01–1.21) | 0.037* |
| Sex: Male vs Female | 1.35 (1.09–1.68) | 0.006* | 1.42 (1.06–1.92) | 0.020* |
| Model 2 | ||||
| Age (Unit = 10), years | 1.10 (1.03–1.17) | 0.007* | 1.09 (0.98–1.20) | 0.102 |
| Sex: Male vs Female | 1.35 (1.09–1.68) | 0.006* | 1.324 (0.96–1.82) | 0.084 |
| SBP (Unit = 10), mmHg | 0.86 (0.82–0.91) | <0.001* | 0.86 (0.81–0.93) | <0.001* |
| Chronic Kidney Disease: Yes vs No | 1.62 (1.01–2.61) | 0.047 | 2.790 (1.55–5.02) | <0.001* |
| History of Diabetes Mellitus: Yes vs No | 1.45 (1.11–1.89) | 0.007 | 1.12 (0.77–1.64) | 0.552 |
| NYHA Class:(3 or 4 vs 1 or 2) | 1.71 (1.37–2.14) | <0.001* | 1.04 (0.76–1.43) | 0.788 |
| In patient vs Out Patient | 3.66 (2.89–4.64) | <0.001* | 2.92 (2.09–4.10) | <0.001* |
| Prior hospitalization for HF: Yes vs No | 1.74 (1.41–2.16) | <0.001* | 1.42 (1.07–1.89) | 0.016* |
| Ischemic Etiology: Yes vs No | 1.27 (0.98–1.64) | 0.075 | 0.96 (0.67–1.38) | 0.813 |
| Depressed LV function: Yes vs No | 1.08 (0.83–1.41) | 0.580 | 0.91 (0.67–1.24) | 0.552 |
| Valve Disease: Yes vs No | 2.54 (1.88–3.44) | <0.001* | 1.88 (1.33–2.66) | <0.001* |
| COPD: Yes vs No | 0.63 (0.26–1.52) | 0.303 | 0.82 (0.30–2.26) | 0.700 |
| BMI Kg/m2 | 0.96 (0.94–0.98) | <0.001* | 1.00 (0.97–1.02) | 0.832 |
| Smoking: Current vs former or Never | 0.75 (0.46–1.23) | 0.256 | 0.78 (0.40–1.50) | 0.451 |
| On Beta Blocker: Yes vs No | 1.01 (0.81–1.25) | 0.950 | 0.80 (0.59–1.08) | 0.152 |
| On ACEI/ARB: Yes vs No | 0.68 (0.54–0.85) | 0.001 | 0.86 (0.62–1.19) | 0.355 |
| On Aldosterone Inhibitor: Yes vs No | 0.92 (0.74–1.14) | 0.459 | 0.82 (0.60–1.12) | 0.222 |
| On Digoxin: Yes vs No | 0.61 (0.48–0.77) | <0.001* | 0.69 (0.49–0.97) | 0.034* |
[i] Key: HR, hazard ratio; NYHA, New York Heart Association; BMI, body mass index; SBP, systolic blood pressure; COPD, chronic obstructive airway disease; ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin II receptor blocker; * p-value statistically significant.
Figure 3
Etiologies of HF in INTER-CHF Africa and THESUS-HF cohorts.
Legend: Common etiologies of HF in the INTER-CHF (Africa and other regions) and THESUS-HF cohorts. HHD, hypertensive heart disease; DCM, dilated cardiomyopathy; RHD, rheumatic heart disease; IHD, ischemic heart disease; PPCM, peripartum cardiomyopathy.