| Summary of the main points |
| • In sub‐Saharan Africa, heart failure is largely a non‐ischaemic disease of the young and middle‐aged adults, which is caused mainly by hypertension, rheumatic heart disease and cardiomyopathy. |
| • Dilated and peripartum cardiomyopathies, and endomyocardial fibrosis, which are endemic in sub‐Saharan Africa, account for 20% of all cases of heart failure. |
| • Endomyocardial fibrosis is a major form of heart disease that is found in 9% of the general population in affected regions of Mozambique. Early surgery is the only intervention that may reduce morbidity and improve survival in symptomatic cases with endomyocardial fibrosis. |
| • Apart from a founder effect for hypertrophic cardiomyopathy in the Afrikaner and mixed ancestry population of South Africa, the epidemiology of hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy is similar to that of other populations of the world. |
| • HIV infection is associated with an increase in the incidence of cardiomyopathy and tuberculous pericarditis, both of which are associated with poor prognosis without antiretroviral drug treatment. |
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| New knowledge |
| • A stat‐3‐deficient mouse model develops peripartum cardiomyopathy owing to excessive production of an abnormal prolactin isoform that causes cardiomyopathy. The prolactin antagonist, bromocriptine, reverses the heart failure in the mouse model. A small clinical trial of 12 African patients with peripartum cardiomyopathy shows the same abnormalities of STAT3 and abnormal prolactin production, with a good response to bromocriptine treatment. |
| • HIV‐associated tuberculous pericarditis is associated with a severe myopericardial disease and mortality of up to 40% at 6 months despite antituberculous treatment. |
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| Unanswered questions and controversies |
| • There is a need for population‐based studies of the incidence, prevalence and aetiology of heart failure in Africa. |
| • The role (if any) of genetic factors in peripartum cardiomyopathy and endomyocardial fibrosis remains unknown. |
| • The effectiveness of pentoxifylline in heart failure due to cardiomyopathy, and bromocriptine in peripartum cardiomyopathy, remains to be established in adequately powered randomised trials with important clinical end points. |
| • It remains to be established whether the early detection of endomyocardial fibrosis and the institution of surgery before end‐stage disease will prevent morbidity and mortality in this condition. |
| • The effectiveness of adjunctive oral corticosteroids in reducing progression to constriction and mortality in tuberculous pericarditis, and safety in patients who are immunosuppressed by HIV, needs to be established in adequately powered randomised trials with important clinical end points. |
