Cardiovascular care in sub-Saharan Africa during the COVID-19 crisis: lessons from the global experience

by 3 methods we may learn wisdom: first by reflection, which is noblest; second is by imitation, which is easiest; and the third is by experience, which is the most bitter

Confucius

Sub-Saharan Africa (SSA) stands on the verge of an unprecedented challenge to its healthcare infrastructure and systems due to a novel infectious disease that has overwhelmed the greatest of healthcare services worldwide. Coronavirus disease 2019 (COVID-19), the clinical disease caused by SARSCoV-2, was classified by the World Health Organisation (WHO) as an international public health emergency in late January and has increased exponentially to pandemic proportions since then.¹ There are currently over four million confirmed cases and 302 059 deaths documented worldwide.² South Africa has become the epicentre of COVID-19 infections in Africa, with approximately 13 524 cases and 247 deaths at the time of writing.²

COVID-19 is a viral syndrome with a predilection for the upper respiratory tract and lungs, which can cause severe dysfunction of multiple organs, including the cardiovascular system.^3,4 Analysis of the large number of COVID-19-related fatalities in New York, China and Italy suggests that male patients with advanced age, hypertension, diabetes, obesity and established cardiovascular disease are at highest risk of mortality from COVID-19.^5-9 New and decompensated heart failure, myocarditis, cardiac arrhythmias, pericarditis with or without tamponade, acute pulmonary embolus and acute myocardial infarction (MI) have all been described as the initial presenting manifestation of COVID-19 and as complications in those with established disease.^10,11 Complicating the picture is the fact that biomarkers of cardiac injury and haemodynamic strain are elevated in up to 30% of patients, even where there is no overt evidence of cardiac involvement.¹²

Despite much goodwill and great effort, factors such as overcrowding and limited testing capacity have meant that the continent’s goal of prevention, control and containment of the virus has had variable and limited success across countries. As we brace ourselves for the impending COVID-19 medical onslaught, we set out to explore the published experience from geographies that have seen the worst of the pandemic and highlight a few important lessons shared in those reports with relevance for cardiovascular disease clinicians in Africa.

Lesson 1: ‘Don’t wait for the rain to prepare the umbrella’- Malaysian proverb

The preparation and re-organisation of healthcare services to deal adequately and appropriately with the burden of both non-COVID-19 and COVID-19 patients with cardiovascular disease should be prioritised. This will be even more important here in SSA where our healthcare systems are already strained with the current COVID-19-free burden of non-communicable and communicable diseases.

Given the vast diversity and heterogeneity of health infrastructure, resources and disease burden, no single effective plan can be recommended or applied throughout Africa. However, there is little doubt that those countries in Europe, Asia and North America that were best prepared fared much better than those who ignored the writing on the wall, confirming that failure to prepare is almost certainly preparation for failure.

Lesson 2: ‘If you hear hooves think horses not zebras’

The vast majority of patients presenting with symptoms and signs of acute cardiac disease will indeed have acute cardiac disease and should be treated as such.

Although the finding that the prevalence of hypertension, diabetes, obesity and cardiovascular disease among those presenting with symptomatic COVID-19 is high, this does not mean that the corollary is also true (that among those presenting with cardiovascular syndromes, COVID-19 is high). In fact, the opposite is true: (1) the vast majority of patients presenting with acute cardiac disorders as their primary presentation will be COVID-19 free, and; (2) the vast majority of patients with COVID-19 do not have cardiovascular complications.³

This is important because the temptation to delay the diagnostic work-up and treatment of acute cardiac syndromes until patients have been tested and the disease has been excluded has major consequences and should be avoided. The outcomes of most acute cardiac disorders such as acute MI are timesensitive and time-dependent. So if you need to test patients for COVID-19, do so, but don’t ignore the obvious in front of you.

Lesson 3: ‘Treatment deferred is treatment denied’

The public at large should be reminded and encouraged to seek immediate medical attention for symptoms compatible with acute cardiac syndromes. Patients with acute chest-pain syndromes, heart failure and other cardiac emergencies such as life-threatening arrhythmias should be advised to seek help at their nearest emergency healthcare centres with little or no delay.

Following nation-wide shutdowns throughout the globe, there was a dramatic and almost universal drop in acute cardiac syndromes such as MI.¹³ While there has been much debate about potential reasons, reports suggest that contributing to this phenomenon was that many patients chose not to go to hospital.¹¹ Anecdotal reports suggest that for some it was out of fear of contracting COVID-19. For others, it was out of a desire to help by not being an extra burden on healthcare workers. In either case, there is also little doubt that for many it was costly beyond measure. Therefore the public health messages that have helped patients get to hospital promptly and receive timely care around the world in the past should be re-iterated loudly to our communities and society at large.

Lesson 4: ‘Practice makes perfect’

Fibrinolytic therapy, pharmaco-invasive therapy and primary percutaneous coronary intervention (PCI) all have pros and cons in this COVID-19 environment. The key to optimal outcomes during COVID-19 is to continue to do what you know how to do best, with appropriate precautions.

There has been much debate about whether patients with acute MI should receive thrombolytic therapy or primary PCI (PPCI). Experience from China, India and Spain suggests that the main potential advantage for a thrombolytic approach is a lower exposure of staff and patients alike to potential COVID-19 transmission.¹⁴ In resource-limited environments where personal protective equipment (PPE) may need to be rationed, thrombolytic therapy may allow for time to test for COVID-19 prior to transfer for pharmaco-invasive therapy, and conservative therapy in low-risk patients, such as those presenting with uncomplicated inferior MI.

Where PPCI is the treatment strategy of choice, the advantages relate to the known superior outcomes compared to fibrinolytic therapy, and the ability to recognise ST-elevation myocardial infarction (STEMI) mimickers such as COVID-19 pseudo- MI and Takotsubo syndrome at the time of angiography.¹⁵ In environments where patients will continue to have access to the laboratory, it is essential that both the laboratory and its staff are fully prepared and trained in the appropriate use of PPE such as caps, masks, gowns, gloves and goggles. What is apparent from the published experience is that changing approach during this period, i.e. from a PPCI service to a fibrinolytic approach or vice versa will not change clinical outcomes.¹⁶ In short, the best strategy is to keep doing what you have been doing.

Lesson 5: ‘Treat the patient not the test’

Routine use of troponin and B-type natriuretic peptide (BNP) adds little to diagnostic or treatment decisions in patients with COVID-19 without an overt acute cardiac syndrome. Mild to moderate elevations in troponin and BNP values are found in up to 7% of hospitalised patients and 27% of those requiring admission to the intensive care unit (ICU), in the absence of evidence of overt cardiac abnormalities.¹⁷

While the mechanisms of these biomarker abnormalities are unclear, their poor prognostic significance is now well established.¹⁸ The American College of Cardiology recently recommended that they should be measured only where there is clinical suspicion of an acute MI or heart failure, after repeated testimony and evidence showed that routine testing triggered a series of additional tests such as echocardiography and angiography, which added little value but exposed additional staff to the virus.¹²

Lesson 6: ‘If it ain’t broke don’t fix it’

Patients on renin–angiotensin–aldosterone system (RAAS) blockers for hypertension, heart failure and diabetic nephropathy should not stop for fear of increased risk of COVID-19.

The combined but unrelated findings that (1) coronavirus attaches to angiotensin converting enzyme-2 (ACE2) receptors for cell entry and infection; and (2) the prevalence of hypertension among hospitalised patients with COVID-19 is high, led to fears that patients on RAAS inhibitors (ACE inhibitors and angiotensin receptor blockers) may be at increased risk of severe infection because of RAAS blocker-induced upregulation of the ACE2 receptor. However, the published evidence is now clear that this hypothesis was incorrect and these first-line therapies do not cause harm and should not be stopped.⁴ This is particularly important in Africa in light of the recently published CREOLE trial, which found that the combination of amlodipine and an angiotensin receptor blockers (ARB) offered better control than diuretic-based combination therapy.¹⁹

Lesson 7: ‘First do no harm’

There are currently over 200 treatment options for COVID- 19 under investigation. At the time of writing, there remains no proven effective therapy for the treatment of COVID-19. Some drugs under investigation, such as chloroquine and hydroxychloroquine with or without azithromycin can prolong the QT interval and cause harm.²⁰ These drugs may increase the risk of life-threatening arrhythmias in patients, especially in patients with a prolonged baseline QT interval because of electrolyte abnormalities (such as hypokalaemia) and use of other long QT-prolonging drugs.²¹ The judicious use of these drugs should be limited to investigational trials where ECG monitoring is performed until such time as these drugs have been shown to be effective and safe.

Lesson 8: ‘Prevention is better than cure’

Given our fragile healthcare infrastructure and limited hospital bed and ICU capacity, the vast majority of African countries will not be able to sustain the massive caseloads experienced elsewhere to date. Therefore, despite the limited success of lockdowns so far, the main self-care tool available to most of society remains to practice social distancing, hand hygiene, wear face masks, practice cough etiquette and avoid crowded spaces where most safe behaviour is near impossible. At the time of writing this article, no drugs have been shown to be effective as prophylaxis therapy and there are no COVID-19 vaccines. However, if all of us receive and recommend the ’flu vaccine to all, the reduced additional burden of respiratory illness on the healthcare system will make a significant difference on our capacity to treat those with non-COVID-19-related emergencies.²²

Conclusion

COVID-19 is here to stay. The WHO released a statement predicting approximately 200 000 deaths from COVID-19 in Africa, describing a unique disease profile with slower rates of transmission in lower age groups with severe disease.²³ South Africa is facing community spread of COVID-19. Only time will tell whether the health experts’ grim predictions about what is to come can be disproved, but the exponentially growing numbers are not promising. As we acclimatise ourselves to this new normal and learn to live with COVID-19, it will be crucial to heed the lessons of those who have fought the good fight before us.