The inaugural meeting of the Africa Heart Rhythm Association (AFHRA)

Summary

Cardiorhythm Africa, the inaugural conference of AFHRA, was conceived during the biennial PASCAR congress held in Johannesburg in November 2019, with the ambition to be the largest ever pan-African conference focused purely on arrhythmia. Significant aims were to (1) bring together arrhythmia specialists from across Africa and from the diaspora; and (2) announce the newly formed African Heart Rhythm Association (AFHRA), an affiliate organisation of PASCAR formed from the amalgamation of the Cardiac Pacing and Arrhythmias taskforces. The meeting held in Nairobi (29–31 January 2020) was organised to provide a focus on resource-constrained arrhythmia management within the African context and novel/advanced and potentially home-grown solutions. There was full representation from all five PASCAR regions (North, East, West, Central and Southern Africa). This report summarises the scope and perspective of the first Cardiorhythm Africa meeting and presents the future directions for this annual meeting.

Cardiorhythm Africa, the inaugural conference of the African Heart Rhythm Association (AFHRA) was conceived during the biennial Pan-African Society of Cardiology (PASCAR) congress held in Johannesburg in November 2019 with the ambition of being the largest ever pan-African conference focused purely on arrhythmia. Significant aims were to (1) bring together arrhythmia specialists from across Africa and from the diaspora; and (2) announce the newly formed AFHRA, an affiliate organisation of PASCAR, formed from the amalgamation of the Cardiac Pacing and Arrhythmias taskforces.

Surveys conducted by PASCAR over the last decade have indicated a significant problem with access to expertise and technology in the field of arrhythmia care in Africa and an unmet gap in training.^1-3 The meeting programme was organised to provide a focus on resource-constrained arrhythmia management within the African context and novel/advanced and potentially home-grown solutions. Presentations at the conference were invited to focus on contemporary management of arrhythmias with emphasis on setting up and sustaining service provision in Africa. This report summarises the scope of the first annual Cardiorhythm Africa meeting held in Nairobi from 29–31 January 2020 and summarily presents the future directions.

Purpose of the meeting

The main scope of the first Cardiorhythm Africa meeting was to (1) raise the profile of cardiac arrhythmia in Africa and form an executive committee to advise and promote healthcare professional education as well as public awareness, (2) develop within African healthcare specialists a network to advance arrhythmia management along clinical, advocacy, research and training lines, (3) initiate a pan-African conversation on improving access to arrhythmia services involving clinicians, funders, industry partners and patients, (4) form a network to demonstrate expertise and referral opportunities within the region and appraise the existing skill and mentorship models that already exist within Africa, (5) provide a connection with the diaspora and specialists from other networks, including Europe and North America, and (6) engage with the specialists in a detailed survey on arrhythmia care among different African nations.

The scientific programme was organised in sessions, aligning with clinical syndromes related to conduction and/or arrhythmia, including (1) heart failure and device therapy, (2) heart block and bradycardia, (3) syncope and sudden cardiac death, (4) drugs and devices, (5) atrial fibrillation in Africa with a focus on rate versus rhythm control and stroke prevention, (6) ventricular arrhythmia, and (7) acute and long-term narrow-complex tachycardia. A session with shared African cases and abstracts allowed clinical discussions of common and unusual arrhythmia presentations from around Africa and beyond. The programme was completed with ‘The big ECG challenge’ a quiz organised by the Egyptian Cardiac Rhythm Association.

The programme narrative was delivered through case scenarios, live-in-box demonstrations and live cases, and allowed showcasing of technology that many were not aware was available in Africa. The scientific programme of the meeting sandwiched three sessions focusing on the critical initiatives of the newly birthed AFHRA. A detailed report of the AFHRA vision, mission, strategies, current activities and future directions is beyond the scope of this article and will be published separately.

Highlights from the scientific sessions

The scientific programme included 10 sessions with over 25 regional and international speakers covering a wide range of topics in cardiac pacing and electrophysiology. Highlights included (1) a live cardiac resynchronisation therapy (CRT-D) implant from Nairobi, Kenya, with tips and tricks on implantation, patient selection, responders and super-responders to optimal CRT; (2) optimising drug therapy in heart failure, including the role and place of novel agents such as sacubitril/valsartan and dapagliflozin, and (3) an overview of conventional pacing indications followed by a pre-recorded demonstration of His bundle pacing with clear guidance on how to insert a His bundle lead.

Also discussed were sudden cardiac death in Africa, challenges with making a diagnosis, challenges with risk stratification and the current lack of data. There was a demonstration on both transvenous and subcutaneous implantable cardioverter defibrillator (ICD) implantation, as well as guidance on selection of patients where this mode of treatment is indicated.

This was followed by an interactive live pre-recorded atrial fibrillation (AF) ablation case, presentation of complications of AF ablation and a heated discussion whether singleshot technologies to ablate AF could be safely employed by non-electrophysiologists. There was a presentation and discussion on the eagerly awaited INVICTUS trial (a randomised trial of rivaroxaban versus warfarin in patients with rheumatic AF), which may have important implications in the management of patients with rheumatic mitral valve disease in both AF and sinus rhythm. Simplified coagulation pathways were presented to assist clinicians in making decisions in the face of the expanding number of locally available anticoagulants.

A masterclass was conducted on ventricular arrhythmia, including case-based discussion around a patient with ischaemic cardiomyopathy and ventricular tachycardia, focusing on work-up and management options with drugs and catheter ablation. The fellows-in-training were treated to a practical workshop on pacemaker implantation and the basics of cardiac electrophysiology.

Following presentations on supraventricular tachycardia management based on current international guidelines, Dr Mohamed Salim (Kenya) presented a pre-recorded case from the only electrophysiology laboratory with three-dimensional mapping capabilities in East and Central Africa (Mombasa, Kenya) where a patient with a manifest right-sided accessory pathway underwent successful ablation with a mapping system without fluoroscopy.

The birth of AFHRA

The opening ceremony of the meeting served as the official launch of AFHRA and was officiated by PASCAR president Saad Subahi, executive officer George Nel and interim president of AFHRA, Aime Bonny. This session invited an open discussion between clinicians, industry players, funders and healthcare advocates on multidimensional and collaborative strategies to improve access to arrhythmia care in Africa in alignment with the vision of AFHRA. Emphasis was placed on success stories of trans-national cardiology training under PASCAR’s training network. Dr Akwanalo, the first fellow to train under the PASCAR fellowship programme in South Africa, has subsequently implanted more than 120 pacemakers in rural Kenya in three years and gave his perspectives on the opportunities and challenges of establishing a pacemaker programme outside the capital of Kenya.

The meeting was attended by 217 specialists with an audience of healthcare practitioners of diverse cadres, including arrhythmologists from the five PASCAR regions, including Egypt (10), Algeria (one), Sudan (four), Nigeria (three), Ghana (one), Cameroon (three), Democratic Republic of Congo (one), Ethiopia (three), Rwanda (one), Tanzania (three), Uganda (two), Kenya (> 100), South Africa (four), Mauritius (one), and from North America, Europe and Asia. Although the majority of attendees were cardiologists, a substantial minority were nurses and allied healthcare professionals. Fellows-in-training comprised 15 attendees, mostly from Egypt, Kenya and Tanzania.

Perspective, opportunities and future directions

PASCAR-affiliated societies are the future of accessible, extensive and specialised cardiology services across Africa. They have great potential to foster training and advocacy, and to levy support from local and international stakeholders. Annual or other interval societal meetings are an invaluable forum to teach, connect, review performance and strategise for the future. AFHRA has determined to plan an annual Cardiorhythm Africa congress with expectations of increased visibility and successive increases in delegate numbers and representation of all African countries. The cardiorhythm meetings will serve as fora for annual review and evaluation of AFHRA’s activities, annual general meetings and for setting of key milestones and strategies.

The next Cardiorhythm Africa meeting will be held in 2021, with the venue to be announced in August 2020. The AFHRA scientific board agreed to maintain the current programme format of a syndrome-based approach but will introduce sessions for allied health professionals and non-cardiologists, and broaden workshops to provide a focus on diagnostic strategies for arrhythmia care in underserved parts of Africa and to build a referral network.

Conclusion

Cardiorhythm Africa 2020, the first meeting of AFHRA, was an ambitious project that met its objectives. Specifically, it created a pan-African conversation on access to arrhythmia care in Africa; allowed the creation of a pan-African arrhythmia network; facilitated the formation of the AFHRA executive council; and provided physicians with information on regional and international expertise with a view to developing referral links for both patient care and training. During the meeting we were able to conduct a more detailed and up-to-date survey of arrhythmia practice from all participating countries. Scientific sessions spanning resource-constrained arrhythmia management through to novel and advanced techniques created a framework for all of these successes. The programme design and objectives of Cardiorhythm Africa as an AFHRA launch meeting may provide a blueprint for other affiliate groups of PASCAR.