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Atrial fibrillation in Sub-Saharan Africa: epidemiology, unmet needs, and treatment options
Bruce Sheldon Stambler1, Leonard M Ngunga2
1Department of Cardiac Electrophysiology, Piedmont Heart Institute Cardiology/Electrophysiology, Atlanta, GA, USA.
Insights
Atrial fibrillation (AF) in Sub-Saharan Africa presents a growing challenge with high mortality, often due to undertreatment with antithrombotics. Non-vitamin K antagonist oral anticoagulants (NOACs) show promise for improving stroke prevention in remote areas.
Area of Science:
- Cardiology
- Public Health
- Global Health
Background:
- Sub-Saharan Africa faces a "double burden" of disease, with rising lifestyle diseases like atrial fibrillation (AF) alongside persistent communicable diseases.
- AF prevalence is increasing in Africa, with patients tending to be younger and having a higher incidence of rheumatic valvular heart disease.
- Permanent AF is common, potentially due to limited use of rhythm control strategies, and high mortality rates are linked to poor healthcare access and suboptimal therapy.
Purpose of the Study:
- To review the current landscape of atrial fibrillation (AF) in Sub-Saharan Africa.
- To examine the challenges in AF management, including diagnosis, treatment barriers, and stroke risk.
- To explore the potential role of non-vitamin K antagonist oral anticoagulants (NOACs) in improving patient outcomes.
Main Methods:
- Literature review and synthesis of existing data on AF epidemiology and management in Sub-Saharan Africa.
- Analysis of treatment patterns, including the use of oral anticoagulants and barriers to care.
- Evaluation of the potential benefits and limitations of NOACs in the African context.
Main Results:
- AF patients in Africa are often younger with a higher prevalence of rheumatic valvular heart disease compared to other regions.
- High mortality rates in African AF patients are attributed to limited healthcare access and underutilization of antithrombotic therapies.
- Barriers such as cost and monitoring challenges limit the use of effective anticoagulation, particularly Vitamin K antagonists.
Conclusions:
- Sub-Saharan Africa faces a significant and growing burden of atrial fibrillation (AF) with high mortality.
- Improved access to care and optimized antithrombotic therapy, potentially including NOACs (excluding valvular AF), are crucial for reducing stroke risk and mortality.
- Further research into AF epidemiology and management strategies is essential to address the predicted rise in cardiovascular disease.
Abstract:
Health care in Sub-Saharan Africa is being challenged by a double burden of disease as lifestyle diseases common in the developed world, such as stroke and atrial fibrillation (AF), increase, while, simultaneously, health issues of the developing world in terms of communicable disease persist. The prevalence of AF is lower in Africa than in the developed world but is expected to increase significantly over the next few decades. Patients with AF in Africa tend to be younger and have a higher prevalence of rheumatic valvular heart disease than patients with AF in other regions. Permanent AF is the most prevalent type of AF in Africa, possibly due to the lower use of rhythm control strategies than in the developed world. Mortality rates of patients with AF in Africa are high, due largely to poor health care access and suboptimal therapy. The risk of stroke in AF, which is moderate to high in Africans as in the developed world, contributes to the high mortality rate. Patients with AF in Africa are often undertreated with antithrombotics, as cost and access to monitoring are major barriers. Vitamin K antagonists, including warfarin, are the most commonly available oral anticoagulants, but regular monitoring can be challenging, especially for patients in remote areas. Several non-vitamin K antagonist oral anticoagulants (NOACs) have been approved for use in countries across Sub-Saharan Africa and have the potential to reduce stroke burden. The higher cost of newer agents may be offset by the reduced need for regular monitoring, fixed dosing, and lower risk of intracranial bleeding; NOACs could provide a treatment option for patients in remote areas with limited access to regular monitoring. However, NOACs are not indicated in valvular AF. More work is needed to increase understanding of the epidemiology of AF and stroke, as well as to improve management strategies to reduce the burden of cardiovascular disease predicted for Africa.
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