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Decentralized Heart Failure Management in Neno, Malawi
Bright G D Mailosi1, Todd Ruderman1, Sheila L Klassen2,3,4
1Partners In Health/Abwenzi Pa Za Umoyo, Neno, Malawi.
Insights
In rural Malawi, non-physician providers successfully used focused cardiac ultrasound (FOCUS) to diagnose and manage heart failure (HF), improving patient outcomes. This model shows promise for expanding healthcare access in resource-limited African settings.
Area of Science:
- Cardiology
- Public Health
- Global Health
Background:
- Cardiovascular disease (CVD) is a leading cause of mortality in Malawi.
- Heart failure (HF) care in rural Malawian districts is scarce and primarily managed by non-physicians.
- The specific causes and patient outcomes of HF in rural African populations remain largely uncharacterized.
Purpose of the Study:
- To describe the clinical characteristics, HF diagnostic categories, and patient outcomes in a rural Malawian setting.
- To evaluate the effectiveness of focused cardiac ultrasound (FOCUS) performed by non-physician providers for HF diagnosis and management.
- To assess the impact of this care model on patient symptoms and clinical status.
Main Methods:
- Non-physician healthcare providers utilized FOCUS for HF diagnosis and longitudinal follow-up in an outpatient chronic disease clinic in Neno, Malawi, from November 2018 to March 2021.
- A retrospective chart review analyzed HF diagnostic categories, changes in clinical status, and outcomes.
- Cardiologists reviewed all available ultrasound images for diagnostic confirmation.
Main Results:
- The study included 178 patients with HF (median age 67 years, 58% women), with a mean follow-up of 11.5 months; 78% were alive and receiving care.
- Hypertensive heart disease (36%), cardiomyopathy (26%), and rheumatic/valvular/congenital heart disease (12.3%) were the most common HF causes identified by ultrasound.
- At follow-up, the proportion of patients in New York Heart Association (NYHA) class I significantly increased from 24% to 50% (p < 0.001), with decreased symptoms of fluid overload and fatigue.
Conclusions:
- Hypertensive heart disease and cardiomyopathy are the primary drivers of HF in this elderly rural Malawian cohort.
- Trained non-physician providers can effectively manage HF, leading to improved symptoms and clinical outcomes in resource-limited settings.
- This care model offers a scalable solution to enhance healthcare accessibility for HF patients in other rural African regions.
Background:
Cardiovascular disease (CVD) is a major cause of death in Malawi. In rural districts, heart failure (HF) care is limited and provided by non-physicians. The causes and patient outcomes of HF in rural Africa are largely unknown. In our study, non-physician providers performed focused cardiac ultrasound (FOCUS) for HF diagnosis and longitudinal clinical follow-up in Neno, Malawi.
Objectives:
We described the clinical characteristics, HF categories, and outcomes of patients presenting with HF in chronic care clinics in Neno, Malawi.
Methods:
Between November 2018 and March 2021, non-physician providers performed FOCUS for diagnosis and longitudinal follow-up in an outpatient chronic disease clinic in rural Malawi. A retrospective chart review was performed for HF diagnostic categories, change in clinical status between enrollment and follow-up, and clinical outcomes. For study purposes, cardiologists reviewed all available ultrasound images.
Results:
There were 178 patients with HF, a median age of 67 years (IQR 44 - 75), and 103 (58%) women. During the study period, patients were enrolled for a mean of 11.5 months (IQR 5.1-16.5), after which 139 (78%) were alive and in care. The most common diagnostic categories by cardiac ultrasound were hypertensive heart disease (36%), cardiomyopathy (26%), and rheumatic, valvular or congenital heart disease (12.3%).At follow-up, the proportion of New York Heart Association (NYHA) class I patients increased from 24% to 50% (p < 0.001; 95% CI: 31.5 - 16.4), and symptoms of orthopnea, edema, fatigue, hypervolemia, and bibasilar crackles all decreased (p < 0.05).
Conclusion:
Hypertensive heart disease and cardiomyopathy are the predominant causes of HF in this elderly cohort in rural Malawi. Trained non-physician providers can successfully manage HF to improve symptoms and clinical outcomes in limited resource areas. Similar care models could improve healthcare access in other rural African settings.
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