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Rules of Thumb
Rules of thumb in Cardiology

Author's details

  • Dr.Khashau Eleburuike
  • MBBS (Ilorin), MSc. Global Health Karolinska Institute Sweden
  • Resident doctor in family medicine in the Northern region of Sweden.

Reviewer's details

  • Dr Isa Omokhudu Oboirien
  • (MBBS; MWACP; MRCP; FMCP) Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State.
  • Dalhatu Araf Specialist Hospital, Lafia, Nasarawa State.

Rules of thumb in Cardiology

Background

Cardiology in Sub-Saharan Africa poses unique challenges due to resource limitations and varying disease prevalence. Here are some essential rules of thumb that may assist in effective cardiology care in primary care settings in this region: 

  1. Comprehensive Clinical Assessment: Start with a detailed history and physical examination. Focus on identifying risk factors such as hypertension, diabetes, smoking family history of sudden death. In addition, history of rheumatic fever, during childhood which is prevalent in the Northern region of Nigeria.  
  2. Basic Diagnostic Tools: Utilize basic diagnostic tools judiciously. Blood pressure measurement, electrocardiography (ECG), and simple blood tests (e.g., glucose, cholesterol) are critical for diagnosing and managing cardiovascular conditions. Portable ultrasound devices can be valuable for echocardiography. 
  3. Early Detection and Management of Hypertension: Given the high prevalence of hypertension, prioritize early detection and management. Implement community screening programs and provide education on lifestyle modifications, such as dietary changes and physical activity. 
  4. Resource Optimization: Optimize the use of available resources by employing cost-effective treatments and protocols. Generic medications for hypertension, heart failure, and anticoagulation should be prioritized. 
  5. Management of Rheumatic Heart Disease (RHD): Focus on the prevention, early detection, and management of rheumatic fever and RHD. This includes antibiotic prophylaxis, managing heart valve damage (though few centers have capacity for this), and patient education to prevent recurrence. 
  6. Emergency Cardiac Care: Be prepared to manage common cardiac emergencies, such as acute coronary syndromes and heart failure exacerbations. Ensure that essential medications like aspirin, beta-blockers, and diuretics are readily available. 
  7. Lifestyle and Risk Factor Modification: Educate patients and communities about lifestyle modifications to reduce cardiovascular risk. This includes smoking cessation, healthy eating, and regular physical activity. 
  8. Community Engagement and Education: Engage communities in cardiovascular health promotion and education. Use culturally appropriate materials and methods to raise awareness about heart disease and its prevention. 
  9. Multidisciplinary Approach: Collaborate with other healthcare professionals, including nutritionists, endocrinologists, and nephrologists, to manage cardiovascular diseases comprehensively. 
  10. Follow-Up and Continuity of Care: Ensure regular follow-up for patients with chronic cardiovascular conditions. Utilize community health workers for home visits and followup reminders to improve adherence to treatment plans. 
  11. Cultural Sensitivity: Provide care that respects local cultural beliefs and practices. Engage with patients and their families to address any cultural concerns and ensure that care plans are acceptable and adhered to. 
  12. Preventive Cardiology: Focus on preventive cardiology by implementing community-based programs that address modifiable risk factors. Encourage regular health checkups and screenings. 

 

Rules of thumb
1. Prioritize Infectious Causes in Cardiac Symptoms
In sub-Saharan Africa, communicable diseases often play a significant role in cardiovascular issues. Rheumatic heart disease, HIV-related cardiomyopathy, and tuberculosis pericarditis are common. Any unexplained heart failure or cardiomegaly in a young patient should prompt a thorough evaluation for infectious causes, especially when there is a history of untreated or poorly managed infections.
Guidelines
WHO Guidelines for Rheumatic Heart Disease recommend early detection and management of streptococcal infections to prevent rheumatic heart disease (RHD). Penicillin prophylaxis should be administered to patients with a history of RHD. For HIV-associated cardiomyopathy, the South African Heart Association (SAHA) Guidelines recommend regular echocardiograms and management of underlying HIV with antiretroviral therapy (ART). WHO TB Guidelines suggest screening for tuberculosis pericarditis in patients presenting with pericardial effusion or heart failure symptoms in high TB-endemic areas.
2. Hypertension: Early Detection and Treatment
Hypertension is a leading cause of cardiovascular morbidity in sub-Saharan Africa, contributing to heart failure, stroke, and chronic kidney disease. A rule of thumb is to start screening adults from the age of 30 or earlier if there is a family history of hypertension. Early and aggressive management with affordable antihypertensive medications (ACE inhibitors, calcium channel blockers, and diuretics) can prevent complications.
Guidelines
The World Heart Federation (WHF) Guidelines recommend screening for hypertension starting at age 18 years and every 2 years, in patients with a family history of hypertension. WHO "Package of Essential NCD Interventions" (PEN) Guidelines promote using affordable medications like ACE inhibitors, diuretics, or calcium channel blockers, as first-line therapy for hypertension in low-resource settings. Task-shifting hypertension management to nurses or community health workers is encouraged to improve screening and follow-up rates.
3. Adapt Management to Resource Availability
Diagnostic tools such as echocardiograms, electrocardiograms (ECG), and cardiac catheterization may be unavailable or limited. Clinicians must rely heavily on clinical signs, basic investigations like chest X-rays and simple lab tests, and clinical scoring systems for decision-making. For example, in diagnosing heart failure, clinical assessment using the Framingham criteria or similar scoring systems may be more practical than relying on sophisticated diagnostics.
Guidelines
The WHO (PEN) Guidelines provide algorithms to manage cardiovascular disease (CVD) using minimal diagnostic tools. For example, the use of clinical scoring systems like the Framingham Risk Score is recommended to assess cardiovascular risk in low-resource settings. Where access to echocardiography is limited, the South African Heart Association suggests reliance on clinical signs and symptoms coupled with measuring natriuretic peptides for diagnosing heart failure.
4. Anticoagulation in Rheumatic Heart Disease (RHD)
Rheumatic heart disease remains a major cause of cardiovascular morbidity and mortality. Patients with atrial fibrillation, mitral stenosis, or mechanical valves due to RHD should receive anticoagulation therapy, usually with warfarin. Where INR monitoring is limited, it is essential to emphasize good adherence and routine clinical follow-up.
Guidelines
WHO Rheumatic Heart Disease Guidelines recommend anticoagulation with warfarin for patients with atrial fibrillation or mechanical valves due to RHD. Regular INR (International Normalized Ratio) monitoring should be done where possible. If unavailable, education on warfarin dosing and bleeding risk is essential. For patients in low-resource settings, penicillin prophylaxis should continue to prevent recurrent rheumatic fever.
5. Recognize and Treat Cardiomyopathies Early
Cardiomyopathy is a common condition, with idiopathic and HIV-related causes often encountered. Any patient presenting with dyspnea, pedal edema, and fatigue should be evaluated for cardiomyopathy. Early treatment with diuretics, ACE inhibitors, and beta-blockers can improve outcomes, particularly in resource-poor settings. In addition, birth control is key in the management of peripartum cardiomyopathy.
Guidelines
According to the South African HIV and Heart Disease Guidelines, patients on long-term ART should be screened for signs of cardiomyopathy. WHO Guidelines recommend treating cardiomyopathies with ACE inhibitors, betablockers, and diuretics when clinically indicated. Where available, regular echocardiography is recommended, but in its absence, clinicians should treat symptomatically based on clinical findings.
6. Emphasize Lifestyle Modifications in Cardiovascular Disease Prevention
Modifiable risk factors, including smoking, poor diet, physical inactivity, and alcohol abuse, contribute to cardiovascular disease (CVD) in sub-Saharan Africa. Community based interventions that promote healthy lifestyles are crucial. Educating patients on dietary changes, physical activity, and smoking cessation is essential, especially where medications may be costly or difficult to obtain.
Guidelines
The WHO Non-Communicable Disease (NCD) Guidelines stress community education programs focusing on reducing smoking, alcohol consumption, promoting a healthy diet, and increasing physical activity. The South African Hypertension Guidelines encourage incorporating these lifestyle changes into primary care interventions, with regular patient follow-up to track progress.
7. Sickle Cell Disease and Cardiovascular Complications
Sickle cell disease (SCD) is common in sub-Saharan Africa, and its complications, such as pulmonary hypertension and ischemic heart disease, should be anticipated. Any patient with SCD presenting with dyspnea or chest pain should be evaluated for potential cardiovascular complications. Management includes routine hydration, oxygen therapy, and, in severe cases, transfusion therapy to prevent vaso-occlusive crises that can lead to further cardiac damage.
Guidelines
The WHO Sickle Cell Disease Guidelines recommend regular screening for pulmonary hypertension and other cardiovascular complications in patients with sickle cell disease. Early treatment of cardiovascular symptoms in SCD includes hydroxyurea therapy to reduce sickling crises, hydration, and oxygen supplementation as first-line treatments. Periodic echocardiograms for patients with suspected pulmonary hypertension should be conducted where feasible.
8. Prompt Recognition of Acute Coronary Syndromes (ACS)
While the incidence of acute coronary syndromes is increasing due to rising rates of diabetes, obesity, and hypertension, the presentation of ACS in sub-Saharan Africa may differ from Western populations. Chest pain in older adults, particularly those with known risk factors, should be treated as ACS until proven otherwise. Given the challenges in accessing cardiac catheterization, thrombolytic therapy may be the initial treatment in resource-limited settings.
Guidelines
WHO Guidelines recommend the use of aspirin and beta-blockers in the acute setting, with follow-up statin therapy and ACE inhibitors to reduce recurrence.
9. Failure: Focus on Symptom Relief and Underlying Causes
Heart failure management in sub-Saharan Africa should prioritize symptomatic relief with diuretics and treatment of underlying causes (e.g., hypertension, RHD, or ischemic heart disease). ACE inhibitors, beta-blockers, and spironolactone should be used where available. Clinicians should also assess for reversible causes such as untreated infections or poorly controlled hypertension.
Guidelines
The African Heart Network Guidelines recommend early initiation of beta-blockers, ACE inhibitors, and diuretics for heart failure patients, focusing on treating underlying conditions like hypertension or rheumatic heart disease. Clinicians should follow WHO PEN protocols for managing heart failure, prioritizing the treatment of reversible causes such as poorly controlled hypertension or infection in some cases.
10. Electrolyte Monitoring in Diuretic Use
Patients on chronic diuretics (especially loop diuretics) should have regular monitoring of electrolyte levels, especially potassium and sodium. Where lab facilities are unavailable, close clinical monitoring for signs of electrolyte imbalance, such as weakness or arrhythmias, is critical.
Guidelines
The South African Heart Association Guidelines recommend regular electrolyte monitoring (potassium, sodium) for patients on loop diuretics, where lab facilities are available. In low-resource settings, clinical signs of electrolyte imbalance (e.g., muscle weakness, arrhythmias) should guide treatment adjustments, especially in the absence of laboratory facilities.
Conclusion

Cardiology in sub-Saharan Africa presents unique challenges due to the region’s diverse population, varying access to healthcare, and the prevalence of communicable and non-communicable diseases. Effective cardiovascular care requires specific guidelines and “rules of thumb” tailored to the region’s realities. These rules of thumb provide practical guidance for clinicians dealing with cardiovascular conditions. By following practical rules of thumb and adhering to region-specific guidelines, healthcare providers can improve outcomes for patients with cardiovascular. 

By adhering to these rules of thumb, alongside the recommended guidelines, clinicians in sub-Saharan Africa can effectively manage cardiovascular disease despite resource constraints. Early detection of infectious and non-communicable causes, proper use of available medications, and prioritizing lifestyle modifications are key elements of cardiovascular care in this region. 

Further readings
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  2. Obonyo, N.G., Etyang, A.O. Cardiovascular Health Priorities in Sub-Saharan Africa. SN Compr. Clin. Med. 5, 262 (2023). https://doi.org/10.1007/s42399-02301605-x
  3. Yuyun MF, Sliwa K, Kengne AP, Mocumbi AO, Bukhman G. Cardiovascular diseases in sub-Saharan Africa compared to high-income countries: an epidemiological perspective. Global heart. 2020;15(1).
  4. Lemogoum D, Seedat YK, Mabadeje AF, Mendis S, Bovet P, Onwubere B, Blackett KN, Lenfant C, Kabangu JR, Block P, Belhocine M. Recommendations for prevention, diagnosis and management of hypertension and cardiovascular risk factors in sub-Saharan Africa. Journal of hypertension. 2003 Nov 1;21(11):19932000.
  5. Amegah AK. Tackling the growing burden of cardiovascular diseases in subSaharan Africa: need for dietary guidelines. Circulation. 2018 Nov 27;138(22):2449-51.
  6. WHO. World Health Organization. Guideline on the prevention and management of acute rheumatic fever and rheumatic heart disease. Available at: https://cdn.who.int/media/docs/default-source/mca- documents/child/consultation/scope-guideline-rf-rhd.pdf Accessed 26 September 2024
  1. WHO consolidated guidelines on tuberculosis. Module 4: treatment – drugsusceptible tuberculosis treatment. ISBN 978-92-4-004812-6 Available at:  https://iris.who.int/bitstream/handle/10665/353829/9789240048126eng.pdf?sequence=1 2022. Accessed 26 September 2024
  2. Jeemon P, Séverin T, Amodeo C, Balabanova D, Campbell NRC, Gaita D, Kario K, Khan T, Melifonwu R, Moran A, Ogola E, Ordunez P, Perel P, Piñeiro D, Pinto FJ,  Schutte AE, Wyss FS, Yan LL, Poulter NR, Prabhakaran D. World Heart Federation Roadmap for Hypertension – A 2021 Update. Glob Heart. 2021 Sep 10;16(1):63.  doi: 10.5334/gh.1066. PMID: 34692387; PMCID: PMC8447967.
  3. World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 7 September 2020. Available at: https://www.who.int/publications/i/item/9789240009226  Accessed 26 September 2024
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