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Heart Disease in Uganda: Present and future

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Added 29th September 2016 10:15 AM

Heart disease represents a heterogenous group of diseases involving the heart and blood vessels. Diseases of the heart have been broadly categorized into congenital heart diseases) or acquired heart disease.

Emmyokello 703x422

Emmy Okello is a consultant cardiologist at the Uganda Heart Institute and General Secretary of the Uganda Heart Association

Heart disease represents a heterogenous group of diseases involving the heart and blood vessels. Diseases of the heart have been broadly categorized into congenital heart diseases) or acquired heart disease.

The recent wave of increasing diagnosis of heart disease among prominent Ugandans has caused a lot of anxiety among members of the public. In this series, “Heart Disease in Uganda: Past, Present, and Future”, I attempt to add historical context, describe our current situation, and highlight directions for future improvements.

Heart disease represents a heterogenous group of diseases involving the heart and blood vessels. Diseases of the heart have been broadly categorized into congenital heart diseases) or acquired heart disease.

Congenital heart disease is typically a problem with how the heart is put together – a hole or a tightness limiting blood flow.  People are born with congenital heart disease, though they may not know about it right at birth.   Acquired heart diseases on the other hand develop as one grows and interacts with the environment. Most have a genetic component – meaning that the diseases are more likely to affect members of a families or lineage.

Notably, these diseases also have a strong environmental aspect with infection, diet and/or lifestyle also impacting if an individual gets the disease. Examples include rheumatic heart disease, high blood pressure and coronary heart disease.

Present

The World Health Organization estimates the incidence of congenital heart disease to be stable at 1%.  This means that each year, 1 of every 100 babies born will have a heart defect.  The seriousness of these heart defects is variable.  Some are incompatible with life and children born with them will die soon after birth.  Some will present later in infancy and childhood with symptoms such as difficulty breathing and poor weight gain while some may never be detected, or may be detected by chance say-during a routine health visit.  

Unlike the congenital heart disease which has a stable incidence, the rates of acquired heart diseases change in response to environmental changes.  A decade ago coronary artery disease was not among the top 10 causes of heart disease in Uganda however today it is the 4th cause of heart disease in the country. The first being high blood pressure –which is also increasing steadily in the number affected, followed by rheumatic heart disease and diseases of the heart muscles.

Epidemiological transition is a phrase that describes the replacement of historical diseases like endomyocardial fibrosis, tuberculosis, and HIV-related heart diseases by those typically associated with high-income nations. These include; coronary artery disease, diabetes and hypertension.

The transition has been fostered by changes in our lifestyle and environment, such as decrease in exercise and increased consumption of unhealthy foods.

Nonetheless there have been improvements in our diagnostic capacity that have increased our ability to detect these diseases which was previously not possible.

When it comes down to the populace, there has been rapid urbanization which has resulted in more people moving from well-aerated dwellings in the countryside to overcrowded suburban dwellings.

Sadly, Rheumatic heart disease, a consequence of rheumatic fever caused by repeated throat infections caused by Group A streptococcus bacteria thrives in this environment. Consequently, we have seen cases of rheumatic fever and rheumatic heart disease go up from as low as 3.5% to 15%  in parts of the country.

Importantly the overcrowding has not been restricted to only homes but also schools especially the boarding primary ones. It is no wonder that the primary school going age group 5-15 years is the peak age affected by rheumatic fever.

Clinical care

In Uganda, 90% of heart diseases can now be diagnosed and treated. Many health facilities in the country provide basic diagnostic and treatment services for heart disease, and have protocols for referring patients with need to higher levels of care.

The Uganda Heart Institute has tertiary care facilities and highly trained cardiac staff.   Our ability to diagnose and treat patients with heart disease in Uganda has been rapidly growing.  We currently offer complex interventions to treat heart rhythm disorders (pacemaker implantation and programming), to treat acute heart attack and heart blockages (coronary angiography, percutaneous coronary interventions with stenting), and to treat some congenial heart diseases (surgical or catheter-based options).

Many of these procedures are aided by our state-of-the-art cardiac catheterization laboratory, which allows for intervention without surgery, or opening the chest thereby reducing pain and speeding recovery.  We estimate that less than 10% of patients with heart disease now require a referral for out-of-country care.

Knowledge of our advancement and expertise is spreading. Patients from Rwanda, Burundi, Kenya and DR Congo filter in for advanced heart care in Uganda. This is a reverse to the previous trend where Ugandan citizens were the ones that needed out-of-country expertise.

Research efforts

We are also rapidly increasing our knowledge about the causes, prevention, and treatment of heart disease in Uganda.  While most historical research on cardiovascular disease has focused on HIV- and tuberculosis related topics, new research is focused on rheumatic heart disease, coronary artery disease, and hypertension.  Recent efforts led by Makerere University’s College of Health sciences, the Uganda Heart Institute, the Uganda Cancer Institute and the Medical Research Council Uganda  have begun to answer important questions around non-communicable diseases, including heart disease, pertaining the local population.

Currently our research has shown that rheumatic fever and rheumatic heart disease is driven by overcrowding but there are chances that a strong genetic factor may play a role. We are currently looking for more genetic factors that may play a role with an aim of early screening and targeted preventive treatment.

We are also characterizing high blood pressure and coronary artery disease to better understand the local drivers of these important heart diseases. Efforts are also underway to understand what role salt plays in the development of high blood pressure in our environment.

We are also in early stages of conducting research looking at a relationship between HIV and heart disease, and heart disease and cancer. All in all more work needs to be done to investigate the drivers of hypertension, coronary artery disease and stroke over the life course, in our setting.

The future

There is no doubt that the number of people diagnosed with heart disease will continue to rise as we experience lifestyle changes, live longer, and improve diagnosis. Management of heart diseases is expensive, and research and clinical strategies should focus on prevention.

To detect congenital heart disease, we advise that you must ensure that your baby is examined by the midwife, medical officer or a neonatologist soon after birth. This simple procedure ensures that 70% of heart defects at birth are detected.

For the acquired heart diseases, I can’t over emphasize the need for routine physical exercise and healthy diet. Adults over the age of 40 years should start routine annual wellness checks and have their heart, kidney, and liver function assessed atleast once every two years or more frequently if a problem is detected.

Although the state of heart disease in Uganda looks gloomy currently, there is light at the end of the tunnel.  The Uganda Heart Institute is dedicated to improving cardiovascular care and diagnosis in Uganda.

We are leading the way with educational programming aimed at increasing community education and awareness about the causes of heart disease. This is in addition to the establishment of regional centers of excellence, to bring high-quality diagnostics and care to all regions of the country.

There are also continuous efforts to improving our own education, skills, and facilities to provide state-of-the-art cardiac services in our country.

Conclusively, we are at the cutting edge of research aimed at decreasing the burden of cardiovascular disease and improving outcomes in Uganda, and around the world.

The writer is a consultant cardiologist at the Uganda Heart Institute and General Secretary of the Uganda Heart Association

 

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