Atrial fibrillation in Sub-Saharan Africa: epidemiology, unmet needs, and treatment options

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.

Keywords:

• stroke
• real-world treatment
• treatment guidelines
• barriers to care
• non-vitamin K antagonist oral anticoagulants

Acknowledgments

Professional medical writing and editorial assistance were provided by Nicole Draghi and Rosemary Perkins at Caudex Medical and were funded by Bristol–Myers Squibb Company and Pfizer Inc.

Disclosure

Dr Stambler has served on speakers bureaus for Pfizer Inc., Bristol–Meyers Squibb Company, Boehringer Ingelheim, and Janssen Pharmaceuticals. He has also consulted for Janssen Pharmaceuticals and has received financial support for publications from Pfizer Inc. and Bristol–Meyers Squibb Company. Dr Ngunga reports no conflicts of interest in this work.