Prevalence of Cardiovascular Complications in Malaria: A Systematic Review and Meta-Analysis

Abstract

Recent studies have suggested that malaria may affect the cardiovascular system. The aim of this systematic review and meta-analysis was to determine the prevalence of cardiovascular complications in symptomatic malaria patients. We searched databases such as Pubmed, Embase, Cochrane, and Web of Science (January 1950-April 2020) for studies reporting on cardiovascular complications in adults and children with malaria. Cardiovascular complications were defined as abnormalities in electrocardiogram (ECG), cardiac biomarkers, and echocardiography on admission or during outpatient examination. Studies of patients with known heart disease or cardiovascular evaluation performed after the start of intravenous antimalarial medication were excluded. The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) (No.: CRD42020167672). The literature search yielded 1,243 studies, and a total of 43 studies with symptomatic malaria patients were included. Clinical studies (n = 12 adults; n = 5 children) comprised 3,117 patients, of which a majority had Plasmodium falciparum (n = 15) and were diagnosed with severe malaria (n = 13). In random-effects models of adults, the pooled prevalence estimate for any cardiovascular complication was 7% (95% CI: 5-9). No meta-analysis was conducted in children, but the range of abnormal ECG was 0-8%, cardiac biomarkers 0-57%, and echocardiography 4-9%. We analyzed 33 cases (n = 10 postmortem), in which the most common cardiovascular pathologies were myocarditis and acute coronary syndrome. All histopathological studies found evidence of parasitized red blood cells in the myocardium. Cardiovascular complications are not uncommon in symptomatic adults and children with malaria. Additional studies investigating malaria and cardiovascular disease are encouraged.

Figure 1.

Flowchart. Flowchart of included studies in the systematic review and meta-analysis.

Figure 2.

Meta-analysis of cardiovascular complications. Forest plot for random-effects meta-analysis displaying the proportions and pooled estimate for having cardiovascular complications. Subgroup meta-analysss are conducted for abnormal electrocardiogram, biomarkers, and echocardiography. Solid black lines indicate the prevalence estimate for each included study. Red dashed line indicates the pooled prevalence estimate for any cardiovascular complication. This figure appears in color at www.ajtmh.org.

Figure 3.

Cumulated incidence of malaria cases and cardiovascular death. Cumulated reporting of malaria cases (blue) and cardiovascular death (orange) according to time period. Data are from the included case reports and series of cases. This figure appears in color at www.ajtmh.org.