Decentralized Heart Failure Management in Neno, Malawi

Abstract

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.

Keywords: Focused cardiac ultrasound; Heart Failure; Malawi; Task-shifting.

Figure 1

Map of Malawi illustrating the location of Neno district in relation to the two major urban areas and Neno’s two major health facilities where PEN-Plus clinics are located.

Figure 2

Heart failure protocol for initial diagnosis and management used by non-physician providers in PEN-Plus clinic in Neno, Malawi. Providers use focused cardiac ultrasound and follow the flow on the left-hand side of the protocol to determine a diagnostic category and management. The right-sided boxes guide management based on the diagnosis made.

Figure 3

Central Illustration: Retention in care, New York Heart Association (NYHA) class improvement, and HF categories among patients managed by non-physician clinicians in Neno, rural Malawi.