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Objective : Few data are available on heart failure (HF) in sub-Saharan Africa. We aimed to provide a current picture of HF aetiologies in urban Uganda, access to heart surgery, and outcomes. Methods : We prospectively collected clinical and echocardiographic data from 272 consecutive patients referred for suspected heart disease to a tertiary hospital in Kampala during seven non-governmental organisation (NGO) missions from 2009 to 2013. We focused the analysis on 140 patients who fulfilled standardised criteria of HF by echocardiography. Results : Rheumatic heart disease (RHD) was the leading cause of HF in 44 (31%) patients. Among the 50 children included (age ≤ 16 years), congenital heart disease (CHD) was the first cause of HF (30 patients, 60%), followed by RHD (16 patients, 32%). RHD was the main cause of HF (30%) among the 90 adults. All 85 patients with RHD and CHD presented with an indication for heart surgery, of which 74 patients were deemed fit for intervention. Surgery was scheduled in 38 patients with RHD [86%, median age 19 years (IQR: 12-31)] and in 36 patients with CHD [88%, median age 4 years (IQR 1-5)]. Twenty-seven candidates (32%) were operated on after a median waiting time of 10 months (IQR 6-21). Sixteen (19%) had died after a median of 38 months (IQR 5-52); 19 (22%) were lost to follow up. Conclusions : RHD still represents the leading cause of HF in Uganda, in spite of cost-efficient prevention strategies. The majority of surgical candidates, albeit young, do not have access to treatment and present high mortality rates.

Summary The cause of endomyocardial fibrosis in Uganda remains unknown in spite of studies dating back to 1948. Herbal decoctions have been used by traditional healers for countless generations to treat many complaints, especially fever. We present evidence – ethnic, geographical, tribal, pathological and distribution by age – that the toxic herbal decoctions taken as medicines in Uganda can cause endomyocardial fibrosis.

SUMMARY The plasma level and percentage of bound cortisol were measured in sixteen African subjects with hypoproteinaemia of varying aetiologies. When compared with a control group it was found that the percentage of the steroid bound was significantly reduced but that the total cortisol level did not differ from that found in the control subjects. This resulted in a significant increase in the absolute level of free cortisol in the hypoproteinaemic subjects. Attention is drawn to the striking similarity between many of the physical and biochemical changes seen in kwashiorkor and those found in Cushing's syndrome.

Absolute eosinophil counts were assessed in 15 African patients with proven endomyocardial fibrosis. Though the mean eosinophil count in patients with endomyocardial fibrosis was higher compared with the normals reported from Kampala (1-13 vs 0.72X10(9)/1), the absolute range was comparable. A high percentage of patients with endomyocardial fibrosis had malarial parasites, high malarial antibody titres, hookworms, or strongyloides, but the correlation of eosinophilia to various parasitic infections was poor. Both eosinophilia and parasitic infections are common in the tropics and they effect patients with endomyocardial fibrosis no more than the population at large. Other aetiological factors, genetic, environmental, and immunological, are felt to be important in the causation of endomyocardial fibrosis in Uganda and evidence for this is reviewed. Though there is a similarity in pathological features, African endomyocardial fibrosis is a distinct entity from Loffler's endocarditis and cardiac lesions seen in eosinophilic leukaemia or reactive eosinophilia. There is no hard evidence to suggest that African endomyocardial fibrosis is a variant of Loffler's endocarditis caused by parasitic infections via eosinophilia.

M mode echocardiographic anteroposterior indexes of left ventricular function derived from long and short axis parasternal planes were compared in one hundred cases. In all the disease groups studied the paired values were within acceptable statistical limits of comparability and interchangeability; that is they were within two standard deviations of the mean difference in both directions. Values from either plane can usually be considered as being representative of the expected values for the individual.

This report describes nine cases of endomyocardial fibrosis occurring in four families. All patients came from Rwanda or South-western Uganda, and five had tropical splenomegaly syndrome as well. It seems likely that genetic as well as environmental factors are operative in the aetiology of endomyocardial fibrosis.

Atrial arrhythmias occurred in 34 out of 97 patients with endomyocardial fibrosis. In 21 instances, atrial fibrillation or flutter was persistent. In 13 cases, atrial arrhythmia was transient and intermittent. It was necessary, in some patients with rapid ventricular re sponses, to employ direct-current cardioversion. Because of the severity of endomyocardial fibrosis at the time of clinical observation, further deterioration at the onset of an atrial arrhythmia was not impressive.