Knowledge, Attitude, and Practice of Heart Failure Management by Physicians Practicing in Cardiology Services in Kinshasa, Democratic Republic of the Congo ()
1. Introduction
For more than five decades, the role of hypertension in the development of heart failure (HF) has been known [1]. In sub-Saharan Africa, a growing number of clinical studies have shown a high prevalence of HF among adult patients in hospital settings [2]-[4]. In most countries, hypertension is by far the most frequent comorbidity associated with HF. Hypertension was associated with 30% to 50% of HF cases in Cameroon [5] [6], 35% of cases in a multi-center study of 1294 patients in Mozambique, Nigeria, South Africa, Sudan, and Uganda [7], 42.2% to 45% of cases in Tanzania [8]-[10], 42.8% of cases in Togo [11], 45.4% of cases among 1006 HF patients observed in 9 countries [12], 48.6% to 78.5% of cases in Nigeria [13]-[15], and with 50.3% of cases in Burkina Faso [16].
In the Democratic Republic of the Congo (DRC), one study assessed the comorbidities associated with HF in 231 patients managed during hospitalizations (n = 159) or in outpatient consultations (n = 72) from November 2014 to September 2016 in Lubumbashi, the second largest city in the DRC [17]. Dilated cardiomyopathies were the most frequent comorbidity associated with HF, found in 47.6% of cases (n = 110), a frequency strikingly similar to the 40% to 54% reported in the neighboring Rwanda [18] [19]. Hypertension was associated with just 4.3% of HF cases (n = 10) in this Lubumbashi series [17]. In Mbuji Mayi, a 2-week in-hospital mortality for hypertension-related morbidities was 22.2% compared to 8.9% in-hospital mortality for non-hypertension-related causes (p < 0.001) [20].
Kinshasa, the capital and the largest city of the DRC with a population of 16 million [21], has a prevalence of hypertension estimated at 30.9% in 2008 [22], increasing from 13.2% twenty-four years earlier [23]. In addition, 42% of patients prescribed anti-hypertensive medication do not adhere to treatment, and 77.5% have uncontrolled hypertension [24]. Despite the existence of these published reports [21]-[24], the risks of cardiovascular complications associated with high blood pressure in Kinshasa are less well characterized [20] [25]. The contribution of hypertension to the development of HF [5]-[17] is consequently unknown. In fact, the prevalence of HF in hospital settings in Kinshasa, its clinical characteristics, its management by local clinicians, its cost to the health care system and to society, are currently unknown.
To begin to gain an understanding of the current state of HF in Kinshasa, we started by surveying physicians who practice medicine in cardiology services in the city to assess their knowledge and to describe their attitude and practice of HF management among adult patients.
2. Methods
2.1. Survey Design
In April 2022, a trained interviewer visited all Kinshasa hospitals and healthcare facilities where cardiology services are provided to adult patients to meet all providers of those services. The interviewer introduced the purpose of the survey research to each provider, solicited their voluntary participation, and answered all their questions regarding the study and their participation. At the end of the meeting, the interviewer gave each provider a copy of a consent form and the survey questionnaire for them to take home, complete and sign at their pace. The survey questionnaire was pilot tested by two cardiologists who did not participate in the study as research subjects. These two cardiologists provided input that was incorporated in the final version to improve its clarity and simplicity of expression.
2.2. Administrative and Ethical Considerations
No payment was provided to respondents as compensation for their time of participation in this study. Providers were given sufficient time before the interviewer returned to their offices to collect the signed consent form and the completed survey questionnaire. Both documents were written in French and were approved by the Ethics Committee of the School of Public Health, Faculty of Medicine, Kinshasa University. One co-Author (MJN) translated the completed questionnaire into English for this report.
2.3. Variables of Interest
Knowledge: The following topics assessed providers’ knowledge of HF, its diagnosis and management according to published guidelines of the European Society of Cardiology (ESC) [26] [27]: recommendations and classifications of HF; its symptoms, signs, and diagnosis; HF and atrial fibrillation (AF) and overall HF management and prevention; treatment recommendations for HF with reduced left ventricular ejection fraction (LVEF) (HFrEF) and for HF with preserved LVEF (HFpEF); acute HF (AHF) and multidisciplinary interventions for the management of chronic HF (CHF); and recommendations for managing comorbidities in HF.
Attitude: The following topics described providers’ attitude towards HF and its management in the DRC: their perception of the in-hospital prevalence of HF in Kinshasa; their perception of morbidities leading to HF in Kinshasa; their self-assessment of their level of satisfaction with HF management in Kinshasa; their perceived role of some selected factors in the non-optimal management of HF; their perceived level of importance of some selected factors in improving HF management in the DRC; and their self-assessment of the degree of influence that some selected factors have on their cardiology practice.
Practice: The following topics described the practice of HF management among respondents: how often they utilize the Framingham criteria to clinically diagnose HF; how often they utilize the classes of the New York Heart Association (NYHA) to describe the functional signs of HF; the diagnostic means they generally utilize to identify HF; any national or international guidelines to which they refer to in their standard practice; and whether they also refer to the guidelines of the ESC for their management of HF [26] [27].
2.4. Survey Respondents
A total of 46 questionnaires were distributed, of them 38 (82.6%) were returned. Of these 38 respondents, 14 (36.8%), all males, were cardiologists and 24 (63.2%) practiced medicine in cardiology services as general practitioners.
2.5. Statistical Analysis
Data were entered into a Microsoft Access database and analyzed by SPSS statistical software (IBM SPSS Statistics 25). All data were recorded on a nominal scale, summarized by descriptive statistics procedures, and reported as percentages. Knowledge, attitude, and practice of HF management were reported separately between cardiologists (n = 14) and general practitioners (n = 24). Chi-square tests were used for all comparisons. Significance level was set at p < 0.05. All tests were two-tailed.
3. Results
3.1. Knowledge of HF, Its Diagnosis and Management According to Published Guidelines of the ESC (Tables 1-5)
The knowledge of recommendations and classifications of HF along with the knowledge of its symptoms, signs and diagnosis are shown in Table 1. Significantly more cardiologists than general practitioners knew that there are no national guidelines for the management of HF for the DRC (92.9% vs. 47.8%, respectively; p = 0.004), and that at the time this study was conducted, the most recent ESC guidelines were published in 2021 (92.9% vs. 45.5%, respectively; p = 0.008). There were no significant differences between cardiologists and general practitioners in the knowledge that the ESC still utilized the classes of the NYHA to characterize the functional severity of HF (p = 0.140), that for the ESC, classification of HF by echocardiography determines disease management (p = 0.283), and in the knowledge of the current ESC classification of HF by the LVEFs and the EFs thresholds (p ≥ 0.059).
Except for significantly more cardiologists than general practitioners knowing that the ambulatory diagnosis of HF can also be made by testing B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) (85.2% vs. 20.8% respectively; p < 0.0001), the knowledge that ambulatory diagnosis of HF can also be made by echocardiography, that the LVEF is influenced by medical treatment and by resynchronization, and the knowledge of ESC indicators that lead to the diagnosis of HFpEF were not distributed significantly differently between the two groups (p ≥ 0.059) (Table 1).
Table 1. Knowledge of recommendations, classifications, symptoms, signs, and diagnosis of heart failure (HF) according to the European Society of Cardiology (ESC).
Variable |
Cardiologists |
General Practitioners |
p value* |
Recommendations and classifications |
|
|
|
There are no national HF management guidelines for the Democratic Republic of the Congo, n = 37 |
13 (92.9%) |
11 (47.8%) |
0.004 |
The most recent ESC guidelines were published in 2021, n = 36 |
13 (92.9%) |
10 (45.5%) |
0.008 |
The ESC still utilizes the classes of the New York Heart Association to characterize the functional severity of HF, n = 36 |
12 (92.3%) |
18 (78.3%) |
0.140 |
Classification by echocardiography determines HF management |
14 (100.0%) |
21 (87.5%) |
0.283 |
The current ESC classification of HF: HF with reduced ejection fraction, HF with moderately reduced ejection fraction, and HF with preserved ejection fraction |
11 (78.6%) |
14 (58.3%) |
0.294 |
Thresholds for classifying HF by the EFLV |
|
|
|
HF with reduced ejection fraction (HFrEF): EF ≤ 40% |
13 (92.9%) |
18 (75.0%) |
0.227 |
HF with moderately reduced ejection fraction (HFmrEF), EF: 41% - 49% |
13 (92.9%) |
15 (62.5%) |
0.059 |
HF with preserved ejection fraction (HFpEF), EF ≥ 50% |
13 (92.9%) |
15 (62.5%) |
0.059 |
Symptoms, signs, and diagnosis of HF |
|
|
|
The ambulatory diagnosis of HF is made by |
|
|
|
Echocardiography |
13 (92.9%) |
15 (62.5%) |
0.059 |
Testing of BNP or NT-proBNP |
12 (85.2%) |
5 (20.8%) |
<0.0001 |
The ejection fraction of the left ventricle (EFLV) is influenced by |
|
|
|
medical treatment, n = 34 |
14 (100.0%) |
20 (100.0%) |
- |
resynchronization, n = 23 |
11 (91.7%) |
8 (72.7%) |
0.317 |
Indicators that lead to the diagnosis of HF with preserved ejection fraction |
|
|
Symptoms or signs of heart failure, n = 33 |
13 (100.0%) |
18 (90.0%) |
0.508 |
An EFLV greater or equal to 50%, n = 33 |
14 (100.0%) |
18 (94.7%) |
1.00 |
A BNP or NT-proBNP above normal thresholds (BNP >35 pg/ml;
NT-proBNP > 125 pg/ml), n = 26 |
11 (100.0%) |
15 (100.0%) |
- |
A functional structural abnormality, n = 21 |
8 (80.0%) |
9 (81.8%) |
1.00 |
*Boldface denotes a statistically significant difference.
In Table 2, the knowledge that atrial fibrillation (AF) is the most frequently associated arrhythmia in HF, that HF contributes to the development of AF and AF can be a triggering factor of HF, that the advent of AF in a patient with chronic HF is associated with worse prognosis and decompensation, that in AF the ESC guideline includes opting for a restauration of sinus rhythm by electrical or pharmacological cardioversion, and the knowledge that oral anticoagulants are associated with fewer hemorrhagic accidents, particularly intra-cranial accidents, were not distributed significantly differently between cardiologists and general practitioners (p ≥ 0.171). However, significantly more cardiologists than general practitioners knew that in AF, the ESC guidelines remind that one considers reducing heart rate with a beta-blocker as first-choice and digoxin as second choice, and that oral anticoagulants are at least as effective as Vitamin K antagonists, (p = 0.008 and p < 0.0001, respectively; Table 2).
To preserve cardiac function, reduce or decelerate the risk towards HF, or to prevent death before the onset of symptoms, the ESC guidelines recommend considering the actions listed in Table 2: revascularization of infarctions, management of rhythm disturbances, treatment of hypertension, moderation in alcohol consumption, utilization of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes, physical activity, statins in primary or secondary prevention, angiotensin-converting enzyme inhibitors (ACEIs) in systolic dysfunction, and beta-blockers in asymptomatic systolic dysfunction after a myocardial infarction. Except for the knowledge of moderation in alcohol consumption and of the utilization of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes that significantly more cardiologists than general practitioners possessed (p = 0.023 and p = 0.044, respectively), the knowledge of all the other recommended actions were not distributed significantly differently between cardiologists and general practitioners (p ≥ 0.115).
In Table 3, the knowledge of the ESC treatment recommendations for HFrEF (LVEF ≤ 40%) and for HFpEF (LVEF ≥ 50%) is shown. Significantly more cardiologists than general practitioners knew that mineralocorticoid receptor antagonists (78.6% vs. 25.0%, respectively; p = 0.001), ACEIs and angiotensin receptor-neprilysin inhibitors (ARNIs) (100.0% vs. 70.8%, respectively; p = 0.033), and sodium glucose co-transporter 2 inhibitors (85.7% vs. 20.8%, respectively; p < 0.0001) are first-choice recommended treatment of HFrEF. The distribution of the knowledge that beta-blockers are first-choice treatment of HFrEF was not significantly different between cardiologists (71.4%) and general practitioners (50.0%) (p = 0.082).
Except for the knowledge of the second-choice therapeutic class recommended in the treatment of HFrEF in patient in sinus rhythm, EF ≤ 35% and heart rate ≥ 75 beats per minute which significantly more cardiologists than general practitioners possessed (If channel inhibitor; p < 0.0001), the knowledge of other therapeutic classes and treatment options based on patient condition was not distributed significantly differently between cardiologists and general
Table 2. Knowledge of Atrial fibrillation (AF) and of heart failure (HF) prevention per the European Society of Cardiology (ESC) guidelines.
Variable |
Cardiologists |
General Practitioners |
p value* |
Atrial fibrillation (AF) |
|
|
|
AF is the most frequently associated arrhythmia in HF, n = 37 |
13 (92.9%) |
17 (73.9%) |
0.171 |
HF contributes to the development of AF and AF can be a triggering
factor of HF, n = 37 |
14 (100.0%) |
22 (95.7%) |
1.00 |
The advent of AF in a patient with chronic HF is associated with
worse prognosis and decompensation, n = 37 |
14 (100.0%) |
22 (95.7%) |
1.00 |
In AF, the ESC guidelines remind to consider, n = 38 |
|
|
|
A reduction of heart rate using a beta-blocker as first-choice and digoxin as second choice |
12 (85.7%) |
10 (41.7%) |
0.008 |
Opting for a restauration of sinus rhythm by electrical or pharmacological cardioversion (amiodarone) |
11 (78.6%) |
16 (66.7%) |
0.488 |
Oral anticoagulants are at least as effective as Vitamin K antagonists, n = 36 |
14 (100.0%) |
8 (36.4%) |
<0.0001 |
Oral anticoagulants are associated with fewer hemorrhagic accidents,
particularly intra-cranial, n = 36 |
12 (85.7%) |
15 (68.2%) |
0.432 |
Delaying or preventing the development of overt heart failure (HF) or
preventing death before onset of symptoms |
|
|
|
To preserve cardiac function, reduce or decelerate the risk toward HF,
the following actions can be considered as appropriate, n = 38 |
|
|
|
Revascularization of infarctions |
11 (78.6%) |
15 (62.5%) |
0.472 |
Management of rhythm disturbances |
14 (100.0%) |
20 (83.3%) |
0.276 |
Treat arterial hypertension |
14 (100.0%) |
21 (87.5%) |
0.283 |
Recommend moderation in alcohol consumption |
10 (71.4%) |
8 (33.3%) |
0.023 |
Recommend utilization of sodium-glucose co-transporter 2 inhibitors in type 2 diabetics (EMPA-REG trial) |
10 (71.4%) |
9 (37.5%) |
0.044 |
Recommend physical activity |
13 (92.9%) |
16 (66.7%) |
0.115 |
Utilize statins in primary or secondary prevention |
5 (35.7%) |
13 (54.2%) |
0.272 |
Utilize converting enzyme inhibitors in systolic dysfunction |
12 (85.7%) |
19 (79.2%) |
1.00 |
Utilize beta-blockers in asymptomatic systolic dysfunction
following myocardial infarction |
11 (78.6%) |
16 (66.7%) |
0.488 |
*Boldface denotes a statistically significant difference.
practitioners (p ≥ 0.051).
The knowledge of the ESC treatment recommendations for HFpEF was similarly distributed between cardiologists and general practitioners (p ≥ 0.140) (Table 3).
The knowledge of major clinical presentations and of urgent therapeutic management of AHF in the ESC guidelines and the knowledge of multidisciplinary
Table 3. Knowledge of the European Society of Cardiology (ESC) treatment recommendations of heart failure (HF) with reduced left ventricular ejection fraction (HFrEF: LVEF ≤ 40%) and of HF with preserved left ventricular ejection fraction (HFpEF: LVEF ≥ 50%).
Variable |
Cardiologists |
General Practitioners |
p value* |
Heart failure with reduced ejection fraction (HFrEF) |
|
|
|
First-choice therapeutic classes recommended in the treatment of HFrEF |
|
|
|
Mineralocorticoid receptor antagonists |
11 (78.6%) |
6 (25.0%) |
0.001 |
Beta-blockers |
10 (71.4%) |
12 (50.0%) |
0.082 |
Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor-neprilysin inhibitors (ARNIs) |
14 (100.0%) |
17 (70.8%) |
0.033 |
Sodium glucose co-transporter 2 inhibitors or Glifozines |
12 (85.7%) |
5 (20.8%) |
<0.0001 |
Second-choice therapeutic classes recommended in the treatment of HFrEF based on patient condition |
|
|
|
Diuretics in veinous congestion |
9 (64.3%) |
11 (45.8%) |
0.272 |
Angiotensin 2-receptor antagonists in intolerance of ACEIs and of ARNIs |
12 (85.7%) |
16 (66.7%) |
0.268 |
If channel inhibitor in sinus rhythm, EF ≤ 35%, heart rate ≥ 75 beats per minute |
13 (92.9%) |
5 (20.8%) |
<0.0001 |
Digitalis in rapid ventricular rate despite first-choice optimal treatment |
10 (71.4%) |
11 (45.8%) |
0.181 |
An implantable defibrillator should be considered in ischemic cardiopathy patients with HFrEF, n = 34 |
11 (78.6%) |
13 (65.0%) |
0.365 |
Cardiac resynchronization should be considered in HFrEF patients in/with, n = 35 |
|
|
|
Sinus rhythm, left bundle branch block, QRS ≥ 150 ms |
7 (50.0%) |
10 (47.6%) |
0.051 |
Sinus rhythm, left bundle branch block, QRS ≥ 130 - 149 ms |
7 (50.0%) |
5 (23.8%) |
|
Heart failure with preserved ejection fraction (HFpEF) |
|
|
|
HFpEF treatment is primarily preventive, n = 28 |
11 (91.7%) |
11 (68.8%) |
0.140 |
To date, no treatment has demonstrated a reduction in patient mortality and morbidity, n = 29 |
6 (46.2%) |
10 (62.5%) |
0.251 |
Preventive treatment of HFpEF aims at controlling hypertension, n = 28 |
12 (100.0%) |
14 (87.5%) |
0.492 |
Symptomatic treatment of HFpEF resorts to diuretics to control congestive signs, n = 30 |
12 (100.0%) |
16 (88.9%) |
0.343 |
Weight reduction in obese patients improves patient outcome, n = 29 |
13 (100.0%) |
16 (100.0%) |
- |
Physical exercise improves symptomatology, n = 30 |
12 (92.3%) |
13 (76.5%) |
0.379 |
*Boldface denotes a statistically significant difference.
interventions for the management of CHF are presented in Table 4. Significantly more cardiologists than general practitioners knew that acute pulmonary oedema (92.9% vs. 58.3%, respectively; p = 0.030) and cardiogenic choc (92.9% vs. 45.8%, respectively; p = 0.004) are major clinical presentations of AHF, and that vasopressors (92.9% vs. 41.7%, respectively; p = 0.002) and inotropes (57.1% vs. 20.8%, respectively; p = 0.035) may be utilized in AHF based on patient condition. The knowledge of team management interventions for the prevention and treatment of CHF was not distributed significantly differently between cardiologists and general practitioners (p ≥ 0.354).
Table 4. Knowledge of major clinical presentations and urgent therapeutic management of acute heart failure (AHF) in the European Society of Cardiology (ESC) guidelines and knowledge of multidisciplinary interventions for the management of chronic heart failure (CHF).
Variable |
Cardiologists |
General Practitioners |
p value* |
Acute heart failure (AHF) |
|
|
|
Major clinical presentations of AHF |
|
|
|
acute pulmonary oedema |
13 (92.9%) |
14 (58.3%) |
0.030 |
cardiogenic choc |
13 (92.9%) |
11 (45.8%) |
0.004 |
acute decompensated heart failure |
5 (35.7%) |
9 (37.5%) |
0.912 |
isolated right ventricular failure |
6 (42.9%) |
6 (25.0%) |
0.296 |
Urgent therapeutics that may be utilized based on the type of AHF |
|
|
|
oxygen therapy |
14 (100.0%) |
20 (83.3%) |
0.276 |
diuretics |
13 (92.9%) |
18 (75.0%) |
0.227 |
ventilatory support (non-invasive ventilation) |
12 (85.7%) |
14 (58.3%) |
0.147 |
vasodilators (nitrates) |
11 (78.6%) |
15 (62.5%) |
0.472 |
vasopressors |
13 (92.9%) |
10 (41.7%) |
0.002 |
inotropes |
8 (57.1%) |
5 (20.8%) |
0.035 |
Multidisciplinary interventions for the management of chronic heart failure (CHF) |
|
|
|
ESC guidelines strongly insist on the importance of etiologic diagnosis to adapt disease management, n = 34 |
12 (92.3%) |
17 (81.0%) |
0.354 |
Patients with HF must be encouraged to actively participate in the management of their disease, n = 36 |
14 (100.0%) |
22 (100.0%) |
- |
A good life hygiene and physical exercise are recommended to improve the quality of life and reduce hospitalizations, n = 35 |
14 (100.0%) |
19 (90.5%) |
0.506 |
ESC guidelines urge that all patients have access to a HF multidisciplinary management plan to ensure that the condition is correctly diagnosed and followed up, n = 36 |
13 (92.9%) |
20 (90.9%) |
0.580 |
*Boldface denotes a statistically significant difference.
Table 5 shows the knowledge of the ESC recommendations for managing comorbidities in HF. For cardiovascular comorbidities, we assessed AF and severe aortic stenosis; for non-cardiovascular comorbidities, we assessed type 2 diabetes and anemia. For the management of patients with HF who present with AF, more cardiologists than general practitioners knew that beta-blockers are preferably recommended for the control of heart rate (85.7% vs. 50.0%, respectively; p = 0.028), that digoxin is utilized when heart rate remains high despite beta-blockers utilization or when beta-blockers are contraindicated (78.6% vs. 45.8%, respectively; p = 0.049), that a cardioversion is recommended in emergency with rapid heart rate and hemodynamic instability (100.0% vs. 70.8%, respectively; p = 0.033)
Table 5. Knowledge of the European Society of Cardiology (ESC) recommendations for managing comorbidities in heart failure (HF).
Variable |
Cardiologists |
General Practitioners |
p value* |
Cardiovascular comorbidities |
|
|
|
For the management of patients with HF who present with an atrial
fibrillation (AF) |
|
|
|
An anticoagulant treatment is recommended in CHA2DS2-VASc score ≥ 2 in men and ≥ 3 in women |
8 (57.1%) |
11 (45.8%) |
0.501 |
Direct-acting oral anticoagulants are preferred over Vitamin K antagonists, except in case of mitral stenosis or of mechanical heart prosthetic valves |
12 (85.7%) |
16 (66.7%) |
0.268 |
For the control of heart rate, it is recommended to preferably
utilize beta-blockers |
12 (85.7%) |
12 (50.0%) |
0.028 |
A digoxin is utilized when the ventricular rate remains high despite
beta-blockers utilization or when beta-blockers are contraindicated |
11 (78.6%) |
11 (45.8%) |
0.049 |
A cardioversion is recommended in an emergency with rapid ventricular
rate and hemodynamic instability |
13 (92.9%) |
11 (45.8%) |
0.004 |
A cardioversion is recommended in AF and persistence of symptoms of
HF despite optimal treatment |
11 (78.6%) |
10 (41.7%) |
0.027 |
In addition to an oral anticoagulant, a strategy of rhythm control including catheter ablation should be considered in patients whose symptoms and/or cardiac dysfunction are associated with AF |
14 (100.0%) |
7 (29.2%) |
<0.0001 |
For the management of severe aortic stenosis |
|
|
|
A surgical treatment is recommended |
7 (50.0%) |
11 (45.8%) |
0.804 |
A percutaneous implantation of an aortic valve is recommended |
11 (78.6%) |
9 (37.5%) |
0.014 |
Non-cardiovascular comorbidities |
|
|
|
Recommended treatment in patients with type 2 diabetes who develop HF
are sodium-glucose co-transporter 2 inhibitors |
13 (92.9%) |
15 (62.5%) |
0.059 |
Management of anemia in patients with HF |
|
|
|
Patients must be periodically screened for anemia and iron deficiency |
12 (85.7%) |
18 (75.0%) |
0.684 |
An iron supplementation with ferric carboxymaltose should be considered in symptomatic patients with LVEF < 45% and iron deficiency |
10 (71.4%) |
9 (37.5%) |
0.044 |
An iron supplementation with ferric carboxymaltose should be considered in symptomatic HF patients recently hospitalized for HF with LVEF < 50% and iron deficiency |
7 (50.0%) |
8 (33.3%) |
0.311 |
*Boldface denotes a statistically significant difference.
or with persistence of symptoms of HF despite optimal treatment (78.6% vs. 41.7%, respectively; p = 0.027), and that in addition to oral anticoagulation, a strategy of rhythm control including catheter ablation should be considered in patients whose symptoms and/or cardiac dysfunction are associated with AF (100.0% vs. 29.2%, respectively; p < 0.0001).
For the management of severe stenosis, significantly more cardiologists (78.6%) than general practitioners (37.5%) knew that a percutaneous implantation of an aortic valve is recommended (p = 0.014), but as many cardiologists (50.0%) as general practitioners (45.8%) knew that surgical treatment is also recommended (p = 0.804).
For non-cardiovascular comorbidities, there were 92.9% of cardiologists and 62.5% of general practitioners who knew that the recommended treatment in patients with type 2 diabetes who develop HF are sodium-glucose co-transporter 2 inhibitors (p = 0.059).
For the management of anemia in patients with HF, 85.7% of cardiologists and 75.0% of general practitioners knew that patients must be periodically screened for anemia and iron deficiency (p = 0.684), 71.4% of cardiologists and 37.5% of general practitioners knew that an iron supplementation with ferric carboxymaltose should be considered in symptomatic patients with LVEF < 45% and iron deficiency (p = 0.044), and 50.0% of cardiologists and 33.3% of general practitioners knew that an iron supplementation with ferric carboxymaltose should be considered in symptomatic HF patients recently hospitalized for HF with LVEF < 50% and iron deficiency (p = 0.311).
3.2. Attitude of Providers towards HF and Its Management
in the DRC (Table 6)
Most providers do not know the in-hospital prevalence of HF in Kinshasa (cardiologists: 46.2%; general practitioners: 55.6%; p = 0.203), but almost all perceive that this unknown prevalence tends to increase (cardiologists: 100.0%; general practitioners: 91.3%; p = 0.517).
Nearly three quarters think that hypertension is the leading morbidity of HF in Kinshasa (cardiologists: 71.4%; general practitioners: 70.8%; p = 1.00), but they think other morbidities including cardiomyopathies, ischemic cardiopathies, AF, and valvular cardiopathies contribute as well. Only one third thinks rheumatism is a leading morbidity of HF in Kinshasa (cardiologists: 35.7%; general practitioners: 37.5%; p = 0.912).
Their level of satisfaction with how HF is managed is low: 61.5% of cardiologists and 62.5% of general practitioners are less, or not much, satisfied with how HF is managed.
Respondents mostly agreed that lack of health insurance in the DRC (cardiologists: 100.0%; general practitioners: 87.0%; p = 0.275), patients lack of financial means (cardiologists: 92.9%; general practitioners: 95.7%; p = 1.00), lack of equipment in health centers (cardiologists: 78.6%; general practitioners: 90.9%; p = 0.357), deficiency in continuing medical education (cardiologists: 85.7%; general
Table 6. Attitude of providers towards heart failure (HF) and its management in the Democratic Republic of the Congo (DRC).
Variable |
Cardiologists |
General
Practitioners |
p value* |
In-hospital prevalence of HF in Kinshasa is, n = 31 |
|
|
|
4% - 9% |
1 (7.7%) |
2 (11.1%) |
0.203 |
10% - 20% |
3 (23.1%) |
2 (11.1%) |
|
21% - 40% |
3 (23.1%) |
1 (5.6%) |
|
41% - 75% |
0 (0.0%) |
3 (16.7%) |
|
Don’t know |
6 (46.2%) |
10 (55.6%) |
|
In-hospital prevalence of HF in Kinshasa tends to, n = 37 |
|
|
|
Increase |
14 (100.0%) |
21 (91.3%) |
0.517 |
Remain the same/Don’t know |
0 (0.0%) |
2 (8.7%) |
|
Primary morbid entity leading to HF in Kinshasa, n = 38 |
|
|
|
Arterial hypertension |
10 (71.4%) |
17 (70.8%) |
1.00 |
Cardiomyopathies |
2 (14.3%) |
5 (20.8%) |
1.00 |
Ischemic cardiopathy |
2 (14.3%) |
5 (20.8%) |
1.00 |
Atrial fibrillation/Valvular cardiopathy/Rheumatism |
0 (0.0%) |
5 (20.8%) |
0.137 |
Morbidities leading to in-hospital HF in Kinshasa, n = 38 |
|
|
|
Arterial hypertension |
13 (92.9%) |
23 (95.8%) |
1.00 |
Cardiomyopathies |
14 (100.0%) |
19 (79.2%) |
0.137 |
Ischemic cardiopathy |
13 (92.9%) |
17 (70.8%) |
0.216 |
Atrial fibrillation |
12 (85.7%) |
16 (66.7%) |
0.268 |
Valvular cardiopathy |
10 (71.4%) |
14 (58.3%) |
0.420 |
Rheumatism |
5 (35.7%) |
9 (37.5%) |
0.912 |
Level of satisfaction in HF management, n = 37 |
|
|
|
Very satisfied/satisfied |
5 (38.5%) |
9 (37.5%) |
1.00 |
Less satisfied/Not much satisfied |
8 (61.5%) |
15 (62.5%) |
|
Role of the following factors in the non-optimal HF management |
|
|
|
The lack of health insurance in the DRC, n = 37 |
|
|
|
Strongly agree/Agree |
14 (100.0%) |
20 (87.0%) |
0.275 |
Somewhat agree/Don’t agree |
0 (0.0%) |
3 (13.0%) |
|
Patients lack financial means, n = 37 |
|
|
|
Strongly agree/Agree |
13 (92.9%) |
22 (95.7%) |
1.00 |
Somewhat agree/Don’t agree |
1 (7.1%) |
1 (4.3%) |
|
The lack of equipment in health centers, n = 36 |
|
|
|
Strongly agree/Agree |
11 (78.6%) |
20 (90.9%) |
0.357 |
Somewhat agree/Don’t agree |
3 (21.4%) |
2 (9.1%) |
|
Deficiency in continuing medical education, n = 35 |
|
|
|
Strongly agree/Agree |
12 (85.7%) |
15 (71.4%) |
0.431 |
Somewhat agree/Don’t agree |
2 (14.3%) |
6 (28.6%) |
|
Deficiency in physicians training, n = 35 |
|
|
|
Strongly agree/Agree |
11 (78.6%) |
12 (57.1%) |
0.282 |
Somewhat agree/Don’t agree |
3 (21.4%) |
9 (42.9%) |
|
Patients lack adherence to care for other than financial reasons, n = 34 |
|
|
|
Strongly agree/Agree |
9 (64.3%) |
11 (55.0%) |
0.588 |
Somewhat agree/Don’t agree |
5 (35.7%) |
9 (45.0%) |
|
Level of importance to improve HF management in the DRC |
|
|
|
Generalization of health mutuals, n = 38 |
|
|
|
Very important/Important |
14 (100.0%) |
20 (83.3%) |
0.276 |
Somewhat/Less important |
0 (0.0%) |
4 (16.7%) |
|
Management of care by the State, n = 36 |
|
|
|
Very important/Important |
12 (85.7%) |
20 (90.9%) |
0.634 |
Somewhat/Less important |
2 (14.3%) |
2 (9.1%) |
|
Reinforcement of providers’ competencies, n = 38 |
|
|
|
Very important/Important |
13 (92.9%) |
20 (83.3%) |
0.633 |
Somewhat/Not much important |
1 (7.1%) |
4 (16.7%) |
|
Organization of patients’ education in therapies, n = 37 |
|
|
|
Very important/Important |
12 (85.7%) |
18 (78.3%) |
0.687 |
Somewhat/Less important |
2 (14.3%) |
5 (21.7%) |
|
Improvement of basic hospital infrastructures, n = 37 |
|
|
|
Very important/Important |
13 (92.9%) |
17 (73.9%) |
0.217 |
Somewhat/Less/Not much important |
1 (7.1%) |
6 (26.1%) |
|
Maintenance of a national HF registry, n = 35 |
|
|
|
Very important/Important |
10 (71.4%) |
11 (52.4%) |
0.260 |
Somewhat/Less/Not much important |
4 (28.6%) |
10 (47.6%) |
|
Granting credits to liberal professionals for the acquisition of materials,
n = 36 |
|
|
|
Very important/Important |
10 (71.4%) |
11 (50.0%) |
0.204 |
Somewhat/Less/Not much important |
4 (28.6%) |
11 (50.0%) |
|
Industries to lease medical equipment to hospitals/liberal cabinets, n = 36 |
|
|
|
Very important/Important |
11 (78.6%) |
4 (18.2%) |
<0.0001 |
Somewhat/Less/Not much important |
3 (21.4%) |
18 (81.8%) |
|
Evaluate the degree of influence of the following factors in your practice |
|
|
Personal experience, n = 36 |
|
|
|
A lot |
7 (50.0%) |
10 (45.5%) |
0.790 |
Enough/Little |
7 (50.0%) |
12 (54.5%) |
|
Professional experience, n = 34 |
|
|
|
A lot |
8 (57.1%) |
6 (30.0%) |
0.113 |
Enough/Little |
6 (42.9%) |
14 (70.0%) |
|
Internet, n = 34 |
|
|
|
A lot |
6 (42.9%) |
8 (40.0%) |
0.868 |
Enough/Little |
8 (57.1%) |
12 (60.0%) |
|
Medical Journals, n = 34 |
|
|
|
A lot |
6 (42.9%) |
7 (35.0%) |
0.643 |
Enough/Little/Very little |
8 (57.1%) |
13 (65.0%) |
|
Meetings, continuing medical education, n = 36 |
|
|
|
A lot |
7 (50.0%) |
6 (27.3%) |
0.166 |
Enough/Little/Very little |
7 (50.0%) |
16 (72.7%) |
|
*Boldface denotes a statistically significant difference.
practitioners: 71.4%; p = 0.431), deficiency in physicians training (cardiologists: 78.6%; general practitioners: 57.1%; p = 0.282), and patients lack of adherence to care for reasons other than financial (cardiologists: 64.3%; general practitioners: 55.0%; p = 0.588), play a role in the non-optimal management of HF in the DRC.
To improve management of HF in the DRC, respondents mostly agreed on the importance of generalizing health mutuals (cardiologists: 100.0%; general practitioners: 83.3%; p = 0.276), management of care by the State (cardiologists: 85.7%; general practitioners: 90.9%; p = 0.634), reinforcement of providers’ competencies (cardiologists: 92.9%; general practitioners: 83.3%; p = 0.633), organization of patients’ education in therapies (cardiologists: 85.7%; general practitioners: 78.3%; p = 0.687), improvement of basic hospital infrastructures (cardiologists: 92.9%; general practitioners: 73.9%; p = 0.217), maintenance of a national HF registry (cardiologists: 71.4%; general practitioners: 52.4%; p = 0.260), granting credits to liberal professionals for the acquisition of materials (cardiologists: 71.4%; general practitioners: 50.0%; p = 0.204), and industries to lease medical equipment to hospitals and to liberal cabinets (cardiologists: 78.6%; general practitioners: 18.2%; p < 0.0001).
Most cardiologists thought that their professional experience influenced their practice a lot (57.1%). The influence of personal experience, the internet, medical Journals, and meetings and other continuing education activities on their practice was deemed by most providers as enough to little.
3.3. Practice of HF Management in Kinshasa (Table 7)
The Framingham criteria to diagnose HF clinically was always utilized by 53.8% of cardiologists and 18.2% of general practitioners (p = 0.057), and almost all providers always utilized the classes of the NYHA to describe the functional signs
Table 7. Practice of heart failure (HF) management in Kinshasa, Democratic Republic of the Congo.
Variable |
Cardiologists |
General Practitioners |
p value* |
How often do you utilize the Framingham criteria to diagnose HF? n = 35 |
|
|
|
Always |
7 (53.8%) |
4 (18.2%) |
0.057 |
Sometimes/Never |
6 (46.2%) |
18 (81.8%) |
|
How often do you utilize the classes of the NYHA to describe the functional signs of HF? n = 38 |
|
|
|
Always |
13 (92.9%) |
22 (91.7%) |
1.00 |
Sometimes |
1 (7.1%) |
2 (8.3%) |
|
Diagnostic means you generally utilize to identify HF |
|
|
|
Echocardiography, n = 38 |
|
|
|
Always |
13 (92.9%) |
17 (70.8%) |
0.216 |
Very often/Sometimes |
1 (7.1%) |
7 (29.2%) |
|
Electrocardiogram, n = 35 |
|
|
|
Always |
9 (69.2%) |
11 (50.0%) |
0.267 |
Very often/Sometimes |
4 (30.8%) |
11 (50.0%) |
|
Dosage of BNP or NT-proBNP, n = 37 |
|
|
|
Always |
6 (42.9%) |
6 (26.1%) |
0.470 |
Very often/Sometimes/Very rarely |
8 (57.1%) |
17 (73.9%) |
|
Chest X-ray, n = 36 |
|
|
|
Always |
2 (14.3%) |
4 (18.2%) |
1.00 |
Very often/Sometimes/Very rarely |
12 (85.7%) |
18 (81.8%) |
|
National or international guidelines to which you refer to in your standard practice |
|
|
|
Of the European Society of Cardiology |
14 (100.0%) |
20 (83.3%) |
0.276 |
Of the French Society of Cardiology |
10 (71.4%) |
9 (37.5%) |
0.044 |
Of the American Heart Association |
9 (64.3%) |
7 (29.2%) |
0.034 |
Of your institution (Health Center) |
0 (0.0%) |
5 (20.8%) |
0.137 |
Of the Congolese Society of Cardiology |
0 (0.0%) |
5 (20.8%) |
0.137 |
Of the Canadian Society of Cardiology |
1 (7.1%) |
1 (4.2%) |
1.00 |
Of the Belgian Society of Cardiology |
1 (7.1%) |
0 (0.0%) |
0.368 |
Do you (also) refer to the guidelines of the European Society of Cardiology (ESC) for the management of HF? |
|
|
|
Yes |
14 (100.0%) |
22 (95.7%) |
1.00 |
Medium used to access them |
|
|
|
Internet |
11 (78.6%) |
17 (70.8%) |
0.715 |
Scientific Journals |
11 (78.6%) |
8 (33.3%) |
0.007 |
Continuing Medical Education |
7 (50.0%) |
11 (45.8%) |
0.804 |
Staff meeting |
6 (42.9%) |
10 (41.7%) |
0.943 |
International scientific meeting |
12 (85.7%) |
3 (12.5%) |
<0.0001 |
National scientific meeting |
2 (14.3%) |
4 (16.7%) |
1.00 |
From colleagues |
0 (0.0%) |
5 (20.8%) |
0.137 |
*Boldface denotes a statistically significant difference.
of HF (cardiologists: 92.9%; general practitioners: 91.7%; p = 1.00).
The diagnostic means generally utilized to identify HF always included echocardiography for 92.9% of cardiologists and 70.8% of general practitioners (p = 0.216), electrocardiogram for 69.2% of cardiologists and 50.0% of general practitioners (p = 0.267), dosage of BNP or NT-proBNP for 42.9% of cardiologists and 26.1% of general practitioners (p = 0.470), and chest X-ray for 14.3% of cardiologists and 18.2% of general practitioners (p = 1.00).
All cardiologists (100.0%) and 83.3% of general practitioners (p = 0.276) refer to guidelines of the ESC in their standard practice, and significantly more cardiologists than general practitioners also refer to guidelines of the French Society of Cardiology (71.4% vs. 37.5%, respectively; p = 0.044) and of the American Heart Association (64.3% vs. 29.2%, respectively; p = 0.034). Significantly more cardiologists than general practitioners access these guidelines via scientific Journals (78.6% vs. 33.3%, respectively; p = 0.007) and attendance in international scientific meetings (85.7% vs. 12.5%, respectively; p < 0.0001).
4. Discussion
Unlike in other sub-Saharan African countries, there is no registry of cardiovascular diseases in the DRC that can be monitored and analyzed to elucidate the patterns of HF in local populations [5]-[19]. This study was therefore designed to begin to gain an understanding of the current state of HF in Kinshasa from descriptions that clinicians who deliver cardiology health services to adult patients in the city could provide. Their descriptions are quite informative.
The fact that there are no national guidelines for the management of HF for the DRC was known by almost all cardiologists (92.9%) but only by less than half of general practitioners (47.8%). HF management in Kinshasa cannot follow national guidelines that do not exist; it may only follow guidelines of international learned societies. The international learned society that influences practice of local providers most per the respondents’ self-reports is the ESC. Providers reported also referring to guidelines of the French Society of Cardiology and of the American Heart Association. However, all cardiologists reported referring to the ESC guidelines in their standard practice [26] [27]; they indicated accessing them electronically, but more significantly than general practitioners, through subscriptions to scientific Journals and attendance to international scientific meetings [28].
The overall knowledge of the ESC guidelines for the diagnosis and treatment of acute and chronic HF [26] [27] among cardiologists was very good, but more needs to be done to improve that knowledge among general practitioners. For example, there was a significant difference between cardiologists and general practitioners in the knowledge of HF management of patients with iron deficiency (71.4% vs. 37.5%, respectively; p < 0.044) and a borderline significant difference in the knowledge of management of patients with type 2 diabetes who develop HF (92.9% vs. 62.5%, respectively; p < 0.059). Both conditions, iron deficiency and poorly controlled type 2 diabetes, are highly prevalent in Kinshasa [29] [30]. The need for improvement was expressed by a general agreement among respondents that a deficiency in continuing medical education was a factor in the non-optimal management of HF (85.7% of cardiologists and 71.4% of general practitioners), and by the importance they attached to reinforcement of providers’ competencies to improve HF management in the DRC (92.9% of cardiologists and 83.3% of general practitioners) [31].
Respondents’ perception of cardiovascular morbidities that contribute to the development of HF in Kinshasa is consistent with registry-based published studies in sub-Saharan Africa. Where hypertension was the comorbidity most frequently associated with HF in most countries [5]-[16], dilated cardiomyopathies were the most frequent comorbidity in HF patients in Rwanda, associated with 40% to 54% of cases [18] [19], with frequencies of 19% to 35.4% in Cameroon [5], Tanzania [8], Nigeria [15], and Burkina Faso [16]. Valve disease was the most frequent comorbidity in HF patients in Ethiopia, associated with 40.8% of cases [32], with frequencies of 11.9% to 18.1% of cases in Cameroon [5], Tanzania [10] and Togo [11]. Ischemic cardiopathies were associated with 62% of HF cases in Djibouti [33] and 15.8% of cases in Ethiopia [32]. HF was attributed to rheumatism in 25% to 27% of cases in Rwanda [18] [19] and 12% to 13% of cases in Tanzania [8] and Djibouti [33].
In general, respondents were less satisfied with HF management in the DRC. They agreed that factors contributing to the non-optimal management of HF were financial (lack of health insurance, patients lacking financial means), structural (lack of equipment in health centers), and organizational (deficiency in continuing medical education, deficiency in physicians training, and patients lacking adherence to care for reasons other than financial). In these financial, structural, and organizational factors were contained what respondents deemed important to improve HF management in the DRC: generalization of health mutuals and management of care by the State; improvement of basic hospital infrastructures, industries to lease medical equipment to hospitals/liberal cabinets; reinforcement of providers’ competencies, organization of patients’ education in therapies, maintenance of a national HF registry, granting credits to liberal professionals for the acquisition of materials.
The information obtained in this study concerning the practice of HF management does not necessarily reflect what respondents do. This study therefore does not address adherence to published international guidelines [28] [34]-[36], which is a limitation that can only be addressed by a retrospective chart review study. Its strength, however, is in paving the way toward setting up a research agenda for starting the as yet non-existing work of systematically studying HF in Kinshasa. This work should probably begin with the establishment of a national HF registry for the DRC [5]-[19].
Acknowledgements
The Authors would like to thank all the physicians who participated in this study and Professors Désiré Mashinda Kulimba and Jean-René M'buyamba-Kabangu for their invaluable contribution in protocol development. The assistance of Frederick Wumba, MD, with data collection is also gratefully acknowledged.