Implementation strategies to improve outcomes in patients with established cardiovascular disease in sub-Saharan Africa: A systematic review

TL;DR

This review identifies gaps in implementing cardiovascular disease treatments in sub-Saharan Africa, especially in acute care and lower-level healthcare settings.

Contribution

The study systematically reviews implementation strategies for CVD management in sub-Saharan Africa, highlighting critical gaps in acute care and pharmacotherapeutic interventions.

Findings

Most studies focused on cardiac rehabilitation and post-discharge strategies, with few addressing acute care.

There is a lack of implementation strategies for ischaemic heart disease in hospitalised patients.

Few studies targeted healthcare workers or organisations, and primary care settings were largely overlooked.

Abstract

Sub-Saharan Africa (SSA) is experiencing an epidemic of cardiovascular disease (CVD). Despite numerous evidence-based therapies and management guidelines for patients with acute or established CVD, significant gaps persist in their implementation in SSA. This systematic review aims to describe, synthesise and identify key gaps in the implementation strategies of evidence-based approaches that can improve clinical outcomes for patients with acute or established CVD in SSA. We searched four databases for studies that examined the implementation strategies of evidence-based interventions for patients with acute or established CVD in SSA. Studies that did not focus on interventions were excluded. The primary outcome was major adverse cardiovascular events including myocardial infarction, stroke, cardiovascular death or hospitalisation. Secondary outcomes included adherence to treatment, improvement in modifiable risk factors, symptom measures, treatment complications, and psychosocial metrics, particularly those related to quality of life. Nineteen studies met the inclusion criteria (nine evaluated patients with heart failure, three evaluated heart failure or ischaemic heart disease, three evaluated ischaemic heart disease, and four evaluated stroke). Of the 19 studies, 14 were targeted at healthcare recipients, two at healthcare workers and three at the healthcare organisation. The most common interventions evaluated were in the field of cardiac rehabilitation. Only three studies (two evaluating stroke and one heart failure) implemented an intervention in the acute setting with the rest evaluating strategies at discharge or in the ambulatory population. No studies evaluated implementation strategies in hospitalised patients with ischaemic heart disease. This study highlights significant gaps in the implementation of interventions in patients with established cardiovascular disease. Gaps were highlighted in the acute care setting, specifically related to cardiac pathologies and implementation strategies targeting pharmacotherapeutic optimisations. We also highlight a notable lack of studies focusing on effective implementation strategies in primary care facilities and lower-level hospital settings.

The protocol was registered in PROSPERO prior to the study implementation (ID: CRD42023465781). The protocol can be accessed at crd.york.ac.uk/PROSPERO/display_record.php?RecordID=465781

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