title: A simplified echocardiographic strategy for heart failure diagnosis and management within an integrated noncommunicable disease clinic at district hospital level for sub-Saharan Africa.
abstract: OBJECTIVE
  This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda.
  
  
  BACKGROUND
  Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery.
  
  
  METHODS
  Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record.
  
  
  RESULTS
  In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up.
  
  
  CONCLUSIONS
  In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.
authors.affiliation: Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, Massachusetts.
authors.forename: Gene F
authors.initials: GF
authors.lastname: Kwan
authors.affiliation: Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Alice K
authors.initials: AK
authors.lastname: Bukhman
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts.
authors.forename: Ann C
authors.initials: AC
authors.lastname: Miller
authors.affiliation: Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Gedeon
authors.initials: G
authors.lastname: Ngoga
authors.affiliation: Department of Paediatrics, King Faisal Hospital, Kigali, Rwanda.
authors.forename: Joseph
authors.initials: J
authors.lastname: Mucumbitsi
authors.affiliation: Inshuti Mu Buzima, Rwinkwavu, Rwanda; Department of Internal Medicine, Endocrinology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda; Ministry of Health, Kigali, Rwanda.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Bavuma
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Symaque
authors.initials: S
authors.lastname: Dusabeyezu
authors.affiliation: Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Partners In Health, Boston, Massachusetts.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Rich
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Francis
authors.initials: F
authors.lastname: Mutabazi
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Cadet
authors.initials: C
authors.lastname: Mutumbira
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Jean Paul
authors.initials: JP
authors.lastname: Ngiruwera
authors.affiliation: Inshuti Mu Buzima, Rwinkwavu, Rwanda; Partners In Health, Boston, Massachusetts.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Amoroso
authors.affiliation: Partners In Health, Boston, Massachusetts.
authors.forename: Ellen
authors.initials: E
authors.lastname: Ball
authors.affiliation: Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts.
authors.forename: Hamish S
authors.initials: HS
authors.lastname: Fraser
authors.affiliation: Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Hirschhorn
authors.affiliation: Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts.
authors.forename: Paul
authors.initials: P
authors.lastname: Farmer
authors.affiliation: Inshuti Mu Buzima, Rwinkwavu, Rwanda; Ministry of Health, Kigali, Rwanda; Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Rusingiza
authors.affiliation: Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Ministry of Health, Kigali, Rwanda; Partners In Health, Boston, Massachusetts; VA Boston Healthcare System, Boston, Massachusetts. Electronic address: gbukhman@pih.org.
authors.forename: Gene
authors.initials: G
authors.lastname: Bukhman
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara; D003663:Decision Trees; D019033:Delivery of Health Care, Integrated; D004452:Echocardiography / Q000379:methods; D005260:Female; D006333:Heart Failure / Q000000981:diagnostic imaging* / Q000628:therapy*; D006767:Hospitals, District; D006801:Humans; D008297:Male; D012432:Rwanda
keywords: cardiomyopathy; epidemiology; global health; health policy; hypertensive heart disease; noncommunicable disease; rheumatic heart disease