Collaboration attempts to establish research capacity for ambulatory rhythm monitoring in sub-Saharan Africa

A recent study published in JACC: Clinical Electrophysiology has placed emphasis on the importance of building research capacity for ambulatory rhythm monitoring in sub-Saharan Africa, where such services are currently scarce. Conducted in collaboration with the University of California San Francisco (UCSF), Weill Cornell Medicine (New York, USA) and Cardiomatics, the study can be seen to provide reassurance to human immunodeficiency virus (HIV) patients on stable antiretroviral therapy (ART), having observed a low incidence of arrhythmias. Researchers believe the study also underscores the need for partnerships between academia, industry and healthcare to expand access to artificial intelligence (AI)-powered digital signal analysis solutions.

“To scale up electrophysiologic services and allocate resources for the management of arrhythmias in sub-Saharan Africa, high-quality studies are needed to determine the incidence of arrhythmia and identify high-risk populations,” the analysis’ authors state, writing in JACC: Clinical Electrophysiology. “Collaborations between researchers, clinicians and industry are needed to facilitate equitable access to ambulatory rhythm monitoring. Creative repurposing of devices that are commonly used in research studies may be necessary; in this study, the devices were borrowed from an ongoing study of sleep in people living with HIV.”

The authors of this research—a cross-sectional analysis from a comparative patient cohort—initially note that there is an increasingly recognised burden of cardiovascular disease, yet limited-to-no access to electrophysiology services, in sub-Saharan Africa. They further highlight the fact that the majority of published studies describing arrhythmia are cross-sectional analyses of electrocardiographs (ECGs) that include no ambulatory rhythm monitoring data.

Against this backdrop—and the fact that HIV infection is a known risk factor for arrhythmia—researchers set out to determine the prevalence of atrial fibrillation (AF) and flutter using 24-hour ambulatory rhythm monitoring in a comparative cohort of adults living with and without HIV in Northwestern Tanzania. In addition, they sought to establish the research capacity for ambulatory rhythm monitoring in this region.

“We conducted a cross-sectional analysis of ambulatory rhythm monitoring data from an ongoing prospective cohort of cardiovascular disease,” the authors detail. “People living with HIV and HIV-uninfected community controls were recruited from Bugando Medical Centre, a tertiary care centre in Mwanza, Tanzania. A total of 478 people living with HIV and 487 consecutively enrolled community controls underwent one day of rhythm monitoring with a single-lead Actiheart 5 ECG (CamNtech) and activity recorder between 1 April 2022 and 1 May 2023. Recordings were analysed using Cardiomatics, a cloud-based AI software package. All 965 recordings were screened for AF and atrial flutter; the first 100 recordings (59 people living with HIV) underwent complete signal analysis.”

The analysis revealed a median age of 44 years and a 70% proportion of female patients across the cohort at the time of ambulatory rhythm monitoring. The authors also report that 95% of those living with HIV were on stable ART, and had suppressed viral loads and high CD4 cell counts. In addition, age, sex, socioeconomic status, hypertension, tobacco and alcohol use were found to be generally similar between people living with HIV and community controls.

“All 965 signals were successfully analysed. The median percentage of high-quality signal was 89%,” the researchers write in JACC: Clinical Electrophysiology. “The overall burden of arrhythmia was low among the 965 adults who underwent screening; only one case of AF was identified. There were no other arrhythmias detected. The participant diagnosed with AF was 64 years of age, HIV-infected, and had a history of hypertension.”

There were no arrhythmias in the subset of the first 100 participants enrolled who underwent complete signal analysis, and, furthermore, there was no difference in the number of pauses or burden of supraventricular ectopy and ventricular ectopy between people living with HIV and community controls, according to the present analysis. The authors describe the latter finding and the low overall burden of clinical arrhythmia they observed as “encouraging”. However, they do concede that their data stem from an “admittedly limited” duration of monitoring.

“Previously, in the USA, HIV has been associated with a higher risk of AF—particularly among those with advanced immunosuppression with low CD4 counts and high viral loads—yet limited data exist from sub-Saharan Africa,” the authors add. “Many HIV clinicians have been concerned that there might be a substantial burden of undiagnosed arrhythmia in people living with HIV in Africa.

“Our findings from a cohort of middle-aged adults living with HIV on stable ART are reassuring. Although this cohort does reflect the population commonly seen in HIV clinics in East Africa, we do acknowledge that it may not reflect higher-risk patients living with undiagnosed or uncontrolled HIV, or those with other known risk factors for arrhythmia (for example, advanced age, active substance use, established cardiovascular disease).”

A key, closing message delivered by the researchers is that ambulatory rhythm monitoring remains “practically unavailable” in sub-Saharan Africa, despite being a key diagnostic tool. They also state that, “as modern ambulatory rhythm monitors and wearable devices become increasingly available, concentrated efforts should be made to provide equitable access to modern digital signal analyses, including AI-powered methods”, citing the fact that the typical price of analysing a 24-hour recording currently ranges from at least 5–10 times the daily wage of the average Tanzanian.

“The research team involved in this study is excited to continue working toward improving global access to high-quality diagnostics and therapeutics for cardiovascular diseases,” said Cody Cichowitz (UCSF, San Francisco, USA), speaking to Cardiac Rhythm News. “Collaborations like this are one example of ways to advance that mission.”

“We are honoured to collaborate with esteemed institutions like UCSF and Weill Cornell Medicine to advance research in ambulatory rhythm monitoring in sub-Saharan Africa,” added Cardiomatics chief executive officer Rafal Samborski. “This partnership underscores our commitment to leveraging AI-driven ECG analysis to enhance cardiovascular care in regions where it is most needed.”