2024 Kenya National Guidelines for CVD Management PDF

KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 2024 KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Developed by the Division of Non-Communicable Diseases - Ministry of Health Copyright 2024 Ministry of Health Any part of this document...

KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 2024 KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Developed by the Division of Non-Communicable Diseases - Ministry of Health Copyright 2024 Ministry of Health Any part of this document may be freely reviewed quoted, reproduced or translated in full or in part so long as the source is acknowledged. It is not for sale or for us in commercial purposes. Enquiries regarding the Kenya National Guidelines for Cardiovascular Diseases Management should be addressed to the: Division of Non-communicable Diseases, Ministry of Health P. O. Box 30016 – 00100 Nairobi, Kenya Telephone: +254 202717077/+254202722599 Email: [email protected] Website: www.health.go.ke  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES FOREWORD The Kenyan government is dedicated to attaining Universal Health Coverage (UHC) as guided by the Sustainable Development Goal Agenda 3.8 and the constitutional right to achieve the highest standards of care for all Kenyan citizens. This commitment is anchored on strengthening four key pillars, including human resources for health, health financing, health products and technology, and the strategic utilization of digital technologies. Additionally, the government has committed to strengthening primary healthcare, prioritizing a strategic shift from a focus on curative to preventive and promotive health services, thereby enhancing the nation’s ability to proactively address the health needs of all citizens. Non-communicable diseases (NCDs), particularly cardiovascular diseases such as hypertension, have been prioritized in these initiatives. The Kenya Health Policy 2014-2030, the Ministry of Health’s roadmap for achieving the constitutional goal, places a high priority on tackling the escalating burden of non-communicable diseases (NCDs). These diseases, which currently account for 41% of all deaths in Kenya, are not just health issues but also significant barriers to social and economic development. To combat this growing NCD burden, the Ministry of Health has formulated the National Strategic Plan for the Prevention and Control of Non-communicable Diseases 2021/22-2025/26, with a target of reducing premature NCD-related deaths, including cardiovascular diseases (CVDs), by one-third. Given that cardiovascular diseases (CVDs) are a leading cause of mortality, it is imperative to implement comprehensive strategies to mitigate their impact on individuals, families, and communities. The second edition of the Kenya Cardiovascular Disease Guidelines serves as a comprehensive framework for proactive prevention, diagnosis, treatment, and management of cardiovascular conditions at all levels of care. These guidelines advocate for integrating multidisciplinary approaches, with a strong emphasis on primary prevention, risk assessment, lifestyle modifications, early detection, timely intervention, and holistic patient-centred care. This approach aligns with the government’s focus on strengthening preventive and promotive health services and ensuring that populations can access quality cardiovascular care without financial hardships. We are committed to ensuring the effective dissemination and use of these guidelines. However, we recognize that our efforts alone are not enough. We need the active participation of county governments and other stakeholders, as their involvement is not just beneficial, but crucial for the impactful strengthening of cardiovascular care in Kenya. We value your role in this process and look forward to the positive impact that will arise from our collective efforts in implementing these guidelines. Dr. Patrick Amoth, EBS AG. Director General For Health Ministry of Health Kenya i KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES PREFACE Cardiovascular diseases (CVDs) are the leading cause of death globally. In Kenya they are the second contributing to 13% of total mortalities and 25% of hospital admissions. CVDs pose a formidable challenge to public health, carrying substantial economic implications in terms of healthcare needs, lost productivity, and premature deaths. Their impact on individuals during their most productive years greatly strains our economy and hampers economic growth. With the rising prevalence of risk factors such as hypertension, diabetes, obesity, and sedentary lifestyle, the burden of CVDs continues to escalate, underscoring the critical need for targeted interventions and evidence-based guidance. Most cardiovascular diseases can be prevented by addressing behavioural risk factors such as tobacco use, unhealthy diet, obesity, physical inactivity, and harmful use of alcohol, using population-wide strategies. People living with cardiovascular conditions or those at high risk (due to the presence of one or more risk factors such as hypertension, diabetes, hyperlipidemia or already established disease) need early detection and management, as appropriate. In response to this crisis, the Ministry of Health in collaboration with the Kenya Cardiac Society (KCS) spearheaded the development of the second edition of the National Guidelines for the Management of Cardiovascular Diseases to provide a standardised way of managing cardiovascular diseases in the country. These guidelines were developed through a collaborative effort of esteemed healthcare professionals, researchers, policymakers, and stakeholders and encapsulates the latest advancements in cardiovascular care, tailored to the unique context and healthcare landscape of Kenya. They embody the collective wisdom, expertise, and dedication of numerous experts who have committed themselves to the advancement of cardiovascular health across our nation. They offer practical recommendations, informed by the latest scientific evidence, and guided by international best practices, to empower healthcare providers in delivering optimal care to individuals at risk of, or living with, CVDs. The cardiovascular disease guidelines are suitable for all health workers and health institutions from both public and private sectors. They give clear directions on what needs to be done for people living with cardiovascular diseases and provide a guide on the continuum of care required throughout their life course. We encourage their thorough adoption and implementation across all levels of healthcare provision to enhance the quality of care and ultimately reduce the burden of cardiovascular diseases on our society. Dr. Issak Bashir Director – Directorate of Family Health Ministry of Health ii  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES ACKNOWLEDGEMENT The publication of the 2nd edition of the Kenya Cardiovascular Disease Guidelines stands as a testament to numerous individuals’ and organizations’ collaborative efforts and invaluable contributions. The development process was marked by active participation and consultation, with significant efforts from our esteemed partners and stakeholders. The Ministry of Health extends heartfelt gratitude to all stakeholders for their unwavering contributions, commitment, and both technical and financial support. Our sincere thanks go to the leadership of the Ministry of Health for their indispensable support, with special mention to the offices of the Cabinet Secretary, Principal Secretary, Director General, and Director- Directorate of family Health, whose guidance played a pivotal role in the successful development of this document. We express deep appreciation to the editorial team, whose tireless efforts were instrumental in ensuring the successful completion of this process. Special recognition for the Division of Non-communicable Diseases for providing strategic leadership during the development process, led by Dr. Gladwell Gathecha, Dr. Elizabeth Onyango, and the focal person for cardiovascular diseases, Dr. Yvette Kisaka, who effectively coordinated the entire effort. Special recognition is also extended to Dr. Bernard Samia, the President of Kenya Cardiac Society, who tirelessly marshalled all the authors and other stakeholders to compile and release the document. Well-deserved recognition goes to Prof. Elijah Ogola, Dr. Anders Barasa, Dr. Felix Barasa, Dr. Loise Mutai, Dr. Jeilan Mohamed, Dr. Mzee Ngunga, Dr. Lilian Mbau, Dr. Tabitha Wambaire, and many others not mentioned here whose dedicated contributions were integral to this undertaking. We extend our sincere gratitude to our partners for providing both technical expertise and financial support. In particular, we recognize the Kenya Red Cross, PATH, and others who played a crucial role in this endeavour. Special recognition to Getz Pharma for their technical input and liaison to support external editorial review. We are greatly indebted to the Clinton Health Access Initiative (CHAI) for their financial support in designing and initial printing of the booklet. The success of this collaborative effort underscores the collective commitment to advancing cardiovascular health in Kenya. We acknowledge and appreciate the dedication and support of each individual and organization involved in this significant undertaking. Dr. Gladwell Gathecha, Head; Division of Non-communicable Diseases Ministry of Health iii KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES ABBREVIATIONS ACS Acute Coronary Syndrome aPTT Activated Partial Thromboplastin Clotting Time ASCVD Atherosclerotic Cardiovascular Disease CAD Coronary Artery Disease CHP Community Health Promoter CKD Chronic Kidney Disease CVD Cardiovascular Disease DBP Diastolic Blood Pressure DIC Disseminated Intravascular Coagulation DM Diabetes Mellitus DVT Deep Venous Thrombosis EF Ejection Fraction ESC European Society of Cardiology GFR Glomerular Filtration Rate HF Heart Failure HIV Human Immunodeficiency Virus HMOD Hypertension-mediated Organ Dysfunction HTN Hypertension LMWH Low Molecular Weight Heparin MI Myocardial Infarction NSTEMI Non-ST elevated MI NYHA New York Heart Association PE Pulmonary Embolism PERT Pulmonary Embolism Response Team PT Prothrombin Time SBP Systolic Blood Pressure STEMI ST- elevated MI UFH Unfractionated Heparin VTE Venous Thromboembolism iv  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES TABLE OF CONTENTS FOREWORD I PREFACE II ACKNOWLEDGEMENT III ABBREVIATIONS IV TABLE OF CONTENTS V LIST OF TABLES XII LIST OF FIGURES XIV INTRODUCTION XVI Organization of the Guideline xvi Dissemination and Use of the National Guidelines for Prevention and Control of Cardiovascular Disease xvi Resources needed for cardiovascular healthcare delivery xviii Priority Research Areas xx 1. PREVENTION OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASES 1 1.0 Introduction 2 1.1 Aetiology and Risk Factors 2 1.2 Classification of Prevention Strategies in Cardiovascular Disease 3 1.3 Cardiovascular Risk Assessment 4 1.4 Recommendations for Prevention and Care of CVD Based on Individual Risk Level 8 1.5 Prevention Interventions 8 1.5.1 Non-Pharmacological Therapy 8 1.5.2 Pharmacological Therapy 12 2. HYPERTENSION 14 2.1 Introduction 15 2.2 Epidemiology 15 2.3 Classification and Grading of Hypertension 15 2.4 Causes and risk factors of hypertension 16 2.5 Clinical presentation and diagnosis 16 2.5.1 History 16 2.5.2 Physical Examination 17 2.5.3 Blood Pressure Measurement 18 2.5.4 Out of Office Blood Pressure Monitoring 18 2.5.5 Actions after Health Facility BP Measurement 19 2.5.6 Basic Investigations 19 2.5.7 Assessment for Complications 19 2.6 Management of Hypertension 20 2.6.1 Non-pharmacologic Therapy/Lifestyle Modification 20 2.6.2 Pharmacologic Therapy 21 2.7 Follow-up Considerations 24 2.8 Indications for Referral 24 2.9 Treatment of Hypertensive Emergencies 25 3. DYSLIPIDAEMIA 28 3.0 Introduction 29 3.1 Screening 29 3.2 Measurement of Lipids and Lipoproteins 31 v KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 3.3 Management of Dyslipidaemia 31 3.3.1 Primary Prevention 31 3.3.2 Secondary Prevention 32 3.4 Treatment Targets and Goals 35 3.5 Common Side Effects of Lipid-lowering TherapiesStatins 36 3.6 Dyslipidaemia in Special Populations 36 3.6.1 Familial Dyslipidaemias 36 3.6.2 Diabetes 38 3.6.3 Patients with Established ASCVD 38 3.6.4 Chronic Kidney Disease 38 3.6.5 Women 39 3.6.6 Older Patients (>75 years) 39 4. HEART FAILURE 43 4.1 Definition 44 4.2. Epidemiology of Heart Failure 44 4.3 Aetiology 44 4.4 Pathophysiology of Heart Failure 45 4.5 Classification of Heart Failure 45 4.5.1 The New York Heart Association (NYHA) Classification 46 4.5.2 Acute Vs Chronic Heart Failure 46 4.6 Diagnostic Work-up for HF 47 4.6.1 When to Suspect Heart Failure 47 4.6.2 Initial Tests 47 4.6.3 Biomarkers in The Definition of HF 47 4.6.4 Cardiovascular Tests 47 4.6.5 Additional Tests that may be done in Higher/specialised Centres 50 4.7 Management of Heart Failure 50 4.7.1 Pharmacological Management of HFrEF 51 4.7.2 Treatment of Comorbidities 53 4.7.3 Other Treatment Modalities 54 4.8 Right Heart Failure 55 4.9 Common Challenges in Patients with Heart Failure 56 4.10 HFpEF and HFmrEF 57 4.11 Palliative Care 58 5. RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE 60 5.1 Introduction 61 5.2 Epidemiology and Burden of Disease 61 5.3 Etiology and Pathogenesis 61 5.4 Clinical Manifestations 62 5.5 Diagnosis 63 5.5.1 Diagnostic Criteria for Rheumatic Fever and RHD 64 5.5.2 Differential Diagnosis 65 5.6 Management of Acute Rheumatic Fever 65 5.6.1 Principles of Management 66 5.6.2 Consideration for Admission 67 5.6.3 Health Education Activities 67 5.6.4 Treatment of Streptococcal Pharyngitis: Antimicrobial Therapy 67 5.6.5 Anti-inflammatory Therapy 68 vi  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 5.6.6 The Role of Surgery in Active Rheumatic Carditis 69 5.7 Secondary Prevention and Rheumatic Heart Disease Control 70 5.7.1 Secondary Prophylaxis 70 5.8 Management of Rheumatic Fever at Different Levels of Care 71 5.9 Rheumatic Heart Disease 71 5.9.1 Clinical Presentation and Recommendations 71 6. INFECTIVE ENDOCARDITIS 74 6.1 Introduction 75 6.2 Epidemiology 75 6.3 Risk Factors for Developing IE 75 6.4 Diagnosis 75 6.4.1 History and Physical Examination 75 6.4.2 Investigations 76 6.4.3 Diagnostic criteria for IE 77 6.5 Management of Infective Endocarditis 78 6.5.1 Antibiotic Therapy 79 6.5.2 Indications for Surgery in IE 80 6.5.3 Indications for Antibiotic Prophylaxis 81 6.6 Complications 82 6.7 Patient Follow-up 83 7. CONGENITAL HEART DISEASE 85 7.1 Definition of Congenital Heart Disease 86 7.2 Aetiology 86 7.3 Epidemiology 86 7.4 Classification of CHD 86 7.5 Clinical Presentation 87 7.6 Diagnosis: History, Physical Examination, Laboratory, and Imaging Investigations 87 7.7 Patient Referral 88 7.8 Management 88 7.9 Complications 88 7.10 Patient Follow-up 88 7.11 Prevention 88 7.12 Recommendations for Delivery of Care 89 7.13 Further Recommendations 90 8. CARDIAC RHYTHM DISORDERS 94 8.1Arrhythmia 95 8.2 Bradycardia 95 8.2.1 Sinus Node Disease 95 8.2.2 AV Node Disease 95 8.2.3 Treatment of Bradycardias 96 8.3 Tachycardias 97 8.3.1 Supraventricular Tachycardias 97 8.3.2 Treatment of Atrial Fibrillation/Flutter 99 8.3.3 Ventricular Arrythmias 100 8.4 Recommendations to Institutions that Offer Care for Patients with Arrhythmia 102 8.5 Cardiac Rhythm Disorders and Driving 103 9. ISCHAEMIC HEART DISEASE 105 9.1 Introduction 106 vii KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 9.2 Clinical Presentation of IHD 106 9.3 Diagnosis of IHD 107 9.3.1 Diagnosis of Chronic Coronary Syndromes 107 9.3.2 Diagnosis of Acute Coronary Syndromes 108 9.4. Treatment of Acute IHD 110 9.4.1 Recommendations 110 9.4.2 Treatment approach 111 9.5 Treatment of Chronic Coronary Syndromes 113 9.6 Secondary Prevention of IHD 114 9.7 Health Systems Recommendations for the Management of IHD 115 9.8 Screening for Asymptomatic IHD 115 9.9 Testing for Asymptomatic IHD 116 9.10 Cardiac Arrest in IHD 116 9.11 IHD in Special Populations 116 10: VENOUS THROMBOEMBOLISM 119 10.1 Introduction 120 10.2 Epidemiology 120 10.3 Aetiology/ Risk Factors 120 10.4 Diagnosis of DVT 121 10.5 Diagnosis of Acute Pulmonary Embolism 123 10.6 Risk Factor Assessment in VTE 124 10.7 Prevention of Venous Thromboembolism 124 10.8 VTE Treatment & Patient Management 125 10.8.1 Anticoagulation 125 10.8.2 Duration of Anticoagulation Therapy in VTE 127 10.8.3 Antidotes to Anticoagulants 129 10.8.4 Important Considerations 129 10.8.5 Practice Recommendations 129 10.9 Venous Thromboembolism in Pregnancy 129 10.9.1 Epidemiology 129 10.9.2 Diagnosis 129 10.9.3 Treatment 129 10.10 Cancer-Associated Thrombosis 131 10.10.1 Thromboprophylaxis in Cancer: Risk Assessment of VTE 131 10.10.2 Treatment of VTE in Cancer 131 10.11 COVID-19 and Thrombosis 132 10.11.1 COVID-19 and Hypercoagulability 132 10.11.2 Evaluation and Management of COVID-19 Associated Hypercoagulability 132 10.11.3 Summary of Anticoagulation in Covid-19 133 11. STROKE 136 11.1 Introduction 137 11.2 Epidemiology 137 11.3 Classification of Stroke 137 11.4 Risk Factors for Stroke 138 11.5 Prevention 138 11.5.1 Primary Prevention of Stroke 138 11.5.2 Secondary Prevention of Stroke 139 11.6 Diagnosis 140 viii  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 11.7 Management of Stroke 140 11.7.1 Hyper-acute Management of Stroke 140 11.7.2 Initial Emergency Assessment 141 11.7.3 Initial Supportive Care 143 11.7.4 Blood Pressure in the Acute Stroke Patient 143 11.7.5 Medical Management of Stroke 144 11.7.6 Management of Haemorrhagic Stroke 144 11.7.7 Treatment of Comorbid Conditions 144 11.8 Inpatient Supportive Care 145 11.9 Management of Stroke-specific Complications 145 11.9.1 Cerebral Oedema 145 11.10 Long-TERM CARE 146 11.11 Management of Stroke at Different Levels of Care 146 11.12 Referral Criteria 147 11.13 Recommendations for Health System Strengthening 147 12. PULMONARY HYPERTENSION 149 12.1 Introduction 150 12.2 Epidemiology 150 12.3 Definition 150 12.4 Classification 150 12.5 Diagnosis 152 12.5.1 History 152 12.5.2 Physical Examination 153 12.5.3 Investigations 154 12.6 Prognosis 157 12.7 Referral to Highly Specialized Units 158 12.8 General Recommendations 159 12.9 Pharmacological Treatment 159 12.9.1 General 159 12.9.2 Specific Pharmacological Treatment of PAH (Group 1) 159 12.9.3 Treatment Targets and Monitoring 160 12.9.4 Combination Therapy 160 13: PERICARDIAL DISEASES 163 13.1 Introduction 164 13.2 Pericarditis 164 13.2.1 Clinical Presentation 165 13.3 Acute Pericarditis 165 13.4 Treatment of Tuberculous Pericarditis 166 13.5 Treatment of Recurrent pericarditis 167 13.6 Pericardial Effusions 167 13.7 Constrictive Pericarditis 167 13.8 Congenital Disorders of the Pericardium 168 13.9 Pericardial Tumours 168 14. CARDIOVASCULAR DISEASE IN DIABETES 170 14.1 Introduction 171 14.2 Mechanisms of Developing CVD in the Diabetes Setting 171 14.3 Principles of Management of CVD in Diabetes Melllitus 172 14.3.1 Management of Hypertension in Diabetes Mellitus 172 ix KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 14.4 Multifaceted Management Approach 173 15. CARDIOVASCULAR DISEASE IN PEOPLE LIVING WITH HIV/AIDS 175 15.1 Introduction 176 15.2 Epidemiology 176 15.3 Pathophysiology of CVD (Hypertension, CKD, Heart Failure) in HIV 176 15.4 Recommended Investigations for Diagnosis and Follow-up for CVD in PLHIV 177 15.5 Treatment and Prevention of CVD in HIV 178 15.5.1 Lifestyle Modification 178 15.5.2 Dyslipidaemia 178 15.5.3 Chronic Kidney Disease 179 15.5.4 Hypertension 180 15.6 ARVs Commonly Used in Kenya 180 15.7 Potential Drug-drug Interactions 181 16. CARDIOVASCULAR DISEASE IN CHRONIC KIDNEY DISEASE 184 16.1 Definition 185 16.2 Introduction 185 16.3 Economic and Public Health Burden 185 16.4 Etiology and Risk Factors 186 16.5 Pathophysiology 186 16.6 Important Considerations in Management 187 16.7 Treatment 188 16.8 Prevention 189 17. CARDIOVASCULAR DISEASE IN ATHLETES AND SPORTS CARDIOLOGY 191 17.1 Introduction 192 17.2 Definitions 192 17.3 Physiology 192 17.4 ECG Changes in Athletes 193 17.5 Sudden Death in the Athlete 194 17.5.1 Conditions Associated with Sudden Death 194 17.6 Preparticipation Screening 195 17.7 Referral and Follow-up 196 17.8 Sports Participation in Patients with Cardiovascular Conditions 196 17.8.1 Hypertension 198 17.8.2 Coronary Disease 198 17.8.3 Hypertrophic Cardiomyopathy 200 17.8.5 Arrhythmias 202 17.8.6 Congenital Heart Disease 204 17.8.7 Valvular Heart Disease 206 18. CARDIOVASCULAR DISEASE AMONG THE ELDERLY 208 18.1 Introduction 209 18.2 Epidemiology 209 18.3 Pathophysiology 209 18.4 Common Comorbidities 210 18.4.1 Special Considerations in Management of Hypertension 210 18.5 Treatment Cut-offs and Targets: 210 18.6 Preventive Therapy 211 18.7 Treatment Approach for Heart Failure in the Elderly 211 19. CARDIO-ONCOLOGY 213 x  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 19.1 Introduction 214 19.2 General Principles of Cardio-oncology 214 19.2.1 Cancer Therapy-related Cardiovascular Toxicity Spectrum 215 19.2.2 Cardiovascular Toxicity Risk Stratification before Anticancer Therapy 215 19.2.3 General Approach to Cardiovascular Toxicity Risk in Patients with Cancer 215 19.3 Clinical Presentation 216 19 3.1 Screening 216 19.3.2 Cardiovascular Imaging 217 19.3.3 Cardiovascular Risk Evaluation before Cancer Surgery 217 19.4 Genetic Testing 217 19.5 Prevention and Monitoring of Cardiovascular Complications during Cancer Therapy 217 19.5.1 General Principles 217 19.5.2 Primary Prevention Strategies 218 19.5.3 Secondary Prevention Strategies 218 19.5.4 Cardiovascular Surveillance during Cancer Therapies 218 19.6 Diagnosis and Management 219 19.6.1 Anthracycline Chemotherapy-related Cardiac Dysfunction 219 19.6.2 Human Epidermal Receptor 2-targeted Therapy-related Cardiac Dysfunction 219 19.6.3 Immune Checkpoint Inhibitor-associated Myocarditis and Non-inflammatory Heart Failure 219 19.6.4 Chimeric Antigen Receptor T cell and Tumour-infiltrating Lymphocytes Therapies and Heart 220 Dysfunction 19.6.5 Heart Failure during Haematopoietic Stem Cell Transplantation 220 19.6.6 Takotsubo Syndrome (TTS) and Cancer 220 19.7 Follow-up 222 19.7.2 Management of Cancer Therapy-related Cardiac Dysfunction at the End-of-therapy Assess- 222 ment 20. CARDIAC REHABILITATION 225 20.1 Introduction 226 20.2 Phases of Cardiac Rehabilitation 226 20.3 Indications for Cardiac Rehabilitation 227 20.4 Components of Cardiac Rehabilitation Services 227 20.5 The Cardiac Rehabilitation Team 228 20.5.1 Roles and Competencies of CR Team Members 228 20.6 Equipment Required for Cardiac Rehabilitation 229 20.7 Patient Referral 230 20.8 Initial Assessment and Patient Preparation 230 20.8.1 Phase 1 Cardiac Rehabilitation (Inpatient) 230 20.8.2 Phase 2 Cardiac Rehabilitation (Outpatient) 230 20.8.3 History 230 20.8.4 Physical Exam and Diagnostic Testing 231 20.8.5 Risk Stratification 231 20.8.6 Develop an Individualised Treatment Plan 232 20.9 Delivery of the Core Components 232 20.9.1 Health Behaviour Change Education 232 20.9.2 Lifestyle Risk Factor Management 233 20.10 Psychosocial Health 238 20.11 Medical Risk Management 239 20.12 Long-Term Strategies 239 xi KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 20.13 Monitor Outcomes 239 20.14 Models of Service Delivery 239 20.15 Risks and Complications 240 20.16 Organization of Services at County Level 240 21. PALLIATIVE CARE 243 21.1 Introduction 244 21.2 Epidemiology 244 21.3 Benefits of Palliative Care 244 21.4 Cardiovascular Conditions Requiring Palliative Care 244 21.5 Provision of Palliative Care Services 245 21.5.1 Palliative Care Plan 245 21.5.2 Pharmacological Measures 245 21.5.3 Non-Pharmacological Measures 245 21.6 Special Considerations 246 21.6.1 HF and Palliative Care 246 21.6.2 Heart Transplant (HT) 246 21.6.3 Mechanical Circulatory Support (MCS) and Palliative Care 246 21.6.4 Stroke and Palliative Care 247 21.7 Paediatric Palliative Care (0-16 years) 247 LIST OF CONTRIBUTORS 249 LIST OF TABLES Table 0:1 Resources Needed for CVD Care Delivery xviii Table 1.1: Risk factors for CVD 2 Table 1.2: CVD Prevention Strategies 4 Table 1.3: Management of Total 10-year risk of Fatal or Non-fatal CVD Event 8 Table 1.4: Basic Elements of a Healthy Diet 9 Table 1.5: Classification of Physical Activity Intensity and Examples 10 Table 1.6: Recommendations for Antiplatelet Therapy 12 Table 2.1: Definition and Grading of Hypertension 15 Table 2.2: The Differences between Primary and Secondary Hypertension 15 Table 2.3: Types and Risk factors for Hypertension 16 Table 2.4: Components of Past Medical and Family History 16 Table 2.5: Detection of White Coat or Masked Hypertension in Patients not on Drug Therapy 19 Table 2.6: Actions after Initial BP Measurement 19 Table 2.7: Hypertension Complications and Diagnostic Approaches 20 Table 2.8: Simplified Classification of Hypertension Risk in a 60-year Male Patient 20 Table 2.9: Antihypertensive Agents and Their Common Side Effects 22 Table 2.10: Characteristics of Secondary Hypertension 24 Table 2.11: Drugs of Choice in Hypertensive Emergencies 25 Table 3.1 Who to Screen for Dyslipidaemia 30 Table 3.2: Frequency of Screening in Different Populations 30 Table 3.3: How to Screen for Dyslipidaemia 31 xii  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Table 3.4: Cardio-protective Diets 32 Table 3.5: Cardiovascular Risk Stratification 33 Table 3.6: Definition of Very high Risk (Clinical ASCVD) & High-risk Conditions 34 Table 3.7: Recommended Treatment for Patients with Established ASCVD 35 Table 3.8: Lipid Parameter Targets for different Risk Categories 35 Table 3.9: Genetic Disorders of Lipoprotein Metabolism 37 Table 3.10: Dose Adjustment of Statins in Patients with CKD 39 Table 4.1: The NHYA Classification-The Stages of Heart Failure 46 Table 4.2: Recommended Diagnostic Tests in all Patients with Suspected Chronic Heart Failure 48 Table 5.1: Direct and Indirect Results of Environmental and Health-system Determinants on Rheumatic Fever and 62 Rheumatic Heart Disease Table 5.3: Revised Jones Criteria for Diagnosis of Acute Rheumatic Fever 64 Table 5.4: Differential Diagnosis of Arthritis, Carditis and Chorea 65 Table 5.5: Priorities in Managing ARF 66 Table 5.6: Antibiotic Medications for Streptococcal Pharyngitis 67 Table 5.7: Medication for ARF 68 Table 5.8: Selection of Therapy for Secondary Prevention of Rheumatic Fever 70 Table 5.9: Valvular Lesions in Chronic RHD 71 Table 5.10: Valvular Lesions in Chronic RHD 71 Table 6.1: Cardiac and Non-cardiac Risk Factors 75 Table 6.2: Clinical Presentation of Infective Endocarditis 76 Table 6.3: Diagnosis of Infective Endocarditis (Adapted from the 2023 ESC Guidelines) 77 Table 6.4: Diagnostic Criteria for Infective Endocarditis 77 Table 6.5: Antibiotic Treatment of Infective Endocarditis due to Streptococcus Group 79 Table 6.6: Indications and Timing of Surgery for IE 80 Table 6.7: Recommendations for Prophylaxis of IE in High-risk Patients According to the Type of Procedure 82 Table 7.1: Perinatal Conditions Associated with Increased Incidence of Congenital Heart Disease 86 Table 7.2: Management by Level of Care 89 Table 7.3: Heart Failure Medications for Children 90 Table 8.1: DVLA Guidance on Driving following Arrhythmia and Device Therapy 103 Table 9.1: Canadian Cardiovascular Society Classification of Angina 106 Table 9.2: Angina Risk Prediction Tool 107 Table 9.3: HEART Score for Possible ACS 108 Table 9.4: Differential Diagnosis for Acute Chest Pain in the ER 110 Table 10.1: VTE Risk Factors 120 Table 10.2: Simplified Wells’ Score for Suspected DVT 121 Table 10.3: The Revised Geneva Clinical Prediction Rule for PE 123 Table 10.4 Recommendations for the Duration of Anticoagulation in VTE 128 Table 10.5: Choice of Anticoagulation in Pregnancy 130 Table 10.6: Choice of Anticoagulants in Lactation 130 Table 10.7: VTE prophylaxis in Pregnancy and Breastfeeding 130 Table 10.8 The KHORANA score 131 Table 10.9: Haematological Changes in COVID-19 and their Clinical Significance 132 Table 10.10: Evaluation and Management of COVID-19-associated Hypercoagulability 132 Table 11.1: Risk Factors for Stroke 138 Table 11.2: Recommended Initial Supportive Care 143 Table 11.3: Medical Management of Stroke 144 xiii KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Table 10.4: Management of Stroke at Different Levels of Care 146 Table 12.1: Haemodynamic Definitions of Pulmonary Hypertension 150 Table 12.2: Clinical Classification of Pulmonary Hypertension 151 Table 12.3: World Health Organization (WHO) Functional Assessment 153 Table 12.4: Comprehensive Risk Assessment in Pulmonary Arterial Hypertension (three-strata model)6 158 Table 13.1: Causes of Pericarditis 164 Table 13.2: The Tygerberg Score 166 Table 13.3: Classification of Pericardial effusion 167 Table 14.1: The Risk Factors for Developing Heart Failure in T2DM 172 Table 14.2: Hypertension Treatment Target for Various Categories of Diabetic Patients 172 Table 14.3: Multi-faceted Vascular Protection Checklist 173 Table 15.1: Baseline Investigations for CVD Risk Factors in Patients with HIV (already on treatment) 177 Table 15.2: Screening, Diagnosis, and Initial Management of Dyslipidaemia in PLHIV 178 Table 15.3: CKD Screening, Diagnosis, and Management among PLHIV 179 Table 15.4: Dose Adjustment of TDF and 3TC in Patients with Impaired Renal Function 179 Table 15.5: Screening, Diagnosis, and Initial Management of Hypertension in PLHIV 180 Table 15.6: Classes of ARV Drugs Commonly used in Kenya 181 Table 15.7: Potential Drug Interactions between Antihypertensive and ARV Drugs 181 Table 16.1: Targeting Risk Factors for Prevention of CVD in CKD 189 Table 17.1: The American Heart Association 14-point Screening Questionnaire for Conditions Associated with 195 SCD2 Table 17.2: Factors Associated with Sudden Cardiac Death in Adult Patients With HCM 200 Table 17.3 Key Components Before Commencing an Exercise Programme and Sports Participation 202 Table 17.4: General Guidelines for the Management of Various Arrhythmic Conditions and Sports Participation 202 Table 17. 5 The Borg Rating of Perceived Exertion Scale 206 Table 18.1: Age Associated Changes and Cardiovascular Disease in Older People 209 Table 18.2: Compelling Indications for Antihypertensive Medications in the Elderly Patient 210 Table 18.3: Hypertension Treatment Indications and Targets 210 Table 18.4: Indications for Statins and Anticoagulants in Patients Above 60 Years of Age 211 Table 19.1: Grading of Cancer Related Cardiac Dysfunction 214 Table 20.1: Recommended CR Team Members for Each CR Phase 228 Table 20.2: Roles and Competencies of The CR Team 228 Table 20.3: Basis Equipment Required for Phase 2 CR Centre 229 Table 20.4: Risk Stratification of Patients Undergoing CR 231 Table 20.5: Components of an Individualized Treatment Plan 232 Table 20.6: A Standard Aerobic Exercise Prescription for CR 236 Table 20.7: Resistance Exercises 237 Table 20.8: Recommended Organization Of CR Services at County Level 240 xiv  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES LIST OF FIGURES Figure 0.1: Service Delivery Model for CVD Management: Adapted from the WHO Hearts Technical xviii Figure 1.1: Causal Pathway for ASCVD 3 Figure 1.2: WHO Cardiovascular Disease Risk Non-Laboratory Based Charts 5 Figure 1.3: WHO Cardiovascular Disease Risk Laboratory-Based Charts 7 Figure 1.4: Counselling on Cessation of Tobacco Use. 11 Figure 2.1: BP Measurement 18 Figure 2.2: Threshold for Treatment Initiation 21 Figure2.3: Stepwise Titration of Anti-Hypertensive Medication 22 Figure2.4: Blood Pressure Treatment Targets 23 Figure 3.1: Algorithm for Management of Statin Intolerance 36 Figure 4.1: Forrester Classification of Heart Failure 46 Figure 4.2: The Diagnostic Algorithm for Heart Failure 49 Figure 4.3: ESC HFPEF Scoring 57 Figure 5.1: Opportunities for Intervention for RF and RHD 66 Figure 5.2: Recommended Duration of Secondary Prophylaxis 70 Figure 7.1: Classification and Presentation of CHD 87 Figure 7.2: Pulse Oximetry Protocol for Screening for CHD in Neonates 91 Figure 9.1: Common Complications of IHD 113 Figure 10.1. Ultrasonography Images of Femoral Vessels before and with Compression 122 Figure 10.2: Algorithm for the Diagnosis of Suspected DVT 122 Figure 10.3: Summary of Anticoagulation in COVID-19 133 Figure 11.1: Illustration Demonstrating the Main Types of Stroke 137 Figure 11.2: Flow Diagram Decision Tree on Medical Management for Secondary Stroke Prevention 139 Figure 11.3: Recommended Timelines in Emergency Management of Stroke 141 Figure 11.4: World Stroke Organisation Decision-Making Flowchart 142 Figure 12.1: Echo Findings in PH (Courtesy of ESC/ERS Guideline for PH 2022, Copyright) 155 Figure 12.2: Diagnostic Algorithm for Pulmonary Hypertension 157 Figure 13.1: Management Algorithm for Constrictive Pericarditis 168 Figure 14.1: Mechanisms of Cvd Development in Diabetes 171 Figure 15.1: Interaction Between HIV and HTN 177 Figure 16.1: Classification and Prognosis of Chronic Kidney Disease (CKD) from 2012 Kdigo (Kidney Disease 185 Improving Global Outcomes) Guidelines. Figure 16.2: Interaction of CVD Risk Factors. 186 Figure 16.3: Changing CVD Risk with Progressive CKD 187 Figure 17.1: International Consensus Standards for ECG Interpretation in Athletes 193 Figure 17.2: Cardiovascular Reasons for Sudden Cardiac Death in Athletes 194 Figure 17.3: Proposed Algorithm for Cardiovascular Risk Assessment in ‘Master Athletes’ 197 Figure 17.4: Recommendations for Sports Participation in Individuals with Established Coronary Artery Disease 199 Figure 17.5: A Recommended Approach to Preparticipation Assessment and Intensity of Recommended Activ- 205 ities Figure 20.1: Components of Cardiac Rehabilitation 227 xv KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES INTRODUCTION The World Health Organization (WHO) estimates that cardiovascular diseases (CVDs) are the leading cause of mortalities worldwide. In 2019 alone, an estimated 17.9 million individuals succumbed to CVDs, constituting 32% of all global deaths. Predominantly, 85% of these fatalities were attributed to heart attacks and strokes. Alarmingly, more than three-quarters of CVD-related deaths occur in low- and middle-income nations. Moreover, out of the 17 million premature deaths (those under 70 years old) caused by noncommunicable diseases in 2019, CVDs accounted for 38%. In Kenya, approximately a quarter of hospital admissions are attributed to cardiovascular diseases (CVDs), with 13% of autopsies identifying CVDs as the primary cause of death. This places CVDs as the second leading cause of mortality, following infectious, maternal, and perinatal causes. The diagnosis and management of CVDs entail significant costs, and when these are not met often results in premature death among productive members of households and society at large. Moreover, these diseases play a pivotal role in perpetuating poverty due to the financial burden of healthcare expenses, leading to high levels of out-of-pocket spending and catastrophic health expenditures. The National Cardiovascular Disease Management guidelines has outlined essential messages to support health workers in delivering top-quality care for CVDs. These guidelines are intended for adoption by policymakers, program developers, implementers of noncommunicable disease (NCD) interventions, healthcare professionals, community educators, and academic institutions alike. Organization of the Guideline The guidelines begin with an introduction, underscoring the necessity of the document and explaining the responsibilities of both levels of government in its dissemination. A pivotal emphasis is placed on the role of community health interventions in supporting CVD care, aligning with the government’s transformative agenda to promote preventive and promotive healthcare while bolstering primary healthcare services. This underscores the significance of community health promoters as integral components of Kenya’s healthcare workforce. Following the introduction, the guidelines elaborate on the prevention of cardiovascular diseases, offering specific recommendations for managing risk factors. Subsequently, they delve into a comprehensive discussion of various conditions and their management across the healthcare system. Moreover, they provides guidance on managing CVD in special populations, including athletes, older individuals, and people living with HIV, diabetes, and kidney disease. Palliative care guidance follows this section, with the document concluding with annexes. Dissemination and Use of the National Guidelines for Prevention and Control of Cardiovascular Disease Roles of the Different Levels of Care a. Level one (Tier 1) – Community Community Health promoters (CHPs) are the core resource persons at this level; they should be well-trained and equipped with a kit designed to assess CVD risk in the community. The kit should include: A blood pressure machine A Glucometer and strips A weighing scale A tape measures xvi  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Waist/hip charts BMI charts T The CHPs are the link between households, communities, and health facilities. Community health assistants (CHAs) should be trained in CVDs and coordinate CHP activities. The main intervention entails carrying out public awareness campaigns on CVD risk management through mass media, e.g. posters, mass media outlets, e.g. vernacular radio stations, barazas, community health education forums, community dialogue and action days. b. Level two and three (Tier 2) – Dispensaries and Health Centres The CVD package at this level includes: Provision of lifestyle intervention/advice CVD risk assessment and this entails blood pressure (BP) monitoring, blood sugar assessment, electrocardiography, measuring of lipid profiles, renal functions and urinalysis Provision of the initial treatment for type II diabetes mellitus and hypertension Referral and follow-up for patients on management for CVD in higher levels of care c. Level four and five (Tier 3) – Subcounty and County referral health facilities The CVD package at this level entails a comprehensive CVD risk assessment using the appropriate risk assessment tools. Complete cardiovascular imaging and laboratory assessment (echocardiogram etc.) Comprehensive management of both primary and secondary prevention interventions Referral up (to level 6) for further management and down to lower levels for follow-up after management is initiated. d. Level six (Tier 4) – National referral health facilities. These facilities should offer advanced cardiovascular assessment and treatment, including cardiac catheterization, angioplasty, bypass surgery, endarterectomy, prostheses and pacemakers, ventricular devices, heart transplants, and rehabilitation services. xvii KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Service Delivery Model for CVD Management: Adapted from the WHO Hearts Technical Specialist treatment Initial review of high -risk patients and all second- ary prevention cases Review of complex cases referred from outpatient health clinics Secondary and tertiary care Provide expertise/capacity to supervise medical (Tier 3 and 4) clinics in primary health care Risk screening assessment and management Cardiovascular risk assessment Primary health care Blood pressure, body mass index, urinalysis, (Tier 2) blood glucose, total cholesterol measurement Counselling on risk actors Referral of acute events to the next Health education Community Health Services Screening of population for risk factors (Tier 1) Providing lifestyle interventions (tobacco cessa- tion, physical activity, diet) Referral of individuals with risk factors to primary health care Figure 0.1: Service Delivery Model for CVD Management: Adapted from the WHO Hearts Technical Resources needed for cardiovascular healthcare delivery The table below lists the recommended resources for the management of CVD in health facilities: Table 0:1 Resources Needed for CVD Care Delivery Resources needed Level 1 Level 2 and 3 Level 4 Levels 5 and 6 Human resources Community health Nurses Cadres in level 2 Cadres in Level promoters Clinical officers and 3 2,3,4 Community health Nutritionist Physician Cardiologist assistants Medical Officer Pediatrician Pediatric Cardiol- Community health Lab personnel Echocardiogra- ogist extension workers Radiographers pher Perfusionists Pharmacists Radiologist Cardiac anesthe- Pharmaceutical tists Technologists Specialized nurses Cardiothoracic surgeons Clinical pharma- cist Pathologist xviii  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Screening/Diag- BP machine BP Machine Equipment in level 2 Equipment in level 2, nostic equipment Weighing scale Stethoscope and 3 3 and 4 Thermometer Weighing scale Echo machine Echo machine Height meter Height meter Biochemistry and (high specifica- BMI charts Thermometer Haematological tion) CVD risk assess- machines Blood analysis: ment tools Ophthalmoscope fasting blood Strips for urinalysis sugar, electro- Glucometer lytes, creatinine, Hematology cholesterol and equipment and lipoproteins reagents Cardiac catheter- Biochemistry ization lab equipment and Ambulatory BP reagents 24 hr Holter X-Ray machine ECG machine Treadmill Facilities for tele- medicine A critical care unit Medications None Thiazide-like* Diuretics (including Diuretics (includ- diuretic spironolactone and ing spironolac- Calcium-channel furosemide) tone and furose- blocker* Beta-blockers*** mide) ACEI/ARB* Digoxin**** Beta blockers Furosemide** Warfarin Angiotensin con- Statins** Clopidogrel verting enzyme Aspirin** inhibitors/ARBs/ ARNi Calcium channel blockers Aspirin SGLT2i Digoxin**** Dopamine Dobutamine Sildenafil/tada- lafil Main Services Awareness cre- Detection Diag- Services offered in Services offered in ation nosis level 2&3of general level 4 Detection Initiate treatment medical conditions Referral and link- of uncomplicated Cardiac catheter- age to care hypertension Comprehensive ization and open Follow up Follow-up clinic diagnosis heart surgery for hypertension Management of Referral complications Treatment of e.g heart failure non-cardiac and as you prepare cardiac surgical for referral complications Referral rehabili- Management of tation and follow pregnancy in a up Training cardiac patient including safe delivery KEY: *Medications can be initiated at level 2 or 3 **Medications are not to be initiated, but prescription can be refilled at level 2/3 ***Beta-blockers recommended for children are propranolol and carvedilol *****Digoxin use limited to physicians and other specialist xix KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Priority Research Areas Regional mapping of the burden of priority CVDs at the population level and health facilities in Kenya Determinants of occurrence, severity and outcome of priority CVDs in Kenya Qualitative studies on the quality of CVD care across counties in Kenya Integration of CVD care in communicable diseases service e.g. HIV – outcomes, feasibility, cost, ROI, models of integration xx  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 1 1. PREVENTION OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASES Key Messages Early detection and appropriate control of hypertension is the hallmark of preventing atherosclerosis. CVD risk assessment refers to the use of a systematic approach to enable identification and classification of individuals who are at an increased risk of cardiovascular disease. To keep cost of risk stratification low, it is advisable that CVD risk factors already available in the individuals’ medical records be utilized. An informed discussion about CVD risk and treatment benefits tailored to the needs of a patient is recommended. Treatment of ASCVD risk factors is recommended in apparently healthy people without DM, CKD, genetic/rarer lipid, or BP disorders who have high CVD risk assessment scores. 1 KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 1.0 Introduction Majority of cardiovascular diseases are preventable with control of risk factors, early detection, and prompt management. Cardiovascular disease (CVD) can be categorized into atherosclerotic and non-atherosclerotic disease based on the underlying pathophysiologic mechanisms. Non-atherosclerotic cardiovascular diseases include rheumatic heart disease, endocarditis, congenital heart disease, venous thromboembolism, pericardial heart disease, and cardiomyopathies among others. Prevention of the non-atherosclerotic cardiovascular disease has been discussed in the various relevant chapters. Atherosclerotic cardiovascular disease (ASCVD) results from the build-up of cholesterol plaques in arteries due to deposition of fatty material, cholesterol, and other substances in the walls of the vessels which may in turn reduce blood flow to end organs such as the heart, brain, kidneys, and limbs.1 They include coronary heart disease, stroke, peripheral artery disease, and aortic disease. The most important way to prevent atherosclerotic cardiovascular disease (ASCVD) is to promote a healthy lifestyle throughout life. A team-based care approach is an effective strategy for the prevention of CVD. Additionally, a comprehensive patient-centred approach that addresses all aspects of a patient’s lifestyle habits and estimated risk of a future ASCVD event forms the key aspect in prevention. 1.1 Aetiology and Risk Factors A small proportion of the population have genetic conditions that predispose them to CVDs, while the majority who develop them do so because of a combination of modifiable and non-modifiable risk factors as listed below: Table 1.1: Risk factors for CVD Modifiable Risk Factors Non-Modifiable Risk Factors Tobacco use and exposure to tobacco Sex (male) smoke Age (Male >50; female >60) Unhealthy diet- Race- Blacks, Asians Overweight/obesity Family history Physical inactivity Harmful use of alcohol Hypertension Diabetes Dyslipidaemia Infections e.g., HIV Source: Kenya National Stepwise Survey for NCD risk factors2 There are many risk factors that contribute to CVDs. Hypertension is the single most important risk factor. The figure below demonstrates a proposed causal pathway for Atherosclerotic CVD. 2  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Lifestyle-associated risk factors Social risk factors Smoking Social Diet Deprivation Stress Environment Non- modifiable risk factors Modifiable risk factors Genetics Age Blood Pressure Gender Atherosclerosis Cholesterol Level Family history of CVD Blood glucose level Previous history of Body mass index CVD Cardiovascular diseases Figure 1.1: Causal Pathway for ASCVD (Adapted from: Front. Cardiovasc. Med., 22 August 2022 Sec. Atherosclerosis and Vascular Medicine) 1.2 Classification of Prevention Strategies in Cardiovascular Disease Prevention strategies involve a wide array of interventions that aim to reduce the risk of developing cardiovascular disease. Strategies to prevent cardiovascular disease in people at higher risk are crucial to reduce the global burden of CVD. Prevention strategies are mainly classified into four: primordial prevention, primary prevention, secondary prevention, and tertiary prevention. Primordial prevention is a strategy to prevent the development of cardiovascular risk factor at the population level. Primary prevention represents the earliest possible interventions and aims to prevent the onset of disease in people who are at high risk of CVD but have not developed a cardiovascular condition. Secondary prevention is any strategy aimed at reducing the probability of a recurrent cardiovascular event in patients with known cardiovascular disease. Tertiary prevention targets people who are already affected by cardiovascular disease and who are experiencing its long-term effects by slowing, arresting, or reversing disease to prevent recurrent symptoms, further deterioration, and subsequent events. It is generally more costly and more invasive than primary and secondary prevention. 3 KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES Table 1.2: CVD Prevention Strategies Prevention Health Promotion/ Primary Prevention Secondary Tertiary Prevention Strategy Primordial Prevention Prevention Target Entire population People with one or People at early stage People with symptomatic more risk factors of disease or advanced diseases Effects Prevent risk factors, lower Prevent development Prevent disease Reduce complications or population risk of disease at early progression or disability age recurrence Examples Public awareness Early detection, Providing appropriate Cardiac Rehabilitation and campaigns appropriate treatment and care, palliative care at the various Increased taxes on screening, and support groups stages of the disease cigarettes and alcohol surveillance Promoting medication pathway. and banning of smoking Vaccination adherence together Revascularization i.e., in public places Lifestyle with lifestyle percutaneous coronary Encourage safe modification: modification (cardiac intervention, coronary pregnancy by avoidance cessation of tobacco rehabilitation) artery bypass grafting of exposure to risk factors and alcohol use, (CABG), carotid artery and unnecessary and consumption of endarterectomy, non-prescribed use of healthy diet low in pacemakers, defibrillators, medicines. saturated fat, salt, and left ventricular assist Use folate and iron and refined sugars, devices supplements in women and high in fruits and of childbearing age. vegetables 1.3 Cardiovascular Risk Assessment Cardiovascular risk refers to the likelihood of an individual developing ASCVD over a defined period of time; usually 10 years. Cardiovascular risk assessment/stratification refers to the use of a systematic approach to enable identification and classification of individuals who are at an increased risk of CVD. The total CVD risk is thus an estimate of the combined risk posed by each of the risk factors. The assessment helps health care workers and patient to make appropriate decisions on effective prevention and management of CVD. CVD risk estimation helps in prioritization of individuals for further formal and more elaborate risk assessment. This is based on key risk factors using the World Health Organization/International Society of Hypertension (WHO/ISH) assessment tools. The recommended tool for the Kenyan context is the WHO Eastern Sub-Saharan region charts.3 Recommendations for prevention and care of CVD based on individual risk level are then made, focusing on tobacco and alcohol control, dietary modification, physical activity, and pharmacological management as shown below. Assessment of total CVD risk can be used for routine management of hypertension (HTN) and diabetes mellitus (DM), and for targeting the following categories of people who are/have:  aged >40 years  smokers  obesity  known to have HTN  known to have DM  history of premature CVD in first-degree relative  history of DM or kidney disease in first-degree relative. (Adapted from the HEARTS technical package,2020) 4  KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES WHO/ISH Risk Prediction Charts for Eastern Sub-Saharan Africa Region These are 10-year risk prediction tools for a fatal or non-fatal cardiovascular event by gender, age, systolic blood pressure, total blood cholesterol, smoking status, and presence or absence of diabetes mellitus. The charts are shown below. WHO Cardiovascular disease risk non-laboratory-based charts Eastern Sub-Saharan Africa Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mozambique, Rwanda, Somalia, Uganda, United Republic of Tanzania, Zambia 50% LM stenosis* >50% stenosis proximal LAD* Asymptomatic 2-3 vessel disease with >50% LVEF >50% stenosis* >90% lesion in a No exercise induced vessel arrhythmias LOW RISK Revascularisation May participate in intensive exercise programmes Revascularisation Revascularisation although some restrictions may apply not possible or on- possible going symptoms/ ischaemia despite medical therapy Asyntomatic LVEF >50% No exercise induced arrhythmias LOW RISK May participate in May participate in intensive skill competitive sport exercise programmes although and mild to moderate some restrictions may apply intensityleisure sport Figure 17.4: Recommendations for sports participation in individuals with established coronary artery disease Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease: The Task Force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC). European heart journal. 2020;42(1):17-96.1 199 KENYA NATIONAL GUIDELINES FOR THE MANAGEMENT OF CARDIOVASCULAR DISEASES 17.8.3 Hypertrophic Cardiomyopathy The diagnosis of hypertrophic cardiomyopathy (HCM) is based on the presence of unexplained LV hypertrophy, defined as a maximum end-diastolic wall thickness ≥15 mm, in any myocardial segment on echocardiography, CMR, or CT imaging. HCM may also be considered in individuals with a lesser degree of LV hypertrophy (wall thickness ≥13 mm) in the context of a family history of definite HCM or a positive genetic test. A systematic approach is required when assessing an individual with HCM who requests exercise advice. The baseline evaluation should include a comprehensive personal and family history with consideration of the age of the individual and years of exercise prior to diagnosis, assessment of the severity of the HCM phenotype, and the presence of any conventional risk factors for SCD/SCA. In older patients with HCM, the physician should review the presence of cardiac comorbidities such as hypertension and ischaemic heart disease, which may confer a worse prognosis in HCM. The presence of symptoms attributed to HCM should prompt more conservative exercise recommendations. Individuals with a history of cardiac arrest or unheralded syncope and individuals with exercise-induced symptoms should be advised to engage in low-intensity recreational sports only. Further assessment of risk can be carried out using echocardiography, ambulatory ECG monitoring and exercise testing. In relation to risk stratification for SCD the clinician should assess the following echocardiographic indices: (i) LV wall thickness (ii) LV outflow tract (LVOT) gradient (iii) left atrial diameter All individuals should have the LVOT gradient assessed at rest, during the Valsalva manoeuvre, on standing suddenly, and after light exercise on the spot, such as repeated squats. By convention, LVOT obstruction is defined as a peak pressure gradient ≥30 mmHg at rest or during physiological provocation. A gradient ≥50 mmHg is haemodynamically important. Exercise stress echocardiography should be considered in individuals with exertional symptoms who have resting systolic anterior motion of the mitral valve leaflets but who do not reveal LVOT obstruction or show only mild to moderate LVOT obstruction with the aforementioned manoeuvres. Asymptomatic non-sustained ventricular tachycardia (NSVT) on ambulatory ECG confers considerable risk of SCD in individuals ≤35 years. Exercise testing should be part of the routine evaluation to assess functional capacity in an individual with HCM who intends to exercise. In addition, an abnormal BP response to exercise defined as