BACKGROUND:Peripartum cardiomyopathy (PPCM) occurs globally, but there is significant variability in its epidemiology within and between countries. OBJECTIVES:In this post hoc analysis of PPCM data of EURObservational Research Programme, we aimed to compare the sociodemographic and clinical features, pattern of management, and 6-month clinical outcomes of the patients from six Sub-Saharan African (SSA) countries with those from Europe. METHODS:Two hundred and eight PPCM patients were recruited from Burkina Faso (14.9%), Democratic Republic of Congo (1.9%), Mozambique (20.7%), Nigeria (22.6%), South Africa (34.1%), and Uganda (5.8%) between 2012 and 2018 and were compared with 249 PPCM patients from 23 European countries. Clinical outcomes were death from any cause, thromboembolism, stroke, and readmission to hospital for any cause. RESULTS:All the SSA patients were Black, except for a minority of Caucasians (2.4%) and other races (9.6%) recruited from South Africa. Their baseline demographic and clinical characteristics differed significantly. The 249 patients recruited from Europe were more ethnically diverse (73.9% were Caucasians and 5.6% were Blacks) and were older, with a higher prevalence of diabetes, smoking, and atrial fibrillation. Patients from SSA had a higher prevalence of human immunodeficiency virus, multiparity, and prior history of PPCM. Although the frequencies of all-cause mortality and rehospitalization did not differ significantly between the various countries, European patients had more frequent left ventricular functional recovery at 6 months than the Africans. CONCLUSION:This comparative analysis demonstrated differences in the demographic and clinical characteristics among patients from the SSA countries and Europe. However, the rates of all-cause mortality and rehospitalization were similar.

INTRODUCTION:Peripartum cardiomyopathy (PPCM) affects previously healthy women commonly of African ancestry resulting into elevated morbidity and mortality rates. The clinical characteristics of PPCM are diverse but there is yet limited data on outcomes for women with PPCM in Uganda. We sought to elucidate the clinical presentation, echocardiographic findings, and 6-month outcomes among women with PPCM in Uganda. METHODS:A prospective cohort study of 80 PPCM women matched for age were monitored over a 6-month period while on goal-directed medical therapy (GDMT) was conducted. All participants underwent a physical examination, 12-lead electrocardiography, echocardiography and biomarkers including NT-pro BNP and Prolactin at baseline and at 6-month follow-up visit. Additionally, 80 matched controls were recruited at baseline as comparison for the biomarkers. RESULTS:The mean age of cases and controls was 33.6 ± 6.6 and 30.2 ± 5.9 years respectively. Clinical data for cases were as follows: mean left ventricular ejection fraction (LVEF) was 35.7 ± 11.0%, mean LV global longitudinal strain (GLS) was -11.9 ± 4.7%, mean right ventricular GLS was -14.7 ± 10.9%. A total of 22 (27.5%) participants had a LVEF <35% while 6 (7.5%) participants had severe RV systolic dysfunction. 20 (25%) participants were in NYHA IV. 54 (68%) participants received bromocriptine therapy in addition to other GDMT. Clinical data for controls were as follows: mean LVEF was 67.2 ± 4.5%, mean LV GLS was -17.1 ± 4.9%, all controls had normal RV systolic function parameters. After 6-months of follow-up, 6 (7.5%) of the cases had died. Atrial fibrillation occurred in 2 (2.5%) participants and intracardiac thrombus was documented among 8 (10%) participants. 52 (65%) participants were in NYHA I. LV recovery (LVEF ≥ 50%) was observed in 37 (46.3%) cases. CONCLUSION:This study shows a high mortality rate of 7.5% aligning with global studies, the observed high thrombus burden and stroke occurred in 10% and 2.5%, respectively which may indicate severity of LV systolic dysfunction at presentation. Two-thirds of patients received Bromocriptine in addition to GDMT which may explain the high rate of LV recovery in this cohort.

Peripartum cardiomyopathy (PPCM) can be a serious condition, presenting with heart failure with reduced ejection fraction towards the end of pregnancy or in the months following delivery. Less than half of the patients fully recover their cardiac function within 6 months of diagnosis, with substantial regional variation. This clinical consensus statement addresses the global and regional heterogeneity of epidemiological data on PPCM, substantial variation in access to medical care, and the contributing factors to poor adherence, as well as the impact of socioeconomic factors. The scope of this document encompasses contemporary challenges and approaches for the management of women diagnosed with PPCM. We provide a framework of practical aspects of starting disease-specific and guideline-recommended medical therapy, rapid up-titration, and improving adherence. Furthermore, the importance of involving women with a new diagnosis of PPCM in the decision-making processes regarding various therapeutic options is highlighted, as this also affects the mental health and quality of life for the patient, as well as for the extended family.

Cardiovascular disease (CVD) remains the leading cause of mortality in women, yet sex-specific risk factors are usually not included in conventional predictive models. Specifically, heart failure (HF) in women may be influenced by sex-specific hormones and pathologies that need to be addressed to improve prevention and treatment. This expert consensus statement aims to provide a comprehensive roadmap for HF prevention and management across specific conditions affecting women during their life-course. Each section focuses on the impact of a specific female condition on CVD and how to prevent and manage HF in specific settings: 1. Pregnancy with a specific focus on how to deal with hypertensive disorders in the acute and chronic setting and how to prevent and treat Peripartum Cardiomyopathy (PPCM); 2. Gynecological conditions predisposing to HF, such as Polycystic Ovary Syndrome (PCOS), endometriosis, and the menopausal transition. Emphasis is placed on chronic inflammation, metabolic dysfunction, and the "window of opportunity" for Menopausal Hormone Therapy (MHT); 3. Cardio-Oncology: mitigating Cancer Therapy-Related Cardiac Dysfunction (CTRCD) in breast and gynecological cancers, focusing on female-specific cardiotoxicity profiles, the importance of subclinical detection of cardiac dysfunction and the implementation of cardioprotective strategies (ACE-inhibitors, Beta-blockers, SGLT2 inhibitors) during cardiotoxic treatments. Lifestyle interventions such as the DASH diet and exercise-based rehabilitation are highlighted as essential for maintaining cardiac reserve.

BACKGROUND:Recently under the European Society of Cardiology (ESC) EURObservational Research Programme (EORP) PPCM registry the first predictive score was derived. This study sought to test the validity of this predictive score in a cohort of women with PPCM in Uganda. METHODS:80 PPCM cases enrolled had a 12-lead electrocardiography, echocardiography at baseline and at 6-months follow-up. Core clinical data included LVEF, LVEDD, duration of symptoms, QRS duration and pre-eclampsia were captured. RESULTS:Recovered participants' scores included one case who scored ≤ 1 and one of 2, six cases had a score of 3, fifteen cases had a score of 4, six cases had a score of 5, two cases had a score of 6 and only five cases had the highest score of 7. The discrimination analysis achieved a c-statistic of 0.67. CONCLUSION:The ESC EORP PPCM LV predictive recovery score under performed in predicting LV recovery in our Ugandan PPCM cohort.

Heart failure (HF) remains a pressing health concern, with rising prevalence globally. Subjectivity and ambiguity in the definition of HF and its antecedent stages have limited research, global surveillance, and prevention programs. To address this, several cardiac societies and foundations convened to standardize the definition of HF in 2021 and designated stage B or pre-HF to identify individuals at risk of developing HF. In subsequent years, substantial progress and changes have been made in aspects of preventing HF, improving HF diagnosis and management, and recognizing the importance of the affected individual’s voice. Global differences and disparities in HF are better understood, as are causes and comorbidities leading to differences in care, which are also influenced by access to care. This consensus document presents the Second Universal Definition of Heart Failure, aiming to standardize terminology and facilitate a uniform approach for clinicians, researchers, health systems, and policymakers. In this definition, the classification of HF phenotypes moves away from rigid left ventricular ejection fraction cutoffs, instead grouping HF into reduced, preserved, and improved ejection fraction categories to better reflect clinical realities. A universal classification of HF causes is also proposed. The document also addresses the dynamic trajectories of HF—improvement, remission, and recovery—and highlights the impact of social determinants and geographic variation on HF risk and outcomes. By providing a comprehensive, standardized framework for HF definition and classification, this document seeks to improve prevention, early detection, and management of HF worldwide, ultimately enhancing patient care and advancing global cardiovascular health.

BACKGROUND: Congenital heart disease (CHD) is a leading cause of pediatric morbidity and mortality worldwide. The genetics of CHD in African populations is not well understood, although it has been shown in other settings that a genetic diagnosis can have implications for patient management and risk stratification. In this study, we aimed to identify pathogenic and likely pathogenic (P/LP) variants in a cohort of patients with CHD from Southern Africa. METHODS: Exome sequencing was used to screen 356 patients with diverse cardiac phenotypes from South Africa and Namibia. RESULTS: A P/LP variant was identified in 28 patients (7.9%). Analysis of 11 parent-child trios revealed a further LP variant in MYLK in 1 patient, bringing the overall yield to 8.1%. Variants of uncertain significance with high pathogenic potential were found in 30 additional patients. NOTCH1 , MYH11 , and MYH6 had the most recurrent variants in this cohort. Our data expand on the phenotypic spectrum of many established CHD genes, including the overlap between syndromic CHD genes and nonsyndromic presentation, and a potential link between aortopathy genes and conotruncal anomalies such as Tetralogy of Fallot. Variants were identified across the spectrum of CHD subtypes, with an increased yield in patients with atrioventricular septal defects and syndromic CHD, and a slight enrichment of P/LP variants in patients who died after CHD surgery. There were significantly fewer P/LP variants in patients who were of mixed ancestry. CONCLUSIONS: Together, these data confirm a role for rare deleterious variation in nonsyndromic CHD and demonstrate that a P/LP variant can be identified in 8% of patients from Southern Africa.

BACKGROUND:Contemporary data on the aetiology, management, and outcomes of acute heart failure across Africa are scarce. We aimed to conduct a contemporary assessment of acute heart failure aetiology, treatment patterns, presentation rates, and 180-day outcomes across Africa. METHODS:THESUS-HF II was a prospective, multicentre, observational cohort study in 50 hospitals across 17 African countries. Adults aged 18 years or older with acute heart failure were enrolled during seven 24 h surveillance periods within an 8-week, site-specific window. Acute heart failure was identified by acute dyspnoea and congestion, supported by electrocardiography, chest radiography, and point-of-care echocardiography. We assessed presentation rates per 10 000 people in the adult catchment population per week, treatment patterns (including medication use at discharge), readmission, and all-cause mortality through to 180 days. This study was registered with the Pan African Clinical Trial Registry (PACTR202410553810557) and is completed; however, substudies are ongoing. FINDINGS:Between July 1, 2024, and July 31, 2025, 1741 patients were assessed for eligibility at participating hospitals and 1578 were included in the study cohort. 793 (50·5%) of 1570 participants were female, 777 (49·5%) were male, and 1533 (97·8%) of 1567 were of African descent; median age was 56·0 years (IQR 40·0-69·0). The weekly acute heart failure presentation rate was 0·03 per 10 000 people (95% CI 0·02-0·05) overall and 0·02 per 10 000 people (0·01-0·04) for de novo acute heart failure. De novo acute heart failure accounted for 1007 (64·2%) of 1568 presentations. The leading aetiologies were hypertensive heart disease (576 [36·5%] of 1578), cardiomyopathy (370 [23·4%]), and ischaemic heart disease (367 [23·3%]). Median hospital ward stay was 6·0 days (IQR 4·0-10·0), and in-hospital mortality was 8·7% (95% CI 7·3-10·2; 134 of 1542 patients). At discharge, renin-angiotensin-aldosterone system inhibitors were prescribed in 1014 (73·9%) of 1373 patients, β blockers in 1053 (76·9%) of 1369 patients, mineralocorticoid receptor antagonists in 982 (71·9%) of 1366, and SGLT2 inhibitors in 743 (54·7%) of 1359; target doses were reached in fewer than half of patients. Of 1567 patients included in time-to-event analyses, 528 (33·7%) were lost to follow-up before 180 days. All-cause mortality was 11·1% (95% CI 9·6-12·9; 160 deaths) at 30 days and 20·6% (18·4-23·0; 255 deaths) at 180 days. All-cause mortality did not differ across aetiological groups over 30 days (log-rank p=0·39), but differed over 180 days (p=0·019). INTERPRETATION:Compared with THESUS-HF, THESUS-HF II suggests an evolving aetiological profile of acute heart failure in Africa, although differences in ascertainment and diagnostic capability might have contributed to the apparent aetiological shift. High mortality in this relatively young cohort highlights the importance of heart failure prevention, access to cardiac care, guideline-directed therapy, and post-discharge follow-up. These findings suggest that short-term acute heart failure outcomes are not driven by its demographic, aetiological, and echocardiographic factors. FUNDING:Cape Heart Institute, University of Cape Town; Hippocrate Foundation; The Heart Initiative; and Pan African Society of Cardiology.

Cardiovascular disease remains one of the leading causes of maternal mortality worldwide and a major driver of long-term morbidity. Yet, pregnancy-related cardiovascular complications are often under-recognised and variably managed across global settings. This three-part Series examines the continuum of cardiovascular risk surrounding pregnancy-from preconception through to lifelong surveillance. In the first paper in this Series, we describe the haemodynamic changes of pregnancy and global trends of congenital and acquired heart disease before pregnancy, evaluate established risk-stratification tools, and discuss the importance of multidisciplinary care. We focus on the existing burden of cardiovascular disease during pregnancy and related maternal and fetal complications. The second paper focuses on hypertensive disorders of pregnancy-the most common cardiovascular complication during pregnancy worldwide-detailing the pathophysiology, risk factors, and innovative care-delivery models to bridge gaps in longitudinal management. Finally, the third paper examines the association between adverse pregnancy outcomes and future cardiovascular disease, delineating mechanistic pathways, early interventions, and subsequent cardiovascular care. Together, this Series underscores pregnancy as a pivotal window into women's lifelong cardiovascular health and calls for integrated, equitable strategies to prevent avoidable maternal and fetal complications, while substantially lowering the lifetime risk of cardiovascular disease across diverse populations.

Background and Aims Pregnancy in women with a prosthetic heart valve is considered high risk, primarily due to the need for effective anticoagulation. However, data on the relationship between anticoagulation practices and pregnancy outcomes are very limited. Methods The Registry of Pregnancy and Cardiac disease is a global registry that prospectively enrolled pregnancies in women with a prosthetic heart valve between January 2018 and April 2023. Detailed data on anticoagulation, including dosage and monitoring, and cardiovascular, pregnancy, and perinatal outcomes were collected. Results In total, 613 pregnancies were included of which 411 pregnancies were in women with a mechanical valve and 202 were in women with a biological valve. The chance of an uncomplicated pregnancy with a live birth in women with a mechanical valve was 54%, compared with 79% in women with a biological valve (P < .001). Thromboembolic and haemorrhagic complications most frequently occurred when low-molecular weight heparin (LMWH)-based regimens were used. Valve thrombosis occurred in 24 (6%) women, and a prosthetic valve in mitral position was associated with valve thrombosis (odds ratio 3.3; 95% confidence interval 1.9-8.0). A thromboembolic event occurred in 12 (10%) women with anti-Xa monitoring and in 9 (21%) women without (P = .060). Foetal death occurred in 20% of all pregnancies. Conclusions More favourable outcomes were found in women with a biological valve compared with a mechanical valve. In women with a mechanical valve, the use of LMWH was associated with an increased risk of thromboembolic complications. A mitral prosthetic valve was identified as a predictor for valve thrombosis. The benefit could not be confirmed nor refuted, in terms of reduced thromboembolic events, from using anti-Xa level monitoring in women on LMWH.

Heart failure with reduced ejection fraction (HFrEF) imposes a significant clinical burden on patients and a major economic burden on healthcare systems. In HFrEF, mineralocorticoid receptor antagonists (MRAs) constitute a cornerstone of guideline-directed medical therapy (GDMT) reducing both mortality and hospitalisation. Their use in practice remains suboptimal, largely because of physicians' concerns about adverse events, particularly hyperkalaemia, which may deprive eligible patients of benefit. Only the steroidal MRAs spironolactone and eplerenone are approved for HFrEF, and this consensus document is restricted to these agents. We summarise contemporary evidence across multiple domains related to MRA therapy in HFrEF, including pharmacoepidemiology, the role of biomarkers in predicting outcomes and response to MRA, the pathological role of aldosterone and the pharmacology and clinical efficacy of steroidal MRAs. Practical, evidence-based guidance is provided on the prevention and management of hyperkalaemia, the timing of MRA initiation, and strategies to overcome barriers to MRA use. The positioning of MRAs in current guidelines is outlined to reinforce their central role in HFrEF. The process of consensus finding was started in April 2025 with a core group by online conference. We searched PubMed with the terms "MRA, eplerenone and heart failure with reduced ejection fraction". Articles published in English with no date restriction were considered. The final manuscript passed two rounds of final approval by all authors. As a result, this consensus statement advocates proactive, evidence-based approaches to optimise MRA use to improve outcomes. These recommendations aim to mitigate the persistent underuse of MRAs in clinical practice.

AIMS:Synthesizing contemporary data from sub-Saharan African countries, we did a systematic review and meta-analysis of blood pressure (BP) levels and hypertension among adults living in the region. METHODS AND RESULTS:We searched PubMed and other databases to identify studies published from 1 January 2010 to 31 December 2021. We used a random-effects model to estimate the pooled-prevalence of hypertension and mean systolic/diastolic BP overall and on a sex- and age-specific basis. Heterogeneity (I²) was assessed via the χ² test on Cochran's Q statistic. We identified 170 high-quality studies (195 samples) comprising 533 167 adults living in 26 countries. The pooled prevalence of hypertension was 30.5% (95% CI 28.4-32.6%). Overall mean systolic/diastolic BP was 128 (95% CI 127-129)/80 (95% CI 79-80) mmHg, with males recording higher mean BP levels (3.10 [95% CI 2.30-3.90]/0.69 [95% CI 0.10-1.29] mmHg) compared with females. Reflecting increasingly higher BP levels with age, the pooled estimates of hypertension prevalence initially rose three-fold (from 10.6% [95% CI 8.2-13.0%] to 30.9% [95% CI 27.8-34.0%]) in those aged 21-30 to 41-50 years, and then two-fold to 66.4% (95% CI 64.2-68.7%) among those aged 71-80 years, respectively. Hypertension prevalence was lower in healthy weight [28.4% (95% CI 26.1-30.6%)] compared with overweight [35.8% (95% CI 31.4-40.1%)] adults. Regionally, prevalent hypertension was lowest in those living in Eastern Africa [27.2% (95% CI 24.8-29.7%)]. CONCLUSION:Our findings suggest a steep age-related pattern of increasing BP levels in the region that will adversely affect millions of people within the next 10-20 years without urgent intervention.