SA Heart Journal

ECG Quiz 69

A Chin — 2025-10-02

ECG Quiz 69 answers

A Chin — 2025-10-02

A simple guide to analyse data: Descriptive statistics in quantitative research

E Libhaber — 2025-10-02

Statistical data analysis can be divided into two big domains: descriptive statistics and inferential statistics. The process of statistical inference in drawing conclusions about the entire population is based on the information from a sample.⁽¹⁾ Notably, “the inferential statistics process fails if the sample is not representative of the population”.⁽²⁾ To achieve statistical inference, the first step of data analysis before hypothesis testing is descriptive statistics, which is directly linked to the research questions or the study objectives. This guide assumes that sampling and sample size were adequately considered before data analysis. The various steps involved in the analysis of descriptive data are discussed below.

SASCI-Mayo Clinic Fellows webinar: Managing bleeding complications in acute coronary syndrome

H Weich — 2025-08-25

Education remains a core purpose of the South African Society of Cardiovascular Intervention (SASCI), with an emphasis on engaging cardiology fellows in training through regular, structured educational initiatives. In support of this mission, SASCI has partnered with two of our past "Visiting Professors", David Holmes and Gregory Barsness of the Mayo Clinic in Rochester Minnesota, to host quarterly, case-based Fellows Webinars. The webinars are designed to foster critical thinking and clinical decision-making through interactive, case-based discussions and have thus far been very well received, with an average of 70 participants across Southern Africa and beyond.

Specific topics are selected by the SASCI faculty in collaboration with the Mayo cardiologists. Each webinar session has a structured agenda, starting with a clinical case presentation by a cardiology fellow. This is followed by a concise, focused lecture by a Mayo Clinic expert, to provide context and evidence-based guidance. A robust discussion then follows, moderated jointly by the SASCI and Mayo faculty, where active participation by fellows is encouraged. The session concludes with the case presenter sharing a brief follow-up, detailing patient outcomes and the rationale behind management decisions.

All cases are anonymised to protect patient confidentiality. Each webinar is recorded and made available online at https://form.jotform.com/251685088627570. Access is restricted to verified healthcare professionals.

In line with our commitment to ongoing academic contribution, each webinar is intended to culminate in a peer-reviewed manuscript for publication in the South African Heart Journal. As part of the webinar series, the current manuscript focuses on uncommon bleeding complications in patients with acute coronary syndromes, a clinically relevant yet often underappreciated challenge in contemporary interventional cardiology.

The promise and challenges of oral step-down therapy for infective endocarditis in South Africa – Rethinking endocarditis treatment

A Engelbrecht — 2025-08-25

Infective endocarditis (IE) remains a complex clinical challenge globally and in South Africa, where it predominantly affects a younger population. Historically, it was managed with prolonged intravenous (IV) antibiotic therapy, an approach mainly based on expert opinion and low-level evidence. However, recent studies, including the landmark Partial Oral Treatment of Endocarditis (POET) trial, have demonstrated that oral step-down therapy is a safe and effective alternative in selected, clinically stable patients. Modern oral antibiotics now exhibit pharmacokinetic profiles comparable to their IV counterparts, and multiple randomised controlled trials (RCT) have confirmed their efficacy in clearing bacteraemia. While oral step-down therapy has been adopted in high-income settings and incorporated into international guidelines, its implementation in South Africa faces significant challenges. These include a high burden of blood culture-negative infective endocarditis (BCNIE), unique pathogens, such as Bartonella species (spp.) and Mycobacterium tuberculosis (TB), systemic healthcare constraints, limited access to cardiac surgery, and barriers to patient education and followup. In South Africa, locally feasible strategies are required to enable the safe and effective use of oral step-down therapy. Continued local research is needed to guide policy and adapt global evidence to the realities of the South African healthcare system.

Challenges with international normalised ratio control in paediatric patients with rheumatic heart valve replacement surgery in the Eastern Cape Province, South Africa

ZM Makrexeni — 2025-08-25

Introduction: Rheumatic heart disease (RHD) is a preventable chronic condition that affects the heart valves. The incidence of acute rheumatic fever (ARF) and RHD has waned in Western countries; however, this is not the case in developing countries. Poor access to healthcare and a lack of adherence to international normalised ratio (INR) monitoring in RHD contribute to thromboembolic complications.

Methods: Records of patients from the Eastern Cape municipal districts with RHD were reviewed over 10 years. Patients who underwent rheumatic valve replacement surgery were isolated and analysed for their INR control.

Results: A total of 30 patients with RHD were reviewed. All patients presented with severe RHD. Of the 30 patients, 20 had mitral valve replacement surgery, and 6 had mitral valve repair surgery. The 6 patients who had mitral valve repair surgery eventually required mitral valve replacement. Those who had mitral valve replacement surgery were started on anticoagulation (warfarin) post-operatively. Two patients died due to mitral valve thrombosis. Four patients were subsequently admitted for anticoagulation due to a thrombosed prosthetic mitral valve. Most of the patients were struggling to maintain a therapeutic range INR with values ranging from 1.1 to 2, and up to 8–10 on rare occasions.

Conclusion: Most chronic RHD patients underwent mitral valve replacement surgery with a prosthetic valve. Most patients who were started on warfarin struggled to maintain a therapeutic range INR postoperatively due to poor healthcare access and adherence.

Keywords: acute rheumatic fever, rheumatic heart disease, valve replacement surgery, international normalised ratio, disease outcomes

The prevalence, characteristics, associated comorbidities and medical management of patients with atrial fibrillation in a tertiary setting in the Western Cape

S Potgieter — 2025-10-02

Introduction: The prevalence of atrial fibrillation (AF) in high-income countries is high, with less known about low- to middle-income countries. Information on the patient profile and application of adequate guideline-directed management in this low-middle income setting is lacking. This study aimed to determine the prevalence, clinical profile and management of patients with AF across all disciplines in a tertiary setting, and to compare the management of these patients with current guidelines.

Methods: Electrocardiograms (n = 13 414) recorded at Tygerberg Hospital for patients > 18 years between 1 July 2018 – 30 June 2019 were screened and medical records reviewed.

Results: An AF prevalence of 3.4% (n = 460) was found, which corresponded to 341 patients and 238 complete medical records. The mean age was 65.4 (±13.9) years and the most prevalent comorbidities reported were hypertension (63.9%, n = 152) and diabetes mellitus (21%, n = 46). Valvular heart disease was found in 31.1% (n = 74). In 80.7% (n = 192) of patients anticoagulation was indicated; however, only 65.1% (n = 125) of those indicated received it, mostly with warfarin. Time in therapeutic range (TTR) was poor (26.5%). Rate control (< 110 bpm), was seen on 80.9% (n = 372) of ECGs and beta blockers were most frequently used for rate control (65.1%, n = 155). No patients had documented information indicating that they received medical or interventional rhythm control management.

Discussion: The AF prevalence and patient profile resemble those of patients in high-income countries. Slightly more than half of patients qualifying for anticoagulation received this with warfarin, with suboptimal TTR. Rate control strategies were somewhat reassuring; however, the lack of early rhythm control may be disadvantageous to our patients.

The diastolic inflow and longitudinal movement of the heart in the African full-term newborn infant

BJ Beckerling — 2025-10-02

Introduction: Echocardiography is essential in the assessment of systolic and diastolic left ventricular (LV) function. The diastolic component of the cardiac cycle which is a crucial aspect of cardiac output has been less researched in the neonatal population.

Aim: To determine normal echocardiographic references for diastolic inflow and longitudinal movement of both the left and right heart in healthy full-term Black African neonates.

Methodology: A descriptive, bidirectional study design was undertaken. Healthy African (Black) full-term newborn infants who met inclusion criteria were recruited at the Chris Hani Baragwanath Academic Hospital. Left and right ventricular (RV) systolic and diastolic function were assessed using various echocardiographic M-mode, flow Doppler and tissue Doppler measurements. Statistical analysis was performed using Excel and Statistica version 13.1. Normal ranges were calculated using means ± standard deviations.

Results: Two hundred and ninety-two neonates (142 males, 152 females; median gestational age 39 weeks, range 37–42 weeks) were included in the study. Most subjects (175/292;60%) were born by caesarean section.
Median body surface area was 0.20 m² (range 0.16–0.25 m2). Median weight was 3.12 kg (range, 2.5–4.43 kg). Median post-delivery age at echocardiography was 31 hours (range 12–216 hours). The following measurements (means ±SD) were documented: LVEF and LVFS were 73.56% (±8.93) and 40.34% (±7.91) respectively. Mitral valve (MV) peak E = 0.58 m/s (±0.113), MV peak A = 0.59 m/s (±0.123), MV peak E/A ratio = 1.01 (±0.21), MV E’ = 0.058m/s (±0.012), MV E/E’ ratio = 10.38 (±2.65), MV S’ = 0.052 m/s (±0.009) and LV Tei = 0.306 (±0.139). Measurements pertaining to the RV function were: TAPSE = 7.51 mm (±1.304), tricuspid valve (TV) peak E = 0.512 m/s (±0.126), TV peak A = 0.616 m/s (±0.127), TV E/A = 0.845 (±0.199), TV E’ = 0.079 m/s (±0.021), TV E/E’ ratio = 6.78 (±2.02), TV S’ = 0.071 m/s (±0.045) and RV Tei = 0.283 (±0.132).

Conclusion: This large study established normal reference values for diastolic function and longitudinal systolic and diastolic movement of the heart in healthy full-term African neonates using echocardiography.

Cardioneuroablation for treating refractory vasovagal syncope

L Dando — 2025-08-25

Vasovagal syncope (VVS), also known as neurocardiogenic syncope, often presents significant management challenges in patients with frequent refractory episodes. Cardioneuroablation (CNA) targets ganglionated plexi (GP) through catheter ablation to mitigate excessive vagal tone. This case report demonstrates the successful application of CNA in a patient with recurrent neurocardiogenic syncope, initially characterised by a mixed response with a minimal cardioinhibitory component and subsequent electrophysiological evaluation, which revealed significant cardioinhibitory and vasodepressor components, prompting a targeted ablation approach. While future studies are required to evaluate the longterm safety and efficacy, this case adds to the growing evidence that supports CNA as a safe and effective intervention for select patients with refractory VVS.

Keywords: cardioneuroablation, vasovagal syncope, cardioinhibitory response, mixed response, vasodepressor response

Acute myocardial infarction in a patient with anomalous left main coronary artery origin with a hypoplastic left anterior descending artery: A diagnostic and therapeutic challenge

M Cremer — 2025-08-25

Congenital coronary artery anomalies are rare but clinically significant. We present a 41-year-old Caucasian male who presented with acute ST-elevation myocardial infarction (STEMI) involving two distinct vascular territories. Initial electrocardiogram (ECG) findings showed ST-segment elevation in the inferior and anterolateral leads, raising suspicion of multivessel involvement. Delayed access to a cardiac catheterisation laboratory warranted thrombolysis as the primary reperfusion strategy; however, this was unsuccessful. Emergent coronary angiography revealed an anomalous left main coronary artery (LMCA) originating from the right coronary cusp, sharing a common ostium with the right coronary artery (RCA). A critical stenosis of the mid-RCA was identified, attenuated proximally by a thrombolysis in myocardial infarction (TIMI) 3 thrombus burden and complete occlusion of its distal branches. Coronary computed tomography angiography (CCTA) further revealed a hypoplastic left anterior descending artery (LAD). The patient was initially managed with medical therapy alone, and subsequent percutaneous coronary intervention (PCI) was performed for ongoing stable angina, resulting in complete coronary revascularisation. This case highlights the importance of considering coronary anomalies in patients with atypical clinical presentations and the need for individualised treatment approaches. The coexistence of congenital and atherosclerotic coronary artery disease poses significant challenges, and further studies are needed to refine screening and management guidelines.

Keywords: congenital coronary artery anomal, anomalous left main coronary artery origin, anomaly, hypoplastic left anterior descending artery, myocardial infarction, coronary computed tomography angiography

Golden Gate Highlands National Park

Ruchika Meel — 2025-08-30

Photo: Ruchika Meel

Cardiac Imaging Quiz

R Meel — 2025-10-02

Current status of acute rheumatic fever and heart disease in South Africa: Is it on fire, dead, or smouldering?

A Cilliers — 2025-08-25

Rheumatic heart disease (RHD) is the most common acquired heart disease in people aged under 25 years. It affects an estimated 55 million people worldwide and claims approximately 360 000 lives each year, mostly from low- to middle-income countries.⁽¹⁾

RHD results from damage to heart valves caused by one or several episodes of acute rheumatic fever (ARF), which is a complex autoimmune inflammatory reaction to a throat infection caused by the group A β-haemolytic Streptococcus (GAS) organism in genetically susceptible individuals, most often during childhood. It is preventable through controlling the spread of GAS by addressing poverty and overcrowding, and prompt treatment of streptococcal throat infections with antibiotics.⁽¹⁾

Despite RHD’s eradication in many parts of the world, it remains prevalent in sub-Saharan Africa, the Middle East, Central and South Asia, the South Pacific, and among immigrants and older adults in high-income countries (HIC), especially indigenous peoples.⁽¹⁾ RHD epidemiology in Africa, where it remains an important health problem, is largely unknown and poorly documented. Prevalence rates vary in relation to poverty, limited education, awareness, and inadequate healthcare infrastructure.⁽²⁾

Instructions for authors

Editorial Office — 2025-10-02

SA Heart^® publishes peer reviewed articles dealing with cardiovascular disease, including original research, topical reviews, state-of-the-art papers and viewpoints. Regular features include an ECG quiz, image in cardiology and local guidelines. Case reports are considered for publication only if the case or cases are truly unique, incorporates a relevant review of the literature and makes a contribution to improved future patient management. All articles will have a DOI number.

Full Issue

Editorial Office — 2025-10-02

Vol 22 No 3 (2025)

Creating opportunities for Cardiology training in South Africa

AJK Pecoraro — 2025-10-02

South Africa continues to see a rise in the prevalence of cardiovascular disease, as is the case for many low- to middle-income countries. This growing cardiovascular disease burden, combined with rapidly evolving treatment modalities, requiring the acquisition of novel skills by practitioners, places an ever-increasing strain on the country’s limited number of cardiologists.

Challenges in advancing clinician scientist careers in cardiology in South Africa

R Meel — 2025-10-02

Clinician scientists (CS) are medically trained professionals with advanced expertise in both clinical practice and biomedical research.⁽¹⁾ Their aim is to develop a complete understanding of disease processes, from molecular mechanisms to clinical manifestations and therapeutics, enabling them to play an important role in advancing translational research.⁽¹⁾