Elijah Ogola

Advance care planning (ACP) is an interactive, person-centred process through which individuals, at any stage of health, engage with healthcare providers to clarify their values, preferences, and goals for future medical care, ensuring that treatment decisions remain concordant with patient wishes even when they are no longer able to communicate them directly. In Kenya, as in the rest of sub-Saharan Africa, cancer ranks as the third leading cause of death, with approximately 35,867 new cases and 22,888 deaths recorded in 2024, reflecting a growing burden of advanced and often incurable disease at diagnosis. Despite evidence that ACP improves end-of-life outcomes, including higher rates of advance directive completion, reduced use of intensive, non-beneficial end-of-life interventions, increased and earlier uptake of hospice and palliative care services, and diminished psychological and bereavement burden among surviving family members, its uptake remains persistently low, particularly in resource-constrained and culturally diverse settings such as Kenya. This chapter provides a comprehensive background on ACP, tracing its conceptual evolution and core components, and reviews global epidemiological and clinical evidence on its uptake and practice among cancer patients. It further examines the facilitators and barriers to ACP engagement, spanning patient, provider, and systemic levels, and contextualises these findings within existing policy, legal, and healthcare environment, including the absence of formal legislative recognition of advance directives. A study on assessment of ACP practice and advance directive uptake among cancer patients in Kenya that offerred evidence to inform local policy and clinical practise serves as the primary study underpinning this review.

Heart failure (HF) remains a leading cause of morbidity and mortality worldwide, with particularly poor outcomes in low- and middle-income countries (LMICs). Despite strong evidence for guideline-directed medical therapy in terms of mortality/morbidity reduction and improvement in quality of life, the real-world implementation remains suboptimal, even in high-income settings. In LMICs, barriers are compounded by limited access to diagnostics, essential pharmaceutical and device therapy, alongside socioeconomic constraints and fragmented healthcare systems. Structural inequities, including the underrepresentation of LMIC populations in clinical trials, further restrict the applicability of evidence-based interventions. This position document highlights key challenges to guideline implementation in resource-limited settings, including affordability, workforce shortages, cultural practices, and gaps in infrastructure and insurance coverage. Strategies to address these barriers include the use of accessible diagnostics, decentralization of care, expanded roles for non-specialist providers, and telemedicine-supported continuity of care. Broader systemic reforms, including improved insurance systems, stronger referral networks and the integration of primary prevention, are critical. Finally, equitable representation of LMIC populations in clinical research should be prioritized to ensure the safety and efficacy of future therapies. Bridging the gaps in HF care at the global level requires context-specific adaptation of international guidelines, targeted healthcare system strengthening, and innovative care delivery models that make evidence-based HF treatment accessible, affordable, and sustainable.

Background Despite treatment, many hypertensive patients with coronary heart disease (CHD) have blood pressure (BP) that remains above guideline targets. However, less is known about patients in whom on-treatment BP is below target and major European guidelines differ substantially in their recommendations for such patients. Specifically, 2023 European Society of Hypertension (ESH) guidelines provide a Class 3 recommendation to proactively avoid BP below target whereas 2024 European Society of Cardiology (ESC) guidelines do not. Methods Between 2020 and 2023, adults hospitalised in the previous 6–24 months with incident or recurrent CHD were sampled in 14 countries from all six WHO regions and invited for a standardised interview and examination as part of the International Action on Secondary and Primary Prevention by Intervention to Reduce Events (INTERASPIRE) study. We measured seated BP twice using an automated oscillometric device after 5 min of rest. We defined participants as having BP above target (BP ≥130/80 mm Hg), at target (BP 120–129/70-79 mm Hg) or below target (Results Among 4548 participants (21.1% female), the mean age (±SD) was 60.0 (±10.3) years. At a median (IQR) of 1.05 (0.76–1.45) years after index CHD hospitalisation, 10.3% of patients had BP readings within the target range of 120–129/70-79 mm Hg, with 53.9% above target and 35.7% below target. Patients with below-target BP were more likely to have heart failure (13.6% vs 10.0%, p=0.041) and estimated glomerular filtration rate Conclusions More than one-third of INTERASPIRE patients with CHD presented with BP <120/70 mm Hg, which is below target per current European hypertension guidelines. Further research is needed in this population to resolve discordant guideline recommendations and determine whether de-escalation of BP-lowering therapies is beneficial or even harmful in this setting.

The 2023 focused update of the European Society of Cardiology 2021 guidelines reviewed the latest scientific evidence and provided recommendations for the guideline‐directed medical therapy for the treatment of heart failure. The class IA level of recommendation for SGLT2i (sodium‐glucose co‐transporter‐2 inhibitor) in heart failure with mildly reduced and preserved left ventricular ejection fraction is of considerable relevance in clinical practice. With a marked increase in the overall burden of heart failure and associated risk factors in the Middle East and Africa region, it is crucial to devise a standardized plan for diagnosis and treatment that accounts for epidemiological nuances, the current evidence on newer treatments, and the health care infrastructure available in the region. A group of 45 cardiologists, moderated by 9 experts from the Middle East and Africa region, reviewed the 2023 focused update of the European Society of Cardiology 2021 guidelines in the context of the current state of guideline‐directed medical therapy‐guided clinical practice. The experts also shared their perspectives on challenges and strategies to overcome for a successful implementation of guideline‐directed medical therapy, particularly SGLT2i, in line with the focused update, for management of heart failure in their respective region/country. Here we present (1) a brief review of the existing literature on the latest burden of disease from the region, (2) a short overview of diagnosis and clinical characteristics of heart failure, (3) a review of the clinical evidence leading to the 2023 update of the European Society of Cardiology 2021 guidelines, and (4) a discussion of the current state and opportunities for implementation of guideline‐directed medical therapy‐guided clinical practice in the region.

Background: With the advancement of technology in genomics and mainstreaming of genomics across all specialties of medicine, physicians will be required to play a pivotal role in coordinating and providing primary genetic services. Objective: To describe the delivery of basic genetic services among physicians in Kenya and factors affecting the integration of genomic medicine into their practice. Materials and methods: This was an online, descriptive, cross-sectional study conducted among registered physicians practicing in Kenya and physicians-in-training (registrars) at the University of Nairobi, using an anonymous, self-administered questionnaire. The following domains were assessed: delivery of genetic services, attitudes and perceptions towards genetics, barriers to the delivery of genomic services, knowledge of genetics and physicians’ demographics. Simple random sampling method was used to recruit participants for the study. Descriptive analysis methods were used for data analysis. The data was summarized using frequencies and proportions. Results: The response rate was 41%, with 190 of the 464 eligible physicians completing the survey. Eighty-seven percent of respondents had not received formal training in genetics, with 80% reporting involvement in the evaluation of genetic patients. Physicians’ involvement in genetic testing and pharmacogenomics was low at 31% and 29% respectively. Sixty-four percent of the respondents graded their knowledge of genetics as moderate. Participants identified limited access to medical geneticist (80%), lack of referral guidelines (86%), high cost of genetic services (93%), and inadequate knowledge of genetics as barriers to genetic service delivery. Conclusion: Uptake of genomic service provision to patients by physicians remains low due to inadequate genetics training, limited number of specialists, in genetics and prohibitive costs of genomic testing. Mitigation of these factors is required to improve access to genetic care.

Aims: Anxiety and depression are associated with poor outcomes in patients with coronary heart disease (CHD), however their association with achieving recommended cardiovascular prevention standards is unclear. We examined this association across all World Health Organization (WHO) regions. Methods and results: Cross-sectional analysis of the INTERASPIRE study of adults hospitalized in the preceding 6–24 months with incident or recurrent CHD who underwent a standardized interview and examination (2020–2023) across 14 countries. The main outcome was the INTERASPIRE-Guideline Target Score (GTS); a 10-point assessment of achieving secondary prevention lifestyle, risk factor, and therapeutic targets. A total of 4546 patients (21.1% women) with a mean (SD) age of 60.0 (10.3) were interviewed. Prevalence’s of anxiety and/or depression were greater in women than men, and prevalence of CHD lifestyle and behavioral risk factors increased alongside severity of anxiety and depression symptoms. Compared to those without symptoms, adjusted odds ratios for achieving a suboptimal INTERASPIRE-GTS were: 1.52 (95% CI 1.13–2.04, P = 0.006) for symptoms of depression; 1.57 (95% CI 1.09–2.26, P = 0.015) for “possible” comorbid anxiety and depression; and 2.09 (95% CI 1.22–3.57, P = 0.007) for those with “probable” comorbid anxiety and depression. Conclusion: Increasing severity of depression and anxiety symptoms are associated with reduced potential for achieving guideline standards for CHD secondary prevention. Secondary prevention programs should integrate risk-stratified management of individuals with symptoms of anxiety and/or depression to improve CHD guideline targets. Lay summary: We examined if patients with symptoms of anxiety and/or depression were more or less likely to achieve guideline standards for secondary prevention of coronary heart disease (CHD).Increasing severity of symptoms of anxiety and depression was associated with reduced potential for achieving guideline standards for secondary prevention of CHD.A higher proportion of women with CHD experience more severe levels of anxiety and depression on their own, and combined as a comorbidity.Patients with CHD should be treated holistically, acknowledging the heart and mind connection.

Background: INTERASPIRE was an observational study of patients with coronary heart disease (CHD) from 88 hospitals in 14 countries across all six WHO regions. The objective was to describe the proportions of patients referred to and attending cardiac rehabilitation (CR) programmes and to compare lifestyle and risk factor target achievement according to participation in a CR programme. Methods: Patients 18–80 years of age, with a first or recurrent coronary hospitalisation (acute coronary syndrome and/or revascularisation procedure) were identified and invited to an interview and examination, between six months and two years after the index hospitalisation. Results: Overall, 4,548 (21.1% female) patients were interviewed a median of 1.05 (interquartile range 0.76–1.45) years after hospitalization. Of those patients, 34.4% reported having been advised to participate in a CR programme, though the percentage varied widely by country, from 4.0% in Kenya to 69.6% in Poland. Among patients advised to participate in CR, 57.1% participated in ≥50% of all sessions, 15.4% participated in <50% of the sessions, and 27.4% did not participate at all. Only 19.6% of all patients recruited to the study attended ≥50% of sessions. Content of programmes reported by patients also varied enormously between countries. Low education level, elective PCI, or unstable angina as recruiting events were associated with lower attendance rates. Attendance at ≥50% of all CR sessions was associated with a lower prevalence of persistent smoking and physical inactivity, better control of blood pressure and LDL-cholesterol, and a higher use of cardioprotective medications. Conclusions: INTERASPIRE provides a standardised international picture of CR provision and attendance in patients with CHD. Despite CR being a Class 1 recommendation in all international guidelines, only one third of CHD patients reported being advised to attend any form of CR and just one in five patients attended 50% of the sessions, with striking heterogeneity between regions and countries. National cardiology societies should advocate to their governments for urgent investment in standardised CR services.

Cardiovascular diseases (CVDs) are the leading global cause of mortality, with treatment adherence posing a major barrier to effective prevention and control. Single pill combinations (SPCs), also known as fixed-dose combinations, simplify treatment by combining multiple agents into one pill, improving adherence and reducing cardiovascular risk. This World Heart Federation Roadmap synthesizes the latest clinical evidence and identifies key barriers to SPC implementation, including limited manufacturing, affordability, regulatory complexity, and inconsistent guideline inclusion. Drawing on global expert input and health systems analysis, the Roadmap outlines practical, context-specific solutions to improve access, scale-up, and integration of SPCs into national strategies, especially in low- and middle-income countries. It serves as a tool for policymakers, clinicians, and advocates to drive progress in aligning cardiovascular prevention efforts with evidence-based, people-centred care.

Background: Sickle cell disease is a severe autosomal recessive disorder most prevalent in people of African descent. It is associated with significant morbidity and premature death. Premarital screening for sickle cell is a cost-effective strategy intended to minimize high risk couplings. Premarital screening for sickle cell is yet to be adopted in Kenya. Aim: this study sought to assess awareness and acceptance of premarital screening for sickle cell among a young Kenyan population. Materials and Methods: A descriptive cross-sectional research design utilizing an online, self-administered, questionnaire was conducted among 314 University students selected by multistage sampling technique. Statistical analysis was done using descriptive methods. The following domains were assessed: Students demographics, Knowledge of inheritance patterns, Attitude and perception towards premarital screening for sickle cell and, acceptance of premarital screening. Chi square test was used to determine significance of association between the study variables and the two groups. Results: A total of 314 unmarried students were recruited with 134 (43%) medical students and 180 (57%) non-medical students. Males were 172(55%) and females 142(45%). Majority; 191(61%) were between ages 21∼25. Overall good knowledge was 241(77%). Sickle cell was identified as a heritable disorder by 123(92%) of medical students and 98(54%) non-medical students. Diagnosis of sickle cell via blood test was correctly identified by 121(90%) medical and 92(51%) non-medical students. Premarital screening was identified as beneficial by 124(93%) medical and 136(76%) non-medical students. Majority of non-medical students (54%) had negative attitude towards pre-marital screening compared 10% medical students. Of all respondents, 74(24%) were unwilling to undergo premarital screening for sickle cell. A Total of 44(14%) were unsure whether to undergo screening or not. Conclusion: Sickle cell is the commonest monogenic disorder in Kenya. Kenyan youths demonstrated significant gaps on knowledge on inheritance patterns, attitude and perception towards premarital screening for sickle cell. There was also limited acceptability to undergo individual premarital screening and genetic counselling. Health education on premarital screening and genetic counselling is an important intervention at reducing burden and prevalence of sickle cell disease.