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Original article

Long-term prognosis of patients with permanent cardiac pacemaker

indication in three referral cardiac centers in Cameroon: Insights from
the National pacemaker registry
Pronostic à long terme des patients avec indication d’un stimulateur cardiaque
permanent dans trois centres cardiaques de référence au Cameroun : aperçu du
registre national des stimulateurs cardiaques
A. Dzudie a,b,c,∗ , C. Ngongang Ouankou d , L. Nganhyim b , S. Mouliom a , H. Ba e , F. Kamdem e ,
J. Ndjebet f , A. Nzali g , C. Tantchou h , C. Nkoke b,i , B. Barche b,e,f , M. Abanda b ,
U.A. Metogo Mbengono e,j , R. Hentchoya j , C. Petipe Nkappe i,k , M. Ouankou d ,
C. Kouam Kouam l , P. Mintom e,g , J. Boombhi c , L. Kuate Mfeukeu c , W. Ngatchou e ,
S. Kingue c , M. Ngowe Ngowe e
a
Cardiology and Cardiac Pacing Unit, Douala General Hospital, P.O Box 4856 Douala, Cameroon
b
Clinical Research Education Networking & Consultancy (CRENC), Douala, Cameroon
c
Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
d
Cardiology and Medical Centre, Yaounde, Cameroon
e
Faculty of Medicine and Phramaceutical Sciences, University of Douala, Douala, Cameroon
f
Douala Cardiovascular Centre, Douala, Cameroon
g
Deido District Hospital, Douala, Cameroon
h
Shisong Cardiac Centre, Kumbo, Cameroon
i
Buea Regional Hospital, Buea, Cameroon
j
Intensive Care Unit, Douala General Hospital, Douala, Cameroon
k
Guidelines Advisory Network, Paris, France
l
Service of internal medicine and cardiology, Bafoussam regional hospital, Bafoussam, Cameroon

a r t i c l e i n f o a b s t r a c t

Article history: Background. – There is evidence that cardiac pacemakers improve symptoms and quality of life in patients
Received 3 February 2020 with severe bradycardia. Globally, the number of pacemaker implantations is on the rise. However,
Accepted 21 July 2020 the associated high-cost limits pacemaker’s accessibility in low resource settings. This study aimed to
Available online xxx
investigate access to pacemakers and the long-term outcome of patients requiring a pacemaker.
Method. – We conducted a cohort study in 03 health care structures in Cameroon. Participants aged at
Keywords: least 18 years with indication for a permanent pacemaker between January 2010 and May 2016 were
Cardiac pacemaker
included. Clinical profile, electrocardiography, pacemaker implantation parameters were recorded. Long-
Indications
Long-term prognosis
term survival was studied by event-free analysis using the Kaplan-Meier method.
Survival Results. – In total, 147 participants (mean age 67.7 ± 13.7 years, female 58.5%) were included. Fatigue
(78.7%), dyspnoea (77.2%), dizziness (47.1%) and palpitations (40.4%) were the main symptoms while
syncope was present in 35.7% of patients. The main indication for cardiac pacemaker was atrioventricular
block (85.3%). Forty (27.2%) could not be implanted with 34 (85%) of participants highlighting cost of
intervention as main reason. VVIR was the main mode of stimulation (70.5%). Of 125 patients in which
follow-up was ascertained, 17(13.5%) died after a median survival time of 2.8 years post diagnosis [IQR:

Abbreviations: AVB, Atrio-Ventricular Block; BP, Blood Pressure; DGH, Douala General Hospital; ECG, Electrocardiogram; ESC, European Society Of Cardiology; SSA, Sub
Saharan Africa.
∗ Corresponding author at: Cardiology and Cardiac Pacing Unit, Douala General Hospital, P.O Box 4856 Douala, Cameroon.
E-mail address: aitdzudie@yahoo.com (A. Dzudie).

https://doi.org/10.1016/j.ancard.2020.07.005
0003-3928/© 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Dzudie A, et al. Long-term prognosis of patients with permanent cardiac pacemaker indication
in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry. Ann Cardiol Angeiol (Paris) (2020),
https://doi.org/10.1016/j.ancard.2020.07.005
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ANCAAN-1357; No. of Pages 7 ARTICLE IN PRESS
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1.8–4.2]. The survival curve was better in participants with a pacemaker with a Hazard ratio of 2.7 [CI:
1.0–7.3, P = 0.045].
Conclusion. – Our patients with severe heart blocks presented late and more than a quarter did not have
access to pacemaker but its implantation multiplied the survival rate by 2.7 times at approximately 3
years post diagnosis. Improving early detection of heart blocks and access to cardiac pacing to reduce
mortality shall be a key future priority.
© 2020 Elsevier Masson SAS. All rights reserved.

r é s u m é

Mots clés : Contexte. – Les stimulateurs cardiaques améliorent sans aucun doute les symptômes et la qualité de vie des
Stimulateur cardiaque patients atteints de bradycardie sévère. À l’échelle mondiale, le nombre d’implantations de stimulateurs
Indications cardiaques est en augmentation. Cependant, le coût élevé limite l’accessibilité dans les pays à ressources
Survie limitées. Ce travail visait à étudier l’accès aux stimulateurs cardiaques et les résultats à long terme des
Pronostic à long terme
patients nécessitant un stimulateur cardiaque.
Méthode. – Nous avons mené une étude de cohorte dans 03 hôpitaux de référence cardiovasculaire au
Cameroun. Les participants âgés d’au moins 18 ans avec indication d’un stimulateur cardiaque permanent
entre janvier 2010 et mai 2016 ont été inclus. Le profil clinique et électrocardiographique ainsi que la
mortalité ont été étudiés. La survie à long terme a été étudiée par analyse sans événement en utilisant la
méthode de Kaplan–Meier.
Résultats. – Au total, 147 participants (âge moyen 67,7 ± 13,7 ans, femmes 58,5 %) ont été inclus. La
fatigue (78,7 %), la dyspnée (77,2 %), les vertiges (47,1 %) et les palpitations (40,4 %) étaient les principaux
symptômes tandis que la syncope était présente chez 35,7 % des patients. La principale indication du
stimulateur cardiaque était le bloc auriculo-ventriculaire (85,3 %). Quarante (27,2 %) n’ont pas pu être
implantés et 34 (85 %) des participants ont souligné le coût de l’intervention comme principale raison. La
stimulation VVIR était le principal mode de stimulation (70,5 %). Sur 125 patients chez lesquels un suivi
a été établi, 17 (13,5 %) sont décédés après une durée médiane de survie de 2,8 ans après le diagnostic
[IQR: 1,8–4,2]. La courbe de survie était meilleure chez les participants avec un stimulateur cardiaque
(HR = 2,7, 1,0–7,3, p = 0,038).
Conclusion. – Nos patients présentant des blocs cardiaques sévères consultaient tardivement et plus d’un
quart n’avaient pas accès à un stimulateur cardiaque mais son implantation multipliait malgré tout le
taux de survie par 2,7 fois environ 3 ans après le diagnostic. L’amélioration de la détection précoce des
blocs cardiaques et de l’accès à la stimulation cardiaque pour réduire la mortalité doit être une priorité
future majeure.
© 2020 Elsevier Masson SAS. Tous droits réservés.

1. Introduction 2. Methods

Cardiovascular diseases are constantly increasing worldwide,
and particularly in low-income countries [1–3]. Bradyarrhyth-
mias are among the common arrhythmias and a real concern to
the health care system due to its increasing prevalence with age
and the cost of the pacemaker implantation [3,4]. In Europe and
the United State, the number of pacemaker implanted increases
every year and is extremely higher than in low-income countries
[4–7]. The aging of the population, the technological advances
of these devices, and the growing number of clinical indications
are the main factors that contribute to the increase of this rate
[6,7]. In a longitudinal study of 6505 after pacemaker implan-
tation in Germany, age, gender, decade of procedure, type of
pacemaker, index arrhythmia and initials symptoms were inde-
pendently associated with long-term survival [8]. In Cameroon,
to our knowledge, only Tantchou C published the pacing activ-
ities of the Shisong’ centre in 2017 and described feasibility of
cardiac pacing and resynchronization therapy with good results
and low complication rate [9]. There is still a huge dearth of qual-
ity data to persuade stakeholders and policy makers on the need
of creating and equipping cardiac electronic services in our sett-
ings, In Cameroon, data are lacking on this subject to help assess
the need for cardiac electronic services in our settings, and until
recent, there was no registry of patients requiring a cardiac device.
Considering all these, it seemed timely to conduct this study, with
the aim of investigating the clinical characteristics of patients with
severe heart blocks, their access to pacemakers and their long-term
outcomes.
2.1. Study design and clinical setting
Data were retrospectively obtained from the National pace-
maker registry, which was created in 2013 by the Cameroon
Cardiac Society Investigator group for improvement of outcomes in
patients with heart blocks. All centres with experience in the diag-
nosis and timely referral or clinical management of patients with
severe heart block were invited to join based on 2 simple criteria:
• availability of a trained and certified cardiologist;
• availability of a resting electrocardiogram.
This national registry enrols patients if they are diagnosed with
heart blocks with indications of cardiac pacing ascertained by a con-
sultant cardiologist based on electrocardiogram with or without
symptoms. In this registry, indications of pacemaker implantation
were likely to change during the study period but remained in
accordance with the European Society of Cardiology (ESC) guide-
lines of cardiac pacing [10]. However, due to limited resources,
physicians in our setting tend to limit pacemaker
However, due to limited resources, physicians in our setting
tend to limit pacemaker indications to class I and IIa of the 2013
ESC guidelines for pacing [10]; which include severe bradycardia
with/without symptoms, Sick Sinus Syndrome with/without symp-
toms, grade 2 Mobitz II or Complete atrioventricular block (Fig. 1)
with/without symptoms. Symptoms that were sought include
syncope, dyspnea, dizziness, fatigue and palpitation. Patients were

Please cite this article in press as: Dzudie A, et al. Long-term prognosis of patients with permanent cardiac pacemaker indication
in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry. Ann Cardiol Angeiol (Paris) (2020),
https://doi.org/10.1016/j.ancard.2020.07.005
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Fig. 1. Electrocardiogram of a needy 55-year-old woman referred to the emer-

gency department of the Douala General Hospital on January 17, 2018 for recurrent
syncope and died by sudden cardiac arrest 16 h after admission.

likely to come from any of the ten regions of Cameroon and

neighbouring countries but three major cardiac services con-
tributed to this registry including the Douala General Hospital
(DGH), the Douala Cardiovascular Centre, and the Cardiologic and
Medical Centre in Yaounde. These centers incorporate specialized
cardiovascular units with capability to diagnosed heart blocks by
well-trained personnel. The two first centers are located in Douala,
which is the economic capital of Cameroon and is one of the largest
cities in the country with an estimated population of 3 million
inhabitants. The third centre is a referral centre for heart blocks
in Yaounde, which is the political city of Cameroon with an esti-
mated population of 2.5 million inhabitants. All patients were
transferred to the DGH where data were collected on a point-of-
service computer-based registry. Ethical approval was obtained Fig. 2. Flow diagram of our study cohort.
from the Ethical Review Board of the Universte des Montagnes and
administrative authorisations from the participating institutions,
and the study conformed to the principles of the Declaration of since diagnosis or cardiac pacing were considered lost to follow
Helsinki. up.

2.2. Inclusion and exclusion criteria 2.4. Statistical analysis

We included participants if they fulfilled the following criteria: Data analyses was done using SPSS version 21.0; continuous
variables are presented as median with an interquartile range
(IQR) while categorical variables are presented as numbers and
• participant aged 21 years or older;
percentages. For group comparisons, we used Chi2 (2 ) analysis
• diagnosis of severe heart block based on resting ECG with or with-
with calculation of hazard ratios (HR) and 95% confidence inter-
out symptoms and indication of cardiac pacing ascertained by a
val (CI), where appropriate. Mortality data was used to generate
consultant cardiologist;
Kaplan–Meier survival curves with initial univariate analysis. We
• documented electrocardiogram showing evidence of severe heart
then used a step-wise multivariate analysis (including the variables
block (Fig. 1) For the purpose of this analysis, we restricted the
of age, sex, pacing mode) to derive unadjusted and adjusted ORs for
dataset to patients who did not leave against medical advice and
mortality during the follow up period. Significance was accepted at
had documented evidence of severe heart blocks.
a P-value level of 0.05.

2.3. Data collection

3. Results
We collected the following data:
3.1. Study cohort
• sociodemographic parameters;
• Fig. 2 summarises the total number of participants recruited
personal and family cardiovascular past history;
• and their distribution according to study sites. Over a period of 77
cardiovascular risk factors;
• months 147 participants were included among which 107 (72.7%)
pacemaker indication diagnosis and management;
• had subsequent pacemaker implantation, 21 (14.3%) participants
signs and symptoms at the diagnosis;
• were lost to follow up.
available electrocardiography interpretation;
• follow up done prior to inclusion. Follow up was done during
visits and if a patient could not come, we collected data on sur- 3.2. Sociodemographic and risk profile
vival by phone calls. In case of death, we noted the date of death
as provided by the family. Subjects were considered unreach- Table 1 summarises the socio-demographic characteristics and
able or lost to follow up after a minimum of 9 phone calls on risk factor profile of our study population by pacing status. Overall,
three different days and in which case we considered the infor- as shown in Table 1, participants were likely to be female (58.5%),
mation of the latest follow up prior to commencement of the unemployed or retired, aged above 60 years with a median age of
study. Unreachable participants who had never attended visits 71 years hypertensives (68.7%) and overweight (60%). Distribution

Please cite this article in press as: Dzudie A, et al. Long-term prognosis of patients with permanent cardiac pacemaker indication
in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry. Ann Cardiol Angeiol (Paris) (2020),
https://doi.org/10.1016/j.ancard.2020.07.005
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Table 1
Socio-demographic and risk factor profile of our study population by pacemaker status.

All Paced Not paced P-value

Subjects, n (%) 147 107 (72.8) 40 (27.2)

Sociodemographic characteristics
Age
Median (IQR) 71 (6–77) 71.5 (63–78) 70.0 (50–77) 0.34
Gender, n
Female 86 64 22 0.56
Male 61 42 19 0.67
Employment, n
Worker formal sector 11 7 04 0.43
Worker informal sector 19 07 13 0.27
Without employment 62 53 09 < 0.01
Retired 55 44 11 < 0.01
Risk factors profile
Cardiovascular risk factors, n
Hypertension 86 70 16 0.01
Diabetes 18 12 6 0.38
Smoke 8 6 2 0.98
Overweight 27 26 1 < 0.01
Obesity 21 16 5 < 0.01
Comorbidity, n
Rheumatic heart disease 01 0 01 0.40
CKD 03 01 02 0.74

CKD: chronic kidney disease; IQR: interquartile range.

(Fig. 4) showed that the survival in the short, medium and long term
was better among participants with a pacemaker (P = 0.038), with
a significant survival rate of 2.7 [OR: 2.7; IC: 1.0–7.4; P = 0.045]. In
multivariable analysis, not paced participants had a 28% increased
hazards risk of death (Table 4).

4. Discussion

From this analysis of the national registry-based cohort of

Fig. 3. Distribution of participants by pacemaker implantation status and age group.
by pacemaker inplantation status and by age group is provided in
Fig. 3.
3.3. Clinical findings, pacemaker implantation and survival
Table 2 summarises the clinical profile of our participants by
pacing status. Overall, all participants presented with advance
symptoms, but paced participants presented with more severe
symptoms including fatigue, dyspnoea, syncope and cough (all
P < 0.05). Median heart rate was lower in paced participants (38.0,
IQR: 35.0–44.0 vs 40.5, IQR: 39.0–52.0, P = 0.01) but there was no
difference in structural heart disease between the two groups. Syn-
cope was found in 37.5% of our participants.
Indications for pacemaker implantation were predominantly
complete atrioventricular block at 57.4% (Table 3) especially in the
paced group while sick sinus syndrome was predominant in non-
paced group (03 vs 11, P = 0.00). Forty (27.2%) participants were
not implanted with 34 (85%) due financial constraints and 06 other
(15%) due to fear. Among the 107 paced patients, 105 (98.1%) were
implanted in Cameroon. As reflected in Table 3, left sub clavicular
vein was the dominant route of implantation (93.5%) and VVIR was
the most frequent mode of pacing (70.5%). Our median follow-up
time since diagnosis was 34 months [IQR: 21–50]. Of 17 (13.5%)
patients who died, 10 (10.5%) were from the paced group while
07 (22.6%) were from the non-paced group. Kaplan Meier curve
patients with indications of cardiac pacing, 27% could not be
implanted mainly due to inability to pay for the device. Typically,
patients needing cardiac pacing in our setting were more likely to
be unemployed or retired individuals around 70 years of age with
complete atrioventricular block, who presented late with advanced
symptoms, but still, their survival in the short, medium and long
term was better with implantation of a pacemaker. This study
remains one of the largest cohorts with long-term follow-up of
patients with severe heart blocks diagnosed and managed at ref-
erence cardiovascular centres in Cameroon. Our findings quantify
the substantial burden that heart blocks places on patients, health
care systems, and society and highlights the critical need to define
a national strategy to early identify and implant these patients so
as to improve outcomes.
The predominance of elderly in our study is similar to results
obtained in other studies in Europe and Africa. Indeed, Brunner
et al. in 2004 in Germany [8], and Bouraoui et al. in Tunisia [11],
described a mean age of 72 and 69 years respectively. That aeti-
ologies of bradyarrhythmias requiring a pacemaker are dominated
degenerative diseases of the conducting system might explain the
dominance of old age [10,12]. We described a predominance of
atrio-ventricular block (AVB) (86.9%) with 98.1% of patients pre-
senting with dyspnoa and 33.6% with syncope. In another study of
patients with heart blocks in Cameroon, Tantchou et al. described
dyspnoea in 58% and syncope in 23% of cases [13]. The predomi-
nance of complete atrio-ventricular block in symptomatic patients
with heart blocks has been previously described in their clinical
study by Ondze et al. in Congo in 2016 [14]. However, we cannot
rule out the possibility that this dominance of complete AVB in
clinical series could be a selection bias. Indeed, patients with com-
plete AVB are generally symptomatic and would tend to seek for
care earlier than those with less severe heart blocks, and resting

Please cite this article in press as: Dzudie A, et al. Long-term prognosis of patients with permanent cardiac pacemaker indication
in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry. Ann Cardiol Angeiol (Paris) (2020),
https://doi.org/10.1016/j.ancard.2020.07.005
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Table 2
Clinical and biological findings of our study populationbefore pacemaker implantation and by pacing status.

All Paced Not paced P-value

Symptoms
Fatigue 107 83 24 0.006
Dyspnoea 105 80 25 0.048
Dizziness 64 55 9 0.01
Palpitations 55 41 14 0.59
Syncope 36 32 4 0.009
Cough 32 30 2 0.002
Chest pain 29 21 8 0.96
Lower limb oedema 25 18 7 0.99
Lipothymia 18 12 6 0.58
Orthopnoea 8 7 1 0.17
Physical parameters
Median Systolic BP 153 (132–172) 158.05 (27.95) 148.50 (30.33) 0.09
Median Diastolic BP () 73.54 (13.60) 76.55 (14.16) 0.1
Heart rate
Median HR (IQR) 40 (35.3–45.5) 38.0 (35.0–44.0) 40.5 (39.0–52.0) 0.01
BMI category, n (%)
25–30 27 (18.4) 21 6 0.2
≥ 30 21 (14.2) 16 5
Clinical signs of HF 75 (51.1) 33 42 0.56
Cardiac echography
Structural heart disease n (%) 65 (63.1) 34 (29.3) 31 (15.0) 0.63
65.8 (15.2) 63.3 (15.3) 66.9 (12.4) 0.17
Laboratory test mean (SD)
Na+ 139.7 (5.6) 139.54 (5.80) 140.13 (4.69) 0.72
K+ 4.2 (0.6) 4.18 (0.63) 4.28 (0.68) 0.61
Urea 0.64 (0.6) 0.64 (0.59) 0.65 (0.76) 0.95
Creatinine 14.7 (15.4) 14.99 (16.02) 12.47 (8.36) 0.68

BP: blood pressure, BMI: body mass index, HF: heart failure, LV: Left Ventricular, SD: standard deviation.

Table 3
Pacemaker indications, route of implantation, mode of stimulation, and post-operative complications.

All Male Female P-value Paced Not paced P-value

Indications

Complete atrio-ventricular block 94 39 55 0.76 75 18 0.00

Mobitz 2 atrio-ventricular block 15 05 10 0.17 09 06 0.09
Slow rate atrial Fibrillation 17 05 12 0.41 14 03 0.06
Sick Sinus Syndrome 14 09 05 0.15 03 11 0.00
Trifascicular Block 07 05 02 0.20 02 05 0.00
Route for pacing 105
Left subclavian vein 81 41 40 0.97
Right subclavian vein 11 06 05 0.32
Other 13 06 07 0.15
Mode of stimulation
VVIR 65 27 38 0.84
VDDR 09 04 05 0.82
DDIR 2 01 01 0.79
DDDR 31 12 19 0.65
Post-operative complications 03
Infection 01 01 0 0.22
Lead displacement 02 01 01 0.76

Table 4 et al. who observed that the cost of the device and the procedure
Predictors of all cause mortality.
where the obstacles to pacemaker implantation in Congo [14]. That
Variable HR (95% CI) P-value the pathology affects people at their old age and usually retired as
Age 1.03 (0.96–1.10) 0.41 in our setting leaves the financial decision to the family council
Gender (male) 1.66 (0.50–5.46) 0.41 in absence of a universal health coverage. This financial constraint
Hypertension 0.78 (0.11–5.56) 0.81 further explains the choice of a single chamber as the commonest
Diabetes 2.31 (0.59–9.09) 0.23 mode of stimulation in our study, which is similar to what described
Not paced 1.28 (1.16–4.49) 0.04
in another African study [16]. That a single chamber involves only
HR: hazards ratio; CI: Confidence Interval. one lead makes it cheaper and reduces both the time of inter-
vention and possibility of operative complications [17]. The poor
access to cardiac implantable electronic devices in sub-saharan
ECG would easily pick them up. Contrary, sick sinus syndrome is Africa has been reported as a common scenario in the majority of
rarely diagnosed on a resting electrocardiography (ECG), and only SSA countries, resulting in sub-optimal care and a subsequent high
a regular practice of the Holter ECG would increase the chances to burden of premature cardiac death [18,19].
diagnose of this pathology in our context [15]. All patients in this cohort, regardless of pacing, had a remarkably
The cost of the intervention was the main obstacle to the pace- high mortality rate at approximately 3 years from index diagno-
maker implantation in our study, a finding which is similar to Ondze sis of heart block (13.5%). This high rate mortality highlights the

Please cite this article in press as: Dzudie A, et al. Long-term prognosis of patients with permanent cardiac pacemaker indication
in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry. Ann Cardiol Angeiol (Paris) (2020),
https://doi.org/10.1016/j.ancard.2020.07.005
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ANCAAN-1357; No. of Pages 7 ARTICLE IN PRESS
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Fig. 4. Kaplan–Meier curves of patients diagnosed with heart blocks separated by pacemaker implantation for 2500-days of all-cause mortality.
relatively old age as well as diagnostic delay and comorbidities
treatment gaps. However, it is of note that in spite of the overall late
clinical presentation, survival rate was higher in patients who ben-
efited from pacemaker implantation. These findings demonstrate
the need for a continued effort to identify novel strategies to early
diagnose heart blocks, to develop improve access to cardiac pace-
maker services to reduce the burden of mortality associated with
heart blocks, and to measure their integration into clinical practice.
4.1. Study limitations
The limitations of this study are inherent to most observational
studies. First there are potential selection biases inherent to referral
and the paced group, because it is dependent on financial capabil-
ity to access the pacemaker and we cannot rule out the possibility
that this group was also more likely to afford treatment for other
comorbidities that otherwise would have limited their survival.
Secondly, there was a high lost to follow up. Thirdly, the gener-
alizability of this data is limited given the small sample hospital
patient population, as we cannot rule out the possibility that some
severe heart block might have been too severe or patients too poor
to afford consultations at our referral centres or may have navigated
between non cardiologists until death. Poverty is undoubtedly a
strong roadblock to cardiovascular health in SSA [20]. Fourthly, in
absence of a regular practice of holter ECG recording, patients with
severe but intermittent or paroxysmal heart block might have been
missed. These patients would not be reported in the hospitalization
registries, thus would not be captured in this study. Nevertheless,
these limitations have to be balanced against the national referral
approach, the relatively long duration of follow up and the deep
dearth of evidence on cardiac electronic services and devices from
limited resource settings. Our study therefore provides useful infor-
mation on the epidemiology of heart blocks and their management
in SSA.
5. Conclusion
Bradyarrhythmias with pacemaker indications are a real con-
cern to our health care system due to its increasing prevalence.
There is limited access to pacemaker in Cameroon as more than a
quarter of patients with severe heart blocks could not be implanted.
However, pacemaker implantation improved 2.7 times the sur-
vival of patients requiring a pacemaker. These findings underscore
the need to improve early detection of heart blocks and car-
diac arrhythmias management by creating dedicated services and
Please cite this article in press as: Dzudie A, et al. Long-term prognosis of patients with permanent cardiac pacemaker indication
in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry. Ann Cardiol Angeiol (Paris) (2020),
https://doi.org/10.1016/j.ancard.2020.07.005
facilitating accessibility and affordability of cardiac pacemakers in
Cameroon.
Disclosure of interest
The authors declare that they have no competing interest.
Acknowledgments
The authors thank all of the doctors, nurses, and patients who
participated in the registry. They also acknowledge the CRENC team
for trial coordination and data management.
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Please cite this article in press as: Dzudie A, et al. Long-term prognosis of patients with permanent cardiac pacemaker indication
in three referral cardiac centers in Cameroon: Insights from the National pacemaker registry. Ann Cardiol Angeiol (Paris) (2020),
https://doi.org/10.1016/j.ancard.2020.07.005