Cardiologia Croatica. 2022;17(11-12)

Lukoye Atwoli, Gregory E. Erhabor, Aiah A. Gbakima, Abraham Haileamlak, Jean-Marie Kayembe Ntumba, James Kigera, Laurie Laybourn-Langton, Bob Mash, Joy Muhia, Fhumulani Mavis Mulaudzi, David Ofori-Adjei, Friday Okonofua, Arash Rashidian, Maha El-Adawy, Siaka Sidibé, Abdelmadjid Snouber, James Tumwine, Mohammad Sahar Yassien, Paul Yonga, Lilia Zakhama, Chris Zielinski

The 2022 report of the Intergovernmental Panel on Climate Change (IPCC) paints a dark picture of the future of life on earth, characterised by ecosystem collapse, species extinction, and climate hazards such as heatwaves and floods (1). These are all linked to physical and mental health problems, with direct and indirect consequences of increased morbidity and mortality. To avoid these catastrophic health effects across all regions of the globe, there is broad agreement—as 231 health journals argued together in 2021—that the rise in global temperature must be limited to less than 1.5oC compared with pre-industrial levels. While the Paris Agreement of 2015 outlines a global action framework that incorporates providing climate finance to developing countries, this support has yet to materialise (2). COP27 is the fifth Conference of the Parties (COP) to be organised in Africa since its inception in 1995. Ahead of this meeting, we—as health journal editors from across the continent—call for urgent action to ensure it is the COP that finally delivers climate justice for Africa and vulnerable countries. This is essential not just for the health of those countries, but for the health of the whole world. ## Africa has suffered disproportionately although it has done little to cause the crisis The climate crisis has had an impact on the environmental and social determinants of health across Africa, leading to devastating health effects (3). Impacts on health can result directly from environmental shocks and indirectly through socially mediated effects (4). Climate change-related risks in Africa include flooding, drought, heatwaves, reduced food production, and reduced labour productivity (5). Droughts in sub-Saharan Africa have tripled between 1970-79 and 2010-2019 (6). In 2018, devastating cyclones impacted three million people in Malawi, Mozambique and Zimbabwe (6). In west and central Africa, severe flooding resulted in mortality and forced migration from loss of shelter, cultivated land, and livestock (7). Changes in vector ecology brought about by floods and damage to environmental hygiene have led to increases in diseases across sub-Saharan Africa, with rises in malaria, dengue fever, Lassa fever, Rift Valley fever, Lyme disease, Ebola virus, West Nile virus and other infections (8, 9). Rising sea levels reduce water quality, leading to water-borne diseases, including diarrhoeal diseases, a leading cause of mortality in Africa (8). Extreme weather damages water and food supply, increasing food insecurity and malnutrition, which causes 1.7 million deaths annually in Africa (10). According to the Food and Agriculture Organization of the United Nations, malnutrition has increased by almost 50% since 2012, owing to the central role agriculture plays in African economies (11). Environmental shocks and their knock-on effects also cause severe harm to mental health (12). In all, it is estimated that the climate crisis has destroyed a fifth of the gross domestic product (GDP) of the countries most vulnerable to climate shocks (13). The damage to Africa should be of supreme concern to all nations. This is partly for moral reasons. It is highly unjust that the most impacted nations have contributed the least to global cumulative emissions, which are driving the climate crisis and its increasingly severe effects. North America and Europe have contributed 62% of carbon dioxide emissions since the Industrial Revolution, whereas Africa has contributed only 3% (14). ## The fight against the climate crisis needs all hands on deck Yet it is not just for moral reasons that all nations should be concerned for Africa. The acute and chronic impacts of the climate crisis create problems like poverty, infectious disease, forced migration, and conflict that spread through globalised systems (6, 15). These knock-on impacts affect all nations. COVID-19 served as a wake-up call to these global dynamics and it is no coincidence that health professionals have been active in identifying and responding to the consequences of growing systemic risks to health. But the lessons of the COVID-19 pandemic should not be limited to pandemic risk (16, 17). Instead, it is imperative that the suffering of frontline nations, including those in Africa, be the core consideration at COP27: in an interconnected world, leaving countries to the mercy of environmental shocks creates instability that has severe consequences for all nations. The primary focus of climate summits remains to rapidly reduce emissions so that global temperature rises are kept to below 1.5 °C. This will limit the harm. But, for Africa and other vulnerable regions, this harm is already severe. Achieving the promised target of providing $100bn of climate finance a year is now globally critical if we are to forestall the systemic risks of leaving societies in crisis. This can be done by ensuring these resources focus on increasing resilience to the existing and inevitable future impacts of the climate crisis, as well as on supporting vulnerable nations to reduce their greenhouse gas emissions: a parity of esteem between adaptation and mitigation. These resources should come through grants not loans, and be urgently scaled up before the current review period of 2025. They must put health system resilience at the forefront, as the compounding crises caused by the climate crisis often manifest in acute health problems. Financing adaptation will be more cost-effective than relying on disaster relief. Some progress has been made on adaptation in Africa and around the world, including early warning systems and infrastructure to defend against extremes. But frontline nations are not compensated for impacts from a crisis they did not cause. This is not only unfair, but also drives the spiral of global destabilisation, as nations pour money into responding to disasters, but can no longer afford to pay for greater resilience or to reduce the root problem through emissions reductions. A financing facility for loss and damage must now be introduced, providing additional resources beyond those given for mitigation and adaptation. This must go beyond the failures of COP26 where the suggestion of such a facility was downgraded to “a dialogue” (18). The climate crisis is a product of global inaction, and comes at great cost not only to disproportionately impacted African countries, but to the whole world. Africa is united with other frontline regions in urging wealthy nations to finally step up, if for no other reason than that the crises in Africa will sooner rather than later spread and engulf all corners of the globe, by which time it may be too late to effectively respond. If so far they have failed to be persuaded by moral arguments, then hopefully their self-interest will now prevail.

Lucija Lisica, Zrinka Jurišić

Atrial fibrillation (AF) is one of the preventable risk factors for embolic ischemic stroke. The high prevalence and the possibility of stroke prevention suggest the need for effective screening for AF. The aim of this study was to assess the prevalence of and methods for diagnosing AF in patients with ischemic stroke, compare their clinical characteristics, and subsequently outcomes in the AF and non-AF group. This was a retrospective observational study. Medical history of patients with ischemic stroke in 2019 was collected and analyzed. Out of the total number of the patients with ischemic stroke, 39% had AF, which was newly discovered in 50.3% of all patients with AF. Almost three-quarters (73%) of patients with known AF in their medical history were not receiving adequate anticoagulation therapy. Most of the patients with newly discovered AF (87%) were diagnosed using a standard 12-lead ECG, while the rest was diagnosed using 24-hour Holter monitoring (12.5%). AF was associated with mortality as well as with a higher CHA 2 DS 2 -VASc score. As many as half of patients with AF in our cohort were diagnosed with AF only after suffering a stroke. In addition, most of the previously diagnosed patients with AF were not receiving adequate anticoagulation therapy. Outcomes were worse in patients with stroke who had concomitant AF, especially those with higher CHA 2 DS 2 -VASc scores. Therefore, more frequent screening of patients is encouraged, with continuous monitoring as an ideal solution.

Matko Spicijarić, Vjekoslav Tomulić, Luka Zaputović

The use of tyrosine kinase inhibitors is becoming increasingly common in oncological therapy due to their anti-tumor and anti-angiogenic effects. One of the more significant representatives of this group of medications is sunitinib, an oral multi-target inhibitor used in certain forms of gastrointestinal stromal tumors, metastatic renal cell carcinoma, and advanced neuroendocrine pancreatic cancer. In addition to the positive effects of this group of medications, some unwanted effects have also been observed. Depending on the authors, 10% to 30% of patients experienced some form of cardiovascular (CV) event during the application of tyrosine kinase inhibitors. Herein we present the case of a 73-year-old patient who initially received surgery for metastatic cancer in the right kidney, followed by treatment with sunitinib. Approximately eight months after starting this treatment, the patient presented to the Integrated Emergency Hospital Admission department due to chest pains. An electrocardiogram was performed, and suspicion of acute coronary syndrome with ST-segment elevation in the inferior, posterior, and lateral leads was established. Emergency coronarography showed occlusion of the proximal part of the right coronary artery, and treatment continued with primary percutaneous coronary intervention. Given that no significant CV comorbidities had been previously recorded in the patient, a potential link to the application of tyrosine kinase inhibitors was suspected. Examination of other international publications on similar topics indicates a significant incidence of a wide spectrum of CV events associated with these medications. Some studies found that the application of this group of medications leads to increased arterial pressure, arterial stiffness, and reduced elasticity. A case report by Italian authors described a patient who underwent a cardiosurgical bypass procedure after 2 years of sorafenib use, despite having no significant CV comorbidities. These publications and the present case report lead to the conclusion that higher-quality CV monitoring is needed in oncological patients using tyrosine kinase inhibitors with the goal of preventing unwanted events and outcomes.