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The Journal of Medical Research 2016; 2(3): 77-80 Research Article JMR 2016; 2(3): 77-80 May- June ISSN: 2395-7565 © 2016, All rights reserved www.medicinearticle.com Heart failure subjects among Africans: Any contributions from coronary artery diseases? An electrocardiographic and echocardiographic analysis Adeseye A. Akintunde 1,2 1 Department of Medicine, Faculty of Clinical Sciences, College of Health Sciences, Ladoke Akintola Unive rsity of Technology (LAUTECH) & LAUTECH Teaching Hospital, Ogbomoso, Nige ria 2 Goshen Heart Clinic, Osogbo, Nigeria Abstract Background: Despite the rise in risk factor burden for coronary artery disease (CAD) and heart failure among Africans, post myocardial infarction heart failure is rarely reported. Aim and Objectives: We aim to use major electrocardiographic indices suggesting old myocardial infarction and echocardiographic evidence of relative wall motion abnormalities to determine the possible contribution of CAD to the aetiology of heart failure among Africans. Study Design: Prospective observational study. Setting: Goshen Heart Clinic, Osogbo, Nigeria. Methods: 129 consecutive subjects with heart failure diagnosed using the Framinghams’s criteria were included in this study seen at the Goshen Heart Clinic, Osogbo, Nigeria. They had ECG and echocardiography among other investigations. Old Myocardial infarction (MI) on ECG was assessed using standardized criteria using the Third Universal definition of MI while relative wall motion abnormalities were assessed during echocardiography. Statistics: Statistical Package for Social Sciences 17.0 was used for statistical analysis. Results: The mean age of the study participants was 62.1 ± 13.7 years. There were 57 females (44.2%). Possible CAD was identified in 18 (13.95%) of study participants and they were more likely to be significantly older, had a lower ejection fraction , a higher fasting blood sugar and a higher left ventricular chamber walls dimensions compared to those without possible CAD. Conclusion: CAD may be a significant contributor to the aetiology of heart failure subjects among Africans and it is important to look for possible significant coronary atherosclerosis and treat appropriately even among Africans with heart failure. Concerted treatment for CAD risk factors is an important way to reduce the increasing burden of CAD among Nigerians. Keywords: Corona ry a rtery diseases (CAD), Electroca rdiographi c, Echoca rdiogra phi c, Morphine . INTRODUCTION *Corresponding author: Dr. Adeseye A. Akintunde Department of Medicine, Faculty of Clinical Sciences, College of Health Sciences, Ladoke Akintola University of Technology (LAUTECH) & LAUTECH T eaching Hospital, Ogbomoso, Nigeri Morphine a ddi ction is Hea rt failure has been des cribed as the ca rdiovas cula r epi demi c of the 21 st century.[1-2] There is also reported increased incidence in mos t pa rts of Afri ca mainl y due the increasing prevalence of many ca rdi ovas cula r risk fa ctors such as hypertension, diabetes, obesity etc. [3-4] Corona ry a rtery disease/ is chaemi c hea rt disease has ea rlier being reported to be ra re among Afri cans is fast becoming an i mporta nt cause of morbidi ty and mortality in Afri ca wi th similar risk fa ctor profile and [5,6] prognosis as in the Caucasians. i t has been pos tula ted tha t Afri cans ma y not present classicall y wi th the angina pain in CAD due to geneti c and/or envi ronmental factors . [7] Some signifi cant proporti on of corona ry a rtery disease patients who gets to the hospi tal ca re ul tima tel y presents wi th hea rt failure.[8,9] The management of hea rt failure is an important milestone in the pos t-infa rction s ta ges of CAD pa tients .[10,11] Due to the s ca rci ty of ca rdiac ca theteri za tion labora tories in most pa rts of Afri ca, corona ry angiogra phies a re not routinel y done for many hea rt failure pa tients tha t could ha ve benefi tted from them. The aetiology of hea rt failure in Afri ca a re mainl y rela ted to hypertension, ca rdiomyopa thy and rheuma ti c val vula r hea rt disease. [12] Among 1006 Afri cans wi th hea rt failure from 9 countries , is chaemic hea rt disease was reported to be an uncommon cause of a cute hea rt failure. [5,13] It is possible tha t some mi ght suffer silent is chaemi c hea rt disease wi thout i ts classical ches t pain. Afri cans also possibly ha ve a hi gher pain threshold and ma y therefore present la ter wi th sequeale of loss of signifi cant myocardial mass presenting wi th fea tures of hea rt failure. It is pos tulated tha t a signifi cant proportion of our heart failure subjects ma y ha ve electroca rdiographic indi ces of silent corona ry is chaemia/infa rction and or echoca rdiographi c i ndi cati on of relati ve wall motions abnormalities. According to the Thi rd Uni versal defini tion of myoca rdial infa rction released recentl y by the European Society of Ca rdiol ogy (ESC), electroca rdiogra phi c abnormalities and echoca rdiographi c abnormalities a re a djuncts in the diagnosis of 77 The Journal of Medical Research CAD i n subjects . [14] We therefore aimed at using 12-lead ECG of patients wi th hea rt failure( both wi th reduced and preserved ejection fra ction) and echoca rdiography to identi fy those wi th likel y CAD and therefore those who ma y likel y benefi t from corona ry revas cula riza tion and optimi zed medi cal therapy to reduce the associated morbi dity and mortali ty. MATERIALS AND METHODS The clini cal records of all hea rt failure seen between Ma y 2011 a nd December 2014 in a pri va te Ca rdiology clini c in Osogbo, South Wes t Nigeria were retrieved. The s tudy centre is Goshen Hea rt Clini c, Osogbo, Nigeria . All potential subjects were included if they were >18 yea rs ol d. Subjects wi th previous ECG dia gnosis of left bundle bra nch block or other serious co-morbidities including cancers , adva nced ki dney disease and s troke were excluded. Subjects wi th metaboli c abnormali ties such as hyperkalaemia , those taking tri cycli c antidepressants , ea rl y repola risation a bnormalities , his tory sugges ti ve of pul mona ry embolism were also excluded from the anal ysis. Informa tion obtained from the clini cal records include age, gender, occupa tion, clini cal fea tures of hea rt failure, drug history, history of hypertension and diabetes mellitus , smoking his tory, alcohol history and dura tion of s ymptoms. Height, weight, waist ci rcumference, a vera ge s ys toli c and diastoli c blood pressure and pulse ra te were obtained. Electroca rdiography was done using ECG 1200 by Contec Medical s ys tems , China . Echoca rdiogra phy was performed using the HP Sonos 2500 by HP inc. USA wi th a 2.7/3.5MHz probe. All echoca rdiography were performed a ccording to standa rdized Ameri can Society of Echoca rdiography guideline on quantifi ca tion and evalua tion of s ys toli c a nd diastolic pa ra meters and chambers assessment.[14,15] The following pa rameters were obtained: left ventri cula r internal di mension in dias tole (LVIDd), left ventri cular internal dimension in s ys tole (LVIDs ), left ventri cula r pos terior (PWTd) and septal wall di mension (IVSd) in diastole , ejection fra ction (EF), fra ctional shortening (FS), left a trial di mension (LAD), ri ght ventri cula r wall di mension (RVD), aorti c root di mension(AOD) and aorti c cusp sepa ra tion (ACS). Global and regional assessment for wall motion abnormali ties were made visuall y and reported. The electroca rdiogra phy was interpreted by the a uthor blinded to the clini cal da ta of the subjects. Pa ra meters such as hea rt rate, rhythm, QRS a xis, PR interval and QTc were obtained. Left ventri cula r hypertrophy was defined using ei ther the Sokolow Lyon cri teria and/or .[16-18] the Araoye cri teria Fas ting blood suga r, lipid profile including hi gh density lipoprotein- choles terol , low densi ty lipoprotein choles terol , total cholesterol and tri gl yceri des were obtained using a ra pid poin t of ca re, stri p based tes t LipidPro by Infopia Ltd, Korea . Possible contribution from corona ry a rtery diseases were identified using the cri teria from the Thi rd Uni versal defini tion for a cute myoca rdial infa rcti on as any of the following. [19] 1. 2. ECG changes of left bundle branch block Persis tent Reciprocal ST-T changes in a t leas t two contiguous ECG leads 3. Pa thologi c Q wa ves on the 12 lead ECG 4. Echoca rdiographi c evidence of regional wall motion abnormali ties The ECG cri teria for prior myoca rdial infa rction was defined as 1. 2. 3. Any Q wa ve ≥ 0.02sec or QS complex in V2/V3 OR Q wa ve≥ 0.03 sec or ≥ 0.1mV deep or QS complex in leads I, II, aVL, a VF or V4-V6 in any 2 leads of conti guous lead grouping (I, aVL, V1-V6; II, III, aVF) OR R wa ve ≥ 0.04 sec in V1-V2 and R/S ≥1 wi th a concordant positi ve T wa ve. A pa tient was classified as ha ving an old myoca rdial infa rcti on if he/she has any signi fi cant ECG change including any of the three cri teria above or echoca rdiographic evi dence of rela ti ve wall thi ckness . Da ta was anal ysed using the Sta tisti cal Pa ckage for Social Sciences SPSS version 17.0. Numeri cal da ta were summa rized as mean ± standa rd devia tion. Qualita ti ve da ta were summa rized as frequency a nd percentages . Student t-tes t, Anal ysis of va riance a nd chi squa re tes t were used as appropria te to determine differences between groups. P <0.05 was taken as s ta tisti call y signifi cant. RESULTS Table 1 s hows the clini cal , electroca rdiogra phi c and echoca rdiographi c cha ra cteris ti cs of the s tudy pa rti cipants . The mean age was 62.1 ±13.7 yea rs and females cons ti tuted 43.4% of the s tudy popula tion. The mean s ystolic bl ood pressure was 136.6 ±28.6 mmHg while the mean dias tolic bl ood pressure was 83.2 ±17.6 mmHg. The mea n fasting blood suga r was 4.7±2.2 mmol /l. Wi th respect to ECG ma rkers of old MI, R wa ve abnormali ties as s tated i n the methodology section was found in 11(8.5%), while relati vewall motion abnormalities on echoca rdiogram was detected in 8(6.2%) of s tudy pa rti cipants . Pa thologi c Q wa ves in contiguous leads and left bundle branch bloc were found in 13(10.1%) a nd 3(2.3%) respecti vel y. ST-T wa ve abnormali ties were however found in majori ty of heart failure subjects 68(52.7%). The frequency of s tudy pa rti cipants wi th a t leas t one of the three ma jor cri teria used to identi fy old MI was 18 (13.95%). ST-T changes was not used because of i ts non specifi ci ty while left bundle bra nch block was not used due to the fa ct tha t i t could not be subs tantia ted tha t i t developed recentl y or was caused by other pa thologies . Table 1: clini cal cha ra cteris ti cs of s tudy pa rticipa nts Variables Age (years) Female Gender (n) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Fasting blood sugar (mmol/l) LVDD (mm) LVSD (mm) PWTd (mm) IVSd (mm) EF (%) RVD (mm) LAD (mm) R wave abnormalities (n) Relative wall motion abnormalities (n) ST-T wave abnormalities Pathologic Q wave in contiguous leads (n) Left bundle branch block (n) Proportion of those with possible silent old CAD(n) 62.1 ±13.7 years 56 (43.4%) 136.6 ±28.6 mmHg 83.2 ±17.6 mmHg 4.7±2.2 mmol/l 49.0± 11.9 37.3±12.7 12.6 ±1.9 12.7±2.4 56.2 ± 12.4% 29.5± 5.4 45.9± 9.2 11(8.5%) 8(6.2%) 68(52.7%) 13(10.1%) 3(2.3%) 18/129 (13.95%) KEY TO WORDS- LVDD-left ventricular internal dimension in diastole, LVSD- left ventricular end systolic dimension,, PWTd- posterior wall thickness in diastole, IVSdinterventricular septa l thickness, EF-Ejection fraction, RVD-right ventricular dimension, Left atrial dimension, CAD-coronary arte ry disease. Table 2 shows the clini cal, demographi c and echoca rdiographi c di fferences between subjects identified wi th possible old MI and those wi thout. Those wi th possible old MI were more likel y to be signifi cantl y older i n a ge, (65.44 ± 10.3 yea rs vs . 61.3 ± 14.6, P<0.05), more likel y to be males and had a signifi cantl y lower ejection fra ction (41.11± 10.5% vs . 48.0 ± 12.1%, p<0.05) compa red to those wi thout possible old MI. The his tories of previ ous diagnosis of diabetes mellitus or hypertension 78 The Journal of Medical Research were not si gnifi cantl y different between the two groups . The mean fas ting blood s uga r was signifi cantl y higher a mong those with possible old MI compa red to those wi thout possible old MI as shown in table 2. Left ventri cula r chamber wall dimensions were si gnifi cantl y hi ghe r among those wi thout possible old MI in the s tudy populati on. Left ventri cula r end diastolic internal dimension was signifi cantl y hi gher among those wi th possible old myoca rdial i nfa rction compa red to those wi thout possible old MI (51.4± 9.9mm vs . 48.6± 12.6, p<0.05 respecti vel y). Table 2: clini cal cha racteris ti cs of hea rt failure subjects with silent old MI compa red to those wi thout Variable Those with silent MI (18) P value 65.44 ± 10.3 6/12 (33.3%) 6/18 3/18 Those without ECG/Echo features of silent MI 61.3 ± 14.6 49/62 (44.1%) 36/111 21/111 Age(years) Gender (F/M) NYHA III/IV (n) Previous diagnosed T2DM (n) LVDD (mm) EF (%) PWTd (mm) IVSd (mm) History of HTN (n) Fasting blood sugar (mmol/l) 51.4± 9.9 41.11± 10.5 11.7 ±1.7 12.0 ±1.5 14/18 6.3± 2.3 48.6± 12.6 48.0 ± 12.1 12.8± 2.5 12.7± 2.0 87/111 5.4 ± 1.7 0.048* 0.034* 0.0219* 0.0307* 0.954 0.04* 0.0351* 0.390 0.284 0.567 *- statistically significant KEY TO WORDS- LVDD-left ventricular internal dimension in diastole, LVSD- left ventricular end systolic dimension, PWTd- pos terior wall thickness in diastole, IVSdinterventricular septal thickness, EF-Ejection fraction, HTN- hypertension, NYHA- New York Heart Association, T2DM- Type 2 Diabe tes Mellitus DISCUSSION Hea rt failure is a signifi cant and rela ti vel y common compli cation of a cute myoca rdial infa rction. In a na tional registry of myoca rdial infa rction pa tients , 20.4% were admi tted with hea rt failure and an addi tional 8.6% developed HF subsequentl y. [20] In the Valsartan in Acute Myoca rdial Infa rction Trial (VALIANT Trial) hea rt failure a fter admission was recorded i n 23.1% of pa tients. [21] this increased to 36% over a mean follow up of 7.6 yea rs in the Fra mingham hea rt s tudy. [22] In other reports , hea rt failure compli cates up to 60% of myoca rdial infa rction and those tha t a re a t grea tes t risk include elderl y, females and those wi th previ ous myoca rdial infa rction. Long term mortali ty remains hi gh in them. [23] This s tudy revealed that a sizable proporti on of hea rt failure subjects in Nigeria ha ve electroca rdiographi c and /or echoca rdiographi c fea tures of silent old Myoca rdial infa rcti on/corona ry hea rt disease despi te the absence of signifi cant ches t pain sugges ting same in thei r previous medi cal his tory. This is signifi cant because these a re likel y subjects whose heart failure prognosis can grea tl y be improved by revas cula ri zation and other ancillary thera py for corona ry hea rt disease. Hea rt failure a mong Afri cans has been predominantl y linked to hypertension, rheuma ti c hea rt disease and ca rdiomyopa thies in aetiology. [24,25,26] The prognosis of hea rt failure is equally dismal like in developed countries . [27] In the INTERHEART study, CAD has been related to simila r ris k fa ctors among Bla cks and whites in more tha t 95% of cases including hypertension, dyslipidaemia , obesi ty and physi cal ina cti vi ty. [28] Recent report ha ve sugges ted tha t CAD is continuall y being reported a mong Afri cans.[29,30] Therefore it is not out of pla ce to sugges t tha t a sizable fra ction of pa tients with CAD ma y a ctuall y present with hea rt failure following a cute corona ry s yndrome/ myoca rdial infa rction. We sugges t tha t there ma y be a va ria tion in the pain sensiti vi ty among Bla ck Afri cans so tha t they present wi th little or no pain duri ng a cute corona ry s yndrome or due to the widespread a vailability of a nalgesics , mos t pa tients would ha ve abuse them and ma y lead to la ck of presenta tion in the usual wa y. Despi te growing recogni tion of increasing burden of ca rdiovas cula r disease in low and middle income countries , trends in the prevalence of a cute myoca rdial i nfa rction in s ub -Saha ran Afri ca has not been well des cribed mainl y due to the la ck of ca rdiac ca theteri za tion labora tories for corona ry a ngiography. In a review of studies reportin g a cute myoca rdial infa rction in sub-Saha ran Afri ca defined by eleva tion of ca rdia c enzymes a nd ECG changes, a prevalence of 0.1% to 10.4% was reported. [31] This sugges t tha t Acute myoca rdial infa rction is not too uncommon a fterall among Afri cans . This s tudy underscores limi ted report of pos t myoca rdial infa rction hea rt failure from Afri ca . Kolo et al . reported 3/13 (23.1%) of subjects who had myoca rdial infarcti on in Uni versi ty of Ilorin Teaching Hospital in North Central Nigeria , over a four yea r period developed chroni c left ventri cula r s ystolic failure. Corona ry a rtery disease is all the same not too ra re i n Nigerians . Johnson et al . reported the prevalence of CAD among Nigerians who had corona ry angiography in a pri va te fa cility in Lagos Nigeria as 52.6% wi th 96.3% of them ha vi ng signi fi cant stenosis [32] and were candida tes for revas cula riza tion. in other clime except in Afri ca, is chaemi c hea rt disease was reported to be the mos t common cause of heart failure. [33] This s tudy also revealed tha t those wi th likel y silent CAD among hea rt failure subjects were more likel y to be signi ficantl y older, more likel y to be females ,had a signifi cantl y la rger left ventri cula r internal di mension in diastole and a hi gher fasting blood suga r compa red to those wi th no ECG /echoca rdiographi c indi ca tion of CAD. Pos terior wall thi ckness, interventri cula r septal diameter were signi fi cantl y hi gher among those wi th silent MI while ejection fra ction was signifi cantl y l ower a mong those wi th silent MI compa red to those wi tho ut MI. This further lends credence to the fa ct tha t those wi th silent MI ma y ha ve a grea ter burden of disease and ma y be a t a grea ter ca rdiovas cular risk compa red to thei r counterpa rt. Revas cula riza tion ma y likel y i mprove the prognosis of such patient over time as it has been shown in many s tudies . It is noteworthy tha t no di fferences were reported for frequencies of diabetes mellitus or hypertension among subjects wi th silent CAD compa red to those wi thout i t in this s tudy. Mos t of these a re in keeping with the pa ttern des cribed among Ca ucasians except tha t the gender associa tion in males descri bed in this s tudy ma y be pa rti cula rl y related to the increased burden of CV risk fa ctors a mong men in Afri ca . Al though ST-T wa ve abnormali ties were very common among hea rt failure subjects , we sugges t they a re due to repolarisa tion abnormali ties, subendoca rdial is chemia and possible electrol yte abnormali ties associa ted with hea rt failure and/or its mana gement. CONCLUSIONS This s tudy therefore concludes tha t a siza ble p roportion of hea rt failure subjects seen in a specialty outpa tient clini c had ECG/echoca rdi ographi c pointers of possible old MI/ CAD and this mi ght ha ve contri buted as aetiology of thei r hea rt failure with potential benefi t from corona ry angiography a nd re vas cula riza tion. It also sugges ts that these subjects had a hi gher ca rdiovas cula r burden and seem to ha ve a worse disease association. Therefore, is chemic hea rt disease should be borne in mind as a possible aetiology in hea rt failure among Afri cans especiall y among those with advanced diseases. Author’s contribution AAA desi gned the s tudy, collected the da ta, a nal ysed the da ta and wrote the manus cript. 79 The Journal of Medical Research Sources of support: None Acknowledgement: Nil Conflicts of Interest The authors decla re no conflict of interes t. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 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