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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.
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