Sudden unexpected death from cardiac causes in Nigerians: a review of 50 autopsied cases

Sudden death in young South European population: a cross-sectional study of postmortem cases

To describe the annual incidence and the leading causes of sudden non-cardiac and cardiac death (SCD) in children and young adult Portuguese population. We retrospectively reviewed autopsy of sudden unexpected deaths reports from the Portuguese National Institute of Legal Medicine and Forensic Sciences' database, between 2012 and 2016, for the central region of Portugal, Azores and Madeira (ages 1-40: 26% of the total population). During a 5-year period, 159 SD were identified, corresponding to an annual incidence of 2,4 (95%confidence interval, 1,5-3,6) per 100.000 people-years. Victims had a mean age of 32 ± 7 years-old, and 72,3% were male. There were 70,4% cardiac, 16,4% respiratory and 7,5% neurologic causes of SD. The most frequent cardiac anatomopathological diagnosis was atherosclerotic coronary artery disease (CAD) (33,0%). There were 15,2% victims with left ventricular hypertrophy, with a diagnosis of hypertrophic cardiomyopathy only possible in 2,7%. The prevalence of cardiac pathological findings of uncertain significance was 30,4%. In conclusion, the annual incidence of SD was low. Atherosclerotic CAD was diagnosed in 33,0% victims, suggesting the need to intensify primary prevention measures in the young. The high prevalence of pathological findings of uncertain significance emphasizes the importance of molecular autopsy and screening of first-degree relatives.

The Pandemic of Coronary Artery Disease in the Sub-Saharan Africa: What Clinicians Need to Know

PURPOSE OF REVIEW

Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality globally with an accelerated increase in CVD‑related death in Africa and other low‑middle‑income countries. This review is aimed at highlighting the burden of coronary artery disease CAD, its peculiarities as well as challenges of management in sub-Saharan Africa.

RECENT FINDINGS

Recent data revealed a shift from high incidence of CVDs associated with poverty and malnutrition (such as rheumatic heart disease) initially, which are now falling, to rising incidence of other non-communicable CVDs (such as hypertension, coronary artery disease (CAD), and heart failure). Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide, which is projected to supersede communicable diseases in the future. Previous studies have shown that CAD was rare among Africans. Those studies conducted in Africa in the 1940s-1960s reported that Black Africans were almost immune to developing CAD and were even thought to have specific genetic make-up protecting them from CAD. However, the continent is now experiencing a steady rise in the prevalence of CAD associated with severe disease burden, compared to other regions of the world. The changes seen have been attributed to the current epidemiological transition with increase in CVD risk factors that are poorly controlled, lack of awareness as well as the poor health facilities to tackle the menace of the disease. The Global Burden of Disease (GBD) estimates have also shown that over the past three decades the highest contribution to CVD burden in Africa is attributed to atherosclerotic diseases, with 71.4, 37.7, and 154% increases in the burden of ischemic heart disease, stroke, and peripheral artery disease respectively. There is a steady increase of CAD prevalence in Africa as a result of increase in CV risk factors. Hypertension, obesity, diabetes, dyslipidemia, and cigarette smoking are the rapidly rising risk factors for CAD on the continent. Africa also faces challenges in diagnosis and management of CAD. There is need for increased public and health personnel awareness on prevention and control of commonly identifiable risk factors, provision of prehospital emergency services, and provision of modern therapeutic facilities for treatment of CAD including reperfusion therapy. These are priority areas where efforts could be intensified in the future with potential to improve the current rate of progress of the disease on the continent.

Electrophysiology practice in low- and middle-income countries: An updated review on access to care and health delivery

Concurrent with the epidemiological transition to cardiovascular diseases in low- and middle-income countries (LMICs), the burden of arrhythmias is increasing significantly. However, registries of electrophysiological disorders and their management in LMICs are limited. The advancement of telemedicine technology can play a distinctive role in providing accurate diagnoses in resource-limited settings. The estimated pacemaker implantation requirements (1 million per year) demand an alternate source of pacemakers, including reused permanent pacemakers and implantable cardioverter-defibrillators. In addition, the majority of supraventricular tachycardias and atrial fibrillation can be managed with radiofrequency ablation, which not only is cost-effective but is curative for most patients.

Pathophysiologically based antihypertensive pharmacotherapeutics rationality, efficacy and safety in Sub Saharan African Nations – A review

Background

Hypertension (HT) prevalence, Uncontrolled Blood Pressure (UBP), morbidity and mortality are highest in Sub-Saharan Africa (SSA). Correlating pathophysiology of HT to pharmaco-therapy with antihypertensive drugs (AHD) may bring amelioration. Aims:To review peculiarities of HT in SSA, UBP causes, diagnostic modalities, AHD use, rationality and efficacy.

Methods and results

14 published therapeutic audits in 4 SSA nations on Google Scholar or PUBMED, (total n = 6496 patients) were evaluated. Calcium Channel blockers (CCB) amlodipine, and thiazide diuretics (TD), hydrochlorothiazide (HCTZ) were the commonest AHD. Thiazide Like Diuretics (TLD) were underutilized. The % of patients on AHD were: 1 drug 5.4–55%; 2 drugs 37–82%; >/ = 3 drugs 6–50.3%. 2-drug combinations were: ACEI/ARB + TD (42%); CCB + TD (36.8%); ACEI + CCB (15.8%) of studies. Triple/quadruple therapy included Methyldopa (MTD) with ACEI + CCB or TD. The (%) attaining BP < 140/< 90 mmHg, ranged from 29 to 53.6%, median, 44%. The co-morbidities, range and median were: Diabetes Mellitus (DM): 9.8–64%, 19.2%; Chronic Kidney Disease (CKD): 5.7–7.5%, 6.9%, and Coronary artery Disease (CAD): 0.9–2.6%, 2.3%. ACEI + CCB ± TD were the preferred AHD for comorbidities.

Conclusions

Therapeutic inertia; Non-compliance; co-morbidities; refractory HT; ignorance; substandard AHD; contribute to UBP. Studies relating 24 hour ABPM to complications and mortality in SSA hypertensives; and impact of different AHD classes on ABPM, are needed. Study of ACEI + alpha-₁ blockers + TLD on 24 hour ABPM and personalized care, are required.

A Systematic Review of the Spectrum of Cardiac Arrhythmias in Sub-Saharan Africa

Major structural cardiovascular diseases are associated with cardiac arrhythmias, but their full spectrum remains unknown in sub-Saharan Africa (SSA), which we addressed in this systematic review. Atrial fibrillation/atrial flutter (AF/AFL) prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, but <1% in the general population. Use of oral anticoagulation is heterogenous (9-79%) across SSA. The epidemiology of sudden cardiac arrest/death is less characterized in SSA. Cardiopulmonary resuscitation is challenging, owing to low awareness and lack of equipment for life-support. About 18% of SSA countries have no cardiac implantable electronic devices services, leaving hundreds of millions of people without any access to treatment for advanced bradyarrhythmias, and implant rates are more than 200-fold lower than in the western world. Management of tachyarrhythmias is largely non-invasive (about 80% AF/AFL via rate-controlled strategy only), as electrophysiological study and catheter ablation centers are almost non-existent in most countries.

Highlights

- Atrial fibrillation/flutter prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, and <1% in the general population in sub-Saharan Africa (SSA).- Rates of oral anticoagulation use for CHA2DS2VASC score ≥2 are very diverse (9-79%) across SSA countries.- Data on sudden cardiac arrest are scant in SSA with low cardiopulmonary resuscitation awareness.- Low rates of cardiac implantable electronic devices insertions and rarity of invasive arrhythmia treatment centers are seen in SSA, relative to the high-income countries.

Cardiac arrhythmias in low- and middle-income countries

Many low- and middle-income countries (LMICs) are undergoing an epidemiological transition. With an improvement in socioeconomic conditions and an aging population, cardiovascular diseases (CVDs), like cardiac arrhythmias, are expected to increase in these countries. However, there are limited studies on the epidemiology and management of cardiac arrhythmias in LMICs. This review will highlight the unique challenges and opportunities that these countries face when managing cardiac arrhythmias.

Explaining Heart Failure Hyper-mortality in Sub Saharan Africa: Global Genomic and Environmental Contribution Review

The annual heart failure (HF) mortality rate in Africa is 34% according to the INTERHF study. This is twice the world average of 16.5% and 3.7 times that of South America, 9%. We review evidence-based explanations for the Hyper-mortality of HF, by comparison of North American, Caribbean, Afro-Brazilian with Sub-Saharan African (SSA) nations profiles, and suggest amelioration. 1 year HF mortality rates in SSA ranged from 29% to 58%, and intra-hospital mortality rate from 8 to 26% (n = 8). A clustering of adverse genetic single nucleotide polymorphisms (SNP) predisposing to hypertension and/or left ventricular hypertrophy (LVH) in the black diaspora may contribute. A higher prevalence of HF with reduced Ejection Fraction (HF r EF) phenotype, which is associated with greater mortality is more common in SSA nations. Additionally, a worse co-morbidity burden, especially valvular regurgitations causing LV remodeling (LVR), chronic kidney disease (CKD), anemia, lung disease, infections, late presentation in NYHA III/IV, right ventricular disease (RVD) were also common in SSA. Geographic variation in SSA, HF risk factors and co-morbidity was observed. There was sub-optimal use of guideline directed medical therapy (GDMT) and intracardiac device (ICD) unavailability. Gross Domestic Product -per purchasing power parity (GDP-PPP), which is low in SSA, was inversely correlated both to higher intra-hospital mortality rate % (r = -0.73, r 2 = 0.54 p = 0.038) and higher 1 year HF mortality rate % (r = -0.62, r 2 = 0.38, = 0.098). Localized primary prevention, early detection and prompt treatment of hypertension, diabetes, rheumatic fever, early cardiac valve repair and use of cardiovascular polypill, optimal use of GDMT, national health insurance scheme are advocated to stem the dismal mortality and cost burden of HF.

Epidemiology of sudden cardiac death in Cameroon: the first population-based cohort survey in sub-Saharan Africa

Background

Incidence estimates of sudden cardiac death (SCD) in sub-Saharan Africa (SSA) are unknown.

Method

Over 12 months, the household administrative office and health community committee within neighbourhoods in two health areas of Douala, Cameroon, registered all deaths among 86 188 inhabitants aged >18 years. As part of an extended multi-source surveillance system, the Emergency Medical Service (EMS), local medical examiners and district hospital mortuaries were also surveyed. Whereas two physicians investigated every natural death, two cardiologists reviewed all unexpected natural deaths.

Results

There were 288 all-cause deaths and 27 (9.4%) were SCD. The crude incidence rate was 31.3 [95% confidence interval (CI): 20.3–40.6]/100 000 person-years. The age-standardized rate by the African standard population was 33.6 (95% CI: 22.4–44.9)/100 000 person-years. Death occurred at night in 37% of cases, including 11% of patients who died while asleep. Out-of-hospital sudden cardiac arrest occurred in 63% of cases, 55.5% of which occurred at home. Of the 88.9% cases of witnessed cardiac arrest, 63% occurred in the presence of a family member and cardiopulmonary resuscitation was attempted only in 3.7%.

Conclusion

The burden of SCD in this African population is heavy with distinct characteristics, whereas awareness of SCD and prompt resuscitation efforts appear suboptimal. Larger epidemiological studies are required in SSA in order to implement preventive measures, especially in women and young people.

Epidemiology of sudden cardiac death in Cameroon: rationale and design of the Douala-SUD survey

BACKGROUND

The burden of sudden unexplained death in sub-Saharan Africa is unknown.

AIM

The aim of this study is to establish the epidemiology of sudden cardiac death in Cameroon.

METHODS

The Douala sudden unexplained death (Douala-SUD) study is a prospective, multiple-source, community-based surveillance of all cases of unexpected death (< 24 hours from onset of symptoms) occurring in victims aged>15 years. After approval from institutional boards, all deaths occurring in residents of four areas of Douala city will be checked for circumstances of death and past medical history. Subjects who die naturally will be further investigated. Unexpected death victims will be checked for detailed demographic, clinical, electrocardiographic, echocardiographic and biological records. Autopsy background and genetic analysis (postmortem or in first relatives if the young victim is aged<40 years) will be performed as far as possible. Finally, the use of cardiopulmonary resuscitation efforts during the timeframe of sudden cardiac arrest will also be evaluated.

CONCLUSION

The Douala-SUD study will provide comprehensive, contemporary data on the epidemiology of sudden unexplained and cardiac death in sub-Saharan Africa and will help in the development of strategies to prevent and manage cardiac arrest in Cameroon as well as in other sub-Saharan countries.

Rationale and design of the Pan-African Sudden Cardiac Death survey: the Pan-African SCD study

BACKGROUND

The estimated rate of sudden cardiac death (SCD) in Western countries ranges from 300,000 to 400,000 annually, which represents 0.36 to 1.28 per 1 000 inhabitants in Europe and the United States. The burden of SCD in Africa is unknown. Our aim is to assess the epidemiology of SCD in Africa.

METHODS

The Pan-Africa SCD study is a prospective, multicentre, community-based registry monitoring all cases of cardiac arrest occurring in victims over 15 years old. We will use the definition of SCD as 'witnessed natural death occurring within one hour of the onset of symptoms' or 'unwitnessed natural death within 24 hours of the onset of symptoms'. After approval from institutional boards, we will record demographic, clinical, electrocardiographic and biological variables of SCD victims (including survivors of cardiac arrest) in several African cities. All deaths occurring in residents of districts of interest will be checked for past medical history, circumstances of death, and autopsy report (if possible). We will also analyse the employment of resuscitation attempts during the time frame of sudden cardiac arrest (SCA) in various patient populations throughout African countries.

CONCLUSION

This study will provide comprehensive, contemporary data on the epidemiology of SCD in Africa and will help in the development of strategies to prevent and manage cardiac arrest in this region of the world.

Global health and emergency care: a resuscitation research agenda--part 1

At the 2013 Academic Emergency Medicine global health consensus conference, a breakout session on a resuscitation research agenda was held. Two articles focusing on cardiac arrest and trauma resuscitation are the result of that discussion. This article describes the burden of disease and outcomes, issues in resuscitation research, and global trends in resuscitation research funding priorities. Globally, cardiovascular disease and trauma cause a high burden of disease that receives a disproportionately smaller research investment. International resuscitation research faces unique ethical challenges. It needs reliable baseline statistics regarding quality of care and outcomes; data linkages between providers; reliable and comparable national databases; and an effective, efficient, and sustainable resuscitation research infrastructure to advance the field. Research in resuscitation in low- and middle-income countries is needed to understand the epidemiology, infrastructure and systems context, level of training needed, and potential for cost-effective care to improve outcomes. Research is needed on low-cost models of population-based research, ways to disseminate information to the developing world, and finding the most cost-effective strategies to improve outcomes.

Valvular regurgitations may increase risk of arrhythmias in Nigerians with hypertensive heart failure

BACKGROUND

Hypertensive heart disease (HHD) is the commonest cause of sudden cardiac death among Nigerians. A high frequency and early onset of valvular regurgitations (VHD) in hypertensives, and greater concentric hypertrophy are also common in that population.

AIMS AND METHODS

To further investigate the relationship between VHD and cardiac arrhythmias and their correlates seen in the hypertensive spectrum and to test the hypothesis that VHD predisposes to cardiac arrhythmias in hypertensive heart failure (HHF). HHF patients (n = 14), HHD patients n = 23, and normotensive controls (n = 9) all underwent 24 h electrocardiogram Holter monitoring as well as two-dimensional and Doppler echocardiography. Participants in each patient category were classified according to the presence and severity of VHD or its absence (NVHD).

RESULTS

There were statistically significant differences in the mean supraventricular tachycardia (SVT) (P < 0.001 analysis of variance; ANOVA), the mean and median frequency of ventricular tachycardia episodes (P < 0.02 ANOVA), and couplets (P = 0.0002 ANOVA) between groups. HHF-VHD always had more SVT (81/24 versus 4.4/24 h; P = 0.016) and ventricular arrhythmias 69/24 versus 34/24 h (P < 0.02) than HHF-NVHD. Multivalvular regurgitations (three or more valves), higher left ventricular mass index (g/m2) [274 (24) versus 191(19); P < 0.001 ANOVA], and lower ejection fraction (EF; %) [29(3) versus 53(14)] in HHF-VHD were arrhythmogenic. Mean ventricular tachycardia/triplet frequency/24 h were HHF-VHD 69, HHF-NVHD 39, HHD-VHD 0.3, HHD-NVHD 6, and controls 0.2 (P < 0.02 ANOVA). Compared with 35% (10/27) of all VHD, 15.7% (3/19) of all NVHD participants had nonsustained ventricular tachycardia. The number of regurgitant valves was positively correlated with the frequency of the Lown class of the arrhythmias 0-IVB (r = 0.42, P = 0.003) and to ventricular tachycardia (r = 0.3, P = 0.04) (both n = 46).

CONCLUSION

Left ventricular hypertrophy (LVH) increased arrhythmias. But multivalvular regurgitations predisposes to greater SVT and complex ventricular arrhythmias, especially in HHF. Low EF and concentric LVH are correlates.

Pattern of sudden death at Ladoke Akintola University of Technology Teaching Hospital, Osogbo, South West Nigeria

Background

The purpose of this study was to determine the etiology and epidemiologic characteristics of sudden death at Ladoke Akintola University of Technology (LAUTECH) Teaching Hospital, South West Nigeria.

Methods

This was a retrospective descriptive study of all cases of natural unexpected death, either occurring out of hospital or less than 24 hours after admission to LAUTECH Teaching Hospital, over a nine-year period from January 2003 to December 2011. Data were generated from information in the case notes and autopsy reports for these cases.

Results

Sudden death accounted for 29 (4.0%) of 718 adult medical deaths and 1.0% of all adult medical admissions. Out-of-hospital deaths occurred in 72.4% of cases. The mean age of the patients was 46.8 ± 11.5 (range 25–74) years. The male to female ratio was 6.25:1. Cardiovascular disease were the most common cause of death (51.7%), followed by respiratory disease (20.7%), pulmonary thromboembolism (10.4%), central nervous system disease (13.8%), gastrointestinal disorders (13.8%), severe chemical/drug poisoning (13.8%), and combined cardiovascular and central nervous system disease (13.8%). Hypertension-related causes were responsible for 14/29 (48.3%) of the sudden deaths. Hypertensive heart disease accounted for 86.7% of the cardiovascular deaths, hypertensive heart failure accounted for 73.3%, whilst all heart failure cases accounted for 80.0%. Left ventricular hypertrophy was present in 69.2% of the patients with hypertensive heart disease. Moderate to severe atheromatous changes occurred in the aorta in 38.5% of patients aged ≥50 years. No case of myocardial infarction was found.

Conclusion

Hypertensive heart disease and hypertension-related disorders are the most common causes of sudden death in South West Nigeria, so effective public health strategies should be channeled towards prevention, detection, and treatment of hypertension.

Sudden cardiac death in low- and middle-income countries

Cardiovascular disease, and the incidence of sudden cardiac death (SCD), will increase significantly in low- and middle-income countries (LMIC). Thus, SCD threatens to become a global public health problem. We present a summary of the current research that has investigated the epidemiology of SCD in LMIC. Few studies of SCD in LMIC exist, and they are of variable methodological quality. Risk factors for SCD are described, taking into account recent global burden of disease and risk factor statistics. We describe 1 proposal for a community-based, prospective, multiple-source methodology for SCD monitoring and surveillance that can be implemented in LMIC. Further research into the epidemiology of SCD in LMIC, using standardized methodology, would allow investigators and policy makers to determine the regions, communities, and individuals most at need for SCD prevention. Focusing on SCD and its prevention in LMIC should be a priority for the global health community.

Epidemiology of heart failure in sub-Saharan Africa

Heart failure has emerged as a dominant form of cardiovascular disease in Africa, and has great social and economic relevance owing to its high prevalence, mortality and impact on young, economically active individuals. The causes of heart failure in Africans remain largely nonischemic. Hypertension, cardiomyopathy, rheumatic heart disease, chronic lung disease and pericardial disease are the main contributors to the etiology of cardiac failure in sub-Saharan Africa, accounting for over 90% of cases. Hypertensive heart disease complications occur more frequently in Africans and the majority of affected patients are younger. Endemic cardiomyopathies include dilated cardiomyopathy, peripartum cardiomyopathy and endomyocardial fibrosis. Nonendemic cardiomyopathies apparently occur with the same frequency as in other parts of the world, and include hypertrophic cardiomyopathy and arrhythmogenic right ventricular dysplasia/cardiomyopathy. Coronary artery disease and its complications remain uncommon in Africa, but the situation is changing due to modifications in lifestyle, risk-prone behavior, diet, cultural attitudes and other consequences of rapid urbanization. As the prevalence of heart failure is expected to rise substantially in sub-Saharan Africa, the authors call for population-based studies and registries of the epidemiology of heart failure in Africans and the urgent study of interventions that will decrease morbidity and mortality from the causes of heart failure, with a focus both on nonischemic and ischemic risk factors.

Left Ventricular Diastolic Function in Nigerian Patients with Essential Hypertension: A Retrospective Study to Compare Angiotensin Converting Enzyme Inhibitors, Calcium Channel Blockade or Their Combination

Background

Hypertension in blacks imposes a greater left ventricular hypertrophy, and accelerated heart failure onset. We evaluated and compared the echocardiographically determined systolic and left ventricular diastolic functional indices in Nigerian hypertensive patients, associated with the chronic use of ACE inhibitors, Calcium channel blockers (CCB) or their combinations.

Methods

Ejection fraction -EF, intraventricular relaxation time (IVRT), E/A peak velocity ratio, E wave deceleration time] as well as the left ventricular mass index (LVMI) was undertaken among 41 Nigerian patients with essential hypertension only, on treatment for 4–6 months prior. The 41 patients (aged 59 ± 10 years, 40% females) were divided into three groups; those receiving (i) ACE inhibitors; or (ii) CCB or (iii) combination of ACEI and CCB. All the three groups had a background of diuretic treatment for optimal blood pressure control.

Results

There were no statistically significant differences in the mean LVMI or sitting blood pressure between treatment groups. E/A ratio for ACEI treatment was 1.06 ± 0.44, CCB 0.74 ± 0.19, and for ACEI + CCB 0.87 ± 0.26 (F = 3.29, P = 0.048 anova). The 95% confidence interval for the E/A ratio on ACEI was 0.8 to 1.33. The A wave duration time integral (AVVTi) were all abnormally large, but showed a significant between treatment group difference (P = 0.037, anova). The values were 21.9 ± 4.7 for ACEI, 25.3 ± 6.3 for CCB, and least at 20.1 ± 3.6 cm for the ACE + CCB combination. Similarly, the IVRT was lowest and <100 ms with ACEI + CCB being 93 ± 18 ms, ACEI 115 ± 23 ms, and CCB being 117 ± 22 ms (F = 4.92, P = 0.01, anova). The 95% CI for IVRT on ACEI + CCB was 82 to 104 ms. There were no between treatment group differences in systolic contractility, (fractional shortening or EF).

Conclusions

The results indicate that use of an antihypertensive drug regime inclusive of an ACE inhibitor (±CCB) may be associated with greater salutary effect on indices of diastolic function, (E/A > 1, lower AVVTi, IVRT < 100 ms) even in the presence of an equivalent effect on systolic function and blood pressure.

Prevalence and correlates of major depressive disorder in Nigerian outpatients with heart failure

This study aims to estimate the prevalence and correlates of major depressive disorder (MDD) in Nigerian outpatients with heart failure. Authors assessed patients with heart failure (N = 102) for DSM-IV diagnosis of MDD and obtained sociodemographic and clinical data. MDD was found in 28 (27.5%) of the patients. The significant correlates predicting MDD included unemployment and disability due to the illness, more severe illness (NYHA class), age younger than 60 years, and not being married. These factors should be considered in planning further studies and in screening and intervention programs for patients with heart failure.

Relationship between depression and quality of life in Nigerian outpatients with heart failure

OBJECTIVE

Our objective was to evaluate the relationship between depression and health-related quality of life (QoL) in Nigerian outpatients with heart failure (HF).

METHODS

We used a cross-sectional study in which outpatients with HF (n=100) completed the WHO Quality of Life Scale-Brief Version to assess their subjective QoL. The patients were also assessed for the diagnosis of major depressive disorder (MDD) in accordance with the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition.

RESULTS

The factors independently associated with poor QoL include disability due to illness, presence of MDD, younger age, and longer duration of illness. Patients with MDD had worse QoL than patients without MDD on dimensions of physical health, psychological health, and environment.

CONCLUSION

Depression adversely affects the QoL of patients with HF. Programs designed to improve the QoL of patients with HF need to incorporate the early identification and treatment of depression. Future studies are warranted to investigate the impact of improved depression management on QoL in patients with HF.

Hypertension in sub-Saharan African populations

BACKGROUND

Hypertension in sub-Saharan Africa is a widespread problem of immense economic importance because of its high prevalence in urban areas, its frequent underdiagnosis, and the severity of its complications.

METHODS AND RESULTS

We searched PubMed and relevant journals for words in the title of this article. Among the major problems in making headway toward better detection and treatment are the limited resources of many African countries. Relatively recent environmental changes seem to be adverse. Mass migration from rural to periurban and urban areas probably accounts, at least in part, for the high incidence of hypertension in urban black Africans. In the remaining semirural areas, inroads in lifestyle changes associated with "civilization" may explain the apparently rising prevalence of hypertension. Overall, significant segments of the African population are still afflicted by severe poverty, famine, and civil strife, making the overall prevalence of hypertension difficult to determine. Black South Africans have a stroke rate twice as high as that of whites. Two lifestyle changes that are feasible and should help to stem the epidemic of hypertension in Africa are a decreased salt intake and decreased obesity, especially in women.

CONCLUSIONS

Overall, differences from whites in etiology and therapeutic responses in sub-Saharan African populations are graded and overlapping rather than absolute. Further studies are needed on black Africans, who may (or may not) be genetically and environmentally different from black Americans and from each other in different parts of this vast continent.

Coronary artery disease in the developing world

BACKGROUND

Coronary artery disease (CAD) is the leading cause of cardiovascular mortality worldwide, with >4.5 million deaths occurring in the developing world. Despite a recent decline in developed countries, both CAD mortality and the prevalence of CAD risk factors continue to rise rapidly in developing countries. The objectives of the current article are to review (1) the literature regarding CAD mortality and the prevalence of CAD risk factors in the developing world, and (2) prevention and control measures.

METHODS

We conducted a MEDLINE search of the English language literature for the years 1990 to 2002 to identify articles pertaining to the prevalence of CAD in developing countries. The search was performed using the following key terms: coronary artery disease, developing countries, ischemic heart disease, incidence, prevalence, prevention and risk factors. We also obtained relevant statistical information from The World Health Organization's Internet database.

RESULTS

There is a paucity of data regarding CAD and its prevalence in the developing world. However, it is projected that CAD mortality rates will double from 1990 to 2020, with approximately 82% of the increase attributable to the developing world. Existing data suggest that rapid socioeconomic growth in developing countries is increasing exposure to risk factors for CAD, such as diabetes, genetic factors, hypercholesterolemia, hypertension, and smoking. There is a relative lack of prevention and control measures to decrease exposure to these risk factors in developing countries.

CONCLUSION

Documented information on the prevalence of CAD in developing countries is sparse, but there is sufficient data to suggest an impending epidemic. Prevention and targeted control of risk factors for CAD could potentially reduce the impact of CAD in the developing world as it has in industrialized nations.

[Infeccious diseases as causes of death in autopsied elderly]

The population aging in Brazil was associated with the alterations in the morbimortality of the population. The aim of this study was to verify the causes of death and other pathological processes in autopsied elderly. The elderly with 60 years or more in the period from 1976 to 1998 represented 394 cases (24.4%). The age median was 69 years ranged from 60 to 120 years, being higher in the women (70.5 versus 68 yrs;p<0.05). The male gender (67.5%), white color (69.8%), and the cardiovascular (43.7%) and infectious (31%) causes of death were dominate. In the malnourished (76.2%) it had association of pneumonia and cystitis, (p<0.05). Arteriosclerosis (61.9%), and the chagasic (42.1%) and hypertensive cardiopathies (39.1%) were the most frequent processes. Therefore, it was observed an overlapping of chronic-degenerative and infectious causes of death. This study shows the necessity to value of follow up of body mass index and of risk factors for the development of illness in aging patients like pneumonia.

Shifting trends in the pharmacologic treatment of hypertension in a Nigerian tertiary hospital: a real-world evaluation of the efficacy, safety, rationality and pharmaco-economics of old and newer antihypertensive drugs

The current prescription patterns for essential hypertension and the efficacy, safety, tolerability and cost-effectiveness of the newer antihypertensive drugs were evaluated in Nigerian patients. The findings were compared with that of a previous study conducted in the same tertiary hospital 10 years earlier. A cross-sectional evaluation of blood pressure (BP) control in a hypertension clinic was undertaken among 150 Nigerian patients aged 61 +/- 12 years (55% females), with a duration of treatment on a particular drug class or combination of 9 +/- 3 months. The initial blood pressure was 176 +/- 20/108 +/- 11 mmHg and 22% of the patient had concurrent diabetes mellitus. Thiazide diuretics (D) alone or in combination remained the most commonly prescribed drugs in 56% of all patients. There were significant increases in the prescriptions of calcium channel blockers (CCBs) (51%), P < 0.0001, and ACE-inhibitors (ACEIs) (24%), P < 0.0001, but a slight reduction in the use of methyldopa, and fixed drug combinations (P < 0.01) compared to the previous study. The fall in systolic blood pressure on D (r = 0.65, P < 0.001) or CCB (r = 0.48, P < 0.02) was significantly correlated with the initial systolic blood pressure, but not age. More patients achieved normotension BP < 140/90 mmHg on CCB monotherapy (71%), than D monotherapy (56%). Combination therapy with ACEIs + D or methyldopa+thiazides normalized BP in 63 and 68%, respectively. Pulse pressure, a surrogate marker for cardiovascular complications and mortality in essential hypertension, was significantly reduced (P < 0.01) equally by all treatments, with 95% confidence intervals ranging from -28 to -1 mmHg. However, hypertensive-diabetic (HT-DM) patients (n = 33) exhibited no significant change in pulse pressure in response to treatment. Adverse drug reactions that occurred in 11% were impotence or postural dizziness with D, headache and pitting oedema with CCB, and dry cough with ACEI. Pharmaco-economic comparison of the drug classes revealed that for every US dollar (dollar) spent per month, the percentage of treated patients attaining normotension was 18.6 for D, 4.73 for CCB, 3.5 for ACEI + D and 13.6 for methyldopa + thiazides. A combination of ACEI + CCB or D was the preferred treatment for hypertensive-diabetic Nigerians, but only 24% attained a BP < 130/85 mmHg. These results demonstrate a shift in trend to a more rational and efficacious treatment of hypertension over a 10 year period. This may be associated, at least in part, with the intensive and continuous education of the prescribers in rational drug use and the introduction of a hospital formulary. Methyldopa is still a highly efficacious and cost-effective drug in this population. Black HT-DM Africans still constitute a subgroup who not only require more and costlier antihypertensive drugs, but whose BP control is suboptimal, and exhibit a poor therapeutic response to other risk factors (pulse pressure) that constitute a continuing risk for cardiovascular mortality.

Prospective study of coroner's autopsies in Benin City, Nigeria

A prospective study of 726 cases of coroner's autopsies carried out over a period of two years (1st January, 1996 - 31st December, 1997) was reviewed. The causes and circumstances of death are defined and classified into natural and unnatural deaths. Fifty cases (6.3%) were children while the remaining 676 cases (93.1%) were adults in a male to female ratio of 2.6 to 1. The most common indications for coroner's autopsies were sudden unnatural deaths (SUDs) accounting for 485 cases (66.8%) and also sudden unexpected natural deaths (SUNDs) (241 cases) accounting for 33.2%. In the first category, road traffic accidents accounted for 86.7% of cases with deaths involving motor vehicle drivers and their passengers (41.8%); pedestrians (37.1%); and motorcyclists and their passengers (18.6%). The commonest causes of death in all road traffic accidents were craniocerebral injuries and haemorrhagic shock. In the second category the most common causes of sudden unexpected natural death were cardiovascular diseases resulting from complications of hypertension (54.7%) occurring in apparently healthy individuals. Other causes of death were pneumonia, pulmonary tuberculosis, typhoid fever and neoplastic diseases. This study showed that in Nigeria, with an increasing acquisition of dietary and life style habits of the developed western world, there is becoming a concomitant risk of deaths from road traffic accidents and sudden unexpected natural deaths from hypertensive cardiovascular disease.

Prognostic indices for intra-hospital mortality in Nigerian diabetic NIDDM patients. Role of gender and hypertension

Hypertension and diabetes mellitus are independently associated with a high rate of target organ complications, which is particularly accentuated in the Negroid race. The aims of this study were to evaluate the mortality associated with diabetes mellitus and concurrent hypertension and diabetes mellitus in indigenous Africans, and to identify and assess the factors that are predictive of intra-hospital mortality in Non-Insulin Dependent Diabetes Mellitus (NIDDM) diabetic Nigerians. The subsequent impact of the modification of these risk factors was also evaluated. A prospective study of 51 hypertensive-diabetic (Non-Insulin Dependent Diabetics, NIDDM) Nigerians (32 males, 19 females) over a 15-month period, from 1996 to 1997 was undertaken. The mean admission blood pressures were 170/102+/-35/22 mm Hg, with a body mass index (BMI) of 25.4+/-10.2 kg/m(2). A total of 54 normotensive (BP<130/85 mm Hg)-NIDDM diabetic Nigerians (30 men, 24 women), who were concurrently admitted in the hospital, were compared to the hypertensive-NIDDM. The total mortality of all the NIDDM diabetics, as well as the mortality rates in normotensives and hypertensive-diabetics, were computed. The causes of death and associated complications were noted. Predictive indices of intrahospital mortality were statistically evaluated by comparison of proportions, chi(2) test, Fischer's exact test, logistic regression, and analysis of variance (ANOVA).Over-all mortality rate among all the diabetics (both normotensive and hypertensive) was 26.6% (28/105), which was significantly higher than the crude death rate on the Internal Medicine service of 17.8% (P=0.006) or the non-obstetric crude death rate in the hospital of 10.96% (P=0.001) Among the hypertensive-NIDDM patients (n=51) the mortality rate was 31.4% (16 deaths/51 patients). This was slightly higher than the value of 22.2% (12 deaths/54 patients) seen in normotensive -NIDDM patients. The mortality rate among the male diabetics (23/63 patients) 46.6% was significantly higher than female mortality rate of 11.6% (5/43). The 95% Confidence interval for the difference in mortality rates being 16.9% to 53.3% (P<0.0001, z=3.57). The impact of gender remained significant by the chi(2) test, chi(2)=7.17, P=0.007. 50% of the deaths in hypertensive-diabetics had associated stroke (8/16), while none of the 12 deaths among the normotensive-diabetics was stroke-related (P=0.008, Fisher's exact test). The case fatality rate for stroke in hypertensive-NIDDM men (7/7.9) was significantly greater than in hypertensive-NIDDM women (1.0/7) (P=0.04,by Fisher's exact test). Male gender, presence of Hyperosmolar Non-Ketotic Coma (HONK) (P<0. 05), associated stroke (P<0.01) and a Glasgow coma < or =10 (P<0.01) were found to be poor prognostic indices for mortality in hypertensive-NIDDM. Aggressive anti-platelet, (aspirin) anti-hypertensive, and strict glycemic control, instituted early and intensively, especially in male hypertensive-NIDDM Nigerians have resulted in reduction in the mortality rates from 26.6% in 1997 to 12.6% in 1999 [P=0.05, 95% CI -26.9% to -1.3%]. The prognosis in 1999 of hospitalized African diabetics is still dismal. Hypertensive-NIDDM represents a higher risk group for intra-hospital mortality in black Africans. Male patients appear to have significantly (P<0.001) enhanced risk, especially with thrombotic/stroke-related deaths (P<0.01). However, intervention measures can reduce the mortality rate considerably, even in developing countries. The mechanisms of the apparent male mortality excess require elucidation.

Vasodilator therapy of hypertensive acute left ventricular failure: comparison of captopril-prazosin with hydralazine-isosorbide dinitrate

A prospective study to evaluate and compare the cardiorespiratory effects and clinical efficacy of the Neurohormonal inhibitors (Captopril 50 mg+prazosin 1 mg only) and direct arteriolar and venular dilators (Intravenous hydralazine 30 mg+oral isosorbide dinitrate 30 mg) used as vasodilator therapy, was undertaken in a randomized, single blind study in 17 Nigerian patients with hypertensive acute left ventricular failure. Both vasodilator regimes separately and significantly reduced the systolic and diastolic blood pressures (P<0.001 ANOVA), heart rate (P<0.001 ANOVA), and the respiratory rate (P<0.05 ANOVA), the double product, but increased the peak expiratory flow rate (P<0.05 ANOVA). However, the neurohormonal antagonists, captopril and prazosin (n=9) caused a statistically significantly greater reduction in heart rate (P<0.05 ANOVA) respiratory rate (P<0.05 ANOVA) and induced a significantly greater increase in the self-paced exercise capacity, 24 h after initiation of treatment, (P<0.02) compared to the hydralazine and isosorbide dinitrate combination (n=8). Five of the nine patients on the neurohormonal antagonist therapy were ambulant at 24 h, compared to none of the eight patients receiving conventional venular and arteriolar dilators hydralazine and isosorbide dinitrate (chi2=5.84 dfi P<0.05). There was a significant inverse correlation between the systolic blood pressure heart rate product, and the distance covered during symptom limited self paced exercise capacity (r=-0.58, P=0.0146 ANOVA). One of eight patients in the hydralazine+isosorbide nitrate combination died, but there was no mortality in the captopril+prazosin group. These findings collectively suggest that captopril+prazosin combination may be a superior vasodilator therapy compared to hydralazine-isosorbide dinitrate, in hypertensive acute pulmonary oedema.