Prognostic indices among hypertensive heart failure patients in Nigeria: the roles of 24-hour Holter electrocardiography and 6-minute walk test

Burden of atrial fibrillation among adults with heart failure in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

This study aimed to estimate the prevalence of atrial fibrillation (AF) in adults with heart failure (HF) and summarise the all-cause mortality ratio among adult patients with coexisting HF and AF in sub-Saharan Africa (SSA).

SETTING

This was a systematic review and meta-analysis of cross-sectional and cohort studies with primary data on the prevalence and incidence of AF among patients with HF and the all-cause mortality ratio among patients with HF and AF in SSA. We combined text words and MeSH terms to search MEDLINE, PubMed and Global Health Library through Ovid SP, African Journals Online and African Index Medicus from database inception to 10 November 2021. Random-effects meta-analysis was used to estimate pooled prevalence.

PRIMARY OUTCOME MEASURES

The prevalence and incidence of AF among patients with HF, and the all-cause mortality ratio among patients with HF and AF.

RESULTS

Twenty-seven of the 1902 records retrieved from database searches were included in the review, totalling 9987 patients with HF. The pooled prevalence of AF among patients with HF was 15.6% (95% CI 12.0% to 19.6%). At six months, the all-cause mortality was 18.4% (95% CI 13.1% to 23.6%) in a multinational registry and 67.7% (95% CI 51.1% to 74.3%) in one study in Tanzania. The one-year mortality was 48.6% (95% CI 32.5% to 64.7%) in a study in the Democratic Republic of Congo. We did not find any study reporting the incidence of AF in HF.

CONCLUSION

AF is common among patients with HF in SSA, and patients with AF and HF have poor survival. There is an urgent need for large-scale population-based prospective data to reliably estimate the prevalence, incidence and risk of mortality of AF among HF patients in SSA to better understand the burden of AF in patients with HF in the region.

PROSPERO REGISTRATION NUMBER

CRD42018087564.

Ventricular Arrhythmias in Seniors with Heart Failure: Present Dilemmas and Therapeutic Considerations: A Systematic Review

BACKGROUND

Heart Failure (HF) is a global public health problem, which affects over 23 million people worldwide. The prevalence of HF is higher among seniors in the USA and other developed countries. Ventricular Arrhythmias (VAs) account for 50% of deaths among patients with HF. We aim to elucidate the factors associated with VAs among seniors with HF, as well as therapies that may improve the outcomes.

METHODS

PubMed, Web of Science, Scopus, Cochrane Library databases, Science Direct, and Google Scholar were searched using specific keywords. The reference lists of relevant articles were searched for additional studies related to HF and VAs among seniors as well as associated outcomes.

RESULTS

The prevalence of VAs increases with worsening HF. A 24-hour Holter electrocardiogram may be useful in risk stratifying patients for device therapy if they do not meet the criterion of low ventricular ejection fraction. Implantable Cardiac Defibrillators (ICDs) are superior to anti-arrhythmic drugs in reducing mortality in patients with HF. Guideline-Directed Medical Therapy (GDMT) together with device therapy may be required to reduce symptoms. In general, the proportion of seniors on GDMT is low. A combination of ICDs and cardiac resynchronization therapy may improve outcomes in selected patients.

CONCLUSION

Seniors with HF and VAs have high mortality even with the use of device therapy and GDMT. The holistic effect of device therapy on outcomes among seniors with HF is equivocal. More studies focused on seniors with advanced HF as well as therapeutic options are, therefore, required.

Risk factors of heart failure among patients with hypertension attending a tertiary hospital in Ibadan, Nigeria: The RISK-HHF case-control study

Aim

Hypertension is the leading cause of heart failure (HF) in sub-Saharan Africa. Preventive public health approach to reduce the scourge of HF must seek to understand the risk factors of HF in at-risk populations. The aim of this study was to characterize the risk factors of HF among patients with hypertension attending a cardiology clinic.

Methods and results

One hundred and one (101) case-control age- and sex-matched pairs were recruited. The study population were adults with a clinical diagnosis of hypertensive HF (cases) and individuals with systemic hypertension without HF. They were interviewed and evaluated for cardiovascular risk factors. Associations between variables were tested with chi square test, Fisher’s exact test and independent sample t test as appropriate. Logistic regression modelling was used to determine the independent risk factors of hypertensive HF (HHF) in the study population while ‘punafcc’ package in stata12 was used to calculate the population attributable fraction (PAF) of the risk factors. Suboptimal medication adherence was the strongest adverse risk factor of HHF (medium adherence aOR: 3.53, 95%CI: 1.35–9.25; low adherence aOR: 9.44, 95%CI: 3.41–26.10) with a PAF of 67% followed by dipstick proteinuria (aOR: 4.22, 95%CI: 1.62–11.02; PAF: 34%) and alcohol consumption/day per 10grams (aOR: 1.23, 95%CI: 1.02–1.49; PAF: 22%). The protective risk factors of HHF were use of calcium channel blockers (aOR 0.25, 95%CI: 0.11–0.59; PAF: 59%), then daily fruits and vegetable consumption (aOR 0.41, 95%CI: 0.17–1.01; PAF: 46%), and eGFR (aOR 0.98, 95%CI: 0.96–0.99; PAF: 5.3%).

Conclusions

The risk factors of HHF are amenable to lifestyle and dietary changes. Public health interventions and preventive cardiovascular care to improve medication adherence, promote fruit and vegetable consumption and reduce alcohol consumption among patients with hypertension are recommended. Renoprotection has utility in the prevention of HF among hypertensives.

Development and Validation of a Electrocardiographic Diagnostic Score of Heart Failure Among Patients with Hypertension Attending a Tertiary Hospital in Ibadan, Nigeria: The RISK-HHF Case-Control Study

Objectives

Hypertension is the leading cause of HF in sub-Saharan Africa. Electrocardiography (ECG) is a cheap and easily available stratification tool for the diagnosis and prognostication of individuals with hypertension. The aim of this study was to develop an ECG-based HF diagnostic score among patients with hypertension attending a specialist cardiology clinic.

Methods

One hundred and one (101) case-control age- and sex-matched pairs were recruited. The study population were adults with a clinical diagnosis of hypertensive HF failure (cases) and systemic hypertension without HF (controls). Participants underwent clinical assessment and ECG. Associations between ECG variables and HF risk were tested with chi square test. Logistic regression modelling (age- and sex adjusted) was trained on a random subset of participants and tested on the remaining participants to determine the ECG abnormalities that are diagnostic of HF and develop a HF diagnostic score. The HF diagnostic score was then validated in an independent dataset of the ECG-Hypertension Audit. Goodness of fit and c-statistics of the HF summed diagnostic score in the training, testing and validation datasets are presented. A two-sided p value of <0.05 was considered statistically significant.

Results

The independent ECG diagnostic markers of HF among hypertensive patients in this study in decreasing order of effect size were sinus tachycardia (aOR: 7.72, 95% CI: 2.31-25.85). arrhythmia (aOR: 7.14, 95% CI: 2.57-19.86), left ventricular hypertrophy (aOR: 4.47; 1.85-10.77) and conduction abnormality (aOR: 3.41, 95% CI: 1.21-9.65). The HF summed diagnostic score showed excellent calibration and discrimination in the training (Hosmer Lemeshow p = 0.90; c-statistic 0.82; 95% CI 0.76–0.89) and test samples (Hosmer Lemeshow p=0.31; c-statistic 0.73 95% CI 0.60 to 0.87) of the derivation cohort and an independent validation audit cohort (Hosmer Lemeshow p = 0.17; c-statistic 0.79 95% CI 0.74 to 0.84) respectively. The model showed high diagnostic accuracy in individuals with different intermediate pre-test probabilities of HF.

Conclusions

A ECG based HF score consisting of sinus tachycardia, arrhythmia, conduction abnormality and left ventricular hypertrophy is diagnostic of HF especially in those with intermediate pre-test probability of HF. This has clinical importance in the stratification of individuals with systemic hypertension.

Physical functional performance and prognosis in patients with heart failure: a systematic review and meta-analysis

Background

Patients with Heart Failure (HF) show impaired functional capacities which have been related to their prognosis. Moreover, physical functional performance in functional tests has also been related to the prognosis in patients with HF. Thus, it would be useful to investigate how physical functional performance in functional tests could determine the prognosis in patients with HF, because HF is the leading cause of hospital admissions for people older than 65 years old. This systematic review and meta-analysis aims to summarise and synthesise the evidence published about the relationship between physical functional performance and prognosis in patients with HF, as well as assess the risk of bias of included studies and the level of evidence per outcome.

Methods

Major electronic databases, such as PubMed, AMED, CINAHL, EMBASE, PEDro, Web of Science, were searched from inception to March 2020 for observational longitudinal cohort studies (prospective or retrospective) examining the relationship between physical functional performance and prognosis in patients with HF.

Results

44 observational longitudinal cohort studies with a total of 22,598 patients with HF were included. 26 included studies reported a low risk of bias, and 17 included studies showed a moderate risk of bias. Patients with poor physical functional performance in the Six Minute Walking Test (6MWT), in the Short Physical Performance Battery (SPPB) and in the Gait Speed Test showed worse prognosis in terms of larger risk of hospitalisation or mortality than patients with good physical functional performance. However, there was a lack of homogeneity regarding which cut-off points should be used to stratify patients with poor physical functional performance from patients with good physical functional performance.

Conclusion

The review includes a large number of studies which show a strong relationship between physical functional performance and prognosis in patients with HF. Most of the included studies reported a low risk of bias, and GRADE criteria showed a low and a moderate level of evidence per outcome.

Clinical and Echocardiographic Predictors of Arrhythmias Detected With 24-Hour Holter Electrocardiography Among Hypertensive Heart Failure Patients in Nigeria

Background

Hypertensive heart failure (HHF) is the commonest form of heart failure in Nigeria. There is paucity of data in Nigeria on 24-hour Holter electrocardiography (24-HHECG) and important predictors of arrhythmias among HHF patients.

Objectives

To determine the 24-HHECG characteristics among HHF patients. To determine the clinical and echocardiographic predictors of arrhythmias detected using 24-HHECG among HHF patients.

Methods

A total of 100 HHF patients as well as 50 age-matched and sex-matched apparently healthy controls were prospectively recruited over a period of 1 year. They all had baseline laboratory tests, echocardiography, and 24-HHECG.

Results

Hypertensive heart failure patients had significantly higher counts of premature ventricular contractions (PVCs) than the controls (P ≤ .001). Ventricular tachycardia (VT) was recorded in 29% of HHF patients as compared with controls who had no VT on 24-HHECG. The standard deviation of all normal to normal sinus RR intervals over 24 hours (SDNN) was abnormally reduced among HHF patients when compared with controls (P = .046). There was positive correlation between atrial fibrillation (AF) and the following parameters: PVCs (r = .229, P = .015), New York Heart Association (NYHA) (r = .196, P = .033), and VT (r = .223, P = .018). Following multiple linear regression, left ventricular ejection fraction (LVEF) (P ≤ .001) and serum urea (P = .037) were predictors of PVCs among HHF patients. Serum creatinine (P ≤ .001), elevated systolic blood pressure (SBP) (P = .005), and PVCs (P ≤ .001) were important predictors of VT among HHF patients.

Conclusions

Renal dysfunction and reduced LVEF were important predictors of ventricular arrhythmias. High counts of PVCs and elevated SBP were predictive of the occurrence of VT among HHF patients. The NYHA class and ventricular arrhythmias have a significant positive correlation with AF. The SDNN is reduced in HHF patients.