Childhood acquired heart disease in Nigeria: an echocardiographic study from three centres

Kawasaki disease in Kenya and review of the African literature

BACKGROUND

Kawasaki disease has been described across the globe, although publications from Africa are limited. To our knowledge, there are no publications on Kawasaki disease from Kenya, which triggered this report.

METHODS

A retrospective cross-sectional study was undertaken to identify in-patients with a discharge diagnosis of Kawasaki disease, over 2 different 5-year periods, at two pediatric hospitals in Nairobi, Kenya. We reviewed the medical records of all patients and report their clinical findings, diagnostic workup and treatment. In addition, we undertook a detailed review of the literature.

RESULTS

Twenty-three patients with Kawasaki disease were identified, of those 12 (52.2%) had incomplete disease. The mean age was 2.3 years (SD+/-2.2) (range 0.3-10.3) with a male to female ratio of 1:1. The mean duration of fever at diagnosis was 8.3 days (SD+/-4.7) (range 2-20). Oral changes were the most common clinical feature and conjunctivitis the least common. Thrombocytosis at diagnosis was seen in 52% (12/23). Twenty-one patients (91.3%) were treated with intravenous immunoglobulin and all except 1 received aspirin. Baseline echocardiograms were performed in 95.7% (22/23) and found to be abnormal in 3 (13.6%). Follow-up data was limited. Our literature review identified 79 publications with documented cases of Kawasaki disease in children from 22 countries across the African continent with a total of 1115 patients including those from this report. Only 153 reported cases, or 13.7%, are from sub-Saharan Africa.

CONCLUSIONS

This is the first publication on Kawasaki disease from Kenya and one of the largest reports from sub-Saharan Africa. It is the first to have a complete review of the number of published cases from the African continent. Challenges in the diagnosis and management of Kawasaki disease in many African countries include disease awareness, infectious confounders, access and cost of intravenous immunoglobulin, access to pediatric echocardiography and follow-up. Increasing awareness and health care resources are important for improving outcomes of Kawasaki disease in Africa.

Access to essential cardiovascular medicines for children: a pilot study of availability, price and affordability in Nigeria

Policies to improve access to medicines for children in low- and middle-income countries, such as Nigeria, should consider the growing threat of non-communicable diseases. The aim of this pilot study was to scope availability, price and affordability of essential cardiovascular medicines for children in selected states in Nigeria. The study was a descriptive longitudinal survey conducted in three phases. Availability was determined as percentage of facilities having the medicine on the survey date. Medicines with good availability (>80%) were noted. Prices were cross-referenced against international Reference Prices and the Nigerian National Health Insurance Scheme Prices. Affordability was calculated using the Least-Paid Government Worker method. For medicines compounded to improve availability, a model for calculating affordability was proposed. In Phase I, the availability of all 17 strengths of the cardiovascular medicines or diuretics listed in the Essential Medicines List for Children (2015) were surveyed in two conveniently selected states using the WHO/HAI questionnaire. Data were collected from 17 hospitals and pharmacies. Phases II and III focused on tablet formulations (enalapril, furosemide, hydrochlorothiazide and spironolactone) in three purposively selected state capitals: Lagos, Abuja and Yenagoa. In Phase II, 11 private pharmacies were surveyed in December 2016: Phase III tracked price changes in Abuja and Yenagoa in August 2018. Only furosemide and hydrochlorothiazide tablets had good availability. Oral liquids were unavailable. Prices for four generic oral tablets were 2-16× higher than the International Reference Prices; prices for two of these did not change significantly over the study period. Affordable medicines were generic furosemide and hydrochlorothiazide tablet. Where a fee is charged, compounded medicines were also not affordable. While the small sample sizes limit generalization, this study provides indicative data suggesting that prices for cardiovascular medicines remain high and potentially unaffordable in the private sector in these selected states, and when compounded. Regular systematic access surveys are needed.

Challenges in addressing the knowledge gap on endomyocardial fibrosis through community-based studies

Endomyocardial fibrosis (EMF) is a poverty-related disease of unknown origin that afflicts predominantly young people of certain rural areas in low-income countries and can be used to expose global disparities in cardiovascular research. Despite affecting predominantly young people and causing high morbidity and mortality, efforts to understand its mechanisms and natural history have been hampered by the incapacity to detect the early stages of the disease in endemic areas. Dietary, environmental and infectious factors seem to combine in susceptible individuals to give rise to an inflammatory process that leads to endomyocardial damage and scar formation. Lack of awareness by health professionals and low access to health care determine late diagnosis, when complications such as chronic heart failure, thromboembolism and arrhythmia are already present. Open-heart surgery to detach the endocardial fibrous tissue and repair the atrioventricular valve, remains the last resource to prolong patients' survival. Community-based research is therefore needed to understand the epidemiology of EMF, detect early disease, uncover its pathogenesis and explore new therapeutic targets. Our research has shown that echocardiographic screening using standard criteria adds sensitivity and precision to the diagnosis, particularly in asymptomatic disease, providing an opportunity for longitudinal community-based research. However, researchers face major constraints in rural settings where EMF is endemic, including socioeconomic, cultural, geographical and administrative barriers. In presenting our experience we aim to describe the challenges and discuss the lessons learned while implementing community-based research in a highly endemic area in southern Mozambique, one of the poorest countries in the world. Additionally, we discuss how recent advances in medicine-such as use of point-of-care diagnostics, heart failure biomarkers and new imaging techniques-may open new possibilities for high quality research through collaborative partnerships and regional initiatives.

Endomyocardial Fibrosis: an Update After 70 Years

PURPOSE OF REVIEW

This review aims at highlighting the need to better understand the pathogenesis and natural history of endomyocardial fibrosis when set against its changing endemicity and disease burden, improvements in diagnosis, and new options for clinical management.

RECENT FINDINGS

Progress in imaging diagnostic techniques and availability of new targets for drug and surgical treatment of heart failure are contributing to earlier diagnosis and may lead to improvement in patient survival. Endomyocardial fibrosis was first described in Uganda by Davies more than 70 years ago (1948). Despite its poor prognosis, the etiology of this neglected tropical restrictive cardiomyopathy still remains enigmatic nowadays. Our review reflects on the journey of scientific discovery and construction of the current guiding concepts on this mysterious and fascinating condition, bringing to light the contemporary knowledge acquired over these years. Here we describe novel tools for diagnosis, give an overview of the improvement in clinical management, and finally, suggest research themes that can help improve patient outcomes focusing (whenever possible) on novel players coming into action.

Acquired heart disease in children is not necessarily rheumatic

Acquired heart diseases (AHD) cause significant morbidity and mortality in children. There are limited studies on their burden in children. We conducted a retrospective study of 85 consecutive children diagnosed with AHD using clinical evaluation and echocardiography at Medical College, Kanpur, India to determine the aetiology and outcome of AHD in children. We found rheumatic heart disease (RHD) in one-third, cardiomyopathies or myocarditis combined in a further third and the remaining third were other causes, including pericardial diseases and metabolic or genetic disorders. These latter diseases were frequently misdiagnosed, causing significant morbidity and mortality. Hence, in children of all age groups presenting with unexplained shock, dyspnoea, hepatomegaly and ascites, cardiac status should be carefully and critically evaluated so that non-rheumatic AHD may not be missed.

The burden of rheumatic heart disease among children in Lagos: how are we fairing?

INTRODUCTION

Rheumatic heart disease still remains a cause of morbidity and mortality in low and middle income countries, despite its eradication in developed societies. The study aimed to document the features of children with rheumatic heart disease using clinical evaluation and echocardiography and compare it with reports from other part of the country.

METHODS

A review of a prospectively collected data of patients with rheumatic heart disease who had echocardiography done from April 2007-Dec 2016. Information obtained from patients include age, sex, clinical indication for echocardiography, echocardiographic characterization of the valvular lesions and associated complications.

RESULTS

A total of 324,676 patients were seen at the Paediatric unit of LASUTH from 2007 to 2016, out of which 36 had Rheumatic heart disease. This translates to a prevalence of 1.1 per 10,000 patients who presented at the study site during the study period. The prevalence of RHD amongst all the patients with structural heart disease was 2.6%. The mean age of patients was 9.12 ± 2.75 years with a male to female ratio of 1.6: 1. The most common valve affected was mitral valve. Heart failure was the most common mode of presentation found in 91.6%. Other complications were pulmonary hypertension and pericardial effusion.

CONCLUSION

Rheumatic heart disease is still prevalent among children in Lagos although the prevalence is reducing. Heartfailure is the commonest mode of presentation and complication in them.

Nigerian Children with Acquired Heart Disease: The Experience in Lagos

Background: Most of the recent reports on acquired heart diseases (AHDs) among Nigerian children are either retrospective or cover a short period of time with fewer subjects. The last report on AHDs among children in Lagos was about a decade ago; it was, however, not specific to children with AHDs but was part of a report on structural heart diseases among children in Lagos. The present study was carried out to document the prevalence and profile of different AHDs in children and to compare the findings with those previously reported. Methods: We conducted a quantitative, nonexperimental, prospective, and cross-sectional review of all consecutive cases of AHDs diagnosed with echocardiography at the Lagos State University Teaching Hospital between January 2007 and June 2016. Comparisons between the normally distributed quantitative data were made with the Student t test, while the χ² test was applied for the categorical data. Results: The subjects with AHDs were 73 males and 52 females, with a male-to-female ratio of 1.4:1. The children were aged 15 days to 14 years, with a mean of 6.61 ± 4.26 years. Rheumatic heart disease was the most common AHD, documented in a quarter of the children, followed by dilated cardiomyopathy and pericardial effusion in 20.8% and 17.3%, respectively. Less common lesions encountered were Kawasaki disease, mitral valve prolapse, hyperdynamic circulation, and supraventricular tachycardia. Conclusion: Rheumatic heart disease was still the most common AHD in the children in the present study. Dilated cardiomyopathy and pericardial effusion are on the increase as has been reported earlier.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

Echocardiographic pattern of acquired heart diseases in Nigeria

Background:

Acquired heart diseases (AHDs) are present from childhood to old age, and the frequency of pathology differs according to age and the geographical region of the patients. The aim of this study was to document the echocardiographic patterns of AHDs in our setting.

Materials and Methods:

Retrospective analysis of echocardiographic diagnosis of AHD was done for age, sex, and echocardiographic pattern.

Results:

There were 190 diagnoses in the 163 patients with 27 patients having a double diagnosis, consisting of 88 (54%) males and 75 (46%) females. The mean age was 50.4 years (age range 9-85 years). Ten types of acquired heart pathologies were identified and they included hypertensive heart disease in 49.47%, rheumatic heart disease in 26.32%, cardiomyopathy in 11.05%, endomyocardial fibrosis in 4.74%, and pericarditis in 3.68%. Others were cor pulmonale, pulmonary hypertension, intracardiac thrombi, left atrial myxoma and degenerative heart disease which accounted for the remaining 4.74%.

Conclusion:

This study identifies 10 types of AHDs among the study population. The huge impact of hypertensive heart disease and rheumatic heart disease is a big indicator pointing to the existence of a sub-optimal level of healthcare in the country.

A new look at acquired heart diseases in a contemporary sub-Saharan African pediatric population: the case of Yaoundé, Cameroon

BACKGROUND

Acquired heart diseases (AHD) in children cause significant morbidity and mortality especially in low resource settings. There is limited description of acquired childhood heart diseases in Cameroon, making it difficult to estimate its current contribution to childhood morbidity and mortality. Echocardiography is the main diagnostic modality in low resource settings and has a key role in the characterization and management of these disorders. We aimed to determine the prevalence and spectrum of AHD in children in Yaoundé-Cameroon, in an era of echocardiography. These data are needed for health service and policy formulation.

METHODS

Echocardiography records from August 2003 to December 2013 were reviewed. Echocardiography records of children ≤18 years with an echocardiographic diagnosis of a definite AHD were identified and relevant data extracted from their records.

RESULTS

One hundred and fifty eight children (13.4%) ≤18 years had an AHD. The mean [± standard deviations (SD)] age was 11.9 (±4.4) years .The most common affected age group was 15-18 years (36.1%). Heart failure (20.3%), suspicion of rheumatic heart disease (RHD) (12.0%) and the presence of a heart murmur (8.9%) were the most common indications for echocardiography. RHD (41.1%), pericardial disease (25.3%), dilated cardiomyopathy (DCM) (15.8%) and endomyocardial fibrosis (EMF) (13.9%) were the most common AHD. Cor pulmonale was rare (1.3%). Fifty-seven (87.7%) children with RHD had mitral regurgitation alone or in combination with other heart valve lesions and 63.3% of the lesions were severe.

CONCLUSIONS

RHD remains the most common AHD in children in this setting and is frequently severe. Multicenter collaborative studies will help to better describe the pattern of AHD and there should be a renewed focus on the prevention of RHD.