[Acute heart failure with altered ejection fraction : Electrocardiographic signs with mortality at the Abidjan cardiology institute]

INTRODUCTION

Heart failure with impaired ejection fraction (HFIEF) represents the end-stage of most cardiac diseases, and is responsible for a high mortality rate. In order to identify patients at risk, numerous clinical and paraclinical prognostic factors have been proposed. The electrocardiogram (ECG), easy to perform and inexpensive, retains a powerful role in the prognostic evaluation of heart failure patients. The aim was to evaluate ECG signs associated with mortality in a retrospective cohort of patients with ICFEA.

METHODOLOGY

The study was observational and analytical based on retrospective data collected from patients benefiting from a primary hospitalization for ICFEA at the Abidjan Heart Institute from January 2018 to July 2020.

RESULTS

Of the 370 patients included, 197 had died by August 1, 2020, representing an overall mortality of 53%. Mortality progressed gradually up to one year, then remained unchanged up to 30 months. In multivariate Cox regression including ECG variables only, the presence of intra-ventricular conduction disorders (OR: 1.80; 95% CI [1.01-3.25]), microvoltage (OR: 1.82; 95% CI [1.05-16]), and pathological Q waves (OR: 1.70; 95% CI [1.02-2.83]), were significantly associated with overall mortality. When ECG variables and clinical, paraclinical and therapeutic demographic variables were included, only the presence of pathological Q waves (OR:1.74; 95% CI [1.01-3.01]) persisted as a risk factor for mortality. Hypertension and treatment of heart failure, in particular ACEI/ARII, beta-blockers and ARM, were protective factors. The presence of Q waves was associated with a significant reduction in survival, based on curves obtained using the Kaplan-Meier model.

CONCLUSION

ICFEA is responsible for high mortality, mainly in the year following the 1st hospitalization for cardiac decompensation. The presence of pathological Q waves is the only electrocardiographic sign that remains statistically associated with a poor prognosis, after adjustment.

Post discharge management of heart failure patients: clinical findings at the first medical visit in a single-center study

BACKGROUND

The Post Discharge Management of patients with heart failure impact significantly their incomes. This study aims to analyze the clinical findings and management at the first medical visit of these patients in our context.

MATERIAL AND METHODS

This is a retrospective cross-sectional descriptive study on consecutive files of patients hospitalized for heart failure from January to December 2018 in our Department. We analyse data from the first post discharge medical visit including medical visit time, clinical conditions and management.

RESULTS

Three hundred and eight patients (mean age: 53.4 ± 17.0 years, 60% males) were hospitalized on median duration of 4 days [1-22 days]. One hundred and fifty-three patients (49,67%) were presented at the first medical visit after 66.53 days[0.06-369] on average, 10 (3.24%) patients died before this first medical visit and 145 (47.07%) had been lost to follow-up. The re-hospitalization and treatment non-compliance rates were 9.4% and 3.6%, respectively. Male gender (p = 0.048), renal failure (p = 0.010), and Vitamin K antagonist (VKA) /direct oral anticoagulant (DOAC) (p = 0.049) were the main lost to follow-up factors in univariate analysis without statistic signification in multivariate analysis. Hyponatremia (OR = 2.339; CI 95% = 0.908-6.027; p = 0.020) and atrial fibrillation (OR = 2.673; CI 95% = 1.321-5.408; p = 0.012) were the major mortality factors.

CONCLUSION

The management of patients with heart failure after discharge from hospital seems to be insufficient and inadequate. A specialized unit is required to optimize this management.

Detection and characteristics of hypertension patients admitted in 37 cardiology departments from 17 Sub-Saharan African countries

Background

High blood pressure (BP) is a major risk factor for several common cardiovascular (CV) disease such as stroke, heart failure or chronic kidney disease. The Sub-Saharan Africa (SSA) should face the highest rate of hypertension worldwide with an overall prevalence estimation of 46%. Due to scarce resources and inadequate healthcare provision, SSA have scarce hard data on treatment and control of high BP.

Purpose

To assess the detection and characteristics of hypertension patients admitted in hospitalizations 17 SSA countries

Methods

We conducted a transversal and longitudinal study in CV department of 37 hospitals from 23 cities in 17 SSA countries (10 low income: Niger, Guinea, Benin, Mali, Democratic Republic of the Congo, Tchad, Burkina Faso, Togo, Burundi, Ethiopia and 7 middle income: Cote d'Ivoire, Senegal, Cameroon, Congo, Soudan, Mauritania, Gabon). The February study was designed by a multidisciplinary collaborative team of epidemiologists, pharmacists and cardiologists from Africa and France. This ongoing observatory included all inpatients in February from each year since 2016. Data including socio-demographic and clinical characteristics, causes of admission, clinical, biological, complementary examinations, treatments, length of stay and discharge diagnosis were collected by the investigating physicians. Hypertension and severity of hypertension were defined according to 2018 ESC/ESH guidelines and BP was measured twice using standardized method. All analyses were performed through scripts developed in the R software (4.0.3 (2020-10-10))

Results

The study involved 4360 patients. Hypertension was measured on 1906 (43.7%) patients at admission. Proportion of patients with high BP in hospital increased from 42.2% in 2016 to 52.2% in 2021 (p<0.05) and differed significantly across countries from 77.6% in Niger to 100% in Chad. Among hypertensive patients, men represented 59.6% of patients and mean of age was 59±15.1 years. Overall, 61.4% of patients were from low income countries. The mains causes of admission among hypertensive patients were heart failure (37.8%) and stroke (18.9%). Average of systolic BP was 159±29.3 mmHg and average of diastolic BP was 96.7±16mmHg. Overall, 760 (40.3%), 525 (27.8%) and 602 (31.9%) had grade 1, grade 2 and grade 3 hypertension respectively. History of CV disease was observed in 51.5% of patients. Thus, 70.4% of patients had at least one CV risk factor other than hypertension. Angiotensin converting enzyme inhibitors and diuretics was prescribed in 56.9% and 55.8% of patients respectively. The average amount of antihypertensive drugs prescribed in hospital was 2.09±1.18. Overall, 237 (12.4%), 295 (15.5%), 640 (33.6%) and 734 (38.5%) received respectively no drug, monotherapy, two-drug strategies and three and more drug strategies.

Conclusion

In patients admitted in cardiology departments, hypertension is a huge burden in SSA.

Funding Acknowledgement

Type of funding sources: None.

P3459Research Network in Africa (RNA): gender differences in cardiovascular risk factors and complications in 12 African countries

Background

Cardiovascular diseases are rapidly growing epidemic in Sub-Saharan Africa. Unlike other regions of the world, death rates due to hypertension are greater for women than men in Africa. Scarce data were available on factors associated with gender in cardiovascular risk factors and complications in Sub-Saharan Africa.

Purpose

To assess gender differences in cardiovascular risk factors pattern in patients with hypertension in 12 Sub-Saharan countries.

Methods

We conducted a cross-sectional survey in urban clinics of twelve countries in Africa. Data were collected on demographics, treatment and standardized BP measures were made among the hypertensive patients attending the clinics. BP control was defined as BP<140/90 mmHg and hypertension grades were defined according to European Society of Cardiology guidelines. The separate association between women factors and BP control was investigated using Generalized Linear Mixed-Effects Models adjusted on age; A random effect on the country was added (generalized estimated equation models) to account for inter-country variability.

Results

The EIGHT study enrolled 2198 patients with hypertension in 12 sub-Saharan countries between January 2014 and November 2015. The proportion of women (60,2%) was higher than men and varied significantly according to countries (p<0.001), ranged from 33.7% (Guinea) to 71.9% (Gabon). Mean age was 57.7±12.0 years for women and 59.2±11.4 years for men (p<0.001).

Compared to men, women had a higher rate of family cardiovascular background (79% vs 70%, for women and men respectively) (p<0.0001), cardiovascular risk factors (74.3% vs 68.1) (p=0.008), such as obesity (25.8% vs 12.1%) (p<0.0001), sedentary behavior (42.1% vs 35.0%) (p=0,006). BP control didn't differ according to gender, the repartition of grades of hypertension was similar between women and men and proportion of uncontrolled BP was 77.2% in women and 77.8% in men (p=0.4), with same proportion of women and men receiving antihypertensive treatment (96 vs 97.5%) (NS).

However, African women had less cardiovascular complications than men (39% vs 52.4%) (p<0.0001) (OR: 0.50 [CI 95% 0.41–0.61]).

Conclusions

Our study highlighted gender differences in cardiovascular risk factors pattern in Sub-Saharan hypertensive patients. Tailoring medical (public health) programs to improve cardiovascular disease prevention that take into women characteristics may enhance their effectiveness.

[Pulmonary embolism and complete atrioventricular block]

Complete atrioventricular block is a rare complication of pulmonary embolism. We describe the case of a black African patient, aged 42 years, who presented to the emergency department of Abidjan Heart Institute for sudden onset dyspnea and hemoptysis. ECG revealed a third degree atrioventricular block. Computed tomographic angiography showed proximal pulmonary embolism of the right main pulmonary artery. To our knowledge, this is the first case of complete atrioventricular block in pulmonary embolism in Sub-Saharan Africa. In case of pulmonary embolism, clinical and electrocardiographic monitoring is necessary in order to identify this uncommon and potentially serious outcome.

[Presumption of sleep apnea in a black African hypertensive population: Importance of the Epworth sleepiness scale in the diagnostic approach]

INTRODUCTION

Sleep apnea syndrome (SAS) is very little described in the hypertensive black African.

PURPOSE

To screen sleep apnea syndrome using the rating scale of Epworth daytime sleepiness, and to investigate the determinant factors and to infer therapeutic consequences.

METHOD

This is a retrospective and prospective study with descriptive and analytical purpose that focused on 200 hypertensive outpatients of the Cardiology Institute of Abidjan. The primary endpoint studied was the SAS. The diagnostic approach of SAS was performed using the rating scale of Epworth daytime sleepiness.

RESULTS

The prevalence of sleep apnea was 45%. The average age of sleep apnea carriers was 56.1 years, with a male predominance (60%). The determinant factors of sleep apnea syndrome were male gender (60% versus 40%, P=0.021), obesity (77.8% versus 62.7%, P<0.0001), diabetes (26.7% versus 15.5%, P=0.5) and dyslipidemia (54.4% versus 27.3%, P=0.0009). Life in urban areas, occupation and smoking were not correlated with SAS in our series. The control of hypertension was better in non-apneic patients compared to apneic patients (63.6% versus 38.9%, P=0.04). The visceral impact of hypertension in apneic patients was highly significant (77.8% versus 41.7%, P=0.014). Therapeutically, it was noted the preferential prescription of combination therapy in apneic patients compared to non-apneic patients (82.3% versus 74.4%).

[Peripheral arterial disease of the lower limbs in African diabetic patients: ultrasonography and determining factors]

INTRODUCTION

Diabetic peripheral arterial disease (PAD) of the lower limbs is underdiagnosed.

METHODOLOGY

This was a prospective study conducted over a six-month period from November 2012 to April 2013. A total of 308 diabetic patients were included from three diabetes centers in Abidjan (Ivory Coast).

AIM

To screen for PAD of the lower limbs in a diabetic population and to identify the determining factors.

RESULTS

Among the 308 patients, the ankle-brachial index (ABI) was<0.9 in 68 (22.07%) patients considered to have PAD; the ABI was>1.3 in 56 (18.2%) patients who had suspected mediacalcosis. The average age of the PAD patients was 60.2 years. Female gender predominated (55.9%). The mean duration of diabetes was 9.6 years: 97.1% type 2 diabetes. The other cardiovascular risk factors in this population were hypertension (58.8%) and dyslipidemia (40.9%). Smoking was present in 29.4% of patients and obesity in 23.9%. PAD of the lower limbs was mild in 46 patients (67.6%), moderate in 16 (23.5%) and severe in 6 (8.8%). Duplex Doppler commonly showed lesions of the tibial arteries. Determining factors of diabetic PAD of the lower limbs were hypertension (58.8% vs 36.6%; OR=2.46; 95% CI: 1.13-5.36; P=0.034) and dyslipidemia (40.9% vs 8.3%; OR=7.6; 95% CI: 2.31-25.08; P=0.0009). For mediacalcosis, male gender (71.5% vs 39.7; OR=0.26 95% CI/0.10-0.64. P=0.004) was the only factor identified.

CONCLUSION

Hypertension and dyslipidemia were predictive factors for diabetic PAD of the lower limbs in our African population.

[Impact of anaemia on the prognosis of myocardial infarction in black Africans]

OBJECTIVE

Anaemia is increasingly being described as a negative predictor of outcome after myocardial infarction. The objective of our study was to assess the prognosis post myocardial infarction in the short and medium term in black Africans with chronic anaemia.

METHODS

We carried out a comparative case-control study on 272 patients (93 anaemic and 179 non-anaemic) hospitalised for myocardial infarction at the Cardiology Institute of Abidjan. One group included 93 patients who presented with anaemia concurrent with the myocardial infarction (haemoglobin level low: 13 g/dl for males and 12 g/dl for females, respectively). The other group comprised 172 patients who presented without anaemia during the acute phase of myocardial infarction. The haemoglobin rate was measured at admission, as were the biological markers of myocardial infarction.

RESULTS

The mean age was 53.5 years for the anaemic patients and 52.6 years for the non-anaemic patients. We noticed a clear male predominance in both populations (81.7 vs 78.8%; p = 0.56). The mean haemoglobin level was lower in the anaemic patients compared to that in the non-anaemic patients (10.2 vs 15 g/dl). The anaemic patients were eight times more at risk for an unfavourable outcome (complications or death) compared to the non-anaemic patients (91.4 vs 57%; OR = 8.02; 95% CI: 3.5-19.07; chi(2) = 33.74; p < 0.0001). The anaemic patients were 3.7 times more at risk for right ventricular failure (NYHA class II and III) compared to the control population (69.9 vs 38.5%; OR = 3.7; 95% CI: 08-6.60; chi(2) = 24.06; p < 0.0001) and six times more at risk for cardiogenic shock (24.7 vs 5.3%; OR = 6.21; 95% CI: 2.56-15.43; chi(2) = 22.89; p < 0.0001). The mortality rate was significantly higher in the anaemic than the non-anaemic patients (35.5 vs 12.8%; OR = 3.73; 95% CI: 1.94-7.19; chi(2) = 19.18; p < 0.0001).

CONCLUSION

Anaemia is an independent risk factor for a poor prognosis during the acute phase of myocardial infarction in black Africans.

[Unusual association of endomyocardial fibrosis and aberrant migration of Dracunculus medinensis in the pericardium]

We report one case of endomyocardial fibrosis with a relapsing pericarditis, associated with an aberrant migration of Dracunculus medinensis in the pericardium, in a 22-year-old patient from an endemic zone of bilharziasis and dracunculosis in Côte d'Ivoire. The evolution has been marked by the appearance of thrombus in the right atrium. The patient died on the 49th day of hospitalization following an refractory cardiac insufficiency.

[Clinical and electrophysiological study of asymptomatic Wolff-Parkinson-White syndrome]

AIM

This study was designed to describe clinical characteristics and electrophysiologic in patients with asymptomatic Wolff-Parkinson-White syndrome.

METHODS

From December 2000 to August 2005, a total of 154 patients with accessory pathway-mediated reentry mechanism underwent electrophysiologic studies at Sainte-Marguerite and Timone hospitals in Marseille. Ninety-six patients had WPW syndrome, out of which 78 were symptomatic patients and 18 were asymptomatic. The mean age was 26 years. Sex (masculine) 17.

RESULTS

The incidence of intermittent arrhythmia associated with Wolff-Parkinson-White syndrome was lower in 2 patients (11%). There was a higher occurrence of rapid induced tachycardia in 9 patients (50%). However, atrial fibrillation occurred more commonly in 6 (33%) patients. The anterograde accessory pathway effective refractory period (APRP) in patients was much shorter (less than 250 ms [N=16]) 13 patients with accessory pathways were managed by ablation.

CONCLUSION

This study demonstrated the difference in the electrophysiologic characteristics of anterograde accessory pathway and the atrioventricular node in asymptomatic WPW patients, and thus concluded that radiofrequency (RF) catheter ablation is a safe and effective method to manage patients with asymptomatic WPW syndrome.

[Acute nontraumatic limb ischemia]

Twenty four patients (18 males, 6 females, Mean age 50 years) with acute non traumatic limb ischemia were operated on in our institution. The ischemia has been observed after 24 hours in 15 patients (62,5 % versus 7 patients (37,5 %) within 24 hours. The arterial femoral was often (54,1 %) the site of occlusion. Embolism (29,2 %) and thrombosis (54,2 % were the cause of acute limb ischemia. All patients were treated by embolectomy or thrombectomy. The overall mortality was 29,2 % with a limb salvage rate of 45,8 % and secondary amputation rate of 29,2 %. According to our experience, the diagnosis of acute non traumatic limb ischemia is not instituted early and the rate of hospital mortality and morbidity remain high.