Medical mortality in an emergency department in Nigeria: the transition is obvious!

Introduction

The emergency department (ED), a major entry point into the hospital, provides an insight to the type of cases seen, the quality of care and mortality spectrum in a health institution. We aim to identify the spectrum of medical causes of mortality in our ED, the demographic pattern and duration of stay before death.

Method

This is a retrospective study that looked at medical mortality in the ED from January 2004 to December 2009. We obtained data on the demographics and causes of death from the medical records and case notes of the deceased.

Results

A total of 16587 patients were admitted during the period under review, of these 1262 (7.61%) died in the ED. The male to female ratio was 1.58:1.0 [772 males (61.2%), and 489 females (38.8%)]. Mortality was highest among the 20–45 years age range, followed by 46–65 years, >65 years and < 20 years in decreasing frequency [589(46.7%), 421(33.4%), 186 (14.8%) and 66(5.2%) respectively]. The three most common causes of death were stroke 315(25%), HIV related illnesses 126(10.0%), and heart failure 123(9.7%). Most deaths occurred less than 24hours of admission, 550(43.6%), followed by one day (36.0%) and two days (10.8%) post admissions respectively.

Conclusion

The commonest cause of death in the ED was stroke. The burden of death was highest in the younger age group, with most occurring less than 24 hours of admission.

Impact of prehypertension on left ventricular mass and QT dispersion in adult black Nigerians

Background

Prehypertension has been associated with target-organ damage. This study sought to determine the impact of prehypertension (PHT) on QT dispersion and left ventricular hypertrophy (LVH) in adult black Nigerians.

Methods

One hundred and one subjects with office blood pressure (BP) < 140/90 mmHg were categorised according to their office BP into normotensive (BP < 120/80 mmHg, n = 57) and prehypertensive (BP 120–139/80–89 mmHg, n = 44) groups. Echocardiography and electrocardiography (ECG) were performed on the subjects.

Results

Thirty-four males aged 53.65 ± 16.33 years and 67 females aged 52.42 ± 12.00 years were studied. The mean QT interval dispersion (QTd) of the normotensive (38.96 ± 11.06 ms) and prehypertensive (38.41 ± 11.81 ms) groups were similar (p = 0.81). Prehypertensive subjects had higher left ventricular mass (LVM) (165.75 ± 33.21 vs 144.54 ± 35.55 g, p = 0.024), left ventricular mass index 1 (LVMI-1) (91.65 ± 16.84 vs 80.45 ± 18.65 g/m², p = 0.021) and left ventricular mass index 2 (LVMI-2) (54.96 ± 10.84 vs 47.51 ± 12.00 g/m^2.7, p = 0.017). QTd was independent of echocardiographic and electrocardiographic LVH (p > 0.05).

Conclusion

Compared with normotension, prehypertension is associated with higher LVM but similar QTd. This suggests that structural remodelling precedes electrical remodelling in prehypertension.

Therapeutic Effects of Exercise Training On Selected Cardio-Pulmonary Parameters and Body Composition of Nigerians with Chronic Heart Failure (A Preliminary Study)

BACKGROUND

The use of exercise training in the management of individuals with chronic heart failure has not been widely accepted by health care providers especially in Sub-Saharan Africa because of the possibility that the failing hearts may have a negative response to the increased workload and stress of exercise.

OBJECTIVE

The study aimed to evaluate the effects of exercise training (ET) on selected cardio-respiratory and body composition variables of Nigerians with chronic heart failure (CHF).

METHODS

Thirty two Nigerians with CHF (male - 17), aged 30 to 71 years, mean age 54.2 ± 1.9 years and New York Heart Association Functional Class (NYHA) II-III recruited from Cardiology Clinic of Lagos University Teaching Hospital Nigeria participated in the study. They were randomized into exercise (EG) and control groups (CG). Exercise group performed 12-weeks of aerobic and resistance training for 60 minutes, three sessions per week. Selected cardio-respiratory and body composition variables were measured pre and post intervention in both groups. Data was analyzed using SPSS-17 package. Level of significance was set at 0.05.

RESULTS

There was no significant difference in the measured variables between the groups at baseline (p > 0.05). Significant improvement was seen in EG in all the measured variables except the systolic (p = 0.29) and diastolic blood pressure (p = 0.45). No adverse effect was observed during the exercise training. No significant improvement was observed in the control group (p > 0.05).

CONCLUSION

Exercise training may improve cardiorespiratory and body composition variables in patients with chronic heart failure.

QT dispersion in hypertensive Nigerians with and without left ventricular hypertrophy

BACKGROUND

Increased QT dispersion (QTd) has been implicated as a marker of arrhythmogenesis and cardiac death. Paucity of literature on QTd in Nigeria necessitated an inquiry into QTd in adult hypertensive population. This study sought to: (i) compare the QTd values of adult hypertensive subjects with age and sex matched normotensive subjects and (ii)examine the relationship between QTd and left ventricular hypertrophy (LVH).

STUDY DESIGN

One hundred and fifty-one hypertensive patients and 101 age and sex-matched controls were recruited into this study. A resting 12- lead ECG was obtained from all subjects for determination of QTd and ECG LVH using Sokolow Lyon (SL) and Araoye's codes. Echocardiographic LVH was determined for 60 hypertensive subjects and 60 age/sex matched controls.

RESULTS

Hypertensive subjects had higher mean QTd than the controls (65.6 ± 28.1 ms vs 38.7 ± 11.3 ms, p< 0.0001). QTd of hypertensives with ECG LVH was significantly higher than those without ECG LVH (Araoye: 71.5 ± 22.0 ms vs 62.2 ± 24.1 ms, p = 0.02, SL; 72.0 ± 24.4 ms vs 61.6 ± 23.1 ms p = 0.009). Similarly the QTd of hypertensives with echocardiographic LVH (72.6 ± 21.3 ms) was higher than those without (60.1 ± 22.2 ms) but did not achieve statistical significance (p = 0.085).

CONCLUSIONS

Hypertension with or without ECG LVH is associated with significantly increased QTd. Echo-cardiographic LVH is associated with a non significant increase in QTd in hypertensive subjects.

Blood pressure, heart rate, cardiovascular reflexes and electrocardiographic changes in some hypertensive Nigerians

The effects of hypertension on resting and reflex cardiovascular function were investigated in this study.  Blood pressure, heart rate and electrocardiogram were recorded in male and female control subjects and hypertensive Nigerian patients.  Blood pressure was measured, using the sphygmomanometer/auscultatory method.  Heart rate was determined from palpating the radial pulse or from the resting electrocardiograph. The systolic and diastolic blood pressures were high in the hypertensive patient (160.90 + 2.06 mmHg and 110.8 + 1.95 mmHg respectively compared with control subjects (119.3 + 2.05 and 73.58 + 1.09mmHg).  Pulse pressure and mean arterial pressures were also higher in the hypertensive patients.  Heart rate was higher in the hypertensive compared to the control groups (86.93 + 2.83 cf 71 + 1.35 beats per minute).  ECG analysis showed that the intervals were lower in the controls than in the hypertensive group except for PR intervals (0.21 + 0.01 cf 0.23 + 0.01 sec).  The amplitude of the waves was also lower in the control group than the hypertensive group. Cardiovascular response to exercise assessed from the post-exercise recovery graph showed that the aggregate recovery (6min after) was lower in the hypertensive subjects (22% cf 28%) than in controls.  This suggests that the baroreflex sensitivity was higher in the control than in the hypertensive subjects. Results from this study suggest that in hypertension there may be increased heart rate, altered electrocardiograph readings indicating ventricular hypertrophy and delay in ventricular conduction.  In hypertension baroreflex sensitivity may be reduced.

Diagnostic usefulness of N-terminal pro-brain natriuretic peptide among children with heart failure in a tertiary hospital in Lagos, Nigeria

BACKGROUND

N-terminal pro-brain natriuretic peptide (NTproBNP) is useful in the diagnosis and management of adult patients with heart failure.

OBJECTIVE

The objective of the study was to determine the usefulness of NT-proBNP in diagnosing congestive heart failure (CHF) in children and its correlation with left ventricular ejection fraction (LVEF) and clinical heart failure score.

METHODS

Plasma NT-proBNP was measured in 28 children with CHF and age matched controls. Heart failure assessment was done using modified Ross score and all had echocardiography done.

RESULTS

Mean plasma NT-proBNP of children with CHF (377.86±1026.49pg/mL) was significantly higher than that of controls (353.61±328.50 pg/mL) (p<0.001). A plasma NT-pro BNP of 951pg/mL was used as the cut off value for heart failure. The sensitivity, specificity, negative and positive predictive values were 57%, 96%, 69% and 94% respectively. NT-pro BNP levels showed a high positive correlation with the modified Ross score (r= 0.502; p<0.001) but low correlation with LVEF (r= -0.137; p>0.3).

CONCLUSION

Our findings indicate that measuring NT-pro BNP may be useful as a diagnostic tool in congestive cardiac failure in children. The fact that its levels also correlated positively with modified Ross score thereby objectively determining severity of heart failure suggests that this biomarker may also be useful as an evaluation tool in congestive cardiac failure in children.

The examination of the jugular venous pressure (JVP): variation of technique amongst Nigerian resident doctors

Resident doctors in Internal Medicine Faculty and General Medical Practice from accredited residency programmes from all over Nigeria were surveyed to investigate the existence of variation in the technique of clinical examination. Using a 10 item self administered questionnaire, the doctors were required to answer questions to test knowledge and skill of examining the jugular venous pressure. Data from 70 Internal Medicine (IMR) and 30 General Medical Practice Residents (GMP) were analysed. For both groups, years of post medical graduation and period spent in residency programme were comparable. On methodology of examination of JVP, there was significant inter- and intra group variation. Sixty per cent (60%) of IMR and only 10% of family practice doctors will use the internal jugular vein alone for assessment, whilst a comparable proportion (30% of IMR and 25% of GMP) will use both internal and external jugular veins. Whilst the sternal angle was the choice of reference point in the majority (87% of IMR versus 80% of GMP), the patient placement angle of 45 degrees was 93% for IMR and 100% for GMP. No respondent chose 60 degrees. Only 40% of both IMR and GMP will always use confirmatory maneuvers, especially the hepatojugular reflux. No GMP doctor and 25% of internal medicine will sometimes use posture and respiratory maneuvers to enhance their clinical decisions. Only 33% IMR and 40% of GMP indicated a correct value and/or unit of measurement for normal jugular venous pressure (JVP). Comparing the internal medicine and General Medical Practice Residents, there was marked inter- and intra-group variation, with more variation noted amongst the IMR. Most importantly, less than 50% of residents knew the correct value of an abnormal JVP. This variability of methodology and poor knowledge will impact on performance in the residency programme, patient care and medical education.

Clinical and echocardiographic assessment of Nigerian patients seen at the Lagos University Teaching Hospital with features of mitral valve prolapse

In a 3-year prospective echocardiographic study of patients with clinical features of mitral valve prolapse who presented to the cardiology clinic of the medical out patients clinic of the Lagos University Teaching Hospital comprising of sixty-two patients. The most common complaints found were vague chest discomfort (42%) and chest pain. (28%) Their mean body mass index was 20.8 +/- 5.56 Kg/m2. The most common auscultatory sign was apical clicks (8%). Hypertension (12%) was the most common clinical association while the anterior leaflet (87%) was more affected. Mitral regurgitation was present in 35.7% of cases, which were mostly mild in severity (93%). There were statistical differences in the chamber and wall dimension measurements of those with isolated mitral valve prolapse when compared with those associated with other clinical conditions. (p < 0.05). Subjects with isolated mitral valve prolapse were found to have significant differences in the echocardiographic measurements when compared with those with coexisting diseases suggesting that mitral valve prolapse is a relatively benign condition except coexisting with other conditions like hypertension, valvular defects and obesity. These associated conditions tended to increase cardiac risk.