A study of the contemporary profile, clinical outcomes and economic burden of acute heart failure in Abeokuta, Nigeria

A thesis submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg in fulfillment for the requirements for the for the degree of Doctor of PhilosophyBackground Heart failure has become a global public health issue because of the rising global burden, high cost of care, frequent rehospitalisation and poor prognosis. Compared to other regions of the world, there are limited data on contemporary clinical profile, outcome, and economic cost of heart failure in Sub-Saharan Africa in general and Nigeria (Africa’s most populous country) in particular. We examined these in patients admitted with acute heart failure to a tertiary hospital in Nigeria. Methods This was a hospital based, prospective, observational study conducted at the Federal Medical Centre, Idi-Aba, Abeokuta, Nigeria. Detailed clinical documentation on cases of acute heart failure was carried out. The following data were obtained: demographic data, pre-admission history (previous heart failure related admissions). Others include NYHA functional class, symptoms, signs, self-reported cardiovascular risk factors, aetiology of heart failure, precipitating factors, co-morbidities, blood investigations, 12-lead ECG, echocardiography, medications and intra-hospital and 6-month outcomes. The study cohort was prospectively followed up for 6 months post initial hospitalisation. The subjects were contacted through clinic visits or telephone calls at one and six months. Information obtained during follow-up included their wellbeing, prescribed pharmacotherapy, history of re-hospitalization and deaths (from next of kin if they died at home). In addition to patient or relation’s telephone interviews, where necessary referring physicians were contacted for additional information. The following health outcomes were documented - 1) length of initial hospital stay (LoS) in days, 2) survival status on discharge (dead or alive), 3) short-term case-fatality (30 days), 4) medium-term case-fatality (180 days), and 5) re-hospitalization status (180 days) Heath economic data were extracted from the registry. Outpatient and inpatient costs were computed from the cohort of HF cases admitted in 2010 including personnel, diagnostic and treatment resources used for their management over a 12-month period. Indirect costs were also calculated. The annual cost per person was then calculated. Results The mean age of the subjects was 56.6±15.3 years (57.3±13.4 for men, 55.7±17.1 for women) and 204 (45.1%) were women. Overall, 415 (91.8%) subjects presented with de novo acute heart failure. The most common risk factor for HF was hypertension (pre-existing in 64.3% of cases). Type 2 diabetes mellitus was present in 41(10.0%). Hypertensive HF was the commonest aetiological cause of heart failure being responsible for 78.5% of cases. Dilated cardiomyopathy (7.5%), cor-pulmonale (4.4%), pericardial disease (3.3%), rheumatic heart disease (2.4%) and ischemic heart disease were less common (0.4%) causes. The majority (71.2%) of subjects presented with left ventricular dysfunction (mean left ventricular ejection fraction 43.9 ± 9.0%) and valvular dysfunction and abnormal left ventricular geometry were frequently documented. Mean duration of hospital stay was 11.4± 9.1 days and intra-hospital mortality was 3.8%. Case fatality at 30-days was 4.2% (95%CI, 2.4-7.3%) for the cohort of newly presenting acute HF subjects that were followed up [3.9% (95%CI, 1.7-8.5%) in men and 4.5% (95%CI 2.1-9.3%) in women]. At 180-days, case-fatality was 7.3% (95%CI, 4.7-11.2%) [7.1% (95%CI, 3.8-12.7%) in men and 7.5% (95%CI 3.9-14.0%) for women] Patients with pericardial diseases had the highest early mortality. Mortality was related to some socio-demographic and clinical characteristics. Thirty two denovo HF subjects (12.2%) were rehospitalised at least once. There were 21 men (65.6%) and 11(34.4%) women. Worsening heart failure was the commonest reason for readmission. Among others, factors associated with rehospitalization include presence of mitral regurgitation (OR, 2.37; 95%CI, 1.26-4.46), age greater than 60 years (OR, 2.04; 95%CI, 0.96-3.29), presence of tricuspid regurgitation (OR, 1.77; 95% CI, 0.86-3.61), and presence of atrial fibrillation (OR, 1.34; 95%CI, 0.59-3.03). The total computed cost of care of HF in Abeokuta was 76, 288,845 Naira (US$508, 595) translating to 319,200 Naira (US$2,128 US Dollars) per patient per year. Inpatient and outpatient care contributed 46% and 54% of total cost respectively. The high cost of outpatient care was largely due to cost of transportation for monthly follow up visits. Payments were mostly made through out-of-pocket spending. Conclusions Compared to high income countries, individuals presenting with AHF in Abeokuta, Nigeria are relatively younger and still of a working age. It is also commoner in men and associated with severe symptoms because of late presentation. Intra-hospital mortality is similar to other parts of the world. Rehospitalization after admission for HF is relatively common within 6-months. The economic burden of heart failure in the study setting is high considering the minimum wage of 18,000 Naira (120 US dollars) per month in the country. This calls for financing reforms for the control of the disease, which may include a reduction or waiver of user fees in government hospitals, scaling up of financial risk protection pre-payment mechanisms such as health insurance and use of primary healthcare centres for follow-up visits for mild cases. The development and adequate funding of community HF care programmes in the country is also a possible panacea.MT201

Cardiomyopathies in Sub-Saharan Africa: Hypertensive Heart Disease (Cardiomyopathy), Peripartum Cardiomyopathy and HIV-Associated Cardiomyopathy

Cardiomyopathy is an important cause of cardiac-related morbidity and mortality in sub-Saharan Africa. Dilated cardiomyopathy is responsible for 20–30% of adult heart failure (HF) in the region. It is only second to hypertensive heart disease as etiological risk factor for HF in many parts of the continent. The aim of the chapter is to review the current epidemiology, clinical features, management, and prognosis of hypertensive heart disease, peripartum cardiomyopathy, and HIV-associated cardiomyopathy in sub-Saharan Africa

Heart Failure in Sub-Saharan Africa

Sub-Saharan Africa (SSA) is currently experiencing multiple burden of disease as a result of demographic and epidemiologic transition. This is occasioned rapid urbanization, unhealthy diets rich in fats and salt, western lifestyle and sedentary living. Heart failure (HF) has become a global public health issue. It is associated with high morbidity and mortality, frequent hospitalization and high economic cost. In SSA, HF is a disease of young and middle-aged adults with the attendant high disability-adjusted life years. This is unlike to the clinical profile and pattern of HF in high-income countries of North America, Western Europe and Japan where HF is a disease of the elderly. In addition, while ischaemic heart disease is the commonest aetiologic risk factor for HF in high income countries, HF in SSA is essentially non-ischaemic in origin. Hypertensive heart failure, dilated cardiomyopathy, rheumatic heart disease, pericardial diseases and HIV associated cardiomyopathy are the common risk factors. The chapter reviews the contemporary information on HF in SSA in terms of socio-demographic features, clinical characteristics, aetiological risk factors, management, prognosis and economic burden

A systematic review and appraisal of methods of developing and validating lifestyle cardiovascular disease risk factors questionnaires

Background: Well developed and validated lifestyle cardiovascular disease (CVD) risk factors questionnaires is the key to obtaining accurate information to enable planning of CVD prevention program which is a necessity in developing countries. We conducted this review to assess methods and processes used for development and content validation of lifestyle CVD risk factors questionnaires and possibly develop an evidence based guideline for development and content validation of lifestyle CVD risk factors questionnaires. Materials/Methods: Relevant databases at the Stellenbosch University library were searched for studies conducted between 2008 and 2012, in English language and among humans. Using the following databases; pubmed, cinahl, psyc info and proquest. Search terms used were CVD risk factors, questionnaires, smoking, alcohol, physical activity and diet. Results: Methods identified for development of lifestyle CVD risk factors were; review of literature either systematic or traditional, involvement of expert and /or target population using focus group discussion/interview, clinical experience of authors and deductive reasoning of authors. For validation, methods used were; the involvement of expert panel, the use of target population and factor analysis. Conclusion: Combination of methods produces questionnaires with good content validity and other psychometric properties which we consider good

Childhood and infant exposure to famine in the Biafran war is associated with hypertension in later life: the Abia NCDS study

There are very few studies in Africans investigating the association between early life exposure to malnutrition and subsequent hypertension in adulthood. We set out to investigate this potential association within an adult cohort who were born around the time of the Biafran War (1968–1970) and subsequent famine in Nigeria. This was a retrospective analysis of Abia State Non-Communicable Diseases and Cardiovascular Risk Factors (AS-NCD-CRF) Survey, a community-based, cross-sectional study that profiled 386 adults (47.4% men) of Igbo ethnicity born in the decade between January 1965 and December 1974. Based on their date of birth and the timing of the famine, participants were grouped according to their exposure to famine as children (Child-Fam) or in-utero fetus/infant (Fet-Inf-Fam) or no exposure (No-Fam). Binomial logit regression models were fitted to determine the association between famine exposure and hypertension in adulthood. Overall, 130 participants had hypertension (33.7%). Compared to the No-Fam group (24.4%), the prevalence of hypertension was significantly elevated in both the Child-Fam (43% - adjusted OR 2.47, 95% CI 1.14–5.36) and Fet-Inf-Fam (44.6% - adjusted OR 2.54, 95% CI 1.33–4.86) groups. The risk of hypertension in adulthood was highest among females within the Child-Fam group. However, within the Fet-Inf-Fam group males had a equivalently higher risk than females. These data suggest that early life exposure to famine and malnutrition in Africa is associated with a markedly increased risk of hypertension in adulthood; with sex-based differences evident. Thus, the importance of avoiding armed conflicts and food in-security in the region cannot be overstated. The legacy effects of the Biafran War clearly show the wider need for ongoing programs that support the nutritional needs of African mothers, infants and children as well as proactive surveillance programs for the early signs of hypertension in young Africans

Graves’ disease presenting as paranoid schizophrenia in a Nigerian woman: a case report

Paranoid syndromes in Graves’ disease are rare. The true incidence is lacking. Most reports have emanated from developed countries where medical investigations are readily available. No report of such has emanated from Nigeria. We report a 43-year-old female Nigerian with Graves’ disease associated with paranoid schizophrenia and review the literature

Economic burden of heart failure: investigating outpatient and inpatient costs in abeokuta, southwest Nigeria

Background: Heart failure (HF) is a deadly, disabling and often costly syndrome world-wide. Unfortunately, there is a paucity of data describing its economic impact in sub Saharan Africa; a region in which the number of relatively younger cases will inevitably rise. Methods: Heath economic data were extracted from a prospective HF registry in a tertiary hospital situated in Abeokuta, southwest Nigeria. Outpatient and inpatient costs were computed from a representative cohort of 239 HF cases including personnel, diagnostic and treatment resources used for their management over a 12-month period. Indirect costs were also calculated. The annual cost per person was then calculated. Results: Mean age of the cohort was 58.0±15.1 years and 53.1% were men. The total computed cost of care of HF in Abeokuta was 76, 288,845 Nigerian Naira (US$508, 595) translating to 319,200 Naira (US$2,128 US Dollars) per patient per year. The total cost of in-patient care (46% of total health care expenditure) was estimated as 34,996,477 Naira (about 301,230 US dollars). This comprised of 17,899,977 Naira- 50.9% ($US114,600) and 17,806,500 naira −49.1$US118,710) for direct and in-direct costs respectively. Out-patient cost was estimated as 41,292,368 Naira ($US 275,282). The relatively high cost of outpatient care was largely due to cost of transportation for monthly follow up visits. Payments were mostly made through out-of-pocket spending. Conclusion: The economic burden of HF in Nigeria is particularly high considering, the relatively young age of affected cases, a minimum wage of 18,000 Naira ($US120) per month and considerable component of out-of-pocket spending for those affected. Health reforms designed to mitigate the individual to societal burden imposed by the syndrome are required

Differences in socio-demographic and risk factor profile, clinical presentation, and outcomes between patients with and without RHD heart failure in Sub-Saharan Africa: results from the THESUS-HF registry

Background: Rheumatic heart disease (RHD) was found in the THESUS-HF registry to be the third most common cause of acute heart failure (AHF) in Sub-Saharan Africa. Methods: One thousand six patients with AHF from 9 Sub-Saharan African countries were recruited in THESUS-HF, of which 143 (14.3%) had RHD-AHF. Clinical characteristics and outcomes in patients with RHD-AHF and non-RHD-AHF were compared. Kaplan-Meier plots for time to all-cause death and/or HF readmission according to the presence of RHD-AHF and non-RHD-AHF were performed and survival distributions compared using the log-rank test. Cox regression was used to determine the hazard ratio of death to day 180 and death or readmission to day 60 after adjusting for confounders. Results: Patients with RHD-AHF were younger, more often females, had higher rates of atrial fibrillation, had less hypertension, hyperlipidemia and diabetes, had lower BP, and higher pulse rate and better kidney function and echocardiographic higher ejection fraction larger left atria and more diastolic dysfunction. Patients with RHD-AHF had a numerically longer mean stay in the hospital (10.5 vs. 8.8 days) and significantly higher initial hospitalization mortality (9.1% vs. 3.4%). Conclusions: In conclusion, patients with HF related to RHD were younger, have higher rate of atrial fibrillation and have a worse short-term outcome compared to HF related to other etiologies in Sub-Saharan Afric

Spectrum of heart diseases in a new cardiac service in Nigeria: An echocardiographic study of 1441 subjects in Abeokuta

<p>Abstract</p> <p>Background</p> <p>Echocardiography is a non-invasive, relatively cheap and useful imaging technique for the evaluation of cardiac diseases. The procedure has reliable levels of accuracy.</p> <p>Echocardiography commenced at the Federal medical centre Abeokuta on September 9, 2005.</p> <p>The aim of this study is to report our experience with the procedure, and to define the clinical cases seen in our setting.</p> <p>Methods</p> <p>This is a retrospective analysis of a prospectively collected data. Echocardiography was performed using Aloka SSD 1,100 echocardiograph equipped with 2.5–5.0 MHz transducer</p> <p>Results</p> <p>During the period of 18 months under review (September 2005–February 2007), 1629 procedures were performed. The reports of 188 echocardiograms were excluded due to poor echo-window, repeated procedure or incomplete report. 1441 reports were reviewed for demographic parameter, indications for the procedure and the main echocardiographic diagnoses.</p> <p>The mean age of the 1441 individuals studied was 54 +/- 14.3 years (15–90). There were 744 men and 697 women. Eight hundred and seventeen subjects (56.7%) had hypertensive heart disease, 53 subjects (3.7%) had rheumatic heart disease while 44(3.0%) had dilated cardiomyopathy. Pericardial diseases, cor-pulmonale, ischaemic heart disease, congenital heart diseases, diabetic heart disease, thyroid heart disease, sickle cell cardiopathy were present in 26(1.8%), 23(1.6%), 9(0.6%), 6(0.4%), 6(0.4%), 6(0.4%), 1(0.1%), and 1(0.1%) respectively. Four hundred and forty nine (31.2%) subjects had normal study.</p> <p>Conclusion</p> <p>Hypertensive heart disease was found to be the most prevalent cardiac condition in this study. The relatively frequent diagnoses of rheumatic heart disease, cardiomyopathies and pericardial diseases reflect the impact of infections and infestations on the cardiovascular health of adult Nigerians.</p> <p>We suggest that prevention and treatment of cardiac diseases in our setting should among other things focus on blood pressure control and early treatment of infections causing heart diseases.</p