A CAJM article on microcardia in African patients.We have been aware for some considerable time of the existence of what 'has been called “the small or tiny” heart in our Rhodesian African adult patients admitted to Harare Hospital. It is our purpose merely to draw attention to its existence and so perhaps encourage those in other parts of Africa or other parts of the world to describe their experiences. We usually found the condition in those who appeared to be underweight rather than suffering from a specific nutritional disorder like scurvy or pellagra. Indeed in these disorders of malnutrition, the heart is either normal in size or may be enlarged. However, it was found in a large.series of children in South Africa with Kwashiorkor, that the cardiothoracic diameter was significantly decreased, (Smythe, Swanepoel, Campbell 1962) to increase again on recovery

Gelfand, M.

Parker, T.

Central African Journal of Medicine

English

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The Central African Journal of Medicine
Editor-.
MICHAEL GELFAND, C.B.E., M.D., F.R.C.P.
Assistant Editor-. 
JOSEPH RITCHKEN, M.D.
Volume Nineteen 
JANUARY - DECEMBER 
1973
I
Salisbury
VciPceAi rS l
R hodesia
T h e C e n t r a l  A f r i c a n
Journal of Medicine
Volume 19 MARCH, 1973 No. 3
Microcardia in the African
BY
TREVOR PARKER
AND
MICHAEL GELFAND
Department of Medicine, University of Rhodesia.
We have been aware for some considerable time 
of the existence of what 'has been called “the 
small or tiny” heart in our Rhodesian African 
adult patients admitted to Harare Hospital. It 
is.our purpose merely to draw attention to its 
existence and so perhaps encourage those in 
other parts of Africa or other parts of the world 
to describe their experiences. We usually found 
the condition in those who appeared to be under­
weight rather than suffering from a specific 
nutritional disorder like scurvy or pellagra. In­
deed in these disorders of malnutrition, the heart 
is either normal in size or may be enlarged. How­
ever, it was found in a large.series of children in 
South Africa with Kwashiorkor, that the cardio- 
(horacic diameter was significantly decreased, 
(Smythe, Swanepoel, Campbell 1962) to increase 
again on recovery.
A natomical Considerations
There are several methods of determining heart 
size all of which have their critics. Amongst 
these is the cardiothoracic ratio which is the 
transverse diameter of the heart over the widest 
internal diameter of the thorax and which Should 
not exceed 0,5. In normal adults the transverse 
diameter of the heart averages 12,2 cm. in the 
male and 11 cm. in the female, the range being. 
8 to 14,5 cm. (Roesler .1937).
As we used the transverse diameter of the 
heart to decide- on what would be a “small 
heart”, and also as it has been the subject of 
much discussion,. it would be in order to discuss 
it briefly.
Jacobs (1949) found that the use of the trans­
verse heart diameter is justified by the fact that 
no better correlation is Obtained while complexi­
ties are introduced when area (or other measures) 
are used; Comeau and White (1942) found that
the transverse diameter of the heart compares 
favourably with the other actual measurements 
and is the most satisfactory from the clinical 
standpoint. Indeed, by;using this diameter along 
with other parameters Gustafson and Friedenberg 
(1965) were able to differentiate qualitatively oc­
clusive coronary artery disease, aortic valve 
stenosis or insufficiency and coarotation of the 
aorta.
In a recent study on variations in transverse 
cardiac diameter during diastole and systole, 
Gamill (1970) showed that in 324 patients, 52 
per cent, of patients showed changes of 0,3 cm. 
or less, 41 per cent, showed alterations of 0,4 
to 0,9 cm. and 7 |  per cent, a variation of 1,0 to! 
1,7 cm. It was concluded that the set o f  films 
(i.e. one exposed during diastole and one exposed 
during systole) was more useful in evaluating 
heart size than ope film exposed at a random, 
point along the cardiac cycle.
Both the size and shape of the heart vary 
greatly in normal individuals. For instance in 
lean asthenic subjects the heart may be elongated 
and central in position, whereas in short stocky 
individuals it tends to lie transversely. Rotation; 
of the spine may cause displacement or rotation 
of the heart. In emphysema the heart tends 
to be small and vertical because the diaphragm is 
low.
As yet there is no established range or normal 
heart weights in the Rhodesian African. Is was 
found that the heart-of the Ugandan African was 
smaller than those reported from Europe and 
America because the: Ugandan African was a 
small person (Coles and Davies 1959).
Concurrently' the authors ' could not support 
the view that heart weight rises with age irre­
spective of body weight.
In an autopsy study on Jamaicans of mainly 
African origin, Hayes and Levill (1966) reported 
similar findings to those found in Uganda i.e. 
lower heart weights than those from Britain and 
North America. ' Similarly, they stated that the 
differences in heart weight are probably correlated 
with differences in body size. It is likely therefore 
that a -study here in Rhodesia would reveal simi­
lar results, although this, is conjecture.
41 ■
1'
March, 1973, MICROCARDIA IN  THE AFRICAN t * k Central African
J ournal of Medicine
Pathophysiological Considerations
Keyes et al. (1947) drew attention" to the re­
duced heart size in semi-starvation. As total 
blood volume remained in the normal range, the 
reduced cardiac size was attributed to myocardial 
wasting, and the degree of calculated reduction 
in volume of the heart (16 per cent.) approxi­
mated to the overall loss of weight (25 per cent.) 
Previously held views that the heart being a vital 
organ enjoyed preferential nutritive status, ap­
peared to be incorrect.
Swanepoel et al. (1964) state that little at­
tention has been directed towards the heart in 
starvation, and the probability that it may waste 
in common with muscle elsewhere has been large­
ly overlooked. Possibly this is because the heart 
being a robust organ, has a large structural and 
functional reserve, so that the substantial loss of 
muscle bulk fails to exert clinical effects.
Bloom (1966) found that heart size decreased 
in 21 fasting subjects and plasma volume in 7 
of these (he measured apparent volume o f distri­
bution tagged with 131), decreased significantly 
also. No correlation was found between change 
in heart size or blood volume and amount of 
weight loss or duration of fasting. These findings 
were related to the saluresis of fasting.
Simonson (1948) states that there are pro­
found changes in the size and function of the 
heart in semi-starvation and subsequent reha­
bilitation. Further, except for the beriberi heart, 
the condition of the heart in states of malnutrition 
has found little attention in clinical medicine. 
Authors as a  rale rather tend to believe that 
nutritional effects on the myocardium were , in­
significant. In observations on the ECG in semi- 
starvation, Simonson found highly significant 
changes occurred in most electrocardiagraphic 
items and the ECG’s became clinically abnormal 
in the majority of subjects. These included pro­
nounced slowing o f the heart rate (mostly sinus 
bradycardia), QT. interval increase, considerably 
decreased amplitudes of all diflections (P wave, 
QRS complex and T  wave) and marked right 
axis shift of the QRS axis and even more of the 
T axis.
. Kjelberg (1949) found a very high correlation 
between heart volume and total haemaglobin or 
blood volume.
Experimental hypophysectorny in rats was 
shown to cause a rapid and progressive diminution 
in . the . size of the heart proportionately greater 
than the eoneommitaht loss o f body weight. This 
was attributed to lower demands on the heart
(lowered venous return, decreased cardiac out­
put and hypotension) resulting from a reduced 
metabolism. (Beznak, 1960).
Haggveit (1966) reports three cases of small 
hearts in women who had undergone hypophysec­
tomy for mammary cancer. These patients were 
not emaciated. Kerley (Textbook of X-ray Diag­
nosis) mentions the small heart and is worth 
quoting in full; “Wenfcebadh postulated the theory 
that the small heart was due to insufficient venous 
return because of a low weak diaphgram and a 
diminshed respiratory reserve. Other authors have 
stated that the small heart may be due to dimin­
ished tone in the splanchnic vessels or in the 
skeletal muscles so that the heart is never ade­
quately filled, and on the Continent the small 
heart shadow has been associated with such 
symptoms as fatigue, weakness, headache, faint­
ing etc. There is no proof of such an association. 
It is true that in many chronic wasting diseases, 
atrophy o f the heart musde and a weak periphe­
ral circulation produce a small heart shadow and 
with great loss of body fluid such as occurs in 
severe dysentery, haemorrhage and starvation, 
there may be significant decrease in the transverse 
diameter o f the heart. Apart from such excep­
tional circumstances, a small heart shadow should 
never be considered in terms of pathology.”
Certain drugs are known to produce a reduc­
tion in heart size:— Digitalis produces a signifi­
cant decrease in the size of the normal heart. 
Amyl nitrate causes a slight decrease in size by 
decreasing vagal tone. Atropine causes a dra­
matic decrease in heart size in sinus bradycardia.
Definition  of Small H eart
For the purpose of deciding which of our 
African hospital patients had a significantly sniall 
heart, the following method was adopted. 100 
male and 100 female chest X-rays which were free 
from gross pathology were taken from the files.
The distance (x +  y) was measured on all. This 
is the transverse cardiac diameter. The mean for 
the males was i2,6 oms. Statistically it would 
be anticipated that about per cent, of normal 
hearts would be smaller than 12,6 cms.-12,68 and 
we decided that 10 oms. would be our limit 
so that a “small” male heart would be equal 
to ot smaller than 10 oms. The female’s average 
transverse cardiac diameter was 11,75 cms. with 
a standard deviation of 1,89 and we selected 8 
cms. as the limit. We did not include cases of 
emphysema in this study, as mentioned previous­
ly; an artificially, small heart is produced.
42
March, 1973. MICROCARDIA
Fig. 1:—Transverse diameter of heart is 9,5 cm.
Case Illustrations
(1) W.M. — A male aged 52 years was admit­
ted to hospital in March 1971 because of severe 
anaemia (8.O.G.) Which proved to be megalo­
blastic. He was weak and markedly wasted, his 
weight being 90 lbs. He was troubled with a 
diarrhoea but the cause of the anaemia could not 
be put down to a malabsorption syndrome. The 
transverse diameter of his heart was 9,5 cm. (Fig. 
1). He lived in the Eeki Tribal Trust Lands.
(2) J.M. — A male over 20 years was referred 
from Marandellas Hospital in November 1971 
suspected of having pulmonary T.B. He was a 
little thin but otherwise healthy looking. Little 
else was found on him except that he had old 
lesions in the lungs consistent with a diagnosis 
of tuberculosis.
(3) P.M .— A male aged 50 years (Fig. 2) Who 
worked on a European farm was found to be 
suffering, in March 1971, with carcinoma of the 
stomach. He was thin and emaciated. His 
haemoglobin was 11,49 G%. T h e ' heart was 
small, transverse diameter being 9,8 cm. (Fig. 3).
(4) G.Z. — A male aged 38 years who work­
ed in a Salisbury hotel developed a sudden attack 
of gastroenteritis. He was slightly dehydrated. He
had a good diet. The transverse diameter of his 
heart was 9,0 oms. His oxogenic steroids were 
10,6 mg. per day and 17 oxosteroids 11,5 mg. 
per day (both normal figures).
(5) W.J. — A female aged 58 years was ad­
mitted in a confused state to Harare Hospital 
(Fig. 4 ). She was well until one week before 
When she refused to eat. There was also a history 
of vague pains in her chest and a slight cough, 
according to her husband. In January 1970 she 
was admitted to the pyschiatric ward Harare 
Hospital for treatment for endogenous depression. 
Her blood pressure then was 100/80 and her 
haemoglobin 13,7 G%; sodium 132 m/Eq. Her 
first attack of depression occurred in 1968 when 
she was treated by Dr. John Forbes for de­
pression. She recovered from this attack. At 
this time of her admission in 1971 she; was much 
dehydrated, emaciated, stuporose and shouting 
at odd times. Her skin showed patches of excess 
or dark pigmentation and in other areas those of 
hypopigmentation and her hair was sparse and 
soft and had largely lost its curl. Her blood pres-
IN THE AFRICAN t h e  cent™ . Afeican
J ournal op M edicine
Fig. 2 —The patient.
43
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ar
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 fi
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 in
 5
 o
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es
.
March, 1973, MICROCARDIA IN THE AFRICAN T he Centhai, African 
J ournal of Medicine
'j !
44,
March, 1973. M ICROCARDIA IN  THE AFRICAN thecental.a™cak
. Journal of M edicine
Fig. 3.—The heart of the patient in Fig. 2. The transverse 
diameter is 9,8 cm.
sure was 90/60. The heart sounds appeared to be 
normal. No murmurs were audible. H er .blood 
sugar was 76 mg.%, calcium 4,4 m/Eq/1 sodium 
105 m /Eq/1, blood urea 100 mg.%. Transverse 
diameter of heart was 7,5 cm. (Fig. 5). With 
treatment she gradually regained consciousness 
and began to ta'ke an interest in her surroundings.
(6) Kafamibi was a very emaciated, dehydrated 
patient aged about 60 years. (Fig. 6). She com­
plained of lower abdominal pain, accompanied jby 
a severe diarrhoea of eight days duration, but 
mentioned nothing referable to the heart. Her 
weight was 80 lbs. and the blood pressure 90/70. 
No abnormality df the heart was detected on 
physical examination. The lungs were clear; the 
liver was not palpable. Both legs were moderate­
ly swollen and the neck veins distended.
The results of the six illustrated cases are 
given in Table I.
Comment
A small atrophic heart can be expected in gross 
states of emaciation. Indeed, Wood (1961) 
would not ascribe any special significance to this. 
In Addison’s disease in which there is character­
istically a hypotensive state as well as a hypo-, 
natraemia, one may encounter what has come to 
be known as the vanishing heart syndrome!
One of us has been aware ■ of this state for a 
long time (Gelfand, 1957) and referred to it in 
both cases of emaciation and also in patients 
where there was no sign Of malnutrition, .i.e. as 
an isolated finding, without clinical symptoms or 
signs. This was the case in subject two.
With the prevalence of malnutrition states 
and kwashiorkor and their rather unknown 
effects in later life it is tempting to ascribe the 
small heart to these. However, in a series of 
South African Bantu cases of malnutrition, the 
heart was found to be large (Higginson et al. 
1952). These findings were classified pathologi­
cally as a process similar to that of endomyocar­
dial fibrosis but the clinical features were differ­
ent (Ediiigton, 1963).
The possibility of the small heart perhaps being 
related to a cardiomyopathy has occurred to the 
authors. Proof of this is lacking, but Prof. 
Barclay in a personal communication, states that 
in cases of cardiomyopathy he has observed, that 
a large heart is not always the rule and in fact- 
he has found amongst these, anatomically small 
hearts (by weight only).
Once a normal range of weights for Rhodesian 
Africans -is established it will be possible for 
histopathological examination to be made of the
Fig. 4c—The female patient, showing the gross wasting.
45
M arch, 1973. MICROCARDIA IN  TH E AFRICAN T h e  Central African
J ournal of M edici^
Fig. 5.—Heart, with a transverse diameter of 7,5 cm.
Fig. 6.—The emaciation of the patient is clearly evident 
a feature which is often associated with the 
small heart.
anatomically small heart. Further cases of the ' 
small heart will be analysed more olosely with 
special regard to physiological findings suoh as 
plasma volume etc., as and when they present.
Whether the small heart has any significance 
locally or more widely, we cannot at this time 
say. * The literature is excessively scanty on this 
sulbject and we feel that having brought it up 
more thought might be turned in its direction; 
certainly additional clinical and pathological in­
vestigations are needed to confirm this obser­
vation.
Acknowledgment
We wish to thank the Secretary for Health 
for the facilities of Harare Hospital.
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Microcardia In The African

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