|Year : 2015 | Volume
| Issue : 1 | Page : 39-44
Echocardiographic pattern of heart diseases in a North - Western Nigerian tertiary health institution
Hadiza Saidu1, Mahmoud Umar Sani2, Muhammad Sani Mijinyawa2, Ahmad Maifada Yakasai3
1 Department of Medicine, Bayero University/Murtala Muhammad Specialist Hospital, Kano, Nigeria
2 Department of Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Medicine, Public Health and Diagnostic Institute, College of Medical Sciences, North West University, Kano, Nigeria
|Date of Web Publication||8-May-2015|
Department of Medicine, Bayero University/Murtala Muhammad Specialist Hospital, Kano
Source of Support: None, Conflict of Interest: None
Background: Transthoracic Echocardiography is an important non-invasive technique which provides information about cardiac structure and function, thus useful in the evaluation and management of cardiac diseases. Previous studies on echocardiography findings in our environment documented Hypertensive heart disease, Dilated Cardiomyopathy and Rheumatic Heart Disease as the commonest findings in patients with cardiac diseases. This study aimed to provide an update on the common echocardiography findings in this part of the country since previous studies were done over a decade ago. Materials and Methods: We reviewed echocardiographic reports of 1012 consecutive patients aged ≥15 years from September 2011 to August 2014 (3 years). The reports were reviewed for demographic parameters, indications for the procedure and main echocardiography diagnoses. Results: The mean age of the 1,012 individuals studied was 41.28 ± 16.25 years. There were 330 males and 682 females. The commonest clinical indication for echocardiography was Systemic hypertension/Hypertensive heart disease (41%) followed by Peripartum cardiomyopathy (20%) and Congestive cardiac failure (12%) of unknown cause. The most prevalent echocardiographic diagnoses was Hypertensive heart disease seen in 40.3%, followed by Peripartum cardiomyopathy (32%), Dilated cardiomyopathy (5.9%), and Rheumatic heart disease 4.6%. Normal echocardiographic findings were seen in 14.9% of the subjects. Conclusion: Hypertensive heart disease remains the most common echocardiographic indication and diagnosis. Peripartum cardiomyopathy was frequent in our centre and this may be related to the increased availability and accessibility to echocardiographic facility as well as the low socioeconomic status of the category of patients that attend the centre.
Keywords: Echocardiographic pattern, heart diseases, north-western Nigeria
|How to cite this article:|
Saidu H, Sani MU, Mijinyawa MS, Yakasai AM. Echocardiographic pattern of heart diseases in a North - Western Nigerian tertiary health institution. Niger J Basic Clin Sci 2015;12:39-44
|How to cite this URL:|
Saidu H, Sani MU, Mijinyawa MS, Yakasai AM. Echocardiographic pattern of heart diseases in a North - Western Nigerian tertiary health institution. Niger J Basic Clin Sci [serial online] 2015 [cited 2023 Feb 4];12:39-44. Available from: https://www.njbcs.net/text.asp?2015/12/1/39/156685
| Introduction|| |
Cardiovascular diseases constitute major health problem in developing countries with over 80% of global morbidity and mortality occurring in these countries.  They account for 7-10% of all adult medical admissions to hospitals in Africa with heart failure contributing 3-7%. , Knowledge of the prevalent and patterns of the heart diseases in any environment is important in health care planning and in the provision of health care services.
Echocardiography remains a key and most widely used imaging technique in cardiology. It provides comprehensive information about cardiac structure and function which often guides management of cardiac patients.  The widespread availability of and accessibility of echocardiographic services in the western world have greatly enhanced the classification and management of cardiac diseases. Despite availability in many health care facilities in Nigeria, the high cost and concentration of the facilities in urban centres limits its use. Indeed many patients with heart diseases are diagnosed late, often when complications have developed.
Previous studies on the indications and echocardiographic diagnoses had documented Valvular heart disease, Hypertensive heart disease, Dilated cardiomyopathy, and Congenital heart disease as the commonest in Nigeria. ,,,,,, Some of the studies were done over a decade ago, and there is a need for an update on the results of echocardiographic examinations. This is especially important in the face of changing patterns of cardiovascular diseases in our environment and availability of more centres offering echocardiography service.
| Materials and methods|| |
This was a retrospective study of the echocardiographic data collected over 3 years period. Between September 2011 and August 2014, the echocardiographic diagnoses of patients aged ≥15 years referred for echocardiography were analysed. The study was carried out at the echocardiographic laboratory of Murtala Muhammad Specialist Hospital (MMSH), a tertiary health institution established in 1928 and the largest Government owned hospital in Northern Nigeria. It is located within Kano metropolis. It is highly accessible to patients as no fees are charged for consultation and investigations are highly subsidised. These factors attract the low income earners to the centre. The echo laboratory serves the hospital and referrals from other hospitals and clinics in Kano State as well as neighbouring states.
Ethical approval was obtained from the institution's ethical review committee.
Baseline clinical and demographic characteristics were obtained from the patients folders and echocardiography register. These include: Age, gender and indication for the echocardiogram.
Echocardiography was carried out using Toshiba HDI Machine and a 2.5-5.0Hz linear array transducer. On each subject in the partial decubitus position, complete 2D echocardiographic examination was performed according to the recommendation of the American Society of Echocardiography (ASE).  M- mode echocardiography was derived from the 2D images. The M-mode cursor on the 2D scan was moved to specific areas of the heart to obtain measurements according to the recommendations of the committee on M- mode standardization of the ASE.  Complete Doppler study was done according to the recommendation of ASE.  From the M-mode measurements, indices of Left Ventricular (LV) function were derived. These included shortening fraction, ejection fraction (EF), left ventricular mass and relative wall thickness.
The specific echocardiographic diagnoses were done as follows:
Hypertensive Heart Disease (HHD) was diagnosed in the presence of any or combination of the following abnormalities: Left Ventricular Hypertrophy (LVH) and dilated left atrium (LA); LA diameter in women >3.8 cm and in men >4.2 cm. LV geometric patterns were defined according to Ganau et al. 
Diagnosis of Rheumatic heart disease was made using World Heart Federation criteria. 
Dilated Cardiomyopathy (DCM) was diagnosed when there are dilated heart chambers with normal or reduced wall thickness as well as LV systolic dysfunction with ejection fraction <40%. 
Peripartum Cardiomyopathy (PPCM) was diagnosed based on the temporal relation of heart failure to last pregnancy and delivery as proposed in the European Society of Cardiology (ESC) working group on PPCM guidelines. 
Pericardial Effusion was diagnosed when there is echo free space between the visceral and parietal pericardium.
Cor pulmonale was said to be present when there is dilated and hypertrophied right ventricle and Doppler evidence of pulmonary hypertension. 
Ischaemic heart disease (IHD) was diagnosed based on the combination of documented history of chest pain, ECG abnormalities and segmental wall motion abnormalities. 
Hypertrophic Cardiomyopathy (HCM) was considered when there is asymmetrical septal hypertrophy with a septal- to- free wall thickness ratio 1.5:1, a small LV cavity, septal immobility, premature closure of the AV and systolic anterior motion of the mitral valve (SAM), if there is LV outflow obstruction.
Data analyses were performed with SPSS version 18. Continuous variables were expressed as mean ± SD (Standard deviation) and categorical variables expressed as percentages. Differences in categorical variables were assessed by chi- square analysis. P ≤ 0.05 was considered to be significant.
| Results|| |
There were 1048 echocardiographic reports during the period of review. 11 reports were excluded from the analysis due poor window and 25 due to incomplete data or repeated procedure in the course of management. A total of 1012 reports were therefore analysed. Of these, 891 (88.0%) had abnormal echocardiograms. Analysis of the abnormal echocardiograms shows that there were 307 (35%) males and 584 (65%) females (ratio 1:2); and their age ranged from 15-90 years (mean 41.28 ± 16.25) years.
The main clinical indications for the echocardiography included Systemic Hypertension/HHD (41%), PPCM (20%), Congestive Cardiac Failure (12%), RHD (6.2%) and DCM (4.8%).
[Table 1] shows indications for referrals for echocardiography.
HHD was the commonest echocardiographic diagnoses followed by PPCM and then RHD. PPCM was the commonest echocardiographic diagnosis among women. [Figure 1] shows the echocardiographic diagnoses of the various cardiac diseases.
HHD was present in 408 (40.3%) of the patients. Most of them had eccentric hypertrophy (40.4%) while 30.6% had concentric hypertrophy. Diastolic dysfunction was found in 58% of the patients while 39.8% had both diastolic and systolic dysfunction. The remaining had other echocardiographic evidence of HHD. The comparison of the echocardiographic diagnoses by gender is as shown in [Table 2]. HHD and DCM were commoner in males while RHD was commoner in females.
|Figure 1: Echocardiographic diagnoses of heart diseases in murtala muhammad specialist hospital, Kano, Nigeria|
Click here to view
PPCM was seen in 323 (32.0%) of the patients. 56 (17.3%) of them had intracardiac thrombus while up to 226 (70%) of them had secondary pulmonary hypertension.
The commonest types of valvular affectations among patients with RHD were Pure MR, found in 19 (40.4%), followed by mixed MV disease in 17 (36.2%), pure MS in 9 (19.1%) and pure AR in 2 (4.3%).
Amongst 60 (5.9%) of the patients with DCM, 10 (16.6%) of them had intracardiac thrombus while 22 (36.7%) had secondary pulmonary hypertension. More males had DCM than females.
The commonest form of pericardial disease was effusive pericarditis 14 (87.5%) and 2 (12.5%) had constrictive pericarditis.
| Discussion|| |
The results of this study show that systemic hypertension and HHD are the commonest clinical indication and echocardiographic diagnoses at our centre. These findings are similar to previous reports from other centres in Nigeria. ,,,,, However, similar research in Enugu, South-East, Nigeria, reported valvular heart disease as the commonest echocardiographic indication and diagnosis ahead of HHD.  This may reflect the fact that there is an active cardiac surgical unit in that center, there by attracting referrals of patients with structural heart disease.
Peripartum cardiomyopathy rank 2 nd as indication (20%) and echocardiographic finding (32%). These finding differs from what was previously reported by other authors. Some authors reported DCM as second, while others reported RHD as second. ,,, DCM ranked 3 rd in this study. Interestingly, in a prospective study of cases of in Katsina, Northern Nigeria, over three decades ago, Antony KK reported that cardiomyopathies were commonest cause (47%) of heart failure in Northern savannah, congestive cardiomyopathy being the predominant type (31%). These were followed by RHD. HHD was responsible for only 12% of cases of heart failure in his series.  Whereas he did not specifically study PPCM, our findings may suggest an epidemiologic transition with HHD becoming very relevant cause of heart failure and cardiomyopathies still persisting.
Although PPCM has been found to be more common in the Northern part of the country, our study so far, reported the highest prevalence. In a previous study by Sani et al., in a different centre, but in same locality, DCM ranked 2 nd with PPCM accounting for only 2.8%.  Adesanya et al., in Zaria, another centre in the North Western Nigeria reported RHD as 2 nd followed by DCM accounting for 5.6%, with PPCM inclusive. 
The relatively high prevalence of PPCM observed in this study might be due to availability of the echocardiographic service in our centre where due to very cheap services compared to other centres around, patients from low socioeconomic status patronize. Apart from low socioeconomic status, other factors that have been postulated to increase the risk of PPCM include non - Caucasian ethnicity, advanced maternal age, multiparity, multiple pregnancy and pregnancies complicated by preeclampsia. ,, While we did not analyse most of these factors because of incomplete data, we observed a positive association between PPCM and young primigravidae. These findings therefore suggests the need to carry out studies and update findings on the demographic and clinical characteristics of patients with PPCM.
Karaye et al., over a decade ago, in same region, determined the impact of income on echocardiographic pattern of heart disease.  He reported a prevalence rate of PPCM as 4.3% among low income earners patronizing the general hospital and none among the high income earners patronizing the teaching hospital.  It is also possible that there are women with preexisting assymptomatic cardiomyopathy that then deteriorated late in pregnancy or post natal period thereby making it difficult to be distinguished from actual PPCM.
Although we reported a lower prevalence of RHD, the spectrum is similar to earlier findings in the country with MR being the commonest valve lesion. ,,, The prevalence of RHD is going down in the urban cities with improved sanitation and the use of antibiotics in the treatment of streptococcal throat infection and rheumatic fever.
Our report also demonstrated low prevalence of IHD (1.4%), with significant proportion having normal echocardiogram. The low prevalence is consistent with earlier studies despite the reported rising incidence of coronary artery disease in developing countries. ,,, The figure may be higher if other diagnostic facilities were considered, the gold standard for diagnosis being Coronary angiogram.
The low prevalence of Congenital heart disease reported is also similar to what was reported previously, because only adults were included in the study.
The large number of normal finding at echocardiography in this study is similar to previous studies in Nigeria. ,,, This can be explained by the fact that many referrals come from diverse population of doctors with most patients not being properly screened for cardiac disease before referral.
Limitations of the study
Our study has a number of limitations. Being a retrospective study, we were not able to get complete records of some of the patients. As with previous documentations, it was difficult to determine cases with preexisting asymptomatic cardiomyopathy that might have deteriorated late in pregnancy or post natal period with actual PPCM. Other diagnostic tools such as stress testing or coronary angiogram were not considered. These might have probably pick more cases of IHD.
| Conclusion|| |
This study shows that HHD, PPCM and RHD are the common causes of heart disease in our centre. It also shows the increasing burden of non- communicable diseases in the country.
There is therefore the need for strategies for the prevention, early detection and treatment of systemic hypertension in order to prevent its complications. There is also the need for proper antenatal and postnatal care with reinforced health education on healthy diet, life style and avoidance of harmful traditional practices with regards to pregnancy and puerperium. This is aimed at at prevention, early diagnosis and treatment in order to prevent complications.
| References|| |
Whelton PK, Brancati FL, Appel LJ, Klag MJ. The challenge of hypertension and artherosclerotivc vascular disease in economically developing countries. High Blood Press 1995;4:36-45.
Antony KK. Pattern of cardiac failure in Northern Savannah Nigeria. Trop Geogr Med 1980;32:118-25.
Oyoo GO, Ogolo FN. Clinical and socio demographic aspects of congestive heart failure patients of Kenyatta National Hospital, Nairobi. East Afr Med J 1999;76:23-7.
Hill GS, Bloonfeild P. Basic transthoracic echocardiography. BMJ 2005;330:1432-6.
Balogun MO, Urhogide GE, Ukoh VA, Adebayo RA. A preliminary audit of two - Dimensional and Doppler echocardiographic services in a Nigerian tertiary Private hospital. Niger J Med 1999;8:139-41.
Ukoh VA, Omuemu C. Spectrum of heart diseases in adult Nigerians: An echocardiographic study. Niger J Cardiol 2005;2:24-7.
Agomuoh DI, Akpa MR, Alasia DD. Echocardiography in the University of Port Harcourt Teaching Hospital: April 2000 to March 2003. Niger J Med 2006;15:132-6.
Ogah OS, Adegbite GD, Akinyemi RO, Adesina JO, Alabi AA, Udofia OI, et al
. Spectrum of heart diseases in a new cardiac service in Nigeria: An echocardiograhic study of 1441 subjects in Abeokuta. BMC Res Notes 2008;1:98.
Adebayo RA, Akinwusi PO, Balogun MO, Akintomide AO, Adeyeye VO, Abiodun OO, et al
. Two-dimensional and Doppler echocardiographic evaluation of patients at Obafemi Awolowo University Teaching Hospitals Complex, Ile - Ife, Nigeria: A prospective study of 2501 subjects. Int J Gen Med 2013;6:541-4.
Kolo PM, Omotosho AB, Adeoye PO, Falase AJ, Adamu UG, Afolabi J, et al
. Echocardiography at the University of Ilorin Teaching Hospital, Nigeria: A three years audit. Res J Med Sci 2009;3:141-5.
Ejim EC, Ubani-Ukoma CB, Nwaneli UC, Onwubere BJ. Common echocardiographic abnormalities in Nigerians of different age groups. Niger J Clin Pract 2013;16:360-4.
Sahn DJ, De Maria A, Kisslo J, Weyman A. Recommendations regarding quantitations in the M-mode echocardiography: Results of the survey of echocardiographic measurements. Circulation 1978;58:1072-83.
Quininones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA. Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. Reccommendation for quantification of Doppler echocardiography: A report from the Doppler Quatification Task force of the Nomenclature and Standards Committee of the American Society of echocardiography. J Am Soc Echocardiogr 2002;15:167-84.
Ganau A, Devereux RB, Roman MJ, de Simone G, Pickering TG, Saba PS, et al
. Patterns of left ventricular hypertrophy and geometric remodeling in essential hyprtension. J Am Coll Cardiol 1992;19:1550-8.
Reményi B, Wilson N, Steer A, Ferreira B, Kado J, Kumar K, et al
. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease- An evidence based guidelines. Nat Rev Cardiol 2012;9:297-309.
Cardiomyopathies: Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1984;697:7-64.
Sliwa K, Hilfiker-Kleino D, Petrie MC, Mebazaa A, Pieske B, Buchmann E, et al
. Heart Failure Association of the European Society of Cardiology Working Group on Peripartum Cardiomyopathy. Current state of knowledge on aetiology, diagnosis, management and therapy of peripartum cardiomyopathy: A Position statement from the Heart failure Associations of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12:767-78.
Jaffe CC, Weltin G. Echocardiography of the right side of the heart. Cardiol Clin 1992;10:41-57.
Armstrong WF, Ryan T. 'Echocardiography and coronary heart disease' in Feigenbaum's Echocardiography. Vol 1. 7 th
ed. Philadelphia: Lippincott Williams and Williams; 2010. p. 427-72.
Sani MU, Karaye KM, Ibrahim DA. Cardiac morbidity in subjects referred for echocardiographyic assessment at a tertiary medical institution in the Nigerian Savannah Zone. Afr J Med Sci 2007;36:141-7.
Adesanya CO, Sanderen JE. M-mode echocardiography in the diagnosis of heart diseases in Africans. Trans R Soc Trop Med Hyg 1979;73:400-5.
Shaikh N. An obstetric emergency called peripartum cardiomyopathy! J Emerg Trauma Shock 2010;3:39-42.
Okeke T, Ezanyeaku C, Ikeako L. Peripartum cardiomyopathy. Ann Med Health Sci Res 2013;3:313-9.
Ntusi N, Mayosi B. Aetiology and risk factors of peripartum cardiomyopathy: A systematic review. Int J Cardiol 2009;131:169-79.
Karaye KM, Sani MU. The impact of income on the echocardiographic pattern of heart diseases in Kano, Nigeria. Niger J Med 2008;17:350-5.
Akinboboye O, Idris O, Akinkugbe O, Akinkugbe O. Trends in conary artery disease and associated risk factors in the Sub-Saharan Africa. J Hum Hypertens 2003;17:381-7.
Sani MU, Adam B, Mijinyawa MS, Abdu A, Karaye KM, Maiyaki MB, et al
. Ischaemic heart disease in Aminu Kano Teaching Hospital, Kano, Nigeria: A 5 year review. Niger J Med 2006;15:128-31.
[Table 1], [Table 2]