Mixed connective tissue disease complicated by heart failure in Ile-Ife, Nigeria: management challenges in a resource-limited economy.

BACKGROUND: Mixed connective tissue disease (MCTD; also known as Sharp's syndrome) is a rare autoimmune inflammatory disorder characterized by high titer of U1 ribonucleoprotein (U1RNP) antibody and clinical and serological overlap of systemic lupus erythematosus, systemic sclerosis, and polymyositis. The diagnosis is based on clinical and serological factors in criteria such as Alarcon-Segovia, Khan, Kusakawa, and Sharps. Cardiac disease can be a complication of connective tissue disease (CTD). There are few reports in Africa. AIMS: To present MCTD as underlying cause of heart failure with reduced ejection fraction and highlight challenges of investigations and treatment. OBJECTIVES: To highlight the first case in our center and discuss the cardiac, respiratory, and rheumatologic management. PATIENT AND METHODS: We present a 52-year-old woman with 3 weeks history of productive cough with whitish sputum, severe dyspnea, orthopnea, paroxysmal nocturnal dyspnea, right sided abdominal pain, leg swellings, a one year history of recurrent fever, Raynaud's phenomenon, small joint swellings and deformities with pain in both hands. RESULTS: On examination there was microstomia, tethered forehead and lower eyelid skin, tender swelling of the interphalangeal joints and arthritis mutilans. Laboratory findings showed estimated glomerular filtration rate <60 mL/kg/min/1.73 m2, U1RNP antibody levels were eight times upper limit of normal, elevated rheumatoid factor, speckled antinuclear antibody pattern, negative anticentromere antibody, anti Scl-70 and anticyclic citrullinated peptide. Chest X-ray/CT revealed pulmonary fibrosis. Echocardiography findings showed reduced ejection fraction of 40%, elevated pulmonary arterial pressure at rest of 60.16 mmHg. The patient showed improvement on antifailure drugs, but prednisolone was stopped for sudden reversal of previously controlled stage 2 hypertension (HTN), and the patient was discharged in a stable condition. Difficulties ensued in obtaining prompt definite results due to the unavailability of serologic tests in the hospital, and the tests were done outside the state and country. CONCLUSION: Identifying MCTD is critical, especially in patients requiring steroids that may worsen systemic HTN and heart failure. There is a need to have definitive investigative facilities for such patients in hospitals.

Pulmonary Hypertension in Heart Failure Patients Presenting at OAUTHC, Ile-Ife, Nigeria.

BACKGROUND: Pulmonary hypertension (PH) is common in heart failure patients. Literature on PH in heart failure is sparse in Nigeria. This study was carried out to determine the prevalence of PH in heart failure patients and ascertain the relationship between left ventricular systolic and diastolic function and the degree of PH. METHODS: A total of 125 heart failure patients had echocardiography done. PH was diagnosed using tricuspid regurgitation jet and pulmonary ejection jet profile. RESULTS: PH was present in 70.4% of heart failure patients. Estimated mean pulmonary arterial pressure increased with increasing severity of systolic and diastolic dysfunction and had significantly negative correlation with ejection fraction, fractional shortening, and early mitral annular tissue diastolic velocity (E'), but positive correlation with left ventricular end-systolic volume, right ventricular dimension, transmitral E to A ratio, and E/E' ratio. CONCLUSION: PH is very common in heart failure and has significant relationship with left ventricular function.

Comparison between treadmill and bicycle ergometer exercise tests in mild-to-moderate hypertensive Nigerians.

BACKGROUND: Comparative cardiovascular responses to treadmill and bicycle ergometer (bike) exercise tests in hypertensive Nigerians are not known. This study compared cardiovascular responses to the two modes of exercise testing in hypertensives using maximal exercise protocols. METHODS: One hundred and ten male subjects with mild-to-moderate hypertension underwent maximal treadmill and bike test one after the other at a single visit in a simple random manner. Paired-sampled t-test was used to compare responses to both exercise tests while chi-squared test was used to compare categorical variables. RESULTS: The maximal heart rate (P<0.001), peak systolic blood pressure (P=0.02), rate pressure product (P<0.001), peak oxygen uptake (P<0.001), and exercise capacity (P<0.001) in metabolic equivalents were signifcantly higher on the treadmill than on the bike. CONCLUSION: Higher cardiovascular responses on treadmill in Nigerian male hypertensives in this study, similar to findings in non-hypertensives and non-Nigerians in earlier studies, suggest that treadmill may be of better diagnostic utility in our population.

Pattern of arrhythmias among Nigerians with congestive heart failure.

BACKGROUND: In patients with heart failure, death is often sudden due to life-threatening arrhythmias. This work was carried out to evaluate the pattern of arrhythmias in Nigerians with heart failure. MATERIALS AND METHODS: Thirty subjects with congestive heart failure (CHF), 30 subjects with hypertensive heart disease, and 15 normal subjects with no obvious features of heart disease were evaluated with resting and 24-hour electrocardiographic monitoring and transthoracic echocardiography. Data were analyzed with one-way analysis of variance with post hoc Duncan's analysis, Fisher's exact test, and linear regression analysis using SPSS version 16. RESULTS: CHF subjects had more instances of supraventricular tachycardia (P=0.005), ventricular extrasystoles (P<0.001), bigeminy (P<0.001), trigeminy (P<0.001), couplets (P<0.001), triplets (P<0.001), and nonsustained ventricular tachycardia (VT) (P=0.003) than the other two control groups. They also showed a significantly longer VT duration (4.6±5.6 seconds) compared with the other groups (P<0.001). Linear regression analysis showed a significant direct relationship between VT and the maximum number of ventricular extrasystoles per hour (P=0.001). CONCLUSION: Cardiac arrhythmias are common in subjects with CHF and are more frequent when compared with patients with hypertensive heart disease and normal subjects.

Evaluation of the indications and arrhythmic patterns of 24 hour Holter electrocardiography among hypertensive and diabetic patients seen at OAUTHC, Ile-Ife Nigeria.

BACKGROUND: There are very limited published studies in Nigeria on the use of 24 hour Holter electrocardiogram (Holter ECG) in the arrhythmic evaluation of hypertensive and diabetic patients. OBJECTIVE: To evaluate indications, arrhythmic pattern of Holter ECG, and heart rate variability (HRV) among patients with hypertensive heart disease (HHD) with or without heart failure and type 2 diabetes mellitus (T2DM) seen in our cardiac care unit. METHODS: Seventy-nine patients (32 males and 47 females) were studied consecutively over a year using Schiller type (MT-101) Holter ECG machine. RESULTS: Out of the 79 patients, 17 (21.5%) had HHD without heart failure, 33 (41.8%) had HHD with hypertensive heart failure (HHF), while 29 (36.7%) were T2DM patients. The mean (standard deviation) ages of HHD without heart failure, HHF and T2DM patients were 59.65 (±14.38), 65.15 (±14.30), and 54.66 (±8.88) respectively. The commonest indication for Holter ECG was palpitation (38%), followed by syncope (20.3%). Premature ventricular contraction was the commonest arrhythmic pattern among the 79 patients, especially among HHF patients. The HRV using standard deviation of all normal-normal intervals was significantly reduced in T2DM patients (81.03±26.33, confidence interval [CI] =71.02-91.05) compared to the HHD without heart failure (119.65±29.86, CI =104.30-135.00) and HHF (107.03±62.50, CI =84.00-129.19). There was a negative correlation between the duration of T2DM and HRV (r=-0.613). CONCLUSION: Palpitation was the commonest Holter ECG indication and premature ventricular contractions were the commonest arrhythmic pattern among our patients. HRV was reduced in T2DM patients compared with hypertensive patients.

Marked First Degree Atrioventricular Block: an extremely prolonged PR interval associated with Atrioventricular Dissociation in a young Nigerian man with Pseudo-Pacemaker Syndrome: a case report.

BACKGROUND: The diagnosis of Marked First Degree Atrioventricular Block is made with electrocardiogram when PR interval ≥0.30 s. A PR interval of up to 0.48 s had been reported in literature. Data is sparse on an extremely prolonged PR interval associated with Atrioventricular Dissociation and Pseudo-Pacemaker Syndrome. Electrocardiogram with this type of uncommon features poses diagnostic and management challenges in clinical practice. CASE PRESENTATION: We report a case of a 22 year old Nigerian male from Igbo ethnic group who presented himself for medical screening with a history of exercise intolerance, occasional palpitation and fainting spells. He has no history of cough, orthopnoea, paroxysmal nocturnal dyspnoea nor body swelling. A physical examination revealed that the patient has a pulse rate of 64 beats per minute, blood pressure of 110/70 mmHg and soft heart sounds. Standard 12-lead electrocardiogram showed an uncommon Marked First Degree Atrioventricular Block with an extremely prolonged PR interval of 0.56 s. Long rhythm strips of the electrocardiogram showed extremely prolonged PR interval associated with Atrioventricular Dissociation and variable degrees of Atrioventricular Block (Mobitz type I and II). CONCLUSIONS: An extremely prolonged PR interval may occur in First Degree Atrioventricular Block and it may be associated with Atrioventricular Dissociation and Pseudo-Pacemaker Syndrome which may pose diagnostic and management challenges. This suggests that not all cases of First Degree Atrioventricular Block are benign and so should be sub-classified based on degree of PR interval prolongation and associated electrical abnormalities.

Valvular regurgitations may increase risk of arrhythmias in Nigerians with hypertensive heart failure.

BACKGROUND: Hypertensive heart disease (HHD) is the commonest cause of sudden cardiac death among Nigerians. A high frequency and early onset of valvular regurgitations (VHD) in hypertensives, and greater concentric hypertrophy are also common in that population. AIMS AND METHODS: To further investigate the relationship between VHD and cardiac arrhythmias and their correlates seen in the hypertensive spectrum and to test the hypothesis that VHD predisposes to cardiac arrhythmias in hypertensive heart failure (HHF). HHF patients (n = 14), HHD patients n = 23, and normotensive controls (n = 9) all underwent 24 h electrocardiogram Holter monitoring as well as two-dimensional and Doppler echocardiography. Participants in each patient category were classified according to the presence and severity of VHD or its absence (NVHD). RESULTS: There were statistically significant differences in the mean supraventricular tachycardia (SVT) (P < 0.001 analysis of variance; ANOVA), the mean and median frequency of ventricular tachycardia episodes (P < 0.02 ANOVA), and couplets (P = 0.0002 ANOVA) between groups. HHF-VHD always had more SVT (81/24 versus 4.4/24 h; P = 0.016) and ventricular arrhythmias 69/24 versus 34/24 h (P < 0.02) than HHF-NVHD. Multivalvular regurgitations (three or more valves), higher left ventricular mass index (g/m2) [274 (24) versus 191(19); P < 0.001 ANOVA], and lower ejection fraction (EF; %) [29(3) versus 53(14)] in HHF-VHD were arrhythmogenic. Mean ventricular tachycardia/triplet frequency/24 h were HHF-VHD 69, HHF-NVHD 39, HHD-VHD 0.3, HHD-NVHD 6, and controls 0.2 (P < 0.02 ANOVA). Compared with 35% (10/27) of all VHD, 15.7% (3/19) of all NVHD participants had nonsustained ventricular tachycardia. The number of regurgitant valves was positively correlated with the frequency of the Lown class of the arrhythmias 0-IVB (r = 0.42, P = 0.003) and to ventricular tachycardia (r = 0.3, P = 0.04) (both n = 46). CONCLUSION: Left ventricular hypertrophy (LVH) increased arrhythmias. But multivalvular regurgitations predisposes to greater SVT and complex ventricular arrhythmias, especially in HHF. Low EF and concentric LVH are correlates.

The "obesity paradox" in Nigerians with heart failure.

BACKGROUND: Previous studies have suggested that a high body mass index (BMI) was associated with improved outcome in congestive heart failure (CHF). The aim of this study was to examine the relationship between BMI and echocardiographic variables of cardiac function in stable outpatients with heart failure. METHODS AND MATERIALS: This is a cross-sectional study in which the cardiology clinic out-patients of Obafemi Awolowo University Teaching Hospital with heart failure were recruited. Patients were categorized using baseline BMI as normal weight BMI = 18.5-24.9 kg/m(2) and overweight/obese (BMI > 25.0 kg/m(2)). Risks associated with BMI groups were evaluated and the data were analyzed with the aid of SPSS 15.0 software. RESULTS: Patients with higher BMI have higher left ventricular ejection fraction and fractional shortening and lesser tendency to have an abnormal left ventricular geometry and better functional (New York Heart Association) class of heart failure at presentation. CONCLUSION: Overweight and obese patients had less severe degree of heart failure than normal weight patients and efforts should be made to prevent excessive weight loss in patients with heart failure.

Valvular regurgitation impact on left ventricular 2-dimensional and Doppler echocardiographic indices in patients with essential hypertension.

BACKGROUND: Blacks have both a higher hypertension prevalence and accelerated cardiac end organ damage. Because blacks also have a higher prevalence of valvular heart disease, which occurs at a younger age than for whites, we further examined the contribution of valvular regurgitation to the severity of hypertensive heart disease in Nigerians. METHODS: We evaluated and compared echocardiographic indexes in 75 essential hypertensive Nigerians with (n=48) and without (n=27) valvular regurgitations. Demographic and echocardiographic indices, as well as the types and severity of valvular lesions were compared between the groups using bivariate logistic regression and analysis of variance. RESULTS: The 2 groups were of similar demographics, but those with regurgitations had larger cardiac size (p < .05), greater mass (147 +/- 31 vs. 122 +/- 32 g/m2, p = .01) higher volume (p < .01), and left atrial size (35.6 +/- 4.6 vs. 33.3 +/- 4.6 mm, p < .05). Atrial size, cardiac volume, and dimension were independent correlates/predictors of regurgitation occurrence. Relative wall thickness of at least 0.6 was more common in regurgitation patients. Cardiac mass was correlated to increasing age (r = 0.23, p = .043). The valvular lesions frequencies were aortic regurgitation, 8; mitral regurgitation, 22; and mixed, 18. The aortic orifice dimension was significantly different among the regurgitant cases, highest in aortic regurgitation (p = .001). Aortic orifice dimension increased with hypertension duration (p = .028). CONCLUSIONS: Regurgitant lesions are common and occur early in hypertensive Africans. Apparently mild valvular regurgitation may accentuate preclinical concentric hypertrophy in hypertensive blacks.

Left Ventricular Diastolic Function in Nigerian Patients with Essential Hypertension: A Retrospective Study to Compare Angiotensin Converting Enzyme Inhibitors, Calcium Channel Blockade or Their Combination.

BACKGROUND: Hypertension in blacks imposes a greater left ventricular hypertrophy, and accelerated heart failure onset. We evaluated and compared the echocardiographically determined systolic and left ventricular diastolic functional indices in Nigerian hypertensive patients, associated with the chronic use of ACE inhibitors, Calcium channel blockers (CCB) or their combinations. METHODS: Ejection fraction -EF, intraventricular relaxation time (IVRT), E/A peak velocity ratio, E wave deceleration time] as well as the left ventricular mass index (LVMI) was undertaken among 41 Nigerian patients with essential hypertension only, on treatment for 4-6 months prior. The 41 patients (aged 59 +/- 10 years, 40% females) were divided into three groups; those receiving (i) ACE inhibitors; or (ii) CCB or (iii) combination of ACEI and CCB. All the three groups had a background of diuretic treatment for optimal blood pressure control. RESULTS: There were no statistically significant differences in the mean LVMI or sitting blood pressure between treatment groups. E/A ratio for ACEI treatment was 1.06 +/- 0.44, CCB 0.74 +/- 0.19, and for ACEI + CCB 0.87 +/- 0.26 (F = 3.29, P = 0.048 anova). The 95% confidence interval for the E/A ratio on ACEI was 0.8 to 1.33. The A wave duration time integral (AVVTi) were all abnormally large, but showed a significant between treatment group difference (P = 0.037, anova). The values were 21.9 +/- 4.7 for ACEI, 25.3 +/- 6.3 for CCB, and least at 20.1 +/- 3.6 cm for the ACE + CCB combination. Similarly, the IVRT was lowest and <100 ms with ACEI + CCB being 93 +/- 18 ms, ACEI 115 +/- 23 ms, and CCB being 117 +/- 22 ms (F = 4.92, P = 0.01, anova). The 95% CI for IVRT on ACEI + CCB was 82 to 104 ms. There were no between treatment group differences in systolic contractility, (fractional shortening or EF). CONCLUSIONS: The results indicate that use of an antihypertensive drug regime inclusive of an ACE inhibitor (+/-CCB) may be associated with greater salutary effect on indices of diastolic function, (E/A > 1, lower AVVTi, IVRT < 100 ms) even in the presence of an equivalent effect on systolic function and blood pressure.

Relationship between depression and quality of life in Nigerian outpatients with heart failure.

OBJECTIVE: Our objective was to evaluate the relationship between depression and health-related quality of life (QoL) in Nigerian outpatients with heart failure (HF). METHODS: We used a cross-sectional study in which outpatients with HF (n=100) completed the WHO Quality of Life Scale-Brief Version to assess their subjective QoL. The patients were also assessed for the diagnosis of major depressive disorder (MDD) in accordance with the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition. RESULTS: The factors independently associated with poor QoL include disability due to illness, presence of MDD, younger age, and longer duration of illness. Patients with MDD had worse QoL than patients without MDD on dimensions of physical health, psychological health, and environment. CONCLUSION: Depression adversely affects the QoL of patients with HF. Programs designed to improve the QoL of patients with HF need to incorporate the early identification and treatment of depression. Future studies are warranted to investigate the impact of improved depression management on QoL in patients with HF.

Prevalence and correlates of major depressive disorder in Nigerian outpatients with heart failure.

This study aims to estimate the prevalence and correlates of major depressive disorder (MDD) in Nigerian outpatients with heart failure. Authors assessed patients with heart failure (N = 102) for DSM-IV diagnosis of MDD and obtained sociodemographic and clinical data. MDD was found in 28 (27.5%) of the patients. The significant correlates predicting MDD included unemployment and disability due to the illness, more severe illness (NYHA class), age younger than 60 years, and not being married. These factors should be considered in planning further studies and in screening and intervention programs for patients with heart failure.