Pattern of Right Ventricular Changes in Patients with Uncomplicated Systemic Hypertension at a Tertiary Centre in Southwest Nigeria.

BACKGROUND AND AIMS: Hypertension is an independent risk factor for cardiovascular complications. The effect of systemic hypertension on the right ventricle (RV) has received less attention probably due to its complex structure and location. The aim of the study was to assess the effect of systemic hypertension on the structure and function of the right ventricle using transthoracic echocardiography. METHOD: One hundred hypertensives and 100 healthy controls were recruited into the study. Transthoracic echocardiography was used to measure RV wall thickness (RVWT) in diastole, RV internal dimensions in diastole, tricuspid annular plane systolic excursion (TAPSE), right ventricular filling velocities (TE and TA), and RV systolic excursion velocity (RVSm). These measurements were repeated on the left ventricle. RESULTS: There was significantly thicker RV wall (0.51 + 0.08cm vs 0.44+0.08cm; p=0.001) in the hypertensive group and higher frequency of RV hypertrophy (48.45% vs 18.75%; p<0.001). Tricuspid annular plane systolic excursion (TAPSE) and the tricuspid annular peak systolic excursion velocity (TSm) were significantly lower in the hypertensive group (2.34+0.45cm vs 2.50+0.36cm; p=0.008, and 11.70+3.03cm/s vs 12.60+2.93cm/s p=0.039, respectively), though no participant had abnormal TAPSE. Tricuspid E/A ratio was lower in the hypertensive group (1.13+ 0.33 vs 1.24+0.27; p=0.011). The tricuspid E/A ratio had positive correlation with mitral E/A ratio. CONCLUSION: Right ventricular structural and functional changes are found in systemic hypertension, even in the absence of other systemic complications. These changes could have been mediated by ventricular interdependence and altered humoral factors.

CONTEXTES ET OBJECTIFS: L'hypertension artérielle est un facteur de risque indépendant pour les complications cardiovasculaires. L'effet de l'hypertension artérielle systémique sur le ventricule droit (VD) a reçu moins d'attention probablement en raison de sa structure complexe et de son emplacement. L'objectif de l'étude était d'évaluer l'effet de l'hypertension artérielle systémique sur la structure et la fonction du ventricule droit en utilisant l'échocardiographie transthoracique. MÉTHODE: Cent hypertendus et 100 témoins en bonne santé ont été recrutés dans l'étude. L'échocardiographie transthoracique a été utilisée pour mesurer l'épaisseur de la paroi du VD (EPVD) en diastole, les dimensions internes du VD en diastole, l'excursion plane systolique annulaire tricuspide (TAPSE), les vitesses de remplissage ventriculaire droit (TE et TA), et la vitesse d'excursion systolique ventriculaire droit (RVSm). Ces mesures ont été répétées sur le ventricule gauche. RÉSULTATS: Il y avait une paroi du VD significativement plus épaisse (0,51 ± 0,08 cm vs 0,44 ± 0,08 cm ; p=0,001) dans le groupe hypertendu et une fréquence plus élevée d'hypertrophie ventriculaire droite (48,45% vs 18,75% ; p<0,001). L'excursion plane systolique annulaire tricuspide (TAPSE) et la vitesse maximale systolique annulaire tricuspide (TSm) étaient significativement plus basses dans le groupe hypertendu (2,34 ± 0,45 cm vs 2,50 ± 0,36 cm ; p=0,008, et 11,70 ± 3,03 cm/s vs 12,60 ± 2,93 cm/s p=0,039, respectivement), bien qu'aucun participant n'ait eu de TAPSE anormal. Le rapport E/A tricuspide était plus bas dans le groupe hypertendu (1,13 ± 0,33 vs 1,24 ± 0,27 ; p=0,011). Le rapport E/A tricuspide avait une corrélation positive avec le rapport E/A mitral. CONCLUSION: Des modifications structurales et fonctionnelles du ventricule droit sont retrouvées dans l'hypertension artérielle systémique, même en l'absence d'autres complications systémiques. Ces changements pourraient avoir été médiés par l'interdépendance ventriculaire et des facteurs humoraux modifiés. MOTS-CLÉS: Hypertension ; Échocardiographie ; Hypertrophie ventriculaire droite ; Dysfonction diastolique ventriculaire droit.

Influence of systolic blood pressure on outcomes in Nigerians with peripartum cardiomyopathy.

Background: The relationship between blood pressure (BP) trajectories and outcomes in patients with peripartum cardiomyopathy (PPCM) is not clear. Aim: The study aimed to assess the clinical features and outcomes (all-cause mortality and unrecovered left ventricular [LV] systolic function) of PPCM patients grouped according to their baseline systolic BP (SBP). Patients and Methods: PPCM patients presenting to 14 tertiary hospitals in Nigeria were consecutively recruited between June 2017 and March 2018 and then followed up till March 2019. SBP at first presentation was used to categorize the patients into seven groups: <90, 90-99, 100-109, 110-119, 120-129, 130-139, and ≥140 mmHg. Unrecovered LV systolic function was defined as echocardiographic LV ejection fraction (LVEF) below 55% at the last profiling. Results: Two hundred and twenty-seven patients were recruited and followed up for a median of 18 months. Of these, 4.0% had <90 mmHg, 16.3% had 90-99 mmHg, 24.7% had 100-109 mmHg, 24.7% had 110-119 mmHg, 18.5% had 120-129 mmHg, 7.5% had 130-139 mmHg, and 4.4% had ≥140 mmHg of SBP at presentation. The highest frequency of all-cause mortality was recorded among patients with SBP ≤90 mmHg (30.8%) followed by those with 90-99 mmHg (20.5%) (P = 0.076), while unrecovered LV systolic function did not differ significantly between the groups (P = 0.659). In a Cox proportional regression model for all-cause mortality, SBP <90 mmHg had a hazard ratio (HR) of 4.00 (95% confidence interval [CI] 1.49-10.78, P = 0.006), LVEF had an HR of 0.94 (95% CI 0.91-0.98, P = 0.003, B = 0.06%), and use of angiotensin-converting enzyme or angiotensin receptor and/or ß-receptor blockers had an HR of 1.71 (95% CI 0.93-3.16, P = 0.085). However, SBP was not associated with LV function recovery. Conclusion: In our cohort of PPCM patients, one-fifth was hypotensive at presentation. SBP <90 mmHg at presentation was associated with a four-fold higher risk of all-cause mortality during a median follow-up of 18 months.

Incidence, clinical characteristics, and risk factors of peripartum cardiomyopathy in Nigeria: results from the PEACE Registry.

AIMS: The aim of this study was to describe the incidence, clinical characteristics and risk factors of peripartum cardiomyopathy (PPCM) in Nigeria. METHODS AND RESULTS: The study was conducted in 22 hospitals in Nigeria, and PPCM patients were consecutively recruited between June 2017 and March 2018. To determine factors associated with PPCM, the patients were compared with apparently healthy women who recently delivered, as controls. Four hundred six patients were compared with 99 controls. The incidence and disease burden (based on the rate of consecutive recruitment of subjects) varied widely between the six geographical zones of Nigeria. From the North-West zone, 72.3% of the patients was recruited, where an incidence as high as 1 per 96 live births was obtained in a centre, while the disease was uncommon (7.6% of all recruited patients) in the South. Majority of the patients (76.6%) and controls (74.8%) (p = 0.694) were of Hausa-Fulani ethnic group. Atrial fibrillation, intracardiac thrombus, stroke, and right ventricular systolic dysfunction were found in 1.7%, 6.4%, 2.2%, and 54.9% of the patients, respectively. Lack of formal education (odds ratio [OR] 3.08, 95% confidence interval [1.71, 5.53]; P < 0.001), unemployment (OR: 3.28 [2.05, 5.24]; P < 0.001), underweight (OR: 13.43 [4.17, 43.21]; P < 0.001) and history of pre-eclampsia (OR: 9.01 [2.18, 37.75]; P = 0.002) emerged as independent PPCM risk factors using regression models. Customary hot baths (OR: 1.24 [0.80, 1.93]; P = 0.344), pap enriched with dried lake salt (OR: 1.20 [0.74, 1.94]; P = 0.451), and Hausa-Fulani ethnicity (OR: 1.11 [0.67, 1.84]; P = 0.698) did not achieve significance as PPCM risk factors. CONCLUSIONS: In Nigeria, the burden of PPCM was greatest in the North-West zone, which has the highest known incidence. PPCM was predicted by sociodemographic factors and pre-eclampsia, which should be considered in its control at population level. Postpartum customary birth practices and Hausa-Fulani ethnicity were not associated with PPCM in Nigeria.

Clinical and echocardiographic correlates of pulmonary hypertension among heart failure patients in Lagos, south-western Nigeria.

BACKGROUND: Pulmonary hypertension (PH) is very prevalent among heart failure (HF) subjects and is now recognised as an independent predictor of poor prognosis. There is a paucity of data in our environment about the frequency and correlates of PH in HF. We aimed to determine the frequency of PH in HF patients in an academic hospital and assess its correlates using echocardiography. METHODS: A total of 219 heart failure patients in NYHA functional class II to IV, and without co-morbidities that could cause PH, were consecutively recruited. Demographic, clinical and echocardiographic data were obtained from all subjects. RESULTS: The frequency of PH was 38.8%, using an estimated pulmonary artery systolic pressure (PASP) cut-off value of > 36 mmHg. HF subjects with PH tended to be male with a worse NYHA functional class compared with subjects without PH. HF subjects with PH also had significantly higher left ventricular (LV) filling pressures (higher left atrial volume index and E/e' ratio), more severe mitral regurgitation (MR), poorer LV systolic function, and worse parameters of right ventricular (RV) structure and function compared with those without PH. Echocardiographic variables that correlated significantly with PASP include LV filling pressures (p < 0.001 for all), mitral regurgitant volume (r = 0.269, p < 0.001) and LV ejection fraction (r = -0.239, p > 0.001). On multivariate analysis, the left atrial volume index and E/e' ratio were independently associated with PASP. CONCLUSIONS: PH is common among HF subjects in our environment and is associated with higher LV filling pressure, more severe MR, poorer LV systolic function and worse RV remodelling. Routine screening for PH among HF patients is recommended for better risk stratification and management.

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 (normal BP < 120/80 mmHg, n = 57) and prehypertensive (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 (QT(d)) 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/m(2), 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). QT(d) was independent of echocardiographic and electrocardiographic LVH (p > 0.05). CONCLUSIONS: Compared with normotension, prehypertension is associated with higher LVM but similar QT(d). This suggests that structural remodelling precedes electrical remodelling in prehypertension.

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.

QT Dispersion in Healthy Adult Nigerians.

BACKGROUND: Increase in QT dispersion (QTd) is associated with an increased risk of cardiovascular morbidity and mortality. OBJECTIVES: This study sought to (i) determine the mean QTd and (ii) characterise QTd in a healthy Nigerian population. METHODS: One hundred healthy Nigerian adults were studied. Healthy status of the subjects was determined by history and physical examination. A resting 12- lead ECG was obtained from all subjects for determination of QTc, QTd and ECG left ventricular hypertrophy (LVH) using Sokolow Lyon (SL) and Araoye's codes. Echocardiography was used to determine LV systolic function, LVM and LVMI for 60 subjects. RESULTS: The QTd ranged from 15-70ms with a mean value of 38.5 ± 11.2ms. QTd was independent of age (p = 0.86), sex (p = 0.97), heart rate (p = 0.22), blood pressure (p > 0.05), BMI (p = 0.81), QTc (p = 0.41), LVH (ECG and echo) and LV systolic function (p > 0.05). CONCLUSION: QT dispersion is independent of demographic parameters, LV systolic function and LV hypertrophy in healthy adult Nigerians.

Echocardiographic patterns in treatment-naïve HIV-positive patients in Lagos, south-west Nigeria.

INTRODUCTION: Cardiovascular abnormalities are common in HIV-infected patients, although often clinically quiescent. This study sought to identify by echocardiography early abnormalities in treatment-naïve patients. METHODS: One hundred patients and 50 controls with no known traditional risk factors for cardiovascular disease were recruited for the study. The cases and controls were matched for age, gender and body mass index. Both groups had clinical and echocardiographic evaluation for cardiac abnormalities, and CD4 count was measured in all patients. RESULTS: The cases comprised 57 females (57.0%) and 43 males (43.0%), while the controls were 28 females (56.0%) and 22 males (44.0%) (χ(2) = 0.01; p = 0.913). The mean age of the cases was 33.2 ± 7.7, while that of the controls was 31.7 ± 9.7 (t = 1.02; p = 0.31). Echocardiographic abnormalities were significantly more common in the cases than the controls (78 vs 16%; p = 0.000), including systolic dysfunction (30 vs 8%; p = 0.024) and diastolic dysfunction (32 vs 8%; p = 0.002). Other abnormalities noted in the cases were pericardial effusion in 47% (χ(2) = 32.10; p = 0.000) and dilated cardiomyopathy in 5% (five); none of the controls had either complication. One patient each had aortic root dilatation, mitral valve prolapse and isolated right heart dilatation and dysfunction. CONCLUSION: Cardiac abnormalities are more common in HIV-infected people than in normal controls. A careful initial and periodic cardiac evaluation to detect early involvement of the heart in the HIV disease is recommended.

Trends in acute emergency room hypertension related deaths: an autopsy study.

INTRODUCTION: Hypertension is associated with increased morbidity and mortality. Paradigm shift and novel drugs that go beyond blood pressure control have debuted in the last decade globally and in Nigeria. The study therefore proposed to investigate the effect of the above if any on hypertension related acute deaths in patients admitted to the emergency room of the Lagos University Teaching Hospital. METHOD: Autopsy reports for bodies deposited from the medical emergency room (ER) were reviewed. Details of the time of admission, time of death and blood pressure status prior to the event were obtained. Subjects were batched into two groups 1982 1991 and 1992 2001 based on periods of paradigm shift in hypertension diagnosis and management. RESULT: There were 297 hypertension related deaths but 252 were analyzed. There were 168 (66.7%) males and 84 (33.3%) females (M:F 2:1) and mean age was 47.33 +/- 12.18 years (14-85 yr). Two thirds of the subjects (65.5%) were = 50 yrs of age. The mean duration of admission was 5.88 +/- 6.41 hours. One third (35.3%) died within an hour of admission. The commonest causes of death were stroke (52.8%) and heart failure 103 (40.9%). Intra-cerebral hemorrhage was the commonest type of stroke seen, 69 (52.3%). There were fewer cases of acute deaths in the second decade under review 95 (37.7%) vs. 157 (62.3%), p = 0.02 and strokes during this period, 47 (49.47) Vs 86 (54.78), p = 0.06. CONCLUSION: There is a trend towards reduction of hypertension related acute deaths. However stroke remains a major cause of acute hypertensive death and the patients are still dying young.

Perception of Nigerian internal medicine residents on the diagnosis and management of heart failure.

AIM: To evaluate the perception of internal medicine residents on diagnosis and management of heart failure in Nigeria. METHOD: A modified version of the Euro-F study questionnaire was administered to internal medicine residents (IMRs) from Nigeria who were attending the pre part I Fellowship examination of the Faculty of Internal Medicine of the National Postgraduate Medical College. Responses were compared with data from the Nigerian primary physicians (PCP) survey and the Euro-HF study. RESULTS: The commonest symptoms used by the IMRs in heart failure diagnosis were exertional dyspnoea 68.85%(42), pedal oedema 63.93%(39) and orthopnoea 50.82%(31), while the signs included elevated jugular venous pressure 50.82%(31), basal crepitations 47.50%(29) and a gallop heart rhythm 39.34%(24). Categorisation using the Framingham criteria for diagnosis showed that 52% of the IMRs knew three or more major signs of heart failure. The IMRs use of investigations in diagnosing heart failure was fair to good and was significantly higher than results from the Euro-F study and the primary care physicians (PCPs) in Lagos study; echocardiogram, (p=0.007and <0.00001); electrocardiogram, (p= 0.0002 and p=0.001); chest x-ray (p=0.05 and 0.5) respectively. However the mean proportion of IMRs that would rely on investigation to make a diagnosis was significantly lower than in the Euro-F study (p=0.0001) and in the PCPs (p = 0.02). Although the mean proportion of the IMRs patients using ACE-inhibitors was significantly higher than in the Euro-F survey (p<0.001) and the PCPs (p <0.00001), majority (93.94%) of the IMRs were using less than half the trial doses for treatment. On the other hand, the knowledge of survival benefits with the use of b-blockers was very poor in the all the groups, p>0.05. CONCLUSION: A substantial knowledge gap still exists among the IMRs as regards the diagnosis and management of heart failure and this need to be addressed by the trainers.

Comparative study of the effect of tocotrienols and -tocopherol on fasting serum lipid profiles in patients with mild hypercholesterolaemia: a preliminary report.

OBJECTIVES: Hypercholesterolaemia is a risk factor for cardiovascular diseases. Tocotrienols reportedly possess hypocholesterolaemic activity. This study examined the effect of tocotrienols (T3) in TOCOVIDTM Suprabio TM on serum lipids. Patients and Methods :A randomised (2:1), open-label study of patients with mild hypercholesterolaemia (= 5.18mmol/L to <7.77mmol/L) and one additional cardiovascular risk factor was carried out. Subjects received either tocotrienols (as TOCOVIDTM Suprabio TM ) (n=28) or vitamin E (a-tocopherol) 500mg daily (n=16). Fasting lipids were compared at baseline and after 4 weeks therapy. RESULTS: Following 4 weeks therapy, mean +/- SD total cholesterol declined significantly in the tocotrienol group (from 6.10+/-0.66 to 5.47+/-1.16; P=0.02) compared to the a-tocopherol group (from 5.92+/-0.52 to 5.47+/-0.76; P>0.05). Mean LDL-C levels (mmol/L) were also significantly reduced in the tocotrienol group (3.82+/-0.85 to 3.24+/-1.26; P=0.04), but not in those on a-tocopherol (3.84+/-0.75 to 3.28+/-0.94; P>0.05). There were no significant changes in HDL-C and triglycerides in both groups. The tocotrienol group experienced a net decline in TG (7.1+/-31.4 %; P>0.05) while the a-tocopherol group had a net increase at week 4 (38.6+/-61.7%; P>0.05). CONCLUSION: The study adds to existing evidence of the favourable effect of tocotrienols on total cholesterol and LDL-C. However, the results need further evaluation.

A randomised trial to compare the efficacy and safety of Felodipine (Plendil) and Nifedipine (Adalat) retard in patients with mild-to-moderate hypertension.

The efficacy and tolerability of Felodipine extended-release was compared with Nifedipine retard in the management of patients with mild-to-moderate hypertension. A total of one hundred and thirty three patients were screened out of which one hundred and twenty-one patients were enrolled in a 9-week multicentre open, randomised rising-dose trial to receive either Felodipine 5-10 mg once daily or Nifedipine 10-20 mg twice daily. Blood pressure was measured at the end of the dosing interval that is 24 hours and 12 hours after Felodipine and Nifedipine respectively. Both drugs, Felodipine and Nifedipine were found to lower blood pressure significantly compared with baseline. After three weeks of treatment, seated blood pressure was reduced by 20/14 mmHg (systolic/diastolic) and by 24/16 mmHg after 6 weeks in the felodipine group. Corresponding values in the Nifedipine group were 16/09 mmHg and 24/13mmHg. Pulse rate was not significantly affected by either drugs. The percentage of patients who had satisfactory control after 3 weeks treatment was 57.6% for Felodipine and 33.3% for Nifedipine (significant). After dose titration (where necessary), at the end of the study the response rates were 76.3% (n=45) and 79.6% (n=43) for Felodipine and Nifedipine respectively (non significant). Both drugs were metabolically inert and did not derange the haematologic and biochemical profile of patients. They produced no significant weight changes. The pattern of side effects were similar in both groups but tended to be more severe with Nifedipine necessitating withdrawal of two patients in this group. In conclusion, Felodipine ER 5mg - 10mg once daily, and Nifedipine Retard, 20mg twice daily were equally effective medications for mild-to-moderate hypertension but Felodipine was better tolerated.