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European Journal of Heart Failure 2008 10(4):367-372; doi:10.1016/j.ejheart.2008.02.009
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© 2008 European Society of Cardiology

Chronic heart failure, selected risk factors and co-morbidities among adults treated for hypertension in a cardiac referral hospital in Cameroon

Anastase Dzudiea,b,*, Andre Pascal Kengnec, Salomon Mbaheb, Alain Menangad, Monique Kenfackb and Samuel Kingueb,d

a Heart failure and transplantation Unit, Louis Pradel's Cardiovascular Hospital Lyon, France
b Department of Internal medicine and subspecialties, University of Yaoundé I Cameroon
c The George Institute For International Health, University of Sydney Australia
d Cardiology Unit, Service of Internal Medicine B, Yaoundé General Hospital Cameroon

* Corresponding author. Heart failure and transplantation Unit, Hospices Civils Lyon, Louis Pradel's Cardiovascular Hospital and Claude Bernard University, 28, Avenue du Doyen Lepine, 69500 Bron, Lyon, France. Tel.: +33 660054389. E-mail address: aitdzudie{at}yahoo.com (A. Dzudie).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Acknowledgments
 References
 
Background: Information on clinical characteristics of heart failure (HF) among Africans with hypertension is needed to help define the burden of hypertension in this population, but currently there is little data available.

Aims: To determine the clinical characteristics of HF, related risk factors and co-morbidities among adult Cameroonians treated for hypertension.

Methods and results: Medical files of 1218 patients with hypertension followed at the cardiac clinic of Yaounde General Hospital were evaluated over a 10-year period from 1995 to 2005. One hundred and forty (11.5%) patients with clinical HF or asymptomatic left ventricular dysfunction were included in the present analysis. Ages ranged from 26 to 84 years (mean 54.9 years) and 86 (61.4%) were men. Systolic dysfunction and isolated diastolic HF were found in 64% and 23% of patients, respectively. Seventy nine (56.4%) patients had at least one co-morbidity and 43 (30.7%) had multiple co-morbidities. Co-morbidities included: renal impairment (24.3%), overweight and obesity (20.7%), chronic obstructive pulmonary disease (17.1%), gout (16.4%), anaemia (15.7), diabetes mellitus (13.5%), atrial fibrillation (12.9%), stroke (9.3%), and ischaemic heart disease (5.7%).

Conclusions: HF is frequent among Cameroonian patients treated for hypertension and is regularly associated with co-morbidities. Efforts are needed to improve the control of hypertension and enhance early detection of these co-morbidities in this context.

Key Words: Hypertension • Heart failure • Cardiomyopathy • Africa • Co-morbidities • Risk factors

Received May 18, 2007; Revised November 25, 2007; Accepted February 4, 2008


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 Acknowledgments
 References
 
Heart failure (HF) is a major and growing public health problem resulting from the cardiac damage caused by a variety of disease processes [1-3]. In western countries these processes are dominated by coronary heart disease [1]. In developing countries however, despite the growing prevalence of ischaemic heart disease, HF is still fuelled by systemic hypertension, valvular heart disease and cardiomyopathy [3-6]. High blood pressure is recognized as a leading cause of the global burden of disease, with most of this burden occurring in developing countries [7]. In most African countries and in Cameroon in particular, hypertension is the commonest non-communicable disease [8,9]. Hypertension often occurs in association with other cardiovascular risk factors like diabetes mellitus, non-optimal levels of serum lipids, obesity and smoking. This clustering pattern is highly frequent in African natives and migrants and further increases the risk of target organ damage such as kidney impairment, stroke and heart failure [2]. Although limited, data on stroke outcomes and the association with hypertension are available for African countries [10,11]; however, somewhat surprisingly, information on heart failure and its incidence among patients with hypertension in Cameroon in particular are not available. Such data are urgently needed, not only to help define the burden of hypertension in this context, but also to monitor treatment outcomes and to guide the implementation of effective cardiovascular prevention programmes.

This study uses the Hypertension Register from the Outpatient Department of the service of Internal Medicine of the Yaounde General Hospital (YGH) in Cameroon, and presents data on the prevalence of heart failure among patients treated for hypertension. Concurrent risk factors and selected co-morbidities are also described.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 Acknowledgments
 References
 
The register of specialized cardiovascular outpatient consultation of Yaounde General Hospital (YGH) provided the population base for recruitment into this study. Between 1995 and 2005, YGH was the main referral centre for cardiovascular diseases in the Cameroon. Patients from the capital city Yaounde and the rest of the country (approximately 15 million population), with chronic and severe cardiovascular conditions were likely to receive care in our clinic during the study period. Overall, the health system in Cameroon is organized into primary, secondary and tertiary levels. Care at the primary level is provided by nurses and general practitioners and is essentially geared toward acute conditions. Secondary levels are set to provide access to some form of specialist care. However, during the study period, few health facilities in this category had adequate resources to provide such care for cardiovascular diseases. Tertiary level facilities (including the study hospital) serve both as a referral hospital for primary and secondary level health facilities, and also for routine consultation and follow-up. Tertiary facilities are designed to provide comprehensive management. In the absence of a social security system, the cost of medical consultation, investigation and treatment falls on the patients and their relatives.

2.1. Data sources
The register of the cardiovascular outpatient section of the service of Internal Medicine of YGH served as the primary source of data for this study. Patients followed for hypertension in this clinic, generally attend for a consultation at least twice a year. At each consultation, routine assessments include a risk factor survey, blood pressure, weight measurements and assessment of compliance to medications. Parameters are assessed by trained nurses. For each new patient, blood pressure is recorded twice, with measurements performed approximately 5-minutes apart. On follow-up visits only one blood pressure measurement is done. Blood pressure is recorded at rest, on the right arm and in a seated position. Once a year each patient undergoes a more comprehensive evaluation, which includes; ECG, assessment of kidney function, fasting blood glucose and serum electrolytes. Echocardiography and other investigations are performed depending on the clinical presentation of the patient. Records are kept in detail in the individual patient file and are also summarized in a collective register. For the purpose of this study, summary records of patients received and treated for hypertension between February 1995 and January 2005 were evaluated for evidence of heart failure. Clinical notes of those with heart failure were reviewed for additional details. These included age, sex, weight, height, average systolic and diastolic BP for the 3 last consultations attended, history of diabetes, tobacco consumption, echocardiographic parameters/diagnoses and concomitant diseases. Of the 1218 medical files of hypertensive patients registered during the study period, 151 adult patients were identified as presenting with clinical HF or asymptomatic left ventricular dysfunction and were considered for this study. Four patients with congenital heart disease were excluded. We also excluded three patients with valvular heart disease and four others with missing echocardiographic results. Complete data were available for the remaining 140 patients. This study received approval from the administrative authorities of the hospital.

2.2. Definitions and classifications
2.2.1. Hypertension and heart failure
Due to the long duration of the study, the criteria for diagnosis of hypertension and heart failure are likely to have changed over the study period. Hypertension was considered on the basis of a reported history of hypertension and/or the use of any blood pressure lowering medication. Patients with heart failure who were on an ACEI/AIIRB alone, needed to have a clear mention of hypertension in their diagnosis to be included in the study, since these medications could be prescribed for heart failure not-related to hypertension. A diagnosis of HF was based on the clinical records of the consultant cardiologist. For participants with a reported diagnosis of heart failure, clinical notes were surveyed for supporting evidence. Diagnosis of clinical HF was confirmed by the presence in the medical file of 2 major, or 1 major and 2 minor clinical criteria, provided they could not be attributed to other causes. Major criteria included paroxysmal nocturnal dyspnoea or orthopnoea, distended neck veins, crackles, radiographic cardiomegaly (defined by a cardiothoracic index above 0.55 on chest radiogram), pulmonary oedema, a third heart sound, increased venous pressure, hepatojugular reflux, and weight loss on diuretic therapy. Minor criteria were bilateral ankle oedema, night cough, dyspnoea on exertion, hepatomegaly, pleural effusion, pulmonary vascular redistribution and tachycardia.

During echocardiography studies in participants with HF, interventricular septal, LV posterior wall thickness and LV end-diastolic /systolic cavity dimension and ejection fraction were assessed following the recommendations of the American Society of Echocardiography. Left ventricular mass (LVM) was then calculated using the formula by Devereux [12] and left ventricular hypertrophy was defined as a body surface area indexed LVM >125 g/m2 (men) and >110 g/m2 (women). Systolic HF was diagnosed as an echocardiographic ejection fraction (EF) lower than 50% in patients with or without clinical symptoms or history of HF (asymptomatic left ventricular systolic dysfunction ASLVD) [13]. Diastolic heart failure was diagnosed in patients with unexplained clinical signs of HF and a preserved ejection fraction (EF >50%). Other echocardiographic features of diastolic heart failure included:

  • A mitral flow Doppler pattern of relaxation with E/A <0.5, an isovolumic relaxation time >105 ms and a deceleration time >280 ms.
  • Or a restrictive mitral flow Doppler pattern with E/A >2 and an isovolumic relaxation time ≤90 ms.

The prevalence of HF was defined as the number of subjects with HF divided by the total number of subjects on blood pressure lowering medication. The level of blood pressure control was assessed against the JNC 7 treatment goals [14] using the average blood pressure measurement from the last 3 visits within the study period. Patients were staged for HF using the New York Heart Association (NYHA) classification system. Due to the low number of patients in some classes we combined classes I and II and classes III and IV in the following analyses.

2.2.2. Renal dysfunction
Creatinine clearance was calculated using the Cockcroft and Gault formula. Kidney impairment was defined as a serum creatinine clearance value less than 60 ml/min. This calculation used the creatinine value available from the most recent annual assessment.

2.2.3. Other co-morbidities
Other co-morbidities were recorded from the diagnosis provided by the consultant cardiologist, clinical notes, paraclinical investigations, personal experience and arguments of probability.

2.3. Data analysis
Data analysis was performed using SPSS® statistical software version 9 for Windows. The level of significance was set at p<0.05. We have reported results as mean and standard error of the mean, percentages and proportions. Chi-square or Fischer exact test was used to compare categorical variables.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 Acknowledgments
 References
 
3.1. General characteristics of the study population
Of the 1218 patients treated for hypertension during the study period, 140 had chronic HF, giving an overall prevalence of 11.5%. This prevalence increased steadily from 7.2% in the first two years of the study, to 12.4% in the two last years. The distribution of participants with and without heart failure by 2-year intervals over the study period is depicted in Fig. 1. Participants with heart failure were relatively young (mean age 54.9 years) and were less likely to be women (Table 1). Medications regularly prescribed included diuretics (87.1%), ACE/AIIRB (68.6%), calcium channel blockers (48.6%), beta blockers (11.1%) and centrally acting blood pressure lowering drugs (4.1%). Mean BP was 164.7 mm Hg (systolic) and 98 mm Hg (diastolic) and patients were followed for an average of 6.9 years. At the last evaluation, 22.8% of patients had optimal blood pressure control according to the JNC 7 treatment goal. 44.2% of patients were in NYHA class III-IV and 50% had echocardiographic evidence of left ventricular hypertrophy (LVH). Systolic dysfunction was present in 64.2% of patients with 14.3% being ASLVD. Isolated diastolic dysfunction occurred in 22.8% of patients. There was no significant difference between men and women for most variables. However, a borderline p value (0.05) was observed for the distribution of isolated diastolic dysfunction, with a higher prevalence observed in women (Table 1). There was no significant difference in mean blood pressure levels and presence of renal dysfunction between those patients with systolic HF and those with diastolic HF.


Figure 01
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  		Fig. 1 Distribution of participants with hypertension and heart failure (HTHF) and those with hypertension without heart failure (HTNHF) by two year periods.

 


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  		Table 1 General characteristics and risk factors for the population with heart failure

 
3.2. Risk factors
There was no difference in the mean BMI between men and women, with an equal frequency of obesity in each sex group. In all, 11.4% of the participants were obese. Among the men, all smokers were current smokers (100%), while 60% of the women who reported smoking had stopped. The incidence of smoking was much higher among men (p=0.007). Dyslipidaemia was present in 14.9% of participants, with an equal distribution by sex.

3.3. Co-morbidities
The distribution of co-morbidities in our sample population is depicted in Fig. 2. At least one co-morbidity was present in 79 patients (56.4%), and 43 patients (30.7%) had multiple co-morbidities. The main co-morbidities recorded were: renal dysfunction (n=34, 24.3%), overweight and obesity (n=29, 20.7%), chronic obstructive pulmonary disease (n=24, 17.1%), gout (n=23, 16.4%), anaemia (n=22, 15.7%), diabetes mellitus (n=19, 13.5%), atrial fibrillation (n=18, 12.9%), stroke (n=13, 9.3%), gastritis (n=9, 6.4%) and ischaemic heart disease (n=8, 5.7%). No sex related difference was observed in the distribution of these co-morbidities.


Figure 02
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  		Fig. 2 Distribution (percentage) of risk factors and co-morbidities, overall and for men and women separately. (COPD: chronic obstructive pulmonary disease; IHD: ischaemic heart disease).

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
Acknowledgments
 References
 
There are few prevalence studies of HF and related co-morbidities in sub-Saharan Africa. In our selected population of patients with hypertension, we found a prevalence of HF of 11.5%. These patients were more likely to be younger, male and display an array of risk factors and co-morbidities. Men and women in this population had similar features, indicating the absence of any major sex related differences in the occurrence of HF among people treated for hypertension in this setting.

The importance of hypertension as a leading cause of heart failure in Africa has been suggested by a few previous studies [2,4,5]. However, data on the prevalence of HF and asymptomatic left ventricular dysfunction in patients with treated hypertension are still limited. The 11.5% prevalence of HF reported in our study is similar to the 10.5% found by Ayodele and co-workers in Nigeria [15], and this is likely to be an underestimate, given the non-systematic echocardiographic assessment of patients with hypertension in the study context. Elsewhere, over the past decade it has become apparent that in 20-30% of HF patients, systolic function is normal, while diastolic left ventricular dysfunction with impairment of filling and relaxation properties leads to overt clinical manifestations of HF, particularly in elderly patients with hypertension or ischaemic heart disease. Isolated diastolic dysfunction in our study was as frequent as described in a Caucasian population-based cohort [16], but higher than the 12.6% described by Oyati in Nigeria [17]. Differences in the echocardiographic criteria used for defining diastolic dysfunction may have accounted at least in part for this imbalance. Indeed, Oyati [17] used mitral flow Doppler pattern exclusively to define diastolic dysfunction. In Western countries, diastolic dysfunction is found in about one quarter of individuals with early stage LV hypertrophy and is characterized by abnormalities in LV relaxation and filling, diastolic distensibility and diastolic stiffness. With progression of the HF process, the heart dilates and systolic dysfunction develops [18]. Explanations for the relatively low frequency of diastolic dysfunction in Black Africans with hypertension as compared with western countries may include the late diagnosis of HF as well as a likely contribution of renal dysfunction via volume overload to the systolic dysfunction dilated hypertrophic pattern.

Renal dysfunction, defined as a serum creatinine clearance <60 ml/min, was present in a quarter of our hospital based population. This is a classical finding, and the complex association between HF and renal dysfunction has been reported elsewhere. In a European multicenter study of HF patients followed by primary care physicians, a lower prevalence (19%) of renal dysfunction was described [19]. However, in the selected CHARM population, renal dysfunction occurred in up to 43% of patients [20-22]. Reasons for the high frequency of renal dysfunction among our relatively young population deserve particular attention. Potential contributing factors include medication, low cardiac output, and the severe nature of hypertension among Blacks. Whatever the aetiological factors, several studies have demonstrated that renal dysfunction independently increases morbidity and mortality risk in patients with HF [23,24]. A number of studies support the association of diabetes mellitus with HF, with the reported prevalence varying from 23% in the SOLVD registry to 26% in the VALIANT trial and the EPICAL study [25-27]. In these studies, diabetes was shown to be an independent predictor of morbidity and mortality in HF. We found a much lower prevalence of diabetes in our HF population; however, our prevalence was similar to that described by Thiam [6] in a group of hospitalised HF patients in Senegal. Among the mechanisms linking diabetes to HF, the still controversial diabetic cardiomyopathy, as well as the role of co-morbidities such as hypertension and the increased propensity of people with diabetes to coronary artery disease are all important issues. Chronic obstructive pulmonary disease (COPD) is another important co-morbidity that merits investigation in patients with HF, both for diagnostic and therapeutic reasons. Indeed, the two conditions have overlapping clinical symptoms and some medications for HF such as beta-blockers can exacerbate COPD [28,29]. Although the co-occurrence of HF and COPD has so far received less attention, the available evidence suggests a high frequency of co-occurrence, with a 20 to 30% prevalence of chronic pulmonary disease in HF patients [29].

Atrial fibrillation was diagnosed in 13% of our young population, which is similar to that reported in a recent non-selective study of HF in a similar setting [5]. This prevalence is also in keeping with a reported 15% prevalence of AF from a large multicenter European study of HF in a much older population [30]. Common risk factors for AF include age, hypertension, valve disease, and myocardial infarction [31,32]. Since our subjects were relatively young, free from valve disease and with a lower prevalence of suspected ischaemic heart disease, our prevalence of AF should be regarded as being relatively high.

The present study has some limitations. These relate to the retrospective nature of the study, and the selected characteristics of the study population which are likely to favour subjects self-selected by symptoms from the total hypertension population and therefore provide non-precise estimates and limit the generalisability of the findings. These limitations however have to be considered in the context of the study setting, where major constraints to high quality clinical and epidemiological studies are commonplace, particularly in the field of non-communicable diseases. By choosing to conduct this study in this selected population at high risk for HF, we also increased our chances of generating enough evidence to backup the growing importance of chronic cardiovascular disease in this population, who are often believed to suffer only from infectious diseases.

Despite these shortcomings, the present study has relevance both for clinical and public health reasons. Given the high prevalence of hypertension and other risk factors of heart failure in the Cameroon population at large [33], the findings of our study are indicative of future increase in the incidence of major target organ damages like heart failure, kidney impairment and stroke. This will occur against a background of concurrent communicable diseases lead by HIV/AIDS, malaria and tuberculosis and will place a substantial burden on the already strained health resources. There is therefore an urgent need for multilevel preventive action through a coordinated national non-communicable diseases programme to reduce the incidence of hypertension and help prevent related complications. The training curriculum for health personnel should be expanded to include more components on prevention and management of chronic cardiovascular diseases. We also recommend setting-up of a clinical registry to monitor performance and improve clinical practice. Community studies are also needed to generate precise estimates of the prevalence of hypertension related co-morbidities in our population.


   Acknowledgments
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Acknowledgments
References
 
The authors thank Dr. Laurent Sebbag, MD, PhD, for his valuable comments on a previous draft of this manuscript. Also, we are indebted to all our colleagues who contributed in the follow up of these patients in our setting.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 Acknowledgments
 References
 

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