Amam Mbakwem

Clinical characteristics of patients from the worldwide registry on peripartum cardiomyopathy (PPCM)

The purpose of this study is to describe disease presentation, co‐morbidities, diagnosis and initial therapeutic management of patients with peripartum cardiomyopathy (PPCM) living in countries belonging to the European Society of Cardiology (ESC) vs. non‐ESC countries.

Rationale and design of the Pan African Pulmonary hypertension Cohort (PAPUCO) study: implementing a contemporary registry on pulmonary hypertension in Africa

Introduction Pulmonary hypertension (PH) is a devastating, progressive disease with increasingly debilitating symptoms and usually shortened overall life expectancy due to a narrowing of the pulmonary vasculature and consecutive right heart failure. Little is known about PH in Africa, but limited reports suggest that PH is more prevalent in Africa compared with developed countries due to the high prevalence of risk factors in the region. Methods and analysis A multinational multicentre registry-type cohort study was established and tailored to resource-constraint settings to describe disease presentation, disease severity and aetiologies of PH, comorbidities, diagnostic and therapeutic management, and the natural course of PH in Africa. PH will be diagnosed by specialist cardiologists using echocardiography (right ventricular systolic pressure >35 mm Hg, absence of pulmonary stenosis and acute right heart failure), usually accompanied by shortness of breath, fatigue, peripheral oedema and other cardiovascular symptoms, ECG and chest X-ray changes in keeping with PH as per guidelines (European Society of Cardiology and European Respiratory Society (ESC/ERS) guidelines). Additional investigations such as a CT scan, a ventilation/perfusion scan or right heart catheterisation will be performed at the discretion of the treating physician. Functional tests include a 6 min walk test and the Karnofsky Performance Score. The WHO classification system for PH will be applied to describe the different aetiologies of PH. Several substudies have been implemented within the registry to investigate specific types of PH and their outcome at up to 24 months. Data will be analysed by an independent institution following a data analyse plan. Ethics and dissemination All local ethics committees of the participating centres approved the protocol. The data will be disseminated through peer-reviewed journals at national and international conferences and public events at local care providers.

Heart and brain interaction in patients with heart failure: overview and proposal for a taxonomy. A position paper from the Study Group on Heart and Brain Interaction of the Heart Failure Association

Heart failure (HF) is a complex clinical syndrome with multiple interactions between the failing myocardium and cerebral (dys‐)functions. Bi‐directional feedback interactions between the heart and the brain are inherent in the pathophysiology of HF: (i) the impaired cardiac function affects cerebral structure and functional capacity, and (ii) neuronal signals impact on the cardiovascular continuum. These interactions contribute to the symptomatic presentation of HF patients and affect many co‐morbidities of HF. Moreover, neuro‐cardiac feedback signals significantly promote aggravation and further progression of HF and are causal in the poor prognosis of HF. The diversity and complexity of heart and brain interactions make it difficult to develop a comprehensive overview. In this paper a systematic approach is proposed to develop a comprehensive atlas of related conditions, signals and disease mechanisms of the interactions between the heart and the brain in HF. The proposed taxonomy is based on pathophysiological principles. Impaired perfusion of the brain may represent one major category, with acute (cardio‐embolic) or chronic (haemodynamic failure) low perfusion being sub‐categories with mostly different consequences (i.e. ischaemic stroke or cognitive impairment, respectively). Further categories include impairment of higher cortical function (mood, cognition), of brain stem function (sympathetic over‐activation, neuro‐cardiac reflexes). Treatment‐related interactions could be categorized as medical, interventional and device‐related interactions. Also interactions due to specific diseases are categorized. A methodical approach to categorize the interdependency of heart and brain may help to integrate individual research areas into an overall picture.

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%) (χ2 = 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% (χ2 = 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.

Comparative study of depression in hospitalized and stable heart failure patients in an urban Nigerian teaching hospital

OBJECTIVE There are conflicting reports about the presence of depression in Black patients with heart failure (HF). We therefore evaluated the pattern of depression among hospitalized and stable HF patients in a homogenous Black population. METHOD Patients hospitalized for new or decompensated HF were assessed. The Zung Self-Rating Depression Scale (SDS) questionnaire was administered to the subjects who were subsequently interviewed by a psychiatrist using the Hamilton Depression Rating Scale (HDRS). Stable HF patients at the outpatient clinic were used as controls. RESULTS There were 123 hospitalized and 82 stable outpatients. Depression was present in 67% of hospitalized patients and 30.50% of the outpatients (P<.0001, using the SDS indexed scores). Stratifying the SDS indexed scores showed that 45.50%, 19.60% and 1.80% of the hospitalized patients compared with 26.80%, 3.70% and 0% of the outpatients had mild, moderate and severe depression (P=.007 and P=.001), respectively. The HDRS assessment showed that 63.40% of the hospitalized patients and 28.0% of the stable outpatients had significant depression (P<.0001). CONCLUSION Depression affects two thirds of hospitalized urban Nigerian HF patients compared to one third of stable outpatients with HF. The prevalence of depression is similar to the prevalence among European and North American samples.

Prospective assessment of the risk of obstructive sleep apnea in patients attending a tertiary health facility in Sub-Saharan Africa

Introduction The impact of Obstructive sleep apnea (OSA) in worsening outcomes is profound, especially in the presence of comorbid conditions. This study aimed to describe the proportion of patients at a high risk of OSA in our practice setting. Methods The STOP BANG questionnaire and the Epworth Sleepiness scale were used to assess for OSA risk and excessive daytime sleepiness respectively. Hospitalized patients and out-patients were recruited. Intergroup differences in continuous variables were compared using the analysis of variance. The proportion of patients with high risk of OSA and excessive daytime sleepiness was presented as frequencies and group differences compared with the Pearson χ2 test. Independent risk predictors for OSA were assessed in multivariate logistic regression analysis. Results A total of 1100 patients (53.4% females) participated in the study. Three hundred and ninety nine (36.3%) had a high risk of OSA, and 268 (24.4%) had excessive daytime sleepiness. Of the participants with high OSA risk, 138 (34.6%) had excessive daytime sleepiness compared to 130 (18.5%) of those with low OSA risk (p). Conclusion A significant proportion of patients attending our tertiary care center are at high risk of OSA.

Long-term prognosis, subsequent pregnancy, contraception and overall management of peripartum cardiomyopathy: practical guidance paper from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy: Long-term prognosis and management of PPCM

Peripartum cardiomyopathy is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause for heart failure is identified. Outcome varies from full recovery to residual left ventricular systolic dysfunction and even death. Many women return to their physician to acquire information on their long‐term prognosis, to seek medical advice regarding contraception, or when planning a subsequent pregnancy. This position paper summarizes current evidence for long‐term outcome, risk stratification of further pregnancies and overall management. Based on the best available evidence, as well as the clinical experience of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy members, a consensus on pre‐ and postpartum management algorithms for women undergoing a subsequent pregnancy is presented.

Depression in Patients with Heart Failure: Is Enough Being Done?

Depression is a major issue in heart failure (HF). Depression is present in about one in five HF patients, with about 48 % of these individuals having significant depression. There is a wide variation in reported prevalences because of differences in the cohorts studied and methodologies. There are shared pathophysiological mechanisms between HF and depression. The adverse effects of depression on the outcomes in HF include reduced quality of life, reduced healthcare use, rehospitalisation and increased mortality. Results from metaanalysis suggest a twofold increase in mortality in HF patients with compared to those without depression. Pharmacological management of depression in HF has not been shown to improve major outcomes. No demonstrable benefits over cognitive behavioural therapy and psychotherapy have been demonstrated.

Hypertrophic Cardiomyopathy in South Western Nigeria

AIMS: To evaluate the prevalence of hypertrophic cardiomyopathy (HCM) and its characteristics (clinical, electrocardiographic and echocardiographic) in a hospital population presenting for echocardiography at the Lagos University Teaching Hospital (LUTH). MATERIALS AND METHOD: The echocardiographic records of patients over a two year period (1998-2000) were reviewed. Patients with a diagnosis of HCM were re-evaluated and included if they had a hypertrophied non-dilated left ventricle with maximal interventricular septum thickness ≥ 15mm and interventricular/posterior wall ratio >1.3 in the absence of any known cause of hypertrophy. RESULT: Fourteen (2%) of the 712 patients examined had hypertrophic cardiomyopathy with a male preponderance (M/F 3.7:1) and mean age of 43.14±15.00yrs. The commonest symptoms were chest pain and palpitations in about 50% of the subjects. Giant T wave inversion was present on the electrocardiogram of 42.9% of the subjects. The mean interventricular septum was 23.25±7.86mm (range 16 - 36mm) and the mean posterior wall thickness was 13.66±7.86mm (range 8.3 – 20mm). CONCLUSION: Hypertrophic cardiomyopathy occurs in about 2% of our population referred for echocardiographic examination. Hypertrophic cardiomyopathy should be considered in young males presenting with chest pain in Nigeria.

Echocardiographic abnormalities and disease severity (based on CD4 count) in treatment-naive HIV positive patients

Purpose: Human immunodeficiency virus (HIV) infection may be associated with cardiac abnormalities. These abnormalities appear to be more frequent with disease progression. This study sought to examine the relationship between HIV disease severity in treatment-naive patients and cardiac abnormalities identified by echocardiography. Material and methods: 100 HIV-positive, treatment-naive patients, comprising 53 patients with CD4 count < 200/μl (AIDS group) and 47 patients with CD4 count ≥ 200/μl (non-AIDS group) without any traditional risk factors for cardiac disease were recruited for the study. Both groups had clinical and echocardiographic evaluation for cardiac abnormalities. Results: Of the 53 patients in the AIDS group, 11.5% had dilated cardiomyopathy (DCM), compared with none in the non-AIDS group (p = 0.018). Systolic dysfunction was higher in the AIDS group when compared with the non-AIDS group (42.3% and 17.0%, respectively; p = 0.006). Also, those in the AIDS had a significantly higher left ventricular end diastolic diameter index when compared with the non-AIDS group (2.87 ± 0.37 and 2.67 ± 0.29, respectively; p = 0.004). Furthermore, moderate to severe pericardial effusion was more frequent in the AIDS group, when compared with non-AIDS group (15.38% and 2.12%, respectively; p = 0.045). Diastolic dysfunction was also more frequent in AIDS group, although this did not achieve statistical significance (34.64% and 29.78%, respectively; p = 0.61). Conclusion: Cardiac abnormalities are more frequent with disease progression in HIV infected patients. Patients with more advanced disease (CD4 < 200/μl) had significantly more frequent systolic dysfunction, DCM, larger left ventricular dimension, and moderate to severe pericardial effusion than those with CD4 ≥ 200/μl. HIV AIDS Rev 2017; 16, 3: 169-175 DOI: https://doi.org/10.5114/hivar.2017.70945