M.B. Ndiaye

Pregnancy in women with heart disease in sub-Saharan Africa

BACKGROUND Although previous studies showed that pregnancy with heart disease is associated with significant complications, few focused on patients with valvular heart disease in sub-Saharan Africa. METHODS We report maternal and foetal outcomes in 50 pregnant women with heart disease admitted to the Department of Cardiology of the University of Dakar, during an 8-year period. RESULTS Rheumatic heart disease was observed in 46 women, seven of whom had previously been operated on. Among the remaining 39, 32 had mitral stenosis (isolated or associated with other valvular lesions). At admission, 36 women presented with pulmonary oedema, two with pulmonary embolism and 18 with arrhythmia. There were 17 maternal deaths (34%). Maternal death was associated with: mitral stenosis (P=0.03); severe tricuspid regurgitation (P=0.001); New York Heart Association functional class III or IV (P=0.001); symptoms of heart failure (P<0.001). A favourable maternal outcome was associated with: prior cardiac events (P<0.001); prior surgical valve replacement (P=0.03); cardiac prosthetic valve (P=0.03). There were 30 live births, six foetal deaths and five therapeutic abortions; nine women were lost to follow-up. Delivery was vaginal in 19 out of 30 cases and by caesarean section in 11 cases. Median gestational age at delivery was 28weeks (range, 8-38weeks). Five births occurred preterm. There were four stillbirths (neonatal mortality, 7.6%). CONCLUSIONS Heart disease severely impacts maternal and foetal outcome in our study. Pregnant women who underwent appropriate valve replacement before pregnancy had a better prognosis.

Prevalence and determinants of hypertension and associated cardiovascular risk factors: data from a population-based, cross-sectional survey in Saint Louis, Senegal.

Background The incidence of cardiovascular disease is growing worldwide and this is of major public health concern. In sub-Saharan Africa, there is a lack of epidemiological data on the prevalence and distribution of risk factors of cardiovascular disease. This study aimed at assessing the prevalence of hypertension and other cardiovascular risk factors among an urban Senegalese population. Methods Using an adaptation of the WHO STEPwise approach to chronic disease risk-factor surveillance, we conducted a population-based, cross-sectional survey from 3 to 30 May 2010 on 1 424 participants aged over 15 years. Socio-demographic and behavioural risk factors were collected in step 1. Physical anthropometric measurements and blood pressure were documented in step 2. Blood tests (cholesterol, fasting blood glucose, and creatinine levels) were carried out in step 3. Results The prevalence of hypertension was 46% (95% CI: 43.4–48%), with a higher prevalence in females (47.9%) than males (41.7%) (p = 0.015), and 50% of these hypertensive were previously undiagnosed. Mean age was 53.6 years (SD: 15.8). In known cases of hypertension, the average length of its evolution was 6 years 9 months (range 1 month to 60 years). Hypertension was significantly associated with age (p = 0.001), socio-professional category (p = 0.003), dyslipidaemia (p < 0.001), obesity (p < 0.001), physical inactivity (p < 0.001), diabetes (p < 0.001) and stroke (p < 0.001). Conclusion We found a high prevalence of hypertension and other cardiovascular risk factors in this population. There is need of a specific programme for the management and prevention of cardiovascular disease in this population.

Évolution et complications thromboemboliques de la myocardiopathie idiopathique du péripartum au CHU de Dakar : étude prospective à propos de 33 cas

UNLABELLED The aims of this work are to study the nursery futures during idiopathic myocardiopathy of peripartum (IMPP), to measure the prevalence of thromboses and spontaneous contrast during the IMPP and to determine their evolution. METHODOLOGY It is about a longitudinal exploratory study carried out with the Aristide-Le-Dantec teaching hospital of Dakar, beginning January 2001 to November 2004, having included 33 patients. RESULTS The average age of the patients was 26 years; the average pregnancy was of 3.39 gestures. The signs of cardiac insufficiency were constant and four patients (12%) had presented an ischemic cerebral vascular accident. We had raised an auricular case of fibrillation and tachycardia atrial multifocal. The transthoracic echography (ETT) noted an aspect of hypokinetic myocardiopathy dilated with deterioration of the systolic function of the left ventricle, a thrombus in ten patients (30.3%) and a spontaneous contrast in two cases (6%). The transoesophageal echocardiography (ETO) was superposable with the ETT with regard to dimensions of the cardiac cavities and the presence of thrombus but its sensitivity was higher (100% against 66%) with regard to the detection of contrasts spontaneous. All the patients had the treatment of a congestive heart failure associated to an anticoagulant treatment. The evolution was marked by an improvement of the heart failure. The thrombus and spontaneous contrast had disappeared in all the patients. The absence of anaemia and the presence of spontaneous contrast (p=0.003) were correlated with the presence of thrombosis (p=0.05). CONCLUSION The idiopathic myocardiopathy of the peripartum is a relatively frequent affection in zone Soudano-Sahelian. Occurrence of thromboses is frequent at the time of this affection. Our study confirms the superiority of the echocardiography transoesophageal in the detection of intracardiac spontaneous contrast. The evolution can be favourable subject to a rigorous care and a regular surveillance.

Vascular complications of infective endocarditis

UNLABELLED The complications of infective endocarditis (IE) are frequent and severe. Our objectives were to analyze the clinical, paraclinical, and prognostic features of IE vascular complications observed in two cardiology units, in Dakar. PATIENTS AND METHODS We retrospectively studied 90 patients presenting with of IE, hospitalized between January 2005 and February 2011. The diagnostic criteria for IE were modified Duke University criteria. We selected in our study population, patients with vascular complications. RESULTS Seventeen patients (18.8%) presented with one or more vascular complications of IE: eight male and nine female patients, with a mean age of 28 years. Infective endocarditis occurred on an abnormal valve in 15 cases. We identified 22 vascular lesions: ten neurological complications, seven arterial complications in the limbs, two myocardial infarctions, two cases of pulmonary embolism, and one splenic infarction. The vascular complication revealed an IE in seven cases. The vascular complication occurred during antibiotic treatment, in 15 cases including seven cases before the 14th day, nine of the 17 patients died. Death was related to vascular complications in six cases, in one case it was related to septic shock. CONCLUSION Vascular complications of IE are frequent, the most common are neurological. Their prevention requires early and adequate management of IE.

Rationale and design of the Newer Versus Older Antihypertensive Agents in African Hypertensive Patients (NOAAH) trial

Abstract Background. Sub-Saharan Africa experiences an epidemic surge in hypertension. Studies in African Americans led to the recommendation to initiate antihypertensive treatment in Blacks with a diuretic or a low-dose fixed combination including a diuretic. We mounted the Newer versus Older Antihypertensive Agents in African Hypertensive Patients (NOAAH) trial to compare in native African patients a fixed combination of newer drugs, not involving a diuretic, with a combination of older drugs including a diuretic. Methods. Patients aged 30–69 years with uncomplicated hypertension (140–179/90–109 mmHg) and two or fewer associated risk factors are eligible. After a 4-week run-in period off treatment, 180 patients will be randomized to once daily bisoprolol/hydrochlorothiazide 5/6.25 mg or amlodipine/valsartan 5/160 mg. To attain and maintain blood pressure below 140/90 mmHg during 6 months of follow-up, the doses of bisoprolol and amlodipine in the combination tablets will be increased to 10 mg/day with the possible addition of α-methyldopa or hydralazine. NOAAH is powered to demonstrate a 5-mmHg between-group difference in sitting systolic pressure with a two-sided p-value of 0.01 and 90% power. NOAAH is investigator-led and complies with the Helsinki declaration. Results. Six centers in four sub-Saharan countries started patient recruitment on September 1, 2010. On December 1, 195 patients were screened, 171 were enrolled, and 51 were randomized and followed up. The trial will be completed in the third quarter of 2011. Conclusions. NOAAH (NCT01030458) is the first randomized multicenter trial of antihypertensive medications in hypertensive patients born and living in sub-Saharan Africa.

A cross-sectional evaluation of venous thromboembolism risk and use of venous thromboembolism prophylaxis in hospitalized patients in Senegal

BACKGROUND Venous thromboembolism is a common and preventable cause of morbidity and mortality in hospitalized patients. There is a lack of data on the distribution of risk factors and prophylaxis practices in sub-Saharan Africa. AIM To assess the prevalence of venous thromboembolism risk in hospitalized patients and to determine the proportion of at-risk patients who receive prophylaxis. METHODS The study was a cross-sectional hospital-based survey. On the basis of the global ENDORSE methodology, patients aged≥40 years admitted to a medical ward or those aged≥18 years admitted to a surgical ward were assessed for risk of venous thromboembolism by hospital chart review. Distribution of risk factors and coverage of prophylaxis in at-risk patients were determined using the 2004 American College of Chest Physicians evidence-based consensus guidelines. RESULTS From October to November 2008, 520 patients (278 medical; 242 surgical) were enrolled in 12 hospitals across Senegal. Two hundred and ninety-eight (57%) were at risk of venous thromboembolism; 152 (57.4%) medical patients and 146 (60.3%) surgical patients. Among those at risk, 48 (31.6%) medical patients and 52 (35.6%) surgical patients received a prescription for prophylaxis. Among patients without contraindication to anticoagulants, 33.8% (46/136) on medical wards and 37.5% (48/128) on surgical wards received prophylaxis. CONCLUSION The risk of venous thromboembolism was frequent in hospitalized patients in Senegal but only a few received the recommended prophylaxis. There is a need to implement a programme to improve venous thromboembolism awareness and prophylaxis.

Progress report on the first sub-Saharan Africa trial of newer versus older antihypertensive drugs in native black patients

BackgroundThe epidemic surge in hypertension in sub-Saharan Africa is not matched by clinical trials of antihypertensive agents in Black patients recruited in this area of the world. We mounted the Newer versus Older Antihypertensive agents in African Hypertensive patients (NOAAH) trial to compare, in native African patients, a single-pill combination of newer drugs, not involving a diuretic, with a combination of older drugs including a diuretic.MethodsPatients aged 30 to 69 years with uncomplicated hypertension (140 to 179/90 to 109 mmHg) and ≤2 associated risk factors are eligible. After a four week run-in period off treatment, 180 patients have to be randomized to once daily bisoprolol/hydrochlorothiazide 5/6.25 mg (R) or amlodipine/valsartan 5/160 mg (E). To attain blood pressure <140/<90 mmHg during six months, the doses of bisoprolol and amlodipine should be increased to 10 mg/day with the possible addition of up to 2 g/day α-methyldopa.ResultsAt the time of writing of this progress report, of 206 patients enrolled in the run-in period, 140 had been randomized. At randomization, the R and E groups were similar (P ≥ 0.11) with respect to mean age (50.7 years), body mass index (28.2 kg/m2), blood pressure (153.9/91.5 mmHg) and the proportions of women (53.6%) and treatment naïve patients (72.7%). After randomization, in the R and E groups combined, blood pressure dropped by 18.2/10.1 mmHg, 19.4/11.2 mmHg, 22.4/12.2 mmHg and 25.8/15.2 mmHg at weeks two (n = 122), four (n = 109), eight (n = 57), and 12 (n = 49), respectively. The control rate was >65% already at two weeks. At 12 weeks, 12 patients (24.5%) had progressed to the higher dose of R or E and/or had α-methyldopa added. Cohort analyses of 49 patients up to 12 weeks were confirmatory. Only two patients dropped out of the study.ConclusionsNOAAH (NCT01030458) demonstrated that blood pressure control can be achieved fast in Black patients born and living in Africa with a simple regimen consisting of a single-pill combination of two antihypertensive agents. NOAAH proves that randomized clinical trials of cardiovascular drugs in the indigenous populations of sub-Saharan Africa are feasible.

Efficacy of newer versus older antihypertensive drugs in black patients living in sub-Saharan Africa

To address the epidemic of hypertension in blacks born and living in sub-Saharan Africa, we compared in a randomised clinical trial (NCT01030458) single-pill combinations of old and new antihypertensive drugs in patients (30–69 years) with uncomplicated hypertension (140–179/90–109 mm Hg). After ⩾4 weeks off treatment, 183 of 294 screened patients were assigned to once daily bisoprolol/hydrochlorothiazide 5/6.25 mg (n=89; R) or amlodipine/valsartan 5/160 mg (n=94; E) and followed up for 6 months. To control blood pressure (<140/<90 mm Hg), bisoprolol and amlodipine could be doubled (10 mg per day) and α-methyldopa (0.5–2 g per day) added. Sitting blood pressure fell by 19.5/12.0 mm Hg in R patients and by 24.8/13.2 mm Hg in E patients and heart rate decreased by 9.7 beats per minute in R patients with no change in E patients (–0.2 beats per minute). The between-group differences (R minus E) were 5.2 mm Hg (P<0.0001) systolic, 1.3 mm Hg (P=0.12) diastolic, and 9.6 beats per minute (P<0.0001). In 57 R and 67 E patients with data available at all visits, these estimates were 5.5 mm Hg (P<0.0001) systolic, 1.8 mm Hg (P=0.07) diastolic and 9.8 beats per minute (P<0.0001). In R compared with E patients, 45 vs 37% (P=0.13) proceeded to the higher dose of randomised treatment and 33 vs 9% (P<0.0001) had α-methyldopa added. There were no between-group differences in symptoms except for ankle oedema in E patients (P=0.012). In conclusion, new compared with old drugs lowered systolic blood pressure more and therefore controlled hypertension better in native African black patients.

Infections secondary to pacemaker implantation : a synopsis of six cases : case report - online article

INTRODUCTION Permanent cardiac pacing is a technique whose indications have increased in the last 20 years. As with any foreign body, pacemaker implantation is associated with the risk of infection. The objective of this study was to describe the clinical, paraclinical and treatment options of infections secondary to pacemaker implantation at the Cardiology Department of the Aristide le Dantec Teaching Hospital (CHU Aristide le Dantec) in Dakar, Senegal. METHODS We conducted a retrospective study over a period of three years (from January 2005 to December 2007) during which pacemaker implantation was carried out in 107 patients. All patients with local and/or systemic signs of infection were included in our study. RESULTS The prevalence of infection in patients with pacemakers was 5.6% in our series and infection occurred in three women and three men, with a mean age of 66.2 years (range 23-83). The delay time for the onset of clinical signs of infection was 6.6 months, with a range of eight days to 12 months. The clinical signs were externalisation of the pacemaker with suppuration (five cases), fever (one case) and inflammatory signs (one case). Factors favouring the occurrence of infection were co-morbidity (four cases), pre-operative length of stay (average eight days), use of temporary cardiac pacing (three cases), the number of people in the theatre (average 4.5), postoperative haematoma (one case) and repeating the surgical procedure (three cases). Staphylococcus epidermidis (two cases), Staphylococcus aureus (two cases) and Klebsiella pneumonia (one case) were the organisms isolated at the local site. Transthoracic echocardiography showed no objective signs of endocarditis. The treatment was antibiotic therapy for an average duration of 50.4 days after debridement of the infected site (six cases). We noted four recurrences at six months and one death from sepsis at 12 months. CONCLUSION Infections secondary to pacemaker implantation are rare but serious. Their management is difficult and requires the removal of the implanted material, hence the importance of prevention of infection, or the removal and re-implantation of the pacemaker at another site in cases of infection. This is particularly important in our region where pacemakers are very expensive.

[Meningoencephalitis due to Morganella morganii: a case report].

A central nervous system infection due to Morganella morganii is uncommon. We report a case diagnosed at the neurological department of Fann teaching hospital in Dakar, Senegal. A 12-year-old boy was hospitalized for acute meningoencephalitis. The CT scan was normal and the study of cerebrospinal fluid (CSF) revealed cytological and biochemical abnormalities and M. morganii. HIV and syphilitic serologies were negative and blood CD4 lymphocyte count showed 354 per mm(3). The treatment with cefotaxime associated with gentamicin for 6 weeks was successful. The outcome of infection depends on many factors such as the onset and quality of treatment, the virulence of the germ and the status of immune system.