|Year : 2015 | Volume
| Issue : 1 | Page : 18-22
Comparison of spectrum of heart diseases between an Indian and a Nigerian tertiary centre: An echocardiographic study
Kelechukwu Uwanuruochi1, Ruchita Shah2, Okechukwu S Ogah3, Clement O Odigwe4
1 Department of Medicine, Federal Medical Centre, Umuahia, Nigeria
2 Department of Medicine, Madras Medical Mission, Chennai, Tamil Nadu, Nigeria
3 Department of Medicine, Division of Cardiology, University College Hospital, Ibadan, Oyo, Nigeria
4 Department of Medicine, Federal Medical Centre, Umuahia; Department of Medicine, Cardiology Unit, University of Calabar Teaching Hospital, Calabar, India
|Date of Web Publication||5-Jan-2015|
Department of Medicine, Federal Medical Centre, Umuahia, PMB 7001
Source of Support: None, Conflict of Interest: None
Background: Changing epidemiographic profile with increase in cardiovascular risk factors in developing nations is well documented. Our study sought to describe how this has affected the cardiovascular disease profile of patients reviewed by echocardiography in two hospitals, one in South-East Nigeria and the other in South-East India.
Objective: We compared the range of cardiovascular diagnoses encountered in a Nigerian hospital and an Indian hospital. The underlying objective was to document any difference in cardiovascular disease patterns between the two tertiary hospitals in different regions of the developing world.
Materials and Methods: This is a descriptive, retrospective study of echocardiographic records of the two hospitals: November 19, 2012 to September 20, 2013 for Federal Medical Centre (FMC), Umuahia, Nigeria and March 4, 2013 to April 30, 2013 for Madras Medical Mission (MMM), Chennai, India.
Results: In FMC, Umuahia, hypertensive heart disease was the only common echocardiographic abnormality. Valvular heart disease and cardiomyopathy were also frequently encountered. In the MMM, ischemic heart disease and valvular heart disease were common echocardiographic abnormalities. Echocardiographic diagnosis correlated significantly with gender in MMM.
Conclusions: The findings of this limited study underscore the need for the intensification of therapeutic measures and lifestyle modifications to reverse the trend in India as well as Blood pressure control and other strategies to avert the gathering cardiovascular storm in Nigeria.
Keywords: Heart diseases, Indian, Nigerian, spectrum
|How to cite this article:|
Uwanuruochi K, Shah R, Ogah OS, Odigwe CO. Comparison of spectrum of heart diseases between an Indian and a Nigerian tertiary centre: An echocardiographic study. Nig J Cardiol 2015;12:18-22
|How to cite this URL:|
Uwanuruochi K, Shah R, Ogah OS, Odigwe CO. Comparison of spectrum of heart diseases between an Indian and a Nigerian tertiary centre: An echocardiographic study. Nig J Cardiol [serial online] 2015 [cited 2021 Dec 4];12:18-22. Available from: https://www.nigjcardiol.org/text.asp?2015/12/1/18/148481
| Introduction|| |
The pattern of cardiovascular diseases in developing countries has generated a lot of interest in recent years. An upsurge of cardiovascular diseases in developing countries has been reported. , From 1990 to 2020, the rise in mortality due to ischemic heart disease (IHD) in developing countries (137% in men and 120% in women) is predicted to be much higher than that in the developed countries (48% in men and 29% in women)  whereas in some developed countries, the prevalence of IHD is actually on the decline.  It has been predicted that in the next few decades, IHD may become the leading non-communicable disease in most developing countries.  This supports on-going research in cardiovascular disease pattern.
A number of reports have documented increase in cardiovascular disease and risk factors in both sub-Saharan Africa and the Indian subcontinent, ,,, and studies have also compared cardio-vascular diseases in migrants from both regions living in the western world.  However, to the best of our knowledge, no report has made a direct comparison between patients native to these two parts of the developing world. We sought to document this by comparing patients reviewed by echocardiography in a Nigerian and an Indian hospital.
| Materials and methods|| |
This study is a descriptive and retrospective study of consecutive echocardiographic records obtained in the two hospitals between November 19, 2012 and September 20, 2013 for Federal Medical Centre, Umuahia and March 4, 2013 to April 30, 2013 for Madras Medical Mission, Chennai.
The underlying objective was to document any difference in cardiovascular disease patterns between the two tertiary hospitals in different regions of the developing world.
We reviewed the results of 314 consecutive echocardiographic results done at Madras Medical Mission, and compared the results with 318 consecutive echocardiographic results from Federal Medical Centre, Umuahia. The data of interest included age, sex, pulse, systolic blood pressure, diastolic blood pressure, aortic root diameter, left atrial diameter, left ventricular internal diameter, interventricular septal thickness, posterior wall thickness, ejection fraction, and echocardiographic diagnosis. The comparison was with respect to demographic characteristics and range of cardiovascular diagnoses. Hypertensive heart disease was diagnosed in the presence based on systemic hypertension or a history, coupled with symmetric hypertrophy of the left ventricle, and/or dilatation of the left ventricle. Presence of left atrial dilatation or diastolic dysfunction was also considered. 
Valvular heart diseases were diagnosed based on presence of any of the following:
- Mitral stenosis detected based on reduced mobility of leaflets, and diastolic turbulence on Colour Doppler,
- Aortic stenosis diagnosed from any of the following: Thickened and/or calcified leaflets, reduced cusp separation, mosaic pattern with color flow mapping, aortic jet velocity greater than 2.5 m/s, or aortic valve area less than 2 cm 2 by planimetry, and
- Mitral Regurgitation and aortic regurgitation diagnosed based on regurgitant jets.
Diagnosis of ischemic heart disease was based on presence of regional wall motion abnormalities, supplemented in some cases by finding of stenosis on coronary angiography.
Dilated cardiomyopathy was diagnosed based on dilatation and impaired contraction of the left ventricle or both ventricles in the absence of any underlying disease.  Pericardial effusion was diagnosed when there is echo free space between the visceral and parietal pericardium while Cor pulmonale was defined as present by the presence of pulmonary hypertension, and history or evidence of respiratory disease.  Data was obtained from the records of the Echocardiographic departments of the two hospitals.
Data obtained was analyzed using SpSS statistical software version 15 (SPSS, Inc. Chicago Illinois). Categorical data was compared using the Chi-square-test while continuous data will be compared using T-test. Probability levels of less than 0.05 were considered significant.
| Results|| |
[Table 1] depicts the basic characteristics of study population. Male-female disposition of patients was almost equal in FMC (52.7-47.3%) while it was preponderantly male in MMM (68.0-32.0%). The percentage of patients with hypertension was 40.6% for FMC but 38.8% for MMM (C2 = 0.159, P = 0.690) [Table 2]. Compares parameters between the two groups [Table 3]. Shows the frequency of echocardiographic diagnoses, also illustrated by the bar chart in [Figure 1]. The most common echocardiographic diagnosis in FMC was hypertensive heart disease (37.6%) while ischemic heart disease was most common in MMM (38.0%). Valvular heart disease was significantly more frequent in MMM (25.2%) as against in FMC (9.2%), while cardiomyopathies, pericardial disease, and CorPulmonale were more frequent in FMC. An equivalent percentage of patients had normal echocardiographic diagnosis (28.0% in FMC and 25.2% in MMM). The distribution of echocardiographic diagnoses was compared by gender in [Table 4]. The correlation of gender with diagnosis was highly significant in MMM but not significant in FMC.
|Figure 1: Bar chart showing prevalence (%) of echocardiographic abnormalities|
Click here to view
|Table 4: Distribution of echocardiographic diagnoses (%) compared across the genders|
Click here to view
| Discussion|| |
Only 3.1% were diagnosed with hypertensive heart disease in MMM, notwithstanding 38.8% having hypertension. The explanation is that many of the patients who had hypertension were diagnosed of ischemic heart disease, of which hypertension is a risk factor. Mandal et al.  in their study of an urban Indian population found that the prevalence of IHD increases with the increase in blood pressure (P < 0.01). In their study, the highest prevalence of IHD was found among the severe hypertensive population (26.7%) and the lowest prevalence was found in those patients with normal blood pressure (3.3%).
The prevalence of ischemic heart diseases were much higher in MMM. The prevalence of ischemic heart disease has been reported by various authors to be high in the Indian subcontinent. ,, This has followed decline in both infectious disease mortality and childhood deaths from perinatal causes. On the other hand, increased smoking and increases in sedentary living, high fat dieting, weight gain, and rates of diabetes, hypertension, and dyslipidemia are all attributable to increasing rates of urbanization in India with major changes in lifestyle patterns (epidemiologic transition).  The World Health Organization database puts the overall prevalence of current smoking in India (as at 2011) as 15% (25% in males and 4% in females) compared to overall prevalence of 6% (10% in males and 2% in females) in Nigeria.  On the other hand, the same database reports 21.1% overall prevalence of hypertension in India (as at 2008) compared to 34.8% overall prevalence in Nigeria. These factors also contribute to the varying prevalence of ischemic heart disease and hypertensive heart disease in our study. It must also be noted that urbanization has been especially rapid in Chennai, where MMM is located.
The prevalence of type 2 Diabetes mellitus is high particularly in Asian Indians, and this has been attributed to a high genetic susceptibility with high fat diet and lower levels of physical activity being common factors environmental triggers.  All these suggest that guided urbanization should be implemented if sub-Saharan Africa is to escape its own cardiovascular epidemic in the future. Strategies in this regard would include urban planning policies to create environments conducive to physical activity, education (mass and targeted), advocacy of healthy diets, and national food policies to encourage rural communities to retain self-sufficiency in the production, and local consumption of fresh fruits and vegetables. It also includes international co-operation to tackle the threat of tobacco and share expertise in cardiovascular disease prevention. ,
There was a high prevalence of valvular heart disease in MMM compared to FMC. The reason for this is that MMM is renowned internationally as a specialist centre for quarternary-level cardiac care. It receives patients referred from all India and abroad. Patients needing cardiac surgery are frequently referred to it. This also explains the relatively high volume of cardiac patients in MMM-the number of patients who had echocardiography in two months-compared to those seen in one year at FMC. The higher prevalence of cardiomyopathy in FMC can be explained because cases of ischemic cardiomyopathy in MMM were placed under heading of ischemic heart disease.
The gender distribution was preponderantly male in MMM, unlike in FMC where the distribution was roughly even. It has been observed that women have less access to medical care in the Indian society due to social and cultural norms. 
Analysis showed that gender was significantly associated with echocardiographic diagnoses in MMM but not in FMC. The reasons for this are not far-fetched. IHD, which was much more prevalent in MMM, has been reported to be associated with male gender, both in India and in other parts of the world. ,, The greater predisposition of males to cardiovascular illnesses has been attributed to the protective antioxidant effect of the estrogen hormone in women. 
The mean age of patients with normal echocardiograms was significantly lower in FMC. The percentage of subjects aged below 30 years was 21.5% of subjects in FMC compared to 5.2% in MMM. The higher mean age higher for cardiomyopathy and congenital heart disease in MMM suggest greater longevity for patients in a hospital with improved cardiac care, including cardiac surgery and resynchronization therapies, which are not rendered at FMC as at the time of this study.
| Conclusion|| |
Overall, there exists a difference in spectrum of cardiovascular disease between MMM and FMC, and gender correlated significantly with echocardiographic diagnoses in MMM. These differences are attributable to genetic, lifestyle, and sociocultural differences. This is the time for attention to balanced socioeconomic progress, to study modifiable mechanisms that impinge on smoking habit, physical exercise, and dietary habit, and to intensify therapeutic measures. These would help prevent the looming epidemic on one hand and reduce the high prevalence of ischemic heart disease on the other.
| Limitations|| |
It was difficult comparing the datasets, as they were not originally designed for such comparison, and the data collected did not contain all the required information. This explains why the country of origin was not indicated. The study was retrospective, and patients were seen over one year at FMC but over two months at MMM.
| Appreciation|| |
The Medical Director of Federal Medical Centre Umuahia, Dr. Abali Chuku and the Staff of the Electrophysiology clinical research office of Madras Medical Mission.
| References|| |
Srinath RK, Yusuf S. Emerging epidemic of cardiovascular disease in developing countries. Circulation 1998;97:596-601.
Celermajer DS, Chow CK, Marijon E, Anstey NM, Woo KS. Cardiovascular disease in the developing world: Prevalences, patterns, and the potential of early disease detection. J Am Coll Cardiol 2012;60:1207-16.
Kazim SF, Itrat A, Butt NW, Ishaq M. Comparision of cardiovascular disease patterns in two data sets of patients admitted at a tertiary care public hospital in karachi five years apart. Pak J Med Sci 2009;25:55-60.
Unal B, Critchley JA, Capewell S. Explaining the decline in coronary heart disease mortality in England and Wales Between 1981 and 2000. Circulation 2004;109:1101-7.
Manton KG. The global impact of noncommunicable diseases: Estimates and projections. World Health Stat Q 1988;41:255-66.
Ejim EC, Okafor CI, Emehel A, Mbah AU, Onyia U, Egwuonwu T, et al
. Prevalence of cardiovascular risk factors in the middle-aged and elderly population of a nigerian rural community. J Trop Med 2011;2011:308687.
Uwanuruochi K, Ukpabi OJ, Onwuta CN, Onwubere BJ, Anisiuba BC, Michael FS. Cardiovascular risk factors in adult staff of federal medical centre, Umuahia: A Comparison with other Nigerian Studies. West Afr J Med 2013;32:243-7.
Mukadas AO, Misbau U. Incidence and patterns of cardiovascular disease in north western Nigeria. Niger Med J 2009;50:55-7.
Ike SO, Arodiwe EB, Onoka CA. Profile of cardiovascular risk factors among priests in a Nigerian rural community. Niger Med J 2007;48:79-84.
Chaturvedi N. Ethnic differences in cardiovascular disease. Heart 2003;89:681-6.
Toshima H, Koga Y, Yoshioka H, Akiyoshi T, Kimura N. Echocardiographic classification of hypertensive heart disease. A correlative study with clinical features. Jpn Heart J 1975;16:377-93.
Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of Cardiomyopathies Circulation 1996;93:841-2.
Weitzenblum E, Chaouat A. Cor pulmonale. Chron Respir Dis 2009;6;177-85.
Mandal S, Saha JB, Mandal SC, Bhattacharya RN, Chakraborty M, Pal PP. Prevalence of ischemic heart disease among urban population of Siliguri, West Bengal. Indian J Community Med 2009;34:19-23.
Sarvotham SG, Berry JN. Prevalence of coronary heart disease in an urban population in northern India. Circulation 1968;37:939-53.
Gupta R, Guptha S, Sharma KK, Gupta A, Deedwania P. Regional variations in cardiovascular risk factors in India: India heart watch. World J Cardiol 2012;4:112-20.
Yusuf S, Ôunpuu S. Tackling the growing epidemic of cardiovascular disease in South Asia. J Am Coll Cardiol 2001;38:688-9.
Ramachandran A, Snehalatha C, Shetty AS, Nanditha A. Trends in prevalence of diabetes in Asian countries. World J Diabetes 2012;3:110-7.
Reddy KS. Cardiovascular diseases in the developing countries: Dimensions, determinants, dynamics and directions for public health action. Public Health Nutr 2002;5:231-7.
Mensah GA. Ischaemic heart disease in Africa. Heart 2008;94:836-43.
Ramakrishnan S, Khera R, Jain S, Saxena A, Kailash S, Karthikeyan G, et al
. Gender differences in the utilisation of surgery for congenital heart disease in India. Heart 2011;97:1920-5.
Pranavchand R, Reddy BM. Current status of understanding of the genetic etiology of coronary heart disease. J Postgrad Med 2013;59:30-41
[Table 1], [Table 2], [Table 3], [Table 4]