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Contemporary Profile of Acute Heart Failure
in Southern Nigeria
Data From the Abeokuta Heart Failure Clinical Registry
Okechukwu S. Ogah, MBBS, MSC,*ySimon Stewart, PHD,zAyodele O. Falase, MBBS, MD,*
Joshua O. Akinyemi, BTECH,MSC,xGail D. Adegbite, MBBS,kAlbert A. Alabi, MBBS,k
Akinlolu A. Ajani, MBBS,{Julius O. Adesina, MBBS,{Amina Durodola, MBBS,{
Karen Sliwa, MD, PHDy#
Ibadan and Abeokua, Nigeria; Johannesburg and Cape Town, South Africa; and Melbourne, Australia
Objectives The aim of this study was to determine the contemporary profile, clinical characteristics, and intrahospital outcomes
of acute heart failure (AHF) in an African urban community.
Background There are limited data on the current burden and characteristics of AHF in Nigerian Africans.
Methods Comprehensive and detailed clinical and sociodemographic data were prospectively collected from 452 consecutive
patients presenting with AHF to the only tertiary hospital in Abeokuta, Nigeria (population about 1 million) over a
2-year period.
Results The mean age was 56.6 15.3 years (57.3 13.4 years for men, 55.7 17.1 years for women), and 204 patients
(45.1%) were women. Overall, 415 subjects (91.8%) presented with de novo AHF. The most common risk factor
for heart failure was hypertension (pre-existing in 64.3% of patients). Type 2 diabetes mellitus was present in 41
patients (10.0%). Hypertensive heart failure was the most common etiological cause of heart failure, responsible for
78.5% of cases. Dilated cardiomyopathy (7.5%), cor pulmonale (4.4%), pericardial disease (3.3%), rheumatic heart
disease (2.4%), and ischemic heart disease were less common (0.4%) causes. The majority of subjects (71.2%)
presented with left ventricular dysfunction (mean left ventricular ejection fraction 43.9 9.0%), with valvular
dysfunction and abnormal left ventricular geometry frequently documented. The mean duration of hospital stay
was 11.4 9.1 days, and intrahospital mortality was 3.8%.
Conclusions Compared with those in high-income countries, patients presenting with AHF in Abeokuta, Nigeria, are relatively
younger and still of working age. It is also more common in men and associated with severe symptoms because
of late presentation. Intrahospital mortality is similar to that in other parts of the world. (J Am Coll Cardiol HF
2014;2:250–9) ª2014 by the American College of Cardiology Foundation
Although recognized as a significant health problem in
high-income countries (1,2), the syndrome of heart failure
(HF), in both its acute (2) and chronic (2) forms, has
emerged as an issue of global public health importance.
It has been established that the burden of HF doubles with
each passing decade after the age of 40 years, especially in
industrialized countries, because of an aging population
and the increasing burden of risk factors, including
hypertension, diabetes mellitus, ischemic heart disease, and
more recently, obesity (3). HF is estimated to affect about 15
million people worldwide (0.2% of the world population).
Although there are robust estimates to describe the inci-
dence, prevalence, and overall burden of HF in Europe (4–6)
and North America (7,8), there is a paucity of data
describing these aspects in other major populations around
the globe. For example, HF in Africa (including Nigeria)
From the *Division of Cardiology, Department of Medicine, University College
Hospital, Ibadan, Nigeria; ySoweto Cardiovascular Research Unit, Faculty of Health
Sciences, University of the Witwatersrand, Johannesburg, South Africa; zNHMRC
Centre of Research Excellence to Reduce Inequality in Heart Disease, Baker IDI
Heart and Diabetes Institute, Melbourne, Australia; xDepartment of Epidemiology
and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria;
kDepartment of Medicine, Sacred Heart Hospital, Lantoro, Abeokua, Nigeria;
{Department of Medicine, Federal Medical Centre, Abeokua, Nigeria; and the
#Hatter Institute for Cardiovascular Research in Africa & IIDMM, Department of
Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South
Africa. Dr. Ogah is a doctoral student at the University of the Witwatersrand
(Johannesburg, South Africa). Dr. Stewart is supported by the National Health and
Medical Research Council of Australia. All other authors have reported that they have
no relationships relevant to the contents of this paper to disclose.
Manuscript received October 2, 2013; revised manuscript received December 16,
2013, accepted December 18, 2013.
JACC: Heart Failure Vol. 2, No. 3, 2014
2014 by the American College of Cardiology Foundation ISSN 2213-1779/$36.00
Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jchf.2013.12.005
Downloaded From: http://heartfailure.onlinejacc.org/ by Okechukwu Ogah on 06/07/2014
appears to occur at a relatively younger age, afflicting
individuals in the prime of life, and is mostly of non-
ischemic origin. However, there are limited systematically
collected and contemporary data to describe clinical
characteristics, outcomes, and costs of HF for the conti-
nent (9,10).
As an extension of this, there are limited data derived
from systematically and prospectively conducted studies
of HF in Nigeria, the most populous region in sub-
Saharan Africa. Previous studies in the 1960s, 1970s,
and 1980s were mainly retrospective, and the various
diagnoses were not confirmed by echocardiography
(11–13). Moreover, there are even fewer data to describe acute
clinical presentations of HF to
match the clinical registry data
derived from large cohorts in
Europe and North America (14).
Considering the paucity of
data on acute HF (AHF) in sub-
Saharan Africa, we used data
fromtheAbeokutaHeartFail-
ureClinicalRegistrytoexplore
and determine the current etiol-
ogy and characteristics of acute (both de novo and recurrent)
presentations of the syndrome in southern Nigeria. The
possible role of epidemiologic and demographic transitions
Table 1 Sociodemographic and Clinical Profile of Study Cohort
All
(n ¼452)
Men
(n ¼248)
Women
(n ¼204) p Value
Age, yrs 56.6 15.3 57.3 13.4 55.7 17.1 0.265
Yoruba tribe 415 (91.8%) 225 (90.7%) 190 (93.1%) 0.450
Other tribes 37 (8.2%) 23 (9.3%) 14 (6.9%) 0.448
Married 363 (80.3%) 221 (89.1%) <0.001
No education 147 (32.5%) 63 (25.4%) 84 (41.2%) 0.006
Unemployed 13 (5.2%) 25 (12.3%) 38 (8.4%) 0.002
Urban residence 388 (74.8%) 185 (74.6%) 153 (75.0%) 0.922
Current smokers 15 (3.3%) 14 (5.6%) 1 (0.5%) 0.006
Never consumed alcohol 286 (63.3%) 100 (40.3%) 186 (91.2%) <0.001
Known hypertension 293 (64.3%) 174 (70.2%) 119 (58.3%) 0.010
Known diabetes mellitus 45 (10.0%) 20 (8.1%) 25 (12.3%) 0.157
Asthma 9 (2.0%) 3 (1.2%) 6 (2.9%) 0.311
COPD 16 (3.5%) 12 (4.8%) 4 (2.0%) 0.127
Arthritis 64 (14.2%) 10 (4.0%) 35 (17.2%) 0.105
Family history of heart disease 14 (3.1%) 8 (3.2%) 6 (2.9%) 0.862
NYHA functional class (n ¼308) 0.502
II 79 (17.5%) 47 (19.0%) 32 (15.7%)
III 284 (62.8%) 150 (60.5%) 134 (65.8%)
IV 89 (19.7%) 51 (20.4%) 38 (18.6%)
BMI, kg/m
2
23.9 5.7 24.0 5.1% 23.7 6.4% 0.470
Obesity 41 (9.1%) 21 (10.7%) 20 (12.4%) 0.428
Temperature, C(n¼299) 36.4 0.8 36.4 0.7 36.4 0.80 0.801
Respiratory rate, breaths/min (n ¼395) 27.8 6.3 27.9 6.3 27.7 6.2 0.706
Pulse rate, beats/min (n ¼418) 96.6 18.3 96.9 17.9 96.3 18.7 0.765
SBP, mm Hg (n ¼424) 137.5 31.8 138.7 32.2 136.2 31.4 0.416
DBP, mm Hg (n ¼424) 87.3 20.3 88.5 21.0 85.9 19.4 0.186
PCV (n ¼381) 37.6 7.0 37.9 7.0 37.2 7.1 0.372
WCC (n ¼377) 7.13 3.73 7.0 3.8 7.27 3.68 0.519
Lymphocytes, % (n ¼303) 35.8 12.8 35.3 12.4 36.4 13.2 0.452
Serum sodium, mmol/dl 135.2 10.0 134.9 10.2 135.6 9.8 0.640
Serum potassium, mmol/dl 3.61 0.74 3.63 0.76 3.58 0.72 0.661
Total cholesterol, mg/dl 171.0 70.5 164.1 72.2 188.6 64.8 0.228
Urea, mg/dl 44.0 39.6 48.3 44.4 38.8 32.1 0.037
Creatinine, mg/dl 1.45 2.15 1.67 2.56 1.19 1.46 0.857
Glucose, mg/dl 112.8 53.3 112.2 46.6 113.4 61.0 0.028
Duration of hospital admission, days 11.4 9.1 10.8 0.78 6.48 0.52 0.608
Anemia (n ¼382) 40 (10.5%) 18 (8.8%) 22 (12.4%) 0.169
Renal dysfunction (n ¼366) 174 (47.5%) 97 (48.0%) 77 (47.0%) 0.461
HIV positive (n ¼222) 2.7% 3.5% 1.9% 0.474
Values are mean SD or n (%).
BMI ¼body mass index; COPD ¼chronic obstructive pulmonary disease; DBP ¼diastolic blood pressure; HIV ¼human immunodeficiency virus;
NYHA ¼New York Heart Association; PCV ¼packed cell volume; SBP ¼systolic blood pressure; WCC ¼white blood cell count.
Abbreviations
and Acronyms
AHF = acute heart failure
ECG = electrocardiography
HF = heart failure
LV = left ventricular
NYHA = New York Heart
Association
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occurring in Nigeria in the profile of HF in the country was also
assessed (15).
Methods
Design and setting. This was a prospective, observa-
tional study conducted at the Federal Medical Centre,
Idi-Aba, and Abeokuta, Nigeria. Abeokuta is the capital
city of Ogun State, 1 of the 36 states that make up the
Federal Republic of Nigeria. The Federal Medical
Centre was established in 1993 by the federal govern-
mentofNigeriatocatertothehealthneedsofthepeople
of Ogun State and its environs in southwestern Nigeria.
The center is the only tertiary hospital in the city,
receiving referrals from all health facilities in the city,
state, and neighboring states. The state has a population
of about 3.2 million and a land area of about 16,409.26
km
2
. The city itself has an estimated population of about
1 million inhabitants (16) Theprevalenceofhuman
immunodeficiency virus antibodies in patients attending
the hospital clinics in 2010 was 11.6% (16% in women
and 7.3% in men) (17).
Health care costs in Abeokuta (and in fact in all parts of
the country) are generally borne by patients through out-of-
pocket payments. Health insurance in the country is still at a
rudimentary stage. Only a very small segment of the popu-
lation has access to this. However, strong family ties exist in
the country whereby poor patients are assisted by their
wealthy or well-to-do family members. This is in fact a
considerable challenge to health care delivery in the city and
the country in general.
A cardiologist (O.S.O.) covers the cardiac unit, assisted
by postgraduate resident doctors and experienced nurses.
Facilities for cardiac evaluation at the center include chest
radiography, 12-lead electrocardiography (ECG), exercise
ECG, Holter ECG, ambulatory blood pressure monitoring,
Figure 1 Symptoms and Signs in the 452 Subjects With AHF
AHF ¼acute heart failure; JVP ¼jugular venous pressure; PND ¼paroxysmal nocturnal dyspnea.
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spirometry, and echocardiography. All electrocardiographic
and echocardiographic examinations were carried out within
72 h of admission, as prescribed by the study protocol.
Study population. All cases of AHF, both de novo
presentations and recurrent decompensation with pre-
established diagnoses of HF, were consecutively recruited
(with no refusals) into the registry between January 1, 2009,
and December 2010. All subjects provided written and/or
informed consent to participate in the study. Ethical
approval was obtained from the ethics committee or ethics
review board of the Federal Medical Centre. The study
was carried out in accordance with international ethical
principles (18).
Enrollment and data collection. Data from each subject
were obtained using a uniform and standardized case report
form. Detailed clinical documentation of newly diagnosed
or newly presenting cases or pre-existing cases of HF was
carried out. The following data were obtained: study
identification number, demographic data, date of diagnosis
of HF, and preadmission history (previous HF-related
admissions). Others include New York Heart Associa-
tion (NYHA) functional class, symptoms, signs, self-
reported cardiovascular risk factors, etiology of HF,
precipitating factors, comorbidities, blood investigations,
12-lead ECG, echocardiography, medications, and intra-
hospital mortality.
Figure 2 Etiology of HF in the 452 Subjects
DCM ¼dilated cardiomyopathy; EMF ¼endomyocardial fibrosis; HD ¼heart disease; HF ¼heart failure; HHF ¼hypertensive heart failure.
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Clinical evaluation. Blood pressure measurements were
obtained according to standard guidelines using a mercury
sphygmomanometer (Accuson, Siemens UK, London,
United Kingdom). Body mass index was calculated as
weight in kilograms divided by the square of height
in meters. Values of 25.0 to 29.9 kg/m
2
and 30.0 kg/m
2
defined overweight and obesity, respectively. Anemia was
defined as hemoglobin <10 g/dl. Glomerular filtration
rate was estimated using the 4-variable Modification of
Diet in Renal Disease formula (19).Renaldysfunction
was defined as an estimated glomerular filtration
rate <60 ml/min/1.73 m
2
(the same criteria used by
Stewartetal.[20]).
Diagnosis of HF. A standardized diagnosis of HF was
made using the Framingham criteria (21) as well as the
guidelines of the European Society of Cardiology on the
diagnosis and treatment of AHF (22) (Online Table 1). As
such, both de novo presentation of AHF and recurrent
presentation of typically decompensated HF (i.e., acute-
on-chronic HF) were included in the registry.
ECG. A standard 12-lead resting electrocardiogram was
recorded for each subject using a Schiller electrocardiograph
(Schiller AG, Baar, Switzerland). All 12-lead resting
electrocardiographic studies were performed by trained
nurses or technicians and analyzed by a reviewer who was
blinded to the clinical data of the patients. The Minnesota
code classification (23) system was used in sorting out the
various abnormalities. Electrocardiographic abnormalities
were diagnosed on the basis of standard criteria (24).
Echocardiography. An Aloka SSD-4000 echocardiograph
(Aloka Co. Ltd., Tokyo, Japan) was used to assess all
patients. Two-dimensionally guided M-mode measure-
ments were made according to the recommendations of
the American Society of Echocardiography (25). Left ven-
tricular (LV) internal dimension, posterior wall thickness,
and interventricular septal thickness were measured at
end-diastole and end-systole. When optimal M-mode im-
aging could not be obtained, 2-dimensional linear mea-
surements were obtained according to American Society of
Echocardiography criteria (25). Left atrial end-systolic
diameter was obtained from the trailing edge of the poste-
rior aortic–anterior left atrial complex. Measurements were
obtained in up to 3 cardiac cycles according to American
Society of Echocardiography convention (25). One experi-
enced cardiologist (O.S.O.) performed all echocardiogra-
phic studies. The intraobserver concordance correlation
Table 2 Echocardiographic Variables of the Cohort in Men and Women
All
(n ¼452)
Men
(n ¼248)
Women
(n ¼204) p Value
Aortic root, cm 3.04 0.50 3.22 0.51 2.81 0.39 <0.001
Left atrium, cm 4.80 0.66 5.00 1.43 4.54 1.05 0.157
IVSTd 1.32 0.37 1.38 0.40 1.25 0.36 0.001
PWTd, cm 1.17 0.35 1.20 0.36 1.12 0.33 0.031
LVIDd, cm 5.48 1.43 5.79 1.44 5.11 1.33 <0.001
LVIDs, cm 4.51 1.40 4.82 1.42 4.14 1.29 <0.001
FS, cm 18.5 9.0 17.6 8.74 19.5 9.12 0.039
EF, % 43.9 9.0 42.1 16.8 45.9 17.1 0.037
LVM, % 320.7 132.8 360.0 141.8 272.4 102.4 <0.001
LVMI, g 86.2 37.0 92.8 40.9 77.9 26.6 <0.001
RWT, g/m
2.7
0.44 0.15 0.43 0.15 0.46 0.15 0.189
E wave, m/s 0.82 0.29 0.79 0.28 0.86 0.31 0.031
A wave, m/s 0.52 0.15 0.49 0.22 0.56 0.28 0.017
E/A ratio 2.04 0.40 2.10 1.48 1.97 1.28 0.460
IVRT, ms 145.0 59.7 117.1 35.9 110.6 32.8 0.174
DT, ms 114.4 34.7 142.6 56.0 148.3 64.4 0.397
LV geometry
CH 38.3% 39.6% 36.8% 0.069
EH 45.4% 47.6% 42.8% 0.069
MR 77.9% 75.5% 80.7% 0.256
TR 69.7% 65.5% 74.7% 0.068
AR 8.2% 8.5% 7.8% 0.851
Systolic HF 66.4% 71.2% 60.6% 0.028
Spontaneous echocardiograms 6.8% 8.5% 4.8% 0.212
Intramural thrombi 0.8% 1.0% 0.6% 0.670
Values are mean SD or %.
A¼left ventricular late filling velocity; AR ¼aortic regurgitation; CH ¼concentric hypertrophy; DT ¼deceleration time of E velocity; E ¼left
ventricular early filling velocity; EH ¼eccentric hypertrophy; EF ¼ejection fraction; FS ¼fractional shortening; IVRT ¼isovolumic relaxation time;
IVSTd ¼interventricular septal wall thickness in diastole; LVIDd ¼left ventricular internal diameter in diastole; LVIDs ¼left ventricular internal
diameter in systole; LVM ¼left ventricular mass; LVMI ¼left ventricular mass index; MR ¼mitral regurgitation; PWTd ¼left ventricular posterior wall
thickness in diastole; RWT ¼relative wall thickness; TR ¼tricuspid regurgitation.
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coefficient and measurement error for our laboratory have
been reported (26). LV mass was calculated using the for-
mula of Devereux and Reichek (27) LV geometry was
defined according to standard criteria (28).
Left atrial dimension and area were measured using
standard methods (29,30).
Transmitral flow velocities were obtained with the
Doppler sample volume placed just beyond the tip of mitral
valve leaflets, and standard measurements were obtained
(31). Tissue Doppler imaging was applied only to identify
true pseudonormal filling pattern.
Statistical analysis. Data were entered into EpiData soft-
ware (EpiData Association, Odense, Denmark) by experi-
enced personnel and analyzed using SPSS version 11.0
(SPSS, Inc., Chicago, Illinois). Descriptive statistical anal-
ysis for baseline data was performed on continuous
variables using means, standard deviations, ranges, and
medians as appropriate. Categorical variables are expressed
as percentages. McNemar and chi-square tests (for cate-
gorical variables) and Student ttests or analysis of variance
(for continuous variables) were used for comparisons as
appropriate. Two-sided p values <0.05 were considered
significant.
Results
Cohort profile. Table 1 summarizes the demographic
information, history, and risk profile of the study cohort.
A total of 452 subjects were recruited into the registry.
This constituted 9.4% of the total number of medical
admissions during the period. There were 248 men (54.9%)
and 204 women (45.1%). The mean age of the cohort was
56.4 15.2 years. The majority of subjects were >45 years
of age and married, whereas 67.5% had at least a primary
school education. More than two-thirds also lived in ur-
ban communities. Few subjects (3.3%) were current
cigarette smokers, and smoking was more commonly re-
ported in men than in women (5.6% and 0.5%, respec-
tively), with a similarly low level reporting positive family
histories of heart disease. More than one-half the cohort
was being actively treated for hypertension. The overall
prevalence of diabetes mellitus was 10.0%. Of note, 415
subjects (91.8%) had de novo presentation of AHF. About
90% of the subjects were in NYHA functional class II or
III 1 month before evaluation, 27% were either overweight
or obese, 21.7% had moderate to severe renal dysfunction
(estimated glomerular filtration rate <60 ml/min/1.73 m
2
),
and 10.5% were anemic. Presenting symptoms and signs are
summarized in Figure 1.
Precipitating factors for acute HF. The common precip-
itating factors for HF in the cohort included infections,
especially chest infection (n ¼284 [62.8%]); uncontrolled
hypertension (n ¼200 [44.2%]); and arrhythmias, especially
atrial fibrillation (n ¼123 [27.3%]). Less common pre-
cipitants included anemia (n ¼33 [7.3%]), excessive phys-
ical activity (n ¼25 [5.5%]), and electrolyte imbalance
(e.g., hyponatremia, hypokalemia; n ¼10 [2.2%]). Of note,
there was only 1 case of acute myocardial infarction (0.2%).
12-lead ECG. A majority of subjects presented with
abnormal results on 12-lead ECG. Axis deviations (most
commonly left axis deviation) were determined in 76.1%
of patients. Atrial enlargement or abnormalities were re-
corded in 69.7% of electrocardiograms. ECG-defined LV
hypertrophy was observed in 82.8% of patients, of whom
38.5% had electrocardiographic LV hypertrophy with
strain pattern, 13.1% had right ventricular hypertrophy,
and 28.7% had arrhythmias; atrial fibrillation was also
present in 52 subjects (11.5%).
Echocardiography and etiology of HF. Figure 2 shows
the etiological risk factors for HF in the cohort. Hyperten-
sive heart disease, dilated cardiomyopathy, cor pulmonale
(right heart disease), pericardial disease, and rheumatic
heart disease were the common risk factors for HF in the
cohort, constituting 78.5%, 7.5%, 4.4%, 3.3%, and 2.4% of
cases, respectively. Pericardial diseases and right HF were
more common in women, whereas hypertensive HF and
dilated cardiomyopathy were more common in men. Other
causes of HF in the cohort included peripartum cardio-
myopathy (1.3%), endomyocardial fibrosis (0.9%), thyroid
heart disease (0.7%), ischemic heart disease (0.4%), and adult
congenital heart disease (0.4%). The echocardiographic
features of the subjects according to sex are shown in Table 2.
Aortic root diameter, LV septal wall thickness in diastole,
posterior wall thickness, indexes of LV systolic function, and
LV mass were significantly higher in men than in women.
Men also had a significantly higher frequency of systolic HF
than women (71.2% vs. 60.6%, p ¼0.028). Online Table 2
shows the echocardiographic characteristics of the cohort
according to the etiological risk factors for HF.
LV wall thickness was higher in the hypertensive HF
group, whereas LV dilation was found to be greatest in the
dilated cardiomyopathy group, which also had the highest
frequency of LV systolic dysfunction.
In terms of LV geometry, 93.5% of the cohort had
abnormal LV geometry (concentric remodeling in 9.7%,
concentric hypertrophy in 38.3%, and eccentric hypertrophy
in 45.4%).
Intrahospital medications. On admission, 431 (95.4%),
419 (92.7%), 383 (84.7%), and 338 (74.7%) patients were
placed on diuretic agents, angiotensin-converting enzyme
inhibitors, angiotensin receptor blockers, and digitalis,
respectively. Calcium-channel blockers, centrally acting
antihypertensive agents beta-blockers, anticoagulant agents
(heparin), and hypoglycemic agents were prescribed for
78 (17.3%), 54 (12.0%), 42 (9.4%), 292 (64.7%), and 30
(6.7%) subjects, respectively.
At discharge, 448 patients (99.1%) were prescribed
angiotensin-converting enzyme inhibitors, 398 (88.1%)
loop diuretic agents, 327 (72.3%) digoxin, 121 (26.8%)
long-acting calcium-channel blockers, 65 (14.4%) com-
bined hydralazine and isosorbide dinitrate, and 41 (9.1%)
beta-blockers. Ancillary medications used during the
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course of admission were aspirin in 197 (43.6%), centrally
acting antihypertensive agents in 79 (17.5%), hypoglycemic
agents in 49 (10.8%), thiazide diuretic agents in 32 (7.1%),
and amiodarone in 10 (2.2%).
Intrahospital outcomes. Seventeen subjects died during
the course of admission. Causes of death were pump
failure (n ¼7), sudden death possibly due to arrhythmia
(n ¼5), pulmonary embolism (n ¼3), and stroke (n ¼2).
All intrahospital deaths occurred in patients with de novo
HF, mostly in women. Those who died were younger
(mean age 48.2 vs. 56.8 years, p ¼0.025). The majority
(n ¼9) had either hypertension (52.9%) or dilated cardio-
myopathy (29.4%) and were more likely to present with
systolic dysfunction (n ¼5) and/or in NYHA functional
class III or IV (n ¼15).
The mean overall length of hospital stay was 10.8 6.1
days (range 2 to 61 days; median 9 days).
International comparisons. Table 3 shows a comparison
of our findings with those of other workers in sub-Saharan
Africa and other parts of the world.
Discussion
This is the first detailed, comprehensive, and prospective
study of AHF in Abeokuta and in southern Nigeria. Our
data show that acute presentation of HF (predominantly
de novo) constitutes just fewer than 10% of all medical ad-
missions in the city. In general, cardiologic conditions are
responsible for just under 1 in 5 emergency medical ad-
missions in Abeokuta, second only to infections and in-
festations, which account for almost 1 in 2 cases (32). These
data suggest that AHF in Abeokuta predominantly afflicts
young and middle-age individuals in the prime of life, most
of whom present with de novo AHF. Clinically late pre-
sentation is common, with more than 80% presenting in
NYHA functional class III or IV. More than two-thirds of
our cohort had systolic HF, with hypertensive heart disease
the most common risk factor for HF overall (almost 4 in 5
cases). Alternatively, ischemic heart disease is relatively un-
common. Infections and uncontrolled hypertension are the
most common precipitating factors, with comorbidities and
secondary valvular dysfunction also common. We also noted
low use of disease-modifying drugs such as beta-blockers
and combined hydralazine and isosorbide. The intra-
hospital mortality rate was relatively low at just under 4%.
Contrary to the situation in advanced countries of Europe
and North America, and in Japan, where HF is essentially a
problem of the elderly (with a mean age at presentation of
72 years), ours was a relatively young cohort. Our finding of
a lower rate of HF in women is consistent with many pre-
vious reports. Alternatively, there have been reports (notably
from South Africa and the East African countries of Kenya
and Uganda) of more women than men presenting with HF
(20,33,34). Other aspects of this cohort (including precipi-
tating factors, a predominance of de novo cases, and late,
severe presentations) are similar to equivalent African re-
ports. The etiological pattern in our cohort is also consistent
with findings in other parts of Nigeria, where hypertensive
HF contributes to 52.7% to 62.6% of cases of HF (35–38).
In a recent systematic review, we showed that the pooled
prevalence of hypertension increased from 8.6% (confidence
interval: 13.7% to 16.3%) in the only study during the period
Table 3 Comparison of the Present Study With Other HF Studies in Sub-Saharan Africa and Other Parts of the World
Study/First Author (Ref. #), Country n
Women
(%)
Mean Age
(yrs)
Smoking
(%)
Hypertension
(%)
Diabetes
(%)
Obesity
(%)
Cholesterol
(mg/dl)
Present study, Nigeria 452 45.1 56.6 3.3 64.3 10.0 10.7 164.1
Stewart et al. (20), South Africa 844 57.0 55.0 48.0 55.0 10.0 34.0 162.4
THESUS-HF (40) 1,006 50.7 52.0 9.8 55.5 11.1 16.3 157.6
Laabes et al. (36), Nigeria 102 68.6 44.8 5.9 44.1 6.9 25.5 NR
Ojji et al. (35), Nigeria 315 49.1 50.6 NR NR NR NR NR
Oyoo and Ogola (33), Kenya 91 51.6 NR NR NR NR NR
Kingue et al. (41), Cameroon 167 40.7 57.0 NR NR NR NR NR
Soliman and Juma (48), Malawi 3,908 39.9 58.9 NR NR NR NR NR
Habte et al. (49), Ethiopia 781 47.6 43.5 NR NR NR NR NR
Amoah and Kallen (50), Ghana 572 NR 42.0 NR NR NR NR NR
Onwuchekwa and Asekomeh (37),
Nigeria
423 42.8 54.0 NR NR NR NR NR
Kuule et al. (34), Uganda 157 66.2 45.0 NR NR NR NR NR
Ogah et al. (51), Nigeria 1,441 48.4 54.0 NR NR NR NR NR
Tantchou et al. (42), Cameroon 462 42.9 42.5 NR NR NR NR NR
Karaye and Sani (38), Nigeria 79 44.3 46.9 NR NR NR NR NR
EHFS II (44) 3,580 38.7 69.9 NR 62.5 32.8 NR NR
ADHERE (7), United States 105,388 52.0 72.4 NR 73 44.0 NR NR
OPTIMIZE-HF (52), United States 48,612 52.0 73.0 NR NR NR NR NR
ADHERE (53), Indonesia 1,687 64.5 60.0 74.0 54.8 31.2 NR NR
JCARE-CARD (45), Japan 2,675 40.3 71.0 37.7 52.9 29.9 NR 24.8
Continued on the next page
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from 1970 to 1979 to 22.5% (confidence interval: 21.8% to
23.2%) from 2000 to 2011. Awareness, treatment, and
control of hypertension were generally low (14.2% to 30%,
18.6% to 21%, and 9%, respectively), with an attendant high
burden of hypertension-related complications (39).
Hypertension is also the predominant etiological factor
for HF in adjacent Cameroon (40). Alternatively, in East
Africa (Kenya, Uganda) as well as the horn of Africa (34),
cardiomyopathy is more common.
Generally, two-thirds of patients with HF have systolic
dysfunction. This is in keeping with the findings of our
study and other workers (Table 3). Consistent with the
findings of the EuroHeart Failure Survey II and the Heart of
Soweto Study, valvular dysfunction was also common. The
use of angiotensin-converting enzyme inhibitors and spi-
ronolactone is quite comparable with findings in advanced
countries. However, this was not the case with beta-blockers
and combined hydralazine and isosorbide. This observation
presents an opportunity for improvement in the care of
patients with HF in Abeokuta in particular and Nigeria in
general. Previously reported intrahospital mortality rates
from sub-Saharan Africa are generally higher than in our
cohort; ranging from 4.3% to 9.2% (33,40–42) compared
with 3.8% to 6.7% (7,43–45) in high-income countries. The
mean length of hospital stay (11 days) was longer than that
reported in the Sub-Saharan Africa Survey of Heart Failure
(7 days) (40) but shorter than a cohort from Cameroon (13
days) (42). These are all longer than is the lengths of stay
reported in high-income countries (4 to 7 days) (7).
The younger age at presentation of patients with HF in
our cohort and in many parts of Africa may be related to
the etiology of HF. Rheumatic heart disease and cardio-
myopathies are essentially problems of youth and middle
age. Also, hypertension is known to occur early in Africans
and African Americans, with greater adverse consequences.
The sex differences reported from different regions of sub-
Saharan Africa may be related to patient selection, sex
differences in the burden of cardiovascular risk factors, and
regional variations. In areas with a predominance of
rheumatic heart disease and cardiomyopathy (especially
peripartum cardiomyopathy), HF rates tend to be higher in
womenthaninmen.Healthcare–seeking behaviors may
also play an important role. It is more likely that the
breadwinner is taken to the hospital in Africa, especially
where there is no health insurance coverage for the entire
family. Some of the possible reasons for underuse of
standard medications for HF in our cohort may include
poor awareness of these therapies for HF in the city, high
costs, and the late presentation and severity of HF in our
subjects. Many physicians are still not comfortable
commencing beta-blockers or combined hydralazine and
isosorbide in severely ill patients with HF, and this pre-
sents an opportunity for improved management and out-
comes in Abeokuta and wider Nigeria. In the EuroHF
Registry, “the best survival was seen in hypertensive HF, as
almost all the patients were discharged alive”(7).Thefact
that patients with hypertension represented the bulk of our
cohort may explain, therefore, the lower intrahospital
Table 3 Continued
Anemia
(%)
CKD
(%)
NYHA Class
(III and IV) (%)
Mean EF
(%)
HHF
(%)
DCM
(%)
VHDX
(%)
RHF
(%)
IHD
(%)
LOS
(days)
Mortality
(%)
8.8 48.0 82.5 42.0 78.5 7.5 2.4 4.4 0.4 11.0 3.8
10.0 25.0 34.0 45 33.3 35.3 7.9 14.3 7.9 NR NR
15.2 7.7 34.6 39.5 45.4 18.8 14.3 NR 7.7 7.0 4.2
NR NR 93.1 NR 44.1 21.6 22.5 NR 1.0 NR NR
NR NR NR NR 62.6 13.8 7.4 1.8 NR NR NR
NR NR 37.4 NR 13.2 25.2 32.0 NR 2.2 NR NR
NR NR NR NR 54.5 26.3 24.6 NR 2.4 NR NR
NR NR NR NR 24.0 19.0 34.0 NR 0.08 NR NR
NR NR NR NR 24.2 20.2 32.8 3.8 12.0 NR NR
NR NR NR NR 21.3 16.6 20.1 NR 10.0 NR NR
NR NR NR NR 56.3 12.3 4.3 2.1 0.2 NR NR
64.3 NR 96.8 NR 25.1 27.3 28.2 NR 1.9 NR NR
NR NR NR NR 56.7 3.0 3.7 1.6 0.6 NR NR
NR NR 51.0 NR 15.0 32.0 35.0 8.0 NR 13.0 9.2
NR NR NR NR 57.0 24.0 12.7 2.5 7.6 NR NR
14.7 16.8 NR 38.0 11.4 19.3 3.2 53.6 9.0 6.7
NR 30.0 76.0 34.4 4.3 4.0
NR NR NR 39.0 3.8
NR NR NR 37.9 54.8 NR NR NR 23.3 7.1 6.7
20.8 11.7 87.5 42.2 24.6 21.9 15.7 NR 32.0 NR NR
ADHERE ¼Acute Decompensated Heart Failure National Registry; CKD ¼chronic kidney disease; DCM ¼dilated cardiomyopathy; EHFS II ¼EuroHeart Failure Survey II; EF ¼ejection fraction;
HHF ¼hypertensive heart failure; HF ¼heart failure; IHD ¼ischemic heart disease; JCARE-CARD ¼Japanese Cardiac Registry of Heart Failure in Cardiology; LOS ¼length of stay in hospital;
NR ¼not reported; NYHA ¼New York Heart Association; OPTIMIZE-HF ¼Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure; RHF ¼right heart failure;
THESUS-HF ¼Sub-Saharan Africa Survey of Heart Failure; VHDX ¼valvular heart disease.
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mortality rate. Our data also afford us the opportunity to
compare our findings with those of a similar study in the
region of the country reported 41 years ago. It does appear
that hypertension now plays an increasingly predominant
role in driving heart disease in southern Nigeria. Rheu-
matic heart disease appears to be less prominent. Endo-
myocardial fibrosis is almost disappearing from the scene,
whereas pulmonary heart disease is emerging as a promi-
nent risk factor (Fig. 3).
Study limitations. This was a cross-sectional study, with all
the inherent limitations of this method. Because this was a
tertiary cohort, those with milder forms of HF were likely to
have been underrepresented. To overcome this likelihood,
all local health facilities were contacted before study
commencement requesting referral of all HF cases to our
clinic (the only center with cardiologic services, including
echocardiography). Cases of ischemic heart disease may
also have been underrepresented because of an increased
likelihood of sudden out-of-hospital death and the lack of
coronary angiography (all documented cases were investi-
gated with coronary angiography elsewhere). We also did
not collect data on the duration of hypertension before
the onset of HF. Finally, we did not assess for nutritional
deficiencies and malnutrition as possible factors for the
earlier development of HF in this population, although in
a related study in the country, Olubodun (46) reported
that patients with HF were more likely to be thiamine
deficient, hypoalbuminemic, and anemic.
Conclusions
These data suggest that AHF in Abeokuta, Nigeria, pre-
dominantly affects younger individuals of working age.
Overall, HF is more common in men and is associated with
severe symptoms because of late presentation. Severe LV
systolic dysfunction and abnormal LV remodeling pattern
are also common. Intrahospital mortality was similar to
findings in many parts of the world. Hypertension has
become the most common (and indeed preventable) ante-
cedent in the region. Because hypertension has been pro-
jected to rise by 89% in countries of sub-Saharan Africa (47),
especially Nigeria, which is the most populous country in the
region (compared with a projected 24% increase in high-
income countries) between 2000 and 2025, efforts should
be made in the area of primordial and primary prevention as
well as health promotion to combat this emerging epidemic.
Reprint requests and correspondence: Dr. Okechukwu S. Ogah,
Division of Cardiology, Department of Medicine, University
College Hospital, PMB 5116, Ibadan, Nigeria. E-mail:
osogah56156@yahoo.com.
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Key Words: acute heart failure -clinical registry -health outcomes -
Nigeria.
APPENDIX
For supplemental tables, please see the online version of this article.
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