Heart failure remains a major global public health problem, with rising prevalence and costs, and a particularly heavy burden of morbidity and mortality in low- and middle-income countries (LMICs) [1]. In Sub-Saharan Africa, etiologic profiles and age at onset differ from Western settings, with hypertensive heart disease, dilated cardiomyopathies, and acute rheumatic fever continuing to be the leading causes of hospitalization [2]. In Cameroon, several hospital-based studies have highlighted the burden of heart failure and documented local particularities in presentation and management [3]-[5].

In this context, the electrocardiogram (ECG) and Doppler transthoracic echocardiography (TTE) are central and accessible tools to support diagnosis, refine severity, explore etiology, and guide therapeutic strategy [6][7]. Beyond diagnosis, electrocardiographic parameters (e.g., atrial fibrillation, QRS widening, left bundle branch block, left ventricular hypertrophy) and echocardiographic parameters (left ventricular ejection fraction, chamber remodeling and dilation, diastolic function and right ventricular function, pulmonary pressures) are associated with prognosis [8]-[11]. International guidelines detail measurement methods, thresholds, and phenotypic categories, notably for chamber quantification and for measuring ejection fraction using Simpson’s method [6][12].

Sex-related differences have also been described in heart failure—ranging from risk factors and phenotypes (including the higher frequency of heart failure with preserved ejection fraction in women) to therapeutic response and certain clinical outcomes [12]-[14]. Yet these differences remain under-documented in LMICs and particularly in Central African hospital settings, where limited access to advanced imaging and cardiac resynchronization devices further elevates the role of ECG and echocardiography [2][6][7]. In Cameroon, some hospital-based studies exist but are often dated, focused on specific populations, or do not systematically describe electrocardiographic and echocardiographic profiles by sex [3]-[5]. Describing, in a referral hospital in Yaoundé, the sex-specific electrocardiographic and echocardiographic characteristics among patients hospitalized for heart failure helps fill this local knowledge gap, contextualize international data, and identify potential disparities useful for risk stratification and care-pathway optimization. Accordingly, the objective of our study was to characterize electrocardiographic and echocardiographic profiles by sex among adult patients hospitalized for heart failure in Yaoundé, and to situate these profiles relative to regional data and international standards for measurement and interpretation.

The main findings of our study showed that sex differences were primarily behavioral: smoking and alcohol consumption were higher in men, whereas classical metabolic risk factors (hypertension, diabetes, dyslipidemia, obesity) and median age did not differ significantly. On electrocardiography, no parameter differed by sex (predominant sinus rhythm, atrial fibrillation ~8%, left bundle branch block ~3%). On echocardiography, only right atrial dilation was more frequent in women; the distribution of left ventricular ejection fraction categories was comparable. Our observations fit within an African landscape in which heart failure remains strongly linked to hypertension and non-ischemic cardiomyopathies, with hospitalizations at relatively young ages—findings demonstrated in the systematic review and Meta-analysis by Agbor etal. (2018), as well as the works of Bloomfield etal. (2013) and Ntusi etal. (2009) [2][15][18].

Numerous studies in Sub-Saharan Africa describe an epidemiology of heart failure dominated by hypertensive heart disease and dilated cardiomyopathy, with a high burden of hospitalizations and constrained care pathways; our results align with this trend [4][19][20]. Overall, heart failure in women more often presents with preserved ejection fraction but distinctive alterations in internal cardiac structure [12][21][22]. The literature provides standardized thresholds and measurement methods for reliably interpreting these parameters. In this context, the observation of more frequent right atrial dilation among women in our sample deserves confirmation and interpretation in light of the recommendations for echocardiographic assessment of the right heart in adults issued by the American Society of Echocardiography, with endorsement from the European Association of Echocardiography (a branch of the European Society of Cardiology) and the Canadian Society of Echocardiography, to distinguish what is attributable to biology, clinical phenotype, or measurement effects [23][24].

From a pathophysiological standpoint, our results are first interpreted through risk behaviors: smoking increases the risk of heart failure and worsens prognosis, which is consistent with the male overrepresentation observed [25][26]. Likewise, alcohol can induce dilated cardiomyopathy and destabilize heart failure; even at low doses, its cardiovascular effects are complex, supporting abstinence in cases of myocardial disease [27][28]. Regarding the atria and sex, atrial dilation—especially left atrial dilation—is a robust marker of diastolic load and events, modulated by body size and hemodynamic profiles that often differ in women [29][30]. Our signal of more frequent right atrial dilation in women could reflect higher right-sided pressures in phenotypes with preserved ejection fraction and exercise-induced pulmonary hypertension, which are reported more often in women [12][21]. Finally, from the electrocardiographic perspective, the absence of sex differences in atrial fibrillation or left bundle branch block does not diminish their prognostic significance: a widened QRS and bundle branch blocks are associated with a higher risk of adverse events, while cardiac resynchronization therapy improves morbidity and mortality in eligible patients [8][10][31][32].

Echocardiographic acquisition and interpretation should follow international recommendations (dimensions, biplane Simpson ejection fraction, indexation); our results are aligned with these methodological frameworks and facilitate external comparisons [33]. Similarly, the ECG remains a key tool; for left ventricular hypertrophy, the Sokolow-Lyon and Cornell criteria perform differently according to sex and body habitus, underscoring the value of analyses that integrate multiple indices [16][34]-[36].

From a clinical and public health perspective, our findings first call for targeted prevention: the marked sex disparity in smoking and alcohol use justifies differentiated, culturally tailored interventions, given the well-documented benefits of smoking cessation and alcohol reduction or abstinence in people with heart failure [25][27]. For risk stratification, patients with a widened QRS complex and an appropriate phenotype should be considered for cardiac resynchronization therapy in line with international guidelines and pivotal trials [6][17][31][32]. In addition, right-heart phenotyping should be strengthened—particularly in view of the female overrepresentation of right atrial dilation—through rigorous measurement of right-sided dimensions, tricuspid annular plane systolic excursion (TAPSE), and estimated pulmonary artery pressure, aligned with society recommendations [24].

The main limitations of our study lie in its retrospective, single-center design, which introduces selection bias toward hospitalized patients and limits the generalizability of the findings. Medical records contained missing data, weakening some estimates. The lack of detailed exposure measurements (quantity and duration of smoking and alcohol use) reduced the precision of risk-behavior analyses. Finally, the low frequency of certain events (e.g., left bundle branch block) decreased statistical power to detect differences. These limitations underscore the need for prospective, multicenter studies with standardized data collection and granular documentation of exposures.

Among the 397 patients hospitalized for heart failure at Central Hospital of Yaoundé, sex differences chiefly involved risk behaviors (higher smoking and alcohol use in men) and a higher frequency of right atrial dilation on Doppler transthoracic echocardiography in women; aside from these elements, electrocardiographic and echocardiographic profiles—including left ventricular ejection fraction—were broadly similar between sexes. These findings support strategies prioritizing prevention of modifiable behaviors, careful right-heart assessment, and the implementation of prospective multicenter studies to confirm and deepen these observations.