Background:
Cardiovascular emergencies have become a public health problem with a high burden in low-income settings. This is due to the high rates of cardiovascular risk factors that are fast reaching epidemic proportions. There is paucity of data on cardiovascular emergencies to guide repost strategies in our setting. Our aim was to determine the clinical presentation and outcome of cardiovascular emergencies
at
Yaounde Emergency Center.
Methods:
We carried out this cross-sectional study between June 2015 and May 2017. We included all patients with confirm
ed
cardiovascular emergency. We consecutively collected data on socio-demography, symptoms on admission, past history, clinical findings, and final diagnosis at discharge or in the event of death.
Results:
Of the 8285 patients admitted for medical emergencies, 388 (4.7%) were cardiovascular emergencies. Their mean age was 59.5 ± 13.8 years, and 59% were males. The Medical Emergency Aid Service was the means of transport
ing
4% of patients. The median time of arrival at the hospital was 48 hours. Symptoms on admission were mainly weakness of a limb (43.8%), and altered consciousness (33.5%). The most common cardiovascular emergencies were ischemic stroke (30.9%), hypertensive emergency (21.4%), and hemorrhagic stroke (16.5%). The most common comorbidit
y
w
as
diabetes (21.9%). The death rate in the 24
-
72 hours was 14.4%. The causes of death were hypertensive emergency (35.7%), and hemorrhagic stroke (30.3%).
Conclusion:
Stroke and hypertensive emergency were the most frequent cardiovascular emergencies. The early mortality was high. Hemorrhagic stroke and hypertensive emergencies accounted for most cases of death.
Cardiovascular diseases (CVD) are a major public health problem in the world, with the greatest burden in low-income settings. They are the leading cause of death due to non-communicable diseases (NCD) worldwide [1] [2] [3] . Cardiovascular emergencies are life threatening, and are the frequent mode of expression of CVD [4] . CVD are estimated to account for about 17.3 million death yearly, and this is expected to reach 23.6 million by 2030 [5] . The cost of management was estimated at 100 billion Euros, and this is expected to reach 122.6 billion by 2020. CVD accounted for about 1 billion deaths in sub-Saharan Africa (SSA) in 2013 [6] . This high burden of CVD is associated with high rates of classical risk factors [7] [8] . Cardiovascular emergencies are mode of expression in most patients, due to the high rate of unawareness and under-treatment [6] [9] . Cardiovascular emergencies accounted for about 12% to 46% of all medical emergencies, with an early mortality of up to 21% [10] [11] [12] [13] . The pattern of cardiovascular emergencies varied with the setting, with higher rates of stroke in SSA, and acute coronary syndrome in high income settings.
An efficient strategy to control CVD and reduce death due to cardiovascular emergencies requires data oriented decision-making. There is a paucity of data on cardiovascular emergencies in our setting. The aim of this cross-sectional study was to report on the spectrum and outcome of cardiovascular emergencies in Cameroon.
2. Methods2.1. Study Design and Setting
This was a cross-sectional study carried out at the Yaounde Emergency Center (YEC). We prospectively recruited patients between June 2015 and May 2017. The YEC is located at the center of Yaounde, with the aim of managing and coordinating emergencies in the center region and beyond. It went operational in June 2015. The center is well equipped with state of the art equipments, and staffed with 256 personnel including two dedicated Cardiologists. Cardiovascular emergency is a situation involving vital prognosis of an individual as a result of heart and/or vessels damage which imposes immediate care.
2.2. Participants
These were all consenting patients of both sex admitted for a cardiovascular emergency during the study period. Those with incomplete records were excluded.
2.3. Variables and Measurements
Patients were consecutively recruited on admission, and data were collected with standardized medical records for all patients. We collected data on socio-demography (age, sex, profession, level of education, marital status), means of transportation, origin, presenting complaints, cardiovascular risk factors and comorbidities, family history of cardiovascular disease, findings on physical examination, and findings after an oriented complementary examination. The diagnosis retained for this study was that made by the attending Cardiologist on discharge or after death.
2.4. Sample Size and Statistical Analysis
A consecutive sample of all eligible patients was considered. We analyzed the data using the software IBM SPSS version 23. We have presented discrete variables as counts and percentages, and continuous variables as means ± standard deviation. In univariate analysis, we calculated the odds (95% confidence interval) of a poor outcome (Death) for each cardiovascular emergency diagnosed. A p value < 0.05 was considered statistically significant for the observed associations.
2.5. Ethical Considerations
This study was approved by the Institutional Review Board of the Faculty of Medicine and Biomedical Sciences of the University of Yaounde 1. We carried out this study in accordance with the declarations of Helsinki [14] . We have reported this work following the STROBE checklist [15] .
3. Results3.1. Participants
A total of 8285 patients were admitted, of which 388 (4.7%) were cardiovascular emergencies. There were 229 (59%) males and 159 (41%) females. Their mean age was 59.5 ± 13.8 years, and ranged from14 to 95 years.
3.2. Descriptive Data
The age range 60 to 69 years were the most represented (30.4%), and Housewives were the most frequent (33.8%). Most of the patients attained secondary school (72.4%), came from home (86.1%), and were transported non-medically (95.9%) (Table 1). Most patients arrived the hospital between the 24th and 48th hour (51%), and 0.5% arrived less than 6 hours to hospital.
3.3. Main Results
Headache was the most frequent symptom on admission (52.8%), and paralysis/Paresia was the most frequent physical finding (43.8%). Excessive alcohol consumption (56.4%), and obesity (42.3%) were the most frequent cardiovascular risk factors. A history of stroke was reported by 92.2% of patients (Table 2). Ischemic stroke was the most frequent cardiovascular emergency (30.9%), followed by hypertensive emergency (20.9%) (Table 3). Death occurred in 56
Socio-demographic characteristics of the study population
Variable
Frequency (n)
Percentage (%)
Age range (Years)
<40
30
7.7
40 - 49
60
15.5
50 - 59
93
24
60 - 69
118
30.4
70 - 79
52
13.4
>79
35
9
Profession
Student
5
1.3
House wife
131
33.8
Retired
126
32.5
Civil servant
121
31.2
Others
5
1.3
Level of education
Primary
36
9.3
Secondary
281
72.4
Higher
71
18.3
Origin
Home
334
86.1
Referred
50
12.9
Public place
4
1
Mode of transportation
Ambulance
16
4.1
Others
372
95.9
(14.4%) patients, and this was mainly due to hypertensive emergency (35.7%), hemorrhagic stroke (30.3%), and acute pulmonary edema (12.5%). Acute pulmonary edema was associated with the highest odds of death (OR: 15.7, p < 0.001), while those with ischemic stroke were less likely to die (OR: 0.1, p < 0.001) (Table 4). A history of hypertensive emergency was not associated with poor outcome (OR: 1.85, [95% CI: 0.8 - 4.2], p = 0.17). Of those alive in hospital (n = 332), 252 (75.9%) were discharged home, while 80 (24.1%) were transferred to specialized centers. Most of the patients were hospitalized for ≤5 days (96.4%).
4. Discussion
The aim of this study was to assess the clinical presentation and outcome of cardiovascular emergencies admitted at the Yaounde Emergency Centre (YEC).
Symptoms on admission, risk factors, past medical history, and physical findings
Variable
Frequency (n)
Percentage (%)
Symptoms on admission
Headache
205
52.8
Vertigo
64
16.5
Blurred vision
39
10.1
Dyspnea
32
8.3
Asthenia
19
4.9
Chest pain
16
4.1
Cough
4
1
Abdominal pains
4
1
Nausea/Vomiting
4
1
Classical cardiovascular risk factors
Hypertension
118
30.5
Diabetes
85
21.9
Tobacco use
110
28.4
Sedentarity
151
38.9
Dyslipidemia
153
39.4
Obesity
164
42.3
Alcoholism
219
56.4
Past medical history
Stroke
358
92.2
Hypertensive Emergency
54
14
Acute Coronary Syndrome
37
9.5
Acute Heart Failure
6
1.6
Co-morbidities
HIV infection
49
12.6
Chronic Kidney Disease (failure)
18
4.6
Pneumonia
85
21.9
Clinical findings on admission
Systolic BP > 140 mmHg
356
91.8
Diastolic BP >90 mmHg
364
93.8
Tachycardia
385
99.2
Polypnea
388
100
Dysarthria
7
1.7
Fever
12
3
Seizures
23
6
Altered consciousness
130
33.5
Paralysis/Paresia
170
43.8
Cardiovascular emergencies
Variable
Frequency (n)
Percentage (%)
Ischemic Stroke
120
30.9
Hemorrhagic Stroke
64
16.5
Hypertensive Emergency
81
20.9
Acute Coronary Syndrome
47
12.1
Acute Heart Failure
40
10.3
Pulmonary Embolism
23
5.9
Acute Pulmonary Edema
10
2.5
Ventricular Tachycardia
1
0.2
Aortic Dissection
1
0.2
Cardiac Tamponade
1
0.2
Causes of death and the determinants
Variable
Frequency (n)
% of all deaths
% of admitted cases
OR (95% CI)
p value
Ischemic Stroke
3
5.3
2.5
0.1 (0.03 - 0.3)
<0.001
Hemorrhagic Stroke
17
30.3
26.6
2.6 (1.4 - 5.1)
0.001
Acute Heart Failure
3
5.3
7.4
0.5 (0.1 - 1.5)
0.188
Pulmonary Embolism
5
8.9
21.7`
2.8 (1.1 - 7.2)
0.024
Acute Coronary Syndrome
0
0
0
NA
NA
Aortic Dissection
0
0
0
NA
NA
Ventricular Tachycardia
0
0
0
NA
NA
Cardiac Tamponade
1
1.7
100
NA
NA
Hypertensive Emergency
20
35.7
24.7
2.5 (1.3 - 4.6)
0.003
Acute Pulmonary Edema
7
12.5
70
15.7 (3.9 - 62.6)
<0.001
OR: Odds Ratio; CI: Confidence Interval; NA: Not Applicable.
Cardiovascular Emergencies accounted for 4.7% of all admissions. These were mainly due to stroke and hypertensive emergencies. The early mortality was about 21%, and mainly due to hemorrhagic stroke and hypertensive emergency.
Few studies in SSA have addressed cardiovascular emergencies (CE). The prevalence of CE was comparable to the 7% reported by Gombet et al. [16] in 2007. Patients with cardiovascular diseases were younger, compared to high income settings [17] [18] . This has economic consequences as the active population necessary for economic growth is affected. Male predominance has also been reported [17] [19] . It is not certain if this is true predominance, or it is due to selective presentation at the emergency. Hospital based studies are inappropriate to provide answers on the sex distribution of CVD. Hypertension has been shown to be the main CVD risk factor in SSA [11] [16] [20] . It affects one in three adult in our setting, where most patients go undiagnosed, under investigated, and under treated [9] [21] . Access to diagnostic tests and essential medicines remain very low [22] . This low rate of awareness and undertreatment will often translate as a cardiovascular emergency. The clinical presentation was dominated by stroke. This was similarly reported by other authors [1] [18] . Myocardial infarction has been reported to be relatively less frequent in SSA [23] . It is not known if Africans in SSA are predisposed to stroke than myocardial infarction, or those with myocardial infarction die before reaching hospital and are thus not accounted for. Cases of acute coronary syndrome could be misdiagnosed and treated as peptic ulcer disease in our setting [24] . The setting of the study could significantly modify the statistics of CV emergencies. Specialized centres will attract more cases of the specialty. Kane et al. [13] reported up to 28% of acute coronary syndrome in a cardiology clinic in Dakar. Acute aortic syndromes and venous thrombo-embolic diseases were relatively low. Autopsy studies to investigate sudden deaths are often not performed, thus creating uncertainties in the distribution of cases of CV emergencies. Life threatening arrhythmia such as ventricular tachycardia was also less frequent, as few patients might make it to the emergency for timely and effective treatment [25] . Few patients were transported medically to the emergency unit. This has not improved in our setting [11] . Medicalized transportation and pre-hospital treatment are crucial in reducing mortality. Patients often arrived very late to the emergency, thus a substantial delay in receiving lifesaving treatment [11] [13] . This further worsens the outcome, with a high rate of mortality compared to high income settings [20] . There is clearly the need for educating the population and primary health personnel in the early detection and referral of cases of CV emergencies. Efficient transportation system with pre-hospital management should be put in place. Access to emergency CVD healthcare should be improved, as affordability has been shown to be low [1] [22] . Dedicated emergency centres such as stroke units should be put in place, as stroke accounted for most cases of death.
5. Limitations and Strengths
This study should be interpreted in the light of some limitations. This was a hospital based study, with the risk of presentation bias at the emergency department. The prevalence of CVD emergency reported might not truly reflect CVD in the community. This stresses the need for a community survey to give a clearer picture of the burden of each CVD. We could not provide a trend in the rate of CV emergencies due to the short study period of about two years. Observations are still underway. Despite these limitations, this study provides baseline data for an informed decision making, and the basis for further research.
6. Conclusion
Stroke and hypertensive emergency were the most frequent cardiovascular emergencies. The early mortality was high. Hemorrhagic stroke and hypertensive emergencies accounted for most cases of death. Community studies are needed to assess the true burden of CV emergencies in our setting. Education of the community and health workers in remote areas is needed. This will allow the screening and treating of CVD risk factors, and the early detection and treatment of CV emergencies. Availability, accessibility, and affordability of emergency care should be improved.
Authors’ Contributions
Conception: BH, SK. Design: BH, SK. Data collection: BH, YTK, AMJ, SNA. Data analysis and interpretation: BH, YTK, AMJ, SNA, SK. Drafting of the manuscript: BH, YTK, AMJ, SK. All the authors read and approved of the final draft for publication.
Acknowledgements
We thank the support staff of the Yaounde Emergency Centre for assisting with patient care.
Cite this paper
Hamadou, B., Kalissou, Y.T., Jingi, A.M., Amougou, S.N., Dikosso, S.E., Njouoguep, R. and Kingue,S. (2018) Clinical Presentations and Outcome of Cardiovascular Emergencies in Yaounde: A Cross-Sectional Study. World Journal of Cardiovascular Diseases, 8, 133-142. https://doi.org/10.4236/wjcd.2018.82013
ReferencesGombet, T.R., Ellenga-Mbolla, B.F., Ikama, M.S., Ekoba, J. and Kimbally-Kaky, G. (2009) Cost of Emergency Cardiovascular Care at the University Hospital Center in Brazzaville, Congo. Medecine Tropicale: Revue du Corps de Sante Colonial, 69, 45-47.Kochanek, K.D., Xu, J., Murphy, S.L., Minico, A.M. and Kung, H.-C. (2011) Deaths: Preliminary Data for 2009. National Vital Statistics Reports: From the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, 59, 1-51.Heidenreich, P.A., Trogdon, J.G., Khavjou, O.A., Butler, J., Dracup, K., Ezekowitz, M.D., et al. (2011) Forecasting the Future of Cardiovascular Disease in the United States. Circulation, 123, 933-944. https://doi.org/10.1161/CIR.0b013e31820a55f5Adoubi, K.A., Diby, F., Ouattara, I., Ouattara, P., Gnaba, A., Meneas, C., et al. (2014) Urgences cardiovasculaires au CHU de Bouake: aspects épidémiologiques, cliniques et évolutifsde 2011 à 2014. Cote d’ivoire.Leal, J., Luengo-Fernández, R., Gray, A., Petersen, S. and Rayner, M. (2006) Economic Burden of Cardiovascular Diseases in the Enlarged European Union. European Heart Journal, 27, 1610-1619. https://doi.org/10.1093/eurheartj/ehi733World Health Organization (WHO) (2015) Maladies cardiovasculaires.
http://www.who.int/mediacentre/factsheets/fs317/fr/Mendis, S. and Norrving, B. (2011) Global Atlas on Cardiovascular Disease Prevention and Control. World Health Organisation, WHO, Genève.
http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/Mbouemboue, O.P., Ngoufack, J.O., Koona, A.K., Maha, F. and Kingue, S. (2015) Place et Profil évolutif des Maladies Cardiovasculaires en Milieu Hospitalier Nord Camerounais: Le Cas de L’Hopital Régional de Ngaoundere. Health Sciences and Diseases, 16, 1-7.Kingue, S., Ngoe, C.N., Menanga, A.P., Jingi, A.M., Noubiap, J.J.N., Fesuh, B., et al. (2015) Prevalence and Risk Factors of Hypertension in Urban Areas of Cameroon: A Nationwide Population-Based Cross-Sectional Study. The Journal of Clinical Hypertension, 17, 819-824. https://doi.org/10.1111/jch.12604Vinsonneau, U., Bombert, C., Brondex, A., Castellant, P., Cornily, J.-C., Pennec, P.-Y., et al. (2009) à propos des urgences cardiovasculaires au cours des évacuations médicales héliportées réalisées par la Marine Nationale, au large des cotes du Finistère. étude rétrospective de 2000 à 2007. Annales de cardiologie et d’angéiologie, 197-202.Bertrand, E., Muna, W.F., Diouf, S.M., Ekra, A., Kane, A., Kingue, S., et al. (2006) Cardiovascular Emergencies in Subsaharan Africa. Archives Des Maladies Du Coeur Et Des Vaisseaux, 99, 1159-1165.Akpa, M.R., Alasia, D.D., Altraide, D.D., Emem-Chioma, P.C. and Wokoma, I.S. (2013) Profile and Outcome of Medical Emergencies in a Tertiary Health Institution in Port Harcourt, Nigeria. The Nigerian Health Journal, 13, 48-53.Kane, A., Diao, M., Kimbally-Kaki, G., Diop, I., Sarr, M., Ba, S., et al. (2002) Prise en charge des urgences cardiovasculaires au Sénégal. Cardiologie Tropicale, 28, 15-16.World Medical Association Declaration of Helsinki (1997) Recommendations Guiding Physicians in Biomedical Research Involving Human Subjects. JAMA, 277, 925-926. https://doi.org/10.1001/jama.1997.03540350075038von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gotzsche, P.C., Vandenbroucke, J.P., et al. (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. Bulletin of the World Health Organization, 85, 867-872.
https://doi.org/10.2471/BLT.07.045120Gombet, T.H., Ellenga-Mbolla, B.F., Ikama, M.S., Okiemy, G. and Etitiele, F. (2007) Urgences cardiovasculaires au centrehospitalier et universitaire de Brazzaville. Medecine d’Afrique Noire, 54, 505-511.Damorou, F., Baragou, S., Pio, M., Afassinou, Y.M., N’da, N.W., Pessinaba, S., et al. (2014) Hospital-Based Morbidity and Mortality from Cardiovascular Diseases in Tropical Areas: Example of a Hospital in Lomé (Togo). Pan African Medical Journal, 17, 62-62. https://doi.org/10.11604/pamj.2014.17.62.2237Coulibaly, T., Touré, M. and Traoré, M. (2001) Etude des accidents vasculaires cérébraux du sujet jeune dans les services de Cardiologie et de Neurologie au Mali. Thèse Médecine, FMPOS, Bamako.Kotto, R.M. and Bouelet, B.A. (2000) Cardiovascular Diseases in Adults in Douala (Cameroon). Cardiologie Tropicale, 26, 61-64.Lafay, V., Fourcade, L. and Bertrand, E. (2014) Prise en charge socioculturelle et médicale de l’hypertension artérielle en Afrique subsaharienne. Medecine Et Sante Tropicales, 24, 283-288.Noubiap, J.J.N., Jingi, A.M., Veigne, S.W., Onana, A.E., Yonta, E.W. and Kingue, S. (2014) Approach to Hypertension among Primary Care Physicians in the West Region of Cameroon: Substantial Room for Improvement. Cardiovascular Diagnosis and Therapy, 4, 357-364.Jingi, A.M., Noubiap, J.J.N., Onana, A.E., Nansseu, J.R.N., Wang, B., Kingue, S., et al. (2014) Access to Diagnostic Tests and Essential Medicines for Cardiovascular Diseases and Diabetes Care: Cost, Availability and Affordability in the West Region of Cameroon. PloS ONE, 9, e111812. https://doi.org/10.1371/journal.pone.0111812Falase, A.O., Oladapo, O.O. and Kanu, E.O. (2001) Relatively Low Incidence of Myocardial Infarction in Nigerians. Cardiologie Tropicale, 27, 45-47.Nkoke, C. and Luchuo, E.B. (2016) Coronary Heart Disease in Sub-Saharan Africa: Still Rare, Misdiagnosed or Underdiagnosed? Cardiovascular Diagnosis and Therapy, 6, 64-66.Nkoke, C., Luchuo, E.B. and Dikoume, L. (2017) Fatal Monomorphic Ventricular Tachycardia in a Semi-Urban Setting in Cameroon: A Case Report. BMC Research Notes, 10,180. https://doi.org/10.1186/s13104-017-2501-4