Inhospital cardiovascular morbidity and mortality in the department of internal medicine at CHU Kigali (Rwanda) Etienne Amendezo l , Marc Twagirumukiza l 'l,3, Osee Sebatunzi1,1, Abel Kagame1•2 'Department ofIntemal Medicine, University Teaching Hospital of Kigali and Butare, 2Faculty of Medicine, National University of Rwanda, Butare,Rwanda, lHeymans Institute ofPhannacology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
SUMMARY
Cardiovascular diseases (CVD) formerly considered as developed countries pandemic, are becoming nowadays increasingly ubiquitous in developing countries, where in addition to a steady increase in different risk factors, there is substantial inaccessibility to health care. However. data about the burden of CVD is lacking in many sub-Saharan African countries, and their morbimortality characteristics have been poorly described. Authors carried out a descriptive and retrospective study over a 12wmonth period, to describe the inhospital morbidity and mortality of CVD in the Department of Internal Medicine at University Teaching Hospital in Kigali City. Data - were collected from 226 CVD cases (91 males and 135 females). The patients' age ranged from 26 to 94 years (mean age of 47.17 ± 16.04). The 226 CVD cases account for the 8.2% of hospitalized patients. Hypertension was the principal cause of death (43.1% of deaths) and the predominant cause of patients' admission (42.9%), followed by cardiomyopathies (11.9%) and valvular heart diseases (11.5%). The association betvv"een a CVD and HIV/ AIDS infection was observed in 23.9% of the total patients, but no causality relationship was investigated. Isolated heart failure takes the first place (33.6%) among the cardiovascular complications, followed by stroke (14.2%) and isolated renal failure (7.5 0;b). Findings of this study confirm the importance of CVO-in CHU Kigali, not only by their inhospital frequency but also wand especially by their lethality rate and their' complications associated. This study stresses also a real need of CVD community survey in Rwanda Key words: Cardiovascular disease, cardiomyopathy, HIV / AIDS, morbidity, mortality, Rwanda, sdhwSaharan Africa.
Introduction Cardiovascular diseases (CVDs) represent more than a half of noncommunicable diseasesll ] and a major public health problem all over the world because of their high morbidity and mortality/I,21 and by related economic impact on health expenditures,!JI Among a total of 58 millions deaths registered worldwide in 2005, noncommunicable diseases represented 35 millions, and among these, 17.5 millions (50.8%) were attributable to CVDs.l 41The CVDs were therefore qualified as the first cause of death worldwide ll ,51 and is set to overtake infectious diseases in the developing world in term of morbidity and mortality.l2,61 It has been discussed in the literature that, the increase of cardiovascular incidence in modern society is associated to the aging, however in sub-Saharan Africa (SSA) countries where life expectancy is still low, the CVDs burden seem to be related to life style change,
epidemiologic transition and therefore an increase of exposure to different risk factors associated with CVDs.17J The emerging cardiovascular risk factors linked to modernization accounts for the growing burden of CVD in SSA, are challenged by deficient and/or insufficient infrastructure and thus experiencing inadequate health care.l6,8.9J According to World Health Organization (WHO) 2005, these epidemiologic transition linked factors are responsible for 75% of all CVDsllOI and hence constitute a priority because of their impact on the increasing cardiovascular morbidity and mortality)lI-l31 as well as the possibility of modifying them by effective preventive measures.!I,14] In developing countries moreover, the access to health care facilities being still difficult,(ls,161 there is delay in diagnosis, leading to a late treatment, and to a very difficult follow-UPi I17,18! justifying among other causes - the high morbidity and mortality rates associated with CVDs.114,16]
Correspondence: Marc Twagirumukiza, Heymans Institute ofPhannacology, Faculty ofMedictne and Health Sciences, Gent University, 9000, Gent, Belgium. E-mail:
[email protected] Ann Trop Med Public Health I Jan:Jun 2008 I Vol 1 I Issue t
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AmendelO, et aI.: Inhospital cardiovascular morbid·mortality in Rwanda
In contrast to other low setting places}ll,19-111 inhospital studies in Rwanda to evaluate the current situation of CVDs are still scarce.l231 The authors are not aware of any community-based cardiovascular survey which should have been conducted in Rwanda. The one published paper reported an hospital data in 2001 at Butare University Hospitalli 41 and during this study the literature search listed six other hospital unpublished data.[24. 291 The aim of this study is to investigate the epidemiologic, clinical, and prognostic features of CVDs in the department of internal medicine at CHU Kigali.
The patients' age ranged from 16 to 94 years with a mean age of 47.17 ± 16.04 SD years. There were 91 males {40.3%) and 135 females {59.7%) with a sex ratio MIF of 0.67. CVD were more frequent in females than in males (59.7% females vs. 40.3% males) and people in the age range of 46-60 years were the most affected {25.2%}. However, the frequency of 24.3% in the younger population is surprising [Table 1]. In all age groups, gender is not associated with cardiovascular morbidity [Table 1Lexcept in advanced age where men are more affected than women (P = 0.031).
Materials and Methods A descriptive and retrospective study was carried out at University Teaching Hospital of Kigali, namely 'Centre Hospitalier Universitaire {CHU) de Kigali'- Internal Medicine Department, in Kigali City, between January I, 2005 and December 31, 2005 (l2 months). Data were collected from patients' records admitted for cardiovascular problems in the medical wards. Files for patients transferred nom the medical wards to the Intensive Care Unit, during the study period, were reviewed as well. All patients aged below 15 years, ambulatory patients and patients not diagnosed with CVD were excluded from the study. A questionnaire was used for data collection. The following parameters were systematically collected: age, sex, residence, socioprofessional category, medical and family past histgry, clinical signs/symptoms on admission, time between appearance of first signs/symptoms and the start of treatment, diagnosis, type of CVD, treatment received, complications, inhospital stay duration, and patient's prognosis at discharge. Data entry and analysis were realized using EpiData and SPSS 11.5. Results
Epidemiologic features Out of 2858 patients, the total number of patients admitted in the Department of Internal Medicine, 226 were admitted for cardiovascular problems. Hence, the cardiovascular in hospital frequency was 8.2%. The patient's in hospital stay period ranged between 1 and 120 days with a mean range of 15 ± 23 SD days. The follow-up noticed a mortality of 581 {20.3%) cases, of whom 67 {27 males and 40 females) were attributable to CVDs. The inhospital cardiovascular mortality rate byCVD is 2.34% (67/2858); where as the cardiovascular fatality rate is 29.6% (67/226).
II
Clinical and diagnostic features Medical history Fifty-four {23.9%) patients were HIV positive. For 45 cases (19.9%) cases whose past medical history was not known. As the time between the appearance of the first symptom and start of treatment is analyzed, the study found that 41.6% of patients begun the treatment within 2 weeks vs. 26.5% who begun it 2 months or more, after appearance of the first symptoms. Clinical signs of CVDs \ Vertigo, respiratory distress, cough, ch,est pain, and headache were the most frequent clinical signs! symptoms with respective frequencies of 70.8%,54.9%, 52%,50.9%, and 50%. The study found that 23% of the patients presented with generalized edema. Arterial Hypertension (HT) was found to be the most common diagnosis at admission day (42.9%). Other early diagnoses included cardiomyopathies {Il.9%), valvular heart disease {Il.5%), pericarditis (8%), vascular disease {7.l %), and others (11 %). Therefore, 7.5% patients were admitted for heart failure of unknown etiology. The outcome of those patients is dominated by recovering (70.1 %). HoweveI; inhospital-specific mortality for CVD was high {29.60,'0) ITable 2]. The HT was the principal cause of death {43.1 %), followed by heart failure of unknown etiology (16.4%). Table 1: Patients' distribution according to age and sex So
75
18 19 27 17 I.
Total
91 (40.3%)
135 (59.7%)
55 (24.3) 54 (23.9) 57 (25.2) 45 (19.9) 15 (6.6) 226(100)
