Clinical Presentations and Outcome of Cardiovascular Emergencies in Yaounde: A Cross-Sectional Study ()
1. Introduction
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. Methods
2.1. 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. Results
3.1. 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
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Table 1. Socio-demographic characteristics of the study population.
(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).
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Table 2. Symptoms on admission, risk factors, past medical history, and physical findings.
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Table 3. Cardiovascular emergencies.
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Table 4. Causes of death and the determinants.
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.