Pulmonary Heart Disease in Ibadan

Thorax: first published as 10.1136/thx.26.3.339 on 1 May 1971. Downloaded from

Thorax (1971), 26, 339.

Pulmonary heart disease in Ibadan

E. 0. SOFOWORA University College Hospital, Ibadan, Nigeria

Pulmonary heart disease is encountered and is not uncommon in the tropics. The incidence of the chronic form is expected to increase, while the causes of the acute form may be different from those in temperate countries and so require different prophylactic measures.

There is an extensive literature on various (b) disorders causing alveolar hypoventilation: disorders of the cardiovascular system in the (1) disorders of the chest bellows such as African (Davies, 1948; Abrahams, 1959; Brock neuromuscular diseases (poliomyelitis); and Gordon, 1959; Higginson, Isaacson, and chest deformities (kyphoscoliosis); extreme Simson, 1960; Phillips and Burch, 1960). There obesity; is, however, little reference to cor pulmonale (2) diseases with chronic obstructive airways- defined as right-sided heart disease secondary to emphysema, chronic bronchitis; asthma; disease of the lungs or pulmonary vessels. This (3) diminished activity of respiratory centre. no doubt stems from a dearth of information on the occurrence and prevalence of respiratory Although the above classification gives the diseases in the tropics, where respiratory disease impression that pulmonary heart disease is a has been almost synonymous with pulmonary chronic disorder, this is not so. Acute pulmonary tuberculosis. Further, it has been conjectured heart failure following on pulmonary embolism that the warm climate in the tropics, minimal air is one of the commoner and most lethal forms pollution, and, possibly, differences in smoking of pulmonary disease seen at necropsy in any http://thorax.bmj.com/ habits are all responsible for the apparently lower general medical hospital population. prevalence of chronic respiratory diseases such as chronic bronchitis compared with temperate CHRONIC COR PULMONALE countries. The present communication is a study of During the 33-month period at the University pulmonary heart disease or cor pulmonale as seen College Hospital, Ibadan (1966 to 1969), 54 cases in Ibadan over a 33-month were diagnosed as chronic cor pulmonale. The period (October 1966 criteria used for right ventricular hypertrophy to June 1969). The bias introduced into such a on September 28, 2021 by guest. Protected copyright. hospital sample is that common to similar studies. included prominent papillary muscles, thickness Pulmonary heart disease is defined here as right- of the right ventricle at the outflow tract exceed- sided heart disease manifesting as congestive heart ing 6 mm, and atheromatous plaques on the failure or right ventricular hypertrophy or both, intima of the pulmonary trunk. There was also secondary to disease of the lungs or pulmonary evidence of pulmonary vascular sclerosis on vessels. The ways in which the lung can adversely histological examination in all the cases. The affect the heart are two-fold: ventricles were not detached and weighed separ- principally ately but all the hearts were examined by a senior pathologist. The material has been analysed with (a) pulmonary vascular obstruction, obliteration respect to age, sex, clinical features, and associated or reduction as occurs in: diseases. (1) diffuse pulmonary fibrosis (e.g., sarcoidosis, AGE/SEX DISTRIBUTION Table I shows the age and pneumonociosis such as asbestosis, silicosis, sex distribution of the 54 patients studied. There Hamman-Rich syndrome); were 36 males and 18 females. Chronic cor (2) obstructive vascular disease (e.g., recurrent pulmonale appears commonest over the age of pulmonary embolism, collagen disorders, 40 years. The males were more affected than schistosomiasis); females with a ratio of about 3:1. 339 Thorax: first published as 10.1136/thx.26.3.339 on 1 May 1971. Downloaded from

340 E. 0. Sofowora

TABLE I ACUTE COR PULMONALE CHRONIC COR PULMONALE: AGE/SEX DISTRIBUTION By far the commonest cause of acute cor pul- Age (yr) Male Female monale in a general medical ward is pulmonary Under 30 1 3 30-39 4 2 embolism. Clinically, this is manifested by one 40-49 9 1 or more of the following features in a convalescent 50-59 5 6 60+ 17 6 postoperative or postpartum patient: unexplained Total 36 18 dyspnoea, sudden chest pain, haemoptysis, collapse, or tachycardia. Resistant oedema in a cardiac patient, cyanosis, and apprehension are occasion- ally presenting features. CLINICAL FEATURES The usual clinical features of In the period under study (1966-9), 49 cases cough, dyspnoea, cyanosis, clubbing of fingers and were diagnosed clinically and at necropsy. When toes, oedema of limbs with enlarged liver and compared with chronic cor pulmonale, the older raised jugular venous pressure were encountered. age group (over 40) was more affected and males These clinical features were not different from were affected more than females (Tables I and III). those in the Caucasians. The usual assumption Cardiac and other debilitating medical states were that cyanosis is difficult to observe in the African the commonest associated conditions (Table IV). is not absolutely correct although mild cases may Improved anaesthesia, pre- and postoperative care, present difficulty to the inexperienced eye. In fact, and early mobilization have greatly reduced the central cyanosis is best seen under the tongue in numbers following surgery. In spite of increased good light. surgical admissions to the University College Hos- pital due to the Nigerian civil war during the TABLE IL period under study, there were surprisingly few CHRONIC COR PULMONALE: ASSOCIATED DISEASE cases of pulmonary emboli. 1966/9 1963/5 (Present study) (Okuwobi, 1967) University College Lagos University TABLE III Hospital Teaching http://thorax.bmj.com/ Ibadan Hospital ACUTE COR PULMONALE: AGE/SEX DISTRIBUTION Total no. of cases 54 28 1959-64 Obstructive airways 32 19 Present Study Nwokolo and Ikoku (1966) Tuberculosis 15 8 1966-9 University College Chest deformity Hospital (Kyphoscoliosis) I - Bronchiectasis 4 Age (yr) Male Female Male Pulmonary hypertension Female (Hb SC disease) 2 0-19 4 1 4 1 Unknown (? sarcoidosis) - 1 20-39 4 16 9 17 40-59 7 8 10 8 60+ 8 1 9 0 on September 28, 2021 by guest. Protected copyright. ASSOCIATED DISEASES Table II shows the diseases found commonly to be associated with chronic TABLE cor pulmonale in this series. This is compared IV with figures from a teaching hospital in Lagos- ACUTE COR PULMONALE: ASSOCIATED DISEASES a distance of about 90 miles from Ibadan Cardiac disease 11 Post-surgical . 4 (Okuwobi, 1967). Diabetes mellitus . . 3 Diseases which have obstructive airways- Post-partum . . 3 Malignancy... .. 3 chronic bronchitis, emphysema, bronchial asthma Tetanus 2 -form by far the commonest causes of chronic Miscellaneous medical cases 25 cor pulmonale in these two series, closely followed by pulmonary tuberculosis. The mortality in the present series was 83-7%. INVESTIGATlONS Chest radiographs, ECGs, sputum Although this is a potentially curable disorder examinations, blood counts, and haemoglobin surgically and prevention of further attacks is genotypes were carried out in all patients, 10 of highly successful in special centres, these thera- whom also had pulmonary function tests. The peutic measures can be introduced only if a results showed in general reduced Po2 and correct diagnosis is made, and unfortunately this increased Pco2 as expected. is notoriously difficult. As chest radiographs may Thorax: first published as 10.1136/thx.26.3.339 on 1 May 1971. Downloaded from

Pulmonary heart disease in Ibadan 341 not be helpful and ECGs, lactic dehydrogenase Diseases with obstructive airways form by far estimation, pulmonary angiography, and lung the commonest cause of chronic cor pulmonale scanning are not universally available, a high in temperate countries. In contrast to our expec- index of suspicion is desirable. tation, this is the finding in the two series from In the tropics, patients with abnormal haemo- Nigeria (Table II). These conditions are pre- globin need particular observation as they are sumed to be uncommon in the tropics because especially prone to thrombosis (Edington, 1955; of a relative absence of significant aetiological Moser and Shea, 1957; Woodruff, 1961; Nwokolo factors. The prevalence of chronic obstructive and Ikoku, 1966). airways has not been determined in the tropics Although attention has so far been directed although evidence from necropsy studies by Stuart to thromboembolism as a source of acute cor and Hayes (1963) in Jamaica showed that 14% pulmonale, other types of emboli have been seen, of all cases of right-sided heart failure were due for example, marrow emboli in sickle-cell crisis; to chronic lung disease. Hayes and Summerell tumour emboli in malignant trophoblastic disease; (1963) thought that emphysema in Jamaica was and amniotic and fat emboli. as prevalent as in a temperate environment. The author has also observed that in rural com- DISCUSSION munities in Igboora in Western Nigeria chronic respiratory diseases are not uncommon (Sofowora, Over the last few years at the University College in preparation). Hospital, Ibadan, there has been an upward trend The figure for tuberculosis may be an under- in the percentage of all cases of cardiac disease estimate because most cases, in both Lagos and attributable to cor pulmonale as compared with Ibadan, go to the Government chest clinics which the series of Lauckner, Rankin, and Adi (1961) have been operating for the last 10 years. Tuber- and Ikeme and Parry (1966) shown in Table V. culosis, fast disappearing in the developed coun- In Lagos, cor pulmonale forms the second com- tries, is still rampant in the tropics, and inadequate monest cause of heart failure (Okuwobi, 1967). treatment due to a high default rate and an This rise is due to an increased awareness of the insufficiency of drugs often leads to fibrosis which

presence of the condition and the fact that every then predisposes to cor pulmonale. It is still a http://thorax.bmj.com/ chronic cough is no longer regarded as due to great problem in Nigeria and the resistant variety tuberculosis. Furthermore, people tend to seek is increasing due to poor management. Unless medical attention earlier because they are aware measures are taken to improve the overall manage- of the facilities and services of a chest clinic. ment of tuberculosis, the contribution of this disease to chronic cor pulmonale will either remain the same or increase. TABLE V Chest deformity, including kyphoscoliosis, due FREQUENCY OF COR PULMONALE IN CARDIAC CASES STUDIED to tuberculosis is also seen. Bronchiestasis is common and tends to progress to cor pulmonale at on September 28, 2021 by guest. Protected copyright. University College University Teaching Hospital Hospital an early age because of improper management Ibadan Lagos early on in the disease. Other aetiological factors 1966-9 which have been seen in the University College 1958 1965 (Present 1963-5 review) Hospital infrequently are schistosoma affection of (Lauckner (Ikeme the lungs and recurrent intravascular sickling from et al., and (Okuwobi, 1961) Parry, 1967) microemboli in haemoglobin SS and SC disease. 1966) Chronic bronchitis and emphysema form the Total highest percentage of our cases, and with increas- cardiac 139 151 245 157 cases ing industrialization, atmospheric pollution, and Cor pul- 1% 9 Y, 23-9y% 21% smoking habits the frequency and severity will monale probably increase. Further studies into the role of abnormal The age-sex distribution observed is in keeping haemoglobin in the pathogenesis of pulmonary with that of temperate countries. The younger hypertension and eventual cor pulmonale are in age groups suffer from the end result of badly progess. While the SS (homozygous) patient group managed pulmonary tuberculosis and bronchi- tends to die at an early age, the AS and SC ectasis while the older age groups suffer from patients tend to live a normal life span. Intra- chronic bronchitis and emphysema. vascular sickling, leading eventually to vascular Thorax: first published as 10.1136/thx.26.3.339 on 1 May 1971. Downloaded from

342 E. 0. Sofowora narrowing and hypertension have been well docu- Davies, J. N. P. (1948). Endomyocardial fibrosis in Africans- mented (Moser and Shea, 1957; Olazabal et al., E. Afr. med. J., 25, 10. 1968). It seems, therefore, that with these other Edington, G. M. (1955). The pathology of sickle-cell disease- in West Africa. Trans. roy. Soc. trop. Med. Hyg., aetiological factors prevalent in the tropics, the 49, 253. frequency of chronic cor pulmonale will closely Hayes, J. A., and Summerell, J. (1963). Emphysema in, approach and, in due course, may even exceed Jamaica. W. Indian. med. J., 12, 34. that in temperate countries. The acute variety Higginson, J., Isaacson, C., and Simson, I. (1960). The is possibly commoner than in the temperate coun- pathology of cryptogenic heart disease. Arch. Path., tries because of the added effects of abnormal 70, 497. Ikeme, A. C., and Parry, E. H. 0. (1966). Cardiovascular- haemoglobins. As therapy and prophylaxis are Disease in Nigeria, p. 81. Ibadan University Press. far ahead of diagnosis in this latter variety, a high Lauckner, J. R., Rankin, A. M., and Adi, F. C. (1961). index of suspicion is called for. There is an Analysis of medical admissions to University College urgent need for the determination of the extent Hospital, Ibadan, 1958. W. Afr. med. J., 10, 3. of these disorders, especially the chronic variety. Moser, K. M., and Shea, J. G. (1957). The relationship between pulmonary infarction, cor pulmonale and the We may find that measures necessary to reduce sickle states. Amer. J. Med., 22, 561. the incidence and severity of these conditions in Nwokolo, C., and Ikoku, N. (1967). Pulmonary embolism the tropics may be different from those currently in Nigeria. J. Nig. med. Ass., 4, 45. being applied in temperate countries. Okuwobi, B. 0. (1967). Pattern of heart failure at Lagos University Teaching Hospital. W. Afr. med. J., 16, 198. I wish to express my gratitude to Dr. T. I. Francis, Olazabal, F., Roman-Irizarry, L., Oms, J. D., Conde, L., Dr. R. Carlisle, Professors T. 0. Ogunlesi, B. K. and Marchand, E. J. (1968). Pulmonary emboli mas- Adadevoh, and A. 0. Williams, for various sugges- querading as asthma. New Engl. J. Med., 278, 999. tions in the preparation of this paper, and to Mrs. 0. Phillips, J. H., and Burch, G. E. (1960). A review of cardio- Olunloyo for secretarial assistance. vascular diseases in the white and Negro races. Medicine- (Baltimore) 39, 241. Stuart, K. L., and Hayes, J. A. (1963). A cardiac disorder REFERENCES of unknown aetiology in Jamaica. Quart. J. Med., Abrahams, D. G. (1959). An unusual form of heart-diseas! 32, 99. in West Africa. Its relation to endomyocardial fibrosis. Woodruff, A. W. (1961). In Recent Advances in Tropical Lancet, 2, 111. Mledicine, 3rd. ed., ed. N. H. Fairley, A. W. Woodruff, http://thorax.bmj.com/ Brock, J. F., and Gordon, H. (1959). Ischaemic heart and J. H. Walters. p. 421, Churchill, London. disease in African populations. Postgrad. med. J., World Health Organization (1961). Chronic cor pulmonalev 35, 223. Wld Hlth Org. techn. Rep. Ser. No. 213, Geneva. on September 28, 2021 by guest. Protected copyright.