Lupine Publishers | Advancements in Cardiology Research & Reports
Introduction: Cardiac decompensation factors are numerous. Their identification allows better management of patients
and limits the rate of rehospitalization. The aim of this work was to identify cardiac decompensation factors and improve their
management at the renaissance hospital in N’Djamena, Chad.
Patients and Methods: This was a cross-sectional retrospective study conducted in the cardiology department at N’Djamena
Renaissance Hospital, over a period of one year, from 01 January 2018 to 01 January 2019. All patients hospitalized for cardiac
decompensation during this period and consented, were included.
Results: During the period of our study, 52 patients were
included. The sex ratio was 1.9. The mean age was 48±9 years old. The
predominant cardiovascular risk factors were arterial hypertension (37%,
n = 19) and diabetes (27%, n = 14). The monthly income
of our patients was in the majority of cases less than 200,000 FCFA
(44%, n = 23). The main factors of cardiac decompensation were
respectively, infections (18%, n = 9), supraventricular arrhythmias
(16%, n = 8), changes in temperature (11%, n = 6), therapeutic
nonobservance (11%, n = 6), dietary gap (10%, n = 5), and hypertensive
relapses (10%, n = 5). The main etiologies of heart failure
were ischemic cardiomyopathies (31%, n = 16), dilated cardiomyopathies
(25%, n = 13), hypertensive cardiomyopathies (17%, n =
9), and rheumatic valvulopathies (15%). %, n = 8).
Conclusion: Rehospitalizations for cardiac decompensation are common after the first episode of hospitalization. The
identification of the risk factors for this decompensation and their management make it possible to avoid these readmissions.
Keywords: Cardiac decompensation factors; Heart failure; Renaissance hospital N’Djamena characterized
Abbreviations: HF: Heart Failure; FFCA: Franc of the Financial Community in Africa; AFA: Atrial Fibrillation Arrhythmia; LV: Left
Ventricle
Introduction
Heart failure (HF) is defined as a clinical syndrome
characterized by chronic symptoms (dyspnea, fatigue) that may be
accompanied by physical signs (crepitus, peripheral edema) caused
by a structural cardiac abnormality and / or functional, resulting in
decreased cardiac output [1]. It is a major public health problem
because of its frequency and consequences in terms of morbidity
and mortality and its economic impact on the health care system.
Its prevalence is increasing because of the aging of the population
but also because of the improvement of the management of
many heart diseases including ischemic heart disease. It is one
of the leading causes of hospitalization, morbidity and mortality,
especially among the elderly [2]. Its evolution is clinically marked
by periods of remission and exacerbation leading to recurrent
hospitalizations. The number of readmissions for IC remains
significant despite the therapeutic progress of recent years. The
identification of decompensation factors and the optimization of
their management could prevent these readmissions, particularly
after hospitalization. The objective of this study was to identify
cardiac decompensation factors and improve their management at
the renal hospital in N’Djamena, Chad.
Patients and Methods
This was a cross-sectional retrospective study conducted in the
cardiology department at N’Djamena Renaissance Hospital, over
a period of one year, from 01 January 2018 to 01 January 2019.
Were included all patients readmitted for cardiac decompensation
during the study period and who gave their consent.
The parameters studied
Epidemiological characteristics: age, sex, cardiovascular risk
factors (arterial hypertension, diabetes, chronic renal dysfunction
with glomerular filtration rate <60ml/min / 1.73m2, obesity,
dyslipidemia, alcohol, smoking), monthly cost of treatment in
FFCA (1 US dollar = 593,720 FFCA). Clinical features: cardiac
decompensatory factors (difference in diet, unsuitable exercise,
temperature, alcohol, AFA, other rhythm disorders, hypertensive
pressure, ischemic episode, anemia, bronchopulmonary
infection, other infection, renal failure, poor compliance drug,
hyperthyroidism, untreated sleep apnea syndrome), etiologies
of HF. Electrocardiographic characteristics: arrhythmias (atrial
or ventricular extrasystoles, atrial fibrillation or flutter, atrial
tachycardia, ventricular tachycardia), repolarization abnormalities,
sinoatrial or atrioventricular blocks. Echocardiographic features:
dilated cardiac cavities, wall hypertrophy, diastolic dysfunction
of the left ventricle (LV); abnormalities of left ventricular kinetics
(hyperkinesia, hypokinesia, akinesia), LV systolic dysfunction
(systolic ejection fraction <45%), valvular abnormality, congenital
anomaly, pulmonary arterial hypertension.
Statistical Analysis
In this study, a descriptive statistical analysis was applied using
Microsoft Excel, quantitative variables were presented by their
mean and standard deviation and qualitative variables were by
percentages.
Ethics
This work was done by obtaining the approval of the hospital
management and the consent of the patients.
Results
During the period of our study, 52 patients were included. Men
predominated with 65% of cases (n = 34). The sex ratio was 1.9. The
average age was 48±9 years old with a minimum age of 22 years and
a maximum age of 79 years. Patients were educated only in 38% of
cases (n = 20). The predominant cardiovascular risk factors were
hypertension (19%), diabetes (14%), dyslipidemia (11%), and
19%). The monthly income of our patients was in the majority of
cases less than 200,000 FCFA. The rates were, respectively, between
CFAF 100,000 and 200,000 in 44% of cases (n =23) and less than
CFAF 100,000 in 33% of cases (n = 17). Only 12 patients (23%)
had an income above 200,000 FCFA. The health insurance rate was
observed in 13% of cases (n=7). (Table 1) shows the characteristics
of the patients. The main factors of cardiac decompensation are
shown in Table 2. The most frequent were respectively, infections
in 18% of cases (n = 9), including 4 cases of bronchopulmonary
infections (8%), supraventricular rhythm disorders in 16% of cases
(n=8) including 5 cases of AFA (10%), changes in temperature
especially heat with 6 cases (11%), poor therapeutic compliance
6 cases (11%), the difference diet in 10% of cases (n = 5), and
hypertensive outbreaks in 10% of cases (n=5). The most common
etiologies of IC (Table 3) were ischemic cardiomyopathies in 31%
of cases (n=16), of which 4 patients (8%) had benefited from
myocardial revascularization, dilated cardiomyopathies in 25%
(n=16). = 13), hypertensive cardiomyopathies in 17% of cases (n
=9) and rheumatic valvulopathies in 15% (n=8). Other etiologies
were less frequent in this series such as post-embolic pulmonary
heart in 6% of cases (n=3), congenital heart disease in 4% (n=2)
and pericardial affections in 2% of cases (n= 1).
Table 1: Patient Characteristics.
Table 2: Cardiac Decompensation Factors.
Table 3: Etiologies of HF.
Discussion
The post-hospitalization period is conducive to rehospitalization,
but long-term chronic HF patient follow-up is
important because the morbidity and mortality rate remains
high in this group of patients, even though many treatments have
been shown to be effective. The follow-up of these patients makes
it possible to optimize the therapeutics, the monitoring and to
detect early the signs of decompensation. Cardiac rehabilitation
plays an important role in the management of HF and should be
part of the modern strategy for the management of patients with
stable heart failure. This includes not only physical training, but
also rehabilitation of drug treatments, control of risk factors,
psychological management and finally, patient education [3]. The
search for this factor that shifts a situation of balance during a
decompensation is fundamental because its treatment can be very
profitable. Several standards for HF support highlight the need to
look for a triggering factor [4]. We studied the importance of triggers
for cardiac decompensation in a population of readmitted patients
who were followed for chronic HF. The main triggering factors
identified were, in order of frequency, infections, atrial fibrillation,
therapeutic nonobservance, temperature variations, mainly heat,
uncontrolled hypertension, diet deviation, anemia, myocardial
ischemia. These factors are globally found in the literature data.
In this study, the first triggering factor found was the existence
of an infection (18%) with bronchopulmonary infections (8%)
at their head. They are promoted by decreasing the effectiveness of
coughing, bronchiolar elasticity, efficiency of the mucociliary
system and swallowing disorders.
The mechanisms involved in cardiac decompensation are
multiple. Several studies have highlighted the important role of
infections, particularly bronchopulmonary infections, in cardiac
decompensation, especially in elderly patients [5-8]. The second
triggering factor was a supraventricular rhythm disorder (16%),
especially ACFA (10%). Suppression of atrial systole results in
increased LV filling pressures and promotes the onset of HF thrust.
AFA is common in HF and its prevalence increases with the severity
of CI [9-13]. Cardiac decompensation was attributed to noncompliance
in 8% of the cases in this study, but adherence remains
difficult to assess. This non-compliance was favored by several
factors in our patients; the high number of drugs with their adverse
effects, given the high rate of comorbidities observed (diabetes,
high blood pressure, kidney failure), the economic level which was
low in almost 50% of patients and the absence of health insurance,
the level of education and the influence that might have on the
understanding of the disease. The therapeutic nonobservance in
the HF varies in the literature from 10 to 99% according to the
evaluation method used [14]. Compliance is responsible for an
increase in the number of hospitalizations and a worsening of
clinical signs [15]. A multidisciplinary intervention has shown
its effectiveness on adherence to 30-day treatment [16] and an
educational intervention has improved compliance and decreased
re-hospitalization rates [17]. Anemia was found in 4 patients in our
series.
This result is weak compared to data from the literature because,
according to several authors, anemia is frequent during IC and is
a poor prognostic factor in chronic HF [18,19], increased clinical
signs, aggravation of functional status [20]. However, there is little
data on the involvement of acute anemia in cardiac decompensation.
In addition, the management of the etiology of HF remains essential
to prevent complications and readmissions and to improve the
prognosis. In our study we found that in coronary patients (31%)
only 8% had benefited from myocardial revascularization, valvular
patients (15%) and those with congenital heart disease (4%) had
not received reparations. surgical procedures that were necessary.
In our context, the identification of the decompensation factors
must be of paramount importance for the clinician and should allow
the improvement of the management of the pathology in particular
at the preventive level. Hence the importance of educating the
patient and those around him. The establishment of appropriate
structures and care networks for heart failure in all regions of Chad
will allow better monitoring of patients with rapid access to the
specialist physician.
The limits of our work
Our study presents several methodological limitations. First, it
is a retrospective study with information gathered from the reports
that sometimes did not contain all the necessary data. The size of
our sample is small, we will have to lead other more representative
studies in the future. And many patients have not received etiologic
treatment of HF.
Conclusion
Rehospitalizations for cardiac decompensation are common
after the first episode of hospitalization. The identification of the
risk factors for this decompensation and their management make
it possible to avoid these readmissions. Hence the importance of
emphasizing access to care with appropriate therapeutic means,
regular monitoring and therapeutic education.
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