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

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.

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.

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.

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.

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.

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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