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Background: The increasing prevalence of cardiovascular diseases in subsaharan Africa and their related mortality and morbidity have been established. A large number of them present as emergencies. The purpose of this first multicentric study was to assess the causes, management and outcome of cardiovascular emergencies in savannah and forest environments., Methods: A total of 665 patients were included from seven participating centers in seven countries: 417 were classified as belonging to the savannah zone (Dakar, Nouakchott, Ouagadougou, N'djamena) whereas 248 patients were from the forest zone (Abidjan, Libreville, Yaounde). Patients were examinated by one or several cardiologists. Statistical analysis was performed by the Medical Statistic Unit of the Hopital Nord, Marseille (France)., Results: There were more men (53.4%) than women (46.6%). 77.7% of the patients lived in urban areas. Most of them had low or very low incomes. Patients reached the hospitals in ambulances only in 6.2% of cases. The remaining others were transported by routine urban vehicle or bicycle or ambulation. The mean delay between the onset of symptoms and the arrival to the emergency unit was 6.8 days. Three immediate situations were preponderant: severe hypertension (32.2%), heart failures NYHA IV (27.5%), stroke (20.3%). Underlying conditions were: mainly chronic hypertension (52.3%), cardiomyopathies (20.6%), valvular heart diseases (11.1%). Coronary heart diseases were rare (6.1%). The observed mortality was 21.2% without any differences in age groups. The most common emergencies resulting in death included: stroke (31.9%), vascular collapses (18.4%), pulmonary embolism (9.2%). The patients from the savannah zone were younger, more often classified in the low or average socioeconomic level. Hypertension was more frequent in forest zones. Valvular heart diseases were more frequent in savannah. Cardiomyopathies were comparable in both zones. Coronary heart disease was slightly more common in the savannah area., Discussion: Compared with patients from western countries, the African patients are younger because some diseases affect young people like rheumatic heart disease or postpartum and infectious cardiomyopathies. The difficulties to reach health care facilities made the outcome more severe. Hypertension and valvular heart disease deserve priority in preventive strategy. Cardiomyopathies have to be studied to precise their causes. Finally, the management of cardiovascular emergencies needs a special care in the hospitals owing to their increasing frequency and their severity.

Though the environmental and medical conditions are very different, similar population characteristics can be observed in the developing countries. The mean age of the population is young. Most people have a rural way of life, but migrations towards towns result in a disorganized urbanization and in habits more predisposing to cardiovascular diseases. Care access is often difficult for the patients. With respect to risk factors, smoking is increasing, hypertension is highly prevalent and severe, a trend towards obesity is frequent in medium or high economical level people. S or C hemoglobin diseases seem to be associated with coronary heart disease. In spite of very insufficient statistical data, it appears that: cardiovascular disease mortality is increasing when total mortality is decreasing: ischemic and hypertensive heart diseases are increasing when streptococcal or nutritional heart diseases are stabilizing or decreasing. The authors seem to be the different developing countries in respect to the crossing of these curves. Some countries have not reached the crossing. Subsaharan Africa for instance. Others have gone beyond the crossing, some Asian countries for instance. Other countries seem to be at the intersection (Mediterranean or Latin American countries). But many countries suffer the double burden of increasing and decreasing diseases. There is a general lack of prevention owing to other competing priorities and also to economical, social and educational difficulties. However in some developing countries feasibility and efficacy of preventive measures have been proved.

The incidence of post-partum cardiomyopathies (PPCM) represents 5% of all cardiomyopathies and 10-13% of cardiomyopathies in women. The outcome of PPCM may be: a) death in the acute phase, b) evolution to chronic myocardial disease or c) complete recovery, in which PPCM differs from dilated cardiomyopathy. Another difference is that PPCM may not recur in subsequent pregnancies. The aetiology and pathogenesis of PPCM are still unknown. Infectious diseases, nutritional disorders have been reported but they do not account for the majority of cases. Immune responses to the foreign tissue of the placenta and foetus may explain alteration of immune function associated with myocardial lesion. In the author's experience, the most common pathogenic mechanism is latent myocardial insufficiency observed in each woman in the normal post-partum period. The different noted "causes" could be factors which reveal this latent common condition. Recently, cardiac transplants for PPCM have been reported. As patients with PPCM may recover completely, we believe that PPCM is not a special priority for transplantation. Two recent studies have compared the outcome of women undergoing transplantation for PPCM and those for dilated cardiomyopathy. The risk of rejection and infection was greater in PPCM (but the difference was significant in only one report). The long-term survival was favourable in both groups.

The authors studied 31 cases of coronary artery disease with normal or minimally diseases coronary arteries in black Africans, 29.8% of 104 coronary patients undergoing coronary angiography in this series. These 31 cases comprised 16 cases of infarction, 10 cases of angina, 3 ventricular aneurysms and 2 cases of silent ischemia in diabetic patients. Twenty-five patients were men (80.6%). There were 6 women (19.3%) two of whom presented in the post-partum period. The average age of these patients was 45 years (males: 47.7 years; females: 41.8 years). The following risk factors were noted: smoking (60%), hypertension (25.8%), obesity (29%), diabetes (12.9%), serum cholesterol (average 2.15 g/l), serum triglycerides (average 1.25 g/l). The risk index per patient was 1.29. In comparison with coronary patients with angiographic coronary lesions (n = 73), the patients with normal angiography were significantly younger, comprised more females and had fewer risk factors (especially hypertension and diabetes), though this was not statistically significant. The prevalence of inaugural infarction was 81.2% in the cases of infarction with normal coronary arteries. These infarcts may be complicated by ventricular aneurysm formation. Spontaneous spasm was observed in 3 out of 31 patients (9.6%) at coronary angiography. A provocative test was performed in only 2 cases and 1 was positive. This deserves further study and may have therapeutic implications. The authors emphasise the high incidence of hemoglobin S or C traits (57.1%). These heterozygotic hemoglobinopathies could be a risk factor in these coronary patients with normal coronary angiography.

This study reports the results of a multicentre enquiry performed in France in 1990 which included 41,242 adults hospitalised in Cardiology Units, 33,907 children hospitalised in Pediatric departments and 8,868 soldiers. A comparative enquiry was also carried out in North Africa (Tunis) and West Africa (Abidjan, Ouagadougou). The results of the French arm of the enquiry showed that rheumatic heart disease (RHD) has become very rare in adults (3.1% of all cardiac disease) and that it tends to occur in older subjects (average 54.4 years of age). There is practically no RHD in young adults. This decreased prevalence of RHD is confirmed in children in whom this diagnosis represents only 0.04% of cases of all cardiac disease--of which 87.5% are of extra-European origin. In contrast, there is a high frequency of RHD in Tunisia (29.3%) and West Africa (13.2% in Abidjan and 13% in Ouagadougou). The disease remains active as is shown by the age of affected adults in Africa (average 21 and 27 years of age). The results also show a reduction to a very low prevalence of acute rheumatic fever in French pediatric departments (0.005%). The authors discuss the reasons for the persistence of endemic infection in Africa: virulence of the streptococcus, predisposing factors (HLA group?), geographic factors and, above all, socioeconomic factors and difficulties in obtaining treatment and prophylaxis. A movement of international cooperation is suggested in order to combat RHD in Africa, especially with regards to its prevention in childhood.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report the case of a 34 year old woman with postpartum myocardial infarction due to spontaneous coronary dissection of the distal circumflex artery. A spontaneously regressive spasm of the right coronary artery was also observed. The outcome with heparin, glyceryl trinitrate and calcium antagonist therapy was favourable. Over one year later, coronary angiography showed total resolution of the dissection and a large aneurysm of the inferior and septal walls of the left ventricle. This case is an example of post-partum spontaneous coronary dissection, in a particular vascular context. There are, however, other causes of spontaneous coronary artery dissection (atherosclerosis, eosinophilic syndrome...). Spasm may aggravate the consequences of coronary artery dissection and cause worse myocardial damage. The medical treatment, especially with regards to thrombolytic therapy, requires further codification.

The aim of this study was to evaluate spontaneous changes of Doppler and echocardiographic parameters of cardiac transplants in the absence of rejection. Based on 258 recordings representing the follow up of 30 patients after orthotopic cardiac transplantation in the absence of histological signs of rejection on biopsy within 24 hours, we tried to define: the evolution of these parameters from the first postoperative week to after the 30th month (average 12 months); the Doppler echocardiographic values of "normal" transplants: the values observed one year after surgery were compared with a control group age-matched to the donors.(ABSTRACT TRUNCATED AT 250 WORDS)

During the last 10 years, 17 children with transposition of the great arteries (TGA) were admitted to the Cardiology Institute of Abidjan: 1 case between March 1978 and December 1985, 16 cases between January 1986 and December 1989. The average age was 58 days (range 5 to 270 days) at the first consultation, and 90 days (5 to 270 days) at the time of admission. The diagnosis was confirmed by echocardiography and hemodynamic investigation in 12 cases. There were 9 simple forms of TGA, 7 with ventricular septal defects (VSD) and 1 with VSD and pulmonary stenosis. Two children were taken back by their parents before any treatment was given. A Rashkind atrial septostomy was carried out in 11 children which increased aortic oxygen saturation from 35 +/- 18 percent to 57 +/- 19 percent; there were 3 unsuccessful procedures in children aged 2, 3 and 5 months with 2 deaths. Five patients later underwent surgical correction by a Senning procedure in 4 cases and anatomical correction in 1 case with VSD. All are well after an average 15 months follow-up (1 to 48 months). One of the 8 children awaiting surgery died. Therefore, TGA is not a rare abnormality in Black Africa; it represents 2 percent of the 887 cases of congenital heart disease observed during the same period. The inadequacy of means of diagnosis is certainly the cause of the relatively low incidence of this malformation, of the considerable delay in under specialist care and, as a consequence, of the greater difficulties in treatment, especially with regards to atrial septostomy.(ABSTRACT TRUNCATED AT 250 WORDS)

The echocardiographic, angiographic and haemodynamic evolution of endomyocardial fibrosis (EMF) was assessed in 19 patients: 8 patients with isolated right sided EMF, 3 with predominantly right-sided EMF, and 8 with isolated left sided EMF with mitral regurgitation. Echocardiographic controls were preformed in 16 patients, on average 11.3 months after surgery; angiographic and haemodynamic controls were preformed in 14 patients, on average 14 months after surgery. In isolated or predominantly right-sided EMF, echocardiographic abnormalities of septal motion (paradoxal) disappeared. Although the volume of the right heart chambers decreased, they remained dilated. The syndrome of adiastole disappeared in patients operated early. In left EMF with mitral regurgitation, the M-shaped motion of the septum regressed in the 4 cases in which this abnormality was observed preoperatively. The size of the left heart chambers decreased on post-operative echo and angiographic studies. Left ventricular function returned to normal after surgery. The author underline the differences between right and left-sided EMF with mitral regurgitation. In right-sided EMF the evolution is that of adiastole and surgery should be preformed early because the right ventricular reserve is small. In left-sided EMF with mitral regurgitation, the evolution is that of a valvular lesion with a good postoperative result.

A standardized Flack's test with continuous electrocardiographic recording was performed in 351 moderately trained athletes (317 men and 34 women; mean age 23.7 years). The test gave normal results in 310 subjects (88.3%). Tachycardia in excess of 100 beats/min was observed in 12 subjects (3.4%), and 56 abnormalities which were not present on previous ECG recordings at rest were noted in 29 subjects (8.3%); 27 of these abnormalities appeared immediately after a previous one. Out of these 56 abnormalities, 26 (44.6%) were associated with sinus dysfunction: sinus bradycardia in 8 cases, second degree sinoatrial block in 2 cases, third degree sinoatrial block in 3 cases and sinus arrest in 13 cases. In 16 cases of third degree sinoatrial block or sinus arrest escape rhythms were observed, including coronary sinus rhythm (3), junctional rhythm (12) and accelerated idioventricular rhythm (1). Five of the 56 abnormalities (8.9%) were disorders of conduction, i.e. first or second degree atrioventricular block, atrioventricular dissociation and blocked P waves. These disorders are known to be frequently associated with sinus dysfunction. In 9 out of 56 abnormalities (16.1%) disorders of excitability were present as atrial, junctional and ventricular extrasystoles. In 8 subjects the Flack's test resulted in the disappearance of disorders of conduction or excitability of the "athlete" type present at rest, as the Ruffier-Dickinson test, or the cycloergometric exercise test.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood pressure readings of 15756 coloured African schoolchildren aged between 11 and 18 years old were studied. The measurements were casual readings. The study group was not perfectly representative of the school population. However, from the practical point of view, the data may be used in the whole Ivory Coast school population in the 11 to 18 years age range. The distribution of the average readings with respect to age and sex is indicated on Table II. Abnormally high blood pressure was defined as readings greater than the average BP + 2 standard deviations, to the nearest 0,5 cm Hg (to take the practical problems of BP measurement into account). Under these conditions, all boys and girls between 11 and 18 years of age with BP greater than or equal to 150/90 (except boys of 17-18 years of age for whom the limit was 155/95) were considered to be hypertensive. According to these criteria the prevalence of hypertension in coloured African schoolchildren was: -systolic hypertension: 4,86% boys and 4,03% girls; -diastolic hypertension: 4,20% boys and 5,09% girls; -systolic or diastolic hypertension: 6,77% boys and 7,54% girls; -systolic and diastolic hypertension: 2,29% boys and 1,57% girls. In fact, these would be children "at risk" rather than hypertensive. The true number of hypertensive children would only become apparent on follow-up. A comparison with coloured African and white European schoolchildren in the same schools in Abidjan showed that the average BP readings and prevalence of hypertension was higher in the coloured population but the difference was not always statistically significant. The small number of European children made comparison difficult. The data obtained was compared to previously reported series but it was difficult to draw conclusions because of differences in methodology.

The authors have studied the clinical, electrocardiographic, radiological, phonomechanographic and haemodynamic features of 20 cases of apparently primary pulmonary hypertension of fairly severe degree. An attempt has been made to correlate on the one hand the haemodynamic values, and on the other the clinical findings, ECG signs of right-sided preponderance, the size of the artery to the right lower lobe on X ray, and the phonomechanographic results. Particular importance is given to a discussion on the aetiology. It is recalled that syphilis can be excluded, that it is possible the operate on thromboses, and that bilharzia and the haemoglobinopathies may play a part which is yet to be defined.

The authors report their experience of conservative valvular surgery in endomyocardial fibrosis (EMF) (8 cases among 46 surgical cases). These patients were divided into 3 groups: Group I: bilateral EMF predominating on the left side with associated tricuspid involvement (n: 3). Group II: bilateral EMF predominating on the right side with moderate associated mitral involvement (n: 3). Group III: unilateral EMF with massive mitral insufficiency, (n: 2). At surgery, on the side of the conserved valve, the patients had a transvalvular endocardectomy (n: 3) and a valvuloplasty either tricuspid (n: 3) or mitral (n: 5). The results of the valvuloplasty were satisfactory. Two patients died in the post-operative period. Their death was unrelated with the conservative procedure. The authors study the literature concerning the cases of valvular conservative surgery in EMF (n: 4) and define the conditions under which this surgery can be done. They report 2 original cases of pure left sided limited EMF with massive mitral insufficiency successfully treated by a valvuloplasty.

1. Study of a group of 50 patients suspected to have coronary artery disease. This is a complement to a previous study concerning "definite" coronary patients. 2. The method followed consisted in cross-examination of the files by three observers in order to separate the subjects who seemed really affected by coronary artery disease. This treble examination led to a rather restrictive selection. To facilitate the study, the patients were subdivided into 4 groups: patients with arterial hypertension, with diabetes mellitus, with cardiac failure, with a heart disease and miscellaneous patients. 3. The study of the 20 files which were discarded was peculiarly interesting as it provided the opportunity to underline the differential diagnosis either with common diseases (left ventricular overload, heart block, brain vascular accident), or with more specific diseases for Black Africa (endomyocardial fibrosis, aneurysm of the left ventricle, cardiomyopathy). In that respect, it is underlined that, in the absence of any anatomical or functional disease, the electrocardiogram of the healthy Black is identical to that of the White. 4. Study of the 30 patients considered as coronary made it possible to underline aetiological and epidemiological factors, although some are still lacking. However the facts observed could be compared with those reported in a previous work concerning 45 "definite" coronary patients. The overall documents thus gathered in 75 patients suggest that the African candidate to coronary artery diseases resembles his Occidental homologue, but that he might have kept a traditional diet.

An anatomo-clinical entity, fibrous constrictive endocarditis can betreated srugically, and we carried out this procedure for the first time in 1971, since when we have used it seven times; it consists of an internal stripping of one or both centricles, with removal of one or both the mitral and tricuspid valves. The results were encouraging in the first two cases, and so good in the succeeding ones that this endocardial resection could be put forward as the treatment of choice for a condition whose aetiology is still unclear.

A phonomechanographic study of 12 patients with restrictive endomyocardial fibrosis (EMF) has highlighted the essential criteria for the diagnosis of this condition. The "ventricular" type of JVP, with a dip-plateau, is a reliable sign of right-sided EMF; this sign is more rarely of the tricuspid incompetence type. A similar picture emerges from recordings of hepatic pulsation, or other venous pulses. An apex-cardiogram with a dip-plateau is in favour of the diagnosis of left-sided EMF. The finding of a recordable infundibular impulse supports a left-sided EMF. Demonstration of an early-diastolic thrill, of endocardial origin, is an essential feature of this condition. It coincides with the rising phase of the dip, and was found in 10 of our 12 cases. There may also be murmurs arising from the pulmonary and atrio-ventricular valves. The characteristic feature of the carotid tracing is a prolonged pulse wave, with corresponding reduction of the haemodynamic quotient. These signs result from contraction of the potential filling space of the ventricle, from the restricted movement of the atrio-ventricular valves, and from a reduced blood flow.

Constrictive endocardial fibrosis (CEF) or endomyocardial fibrosis (EMF) was studied on 14 files of this rather frequent disease in Ivory Coast. On the basis of the data derived from angiocardiography, catheterization and mechanograms, the clinical signs are interpreted better. Thus one is able to describe with accuracy some clinical forms, the commonest of which being a right heart restriction combined with left-sided signs. It seems important underline how useful the external pulse recordings might be useful for the diagnosis in view of their analogy with the pressure curves. In this disease with a severe course, bold surgical treatments provide some hope. On the contrary, its aetiology remains mysterious. Our best landmark being the link of CEP with tropical ecology, and in particular, in our cases, with the warm and damp forest ecology of some areas.

The authors studied 22 patients with operated left sided endomyocardial fibrosis (EMF). Twenty patients had pure left sided and 2 bilateral (mainly right sided) EMF. The mean age of the patients was 14 years (range 7-51 years). Three clinico-pathological forms of the disease were identified: obliterating, diffuse and limited. The mechanism of associated mitral regurgitation was papillary muscle and/or posterior leaflet involvement. The anterior mitral leaflet was not affected in any of these cases. Echocardiographic diagnosis was possible in 18 cases by M mode recording showing M-shaped septal wall motion. The diagnosis was made in 5 out of 13 patients by 2D echocardiography. This method was satisfactory in the obliterating form of the disease but direct visualisation of the fibrosis in the diffuse and limited forms was very difficult. Catheter studies showed severe pulmonary hypertension in all cases. The presence of a dip-plateau pressure recording was inconstant and was only observed in the obliterating and diffuse forms of EMF. Angiocardiography was characteristic in the obliterating and diffuse forms and enabled an accurate anatomical diagnosis before surgery. The diagnosis of the limited form was difficult and could only be suspected in cases of mitral regurgitation associated with right ventricular EMF or in the presence of parietal recesses. This surgical series does not include cases of EMF limited to the ventricular apex without mitral regurgitation or adiastole, treated medically.

The authors have made a retrospective study of the case notes of 200 patients with valvular disorders seen over the course of 35 months (excluding those due to constrictive endocardial fibrosis). The cases represent the frequency of cardiac failure, especially in the mitral group. The authors found 61% to have mitral valve disease, 28.5% aortic valve disease, and 9.5% disease of more than one valve. Mitral valve lesions were found most frequently in young females (average age 26 years); aortic valve lesions were found more commonly in an older age group of men (average age 47 years). The authors discuss the aetiology. Rheumatic fever was responsible in 60% of cases, and caused particularly mitral valve disease. Atherosclerosis and syphilis were the commonest causes in the aortic group. Indications for surgery were found in 74 cases (37%), and 28% of these were closed heart techniques. The course of the disease is best appreciated during the first hospital admission. The mortality rate was 5.5%, and most of the patients (65%) were stabilised on treatment.

The authors reviewed the operative and function results of 24 isolated tricuspid valve replacements with bioprostheses in 22 patients. The patient population was young (average age 15 +/- 8 years). The surgical indication was massive tricuspid regurgitation due to chronic parietal endocarditis in 19 cases and to bacterial endocarditis in 3 cases. Tricuspid valve replacement was associated with 19 right ventricular endocardectomies, 2 direct closures of ventricular septal defects, 2 Wooler mitral valvuloplasties and 1 pericardectomy. The operative mortality was 13.5% and the secondary mortality 13.5%. Of the 16 survivors, 13 are in the NYHA Class I with no regular medical therapy. Their cardiothoracic ratio has slightly decreased. Two patients have permanent atrial fibrillation, and 12 have acquired definitive complete right bundle branch block. Eight of these patients had significant improvement of atrial and right ventricular pressures, of Yu's index and cardiac index at postoperative catheterisation. Three of the 16 patients developed progressive calcific degeneration of their bioprostheses. They are among the 6 patients who have been followed up for more than 3 years. There was no mortality at reoperation. Isolated tricuspid valve replacement by bioprosthesis was chosen despite the young age of these patients because of the disadvantages of mechanical prostheses which are associated with a much higher mortality related to incarceration and thrombosis of the prosthesis. The relatively high operative and secondary mortality in this series of isolated tricuspid valve replacement compared to mitral, aortic or micro-aortic valve replacement, is related to the gravity of the underlying causal pathology.

Two cases of pulmonary artery aneurysm are reported in patients with persistent ductus arteriosus (PDA). The first was a mycotic aneurysm complicating staphylococcal pneumonia; the other was a calcific aneurysm of the right pulmonary artery. The mycotic origin was confirmed in the first case. The aetiological roles of pulmonary hypertension and previous endocarditis are discussed in the second case. Based on these two observations, the authors analyse the aetiology and evolution of mycotic aneurysms and review the therapeutic problems posed by their association with PDA.

1. A systematic search was made for cardiac abnormalities (clinical, radiological and ECG) and haemodynamic disorders (catheterisation of the right side of the heart and pulmonary artery) in 37 cases of confirmed biharziasis. It was generally found that:--14 patients (37.8%) had no symptoms;--8 patients (21.6%) had pulmonary hypertension (PH) with the corresponding cardiac signs (these will be reported separately);--15 patients (40.5%) had cardiac signs with no PH; these are studied in this paper. 2. Iatrogenic myocarditis was noted on the ECG. It was found in 3 of the 37 cases (8.1%). This points to the importance of careful monitoring of treatment. There was also ECG evidence of anaemyic myocardial changes in 5 cases of the 37 (13.5%). In 3 of these 5 cases this was found to be due to bleeding. Hypertensive myocardial disease was found in 1 case (2.7%), a patient with renal disease. Myocardial signs were also found in 3 cases because of coexistant disease. 3. Three cases (8.1%) remain in whom there were ECG changes, but without PH and without any other definable cause. These could have been due to bilharzia myocarditis; the authors review the experimental and clinical evidence for such a possibility. The real incidence of this condition remains to be determined. 4. Although there was no such case in this series, the authors suggest that bilharziasis might cause endomyocardial fibrosis (EMCF). 5. The authors put forward the hypothesis that the pulmonary arteritis is a tissue immunological reaction, and also that the myocarditis (and possibly the EMCF) is a manifestation of circulating antibodies.