The verdict is out: Over 93.7 per cent of sudden unexpected deaths (SUD) in Nigeria are due to hypertension-induced medical conditions such as stroke and heart failure even as experts have associated the increasing cases of the condition to decline in physical activities, increased salt and fat intake from the consumption of processed foods, and tobacco use. They, however, called for an urgent review and upgrading of critical care management facilities in Nigeria as well as improve the awareness, control and management of hypertension. CHUKWUMA MUANYA (Assistant Editor) writes.
Fifty-five-year-old Godwin Okagbue was married with 11 children. Okagbue who resided at Abaranje Ikotun in Alimosho Local Council of Lagos State lost his wife in January this year, after a long battle with cancer.
Okagbue who hailed from Nnewi in Anambra State slumped and died on his seat, last week, almost immediately after waving at a passer-by from his compound. He was confirmed dead at a nearby hospital. Post mortem reports showed that Okagbue had cardiac arrest.
Mrs. Adebisi Adeoye, 38 year-old, slumped and died as she tried to pick up a pen that fell from her husband’s hand early in April, 2016.
Forty two-year-old Musa Bala is married with four wives and 18 children. Bala who has been battling with high blood pressure died in his sleep.
Okagbue, Adeoye and Bala are some of the victims of sudden unexpected, natural death (SUD) in Nigeria.
Also, the country recently lost former Captain and Coach of the Super Eagles, Stephen Keshi, and former Eagles Coach, Shuaibu Amodu, to SUD caused largely by Non Communicable Diseases (NCDs) such as stroke and heart attack.
The World Health Organisation (WHO) defines SUD as “death within 24 hours from the onset of symptoms.” Mason, however, defines it as “unexpected death following so rapidly from the onset of symptoms that the cause of death could not be certified with confidence by a medical practitioner familiar with the patient.”
The Guardian investigation revealed that Nigeria does not have up to date national data on NCDs because the last survey was carried out over 20 years ago.
However, according to the WHO country profile for Nigeria in 2014, it is estimated that NCDs account for 25 per cent of total deaths in Nigeria. Cardiovascular disease/heart-related disease (CVD) is responsible for seven per cent; Cancers three per cent; Diabetes two per cent; chronic obstructive respiratory diseases one per cent; and others 11 per cent.
What are the causes of SUD in Nigeria? Why are more Nigerians succumbing to SUD?
National Coordinator, NCDs at the Federal Ministry of Health (FMoH), Dr. Nnenna Ezeigwe, told The Guardian: “Whilst there is no straightforward answer to this question we have reasons to believe that the rise in sudden deaths in Nigeria is linked to the rise in the prevalence of NCDs, prominent among which are CVDs, various cancers, diabetes, and chronic obstructive respiratory disease. Most of these diseases are capable of causing sudden death manifested as slumping or dying in sleep.”
The public health physician said unlike communicable diseases such as malaria or Human Immuno-deficiency Virus (HIV), most of the NCDs do not have just a singular cause.
“Rather than dwell on singular causative agents, we talk about risk factors, which we try to encourage people to avoid or control,” she said.
Ezeigwe said the important risk factors for most of the NCDs are physical inactivity, smoking, unhealthy diet (comprising mainly processed food often devoid of fruits and vegetables) and excessive consumption of alcohol. “There is also genetic predisposition but since there is little we can do about genetics we focus our energy on the preventable risk factors listed above,” she added.
British and Nigerian researchers from the Institute of Pathology, Leeds General Infirmary, Leeds, England, United Kingdom (U.K.) and Obafemi Awolowo University (OAU) Ile-Ife, Osun State identified hypertensive heart disease (HHD) as the most common cause of SUD in Nigerians, and many of hypertensive cases were previously undiagnosed.
The pathologists in a study published in West African Journal of Medicine (WAJM) titled “Sudden cardiac death in Nigerians-The Ile-Ife experience” said cases of coronary heart disease and myocardial infarction played significant roles as causes of SUD, indicating that their incidence may not be as rare among Nigerians as previously thought.
They wrote: “…Our result indicating HHD as the most common primary cause of death agrees with that of other studies on sudden natural deaths among Nigerians. Majority of the hypertensive were previously undiagnosed and, thus, not on any form of treatment. HHD is increasingly considered a strong and independent risk factor for sudden cardiac death…”
According to WHO’s Global status report on NCDs 2010, of WHO’s six regions, the African region has the highest prevalence of hypertension estimated at 46 per cent of adults aged 25 and above.
Local studies have shown the prevalence of hypertension varies across the country: from 10 to 33 percent in the rural areas to 13 to 50 per cent in the urban settlers.
A recent study by the Medical Village in Ondo State on the prevalence of hypertension among semi-urban women in Ondo showed a prevalence of 33 per cent. The researchers link their findings to rise in kidney failure and sudden deaths.
Cardiologists at the Lagos University Teaching Hospital (LUTH) Idi-Araba, led by Prof. Jane Ajuluchukwu and Prof. Amam Chinyere Mbakwem found that stroke still remains the major cause of acute hypertensive deaths.
The cardiologists said hypertension is associated with increased morbidity and mortality. These, they said, usually arise from end organ damage like cerebrovascular disease, hypertensive heart disease, myocardial infarction (heart attack), renal disease and occlusive peripheral vascular disease.
Occlusive peripheral arterial disease is blockage or narrowing of an artery in the legs (or rarely the arms), usually due to atherosclerosis (hardening and narrowing of the arteries) and resulting in decreased blood flow.
According to Doctors Christopher Chinedu Obiorah of the Department of Anatomical Pathology; and Charles Ngozi and Timothy Amakiri of Braithwaite Memorial Specialist Hospital Port Harcourt, Rivers State, in children and adolescents, causes of sudden natural deaths are diverse with cardiomyopathy (diseases of the heart muscle) as a common cardiac (relating to the heart) cause.
Various reports have consistently demonstrated that males are at higher risk for non-violent SUD than females.
Medical experts have also associated the increasing cases of sudden deaths to global decline in physical activities.
The WHO has reported that global levels of physical activity are declining. The six country survey published jointly with the World Heart Federation (WHF) revealed that between 14 and 37 per cent of adults do not pay any attention to one of the simplest things most people can do to protect their heart health – walking.
More than a quarter of people who took part in a new multi-country survey said they did not know how much time they spent briskly walking at a speed faster than normal.
According to the WHO, in 2012, 38 million people lost their lives due to NCDs such as hypertension and heart attack, 16 million or 42 per cent of who died prematurely – before 70 years – from largely avoidable conditions. More than 80 per cent of people who died prematurely from a NCD were in developing countries such as Nigeria.
Consultant Cardiologist, James Paget University Hospital, Norfolk, United Kingdom (U.K.), and Honorary Senior Lecturer, University of East Anglia, Norwich, Norfolk, UK, Dr. Justin Zaman, blamed the rise in hypertensive heart disease on rural to urban migration, increased salt and fat intake from the consumption of processed foods; increased tobacco use and sedentary lifestyle.
Ajuluchukwu and Mbakwem in a study titled “Trends in acute emergency room hypertension related deaths: an autopsy” investigated hypertension related acute deaths in patients admitted to the emergency room of LUTH.
They found that the commonest causes of death were stroke (52.8 per cent) and heart failure (40.9 per cent).
The study was published in the Nigerian Journal of Clinical Practice.
Autopsy reports for bodies deposited from the medical emergency room (ER) were reviewed. Details of the time of admission, time of death and blood pressure status prior to the event were obtained.
The result showed there were 297 hypertension related deaths but 252 were analyzed. There were 168 (66.7 per cent) males and 84 (33.3 per cent) females (M: F 2:1) and mean age was 47.33±12.18 years (14 to 85 year). Two thirds of the subjects (65.5 per cent) were =50 years of age. The mean duration of admission was 5.88±6.41 hours. One third (35.3 per cent) died within an hour of admission.
The commonest causes of death were stroke 149 (52.8 per cent) and heart failure 103 (40.9 per cent). Intra-cerebral hemorrhage was the commonest type of stroke seen, 69 (52.3 per cent).
Intracerebral hemorrhage (ICH) is a type of stroke caused by bleeding within the brain tissue itself — a life-threatening type of stroke. A stroke occurs when the brain is deprived of oxygen and blood supply. ICH is most commonly caused by hypertension or head trauma.
Mbakwem, told The Guardian: “We have a big problem in our hands. That is a time bomb waiting to go off. Nigerians are no longer walking. More people are slumping and dying on daily basis. There is no single day that we do not see at least two new cases of stroke in our clinic here. Strokes are getting so common.
“Why? People are no longer exercising. We are not moving. Most of us are living a very sedentary lifestyle.”
A Systemic Analysis of Sudden Natural Deaths at Braithwaite Memorial Specialist Hospital Port Harcourt, Rivers State, published in The Nigerian Health Journal concluded: “Cardiovascular system pathologies especially hypertensive heart disease remain the leading cause of sudden natural deaths in this study.”
A retrospective analysis of coroners’ autopsy findings in patients without known medical diseases, who died suddenly and non-violently and were autopsied in Braithwaite Memorial Specialist Hospital (BMSH) between March 2000 and February 2008, was undertaken.
The result of the study showed that of the 9,164 bodies received, 2,415 (26.4 per cent) were autopsied for varied reasons, out of which 249 (2.7 per cent) were sudden natural deaths in persons without known significant medical history.
Male: female ratio (MFR) was 2.2:1. The mean age was 39.7 years with a range of three weeks to 97 years. Peak age group was 30 to 39 years with 27.7 per cent.
The commonest causes of these deaths were cardiovascular system related, with 218 cases (87.5 per cent). It included hypertensive heart disease, myocardial infarction, stroke, cardiac rupture, and coronary atherosclerosis with thrombosis.
Thrombosis is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system.
Lymphoreticular and Hematopoietic system pathologies were next with 11 cases (4.4 per cent). They consisted of seven cases of malaria and cases of sepsis.
The Lymphoreticular and Hematopoietic system help in removal of ageing cells and production of immune cells.
Respiratory system disorders followed with nine cases (3.6 per cent). Other system accounting for sudden natural deaths in descending order were: genitourinary system causes with five cases (2.01 per cent), gastro intestinal system causes with three cases (1.2 per cent) and central nervous system causes with two cases (0.8 per cent). Prematurity was the least cause with one case (0.4 per cent).
Another study titled “Sudden Cardiac Death: Clinical Perspectives from the University of Maiduguri Teaching Hospital, Nigeria” and published in World Journal of Cardiovascular Diseases concluded: “Sudden cardiac death is common among our patients admitted with cardiovascular diseases. The most common etiology is ischemic cardiomyopathy, followed by peripartum cardiomyopathy. Most of the victims were young, and there were no optimum resuscitative measures.”
The researchers from the University of Maiduguri Teaching Hospital,
Maiduguri, Borno State, Nigeria; Teaching Hospital Laquintinie, University of Douala, Douala, Cameroon; and Service de Cardiogie, Centre Hospitalier le Dantec, Dakar, Senegal, found: “Despite tremendous advances in the management of cardiovascular diseases and cardiac arrest, there is paucity of information regarding sudden cardiac death in sub-Saharan Africa…”
An autopsy review of sudden unexpected natural deaths in a suburban Nigerian population published in Population Health Metrics and Open Access Research concluded: “Cardiovascular, respiratory, central nervous system, and cancer-related causes were the major causes of sudden unexpected natural deaths in our series. Hypertension-related disorders constituted a large proportion of cases especially in people over 40 years, whereas infectious diseases were more common below this age. The majority of deaths occurred outside the hospital setting. It is imperative that appropriate public health strategies be developed to address these issues.”
The study was a descriptive retrospective autopsy-based review of cases of sudden unexpected natural deaths seen at the Obafemi Awolowo University Teaching Hospitals Complex in Ile-Ife, Nigeria (OAUTHC) over a 10-year period.
The researchers concluded: “… Hypertension-related disorders were mainly seen in people between 40 and 70 years of age, while infectious disorders were more commonly seen below 40 years and above 70 years. The majority of deaths occurred outside the hospital setting…”
Also, the pattern of sudden death at Ladoke Akintola University of Technology Teaching Hospital (LAUTECH), Osogbo, Osun State, published in the journal Vascular Health and Risk Management concluded: “Hypertensive heart disease and hypertension-related disorders are the most common causes of sudden death in South West Nigeria, so effective public health strategies should be channeled towards prevention, detection, and treatment of hypertension.”
Elsewhere
THE incidence of sudden death has been shown to be high in industrialised societies. It is estimated to be the mode of death of about 20 per cent of fatalities in the United States (U.S.) and Europe, amounting to between 300,000 and 450,000 persons annually depending on the definition used. Many of the cases of sudden death occur in persons in apparent good health, without any prior evident of heart disease and outside the hospital. Sudden death is the most common and often the first manifestation of coronary artery disease and is responsible for about 50 per cent of mortality from cardiovascular disease in the US and other developed countries.
Reports from Asia on sudden death estimated an annual incidence of 145 per 100,000 in people over 15 years. Though disease of the circulatory system made up approximately 90 per cent of all cases of sudden death, cases due to ischaemic heart disease were less frequent than in Western countries.
Ischaemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue.
Whereas coronary artery disease is the most common cause of sudden death in Caucasians and Asians, the situation appears different for blacks of Africa and the Caribbean.
Coronary artery disease develops when the major blood vessels that supply the heart with blood, oxygen and nutrients (coronary arteries) become damaged or diseased. Cholesterol-containing deposits (plaque) in the arteries and inflammation are usually to blame for coronary artery disease.
Ischaemic heart disease has been reported to be rare in most African communities.
