Reducing sudden deaths in Nigeria
Agboola reportedly slumped and died while playing football at his off campus residence close to the institution’s south gate. Tinubu passed on around 7.30pm during a five-a-side novelty football match in Epe, Lagos. Akogu died during his church’s cross over service in Anyigba, Kogi state at about 11.40pm on December 31, 2017.
Unfortunately, there are no official figures in Nigeria on the number of adults who suddenly die without explanation. Recent events suggest that the numbers could be much higher than reported cases.
Although there are controversies over the definition of the time frame for sudden unexpected death, the World Health Organisation (WHO) defines it as “death within 24 hours from the onset of symptoms.”
But a consultant cardiologist and Executive Secretary of Nigerian Heart Foundation (NHF), Dr. Kingsley Akinroye, defined sudden cardiac death as an unexpected natural death due to cardiovascular disease, which occurs within one hour of the onset of symptoms.
What causes sudden deaths? Akinroye told The Guardian: “A major proportion of sudden death is of cardiac (heart) origin.”
To another consultant cardiologist at the Lagos University Teaching Hospital (LUTH) Idi-Araba, Prof. Amam Mbakwem, increase in episodes of sudden death is related to the increasing prevalence of risk factors for heart disease like hypertension, Diabetes Mellitus, obesity, abnormal lipids, smoking, excessive alcohol intake and lack of exercise
Mbakwem said the causes are majorly from cardiovascular disease either a massive heart attack or abnormal electrical activities in the heart which could be either very fast, chaotic and ineffective abrupt cessation of electrical activity.
Other causes, she said, include big clots, which are dislodged from the deep veins that travel to the lungs and block the big arteries in the lungs or a massive stroke. “Other conditions are inherited heart abnormalities which may cause the heart to start firing abnormally especially during strenuous activity,” the cardiologist said.
Meanwhile, an autopsy review of sudden unexpected natural deaths in a suburban Nigerian population published in the journal Population Health Metrics 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 researchers from Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) Ile-Ife; and Ladoke Akintola University of Technology Teaching Hospital Osogbo did a descriptive retrospective autopsy-based review of cases of sudden unexpected natural deaths seen at the OAUTHC over a 10-year period.
The researchers found that sudden unexpected natural deaths accounted for 13.4 per cent of all medico-legal autopsies. “The male to female ratio was 2.1:1, and the mean age was 43.1 years. Cardiovascular (28.3 per cent), respiratory (18.2 per cent), and central nervous system (12.6 per cent) disorders were the major groups of causes. About 64.4 per cent of cardiovascular deaths were due to hypertensive heart disease,” they noted.
The researchers added: “Bacterial pneumonia, intracerebral haemorrhage, and breast carcinoma accounted for 34.4 per cent, 60.0 per cent, and 52.6 per cent of respiratory, central nervous system, and cancer-related deaths respectively. Infectious causes predominated in all age groups below 40 years and above 70 years while hypertensive disorders predominated between 40 and 70 years. Only 16.9 per cent of cases occurred while the patient was admitted to the hospital.”
Also, a European Society of Cardiology (ESC) study published January 24, 2018, in European Heart Journal, found that four in ten cardiomyopathies – a major cause of sudden cardiac death and heart failure in young people – are genetic. The paper noted that family screening is urgently needed to prevent early death in apparently healthy relatives.
Cardiomyopathy is where the heart muscle becomes enlarged, thick or rigid. As the condition worsens, the heart becomes weaker and less able to pump blood through the body and maintain a normal electrical rhythm.
Akinroye said about four million lives per year are lost globally to sudden cardiac death. “In the United States of America, sudden cardiac death causes approximately 300,000 deaths per year; with diseases of the blood vessels of the heart (Ischaemic heart disease) being responsible for 80 per cent of cases, followed by non- ischaemic heart muscle diseases such as hypertrophic and dilated cardiomyopathy, which account for 10 to 15 per cent of cases,” he said.
The cardiologist said approximately five per cent of cases of sudden cardiac diseases can be attributed to primary electrical disorders of the heart such as congenital long QT syndrome.
Long QT syndrome (LQTS) is a condition, which affects repolarization of the heart after a heartbeat. This results in an increased risk of an irregular heartbeat, which can result in fainting, drowning, or sudden death. These episodes can be triggered by exercise or stress.
In Africa, epidemiology of sudden cardiac death is scanty in the black African population. However, the available evidence indicates that most of the cases are due to non – ischaemic heart diseases – hypertensive heart disease, hypertrophic cardiomyopathy and rheumatic heart disease. In Nigeria, hypertensive heart disease has been found to be the most common cause of sudden cardiac death.
A strong predictor of sudden cardiac death is enlargement of the left side of the heart (left ventricular hypertrophy) which can be confirmed by Electrocardiogram (ECG) or Echocardiogram. ECG is a record or display of a person’s heartbeat produced by electrocardiography. Most documented sudden cardiac death in Africa has been in the young athletic population below the age of 40.
To address the situation, Akinroye recommended that compulsory electrocardiogram and echocardiogram should be included in the annual medical screening programmes of African footballers, athletes and referees. “In addition, any young person with a family history of sudden death and with any of the following complaints – dizziness, palpitations, fainting, chest pain or difficulty in breathing should have an electrocardiogram screening,” he said.
The cardiologist said thorough prospective epidemiological and population studies in Africa are necessary for prevention and control of sudden cardiac death. “Research and training of various experts in the relevant fields of electrophysiology, cardiology, cardiac surgery, cardiovascular epidemiology, intensive cardiac nurses and professionals in ambulatory care like ambulance drivers are necessary for the healthcare system to impact on interventions to control sudden cardiac death,” he said.
For prevention of sudden death in the population, Akinroye recommended: “Awareness about this condition needs to be actively promoted in view of the progressive rise in the number of Nigerians between the ages of 18 and 40 years dying from this preventable disease especially as these are ‘hearts too precious to die’.
“The awareness should target the whole population but with emphasis on the ages between 15 – 45 years especially the athletes, footballers, referees and other sports; and also healthcare providers especially clinicians. Prospective epidemiological studies for reliable data collection in the target population should be supported.
“The National Sports Commission (NSC) needs to have a National data registry of sudden cardiac deaths in athletes and other sports in Nigeria.
“Government needs to be supported by Research institutions and NHF to gather information, initiate guidelines that are necessary to develop healthcare policies, training of healthcare providers and ancillary staff in out-of-hospital resuscitation procedures, promotion of medical screening for athletes and sports men; placement of emergency care equipment in public places, such as schools, sports venue, airports and health facilities.”
On the solutions, Mbakwem recommended: “We should be more health conscious and also do routine medical checks especially for people who are 40 years and above. Also we should report any unusual symptoms to our doctors because so many of the sudden death cases will have experienced some symptoms before the events which are usually ignored or are assumed to be trivial.
“A healthy lifestyle is also very important. People should eat right, reducing excessive refined sugar, salt and fat intake and increasing their vegetable and fruit intake. They must stop smoking, reduce alcohol consumption, reduce weight and exercise regularly.”
The cardiologist urged the government to help by equipping hospitals to handle the cases. “These are emergency situations and the patients need to be resuscitated immediately and the underlying cause dealt with swiftly. This is because the golden period that we have to save a patient and to save them before the brain is permanently damaged is very short,” she said.
The OAUTHC researchers recommended: “It, therefore, becomes important that appropriate mass education programmes and laws are put in place to ensure that all cases of sudden unexpected natural deaths are reported to the appropriate authorities so that detailed enquiries may be conducted on such cases, as this will impact greatly on our health care delivery system.”
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