Rheumatic Heart Disease, taming silent killer of Nigerian children, young adults

DATELINE. April 2020.
Chioma Vivian Eleleme sits on the living room sofa, trying her hands on a weave on. Next to her are three intimate friends — Faith, Sandra and Justina. They are all fixing different weave on.

After some minutes, Chioma leaves the sofa for the floor. She tries her hand on another hair, her face softening, briefly. She brushes the hair and makes each strand straight. The cropped hair is luxuriant and brown. It is carefully made into a style most young ladies wear if not on wig. She threads the line to fall in place, as she fixes the third weave on. She wears the wig on the Styrofoam mannequin head and nods her head in acceptance.

Her phone rings.

“Have you bought the drugs now?” the voice on the other side asks.

“Yes,” she breathes.

“Okay, make sure you follow your medications, religiously,” the caller reminds her.

Since she left hospital after an open-heart surgery to replace her valves in March 2018, Chioma has praised God more than ever.

She says, quietly, “it was God that brought me back from the dead.”

She stands from where she is seated, tottering as her frame carried her. She has learnt to be careful with her movement. She avoids engaging in vigorous exercises.

“My recovery was very fast and people are surprised,” the 26-year old public administration student of the Abia State Polytechnic, Aba, says.

She was diagnosed of a severe Mitral Valve Stenosis with clinically NYHA (New York Heart Association) Class 2 in November 2017.

Her medical report with Ref No: SUB/LASUTH/SURG/2017/044, signed by Bode Falase, consultant cardiothoracic surgeon, says though she has good LV function with EF of 60 per cent, there is mild pulmonary hypertension with PASP of 19mm Hg.

“IVC measures 19mm, collapses on inspiration >50% and TAPSE is 18mm, showing preserved right ventricular function. The mitral valve is rheumatic, severely thickened and stenotic with a valvale area of 0.7cm. It is unlikely this valve can be repaired and will need to be replaced.”

She confesses, “I don’t have that short of breath again.”

When she was diagnosed of mitral valve stenosis, she thought that was the end of life for her.

She smiles, “but God gave me a new life when I encountered the medical team of Tristate Heart and Vascular Centre, Babcock University Teaching Hospital, Ilishan Remo, Ogun State.”

Her younger sister, Augustina, walks in with a bag. She drops it on the table. She sits quietly by her sister’s side and whispers something. Chioma grabs a piece of biscuit from the bag and bites it.

Suddenly, Chioma figures that food is ready and she goes to the kitchen to check. The kitchen is silent. She discovers that her mum was still washing the vegetable.
She slips behind her mother and laughs. “Mummy I thought food was ready, I’m famished,” she says.

Chioma may have had her diseased valves replaced, the challenge ahead is that she will be permanently on drugs and would need to go back to the hospital before she becomes pregnant.

Recently, Chioma was careless in school. She tried to lift a jerry can of water and she fainted. For days, she felt sharp pains in her chest area and was uncomfortable.
“But I’m okay now. My surgeon directed me on what to do,” she says.

While precise statistics are unavailable, rheumatic heart disease (RHD) is still a major health problem in low-income and middle-income countries, where poor socio-economic status, overcrowded housing and lack of medical care still prevail. There is an absence of accurate medical records in most of the rural regions where RHD mainly exists.

RHD remains a public issue in developing countries, as it accounts for a major proportion of all cardiovascular disease in children and young adults in Africa, and by extension, the world, because 80 per cent of the world’s population lives in developing countries, where the disease is still rampant.

It has an endemic pattern in Africa with highest prevalence in sub-Saharan Africa where there is a reported prevalence of clinically detected RHD of 1-14/1,000 school children, which jumped to 7.5-51.6/1,000 when echocardiography was used to detect clinically silent RHD, also known as latent RHD.

Surveys by the World Health Organisation (WHO) show that RHD affects about 15.6 million people worldwide, with 282, 000 new cases and 233, 000 deaths each year.

There are 2.4 million affected children between 5 and 14 years of age in developing countries, one million of whom live in sub-Saharan Africa, making the continent the major hot spot.

There are about two million people with RHD requiring repeated hospitalisation, and one million likely to require surgery globally.

Health experts, however, point out that one of the reasons for the recent upsurge in heart diseases in the country is the growing case of rheumatic fever. They note that RHD develops in at least half of those affected with acute rheumatic fever (ARF).

In their study titled, Echocardiographic Pattern of Rheumatic Heart Disease In Makurdi Nigeria, published in December 2017, Okpara Ihunanya Chinyere and Ereh Simon Edward note, “rheumatic heart disease was found to account for 15.6 per cent of heart diseases in Makurdi. This is higher than the 9.2 per cent found in Port Harcourt and the 9.8 per cent found in Kano. It is, however, closer to the 11 per cent found among 500 patients referred for echocardiography in Uganda and much lower than 25.1 per cent per cent of 1153 patients referred for echocardiography in Zimbabwe. All these findings are higher than the WHO documented RHD prevalence of 5.7/1000 patients in sub-Saharan Africa.”

Chioma says, “it all started in 2013, when I had a fall. I told my parents and they took me to a hospital, where tests and X-rays were carried out, but nothing was found. I was given medical attention, afterwards.”

Left untreated, mitral valve stenosis can lead to serious heart complications. It usually progresses slowly over time. The signs include, shortness of breath, especially with exertion or when the sufferer is lying down; with fatigue, especially during increased physical activity, swollen feet or legs, heart palpitations — sensations of a rapid, fluttering heartbeat, dizziness or fainting, coughing up blood and chest discomfort or chest pain.

Early 2017, she spent close to two weeks in a private hospital, where nothing challenging, health-wise, was discovered. But when she went back to school, her health deteriorated.

The normal polite girl stared at friends and family blankly. She was withdrawn from everybody, only calling out for assistance when the pain was much.

There were constant seizures and days when she would find it difficult to even eat her meal. She was losing weight, growing pale and haggard. She would wake up in the middle of the night with a jolt.

“The pains became severe that I could not bear it. My parents were called to take me home for adequate medical attention. Before their coming, I was already undergoing treatment in school,” she says.

In Lagos, her seizure spiked and breath slowed. Her parents could no longer do anything, but cradle her in their arms until she regained consciousness. The doctors prescribed drugs to keep her going before eventual surgery, but nothing changed.

Further investigations on her health were conducted at the Federal Medical Centre, Lagos and the Lagos State University Teaching Hospital (LASUTH), where it was discovered that she had mitral stenosis.

“Chioma has a good chance of survival if surgery is done early,” Falase said then.

The estimate required for the corrective surgery was put at N2 million and about N2.5 million for post surgery care at the Lagos State University Teaching Hospital (LASUTH).

Heart valve repair or replacement surgery are only done when valves are damaged or diseased and do not work the way they should. Conditions that may cause heart valve dysfunction are valve stenosis (stiffness) and valve regurgitation (leaky valve).

When one (or more) valve(s) becomes stenotic (stiff), the heart must work harder to pump blood through the valve.

Some reasons why heart valves become narrow and stiff include infection (such as rheumatic fever or staphylococcus infections) and aging. If one or more valves become leaky, blood leaks backwards, which means less blood is pumped in the right direction.

However, the medical expenses required for the treatment of heart abnormality are a burden to the sufferer. Not only did she visit different hospitals, each time she did, Chioma discovered the medical expenses kept growing rather than coming down.

A further visit to the First Cardiology Consultants in Ikoyi showed that it was not just one, but two of the heart valves that were damaged or diseased. The figure required for the replacement of the two valves at the hospital was put at N8.5 million, while $8,700 was needed for same operation at the Fortis Hospital, Bangalore, India.

The estimate for mitral valve replacement from Vikram Hospital, a leading health care provider in central Bengaluru, India, and with maze procedure, was put at $8,940 for semi private room and $7,320 in general ward, without maze procedure is $ 6,880 (semi private room) and $5630 (general ward).

Her parents didn’t tell her she had few months to live if the corrective surgery is not done.

Traditionally, open-heart surgery is used to repair or replace heart valves. This means that a large incision is made in the chest and the heart stopped for a time so that the surgeon can repair or replace the valve(s).

“What of if the surgery goes bad?” She sobs, startling herself and casting a sideways glance.

She had no doubt that it was up to God.

Each time an announcement was made in her church, St. Lawrence Catholic Church, Paiko-Idimu, Lagos,appealing for fund, she would burst into tears.

“The moment was terrifying. I was thinking: ‘Am I going to die from this’?”

But she wasn’t. It was not even close.

Her parents, Mr. and Mrs. Daniel Onwere, close to tears, also joined in the call to kind-hearted Nigerians to save their daughter’s life.

“I was not bothered about her school, all I wanted was for my daughter to get well again and get her life back,” Onwere says.

Her parents began the search for another hospital, where the surgery could be done cheaper. They had a few weeks to do so. Then the idea of Babcock came up.

JANUARY 25, 2018.
Chioma is with Dr. Michael Sanusi, a cardio thoracic surgeon at the centre.

“Mitral valve stenosis — or mitral stenosis — is a narrowing of the heart’s mitral valve. This abnormal valve doesn’t open properly, blocking blood flow into the main pumping chamber of the heart (left ventricle). This heart condition makes the sufferer tired and short of breath, among other problems,” the surgeon explains.

He adds, “in mitral valve stenosis, pressure that builds up in the heart is sent back to the lungs, resulting in fluid buildup (congestion) and shortness of breath.”

Symptoms of mitral valve stenosis most often appear in between the ages of 15 and 40, but they can occur at any age — even during childhood.

During each heartbeat, the atria contracts to push blood into the ventricles. The mitral valve opens to allow blood through, and then snaps shut once the left ventricle is full of blood, to prevent backflow.

“The valve is made up of two flaps, or ‘leaflets’, which come together to seal it shut. These flaps have tendons attached to them, which anchor them and keep the valve taut. But if the valve leaks — known as mitral regurgitation — more than half of the blood may go back into the left atrium during each heartbeat. This leads to shortness of breath as blood starts to collect in the lungs. The leak occurs either, because the leaflets don’t shut properly or because the ring of muscle surrounding the valve slackens,” Sanusi says, as he explains the working of the heart valves to Chioma.

This can be as a result of age, damage from persistent high blood pressure or because of other diseases affecting the heart, such as cardiomyopathy (where the heart walls become stretched or thickened).

Even after a valve condition has been diagnosed, it can sometimes be 10 or even 20 years before symptoms show. Important changes can happen to the heart muscle even if there’s no significant change in symptoms. This is why it’s important to have the heart function checked regularly.

Dr. Ifeoluwa Adewoye, one of the cardiologists The Guardian spoke with when Chioma first visited Tristate Heart and Vascular Centre, Babcock University Teaching Hospital, says, “left untreated, mitral valve stenosis can lead to serious heart complications.”

The doctor can tell, from the type of murmur he or she hears, whether a person needs to have further tests.

Abnormalities of the heart valves are often picked up at a routine examination when the doctor listens to the heart with a stethoscope and hears an extra noise called a ‘murmur’ (however, sometimes, murmurs are also heard in hearts that are otherwise completely normal).

There are countless other stories affirm a growing epidemic of heart disease in the world.

When Bolton Wanderers star Fabrice Ndala Muamba collapsed, 43 minutes after kick-off in the FA Cup tie between Bolton Wanderers and Tottenham Hotspur, played at White Hart Lane, north London, home of Spurs in March 2012, the eyes of many became open to the growing case of heart abnormality.

Muamba had ‘ventricular fibrillation’ — rapid chaotic electrical activity within the heart, that is, the heart stopped its usual pumping function.

Before Muamba, a routine medical check-up on ex-Super Eagles skipper, Kanu Nwankwo, in 1996, at Inter Milan, revealed a serious defect in the heart valve before he underwent a successful heart surgery.

However, footballers such as, Cheick Tiote, Samuel Okwaraji, Amir Angwe, Endurance Idahor, Marc-Vivien Foe, Patrick Ekeng and Ambrose Wleh, were not that lucky on the pitch.

In June 2016, Stephen Keshi, former Super Eagles head coach, died at age 54 of a suspected cardiac arrest. Four days later, Shaibu Amodu, another former Super Eagles coach, was found dead in his bed, aged 54, after complaining of chest pains the night before.

Dr. Anthony Rotimi Agboola of the Society of Family Physicians of Nigeria, says, “the main cause of mitral valve stenosis is an infection called rheumatic fever, which is related to strep infections.”

Agboola advises that parents should make sure that when their kids suffer from sore throat, they are properly treated, “because of the toxins deposited in the heart region.”

Given the prevailing situation of a very weak health sector in Nigeria, which lacks the capacity and needed human and financial resources to prevent and treat cardiovascular disease and its risk factors, the situation becomes even more dire.

Agboola believes there’s need for health insurance in the country. According to him, “the Nigerian health sector currently lacks the needed human and financial resources to prevent and treat cardiovascular disease and its risk factors.”

He says, “there is a lack of primary, secondary and tertiary (medical and surgical treatment) programmes in Nigeria and many other countries in sub-Saharan Africa.”

To him, there is urgent need for all African countries to implement a national ASAP programme as suggested by the Drakensberg declaration to control and reduce morbidity and mortality from this disease.

“To ensure that the largest number of Nigerians can access care regardless of their socioeconomic status, a strong health sector is needed with appropriate medications and equipment to diagnose, treat and monitor these conditions,” Agboola says.