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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 4 | Page : 440-445
Indications for echocardiography and confirmation rates of cardiovascular diseases: experience of a specialist cardiac outpatient clinic in Kumasi, Ghana
Yaw Amo Wiafe1, Emmanuel Acheamfour-Akowuah2, Isaac Kofi Owusu2
1 Department of Medical Diagnostics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
2 Department of Medicine, School of Medicine and Dentistry, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
Correspondence Address:
Yaw Amo Wiafe
Kwame Nkrumah University of Science and Technology, Kumasi
Ghana
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_151_22
Abstract
Background: Transthoracic echocardiography is a very helpful noninvasive cardiovascular imaging technique for the diagnosis and risk stratification in the management of patients with cardiovascular diseases. We aimed to review the clinical indications for transthoracic echocardiography and the confirmation rate of cardiovascular diseases by echocardiography at a specialist cardiac clinic in Ghana. Methods: Using a cross-sectional study design, the echocardiography reports of all patients above the age of 15 who were assessed at the clinic were analyzed. Data on patient demographics, clinical history, clinical indication for echocardiography, and the echocardiographic findings were analyzed using version 25.0 of the Statistical Package for Social Sciences (SPSS). Results: A total of 594 participants were studied. The age range of participants was 15–96 years, with a mean (± standard deviation) age of 53.72 (± 17.25) years. There were more females (50.17%) than males (49.83%). Most (54.21%) of the participants had echocardiography for cardiac evaluation. Other indications included hypertension/hypertensive heart disease (HHD) (n = 131; 22.06%), heart failure (n = 69; 11.62%), chest pains (n = 12; 2.02%), and valvular heart disease (VHD) (n = 11; 1.85%). Three hundred and eight-nine (70.30%) of the participants had their clinical diagnoses confirmed by echocardiography; echocardiographic confirmation rates for heart failure, VHD, and HHD were 92.75%, 90.91%, and 88.54%, respectively. Conclusion: Echocardiography showed high confirmation rates for our patients with heart failure, VHD, and HHD. Prompt usage of this noninvasive cardiovascular imaging for the initial evaluation of patients with cardiovascular diseases is highly recommended.
Résumé
Contexte: L'échocardiographie transthoracique est une technique d'imagerie cardiovasculaire non invasive très utile pour le diagnostic et la stratification du risque dans la gestion des patients atteints de maladies cardiovasculaires. Notre objectif était d'examiner les indications cliniques de l'échocardiographie transthoracique et le taux de confirmation des maladies cardiovasculaires par échocardiographie dans une clinique spécialisée en cardiologie au Ghana. Méthodes: En utilisant un plan d'étude transversal, les rapports d'échocardiographie de tous les patients âgés de plus de 15 ans qui ont été évalués à la clinique ont été analysés. Les données sur les caractéristiques démographiques des patients, les antécédents cliniques, l'indication clinique de l'échocardiographie et les résultats de l'échocardiographie ont été analysés à l'aide de la version 25.0. ont été analysées à l'aide de la version 25.0 du Statistical Package for Social Sciences (SPSS). Résultats: Un total de 594 participants ont été étudiés. La tranche d'âge des participants était de 15 à 96 ans, avec un âge moyen (± écart-type) de 53,72 (± 17,25) ans. Il y avait plus de femmes (50,17 %) que d'hommes (49,83 %). La plupart (54,21 %) des participants ont subi une échocardiographie pour une évaluation cardiaque. Les autres indications comprenaient l'hypertension/la cardiopathie hypertensive (HHD) (n = 131 ; 22,06%), l'insuffisance cardiaque (n = 69 ; 11,62%), les douleurs thoraciques (n = 12 ; 2,02%), et cardiopathie valvulaire (VHD) (n = 11 ; 1,85 %). Le diagnostic clinique de trois cent huit-neuf (70,30 %) des participants a été confirmé par échocardiographie. confirmé par échocardiographie ; les taux de confirmation échocardiographique pour l'insuffisance cardiaque, la VHD et la HHD étaient de 92,75 %, 90,91 % et 88,54 %, respectivement. Conclusion: L'échocardiographie a montré des taux de confirmation élevés pour nos patients souffrant d'insuffisance cardiaque, de VHD et de HHD. L'utilisation rapide de cette technique cardiovasculaire non invasive L'utilisation rapide de cette imagerie cardiovasculaire non invasive pour l'évaluation initiale des patients atteints de maladies cardiovasculaires est fortement recommandée.
Mots-clés: Maladies cardiovasculaires, échocardiographie, Ghana, indications, hypertension systémique
Keywords: Cardiovascular diseases, echocardiography, Ghana, indications, systemic hypertension
Introduction 
Cardiovascular diseases are a broad category of diseases that affect the heart and its complex vascular network, and they are by far the most important noncommunicable disease in both resource-poor and resource-abundant countries in terms of morbidity and mortality.[1],[2],[3],[4] Some of the most useful diagnostic tools for detecting cardiovascular disease include: chest X-ray; electrocardiography (ECG); echocardiography; coronary computed tomography angiography; cardiac magnetic resonance imaging; and nuclear cardiology.[5],[6],[7],[8] Each of these tools has strengths and limitations. However, some of these imaging modalities, particularly echocardiography, may be better suited for specific individuals than other methods based on a patient's demographics, clinical presentations, and geographic location.
Transthoracic echocardiography is a noninvasive cardiovascular imaging technique for diagnosing and stratifying the risk of cardiovascular disease. It has the unmatched advantage of being easily accessible, efficient, and relatively inexpensive as a tool for cardiac assessment, and it has a high level of diagnostic accuracy in detecting morphological and functional cardiac abnormalities.[9],[10] With echocardiography, a wide range of cardiovascular conditions such as evaluating suspected heart failure, monitoring patients with valvular heart disease (VHD) who have already been diagnosed, and screening patients whose first-degree relatives have certain genetic disorders such as hypertrophic cardiomyopathy (HCM) which can cause sudden cardiac death.[11] The characterization and treatment of a variety of cardiovascular-related disorders have been greatly improved by the availability and accessibility of echocardiography in the resource-abundant world.[12]
However, the profile of cardiovascular conditions in Sub-Saharan Africa that is amendable to echocardiography evaluations remains unclear. While previous studies conducted in Nigeria identified hypertensive heart disease (HHD), VHD, and cardiomyopathy as the commonest indications that were assessed with echocardiography,[13],[14],[15] data from neighboring countries are rarely available. In order to strategically plan the use of scarce resources in the management and preventive measures to reduce the burden of disease, it is critical to have adequate knowledge of the profile of the cardiovascular disease in a community. Therefore, this study was done in Kumasi, Ghana, in order to obtain up-to-date echocardiographic data on Ghana's cardiovascular disease trends, symptoms, and confirmation rate.
Methods This cross-sectional study was carried out at a specialist cardiac outpatient clinic in Kumasi, Ghana. Echocardiography reports of all patients above the age of 15 years who attended the Specialist Clinic between September 2015 and August 2018 were analyzed retrospectively. In this clinic, echocardiography is routinely done throughout the week for both emergencies and stable patients. Referrals come from across the various regions of the country, but mostly from within Kumasi Metropolis in the Ashanti region. During the study, a total of 594 patients with varying indications were reviewed with a complete echocardiography report.
Clinical evaluation
Baseline clinical and demographic characteristics were obtained from patients' records. Age, sex, pulse, blood pressure, weight, height, indication for echocardiography, and the findings of echocardiography were all obtained. The blood pressure was taken with Accoson's mercury sphygmomanometer in the sitting position after 5 min of rest.
Echocardiography
Using a GE Vivid S5 ultrasound machine with a 3.0 MHz sector transducer, transthoracic echocardiography was performed with the patient in the left lateral decubitus position. Images included two-dimensional, M-mode, and Doppler findings. The American Society of Echocardiography (ASE), which advocates the leading edge to leading edge convention, was followed for all measurements.[16] The apical four-chamber view, the parasternal long axis view, the short axis view, the subcostal view, and occasionally the suprasternal view, were used for the echocardiographic assessment. In the parasternal long axis views, the Left Ventricle (LV) measures were taken at the end-diastole and end-systole. The left atrial diameter (LA), aortic root diameter, and aortic valve opening (AVO) were measured in the left ventricle (LV) AVO. Other measurements include the thickness of the interventricular septum at end-diastole and end-systole, the thickness of the posterior wall at end-diastole and end-systole, and the internal dimensions of the left ventricle (LVIDd) at end-diastole LVIDd and end-systole.
Based on currently accepted standard ASE[16] guidelines, the following echocardiographic diagnoses were made:
HHD was diagnosed when LV diastolic dysfunction and/or LV systolic dysfunction (ejection fraction 50%), LV hypertrophy, and dilated left atrium, with a LA of 3.8 cm in women and 4.0 cm in men were present.[17] The World Heart Federation's echocardiographic criteria were used to make the diagnosis of rheumatic heart disease.[18] Dilated cardiomyopathy was diagnosed when dilated heart chambers with normal or reduced wall thickness and LV systolic dysfunction with an ejection fraction of <40% is present.[19] In the absence of another clearly recognizable cause of heart failure, peripartum cardiomyopathy was defined as idiopathic cardiomyopathy that manifested as LV systolic dysfunction with a 45% ejection fraction in the 9th month of pregnancy or within 6 months after delivery.[20]
The diagnosis of HCM was made when there is an unexplained maximal wall thickness of >15 mm in any cardiac segment, or a septal/posterior wall thickness ratio of >1.3 in normotensive individuals, or >1.5 in hypertensive patients.[21],[22] The diagnosis of ischemic heart disease was made when regional wall motion abnormalities involving the left ventricle is identified.[23] A right ventricular systolic pressure of 35 mmHg in the absence of pulmonary stenosis was used to characterize pulmonary hypertension.
Cor-pulmonale was diagnosed when the right ventricle was dilated; there is hypertrophied right ventricle with evidence of pulmonary hypertension on spectral Doppler.[24]
Pericardial effusion is identified when an echo-free gap exists between the visceral and parietal pericardium. Congenital heart disease was evaluated systematically using the sequential segmental technique (European approach) as the originator of the concept.[25]
Cardiac evaluation for which echocardiography was requested included general medical examination, preoperative assessment, routine medical check-up and unspecified indications. Abnormal ECG findings included LV hypertrophy, ST-T waves abnormalities, bundle branch blocks, and complete heart blocks.
Statistical design and analysis
Data were transferred from Microsoft Excel into SPSS version 25.0 for analysis (SPSS Inc., Chicago, IL, USA). Means and standard deviations for quantitative variables were determined, and the means were compared using the independent samples t-test. The presentation of categorical variables was presented as counts and percentages. Statistics were considered significant using a P = 0.5.
Results Demographic and clinical characteristics of the research participants
[Table 1] shows the demographic and clinical characteristics of the participants. A total of 594 transthoracic echocardiograms with all data available were analyzed. The age range of participants was 15–96 years, with a mean (± standard deviation) age of 53.72 (± 17.25) years. There were more females (50.17%) than males (49.83%). The peak age range for the study population was 50 to 69.
Clinical indications for echocardiography in the study subjects
Clinical indications for echocardiography are illustrated in [Table 2]. The most common clinical indication for the echocardiography was for cardiac evaluation (54.21%), followed by systemic hypertension/HHD (22.06%) and heart failure (11.62%). Other indications included: chest pains (2.02%), VHD (1.85%), congenital heart disease (1.35%), syncopal attack (1.35%), palpitation (1.35%), ECG abnormalities (1.18%), cardiac arrhythmia (1.18%), ischemic heart disease (1.01%), and pulmonary hypertension (0.84%).
The cardiac evaluation for which echocardiograms was requested included medical examination, preoperative assessment, routine medical check-up, and unspecified indications. Abnormal ECG findings included LV hypertrophy, ST-T waves abnormalities, bundle branch blocks, and complete heart blocks.
Echocardiographic confirmation rate of clinical diagnoses
Of the 594 patients' echocardiographic reports examined, 553 had clinical diagnosis that could be confirmed by echocardiography. [Figure 1] and [Table 3] show the overall confirmation rate and the confirmation rates for the various clinical diagnoses. Three hundred and eight-nine (70.30%) of the participants had their clinical diagnoses confirmed by echocardiography. Data analysis of the echocardiographic diagnostic sensitivity showed that, 92.75%, 90.91%, 88.54%, and 75.00% of those screened on account of heart failure, VHD, HHD and congenital heart disease, respectively, had confirmed cardiovascular diseases. Of the 223 patients requested for cardiac evaluation, 57.45% had abnormal echocardiographic findings indicating various cardiovascular diseases.
Discussion In many sub-Saharan African nations, cardiovascular diseases continue to impose a growing strain on an already overburdened healthcare system. It is well recognized that transthoracic echocardiography is gradually becoming a critical noninvasive cardiovascular investigative tool in complete cardiac assessment and patient care, particularly with the rise in cardiovascular diseases in Ghana. This study provides useful information on echocardiographic indications, and confirmation rates of cardiovascular diseases, which may be useful for healthcare systems in developing countries.
The most frequent reason for echocardiography in our analysis was cardiac assessment (54.21%), for a general medical examination, preoperative assessment, routine medical check-up or unspecified indications. This was followed by systemic hypertension/HHD (22.06%) and heart failure (11.61%). The discovery of cardiac evaluation as the most common indication, accounting for more than half of all echocardiographic tests in our study, contradicts reports by other authors in the sub-region.[13],[26],[27],[28] According to studies from nearby Nigeria, HHD is the most common reason for requesting echocardiography.[13],[26],[27],[28] Notably, a comparable study in Enugu similarly found VHD to be the most common rationale for echocardiography, and the authors attributed this to the study site being a national referral center for cardiovascular-related surgery, thus garnering more referrals of patients requiring cardiac surgical treatments.[11] The high incidence of cardiac assessment as a clinical justification in this study may reflect some clinicians' lax and indolent attitude about referring patients for echocardiography.
In this study, hypertension/HHD was the second most prevalent clinical indication, with a prevalence of 21.72%. This finding is comparable to the prevalence of 32.1% reported by Ejim et al.,[29] but significantly lower than the values of 42.5%, 52.1%, 76.0%, and 86.0% reported by Ajayi et al.,[30] Adebayo et al.,[27] Ansa et al.,[31] and Kolo et al., respectively.[32] The high rate of hypertension/HHD in this study, as well as in other similar series, may be due in part to the disproportionately larger number of hypertensives referred for echocardiography, despite the fact that hypertension is a major risk factor for cardiovascular disease and is still the most common cardiovascular disease in sub-Saharan Africa.[33]
Heart failure constituted 11.62% of indications for echocardiography in this study and ranked behind cardiac evaluation and hypertension/HHD. In the series by Ejim et al.,[29] Adebayo et al.[27] and Ajayi et al.,[30] heart failure was the second most common indication for echocardiography in all the studies. This finding lends support to the notion that heart failure is a major contributor to the cardiovascular disease burden in the majority of sub-Saharan African countries.[34] Chest pain ranked fourth as a clinical indication (2.02%) for echocardiography in our study, and it has a similar rate with other reports from the sub-region[27] but lower than the rate reported by Kolo et al.[32] in the north central region of Nigeria and Adebayo et al.[9] Southwest Nigeria. The difference in findings in this study may be attributed to difference in sample sizes and population studied.
In earlier studies, the prevalence rate of VHDs as an echocardiographic indication has been found to be generally low. We found a prevalence of 4.24%, whereas previous research found frequencies ranging from 0.4% to 2.4%.[35] The low risk of VHD may be owing in part to the study's inclusion of only adults.
A significant number of the study subjects, 29.7% (164) had normal echocardiographic findings in this study. This finding is substantially in keeping with the prevalence of 29.3%, 30.5% and 31.2% reported by Ajayi et al.[30] Agomuoh et al.[36] and Ogah et al.,[13] respectively, but higher compared to other similar studies in the subregion.[14],[26],[27] A lot of factors could contribute to this large number of normal echocardiographic studies, including the fact that myriad number of clinicians with barely superficial knowledge in cardiology and nonclinicians (such as nurses, pharmacist, and medical technologist) referred patients for echocardiography with high degree of uncertainty of the appropriateness of the request. No wonder, the American College of Cardiologists Foundation in association with other bodies issued the appropriateness criteria for transthoracic echocardiography,[37],[38] with the principal aim of encouraging appropriate and rational use of this useful imaging modality. This will guide the clinician in their request for this important cardiovascular imaging and also help to reduce the potential clinical tendencies of causing financial loss to the vulnerable patients.
In this study, the overall cardiovascular disease confirmation rate by echocardiography was shown to be as high as 70.3%. This finding is similar to a previous study conducted in rural Tanzania, which discovered abnormal echocardiographic findings in 72% of participants.[39]
As evidenced by the fact that the majority of clinical indications in this study were validated on echocardiography, the echocardiographic detection rate of clinical diagnoses revealed high sensitivity for heart failure (92.75%), VHD (90.91%), HHD (88.37%), and congenital heart disease (75.00%). These findings are consistent with earlier research in the sub-region.[27],[30] This demonstrates that echocardiography may be a particularly reliable and reproducible investigative technique for objective evaluation and monitoring of patients suffering from these frequent cardiovascular disorders.
One major limitation of this study is its retrospective nature, notwithstanding, this report includes contemporary, accurate and reliable data which may be helpful to health care planners and policy makers in Ghana and other sub-Saharan African countries. This study was hospital based with referrals from different primary health-care facilities. Cardiac abnormalities were identified in over 50% of cases that came for cardiac evaluation as part of general medical examination, general check-up, and pre-operative evaluation, without prior history of cardiac disease or a specified clinical indication. The high rate of cardiac abnormalities incidentally detected in this group underscores the importance of having wider availability of transthoracic echocardiography in primary healthcare facilities, which is still unavailable to many in the subregion.'
Conclusion Echocardiography showed high confirmation rates for our patients with heart failure, VHD, and HHD. Prompt usage of this noninvasive cardiovascular imaging for the initial evaluation of patients with cardiovascular diseases is highly recommended.
Ethics approval and consent to participate
This research was approved by the Committee on Human Research Publication and Ethics (CHRPE) of the School of Medical Sciences at Kwame Nkrumah University of Science and Technology and the Committee on Human Research Ethics at KATH Kumasi. Prior to analysis, patient data and records were de-identified and anonymized.
Availability of data and material
Data are available on request to corresponding author address.
Author's contributions
All authors made a significant contribution to this work including conceptualization, study design, acquisition of data and data analysis. All authors were involved in the initial write-up of manuscript and review and of this manuscript.
Acknowledgment
The authors would like to express their sincere gratitude to the staff and the study participants at Precise Specialist Clinic, Kumasi, Ghana, for their support. Without their co-operation, this study would not have been done.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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