Experts lament inadequate infrastructure, advocate healthy lifestyle
By Azoma Chikwe
A heart attack or myocardial infarction (MI) is an event that causes permanent damage to the heart muscle. “Myo” means muscle, “cardial” refers to the heart and “infarction” means death of muscle tissue due to lack of blood and oxygen supply.
Heart muscle requires a constant supply of oxygen-rich blood to nourish it. The coronary arteries provide the heart with this critical blood supply. If someone has coronary artery disease, those arteries become narrow, or obstructed, and blood cannot flow as well as it should. Fatty matter, calcium, proteins and inflammatory cells build up within the arteries to form plaques of different sizes and consistencies.
This is sometimes what causes the initial symptoms of coronary artery disease. With the build up of plaque, there is less delivery of oxygen to the heart muscle, especially when there is a demand for oxygen during exertion or exercise and chest pain or symptoms can develop.
The outer surface of the plaque may rupture or crack and platelets (disc-shaped particles in the blood that help form blood clots) then come to the area to form blood clots around the plaque like a scab. If a blood clot totally obstructs the artery, the heart muscle can become starved for oxygen. This is called ischemia. And within a short time (even minutes), death of heart muscle cells occurs, causing permanent damage. This is a heart attack.
While it is unusual, a heart attack can also be caused by a spasm of a coronary artery. Coronary arteries have a muscle lining which can contract or relax depending on the needs of the heart muscle at a given time. During a coronary spasm, the coronary arteries constrict or spasm without warning, reducing blood supply to the heart muscle and potentially causing a heart attack. It may occur at rest and can even occur in people without significant coronary artery disease.
Each coronary artery supplies blood to a specific region of heart muscle. The amount of damage to the heart muscle depends on the size of the area supplied by the blocked artery and the time between injury and treatment. Earlier treatment can reduce the impact of the heart attack.
Healing of the heart muscle begins soon after a heart attack and takes about eight weeks. Similar to a skin wound, the heart’s wound heals and a scar will form in the damaged area. However, the new scar tissue does not contract. Therefore, the heart’s pumping ability can be reduced after a heart attack. The amount of lost pumping ability depends on the size and location of the scar.
Number one cause of death
Consultant Interventional Cardiologist, Tristate Heart Foundation, Ibadan, Prof. Kamar Adeleke, said, “the average life expectancy in Nigeria today is 50 years, the average life expectancy in United States where I have lived for over 40 years is 79.8 years, the average life expectancy in Cuba is 80 years. So, you can see the difference of 30 years between Nigeria and Cuba, that is huge. That means the majority of our people are dying in their most productive age because our health care delivery system is bad. People like us now, if you say 50, we say the person is a baby.. And what is the number one cause of death? If it was ten years ago, we say it is witchcraft, that is not the case anymore.The number one cause of death is in sub-saharan Africa is heart attack, the number two cause is stroke. So, if someone put heart attack and stroke together, they have taken 70 per cent of the major cause of demise in our society.
“The most important thing in handling heart attack is availability of services. When someone is having a heart attack, to save the person’s life, we have to get into his heart within 90 minutes and open up whatever is causing the heart attack. Can you imagine moving from Lagos to Babcock University and from Babcock to Ibadan in 90 minutes. There has to be a facility within the reach of the people. We want to make sure there is impressive state-of-the -art facility at every corner of Nigeria. That is what Tristate Heart and Cardiovascular Center is doing. We will make sure it is very affordable, because that is the key.
“ We have done 132 open heart surgeries in Nigeria with a success rate of 98 .5 per cent , in the carth. lab we have 100 per cent success rate. To do one open heart surgery we charge between 5,000 – 6,000 dollars, in the United States, one open heart sdrgery costs a minimum 75,000 – 125, 000 dollars. That is quite affordable, and yet we are using the same equipment. That is quite impressive. Now, we know we can do it, we know we can provide the services here in Nigeria.”
Intervention
On the mission of Tristate cardiovascular centres to reduce death from hearth attack, Chief Operating Officer, Dr Olakunle Iyanda, said, “ as the name implies we deal with anything that has to do with the heart or cardiovascular diseases. And globally when you talk of non-communicable killer diseases, the first thing that comes to mind is cardiovascular diseases. And unfortunately for us we don’t have capacity to handle that. In 2014, Prof. Kamar Adeleke came to Nigeria on a medical mission with 68 clinicians. In one week they spent here they treated 5 000 people. And he said, lets do a ramdom sampling for cardiovascular diseases on eight people, six had complete blockage of the artery and nobody knew that. Prof. Adeleke got alarmed and he said something must be done about it.
“ When the governor of Oyo state, Abiola Ajimobi hosted them, the Chief Medical Director(CMD), University College Hospital, Ibadan, Prof. Temitope Alonge, was there. And the governor said meet Prof. Adeleke an interventional cardiologist from Delaware, United States, and the CMD jumped up. Why he jumped up was because prior to 2014, government spent a lot of money at UCH to established cath. lab., cardiac intensive care unit, cardiac ward, but unfortunately, there was nobody to operate it. And the place was like that for three years. Prof. Adeleke was actually the Director of the Cath. Lab in the hospital he works in abroad and he has a very big practice.
“He was approached to head the place at UCH, and he said there is no way they can pay him, and even if they can, they don’t have the facility, they don’t have the support., They don’t have the anaesthetists , the perfutionists, the nurses , the back-up . However, Prof Adeleke discovered the prevalence of heart disease in the country was high , and to cut a long story short , that was the beginning of Tristate.
“ He signed an agreement with UCH for ten years to manage their heart and cardiovascular unit. We were there for six weeks, and in that space of time, we did about 42 open heart surgeries. And the beauty of it was that the first open heart surgery we did, we did for free. And some of the next few that we did, we also did for free. A lot of people have heart problems, but they cannot afford the surgery.
“Of the 42, I think about 70 per cent of them were children, of the 70 percent, 75 of them could not pay, we had to do it free. We said well, it is not sustainable, you know government and business, the programme had a lot of issues. And the programme at UCH was affected . But among what we achieved at UCH was we trained 15 of their nurses in critical care, which has not been done before. The few surgeries at UCH, all the support staff, the perfutionists, anaesthetists, and even the nurses were all brought in from United States, but now 100 per cent of the services at the centre are done by Nigerians. One of the things we do at Tristate is to train local capacity.
“When we moved to Babcock University, to establish the Tristate Cardiovascular Center , we spent about ten million dollars. We had to engage, employ cardiologists who are already trained but they have what it takes to practice. We had to send them for fellowship in interventional cardiology. Interventional cardiologists are those who help those with heart attack with stent without having to open the heart.
“We want to make this accessible and affordable, we want to take our services closer to the people. Currently we have people coming from all over Nigeria. We have a small clinic that we do in Lagos. We have a twenty million dollar project that is coming up in Lagos. You know Nigeria is a tough country to do business in. We want to engage people, we want to attract investors, who will be part of the noble thing that we are doing. So that people don’t have to die aimlessly. From our interactions, you would be able to see some critical cases and people that we have been able to rescue. We are talking of expatriates, Nigerians, women and children. We do hope that the Tristate Heart and Cardiovascular Center in Lagos will be ready before the end of the year. We are working seriously on that, we also hope that our Heart and Cardiovascular Centre in Abuja will be ready. “
On the prevalence of heart diseases,Minister of Health, Prof. Isaac Adewole , said, “Nigeria is experiencing demographic and epidemiological transition like the rest of the world, such that Non-Communicable Diseases(NCDs) are becoming a leading cause of deaths. The burden of NCD’s emanates primarily from cardiovascular diseases (hypertension, stroke, coronary heart disease), diabetes mellitus, cancers, sickle cell disease and chronic obstructive airway diseases including asthma. Other leading causes of morbidity and mortality include mental health disorders, violence and road traffic injuries. This group of chronic diseases exerts a lot of stress on our socioeconomic life and put significant strain on the very fragile health care infrastructure.
Statistics
“The WHO data has consistently shown that cardiovascular diseases (CVDs) are the leading cause of death globally. The 2010 WHO Global Status Report on NCDs shows that in 2008, the four major NCDs namely cardiovascular diseases, diabetes, cancers and chronic respiratory diseases put together killed 36 million (63%) persons out of the 57 million global deaths recorded. Of these, CVDs ranks first with 17 million deaths (48%) out of the 36 million NCD deaths.
“ Furthermore, the 2014 report showed that in 2012, the 4 major NCDs claimed 38 million (68%) lives out of the world’s 56 million deaths, and over 40% of the deaths were premature deaths under the age of 70 years. CVDs alone killed 17.5 million people representing 31% of all the global deaths and 46% of NCD deaths.
“ Over 75% of the CVD deaths occurred in low-income and middle-income countries (LMIC), of which Nigeria is one. During the same period, heart attacks and strokes alone accounted for 80% of all the CVD deaths, and together they all to the top three causes of years of life lost due to premature mortality.
“In terms of prevalence, hypertension is the leading CVD in Nigeria and the world at large. Although, the current exact prevalence of hypertension in Nigeria is unknown, extrapolation from the last national survey conducted in 1990/92 which was published in 1997 put the prevalence of hypertension at over 20%, suggesting that one out of every five Nigerians is hypertensive.
“ Current hospital records estimates showed that the prevalence of hypertension is 25% while estimated mortality from stroke is 40 – 50% within the first three months of diagnosis. Another hospital based study showed that 39% of those who survived stroke after three months died within 12 months and the remaining 12% developed severe disability.
“ We should not be too surprised about the figures stated so far because we know that sudden deaths are commonplace and everyone can recall immediately recent cases of prominent Nigerians who have died suddenly and majority of these are probably due to heart attack, stroke or diabetic complications.
“ We can also easily call to mind numerous relatives and friends who are living with disability resulting from stroke or limb amputation from diabetes. I can also say without fear of contradiction that at least 5 out of 10 adults have elevated blood pressure and more than half of these are not aware of their situation. This is frightening because the dire consequence of neglected hypertension is stroke without warning.
“ The economic consequences are enormous. Deaths from these causes mean permanent loss of livelihood and affected individuals who survive loss productivity and in both cases the families suffer. Socially it is traumatic for the affected individuals who survive as they are virtually dependent on others for even most routine of chores and this can be psychologically devastating. Family members who take care of these individuals are also unproductive and families can plunge into penury for these reasons.
“The cumulative economic losses due to NCDs under a ‘‘business as usual’’ scenario in low – and middle-income countries have been estimated at US$ 7 trillion in 2011-2025. This sum, far outweighs the annual US$ 11.2 billion cost of implementing a set of high-impact interventions to reduce the NCD burden (WHO NCDs Global report 2014).
“ In Nigeria, the economic loss from heart disease, stroke and diabetes alone was estimated by WHO at US$400 million in 2005 and projected to rise to US$8 billion in the next 10 years unless we take drastic and sustained actions. Otherwise, we will keep counting loses.”
Risk factors
Prevention is not only better but also cheaper than cure, it is important to leverage commitment and enthusiasm to advance this course. Fortunately, the NCDs share common risk factors.
The major NCD risk factors are use of tobacco products, unhealthy diet, harmful alcohol intake, physical inactivity and air pollution. These factors are aggravated by poor awareness, harmful cultural practices, beliefs and misconceptions by the public.
Tobacco use is the most sjgnificant risk factor of NCDs and accounts for 80% of the six million premature deaths annually in low and medium income countries including Nigeria. 5.6% adults (4.5 million adults) currently use tobacco products out of which 4.1 million are men and 0.45 million are women. In addition, 29.3% of adults (6.4 million adults) are exposed to tobacco smoke when visiting restaurants, hotels and other public settings.
Alcohol consumption is another risk factor and this is quite high in Nigeria, with a per capita consumption of 10.57 litres to rank among the highest in Africa. So also is physical inactivity. About 30.3-74.6% of Nigerian children and youths aged 5-25 years are not sufficiently active (NHF, 2013) and 80% of working class adults in urban areas in Nigeria do not meet the WHO recommended level of physical activity.
Adewole said, “ Unhealthy diets contribute significantly to the development of NCDs in Nigeria. Sadly, there is widespread low consumption of protein, fruits and vegetables and increasing patronage of fast food outfits by the population. There is also large promotion of sweetened products such as carbonated drinks, pastries, candies, and other refined sugars, while excessive intake of salt is promoted by food additives such as monosodium glutamate (MSG) common in local delicacies such as suya, kilishi, isi-ewu, ngwo-ngwo, among others. The high caloric intake resulting from refined sugars promote overweight and obesity especially in a country where exercise is not a form.
“You will recall that in the not too distant past, noncommunicable disease were erroneously believed to be the problem of the affluent. But the reality is that both the rich and the poor are affected and the poor actually bear the greater brunt for obvious reasons.
“ The poor generally find it more difficult to access requisite health care services for prevention and adequate management of NCDs. The reason is not all financial. They also usually have a lower levels form education, which constrain them from adopting preventive measures. Also they are more exposed to some risk factors especially air pollution arising from use of inefficient fuel for cooking.
Adopt healthy lifestyle
“ I want to also use this opportunity to advise Nigerians to adopt healthy lifestyles to stem the rising tide of cardiovascular and other NCDs. To this effect, I am advising that fruits and vegetables should be included in every meal we take. Fatty foods and fizzy drinks loaded with sugar should be reduced and possibly avoided.
“ Every individual should do minimum of 30 minutes physical exercise per day at least five times in a week. Alcohol, when necessary, socially should be taken sparingly and binging should not be done. Similarly tobacco in any form must be avoided and conscious efforts must be made to maintain tobacco smoke free environment,” he said.