Original Article
Is it time to change? Portable echocardiography demonstrates high prevalence of abnormalities in self-presenting members of a rural community in Kyrgyzstan
JRSM Cardiovascular Disease Volume 7: 1–7 ! The Author(s) 2018 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2048004018779736 journals.sagepub.com/home/cvd
Anthony James Barron1, Turgunbai Aijigitov2 and Aigul Baltabaeva1
Abstract Objectives: Cardiovascular disease accounts for 42% of male and 51% of female mortality within Europe. Kyrgyzstan, population of almost 6 million, has amongst the highest rates within Europe, second only to Uzbekistan for female cardiovascular disease mortality (588 per 100,000). We attempted to identify established cardiovascular disease prevalence within a rural community in Kyrgyzstan using portable echocardiography. Design: Free open access echocardiography (VIVID-I, GE, USA) was offered to all adults in Batken district. Routine echocardiographic views were obtained and analysis performed using EchoPac Clinical Workstation (GE, USA). Mild valvular regurgitation, mild LV hypertrophy, patent foramen ovales and mild atrial enlargement were considered mild abnormalities; compensated ischaemic or valvular heart disease – moderate abnormalities, and decompensated congenital, ischaemic or valvular disease – severe abnormalities. Results: One hundred and twenty five adults (48 male, 77 female), mean age 53 16 years, underwent echocardiography. Only 16% of participants had no significant abnormality, 46% had mild disease, 25% moderate, compensated disease and 13% had severe disease. Nine percent had congenital heart disease including one tetralogy of Fallot and one Ebstein’s anomaly. Average LV function was normal, however, 19 participants had EF < 50%. Forty percent of participants had a new diagnosis warranting formal follow-up, 12% a new diagnosis of heart failure. Conclusion: Using portable echocardiography, we identify a higher than reported prevalence of cardiovascular disease in rural Kyrgyzstan. Absence of portable tools and specialists for early diagnosis might lead to presentation in an advanced stage of disease when little can be done to improve mortality. Embracing remote access diagnostics is essential for disease identification within rural communities. Keywords Cardiology, cardiology, diagnostic testing, echocardiography, epidemiology, etiology, population cardiology Date received: 22 August 2017; revised: 19 April 2018; accepted: 23 April 2018
Introduction Cardiovascular disease (CVD) remains the principal cause of mortality within European and Central Asian states and across the world, and marked inequalities still remain in the impact of CVD between countries.1,2 Within the recent Epidemiological Update from the European Society for Cardiology, Kyrgyzstan in Central Asia, was identified as a country with substantial inequalities and significant premature mortality compared with many Western European states. Despite the national programme, “Manas-
taalimi” aimed at prevention of cardio vascular diseases,3 with integration of cardiology service systems and education of personnel and investment in 1 Harefield Hospital, Royal Brompton and Harefield NHS Trust, London, UK 2 Batken District General Hospital, Batken, Kyrgyzstan
Corresponding author: Anthony James Barron, Harefield Hospital, Harefield, Uxbridge UB9 6JH, UK. Email:
[email protected]
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2 diagnostics, the CVD mortality rates in 55–64 year old males and females matched that of 75–79 year olds from France. We must also consider that in largely rural countries, access to healthcare is not readily available, and therefore accurate diagnosis at the time of death may be hindered; this could either falsely increase the cardiovascular mortality as patients are wrongly labelled as dying of CVD, or underestimate the true prevalence due to lack of correct timely diagnosis in patients with CVD. Previous cohort studies utilising echocardiography have been used around the world to identify the undiagnosed burden of CVD, and perhaps give us an indication of its true prevalence but these have largely been performed in developed nations. For over 20 years, the idea of remote telemedicine has been considered in cardiology, with echocardiography performed in rural areas and sent to experts for interpretation.4–6 As mentioned above, this has largely been confined to rural areas of developed nations. The limited resources of both equipment and expertise within developing nations with large rural populations do not just limit the ability to investigate disease, but also may influence the ease of access to appropriate treatments. In this study, local residents of a rural area of Kyrgyzstan were invited to have a full echocardiographic study performed by a visiting consultant cardiologist from London, UK. Any individuals living within the Batken district of Kyrgyzstan were eligible to attend an open-access clinic to have the echocardiogram performed.
Methods Local residents within the Batken district of Kyrgyzstan were invited to undergo free echocardiography between 9 August 2015 and 26 August 2015. The studies were performed by one operator using portable echocardiographic equipment with an S3 probe (VIVID-I, GE, USA). This open-access, free service was advertised to local residents via local television and newspaper media. Whilst children were included in scanning, only adults (>16 years of age) were included in this cohort study. This service was supplied because this region did not have local access to echocardiography, and for some patients this information could help guide their clinical management. These echocardiographic studies were not done for research purposes and ethical approval and consent were not obtained, as this is a descriptive observational study based on a clinical cohort. This local area is supplied by a Batken District Hospital, which serves a population of 428,800. This has access to basic medical provisions, but not
JRSM Cardiovascular Disease specialist cardiac care, for which you would have to travel to the capital Bishkek. Whilst two-thirds of the population of Kyrgyzstan is rural, this rises to three quarters in Batken district.
Echocardiographic assessment Standard echocardiographic views were taken and analysed as per EACVI guidelines.7 These were stored principally as loops comprising two cardiac cycles. Doppler imaging was performed at a sweep speed of 75 cm/s with scale maximised to optimise the Doppler trace. Atrial areas, not volumes, were measured in the apical four-chamber view. One patient, due to a known recent history of a transient ischaemic attack (TIA), underwent a bubble contrast study alongside the full echocardiographic study, with 10 ml saline, 2 ml blood and
