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Nigerian J Paediatrics 2019 vol 46 issue 2

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Screening for arrhythmias in secondary school students in Port Harcourt Nigeria
Niger J Paediatr 2019; 46 (2): 61 - 67
ORIGINAL
Tabansi PN
CC – BY
Screening for arrhythmias in
Dibua O
secondary school students’ in
Port Harcourt, Nigeria
DOI:http://dx.doi.org/10.4314/njp.v46i2.4
Accepted: 2019
Abstract: Introduction:
Results: There were 595 males and
Undetected arrhythmias are the
407 females (ratio of 1.5:1), age
Tabansi PN (
)
most common cause of sudden
ranged from 10 to 19years.
Department of Paediatrics and
cardiac deaths, and the prevalence
Seventy-four (7.4%) were under-
Child Health,
of primary cardiac arrhythmias
weight, 52 (5.2%) overweight and
University of Port Harcourt
increases with age, being twice as
29 (2.9%) were obese. Majority of
East-west Road, Choba. Port
common in adolescence as in
students (96.2%) had normal ECG
Harcourt. Rivers State. Nigeria.
younger children. The period of
– sinus rhythm and normal ECG
Email:
secondary school education is a
variants (sinus arrhythmia, first
petronillatabansi@yahoo.com
time of participation in active and
degree heart block, incomplete
competitive sports by most ado-
right bundle branch block, AV
Dibua O
lescents. Since sudden cardiac
nodal rhythm, wandering a trial
Neonatal Department, Luton and
death often occurs during physical
pacemaker, ST segment elevation,
Dunstable University Hospital.
activity of sporting event, it there-
premature atrial and ventricular
United Kingdom.
fore becomes necessary to screen
contractions), while 38 (3.8%) had
adolescence in secondary school
ECG with pathologic abnormali-
for arrhythmia for purposes of
ties.
early detection and risk profiling
The commonest ECG abnormality
for intervention.
was prolonged QT interval which
Methodology:
A
multi-staged
was seen in 18 students (47.4% of
sampling technique was employed
abnormalities).
to select 1002 adolescent from 18
Conclusion:
Some
secondary
secondary school in Port Har-
school students in Port Harcourt
court. An investigator adminis-
have potentially life-threatening
tered questionnaire was used to
arrhythmias. Regular screening of
obtain relevant biodata and health
adolescents in secondary schools
information; physical examina-
for risk profiling and early inter-
tion, anthropometry and a 12-lead
vention is recommended.
electrocardiogram (ECG)
was
subsequently performed and data
Keywords: Arrhythmia, secondary
analyzed.
school students, Port Harcourt
Introduction
arrhythmia to life threatening arrhythmias such as ven-
tricular tachycardia and bradycardia.
7
The adolescent period is one of the physically active
Sinus tachycardia is by far the most commonly reported
times of a child’s life where participation in competitive
arrhythmia in children, followed by supraventricular
sports in secondary schools occurs. Sudden Cardiac
tachycardia (SVT) which represents about 13%, and
bradycardias, accounting for about 6% of cases. Ar-
7
Deaths often occur during physical activity or sporting
events . Primary cardiac arrhythmias are probably ten
1
rhythmias may also occur as side effects of medications
times more common as a cause of sudden cardiac deaths
used in the treatment of chronic conditions in children,
compared to the other causes and their prevalence have
including antiretroviral drugs like Lopinavir and Saqui-
been shown to rise with age ; with the prevalence in
2
navir which are associated with PR interval and QT in-
adolescents being twice as much as in younger children.
3
terval prolongation respectively.
8,9
The major risk of
Sudden cardiac death of arrythmogenic etiology in chil-
arrhythmia is that it causes either severe tachycardia or
dren has been reported in hypertrophic cardiomyopathy,
bradycardia leading to decreased cardiac output; or it
Long QT Syndrome (LQTS), Wolff-Parkinson-White
degenerates into more critical arrhythmias such as ven-
syndrome (WPWS), complete heart block, ventricular
tricular tachycardia and ventricular fibrillation which
subsequently may lead to sudden death.
10
arrhythmias, acquired heart diseases and post-cardiac
surgery. Arrhythmias may also occur in children with
4
Unexpected sudden death is a tragedy at any age, but is
structurally normal heart and has been reported to occur
particularly so in childhood and adolescence. Some
in 0.02% to 5% of children
5-7
varying from benign sinus
studies have been carried out on the prevalence of ar-
62
Seriki and Smith
11
rhythmias in Nigerian children.
11,12,13
diovascular, respiratory, central nervous system, genito-
in 1966 obtained a prevalence of 20% amongst univer-
urinary and haematologic systems. Afterwards, weight
sity students in Lagos while Ogedengbe et al in 2012
12
and height measurements were taken and BMI calcu-
lated using the formula weight (kg) / height (m ). A
2
2
got a prevalence of 8% for left a trial enlargement.
The fundamental strategies for prevention of Sudden
general physical and cardiovascular examination was
cardiac death include electrocardiographic screening of
also performed. The BMI was subsequently plotted on
general population, risk profiling and interventions
the WHO BMI percentile chart for age and sex. Any
BMI below the 5 percentile was regarded as under-
th
among patients with identified cardiac disease.
[14]
How-
ever, in Nigeria, there are limited measures in place to
weight. BMI between the 5 and less than the 85 was
th
th
regarded as normal, while BMI between the 85 percen-
th
screen for and reduce the burden of sudden cardiac
tile to less than the 95 percentile was regarded as over-
th
death, especially in children. Long term experience has
weight and BMI equal to or greater than the 95 percen-
th
provided evidence that systematic screening, with 12-
tile was regarded as obese.
18
lead ECG, after history and physical examination, is
effective in identifying individuals with potentially le-
thal cardiovascular disease for early intervention, and
Blood Pressure was measured in accordance with the
technique described by Moss, and then a 12-lead ECG
19
saves lives.
15,16
This study set about to determine the prevalence and
recording was done using a portable digital electrocar-
types of arrhythmias in adolescents in secondary schools
diograph in the standard way based on the American
Heart Association specifications. Measurement and
20
in Port Harcourt, using ECG as a screening tool. The
findings have the potential to aid in the institution of
interpretation of the heart rate, rhythm, cardiac axis, PR-
cardiovascular health screening services for Nigerian
interval, QRS duration and QTc interval was done by
children especially as an integral component of school
the investigators. The QT c was calculated using the
Bazzet’s formula: QTc = QT/√RR interval
19
health program.
Data Analysis
Methods
Data was analyzed using Statistical Package for Social
Sciences (SPSS) version 20.0 software.
The study was carried out in Port Harcourt Local Gov-
ernment Area (PHALGA) of Rivers State in Southern
The following were determined from the data;
Nigeria from September to December 2014. Employing
a multi-staged sampling technique, 1002 adolescent sec-
Demographic pattern of the study population.
ondary school students aged 10 to 19 years were ran-
ECG pattern in relation to BMI.
domly selected from 55 secondary schools located
Prevalence and types of abnormal ECGs in the
within the three school districts of PHALGA. (Diobu,
study population, in relation to age, sex and BMI.
Township and Trans-Amadi) Students with known un-
The student t- test and ANOVA were used for compari-
derlying cardiac and other chronic illnesses were ex-
son of means, while chi square test was used for propor-
cluded from the study. Ethical clearance was obtained
tions. Statistical significance at 95% confidence interval
from the Research and Ethics Committee of the Univer-
was p-value <0.05.
sity of Port Harcourt Teaching Hospital (UPTH) and
All children who were found to have abnormal ECG
permission obtained from the principals of selected
patterns were referred to the Paediatric Cardiology Unit
schools. Informed consent and assent was obtained from
of UPTH for further cardiac evaluation.
parents and selected students respectively.
Sample size was calculated using the formula
17
N = z (pq)
2
e
2
Result
where N = minimum sample size
z = 1.96 at 95% confidence limits, so that
One thousand and sixty-six questionnaires were distrib-
z = 3.8416
2
uted to students selected from eighteen secondary
p = Prevalence of ECG abnormalities in adolescent
schools. However, 15 of the students had known chronic
school students. (50% was used as there are no docu-
illnesses (asthma and congenital heart disease) while
mented data on the prevalence of abnormal ECG in ado-
forty-nine of them had signs suggestive of cardiovascu-
lescent Nigerian students).
lar disease (pathologic murmur and elevated blood pres-
q = 1 – p
sure for age). These students were excluded from the
e = error margin tolerated at 5% = 0.05
study. Thus data was analyzed for 1,002 of the recruited
Allowance for Attrition of 20% was also added to the
students, who met study inclusion criteria.
minimum sample size.
School distribution of the study
A structured investigator administered questionnaire
was used to obtain relevant information from selected
Six hundred and fifty-nine respondents (65.8%) were
students including biodata, past medical history, drug
from private schools while 343 (34.2%) were from pub-
history, family and social history, and review of the car-
lic schools, giving a ratio of 1.9:1. Of the 1,002 students,
63
324 (32.34%) were from Township district, 347
BMI compared to the males across all age groups. The
(34.63%) from Diobu and 331 students (33.03%) were
overall mean BMI of the female subjects was signifi-
cantly higher at 20.43 ± 3.42 Kg/m compared to that of
2
from Trans-Amadi district, as shown in Table 1.
the males which was 18.89 ± 2.60 Kg/m (p = 0.0001).
2
Table 1: School distribution of the study population
This is illustrated in table 5.
School district
Private school
Public school
Total (%)
Table 5: Body mass index (Kg/m ) according to age and sex
2
students
students
(kg/m )(range)
2
Township
223
101
324 (32.34)
Age
Mean BMI
Diobu
227
120
347 (34.63)
group
Trans-Amadi
209
122
331 (33.03)
Male
Female
Total
T-test
P-value
Total (%)
659 (65.8)
343 (34.2)
1,002 (100)
10 – 14
17.90±2.58
19.43±3.32
18.40±2.
-5.490
0.0001
years
(14.9-26.47)
(10.57-31.04)
92
15 – 19
19.88±2.61
21.42±3.52
20.62±3.
-5.721
0.0001
Age and sex distribution of the students
years
(12.5-35.35)
(16.25-38.6)
17
The age and sex distribution of the study population is
BMI distribution of study population
shown in Table 2. The mean age of the study population
was 15 ± 2 years, with a male to female ratio of 1.5:1.
Fig 1 illustrates the BMI distribution of the study popu-
lation. Eight hundred and forty-seven (84.5%) of the
Table 2: Age and sex distribution
students had a normal BMI, 74 (7.4%) were under-
Age group
Sex
Total (%)
weight, 52 (5.2%) overweight and 29 (2.9%) were
(years)
Male (%)
Female (%)
obese.
10-14
322 (54.1)
154 (37.8)
476 (47.5)
15-19
273 (45.9)
253 (62.2)
526 (52.5)
Fig 1: Body mass index of students
Total
595 (59.4)
407 (40.6)
1,002(100%)
Weight distribution of the subjects by age and sex
The weight distribution of the student population is
shown in Table 3. The weight ranged between 19 and
98.9kg, with a mean of 49.5 ± 11.4kg.
Table 3: Mean Weight (Kg) according to age and sex
Age-group
Mean weight (kg) (range)
ECG Rhythm and Conduction Patterns in the study
Male
Female
Total
T-test
P-value
population
10-14 years 42.2±9.6 46.4±10.7 43.56±10 -4.117 0.000
(19-98.6) (22.5-
.17
Table 6 shows the ECG rhythms of the study population.
76.8)
Majority of the students (96.2%) had normal ECG –
15-19 years 55.7±9.8 53.8±9.3
54.80±9. 2.365
0.018
sinus rhythm and normal ECG variants (sinus arrhyth-
(33.5-
(36-98.9)
62
mia, first degree heart block, incomplete right bundle
87.4)
branch block, AV nodal rhythm, wandering a trial pace-
maker, ST segment elevation, premature a trial and ven-
Height distribution of the subjects by age and sex
tricular contractions), while 38 (3.8%) had ECG abnor-
malities.
The mean height of the students was 1.68 ± 0.31m
(range – 1.27 to 1.93m). This is illustrated in Table 4.
Table 6: ECG Rhythm and Conduction patterns of the study popula-
tion
Table 4: Height (m) according to age and sex
ECG finding
No of students
Percentage (%)
Age
Mean height (m)(range)
Sinus rhythm
805
80.3
groups
Sinus arrhythmia
96
9.6
First degree heart block
19
1.9
Male
Female
Total
T-test
P-value
Prolonged QTc interval
18
1.8
10-14
1.55±0.33
1.62±0.36
1.57±0.34 -1.959 0.051
Right bundle branch block
11
1.1
years
(1.27-1.85) (1.30-1.70)
Right a trial dilatation
11
1.1
AV nodal rhythm
10
1.0
15-19
1.78±0.19
1.79±0.27
1.78±0.23 -0.515 0.606
Wandering a trial pacemaker
10
1.0
years
(1.52-1.93) (1.44-1.90)
Premature ventricular contractions
7
0.7
Right ventricular hypertrophy
5
0.5
Body mass index of the subjects
Premature a trial contractions
3
0.3
ST segment elevation
3
0.3
The BMI of the students ranged between 11 and 39 kg/
Left ventricular hypertrophy
2
0.2
m with a mean of 19.51 ± 3.05 kg/m . The mean BMI
2
2
Left a trial dilatation
1
0.1
was seen to increase with increasing age in both males
First degree heart block and com-
plete RBBB
1
0.1
and females. The females however had a higher mean
Total
1002
100
64
Prevalence of ECG abnormalities in the study popula-
dilation was found in an overweight student. Normal
tion
weight children also had ECG abnormalities. Table X
illustrates the distribution of the ECG abnormalities ac-
Of the 1002 students screened, 38 had ECG abnormali-
cording to BMI.
ties, giving a prevalence of 3.8%. This is illustrated in
Figure 2.
Table 8: Age-group specific prevalence of ECG abnormalities
Age groups
10 – 14
15 – 19 years
To-
χ
2
Fig 2: Prevalence of ECG abnormalities
P-
years
tal
value
Abnormality
No
%
No
%
(18)
(20)
Prolonged QTc
12
66.
6
33.3
18
0.3
0.673
interval
7
15
Right a trial dilata-
2
18.
9
81.8
11
3.8
0.05*
tion
2
34
0.673
+
Right ventricular
3
60.
2
40.0
5
-
hypertrophy
0
Left ventricular
1
50.
1
50.0
2
-
-
hypertrophy
0
Left a trial dilatation
0
0.0
1
100.0
1
-
-
First degree heart
block and Complete
0
0.0
1
100.0
1
-
-
RBBB
*Significant value, + Fisher's exact test
Type specific prevalence of ECG abnormalities
Table 9: Sex prevalence of ECG abnormalities
Sex
P-
Table 7 illustrates the type-specific prevalence of the
χ
2
Male
Female
To-
valu
ECG abnormalities seen. The commonest ECG abnor-
tal
e
mality in the study population was prolonged QT inter-
Abnormality
No
%
No
%
(30)
(8)
val which was seen in 18 students (47.4% of abnormali-
Prolonged QTc
12
66.7
6
33.3
18
0.3
0.53
ties).
interval
91
2
Right a trial dilata-
11
100.0
0
0.0
11
7.5
0.00
tion
71
6*
Table 7: Prevalence of ECG abnormalities
RVH
4
80.0
1
20.0
5
-
0.32
8
+
ECG Abnormality
No of
Percent-
Preva-
students
age (%)
lence
LVH
2
100.0
0
0.0
2
-
-
Left a trial dilatation
0
0.0
1
100.0
1
-
-
Prolonged QTc interval
18
47.4
1.8
First degree heart
Right atrial dilatation
11
28.9
1.1
block and Complete
1
100
0
0.0
1
-
-
Right ventricular hypertrophy
5
13.2
0.5
RBBB
Left ventricular hypertrophy
2
5.3
0.2
Left atrial dilatation
1
2.6
0.1
*Significant value, + Fisher's exact
First degree heart block and Com-
1
2.6
0.1
RVH – right ventricular hypertrophy
plete RBBB
LVH – left ventricular hypertrophy
Total
101
100
3.8
Distribution of ECG abnormalities according to age
ECG abnormalities were more common among the 15 to
19 years’ age group, though the difference was not sta-
tistically significant, except for right atrial dilatation.
Nine (81.8%) of the subjects with right atrial dilatation
were in the 15- 19 years’ age group, and the difference in
proportion (18.2%) in the 10-14-year age group was
significant (p=0.05). This is shown in Table 8.
Distribution of ECG abnormalities according to sex
Table 9 shows that there was a higher frequency of all
the ECG abnormalities (except left atrial hypertrophy) in
the male students. All (100%) of the right a trial dilata-
tion were seen among the male students; the difference
was statistically significant.
Distribution of ECG abnormalities according to BMI
Right ventricular hypertrophy was significantly higher
in obese adolescents as three (60%) of the 5 cases of
right ventricular hypertrophy were found among the
obese students (p=0.001). The only case of left atrial
65
Table 10: Distribution of ECG abnormalities according to BMI
BMI STATUS
Underweight
Normal
Underweight
Obese
Total
%
χ
2
P-value
Abnormality
Number
%
Number
%
Number
%
Number
(5)
(27)
(1)
(5)
+
Prolonged QTc interval
3
16.7
13
72.2
0
0.0
2
11.1
18
6.615
0.056
+
RAD
2
18.2
9
81.8
0
0.0
0
0.0
11
2.029
0.493
RVH
0
0.0
2
40.0
0
0.0
3
60.0
5
16.449
0.001*
LVH
0
0.0
2
100.0
0
0.0
0
0.0
2
-
-
Left a trial dilatation
0
0.0
0
0.0
1
100.0
0
0.0
1
-
-
First degree heart block &
RBBB
0
0.0
1
100.0
0
0.0
0
0.0
1
-
-
*Significant value, + Fisher's exact
incomplete RBBB, AV junctional rhythm, wandering a
trial pacemaker, isolated premature ventricular complex,
premature a trial complex and ST segment elevation. On
the contrary, Seriki and Smith obtained a higher preva-
11
Discussion
lence as all 20% of the ECG abnormalities noted among
the 302 Nigerian children and youths studied in 1966
From the study, 38 adolescent students had ECG abnor-
were considered normal variants. The lower prevalence
mality give a prevalence of arrhythmias of 3.8%. This is
of the normal ECG variants in this present study may be
comparable to the 3.4% obtained by Mayer et al in
21
due to the differences in the study population – as the
Germany. However, Riddle et al got a higher preva-
22
Seriki
11
study had a higher proportion of younger chil-
lence of 9.8% possibly because of their higher sample
dren less than 10 years compared to this study.
size as they studied 4,138 adolescents (aged 14-18
years). The most common abnormalities observed in this
Cross analysis of ECG abnormalities in relation to sex
study included prolonged QTc interval (1.8%), right a
showed a significantly higher rate of abnormalities
trial dilatation (1.1%) and right ventricular hypertrophy
among the male subjects (p=0.006), similar to reports by
(0.5%). These findings have also reported in other stud-
other studies.
11,27,28
The abnormalities in this present
ies in Chicago and California by Marek et al , and Rid-
23
study were three times more prevalent in males (3%
dle et al respectively. On the contrary, other studies by
22
versus 0.8% in the female subjects). These may require
Hevia et al Grossman et al reported T wave abnor-
24
25
further evaluation, such as echocardiogram to eliminate
malities and shortened PR interval as the common ECG
intrinsic heart disease such as hypertrophic cardio-
abnormalities observed. The prevalence of 1.8% of pro-
myopathy, which is commoner in males. Right a trial
longed QT interval obtained in this study was much
dilatation, for example, was significantly higher in the
higher than that obtained by Marek et al and Riddle et
23
male students, with none of the 11 cases detected oc-
al who reported a prevalence of prolonged QT interval
22
curred in females. The higher prevalence of the ECG
of 0.3% and 0.4% respectively among apparently
abnormalities in the male students may be as a result of
healthy adolescents. The reason for these variations may
the effect of testosterone on the heart and a different
be due to environmental and ethnic factors. It may also
distribution of ion channels across the heart in males
be due to the criteria used in the definition of prolonged
compared to females.
29,30
QT interval. In this study, QTc above 0.45 in males and
0.46 in females was considered abnormal while the cri-
Analysis of ECG abnormalities according to the age
teria used by Riddle et al was >0.47 in both sexes.
22
group showed that the overall prevalence of ECG abnor-
malities was higher among the older age group although
Of specific importance is the finding of a case of com-
this wasn’t the case with some specific ECG abnormali-
plete RBBB, which has been considered in studies to be
ties. Right a trial dilation was significantly higher
an essential ECG feature of Brugada syndrome-a clinical
among older adolescents aged 15-19 years while in the
entity that causes sudden death from ventricular fibrilla-
younger adolescents (i.e. 10-14 years), there was a
tion. Another subject had a prolonged QT interval of
26
higher proportion of prolonged QT interval. On the con-
0.5sec which is highly suggestive of long QT syndrome
trary, in other studies,
26,31
most ECG abnormalities were
(LQTS), a condition also known to be associated with
higher among the older age groups. This difference may
sudden death following torsade de pointe. The prognos-
be due to the fact that, this study population consisted of
tic value of incidentally discovered RBBB and pro-
adolescents only, unlike the other studies which in-
longed QT interval has important implications for car-
cluded younger children and older youths.
11
diovascular risk assessment. It is difficult to categori-
cally state that these subjects have these syndromes from
As it relates to BMI, this study revealed a significantly
an ECG obtained following a single screening test, thus,
higher prevalence of right ventricular hypertrophy
there is need to have follow up ECGs and other cardiac
among obese students; three (60%) of the five students
investigations to confirm the diagnosis; for which they
with right ventricular hypertrophy seen were obese. This
were appropriately referred.
finding is important because it may suggest increased
risk of heart disease in obese adolescents that may re-
Sixty-three (6.3%) of the study population had normal
quire risk profiling and intervention. Similar findings
ECG variants including: first heart degree heart block,
were obtained by Masaidi et al in Italy, who also re-
32
66
ported an increased prevalence of right ventricular hy-
detected to have arrhythmias and other ECG abnormali-
pertrophy in obese patients.
ties in this study were referred to the Paediatric Cardi-
All of the students who were detected to have arrhyth-
ologistatthe University of Port Harcourt Teaching Hos-
mias were unaware of their condition as they were as-
pital for further evaluation and follow up.
ymptomatic and had no suggestive history. The import
of this cannot be overlooked as detected ECG abnor-
Conflict of interest: None
malities can mitigate sudden death by risk profiling af-
Funding: None
fected adolescents for intervention. All the students
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