West African Journal of Radiology                                                                   April 2003 Vol. 10 No....
West African Journal of RadiologyApril 2003 Vol. 10 No. 1Les principes, types et plus nouveaux                private hosp...
West African Journal of Radiology                                                                    April 2003 Vol. 10 No...
West African Journal of RadiologyApril 2003 Vol. 10 No. 1related works in the country, as to the                    depth ...
West African Journal of Radiology                                                                 April 2003 Vol. 10 No. 1...
West African Journal of RadiologyApril 2003 Vol. 10 No. 1    There is a recent development in                  intravascul...
West African Journal of Radiology                                                                     April 2003 Vol. 10 N...
West African Journal of RadiologyApril 2003 Vol. 10 No. 1                                    TABLE 1: INDICATIONS FOR ECHO...
West African Journal of Radiology                                             April 2003 Vol. 10 No. 1        TABLE 2: ECH...
West African Journal of RadiologyApril 2003 Vol. 10 No. 1REFERENCES                                       8. Balogun MO, U...
West African Journal of Radiology                                                                     April 2003 Vol. 10 N...
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  1. 1. West African Journal of Radiology April 2003 Vol. 10 No. 1ECHOCARDIOGRAPHY IN NIGERIA: EXPERIENCE FROM UNIVERSITY OF NIGERIA TEACHING HOSPITAL (UNTH) ENUGU By Ike, S. O. MBBS, FMCP, Department Of Medicine, University Of Nigeria Teaching Hospital, P.M.B 01129, Enugu, Nigeria Correspondence: Dr. S.O. Ike, Department of Medicine, UNTH, Enugu Email: sobiajuluike@yahoo.comABSTRACT noninvasive imaging technique, are alsoThis study evaluated our experience with discussed in this paper.echocardiographic studies over a periodof 10 years (February 1991 to January ABSTRAIT2001). Two thousand five hundred and Cette étude a évalué notre expériencetwenty seven patients (1577 males, 950 avec des etudes échocardiographiquesfemales), aged between 3 weeks to 85, pendant 10 ans (février 1991 à janvieryears were referred for echocardiography 2001). Deux mille cinq cents et vingt septat the University of Nigeria Teaching patients (1577 mâles, 950 femelles), âgéHospital (UNTH) Enugu. entre 3 semaines à 85, des années ont été référées pour léchocardiographie àThe commonest indications for luniversité de lhôpital denseignementechocardiography were found to be du Nigéria (UNTH) Enugu.Valvular Heart Diseases (16%),Hypertensive Heart Disease (15%) and Les indications les plus communes pourCongenital Heart Diseases (14.3%). léchocardiographie se sont avérées les maladies de coeur de Valvular (16%),Echocardiography was able to confirm Maladie de coeur hypertendue (15%) et868 (34.4%) of Valvular Heart Diseases (n maladies de coeur congénitales (14.3%).= 868), 436 (17.3%) Hypertensive heartDiseases, (13.2%) Congenital Heart Léchocardiographie pouvait confirmerDiseases and Cardiomyopathies 868 (34.4%) de maladies de coeur de237(9.5%). Normal studies were Valvular (n = 868), 436 (17.3%) maladiesdocumented in 275(10.9%) of the de coeur hypertendues, (13.2%) Maladiespatients. de coeur et cardiomyopathiesThe functional states of prosthetic valves congénitales 237(9.5%). Des étudesas well as the position of pacemakers normales ont été documentées danswere some of the clinical usefulness of 275(10.9%) des patients.echocardio-graphic studies documentedby the study. Les états fonctionnels de valves prosthétiques aussi bien que la positionMore accurate diagnoses and influencing des stimulateurs étaient une partie dethe direction of management were lutilité clinique des étudesdefinitely the outcomes of the échocardiographiques documentées parechocardiographic studies of these létude. Des diagnostics plus précis etpatients. influencer la direction de la gestion étaient certainement les résultats desThe principles, types and newer études échocardiographiques de cesdevelopments in echocardiography, as a patients. 43
  2. 2. West African Journal of RadiologyApril 2003 Vol. 10 No. 1Les principes, types et plus nouveaux private hospitals, have since thendéveloppements en échocardiographie, acquired both the two-dimensional andcomme technique non envahissante de Doppler echocardiography facilities, bothformation image, sont également for diagnosis and medical research8, 14, 15.discutés en cet article. This study evaluates the diagnostic profile of Nigerian patients presenting forINTRODUCTION echocardiography at the University ofThe world of Echocardiography has Nigeria Teaching Hospital (UNTH) Enuguwitnessed a phenomenal growth, from a designated National Centre ofthe first attempts in echocardiography, Excellence for Cardiovascular Diseasesby Elder and Hertz, in Lund in Sweden in in Nigeria. It also highlights the19543, to 3-Dimensional principles of, and emerging global trendsechocardiography in current use. in, echocardiography.Echocardiography is now a particularlyattractive and established technique for MATERIALS AND METHODSevaluation and accurate diagnosis of A retrospective study of all patientsvarious forms of cardiovascular referred for echocardiographic study atdisorders. It gives validated simple, the University of Nigeria Teachingreliable, serial and non-invasive Hospital, (UNTH), Enugu, over a 10 yearassessment of the heart. Findings from period, from February 1991 to January2D, M-mode and Doppler 2001, is reported. Information wasechocardiography correlate well with collected from the Echocardiographythose of cardiac catheterization and Register maintained at theradionuclide studies and offer prognostic echocardiographic scanning room. Alloptions and may influence management the patients had undergone M-mode,and longitudinal follow-up of patients4 - 8. Two-Dimensional and Pulsed DopplerDespite the rapid phenomenal growth in echocardiographic study, in standardthe use of echocardiography worldwide, positions.there is little information about the utility Data collected were analysed for age,of two dimensional and Doppler gender, indications forechocardiography in Nigerians with echocardiography, and thevarious categories of heart disease8, 9. echocardiographic diagnoses.Echocardiography made a debut inNigeria about three decades ago10. Since RESULTSthen, physicians have found it most Generaluseful both in diagnosis of various forms During the study period, a total of 2527of heart disease and clinical research11. referral cases for echocardiographicM-mode echocardiography was the first study, was recorded. One thousand fiveform to be introduced in Nigeria, with hundred and seventy seven (67%) ofLawal and Falase having used this to these patients were males, while 950assess left ventricular function in a study (38%) were females, giving a male: femaleof hypertensive patients at University ratio of 1.7:1. Their ages ranged from 3College Hospital, Ibadan12. weeks to 85 years.Two dimensional echocardiography The referral sources were from differentbecame available at the University of units at the UNTH, general and privateNigeria Teaching Hospital (UNTH), hospitals within Enugu metropolis andEnugu in 198713, followed by Doppler from state hospitals from Southeast zoneechocardiography (pulsed-wave and of Nigeria.continuous-wave Doppler) in 1990. Manyother health institutions, especially the 44
  3. 3. West African Journal of Radiology April 2003 Vol. 10 No. 1Indications for Echocardiography in 92 (26.7%) of the pre-echo indicationsFrom the analysis of our data in Table I, and 91 (30.8%) of the echocardiographicthe commonest indications for cases of congestive cardiac failure.echocardiography were: Valvular Heart One hundred and seventy five (6.9%) ofDiseases (16%), Hypertensive Heart the patients had diastolic dysfunction.Diseases (15%), Congenital HeartDiseases (14.3%) and Cardiomyopathies(8.1%). Cardiovascular related diseases DISCUSSIONalone accounted for 1814 (71.8%) of the The study shows Valvular heart diseasesindications. Non-specific diagnoses as the commonest indication forformed 524 (20.7%) of the indications echocardiography, as well as the most335 of which had no stated diagnostic documented echocardiographic finding.indication. The latter is made up 13.3% Equally significant is the high percentageof the total number of documented of congenital heart diseases presenting,indications and had such indications as; both as indications (14.3%), andpansystolic murmur, organic heart diagnoses (13.2%). These findings are indisease and tachypnoea. The rest of the contrast to the picture in related works atsystems contributed 7.5% of the other centres in Nigeria. Ukoh et al,16 in aindications for echocardiography in our similar retrospective study, spanningstudy population. about the same period, January 1992 to May 2001, rated systemic hypertension and hypertensive heart diseaseEchocardiographic Diagnoses respectively as the commonest indicationTable 2 shows that valvular heart and diagnoses, while congenital heartdiseases were diagnosed in 868 (34.4%) disease contributed just 6% of the 820of the patients, hypertensive heart echocardiographic diagnoses. Balogundisease in 436 (17.3%) patients, et al,8 in a retrospective study at Okada,congenital heart disease in 334 patients, Edo State, Nigeria, in 100 patients,cardiomyopathies in 237% (9.5%) of the documented valve dysfunction as anpatients, and pericardial diseases in indication in 11% of the patients and228(9%) patients. Normal study was diagnosis in 7%, with congenital heartdemonstrated in 275 (10.9%) of the disease presenting just once as anpatients. Nine (0.4%) of the studies indication, and not at all as a diagnosis8.returned inconclusive these were The disparity in these findings may bestudies aborted by power failure, explained by a number of factors. Ukohprogressive discomfort (such as et al16 studied only adult patients, whichdyspnoea) warranting stoppage of may account for the relatively low rate ofscanning or children whose excessive congenital heart disease presentations.crying and restlessness make The Okada study by Balogun et al8 wascontinuation of the study impossible. on comparatively fewer patients just 100. The UNTH Enugu, is a NationalTable 3 shows that 344 (13.6%) of the centre of Excellence for Cardiovascularpatients were in clinical congestive heart Diseases and Surgery. It thus attracts afailure, while 295 (11.7%) were also comparatively higher number of patientsdocumented from echocardiographic for assessment, and stabilization forstudy. Dilated cardiomyopathy heart surgeries. The post surgicalaccounted for 161 (46.8%) of the pre- indications (32 in the study), andecho indications and 171 (58%) of the prosthetic valve functional status,echocardiographic studies, while further lend credence to this observation.hypertensive heart disease was recorded The study corroborates the findings in 45
  4. 4. West African Journal of RadiologyApril 2003 Vol. 10 No. 1related works in the country, as to the depth of the structures with respectrelative rarity of Ischaemic heart disease. to time. The spatial resolution (theWhile this study reported 0.8% ability to differentiate and recogniseprevalence, Ukoh et al16 recorded 2.7% structures that are close together) isand Balogun et al,8 2%. This may need very high, about 1 to 2cm along thefurther prospective study, as current axis of the sound beam. Thetrends tend to portend an increase in temporal resolution is also very high.prevalence. This makes it possible to obtain high resolution images of rapidly movingIt is noteworthy that as many as 275 structures such as valve opening,(10.9%) of the patients had normal closing, fluttering, and subtle wallechocardiographic study. This definitely motion abnormalities.influenced their management outcome, M-Mode echocardiography is usefulobviating the need for any additional in measuring left ventricular wallmedication. thickness and internal dimensions. It is superior to electrocardiographyPRINCIPLE OF ECHOCARDIO- in detecting left ventricularGRAPHY hypertrophy.18 Left ventricularThree inter-related modalities of internal dimensions can be used toechocardiography in common use now assess the systolic function of the leftare: M-mode, two dimensional and ventricle by calculating the fractionalDoppler echocardiography. M-mode shortening. Left ventricular mass isechocardiography uses a narrow also derived from M-modeultrasound beam to depict a one- measurements.dimensional image of the heart. Two The main disadvantages of M-modedimensional echocardiography records a echocardiography are that: itspatially correct image of the heart while provides only a one-dimensional viewDoppler echocardiography tracks the of the heart; the cardiac structuresvelocity of blood flow through the heart are displayed in an unfamiliar formatand great vessels. that bears no resemblance to the cardiac anatomy and it is limited inThe Doppler echocardiography utilises its ability to provide informationthe principle that moving objects alter regarding the spatial orientation ofthe frequency of any sound they reflect to the cardiac structure. Tworecognize blood flow and to characterize dimensional echocardiography wasits pattern.1,2,17 introduced to overcome these disadvantages.TYPES OF ECHOCARDIOGRAPHY 2. Two Dimensional echocardiographic1. M - M o d e e c h o c a r d i o g r a p h i c equipments use a transducer equipments use a transducer containing one or more crystals that containing one crystal which emits a are mechanically rotated or single ultrasound beam of 1000 to electronically fired in a sequential 2000 pulses per second. This manner. The transducer transmits produces a very narrow “ice-pick” and receives 120 discrete ultrasound image of the cardiac structures. The beams through a 60 to 90o sector in depth of the echo is displayed on the order to produce a fan-shaped image vertical axis, and time on the of the heart in a cross section. Since horizontal axis. The recording thus it utilises multiple ultrasound appears as a continuous graph of the beams, processing of a two- 46
  5. 5. West African Journal of Radiology April 2003 Vol. 10 No. 1 dimensional image takes a longer frequency of the returning echo is time than an M-mode image. The different; higher if the target is sampling rate is thus lower (30 to 60 moving towards the transducer. This times per second as against 1000 difference in frequency-the Doppler times per second with M-mode). shift-is within the audible range and There is therefore, a substantial can be displayed as audible signals or decrease in resolution. as visual signals called spectral A cross-sectional image of the heart is trace, on an oscilloscope. depicted with two-dimensional There are several types of Doppler echocardiography. Thus direct and studies, all of which can be accurate visualisation of the entire performed using a single probe: heart, intracardiac structures and Pulsed Doppler Echocardiography great vessels is possible. Global left uses a single crystal to study the ventricular function can be assessed patterns of blood flow, including the by this technique. Left ventricular detection of abnormal flows, shunts systolic and diastolic volumes are and cardiac output; continuous wave calculated using the Simpsons Doppler with two separate adjacent rule.19 Stroke volume and cardiac crystals, one that continuously output can be derived from these transmits sound and the other, values. which continuously receives The major limitation of two- reflected sound. This adds the dimensional echocardiography is its possibility of studying pressure inability to image blood cells and gradients across valves from flow and provide data about velocity, valve area observations. direction, timing and spatial profile of Doppler echocardiography can thus blood flow. To correct this limitation, detect diastolic dysfunction, which Doppler echocardiography was results from left ventricular filling introduced. abnormalities, a possible consequence of hypertension.3. Doppler Echocardiography is based Transmitral Doppler recordings are on a physical principle known as the now actually the most frequently Doppler Effect. This was first used methods for evaluating left described in 1842 by an Austrian ventricular diastolic filling. mathematician and physicist, The main limitation of Pulsed Johann Christian Doppler.20 Doppler Doppler echocardiography is that effect is the change in the frequency determination of diastolic function by of sound waves when the source of this technique is imprecise: it sound is moving in relation to the permits only an indirect measure of receiver. If the source of sound is diastolic function in relation to left moving towards the receiver, the ventricular filling, since it cannot frequency would be increasing but if assess all the factors influencing left the source of sound is moving away ventricular diastolic filling directly. from the receiver, the frequency Combined alterations of influencing would be decreasing. Doppler factors may actually echocardiography is, therefore, “pseudonormalize” the trans-mitral based on the frequency shift between flow pattern, thus complicating the the transmitted and the returning evaluation of diastolic filling, ultrasound. When a transmitted especially with the presence of both ultrasound meets a moving target prolonged relaxation and restrictive such as a column of blood, the filling abnormalities. 4,5, 21 47
  6. 6. West African Journal of RadiologyApril 2003 Vol. 10 No. 1 There is a recent development in intravascular bubbles. The injection Doppler echocardiography, known as of almost any liquid into the Colour Flow Mapping: This intravascular spaces will introduce technique allows the visualisation of many microbubbles that appear as a intracardiac blood flow super- cloud of echoes on the echo- imposed on a two-dimensional cardiogram. Thus the injection into echocardio-graphic display. Flow the blood stream of a marker such as towards the transducer is depicted as saline, agitated or sonicated red, flow away from transducer as angiographic contrast agents, blue. Green is added in a mosaic sonicated albumen, indocyanine or pattern to represent turbulent flow. some of the patients own blood, may Colour-coded Doppler is very useful be used as a substitute for the in the detection and mapping of Doppler examination for certain regurgitant and shunt lesions, while types of flow and shunt visualization. facilitating the evaluation of This technique has potential for congenital heart disease. numerous clinical uses. (d) Stress Echocardiography: This aids4. N e w e r D e v e l o p m e n t s i n the overall management of patients Echocardiography with suspected coronary artery Other echocardiography modalities disease and acute myocardial have come into use to a varying infarction since stunned or extent in the recent past, especially hibernating myocardium can be within the last decade. These unmasked, even before patient include: reports chest pain or ST segmenta) T r a n s o e s o p h a g e a l changes are seen in the Echocardiography: This is of great electrocardiogram. Global changes use in patients in whom the in left ventricular function can also examination from the usual be assessed. Dobutamine is transthoracic approach is technically commonly used as the biochemical difficult or impossible. It allows stress agent. examination of structures such as (e) Digital Echocardiography: This is the the atria, assessing prosthetic valves, digital acquisition, formatting, aortic dissection, vegetations and analysis, storage and review of intracardiac masses. It has a major ultrasound data. The technique was application now in cardiac surgery, initially developed to reduce some of both during and after surgery. the practical difficulties encounteredb) Intravascular Ultrasound. The during the performance of stress ultrasonic transducer is placed in a echocardiography. The most small catheter so that a vessel can be common format used for the imaged through the lumen. This can observation of cardiac wall motion is evaluate athero-sclerosis from within quad screen format where four the arteries, and the heart from synchronized image loops are within the cardiac chambers, using a displayed simultaneously on the rotation transducer, rotating screen. ultrasonic mirror, or phased array (f) Doppler Tissue Imaging and Colour multielement systems. Kinesis: These are new technologies (c) C o n t r a s t which directly examine myocardial Echocardiography: This makes use of motion and encode movement of the the fact that ultrasound is an myocardium or endocardium in extremely sensitive detector of colour. Hypokinetic, akinetic or 48
  7. 7. West African Journal of Radiology April 2003 Vol. 10 No. 1 dyskinetic segments of cardiac wall cardiac surgeries. It has also highlighted are thus demonstrated. Regional the more recent developments in myocardial thickening and echocardiography, pointing out the way ventricular synchrony are readily forward for other modalities. apparent, and chamber volume Further longitudinal studies are measurements may be more recommended to investigate the accurately defined. These new changing trends in cardiac diseases, techniques need additional studies especially with respect to ischaemic before they can be applied clinically. heart disease in developing countries like(g) Automated Boundary Detection: This Nigeria. is a recently developed technique Echocardiographic examination can be which uses ultrasonic backscatter performed as a safe, non-invasive technology to characterize tissue procedure, with insignificant adverse properties. It incorporates a border effects, in a relatively short period of 15 to detection algorithm for delineating 30 minutes26, 27. These advantages, the endocardial blood interface. The however, lend its request to abuse, with system automatically detects the the attendant result that insufficient blood and tissue borders, which can effort is made to establish a definite be displayed on a two-dimensional clinical diagnosis before referring sector image. It is of use in patients for the investigation. calculating blood area changes in the Consequently, as shown in the study, cardiac cycle, and subsequently many patients end up undergoing diastolic function indices. echocardiography without any stated(h) T h r e e - D i m e n s i o n a l diagnosis [up to 335 (13.3%) in this Echocardiography: Reconstructed study]. With the financial implication to three-dimensional images of the the patient echocardiographyic studies heart using multiple two- should not be regarded as a clearing dimensional image are now being house: A more rational and painstaking proposed and actually put into use. referral approach to be adopted by all A technique that orientates a two- referring practitioners, is therefore, dimensional transducer in a three- strongly recommended from this study. dimensional space using spark gap sensors. Another technique creates ACKNOWLEDGEMENT 3-D images of the heart using gated, The author wishes to thank particularly reconstructed 2-D examinations. Dr. E. Onuigbo, and Chukwuma Chamber dimensions can, with this Umeokonkwo house officer and medical technique, be estimated with greater student respectively, for their assistance accuracy than is possible using in the collation of these data. My cross-sectional methods. Valves can gratitude also goes to Miss Josephine be seen and assessed with great Nebeokike for her secretarial assistance. accuracy.6, 7, 22 -25CONCLUSION ANDRECOMMENDATIONSThis study has provided a profile of theclinical usefulness of echocardiographyin a tertiary specialist centre withreferrals drawn from all over Nigeria -especially with a bias to performance of 49
  8. 8. West African Journal of RadiologyApril 2003 Vol. 10 No. 1 TABLE 1: INDICATIONS FOR ECHOCARDIOGRAPHY PRESUMED INDICATIONS NUMBER OF PERCENTAGE PATIENTS (%) 1. Cardiovascular-Related Diseases Valvular Heart Diseases 403 16.0 Hypertensive Heart Diseases 378 15.0 Congenital Heart Diseases 362 14.3 Cardiomyopathies 204 8.1 Pericardial Diseases 105 4.2 Congestive Cardiac Failure (Cause 91 3.6 Unspecified) 62 2.5 Arrhythmias/Conduction Disorders 59 2.3 Ischaemic Heart Diseases 34 1.4 Rheumatic Heart Diseases 30 1.2 Cardiac Tumours/Mass 23 0.9 Other Circulatory Disorders 18 0.7 Aortic Dissection/Aneurysm 17 0.7 Endomyocardial Fibrosis 17 0.7 Infective Endocarditis 11 0.4 Pacemaker Displacement/Malfunction Total 1814 (71.8) 2. Non-Specific Not-stated 335 13.3 Routine Check 97 3.8 Chest Pain 63 2.5 Palpitation 26 1.0 Anxiety State 3 0.1 Total 524 (20.7) 3. Central Nervous System Indications Transient Ischaemic Attack/Cerebro Vascular Accident 28 1.1 Syncope 11 0.4 Total 39 (1.5) 4. Post-Surgical Conditions 32 1.3 5. Pulmonary Disorders 30 1.2 6. Musculoskeletal Disorders 29 1.2 7. Congenital Anomalies 25 1.0 8. Endocrine/Metabolic Disorders 10 0.4 9. Malignancies 8 0.3 10. Renal Diseases 7 0.3 11. Haematological Disorders 6 0.2 12. Hepatobiliary System 3 0.1 TOTAL 2527 100.0 50
  10. 10. West African Journal of RadiologyApril 2003 Vol. 10 No. 1REFERENCES 8. Balogun MO, Urhogide GE, Ukoh VA, Adebayo RA: A Preliminary Audit of1. Termini BA, Lee Y: Essentials of Two-Dimensional and Doppler Echocardiography. New Jersey. Echocardiographic Service in a Medical Economics Company. 1976. Nigerian Tertiary Private Hospital. p. 11. Nig. Journ. Of Med. 1999; 8(40): 139 141.2. Feigenbaum H: Echocar-diography. In Heart Disease: A Textbook of 9. Adesanya CO, Sanderson JE: M- Cardiovascular Medicine. Mode Echocardiography in the Braunwald E. (ed.). Philadelphia. Diagnosis of Heart Disease in WB Saunders Company. 5th Edition. Africans. Trans. Roy. Soc. Trop. Med. 1999. p. 53. Hyg. 1979; 73:400 405.3. Wells PNT: History. In Cardiac 10. Falase A. O.: Echocardiography: Its Ultrasound. Wilde P. (ed.). London. Relevance in the Nigerian Setting. Churchill Livingstone. 1993. 3 8. Nig. Med. J. 1976; 2374. Appleton CP, Hatle LK, Popp RL: 11. Obasohan AN, Ukoh VA, Onyia KA, Relation of transmitral flow Velocity Isah AO: Salt Taste Threshold in Patterns to left Ventricular Diastolic Normotensive and Hypertensive Dysfunction: New Insights from a Nigerians. Trop. Cardiol. 1992; 18 Combined Haemodynamic and (72): 183 187. Doppler Echocardiographic study. J. Am. Coll. Cardiol. 1988; 12:426 12. Lawal SOA, Falase AO: The Effect of 440. Hypertension on the Heart of Adult Nigerians. Trop. Cardiol. 1988;5. Rakowski H, Appleton C, Chan KL, 14(56): 153 157. Dumesnil JG, Jue J, et al: for C a n a d i a n C o n c e n s u s 13. Okereke OUJ: One Year Experience Recommendations for the with Two-Dimensional Echocardio- Measurement and Reporting of graphy in Nigeria. In Proceedings of Diastolic Dysfunction by the 18th Annual Conference of the Echocardiography. J. Am. Soc. Nigerian Cardiac Society. Lagos. Echocardiogr. 1996; 9: 736 760. 1989 p. 20.6. Nishimura RA, Tajik J: Evaluation of 14. Anisiuba BC: Echocardiographic Diastolic Filling of left Ventricle in Evaluation of left Ventricular Health and Disease: Doppler Function in Nigerian Male Echocardiography is the Clinicians Hypertensives. Part II FMCP Thesis. Rosetta Stone. J. Am. Coll. Cardiol. May 1994. 1997; 30: 8-18. 15. Okereke OUJ, Chikwendu VC,7. Chesman MG, Leech G, Chambers J, Ihenacho HNC, Ikeh VO: Non Monaghan MJ, Nihoyannopoulous P: Invasive Diagnosis of Central Role of Echocardiography in Endomyocardial Fibrosis in Nigeria the Diagnosis and Assessment of using Two-Dimensional Echocardio- Heart Failure. Heart. 1998; 80 (1): graphy. Trop. Cardiol. 1991 (67): S1 S5. 97 103. 52
  11. 11. West African Journal of Radiology April 2003 Vol. 10 No. 1 Vessels. 1996; 11(6): 303 309.16. U k o h V A , O m u e m u C O : Echocardiography in the University 23. Parry RL, Fraser AG: Recent of Benin Teaching Hospital, Benin advances. In Cardiac Ultrasound. City, Nigeria. In Proceedings of the 7th Wilde P. (ed). London. Churchill Congress of the Pan-African Society Livingstone. 1993. 519 537. of Cardiology. Abuja. 2001 p. 29 24. Come PC, Lee RT, Braunwald E: Non17. Come PC, Lee RT, Braunwald E: Invasive Methods of Cardiac Noninvasive Methods of Cardiac examination. In Harrisons examination. In Harrisons Principles of Internal Medicine. Principles of Internal Medicine Isselbacher KJ, Wilson JD, Isselbacher KJ, Wilson JD, Braunwald E, Martin JB. (ed). Braunwald E, Martin JB. (ed.) London. McGraw-Hill. 13th edition. London. McGraw-Hill. 13th Edition. 1994. 967 969. 1994. p. 967. 25. Feigenbaum H: Echocardiography.18. Koren MJ, Devereux RB, Casale PM, In Heart Disease: A Textbook of Savage DD, Laragh JH: Relation of Cardiovascular Medicine. left Ventricular mass and Geometry Braunwald E. (ed). Philadelphia. WB to Morbidity and Mortality in Saunders Company. 5th Edition. 53 Uncomplicated Essential 68. Hypertension. Ann. Int. Med. 1991; 114(5): 345 352. 26. Strang G: Echocardio-graphy in the Developing World. In Cardiac Ultra-19. Feigenbaum H: Echocardiography. sound. Wilde P (ed). London Philadelphia Lea and Befiger. 4th Churchill Livingstone. 1993. p. Edition 1986. p. 622. 302.20. Kisslo J, Adams D, Mark DB: 27. Ike S.O.: The Prevalence of Diastolic Introduction to Doppler. In Clinics in Dysfunction in Adult Hypertensive Diagnostic Ultrasound. New York. Nigerians Presenting at University of Churchill Livingstone. 1986. p. 2. Nigeria Teaching Hospital (UNTH) Enugu: An Echocardiographic21. Nicolino A, Ferrara N, Longobardi G, Study. Part II FMCP Thesis. Acanfora D, Rengo C, Rengo F: Left November 2000. Ventricular Diastolic Filling in Elderly Hypertensive Patients. J. Am. Geriatr. Soc. 1993; 41:217 222.22. Angiomachalelis N, Hourzamanis AI, Sideris, Seralsi E, Vamualis C: Improvement of left Ventricular Diastolic Dysfunction in Hypertensive Patients 1 Month after ACE Inhibition Therapy. Heart 53