CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
318
AFRICA
Abstract
Objectives:
To determine the epidemiology of acute coronary
syndromes (ACS) in sub-Saharan Africa.
Methods:
A prospective survey was carried out of all
patients with a diagnosis of ACS who were admitted to
the critical care unit of a tertiary teaching hospital over a
25-month period. Demographics, presentation, management
and outcomes were subsequently recorded.
Results:
A total of 111 (5.1
%
of all hospitalisations) patients
were recruited, with 56
%
presenting with ST-elevation
myocardial infarction (STEMI) and the rest non-ST-eleva-
tion myocardial infarction (NSTEMI) or unstable angina
(UA). Chest pain was the most common presenting symptom,
and up to one-third of all STEMI patients did not receive any
form of reperfusion therapy, primarily due to late presenta-
tion. As in the developed world, diabetes, hypertension and
cigarette smoking still account for the most common predis-
posing risk-factor profile, and the mortality associated with
ACS is about six to 10
%
in our unit.
Conclusions:
ACS, contrary to common belief, is increasing-
ly more prevalent in sub-Saharan Africa, with similar risk
profiles to that in the developed world. Late presentation to
hospital is common and accounts for the increased mortality
associated with this condition.
Keywords:
acute coronary syndrome, clinical characteristics,
sub-Saharan Africa
Submitted 8/2/11, accepted 16/1/12
Cardiovasc J Afr
2012;
23
: 318–321
DOI: 10.5830/CVJA-2012-002
Sub-Saharan Africa has traditionally been viewed as the home of
communicable diseases, and coronary artery disease was thought
to be an extremely rare occurrence. Evidence for this emerged
about 50 years ago when Florentin
et al
.
1
reported no myocardial
infarctions in 182 consecutively performed autopsies among
Ugandans. At about the same time, Shaper
2
reported no coronary
artery disease in 100 Samburu elders, based on a physical
examination and electrocardiography. These were about the only
tools available to make an ante-mortem diagnosis of ischaemic
heart disease at the time.
Smaller studies from other parts of East and central Africa
consistently reported a paucity of ischaemic heart disease with
little evidence of the traditional risk factors of hypertension,
hyperlipidaemia and obesity.
3-6
No information regarding diabetes
mellitus and smoking status has been reported in these groups.
The last few decades have witnessed considerable transition
in epidemiology and with it came a change in the pattern of
disease. Increasing urbanisation and changing lifestyle profiles
have triggered an exponential rise in the frequency of the
historically absent traditional coronary artery disease risk factors
in black Africans.
7-11
In addition to the unfinished agenda on communicable
diseases, health planners in African countries are now being
faced with a rising burden of non-communicable diseases.
12
Cardiovascular disease, particularly coronary artery and
cerebrovascular disease are on the rise, and will soon represent
the bulk of the morbidity and mortality in this non-communicable
medical disease bracket. We set out to define the demographics,
presentation and outcomes of patients admitted with an acute
coronary syndrome (ACS) at the Aga Khan University Hospital,
Nairobi (AKUHN), a tertiary-care hospital running a cardiac
catheterisation laboratory with a cardiac intervention programme
in Nairobi, Kenya.
Methods
A prospective survey was done of all consecutive patients with
a diagnosis of ACS admitted to AKUHN between April 2008
and May 2010. All patients had their data regarding the study
variables entered into the study questionnaire after giving
informed consent. ACS was defined as patients admitted with
ST-elevation myocardial infarction (STEMI), non-ST-elevation
myocardial infarction (NSTEMI) and unstable angina (UA).
STEMI was diagnosed if ST-segment elevation at the J point
of
≥
1 mm occurred in any location or a new left bundle branch
block (LBBB) was found on the electrocardiogram (ECG) with
biochemical evidence of myocyte necrosis.
13
NSTEMI was
diagnosed in patients with biochemical indication of myocyte
necrosis without new ST-segment elevation or LBBB on ECG.
13
Markers of myocyte necrosis utilised in our study included
an elevated (exceeding the 99th percentile of a reference
control group) serum troponin I and CK-MB level.
13
Unstable
angina was considered to be present in patients with ischaemic
symptoms and no elevation in CK-MB or troponin levels, with or
without ECG changes suggestive of ischaemia (e.g. ST-segment
depression or new T-wave inversion).
14
All patients with a confirmed diagnosis of ACS were
prospectively recruited from either the intensive care or the
high dependency units, where critically ill patients requiring
continuous monitoring were admitted. Data were entered into a
questionnaire within 24 hours of the patient’s hospitalisation. The
questionnaire was subdivided into the following components:
•
Demographics: age (years), gender, height (cm) and weight
(kg) were recorded and a body mass index (kg/m
2
) was subse-
quently computed.
•
Clinical presentation: patients presenting with symptoms
(chest pain, syncope, dyspnoea, cardiac arrest, other), systolic
blood pressure (mmHg), heart rate (beats/minute), Killip class
A prospective review of acute coronary syndromes in an
urban hospital in sub-Saharan Africa
JAY SHAVADIA, GERALD YONGA, HARUN OTIENO
Aga Khan University Hospital, Nairobi, Kenya
JAY SHAVADIA, MD,
GERALD YONGA, FACC, FESC
HARUN OTIENO, FACC
