CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
320
AFRICA
The mean door-to-needle time in our study was 47 ± 48
minutes while the mean door-to-balloon time was 84 ± 67
minutes. Patients with STEMI had an average hospital stay of
5.2 ± 3.9 days while patients with NSTEMI were in hospital for
an average of 4.7 ± 2.8 days (
p
= 0.54).
Just under half (48%) of the STEMI subgroup, and 49% of the
NSTEMI/UA subgroup underwent coronary angiography, with
the following findings: in the STEMI group, the left anterior
descending artery was the culprit vessel in 40% of the patients,
and 33% had the right coronary and 7% the left circumflex
arteries as the culprit arteries, respectively. Twenty per cent
(six) of the patients who had coronary angiography in the
STEMI subgroup had multi-vessel disease. These patients were
maintained on optimal medical therapy, and none underwent
multi-vessel PCI at the time of their STEMI presentation.
As anticipated, over half (56%) the patients in the NSTEMI/
UA subgroup had angiographically double- or triple-vessel
disease. Of this subgroup, 29% (14) were deemed appropriate,
and referred for surgical revascularisation, since this service
was not being offered at our institution. Data on the surgical
outcomes of these patients were not available, as a majority were
referred to overseas centres for surgery. An additional 12% (six)
underwent staged PCI. Data on the revascularisation strategy for
the remainder of the NSTEMI/UA subgroup were unknown.
Ninety per cent (56) of the STEMI patients were alive at
discharge, compared to 94% (46) of the NSTEMI/UA patients.
Of all the patients in the study, 10% (11) developed clinical
heart failure, 1.8% (two) major bleeding (according to TIMI 7,
8 11B criteria)
15
and 1.8% (two) had other complications. One
of the patients in the major bleed subgroup had intracranial
haemorrhage and was discharged with severe disability (modified
Rankin scale 5). None of the study patients developed post MI
re-infarction.
Discussion
Contrary to earlier statistics that ACS is rare in sub-Saharan
Africa, our study illustrates that nearly 5% of all the high
dependency and intensive care admissions in our hospital are
due to an acute coronary event. This clearly illustrates the
changing prevalence of ischaemic heart disease in eastern Africa
in comparison with earlier data.
Over half of the patients admitted in our study had a diagnosis
of STEMI. This contrasts to larger databases, such as the GRACE
registry from North America and Europe, which reported 30%
of their total number to be STEMI.
16
This difference could
primarily be due to the small numbers involved in our study.
The mean age of 63–64 years at presentation in our two study
subgroups was comparable, however the mean age in our study
was about a decade older compared to that in the INTERHEART
Africa cases.
11
There was an overwhelming male predominance
in both subgroups in our study, similar to data from the
INTERHEART Africa study.
11
This could be due to the already
established risk the male gender confers, or represents the health-
seeking behaviour of the male gender in our country.
Diabetes mellitus, hypertension and current smoking, akin
to data from other parts of the world, comprised the commoner
risk factors for the development of CAD in our study. Data from
INTERHEART Africa showed that the traditional cardiovascular
risk factors (current/former tobacco smoking, diabetes,
hypertension, obesity and dyslipidaemia) relating to ischaemic
heart disease in the West also account for nearly 90% of the risk
for an initial MI in Africans.
11
Our data reaffirm the fact that
the risk-factor profile for the development of an MI may be no
different in a black African, and that the rise in ischaemic heart
disease is probably due to the increasing prevalence of these
traditional risk factors in sub-Saharan Africa.
Chest pain was the commonest presenting symptom. However,
one in every five (20%) patients in our study presented with a
symptom other than chest pain. These atypical presentations
included epigastric pain, dyspnoea or syncope. It is this cohort of
patients who are likely to be improperly triaged in the emergency
room, only to present later as a medical catastrophe. Emphasis
should therefore be laid on these atypical presentations in
patients at risk for ACS presenting to the triage facilities of the
emergency departments in this part of the continent.
It was surprising to note that patients with STEMI took over
13 hours, while NSTEMI more than twice as long to present to
the emergency room from the onset of their symptoms. Since
these patients had had on-going symptoms for over 12 hours, the
reasons for late presentation will be important to evaluate in the
future. This information may help improve patient education in
the community on the symptoms of ACS, and hopefully improve
outcomes in such patients in our setting by earlier administration
of reperfusion therapy in the hospital.
Reperfusion strategies in STEMI have clearly been outlined
in many international management guidelines.
17
However, the
unavailability of PCI facilities and trained personnel, as well as
cost implications are the major causes of deviance from these
guidelines in our set up. This is highlighted by the low rates of
primary PCI and prolonged door-to-balloon times in our study,
with the majority of the eligible patients receiving fibrinolysis.
An even more grim observation is the failure of one-third of all
STEMI patients to receive any form of reperfusion due to late
presentation to hospital.
The presumed reasons for this could be several, but include
challenges at multiple tiers in the healthcare delivery system,
including patient awareness of symptoms of myocardial
Fig 1. Site of myocardial involvement in patients with
STEMI.
SITE OF INFARCTION BY ECG
Anterior
41%
Inferior
37%
Lateral
6% Septal
6%
Anterolateral
10%
