CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
AFRICA
321
ischaemia, the risks of delayed medical care for STEMI, lack
of pre-hospital transportation systems and ECGs, and failure to
diagnose STEMI on initial ECG by poorly exposed healthcare
personnel. All these areas deserve future evaluation and study
in order to reduce the time of presentation to hospital for ACS.
In our study, the majority of patients received loading doses
of aspirin, clopidogrel and enoxaparin as the anticoagulant of
choice. The anticoagulant doses were calculated on approximate
body weight; however, no record of dose adjustment on the
estimated creatinine clearance rate was noted. Over half the
patients in both arms of the study received ACE inhibitors or
ARBs and over three-quarters received a beta-blocker. The
adherence rates to guideline-based therapies for ACS were
similar to centres in North America and Europe, reflecting
similarities in practice for adjunctive therapies for ACS.
18,19
GP II
b
/III
a
inhibitors were more commonly utilised in
the NSTEMI subgroup and this group had more coronary
angiographies compared to the STEMI subgroup. As anticipated,
patients with NSTEMI had more double- and triple-vessel
disease. However, the lower rates of total revascularisation in
this subgroup were due to associated patient comorbidities tilting
the risk–benefit balance, cost of surgical revascularisation, and
the lack of an effective surgical revascularisation team, hence
treating physicians opting for a staged PCI procedure or medical
treatment alone in these patients with multi-vessel coronary
artery disease.
The average length of hospital stay in the study was five
days, accounting to direct hospital costs of approximately Kenya
Shillings 400 000 (US$ 6 000; 1 US$ = KSh 70). This includes
the cost of admission to the critical care unit and ward stay,
laboratory and radiological investigations, cardiac catheterisation
and stenting, and drug therapy in hospital. Strategies to lower
costs and make this superior reperfusion strategy more available
will need to be addressed.
The in-hospital mortality rates were 9.7 and 6.0% in the
STEMI and NSTEMI subgroups, respectively. These figures
are much higher than those reported in the GRACE and NRMI
registries. This reflects the delayed presentation time of our
STEMI patients. One-year data for the UA/NSTEMI patients
will need to be evaluated to see the long-term mortality trends.
The beginning of every good policy is generation of good
local data. This article serves as an important first step in
understanding the characteristics of patients with ACS in
sub-Saharan Africa. AKUHN receives patients from all over the
East African region and reflects practice in a modern sub-Saharan
tertiary referral hospital. Improved public and patient education
on the early recognition of myocardial ischaemia, development
of an integrated pre-hospital emergency medical transportation
system and reducing costs of reperfusion therapy may facilitate
reduction of mortality associated with ACS.
This observational study was limited by its small numbers
and therefore was unable to be conclusive. We were also
unable to make strong comparisons between the differences in
presentation, management and outcomes of patients with STEMI
compared to NSTEMI.
We thank Dr Sitna for her valuable critique, and the Medical Records
Department, Accident and Emergency and the Catheter Laboratory team.
References
1.
Florentin RA, Lee KT, Daoud AS,
et al
. Geographic pathology of
atherosclerosis: a study of the age of onset of significant coronary
arterio-sclerosis in adult Africans and New Yorkers.
Exper Molec Path
1963;
2
: 103.
2.
Shaper A. Cardiovascular studies in the Samburu tribe of northern
Kenya.
Am Heart J
1962;
63
: 437.
3.
Shaper AG, Jones KW, Jones M,
et al
. Serum lipids in three nomadic
tribes of northern Kenya.
Am J Clin Nutr
1963;
13
: 135.
4.
Miller DC, Spencer SS, White. P. Survey of cardiovascular disease
among Africans in the vicinity of the Albert Schweitzer Hospital in
1960.
Am J Cardiol
1962;
10
: 432.
5.
Blahos J, Reisenauer I. Levels of serum uric acid and serum cholesterol
in various population groups in Ethiopia.
Am J Med Sci
1965;
250
: 308.
6.
Loginov A. Blood cholesterol and cholesterol-ester level in Ethiopians.
Kardiologiia
1962;
2
: 145.
7.
Jagoe K, Edwards R, Mugusi F,
et al
. Tobacco smoking in Tanzania,
East Africa: population-based smoking prevalence using expired
alveolar carbon monoxide as a validation tool.
Tob Control
2002;
11
:
210–214.
8.
Otiento C. Type 2 diabetes – an emerging epidemic in Kenya.
East Afr
Med J
2007;
84
(6): 249–250.
9.
Addo J, Smeeth L, Leon D. Hypertension in sub-Saharan Africa: a
systematic review.
Hypertension
2007;
50
(6): 1012–1018.
10. Seedat Y. Hypertension in developing nations in sub-Saharan Africa.
J
Hum Hypertens
2000;
14
(10–11): 739–747.
11. Krisela S, Karen S, Steven H,
et al
. risk factors associated with myocar-
dial infarction in Africa: The INTERHEART Africa study.
Circulation
2005;
112
: 3554–3561.
12. Jamison DT, Breman JG, Measham AR,
et al
.
Disease Control
Priorities in Developing Countries.
New York: Oxford University
Press, 2006.
13. Kristian T, Joseph SA, Harvey D. Universal definition of myocardial
infarction.
Circulation
2007;
116
: 2634–2653.
14. Jeffrey LA, Cynthia DA, Elliott MA,
et al
. ACC/AHA 2007 guidelines
for the management of patients with unstable angina/non–ST-elevation
myocardial infarction.
J Am Coll Cardiol
2007;
50
: 1–157.
15. Steinhubl SR, Kastrati A, Berger PB. Variation in the definitions of
bleeding in clinical trials of patients with acute coronary syndromes and
undergoing percutaneous coronary interventions and its impact on the
apparent safety of antithrombotic drugs.
Am Heart J
2007;
154
: 3–11.
16. Steg PG, Goldberg RJ, Gore JM,
et al.
Baseline characteristics,
management practices, and in-hospital outcomes of patients hospital-
ized with acute coronary syndromes in the Global Registry of Acute
Coronary Events (GRACE).
Am J Cardiol
2002;
90
: 358–363.
17. Kushner FG, Hand M, Smith SC,
et al
. 2009 focused updates: ACC/
AHA guidelines for the management of patients with ST-elevation
myocardial infarction.
J Am Coll Cardiol
2009;
54
(23): 2205–2241.
18. Dziewierz A, Siudak Z, Dykla D,
et al.
Management and mortal-
ity in patients with non-ST-segment elevation vs.ST-segment elevation
myocardial infarction. Data from the Malopolska Registry of Acute
Coronary Syndromes.
Kardiol Pol
2009;
67
: 115–120.
19. Gibson C. NRMI and current treatment patterns for ST-elevation
myocardial infarction.
Am Heart J
2004;
148
: S29–33.
