CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 7, August 2012
AFRICA
367
total ACCESS study, 11 731 patients were confirmed as having
an ACS. A flow chart of the study patients is given in Fig. 1.
In South Africa, of the 642 total patients, 615 patients were
confirmed as having an ACS and form the basis of this report.
Completed data at the one-year follow up was available on 548
(89.1%) patients; 35(5.7%) had died and 32 (5.2%) were lost to
follow up.
Diagnosis at discharge (end of hospital stay) was STEMI in
41.1% and NSTE-ACS in 58.9%, including non-ST-segment
elevation MI in 32.4% and unstable angina (no biomarker
elevation) in 26.4%. Four patients enrolled in the survey
had a ‘discharge’ diagnosis of death, indicating a 0.65%
in-hospital mortality rate. In the entire ACCESS study, overall
the in-hospital death rate was 2.6%.
Within the South African cohort, 60.7% were Caucasian,
22.8% Asian, 10.7% of mixed ancestry and 5.9% of African
ancestry. The population was predominantly male (75.9%) with
a mean age of 58.0
±
12.1 years. STEMI patients were younger
than NSTE-ACS patients (mean age 54.5 vs 60.5 years).
Selected patient baseline characteristics are shown in Table
1; 46.7% of patients had a history of angina, 29% a previous
MI, and 6% a history of either cerebro- or peripheral vascular
disease. Fifty-two per cent of patients gave a family history of
cardiovascular disease, far higher than the 31% of the entire
ACCESS cohort, and more patients had dyslipidaemia (56 vs
40% for the entire ACCESS population). More patients had had
a prior CABG (10 vs 5%), previous PCI (19 vs 12%) and positive
current smoking status (44 vs 39%). However there were fewer
patients with pre-existing diabetes mellitus (24 vs 35%), but
equal numbers of hypertensive subjects (56 vs 55%). Diabetic
patients tended to be poorly controlled with a glycosylated
haemoglobin (HbA
1c
) level on admission of
>
8.0% in 37.3%
of patients. Diabetic patients with STEMI were more likely to
have an HbA
1c
level
>
8.0% than those with NSTE-ACS (46.7
vs 31.1%).
Forty-nine per cent of patients admitted either moderate
or heavy alcohol consumption. Patients were predominantly
overweight [body mass index (BMI) 28.4
±
5.2 kg/m
2
], with only
25% of patients having a BMI below 25 kg/m
2
. Women with
STEMI had a larger waist circumference than the women with
NSTE-ACS (98.6
±
13.6 vs 95.1
±
14.0 cm), while men with
STEMI had smaller waist circumferences than those presenting
with NSTE-ACS (99.9
±
12.6 cm vs 103.1
±
12.5 cm).
Patients presenting with STEMI arrived at hospital sooner
after onset of symptoms than the NSTE-ACS patients [median
(Q1; Q3) 3.6 (1.6; 9.5) vs 7.4 (2.5; 25.7) hours], with 64.4%
of STEMI patients arriving within six hours and 85.3% of the
group within 12 hours of the onset of symptoms. This was
despite 63.8% of patients living within a 30-minute drive from
the admitting hospital. In the complete ACCESS database, the
median delay from onset of symptoms to arrival in hospital was
4.0 (1.8; 12.6) hours for STEMI patients and 6.0 (2.0; 19.0)
hours for NSTE-ACS patients.
Patients with a discharge diagnosis of STEMI were more
likely to have ischaemic symptoms (91.7 vs 69.6%), ECG
changes suggestive of ischaemia (97.2 vs 59.7%) and elevated
cardiac biomarkers (67.2 vs 53.3%) than patients with a
discharge diagnosis of NSTE-ACS. Left bundle branch block
was noted in 2.9% of patients overall (3.9% of NSTE-ACS and
1.6% of STEMI).
Prior to hospitalisation, treatment with aspirinwas commenced
in 43.1% of patients, clopidogrel in 1.6%, unfractionated heparin
(UFH) in 2.3% and low-molecular weight heparin (LMWH)
in 1.5%. No form of thrombolytic therapy was administered
pre-hospitalisation.
Selected interventions and in-hospital treatments are shown
in Table 2. Only 18% of patients received a thrombolytic on
admission (36.0% of the STEMI patients and 5.5% of the
NSTE-ACS patients). Less than 1% of patients were considered
to have a contraindication to the use of a thrombolytic agent.
TABLE I. PATIENT BASELINE CHARACTERISTICS: SOUTH
AFRICAN COHORTACCORDINGTO DISCHARGE DIAGNOSIS
AND OVERALL, AND COMPLETEACCESS STUDY OVERALL
Discharge diagnosis
South Africa
ACCESS
NSTE-ACS
(
n
=
362)
STEMI
(
n
=
253)
All
(
n
=
615)
All
(
n
=
12 068)
Myocardial infarction 119 (32.9) 62 (24.5) 181 (29.4) 2588 (21.4)
Stroke/TIA
6 (1.7)
4 (1.6)
10 (1.6)
493 (4)
Angina
216 (59.7) 71 (28.1) 287 (46.7) 5293 (43.8
Family history of
cardiovascular disease 194 (53.6) 126 (49.8) 320 (52) 3728 (30.8)
Congestive heart
failure
27 (7.5)
9 (3.6)
36 (5.9)
640 (5.3)
Peripheral arterial
disease
18 (5)
8 (3.2)
26 (4.2)
541 (4.4)
Prior PCI
85 (23.5) 32 (12.6) 117 (19) 1483 (12.2)
Prior PCI: Stent
no stent
75 (88.2) 26 (81.3) 101 (86.3)
N/A
10 (11.8)
6 (18.7) 16 (13.7)
N/A
Prior CABG
57 (15.7)
6 (2.4)
63 (10.2)
602 (4.9)
Diabetes
97 (26.8) 50 (19.8) 147 (23.9) 4208 (34.8)
Hypertension
238 (65.7) 104 (41.1) 342 (55.6) 6655 (55.1)
Dyslipidaemia
228 (63.0) 117 (46.2) 345 (56.1) 4864 (40.3)
Current smoking
133 (37.0) 135 (53.6) 268 (43.9) 4730 (39.1)
Body mass index
(kg/m
2
)
28.7
28.1
28.4
27.0
PCI: percutaneous coronary intervention; CABG: coronary artery bypass
graft. Unless otherwise indicated, results are reported as number (percent);
ACCESS includes South Africa.
TABLE 2. SELECTED IN-HOSPITAL INTERVENTIONS
AND DRUGTREATMENTS: SOUTHAFRICAN COHORT
ACCORDINGTO DISCHARGE DIAGNOSISAND OVERALL,
AND COMPLETEACCESS STUDY OVERALL
In-hospital inter-
ventions and drug
treatments
South Africa
ACCESS
NSTE-ACS
(
n
=
362)
STEMI
(
n
=
253)
All
(
n
=
615)
All
(
n
=
11731)
Thrombolytics
20 (5.5)
91 (36)
111 (18) 2127 (18.1)
Angiography
344 (95) 228 (90.1) 572 (93) 6787 (57.8)
PCI
179 (49.4) 151 (59.7) 330 (53.7) 4141 (35.2)
CABG
70 (19.3)
20 (7.9) 90 (14.6)
668 (5.6)
Stent (% of PCI)
172 (96.1) 139 (92.1) 311 (94.2) 3900 (33.2)
Drug-eluting stent
(% of total stent usage) 108 (62.8) 72 (51.8) 180 (57.9) 1713 (43.9)
Aspirin
331 (91.4) 247 (97.6) 578 (94) 10920 (93)
Unfractionated heparin 131 (36.2) 113 (44.7) 244 (39.7) 4636 (39.5)
LMWH
264 (72.9) 188 (74.3) 452 (73.5) (7144) 60.8)
PCI: percutaneous coronary intervention; CABG: coronary artery bypass
graft; LMWH: low-molecular weight heparin. Unless otherwise indicated,
results are reported as number (percent); ACCESS includes South Africa.
