16 / 92
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 4, July/August 2016
218
AFRICA
Assessment of the management of acute myocardial
infarction patients and their outcomes at the Nairobi
Hospital from January 2007 to June 2009
Redemptar Kimeu, Charles Kariuki
Abstract
Introduction:
The demographics, clinical characteristics and
management of patients presenting at the Nairobi Hospital with
acute myocardial infarction have not been documented in the
past. There is a paucity of studies on this subject in this region.
Methods:
A retrospective, hospital-based study was carried out,
examining data of patients presenting at Nairobi Hospital with
acute myocardial infarction between January 2007 and June
2009. The data collected were patient demographics, coronary
artery disease (CAD) risk factors, clinical presentation, GRACE
score risk stratification, coronary anatomical findings on angi-
ography, interventions and outcomes during hospitalisation.
Results:
Sixty-four patients were recruited (mean age 56.7
years). The CAD risk-factor profile included systemic hyper-
tension in 71.9%of patients, age over 55 or 65 years inmen and
women, respectively in 42.2%, 35.9% of subjects were smok-
ers, low high-density lipoprotein cholesterol levels in 25%,
diabetes mellitus in 25%, family history of premature coro-
nary artery disease in 8%, prior acute coronary syndrome in
18.8%, ST-segment elevation myocardial infarction (STEMI)
in 60.9% and non-ST-segment elevation myocardial infarction
(NSTEMI) in 39.1% of patients. In the STEMI arm, 79.5% of
patients underwent thrombolysis, 17.9% had rescue percuta-
neous coronary intervention (PCI) and 2.6% had no reperfu-
sion therapy. Medical management was carried out in 29% of
the patients, 19.1% had a coronary artery bypass graft and
40.4% had PCI. The mean duration of hospitalisation was
6.69 days. The in-hospital mortality rate was 9.4% and mean
in-hospital probability of death according to the GRACE risk
score was 16.05%. Discharge medication was a
β
-blocker in
84.5% of patients, an ACE inhibitor or angiotensin receptor
blocker in 48.3%, low-dose aspirin in 96.6%, clopidogrel in
96.6% and statins in 93.1%.
Conclusion:
The risk-factor assessment in our population,
albeit small, was in keeping with the traditional risk factors
for coronary artery disease. There is, however, room for
improvement in reconciling the gap between actual and
recommended patient care.
Keywords:
acute myocardial infarction, CAD risk factors,
outcomes of acute myocardial infarction, Nairobi Hospital,
Kenya
Submitted 27/8/13, accepted 7/12/15
Cardiovasc J Afr
2016;
27
: 218–221
www.cvja.co.zaDOI: 10.5830/CVJA-2015-091
The demographic and clinical characteristics of patients
presenting with acute myocardial infarction at the Nairobi
Hospital have not been documented in the past. Abnormal
lipid levels, smoking, hypertension, diabetes mellitus, abdominal
obesity, psychosocial factors, low consumption of fruit and
vegetables, alcohol abuse, and no regular physical activity
account for most of the risk factors for myocardial infarction
worldwide in both genders and all ages in all regions.
1
The risk-
factor distribution for coronary artery disease (CAD) in our
sub-population may be similar to those in the Western world.
1,2
Control of these risk factors is key to the prevention of and
reduction in the incidence of CAD.
3
Over the past 20 years, there has been considerable progress
with improved outcomes in the treatment of acute coronary
syndromes (ACS). These include the establishment of coronary
care units and the development of antiplatelet therapy,
refinement of anticoagulation strategies and introduction of
fibrinolytic therapies. Percutaneous coronary intervention (PCI)
has become the intervention of choice in the acute setting in
ST-segment elevation myocardial infarction (STEMI). Early
invasive intervention in non-ST-segment elevation myocardial
infarction (NSTEMI) is also advocated.
4-8
Randomised clinical trials in STEMI patients have shown
that efficient triaging and early reperfusion therapy decreases
mortality rates. Early thrombolysis is effective in improving
outcomes in acute STEMI. Although timely performance of
primary PCI is more effective in the restoration of patency, and
for lower re-occlusion rates, improved residual left ventricular
function and better clinical outcomes, this benefit diminishes
with any delays.
5,9
The initial strategy in NSTEMI is to alleviate ischaemia
and symptoms by using anti-ischaemic agents, antiplatelets,
anticoagulants, IIb/IIIa inhibitors, to monitor the patient with
serial ECGs, and carry out repeat measurements of markers of
myocardial necrosis. The invasive coronary approach has been
shown to reduce mortality rates in NSTEMI patients.
10
Research
evidence has documented reduced mortality rates at 30 days
with the use of
β
-blockers, ACE inhibitors, antiplatelet therapy
and statins, smoking cessation, and timely reperfusion therapy in
acute myocardial infarction.
11,12
The GRACE risk model has been validated to establish the
in-hospital mortality risk in patients with STEMI and NSTEMI.
In this model, the risk factors predicting early mortality include
age over 70 years, prior myocardial infarction, Killip class at
Nairobi Cardiovascular Clinic, Nairobi, Kenya
Redemptar Kimeu, MD,
drkimeulekasi@talanasc.co.keNairobi Cardiovascular Clinic, Nairobi, Kenya
Charles Kariuki, MD, FACC, FRCP