Cardiovascular Journal of Africa: Vol 28 No 6 (November/December 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018 4 AFRICA
Editorial
Appropriate strategies for South Africa for the
management of acute myocardial infarction in patients
presenting with ST-segment elevation
Rhena Delport
Timely reperfusion
Both patient and health-system delays contribute to delays in
restoring myocardial perfusion. Patient-related delays constitute
the time from onset of symptoms to the call for help, and onset
of symptoms to first medical contact. These will not be discussed
here. Of relevance are time metrics relating to ‘symptom onset to
initiation of fibrinolysis or first balloon or device, and hospital
door to either onset of fibrinolytic therapy (door-to-needle time)
or to first balloon or device (door-to-balloon time)’, as well as
strategies that may be considered if circumstances are not ideal,
as elegantly interrogated by Gershlick et al.1
Evidence-based guidelines provide clear time targets and
recommendations for reperfusion therapy, as discussed in the
report by Ibanez et al., 2 but in essence, primary percutaneous
coronary intervention (PCI) is advocated as the primary strategy,
and if not anticipated to be achievable within 120 minutes
of ST-elevation myocardial infarction (STEMI) diagnosis,
fibrinolysis should be initiated immediately. The study by Stassen
et al., published in this edition (page 6), reports on the feasibility
of PCI within the proposed time frame, while considering
driving times and distances to public and private PCI facilities in
different regions of South Africa.
Mortality data
In the 2015 list of the 10 leading underlying natural causes of
death in each province, the Western Cape (WC) ranks third, with
ischaemic heart diseases (ICD-10: I20-I25) as cause of death
(5.8% of all-cause deaths), followed by Gauteng (GP) ranking
seventh (3% of all-cause deaths), and KwaZulu-Natal (KZN)
ranking ninth (2.6% of all-cause deaths).3 Despite 100% of the
inhabitants of GP living within 120 minutes of a PCI facility,
calculated from mid-year population estimates for 2015,4 the
proportionate mortality rate of 0.22/1 000 was higher than the
mortality rate of 0.19/1 000 for KZN and markedly lower than
that of 0.47/1 000 for the WC region, the respective proportions
of inhabitants living within 120 minutes of a PCI facility for
the latter two regions being 64.7 and 87.6%. These findings
suggest that factors other than proximity to PCI facilities explain
ischaemic heart disease mortality rates for South Africa.
Disparities
Statistics South Africa (2011)5 reports a total medical aid
coverage of 16% for the total population, the respective
population covered by medical aid or medical benefit schemes or
other private health insurance, and for the three aforementioned
regions it is 23.7% for GP, 12.2% for KZN and 25% for WC.
Access to healthcare facilities includes means of transport to
reach the health facility normally used (walking: 47.4%, public
transport: 29.1%, or own transport: 22.1%) and time taken to
reach the health facility normally used (80% of households take
less than 30 minutes to reach the health facility normally used).
Information relating to type of health facility used first when
household members fell ill and decided to seek medical help may
be relevant when interpreting the report of Stassen et al. on the
proportion of the South African population living within 60
and 120 minutes of a public PCI facility. The authors calculated
that 32.6 million (63%) of the total population lived within 120
minutes of a public PCI facility, whereas in reality only 9.5% of
the population purportedly used public hospitals and 2.0% used
private hospitals when household members fell ill. Public sector
services are sourced by 70.6% of the total population (mainly
public clinic services: 61.2%) and private sector services by 27.9%
(mainly private doctor services: 24.3%).
Coming back to PCI services in particular, Stassen et al.
previously reported that 48 (77%) PCI facilities are privately
owned, whereas the 14 state-owned facilities are tasked with
providing services to the population with no medical aid
coverage (79.9%) and a high poverty rate (59.6%).6
Recommendations
Given all these disparities, compounded by population dispersion
across metropolitan and rural regions, equitable healthcare
related to PCI services may be deemed questionable for South
Africa. The White Paper on Management of STEMI in Low-
and Middle-Income Countries by Baliga et al . 7 provides much-
needed insight into the challenges experienced in countries such
as South Africa, relating, among others, to lack of essential
resources and services. Clear strategies are proposed, as in the
ST-Elevation Myocardial Infarction South Africa: National
Project Manager, SA Heart Association; Department of
Chemical Pathology, University of Pretoria, Pretoria, South
Africa
Rhena Delport, PhD,