6 / 64
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 3, May/June 2020
114
AFRICA
Lesson 3: ‘Treatment deferred is treatment
denied’
The public at large should be reminded and encouraged to
seek immediate medical attention for symptoms compatible
with acute cardiac syndromes. Patients with acute chest-pain
syndromes, heart failure and other cardiac emergencies such as
life-threatening arrhythmias should be advised to seek help at
their nearest emergency healthcare centres with little or no delay.
Following nation-wide shutdowns throughout the globe,
there was a dramatic and almost universal drop in acute cardiac
syndromes such as MI.
13
While there has been much debate
about potential reasons, reports suggest that contributing to
this phenomenon was that many patients chose not to go to
hospital.
11
Anecdotal reports suggest that for some it was out of
fear of contracting COVID-19. For others, it was out of a desire
to help by not being an extra burden on healthcare workers. In
either case, there is also little doubt that for many it was costly
beyond measure. Therefore the public health messages that have
helped patients get to hospital promptly and receive timely care
around the world in the past should be re-iterated loudly to our
communities and society at large.
Lesson 4: ‘Practice makes perfect’
Fibrinolytic therapy, pharmaco-invasive therapy and primary
percutaneous coronary intervention (PCI) all have pros and cons
in this COVID-19 environment. The key to optimal outcomes
during COVID-19 is to continue to do what you know how to do
best, with appropriate precautions.
There has been much debate about whether patients with
acute MI should receive thrombolytic therapy or primary PCI
(PPCI). Experience from China, India and Spain suggests that
the main potential advantage for a thrombolytic approach
is a lower exposure of staff and patients alike to potential
COVID-19 transmission.
14
In resource-limited environments
where personal protective equipment (PPE) may need to be
rationed, thrombolytic therapy may allow for time to test for
COVID-19 prior to transfer for pharmaco-invasive therapy,
and conservative therapy in low-risk patients, such as those
presenting with uncomplicated inferior MI.
Where PPCI is the treatment strategy of choice, the advantages
relate to the known superior outcomes compared to fibrinolytic
therapy, and the ability to recognise ST-elevation myocardial
infarction (STEMI) mimickers such as COVID-19 pseudo-
MI and Takotsubo syndrome at the time of angiography.
15
In
environments where patients will continue to have access to the
laboratory, it is essential that both the laboratory and its staff are
fully prepared and trained in the appropriate use of PPE such as
caps, masks, gowns, gloves and goggles. What is apparent from
the published experience is that changing approach during this
period, i.e. from a PPCI service to a fibrinolytic approach or
vice versa will not change clinical outcomes.
16
In short, the best
strategy is to keep doing what you have been doing.
Lesson 5: ‘Treat the patient not the test’
Routine use of troponin and B-type natriuretic peptide (BNP)
adds little to diagnostic or treatment decisions in patients with
COVID-19 without an overt acute cardiac syndrome. Mild to
moderate elevations in troponin and BNP values are found in
up to 7% of hospitalised patients and 27% of those requiring
admission to the intensive care unit (ICU), in the absence of
evidence of overt cardiac abnormalities.
17
While the mechanisms of these biomarker abnormalities
are unclear, their poor prognostic significance is now well
established.
18
The American College of Cardiology recently
recommended that they should be measured only where there is
clinical suspicion of an acute MI or heart failure, after repeated
testimony and evidence showed that routine testing triggered
a series of additional tests such as echocardiography and
angiography, which added little value but exposed additional
staff to the virus.
12
Lesson 6: ‘If it ain’t broke don’t fix it’
Patients on renin–angiotensin–aldosterone system (RAAS)
blockers for hypertension, heart failure and diabetic nephropathy
should not stop for fear of increased risk of COVID-19.
The combined but unrelated findings that (1) coronavirus
attaches to angiotensin converting enzyme-2 (ACE2) receptors
for cell entry and infection; and (2) the prevalence of hypertension
among hospitalised patients with COVID-19 is high, led to
fears that patients on RAAS inhibitors (ACE inhibitors and
angiotensin receptor blockers) may be at increased risk of severe
infection because of RAAS blocker-induced upregulation of the
ACE2 receptor. However, the published evidence is now clear
that this hypothesis was incorrect and these first-line therapies do
not cause harm and should not be stopped.
4
This is particularly
important in Africa in light of the recently published CREOLE
trial, which found that the combination of amlodipine and an
angiotensin receptor blockers (ARB) offered better control than
diuretic-based combination therapy.
19
Lesson 7: ‘First do no harm’
There are currently over 200 treatment options for COVID-
19 under investigation. At the time of writing, there remains
no proven effective therapy for the treatment of COVID-19.
Some drugs under investigation, such as chloroquine and
hydroxychloroquine with or without azithromycin can prolong
the QT interval and cause harm.
20
These drugs may increase
the risk of life-threatening arrhythmias in patients, especially
in patients with a prolonged baseline QT interval because of
electrolyte abnormalities (such as hypokalaemia) and use of
other long QT-prolonging drugs.
21
The judicious use of these
drugs should be limited to investigational trials where ECG
monitoring is performed until such time as these drugs have been
shown to be effective and safe.
Lesson 8: ‘Prevention is better than cure’
Given our fragile healthcare infrastructure and limited hospital
bed and ICU capacity, the vast majority of African countries will
not be able to sustain the massive caseloads experienced elsewhere
to date. Therefore, despite the limited success of lockdowns so
far, the main self-care tool available to most of society remains
to practice social distancing, hand hygiene, wear face masks,
practice cough etiquette and avoid crowded spaces where most
safe behaviour is near impossible. At the time of writing this
article, no drugs have been shown to be effective as prophylaxis