CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 3, May/June 2011
158
AFRICA
able addition to the tools at our disposal.
It targets the alpha
4
-beta
2
receptor, which
is critical for self-administration of nico-
tine. It has been shown to be a partial
agonist
in vivo
, but because it has no effect
when combined with nicotine, it is also
an antagonist. As an agonist it reduc-
es cravings and withdrawal symptoms,
while its antagonist effect reduces the
reward the smoker gets from nicotine’, Dr
Fagerstrom explained.
The drug’s pharmacokinetics are easy
and straightforward. T
max
is reached in
three to four hours and steady state is
attained after four days. Varenicline has
a 24-hour half-life and the fact that it
is minimally metabolised means it has
no adverse effects on the liver. Its oral
bioavailability is unaffected by food or
time of delivery, and there are no phar-
macokinetic differences related to age or
special patient populations. There are no
clinically meaningful drug interactions.
However, there are no data yet on its
safety in pregnant women and children,
so it is therefore not recommended in
these patients.
Two key studies have shown confirmed
continued cessation rates at weeks nine to
12 with varenicline. Bupropion was used
as an active comparator, and while it was
significantly superior to placebo, vareni-
cline was significantly superior to bupro-
pion. Varenicline’s superiority relative to
placebo was consistently confirmed in a
further 10 studies.
Recent findings suggest that the
effects are even greater when vareni-
cline is combined with bupropion or
another antidepressant. Depressed mood
is often a symptom of nicotine with-
drawal and healthcare professionals need
to be alert to this. ‘Varenicline does not
vaccinate people against unhappiness’,
Dr Fagerstrom pointed out.
He concluded by pointing out that
while doctors routinely intervene when
a patient has elevated blood pressure
or cholesterol, they are less inclined to
prescribe pharmacological therapy to
aid in smoking cessation. He therefore
encourages a move towards taking more
active steps in this regard. ‘Varenicline
is easy to use. The recommended course
is 12 weeks and patients should set their
cessation date at seven to 14 days after
initiation of the medication.’
Peter Wagenaar, Gauteng correspondent
Free-of-charge cardiac surgery in Africa
Introduction
‘Emergency’ is an Italian humanitarian
organisation established in 1994 with the
goal of providing high-quality, free-of-
charge medical assistance to victims of
war and poverty. In 2007, Emergency
established a centre in Khartoum provid-
ing free-of-charge cardiac surgery. This
is the only high-volume cardiac centre
with 24/7/365 availability, managed by a
humanitarian organisation. The aim of this
study is to present our experiences from
the first four years of activity.
Patients
Between 2007 and October 2010, 18 652
patients underwent cardiological exami-
nations at the centre, of whom 2 733 had
cardiac surgery. Mean and median age
was 26 years (13 days to 65 years). Fifty
per cent were females; 12% of admit-
ted patients came from countries outside
Sudan, representing 18 different African
countries. Risk factors in this region
differ considerably from high-economy
countries (lower age, less arteriosclero-
sis) but other factors are much more
common (malnutrition, extreme pulmo-
nary hypertension). More than half of our
valve patients had severe pulmonary arte-
rial hypertension (PAP), according to the
Euroscore definition (PAP > 60 mmHg).
According to WHO definitions, 47% were
underweight (BMI < 18.5 kg/m
2
) and 20%
had ‘severe thinness’ (BMI < 16 kg/m
2
).
The centre participated in the 2010 world-
wide update of the Euroscore database.
Procedures
Seventy-one per cent of operations were
valve procedures, mainly mitral or multi-
valvular operations. Mechanical valves
were used in most patients but valve repair
was possible in 24% of patients under-
going isolated mitral valve procedures.
Five per cent underwent CABG. Twenty-
three per cent of the operations were for
congenital disease, the most prevalent
procedures being total correction of tetral-
ogy of Fallot (28% of congenital proce-
dures), ASD closure (17%) and VSD
closure (15%).
Follow up
All patients coming from outside
Khartoum are requested to remain in
Khartoum for 30 days postopera-
tively (staying with relatives or at the
Emergency guest-house) and all patients
from Khartoum have a follow-up visit
one month postoperatively. The 30-day
follow up has been completed on all
patients.
Results
The 30-day mortality rate was 3.1%.
Re-operation for bleeding occurred in
6.5% and for mediastinitis in 0.1% of
patients. In the adult cohort operated on
between May and July 2010 and therefore
reported to Euroscore, the 30- and 90-day
mortality rates were 1.6%.
Conclusions
It is possible to establish and maintain a
high-volume, high-quality cardiac surgical
centre in low-economy countries.
