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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 6, November/December 2014
256
AFRICA
Editorial
Towards developing guidelines and systems of care to
facilitate early reperfusion for ST-elevation myocardial
infarction in Africa
Rhena Delport
Outline
The theme for the 15th annual SA Heart Congress for 2014,
‘Bridging the divide’ between best practice and current challenges
in the management of cardiovascular conditions, inspired this
editorial on the feasibility of implementing the European Society
of Cardiology ‘Stent-for-Life’ initiative in sub-Saharan Africa or
alternate measures of ensuring early reperfusion for myocardial
ischaemia. This editorial explores the changing burden of
non-communicable diseases (NCD) in Africa that impact on the
occurrence of ST-elevation myocardial infarction (STEMI) in
Africa, revisits international guidelines on early reperfusion and
implementation of systems of care, and identifies factors related
to timely myocardial reperfusion in remote areas.
Current status in Africa
Recent comments by Kengne and Mayosi on the rising incidence
of chronic NCD in sub-Saharan Africa in both rural and urban
areas express concern about the lack of preparedness of African
states for the pending pressure on healthcare services,
1
pertain
to South African healthcare services as well.
2,3
The World
Health Organisation (WHO) estimates that NCDs will exceed
communicable diseases as the leading cause of death in Africa
in 2030.
4,5
An increase in cardiovascular disease (CVD) burden is also
expected due to the increased prevalence and incidence of CVD
risk factors, paucity of surveillance data and registries, lack of
interventional measures, as well as a shortage of physicians and
cardiologists, inadequate diagnostic capabilities, and misguided
opinions.
6-8
Although CVD remains the leading cause of death
in the world,
9
three-quarters of which occur in low- and middle-
income populations,
6
the burden of ischaemic heart disease
(IHD) remains low in comparison with other causes of heart
disease, particularly in people of African descent.
6,10,11
Marked
variability is however observed in the incidence, prevalence and
mortality rates of IHD across developing countries, as in Africa,
mainly due to the differences in composition and severity of
risk factors and management thereof, as well as the stage of
epidemiological transition.
6,11-20
Concerted action among the WHO and international cardiac
societies to improve cardiovascular health and prevent death
from cardiovascular disease is increasingly becoming evident.
21,22
Hopefully African societies will follow suit.
Current guidelines
The majority of recommendations in the European
23
and
American
24
guidelines for the management of STEMI were
perceived as either identical or overlapping.
25
The detail of the
guidelines will not be replicated here, neither is the aim of this
editorial to perform further comparisons with other international
guidelines. A brief exposition on primary reperfusion strategies
will be provided from random sources, with the emphasis on the
African context where percutaneous coronary intervention (PCI)
facilities are sparsely distributed and emergency medical services
(EMS) are not readily available.
Primary percutaneous coronary intervention is the preferred
and most effective option for reperfusion, provided that the
intervention is performed timely by an experienced operator.
26,27
Although performance metrics such as ‘door-to-balloon time’ or
‘door-to-needle time’ are employed to quantify time lapses from
the onset of symptoms to definitive treatment, the concept of
‘first medical contact (FMC)-to-device time’ recognises the need
for speedy diagnosis and treatment as the primary outcome.
26
The patient as well as factors relating to EMS determine the
time delay between the onset of symptoms and the FMC, while
FMC and the beginning of reperfusion is explained by EMS
transport time to a PCI-capable facility and determinants of
‘door-to-balloon’ time.
27
Ideally the patient should be transported
directly to a PCI-capable hospital for primary PCI but if the
patient is admitted to a non-PCI facility, the door-in-door-out
time should ideally be 30 minutes or less before the patient is
transported to a PCI-capable hospital.
26
The FMC-to-device
time should be 90 minutes or less, and in the case of necessity
to transfer the patient for PCI, 120 minutes or less. If primary
PCI is not achievable within 120 minutes thrombolytics should
be administered with FMC within 30 minutes of diagnosis of
STEMI either pre-hospital by a trained paramedic/clinic nurse, or,
alternatively, by a physician in the nearest ER.
26,27
Additional recommendations of relevance as proposed in the
United Kingdom ‘NICE’ guidelines
28
entail the following (as
quoted):
•
Offer coronary angiography, with follow-on PPCI if indicated,
as the preferred coronary reperfusion strategy for people with
Department of Chemical Pathology, University of Pretoria,
Pretoria, South Africa
Rhena Delport, PhD,
rhena.delport@up.ac.za