Cardiovascular Journal of Africa: Vol 25 No 6 (November/December 2014)

7 / 66

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 6, November/December 2014 AFRICA 257
acute STEMI if:
––Presentation is within 12 h of onset of symptoms and
––PPCI can be delivered within 120 min of the time when
fibrinolysis could have been given.
• Offer fibrinolysis to people with acute STEMI presenting with-
in 12 h of onset of symptoms if PPCI cannot be delivered within
120 min of the time when fibrinolysis could have been given.
• Consider coronary angiography, with follow-on PPCI if indi-
cated, for people with acute STEMI presenting more than 12 h
after the onset of symptoms if there is evidence of continuing
myocardial ischaemia.
• Offer coronary angiography, with follow-on PPCI if indicated,
to people with acute STEMI and cardiogenic shock who present
within 12 h of the onset of symptoms of STEMI.
• Offer an ECG to people treated with fibrinolysis, 60–90 min
after administration. For those who have residual ST-segment
elevation suggesting failed coronary reperfusion:
––Offer immediate coronary angiography, with follow-on PCI
if indicated
––Do not repeat fibrinolytic therapy.
• If a person has recurrent myocardial ischaemia after fibrinoly-
sis, seek immediate specialist cardiological advice and, if
appropriate, offer coronary angiography, with follow-on PCI
if indicated.
• When commissioning PPCI services for people with acute
STEMI, be aware that outcomes are strongly related to how
quickly PPCI is delivered, and that they can be influenced by
the number of procedures carried out by the PPCI centre.
Factors that may contribute to earlier treatment for PCI-treated
patients include bypassing non-PCI-capable hospitals and
bypassing the emergency department of the PCI-capable
hospital, pre-hospital ECG diagnosis of STEMI, and
pre-hospital activation of the catheterisation laboratory by
emergency physician or EMS, and early (within 20 minutes)
activation of the catheterisation laboratory team.27,28
Current guidelines for remote areas
For the treatment of STEMI patients living in remote, sparsely
populated areas with no ready access to PCI facilities, the
pharmaco-invasive strategy is advocated. Fibrinolysis should
be commenced as soon as possible if there are no contra-
indications, followed by transfer to a PCI facility for rescue PCI
or angiography with possible PCI as a routine measure. Patients
with contra-indications for fibrinolysis, late presenters, and
patients with cardiogenic shock should be transferred to a PCI
facility irrespective of the duration of transfer. Clear treatment
protocols and a well-organised STEMI network are pivotal in
STEMI management in these areas.29
From the Australian experience, we learn that direct transport
to PCI facilities and inter-hospital transfer for primary PCI
positively impact on timely access to primary PCI (defined as ‘the
proportion of the population capable of reaching a PPCI facility
≤ 120 minutes from emergency medical services activation’) and
that pre-hospital fibrinolysis significantly improves timely access
to reperfusion PCI (defined as ‘the proportion of the population
capable of reaching a fibrinolysis facility in ≤ 60 minutes
from emergency medical services activation’) in remote areas.29
Geographical information systems were employed to integrate
hospital, classified as hospitals that provided PCI or fibrinolysis,
and population and road network data,30 which in all probability
contributes to informed management of STEMI care.
Concluding remark
In our endeavour to facilitate early reperfusion for ST elevation
myocardial infarction in Africa we need to bear in mind that
‘ Improvements in access to timely care for patients with STEMI
will require a multifaceted approach involving patient education,
improvements in the emergency medical services and emergency
department components of care, the establishment of networks
of STEMI-referral hospitals (not PCI capable) and STEMI-
receiving hospitals (PCI capable), as well as coordinated advocacy
efforts to work with payers and policy makers to implement a
much-needed healthcare system redesign. By focusing now on
system efforts for improvements in timely care for STEMI, we will
complete the cycle of research initiated by Reimer and Jennings 30
years ago. Time is muscle . . . we must translate that into practice’
(Elliott M Antman, 2008).31
References
1. Kengne AP, Mayosi BM. Readiness of the primary care system for
non-communicable diseases in sub-Saharan Africa.
lancetgh Vol 2 May 2014. Published online April 14, 2014,
org/10.1016/, S2214-109X(14)70212-8. PMID: 23736126.
2. Brand M, Woodiwiss AJ, Michel F, Booysens HL, Majane OH, Maseko
MJ, Veller MG, Norton GR. Chronic diseases are not being managed
effectively in either high-risk or low-risk populations in South Africa.
S Afr Med J 2013; 103(12): 938–941. doi: 10.7196/samj.6018. PMID:
24300634.
3. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw
D. The burden of non-communicable diseases in South Africa. Lancet
2009; 374: 934–947.
4. WHO. The global burden of disease: 2004 update. Geneva: World
Health Organization, 2008.
5. WHO. Health statistics and health information systems – Global Health
Estimates (GHE), 2013.
disease/en/ (accessed March 11, 2014).
6. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A.
Growing epidemic of coronary heart disease in low- and middle-income
countries. Curr Probl Cardiol 2010; 35(2): 72–115. doi: 10.1016/j.cpcar-
diol.2009.10.002.
7. Onen CK. Epidemiology of ischaemic heart disease in sub-Saharan
Africa. Cardiovasc J Afr 2013; 24: 34–42. doi: 10.5830/CVJA-2012-071.
8. Hertz JT, Reardon JM, Rodrigues CG, de Andrade L, Limkakeng AT,
Bloomfield GS, Lynch CA. Acute myocardial infarction in sub-Saharan
Africa: the need for data. PLoS One 2014; 9(5): e96688. doi: 10.1371/
journal.pone.0096688. eCollection 2014. PMID: 24816222.
9. Fuster V, Voute J. MDGs: chronic diseases are not on the agenda.
Lancet 2005; 366: 1512–1514.
10. Ntsekhe M, Damasceno A. Recent advances in the epidemiology,
outcome, and prevention of myocardial infarction and stroke in
sub-Saharan Africa. Heart 2013; 99(17): 1230–1235. doi: 10.1136/
heartjnl-2012-303585.
11. Gersh BJ, Sliwa K, Mayosi BM, Yusuf S. Novel therapeutic concepts:
the epidemic of cardiovascular disease in the developing world: global
implications. Eur Heart J 2010; 31(6): 642–648. doi: 10.1093/eurheartj/
ehq030.
12. Mayosi BM, Flisher AJ, Lalloo UG, Sitas F, Tollman SM, Bradshaw