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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
AFRICA
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The median age of presentation found in this study is similar
to other studies from sub-Saharan Africa, which demonstrate
that ACS cases in sub-Saharan Africa tend to present at a
younger age, typically in their 50s, compared to high-income
countries, which have a median age in the mid-to-late 60s.
4
A
2010 retrospective study by Ogeng’o
et al
. at Kenyatta National
Hospital of 120 ACS cases admitted between 2000 and 2009
reported the mode of diagnosis, demographics, risk factors and
in-hospital heart failure and mortality rates.
8
The mean age in
this study was 56.8 years with a similar 2:1 male-to-female ratio.
Our study also demonstrates a doubling in rates of
hypertension and diabetes (63 and 41%, respectively) compared
to the 35 and 21% rates reported in the Ogeng’o study, while
smoking rate was similarly low (9 and 13%, respectively).
8
The
2010 Ogeng’o study did not specify ACS subtypes and overall
rates of in-hospital diagnostics such as ECG, echocardiography
and coronary angiography, and therefore we were unable to
make comparisons in those areas. However, total mortality rate
demonstrated in our study was notably higher (17%) compared
with the previous report of 5%.
8
The 2004 INTERHEART study, a multi-continental
case–control study, which incorporated nine countries from
sub-Saharan Africa, including Kenya, demonstrated that acute
myocardial infarction risk factors among the sub-Saharan
African cohort were similar to that of the overall study
population. However, a history of hypertension was associated
with increased myocardial infarction risk among the black
African group compared to the general study population.
9
The high frequency of STEMI (57%) presentation
demonstrated in this study is also similar to other studies
from sub-Saharan Africa, including a 2012 prospective study
of 111 ACS admissions from the Aga Khan University
Hospital, a private institution in Nairobi (56%,
n
=
111).
10
The
Acute Coronary Events – a Multinational Survey of Current
Management Strategies (ACCESS) registry is another large-
scale multi-national study that included 642 patients from South
Africa. This study had 41% STEMI, 32% NSTEMI and 27%
unstable angina cases.
Rates of in-hospital medical therapy such as aspirin and
beta-blocker use demonstrated in this study are comparable
to the ACCESS-South Africa cohort findings; however, there
are important differences in reperfusion rates. The Aga Khan
University study demonstrated a 68% reperfusion rate [either
percutaneous coronary intervention (PCI) or thrombolysis],
while the ACCESS registry reported 96% in-hospital reperfusion
rate with thrombolysis and/or PCI.
11
Caution must be applied
when comparing these reperfusion rates to our study, given
the likely significant patient- and hospital-level socio-economic
variation across these studies.
Future directions of study include evaluating initiatives
for quality improvement related to diagnostics (e.g. ECG
evaluation of all patients with chest pain) and management
(e.g. reperfusion of eligible patients). One integral component
includes an ongoing, prospective ACS registry to assess time
trends in presentation, management and outcomes and devise
future quality-improvement initiatives.
Internationally, results of large-scale registries such as
GRACE-ACS
4
have contributed significantly to better
understanding of ACS presentation, management and
outcomes and have led to the design of other ACS registries
globally, including in low-middle-income countries such
as the Kerala ACS registry,
13
China Acute Myocardial
Infarction (CAMI) registry
14
and the Registry for Acute
Coronary Syndrome Events in Nigeria (RACE-Nigeria)
from a sub-Saharan African country.
2
Cardiology societies
in sub-Saharan Africa including the Kenyan Cardiac Society
(KCS) and the Pan-African Society of Cardiology (PASCAR)
have recognised the need for data on ACS and are advocating
for initiatives to build local and regional ACS registries to have
improved understanding of disease presentation, management
and outcomes in the region.
ACS registries in both high- and low-middle-income countries
have also led to subsequent quality-improvement initiatives.
These include ACS quality-improvement randomised, control
trials, such as the Brazilian Intervention to Increase Evidence
Usage in Acute Coronary Syndromes (BRIDGE-ACS),
15
the
Clinical Pathways for Acute Coronary Syndromes, phases 2 and 3
(CPACS-2 and -3)
16
in China, and the Acute Coronary Syndrome
Quality Improvement in Kerala (ACS QUIK) study in India.
17
These multi-institutional randomised, control trials have
investigated the impact of quality-improvement tools such as
clinical pathways, audits and performance feedback on both
processes of care and outcomes, with the goal of improving
ACS management. Such future efforts within sub-Saharan
Africa could be instrumental in identifying unique solutions
tailored to the needs and capacity of the region to improve ACS
care. Through this research process, we have engaged with key
stakeholders at Kenyatta National Hospital within the division
of cardiology and department of research to assess the existing
research infrastructure and capacity, to improve processes and
outcome measures of patients with ACS.
Strengths and limitations
This study, the largest study at Kenyatta National Hospital to
date, has assessed the presentation, management and outcomes
of ACS patients managed at the hospital. The main study
limitation is based upon the retrospective design of the study.
Like most hospitals in the region, Kenyatta National Hospital
uses paper charts for medical records, and we were not able to
locate 51 charts that met our study criteria. Additionally, there
was loss of electronic disease code database at Kenyatta National
Hospital in 2013, which resulted in only 40 admissions being
identified from 2013. However, it is unlikely that these omissions
would have influenced the overall findings from this study. One
author (EB) made assessments to include and exclude cases and
completed the data extraction, which adds another potential
limitation to data quality.
Conclusions
This is the largest study at Kenyatta National Hospital to evaluate
the presentation, management and outcomes of ACS patients
managed at a public referral hospital that provides care to a diverse
pool of patients in Kenya. The findings present opportunities
for future quality-improvement initiatives, especially in the
areas of initial diagnostic capabilities and reperfusion therapy.
A prospective ACS registry and linked quality-improvement
programme would be valuable to improve quality and safety of
ACS patients and as a model for other cardiovascular conditions.