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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
AFRICA
237
Management of stable angina pectoris in private
healthcare settings in South Africa
Pride Tlhakudi, Lehlohonolo John Mathibe
Abstract
Aim:
Angina pectoris continues to affect multitudes of
people around the world. In this study the management of
stable angina pectoris in private healthcare settings in South
Africa (SA) was investigated. In particular, we reviewed the
frequency of medical versus surgical interventions when used
as first-line therapy.
Methods:
This was a retrospective inferential study carried
out using records of patients in private healthcare settings.
All cases that were authorised for reimbursement by medical
aid schemes for revascularisation between 2009 and 2014 were
retrieved and a database was created. Data were analysed
using Microsoft
®
Excel and GraphPad Prism
®
version 5. The
differences (where applicable) were considered statistically
significant if the
p
-value was
≤
0.05.
Results:
Nine hundred and twenty-two patients, consisting of
585 males (average age 64.7 years; SD 12.9) and 337 females
(average age 65.5 years; SD 14.3), met the inclusion criteria.
One hundred and seventy-eighty or 54%, 156 (43%) and 86
(63%) patients with hypertension, hyperlipidaemia and diabe-
tes, respectively, were treated with surgery only. For these
patients, percutaneous coronary interventions (PCIs) were
significantly (
p
<
0.0001) preferred first-line interventions over
optimal medical therapy (OMT). Four hundred and thirty-six
or 47% of all patients studied were managed with surgery
only, while only 25% (227) were managed with OMT. It took
60 months (five years) for patients who were treated with
OMT before their first surgical intervention(s) to require the
second revascularisation. About 71% of patients who received
medical therapy were placed on only one drug, the so called
sub-optimal medical therapy (SOMT).
Conclusion:
The management of stable angina pectoris in
private healthcare settings in SA is skewed towards surgical
interventions as opposed to OMT. This is contrary to what
consistent scientific evidence and international treatment
guidelines suggest.
Keywords:
revascularisation, angina pectoris, optimal medi-
cal therapy (OMT), medical aid scheme, South Africa, private
healthcare
Submitted 6/1/16, accepted 15/3/18
Published online 10/2/18
Cardiovasc J Afr
2018;
29
: 237–240
www.cvja.co.zaDOI: 10.5830/CVJA-2018-020
The World Health Organisation (WHO) estimates indicate that
in 2010, ischaemic heart diseases were responsible for 7.3 million
deaths worldwide, and that 58 million disability-adjusted life
years (DALYs) were lost as per the global burden of this disease.
1
Furthermore, the American Heart Association has reported
that about 15.4 million people in the United States of America
in 2010 had ischaemic heart diseases.
2
In South Africa (SA),
ischaemic heart disease is one of the 10 leading causes of death.
3
This is in line with global trends.
4
However, there is very little
epidemiological data about the burden caused by stable angina
and the economic implications of the way it is managed in SA
(both in the public and private healthcare settings).
Angina pectoris is one of the symptoms of various ischaemic
heart diseases that affect the coronary arteries. It is mainly due
to atherosclerosis, coronary embolism and/or calcific aortic
stenosis.
5,6
Angina is characterised by thoracic pain that occurs
as a result of deficiency in blood delivery to the myocardium.
Depending on the nature, duration and its responsiveness to
medical therapy, angina pectoris may be regarded as stable or
unstable.
7
With the former, the symptoms, which are associated
with the extent of physical exertion, are generally responsive
to medical therapy. However, in patients with unstable angina,
a thoracic pain, which occurs even at rest, is not amenable to
medical therapy.
8
Managementof anginapectorisincludesnon-pharmacological
measures, such as lifestyle modifications. For the relief of
symptoms, a step-wise management approach or an optimal
medical therapy (OMT) is recommended.
9
For OMT, eligible
patients are treated with a triple-drug regimen, which consists
of aspirin, beta-blockers, nitrates, calcium channel blockers,
potassium channel activators and/or vasodilators, such as
nicorandil, sodium channel blockers, such as ranolazine, or
3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase
inhibitors, such as simvastatin.
10-12
Revascularisation and other surgical procedures play a
life-saving role for the majority of patients with angina.
13-15
Commonly used surgical techniques include percutaneous
coronary interventions (PCIs), bare-metal stents (BMS),
coronary artery bypass grafting (CABG) and drug-eluting stents
(DES). Myocardial infarction causes death in many untreated
and asymptomatic angina patients.
5
Treatment of unstable angina, an emergency condition, is
undisputed.
16
However, management of stable angina remains
the elephant in the room.
17
In several developed countries, about
85% of revascularisations were performed on stable coronary
patients who could have been well controlled on OMT.
18
This
continues to happen despite overwhelming evidence from studies
such as the Clinical Outcomes Utilizing Revascularisation and
Aggressive drug Evaluation Trial (COURAGE trial) pointing
to the contrary.
19
Unfortunately, in developing countries such
as SA, there is insufficient evidence on how stable angina is
managed, especially in private healthcare settings.
Division of Pharmacology (Therapeutics), University of
KwaZulu-Natal, Durban, South Africa
Pride Tlhakudi, MPharm
Lehlohonolo John Mathibe, MSc, PhD,
mathibel@ukzn.ac.za