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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
AFRICA
261
•
FFR/iFR (fractional flow reserve/instantaneous free-wave
ratio) helps to identify haemodynamically significant disease
in non-culprit vessels.
•
Many patients in the developing world live far away from
cities and the need for urgent repeat revascularisation may
translate into a mortality difference due to treatment delay.
•
Saving costs initially via the IRA-only approach could incur
higher costs at a later stage and this is particularly relevant in
the African setting since most patients are liable for ‘out-of
pocket’ expenses.
The counter argument that the initial strategy should be primary
percutaneous coronary intervention (PPCI) of the IRA-only was
made by Dr Suliman who presented the evidence cited below:
•
All studies did not demonstrate a mortality benefit and event
rates were primarily driven by the need for repeat revascu-
larisation.
•
All studies cited above performed complete revascularisation
on the IRA-only without any attempt to risk-stratify the
haemodynamic significance of the lesions in the non-IRA
vessels using non-invasive testing. The Prague 13 trial, which
excluded patients with angina more than a month before
STEMI, was equivocal.
•
Patients with left main stem or proximal significant disease in
the N-IRA should undergo full revascularisation with PCI or
coronary artery bypass grafting (CABG).
•
FFR is not available in most cardiac catheterisation laborato-
ries on the African continent.
•
On average, one to two extra stents were used in patients
undergoing complete revascularisation and extra contrast
was used, adding a significant financial burden. Such valuable
resources can be shifted to perform more primary angioplasty
procedures for STEMI patients.
Dr Suliman concluded by advocating a strategy of culprit-
artery only and non-invasive ischaemia-testing for limited-resource
settings. At the end of the debate, the audience was almost evenly
split when polled regarding the two approaches. Results of
ongoing trials are eagerly awaited to shed more light on the subject
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South Africa–Cuba medical training programme: flawed but successful
After more than 20 years, the contentious South Africa–
Cuba medical training programme is being downscaled.
Business Day’
s Tamar Kahn assessed the situation as the
largest-ever cohort of 720 students prepares to return to
embark on local clinical training.
More than 20 years ago, Desmond Kegakilwe left
Tlakgameng village in rural North West to study medicine in
Cuba. According to a
Business Day
report, back then there
were few local doctors serving in his community and little
hope for young people from underprivileged backgrounds
who aspired to a medical career. Today he is the acting
clinical manager at Ganyesa District Hospital near Vryburg,
and five of the eight doctors employed at the rural facility are
Cuban-trained South Africans.
‘Obviously it was not an easy route, but rural areas now
have permanent South African doctors who can speak the
language of their patients. Some of us would never have
had the opportunity to study medicine in South Africa,’
Kegakilwe says.
The report says South Africa began sending aspirant
doctors to train in Cuba in 1997 under a deal that also saw
Cuba send its doctors to work in South Africa’s rural areas.
The South Africans joined students from all over the world
taking advantage of the many medical schools created under
Fidel Castro’s watch to provide personnel for his country’s
free universal healthcare system.
South Africa recruited bright young people from
underprivileged backgrounds and sent them to Cuba on
bursaries that required them to work for an equal number
of years in the state sector after they had qualified. But,
the report says, the programme was contentious from the
beginning, as the ANC-led government maintained close
political ties to Castro, in recognition of his support for the
organisation when it was in exile during apartheid.
continued on page 264…