Cardiovascular Journal of Africa: Vol 30 No 2 (March/April 2019)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 2, March/April 2019 88 AFRICA
Conclusions: Central obesity and smoking are extremely
prevalent in Egypt, contributing to an increased burden of
premature ACS, which warrants tailored prevention strate-
gies. The recognised tendency worldwide to treat men more
aggressively was less pronounced than expected.
Keywords: Egypt, acute coronary syndrome, risk factors
Submitted 22/6/18, accepted 10/12/18
Published online 16/1/19
Cardiovasc J Afr 2019; 30: 87–94
DOI: 10.5830/CVJA-2018-074
Ischaemic heart disease is the leading cause of years of life lost
worldwide.1 Despite advances in treatment, between 1990 and
2016, the global number of deaths from cardiovascular diseases
(CVD) for people aged more than 70 years increased by 54%.1
While the CVD mortality rate has receded in high-income
countries between 2000 and 2012, low- and middle-income
countries have witnessed an increase.2 Attempts at lowering
incident CVD require population-based preventative guidelines
that address the specific risk factors for each age and gender
group. Prevention is even more vital in lower-income countries
considering the high treatment cost of CVD, plus infections
and malnutrition, using limited health resources. Egypt is a
classic example, with overpopulation and a low per capita health
expenditure.3
A gender-specific pattern of risk factors has emerged
worldwide, with female patients presenting with acute coronary
syndrome (ACS) having higher rates of diabetes mellitus,
hypertension and obesity, compared to men.4 Furthermore,
universally there is a tendency for women to receive less-
intensive pharmacological and invasive treatment following
ACS.4 The Middle East and North African (MENA) region is
no exception, with the Gulf countries overall reporting less-
aggressive treatment strategies in females, accounting for higher
complication and mortality rates in women.5
Egypt is the most populous of the 20 MENA countries,
harbouring about 20% of the total MENA population of about
409 million.6 It is unknown whether Egypt follows a similar
pattern of ACS risk factors and treatment strategies to that
observed in the MENA region and worldwide.
The past decades in Egypt have seen a transition from
prevalent undernutrition to obesity.7 Over two-thirds of adults
and one-third of children are overweight or obese, surpassing
the average for Europe.8 Three traditional CVD risk factors,
namely obesity, diabetes and hypertension, were the leading risk
factors for early death and disability in Egypt, as measured by
attributable disability-adjusted life years.9 One in six individuals
has diabetes.8 These factors are expected to be a major contributor
to ACS risk in Egypt but have not previously been quantified in
ACS patients across Egypt.
The CardioRisk project is a nationwide, cross-sectional study
of existing risk factors and management strategies for ACS in
Egypt. The present study is the first report of data collected in
the CardioRisk project, from November 2015 to August 2017.
The primary objective was to describe the risk-factor profile
among Egyptian patients with ACS and the different treatment
strategies adopted in intensive care units dealing with ACS
patients across Egypt. A secondary aim was to explore gender
differences with regard to ACS risk factors and treatments, to
enable informed design of national treatment guidelines and
gender-specific prevention protocols.
Methods
CardioRisk is a multi-centre, observational, cross-sectional
study of risk factors and management of patients presenting
with ACS to coronary care units in Egypt. A total of 30 units
participated from 11 governorates spanning the Mediterranean
coast, Nile Delta region and southern Egypt. Participating
coronary care units in each area included hospitals of different
levels of complexity, in order to capture a network of centres
representative of Egyptian reality.
Data were collected on patients presenting with ACS during
their hospital stay, with a focus on CVD risk factors, diagnostic
and management strategies, as well as in-hospital complications
and in-hospital mortality. To minimise selection bias, patient
enrolment was done consecutively on all weekdays for some
centres, and on pre-determined days in others. Management
of patients followed the existing diagnostic and therapeutic
strategies currently followed in each centre. No recommendations
for management were put forth during the study, and drug
prescriptions and management strategies were completely left to
the participating cardiologists’ decision.
Detailed information was given to each patient prior to
enrolment in the study, and data were included only after
obtaining signed informed consent. The study was approved by
the ethics committee of the Egyptian Association of Vascular
Biology and Atherosclerosis (EAVA) ].
This study is an analysis of data collected during phase I
(November 2015 to January 2016) and phase II (February 2016
to August 2017) of the CardioRisk project. A total of 1 681
patients were included.
A 12-lead ECG was performed in all patients by a cardiologist
participating in the study. Based on electrocardiogram (ECG)
findings,patientswereclassifiedashavingST-elevationmyocardial
infarction (STEMI), non-ST-elevation myocardial infarction
(NSTEMI), unstable angina or other electrocardiographic
abnormalities. Plasma concentrations of troponins and the MB
fraction of total creatinine phosphokinase (CPK) were measured
to detect evidence of myocardial cell death.
Acutemyocardial infarction (STEMIorNSTEMI)wasdefined
by at least two of the following features: (1) electrocardiographic
changes (patients with or without ST-segment elevations), (2)
compatible clinical symptoms, and (3) troponin I > 0.4 ng/ml
and/or MB fraction of CPK > 8.8 ng/ml. Patients were enrolled
in the study if they were 18 years or older and diagnosed with
STEMI, NSTEMI or unstable angina.
Data were collected using a web-based system case-report
form (available on , with a pre-determined
username and password for each participating investigator. The
following information was captured for each enrolled patient:
socio-demographics, CVD risk factors, history of co-morbidities
and prior drug use, presenting symptoms, laboratory data, ECG
findings, diagnostic and therapeutic procedures, in-hospital
complications and in-hospital mortality.