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

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 2, March/April 2019

AFRICA

blockers were given to a smaller proportion of patients on an

individual basis according the protocol of each medical centre.

The frequency of non-invasive diagnostic procedures is

shown in Table 4, pooled for men and women, since there was

no gender difference for any of the procedures (

0.18 for

all). Among all ACS patients, 96% had an echocardiography

performed, revealing a normal left ventricular ejection fraction

(LVEF) in nearly half the patients. On the other hand, 22 and 4%

of patients, respectively, underwent subsequent stress ECG and

radionuclide imaging.

Table 5 shows the difference between males and females

in revascularisation-related interventions. Diagnostic coronary

angiography was performed in a similar proportion of men and

women (62 and 59%, respectively). However, radial access was

more likely to be used in men (12 in men vs 6% in women) (

0.001). There was also a trend for lower rates of percutaneous

coronary intervention (PCI) in women compared to men.

Among all ACS patients, PCI was attempted in 54% of men vs

43% of women (

0.001). Patients diagnosed with STEMI were

either treated with PCI or thrombolytic therapy, with a small

proportion undergoing neither treatment (Table 5).

Primary PCI was conducted in 51% of men compared to

46% of women with STEMI (

0.064), while 43 and 44%

of male and female STEMI patients, respectively, underwent

thrombolytic therapy (in the form of streptokinase). Among

all ACS patients, 5% were referred for cardiac coronary artery

bypass graft (CABG) surgery, again with no gender disparity.

Cardiac surgery was performed in a larger proportion of women

(1.7%) than men (0.6%;

0.03).

Overall, men and women had similar rates of most in-hospital

complications recorded, including re-infarction (4% of all ACS

patients), atrial fibrillation (5%), ventricular tachycardia or

fibrillation (5.5%), cerebrovascular stroke (1%), major bleeding

(0.5%) and acute renal failure (2.5%) (

0.34 for all). However,

more women experienced second- or third-degree atrioventricular

block (3.1 vs 1.5% in men) (

0.042), and mechanical

complications (3.6 vs 1.8% of men) (

0.024).

Discussion

The eastern Mediterranean region, comprising 22 countries,

witnessed 1.3 million CVD deaths in 2015; 16% of these were in

Egypt.

This calls for tailored programmes to reduce the burden of

risk factors in the country. A

Cochrane Systematic Review

showed

that risk-factor interventions may lower blood pressure, BMI and

waist circumference in low- and middle-income countries.

However, strategies to improve the prevention and

management of ACS in Egypt and other low- and middle-income

countries are hampered not only by economic considerations but

also by the paucity of data emerging from these countries. These

countries have experienced an increase in CVD, and most of the

CVD burden and mortality occurs there.

15,16

To our knowledge, this is the first study to assess the

epidemiology of risk factors and treatment strategies for patients

with ACS across Egypt. Two traditional risk factors had

a strikingly high prevalence: smoking and obesity. Smoking

and ex-smoking were reported by 48 and 13% of patients,

respectively, exceeding the rate for Gulf countries, where 38%

were current smokers.

It also exceeded that reported for the 25

countries represented in the GRACE registry, where current and

past smokers together accounted for 47% of ACS patients.

Of all men presenting with ACS in this study, 46% had

premature ACS by global standards (aged

55 years); of

these, 74% were current smokers and 12% ex-smokers. There

was a strong gender disparity, where only 5% of women

reported current smoking. Devising accessible health-awareness

campaigns utilising local TV and social media to alter attitudes of

young and middle-aged men towards smoking may substantially

reduce the CVD burden in Egypt.

Egypt currently has the third highest prevalence of obesity

in the MENA region, after Saudi Arabia and the United Arab

Emirates.

Even metabolically healthy obesity increases the

risk for future CVD events by 49%,

and associated metabolic

abnormalities confer additional risk.

Median BMI in the

present study was 29 kg/m

in men and 33 kg/m

in women.

Correspondingly, obesity was more prevalent in women (71%)

than men (41%). A similar higher prevalence of obesity in

women is uniformly observed in the general population across

all countries in the Middle East.

Dyslipidaemia was correspondingly more prevalent in women.

However, atherogenic dyslipidaemia, which is linked to central

adiposity

and independently predicts major cardiovascular

events in coronary disease patients,

was present in approximately

one-third of patients, with no gender difference.

Waist/height ratio, a marker of central adiposity, is superior

to BMI in predicting metabolic perturbations and incident CVD

and diabetes, with a ratio

≥

0.5 predicting increased risk.

24-26

a survey of more than 2 000 adults in the Egyptian National

Table 5.Thrombolytic therapy and other

interventions in men and women

Interventions

Men

(

1256)

Women

(

425)

value

Coronary angiogram

Radial access

0.001

Normal coronaries

0.001

PCI

0.001

Primary PCI (% of STEMI cases)

0.064

Thrombolytic therapy

0.021

Thrombolytic therapy (% of STEMI cases)

CABG

Cardiac surgery

0.6

1.7

0.033

Temporary pacemaker

1.3

2.4

Permanent pacemaker

0.4

Data are presented as % within gender for all acute coronary syndrome patients,

unless otherwise indicated.

values are from Pearson

test. NS,

≥

0.1. PCI,

percutaneous coronary intervention; CABG, coronary artery bypass graft.

Table 4. Non-invasive diagnostic procedures and

echocardiography findings in the total population

Procedures

Percentage

Stress ECG

Echocardiography

Echocardiography findings

Normal (LVEF

50%)

Mild impairment (LVEF 41–50%)

Moderate impairment (LVEF 31–40%)

Severe impairment (LVEF

31%)

Radionuclide imaging

No significant gender difference was observed for any of the procedures or

outcomes (

≥

0.36). LVEF, left ventricular ejection fraction.

1 256 men and 425 women.