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

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

AFRICA

Hypertension Survey Program, central obesity was present in

50% of subjects. In our study, 80 and 89% of men and women,

respectively, had central obesity, defined by a waist/height ratio

≥

0.5. This is linked to an increasing burden of diabetes and related

morbidity.

Egypt harbours 21% of all diabetes cases in MENA.

The

most recent International Diabetes Federation report estimates

diabetes prevalence in Egypt in adults aged 20 to 79 years at 15%,

substantially exceeding the global estimate of 9%, as well as the

overall estimate for MENA (11%).

The present study showed

that 53% of women and 34% of men with ACS in Egypt had

type 2 diabetes. The higher prevalence in women is unlikely to be

solely explained by their older age, since the discrepancy persisted

even within age sub-groups. A likely contributing factor is the

substantially higher frequency of obesity in women. Overall, the

present study highlights the extremely high prevalence of central

obesity and related morbidity in ACS patients in Egypt.

In line with global rates, STEMI was more common in men,

while NSTEMI and unstable angina were more frequent in

women. An echocardiograph was conducted in most patients,

while coronary angiography was done in only 61% of patients,

with no significant gender difference. Radial access for coronary

angiography was twice as frequent in men (12%) compared to

women (6%). This paradoxically lower tendency to utilise radial

access in women despite their recognised higher propensity

to bleeding complications following femoral catheterisation,

reflects a universal trend.

The trend is likely explained by fear

of technical difficulties related to the smaller radial artery calibre

in women and its liability to undergo spasm. However, the rate of

radial catheterisation in the present study remains low compared

to other settings.

In a study of 19 countries in the ACCOAST trial, a radial

approach was used in 43% of cases of coronary angiography.

This study demonstrated marked regional variations, with some

countries, notably France and Hungary, using a radial approach

for most cases, and others, particularly in Eastern Europe,

resorting to radial access in under 1% of patients.

Over 90% of ACS patients received antiplatelet therapy

and statins upon hospitalisation, and more than 80% received

ACEIs. Among all ACS patients, PCI was attempted in a

larger proportion (54% of men and 43% of women) compared

to rates reported for the Gulf countries in 2013 (16 and 11%,

respectively).

The rates of PCI in Egypt are also higher than

those in the GRACE (

7 609; 33 and 25%) and CANRACE

registries (

1 336; 41 and 31%).

The apparently higher rates and lower gender disparity

in Egypt are possibly explained by a nine-year difference

between the reports (2007–8 for GRACE and CANRACE,

vs 2016–7 for the present study). Another factor is the higher

proportion of STEMI in the present study compared to GRACE

and CANRACE.

In all ACS patients in the present study,

thrombolytic therapy was administered to 22% of men and 17%

of women. A greater gender disparity and an overall lower rate

of usage was reported in the Gulf RACE study (20% in men vs

7% in women).

Clinical trials have established that once STEMI is diagnosed,

men and women derive an equally greater benefit from immediate

revascularisation via PCI relative to thrombolysis.

32,33

However, in

many regions of the world, women continue to be treated less

aggressively than men.

The present study shows a similar trend,

although the difference did not reach statistical significance.

Primary PCI was attempted in 51% of men and 46% of women

diagnosed with STEMI. However, the rate of thrombolytic

therapy in STEMI patients was similar in men and women.

Our data shows that 8% of men and 11% of women with

STEMI received neither PCI nor thrombolytic therapy. We

speculate that this may be related to delays in presentation and/

or diagnosis beyond the guideline-recommended time window

for revascularisation, although time elapsing from symptom

onset to hospital admission was not recorded.

Financial obstacles are another possible contributor. Egypt

government health expenditure per capita is about one-third

lower than the average for the MENA region,

with the majority

of the population resorting to out-of-pocket health expenditure.

A small proportion of patients were scheduled for CABG (5%),

a rate comparable, however, to that recorded for Arabian Gulf

countries.

Conclusion

This is the first collective report on phases I and II of the

CardioRisk project, investigating the risk factors and treatment

strategies in ACS patients across Egypt. Central obesity emerged

as a near-universal risk factor, together with hypertension and

diabetes, in addition to smoking in younger men. There was

widespread use of antiplatelet drugs, statins and ACEIs, as

well as frequent use of coronary angiography and thrombolytic

therapy, with no gender difference within STEMI cases. Primary

PCI was performed in a relatively high proportion of STEMI

patients, with a modest gender disparity (51% in men and 46%

in women). This study may help provide a basis for age- and

gender-specific national preventative guidelines and strategies to

increase adherence to global management protocols.

We acknowledge the support of the Egyptian Association of Vascular Biology

and Atherosclerosis (EAVA). The study was funded by a grant from AstraZenica

Egypt. The sponsors of the study had no role in data collection, analysis, inter-

pretation, writing of the report or the decision to submit it for publication.

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