Cardiovascular Journal of Africa: Vol 31 No 4 (July/August 2020)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 4, July/August 2020 AFRICA 203
There are important differences in PCI reperfusion rates
across countries in sub-Saharan Africa. The ACCESS South
Africa registry reported 59.7% of PCI in STEMI patients. In
Côte d’Ivoire, PCI was performed in 34.9% of STEMI patients
(272/780), with primary PCI in 21.3% of cases (166/780). In Kenya,
the primary PCI rate was 13%.13 These low rates of primary PCI
differ widely from wealthy countries, where 52.7–71% of patients
underwent primary PCI.3,4 However, caution must be applied
when comparing these reperfusion rates, taking into consideration
differences between health coverage rates, and in-hospital technical
support level and interventional cardiology team.
One of the main challenges remains to shorten delays from
onset of symptoms to first ECG and to admission in heart
centres.14 In this study, median delay from onset of symptoms to
admission overall in STEMI patients was 20 hours. In Senegal,
this time was 53.2 hours.15 A study in Burkina-Faso reported 4.35
days between the onset of pain and admission to a cardiology
department.16 Minimising admission delays should be a public
health priority because there is a direct relationship between
delay of care and mortality rate.17 There is limited access to
trained emergency medical services (EMS), so transportation to
hospital is mostly unsafe: 65.9% in Abidjan,4 91.1% in Senegal15
and 81.2% in Togo.18 Therefore, these short-comings result in
relatively high mortality rates in STEMI patients, ranging from
11 to 21%.5-7
Overall mean age of presentation in STEMI patients in
our practice was reported in a previous study (56 years).5 This
younger age is in accordance with findings in most sub-Saharan
African countries. The main risk factor was hypertension,
as commonly reported,19 but we observed increased rate of
active smoking, dyslipidaemia and diabetes compared to recent
results,5 consistent with epidemiological transition and lifestyle
behavioural changes in sub-Saharan Africa.
Most patients underwent primary PCI with stent
implantation. Current Western guidelines recommend the use of
new-generation DES.1,2 In sub-Saharan Africa, where resources
for healthcare are limited and the majority of patients do
not have health coverage, DES use is minimised. The most
commonly used stents in our study were BMS (57.9%). Even in
some countries where financial resources are more important,
such as South Africa, in a previous study, the use of DES in
STEMI accounted for 57.8% of PCI.7
In the management of STEMI, the radial approach should
be preferred when there are experienced radial operators.1 In
our practice, femoral access was the most used from 2010, but
radial access is now the first choice. There is robust evidence in
favour of the radial approach in ACS patients. Radial access
was associated with lower risks of complications (vascular
complications and access site bleeding) and lower mortality
rates.20,21 The widespread use of the femoral route explains the
occurrence of haematomas at the access site (3.6%), which
accounted for the majority of non-fatal complications observed,
more so than in our practice where there are no vascular closure
devices.
To improve the management of STEMI in sub-Saharan
Africa, and considering all these short-comings, a consensus
statement from the AFRICARDIO-2 conference has been
proposed.14 Selected and achievable targets have been suggested,
including: awareness of both patients and first-line practitioners,
establishment of networks with cardiology referral centres,
and training of EMS in STEMI diagnosis and pre-hospital
fibrinolytic treatment.14 These actions may yield a reduced
mortality rate in STEMI, but PCI remains essential and should
be widely implemented in our countries.
Conclusion
Despite recent achievements in the management of STEMI,
the Abidjan Heart Institute is currently a small-volume centre.
Nevertheless, PCI can be performed safely with good outcomes.
Healthcare policies and financial support must be encouraged
to make PCI affordable. Improvement in the management of
STEMI patients also requires implementation of ACS registries
in African countries and tailored guidelines adapted to our
specific circumstances. The establishment of networks, and
south–south and north–south co-operation should help us
improve the management of STEMI.
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