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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 4, July/August 2020
AFRICA
167
Coronary reperfusion in STEMI patients in sub-Saharan
Africa
Tom Mabin
A paradigm shift in the management of patients with acute
myocardial infarction occurred in the 1970s when it was
appreciated that opening the culprit thrombotic coronary
occlusion could bring significant benefit to patient outcomes,
both in terms of myocardial salvage and mortality. Reperfusion
can now be achieved with varying degrees of success using
streptokinase (50%), target lytics (70%) or primary percutaneous
coronary intervention (PPCI) and stent implantation (> 90%). It
was also quickly appreciated that the sooner reperfusion could
be established, the better the outcome for the patient.
Studies showed that there is an incremental time-related
myocardial salvage opportunity up to about 12 hours after
presentation of a ST-elevation myocardial infarction (STEMI)
patient, with the best outcomes if reperfusion can be achieved
within the first two hours of presentation. In fact, within this
very early time window, thrombolysis may achieve reperfusion
rates equal to PPCI of > 90%. Thereafter the superiority of
PPCI over thrombolysis increases up to about 12 hours, when
the benefits of reperfusion accrued are small unless there are
signs of ongoing ischaemia.
1
‘Time is muscle’ became the mantra
and a plethora of facilities with catheterisation laboratories (cath
labs) were established worldwide to offer greater opportunities
for STEMI management as well as for all chronic cardiovascular
conditions.
The Abidjan Institute in Cote D’Ivoire was established as such
a facility nearly 50 years ago and is one of the largest of a few,
but growing number in sub-Saharan Africa. In this edition of
the Journal, Yao and colleagues (page 201) present observational
data on their PPCI experience in STEMI patients admitted to
their centre over a 10-year period up to March 2019. There are
some telling statistics worthy of comment and discussion.
2
Of the 780 patients admitted with STEMI, only 208 (27%)
received reperfusion therapy within the crucial 12-hour window;
102 had thrombolysis and 106 had PPCI. Another 38 patients
underwent PPCI within 48 hours because of ongoing ischaemia.
This means the opportunity for STEMI patients to benefit from
the sophisticated cath lab facilities occurred in only 166 patients
(21%). These are disappointing statistics and can hardly be
considered optimal for an expensive facility capable of providing
a PPCI programme for STEMI patients within the community
of Cote D’Ivoire. It would be of interest to have a further
breakdown of the time frames of presentation and see how many
of the PPCI patients presented within the very earlier hours of
symptoms, where most of the benefits of reperfusion would be
expected to accrue.
There is no lack of expertise in the hospital itself, and the
procedural success and complication rates reported are good,
although the relatively late presentations may reflect a cohort
of patients who had survived the most dangerous early stages
of their STEMI. The radial approach has been more recently
adopted, and antiplatelet regimes where appropriate. The
reader would be interested in more details of the interventions
themselves: the completeness of revascularisation achieved
during initial presentation, how many were brought back
for complete revascularisation before discharge, and whether
their usage of drug-eluting stents versus bare-metal stents is
increasing. It would be valuable for assessment of their STEMI
programme going forward to have a more regimented approach
to left ventricular assessments pre- and post reperfusion and
one would like to know details of the policy towards late
revascularisation post myocardial infarction.
It is also of particular interest to note that more than 90% of
patients were male. The authors make no comment on this. Is it
a true reflection of the distribution of STEMI in the population
or is it possibly reflecting the socio-economic circumstances that
women find themselves in within the same community.
The authors themselves acknowledge that optimal benefits
of a sophisticated facility like this for STEMI patients will only
accrue if patients are referred earlier and more promptly to the
facility, or receive thrombolysis in outlying clinics and are then
referred for PCI, the so-called ‘facilitated’ PCI.
The problem of delayed referrals of STEMI patients is
worldwide, but is profound in sub-Saharan Africa, as indicated
in the discussion section. It was addressed at the AFRICARDIO
2015 consensus meeting, although the outcome of this is not
mentioned.
3
The same challenge was addressed some years ago in
Europe with the establishment of the Stent-for-Life programme
under the auspices of the European Society of Cardiology
(ESC).
The Stent-for-Life initiative supports implementation of local
STEMI treatment guidelines, helps identify specific barriers to
implementation of guidelines and defines actions to make sure
that the majority of STEMI patients have access to the lifesaving
indication of PPCI. This has proven to be a great success in
most participating countries, where the time to reperfusion has
been significantly reduced by both thrombolysis and PPCI. The
Stent-for-Life programme has established relationships with
organisations in many sub-Saharan countries to apply similar
principles to STEMI management.
Franschoek, South Africa
Tom Mabin, MB ChB (Birm), FRCP, FACC, FESC,
tmabin@mweb.co.zaEditorial