CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 138 AFRICA Profile and management of acute coronary syndromes at primary- and secondary-level healthcare facilities in Cape Town F Uys, AT Beeton, S van der Walt, M Lamprecht, M Verryn, Y Vallie, D Stokes, RS Millar, CA Viljoen Abstract Background: Little is known about the clinical profile and management of patients with acute coronary syndromes (ACS) in the South African public sector. Methods: We conducted a retrospective study of patients presenting with ACS to a secondary-level healthcare facility in Cape Town during a one-year period to study the clinical profile and management of these patients. Results: Among the 214 patients in this cohort, 48 (27.5%) had ST-segment elevation myocardial infarction (STEMI), 43 (24.7%) had non-ST-segment elevation myocardial infarction and 83 (47.7%) unstable angina pectoris. We identified high rates of >12-hour delays in first medical contact after symptom onset (46%) and inaccurate ECG diagnosis of STEMI (29.2%), which were associated with low rates of thrombolysis (39.6%). High rates of non-adherence and ACS recurrence were also observed. Conclusions: To address the local challenges in ACS management highlighted in this study, we propose the development of a regional referral network prioritising access to expedited care and primary reperfusion interventions in ACS. Keywords: acute coronary syndrome, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, unstable angina pectoris Submitted 26/4/21, accepted 26/10/21 Published online 16/11/21 Cardiovasc J Afr 2022; 33: 138–144 www.cvja.co.za DOI: 10.5830/CVJA-2021-054 Cardiovascular disease (CVD) is a global health issue and the leading cause of mortality worldwide.1,2 In sub-Saharan Africa, CVD was historically caused by non-ischaemic pathologies, such as rheumatic heart disease and cardiomyopathy.3 However, due to factors such as the rapid urbanisation of less affluent communities, the spectrum of CVD is changing and increasingly appears to resemble that of industrialised countries. In this regard, developing countries such as South Africa are faced with an increasing incidence of ischaemic heart disease (IHD).3-8 In the Western Cape, IHD has consistently contributed to high rates of cardiovascular mortality since 2000.9 It is predicted that, in sub-Saharan Africa, coronary artery disease will continue to escalate within the next decade,6 and that CVD will ultimately supersede human immunodeficiency virus/acquired immunodeficiency syndrome as the leading cause of morbidity and mortality.5,8,10 Rapid urbanisation is associated with a change in lifestyle, leading to a sharp rise in risk factors associated with cardiac disease in sub-Saharan Africa.11 In South Africa, eight modifiable risk factors contribute to 90% of the population’s attributable risk of myocardial infarction.5 These risk factors include hypertension, diabetes mellitus, tobacco use, high lipoprotein ApoB/ApoA ratio, abdominal obesity, unhealthy diet, increased psychosocial stress and physical inactivity. Of these, obesity was found to be the most prevalent risk factor, affecting one-third of men and half of women in South Africa.3 A significant proportion of individuals with obesity (particularly women) also had concomitant risk factors associated with the metabolic syndrome, including hypertension, diabetes and elevated serum cholesterol levels.3,8,10 Where primary prevention fails, morbidity and mortality of patients with acute coronary syndromes (ACS) can be reduced through early implementation of guideline-directed therapy, including medical and invasive revascularisation strategies.9,12-14 However, in the larger South African context, multiple challenges exist that hinder the enforcement of these guidelines. These include, among others, a lack of patient awareness and insufficient resource allocation to healthcare, with resultant delays in initiation of treatment.4,9,15-19 Meel et al. reported that only 16% of patients in South Africa made use of ambulance services. Furthermore, the prolonged time between symptom onset and the first call for medical assistance inevitably resulted in delayed first medical contact (FMC). This is a major concern, as 32.6 million (63%) of the total population live within 120 minutes of centres equipped Department of Medicine, New Somerset Hospital, Cape Town, South Africa F Uys, MB ChB, Dip PEC (SA), fuys24@gmail.com M Lamprecht, MB ChB Y Vallie, MB ChB, FCP (SA) Division of Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa RS Millar MB ChB, FCP (SA) CA Viljoen, MB ChB, MMed, FCP (SA) Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa AT Beeton, MB ChB S van der Walt, MB ChB M Verryn, BMedSc (Hons) RS Millar, MB ChB, FCP (SA) CA Viljoen, MB ChB, MMed, FCP (SA) Cape Heart Institute, University of Cape Town, Cape Town, South Africa CA Viljoen, MB ChB, MMed, FCP (SA) New Somerset Hospital, Cape Town, South Africa D Stokes, MB ChB
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