CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 142 AFRICA Discussion We aimed to define the demographic and clinical profile of patients presenting with ACS to primary- and secondary-level facilities within the public healthcare sector of the Western Cape. We evaluated contextual factors that impacted on time to FMC and the subsequent effects thereof on in- and out-patient management. We found a high prevalence of risk factors traditionally associated with the development of coronary artery disease, and considerable rates of non-adherence to chronic medication. This study also highlights significant delays in time to FMC. Furthermore, our results demonstrate high rates of missed STEMI diagnoses on the ECG. Both factors contributed to lower rates of thrombolysis at both the index secondary-care facility, as well as the primary referral facilities. Although the in-patient mortality rate was low, a significant number of patients were re-admitted with recurrent episodes of ACS within one year of discharge. When comparing the spectrum of ACS presentations within this cohort to those of other local6 and international registries,25-28 we identified a higher proportion of patients diagnosed with STEMI than those with NSTEMI. This was not anticipated nor in keeping with the contemporary literature. This could be the result of poor control of cardiovascular risk factors, as demonstrated by high non-adherence rates in this population. This study shows that the demographic profile of patients with ACS treated in public healthcare facilities in the Western Cape was different to studies performed in the developed world. Patients enrolled in our study were younger than those from the EuroHeart Survey of Acute Coronary Syndromes (EHS-ACS-II) and GRACE registry,26-28 but were of a similar age to those included in the ACCESS registry, which predominantly represented patients treated in the South African private sector.6 In keeping with the findings of local and international registries, our study demonstrated a male preponderance in the STEMI group.6,25-28 Patients with STEMI were found to be younger than those with NSTEMI, which correlates with the findings of the ACCESS registry locally6 and EHS-ACS-II and GRACE internationally.25-28 In our cohort the most common presenting complaint was chest pain, which is in keeping with the findings of a local study performed by Geyser et al., which showed high rates of admission in patients presenting with chest pain secondary to cardiovascular causes.29 There was a high prevalence of co-morbidities associated with coronary artery disease throughout the cohort, without any identifiable differences between the STEMI, NSTEMI and UAP groups, which relates to the findings of local and international registries.6,25-28,30 Despite high rates of previously diagnosed risk factors, a large proportion of patients in this cohort, particularly those with STEMI, reported non-adherence to their chronic medication prior to admission for ACS. In our study, patients with STEMI were more likely to have a smoking history than those with NSTEMI or UAP. This correlates with the findings of Kenelly, who studied young patients with STEMI in Cape Town, and found that 85% had smoked cigarettes within the last year.31 As a matter of great concern, nearly half of all patients were able to access appropriate treatment for their ACS only more than 12 hours after onset of their symptoms. The reasons for these delays in FMC are multi-factorial, and could possibly be attributed to pre-hospital factors (such as poor patient education and overburdened emergency medical services), and hospital factors (such as prolonged triage times, resource limitations and insufficient ECG diagnostic proficiency).4,9,15-19 As expected, those with delayed presentation were unlikely to receive thrombolytic therapy at the non-PCI centres in this study. This is in keeping with the findings of Chetty et al., who observed that late presentation with STEMI was the most common contraindication to thrombolysis.32 The establishment of structured rapid referral networks for STEMI management has been identified as a key factor in improving rates of reperfusion and mitigating mortality in patients with STEMI.12-14 Despite the challenges that are imposed by resource constraints in developing countries, several countries have been successful in implementing such systems to improve outcomes in STEMI.33-35 Implementation of the Latin American Telemedicine Infarct Network was associated with improved rates of reperfusion and reduced mortality rates from STEMI in Brazil.33 Similarly, implementation of the Tamil Nadu-ST-Segment Elevation Myocardial Infarction programme was associated with improvements in one-year survival after STEMI in India.34 InCape Town, ACS is treated according to a hub–spokemodel, where patients present to their nearest primary or secondary healthcare hospitals. In the case of STEMI, thrombolytic therapy can be instituted in these healthcare facilities and patients are referred to tertiary centres for failed thrombolysis or whenever haemodynamically or electrically unstable. As the ECG is central in the diagnosis of STEMI, it is worrying that almost a third of STEMIs were missed by the managing physicians, and as a result, none of these patients received thrombolytic therapy. However, ECG proficiency in this study was better than that reported by Mabuza et al. locally36 and in a recent meta-analysis including 78 international studies.37 This highlights the need for continuous ECG education globally, particularly in the context of ACS. The low in-patient mortality rate in this study (1.7%) is in line with the ACCESS (2.6%) and EHS-ACS-II registries (4.0%).6,28 However, we did identify a concerning rate of recurrence of ACS within the first year of the index diagnosis. This may be explained by poor access to healthcare services for appropriate Table 2. Acute management and discharge medication of patients with ACS Medication and management Total (n = 174) STEMI (n = 48) NSTEMI (n = 43) UAP (n = 83) p-value Discharge medication, n (%) Statin 127 (72.99) 41 (85.4) 34 (79.1) 52 (62.65) 0.011 Aspirin 115 (66.09) 38 (79.2) 33 (76.7) 44 (53.01) 0.002 Clopidogrel 66 (37.93) 35 (72.9) 24 (55.8) 7 (8.43) 0.000 Warfarin 9 (5.17) 4 (8.3) 2 (4.7) 3 (3.61) 0.494 Beta-blocker 103 (59.20) 38 (79.2) 26 (60.5) 39 (46.99) 0.001 Calcium channel blocker 42 (24.14) 7 (14.6) 11 (25.6) 24 (28.92) 0.176 ACEI/ARB 107 (61.49) 34 (70.8) 29 (67.4) 44 (53.01) 0.085 Nitrate 64 (36.78) 20 (41.7) 16 (37.2) 28 (33.73) 0.661 Diuretic 60 (34.48) 15 (31.2) 15 (34.9) 30 36.14) 0.849 Acute management, n (%) Thrombolysis 20 (11.49) 19 (39.58) 0 1 (1.20) 0.000 Local ACS protocol 104 (59.77) 26 (54.17) 34 (79.07) 44 (53.01) 0.012 ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; ACS, acute coronary syndrome.
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