The incidence and outcomes of high-risk acute coronary syndromes in Western Cape Province, South Africa: A prospective cohort study
DOI:
https://doi.org/10.7196/SAMJ.2023.v113i5.16764Keywords:
high-risk acute coronary syndromesAbstract
Background. Tygerberg Hospital (TBH) is a tertiary-level hospital in Western Cape Province, South Africa, that provides healthcare to a large low- to middle-income population with services including centralised advanced cardiac care. Acute coronary syndrome (ACS) remains an important cause of death in the region despite a high burden of communicable diseases, including HIV.
Objectives. To describe the incidence of ST-elevation myocardial infarction (STEMI) and high-risk non-ST-elevation ACS (HR-NSTEACS) in the TBH referral network, describe the in-hospital and 30-day mortality of these patients, and identify important high-risk population characteristics.
Methods. The Tygerberg Acute Coronary Syndrome Registry database is an ongoing prospective study that enrols all STEMI and HR-NSTEACS patients in the TBH referral network. All patients aged >18 years presenting with STEMI or HR-NSTEACS were treated in accordance with current European Society of Cardiology guidelines and were included prospectively over a 9-month surveillance period. A waiver of consent was granted to include patients who died before giving informed consent. Data collected included a demographic profile, risk factors for cardiovascular disease, in-hospital therapy and 30-day mortality.
Results. A total of 586 patients were enrolled, with a male predominance (64.5%) and incidence rates of STEMI and HR-NSTEACS of 14.7 per 100 000 and 15.6 per 100 000, respectively. The mean patient age was 58 years, and STEMI patients tended to be younger than HR-NSTEACS patients (56 v. 58 years; p=0.01). Cardiovascular risk factors were prevalent overall, but hypertension (79.8% v. 68.3%; p<0.01) and pre-existing IHD (29.1% v. 7.0%; p=0.03) were more prevalent in the HR-NSTEACS group. HIV was present in 12.6% of patients tested, similar to the background population rate. The overall 30-day all-cause mortality rate was 6.1%, with an in-hospital mortality rate of 3.9%. The 30-day mortality rates were similar for STEMI (1.8%) and HR-NSTEACS (2.6%) (p=0.75). HIV did not affect mortality rates.
Conclusion. Use of a guideline-based approach to treating ACS in a low- to middle-income country setting yields mortality rates comparable to those in high-income countries. However, the lower-than-expected incidence rates of both STEMI and HR-NSTEACS in a relatively young population with a high prevalence of traditional cardiovascular risk factors, and a relatively high proportion of STEMI, suggest potential under-recording of ischaemic heart disease in the region. The rate and outcomes of coronary artery disease (CAD) in people living with HIV were similar to those in people without HIV, suggesting that traditional risk factors still drive CAD outcomes in the region.
References
Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2018;39(2):119-177. https://doi.org/10.1093/eurheartj/ehx393
Statistics South Africa. Mortality and causes of death in South Africa, 2016: Findings from death notification. Statistical release P0309.3. Pretoria: Stats SA, 2018. https://www.statssa.gov.za/ publications/P03093/P030932016.pdf (accessed 22 September 2022).
Sheik S, Evans J, Morden R, Coetzee D. Non-communicable diseases in the Western Cape: Burden of disease update. Epidemiology and Surveillance sub-directorate, Health Impact Assessment Unit, Western Cape Government: Health, 2016. https://www.westerncape.gov.za/assets/departments/ health/burden_of_disease_update_ncds.pdf (accessed 21 October 2022).
World Bank. South Africa: Social assistance programs and systems review. 2021. https://documents1. worldbank.org/curated/en/238611633430611402/pdf/South-Africa-Social-Assistance-Programs-and- Systems-Review.pdf (accessed 20 October 2022).
Hasdai D, Behar S, Wallentin L, et al. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin: The Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J 2002;23(15):1190- 1201. https://doi.org/10.1053/euhj.2002.3193
Steg PG, Goldberg RJ, Gore JM, et al. Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). Am J Cardiol 2002;90(4):358-363. https://doi.org/10.1016/s0002- 9149(02)02489-x
Roffi M, Patrono C, Collet J-P, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37(3):267-315. https://doi. org/10.1093/eurheartj/ehv320
Beyers BD, Doubell AF, Griffiths B, Jalavu T. ST-segment elevation myocardial infarction: Evaluating the time interval from diagnosis to fibrinolysis at centres in the drainage area of Tygerberg Hospital, Cape Town, South Africa. S Afr Med J 2020;110(4):327-331. https://doi.org/10.7196/SAMJ.2020. v110i4.14330
Stassen W, Kurland L, Wallis L, Castren M, Vincent-Lambert C. Barriers and facilitators to implementing coronary care networks in South Africa: A qualitative study. Afr Health Sci 2020;20(1):338-350. https://doi.org/10.4314/ahs.v20i1.39
Western Cape Government: Health. Burden of disease. https://www.westerncape.gov.za/assets/ departments/health/bod_a5_booklet_0.pdf (accessed 23 March 2023).
Pennefather C, Esterhuizen T, Doubell A, Decloedt EH. The 12-month period prevalence and cardiac manifestations of HIV in patients with acute coronary syndrome at a tertiary hospital in Cape Town, South Africa: A retrospective cross-sectional study. BMC Infect Dis 2021;21(1):657. https://doi. org/10.1186/s12879-021-06367-2
Hertz JT, Reardon JM, Rodrigues CG, et al. Acute myocardial infarction in sub-Saharan Africa: The need for data. PLoS ONE 2014;9(5):e96688. https://doi.org/10.1371/journal.pone.0096688
Van Deventer JD, Doubell AF, Herbst PG, et al. Evaluation of the SUNHEART Cardiology Outreach Programme. SA Heart 2015;12(2):82-86. https://doi.org/10.24170/12-2-1723
Western Cape Government. Socio-economic profile (SEP): City of Cape Town, 2017. https://www. westerncape.gov.za/assets/departments/treasury/Documents/Socio-economic-profiles/2017/city_of_cape_ town_2017_socio-economic_profile_sep-lg_-_26_january_2018.pdf (accessed 23 November 2023).
Armstrong PW, Gershlick AH, Goldstein P, et al.; STREAM Investigative Team. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;15:1379-1387. https:// doi.org/10.1056/NEJMoa1301092
Antman EM, Cohen M, Bernink PJLM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284(7):835-842. https://doi.org/10.1001/jama.284.7.835
Van Leeuwen MAH, Daemen J, van Mieghem NM, et al. Comparison of long-term outcomes in STEMI and NSTE-ACS after coronary stent placement: An analysis in a real world BMS and DES population. Int J Cardiol 2013;167(5):2082-2087. https://doi.org/10.1016/j.ijcard.2012.05.064
Gurm HS, Eagle KA. Channelling regional registries for optimisation of cardiac care: Lessons from around the world. Eur Heart J 2013;34(2):83-85. https://doi.org/10.1093/eurheartj/ehs328
Schamroth C; ACCESS South Africa Investigators. Management of acute coronary syndrome in South Africa: Insights from the ACCESS (Acute Coronary Events – a Multinational Survey of Current Management Strategies) registry. Cardiovasc J Afr 2012;23(7):365-370. https://doi.org/10.5830/CVJA- 2012-017
Desta DM, Nedi T, Hailu A, et al. Treatment outcome of acute coronary syndrome patients admitted to Ayder Comprehensive Specialised Hospital, Mekelle, Ethiopia; A retrospective cross-sectional study. PLoS ONE 2020;15(2):e0228953. https://doi.org/10.1371/journal.pone.0228953
Fanta K, Daba FB, Asefa ET, et al. Management and 30-day mortality of acute coronary syndrome in a resource-limited setting: Insight from Ethiopia. A prospective cohort study. Front Cardiovasc Med 2021;8:707700. https://doi.org/10.3389/fcvm.2021.707700
Pecoraro AJK. Delivering cardiac care: The next frontier. SA Heart 2016;13(3):148-149. https://doi. org/10.24170/13-3-1595
Onen CL. Epidemiology of ischaemic heart disease in sub-Saharan Africa. Cardiovasc J Afr 2013;24(2):34-42. https://doi.org/10.5830/CVJA-2012-071
Alexander T, Mullasari AS, Kaifoszova Z, et al. Framework for a National STEMI Program: Consensus document developed by STEMI India, Cardiological Society of India and Association Physicians of India. Indian Heart J 2015;67(5):497-502. https://doi.org/10.1016/j.ihj.2015.05.017
Maharaj RC, Geduld H, Wallis LA. Door-to-needle time for administration of fibrinolytics in acute myocardial infarction in Cape Town. S Afr Med J 2012;102(4):241-244.
Joubert LH, Herbst PG, Doubell AF, Pecoraro AJK. Clinical v. laboratory-based screening for COVID-19 in asymptomatic patients requiring acute cardiac care. S Afr Med J 2020;110(11):1064. https://doi.org/10.7196/SAMJ.2020.v110i11.15306
Pecoraro AJK, Herbst PG, Joubert LH. Dwindling myocardial infarctions. Eur Heart J 2020;41(37):3497-3499. https://doi.org/10.1093/eurheartj/ehaa282
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