CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 7, August 2012
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to assume that patients receiving a stent were discharged on a
thienopyridine.
This therefore leaves the suggestion that patients being
referred for surgery or undergoing angiography without a PCI
are not receiving a thienopyridine at discharge despite the
diagnosis of an acute coronary syndrome. This is particularly
worrying for those patients without STEMI, in whom there are
clear guidelines for the prescription of a thienopyridine.
10
ACS registry populations
In terms of ACS types, patients enrolled in the ACCESS South
Africa study were broadly similar to those in other observational
studies conducted in Western populations. Just over half (56%)
of the patients were diagnosed with NSTE-ACS and 39% with
STEMI. In the second Euro-Heart Survey of Acute Coronary
Syndromes (EHS-ACS-II) conducted in 2004, which included
6 385 patients from 32 European countries, the ACS population
comprised almost equal proportions with NSTE-ACS and
STEMI (48 and 47%, respectively) patients.
11
In the GRACE
study, which enrolled patients in 14 countries in Europe, North
and South America, and Australia and New Zealand between
1999 and 2007,
12-14
the proportion of patients with STEMI ranged
from 30–40%, and 60–70% were diagnosed with NSTE-ACS.
Patients enrolled in ACCESS South Africa were younger
than those enrolled in other Western observational studies (58 vs
63–66 years),
11,15
and there were more men (75 vs 64–72%).
11,15,16
Current smoking (43.9%) and diabetes were also common
(23.9%). The actual prevalence of diabetes may have been even
higher, as the diagnosis was based on a prior history and did not
include admission hyperglycaemia and the subsequent diagnosis
of diabetes.
When compared with the CREATE registry conducted
exclusively in India and involving over 20 000 patients with an
ACS, ACCESS South Africa had a higher percentage of patients
aged 70 years and older (17.7 vs 13%), an equivalent percentage
of male patients (75 vs 76%), and a much lower percentage with
STEMI (39.4 vs 61%).
17
Limitations
The ACCESS South Africa study was an observational study
and had all the limitations that such a study inherently has.
The enrolling centres were all located in urban areas and were
largely those that provided tertiary care (i.e. they had facilities
for angiography and interventional therapy). Almost all enrolling
centres were from the private healthcare sector. Patients were
therefore mostly those that had access to private healthcare
funding. These factors may all have influenced the population
of patients studied.
Patients enrolled had to be alive upon admission and provide
consent. This therefore excluded ACS patients who died prior
to hospitalisation or within a short time of arrival. It therefore
represents more the demographics of survivors of the acute
phase of ACS. As in all observational studies, the data were
non-randomised and treatment protocols were non-standardised.
Although the study called for recruitment of consecutive
patients, it cannot be verified to what extend this aspect was
complied with, and hence patient selection bias may also have
been present. The number of patients lost to follow up (5.2%) is
always of concern. However this was less than that of the overall
ACCESS registry data (8.4%) and is probably acceptable for a
registry, as opposed to a trial.
The data for the registry were compiled between January
2007 and January 2008. Subsequent to this, guidelines have
changed and with this, changes in treatment protocols and
prescription habits may also have occurred. Therefore some data
may be out dated, but are nevertheless still relevant.
Conclusions
In this study of ACS patients in South Africa, management
tended to be aggressive, with high percentages of patients
receiving angiography and an invasive treatment strategy. Drug
usage was comparable to that in other countries and registries.
Although this invasive approach may seem to be potentially
costly, the 12-month death rate compared very favourably with
other observational reports, and re-admission rates for bleeding
and recurrent ischaemic events were low, suggesting that the cost
may be justified and even economical in the long term.
The use of evidence-based medications and interventions is in
line with practices in the developed world. There is however still
room for improvement. The drop-off in drug usage over time is
of concern, particularly the finding that only 77% of patients
were still on a statin at one year. Also the discharge prescription
of thienopyridines was relatively low, particularly given the
nature of the population studied. Increased efforts need to be
directed at proven secondary prevention treatment strategies.
This study was by no means complete or exhaustive, but
serves as a template for practitioners and healthcare funders to
take cognisance of the findings, make amendments to existing
treatment protocols, and endeavour to improve drug utilisation
and ultimately patient outcomes.
The ACCESS registry was sponsored by Sanofi-aventis, Paris, France.
ACCESS steering committee members: Gilles Montalescot (principal inves-
tigator) (France), Norka Antepara (Venezuela), Alvaro Escobar (Colombia),
Samir Alam (Lebanon), Alain Leizorovicz (France), Carlos Martinez
(Mexico), Jose Nicolau (Brazil), and Mohamed Sobhy (Egypt).
ACCESS South Africa investigators: Colin Schamroth (national coordina-
tor), Clive Corbett, Matthew Krausey, Goran Ignjatovic, David Kettles,
Hennie Theron, Cobus Steyn, Braam Barnard, Iftikhar Ebrahim, Roland
Zeelie, Victor Singh, Pule Mutati, Agostinho da Silva, Tjaart Venter, Ilse
Kapp, Pieter Blomerus, Graham Cassel, Anthony Dalby, Juan Deseta, Nalin
Patel, Nico van der Merwe, Fazul Tayob, Pule Mutati, Agostinho da Silva,
Guy Letcher, Shirley Middlemost, Mohammed Essop, Theema Nunkoon, A
Pappachan, Anthony Becker, Yasmin Bera, Christos Zambakides, Leonard
Steingo, John Benjamin, Patrick Commerford, Jeffrey King, Sajidah Khan,
Adriaan Snyders, Mohamed Khan.
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