CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 7, August 2012
AFRICA
365
Cardiovascular Topics
Management of acute coronary syndrome in South
Africa: insights from the ACCESS (Acute Coronary
Events – a Multinational Survey of Current Management
Strategies) registry
COLIN SCHAMROTH, ACCESS South Africa investigators
Abstract
Background:
The burden of cardiovascular diseases is
predicted to escalate in developing countries. While many
studies have reported the descriptive epidemiology, practice
patterns and outcomes of patients hospitalised with acute
coronary syndromes (ACS), these have largely been confined
to the developed nations.
Methods:
In this prospective, observational registry, 12 068
adults hospitalised with a diagnosis of ACS were enrolled
between January 2007 and January 2008 at 134 sites in 19
countries in Africa, Latin America and the Middle East.
Data on patient characteristics, treatment and outcomes
were collected.
Results:
Of the 642 patients from South Africa in the regis-
try, 615 had a confirmed ACS diagnosis and form the basis
of this report; 41% had a discharge diagnosis of ST-segment
elevation myocardial infarction (STEMI) and 59% a diag-
nosis of non-ST-segment elevation acute coronary syndrome
(NSTE-ACS), including 32% with non-ST-segment elevation
myocardial infarction (NSTEMI) and 27% with unstable
angina (UA).
During hospitalisation, most patients received aspi-
rin (94%) and a lipid-lowering medication (91%); 69%
received a beta-blocker, and 66% an ACE inhibitor/angio-
tensin receptor blocker. Thrombolytic therapy was used in
only 18% of subjects (36% of STEMI patients and 5.5%
of NSTE-ACS patients). Angiography was undertaken in
93% of patients (61.3% on the first day), of whom 53%
had a percutaneous coronary intervention (PCI) and 14%
were referred for coronary artery bypass surgery. Drug-
eluting stents were used in 57.9% of cases. Clopidogrel was
prescribed at discharge from hospital in 62.2% of patients.
All-cause death at 12 months was 5.7%, and was higher
in patients with STEMI versus non-ST-elevation ACS (6.7
vs 5.0%,
p
<
0.0001). Clinical factors associated with higher
risk of death at 12 months included age
≥
70 years, presence
of diabetes mellitus on admission, and a history of stroke/
transient ischaemic attack (TIA).
Conclusions:
In this observational study of ACS patients, the
use of evidence-based pharmacological therapies for ACS
was quite high. Interventional rates were high compared
to international standards, and in particular the use of
drug-eluting stents, yet the clinical outcomes (mortality,
re-admission rates and severe bleeding episodes at one year)
were favourable, with low rates compared with other studies.
Keywords:
acute coronary syndrome, myocardial infarction,
unstable angina, registry, death
Submitted 20/1/12, accepted 1/3/12
Published online 13/3/12
Cardiovasc J Afr
2012;
23
: 365–370
DOI: 10.5830/CVJA-2012-017
Knowledge on the prevention and treatment of cardiovascular
diseases derives from randomised, controlled clinical trials
and observational studies. Registries of treatment patterns
of particular disease processes have shaped and influenced
treatment practices. These observational studies have also helped
map out differences in the populations studied, whether this be
geographical or ethnic.
Current data derive almost exclusively from the developed
world populations, and whether these data are applicable to
population groups outside of the developed world is unknown.
1-6
Knowledge on treatment trends and practices from the developing
world is scanty or entirely absent. While studies such as the
INTERHEART have demonstrated that the risk factors for the
development of acute myocardial infarction are similar across
population groups, the patterns of treatment of ischaemic heart
disease among different population groups in underdeveloped
nations remains unknown.
7
Cardiovascular disease mortality and associated major risk
factors (elevated blood pressure, raised cholesterol levels,
cigarette smoking, diabetes mellitus, physical inactivity and
high-fat diet) vary widely from country to country, but it is
predicted that within the next decade, the major burden of
cardiovascular diseases will shift to the developing countries.
8
There is therefore a need to establish registries in developing
countries to increase awareness of the cardiovascular disease
burden and establish appropriate preventive and management
strategies. To date there are no published registries on the
Milpark Hospital, Johannesburg, South Africa
COLIN SCHAMROTH, MB BCh (Wits), FCP (SA), MMed (Wits),
