Cardiovascular Journal of Africa: Vol 30 No 1 (January/February 2019)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 1, January/February 2019 AFRICA 29
Outcomes in patients with acute coronary syndrome in a
referral hospital in sub-Saharan Africa
Mohamed Hasham Varwani, Mohamed Jeilan, Mzee Ngunga, Anders Barasa
Abstract
Background: Coronary artery disease and its acute presenta-
tion are being increasingly recognised and treated in sub-
Saharan Africa. It is just over a decade since the introduction
of interventional cardiology for coronary artery disease in
Kenya. Local and regional data, and indeed data from sub-
Saharan Africa on long-term outcomes of acute coronary
syndromes (ACS) are lacking.
Methods: A retrospective review of all ACS admissions to the
Aga Khan University Hospital, Nairobi (AKUHN) between
January 2012 and December 2013 was carried out to obtain
data on patient characteristics, treatment and in-patient
outcomes. Patient interviews and a review of clinic records
were conducted to determine long-term mortality rates and
major adverse cardiovascular events.
Results: A total of 230 patients were included in the analysis;
101 had a diagnosis of ST-segment myocardial infarction
(STEMI), 93 suffered a non-ST-segment myocardial infarc-
tion (NSTEMI), and 36 had unstable angina (UA). The mean
age was 60.5 years with 81.7% being male. Delayed presenta-
tion (more than six hours after symptom onset) was common,
accounting for 66.1% of patients. Coronary angiography was
performed in 85.2% of the patients. In-hospital mortality rate
was 7.8% [14.9% for STEMI and 2.3% for non-ST-segment
ACS (NSTE-ACS, consisting of NSTEMI and UA)], and the
mortality rates at 30 days and one year were 7.8 and 13.9%,
respectively. Heart failure occurred in 40.4% of STEMI and
16.3% of NSTE-ACS patients. Re-admission rate due to
recurrent myocardial infarction, stroke or bleeding at one
year was 6.6%.
Conclusion: In our series, the in-hospital, 30-day and one-year
mortality rates following ACS remain high, particularly for
STEMI patients. Delayed presentation to hospital following
symptom onset is a major concern.
Keywords: acute coronary syndromes, myocardial infarction,
outcomes, Kenya, sub-Saharan Africa
Submitted 26/9/17, accepted 31/10/18
Published online 4/12/18
Cardiovasc J Afr 2019; 30: 29–33
DOI: 10.5830/CVJA-2018-066
The burden of cardiovascular diseases (CVD) in sub-Saharan
Africa (SSA) is rapidly increasing, with a rising prevalence of
cardiovascular risk factors.1-3 In SSA, CVD occurs in younger
patients who are often in the working age group, thereby having
a significant economic bearing.4
Coronary artery disease (CAD), once thought to be rare among
native Africans, is increasingly being diagnosed.5,6 In a recent
prospective survey carried out at an urban hospital in Kenya, acute
coronary syndromes (ACS) contributed to 5.1% of all admissions
to the critical care units.7 An autopsy study by Ogeng’go et al.
reported that cardiovascular deaths comprised 13.2% of all
autopsies performed during the study period. 8 Among these, the
leading aetiology was myocardial infarction (18.7%). The findings
of these more recent studies contrast with reports from the 1960s
that suggested a very low prevalence of CAD.9
It is nearly a decade since the introduction of coronary
interventions and coronary surgery in Kenya. The supporting
infrastructure for emergency response and intervention, however,
lags behind. Most cardiovascular specialists and catheterisation
laboratories (cathlabs) in the country are disproportionately
located in Nairobi, the capital city.
Following an ACS, a patient remains at elevated risk of
death and major adverse events such as heart failure, recurrent
myocardial infarction, stroke and bleeding, compared to the
general population. 10 Over the last three decades, both short-
term (in-hospital and 30-day) and long-term survival following
myocardial infarction has been improving worldwide.11 This
is thought to be due to improved response infrastructure,
availability of better drugs and interventions for the acute phase,
and use of secondary preventative therapies such as statins and
beta-blockers.
Little is known about the outcomes of patients following an
ACS in SSA. 5 Apart from a report based on South African data
from the ACCESS registry, no published studies were found that
looked at out-of-hospital outcomes following ACS in SSA.12 A
few local reports have described the management and in-hospital
outcomes in patients with ACS.7,13,14 Long-term outcomes in the
country and region however remain unknown.
The Aga Khan University Hospital, Nairobi, is a private
teaching hospital, serving as a referral centre for patients within
Kenya and the broader region of East and Central Africa. A
heterogenous cohort of patients is therefore served at the facility.
The cathlab operates during the daytime, but is available for
emergencies after that, with an on-call interventional cardiologist
and cathlab team.
Department of Medicine, the Aga Khan University Hospital,
Nairobi, Kenya
Mohamed Hasham Varwani, MB ChB, MMed,
Mohamed Jeilan, MD, MRCP
Mzee Ngunga, MB ChB, MMed
Anders Barasa, MD, PhD
Department of Clinical and Molecular Medicine, University
of Gothenburg, Gothenburg, Sweden
Anders Barasa, MD, PhD