Summary
Background
Whereas the coronary artery disease death rate has declined in high-income countries, the incidence of acute coronary syndromes (ACS) is increasing in sub-Saharan Africa, where their management remains a challenge.
Aim
To propose a consensus statement to optimize management of ACS in sub-Saharan Africa on the basis of realistic considerations.
Methods
The AFRICARDIO-2 conference (Yamoussoukro, May 2015) reviewed the ongoing features of ACS in 10 sub-Saharan countries (Benin, Burkina-Faso, Congo-Brazzaville, Guinea, Ivory Coast, Mali, Mauritania, Niger, Senegal, Togo), and analysed whether improvements in strategies and policies may be expected using readily available healthcare facilities.
Results
The outcome of patients with ACS is affected by clearly identified factors, including: delay to reaching first medical contact, achieving effective hospital transportation, increased time from symptom onset to reperfusion therapy, limited primary emergency facilities (especially in rural areas) and emergency medical service (EMS) prehospital management, and hence limited numbers of patients eligible for myocardial reperfusion (thrombolytic therapy and/or percutaneous coronary intervention [PCI]). With only five catheterization laboratories in the 10 participating countries, PCI rates are very low. However, in recent years, catheterization laboratories have been built in referral cardiology departments in large African towns (Abidjan and Dakar). Improvements in patient care and outcomes should target limited but selected objectives: increasing awareness and recognition of ACS symptoms; education of rural-based healthcare professionals; and developing and managing a network between first-line healthcare facilities in rural areas or small cities, emergency rooms in larger towns, the EMS, hospital-based cardiology departments and catheterization laboratories.
Conclusion
Faced with the increasing prevalence of ACS in sub-Saharan Africa, healthcare policies should be developed to overcome the multiple shortcomings blunting optimal management. European and/or North American management guidelines should be adapted to African specificities. Our consensus statement aims to optimize patient management on the basis of realistic considerations, given the healthcare facilities, organizations and few cardiology teams that are available.
Résumé
Contexte
Alors que la mortalité liée à la maladie coronaire a diminué dans les pays industrialisés, son incidence augmente en Afrique subsaharienne où le traitement des syndromes coronaires aigus (SCA) reste problématique.
Objectif
Proposer un consensus de prise en charge des SCA en Afrique subsaharienne prenant en compte les réalités locales.
Méthodes
La conférence AFRICARDIO-2 sur la maladie coronaire en Afrique subsaharienne (Yamousoukro, mai 2015) a revu les aspects évolutifs des SCA observés dans 10 pays (Bénin, Burkina-Faso, Congo-Brazzaville, Guinée, Côte d’Ivoire, Mali, Mauritanie, Niger, Sénégal, Togo), et analysé les stratégies susceptibles d’améliorer leur pronostic sur la base des moyens disponibles actuellement.
Résultats
Le pronostic des patients atteints de SCA est impacté par des facteurs identifiés, comprenant le délai avant premier contact médical, transport vers l’hôpital, délai entre premier symptôme et revascularisation, nombre de services d’urgences limité, en particulier en milieu rural, absence d’urgences pré-hospitalières, et, de fait, faible proportion de malades éligibles pour une revascularisation (fibrinolyse ou interventionnelle). Avec 5 unités de cardiologie interventionnelle pour les 10 pays concernés, les taux de revascularisation interventionnelle sont très bas. Néanmoins, des unités de cardiologie interventionnelle ont vu le jour récemment dans des grandes villes comme Abidjan et Dakar. Les améliorations à attendre doivent cibler des objectifs immédiats simples mais précis : éducation de la population, formation des acteurs de santé en milieu rural, structuration des réseaux de prise en charge entre premier recours, urgences, antennes pré-hospitalières, services de cardiologie et de cardiologie interventionnelle.
Conclusion
Compte tenu de l’augmentation des SCA en Afrique et de la faible adaptation des recommandations européennes ou nord-américaines, le consensus de prise en charge a été proposé pour optimiser la prise en charge en fonction des moyens matériels et humains disponibles actuellement.
Background
Whereas the rate of death from cardiovascular diseases has declined markedly in high-income countries in recent decades, the incidence is increasing in low-income and middle-income countries. The shift to non-communicable diseases in sub-Saharan Africa is progressing consistently, driven by changes in lifestyle, increased prevalence of cardiovascular risk factors, improved access to care, quality and affordability of health care and population ageing . The World Health Organization estimated that in 2005, ischaemic heart disease caused approximately 361,000 deaths in the African region, and current projections suggest that this number will nearly double by 2030 .
The main cardiovascular risk factors fuelling ischaemic heart disease epidemiology in Africa are similar to those identified in the other regions of the world, apart from high cholesterol concentrations, to which fewer myocardial infarctions are attributable . The ischaemic heart disease-attributable fraction of in-patients with heart failure in African cardiology departments increased 4–6-fold between 2007 and 2014, accounting for 8.1% of patients in the THESUS study and 12% in South Africa . Over the past two decades, the hospital prevalence of acute coronary syndromes (ACS) in the cardiology departments in Dakar has increased from 5% to 12%, concomitantly .
While the management and outcomes of patients with ACS have been studied extensively in the developed world, limited data are available from sub-Saharan Africa. Indeed, sub-Saharan African countries have limited access to a prehospital emergency medical service (EMS) and expensive therapies, such as fibrinolytic drugs (especially the newer ones) and stents, balloon catheters and accessory devices required to perform percutaneous coronary interventions (PCI). Also, few interventional cardiology facilities and catheterization laboratories are readily available across sub-Saharan Africa. Faced with these shortcomings, the European and/or North American guidelines on the management of patients with ACS are less applicable in most instances.
Optimization of the management of ACS in sub-Saharan Africa remains a challenging issue. As current data are derived almost exclusively from developed world populations, there is a need to establish registries in African countries, to increase awareness of the ACS burden and to establish appropriate preventive and management strategies. However, most prospective cohort studies of cardiovascular disease in sub-Saharan Africa have focused on cardiovascular risk factors and heart failure , with fewer studies specifically devoted to ACS, apart from the ACCESS South African sub-study, which included a large number of patients .
The AFRICARDIO-2 conference on coronary artery disease in sub-Saharan Africa (6–8 May 2015, Yamoussoukro, Ivory Coast) reviewed the ongoing features of ACS in 10 sub-Saharan countries (Benin, Burkina-Faso, Congo [Brazzaville], Guinea, Ivory Coast, Mali, Mauritania, Niger, Senegal and Togo). We looked at current trends in ACS in sub-Saharan Africa, and whether improvements in strategies and policies relevant to the clinical management and care of ACS patients may be expected, using readily available healthcare organizations.
ACS in sub-Saharan countries
Among the 665 patients included in 2006 in a multicentre study of cardiovascular emergencies in sub-Saharan Africa, ACS accounted for only 6.1% of patients . This study did not, however, specifically address the management of ACS, which has emerged gradually over subsequent years. Several studies from West and Central Africa, the results of which were reported at the annual cardiology meetings in Abidjan (Ivory Coast), Dakar (Senegal) and Yaounde (Cameroon), and at the meetings of the Working Group on Tropical Cardiology of the French Society of Cardiology, have shown an increased occurrence of ACS. These contributions were analysed at the AFRICARDIO-2 conference, and an overview is provided in Table 1 .
| Country | Author, year [reference] | Patients ( n ) | Age (years) | Men (%) | Delay from symptom onset to therapy | EMS transportation to hospital | EF (%) | HF or shock (%) | Thrombolysis (%) | PCI (%) | Hospital mortality (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Benin | Vehounkpe, 2007 | 80 | 56 | 75 | 25 | 0 | 0 | ND | |||
| Burkina-Faso | Samadoulogou, 2007 | 65 | 58 | 0 | 23 | ||||||
| Burkina-Faso | Yameogo et al., 2012 | 43 | 56.5 | 88 | 9.6 days | 0 (private car, public transport) | 16 | 4 | 0 | 11.6 | |
| Congo-Brazzaville | Ikama, 2007 | 55 | 65.5 | 36.5 | 25 | 0 | |||||
| Congo-Brazzaville | Ondze-Kafata, 2013 | 66.3 | 49.6 | ||||||||
| Guinea Conackry | Balde, 2013 | 127 | (41) | 14.5 hours | |||||||
| Ivory Coast | N’Guetta, 2013 | 716 coronary catheterizations; 501 ACS (200 STEMI) | 54.5 | 80 | 3.7 | 11.2 | 6.7 | ||||
| Mali | Diarra, 2007 | 162 | 80 | ||||||||
| Mauritania | Ba, 2013 | 37 | 58.1 | 75 | 22 | 21.6 | |||||
| Niger | Toure, 2013 | 98 | 71 | ||||||||
| Senegal | Diao, 2007 | 59 | 57 | 85 | 53 hours | 39.5 | 20 | 11.5 | 15 | ||
| Senegal | Sarr, 2015 | 100 | 55 | 73 | 37 hours | 25 | 31 | 14 | |||
| Senegal | Sarr, 2013 a | 21 a | 34 | 85 | 14.5 hours | LVD: 37.5 | 44 | 14 | |||
| South Africa | ACCESS investigators, 2011 | 642 | 58 | 76 | 3.6 hours (STEMI) | EMS 30-min drive | 36 (STEMI) | 53 (+14 CABG) | 6.7 (1 year) |
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