Abstract
Background
Data in the literature on acute coronary syndrome in sub‐Saharan Africa are scarce.
Methods and Results
We conducted a systematic review of the MEDLINE (PubMed) database of observational studies of acute coronary syndrome in sub‐Saharan Africa from January 1, 2010 to June 30, 2020. Acute coronary syndrome was defined according to current definitions. Abstracts and then the full texts of the selected articles were independently screened by 2 blinded investigators. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses standards. We identified 784 articles with our research strategy, and 27 were taken into account for the final analysis. Ten studies report a prevalence of acute coronary syndrome among patients admitted for cardiovascular disease ranging from 0.21% to 22.3%. Patients were younger, with a minimum age of 52 years in South Africa and Djibouti. There was a significant male predominance. Hypertension was the main risk factor (50%–55% of cases). Time to admission tended to be long, with the longest times in Tanzania (6.6 days) and Burkina Faso (4.3 days). Very few patients were admitted by medicalized transport, particularly in Côte d'Ivoire (only 34% including 8% by emergency medical service). The clinical presentation is dominated by ST–elevation sudden cardiac arrest. Percutaneous coronary intervention is not widely available but was performed in South Africa, Kenya, Côte d'Ivoire, Sudan, and Mauritania. Fibrinolysis was the most accessible means of revascularization, with streptokinase as the molecule of choice. Hospital mortality was highly variable between 1.2% and 24.5% depending on the study populations and the revascularization procedures performed. Mortality at follow‐up varied from 7.8% to 43.3%. Some studies identified factors predictive of mortality.
Conclusions
The significant disparities in our results underscore the need for a multicenter registry for acute coronary syndrome in sub‐Saharan Africa in order to develop consensus‐based strategies, propose and evaluate tailored interventions, and identify prognostic factors.
Keywords: acute coronary syndrome, acute myocardial infarction, sub‐Saharan Africa
Subject Categories: Cardiovascular Disease, Epidemiology
Nonstandard Abbreviations and Acronyms
- SSA
sub‐Saharan Africa
Clinical Perspective
What Is New?
This is an original paper addressing the knowledge gap on acute coronary syndrome in sub‐Saharan Africa.
Based on a systematic review, we showed disparities in population characteristics in acute coronary syndrome, outcomes, and tools of management available across countries.
Acute management of acute coronary syndrome is a challenging issue in sub‐Saharan Africa.
What Are the Clinical Implications?
In sub‐Saharan Africa setting, improvement of the delivery of care in acute coronary syndrome is an urgent need in contemporary cardiology practice.
Implementation of multicenter registries is required to develop consensus strategies.
Primary prevention and awareness of populations remain the best weapons to reduce the growing burden of coronary disease in sub‐Saharan Africa.
In recent years, many developing countries, and particularly those in sub‐Saharan Africa (SSA), have experienced a sharp increase in acute coronary syndrome (ACS) in a context of rapid urbanization, changes in lifestyle and diet, an aging population and, above all, uncontrolled cardiovascular risk factors. 1 Coronary heart disease (CHD) is now 1 of the 3 leading causes of death in most SSA countries 2 increasing the burden of health expenditures in regions that are also struggling with uncontrolled infectious diseases and malnutrition.
Since the CORONAFRIC I study, the first multicenter study of CHD in SSA conducted in the 1990s, 3 only a few, mostly single‐center studies have been conducted. These studies have shown an overall increase in incident cases of ACS and confirmed the epidemic of CHD that was declared 30 years ago. 4 Although the burden of ACS has been steadily increasing in recent years in SSA cardiology departments, there are still few published articles on ACS patients in SSA. Yet published data can help to focus the attention of health authorities on developing prevention and management strategies for ACS and at the same time raise public awareness. The low level of mobilization within governments and ministries of health can therefore be attributed in part to the lack of data in the literature. For instance, only 39% of African countries had an action plan against noncommunicable diseases compared with 65% in the United States and 94% in Europe. 5
In this study, we set out to conduct a systematic review in order to identify the main observational studies over the past decade and to report on the current state of knowledge on the epidemiology of ACS, how it is managed, and patient outcomes. Furthermore, we present the opportunity for a large multinational registry of ACS, to increase awareness of population and healthcare providers, and to improve management of ACS in our practice.
METHODS
Inclusion Criteria
We conducted a systematic review of the MEDLINE (PubMed) database of observational studies (cohort, case‐control, longitudinal and cross‐sectional studies) of ACS in SSA from January 1, 2010 to June 30, 2020. Included studies were required to report the incidence and/or prevalence, epidemiological data, means of management, and/or prognosis of patients with ACS, regardless of the language of writing. Myocardial infarction (MI) was defined according to the current universal definition. 6 , 7 ST‐segment–elevation MI (STEMI) was defined by the presence of symptoms of myocardial ischemia, at least 2 contiguous leads with ST‐segment–elevation ≥1 mm or pathological Q waves, and an increase in serum markers of myocardial necrosis above the upper limit of normal for troponin and/or enzymes. 8 ACS without persistent ST‐segment–elevation was defined by the presence of symptoms or signs of myocardial ischemia, the absence of persistent ST‐segment elevation on the ECG, and elevation of cardiac biomarkers (non–ST‐segment–elevation myocardial infarction [NSTEMI] or non‐Q‐wave MI) or not (unstable angina). 9 The included studies had to have been conducted in unselected populations (including young subjects, elderly subjects, women, etc) and must have specifically involved hospitalized patients with the exclusive diagnosis of ACS. Randomized studies, meta‐analyses, and case reports were excluded from our study.
Research Protocol
The search strategy was based on the Medical Subject Headings tree headings "Africa South of the Sahara," "Africa, Western," "Africa, Eastern," "Africa, Central," "Africa, Southern," "South Africa," "Acute Coronary Syndrome," and "Myocardial Infarction," and associated terms. Table S1 presents the full search strategy used in our study. Two independent reviewers (H.Y. and A.E.) conducted a manual literature search and cross‐referenced their results.
Selection of Studies
The titles and abstracts of the selected papers were then independently screened by the 2 investigators (H.Y. and A.E.) for eligibility according to the inclusion criteria. Once the titles and abstracts were selected, an evaluation of the full text of the article was conducted to determine inclusion. Differences regarding the inclusion of studies were resolved by consensus. If disagreement persisted, the decision was made by a third independent reviewer (R.N.).
Data Extraction
Data extraction was performed by both reviewers. The characteristics considered were:
First author and year of publication
Country in which the study was conducted
Study design: prospective, retrospective, cross‐sectional
Number of patients included in the study
Prevalence of ACS: recovered in each study, or calculated by dividing the number of patients diagnosed with ACS by the total population over the period
Mean (or median) age of ACS patients
Male patient rate (percentage).
Time from symptom onset to admission (in hours or days)
Management tools: fibrinolysis or coronary angioplasty.
Hospital mortality rate
Follow‐up time and mortality rate
Study Quality and Bias
We used the Loney scoring system to evaluate the quality of the included studies. 10 The Loney scoring system is based on the presence (score=1) or absence (score=0) of the following criteria, with a maximum score of 8 points:
Random sample or entire population
Unbiased sampling
Adequate sample size: prevalence of ACS in SSA cardiology departments is scarce. We considered assumption of 6.1% of coronary emergencies, 11 5% error, and 95% CI. The calculated minimum sample size is 88 patients.
Measurements carried out according to validated criteria
Results reported by unbiased interviewers
Satisfactory response rate (at least 70%), description of patients who refused
CIs, subgroup analyses
Description of study subjects
A score ≥5 indicates a good quality study, whereas a score <5 suggests a poor quality study.
Ethics
This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses standards. 12 , 13 As we conducted a literature review, no intervention on human subjects was required, and no consent or ethics committee authorization was required. Our research protocol was submitted to https://www.crd.york.ac.uk/prospero/ (International Prospective Register of Systematic Reviews). It was published under registration number CRD42020201077. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses Checklist of our review is in Table S2.
Data Collection and Analysis
A descriptive analysis of the included studies was conducted. A map of SSA was inserted to show the distribution of all studies.
RESULTS
Based on our search strategy, 784 articles were included in the MEDLINE (PubMed) database. Twenty‐seven studies met our criteria and were retained. The flow chart is detailed in Figure 1.
Figure 1. Flow chart of the study.
CVD indicates cardiovascular disease; and NCD, noncommunicable diseases.
Table 1 summarizes the characteristics of the 27 studies. 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 In 6 studies, the patients included were exclusively STEMI. 15 , 19 , 29 , 34 , 35 , 37 Table S3 show the 12 studies including patients hospitalized for MI.* One study evaluated a population of patients with only NSTEMI. 32 The other studies evaluated a heterogeneous ACS population (STEMI and NSTEMI).
Table 1.
Studies on ACS in Sub‐Saharan Africa Available on MEDLINE Based on Our Research Strategy (2010–2020)
| Author (y) | Country | Design | Population | Prevalence (%) | Age (y) | Male sex (%) | Time from symptoms to admission | Fibrinolysis/angioplasty | In‐hospital mortality (%) | Follow‐up mortality (follow‐up time) |
|---|---|---|---|---|---|---|---|---|---|---|
| Hertz (2020) 14 | Tanzania | Prospective | 152 ACS | 22.3 | 61.2 | 59.9 | 6.6 h | N/N | … | 43.3% (30 d) |
| Ekou (2020) 15 | Côte d’Ivoire | Cross‐sectional | 166 STEMI | … | 54.5 | 91.6 | 20 h | N/Y | 1.2 | … |
| Desta (2020) 16 | Ethiopia | Retrospective | 151 ACS | … | 59.1 | 72.2 | 95.85 h | Y/Y | 24.5 | … |
| Ba (2019) 17 | Mauritania | Cross‐sectional | 80 ACS | 10.2 | 62.4 | 70.0 | 34.8 h | Y/Y | 3.8 | … |
| Yao (2019) 18 | Côte d’Ivoire | Cross‐sectional | 256 ACS | … | 53.2 | 85.9 | … | N/Y | … | … |
| Yao (2019) 19 | Côte d’Ivoire | Prospective | 329 STEMI | … | 57 | 82.6 | 20 h | Y/Y | 14.3 | 10.4% (39 mo) |
| Kaboré (2019) 20 | Burkina‐Faso | Prospective | 111 ACS | 4.2 | 57.6 | 77.5 | 30.55 h | Y/N | 8.1 | 16.2% (30 d) |
| Varwani (2019) 21 | Kenya | Retrospective | 230 ACS | 60.5 | 81.7 | Y/Y | 7.8 |
7.8% (30 d) 13.9% (1 y) |
||
| Pessinaba (2018) 22 | Togo | Cross‐sectional | 67 ACS | 3.5 | 60 | 65.7 | 81.9 h | Y/N | 10.5 | … |
| Bahiru (2018) 23 | Kenya | Retrospective | 196 ACS | 57.5 | 65 | Y/Y | 17 | |||
| N’Guetta (2018) 24 | Côte d’Ivoire | Prospective | 165 ACS | … | 55.6 | 93 | … | N/Y | 1.2 | 1.2% (1 y) |
| Chetty (2016) 25 | South Africa | Cross‐sectional | 122 MI | … | 61 | 65 | … | Y/N | 1.8 (STEMI) | … |
| Kimeu (2016) 26 | Kenya | Retrospective | 64 MI | … | 56.7 | 87.5 | Y/Y | 9.4 | ||
| N’Guetta (2016) 27 | Côte d’Ivoire | Cross‐sectional | 425 ACS | 13.5 | 55.4 | 44.7 h | Y/Y | 10 | … | |
| Mirghani (2015) 28 | Soudan | Cross‐sectional | 197 ACS | … | 56.8 | 56.8 | … | Y/Y | 6.6 | … |
| Meel (2015) 29 | South Africa | Prospective | 100 STEMI | … | 52 | 70 | 2.3 h | Y/N | … | … |
| Mboup (2014) 30 | Senegal | Prospective | 59 ACS | 4.05 | 57.1 | 79.7 | 53.2 h | Y/N | 15.25 | 18.6% (30 d) |
| Giday (2013) 31 | Ethiopia | Retrospective | 21 ACS | … | 57.1 | 65.2 | … | N/N | 14.4 | … |
| Moses (2013) 32 | South Africa | Retrospective | 76 NSTEMI | … | 60.5 | 21.5 | 24.21 h | N/Y | 15.8 | … |
| Kolo (2013) 33 | Nigeria | Retrospective | 14 MI | 0.21 | 56 | 92 | … | N/N | 21.44 | |
| Yameogo (2012) 34 | Burkina‐Faso | Cross‐sectional | 43 STEMI | 56.5 | 88 | 4.3 d | Y/N | 11.6 | … | |
| Maurin (2012) 35 | Djibouti | Prospective | 35 STEMI | 40 | 52 | 88.6 | 23 h | Y/N | 20% |
14% (30 d) 20% (1 y) |
| Shavadia (2012) 36 | Kenya | Cross‐sectional | 111 ACS | 5.1 | 63.3 | 75.7 | 12.9 h (STEMI) | Y/Y | 8.1 | … |
| Maharaj (2012) 37 | South Africa | Retrospective | 161 STEMI | … | 54 | … | 3.2 h | Y/N | … | … |
| Schamroth (2012) 38 | South Africa | Prospective | 615 ACS | … | 58 | … | 3.6 h (STEMI) | Y/Y | … |
2.4% STEMI (30 d) 1.7% NSTEMI (30 d) 5.7% (1 y) |
| Ogeng’o (2010) 39 | Kenya | Retrospective | 120 MI | … | 56.8 | 66 | … | N/Y | 5% | … |
| Bèye (2011) 40 | Mali | Cross‐sectional | 8 MI | 7.3 | 54.62 | 100 | … | N/N | 28.6% | … |
ACS indicates acute coronary syndrome; MI, myocardial infarction; N, no; NSTEMI, non–ST‐segment–elevation myocardial infarction; STEMI, ST‐segment–elevation myocardial infarction; and Y, yes.
The 27 published studies were conducted in 13 (Burkina Faso, Côte d'Ivoire, Djibouti, Ethiopia, Kenya, Mali, Mauritania, Nigeria, Senegal, South Africa, Sudan, Tanzania, and Togo) out of a total of 48 sub‐Saharan African countries. With 5 studies each, Côte d'Ivoire (Table 2), South Africa (Table 3), and Kenya (Table 4) present the highest number of publications, according to the specified criteria. The geographic distribution of the 27 studies is shown in Figure 2.
Table 2.
Studies on ACS in Côte d’Ivoire (2010–2020)
| Author (y) | Country | Design | Population | Prevalence (%) | Age (y) | Male sex (%) | Time from symptoms to admission | Fibrinolysis/angioplasty | In‐hospital mortality (%) | Follow‐up mortality (follow‐up time) |
|---|---|---|---|---|---|---|---|---|---|---|
| Ekou (2020) 15 | Côte d’Ivoire | Cross‐sectional | 166 STEMI | … | 54.5 | 91.6 | 20 h | N/Y | 1.2 | … |
| Yao (2019) 18 | Côte d’Ivoire | Cross‐sectional | 256 ACS | … | 53.2 | 85.9 | … | N/Y | … | … |
| Yao (2019) 19 | Côte d’Ivoire | Prospective | 329 STEMI | … | 57 | 82.6 | 20 h | Y/Y | 14.3 | 10.4% (39 mo) |
| N’Guetta (2018) 24 | Côte d’Ivoire | Prospective | 165 ACS | … | 55.6 | 93 | … | N/Y | 1.2 | 1.2% (1 y) |
| N’Guetta (2016) 27 | Côte d’Ivoire | Cross‐sectional | 425 ACS | 13.5 | 55.4 | 44.7 h | Y/Y | 10 | … |
ACS indicates acute coronary syndrome; N, no; STEMI, ST‐segment–elevation myocardial infarction; and Y, yes.
Table 3.
Studies on ACS in South Africa (2010–2020)
| Author (y) | Country | Design | Population | Prevalence (%) | Age (y) | Male sex (%) | Time from symptoms to admission | Fibrinolysis/angioplasty | In‐hospital mortality (%) | Follow‐up mortality (follow‐up time) |
|---|---|---|---|---|---|---|---|---|---|---|
| Chetty (2016) 25 | South Africa | Cross‐sectional | 122 MI | … | 61 | 65 | … | Y/N | 1.8 (STEMI) | … |
| Meel (2015) 29 | South Africa | Prospective | 100 STEMI | … | 52 | 70 | 2.3 h | Y/N | … | … |
| Moses (2013) 32 | South Africa | Retrospective | 76 NSTEMI | … | 60.5 | 21.5 | 24.21 h | N/Y | 15.8 | … |
| Maharaj (2012) 37 | South Africa | Retrospective | 161 STEMI | … | 54 | … | 3.2 h | Y/N | … | … |
| Schamroth (2012) 38 | South Africa | Prospective | 615 ACS | … | 58 | … | 3.6 h (STEMI) | Y/Y | … |
2.4% STEMI (30 d) 1.7% NSTEMI (30 d) 5.7% (1 y) |
ACS indicates acute coronary syndrome; MI, myocardial infarction; N, no; NSTEMI, non–ST‐segment–elevation myocardial infarction; STEMI, ST‐segment–elevation myocardial infarction; and Y, yes.
Table 4.
Studies on ACS in Kenya (2010–2020)
| Author (y) | Country | Design | Population | Prevalence (%) | Age (y) | Male sex (%) | Time from symptoms to admission | Fibrinolysis/angioplasty | In‐hospital mortality (%) | Follow‐up mortality (follow‐up time) |
|---|---|---|---|---|---|---|---|---|---|---|
| Varwani (2019) 21 | Kenya | Retrospective | 230 ACS | 60.5 | 81.7 | Y/Y | 7.8 |
7.8% (30 d) 13.9% (1 y) |
||
| Bahiru (2018) 23 | Kenya | Retrospective | 196 ACS | 57.5 | 65 | Y/Y | 17 | |||
| Kimeu (2016) 26 | Kenya | Retrospective | 64 MI | … | 56.7 | 87.5 | Y/Y | 9.4 | ||
| Shavadia (2012) 36 | Kenya | Cross‐sectional | 111 ACS | 5.1 | 63.3 | 75.7 | 12.9 h (STEMI) | Y/Y | 8.1 | … |
| Ogeng’o (2010) 39 | Kenya | Retrospective | 120 MI | … | 56.8 | 66 | … | N/Y | 5% | … |
ACS indicates acute coronary syndrome; MI, myocardial infarction; N, no; STEMI, ST‐segment–elevation myocardial infarction; and Y, yes.
Figure 2. Sites and number of studies on ACS in sub‐Saharan Africa available on MEDLINE 2010 to 2020.
ACS indicates acute coronary syndrome.
Twenty‐one of the 27 studies (77.8%) were of good quality according to Loney's criteria. The lowest reported criteria were satisfactory response rate (>70%), subgroup analyses and study size >88 patients (Figure 3).
Figure 3. Quality bias assessment according to Loney's criteria.
Ten studies reported the prevalence of ACS among patients admitted in cardiology departments. Their results ranged from 0.21% to 22.3%. 14 , 22 The average age in South Africa 29 and Djibouti 35 is 52 years, the highest age was in Kenya (63.3 years). 36 Burden of cardiovascular risk factors across 3 studies was performed in Figure 4. There were some disparities in the burden of diabetes, dyslipidemia, and smoking habits.
Figure 4. Distribution of cardiovascular risk factors in patients with acute coronary syndrome.
Data derived from 3 studies: N’Guetta et al, 27 Shavadia et al, 36 and Schamroth et al. 38
The longest average times between the onset of pain and admission to a cardiology department are found in Tanzania (6.6 days) 14 and Burkina Faso (4.3 days), 34 where recent data have shown a significant decrease in this time to 30.55 hours. 20 The shortest time was found in South Africa (2.3–3.6 hours). In this systematic review, very few patients were transferred in an appropriate means of transport: 34% (including only 8% by emergency medical service) in Côte d'Ivoire, 27 29% in Mauritania, 17 11.9% in Senegal, 30 and 4.5% in Togo. 22
The clinical presentation of ACS is dominated by STEMI in most studies, as in Côte d'Ivoire 27 and Kenya 23 with 71.5% and 57.1%, respectively, but it was found in lower proportions in South Africa (41.1%). 38 Percutaneous coronary interventions (PCI) were performed in South Africa, 25 , 29 , 32 , 37 , 38 Kenya, 21 , 23 , 26 , 36 Côte d'Ivoire, 15 , 18 , 24 , 27 Sudan, 28 and Mauritania. 17 Fibrinolysis was the most widely reported and available means of revascularization in most of our studies (18/27 or 66.7%). 16 , 17 , 19 , 20 , 21 , 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 , 34 , 35 , 36 , 37 , 38
Hospital mortality in ACS was highly variable across studies, with estimates ranging between 1.2% and 24.5%.† The highest mortality rate was reported in Ethiopia (24.5%). In STEMI, the reported mortality was very low, varying from 1.2% to 1.8% of patients who underwent primary PCI 15 or early thrombolysis (median admission‐fibrinolysis time of 45 minutes). 25
Mortality at 30 days was estimated to range from 7.8% to 43.3%. 14 , 20 , 21 , 30 , 35 The highest 30‐day rate in the study period, 43.3%, was reported in Tanzania. 14 In South Africa, mortality at 30 days was 2.4% in STEMI and 1.7% in NSTEMI. 38 In the longer term, 1‐year mortality was 5.7% in South Africa, 38 13.9% in Kenya, 21 and 20% in Djibouti. 35 After a median follow‐up of 39 months, a study conducted in Côte d'Ivoire found an all‐cause mortality rate of 10.4%, with a higher rate in patients who did not receive coronary reperfusion (13.3%). 19
DISCUSSION
Epidemiology
Prevalence
The first multicenter epidemiological data on CHD in SSA, CORONAFRIC I, dates back to the period 1988 to 1991. 3 The cumulative incidence of CHD was 3.17%. In 2006, Bertrand et al 11 conducted the multicenter MULTAF‐UCASS study on cardiovascular emergencies in SSA. Six hundred and sixty‐five patients were included from 7 participating centers (Burkina Faso, Cameroon, Chad, Côte d'Ivoire, Gabon, Mauritania, Senegal). Although CHD accounted for only 6.1% of admissions, the burden of CHD had significantly increased in just over a decade.
Significant differences in prevalence across studies included reflect disparities in the diagnostic criteria and tools available between SSA countries and the population’s level of knowledge about the symptoms of coronary disease, which can lead to the underdiagnosis of ACS. 41 The limited availability of diagnostic tools (notably troponins) reported in several studies, including those by Kolo et al 33 and Hertz et al in Tanzania, 42 may also explain the low rate of documented MI cases (notably NSTEMI). The widespread use of troponin testing, as in developed countries, allows a greater screening of infarction cases, particularly NSTEMI. 43
Age, Sex
All the studies conducted in SSA are unanimous: patients with ACS are much younger than those in developed countries, with an age difference that often reaches 10 years. The population of SSA, which is younger as a result of population dynamics, 44 including lower life expectancy, appears to be at earlier risk for the most severe form of CHD. Male predominance was very strong in all studies, reaching 91.2% in a series of 166 patients in Côte d'Ivoire in whom primary PCI was performed. 15 The highest female representations was found in Sudan (43.1%) 28 and Tanzania and Kenya (40.1%). 14 , 23
Cardiovascular Risk Factors
In the INTERHEART Africa multicentric study, 45 hypertension was the risk factor most positively associated with the occurrence of a first episode of myocardial infarction in Black Africans (50.4%; OR, 6.99; 95% CI, 4.23–11.55). Overall, hypertension was the main risk factor in this review and was found in 50% to 55% of patients with ACS. The preponderance of hypertension as a risk factor for CHD is probably related to a higher prevalence and a lower control rate compared with developed countries. 46
Time to Hospital Admission
The time to admission remained very high in most studies, influencing the rate of patients who benefit from urgent myocardial reperfusion. Continuous training and equipment for prehospital and emergency services for the management of ACS (ECGs, fibrinolytics, etc) are essential measures to reduce the time required for treatment. 47 South Africa has the shortest time, between 2.3 and 3.6 hours for patients with STEMI, which means that primary PCI or thrombolysis are performed more often than in other SSA countries. In Côte d'Ivoire, there has been an encouraging reduction of more than 50% in the time to admission from 44.7 to 20 hours within 4 years. 15 , 27
Mode of Transport
In the majority of studies, patients are admitted by nonmedical transport. Prehospital structures like ambulances and firefighters are rarely used, unlike in Western countries where they are in the front line of care. These observations underlie the enormous need for public awareness and information but also for the establishment of care networks and collaboration between specialized care centers and prehospital emergency services to improve patient care and outcomes.
Angiographic Data: Severity of Coronary Lesions
Scarcity of angiographic data in SSA is related to the lack of centers with catheterization laboratories. 47 In a South African study of patients with NSTEMI, 80% of the patients had multivessel CHD (40% 2 vessel and 40% 3 vessel), 32 confirmed in 2 other series of patients in Côte d'Ivoire 18 and Kenya. 36 Among STEMI, data from an Ivorian catheterization laboratory 18 , 24 reported a predominance of 1‐vessel CHD up to 52.4% of cases, and a minority of patients (between 10% and 16%) had multivessel CHD.
Disease Management
Percutaneous Coronary Intervention
The implementation of PCI in SSA remains a challenge. Most countries have limited access to heart centers where PCI can be performed. In East and Central Africa, there were 2 catheterization laboratories with routine procedures in 2006 (both located in Kenya). This number increased recently to 12 in 2017, spread over 3 countries. 21 South Africa is an exception considering that it has, to our knowledge, the most cardiac catheterization facilities of any SSA country (62 in 2017). 48
Fibrinolysis
Given the low number of catheterization laboratories in SSA, fibrinolysis is often a therapeutic alternative of choice, and there is evidence of comparable clinical benefits with primary PCI. 49 , 50 , 51 In SSA, early fibrinolysis is worth developing, particularly through prehospital emergency medical services, or even by implementing a pharmacoinvasive strategy. Streptokinase is the most widely used fibrinolytic in more than 80% of studies reporting fibrinolysis, probably because of its low cost and availability. 16 , 17 , 20 , 22 , 29 , 30 , 34 , 38 Alteplase is used in Côte d'Ivoire 27 and South Africa. 29 , 38 As in European and North American countries, tenecteplase is available in routine practice in Kenya 26 , 36 and South Africa. 38
Mortality
Hospital Mortality
The high variability of mortality across studies was certainly a result of the varying populations (ACS, STEMI, and NSTEMI) and revascularization procedures performed. In studies that evaluated heterogeneous ACS populations (including STEMI and NSTEMI), mortality ranged from 1.2% to 24.5%. The lowest rate (1.2%), found in the study by N'Guetta et al, involved patients hospitalized for ACS who underwent PCI. 24 The highest mortality rate in Ethiopia may certainly have been influenced by very long treatment times (95.85 hours).
Mortality During Follow‐Up and Predictors of Mortality
Few studies reported mortality rates in the follow‐up of patients with ACS. In multivariate analysis, STEMI and heart failure at admission (OR, 10.7; 95% CI, 3.34–34.6) was associated with in‐hospital occurrence of a combined major adverse cardiovascular event end point (death, recurrent infarction, stroke, major bleeding, or cardiac arrest). 23 Left ventricular dysfunction <50% was also a factor associated with mortality in Djibouti, whereas the successful thrombolysis (73%) seemed positively associated with hospital survival and at 1 month (P<0.005). 35 In a study conducted in Côte d'Ivoire, after a longer period of follow‐up (39 months), age ≥70 years (OR, 4.61; 95% CI, 2.09–10.17), female sex (OR, 2.55; 95% CI, 1.13–5.74) and heart failure at admission (OR, 2.17; 95% CI, 1.01–4.69) were predictors for death, after adjustment for risk factors, history of MI, left ventricular ejection fraction <50%, and revascularization procedures. 19
Limitations
Our study has several limitations. There were sometimes large disparities in the numbers of inclusions and the different populations, the designs and periods of the studies, and the procedures performed (PCI, fibrinolysis, etc) making comparisons between studies and a possible meta‐analysis difficult. Although blinded by 2 investigators, some studies may have been omitted. Only 1 database was chosen for this systematic review (MEDLINE), which could lead to selection and publication bias. Most of these studies were carried out in reference hospitals in urban areas and are not representative of the entire population. The period of interest (2010–2020) was chosen arbitrarily.
However, we have excluded studies that used selected populations, allowing us to obtain more reliable and comprehensive observations on CHD in our practice. Moreover, over 70% of studies included were of good quality according to Loney criteria.
Outlook: Need for an International Multicenter Registry in SSA
In developed countries, the implementation and application of recommendations for good practice in ACS has led to significant reductions in mortality in recent years. 52 In contrast, consensus teams have published "feasible" proposals to improve patient management in SSA, but these have yet to be implemented. 47 , 53
This systematic review underlines the heterogeneity of study enrolments and procedures performed in patients with ACS but also the heterogeneity of study designs. Taking into account the available human resources and the rather limited technical means, it would be interesting to develop shared management protocols adapted to the specificities of the region. This underlines the need for an international multicenter prospective registry in SSA on ACS. Such a registry could be used to provide more reliable data on coronary emergencies, evaluate practices, implement interventions and assess their impact, and identify prognostic factors in order to target management strategies, similar to developed countries. 54 The data from these registries would make it possible to develop recommendations that are tailored to the specificities of SSA.
CONCLUSIONS
ACS has been on the rise in recent years in SSA, where it affects a relatively young population. In most countries, treatment times remain very high, access to emergency coronary care is limited, and the prehospital system is inadequate. Mortality is also very high, though certain prognostic factors were confirmed in the studies. However, there are significant disparities according to the countries, the populations considered, and the procedures performed. These alarming findings should attract the attention of populations and practitioners. Health policy must allocate more resources to the prevention and management of CHD, which is today, according to the World Health Organization, 1 of the 3 main causes of mortality in SSA, ahead of HIV‐AIDS, tuberculosis, and malaria. Similar to what is done in developed countries, there is a need to create a multicenter registry in order to develop consensus strategies, evaluate them, and propose feasible interventions. Improving the management of CHD in developing countries also requires primary prevention through public awareness campaigns, continuing education of healthcare personnel, and ongoing efforts to limit cardiovascular risk factors.
Sources of Funding
None.
Disclosures
None.
Supporting information
Tables S1–S3
Acknowledgments
We thank Suzanne Rankin for English assistance, and Marc Antoine Aie for Figure 2 art design.
Supplemental Material for this article is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.120.021107
For Sources of Funding and Disclosures, see page 12.
Footnotes
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Associated Data
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Supplementary Materials
Tables S1–S3