Acute management of ST-elevation myocardial infarction in a tertiary hospital in Kenya: are we complying with practice guidelines?

Introduction: Current practice guidelines emphasize the importance of rapid reperfusion of patients with ST-elevation myocardial infarction (STEMI). The aim of this study was to evaluate the current rate of compliance with evidence-based practice guidelines for the management of STEMI patients at a tertiary hospital in Kenya. Methods: This was a retrospective chart review. Data on patient characteristics, emergency treatment, and outcomes were collected on adults admitted with a diagnosis of STEMI from January 2012 to February 2013. Results: Data were collected for 45 patient presentations. There were 37 male patients (82%). The mean age was 59.7 ± 3.8 years. Of the 45 patients, 23 were Asian (51%), 18 were Black (40%) and four were Caucasian (9%). Thirty-five patients (78%) presented within 12 h of symptom onset. Within 10 min of arrival to the hospital, 40 patients (89%) had electrocardiographs performed and 39 patients (87%) were reviewed by a doctor. Medications given on presentation were aspirin (98%), clopidogrel (91%) and anticoagulants (73%). All patients received reperfusion therapy. Twenty-eight patients (62%) received fibrinolytic therapy and 17 patients (38%) had primary percutaneous coronary intervention. Door-to-needle time of43% of the cases. Door-to- balloon time was29% of the cases. All the patients survived to hospital discharge. The average length of stay was 5.3 ± 1.0 days. In-hospital complications occurred in six patients (13.3%). These included bleeding (three patients), stroke (one patient) and cardiogenic shock requiring intra- aortic balloon pump support (two patients). Conclusion: Whereas the majority of STEMI patients are evaluated within 10 min of presentation, less than 50% receive reperfusion therapy within the recommended time frame. While there are attempts to comply with evidence based guidelines in resource-limited settings, there is a need to improve acute care systems to target early reperfusion of STEMI patients

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact

Background: In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally. Methods: This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen\u27s kappa \u3e0.6 indicative of good inter-rater agreement. Results: Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties. Conclusions: Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives

Comprehensive transcriptome of the maize stalk borer, Busseola fusca, from multiple tissue types, developmental stages, and parasitoid wasp exposures

International audienc

A prospective review of acute coronary syndromes in an urban hospital in sub-Saharan Africa

Objectives: To determine the epidemiology of acute coronary syndromes (ACS) in sub-Saharan Africa. Methods: A prospective survey was carried out of all patients with a diagnosis of ACS who were admitted to the critical care unit of a tertiary teaching hospital over a 25-month period. Demographics, presentation, management and outcomes were subsequently recorded. Results: A total of 111 (5.1% of all hospitalisations) patients were recruited, with 56% presenting with ST-elevation myocardial infarction (STEMI) and the rest non-ST-elevation myocardial infarction (NSTEMI) or unstable angina (UA). Chest pain was the most common presenting symptom, and up to one-third of all STEMI patients did not receive any form of reperfusion therapy, primarily due to late presentation. As in the developed world, diabetes, hypertension and cigarette smoking still account for the most common predisposing risk-factor profile, and the mortality associated with ACS is about six to 10% in our unit. Conclusions: ACS, contrary to common belief, is increasingly more prevalent in sub-Saharan Africa, with similar risk profiles to that in the developed world. Late presentation to hospital is common and accounts for the increased mortality associated with this condition

Clinical characteristics and outcomes of atrial fibrillation and flutter at the Aga Khan University Hospital, Nairobi

Introduction: Scant data exist on the epidemiology and clinical characteristics of atrial fibrillation in Kenya. Traditionally, atrial fibrillation (AF) in sub-Saharan Africa is as a result of rheumatic valve disease. However, with the economic transition in sub-Saharan Africa, risk factors and associated complications of this arrhythmia are likely to change. Methods: A retrospective observational survey was carried out between January 2008 and December 2010. Patients with a discharge diagnosis of either atrial fibrillation or flutter were included for analysis. The data-collection tool included clinical presentation, risk factors and management strategy. Follow-up data were obtained from the patients\u27 medical records six months after the index presentation. Results: One hundred and sixty-two patients were recruited (mean age 67 ± 17 years, males 56%). The distribution was paroxysmal (40%), persistent (20%) and permanent AF (40%). Associated co-morbidities included hypertension (68%), heart failure (38%) diabetes mellitus (33%) and valvular abnormalities (12%). One-third presented with palpitations, dizziness or syncope and 15% with a thromboembolic complication as the index AF presentation. Ratecontrol strategies were administered to 78% of the patients, with beta-blockers and digoxin more commonly prescribed. Seventy-seven per cent had a CHA2DS2VASC score ≥ 2, but one-quarter did not receive any form of oral anticoagulation. At the six-month follow up, 6% had died and 12% had been re-admitted at least once. Of the high-stroke risk patients on anticoagulation, just over one-half were adequately anticoagulated. Conclusion: Hypertension and diabetes mellitus, not rheumatic valve disease were the more common co-morbidities. Stroke risk stratification and prevention needs to be emphasised and appropriately managed

Improved blood pressure control via a novel chronic disease management model of care in sub‐Saharan Africa: Real‐world program implementation results

Abstract A chronic disease management model of care (Empower Health) was launched in rural and urban areas of Ghana and Kenya in 2018. The goal was to improve disease awareness, reduce the burden of disease, and improve the clinical effectiveness and efficiency of managing hypertension. Leveraging the model, clinicians provide patients with tailored management plans. Patients accessed regular blood pressure checks at home, at the clinic, or at community‐partner locations where they received real‐time feedback. On the mobile application, clinicians viewed patient data, provided direct patient feedback, and wrote electronic prescriptions accessible through participating pharmacies. To date, 1266 patients had been enrolled in the “real‐world” implementation cohort and followed for an average of 351 ± 133 days across 5 facilities. Average baseline systolic blood pressure (SBP) was 145 ± 21 mmHg in the overall cohort and 159 ± 16 mmHg in the subgroup with uncontrolled hypertension (n = 743) as defined by baseline SBP ≥ 140 mmHg. SBP decreased significantly through 12 months in both the overall cohort (−9.4 mmHg, p < .001) and in the uncontrolled subgroup (−17.6 mmHg, p < .001). The proportion patients with controlled pressure increased from 46% at baseline to 77% at 12 months (p < .001). In summary, a new chronic disease management model of care improved and sustained blood pressure control to 12 months, especially in those with elevated blood pressure at enrollment

Development of the roadmap and guidelines for the prevention and management of high blood pressure in Africa: Proceedings of the PASCAR: Hypertension task force meeting: Nairobi, Kenya

Africa has one of the fastest growing economies in the world. The economic changes are associated with a health transition characterised by a rise in cardiovascular risk factors and complications, which tend to affect the African population at their age of maximum productivity. Recent data from Africa have highlighted the increasing importance of high blood pressure in this region of the world. This condition is largely underdiagnosed and poorly treated, and therefore leads to stroke, renal and heart failure, and death. Henceforth, African countries are taking steps to develop relevant policies and programmes to address the issue of blood pressure and other cardiovascular risk factors in response to a call by the World Health Organisation (WHO) to reduce premature deaths from non-communicable diseases (NCDs) by 25% by the year 2025 (25 × 25). The World Heart Federation (WHF) has developed a roadmap for global implementation of the prevention and management of raised blood pressure using a health system approach to help realise the 25 × 25 goal set by the WHO. As the leading continental organisation of cardiovascular professionals, the Pan-African Society of Cardiology (PASCAR) aims to contextualise the roadmap framework of the WHF to the African continent through the PASCAR Taskforce on Hypertension. The Taskforce held a workshop in Kenya on 27 October 2014 to discuss a process by which effective prevention and control of hypertension in Africa may be achieved. It was agreed that a set of clinical guidelines for the management of hypertension are needed in Africa. The ultimate goal of this work is to develop a roadmap for implementation of the prevention and management of hypertension in Africa under the auspices of the WHF

Rationale and design of the Pan-African sudden cardiac death survey: The Pan-African SCD study

Background: The estimated rate of sudden cardiac death (SCD) in Western countries ranges from 300,000 to 400,000 annually, which represents 0.36 to 1.28 per 1 000 inhabitants in Europe and the United States. The burden of SCD in Africa is unknown. Our aim is to assess the epidemiology of SCD in Africa. Methods: The Pan-Africa SCD study is a prospective, multicentre, community-based registry monitoring all cases of cardiac arrest occurring in victims over 15 years old. We will use the definition of SCD as \u27witnessed natural death occurring within one hour of the onset of symptoms\u27 or \u27unwitnessed natural death within 24 hours of the onset of symptoms\u27. After approval from institutional boards, we will record demographic, clinical, electrocardiographic and biological variables of SCD victims (including survivors of cardiac arrest) in several African cities. All deaths occurring in residents of districts of interest will be checked for past medical history, circumstances of death, and autopsy report (if possible). We will also analyse the employment of resuscitation attempts during the time frame of sudden cardiac arrest (SCA) in various patient populations throughout African countries. Conclusion: This study will provide comprehensive, contemporary data on the epidemiology of SCD in Africa and will help in the development of strategies to prevent and manage cardiac arrest in this region of the world

Roadmap to Achieve 25% Hypertension Control in Africa by 2025.

BACKGROUND: The Pan-African Society of Cardiology (PASCAR) has identified hypertension as the highest area of priority action to reduce heart disease and stroke on the continent. OBJECTIVES: The aim of this PASCAR roadmap on hypertension was to develop practical guidance on how to implement strategies that translate existing knowledge into effective action and improve detection, treatment and control of hypertension and cardiovascular health in sub-Saharan Africa (SSA) by the year 2025. METHODS: Development of this roadmap started with the creation of a consortium of experts with leadership skills in hypertension. In 2014, experts in different fields, including physicians and nonphysicians, were invited to join. Via face-to-face meetings and teleconferences, the consortium made a situation analysis, set a goal, identified roadblocks and solutions to the management of hypertension and customized the World Heart Federation roadmap to Africa. RESULTS: Hypertension is a major crisis on the continent but very few randomized controlled trials have been conducted on its management. Also, only 25.8% of the countries have developed or adopted guidelines for management of hypertension. Other major roadblocks are either government and health-system related or health care professional or patient related. The PASCAR hypertension task force identified a 10-point action plan to be implemented by African ministries of health to achieve 25% control of hypertension in Africa by 2025. CONCLUSIONS: Hypertension affects millions of people in SSA and if left untreated, is a major cause of heart disease and stroke. Very few SSA countries have a clear hypertension policy. This PASCAR roadmap identifies practical and effective solutions that would improve detection, treatment and control of hypertension on the continent and could be implemented as is or adapted to specific national settings