Quality of acute coronary syndrome care and in-hospital outcome in a resource-poor setting in Northern Ghana

¹Department of Internal Medicine, Tamale Teaching Hospital, Tamale, Ghana

^&Corresponding author
Abdul-Subulr Yakubu, Department of Internal Medicine, Tamale Teaching Hospital, Tamale, Ghana

Introduction    

Besides communicable diseases, countries in the African region are now facing an epidemic of cardiovascular diseases (CVDs) for which they lack the resources to adequately diagnose and manage. Coronary artery disease (CAD) is the single most common cause of mortality and loss of Disability Adjusted Life Years globally, with the greatest burden in low- and middle-income countries [1]. Sub-Saharan Africa has seen an increase in the incidence of CAD mainly due to the adoption of Western lifestyles and an aging population, leading to a higher prevalence of cardiovascular risk factors [1-3].

Acute coronary syndrome (ACS) represents a devastating manifestation of CAD. It comprises a spectrum of clinical manifestations that result from a sudden reduction of blood supply to the myocardium, resulting in myocardial ischaemia or injury [4]. The designation of ACS includes ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA) [5]. The long-term outcomes of ACS have progressively improved in high-income countries over recent decades, mainly due to effective acute treatment and improved primary and secondary preventive measures [6]. However, this is not the case in developing countries. Empirical evidence and limited studies suggest that the incidence of ACS is increasing in many African countries, and its management is frequently suboptimal, partly due to limited access to advanced care, resulting in high morbidity and mortality [2,7,8].

Care of patients with ACS in low-middle-income countries is fraught with challenges at all levels of health systems. Acute care is hampered by late presentation, inability to adhere to critical timelines for intervention, limited availability of acute reperfusion as a therapeutic option, and lack of health financing schemes that cater to emergency care [7]. Compliance with guideline medications like antiplatelet agents and statins is also frequently poor [9]. Other evidence-based non-pharmacological interventions such as smoking cessation, heart-healthy diets, exercise, and cardiac rehabilitation are frequently unavailable or not adhered to [10]. In a few centers in Africa that are adequately equipped with well-trained staff and logistics to manage CAD and its complications, including ACS, outcomes similar to those reported in high-income countries have been reported [11]. This demonstrates the feasibility of comprehensive ACS care with favourable outcomes if the proper measures are implemented to mitigate the challenges that hamper ACS care in Africa.

Data on the quality of ACS care provided in Ghana is scarce. In this study among patients presenting with ACS to the Tamale Teaching Hospital (TTH) in Northern Ghana, we assessed in-hospital outcomes and the extent of compliance to evidence-based therapy as outlined in the 2017 American Heart Association (AHA)/American College of Cardiology (ACC) report on clinical performance and quality measures for adults with STEMI and NSTEMI [12]. This information will help identify gaps and limitations to ACS care that can be improved upon and facilitate advocacy efforts for equitable allocation of healthcare resources.

Methods     

Study design and setting: this was a cross-sectional retrospective review of the medical records of patients admitted with a diagnosis of ACS to the Department of Internal Medicine of TTH from January 2021 to December 2022. Tamale Teaching Hospital is one of five public teaching hospitals in Ghana with a bed capacity of 800 that serves as a major referral center for the Northern part of Ghana. The population served is primarily rural and poor.

Study population: the study population comprised all patients with a diagnosis of ACS admitted to the Internal Medicine Department of TTH from January 2021 to December 2022. Patients were admitted primarily through the accident and emergency department of the hospital. Other routes of admission included the outpatient departments and in-patient transfers from other wards. Care was provided by a medical team comprising emergency room physicians, cardiologists, internal medicine specialists, and primary care physicians. Inclusion criteria were age ≥ 18 years and a diagnosis of ACS according to standard criteria [5]. The criteria for STEMI was a new ST-elevation at the J-point in two contiguous leads ≥ 1 mm except in leads V2 and where the cut-off was ≥ 2mm in men 40 years and older, ≥ 2.5 mm in men less than 40 years or ≥ 1.5 mm in women regardless of age [5]. Patients without ST elevation at presentation were categorized into NSTEMI or UA based on an elevated (at least one value above the 99^th percentile upper reference limit) or normal cardiac troponin level, respectively. Patients with other causes of myocardial injury or elevated cardiac troponins not attributable to acute ischemia such as chronic heart failure, renal failure, pulmonary embolism, or myocarditis were excluded. Also, patients without outcome data, those discharged against medical advice, or those who had another competing reason for their symptoms other than ACS were excluded.

Data collection: relevant patient medical records were retrieved from the electronic medical records database of the hospital and transferred onto a data collection template by trained research assistants under the supervision of a cardiologist. Data extracted included demographic information, cardiovascular risk factors, presenting symptoms, delay in presentation, treatment received, and in-hospital outcome. Treatment of interest included the appropriate use of antiplatelet agents, an appropriate dose of statin therapy, beta-blockers, angiotensin/aldosterone system antagonists, the reperfusion strategy employed as well as the delay in receiving such therapy. Any referrals for cardiac rehabilitation therapy were specifically looked for. Laboratory investigations including cardiac troponin levels were reviewed to confirm the diagnosis and identify comorbidities. Electrocardiograms (ECG) and echocardiograms were reviewed by a cardiologist to confirm the diagnosis and identify complications such as left ventricular systolic dysfunction, left ventricular aneurysms, thrombus formation, mitral regurgitation, myocardial wall rupture or pseudoaneurysms. In-hospital outcome measures assessed at discharge included left ventricular systolic dysfunction and other mechanical complications, symptomatic heart failure, persistent angina, or cardiac arrhythmia. With the information gathered, the level of adherence to 24 key performance and quality measures as contained in the 2017 AHA/ACC guidelines for adults with STEMI and NSTEMI was assessed to determine the quality of care provided and identify opportunities for improvement [12].

Statistical analysis: categorical variables were presented as counts and percentages (%), whilst continuous variables were summarized as their means with standard deviation or as median with their interquartile ranges, as appropriate. Results were summarized into tables. Data transformations and analysis were performed using the Statistical Package for the Social Sciences version 21.0 software (SPSS, IBM Corporation, Armonk, NY, USA).

Ethical considerations: the ethical approval for this study was waived by the Tamale Teaching Hospital Ethical Review Committee, Tamale, Northern Region, Ghana. All methods were carried out following local guidelines and regulations. The study conformed to the principles outlined in the Declaration of Helsinki on the ethical principles for medical research involving human subjects.

Results     

Between January 2021 and December 2022, 62 patients with ACS were admitted to TTH, of which 37 (59.7%) were males. The mean age was 56.0 ± 16.1 years, with a range of 21 - 89 years. It was observed that 61.3% had National Health Insurance coverage, whilst the rest paid out of pocket for their medical bills (Table 1). 21 (33.9%) were diagnosed with STEMI, whilst 35 (56.5%) and six (9.7%) had a diagnosis of NSTEMI and UA, respectively. The common presenting symptoms are summarized in Table 1. Chest pain, or dyspnoea was the presenting complaint in 80.6% of the patients. Gastrointestinal symptoms, including nausea, vomiting, or abdominal pains, were reported by 11.3% of patients. The median duration from symptom onset to hospital presentation was 24 hours (IQR 15-96 hours). Hypertension was the most common cardiovascular risk factor identified in the study participants (69.4%), while smoking was uncommon (3.2%).

To assess the quality of care experienced by individuals with ACS in the in-patient setting, the proportion of patients meeting key performance and quality measures defined in the 2017 AHA/ACC guidelines for adults with STEMI and NSTEMI were calculated and summarized in Table 2 [12]. Most patients received aspirin or a P2Y12 inhibitor at discharge (87.3% each), with 78.2% receiving dual antiplatelet therapy. Fewer patients received recommended high-intensity statin therapy (65.5%) or beta-blockers (69.1%). The left ventricular ejection fraction (LVEF) was documented for 38.2% of the patients by discharge. 75% of those with documented left ventricular systolic dysfunction (LVEF < 40%) were prescribed an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) at discharge. Among patients who had an LVEF ≤ 40% who were already receiving an ACEi and beta-blocker, and who had either heart failure or diabetes mellitus but had no documented contraindication to an aldosterone antagonist, only 16.7% were prescribed an aldosterone antagonist (spironolactone) at discharge.

Three (14.3%) patients presenting with STEMI received reperfusion therapy. Two patients had thrombolysis with streptokinase, and one was transferred out for primary percutaneous coronary intervention (PCI). One patient with NSTEMI who had persistent symptoms with conservative management was transferred for PCI. Among the 11 patients with STEMI who had no absolute contraindication to using fibrinolytic therapy, none received thrombolysis within the recommended 30 minutes of arrival. All patients with NSTEMI had cardiac troponin measurements; however, the median time to obtain the results after the presentation was 24 hours (IQR 15-24 hours). Only in one instance was the result available within six hours of arrival. No formal risk stratification score was documented for patients with NSTEMI. Stress testing for conservatively managed patients was not part of routine practice.

Since TTH was not a PCI-capable facility, performance measures related to PCI or coronary angiography were not scored. Similarly, no cardiac rehabilitation program existed in Northern Ghana over the study period. The performance measure assessing participation in an acute myocardial infarction registry is a binary question requiring a “yes” or “no” answer. There was no national or regional ACS registry during the study period. Door-in-door-out Time refers to the time from emergency department (ED) arrival to ED discharge for patients with acute STEMI who were transferred for primary PCI. The single patient transferred for primary PCI over the study period had a door-in-door-out time of several hours.

The last three quality measures regarding inappropriate use of nonsteroidal anti-inflammatory drugs (NSAIDs), inappropriate prescription of prasugrel in patients with prior stroke, and the inappropriate prescription of high-dose aspirin with ticagrelor are patient safety measures. Apart from 3 patients (4.8%) for whom NSAIDs were prescribed on admission, the scores for these measures were generally satisfactory. Seven (11.3%) in-hospital deaths were recorded. In-hospital mortality was 19% for those with STEMI. Common complications included left ventricular systolic dysfunction (19.4%) and symptomatic heart failure (38.7%) (Table 3).

Discussion     

The growth of CVD care infrastructure and human resources in the African region has yet to match up with the increasing burden of these diseases, and budget allocations in many of these countries still prioritize communicable diseases [10]. In this study, we shed light on the quality of ACS care offered in a tertiary hospital in northern Ghana using the 2017 AHA/ACC clinical performance and quality measures guidelines for myocardial infarction as a yardstick [12]. This guideline is intended to provide healthcare practitioners and their institutions with tools to assess the quality of care delivered and identify opportunities for improvement. The domains assessed include effective clinical care, patient safety, communication, coordination, efficiency, cost reduction, and public health [12]. It is believed that implementing these measures by healthcare providers and facilities will ultimately improve the quality of care and outcomes of patients with acute myocardial infarction [12].

Atherosclerotic plaque disruption and superimposed platelet-rich thrombus formation are the main pathophysiological mechanisms causing ACS. Aspirin inhibits the formation of thromboxane A2, a potent platelet aggregation stimulator. In the Second International Study of Infarct Survival (ISIS-2) trial, aspirin therapy within the first 24 h after STEMI resulted in a 23% relative risk reduction in 5-week cardiovascular mortality [13]. The use of P2Y12 receptor inhibitors has incremental benefits to aspirin, and dual antiplatelet therapy has become the mainstay treatment strategy after ACS as this is associated with improved cardiovascular outcomes [14,15]. Compliance with prescribing aspirin or P2Y12 inhibitors at discharge was high. The lower rates of aspirin prescriptions within 24 hours of arrival could be attributed to delays in establishing the diagnosis of ACS, especially NSTEMI or UA. We observed that the median time to obtain cardiac troponin measurements was 24 hours (IQR 15-24 hours). Out-of-pocket payment for these tests, as well as system delays, are contributory. A rise or fall in cardiac troponins is essential to diagnose acute myocardial infarction in the correct clinical setting [16]. Whilst STEMI is usually readily diagnosed on ECG, patients with NSTEMI may present with nonspecific ECG changes, making the timely measurement of troponin levels essential in the early diagnosis and risk stratification of these patients.

Despite the documented benefits of these medications in all patients with ACS, only about two-thirds of the patients in this study were discharged on a beta blocker or a high-intensity statin. Oral beta blockers also reduce cardiac automaticity and the risk of ventricular fibrillation following a myocardial infarction, in addition to their anti-ischemic and anti-anginal properties [17]. Statins, on the other hand, delay coronary atherosclerosis progression and can induce plaque regression and reduce cardiovascular events, including recurrent myocardial infarction, cerebrovascular events, and all-cause mortality [18]. These medications are now available as generics, making them easily accessible and affordable. Their coverage under the Ghana National Health Insurance Scheme presents an opportunity to improve their uptake for patients with an indication such as ACS.

Left ventricular ejection fraction is one of the strongest predictors of survival after ACS [19]. Transthoracic echocardiography (TTE) is a noninvasive and inexpensive means of assessing left ventricular function and identifying post-myocardial infarction complications to help guide therapy. However, due to the scarcity of skilled personnel and equipment in low-income countries like Ghana, ready access to TTE is limited and comes with substantial out-of-pocket patient costs [20]. It is noteworthy that for most of the period from January 2021 to March 2022, there was no in-hospital TTE service available at the study site, partly accounting for the low rate of in-hospital assessment of LVEF (38.2%) found in this study. Training non-cardiologists to perform focused point-of-care echocardiography to estimate LVEF can be a viable strategy to bridge this care gap [21].

Primary PCI has demonstrated superiority over fibrinolytic in terms of infarct artery patency, rates of recurrent ischemia, repeat revascularization, and overall clinical outcomes [22,23]. The study site did not offer primary PCI, and the nearest PCI-capable facility was more than ten hours away by road. As a result, thrombolysis was the primary reperfusion strategy available for eligible patients with STEMI, and primary PCI was generally inaccessible to most patients presenting at the study site. Additionally, thrombolysis for STEMI was only recently available (in the last quarter of 2022) at the study site, with streptokinase being the main thrombolytic agent used because of the high cost of alternative agents. In addition to late presentation (median time after symptom onset was 24 hours), these limitations meant that almost all patients presenting with ACS were managed medically, with only three patients receiving reperfusion therapy.

Late presentation characterizes ACS in many SSA countries. It can be attributed to a lack of patient education, poor or nonexistent emergency ambulance systems, low index of suspicion by physicians, and failure to obtain ECGs on time [2,24]. It is recommended that patients who present with STEMI to a non-PCI-capable hospital should receive timely fibrinolysis if timely transfer time for primary PCI (within ≤ 120 min of first medical contact) is not feasible [25,26]. The survival benefit of fibrinolysis is greatest when administered within the first 2 hours of symptom onset and declines progressively after that. Thus, the benefit of fibrinolytic therapy is most effective when provided promptly with a recommended Door-to Needle time of ≤ 30 minutes [25,26]. Given the cost implications of cardiac catheterization laboratories and the lack of sufficiently trained personnel to deliver primary PCI services in resource-poor settings like Ghana, it would seem more feasible, at least in the short term, to develop an efficient thrombolysis service to ensure eligible patients with STEMI have access to reperfusion therapy. Evidence shows that with adequate training, facilities without onsite cardiologists can adequately offer thrombolysis with encouraging door-to-needle times [27].

Some conservatively managed ACS patients have high-risk coronary artery disease, though they may not exhibit symptoms at rest during hospitalization. Further risk stratification with a submaximal stress test (exercise-based or pharmacological) before discharge can be employed to identify patients needing invasive angiography and possibly revascularization [28]. No risk-stratifying tool, such as the Global Registry of Acute Coronary Events (GRACE) score or the Thrombolysis in Myocardial Infarction (TIMI) score, was employed in patients with NSTEMI in this study [29,30]. Additionally, noninvasive stress tests were not performed or scheduled for conservatively managed patients with ACS, mainly because the study site could not offer these services.

No cardiac rehabilitation program existed within the study area at the time of the study. Cardiac rehabilitation programs offer supervised exercise training alongside other secondary prevention strategies and are designed to speed recovery and improve quality of life following acute cardiovascular events like myocardial infarction. Evidence abounds that timely referral of patients improves subsequent attendance and overall clinical outcomes [31]. Despite its proven benefits and the increasing burden of cardiovascular diseases, little emphasis has been placed on cardiac rehabilitation programs in the African region, where it is almost nonexistent [32]. The available evidence, however, supports the feasibility and benefit of a cardiac rehabilitation program, whether in its comprehensive form or modified to suit the local context, in low-income African countries [33,34].

This study was limited by its retrospective design. Sources of error, such as improper or non-documentation of interventions or timelines, can only partially be eliminated. Another limitation was the involvement of a single study site. However, since TTH is the largest tertiary facility that serves as a referral center in the northern part of Ghana, the result of this study is expected to closely reflect the current situation in northern Ghana.

Conclusion     

This study has provided insights into the care of patients presenting with ACS at a tertiary referral facility in Northern Ghana. Acute management of ACS remains challenging in Northern Ghana, where reperfusion therapy is almost nonexistent. Several gaps exist in the care quality, timeliness of interventions, and rehabilitation of patients presenting here with ACS. Given the increasing burden of CVDs in low-middle-income countries, there is an urgent need to improve the delivery of ACS care alongside promoting primary prevention strategies and population awareness campaigns.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Abdul-Subulr Yakubu conceptualized the study, analyzed the data, and wrote the initial draft manuscript. Dzifa Ahadzi revised the work and made important contributions to the main parts of the manuscript. All authors have read and approved the final manuscript.

Acknowledgments     

We wish to thank Dr. Moses Musah, Dr Philip Baalaboore, and Dr Fatima Chentiwuni Iddrisu for their various roles in data collection and the care of the patients.

Tables     

Table 1: baseline characteristics of patients

Table 2: performance and quality measures for acute coronary syndrome management

Table 3: in-hospital complications

References