Acute coronary syndrome patterns in the Young: risk factor profile and in-hospital outcomes in a tertiary referral hospital in Kenya.

INTRODUCTION: Acute coronary syndrome (ACS) accounts for coronary artery disease (CAD) -related morbidity and mortality. There has been growing concern about the rising incidence of ACS among young individuals globally both in developed and developing countries, including Sub-Saharan Africa. This group's phenotypic characteristics; risk factors and clinical outcomes are not well described. contextual and regional studies are necessary to understand the magnitude of ACS among young Individuals and help highlight challenges and opportunities for improved ACS outcomes in the region. The study aimed to describe the demographic and clinical characteristics of young individuals hospitalized with ACS and report on in-hospital outcomes. METHODOLOGY: This single-center retrospective study was conducted at the Aga Khan University Hospital, Nairobi. Medical records of all young individuals hospitalized with ACS from 30th June 2020 to 1st May 2023 were reviewed. We defined young individuals as 50 years or below. Categorical variables were reported as frequencies and proportions, and compared with Pearson chi- square or Fisher's exact tests. Continuous variables were reported as means or medians and compared with independent t-tests or Mann-Whitney U tests. P- value < 0.05 was considered statistically significant. RESULTS: Among 506 patients hospitalized with ACS, (n = 138,27.2%) were aged 50 years and below. The study population was male (n = 107, 79.9%) and African(n = 82,61.2%) predominant with a median age of 46.5 years (IQR 41.0-50.0). Hypertension (n = 101,75.4%) was noted in most study participants. More than half of the cohort were smokers (n = 69,51.5%) having a family history of premature ASCVD(n = 70,52.2%) and were on lipid-lowering therapy(n = 68,50.7%) prior to presentation. ST-segment-elevation myocardial infarction (STEMI) was the most common clinical manifestation of ACS (n = 77, 57.5%). Of the significant coronary artery disease (n = 75,56.0%), the majority of the individuals had single vessel disease (n = 60, 80%) with a predilection of left anterior deciding artery(n = 47,62.6%). The Main cause of ACS was atherosclerosis (n = 41,54.6%). The mean left ventricular ejection fraction was 46.0 (± 12.4). The in-hospital mortality was (n = 2, 1.5%). CONCLUSION: This study highlights that young individuals contribute to a relatively large proportion of patients presenting with ACS at our center. The most common presentation was STEMI. The principal cause was atherosclerosis. The findings of this study highlight the importance of developing systems of care that enable the early detection of CAD. Traditional cardiovascular risk factors were prevalent and modifiable, thus targets of intervention.

Predictors of Coronary Artery Disease in Heart Failure with Reduced Ejection Fraction at the Aga Khan University Hospital in Nairobi.

There appears to be an epidemiological transition in the etiology of heart failure in sub-Saharan Africa (SSA) in parallel with a steady increase in risk factors for coronary artery disease (CAD). SSA has limited access to heart failure and CAD diagnostics, limiting the number of patients who receive optimal care. Our objectives were to study the predictors of coronary artery disease among patients with heart failure with reduced ejection fraction (HFrEF) and develop a model to assist clinicians in determining the likelihood of CAD before cardiac catheterization. Methodology: This was a retrospective study at the Aga Khan University Hospital, Nairobi, which is equipped with diagnostic capabilities for heart failure and coronary artery assessment. We evaluated patients with HFrEF based on echocardiographic data over a 12-year period. Patients with coronary anatomical evaluation data were included. A multivariable model of CAD was generated using stepwise logistic regression. Results: Of the 1329 patients screened, 514 met the inclusion criteria. The mean age was 61.0 ± 12.8 years. There were 381 male cases (75.2%), and the predominant race was African, numbering 386 (75.2%). Most patients, 97%, were evaluated through conventional coronary angiography. Further, 310 (60.3%) cases had significant CAD. The prevalence of CAD in HFrEF was 52.3% in Africans, 85% in Asians, and 79% in Caucasians. In the multivariable logistic regression, the odds of having significant CAD was higher among participants with diabetes mellitus (aOR: 1.86; 95%CI: 1.15-3.03), Q waves (aOR: 2.12; 95%CI: 1.12-4.10), significant ST segment deviation (aOR: 4.14; 95%CI: 2.23-8.03), and regional wall motion abnormalities on echocardiogram (aOR: 6.53; 95%CI: 3.94-11.06). Conclusion: In this population, CAD was a major etiology in HFrEF among the African population. The most powerful predictors of CAD were type 2 diabetes, the presence of pathological Q waves, or ST segment shift on a 12-lead electrocardiogram, and regional wall motion abnormality on 2D echocardiogram. Highlights: There is an epidemiological transition in the cause of heart failure in sub-Saharan Africa (SSA) in keeping with the steady increase in cardiovascular risk factors for coronary artery disease (CAD).The prevalence of CAD in African patients with heart failure with reduced ejection fraction (HFrEF) was 52.3%.In the multivariable logistic regression, diabetic mellitus, pathological Q waves, significant ST segment deviation, and regional wall motion abnormalities were significantly associated with CAD.

Bleeding complications in patients on new oral anticoagulants for venous thromboembolism in Kenya.

BACKGROUND: The incidence of bleeding complications in patients with venous thromboembolism (VTE) on new oral anticoagulants (NOACs) has not been widely studied in contemporary clinical practice in Africa. The purpose of this study was to determine the rates of major bleeding, clinically relevant non-major bleeding (CRNM) and minor bleeding associated with NOAC use. METHODS: A retrospective review was carried out of patients diagnosed with venous thromboembolism and treated with NOACs at the Aga Khan University Hospital, Nairobi, from January 2014 to December 2019. Clinical and outcome data were collected from medical records and the hospital mortality database. All patients with VTE aged > 18 years and initiated on NOACS were recruited. Patients with missing information were excluded. They were followed up from the time of commencement of oral anticoagulation to completion of therapy, or to the time of the first major bleed, CRNM or minor bleeding. Data on bleeding were obtained from the hospital database and through telephone interviews. Unadjusted rates of the first major bleeding event or CRNM were calculated as the number of bleeding events per 100 person-years. RESULTS: Two hundred and forty-three patients with VTE were recruited and 222 (91.4%) were initiated on rivaroxaban, 12 (4.9%) on dabigatran and nine (3.7%) on apixaban, with a median follow up of 213 [interquartile range (IQR): 119-477] days. The median age of the patients was 57 (IQR: 45-71) years. A total of 64 bleeding events were identified in 50 (20.6%) patients. Overall, the incidence rate for bleeding events was 17.24 per 100 patient-years. The incidence rate of major bleeding was 3.79 per 100 person-years. Gastrointestinal bleeding was the most common major bleeding site. There were more females with bleeding events (70.7%) compared to males. Anaemia and the use of aspirin and other antiplatelets were associated with a higher incidence of major and CRNM bleeding [relative risk (RR) = 3.77, confidence interval (CI) = 1.37-10.39, p = 0.005 and RR = 8.89, CI = 2.06-38.33, p = 0.0003, respectively]. CONCLUSIONS: Most of these bleeds were minor, with the gastrointestinal tract being the most common source of major bleeding and menorrhagia being the commonest cause of bleeding. Anaemia and the use of aspirin were associated with a higher incidence of major bleeding.

Treatment and outcomes in patients with left ventricular thrombus - experiences from the Aga Khan University Hospital, Nairobi - Kenya.

INTRODUCTION: left ventricular thrombus (LVT) may lead to thromboembolism and has been associated with increased morbidity and mortality. Little is known about the incidence, etiology and outcomes in patients with LVT in Africa. The objective was to determine the etiology, treatment practices, rate of resolution and clinical outcomes in patients with LVT in the region. METHODS: a review of all echocardiograms performed in 2017 and 2018 at the Aga Khan University Hospital, Nairobi was carried out and patients with LVT identified. Physician review of charts was performed to document clinical characteristics and outcomes. RESULTS: during the study period 100 patients with LVT were identified (1.3% of adult echoes). The mean LVEF was 28.5% (±11.0%) and 88 (88%) patients had an LVEF of less than 40%. Underlying etiology of LV dysfunction was post myocardial infarction (MI) in 28 (28%), chronic ischemic cardiomyopathy in 42(42%) and non-ischemic cardiomyopathy in 30 (30%) patients. In 15 (15%) patients a stroke or TIA predated the diagnosis of LVT. Long term anticoagulation was given to 92 (92%) patients. Among these, 34 (37%) received warfarin while 58 (63%) were treated with a DOAC. In the 64 patients who had reassessment imaging (median duration 177 days), complete thrombus resolution was noted in 38 (59.4%). One-year clinical outcome data was available for 85 patients: 13 (15.3%) patients had died, 4 (4.7%) had suffered a stroke, and 8(9.4%) had had a bleeding episode. Rates of thrombus resolution (warfarin 64%, DOAC 55.6%, p=0.51), stroke (warfarin 2.9%, DOAC 1.7%, p=1.0) and bleeding (warfarin 5.9%, DOAC 5.2%, p = 1.00 were not significantly different among patients treated with warfarin and DOAC. CONCLUSION: we noted a high incidence of LVT compared to contemporary Western series. The majority of our patients were treated with DOACs. There were no significant differences in outcomes between patients treated with a DOAC and those receiving warfarin. Prospective evaluation on the efficacy and safety of DOACs for this indication is needed.

International Prospective Registry of Acute Coronary Syndromes in Patients With COVID-19.

BACKGROUND: Published data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear. OBJECTIVES: The purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre-COVID-19 cohorts. METHODS: From March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re-myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre-COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019). RESULTS: In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p < 0.001; COVID NSTE-ACS vs. MINAP: 417.0 min vs. 295.0 min; p = 0.012). Mortality in COVID-ACS patients was significantly higher than BCIS/MINAP control subjects in both subgroups (COVID-STEMI: 22.9% vs. 5.7%; p < 0.001; COVID NSTE-ACS: 6.6% vs. 1.2%; p < 0.001), which remained following multivariate propensity analysis adjusting for comorbidities (STEMI subgroup odds ratio: 3.33 [95% confidence interval: 2.04 to 5.42]). Cardiogenic shock occurred in 20.1% of COVID-STEMI patients versus 8.7% of BCIS patients (p < 0.001). CONCLUSIONS: In this multicenter international registry, COVID-19-positive ACS patients presented later and had increased in-hospital mortality compared with a pre-COVID-19 ACS population. Excessive rates of and mortality from cardiogenic shock were major contributors to the worse outcomes in COVID-19 positive STEMI patients.

Long-Term Outcomes and Factors Associated with Mortality in Patients with Moderate to Severe Pulmonary Hypertension in Kenya.

Background: Pulmonary hypertension is poorly studied in Africa. The long-term survival rates and prognostic factors associated with mortality in patients with moderate to severe pulmonary hypertension (PH) in Africa are not well described. Objectives: To determine the causes of moderate to severe PH in patients seen in contemporary hospital settings, determine the patients' one-year survival and the factors associated with mortality following standard care. Methods: A retrospective review of patients diagnosed with moderate to severe PH at Aga Khan University Hospital (AKUHN) from August 2014 to July 2017 was carried out. Clinical and outcome data were collected from medical records and the hospital mortality database. Telephone interviews were conducted for patients who died outside the hospital. Survival analysis was done using Kaplan-Meier, and log-rank tests were used to assess differences between subgroups. Cox regression modelling with multivariable adjustment was used to identify factors associated with all-cause mortality. Results: A total of 659 patients with moderate to severe PH were enrolled. Median follow-up time was 626 days. The survival rates of the patients at 1 and 2 years were 73.8% and 65.9%, respectively. The following variables were significantly associated with mortality: diabetes mellitus [adjusted HR 1.52, 95% CI (1.14-2.01)], WHO functional class III/IV [adjusted HR 3.49, 95% CI (2.46-4.95)], atrial fibrillation [adjusted HR 1.53, 95% CI (1.08-2.17)], severe PH [adjusted HR 1.72, 95% CI (1.30-2.27)], right ventricular dysfunction [adjusted HR 2.42, 95% CI (1.76-3.32)] and left ventricular dysfunction [adjusted HR 1.91, 95% CI (1.36-2.69)]. Obesity [adjusted HR 0.68, 95% CI (0.50-0.93)] was associated with improved survival. Conclusion: Pulmonary hypertension is associated with poor long-term outcomes in African patients. Identification of prognostic factors associated with high-risk patients will assist in patient management and potentially improved outcomes.

Cardiovascular risk factors among people living with HIV in rural Kenya: a clinic-based study.

OBJECTIVE: To determine the prevalence of cardiovascular risk factors and their association with antiretroviral therapy (ART) among HIV-infected adults in a rural sub-county hospital in Kenya. METHODS: This was a descriptive survey of patient charts characterising cardiovascular risk among adult patients (> 18 years) at Ukwala sub-county hospital between June 2013 and January 2015. Post-stratification survey weights were applied to obtain prevalence levels. Adjusted odds ratios (AOR) for each variable related to cardiovascular risk factors were calculated using logistic regression models. RESULTS: Overall, the prevalence of diabetes mellitus was 0.4%, 0.3% of patients had had a previous cardiovascular event (heart attack or stroke), 40.4% had pre-hypertension, while 10.4% had stage 1 and 2.9% stage 2 hypertension. Up to 14% of patients had elevated non-fasting total cholesterol levels. Factors associated with hypertension were male gender (AOR 1.59, p = 0.0001), being over 40 years of age (AOR 1.78, p = 0.0001) and having an increased waist circumference (OR 2.56, p = 0.0014). Raised total cholesterol was more likely in those on tenofovir disoproxil fumarate (TDF) (AOR 2.2, p = 0.0042), azidothymidine (AZT) (AOR 2.5, p = 0.0004) and stavudine (D4T) -containing regimens (AOR 3.13, p = 0.0002). CONCLUSIONS: An elevated prevalence of undiagnosed cardiovascular risk factors such as hypertension and raised total cholesterol levels was found among people living with HIV. There was an association between raised total cholesterol and nucleoside reverse-transcriptase inhibitor (NRTI) -based ART regimens. Our findings provide further rationale for integrating routine cardiovascular risk-factor screening into HIV-care services.

Outcomes in patients with acute coronary syndrome in a referral hospital in sub-Saharan Africa.

BACKGROUND: Coronary artery disease and its acute presentation 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 infarction (NSTEMI), and 36 had unstable angina (UA). The mean age was 60.5 years with 81.7% being male. Delayed presentation (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%. CONCLUSIONS: 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.