ST-Elevation Myocardial Infarction Systems of Care in Africa: A Scoping Review

Albertus Johannes Pool; Pierre Christo Smit; Helen Slabber; Willem Stassen

doi:10.5334/gh.1524

Figures & Tables

PRISMA flow diagram of database searches conducted.

Table 1

Patient-related challenges.

BARRIER	COUNTRY	COMMENTS	POTENTIAL SOLUTION
Delayed patient presentation	RSA, Egypt, Tunisia, Maghreb region, Kenya, Senegal, Ethiopia, Côte d’Ivoire, Libia, Nigeria, Sudan	Lack of ACS symptom recognition Education level Socio-economic status Reluctance to seek help	Effective education campaigns for patients and healthcare workers Awareness of early STEMI management Build trust with patient and families
Long travel distance	Egypt, Sudan, Ethiopia		Telemedicine Task shifting Inclusion of PHCs and small clinics as spokes
Non-adherence to discharge medications	RSA, Tanzania		Education Policy guidelines
Younger age STEMI and HIV presentation	RSA		Early management of risk factors
Delayed treatment times in elderly and women	Tunisia, Sudan		Education
Younger age STEMI presentation	RSA, Egypt, Maghreb region, Kenya, Ethiopia, Côte d’Ivoire, Nigeria, Tunisia		Early management of risk factors
FACILITATOR	COUNTRY	COMMENTS	RESULTS
Education campaigns	Egypt	Education campaigns focusing on social media, TV advertisements, press releases, and public sessions, including the education of relatives.	Decrease in FMC-to-balloon time.

[i] Abbreviations: ACS, acute coronary syndrome; FMC, first medical contact; Maghreb, combined Tunisia, Morocco, and Algeria; PHC, primary healthcare centre; RSA, Republic of South Africa; STEMI, ST-elevation myocardial infarction.

Table 2

Healthcare funding challenges.

BARRIER	COUNTRY	COMMENTS	POTENTIAL SOLUTION
Lack of health insurance	Cameroon, Côte d’Ivoire, Nigeria, Ethiopia, RSA		Government funding for STEMI care Bundling cost of STEMI care Education about importance of treatment costs and insurance Small amount to be paid by patient
Private sector owned facilities	RSA	Can only be availed by insured patients or after significant upfront payments. Causes delays and denial of thrombolysis	Government social funding for STEMI care to those below poverty line Public private partnerships
FACILITATOR	COUNTRY	COMMENTS	RESULTS
Health insurance available	Egypt, Maghreb region		Increase access to STEMI care
Cost-effective analysis	Ethiopia	An integrated package consisting of aspirin, ACE-inhibitor, beta-blocker, and streptokinase yielded significant cost-benefit compared to PPCI	Advised to reprioritise basic pharmacologic regimens for AMI treatment in resource-constrained settings rather than investing in high-cost interventions like PCI

[i] Abbreviations: AMI, acute myocardial infarction; PPCI, primary percutaneous coronary intervention; RSA, Republic of South Africa; STEMI, ST-elevation myocardial infarction.

Table 3

Prehospital challenges.

BARRIER	COUNTRY	COMMENTS	POTENTIAL SOLUTION
Limited/overburdened EMS	Ethiopia, Nigeria, Tunisia, Egypt, RSA, Côte d’Ivoire, Tanzania		Government funding to increase availability of EMS Trained prehospital providers Transfer policies in place between PCI and non-PCI facilities Availability of telemedicine Availability of bolus thrombolytics
FACILITATOR	COUNTRY	COMMENTS	RESULTS
Accessibility of prehospital fibrinolysis	Tunisia, Senegal		Shorten delay to fibrinolysis

[i] Abbreviations: EMS, emergency medical services; PCI, percutaneous coronary intervention; RSA, Republic of South Africa.

Table 4

Healthcare facility challenges and referral.

BARRIER	COUNTRY	COMMENTS	POTENTIAL SOLUTION
Inefficient healthcare facilities	RSA, Côte d’Ivoire, Kenya, Maghreb region, Libya, Somalia, Nigeria, Egypt	Delays in STEMI treatment Ineffective patient flow Junior healthcare providers Uncoordinated systems of care	Government funding ECG analysis campaigns Implement STEMI Systems of Care Geographic mapping Feedback and quality assurance initiatives Pharmacoinvasive approach
Lack of resources	Ethiopia, Côte d’Ivoire, Kenya, RSA, Egypt	Lack of medications Utilisation of BMS Lack of CCU beds	Government funding Better use of health insurance scheme Lobbying to government that organisation of care is cost-effective and essential for resource optimisation Focus on set-up of 24/7 hub, and then spokes with access to fibrinolytics
FACILITATOR	COUNTRY	COMMENTS	RESULTS
Establishment of new PCI facilities	Côte d’Ivoire, Senegal		Thrombolysis rates increased from 11.3% to 31%
Availability of trained physicians and expert consultation	RSA		Decreased reperfusion times
Hub-and-spoke model	RSA	STEMI patients receive thrombolytics at spoke hospital, and further referral to tertiary institutions for failed thrombolysis if required	However, these systems are still troubled by prolonged triage times, limited resources, a high patient burden, and insufficient ECG diagnostic proficiency
Greater adherence to recommendations and better organisation of STEMI treatment stakeholders	Tunisia		A substantial increase in reperfusion rates
STEMI stent for life initiative	Egypt		An improvement of primary PCI rates along with median D2B times
Education campaigns	Egypt		Increase in immediate transfers to PCI facilities, increased number of PCIs, a decrease in fibrinolysis, and a significant decrease in D2B times
Hub-and-spoke model	Egypt		D2B times were reduced, the use of fibrinolysis decreased, primary PCI increased, both median CCU and total hospital stay days decreased, In-hospital mortality improved from 6.4% to 2.8%.

[i] Abbreviations: BMS, bare metal stents; CCU, coronary care unit; D2B, door-to-balloon; Maghreb region, Morocco, Tunisia, Algeria; PCI, percutaneous coronary intervention; RSA, Republic of South Africa; STEMI, ST-elevation myocardial infarction.

Table 5

Policies, legislation, and quality insurance.

BARRIER	COUNTRY	COMMENTS	POTENTIAL SOLUTION
Non-compliance to discharge medication	Ethiopia, Kenya, Nigeria, Tunisia		Discharge algorithms, policies Awareness campaigns
Absence of STEMI SOC	RSA, Egypt, Tunisia, Kenya		Create STEMI networks in individual communities Legislation to by-pass non-PCI/fibrinolysis capable hospitals
FACILITATOR	COUNTRY	COMMENTS	RESULTS
STEMI register introduction	Tunisia, RSA, Nigeria, Kenya		Stimulated improvement in ACS care, increased PCI, aided in data collection to assess time trends, current status, and areas for improvement

[i] Abbreviations: ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; RSA, Republic of South Africa; STEMI SOC, ST-elevation myocardial infarction Systems of Care.

Table 6

Technology gaps.

BARRIER	COUNTRY	COMMENTS	POTENTIAL SOLUTION
Lack of ECGs	Egypt, Kenya, RSA		Explore cheap but high-quality ECG machines like STEMI India ECG telemetry from FMC to higher centre
FACILITATOR	COUNTRY	COMMENTS	RESULTS
Use of instant messaging for telemetry purposes	RSA, Egypt	Use of WhatsApp® to send ECGs	Improve STEMI care.
Telecardiology	Côte d’Ivoire	Hub-and-spoke telecardiology project	Cardiologists were able to support non-urban hospitals in early diagnosis and treatment of STEMI
GIS	RSA		Use of geospatial analysis to determine STEMI treatment and transportation pathways

[i] Abbreviations: FMC, first medical contact; GIS, geographic information system; RSA, Republic of South Africa; STEMI, ST-elevation myocardial infarction.

Table 7

Healthcare worker challenges.

BARRIER	COUNTRY	COMMENTS	POTENTIAL SOLUTION
Healthcare worker shortage	Cameroon, Egypt, RSA, Kenya, Ethiopia	Shortage of trained interventional cardiologists, nurses, and technicians.	Task shifting HCW incentives
Hesitancy in ECG diagnosis and thrombolytic administration	Kenya, RSA	Delayed fibrinolytic therapy.	HCW training campaigns
FACILITATOR	COUNTRY	COMMENTS	RESULTS
Healthcare worker training	Egypt, Tunisia	CME campaigns	Improved ACS management

[i] Abbreviations: ACS, acute coronary syndrome; CME, continuous mandatory education; HCW, healthcare worker; RSA, Republic of South Africa.

ST-Elevation Myocardial Infarction Systems of Care in Africa: A Scoping Review

Figures & Tables

Figure 1

Figure 2