Profile Of Coronary Artery Disease Patients At Universitas Academic Hospital: 1994 Versus 2014

Abstract

Introduction Coronary artery disease (CAD) is a condition that decreases the flow of blood through the coronary arteries around the heart (Merriam-Webster Incorporated, 2019) that can lead to a heart attack (Yayan, 2014). It is the leading cause of death worldwide (Nowbar et al., 2019) and there are several risk factors that contribute to its development (Fuster and Kelly, 2010). Non-modifiable risk factors are age, gender and ethnicity/race and family history, while modifiable risk factors include hypertension, hypercholesterolemia, obesity and sedentary lifestyle, diabetes mellitus and smoking (Jaggi & Kearns, 2012; Winham et al., 2014; Yayan, 2014; Papadakis & McPhee, 2016; Nowbar et al., 2019). While it is reported that CAD in Sub-Saharan Africa is rare (Forouzanfar et al., 2012) reports from the World Health Organization (WHO) African region suggest that non-communicable diseases in this region are on the rise (World Health Organization African Regional Office, 2018). However, epidemiological data of this region is scanty. The only major studies available for South Africa (SA) are the Heart of Soweto study and the work of Prof. Bongani M Mayosi which report that the prevalence of modifiable risk factors for CAD is high and rising, especially in the black African population (Sliwa et al., 2008; Tibazarwa et al., 2009; Mayosi et al., 2009; Pretorius et al., 2011; Mayosi et al., 2012; Mayosi & Benatar, 2014), emphasizing the need for epidemiological studies into this phenomenon (Stewart et al., 2006; Sliwa & Mocumbi, 2010; Senkubuge & Mayosi, 2013). No CAD data exists for central SA. The profile of patients of patients presenting with CAD at Universitas Academic Hospital (UAH) have not been documented in the past. Aim To document the profile of public sector patients who had confirmed CAD (on coronary angiography) in central SA and determine if there was a change over twenty years. Methods This was a retrospective single-centre observational cohort comparing two time periods, twenty years apart, conducted at UAH, Bloemfontein. The main inclusion criterion was confirmed atherosclerotic CAD as reported on coronary angiography. Medical records/data of all public sector patients who underwent coronary angiography during 1994 and 2014 were evaluated. Demographic data, which forms part of the non-modifiable risk factors for CAD, and other relevant clinical information was recorded. Results Acute coronary syndrome (ACS) increased over the study period (p<0,0001) and this can be attributed to a notable increase in both Non-ST-Elevation Myocardial Infarction (NSTEMI) (p<0,0001) and ST-Elevation Myocardial Infarction (STEMI) (p<0,0001). Unstable angina decreased significantly over the study period (p<0,0001). There was a significant increase in the number of African patients who experienced STEMI over the study period (p<0,0001) and there was a substantial decrease in Caucasian patients who had ACS (p=0,0015). While NSTEMI increased significantly in Caucasian patients (p<0,0001), unstable angina in this group decreased significantly (p<0,0001). Females with ACS presented 4 years earlier in 2014 than those in 1994 (1994 median age = 66 years vs. 2014 median age = 62 years) (p=0,0031, 95% CI 1,3941; 6,7202). This trend was predominantly demonstrated in Caucasian females only (1994 median age = 66 years vs. 2014 median age = 62 years; p=0,04811, 95% CI 0,0276; 6,5743). The age of females with STEMI decreased significantly from 1994 (median age 69 years) to 2014 (median age 60 years) (p=0,0119; 95% CI 1,4195; 10,8305). Females with unstable angina were six years younger in 2014 (median age 60 years) than in 1994 (median age 66 years) (p=0,0269, 95% CI 0,5800; 9,1978). Caucasian females with NSTEMI was markedly older in 2014 (median age 66 years) than in 1994 (median age 50 years) (p<0,0001, 95% CI -19,7368; -12,8882), while those with STEMI became younger (1994 median age = 69 years vs. 2014 median age = 60 years, p=0,0269; 95% CI 0,9640; 14,6464). Conclusions There was an epidemiological change in public sector patients who had confirmed CAD in central SA with CAD increasing in patients of African and mixed ethnicity. ACS rose significantly over time with females presenting at a significantly younger age. STEMI became the most important presenting condition in patients of African ethnicity whilst NSTEMI increased in Caucasian patients. These findings have important implications for central SA public sector patients presenting with chest pain – the risk of STEMI in patients of African ethnicity is increasing and should not be ignored by clinicians.