Delays in Cardiovascular Emergency Responses in Africa: Health System Failures or Cultural Challenges?

INTRODUCTION

Noncommunicable diseases are the leading cause of morbidity and mortality in low- and middle-income countries (LMICs).¹ Among noncommunicable diseases, the incidence of cardiovascular disease (CVD) has increased by about 50% over the last 30 years in sub-Saharan Africa (SSA).² The incidence and outcomes of CVD in LMICs are influenced by factors, including urbanization and related lifestyle changes, belief systems and practices, level of education, and economic and political systems, translating into poor health-seeking behavior and emergency health care systems.^1,2 The scope of cardiovascular emergencies includes hypertensive emergencies, acute heart failure (HF), acute coronary syndromes (ACS), stroke, aortic dissection, pulmonary embolism, cardiac tamponade, and cardiac arrest. In 2017, ischemic heart disease accounted for about 5% of all deaths and 40% of cardiovascular deaths in SSA, commonly presenting as HF.² HF has an estimated 6-month mortality of 18%, a 5-year survival rate of 50%, and a 30-day rehospitalization rate of 25% in SSA.² The surge in cardiovascular emergencies and their sequelae has been driven by increases in the incidence of cardiovascular risk factors, like hypertension, diabetes, and adoption of a Western lifestyle.^2,3 The pooled prevalence of hypertension in SSA, according to the Pan-African Society of Cardiology, is about 30%, with figures from individual studies ranging from 19.3% to 39.6%.⁴ The role of hypertension in atherosclerotic CVDs, such as ACS and stroke, has been demonstrated in the multinational INTERHEART and INTERSTROKE studies.⁵

Timely intervention is critical in ACS and stroke to prevent complications. Immediate action is necessary to achieve maximum benefit within a narrow window of opportunity. Prompt identification, diagnosis, and appropriate therapeutic measures are crucial for successful management. Delay in intervention may result in significant morbidity and mortality, underscoring the importance of early and decisive action in these clinical scenarios.^6,7 The current standard of care for patients with ACS is to have revascularization therapy, preferably within 12 hours of symptom onset and within 120 minutes of diagnosis by a medical professional, with a door-to-needle time not exceeding 30 minutes from first contact with the health facility.⁶ However, for infarctive strokes, revascularization therapy is recommended within a maximum of 4.5 hours of symptom onset, with earlier times being preferred.⁷ For ACS, the inability to reach a facility capable of performing a percutaneous coronary intervention (PCI) within 120 minutes is an indication to offer fibrinolytic therapy, preferably within 10 minutes of taking the decision.⁶ Failing to adhere to these timelines puts the patient at risk of complications, such as heart failure, malignant cardiac arrhythmias, permanent neurological deficits, and, ultimately, cardiac arrest. Therefore, it is essential to ensure prompt and appropriate action is taken to mitigate these risks.

Cardiac arrest is the ultimate cardiovascular emergency, denoting a sudden cessation of mechanical activity of the heart, with or without the presence of electrical activity. These patients have no active circulation, and failure to promptly restore circulation results in ischemia to major organs, culminating in multi-organ failure and death. Irreversible anoxic brain injury begins after 4 minutes of cerebral ischemia, underscoring the importance of time in resuscitation efforts. ACS is a common cause of cardiac arrest, often due to related cardiac arrhythmias.⁶ Other common causes are collectively referred to as the “Hs” (hypovolemia, hyperkalemia, hypokalemia, hypoxia, acidosis, and hypothermia) and “Ts” (tension pneumothorax, cardiac tamponade, coronary and pulmonary thrombosis, and toxins).⁸ Management of cardiac arrest involves early defibrillation based on the underlying heart rhythm, fast and rhythmic chest compressions to maintain perfusion, rescue breaths to maintain oxygenation, and the use of emergency medications, such as adrenaline and amiodarone, as appropriate.⁸

In clinical practice, there have been several situations in LMICs, including SSA, where sufferers of ACS and infarctive stroke report to the intervention-capable facilities outside the ideal timelines, precluding the administration of standard therapy, which results in greater expenditure on treatment and rehabilitation.^9–11 The reasons for these delays in arrival are multifactorial and broadly categorized into patient-related and health system delays.

Considering the aforementioned, it is prudent to question whether personal and systemic deficiencies weigh equally in delayed optimal therapy for cardiovascular emergencies in Africa. Given the ravaging effects of these emergencies on families, communities, and the economy, what are the most appropriate measures to mitigate them?

CASE VIGNETTES IN AFRICA

CAUSES AND CLINICAL RELEVANCE OF TIME DELAYS IN MANAGING CARDIOVASCULAR EMERGENCIES

CVD management guideline recommendations for physicians recommend intervention within specific time frames to maximize outcomes.^6,7 Unfortunately, both patients in the described cases reported to the hospital many hours after onset of symptoms, limiting their therapeutic options. The first patient arrived outside the time limit for considering thrombolytic therapy for infarctive stroke.⁷ Late arrival at the hospital has been described by various authors across Africa: in Senegal,¹² Morocco,¹³ South Africa,¹⁴ and Egypt.¹⁵ Pre-hospital delays have been attributed to various factors, including poor understanding of symptoms by patients,^13,16 being married, female gender,¹² the absence of emergency services to transport patients from home on good road networks to the hospital, and absence of a centralized referral system.^12,13 Similar observations have been made among patients with ACS. The second patient interpreted her chest pain as heartburn, which is a common misinterpretation of chest pain as stated in a study by Stassen et al.¹⁶ Just as this patient presented outside the recommended 12-hour window,⁶ various studies have shown this to be the trend in the African setting as demonstrated in Egypt,¹⁰ Burkina Faso,¹⁷ and Senegal.¹⁸ Her presentation with acute HF was, therefore, unsurprising.

Though the patient in case 1 got a diagnostic CT scan of the brain done, delays in this process were demonstrated. Similarly, there have been delays in getting ECGs to aid physicians in diagnosing and instituting management for patients reporting with ACS. This may either be due to unavailable diagnostic logistics in the primary facilities or health workers failing to attach the level of urgency that befits the situation. The absence of a clear plan for such emergencies results in some health workers not knowing what roles to play, how urgently to do so, and which channels to activate for prompt care.

While the availability of reliable emergency services is low in SSA, there is varied patronage of these services even when present, from as low as about 4% in Senegal¹² to 31% in South Africa.¹⁴ Emergency services are provided by trained paramedics who, in some jurisdictions, can identify emergencies and offer life-saving therapy en route to the appropriate facility. These paramedics can perform ECGs, administer thrombolytics where appropriate,¹⁶ and liaise with PCI services in hospitals to ensure that relevant interventional teams are on standby awaiting the patient’s arrival. This is absent in SSA and is described as a fragmented coronary care network.¹⁶ As a result, patients may arrive in hospitals without any prior arrangements made, prolonging the time to receive the required care. Non-emergency vehicles, which are the more frequently used type of transportation, do not have these privileges, while the absence of sirens on these vehicles makes them subject to the prevailing vehicular traffic conditions. Poor roads in rural and semi-urban areas in most African countries also prolong the time taken to arrive at facilities capable of these services. This contributes to delays in arriving at the relevant health facilities to obtain the required help.

On arrival in the hospital, triage formalities delay revascularization therapy as reported in South Africa,¹⁶ where health workers confirmed that patients with chest pain are triaged and seen as usual. Brain and heart tissue lost cannot be regenerated, requiring that these ACS and strokes be prioritized above the regular bureaucratic systems to prevent life-threatening complications. ECGs and head CT scans (depending on which is appropriate for the suspected diagnosis) for such patients must be done as part of the initial assessment for prompt therapy where required.

A unique source of delay is observed in the second case: inability to afford therapy. The cost of these interventions is high in SSA.¹⁸ They are priced in U.S. dollars, a currency against which most African currencies perform poorly. In Ghana, a coronary angiogram with a stent costs a minimum of US$3500, with thrombolytic therapy costing about 30% of this. Considering a minimum wage of less than US$2 per day, it can be appreciated how steep the costs of these services are. The second patient was denied revascularization therapy as she could not afford PCI, which exposed her to the full extent of morbidity associated with myocardial infarction.⁶

IMPROVING THE STATUS QUO

We propose that to effectively tackle the delays related to cardiovascular emergencies, they should be addressed in “3 delay domains”: personal/patient-related delays, systemic delays (which encompasses provisions in place to ensure that a person who decides to report to the hospital has a safe means of transportation to arrive at the appropriate facility with minimum delay), and health facility-related delays.

CONCLUSION AND RECOMMENDATIONS

Cultural characteristics, which influence personal health behavior, are key causes of delays in accessing emergency cardiovascular services. However, it is evident that systemic issues synergize with these factors in limiting prompt reportage to hospitals and start of treatments.

Improving the standard of care requires multidisciplinary collaboration, including educating the populace on symptoms of cardiovascular emergencies, like ACS and stroke, and what to do during an event. Improving public awareness and referral systems is crucial to reduce prehospital fatalities. An improved understanding of cardiovascular emergencies and their attendant health implications will reduce delays. There must also be investment in the emergency services to improve their reliability and professionalism and bolster their role in the emergency cardiovascular care network. However, this cannot be achieved without ample investment from governments and the private sector, as the costs are too high for the average citizens to afford in SSA.