Non-traumatic chest pain in patients presenting to an urban emergency Department in sub Saharan Africa: a prospective cohort study in Tanzania

Abstract

Background Non-traumatic chest pain (NTCP) is a common reason for emergency department (ED) attendance in high-income countries, with the primary concern focused on life threatening cardiovascular diseases. There is general lack of data on aetiologies, diagnosis and management of NTPC in Sub Sahara African (SSA) countries. We aimed to describe evaluation, diagnosis and outcomes of adult patients presenting with NTCP to an urban ED in Tanzania. Method This was a prospective observational cohort study of consecutive adult (≥18 years) patients presenting with non-traumatic chest pain to the Emergency Medicine Department (EMD) of Muhimbili National Hospital (MNH) in Dar es salaam from September 2017 to April 2018. Structured case report form was used to collected demographics, clinical presentation, investigations, diagnosis, and EMD disposition and in hospital mortality. We determined frequency of NTCP among our patients, aetiologies, 24-h and 7-day in-hospital mortality, and predictors for mortality. Results We screened 29,495 adults attending EMD-MNH during the study and 389 (1.3%) presented with NTCP of these, 349 (90%) were enrolled. The median age was 45 (IQR 29–60) years and 177 (50.7%) were female. Overall, 69.1% patients received electrocardiography (ECG) in the EMD and 34.1% had a troponin test. Heart failure and pulmonary tuberculosis (PTB) were the leading hospital diagnoses (12.6% each), followed by chronic kidney disease (10%) and acute coronary syndrome (ACS) (9.6%). Total of 167 (48%) patients were admitted, and the 24-h and 7-day in-hospital mortality were 5 (3%) and 16 (9.6%) respectively. Univariate risk factors for mortality were a Glasgow Coma Scale of < 15 [RR = 3.4 (95%CI 3.2–23)], Acute Coronary Syndrome [RR = 5.7 (95% CI 1.7–11.8) and Troponin > 0.04 ng/ml [RR 2.9 (95%CI 1.2–7.3)]. Features distinguishing cardiovascular from other causes were: bradycardia [RR = 2.6 (95%CI 2.1–3.2)], heart beat awareness [RR = 2.3 (95%CI 1.7–3.2)] and history of diabetic mellitus [RR = 2.2 (95% CI 1.6–3.0)]. Conclusion In this ED of SSA country, heart failure and pulmonary tuberculosis were the leading causes of NCTP, and ACS was present in 9.6%. NTCP in this setting carries high mortality, and ACS was the leading risk factor for death. ED providers in SSA must increasingly consider cardiovascular causes of NTCP.

Patterns of Emergency Care for Possible Acute Coronary Syndrome Among Patients with Chest Pain or Shortness of Breath at a Tanzanian Referral Hospital

“…The majority of patients were diagnosed with symptomatic hypertension or heart failure, two diagnoses that arguably require exclusion of ACS. Although not the focus of our study, the large numbers of ED patients we observed being diagnosed with heart failure or hypertension are consistent with what has been reported elsewhere in Tanzania [9,23], suggesting that these diseases warrant particular attention from public health officials. Less than 1% of enrolled patients received empiric treatment with aspirin, an inexpensive and widely available treatment known to reduce mortality in ACS.…”

“…Chest pain was present in 6.7% of adult ED patients, more than five-fold higher than the prevalence observed elsewhere in Tanzania, and similar to the prevalence observed in EDs in Europe and the United States [5,21,22,23]. The prevalence of chest pain noted in our setting is remarkable, given the recent finding that most Tanzanian adults would not present to a hospital for chest pain [15].…”

“…As there have been few other studies of diagnostic workups for chest pain and shortness of breath in SSA, additional research is needed to determine if the care we observed in northern Tanzania is representative of practices across SSA. At a national referral hospital elsewhere in Tanzania, 69% of ED patients with chest pain received an ECG and 39% underwent cardiac biomarker testing [23]. As many hospitals in SSA do not have access to electrocardiograms or cardiac biomarker testing [14], complete diagnostic workups for ACS may be even rarer in other settings.…”

“…In settings outside SSA, ACS symptoms such as chest pain or shortness of breath are common among emergency department (ED) patients, and diagnostic workups for ACS are routine [5,8,21]. In contrast, in a single-center study in urban Tanzania, chest pain was present in only 1.3% of adult ED patients and 9.6% of those with chest pain were diagnosed with ACS [23]. However, beyond this single study, there is currently limited data regarding the prevalence of chest pain among ED patients, the risk profiles of such patients, and the diagnostic workups and treatments given to such patients in SSA.…”

The NSW Pathology Atlas of Variation: Part I—Identifying Emergency Departments With Outlying Laboratory Test–Ordering Practices

“…[38][39][40] As a presenting complaint, abdominal pain has been described as a diagnostic challenge 34,41,42 for ED clinicians, with an array of potential causes ranging from mild to serious lifethreatening conditions 36,41,43,44 and hospital admission rates ranging between 16.5% and 36%. 36,38,44 Similarly, chest pain is frequently cited as one of the top 5 reasons for patients' presentation to the ED, 30,33,40,45 with studies between 2014 and 2019 reporting chest pain in ED cohorts representing between 1.5% and 1.82% in sub-Saharan Africa, 46,47 4.11% and 4.7% in the United States, 30,33,48 and 11% and 13% in Norway 40,45 (where EDs require general practitioner referral 45 ). Commensurate with abdominal pain, the cause of chest pain is diverse, [47][48][49] ranging from nonspecific to life-threatening conditions, with reported admission rates varying between 30.6% 48 and 89%.…”