Registry for Acute Coronary Events in Nigeria (RACE‐Nigeria): Clinical Characterization, Management, and Outcome

Abstract

Background Coronary artery disease was hitherto a rarity in Africa. Acute coronary syndrome (ACS) accounts for coronary artery disease–related morbidity and mortality. Reports on ACS in Africa are few. Methods and Results We enrolled 1072 indigenous Nigerian people 59.2±12.4 years old (men, 66.8%) with ACS in an observational multicentered national registry (2013–2018). Outcome measures included incidence, intervention times, reperfusion rates, and 1‐year mortality. The incidence of ACS was 59.1 people per 100 000 hospitalized adults per year, and comprised ST‐segment–elevation myocardial infarction (48.7%), non–ST‐segment–elevation myocardial infarction (24.5%), and unstable angina (26.8%). ACS frequency peaked 10 years earlier in men than women. Patients were predominantly from urban settings (87.3%). Median time from onset of symptoms to first medical contact (patients with ST‐segment–elevation myocardial infarction) was 6 hours (interquartile range, 20.1 hours), and only 11.9% presented within a 12‐hour time window. Traditional risk factors of coronary artery disease were observed. The coronary angiography rate was 42.4%. Reperfusion therapies included thrombolysis (17.1%), percutaneous coronary intervention (28.6%), and coronary artery bypass graft (11.2%). Guideline‐based pharmacotherapy was adequate. Major adverse cardiac events were 30.8%, and in‐hospital mortality was 8.1%. Mortality rates at 30 days, 3 months, 6 months, and 1 year were 8.7%, 9.9%, 10.9%, and 13.3%, respectively. Predictors of mortality included resuscitated cardiac arrest (odds ratio [OR], 50.0; 95% CI, 0.010–0.081), nonreperfusion (OR, 34.5; 95% CI, 0.004–0.221), pulmonary edema (OR, 11.1; 95% CI, 0.020–0.363), left ventricular diastolic dysfunction (OR, 4.1; 95% CI, 0.091–0.570), and left ventricular systolic dysfunction (OR, 2.1; 95% CI, 1.302–3.367). Conclusions ACS burden is rising in Nigeria, and patients are relatively young and from an urban setting. The system of care is evolving and is characterized by lack of capacity and low patient eligibility for reperfusion. We recommend preventive strategies and health care infrastructure‐appropriate management guidelines.

Sex Differences in Acute Coronary Syndromes: A Global Perspective

“…Traditionally, there has been a focus on infectious diseases research in most of Sub-Saharan Africa (SSA), with a prior perception of low NCDs and, indeed, CAD mortality rates [ 89 ]. Although the increasing burden of ACS, and particularly STEMI, is being recognized in SSA, only small-scale data are available for most countries and much less on sex differences.…”

“…Overall, African patients are much younger than those in high-income countries [ 10 ], with an age difference that frequently reaches 10 years [ 90 ]. A contemporary national Registry for Acute Coronary Events in Nigeria (RACE Nigeria) reports a mean age of 59.2 ± 12.4 years [ 89 ]. Male predominance in registries was common.…”

“…Male predominance in registries was common. Similar to global trends, men presented about a decade earlier than women in frequency of ACS [ 89 ]; a high prevalence of CV risk factors was noted among women, particularly diabetes, hypertension and obesity [ 91 , 92 ], with a lower prevalence of smoking [ 92 , 93 ].…”

“…STEMI, comprising over half of all ACS presentations, was the predominant presentation in both sexes in many analyses [ 91 , 92 ], possibly reflecting the limited availability of diagnostic tools such as troponin, leading to a lower rate of documented MI cases, notably NSTEMI [ 9 ]. In RACE Nigeria, women presented with more NSTEMI [ 89 ].…”

“…Delays in the presentation were common for both sexes, with less than 10.9–11.2% presenting within the 12-h reperfusion window [ 89 , 92 ], reflecting the common use of non-medical transport to reach hospitals, where organized structures and ambulances may be lacking [ 9 ]. Women have been demonstrated to have longer door-to-admission times at the emergency department (ED) in Senegal, and more frequently presented with what was termed “atypical symptomatology” [ 92 ].…”