SA Heart Journal

Cape Recife nature reserve

Photo: Ruchika Meel — Fri, 07 Mar 2025 10:33:26 +0000

The original Portuguese name “Cape Recife” translates to “Cape of the reefs”, a reference to the geological features of this south-eastern part of South Africa’s coastline upon which many ships met their end.

A contemporary perspective on coronary artery disease in sub-Saharan Africa

K. McCutcheon — Thu, 27 Feb 2025 00:00:00 +0000

The Hub and Spoke model: Is it out of reach in South Africa?

R. Meel — Fri, 28 Feb 2025 00:00:00 +0000

Management and outcomes of patients with ST-segment elevation myocardial infarction in the Western Cape Province of South Africa

Fri, 07 Mar 2025 10:15:00 +0000

Ischemic heart disease (IHD) is the leading cause of mortality globally and ranking among the top five causes of death in South Africa (SA). Acute coronary syndromes (ACS), particularly ST-segment elevation myocardial infarction (STEMI), contribute significantly to this burden. Despite its importance, SA lacks comprehensive ACS data, limiting the detection, estimation of cases, and understanding of patient outcomes. This study aimed to assess STEMI care within the Tygerberg Hospital (TBH) referral network in SA’s Western Cape Province. The study objectives were to evaluate the distribution of patients undergoing primary percutaneous coronary intervention (PCI) versus the pharmacoinvasive strategy, assess mortality and ACS recurrence, and investigate reasons for not performing angiography or PCI.

This retrospective analysis of STEMI data from the Tygerberg Registry of ACS (TRACS) included 292 patients admitted between April and December 2020. The pharmacoinvasive strategy was employed in 65.1% of cases, with 18.5% receiving primary PCI. In-hospital and 30-day mortality rates were 5.5% and 6.9%, respectively, with a 3.1% recurrence of ACS.

The study concluded that despite SA’s healthcare limitations, the pharmacoinvasive strategy, facilitated by a hub and spoke outreach model, yields outcomes comparable to international cohorts. This underscores the clinical relevance of protocolized STEMI care in resource-limited settings.

Ethnic differences in risk factor profiles in subjects with coronary disease attending a state hospital in KwaZulu-Natal

D.P. Naidoo — Fri, 07 Mar 2025 00:00:00 +0000

Objectives: This study compares the profile of coronary artery disease (CAD) across different ethnic groups at a tertiary referral hospital in KwaZulu-Natal.

Method: We reviewed the clinical records of 1 104 subjects who underwent coronary angiography at Grey’s Hospital for suspected CAD over a 5-year period (2012 - 2016). Uni- and multivariable analysis was used to identify associations of risk factors with CAD.

Results: Coronary artery disease was present in 886 subjects, of whom 69.9% were male. The majority were of Indian ethnicity (60.8%). The mean age of Africans was younger (54.9 ± 10.8 years) compared to Indians (58.0 ± 11.0 years), Coloureds (58.6 ± 12.3 years) and Whites (60.0 ± 10.5 years) (p=0.001). The prevalence of premature CAD (PCAD) (<55 years in males and <65 years in females) was 46% of males and 66,7% in females. Most African females (84,6%, p=0.01) and white females (75,6%, p=0.01) presented with PCAD. ST-elevation myocardial infarction was the most frequent presentation among African subjects (n=99, 66.0%), followed by Whites (n=76, 45.2%) and Indians (n=240, 44.5%), and least common among Coloureds (n=11, 37.9%) (p<0.001). The most prevalent risk factors were dyslipidaemia (95.1%), hypertension (70.3%), smoking (67.4%) and diabetes (57.2%). The prevalence of smoking was lowest in the African group (51.3%) compared to about 66% in the other groups (p<0.001) (Table I). About 80% of Indians and Whites had clustering of 3 or more risk factors compared to 39.3% of Africans (p<0.001). A family history of CAD lowest among African (n=13, 8.7%) and Coloured subjects (n=11,37.9%) (p<0.001) and a history of previous MI was obtained in 5.3% of African subjects compared to >23% in each of the other ethnic groups (p<0.001). Single vessel disease was commoner among Africans (48.7%), while Indians had more triple vessel disease (47.7%), (p<0.001). Univariate analysis identified risk factors and ethnicity (Indians, p=0.02) and Whites, p=0.02) as being associated with CAD, but on multivariable analysis ethnicity fell away. Age (46 - 65 years: OR: 2.2 [1.5 - 3.3], age >65 years: OR: 4.8 [2.8 - 8.2], male gender (OR: 2.7 [1.9 - 3.9]), history of smoking (OR: 2.0 [1.4 - 3.1] (all p<0.001) as well as diabetes (OR: 1.7 [1.2 - 2.4], p=0.005) and atherogenic dyslipidaemia (OR: 1.7 [1.2 - 2.4], p=0.004) were independent cardiovascular risk factors associated with the presence of CAD.

Conclusion: Major risk factors were associated with CAD at a young age across all race groups. Although Africans had a lower risk factor burden, the low prevalence of a family history of MI and near absence of a previous history of MI indicate that recent environmental and / or lifestyle changes that have contributed to the emergence of CAD, often premature, in this group.

The profile of subjects with suspected coronary artery disease who have atypical chest pain symptoms

P. Premsagar, D.P. Naidoo — Fri, 07 Mar 2025 00:00:00 +0000

Background: This study describes the risk factor profile of subjects with coronary artery disease (CAD) who present with atypical chest pain.

Method: Hospital records of patients with chest pain who did not satisfy the criteria for typical angina and who underwent both sestamibi nuclear imaging and coronary angiography were evaluated over a 6 year period (2002 - 2008).

Results: Amongst 5 378 subjects referred for evaluation of myocardial ischaemia to a tertiary hospital, the prevalence of atypical / non-anginal pain was 9.9% (531 patients). Of the 173 subjects who underwent both nuclear scans and coronary angiography, 99 (M 66, F 33) (57%) had epicardial CAD at angiography (>50% stenosis) with equal distribution of single, double and triple vessel disease. There was no difference in the pretest probability of CAD in subjects with and without CAD (20.5% vs. 21.9% p=0.891). Neither the number of chest pain criteria nor the individual pain characteristics were associated with the presence of CAD (p>0.05). CAD was more likely in the middle age and older subjects (p<0.001), in males (p<0.001) and in those who smoked (LR 5:2 p=0.001). On multivariate analysis age, smoking, waist circumference and gender emerged as predictors of CAD. Clustering of 3 or more risk factors was associated with the presence of myocardial perfusion deficits (p=0.001).

Conclusion: Characterisation of chest pain symptomatology did not prove to be helpful in the detection of CAD among subjects with a low pretest probability. Decision-making and triage should be supported by a positive smoking history and risk factor clustering.

Five-year outcomes of percutaneous coronary intervention using second generation drug-eluting stents for multivessel coronary artery revascularisation

A. Sahue, D.R. Prakaschandra, J.J. Patel, D.P. Naidoo — Fri, 07 Mar 2025 12:24:35 +0000

Aim: This report evaluated outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents (DESs) compared to coronary artery bypass grafts (CABG) for multivessel coronary artery disease (CAD).

Methods: Sixty patients (43M, 17F); mean = 64.35 years (SD ± 10.4) who underwent PCI or CABG were followed up for 5 years. Revascularisation included 19 elective and 5 emergency cases. The composite outcome (defined as major adverse cardiac and cerebral events [MACCE]), and rates of repeat revascularisation were compared in each group using survival curves and adjusted Cox pro-portional hazard models.

Results: Nine (15%) patients sustained acute MI and 6 (10%) suffered a stroke during follow-up (PCI n=5, CABG n=4). There were 10 deaths (DVD n=2, TVD n=8) (6 CABG, 4 PCI). There was no difference in treatment effects between the 2 groups for time to MI, stroke, and angina (PCI 40% vs. CABG 23.3%, p=0.194). Adjusted 5-year risk of death (11.7% vs. 17.6%, OR=1.300, CI=0.313 - 5.404, p=1.000) and the composite of death, stroke and MI (51.3% vs. 44% p=0.566) were similar in the 2 groups. There was a higher rate of repeat revascularisation in PCI group (52.8% vs. 29.3%) (p=0.121.)

Conclusions: PCI using DESs for patients with multivessel CAD showed similar outcomes to CABG.

The prevalence, characteristics and outcomes of anomalous left coronary artery from the pulmonary artery at the Chris Hani Baragwanath Academic Hospital over a 28-year period

A.-L. Chhiba, A. Cilliers — Fri, 07 Mar 2025 12:31:42 +0000

Background: Anomalous left coronary artery from the pulmonary artery (ALCAPA) accounts for 0.25% - 0.5% of congenital cardiac disease. ALCAPA results in myocardial ischaemia and a dilated left ventricle with impaired systolic function which can be reversed postsurgical correction. We describe the presenting clinical features, diagnostic findings (including classical electrocardiographic findings) and post-operative outcomes, including the improvement in left ventricular function, in patients at a South African tertiary care centre.

Methods: A retrospective analysis of patients with ALCAPA over a 28-year period at the Chris Hani Baragwanath Academic Hospital (CHBAH).

Results: A total of 38 patients were included, with 24 (63.2%) females, and a median age at diagnosis of 4.6 months (IQR: 3.2 - 9.1 months). The clinical presentation was variable and included dyspnoea, poor feeding, and a cough. The majority were diagnosed to have a lower respiratory tract infection (71%). Cardiomegaly on chest X-ray (CXR) was present in 84.2% of patients. Deep Q waves in leads I and aVL was the most prevalent finding on electrocardiography in 96.9% of patients. ST segment depression (8 patients) and T wave inversion (21 patients) was evident in the lateral and inferior diaphragmatic leads. Left ventricular ejection fraction (LVEF) improved significantly from 38.8 ± 6.3% to 57.5 ± 9.1% post-surgical correction (p-value=0.0004) at the first follow up (median of 1.3 months). The early mortality rate was 21.6%.

Conclusion: The clinical presentation is often suggestive of a chest infection and cardiomegaly on CXR is common. Specific electrocardiographic features commonly present in patients with ALCAPA may be a guide to making the diagnosis. Surgical correction is associated with improved left ventricular function.

Endothelial-independent vasorelaxant effect of the non-steroidal anti-inflammatory drugs diclofenac and flufenamic acid on rat isolated aortic vascular rings

P. Letuka, A. Gwanyanya — Fri, 07 Mar 2025 12:50:24 +0000

Background: Diclofenac is a non-steroidal anti-inflammatory drug (NSAID) that is frequently prescribed as an analgesic agent. Most of the NSAIDs’ pharmacological effects are attributed to the inhibition of cyclooxygenase
(COX) enzymes, but they also have COXindependent actions. Notably, diclofenac has substantial cardiovascular side effects, of which the underlying mechanisms are not fully understood.

Aim: We investigated the effect of diclofenac and the structurally-related COX-inhibiting NSAID flufenamic acid on the contractile activity of aortic vascular rings.

Methods: The contractile force of rat aortic rings was measured using a tension transducer coupled to a PowerLab data-acquisition system. Diclofenac or flufenamic acid was applied on phenylephrine pre-contracted aortic rings. Carbachol was used to induce endothelialdependent relaxation, whereas the endothelial function was eliminated by denudation of the intimal surface.

Results: Diclofenac induced a dose-dependent relaxation of phenylephrine pre-contracted aortic rings (EC₅₀≈10μM), but had no effect on unstimulated rings. The addition of carbachol to diclofenac, significantly induced further relaxation. Similar results were obtained with flufenamic acid. In endothelium-denuded vessels, either diclofenac or flufenamic acid induced a relaxation of phenylephrine pre-contracted aortic rings, and carbachol had no additional effect.

Conclusion: Diclofenac and flufenamic acid induced aortic vascular relaxation through an endothelial-independent
mechanism, but the involvement of COX inhibition cannot be ruled out. The results shed novel insights into the potential therapeutic or adverse effects of diclofenac on vascular function.

The initial experience and outcomes of patent ductus arteriosus closure at Nelson Mandela Academic Hospital, Mthatha, Eastern Cape

Z.M. Makrexeni, L. Bobotyana — Fri, 07 Mar 2025 12:58:07 +0000

Background: Transcatheter closure of the patent ductus arteriosus (PDA) is a common intervention worldwide. An initial experience and outcomes in percutaneous closure of patent ductus arteriosus in a new catheterisation laboratory at Nelson Mandela Academic Hospital (NMAH) in Mthatha was reviewed.

Methods: Data regarding ductal closure using the Amplatzer Duct Occluder type 1 (ADO1) and Amplatzer Vascular Plug II (AVP II) were reviewed and prospectively collected. Demographics, haemodynamics, angiographic patent ductus arteriosus type, complications and outcomes were documented.

Results: A total of 26 patients underwent percutaneous patent ductus arteriosus closure from September 2019 - August 2021(1year 11 months). There were 17 females and 9 males. The median age of the patients was 23 months (range 3 - 60 months) and the median weight was 8.3kg (range 3.6 - 14kg). The mean pulmonary vascular resistance was 4 Wood unit (WU). Seven patients had Krichenko Type C Duct (27%) and 15 (58%) patients had Type A Duct. The ductal size (narrowest diameter at the pulmonic end) mean was 6mm for the Type C Ducts and 3.5mm for the Type A Ducts. Fluoroscopy time was mean was 18 minutes and the radiation dose was about 450 microGreys. Out of the 26 patients that were done catheterisation, 4 patients were not done patent ductus arteriosus closure. Of the 4 patients, 2 patients had tiny PDAs that could not be closed percutaneously, and the other 2 patients had associated coarctation of the aorta. Six of the 7 patients with Type C Duct were closed successfully with Amplatzer Vascular Plug, and 1 patient had device embolisation. Fifteen patients with Type A Duct were closed successfully with Amplatzer Ductal Occluder 1 with no complications. Complete ductal occlusion was achieved in 21 patients on day 1 and only 1 patient had residual ductal flow following the ductal closure.

Conclusion: Percutaneous ductal closure with Amplatzer Duct Occluder at Nelson Mandela Academic Hospital is comparable to other centres in South Africa in terms of safety and outcomes.

The skeletonised right gastroepiploic artery for coronary artery bypass grafting: A case report

S. Naidoo — Fri, 07 Mar 2025 13:03:00 +0000

Coronary artery bypass grafting(CABG) has been the mainstay for treating multivessel coronary artery disease for many decades. Various conduits have been studied to optimise surgical outcomes of CABG. The gastroepiploic artery(GEA) has been used as an in-situ graft for over 30 years. Multi- and total arterial revascularisation using the internal thoracic artery, radial artery, and GEA grafts are an option for better outcomes.

ECG Quiz 67 question

A. Chin, R. Scott Millar — Thu, 27 Feb 2025 00:00:00 +0000

ECG Quiz 67 answers

A. Chin, R. Scott Millar — Thu, 27 Feb 2025 00:00:00 +0000

Cardiac Imaging Quiz

R. Meel, A. Patel — Thu, 27 Feb 2025 00:00:00 +0000

25th Annual SA Heart® Congress 2025

SA Heart Association — Fri, 07 Mar 2025 11:30:05 +0000

SA Heart Journal of the South Afrian Heart Association

SA Heart Association — Fri, 07 Mar 2025 11:25:04 +0000

Instructions for Authors

Thu, 27 Feb 2025 00:00:00 +0000