Browsing by Author "Hertz, Julian"

Background: Myocardial Infarction (MI) was previously thought to be rare in sub-Saharan Africa (SSA) but a growing body of evidence suggests MI is in reality under-diagnosed. Multiple studies from Tanzania show there is a need for intervention to improve MI diagnosis, treatment, and outcomes. Our objective was to create an intervention targeting MI care in the emergency department of a Tanzanian referral hospital. Methods: To address this gap an interdisciplinary group of individuals from Tanzania and the United States formed a Design Team to co-create an intervention. The group utilized the ADAPT-ITT model to guide the process of assessing need, identifying an intervention to adapt, and begin the process of adaptation and production to meet the needs of the target population. Results: In the Assessment phase, the team found substantial under-diagnosis of MI, a low rate of aspirin administration, and a lack of both patient and provider awareness. In the Decision phase, the team reviewed 10 interventions of various types before deciding upon the BRIDGE-ACS study as an ideal target for adaptation. In the Adaptation phase, the team discussed intervention content with a focus on ensuring appropriateness for local context. The team is currently in the Production phase creating the necessary materials for implementation of the intervention. Conclusions: In the emergency department of a Tanzanian referral hospital, intervention is needed to improve MI diagnosis, treatment, and outcomes. While the adaptation process is still ongoing, this paper can serve as a guide for others wanting to engage in collaborative intervention development targeting clinical care.

Background: People living with HIV (PLWH) are at increased risk for ischemic heart disease (IHD) and myocardial infarction (MI). Our objectives in this study were the following: identify the prevalence of prior MI and myocardial ischemia among PLWH, compare with HIV-uninfected participants, identify correlates of prior MI among PLWH; examine PLWH knowledge, attitudes, and practices (KAP) regarding IHD, identify predictors of improved knowledge, and explore patient and provider perspectives on barriers to MI care. Methods: Adults presenting for routine HIV-care were recruited. Trained research assistants collected basic sociodemographic information and medical history and administered a standardized knowledge, attitudes, and practices survey regarding IHD. An IHD knowledge score between 0 and 10 was calculated for each participant based on the number of correct answers on the KAP knowledge questions. Associations between participant characteristics and IHD knowledge scores were assessed via Welch’s t-test. Age- and sex- matched participants without HIV were selected as controls from an outpatient department in the same district. Both PLWH and control participants underwent 12-lead resting ECG testing. ECG criteria for prior MI was defined as pathologic Q waves in ≥2 contiguous lead and myocardial ischemia as ST segment depression or T wave inversion in ≥2 contiguous leads. Each ECG was reviewed by two independent physician adjudicators, and Pearson’s chi-squared test was used to compare the prevalence of ischemic ECG findings among those with and without HIV. Multivariate logistic regression was also performed to identify patient characteristics correlating with prior MI in PLWH on ECG. Finally, PLWH with ECG findings of prior MI and physicians caring for PLWH were recruited via purposive sampling for in-depth interviews regarding barriers to MI care in PLWH. Inductive thematic analysis was conducted to identify emergent themes and all transcripts were independently coded in NVivo 12. Results: Of 500 enrolled PLWH, the mean (sd) age was 45.3 (11.4) years and 139 were (27.8%) males. The study found an average knowledge score of 5.6, with higher IHD knowledge scores being associated with post-primary education (mean = 6.27 vs 5.35, p = 0.001) and with >10% five-year risk of cardiovascular event (mean = 5.97 vs 5.41, p = 0.045). Control participants without HIV were recruited for 497 participants with HIV. Prior MI (11.1% vs 2.4%, OR 4.97, 95% CI: 2.71-9.89, p<0.001), and myocardial ischemia (18.7% vs 12.1% OR 1.67, 95% CI: 1.18-2.39, p=0.004) were significantly more common among participants with HIV than those without HIV. On multivariate analysis, prior MI among participants with HIV was associated with male sex (OR 2.05, 95% CI: 1.06-3.89, p=0.030) and self-reported family history of cardiovascular disease (OR 2.05, 95% CI: 1.05-3.88, p=0.031). The 24 in-depth interviews of providers and patients revealed barriers related to perceptions and understanding of MI among patients and providers, delays in MI diagnosis and initiation of treatment, and challenges in the provision of long-term MI care. Conclusions: Tanzanians with HIV have a significantly higher burden of IHD than those without HIV, but significant barriers exist to high quality cardiovascular care in this population. Further study is required to characterize cardiovascular disease burden and improve care for PLWH.

Background: Acute coronary syndrome (ACS) is a rare diagnosis in sub-Saharan Africa, but patient and physician-related factors that may contribute to under-diagnosis are poorly understood. Methods: A community survey was performed of adults in northern Tanzania, and respondents were asked to describe symptoms of ACS, personal healthcare-seeking preferences for chest pain, and perceptions of self-risk. A retrospective chart review was conducted at a referral hospital in northern Tanzania to determine rates of various diagnoses among admitted adults over a six-month period. A prospective observational study was conducted in the emergency department, and diagnostic workups, treatments, and diagnoses for adults with chest pain or shortness of breath were recorded. Results: Of 718 survey respondents, 277 (38.6%) stated they would present to a hospital for chest pain and 115 (16.0%) were able to identify a conventional ACS symptom. Retrospectively, ACS accounted for 9 (0.3%) adult admissions, whereas heart failure accounted for 294 (12.2%) admissions. Prospectively, among 339 adults presenting with chest pain or shortness of breath, 170 (50.1%) received an electrocardiogram, 9 (2.7%) underwent cardiac biomarker testing, and 6 (1.8%) were diagnosed with ACS. Conclusions: In northern Tanzania, community awareness of ACS symptoms is low and only a minority of adults would present to a hospital for chest pain. Full diagnostic workups are rare among patients with symptoms of possible ACS, and ACS is a rare diagnosis.

Background: There is a rising burden of myocardial infarction (MI) within sub-Saharan Africa. Prospective studies of detailed MI outcomes in the region are lacking.

Methods:Adult patients with confirmed MI from a prospective surveillance study in northern Tanzania were enrolled in a longitudinal cohort study after baseline health history, medication use, barriers to care, and sociodemographics were obtained. Thirty days following hospital presentation, symptom status, rehospitalizations, medication use, and mortality were assessed via telephone or in-person interviews using a standardized follow-up questionnaire. Multivariate logistic regression was performed to identify baseline predictors of thirty-day survival.

Results:Thirty-day follow-up was achieved for 150 (98.7%) of 152 enrolled participants. Of these, 85 (56·7%) survived to thirty-day follow-up. Of the surviving participants, 71 (83·5%) reported persistent anginal symptoms, four (4·7%) reported taking aspirin regularly, seven (8·2%) were able to identify MI as the reason for their hospitalization, and 17 (20·0%) had unscheduled rehospitalizations. Baseline predictors of thirty-day survival included self-reported history of diabetes (OR 0·32, 95% CI 0·10-0·89, p = 0·04), self-reported history of hypertension (OR 0·34, 95% CI 0·15-0·74, p = 0·01) and antiplatelet use at initial presentation (OR 0·19, 95% CI 0·04-0·65, p = 0·02).

Conclusions:In northern Tanzania, thirty-day outcomes following acute MI are poor, and mortality is associated with comorbidities and medication usage. Further investigation is needed to develop interventions to improve care and outcomes of MI in Tanzania.