Patterns of Emergency Care for Possible Acute Coronary Syndrome Among Patients with Chest Pain or Shortness of Breath at a Tanzanian Referral Hospital.
Date
2020-02-06
Journal Title
Journal ISSN
Volume Title
Repository Usage Stats
views
downloads
Citation Stats
Abstract
Background:Acute coronary syndrome (ACS) is thought to be a rare diagnosis in sub-Saharan Africa, but little is known about diagnostic practices for patients with possible ACS symptoms in the region. Objective:To describe current care practices for patients with ACS symptoms in Tanzania to identify factors that may contribute to ACS under-detection. Methods:Emergency department patients with chest pain or shortness of breath at a Tanzanian referral hospital were prospectively observed. Medical histories were obtained, and diagnostic workups, treatments, and diagnoses were recorded. Five-year risk of cardiovascular events was calculated via the Harvard National Health and Nutrition Examination Survey risk score. Telephone follow-ups were conducted 30 days after enrollment. Results:Of 339 enrolled patients, the median (IQR) age was 60 (46, 72) years, 252 (74.3%) had hypertension, and 222 (65.5%) had >10% five-year risk of cardiovascular event. The median duration of symptoms prior to presentation was 7 days, and 314 (92.6%) reported symptoms worsened by exertion. Of participants, 170 (50.1%) received an electrocardiogram, and 9 (2.7%) underwent cardiac biomarker testing. There was no univariate association between five-year cardiovascular risk and decision to obtain an electrocardiogram (p = 0.595). The most common physician-documented diagnoses were symptomatic hypertension (104 patients, 30.7%) and heart failure (99 patients, 29.2%). Six patients (1.8%) were diagnosed with ACS, and 3 (0.9%) received aspirin. Among 284 (83.8%) patients completing 30-day follow-up, 20 (7.0%) had died. Conclusions:Many patients with ACS risk factors present to the emergency department of a Tanzanian referral hospital with possible ACS symptoms, but marked delays in care-seeking are common. Complete diagnostic workups for ACS are uncommon, ACS is rarely diagnosed or treated with evidence-based therapies, and mortality in patients with these symptoms is high. Physician practices may be contributing to ACS under-detection in Tanzania, and interventions are needed to improve ACS care.
Type
Department
Description
Provenance
Citation
Permalink
Published Version (Please cite this version)
Publication Info
Hertz, Julian T, Godfrey L Kweka, Gerald S Bloomfield, Alexander T Limkakeng, Zak Loring, Gloria Temu, Blandina T Mmbaga, Charles J Gerardo, et al. (2020). Patterns of Emergency Care for Possible Acute Coronary Syndrome Among Patients with Chest Pain or Shortness of Breath at a Tanzanian Referral Hospital. Global heart, 15(1). p. 9. 10.5334/gh.402 Retrieved from https://hdl.handle.net/10161/21132.
This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.
Collections
Scholars@Duke
Julian T Hertz
Julian Hertz, MD, MSc, is an Associate Professor of Emergency Medicine & Global Health. He graduated summa cum laude from Princeton University and attended medical school at Duke University, where he received the Dean's Merit Scholarship and the Thomas Jefferson Award for leadership. He completed his residency training in emergency medicine at Vanderbilt University Medical Center and his fellowship in Global Health at Duke.
Dr. Hertz's primary interests include global health, implementation science, and undergraduate and graduate medical education. Dr. Hertz's research focuses on using implementation science methods to improve cardiovascular care both locally and globally. His current projects involve developing interventions to improve acute myocardial infarction care in Tanzania, to improve management of hypertension among Tanzanians with HIV, and to improve post-hospital care among patients with multimorbidity in East Africa.
Dr. Hertz has received numerous awards for clinical, educational, and research excellence, including the Duke Emergency Medicine Faculty Teacher of the Year Award, the Duke Emergency Medicine Faculty Clinician of the Year Award, and the Duke Emergency Medicine Faculty Researcher of the Year Award. He has also received the Golden Apple Teaching Award from the Duke medical student body, the Duke Master Clinician/Teacher Award, and the Global Academic Achievement Award from the Society of Academic Emergency Medicine.
Gerald Bloomfield
Gerald Bloomfield, MD, MPH, joined the faculty in Medicine and Global Health after completing his Cardiovascular Medicine fellowship training at Duke University Medical Center and Duke Clinical Research Institute. Bloomfield also completed the Duke Global Health Residency/Fellowship Pathway and a Fogarty International Clinical Research Fellowship. He received his medical education, internal medicine residency and Master of Public Health degree from Johns Hopkins University. Bloomfield leads a longstanding research and capacity building program on cardiovascular global health which includes work in under-resourced communities in the US and a number of low- and middle-income country settings.
Alexander Tan Limkakeng
Dr. Alexander T. Limkakeng, Jr., MD, MHSc, FACEP is a Professor of Emergency Medicine, Vice Chair of Clinical Research, Director of the Acute Care Research Team, and Director of the Resident Research Fellowship for the Department of Emergency Medicine in the Duke University School of Medicine in Durham, North Carolina.
Dr. Limkakeng has served as chair of the American College of Emergency Physicians (ACEP) Research Committee, and been the Course Director of the ACEP Research Forum from 2016-2018, the largest emergency medical research platform in the nation. He is also the Assistant Director of ACEP’s Emergency Medicine Basic Research Skills course. He was elected to the Nominating Committee of the Society of Academic Emergency Medicine.
As a researcher, Dr. Limkakeng has led multiple clinical trials and interdepartmental sponsored projects and is author on over 100 peer-reviewed manuscripts. These include studies in emergency conditions such as COVID-19, traumatic brain injury, hypertension, heart failure, thrombosis, stroke, envenomations, and septic shock. His research has been funded by grants and contracts totaling over $9 million dollars. He has lectured internationally on acute coronary syndrome, responsible conduct of research, design of clinical trials, and precision medicine in emergency care. He has led Duke’s involvement in NIH-funded research networks and in industry-funded work that led to FDA approval for multiple high-sensitivity cardiac troponin assays and point-of-care COVID-19 diagnostic tests. He has servesd as Co-PI for the Duke U24 Hub in the NIH Early Phase Pain Investigation Clinical Network (EPPIC-Net) (1U24NS114416) and now serves as a co-PI on the Duke U24 Hub award (1U24NS129498) in the NIH Strategies to Innovate Emergency Care Clinical Trials (SIREN) Network and in the NIH NINDS Strokenet network (1U24NS135250)
His personal research interest is finding new ways to diagnose acute coronary syndrome. In particular, he is interested in novel biomarkers and precision medicine approaches to this problem. The common element throughout this work is a focus on time-sensitive health conditions.Zak Loring
I am a cardiac electrophysiologist specializing in the treatment of heart rhythm disorders and management of cardiac implantable electronic devices (CIEDs). My research utilizes signal processing of electrocardiographic data and novel analytic techniques to better phenotype patients and identify those for whom interventional electrophysiology procedures may be most beneficial. This includes predicting which patients with left bundle branch block may benefit from early cardiac resynchronization therapy or conduction system pacing. I also analyze population level data to identify patients at high risk for adverse sequelae of rhythm disorders who may benefit from early intervention.
Blandina Mmbaga
Charles J. Gerardo
Dr. Gerardo is Professor and Chair for the Department of Emergency Medicine. He graduated with honors from Stanford University with a Bachelor’s of Science in Biology, and received his MD degree from University of California, Davis. He went on to complete his residency training in Emergency Medicine at Loma Linda University Medical Center. He completed his Masters of Health Sciences from the Duke University Clinical Research and Training Program. In 2000, he joined Emergency Medicine faculty at Duke University and has served in numerous educational, research and administrative leadership roles. His current research focuses on US and global snake envenomation using a variety of methodologies from transitional science and clinical trials to machine learning and implementation science. He has over 90 peer reviewed publications and book chapters, and is published in JAMA, PLOS Medicine, Annals of Emergency Medicine, Academic Emergency Medicine and Clinical Toxicology.
Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.