Godfrey L. Kweka

Acute myocardial infarction (AMI) is an increasing cause of morbidity and mortality in Sub-Saharan Africa (SSA) but is often underdiagnosed and undertreated. To address this gap, the Multicomponent Intervention to Improve Myocardial Infarction Care (MIMIC) was developed and implemented in the emergency department (ED) of a regional referral center in northern Tanzania. We conducted in-depth interviews with 20 key stakeholders (physicians, nurses, administrators, and patients) who participated in MIMIC during the first year of implementation. Purposive sampling was used to recruit a broad range of participants. Interviews were guided by a semi-structured interview guide informed by the Theoretical Framework of Acceptability (TFA). Interview transcripts were thematically analyzed by a team of coders using an inductive, grounded theory approach guided by the seven TFA domains. Nineteen major themes emerged across all TFA domains. Overall, participants described MIMIC as highly acceptable, minimally burdensome, and well-aligned with professional and ethical values. Perceived effectiveness was most emphasized, with staff citing improvements in AMI recognition, ECG and troponin testing, and use of evidence-based therapies. All components were highlighted as effective and easily integrated into existing workflows. Patients valued the educational pamphlet for improving knowledge and self-efficacy, though staff expressed concerns about distributing it during acute care, contributing to inconsistent delivery. Champions were viewed as key in promoting adherence and sustaining implementation of the intervention. MIMIC was widely acceptable in all seven TFA domains among ED providers and patients, with perceived effectiveness driving positive attitudes across stakeholder groups. Use of a co-design approach in MIMIC development likely contributed to high intervention acceptability. Patient education strategies may require adaptation to improve fidelity. These findings suggest that continued implementation and future adaptation of MIMIC may be feasible.

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HIV confers increased risk of myocardial infarction (MI), but there has been little study of ischemic electrocardiogram (ECG) findings among people with HIV in sub-Saharan Africa. To compare the prevalence of ischemic ECG findings among Tanzanians with and without HIV and to identify correlates of ischemic ECG changes among Tanzanians with HIV. Consecutive adults presenting for routine HIV care at a Tanzanian clinic were enrolled. Age- and sex-matched HIV-uninfected controls were enrolled from a nearby general clinic. All participants completed a standardized health questionnaire and underwent 12-lead resting ECG testing, which was adjudicated by independent physicians. Prior MI was defined as pathologic Q-waves in contiguous leads, and myocardial ischemia was defined as ST-segment depression or T-wave inversion in contiguous leads. Pearson’s chi-squared test was used to compare the prevalence of ECG findings among those with and without HIV and multivariate logistic regression was performed to identify correlates of prior MI among all participants. Of 497 participants with HIV and 497 without HIV, 272 (27.8%) were males and mean (sd) age was 45.2(12.0) years. ECG findings suggestive of 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. On multivariate analysis, ECG findings suggestive of prior MI among all participants were associated with HIV infection (OR 4.73, 95% CI: 2.51–9.63, p = 0.030) and self-reported family history of MI or stroke (OR 1.96, 95% CI: 1.08–3.46, p = 0.023). There may be a large burden of ischemic heart disease among adults with HIV in Tanzania, and ECG findings suggestive of coronary artery disease are significantly more common among Tanzanians with HIV than those without HIV.

Background: Little is known about long-term outcomes and uptake of secondary preventative therapies following acute myocardial infarction (AMI) in sub-Saharan Africa. Methods: Consecutive patients presenting with AMI (as defined by the Fourth Universal Definition of AMI Criteria) to a northern Tanzanian referral hospital were enrolled in this prospective observational study. Follow-up surveys assessing mortality, medication use, and rehospitalization were administered at 3, 6, 9, and 12 months following initial presentation, by telephone or in person. Multivariate logistic regression was performed to identify baseline clinical and sociodemographic factors associated with one-year mortality. Results: Of 152 enrolled patients with AMI, 5 were lost to one-year follow-up (96.7% retention rate). Mortality rates were 34.9% (53 of 152 participants) during the initial hospitalization, 48.7% (73 of 150 patients) at 3 months, 52.7% (78 of 148 patients) at 6 months, 55.4% (82 of 148 patients) at 9 months, and 59.9% (88 of 147 patients) at one year. Of 59 patients surviving to one-year follow-up, 43 (72.9%) reported persistent anginal symptoms, 5 (8.5%) were taking an antiplatelet, 8 (13.6%) were taking an antihypertensive, 30 (50.8%) had been rehospitalized, and 7 (11.9%) had ever undergone cardiac catheterization. On multivariate analysis, one-year mortality was associated with lack of secondary education (odds ratio, 0.26 [95% CI, 0.11–0.58]; P =0.001), lower body mass index (odds ratio, 0.90 [95% CI, 0.82–0.98]; P =0.015), and higher initial troponin (odds ratio, 1.30 [95% CI, 1.05–1.80]; P =0.052). Conclusions: In northern Tanzania, AMI is associated with high all-cause one-year mortality and use of evidence-based secondary preventative therapies among AMI survivors is low. Interventions are needed to improve AMI care and outcomes.

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. To describe current care practices for patients with ACS symptoms in Tanzania to identify factors that may contribute to ACS under-detection. 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. 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. 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.