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Rahim FO, Sakita FM, Coaxum LA, Kweka GL, Loring Z, Mlangi JJ, Galson SW, Tarimo TG, Temu G, Bloomfield GS, Hertz JT. Characteristics and outcomes of patients with symptomatic chronic myocardial injury in a Tanzanian emergency department: A prospective observational study. PLoS One 2024; 19:e0296440. [PMID: 38691571 PMCID: PMC11062551 DOI: 10.1371/journal.pone.0296440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/12/2023] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Chronic myocardial injury is a condition defined by stably elevated cardiac biomarkers without acute myocardial ischemia. Although studies from high-income countries have reported that chronic myocardial injury predicts adverse prognosis, there are no published data about the condition in sub-Saharan Africa. METHODS Between November 2020 and January 2023, adult patients with chest pain or shortness of breath were recruited from an emergency department in Moshi, Tanzania. Medical history and point-of-care troponin T (cTnT) assays were obtained from participants; those whose initial and three-hour repeat cTnT values were abnormally elevated but within 11% of each other were defined as having chronic myocardial injury. Mortality was assessed thirty days following enrollment. RESULTS Of 568 enrolled participants, 81 (14.3%) had chronic myocardial injury, 73 (12.9%) had acute myocardial injury, and 412 (72.5%) had undetectable cTnT values. Of participants with chronic myocardial injury, the mean (± sd) age was 61.5 (± 17.2) years, and the most common comorbidities were CKD (n = 65, 80%) and hypertension (n = 60, 74%). After adjusting for CKD, thirty-day mortality rates (38% vs. 36%, aOR 1.03, 95% CI: 0.52-2.03, p = 0.931) were similar between participants with chronic myocardial injury and those with acute myocardial injury, but significantly greater (38% vs. 13.6%, aOR 3.63, 95% CI: 1.98-6.65, p<0.001) among participants with chronic myocardial injury than those with undetectable cTnT values. CONCLUSION In Tanzania, chronic myocardial injury is a poor prognostic indicator associated with high risk of short-term mortality. Clinicians practicing in this region should triage patients with stably elevated cTn levels in light of their increased risk.
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Affiliation(s)
- Faraan O. Rahim
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Francis M. Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Lauren A. Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Godfrey L. Kweka
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Zak Loring
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Jerome J. Mlangi
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Sophie W. Galson
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Tumsifu G. Tarimo
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gloria Temu
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gerald S. Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
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Coaxum LA, Sakita FM, Mlangi JJ, Kweka GL, Tarimo TG, Temu GA, Kilonzo KG, Arthur D, Bettger JP, Thielman NM, Limkakeng AT, Hertz JT. Provider attitudes towards quality improvement for myocardial infarction care in northern Tanzania. PLOS Glob Public Health 2024; 4:e0003051. [PMID: 38574056 PMCID: PMC10994299 DOI: 10.1371/journal.pgph.0003051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 03/03/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Myocardial Infarction (MI) is a leading cause of death worldwide. In high income countries, quality improvement strategies have played an important role in increasing uptake of evidence-based MI care and improving MI outcomes. The incidence of MI in sub-Saharan Africa is rising, but uptake of evidence-based care in northern Tanzania is low. There are currently no published quality improvement interventions from the region. The objective of this study was to determine provider attitudes towards a planned quality improvement intervention for MI care in northern Tanzania. METHODS This study was conducted at a zonal referral hospital in northern Tanzania. A 41-question survey, informed by the Theoretical Framework for Acceptability, was developed by an interdisciplinary team from Tanzania and the United States. The survey, which explored provider attitudes towards MI care improvement, was administered to key provider stakeholders (physicians, nurses, and hospital administrators) using convenience sampling. RESULTS A total of 140 providers were enrolled, including 82 (58.6%) nurses, 56 (40.0%) physicians, and 2 (1.4%) hospital administrators. Most participants worked in the Emergency Department or inpatient medical ward. Providers were interested in participating in a quality improvement project to improve MI care at their facility, with 139 (99.3%) strongly agreeing or agreeing with this statement. All participants agreed or strongly agreed that improvements were needed to MI care pathways at their facility. Though their facility has an MI care protocol, only 88 (62.9%) providers were aware of it. When asked which intervention would be the single-most effective strategy to improve MI care, the two most common responses were provider training (n = 66, 47.1%) and patient education (n = 41, 29.3%). CONCLUSION Providers in northern Tanzania reported strongly positive attitudes towards quality improvement interventions for MI care. Locally-tailored interventions to improve MI should include provider training and patient education strategies.
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Affiliation(s)
- Lauren A. Coaxum
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Francis M. Sakita
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Jerome J. Mlangi
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Godfrey L. Kweka
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Tumsifu G. Tarimo
- Department of Emergency Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Gloria A. Temu
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Kajiru G. Kilonzo
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - David Arthur
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Janet P. Bettger
- Department of Health and Rehabilitation Sciences, Temple University, Temple University, Philadelphia, Pennsylvania, United States of America
| | - Nathan M. Thielman
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Alexander T. Limkakeng
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Julian T. Hertz
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
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Stark K, O'Leary PRE, Sakita FM, Ford JS, Mmbaga BT, Blass B, Gedion K, Coaxum LA, Rutta A, Galson SW, Rugakingira A, Manavalan P, Bloomfield GS, Hertz JT. Six month incidence of major adverse cardiovascular events among adults with HIV in northern Tanzania: a prospective observational study. BMJ Open 2023; 13:e075275. [PMID: 37984949 PMCID: PMC10660832 DOI: 10.1136/bmjopen-2023-075275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES We aimed to prospectively describe incident cardiovascular events among people living with HIV (PLWH) in northern Tanzania. Secondary aims of this study were to understand non-communicable disease care-seeking behaviour and patient preferences for cardiovascular care and education. DESIGN A prospective observational study. SETTING This study was conducted at the Majengo HIV Care and Treatment Clinic, an outpatient government-funded clinic in Moshi, Tanzania PARTICIPANTS: Adult patients presenting to an HIV clinic for routine care in northern Tanzania were enrolled from 1 September 2020 to 1 March 2021. INTERVENTIONS At enrolment, participants completed a survey and a resting 12-lead ECG was obtained. At 6 month follow-up, a repeat survey regarding interim health events and repeat ECG was obtained. PRIMARY AND SECONDARY OUTCOME MEASURES Interim major adverse cardiovascular events (MACE) were defined by: self-reported interim stroke, self-reported hospitalisation for heart failure, self-reported interim myocardial infarction, interim myocardial infarction by ECG criteria (new pathologic Q waves in two contiguous leads) or death due to cardiovascular disease (CVD). RESULTS Of 500 enrolled participants, 477 (95.4%) completed 6 month follow-up and 3 (0.6%) died. Over the 6 month follow-up period, 11 MACE occurred (3 strokes, 6 myocardial infarctions, 1 heart failure hospitalisation and 1 cardiovascular death), resulting in an incidence rate of 4.58 MACE per 100 person-years. Of participants completing 6 month follow-up, 31 (6.5%) reported a new non-communicable disease diagnosis, including 23 (4.8%) with a new hypertension diagnosis. CONCLUSIONS The incidence of MACE among PLWH in Tanzania is high. These findings are an important preliminary step in understanding the landscape of CVD among PLWH in Tanzania and highlight the need for interventions to reduce cardiovascular risk in this population.
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Affiliation(s)
- Kristen Stark
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Paige R E O'Leary
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Francis M Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - James S Ford
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical University College, Moshi, Tanzania, United Republic of
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania, United Republic of
| | - Beau Blass
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kalipa Gedion
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Lauren A Coaxum
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alice Rutta
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania, United Republic of
| | - Sophie Wolfe Galson
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anzibert Rugakingira
- Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania, United Republic of
| | - Preeti Manavalan
- Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Gerald S Bloomfield
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Julian T Hertz
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
- Department of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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