Closing Gaps in Evidence-Based Care for Acute Myocardial Infarction in northern Tanzania: Insights from a Prospective Study

Abstract

Background: The burden of Acute Myocardial Infarction (AMI) is growing in sub-Saharan Africa. In Tanzania, uptake of diagnostic testing and evidence-based therapy for AMI is suboptimal. We aimed to describe current gaps in evidence-based AMI care in a Tanzanian emergency department (ED) and estimate the potential benefit of closing key performance gaps. Methods: Adults presenting with chest pain or dyspnea to the Kilimanjaro Christian Medical Centre (KCMC) ED were prospectively enrolled from February to September 2023 and their diagnostic tests and treatments were recorded. Thirty days following enrollment, a follow-up telephone survey was administered to assess mortality and medication use. Key performance metrics included the proportion of participants receiving both electrocardiography (ECG) and cardiac biomarker testing, as well as the proportion of participants with AMI receiving evidence-based therapies. To estimate the benefits of closing performance gaps, the the annualized number of participants not receiving each element evidence-based therapy was divided by published numbers needed to treat (NNTs) for each intervention. An exploratory analysis was conducted using performance metrics at KCMC and published national incidence data to estimate the potential benefits of closing performance gaps in AMI care at scale across Tanzania. Results: Of 275 enrolled participants, 41 (14.9%) met criteria for AMI. Of participants, 91 (33.1%) received both ECG and cardiac biomarker testing. Of participants with AMI, 14 (34%) received aspirin, 11 (27%) received clopidogrel, and 2 (5%) received heparin. At 30-day follow-up, 25 (61%) participants with AMI were still alive, of whom 3 (12%) were taking dual antiplatelet therapy. Closing the diagnostic gap at KCMC could lead to the identification of an estimated 121 additional AMI cases annually. Aggregate estimated total benefit for closing gaps in uptake of aspirin, clopidogrel, heparin, and dual-antiplatelet therapy would result in approximately 6 deaths prevented and 33 serious cardiovascular events prevented at KCMC annually. Closing performance gaps at scale across Tanzania would result in approximately 69,206 additional AMI cases identified, 3,003 deaths prevented, and 11,405 serious cardiovascular events prevented annually. Conclusions: Closing diagnostic and treatment gaps in AMI care in northern Tanzania presents an opportunity to increase case identification, save lives, and prevent cardiovascular events and rehospitalizations.