Browsing by Author "Mpanya, Dineo"

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Anticoagulation For Nonvalvular Atrial Fibrillation In South Africa
(University of the Witwatersrand, Johannesburg, 2024) Mogashoa, Vanessa; Tsabedze, Nqoba; Mpanya, Dineo
Background: Nonvalvular Atrial fibrillation (NVAF) is a growing epidemic in Africa. Anticoagulation, considered the backbone of NVAF management, is limited to warfarin as the mainstay of available anticoagulation therapy in most low-and-middle-income countries (LMICs). The optimal time in the therapeutic range (TTR) while on warfarin is crucial to avoid bleeding and thromboembolic complications. This study aimed to assess anticoagulation control in patients with NVAF on warfarin in Johannesburg, South Africa. Methods: We conducted a cross-sectional retrospective study on consecutive patients with NVAF managed between the 1st of January 2015 and the 31st of December 2019 at a tertiary- level academic centre in Johannesburg, South Africa. Anticoagulation control for patients with NVAF was assessed by calculating the time in therapeutic range using the Rosendaal method. Results: The study population comprised of 177 patients diagnosed with NVAF. The mean age in the study population was 65.0 ± 13.1 years. The median TTR among patients with NVAF was 46% [interquartile range (IQR): 8.7 – 86.0], and 63 (35.6%) patients with NVAF had a TTR ≥ 70%. Patients with poor anticoagulation control (TTR<70%) were on warfarin for a shorter duration compared with those with optimal anticoagulation control [56 days (IQR: 43 – 84) vs 70 days (IQR: 56 – 140), p=0.0013]. The mean CHA2DS2-VASc score was 4 ± 1.5, and it did not differ between patients with poor or optimal anticoagulation control. Among the 175 patients with calculable HAS-BLED scores, 21 (12.0%), 112 (64.0%) and 42 (24.0%) were at a low, moderate, and high risk for bleeding, respectively. Of the 21 patients in the HAS BLED low risk category, only 4 (19.0%) had a TTR<70% (p<0.001). Warfarin toxicity was documented in 13 (7.3%) patients. Conclusion: In our study, a TTR ≥ 70%, suggesting poor anticoagulation control was found in 35.6% of NVAF patients on warfarin. Larger multicentre trials comparing the occurrence of bleeding, thromboembolic events, as well as the total cost to the healthcare system in patients treated with warfarin compared to direct oral anticoagulation therapy are required to guide oral anticoagulation strategies in Africa
Diagnostic Coronary Angiography Access In Johannesburg
(University of the Witwatersrand, Johannesburg, 2023-10) Ntaka, Khulasande Liso Sifiso; Tsabedze, Nqoba; Kalk, Thomas; Mpanya, Dineo
Background: Contemporary interventional cardiology guidelines prefer radial over femoral artery access when performing diagnostic coronary angiograms (DCA). There is a paucity of data on the safety and efficacy of radial and femoral DCA in low-and-middle-income countries. Methods: We retrospectively reviewed inpatient medical records and DCA reports of patients referred for DCA and evaluated the safety and efficacy of the femoral versus radial artery access route. Results: There were 653 patients with a mean age of 58.2 ±12.6 years. Radial access was used in 318 (48.7%) patients. The median duration of the DCA was slightly longer with radial access and was 50 minutes (Interquartile range (IQR): 40–60), while the median procedural duration for femoral artery access was 45 minutes (IQR: 35–60) (P = 0.010). The median total radiation dose in the femoral artery access group was 3511 µGym2 (IQR: 2154–5821), and patients in the radial artery access group were exposed to a median radiation dose of 4011 µGym2 (IQR: 2298–6411) (P = 0.0661). A total of 639 (97.9%) DCA were performed without crossover, and 99.0% (95% CI: 97.2 – 99.8) of DCA performed via the radial artery did not require crossover to transfemoral access, and 96.1% (95% CI: 93.4 – 97.9) of the DCA done via the femoral artery did not require crossover to transradial access (P = 0.009). Conclusion: Almost half of all diagnostic angiograms were performed via the radial artery. Both radial and femoral artery access were equally safe and efficacious in patients with coronary artery disease.
HbA1c Control in Type 2 Diabetic Patients with Coronary Artery Disease
(University of the Witwatersrand, Johannesburg, 2023-10) Mhlaba, Lona; Tsabedze, Nqoba; Mpanya, Dineo
Background: Type 2 diabetes mellitus (T2DM) patients with coronary artery disease (CAD) have an increased risk of recurrent cardiovascular events. These patients require optimal glucose control to prevent the progression of atherosclerotic cardiovascular disease (ASCVD). Current guideline recommendations target an HbA1c ≤7% to mitigate this risk. This study evaluated the level of HbA1c control in T2DM patients with CAD. Methods: This retrospective study assessed consecutive patients who presented with CAD to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between April 2017 and December 2019. The study included T2DM patients on anti-diabetic medication with angiographically confirmed CAD. HbA1c control was assessed using the HbA1c level measured at the index presentation and during the most recent follow-up visit. Results: The study population comprised 262 T2DM patients with a mean age was 61.3 ±10.4 years. Among the T2DM patients, 188 (71.8%) were males. At index presentation, 110 (42.1%) T2DM patients presented with ST-segment elevation myocardial infarction, 69 (26.4%) had non-ST-segment elevation myocardial infarction, 43 (16.5%) had unstable angina, and 39 (14.9%) had stable angina. The baseline median systolic blood pressure was higher in patients with an HbA1c ≤7% [136 mmHg (Interquartile range (IQR): 117-151) vs 124 mmHg (IQR: 112-142), p= 0.0121], compared to those with an HbA1c level above 7%. Furthermore, T2DM with an HbA1c ≤7% also had a higher median diastolic blood pressure [85 mmHg (IQR: 75.5-97) vs 78 mmHg (IQR: 71-88), p=0.0205]. After a median follow-up of 16.5 months (IQR: 7-29), 28.7% of the study participants had an HbA1c ≤7%. On multivariable regression analysis, patients with ST-segment depression on the resting electrocardiogram and index presentation had optimal glycaemic control (Odds ratio: 0.27, CI: 0.12-0.59, p= 0.001). Conclusion: After a median follow-up duration of 16.5 months, only 28.7% of T2DM patients with CAD had optimal glycaemic control. This finding underscores the substantial unmet need for optimal diabetes control in this very high-risk group.
Predicting in-hospital mortality in heart failure patients using machine learning
(2024) Mpanya, Dineo
The age of onset and causes of heart failure differ between high-income and low-and-middle-income countries (LMIC). Heart failure patients in LMIC also experience a higher mortality rate. Innovative ways that can risk stratify heart failure patients in this region are needed. The aim of this study was to demonstrate the utility of machine learning in predicting all-cause mortality in heart failure patients hospitalised in a tertiary academic centre. Six supervised machine learning algorithms were trained to predict in-hospital all-cause mortality using data from 500 consecutive heart failure patients with a left ventricular ejection fraction (LVEF) less than 50%. The mean age was 55.2 ± 16.8 years. There were 271 (54.2%) males, and the mean LVEF was 29 ± 9.2%. The median duration of hospitalisation was 7 days (interquartile range: 4–11), and it did not differ between patients discharged alive and those who died. After a prediction window of 4 years (interquartile range: 2–6), 84 (16.8%) patients died before discharge from the hospital. The area under the receiver operating characteristic curve was 0.82, 0.78, 0.77, 0.76, 0.75, and 0.62 for random forest, logistic regression, support vector machines (SVM), extreme gradient boosting, multilayer perceptron (MLP), and decision trees, and the accuracy during the test phase was 88, 87, 86, 82, 78, and 76% for random forest, MLP, SVM, extreme gradient boosting, decision trees, and logistic regression. The support vector machines were the best performing algorithm, and furosemide, beta-blockers, spironolactone, early diastolic murmur, and a parasternal heave had a positive coefficient with the target feature, whereas coronary artery disease, potassium, oedema grade, ischaemic cardiomyopathy, and right bundle branch block on electrocardiogram had negative coefficients. Despite a small sample size, supervised machine learning algorithms successfully predicted all-cause mortality with modest accuracy. The SVM model will be externally validated using data from multiple cardiology centres in South Africa before developing a uniquely African risk prediction tool that can potentially transform heart failure management
The prevalence of myocardial viability as detected by 18F-Fluorodeoxyglucose positron emission tomography
(2017) Mpanya, Dineo
Background: Positron Emission Tomography (PET) is an imaging modality that guides the revascularization management of patients with left ventricular systolic dysfunction secondary to coronary artery disease. Segments of the myocardium demonstrating reduced perfusion and increased or preserved 18FFluorodeoxyglucose (18F-FDG) uptake are considered to be viable and thus suitable for revascularization. The aim of our study was to determine the prevalence of myocardial viability as determined by FDG-PET in our local cohort and to compare our prevalence of myocardial viability to data published elsewhere. Methods: We retrospectively reviewed 240 consecutive 99mTc-sestamibi myocardial perfusion Gated Single Photon Emission Tomography (SPECT) and 18FFDG PET reports of patients referred for evaluation of myocardial viability between January 2009 and June 2015. Results: 236 patients met the inclusion criteria. There were 194 (82.2%) males. The mean age was 59.1 (SD 11.0) years. A total of 4012 segments of the left ventricle were analyzed on the gated SPECT and reduced perfusion was noted in 1862 (46.4%) segments. Perfusion-metabolism mismatch (viable myocardium) was observed in 586 (31.5%) out of 1862 perfusion defects. The prevalence of myocardial viability in the study population was 61.4%. On the multivariate logistic regression model, aspirin intake [OR:0.37; CI:0.16-0.83; p=0.016] and hypertension [OR:0.26; CI:0.12-0.58; p=0.001] were associated with the presence of viable myocardium. Smoking was associated with the likelihood of having non-viable myocardium [OR:2.31; CI:1.01-5.29; p=0.048] Conclusion: The prevalence of myocardial viability as detected by 18F FDG PET in our local cohort is similar to prevalence rates reported in the developed world.
Secondary prevention and management of dyslipidaemia in patients with coronary artery disease on statin therapy in a tertiary academic centre in Johannesburg
(University of the Witwatersrand, Johannesburg, 2023-11) Ntila, Patience Mtwakazi; Tsabedze, Nqoba; Mpanya, Dineo
Background and aims: Low-density lipoprotein-cholesterol (LDL-C) is essential in initiating atherosclerosis, and its control is paramount in reducing future major adverse cardiovascular events. New guidelines recommend an LDL-C target of <1.4 mmol in patients with atherosclerotic cardiovascular disease. However, whether patients on statin therapy achieve these LDL-C targets in South African public hospitals is unknown. Therefore, this study aimed to determine the achievement of LDL-C targets in patients with coronary artery disease (CAD) on statin treatment at a public tertiary academic hospital. Methods: We analysed data from 458 patients with angiographically confirmed CAD on statin therapy, comparing index admission to the most recent follow-up LDL-C level. Results: After a median duration of 17 months (interquartile range: 7 - 31), 93 (20.3%) patients achieved the LDL-C target. Among the 329 (71.8%) patients on a high-potency statin, 76 (23.2%) achieved the LDL-C target. On univariable logistic regression analysis, a history of previous CAD or stroke [odds ratio (OR):1.73; 95% confidence interval (CI): 1.05 - 2.85; p value= 0.031], presentation with non-ST-elevation myocardial infarction [OR:0.55; 95% CI: 0.34 - 0.90; p = 0.017] and unstable angina [OR: 2.25; 95% CI: 1.08 to 4.70; p = 0.030] were related with failure to attain LDL-C targets. Conclusions: Only 20.3% of all patients with atherosclerotic CAD and 23.2% on high-intensity statins achieved the guideline-recommended LDL-C target.