Browsing by Author "Ntsekhe, Mpiko"

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    Achievement of secondary prevention goals 6 to 9 months after Acute Coronary Syndrome : a retrospective, cross-sectional analysis
    (2014) Griffiths, Bradley Paul; Ntsekhe, Mpiko
    Study Rationale: Good evidence exists to support the use of secondary prevention medications (aspirin, HMG-CoA reductase inhibitors [statins], beta-blockers and angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs]) and smoking cessation in patients after acute coronary syndromes. At present, little is known about adherence to medication and smoking behaviour after discharge in South Africa. This information is essential to optimising both in-patient care and post-discharge planning of these patients. Methods: We conducted a cross sectional analysis of all patients discharged from the Groote Schuur Hospital Coronary Care Unit with a diagnosis of acute coronary syndrome between 15 November 2011 and 15 April 2012. A follow up telephone call was performed 6 to 9 months after discharge, and a standardized questionnaire completed detailing current medication use, reasons for non-adherence, and smoking status at time of the interview. Results: Prescribing of secondary prevention medications at discharge was found to be high (aspirin 94.5%, statins 95.7%, beta blockers 85.4%, ACEIs/ARBs 85.9%), and 70.7% of patients were discharged on a combination of all 4 drugs. At 6 to 9 month follow-up, the proportion of patients using these medications had reduced by 8.9% for aspirin, 10.1% for statins, 6.2% for beta-blockers and 17.9% for ACEIs/ARBs. Only 47.2% remained on all 4 drugs, a reduction of 23.5%. Of the 56% of patients who were smokers on admission to hospital, 31% had stopped smoking at the time of interview. Conclusions: Despite high rates of pre-discharge prescription of recommended therapy following admissions for acute coronary syndromes, we observed a significant decline in adherence rates 6 to 9 months post discharge and a poor rate of smoking cessation. An exploration of possible reasons for these findings suggests that efforts to educate patients about the importance of long-term adherence need to be improved. Furthermore, more effective interventions are needed to improve smoking cessation than in-hospital reminders about the hazards of smoking
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    Advancing global health through cardiovascular research, mentorship, and capacity building: in memoriam, professor Bongani Mayosi (1967–2018)
    (BioMed Central, 2018-10-03) Nachega, Jean B; Ntsekhe, Mpiko; Volmink, Jimmy; Thabane, Lehana
    We are deeply saddened by the passing of Professor Bongani Mayosi. Bongani was one of the inaugural board members of Pilot and Feasibility Studies. He contributed greatly to the design and conduct of pilot and feasibility studies in cardiovascular research. Before his untimely death on Friday, July 27, 2018, he rose rapidly through the ranks to become a top cardiologist and one of the premier medical researchers in South Africa, Africa and the World Born in Mthatha, Eastern Cape Province on January 28, 1967, Bongani Mawethu Mayosi followed in his father’s footsteps to become a doctor. He trained at the now Nelson R. Mandela School of Medicine at University of KwaZulu-Natal, where he received his M.B., Ch.B. (Cum Laude) in 1989 and also met his wife, Professor and Head of Dermatology, Nonhlanhla Khumalo, in their first week of medical school. In 1990, the pair made their way to Port Elizabeth to work at the Livingstone Hospital as interns, before moving to Cape Town to establish long-term careers. After completing his specialist training in internal medicine and cardiology at the University of Cape Town (UCT), Professor Mayosi moved to Oxford University, UK, on a prestigious Nuffield Medical Fellowship where he completed a D.Phil. in cardiovascular genetics at the Wellcome Trust Centre for Human Genetics.
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    Cardio-thoracic ratio is stable, reproducible and has potential as a screening tool for HIV-1 related cardiac disorders in resource poor settings
    (Public Library of Science, 2016) Esmail, Hanif; Oni, Tolu; Thienemann, Friedrich; Omar-Davies, Nashreen; Wilkinson, Robert J; Ntsekhe, Mpiko
    BACKGROUND: Cardiovascular disorders are common in HIV-1 infected persons in Africa and presentation is often insidious. Development of screening algorithms for cardiovascular disorders appropriate to a resource-constrained setting could facilitate timely referral. Cardiothoracic ratio (CTR) on chest radiograph (CXR) has been suggested as a potential screening tool but little is known about its reproducibility and stability. Our primary aim was to evaluate the stability and the inter-observer variability of CTR in HIV-1 infected outpatients. We further evaluated the prevalence of cardiomegaly (CTR≥0.5) and its relationship with other risk factors in this population. METHODOLOGY: HIV-1 infected participants were identified during screening for a tuberculosis vaccine trial in Khayelitsha, South Africa between August 2011 and April 2012. Participants had a digital posterior-anterior CXR performed as well as history, examination and baseline observations. CXRs were viewed using OsiriX software and CTR calculated using digital callipers. RESULTS: 450 HIV-1-infected adults were evaluated, median age 34 years (IQR 30-40) with a CD4 count 566/mm 3 (IQR 443-724), 70% on antiretroviral therapy (ART). The prevalence of cardiomegaly was 12.7% (95% C.I. 9.6%-15.8%). CTR was calculated by a 2 nd reader for 113 participants, measurements were highly correlated r = 0.95 (95% C.I. 0.93-0.97) and agreement of cardiomegaly substantial κ = 0.78 (95% C.I 0.61-0.95). CXR were repeated in 51 participants at 4-12 weeks, CTR measurements between the 2 time points were highly correlated r = 0.77 (95% C.I 0.68-0.88) and agreement of cardiomegaly excellent κ = 0.92 (95% C.I. 0.77-1). Participants with cardiomegaly had a higher median BMI (31.3; IQR 27.4-37.4) versus 26.9; IQR 23.2-32.4); p<0.0001) and median systolic blood pressure (130; IQR 121-141 versus 125; IQR 117-135; p = 0.01). CONCLUSION: CTR is a robust measurement, stable over time with substantial inter-observer agreement. A prospective study evaluating utility of CXR to identify cardiovascular disorder in this population is warranted.
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    Clinical characteristics and initial management of patients with tuberculous pericarditis in the HIV era: the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry
    (BioMed Central Ltd, 2006) Mayosi, Bongani; Wiysonge, Charles; Ntsekhe, Mpiko; Volmink, Jimmy; Gumedze, Freedom; Maartens, Gary; Aje, Akinyemi; Thomas, Baby; Thomas, Kandathil; Awotedu, Abolade; Thembela, Bongani; Mntla, Phindile; Maritz, Frans; Blackett, Kathleen; Nkouonlack,
    BACKGROUND:The incidence of tuberculous pericarditis has increased in Africa as a result of the human immunodeficiency virus (HIV) epidemic. However, the effect of HIV co-infection on clinical features and prognosis in tuberculous pericarditis is not well characterised. We have used baseline data of the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry to assess the impact of HIV co-infection on clinical presentation, diagnostic evaluation, and treatment of patients with suspected tuberculous pericarditis in sub-Saharan Africa. METHODS: Consecutive adult patients in 15 hospitals in three countries in sub-Saharan Africa were recruited on commencement of treatment for tuberculous pericarditis, following informed consent. We recorded demographic, clinical, diagnostic and therapeutic information at baseline, and have used the chi-square test and analysis of variance to assess probabilities of significant differences (in these variables) between groups defined by HIV status. RESULTS: A total of 185 patients were enrolled from 01 March 2004 to 31 October 2004, 147 (79.5%) of whom had effusive, 28 (15.1%) effusive-constrictive, and 10 (5.4%) constrictive or acute dry pericarditis. Seventy-four (40%) had clinical features of HIV infection. Patients with clinical HIV disease were more likely to present with dyspnoea (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.4 to 7.4, P = 0.005) and electrocardiographic features of myopericarditis (OR 2.8, 95% CI 1.1 to 6.9, P = 0.03). In addition to electrocardiographic features of myopericarditis, a positive HIV serological status was associated with greater cardiomegaly (OR 3.89, 95% CI 1.34 to 11.32, P = 0.01) and haemodynamic instability (OR 9.68, 95% CI 2.09 to 44.80, P = 0.0008). However, stage of pericardial disease at diagnosis and use of diagnostic tests were not related to clinical HIV status. Similar results were obtained for serological HIV status. Most patients were treated on clinical grounds, with microbiological evidence of tuberculosis obtained in only 13 (7.0%) patients. Adjunctive corticosteroids were used in 109 (58.9%) patients, with patients having clinical HIV disease less likely to be put on them (OR 0.37, 95% CI 0.20 to 0.68). Seven patients were on antiretroviral drugs. CONCLUSION: Patients with suspected tuberculous pericarditis and HIV infection in Africa have greater evidence of myopericarditis, dyspnoea, and haemodynamic instability. These findings, if confirmed in other studies, may suggest more intensive management of the cardiac disease is warranted in patients with HIV-associated pericardial disease.
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    Clinical profiles and outcomes of patients receiving acute renal replacement therapy in the cardiac intensive care unit at a South African tertiary centre
    (2022) Mbanga, Luyanda C; Ntsekhe, Mpiko
    Background At least a quarter of patients admitted to the Cardiac Intensive Care Unit (CICU) will develop Acute Kidney Injury (AKI) and some of these patients receive Renal Replacement Therapy (RRT). The clinical profiles and outcomes of CICU patients receiving RRT in resource constraint settings like South Africa is unknown. Objectives The objectives of this study were to determine the clinical profiles and outcomes of patients receiving RRT in the CICU in a South African Tertiary Centre. Methods In this retrospective study we included consecutive patients admitted and receiving RRT at the Groote Schuur Hospital CICU from 01/01/2012 to 31/12/2016. Results During the study period 3247 patients were admitted to the CICU and 46 received RRT. The RRT patients had a mean (SD) age of 52 (17) years, 56% were males, and 65% had a background history of systemic hypertension. Heart failure syndromes accounted for 60.9% of CICU admission in the RRT patient group, followed by acute coronary syndromes and arrhythmias, which accounted for 26.1% and 13.0% respectively. The RRT patient population had an in-hospital and 30-day mortality of 58.7% and 60.9% respectively. Baseline use of Angiotensin Converting Enzyme (ACE) inhibitor or Angiotensin Receptor Blocker (ARB) was associated with a reduced 30 day mortality, Hazards Ratio (HR) 0.43; 95% Confidence interval (95%CI) 0.20 – 0.93; p = 0.031. In addition, heart failure was associated with an increased 30 day mortality, HR 2.52; 95% CI 1.10 – 5.78; p = 0.029. Conclusion Heart failure syndrome accounts for a majority of RRT patients admitted to the our CICU. Patients receiving RRT in CICU have a high in-hospital and 30-day mortality.
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    Development of a risk score for constrictive pericarditis using the Investigation of the Management of Pericarditis randomised clinical trial dataset
    (2022) Geffen, Hayli; Gumedze, Freedom; Ntsekhe, Mpiko
    Despite the recent global decline of tuberculosis infections, constrictive pericarditis, one of the most serious consequences of tuberculous pericarditis, continues to be a major cause of morbidity and mortality in sub-Saharan Africa. Currently, while the risk of constrictive pericarditis in individuals with tuberculous pericarditis does not appear to be uniform, there is no defined risk score available to predict an individual's baseline risk of constrictive pericarditis. Therefore the main aim of this research was to employ supervised learning classification using the data from 1400 participants enrolled in the first Investigation of the Management of Pericarditis randomised clinical trial to derive a risk score for constrictive pericarditis. While various supervised learning classification methods, including tree-based algorithms, support vector machines and artificial neural networks, were compared to stratify individuals according to low, medium and high risk for constrictive pericarditis, the final risk score was developed using logistic regression. Significant associations were found between constrictive pericarditis and the following predictors: HIV, New York Heart Association functional class, cardiac tamponade and effusive-constrictive pericarditis. Although prednisolone treatment was associated with a reduced relative risk of constrictive pericarditis in high (risk ratio = 0.59; 95% CI = 0.378 – 0.925) and medium (risk ratio = 0.12; 95% CI = 0.016 – 0.971) risk individuals, prednisolone treatment did not seem to benefit the individuals predicted to be at low risk (risk ratio = 0.92; 95% CI = 0.084 - 10.047) for constrictive pericarditis. These results confirm that the baseline risk of developing constrictive pericarditis in individuals with suspected or confirmed tuberculous pericarditis is not uniform. Importantly, interventions such as adjunctive prednisolone should only be recommended for individuals suspected to be at either medium or high risk for constrictive pericarditis as they are the most likely to benefit while prednisolone treatment should potentially be avoided in treating individuals with tuberculous pericarditis that are suspected to be at low risk for constrictive pericarditis as they are the least likely to derive any benefit.
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    Diagnostic accuracy of quantitative PCR (Xpert MTB/RIF) for tuberculous pericarditis compared to adenosine deaminase and unstimulated interferon-γ in a high burden setting: a prospective study
    (2014-06-18) Pandie, Shaheen; Peter, Jonathan G; Kerbelker, Zita S; Meldau, Richard; Theron, Grant; Govender, Ureshnie; Ntsekhe, Mpiko; Dheda, Keertan; Mayosi, Bongani M
    Background: Tuberculous pericarditis (TBP) is associated with high morbidity and mortality, and is an important treatable cause of heart failure in developing countries. Tuberculous aetiology of pericarditis is difficult to diagnose promptly. The utility of the new quantitative PCR test (Xpert MTB/RIF) for the diagnosis of TBP is unknown. This study sought to evaluate the diagnostic accuracy of the Xpert MTB/RIF test compared to pericardial adenosine deaminase (ADA) and unstimulated interferon-gamma (uIFNγ) in suspected TBP. Methods: From October 2009 through September 2012, 151 consecutive patients with suspected TBP were enrolled at a single centre in Cape Town, South Africa. Mycobacterium tuberculosis culture and/or pericardial histology served as the reference standard for definite TBP. Receiver-operating-characteristic curve analysis was used for selection of ADA and uIFNγ cut-points. Results: Of the participants, 49% (74/151) were classified as definite TBP, 33% (50/151) as probable TBP and 18% (27/151) as non TBP. A total of 105 (74%) participants were human immunodeficiency virus (HIV) positive. Xpert-MTB/RIF had a sensitivity and specificity (95% confidence interval (CI)) of 63.8% (52.4% to 75.1%) and 100% (85.6% to 100%), respectively. Concentration of pericardial fluid by centrifugation and using standard sample processing did not improve Xpert MTB/RIF accuracy. ADA (≥35 IU/L) and uIFNγ (≥44 pg/ml) both had a sensitivity of 95.7% (88.1% to 98.5%) and a negative likelihood ratio of 0.05 (0.02 to 0.10). However, the specificity and positive likelihood ratio of uIFNγ was higher than ADA (96.3% (81.7% to 99.3%) and 25.8 (3.6 to 183.4) versus 84% (65.4% to 93.6%) and 6.0 (3.7 to 9.8); P = 0.03) at an estimated background prevalence of TB of 30%. The sensitivity and negative predictive value of both uIFNγ and ADA were higher than Xpert-MT/RIF (P < 0.001). Conclusions: uIFNγ offers superior accuracy for the diagnosis of microbiologically confirmed TBP compared to the ADA assay and the Xpert MTB/RIF test.
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    Diagnostic utility of pericardial fluid pH in diagnosing infectious pericardial effusions among patients with moderate and large effusions undergoing pericardiocentesis at Groote Schuur Hospital: a subs-study of the IMPI trial
    (2020) Kiggundu, Brian; Ntsekhe, Mpiko
    Diagnosis of infectious pericardial disease has been challenging in the developing world despite improvement of treatment modalities. The diagnostic utility of pH in diagnosing infectious pericardial fluid is unknown, yet this concept is well studied in pleural fluid. This cross-sectional diagnostic study evaluated the diagnostic utility of pH in infectious compared to non-infectious pericardial effusions in a high-burden setting. Methods: Patients of 18 years with moderate to large effusion between the 1st February 2016 and 31st May2018 were enrolled at Groote Schuur Hospital in Cape Town, South Africa. After safe pericardiocentesis, pH was measured with a blood gas analyzer. Mycobacterium tuberculosis culture and/or gene Xpert for TB and/or bacteria culture and/or microscopy served as the reference standard for definite infectious pericardial effusions. We calculated sensitivity, specificity, positive and negative predictive values, negative and positive likelihood ratios for an a priori pH cut off of 7.35. Receiver operating characteristic curve analysis was used for selection of ideal pH cut off. RESULTS Using a set sensitivity of 70% we estimated that we needed to recruit a sample size of 149 subjects for a 95% confidence interval and power of 80%. We screened 200 patients, and excluded 60 because they did not meet the appropriate exclusion criteria. The prevalence of infectious pericarditis was 27.1% (n/N=34/140) as confirmed by the reference standard. We found the median pH (IQR) was 7.30(7.20-7.30) for definite infection, 7.30(7.30-7.35) for probable infection and 7.50(7.40-7.55) for non-infectious effusions p value <0.01 (test for trend). At a cut off or <7.35, the sensitivity was 89.5(95%CI: 75%.5-97.1%) and the specificity was 72.5% (95% CI: 62.8%-80.9%). The ideal ROC- determined cut off for pH that would give maximum sensitivity and specificity was ≤7.30 and the maximum sensitivity and specificity at optimum cut off are 86.8% (95% CI:71.9 - 95.6) and 86.8% (95% CI:71.9 - 95.6), respectively. The area under the curve at this cut-off point is 0.86 (95% CI 0.79 to 0.9), p<0. 001. CONCLUSION: In conclusion, pericardial PH offers diagnostic utility for infectious causes of pericardial effusions using both a PH of 7.35 and an ideal cut-off of 7.30. We recommend that given the simplicity of the test it should be adopted in evaluation of patients with pericardial effusions.
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    Evaluating the performance of the GRACE and TIMI risk scores in acute coronary syndromes: a South African cohort
    (2024) Khiroya, Mitesh Satish; Ntsekhe, Mpiko; Lukhna, Kishal
    Introduction: The GRACE and TIMI scores are validated risk stratification tools that accurately predict risk of in-hospital, 30-day, and one-year major adverse cardiac events (MACE) in patients with Acute Coronary Syndromes (ACS). The performance of GRACE and TIMI scores in a setting where most ST-elevation myocardial infarction (STEMI) patients receive thrombolytic reperfusion therapy after 6 hours and a considerable proportion of non-ST elevation myocardial infarction (NTSEMI) patients receive delayed angiography and revascularisation after 48 hours, is unknown. Objective: To evaluate the accuracy of GRACE and TIMI risk scores in predicting in-hospital and 30-day mortality in a population characterised by a significant prevalence of delayed ACS presentation, limited access to primary percutaneous coronary intervention (PPCI) and delayed revascularisation. Methods: We conducted a retrospective review of all patients admitted to the coronary care unit (CCU) at Groote Schuur Hospital, Cape Town, with either STEMI or NSTEMI, between January 1 st to December 31st, 2019. For each participant, both GRACE and TIMI risk scores were calculated and recorded electronically. Performance of each score was determined and compared using receiver operating characteristic curve (ROC) analysis. Results: Of 329 participants with ACS, 58.6% presented with STEMI and 41.4% with NSTEMI. Mean age was 61.3 (SD±11.9) years, and 59.6% were male. Mean time from symptom onset to hospital admission was 18.3 (SD ± 37.4) hours, with only 4 participants (2.1%) receiving PPCI. STEMI in-hospital and 30-day mortality was 4.1% and 4.2%, respectively, whereas in-hospital mortality for NSTEMI was 1.5%. In the STEMI cohort, both GRACE and TIMI risk scores were comparable, showed excellent discrimination for in-hospital mortality (AUC=0.927, 95% CI: 0.83- 1.00 versus AUC=0.923, 95% CI: 0.87-0.98; p 0.91), and demonstrated modest accuracy for predicting 30-day mortality (GRACE AUC=0.587, 95% CI: 0.29-0.88; TIMI AUC=0.530, 95% CI: 0.12-0.94; p 0.44). In the NSTEMI cohort, GRACE performed significantly better than TIMI (AUC=0.905, 95% CI: 0.85-0.96 versus AUC=0.278, 95% CI: 0.00-0.68; p 0.001) for predicting in-hospital mortality. Conclusion: Both GRACE and TIMI scores demonstrated high accuracy in predicting in-hospital mortality and their predictive accuracy was modest when predicting 30-day mortality for STEMI patients. In addition, GRACE outperformed the TIMI score in assessing NSTEMI in-hospital mortality. Further research in low-and middle-income countries in SSA is needed to evaluate the potential impact of these scores on treatment strategies and cardiovascular outcomes.
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    HIV infection is associated with a lower incidence of constriction in presumed tuberculous pericarditis: a prospective observational study
    (Public Library of Science, 2008) Ntsekhe, Mpiko; Wiysonge, Charles S; Gumedze, Freedom; Maartens, Gary; Commerford, Patrick J; Volmink, Jimmy A; Mayosi, Bongani M
    BACKGROUND: Pericardial constriction is a serious complication of tuberculous pericardial effusion that occurs in up to a quarter of patients despite anti-tuberculosis chemotherapy. The impact of human immunodeficiency virus (HIV) infection on the incidence of constrictive pericarditis following tuberculous pericardial effusion is unknown. Methods and RESULTS: We conducted a prospective observational study to determine the association between HIV infection and the incidence of constrictive pericarditis among 185 patients (median age 33 years) with suspected tuberculous pericardial effusion. These patients were recruited consecutively between March and October 2004 on commencement of anti-tuberculosis treatment, from 15 hospitals in Cameroon, Nigeria and South Africa. Surviving patients (N = 119) were assessed for clinical evidence of constrictive pericarditis at 3 and 6 months of follow-up. Clinical features of HIV infection were present in 42 (35.2%) of the 119 patients at enrolment into the study. 66 of the 119 (56.9%) patients consented to HIV testing at enrolment. During the 6 months of follow-up, a clinical diagnosis of constrictive pericarditis was made in 13 of the 119 patients (10.9 %, 95% confidence interval [CI] 5.9-18%). Patients with clinical features of HIV infection appear less likely to develop constriction than those without (4.8% versus 14.3%; P = 0.08). None of the 33 HIV seropositive patients developed constriction, but 8 (24.2%, 95%CI 11.1-42.3%) of the 33 HIV seronegative patients did (P = 0.005). In a multivariate logistic regression model adjusting simultaneously for several baseline characteristics, only clinical signs of HIV infection were significantly associated with a lower risk of constriction (odd ratio 0.14, 95% CI 0.02-0.87, P = 0.035). CONCLUSIONS: These data suggest that HIV infection is associated with a lower incidence of pericardial constriction in patients with presumed tuberculous pericarditis.
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    International normalised ratio control in a non-metropolitan setting in Western Cape Province, South Africa
    (2021) Prinsloo, Dawid Nicolaas; Ntsekhe, Mpiko; Gould, T J
    Background: The quality of INR control determines the effectiveness and safety of Warfarin. Data on INR control in non-metropolitan settings of South Africa (SA) is sparse. Objectives: To examine the Time in Therapeutic Range (TTR) and its potential predictors in a sample of Garden Route District Municipality INR clinics Methods: INR records from eight Primary Healthcare Clinics (PHCs) were reviewed. The TTR and percentage of patients with a TTR greater than 65% were determined. A host of variables were analysed for association with TTR. Results: The median age of the cohort of 191 was 56 years (IQR 44-69). The median TTR was 37.17% (IQR 20.21-58.78); only 17.8% of patients had a TTR > 65%. Compared to patients older than 50, those under 50 had worse INR control (TTR 26.63%, IQR 16.05-52.98 vs. 43.5%, IQR 23.52- 60.08, p=0.01). Patients hospitalised for any reason during the study period had worse INR control than patients not hospitalised (TTR 26.23%, IQR 16.24-50.16 vs. 42.89, IQR 23.5-61.95, p=0.02). On multivariable regression analysis, participants on warfarin for atrial fibrillation/flutter had better INR control (OR 2.21, CI 1.02-4.77, p=0.04) but the control was still very poor. Conclusion: INR control as determined by TTR and proportion of TTR >65% in these non-metropolitan clinics was poor. Age and markers of illness predicted poor control. There was a difference in control between groups depending on the indication for warfarin. Evidence-based measures to improve the quality of INR control amongst patients on warfarin therapy need to be instituted as a matter of urgency.
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    Investigation of the management of tuberculous pericarditis (IMPI) registry : survival and outcomes sub-study
    (2012) Mubanga, Mwenya; Ntsekhe, Mpiko; Myer, Landon; Mayosi, Bongani
    Includes abstract. Includes bibliographical references.
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    Mortality in patients treated for tuberculous pericarditis in sub-Saharan Africa.
    (Health & Medical Publishing Group, 2008) Mayosi, Bongani M; Wiysonge, Charles Shey; Ntsekhe, Mpiko; Gumedze, Freedom; Volmink Jimmy A; Maartens, Gary; Aje, Akinyemi; Thomas, Baby M; Thomas, Kandathil M; Awotedu, Abolade A; Bongani, Thembela; Mntla, Phindile; Maritz, Frans; Blackett, Kathleen Ngu; Nkouonlack, Duquesne C; Burch, Vanessa C; Rebe, Kevin; Parrish, Andy; Sliwa, Karen; Vezi, Brian Z; Alam, Nowshad; Brown, Basil G; Gould, Trevor; Visser, Tim; Magula, Nombulelo P; Commerford, Patrick J
    Tuberculous pericarditis is one of the most severe forms of extrapulmonary tuberculosis, causing death or disability in a substantial proportion of affected people.1,2 In Africa, the incidence of tuberculous pericarditis is rising as a result of the HIV epidemic.3 The effect of HIV infection on survival in patients with tuberculous pericarditis is unknown.2,4 Whereas some investigators have suggested that HIV-infected patients with tuberculous pericarditis have a similar outcome to non-infected cases,5 others have shown that there may be an increase in mortality in HIV associated with tuberculous pericarditis.2,6,7 We established a prospective observational study, the Investigation of the Management of Pericarditis in Africa (IMPI Africa) registry, to obtain current information on the diagnosis, management and outcome of patients with presumed tuberculous pericarditis living in sub-Saharan Africa, where the burden of HIV infection is the greatest in the world.4,8-10 In this paper, we report the mortality rate and its predictors during the 6 months of antituberculosis treatment among patients enrolled in the regist
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    Prevalence, hemodynamics, and cytokine profile of effusive-constrictive pericarditis in patients with tuberculous pericardial effusion
    (Public Library of Science, 2013) Ntsekhe, Mpiko; Matthews, Kerryn; Syed, Faisal F; Deffur, Armin; Badri, Motasim; Commerford, Patrick J; Gersh, Bernard J; Wilkinson, Katalin A; Wilkinson, Robert J; Mayosi, Bongani M
    BACKGROUND: Effusive constrictive pericarditis (ECP) is visceral constriction in conjunction with compressive pericardial effusion. The prevalence of proven tuberculous ECP is unknown. Whilst ECP is distinguished from effusive disease on hemodynamic grounds, it is unknown whether effusive-constrictive physiology has a distinct cytokine profile. We conducted a prospective study of prevalence and cytokine profile of effusive-constrictive disease in patients with tuberculous pericardial effusion. METHODS: From July 2006 through July 2009, the prevalence of ECP and serum and pericardial levels of inflammatory cytokines were determined in adults with tuberculous pericardial effusion. The diagnosis of ECP was made by combined pericardiocentesis and cardiac catheterization. RESULTS: Of 91 patients evaluated, 68 had tuberculous pericarditis. The 36/68 patients (52.9%; 95% confidence interval [CI]: 41.2-65.4) with ECP were younger (29 versus 37 years, P=0.02), had a higher pre-pericardiocentesis right atrial pressure (17.0 versus 10.0 mmHg, P<0.0001), serum concentration of interleukin-10 (IL-10) (38.5 versus 0.2 pg/ml, P<0.001) and transforming growth factor-beta (121.5 versus 29.1 pg/ml, P=0.02), pericardial concentration of IL-10 (84.7 versus 20.4 pg/ml, P=0.006) and interferon-gamma (2,568.0 versus 906.6 pg/ml, P=0.03) than effusive non-constrictive cases. In multivariable regression analysis, right atrial pressure > 15 mmHg (odds ratio [OR] = 48, 95%CI: 8.7-265; P<0.0001) and IL-10 > 200 pg/ml (OR=10, 95%CI: 1.1, 93; P=0.04) were independently associated with ECP. CONCLUSION: Effusive-constrictive disease occurs in half of cases of tuberculous pericardial effusion, and is characterized by greater elevation in the pre-pericardiocentesis right atrial pressure and pericardial and serum IL-10 levels compared to patients with effusive non-constrictive tuberculous pericarditis.
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    Profile and outcomes of acute myocardial infarction amongst young South Africans
    (2023) Hoosain, Shakeel; Ntsekhe, Mpiko
    Background Acute myocardial infarction (AMI) is a leading cause of death worldwide; however, little is known about the clinical profile and outcomes in South Africans under the age of 45 years with AMI. Therefore, we aimed to compare the clinical profile and outcomes of patients younger and older than 45 years treated for AMI at a South African tertiary centre. Method We reviewed the hospital records of all patients admitted with AMI to the Coronary Care Unit at Groote Schuur Hospital, Cape Town in 2016. Poor outcome was defined as death, readmission with heart failure or an acute coronary syndrome (ACS) within 12 months of the index presentation. Results This study included 302 patients, of which 48 (15.9%) were younger than 45 years. A third of the young cohort had premature coronary artery disease. Smoking was the most common risk factor amongst young patients (72.2%). In terms of metabolic risk factors, the older cohort was more likely to have hypertension (68.9% vs 52.1%, p=0.024) and dyslipidaemia (49.6% vs 31.2%, p=0.019). Albeit common in both cohorts, there was no significant difference in prevalence between diabetes mellitus or smoking history. The older cohort was more likely to have poorer outcomes (27.2% vs 6.2%, p=0.002), a significantly higher prevalence of death (10.1% vs none, p=0.033) and readmission for either heart failure or ACS (18.9% vs 6.2%, p=0.032). Page 8 of 27 Conclusion We showed significant differences in the risk factor profile and outcomes of young patients with AMI compared to older counterparts, however, traditional risk factors for coronary artery disease remained common. This highlights the importance of implementing prevention strategies for AMI at earlier ages in South Africa.
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    Profile, Presentation and Outcomes of Prosthetic Valve Endocarditis in a South African Tertiary Hospital: Insights From the Groote Schuur Hospital Infective Endocarditis Registry
    (2022) Mkoko, Philasande; Ntsekhe, Mpiko
    Background Prosthetic valve infective endocarditis (PVE) is associated with high morbidity and mortality. The prevalence of PVE in local retrospective studies ranges between 13% and 16%. However, the clinical patient profile and outcomes remains unknown. Methods We performed a prospective observational study of patients presenting or referred to Groote Schuur Hospital with definitive or probably infective endocarditis based on the 2015 European Society of Cardiology (ESC) infective endocarditis diagnostic criteria. Consenting adult patients who met inclusion criteria were enrolled into the Groote Schuur Hospital Infective Endocarditis Registry which was approved by the University of Cape Town Human Research Ethics. The current study is an analysis of the cohort of patients who were enrolled between 01/01/2017 to 31/12/2019. The primary objective of this study was to define the clinical profile and outcomes of patients with PVE. The secondary objective aimed to compare the clinical profile and outcomes of PVE patients with those of native valve endocarditis patients (NVE). Results During the study period a total of 135 patients received a diagnosis of possible and definitive infective endocarditis (IE). Of these, 18 patients had PVE and 117 patients NVE. Therefore, PVE accounted for 13.3% of the overall IE cohort. PVE patients had mean (Standard Deviation) age of 39.1 (14.6) years, 56.6% were male. PVE occurred within one year of valve surgery in 50% and the Duke's modified diagnostic criteria for definitive IE was met in 94.4% of the PVE cohort. Prosthetic valves in the aortic position were affected in isolation or in combination with prostheses in the mitral area in 66.7%. Further, tissue prosthetic valves were affected in 61.1% of the PVE cases. 55.6% of the PVE cases were health care associated. On transthoracic echocardiography, vegetations (61.1%), prosthetic valve regurgitation (44.4%) and abscess (22.2%) were discovered. Staphylococcus species and streptococcus species accounted for 38.8% and 22.2% of PVE cases, respectively. 27.8% cases were blood culture negative. Valve surgery was performed in 38.7% of the PVE patients. 55.6% of the PVE patients demised during the index hospitalisation. The secondary analysis indicated that the PVE patients were sicker, with a higher frequency of septic shock and heart block than the NVE patients, 22.2% vs 7% p= 0.02 and 27.8% vs 12% p =0.04 respectively. In addition, in hospital mortality was higher in PVE patients than NVE patients, 55.6% vs 31.6% p=0.04. Conclusion PVE is relatively uncommon in resource-limited settings and is associated with a high in hospital mortality. Staphylococcus and streptococcus species are the leading microbiological causes of PVE. The selected PVE patients that receive surgical treatment for endocarditis demonstrate better in-hospital survival than those who do not receive surgical treatment. This finding not only reaffirms the importance of surgery as treatment option for IE but further demonstrate the importance of the Heart team in selecting appropriate surgical candidates.
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    Open Access
    Quantification of echodensities in tuberculous pericardial effusion using fractal geometry: a proof of concept study
    (BioMed Central Ltd, 2012) Ntsekhe, Mpiko; Mayosi, Bongani; Gumbo, Tawanda
    BACKGROUND:The purpose of this study was to quantify the heterogeneous distribution of echodensities in the pericardial fluid of patients with tuberculous pericarditis using echocardiography and fractal analysis, and to determine whether there were differences in the fractal dimensions of effusive-constrictive and effusive non-constrictive disease. METHODS: We used fractal geometry to quantify the echocardiographic densities in patients who were enrolled in the Investigation of the Management of Pericarditis in Africa (IMPI Africa) Registry. Sub-costal and four chamber images were included in the analysis if a minimum of two clearly identified fibrin strands were present and the quality of the images were of a standard which allowed for accurate measurement of the fractal dimension. The fractal dimension was calculated as follows: Df=limlog N(s)/[log (l/s)], where Df is the box counting fractal dimension of the fibrin strand, s is the side length of the box and N(s) is the smallest number of boxes of side length s to cover the outline of the object being measured. We compared the fractal dimension of echocardiographic findings in patients with effusive constrictive pericarditis to effusive non-constrictive pericardial effusion using the non-parametric Mann-Whitney test. RESULTS: Of the 14 echocardiographs from 14 participants that were selected for the study, 42.8% (6/14) of images were subcostal views while 57.1% (8/14) were 4-chamber views. Eight of the patients had tuberculous effusive constrictive pericarditis while 6 had tuberculous effusive non-constrictive pericarditis. The mean fractal dimension Df was 1.325 with a standard deviation (SD) of 0.146. The measured fibrin strand dimension exceeded the topological dimension in all the images over the entire range of grid scales with a correlation coefficient (r2) greater than 0.8 in the majority. The fractal dimension of echodensities was 1.359+/-0.199 in effusive constrictive pericarditis compared to 1.330+/-0.166 in effusive non-constrictive pericarditis (p=0.595). CONCLUSIONS: The echocardiographic densities in tuberculous pericardial effusion have a fractal geometrical dimension which is similar in pure effusive and effusive constrictive disease.
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    Open Access
    Spectrum Of Causes Of Isolated Aortic Regurgitation At A South African Public Sector Tertiary Care Institution
    (2023) Masikati, Malcolm; Ntsekhe, Mpiko; Pennel Timothy
    BACKGROUND Aortic Regurgitation (AR) is due to primary abnormalities of the aortic valve, peri-valvular apparatus and/or the aortic root and the ascending aorta. Whereas the etiology and mechanisms of AR are relatively well described in Europe and North America, little information exists about their spectrum and frequency in sub-Saharan and South Africa. Understanding the precise mechanisms of AR informs surgical planning of valve and aorta repair. Reports from local studies suggest that rheumatic heart disease in the commonest cause of valvular heart disease in RSA particularly in population under 40 but whether it's the most common cause of isolated AR is not known. The aims of this study were to report the spectrum of causes of isolated aortic regurgitation and their distribution, including the main mechanisms of aortic regurgitation in our setting. The accuracy of pre-op assessment of etiology by clinical and imaging evaluation was also analyzed along with its concordance to surgical findings. METHODS This is a retrospective review of hospital records of patients who had aortic valve replacement (AVR) for isolated AR from Jan 2003 to June 2018 at Groote Schuur Hospital (GSH). Most patients had a presumptive etiological diagnosis determined by pre-operative echocardiography. For this study the etiology and pathological mechanism was confirmed by macroscopic examination at surgery and pathological examination of explanted valves. RESULTS There were 141 patient records available over the period. The mean age for the cohort was 43 years (range 29-57) with a male predominance of 63%. Baseline co-morbid conditions of the participants included hypertension 43.3%, Human immunodeficiency virus (HIV)16.9%, and chronic kidney disease 4.3%. The mechanistic and etiological diagnosis was available for all 141 study participants. The five predominant mechanisms were: 1- thickening/fibrosis/retraction with commissary fusion in 32.6%. 2- cusp perforation/leaflet destruction in 24.8%. 3- prolapse of the aortic leaflet cusps in 7.1%. 4- aortic root or annular dilatation in 27%. 5- Mixed mechanisms in 8.5%. The most common diseases which caused aortic regurgitation by affecting the valve leaflets were rheumatic heart disease, infective endocarditis, degenerative valve disease and bicuspid aortic valve. Diseases that affect the root and aorta included hypertension, Marfan' syndrome, syphilitic aortitis, Takayasu's arteritis; and pyogenic aortitis. Of the 141 patients in the study complete information on the pre-op echo, surgical macroscopic inspection and histological evaluation was available in 92. Of the 92 patients there was consistency in the pre and post of diagnosis in 93.5% (86/92). The most common discrepant diagnosis was rheumatic heart disease at histology or on surgical inspection but having been referred with a preoperative echo diagnosis of infective endocarditis.
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    Open Access
    Studies of effusive constrictive pericarditis
    (2011) Ntsekhe, Mpiko
    Tuberculous (TB) pericarditis is associated with a mortality rate of 17-40% despite treatment with anti-tuberculosis drugs. The complications of TB pericarditis that confer mortality and morbidity are pericardial tamponade, effusive constrictive pericarditis, and constrictive pericarditis. Whilst the diagnosis and treatment of pericardial tamponade and constriction are well established, there is a paucity of evidence on the frequency and significance of tuberculous effusive constrictive pericarditis. The primary purpose of this work was to determine the prevalence, predictors, fractal (geometric) structure, biomarker signature, and outcome of effusive constrictive TB pericarditis.