Quality of Acute Coronary Syndrome Care and in-hospital Outcome in a Resource-poor Setting in Northern Ghana

doi:10.21203/rs.3.rs-3098150/v1

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Research Article

Quality of Acute Coronary Syndrome Care and in-hospital Outcome in a Resource-poor Setting in Northern Ghana

https://doi.org/10.21203/rs.3.rs-3098150/v1

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published 25 Mar, 2024

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Background

African countries are facing an epidemic of cardiovascular diseases for which they lack the resources to diagnose and manage adequately. Information on the quality of acute coronary syndrome care offered in underserved communities in low to middle-income countries like Ghana is limited. We examined the quality of acute coronary syndrome care offered to patients presenting to the Tamale Teaching Hospital in Northern Ghana.

Methods

We conducted a retrospective review of the medical records of patients ≥ 18 years with acute coronary syndrome managed in the Tamale Teaching Hospital of Northern Ghana from January 2021 to December 2022. We characterised the clinical profile of these patients and assessed in-hospital outcomes and the extent of compliance to key performance and quality indicators as contained in the 2017 American Heart Association /American College of Cardiology guideline for adults with myocardial infarction.

Results

Between January 2021 and December 2022, 62 patients with a mean age of 56.0 ± 16.1 years were admitted with acute coronary syndrome. Median time to hospital presentation after symptom onset was 24 hours (IQR 15–96 hours). 33.9% had ST-elevation myocardial infarction, of which only 14.3% received reperfusion therapy. About three-quarters of patients received dual antiplatelet therapy at discharge (78.2%), with fewer patients receiving recommended high-intensity statin therapy (65.5%) or beta-blockers (69.1%). Only 38.2% of patients had their left ventricular ejection fraction documented. Among those with documented left ventricular systolic dysfunction, 75% were prescribed an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker at discharge. No cardiac rehabilitation program existed. Risk stratification of patients with non-ST-elevation myocardial infarction or stress tests for conservatively managed patients was not part of routine practice.

Conclusion

Acute coronary syndrome management remains a challenging issue in Northern Ghana. Several gaps exist in the care quality, timeliness of interventions and rehabilitation of affected patients. There is an urgent need for measures to improve the delivery of acute coronary syndrome care alongside primary prevention strategies.

Acute coronary syndrome

Ghana

Myocardial infarction

Performance measure

Quality indicators

Besides communicable diseases, countries in the African region are now facing an epidemic of cardiovascular diseases (CVDs) for which there is a lack of resources for adequate diagnosis and management. Coronary artery disease (CAD) is the single most common cause of mortality and loss of Disability Adjusted Life Years globally, with the greatest burden in low-and middle-income countries [1, 2]. Sub-Saharan Africa has seen an increase in the incidence of CAD mainly due to the adoption of Western lifestyles and an ageing population, leading to a higher prevalence of cardiovascular risk factors [1–4].

Acute coronary syndrome (ACS) represents a devastating manifestation of CAD. It comprises a spectrum of clinical manifestations that result from a sudden reduction of blood supply to the myocardium resulting in myocardial ischaemia or injury [5]. The designation of ACS includes ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) [6]. The long-term outcomes after ACS have progressively improved in high-income countries over recent decades, mainly due to effective acute treatment and improved primary and secondary preventive measures [2, 7]. However, this is not the case in developing countries which are now facing an epidemic of non-communicable diseases which they lack the resources to manage adequately.

Empirical evidence and limited studies suggests that the incidence of ACS is increasing in many African countries [4, 8]. The limited publications available report wide variations in the incidence of ACS with scarce data on its acute and long-term outcomes [3, 4, 9–13]. It is however clear that the management of ACS is frequently suboptimal in most countries in the African region partly due to limited access to advanced care with attended high morbidity and mortality [14–16]. In a study in northern Tanzania, as many as 60% of patients with an acute myocardial infarction died within 12 months of diagnosis [10].

Care of patients with ACS in low-middle income countries is fraught with challenges at all levels of health systems. Acute care is hampered by late presentation, inability to adhere to critical timelines for intervention, limited availability of acute reperfusion as a therapeutic option, and lack of health financing schemes that cater for emergency care [8]. Additionally, compliance with guideline medications like antiplatelet agents and statins is frequently poor [14]. Other evidence-based non-pharmacological interventions such as smoking cessation, heart-healthy diets, exercise and cardiac rehabilitation are frequently unavailable or not adhered to [17]. In a few centres in Africa that are adequately equipped with well-trained staff and logistics to manage CAD and its complications, including ACS, outcomes similar to that reported in high-income countries have been reported [18]. This demonstrates the feasibility of comprehensive ACS care with favorable outcomes if the right measures are put in place to mitigate the challenges that hamper ACS care in Africa.

Information on the quality of ACS care provided in Ghana is scarce. In this study, we characterise the clinical profile of patients presenting with ACS to the Tamale Teaching Hospital (TTH) in Northern Ghana and assess in-hospital outcomes and the extent of compliance to evidence-based therapy as outlined in the 2017 American Heart Association (AHA)/American College of Cardiology (ACC) report on clinical performance and quality measures for adults with STEMI and NSTEMI [19]. This information will help identify gaps and limitations to ACS care that can be improved upon. It may also facilitate advocacy efforts for equitable allocation of healthcare resources and the development of context-appropriate ACS care strategies that will be useful in Ghana and other low resource settings in the African region.

Study site

The study was conducted in TTH, a tertiary facility that serves as a referral centre for the Northern part of Ghana. The population served is primarily rural and poor. Tamale Teaching Hospital is one of 5 public teaching hospitals in Ghana with a bed capacity of 800. It provides services to over 100,000 patients each year and serves as a major referral centre providing diverse specialist services to people in the Savanna regions of Ghana, including the Upper East and West regions, Northern region, some parts of the Brong–Ahafo region and the northern parts of the Volta region [20].

Study design

This was a retrospective descriptive study of patients admitted with a diagnosis of ACS to the Department of Internal Medicine of TTH from January 2021 to December 2022.

Study population

The study population comprised all patients with a diagnosis of ACS admitted to the Internal Medicine Department of TTH from January 2022 to December 2022. Inclusion criteria were age ≥ 18 years and a diagnosis of ACS according to standard criteria [6, 21]. Patients with other causes of myocardial injury other than ischaemia or those without outcome data, including discharge against medical advice, were excluded.

Sampling and data collection

The medical records of patients with a diagnosis of ACS who were admitted to the Internal Medicine Department of the hospital from January 2021 to December 2022 were retrieved from the electronic medical records database of the hospital. All eligible patients (who satisfy the inclusion criteria with no exclusion criteria) were included in the study.

The medical records were reviewed for demographic information, cardiovascular risk factors, presenting symptoms, treatment received and in-hospital outcomes. Findings such as cardiac troponin levels and basic biochemical and haematologic parameters were also reviewed. Electrocardiograms (ECG) and echocardiography findings were recorded. In-hospital outcome measures included death, left ventricular systolic dysfunction, symptomatic heart failure or persistent angina. Adherence to key performance and quality measures as contained in the 2017 AHA/ACC guidelines for adults with STEMI and NSTEMI was assessed to determine the quality of care provided and identify opportunities for improvement [19].

Statistical analysis

Categorical variables were presented as counts and percentages (%), whilst continuous variables were summarised as their means with standard deviation or as median with their interquartile ranges, as appropriate. Results were summarised into tables. Data transformations and analysis were performed using the Statistical Package for the Social Sciences version 20.0 software (SPSS, IBM Corporation, Armonk, NY, USA).

Ethical considerations

The study conformed to the principles outlined in the Declaration of Helsinki on the ethical principles for medical research involving human subjects.

Between January 2021 and December 2022, 62 patients with ACS were admitted to TTH, of which 37 (59.7%) were males. The mean age was 56.0 ± 16.1 years, with a range of 21–89 years. It was observed that 61.3% had National Health Insurance coverage, whilst the rest paid out of pocket for their medical bills (Table 1). Twenty-one (33.9%) were diagnosed with STEMI, whilst 35 (56.5%) and 6 (9.7%) had a diagnosis of NSTEMI and UA, respectively.

Table 1

Baseline characteristics of patients
Variable	n (%)
Sociodemographic information
Age in years (mean ± SD)	56.0 ± 16.1
Gender (males)	37 (59.7%)
Health Insurance Coverage	38 (61.3%)
Cardiovascular risk factors
Hypertension	43 (69.4%)
Diabetes mellitus	8 (12.9%)
Dyslipidaemia	6 (9.7%)
Prior MI/stroke	4 (6.4%)
Obesity	3 (4.8%)
Alcohol	3 (4.8%)
Smoking	2 (3.2%)
Presenting symptoms
Chest pain	41 (66.1%)
Dyspnoea	32 (51.6%)
GI symptoms	7 (11.3%)
Easy fatigue	6 (9.7%)
Diaphoresis	4 (6.4%)
Dizziness	4 (6.4%)
Syncope	2 (3.2%)
Symptom onset to presentation (hours), median IQR	24 (15–96)
Duration of Hospital Stay (days), median IQR	5 (3–8)
Body mass index (kg/m²), mean ± SD	26.8 ± 4.5
Systolic blood pressure (mmHg), mean ± SD	137.9 ± 23.8
Diastolic blood pressure (mmHg), mean ± SD	87.1 ± 8.5
Heart rate (beats per minute), mean ± SD	95 ± 18
GI, Gastrointestinal; IQR, Interquartile Range; MI, Myocardial Infarction; SD, Standard Deviation

The common presenting symptoms are summarised in Table 1. Chest pain, or dyspnoea, was the presenting complaint in 80.6% of the patients. Gastrointestinal symptoms, including nausea, vomiting or abdominal pains, were reported by 11.3% of patients. The median duration from symptom onset to hospital presentation was 24 hours (IQR 15–96 hours).

Hypertension was the most common cardiovascular risk factor identified in the study participants (69.4%), while smoking was uncommon (3.2%).

Table 1: Baseline characteristics of patients

To assess the quality of care experienced by individuals with ACS in the in-patient setting, the proportion of patients meeting key performance and quality measures as defined in the 2017 AHA/ACC guidelines for adults with STEMI and NSTEMI were calculated and are summarised in Table 2 [19].

Table 2

Performance and quality measures for acute coronary syndrome management
VARIABLES	n (%)
Performance Measures
Aspirin at Arrival, N = 62	43 (69.4%)
Aspirin Prescribed at Discharge, N = 55	48 (87.3%)
Beta Blocker Prescribed at Discharge, N = 55	38 (69.1%)
High-Intensity Statin Prescribed at Discharge, N = 55	36 (65.5.%)
Evaluation of LVEF, N = 55	21 (38.2%)
ACEI or ARB Prescribed for LVSD, N = 16	12 (75.0%)
Time to Fibrinolytic Therapy (Door-to-Needle Time ≤ 30 minutes) *, N = 11	0 (0.0%)
Time to Primary PCI (FMC-to-device time ≤ 90 minutes) *, N/A	-
Reperfusion Therapy*, N = 21	3 (14.3%)
Door-in-Door-Out Time ≤ 30 minutes*, N = 1	0 (0.0%)
Time to Primary PCI Among Transferred Patients ≤ 120 minutes*, N/A	-
Cardiac Rehabilitation Referral, N/A	-
P2Y12 Receptor Inhibitor Prescribed at Discharge, N = 55	48 (87.3%)
Immediate Angiography After Cardiac Arrest*, N/A	-
Stress Test in Conservatively Treated Patients, N = 53	0 (0.0%)
Early Troponin Measurement After NSTEMI (Within 6 Hours of Arrival) †, N = 35	1 (2.9%)
Acute Myocardial Infarction Registry Participation (Yes/No)	No
Quality Measures
Risk Stratification of NSTEMI Patients with a Risk Score†, N = 31	0 (0.0%)
Early Invasive Strategy (Within 24 Hours) for High-Risk NSTEMI †, N/A	-
Therapeutic Hypothermia for STEMI Patients*, N = 1	0 (0.0%)
Aldosterone Antagonist Prescribed at Discharge for eligible patients, N = 6	1 (16.7%)
Inappropriate In-Hospital Use of NSAIDs, N = 62	3 (4.8%)
Inappropriate Prasugrel at Discharge in TIA/Stroke Patients, N = 1	0 (0.0%)
Inappropriate High-Dose Aspirin with Ticagrelor at Discharge, N = 2	0 (0.0%)
* Applies to STEMI patients only † Applies to NSTEMI patients only ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; ED, emergency department; FMC, first medical contact; LVEF, left ventricular ejection fraction; LVSD, left ventricular systolic dysfunction; N/A, Non-applicable; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTEMI, non–ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; and TIA, transient ischemic attack.

Most patients received aspirin or a P2Y12 inhibitor at discharge (87.3% each), with 78.2% receiving dual antiplatelet therapy. Fewer patients received recommended high-intensity statin therapy (65.5%) or beta-blockers (69.1%). The left ventricular ejection fraction (LVEF) was documented for 38.2% of the patients by discharge. 75% of those with documented left ventricular systolic dysfunction (LVEF < 40%) were prescribed an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker at discharge. Among patients who had an LVEF ≤ 40% who were already receiving an ACE inhibitor and beta-blocker, and who had either heart failure or diabetes mellitus but had no documented contraindication to an aldosterone antagonist, only 16.7% were prescribed an aldosterone antagonist (spironolactone) at discharge.

Three (14.3%) patients presenting with STEMI received reperfusion therapy. Two patients had thrombolysis with streptokinase, and one was transferred out for primary percutaneous coronary intervention (PCI). One patient with NSTEMI who had persistent symptoms with conservative management was transferred for PCI. Among the 11 patients with STEMI who had no absolute contraindication to using fibrinolytic therapy, none received thrombolysis within the recommended 30 minutes of arrival. All patients with NSTEMI had cardiac troponin measurements; however, the median time to obtain the results after the presentation was 24 hours (IQR 15–24 hours). Only in one instance was the result available within 6 hours of arrival. No formal risk stratification score was documented for patients with NSTEMI. Stress testing for conservatively managed patients was not part of routine practice.

Since TTH was not a PCI-capable facility, performance measures related to PCI or coronary angiography were not scored. Similarly, no cardiac rehabilitation program existed in Northern Ghana over the study period. The performance measure assessing participation in an acute myocardial infarction registry is a binary question requiring a “yes” or “no” answer. There was no national or regional ACS registry during the study period.

Door-in-Door-Out Time refers to the time from emergency department (ED) arrival to ED discharge for patients with acute STEMI who were transferred for primary PCI. The single patient transferred for primary PCI over the study period had a Door-in-Door-Out Time of several hours.

The last three quality measures regarding inappropriate use of nonsteroidal anti-inflammatory drugs (NSAIDs), inappropriate prescription of prasugrel in patients with prior stroke and the inappropriate prescription of high-dose aspirin with ticagrelor are patient safety measures. Apart from 3 patients (4.8%) for whom NSAIDs were prescribed on admission, the scores for these measures were generally satisfactory.

Table 2: Performance and quality measures for acute coronary syndrome management

Seven (11.3%) in-hospital deaths were recorded. In-hospital mortality was 19% for those with STEMI. Common complications included left ventricular systolic dysfunction (19.4%) and symptomatic heart failure (38.7%) (Table 3).

Table 3

In-hospital complications
Complications	n (%)
Heart failure	24 (38.7%)
Left ventricular systolic dysfunction	16 (25.8%)
Left ventricular aneurysm	2 (3.2%)
Cardiac arrhythmias	4 (6.5%)
Stroke	2 (3.2%)
Deaths	7 (11.3%)

The growth of CVD care infrastructure and human resources in the African region has yet to match up with the increasing burden of these diseases, and budget allocations in many of these countries still prioritise communicable diseases [17]. In this study, we shed light on the quality of ACS care offered in a tertiary hospital in northern Ghana using the 2017 AHA/ACC clinical performance and quality measures guidelines for adults myocardial infarction as a yardstick [19]. This guideline is intended to provide healthcare practitioners and their institutions with tools to assess the quality of care delivered and identify opportunities for improvement. The domains assessed include effective clinical care, patient safety, communication, coordination, efficiency, cost reduction and public health [19]. It is believed that implementing these measures by healthcare providers and facilities will ultimately improve the quality of care and outcomes of patients with acute myocardial infarction [19].

Atherosclerotic plaque disruption and superimposed platelet-rich thrombus formation are the main pathophysiological mechanisms causing ACS. Aspirin inhibits the formation of thromboxane A2, a potent platelet aggregation stimulator. In the Second International Study of Infarct Survival (ISIS-2) trial, aspirin therapy within the first 24 h after STEMI resulted in a 23% relative risk reduction in 5-week cardiovascular mortality [22]. The use of P2Y12 receptor inhibitors has incremental benefits to aspirin, and dual antiplatelet therapy has become the mainstay treatment strategy after ACS as this is associated with improved cardiovascular outcomes [23–25]. Compliance with prescribing aspirin or P2Y12 inhibitors at discharge was high. The lower rates of aspirin prescriptions within 24 hours of arrival could be attributed to delays in establishing the diagnosis of ACS, especially NSTEMI or UA. We observed that the median time to obtain cardiac troponin measurements was 24 hours (IQR 15–24 hours). Out-of-pocket payment for these tests, as well as system delays, are contributory. A rise or fall in cardiac troponins is essential to diagnose acute myocardial infarction in the correct clinical setting [26]. Whilst STEMI is usually readily diagnosed on ECG, patients with NSTEMI may present with nonspecific ECG changes making the timely measurement of troponin levels essential in the early diagnosis and risk stratification of these patients.

Despite the documented benefits of these medications in all patients with ACS, only about two-thirds of the patients in this study were discharged on a beta blocker or a high-intensity statin. Oral beta blockers also reduce cardiac automaticity and the risk of ventricular fibrillation following a myocardial infarction, in addition to their anti-ischemic and anti-anginal properties [27]. Statins, on the other hand, delay coronary atherosclerosis progression and can induce plaque regression and reduce cardiovascular events, including recurrent myocardial infarction, cerebrovascular events, and all-cause mortality [28]. These medications are now available as generics making them easily accessible and affordable. Their coverage under the Ghana National Health Insurance Scheme presents an opportunity to improve their uptake for patients with an indication such as ACS.

Left ventricular ejection fraction is one of the strongest predictors of survival after ACS [29]. Transthoracic echocardiography (TTE) is a noninvasive and relatively inexpensive means of assessing left ventricular function and identifying post-myocardial infarction complications to help guide therapy. However, due to the scarcity of skilled personnel and equipment in low-income countries like Ghana, ready access to TTE is limited and comes with substantial out-of-pocket patient costs [30]. It is noteworthy that for most of the period from January 2021 to March 2022, there was no in-hospital TTE service available at the study site, partly accounting for the low rate of in-hospital assessment of LVEF (38.2%) found in this study. Training of non-cardiologists to perform focused point-of-care echocardiography for estimation of LVEF can be a viable strategy to bridge this care gap [31].

Primary PCI has demonstrated superiority over fibrinolytic in terms of infarct artery patency, rates of recurrent ischemia, repeat revascularisation and overall clinical outcomes [32, 33]. Ghana, which has a population of about 32.8 million, has five PCI-capable hospitals, all located in the capital city along the country's coast [34]. The study site does not offer primary PCI, and the nearest PCI-capable facility is more than ten hours away by road. As a result, thrombolysis was the primary reperfusion strategy available for eligible patients with STEMI, and primary PCI was generally inaccessible to most patients presenting at the study site. Additionally, thrombolysis for STEMI was only recently available (in the last quarter of 2022) at the study site, with streptokinase being the main thrombolytic agent used because of the high cost of alternative agents. In addition to late presentation (median time after symptom onset was 24 hours), these limitations meant that almost all patients presenting with ACS were managed medically, with only three patients receiving reperfusion therapy.

Late presentation characterises ACS in many SSA countries. It can be attributed to a lack of patient education, poor or nonexistent emergency ambulance systems, low index of suspicion by physicians and failure to obtain ECGs on time [4, 35]. It is recommended that patients who present with STEMI to a non–PCI-capable hospital should receive timely fibrinolysis if timely transfer time for primary PCI (within ≤ 120 min of first medical contact) is not feasible [36, 37]. The survival benefit of fibrinolysis is greatest when administered within the first 2 hours of symptom onset and declines progressively after that. Thus, the benefit of fibrinolytic therapy is most effective when provided promptly with a recommended Door-to Needle time of ≤ 30 minutes [36–38]. Given the cost implications of cardiac catheterisation laboratories and the lack of sufficiently trained personnel to deliver primary PCI services in resource-poor settings like Ghana, it would seem more feasible, at least in the short term, to develop an efficient thrombolysis service to ensure eligible patients with STEMI have access to reperfusion therapy. Evidence shows that with adequate training, facilities without onsite cardiologists can adequately offer thrombolysis with encouraging door-to-needle times [39].

Some conservatively managed ACS patients have high-risk coronary artery disease though they may not exhibit symptoms at rest during their hospitalisation. Further risk stratification with a submaximal stress test (exercise-based or pharmacological) before discharge can be employed to identify patients needing invasive angiography and possibly revascularization [40]. No risk-stratifying tool such as the Global Registry of Acute Coronary Events (GRACE) score or the Thrombolysis in Myocardial Infarction (TIMI) score was employed in patients with NSTEMI in this study [41, 42]. Additionally, noninvasive stress tests were not performed or scheduled for conservatively managed patients with ACS, mainly because the study site could not offer these services.

No cardiac rehabilitation program existed within the study area at the time of the study. Cardiac rehabilitation programs offer supervised exercise training alongside other secondary prevention strategies and are designed to speed recovery and improve quality of life following acute cardiovascular events like myocardial infarction. Evidence abounds that timely referral of patients improves subsequent attendance and overall clinical outcomes [43]. Despite its proven benefits and the increasing burden of cardiovascular diseases, little emphasis has been placed on cardiac rehabilitation programs in the African region where it is almost nonexistent [44]. Available evidence, however, supports the feasibility and benefit of a cardiac rehabilitation program, whether in its comprehensive form or modified to suit the local context, in low-income countries in Africa [45, 46].

This study was limited by its retrospective design. Sources of error, such as improper or non-documentation of interventions or timelines, can only partially be eliminated. Another limitation was the involvement of a single study site. However, since TTH is the largest tertiary facility that serves as a referral centre in the northern part of Ghana, the result of this study is expected to closely reflect the current situation in northern Ghana.

This study has provided insights into the care of patients presenting with ACS at a tertiary facility in Northern Ghana. Acute management of ACS remains challenging in Northern Ghana, where reperfusion therapy is almost nonexistent. Several gaps exist in the care quality, timeliness of interventions and rehabilitation of patients presenting here with ACS. Given the increasing burden of CVDs in low-middle-income countries, there is an urgent need to improve the delivery of ACS care alongside promoting primary prevention strategies and population awareness campaigns.

ACC American College of Cardiology

ACS Acute coronary syndrome

AHA American Heart Association

CAD Coronary artery disease

CVD Cardiovascular disease

ECG Electrocardiogram

GRACE Global Registry of Acute Coronary Events

LVEF Left ventricular ejection fraction

NSAID Nonsteroidal anti-inflammatory drugs

NSTEMI Non-ST-segment elevation myocardial infarction

PCI Percutaneous coronary intervention

STEMI ST-segment elevation myocardial infarction

TIMI Thrombolysis in Myocardial Infarction

TTE Transthoracic echocardiography

TTH Tamale Teaching Hospital

UA Unstable angina

Ethics approval and consent to participate.

The ethical approval for this study was waived by the Tamale Teaching Hospital Ethical Review Committee, Tamale, Northern Region, Ghana. Informed consent was obtained from all the participants. All methods were carried out in accordance with local guidelines and regulations.

Consent for publication

Not applicable

Availability of data and materials

The datasets used during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

None

Authors' contributions

A-S Y conceptualized the study, analysed the data, and wrote the initial draft manuscript. DA

revised the work and made important contributions to the main parts of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We wish to thank Dr Moses Musah, Dr Philip Baalaboore and Dr Fatima Chentiwuni Iddrisu for their various roles in data collection and the care of the patients.

Authors' information

A-S Y and DA are senior physician specialists and cardiologists in the Department of Internal Medicine of the Tamale Teaching Hospital, Tamale, Ghana. A-S Y and DA are currently the only resident cardiologists in the Northern part of Ghana.

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No competing interests reported.

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published 25 Mar, 2024

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Quality of Acute Coronary Syndrome Care and in-hospital Outcome in a Resource-poor Setting in Northern Ghana

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BACKGROUND

METHODS

Study site

Study design

Study population

Sampling and data collection

Statistical analysis

Ethical considerations

RESULTS

DISCUSSION

CONCLUSION

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