Lancet: Heart disease not treated well in developing countries

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Patients in India who have acute coronary syndromes (ACS) have a higher rate of STEMI than patients in developed countries, according to the CREATE study published in the April 26 issue of the Lancet.

The authors noted that though India has the highest burden of ACS in the world, “little is known about the treatments and outcomes of these diseases.”

Denis Xavier, MD, of St John's Medical College and St John's Research Institute in Bangalore, India, and colleagues attempted to document the characteristics, treatments and outcomes of patients with ACS who were admitted to hospitals in India to further understand the disease in the developing country.

The researchers conducted a prospective registry study in 89 centers from 10 regions and 50 cities in India. They recorded a range of clinical outcomes and all-cause mortality at 30 days.

The investigators enrolled 20,937 patients. Of the 20,468 patients who were given a definite diagnosis, 12,405 (60.6 percent) had STEMI. The mean age of the patients was 57.5 years; patients with STEMI were younger (56.3 years) than were those with non-STEMI or unstable angina (59.3 years). Most patients were from lower middle 10,737 (52.5 percent) and poor 3,999 (19.6 percent) social classes.

The median time from symptoms to hospital was 360 minutes, with 50 minutes from hospital to thrombolysis, according to researchers. The authors wrote that 6,226 (30.4 percent) patients had diabetes; 7,720 (37.7 percent) had hypertension; and 8,242 (40.2 percent) were smokers.

Xavier and colleagues said that treatments for STEMI differed from those for non-STEMI or unstable angina: More patients with STEMI than with non-STEMI were given anti-platelet drugs (98.2 percent vs. 97.4 percent); angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) (60.5 percent vs. 51.2 percent); and PCI (8 percent vs. 6.7 percent). Thrombolytics (96.3 percent streptokinase) were used for 58.5 percent of patients with STEMI.

Conversely, the investigators found that fewer patients with STEMI than those with non-STEMI or unstable angina were given _ blockers (57.5 percent vs. 61.9 percent); lipid-lowering drugs (50.8 percent vs. 53.9 percent); and coronary bypass graft surgery (CABG) (1.9 percent vs. 4.4 percent).

The researchers found that 30-day outcomes for patients with STEMI were death (8.6 percent), reinfarction (2.3 percent) and stroke (0.7 percent). Outcomes for those with non-STEMI or unstable angina were better: death (3.7 percent), reinfarction (1.2 percent) and stroke (0.3 percent), according to the authors.

The investigators said that the use of key treatments also differed by socioeconomic status: more rich patients than poor patients were given thrombolytics (60.6 percent vs. 52.3 percent), _ blockers (58.8 percent vs. 49.6 percent), lipid-lowering drugs (61.2 percent vs. 36 percent), ACE inhibitors or ARB (63.2 percent vs. 54.1 percent), PCI (15.3 percent vs. 2 percent) and CABG (7.5 percent vs. 0.7 percent).

The authors wrote that mortality was higher for poor patients than for rich patients (8.2 percent vs. 5.5 percent).

Based on these results, the researchers found that patients with ACS in India tend to be young and from low socioeconomic groups and to have a higher rate of STEMI than do patients in developed countries, as well as receive medical attention late and proven therapies less often.

Xavier and colleagues also noted that since most of the patients were poor, less likely to get evidence-based treatments, and had greater 30-day mortality, reduction of delays in access to hospital and provision of affordable treatments could reduce morbidity and mortality.

The division of clinical trials at St. John's Research Institute in Bangalore, India; Population Health Research Institute at McMaster University in Hamilton, Ontario; and Sanofi-Aventis India funded the study.