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. 2023 Sep 12;9(6):552-563.
doi: 10.1093/ehjqcco/qcad008.

Presentation, care, and outcomes of patients with NSTEMI according to World Bank country income classification: the ACVC-EAPCI EORP NSTEMI Registry of the European Society of Cardiology

Ramesh Nadarajah  1   2   3 , Peter Ludman  4 , Cécile Laroche  5 , Yolande Appelman  6 , Salvatore Brugaletta  7   8 , Andrzej Budaj  9 , Hector Bueno  10   11   12 , Kurt Huber  13   14 , Vijay Kunadian  15   16 , Sergio Leonardi  17   18 , Maddalena Lettino  19 , Dejan Milasinovic  20 , Chris P Gale  1   2   3 ; NSTEMI investigator group
Collaborators, Affiliations

Presentation, care, and outcomes of patients with NSTEMI according to World Bank country income classification: the ACVC-EAPCI EORP NSTEMI Registry of the European Society of Cardiology

Ramesh Nadarajah et al. Eur Heart J Qual Care Clin Outcomes. .

Abstract

Background: The majority of NSTEMI burden resides outside high-income countries (HICs). We describe presentation, care, and outcomes of NSTEMI by country income classification.

Methods and results: Prospective cohort study including 2947 patients with NSTEMI from 287 centres in 59 countries, stratified by World Bank country income classification. Quality of care was evaluated based on 12 guideline-recommended care interventions. The all-or-none scoring composite performance measure was used to define receipt of optimal care. Outcomes included in-hospital acute heart failure, stroke/transient ischaemic attack, and death, and 30-day mortality. Patients admitted with NSTEMI in low to lower-middle-income countries (LLMICs), compared with patients in HICs, were younger, more commonly diabetic, and current smokers, but with a lower burden of other comorbidities, and 76.7% met very high risk criteria for an immediate invasive strategy. Invasive coronary angiography use increased with ascending income classification (LLMICs, 79.2%; upper middle income countries [UMICs], 83.7%; HICs, 91.0%), but overall care quality did not (≥80% of eligible interventions achieved: LLMICS, 64.8%; UMICs 69.6%; HICs 55.1%). Rates of acute heart failure (LLMICS, 21.3%; UMICs, 12.1%; HICs, 6.8%; P < 0.001), stroke/transient ischaemic attack (LLMICS: 2.5%; UMICs: 1.5%; HICs: 0.9%; P = 0.04), in-hospital mortality (LLMICS, 3.6%; UMICs: 2.8%; HICs: 1.0%; P < 0.001) and 30-day mortality (LLMICs, 4.9%; UMICs, 3.9%; HICs, 1.5%; P < 0.001) exhibited an inverse economic gradient.

Conclusion: Patients with NSTEMI in LLMICs present with fewer comorbidities but a more advanced stage of acute disease, and have worse outcomes compared with HICs. A cardiovascular health narrative is needed to address this inequity across economic boundaries.

Keywords: Country income; Mortality; NSTEMI; Quality indicators; Registry.

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Conflict of interest statement

H.B., K.H., P.L., R.N., V.K., and Y.A. report no conflict of interest.

C.P.G. reports personal fees from AstraZeneca, Amgen, Bayer, Boehrinher-Ingelheim, Daiichi Sankyo, Vifor, Pharma, Menarini, Wondr Medical, Raisio Group, and Oxford University Press. He has received educational and research grants from BMS, Abbott inc., the British Heart Foundation, National Institute of Health Research, Horizon 2020, and from the European Society of Cardiology, outside the submitted work.

S.B. reports personal fees from Boston Scientific, Insight, Lifetech, iVascular, and Abbott Vascular.

D.M. reports personal fees from Abbott, Boston Scientific, Biosensors, and Terumo. He has participated on Data Safety Monitoring Boards or Advisory Boards for Abbott and Boston Scientific.

A.B. reports personal and institutional investigator fees from AstraZeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, Novartis, Amgen, Novo Nordisk, and Bayer. He reports personal fees from AstraZeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, Novartis, and Bayer. He has participated in Data Safety Monitoring Boards or Advisory Boards for AstraZeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, and Bayer. He has received support for attending meetings by Astra Zeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, and Bayer.

S.L. reports personal fees from ICON, Chiesi, AstraZeneca, Daiichi Sankyo, Bayer, Bristol Myers Squibb/Pfizer, and Novo Nordisk.

M.L. reports speaker fees from Bristol Myers Squibb/Pfizer, Boehrinher-Ingelheim, Novartis and Sanofi, and manuscript writing fees from Edwards Lifesciences. She has also participated as an advisory board member for Sanofi, Bristol Myers Squibb/Pfizer, and Boehrinher-Ingelheim.

Y.A. reports a research grant from the Dutch Heart Foundation.

Signed COIs available for all authors.

Figures

Graphical Abstract
Graphical Abstract
Analysis of the ACVC-EAPCI EORP NSTEMI registry stratified by country income classification.
Figure 1
Figure 1
STROBE diagram for the EORP NSTEMI registry analytical cohort.
Figure 2
Figure 2
Guideline-recommended for treatment for NSTEMI by World Bank country income classification.
Figure 3
Figure 3
Performance by quality indicator grouping stratified by receipt of optimal care and country income classification. (A) Overall, (B) Pharmacological therapies, (C) Investigative and invasive coronary strategies, (D) Lifestyle care opportunities.
Figure 4
Figure 4
In-hospital outcomes and 30 day mortality by country income classification. * indicates statistical significance (P < 0.05).
See this image and copyright information in PMC

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