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, Peter Ludman, Cécile Laroche, Yolande Appelman, Salvatore Brugaletta, Andrzej Budaj, Héctor Bueno, Kurt Huber, Vijay Kunadian, Sergio Leonardi, Maddalena Lettino, Dejan Milašinović, Chris P Gale, the NSTEMI investigator group, Alec Vahanian, A Budaj, N Dagres, Nicolas Danchin, Victoria Delgado, Jonathan Emberson, Örjan Friberg, C P Gale, Guy R. Heyndrickx, Bernard Iung, Stefan James, A P Kappetein, Aldo P. Maggioni, Nikos Maniadakis, K V Nagy, G Parati, A-S Petronio, Mikko Pietilä, E Prescott, Frank Ruschitzka, Frans Van de Werf, Franz Weidinger, Uwe Zeymer, Chris P Gale, B Beleslin, Andrzej Budaj, Ovidiu Chioncel, N Dagres, Nicolas Danchin, Jonathan Emberson, David Erlinge, M Glikson, A Gray, M Kayikcioglu, Aldo P. Maggioni, Klaudia Vivien Nagy, А. О. Недошивин, A-P Petronio, J W Roos-Hesselink, L Wallentin, Uwe Zeymer, Bogdan A. Popescu, David Adlam, Alida L.P. Caforio, D Capodanno, Marc R. Dweck, David Erlinge, M Glikson, J Hausleiter, Bernard Iung, M Kayikcioglu, P Ludman, Lars Christian Lund, Aldo P. Maggioni, С.Т. Мацкеплишвили, Benjamin Meder, K V Nagy, А. О. Недошивин, Carlijn G. E. Thijssen, Agnès Pasquet, J W Roos-Hesselink, Fernando J. Rossello, Sameh Shaheen, Aleksandra Torbica, Chris P Gale, Peter Ludman, Maddalena Lettino, Héctor Bueno, Kurt Huber, Sergio Leonardi, Andrzej Budaj, Dejan Milašinović, Salvatore Brugaletta, Yolande Appelman, Vijay Kunadian, W A R Al Mahmeed, H Kzhdryan, Carlos Dumont, Alexander Geppert, Nirvana Šabanović-Bajramović, Fathima Aaysha Cader, Christophe Beauloye, Daniel Quesada, Ota Hlinomaz, Christoph Liebetrau, Toomas Marandi
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.