Acute Coronary Syndrome in India
- Acute Coronary Syndrome (ACS) is a general term used by doctors that usually means a person is experiencing one of two things: a small or large heart attack or the person is suffering severe chest pain called an unstable angina (a heart attack has not yet occurred but is likely to happen, see Heart Attack Video).
- A heart attack is further categorized as STEMI (which usually means a large heart attack) and Non-STEMI (which usually means a small heart attack). Indian patients with ACS have a higher rate of STEMI (61%) than do patients in high income countries (15-25%).
- India has the highest burden of ACS in the world. The CREATE registry has provided contemporary data on 20,468 patients from 89 centers from 10 regions and 50 cities in India.1
- The three most common risk factors for ACS were smoking (40%), high blood pressure (38%), and diabetes (30%). The prevalence of dyslipidemia (cholesterol abnormalities) was unfortunately not available or reported.
- The median time from symptoms to hospital was 360 min (several times higher than in the US and other high income countries). However from hospital to thromolysis (a procedure to dissolve the offending blood clot in people with STEMI) was only 50 minutes.1 Reduction of delays in access to hospital and provision of affordable treatments could reduce morbidity and mortality in India.1
- The mean age of these patients was 58 years. 53% were from lower middle class and 20% were from poor social classes. Poor patients received less medical treatments and coronary procedures (angioplasty/stents or bypass surgery).
- 59% of patients with STEMI received thrombolytics (96% streptokinase). Coronary angioplasty was given to 8% of STEMI and 7% of non-STEMI; coronary bypass surgery was given to 2% of STEMI and 4% of NSTEMI/UA. The 30-day outcomes for patients with STEMI were: death 9%; reinfarction 2%; and stroke 0.7%.
- Poor patients were less likely to get evidence-based treatments, and had greater 30-day mortality than wealthy patients (8% vs 6% p<0.0001). Adjustment for treatments (but not risk factors and baseline characteristics) eliminated this difference in mortality.
- 98% received anti-platelet drugs; 51%-61% received angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) and 51-54% received lipid-lowering therapy.
- Most of the decline in coronary mortality in the US is believed to be secondary to improving risk-factor profiles and effective primary and secondary treatments of ACS with aspirin, beta blockers, statins, and when appropriate, ACE inhibitors or angiotensin-receptor antagonists. Expensive interventions, such as coronary angioplasty and bypass surgeries, account for only 5% of the mortality benefit in the US and other high-income countries.
- These strategies of primary prevention and secondary prevention are highly effective and not expensive. There is no reason why similar results cannot be achieved in India and elsewhere.2
- In the OASIS 2 registry, the two-year mortality rates adjusted for baseline covariates were double in India (15%) than China (7%).3 The prevalence of diabetes in these ACS patients was highest at 39%.
- World-class medical facilities already exist in India to provide a high caliber of care to the minority who can afford it. Ironically, the focus on high tech interventions is distracting from the goal of providing relatively inexpensive but evidence-based medications on a much wider scale.
1. Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. Apr 26 2008;371(9622):1435-1442.
2. Eagle K. Coronary artery disease in India: challenges and opportunities. Lancet. Apr 26 2008;371(9622):1394-1395.
3. Prabhakaran D, Yusuf S, Mehta S, et al. Two-year outcomes in patients admitted with non-ST elevation acute coronary syndrome: results of the OASIS registry 1 and 2. Indian Heart J. May-Jun 2005;57(3):217-225.