Presentation and outcomes of patients with acute coronary syndromes in eastern Nepal
BACKGROUND: The burden of ischemic heart disease (IHD) in developing countries is on the rise, due to urbanisation, industrialisation and the low availability of evidence based therapies and interventions.
AIMS AND OBJECTIVES:Data was collected on consecutive patients admitted with acute coronary syndrome (ACS), from 1st January to 31st December 2008, to a tertiary care centre in eastern Nepal. Final diagnosis, risk factors, educational status, time delays, treatment and in-hospital outcomes were evaluated.
RESULTS:A total of153 patients with ACS were admitted in 2008: 58 with ST elevation myocardial infarction (STEMI) (38%), 28 with non-ST elevation myocardial infarction (NSTEMI) (18%) and 67 with unstable angina (UA) (44%). 40% of patients with STEMI presented within 12 hours of symptom onset. Most patients presented late and 33% of them presented after 2 days or more. Over half the patients were not literate. Due to the unavailability of percutaneous coronary intervention (PCI) at the centre, thrombolysis with Streptokinase was considered for patients presenting with STEMI up to 24 hours after symptom onset. However, due to financial constraints, only 53% of patients in this broadened time window actually received thrombolytic treatment. The in-hospital mortality was 14% for all patients with ACS, and 17% for the patients with STEMI.
CONCLUSIONS:Only a small proportion of patients with ACS in Eastern Nepal are admitted to hospital, and those who are often arrive late, or cannot afford optimal medical management. Awareness, better referral and transport facilities, financial support for the needy, and the availability of on-site coronary angiography and angioplasty for selected patients should contribute to treat more ACS patients and improve their prognosis.
- WHO, The World Health Report 2002: Reducing Risks, Promoting Healthy Life, World Health Organization, Geneva (2002).
- Gaizano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middle-income countries. Curr Probl Cardiol. 2010;35(2):72–115.
- Reddy KS. Cardiovascular Disease in Non-Western Countries. N Engl J Med. 2004;350:2438–40.
- Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al; CREATE registry investigators. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. 2008;371(9622):1435–42.
- Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007;297(3):286–94.
- Mohan V, Deepa R, Rani SS, Premalatha G; Chennai Urban Population Study (CUPS No.5). Prevalence of coronary artery disease and it relationship to lipids in a selected population in South India: The Chennai Urban Population Study (CUPS no.5). J Am Coll Cardiol. 2001;38(3):682–7.
- Murray CJ, Lopez AD, editors. The global burden of disease. A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press; 1996.
- Goyal A, Yusuf S. The burden of cardiovascular disease in the Indian subcontinent. Indian J Med Res. 2006;124:235–44.
- Radovanovic D, Urban P, Simon R, Schmidli M, Maggiorini M, Rickli H, et al. Outcome of patients with acute coronary syndrome in hospitals of different sizes. A report from the AMIS plus registry. Swiss Med Wkly. 2010;140: 314–22.
- Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas Fe, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–52.
- Acharya P, Adhikari RR, Bhattarai J, Shrestha NR, Sharma SK, Karki P. Delayed presentation of acute coronary syndrome: a challenge in its early management. JNMA J Nepal Med Assoc. 2009;48(173):1–4.
- Rosengren A, Subramanian SV, Islam S, Chow CK, Avezum A, Kazmi K et al; INTERHEART Investigators. Education and risk for acute myocardial infarction in 52 high, middle and low-income countries: INTERHEART case-control study. Heart. 2009;95(24):2014–22.
- Gerber Y, Weston SA, Killian JM, Therneau TM, Jacobsen SJ, Roger VL. Neighborhood income and individual education: effect on survival after myocardial infarction. Mayo Clin Proc. 2008;83(6):663–9.