Elsevier

The Lancet

Volume 371, Issue 9622, 26 April–2 May 2008, Pages 1435-1442
The Lancet

Articles
Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data

https://doi.org/10.1016/S0140-6736(08)60623-6Get rights and content

Summary

Background

India has the highest burden of acute coronary syndromes in the world, yet little is known about the treatments and outcomes of these diseases. We aimed to document the characteristics, treatments, and outcomes of patients with acute coronary syndromes who were admitted to hospitals in India.

Methods

We did a prospective registry study in 89 centres from 10 regions and 50 cities in India. Eligible patients had suspected acute myocardial infarction with definite electrocardiograph changes (whether elevated ST [STEMI] or non-STEMI or unstable angina), or had suspected myocardial infarction without ECG changes but with prior evidence of ischaemic heart disease. We recorded a range of clinical outcomes, and all-cause mortality at 30 days.

Findings

We enrolled 20 937 patients. Of the 20 468 patients who were given a definite diagnosis, 12 405 (60·6%) had STEMI. The mean age of these patients was 57·5 (SD 12·1) years; patients with STEMI were younger (56·3 [12·1] years) than were those with non-STEMI or unstable angina (59·3 [11·8] years). Most patients were from lower middle 10 737 (52·5%) and poor 3999 (19·6%) social classes. The median time from symptoms to hospital was 360 (IQR 123–1317) min, with 50 (25–68) min from hospital to thrombolysis. 6226 (30·4%) patients had diabetes; 7720 (37·7%) had hypertension; and 8242 (40·2%) were smokers. 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% vs 97·4%); angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) (60·5% vs 51·2%); and percutaneous coronary interventions (8·0% vs 6·7%, p<0·0001 for all comparisons). Thrombolytics (96·3% streptokinase) were used for 58·5% of patients with STEMI. Conversely, fewer patients with STEMI than those with non-STEMI or unstable angina were given β blockers (57·5% vs 61·9%); lipid-lowering drugs (50·8% vs 53·9%); and coronary bypass graft surgery (1·9% vs 4·4%, p<0·0001 for all comparisons). The 30-day outcomes for patients with STEMI were death (8·6%), reinfarction (2·3%), and stroke (0·7%). Outcomes for those with non-STEMI or unstable angina were better: death (3·7%), reinfarction (1·2%), and stroke (0·3%, p<0·0001 for all comparisons). Use of key treatments also differed by socioeconomic status: more rich patients than poor patients were given thrombolytics (60·6% vs 52·3%), β blockers (58·8% vs 49·6%), lipid-lowering drugs (61·2% vs 36·0%), ACE inhibitors or ARB (63·2% vs 54·1%), percutaneous coronary intervention (15·3% vs 2·0%), and coronary artery bypass graft surgery (7·5% vs 0·7%, p<0·0001 for all comparisons). Mortality was higher for poor patients than for rich patients (8·2% vs 5·5%, p<0·0001). Adjustment for treatments (but not risk factors and baseline characteristics) eliminated this difference in mortality.

Interpretation

Patients in India who have acute coronary syndromes have a higher rate of STEMI than do patients in developed countries. Since most of these 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.

Funding

Division of Clinical Trials, St John's Research Institute, Bangalore, India; Population Health Research Institute (PHRI), McMaster University, Canada; Sanofi-Aventis India.

Introduction

Ischaemic heart disease is the leading cause of death globally.1 In 2001, ischaemic heart disease accounted for 7·1 million deaths worldwide,1 5·7 million (80%) of which were in low-income countries.2, 3 Between 1990 and 2020, these diseases are expected to increase by 120% for women and 137% for men in developing countries, compared with 30–60% in developed countries.4 By 2010, 60% of the world's heart disease is expected to occur in India.5 Furthermore, South Asians have a high prevalence of risk factors, and have ischaemic heart disease at an earlier age than do people in developed countries.6, 7

Most data for patients with acute coronary syndromes are from several large registries8, 9, 10, 11, 12, 13, 14, 15, 16 with data on demography, treatments, and outcomes of patients in middle-income and high-income countries. The few studies in India are small and restricted to a few hospitals.17, 18, 19 We established a collaborative national registry of more than 20 000 patients with acute coronary syndromes (defined as myocardial infarction with ST elevation [STEMI] or non-STEMI or unstable angina). We aimed to document the characteristics, treatments, and outcomes of patients with acute coronary syndromes who were admitted to hospitals in India.

Section snippets

Study participants

We established a prospective multicentre registry that recruited patients with acute coronary syndromes from 89 hospitals in 50 cities from 10 regions in India (panel 1). St John's Research Institute, in Bangalore, and the Population Health Research Institute, at McMaster University in Canada, jointly coordinated the study and managed the data.

Every centre enrolled consecutive patients who were admitted to hospital with acute coronary syndromes, and prospectively recorded data during admission

Results

During a 4-year period until 2005, 20 937 patients were enrolled. 40 teaching hospitals recruited 11 054 (54·0%) patients, and 49 non-teaching hospitals recruited 9414 (46·0%) patients. 41 of these hospitals were equipped for tertiary care (with a catheterisation lab) and 48 for secondary care; they recruited 10 790 (52·7%) and 9678 (47·3%) patients, respectively. Additional data, about patients' geographical areas, their transportation to hospitals, and their modes of payment, were collected

Discussion

We analysed data from a large registry of patients with acute coronary syndromes from India. We assessed characteristics of patients, practice patterns, and the rates of major outcomes from a range of hospitals in different regions of India. By contrast with data from developed countries, we recorded more cases of STEMI than non-STEMI or unstable angina; longer delays before admission to hospital and between admission and reperfusion therapy; and different practice patterns and outcomes.

References (26)

  • A Ghaffar et al.

    Burden of non-communicable diseases in South Asia

    BMJ

    (2004)
  • P Joshi et al.

    Risk factors for early myocardial infarction in South Asians compared with individuals in other countries

    JAMA

    (2007)
  • KA Fox et al.

    Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE)

    Eur Heart J

    (2002)
  • Cited by (0)

    Investigators listed at end of paper

    View full text