Editorial
Tackling acute coronary syndrome
in low-income and middle-
income countries
Lucas Lodi-Junqueira,1 Antonio Luiz Ribeiro1,2
Cardiovascular disease (CVD) is now the
leading cause of mortality and morbidity
worldwide, accounting for approximately
one-third of all deaths globally.1 While
popular belief presumes that non-commu-
nicable diseases (NCDs) afflict mostly
high-income populations, the evidence
tells a very different story. Nearly 80% of
NCD deaths occur in low-income and
middle-income countries (LMICs). Isch-
aemic heart disease (IHD) is the leading
component of the global CVD burden.1
Mortality of IHD has decreased globally,
especially in high-income countries
(HICs), due to population-level changes in
risk factors and to improvements in
systems of care. Meanwhile, ageing of
population, rapid economic growth,
increasingly sedentary lifestyles and calo-
rie-rich diets have increased the propor-
tion of deaths attributable to CVD in
many poorer regions of the world and, as
a result, the mortality gap between LMIC
and HIC over the past 20 years has
narrowed.1
Improved systems of care, early detec-
tion and timely treatment are effective
approaches for reducing the impact of
CVD. However, appropriate care for
people with NCDs is lacking in many
settings, and access to essential technol-
ogies and medicines is limited, particu-
larly in LMICs. In this context of scarce
resources, it is imperative to get the most
out of known effective interventions,
such as the implementation of regional
acute coronary syndrome (ACS) systems
of care, lowering healthcare system delay
(diagnosis, transportation and treat-
ment), increasing reperfusion therapy and
reducing in-hospital mortality.2 3
In their Heart manuscript, Galap-
patthy and colleagues4 presented the
results of The ACS Sri Lanka Audit Project
(ACSSLAP), a prospective cohort of
1
Hospital das Clínicas and Faculdade de Medicina,
Universidade Federal de Minas Gerais, Belo Horizonte,
Brazil
2
National Institute of Science and Technology for Health
Technology Assessment (IATS), Belo Horizonte, Brazil
Correspondence to Professor Antonio Luiz Ribeiro,
Centro de Telessaúde do Hospital das Clínicas da
UFMG, Belo Horizonte, MG, Brazil; ​tom@​hc.​ufmg.​br, ​
tom1963br@​yahoo.​com.​br
1390   Lodi-Junqueira L, Ribeiro AL. Heart September 2018 Vol 104 No 17
patients with ACS treated in the public
healthcare system in Sri Lanka. It was
the first nationwide study in a LMIC to
assess management, clinical outcomes,
prevalence of risk factors and discharge
care plans in ACS. The study included
data from nearly all of public secondary
and tertiary care hospitals (88.7%) in all
districts of the country. Data were audited
and showed a panorama of the treatment
of ACS, with potential value in terms of
policy-making and comparison with other
countries. Demographic characteristics
were different from previous large ACS
registry-based Asian studies in LMICs,5 6
with higher mean age (61.4 years),6 lower
rates of male patients (58.7%), previous
hypertension (45.9%)5 6 and diabetes
(28.4%),6 but higher rates of current
smokers (35.2%).5 6 The majority of
patients presented to the respective hospi-
tals as direct admissions (73.6%) and were
treated in emergency or progressive care
units (68.1%).
Some results are quite impressive. Most
patients were treated in non-specialised
hospitals and only 15.9% (n=336) of
patients were managed in hospitals capable
of providing primary percutaneous coro-
nary intervention (PCI). In the absence
of a public ambulance system, only 5.3%
(n=112) were transferred for further
management in a specialised hospital.
Reperfusion therapy was offered to 66.9%
of patients with ST-elevation myocardial
infarction (STEMI), although only 5.7% of
those were treated with primary PCI. After
admission, the median time to perform
the ECG was 10 min. The door-to-needle
time less than 30 min was achieved only in
42.3% and the door-to-balloon time less
than 90 min was achieved only in 62.5%.
The major reasons for these delays were
clinical decision and logistical reasons in the
thrombolytic group and financial reasons in
the primary PCI group. Cardiac catheterisa-
tion was performed only in 14.0%, which
is a very low rate comparing with other
LMIC registries.5 6 Over 90% of patients
received aspirin, clopidogrel and statin in
the acute setting and on discharge. Those
surprisingly high rates of prescription of
secondary prevention medications were not
seen on previous LMIC registries.5 6 Despite
the absence of a structured ACS system of
care (including an efficient healthcare trans-
Heart: first published as 10.1136/heartjnl-2018-313013 on 9 March 2018. Downloaded from http://heart.bmj.com/ on 30 August 2018 by guest. Protected by copyright.
portation system) and the reduced access to
cardiac catheterisation, in-hospital overall
mortality was 2.1% (4.0% in the STEMI
group), which was similar or even lower
than registries from HICs.7 8
Indeed, it is important to understand
the reasons for these excellent results. The
authors reported that, since this is an open-
label prospective study, the ‘Hawthorne’
effect (awareness of being observed influ-
encing the outcomes assessed) may have
resulted in some degree of bias during
data collection. Otherwise, the study has
been carefully described, including details
on missing data, and the results reported
seems to reflect reliably the current prac-
tice in this country. Random monitoring of
research forms (2%–5%) for data accuracy
and quality was performed, further rein-
forcing the reliability of the results. Thus,
the study suggests that a wide, well-trained
network of general hospitals, compliant
with the simplest evidence-based practices,
as rapid diagnosis by ECG and the use of
basic, low-cost medications, as aspirin,
clopidogrel and statin, can result in a very
low mortality for ACS, a model that could
be tested elsewhere. The registry itself, the
ACSSLAP, could be used as a benchmark for
future national and regional interventions
and subsequent surveys.
The study also pointed out some limita-
tions and opportunities for improvement
in this nationwide initiative. The absence
of public funding for stent implanta-
tion and troponin testing, by the time
of the survey, is a challenge to a high-
quality assistance, but also a marker of
inequality of the healthcare system, since
only wealthier patients would be able to
pay for these standard procedures. Thus,
we should applaud the decision of Sri
Lanka Ministry of Health, taken after
the survey, to provide cardiac stents to
hospitals with PCI facilities and to include
troponin testing as a routine examination
in state sector hospitals. It is also laudable
the recent introduction of state-operated
ambulance services in some parts of Sri
Lanka, which could lead to the reduction
of the total ischaemic time, with further
reduction of STEMI in-hospital mortality.
No information exists at all about the
posthospitalisation care and there is a lot
to be done in secondary prevention of
new cardiovascular events, including the
establishment of cardiac rehabilitation
programmes and the providing of essen-
tial drugs for those who cannot buy them.
While attempting to reduce the
burden of CVD, LMICs face the chal-
lenges of limited healthcare budgets and

infrastructure as well as constrained
professional health workforce capacity.
Quality care delivery in lower resource
settings does not necessarily mean dissem-
ination and implementation of a universal
set of standards formulated in HICs.
Adaptation to local settings is necessary
to achieve optimal clinical outcomes. This
country-level surveillance and monitoring
on ACS done by ACSSLAP was the first
major step to reduce the burden of IHD
according to the Global Status Report on
Noncommunicable Diseases, published by
WHO.9 An increased awareness of these
global NCD goals has expanded attempts
to track and benchmark national efforts at
reducing CVD. Accurate data from coun-
tries are vital to reverse the global rise in
death and disability from NCDs.
In this way, it is mandatory that each
country, due to its population and resource
diversities, appraises and monitors its ACS
scenario to find its proper way to achieve
the best clinical outcomes, adapting HIC
standards of care to the country reality.
Contributors Both authors contributed equally to
this article.
Funding This study was funded by Fundação de
Amparo à Pesquisa do Estado de Minas Gerais (PPM-
Lodi-Junqueira L, Ribeiro AL. Heart September 2018 Vol 104 No 17
00428-17) and Conselho Nacional de Desenvolvimento
Científico e Tecnológico (465518/2014-1 and
310679/2016-8).
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Commissioned;
internally peer reviewed.
© Article author(s) (or their employer(s) unless
otherwise stated in the text of the article) 2018. All
rights reserved. No commercial use is permitted unless
otherwise expressly granted.
To cite Lodi-Junqueira L, Ribeiro AL. Heart
2018;104:1390–1391.
Published Online First 9 March 2018
►► http://​dx.​doi.​org/​10.​1136/​heartjnl-​2017-​312404
Heart 2018;104:1390–1391.
doi:10.1136/heartjnl-2018-313013
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