London, UK - A new analysis from the CREATE registry, published in the April 26, 2008 issue of the Lancet, provides a first true glimpse of the scope, treatments, and outcomes of acute coronary syndromes in India [1]. The picture is bleak: according to Dr Denis Xavier (St John's Medical College, Bangalore, India) and colleagues, people admitted for ACS in India are younger, poorer, sicker, and more likely to die than ACS patients in the developed world.

Dr Salim Yusuf

According to Dr Salim Yusuf (McMaster University, Hamilton, ON), senior author on the study, the findings should serve as a wake-up call to cardiologists and academics seemingly preoccupied with cardiovascular disease in Western countries, which accounts for just 20% of the world's CVD burden.

If you really want to solve the problem of heart disease, you don't focus on new GP IIb/IIIa inhibitors or new stents that, in the full scheme of things, are actually quite unimportant.

"This calls for much more awareness in developing countries," he told heartwire. "Very few scientists are working in this area, but if you really want to solve the problem of heart disease, you don't focus on new GP IIb/IIIa inhibitors or new stents that, in the full scheme of things, are actually quite unimportant. In a recent issue of JAMA there are two papers, both of which have no relevance whatsoever to beating the heart-disease burden in the world, yet these are the types of things being published in the major journals. Even if we made significant progress in these focused areas, which we're not even making any more, the real progress needs to be made in the low- and middle-income countries."

Xavier et al's paper examined the incidence of STEMI and non-STEMI among almost 21 000 patients from 89 centers in 50 Indian cities. They found that more than 60% of these patients were diagnosed with STEMI, mean age was 57.5 years (although STEMI patients tended to be even younger), and the vast majority were from lower-middle-income or poor families.

Times from symptom onset to hospital admission were at least double that of Western countries, where patients typically take 130 to 170 minutes to get help: in Xavier et al's registry, STEMI patients took a median of 300 minutes from symptom onset to hospital admission, while non-STEMI and unstable-angina patients took a median of 420 minutes to get to the hospital. Authors of the study point to the lack of organized emergency transport systems and ambulance services.

"There is no real system in India for managing heart-attack patients, no education of patients to recognize symptoms and come to the hospital early, and no proper ambulance system—most people come by public transportation or taxi or some other mode of transportation," Yusuf explained. "All of this means that there is a delay in implementing effective therapies."

Once admitted, almost all STEMI and non-STEMI patients were treated with antiplatelet drugs (primarily aspirin, with clopidogrel used in just 15%), but use of ACE inhibitors or angiotensin-receptor blockers (ARBs), thrombolytics, beta blockers, statins, and PCI/CABG were all far lower than rates seen in the West.

Not surprisingly, 30-day death, reinfarction, and stroke rates were higher for STEMI patients than non-STEMI, and mortality, notably, was significantly higher in poor patients than in rich patients, a difference eliminated when adjusted for treatment use.

"These are major, major issues that call for governmental action, a national health-insurance system, and education of patients about the signs and symptoms of a heart attack," Yusuf commented. "Government insurance that provides some sort of basic care in acute emergencies is urgently needed, so patients don't worry whether they can afford treatment. In India, often when a patient is first admitted with a heart attack and a thrombolytic is needed, the hospital will start to discuss with the patient's relatives whether it's worth doing, whether they can afford the cost."

While the number of health insurance companies is on the rise in India, plans are typically provided through larger employers, and a disproportionate number of Indian workers are actually self-employed, Yusuf noted.

Yusuf emphasized that this paper provides key information previously unknown about ACS in a country expected to account for 60% of the world's CVD by 2010 and where risk factors like obesity and diabetes are soaring.

"India has the largest percentage of heart disease in the world, and this is the first paper to clarify how people are being treated," he told heartwire. "The key thing is that the pattern of presentation of patients is similar to what we saw in the West 25 or 30 years ago: patients arrive late, they're younger (by about a decade compared with the West), and they have more ST-segment MI rather than non-STEMI. This is classical when disease is on the rise. And added to that, you have the burden of a healthcare system that's not geared toward dealing with these kinds of things."

Yusuf also stated that India may be "a good example for what is happening in most of the world."

"We are all very much focused on treatment as it applies to Western countries, but the problem with that is that only 20% of heart disease actually occurs in these countries," he said. "If you want to deal with the global problem, we have to find a way of paying attention to the developing countries. And this paper identifies the problems."

In an editorial accompanying the study [2], Dr Kim Eagle (University of Michigan Medical Center, Ann Arbor) calls this registry analysis "a major milestone" that, by identifying the issues, provides opportunities for tackling them. He proposes efforts targeting tobacco use; policies and education to switch the emphasis from saturated to polyunsaturated fat in Indian diets; and screening for hyperlipidemia and hypertension—relatively cheap and simple strategies that have had an enormous impact in other parts of the world.

Eagle also observes that world-class medical care already exists in India but suggests that provision of this caliber of care to the minority who can afford it may be distracting from the goal of providing relatively inexpensive drugs on a much wider scale.

"On average, these strategies are not expensive," Eagle writes. "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 acute coronary syndrome with aspirin, beta blockers, statins, and, when appropriate, ACE inhibitors or angiotensin-receptor antagonists. Expensive interventions, such as revascularization, account for only 5% of this benefit. There is no reason why similar results cannot be achieved in India and elsewhere."