In low-income countries, reduced LVEF common in STEMI, confers poor outcomes
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In a cohort of patients with STEMI in India, reduced left ventricular ejection fraction was common and associated with mortality, and medication adherence at 1 year was low, researchers reported.
“Since there is a significant delay from symptom onset to presentation to hospital with STEMI in India, and also there is a delay when patients get PCI, we anticipated that a large proportion of patients will suffer myocardial damage and develop heart failure. Thus, we aimed to examine the severity of LV dysfunction in patients presenting with STEMI in India,” Arman Qamar, MD, MPH, interventional cardiologist and auxiliary research scholar at NorthShore Cardiovascular Institute, NorthShore Health System, Evanston, Illinois, told Healio. “Since based on our findings, more than 50% of the patients presenting with STEMI in India will develop heart failure, we hope that this will increase awareness to seek immediate medical attention and receive timely PCI. Also, this work will alarm the government to improve infrastructure for STEMI care in India (ambulance, medications, stents and hospitalizations).”
STEMI and LVEF
Qamar, Mohit D. Gupta, MD, DM (Cardiology), FRCP (Edin), FACC, FSCAI, FESC, FCSI, FAPI, professor of cardiology at GB Pant Institute of Post Graduate Medical Education and Research New Delhi, and colleagues analyzed 3,597 patients from the NORIN-STEMI registry, which includes adults presenting with STEMI to two tertiary centers in Delhi, India.
Among the cohort, 13% had LVEF > 50%, 41% had LVEF between 40% and 49%, 38% had LVEF 30% to 39% and 8% had LVEF less than 30%, according to the researchers.
Factors associated with lower LVEF included presentation delay of more than 24 hours, prior MI and hyperlipidemia, the researchers wrote.
While most patients were discharged on guideline-recommended medications, adherence at 1 year was poor, Qamar, Gupta and colleagues found, noting that 91% of patients were discharged on an ACE inhibitor or angiotensin receptor blocker but 41% were adherent to it at 1 year; 98% of patients were discharged on a beta-blocker but 78% were adherent to it at 1 year; and 69% were discharged on an aldosterone receptor antagonist and 6% were adherent to it at 1 year.
Low LVEF and mortality
After multivariable adjustment, compared with LVEF > 50%, LVEF 30% to 39% (aHR = 1.77; 95% CI, 1.2-2.6) and LVEF < 30% (aHR = 3.63; 95% CI, 2.41-5.48) were associated with increased risk for mortality at 1 year, according to the researchers.
“Note that patients pay cash for stents in India, and a major number of patients decide to let the heart muscle die since they don’t have cash to pay,” Qamar told Healio. “This is very unfortunate.”
The results suggest that systematic initiatives are needed to improve STEMI care in low-income countries, the researchers wrote.
“We must increase awareness about heart attack symptoms and signs so that patients can get timely medical attention before it’s too late,” Qamar told Healio. “We also want to work with government to increase availability of health centers with fibrinolysis and primary PCI capability. [Guideline-directed medical therapy] for STEMI and heart failure should be available at no cost to patients who cannot afford to buy them. We plan to do this with public-private partnership.”
For more information:
Arman Qamar, MD, MPH, can be reached at aqamar@northshore.org; Twitter: @aqamarmd.
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