title: Impact of Human Development Index on the profile and outcomes of patients with acute coronary syndrome.
abstract: OBJECTIVE
  To study the impact of national economic and human development status on patient profiles and outcomes in the setting of acute coronary syndrome (ACS).
  
  
  METHODS
  We conducted a retrospective analysis of the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes trial (TRILOGY ACS) population (51 countries; 9301 patients). Outcome measures compared baseline characteristics and clinical outcomes through 30 months by 2010 country-level United Nations Human Development Indices (HDIs) and per-capita gross national income.
  
  
  RESULTS
  TRILOGY ACS enrolled 3659 patients from 27 very-high HDI countries, 3744 from 18 high-HDI countries and 1898 from 6 medium-HDI countries. Baseline characteristics of groups varied significantly, with the medium-HDI group having a lower mean age (63.0 years, vs 65.0 and 68.0 years for high-HDI and very-high HDI, respectively; p<0.001), lower baseline Global Registry of Acute Coronary Events risk score and lower rate of non-ST-segment elevation myocardial infarction (58.0%, vs 62.2% and 83.9% among high-HDI and very-high HDI, respectively). Medium-HDI and high-HDI patients had lower unadjusted 30-month rates for the composite of cardiovascular death/myocardial infarction/stroke (17.6%, 16.9% and 23.1% for medium-HDI, high-HDI and very-high HDI, respectively); this difference disappeared after adjusting for baseline characteristics. Adjusted HRs for the composite endpoint were lower in lower-income/middle-income countries vs upper-income/middle-income (0.791(95% CI 0.632 to 0.990)) and high-income countries (0.756 (95% CI 0.616 to 0.928)), with differences largely attributable to myocardial infarction rates.
  
  
  CONCLUSIONS
  Clinical patient profiles differed substantially by country HDI groupings. Lower unadjusted event rates in medium-HDI countries may be explained by younger age and lower comorbidity burden among these countries' patients. This heterogeneity in patient recruitment across country HDI groupings may have important implications for future global ACS trial design.
  
  
  BACKGROUND
  NCT00699998.
authors.affiliation: Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ambuj
authors.initials: A
authors.lastname: Roy
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: Megan L
authors.initials: ML
authors.lastname: Neely
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: Derek D
authors.initials: DD
authors.lastname: Cyr
authors.affiliation: Daiichi Sankyo, Inc., London, UK.
authors.forename: Dmitry
authors.initials: D
authors.lastname: Zamoryakhin
authors.affiliation: British Heart Foundation Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, Scotland, UK.
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
authors.affiliation: Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.affiliation: Canadian VIGOUR Centre/Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.affiliation: Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA.
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.affiliation: Centre for Chronic Disease Control and Public Health Foundation of India, New Delhi, India.
authors.forename: Dorairaj
authors.initials: D
authors.lastname: Prabhakaran
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics* / Q000401:mortality; D000367:Age Factors; D000368:Aged; D015897:Comorbidity; D005260:Female; D054624:Health Status Disparities; D054625:Healthcare Disparities / Q000191:economics; D006803:Human Development; D006801:Humans; D007182:Income; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D012923:Social Class; D012959:Socioeconomic Factors; D020521:Stroke / Q000209:etiology / Q000401:mortality; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors