Management of acute coronary syndromes in a developing country; time for a paradigm shift? an observational study.
BACKGROUND
There are limited contemporary data on the presentation, management and outcomes of acute coronary syndromes (ACS) in Sri Lanka. We aimed to identify the critical issues that limit optimal management of ACS in Sri Lanka.


METHODS
We performed a prospectively observational study of 256 consecutive patients who presented with ACS between November 2011 and May 2012 at a tertiary care general medical unit in Sri Lanka.


RESULTS
We evaluated data on presentation, management, in-hospital mortality, and major adverse cardiovascular events (MACE) of participants. Smoking, alcohol abuse, and obesity were more common in patients with ST elevation myocardial infarction (STEMI) (P < 0.05). Discharge diagnoses were STEMI in 32.8 % (84/256) and unstable angina (UA)/non-ST elevation myocardial infarction [NSTEMI] in 67.1 % (172/256) of participants. The median time (IQR) from onset of pain to presentation was 60 (319) minutes for STEMI and 120 (420) for UA/NSTEMI (P = 0.058). A median delay of 240 min was noted in patients who had presented initially to smaller hospitals. Cardiac markers were assessed in only 35 % of participants. In-hospital anti-platelet use was high (>92 %). Only 70.2 % of STEMI patients received fibrinolytic therapy. Fewer than 20 % of patients were received fibrinolytic therapy within 30 min of arrival. Major adverse cardiac events (MACE) were recorded in 11.9 % of subjects with STEMI and 11.6 % of those with UA/NSTEMI (P = 0.5). According to logistic regression analysis, body mass index (P = 0.045) and duration of diabetes (P = 0.03) were significant predictors of in-hospital MACE. On discharge, aspirin, thienopyridine, and statins were prescribed to more than 90 % of patients. Only one patient underwent coronary angiography during the index admission.


CONCLUSIONS
Delays in presentation and in initiation of thrombolytic therapy and coronary interventions are key hurdles that need attention to optimize ACS care in Sri Lanka.
Department of Medicine, Faculty of Medicine, University of Peradeniya, Galaha Rd, Peradeniya, 20400, Sri Lanka. arjuna.medagama@gmail.com.
Arjuna
A
Medagama
Professorial Medical Unit, Teaching Hospital, Peradeniya, Sri Lanka. ruwanthibandara@yahoo.com.
Ruwanthi
R
Bandara
Department of Medicine, Faculty of Medicine, University of Peradeniya, Galaha Rd, Peradeniya, 20400, Sri Lanka. chinthanids@gmail.com.
Chinthani
C
De Silva
Department of Medicine, Faculty of Medicine, University of Peradeniya, Galaha Rd, Peradeniya, 20400, Sri Lanka. manojgalgomuwa@gmail.com.
Manoj Prasanna
MP
Galgomuwa
D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D000368:Aged; D000437:Alcoholism / Q000150:complications; D000789:Angina, Unstable / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D001241:Aspirin / Q000627:therapeutic use; D057210:Delayed Diagnosis; D003906:Developing Countries; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D017052:Hospital Mortality; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D009765:Obesity / Q000150:complications; D062645:Percutaneous Coronary Intervention; D011446:Prospective Studies; D012307:Risk Factors; D012907:Smoking / Q000009:adverse effects; D013188:Sri Lanka / Q000453:epidemiology; D058924:Thienopyridines / Q000627:therapeutic use; D015912:Thrombolytic Therapy
D005343:Fibrinolytic Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D058924:Thienopyridines; D001241:Aspirin