Management of acute coronary syndromes in developing countries: The ACCESS registry

Transcripción

1 Management of acute coronary syndromes in developing countries: The ACCESS registry Mohamed SOBHY (Egypt), Norka ANTEPARA (Venezuela), Alvaro ESCOBAR (Colombia), Samir ALAM (Lebanon), Alain LEIZOROVICZ (France), Carlos MARTINEZ (Mexico), José NICOLAU (Brazil), Gilles MONTALESCOT (France), on behalf of the ACCESS investigators

2 Funding & disclosures The ACCESS registry is sponsored by sanofiaventis, Paris, France

3 I have no disclosure Disclosure

4 ACCESS: background The burden of cardiovascular diseases is predicted to escalate in developing countries. Study aim To investigate the descriptive epidemiology, practice patterns, and primary outcomes of patients hospitalized with an acute coronary syndrome (ACS) in countries in Latin America, the Middle East, and North and South Africa.

5 ACCESS: study design Prospective, observational, multinational registry in patients hospitalized for an ACS (Jan Jan 2008). Patients enrolled at 134 sites in 19 countries in Latin America: Argentina, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Mexico, Venezuela Middle East: Egypt, Iran, Jordan, Kuwait, Lebanon, Saudi Arabia, United Arab Emirates North Africa: Algeria, Morocco, Tunisia South Africa

6 Participating Countries

7 ACCESS: study population Patients (age 21 years) admitted alive to hospital with: ischaemic symptoms of ACS within 24 hours of presentation, and At least 1 of the following: ECG changes: transient ST or ST 1 mm, new T-wave inversion 1 mm, pseudonormalization of previously inverted T waves, new Q-waves, new R wave S wave in lead V1, or new left bundle branch block documentation of coronary artery disease Elevated troponin or CK-MB concentration Data at baseline, discharge and at 6+ 1 mo., 12+ 1mo. Follow up.

8 ACCESS: endpoints 12-months from hospitalization Primary endpoint: all-cause death Secondary endpoints: cardiovascular death cardiovascular death & non-fatal MI non-fatal stroke non-fatal MI CV death, stroke, or MI & rehospitalization for ischaemic events bleeding episodes

9 ACCESS: results 9732 ACS patients with 1-year follow-up Discharge diagnoses: STEMI 45% NSTE ACS 52% NSTEMI 24% Unstable angina 28%

10 ACCESS: baseline characteristics Overall ACS (n=12,068) NSTE ACS (n=6320) STEMI (n=5411) Men, n (%) Age 70 years Medical history, n (%) Angina Myocardial infarction CHF Family history of CVD PAD PCI CABG TIA/stroke Bleeding

11 ACCESS: risk factors Overall ACS (n=12,068) NSTE ACS (n=6320) STEMI (n=5411) Diabetes Hypertension Treated Dyslipidemia Treated Overweight (BMI, 25 <30 kg/m 2 ) Class I obesity (BMI, 30 <35 kg/m 2 ) Class II obesity (BMI, 35 kg/m 2 ) Abdominal obesity Current smoker Alcohol misuse

12 ACCESS: laboratory data Overall ACS (n=12,068) NSTE ACS (n=6320) STEMI (n=5411) Serum creatinine (umol/l) 88 [77, 108] 88 [76, 108] 88 [79, 108] Total cholesterol (mmol/l) 5.0 [4.1, 5.9] 4.9 [4.1, 5.9] 5.0 [4.2, 5.9] Low-density lipoprotein (mmol/l) 3.1 [2.3, 3.8] 3.1 [2.3, 3.8] 3.0 [2.4, 3.8] Haemoglobin (mmol/l) 8.7 [7.4, 9.3] 8.5 [7.4, 9.3] 8.7 [8.1, 9.6] Left-ventricular ejection fraction (%) 52 [44, 60] 55 [45, 61] 50 [40, 57] At least 1 elevated cardiac biomarker 6177 (53) NSTEMI: 1851 (83) UA: 830 (25) 3496 (65)

13 ACCESS: in-hospital medications

14 ACCESS: in-hospital antithrombotic therapy

15 ACCESS: in-hospital interventions

16 ACCESS: reperfusion in STEMI *94% with stent; 39% with drug-eluting stent

17 ACCESS: medications at discharge

18 ACCESS: death at 12 months *P<0.05 for NSTE ACS vs STEMI

19 ACCESS: cause of death

20 NSTE ACS vs STEMI P < ACCESS: Survival curves

21 *P 0.05 NSTE ACS vs STEMI Endpoint: CV death, non-fatal stroke or MI ACCESS: 12-month events

22 Main factors* associated with 12-month death (n=8788) OR (95% CI) Cardiac arrest Cardiogenic shock Stroke/TIA Age >70 years 8.9 (6.2, 12.8) 5.6 (3.9, 8.0) 3.2 (1.8, 5.7) 2.2 (1.8, 2.7) *Four strongest independent factors among 17

23 ACCESS: conclusions In this multinational, observational study of ACS patients, use of evidence-based pharmacological therapies for ACS was quite high, but reperfusion rates for STEMI (40%) were disappointingly low. These findings suggest opportunities to reduce further the risk of long-term ischaemic events in ACS patients in developing countries.

24 Acknowledgements Principal Investigator: Gilles MONTALESCOT (France) Steering Committee: Norka ANTEPARA (Venezuela), Alvaro ESCOBAR (Colombia), Samir ALAM (Lebanon), Alain LEIZOROVICZ (France), Carlos MARTINEZ (Mexico), José NICOLAU (Brazil), Mohamed SOBHY (Egypt) National Coordinators: Oscar BAZZINO (Argentina), Wilson RAMIREZ (Dominican Republic), Ricarddo MARMOL (Ecuador), Ismael GUZMAN (Guatemala), Wael ALMAHMEED (UAE), Mohammed ZUBAID (Kuwait), Ashraf HAMMOUDA (Saudi Arabia), Gholamreza Davoodi (Iran), Akram AL SALEH (Jordan), Mohand HADDAK (Algeria), Abdelhamid MOUSTAGHFIR (Morocco), Rachid MECHMECH (Tunisia), Colin SCHAMROTH (South Africa) And all Study Investigators who participated in the ACCESS Registry

25 Thank YOU

26 7-10 June 2010, Bibliotheca Alexandrina, Egypt