Introduction: Cardiovascular disease is the leading cause of death among adults in developing countries. However, a comprehensive assessment of acute coronary syndrome (ACS) care is lacking. We performed a systematic review of ACS care in developing countries in the Middle East, Africa, and Southeast Asia.
Methods: We performed searches on PubMed and Embase for studies published between 1995 and 2017 related to ACS care in Middle Eastern, Northern African, and Subsaharan African countries, including STEMI door-to-needle and -balloon times, thrombolytic and PCI rates, and in-hospital mortality. Our Pubmed keywords included “Africa,” “ACS,” “Southeast Asia,” “myocardial infarction,” and “Middle East.” We included studies with > 30 patients that included STEMI and NSTEMI patients or STEMI patients alone. Our searches returned 763 studies. Countries were listed with nominal Gross Domestic Product (GDP) global rankings.
Results: Fifteen studies met inclusion criteria (Table 1) including 33,844 patients (13,730 with STEMI). Most patients were men (65-94%) and were 50-60 years old at presentation. The proportion of patients presenting with a STEMI ranged from 25.7-69.8%. Many countries do not offer primary PCI with rates of primary reperfusion in many countries remaining low. The percentage of patients using EMS transport remained under 20% for most low-middle income countries. In-hospital mortality rates were highest countries with the lowest rates of primary reperfusion. Countries with lower GDP rankings tended to have fewer STEMI patients undergoing reperfusion with thrombolysis [Correlation coefficient: -0.57 (95% CI -0.87, 0.08), p= 0.026].
Conclusion: Utilization of emergency medical services, thrombolysis and primary PCI for STEMI remains low in many developing countries likely secondary to underdeveloped infrastructure and lack of resources. Further study is required to understand factors that can be targeted for quality improvement efforts.