Management of acute coronary syndromes in developing countries: The ACCESS registry Mohamed SOBHY...
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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
Participating Countries
Funding & disclosures
• The ACCESS registry is sponsored by sanofi-aventis, Paris, France
Disclosure
• I have no disclosure
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.
ACCESS: study design
• Prospective, observational, multinational registry in patients hospitalized for an ACS (Jan 2007- 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
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.
ACCESS: endpoints12-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
ACCESS: results
• 9732 ACS patients with 1-year follow-up
• Discharge diagnoses:– STEMI 45%– NSTE ACS 52%
• NSTEMI 24%• Unstable angina 28%
ACCESS: baseline characteristicsOverall ACS
(n=12,068)
NSTE ACS
(n=6320)
STEMI
(n=5411)
Men, n (%) 74 67 81
Age ≥70 years 21 24 18
Medical history, n (%)
Angina 45 58 31
Myocardial infarction 22 26 18
CHF 5.5 6.8 3.9
Family history of CVD 32 34 29
PAD 4.6 5.5 3.5
PCI 13 17 7.1
CABG 5.1 8.4 1.3
TIA/stroke 4.2 4.7 3.6
Bleeding 1.4 1.4 1.5
ACCESS: risk factors
Overall ACS
(n=12,068)
NSTE ACS
(n=6320)
STEMI
(n=5411)
Diabetes 36 38 33
Hypertension 57 65 47
Treated 84 87 78
Dyslipidemia 42 49 33
Treated 59 65 50
Overweight (BMI, 25–<30 kg/m2) 43 43 44
Class I obesity (BMI, 30–<35 kg/m2) 21 22 20
Class II obesity (BMI, ≥35 kg/m2) 7.4 8.5 6.1
Abdominal obesity 77 79 74
Current smoker 41 34 49
Alcohol misuse 3.4 2.8 4.1
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)
ACCESS: in-hospital medications
ACCESS: in-hospital antithrombotic therapy
ACCESS: in-hospital interventions
ACCESS: reperfusion in STEMI
*94% with stent; 39% with drug-eluting stent
ACCESS: medications at discharge
ACCESS: death at 12 months
*P<0.05 for NSTE ACS vs STEMI
ACCESS: cause of death
ACCESS: Survival curves
NSTE ACS vs STEMI P <0.0001
ACCESS: 12-month events
*P ≤0.05 NSTE ACS vs STEMI†Endpoint: CV death, non-fatal stroke or MI
Main factors* associated with 12-month death (n=8788)
0 2 4 6 8 10 12 14
Cardiac arrest
Cardiogenic shock
Stroke/TIA
Age >70 years
OR (95% CI)
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
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.
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
Thank YOU
June 2012June 2012See you next year!See you next year!