Article Text

Original article
Impact of Human Development Index on the profile and outcomes of patients with acute coronary syndrome
  1. Ambuj Roy1,
  2. Matthew T Roe2,3,
  3. Megan L Neely3,
  4. Derek D Cyr3,
  5. Dmitry Zamoryakhin4,
  6. Keith A A Fox5,
  7. Harvey D White6,
  8. Paul W Armstrong7,
  9. E Magnus Ohman2,3,
  10. Dorairaj Prabhakaran8
  1. 1Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
  2. 2Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
  3. 3Duke Clinical Research Institute, Durham, North Carolina, USA
  4. 4Daiichi Sankyo, Inc., London, UK
  5. 5British Heart Foundation Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, Scotland, UK
  6. 6Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
  7. 7Canadian VIGOUR Centre/Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
  8. 8Centre for Chronic Disease Control and Public Health Foundation of India, New Delhi, India
  1. Correspondence to Professor Dorairaj Prabhakaran, Public Health Foundation of India, Tower No. 4, Commercial Complex, Sector-C, Pocket-9, Vasant Kunj, New Delhi 110070, India; dprabhakaran{at}


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.

Trial registration number NCT00699998.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

View Full Text

Statistics from

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Files in this Data Supplement:

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles