• acute coronary syndromes
• acute myocardial infarction
• global health care delivery
• quality and outcomes of care

Cardiovascular disease (CVD) is now the leading cause of mortality and morbidity worldwide, accounting for approximately one-third of all deaths globally.1 While popular belief presumes that non-communicable diseases (NCDs) afflict mostly high-income populations, the evidence tells a very different story. Nearly 80% of NCD deaths occur in low-income and middle-income countries (LMICs). Ischaemic heart disease (IHD) is the leading component of the global CVD burden.1 Mortality of IHD has decreased globally, especially in high-income countries (HICs), due to population-level changes in risk factors and to improvements in systems of care. Meanwhile, ageing of population, rapid economic growth, increasingly sedentary lifestyles and calorie-rich diets have increased the proportion of deaths attributable to CVD in many poorer regions of the world and, as a result, the mortality gap between LMIC and HIC over the past 20 years has narrowed.1

Improved systems of care, early detection and timely treatment are effective approaches for reducing the impact of CVD. However, appropriate care for people with NCDs is lacking in many settings, and access to essential technologies and medicines is limited, particularly in LMICs. In this context of scarce resources, it is imperative to get the most out of known effective interventions, such as the implementation of regional acute coronary syndrome (ACS) systems of care, lowering healthcare system delay (diagnosis, transportation and treatment), increasing reperfusion therapy and reducing in-hospital mortality.2 3

In their Heart manuscript, Galappatthy and colleagues4 presented the results of The ACS Sri Lanka Audit Project (ACSSLAP), a prospective cohort of patients with ACS treated in the public healthcare system in Sri Lanka. It was the first nationwide study in a LMIC to assess management, clinical outcomes, prevalence of risk factors and discharge care plans in ACS. The study included data from nearly all of public secondary and tertiary care hospitals (88.7%) in all districts of the country. Data were audited and showed a panorama of the treatment of ACS, with potential value in terms of policy-making and comparison with other countries. Demographic characteristics were different from previous large ACS registry-based Asian studies in LMICs,5 6 with higher mean age (61.4 years),6 lower rates of male patients (58.7%), previous hypertension (45.9%)5 6 and diabetes (28.4%),6 but higher rates of current smokers (35.2%).5 6 The majority of patients presented to the respective hospitals as direct admissions (73.6%) and were treated in emergency or progressive care units (68.1%).

Some results are quite impressive. Most patients were treated in non-specialised hospitals and only 15.9% (n=336) of patients were managed in hospitals capable of providing primary percutaneous coronary intervention (PCI). In the absence of a public ambulance system, only 5.3% (n=112) were transferred for further management in a specialised hospital. Reperfusion therapy was offered to 66.9% of patients with ST-elevation myocardial infarction (STEMI), although only 5.7% of those were treated with primary PCI. After admission, the median time to perform the ECG was 10 min. The door-to-needle time less than 30 min was achieved only in 42.3% and the door-to-balloon time less than 90 min was achieved only in 62.5%. The major reasons for these delays were clinical decision and logistical reasons in the thrombolytic group and financial reasons in the primary PCI group. Cardiac catheterisation was performed only in 14.0%, which is a very low rate comparing with other LMIC registries.5 6 Over 90% of patients received aspirin, clopidogrel and statin in the acute setting and on discharge. Those surprisingly high rates of prescription of secondary prevention medications were not seen on previous LMIC registries.5 6 Despite the absence of a structured ACS system of care (including an efficient healthcare transportation system) and the reduced access to cardiac catheterisation, in-hospital overall mortality was 2.1% (4.0% in the STEMI group), which was similar or even lower than registries from HICs.7 8

Indeed, it is important to understand the reasons for these excellent results. The authors reported that, since this is an open-label prospective study, the ‘Hawthorne’ effect (awareness of being observed influencing the outcomes assessed) may have resulted in some degree of bias during data collection. Otherwise, the study has been carefully described, including details on missing data, and the results reported seems to reflect reliably the current practice in this country. Random monitoring of research forms (2%–5%) for data accuracy and quality was performed, further reinforcing the reliability of the results. Thus, the study suggests that a wide, well-trained network of general hospitals, compliant with the simplest evidence-based practices, as rapid diagnosis by ECG and the use of basic, low-cost medications, as aspirin, clopidogrel and statin, can result in a very low mortality for ACS, a model that could be tested elsewhere. The registry itself, the ACSSLAP, could be used as a benchmark for future national and regional interventions and subsequent surveys.

The study also pointed out some limitations and opportunities for improvement in this nationwide initiative. The absence of public funding for stent implantation and troponin testing, by the time of the survey, is a challenge to a high-quality assistance, but also a marker of inequality of the healthcare system, since only wealthier patients would be able to pay for these standard procedures. Thus, we should applaud the decision of Sri Lanka Ministry of Health, taken after the survey, to provide cardiac stents to hospitals with PCI facilities and to include troponin testing as a routine examination in state sector hospitals. It is also laudable the recent introduction of state-operated ambulance services in some parts of Sri Lanka, which could lead to the reduction of the total ischaemic time, with further reduction of STEMI in-hospital mortality. No information exists at all about the posthospitalisation care and there is a lot to be done in secondary prevention of new cardiovascular events, including the establishment of cardiac rehabilitation programmes and the providing of essential drugs for those who cannot buy them.

While attempting to reduce the burden of CVD, LMICs face the challenges of limited healthcare budgets and infrastructure as well as constrained professional health workforce capacity. Quality care delivery in lower resource settings does not necessarily mean dissemination and implementation of a universal set of standards formulated in HICs. Adaptation to local settings is necessary to achieve optimal clinical outcomes. This country-level surveillance and monitoring on ACS done by ACSSLAP was the first major step to reduce the burden of IHD according to the Global Status Report on Noncommunicable Diseases, published by WHO.9 An increased awareness of these global NCD goals has expanded attempts to track and benchmark national efforts at reducing CVD. Accurate data from countries are vital to reverse the global rise in death and disability from NCDs.

In this way, it is mandatory that each country, due to its population and resource diversities, appraises and monitors its ACS scenario to find its proper way to achieve the best clinical outcomes, adapting HIC standards of care to the country reality.