Socioeconomic Status, Mortality, and Access to Cardiac Services After Acute Myocardial Infarction in Canada: A Systematic Review and Meta-analysis

Background

Low socioeconomic status (SES) is an important prognosticator for those with acute myocardial infarction (AMI), having previously been described to be associated with increased short-term mortality. Whether this effect persists over time, and whether access to cardiac interventions is equitable within Canada’s universal health care system, remains unknown.

Methods

We conducted a systematic review to determine the associations of SES with mortality and access to a spectrum of interventions including cardiac catheterization, revascularization, and cardiac rehabilitation. Electronic databases (EMBASE and MEDLINE) were searched in March 2019 and December 2019. Original studies from Canada examining associations between SES and any of the above outcomes in AMI patients were included. Meta-analyses were conducted using random effects models.

Results

Nineteen studies were included, 11 of which could be meta-analyzed. Low SES was associated with a 48% and 34% increase in short-term and intermediate-term mortality, respectively. There was a trend toward increased long-term mortality more than 1-year post-event (pooled odds ratio [OR] 1.34 [95% confidence interval {CI} 0.95-1.88]). Low SES was also associated with lower rates of cardiac catheterization (pooled OR 0.80 [95% CI 0.65-0.99]) and revascularization (pooled OR 0.76 [95% CI 0.63-0.90]) post-AMI. Studies on cardiac rehabilitation showed reduced access and participation in low-SES groups.

Conclusions

Low SES is associated with not only increased mortality post-AMI, but also reduced access to cardiac interventions that have demonstrated benefits for mortality and morbidity. Interventions that improve access to catheterization, revascularization, and cardiac rehabilitation for low-SES populations are needed if true equitable care in Canada is desired.

Management of Patients with Coronary Artery Disease in Lithuania: a Comparison with Other Central Eastern European Countries Based on Data From the International CLARIFY Registry

INTRODUCTION

Lithuania has one of the highest mortality rates from coronary heart disease (CHD) among European countries. Most CHD are preventable, but when they occur, the management of these patients is important in secondary prevention. The purpose of the present analysis was to describe the demographics, clinical profile, and contemporary management of patients with stable CHD in the Lithuanian population and to compare data with other Central Eastern European countries.

METHODS

CLARIFY (prospective observational longitudinal registry of patients with stable CHD) is an international cohort study in outpatients with stable CHD. Treated outpatients with established CHD from the CLARIFY registry in Lithuania (214 patients) were compared with those from the rest of Central Eastern Europe (2794 patients).

RESULTS

Lithuanian patients were younger (p = 0.0275), had a higher body mass index (p = 0.0003), and more frequently received treatment for hypertension (p < 0.0001). Prevalence of dyslipidemia (p < 0.0001) was higher in Lithuanian patients but a smaller group of people had diabetes (p < 0.0001). The total cholesterol (p < 0.0001), low-density lipoprotein cholesterol (p < 0.0001), and blood pressure (p < 0.0001) were higher in the Lithuanian population. A smaller proportion of Lithuanian patients were physically inactive, and the majority of patients in Lithuania were engaged in light physical activity compared with Central Eastern European patients (p = 0.0018).

CONCLUSION

The data analysis shows that management of hypertension, dyslipidemia, smoking, and obesity in patients with CHD in Lithuania is insufficient and needs further improvement.

Melatonin, a toll-like receptor inhibitor: Current status and future perspectives

Toll-like receptors (TLRs) are crucial activators of inflammatory responses, they are considered immune receptors. TLRs are of fundamental importance in the pathophysiology of disorders related to inflammation including neurodegenerative diseases and cancer. Melatonin is a beneficial agent in the treatment of inflammatory and immune disorders. Melatonin is potent anti-inflammatory hormone that regulates various molecular pathways. Withal, limited studies have evaluated the inhibitory role of melatonin on TLRs. This review summarizes the current knowledge related to the effects of melatonin on TLRs in some common inflammatory and immunity disorders.

Is There Still a Role for Fibrinolysis in ST-Elevation Myocardial Infarction?

OPINION STATEMENT

Fibrinolysis had long been the reference treatment in patients with ST-Elevation Myocardial Infarction (STEMI). It was associated with a large reduction in mortality as compared with delayed or no reperfusion in patients managed early, within the first 2 hours from the onset of symptoms. Fibrinolysis also had well-known potential complications: cerebral haemorrhage, especially in patients beyond 75 years, and reinfarction. Primary percutaneous intervention (PCI) has overcome most of these limitations, but at a price: PCI-related delays that can reduce the expected benefit of primary PCI compared with fibrinolysis. That primary PCI is today the treatment of choice in patients with STEMI is no longer discussed. However, fibrinolysis should still maintain a role in the management of acute myocardial infarction (AMI) for three reasons. First, fibrinolysis is no longer a stand-alone treatment. Modern fibrinolytic strategies combine immediate fibrinolysis, loading dose of thienopyridines, and transfer to a PCI hospital for rescue or early PCI within 24 hours. These strategies capitalize on the hub-and-spoke networks that have, or should have, been built everywhere to implement primary PCI. The overall clinical results of these modern fibrinolytic strategies are now similar to those of primary PCI. Second, a substantial number of patients cannot be managed with primary PCI within the reasonable time thresholds set by the guidelines. In the case of long PCI-related delays, patients will benefit from fibrinolysis before or during transfer to a PCI hospital. Third, modern fibrinolytic strategies-immediate fibrinolysis followed by rescue or early PCI-may even offer the best results of all in a subset of patients. Patients of less than 75 years, managed within the first 2 hours and who cannot have immediate PCI, will fare better with a modern fibrinolytic strategy than with primary PCI. Guidelines advocate regional networks between hospitals with and without PCI capabilities, an efficient ambulance service and standardization of AMI management through shared protocols. These regional logistics of care are essential to take full advantage of fibrinolysis strategies. In order to check that these strategies are correctly applied, networks need ongoing registries, as well as benchmarking and quality improvement initiatives.