Prevalence of Cardiovascular Diseases in South Asians: Scrutinizing Traditional Risk Factors and Newly Recognized Risk Factors Sarcopenia and Osteopenia/Osteoporosis

One of the primary reasons for complications and death worldwide are cardiovascular diseases (CVDs), with a death toll of approximately 18 million per year. CVDs include cardiomyopathy, hypertension, ischemic heart disease, coronary heart disease, myocardial infarction, heart attack, hearth failure, etc. Over 80% of the CVD mortality is recorded from lower and middle-income countries. Records from the past decade have highlighted the increase of CVDs among the South Asian populations, and the prime purpose of the review is to jot down the reasons for the steep spike in CVDs. Studies analyzing the causative factors for the increase of CVDs in South Asians are still to be verified. Apart from known predisposing and lifestyle factors, other emerging risk factors associated with CVDs, namely the musculoskeletal diseases sarcopenia and osteopenia, should be tracked to tackle research gaps in upcoming analyses. This requires loads of scientific efforts. With proper monitoring, the raising alarm that the CVD burden generates can be reduced. This review discusses the already established signs and recognizes important clues to the emerging etiology of CVDs in the Asian population and prevention measures to keep it at bay.

Inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the United Kingdom

Cardiovascular diseases are a leading cause of death and disability globally, with inequalities in burden and care delivery evident in Europe. To address this challenge, The Lancet Regional Health-Europe convened experts from a range of countries to summarise the current state of knowledge on cardiovascular disease inequalities across Europe. This Series paper presents evidence from nationwide secondary care registries and primary care healthcare records regarding inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the National Health Service (NHS) across the United Kingdom (UK) by age, sex, ethnicity and geographical location. Data suggest that women and older people less frequently receive guideline-recommended treatment than men and younger people. There are limited publications about ethnicity in the UK for the studied disease areas. Finally, there is inter-healthcare provider variation in cardiovascular care provision, especially for transcatheter aortic valve implantation, which is associated with differing outcomes for patients with the same disease. Providing equitable care is a founding principle of the UK NHS, which is well positioned to deliver innovative policy responses to reverse observed inequalities. Understanding differences in care may enable the implementation of appropriate strategies to mitigate differences in outcomes.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Gender divides in the clinical profiles of patients with acute myocardial infarction at a tertiary care center in South India

BACKGROUND:

Early identification of myocardial infarction (MI) is a determinant in the provision of appropriate treatment modalities. The focus of the present study is on the identification of gender-based differences in risk factors, clinical manifestations, and coronary angiography findings in patients presenting with MI.

MATERIALS AND METHODS:

A cross-sectional study was conducted among patients admitted with MI at a tertiary care center in South India during March 2016 to June 2017. Selected 120 male and 120 female consecutive patients admitted with acute MI, who had survived and been stabilized. Data was collected using a pre-tested structure data sheet. Appropriate parametric and nonparametric tests were used to analyze the data.

RESULTS:

Participants were homogenous as regards age (P < 0.107); majority of men and women were from the rural areas. About 32.5% of the men interpreted the pain as due to a cardiac problem or indigestion, whereas 60.8% of the women thought it was fatigue/muscle pain. The self-interpretation or perception of pain in both genders was statistically significant (P < 0.001). Compared to the men, the females increasingly presented with atypical symptoms (P = 0.005). Regarding ST-elevated MI, male preponderance was noted (P = 0.004)). Considering the anatomical location of MI, the presentation of Inferior Wall Myocardial Infarction (IWMI) was predominant in females compared to men (P = 0.003). The majority of men had increased presentation of single-vessel disease compared to women (P = 0.02), whereas normal coronaries and double-vessel disease were found statistically significantly higher in females (P = 0.03 and P = 0.008, respectively).

CONCLUSION:

Public education is needed on the atypical presentations which are common with women than in men. The public should, therefore, be informed of those symptoms and how to recognize them so that they may seek medical care promptly.

The impact of the Type D Personality pattern on prehospital delay in patients suffering from acute myocardial infarction

Background

The Type D Personality (TDP) has been specifically linked to acute myocardial infarction (AMI). However, the impact on prehospital delay of AMI patients is unclear. The aim of this study was to assess the relationship between TDP and pre-hospital delay time (PHT) in a Chinese population.

Methods

A total of 256 AMI patients (47 women and 209 men) were taken from the Multicenter Delay in Patients Experiencing AMI in Shanghai (MEDEA FAR-EAST) study. Sociodemographic and psycho-behavioral characteristics were assessed by bedside interviews and questionnaires. TDP was evaluated according to the Type D Personality Scale (DS14) subdivided in social inhibition (SI) and negative affectivity (NA). Based on a significant interaction analysis of TDP and sex on PHT, all analyses were stratified by sex.

Results

PHT of female patients with TDP were substantially shorter compared to non-TDP female patients (108 vs. 281 min, P=0.029). In male patients, no effect of TDT on PHT was found. Spearman correlation analysis suggests that NA was negatively correlated with PHT (r=−0.358, P=0.014). Further age-adjusted logistic regression analyses showed that female patients with TDP were generally less likely to prehospital delay compared with non-TDP patients (OR =0.28; 95% CI, 0.08–0.98) and had a lower risk of PHT >360 minutes (OR =0.10; 95% CI, 0.01–0.91). However, statistical significance disappeared after adjustment for psychological factors (anxiety, depression, suboptimal wellbeing, cardiac denial and stress event).

Conclusions

TDP is associated with less prehospital delay in female patients during AMI—an effect which may be particularly mediated by NA.

ST-elevation myocardial infarction in a migrant population: a registry-based study of patient treatment and outcomes

BACKGROUND

Internationally, a growing number of studies has identified race-related disparities in the presentation, treatment and outcomes of patients with ST-elevation myocardial infarction (STEMI). With a large migrant population, Australia presents a unique microcosm in which to study the impact of migrant status and ethnicity in STEMI patients.

AIM

To investigate if first-generation migrants differed in presentation, treatment or outcomes following STEMI compared with the Australian-born population.

METHODS

We conducted a retrospective observational study using data from a clinician-initiated registry. The study involved 2154 patients who presented to 12 hospitals between 2004 and 2012. Our main outcome measures included time to reperfusion, 30-day mortality and complications.

RESULTS

Migrants (n = 1035, 48.8%) were more likely to be older (61 vs 58 years, P < 0.001), diabetic (29.3 vs 21.5%, P < 0.001) and have a prolonged symptom to door time (102 vs 91 min, P = 0.04). Despite lower rates of previous known ischaemic heart disease (22.5 vs 26.6%, P = 0.03), migrants had more diffuse disease (triple vessel or left main (3VD/LM): 29.8 vs 22.0%, P < 0.001) and higher troponin values (3.77 vs 3.22 μg/L, P = 0.01). We found no significant differences in hospital treatment times, intervention types or rates. Multivariate regression identified age, diabetes, female gender and multi-vessel disease as predictors of complications and death at 30 days.

CONCLUSIONS

Migrants had longer pre-hospital delays and exhibited different cardiovascular risk profiles than Australian-born patients but received comparable treatment in the acute hospital setting. Higher rates of diabetes and multi-vessel coronary artery disease were seen among migrant patients, indicating a relatively higher risk population.

Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association

South Asians (from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) make up one quarter of the world's population and are one of the fastest-growing ethnic groups in the United States. Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the United States can differ in socioeconomic status, education, healthcare behaviors, attitudes, and health insurance, which can affect their risk and the treatment and outcomes of atherosclerotic cardiovascular disease (ASCVD). South Asians have higher proportional mortality rates from ASCVD compared with other Asian groups and non-Hispanic whites, in contrast to the finding that Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) aggregated as a group are at lower risk of ASCVD, largely because of the lower risk observed in East Asian populations. Literature relevant to South Asian populations regarding demographics and risk factors, health behaviors, and interventions, including physical activity, diet, medications, and community strategies, is summarized. The evidence to date is that the biology of ASCVD is complex but is no different in South Asians than in any other racial/ethnic group. A majority of the risk in South Asians can be explained by the increased prevalence of known risk factors, especially those related to insulin resistance, and no unique risk factors in this population have been found. This scientific statement focuses on how ASCVD risk factors affect the South Asian population in order to make recommendations for clinical strategies to reduce disease and for directions for future research to reduce ASCVD in this population.

Short and long-term prognosis following acute myocardial infarction according to the country of origin. Soroka acute myocardial infarction II (SAMI II) project

BACKGROUND

Reports from many countries have shown birthplace-associated disparities in the incidence and mortality following acute myocardial infarction (AMI). The aims of the study were to identify and compare short- and long-term post-AMI mortality according to birthplace.

METHODS

A retrospective analysis of Israeli AMI patients from a tertiary medical center in Southern Israel throughout 2002-2012.

DATA SOURCE

the hospital's computerized systems. Patients were classified according to the country of birth (Israel, Southern Europe/Balkans, Northern Africa, Eastern/Central Europe, India/Pakistan, Middle-East, Yemen, and Ethiopia).

STUDY OUTCOMES

in-hospital and up to 10-years post-discharge all-cause mortality.

RESULTS

The study included 11,143 patients, age 67.4 ± 13.9 and 67.5% men. Israeli-born patients were significantly younger, with lower rate of diabetes mellitus and hypertension but significantly higher rate of obesity, smoking, history of coronary artery disease and male sex compared with immigrants. The rate of STEMI and administration of percutaneous coronary revascularization was higher, yet extent of coronary findings and severe left ventricular dysfunction was lower in Israeli-born patients. In-hospital as well as post-discharge 1-and 10-year mortality rates were approximately 65% lower in Israeli-born patients compared with immigrants. Following adjustment for potential confounders the inequalities in post-discharge mortality attenuated (Yemen OR = 2.3 [95%CI: 1.4-3.6], Southern Europe/Balkans 1.75 [1.2-2.5], Northern Africa 1.5 [1.3-1.8], Eastern/Central Europe 1.4 [1.2-1.7] and India/Pakistan 1.4 [1.1-1.9], for 10-years mortality, p < 0.05 for each) and those for in-hospital mortality disappeared.

CONCLUSIONS

Immigrants are at increased risk for post-discharge, yet not in-hospital mortality following AMI. Appropriate targeted preventive programs are required for these groups of patients.

Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature

There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.

The association between ethnicity and delay in seeking medical care for chest pain: a systematic review

BACKGROUND

Acute coronary syndrome (ACS) is a leading cause of mortality and morbidity worldwide, and chest pain is one of the most common symptoms of ACSs. A rapid response to chest pain by patients and appropriate management by health professionals are vital to improve survival rates.People from different ethnic groups are likely to have different perceptions of chest pain, its severity and the need for urgent treatment. These differences in perception may contribute to differences in response to chests pain and precipitate unique coping strategies. Delay in seeking medical care for chest pain in the general population has been well documented; however, limited studies have focused on delay times within ethnic groups. There is little research to date as to whether ethnicity is associated with the time taken to seek medical care for chest pain. Consequently, addressing this gap in knowledge will play a crucial role in improving the health outcomes of culturally and linguistically diverse (CALD) patients suffering from chest pain and for developing appropriate clinical practice and public awareness for these populations.

OBJECTIVES

The current review aimed to determine if there is an association between ethnicity and delay in seeking medical care for chest pain among CALD populations.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Patients from different ethnic minority groups presenting to emergency departments (EDs) with chest pain.

TYPES OF EXPOSURE

The current review will examine studies that evaluate the association between ethnicity and delay in seeking medical care for chest pain among CALD populations.

TYPES OF STUDIES

The current review will consider quantitative studies including randomized controlled trials (RCTs), non-RCTs, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies.

OUTCOMES

The current review will consider studies that measure delay time as the main outcome. The time will be measured as the interval between the time of symptom onset and time to reach an ED.

SEARCH STRATEGY

A comprehensive search was undertaken for relevant published and unpublished studies written in English with no date restriction. All searches were conducted in October 2014. We searched the following databases: MEDLINE, PubMed, Cochrane Central Register of Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, ProQuest (health databases only), Informit, Sociological Abstracts, Scopus and Web of Science. The search for unpublished studies included a wide range of 'gray literature' sources including national libraries, digital theses repositories and clinical trial registries. We also targeted specific health research, specialist cardiac, migrant health, and emergency medicine organizational websites and/or conferences. We also checked the reference lists of included studies and contacted authors when further details about reported data was required to make a decision about eligibility.

METHODOLOGICAL QUALITY

Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to being included in the review. Validity was assessed using standardized critical appraisal instruments from the Joanna Briggs Institute. Adjudication was produced by the third reviewer.

DATA EXTRACTION

Data were extracted from included articles by two independent reviewers using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

The extracted data were synthesized into a narrative summary. Meta-analysis could not be performed due to the heterogeneity of study protocols and methods used to measure outcomes.

RESULTS

A total of 10 studies, with a total of 1,511,382 participants, investigating the association between ethnicity and delay met the inclusion criteria. Delay times varied across ethnic groups, including Black, Hispanic, Asian, South Asian, Southeast Asian and Chinese. Seven studies reported delay in hours and ranged from 1.90 to 3.10 h. Delay times were longer among CALD populations than the majority population. The other three studies reported delay time in categories of time (e.g. <1, <4 and <6 h) and found larger proportions of later presentations to the EDs among ethnic groups compared with the majority groups.

CONCLUSION

There is evidence of an association between ethnicity and time taken in seeking medical care for chest pain, with patients from some ethnic minorities (e.g. Black, Asian, Hispanic and South Asian) taking longer than those of the majority population. Health promotions and health campaigns focusing on these populations are indicated.

A cross-sectional study of ethnicity-based differences in treatment seeking for symptoms of acute coronary syndrome

BACKGROUND

Patient-related delays in acquiring medical care for symptoms of acute coronary syndrome remain unacceptably long. Many clinical and sociodemographic characteristics associated with treatment-seeking delay are known; however, ethnicity has not been extensively evaluated.

OBJECTIVE

The purpose of this study was to examine ethnicity-based differences in the time-to-treatment-seeking intervals of patients experiencing symptoms of acute coronary syndrome.

METHOD

Data for this descriptive study were collected for the larger Acute Coronary Syndrome Care in Emergency Departments (ASCEND) study. The larger study is a prospective, observational study in which patients presenting to hospital emergency departments and triaged as having symptoms suggestive of acute coronary syndrome are identified. The primary outcome of this study, the time-to-treatment-seeking interval, was defined as the time between symptom onset and treatment seeking. The predictor variable, ethnicity, was measured with self-reported data and categorised as Chinese, South Asian, or 'Other' ethnic group. Participants in the 'Other' ethnic group were predominantly of European ancestry. Univariate and multivariate analyses were undertaken, along with nonparametric testing.

RESULTS

The study sample consisted of 419 participants: 36 Chinese, 126 South Asian, and 257 'Other' participants. The median time-to-treatment-seeking interval, for the total sample, was 180 minutes. A Kruskal-Wallis test demonstrated no statistically significant differences in the time-to-treatment-seeking intervals by ethnicity.

CONCLUSION

No ethnicity-based differences in the time-to-treatment-seeking intervals for symptoms of acute coronary syndrome were found. It is possible that Chinese and South Asian patients living in western countries are more aware of the potential signs and symptoms of acute coronary syndrome or feel more confident to access healthcare services than they have been previously.

Prehospital delay and time to reperfusion therapy in ST elevation myocardial infarction

Background:

Despite efforts aimed at reducing the prehospital delay and treatment delay, a considerable proportion of patients with ST elevation myocardial infarction (STEMI) present late and receive the reperfusion therapy after unacceptably long time periods. This study aimed at finding out the patients' decision delay, prehospital delay, door-to-electrocardiography (ECG), door-to-needle, and door-to-primary percutaneous coronary intervention (PCI) times and their determinants among STEMI patients.

Materials and Methods:

A cross-sectional study conducted among 96 patients with STEMI admitted in a tertiary care center in South India. The data were collected using interview of the patients and review of records. The distribution of the data was assessed using Kolmogorov–Smirnov test, and the comparisons of the patients' decision delay, prehospital delay, and time to start reperfusion therapy with the different variables were done using Mann–Whitney U-test or Kruskal–Wallis test based on the number of groups.

Results:

The mean (standard deviation) and median (range) age of the participants were 55 (11) years and 57 (51) years, respectively. The median patients' decision delay, prehospital delay, door-to-ECG, door-to-needle, and door-to-primary PCI times were 75, 290, 12, 75, 110 min, respectively. Significant factors associated (P < 0.05) with patients' decision delay were alcoholism, symptom progression, and attempt at symptom relief measures at home. Prehospital delay was significantly associated (P < 0.05) with domicile, difficulty in arranging money, prior consultation at study center, place of symptom onset, symptom interpretation, and mode of transportation.

Conclusions:

The prehospital delay time among the South Indian population is still unacceptably high. Public education, improving the systems of prehospital care, and measures to improve the patient flow and management in the emergency department are essentially required. The time taken to take ECG and to initiate reperfusion therapy in this study points to scope for improvement to meet the American Heart Association recommended timings.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.

Objectives

To generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.

Design

Cross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).

Results

The utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.

Conclusions

We found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Are There Ethnic Inequalities in Revascularisation Procedure Rate after an ST-Elevation Myocardial Infarction?

Background

Previously, ethnic inequalities in prognosis after a first acute myocardial infarction were observed in the Netherlands. This might be due to differences in revascularisation rate between ethnic minority groups and ethnic Dutch. Therefore, we investigated inequalities in revascularisation rate after occurrence of an ST-elevation myocardial infarction (STEMI) between first generation ethnic minority groups (henceforth, migrants) and ethnic Dutch.

Methods

All STEMI events between 2006 and 2011 were identified in a subset of the Achmea Health Database, which records medical care to persons insured at the Achmea health insurance company, a major health insurance company in the central part of the Netherlands. Ethnic Dutch and migrants from Suriname (Hindustani Surinamese and non-Hindustani Surinamese), Morocco, and Turkey were included (n = 1,765). Multivariable Cox proportional hazards regression analyses were used to identify ethnic inequalities in revascularisation rate (percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)) after a STEMI event.

Results

On average, 73.2% of STEMI events were followed by a revascularisation procedure. After adjustment for confounders (age, sex, degree of urbanization) no significant differences in revascularisation rate were found between the ethnic Dutch population and Hindustani Surinamese (HR: 1.04; 0.85–1.27), non-Hindustani Surinamese (HR: 0.98; 0.63–1.51), Moroccan (HR: 0.94; 0.77–1.14), and Turkish migrants (HR: 1.04; 0.88–1.24). Additional adjustment for comorbidity and neighborhood income did not change our findings.

Conclusion

Our study suggests no ethnic inequalities in revascularisation rate after a STEMI event. This finding is in agreement with the universally accessible health care system in the Netherlands.

The influence of ethnicity and gender on navigating an acute coronary syndrome event

BACKGROUND

Ethnicity and gender may influence acute coronary syndrome patients recognizing symptoms and making the decision to seek care.

OBJECTIVE

To examine these potential differences in European (Caucasian), Chinese and South Asian acute coronary syndrome patients.

METHODS

In-depth interviews were conducted with 20 European (Caucasian: 10 men/10 women), 18 Chinese (10 men/eight women) and 19 South Asian (10 men/nine women) participants who were purposively sampled from those participating in a large cohort study focused on acute coronary syndrome. Analysis of transcribed interviews was undertaken using constant comparative methods.

RESULTS

Participants followed the process of: having symptoms; waiting/denying; justifying; disclosing/ discovering; acquiescing; taking action. The core category was 'navigating the experience'. Certain elements of this process were in the forefront, depending on participants' ethnicity and/or gender. For example, concerns regarding language barriers and being a burden to others varied by ethnicity. Women's tendency to feel responsibility to their home and family negatively impacted the timeliness in their decisions to seek care. Men tended to disclose their symptoms to receive help, whereas women often waited for their symptoms to be discovered by others. Finally, the thinking that symptoms were 'not-urgent' or something over which they had no control and concern regarding potential costs to others were more prominent for Chinese and South Asian participants.

CONCLUSION

Ethnic- and gender-based differences suggest that education and support, regarding navigation of acute coronary syndrome and access to care, be specifically targeted to ethnic communities.