Article Text
Abstract
Objective To measure medium-term outcomes and determine the predictors of mortality in patients with coronary artery disease (CAD) both during and after hospitalisation in a resource-limited South-East Asian setting.
Methods From February 2013 to December 2014, we conducted a prospective observational cohort study of 477 patients admitted to Makassar Cardiac Center, Indonesia, with acute coronary syndrome and stable CAD. We actively obtained data on clinical outcomes and after-discharge management until April 2017. Multivariable Cox proportional hazard analysis was performed to examine predictors for our primary outcome, all-cause mortality.
Results From hospital admission, patients were followed over a median of 18 (IQR 6–36) months; in total 154 (32.3%) patients died. More patients with acute myocardial infarction died in the hospital compared with patients with unstable and stable angina (p=0.002). Over the total follow-up, there was a difference in mortality between non-ST-segment elevation myocardial infarction (n=41, 48.2%), ST-segment elevation myocardial infarction (n=65, 30.8%), unstable angina (n=18, 26.5%) and stable coronary artery disease (n=30, 26.5%) groups (p=0.007). The independent predictors of all-cause mortality were hyperglycaemia on admission (HR 1.55 (95% CI 1.12 to 2.14), p=0.008), heart failure/Killip class ≥2 (HR 2.50 (95% CI 1.76 to 3.56), p<0.001), estimated glomerular filtration rate <60 mL/min (HR 1.77 (95% CI 1.26 to 2.50), p=0.001), no revascularisation (percutaneous coronary intervention/coronary artery bypass grafting) (HR 2.38 (95% CI 1.31 to 4.33), p=0.005) and poor adherence to after-discharge medications (HR 10.28 (95% CI 5.52 to 19.16), p<0.001). Poor medication adherence predicted postdischarge mortality and did so irrespective of underlying CAD diagnosis (p interaction=0.88).
Conclusions Patients with CAD in a poor South-East Asian setting experience high in-hospital and medium-term mortality. The initial severity of the disease, lack of access to guidelines-recommended therapy and poor adherence to after-discharge medications are the main drivers for excess mortality. Improved access to early and late hospital care and patient education should be prioritised for better survival.
- coronary artery disease
- all-cause mortality
- adherence to medications
- risk factors
- quality of care and outcomes
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Footnotes
Contributors CSPMU, AQ and BAJMdM conceived the idea of the study and were responsible for the design of the study. AQ, IM, II and MA were responsible for the data collection. AQ was responsible for undertaking the data analysis and produced the tables and graphs. CSPMU, BAJMdM and JPSH provided input into the data analysis and interpretation. AQ has made the first complete paper draft, and the draft was then circulated repeatedly to CSPMU, BAJMdM and JPSH for critical revisions. All authors approved the final version of the manuscript.
Funding This work was supported by the Directorate General of Higher Education/Direktorat Jenderal Pendidikan Tinggi (DIKTI), Ministry of National Education Republic of Indonesia (grant number 600/E4.4/K/2011, 2011).
Competing interests None declared.
Patient consent Obtained.
Ethics approval The study protocol was approved by the Ethics Committee and Institutional Review Board of the Faculty of Medicine, University of Hasanuddin, Makassar, Indonesia (letter number 030/H4.8.4.5.31/PP 36-KOMETIK/2013).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data set available from the corresponding author at a.qanitha@amc.uva.nl/ myaqanitha@gmail.com.
Presented at The abstract of this paper was presented at the 21st Asian Pacific Society of Cardiology (APSC) Congress, 13–15 July 2017, in Singapore.