Management of acute coronary syndromes in developing countries: The ACCESS registry Mohamed SOBHY (Egypt), Norka ANTEPARA (Venezuela), Alvaro ESCOBAR (Colombia), Samir ALAM (Lebanon), Alain LEIZOROVICZ (France), Carlos MARTINEZ (Mexico), José NICOLAU (Brazil), Gilles MONTALESCOT (France), on behalf of the ACCESS investigators

Participating Countries

Funding & disclosures The ACCESS registry is sponsored by sanofi- aventis, Paris, France

Disclosure I have no disclosure

ACCESS: background The burden of cardiovascular diseases is predicted to escalate in developing countries. Study aim To investigate the descriptive epidemiology, practice patterns, and primary outcomes of patients hospitalized with an acute coronary syndrome (ACS) in countries in Latin America, the Middle East, and North and South Africa.

ACCESS: study design Prospective, observational, multinational registry in patients hospitalized for an ACS (Jan Jan 2008). Patients enrolled at 134 sites in 19 countries in – Latin America: Argentina, Brazil, Colombia, Dominican Republic, Ecuador, Guatemala, Mexico, Venezuela – Middle East: Egypt, Iran, Jordan, Kuwait, Lebanon, Saudi Arabia, United Arab Emirates – North Africa: Algeria, Morocco, Tunisia – South Africa

ACCESS: study population Patients (age ≥21 years) admitted alive to hospital with: – ischaemic symptoms of ACS within 24 hours of presentation, and – At least 1 of the following: ECG changes: transient ST  or ST  ≥1 mm, new T-wave inversion ≥1 mm, pseudonormalization of previously inverted T waves, new Q-waves, new R wave S wave in lead V1, or new left bundle branch block documentation of coronary artery disease Elevated troponin or CK-MB concentration – Data at baseline, discharge and at 6+ 1 mo., 12+ 1mo. Follow up.

ACCESS: endpoints 12-months from hospitalization Primary endpoint: all-cause death Secondary endpoints: – cardiovascular death – cardiovascular death & non-fatal MI – non-fatal stroke – non-fatal MI – CV death, stroke, or MI & rehospitalization for ischaemic events – bleeding episodes

ACCESS: results 9732 ACS patients with 1-year follow-up Discharge diagnoses: – STEMI 45% – NSTE ACS 52% NSTEMI 24% Unstable angina 28%

ACCESS: baseline characteristics Overall ACS (n=12,068) NSTE ACS (n=6320) STEMI (n=5411) Men, n (%) Age ≥70 years Medical history, n (%) Angina Myocardial infarction CHF Family history of CVD PAD PCI CABG TIA/stroke Bleeding

ACCESS: risk factors Overall ACS (n=12,068) NSTE ACS (n=6320) STEMI (n=5411) Diabetes Hypertension Treated Dyslipidemia Treated Overweight (BMI, 25–<30 kg/m 2 )43 44 Class I obesity (BMI, 30–<35 kg/m 2 ) Class II obesity (BMI, ≥35 kg/m 2 ) Abdominal obesity Current smoker Alcohol misuse

ACCESS: laboratory data Overall ACS (n=12,068) NSTE ACS (n=6320) STEMI (n=5411) Serum creatinine (umol/L)88 [77, 108]88 [76, 108]88 [79, 108] Total cholesterol (mmol/L)5.0 [4.1, 5.9]4.9 [4.1, 5.9]5.0 [4.2, 5.9] Low-density lipoprotein (mmol/L)3.1 [2.3, 3.8] 3.0 [2.4, 3.8] Haemoglobin (mmol/L)8.7 [7.4, 9.3]8.5 [7.4, 9.3]8.7 [8.1, 9.6] Left-ventricular ejection fraction (%)52 [44, 60]55 [45, 61]50 [40, 57] At least 1 elevated cardiac biomarker 6177 (53)NSTEMI: 1851 (83) UA: 830 (25) 3496 (65)

ACCESS: in-hospital medications

ACCESS: in-hospital antithrombotic therapy

ACCESS: in-hospital interventions

ACCESS: reperfusion in STEMI *94% with stent; 39% with drug-eluting stent

ACCESS: medications at discharge

ACCESS: death at 12 months *P<0.05 for NSTE ACS vs STEMI

ACCESS: cause of death

ACCESS: Survival curves NSTE ACS vs STEMI P <0.0001

ACCESS: 12-month events *P ≤0.05 NSTE ACS vs STEMI †Endpoint: CV death, non-fatal stroke or MI

Main factors* associated with 12-month death (n=8788) Cardiac arrest Cardiogenic shock Stroke/TIA Age >70 years OR (95% CI) 8.9 (6.2, 12.8 ) 5.6 (3.9, 8.0) 3.2 (1.8, 5.7) 2.2 (1.8, 2.7) *Four strongest independent factors among 17

ACCESS: conclusions In this multinational, observational study of ACS patients, use of evidence-based pharmacological therapies for ACS was quite high, but reperfusion rates for STEMI (40%) were disappointingly low. These findings suggest opportunities to reduce further the risk of long-term ischaemic events in ACS patients in developing countries.

Acknowledgements Principal Investigator: Gilles MONTALESCOT (France) Steering Committee: Norka ANTEPARA (Venezuela), Alvaro ESCOBAR (Colombia), Samir ALAM (Lebanon), Alain LEIZOROVICZ (France), Carlos MARTINEZ (Mexico), José NICOLAU (Brazil), Mohamed SOBHY (Egypt) National Coordinators: Oscar BAZZINO (Argentina), Wilson RAMIREZ (Dominican Republic), Ricarddo MARMOL (Ecuador), Ismael GUZMAN (Guatemala), Wael ALMAHMEED (UAE), Mohammed ZUBAID (Kuwait), Ashraf HAMMOUDA (Saudi Arabia), Gholamreza Davoodi (Iran), Akram AL SALEH (Jordan), Mohand HADDAK (Algeria), Abdelhamid MOUSTAGHFIR (Morocco), Rachid MECHMECH (Tunisia), Colin SCHAMROTH (South Africa) And all Study Investigators who participated in the ACCESS Registry

Thank YOU

June 2012 See you next year!