Abstract
Background
The majority of NSTEMI burden resides outside high-income countries (HICs). We describe presentation, care, and outcomes of NSTEMI by country income classification.
Methods and results
Prospective cohort study including 2947 patients with NSTEMI from 287 centres in 59 countries, stratified by World Bank country income classification. Quality of care was evaluated based on 12 guideline-recommended care interventions. The all-or-none scoring composite performance measure was used to define receipt of optimal care. Outcomes included in-hospital acute heart failure, stroke/transient ischaemic attack, and death, and 30-day mortality. Patients admitted with NSTEMI in low to lower-middle-income countries (LLMICs), compared with patients in HICs, were younger, more commonly diabetic, and current smokers, but with a lower burden of other comorbidities, and 76.7% met very high risk criteria for an immediate invasive strategy. Invasive coronary angiography use increased with ascending income classification (LLMICs, 79.2%; upper middle income countries [UMICs], 83.7%; HICs, 91.0%), but overall care quality did not (≥80% of eligible interventions achieved: LLMICS, 64.8%; UMICs 69.6%; HICs 55.1%). Rates of acute heart failure (LLMICS, 21.3%; UMICs, 12.1%; HICs, 6.8%; P < 0.001), stroke/transient ischaemic attack (LLMICS: 2.5%; UMICs: 1.5%; HICs: 0.9%; P = 0.04), in-hospital mortality (LLMICS, 3.6%; UMICs: 2.8%; HICs: 1.0%; P < 0.001) and 30-day mortality (LLMICs, 4.9%; UMICs, 3.9%; HICs, 1.5%; P < 0.001) exhibited an inverse economic gradient.
Conclusion
Patients with NSTEMI in LLMICs present with fewer comorbidities but a more advanced stage of acute disease, and have worse outcomes compared with HICs. A cardiovascular health narrative is needed to address this inequity across economic boundaries.
Keywords: NSTEMI, Registry, Country income, Quality indicators, Mortality
Graphical Abstract
Graphical Abstract.
Analysis of the ACVC-EAPCI EORP NSTEMI registry stratified by country income classification.
Introduction
The prevalence of acute coronary syndromes in low to middle-income countries is rising rapidly, accounting for ∼80% of burden and 85% of disability worldwide.1 Care for non-ST-segment elevation myocardial infarction (NSTEMI) that conforms to the European Society of Cardiology (ESC) guidelines has been demonstrated to improve outcomes,2–6 but places a financial burden on healthcare systems as it requires a network of specialist healthcare professionals, provision of interventional procedures, and the prescription of several different medications.7,8 Accordingly, there may be variation in the delivery of treatment between economically advantaged and disadvantaged countries and associated disparities in outcomes.
Previous studies have reported variation in care and outcomes for NSTEMI within and between countries,2,6,9–11 as well as across regions,12,13 but the relationship across income classification is unknown. Furthermore, some reports with wide representation have focussed primarily on the provision of in-hospital revascularisation,14 and so do not adequately describe the wider pathway of NSTEMI care.
This registry was designed and implemented to identify patterns in the care of patients presenting with NSTEMI and their outcomes across the heterogeneous context of ESC country members and affiliated countries. Here we report the results of the registry stratified by World Bank country income classification.15
Methods
Study design
This registry is an international prospective, multicentre, observational study of patients presenting to hospitals in ESC member, and affiliated countries. The study design has been published previously.16
Study organisation and selection of centres
This registry is a joint initiative of the Association for Acute Cardiovascular Care (ACVC) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) under the umbrella of the EURObservational Research Programme (EORP). A feasibility survey was sent to potential sites, and selection based upon their responses. Consecutive consenting participants hospitalised with confirmed diagnosis of NSTEMI within a two-week period at each centre were recorded.
Patients
Inclusion criteria were the patients aged ≥18 years with a final diagnosis of NSTEMI, that is, patients with Universal Definition acute myocardial infarction, type 1 myocardial infarction, and who did not have persistent ST-segment elevation.17,18 Patients unwilling or unable to consent were excluded. Centre enrolment took place between 11 March 2019 and 6 March 2021. Characteristics of the recruiting centres were recorded. For each patient, demographic features, mode of admission, therapeutic methods, time delays to reperfusion, risk stratification, and medication prescription during admission and on discharge were also recorded on an electronic case report form. Follow-up for clinical events and life status was recorded at 30 days.
Quality of care
Quality of care was evaluated based on 12 ESC guideline-recommended NSTEMI care interventions.7 These included: electrocardiogram (ECG) pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, invasive coronary angiography, medication at discharge to include aspirin, P2Y12 inhibition, angiotensin converting ezyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker and statin, referral to cardiac rehabilitation, smoking cessation advice, and dietary advice. The study period traversed two publications of ESC quality indicators for acute myocardial infarction, but the indicators we collected and analysed were consistent across both.19,20 We included two additions lifestyle interventions—smoking cessation advice and dietary advice—because both are associated with a reduction in mortality and cardiovascular events,21,22 and can be provided even in the absence of a full cardiac rehabilitation programme.
For each intervention, patients were considered ineligible if they were recorded as having a contra-indication or the data field recorded as not applicable. The all-or-none scoring composite performance measure was used as an aggregation method to define receipt of optimal care, i.e. patients who received all 12 of the care interventions for which they were eligible were considered to have received optimal care, but patients missing one or more interventions were considered to have received sub-optimal care.2 If the data were missing, the patient was assumed not to have received the intervention. Overall, receipt of optimal care was split into four categories: no interventions received, <40% of eligible interventions received, ≥40%–<80% of eligible intervention received, and ≥80% of interventions received.2
To further distinguish patterns in care provision, guideline recommendations were also grouped as follows: pharmacological therapies (pre-hospitalization receipt of aspirin and prescription on discharge of each of aspirin, P2Y12 inhibitor, ACEi/ARB, beta-blocker, and statin), investigative and invasive coronary strategies (electrocardiogram pre- or in-hospital, echocardiography, invasive coronary angiography) and lifestyle care interventions (referral to cardiac rehabilitation, smoking cessation advice, and dietary advice). This categorisation has been shown to offer higher resolution insights into the impact of care delivery on survival according to the GRACE risk score.5
Recorded outcomes included in-hospital episodes of acute heart failure, cardiogenic shock, use of mechanical circulatory support, bleed (BARC Type ≥ 3),23 stroke/transient ischaemic attack, repeat myocardial infarction, and death from any cause, as well as 30 day-all-cause mortality.
Statistics
Categorical data were described using numbers and percentages for non-missing data, and continuous data were described using medians, interquartile range (IQR), means, and standard deviations (SD). Comparison between groups was performed using the Kruskal–Wallis test or using Pearson's χ2 test or Fisher's exact test if any count was <5.
To explore for differences in NSTEMI care quality by country wealth, we stratified the cohort into low (LICs), lower-middle (LMICs), upper-middle (UMICs), and high-income countries (HICs) according to the World Bank classification of the 2021 fiscal year.15 Given the numbers of countries in the study, the LICs and LMICs were combined to form a single larger group of low to lower-middle-income countries (LLMICs). All analyses were conducted using SAS version 9.4, with statistical significance determined at 5%. Findings are reported in accordance with the Strengthening the reporting of observational studies in epidemiology (STROBE) statement.24
Ethics
Favourable ethics approval for the study was granted at the local and/or regional ethics committees or Institutional Review Boards in each country, according to local regulations. National coordinators, in conjunction with local centres, or participating centres managed the approvals of national or regional ethics committees or Institutional Review Boards, according to local regulations.
Results
Study population
From the recruited cohort of 3620 participants, 2947 formed the analytical cohort from 59 countries, across four continents and 287 centres (Figure 1, Supplementary material online, Table S1). Most participating centres were teaching research hospitals (45.0%) followed by general hospitals (41.1%) and 58.2% of hospitals had cardiac surgery onsite (Supplementary material online, Table S2). The majority of patients (1761, 59.8%) and participating centres (192, 66.9%) were from HICs. The median (IQR) age and proportion of women was 66 (57–75) years and 30.8%, with NTSEMI patients in HICs being older and more commonly men and Caucasian (Table 1).
Figure 1.
STROBE diagram for the EORP NSTEMI registry analytical cohort.
Table 1.
Baseline characteristics of NSTEMI patients in analytical cohort by country income classification
| Total | LLMICs | UMICs | HICs | Missing data, | |
|---|---|---|---|---|---|
| (n = 2947) | (n = 361) | (n = 825) | (n = 1761) | n (%) | |
| Patient characteristics | |||||
| Age (years), median (IQR) | 66 (57–75) | 58 (51–65) | 64 (56–73) | 68 (59–77) | 0 |
| >= 75 years | 761 (25.8) | 31 (8.6) | 177 (21.5) | 553 (31.4) | 0 |
| >= 80 years | 447 (15.2) | 16 (4.4) | 93 (11.3) | 338 (19.2) | 0 |
| Women | 907 (30.8) | 122 (33.8) | 259 (31.4) | 526 (29.9) | 0 |
| Ethnic origin | 107 (3.6) | ||||
| Caucasian | 2252 (79.3) | 142 (43.2) | 553 (69.6) | 1557 (90.7) | |
| Black | 41 (1.4) | 31 (9.4) | 0/795 | 10 (0.6) | |
| Asian | 278 (9.8) | 129 (39.2) | 88 (11.1) | 61 (3.6) | |
| Other | 269 (9.5) | 27 (8.2) | 154 (19.4) | 88 (5.1) | |
| Cardiovascular risk factors | |||||
| Hypertension | 2023 (69.0) | 235 (65.3) | 597 (72.9) | 1191 (67.9) | 15 (0.5) |
| Ever smoker | 1591 (56.9) | 159 (45.6) | 456 (56.6) | 976 (59.4) | 151 (5.1) |
| Current smoker | 857 (30.7) | 128 (36.7) | 297 (36.9) | 432 (26.3) | |
| Former smoker | 734 (26.3) | 31 (8.9) | 159 (19.8) | 544 (33.1) | |
| Diabetes Mellitus | 1104 (37.7) | 174 (48.6) | 332 (40.5) | 598 (34.2) | 19 (0.6) |
| Hypercholesterolaemia | 1427 (51.9) | 125 (39.4) | 324 (45.3) | 978 (57.0) | 200 (6.8) |
| Cardiovascular comorbidities | |||||
| Atrial fibrillation | 302 (10.3) | 13 (3.6) | 82 (10.0) | 207 (11.8) | 17 (0.6) |
| Heart failure | 464 (15.9) | 41 (11.5) | 163 (20.0) | 260 (14.9) | 30 (1.0) |
| Prior myocardial infarction | 759 (26.1) | 49 (13.7) | 277 (34.5) | 433 (24.8) | 41 (1.4) |
| Prior PCI | 649 (22.1) | 31 (8.6) | 209 (25.5) | 409 (23.3) | 14 (0.5) |
| Prior CABG surgery | 217 (7.4) | 9 (2.5) | 79 (9.6) | 129 (7.3) | 5 (0.2) |
| Peripheral vascular disease | 243 (8.6) | 12 (3.6) | 51 (6.6) | 180 (10.4) | 115 (3.9) |
| Stroke | 204 (6.9) | 19 (5.3) | 55 (6.7) | 130 (7.4) | 6 (0.2) |
| Relevant comorbidities | |||||
| Active malignancy | 82 (2.8) | 8 (2.2) | 9 (1.1) | 65 (3.7) | 37 (1.3) |
| COPD | 234 (8.0) | 27 (7.5) | 50 (6.1) | 157 (9.0) | 30 (1.0) |
| Chronic kidney disease | 367 (12.5) | 23 (6.4) | 108 (13.2) | 236 (13.5) | 16 (0.5) |
CABG, coronary artery bypass grafting; COPD, chronic obstructive pulmonary disease; HICs, high-income countries, LLMICs, low to lower-middle-income countries; PCI, percutaneous coronary intervention; UMICs, upper-middle-income countries.
Overall, the comorbidity burden of the cohort was high (Table 1). Each of hypertension, hypercholesterolaemia, or ever smoking was prevalent in over half of the patients at time of diagnosis, more than a third had diabetes mellitus and over a quarter had a previous myocardial infarction. Notably, the patients admitted with NSTEMI in HICs were older than those from LLMICs, and had a higher burden of comorbidity, with a three-fold increased prevalence of atrial fibrillation, peripheral vascular disease, prior percutaneous coronary intervention or coronary artery bypass graft surgery and a two-fold increased prevalence of chronic kidney disease and treatment with dialysis. In HIC countries, patients with NSTEMI also had higher rates of heart failure, COPD, hypercholesterolaemia, and cancer, but lower rates of diabetes.
Presenting characteristics
Patients admitted in LLMICs, compared with patients in UMICs or HICS, had a longer delay to presentation at hospital following their symptom onset and showed signs of more severe disease at time of their presentation (Table 2). That is, the proportion of patients presenting in Killip Class III or IV was three-fold higher in LLMICs than HICs and ongoing chest pain, life-threatening arrhythmias (or cardiac arrest), and haemodynamic instability were at least twice as common. More than three-quarters of patients presenting with NSTEMI in LLMICs met very high risk criteria for an invasive coronary strategy, whereas only a third of patients did so in HICs (Table 2).
Table 2.
Presenting characteristics of NSTEMI patients in analytical cohort by country income classification
| Total | LLMICs | UMICs | HICs | Missing data, | |
|---|---|---|---|---|---|
| (n = 2947) | (n = 361) | (n = 825) | (n = 1761) | n (%) | |
| Clinical presentation | |||||
| Symptom onset to hospital admission, median (IQR) | 6.3 (2.4–26.6) | 8.0 (4.0–44.5) | 7.5 (2.3–29.8) | 5.6 (2.1–23.7) | 11 (0.4) |
| Heart rate (bpm), median (IQR) | 77 (67–90) | 86 (76–98) | 80 (70–90) | 75 (65–86) | 7 (0.2) |
| Systolic Blood pressure (mmHg), median (IQR) | 139 (120–155) | 130 (110–140) | 136 (120–151) | 140 (124–158) | 7 (0.2) |
| Cardiac arrest | 41 (1.4) | 8 (2.2) | 14 (1.7) | 19 (1.1) | 12 (0.4) |
| Killip class | 12 (0.4) | ||||
| Class I | 2351 (80.1) | 247 (68.4) | 653 (79.2) | 1451 (82.9) | |
| Class II | 400 (13.6) | 65 (18.0) | 120 (14.6) | 215 (12.3) | |
| Class III | 151 (5.1) | 40 (11.1) | 41 (5.0) | 70 (4.0) | |
| Class IV | 33 (1.1) | 9 (2.5) | 10 (1.2) | 14 (0.8) | |
| Ongoing chest pain | 1150 (39.3) | 248 (69.9) | 382 (46.4) | 520 (29.8) | 23 (0.8) |
| Life threatening arrhythmia or cardiac arrest | 91 (3.1) | 20 (5.5) | 31 (3.8) | 40 (2.3) | 3 (0.1) |
| Acute heart failure | 336 (11.5) | 78 (21.7) | 127 (15.4) | 131 (7.5) | 13 (0.4) |
| Mechanical complication of MI | 28 (1.0) | 11 (3.1) | 9 (1.1) | 8 (0.5) | 9 (0.3) |
| Haemodynamic instability | 147 (5.0) | 27 (7.5) | 57 (6.9) | 63 (3.6) | 7 (0.2) |
| ST segment deviation indicative of ischaemia | 1502 (51.1) | 239 (66.2) | 514 (62.4) | 749 (42.6) | 5 (0.2) |
| Laboratory results | |||||
| Peak troponin I/Upper reference, median (IQR) | 21 (4–100) | 39 (6–100) | 12 (2–86) | 22 (6–111) | 1183 (40.1) |
| Peak troponin T/Upper reference, median (IQR) | 11 (4–32) | 6 (3–19) | 16 (6–39) | 10 (3–30) | 1842 (62.5) |
| Haemoglobin (g/L), median (IQR) | 138 (123–150) | 125 (112–138) | 139 (123–150) | 140 (126–150) | 69 (2.3) |
| eGFR CG (ml/min/1.73 m²), median (IQR) | 77 (57–93) | 76 (55–95) | 75 (56–92) | 77 (58–93) | 51 (1.7) |
| Risk assessment | |||||
| GRACE, median (IQR) | 135 (113–161) | 136 (119–163) | 139 (116–163) | 133 (111–160) | 116 (3.9) |
| Very-high risk for invasive strategy criterion met | 1358 (46.3) | 276 (76.7) | 450 (54.6) | 632 (36.1) | |
| In-hospital revascularisation (of those eligible) | |||||
| Diagnostic coronary angiography | 2578 (87.5) | 286 (79.2) | 690 (83.7) | 1602 (91.0) | 1 (0.0) |
| PCI | 1791 (60.9) | 225 (62.5) | 462 (56.2) | 1104 (62.7) | |
| CABG surgery | 328 (11.1) | 33 (9.2) | 110 (13.4) | 185 (10.5) | |
CABG, coronary artery bypass grafting; HICs, high-income countries, LLMICs, low to lower-middle-income countries; PCI, percutaneous coronary intervention; UMICs, upper-middle-income countries.
Quality of care
There was geographic variation in the attainment of the 12 measured quality indicators for NSTEMI care (Figure 2). Whilst all patients were recorded as having received an ECG at baseline, only 45% and 46% received aspirin pre-hospitalization and referral for cardiac rehabilitation, respectively. Across the 12 quality indicators 98.3% of patients received at least 40% of the assessed interventions (60.3% of patients received ≥80% of interventions, 38.0% received ≥40% to <80% of eligible interventions). By care grouping, 80.2% received ≥80% of eligible interventions related to investigation and invasive coronary strategies, but only 31.2% for lifestyle care interventions.
Figure 2.
Guideline-recommended for treatment for NSTEMI by World Bank country income classification.
Across the spectrum of country income classification 100% of patients received an ECG at baseline, and ≥90% each of aspirin, P2Y12 inhibitors and statins at discharge (Figure 2). In contrast, pre-hospitalisation use of aspirin varied substantially (LLMICs, 39.4%; UMICs, 55.6%; HICs, 41.4%). The use of invasive coronary angiography increased with increasing country economic prosperity (LLMICs, 79.2%; UMICs, 83.7%; HICs, 91.0%). A greater proportion of NSTEMI patients in HICs received referral for cardiac rehabilitation than their counterparts in LLMICs (52.0% vs. 39.9%), but a smaller proportion received dietary advice (79.5% vs. 95.0%)
Overall, attainment of the measured quality indicators was higher in LLMICs and UMICs than HICs (≥80% of eligible interventions achieved: LLMICS, 64.8%; UMICs 69.6%; HICs 55.1%). Whilst the proportion of patients who received ≥80% of eligible interventions related to investigation and invasive coronary strategies was high and increased with ascending income classification (LLMICs, 74.8%; UMICs, 80.1%; HICs, 81.3%), the proportion of patients who received ≥80% of eligible lifestyle care interventions (LLMICS, 33.5%; UMICs, 30.8%; HICs, 30.9%) was uniformly low (Figure 3).
Figure 3.
Performance by quality indicator grouping stratified by receipt of optimal care and country income classification. (A) Overall, (B) Pharmacological therapies, (C) Investigative and invasive coronary strategies, (D) Lifestyle care opportunities.
In-hospital outcomes and 30-day mortality
Adverse outcomes for patients admitted for NSTEMI were more frequent in less economically developed countries, in spite of their younger age at presentation (Figure 4). The rate of acute heart failure (LLMICS, 21.3%; UMICs, 12.1%; HICs, 6.8%; P < 0.001), cardiogenic shock (LLMICS, 9.1%; UMICs, 3.2%; HICs, 2.1%; P < 0.001), and stroke/transient ischaemic attack (LLMICS: 2.5%; UMICs: 1.5%; HICs: 0.9%; P = 0.04) increased down the income classification economic gradient. Crude in-hospital and 30-day mortality were low (1.8% and 2.5%, respectively) but increased with declining country wealth (in-hospital mortality: LLMICS, 3.6%; UMICs: 2.8%; HICs: 1.0%; P < 0.001; 30 day mortality: LLMICs, 4.9%; UMICs, 3.9%; HICs, 1.5%; P < 0.001).
Figure 4.
In-hospital outcomes and 30 day mortality by country income classification. * indicates statistical significance (P < 0.05).
Discussion
This prospective international study of 2947 patients with NSTEMI presenting to 1 of 247 recruiting centres from 59 ESC member countries and affiliates provides novel and high resolution insights into variation in presentation, care, and early outcomes by World Bank country income classification. Our main finding is that patients admitted with NSTEMI in LLMICs, compared with patients in HICs, are younger, have fewer comorbidities, present with a more advanced manifestation of acute disease, and have worse early clinical outcomes. Furthermore, invasive coronary angiography was used less often for patients with NSTEMI in LLMICs than HICs. A cardiovascular health narrative is needed to address this inequity across international economic boundaries.
Disparities in NSTEMI care delivery and outcomes by country income classification are insufficiently characterized in the literature. Previous reports have provided comparisons between countries within the same income classification,9,11,13 or not stratified by economic prosperity even when including a wide representation of countries.12,14 The Global Burden of Disease Study and ESC cardiovascular disease statistics have demonstrated divergent burden of disability-adjusted life-years as a result of ischaemic heart disease by country wealth,8,25 but they do not specifically address NSTEMI or provide high resolution patient-level clinical data. The EORP Acute Coronary Syndrome (ACS) STEMI registry and EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) registries have delivered important insights on geographical variation in care delivery across ESC member countries, for ST-segment elevation myocardial infarction (STEMI) care and coronary artery disease primary and secondary prevention, respectively.26,27
Patients in LLMICs presented with NSTEMI a decade earlier and with fewer comorbidities than their counterparts in HICs. The earlier manifestation of NSTEMI in LLMICs compared with HICs is likely because key risk factors for development and acute presentation of ischaemic heart disease—such as smoking, blood pressure control, and air pollution—are significantly more burdensome.8 The adoption of western lifestyles has also contributed to an increasing burden of diabetes mellitus, such that 80% people who have diabetes mellitus live in low- and middle-income countries;28 and in our cohort almost half of the patients presenting with NSTEMI in LLMICs were diabetic. Furthermore low educational levels in low income countries have been found to be particularly correlated with adverse cardiovascular events, and this may be because medical care (e.g. management of hypertension, diabetes, and secondary prevention) is likely to be poorer in people with the lowest levels of education compared with those with higher levels of education in low-income countries.29 Comorbidity burden was higher in patients in HICs and this reflects the notion that additional life years constitute an additional risk for acquiring chronic conditions;30 that is, amongst ESC member countries and affiliates, premature death is more common and life expectancy shorter in low- and middle-income countries and so individuals may not have the chance to accumulate multiple conditions.8
Three-quarters of patients with NSTEMI in LLMICs were defined as very high-risk. Time from symptom onset to hospital admission varied substantially in LLMICs, but a quarter of patients had delays in excess of 45 h. Though we do not have data for the reason for delay, a previous systematic review has demonstrated that pre-hospital emergency services are underdeveloped in low- and middle-income countries, and that use of an ambulance can be cost-prohibitive for most patients who are required to pay out of pocket in countries that lack a national insurance programme.1 Thus many patients with acute myocardial infarction travel to hospital by public transport and private cars,31,32 which can be particularly disadvantageous in rural areas.33 Furthermore, lack of knowledge of symptoms consistent with myocardial ischaemia has been reported as a prominent reason for treatment delay,34 especially amongst older and illiterate patients.35
An invasive strategy was more likely to be employed for NSTEMI patients in more prosperous economies. Observational data has demonstrated that rates of coronary angiography and revascularization during index hospitalization are inversely related to mortality rates in patients admitted for NSTEMI at 28 days, 6 months and one year after comprehensive adjustment.11,14,36 Accordingly, interventional technologies have come to dominate cardiology practice for NSTEMI and this creates a financial burden on cardiovascular healthcare delivery.8 In middle income countries, compared with high income countries, the number of interventional cardiologists is lower by nearly a half and 24/7 catheter laboratory facilities lower by a third.8 The structural deficit affecting person power and facilities in less wealthy countries inevitably translates into the procedural deficit we observed.
We also observed underuse of cardiac rehabilitation, with only 36 and 40% of NSTEMI patients in UMICs and LLMICS, respectively, being referred. Though cardiac rehabilitation can reduce mortality, morbidity, and hospital re-admissions,37 it is only available in approximately one-quarter of low-to-middle income countries,38 and the costs of a typical supervised cardiac rehabilitation model employed in HICs are prohibitive in a low-income country setting.39 Conversely, provision of guideline-recommended pharmacological treatments on discharge was very high with >95% of patents with NSTEMI in LLMICs receiving dual antiplatelet therapy and statins. This shows that factors such as a skilled workforce,2 high levels of knowledge transfer from scientific studies to healthcare professionals,40 and greater uniformity of recommendations from guidelines of national and regional societies,13 can overcome economic conditions to achieve guideline-recommended care. The ACVC-EAPCI EORP STEMI registry also documented excellent provision of these medications in Europe and the Middle East,26 demonstrating the widespread acceptance of the importance of these pharmacological therapies for patients with an acute myocardial infarction.
Limitations
First, because of the observational nature of the data, the study design cannot show a causal relationship, but only an association between country wealth and differences in presentation, care, and outcomes for NSTEMI. Second, the minority of patients were from LLMICs. Third, a greater proportion of participating centres in LLMICs, compared with HICs, were specialty or teaching research hospitals (73% vs. 50%), had PCI capability (89.3% vs. 82.5%), and had cardiac surgery on site (71% vs. 51%) (Supplementary material online, Table S2); thus, the selected sites in LLMICs are not truly representative of all centres in those countries, and the disparities in interventional care by income classification may be wider than we report. Fourth, the majority of participants from HICs were Caucasian (91%), whereas only 43% of participants in LLMICs were Caucasian (with 39% Asian and 9% Black), so biological determinants may have influenced the adverse event rates we observed in different income classifications. Fifth, we assessed for variation by country income classification but did not additionally investigate for an effect of income inequality amongst a country's residents, which has been associated with worse cardiovascular outcomes.41,42 Sixth, the majority of patients included in the study were men, consequently the results cannot be automatically translated to women. Seventh, the representation of low-income countries within the LLMIC stratification was relatively small (Supplementary material online, Table S1), so the disparities in care and outcomes for NSTEMI in these countries may be greater than we observed. Eighth, despite its wide representation, this is not a global study as not all regions are included. Ninth, the number of outcomes was insufficient to allow adjustment of crude rates by baseline differences and confounders.
Actions to be taken
The findings of this registry imply further steps to be taken into consideration to achieve equity in NSTEMI outcomes across country income classification. All efforts should be made to increase the availability and use of coronary intervention for NSTEMI in LLMICs. An initiative could follow the example of the highly successful ‘Stent for Life’, which aimed to drive equal access to primary PCI across 19 countries in Europe, and coincided with increasing rates of primary PCI across ESC member states.26,43 Cardiac rehabilitation could also be made more widely available in LLMICs through the adaptation of models tailored to low resource settings.39 Policy strategies to reduce the population burden of ischaemic heart disease are required in LLMICs, where there is a trend towards widening disparities in the prevalence of key risk factors—such as smoking, blood pressure, and diabetes mellitus—compared with HICs.8 The European Association of Preventative Cardiology ‘Prevention in your country’ initiative provides a comprehensive resource of exemplar initiatives for risk factor modification.44 Both the ESC and the World Health Organization must continue to advocate to raise the priority accorded to prevention of disease, create health-promoting environments, and strengthen national capacity, leadership, and governance for disease prevention.8,45
Supplementary Material
Acknowledgements
The EORP Oversight Committee, Registry Executive and Steering Committees. The project management (study launch, data collection coordination, data management, and statistical analyses) was conducted by the EURObservational Research Programme (EORP), European Society of Cardiology, Sophia-Antipolis, France: Catherine Bosc and Carole Toulouse as Clinical Project Managers, Sylvie Chanoni and Emanuela Fiorucci as Project Officers; Gagan Chhabra and Sandrine Anglars as Data Managers, Cécile Laroche as Statistical Project Lead and Stateo as Consultant Statistician. Overall activities were coordinated and supervised by Doctor Aldo P. Maggioni (EORP Scientific Coordinator). Special thanks to the Acute Cardiovascular Care Association and the European Association of Percutaneous Cardiovascular Interventions (EAPCI).
Appendix—ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry Investigator Group
EORP Oversight Committee
2016–18 : A. Vahanian, FR (Chair): A. Budaj, PL: N. Dagres, DE: N. Danchin, FR: V. Delgado, NL: J. Emberson, GB: O. Friberg, SE: C.P. Gale, GB: G. Heyndrickx, BE: B. Iung, FR: S. James, SE: A.P. Kappetein, NL: A.P. Maggioni, IT: N. Maniadakis, GR: K.V. Nagy, HU: G. Parati, IT: A-S. Petronio, IT: M. Pietila, FI: E. Prescott, DK: F. Ruschitzka, CH: F. Van de Werf, BE: F. Weidinger, AT: U. Zeymer, DE. 2018–20: C.P. Gale, GB (Chair): B. Beleslin, RS: A. Budaj, PL: O. Chioncel, RO: N. Dagres, DE: N. Danchin, FR: J. Emberson, GB: D. Erlinge, SE: M. Glikson, IL: A. Gray, GB: M. Kayikcioglu, TR: A.P. Maggioni, IT: K.V. Nagy, HU: A. Nedoshivin, RU: A-P. Petronio, IT: J.W. Roos-Hesselink, NL: L. Wallentin, SE: U. Zeymer, DE. 2020–22: B.A. Popescu, RO (Chair): D. Adlam, GB: A.L.P. Caforio, IT: D. Capodanno, IT: M. Dweck, GB: D. Erlinge, SE: M. Glikson, IL: J. Hausleiter, DE: B. Iung, FR: M. Kayikcioglu, TR: P. Ludman, GB: L. Lund, SE: A.P. Maggioni, IT: S. Matskeplishvili, RU: B. Meder, DE: K.V. Nagy, HU: A. Nedoshivin, RU: D. Neglia, IT: A.A. Pasquet, BE: J.W. Roos-Hesselink, NL: F.J. Rossello, ES: S.M. Shaheen, EG: A. Torbica, IT.
Executive Committee
Christopher Peter Gale (Chair), Peter F Ludman (Chair), Maddalena Lettino, Hector Bueno, Kurt Huber, Sergio Leonardi, Andrzej Budaj, Dejan Milasinovic (Serbia), Salvatore Brugaletta, Yolande Appelman, Vijay Kunadian
National Coordinators
AE: Wael Abdul Rahman Al Mahmeed, AM: Hovhannes Kzhdryan, AR: Carlos Dumont, AT: Alexander Geppert, BA: Nirvana Sabanovic Bajramovic, BD: Fathima Aaysha Cader, BE: Christophe Beauloye, CR: Daniel Quesada, CZ: Ota Hlinomaz, DE: Christoph Liebetrau, EE: Toomas Marandi, EG: Khaled Shokry, ES: Héctor Bueno, FR: Jacques Mansourati, GB: Chris P Gale, GE: David Maisuradze, GR: Theodoros Sinanis, ID: Surya Dharma, IL: Katia Orvin, IN: Ajay Sinha, IQ: Hasan Ali Farhan, IR: Parham Sadeghipour, IS: Ingibjorg Gudmundsdottir, IT: Ciro Indolfi, JP: Takeshi Kitai, KG: Erkin Mirrakhimov, LT: Olivija Gustiene, LU: François Philippe, LV: Andrejs Erglis, MD: Mihail Popovici, MK: Oliver Kalpak, MN: Mungunchimeg Dagva, MT: Robert George Xuereb, MY: Wan Azman Wan Ahmad, NL: Yolande Appelman, OM: Sunil K. Nadar, PK: Nadeem Qamar, PL: Marek Gierlotka, PT: Silvia Monteiro, RO: Gheorghe-Andrei Dan, RS: Mina Radovanovic, RU: Elena Vladimirovna Reznik, SA: Mohammed Balghith, SD: Awad Mohamed, SI: Miha Cercek, SK: Denisa Brozmannová, TR: Vedat Aytekin, UG: Prossie Ingabire, UZ: Baxrom Alyavi.
Investigators
Argentina: La Plata: L. Cartasegna, V. Nomberto Gomez, C. Beltrano, V. Novas, Rosario: C. Dumont, H. Balparda, M. Cardona, C. Cigalini, V. Hoyle, Rosario: E. San Dámaso, V. Tapia, Armenia:Yerevan: K. Poghosyan, S. Mkhitaryan, M. Adamyan, S. Boyadjian, Yerevan: H. Hayrapetyan, K. Azaryan, M. Tadevosyan, H. Poghosyan, Yerevan: H. Kzhdryan, A. Vardanyan, Austria:Vienna: K. Huber, A. Geppert, A. Ahmed, Vienna: F. Weidinger, M. Derntl, M. Hasun, T. Schuh-Eiring, L. Riegler, Bangladesh:Dhaka: M.M. Haq, F.A. Cader, M.A-M. Dewan, M-E. Fatema, A.S. Hasan, M.M. Islam, F. Khandoker, R. Mayedah, S.U. Nizam, Dhaka: M.G. Azam, M.M. Arefin, J. Jahan, Belgium:Aalst: D. Schelfaut, H. De Raedt, S. Wouters, S. Aerts, H. Batjoens, Brussels: C. Beauloye, M. Dechamps, S. Pierard, O. Van Caenegem, F. Sinnaeve, Edegem: M.J. Claeys, M. Snepvangers, V. Somers, Gent: S. Gevaert, H. Schaubroek, P. Vervaet, M. Buysse, Kortrijk: F. Renders, M. Dumoulein, N. Hiltrop, M. De Coninck, S. Naessens, I. Senesael, Liege: E. Hoffer, S. Pourbaix, J. Beckers, C. Dugauquier, S. Jacquet, D. Malmendier, M. Massoz, Liege: P. Evrard, L. Collard, Mons: P. Brunner, S. Carlier, M. Blockmans, D. Mayne, E. Timiras, Yvoir: A. Guédès, F. Demeure, C. Hanet, J. Domange, K. Jourdan, Bosnia and Herzegovina:Sarajevo: E. Begic, F. Custovic, A. Dozic, E. Hrvat, I. Kurbasic, D. Mackic, A. Subo, Sarajevo: A. Durak-Nalbantic, A. Dzubur, D. Rebic, A. Hamzic-Mehmedbasic, A. Redzepovic, A. Djokic-Vejzovic, E. Hodzic, M. Hujdur, E. Musija, Z. Gljiva-Gogic, N. Serdarevic, Sarajevo: N. Sabanovic Bajramovic, L. Brigic, M. Halilcevic, M. Cibo, N. Hadžibegic, N. Kukavica, Sarajevo: A. Begic, A. Iglica, A. Osmanagic, N. Resic, M. Vucijak Grgurevic, F. Zvizdic, Zenica: B. Pojskic, E. Mujaric, H. Selimovic, M. Ejubovic, L. Pojskic, E. Stimjanin, M. Sut, Colombia:Medellin: P. Sanchez Zapata, C. Gallego Munoz, L.A. Fajardo Andrade, M.P. Tobon Upegui, L.E. Perez, Costa Rica:Heredia: J. Chavarria, D. Quesada, K. Alvarado, Croatia:Rijeka: L. Zaputovic, V. Tomulic, D. Gobic, T. Jakljevic, D. Lulic, G. Bacic, L. Bastiancic, Cyprus:Nicosia: P. Avraamides, C. Eftychiou, N. Eteocleous, A. Ioannou, C. Lambrianidi, M. Drakomathioulakis, Czech Republic:Brno: L. Groch, O. Hlinomaz, M. Rezek, J. Semenka, J. Sitar, M. Beranova, P. Kramarikova, Ceske Budejovice: L. Pesl, S. Sindelarova, F. Tousek, Egypt:Alexandria: H.M. Warda, I. Ghaly, S. Habiba, A. Habib, Aswan: M.N. Gergis, H. Bahaa, A. Samir, Cairo: H. Salah Eldin Taha, M. Adel, H. Mahrous Algamal, M. Mamdouh, Cairo: A. Foad Shaker, K. Shokry, A. Konsoah, A. Magdy Mostafa, A. Ibrahim, Cairo: A. Imam, B. Hafez, A. Zahran, Cairo: M. Abdelhamid, K. Mahmoud, A. Mostafa, A. Samir, M. Abdrabou, A. Kamal, S. Sallam, Minya: A. Ali, K. Maghraby, A. Radi Atta, Zagazig: A. Saad, M. Ali, Estonia:Tallinn: E-M. Lotman, R. Lubi, H. Kaljumäe, Tallinn: T. Uuetoa, U. Kiitam, France:Argenteuil: C. Durier, Auxerre: O. Ressencourt, A. Alaa El Din, A. Guiatni, M. Le Bras, E. Mougenot, Bayonne: J-N. Labeque, J-L. Banos, O. Capendeguy, Brest: J. Mansourati, A. Fofana, M. Augagneur, L. Bahon, A. Le Pape, Chambery: L. Batias-Moreau, A. Fluttaz, F. Good, F. Prieur, La Roche-Sur-Yon: E. Boiffard, A-S. Derien, I. Drapeau, N. Roy, Lyon: T. Perret, O. Dubreuil, S. Ranc, S. Rio, Marseille: J-L. Bonnet, G. Bonnet, T. Cuisset, P. Deharo, J-P. Mouret, J-C. Spychaj, A. Blondelon, Pau: N. Delarche, Pontoise: V. Decalf, N. Guillard, A. Hakme, M-P. Roger, Rennes: Y. Biron, P. Druelles, C. Loubeyre, A. Lucon, P. Hery, Saint Denis: M. Nejjari, F. Digne, Saint Nazaire: F. Huchet, Thonon-Les-Bains: A. Neykova, B. Tzvetkov, M. Larrieu, Toulon: G. Quaino, P. Armangau, Toulouse: A. Sauguet, L. Bonfils, N. Dumonteil, J. Fajadet, B. Farah, B. Honton, B. Monteil, R. Philippart, D. Tchetche, M. Cottin, F. Petit, A. Piquart, Vandoeuvre-Les-Nancy: B. Popovic, J. Varlot, Georgia:Tbilisi: D. Maisuradze, E. Sagirashvili, Tbilisi: Z. Kereselidze, L. Totladze, T. Ginturi, D. Lagvilava, Germany:Bad Nauheim: C. Hamm, C. Liebetrau, M. Haas, C. Hamm, T. Koerschgen, M. Weferling, J-S. Wolter, K. Maier, Bonn: G. Nickenig, A. Sedaghat, C. Zachoval, Greece:Athens: K. Lampropoulos, A. Mpatsouli, A. Sakellaropoulou, K. Tyrovolas, N. Zibounoumi, K. Argyropoulos, F. Toulgaridis, Athens: A. Kolyviras, G. Tzanis, V. Tzifos, Athens: A. Milkas, S. Papaioannou, K. Kyriazopoulos, Athens: V. Pylarinou, I. Kontonassakis, C. Kotakos, G. Kourgiannidis, P. Ntoliou, N. Parzakonis, A. Pipertzi, A. Sakalidis, C-L. Ververeli, Chania: K. Kafkala, T. Sinanis, G. Diakakis, K. Grammatikopoulos, E. Papoutsaki, T. Patialiatos, M. Mamaloukaki, S.T. Papadaki, Serres: I.E. Kanellos, A. Antoniou, G. Tsinopoulos, C. Goudis, M. Giannadaki, S. Daios, M. Petridou, P. Skantzis, P. Koukis, F. Dimitriadis, M. Savvidis, Thessaloniki: I. Styliadis, V. Sachpekidis, A. Pilalidou, N. Stamatiadis, A. Fotoglidis, A. Karakanas, Hungary:Budapest: Z. Ruzsa, D. Becker, F. Nowotta, Iceland:Reykjavík: I. Gudmundsdottir, B. Libungan, F. Bjork Skuladottir, H. Halldorsdottir, India:Bangalore: R. Shetty, S. Iyengar, C. Bs, S. G, S. Lakshmana, R. S, Patna: N. Tripathy, A. Sinha, B. Choudhary, A. Kumar, A. Kumar, R. Raj, R. Sagar Roy, Indonesia:Jakarta: S. Dharma, B.B. Siswanto, Iraq:Baghdad: H. Ali Farhan, I.F. Yaseen, Baghdad: M. Al-Zaidi, Z. Dakhil, Erbil: S. Amen, B. Rasool, Najaf: A. Rajeeb, K. Amber, H. Hameed Ali, Nasiriyah: T. Al-Kinani, M. Hashim Almyahi, F. Al-Obaidi, Islamic Republic of Iran:Isfahan: G. Masoumi, M. Sadeghi, K. Heshmat-Ghahdarijani, H. Roohafza, N. Sarrafzadegan, M. Shafeie, Z. Teimouri-Jervekani, F. Noori, Tehran: M. Kyavar, P. Sadeghipour, A. Firouzi, M.J. Alemzadeh-Ansari, B. Ghadrdoost, R. Golpira, A. Ghorbani, F. Ahangari, Tehran: M. Salarifar, Y. Jenab, A. Biria, S. Haghighi, P. Mansouri, S. Yadangi, Israel:Petah-Tikva: R. Kornowski, K. Orvin, A. Eisen, N. Oginetz, R. Vizel, H. Kfir, Italy:Bologna: G. Di Pasquale, G. Casella, L.S. Cardelli, E. Filippini, S. Zagnoni, Bolzano: L. Donazzan, D. Ermacora, Catanzaro: C. Indolfi, A. Polimeni, A. Curcio, A. Mongiardo, S. De Rosa, S. Sorrentino, C. Spaccarotella, Crema: M. Landolina, M. Marino, M. Cacucci, L. Vailati, Genoa: P. Bernabò, Monserrato: R. Montisci, L. Meloni, M.F. Marchetti, M. Biddau, E. Garau, Naples: E. Barbato, C. Morisco, T. Strisciuglio, G. Canciello, Nuoro: G. Lorenzoni, G. Casu, P. Merella, Palermo: G. Novo, A. D'Agostino, D. Di Lisi, A. Di Palermo, S. Evola, F. Immordino, L. Rossetto, G. Spica, Pordenone: D. Pavan, A. Della Mattia, R. Belfiore, U. Grandis, F. Vendrametto, C. Spagnolo, L. Carniel, E. Sonego, Rome: C. Gaudio, F. Barillà, F.G. Biccire, N. Bruno, I. Ferrari, V. Paravati, C. Torromeo, Salerno: G. Galasso, A. Peluso, C. Prota, I. Radano, R.M. Benvenga, D. Ferraioli, San Bonifacio: M. Anselmi, G.M. Frigo, Trieste: G. Sinagra, M. Merlo, A. Perkan, F. Ramani, A. Altinier, E. Fabris, Turin: M. Rinaldi, T. Usmiani, L. Checco, S. Frea, M. Mussida, Japan:Fukuoka: R. Matsukawa, Hidaka City: K. Sugi, Kobe: T. Kitai, Y. Furukawa, A. Masumoto, Y. Miyoshi, Shimotsugagun-Tochigi: S. Nishino, Kazakhstan:Almaty: B. Assembekov, B. Amirov, Y. Chernokurova, F. Ibragimova, Kyrgyzstan:Bishkek: E. Mirrakhimov, A. Ibraimova, T. Murataliev, Z. Radzhapova, E. Sultan Uulu, N. Zhanyshbekova, V. Zventsova, Latvia:Riga: A. Erglis, L. Bondare, Lithuania:Kaunas: R. Zaliunas, O. Gustiene, R. Dirsiene, J. Marcinkeviciene, G. Sakalyte, A. Virbickiene, G. Baksyte, L. Bardauskiene, R. Gelmaniene, A. Salkauskaite, G. Ziubryte, Siauliai: N. Kupstyte-Kristapone, Vilnius: J. Badariene, S. Balciute, L. Kapleriene, M. Lizaitis, J. Marinskiene, A. Navickaite, A. Pilkiene, D. Ramanauskaite, R. Serpytis, D. Silinskiene, T. Simbelyte, J. Staigyte, Luxembourg:Luxembourg: F. Philippe, P. Degrell, E. Camus, Malaysia:Kuala Lumpur: W.A. Wan Ahmad, Z. Abu Kassim, Malta:Msida: R.G. Xuereb, L-L. Buttigieg, W. Camilleri, E. Pllaha, S. Xuereb, Moldova, Republic Of:Chisinau: M. Popovici, V. Ivanov, A. Plugaru, V. Moscalu, I. Popovici, M. Abras, L. Ciobanu, N. Litvinenco, S. Fuior, C. Dumanschi, M. Ivanov, T. Danila, Chisinau: L. Grib, S. Filimon, L. Cardaniuc, Chisinau: A. Batrinac, M. Tasnic, C. Cozma, V. Revenco, Chisinau: G. Sorici, Mongolia:Ulaanbaatar: M. Dagva, G. Choijiljav, E. Dandar, M-U. Khurelbaatar, B. Tsognemekh, Netherlands:Amsterdam: Y. Appelman, A. Den Hartog, H. Jan Te Kolste, D. Van Den Buijs, Heerlen: A. Van'T Hof, T. Pustjens, V. Houben, I. Kasperski, Nieuwegein: J. Ten Berg, J. Azzahhafi, W. Bor, D. Chan Pin Yin, Nigeria:Lagos: A. Mbakwem, C. Amadi, O. Kushimo, M. Kilasho, E. Oronsaye, North Macedonia:Ohrid: N. Bakracheski, E. Kovacheska Bashuroska, V. Mojsovska, S. Tupare, M. Dejan, J. Jovanoska, D. Razmoski, T. Marinoski, Skopje: A. Antovski, Z. Jovanovski, S. Kocho, R. Markovski, V. Ristovski, A.B. Samir, S. Biserka, Skopje: O. Kalpak, I. Mitevska Peovska, B. Zafirovska Taleska, H. Pejkov, O. Busljetik, Z. Zimbakov, E. Grueva, I. Bojovski, M. Tutic, Skopje: L. Poposka, M. Vavlukis, Oman:Muscat: A. Al-Riyami, S.K. Nadar, W. Abdelmottaleb, S. Ahmed, M. Shaikh Mujtaba, S. Al-Mashari, H. Al-Riyami, Pakistan:Karachi: A.H. Laghari, O. Faheem, S. Waqar Ahmed, Karachi: N. Qamar, S. Furnaz, K. Kazmi, T. Saghir, A. Aneel, A. Asim, F. Madiha, Poland:Bialystok: B. Sobkowicz, A. Tycinska, E. Kazimierczyk, A. Szyszkowska, Katowice: K. Mizia-Stec, M. Wybraniec, A. Bednarek, K. Glowacki, Kedzierzyn-Kozle: J. Prokopczuk, W. Babinski, A. Blachut, M. Kosiak, A. Kusinska, S. Samborski, J. Stachura, H. Szastok, A. Wester, D. Bartoszewska, Kielce: B. Sosnowska-Pasiarska, M. Krzysiek, Krakow: J. Legutko, B. Nawrotek, Lodz: J.D. Kasprzak, M. Klosinska, K. Wiklo, Lodz: M. Kurpesa, T. Rechcinski, U. Cieslik-Guerra, Opole: M. Gierlotka, J. Bugajski, P. Feusette, J. Sacha, P. Przybylo, Warsaw: P. Krzesinski, R. Ryczek, A. Karasek, A. Kazmierczak-Dziuk, M. Mielniczuk, K. Betkier-Lipinska, Warsaw: M. Roik, A. Labyk, M. Krakowian, M. Machowski, M. Paczynska, M. Potepa, P. Pruszczyk, Warsaw: A. Budaj, M. Ambroziak, E. Omelanczuk-Wiech, A. Torun, Warsaw: G. Opolski, R. Glowczynska, A. Fojt, R. Kowalik, Warsaw: Z. Huczek, S. Jedrzejczyk, Wroclaw: T. Roleder, K. Brust, Zabrze: M. Gasior, P. Desperak, M. Hawranek, Portugal:Amadora: P. Farto-Abreu, M. Santos, S. Baptista, L. Brizida, D. Faria, J. Loureiro, P. Magno, C. Monteiro, M. Nédio, Barreiro: J. Tavares, C. Sousa, I. Almeida, S. Almeida, H. Miranda, H. Santos, A.P. Santos, Coimbra: L. Goncalves, S. Monteiro, R. Baptista, C. Ferreira, J. Ferreira, F. Goncalves, C. Lourenço, P. Monteiro, Evora: B. Picarra, A.R. Santos, R. Azevedo Guerreiro, M. Carias, M. Carrington, J. Pais, M. Paralta de Figueiredo, A.R. Rocha, Faro: J. Mimoso, I. De Jesus, R. Fernandes, J. Guedes, T. Mota, Lisbon: M. Mendes, J. Ferreira, A. Tralhão, C. Tavares Aguiar, C. Strong, F. Fernandes Da Gama, G. Pais, Lisbon: A.T. Timóteo, S. Aguiar Oliveira Rosa, T. Mano, J. Reis, M. Selas, Loures: D. Espregueira Mendes, M. Satendra, Penafield: P. Pinto, C. Queirós, I. Oliveira, L. Reis, I. Cruz, R. Fernandes, Porto: S. Torres, A. Luz, A. Campinas, R. Costa, A. Frias, M. Oliveira, Santarem: V. Martins, B. Castilho, C. Coelho, A.R. Moura, N. Cotrim, Vila Franca de Xira: R. Carvalheira Dos Santos, P. Custodio, R. Duarte, R. Gomes, F. Matias, C. Mendonca, J. Neiva, C. Rabacal, A. Rocha Almeida, Vila Nova de Gaia: D. Caeiro, P. Queiroz, G. Silva, Romania:Arad: A.L. Pop-Moldovan, D. Darabantiu, S. Mercea, Bucharest: G-A. Dan, A-R. Dan, M. Dobranici, R.A. Popescu, C. Adam, Bucharest: C-J. Sinescu, C-L. Andrei, R. Brezeanu, N. Samoila, Bucharest: M.M. Baluta, Cluj-Napoca: D. Pop, R. Tomoaia, Craiova: O. Istratoaie, I. Donoiu, A. Cojocaru, O.C. Oprita, A. Rocsoreanu, Iasi: M. Grecu, S. Ailoaei, Oradea: M. Ioachim Popescu, A. Cozma, E. Emilia Babes, M. Rus, A. Ardelean, R. Larisa, M. Moisi, E. Ban, A. Buzle, G. Filimon, Targu-Mures: D. Dobreanu, S. Lupu, A. Mitre, R. Rudzik, I. Sus, D. Opris, C. Somkereki, Timisoara: C. Mornos, L. Petrescu, A. Betiu, A. Volcescu, O. Ioan, C. Luca, D. Maximov, S. Mosteoru, L. Pascalau, C. Roman, D. Brie, S. Crisan, C. Erimescu, L. Falnita, D. Gaita, M. Gheorghiu, Russian Federation:Chelyabinsk: S. Levashov, M. Redkina, Kaluga: N. Novitskii, E. Dementiev, A. Baglikov, Moscow: D. Zateyshchikov, E. Zubova, A. Rogozhina, Moscow: A. Salikov, I. Nikitin, E.V. Reznik, M.S. Komissarova, M. Shebzukhova, K. Shitaya, S. Stolbova, Moscow: V. Larina, F. Akhmatova, G. Chuvarayan, Moscow: M.N. Arefyev, O.V. Averkov, A.L. Volkova, M.S. Sepkhanyan, V.I. Vecherko, Moscow: I. Meray, L. Babaeva, L. Goreva, A. Pisaryuk, P. Potapov, M. Teterina, Moscow: F. Ageev, G. Silvestrova, Moscow: Y. Fedulaev, T. Pinchuk, Moscow: I. Staroverov, D. Kalimullin, T. Sukhinina, N. Zhukova, Tomsk: V. Ryabov, E. Kruchinkina, D. Vorobeva, Voronezh: I. Shevchenko, V. Budyak, O. Elistratova, E. Fetisova, R. Islamov, E. Ponomareva, Saudi Arabia:Hail: H. Khalaf, A. Al Shaimaa, W. Kamal, Jeddah: J. Alrahimi, A. Elshiekh, Riyadh: M. Balghith, A. Ahmed, N. Attia, A.A. Jamiel, Serbia:Belgrade: T. Potpara, M. Marinkovic, M. Mihajlovic, N. Mujovic, A. Kocijancic, Z. Mijatovic, Belgrade: M. Radovanovic, D. Matic, A. Milosevic, L. Savic, I. Subotic, A. Uscumlic, N. Zlatic, J. Antonijevic, O. Vesic, Kragujevac: R. Vucic, Nis: S. Salinger Martinovic, T. Kostic, V. Atanaskovic, V. Mitic, D. Stanojevic, Sremska Kamenica: M. Petrovic, M. Kovacevic, B. Crnomarkovic, M. Cankovic, D. Dabovic, M. Jarakovic, T. Pantic, M. Trajkovic, L. Pupic, Valjevo: D. Ruzicic, D. Cvetanovic, I. Obradovic, M. Stankovic, Singapore:Singapore: P.H. Loh, W. Kong, K-K. Poh, C-H. Sia, K. Saw, Slovakia:Bratislava: D. Liška, D. Brozmannová, Kosice: M. Gbur, R. Maxian, Slovenia:Celje: D. Kovacic, N. Glavnik Poznic, T. Keric, G. Kotnik, Ljubljana: M. Cercek, K. Steblovnik, M. Sustersic, A. Cerne Cercek, I. Djokic, B. Drnovsek, L. Lipar, M. Mocilnik, A. Pleskovic, Murska Sobota: M. Lainscak, D. Crncic, I. Nikojajevic, M. Tibaut, M. Cigut, Trbovlje: B. Leskovar, T. Furlan, V. Grilj, M. Rezun, Spain:Alcazar de San Juan: V. Martinez Mateo, M.J. Fernandez Anguita, Aviles: I.C. Möller Bustinza, R. Bangueses Quintana, O.C. Fernandez Cimadevilla, J. Fuertes, F. Lopez, M.D. Martin, L. Martinez, Barcelona: J.A. Barrabes, J. Bañeras, Y. Belahnech, I. Ferreira-Gonzalez, P. Jordan, R-M. Lidon, L. Mila, A. Sambola, Barcelona: A. Sionis, W. Bragagnini, A. Duran Cambra, C. Simon, M. Vidal Burdeus, Barcelona: A. Ariza-Solé, O. Alegre, M. Alsina, J.I. Llao Ferrando, Barcelona: X. Bosch, P. Vidal, M. Izquierdo, El Palmar: F. Marin, M.A. Esteve-Pastor, A. Tello-Montoliu, C. Lopez-Garcia, J.M. Rivera-Caravaca, P. Gil-Pérez, Lorca: S. Nicolas-Franco, I. Keituqwa, Madrid: L. Silva, A. Blasco, J.M. Escudier, J. Ortega, Madrid: J.L. Zamorano, M. Sanmartin, D. Cordero Pereda, L.M. Rincon, P. Gonzalez, T. Casado, Madrid: J.L. Lopez-Sendon, A.M. Iniesta Manjavacas, L.A. Martinez Marin, L. Rodriguez Sotelo, S.O. Rosillo Rodriguez, Madrid: H. Bueno, R. Martin, R. Maruri, G. Moreno, Oviedo: C. Moris, P. Avanzas, A. Ayesta, A. Junco-Vicente, H. Cubero-Gallego, I. Pascual, Pamplona: N. Basterra Sola, O. Alcalde Rodriguez, L. Malagon, J. Martinez-Basterra, A. Munarriz Arizcuren, J. Romero, A. Gainza Calleja, Puertollano: D. García Fuertes, M. Crespín Crespín, F.J. Castillo Bernal, San Cristobal de La Laguna, Islas Canarias: F. Bosa Ojeda, A. Lara Padron, M. Martin Cabeza, C. Mendez Vargas, G. Yanes, M.J. Garcia Gonzalez, J. Gonzalez Gonzalez, P. Jorge, B. De La Fuente, Sant Joan Despi: M. Garcia Bermúdez, C.M. Bianchi Perez-Lopez, A. Bonet Basiero, A. Carol Ruiz, R. Freixa Pamias, P. Sanchez Chamero, Sevilla: R. Hidalgo-Urbano, J.C. Garcia-Rubira, T. Seoane-Garcia, D.F. Arroyo-Monino, Tarragona: A. Bardají Ruiz, E. Sanz-Girgas, G. Bonet, J. Rodríguez-López, C. Scardino, D. De Sousa, Sudan:Khartoum: E. Elbasheer, A. Humida, H. Mahmoud, Khartoum: A. Mohamed, E. Hamid, S. Hussein, Khartoum: M. Abdelhameed, T. Ali, Y. Ali, M. Eltayeb, Medani: M. Ali, E. Almubarak, Omdurman: M. Badri, S. Altaher, M. Dafa Alla, Sweden:Goteborg: M. Dellborg, H. Dellborg, G. Hultsberg-Olsson, Syrian Arab Republic:Damascus: Y. Bani Marjeh, A. Abdin, F. Alhussein, F. Mgazeel, Tunisia:Sfax: R. Hammami, L. Abid, A. Bahloul, S. Charfeddine, T. Ellouze, Turkey:Ankara: U. Canpolat, M. Oksul, Ankara: H. Muderrisoglu, E. Karacaglar, A. Akgun, Bursa: H. Ari, S. Ari, V. Can, B. Tuncay, Diyarbakir: H. Kaya, L. Dursun, Elazig: K. Kalenderoglu, O. Tasar, Gaziantep: S. Kilic, M. Kucukosmanoglu, Istanbul: V. Aytekin, O. Baydar, Y. Demirci, E. Gürsoy, A. Kilic, Ö. Yildiz, Istanbul: A. Arat-Ozkan, U.Y. Sinan, Istanbul: B. Gungor, S. Sert Sekerci, G. Zeren, Istanbul: M. Erturk, A.R. Demir, C. Yildirim, C. Can, Izmir: M. Kayikcioglu, B. Yagmur, S. Oney, Kirikkale: C. Sabanoglu, I.H. Inanc, Konya: M. Ziyrek, Kutahya: T. Sen, M.A. Astarcioglu, F. Kahraman, O. Utku, Mersin: A. Celik, A.O. Surmeli, Mugla: O. Basaran, Sanliurfa: R. Demirbag, F. Besli, F. Gungoren, Uganda:Kampala: P. Ingabire, C. Mondo, S. Ssemanda, T. Semu, United Arab Emirates:Abu Dhabi: A. Al Mulla, J.S. Atos, I. Wajid, Abu Dhabi: W.A.R. Al Mahmeed, B. Atallah, K. Bakr, R. Garrod, F. Makia, Dubai: F. Eldeeb, R. Abdekader, A. Gomaa, S. Kandasamy, R. Maruthanayagam, G. Nakad, R. Nair, United Kingdom:Ashford: P. Mota, P. Prior, S. Mcdonald, J. Rand, N. Schumacher, Ashton Under Lyne: A. Abraheem, M. Clark, M. Coulding, V. Turner, Barnsley: A.Q. Negahban, A. Crew, S. Hope, J. Howson, S. Jones, N. Lancaster, A. Nicholson, G. Wray, Belfast: P. Donnelly, L. Hammond, S. Hammond, S. Regan, Birmingham: R. Watkin, C. Papadopoulos, Birmingham: P. Ludman, K. Hutton, S. Macdonald, A. Nilsson, S. Roberts, Blackburn: S. Garg, K. Balachandran, J. Mcdonald, R. Singh, K. Marsden, K. Davies, H. Desai, W. Goddard, N. Iqbal, Blackpool: S. Chalil, G. Galasko, O. Assaf, L. Benham, J. Brown, S. Collins, C. Fleming, J. Glen, M. Mitchell, S. Preston, A. Uttley, Bradford: S. Lindsay, N. Akhtar, C. Atkinson, M. Vinod, A. Wilson, Buckinghamshire: P. Clifford, S. Firoozan, M. Yashoman, N. Bowers, J. Chaplin, S. Harvey, M. Kononen, G. Lopesdesousa, F. Saraiva, Chertsey, Surrey: S. Sharma, E. Cruddas, J. Law, E. Young, Cottingham: A. Hoye, P. Harper, K. Rowe, Coventry: M. Been, H. Cummins, E. French, C. Gibson, Durham: J.A. Abraham, S. Hobson, A. Kay, M. Kent, A. Wilkinson, S. Clark, L. Duncan, Fulwood: I.M. Ahmed, D. Khatiwada, A. Mccarrick, I. Wanda, Ipswich: P. Read, A. Afsar, V. Rivers, T. Theobald, S. Bell, C. Buckman, R. Francis, G. Peters, Liverpool: R. Stables, M. Morgan, M. Noorzadeh, B. Taylor, S. Twiss, P. Widdows, V. Wilkinson, M. Black, A. Clark, N. Clarkson, J. Currie, L. George, C. Mcgee, Llanelli: L. Izzat, T. Lewis, Z. Omar, S. Phillips, Manchester: F. Ahmed, S. Mackie, A. Oommen, H. Phillips, M. Sherwood, S. Aleti, T. Charles, M. Jose, L. Kolakaluri, Margate: R. Al Karoudi, J. Deery, T. Hazelton, A. Knight, C. Price, S. Turney, Milton Keynes: A. Kardos, F. Williams, L. Wren, G. Bega, D. Scaletta, Newscastle Upon Tyne: V. Kunadian, K. Cullen, S. Jones, E. Kirkup, North Shields: D.P. Ripley, I.G. Matthews, A. Mcleod, C. Runnett, H.E. Thomas, Nottingham: A. Gunarathne, J. Burton, R. King, J. Quinn, Oldham, Greater Manchester, Lancs: J. Sobolewska, S. Munt, Peterborough: J. Porter, V. Christenssen, K. Leng, T. Peachey, N. Temple, K. Wells, Plymouth: G. Viswanathan, A. Taneja, E. Cann, C. Eglinton, B. Hyams, E. Jones, F. Reed, J. Smith, D-C. Affleck, A. Turner, T. Ward, N. Wilmshurst, Reading: J. Stirrup, M. Brunton, A. Whyte, Rotherham: S. Smith, V. Murray, R. Walker, C. Weston, C. Brown, D. Collier, K. Curtis, K. Dixon, Salisbury: T. Wells, F. Trim, Scarborough, East Yorkshire: J. Ghosh, M. Mavuri, L. Barman, K. Elliott, R. Harrison, J. Mallinson, T. Neale, J. Smith, J. Toohie, A. Turnbull, Scunthorpe: E. Parker, R. Hossain, M. Cheeseman, J. Hill, M. Hood, D. Hutchinson, K. Mellows, C. Pendlebury, Sheffield: R.F. Storey, J. Barker, K. Birchall, H. Denney, K. Housley, J. Middle, Stevenage: N. Kukreja, S. Gati, P. Kirk, M. Lynch, M. Srinivasan, J. Szygula, P. Baker, C. Cruz, J. Derigay, K. Lamb, S. Nembhard, A. Price, Stoke-On-Trent: M. Mamas, I. Massey, J. Wain, J. Delaney, Sunderland, Tyne and Wear: S. Junejo, K. Martin, Swansea, Wales: D. Obaid, E. Brinkworth, C. Davies, D. Evans, S. Richards, C. Thomas, M. Williams, Taunton: M. Dayer, H. Mills, K. Roberts, F. Goodchild, N. Greig, Telford: S. Kundu, D. Donaldson, L. Tonks, M. Beekes, H. Button, F. Hurford, N. Motherwell, J. Summers-Wall, Torquay: D. Felmeden, P. Keeling, U. Sheikh, A. Yonis, L. Felmeden, D. Hughes, L. Micklewright, A. Summerhayes, J. Sutton, Uxbridge: V. Panoulas, C. Prendergast, P. Rogers, L.N. Barker, Wakefield: P. Batin, D. Conway, D. Exley, A. Fletcher, J. Wright, Westcliff-On-Sea: T. Nageh, B. Hadebe, S. Kunhunny, E. Mshengu, Wigan: V.J. Karthikeyan, H. Hamdan, J. Cooper, C. Dandy, V. Parkinson, P. Paterson, S. Reddington, T. Taylor, C. Tierney, K. Vandesnepscheut Jones, Yeovil: A. Broadley, K. Beesley, C. Buckley, C. Hellyer, L. Pippard, T. Pitt-Kerby, York: J. Azam, C. Hayes, K. Freshwater, L. Johnson, Y. Mcgill, H. Redfearn, M. Russell, Uzbekistan:Tashkent: A. Alyavi, B. Alyavi, J. Uzokov.
Contributor Information
Ramesh Nadarajah, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, LS2 3AA, Leeds, UK; Leeds Institute of Data Analytics, University of Leeds, LS2 9NL, Leeds, UK; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
Peter Ludman, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
Cécile Laroche, EURObservational Research Programme, European Society of Cardiology, European Heart House, Route des Colles, Sophia Antipolis, 2035, France.
Yolande Appelman, Department of Cardiology, Amsterdam UMC-Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
Salvatore Brugaletta, Hospital Clinic de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
Andrzej Budaj, Department of Cardiology, Center of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland.
Hector Bueno, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
Kurt Huber, 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria.
Vijay Kunadian, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK; Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.
Sergio Leonardi, University of Pavia, Pavia, Italy; Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy.
Maddalena Lettino, Cardio-Thoracic and Vascular Department, San Gerardo Hospital, ASST-Monza, Monza, Italy.
Dejan Milasinovic, Department of Cardiology, University Clinical Center of Serbia and Faculty of Medicine, University of Begrade, Belgrade, Serbia.
Chris P Gale, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, LS2 3AA, Leeds, UK; Leeds Institute of Data Analytics, University of Leeds, LS2 9NL, Leeds, UK; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
the NSTEMI investigator group:
A Vahanian, A Budaj, N Dagres, N Danchin, V Delgado, J Emberson, O Friberg, C P Gale, G Heyndrickx, B Iung, S James, A P Kappetein, A P Maggioni, N Maniadakis, K V Nagy, G Parati, A-S Petronio, M Pietila, E Prescott, F Ruschitzka, F Van de Werf, F Weidinger, U Zeymer, C P Gale, B Beleslin, A Budaj, O Chioncel, N Dagres, N Danchin, J Emberson, D Erlinge, M Glikson, A Gray, M Kayikcioglu, A P Maggioni, K V Nagy, A Nedoshivin, A-P Petronio, J W Roos-Hesselink, L Wallentin, U Zeymer, B A Popescu, D Adlam, A L P Caforio, D Capodanno, M Dweck, D Erlinge, M Glikson, J Hausleiter, B Iung, M Kayikcioglu, P Ludman, L Lund, A P Maggioni, S Matskeplishvili, B Meder, K V Nagy, A Nedoshivin, D Neglia, A A Pasquet, J W Roos-Hesselink, F J Rossello, S M Shaheen, A Torbica, Christopher Peter Gale, Peter F Ludman, Maddalena Lettino, Hector Bueno, Kurt Huber, Sergio Leonardi, Andrzej Budaj, Dejan Milasinovic, Salvatore Brugaletta, Yolande Appelman, Vijay Kunadian, Wael Abdul Rahman Al Mahmeed, Hovhannes Kzhdryan, Carlos Dumont, Alexander Geppert, Nirvana Sabanovic Bajramovic, Fathima Aaysha Cader, Christophe Beauloye, Daniel Quesada, Ota Hlinomaz, Christoph Liebetrau, Toomas Marandi, Khaled Shokry, Héctor Bueno, Jacques Mansourati, Chris P Gale, David Maisuradze, Theodoros Sinanis, Surya Dharma, Katia Orvin, Ajay Sinha, Hasan Ali Farhan, Parham Sadeghipour, Ingibjorg Gudmundsdottir, Ciro Indolfi, Takeshi Kitai, Erkin Mirrakhimov, Olivija Gustiene, François Philippe, Andrejs Erglis, Mihail Popovici, Oliver Kalpak, Mungunchimeg Dagva, Robert George Xuereb, Wan Azman Wan Ahmad, Yolande Appelman, Sunil K Nadar, Nadeem Qamar, Marek Gierlotka, Silvia Monteiro, Gheorghe-Andrei Dan, Mina Radovanovic, Elena Vladimirovna Reznik, Mohammed Balghith, Awad Mohamed, Miha Cercek, Denisa Brozmannová, Vedat Aytekin, Prossie Ingabire, Baxrom Alyavi, L Cartasegna, V Nomberto Gomez, C Beltrano, V Novas, C Dumont, H Balparda, M Cardona, C Cigalini, V Hoyle, E San Dámaso, V Tapia, K Poghosyan, S Mkhitaryan, M Adamyan, S Boyadjian, H Hayrapetyan, K Azaryan, M Tadevosyan, H Poghosyan, H Kzhdryan, A Vardanyan, K Huber, A Geppert, A Ahmed, F Weidinger, M Derntl, M Hasun, T Schuh-Eiring, L Riegler, M M Haq, F A Cader, M A-M Dewan, M-E Fatema, A S Hasan, M M Islam, F Khandoker, R Mayedah, S U Nizam, M G Azam, M M Arefin, J Jahan, D Schelfaut, H De Raedt, S Wouters, S Aerts, H Batjoens, C Beauloye, M Dechamps, S Pierard, O Van Caenegem, F Sinnaeve, M J Claeys, M Snepvangers, V Somers, S Gevaert, H Schaubroek, P Vervaet, M Buysse, F Renders, M Dumoulein, N Hiltrop, M De Coninck, S Naessens, I Senesael, E Hoffer, S Pourbaix, J Beckers, C Dugauquier, S Jacquet, D Malmendier, M Massoz, P Evrard, L Collard, P Brunner, S Carlier, M Blockmans, D Mayne, E Timiras, A Guédès, F Demeure, C Hanet, J Domange, K Jourdan, E Begic, F Custovic, A Dozic, E Hrvat, I Kurbasic, D Mackic, A Subo, A Durak-Nalbantic, A Dzubur, D Rebic, A Hamzic-Mehmedbasic, A Redzepovic, A Djokic-Vejzovic, E Hodzic, M Hujdur, E Musija, Z Gljiva-Gogic, N Serdarevic, N Sabanovic Bajramovic, L Brigic, M Halilcevic, M Cibo, N Hadžibegic, N Kukavica, A Begic, A Iglica, A Osmanagic, N Resic, M Vucijak Grgurevic, F Zvizdic, B Pojskic, E Mujaric, H Selimovic, M Ejubovic, L Pojskic, E Stimjanin, M Sut, P Sanchez Zapata, C Gallego Munoz, L A Fajardo Andrade, M P Tobon Upegui, L E Perez, J Chavarria, D Quesada, K Alvarado, L Zaputovic, V Tomulic, D Gobic, T Jakljevic, D Lulic, G Bacic, L Bastiancic, P Avraamides, C Eftychiou, N Eteocleous, A Ioannou, C Lambrianidi, M Drakomathioulakis, L Groch, O Hlinomaz, M Rezek, J Semenka, J Sitar, M Beranova, P Kramarikova, L Pesl, S Sindelarova, F Tousek, H M Warda, I Ghaly, S Habiba, A Habib, M N Gergis, H Bahaa, A Samir, H Salah Eldin Taha, M Adel, H Mahrous Algamal, M Mamdouh, A Foad Shaker, K Shokry, A Konsoah, A Magdy Mostafa, A Ibrahim, A Imam, B Hafez, A Zahran, M Abdelhamid, K Mahmoud, A Mostafa, A Samir, M Abdrabou, A Kamal, S Sallam, A Ali, K Maghraby, A Radi Atta, A Saad, M Ali, E-M Lotman, R Lubi, H Kaljumäe, T Uuetoa, U Kiitam, C Durier, O Ressencourt, A Alaa El Din, A Guiatni, M Le Bras, E Mougenot, J-N Labeque, J-L Banos, O Capendeguy, J Mansourati, A Fofana, M Augagneur, L Bahon, A Le Pape, L Batias-Moreau, A Fluttaz, F Good, F Prieur, E Boiffard, A-S Derien, I Drapeau, N Roy, T Perret, O Dubreuil, S Ranc, S Rio, J-L Bonnet, G Bonnet, T Cuisset, P Deharo, J-P Mouret, J-C Spychaj, A Blondelon, N Delarche, V Decalf, N Guillard, A Hakme, M-P Roger, Y Biron, P Druelles, C Loubeyre, A Lucon, P Hery, M Nejjari, F Digne, F Huchet, A Neykova, B Tzvetkov, M Larrieu, G Quaino, P Armangau, A Sauguet, L Bonfils, N Dumonteil, J Fajadet, B Farah, B Honton, B Monteil, R Philippart, D Tchetche, M Cottin, F Petit, A Piquart, B Popovic, J Varlot, D Maisuradze, E Sagirashvili, Z Kereselidze, L Totladze, T Ginturi, D Lagvilava, C Hamm, C Liebetrau, M Haas, C Hamm, T Koerschgen, M Weferling, J-S Wolter, K Maier, G Nickenig, A Sedaghat, C Zachoval, K Lampropoulos, A Mpatsouli, A Sakellaropoulou, K Tyrovolas, N Zibounoumi, K Argyropoulos, F Toulgaridis, A Kolyviras, G Tzanis, V Tzifos, A Milkas, S Papaioannou, K Kyriazopoulos, V Pylarinou, I Kontonassakis, C Kotakos, G Kourgiannidis, P Ntoliou, N Parzakonis, A Pipertzi, A Sakalidis, C-L Ververeli, K Kafkala, T Sinanis, G Diakakis, K Grammatikopoulos, E Papoutsaki, T Patialiatos, M Mamaloukaki, S T Papadaki, I E Kanellos, A Antoniou, G Tsinopoulos, C Goudis, M Giannadaki, S Daios, M Petridou, P Skantzis, P Koukis, F Dimitriadis, M Savvidis, I Styliadis, V Sachpekidis, A Pilalidou, N Stamatiadis, A Fotoglidis, A Karakanas, Z Ruzsa, D Becker, F Nowotta, I Gudmundsdottir, B Libungan, F Bjork Skuladottir, H Halldorsdottir, R Shetty, S Iyengar, C Bs, S G, S Lakshmana, R S, N Tripathy, A Sinha, B Choudhary, A Kumar, A Kumar, R Raj, R Sagar Roy, S Dharma, B B Siswanto, H Ali Farhan, I F Yaseen, M Al-Zaidi, Z Dakhil, S Amen, B Rasool, A Rajeeb, K Amber, H Hameed Ali, T Al-Kinani, M Hashim Almyahi, F Al-Obaidi, G Masoumi, M Sadeghi, K Heshmat-Ghahdarijani, H Roohafza, N Sarrafzadegan, M Shafeie, Z Teimouri-Jervekani, F Noori, M Kyavar, P Sadeghipour, A Firouzi, M J Alemzadeh-Ansari, B Ghadrdoost, R Golpira, A Ghorbani, F Ahangari, M Salarifar, Y Jenab, A Biria, S Haghighi, P Mansouri, S Yadangi, R Kornowski, K Orvin, A Eisen, N Oginetz, R Vizel, H Kfir, G Di Pasquale, G Casella, L S Cardelli, E Filippini, S Zagnoni, L Donazzan, D Ermacora, C Indolfi, A Polimeni, A Curcio, A Mongiardo, S De Rosa, S Sorrentino, C Spaccarotella, M Landolina, M Marino, M Cacucci, L Vailati, P Bernabò, R Montisci, L Meloni, M F Marchetti, M Biddau, E Garau, E Barbato, C Morisco, T Strisciuglio, G Canciello, G Lorenzoni, G Casu, P Merella, G Novo, A D'Agostino, D Di Lisi, A Di Palermo, S Evola, F Immordino, L Rossetto, G Spica, D Pavan, A Della Mattia, R Belfiore, U Grandis, F Vendrametto, C Spagnolo, L Carniel, E Sonego, C Gaudio, F Barillà, F G Biccire, N Bruno, I Ferrari, V Paravati, C Torromeo, G Galasso, A Peluso, C Prota, I Radano, R M Benvenga, D Ferraioli, M Anselmi, G M Frigo, G Sinagra, M Merlo, A Perkan, F Ramani, A Altinier, E Fabris, M Rinaldi, T Usmiani, L Checco, S Frea, M Mussida, R Matsukawa, K Sugi, T Kitai, Y Furukawa, A Masumoto, Y Miyoshi, S Nishino, B Assembekov, B Amirov, Y Chernokurova, F Ibragimova, E Mirrakhimov, A Ibraimova, T Murataliev, Z Radzhapova, E Sultan Uulu, N Zhanyshbekova, V Zventsova, A Erglis, L Bondare, R Zaliunas, O Gustiene, R Dirsiene, J Marcinkeviciene, G Sakalyte, A Virbickiene, G Baksyte, L Bardauskiene, R Gelmaniene, A Salkauskaite, G Ziubryte, N Kupstyte-Kristapone, J Badariene, S Balciute, L Kapleriene, M Lizaitis, J Marinskiene, A Navickaite, A Pilkiene, D Ramanauskaite, R Serpytis, D Silinskiene, T Simbelyte, J Staigyte, F Philippe, P Degrell, E Camus, W A Wan Ahmad, Z Abu Kassim, R G Xuereb, L-L Buttigieg, W Camilleri, E Pllaha, S Xuereb, M Popovici, V Ivanov, A Plugaru, V Moscalu, I Popovici, M Abras, L Ciobanu, N Litvinenco, S Fuior, C Dumanschi, M Ivanov, T Danila, L Grib, S Filimon, L Cardaniuc, A Batrinac, M Tasnic, C Cozma, V Revenco, G Sorici, M Dagva, G Choijiljav, E Dandar, M-U Khurelbaatar, B Tsognemekh, Y Appelman, A Den Hartog, H Jan Te Kolste, D Van Den Buijs, A Van'T Hof, T Pustjens, V Houben, I Kasperski, J Ten Berg, J Azzahhafi, W Bor, D Chan Pin Yin, A Mbakwem, C Amadi, O Kushimo, M Kilasho, E Oronsaye, N Bakracheski, E Kovacheska Bashuroska, V Mojsovska, S Tupare, M Dejan, J Jovanoska, D Razmoski, T Marinoski, A Antovski, Z Jovanovski, S Kocho, R Markovski, V Ristovski, A B Samir, S Biserka, O Kalpak, I Mitevska Peovska, B Zafirovska Taleska, H Pejkov, O Busljetik, Z Zimbakov, E Grueva, I Bojovski, M Tutic, L Poposka, M Vavlukis, A Al-Riyami, S K Nadar, W Abdelmottaleb, S Ahmed, M Shaikh Mujtaba, S Al-Mashari, H Al-Riyami, A H Laghari, O Faheem, S Waqar Ahmed, N Qamar, S Furnaz, K Kazmi, T Saghir, A Aneel, A Asim, F Madiha, B Sobkowicz, A Tycinska, E Kazimierczyk, A Szyszkowska, K Mizia-Stec, M 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Broadley, K Beesley, C Buckley, C Hellyer, L Pippard, T Pitt-Kerby, J Azam, C Hayes, K Freshwater, L Johnson, Y Mcgill, H Redfearn, M Russell, A Alyavi, B Alyavi, and J Uzokov
Funding
Since the start of EORP, the following companies have supported the programme: Abbott Vascular Int. (2011–20), Amgen Cardiovascular (2009–18), AstraZeneca (2014–21), Bayer AG (2009–18), Boehringer Ingelheim (2009–19), Boston Scientific (2009–12), the Bristol Myers Squibb and Pfizer Alliance (2011–19), Daiichi Sankyo Europe GmbH (2011–20), the Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–17), Edwards (2016–19), Gedeon Richter Plc. (2014–16), Menarini Int. Op. (2009–12), MSD-Merck & Co. (2011–14), Novartis Pharma AG (2014–20), ResMed (2014–16), Sanofi (2009–11), Servier (2009–21), Vifor (2019–22).
Conflict of interest
H.B., K.H., P.L., R.N., V.K., and Y.A. report no conflict of interest.
C.P.G. reports personal fees from AstraZeneca, Amgen, Bayer, Boehrinher-Ingelheim, Daiichi Sankyo, Vifor, Pharma, Menarini, Wondr Medical, Raisio Group, and Oxford University Press. He has received educational and research grants from BMS, Abbott inc., the British Heart Foundation, National Institute of Health Research, Horizon 2020, and from the European Society of Cardiology, outside the submitted work.
S.B. reports personal fees from Boston Scientific, Insight, Lifetech, iVascular, and Abbott Vascular.
D.M. reports personal fees from Abbott, Boston Scientific, Biosensors, and Terumo. He has participated on Data Safety Monitoring Boards or Advisory Boards for Abbott and Boston Scientific.
A.B. reports personal and institutional investigator fees from AstraZeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, Novartis, Amgen, Novo Nordisk, and Bayer. He reports personal fees from AstraZeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, Novartis, and Bayer. He has participated in Data Safety Monitoring Boards or Advisory Boards for AstraZeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, and Bayer. He has received support for attending meetings by Astra Zeneca, Bristol Myers Squibb/Pfizer, Sanofi Aventis, and Bayer.
S.L. reports personal fees from ICON, Chiesi, AstraZeneca, Daiichi Sankyo, Bayer, Bristol Myers Squibb/Pfizer, and Novo Nordisk.
M.L. reports speaker fees from Bristol Myers Squibb/Pfizer, Boehrinher-Ingelheim, Novartis and Sanofi, and manuscript writing fees from Edwards Lifesciences. She has also participated as an advisory board member for Sanofi, Bristol Myers Squibb/Pfizer, and Boehrinher-Ingelheim.
Y.A. reports a research grant from the Dutch Heart Foundation.
Signed COIs available for all authors.
Data availability
The data underlying this article are subject to an embargo of 12 months from the publication date of the article. Once the embargo expires, the data will be available upon reasonable request to the EORP NSTEMI Executive Committee Chair, with the approval of the EORP Oversight Committee.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article are subject to an embargo of 12 months from the publication date of the article. Once the embargo expires, the data will be available upon reasonable request to the EORP NSTEMI Executive Committee Chair, with the approval of the EORP Oversight Committee.