Socioeconomic deprivation and prognostic outcomes in acute coronary syndrome: A meta-analysis using multidimensional socioeconomic status indices
Graphical abstract
Introduction
Acute coronary syndrome (ACS) is one of the leading causes of death worldwide, accounting for approximately one in six deaths [1,2]. This public health concern has prompted urgent global efforts in tackling traditional cardiovascular risk factors for both the primary and secondary prevention of ACS [3,4]. Beyond addressing conventional biological risk factors, increasing evidence have demonstrated that social determinants of health such as socioeconomic deprivation, play an important role as a non-traditional risk factor affecting post-ACS outcomes, quality of care received and treatment adherence [5]. The World Health Organization (WHO) states that socioeconomic deprivation, often measured by socioeconomic status (SES) [6], contributes heavily to inequitable but avoidable differences in health outcomes worldwide [7]. Patients with low SES have been reported to bear higher burden of cardiovascular risk factors, with more severe presentation of cardiovascular diseases [8,9]. Previous meta-analyses [10,11] have also elucidated higher risks of post-ACS mortality and suboptimal medical care in patients with low SES.
Considering the vast attention on the primary and secondary prevention of ACS in present clinical practice guidelines, our study addresses the current gap in the literature beyond the biological underpinnings of ACS by providing comprehensive analysis on the association between SES and post-ACS survival, its complications and the provision of guideline-directed interventions [8,9,12]. Despite previous meta-analyses [10,11], there remains a paucity of data on the effects of SES on ACS survival based on geographical regions, socioeconomic deprivation indices used, as well as trends of mortality differences across time. Moreover, the included studies of previous meta-analyses used unidimensional indices of socioeconomic parameters which may not holistically encompass the major indicator components of socioeconomic deprivation [10,11] as recommended by the American Psychological Association [13]. As such, with a stricter inclusion criterion of articles adopting multidimensional socioeconomic indices, our study aims to add to the existing evidence with comprehensive evaluations of the impact of socioeconomic deprivation, as well as additional analysis highlighting the differences in the effects of the SES gap across various regions, timelines, and socioeconomic indices. These unique perspectives on the differential effect of SES can help inform stakeholders in designing effective strategies when addressing socioeconomic inequity as a non-traditional risk factor in ACS.
Section snippets
Search strategy
This paper was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines [14] (Fig. 1). Medline and Embase were searched for articles reporting outcomes of ACS patients stratified by socioeconomic status until 1 July 2022. Key search terms such as “acute coronary syndrome”, “socioeconomic deprivation”, “socioeconomic status”, “index”, and a quantitative filter were used. Articles were retrieved and duplicates were removed using EndNote 20. The
Summary of included studies
Our initial search strategy yielded a total of 5092 articles, of which 1121 duplicates were removed. A total of 3500 studies were excluded after title and abstract sieve, with 471 studies selected for full text review. A total of 29 ACS studies were then included in this meta-analysis (Fig. 1). By region, the articles were from Europe (n = 14) [16,18,20,23,25,[37], [38], [39], [40], [41], [42], [43], [44], [45]], Oceania (n = 5) [5,15,19,21,46], Asia (n = 5) [17,[47], [48], [49], [50]] and
Discussion
Established risk classifications tools for ACS such as GRACE [53] and TIMI [54], utilise conventional cardiac risk factors to guide the management of ACS [[55], [56], [57]]; however they fail to account for important socioeconomic factors that have been closely linked with poorer survival in patients with ACS [12]. The present meta-analysis extensively examines comparative data of ACS outcomes across SES groups over the past two decades. Our findings highlight that ACS patients with low SES
Conclusion
Despite similar cardiovascular risk profiles, individuals of low SES received lower rates of coronary revascularisation and had higher mortality rates following ACS compared to those of high SES. The socioeconomic gap in ACS care is a global health concern, that has become more evident in the past decade, with worrisome trends of unfavourable survival in the low SES population likely to persist in the coming years. The unified goal in addressing ACS-related socioeconomic inequity deserves its
Funding sources
None.
CRediT authorship contribution statement
Vickram Vijay Anand: Conceptualization, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Visualization. Ethan Lee Cheng Zhe: Conceptualization, Formal analysis, Data curation, Writing – original draft, Writing – review & editing, Visualization. Yip Han Chin: Conceptualization, Formal analysis, Validation, Data curation, Writing – original draft, Writing – review & editing, Visualization. Rachel Sze Jen Goh: Conceptualization, Writing – original draft,
Declaration of Competing Interest
The authors report no relationships that could be construed as a conflict of interest.
Acknowledgements
All authors have made substantial contributions to all the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. No writing assistance was obtained in the preparation of the manuscript. The manuscript, including related data, figures and tables has not been previously published and the
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