Letter: Ethnic Disparities in ST-Segment Elevation Myocardial-Infarction Outcomes and Processes of Care in Patients With and Without Standard Modifiable Cardiovascular Risk Factors

To the Editor,

We congratulate Weight et al. ¹ for their paper entitled “Ethnic Disparities in ST-Segment Elevation Myocardial Infarction Outcomes and Processes of Care in Patients With and Without Standard Modifiable Cardiovascular Risk Factors: A Nationwide Cohort Study.” We agree with their conclusion that patients without standard modifiable cardiovascular risk factors (SMuRFs) experience a higher incidence of major adverse cardiovascular events (MACE), in-hospital mortality, and cardiac-related deaths compared to those with one or more SMuRFs. This elevated risk remains significant after adjusting for factors such as baseline demographics, hemodynamic status, Killip classification, cardiac arrest, and common comorbidities. However, the increased risk is no longer observed after accounting for invasive coronary angiography (ICA) or revascularization. We would like to offer a few comments that could enhance the overall quality of the article. ²

Firstly, the author explains most of the SMuRFs but does not mention obesity. Obesity, along with genetic predisposition, stands out as a major modifiable risk factor for coronary artery disease (CAD) among both Arab and non-Arab patients with symptomatic CAD, implementing screening programs, educational interventions for obesity management, and ensuring adherence to treatment for co-morbidities should be prioritized to reduce the prevalence of CAD in the Arab population. ² Additionally, recent findings underscore the impact of socioeconomic disadvantage and the higher prevalence of unmanaged modifiable risk factors in underrepresented racial and ethnic groups, and while strides have been made in achieving equitable in-hospital treatment and outcomes, the focus must now shift to out-of-hospital primary and secondary prevention efforts, particularly in regions with marked socioeconomic disparities, to effectively reduce race-ethnic disparities in cardiovascular health. ³

There are additional SMuRFs that need to be considered, as hospital entry mode was the strongest predictor of prolonged treatment times for primary PCI, independent of factors such as age, Latino ethnicity, heart rate, systolic blood pressure, and initial troponin levels, with delays in door-to-ECG and ECG-to-catheter lab activation times being modifiable factors contributing to extended treatment times in walk-in STEMI patients. ⁴

Lastly, the author did not address epidemiology, which should be mentioned due to its significant impact on CAD. Women were generally older and more likely than men to have conditions such as diabetes mellitus, hypertension, dyslipidemia, previous heart failure, and renal failure, yet they were less likely to receive aspirin, beta-blockers, angiotensin-converting enzyme inhibitors (ACE-I), or statins, and were also less likely to undergo angiography or percutaneous coronary intervention (PCI), despite an overall increase in these procedures, and in the STEMI cohort, although there was a marked rise in presentations with Killip class IV, women were less likely to receive primary PCI or fibrinolysis and experienced longer median door-to-needle and door-to-balloon times compared to men, despite improvements in these measures. ⁵