Health Inequalities of STEMI Care Before Implementation of a New Regional Network: A Prefecture-Level Analysis of Social Determinants of Healthcare in Yunnan, China

Document Type : Original Article


1 Department of Cardiology, People’s Hospital of Chuxiong Prefecture, Yunnan, China

2 Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand

3 Faculty of Dentistry, Prince of Songkla University, Hat Yai, Thailand

4 People’s Hospital of Chuxiong Prefecture, Yunnan, China

5 Executive Office, Alliance of Chuxiong Prefecture Chest Pain Centres, Yunnan, China


As one of the most serious types of coronary heart disease, ST-elevation myocardial infarction (STEMI) faces huge challenges in the equal management and care of patients due to its life-threatening and time-critical condition. Health inequalities such as sex and age differences in STEMI care have been reported from developed countries. However, limited outcomes have been investigated and the major drivers of inequality are still unclear, especially in under-developed areas. This study aimed to explore the major drivers of health inequalities in STEMI care before implementation of a new regional network in the south-west of China.
Prefecture-level data of STEMI patients before the implementation of a regional network were analysed retrospectively. Drivers of inequality were identified from six social determinants of health, namely area of residence, ethnicity, sex, age, education and occupation. Outcomes of STEMI care included timely presentation, reperfusion therapy, timely reperfusion therapy, heart failure, inpatient mortality, length of hospital stay, hospital costs, and various intervals of ischaemic time.

A total of 376 STEMI patients in the research area before implementation of the STEMI network were included. Compared with urban residents, rural patients were significantly less likely to have timely presentation (odds ratio [OR] = 0.47, 95% CI: 0.28-0.80, P = .004) and timely reperfusion therapy (OR = 0.32, 95% CI: 0.14-0.70, P = .005). Rural residents were less likely to present to hospital promptly than urban residents (HR = 0.65, 95% CI = 0.52-0.82, P < .001). In the first 3 hours of percutaneous coronary intervention (PCI) reperfusion delay and first 6 hours of total ischaemic time, rural patients had a significantly lower probability to receive prompt PCI (hazard ratio [HR] = 0.40, 95% CI: 0.29-0.54, P < .001) and reperfusion therapy (HR = 0.37, 95% CI: 0.25-0.56, P < .001) compared to urban patients.
Rural residents were a major vulnerable group before implementation of the regional STEMI network. No obvious inequalities in ethnicity, sex, age, education or occupation existed in STEMI care in Chuxiong Prefecture of China.


  1. Kawachi I, Subramanian SV, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health. 2002;56(9):647-652. doi:10.1136/jech.56.9.647
  2. Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017. Accessed July 7, 2019.
  3. Gaziano TA, Bitton A, Anand S, Abrahams-Gessel S, Murphy A. Growing epidemic of coronary heart disease in low- and middle-income countries. Curr Probl Cardiol. 2010;35(2):72-115. doi:10.1016/j.cpcardiol.2009.10.002
  4. Zhang X, Khan AA, Haq EU, et al. Increasing mortality from ischaemic heart disease in China from 2004 to 2010: disproportionate rise in rural areas and elderly subjects. 438 million person-years follow-up. Eur Heart J Qual Care Clin Outcomes. 2017;3(1):47-52. doi:10.1093/ehjqcco/qcw041
  5. Aaronson PI, Ward JPT, Connolly MJ. The Cardiovascular System at a Glance. 4th ed. Wiley-Blackwell; 2013.
  6. Buja LM. Myocardial ischemia and reperfusion injury. Cardiovasc Pathol. 2005;14(4):170-175. doi:10.1016/j.carpath.2005.03.006
  7. Bagai A, Dangas GD, Stone GW, Granger CB. Reperfusion strategies in acute coronary syndromes. Circ Res. 2014;114(12):1918-1928. doi:10.1161/circresaha.114.302744
  8. Ibanez B, James S, Agewall S, et al. [2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.]. Kardiol Pol. 2018;76(2):229-313. doi:10.5603/kp.2018.0041
  9. Huded CP, Johnson M, Kravitz K, et al. 4-step protocol for disparities in STEMI care and outcomes in women. J Am Coll Cardiol. 2018;71(19):2122-2132. doi:10.1016/j.jacc.2018.02.039
  10. Newman L, Baum F, Javanparast S, O'Rourke K, Carlon L. Addressing social determinants of health inequities through settings: a rapid review. Health Promot Int. 2015;30 Suppl 2:ii126-143. doi:10.1093/heapro/dav054
  11. Statistical Communiqué on the 2019 National Economic and Social Development of Chuxiong Yi Autonomous Prefecture [Chinese].
  12. Neumar RW, Shuster M, Callaway CW, et al. Part 1: executive summary: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S315-S367. doi:10.1161/cir.0000000000000252
  13. Clark B, Preto N. Exploring the concept of vulnerability in health care. CMAJ. 2018;190(11):E308-E309. doi:10.1503/cmaj.180242
  14. Leurent G, Garlantézec R, Auffret V, et al. Gender differences in presentation, management and inhospital outcome in patients with ST-segment elevation myocardial infarction: data from 5000 patients included in the ORBI prospective French regional registry. Arch Cardiovasc Dis. 2014;107(5):291-298. doi:10.1016/j.acvd.2014.04.005
  15. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1736-1788. doi:10.1016/s0140-6736(18)32203-7
  16. Song XT, Chen YD, Pan WQ, Lü SZ. Gender based differences in patients with acute coronary syndrome: findings from Chinese Registry of Acute Coronary Events (CRACE). Chin Med J (Engl). 2007;120(12):1063-1067.
  17. Shavadia J, Ibrahim Q, Sookram S, Brass N, Knapp D, Welsh RC. Bridging the gap for nonmetropolitan STEMI patients through implementation of a pharmacoinvasive reperfusion strategy. Can J Cardiol. 2013;29(8):951-959. doi:10.1016/j.cjca.2012.10.018
  18. Kamona A, Cunningham S, Addison B, et al. Comparing ST-segment elevation myocardial infarction care between patients residing in central and remote locations: a retrospective case series. Rural Remote Health. 2018;18(4):4618. doi:10.22605/rrh4618
  19. Pedley DK, Bissett K, Connolly EM, et al. Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics. BMJ. 2003;327(7405):22-26. doi:10.1136/bmj.327.7405.22
  20. Beig JR, Tramboo NA, Kumar K, et al. Components and determinants of therapeutic delay in patients with acute ST-elevation myocardial infarction: a tertiary care hospital-based study. J Saudi Heart Assoc. 2017;29(1):7-14. doi:10.1016/j.jsha.2016.06.001
  21. Mohan B, Bansal R, Dogra N, et al. Factors influencing prehospital delay in patients presenting with ST-elevation myocardial infarction and the impact of prehospital electrocardiogram. Indian Heart J. 2018;70 Suppl 3:S194-S198. doi:10.1016/j.ihj.2018.10.395
  22. Cai L, He J, Song Y, Zhao K, Cui W. Association of obesity with socio-economic factors and obesity-related chronic diseases in rural southwest China. Public Health. 2013;127(3):247-251. doi:10.1016/j.puhe.2012.12.027
  23. Reimer KA, Lowe JE, Rasmussen MM, Jennings RB. The wavefront phenomenon of ischemic cell death. 1. Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation. 1977;56(5):786-794. doi:10.1161/01.cir.56.5.786
  24. Sandiford P, Bramley DM, El-Jack SS, Scott AG. Ethnic differences in coronary artery revascularisation in New Zealand: does the inverse care law still apply? Heart Lung Circ. 2015;24(10):969-974. doi:10.1016/j.hlc.2015.03.013
  25. Kuhn L, Page K, Rahman MA, Worrall-Carter L. Gender difference in treatment and mortality of patients with ST-segment elevation myocardial infarction admitted to Victorian public hospitals: a retrospective database study. Aust Crit Care. 2015;28(4):196-202. doi:10.1016/j.aucc.2015.01.004
  26. Kim HS, Lee KS, Eun SJ, et al. Gender differences in factors related to prehospital delay in patients with ST-segment elevation myocardial infarction. Yonsei Med J. 2017;58(4):710-719. doi:10.3349/ymj.2017.58.4.710
  27. Zhang B, Zhang W, Huang R, et al. Gender and age differences associated with prehospital delay in Chinese patients presenting with ST-elevation myocardial infarction. J Cardiovasc Nurs. 2016;31(2):142-150. doi:10.1097/jcn.0000000000000219
  28. Jäger B, Farhan S, Rohla M, et al. Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality. Eur Heart J Acute Cardiovasc Care. 2017;6(3):254-261. doi:10.1177/2048872616633882
  29. Bugiardini R, Ricci B, Cenko E, et al. Delayed care and mortality among women and men with myocardial infarction. J Am Heart Assoc. 2017;6(8):e005968. doi:10.1161/jaha.117.005968
  30. Ikemura N, Sawano M, Shiraishi Y, et al. Barriers associated with door-to-balloon delay in contemporary Japanese practice. Circ J. 2017;81(6):815-822. doi:10.1253/circj.CJ-16-0905
  31. Peng YG, Feng JJ, Guo LF, et al. Factors associated with prehospital delay in patients with ST-segment elevation acute myocardial infarction in China. Am J Emerg Med. 2014;32(4):349-355. doi:10.1016/j.ajem.2013.12.053
  32. Steele J, Shen J, Tsakos G, et al. The Interplay between socioeconomic inequalities and clinical oral health. J Dent Res. 2015;94(1):19-26. doi:10.1177/0022034514553978
Volume 11, Issue 8
August 2022
Pages 1413-1424
  • Receive Date: 27 September 2020
  • Revise Date: 23 January 2021
  • Accept Date: 16 March 2021
  • First Publish Date: 11 May 2021