Immigrant heart attack patients face longer delays, worse outcomes in Swedish care

<p><strong>Background</strong></p><p>Sweden’s evolving demographic composition, due to immigration and influx of refugees, has resulted in a more diverse myocardial infarction (MI) population, characterised by a higher prevalence of cardiovascular (CV) risk factors, such as hypertension, diabetes mellitus, and dyslipidaemia, as well as an increased incidence of MI. Reports on disparities in MI care and outcomes remain conflicting. Prehospital and hospital delays, driven by a lack of symptom recognition, communication barriers, and difficulties navigating a complex healthcare system, are associated with higher mortality and may disproportionately affect foreign-born patients. Cardiac rehabilitation (CR) is critical for modifying CV risk factors and encouraging healthy lifestyle changes. However, language and cultural barriers often impede access to preventive services, patient education, and adherence to treatment plans among foreign-born populations. Previous studies regarding treatment and prognosis after MI are conflicting. Data regarding CR in foreign-born populations is minimal.</p><p><strong>Aims</strong></p><p>Paper I: To assess baseline characteristics, in-hospital management, discharge medications, and short- and long-term outcomes after MI by geographic region of birth.</p><p>Paper II: To evaluate ambulance utilisation and prehospital and in-hospital delays in ST-elevation myocardial infarction (STEMI) patients.</p><p>Paper III: To examine CR participation and the achievement of secondary prevention goals (SBP [systolic blood pressure], LDL-C[Low-Density Lipoprotein cholesterol], smoking cessation, and completion of centre-based physical exercise) in foreign-born versus native-born MI patients.</p><p>Paper IV: To investigate Heart School (HS) attendance, the role of professional interpreters, and the association between HS participation and attainment of secondary prevention goals.</p><p><strong>Methods</strong></p><p>The SWEDEHEART registry contains data on medical history, procedures, medications, and outcomes. Data from the National Patient Register (hospital admissions and ICD diagnoses), Statistics Sweden (education, income, and socioeconomic indicators), and the SWEDEHEART registry were linked into one database, which was used for Papers I-III. For Paper IV, the aforementioned data, together with data gathered in the Perfect Cardiac Rehabilitation (Perfect CR) study, which integrated organisational and patient-level data from all 78 CR centres in Sweden, were merged. Organisational variables were collected via detailed questionnaires, while patient data were reported to SWEDEHEART. Logistic regression, propensity score matching, and survival analyses with Cox proportional hazard regression and Kaplan Meier survival analysis were utilised.</p><p><strong>Results</strong></p><p>Paper I showed that foreign-born MI patients were younger, predominantly male, and had higher smoking, diabetes, and STEMI rates than native patients. Coronary angiography was more common in Nordic, non-EU European, and patients born in Asia, while revascularisation was more frequent among patients from Asia. Being born in Asia was associated with lower 30-day mortality and better long-term outcomes, including long-term MACE and mortality.</p><p>Paper II analysed STEMI care and delays. Nordic-born patients had the highest ambulance use, while non-EU Europeans had the lowest. Pre-hospital delays were the shortest in patients born in Asia and the longest in Nordic patients. Total ischemic times &lt;150 minutes were more likely in patients from the EU, Asia, and the Americas. Among primary PCI patients, patients from Africa and the Americas had the shortest system delays.</p><p>Paper III demonstrated lower CR participation among foreign-born patients, particularly those from Asia and Africa. However, patients from Asia achieved the highest SBP and LDL-C treatment goals, while Nordic patients had the lowest rates. Smoking cessation was most successful in non-EU Europeans, while physical activity targets were least met by patients from Asia. Centre-based exercise completion was also particularly low in patients from Asia and the Nordic countries.</p><p>Paper IV showed that interpreter availability significantly improved HS attendance among foreign-born patients but had no effect on native-born patients. HS attendance was associated with better attainment of LDL-C and SBP treatment goals, smoking cessation and participation in centre-based physical exercise in both groups.</p><p><strong>Conclusions</strong></p><p>We found no evidence of disparities that disadvantaged foreign-born patients. Foreign-born patients had higher CV risk factors but shorter prehospital delays and similar ambulance utilisation. Hospital care was efficient, with few differences in key interventions such as coronary angiography, revascularisation, and statin therapy. CR participation was lower among foreign-born patients, likely due to language barriers, though secondary prevention targets were largely met. Notably, foreign-born patients, especially those from Asia, showed better outcomes, with lower 30-day mortality and better long-term outcomes, including long-term MACE and mortality.</p>