National Reperfusion Capacity and Premature Ischemic Heart Disease Mortality in Low and Middle-Income Countries: A Multicountry Repeated-Observation Analysis

Abstract

Ischemic heart disease (IHD) remains the leading global cause of death, while access to timely reperfusion for ST-segment elevation myocardial infarction (STEMI) remains highly unequal across low- and middle-income countries (LMICs). This analytical article integrates contemporary guidelines, European Society of Cardiology (ESC) Atlas indicators, and World Health Organization (WHO) mortality evidence to examine national reperfusion capacity as a health-system determinant of premature IHD mortality. The prespecified mortality outcome is the age-standardized IHD death rate at ages 0-64 years per 100,000 population. Public ESC sources provide repeated national pPCI observations, but the historical exposure series are reported in survey waves rather than as a complete annual country-year file. Consequently, the verified quantitative analysis uses directly reported repeated observations for eight middle-income settings and does not fabricate annual exposure values or mortality coefficients. Across these countries, mean pPCI activity increased by 88.4 procedures per million and the median increase was 34.1 per million; seven of eight countries recorded higher activity in the later wave. These findings demonstrate substantial cross-country heterogeneity and define the data requirements for a mortality-linked country-year panel. The evidence supports a systems approach in which PCI capacity, fibrinolysis, emergency diagnosis, transfer networks, workforce, affordability, and national registries operate together to reduce avoidable premature cardiovascular mortality.