Abstract
Indrakumar et al. present a timely and crucial analysis of acute coronary syndrome (ACS) care at Colombo South Teaching Hospital, identifying essential patient characteristics, patterns in management, and gaps in real-world practice and directed therapies. 1 A central theme throughout the findings was the role that delays played in the patient management process: delayed presentation, delayed diagnosis, delayed referral, and delayed initiation of reperfusion therapy. The authors note that only 42.3% of eligible patients received thrombolysis within 30 min, and that primary percutaneous coronary intervention (PCI) was used in a very small minority of cases. 1 The authors also added that fragmented referral pathways, limited rural hospital resources, and anticipated loss to follow-up created additional barriers in patient management.
These observations point to an important construct, structural delay burden (SDB), rooted in the social determinants of health (SDOH). Established cardiovascular research shows that SDOH shape access to timely care and predict cardiovascular outcomes. 2 Dugani et al. found that low education and unemployment increased 1-year mortality after ACS, improving prediction beyond clinical variables. 3 Transportation barriers, health literacy gaps, and geographic access similarly affect ACS risk and outcomes. 2 In South Asia, prehospital delays exceeding 8 h are driven by limited ambulances, multiple care stops, and long travel distances. 4 These patterns mirror the barriers identified by Indrakumar et al., including fragmented referral pathways, limited rural resources, and delayed thrombolysis. 1 This indicates that logistical delays in Sri Lanka stem from structural conditions and not individual behavior.
To strengthen the value of future ACS registries in Sri Lanka, we recommend integrating an SDB score based on variables already routinely captured, including: (a) Time from symptom onset to the first contact of medical attention; (b) Mode and distance of transport; (c) The number/type of facilities visited before definitive care; (d) Time to intervention (electrocardiography [ECG] or PCI); (e) Barriers involved in scheduled follow-up at 1-12 months. The components of ordinal classification (low, moderate, high SDB) can be involved in conjunction with mortality, reinfarction, readmission, and medication adherence.
Health equity is central to ACS outcomes because treatment timelines and survival are shaped by structural conditions that populations experience unevenly.2, 3 Delays in symptom recognition, transport, and access to definitive care reflect broader social and geographic inequities that determine who reaches treatment in time.3, 5 Long travel distances, fragmented referral pathways, and limited follow-up signal unequal exposure to risk.2, 5 Measuring SDB helps understand these inequities by reframing delay as evidence of structural barriers.
Through quantifying structural determinants of delay, SDB can substantially extend the explanatory power of the hospital-based pilot registry described by the authors, enabling more precise identification of high-burden populations, stronger referral pathways, and policy-relevant insights. Indrakumar et al. offer foundational evidence on ACS care in Sri Lanka, and integrating SDB as a routine analytic variable would transform this foundation into a more equitable framework for national ACS management and future registry development.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approval
This article is a scholarly commentary and does not involve original research with human participants. Therefore, ethics approval was not required.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Patient Consent
Not applicable.
