English as a second language and outcomes of patients presenting with acute coronary syndromes: results from the CONCORDANCE registry

Craig P Juergens, Bilyana Dabin, John K French, Leonard Kritharides, Karice Hyun, Jens Kilian, Derek PB Chew and David Brieger
Med J Aust 2016; 204 (6): 239. || doi: 10.5694/mja15.00812


Objectives: To investigate whether patients with English as their second language have similar acute coronary syndrome (ACS) outcomes to people whose first language is English.

Design: Retrospective, observational study, using admissions, treatment and follow-up data.

Participants and setting: : A total of 6304 subjects from 41 sites enrolled in the investigator-initiated CONCORDANCE ACS registry.

Main outcome measures: Baseline characteristics, treatments, and in-hospital and 6-month mortality.

Results: English as a second language (ESL) was reported by 1005 subjects (15.9%). Patients with English as their first language (EFL) were older, and were less likely to have diabetes mellitus or to smoke than the ESL patients. Prior myocardial infarction, heart failure and chronic renal failure were more common in the ESL group. In-hospital mortality was also higher in these patients (7.1% v 3.8% for EFL patients; P < 0.001). Predictors of in-hospital mortality included presentation in cardiogenic shock, cardiac arrest in hospital, a history of renal failure, prior cardiac failure, and ESL. Rates of cardiac catheterisation, percutaneous coronary intervention rates, and referral to cardiac rehabilitation were lower in the ESL group; at 6 months, all-cause mortality was also higher (13.8% v 8.3% for EFL group; P < 0.001). Logistic regression identified language, age, in-hospital renal failure, and recurrent ischaemia as predictors of 6-month mortality.

Conclusion: Patients presenting with an ACS who report English as their second language have poorer outcomes than patients who use English as their first language. This difference may not be entirely explained by baseline demographic disparities or management differences.

Please login with your free MJA account to view this article in full

  • Craig P Juergens1,6
  • Bilyana Dabin2
  • John K French1,6
  • Leonard Kritharides2
  • Karice Hyun3
  • Jens Kilian4
  • Derek PB Chew5
  • David Brieger2

  • 1 Liverpool Hospital, Sydney, NSW
  • 2 Concord Repatriation Hospital, Sydney, NSW
  • 3 The George Institute for Global Health, Sydney, NSW
  • 4 Bankstown Hospital, Sydney, NSW
  • 5 Flinders Medical Centre, Adelaide, SA
  • 6 South Western Sydney Clinical School, University of NSW, Sydney, NSW



We thank all the investigators and study coordinators who contributed to the CONCORDANCE Registry.

Competing interests:

The CONCORDANCE registry has been funded by grants to the Sydney Local Health District from Sanofi Aventis, Astra Zeneca, Eli Lilly, Boehringer Ingelheim, the Merck Sharp and Dohme/Schering Plough joint venture, and the National Heart Foundation of Australia. The sponsors played no role in the design, analysis, or preparation of this article.

  • 1. Australian Bureau of Statistics. Migration, 2009–2010 (Cat. No. 3412.0). Canberra: ABS, 2011. (accessed Jan 2016).
  • 2. Dassanayake J, Dharmage SC, Gurrin L, et al. Are immigrants at risk of heart disease in Australia? A systematic review. Aust Health Rev 2009; 33: 479-491.
  • 3. Fernandez R, Rolley JX, Rajaratnam R, et al. Risk factors for coronary heart disease among Asian Indians living in Australia. J Transcult Nurs 2015; 26: 57-63.
  • 4. Renzaho A. Ischaemic heart disease and Australian immigrants: the influence of birthplace and language skills on treatment and use of health services. HIM J 2007; 36: 26-36.
  • 5. Schouten BC, Meeuwesen L. Cultural differences in medical communication: a review of the literature. Patient Educ Couns 2006; 64: 21-34.
  • 6. Aliprandi-Costa B, Ranasinghe I, Turnbull F, et al. The design and rationale of the Australian cooperative national registry of acute coronary care, guideline adherence and clinical events (CONCORDANCE). Heart Lung Circ 2013; 22: 533-541.
  • 7. Young CM. Migration and mortality: the experience of birthplace groups in Australia. Int Migr Rev 1987; 21: 531-554.
  • 8. Singh M, de Looper M. Australian health inequalities: 1 Birthplace (AIHW Cat. No. AUS 27; Australian Institute of Health and Welfare Bulletin No. 2). Canberra: AIHW, 2002. (accessed Jan 2016).
  • 9. Tillin T, Hughes AD, Mayet J, et al. The relationship between metabolic risk factors and incident cardiovascular disease in Europeans, South Asians and African Caribbeans: SABRE (Southall and Brent Revisited) — a prospective population-based study. J Am Coll Cardiol 2013; 61: 1777-1786.
  • 10. Henderson SO, Magana RN, Korn CS, et al. Delayed presentation for care during acute myocardial infarction in a Hispanic population of Los Angeles County. Ethn Dis 2002; 12: 38-44.
  • 11. Bradley EH, Herrin J, Wang Y, et al. Racial and ethnic differences in time to acute reperfusion therapy for patients hospitalized with myocardial infarction. JAMA 2004; 292: 1563-1572.
  • 12. DuBard CA, Garrett J, Gizlice Z. Effect of language on heart attack and stroke awareness among US Hispanics. Am J Prev Med 2006; 30: 189-196.
  • 13. Daumit GL, Hermann JA, Coresh J, Powe NR. Use of cardiovascular procedures among black persons and white persons: a 7-year nationwide study in patients with renal disease. Ann Intern Med 1999; 130: 173-182.
  • 14. Feder G, Crook AM, Magee P, et al. Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing coronary angiography. BMJ 2002; 324: 511-516.
  • 15. Whittle J, Conigliaro J, Good CB, Joswiak M. Do patient preferences contribute to racial differences in cardiovascular procedure use? J Gen Intern Med 1997; 12: 267-273.
  • 16. Renzaho A. Addressing the needs of refugees and humanitarian entrants in Victoria: an evaluation of health and community services. Melbourne: Centre for Culture, Ethnicity and Health, 2002.
  • 17. Solis JM, Marks G, Garcia M, Shelton D. Acculturation, access to care, and use of preventive services by Hispanics: findings from HHANES 1982–84. Am J Public Health 1990; 80 Suppl: 11-19.
  • 18. Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured. Findings from a national sample. Med Care 2002; 40: 52-59.
  • 19. Woloshin S, Bickell NA, Schwartz LM, et al. Language barriers in medicine in the United States. JAMA 1995; 273: 724-728.
  • 20. Webster RA, Thompson DR, Mayou RA. The experiences and needs of Gujarati Hindu patients and partners in the first month after a myocardial infarction. Eur J Cardiovasc Nurs 2002; 1: 69-76.
  • 21. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004; 116: 682-692.
  • 22. Clark AM, Hartling L, Vendermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005; 143: 659-672.
  • 23. Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2007; 357: 2001-2015.
  • 24. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361: 1045-1057.
  • 25. Sundquist J, Winkleby MA, Pudaric S. Cardiovascular disease risk factors among older black, Mexican-American, and white women and men: an analysis of NHANES III, 1988–94. J Am Geriatr Soc 2001; 49: 109-116.


remove_circle_outline Delete Author
add_circle_outline Add Author

Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

access_time 09:16, 29 April 2016
dani fried

Thanks for this article. I wonder whether you have considered the fact that not all ESL individuals are from overseas. As well as ATSI people, who you have mentioned, Deaf individuals are frequently monolingual in Auslan, or have limited bilingualism in Auslan and English. They frequently do not have access to any (or high quality) interpreting services in medical settings. They are further disadvantaged by the fact that health information is rarely made available in Auslan, and because, unlike many other NESB groups, there are no clinicians available who speak their language. I'd encourage researchers to always make sure that this small but significant group of NESB people are included in future research on the impact of language and culture on health outcomes.

Competing Interests: No relevant disclosures

Ms dani fried

access_time 10:18, 3 May 2016
Craig Juergens

Thanks for your comments. ESL was by self report so they were not necessarily from overseas. 418 patients identified themselves as Aboriginal or Torres Strait Islander and we have not analysied what proportion of these patients, if any, identified as ESL which would be interesting. We did not collect data on deaf patients or the use of Auslan interpreters and agree this is an even more poorly studied population in this context.

Competing Interests: No relevant disclosures

Assoc Prof Craig Juergens
Liverpool Hospital

Responses are now closed for this article.