Beyond distance: Impact of transportation modality on adverse outcomes in acute coronary syndrome in an archipelagic region

Abstract Background and Aims Acute Coronary Syndrome (ACS) outcomes are highly time-dependent; however, in archipelagic health systems, access to care is often hindered by geographic barriers that extend beyond distance alone, including complex transportation pathways. This study aims to analyze the impact of these geographic factors on adverse cardiovascular events among ACS patients. Methods This retrospective observational study included 61 ACS patients admitted to a peripheral type D hospital in Central Maluku Regency. Data collected included demographics, comorbidities, ACS subtype (STEMI vs NSTE-ACS), travel distance (kilometres from symptom onset location to receiving hospital), estimated travel time, transportation mode (land, sea, or combined), and pre-hospital delay (symptom onset to admission). The primary outcome was adverse cardiovascular events, defined as in-hospital mortality, cardiogenic shock, acute heart failure, malignant arrhythmia, or new-onset atrial fibrillation. Fisher’s exact test and multivariable logistic regression were used for analysis. Results Of 61 patients, 16 (26.2%) experienced adverse events. Bivariate analysis showed that combined sea and land transport (OR 21.5; 95% CI 3.86–120.5; p<0.001), pre-hospital delay ≥2 hours (OR 5.42; 95% CI 1.43–20.5; p=0.02), and STEMI presentation (OR 3.75; 95% CI 1.05–13.3; p=0.04) were associated with adverse outcomes. Multivariable analysis identified combined transport (adjusted OR 10.78; 95% CI 1.45–80.2; p=0.018) and STEMI (adjusted OR 5.60; 95% CI 1.02–30.7; p=0.045) remained significantly associated. Conclusion In this archipelagic setting, transportation modality, rather than distance, was independently associated with adverse outcomes in ACS, highlighting the potential importance of system-level transport coordination and referral systems. Larger studies are warranted.