Pathways to Catastrophic Health Expenditure. This figure describes the primary and secondary pathways by which low-, middle-, and high-income households experience CHE and get trapped in a vicious cycle of illness, debt and poverty. Households enter this cycle through their first acute coronary syndrome (ACS) event. The cycle is divided into four segments: 1) illness - treatment: factors that prevent households from receiving adequate treatment; 2) treatment - distress financing: aspects related to treatment financing particularly with respect to hospitalization and interventions as well as the adverse effect of the illness on employment, all of which tend to increase non-compliance and lead to repeat acute events; 3) distress financing - consequences: means of distress financing that increase the intensity and duration of CHE; 4) consequences – illness: short- and long-term consequences of CHE experienced by households in their journey through the cycle. The events grouped together in this segment aggravate CHE as the cycle repeats itself, at the same time, households experiencing CHE are at higher risk of undergoing these consequences leading to prolonged indebtedness and (or) impoverishment (depicted by ⇆).