STEMI in India. Case history

Transcription

1 CardioPulse 2449 ambitious projects. Amstein s marketing knowledge and experience was invaluable when the foundation rebranded itself Zurich Heart House in line with the European Heart House. Informative symposia and meetings helped cement ZHH s reputation with cardiology professionals and the 4-day congress Cardiology Update w became the largest ESC course of its type. Zurich Heart House s unique post-graduate course in heart failure started in 2014 as a 2-year programme leading to a certificate of advanced studies (CAS), certified by the University of Zurich andendorsedbytheesc.developedbyateamofexpertsto address the unmet training needs of cardiology professionals the first course was oversubscribed with 120 applications from around the world for 40 places which finally were expanded to 60. Amstein describes the PCHF as a fusion of her working life and professional skills and identifies it as a career highlight. It followed on from her pioneering role at ECPM where she worked with the US health watchdog the Food and Drug Administration (FDA). The annual Cardiology Update w in Davos, Switzerland is another highlight. doi: /eurheartj/ehw279 STEMI in India A newly developed system towards a practical and equitable ST-segment elevation myocardial infarction (STEMI) system of care connecting rural India Case history Mr A.S., a 45-year-old labourer, presented to a small rural hospital in a small town of Valparai, India, at p.m. with severe chest pain and dizziness. The hospital located in this tea estate town was a 10-bed facility with a small emergency room to admit acutely ill patients. The medical staff consisted of three nursesandajuniordoctor.thedoctorhadretiredforthenight. The duty nurse took an electrocardiogram (ECG) and sent it through a ward attender to the doctor s house, situated 15 min away. The doctor noted the ST elevation in the anterior leads and correctly diagnosed an anterior ST-segment elevation myocardial infarction (STEMI). However, he was not absolutely sure of the diagnosis and felt that he would like a senior doctor who visited the hospital in the morning to confirm the diagnosis before starting streptokinase, the available thrombolytic agent in the hospital. Nonetheless, he decided to go to the hospital and see the patient who continued to be in pain. He advised the relatives to move him to a higher medical centre in the closest city located 110 km away a 2-h journey. The family debated on how to organize the transportation and the costs of transportation and further management in the city hospital. They decided to wait until next morning for the patient s brother to arrive and organize the finances. The meeting has grown to over 600 strong and established a global reputation for delivering high-quality scientific education. She is also immensely proud of having developed and steered ZHH along with Thomas Lüscher from an ambitious idea to an internationally known brand. The development of ZHH as a hub for cardiovascular education for professionals around the globe will continue. The second PCHF is underway and in May 2016 ZHH prepared to welcome 30 cardiologists from the Middle East for a 3-day preceptorship programme in preventive cardiology. These type of activities promoting research, interaction, and dialogue among the global cardiology community are, Amstein says, the future for ZHH. The patient became hypotensive and was started on IV fluids. He rapidly deteriorated and succumbed at 6.30 a.m., the next day before the senior doctor could confirm the diagnosis or transportation to the city hospital could be organized. This is not an isolated case history. This story is repeated in many small towns and villages across India. The names may be different but the ages have progressively become younger and many of the country s young men and women are dying every day of acute myocardial infarction without appropriate medical care. Coronary artery disease (CAD) is currently the most common, non-infectious disease in India and affects over 65 million of its people. Coronary artery disease is a major contributor to death and disability in India, and its overall prevalence has risen dramatically over the past two decades. Approximately 3 4% of Indians in rural areas and 8 10% in urban areas have CAD. Moreover, Indians are more likely to develop CAD at younger ages during an individual s working years, and as a result, there is an extremely high loss of potentially productive years of life in India. Among working-age adults (35 64 years old), nearly 18 million productive years of life are expected to be lost from CAD by 2030, a number more than nine times higher than expected in the USA. This pattern of disease and the type of solutions offered could have substantial implications for India s growing workforce and economy.

2 2450 CardioPulse STEMI INDIA, a not-for-profit national body, was started by Drs Thomas Alexander and Ajit Mullasari. This organization dedicated to STEMI care in India was established in The goals of this organization are as follows: To inform and disseminate the latest information from across the world on STEMI management to all those involved in STEMI care in India To help organize and train STEMI teams in hospitals To develop systems of care, appropriate for STEMI care in India To facilitate and contribute to developing a national STEMI guideline and work towards a national STEMI programme To provide public education to reduce delays in accessing appropriate STEMI care To help organizations and individuals in research projects with expertise and, where feasible, funding Developing systems of STEMI care in India is a challenge because of the complexities involved in allocating scarce healthcare resources which should be effective and equitable and the lack of adequate infrastructure and trained manpower. Furthermore, primary percutaneous coronary intervention (PCI) is seldom used as the means for reperfusion. Thrombolysis is the main mode for reperfusion and is almost always used as a stand-alone treatment. The recent data supporting the use of the pharmacoinvasive strategy as a reasonable option in this subset of patients has opened up a window of opportunity in delivering a more practical and effective reperfusion treatment in the majority of patients in the low- and middle-income countries. STEMI INDIA proposed that STEMI management in India adopt the dual strategy of combining primary PCI with pharmacoinvasive reperfusion to develop a framework for a system of care, referred to as STEMI INDIA model. This has now been endorsed by the Cardiological Society of India and the Association Physicians of India. Primary PCI for patients located close to catheterization laboratories. Such option would be available mostly for patients in urban areas with presumed short transportation time to the hospitals equipped with 24/7 primary PCI capabilities. Patients in rural areas with long transportation time to PCIcapable hospitals would utilize the pharmacoinvasive strategy with thrombolysis therapy followed by catheterization and PCI, if indicated, within 3 24 h of thrombolysis. The architecture of this system is based on a hub-and-spoke model with each unit being called a STEMI cluster. Early reperfusion: combining primary percutaneous coronary intervention with pharmacoinvasive strategy the STEMI INDIA model Most cardiac catheterization labs are located in the cities, and patients with STEMI will have to travel to a hospital with a cath lab to access treatment (primary PCI). A large number of STEMI patients who present to rural or peripheral hospitals arrive beyond the time window when treatment can be started. With this kind of challenge, the pharmacoinvasive approach (Figure 1) shortens the time to reperfusion through pharmacological means at the rural hospital followed by a coronary angioplasty at the city hospital to consolidate the reperfusion process. Figure 1 Pharmacoinvasive strategy.

3 CardioPulse 2451 ST-segment elevation myocardial infarction corridor to access treatment Traffic congestions and transfers to hospitals cause considerable delay in time to treatment. Patient flow and early reperfusion can be optimized with the hub-and-spoke model (Figure 2). This model consists of rural and peripheral hospitals connected to a city hub hospital. An emergency ambulance system (like the GVK EMRI) is activated by the patient or the healthcare facility by using CALL 108. The model also addresses issues of poor expertise and infrastructure in managing medical emergencies at the population level, especially in rural districts. Keeping pace, Tamil Nadu pilot study A STEMI INDIA pilot study was done in partnership with the Government of Tamil Nadu and GVK EMRI in accordance with the current practice guidelines and protocols. The Tamil Nadu study was initiated with four hub hospitals in Chennai, Vellore, and Coimbatore (Figure 3). Featured below is a case study from the Tamil Nadu pilot initiative. The pilot study has confirmed feasibility and efficiency of the STEMI INDIA model in delivering state of the art and affordable care in the Indian setting. Tamil Nadu ST-segment elevation myocardial infarction study This pivotal study conducted by STEMI INDIA, a not-for-profit organization, is an Indian Council of Medical Research-supported study conducted in collaboration with the Government of Tamil Nadu, which demonstrated that by linking several smaller, peripheral spoke hospitals with a centrally located, PCI-capable hub hospital, the use and timelines of reperfusion therapy could be improved. Tamil Nadu STEMI was a multicentre public private initiative to improve access to invasive cardiac services for STEMI connecting local facilities (spokes) with four large PCI hubs. The programme utilized a regional ambulance service and an indigenously developed, low-cost ECG monitoring device. The ECG, done in peripheral hospitals, was transmitted to an on-call cardiologist in the hub hospital for STEMI confirmation. Appropriate treatment was initiated only after that. Data were transmitted and stored in a cloud-based monitoring system. Patients at spokes were transferred to hubs after fibrinolysis, with care for below poverty line patients funded by government insurance. Data were prospectively collected pre- and post-implementation. The primary outcome was the proportion of STEMI patients undergoing coronary angiography/pci with 1-year mortality as a secondary outcome. A patient s story Mr P., a 63-year-old male smoker (8 10 beedies per day), works as a day labourer in a farm. He is not hypertensive or diabetic. He has, however, a below poverty level insurance card. This insurance is provided by the Government of Tamil Nadu and can be used to access medical care at specified public and private hospitals in the state. All aspects of STEMI management including inter-hospital transportation are covered by the scheme. The insurance is run as a public private partnership, with the premium paid by the Government and the insurance managed by a private insurance company. Chest pain started at 4.30 a.m (Figure 4). Called 108 emergency ambulance service at 5.30 a.m. Ambulance arrived at 5.50 a.m. Electrocardiogram was done and transmitted to the on-call cardiologist Figure 2 Hub-and-spoke model. Figure 3 Tamil Nadu pilot.

4 2452 CardioPulse Figure 5 Electrocardiogram done in ambulance using the STEMI INDIA device (photograph taken by the ambulance driver on his mobile smartphone). Figure 6 Electrocardiogram done in ambulance using the STEMI INDIA device (photograph taken by the ambulance driver on his mobile smartphone). Figure 7 Electrocardiogram showing hyperacute inferolateral myocardial infarction. Figure 8 Electrocardiogram showing 50% resolution of ST elevation. Figure 4 Patient journey.

5 CardioPulse 2453 Figure 9 Pre-percutaneous coronary intervention images of the culprit vessel, right coronary artery. Figure 10 Post-percutaneous coronary intervention images of the culprit vessel, right coronary artery. at the hub hospital (Figures 5 and 6). Electrocardiogram was accessed and STEMI was confirmed at 6.05 a.m. (Figure 7). Ambulance left the scene at 6.10 a.m., and the patient was taken to a local hospital at the small town of Oddanchatram. The hospital has a 60-bed facility with a 2-bed CCU and a part of a STEMI system of care a hub-and-spoke model. This spoke hospital is located Figure 11 Patient at discharge. 126 km away from the nearest catheterization laboratory located at the hub hospital at Coimbatore. The ambulance arrived the hospital at 6.30 a.m. Thrombolysis was started with streptokinase at 6.50 a.m. and completed at 8.00 a.m. Mild pain persisted. Electrocardiogram was repeated at 9.30 a.m. Figure 8 shows a 50% reduction in ST elevation with pain settled. The patient was stabilized and transported in a monitored ambulance to the hub hospital at Coimbatore 126 km away. Transportation started at a.m. Mild pain persisted on arrival at the hospital at p.m. Decision was made to transfer the patient to the cath lab. The patient was moved to the cath lab at 1.15 p.m. Radial access cath started at 1.30 p.m. Catheterization revealed a hazy 99% stenosis of a hyperdominant right coronary artery (Figure 9). Percutaneous coronary intervention was performed with a 3.5 mm 18 mm drug-eluting stent with good angiographic result and TIMI III flow (Figure 10). Procedures were completed at p.m. The patient was discharged on Day 3 (Figure 11). Total bill was paid by the state insurance. The success of the pilot programme has spurred interest from other states in India. This programme is now being extended to other areas of the nation and could serve as a model STEMI system of care for low- and middle-income countries.