This paper describes the opportunities and challenges in building ST-elevation acute myocardial infarction (STEMI) systems of care in Stent for Life affiliated and collaborating so-called emerging countries, namely India, China, South Africa and Mexico, where CAD mortality is increasing and becoming a significant healthcare problem. The Stent for Life model supports the implementation of ESC STEMI Guidelines in Europe and endeavours to impact on morbidity and mortality by improving services and developing regional STEMI systems of care, whereby STEMI patients' timely access to a primary percutaneous coronary intervention (PPCI) is assured. In India, the STEMI India model incorporates a dual approach of combining PPCI with a pharmacoinvasive strategy of reperfusion. The architecture of the system is based on a hub and spoke model with each unit called a STEMI cluster. The project is driven by a private non-profit organisation. In China, the STEMI PCI programme is led by the Chinese College of Cardiovascular Physicians and supported by the national government. Although primary PCI is performed nationwide, a thrombolytic treatment strategy is still the first option in many rural areas because of logistic considerations. Establishing local STEMI transfer networks and then implementing a pharmacoinvasive strategy of reperfusion are being considered and promoted currently. In South Africa, the pharmacoinvasive approach currently dominates as STEMI treatment option in many areas. A pilot study shows that low symptom awareness leads to long patient delays. The education of all role players, from patients to healthcare professionals and including institutions and governmental structures, is needed to achieve prompt diagnosis and treatment. In Mexico, improving the treatment of STEMI requires considering myocardial infarction to be an emergency that must be treated by an entire system and not just by a particular service. Patients need to receive quick treatment from clinical and interventional cardiologists, and the emergency medical system (EMS) must understand the importance of early reperfusion therapy when appropriate. Mexican health authorities have used registries as their main strategy for improving the use of health resources for ACS patients. In general, building regional STEMI systems of care and an EMS system infrastructure are critical success factors in the stepwise development of STEMI systems of care at a national level in emerging countries as they are in Europe. An in-depth understanding of healthcare system-level barriers to timely and appropriate reperfusion therapy facilitates the development of more effective strategies for improving the quality of STEMI care in each region and country.
undergo PCI within 90 minutes of FMC, should be treated with fibrinolytic therapy within 30 minutes of hospital presentation, unless such therapy is contraindicated.A recent study in STEMI patients found that while p-PCI was performed in 60%, the majority of the interventions occurred later than 120 minutes, and that only 36% received fibrinolysis.(2) This high percentage of patients receiving angiographyand an invasive treatment strategy may be explained by the location of the participating centers in urban areas, almost all of which were private healthcare facilities.Early and appropriate pre-hospital diagnosis, as well as immediate transport, are of vital importance to avoid unnec- ABSTRACT
Over the past decades, South Africa has undergone rapid demographic changes, which have led to marked increases in specific cardiac disease categories, such as rheumatic heart disease (now predominantly presenting in young adults with advanced and symptomatic disease) and coronary artery disease (with rapidly increasing prevalence in middle age). The lack of screening facilities, delayed diagnosis and inadequate care at primary, secondary and tertiary levels have led to a large burden of patients with heart failure. This leads to suffering of the patients and substantial costs to society and the healthcare system.In this position paper, the South African Heart Association (SA Heart) National Council members have summarised the current state of cardiology, cardiothoracic surgery and paediatric cardiology reigning in South Africa. Our report demonstrates that there has been minimal change in the number of successfully qualified specialists over the last decade and, therefore, a de facto decline per capita. We summarise the major gaps in training and possible interventions to transform the healthcare system, dealing with the colliding epidemic of communicable disease and the rapidly expanding epidemic of non-communicable disease, including cardiac disease.
Background: Hypertensive heart failure in developing communities may be associated with reduced pump function. Whether severity of hypertension impacts differently in patients with hypertensive hypertrophy with systolic dysfunction as compared to patients with hypertensive hypertrophy with preserved systolic function is not clear. We therefore evaluated the relative impact of blood pressure in patients with left ventricular hypertrophy (LVH) with preserved left ventricular systolic function versus patients with LVH with reduced systolic function.Methods: A single-centre study of 175 Black African patients (55% female, age = 53.1±10.1 years) with moderate to severe hypertension (HT) was performed. Using echocardiography, patients were grouped as follows: (1) HT with preserved left ventricular systolic function; and (2) HT with reduced left ventricular systolic function. All measurements were made using standard American Society of Echocardiography definitions. Low ejection fraction (EF) was defined as <50% using the Simpsons method, LVH as LV mass index >120g/m2 in males and >100g/m2 in females. HT was defined as systolic or diastolic daytime ambulatory BP (ABPM) >140mmHg or 95mmHg respectively. Twenty eight healthy normotensive subjects served as controls.Results: There were no observed differences in any measure of blood pressure between patients with reduced EF (31 patients, 18%) and preserved EF (144 patients, 82%). The low EF group had significantly more male patients (81% vs 37%) but similar BMI (32.2 vs 30.7). Results: Mean follow-up was 12.8 +/-5.0 months. The mean age was 39 +/-10.7 years at diagnosis. 13 male and 28 female patients. Mean left ventricular end diastolic diameter 56.8 +/-8.6mm and mean ejection fraction 32.2 +/-12.1%. The major complications at baseline were heart failure, 67% were in NYHA class II/III, left ventricular thrombus formation in 11(26%). At follow-up 31.7% were in NYHA II/III heart failure, 5 (13.1%) patients reported worsening heart failure of which 2 (4.8%) required admission and none had left ventricular thrombi. Warfarin was ABSTRACTS SA HEART CONGRESS 2012 169Winter 2012Volume 9 • Number 3 prescribed in 29% of patients with no bleeding complications. There were 5 deaths: 1 cardiac failure related and 4 sudden cardiac deaths. Conclusion:At one year follow-up, heart failure and sudden cardiac death remained a significant complication of ILVNC despite standard heart failure treatment and meticulous follow-up.
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