Implementing myocardial infarction systems of care in low/middle-income countries

Abstract

Ischaemic heart disease is the leading cause of death worldwide, with an increasing trend from 6.1 million deaths in 1990 to 9.5 million in 2016, markedly driven by rates observed in low/middle-income countries (LMIC). Improvements in myocardial infarction (MI) care are crucial for reducing premature mortality. We aimed to evaluate the main challenges for adequate MI care in LMIC, and possible strategies to overcome these existing barriers.Reperfusion is the cornerstone of MI treatment, but worldwide around 30% of patients are not reperfused, with even lower rates in LMIC. The main challenges are related to delays associated with patient education, late diagnosis and inadequate referral strategies, health infrastructure and insufficient funding. The implementation of regional MI systems of care in LMIC, systematising timely reperfusion strategies, access to intensive care, risk stratification and use of adjunctive medications have shown some successful strategies. Telemedicine support for remote ECG, diagnosis and organisation of referrals has proven to be useful, improving access to reperfusion even in prehospital settings. Organisation of transport and referral hubs based on anticipated delays and development of MI excellence centres have also resulted in better equality of care. Also, education of healthcare staff and task shifting may potentially widen access to optimal therapy.In conclusion, efforts have been made for the implementation of MI systems of care in LMIC, aiming to address particularities of the health systems. However, the increasing impact of MI in these countries urges the development of further strategies to improve reperfusion and reduce system delays.

Quality evaluation and future priorities for delivering acute myocardial infarction care in Sri Lanka

“…Over 50% of patients eligible for reperfusion therapy received treatment within 12 hours of admission, and nearly three-quarters (72.0%) of patients diagnosed with a STEMI underwent PCI. These numbers are higher than previously reported in Sri Lanka and may positively reflect the impact of recent investments in hospital services by the Ministry of Health, such as making stents available for free at PCI centres since 2018 4 5 20–22. Antiplatelet therapies and high-intensity statins essential to reducing mortality in the AMI population were administered in over 75% and nearly 90% of all eligible patients, respectively (domains 4 and 5).…”

“…Despite the recent provision of ambulance service in the region, very few patients used the service when presenting to the tertiary facility from the community. The impact of pre-hospital access on 'time to intervention' is not explored within this evaluation 22…”

“…29 Focus groups held with frontline healthcare workers to map the pathways of AMI care revealed that diagnosis of AMI was delayed due to inconsistencies in patients’ timeliness of presentation, accessibility of ECG investigation for patients when presenting with the symptoms of syndromic acute coronary syndrome and delays in reporting of ECG. These delays resulted in bottlenecks to accessing expert cardiology services 22 26. In response to this, a project is underway by the authors to explore how the m-Health platform used here for the registry might help provide a solution to the organisational aspects of delay.…”

“…Adaptation of the application to enable a digital referral pathway between PCI and non-PCI capable cardiology centres and to enable direct designated communication between medics in the emergency admission unit and the on-call cardiologists is underway. Similar interventions, which have sought to network primary and secondary services around a central PCI centre and to prioritise pharmacoinvasive interventions in the absence of revascularisation services have successfully reduced mortality in India and other LMIC settings 22…”

“…Recent high profile publications,1 22 in this and other international journals, have highlighted the impact that poor quality of care is having on outcomes globally, and specifically, the excess mortality and morbidity associated to poor quality of care for cardiovascular disease in South Asia. However, as highlighted by an editorial in this journal and more recently in a review again earlier this year,1 10 22 the existing quality of care and the impact of these investments on patient recovery remain absent. Efforts to evaluate care in the region have been hampered by sampling and limited to in hospital care 10…”