Stent for Life Initiative: leading example in building STEMI systems of care in emerging countries

Abstract

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.

Referral pathways for reperfusion of STEMI – developing strategies for appropriate intervention

“…(7) We hope to establish an effective network between the various stakeholders and create a fully functional central hub that oversees all initiatives and monitors progress through the maintenance of a registry. The mismatch between need and availability of PCI-capable facilities remains a concern (7) but success stories relating to government involvement in other countries are encouraging.…”

“…(7) We hope to establish an effective network between the various stakeholders and create a fully functional central hub that oversees all initiatives and monitors progress through the maintenance of a registry. The mismatch between need and availability of PCI-capable facilities remains a concern (7) but success stories relating to government involvement in other countries are encouraging. (7,13,14) Perceived South African healthcare challenges (personal observations) that need to be considered relate to: lessons learnt from other countries are encouraging (7) and much may be learnt from their experiences in treating patients coming from remote areas.…”

Prehospital diagnosis of patients with acute myocardial infarction

“…However, the limited accessibility of hospitals with 24-7 PPCI capability is a significant obstacle to widespread use of PPCI, and only few countries have been able to offer PPCI to all patients with STEMI, Figure 1 [10][11][12]. In urban areas PPCI service is within reach for most patients, whereas offering PPCI to patients in rural areas is a challenge.…”

Anticoagulation Strategies for Primary Percutaneous Coronary Intervention

“…43 It is a remarkable tribute to PCI advances that such caution has been replaced by entire countries adopting primary PCI as the default or preferred strategy for STEMI reperfusion. 34,35,44,45 Until the early 1990s, anticoagulation associated with PCI was complex, drug dosages were high, technology was mediocre (balloon angioplasty alone), and complications of dissection, thrombosis, and emergency bypass surgery rates were in excess of 5%. The utilization of unfractionated heparin in the initial primary PCI experience was strikingly different from current trials and clinical practice: patients received 3000 to 5000 U of heparin after femoral vascular access, followed by 5000 to 7000 additional units of heparin after coronary angiography.…”