Systems of care for ST-elevation myocardial infarction in India

Abstract

The prevalence of coronary artery disease and STelevation myocardial infarction (STEMI) are increasing in India. Although recent publications have focused on improving preventive measures in developing countries, less attention has been placed on the acute management of STEMI. Recent policy changes in India have provided new opportunities to address existing barriers but require greater investment and support in the coming years.Coronary artery disease (CAD) is currently the most common, non-infectious disease in India and will affect over 65 million of its people by the year 2015. 1 One of the gravest complications of CAD is ST-elevation myocardial infarction (STEMI), a lifethreatening medical emergency that results from a sudden, occlusive thrombus in the coronary artery. When STEMI patients are treated promptly with reperfusion therapy, significant reductions in mortality and morbidity are possible. 2 3 Unfortunately, the overall use and quality of acute reperfusion therapy in India lags significantly behind North America and Europe.In this paper, we discuss the current state of STEMI care in India and argue for greater investment in acute reperfusion therapy. Although recent publications have focused appropriately on improving preventive measures for CAD in India, 4e6 less attention has been placed on the acute management of STEMI, or in particular, how 'systems of care' approaches, popularised in North America and Europe, may be implemented. 7 8 We specifically highlight recent policy changes that provide new opportunities to address existing barriers and briefly describe a 'real-world' example of a STEMI systems of care programme initiated in the southern Indian state of Tamilnadu.

Predictors of Failed Thrombolysis in Acute Myocardial Infarction

“…2 The unequivocal demonstration of role of the thrombus in acute myocardial infarction quickly led to the systematic testing of thrombolytic strategies to abort myocardial infarctions. 3 The thrombolytic therapy is the main mode of reperfusion in developing countries like India. 3 Although 60 to 70% of treated patients can be successfully reperfused, thrombolytic treatment fails in a substantial proportion.…”

“…3 The thrombolytic therapy is the main mode of reperfusion in developing countries like India. 3 Although 60 to 70% of treated patients can be successfully reperfused, thrombolytic treatment fails in a substantial proportion. These non-responsive patients can have a significant high mortality and morbidity.…”

Management of STEMI in Low- and Middle-Income Countries

“…In Australia, only 40.2% of the population had access to timely PCI [23]. In LMIC, similar to the situation in remote areas of high-income countries, scarce resources and other important barriers [19] to expeditious delivery of PCI means that realistically PCI is generally not the best default option. Important constraints include long transport times from rural areas to PCI-capable hospitals resulting in significant loss of viable myocardium.…”

“…An important opportunity in LMIC is expanding the ability to perform prehospital ECG, delivering pre-hospital fibrinolysis [19], and developing a robust emergency medical system that comprises emergency dispatch, first response teams, and 3. Pain patterns with myocardial ischemia.…”

A Race for the Base

“…In theory, however, integrated networks like this Brazilian program and others have the potential to transform care in LMICs by focusing on few affordable aspects of these systems, such as telecommunication advances and low-cost treatments. 10 Telemedicine services, for instance, played a critical part by automatically linking suspected STEMI patients with the Regional STEMI Alert Team experts. This…”