Challenges in Pre Hospital Diagnosis & Management of Acute MI Dr.Vinod Sharma National Heart Institute

Pre Hospital Management of AMI - Challenges AMI, a most devastating presentation of atherosclerotic CAD. With rising incidence of diabetes & hypertension, the population of India is exposed to the significant risk of AMI.

STEMI represents the critical phase of Acute Coronary Syndrome ST Elevation MI

1. Time is Myocardium 2. Infarct Size is Outcome 100 D 80 60 Mortality Reduction (%) C 40 20 B A Extent of Myocardial Salvage 4 8 12 16 20 24 Time From Symptom Onset to Reperfusion Therapy, h Critical Time-dependent Period Goal: Myocardial Salvage Time-independent Period Goal: Open Infarct-Related Artery Gersh BJ, et al. JAMA. 2005;293:979.

Reduction in Long Term Mortality We expect that this strategy will result in 15 and maybe even 20 extra lives saved per 1000 treated. This estimate is Based on available evidence, showing that a one-hour of reduction in treatment delay Reduces 1-yerar mortality by 14% and an observational study documenting that in our county One-year mortality is 11% among STEMI patients treated by PCI. Therefore, the beneficial effect of earlier reperfusion thereapy may be of the Same magnitude as the beneficial effect obtained when we introduced aspirin instead of placebo, Fibrinolysis instead of placebor or primary PCI instead of fibrinolysis. Every 30-minute delay from onset of symptoms to reperfusion. 1 year mortality is increased by 8% De Luca et al, Circulation 2004 5

“Brave New world” Dark-Ages AMI Therapy : A stunning Evolution !! Best of Angioplasty Techniques Multifacelated Approach + Adjunctive Medication Angioplasty Thrombolysis CCU Bed Rest Dark-Ages

Absolute mortality rate remains same For last 15 years 5.5% in young and 19.7% in elderly

Reperfusion is the key to save myocardium and life…. Aim is to open the blocked I.R.A. and Re-establish the coronary blood flow A. Rapid B. Early C. Complete D. Sustained

Patency should be restored early *Antithrombin agents, antiplatelet agents, and/or fibrinolytic agents.

PTCA vs. Fibrinolysis: Short Term Clinical Outcomes (23 RCTs) Frequency (%) P<0.0001 P=0.0002 P=0.0003 P<0.0001 P=0.032 P=0.0004 P<0.0001 Hem. Stroke Death Death, no SHOCK data ReMI Rec. Isch Stroke Major Bleed Death MI CVA Keeley E. et al., Lancet 2003; 361:13-20. 10

Lytic Vs. PCI in Acute MI Patients Fibrinolysis Primary Angioplasty 100% 50% 0% 0% 50% 100% >95% TIMI 3 0.1% Stroke 2% Reocclusion 5% availability Availability <50% Treated 60% TIMI 3 5% Reocclusion 1% Stroke 25% Late occlusion 11

Selection of Reperfusion Strategy in STEMI Time since the onset of symptoms Risk of Mortality from STEMI Availability of skilled PCI Laboratory Time required for Transport Any contraindication to thrombolysis including bleeding, ICH Patient preference ACC/AHA STEMI Guidelines 2004

Pre hospital management of AMI Medical System in India General Practitioners / Family Physicians Private hospitals - Small nursing homes - Larger hospital run by individual Specialist - Corporate hospitals Government hospitals - Generally used by underprivileged patients

Five doors representing five different levels of decision making

Pre hospital management of AMI – Challenges Delays Patient delay in presentation - A key determinant Patient decision time - Symptoms are often interpreted incorrectly because of psychological defense mechanism viz. denial. Doctors decision time - in diagnosis - therapy viz Thrombolysis Despatching & ambulance response Transportation time

Normal EKG in STEMI LIMITATIONS Diagnostic Test Equivocal - Trop T / I - Normal - EKG - Normal Lack of availability of Echocardiogram in Clinic / Ambulances Physicians hesitation – Restriction in using thrombolysis in Clinics / Nursing Homes

95.8% of patients treated after 90 minutes Door to balloon Door to door

Indian scenario Pain to door time: South India: 10.8 hours (Indian Heart J 2004;56: 210–4) North India: 5.2 hours (Indian Heart J 2003;55: 349–53) Door to drug time: 1 hour Low rate of in-hospital thrombolysis mainly due to late arrival. In an observational study conducted in a tertiary centre in south India, the mean duration between symptom onset and hospitalization was 10.8 hours and the 30 day mortality among the 1320 evaluated patients was 16.9% (Indian Heart J 2004;56: 210–4). In an another observational study from North India, the median pain-to-door time was 5.2 hours Time delay (> 6 hours) was the commonest cause of not receiving thrombolysis (79%) while pre-tertiary centre thrombolysis was the reason only in 5% of the patients. Thus 79% of the patients missed pre-tertiary centre thrombolysis. (Indian Heart J 2003;55: 349–53) Reasons for not receiving in-hospital thrombolysis 30days mortality among 1320 pts 16.9%

Pre hospital management of AMI IN HOSPITAL DELAYS Door to needle / door to balloon time of up to two hours in non-specialized hospitals with basic facilities. Availability of Cath Lab, experienced Cardiologist – very few, hospitals are equipped with round O’ clock facility for PCI

Missed opportunities in re-perfusion for STEMI

Selection of Reperfusion Strategy in STEMI Majority of the hospitals are not PCI enabled. most of PCI enabled hospitals do not have inhouse interventional Cardiologists & paramedics to carry out interventional procedures round the clock. Availability of transport, long transportation time, traffic congestion & weather condition affects access to the PCI enabled centre.

Accounts / Billing section From where, I get 2.0 lacs at this time in night !!! Accounts / Billing section Your patient needs PPCI. Deposit Rs.2.0 lacs immediately for PCI

Pre hospital management of AMI – Cost Implication Majority do not seek Medical facility due to cost constraints. Poor penetration of medical insurance in India. There is no system of blanket permission by the Insurance agencies to hospitals to treat the patient first & fulfill the documentation requirements subsequently.

AMI in India – CREATE REGISTRY N = 20,000 of AMI from 89 hospitals in 50 cities of India 60.6% STEMI 39.4% Non STEMI STEMI presented to hospital an hour earlier than those with Non STEMI, with median time to presentation about 5 hours (40% within 4 hours & 60% after 12 hours) 60% patients received thrombolysis & median time for thrombolysis was 50 minutes. Only minority (8%) had PTCA, 1.9% CABG

AMI in India – CREATE REGISTRY 30 day mortality for STEMI – 8.6% Stroke – 0.7% Only 5.5% patients of STEMI used an Ambulance service to reach hospital, whereas 84% reached through Private transport. 1/10 used Public transport to reach hospital.

AMI in India – CREATE REGISTRY Modes of payments - 74% patients paid from own pocket for treatment - 12.9% Insurance or Govt. funding - 0.4% Free treatment Admission diagnosis of STEMI was more frequent in rural hospitals & rates of thrombolysis were higher in rural hospitals.

Pre hospital management of AMI – Triage Specific diagnosis EKG recording at Home - Telephonic EKG transmission - Computerized ECG interpretation Transport of Patient - Speed - Emergency equipment - Choice of hospital for heart attack victim - Report from the ambulance to receiving hospital

Pre hospital management of AMI – Improving the Outcomes in India Public education. Physicians’ Educations & motivation to participate in community level activities, so patient do not waste “Golden Hour”. Shortening the time to reperfusion & enhance myocardial salvage. - Pre hospital thrombolysis, PPCI

Pre hospital management of AMI – Improving the Outcomes in India (contd….) Reimbursement agencies - Blanket permission for beneficiary in event of AMI treatment without pre-authorization Government, Cardiology Society & Physicians have to come together to develop a “National Strategy”. Training of paramedics, practitioners & young Interventional Cardiologists to enhance the quality of care for AMI.