1. Introducing fibrinolysis as emergency therapy in Timergara hospital, Pakistan – what happens beyond the emergency department? Stefano Malinverni, Rosa Auat, Gul Ghuttai Khalid, Pola Valles, Engy Ali, Rafael Van den Bergh, Fouzullah Mohamed, Iqbal Mohamed, Aftab Ud-Din, Matthias Heukäufer, Catherine Van Overloop, Médecins Sans Frontières- Operational Centre Brussels Headquarter and Pakistan mission

2. Introduction Myocardial infarction (MI) is the most severe result of coronary artery disease (CAD) and major cause of death and disability worldwide The management of ST Myocardial infarction (STEMI) is coronary revascularization includes fibrinolysis with streptokinase (SK)- single high-cost intervention, leading to improved prognosis

3. Context- Timergara, Pakistan Timergara city is located in Lower Dir district, a tribal conflict area Difficult access to healthcare o Security (check points, army presence) o Mountainous area High prevalence of CAD (24-30%) Lack of timely diagnosis and treatment Lack of monitoring and supportive care during and following fibrinolysis

4. Cardiac Care Unit, Emergency Department, Timergara Hospital Organizing a Fast track for thoracic pain diagnosis in ED o Improving triage system (SATS) o Training of staff o Ensuring sufficient staff Setting up a Cardiac Care Unit (CCU) o Introducing streptokinase (SK) within a tightly regulated frame o Improving safety of administration through improved monitoring o Training doctors and nurses on management of CAD and advanced life support by ER and cardiac international specialists.

5. SOP – European recommendations ECG as soon as possible Aspirin 300 mg Clopidogrel 300 mg Enoxaparin 1 mg/kg Streptokinase 1.5 MU over 1 hour Monitor patient during procedure Door to diagnosis time <10 minutes Door to needle time <30 minutes ≤ 30 min≤ 10 min ≤ 12 hrs

6. Objectives To assess whether the provision of fibrinolytic therapy is feasible in an MSF setting in terms of compliance with SOP & international recommendations Specifically, among patients presented with STEMI in the ED of Timergara hospital, to describe:  Quality of care provided  Patient characteristics and outcomes at hospital discharge  Follow up on mortality and quality of life one and three months of post hospital discharge

7. Methods Design: A descriptive study using routine retrospective programme data and follow-up phone interviews. Study population: All patients who presented with acute MI and received SK in the ED between March 2015 and April 2016 Phone follow-up (July 2015-Feburary 2016): o Two national ER doctors o Structured questionnaire was used to gather information on patient outcomes (alive/dead, presence of heart failure, recurrence of chest pain, compliance to pharmacological treatment) Ethics: Approved by MSF ERB & National bioethics committee (NBC) Pakistan

8. Results: Characteristics in the ED Variable n (%) Total STEMI 565 Age (median, Interquartile range), years Male Time lapse between chest pain onset and ED admission  < 12 hours  >= 12 hours Medical history  Hypertension  DM  Smoking 65 (55-70) 324 (57%) 4h10 (2h15–8h49) 416 (81%) 102 (19%) 298 (53%) 127 (23%) 27 (5%) Received SK  Resolution of chest pain and ST elevation  Complications (e.g. anaphylactic shock, bleeding) 434 (76%) 249 (58%) 41 (9.5%)

9. Results ED

11. Results: outcomes at hospital discharge

12. Results- compliance to SOP guidelines

13. Results- follow up 409 patients admitted to CCU during follow up period 308 STEMI patients received SK 294 patient discharged alive 157 followed up after 1 month 90 followed after 3 months

14. Results- one month follow up Variable n (%) Total 157 Alive 149 (96%) Signs of heart failure Dyspnea during light effort Dyspnea during major efforts 6 (4%) 8 (5%) Recurrence of chest pain Consulted a Doctor if chest pain Hospitalized due to chest pain 8 (5%) 8 (100%) 0 (0%) Consulted a doctor for follow up Compliance to treatment o Aspirin o Clopidogrel 137 (87%) 157 (100%) 152 (97%)

15. Results- three months follow up Variable n (%) Total 90 Alive 90 (100%) Signs of heart faliure Dyspnea during light effort Dyspnea during major efforts 4 (4%) Recurrence of chest pain Consulted a Doctor if chest pain Hospitalized due to chest pain 5 (5%) 5 (100%) 0 (0%) Consulted a doctor for follow up Compliance to treatment o Aspirin o Clopidogrel 56 (62%) 88 (98%)

16. Conclusions The intervention had a positive impact, though a limited number of patients were followed up at 3 months A good compliance with SOP can be achieved despite the difficult context Unmet objectives in terms of rapidity of management o Limitations related to the context (e.g. consent) o Oversaturated ER causing shortages in manpower Challenges with the follow up: o Technical & cultural barriers o Security evacuation o Limited manpower

17. A CCU in remote setting is feasible Success of a CCU relies on adequate staffing resources and training More data monitoring would allow for accurate estimate of benefits 17

18. Laughter (and ice cream) is the best medicine. Unless you have a myocardial infarction. Then SK is better.