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

2. 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.

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

4. 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.

5. 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

6. “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

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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. Five doors representing five different levels of decision making

15. 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

16. 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

17. 95.8% of patients treated after 90 minutes
Door to balloon
Door to door

18. 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%

19. 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

20. Missed opportunities in re-perfusion for STEMI

21. 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.

22. 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

23. 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.

24. 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

25. 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.

26. 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.

27. 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

28. 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

29. 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.