In the wake of a severe heart attack, also known as an ST-elevation myocardial infarction (STEMI), receiving effective treatment within several hours is crucial to reduce muscular damage and the risk of death. Effective treatment requires reperfusion (opening the blocked artery) using either thrombolytic medications or a more expensive (and more effective) percutaneous coronary intervention (PCI) performed in a cardiac catheterization laboratory. Given the need for rapid treatment, a few factors can mean the difference between life, death, and long-term disability:
- Patients and those around them require the ability to quickly recognize heart attack symptoms and call for emergency services;
- Ambulance drivers have to easily navigate traffic;
- Properly trained doctors and well-equipped emergency rooms need to be available.
While STEMI is a serious problem in high-income countries such as the United States, it has been an increasingly visible issue in low- and middle-income countries (LMICs) such as India, China and Brazil. People in these countries are now living long enough, thanks to advances in fighting infectious disease, to fall victim to chronic noncommunicable diseases like cardiovascular disease (CVD) and “first-world” medical crises like STEMI. In many LMICs, the infrastructure to treat STEMIs with thrombolytics or PCI in a timely manner simply doesn’t exist or is woefully inadequate, further increasing mortality rates.
In 2014, we were contracted by the Medtronic Foundation to implement HeartRescue Global, an extension of an already existing HeartRescue program in the United States, in selected cities in China, India, and Brazil. The goal of HeartRescue is to create an effective STEMI response program, geared to the unique needs of the local community, that speeds time to effective treatment and improves access to quality health care—in other words, to ensure that all of the medical and EMS infrastructure is on hand to enable effective reperfusion treatment and increase STEMI survival rates.
Implementing HeartRescue Global in China, India and Brazil
Each of the countries involved in HeartRescue Global presents unique challenges. For example:
In Suzhou, China, 10 percent of the population lives on less than two dollars per day, 25 percent lacks adequate health insurance, 20 percent consists of migrant workers with low social status and 20 percent has a low level of education. As a result, many Suzhou residents are unfamiliar with STEMI symptoms and/or resistant to seeking medical help (fearing the high bills that might result). On the positive side, Suzhou does have a robust network of community health centers, a well-equipped EMS program, and several hospitals equipped with Chest Pain Centers specifically designed to cope with CVD.
As part of HeartRescue Global, we are working with the Suzhou municipal EMS and a local hospital to implement a STEMI patient data registry for data collection, performance measurements, and feedback to providers; this registry supports improvements in care and is aligned with the five-year public health plan of the Suzhou Municipal Health and Family Planning Commission. We are also developing STEMI health education and communication plans with local partners, aimed at the underserved population, and we are developing EMS, emergency department, and hospital treatment protocols that will allow patients with STEMI to be more rapidly diagnosed and treated without fear of affordability.
Bangalore, India, suffers from many of the same issues as Suzhou, especially around poverty and lack of education. In addition, Bangalore presents several unique problems of its own. For example, the traffic jams in this city are often so severe that ambulances can’t reach STEMI victims in a timely manner, and private health insurance is of variable quality, with justifiable claims sometimes denied or simply ignored.
We have a variety of HeartRescue Global initiatives in place in Bangalore. We are:
- teaching eighth and ninth graders about the signs and symptoms of STEMI and assigning homework so that they will share this information with their parents
- supplementing ambulances with trained nurses on motor scooters, who can navigate through the traffic jams more quickly and communicate with doctors via cellphones
- developing a “Hub and Spoke” hospital system, in which larger hospitals share their STEMI treatment expertise with less-well-equipped and smaller community hospitals.
- educating health-care providers on clinical methods for more rapid diagnosis of STEMI and reducing time to effective pre-hospital and hospital treatment
As in China, we are also developing a detailed STEMI patient registry system, with data collection on a series of HeartRescue quality measures focused on time from onset of patients’ symptoms through EMS response and transport and emergency department and hospital treatment with thrombolytics or PCI. Continuous quality-improvement methods are being taught to local providers, who will use the patient registry data for feedback and improvement of their interventions to reduce time to effective reperfusion treatment for STEMI patients.
Vitória da Conquista, Brazil, serves as an important regional center for health care, including several smaller cities in its surrounding region of Bahia and Minas Gerais. Our program here is less advanced than in Suzhou or Bangalore; we originally had planned a HeartRescue effort in Sao Paolo, which was discontinued. As an example of the challenges Vitoria da Conquista faces, the only publicly funded reperfusion strategy currently available for STEMI patients in the public health care system is through thrombolytic medications in the General Hospital—that is, when thrombolytic drugs are available.
We believe that the development of a multi-faceted intervention in Vitória da Conquista, including the community, EMS, and public and private hospitals, along with expanding access to thrombolytic medications and privately funded PCI services, will enable improvements in care for STEMI patients. As in China and India, we are developing a systematic STEMI patient registry data-collection system that focuses on the quality measures standardized for the HeartRescue Global program, which will enable tracking of patient access, reducing time to effective reperfusion treatment, and continuous quality improvement of STEMI interventions.
Providing a Model for STEMI Treatment Programs Worldwide
In June 2018 we began the fourth year of our five-year HeartRescue Project in China, India, and Brazil. We are hopeful that the comprehensive approach to interventions across the community, EMS, and hospitals, and the progress we have made in treating STEMI in a more timely fashion, will provide a model for other cities in these countries. This approach is also useful for other LMICs dealing with the rapidly increasing burdens of CVD and STEMI, and can thus help to save countless lives around the world.