The Telegraph
Thursday , March 9 , 2017

Protocol on heart attack

- Health agency recommends nationwide adoption of hub-and-spoke network

New Delhi, March 8: India's health research agency has recommended the nationwide adoption of a heart attack treatment protocol that doctors say is intended to benefit tens of thousands of patients across the country currently unable to access timely care.

The Indian Council of Medical Research (ICMR) has urged states with existing ambulance networks to implement the protocol that relies on a hub-and-spoke network of large and small hospitals and ambulances equipped to exchange electrocardiograph (ECG) readings via mobile devices.

Cardiologists who developed the so-called ST-elevation myocardial infarction (STEMI) protocol and tested it in Tamil Nadu over a period of 32 weeks have observed a sharp increase in the proportion of patients who receive appropriate care and a reduction in mortality. The ST-elevation refers to a signature change in ECG and is the commonest type of heart attack that occurs when a blocked artery obstructs blood flow to the heart.

"Timely, appropriate treatment reduces the risk of heart failure and helps patients return to normal productive lives - this has huge economic implications," said Thomas Alexander, a senior cardiologist at the Kovai Medical Centre Hospital, Coimbatore, and director of the STEMI protocol project.

India has about 800 hospitals with cath labs, or facilities that can provide angiography and angioplasty services - the standard treatment for heart attacks - and an estimated two million patients who suffer heart attacks every year.

But most cath labs are located in cities and large towns and, medical studies have suggested that less than 10 per cent of patients in small towns and rural areas with ST-elevation heart attacks currently receive the ideal treatment in time.

The STEMI protocol, developed by Kovai and collaborating institutions, uses ambulances with trained paramedics, ECG monitors, and mobile devices to transmit patients' ECG readings to hub hospitals where cardiologists will screen the ECG and guide ambulances to spoke centres. There, patients will receive drugs such as clot-dissolvers before they are moved to the nearest hub hospitals for angiography and angioplasty, if required.

"The shorter the time from onset of symptoms to treatment, the better is the outcome for patients," said Ajit Mullasari, a senior cardiologist at the Madras Medical Mission, Chennai, and a member of the STEMI protocol study team. "The thrombolytic (clot-dissolving) therapy clears the blood clot in the artery and extends the window of time available for angioplasty, if required, which is used to treat the blockage itself," Mullasari said.

While similar protocols may already be in place in some locations, senior ICMR officials say, standardised implementation across the country will increase the number of patients who receive timely treatment.

"States may need to tailor the protocol to suit their own needs, depending on where their cath labs are located and on their ambulance and road networks," Meenakshi Sharma, a scientist in the ICMR's division of non-communicable diseases.

The ICMR, which funded the development evaluation of the STEMI protocol, had called a meeting of health officials from 18 states in January to urge them to adopt the protocol. "States will need a strong ambulance network to be able to implement this," Sharma said.

The Tamil Nadu study compared the outcomes of implementing the protocol for a period of 32 weeks on 2,420 patients with those of standard treatment received by 898 patients for a period of 12 weeks.

The cardiologists observed a nearly 10-fold increase (3.7 per cent to 33.5 per cent) in the proportion of patients transferred from spoke centres to hub hospitals, higher rates of coronary angiography (35 per cent to 60 per cent), and higher rates of primary angioplasty (46 per cent to 70 per cent).

At the end of a year, doctors observed three per cent lower mortality among patients who received the STEMI protocol compared to patients who received standard treatment.

The findings of the STEMI protocol study appear today in the Journal of the American Medical Association (JAMA) Cardiology.

"These results are impressive," Amitava Banerjee, a preventive cardiologist at the Fair Institute of Health Informatics Reserarch, London, said in a commentary on the study published in the same issue of the journal. "Importantly, 48.4

per cent of patients were living below poverty level, showing that not only is this program feasible and deliverable in India, but also population coverage is possible across socio-economic boundaries."

An analysis of the impact of the protocol also indicates economic gains. "For every rupee spent on establishing the STEMI network, there is a gain of four rupees through averted economic loss caused by long-term health consequences suffered by heart attack survivors who do not receive timely treatment," Alexander said.

However, a senior cardiologist in India cautioned that the programme may be easier to implement in states with a strong healthcare network such as Tamil Nadu or Kerala than in states with weaker infrastructure.

"We'll have to see how well this can be implemented in the northern states," said Rajeev Gupta, a senior consultant in Jaipur who is trying to implement the protocol through a private hospital.

Cardiologists and ICMR officials also point out that the success of the protocol will also require states to pull down the financial barriers that prevent patients from accessing angioplasty. "Many states now have government-funded health insurance schemes which may help facilitate the easy implementation of the protocol," Gupta said.

"This is a protocol conceived and designed by Indian cardiologists, a creative solution to address uniquely Indian challenges," Brahmajee Nallomothu, professor of cardiovascular diseases at the University of Michigan, Ann Arbor, and co-author of the JAMA Cardiology study said. "This is something other low and middle income countries could learn from for themselves."

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