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Related Read - Multi-Modality Imaging. Dr.HK Chopra Panel: Dr Amal Banerjee, Dr.Satyendra Tewari, Dr. Jagat Narula and Dr.RR KasliwalValue of every tick-tock from the clock? Ask a patient who has survived a heart attack “The first six hours is a crucial period, after which, the benefits of a treatment are comparatively lesser,” says Dr. Ramesh Babu, a faculty member of CSI (Cardiology Society of India), in a conversation with Dr. H.K. Chopra, President CSI. Factors like the patient’s timely realization of it, proximity to a hospital capable of performing angioplasty, a quick ambulance service and availability of an operator combine to determine the fate of a patient, says Dr. Saumitra Kumar, President at the CSI headquarters.. “When medical practitioners, at such a crucial time, play around with medical jargon that confuses patients, advocates and insurance companies alike, the treatment is further delayed.” “Clarity in the patient's mind about the kind of treatment he requires drastically reduces the time taken to deliver it. Financial capability of the patient or response-time of his insurance company is an added burden weighing down on the time it takes to take a life saving decision for intervention.” The lack of facilities in India to conduct an immediate angioplasty, a mechanical intervention, often gives way to the second best option of thrombolytic therapy, a pharmacological intervention. “The mission of CSI is to get the blocked artery to open up, either with medicine or mechanical intervention, within 90 minutes of an attack,” says Dr. Shiv Kumar, Chairman of the upcoming NIC (National Interventional Council) meet. Technology can create a breakthrough via apps which can give patients instant information during an emergency. Smart Heart App is a new initiative of CSI which hopes to facilitate information flow during cardiac emergencies.
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Dr. HK Chopra I would like to ask Saumitra, I think we see a lot of patients of STEMI in our practice. Once they come to you, what are the important variables you consider right from home to the hospital time and the hospital to the needle time and the needle to the balloon time. What are the important variables which you consider? The reason I tell you why, there are going to be lot of medicolegal litigations.People say my patient came here in the hospital in the emergency at 9 o’clock and by the time we took to the patient to the cath lab it was three hours or four hours and by the time your technician came and doctor came it was five hours more.So, should we label this patient as to have primary PCI or only PCI. Why should we use the word primary because that is the legal sword on us? I think it is very important question I am asking you because there are already two or three cases lying in MCI to work on this.So, is it a primary PCI or PCI?
Dr. Saumitra Kumar Ok.The issue at stake is totally ischemic time that the movement patient has the chest pain to the time that he gets effective treatment that is reperfusion as we said, be it thrombolytic therapy or primary angioplasty that is the total ischemic time. Now, here problems are basically under two fold, i.e., one time spent out of the hospital and the moment the patient lands in the hospital what is the time taken to deliver the appropriate treatment. Now, time out of the hospital has two major entities, i.e., first one is dependent on the patient’s awareness about the whole problem that I am having chest pain, is it cardiac?, I should not waste time beyond first 15 to 20 minutes,. I should either report to the doctor I know the matter or I should get whatever transport is available to me and reach the nearest hospital that is competent enough to deal with the problem. So, that is one thing and other is the infrastructural problem, the kind of ambulance service and other services that we can provide so that the patient reaches the hospital in quickest possible time. Now, once the patient reaches the hospital that is the medicolegal entity that you raised that we should deliver the treatment in a time dependent fashion. Now, to take both the things into account, the out of hospital there is a term, now introduced instead of door-to-needle-and-door-to-balloon time, is the first medical contact to needle and first medical contact to door time so that the ambulance is also hospital’s responsibility. The ambulance takes the patient to the hospital and starts effective treatment.Once, the patient is in the hospital, if he gets within a reasonable timeframe, say the first three hours,if the hospital is not equipped enough to do the primary angioplasty, then probably lytic therapy still has a place, but if the patient comes much beyond that then probably the patient should be referred to the nearest PCI capable hospital. Regarding PCI, the time set after the patient reaches the hospital is 60 minutes, so we should try to deliver the effective treatment in 60 minutes and FMC2 angioplasty time is 120 minutes. So, all these timeframes are important because not much time should be wasted in the emergency department, your cath lab technician and other staff and the operator should be intimated as quickly as possible so that the process can be initiated in the quickest possible time. So, things are both technical that is once the patient in the hospital, communication and social awareness about the whole problem, so there are so many angles to the problem.
Dr. HK Chopra Dr. Saumitra Kumar, I think we see lot of patients coming to us in the clinical practice there.We find there are a lot of issues.Once we tell them, they have to go for PCI, they keep on calling their GP or their physician or their family members or their financial issues so many things are there. Are they really done in 120 minutes.
Dr. Saumitra Kumar Very difficult, very difficult.
Dr. HK Chopra That is an issue. Legally, these advocates ask us he had his chest pain at home, he spent almost one-and-a-half hours coming to you and then you spent almost two or three hours and then you need a PCI. Is it a primary PCI? The fight is only on this word, primary. Why do not we label only as PCI and forgot about it?
Dr. Saumitra Kumar The thing is that because time is muscle, every minute that you waste on these trivial issues, I will call that trivial because at the end of the day the time taken to deliver the treatment is all important. The time spent otherwise is all useless and may be harmful as well. So, here again comes issue of awareness that the patient should know that this is the treatment that I have to receive in a time dependent manner to give me the maximum 05:00 benefit and other thing is that the issue of trust that is something the hospital or the doctor in question has to, I mean, develop in the patient or imbibe in the patient. So that is the two or three things of trust, the dependence and the awareness of the problem that you have to get this treatment in the quickest possible time. Another issue is of course monetary that is whether the individual is giving it out of his pocket or it is insurance supported, whether the insurance company is reverting in the quickest possible manner, so these are the issues to be taken into account.
Dr. HK Chopra It is very important Dr. Ramesh Babu I think we see lot of patients, we will say rescue PCI or facilitated PCI or a primary PCI, I do not know they know what a secondary PCI. Our objective is lot of confusion and this confusion is in the dilemma of the insurance company involved in the medicolegal problems. There is lot of jugglery in words. Ultimately, what is my aim and your aim is PCI. Why we confuse the people so much because then we go to the detail is it really primary PCI? Should I reimburse the money, should I not reimburse the money and then the question comes from the patient’s mind and he sues the doctor that they did a primary PCI, I am doubtful because I reached five hours late, so it is not primary PCI, it has already created so much of damage in me. I would like to have a definition. It is a controversial issue.
Dr. Ramesh Babu I think one part is the primary PCI. The second part is the thrombolytic therapy. Probably, in a country like India, probably my guess is obviously the first major delay is the patient taking a call that this is a cardiac pain and going to the hospital probably my guess is less than 1% of the patient with heart attack are reaching a hospital on time. When I say on time, it is less than three hours, and I think probably pubic education is so crucial that any person having a chest pain unless proven otherwise, it could be heart attack and I think they should be asked to report as early as possible so that at least we will not delay that and I think whatever has been said and done unless they come on time it does not have a meaning and as you rightly said I think the real benefit happens in the first six hours, so that is the most crucial period and between 6 hours and 12 hours, the benefit is definitely less as such as the family, time is muscle and every minute is important. I think the most important thing is the spreading the awareness like in a brain stroke, first three hours and in a heart stroke first six hours are so crucial and I think terminology, probably we should not emphasize too much to the patients, this is primary and all that. I think we have a blocked vessel this has to be opened. We have two options, one is the medical therapy, thrombolytic therapy, the second angioplasty that may be far more simpler. Compared may be five or six years ago, lot of words were there, primary angioplasty, facilitated angioplasty, thrombolytic therapy cum angioplasty.
Dr. HK Chopra I think I totally agree with Dr. Ramesh Babu that there is lot of jugglery of words and lot of confusion it creates. We tell the patient should I give you Coltbuster or should I do primary PCI. We do not explain what do you mean by primary PCI and then there is a question is it a PCI or a primary PCI. We say PCI, but when we get primary PCI there is lot of confusion in the mind of an advocate who does know A, B, C, D of medicine and the guy who is from insurance company. Because there are lot of claim issue, why you have done primary PCI, you were not a candidate for that, should I or should I not. I think it is a very important issue and I think I agree with Dr. Ramesh Babu it is a jugglery of words. We should tell our patients in a very simplified manner that you have got a problem and in such a duration we have two options; one is a drug intervention and second is a mechanical intervention by PCI. I think that is a right appropriate word.We have with us Dr. Shiva Kumar who is an interventional cardiologist from Hyderabad, Apollo Hospital. We welcome Shiv. I think you did a lot of work in the era of STEMI with thrombolysis what we call is pharmacoinvasive approach. What is the message you want to give to the audience here? Is it appropriate in today’s way of intervention that pharmacoinvasive is superior when compared to mechanical intervention.
Dr. Shiv Kumar Today’s world, it is absolutely relevant and important that although there is no doubt that the invasive strategies force over the thrombolytic therapy theatrically, but practically if you really consider in our country where the distances are too many and the conditions and so many things, it is practically not possible to reach within 90 minutes by which we should do a revascularization. So, I feel that in our country probably the pharmacoinvasist strategy stands much more better option compared to the directly going for an angioplasty. So, I feel yes wherever possible if the patient is landing to you as we said rightly that from the time of the chest pain and the time of the index if within 90 minutes if the patient lands into the cath lab and if you can open up the artery nothing like it, but if we are failing we know that we are getting delayed so I think the pharmacoinvasive strategies scores over it big.
Dr. HK Chopra I think Dr. Shiva Kumar has given a very kind statement. If your patient is right there in the hospital who got an MI, he is the right person to get an intervention We say what is the primary PCI. He is right there in the hospital. He had to attack right there, no time is wasted, but if the patient goes outside, there is a big question mark. Should we label the primary PCI? He used a very right word that pharmacoinvasive is the way. He said, there is only theoretical distinction, practically the real application if you see is the pharmacoinvasive approach, if you really want to salvage his jeopardized myocardium within the period of three to four hours and to give maximum benefit of morbidity and mortality, 11:00 pharmacoinvasive approach is the answer. There are some patients Shiva who comes from the periphery, you know about long distance. So, we have to send a message across the world and across India as to what kind of treatment they go to pharmacy or they ring up a GP or they ring up a family member, they are confused by themselves about the symptoms of heart attack and by the time they call the ambulance, it is already six to seven hours and by the time they reach you or they come to your hospital in emergency if there is no proper protocol in the emergencies and then there is a delay in emergency and by the time the patient comes to you it is almost 9 or 10 hours delay so what is your opinion on this.
Dr. Shiv Kumar Actually, I would say that we as a CSI, the whole CSI needs to work on this and we have to evolve a strategy. Our mission should be that every patient who gets a heart attack should get his blocked artery to be opened up either by medicine or mechanically within 60 or 90 minutes 12:00 that should be the mission of CSI and what I personally feel is, there are two issues in this; one is that we need to make the people aware, I think awareness is the big problem. So, first we need to make the people aware and how do we this? So, probably we can use a technology here. I think if we can evolve some applications, some apps whereby the people can know that what are the things and most importantly there are many times we must have seen that there are ambulances which go in front of our hospital to some other hospital which is probably medicolegally is not a very right thing and ethically it is not a current thing. So, if they have an app and they know that these are the locations nearby where we know that where the primary PCI is available. So, probably we can cut short the times and similarly like incase if we are getting delayed so we should make them aware even the physician,the referral physician also that okay you can give the latest clot busters like tenecteplase, which can be given very easily outside and without much of a side effects and then subsequently can be shifted.
Dr. HK Chopra I think Dr. Shiva Kumar has mentioned very clearly that we have to have some app. I am sure, you are the Chairman of NIC now. You created an app by the name of CSI, Heart Smart App, a smart heart app on-call for heart attack, it will have massive awareness. The word itself is creating awareness, how to attack heart attack and then its smart heart. It is a smart heart and then how to attack heart attack will be a brilliant idea and I am sure it will happen in near Year since the idea conceived today and we have the conference I think in April may be five or seven months, so it will be a brilliant idea. It will create a huge global impact. I am sure we have enough time to work on this to have a huge impact and that is how we can improve the stigma within a period or the golden hours in treating the STEMI in a big way to reduce the morbidity and morality. In the last, I would like to have a consensus of opinion from my learned family here Dr. Saumitra Kumar what you do think, is it a pharmacoinvasive approach or only a major approach.past Majority leaving aside metropolitan if you go to the middle towns and may be smaller towns and the villages, is the pharmacoinvasive therapy which hold the aid because considering India’s infrastructure and cost constraints, pharmacoinvasive therapy should be the most suitable approach for a country like India or select population living in the metropolitan in the vicinity of Castaic care hospitals is PCI should also prevail.
Dr. Saumitra Kumar Well, going a step back I would say pharmco and pharmacoinvasive therapy will discern the patients for whatever reasons, geographic distances or affordability, 15:00 they do not be able to go to a cath labs, so I think we should not completely discount that pharmcotherapy also has a role to play in the management of heart attack.
Dr. HK Chopra Brilliant idea. If a patient comes to you in the golden hour, the golden hour is only 60 minutes, if any patient comes to you in 60 minutes, may be intervention is not required. You may lyse the clot to make it better 50% or 60% The medical care of her medication, may be stent is not required. So, you use the word pharmaco and pharmacoinvasive approach, I think we analyze it further because lot of clinical impact I am sure. Shiva this word should come in the new app in future designing and if you have some other views on this.
Dr. Shiv Kumar I totally agree with the whole panel that probably it should be pharmaco and pharmacoinvasive. 90% of the people probably would fit into a pharmacoinvasive and remaining 10 also may be in the pharmaco alone and then probably or the rest very few percentage can get the invasive alone.
Dr. HK Chopra Thank you very much ladies and gentleman, I think this was a brilliant exposition and lucid presentation by all the 3 learned speakers on the management of STEMI, how and what we should do in the year 2016 and beyond so that we salvage the jeopardized myocardium to a greater extent, make the people aware about the heart attack and teach them or educate them how to attack heart attack and despite that if somebody gets attack, we salvage it and we postpone the need of further intervention to postpone the event rate and postpone mortality and morbidity. Thank you very much Dr. Saumitra Kumar, Dr. Ramesh Babu, and Dr. Shiva Kumar.
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