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Insights from the world's best medical minds

We Need Systems Of Care To Treat Heart Attacks

The system initiates a whole series of events that ensures treatment of the patient within 24 hours.

Dr. Ajith Mullasari

Dr Ajith Mullasari, Director and Cardiologist from Madras Medical Mission,Chennai on Care of Patients with Heart Attack in India
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Dr. Ajith Mullasari

Director, Cardiology

Madras Medical Mission, Chennai


With hospitals cropping up in every locality, we are still not able to treat heart attacks effectively. That’s because you need more than hospitals to treat a heart attack, you need ‘systems of care’, says Dr. Ajith Mullasari, director of cardiology at the Madras Medical Mission Hospital. These systems of care are designed to take care of the entire chain of events involved in treatment of a heart attack. From arranging an ambulance to diagnosis and treatment, the whole chain is activated by a single call from the patient. For instance, in the US, dialing 911 is all a patient has to do to get complete care. Dr. Mullasari proudly announces the success of a similar pilot project initiated in Tamil Nadu with cooperation from the state government. “Covering 100 hospitals in four districts, this programs arranges for ambulance pick-up, diagnosis of heart attack and basic treatment of thrombolysis at the nearest centre, followed by transportation of the patient to a good facility where an angiogram is done and angioplasty or a bypass surgery is performed.” “This eliminates all the delay that is caused by confusion on the part of both patients and physicians by stipulating protocol in an emergency.” The success of this project has encouraged other states in India to follow suit.


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Dr. HK Chopra

Dear friends, it is certainly a great honor and privilege for me to introduce a very eminent personality in Cardiology, Professor Satyavan Sharma from Mumbai who is a Chief of Cardiology in Mumbai Hospital and he is a past President of CSI. I have with me Dr. Viveka Kumar who is Director of Interventional Cardiology and Electrophysiology at Max Heart Institute, Saket in New Delhi. The topic which we are going to discuss in the next few minutes is purely on STEMI. They are the authorities in STEMI. They do a lot of interventional cardiology and clinical cardiology as well as electrophysiology so I am sure they are the people who are going to give a very important message on the occasion of WCCPCI 2015 being organized at the campus of BK Headquarter, Mount Abu at Shantivan, Rajasthan, India.Ladies and gentleman I welcome 01:00 Dr. Satyavan Sharma who has come all the way from Mumbai after attending EEC_ meeting and is going to give his words of wisdom on this important issue of management of STEMI.

Dr. HK Chopra

Dr. Satyavan Sharma, we see so many patients of STEMI I am sure in Mumbai as well as in Delhi and at times we find there is a lot of difficulty because there is a time delay in management and there is no awareness in the patient’s mind so far the education is concerned. 1. How to recognize a heart attack in time so that they can have a timely treatment? 2. We find even if they identify they do not know what is the next step, whom to call, should they call a chemist, should they call a GP, should they call a family physician or should they call a general physician or should they call a nursing home or a medical center or a hospital or a PCI capable hospital. We would like to have your view point on this before we further on this.

Dr. Satyavan Sharma

Thank you, Dr Chopra for this very kind invitation. It has been a real pleasure for me to be here. As we all know, heart attacks have become very common in our country and the most important thing which we need to emphasize to the public is about the early recognition of the symptoms of the heart attack. There is not much awareness about the heart attack symptoms and the emphasis should be that if you are feeling any discomfort in the chest, any discomfort in the abdomen, any feeling of gaseous symptoms, and if you are having diabetes, if you are having blood pressure, if you have a history in the family, you suspect that you are having some cardiac problem and the patient rather than wasting time should immediately contact a major hospital. I think that should be the message because as we all know the treatment is changing so rapidly and if there is fast recognition of the symptoms and there is a fast approach to a center which can give you the best state-of-the-art treatment, I think that will avoid a lot of delay in the treatment. So I think two messages, one should be on the early recognition of the symptoms and the second should be to rapidly approach whichever is the closet center, which is an advanced center in your area and approach that hospital.

Dr. HK Chopra

Dr. Sharma I think it is very important both the points are very well taken, but how can we increase the awareness? What kind of modus operandi we should utilize so that people have awareness? Should we use print media or the electronic media or the digital health media? How should we educate the masses? And #2 how we can overcome the traffics on the roads especially in the 04:00 daytime or even at night when there is no technologist in the cath labs or if at all they are there. Sometimes the cath labs are too busy or what we should do so that we really enhance the easy accessibility of a patient.

Dr. Satyavan Sharma

I think we should take the help of the elected representatives from those areas with the help of the professional society and we should disseminate the message. Now coming to the problem that how does the patient reach to the hospital quickly looking to the problems of our traffic and that is where I think the role will come of whether before the patient reaches hospital whether we can give the patient some form of treatment and there will be a role that you contact a doctor and again I think we are really still too far away from ideal circumstances.Then there should be that every particular area we should be able to identify that these are the hospitals which are capable of treating heart attacks. The patient makes a call there or patient approaches there and then patients can be given either thrombolysis if there is going to be a time delay in reaching to the hospital and if there is no time delay in reaching to the hospital, then the patient goes there straight away for a primary angioplasty.

Dr. HK Chopra

This is a brilliant exposition by Dr Sharma, I think Satyavan has mentioned very clearly that our objective is we must have a dissemination of information about the awareness and education of the patients as to how to recognize heart attack early. Once they recognize Dr. Sharma you will be very happy to know that for the first time during a CSI Cardiac Program, we are launching an App. We took almost four months to understand the integrity and ups and down of this App. The first component on awareness and I am sure we will have many links that will be given to lot of organization, which are governmental 06:00 and non-governmental, even Rotatory, Lions and various welfare association presidents have to be given to them and the second component is that straight away once we see or a patient realize that he or she had a discomfort in chest which mimics the heart attack, then straight away hold #2 digit when they press they will get the phone numbers, mobile phone numbers or ambulance numbers of the hospitals in the vicinity. They can click on the bottom. The ambulance should reach to them within 5 or 10 minutes. Once the ambulance reaches there, they do an EKG and the EKG can be transmitted straight away by App not by telemedicine, not be telecardiology. It will cut down the cost significantly and as doctor sees the App an EKG and if there is an ST elevation myocardial infarction we can have their first point of contact. If you find there is a time delay because there is lot of traffic on the road or there is a time delay because of the distance from the hospital is long with more than 2 hours then there will be second and third button where you can put a pressure under the supervision of a cardiologist to give a drug like tenecteplase so that with thrombolysis we can salvage the jeopardized myocardium and then the patient can be transmitted to a PCI capable hospital within 3 to 24 hours he is subjected to angio and reduce the clot burden and put a angioplasty or stenting. This App is going to be released in the cardiac program at least first initiative we are starting in Delhi and I am sure that with the help of all the CSI branches it will go in the globe. Your point is very well taken that early intervention is the need of the hour. We have with us Dr. Viveka Kumar who is the Director of Interventional Cardiology and EP in the Max Hospital. Dr Viveka I am aware that there has been a lot of big study done in your hospital on so called primary PCI. I really want to know is it really a primary PCI because the patient reach the hospital in Delhi.I am there in Delhi for the last 40 years now and I know most of the patient reaching there are beyond 2 hours or 2.5 hours. I am really not very sure is it a primary PCI or not and my second question is what is the difference between primary PCI and the PCI, which are not primary.

Dr. Viveka Kumar

That is again a very good question. I would say that answering your first question first that primary PCI in true sense a primary PCI. I would say that most of them would qualify as a rescue PCI or what we call delayed PCI in the acute myocardial infarction setting because well and truly if we look at the definition of primary PCI that should be within 6 hours preferably earlier the better it is, but because of the lack of awareness, late first medical contact and we are talking about primary PCI in those patients who are just tip of the iceberg who are reaching to a cardiologist. Remember 98% of the population who get acute myocardial infarction nationwide they are not in contact with the cardiologist they are looking at the physician level and that is why we are just see the tip of iceberg and large number of patients we see come with heart failures and you know complication of the delayed presentation of myocardial infarction that within the stipulated time primary PCI timeline window and even those who get diagnosed early as you rightly said because there is also be Delhi traffic they do not reach the primary PCI 10:00 capable center well within that time and that you know the new pharmaco-invasive data has come as a great boost because all across the nation there is not a single place where the patient cannot get thrombolyzed and reach primary PCI or the PCI capable center within 2 hours. I think that is a fairly good data as far as the increasing the umbrella of people whocan get coverage of appropriate treatment for acute myocardial infarction. The second thing is awareness I would say that you know unless the population at large and involving all the, you know, means not only the political. I am really impressed with the mobile revolution in India and the penetration of mobile revolution has been really better than any other country in India, so I would request CSI, you being the in-charge of the staff. I would say that we should involve the you known mobile operators Airtel and Vodafone and all so that they can penetrate the biggest penetration of any you know if you look at the technology in India 11:00 is across you know I have gone to many smaller islands also if you go to Andaman and Nicobar there also the mobile technology is working fantastically well. So I think that is a great step by CSI to involve the new technology and the mobile technology would also find out the nearest first medical contact where the patient with acute myocardial infarction can go. A lot of you know general practitioners are not aware of what should be you know the best possible because they forget the importance of first medical contact anti-platelet, use alone thrombolytic therapy. So anti-platelet even given in acute setting would have significant decrease in event rates. And then off course the thrombolysis and then the pharmaco-invasive strategy would be best and the magic of primary PCI as you said that would be comparing the elective PCI how different the primary PCI is. The primary PCI is one intervention which decreases the mortality from 33% to 64% if the patient comes well within a stipulated time period so that is a huge-huge decrease in mortality as compared to you know elective PCI which more often than not gives the better quality of life rather than decreasing the mortality in true sense. So I would say that is a revolutionary technology rate at which the facilities of primary PCI facilities are getting distributed all across the country is used but there is a long way to catch and I think there is a huge difference between the need and the people who can afford it or can reach this facility. So that way I would say that pharmaco-invasive strategy would be the way to go about so we should you know educate the general physicians and the general population at large. At times, we have seen people as young as within their 20s they do not get treatment done well within time because nobody suspected an MI in those patients. So I think since is the incidence of acute MI is so high in our country, we should get that anyone who gets chest pain or pain above umbilicus for more than 10 or 15 minutes they should have an exclusion for acute myocardial infarction.

Dr. HK Chopra

I think the point is very well taken. Viveka Kumar has mentioned very clearly that the Indian population, we are the world capital of diabetes. We are also the world capital of ST elevation myocardial infarction. We are also going to be the world capital of obesity and hypertension very soon and most of the diabetics are silent myocardial infarctions or they may have myocardial infarction without chest pain. They may have breathlessness, sweating, extreme exhaustion or dizzy spell, very difficulty at times to diagnose. I think all those things should be very well mentioned. The point which you mentioned there pharmacology approach is the answer. The reason is in United States only 20% of the population has access to primary PCI. In India, I do not know whether it is 2% or 1% or 3% of the population has access to the primary PCI. I am talking of Delhi. I do not know much about Mumbai. I do not know much about Kolkata or Bengaluru or Kochi but in Delhi it is really difficult. Sometimes going from my hospital to Max Hospital takes 2 hours to reach, so how can a patient reach even in an ambulance. There is a lot of dilemma. Nobody can reach in 2 hours. I think pharmaco-invasive approach, there is a huge data from Steven Fry which has shown very clearly and the data of Mayo Clinic and Vienna Trial has shown very clearly the mortality benefit is same whether to be used TNK first and then PCI or a PCI first then TNK. I think better to use that technology which is easily accessible, easily available so that we salvage the myocardium and reduce the thrombus burden that would really help. The second point which you mentioned is also very-very important that App application is the answer. You mentioned the place like Andaman and Nicobar the people are using the App. So I think we need to change the mindset of people. App application is the answer, digital health is the answer and I think that is what our Prime Minister also wants that we must have a digital approach to improve or enhance the heart care. I have one more question to you Dr. Viveka Kumar. Sometimes in an infarct-related artery after even giving thrombolysis when we see the thrombotic burden is less and do an angioplasty or a stenting of that artery and we find other arteries also 70% or 80% blocked or 85% blocked. What is your recommended strategy? Should we do a total revascularization or should we do one and wait for the other one after sometime or do in two sittings? What is the consensus?

Dr. Viveka Kumar

Again, you know, preventive PAMI trial, which showed that if you do total revascularization that is better but all other trials have come negative. So the recommendation as of now is that we should just touch the culprit artery unless the patient is in cardiogenic shock with other arteries or critically diseased. Just remember the acute myocardial infarction is like a war, so you should not open up war on too many fronts, so just treat the culprit artery by the time the patient would have adequate anti-thrombotic milieu based on the 48 hours to four weeks.We have a window period where the rest of the arteries can be reassessed and can be reassessed by either FFR if they are not very critical or we can you know if we have done well within time period the angioplasty and PTCA, then we can even do you know a stress MPI, stress study, stress echo studies and based on the ischemia we should revascularize them. Now we had in this conference a lot of talk about 17:00 noninvasive FFR by CT angiogram so we can take the help of those technologies also because there is a data that those arteries which are not hemodynamically significantly stenosed, there is no added advantage of revascularizing them. So the recommendation as of now is that treat the culprit artery unless the patient is in cardiogenic shock with critical lesion in all other arteries and the other arteries should be reevaluated and revascularized after 48 hours to four weeks’ time period.

Dr. HK Chopra

Very nice I think Dr. Viveka Kumar mentioned a very important point is that we already have one front where we are having a war why go for two fronts and on the contrary if the is a cardiogenic shock there is a third front. I will ask Dr Satayavan Sharma what should be the approach when we have two front or three front? Should we follow the strategy what Dr. Viveka Kumar is suggesting or if there is a cardiogenic shock we should even open the third front also?

Dr. Satyavan Sharma

I think I will completely agree with what Vivek said 18:00. If the patient is having an infract, open the infract-related artery and for the other arteries choose the appropriate time either by doing an ischemia testing or by the anatomical severity. Now if there is a cardiogenic shock I think this is a completely a different ballgame and in patients of cardiogenic shock for stabilizing the patient whatever amount of maximum revascularization you can do you should do. So with cardiogenic shock certainly if you can open multiple arteries, you should go for that, of course infract-related artery first and then the vessels which are supplying a large amount of myocardium and then the one you know which may be the least productive one.

Dr. HK Chopra

So there is a very clear consensus by both Dr. Satyavan Sharma and Dr Viveka Kumar who are very eminent interventional cardiologists in India. They mentioned very clearly and very categorically to deal the infarct-related artery first. Rest is all secondary. We all can see those later on. We can do all kind of tests, we see the viability either we use the noninvasive modality or the invasive mobility and based on that one can go for perfusion deficit or a viable or nonviable myocardium and can perform the procedure from 48 hours onwards up to four weeks depending on the need in those patients which is very important message and the second thing I think both the learned speakers have mentioned very clearly that approach in a setting like India we must try pharmaco-invasive approach. But if a person is in a very close vicinity of a PCI capable hospital, the first option should be primary PCI. But if time window is delayed, I think it is better to go for the second option and we must have education to the physician or general practitioners so that they also do not misguide the patients.Sometime you know the patient by the time they go to an interventional cardiologist, the cardiac status is already crippled. The ejection fraction had dropped down to 35% with a huge damage and there is aneurysm of the LV and at that time they are going to an interventional center I think it is took late. So we need to enhance the awareness because it has got medical legal implications in the years to come, people will watch the time from home to the hospital and the hospital up to the ECG time and from the ECG to the door-to-balloon time. How much is the difference because these lawyers are going up to this extent now. There is a case going in MCI, they wanted to know exactly from the medical record from what time the patient came, what time he entered the hospital, what time his file was made, what time he went to cath lab, what was the opening time, when the machine was started, when the technician came,because it has got a lot of influence on us. So to overcome this problem, I personally feel that pharmaco-invasiv approach is much superior at least once modality of treatment has been instituted and by the time he come for his second treatment and it is a must,every patient may need to have angioplasty. But I think in a stepwise matter it is always better. I think both the doctors have done a wonderful job.I would like to ask only one more message that we are here in a spiritual ambience in this conference where we talk of preventative cardiology a lot and clinical cardiology a lot.Do you think Dr. Satyavan Sharma preventative cardiology has the role in interventional cardiology arena or you find interventional cardiology is different and preventative cardiology is different?

Dr. Satyavan Sharma

No, preventative cardiology has a tremendous role. In fact, I feel very strongly preventative cardiology is the bigger need of the country. But ultimately both 22:00 things have to go. We need to treat the patients who are already there by the best possible modalities but we need to prevent a large-large-large population which is on the threshold of getting cardiac problems.So preventative cardiology certainly is the need of the hour and all of us, the society, professionals, public, politicians, our public health foundation and all the allied professional bodies should be for prevention. There is no question about that.

Dr. HK Chopra

Dr. Viveka Kumar do you agree with Satyanvan Sharma.

Dr. Viveka Kumar

I fully endorse his views and I would say that I will quote a study where

Dr. Ajit Mullasari Sankardas

Good afternoon, I am Dr. Mullasari Ajit Sankardas, director of cardiology at the Madras Medical Mission Hospital at Chennai, Tamil Nadu. I would like to talk on something which is very important in care of patients with heart attack in India. Acute heart attack or what we call in medical terms STEMI is one of the devastating complications which has very, very high mortality and morbidity if you do not treat it in time and treat it well. To treat a heart attack, you not only need hospitals but you need what we call as systems of care. To give an example, if a person in US gets a heart attack, he calls a number which is 911 which activates a whole system including an ambulance, pickup of the patient with acute heart attack, a diagnosis and then shift to an appropriate center. We in Tamil Nadu have started small pilot program which with the Government of Tamil Nadu and the 108 ambulances has initiated an acute heart attack treatment for patients in four hub-and-spoke models covering about 100 hospitals in four districts of Tamil Nadu which has now finished one year of collection of information. What this entails is a person when he gets heart attack, he calls a number, the number is usually the public number which is the ambulance number which is 108, gets picked up by the ambulance and once he goes to a hospital the diagnosis of heart attack is made by a simple test which is called as the ECG. Many small hospitals in rural India do not have appropriate ECG machines and do not have doctors who can look at those ECGs and make the diagnosis. So we put in a system where we use a very high end technology of telemedicine which basically picks the ECG up and transmits it from the ECG machine into either another similar machine or on to an android phone which makes us the diagnosis of ECG proper and correct. Once the diagnosis of ECG is made with a device which has been completely manufactured in India, the patient’s diagnosis is made and systems of treatment are started based on a protocol which is now initiated in all the small hospitals and the group of hospitals which are involved in this hub-and-spoke. So the basic treatment like giving of aspirin, cholesterol-lowering medicines are initiated, heparin is given and if the facility has a small ICU then the clot-busting drug which is called as a thrombolytic is initiated. Following the successful thrombolysis, the patient is now then shifted by the same 108 ambulance from that small hospital to a larger hub hospital which is in the center, which is more urban centric or in a small to moderate size town which has the facility now to do a test called as the angiogram which then decides the risk of the patient and then follows it up with the treatment, which is either angioplasty, medical treatment, or coronary artery bypass surgery. So in short, this whole treatment is initiated in an organized systems of care treatment where patients do not get confused about what to do, where to go, physicians are clear about initiation of treatment, and within a 24-hour period gets a complete treatment which matches what is available all over the world. This sort of strategy with the Tamil Nadu STEMI project which myself and Dr. Thomas Alexander from Coimbatore have started in Tamil Nadu has now completed about 2500 patients in one year and we are now putting it up for a major publication. This has also become standard of care for acute heart attack in the country and the framework has been accepted by both the bodies of the cardiology society and the physicians of India and is coming up with a framework paper in the National Heart Journal, the Indian Heart Journal. It is also now purported as the best care for developing and developed low cost middle income countries.As you know, in the larger developed nations and in the European Nations primary angioplasty which is an acute angioplasty in an acute heart attack is the best care. Unfortunately, it is system intensive, it is resource intensive and very, very expensive and is not applicable to countries like India or China or Indonesia which have limited resources and has wide spread patients. So clearly I think what we have tried to attempt to do is to create a new system of care in India which now could be replicated in most states outside Tamil Nadu, I am happy to say that Telangana is the next state which is possibly going to start the program and would slowly be scaled up as a national model.Now, it has been a privilege for us in STEMI India, me, Thomas and our colleagues to work with the Tamil Nadu government to foster a very large pubic-private partnership which has been allocated as a very, very successful program in Tamil Nadu and we hope to replicate it in other states and in the country as a national systems program. I would also like to say that this cannot be without the involvement of the governments, the state government has helped as a priority and I think once the citizens of this country make health their priority and the political system establishes health as a priority, I think the governments will invest a large amount of money into systems of care, both for emergencies like acute heart attack, stroke, they have already got it in some areas like road traffic accidents, poisoning, and I think once it scaled up it would provide a very important public health system care which could reduce acute events in most patients.



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