Madras Medical Mission, Chennai
</b> 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
</b> 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.
</b> 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.
</b> 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
</b> 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.
</b> 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
</b> 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
</b> 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?
</b> 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
</b> 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?
</b> I think I will completely agree with what Vivek said 18
</b> 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?
</b> 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
</b> Dr. Viveka Kumar do you agree with Satyanvan Sharma.
</b> I fully endorse his views and I would say that I will quote a study where
</b> 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.