Breach Candy Hospital
</b> Dear friends, its really a great pleasure and honor indeed for me to be here this morning and to interact with a very eminent cardiologist from Mumbai, Dr. D.B. Pahlajani. Dr. D.B. Pahlajani does not need any introduction to the audience of India as well as the world. He is the past president of CSI and a very eminent cardiologist of Mumbai known world wide. Dr. Pahlajani welcome to the studio and especially we are going to have good discussion today on a very, very important subject. We talk of primordial prevention for the heart disease, we talk of secondary prevention, we talk of tertiary prevention and we also talk of primordial prevention these days. My focus of interaction with you is only on ST elevation MI. We are talking of tertiary prevention, what we should do, what we should not do We know in India there is so much of crowd on the roads, so much of rush, traffic on the roads. We find there is a lot of time delay and we all know that it is the time which is a muscle. If there is a time delay, we cannot salvage the jeopardized heart which is under stress because of low circulation which is 100% blocked and by the time they reach to the hospital, the heart muscle is already damaged. Now there are two kind of setups in India. There are some, where there is PCI capable, there are percutaneous intervention, straight away patient can go for intervention, that is the idea, there is no doubt about it, but the question is, 95% of our patients do not reach in time. When we say time, they should reach within two hours if they really want to get benefit of PCI. So we would like to ask you a question, if the PCI capable center is at a longer distance and if the patient had a heart attack which is confirmed, diagnosed at the site of issue, problem which had happened there, either in the office or home or anywhere in the working place and if he has to go to a nearby center, which is non PCI capable, so what are your recommendations? What is your message that how they can be managed meticulously at that point of time and subsequently?
</b> First of all, Chopra ji thank you very much for giving a very, very, sort of a kind introduction and I am really indebted to the conference that you are holding and having invited me to address your audience here. It is a very important topic to be precise, if you see that in this country there are about 3.5 to 4 million individuals who develop ST elevation myocardial infarction and as be as it may the mortality of this kind of an infarction outside the hospital is close to 15 to 20%. So until and unless they receive an appropriate treatment on time, the mortality is going to be very high. It is not only the mortality, it is also the morbidity, these patients will have a very bad ventricle so they will have left ventricular failure, cardiogenic shock, arrhythmias and their long life, even if they pull through this kind of an episode, is going to be a very, very, sort of cripple. So therefore, we strive to save them and save the muscle. I think these are the two most important issues. Now you pointed out very rightly, leave aside in the outside areas of the metropolis, even the metropolis itself, you see this city of Mumbai, Delhi, Kolkata, you see the streets are choked up with the number of cars. There are no dedicated lanes for the emergency services like ambulances, police vans or the fire brigade. Even fire brigade gets struck up, so how do you manage them. So I think there is a solution available and that solution is not just sort of out of the air, but it is based on this solid evidence based medicine on the strength of several trials which have been done. Now some of these trials are what is called as a fast AMI trial which sort of is very off coated in which they found that suppose you find a patient who has got a heart attack or ST elevation myocardial infarction, goes to a community hospital, community hospital means peripheral hospital, these are not PCI capable centers. Now the transfer time may be two hours, three hours for him to reach the hospital. The hospital itself may take sometime to take him to the lab, to do a primary angioplasty because we know the primary angioplasty means door to balloon time of less than 90 minutes, which may not be possible, so what they found that if you gave a thrombolytic or a fibrinolytic treatment at the Community Center then what is called as a systematic PCI, not even deferred, so if it is done two hours after the administration of the thrombolytic treatment, and done within the first 12 to 24 hours, maximum 24 hours, they have taken to the cath lab, you do an angioplasty, what is called as the pharmacoinvasive therapy. On one side you have given a pharmacological treatment, on the other side you have done an invasive treatment. So you do a pharmacoinvasive treatment, they found that the mortality, the benefit of this kind of an approach is good as that of a primary PCI. I think for a country like ours, perhaps this model may be comparable to the primary PCI, of course primary PCI still remains the gold standard, suppose somebody who stays within few 100 yards of the PCI capable hospital, he can be transported, that is a different thing, but what issue that you have raised, it is a very important issue, it is a realistic issue in our country.
</b> I think Dr. Pahlajani has a given a very clearcut message. So, if anybody getting an ST elevation MI or a heart attack or a major heart attack and he is not in the vicinity of the hospital where PCI is possible, the message is very clear, all these patients should be given a clot buster or should be given a thrombolytic therapy in the form of tenecteplase or alteplase or many drugs have liberalized third generation thrombolytic agent and after thrombolytic agent, he was very specific, he mentioned, within 3 hours to 24 hours, he has to go for angiography and he should go for PCI. He used a very good word what we call as systematic PCI. He also used the word selective PCI. I think we have to understand every patient if we give a clot buster, the clot will dissolve to some extent, at least we see the damage to the heart which is already in risk and once that is taken care of, patient can be transferred to another center within 3 hours to 24 hours if he is subjecting for PCI, we can give him a good life, he used the very word very categorically that we do not reduce the mortality but we also reduce the morbidity and that is what he says is feasible and practical. Dr. Pahlajani it is very important, in India the awareness, the education skill, is very poor as compared to the Western world or European world. Do you think is there any need of a smart heart app where a common man can be educated on the symptoms of heart attack and he does not waste time eating some local things like ajwain they take, or they take some salt at home or a home remedy or they call a chemist shop and take a pill, discuss with the chemist or they talk to a general practitioner. I think this is just a waste of time. They should straight away talk to the hospital doctor for such a thing only, once they know that it is a heart attack. So what do you think if we have an app like a heart smart app in India, in every possible state of India, or the city of India or village of India and that app should be both in English, Hindi or multiple languages and we talk of component (a) as symptoms of heart attack and its feasibility. What do you think, it will really help us or it will not help us?
</b> I think it would definitely help us. Dr. Chopra, I feel that tackling ST elevation myocardial infarction is a program, it is not individual’s job, it is not your job, my job as an individual. It is all right for the patient to interact with me, but if you want to save lives in number of, say hundreds and thousands of lives, it is a program. In the program, I think everybody has to participate, like government, the local civic bodies, the lay public, the social organizations, the hospitals, the doctors, all of them have to participate to say okay, here is a situation which is crippling the nation. Thera re, as I said 3.5 to 4 million patients getting heart attacks every year, in Mumbai itself I have got the data, last year 30,000 individuals out of 90,000 died of heart attacks, these are the Bombay Municipal Corporation’s data. Now if so many people are dying, we have to self save them. It has to be saved only by a program. Now the app can be a part of this program, it can be initiated by either the academic bodies or it can be initiated by the government, or the local social agencies, so I think app is a very, very smart idea, it can be on a smart phone, that okay a point, 1, 2, 3, 4when somebody gets chest pain, what you should do next, that is what it is.
</b> It is a very brilliant explanation. Dr. Pahlajani is very vivid in his statement, and the statement is, there is a tremendous need of a smart heart app, which must have a first component, how to recognize the symptoms of heart attack and then how to attack heart attack. How to attack heart attack should also be a second component of it, and this is possible that once we diagnose it, he was very specific, it is not an individual responsibility, it is an integrated system. We create an app and there should be integration in a manner that everybody is aware and we create a system so that component 2 a mobile section should be there, emergency hospitals may be community based, or PCI capable based, city wise or state wise, so that we press the component if I am close to India Gate in Delhi, I know which is the hospital nearby and straight away I press that button and the ambulance reaches in 5 minutes and the clot buster can be given only after doing an ECG. ECG can go by telemedicine to the nearest doctor who can pass on the instructions either through the whatsapp that here is an ST elevation MI and the paramedical staff which is there under the supervision of a cardiologist, can give a clot buster right there by which we can abort MI or we can make a larger heart attack to a smaller heart attack or a transmural to a subendocardial or we can prevent the extension of the heart attack or prevent the complications of a heart attack. I think that is the only way so that there is an awareness campaign or we use IT enabled holdings all over India, or we can go in a digital way. Here we are in the digital herald, people are talking of digital herald, so we go to a school, we go to a college, we go to organizations, we go to public sector undertaking and we go all over the world, what is your word of wisdom on this?
</b> My word of wisdom is only one, spread the net. It could be as you said, rotary organizations, I think rotary organizations time and again should send some sort of handouts so that they distribute amongst their own members, who ultimately as you know Rotary Lion’s Club, they are spread all over the country. So I think, if we send out the messages, as a matter of fact to the save the cost, I think you are tech savy, I am also, so you know, sort of put it on the hard copies, may cost a lot of money, but at least it can go on the net, sent to the president and the secretary of every organization that please read it, a very short message, please read it to your members, may be just like a prayer, read it to your members every month in their meeting. Okay, and stress upon them that if they encounter any chest pain which is for the first time in their life and it is in the center of the chest, please do not ignore it.
</b> I think it is a very important message given by Dr. Pahlajani as a past president of CSI and I am the national president of CSI. I am going to implement everything the way Dr. Pahlajani mentioned. He said, a time has come, we have to enhance or extend the potential of a network, it is the network that can save the myocardium or the heart attack and we have to go to every nook and corner so that people should have an awareness about the heart attack just by bringing drug or just by brining a cath lab, even a mobile cath lab, will not be able to help if there is no awareness. So, awareness is the first goal, how to tackle, subsequently I think a very nice idea given by Dr. Pahlajani that app is the answer, so that they understand and then we have to provide the mobile services. We have to have a network with emergency services. So everybody should have an education and knowledge and then come to PCI. We are not ignoring PCI, there is no doubt, and Dr. Pahlajani was very meticulous. The gold standard is PCI but the limitations are there. So we have to see with those limitations, what to do we should do and our goal is only one that we should save the heart which is under risk. We are very grateful to sir for your thoughts and I am sure we are going to implement it in a very subtle way, we have already approached the prime minister of India to launch this app in the cardiac prevention in Delhi and we are creating a huge network but just a beginning service starting from there, and we are also having a save a heart mission in the form of a mobile van which may also be launched by the prime minister and you will be there as a past friend of CSI as a father figure and your coming and your blessings will be of a tremendous application and it will help us how to treat an ST elevation MI in a center where PCI is not possible and how the patient can be given the maximum benefit despite not having a PCI capable center but can be sent to PCI capable center after the primary treatment is given by a clot dissolving drug or by aspirin or by statins, or by clopidogrel and then subsequently manage so well, so that the damage is minimized and morbidity and mortality can be improved. Let us give a big hand to Dr. Pahlajani for his words of wisdom and we look forward to see you in Delhi sir.
</b> Thank you.
</b> I think it is very important Dr. Pahlajani, I think we discussed at length how the integrated system for ST elevation MI should be in India. It is very important, the number of times patient complains of chest pain or heaviness in chest or perfuse sweating or a dizzy spell or sinking feeling, and we do an EKG and we find that he has an heart attack, ST elevation MI. So the first point of contact may be either a doctor goes there or an ambulance reaches there. What we should do, what is the message, should they be given some drug or should they be given some tablet under the tongue or should they be given some injection, we would like you to focus on each component very specifically so that the message goes.
</b> Well, once the EKG has shown that there is an ST elevation myocardial infarction or even non-ST elevation myocardial infarction, a very simple straightforward drug can be given is what we call as aspirin and given in the doses, it should be a soluble aspirin, remember, you see many of the aspirins are coated aspirins, they take long time to act, so I think immediate action if you want, then I think soluble aspirin should be given 350 mg, then the option is between two drugs at that time, either to give the age old drug which is still very good called as clopidogrel, it is inexpensive and easily available all over the country called as clopidogrel under different brand names, the other drug which is little more expensive and available not actually all over the country but in most of the centers it is available it Ticagrelor available under the trade name of Brilinta and that is given in the doses of 180 mg loading dose and patient should be given these two medicines right away.
</b> What is the loading dose of Clopidogrel, how much is the loading dose?<br>
</b> See now on that there is a little controversy, some people give 300 mg, some people give 600 mg , I usually prefer to give 600 mg, I think that is what I would feel that perhaps it will achieve the desired antiplatelet effect much better than 300 mg but there are people who give still 300 mg, they are still right. I will not sort of try to take an joint issue with them and also I think do not forget the very simple things like when you see a patient, they must insert an IV line, because many times while transporting the patient, patient becomes slightly hypotensive, so the veins are not easily available, insert the line when the time is good, when the going is good, so put an IV line and keep the line patent with some running fluid so that by the time the patient reaches the hospital, the doctors there and the nurses there have no difficulty in starting any intravenous medicines that they wish to start.
</b> What is your recommendation Dr. Pahlajani about the high dose of statin at the point of contact, should we or should we not?
</b> I would feel that many of these patients are already on the statin because many of them have high cholesterol or the high LDL, so majority of our patients do have the cholesterol lowering medicine but it is wise at that time, to give a much higher dose and loading dose of 80 mg of atorvastatin, it is supposed to stabilize the plaque, it is an anti-inflammatory drug, as you know coronary artery disease and inflammatory disease, so giving a large loading dose of 80 mg and continuing it for some time, then coming back to the original dose, I think that may be help.
</b> You mentioned about clopidogrel or Ticagrelor, or Prasugrel, my question is, is only atorvastatin the answer or we can give a Rosuvastatin also?
</b> Well, one can give Rosuvastatin also, one can give a loading dose of 40 mg straight away. <br>
</b> So a high dose of statin and a full pill of soluble aspirin, very important message, people should not give half tablet, a full tablet, should be chewed that is the answer, and clopidogrel may be 300 or 600 mg depending on preference of an individual, other drugs like Ticagrelor or other Prasugrelor depending on the option and then of course the message is a high dose of statin even if a person is on a low dose of statin, can be given a high dose of statin. Just a word, sometimes I have seen lot of physicians, they prefer to give half tablet of Sorbitrate under the tongue, what is your word on that?
</b> But before that Chopra, I feel that when it comes to loading, I would not like to load Prasugrel. The reason is Prasugrel is recommended only if the patient undergoes PCI. A patient goes to the hospital, he is found unsuitable for PCI, then Prasugrel has no role. As a matter of fact, Prasugrel should be loaded in the cath lab, not otherwise.
</b> So the answer is very clear, at home, in the ambulance or at the first point of contact, I personally feel in India, the best answer is clopidogrel.
</b> Yeah I would agree with you there.
</b> Clopidogrel is the answer, it is cost effective with a huge evidence data base and I think everybody is very happy, you use it for a long term, you do not find much complications, I think it is a very, very good drug. The only question is of nitrates, what is your say on nitrates?
</b> If the patient has got an ongoing chest pain, that is the ischemia is ongoing in the form of chest pain, to relieve pain I will give a sort of 10 mg or 5 mg of sublingual nitroglycerin in the lying position, because sitting position, patient may become hypotensive. Otherwise, if the patient is comfortable, has been given some transquilizers and given some pain relieving medications intramuscularly or intravenously, patient is comfortable, I will not give, because sometimes it can have an adverse effect of hypotension, so I would desist from giving, but in the case patient getting chest pain, then of course no question, one has to give nitrates.
</b> Oxygen therapy is a must?
</b> Oh yeah one can wear oxygen.
</b> Dr. Pahlajani is very clear in his statement that for the first time when you have a contact with the patient, please give aspirin 350 mg soluble, you can reduce the morbidity to a very large extent, not only morbidity but also the mortality and he also says in India clopidogrel is the answer, loading dose 300 or 600 mg of a loading dose of clopidogrel and a high dose of statin, may be 40 mg or 50 mg, again choice of the physician and he also says oxygen therapy is a must, but we need to be very selective for drug like nitrates because some patients are hypotensive, some are normotensive, some have undue reaction with nitrate because there may be underlying obstruction in the LVOT, I think it is very important, but he says it is not a must. The message is very clear that all these things should be kept in mind before the patient is given a clot buster and then shifted to a PCI capable center.
</b> Thank you very much Dr. Pahlajani for your very nice expression and I think this is a very, very important initiative for the STEMI care in India in the PCI capable center as well as in non-PCI capable center.
</b> Ticagrelor in the appropriate dose and give nitrates only if the patient has got a severe chest pain, give oxygen, keep the IV line going, run an IV drip so that the line is kept patent and then try to transfer, call the PCI capable center or tertiary center and get an ambulance and transfer the patient, an ambulance which should be actually well equipped with these, say ventilator, defibrillator, monitor, and the paramedics should be quite well trained. I think this kind of a center should have that kind of an ambulance, transfer the patient into this cardiac ambulance and I am sure we will be able to save many lives.
</b> A very important point emerged just now from Dr. Pahlajani, he says there should be awareness in the patient’s relative, patient’s mind about the PCI capable center and PCI non capable center. Ultimately the aim is to save the heart, but the awareness should be there. They should know there are PCI capable centers and there are PCI non capable centers. The more the awareness, more is the care of the heart attack patients and more reduction of morbidity.