Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries

Abstract

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world’s population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment–elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

Pharmacoinvasive Strategy vs Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: Results From a Study in Mexico City

“…Our results are relevant for national practice, as STEMI 30-day mortality in Mexican patients has been reported as high as 27% (23), the highest among OECD countries, and reperfusion rates have been reported as low as 52.6% (24). A recent whitepaper positions PIs as a uniquely attractive option for patients in LMICs, since access to pPCI is limited and unfrequently achieved within the guideline-mandated times (11). In the present study, only 11.0% of the patients from the pPCI group were treated within the guideline mandated timelines (<120 min) (3), which suggests that PIs may be a solid option to improve outcomes in the remaining 89% of patients who cannot access timely pPCI.…”

“…However, it is noteworthy that access to reperfusion therapy is still limited in several countries, and great heterogeneity in treatment and mortality rates exists (4). For example, previous studies have reported lower rates of reperfusion therapy in LMICs 3, where access to either fibrinolytics or pPCI might be challenging due to the lack of awareness, severe paucity of resources, and lack of STEMI systems of care (11). The difficulties for the delivery of timely reperfusion therapy in large metropolitan areas have also been identified (18,19).…”

“…The pharmacoinvasive strategy (PIs) is based on the widespread availability of fibrinolysis and the relative simplicity of its administration to restore myocardial blood flow totally or partially, coupled with cardiac catheterization and clinically appropriate PCI delivered urgently for patients with failure to reperfuse, or scheduled in those with successful reperfusion. Both randomized clinical trials (7,8) and observational studies (9,10) have demonstrated a similar efficacy and safety of PIs when compared with pPCI, and PIs is considered a reasonable alternative when pPCI cannot be delivered timely (11).…”

Health Care Quality Improvement for ST-Segment Elevation Myocardial Infarction: A Retrospective Study Based on Propensity-Score Matching Analysis

“…This study, to our knowledge, is the first retrospective study to examine the impacts of the regionalization of STEMI care, including the combined QI initiatives and the establishment of the information sharing system between the MPDS and the hospital-based CPC registry. The findings have implications for further promoting the measures, with the ongoing engagement of QI efforts and for their potential implementation in low- and middle-income settings where the burden of STEMI is increasing at an unprecedented rate [ 19 ].…”

Reperfusion Therapy and Predictors of 30-Day Mortality after ST-Segment Elevation Myocardial Infarction in a University Medical Center in Western Iran

“…thrombolysis followed by angiography and, if indicated, percutaneous coronary intervention [PCI]), has resulted in a fall in STEMI mortality, particularly in developed countries 5 ; however, in low-and middle-income countries (LMICs), where 80% of all cardiovascular deaths occur, lack of an appropriate care system is the most important barrier to implementing guidelinebased STEMI treatment. 6 A considerable number of STEMI patients, especially in LMICs, are not offered any reperfusion therapy, particularly PPCI which is the preferred reperfusion strategy in STEMI patients. 5 A study in China showed that the in-hospital mortality rate of STEMI in county-level hospitals was 3-times higher than province-level hospitals (10.2% vs. 3.1%, respectively), partly due to hospital facilities and reperfusion therapy.…”