Survival in STEMI in resource limited settings - obstacles and potential solutions. Critical lesson learnt thorough a prospective observational study
Authors: Justin Paul G , Sundaresan S , Sabarish S , Sneha Priya S V , Anne Princy S , Winfred Gnanaraj J P , Ganga R , Panneerselvam G , Manikandan R , Thiyagarajan K , Elangovan C , Elavarasi E , Ashok V , Nandakumaran M , Arul A S 
Published: October 2024

Abstract

Background
Early revascularization in ST segment elevation myocardial infarction(STEMI) by Primary Percutaneous coronary Intervention (PPCI) or fibrinolysis, reduces mortality. In the absence of a well-functioning STEMI care system, patients may not get guideline directed revascularisation (GDR).

Objective
We sought to determine the prevalent mode of revascularisation for STEMI in the community, to discern the factors contributing to lack of GDR during their initial medical encounter, and to investigate the consequences of not getting GDR.

Methods
Consecutive patients within 24 hours of STEMI from October 2021 to December 2021 in a public hospital from a developing nation, were enrolled. In addition to baseline data, the details of the first medical contact (FMC) and second medical contacts (SMC) before reaching the study site were collected. The hospitals where patients sought care earlier, could be lysis capable hospitals (LCH), PCI/lysis capable hospitals (PLCH) and non-lysis-capable hospitals (NLCH). Medical records related to these visits were scrutinised and in-depth interviews were conducted with patients and their care givers. Details of GDR offered / received during FMC/SMC and the reasons for not receiving GDR were collected.

Results
300 patients were enrolled during the study period. 19 reported directly to the study site, while others had visited 1-3 hospitals en route(Figure-1). The 159 who received fibrinolysis in at least one of their medical contacts, had a significantly lower incidence of cardiogenic shock and in-hospital mortality, compared to the rest(Figure-2). 162(54%) patients had had FMC in NLCH and had to be referred to SMC for GDR.
Of the 157 visits by a patient with STEMI in a LCH / PLCH within 6 hours’ time window (6HTW), GDR was provided only 44 visits(28%) (Figure-1). The common reason for not receiving GDR was financial. This revascularisation solutions offered were not affordable. These include, PPCI only or pharmaco-invasive package only in PLCH and high cost bolus lytic only in LCH. Of the 132 patients, who had FMC ≤ 12 hours in LCH, only 33 had lysis. Patients who did not receive revascularisation, despite reaching within 6HTW, had adverse in-hospital outcome. (Figure-2)

Conclusion
The public awareness of the need for early revascularisation in STEMI and the revascularisation solutions available in the neighbourhood hospitals is low. Most patients with STEMI do not receive GDR despite reaching revascularisation capable hospitals within 6HTW. The common reasons for this include, non-availability of low cost fibrinolytics and lack of financial resources. Hospitals should offer fibrinolysis when patients cannot afford PPCI, and low-cost infusion lytics, when patients cannot afford high cost bolus lytics. Provision of GDR in STEMI at the first medical contact, is a social responsibility. Governmental and non-governmental organisations should work in tandem, to ensure 100% GDR at first medical contact.