STEMI is the most common cardiac emergency . It removes more human lives out of this planet than any other illness. Fortunately modern medicine has an answer to this deadly disease . Of course , we are far . . . far away from conquering it. Only if a patient with STEMI reach the hospital one can make a significant impact on it.
This , unfortunately does not happen in about 30 % of patients . They never reach the hospital . It does not imply all those who do not reach hospital die . Current understanding is that the incidence of out of hospital STEMI deaths have been overestimated. The classical teaching of 50% die before reaching the hospital is based on data from old community observations when the awareness , transport, modalities were grossly inadequate.
Now most of the patients has access to emergency care like 911 /108 etc .
It is the era of coronary care in the streets . The concept is , If the patient is not reaching the hospital , let the coronary care reach the patient ! In spite of all these there are major “time pockets” which stand between the patient and his /her ailing heart .
There has been lot of analysis of the various components of delay in STEMI. Of course ,this is directly dependent upon the economic and health status of a country . For example in country like Sweden emergency cardiac services can reach the patient within 10 mts , while a person suffering from an MI in a remote Indian village can reach the hospital only after most of the myocardium undergoes complete necrosis !
Even in urban areas where there is excellent emergency services are available the following factors have a great role in determining the time window and outcome .
- Symptom recognition by self
- Early Reactions -(Example : Spouse response time )
- Calling for help -Role of Close relatives and family members.
- Transport delays ( vehicle personal/public/Traffic jams )
- Hospital entry /ER woos . . .
- Door to ECG time
- ECG interpretation time
- Reperfusion decision time
- Door to Needle ( Hospital door ? CCU door ?)
- Door to Balloon (Cath lab door ?)
Among the above 10 time pockets can you guess which has the greatest potential to make a deep impact on the outcome of STEMI ?
Yes , you are right The first two !Patient misinterpretation of symptoms is the key obstacle for effective care of STEMI .What drives a patient from home or office to a hospital .It is the symptom .If it is severe there is acceleration of every aspect of patient transport to the hospital .The spouse response time is also critical.The problem with STEMI is many times it can occur less dramatically so the patient is likely to miss it!So cognitive response to symptom becomes vital .An intelligent patient or spouse shortens this time window .
Whether to call emergency service or use personal transport ?
This is some times difficult decision especially in country like India. One has to make a rapid assessment , what is the chances of getting a 911/108 services within 15 mts. Developed countries have improved upon ER response time. The issue here is the destination of the patient should be a place where there is a facility to manage a primary VF . In short the ultimate aim of STEMI management in the early hours is to narrow the physical distance between the patient and a defibrillator . This requires availability of health care personnel , equipment , simple physical presence of medical personnel is not sufficient .They should be able to recognise the VF and shock when needed . Next come the method of reperfusion . Shifting to a tertiary hospital for primary PCI or to the nearest hospital for thrombolysis is a separate issue that needs elaborate discussion.
Where should the victim go ?
- To the tertiary care hospital
- A nearest nursing home
- His family physician
- Nearest General practitioner
The answer is not a simple one . There will always be a trade off between optimal STEMI care and the common panic reaction & false alarm and wastage of ER resources .
Since the first hour is very crucial , the outcome depends lot on the patient response pattern .Health education and awareness become vital .Emergency medcation , self adminstred aspirin may be an answer in the future.
What ails emergency cardiac care in our country ?
Every citizen of a country should be made aware of the nearest cardiac medical facility ie . Coronary care unit (CCUs) . It is an unfortuante fact , many of our country people have it in their finger tips , the movie house that is showing the current hit & restaurant that serves best cuisine , have zero knowledge about the nearest coronary care unit in their vicinity . Many lives have been lost because of this ignorance . More important than this , is lives are lost on transit to many ill-equipped ambulances and some times even hospitals .
In the modern era STEMI patient should not die due to an electrical death (Venticular fibrillation) within a ambulance or a hospital .An ambulance that do not have a defibrillator is not an ambulance at all .It is a sorry state of affairs some hospitals do have such ambulances .
There are numerous instances of patients dying in the ER due to poor response time of para medics in defibrillating a VF. It should be made a cognisable offence* to allow a patient die for lack of proper defibrillation within the hospital premises
There has also been instances of good intentional deaths , as a patient is shifted for a better place for catheter reperfusion strategies . If these centres are located in the other end of city , the door ( In fact it is the second door to balloon time ) to balloon time is directly related to the degree of traffic jam ! and has a great potential to accelerate the death of myocardium and some time the patient as well
*Deaths due to pump failure , cardiogenic shock is an allowed mode of death in STEMI as the natural history demands it ! Some body has to die for the sake of statistics
How to recognise the ACS early : Read the link elsewhere in my blog.
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Dr.S.Venkatesan MD 