STEMI India: reimagining STEMI networks in low- and middle-income countries: Reimagining STEMI

Strengthening cardiac services in Faridabad District: A facility mapping exercise to explore implementation of a hub-and-spoke model

Background & objectives Improving access to acute cardiac care requires remodelling of existing health systems into a service delivery network with an anchor establishment (Hub) offering a full array of services, complemented by spoke establishments that offer limited services. We assessed the availability of cardiac services in the district of Faridabad in the northern State of Haryana, India and explored the feasibility and challenges of implementing a hub-and-spoke model. Methods In 2019-2020, we listed all the facilities in private and public sectors in the study-district and mapped their geocoordinates with the help of QGIS (Quantum Geographic Information System) software version 3.20. After consent, we assessed the availability of specific cardiac care-related inputs (medicines, technologies and staff) using a checklist by enquiring from the hospital staff. Each facility was classified as L1 (No ECG) to L5 (cardiac catheterization) as per the national guidelines for the management of ST-elevation myocardial infarction (STEMI). Results There were 109 health facilities (66% private) in the district, 1.6 cardiologists and 5.4 coronary care unit beds per 100,000 population (94% private). Only one district hospital running in a public-private partnership mode at the L5 level provided any cardiac services. Private facilities were providing a range of services with a considerable number of them functional at L5. The higher-level facilities were concentrated in the central and urban parts of the district. Only 46 per cent of the ambulances had oxygen cylinders and 14.7 per cent had defibrillators. Interpretation & conclusions Implementation of a hub-and-spoke model for cardiac care in Faridabad district will require significant strengthening of public health services, development of a private-sector participation model, and strengthening of ambulance services.

[Efficacité du tirofiban intracoronaire avant pose d'un stent suivi d'une perfusion dans une charge de thrombus importante prouvée par angiographie : une étude randomisée]

BACKGROUND

The presence of angiographic thrombus is associated with poor outcomes in contemporary cardiology practice. Percutaneous coronary intervention (PCI) in such lesions is associated with slow flow and no-reflow phenomenon which translate into poor clinical outcomes.

METHODS

This was a single-centre, prospective, open-label, randomized controlled study with 50 patients each in intervention group and control group. Patients with angiographically proven large thrombus burden were recruited. In the intervention group, patients were given loading dose of intracoronary tirofiban (25 mcg/kg infused over 5 minutes) followed by prolonged infusion of tirofiban (0.15 mcg/kg/min for 12-18 hours) followed by PCI after 48-72 hours interval. In control group patients were taken up directly for PCI during the index procedure. Outcomes were assessed angiographically and in terms of clinical endpoints.

RESULTS

The primary composite-endpoint of recurrent angina, myocardial infarction, cardiovascular death, target lesion revascularization and unscheduled CABG was significantly lower in the intervention arm compared to control arm (4% vs 16%, p = 0.04). Amongst the secondary endpoints, a statistically significant 30-day increase in ejection fraction from baseline was observed in the intervention group compared to the control group (1.6 ± 1.3 vs 0.2 ± 0.4, p = 0.0001). Overall mortality was similar in the two groups (4% vs 8%, p = 0.39). The primary safety endpoint of major bleeding was also similar in the 2 groups (2% vs 0%, p = 0.31).

CONCLUSIONS

Tirofiban use prior to PCI in high thrombus burden was associated with improved clinical and angiographic endpoints with similar adverse events compared to controls.