Suma M. Victor

A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in India: The Tamil Nadu–ST-Segment Elevation Myocardial Infarction Program

Importance Challenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors. Objective To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model. Design, Setting, and Participants This multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period. Exposures Creation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology Main Outcomes and Measures Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality. Results A total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04). Conclusions and Relevance A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.

Protocol for a prospective, controlled study of assertive and timely reperfusion for patients with ST-segment elevation myocardial infarction in Tamil Nadu: the TN-STEMI programme

Introduction Over the past two decades, India has witnessed a staggering increase in the incidence and mortality of ST-elevation myocardial infarction (STEMI). Indians have higher rates of STEMI and younger populations that suffer from it when compared with developed countries. Yet, the recommended reperfusion therapy with fibrinolysis and percutaneous coronary intervention is available only to a minority of patients. This gap in care is a result of financial barriers, limited healthcare infrastructure and poor knowledge and accessibility of acute medical services for a majority of its population. Methods and analysis This is a prospective, multicentre, ‘pretest/post-test’ quasi-experimental, community-based study. This programme will use a ‘hub-and-spoke’ model of an integrated healthcare network based on clusters of primary-care health clinics, small hospitals and large tertiary-care facilities. It is an ‘all-comers’ study which will enrol consecutive patients presenting with STEMI to the participating hospitals. The primary objectives of the study is to improve the use of reperfusion therapy and reduce the time from first medical contact to device or drug in STEMI patients; and to increase the rates of early invasive risk stratification with coronary angiography within 3–24 h of fibrinolytic therapy in eligible patients through changes in process of care. Outcomes will be measured with statistical comparison made before and after implementing the TN-STEMI programme. The estimated sample size is based on the Kovai Erode Pilot study, which provided an initial work on establishing this type of programme in South India. It will be adequately powered at 80% with a superiority margin of 10% if 36 patients are enrolled per cluster or 108 patients in three clusters. Thus, the enrolment period of 9 months will result in a sample size of 1500 patients. Ethics This study will be conducted in accordance with the ethical principles that have their origin in the current Declaration of Helsinki and ‘ethical guidelines for biomedical research on human participants’ as laid down by the Indian Council for Medical Research. All participating hospitals will still obtain local ethics committee approval of the study protocol and written informed consent will be obtained from all participants. Dissemination and results Our findings will be reported through scientific publications, research conferences and public policy venues aimed at state and local governments in India. If successful, this model can be extended to other areas of India as well as serve as a model of STEMI systems of care for low-income and middle-income countries across the world. Registration Trial is registered with Clinical trial registry of India, No: CTRI/2012/09/003002.

A prospective, observational, multicentre study comparing tenecteplase facilitated PCI versus primary PCI in Indian patients with STEMI (STEPP—AMI)

Objective To compare the efficacy of pharmacoinvasive strategy versus primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). Primary PCI is the preferred treatment for STEMI, but it is not a feasible option for many. A pharmacoinvasive strategy might be a practical solution in the Indian context, although few empirical data exist to guide this approach. Methods This is a prospective, observational, multicentre pilot study. Two hundred consecutive patients with STEMI aged 18–75 years, presenting within 12 h of onset of symptoms and requiring a reperfusion strategy, were studied from five primary PCI capable centres in South India. Patients who opted for pharmacoinvasive strategy (n=45) formed group A. Group B consisted of patients treated with primary PCI (n=155). One patient was lost to follow-up at 1 year. The primary end point was a composite of death, cardiogenic shock, reinfarction, repeat revascularisation of a culprit artery and congestive heart failure at 30 days. Results The primary end point occurred in 11.1% in group A and in 3.9% in group B, p=0.07 (RR=2.87; 95% CI 0.92 to 8.97). The infarct-related artery patency at angiogram was 82.2% in group A and 22.6% in group B (p<0.001). PCI was performed in 73.3% in group A versus 100% in group B (p<0.001), and a thrombus was present in 26.7% in group A versus 63.2% in group B (p<0.001). Failed fibrinolysis occurred in 12.1% in group A. There was no difference in bleeding risk, 2.2% in group A versus 0.6% in group B, (p=0.4). Conclusions This pilot study shows that a pharmacoinvasive strategy can be implemented in patients not selected for primary PCI in India and hints at the possibility of similar outcomes. Larger studies are required to confirm these findings. Trial registration number Trial is registered with Clinical trial registry of India, CTRI number: REF/2011/07/002556.

Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India

Santanu Guha*, Rishi Sethi, Saumitra Ray, Vinay K. Bahl, S. Shanmugasundaram, Prafula Kerkar, Sivasubramanian Ramakrishnan, Rakesh Yadav, Gaurav Chaudhary, Aditya Kapoor, Ajay Mahajan, Ajay Kumar Sinha, Ajit Mullasari, Akshyaya Pradhan, Amal Kumar Banerjee, B.P. Singh, J. Balachander, Brian Pinto, C.N. Manjunath, Chandrashekhar Makhale, Debabrata Roy, Dhiman Kahali, Geevar Zachariah, G.S. Wander, H.C. Kalita, H.K. Chopra, A. Jabir, JagMohan Tharakan, Justin Paul, K. Venogopal, K.B. Baksi, Kajal Ganguly, Kewal C. Goswami, M. Somasundaram, M.K. Chhetri, M.S. Hiremath, M.S. Ravi, Mrinal Kanti Das, N.N. Khanna, P.B. Jayagopal, P.K. Asokan, P.K. Deb, P.P. Mohanan, Praveen Chandra, (Col.) R. Girish, O. Rabindra Nath, Rakesh Gupta, C. Raghu, Sameer Dani, Sandeep Bansal, Sanjay Tyagi, Satyanarayan Routray, Satyendra Tewari, Sarat Chandra, Shishu Shankar Mishra, Sibananda Datta, S.S. Chaterjee, Soumitra Kumar, Soura Mookerjee, Suma M. Victor, Sundeep Mishra, Thomas Alexander, Umesh Chandra Samal, Vijay Trehan

Apical ballooning syndrome in first degree relatives.

Apical ballooning syndrome (Takotsubo cardiomyopathy) is an unusual stress-related reversible cardiomyopathy occurring commonly in postmenopausal females. Genetic etiology of this condition is uncertain. A 68-year-old female and her daughter aged 43 got admitted to our institute simultaneously with acute chest pain following demise of one of their close relative. Both had features typical of Takotsubo cardiomyopathy and recovered completely. This reports point to the possible genetic predisposition to this abnormality.

The impact of systems-of-care on pharmacoinvasive management with streptokinase: The subgroup analysis of the TN-STEMI programme

Objectives We evaluated the impact of implementation of the TN-STEMI programme on various characteristics of the pharmacoinvasive group by comparing clinical as well as angiographic outcomes between the pre- and post-implementation groups. Methods The TN-STEMI programme involved 2420 patients of which 423 patients had undergone a pharmacoinvasive strategy of reperfusion. Of these, 407 patients had a comprehensive blinded core-lab evaluation of their angiograms post-lysis and clinical evaluation of various parameters including time-delays and adverse cardio- and cerebro-vascular events at 1 year. Streptokinase was used as the thrombolytic agent in 94.6% of the patients. Results In the post-implementation phase, there was a significant improvement in ‘First medical contact (FMC)-to-ECG’ (11 vs. 5 min, p < 0.001) and ‘Lysis-to-angiogram’ (98.3 vs. 18.2 h, p < 0.001) times. There was also a significant improvement in the number of coronary angiograms performed within 24 h (20.7% vs. 69.3%, p < 0.001). The ‘Time-to-FMC’ (160 vs. 135 min, p = 0.07) and ‘Total ischemic time’ (210 vs. 176 min, p = 0.22) also showed a decreasing trend. IRA patency rate (70.2% vs. 86%, p < 0.001) and thrombus burden (TIMI grade 0: 49.1% vs. 73.4%, p < 0.001) were superior in this group. The MACCE rates were similar except for fewer readmissions (29.8% vs. 12.6%, p = 0.0002) and target revascularizations at 1 year (4.8% vs. none, p = 0.002) in the post-implementation group. Conclusion The implementation of a system-of-care (hub-and-spoke model) in the pharmacoinvasive group of the TN-STEMI programme demonstrated shorter lysis-to-angiogram times, better TIMI flow patterns and lower thrombus burden in the post-implementation phase.

Outcome of primary PCI – An Indian tertiary care center experience

Objective To assess the feasibility and outcomes of primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) in Indian Scenario. Methods Between January 2005 and December 2012, consecutive STEMI patients who underwent PPCI within 12 h of onset of chest pain were prospectively enrolled in a PPCI registry. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital and 30 day major adverse cardiovascular events (MACE) [death, reinfarction, bleeding, urgent coronary artery bypass surgery (CABG) and stroke] were assessed. Results A total of 672 patients underwent PPCI during this period. The mean age was 52 ± 13.4 years and 583 (86.7%) were males, 275 (40.9%) were hypertensives and 336 (50%) were diabetics. Thirty one (4.6%) patients had cardiogenic shock (CS). Anterior myocardial infarction was diagnosed in 398 (59.2%) patients. The median chest pain onset to hospital arrival time, door-to-balloon time and total ischemic times were 200 (10–720), 65 (20–300), and 275 (55–785) minutes respectively. In-hospital adverse events occurred in 54 (8.0%) patients [death 28 (4.2%), reinfarction 8 (1.2%), major bleeding 9 (1.3%), urgent CABG 4 (0.6%) and stroke 1 (0.14%)]. Nineteen patients with CS died (mortality rate – (61.3%)). At the end of 30 days, 64 (9.5%) patients had MACE [death 35 (5.2%), reinfarction 10 (2.1%), major bleeding 10 (1.5%), urgent CABG 4 (0.6%) and stroke 1 (0.1%)]. Conclusion Our study has shown that PPCI is feasible with good outcomes in Indian scenario. Even though the recommended door-to-balloon time can be achieved, the total ischemic time remained long. CS in the setting of STEMI was associated with poor outcomes.

Single coronary artery from the right coronary sinus with proximal origin of the left anterior descending coronary artery and left circumflex as distal continuation of the right coronary artery : a rare variant : case report - online article

A single coronary artery is a rare coronary anomaly. A 68-year-old male underwent coronary angiography for recent inferior wall myocardial infarction. It revealed a common coronary trunk arising from the right sinus of Valsalva and bifurcated into the right coronary artery (RCA) and anterior descending coronary arteries. The RCA, after its usual distribution in the right atrioventricular groove, continued as the left circumflex artery in the left atrioventricular groove. There were significant stenoses in the mid and distal RCA, which were treated percutaneously.

☆Predictors of short-term outcomes in patients undergoing percutaneous coronary intervention in cardiogenic shock complicating STEMI—A tertiary care center experience

Background Studying the outcomes in patients presenting with cardiogenic shock with ST-segment elevation myocardial infarction (CS-STEMI) and undergoing primary or rescue percutaneous coronary intervention (PCI) may give an insight to the unmet needs in STEMI-care in our region and may help in future recommendations in improving survival. Materials and methodolgy During the period from January 2001- June 2017, there were 114 patients included in the study. The demographic, clinical and angiographic characteristics were compared between the survivors and non-survivors. All these variables were also compared between two-time frames (Phase 1- January 2001 to June 2007; Phase 2- July 2007 to June 2017). Results Among patients undergoing PCI for STEMI, 7.5% were in cardiogenic shock. In-hospital mortality for the patients included in the study was 53.5%. Total ischemic time (OR = 0.99, 0.99–1; p = 0.02), left ventricular ejection fraction (LVEF) (OR = 0.90, 0.82–0.98; p = 0.02), need for cardio-pulmonary resuscitation (OR = 0.12, 0.24–0.66; p = 0.01), and post PCI TIMI flows (OR = 0.08, 0.02–0.29; p < 0.001) were the significant determinants of in-hospital mortality in the regression analysis. There was no significant change in mortality between the two phases of the study, though there was a reduction in total ischemic and door-to-balloon times, transfer admissions, use of thrombolytics, glycoprotein IIb/IIIa inhibitors, intra-aortic balloon pump, and mechanical ventilation in phase 2. Conclusion Patients presenting in CS-STEMI and undergoing PCI continue to experience high mortality rates, despite improvements in total ischemic times. Further improvement in the systems-of-care are required to bring about reduction in mortality in this high-risk subset.

Multiple giant left atrial thrombi in Mitral Stenosis

Rheumatic Heart Disease (RHD) is rarely seen in developed countries but still is a common cause of Mitral valve Stenosis (MS) in the developing world. This case demonstrates unusual echocardiographic images of multiple giant Left Atrial (LA) thrombi as a consequence of chronic severe MS. Received Date: November 23, 2016 Accepted Date: May 24, 2017 Published Date: May 26, 2017 Citation: Suma M. Victor, et al. Multiple Giant Left Atrial Thrombi in Mitral Stenosis. (2017) J Heart Cardiol 3(2): 3132. DOI: 10.15436/2378-6914.17.1226 Suma M. Victor, et al. Figure 2: Giant left atrial thrombus.