Heart disease has affected the young Indian population 10 years ahead of their Western counterparts -- particularly over the last three decades -- owing to sedentary lifestyles and lack of exercise, the nations top cardiologists have warned. 

Heart disease or cardiovascular disease (CVD) is a collective term for diseases of the heart and blood vessels. The term commonly includes diseases such as coronary heart disease, heart failure, cardiomyopathy, congenital heart disease, peripheral vascular disease and stroke.

With more than three million heart attacks happening every year in India, STEMI India 2014 in collaboration with Stent for Life, the joint EAPCI and EuroPCR Initiative is organising a two-day conference at The Renaissance Mumbai Convention Centre, from 31st May to June 1, 2014. The conference will address designing of high reliability systems which would measure quality of care in hospitals in Western India (Maharashtra, Goa, Gujarat, Madhya Pradesh) in areas of therapeutic procedures, medications and treating of acute myocardial infarction (heart attack).

The course directors of STEMI INDIA 2014, Dr. Thomas Alexander, Head of Division of Cardiology, Kovai Medical Center and Hospital, Coimbatore; Dr. Mullasari Ajit S, Director of Cardiology, The Madras Medical Mission, Chennai; Dr. Rajesh Rajani, Section Coordinator (Cardiology), Hinduja Healthcare Surgical, Khar, Mumbai and Dr. Prafulla Kerkar, Head of Department of Cardiology, King Edwards Memorial VII Hospital, Mumbai; in association with the Heads of Stent for Life and doyens of Cardiology from Mumbai, Europe will inaugurate the conference.

"The objective of organising this important STEMI conference is to train and equip each hospital in Western India to appropriately manage the patients with heart attack. The long term aim of STEMI INDIA – a Not for Profit Organisation dedicated to developing STEMI systems of care in India – is to develop a system of care in Mumbai and Western India to deliver appropriate heart attack care to patients within the golden first hour. Once the process is functional and the system is set in place, STEMI INDIA will train teams for setting up this facility at hospitals in Mumbai and Western India. STEMI accredited hospitals will then treat patients according to current guidelines and within critical golden hour. Doctors from the United States and Europe have done this for the past 10 years and have delivered appropriate care," said, Dr. Thomas Alexander, Director – STEMI INDIA.

According to an extensive study done by CREATE Registry, co-authored by Dr. Prafulla Kerkar, it takes an average 360 minutes from onset of pain to treatment time for a patient in India. The pilot study conducted initially by STEMI INDIA in Tamil Nadu on 84 patients has reduced this critical time to 170 minutes with 75% of patients using an ambulance for travel. Further work is continuing to improve this critical time delay said Dr. Ajit Mullasari, Director – STEMI INDIA.

Proposed STEMI INDIA plan:

The first state to embark on a STEMI system of care has been Tamil Nadu, where the initial STEMI project in four clusters has been run in partnership with the Government of Tamil Nadu, ICMR (Indian Council of Medical Research) and ambulances from the GVK-EMRI. This project has successfully shown the feasibility and effectiveness of this model, now known as the STEMI INDIA model of care.

According to Dr. Prafulla Kerkar – Course Director, STEMI INDIA 2014 , "When the patient realises the symptoms of a heart attack, in India, 95% travel by public transport and only 5% travel by ambulance. In emergency medicine, the golden hour refers to a crucial time period lasting from a few minutes to an hour following heart attack during which there is the highest likelihood that prompt medical treatment will prevent death. STEMI INDIA is initiating proper treatment to a patient with a heart attack in that golden hour."

"This meeting is attended by close to 1,000 delegates from across Western India who will be trained in all aspects of Heart Attack care. We believe that this initiative will significantly improve heart attack care in this region," said Dr. Rajesh Rajani – Course Director, STEMI INDIA 2014.

The international faculty at the conference include Asst. Prof. Petr Kala, SFL Chairman, Czech Society of Cardiology; Dr. Jagat Narula, Associate Dean for Global Affairs; Dr. Umesh Khot, Vice Chairman – Cardiovascular Medicine, Cleveland Clinic, USA; Dr. Venu Menon, Director – Coronary Care Unit, Cleveland Clinic, USA; Dr. Zuzana Kaifoszova, Stent for Life, Czech Republic; Dr. Anuj Gupta, Director – Cardiac Cath Lab, University of Maryland School of Medicine and Dr. Dinesh Shah, CEO & Medical Director, Michigan Physicians Group, Berkley, MI; Dr. Dharam Kumbhani, Assistant Professor, Interventional Cardiology, UT Southwestern Medical Center and Dr. Gotabhaya Ranasinghe, General and Interventional Cardiologist, The President, Sri Lanka Heart Association.

Imagine how many lives could be saved if the time taken for a person with some manner of heart attack to reach the hospital comes down from six hours to just under three hours. And that's exactly what STEMI (ST Elevation Myocardial Infarction) India is aiming to do as they expand their life-saving model to four large hospitals across Tamil Nadu. With three million Indians having cardiac issues every year, a 'huge' number of lives hang in balance.

STEMI INDIA, a project that began two years ago to try and reduce deaths caused due to myocardial infarctions, will now expand their pilot project from one hospital to four major cardiac centres and see how the results compare. Incidentally, they provide training to ambulances, paramedics, doctors and other hospital staff to handle cardiac problems quicker and more effectively, besides networking with hospitals who have the staff and equipment to handle severe emergencies.

"For the last one year we had been studying how well our model worked at the Kovai Medical College and Hospital and the results have been impressive," said Dr Mullasari Ajit S of the Madras Medical Mission, "And that is how we were able to reduce the time that a person took to reach the hospital after a heart attack, so drastically." Now, the project will also extend to the Madras Medical Mission and Stanley Medical College in Chennai and the Christian Medical College in Vellore, to study the response time for 1,000 cases over the next nine months. "We will compare the data from before we started and the data we will collect now and show the increased patient survival rate to the government. Hopefully, that will convince them to adopt this system for the entire State and beyond," he added. STEMI INDIA's project has been bolstered to a great extend by their stakeholders - namely GVK EMRI 108, the TN Government and ICMR. "Between the learning attitude of the ambulance staff and the coverage provided by the CM's Comprehensive Health Insurance Scheme, things have been relatively good for the project," he said. Ways to improve STEMI care in India as well as learning new techniques, is the focus of the STEMI conference being hosted in the city over the weekend. Almost all the top emergency management experts, cardiac surgeons and cardiologists will be a part of this conference.

The STEMI INDIA and ACT 2013 meeting (www.stemiact13.com) will be held in collaboration with the Stent for Life Initiative from 12-14 July 2013 at Chennai, India. This day and a half programme will provide a comprehensive review and training to the medical team involved in the processes and procedures in the care of the STEMI patient – from the emergency room physician, intensivist and nurses in CCU, to the clinical cardiologist involved in thrombolysis and to the cardiac catheterisation laboratory team in PCI capable hospitals. The primary aim of the meeting is to develop "STEMI Teams" in hospitals capable of quickly and appropriately managing STEMI patients thereby reducing reperfusion times and improving outcomes.

A recent paper published in the British Heart Journal highlights the need to develop a system of care for ST elevation myocardial infarction (STEMI) in India.

A recent paper published in the British Heart journal, 'Systems of care for ST-elevation myocardial infarction in India: is it time' highlights the need to develop a system of care for STEMI (Heart attack) in India. According to the recent data, the prevalence of coronary artery disease and ST elevation myocardial infarction (STEMI) are increasing in India. Although recent publications have focused on improving preventive measures in developing countries, less attention has been placed on the acute management of STEMI. Recent policy changes in India have provided new opportunities to address existing barriers but require greater investment and support in the coming years.

The paper further suggests that, this pattern of disease has substantial implications for India's growing workforce and economy. The poor patients with CAD in India appear to be at greater risk of acute presentations of CAD and have worse outcomes following such events.

The data about contemporary trends in STEMI patients for the study has been sourced from CREATE, a large clinical registry of acute coronary syndrome patients from 89 large hospitals in 10 regions and cities across India. The major challenges and opportunities identified for managing STEMI in India as per the paper are mainly arising due to the distinctive structure of India's healthcare system, which is one of the most privatised in the world. As such, specialised Centre's in urban areas offer world class, cutting-edge treatment (which has promoted medical tourism as an industry), while much of the population still relies on inadequately funded public health systems and hospitals.

To take control measures, the state governments have expanded social insurance programmes although still under development, the recent and rapid introduction of social health insurance has potentially profound effects on STEMI care in India. In general these programmes have involved public private partnerships with premiums provided by state governments while claims are administered by private companies.

Two recent models have been the Arogyasree insurance programme in Andhra Pradesh and the government insurance programme in Tamilnadu. Both programmes allow for emergency treatments and procedures through 'fast-track' approval.

Several practical lessons were learnt from this initiative. First, building partnerships between hospitals is critical with transport time only one of many factors under consideration. Financial mechanisms also need to be worked for partnerships to develop, even with the availability of social health insurance.

Third, audit and quality control issues need to be addressed at every level.

Finally and perhaps most importantly, it is clear that STEMI guidelines need to be contextualised to India. Relying on North American and European standards is problematical for providers in India especially in regions with smaller and rural hospitals.

Claim 95% Heart Attack Victims Dont Use Ambulance,Increasing Risk Of Death

Chennai: About 95% of Indians who suffer a heart attack dont use an ambulance to reach a hospital,resulting in many deaths that can be avoided, say cardiologists.Participants at the STEMIINDIA conference on advanced cardiovascular therapeutics here on Friday said most of them took private vehicles to go to hospital.

An ambulance has paramedics to provide first-aid.This would cut the mortality rate by 50%.But not many people understand this.Immense amount of public education is needed on using the ambulance services, said Dr Matthew Samuel K,a course director with STEMIINDIA which is tying up with city hospitals to make sure medical assistance is within the reach of a person in an emergency.

To establish an integrated system to bring down the mortality rate with regard to heart attacks,the first step is to train medical teams,including nurses,paramedical staff,emergency physicians and cardiologists.We follow the hub and spoke model in which the hub would be a STEMI-accredited hospital that can treat heart attacks and the spoke would be district hospitals that can provide the basic first aid.The focus would be on putting a workable system in place from the point the patient has a heart attack and is transported to hospital till he becomes stable, said Dr Mullasari Ajit,director of cardiology at Madras Medical Mission.Medical staff would be trained to dissolve the clot from the artery through medication before the patient is shifted to a STEMI-accredited hospital,he said.

STEMIINDIA partnered the government,ICMR and GVK EMRI ambulance services to conduct a pilot study of 1,000 patients with four hub and spoke hospitals to assess the improvement in terms of treatment,mortality and morbidity of heart attacks.The hospitals are Kovai Medical Centre,Madras Medical Mission,Christian Medical College Vellore and Stanley Medical College and Hospital.Studies say it takes an average of 360 minutes from the onset of pain to treatment time for a patient in India.A mini pilot involving 84 patients has reduced this time to 170 minutes with 75% of ambulance travel.If the pilot project is a success,we will extend the model across the country.It is important for a patient to reach the right hospital at the right time.The first step is to teach them how to recognize a heart attack and use the ambulance services, said Dr Thomas Alexander.

MATTERS OF HEART - What is STEMI?

STEMI (ST segment elevation myocardial infarction) is a type of heart attack that occurs when a coronary artery is totally blocked by a blood clot 3 million Indians die of heart attacks every year Almost 50% of these deaths can be avoided if the patient gets primary PCI (Percutaneous coronary intervention)

The hub & spokes model proposed by members of STEMI

Efficient ambulance services Skilled paramedics Coordination between the hub (a private hospital) and spokes (district) hospitals.

STEMI INDIA, a not-for-profit national organization, is now focused on improving the ST-elevation myocardial infarction (Stemi), a life threatening medical emergency that results from a sudden and occlusive thrombus in the coronary artery in India.

The NGO is now gearing up to review scientific literature, educate and train Stemi teams in hospitals, develop Stemi guidelines and systems of care approaches relevant for India.

It has also released a data from CREATE, a large clinical registry of acute coronary syndrome patients from 89 large hospitals in 10 regions and cities across India conducted by the Kovai Erode Pilot which is a Stemi initiative.

A recent paper was published in the British Heart Journal 'Systems of care for ST-elevation myocardial infarction in India: is it time' highlights the need to develop a system of care for Stemi or heart attack in India. The paper is authored by Dr. Thomas Alexander from Kovai Medical Centre and Hospital, Coimbatore, Sameer Mehta University of Miami, Miami, Florida, USA, Ajit Mullasari , Madras Medical Mission, Chennai, and Brahmajee K Nallamothu, University of Michigan Medical School, Ann Arbor, Michigan.

The data revealed of the 20 000 patients enrolled in CREATE trial, over 60 per cent had Stemi, which was substantially higher than in North American and European registries. These patients young and from the lower socioeconomic status when compared with non- Stemi patients. The median time from the onset of symptoms to hospital arrival was 300 minutes in STEMI patients, which was more than double the delay reported in developed countries. Approximately 60 per cent received fibrinolytic therapy and only 8 per cent underwent percutaneous coronary intervention (PCI) during their hospitalization, suggesting substantial room for improvement in the use of acute reperfusion therapy.

Dr. Thomas Alexander stated that India needs to focus on non-communicable diseases, particularly conditions like Stemi which affects young people.

The major challenges and opportunities identified to manage Stemi in India according to Dr. Alexander is the structure of India's healthcare system, which is advanced at one end in the urban India and basic at the other end in the rural areas with poor infrastructure to manage medical emergencies calling the need for greater investment in acute reperfusion therapy. The gap has been most apparent for pre hospital emergency medical systems (EMS), which until recently were almost non-existent. There is also inadequate public and private health insurance programmes placing Stemi patients and their families at great personal financial risk from treatments, contributing to the under utilization of evidence-based therapies, he said.

Indian healthcare needs to adopt a better acute reperfusion therapy to manage Stemi in India. Approval of two generic drugs - tenecteplase and reteplased by the Drug Controller General of India is a major step towards developing viable Stemi care in the country. The second-generation drugs for fibrinolytic therapy improve reperfusion rates and outcomes in Stemi patients. New data on adjunctive therapy with clopidogrel may also expand the benefits of fibrinolytic therapy. An improved understanding of the role of PCI approach, which is a combination of immediate pharmacological reperfusion with invasive cardiac procedures, suggests controlling high-risk patients. Availability of newer generation and less expensive generic Indian stents will significantly expand PCI to broader populations, he said.

Abstract In India, the prevalence of ST elevation myocardial infarction (STEMI) is rising exponentially leading to cardiovascular morbidity and mortality. Despite advancement in reperfusion therapy (pharmacologic and interventional), the overall utilization, system of care and timely reperfusion remains suboptimal. Justification and Purpose: Alarming treatment delays exist in patients presenting with chest pain observed in real-world and published evidences. Time to diagnose STEMI and initiation of reperfusion therapy at various first medical contacts in India is variable mandating immediate attention. We intend to provide evidence based explicit recommendations for practicing clinicians about time-dependent early management and the concept of pharmaco-invasive (PI) approach, contextualized to the situation in India.

A treatment plan for the acute care of ST elevation myocardial infarction (STEMI) has been launched within a large rural district of Tamil Nadu, India. Taking advantage of recent changes, such as the GVK EMRI ambulance system and the government insurance program in Tamil Nadu, the program's early data demonstrate an improvement in the quality of acute STEMI care by dramatically decreasing the time from symptom onset to hospital arrival and subsequent receipt of percutaneous coronary intervention (PCI).

"This is a pilot project funded by the Indian Council of Medical Research to develop a system of care that could be a model for an eventual STEMI system of care in India. Eventually, we believe that this model could be transplanted across geographies beyond India."

-Thomas Alexander, MD, FACC, FCSI, member of the board of directors of STEMIINDIA and senior consultant and interventional cardiologist at Kovai Medical Center and Hospital, Coimbatore, India

The prevalence of coronary artery disease and STelevation myocardial infarction (STEMI) are increasing in India. Although recent publications have focused on improving preventive measures in developing countries, less attention has been placed on the acute management of STEMI. Recent policy changes in India have provided new opportunities to address existing barriers but require greater investment and support in the coming years.

Coronary artery disease (CAD) is currently the most common, non-infectious disease in India and will affect over 65 million of its people by the year 2015

COIMBATORE: A recently formed national body of interventional cardiologists will look at forming a quick reaction network of hospitals and ambulance service providers in Tamil Nadu to save persons who have suffered a heart attack. The effort is to enable quick shifting of patients to hospitals for life-saving treatment.

ST (a segment) elevation in myocardial infarction (STEMI) or heart attack is one of the leading causes of death in the world, says Chief Cardiologist at Kovai Medical Center and Hospital (KMCH) Thomas Alexander, one of the heart specialists pushing hard for the project.

STEMIINDIA, the new national-level body, may contemplate national-level models after the one in the State becomes fully functional.

Dr. Alexander says the announcement of the Statewide initiative may be made after Kovai Lumen, a two-day workshop here on March 12 and 13. Lumen is the world's premier STEMI meeting held annually at Miami in the U.S.

KMCH and Lumen had teamed up to hold the first workshop here last year. Dr. Alexander is the Course Director of the event this year also. The programme will carry out a comprehensive review and training of medical teams in the management of heart attack patients. Everyone — right from the paramedics in the ambulance to the specialist doctor and also the catheterisation laboratory technicians — will be trained.

"We carried out a pilot project in Erode and identified problems such as the lack of catheterisation laboratories in rural areas. Now the focus is on developing linkage, as it is a difficult task," says Dr. Alexander.

The plan now is to have a hub and spokes model wherein the State will be divided into many regions and each region will have a major heart care centre linked to smaller hospitals or sub-centres.

If the patients are not close to the main centre, they will be taken to the nearest sub-centre for basic measures such as providing drugs to dilute the clot in the blood vessel in the heart. They can then be shifted to the main centre where advanced investigations and procedures such as angioplasty will be done.

"For this, we need ambulances to shift patients first to the sub-centres and from there to the main centre," explains Dr. Alexander. Moves are afoot to involve Emergency Management and Research Institute (EMRI) ambulances. "EMRI does not make hospital to hospital transfer of patients at present. We are trying to work that out because that will be crucial in our programme."

Dr. Alexander says the programme is being planned in co-ordination with Star Health Insurance and Reliance.

"First, we want to link all hospitals that are covered under the insurance programme of Star. Reliance is willing to supply at subsidised rates the latest drugs to dissolve the clot in the blood vessel in the heart. We are trying to rope in other pharmaceutical companies also."

The Tamil Nadu model will lay down clear guidelines to save time and cost for the patients. Star will specify the protocols for myocardial infarction management. Dr. Alexander says the contribution of the pharmaceutical firms will be significant because there is no insurance coverage for the initial, vital dose of drugs to dissolve the clot.

The Indian Council of Medical Research, which has a national registry of cases, has evinced interest in partnering in the Tamil Nadu programme, says Dr. Alexander.

The health care burden of ST elevation myocardial infarction (STEMI) in India is enormous. Yet, many patients with STEMI can seldom avail timely and evidence based reperfusion treatments. This gap in care is a result of financial barriers, limited healthcare infrastructure, poor knowledge and accessibility of acute medical services for a majority of the population. Addressing some of these issues, STEMI India, a not-for-profit organization, Cardiological Society of India (CSI) and Association Physicians of India (API) have developed a protocol of ‘‘systems of care’’ for efficient management of STEMI, with integrated networks of facilities. Leveraging newly-developed ambulance and emergency medical services, incorporating recent state insurance schemes for vulnerable populations to broaden access, and combining innovative, ‘‘state-of-the-art’’ information technology platforms with existing hospital infrastructure, are the crucial aspects of this system. A pilot program was successfully employed in the state of Tamilnadu. The purpose of this article is to describe the framework and methods associated with this programme with an aim to improve delivery of reperfusion therapy for STEMI in India. This programme can serve as model STEMI systems of care for other low-and-middle income countries.