On World Heart Day, a look at the state-of-the-art in Indian medicine on this front
When it comes to managing heart attacks, is India on a par with the developed countries of the West yet? The answer, unfortunately, is ‘not yet’. India has state-of-the-art hospitals, expertise and the latest hardware, but most of the heart attack victims are still being treated with ‘clot buster’ medicines. These drugs are certainly effective, if given within the first three hours of an attack occurring. Some of these drugs have side-effects such as allergic reactions and lowering of blood pressure.
But in the West, most of the heart attacks are being treated by balloon angioplasty and stenting — the so-called ‘primary angioplasty’. This procedure is effective even when the patient reports after the golden hour or after the window period of one to three hours of a heart attack occurring. The principle is to mechanically clear the clogged coronary arteries (the arteries carrying blood to heart muscle), to restore patency and blood flow. Any major damage to the heart muscle is prevented by restoring the blood flow, which helps preserve the heart’s pumping capacity. This, in turn, prevents the development of heart failure and gives the patient a chance for a better quality of life.
The faster the procedure is done, the better are the patient’s chances of survival: you could say, ‘time is muscle’. The time taken for the first medical contact after a heart attack to the balloon dilatation is called the ‘door to balloon’ time. In Europe and the U.S., a lot of efforts are being taken to reduce this time so as to improve the chances of survival. Though this is practised in a small way in India, the time has come to popularise this procedure in a major way.
Step I here involves the patient factor. The patient must recognise the symptoms and report at the earliest to the nearest medical facility. This requires public awareness and health education. The media can play a major role in this.
Step II has to do with the first point of medical contact. This could be a general practitioner, a family physician or the nearest nursing home. The physician should not delay taking an electrocardiogram (ECG) to confirm the diagnosis of heart attack and to decide on the need for primary angioplasty. The patient should be referred to the nearest cardiac centre capable of performing primary angioplasty.
Continuing medical education (CME) programmes will help physicians understand the benefits of such a procedure. Especially the time factor should be stressed. There should not be any delay in transferring the patient to the cardiac facility. The so-called ‘therapeutic inertia’ by the primary physician is better avoided. The physician concerned can actually participate in the continued care of the patient by being in contact with the treating institution and cardiologist. The patient can be followed up after discharge by him.
Step III has to do with emergency ambulance services. The patient should be transported by ambulance at the earliest to the cardiac interventional facility. Paramedical staff can administer the necessary medication during the transportation and provide information to the receiving hospital regarding the medical history and the condition of the patient. Ambulances can be equipped to transmit ECGs for expert opinion and guidance regarding emergency care through telemetry.
Step IV involves interventional care. On reaching the emergency care station of the cardiac interventional facility, after checking the vital parameters, an ECG can be repeated to confirm the diagnosis. The necessary blood tests are carried out and the patient is prepared for the procedure. Informed consent is taken from the family members after detailing all the aspects of care. The patient is transported to the cardiac catheterisation laboratory where an expert team of nurses, technicians and anaesthesiologists is available round-the-clock.
The treating cardiologist should have the necessary expertise to do the interventional procedure. The surgical team should be readily available as standby in the event that surgery is needed to save a patient’s life. A well-equipped catheterisation laboratory with machines such as the intra-aortic balloon pump (IABP) to support the pumping of the heart is mandatory. The hurdle is to obtain consent from the family as any such life-saving invasive procedure involves calculated risks and costs. Public education and counselling by the referring physician may reduce the extent of this problem. The media can play an important role in increasing awareness and acceptance.
The goals here include increasing public awareness regarding the symptoms of a heart attack; improving health education; involving the media in the propaganda; training general practitioners and family physicians to recognise ECG changes during a heart attack and emergency care of victims of heart attacks; identifying hospitals equipped with interventional cardiac facilities and with skilled healthcare personnel for round-the-clock care of such patients; improving availability of ambulance services to minimise transportation time; and alleviating fear from the minds of the public through dialogues with family physicians and improving acceptance by them of interventional cardiac procedures that could prove life-saving.
The cost factor needs to be considered here. Interventional procedures are certainly expensive. The cost of materials is high. These include catheters, balloons, stents, special equipment like IABP support systems, and clot thinner medicines. But it is worth spending the money if heart muscle damage can be prevented and lives can be saved. It was James Hilton who wrote: “This is an era when counting the cost and paying the price are not things to think of any more; all that matters is the value.” There needs to be collective discussion among healthcare systems, providers of health care, insurance companies and interventional cardiologists to address this issue and help patients in the best possible manner.
Since a heart attack is an emergency and timely treatment could be life-saving, insurance companies should permit cashless pre-authorisation facility for such patients on the information given by the treating cardiologist without any delay in giving sanction. Even if this involves a small extra premium, it is worth considering a primary angioplasty pre-authorisation in the event of a heart attack.
The result is gratifying when a patient is treated early. In winning a relay race, the runner in each lap must be fast in handing over the baton to the next one. In the case of treating a heart attack victim too, the care and delivery must be fast and quick without any delay in the Steps one to four mentioned above. Treatment delayed is treatment denied.
If we set the goals properly, in the near future definitely India can be on a par with the West in treating acute heart attacks.
(I. Sathyamurthy is an interventional cardiologist and the Director of the Department of Cardiology, Apollo Hospitals, Chennai. He received the Padma Shri in 2000, the Dr. B.C. Roy National Award in 2001 and a D.Sc (Honoris Causa) from the Dr. M.G.R. Medical University in 2008.)