April 18, 2018 | Paul W. Armstrong, MD, FACC; Juan Simon Rico-Mesa, MD; Jianqiang Li, MD; Konstantinos Stathogiannis, MD, PhD
International

Foreword
By Paul W. Armstrong, MD, FACC, professor of cardiology at the University of Alberta in Canada.

The challenges in delivering high quality ST-elevation myocardial infarction care is universal, and the following article provides stories from three individuals who have experienced STEMI in various parts of the world. Their stories describe in-depth observations from Colombia, where the lack of facilities exacerbated by economic factors is challenging; China, where patient consent and public education are key aspects of care; and Greece, where the "unique landscape" encompassing both mountains and islands affects access for patients.

Each individual experience provides examples of emerging strategies to enhance care. Examples include using mobile devices to facilitate electrocardiogram (ECG) transmission and drive appropriate triage, allowing networks of care to underscore how a team approach facilitates quality assurance programs and showing how registries not only guide improvement but also sow the seeds for future research.

Some other lessons learned about STEMI care over the last 15 years are:

• One size of STEMI treatment does not fit all.
• Fibrinolytic dose reduction is prudent in the elderly.
• Some reperfusion (administered promptly) is better than prolonged delays for primary percutaneous coronary intervention (PCI), especially in patients presenting early and with a large territory at risk.
• We must overcome under or delayed treatment. Even in large urban areas well populated with ample PCI facilities, unexpected delays to PCI are common.
• To be relevant, door-to-needle and door-to-balloon times must be interpreted in the context of total ischemic time.
• Prehospital diagnosis and treatment by paramedics can shave one hour from total ischemic time and save myocardium and lives.

STEMI care is a global challenge. While distinct international differences in care will remain, collaborating effectively with an informed and rational strategy that keeps pharmaco-invasive and PCI options open will result in the best care.

STEMI Treatment Network in Colombia
By Juan Simon Rico-Mesa, MD, Fellow in Training (FIT) at the Mayo Clinic College of Medicine in Rochester, Minnesota.

Management of patients with STEMI represents one of the most challenging cases in interventional cardiology for the Colombian health system. Developing a comprehensive STEMI network around the country has not yet been possible, although different groups such as the LUMEN foundation have tried to develop a network based on telemedicine and design models of care.

Less than 5 percent of hospitals in Colombia have catheterization laboratories. Unfortunately, having a catheterization laboratory implies extra costs that are unaffordable for most patients and the Colombian health system. In addition, most private health care insurance companies have several conflicts with reimbursing interventional cardiology procedures to the hospitals, even if they are emergent or lifesaving. Therefore, health centers are not very eager to provide these services.

Luckily, the few medical centers with catheterization laboratories are mainly cardiovascular centers of reference with a high educational environment, and most offer academic fellowship programs in interventional cardiology. Hence, pharmacological thrombolysis is a very common strategy for STEMI in Colombia. Some patients eventually undergo catheterization once arrangements are held between the health insurance companies and health care providers.

As for the educational standpoint of interventional cardiology in Colombia, we are lucky to have well-trained interventional cardiologists. In fact, several of them complete their training in the U.S., as they are highly exposed with bench research and interested in developing new solutions for the management of STEMI in a developing country.

The low access to PCI in STEMI patients is mostly because of economical issues, secondary to patients' insurance and government policies. Once this health care barrier is addressed and appropriately fixed, STEMI patients will be subjected to a phenomenal health care.

STEMI Treatment Network in China
By Jianqiang Li, MD, cardiologist at the First Affiliated Hospital of Harbin Medical University in Harbin, China.

There is a significant difference in the quality of STEMI care around China due to imbalanced development in different areas. To address this issue, the Chest Pain Center (CPC) was introduced in 2013 to better differentiate patients with chest pain and improve care of STEMI patients. With CPC, China has established the regional collaboration treatment network for STEMI and the number of CPC is expected to reach 1,000 this year. According to data presented in 2016, about 38.91 percent of STEMI patients received primary PCI in the mainland of China while the use of thrombolysis therapy was decreasing. From China CPC data in 2017, door-to-balloon time and in-hospital death rate in STEMI were reduced to 80 minutes and 3.21 percent, respectively.

Lack of medical education in the general public is still the main cause of STEMI treatment delay, as doctors spend a lot of time talking to patients or the patients' family about informed consent. Our government has taken measures to raise people's awareness of reperfusion treatment in STEMI such as media publicity and patient education in hospitals and communities. Currently, primary PCI is the priority treatment for STEMI patients in most areas of China unless door-to-balloon is extended. If a patient is admitted in a non-PCI capable hospital and cannot be transferred to a PCI capable hospital in time, thrombolysis therapy will be applied.

STEMI Treatment Network in Greece
By Konstantinos Stathogiannis, MD, PhD, Fellow in Training (FIT) at the Hippokration General Hospital of Athens in Greece.

Acute myocardial infarction (AMI) with STEMI is part of the acute coronary syndrome (ACS) spectrum and a major cause for increased morbidity and mortality among patients in Greece. In the past 15 years there has been an abundance of information regarding the epidemiology, treatment and prognosis of STEMI patients based on registries and observational studies. Primary PCI centers with experienced operators have been established across the country (49 centers in total), and the rate of primary PCI procedures has increased in the past few years (from 9 percent to 32 percent) according to the Greek ACS national registry. This increased number of procedures has been translated into decreasing mortality rates in STEMI patients.

One unique aspect of Greece is its landscape, combining both the mountainous mainland and hundreds of inhabited islands, which poses a challenge in transferring these patients immediately to a primary PCI center. There is an ongoing project for most mobile units to be electronically connected with a central operator for ECG transmission and STEMI diagnosis in order to bypass non-primary PCI centers and save time, especially in rural areas. Greece has also joined the Stent Save a Life program, a continuum of the Stent for Life program, which is a European initiative by EAPCI and the National Heart Societies for delivering guideline complying therapy. It involves campaigning for public awareness of early recognition of AMI symptoms, prompt request for help and patient education after a STEMI – an important step for secondary prevention.