Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries
Y Chandrashekhar 1, Thomas Alexander 2, Ajit Mullasari 3, Dharam J Kumbhani 4, Samir Alam 5, Erick Alexanderson 6, Damodar Bachani 7, Jacobus Cornelius Wilhelmus Badenhorst 8, Ragavendra Baliga 9, Jeroen J Bax 10, Deepak L Bhatt 11, Eduardo Bossone 12, Roberto Botelho 13, Rabindra Nath Chakraborthy 14, Richard A Chazal 15, Rupinder Singh Dhaliwal 16, Habib Gamra 17, Sivadasan Pillai Harikrishnan 18, Mohamed Jeilan 19, David Ian Kettles 20, Sameer Mehta 21, Padhinhare P Mohanan 22, Christoph Kurt Naber 23, Nitish Naik 24, Mpiko Ntsekhe 25, Harun Argwings Otieno 19, Prem Pais 26, Daniel José Piñeiro 27, Dorairaj Prabhakaran 28, K Srinath Reddy 29, Mustafa Redha 30, Ambuj Roy 24, Meenakshi Sharma 16, Robert Shor 31, Frederik Adriaan Snyders 32, Jack Weii Chieh Tan 33, C Michael Valentine 34, B Hadley Wilson 35, Salim Yusuf 36, Jagat Narula 37
Affiliations
Affiliations
- Division of Cardiology, University of Minnesota/VA Medical Center, Minneapolis (Y.C.).
- Division of Cardiology, Kovai Medical Center and Hospital, Coimbatore, India (T.A.).
- Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India (A.M.).
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K.).
- Division of Cardiology, American University of Beirut Medical Center, Lebanon (S.A.).
- Nuclear Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Universidad Nacional Autonoma de Mexico, Mexico City (E.A.).
- Building Healthy Cities, John Snow India Pvt Ltd, New Delhi (D.B.).
- Netcare Unitas Hospital, City of Tshwane Metropolitan Municipality, Gauteng, South Africa (J.C.W.B.).
- Division of Cardiology, Ohio State University Wexner Medical Center, Columbus (R. Baliga).
- Division of Cardiology, Leiden University Medical Center, The Netherlands (J.J.B.).
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.).
- Department of Cardiology and Cardiac Surgery, Azienda Ospedaliera Universitaria, Salerno, Italy (E.B.).
- Triangulo Heart Institute, Uberlândia, Minas Gerais, Brazil (R. Botelho).
- Department of Cardiology, Apollo Gleneagles Hospital, Kolkata, India (R.N.C.).
- Heart and Vascular Institute for Lee Health, Fort Myers, FL (R.A.C.).
- Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi, India (R.S.D., M.S.).
- Department of Cardiology, Fattouma Bourguiba University Hospital, Monastir, Tunisia (H.G.).
- Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India (S.P.H.).
- Division of Cardiology, Aga Khan University Medical College, Nairobi, Kenya (M.J., H.A.O.).
- Division of Cardiology, St. Dominic's Hospital, East London, South Africa (D.I.K.).
- Lumen Global Foundation, Miami, FL (S.M.).
- Department of Cardiology, Westfort Hi-Tech Hospital, Thrissur, Kerala, India (P.P.M.).
- Department of Cardiology, St.-Marien-Hospital, Mülheim an der Ruhr, Germany (C.K.N.).
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi (N.N., A.R.).
- Division of Cardiology, Groote Schuur Hospital, University of Cape Town, South Africa (M.N.).
- Division of Clinical Trials, St. John's Research Institute, St. John's Medical College, Bangaluru, India (P.P.).
- Universidad de Buenos Aires, Argentina (D.J.P.).
- Centre for Chronic Disease Control, Public Health Foundation of India, New Delhi (D.P.).
- Public Health Foundation of India, New Delhi (K.S.R.).
- Ministry of Health of the State of Kuwait, Adan Hospital, Kuwait City (M.R.).
- Virginia Heart, Inova Alexandria Hospital, Alexandria (R.S.).
- Division of Cardiology, Wilgers Hospital, Pretoria, South Africa (F.A.S.).
- Department of Cardiology, National Heart Centre, Singapore (J.W.C.T.).
- Centra Stroobants Heart Center, Lynchburg General Hospital, VA (C.M.V.).
- Sanger Heart and Vascular Institute, Charlotte, NC (B.H.W.).
- Population Health Research Institute, McMaster University School of Medicine, Hamilton, ON, Canada (S.Y.).
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York (J.N.).
Abstract
The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.
Keywords: LMICs; coronary artery disease; electrocardiography; health policy; percutaneous coronary intervention; telemedicine; thrombolytic therapy; universal health care.
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