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MGH PPCI Network

presented at Asia PCR Sing Live 2017

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MGH PPCI Network

  1. 1. Myanmar PPCI Programme: How primary PCI was started with the right planning training and government support
  2. 2. Potential conflicts of interest Speaker's name:  I do not have any potential conflict of interest
  3. 3. population of Myanmar 60.38 million (2011-12) About 70% of the population resides in the rural areas. population density for the whole country is 89/km2 3 cath labs- Public hosp 3 cath labs- military hosp 2 cath labs- private hosp Myanmar 2013 01/19/2017 3How PPCI Program was started in Myanmar 1 public and 3 private cath labs in 2015
  4. 4. • 75% of STEMI patients were late presenters and not eligible for reperfusion. • Thrombolysis, almost exclusively with streptokinase was the only reperfusion therapy (immunologic reactions and hypotension further reduce the reperfusion rate) • Primary PCI – never done • Pharmaco-invasive – never done • Delayed PCI or ischaemia-driven PCI was performed before discharge for those who can afford and We saved quality of life of patients who survive from STEMI • Several patients have exhausted their financial resources and they end up abandoning the further coronary angiography and PCI. STEMI care in Myanmar before 2013 01/19/2017 4How PPCI Program was started in Myanmar
  5. 5. Health care system Barriers for PPCI • No registry data for AMI and reperfusion data ( on a regional or national level) • No STEMI care Guidelines • No Central chest pain call centre • No EMS and pre-hospital care system in Myanmar • Transport: lack of centralized ambulance system • Delayed presentation ( 75% were late presenters) 01/19/2017 5How PPCI Program was started in Myanmar From saving quality of life to saving lives from STEMI- PPCI
  6. 6. Patients’ barriers for PPCI • Lack of access to healthcare for the common Myanmar people (Geographical differences in infrastructure -Roads/ communication/ transport ) • Lack of awareness of disease -population at large • Traditional delays and Consent issue – People thought PCI is an operation and it has multiple dangerous complications – death from MI is natural and death from procedure is unnatural , even consent for elective PCI need long conversation and explanation • Financial constraints -Sizeable population low-middle group – No health insurance, Paid by patient’s family 01/19/2017 How PPCI Program was started in Myanmar 6
  7. 7. Hospital barriers • Government hospitals -Very small amount of funding for healthcare, not possible to provide expensive procedures • if PPCI after working hrs- no funding for overtime pay to staffs • Private cath labs are low volume centres and have limited staffing (only one private hospital has surgical back-up) 01/19/2017 How PPCI Program was started in Myanmar 7
  8. 8. • Streptokinase is the only available thrombolytic agents ( it is inexpensive, because of the availability of generics). • UFHeparin and enoxaparin are only available anticoagulants • GPIIb IIIa are not available • Aspirin and Plavix are only available antiplatelets and no potent antiplatelets • PCI centres were only available in Yangon, Mandalay and Naypyitaw and most were low volume centers • PCI hardware are expensive because of low volume 01/19/2017 How PPCI Program was started in Myanmar 8 Technology Barriers: devices and drugs
  9. 9. Situation in Mandalay in 2013 • Cath lab established in 2001 • No one was trained for intervention • 2002-2003 first Trainee from MGH at NHC Singapore • first elective PCI was started in April 2003 • Angio and PCI volume grows after 2008 • Only single cath lab which was 12yr old ( Memory 6GB only) when PPCI program was started • Only 3 interventionists and 2 fellows, 6 cath lab nurses, 1 radiographer • Electricity problem ( back up generator ) • Expensive PCI hardware and financial issue notoriously cause delays in obtaining consents. Need Funds to provide life-saving STEMI care. 01/19/2017 9How PPCI Program was started in Myanmar
  10. 10. Driving Force to start PPCI program • Enthusiasm and Team work • Our Mission: No One Should Die from Heart Attack • Devoted Team : Hospital admin, cath lab staffs, CCU staffs 01/19/2017 How PPCI Program was started in Myanmar 10 Our Dream: We want to save lives from STEMI
  11. 11. • Main reason is financial constraints and consent • Funding: • Collect equipment donated by NGO teams •Recycle the sheaths, wires and catheters by staffs •Staffs were happy to save lives without getting overtime pay • Consent: • Try to get Patients trust by performing many cases for elective PCI very cautiously to avoid major complications What have we learned and what can be done to start PPCI? 01/19/2017 11How PPCI Program was started in Myanmar
  12. 12. Cleaning, resterilizing the sheaths, catheters, wires and etc by cath lab nurses to re-use for poor patients 01/19/2017 12How PPCI Program was started in Myanmar
  13. 13. MGH Regional Primary PCI Service Started on 28 Feb 2013 I. 9am/5pm weekdays primary PCI service rolled out 28th Feb 2013 II. 6am/9pm everyday primary PCI service rolled out 1st April 2013 III. 6am/10pm everyday primary PCI service rolled out 1st Jan 2014
  14. 14. Further progress of MGH PPCI service • Appointed as Country Director for LUMEN Global in 2014 • Opportunity to learn about Procedure and Process of PPCI • Collaboration with TTSH Singapore, Tamasek Foundation and Medtronic from 2014 to 2016 • MOH funded for new cath lab and PCI hardware, balloons and stents in 2014 • MOH funded to replace the old cath lab with new one in 2014 01/19/2017 How PPCI Program was started in Myanmar 14
  15. 15. What have we learned and what can be done to improve the process of PPCI? 1. Patients’ delays: Public awareness of heart attacks 2. System Delays: 1. Late Arrival in the ER 2. Delay in the diagnosis at ER 3. Delay in the referral to CCU 01/19/2017 15How PPCI Program was started in Myanmar • single call activation to engage the cath lab • Bypass the ER • Develop prehospital alert and ECG transmission using Smartphone applications and cathlab activation before patient arrived to CCU • avoid delay to activate the team outside working hours • complete coverage for PPCI irrespective of the financial status
  16. 16. 1st March 2015 MGH STEMI Network laughed on the day of celebration of second year anniversary of PPCI and Heart Attack Awareness Week Key To Improving STEMI Care: STEMI network 01/19/2017 16How PPCI Program was started in Myanmar
  17. 17. 01/19/2017 17How PPCI Program was started in Myanmar
  18. 18. Zone 1- 30 mins to MGH Cath lab lab 01/19/2017 18How PPCI Program was started in Myanmar
  19. 19. Zone 2- 1hr to MGH cath lab Zone 3- 3hr to MGH cath lab 01/19/2017 19How PPCI Program was started in Myanmar
  20. 20. Family Doctors ERC GP and Physicians ER MGHVoluntary patient transport Existing system for STEMI care 01/19/2017 20How PPCI Program was started in Myanmar
  21. 21. Family Doctors ERC GP and Physicians ER MGH IDEAL STEMI care system 01/19/2017 21How PPCI Program was started in Myanmar
  22. 22. Family Doctors ERC GP and Physicians ER MGH x x x x Our Aim 01/19/2017 22How PPCI Program was started in Myanmar
  23. 23. Family Doctors GP and Physicians Call us and send ECG by Viber 09-259898661 09-259898662 01/19/2017 23How PPCI Program was started in Myanmar
  24. 24. ERC ER MGH x xCall us and send ECG by Viber 09-259898661 09-259898662 01/19/2017 24How PPCI Program was started in Myanmar
  25. 25. ECGs via Viber to MGH STEMI Network From Madayar From Monywa From Saggaing From Kyauk Se 01/19/2017 25How PPCI Program was started in Myanmar
  26. 26. 1.visited spoke hospitals to participate in the program : address on early diagnosis and quick referral 2.Invited voluntary patient transport teams: address on safe transport of patient and teaching on BLS 3.Health education talks on heart attack awareness to public 4.24/7 primary PCI service rolled out 1st December 2015 Things that are being worked on: 01/19/2017 26How PPCI Program was started in Myanmar
  27. 27. • Message of reducing door-to-device time by •health education to Public through media •CME to ERC doctor/ Staffs, General Physicians and GPs Key To Improving AMI Care: Education 01/19/2017 27How PPCI Program was started in Myanmar
  28. 28. Solution for Patient Delay-Health Education 01/19/2017 28How PPCI Program was started in Myanmar
  29. 29. 0 100 200 300 400 500 600 700 LYSIS PPCI NO REPERFUSION TOTAL 68 49 374 491 92 59 463 614 2013 2014 Reperfusion therapy for STEMI 2013-2014 76%10%14% 01/19/2017 29How PPCI Program was started in Myanmar 15% 10% 75% Before STEMI Network
  30. 30. Reperfusion therapy for STEMI 2015-2016 0 100 200 300 400 500 600 700 Lysis Pharmacoinv PPCI No Reperfusion Total 129 0 133 431 693 34 12 164 352 562 Chart Title 2015 2016 62% 19%19% After STEMI Network 01/19/2017 30How PPCI Program was started in Myanmar 6% 0% 2% 29% 58%
  31. 31. 0 100 200 300 400 500 600 700 2013 2014 2015 2016 374 463 431 352 68 92 129 34 0 0 0 12 49 59 133 164 PPCI pharmacoinv thrombol no reperfu Reperfusion therapy for STEMI 2013 -2016 01/19/2017 31How PPCI Program was started in Myanmar
  32. 32. PPCI In-Hospital Mortality 2013-2016 0 20 40 60 80 100 120 140 160 180 2013 2014 2015 2016 49 59 131 164 1 3 8 5 number of patients death shock patients = 6shock patients = 2 01/19/2017 32How PPCI Program was started in Myanmar 2% 5% 4.5% 3% shock patients = 5
  33. 33. ACS Cases in MGH (2011 – 2016) 0 100 200 300 400 500 600 700 2011 2012 2013 2014 2015 2016 420 437 491 614 693 562 123 133 193 300 328 359 151 135 205 328 209 260 STEMI NSTEMI UAP 01/19/2017 33How PPCI Program was started in Myanmar
  34. 34. In-Hospital Mortality for STEMI MGH (2011-2016) 0 100 200 300 400 500 600 700 2011 2012 2013 2014 2015 2016 420 437 491 614 693 562 60 61 73 93 103 72 STEMI DEATH 14.2% 13.9% 14.8% 14.8%15.1% 12.8%
  35. 35. Door to Device Time • 2013 • Min – 28 minutes • Max – 234 minutes • Mean - 93.79 ± 39.69 minutes • 2014 • Min – 20 minutes • Max – 160 minutes • Mean - 89.89 ± 32.63 minutes • 2015 • Min – 13 minutes • Max – 234 minutes • Mean - 73.21 ± 38.17 minutes • 2016 • Min – 9 minutes • Max – 473 minutes • Mean - 56.75 ± 48.02 minutes 01/19/2017 How PPCI Program was started in Myanmar 35
  36. 36. Achievement of Standard Door to Device Time <90min 2013-2016 51% 51% 74% 84% 37% 30% 11% 12% 8% 19% 10% 2%4% 0% 5% 2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 2013 2014 2015 2016 Door to Device Time 2013-2016 <90min 90-120min 120-180 >180min 01/19/2017 How PPCI Program was started in Myanmar 36
  37. 37. Total Ischemic Time 2013-2016 0 50 100 150 200 250 300 2013 2014 2015 2016 226,02 237,54 297,81 189,96 93,79 89,89 73,21 56,75 Patient delay System delay 01/19/2017 37How PPCI Program was started in Myanmar
  38. 38. Ischaemic time according to mode of admission (2016) 371 300 338 271 33 30 0 50 100 150 200 250 300 350 400 Through ERC Through Network Total ischaemic time Pain to CCU Door to balloon Note: Data including are describing the time in Minutes
  39. 39. % of PPCI cases using Radial access 0 20 40 60 80 100 120 140 160 180 2013 2014 2015 2016 43 23 33 21 6 36 98 143 49 59 131 164 Femoral Radial Total 61% radial12% radial 75% radial 87% radial 01/19/2017 39How PPCI Program was started in Myanmar
  40. 40. Achievements in 4 years • PPCI become well known treatment for STEMI among public and getting consent is not a problem • Awareness and support by Stake holders ( Yadanarpon Health Award 2016) • MGH STEMI Network can be established on 1.3.2015 • Non-Reperfusion rate decreased from 75% to 62% • PPCI rate increased from 10% to 29% • Reduced mean D2B time from 91 to 56 mins • Achieved standard door to device time <90min (51% in 2013 to 84% in 2016) • More radial access ( 12% in 2013 to 87% in 2016) • In hospital MR (14.8% in 2013 to 12.8% in 2016) • One year after our PPCI program,other hosp in Ygn started PPCI 01/19/2017 40How PPCI Program was started in Myanmar
  41. 41. Conclusions • STEMI care is challenging in developing countries because of resource constraints, delayed patient presentation, and system delays. • Late presentation and lack of STEMI networks make management more problematic. • There are no clear guidelines to optimally care for these patients given these deficiencies. • System delays in STEMI care have multiple triggers and regional barriers. • Delayed presentation requires a novel look at pharmaco-invasive strategies that may prolong the window of opportunity for reperfusion therapy. 01/19/2017 How PPCI Program was started in Myanmar 41
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