Prof Ahmed Magdy, MD, FACC, FSCAI
Prof, Head Unit Cardiology
Head CME, National Heart Institute, Cairo
Chairman of COMBATMI Program

Prof Khairy Abdel Dayem, FRCP, Ph.D, FACC

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Advances in Primary PCI, with the advent of better stents and with the mandatesof Door to Balloon (D2B) Times,and withincreasing availability of highly-effective,
third-generation thrombolytics,such as Tenectaplase (TNK) - have dramatically reduced mortality from AMI in the western world. 
This poignant editorial is a passionate plea of conscience to physicians in India to jump out from their beds and provide urgent AMI treatment -
both STEMI interventions and thrombolysis in critical time-dependent, door to balloon and door to needle times (D2N).   

The essential principle of “Time is Muscle”, highlighting the haste required in providing treatment for
AMI has recently been placed into quantifiable markers with induction of D2B (<90 min) and D2N (<30 min) times
into Class I Recommendations for STEMI management in both the ACC/AHA and ESC Guidelines.  Although
philosophically, these new guidelines simply emphasize the vital need for providing TIMI flow to the necrotizing myocardium,
the critical addition of D2B and D2N Times to the guidelines has important logistic, quality, legal and financial implications.
Most importantly, they provide superb tools to monitor performance and quality that is being delivered to provide STEMI care.
Already, progress is being reported in the United States and in Europe in mortality and morbidity statistics of AMI,
from rigid adherence to these guidelines.  As an example, STEMI interventions with D2B times<90 min have
a reported nationwide mortality in the United States (NRMI, National Registry for Myocardial Infarction) of 3%,
and these rates are projected to fall further.

The challenges of meeting both D2B and D2N guidelines in Egypt and in other developing countries are obvious and
most evoke empathy for what these cardiologists have to endure. The painful battles that several cardiologists
tolerate in justifying the expense of life-saving care to the patient and his family in the middle of the AMI, must
end with press, media and physician leadership leading a unified campaign.  Hopefully, access to health insurance
will mitigate some of these issues:  however,  physicians must remain vigilant against American style HMO’s that
may bring in equally difficult issues of profiting from life-saving healthcare.  The lack of infrastructure, in particular,
of well-equipped 24/365 catheterization laboratories,is a major handicap too.  Yet, that will improve as patients
and doctors will mandate their installation and hospitals will recognize their cash-cow potential and the social and
marketing benefits that accrue to the institutions fromlives saved in these specialized suites.  Indeed,
issues of ever-worsening traffic congestion hamperlife-saving efforts – fortunately, with most AMI presenting
in early morning hours, some of the traffic nightmares are mitigated by this fortuitous diurnal pattern.

Yet, beyond all these concerns, is the most critical issue of a complete absence of a well-coordinated, 
ambulance system.  There is undisputed evidence that mortality in AMI is directly linked to efficient
and timely transportation of the AMI patient to the appropriate institution.
In Europe, Canada and in the United States,the system has become sophisticated to this critical need.
Hospitals are thus designated as either a STEMI or a non STEMI facility to streamline the transportation
of the AMI patient by the Emergency Medical System.
With such systems in place, use of anti-platelets, anti-coagulants and even of thrombolytics, is begun in the ambulance –
all in efforts to shave off precious minutes in the delivery of STEMI care.
Pre hospital alert systems have been
created to activate the cardiac catheterization teams.
With such strictly-followed protocols, the STEMI patient bypasses the emergency room altogether and goes straight to
the cardiac catheterization laboratory where the team is already
assembled to perform Primary PCI.  With such remarkable systems in place, landmark reductions in AMI mortality
have been achieved in Ontario, Canada - for more than 3 years, the entire 800,000 population of metropolitan Ottawa has received
Primary PCI and recorded the lowest mortality rates for Primary PCI. The Abbott Northwestern Hospital and the
Mayo Clinic in Minnesota, and the RACE program in North Carolina,are other models where tremendous integrated
systems of care provide optimal management for AMI patients. 
Most importantly, the above three examples providea proven methodology to provide urgent, population-based,
AMI care made possible by developing a very efficient ambulance system.  In Singapore, a statewide
D2B time of 67 minutes has been recorded, courtesy of coordinated
care provided by the cardiologists and the emergency medical services.   

Therefore, a call is made by this author to administrators,healthcare policy makers and to politicians to hasten
the process of developing a rapid, predictable, nationwide,emergency medical service system that will provide
the life-saving care for the AMI patient.  Who knows,the next patient may be you or your loved one! 
The plans and early development of the 108 system are clearly steps in the right direction. 

A more passionate call is made to arouse the cardiologist from his and her slumber to provide this urgent care,
notwithstanding the frustrations of an inefficient system. Remember, the best thrombolytic will not work if
administrated late, and no myocardium will reperfuse even with the most skilled stenting procedure, if not
performed in a timely fashion. 

So, how does a cardiologist solve his dilemma in the midst of chaos?
Follow Mahatma Gandhi’s dictum, “In matters of conscience, the opinion of the majority does not count!”                    

References:

Textbook of STEMI Interventions, Sameer Mehta et al, HMP Communications, 2008