Combat MI

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Identifying and Definitional Attributes
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The need to have a COMBAT MI Program on ACS/MI in Egypt
Report by Ahmed Magdy, MD, FACC, FSCAI
Consultant Cardiologist, National Heart Institute

Acute coronary syndrome (ACS) reflects the spectrum of CAD resulting in acute myocardial ischemia,
and span unstable angina, non-ST segment elevation myocardial infarction (NSTEMI)
and ST-segment elevation myocardial infarction (STEMI). Clinically these diagnoses encompass a wide variation in risk,
require complex and time urgent risk stratification and represent a large social and economic burden.
This is particularly important as accurate identification of the evolving MI patient
or the high/intermediate risk patient leading to the implementation of the appropriate management
pathway impacts on the patient's outcome. Having a nationally recognized set of definitions
in patient's diagnosis, risk status and plan for management is a prerequisite to achieve the best outcome.

Challenges of Heart Attack in Egypt
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In spite of the efforts of the Egyptian organizations and authorities
including the Egyptian Society of Cardiology, we still have
1.Overwhelming increase of CAD in Egypt during the past two decades prevailing over
all other forms of cardiac disease in Egypt, evidenced by the huge
increase in the number of CAD patients in OPD,
most admissions in ICU, CCU and in the ward, most cardiac procedures and surgery, extensive coronary lesions are more common
2.Acute heart attacks in particular had increased tremendously, are the biggest killer of Egyptians,
being more frequent and more severe with high fatality
3.A wide gap between what is needed and what is accomplished in heart attack outcome and management
4.Heart attack in different hospitals is treated by specialized and non specialized doctors in cardiac care
5.No standardized protocol of management for heart attack patients in different centers and even in the same center or unit,
no implemented guidelines or application of evidence based evidence
6.No established training educational programs on how to manage heart attack patients and complications
7.No established system for immediate response to ACS patients and directing them to specialized centers
8.Centers dealing with heart attacks are lagging in number and equipments
9.The data for the patients are neither well recorded nor documented and archived
10.Patient education about CAD in general and heart attack is lagging, most patients arrive late after MI onset
11.The outcome of the patients is unpredictable,
many patients are not receiving proper therapy and strategies
12.No clear consensus when to use interventions, underused in many centers and over used in others
13.MI complications like cardiogenic shock is not handled except in few centers
The Heart Attack in The World’s Interest:
1.Since decades, heart attacks had received great attention, a lot of investigations, research
and investments in developed and many of developing countries
2.Each developed country has a plan to deal with heart attack patients and
they are continuously updating that in terms of pre-hospital, in-hospital protocols to reduce the time window
and improve the whole outcome, putting a lot of resources and strategies involving doctors,
nurses, paramedics and administrations
3.Most of the developed countries have working groups, task forces, societies,
organizations and alert programs to work on every aspect of heart attacks
4.Each country would take the American and European guidelines in to consideration ,
but were modified in practice according to their resources, systems and experience
5.Examples include DANAMI in Denmark, NRMI, GRACE and CRUSSADE in USA,
National Heart Attack Alert Program in USA, RACE program in Carolina USA, OASIS programs,
AEHA SHAPE Task Force, PRAGUE, Working Group on MI in UK and a similar one in Scottland,
Holland and most of European countries, The working group formed under the National
Heart Foundation of Australia (NHFA) and the Cardiac Society of Australia and
New Zealand (CSANZ) Australia as well as in China, Japan
6.All these groups had contributed in registering, documenting and standardizing management of ACS
7.They also contributed in reduction of mortality from CAD in general and case fatality of Mi

The Egyptian Society of Cardiology Agenda for the Heart attack
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1.Heart attacks are concerning the ESC and cardiologists in Egypt and aware of the national threat imposed by heart attacks,
but no clear well designed plan to counteract that danger
2.Heart attacks in spite of its importance, represented by few lectures in the general annual meeting of the society
and in some of the working group meetings, no dedicated campaigns and specified educational programs
3.Sporadic efforts by ESC members to register ACS cases in some centers, no generalized
efforts to gather ideas and strategies in one plan
4.ESC has WG on atherosclerosis, lipidology, thrombosis and hemostasis , interventions and others,
all can touch in part ACS/MI problems and they cover their and each other fields of interest, however,
a dedicated independent WG is needed specifically in the ACS/MI field that is as important and urgently needed as the other fields

Targets of the Egyptian Working Group on Heart Attack (WGHA)
1.Promoting the delivery of evidenced-based ACS management care to patients
2.Facilitating the ongoing improvement in the quality and safety of ACS management in acute care settings in Egypt
3.Supporting acute care services as they develop information systems to complement the above.
4.Work on different means and coordinate with authorities to improve pre-hospital, in-hospital
management and adequate care of discharged patients
5.Improving the epidemiological and public health understanding of this syndrome
6.To run studies on different subsets of patients with ACS, including the young, elderly,
women with MI and those with co-morbidity
7.Have connection with international similar groups and organizations to exchange
information and acquiring their experience

Methods to Accomplish the Targets:
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1.Educational programs through cardiac and medical centers in different
parts of Egypt on the identification of ACS, risk stratification and proper management
2.This will include several levels of knowledge for physicians, nurses and paramedics
and includes primary and advanced care
3.All means to transfer information will be used by lectures, posters and printed materials
4.Try to standardize the paper work and check lists used for ACS patients among all centers by using simplified forms
5.Acquire registry data from the leading cardiac centers representing the Egyptian patients to conform
a profile and understanding of the clinical problems and shortcomings in ACS management
6.Periodic meetings of the steering committee and members of the group to evaluate the results
and optimizing the plans

Design of the Working Group on Heart Attack:
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1.President to coordinate with members to make the plan and achieve the targets of the group
2.Steering committee from different centers to share in putting the plan implement it
3.Members of the Working Group, all cardiologists and internists interested in improving MI care

My Background in This Field:
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1.I work in the acute care of ACS in most of my work since over 26 years
2.I am currently head of CCU at NHI one of the busiest CCU ever that represent the Egyptian real society
3.I worked in Egypt and abroad in countries adopting the western system in dealing with MI patients
4.My master degree 1985 and MD 1991 were in the field of MI and coronary insufficiency
5.I have registries for ACS at the CCU of the NHI well established since years with data acquisition
6.I had similar registries for ACS abroad for years and published in papers
7.Contributed actively in many scientific programs over the last 2 decades in the NHI and outside and
over the last years I shared as a faculty speaker or chairman in most of the Egyptian meetings
8.I contributed actively in two of the successful meeting of the ESC, the annual meeting in Feb 2007
and intervention meeting in December 2007, getting more experience in organizing scientific programs
and having international connections, all are in favor of the ESC.
9.I am member of the Egyptian Board of Cardiology and share in supervising the educational programs of the board,
organized many condensed course for cardiology subjects
10.I am one of the cardiologists who learnt and started interventional cardiology with other colleagues in Egypt
11.I am a fellow of the American College of Cardiology(since 2000), fellow of
the American Society of cardiac Angiography and Intervention(since 2001)}