Stenting heart attacks
Interhospital synergy can help improve outcomes in heart attacks, especially when a patient has the option of treatment with angioplasty.
MUHAMMAD Shahril was having severe shoulder aches. It grew worse as the night went on.
Nothing, including having his wife massage him, worked.
He had also vomited and thought that perhaps he was suffering from food poisoning.
“I drove myself to HKL (Hospital Kuala Lumpur). They did an ECG and immediately transferred me to IJN (National Heart Insitute),” said the 36-year-old catering company supervisor recently.
Muhammad Shahril was having a heart attack.
He was taken to the emergency department, and subsequently the angiogram catheter laboratory, where a primary angioplasty procedure was carried out. The entire process took less than an hour.
The prompt response to a heart attack such as the one Muhammad Shahril experienced is courtesy of the collaboration between HKL and IJN where guidelines have been put in place to quickly identify patients who are having a heart attack and transferring them to IJN for an angioplasty.
IJN consultant cardiologist Dr Al Fazir Omar says the network, HKLIJN ST-elevation Myocardial Infaction Network (HISNET), was formalised in 2014.
Both parties worked together and looked at various factors, including criteria of patients that would be referred to IJN.
“The main delay previously was calling us to discuss and refer patients. But they are empowered now,” he says.
HKL emergency department physicians follow the guidelines that have been agreed upon, and if patients meet the criteria, they are sent immediately to IJN by ambulance.
Once at IJN, they are taken to the cath lab for the angioplasty.
The time that has been set for an effective procedure to be carried out is within 120 minutes, with the clock starting at HKL emergency department (known as first medical contact to balloon time).
“The whole goal of primary PCI (Percutaneous Coronary Intervention or angioplasty) is reperfusion in a timely measure,” he adds.
Since the network was formed, Dr Al Fazir says the number of primary PCI performed in IJN for patients with heart attacks has increased by about 50%, with door to balloon time decreasing from 80 minutes to 47 minutes.
“What we are most excited is that our survival outcome has improved,” he says adding that death from heart attacks had decreased from 8%-10% to below 5% currently.
Expanding network
Since the success of HISNET, the network has now expanded to be the Malaysian STEMI Network (MySTEMI).
This primary PCI network started in December 2015 and saw its first patient in February last year.
It involves five hub hospitals and about nine spoke centres.
The five hub hospitals are IJN, Serdang Hospital, Universiti Teknologi Mara Hospital in Sungai Buloh, University Malaya Medical Centre and Universiti Kebangsaan Malaysia Hospital.
The current spoke centres are Ampang, Banting, Kajang, Kuala Lumpur, Putrajaya, Selayang, Sungai Buloh, Shah Alam and Tengku Ampuan Rahimah hospitals.
If a heart attack patient is admitted to any of the spoke centres, they will be transferred to the hub hospitals for immediate treatment.
However, if the time taken would be more than 120 minutes, Dr Al Fazir says one way is to thrombolise the patient with a strong clot-busting drug before performing the angioplasty procedure.
The goal of MySTEMI is to expand access to primary PCI, and hopefully this will translate into improvement in patient care for heart attack in Malaysia.
Among its mission statements are to shorten first medical contact to reperfusion for heart attack patients and increase community awareness of cardiovascular heart disease, especially acute coronary syndrome.
“We get a good feeling looking at the data. The survival rates are getting better. It is one of the procedures that can really save lives,” he points out.
He adds that the next thing on the programme is to form a MySTEMI Foundation in order to get additional funding, adding that although the initial cost for the procedure is high, the overall cost in the long term is much lower.
“MySTEMI requires buy-in from everybody. It is important for everyone to know that they play an important role. These include paramedics, nurses and doctors. We have done this for two to three years and we have received amazing support from everyone.
“Nevertheless, we need more support from everyone, including the corporate sector, to ensure that we can expand and sustain the MySTEMI program” he said.
Benefits of PCI
Dr Al Fazir opines that having a primary PCI procedure carried out is more favourable compared to thrombolysis in terms of survival and recovery (and with less side effects).
“Thrombolytic therapy involves the intravenous delivery of clot-busting drugs which we hope will dissolve the clot in the heart that occurs during a heart attack. Thrombolysis is good, but not great.
“Primary PCI offers greater and more sustained reperfusion during the treatment for heart attack. This means better results after a heart attack without the potential serious side effects associated with thrombolysis such as major bleeding or stroke,” he adds.
He also points out that there have been studies since 1993 that show that primary PCI is more effective in treating heart attacks.
The situation in Malaysia, however, is that the majority of patients are thrombolised while a small minority undergo primary PCI when they have a heart attack.
Among the reasons for this, he says, are because people delay in going to the medical facility for treatment and lack of an effective network that eases transfer of patients to undergo an angioplasty.
He adds that primary PCI is great as it ensures that the treatment is targeted to the affected area.
This minor surgical procedure involves using a catheter to implant a stent. Usually, before the stent is inserted, a balloon-tipped catheter is threaded from an artery, typically from the arm or groin, to the troubled spot in the heart’s artery.
The balloon is inflated to open the blockage and widens the narrowed artery to restore blood flow.
The stent opens up blood vessels in the heart that have narrowed due to plaque build-up and blood clots.
Time, of course, is of the essence when it comes to treating a heart attack.
This 90-minute golden “time window” starts when patients present themselves at the hub hospital to the point where the angioplasty procedure is completed.
“We aim to complete the angioplasty within 120 minutes if they present to the spoke hospital,” says Dr Al Fazir.
The consultant cardiologist laments the fact that Malaysians are still late in seeking medical treatment when they start experiencing symptoms such as chest pains and breathlessness.
This results in precious time lost when it comes to saving the heart muscles from further deteriorating.
“Seek treatment immediately from a GP or go to the nearest hospital,” he adds.
Among the symptoms is chest heaviness akin to someone sitting on one’s chest. The pain is relentless and gets worse over time. The patient eventually gets more breathless and starts to perspire.
“You need to come early. The longer you take, the more difficult it is to treat,” he says. “The heart damage may be permanent. After three hours, damage can be permanent and lead to heart failure. We have a dedicated 24-hour heart attack centre here in IJN. You can get your heart checked either by turning up to our centre or through one of the spoke hospitals.” Dr Al Fazir Omar is a consultant cardiologist. This article is brought to you by IJN.