Cath lab, Cardiology services for all : Vanam Jwala Narasimha Rao

Cath lab, Cardiology services for all

Vanam Jwala Narasimha Rao

Telangana Today (17-01-2020)

STEMI (ST-Elevation Myocardial Infarction)-Telangana is an extraordinary medical and health intervention designed, developed and almost kept ready for implementation in the state. Myocardial Infarction is commonly known as Heart Attack. The program is aimed at diagnosing heart attacks promptly, at the periphery hospital designated as ‘Spoke’ and confirming the diagnosis using a tele ECG (Electrocardiogram) machine provided there.

STEMI-Telangana makes the ECG facility available to all the people of the state including 108 ambulances and all the Primary Health Centers (PHCs). It would also ensure immediate validation of the diagnosis and proper management of the heart attack patients. All the Government Health Care facilities would ultimately build the capacity to diagnose cases of heart attacks and do thrombolysis treatment. In this the clot-busting drug will be delivered through a peripheral intravenous line, usually through a visible vein in patient’s arm. This is performed at the patient’s bedside in an intensive care unit monitoring heart and lung functions.

Advanced Care

The program also aims at making available the Angio Plasty facility to all the people by establishing Cath labs (Cath lab is an examination room with diagnostic imaging equipment used to visualize the arteries and the chambers of the heart and treat any abnormality found) and Cardiology services round the clock in all the 9 Teaching Hospitals in the state covering 90 spokes. There will be accessibility to   international standards of care to the poor suffering with a heart attack.

According to experts and senior cardiologists, STEMI is the most serious type of heart attack which is the most common cause of mortality in Telangana accounting for almost 17 per cent deaths. This leads to high morbidity and mortality unless diagnosed and treated promptly in the ‘Golden Hour of Heart Attack’. Once the diagnosis is made the patient is stabilized and treated with a drug called Thrombolytic Agent before shifting the patient to the nearest hospital designated as Hub. This could be a tertiary care hospital with high end Cath lab facilities thus saving the patient life by acting promptly and appropriately in the golden hour.

Tackling Challenge

Dealing with STEMI cases is a real challenge due to requirement of early diagnosis as well as providing the facilities and equipment needed for thrombolysis.  Thrombolytic Therapy followed by and Percutaneous Coronary Intervention (PCI) or Angio Plasty, is commonly used procedures which decrease the mortality significantly. Due to non-availability of facilities, especially in rural areas, Hub and Spoke Model is very useful. Hubs and Spokes are to be equipped with the STEMI Kit for timely transmission of ECGs for early diagnosis and thrombolytic agent as well as equipment for timely thrombolysis of the patient.

Although the National Health Mission (NHM) caters to the medical needs of rural areas, the majority of health care facilities include primary or community health centers with only basic amenities. Hence poor patients from rural areas in India appear to be at greater risk. It is advisable that patients in rural areas with limited access to medical care and too long a time to reach a hospital with all facilities, should undergo the Pharmaco-invasive (PI) strategy of thrombolysis with a goal of First Medical Contact (FMC) to drug of 30 minutes or less. Initial thrombolysis should be followed if possible, by referral to Angio Plasty capable hospital for cardiac catheterization within 3–24 hours of thrombolysis. The proposed Hub and Spoke model of STEMI management will definitely bring a significant change in the present way of management of heart attacks.

Dire Need

            The state of Telangana was formed in 2014. Now it has 33 districts with an estimated population of 40.13 million. Hyderabad is the only metro city in Telangana where the estimated population is 12.24 million. Approximately 2.8 million cases of Ischemic heart disease are in Telangana and the approximate incidence of STEMI is 240 cases per one lakh population per year. Greater Hyderabad is well-developed with number of corporate hospitals providing quality tertiary care facilities to the city population. There are approximately 150 Cath labs in private sector in twin cities for patients with heart attack and stroke as well as performing many structural and peripheral interventions. But there are only two teaching hospitals in the public sector in Telangana having Cath lab facility namely Osmania and Gandhi Hospitals free of cost which are the only destinations for poor patients for entire state. Though NIMS also has a Cath Lab it is a paid service. 

The population of Hyderabad is almost doubled in the last fifty years but the number of Cath labs remains the same and both labs are more than ten years old and facing lot of technical difficulties and frequent breakdowns. Three fourths of the Telangana population are living in rural areas and are inaccessible to the Cath lab as well as primary angio plasty facility as there are hardly less than ten Cath Labs in the rest of the Telangana state which again are in the private sector. So, there is no option to give thrombolysis drug at periphery in patients presenting within the golden hour thus stabilizing them before shifting the patient to the tertiary care center for angiogram and further management. But presently it is not happening in the district hospitals, area hospitals and CHCs even though there are many qualified doctors and diagnosis is made early. Almost all the STEMI cases are simply referred to the higher centers or private hospitals sometimes even without providing primary treatment leading to significant delays, morbidity as well as increased mortality.

Right Path

As Telangana is a newly formed state and 23 new districts are formed during the reorganization, most of the area hospitals or CHCs are designated as district hospitals but the infrastructure is still in the phase of development and is far from the quality care ICU facilities. Thus, the Hub and Spoke model of STEMI management is found to be the most appropriate in the management of heart attacks.

The proposed plan of action seems to be that in the first phase of this programme, Osmania and Gandhi Hospitals will be made as 2 Hubs. 13 district hospitals and CHCs will be attached to Osmania Hub and 10 DH, CHCs to Gandhi Hospital as spokes covering 11 districts. Mahatma Gandhi Memorial Hospital, Warangal is the next proposed hub and will be attached to 10 more spokes covering 8 districts once the Cath Lab is established.

The Hubs are going to be provided with infrastructural facilities and disposables to handle the cases in Cath labs which are going to work 24 hours to receive and treat the patients referred from the spokes. The spokes will be equipped with Tele ECG machines and other necessary equipment, drugs including a thrombolytic agent and other emergency drugs.

When this Hub and Spoke Model is fully functionary the treatment of heart attacks will be made simple and easy.