Global STEMI Initiative Helps Low- and Middle-Income Countries Achieve Better Metrics

A program aimed at helping low- and middle-income countries become more familiar with quality-improvement metrics, with the goal of bettering their STEMI outcomes, shows that trends are moving in the right direction after just 1 year, according to data presented recently at the virtual American College of Cardiology (ACC) 2021 Scientific Session.

So far, approximately 90% of STEMI admissions among the participating centers around the world are now adhering to guideline-directed medical therapy and a number of key measures also are showing gains.

“Transportation time decreased over time and the time of first-medical-contact-to-device also decreased,” said Benny J. Levenson, MD, PhD (CV Center Berlin-Charlottenburg, Berlin, Germany), in his presentation during a featured clinical research session. The program, known as Global Heart Attack Treatment Initiative (GHATI), was launched in 2019 by the ACC.

To date, 18 medical centers in 13 countries have been enrolled in GHATI. The 1-year data shared by Levenson come from the initial nine centers that signed up and include more than 2,000 patients. Among the first participating centers, three were located in Argentina, with the others in Bangladesh, Mexico, Dominican Republic, Pakistan, Saudi Arabia, and Malaysia.

Levenson explained that centers that enroll are expected to transmit a variety of anonymized patient data including mean and median first-medical-contact-to-ECG times, arrival times to the cath lab, arrival times to fibrinolytic therapy, use of medications on arrival and at discharge, cardiac arrest before or after intervention, and patient characteristics. GHATI investigators assess the data then provide feedback and advice to the individual cardiology teams.

Motivating Change

The information submitted on 1,073 consecutive STEMIs showed that only 19% of patients were female, which Levenson said may indicate women receive subpar STEMI care. About one-third of the STEMI patients were smokers, 9.5% had cardiogenic shock on arrival, and 6% had cardiac arrest prior to intervention. The average time to hospital arrival decreased by 38 minutes over the 1-year study period. Prevalence of cardiac arrest upon arrival decreased by 4.6%, and first medical contact to device time improved by 28%.

As Levenson noted, the stakes for these countries are high, with an estimated 3 million STEMIs per year reportedly coming from low- and middle-income nations. Part of the incentive in improving metrics and outcomes for these centers is that the process “provides a basis for negotiations with lawmakers about changing structures for the better and/or implementing STEMI care networks,” he added.

While this initial report from the program is small, Levenson said the GHATI investigators are optimistic about expanding their efforts, despite challenges not often encountered in North America or Western Europe. “Many centers have a limited system-based quality assessment experience. It was like learning a new language, and electronic health records were not available everywhere,” he explained. “In one case, ACC had to sponsor a laptop to enable the hospital to join the program.”

Session panelist Akshay K. Khandelwal, MD (Henry Ford Hospital, Detroit, MI), said GHATI is welcome at a time when health inequities are receiving global attention. Importantly, he also picked up on what appeared to be a “herd mentality” effect, in that “over the study period, door-to-balloon times not only seemed to improve within the group, but the interquartile ranges shrunk.”

Indeed, Levenson said, similar observations have been seen in other quality-improvement programs, including one aimed at cath labs in Germany. The overarching message appears to be that the act of joining one of these programs is, in itself, a motivator for change, he concluded.