Delayed Presentation of Acute Coronary Syndrome: A challenge in its - - PowerPoint PPT Presentation

Click to edit Master subtitle style

Delayed Presentation of Acute Coronary Syndrome: A challenge in its early management in a resource poor country

Karki P1, Acharya P1, Adhikari RR1, Bhattarai J, 1 Shrestha NR1,Sharma SK1 1Department of Internal Medicine & Cardiology Division,

• B. P. Koirala Institute of Health Sciences, Dharan

NEPAL

INTRODUCTION

CVDs IN SOUTH –ASIA

ØHigh prevalence of risk factors & have IHD at an earlier age (one decades) than do the people in developed countries. Ø80% deaths & 85% disability CVDs, Low & middle-income countries ØCVDs – prevailing overall cause of mortality.

NEPAL

Ø27 million people, with vast ethnic diversity, ØNepal battling a Double Burden of Diseases, both communicable and non- communicable diseases (NCDs) ØCardiovascular diseases(CVDs) being the most common among the NCDs. Ø Epidemiological transition ,Urbanization & Changes in lifestyle .

• Hospital-based

prevalence study

• f

non communicable diseases in 31 hospitals across the country: Ø36.5% of the admissions were for non communicable diseases, ØCVDs were the most common (38% among NCDs

Prevalence of Non-communicable Disease Nepal: Hospital- based Study. Nepal Health Research Council, 2010.

ØConventional risk factors are present in a high proportion in the Nepalese population Øcommunicable & infectious diseases, maternal & child health Care & Childhood malnutrition Ølimited economy and resources, increasing problems

• f NCDs including CVDs.

BACKGROUND

• The time of presentation of Acute Coronary

Syndrome (ACS) from the onset of chest pain determines the treatment modality and prognosis.

• Delayed presentation is associated with a

poor outcome.

• Resource poor country like Nepal-

Early diagnosis and proper management

• f

ACS is delayed and continued challenging task:

–Lack of awareness in patients. –Lack of suspicion of ACS in medical personnel at primary level. –Delayed referrals. –Lack of transportation facilities. –Financial burden.

OBJECTIVE

To find out the causes of late presentation of Acute Coronary Syndrome (ACS) in tertiary care center in the Eastern part of Nepal.

METHODS

• Cross sectional descriptive study.
• Sample size-100 consecutive patients.
• Center- BPKIHS, Nepal.
• Duration- 8 months.
• Included all patients of ACS.
• Alternative diagnosis for chest pain were

excluded.

• Ethical clearance: taken from Institute Ethical

Review Board.

• Informed consent.

METHODS

• Approved questionnaire filled in for each

patient- included demographic and clinical parameters as well as delay in presentation and its cause in bringing the patient to our hospital

• Management done at the local center & their

final diagnosis.

• Statistical analysis- Data were analyzed with

SPSS 11.5 for Windows software.

RESULTS

• Age ranged 36 to 84 years (mean 62 years, SD

10.4).

• Eighteen patients ≤ 50 years of age.
• Male : female - 1.6:1

ØSymptoms:

–Chest pain - 81% –Shortness of breath - 49%

Graph 1: geographical distribution of Patients.

• Time of presentation from the onset of

symptoms to the healthcare facility:

– 1- 360 hours (mean 32 hours). – 32 patients from Dharan city presented to our institute within mean of 20 hours. – 20 patients came to us directly from places outside Dharan within mean of 63 hours. – Others reached their respective local centers within mean 39 hours. – Males presented earlier (29 hours, mean value) than their female counterparts (39 hours, mean value).

Graph 2: causes of delay reaching BPKIHS

Table 1: comparison of different management done at health facilities before referring patients to BPKIHS

Investigation done or therapies given District hospital (N=22) Health Posts (N=3) Private clinics (N=23)

ECG 15 12 Cardiac Enzymes 1 Aspirin 14 2 9 Beta blockers 1 2 3 Nitrates 14 2 11 CCBs 1 Heparin/LMWH Thrombolysis

Diagnosis of ACS made

13 1 7

Table 2: distribution of ACS components and hemodynamic profile

Diagnosis

• No. of

Patients SBP(SD) DBP(SD) Pulse(SD) STEMI > 24 hours 23 124(34) 86(21) 80(21) STEMI < 24 hours 12 139(36) 92(24) 78(18) Non STEMI 24 130(35) 88(25) 91(24) Unstable Angina 41 134(25) 85(17) 85(21)

• Twenty three cases out of 35 STEMI i.e. 66%

patients were not thrombolysed- late presentation.

• Resulted in sub-optimal treatment.

DISCUSSION

Tip of the Iceberg

• Burden of CVD is large & on

rise.

• Younger population not spared:

18% patients ≤ 50 years (early age at presentation)

• Smoking & Dyslipidemia major

risk factors in premature CAD.

• Addressing these risk factors –

decrease complication of ACS.

ØTransportation- leading cause of delayed presentation.

• Patients brought to hospital via private

vehicles/ambulances.

• Ill-equipped vehicular transport.

Nepali Ambulances!!!!!!!!

ØLack of effective communication causes unnecessary delay- 2nd most common cause for delay.

No communication between the healthcare staffs for transfer of patients.

ØLack of ECGs at the primary care facility.

No ECG machine Not suspecting ACS.

CONCLUSION

§ Strong need to pay attention to the rise of CAD & resulting ACS. § Significant number of patients with ACS presented late in our center & delayed presentation results in sub-optimal treatment & poor outcome. § Early diagnosis and effective treatment is the key reduce morbidity and mortality from ACS in

Nepal

RECOMMENDATIONS

For a healthier Nepal……….

ØImprovement in ambulance services. ØEquipping primary care facilities with ECG ØEffective Communication ØGreater emphasis on CAD awareness programs & initiating preventive measures.

ØLarger community based study of CAD and its risk factors in Collaboration with International Organization.

ØFormulation of an New Health Policy & NCD policy draft , addressing all these issues.

DHARAN CITY HILLS FROM DHANKUTA