Treatment of Heart Attack in Nepal

Nepal is a developing country with rapidly changing trend of disease pattern from communicable to non-communicable disease. It is because of the increasing number of population living in urban areas, sedentary lifestyle, unhealthy eating pattern, and stressful life events. The prevalence of coronary artery disease, which is around 6%, is increasing day by day. Heart attack is one of the manifestations of coronary artery disease. It is a medical emergency. If not treated in time, death rate is high, at around 10 percent.

What is heart attack?
It is the sudden blockage of the artery supplying blood to the heart (coronary artery) by a blood clot formed due to rupture of the atherosclerotic plaque (cholesterol plaque).

How do you know?
If a person develops sudden onset severe pain in the left side of the chest, which sometimes goes towards the jaw and neck, or upper abdomen, or left upper limb, or sometimes, right upper limb, or bilateral, and if the pain lasts for more than 15 minutes, it is more likely due to heart attack. It may be associated with nausea, vomiting, or sweating, or sometimes, the person may fall unconscious.

What should we do immediately?
Any person with the above-mentioned symptoms should be taken to the hospital emergency as early as possible, have an ECG performed immediately, and a doctor, either physician or cardiologist, consulted.

Treatment in the hospital
If the heart attack is a major one, the patient should be thrombolysed (lysis of clot by medicine) or percutaneous coronary intervention (PCI) (removal of clot by devices) should be done immediately. If the heart attack is a minor one, he/she needs to be admitted in the hospital for antiplatelet and anticoagulation procedures, and PCI can be done 24-48 hours later.

Antiplatelet agents

Aspirin
It is a very good medicine for heart attack, which is available in tablet form. The dose is 300 mg, to be chewed by the patient. It is available everywhere. This is the only treatment that is available in remote areas, from where healthcare facilities are far away. We have to give this medicine when heart attack is suspected, because it saves life. The daily dose range is from 75-150 mg. It is a blood thinner.

Clopidogrel
It is also another antiplatelet agent (blood thinner) given to heart attack patients. Suspected patient should receive 300 mg of clopidogrel as early as possible, if not contraindicated. The daily dose is 75 mg.

Heparin
Low molecular weight heparin is given in the dose of 1mg/kg body weight to all minor heart attack patients and major heart attack patients, where PCI is not done.

Statin
High dose statin in the form of atorvastatin or rosuvastatin 40-80 mg daily should be given to heart attack patients. Betablockers and ACEI/ARB can be given according to requirement.

Minute is muscle
Every minute counts during the treatment of heart attack patients. The earlier you treat, the more muscle is salvaged. A patient with major heart attack should be transferred to the hospital as early as possible, and if PCI facility is there, it should be done within 90 minutes, or thrombolysis within 30 minutes. PCI is the best option, if done within 12 hours, and needs to be done within 48 hours in case of persisting chest pain. Thrombolysis is better if performed within 12 hours. Among the two, PCI is the best option if performed in time. If PCI facility is not available, we can thrombolyse the patient and shift him/her to PCI facility. For minor heart attack, we can start the medical treatment and refer to the higher center for possible PCI. Thrombolysis is not indicated in minor heart attack patients because of its risk of complications, as compared to the benefit.

Healthcare facilities in Nepal can be grouped into four categories according to the availability of services:
a. Health posts and primary health centers: Most of the district hospitals or private hospitals with less than 50 beds, where both thrombolysis and PCI facilities are not available. If a patient with chest pain reaches this group of hospitals, he/she should be immediately referred to PCI facility, or a center where thrombolysis is available. The patient should chew 300 mg of Ecospirin and 300 mg of clopidogrel before being referred to a higher center.
b. Zonal hospital or provincial hospital or private hospital: Where thrombolysis is available, but PCI is not. If the patient comes to this group of hospitals and can be transferred to one with PCI facility, where PCI can be performed within 120 minutes, he/she should be referred to the PCI center. Otherwise, the patient should be thrombolysed in this group of hospitals and then sent to one with PCI facility, irrespective of the success of thrombolysis.
c. Zonal hospital, provincial hospital, private medical college: Where PCI or thrombolysis is available, but low in volume. Thrombolysis or PCI can be done according to the need.
d. Tertiary center or cardiac center: Where high volume of PCI is done. Both PCI or thrombolysis can be done in this group of healthcare facilities.

Difficulties in management of heart attack in Nepal:
1. Awareness about heart attack and its consequences: It is very less in rural areas and villages, as compared to urban areas.
2. Economic condition of the patient: Lower the condition, lesser the chance the patient reaches the hospital in time and treatment initiated early.
3. Cost of the procedure and the medication: It is around 1.5-2 lakh (minimum) if PCI is performed in a government setup. Thrombolysis with tenecteplase costs around 50,000 rupees. The government is providing 1 lakh to poor people. So, it’s not that expensive to the average Nepali, but still difficult for poor people. It’s availability is the main concern.
4. Transportation: The most important factor is the transfer time taken, due to our geographical condition and availability of road/airport. The limited number of ambulances and facilities inside the ambulance. We don’t have well-equipped ambulances with thrombolysis facility. Even by helicopters, we can’t transfer heart attack patients on recommended timeframe for appropriate care.
5. Availability of cathlab: Among the seven provinces, only Karnali does not have cath lab facility for PCI, which at this time is a positive development. Only Province 3 and Province 7 have government setup cath lab facilities.
6. Human resource: Lack of trained manpower is the major factor now for not being able to provide optimal facility, even if cath lab setup is available. Let’s hope that in the near future it can be fulfilled by both the government and private sectors by training the required number of manpower.
7. Weather condition: Both the foggy winter and rainy season are difficult times for transferring patients.

Strategies to overcome the difficulties to tackle heart attacks in the near future:
1. Network of early referrals. Right now we don’t have a planned referral system for STEMI patients. We need to develop a therapeutic approach for STEMI patients, and make a network for early referral and transfer of the patients.
2. Awareness programs: Regarding chest pain and its consequences, we can teach the public via health programs, radio, TV, and from health posts, health centers, district hospitals, zonal hospitals, provincial hospitals, and cardiac centers and medical colleges.
3. Availability of cath lab facilities: Installing the cath labs in provinces where it is not available, either government-funded or by the private sector.
4. Training manpower: The training can be given inside the country or outside the country for skills transfer and acquiring the knowledge.
5. Health education and increasing the budget for health sector by the government.
6. Overall development of the nation.