Global STEMI treatment initiative yields care delivery benefits in low-resource countries
WASHINGTON — New, 2-year data from a global registry enrolling patients with STEMI in low- and middle-income countries showed continued improvement in trends for key clinical and system parameters, including mortality, researchers reported.
More than 3 million STEMIs occur annually in low- and middle-income countries, yet little data exist on system-based initiatives and measurement of performance metrics of STEMI in such nations, Cesar J. Herrera, MD, FACC, clinical associate professor of medicine at Montefiore-Einstein Center for Heart and Vascular Care, New York, and chief medical officer at CEDIMAT Cardiovascular Center, Santo Domingo, Dominican Republic, said during a late-breaking clinical presentation at the American College of Cardiology Scientific Session. Data from the GHATI registry, created to encourage adherence to the guidelines and tracking of clinical and institutional indicators, may facilitate the implementation of policies that could reduce morbidity and mortality of STEMI.
“We have doubled our registry numbers, with more than 4,000 STEMIs enrolled in over 30 centers worldwide, and what we are happy to report is by following these quality improvement guidelines with the registry, there was a reduction in mortality,” B. Hadley Wilson, MD, FACC, executive vice chair of Atrium Health Sanger Heart & Vascular Institute immediate past chair of the ACC’s membership committee and board of trustees and the vice president-elect of the ACC, told Healio. “This is another quality improvement project in STEMI that can be implemented in low- and middle-income countries and help reduce mortality from acute MI, which is particularly important since we know the global burden of CVD is primarily in these countries.”
Improvements in care metrics
As Healio previously reported, 1-year data collected from nine hospitals from October 2019 to September 2020 showed that transportation time decreased by 26.25 minutes; the proportion of patients who had first medical contact-to-device time of 90 minutes or less improved by 31%; reperfusion therapy use was high; and adherence to guideline-directed medical therapy reached approximately 90%.
For the new analysis, researchers prospectively analyzed 36 data points, 10 performance metrics and 15 elements derived from the ACC Chest Pain-MI Registry from October 2019 for 39 sites in 18 countries. Researchers compared deidentified patient information over time and reported quarterly to each facility with site anonymity.
From 2019 to 2021, researchers observed significant improvement in clinical combined endpoints of shock on arrival; arrest before/after intervention; EF of less than 40%; and survival at discharge.
Time metrics were most notable for achieving first medical contact to device time in less than 90 minutes for at least 75% of patients undergoing PCI. Researchers also observed sustained high rates of reperfusion therapy (95%) and robust adherence to guideline-directed medical therapy (92%) over time.
“The great thing about registries is that once you tell people what you’re measuring and why, just the fact that people are measuring and caring about those metrics can have a tremendous effect [on performance],” Herrera, also the Americas representative to the ACC Assembly of International Governors and the program’s current chair, said in a press release. “To see the continuing improvements over time is pretty amazing.”
Recruitment, research continues
The researchers are planning additional analyses to understand the impacts of the COVID-19 pandemic on care delivery and examine how differences in a country’s income level may affect STEMI care.
“The next steps from here are we will continue to recruit more centers from more countries and continue to report on the quality improvement metrics,” Wilson told Healio. “By doing that, we hope to show even greater gains, not only in reduction in mortality but also in HF and better outcomes for these patients in STEMI.”
In a separate study, researchers also reported on sex disparities observed in STEMI care across GHATI sites. Findings from that study revealed that only about 19% of patients with STEMI treated at GHATI sites were women, about half of the proportion in the U.S.
Wilson said more research is needed to understand what may be driving this disparity.
“The percent of women being treated for STEMI is about half what it is in the U.S. and Western Europe, about 20%,” Wilson told Healio. “We need to try and improve this gender disparity in care in low- and middle-income countries.”
Perspective
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GHATI represents a start to creating a culture of quality and creating systems around objectively measuring quality and using that as the building blocks for process improvement initiatives. Even in this very early implementation — and given some of its limitations — to see even some small gains is very positive. This is a difficult trial to do with disparate systems of care, but it is important to apply the concept of a structured way to think about quality. We often look at these metrics as being punitive. We must flip the approach and make it a positive.
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Herrera CJ, et al. Late-Breaking Clinical Trials V. Presented at: American College of Cardiology Scientific Session; April 2-4, 2022; Washington, D.C. (hybrid meeting).