We reported on a presentation and outcome of patients presenting with acute coronary syndromes (ACS) to a tertiary care centre in eastern Nepal in April 2011 , and outlined a strategy to improve clinical outcome. Since that report, a cardiac catheterisation laboratory became functional in our centre in January 2011 and has since been operated by one invasive cardiologist, one cardiology resident, one radiology technician, and two trained nurses, together with 4–6 annual 1 week visits by interventional cardiologists (PU, SC, TP) from Switzerland. During that period, public awareness increased with regular broadcasts on the local radio station discussing cardiac prevention, clinical symptoms and treatment options.
Referrals for ACS increased by more than 50%, from 153 patients in 2008 to 231 in 2011. However, due to the absence of a general health insurance in Nepal, and the resulting financial constraints, only 61 patients (26%) agreed to undergo PCI (a single bare-metal stent costs approximately three times the average yearly salary of USD 200.‒, and government participation in the cost of emergency procedures is very limited). 106 patients (46%) presented with ST-segment elevation myocardial infarction (STEMI). In 2008, 20 patients (34%) presenting with STEMI were treated with thrombolysis using streptokinase, and 6 (4%) were referred for coronary angiography to Kathmandu (distance 931 km), in view of possible revascularisation. In 2011, 4 STEMI patients (4%) received streptokinase, 6 (3%) were referred to Kathmandu, and 61 (58%) were treated with primary PCI (thrombolysis: 13% in 2008 vs 4% in 2011; p <0.001) (referral: 4% in 2008 versus 3% in 2011, p = 0.55). For the latter, bare-metal stents were used in 48% and drug-eluting stents in 52% of patients. Multiple stents were used in 10 patients (16%). In-hospital mortality rate for all patients with STEMI decreased from 17% in 2008 to 9% in 2011, while the in-hospital mortality of the overall patient population with ACS decreased from 14% in 2008 to 8% in 2011 (p = 0.06).
Considering the population of eastern Nepal of 8 million, it is fair to assume that the 231 patients presenting to the only tertiary care hospital represent only the very tip of an iceberg and this implies an important selection bias of the reported data, with an over-representation of the educated, middle-class urban-dwelling population. However, this preliminary analysis highlights two main findings associated with the introduction of invasive and interventional techniques: The absolute number of patients admitted with ACS increased (+51% for 2011 vs 2008), and, even if a full assessment of baseline characteristics is lacking, the in-hospital mortality rate tends to decrease (14% in 2008 vs 8% in 2011; p = 0.06).
These preliminary data suggest that real progress has been made in the management of patients with ACS. We expect the volume of procedures to continue increasing, and believe that our activity will be a significant contribution to the improvement of cardiac care in eastern Nepal. In the last eight months of this year, 85 coronary angioplasties have already been performed and the in-hospital mortality for patients undergoing primary percutaneous coronary angioplasty for acute coronary syndrome is documented as 3%. However, several issues will have to be addressed in the future. The awareness of the general public regarding the availability of PCI and the need to intervene early in ACS needs to be disseminated and better referral systems from other hospitals that do not offer PCI services for ACS need to take place. The affordability of PCI to majority of patients presenting with ACS needs to be improved by adopting an insurance system and also by making the procedure inexpensive by resterilising the disposable materials like catheters, sheaths, wires and balloons with the ethylene oxide (EO) steriliser system.
|Overall number of ACS patients||153||231|
|NSTEMI and unstable angina||95||125|
|Mean age (years)||62±12||61±10|
|PCI on site||61|
|Transfer to Kathmandu||6||6|
|Hospital mortality for all ACS (%)||14||8|
|Hospital mortality for STEMI (%)||17||9|
Correspondence: Nikesh Raj Shreshta, MD, FESC, nikeshmd[at]gmail.com
1 Shrestha NR, Basnet S, Bhandari R, Acharia P, Karki P, Pilgrim T, et al. Presentation and outcome of patients with acute coronary syndromes in eastern Nepal. Swiss Med Wkly. http://www.smw.ch/content/smw-2011-13174/ 2011;141:w13174.
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