Primary Angioplasty in MI

Primary angioplasty requires not only specialised training in Interventional Cardiology, but a dedicated team of nurses and cath lab technicians who can react quickly to an emergency call

"Doing angioplasty in a critical patient of heart attack is in itself challenging and doing so in the critical window period further adds to the challenge" - Dr Ganesh Kumar Chief Interventional Cardiologist Dr LH Hiranandani hospital Mumbai

Primary angioplasty is a term used to describe an angioplasty done as a life-saving emergency procedure in a patient with an on-going heart attack (PAMI or Primary Angioplasty in acute Myocardial Infarction). Heart attacks occur due to sudden total occlusion of a pre-existing partial block, thereby completely cutting off the blood supply to a portion of a heart muscle. These 100 per cent blockages need to be removed within three to six hours from the onset of heart attack, else the muscle of the heart gets damaged permanently. Doing angioplasty in a critical patient of heart attack is in itself challenging and doing so in the critical window period of three to six hours further adds to the challenge.

Can you imagine the impact of a short door to balloon intervention on a patient who often comes crashing with a massive acute myocardial Infarction? A few hours later, we are wondering why he is still in the hospital. The only other option available for the treatment of heart attack other than the primary angioplasty is use of specific intravenous medications called 'thrombolytic agents.' These agents are thrombus (clot) busting medications, and when administered, dissolve the clot in 60-65 per cent of cases. The remaining 35-40 per cent of cases either die due to failed thrombolysis (failure of drug to lyse the clot), or even if they survive the attack, go home with a very weak heart due to a large portion of the heart muscle being permanently damaged. These patients who do survive with weak hearts go on to live with either heart failure, valve leaks, ruptures in the portion of the heart or rhythm problems (electrical disturbances) and have a very morbid and unproductive life, with abundant economical, social and psychological burden. We have millions of such patients in our country with this morbidity, which ultimately is a large burden to the state.

On the other hand, success rate of primary angioplasty is more than 95 per cent when performed in experienced hands. Mind you, several procedures are not easy during primary angioplasty- identification of culprit lesion may require a thorough evaluation, vessel access can be challenging, lesion morphology can be tricky, thrombus burden truly ' burdensome' with haemodynamics critical and worsening by the minute. No re-flow may be stubborn to usual treatment. Or, simply, a combination of these variables and darned, bad luck! This requires not only specialised training in interventional cardiology, but more importantly a dedicated team of nurses, and cath lab technicians who can react quickly to an emergency call.

The day-to-day angioplasty and stenting procedures, has become routine and boring in some ways. However, this primary angioplasty is a new challenge in life, something which calls for a little personal sacrifice. Anybody can do a short door to balloon intervention! Most skilled interventional cardiologists across the country can do an exceptionally good job with short procedure times and a door to balloon time of less than 90 minutes, when it is on routine hours. To do it regularly, day to day, and during off hours in a community hospital, in a fairly standardised methodology, does call for a lot more dedication and commitment.

Let me tell you that PAMI is not rocket science. I cannot overemphasise the urgency that exists in achieving the mandatory short door to balloon time guidelines. PAMI reminds of a relay race in a 400 meters race. Like these relays, I am the final person with the baton and I must make up time for the delays of late presentation to the emergency room (ER), at times patient presents late to the ER, the clock is ticking and time to alarm at 90 minutes.

If the ER/transportation doesn't get its act together, the clock continues to tick; if patient's/ relative's decision is delayed, it is still ticking, and always, yes always, I am expected to get it right and finish within 90 minutes. It disseminates a feeling of urgency and team work. It lets the message resonate that each moment is precious.

Remember, the procedure is just one part. Some of these patients need very close follow-up post procedure, in particular, those with cardiogenic shock. Not every patient has a perfect result and often requires additional care. At times, physically it is very exhausting, though mentally it is extremely rewarding. PAMI is one of the most miraculous medical procedures, with incredible gratification for the operator.

Scope for Improvement

It will never be enough when you are trying to save myocardium (heart muscles) and a patient's life. The benefits of early restoration of left ventricular function (cardiac pump) and reducing complications of acute MI are tremendous. Any and every effort will therefore never be enough to strive for even better outcomes. The challenge is not only to perform short DTB time interventions. It is to consistently deliver successful outcomes both during routine hours and off hours (odd hours). The challenge is also for a less experienced interventionlist who may have lower Percutaneous Coronary Interventions PCI volumes. There are so many cath labs clamouring to get on board with PAMI programme, for the good reasons of saving lives and not-so-good reasons of marketing. The challenges are for these cardiologists/ physicians and hospitals to perform PAMI by incorporating teamwork as a rigorous mandate, delivering good results in a standardised fashion, and do it every time.

One area where I think we need to work much harder is in getting the message out that beyond DTB time, it is also the ischemia time that is critical. Ischemia time lengthens if the patient is pondering at home (often self labeling the symptoms as 'gas') or if he or she is going to be delayed by the family or their general practitioners to reach the appropriate facility. We as interventional cardiologists need to continuously educate the primary care providers (general practitioners and physicians) and emphasise on short DTB times.

We also need a seamless system of triage, so that an acute MI patient is transported directly to an adequate facility providing short DTB time interventions. PAMI is not necessarily only a domain for the expertise of the interventional cardiologist. It is very much a public health issue and will require community, local and state support at large.

ganesh.kumar@hiranandanihospital.org