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Original Investigation
May 2017

A System of Care for Patients With ST-Segment Elevation Myocardial Infarction in IndiaThe Tamil Nadu–ST-Segment Elevation Myocardial Infarction Program

Author Affiliations
  • 1Department of Cardiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
  • 2Department of Cardiology, Madras Medical Mission, Chennai, Tamil Nadu, India
  • 3Department of Cardiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
  • 4Department of Cardiology, Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
  • 5Department of Clinical Epidemiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
  • 6Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 7Division of Cardiology, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
  • 8Department of Internal Medicine and Michigan Center for Health Analytics and Medical Prediction, University of Michigan, Ann Arbor
JAMA Cardiol. 2017;2(5):498-505. doi:10.1001/jamacardio.2016.5977
Key Points

Question  Can access to reperfusion and percutaneous coronary intervention during ST-segment elevation myocardial infarction be achieved in low- to middle-income countries where resources are constrained?

Findings  This multicenter, prospective study of 2420 patients in a quality improvement program in India found that overall reperfusion use and time to reperfusion were similar during the preimplementation and postimplementation phases, but both postfibrinolysis angiography and percutaneous coronary intervention were more commonly performed in the postimplementation phase.

Meaning  A hub-and-spoke model may serve as an example for developing ST-segment elevation myocardial infarction systems of care in low- to middle-income countries.


Importance  Challenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors.

Objective  To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model.

Design, Setting, and Participants  This multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period.

Exposures  Creation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology

Main Outcomes and Measures  Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality.

Results  A total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04).

Conclusions and Relevance  A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.