Heart disease is the highest-ranking cause of death in T&T, accounting for 25 per cent of all deaths annually, according to the Pan American Health Organization (PAHO).
According to a well-known cardiologist, people die from heart attacks every day in T&T. While they do not make the front page like COVID, it quietly exists. Almost every household in T&T would have lost a relative or loved one to a heart attack.
T&T has been recognised as a territory with a high incidence of cardiovascular disease, heart attack and myocardial infarction, which has not only been a major cause of premature mortality but has contributed significantly to the loss of productivity in the workforce and has put a strain on the already burdened public health sector.
When the lives of loved ones are lost through heart attacks, families are torn apart as they grieve over the fact that they may not have had the exorbitant sums of money to seek the urgently required health care privately or that the proper treatment measures are not available at the public health facilities to save lives.
In a document received by Guardian Media entitled “Proposal for a National Primary Angioplasty Network for Acute Myocardial Infarction in Trinidad and Tobago”, a group of local cardiologist noted the grave situation that T&T faces as a result of cardiovascular disease and they have created a proposal for effectively treating with heart attacks in T&T. The doctors include interventional cardiologist Dr Ronald Henry and representatives of the local chapter of the Caribbean Cardiac Society like its president Dr Pravinde Ramoutar and members Tricia Cummings and Roy Tilluckdharry.
The cardiologists explained that ST Elevation Myocardial Infarction (STEMI), which is a major concern, represents a form of heart attack where one of the coronary arteries feeding the heart muscle becomes completely blocked, “typically by a combination of cholesterol accumulation and recent thrombus (blood clot).”
They said this condition requires urgent intervention with modern therapies if the “natural history of 30 per cent case fatality is to be reduced to a target of five per cent.” The five-per cent figure, they stated, is a reflection of recent surveys in developed health care systems using best practices.
Currently, in T&T, the proposal revealed, the majority of STEMI patients arriving at public institutions receive either attempted reperfusion with thrombolytic drugs or no reperfusion therapy at all.
“Reperfusion, as the prompt restoration of blood flow, is referred to, may be attempted by either giving clot-dissolving drugs called thrombolytic agents or via mechanical intervention with angioplasty techniques,” they stated.
They noted that angioplasty yields superior results and has become the recommended first-line therapy for STEMI patients in published guidelines throughout the world.
In the angioplasty technique referred to as Primary Percutaneous Coronary Intervention (PPCI), “the artery is reopened using miniature balloons following which a small metal scaffold known as a stent is often left at the site of the blockage to maintain long-term patency.”
The current proposal leans on the experience of countries such as The Czech Republic, The Netherlands, Sweden, Denmark, and Austria which have developed National STEMI Networks to achieve a successful transformation of STEMI therapy. The blueprint of the European Stent for Life Program has been adopted and modified under contemporary international guidelines and local resources, they added.
The handling of STEMI cases in T&T is not the best medically or economically
In a recent interview, Dr Henry noted that the way STEMI cases are being handled in T&T at present was not the best method from a medical and economic standpoint.
Henry said that this was an old way of doing things, where medicine is given and the outcome is awaited, which in turn contributes to the loss of lives and ultimately the loss of productive members of the labour force. As a result of this type of treatment, Henry said people not only stay away from work longer, but many of them never return to work, because even if they survive they have body parts that are weakened permanently.
This is why local representatives of the Caribbean Cardiac Society proposed a National Angioplasty Network and the establishment of a National PPCI service.
The objective, according to the proposal, is to perform primary angioplasty as the treatment of choice, to serve at least 70 per cent of STEMI patients arriving at Regional Health Association (RHA) Emergency Rooms in T&T. Also, to progressively increase the number of PPCI procedures performed nationally to achieve a target of 800 per year (>600 per million population) over five years. It also proposed the uniformity of access to primary angioplasty geographically and during the night time as compared to daytime periods.
The established network, they proposed, should allow for a goal of primary PCI to be performed within two hours of presentation of the STEMI patient. “For STEMI patients not receiving Primary PCI, a coronary angiogram should be performed as early as is feasible during the index hospital admission.”
They stated that the time lost awaiting financial approval is currently the single most important obstacle to successful Primary PCI of a STEMI patient at an RHA hospital “whose care is attempted to be outsourced to a private Cath lab.”
According to the document, “This administrative delay has the effect of nullifying the added benefit of the more effective therapy in a condition where time is critical. Preapproval of an agreed allocation of primary PCI procedures per period for each RHA for STEMI-patients would allow for cost control while at the same time give to each RHA its autonomy to develop its own resource allocation priority.” The aim being–to save lives.
To make this programme work, Emergency Medical Transport is key and there must be enough incentive for Cath lab staff to maintain the rigours of high-volume off-hours work.
“Generally, negotiated fee-for-service arrangements have worked well in Europe when permitted eg, at private institutions. For Government hospitals, special allowances for call-out work or specially rostered extra staff are alternative recommendations,” they noted.
Increasing infrastructure will not solve heart attack problem in T&T
T&T currently has two public state-of-the art Catheterization (Cath) labs–one at the Eric Williams Medical Sciences Complex (EWMSC) and the other at the Scarborough General Hospital. It was recently disclosed in the Business Guardian that at least $70 million was spent on establishing the Cath lab in Tobago, that it is not functional and has not been functional in five years.
There is also a bid out to design and build a Bi-plane Cath Lab at the San Fernando General Hospital, a facility that many doctors have welcomed.
However, according to Dr Henry, infrastructure is not what is missing from establishing a National PPCI service. What is absent is the establishment of a local network.
“Because that is available and possible now, even without putting a single brick or mortar down, there is really no reason to not do that, because over time, within a year’s time, such a system pays for itself.”
Henry argued that the money spent on hospitalisation and care of chronic patients would be paid back through cost savings. He clarified, however, that the metrics that he described relate to the treatment of emergency heart attack situations.
Henry said, “It provides the financial benefits for the emergency care, which happens, by the way, every single day. As you know, people die from heart attacks every day. They don’t make the front page like COVID, but it quietly exists.”
The medical professional contended that lives are saved in two ways; one method is through prevention (lifestyle changes like lowering cholesterol, hypertension and diabetes), and the State is doing a very good job at this. The second way is through emergency services.
Henry said there was the perception in T&T that infrastructure will help the emergency care. However, he emphasised that increasing the infrastructure will not solve the heart attack problem in the country.
He said the country already has enough national infrastructure, all that is necessary now is to coordinate the human resource element. Henry said, “That’s where cost savings would occur and that’s where life savings would occur and that’s where sustainable development would be enhanced because we would be losing our people in the prime working years through heart attacks and sudden death.”
The proposal detailed that success in setting a National STEMI network requires continuous Cath lab resource utilisation at a rate of one available Cath lab per 0.3 to one million population. The cardiologists asserted that T&T would therefore require two to five Cath labs to serve the entire population. They said the combined public and private health sector of this country currently has six operating Cath labs, one in the public sector and five in the private sector (Tobago is not included).
The doctors said of the six local labs, three advertise a 24/7 emergency PCI, one lab (EWMSC) performs daytime elective and urgent PCI, and two labs perform sporadic PCI. They proposed that participating Cath labs should ideally offer a 24/7 emergency service.
What is the Government’s plan?
In light of the country’s current health crisis and economists like Nobel laureate Joseph Stiglitz urging the region to focus on fixing the health system, Guardian Media sought comments from the Ministry of Health on the matter.
Guardian Media forwarded the following questions on September 9:
1. a) Did the ministry receive the local chapter of the Caribbean Cardiac Society’s presentation on the proposal for a national Primary PCI service in 2019?”
b) If yes, why has the ministry not responded to the local chapter of the Caribbean Cardiac Society’s presentation on the proposal for a national Primary PCI service?
2. a) Does the Ministry of Health see the need for the implementation of a national Primary PCI service?
b) If the ministry validates the need for such a service, what are the plans and time frames for the national Primary PCI service to be operational?
However, two months later and Guardian Media has not received a response.
Guardian Media understands, however, that the Caribbean Network proposal was presented to the 27th Meeting of CARICOM Chief Medical Officers (CMOs) on June 17, 2019, in Port-of-Spain and it was also presented to the Ministry of Health at their 37th Council for Human and Social Development (COHSOD) Health Meeting in Washington DC in September 2019. This country’s CMO was also given a hard copy of the updated T&T National Network proposal at the conference.
Dr Henry told Guardian Media that if T&T were to institute a National PPCI Programme “this would also create the opportunity to negotiate Government-to-Government (G2G) arrangements so that CARICOM states with fewer resources could tap into our national grid using a hub-and-spoke model.”
He explained that this would also mean inflows of much needed foreign exchange for T&T. After highlighting that such a model to facilitate G2G transactions would require an overarching Caribbean STEMI (ST Elevation MI) Network plan, Henry said this plan has already been written and celebrated by the American College of Cardiology amongst others.
Henry said, “It has already been presented under the auspices of CARPHA at the CARICOM Heads of Govt meeting in Barbados in February 2019.” If accepted, it would have to be modified to embrace the realities of the pandemic.
The question that arises now is: ‘What will the current Government do?’