Surviving a heart attack in rural Jamaica on New Year's Day


Surviving a heart attack in rural Jamaica on New Year's Day

Ernest Madu and Paul Edwards

Sunday, January 10, 2021

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In our prior columns, we have explored the general theme of access to good quality health care in Jamaica. We have discussed various obstacles and opportunities to improve the quality of health care delivery in Jamaica while making same equitable.

Health care inequity remains a vexing problem, not only in Jamaica but across the globe. A well known concept in health care is the Pareto principle, which basically opines that 20 per cent of the population (usually the more affluent) have access to 80 per cent of health care resources, leaving 80 per cent of the population to scramble for only 20 per cent of health care resources.

The picture is even more dire for the poorest 20 per cent who have access only to five per cent of health care resources. This inequitable distribution of health care resources is seen between countries (rich versus poor countries) and within countries (rich versus poor individuals or communities).

In Jamaica, we see a similar pattern between the more developed urban centres like Kingston and Montego Bay when compared to the more rural areas. While most of the health care resources and manpower are concentrated in the urban areas in Jamaica, rural areas of Jamaica where majority of the less affluent citizens live are largely devoid of any advanced health care facilities and so have very limited access to care in life-threatening emergencies. We experience this reality often when patients have symptoms of heart attack in rural Jamaica. A similar case last week deserves mention. We do so with respect and admiration for the hard-working health care personnel in rural Jamaica who often must make do with extremely limited and handicapping resources.

Our doctors at the Heart Institute of the Caribbean (HIC) Heart Hospital received a panicked call from a doctor at one of the rural hospitals at around 1:00 am on New Year's Day, 2021, concerning a 49-year-old man who presented at the hospital with excruciating chest pain, profuse sweating, and severe breathing difficulties.

An electrocardiogram was obtained which showed a massive heart attack in progress. Without a cardiologist and lacking the standard tools for managing a heart attack, the likelihood of death for this young man was relatively high. To improve his chances for survival and limit injury to his heart muscle, a cooperative and coordinated care plan between our team at HIC Heart Hospital and the doctors at the rural hospital was critical. This was more remarkable happening on New Year's Day at 1:00 am when most facilities had only skeletal staff on duty.

The heart disease problem in Jamaica

Cardiovascular disease is the leading cause of death in Jamaica and around the world. In the USA, despite advanced care and more ready access to care, one person dies every 36 seconds from cardiovascular disease.

About 655,000 Americans die each year from heart disease, representing one in every four deaths in the USA. A significant number of these deaths result from heart attacks. According to the Centers for Disease Control and Prevention (CDC) in Atlanta, three heart attacks occur in America, every two minutes, resulting in more than 800,000 people having a heart attack in the USA each year. For 200,000 of these individuals, it would be their second or more heart attack, a reminder that those who have previously had a heart attack are at an increased risk of having another heart attack.

The number of people having heart attacks each year in Jamaica is not known, but using population and risk factor data, we estimate that nearly 7,500 individuals in Jamaica suffer a heart attack in any given year. With limited infrastructure and lack of adequately trained personnel, the risk of death or major disability from a heart attack in Jamaica is significant. That risk multiplies for individuals in rural Jamaica where infrastructure and manpower deficits for managing heart attacks are dire.

For anyone having a heart attack, rapid medical attention is the only option that may save and preserve life. There are immediate and delayed consequences of a heart attack that can be greatly attenuated by urgent intervention. Much of the adverse consequences of a heart attack are driven by how much of the heart muscle dies. With rapid, appropriate, and aggressive intervention to open the blocked artery, the heart muscle can be preserved, limiting the damage and other adverse outcomes.

Much of the permanent heart muscle damage can be avoided if proper treatment is delivered within four hours of onset of a heart attack. However, when treatment is delayed beyond six hours, the amount of heart muscle that can be saved drops off significantly. After about 12 hours, the damage is usually irreversible. In rural Jamaica, this is an ever-present problem and can only be ameliorated by robust collaboration and coordination between poorly equipped and poorly resourced public facilities and better resourced private centres of excellence for cardiovascular care.

Urgent and appropriate response saves lives

Timely response and appropriate intervention are key to saving lives and minimising heart muscle damage and adverse outcomes when a heart attack occurs. What is often inadequately appreciated is how what may appear to be a small delay in appropriate care could be the literal difference between life and death.

A heart attack occurs when a cholesterol/fat plaque abruptly ruptures and forms a clot, blocking or limiting blood flow in a heart vessel. This abrupt interruption in blood flow leads to progressive heart muscle damage and unless immediate intervention is undertaken to restore flow, extensive heart muscle damage occurs and may lead to heart failure, arrhythmias, and death. The most appropriate intervention for heart attack is urgent coronary angiogram with angioplasty and stent placement. This procedure involves using a tiny wire to access the heart vessels to obtain pictures and determine the extent and severity of the blockage. Following that, balloon inflation is performed to open the blockage and a drug infused metal mesh is deployed to hold the vessel open

We use the concept of door-to-balloon time (D2B) to monitor efficiency of appropriate intervention in patients having a heart attack. This refers to the time it takes for a heart attack victim to receive balloon angioplasty from the moment they arrive at the hospital. The best cardiovascular centres around the world aim to keep the D2B at less than 90 minutes. At the HIC Heart Hospital, we have maintained a door to balloon time of less than 65 minutes.

A new year's gift of life

Back to the 49-year-old man with a heart attack on New Year's Day presenting at a rural hospital. When the team at the Heart Hospital was contacted, it was clear that without timely intervention, death or another adverse outcome was likely. The HIC Heart Hospital team worked collaboratively with the local team at the rural hospital to provide advice and guidance on medical treatment that could be safely initiated with the goal of rapid transfer by ambulance to the Heart Hospital for intervention. The team was mobilised and waiting, and patient was in the Catheterization Lab within minutes of arrival as he was taken into the lab from the ambulance. Within 20 minutes of arrival, the blocked vessel was opened by HIC Heart doctors and patient outcome dramatically changed for the better.

Working collaboratively between a public hospital in rural Jamaica and a private hospital in Kingston, the life of a 49-year-old Jamaican was saved despite all odds. This was a fitting way to start the new year.

Common heart attack signs and symptoms include:

Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw or back, sometimes associated with cold and profuse sweating and a feeling of “impending doom”.

Shortness of breath


Lightheadedness or dizziness

Nausea, indigestion, heartburn, or abdominal discomfort

If you or someone you know is experiencing any of these symptoms and you think you or they might be having a heart attack, please seek emergency medical assistance, have an ambulance or someone drive you to the nearest heart hospital and demand immediate attention. This is how lives are saved.

Dr Ernest Madu, MD, FACC, and Dr Paul Edwards, MD, FACC are Consultant Cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital.

Dr Madu is a main TED Speaker whose TED talk has been translated into 19 languages, seen, and shared by more than 500,000 viewers. He has received the Distinguished Cardiologist Award, the highest award from the American College of Cardiology and has been named among the 100 most influential people in health care and among the 30 most influential in public health. Dr. Madu is also a recipient of the Global Health Champion Award from the University of Pennsylvania. Dr Madu was past CEO of HIC and is currently the Chairman of IHS Holdings Ltd, an asset management company with interests in the USA, Africa, and the Caribbean.

Correspondence to or call 876-906-2107

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