PATIENTS with heart attack are at increased risk of dying unless appropriate intervention is initiated.

While firm numbers are not immediately available, using comparable country data, we have been able to estimate that about 7,500 heart attacks occur each year in Jamaica. Many of these patients unfortunately will die within hours or days of suffering a heart attack. This is not surprising, given the multiple barriers to access and the severe limitation in effective capacity to promptly and appropriately respond to heart attack in most facilities in Jamaica. Our public hospitals receive the majority of heart attack patients in Jamaica and most of these facilities simply do not have the infrastructure, resources, or human capital to effectively respond to heart attack patients in a manner that is consistent with best practices informed by current medical evidence.

The natural history of heart attacks is important. This information allows us to assess the risk of death and long-term morbidity. It also allows us to see the effect of appropriate and timely treatment in improving outcome in heart attack patients. A major limitation in the Jamaican context is patients who present with heart attack who are not diagnosed or properly diagnosed but appropriate treatment is delayed. It is well documented that these patients are at increased risk of death in the near term at the time of the heart attack but also are at high risk of developing significant morbidity and premature death over years. These patients must be identified and offered appropriate treatment to improve survival. If appropriate or timely treatment is not possible at the presenting facility, prompt transfer to a suitable facility should in all cases be considered.

An analysis of 23 published studies, in which 14,211 patients were followed prospectively after heart attack (6,817 deaths were recorded), sought to answer this question.

After a first heart attack, in the absence of appropriate intervention, 36 per cent die in the first month (most before hospital admission). A further 34 per cent of patients die of cardiovascular disease during the next 15 years, in many cases after a subsequent heart attack, for a cumulative death rate of 70 per cent. Approximately half of all heart disease deaths, therefore, occur in the first few months after the first heart attack (one third within minutes and one sixth in hospital), and half occur later. Among survivors without effective treatment, heart failure is a common and major cause of long-term disability severely impacting families and the nation through productivity losses and inability to contribute to economic activity.

After a subsequent heart attack, without timely or appropriate treatment, 53 per cent of patients die in the first month, and a further 39 per cent die of cardiovascular disease during the next 15 years, for a cumulative death rate of 92 per cent. Simply stated, without appropriate or effective treatment and intervention, most patients with heart attack will die prematurely, either shortly after the heart attack or in the months and years to follow. With timely intervention and proper treatment, 90 per cent or more of patients with heart attack will survive and live a long and productive life.

It is disheartening, therefore, that despite these harrowing statistics, we as a nation have given only scant attention to the need for urgent and effective intervention when heart attack occurs or is suspected. In our prior articles in this column, we have sought to highlight the accepted paradigm that every chest pain should be considered an emergency until proven otherwise. We are fully cognisant of the financial implications of urgent and effective intervention that encourages some patients and payers to use every mechanism to impede early treatment. We believe these actions are misinformed and result in more severe economic loss for families and the nation, not to mention the emotional harm inflicted on families from premature deaths and disability resulting from delays and denials of treatment. We can not say it enough. Every chest pain potentially may represent a heart attack and so must be treated as an emergency until a heart attack is properly excluded and this can only be done through appropriate diagnostic investigations.

Appropriate and timely intervention can drastically reduce the risk of untimely death and/or disability in patients with acute heart attack.

Heart attack remains the leading cause of cardiovascular deaths around the globe including Jamaica highlighting the need for timely access to interventions, reductions in risk factors and care quality improvements

A good indicator of quality of care in heart attack victims is the risk of death in the first 30 days after the event. This measure reflects the entire continuum of care from public health efforts to educate the population about symptoms of heart disease, the response of the emergency medical services, the availability of specialised cardiac services and the quality of the hospital care that is delivered. Thirty-day mortality rates for heart attack have decreased substantially in most developed countries but remain unacceptably high in most developing countries including Jamaica. Across developed countries for which data are available, they have fallen to less than 10 per cent. Many factors are responsible for this improvement including early recognition of heart attack symptoms, better and more timely access to acute care, and transportation of patients to specialised health facilities, such as percutaneous catheter intervention-capable centres like HIC Heart Hospital. In many of these patients rapid restoration of blood flow to the muscle of the heart can lower the risk of death and improve outcome.

The alarmingly high death rates for Jamaican patients with heart attacks and acute coronary syndromes can be directly related to adverse economic conditions, lack of access to appropriate care and poor health literacy among many of our citizens. Many patients in the public system have limited financial capacity to pay for acute coronary interventions at the time of their heart attacks and public assistance is not readily accessible for many of these patients. For those with government-funded insurance, the response from third-party payers have not been satisfactory in facilitating timely access to life saving care. These patients therefore are denied timely access when the most benefit is possible.

It is imperative therefore that we must as a national priority improve access to timely and effective interventions for these patients with heart attacks and acute coronary syndromes. A holistic approach that leverages the resources in the private sector to ensure that a uniform level of care is facilitated for patients with heart attack whether presenting in the private or public health-care system is desirable. Patients should have immediate access to angiograms, percutaneous coronary intervention with stent placement if needed and intensive care unit stay when appropriate. Health-care service providers, patients and families should be better informed about heart attacks and acute coronary syndromes so they appreciate the urgency with which treatment must be delivered to not only improve immediate chance of survival but to improve on long-term survival and freedom from disability. If we do not care enough for the thousands of lives lost needlessly, we should be concerned about the severe impact of lost productivity on the nation and the societal disruption resulting from premature death and disability of family members, many of whom are in their most productive years of life. There is a moral imperative to find an affordable and sustainable solution to help attenuate the adverse consequences of heart attacks on our citizens including the most vulnerable.

The time to act is now.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107