presented at Asia PCR Sing Live 2017

1. Myanmar PPCI Programme: How primary
PCI was started with the right planning
training and government support

2. Potential conflicts of interest
Speaker's name:
 I do not have any potential conflict of interest

3. population of Myanmar
60.38 million (2011-12)
About 70% of the population
resides in the rural areas.
population density for the
whole country is 89/km2
3 cath labs- Public hosp
3 cath labs- military hosp
2 cath labs- private hosp
Myanmar 2013
01/19/2017 3How PPCI Program was started in Myanmar
1 public and 3 private cath labs
in 2015

4. • 75% of STEMI patients were late presenters and not eligible for
reperfusion.
• Thrombolysis, almost exclusively with streptokinase was the only
reperfusion therapy (immunologic reactions and hypotension
further reduce the reperfusion rate)
• Primary PCI – never done
• Pharmaco-invasive – never done
• Delayed PCI or ischaemia-driven PCI was performed before
discharge for those who can afford and We saved quality of life of
patients who survive from STEMI
• Several patients have exhausted their financial resources and they
end up abandoning the further coronary angiography and PCI.
STEMI care in Myanmar before 2013
01/19/2017 4How PPCI Program was started in Myanmar

5. Health care system Barriers for PPCI
• No registry data for AMI and reperfusion data ( on a regional or
national level)
• No STEMI care Guidelines
• No Central chest pain call centre
• No EMS and pre-hospital care system in Myanmar
• Transport: lack of centralized ambulance system
• Delayed presentation ( 75% were late presenters)
01/19/2017 5How PPCI Program was started in Myanmar
From saving quality of life to saving lives from STEMI- PPCI

6. Patients’ barriers for PPCI
• Lack of access to healthcare for the common Myanmar people
(Geographical differences in infrastructure -Roads/ communication/
transport )
• Lack of awareness of disease -population at large
• Traditional delays and Consent issue
– People thought PCI is an operation and it has multiple dangerous
complications
– death from MI is natural and death from procedure is unnatural , even
consent for elective PCI need long conversation and explanation
• Financial constraints -Sizeable population low-middle group
– No health insurance, Paid by patient’s family
01/19/2017 How PPCI Program was started in Myanmar 6

7. Hospital barriers
• Government hospitals -Very small amount of funding for
healthcare, not possible to provide expensive procedures
• if PPCI after working hrs- no funding for overtime pay to staffs
• Private cath labs are low volume centres and have limited
staffing (only one private hospital has surgical back-up)
01/19/2017 How PPCI Program was started in Myanmar 7

8. • Streptokinase is the only available thrombolytic agents ( it is
inexpensive, because of the availability of generics).
• UFHeparin and enoxaparin are only available anticoagulants
• GPIIb IIIa are not available
• Aspirin and Plavix are only available antiplatelets and no potent
antiplatelets
• PCI centres were only available in Yangon, Mandalay and Naypyitaw
and most were low volume centers
• PCI hardware are expensive because of low volume
01/19/2017 How PPCI Program was started in Myanmar 8
Technology Barriers: devices and drugs

9. Situation in Mandalay in 2013
• Cath lab established in 2001
• No one was trained for intervention
• 2002-2003 first Trainee from MGH at NHC Singapore
• first elective PCI was started in April 2003
• Angio and PCI volume grows after 2008
• Only single cath lab which was 12yr old ( Memory 6GB only) when PPCI program
was started
• Only 3 interventionists and 2 fellows, 6 cath lab nurses, 1 radiographer
• Electricity problem ( back up generator )
• Expensive PCI hardware and financial issue notoriously cause delays in obtaining
consents. Need Funds to provide life-saving STEMI care.
01/19/2017 9How PPCI Program was started in Myanmar

10. Driving Force to start PPCI program
• Enthusiasm and Team work
• Our Mission: No One Should Die from Heart Attack
• Devoted Team : Hospital admin, cath lab staffs, CCU staffs
01/19/2017 How PPCI Program was started in Myanmar 10
Our Dream: We want to save lives from STEMI

11. • Main reason is financial constraints and consent
• Funding:
• Collect equipment donated by NGO teams
•Recycle the sheaths, wires and catheters by staffs
•Staffs were happy to save lives without getting overtime pay
• Consent:
• Try to get Patients trust by performing many cases for elective
PCI very cautiously to avoid major complications
What have we learned and
what can be done to start PPCI?
01/19/2017 11How PPCI Program was started in Myanmar

12. Cleaning, resterilizing the sheaths, catheters, wires
and etc by cath lab nurses to re-use for poor patients
01/19/2017 12How PPCI Program was started in Myanmar

13. MGH Regional Primary PCI Service
Started on 28 Feb 2013
I. 9am/5pm weekdays primary PCI service rolled out 28th Feb 2013
II. 6am/9pm everyday primary PCI service rolled out 1st April 2013
III. 6am/10pm everyday primary PCI service rolled out 1st Jan 2014

14. Further progress of MGH PPCI service
• Appointed as Country Director for LUMEN Global in 2014
• Opportunity to learn about Procedure and Process of PPCI
• Collaboration with TTSH Singapore, Tamasek Foundation and
Medtronic from 2014 to 2016
• MOH funded for new cath lab and PCI hardware, balloons and
stents in 2014
• MOH funded to replace the old cath lab with new one in 2014
01/19/2017 How PPCI Program was started in Myanmar 14

15. What have we learned and what can be done to
improve the process of PPCI?
1. Patients’ delays: Public awareness of heart attacks
2. System Delays:
1. Late Arrival in the ER
2. Delay in the diagnosis at ER
3. Delay in the referral to CCU
01/19/2017 15How PPCI Program was started in Myanmar
• single call activation to engage the cath lab
• Bypass the ER
• Develop prehospital alert and ECG transmission
using Smartphone applications and cathlab
activation before patient arrived to CCU
• avoid delay to activate the team outside working
hours
• complete coverage for PPCI irrespective of the
financial status

16. 1st March 2015
MGH STEMI Network laughed on the day
of celebration of second year anniversary
of PPCI and Heart Attack Awareness Week
Key To Improving STEMI Care: STEMI network
01/19/2017 16How PPCI Program was started in Myanmar

17. 01/19/2017 17How PPCI Program was started in Myanmar

18. Zone 1- 30 mins to MGH Cath lab lab
01/19/2017 18How PPCI Program was started in Myanmar

19. Zone 2- 1hr to MGH cath lab
Zone 3- 3hr to MGH cath lab
01/19/2017 19How PPCI Program was started in Myanmar

20. Family
Doctors
ERC
GP and
Physicians
ER MGHVoluntary patient transport
Existing system for STEMI care
01/19/2017 20How PPCI Program was started in Myanmar

21. Family
Doctors
ERC
GP and
Physicians
ER MGH
IDEAL STEMI care system
01/19/2017 21How PPCI Program was started in Myanmar

22. Family
Doctors
ERC
GP and
Physicians
ER MGH
x
x x
x
Our Aim
01/19/2017 22How PPCI Program was started in Myanmar

23. Family
Doctors
GP and
Physicians
Call us and send ECG by Viber
09-259898661
09-259898662
01/19/2017 23How PPCI Program was started in Myanmar

24. ERC
ER MGH
x
xCall us and send ECG by Viber
09-259898661
09-259898662
01/19/2017 24How PPCI Program was started in Myanmar

25. ECGs via Viber to MGH STEMI Network
From
Madayar
From Monywa
From Saggaing
From Kyauk Se
01/19/2017 25How PPCI Program was started in Myanmar

26. 1.visited spoke hospitals to participate in the program : address on
early diagnosis and quick referral
2.Invited voluntary patient transport teams: address on safe transport
of patient and teaching on BLS
3.Health education talks on heart attack awareness to public
4.24/7 primary PCI service rolled out 1st December 2015
Things that are being worked on:
01/19/2017 26How PPCI Program was started in Myanmar

27. • Message of reducing door-to-device time by
•health education to Public through media
•CME to ERC doctor/ Staffs, General Physicians and GPs
Key To Improving AMI Care: Education
01/19/2017 27How PPCI Program was started in Myanmar

28. Solution for Patient Delay-Health Education
01/19/2017 28How PPCI Program was started in Myanmar

29. 0
100
200
300
400
500
600
700
LYSIS PPCI NO
REPERFUSION
TOTAL
68 49
374
491
92
59
463
614
2013
2014
Reperfusion therapy for STEMI 2013-2014
76%10%14%
01/19/2017 29How PPCI Program was started in Myanmar
15% 10% 75%
Before STEMI Network

30. Reperfusion therapy for STEMI 2015-2016
0
100
200
300
400
500
600
700
Lysis Pharmacoinv PPCI No
Reperfusion
Total
129
0
133
431
693
34 12
164
352
562
Chart Title
2015
2016
62%
19%19%
After STEMI Network
01/19/2017 30How PPCI Program was started in Myanmar
6% 0% 2% 29%
58%

31. 0
100
200
300
400
500
600
700
2013 2014 2015 2016
374
463 431
352
68
92 129
34
0
0 0
12
49
59
133
164
PPCI
pharmacoinv
thrombol
no reperfu
Reperfusion therapy for STEMI 2013 -2016
01/19/2017 31How PPCI Program was started in Myanmar

32. PPCI In-Hospital Mortality 2013-2016
0
20
40
60
80
100
120
140
160
180
2013 2014 2015 2016
49
59
131
164
1 3 8 5
number of patients death
shock patients = 6shock patients = 2
01/19/2017 32How PPCI Program was started in Myanmar
2% 5% 4.5% 3%
shock patients = 5

33. ACS Cases in MGH (2011 – 2016)
0
100
200
300
400
500
600
700
2011 2012 2013 2014 2015 2016
420 437
491
614
693
562
123 133
193
300
328
359
151
135
205
328
209
260
STEMI
NSTEMI
UAP
01/19/2017 33How PPCI Program was started in Myanmar

34. In-Hospital Mortality for STEMI MGH (2011-2016)
0
100
200
300
400
500
600
700
2011 2012 2013 2014 2015 2016
420 437
491
614
693
562
60 61 73 93 103
72
STEMI
DEATH
14.2% 13.9% 14.8% 14.8%15.1% 12.8%

35. Door to Device Time
• 2013
• Min – 28 minutes
• Max – 234 minutes
• Mean - 93.79 ± 39.69
minutes
• 2014
• Min – 20 minutes
• Max – 160 minutes
• Mean - 89.89 ± 32.63
minutes
• 2015
• Min – 13 minutes
• Max – 234 minutes
• Mean - 73.21 ± 38.17
minutes
• 2016
• Min – 9 minutes
• Max – 473 minutes
• Mean - 56.75 ± 48.02
minutes
01/19/2017 How PPCI Program was started in Myanmar 35

36. Achievement of Standard Door to Device Time <90min
2013-2016
51% 51%
74%
84%
37%
30%
11% 12%
8%
19%
10%
2%4%
0%
5%
2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
2013 2014 2015 2016
Door to Device Time 2013-2016
<90min 90-120min 120-180 >180min
01/19/2017 How PPCI Program was started in Myanmar 36

37. Total Ischemic Time 2013-2016
0
50
100
150
200
250
300
2013 2014 2015 2016
226,02 237,54
297,81
189,96
93,79 89,89
73,21
56,75
Patient delay System delay
01/19/2017 37How PPCI Program was started in Myanmar

38. Ischaemic time according to mode of admission (2016)
371
300
338
271
33 30
0
50
100
150
200
250
300
350
400
Through ERC Through Network
Total ischaemic time
Pain to CCU
Door to balloon
Note: Data including are describing the time in Minutes

39. % of PPCI cases using Radial access
0
20
40
60
80
100
120
140
160
180
2013 2014 2015 2016
43
23
33
21
6
36
98
143
49
59
131
164
Femoral
Radial
Total
61% radial12% radial 75% radial 87% radial
01/19/2017 39How PPCI Program was started in Myanmar

40. Achievements in 4 years
• PPCI become well known treatment for STEMI among public and
getting consent is not a problem
• Awareness and support by Stake holders ( Yadanarpon Health Award
2016)
• MGH STEMI Network can be established on 1.3.2015
• Non-Reperfusion rate decreased from 75% to 62%
• PPCI rate increased from 10% to 29%
• Reduced mean D2B time from 91 to 56 mins
• Achieved standard door to device time <90min (51% in 2013 to 84%
in 2016)
• More radial access ( 12% in 2013 to 87% in 2016)
• In hospital MR (14.8% in 2013 to 12.8% in 2016)
• One year after our PPCI program,other hosp in Ygn started PPCI
01/19/2017 40How PPCI Program was started in Myanmar

41. Conclusions
• STEMI care is challenging in developing countries because of resource
constraints, delayed patient presentation, and system delays.
• Late presentation and lack of STEMI networks make management more
problematic.
• There are no clear guidelines to optimally care for these patients given
these deficiencies.
• System delays in STEMI care have multiple triggers and regional barriers.
• Delayed presentation requires a novel look at pharmaco-invasive
strategies that may prolong the window of opportunity for reperfusion
therapy.
01/19/2017 How PPCI Program was started in Myanmar 41

42. 01/19/2017 How PPCI Program was started in Myanmar 42