ARTICLES Epidemiology Of Hypertension In Cuba Mortality From Ischemic Heart Disease In Cuba The Role Of Diet And Serum Cholesterol Cardiovascular Risk Factors In Health Workers Pre-Hospitalization Thrombolysis Using Cuban Recombinant Streptokinase: A  Preliminary Report A New Approach To The Comprehensive Treatment In Cuba Of Children With Cardiopathies (1986-1996) Rapid Detection Of Elevated Serum Lipoprotein (A) Levels:  Aubiodot Lp (A) ABSTRACTS A Comparative Study Of Patients Perfused With Membrane Oxygenaters And Those Perfused With D-700e Bubble Oxygenators Atrial Flutter With 1: 1 Atrioventricular Conduction Dual Chamber Pacing In Obstructive Hypertrophic Cardiomyopathy. Preliminary Report Endomyocardial Biopsies In Patients With Dilated Cardiomyopathy And Myocarditis Hypertension In Cuba: Evidence Of A Narrow Black-White Difference Is The Much-Maligned Reserpine Worth Reconsideration? Myocardial Revascularization In Acute Myocardial Infarction Myoglobin/Ck Mb: A Rapid Diagnostic Method For Acute Myocardial Infarction Orthodromic And Intra-Nodal Tachycardia.  Diagnostic Failures And Ablation Pre-Hospitalization Treatment Of Acute Myocardial Infarction Use Of Aspirin In Prophylaxis Of Type Iii Hypertension Weight Loss, Fever And Heart Murmur In A 58-Year-Old Woman.    Presentation Of A Case.

Pre-hospitalization thrombolysis using cuban recombinant streptokinase: 
A  preliminary report

  Álvaro Sosa Acosta, M.D.¹,
     Lilian Aguilera Vázquez, M.D.³,
     Ricardo Pereda González, M.D.²,
     Francisco Alonso del Pino, M.D.³,
     Lázaro O. Ruiz Suárez, M.D.³,
     Marilín Ramírez Méndez⁴

1. Assistant Professor of Internal Medicine.  Higher Institute of Medical Sciences of Havana.  Specialist in Intensive and Emergency Care.  President of the Cuban National Academic Committee for Life Support.  Cuban National Director of the Emergency Care Integrated System.
    
2. First-Degree Specialist in Internal Medicine.  Specialist in Intensive and Emergency Care.  Secretary of the Cuban National Academic Committee for Life Support. 
    
3. First-Degree Specialist in Comprehensive General Medicine.  Specialist in Intensive and Emergency Care.
    
4. First-Degree Specialist in Anesthesiology.  Specialist in Intensive and Emergency Care.  Member of the Cuban National Academic Committee for Life Support

ABSTRACT:  A preliminary report was presented on results of pre-hospitalization use of Cuban recombinant streptokinase in patients with acute myocardial infarction in seven provinces, where emergency care systems have been integrated into primary care models.  249 patients received pre-hospitalization thrombolysis in these provinces form late 1997 to May 1999.  Of these, four died (1.6%), and 98.4% survived.  Lethality for patients who received pre-hospitalization thrombolytic treatment was found to be lower (3.45) than that calculated for patients treated in a hospital setting (10.36).  Of all the patients who received pre-hospitalization thrombolysis, 69% were treated within 90 minutes of the onset of symptoms.

Introduction

Cardiovascular disorders are the leading cause of morbidity and mortality in virtually all industrialized countries, and even in some devloping nations, with ischemic heart disease playing a larger role in the 21^st century. (1, 2, 3)

Heart disease accounts for approximately 25% of the estimated 50 million deaths that occur annually worldwide, and for an important share of disabilities, social productivity and deterioration in of life.
(4, 5, 6, 7)

In Cuba, cardiovascular disease is the main cause of death: the 1997 mortality rate from cardiovascular disease was 197.1 per 100,000 inhabitants, and from acute ischemic heart disease, 109.2 per 100,000 inhabitants. (8)

An Integrated System for Emergency Care  (ISEC) was created and partially implemented in several provinces during the second half of 1997, reducing the mortality rate for acute myocardial infarction from 168.3 in 1996 to 109.2 in 1997. (8)

In 1998, the main goal of ISEC was to improve the Cuban National Program for the Management of Ischemic Heart Disease, and to begin a pre-hospitalization thrombolysis pilot plan in several provinces, using Cuban recombinant streptokinase, which had already had positive results in Intensive Care Units. The effectiveness of pre-hospitalization thrombolytic treatment in other countries has been reported extensively by many authors. (4, 5, 6, 7) 

Specially trained staff and advanced life support ambulances were chosen for the pilot plan, which was designed to: ensure early diagnosis of acute myocardial infarctions to gain time, resolve hypovolemias and arrhythmias; provide attention to patients that will allow them to arrive at the hospital pain-free; and use half a tablet of atenolol, half a tablet of aspirin and opiates as effective measures in such emergency services.

During 1999 other provinces were included in the program, and positive results obtained from this pooling of resources.

Objectives

  Assess the usefulness of Mobile Emergency Care Units for an acute ischemic heart disease early detection program

  Demonstrate the possiblity of implementing early pre-hospitalization thrombolysis in Cuba with positive results

Material and Methods

We carried out a descriptive cross-sectional study of patients who required thrombolytic treatment, comparing those who were treated before hospital admission to those treated after. 

Our study began as a pilot plan in Holguín and Villa Clara provinces, from October to December 1997, and has progressively been expanded to other provinces.  By early 1999, seven of Cuba's 14 provinces had been admitted to the program. 

Today, 10 provinces and the Isle of Youth Special Municipality are included in the Integrated System of Emergency Care (ISEC).  Staff charged with administering this type of treatment are doctors specialized in Comprehensive General Medicine (Family Physicians) who have received special training in emergency care, advanced life support and thrombolytic treatment, and who have worked and been evaluated at the Emergency Care Units and Intensive Care Units of Cuba's main provincial hospitals, under the supervision and advice of specialists in Intensive Care and Cardiology. 

The thrombolytic agent used is a recombinant streptokinase produced in Cuba.  The dosage is 1,500,00 units of recombinant streptokinase diluted in 100 ml of saline solution, to be administered intravenously within 20 or 30 minutes.  A physician from the mobile emergency unit carries out treatment at the medical center where the patient has been taken, or in the ambulance itself (never while it is moving).  After the patient's vital signs have become stabilized, he/she is taken to a hospital.Discussion

Between late 1997 and May 1999, a total of 249 pre-hospitalization thrombolysis were performed in seven of the provinces with an ISEC.  Of the patients treated, only four died (1.6%).  Two of them died during pre-hospitalization treatment, due to complications unrelated to the therapeutic procedure; and the other two died in the hospital, due to re-infarctions. (Table 1)

Table 1  Statistical Data on the Use in Cuba of Pre-Hospitalization Thrombolysis.  (From Late 1997 to May 1999)

PROVINCE	NUMBER OF PATIENTS	PRE-HOSP LETHALITY	DEATHS	DEATHS IN HOSPITAL
Pinar del Río	30	1	-	3.3
Villa Clara	116	-	1	0.9
Sancti Spíritus	8	1	-	12.5
Ciego de Avila	11	-	1	9.1
Holguín	67	-	0.0	0.0
Granma	8	-	-	0.0
Guantánamo	9	-	-	0.0
Total	249	2	2	1.6

      Source: Cuban Integrated System for Emergency Care.

From January to June 1999, 87 pre-hospitalization thrombolysis were performed in the provinces studied.  280 patients received thrombolytic treatment in hospital settings. Table 2 shows the differences in lethality for both groups (3.45 for the first group and 10.36 for the second).

Table 2.  Comparison Between the Lethality of Patients who Received Pre-Hospitalization Thrombolysis and those Treated in Hospital.  January-June 1999.

PROVINCE	PRE-HOSP. THROMBO- LYSES	DEATHS	LETHALITY	THROMBO- LYSES IN HOSPITAL	DEATHS	LETHALITY
Pinar del Río	15	1	6.7	21	4	19
Villa Clara	23	-	0.0	73	6	8.3
Sancti Spíritus	8	1	12.5	38	5	13.2
Ciego de Avila	7	1	14.3	32	6	18.7
Holguín	17	-	0.0	16	1	6.2
Granma	8	-	0.0	65	4	6.1
Guantánamo	9	-	0.0	35	3	8.6
Total	87	3	3.45	280	29	10.36

   Source: Cuban Integrated System for Emergency Care.

Our study shows that 69% of cases received pre-hospitalization thrombolysis within 90 minutes of the onset of symptoms. (Table 3)

Table 3.   Average Time Elapsed Between the Onset of Symptoms and the Application of Thrombolytic Treatment

Percentage of Patients	Time
69%	90 minutes
22%	91 minutes - 3 hours
9%	3 hours, 1 minute - 6 hours

   Source: Cuban Integrated System for Emergency Care.

At present, we are working to improve the Cuban National Program for Early Thrombolysis.  Appendix 2 shows the model used in thrombolytic treatments. 

Conclusions

1. Hospital lethality due to acute myocardial infarction has progressively decreased in Cuba with the implementation of the Integrated System for Emergency Care (ISEC) at the primary care level.

2. 22.5% of patients rushed to hospitals by Mobile Emergency Care Units in 1998 had acute ischemic heart disease--a figure that exceeds that of 1997.

3. Lethality for patients for whom pre-hospitalization thrombolysis has been employed to date in Cuba is 1.6--which is similar to that of highly developed countries.

4. In the first semester of 1999, lethality for patients who received pre-hospitalization thrombolysis was 3.45, as compared to 10.36 for patients who received in-hospital thrombolytic treatment.  This demonstrates once more the efficacy of an early pre-hospitalization thrombolysis program in increasing the survival rate of patients with acute ischemic cardiopathy.      

Appendix 1

Steps for implementing the Early Pre-hospitalization Thrombolysis Program in a province:

1. Implementation of the Integrated System for Emergency Care  (ISEC) in the province.

2. Training of health professionals in life support.

3. Training of health professionals in thrombolysis (includes rotations in the Emergency Care and Intensive Care units).

4. Evaluation and authorization of the staff by the provincial authorities of the Integrated System for Emergency Care, as well as the heads of the Cardiology and Intensive Care services.

1. Unequivocal signs of acute ischemic heart disease
2. Changes in the ST segment

a. ST segment depression of 1 mm in two or more precordial leads
b. ST segment elevation of more than 2 mm in two or more standard leads

3. Enzymatic tests were not used for lack of rapid diagnostic kits

  Source: Cuban Integrated System for Emergency Care

Appendix 2

INTEGRATED SYSTEM FOR EMERGENCY CARE:

PROGRAM FOR EARLY THROMBOLYSIS (PRE-HOSPITALIZATION 
AND IN-HOSPITAL TREATMENT)

Case No. ______

This form must be completed for all cases by the unit in which thrombolysis is carried out.  Patient's data should be filled in after the final evaluation of treatment.

1.  Coordinating Center ________________   Province ______________

 Patient's Name: ___________________________  Age: ____________  

 Sex: ________     Date: _____________

2.  Time between onset of symptoms and application of thrombolysis: _____(min.).   

Pre-hosp.____

 Hosp.___

 Emerg. Care Unit _____

 Intensive Care Unit: ____

 Rescued by Emergency Service: ______ 

 Duration of treatment: ________ (min.)

 Perfusion on the way to the hospital _____

 Drip before being taken to the hospital or in the hospital _____

3.  Criteria for applying pre-hospitalization thrombolysis: 

• Within 90 minutes of the onset of symptoms, always perform pre-hospitalization thrombolysis.
• Between 91 minutes and three hours, carry out pre-hospitalization thrombolysis if transportation to the hospital takes longer than 15 minutes.
• Between 3 and 5½ hours, carry out pre-hospitalization thrombolysis if transportation to the hospital takes longer than 30 minutes.
• Perform thrombolysis in the hospital to all patients with a diagnosis of acute ischemic heart disease who arrive in the hospital within 12 hours of the onset of symptoms or who are brought to hospital later by an Emergency Rescue team.

 Direct Cause of Death:  __________________

Source: Cuban Integrated System for Emergency Care

References

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2. Coccolini S, Berti G, Maresta A: La magnitud del beneficio del tratamiento trombolítico Pre-Unidad de Cuidados Coronarios en el IMA.  Int Journal Cardiology. December, 1997.

3. Coccolini S, Berti G: Trombolisis prehospitalaria en una sala de emergencia del Hospital Rural.  Int Journal Cardiology.  August, 1995.

4. Sagarin M. T, Cannon C. P: Causas de extensión del tiempo puerta droga y efectos de no síntomas.  Journal Emergency Medicine .  July-August, 1998.

5. Krall S. P:  Efecto del método continuo de desarrollo de la calidad (CQI) en la reducción del intervalo Triage a trombolítico para el Infarto Agudo del Miocardio.  Accademy of Emergency Medicine.  July, 1995.

6. Mathey D. G, Sheehan F. H, Schofer J, Dodge H. T: Tiempo desde el comienzo de los síntomas al tratamiento trombolítico: un mejor determinante de sobrevida miocárdica en pacientes con Infarto Transmural Agudo.  J Am Coll Cardiol.  June, 1985.

7. Wackers F. J, Terrin M. L, Kayden D.S, et al.: Recuperación de la función de la fase I. J Am Coll Cardiol .  December, 1989.

8. Cuban Yearbook of Statistics.  Cuban National Statistic Division.  Ministry of Public Health.  1998.