Global STEMI Outcomes May Improve With Tracking, GHATI Hints

WASHINGTON, DC—A global initiative to improve STEMI care launched in 2019 shows signs that, over the last 2 years, patients have been getting timelier treatment and are more likely to survive their hospitalizations.

Use of guideline-directed medications at discharge is also slightly up, said Cesar Herrera, MD (CEDIMAT Cardiovascular Center, Santo Domingo, Dominican Republic), who presented the data from the Global Heart Attack Treatment Initiative (GHATI) at the American College of Cardiology (ACC) 2022 Scientific Session last this week.

The registry has “successfully enrolled STEMI patients in countries generally unfamiliar with quality-improvement metrics, [yet] important trends in clinical parameter improvement were observed,” said Herrera during the last late-breaking clinical trial session of this year’s ACC meeting. “We believe that GHATI may facilitate the implementation of policies aimed at enhancing outcomes of cardiovascular disease worldwide.”

Every year, more than 3 million STEMIs are estimated to occur in low- and middle-income countries, which may lack not only guideline-recommended tools, but also the system-based initiatives for tracking performance, Herrera noted. Whereas percent survival following acute MI in Europe and the United States is in the high 90s, rates are significantly worse in other parts of the globe.

GHATI, established by the ACC to encourage uptake of guideline-recommended care while tracking outcomes, has now enrolled more than 4,200 patients from 18 countries on five continents. While the registry includes centers in North and Central Africa, Asia, and the Middle East, South American nations account for the near doubling of growth between years one and two, he said.

The snapshot reported by Herrera at ACC 2022 included 4,015 patients: 19.5% of whom were female and 35.5% smokers. In the 2 years since launch, said Herrera, researchers have seen rates of cardiogenic shock upon hospital arrival, cardiac arrest, and left ventricular ejection fraction below 40% dip by a mean of 3.1%. Proportion of patients discharged alive has ticked upwards by 1.7%.

Delays to care, rates of reperfusion therapy, evaluation of left ventricular ejection fraction, and use of guideline-directed medical therapy are also increasing, he added.

Modest but Encouraging

Commenting on the GHATI numbers during a press conference following the presentation, Frederick Welt, MD (University of Utah, Salt Lake City), congratulated the investigators for “an amazingly successful public health effort.”

“I don't even really know anything quite like it,” said Welt. “I think it's obviously really important that ACC plays a role in bringing this to other countries.

“I think the findings are encouraging,” he continued, calling them “modest, but in the right direction.”

Even more heartening than the acute STEMI outcomes is the fact that physicians working in very diverse countries also appear to be doing better at getting people on the right medications at discharge. “Maybe as important as getting timely reperfusion is making sure that patients are on the right medications to prevent secondary events,” said Welt.

Just by purely measuring, just by knowing that somebody's watching, just by knowing that you [have to] look at your data, things get better. Cesar Herrera

One caveat to keep in mind, Welt said, noting that he had worked in a range of different Asian countries, is that there are “real differences” between regions related to population size, existing infrastructure, and other factors, which complicate comparisons. “So a lot of this will likely require tailoring to the specific circumstances,” he said, “but I think it's a great study and a great start.”

During his presentation, Herrera explained that centers had been blinded to their own outcomes and those of other centers, but that going forward they’d have the opportunity to make their metrics public and learn how they compare to other regions and countries.

More than three-quarters of the participating countries enrolled in GHATI to date are low- and middle-income countries, he noted. “Most did not have previous experience of quality improvement.”

He believes even the act of participating in a registry like GHATI will lead to concrete improvements in patient care. “I think many registries have shown that just by purely measuring, just by knowing that somebody's watching, just by knowing that you [have to] look at your data, things get better,” said Herrera. “And that's the most important message that we would like to transmit to centers who don't even have a list of the last 20 STEMIs they cared for. So that speaks to that level of need that many countries are at in the world.”