What are the gaps in management of Acute Coronary Syndrome (ACS) in this location?

Critical Gaps in Acute Coronary Syndrome Management

The most significant gaps in ACS management globally center on inadequate regional systems of care, delayed patient recognition of symptoms, insufficient emergency medical services infrastructure, and disparities in access to timely reperfusion therapy—all of which directly impact mortality and morbidity outcomes.

Systems-Level Infrastructure Gaps

Regional STEMI Networks

• Regional systems of care for STEMI are virtually nonexistent in low- and middle-income countries (LMICs), representing the single biggest barrier to uniform STEMI care 1
• Even in high-resource settings, recent declines have been reported in achieving established STEMI performance measures, partly due to COVID-19 pandemic-related challenges in ensuring adequate resourcing and staffing of EMS agencies and hospitals 1
• Lack of adequate financial, capital, and personnel resources to establish, administer, and maintain regional STEMI systems remains a fundamental obstacle 1

Emergency Medical Services Deficiencies

• Emergency medical services systems are virtually nonexistent in many LMICs, and emergency departments are ill-equipped to handle patients with ACS 1
• Poor transportation infrastructure and lack of adequately trained/equipped paramedics and ambulances make access to invasive centers difficult, particularly in rural areas 1
• Urban-rural disparities exist even in developed countries, with patients in rural counties experiencing significantly longer EMS response times (median 8 minutes) and transport times (median 17 minutes) compared to urban areas 2

Facility and Resource Distribution Gaps

Geographic Maldistribution of PCI Centers

• Cardiac catheterization laboratories are far too few to serve large patient populations and are almost always clustered in urban locations, while the vast majority of patients live in rural areas 1
• The absence of 24/7 PCI capability in many regions prevents achievement of the recommended FMC-to-device time of ≤90 minutes for direct presenters or ≤120 minutes for transfers 1

Fibrinolytic Therapy Infrastructure

• Many facilities lack the capability to administer fibrinolytic therapy with the goal door-to-needle time of <30 minutes 1
• Cost-prohibitive fibrin-specific thrombolytics (tenecteplase, tissue plasminogen activator) compared to streptokinase in LMICs, though streptokinase efficacy in pharmaco-invasive strategies has not been specifically tested in randomized controlled trials 1

Patient and Community-Level Gaps

Delayed Symptom Recognition and Presentation

• Significant lack of public awareness about ACS symptoms and the need to immediately call emergency services rather than self-transporting to hospitals 1
• Patients in LMICs frequently present late with longer ischemic times, which may affect the efficacy of pharmaco-invasive strategies 1
• Lower literacy and education levels in LMICs result in inadequate awareness of the problem and appropriate therapies 1

Healthcare Literacy Barriers

• When individuals seek help, first healthcare providers encountered may have inappropriate credentials, dubious experience, and less knowledge about complex ACS management 1

Data Collection and Quality Improvement Gaps

Inadequate Data Infrastructure

• Lack of robust mechanisms for data collection that balances adequate capture without introducing data overburden 1
• Insufficient data sharing within hospital departments (emergency department and cardiology) or between hospitals and EMS agencies 1
• Absence of accurate mapping showing what proportion of populations can access existing thrombolytic/PCI centers in a timely fashion, which is essential for planning additional resources 1

Performance Monitoring Deficiencies

• Gap between optimal guideline-based treatment and actual care delivery in real-world practice 1
• Lack of systematic use of well-defined and validated quality indicators to measure and improve STEMI care 1

Clinical Care Process Gaps

Prehospital ECG Acquisition

• Failure to obtain and interpret 12-lead ECG within 10 minutes of first medical contact in many settings 1
• Inadequate prehospital cardiac catheterization laboratory activation from the field for suspected STEMIs 1
• Feasibility challenges with widespread paramedic interpretation of prehospital 12-lead ECGs versus reliance on transmission or computer interpretation 1

Time-to-Treatment Delays

• Failure to achieve FMC-to-device time system goals of ≤90 minutes for patients presenting directly to PCI centers or ≤120 minutes for transferred patients 1
• Scene times frequently exceed the 15-minute benchmark, with only 49% of EMS encounters meeting this target 2
• Obtaining 12-lead ECG and venous access independently associated with lower adherence to scene time benchmarks, suggesting need for process optimization 2

Pharmacologic Management Gaps

Antiplatelet Therapy Uncertainties

• Unclear optimal antiplatelet agent selection in pharmaco-invasive strategies, particularly given that ticagrelor did not reduce cardiovascular events compared to clopidogrel in patients with STEMI receiving fibrinolytic therapy 1
• Timing of platelet inhibition and anticoagulation in prehospital and emergency department settings remains incompletely defined 1

Cost-Related Medication Access

• Lack of insurance coverage for the large majority of populations who are relatively poor, limiting access to expensive procedures and costly medications to a small proportion of patients 1

Socioeconomic and Policy Gaps

Healthcare Financing Barriers

• Absence of universal health coverage or adequate insurance mechanisms to support expensive ACS interventions 1
• Patients often lack stable employment allowing sick leave or time off for medical visits, creating barriers to follow-up care 1

Political and Societal Support

• Political and societal support for cardiovascular care systems may be challenging or transient, with local and national priorities frequently remaining focused on infectious disease programs despite epidemiologic transition to chronic disease predominance 1

Knowledge and Research Gaps

Evidence Base Limitations

• Much ACS research conducted on in-hospital populations rather than specifically in emergency department or out-of-hospital settings, requiring extrapolation of conclusions 1
• Lack of accurate decision rules for early identification of patients with and without ACS in prehospital and emergency department settings 1
• Insufficient evidence on impact of systems-of-care strategies designed to expedite reperfusion on mortality outcomes 1

Special Population Considerations

• Optimal management strategies for elderly patients (≥75 years), patients with diabetes, those with renal insufficiency, and patients with delayed presentations require additional study 1