• Surface: 176 215km²
• Population (2016): 3.5 million inhabitants
• Life expectancy (World Health Organisation 2015-16): 77 years
• Number of cath labs: 8
• Number interventional cardiologists: approx.30

 

During the last EuroPCR week in May, Uruguay signed a Declaration of Intent with Stent-Save a Life! to officially join the global initiative with the objective to implement a local strategic plan for the improvement of the acute myocardial infarction treatment.
Dr Ignacio Batista was appointed Country Champion and Dr Carolina Artucio Project Manager of the Uruguay Stent-Save a Life! organisation.

Out of the 8 catheterisation labs serving the country, 7 are located in the capital city Montevideo and the last one in Salto city in the north of the country, all of them offering primary PCI services 24/7.
Given that 50% of the country population live in Montevideo, while Salto counts 100,000 inhabitants, a significant amount of the Uruguayan population – over 1,000,000 people – still lacks access to primary angioplasty.

One of Uruguay’s advantages is the full financial coverage of PCI and pharmacological reperfusion. These are financed by the National Resource Fund (Fondo Nacional de Recursos), a non-state public institution, that provides financial coverage for high-cost and high-complexity medical treatments and medicines to people established in the country.
Another strength of Uruguay lies in its size and highway system that connects the main cities, thus facilitating the access to catheterisation labs, the maximum distance to a catheterisation lab being approximately 400 km.
Additionally, the STEMI treatment has been given a recent boost thanks to the Ministry of Public Health’s financing programme that, in compliance with certain regulations, remunerates all public and private healthcare providers. This approach aims at promoting better data recording and a more accurate STEMI diagnosis and treatment.

On the challenge side, it is estimated that 50% of STEMI patients still do not receive reperfusion treatment, although indicated, or the intervention is performed late (PIAM study). This is due, among other variables, to the delay between the onset of symptoms and the patient first contact, the diagnosis difficulties and the lack of medical teams adequately trained in these techniques.
Moreover, almost half of the country population does not have access to primary PCI because they live far from a catheterisation lab. Indeed, the 2014 study carried out by Dr Jorge Mayol et al. – who’ve analysed all the country primary PCI cases – demonstrated that 66.2% of the patients came from Montevideo and only 33.7% from other parts of the country (most of them being provinces near the capital city).

Although the current situation of the AMI treatment in Uruguay reinforces the need for a stronger implementation of the pharmaco-invasive strategy, healthcare centres, in rural areas with low population density, do not have fibrinolytic drugs and patients must therefore be transferred to higher level centres, which results in treatment delays. Furthermore, optimised protocols for patient transfer are missing, which could minimise delays if otherwise implemented.

Another important weakness, on the public side this time, is a real lack of awareness regarding the STEMI symptoms recognition and the importance of prompt consultation.
A study conducted in Montevideo with patients who were initially attended by a pre-hospital mobile emergency service, diagnosed with STEMI, and who later underwent primary PCI, showed that the average symptom onset-to-balloon time was 244.7 minutes. The delay in patient consultation was shown to be the main determinant in the overall delay.

In 2012, the primary PCI rate in Uruguay reached 319 per million inhabitants per year. As one of the primary objectives of the Stent-Save a Life! initiative is to reduce STEMI mortality by promoting rapid patient transfer to primary PCI centres for 70% of patients diagnosed with STEMI, the global rate should be around 600 primary PCI per million inhabitants per year – to be adapted to the needs of each country according to the STEMI incidence and accessibility. This would result in more than 2,000 procedures per year, which is almost twice the current figure.

Recently, an intersectoral working group has been formed, the Acute Myocardial Infarction Program (Re-PIAM), whose members – the Ministry of Public Health, the National Resource Fund, the Uruguayan Society of Cardiology and the Cardiology Department of the Universidad de la República – have designed a National Protocol on STEMI management.
A 3-year working plan has also been developed whereby, during the first year, thanks to the national registry data provided by the Ministry of Public Health and the National Resource Fund, the group will analyse the incidence and prevalence of STEMI, the type of reperfusion strategy used, and the delay from the symptom onset to the first medical contact and reperfusion. Based on the outcome of the first objective, the second year will be dedicated to the development of a STEMI network guide with the purpose of encouraging optimal communication between the network actors to provide better treatment for the patient.
Finally, during the third year, results of the implemented actions will be analysed and new objectives defined.

Stent-Save a Life! Uruguay, together with its partners, seeks to boost the improvement of STEMI treatment, particularly focusing on training, network development and the resource optimisation for the medical attention of STEMI patients.