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Implementing myocardial infarction systems of care in low/middle-income countries
  1. Bruno R Nascimento1,2,
  2. Luisa C Caldeira Brant1,2,
  3. Bárbara C A Marino3,4,
  4. Luiz Guilherme Passaglia2,
  5. Antonio Luiz P Ribeiro1,2
  1. 1Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, Minas Gerais, Brazil
  2. 2Departmento de Clinica Medica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  3. 3Servico de Cardiologia, Hospital Madre Teresa, Belo Horizonte, Minas Gerais, Brazil
  4. 4Faculdade de Medicina, Pontifícia Universidade Católica de Minas Gerais (PUC-MG), Belo Horizonte, Minas Gerais, Brazil
  1. Correspondence to Dr Bruno R Nascimento, Centro de Telessaude, Hospital das Clinicas da Universidade Federal deMinas Gerais, Avenida Professor Alfredo Balena 110, 2nd floor, Belo Horizonte, MG, Brazil, 30130-100; ramosnas{at}


Ischaemic heart disease is the leading cause of death worldwide, with an increasing trend from 6.1 million deaths in 1990 to 9.5 million in 2016, markedly driven by rates observed in low/middle-income countries (LMIC). Improvements in myocardial infarction (MI) care are crucial for reducing premature mortality. We aimed to evaluate the main challenges for adequate MI care in LMIC, and possible strategies to overcome these existing barriers.

Reperfusion is the cornerstone of MI treatment, but worldwide around 30% of patients are not reperfused, with even lower rates in LMIC. The main challenges are related to delays associated with patient education, late diagnosis and inadequate referral strategies, health infrastructure and insufficient funding. The implementation of regional MI systems of care in LMIC, systematising timely reperfusion strategies, access to intensive care, risk stratification and use of adjunctive medications have shown some successful strategies. Telemedicine support for remote ECG, diagnosis and organisation of referrals has proven to be useful, improving access to reperfusion even in prehospital settings. Organisation of transport and referral hubs based on anticipated delays and development of MI excellence centres have also resulted in better equality of care. Also, education of healthcare staff and task shifting may potentially widen access to optimal therapy.

In conclusion, efforts have been made for the implementation of MI systems of care in LMIC, aiming to address particularities of the health systems. However, the increasing impact of MI in these countries urges the development of further strategies to improve reperfusion and reduce system delays.

  • acute myocardial infarction
  • healthcare delivery
  • systemic review
  • heart disease

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  • Contributors Acquisition of data: BRN, LCCB, LGP, BCAM. Analysis and interpretation of data: BRN, LCCB, LGP, BCAM. Writing of the manuscript: BRN, LCCB, LGP, BCAM, ALPR. Critical revision of the manuscript for intellectual content: BRN, LCCB, BCAM, LGP, ALPR. Authors responsible for the overall content as guarantors: BRN, ALPR.

  • Funding ALPR was supported in part by CNPq (Bolsa de produtividade em pesquisa, 310679/2016-8, and Instituto de Avaliação de Tecnologias em Saúde–IATS, 465518/2014-1) and by FAPEMIG (Programa Pesquisador Mineiro, PPM-00428-17).

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data sharing statement The data analytic methods and study materials will be made available to other researchers for purposes of reproducing the results or replicating the review procedure from the corresponding author upon reasonable request.