Reperfusion Time of STEMI Patients in Indonesia and Outside Indonesia

Background: STEMI is a medical emergency that requires quick treatment. Several problems might arise from the improper and delayed treatment of STEMI patients. Objective: This study aimed to examine the differences in the reperfusion time of STEMI patients in Indonesia and outside Indonesia. Method: Systematic Review method is used without meta-analysis. The variables to be studied in this study are Door-to-Balloon time and Total Ischemic Time. PubMed, Science Direct, and Scopus are used as search tools using the MeSH terms and keywords that have been determined to look for articles within 2017 – 2020. The selection of the literature that has been obtained was carried out according to the PRISMA algorithm. Results: Twelve journals were used that were relevant, compatible, and following the inclusion and exclusion criteria. It was found that the median door-to-balloon in handling STEMI in Indonesia ranged from 70 to 94 minutes, while the median total ischemic time ranged from 275 to 461 minutes. Meanwhile, the median door-to-balloon time and total ischemic time outside Indonesia ranged from 41 to 87 minutes and 112 to 273 minutes, respectively. Conclusion: In conclusion, the median and average door-to-balloon time and total ischemic time in Indonesia are longer than the door-to-balloon time and total ischemic time outside Indonesia in handling STEMI.


Introduction
STEMI is an emergency condition that needs to be treated as soon as possible because there is a total occlusion of blood flow in the coronary arteries.
Measures to treat STEMI patients are reperfusion therapy, which can be in the form of fibrinolysis or percutaneous coronary intervention (PCI). [1]fty-two point eight percent of 31% or as many as 9.4 million deaths from the total deaths caused by cardiovascular disease are caused by Coronary Heart Disease (CHD).WHO also states that three out of four deaths caused by cardiovascular disease occur in countries with middle-lower economic levels such as Indonesia.Indonesia in 2016, cardiovascular disease caused 35% of total deaths or around 655.1 million deaths.Forty-eight point six percent of 35% or 318.8 million of the total cardiovascular deaths are caused by CHD. [2]me is a very important component in the management of STEMI patients.Experiments on animals show a strong relationship between the duration of occlusion and the extent of necrosis.
Cell death started after 20 minutes of occlusion and peaked after 6 hours [3] .A study at Dr. M. Jamil Padang showed that out of 80 people who received PCI therapy, only 17 people underwent therapy less than 12 hours from the onset of the patient's chest pain.Meanwhile, 63 new patients received therapy after more than 12 hours since the onset of chest pain [4] .The quality of service for STEMI patients can be seen from the delay audit index that must be recorded by STEMI service providers.The results of these records need to be reviewed periodically to ensure that the service quality of the system is maintained.Delays in treating STEMI patients can be caused by several factors, including patient delays, delays in diagnosis, and delays in reperfusion therapy [5] .Inappropriate and delayed treatment of STEMI patients can cause several complications, such as heart failure, hypotension, low cardiac output, cardiogenic shock, arrhythmias, cardiac rupture, and several other complications on hemodynamics. [6]is systematic review aims to examine the differences in the reperfusion time of STEMI patients in Indonesia and outside Indonesia.

Methods
The present review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 [7] .No ethical approval was required as no patients directly participated in this study and all the used data have already been published.

Eligibility
We performed a systematic search on reperfusion

Search Strategy and Selection of Studies
We conducted a comprehensive systematic database search on July 2021 in PubMed, ScienceDirect, and Scopus.The keywords that will be used are derived from "STEMI" and "reperfusion" and "Door-to-balloon", or "Total ischemic time" along with their related MeSH terms, synonyms, and elaboration.Review articles will be excluded but their references will be screened for potentially missed relevant studies.Titles and abstracts of the articles to identify potentially eligible studies were independently screened for full-text review.

Article Extraction
We independently extracted relevant articles from the included studies using a structured and standardized form.The following information was extracted: general information, research characteristics, intervention subject characteristics, and results.Any discrepancy will be resolved by consensus between all authors involved in the data extraction process.

Quality Assessment
Risk of bias assessment will be conducted by at least two authors working independently.
Disagreements will be resolved by discussion with a senior author.The tool used for assessment will be Mixed Methods Appraisal Tool (MMAT) 2018 version.

Data Analysis
The data analysis technique in this study used a systematic review method.Data analysis will be presented in the form of a narrative resume of the studies presented and arrive at each conclusion to explore the relationships within the studies and assess the robustness of the studies.The results of each study will be displayed in a narrative manner to become a comprehensive discussion.September 2023 | Vol 4 | Article 2

Study Selection
The search result in 417 records, 32 are duplicates.After title and abstract screening, 331 articles were excluded.This systematic review included 12 published articles after the full-text assessment.PRISMA flow diagram (Fig. 1) presents the process of study selection and the reasons for exclusion.

PCI Therapy in Indonesia
System that was previously serial with many steps changes to be parallel can make the therapy process shorter.This parallel system is carried out by diagnosing, contacting a cardiologist, and setting up a catheterization laboratory simultaneously.The availability of an on-call cardiologist and a simplified administration system can also make the transfer process and laboratory activation faster. [8] the other hand, although the implementation of an integrated referral system such as CODE STEMI in Indonesia over the last 3 years has succeeded in significantly reducing the DTB duration, this system has not been able to meet the recommendation time according to international standards.In fact, every 1-minute increase in reperfusion time will affect the mortality rate 1 year after perfusion. [8]e STEMI network which involves almost all hospitals with PCI facilities in Jakarta is showing more positive results.After 10 years of implementing the STEMI network, a significant reduction in the median DTB time was obtained to meet the recommended time according to international standards.The adoption of this system also led to a change in the majority of reperfusion strategy choices.The choice of invasive strategies has significantly increased in the management of STEMI patients after the adoption of these systems.
This improvement can be achieved by integrating administrative systems in the emergency department, increasing the number of interventional cardiologists, and providing cardiologists and nurses in the catheterization laboratory with a special guard schedule. [9]st study in Indonesia reported door-to-balloon (DTB) has been able to meet the international recommendation with median range between 70-94 minutes.Even though, there is a study that reported DTB between 158-288 minutes. [8]ter implementing integrated network to minimize the time needed to treat STEMI patients, there's significant decrease in DTB up to 45% decrease in median DTB compare to before the integrated network. [9]eptember 2023 | Vol 4 | Article 2 The problems currently being faced in the STEMI patient management system in Indonesia include traffic congestion, especially in the capital city, which often causes large delays in reperfusion time; PCI centers that do not provide 24/7 services, limitations in peripheral areas that are still far from PCI centers, low proportion of catheterization laboratories compared to the general population, and limited number of interventional cardiologists compared to systems in developed countries. [9]good management system is needed not only to shorten the transfer process and achieve optimal reperfusion time in STEMI patients, but also to provide the best choice of therapeutic strategy for each patient.Good collaboration is needed between medical personnel in primary health facilities, emergency ambulance services, call centers for STEMI patients, and interventional cardiologists to work in a protocol that has been mutually agreed upon, so that the quality of therapy choices can be improved for each STEMI patient in Indonesia. [9]wever, DTB timing cannot be used as the sole reference for evaluating the quality of treatment in STEMI patients.In this case, the total ischemic time can better represent the main problem that must be overcome to reduce reperfusion time, so reperfusion time reduction must focus primarily on total ischemic time. [10]lay in reperfusion time is not always the result of failure of the referral system.establishing the diagnosis of STEMI in the initial contact. [9]though most of the study in Indonesia has succeeded in achieving DTB <90 minutes, all median of total ischemic time in Indonesia still far from meeting the recommended time of <120 minutes.A study in Indonesia found that median of total ischemic time in Indonesia range between 275-330 minutes, more than double the recommended time [11] .Another study even reported that median of total ischemic time in Indonesia is 461 minutes, that is almost 4 times the recommended time. [10]monitoring services. [11]e higher prevalence of PCI in interhospital superior clinical outcomes compared to fibrinolytic therapy, even with the time delay that occurs for this reason. [9]eptember 2023 | Vol 4 | Article 2

PCI outside Indonesia
All Study in outside of Indonesia found succeeded in achieving DTB median <90 minutes, range from 41 minutes, all the way to 89 minutes.The shorter ECG-to-call lab time on the use of social media facilities in the referral process indicates that shortening the activation time of the catheterization laboratory can be achieved because the cardiologist has been able to confirm the presence of STEMI as an indication of laboratory activation even before the patient arrives at the referral hospital. [12]e importance of lifestyle modification and consumption of routine medicines according to clinical indications must also be prioritized to improve the clinical condition of STEMI patients, so that it will not only improve outcomes when patients experience attacks, but can also prevent attacks from occurring and improve the patient's overall quality of life.
Longer reperfusion times, which were independently associated with higher mortality rates, were independent of the type of patient  The integrated STEMI network program is currently the main strategy of choice in shortening reperfusion time in STEMI patients.In addition to increasing the effectiveness and quality of services by increasing the knowledge and skills of medical personnel as well as improving the transportation system and health facilities, increasing efficiency in the economic sector must also be considered.In compiling, developing, and integrating this system, it is necessary to consider the amount of loyalty to related companies, such as transportation service providers and telecommunications network service providers.It is also necessary to consider intercompany market share and patent agreements with contributor companies both in the same or different fields.This integrated system also needs a good and structured allocation of funds so that it can run well [15] .This is expected to increase the commitment of contributing companies in improving service quality and developing new alternatives so as to improve the quality of management of STEMI patients as a whole.

Conclusion
In conclusion, this study shows that there are differences in the reperfusion time of STEMI patients in Indonesia and outside Indonesia, the median door-to-balloon time in Indonesia ranges from 70 to 288 minutes, while the median door-toballoon time outside Indonesia ranges from 41 to 124 minutes, and the median total ischemic time in Indonesia ranges from 275 to 461 minutes, while the median total ischemic time outside Indonesia ranges from 96 to 270 minutes.

Study Limitation
The results of the analysis in this systematic review should be interpreted with clinical considerations found in the field at each health facility where clinicians work.This study has several limitations in evaluating the overall management process of STEMI patients both in Indonesia and outside Indonesia.In this systematic review, there was no justification for the number of samples, research settings, and research methods in comparing the outcomes of each study, so that bias might occur due to differences in these matters.In future studies, it is necessary to carry out a more detailed selection with the main considerations on these three things.
September 2023 | Vol 4 | Article 2 time of STEMI patients in Indonesia and outside Indonesia.Studies reporting patient managed without reperfusion are excluded.The article published between 2017-2020.Any studies written September 2023 | Vol 4 | Article 2 in languages other than English or Indonesian, those with no available full text and with nonhuman subjects were excluded.Duplicate articles were resolved before the title and abstract screening.

Figure 1 .
Figure 1.PRISMA flow of study selection Unclear signs, symptoms, and ECG results indicating the presence of STEMI can be one of the causes of delays in reperfusion time in STEMI patients, due to doubts in September 2023 | Vol 4 | Article 2 ischemic time for STEMI patients is 461 [359-572] minutes.Technological developments in the last decade have contributed to the improvement of digital health systems.Telecardiology technology has helped improve the quality of the pre-hospital treatment system by reducing diagnosis time, improving the quality of diagnosis in STEMI patients, reducing the prevalence of false diagnosis of angina, and reducing readmission rates with post-operative monitoring and post-discharge referral patients could be due to earlier risk identification and stratification in referred patients so that they still meet the recommended time for PCI action.Having carried out risk identification and stratification before the patient arrives at the PCI center also helps shorten the patient's DTB time, by shortening the time for administration and activation of the catheterization laboratory.In referring hospitals, generally education and requests for approval have been carried out regarding plans for PCI action so that patients already have a decision regarding PCI action to be carried out when they arrive at the referral hospital.Inter-hospital referral for PCI action is relevant because of the expected

Table 2 .
Total ischemic time in Indonesia Dakota et al.

Table 3 .
Door-to-balloon outside Indonesia

Table 4 .
Total ischemic time outside Indonesia.

Table 1 .
September 2023 | Vol 4 | Article 2 Distribution of studies in Indonesia

Table 2 .
Distribution of studies outside Indonesia