Tele-electrocardiography in South-East Asia Archipelago: From a Basic Need for Healthcare Services to a Research Implementation

The fundamental principle for telemedicine implementation in the real world is to address the basic needs of healthcare services. The utilization of telemedicine naturally aimed to overcome distance, time, and financial constraints. Remote areas that are far from the cities and healthcare centers are the main regions that would mostly get benefit from the telemedicine program, for instance, in Indonesia, a country with a big archipelago area in South-East Asia. The primary healthcare center in this country is commonly available, however, the facilities and health workers are still limited. The health services are being centralized in big cities, and thus, the rural areas are far left in the context of healthcare services. Telemedicine could bring both standardized and specialized healthcare services nearer to the patients, irrespective of distance and location constraints. After receiving professional cardiology advice, implementation of telemedicine program, such as tele-electrocardiography (tele-ECG) at the primary care level, may be a financially advantageous way to identify cardiovascular disease in the general population and avoid overtreating patients. This is our first time adopting tele-ECG consultations in East Indonesia under the Makassar Telemedicine Program. This program allows us to maintain a big database of cohorts and connect its implementation to real-world clinical practices, and at the end, could guiding the health workers to improve patient’s outcomes

Stress hyperglycemia and poor outcomes in patients with ST-elevation myocardial infarction: a systematic review and meta-analysis

Background: Hyperglycemia, characterized by elevated blood glucose levels, is frequently observed in patients with acute coronary syndrome, including ST-elevation myocardial infarction (STEMI). There are conflicting sources regarding the relationship between hyperglycemia and outcomes in STEMI patients. We aimed to compile evidence to assess the association between hyperglycemia and adverse outcomes. Methods: We conducted a comprehensive search for articles on PubMed and Embase using search strategies which yielded 4,061 articles. After full-text screening, 66 articles were included for systematic review, and 62 articles were further selected for meta-analysis. Results: The 66 included articles spanned the years 2005–2023. Of these, 45 articles reported admission blood glucose, 13 articles used HbA1c, and 7 articles studied fasting blood glucose. Most studies defined STEMI with primary PCI as their inclusion criteria. Mortality was the most often outcome reported related to hyperglycemia. Overall, 55 (83.3%) studies were at low risk of bias. Both admission and fasting blood glucose were significantly related to short- and long-term mortality after STEMI, with a pooled risk ratio (RR) of 3.02 (95%CI: 2.65–3.45) and 4.47 (95% CI: 2.54–7.87), respectively. HbA1c showed substantial association with long-term mortality (HR 1.69, 95% CI: 1.31–2.18)) with a pooled RR of 1.58 (95% CI 1.26–1.97). In subsequent analyses, admission hyperglycemia was associated with an increased risk of reinfarction (pooled RR 1.69, 95% CI 1.31–2.17), heart failure (pooled RR 1.56, 95% CI: 1.37–1.77), cardiogenic shock (pooled RR 3.68, 95% CI 2.65–5.11), repeat PCI or stent thrombosis (pooled RR 1.99, 95% CI 1.21–3.28), and composite major adverse cardiac and cerebrovascular events (MACCE) (pooled RR 1.99, 95% CI: 1.54–2.58). Conclusions: Our study demonstrated that hyperglycemia has a strong association with poor outcomes after STEMI. Admission and fasting blood glucose are predictors for short-term outcomes, while HbA1c is more appropriate for predicting longer-term outcomes in STEMI patients. Systematic Review Registration: PROSPERO 2021 (CRD42021292985)

In-hospital mortality of patients with acute coronary syndrome (ACS) after implementation of national health insurance (NHI) in Indonesia

Background: The National Health Insurance (NHI) was implemented in Indonesia in 2014, and cardiovascular diseases are one of the diseases that have overburdened the healthcare system. However, data concerning the relationship between NHI and cardiovascular healthcare in Indonesia are scarce. We aimed to describe changes in cardiovascular healthcare after the implementation of the NHI while determining whether the implementation of the NHI is related to the in-hospital mortality of patients with acute coronary syndrome (ACS). Methods: This is a retrospective comparative study of two cohorts in which we compared the data of 364 patients with ACS from 2013 to 2014 (Cohort 1), before and early after NHI implementation, with those of 1142 patients with ACS from 2018 to 2020 (Cohort 2), four years after NHI initiation, at a tertiary cardiac center in Makassar, Indonesia. We analyzed the differences between both cohorts using chi-square test and Mann-Whitney U test. To determine the association between NHI and in-hospital mortality, we conducted multivariable logistic regression analysis. Results: We observed an increase in NHI users (20.1% to 95.6%, p < 0.001) accompanied by a more than threefold increase in patients with ACS admitted to the hospital in Cohort 2 (from 364 to 1142, p < 0.001). More patients with ACS received invasive treatment in Cohort 2, with both thrombolysis and percutaneous coronary intervention (PCI) rates increasing more than twofold (9.2% to 19.2%; p < 0.001). There was a 50.8% decrease in overall in-hospital mortality between Cohort 1 and Cohort 2 (p < 0.001). Conclusions: This study indicated the potential beneficial effect of universal health coverage (UHC) in improving cardiovascular healthcare by providing more accessible treatment. It can provide evidence to urge the Indonesian government and other low- and middle-income nations dealing with cardiovascular health challenges to adopt and prioritize UHC

The readiness of public primary health care (PUSKESMAS) for cardiovascular services in Makasar city, Indonesia

Backgrounds: The increasing burden of cardiovascular disease (CVD) has become a major challenge globally, including in Indonesia. Understanding the readiness of primary health care facilities is necessary to confront the challenge of providing access to quality CVD health care services. Our study aimed to provide information regarding readiness to deliver CVD health services in public primary health care namely Puskesmas. Methods: The study questionnaire was adapted from the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA), modified based on the package of essentials for non-communicable disease (PEN) and the Indonesian Ministry of health regulation. Data were collected from all Puskesmas facilities (N = 47) located in Makassar city. We analysed relevant data following the WHO-SARA manual to assess the readiness of Puskesmas to deliver CVD services. Human resources, diagnostic capacity, supporting equipment, essential medication, infrastructure and guidelines, and ambulatory services domain were assessed based on the availability of each tracer item in a particular domain. The mean domain score was calculated based on the availability of tracer items within each domain. Furthermore, the means of all domains’ scores are expressed as an overall readiness index. Higher scores indicate greater readiness of Puskesmas to deliver CVD-related health care. Results: Puskesmas delivers health promotion, disease prevention, and prompt diagnosis for cardiovascular-related diseases, including hypertension, diabetes, coronary heart disease (CHD), and stroke. Meanwhile, basic treatments were observed in the majority of the Puskesmas. Long-term care for hypertension and diabetes patients and rehabilitation for CHD and stroke were only observed in a few Puskesmas. The readiness score of Puskesmas to deliver CVD health care ranged from 60 to 86 for. Furthermore, there were 11 Puskesmas (23.4%) with a score below 75, indicating a sub-optimal readiness for delivering CVD health services. A shortage of essential medicines and a low capacity for diagnostic testing were the most noticeable shortcomings leading to suboptimal readiness for high-quality CVD health services. Conclusion: Close cooperation with the government and other related stakeholders is required to tackle the identified shortcomings, especially the continuous monitoring of adequate supplies of medicines and diagnostic tools to achieve better CVD care for patients in Indonesia

Etiology, management, and outcomes of patients with coronary artery disease in a resource-poor Indonesian setting: Learning from the local evidence

This thesis aims to capture a general picture of the current state of atherosclerotic cardiovascular disease (CVD) in the low-to-middle income South-East Asian population, particularly in Indonesia. As relatively little investigation has been done in this area, this thesis is dedicated to explore and study the unmet needs of cardiovascular practices in eastern Indonesia by identifying the risk factors, patient characteristics, management strategies, and outcomes that may be of considerable importance to the organization of local healthcare systems in the future. There are several important findings highlighted in this thesis: - There exists a significant association between childhood infections and maternal pregnancy complications with the increased burden of atherosclerotic CVD in Indonesia. - In a resource-poor Indonesian setting, it is a life-saving priority to improve early awareness of CVD symptoms, to be followed by guidelines-based diagnosis and treatment. - To optimize patients’ outcomes in Indonesia, the cardiovascular care should focused on control of cardiovascular risk factors, patient education, inter-professional teamwork, and logistics. - The root causes of excess mortality in patients with coronary artery disease in Indonesia are the initial severity of disease, lack of access to the guideline-recommended treatments, and poor adherence to medications.- The adherence to coronary angiography recommendations is too low and must be improved despite the resources-limited Indonesian setting. - The availability of standard screening for cardiovascular risk factors will save lives and reduce disability in Indonesia, and must therefore be made available and affordable at primary care level immediately, particularly for the low-to-middle income populations

Exploring the link between cardiovascular risk factors and manifestations in latent tuberculosis infection: a comprehensive literature review

Abstract Background The global burden of tuberculosis (TB) and cardiovascular disease (CVD) is overt, and the prevalence of this double burden disease remains steadily rising, particularly in low- and middle-income countries. This review aims to explore the association between latent tuberculosis infection (LTBI) and the development of cardiovascular diseases and risk factors. Furthermore, we elucidated the underlying pathophysiological mechanisms that contribute to this relationship. Main body Approximately 25% of the global population carries a dormant form of tuberculosis (TB) infection. During this latent stage, certain subsets of mycobacteria actively reproduce, and recent research suggests that latent TB infection (LTBI) is connected to persistent, long-term low-grade inflammation that can potentially contribute to the development of atherosclerosis and cardiovascular disease (CVD). The presence of LTBI can be confirmed through a positive result on either a tuberculin skin test (TST) or an interferon-gamma release assay (IGRA). Several plausible explanations for the association between LTBI and CVD include increased inflammation, autoimmunity related to heat shock proteins (HSP), and the presence of pathogens within the developing atherosclerotic plaque. The most commonly observed cardiovascular events and risk factors associated with LTBI are acute myocardial infarction, coronary artery stenosis, diabetes mellitus, and hypertension. Conclusions This article highlights the critical role of LTBI in perpetuating the tuberculosis disease cycle and its association with cardiovascular risk factors. Chronic and persistent low inflammation underlined the association. Identifying high-risk LTBI patients and providing targeted preventive medication are crucial strategies for global TB eradication and interrupting transmission chains

Exploring the effects of His and left bundle branch pacing with stylet-driven lead on tricuspid regurgitation: A short-term follow-up study

The stylet-driven delivery system was replaced with a pre-shaped catheter delivery system for conduction system pacing several years ago, as it offered easier access to the pacing location. However, in several countries, including Indonesia, the availability of catheter systems remains limited. This study aimed to evaluate the occurrence and severity of tricuspid regurgitation when using the stylet-driven lead delivery system in patients undergoing His and Left Bundle Branch (LBB) pacing

Managing Challenges in a Symptomatic Patient with Moderate Pulmonary Stenosis: A Case Report

Introduction: Pulmonary stenosis is a common form of obstruction in the right ventricular outflow tract, characterized by the narrowing of the pulmonary valve, which results in obstructed blood flow. Case Presentation: A 17-year-old female presented with recurring shortness of breath, chest pain, and palpitations, especially during physical activity. On examination, a grade III/VI continuous murmur was heard at the upper left sternal border. Echocardiography confirmed moderate pulmonary valve stenosis, a left-to-right patent ductus arteriosus (PDA), and mild to moderate pulmonary regurgitation

Cigarette Smoke Exposure and Stunting Among Under-five Children in Rural and Poor Families in Indonesia

Cigarette smoke exposure in mothers and children is highly prevalent in Asia, especially among rural and poor families. Second-hand smoke exposure might affect the nutritional status of children. Despite the emerging double burden of malnutrition and the very high prevalence of smoking in Indonesia, few studies have examined the effects of parental smoking on children’s nutritional status. This study aims to measure the relationship between family smoking behavior and the occurrence of stunting in children under 5 years. This cross-sectional study used a purposive sampling technique, with 221 households with children aged 0 to 59 months from poor areas in Indonesia. Exposure to cigarette smoke is assessed using The Secondhand Smoke Exposure Scale questionnaire. The outcome measured is child stunting (height-for-age Z-score). The prevalence of stunting was estimated at 145 (65.6%). Children living with smoking parents were counted for 157 (71%), and most smoking exposure comes from fathers 147 (67.4%). The predictors of stunting in children under 5 years were a smoker father with (AOR 1.8; 95% CI 1.281-4.641), both parents are smokers increasing the risk of stunting with (COR 3.591; 95% CI 1.67-3.77), being exposed of smoke for more than 3 hours a day increase the risk of stunted children (COR 2.05; 95% CI 1.214-3.629), and using traditional cigarette or kretek expand the risk of stunting (AOR 3.19; 95% CI 1.139-67.785). The findings demonstrate the negative impact of parental smoking on children’s growth, reinforcing the importance of reducing smoking prevalence by imposing a smoke-free home policy in the stunting prevention strategy.</p

Tele-ECG consulting and outcomes on primary care patients in a low-to-middle income population: the first experience from Makassar telemedicine program, Indonesia

Background: Telemedicine has been a popular tool to overcome the lack of access to healthcare facilities, primarily in underprivileged populations. We aimed to describe and assess the implementation of a tele-electrocardiography (ECG) program in primary care settings in Indonesia, and subsequently examine the short- and mid-term outcomes of patients who have received tele-ECG consultations. Methods: ECG recordings from thirty primary care centers were transmitted to Makassar Cardiac Center, Indonesia from January to July 2017. We cross-sectionally measured the performance of this tele-ECG program, and prospectively sent a detailed questionnaire to general practitioners (GPs) at the primary care centers. We performed follow-up at 30 days and at the end of the study period to assess the patient outcomes. Results: Of 505 recordings, all (100%) ECGs were qualified for analysis, and about half showed normal findings. The mean age of participants was 53.3 ± 13.6 years, and 40.2% were male. Most (373, 73.9%) of these primary care patients exhibited manifested CVD symptom with at least one risk factor. Male patients had more ischemic ECGs compared to women (p 55 years) was associated with ischemic or arrhythmic ECGs (p < 0.05). Factors significantly associated with a normal ECG were younger age, female gender, lower blood pressure and heart rate, and no history of previous cardiovascular disease (CVD) or medication. More patients with an abnormal ECG had a history of hypertension, known diabetes, and were current smokers (p < 0.05). Of all tele-consultations, GPs reported 95% of satisfaction rate, and 296 (58.6%) used tele-ECG for an expert opinion. Over the total follow-up (14 ± 6.6 months), seven (1.4%) patients died and 96 (19.0%) were hospitalized for CVD. Of 88 patients for whom hospital admission was advised, 72 (81.8%) were immediately referred within 48 h following the tele-ECG consultation. Conclusions: Tele-ECG can be implemented in Indonesian primary care settings with limited resources and may assist GPs in immediate triage, resulting in a higher rate of early hospitalization for indicated patients