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Reducing mortality in myocardial infarction

Editor—The epidemic of cardiovascular disease has peaked in Cuba and accounts for 40% of deaths.1 The age adjusted mortality in 2003 was 41% lower than the comparable rate recorded in 1970. The reduction in mortality from coronary heart disease, which accounts for nearly 74% of all cardiovascular deaths, drove the overall decline in cardiovascular mortality.1 Data from Cuba are highly accurate since registration has been consistently high over this 30 year period and deaths attributed to ill defined causes have remained very low (0.7%). Nearly all deaths are certified by a doctor. 
 
In Cienfuegos province, Cuba's showcase for prevention and control of cardiovascular disease, the number of admissions for acute myocardial infarction doubled in 1990-2003. Over the same period, case fatality rates declined by 40-50%, which implies that less severe cases are being admitted, although the quality of care is also improving. This latter possibility is supported by the fact that over this period, thrombolysis—the standard treatment in Cuba—became widely available, and this was recently reinforced with the creation of prehospital treatment units in each municipality. In addition, Cienfuegos Hospital achieved a total thrombolysis rate over 60% and a “door to needle” time of around 30 minutes for more than 90% of all patients with acute myocardial infarction and ST elevation.2,3 
 
We recognise the importance of a “three Ps” approach4 and consider that in poor countries the optimisation of thrombolysis (including the promotion of the “golden hour”) can still reduce mortality from acute myocardial infarction before angioplasty is introduced. Given Cubans' high level of education, the country's universal access to health care, and its large public health infrastructure, an exceptional opportunity exists here to answer some of the questions associated with thrombolytic treatment, particularly in the context of a public, accessible, and free health system for all.