Programa Nacional De Prevención, Diagnóstico, Evaluación, Tratamiento Y Rehabilitación De La Cardiopatía Isquémica

Objectives

The Cuban national programme for ischaemic heart disease seeks to reduce disease incidence, morbidity, mortality, out-of-hospital and in-hospital case fatality, disability and socioeconomic consequences through an integrated continuum of prevention, diagnosis, emergency care, treatment, rehabilitation, secondary prevention, follow-up and research.[1][2][3][4]It is a permanent national programme, updated every five years, spanning family medical practices, polyclinics, hospitals, intensive-care services and rehabilitation centres.[2]

• Reduce the incidence and prevalence of all clinical forms of ischaemic heart disease, including acute myocardial infarction, while improving quality of life and social and occupational reintegration.[1][2]
• Prevent cardiovascular risk by addressing dyslipidaemia, hypertension, diabetes, smoking, unhealthy diet, harmful alcohol use, inactivity, stress and obesity.[5][2]
• Stratify individuals by global cardiovascular risk and intervene promptly among people at highest risk, including through active identification and follow-up in primary care.[2][6]
• Promote healthy diets, healthy weight, regular physical activity and tobacco control through population-wide and individual interventions.[2][7][8]
• Reduce acute-event mortality by shortening the interval from symptom onset to qualified medical attention, fibrinolysis or percutaneous coronary intervention, as clinically appropriate.[9][10][11]
• Ensure early recognition and treatment of chest pain, acute coronary syndromes and myocardial infarction, with access to electrocardiography, emergency transport, coronary care, reperfusion and specialised follow-up.[3][12][13]
• Strengthen secondary prevention through pharmacological treatment, lifestyle modification, cardiac rehabilitation and long-term monitoring after acute events.[12][14][15]
• Extend cardiovascular rehabilitation to improve functional capacity, reduce physical and mental disability, support return to work and social activities, and reduce cardiovascular morbidity and mortality.[16][17]
• Support epidemiological, diagnostic, therapeutic and rehabilitation research, using findings to guide corrective action where progress is insufficient.[4][18]

Implementation

Implementation is organised across all levels of Cuba’s National Health System, with primary health care leading promotion, prevention, lifestyle change, risk detection and community follow-up, and the Integrated Medical Emergency System linking first aid, primary-care emergencies, mobile services, hospitals and intensive-care units.[12]National coordination involves the Ministry of Public Health, relevant vice-ministries, the National Commission for coronary disease, technical and specialist bodies, while provincial, municipal and polyclinic leaders adapt, implement, control and periodically evaluate delivery.[19][20][21]

• Deliver health education through family doctor and nurse practices, hospitals, mass media, conferences, posters, schools and community activities, using individual, informative, persuasive and participatory approaches.[2][22][7]
• Coordinate multisectoral action with education, agriculture, commerce, food industry, sport, culture, mass organisations and other public bodies to enable healthier diets, physical activity and tobacco control.[20][8]
• Train the public to recognise acute chest pain, seek emergency help rapidly and provide basic resuscitation, while expanding cardiopulmonary-resuscitation teaching in schools and among adults.[23][24]
• Train doctors, nurses and other health professionals through undergraduate, postgraduate, refresher and advanced life-support courses, supported by national, provincial and municipal workshops.[24][20][4]
• Provide emergency assessment with rapid electrocardiography, monitoring, defibrillation capacity, essential medicines, diagnostic equipment and timely transfer to emergency intensive-care or coronary-care units.[24][3][13]
• Use fibrinolysis in emergency polyclinics and mobile emergency services, with Cuban streptokinase identified as the principal local fibrinolytic treatment where primary angioplasty is unavailable or cannot be delivered promptly.[9][13][25]
• Organise hospital pathways from emergency departments to coronary or intensive care, cardiology beds, rehabilitation and post-discharge follow-up, with transfer of clinical information to family doctors.[21][12]
• Provide risk assessment before discharge, establish secondary-prevention treatment, refer patients according to need, and support rehabilitation and occupational medical assessment.[12]
• Establish at least one cardiovascular rehabilitation unit per municipality, delivering hospital, convalescent and indefinite maintenance phases through health facilities and community settings.[26][27]
• Use the Institute of Cardiology and Cardiovascular Surgery as the national reference centre, supported by provincial reference centres including Cardio Centro Santiago de Cuba, Cardiocentro Villa Clara, Calixto García Hospital and Hermanos Ameijeiras Hospital.[28][29]
• Implement the programme in stages by distributing and revising guidance, revitalising commissions, assessing resources, training staff, establishing surveillance and research, reorganising hospital services, developing reference centres and consolidating interdisciplinary teams and the national register.[28]
• Review implementation through municipal, provincial and national emergency and management councils, including monthly analysis of local system errors and review of myocardial-infarction deaths at primary-care level.[24][20][21]
• Monitor myocardial infarction through continuous case recording, a national register and epidemiological surveillance, tracking morbidity, mortality, case fatality and major risk factors.[30][4][28]
• Measure programme efficiency annually by completion of planned activities, alongside coverage, training, incidence, mortality-related measures, years of potential life lost, disability and autopsy indicators.[29][31]

Monitoring & Evaluation

The programme combines epidemiological surveillance, clinical monitoring, quality improvement and multi-level management control to track ischaemic heart disease outcomes, service performance and implementation. Core outcomes include incidence, prevalence, mortality, case fatality, disability and cardiovascular risk factors, while national, provincial, municipal and facility-level bodies share evaluation responsibilities.[1][30][29]

• Monitor ischaemic heart disease and acute myocardial infarction morbidity, mortality, incidence, prevalence, disability, out-of-hospital mortality, hospital mortality and case fatality.[1][10][30]
• Record myocardial infarction incidence and prevalence annually by age and sex, and monitor mortality in the community, emergency services and hospitals, together with hospital case fatality, on a quarterly basis.[30]
• Use continuous statistics, clinical-epidemiological studies, sentinel centres, national risk-factor surveys and patient-registration data to assess disease patterns and global cardiovascular risk.[30]
• Track hypertension, diabetes, smoking, hypercholesterolaemia, hypertriglyceridaemia, overweight and obesity through national surveys and investigations, generally every five years.[30]
• Maintain a continuous myocardial-infarction record and notifiable-disease card across primary and secondary care, recording hospital discharges by name, age, sex and patient status through statistics departments.[30][4]
• Incorporate ischaemic heart disease incidence and prevalence into health-situation analyses at family-practice, polyclinic and municipal levels, supported by complete, accurate and timely clinical records.[32]
• Review acute myocardial infarction deaths in primary care, particularly deaths before hospital arrival and among people younger than 60, and analyse mortality and case fatality by service each month.[32]
• Assess acute-care timeliness against targets for fibrinolysis within 60 minutes of symptom onset and within 30 minutes of emergency-service contact.[11]
• Evaluate thrombolysis response through ST-segment resolution at 90 minutes, treating less than 50% resolution as failed thrombolysis and considering rescue angioplasty within 12 hours.[11]
• Maintain electrocardiographic monitoring and defibrillator access in emergency care, repeat electrocardiography every eight hours after admission, and measure troponin, creatine kinase-MB and total creatine kinase every 12 hours for at least 24 hours.[13]
• Monitor adverse reactions throughout fibrinolysis and manage them immediately.[25]
• Assess risk factors in primary care through regular examination and registration, at least three annual assessments for people at cardiovascular risk, annual electrocardiography and fundoscopy, and lipid testing where dyslipidaemia or tobacco use is recognised.[6]
• Review cardiovascular risk profiles every 6 to 12 months for people with 10% to below 20% ten-year risk, and every 3 to 6 months for people at 20% or greater risk.[14][33]
• Use clinical targets for diabetes management, including glycated haemoglobin below 7.0%, blood pressure below 140/80 mmHg and low-density lipoprotein cholesterol below 2.5 mmol/l, with lower targets for very-high-risk patients.[34]
• Evaluate rehabilitation through exercise testing before discharge or within eight weeks, subsequent testing for occupational reintegration and training adjustment, and annual stress testing after infarction or an acute episode.[26][27][17]
• Review hospital myocardial infarction and angina care alongside death-review committees, identify system failures and refer corrective actions to hospital and provincial emergency councils.[3]
• Require municipal programme leads and emergency services to present monthly, area-specific system errors to Municipal Emergency Councils, which determine organisational or training responses.[24]
• Control implementation through provincial management and emergency councils, municipal emergency councils, polyclinic management councils and the provincial ischaemic heart disease commission.[20][21][6]
• Coordinate emergency-system performance assessment through the Integrated Medical Emergency System, linking community first aid, primary-care emergency services, mobile emergency care, hospital emergency services and intensive-care units.[12][19]
• Measure annual programme efficiency as the percentage of planned activities completed, and assess programme coverage across health institutions through updated-programme coverage indicators.[29]
• Assess training by the number of municipal and provincial health areas and institutions completing training within two years.[29]
• Use additional impact indicators including standardised mortality ratio, years of potential life lost, years lived with disability and autopsy index; some indicator labels are unavailable because they appeared in missing images.[31]
• Establish a national epidemiological surveillance system and national register, assess population knowledge before and after implementation, evaluate workforce competence and performance, and investigate the quality of care and intervention impact at every level.[18][28]

Costing & Financing

No programme budget, costed allocation, financing source, funding gap, resource-mobilisation plan or quantified economic assumption is specified. The programme nonetheless identifies substantial service, equipment, medicine, workforce and infrastructure requirements, and recognises that prevention and resource-efficient care can reduce avoidable expenditure.[20][28]

• Provide human and material resources through provincial health authorities, assess coverage of proposed medicines and reagents, and ensure therapeutic resources throughout the National Health System.[20][21]
• Maintain diagnostic equipment, medicines, defibrillators, resuscitation trolleys, emergency communications, mobile emergency units and coronary-care capacity, without assigning monetary values or funding sources.[23][24]
• Maintain information on diagnosis, treatment and rehabilitation resource needs for consideration at Ministry of Public Health strategy meetings.[19]
• Recognise angioplasty as the highest total-cost treatment-related item among patients with acute myocardial infarction admitted to the Institute of Cardiology, although no monetary amount is provided.[9]
• Anticipate increased demand for management of heart failure and other complications, percutaneous coronary intervention and associated devices as survival improves.[9]
• Reduce expenditure on diagnosis and complex invasive treatment by lowering disease incidence through cardiovascular risk-factor modification.[9]
• Prioritise systemic fibrinolysis where primary coronary angioplasty is unavailable across the country, reflecting uneven access to angioplasty services rather than a quantified financing decision.[13][25]
• Recognise that myocardial perfusion scintigraphy has limited availability and may cost more than alternative diagnostic techniques.[35]
• Use population measures for tobacco cessation, physical activity and healthy eating where appropriate, as these may be less costly than individual counselling and treatment for people at low cardiovascular risk; no numerical estimate is supplied.[33]
• Support maintenance rehabilitation through community facilities, as this phase does not require sophisticated equipment or substantial material resources when minimum exercise conditions are available.[27]
• Assess available resources and complete identified needs as far as possible during staged implementation, but without a monetary estimate or explicit funding-gap analysis.[28]