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

Objectives

The national programme seeks to reduce morbidity and mortality from ischaemic heart disease in Cuba through an integrated continuum of prevention, early diagnosis, timely treatment, rehabilitation and social and occupational reintegration. It is intended to operate permanently across the national territory and all levels of care, from family medical practices to specialist intensive-care and rehabilitation services, with five-yearly updates.[1][2][3][4]

• Reduce the incidence and prevalence of clinical forms of ischaemic heart disease, lower acute-event case fatality, reduce physical and mental disability, improve quality of life, and lessen socioeconomic consequences through reintegration.[5][4]
• Prevent disease by identifying and managing cardiovascular risk, promoting healthy diets and physical activity, reducing tobacco exposure and harmful alcohol use, and controlling hypertension, diabetes, dyslipidaemia, obesity and psychosocial stress.[6][2][7][8]
• Prioritise high-risk people through cardiovascular-risk stratification, active detection, regular follow-up and risk-based intensity of lifestyle counselling and pharmacological treatment.[9][10][11]
• Reduce out-of-hospital and in-hospital mortality from acute cardiovascular events by improving recognition of symptoms, access to emergency care, rapid electrocardiography, reperfusion and management of complications.[12][13][14]
• Strengthen secondary prevention after acute coronary events through medicines, rehabilitation, specialist and primary-care follow-up, discharge planning and sustained modification of risk factors.[15][11][16][17]
• Provide phased cardiovascular rehabilitation to improve functional capacity, reduce disability, support healthier lifestyles and enable timely return to family, social and occupational roles.[4][18][19]
• Generate and use evidence on epidemiology, risk factors, diagnostic and therapeutic methods, rehabilitation, quality of life and socioeconomic impact to inform corrective measures and population interventions.[20]

Implementation

Implementation is organised as a whole-system model led by the Ministry of Public Health, combining primary healthcare-led prevention, an Integrated Medical Emergency System continuum, hospital and specialist care, rehabilitation, surveillance, professional development and multisectoral action. National, provincial and municipal structures are expected to adapt, deliver, control and periodically evaluate activities, supported by specialist commissions, emergency councils and reference centres.[15][21][3][22][23]

• Deliver prevention through family doctors, nurses, polyclinics and community settings, using risk registers, screening, patient education, lifestyle support and referral to cardiology where cardiovascular risk remains uncontrolled.[24][25][26]
• Coordinate health promotion with education, agriculture, commerce, food-service, sport, culture, mass media and other institutions to support healthier diets, physical activity, tobacco control and broader community participation.[3][8]
• Improve emergency response through public education on chest-pain symptoms, telephone and radio access, mobile emergency units, trained teams, life-support equipment, early electrocardiography and rapid referral to emergency intensive-care and coronary-care services.[9][12][27][15]
• Provide reperfusion through primary percutaneous coronary intervention where it can be delivered promptly by an experienced team, while using systemic fibrinolysis, including Cuban streptokinase, where angioplasty is unavailable or cannot be performed within the required timeframe.[1][14][28][29]
• Equip emergency and hospital services with electrocardiography, monitoring, diagnostic capacity, medicines, resuscitation equipment, coronary-care beds and trained personnel, and organise transfers between emergency, intensive, intermediate, cardiology and rehabilitation services.[13][15]
• Ensure continuity after discharge through written recommendations, communication of the cardiovascular event and care plan to primary care, cardiology and rehabilitation follow-up, and long-term family-doctor monitoring.[15][11][30]
• Organise rehabilitation in hospital, an approximately eight-week convalescence phase and an indefinite maintenance phase, using supervised exercise, medical assessment, occupational support and community facilities; the programme seeks at least one cardiovascular rehabilitation unit in each municipality.[18][31]
• Assign the Ministry of Public Health responsibility for planning, standards, regulation and control, with national vice-ministerial areas and the National Commission for Cardiovascular Disease coordinating technical, economic, statistical, educational, pharmaceutical and specialist inputs.[21]
• Use provincial and municipal health directorates, programme coordinators, emergency councils, hospitals, polyclinics, family health teams and the Emergency Medical System to organise local delivery, review errors and determine training or organisational corrective action.[27][3][22]
• Designate the Institute of Cardiology and Cardiovascular Surgery as the national reference centre, supported by provincial reference centres in Santiago de Cuba, Villa Clara and Havana.[23][32]
• Strengthen workforce capacity through annual education, clinical update courses, national and territorial seminars, social communication activities, and emergency and pre-hospital life-support training.[33][23]
• Monitor incidence, prevalence, morbidity, mortality, hospital and out-of-hospital case fatality, risk factors, hospital discharges and rehabilitation outcomes through continuous statistics, surveys, patient registers, emergency notification cards, sentinel centres and clinical-epidemiological studies.[19][34][33]
• Review acute myocardial infarction deaths and service-level mortality and case fatality, investigate care-system errors, and route findings through hospital, municipal, area and provincial emergency councils for corrective action.[13][25]
• Evaluate programme performance periodically through activity-completion rates, service coverage, workforce training, population knowledge, professional competence, quality of care and epidemiological indicators.[23][32][35]

Monitoring & Evaluation

The programme establishes a multi-level monitoring and evaluation approach for ischaemic heart disease, linking epidemiological surveillance, service-quality review, clinical follow-up, workforce assessment and corrective action through national, provincial, municipal and facility structures. Core outcome domains are incidence, prevalence, morbidity, mortality, case fatality, disability, quality of life and cardiovascular risk factors.[5][13][34][23]

• Monitor acute myocardial infarction incidence and prevalence annually by age and sex, global cardiovascular risk annually, and major risk factors through national surveys or investigations, generally at five-year intervals.[34]
• Track acute myocardial infarction mortality outside hospital, in emergency services and in hospital quarterly, together with quarterly hospital case fatality; maintain continuous hospital-discharge records containing patient identity, age, sex and status.[34]
• Use mortality, morbidity, incidence, prevalence, case fatality, disability and quality-of-life measures as outcome domains, supported by Cuban statistical yearbooks, national epidemiological studies, the Ministry of Public Health National Directorate of Statistics and national risk-factor surveys.[5][9][6]
• Assess programme efficiency through the annual proportion of planned activities completed, and assess coverage across polyclinics, hospitals, maternal homes, homes for older people and other health institutions.[32]
• Measure impact using age- and sex-specific incidence, mortality by site of death, standardised mortality ratios, potential years of life lost, years lived with disability and the autopsy index, although some reporting frequencies in the extracted indicator table are unclear.[32][35]

Clinical and service-delivery monitoring is specified across the care pathway. Emergency care includes timely electrocardiography, clinical observation, laboratory testing and surveillance for adverse reactions during fibrinolysis.[36][14][28]Primary care uses cardiovascular-risk registers, active investigation of asymptomatic disease, annual electrocardiograms and eye examinations for people at risk, lipid testing where indicated, and at least three assessments each year for people followed by family medicine.[24]Rehabilitation includes submaximal exercise testing before discharge or within eight weeks, further testing during convalescence, testing at 12 months after infarction or an acute episode and annually thereafter, plus specialist follow-up every three months in the first year and every six months subsequently.[18][31][19]

Accountability mechanisms centre on structured review and escalation. Municipal programme leads and the Emergency Medical System are to present monthly service-system errors to municipal emergency councils, which determine training or organisational responses.[27]Hospital-based assessment of patients with myocardial infarction and angina, mortality-review committees and investigations of care-system errors are intended to identify responsible services or specialties and refer corrective findings to hospital, municipal, area-health and provincial emergency councils.[13]Provincial and municipal health directors are responsible for adapting, implementing, monitoring and periodically evaluating activities, while management-council and emergency-council meetings control implementation.[3][22]

National oversight is assigned to the Ministry of Public Health, which plans, standardises, regulates and controls the programme, supported by national vice-ministerial areas and the National Commission for Cardiovascular Disease.[21]The National Technical Advisory Commission is tasked with analysing territorial disease patterns, following corrective actions, maintaining programme information, reviewing resource requirements, strengthening surveillance and periodically reviewing the statistical information system.[21]Statistics departments collect and process discharge records, non-communicable disease working groups periodically analyse them, and information units disseminate findings and recommendations to decision-makers and prevention and control participants.[33]

Evaluation also encompasses population knowledge, health-worker competence and performance, and quality of care for patients and people who have died, using assessment tools, surveys and dedicated software.[23]The programme envisages a national epidemiological surveillance system, a national register, indicators and performance assessment at all levels.[23]Nonetheless, several clinical sections do not define programme-wide targets, standardised reporting templates, independent evaluation arrangements or a public accountability mechanism beyond the internal review structures described.[25][16][32]

Costing & Financing

Costing and financing information is limited. The programme identifies substantial service and resource needs but does not provide an overall budget, expenditure allocation, financing source, quantified funding gap, resource-mobilisation plan or economic assumptions.[12][13][23]

• Provide emergency vehicles, communications systems, basic and advanced life-support equipment, diagnostic equipment, medicines, trained staff and rehabilitation capacity to support emergency and continuing care.[12][27]
• Maintain hospital capacity including electrocardiography, monitoring, resuscitation equipment, coronary-care beds, medicines, diagnostic services and appropriately staffed intensive-care services.[13][21]
• Assess available resources and address identified needs as far as possible during phased national implementation.[23]
• Prioritise rational technology use and treatments with satisfactory cost-effectiveness, recognising that prevention through risk-factor reduction may reduce spending on diagnosis and complex invasive therapies.[1]
• Recognise angioplasty as the highest reported institutional treatment cost for acute myocardial infarction patients admitted to the Institute of Cardiology, although no monetary unit cost is supplied.[1]
• Prioritise individual counselling and care by cardiovascular risk where resources are constrained, while recognising that population measures promoting smoking cessation, physical activity and healthy diets may yield benefits at lower cost than individual management for people at low risk.[10][11]

Cardiovascular rehabilitation requires municipal units and community settings but is described as not requiring sophisticated equipment or substantial material resources during the maintenance phase; no monetary valuation is provided.[18][31]