Reducing system delays in treatment of ST elevation myocardial infarction and confronting the challenges of late presentation in low and middle-income countries

Management algorithms for acute ST elevation myocardial infarction in less industrialized world

“…In context of STEMI in less industrialized counties a major factor in delay in revascularization issue is time from onset of ischemia to presentation to a health-care facility (capable of revascularizing – PCI or thrombolysis). A delay by the patient and FMC physicians often contributes to patient presenting out of the window period (12 h after the chest pain) 2, 3, 4. To address this issue we have developed an algorithm to manage patients presenting out of window period (12 h) (Fig.…”

Editorial: Deconstructing STEMI Chaos

“…Following this management approach, Mehta et al presented 10 top strategies to reduce system delays: Treat STEMI Interventions as a public health initiative. Improve ambulance care, qualitatively and quantitatively. Increase 24/7 STEMI facilities. Create regional STEMI networks and systems of care for each community with a reperfusion protocol for every hospital. Develop pre‐hospital alert whenever possible and ECG transmission Establish unambiguous payment policies and systems that are clearly understood by payers, hospital and patient. Use single call activation to engage the catheterization laboratory, with team work and quality improvement (QI) feedback. Bypass the ED, when possible, relying on pre‐hospital alert and single call activation Consider telemedicine to increase access, accuracy and remote guidance. Educate the patient—this is the hardest assignment and it requires a multi‐pronged approach, including empowering the general physician. …”

What is the ideal fibrinolysis to PCI time: Pharmaco-invasive strategy with streptokinase?

“…Another intriguing aspect in this study is the mean lysis-to-angiogram time of 18.2 h. While every effort must be made to decrease the ischemia to reperfusion, first medical contact −to-ECG time, the time when angiography/angioplasty should be done after fibrinolysis remains controversial. 15 , 16 Although fibrinolytic therapy by definition dissolves clots and thrombus, paradoxically, it can be pro-thrombotic as well. The mechanism behind this effect is generally two-fold: lysis of clots releases thrombin which has a pro-thrombotic effect, and the thrombolytic agents themselves may directly activate platelets.…”

“…In a country with a population upwards of 1.3 billion and burden of ST elevation myocardial infarction (STEMI) estimated to be 30,00,000, this seems woefully inadequate (national primary PCI rate < 1%). 3 , 4 Here, pharmaco-invasive therapy with fibrin specific thrombolytics is a reasonable alternative. 5 , 6 However, in several countries it is not fibrin specific fibrinolytic that is widely available; rather it is still streptokinase (STK) which is not only continues to be widely available but also cheap, so much so that it continues to feature in the literature from less industrialized nations.…”

“… 5 , 6 However, in several countries it is not fibrin specific fibrinolytic that is widely available; rather it is still streptokinase (STK) which is not only continues to be widely available but also cheap, so much so that it continues to feature in the literature from less industrialized nations. 4 , 7 However, a strategy using STK followed by primary PCI has not been well studied.…”