Burden of cardiovascular disease in India has quadrupled in last four decades, and it is estimated that in 2020, almost 60% of these patients are living in India.[1] One of manifestations of cardiovascular disease is ST-elevation myocardial infarction (STEMI), which carries a poor prognosis if not treated immediately using reperfusion therapy to re-establish the flow in the occluded coronary artery [2]. STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent ECG ST elevation and subsequent release of biomarkers of myocardial necrosis [3]. 

Reperfusion therapy with thrombolysis remains the only option in most of the rural setting of India due to non-availability of required infrastructure including cardiac specialist. CREATE registry data from 89 cities suggest that Indian patients with STEMI fail to receive an adequate reperfusion therapy as compare to patients in the developed countries. In INDIA, reperfusion therapy with fibrinolysis is received by less than 60% of patients with STEMI and those who were thrombolysis, they   undergo it after great delays; median time from onset of symptoms to hospital presentation was 6 hours and time taken from hospital to thrombolysis was 50 minutes. Less than 10% of patients receive PCI during their hospitalisation despite growing support for this type of pharmaco-invasive approach. [4] As per HP ACS registry, 83% of ACS population in Himachal was from rural area, thrombolytic therapy is given in only 35.6 % of patients and 0.6 % underwent percutaneous coronary intervention [5].

Those who were thrombolysed, they undergo it after great delays at different level subject to financial barriers, transportation problem, limited healthcare infrastructure and poor accessibility to medical services. These challenges are mostly non-clinical and require extensive research in its own. Delay in clinical care of the patients at facility level i.e. after reaching emergency till initiation of reperfusion theory has been explored at Dr RPGMC&H (a tertiary care institute in rural area of Himachal Pradesh, India) to establish a fast-track system for patients of acute coronary syndrome patients.        

Facility Level Delays Observed

A total of 63 patients with acute coronary syndrome, who were later diagnosed as STEMI and were thrombolysed, had been observed. Mean duration between onsets of symptom to initiation of reperfusion therapy was 387 mins i.e. approximately around six hours.

Table 1: Average Time Observed During Management of Patients with Stemi

Following Points Have Been Observed Regarding Normal Acs Patient Management Process

• Registration: Though registration process hardly takes few minutes still it is difficult to record actual time consumed in it. Unfamiliarity to hospital (as patients are being referred from far areas) and long queue (especially at OPDs at day time) has been observed to delay the process of registration at Hospital. 

• Universal Health Protection Card (Rsby/Pm-Jay) Activation: Attendant or patients has to produce prescribed card in order to claim financial packages of health service under RSBY (Now Ayushman Bharat PM-JAY) scheme. Those who can’t afford costly health service on their own are totally relied on this scheme. In panic situation like this many time attendant forget to either carry their protection card with them or register it during registration. Sometime card don’t work due to server issues or non-payment of premiere. 

• Transportation Within Hospital: Mean duration taken for ECG and CCU admission after registration was 19.5 mins and 65.5 mins respectively. (Table 1) Transportation of patient from causality/OPD to ECG room and then to CCU has been observed very time consuming.Non-availability of trolleys in causalityespecially in heavy patient inflow situation has been observed. Waiting lines for getting ECG done at OPD /causality (technician shortage) and non-availability of specialist doctor to read ECG findings furtherdelay the admission and therefore reperfusion therapy.

• Procuring/Purchasing of Thrombolytic: Reperfusion therapy was initiated after 118 mins (approximately 2 hours) of registration in the hospital. (Table 1)Expensive thrombolytic agent are required forthrombolysis after careful assessment of the patient. They are to be procured by patient’s attendant either from their own pocket or redeemed through universal health coverage scheme. Whole process require paper work (writing and verifying prescription by nursing staff), due verificationfrom designated officer, procurement from accredited medical store and this entire cost patient around 45-60 mins of golden hours. 

• Fast Track Protocol Intervention: A three-step process was proposed to reduce facility level delay in door-to-needle time (registration to reperfusion therapy based upon the observations noticed. Hoarding and signages were established for fast tracking of the patients having acute coronary syndrome. 

• Step 1: Early decision: Since our hospital did not have PCI facilities, all patients of ACS diagnosed as STEMI were to be thrombolyzed. Preference was given to chest pain patients for ECG if there was a queue.The ECG was read within minutes and if findings were suggestive of STEMI it was discussed with the Senior Resident and thrombolysis decision was finalized in preference over other emergencies. Patients were given loading doses of aspirin and clopidogrel as soon as diagnosis was made.

• Step 2: Fast transfer to the CCU: Due to lack of thrombolysis setup in emergency department, patients need to be shifted to CCU for thrombolysis. We ensured ready availability of stretchers and wheel chairs for STEMI patients and an intern to accompany the patient to the CCU.

• Step 3: Advance communication to CCU to prepare for thrombolysis. The drug was kept ready for injection upon arrival of the patient. This step included ready stock of thrombolytics in CCU. This was done to reduce the time wasted in procurement of thrombolytic agents from the pharmacy shops.

Reperfusion with thrombolytic agents remains a key strategy to decrease mortality and major cardiovascular events in STEMI care in developing countries especially in rural or remote areas. However, the benefit is time-dependent and early reperfusion should be the priority.  The shorter the time from symptom onset to reperfusion, the greater the patient will benefit. Reperfusion therapy in the form of thrombolysis is recommended to all eligible patients with STEMI with symptom onset within the prior 12 hours in the absence of more preferred percutaneous coronary intervention (PCI). It is considered a reasonable option for patients with STEMI and symptom onset within the prior 12 to 24 hours who have clinical and/or ECG evidence of ongoing ischemia [2].

Treatment delays in patients depicting acute coronary syndrome have been attributed to various social and economic factors which determine the accessibility to timely clinical care. Various components of treatment delay can be categorized as pre-hospital delays (patient's decision to delay, referral delay, transportation delay etc.) and hospital delays (i.e. door-to-needle time). Limiting pre-hospital delays may require complex planning and strategies, but hospital delays are not that difficult to limit.  The current recommendation for door-to-needle time is less than 30 minutes for reperfusion therapy with thrombolytic agents and has been proven effective and realistic [6]. Door to needle time of 118 minutes (four time of the recommended period), observed in our tertiary care centre cannot be justified by any means may it be the heavy patient’s inflow or poor infrastructure [6]. Implementation of fast-track protocol by making slight feasible change in existing process is targeted to bring down current door to needle time from 118 mins to less than 60 mins. Once the target is achieved further refinement in the system can be done to achieve desired 30 mins target. 

However, efforts are required to be intensified to address pre-hospital delays i.e. recognition of symptoms, early diagnosis & referral from peripheral institutes and better transportation facilities to counter the potential delay in reaching health facility. Percutaneous coronary intervention facility need to be established wherever possible and should remain the first-choice treatment for reperfusion. 

1. Kohn, D. “Getting to the heart of the matter in India.” Lancet, vol. 372, no. –, 2008, pp. 523–524.

2. O’Gara, P.T. et al. “2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.” J Am Coll Cardiol, vol. 61, no. –, 2013, pp. e78–140.

3. Thygesen, K. et al. “Third universal definition of myocardial infarction.” Circulation, vol. 126, no. –, 2012, pp. 2020–2035.

4. Xavier, D. et al. “Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data.” Lancet, vol. 371, no. –, 2008, pp. 1435–1442.

5. Negi, P.C. et al. “Multicenter HP ACS registry.” [Journal name missing], vol. –, no. –, year missing, pp. –.

6. Zhang, Y. and Huo, Y. “Early reperfusion strategy for acute myocardial infarction: a need for clinical implementation.” J Zhejiang Univ Sci B, vol. 12, no. 8, 2011, pp. 629–632.

7. Beig, J.R. et al. “Components and determinants of therapeutic delay in patients with acute ST-elevation myocardial infarction: a tertiary care hospital-based study.” J Saudi Heart Assoc, vol. 29, no. 1, 2017, pp. 7–14.