Role of pharmaco-invasive therapy in improving outcomes for patients with ST-Elevation myocardial Infarction (STEMI) in Indian context

Background: The ischemic myocardium should be promptly reperfused to reduce morbidity and mortality in patients with ST-segment elevation myocardial infarction (STEMI). Conventionally, 2 approaches are the mainstay of reperfusion treatment: primary percutaneous coronary intervention (PCI) and fibrinolytic therapy which are considered as mutually exclusive therapeutic modalities. Primary PCI is considered as the gold standard for STEMI but in a developing country like India, it is not practically achievable in all the cases because of various challenges. Therefore, thrombolysis followed by either PCI or non-urgent coronary angiography seems to be a more practical approach in not only semi-urban and rural areas but also in metro and tier-1 cities in India. Aim: To arrive at a consensus on the importance of pharmaco-invasive (PI) strategy for patients of STEMI in Indian scenario when a delay in PCI is anticipated. Leading experts across India reviewed various fibrinolytics with reference to their availability, ease of administration and risk benefit ratios. Their views were captured in advisory meetings. They then discussed and presented their views and shared their experiences on the practicality of PI strategy in the metro and tier-1 cities of India. Their opinion is captured in the present document. The panel opined that STEMI patients should be given PI therapy, wherever possible, using a third-generation fibrinolytic, namely, reteplase or tenecteplase if the delay in primary PCI of more than 120 minutes from the time of chest pain is expected. Immediate reperfusion by thrombolysis helps in preserving the myocardium and it also provides a time window for further PCI and coronary angiography, whichever is required. The experts concluded that when delay in access to primary PCI is expected, PI therapy is the preferred choice for STEMI patients. It should be practiced not only in semi-urban and rural areas but also in metro and tier-1 cities in India.