Rationale

PPCI within 120 minutes of FMC (90 min for early presenters <2hrs from symptoms onset), is the gold standard in the management of STEMI. However, access to PPCI reperfusion procedures is limited for much of the world’s population. This is not only due to timely transfer concerns (see figure below), but is also related to other factors such as socio-economic status and country-specific healthcare practices and policies.1

Non-patient-related factors that influence timely reperfusion

Graphic showing various non patient related factors influencing timely reperfusion

In developing countries, such as India, door-to-balloon (DTB) times are prolonged, with one study reporting an average delay to PPCI of 260 minutes (range: 185 min to 390 min).2

 

  • Not all medical centres are PPCI-capable3,4 &/or pre-hospital delays often prevent patients from receiving timely PPCI5,6
  • No specialist equipment required and PHT has been established as a safe and effective treatment for STEMI7
  • PHT reduces time to reperfusion and improves outcomes if PPCI is not possible within 2h8,9
  • Pharmaco-invasive strategy may achieve reperfusion directly; in case of thrombolysis failure, reperfusion can be achieved with subsequent rescue PCI10
References: 
  1. Armstrong PW & Van de Werf F. No STEMI Left Behind. JAPI 2014;62:469-470.
  2. Victor SM, et al. A Prospective, Observational, Multicenter Study Comparing Tenecteplase Faciliated PCI Versus Primary PCI in Indian Patients with STEMI (STEPP-AMI) [Abstract]. J Am Coll Cardiol 2014;63(12, Suppl S):S4.
  3. Steg PG et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC).. Eur Heart J 2012;33:2569-2619.
  4. Pinto DS et al. Hospital delays in reperfusion for ST-elevation myocardial infarction. Circulation 2006;114:2019-2025.
  5. Armstrong PW, Bowden WE. Reperfusion paradox in ST-segment elevation myocardial infarction. Ann Intern Med 2011;155:389-391.
  6. Armstrong PW et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;368(15):1379-1387.
  7. O’Gara PT 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 2013;61:e78-e140.
  8. Morrison LJ et al. Mortality and prehospital thrombolysis for acute myocardial infarction. A meta-analysis. JAMA 2000;283(20):2686–2692.
  9. Wallentin L et al. Efficacy and safety of Tenecteplase in combination with low-molecular weight Heparin Enoxaparin or unfractionated Heparin in the prehospital setting. Circulation 2003;108:135-142.
  10. Gershlick AH et al. Rescue angioplasty after failed thrombolytic therapy for acute myocardial infarction. N Engl J Med 2005;353:2758-2768.
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