Reperfusion therapy is the cornerstone of STEMI management
and should be instituted in all patients presenting within 12
hours of onset of symptoms.30,35 The most efficacious reperfusion
therapy available is timely primary PCI,36 but it may not be the
most effective in the Indian context, given the relative paucity of
PCI-capable centers. Moreover, since most of these centers are
located in urban areas, the distances involved in transporting
patients from rural areas become prohibitive. Fibrinolytic
therapy therefore remains the most practicable reperfusion
strategy for India. The most recent data from India suggests that
only about 8% of patients with STEMI receive primary PCI.37
Nearly 60% of patients receive fibrinolysis with streptokinase
as initial treatment. It should be emphasized that even among
urban/semi-urban dwellers (only 17% of patients enrolled in the
CREATE registry were from rural areas), a third of patients did
not receive any form of reperfusion therapy.37 Patients presenting
to PCI-capable centers should of course be treated with timely
primary PCI if the door-to-balloon time is anticipated to be less
than 2 hours from the time of arrival at the hospital.26 It should
be recognized that door-to-balloon times may be greater than
2 hours even in PCI-capable centers during off-duty hours,
weekends and holidays, and immediate fibrinolysis may be the
better option when delays are anticipated. Such hospitals should
implement processes to minimize and monitor door-to-balloon
times. Indication for primary PCI is shown in Table