Advances in Primary PCI, with the advent of better stents and with the mandates of Door to Balloon (D2B) Times, and with increasing availability of highly-effective, third-generation thrombolytics, such as Tenectaplase (TNK) - have dramatically reduced mortality from AMI in the western world.  This poignant editorial is a passionate plea of conscience to physicians in India to jump out from their beds and provide urgent AMI treatment - both STEMI interventions and thrombolysis, in critical time-dependent, door to balloon and door to needle times (D2N).   
            The essential principle of “Time is Muscle”, highlighting the haste required in providing treatment for AMI has recently been placed into quantifiable markers with induction of D2B (<90 min) and D2N (<30 min) times into Class I Recommendations for STEMI management in both the ACC/AHA and ESC Guidelines.  Although philosophically, these new guidelines simply emphasize the vital need for providing TIMI flow to the necrotizing myocardium, the critical addition of D2B and D2N Times to the guidelines has important logistic, quality, legal and financial implications.  Most importantly, they provide superb tools to monitor performance and quality that is being delivered to provide STEMI care. Already, progress is being reported in the United States and in Europe in mortality and morbidity statistics of AMI, from rigid adherence to these guidelines.  As an example, STEMI interventions with D2B times<90 min have a reported nationwide mortality in the United States (NRMI, National Registry for Myocardial Infarction) of 3%, and these rates are projected to fall further.

            The challenges of meeting both D2B and D2N guidelines in India are obvious and most evoke empathy for what Indian cardiologists have to endure.  The painful battles that Indian cardiologists tolerate in justifying the expense of life-saving care to the patient and his family in the middle of the AMI, must end with press, media and physician leadership leading a unified campaign.  Hopefully, access to health insurance will mitigate some of these issues; although Indian physicians must remain vigilant against American style HMO’s that may bring in

equally difficult issues of profiting from life-saving healthcare.  The lack of infrastructure, in particular, of well-equipped 24/365 catheterization laboratories, is a major handicap too.  Yet, that will improve as patients and doctors will mandate their installation and hospitals will recognize their cash-cow potential and the social and marketing benefits that accrue to the institutions from lives saved in these specialized suites.  Indeed, issues of ever-worsening traffic congestion hamper life-saving efforts – fortunately, with most AMI presenting in early morning hours, some of the traffic nightmares are mitigated by this fortuitous diurnal pattern.

            Yet, beyond all these concerns, is the most critical issue of a complete absence of a well-coordinated,   ambulance system.  There is undisputed evidence that mortality in AMI is directly linked to efficient and timely transportation of the AMI patient to the appropriate institution.  In Europe, Canada and in the United States, the system has become sophisticated to this critical need.  Hospitals are thus designated as either a STEMI or a non STEMI facility to streamline the transportation of the AMI patient by the Emergency Medical System.  With such systems in place, use of anti-platelets, anti-coagulants, and even of thrombolytics, is begun in the ambulance – all in efforts to shave off precious minutes in the delivery of STEMI care.  Pre hospital alert systems have been created to activate the cardiac catheterization teams.  With such strictly-followed protocols, the STEMI patient bypasses the emergency room altogether and goes straight to the cardiac catheterization laboratory where the team is already assembled to perform Primary PCI.  With such remarkable systems in place, landmark reductions in AMI mortality have been achieved in Ontario, Canada - for more than 3 years, the entire 800,000 population of metropolitan Ottawa has received Primary PCI and recorded the lowest mortality rates for Primary PCI.  The Abbott Northwestern Hospital and the Mayo Clinic in Minnesota, and the RACE program in North Carolina, are other models where tremendous integrated systems of care provide optimal management for AMI patients.  Most importantly, the above three examples provide a proven

methodology to provide urgent, population-based, AMI care made possible by developing a very efficient ambulance system.  Closer to home, in Singapore, a statewide D2B time of 67 minutes has been recorded, courtesy of coordinated care provided by the cardiologists and the emergency medical services.   
            Therefore, a call is made by this author to administrators, healthcare policy makers and to politicians to hasten the process of developing a rapid, predictable, nationwide, emergency medical service system that will provide the life-saving care for the AMI patient.  Who knows, the next patient may be you or your loved one!  The plans and early development of the 108 system are clearly steps in the right direction.  

A more passionate call is made to arouse the cardiologist from his and her slumber to provide this urgent care, notwithstanding the frustrations of an inefficient system.  Remember, the best thrombolytic will not work if administrated late, and no myocardium will reperfuse even with the most skilled stenting procedure, if not performed in a timely fashion. 
So, how does a cardiologist solve his dilemma in the midst of chaos?  Follow Mahatma Gandhi’s dictum, “In matters of conscience, the opinion of the majority does not count!”                     

 References:
Textbook of STEMI Interventions, Sameer Mehta et al, HMP Communications, 2008