Dr.S.Venkatesan MD

We know,management of STEMI is a race against time.It’s rather a group race run by the patient, his close relatives / associates , the ambulance driver, the ER physician, cath lab staff and finally the  treating cardiologist .While the race is on , continuous monitoring and critical decisions are made.

Every minute gone could be a missed opportunity. While a patient is being moved to the hospital, a decision is to be taken whether its going to be primary PCI or lysis or combination of both.

Now,In India, as we embrace the quirky world of medical insurance  and   glamor based medicine , we have one more participant in this race of human life! The coronary flow dynamics in STEMI  appears  to be determined not only by thrombus load the residual plaque but also by the quantum, type and brand of  insurance the patient is blessed with !

I wish , one could hear the silent howls made by the myocardium under distress even as their loved ones are anxiously waiting for insurance  clearance from the  myocardial reperfusion  centers located in the far away back offices of urban metros !

Things won’t stop with that. Once the  PCI is on,and the cardiac team is confronted with a multi-vessel  CAD ,wondering which is true culprit ?, whether to consider  multi-vessel  stenting or early CABG  . Meanwhile the cath lab  liaison officer would desperately struggle to call the insurance guys again and upgrade the request to a newer therapeutic strategy !

Life was simple for every one till recently ,  when we would treat thousands of MI patients with conventional modality with a well proven reduction in mortality , comparable to the current bests .The concept of primary PCI has made things artificially complex without adding on to significant advantage except in some complicated subsets.

I still keep wondering , achieving a near  TIMI -3  flow in a timely fashion  by thrombolysis  in CCU will far exceed the hype of documented TIMI 3 flow in cath lab in  terms of absolute number and of course favorable outcome .Please realise acute myocardial salvage requires a minimum of  TIMI 2 and not TIMI 3 flow !