Time is muscle. This quote became sort of ” cardiology sermon” in the last few decades .Cardiologist think they stand on a 100 meters sprint track once a patient with STEMI arrives .This is indeed true , if we agree time is muscle and our urge is to reduce the door to balloon time .Please remember , this rush matters much , only if the patient comes through very early when the muscle is really getting damaged . (No issues . . . even if the fire engine comes in slow motion if the house is burnt fully !)
Time is muscle agreed . . . but muscles are kept alive by factors other than time ! So muscles can defy time if God is willing !
Time is one of the important components of management of STEMI. Other things matter too ! Age , baseline co-morbidity , underlying extent of CAD, collateral support of IRA territory , and finally individual variation in hypoxic damage in myocyte is (Rarely been studied in detail.)
Door to balloon time for a patient who lands up within 1 hour window need to be much different from a patient who comes at 10 th hour .The issue is important because we use a procedure which requires delicate decision-making ,(IRA-Non IRA issues etc) the results can be sub optimal , and even be hazardous in low risk STEMI . So , door to balloon time may be a less important component of time window in a patient who comes after 6 hours .This is the reason overall outcomes are not changing in a large cohort of rapidly performed PCI.
The presumed absolute relationship between “Time and muscle” concept is always been a suspect . This is proven by a flawless study from NEJM .
http://www.nejm.org/doi/full/10.1056/NEJMoa1208200
This study should infuse more sense to us , time and again, we are hijacked and sedated by high dose of pseudo scientific concoction .In fact , indiscriminate rapid PCI may not be in the good interest of all patients with STEMI , if it is not properly done .Without realising this fact many developing countries are indulging in extravagance of costly STEMI programs wasting the exchequer.
This landmark NEJM paper convincingly underscores a fact that achieving rapid door to balloon time is not going to be the game changer in conquering the Global STEMI championship . We have to take the coronary care into the streets or to their homes as well .This is where the pre-hospital thrombolysis will emerge in a big way in the future .
A slow and steady thrombolysis beats a fast and furious primary PCI on any given day in all uncomplicated STEMI .This we have proven for over three decades in one of the India’s largest coronary care unit .( Where is the data man ? Genuine experience is data . Why we require , the act of publication to convert an experience into evidence . Often times , I would feel , data is the most unscientific word in medicine . Many Truths lack evidence , false hoods come with plenty ! For all those scientific homo sapiens , please recall 70 % of ACC/AHA class 1 recommendations are backed by level C evidence ie simple opinion from perceived experts! )
Final message
A fast and furious primary PCI may not be the answer in all STEMI population
Thrombolysis can be done with near zero time delay , it does not require special expertise where an ambulance driver can reperfuse a myocardium without much fuss and glamor ! He does not have to split his hair to identify which is the IRA in a complex multivessel STEMI as well ! The streptokinase and TPA will home in to the target site smoothly and swiftly .
If indeed , time is the major factor in STEMI , we have many other ways to tame the time . If muscle is more important than time , pPCI is rarely the answer !
Some India specific thoughts
Is it not a shame , we talk about primary PCI for all our patients who do not even get timely Aspirin* after a STEMI! .It is something akin to what we witness every day , as our country folks wield touch screen Androids . . . conversing in open air toilets !
* While the importance of Aspirin is undermined , It is different story altogether , these patients get sorbitarate promptly whenever they get chest pain (mis-placed and dangerous priority ! ) prescribed by the roaring GPs , who suffer from discontinuous medical education , propelled by the deeply penetrated 1000 crore oral Nitrate market .
And STEMI workshops are conducted by self-proclaimed experts every few months in posh 7 star hotels all over India .
Dr.S.Venkatesan MD 