How can we use AI as a tool of knowledge distillation ?
Here is a deep discussion with Grok 3, on the merits, limitations & validity of DANAMI 2 and PRAGUE 2 , the two old studies on pPCI. Curiously , we don’t have any other studies to quote. As on 2025 , superiority of pPCI hangs precariously on these two decade old studies, which has some serious omissions in the primary end point and its Interpretation. To get into the facts , please go through the following link.
CAPTIM trial was published in 2002, which left a gospel truth in the science of myocardial reperfusion (two decades gone now). It is a sad academic story ,most of the interventional cardiology community shrugged it off as a non-event. After CAPTIM , there were several other studies that tried to reiterate the same. The fact of the matter is, in the art and science of reperfusion, all that glitters may not be gold at the myocardium level.
Yes, we do have a tiny advantage of pPCI in terms of complete revascularisation. But it was blown out of proportion, backed by small but glamorous studies. However, the true benefits are hidden in a timely early reperfusion, best done at out-of-hospital (or even in-hospital*) with the emergency crew’s assistance.
“Since Intravenous lysis looks too simplistic, that do not need expertise, and lacks a commercial trail, it is wrongly depicted as inferior management strategy in STEMI“
Every one of us is equally responsible for this sorry state of affairs. In many countries, the hub-and-spoke model is struggling to deliver. The spokes often fail in their duty to begin the reperfusion, (Perceived low quality treatment and peer pressure) while the further delay happens at the hub , that earn the wrath of the myocardium ultimately. In this context, we need a movement to revive the pre-hospital thrombolysis. This is what CAPTIM told us.
No one knows how the pPCI related delay was legally ratified and academically accepted by the elite cardiology forums. Some poorly designed small cohort RCTS are responsible for this. There were some sensible moves too later on. To counter the logistic limitation of pPCI came the pharmaco-invasive strategy backed upby STREAM, FAST-MI trials etc. Still, no one is able to undo the disproportionate popularity of pPCI .At best, It has a miniscule 1 % edge in the outcome if performed on time, at a expertise intensive place. (Efficiency of thrombolysis is highly reproducible. It is a fact, an ambulance crew is able to equal or even surpass the expertise of cardiologists in terms of absolute myocardial salvage) )
Now, it is heartening to read a meta-analysis addressing pre-hospital thrombolysis, done from my part of the country. This paper is published by Dr. R. Bharathkumar, and his team. He is one of our senior colleague, mentor and former professor of Stanley Medical College. Chennai. With this study ,they have successfully proved an existing truth, in a more refreshing and authoritative manner (Ref 1 )
I am here with sharing this full paper. Readers can infer their own conclusion. Would like to to highlight two important new points told in this paper in a gentle way, yet conveying a powerful message.
1. Much surprisingly, the guideline recommended the “door to needle time” in pPCI is achieved only in a fraction of the population in real world. (NRMI data Ref 2)
2.There is a differential Impact of PCI related delay on the myocardium with reference to IRA. In LAD STEMI time is more crucial. The permissible limit is 40mts not the traditional 90-120 minutes (Ref 3)
Final message
The perceived superiority of pPCI over any other modality of reperfusion is not absolute*. The above paper reemphasize this one more time ,with strong evidence aggregation .I wish ,this paper deserves a more prominent place in major journals like Lancet or JACC or even NEJM.
Meanwhile, we should not make sweeping statements, that tend to convey a wrong idea, which makes pPCI look invincible at all points in ACS time line. The irony is , many of us strongly believe, it is worth loosing the golden hour in lieu of perceived superiority pPCI . This shatters the concept of “time is muscle ” Thanks to the evidence based cardiology.
Counterpoint
*PCI in the setting of ACS do have a critical life saving role in certain subsets of ACS, that can never be undermined . What is being debated is the true benefits of this revolutionary intervention as a population level strategy.
The contents of the this blog is being published as Kindle E book , as per the request of many of the readers. Every article will continue to be open source in this site. Again I shall reiterate the book format is not aimed at any commercial intent. It is only to facilitate learning in a single book format Here is the link to book https://amzn.in/d/euhL5vu
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Please Note
The author acknowledges all the queries posted by the readers and wishes to answer them .Due to logistic reasons only few could be responded. Inconvenience caused is regretted.
Dr.S.Venkatesan MD 