Chief Consultant Cardiologist
PRS Hospital, Kerala
</b> Sir as talking about thrombolytic agents and which one to choose for Indian aam aadmi. Sir, lots of thrombolytic agents are available I market so what is the difference between these available agents?
</b> It is a real, real important question pertaining especially to the Indian background that we talk about, we have the old streptokinase which is the general thrombolytic agent which is not specific to fibrin and not specific to clot. The advantage is it is widely available and the most importantly it is cheap. So that tends to be by default the standard thrombolytic agent for years but now today for the last couple of years we have the new thrombolytic agent, especially the tenecteplase which is fibrin specific. It has ease of administration, but the problem being it is costly. It is about ten times costly than streptokinase.
</b> So what will be the actual difference in the quality of life or the prognosis or the results of the patient who are given streptokinase versus tenecteplase.
</b> Especially that is the most important question, in fact, in my thought that is what I tried to highlight.Apparently, streptokinase is cheap, why not use that but when we look at tenecteplase not only that it gives us a better patency rate, not only that it is fast so that we save lives most importantly we get more of TIMI 2 and 3 flow. This means we end up with the better left ventricular function and today we know that the better left ventricular function indicates that we will have the better quality of life and that is important in Indian diaspora where the person has to be fit to go back and do his work and remember that when we are talking about cost, it is a one time cost. It is not like the hemodialysis or a statin therapy or antihypertensive therapy. One time cost even if it is apparently high, I think we should go for the newer thrombolytic agents which gives us a better long time quality of life, yes.
</b> Sir, if I am right if cost is not a concern you will prefer tenecteplase over streptokinase.
</b> Yes, yes certainly.
</b> Coming to the Indian data so you have done a registry regarding this, so will you like to highlight the findings of that.
</b> I think that is very, very important. We have huge registry data now; we have published it in an Indian Heart Journal. It has 15000 plus patients today whom we have thrombolysed with tenecteplase and the results if they look at them they are very good and very satisfied more than 95% plus patients are obtained TIMI 2 3 flow specially thrombolys is defined by ST resolution to 70% at 90 minutes and resolution of pain and symptom and that is very important. Safety features are good. The mortality reduction survival figures are very good. So, I think by default today we should choose tenecteplase. Our aim should be to try to buffer the cost difference between tenecteplase and streptokinase and try to see how we can do that.I think that would take us a long way forward rather than trying to set up a cath lab in every village in rural India which is not very easy.
</b> But if the patient cannot afford, I think we should not deny him at least streptokinase?
</b> Ooo, not at all because we always go ahead and say that streptokinase is better than no thrombolysis for example a small village clinic which has nothing other than a streptokinase go ahead and give it, you are doing the best, but understand that today we have a better drug than streptokinase which is the tenecteplase.
</b> So what is the time frame when you divide that this is patient of a thrombolysis or the primary PCI. So, what is that golden window.
</b> We say that today by default the gold standard treatment of acute myocardial infarction is in primary PCI. So if the patient can reach a primary PCI hospital at the earliest even that is the point at the earliest for example if we can reach the primary PCI hospital in less than 90 minutes, he gets the best result. If there is a delay rather than waiting for giving him the gold standard treatment, we should thrombolyse. Now in India, ambulance thrombolysis is almost not existent.Our fist contact with the patient is at the hospital door. So the moment we see a patient at the hospital door, the question you should ask, can I take this patient for a primary PCI in the next 90 minutes. If I cannot do that, probably I should thrombolyse and then plan about shifting him to a different hospital or even providing primary PCI in my own hospital.
</b> Sir, thanks for your comments, so what we understand is that best is to give the thrombolysis. If the patient cannot afford, let us go by streptokinase, but the bottom line remains is we should not deny him of possible chance of survival using the right thrombolytic agent.
</b> Thank you sir, thanks for your time sir.
</b> Thank you.