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Insights from the world's best medical minds

Fibrinolytic Therapy: A Saviour In The Absence Of Angioplasty

An Indian dies of Myocardiac Infraction every 17 seconds; Angioplasty clearly not the solution

Dr. Brian Pinto

Dr. Brian Pinto, Chief Cardiologist, Holy Family Hospital, Mumbai, Fibrinolytic therapy: A saviour in the absence of angioplasty
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Dr. Brian Pinto

Chief Cardiologist

Holy Family Hospital, Mumbai


“Every 17 seconds an Indian dies of an acute myocardial infarction and I think it is important for us to realize that we will not be able to tackle this problem by primary angioplasty alone,” says Dr. Brian Pinto. “Fibrinolytic therapy is useful in the absence of angioplasty. We now have agents like tenecteplase and alteplase, which can be administered anywhere- in homes or ambulances.” Once Fibrinolytic therapy is administered, the patient can get optimum treatment of angiography within the first 3-24 hours. This combination, known as the pharmacoinvasive therapy is as good or even better than primary angioplasty.” “It is my default mode 95% to 98% of patients,” Dr. Brian endorses the transradial approach to angioplasty. “The rival trial and matrix trial have clearly shown that the transradial approach is beneficial, with significantly reduced back pain, urinary problems and a very low rate of mortality.” Patients who are on dialysis, have significant hypotension, or have bypass grafts are some exceptions, in whose case, the transradial approach may not work.


Dr.Jonathan C Hsu with Dr.Kunal Jhaveri: Dr.Jonathan C Hsu


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Dr. Brian Pinto

Every 17 seconds an Indian dies because of an acute myocardial infarction and I think it is important for us to realize that we will not be able to tackle this problem by primary angioplasty alone. People need to get educated that they need to reach the hospital in time and they need to get a certain drug which is called as fibrinolytic therapy. This fibrinolytic therapy has become upgraded now where we have agents like tenecteplase and we have agents like alteplase which can be administered not only in the hospital but can also be given in the homes of people and in the ambulances. As all of you realize many of our people are very widespread through the various rural areas as well as they live in urban areas which have extremely strong traffic kind of conditions. So, it is important to get these patients to receive the drugs so that the artery which is closed down can be completely open. It is also important to realize that after doing this, the patient needs to get into the hospital, so that they can have the optimum treatment of having an angiogram done within the first 3-24 hours after this fibrinolytic therapy. This is known as the pharmacoinvasive therapy and it has been proved that if patients have this thing done within the first three hours of symptoms that pharmacoinvasive therapy that is combing the pharmacotherapy with the intervention gives as good results or even better results than primary angioplasty which may not be feasible for many patients in this country and also in America where it is found that only 40% of the patients receive the primary angioplasty. So, I think it is important that we realize that our people need to be trained, our nurses need to be trained, our paramedical people need to be trained and this is the only way that we can go forward to save lives in the situation of acute myocardial infraction. Cardiologists all over the world and especially in the United States of America are now changing over to the transradial approach that is going through the wrist for doing intervention. It is clearly seen today that there is not only a benefit in breathing, but there are mortality benefits that means less patients die if you approach the coronary arteries through the transesophageal approach as versus the conventional transfemoral approach. This approach was first started by Kampu in Canada which was in 1991 and forward it has been taken into many countries. There are many trials that have been put forward, for example the rival trial, the rifle trial and recently the matrix trial which has clearly shown that the transradial approach benefits patients. It is a much more elegant procedure. Patients prefer it. There is less time to ambulation. Patients can get up much quicker. There is less mount of back pain and urinary problems are significantly reduced through the transradial approach. Patients have found this preferable, doctors have to learn the procedure. There are an 80-100 cases learning curve that has required but certainly even difficult cases, patients who need bifurcation stenting, patients who need left main stenting, those who have to have primary angioplasty, those who need situations where you have to treat use IVUS, FFR or any such procedure can be quite easily accomplished through the transradial approach, in fact it is my default mode 95% to 98% of patients I do by the transradial approach. There are only a few groups of patients in whom I do use it, for example those on dialysis or hose who are likely to go under dialysis and those patients who have significant hypotension, so you cannot feel the radial artery. Patients who have a large radial artery loop and therefore, the catheter cannot be advanced and sometimes in patients who have bypass grafts because you cannot approach some of the vein grafts or some of the arteries. Otherwise, it is my mode of therapy or my mode of angiography and intervention for almost 98% of my patients and I clearly can see from the trials today over the last 10-15 years that this is going to be the mode which most physicians or cardiologists will approach in the future.



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