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Insights from the world's best medical minds

Management Of STEMI In The Absence Of PCI

Less than 5 to 10% of the PCI facilities cater to tier 2 and tier 3 cities
Dr. Sreenivas Kumar
Dr.Sreenivas Kumar, Chief Cardiologist at Citizens Hospitals in Hyderabad on A Protocol for PCI and Non-PCI enabled center to follow when they have to transfer the patient to a  PCI Center.
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Dr. Sreenivas Kumar

Chief Cardiologist

Citizens Hospital, Hyderabad


“Though cath lab numbers have been increasing in India, they are unevenly distributed. Majorly concentrated in the tier 1 cities, less than 5 to 10% of these facilities cater to tier 2 and tier 3 cities,” Dr. Sreenivas Kumar says in an interview with Dr. Manish Verma.Most of the myocardial damage can be avoided if the artery can be opened and re-perfused in the first three hours. But less than 4% of the total population which suffers acute MI gets a primary PCI. To buy some time, reperfusion with thrombolytic drugs is the second best option. Newer thrombolytic agents like tenecteplas are more fibrin specific, less complication prone and have better opening rates than the old streptokinase.“After thrombolysis, once the rhythm abnormality settles and BP becomes stable, then patients are in a better shape to be shifted to PCI centres.”“When people are presented to a PCI center after thrombolytic therapy, 50% do not need any further procedure, because the artery is already open.”Usage of high dose statins and newer antiplatelets like ticagrelor and prasugrel is also recommended. With that, diagnosis of MI is the only problem remaining. To solve it, Dr. Sreenivas suggests that every physician must pair up with a cardiologist, so that ECG readings can be transmitted and confirmation regarding acute MI can easily be obtained.In a parallel conversation, Dr. Sreenivas warns that any symptom of a heart attack like chest pain must not be neglected by presumption of acidity or gas to be the reason. “There is no reason to not treat it as a cardiac problem unless proven otherwise,” he adds.Many issues of the dual antiplatelet therapy are also extensively discussed by Dr. Sreenivas Kumar.


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Complete Transcript

Dr. Manish Verma

Thank you so much sir for taking out time and coming here for a very important discussion. The conference is focusing on preventive cardiology. Like for many things in India, there are two Indias when it comes to coronary care, India which gets PCI, and India which does not get PCI. So what is the percentage and distribution of people who are able to manage with PCI and people who are not able to reach to a PCI Enabled Center and if the patient is not reaching at PCI Enabled Center, what recommendation will you give to the physicians who are receiving those patients.

Dr. Sreenivas kumar

Before we go in to discussion about PCI and where is reperfusion status in an acute MI, I expressed my heartfelt welcome to all the delegates who are attending this important conference on World Congress of Clinical and Preventive Cardiology. It is very apt and preventive care is very important to prevent the occurrence of this coronary artery disease epidemic, which culminates into ACS and acute MI what you are talking. If you see acute MI is worst possible thing which can happen in a cardiac disease to anybody, but at the same time, it is also important for us to understand that if proper preventive care is taken, 80% of occurrence of it can be prevented. We have documented proven data and recently published study in Jack that 81% of the incidents can be prevented if the preventive recommendations can be fulfilled, but unfortunately only 1% of the population, which suffers takes care and attributes to all those preventive recommendations, which are being done. So it is very important not to neglect this aspect of preventive cardiology, I congratulate to Dr. Chopra and others for taking this initiative and conducting this conference in this holy place of Brahma Kumaris. Acute MI and primary PCI unfortunately in India, though cath lab numbers are increasing, they are quite unevenly distributed, most of it happens in cities, very few, I would say less than 5 to 10% of labs are catering to tier 2, tier 3 cities, but unfortunately, in India on the other hand has 80% of those villages and then few very less percentage ranks into tier 1 cities. But acute MI happens both in cities as well as villages, both in rich as well as in poor. So what is most important is to re-perfuse the artery in the acute stage, the first one hour is a golden stage and maximum up to three hours and if you can re-perfuse and make the artery open, then most of the myocardial damage can be avoided. This is a well proven fact. But as you said, primary PCI is proven beyond doubt, it is good but the problem with it is access to it is not there in many centers. Coming to last NIC data of ours, if you see less than 4% of the total population which suffers acute MI gets into primary PCI, that means huge 90% is not able to reach it. The other thing is if you see the total number of PCIs which are done in the country, that is may be 1.6 lakhs out of which about 11% done in acute MI stage, though it is important number, but I would say compared to total number of people who suffer myocardial infarction, what is the primary PCI being offered is in less number of patients. So then we are left with what? We are left with the established therapy of pharmacology that is reperfusion with thrombolytic drugs. It is very heartening to note and I am very happy to say that we have very good advancements happened even in pharmacotherapy. The age old streptokinase which we all know many physician colleagues were worried to give that medicine because the moment you started it, there used to be hypotension, there used to be problems and it was needing to be monitored for an hour or so, and patency rates opening of the artery was also about 50%. Now, we have better thrombolytic drugs, which are more fibrin specific and which are less complication prone and more better opening rates. This is documented data. We have done tenecteplase, we also have reteplase coming up but the cost of it is slightly high, so I feel probably tenecteplase is somewhere in between the cost and opening rate is also about 80%. We, in our group in Hyderabad and peripheries, did collect lot of data where we connect patients who come with tenecteplase therapy and then we are promoting this concept of giving tenecteplase in non-ICU setups where a doctor who is confident of diagnosing an MI can give this therapy without wasting time and then shift the patients for places of PCI. Then the, problem, only thing is you have to identify the right patient. You cannot give tenecteplase. There is a challenge sometimes for physicians or peripheral doctors or general practitioners to diagnose acute MI because it should not be given to a wrong patient, and that is where the technology, that is where the internet, WhatsApp and the various other things which are there will help us. We established a protocol where peripheral doctor takes an ECG, and whichever doctor is comfortable, I think it is a good thing, each physician should team up with one of the cardiologists to whomever he is comfortable with and then transmit the data to him, get it confirmed that it is acute MI and immediately then once it is done, giving the therapy is quite easy, anybody who can give ranitidine injection, anybody can give IV injection, can give tenecteplase, it is like a one bolus injection. So I feel this newer thrombolytic therapy is very apt and good for our country. And then one more thing which is also important apart from the thrombolytic therapy is usage of newer antiplatelet drugs and usage of high dose statins. These are again proven beyond doubt that it is beneficial, so apart from the Ecosprin which is aspirin, which is given 325 mg, if generally clopidogrel is very freely available, still people lot of them use clopidogrel, so loading doses of 300 mg but if you have an access to more advanced antiplatelets like ticagrelor or for that matter a prasugrel, the only challenge with Prasugrel is some physicians do feel that prasugrel has more bleeding tendency especially combining with thrombolytic therapy. So ticagrelor can fit somewhere in between and probably it has more better antiplatelets and less chances of bleeding. So if you are combining with a thrombolytic therapy, probably ticagrelor may be more suitable than Prasugrel, but if patient is young diabetic, less chances of bleeding, good body weight, you can as well give prasugrel; that physician needs to use his judgment but if there is a confusion better at least to give clopidogrel, aspirin and then followed by the thrombolytic therapy. One other important with this newer tenecteplase or fibrin specific things which are having very short half life, it has to be immediately followed up or for that matter, we can just simultaneously give it with an antithrombin like heparin or low molecular weight heparin. So we recommend generally giving subcutaneous dose of low molecular weight heparin and then patients will be shifted after that depending upon the comfort level of the patient as well as the doctor and availability of nearby center, then you buy sometime, there is no urgency to shift within one hour now, you give thrombolytic therapy, and then patient could come in time depending upon various arrangements which he needs to make in between three to six hours, then we will ask the patient once he comes to referral center where PCI is available, and patient is unstable, which happens in about 20% of patients, then we may rush to take it up for immediately. If the patient is stable, probably you can do angiogram electively and then decide what needs to be done later after angiogram. In our data, one more interesting fact that we found out is people who are given thrombolytic therapy, when they presented to PCI center, 50% of them did not need anything, 50% of them did not need any stent or any further procedure, because artery is already open and another 15% of them had multivessel disease which otherwise you would have ended up doing a culprit vessel PCI and then followed by PCI again or the surgery depending on the anatomy. So in about 65 to 70% of the patients, outcome or the modality of therapy is changing by following this pharmaco-invasive strategy. Probably in our country where patients are more young, more spasm, more of thrombus, this may be more apt than doing direct primary PCI, but we need to have more random studies and data, on that where you compare pharmaco-invasive versus primary even in centers where primary PCI is available.

Dr. Manish Verma

Any thoughts on transfer protocol, as I remember you mentioned couple of things on that?Any particular protocol, this PCI and non-PCI enabled center should follow when they have to transfer the patient to a PCI Center.

Dr. Sreenivas kumar

Basically when the patient is stabilized with thrombolytic therapy, that means as I said 80% of the time arteries are open, we have seen patient’s pain decreasing, hemodynamics improving, heart rate improving, better once the drug is given. The beauty of it is, if it opens, it opens in 5 to 10 minutes like doing a PCI and immediately the patient’s pain stabilizes, ST elevation settles and hemodynamics improve. So in that case, there is no big urgency but only problem is sometimes you get reocclusion, so it is important to give low molecular weight heparin injection at the same time and then you get some time period of whatever time which is comfortable to the patient. By and large, if reocclusion is not there, patient can take time in getting stabilized and we have initially used to use this 108 ambulance services to transfer this patients where you had sometimes availability of defibrillator, sometimes the defibrillator are not available, ideally stick scenario, probably yes, you should have an ambulance in which you have this ACLS protocol available and if required emergency medical technician, while transferring this patient, if at all in the sense that reperfusion, arrhythmias or VT/VFs if at all happens, sometimes they could be useful. But in our study where we had about 207 patients, I am very happy to note that but for the four patients who had some trouble and died in the primary clinics itself, apart from the rest of the them 203 patients, none of them had any trouble while transfer, so what I am saying is if patient improves immediately, there are less chances of having trouble, so now we are not insisting on transferring in an ambulance with all the facilities, if it is available it is well and good, otherwise sometimes the patients do come in their vehicles also, but idealistically probably you can have some linkup, some sort of ambulance in which they can be transferred and what I want to guide and advise my physician colleagues now who are comfortable now giving thrombolytic is there is no need to rush to shift. Suppose there are arrhythmias happening, there is some hemodynamic instability, watch them, maintain for some time, once the rhythms problem settles, once the blood pressure improves, then he is more comfortable to be shifted. In that low blood pressure stage or beating abnormality stage, if you want to shift, there could be some trouble. So once the pain decreases, little sort of reperfusion arrhythmias keep happening for sometime, so those can be monitored, watched and then once that sort of rhythm abnormality settles, once the BP becomes more stable, then patients are in a better shape to be transferred to these centers. What I mean is, if patient has ongoing pain, if patient is in shock, if patient has some other mechanical complication or something which is continuously troubling the patient, then it is a different ball game, then you should not take your sweet time. You have to have them shifted probably and preferably in a better ambulance where he has all these facilities and then you have to also alert to the tertiary center where the patient is being shifted because may be he will require immediately opening of the artery once he reaches, so door-to-balloon time should be made short and then all those precautions should be done to open up the artery as soon as possible, but this necessity is generally there in about 10 to 20% of acute MI patients, rest 80%, once they have stabilized, may be within three to six hours time they can get shifted and then depending upon the comfort level of the cardiologist and the center which is available what time he is reaching, then we continue giving heparin and the plan angiogram and revascularization if necessary in an elective way.

Dr. Manish Verma

What advice you will give to the people who have symptoms like heart attack, so if they feel like that, what they should do?

Dr. Sreenivas kumar

First of all, whenever there is any doubt of heart attack, please do not neglect. People think it is gas, and they bloat up outside and go on to have, so please do not neglect it, be it any sort of discomfort and do not neglect it. The doctors also should not ignore it, if there is any doubt, you always treat towards more as CAD than as a APD or gas. So any sort of discomfort which happens from umbilicus to jaw and especially when it is increasing with exertion, and especially when there is a diffuse type of discomfort radiating to arms, can pinpoint to one particular place, associated with sweating, sometimes vomiting, these could be the clinical scenarios in which it could be MI and then probably ECG would be more diagnostic but sometimes in the earlier evaluation stage, ECG may not be abnormal, so clinical symptoms, what presentation the patient has is most important. So I would like to mention and again caution is do not neglect any discomfort as gas or anything unless it is proven otherwise, now we have enzymes also available, if possible even in periphery cities it is being there and then ECG also, serial ECG taking is important whenever you have suspicion of a ACS or acute MI evolving. So, by in large, there is nothing wrong towards treating MI, giving antiplatelets, giving statins is okay. If you have may be you can also give pantoprazole or some sort of drug along with it, but err towards treating it as ACS rather than missing it out totally.

Dr. Manish Verma

There are 3 or 4 major antiplatelets which are available options to the physicians, we have discussed briefly about the initial phase but when it comes to a chronic phase, especially the dual antiplatelet, anything you would like to mention about that?

Dr. Sreenivas kumar

Yeah, this is another important question which many physicians have, basically is how long we need to give his dual antiplatelet therapy. If any patient who has suffered acute coronary syndrome, whether it be acute MI, NSTEMI or unstable angina with ST-T changes, at least you should give dual antiplatelet therapy for a year. Probably in our scenario, probably where I feel there is more of platelets stickiness especially with diabetics and young people, it is better to give them a little longer, because we have lot of data coming with clopidogrel that is quite safe and less chances of bleeding because we do see a lot of younger population who suffers with it unlike West. If the patient’s age crossing 70 years, there is more chance of bleeding and other problems, and we do less commonly in our place, especially with clopidogrel. But if we are giving prasugrel, probably we need to watch and have a more cautious approach, but by and large, dual antiplatelet therapy is required for a year after ACS. Along with antiplatelet, it is also important to give high-dose statins. Many physicians we see writing 5 mg of rosuvastatin, 10 mg of atorvastatin which are homeopathic doses I would say. Now it is proven beyond doubt by many studies that high-dose statin therapy is a must. So initially for at least first three to six months, we tend to give 80 mg atorvastatin, 40 mg rosuvastatin and then titrate according to lipid levels which the patient has. If a patient post procedure or during angiogram and PCA had a drug-eluding stent, then it is all the more very useful to give platelet therapy longer, definitely for a year, but many cardiology colleagues do continue it more longer because we are little more comfortable giving antiplatelet more longer but there is more reassuring data that newer type of drug-eluting stents are more patient friendly and less thrombus prone even if you stop the second antiplatelet as early as three to six months, but I would say, the recurrence of events always may be less at least if you continue for a year.

Dr. Manish Verma

Diabetes and young hypertensives you specifically mentioned, are there any other risk categories where you would like to give it longer than a year?

Dr. Sreenivas kumar

It depends upon the type how the patient is behaving, what is the patient’s anatomy also. Suppose the patient has a recanalized vessel and nothing is needed, then probably antiplatelets for a year or so followed by just continuing aspirin and statin longer may be enough, but if the patient has diffuse atherosclerosis, if a patient has multivessel disease, if a patient has two or three stents placed, or if a patient has recurrent symptoms after the procedure and the patient has as we said diabetes and multiple other comorbidities, then he has more reason to continue this longer but even otherwise, I would prefer giving this dual antiplatelet a little longer. We do see sometimes the problems of platelet resistance especially with only aspirin, now there is more thought process going on in diabetics, aspirin alone may not be sufficient. So probably there will be more and more use of clopidogrel and other type of antiplatelets coming up in future.

Dr. Manish Verma

Antiplatelet resistance is of course one of the reasons you mentioned, so on the other side of it, what are the things which point towards having a higher bleeding risk, any particular category you would like to avoid giving a dual antiplatelet therapy?

Dr. Sreenivas kumar

Yeah, the other thing is also important. In medical practice, do no harm to patient is also first important rather than doing benefit by giving some special drug or doing some procedure, so you cannot afford to produce bleeding in patients when you are treating the patient because bleeding not only requires immediate blood transfusion then and there but it indicates higher bad prognosis, higher mortality on followup. We have now data of all the patients who bled not only have trouble acutely but in the long term also there are more chances of them suffering from recurrent problems and higher mortality. So it is very important for us to assess the patient profile and then decide what sort of antiplatelets, how long they are giving. As we discussed before, the thinner body weight and elderly population, more than 70 years and then patients who have borderline kidney function, patients who are anemic, patients we call it as poor protoplasm in clinical practice that is very thin, frail females, these are some of the subsets of patients where we need to be a little more careful, especially if there is a prior history of bleeding or APD in these patients, all these subsets of patients we need to be a little more careful. I would say that in such patients you come down on the dosing of antiplatelets more earlier may be immediately after six weeks to three months come down on the dose, then probably giving less type of antiplatelet potency. One important other factor in these patients as we should understand is when we are using ticagrelor, this aspirin should not cross 100 mg because when aspirin was given at more dose with ticagrelor, there was more bleeding. So when we are using ticagrelor, we are supposed to use only 100 mg or may be 75 mg of aspirin. So this is important unlikely with clopidogrel or prasugrel if we use 165 mg of aspirin, there could be more bleeding chances with ticagrelor that is what the data show.

Dr. Manish Verma

Thank you so much sir. This was a really interesting discussion, we have covered two important topics, one was management of myocardial infarction at a non-PCI-enabled center and second was dual antiplatelet therapy. Any final word you would like to say to the people?

Dr. Sreenivas kumar

As I said, and also very apt with this conference today, putting stents, giving thrombolytic therapy is all good but finally it is always-always more important for all of us to understand that prevention is better than cure be it primary prevention or secondary prevention. Primary prevention is always good, if you can avoid getting the disease itself but the thing is the preventive measures is a challenge for everybody to do it, but you have to be committed and maintain your healthy lifestyle, avoid eating cheese, pizza, burger or junk food, and maintain healthy body weight, do walking, yoga, Brahma Kumari’s support lot of yoga and meditation in prevention but whatever sort of relaxation each person can follow it is very important, because I feel healthy and happy person and being happy is also very important to prevent the occurrence of disease. If person is not happy and if he is stressed out too much, then probably that will be another newer dimension which could get into disease. So that is important, primary prevention and secondary prevention also after somebody suffers or some stent is put, it is very-very important for them to change the lifestyle and take medications as recommended and then follow all the precautions with the doctor and then probably rehabilitation patterns, the yoga, lifestyle measures are also equally important and one very good thing which is heartening for everybody to know especially the cardiac patients and treating doctors is that cardiovascular physicians have done wonders to these patients. In a large study……




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