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The article discusses patients presenting with ST-elevation myocardial infarction, immediate and timely reperfusion is of paramount importance, and the optimal choice between primary percutaneous coronary intervention. Topics include use of fibrin-specific thrombolytics such as tenecteplase and alteplase has cost-prohibitive compared with streptokinase; and a pharmacoinvasive approach has particular promise for low- and middle-income countries.

The prevalence of coronary artery disease and ST-elevation myocardial infarction (STEMI) are increasing in India. Although recent publications have focused on improving preventive measures in developing countries, less attention has been placed on the acute management of STEMI. Recent policy changes in India have provided new opportunities to address existing barriers but require greater investment and support in the coming years. [ABSTRACT FROM AUTHOR]

The article reports on the price regulation for coronary stents by the National Pharmaceutical and Pricing Authority (NPPA) in India. Topics mentioned include the price variation in coronary stents among hospitals in New Delhi, the price management for medical equipment, and the importance of coronary stents to control cardiovascular diseases.

Objective: To compare the clinical presentation, risk factors and outcomes of young patients (≤45 years) presenting with ST segment-elevation myocardial infarction (STEMI) with older STEMI patients in the Tamil Nadu STEMI program (TN-STEMI).Methods: A total of 2,420 patients were enrolled in the TN-STEMI program, which is a pre-implementation and post-implementation quality of care study. The cohort of patients was divided into young STEMI patients (≤45 years) and compared with those aged >45 years.Results: A total of 591(24.4%) patients in this cohort were aged ≤45 years; 92.5% of the young STEMI were males. Smoking was the most common risk factor and its use was significantly more in younger myocardial infarction (MI) patients than in older patients (57% vs 31%; p<0.001). Compared with their older counterparts, younger patients had a lower prevalence of hypertension (14.2% vs 28.3%; p<0.001) and diabetes mellitus (13.2% vs 29.7%; p<0.001). Total ischaemic time was shorter for younger patients (235 vs 255 mins; p=0.03). Young STEMI patients more frequently presented with single vessel disease and the left anterior descending coronary artery was the most common infarct-related artery; they also had a higher thrombus load. Young MI patients had reduced mortality, both in-hospital (3.4% vs 6.4%; p=0.005) and at one year (7.6% vs 17.6%; p<0.001). Younger male STEMI patients also showed lower mortality than younger female patients.Conclusions: Young STEMI patients compared with older STEMI patients had lower prevalence of traditional risk factors, shorter ischaemic time and reduced mortality. Young female STEMI patients had higher mortality than young male STEMI patients. [ABSTRACT FROM AUTHOR]

The TN STEMI Program was a multicenter, prospective, observational study conducted in Tamil Nadu, India, that assessed the effects of implementing the STEMI India Model for the management of STEMI. We discuss the economic and societal impact in this article. Given that the intervention resulted in an absolute mortality reduction of 3.4%, we calculated a number needed to treat of 30 patients. At an annualized project cost of INR 15.11 million, this approximately calculates to INR 193,749 (USD 3,311) per life saved. The utility of the TN-STEMI Program can be estimated to be 1,108 life-years. This calculates to approximately INR 13,643 (USD 233) per life-year saved. Our estimates will likely be of particular interest to policy makers in low and middle-income countries, where financial and resource constraints pose a perennial public health challenge., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2019 The Author(s).)

Importance: Challenges to improving ST-segment elevation myocardial infarction (STEMI) care are formidable in low- to middle-income countries because of several system-level factors., Objective: To examine access to reperfusion and percutaneous coronary intervention (PCI) during STEMI using a hub-and-spoke model., Design, Setting, and Participants: This multicenter, prospective, observational study of a quality improvement program studied 2420 patients 20 years or older with symptoms or signs consistent with STEMI at primary care clinics, small hospitals, and PCI hospitals in the southern state of Tamil Nadu in India. Data were collected from the 4 clusters before implementation of the program (preimplementation data). We required a minimum of 12 weeks for the preimplementation data with the period extending from August 7, 2012, through January 5, 2013. The program was then implemented in a sequential manner across the 4 clusters, and data were collected in the same manner (postimplementation data) from June 12, 2013, through June 24, 2014, for a mean 32-week period., Exposures: Creation of an integrated, regional quality improvement program that linked the 35 spoke health care centers to the 4 large PCI hub hospitals and leveraged recent developments in public health insurance schemes, emergency medical services, and health information technology., Main Outcomes and Measures: Primary outcomes focused on the proportion of patients undergoing reperfusion, timely reperfusion, and postfibrinolysis angiography and PCI. Secondary outcomes were in-hospital and 1-year mortality., Results: A total of 2420 patients with STEMI (2034 men [84.0%] and 386 women [16.0%]; mean [SD] age, 54.7 [12.2] years) (898 in the preimplementation phase and 1522 in the postimplementation phase) were enrolled, with 1053 patients (43.5%) from the spoke health care centers. Missing data were common for systolic blood pressure (213 [8.8%]), heart rate (223 [9.2%]), and anterior MI location (279 [11.5%]). Overall reperfusion use and times to reperfusion were similar (795 [88.5%] vs 1372 [90.1%]; P = .21). Coronary angiography (314 [35.0%] vs 925 [60.8%]; P < .001) and PCI (265 [29.5%] vs 707 [46.5%]; P < .001) were more commonly performed during the postimplementation phase. In-hospital mortality was not different (52 [5.8%] vs 85 [5.6%]; P = .83), but 1-year mortality was lower in the postimplementation phase (134 [17.6%] vs 179 [14.2%]; P = .04), and this difference remained consistent after multivariable adjustment (adjusted odds ratio, 0.76; 95% CI, 0.58-0.98; P = .04)., Conclusions and Relevance: A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.