Why every cardiologist is guilty, in a fundamental Issue in STEMI management ?

Why every cardiologist is guilty, in a fundamental Issue in STEMI management ?

November 1, 2024 by dr s venkatesan

Time windows for intervention for thrombolysis in STEMI starts from onset of chest pain, but when it comes to primary PCI, a different time window takes the center stage pushing the former to the background. For primary PCI , the distorted time window starts from the arrival to the doors of (either the ER ) or cath lab, and extends endlessly to point of balloon Inflation.

Why is this disparity?

No guidelines bothers to mention if the S2D time is prolonged, D2B need to be short or ultrashort. How can we have uniform std of 90-120 minutes D2B in all STEMI cases ? Why the cardiology community is silent on this crucial time mis-management error ? Apart from this, ,ie if the S2D is too prolonged pPCI is to be abandoned is vaguely stressed.

Answer

I think the answer should be one of the following .

1.It is intentional .

2.Out right Ignorance

3.To favor the perceived superiority pPCI .

Only time will answer.

Curiously, none of the globally accepted standard guidelines seem to realize they have not given sufficient weightage to this aspect of coronary time window , while gathering the evidence.(Most papers on pPCI never mention about S2B times vis vis with IRA TIMI flows)

Final message.

No amount of guidelines will lead us to proper pathway of coronary care ,unless we are ready to course- correct and eliminate basic timing errors. Of course, If we are knowingly straying from the right path, there is no escape for our patients from science.

Post- amble

How is this possible in this cutting edge scientific era.?

*The problem with hyper Intelligence is, any amount of scientific evidence can be created to show, what we are doing is right.

What could be a lesson we can learn here ?

If symptom to lysis time is less than 50% of Symptom to needle time , every such patient should enter “pharmaco- Invasive or pharmaco only” strategy according to the prevailing CAG anatomy.

Counterpoint

D2B is under you control. S2B is not in your control*, so simply don’t bother about the former. The other possible argument for ignoring symptom to balloon time ,is late lysis doesn’t work that effectively, hence the only option is PCI however delayed it is. But, in the process, we forget , most times we are the ones who created this deadly delay and master the art of loosing the golden hour in STEMI , that is backed up with flawless RCTs.

*Is S2B is really not in out control ? Yes , it is true, until we replace S2B to S2R (R-Revascularisation) time. This is unlikely to happen as long as we strongly believe balloons have the exclusive capacity to revascularize the IRA.

Reference

S2D -Symptom to door time

S2B-Symptom to balloon time

D2B– Door to balloon time

S2R*-Newly proposed . Symptom to revascularisation time (any modality)