What is the management of ST-Elevation Myocardial Infarction (STEMI) in resource-limited settings?

Management of STEMI in Resource-Limited Settings

A pharmaco-invasive strategy—fibrinolysis followed by planned angiography at 3-24 hours—is the most feasible and desirable pathway for STEMI management in resource-limited settings, particularly when primary PCI cannot be delivered within 120 minutes of presentation. 1

Initial Triage and Immediate Medical Therapy

At First Medical Contact (Any Level Facility)

• Administer chewable/soluble aspirin 300-350 mg stat (non-enteric coated) immediately upon suspicion of acute coronary syndrome, even before ECG confirmation 1
• Obtain 12-lead ECG within 10 minutes of arrival if equipment available 1
• If no ECG capability exists and high suspicion for MI, transfer immediately to closest facility with ECG 1

Once STEMI Confirmed

• Clopidogrel 300 mg if patient <75 years or 75 mg if ≥75 years 1
• High-dose statin: Atorvastatin 80 mg or Rosuvastatin 40 mg 1
• Beta-blockers and ACE inhibitors as appropriate 1

Reperfusion Strategy Selection

Primary Decision Algorithm

The critical time thresholds determine your approach:

• If primary PCI can be performed within 90-120 minutes of first medical contact: Transfer for primary PCI 1, 2
• If fibrinolysis can be given >60 minutes before PCI would be available: Proceed with fibrinolytic therapy 1
• If presenting within first 2 hours of symptom onset: Fibrinolysis outcomes are similar to or better than delayed primary PCI 1

The Golden Hour Principle

• Reperfusion within the first 60 minutes of symptom onset provides 50% mortality reduction 1
• Every minute of delay matters—fibrinolysis can be administered faster than arranging transfer for PCI in most resource-limited settings 1

Fibrinolytic Therapy Implementation

Agent Selection

Streptokinase is the most commonly available and cost-effective option in resource-limited settings 1, though tenecteplase and alteplase (accelerated infusion) show superior mortality outcomes when available 3

• Streptokinase plus parenteral anticoagulants has 14% higher mortality risk compared to accelerated alteplase 3
• Tenecteplase shows trend toward lower bleeding risk (RR 0.79) compared to other regimens 3
• Avoid adding glycoprotein IIb/IIIa inhibitors to fibrinolytic therapy—this increases major bleeding risk by 1.27-8.82 times without mortality benefit 3

Pre-Fibrinolysis Checklist

• Verify no absolute or relative contraindications using standardized checklist 1
• Ensure aspirin and clopidogrel already administered 1
• Initiate parenteral anticoagulation (unfractionated heparin or LMWH) 3, 4

The Pharmaco-Invasive Strategy (Preferred Approach)

This is the most practical and evidence-based pathway for resource-limited settings 1:

Step 1: Immediate Fibrinolysis

• Administer fibrinolytic at facility with thrombolytic capability 1
• Continue dual antiplatelet therapy and anticoagulation 4

Step 2: Risk Stratification Post-Fibrinolysis

For hemodynamically stable patients:

• Plan transfer for angiography at 3-24 hours after fibrinolysis 1
• Monitor for signs of failed reperfusion (persistent chest pain, <50% ST-segment resolution at 90 minutes) 1

For high-risk patients requiring immediate transfer:

• Hemodynamic or electrical instability 1
• Left ventricular dysfunction 1
• Elderly patients 1
• Failed fibrinolysis (rescue PCI needed immediately) 1

Step 3: Selective Angiography Strategy

In severely resource-constrained settings where routine post-lysis angiography is not feasible:

• Triage only high-risk patients (above criteria) to catheterization 1
• Use noninvasive risk stratification for stable low-risk patients: predischarge exercise treadmill test or stress imaging 1
• Refer for angiography only if inducible ischemia demonstrated 1

Hub-and-Spoke System of Care

Establish tiered facility levels with clear transfer protocols 1:

Level 1 (Minimal Capability)

• No ECG available
• Give aspirin, arrange immediate transfer 1

Level 2 (ECG Capability)

• Confirm STEMI diagnosis
• Administer aspirin, clopidogrel, statin 1
• Transfer to reperfusion center 1

Level 3 (Fibrinolysis Capability)

• Administer fibrinolytic therapy 1
• Stabilize and transfer for angiography at 3-24 hours 1

Level 4 (PCI Capability Without 24/7 Availability)

• Provide fibrinolysis during off-hours 1
• Perform PCI when laboratory available 1

Level 5 (Hub Center)

• Full-spectrum capabilities including 24/7 primary PCI 1
• Accepts transfers from spoke facilities 1

Late Presenters (>12 Hours)

For patients presenting >12 hours after symptom onset without ongoing symptoms or hemodynamic instability:

• Stabilize with medical therapy (aspirin, clopidogrel, beta-blockers, ACE-inhibitors, high-dose statins) 1
• Perform noninvasive evaluation for inducible ischemia 1
• Reserve invasive strategy for those with positive stress testing 1

Cost Considerations and Practical Implementation

Stent Selection

• Bare metal stents are acceptable for cost constraints, though drug-eluting stents have better long-term outcomes 1
• Consider drug-eluting stents for high-risk subsets when feasible 1

Multivessel Disease Management

• If hemodynamically stable, consider complete revascularization during index procedure to reduce need for repeat procedures 1
• This approach upgraded to Class IIa recommendation in recent guidelines 1

System-Level Requirements

• Establish contractual arrangements between hub and spoke hospitals 1
• Create cashless payment systems to eliminate upfront out-of-pocket barriers 1
• Implement performance measures for quality improvement (educational, not punitive) 1

Critical Pitfalls to Avoid

• Never delay fibrinolysis waiting for transfer if PCI cannot be achieved within 120 minutes 1
• Do not add glycoprotein IIb/IIIa inhibitors to fibrinolytic regimens—bleeding risk outweighs benefit 3
• Avoid using streptokinase when tenecteplase or accelerated alteplase available—mortality difference is significant 3
• Do not skip the pharmaco-invasive strategy in favor of fibrinolysis alone when angiography is accessible within 3-24 hours 1