STEMI Performance in Asia: Current State and Strategies for Improvement
Asia demonstrates substantial heterogeneity in STEMI care delivery, with reperfusion rates ranging from 54% to 92% across countries, median door-to-balloon times of 132 minutes in Beijing and up to 20.9 hours in India, and 2-year mortality between 2.5% and 7.4%—all falling short of guideline-recommended targets that mandate ≤90-minute door-to-balloon times for direct presentations and ≤120-minute first-medical-contact-to-device times for transfers. 1, 2
Current Performance Metrics Across Asia
Reperfusion Rates and Modalities
Overall reperfusion therapy utilization varies dramatically: Korea achieves 91.6% primary PCI rates, while Malaysia relies predominantly on fibrinolysis (72.6%) with only 9.6% receiving primary PCI, and India delivers reperfusion to just 53.9% of STEMI patients. 1
China demonstrates intermediate performance: In Beijing, 80.9% of patients receive reperfusion therapy (65.5% primary PCI, 15.4% fibrinolysis), but in rural Henan province only 35.1% receive early reperfusion. 3, 4
Southeast Asia shows mixed patterns: Primary PCI rates range from 24.8% in India to 65.6% in Northern Europe comparator regions, with fibrinolysis use between 8.1% in China and 34.2% in Southeast Asia. 2
Time-to-Treatment Performance
Door-to-balloon times consistently exceed guideline targets: Beijing reports a median of 132 minutes, with only 22% of patients achieving the ≤90-minute goal recommended by ACC/AHA guidelines. 3, 5
Door-to-needle times for fibrinolysis are also delayed: Beijing's median of 83 minutes means only 7% meet the ≤30-minute guideline target, while rural China achieves 18 minutes but still falls short of optimal performance. 3, 4, 5
First-medical-contact delays are substantial: Median symptom-onset-to-first-medical-contact time in rural China is 168 minutes (2.8 hours), and India reports median time-to-primary-PCI of 20.9 hours—both far exceeding the 120-minute threshold where fibrinolysis becomes preferable. 4, 2, 5
Mortality Outcomes
Two-year mortality demonstrates significant regional variation: Korea/Hong Kong/Singapore achieve 2.5%, China 4.8%, Southeast Asia 5.9%, and India 7.4%—all higher than the 6.2% seen in Japan and substantially above the 9.5% in-hospital mortality achieved by the Vienna STEMI Registry after implementing guideline-based networks. 1, 2, 5
In-hospital mortality in China ranges from 5.4% to 5.8%, comparable to developed regions but reflecting the fact that two-thirds of patients in rural areas receive no reperfusion therapy at all. 3, 4
Guideline-Recommended Targets for Optimal STEMI Care
Time-Based Performance Standards
First-medical-contact-to-device time ≤90 minutes for patients transported directly to PCI-capable hospitals by emergency medical services. 5
First-medical-contact-to-device time ≤120 minutes for patients initially presenting to non-PCI-capable hospitals who require transfer. 5
Door-to-needle time ≤30 minutes when fibrinolytic therapy is the chosen reperfusion strategy at non-PCI-capable facilities. 5
Door-in-door-out time ≤30 minutes for patients arriving at non-PCI hospitals who require immediate transfer for primary PCI. 5, 6
ECG acquisition and interpretation within 10 minutes of first medical contact to establish "time zero" for all subsequent decisions. 5, 7
Reperfusion Strategy Selection Algorithm
Primary PCI is the preferred method when FMC-to-device time can be ≤120 minutes, performed by experienced operators (≥75 PCI cases/year) in high-volume centers (≥36 primary PCI cases/year). 5
Fibrinolytic therapy should be administered within 10–30 minutes of diagnosis when anticipated FMC-to-device time exceeds 120 minutes due to unavoidable delays. 5, 8
Symptom onset ≤3 hours: Primary PCI and fibrinolysis demonstrate comparable mortality if fibrinolysis is delivered within 2–3 hours; the Vienna Registry showed equivalent outcomes when either strategy was initiated within this window. 5, 6
Symptom onset 3–12 hours: Primary PCI is superior to fibrinolysis for mortality and reinfarction reduction; PCI should be pursued regardless of anticipated delays in this time frame. 5, 7
Absolute indications for immediate primary PCI (any time): Cardiogenic shock, acute severe heart failure, contraindications to fibrinolysis, failed fibrinolysis (≤50% ST-segment resolution at 60–90 minutes), and resuscitated cardiac arrest with ST-elevation. 5, 6, 7
Recommended Strategies to Achieve Guideline Targets in Asia
Regional STEMI Network Development
Establish integrated regional systems that coordinate pre-hospital emergency medical services, non-PCI hospitals, and 24/7 PCI-capable centers through standardized written protocols—the Vienna STEMI Registry demonstrated that such networks increased reperfusion rates from 66% to 86.6% and reduced in-hospital mortality from 16% to 9.5%. 5, 6
Implement pre-hospital 12-lead ECG programs with immediate catheterization laboratory activation by EMS personnel before hospital arrival; this intervention is associated with shorter reperfusion times and lower mortality rates. 5
Create direct catheterization laboratory access pathways that bypass emergency departments and intensive care units; the ESC guidelines document a 20-minute time savings with this approach. 5, 7
Designate a central medical director with authority to modify protocols based on continuous performance data and conduct quarterly multidisciplinary meetings to review outcomes. 6
Addressing Geographic and Resource Constraints
Deploy pre-hospital fibrinolysis capability in regions where FMC-to-device times consistently exceed 120 minutes; a 2025 consensus statement for low- and middle-income countries emphasizes this pharmaco-invasive strategy as essential when primary PCI infrastructure is limited. 9
Establish formal transfer agreements between non-PCI and PCI-capable hospitals with pre-specified protocols for immediate patient handoff; door-in-door-out times ≤30 minutes are achievable with such systems. 5, 6
Avoid the "PCI at any cost" pitfall: The Vienna Registry and ACC/AHA guidelines emphasize that fibrinolysis administered within 3 hours of symptom onset is equivalent to delayed PCI, and overreliance on primary PCI when delays are unavoidable leads to worse outcomes than immediate fibrinolysis. 5, 6
Implement a flexible three-model pathway (fibrinolysis model, pharmaco-invasive model, primary PCI model) tailored to local circumstances, as proposed by the STEMI India and Stent Save a Life initiatives. 9
Quality Monitoring and Continuous Improvement
Mandate real-time tracking of all time intervals from symptom onset through reperfusion, with monthly benchmarking reports to all network participants against national standards. 6
Collect and publicly report standardized quality metrics: door-to-ECG, door-to-balloon, FMC-to-device, door-to-needle, and door-in-door-out times, along with 30-day and 1-year mortality stratified by reperfusion strategy. 6
Conduct root-cause analysis of any case exceeding time targets and perform annual reviews of mortality, reinfarction, and bleeding outcomes. 6
Participate in national quality programs such as Mission: Lifeline and the D2B Alliance to access benchmarking data and best-practice resources. 5, 6
Pharmacotherapy Optimization
Ensure universal aspirin administration (150–325 mg orally or 250–500 mg IV) immediately at first medical contact; Asian registries show 97.8% compliance in Beijing but lower rates in rural areas. 3, 7
Administer potent P2Y12 inhibitors (prasugrel or ticagrelor) before or at the time of PCI; clopidogrel use remains high in Asia (89.7% in Beijing) but should be replaced with more effective agents when available. 3, 7
Prescribe evidence-based secondary prevention: Beta-blockers (76.7% in Beijing), ACE inhibitors (73.5%), and statins (91.0%) are underutilized in some Asian regions and require systematic implementation. 3, 7
Critical Gaps Requiring Urgent Attention
Two-thirds of rural Chinese STEMI patients receive no reperfusion therapy, and tertiary hospitals in these regions fail to leverage around-the-clock primary PCI capabilities—referral systems and patient/physician education about reperfusion safety are essential. 4
Median time-to-primary-PCI of 20.9 hours in India indicates catastrophic system failures; immediate implementation of pre-hospital fibrinolysis and pharmaco-invasive strategies is mandatory in such settings. 2
Regional mortality variations persist after adjustment for reperfusion therapy and known prognostic factors, suggesting that unmeasured quality-of-care differences (operator experience, hospital volume, post-procedural management) require targeted investigation and intervention. 2