National Programme for Prevention and

Control of Non-communicable Diseases

Guidelines for Management of

ST-Elevated Myocardial Infarction

Directorate General of Health Services

Ministry of Health & Family Welfare
Government of India

2022
National Programme for Prevention and
Control of Non-communicable Diseases

Guidelines for Management of

ST-Elevated Myocardial Infarction

Directorate General of Health Services

Ministry of Health & Family Welfare
Government of India

2022
TABLE OF CONTENTS

1. Introduction....................................................................................... 1
2. Magnitude of STEMI burden.............................................................. 2
3. Risk Factors for STEMI..................................................................... 3
4. Objectives......................................................................................... 4
5. Operational Strategies...................................................................... 5
6. Implementation Details..................................................................... 6
7. Management of STEMI.................................................................... 11
8. Hub & Spoke Model for STEMI Management Services.................... 14
9. Conclusion...................................................................................... 16
References.......................................................................................... 17
List of Experts & Contributors.............................................................. 18
Annexures........................................................................................... 19
 1 Introduction
Myocardial infarctions are generally clinically classified into ST elevation MI (STEMI) and
non-ST elevation MI (NSTEMI), based on changes in ECG. When blood flow to a part
of the heart stops or the heart is injured and fails to receive enough oxygen required for
its adequate functioning the condition is termed as STEMI or the ‘heart-attack’ in laymen
language. Patients with elevated cardiac troponin levels but negative CK-MB who were
formerly diagnosed with unstable angina or minor myocardial injury are now reclassified
as non-ST-segment elevation Myocardial Infarction (non-STEMI) even in the absence of
diagnostic changes.1

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 2
Magnitude of STEMI burden
Cardiovascular diseases (CVDs) are the leading cause of death globally, taking an
estimated 17.9 million lives (32% of global deaths) each year (WHO, 2022). Heart
attacks and Stroke account for 85% of these deaths. The mortality and morbidity due to
Myocardial Infarction accounts for more than 15% mortality per year among STEMI and
Non-STEMI patients.2 The ischemic heart disease/ STEMI is the highest-ranking cause
of premature death in terms of number of years of life lost.

In India, CVDs are estimated to account for about 28.1% of deaths. Ischemic Heart
Diseases and Strokes account for 80% of all CVDs. Contribution of CVDs to Disability
Adjusted Life Years (DALYs) is also highest at 14.1%, including 8.7% DALYs caused by
Ischemic Heart Diseases (IHD) alone.3 STEMI is estimated to account for more than 2.5
million cases annually in India (approximately 40% of myocardial infarctions).4

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 3
Risk Factors for STEMI
There are many risk factors leading to STEMI which may be modifiable or non-modifiable.
Risk factors are listed below:
1. Behavioral Risk Factors:
a. Harmful consumption of Alcohol
b. Smoking
c. Lack of physical activity
d. Unhealthy diet
e. Psychological Stressors
2. Intermediate Risk Factors:
2.1. High blood pressure/Hypertension
2.2. High blood sugar/diabetes
2.3. High blood cholesterol levels
2.4. Overweight/obesity
3. Non – modifiable:
a. Age (older age increases risk)
b. Gender (males are at comparatively greater risk)
c. Family history
d. Racial ethnicity
e. Others
These “intermediate risks factors” can be measured in primary care facilities and indicate
an increased risk of heart attack, stroke, heart failure and other complications. Modifiable
risk factors account for more than 90% of the risk of MI.

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 4
Objectives
The guideline for management of STEMI under National Programme for Prevention &
Control of Non-Communicable Diseases (NP-NCD) tries to enhance the awareness
regarding it. The broad guiding principle of the document is to provide reperfusion
therapy closer to the community, within the acceptable framework, with proper linkages
with referral centres to reduce preventable morbidity and mortality.

The document emphasizes to provide thrombolysis to STEMI patient close to community

with adequate safeguards, in a graded manner as per the availability of required resources
at the health facilities. It would enable States/ UTs to develop and effectively run a suitable
model of management of STEMI depending on their geography and infrastructure.

It would facilitate in reducing the delays in providing the reperfusion therapy to STEMI
patients due to non-availability of a Percutaneous Coronary Intervention (PCI) performing
health facility nearby. The document would help to curtail the system related delays
by enabling the non-PCI performing health facilities to administer thrombolytic agents
as an emergency procedure. It would establish the thrombolytic capacity at non-PCI
health facilities (PHCs/CHCs/SDH/DH), fulfilling the criteria for availability of resources
as required for the implementation of the programme, with referral linkages with PCI
enabled facilities for further management and care.

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 5
Operational Strategies
To facilitate the provision of thrombolysis to the patients closer to community with
adequate safeguards the strategy of the STEMI management services at any public
healthcare facility will depend on the infrastructure availability. This can be achieved in a
graded manner initially providing thrombolysis at the secondary level healthcare facilities
i.e., Sub District Hospital (SDH)/ District Hospital (DH) level where emergency care is
well established. The implementation of the services for STEMI is advised in phased
manner with gradual expansion to the lower-level health facilities i.e., Community Health
Centres (CHCs)/ Primary Health Centres (PHCs) depending upon the availability of
required resources.

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 6
Implementation Details
The healthcare facility level at which to start with the implementation of STEMI management
services will depend on the gap analysis* performed by the States/UTs. Facility and HR
mapping should be undertaken by the States/UTs for all the health facilities. It includes
trained HR (MD Medicine/MBBS, ECG technician & Staff Nurse), essential medical
equipment, emergency drugs & capability for undertaking thrombolysis at the health
facility. For States/UTs which do not have these services functional as on date, it would
be a prudent strategy to pilot the STEMI management services implementation first in
2-3 districts at the DH/CHC level and expand later in all the districts proceeding gradually
to include all PHCs under the programme. Each State/UT desirous of starting a STEMI
management services is required to be well equipped before employing it state-wide.

6.1. Mapping & Grading of Health Care Facilities

The Healthcare facilities may be mapped according to the services provided as follows:

Grade Level of Care Health facility

L-1 Medical officer with no ECG facility and not capable of PHC-HWC
Thrombolysis.
L-2 Medical Officer (MBBS Doctor) having ECG facility and capable PHC-HWC, CHC
of Thrombolysis.
L-3 Facility with MBBS doctor & MD Medicine, ECG technician, DH, SDH, RH,
Staff Nurse and having emergency care (ICU/HDU) set-up with CHC
Thrombolysis capability
L-4 Public Healthcare Facility with ICU/ HDU (Emergency care) Medical College or
setting having MD Medicine/ Cardiologist & CCU setup. District Hospital
L-5 Facility having Cardiac Cath lab/ PMJAY empaneled facility. Medical College/
Private Cath lab
Centre

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6.2. Implementation Framework
The resources/ services required at various health facility level for management of STEMI
patients are as follows:

a) Infrastructure: Chest Pain clinics at levels of healthcare system with ECG

facility. The set-up of infrastructure like Cath lab, Critical Care Unit (CCU), etc.
and procurement of equipment, dugs & consumables can be done under NP-
NCD as per the Operational guidelines for the programme (NP-NCD) or under
NHM as per the XV Finance Commission financial norms.
b) Human Resources: Availability of MBBS/MD Medicine doctors and paramedical
staff (ECG technician & Staff Nurse) trained in diagnosis & treatment of
STEMI (including management of post-thrombolysis complications, absolute
contraindications to thrombolysis therapy, and follow-up requirements). Engaging
service providers for Tele-reporting of ECG by MD Medicine/ Cardiologist can also
be done and similarly drugs/consumables (Bolus thrombolytic agents) through
Free Drugs Initiative (FDI).
c) Capacity Building: It is important to build provider-level education and point of-
care interventions for successful outcomes. All MBBS/MD Medicine doctors, who
are likely to be the first responder should undergo training in the interpretation of
ECG and management protocols of STEMI (remote training can be provided in
virtual mode with the state apex hospital/medical college). In this regard AIIMS
(or any other similar designated entity) can be a facilitator providing training
tools & curriculum to the State Medical Colleges for in STEMI management
services. The training would also include familiarization of MBBS doctors/ MOs
with the e-Sanjeevni teleconsultation module, ECG transmission and its remote
interpretation. States may organize short refresher hands-on training courses for
the MOs in ECG recording and interpretation at the nearest DH/SDH under the
supervision of MD Medicine/Cardiologist, periodically as per requirement.
Training and capacity building of healthcare staff at different level of health
facilities is necessary for the successful implementation of STEMI management
services.
• Aim of MO and para medical training at L1 facility: The importance of early
reperfusion and emphasize the need to rapidly triage STEMI and refer to a
reperfusion-capable nearest spoke/hub facility
• Aim of MO and paramedical training at L2 and L3 facilities: it is to train and re-
train the importance of early reperfusion and emphasize the need to rapidly
triage STEMI, administer thrombolytic therapy transfer in eligible patients
and transfer to a reperfusion-capable hub facility. The MBBS doctor may be
trained to build STEMI green channels. This will avoid delays in reopening the
occluded coronary artery.
• Aim of cardiologist/MD Medicines training at L4 and L5 facilities: It is to build
a network of cardiologist and MD Medicines in the State for interpreting
ECGs and providing tele-consultation to MBBS doctors at non-PCI STEMI
centers, to train non-PCI STEMI centers in building STEMI green channels,
transmit ECG to Central Command centre 24X7 and initiate thrombolysis in
consultation with cardiologist/ MD Medicine.

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 d) Equipment: A functional 12-lead ECG machine with PC port, Troponin point of
care device, Multi Para Monitor (To consider Biosensors), Defibrillator (Manual &
Automatic External Defibrillator mode), GPS enabled smartphone. The indicative
list of medical equipment & consumables required is given in Appendix ‘D’.
e) Teleconsultation: States/UTs are encouraged to use the tele-consultation
module of e-Sanjeevni platform for ECG interpretation & tele-consultation.
Centralized 24X7 Command Centre to be set up at the State or the District Level
with cardiologist and/or MD Medicines for tele ECG support and consultation
for STEMI management through e-Sanjeevni portal. This may be required only
in a L1 or L2 grade facility, and occasionally in a L3 grade facility for remote
interpretation of ECG. To enable every MBBS doctor to thrombolyse patients with
STEMI at public healthcare facility, a system of immediate ECG transmission
and remote interpretation by a trained MD Medicine or a cardiologist should be
established.
For engaging service providers in PPP mode mapping of the district wise health
facilities can be done to provide support in digitalizing the ECG recordings
and transmitting the same to the nearest PCI capable hospital’s MD Medicine/
Cardiologist for reporting ECGs and providing teleconsultation. The tele-
consultation can be held using the already established e-Sanjeevni doctor-to-
doctor module.

f) Referral system: The suspected STEMI cases are referred to higher health
facilities for further diagnosis and management. The linkages with 108-ambulance
to transport the patients to the nearest secondary/ tertiary level healthcare facility
with reperfusion services for further management of the patients as required.
Trained paramedical staff (EMT) in ALS ambulance has to be provided while
transportation. The facility wise linkages from L1 to L5 grade may be ensured in
advance to reduce the referral delays.
The success of the STEMI implementation depends upon the linkages built
within the implementation framework. States can implement their own model for
building linkages with electronic data communication (Patient data, test results &
ECG recording), treatment/ management protocols, Insurance re-imbursement
models and dedicated transport system. The existing 104 Health Helpline and

8
 108 Ambulance (National Ambulance Service) Central call center can be linked
with the programme.
To have a successful programme it is important to must have a robust ambulance
network either (in-house) or PPP model with a 24 X 7 (round the clock) Central
Call facility for providing Ambulance support to convey patient to nearest health
facility. The Ambulance should be equipped with Vital parameter Monitor, AED,
oxygen, and trained Emergency Medicine Technician (EMT). The National Health
Mission, MoHFW supports the National Ambulance Services as part of Health
systems strengthening.
g) Supply Chain Management: Robust system using DVDMS (Drugs and Vaccine
Distribution Management System) platform for uninterrupted supply of thrombolytic
agents and other listed medications & life-saving drugs; Oxygen Cylinder with
oxygen delivery system; emergency medicines for managing cardiac arrest, etc.
should be ensured.
h) Information Education and Communication (IEC): Public education efforts are
the hall mark of any programme including STEMI. Following measures could be
taken under the IEC components under NP-NCD to improve the awareness and
utilization of the services under the programme:
• Sustained IEC campaign focusing on Behavior Change Communication (BCC)
for lifestyle modification & CVDs prevention by creating mass awareness
regarding risk factors for STEMI.
• Educating public towards recognizing the symptoms of STEMI/ heart attack
e.g., chest discomfort with or without radiation to the arms[s], back, neck, jaw,
or epigastrium; shortness of breath; weakness; diaphoresis; nausea; light
headedness.
• Educating public about the concept of “Time is Muscle’ for early presentation
to STEMI-ready healthcare facility nearest to their home/ workplace.
• Awareness efforts should also be directed toward pre-hospital use of soluble/
chewable aspirin before transport to an appropriate healthcare facility.
The facilities available for management of STEMI need to be listed by the State/
district and prominently displayed at common places.
i) Monitoring & Evaluation – State Nodal Officer for NP-NCD will be responsible
for implementation of the STEMI services. Regular review meetings should be
conducted once in six months at State level. Frequent supervisory visits should
be made by NCD officers to various health facilities for supportive supervision of
the programme under NP-NCD.
The key metrics that will be collected during the monitoring and evaluation at the
facility level. It includes the following –
• Time from symptom onset to doctor at health facility.
• Time from doctor at health facility to ECG (the ECG should have a time stamp
enabled)
• Door-to-needle (Thrombolysis) time (if facility is lysis capable)
• For transfers, facility (non-lysis) to lysis/device time (Door into Door Out Time

9
 (DIDO), transfer time, and door to lysis/device time at receiving hospital
should be captured separately).
• Complications
• Death & cause of death
j) Recording, Reporting and Data Management - An analysis of the data related
to STEMI incidences, morbidity & mortality during the past is required, prior
implementing a STEMI program in the State/UTs. A three-to- four-month pre-
implementation data collection from the hospitals having Cardiology OPD/
Cath Lab Centre would help to understand the current case load and treatment
practices. This would help in planning the program as well as estimating the
resource and manpower allocation requirements for the program by the States/
UTs. States/UTs are advised to enter data in CPHC-NCD application.
The programme data and reports should be compiled and analysed at facility,
district and state level to generate quarterly reports and send it to national
NCD division. Regular review meetings may be conducted at State/UTs on a
regular basis, to understand the service delivery requirements and performance
assessment of STEMI services.

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 7
Management of STEMI
Goal is to move towards reducing the time taken from symptom onset to presentation,
as much as possible (a 2 hours or less target may be aimed for). The patient should be
transferred to a nearby appropriate hospital for further management as soon as possible.

At the non-PCI healthcare facility, key processes should include:

a) Physical examination of patients with chest pain to aid in diagnosis of STEMI.
b) Performing an ECG in patient with acute chest pain suspected of STEMI.
c) Transmission of ECG and vital parameters to Centralized Command Centre.
d) Act as per the interpretation/ decision support based on ECG readings and
other vital parameters by Centralized 24X7 Command Centre’s MD Medicines/
Cardiologists.
e) Thrombolysis and organizing transport for further care of STEMI at higher PCI
capable centre.

The registered medical practitioner (MBBS doctor) posted in public healthcare system who
is trained to diagnose & manage post thrombolysis complications, relative and absolute
contraindications to thrombolysis therapy, and follow-up requirements in consultation
can perform thrombolysis. The support from the MD Medicines/Cardiologists at linked
Centralized 24X7 Command Centre can be taken to prescribe and perform thrombolysis
at the given health facility.

Diagnosis - Early diagnosis of STEMI needs to be established reducing the system

delays through STEMI green channels. ECG is often the only investigation required to
make a diagnosis of STEMI. STEMI is defined as new ST elevation at the ‘J’ point in at
least 2 contiguous leads of:

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 • ≥ 2.5 mm (0.25 mV) in men younger than 40 years, ≥ 2 mm (0.2 mV) in men
older than 40 years or ≥ 1.5 mm (0.15 mV) in women in leads V2– V3 and/or
• ≥ 1 mm (0.1 mV) in other contiguous chest leads or the limb leads in the
absence of left ventricular (LV) hypertrophy or left bundle-branch block
(LBBB).
(Details in Appendix B)

Treatment - As per the ICMR’s Standard treatment workflow (STW) (Appendix ‘A’):
• Thrombolyse STEMI patient at the non-PCI health facility having emergency
care capability.
• Transport STEMI patients after thrombolysis to PCI enabled facility for
pharmaco-invasive approach.
• Reperfuse the patients at PCI enabled facilities

According to the type of facility grade as per the mapping with the availability of resources,
following package of services are recommended for management of STEMI:
A. (L-1) - Facility having medical officer with No ECG facility and not capable of
thrombolysis
• Record pulse rate, BP, SpO2 & respiration rate.
• Pain relief by NTG spray (in case angina) and Inj. Morphine Intravenous if
available (2-4 mg).
• Supplemental Oxygen inhalation if SpO2 is <90%
• Tab Aspirin 325 mg + Tab Clopidogrel 300 mg + Tab Atorvastatin 80 mg orally
• Transport patient as lying case in ambulance (108) with oxygen accompanied
by a MO.
• Inform the higher centre where the patient is being transferred.

B. (L-2) - Facility having Medical Officer with ECG facility and capable of Thrombolysis
• Record pulse rate, BP, SpO2 & respiration rate.
• Take ECG and diagnose ST changes
• Consult MD Medicine/Cardiologist through tele-consultation and transmit
ECG
• Quickly check for contra-indications or other risk factors.
• Thrombolyse with a bolus thrombolytic agent after approval by the MD
Medicine /Cardiologist
• Repeat ECG at 60-90 min after start of thrombolysis to assess whether
thrombolysis is successful (Less than 50% ST settlement with pain relief) or
not.
• If ongoing pain even after thrombolysis, transfer immediately.
• Hold at the facility for observation and transfer to nearest facility having MD
Medicine/Cardiologist with ICU/HDU facility on stabilization within 24 hours.
• Monitor patient for any complications.
• Transport patient as lysing case in ambulance (108) with oxygen support
(SpO2<90%) & defibrillator within 24 hours accompanied by a MO (may not
be possible), if possible, upon stabilization.
• Inform the higher center where the patient is being transferred.

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C. (L-3) - Facility with Medical Officer & MD Medicine, Technician, Nurse and having
emergency care (ICU/HDU) set up with thrombolysis capability
• Admit patient in ICU/HDU equipped with continuous ECG monitoring &
De-fibrillation for observation & monitor patient for any complications.
• Conduct routine biochemistry tests and serial cardiac enzymes (Troponin)
• Assessment by MD Medicine/Cardiologist
• Repeat ECG at 60-90 min after start of thrombolysis to assess whether
thrombolysis is successful (Less than 50% ST settlement with pain relief)
or not.
• Start Pharmaco-invasive treatment for patients transferred from L1 or L2
facilities as per STW protocol (Unfractionated heparin - Bolus of 60 U/Kg max
up to 5000 Units followed by 12U/kg hourly infusion to maintain APTT at 50-
70 sec alternatively Inj. Enoxaparin 1mg/kg subcutaneous 12 hourly).
• Echocardiography if available, for mechanical complication if any.
• Inform the PCI capable centre for further management and transfer patient on
stabilization within 3-24 hours for angiography.

D. (L4 & L5) - In hospitals where thrombolysis/ PCI for STEMI is already happening
• The data regarding STEMI presentation, treatment strategy and outcomes
need to be captured. Protocol for early triage & hospitalization is placed as
Appendix ‘C’.

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 8
Hub & Spoke Model for
STEMI Management Services
The Hub and Spoke Model arranges service delivery assets into a network consisting
of an anchor establishment (Hub), which offers a full array of services, complemented
by secondary establishments (Spokes), which offer more limited-service arrays, routing
patients needing more intensive services to the hub for treatment.

Benefits of Hub and Spoke Model in STEMI Care are:

i. Extend quality acute STEMI care to spoke hospitals
ii. Access to the specialist to provide consultation before Initiating thrombolysis
(t-PA etc.)
iii. Ability to transfer the patients requiring complex care to the hub
iv. Reduce unnecessary transfers

“Hub & Spoke Model” for STEMI-cardiac patients in the country can be developed in a
way where Hub hospitals are established preferably at State Capital and at some of super
district administrative divisions (here called Divisions where such divisions exist in States/
UTs)/ big sized districts or group of districts (where division does not exist) according to the
choice of the States/ UTs. The spoke hospitals have to be developed at district and CHC
hospitals and then may be scaled up to PHCs. This should ensure that one can get access
to a spoke hospital at least within 50-60 km of their residence.

To treat the STEMI cases in ‘Golden Hours’ (within 2 hours or less from the onset of
STEMI) the implementation of the STEMI management services may be provided
through the Hub and Spoke models. A hub-and-spoke model has to be designed with

14
thrombolysis arrangements to be provided by the Spoke hospitals throughout 24*7
and cover provided by the Hub hospitals. The Hub hospitals are supposed to provide a
24-hour service at State/ UT capital first and then to be scaled up to Divisions/ Districts
as part of a planned rollout of the regional thrombolysis and PCI (Cath lab)/ Mechanical
thrombectomy service. An out-of-hours service is to be provided in the spoke hospitals
for patients assessed as being potentially eligible for thrombolysis. Patients need to be
thrombolysed within 2 hours in case of onset of development of STEMI. Patients are to
be transported in ALS ambulance, investigated and treated as appropriate.

Confirmation for the STEMI: After receiving the patient at the spoke hospital doctors
seek confirmation for the STEMI case from the MD Medicine/Cardiologists of the hub-
hospital. Once the patient reached the spoke hospital, doctors have to take the CT scan
or ECG.

Thrombolising: Once the doctors at the hub hospital confirmed the Stroke/STEMI
case then the medical officer at the spoke hospital start the intervention by initiating
the thrombolising process. The thrombolising process need to get confirmation at the
spoke hospital again after considering the medical history of the patient as it is life-
threatening process. Patient with previous history of thrombolising and other chronic
health conditions/ diseases such as stroke, heart diseases etc. are not thrombolize
at spoke hospital instead they are referred to the hub hospital. This whole process of
confirmation STEMI from hub hospital takes a maximum of 15-45 min. After thrombolising
and stabilizing the patient, the ALS ambulance transfer that patient to the hub hospital for
further treatment

Treatment at Hub hospital: The cardiology department proceed for further treatment as
per the patient health status and time. Almost all the patient reached the hub hospital with
thrombolising undergone with the MRI/ Angiography followed by Angioplasty/ Mechanical
Thrombectomy if required.

Follow-up of the patient: The Hub hospital follow-up the patients after angioplasty/
Mechanical Thrombectomy treatment. Few spokes also have their patient follow-up a
system where they informed to Auxiliary Nurse Midwives (ANM) in that area to follow-up
the patients treated for the STEMI.

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 9
Conclusion
STEMI management services in the country will obviously require a robust organized
system of care to address the inherent challenges and improve key processes. To
achieve the goal of door to needle time (Thrombolysis) within 2 hours, at the community
level will require executing and adherence to the guideline-based treatment protocols,
with efficient and rapid inter hospital transfer within the designated hub and spokes health
facilities, and most importantly capacity building of healthcare staff at the peripheral health
facilities (HWCs & PHCs) to interpret ECGs and facilitate early diagnosis for appropriate
intervention.

Addressing appropriate STEMI care in the country, is the need of the hour. In addition to
patient awareness and education for early symptom identification, extensive education is
required for general practitioners and MD Medicines/intensivists to implement early time
dependent STEMI management. The STEMI management services needs to be linked
with CCUs and Cardiac Cath labs and a graded approach for appropriate management
of all patients needs to be planned by all States/ UTs.

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References
i. Alexander T, Mullasari A, Kaifoszova Z, Khot U, Nallamothu B, Ramana R et al.
Framework for a National STEMI Program: Consensus document developed by
STEMI INDIA, Cardiological Society of India and Association Physicians of India.
Indian Heart Journal. 2015;67(5):497-502.
ii. Cardiovascular diseases (CVDs) [Internet]. who.int. 2022 [cited 27 September
2022]. Available from: https://www.who.int/en/news-room/fact-sheets/detail/
cardiovascular-diseases-(cvds)
iii. India: Health of the Nation’s State. New Delhi: ICMR, PHFI & IHME; 2017.
iv. Salve P, Vatavati S, Hallad J. The hub-and-spoke model of national STEMI
programme of India: An investigation of STEMI-Goa project. Indian Heart Journal.
2021;73(4):P424-428.
v. Yunyun W, Tong L, Yingwu L, Bojiang L, Yu W, Xiaomin H et al. Analysis of risk
factors of ST-segment elevation myocardial infarction in young patients. BMC
Cardiovascular Disorders. 2014;14(1).

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 LIST OF CONTRIBUTORS

• Dr Balram Bhargava, Secretary, DHR and DG, ICMR

• Sh. Vishal Chauhan, Joint Secretary, Policy, MoHFW
• Dr. Sudarsan Mandal, DDG, Dte.GHS, MoHFW
• Dr. Atul Kotwal, Executive Director, NHSRC
• Dr. Bhanu Duggal, Prof. & HOD, Cardiology, AIIMS, Rishikesh
• Dr Anita Saxena, Prof. & HOD, Cardiology, AIIMS, New Delhi
• Dr. R.K. Nath, Prof. & HOD, Cardiology, Dr RML Hospital, New Delhi
• Dr. Sandeep Bansal, Prof. & HOD, Cardiology, SJH & VMMC, New Delhi
• Dr. (Prof.) J. S. Thakur, Prof. of Community Medicine, PGIMER, Chandigarh
• Ms. Sarita Nair, Deputy Secretary, MoHFW
• Dr G. Karthikeyan, Professor of Cardiology, AIIMS, New Delhi
• Dr S. Ramakrishnan, Professor of Cardiology, AIIMS, New Delhi
• Dr. Kiran Ranganath, CMO, NP-NCD, Dte.GHS, MoHFW
• Dr. Manoj Singh, Assistant Director, NP-NCD, Dte.GHS, MoHFW
• Dr. Sunny Swarnkar, DADG, Dte.GHS, MoHFW
• Dr. Jerard Maria Selvam, SNO, NP-NCD, Tamil Nadu
• Dr. L R Pathak, SNO, NP-NCD, Jharkhand
• Dr. Ranjan Choudhary, Advisor, NHSRC
• Dr. Pradeep Joshi, National Professional Officer – NCDs, WHO
• Dr. Abhishek Kunwar, National Professional Officer – CVDs, WHO
• Dr. Meenakshi Sharma, Scientist F, ICMR
• Dr. Shweta Singh, National CVH Consultant, NP-NCD, WHO
• Dr. Ashish Bhat, National CVH Consultant, NP-NCD, WHO
• Dr. Harsavardhan Nayak, Technical Consultant, NP-NCD, UNDP
• Dr. Payal Das, Partnership Consultant, NP-NCD, UNDP
• Mr. Himanshu Pandey, Monitoring & Evaluation Consultant, NP-NCD, UNDP
• Ms. Neha Rathore, Finance Consultant, NP-NCD, UNDP
• Mr. Naiyar Azam, Communication Consultant, NP-NCD

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Appendix

Appendix Subject Page No.

Appendix ‘A’ Standard Treatment Workflow (STW) for STEMI 11

Appendix ‘B’ Diagnosis of STEMI 12 - 16

Appendix ‘C’ Early Triage & Hospitalization 17 - 27
Appendix ‘D’ Indicative STEMI medical equipment & consumables 28 - 30

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 Appendix ‘A’
STANDARD TREATMENT WORKFLOW
for
Management of ST ELEVATION MYOCARDIAL INFARCTION (STEMI)

20
 Appendix ‘B’
DIAGNOSIS OF STEMI
1. Acute chest pain is the most common presenting symptom of acute myocardial
ischemia. STEMI encompasses all acute chest pain syndromes resulting from
myocardial ischemia. Only 20–30% of patients presenting with acute chest pain
are ultimately confirmed to have STEMI upon detailed evaluation. ST segment
elevation myocardial infarction (STEMI) is characterized by myocardial ischemia
that results in persistent ST segment elevation on electrocardiogram (ECG) and
subsequent release of biomarkers of myocardial damage.
2. Increased biomarkers alone in the absence of ST segment elevation constitute
non- ST segment elevation MI (NSTEMI). NSTEMI may manifest with transient/
persistent ST segment depression and/or T wave inversion in ECG. Prolonged
ischemic chest pain without elevation of markers of myocardial necrosis constitutes
unstable angina. STEMI is the most common form of STEMI in India, accounting
for 40–60% of STEMI cases.
3. For the diagnosis of acute myocardial infarction, the presence of any two of the
following three features is essential: characteristic chest pain, ECG changes
and elevated cardiac enzymes. However, patient’s interpretation of symptoms,
availability of ECG and its interpretation, and widespread non-availability of
Troponin testing are among the major recognized challenges in the diagnosis of
STEMI in India.

4. The diagnosis and early risk stratification are usually done at the facility having
doctor (first responder).

ECG Diagnosis
5. The task force for the universal definition of MI defines “STEMI as new ST elevation
at the J point in at least 2 contiguous leads of 2mm (0.2 mV) in men or 1.5mm
(0.15mV) in women in leads V2– V3 and/or of 1 mm (0.1mV) in other contiguous
chest leads or the limb leads in the absence of left ventricular (LV) hypertrophy
or left bundle-branch block (LBBB)”. A concordant ST elevation in a lead with the
positive QRS complex is the best indicator of STEMI in the presence of LBBB. A
score of more than or equal to 3 has a specificity of 98% for diagnosing STEMI.
6. However, STEMI may not be ruled out even when none of the features are
identified. Cases of acute ischemic chest pain with LBBB not accompanied by
other ECG evidence of STEMI poses serious management challenge. In such

21
 patients Troponin levels and regional wall motion abnormalities may guide
reperfusion therapy. If the index of suspicion of STEMI is high, such patients
may be taken up for coronary angiogram. Right bundle branch block (RBBB) left
anterior fascicular block (LAFB) and left posterior fascicular block do not interfere
with the interpretation of ST segment elevation. Cases of acute ischemic chest
pain with LBBB not accompanied by other ECG evidence of STEMI poses serious
management challenge. In such patients Troponin levels and regional wall motion
abnormalities may guide reperfusion therapy. If the index of suspicion of STEMI
is high, such patients may be taken up for coronary angiogram.

Table 1: ECG changes at presentation in STEMI

Typical Atypical
ST Elevation (at least 2 contiguous leads) STEMI in Evolution
• 2 mm (0.2mV) in men or 1.5 mm (0.15 mV) • Hyperacute T-wave changes evolving/
in women in leads V2-V3 evolved STEMI
• 1 mm (0.1 mV) in other contiguous chest • Q wave with T wave inversion with
leads, or the limb leads variable ST elevation
New or presumably new LBBB Posterior wall MI
• ST depression in 2 precordial leads (V1
V3) + positive T waves in V1
Left Main or proximal left anterior
descending artery occlusion
• ST depression in multiple leads with ST
elevation in lead aVR and V1 (aVR > V1;
left main V1 > aVR: proximal LAD)

Table 2: Criteria to diagnose STEMI in presence of LBBB

Sl. No. Criteria Score

1. ST elevation more than or equal 1 mm and concordant with QRS complex 5
2. ST segment depression more than or equal 1 mm in Lead V1, V2 or V3. 3
3. ST elevation more than or equal 5mm and discordant with QRS complex 2

7. Patients may have a first ECG that is not diagnostic of STEMI. In such a situation,
a repeat ECG must be obtained at 10–15 min, and at 30 min intervals (Table
3). The ECGs should be carefully looked for even subtle changes. Cardiac
biomarkers and echocardiogram may be useful guides to reperfusion therapy in
such patients. If the suspicion of ongoing serious myocardial ischemia is high, the
patient should be taken for a coronary angiogram to demonstrate coronary artery
occlusion or intracoronary thrombus. A CT angiogram is usually reserved for
patients with persistent symptoms with low to intermediate likelihood of ischemia
or in patients with suspected aortic dissection or pulmonary embolism.

22
Table 3: Recommendation for ECG
Indication Recommendation Recommendation
1. Chest pain 1. A 12-lead ECG to be 1. Repeat ECG – 10 min, 30
2. Acute pain anywhere performed in all patients min and as needed
from jaw to umbilicus with suspected STEMI 2. Compare with previous
(beyond 20 years 2. Presentation to ECG ECGs for even subtle
of age) diagnosis of STEMI – < 10 changes
3. Atypical symptoms of min 3. Troponin I or T to guide
STEMI 3. A low threshold for therapy
4. Unexplained acute performance of ECG in 4. Echocardiogram for
breathlessness, patients likely to present regional wall motion
hypotension, and with atypical symptoms abnormalities.
hemodynamic collapse 4. Continuous ECG monitoring 5. Emergency coronary
should be started as soon angiography if high index
as possible of suspicion of STEMI
5. Right precordial leads (V3R, 6. CT angiogram only
V4R) must be recorded in if aortic dissection or
patients with inferior wall MI pulmonary embolism to
6. True posterior wall MI be ruled out
may be diagnosed as
ST elevation (>1 mm) in
additional lateral chest
leads V7 – V9

8. The lack of availability of standardized cardiac biomarker assays across the

country is a major limitation in the early diagnosis and risk stratification of STEMI.
Availability of point-of-care Troponin assays across India is even more limited,
which results in overreliance on symptoms and repeated ECGs for diagnosing
STEMI in doubtful cases. Often only semi-quantitative and qualitative assays
of Troponin are available even in referral hospitals. These tests have varying
standards and cut offs. A thorough understanding of the Troponin assay available
at each centre is essential.

Diagnosis of STEMI in India: Challenges

9. All the Indian STEMI registries report that less than 50% of patients with STEMI
have received thrombolysis or PCI. Most of the non-reperfusion resulted from
late presentation of patients beyond the therapeutic window of reperfusion. Lack
of awareness among patients, relatives, paramedics and even doctors is a major
factor responsible for suboptimal acute care of STEMI in India.
10. NSTEMI is diagnosed in patients determined to have symptoms consistent with
STEMI and troponin elevation but without ECG changes consistent with STEMI.
Unstable angina and NSTEMI differ primarily in the presence or absence of
detectable troponin leak. Findings suggestive of NSTEMI include transient ST
elevation, ST depression, or new T wave inversions. ECG should be repeated at
predetermined intervals or if symptoms return.

23
 Appendix ‘C’
EARLY TRIAGE AND HOSPITALIZATION
1. Timely delivery of reperfusion therapy (whether pharmacological or mechanical)
in patients with STEMI is more important than the choice of therapy and the
entire emphasis should be to deliver reperfusion therapy to a patient of STEMI as
rapidly as possible. Efficient protocols of early triage of patients with STEMI should
primarily aim to reduce time delays in patient care since these are associated
with adverse outcomes. Delay in patient care in our country often occur at the
following levels of care.
2. The time delay from the patient side may be due to delay in recognizing symptoms
and therefore in seeking timely medical help. On reaching the hospital, financial
issues, lack of consensus amongst patient relatives and consent regarding
procedure, system delays in hospitals (e.g. registration, transport to emergency
department, coronary care units, cardiac catheterization lab etc.) are the common
cause of delay associated with adverse outcomes.

Aim of Triage protocol

3. The aims should be to develop a smooth continuum of care including:
(a) Early recognition of symptoms of STEMI
(b) Activation of efficient emergency medical services (EMS)
(c) Pre-hospital management
(d) Pre-determined hospital destination protocols and
(e) Timely establishment of reperfusion.

Proposed Triage Plan

4. Once a diagnosis has been made, the patient and his family should be taken into
confidence and a reperfusion strategy should be planned. In case it is possible
to shift the patients to a PCI capable center while maintaining the doctor to
Balloon time of thrombolysis the patients and shift to a PCI capable center for a
PI approach whenever possible and feasible.
5. The following is the proposed triage plan which can be modified based on local
setting and the geographical area. The following flow chart is recommended for
arriving to a decision for thrombolysis at the health facility.

24
Identification of Patients at Risk of STEMI
6. Cardiovascular diseases result from a complex interplay of multiple genetic,
environmental, and lifestyle factors. Primary care providers should evaluate
the presence and status of control of major risk factors for coronary heart
disease (CHD) for all patients at regular intervals (approximately every 3 to 5
years). Patients with established CHD should be identified for secondary
prevention, and patients with a CHD risk equivalent (e.g., diabetes mellitus,
chronic kidney disease, or 10-year risk greater than 20% as calculated by
Framingham equations) should receive equally intensive risk factor intervention
as those with clinically apparent CHD.
7. Many methods for CVD screening have insufficient evidence to currently
recommend use in a general, asymptomatic adult population. This corresponds
well with a 2012 Cochrane Review evaluating the impact of general health checks
(including screening measures) that found general health checks did not improve
either overall health or cardiovascular morbidity and mortality. Nonetheless, there
is good evidence for some specific CVD screening modalities when used in the
proper risk setting. Lipid measurement and abdominal aortic ultrasound, for
example, are two screening techniques with strong data regarding who benefits
from screening and the impact of screening on outcomes. While current evidence
does not support the use of other newer screening modalities for primary
prevention of CVD, this may very well change as more high-quality trials are
completed in the future.

Patient Education for Early Recognition and Response to STEMI

8. Patients with symptoms of STEMI (chest discomfort with or without radiation
to the arms[s], back, neck, jaw, or epigastrium; shortness of breath; weakness;
diaphoresis; nausea; light headedness) should be transported to the hospital
by ambulance rather than by friends or relatives. Healthcare providers should
actively address the following issues regarding STEMI with patients and their
families:
9. The patient’s heart attack risk profile (Risk factors like – smoking, hypertension,
Diabetes Mellitus, high lipid counts, sedentary lifestyle, family history etc).
Importance of early presentation and reperfusion strategies including availability
of treatment for AMI at nearby hospitals. Encourage the patients to carry baseline
ECG during transfer to PCI/Non- PCI Hospitals

MD Medicine Education
10. The doctor must be aware/trained for the following:
• Time dependent decision taking.
• Immediate ECG in patients of suspected AMI and confirmation of STEMI.
• To avoid delay in reperfusion and importance of early reperfusion.
• Systematic protocol, guideline adherence and knowledge of newer fibrinolytic
agents and their advantages.
• Pharmaco-invasive concept in STEMI management

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 TIMI risk scoring tool
11. The thrombolysis in myocardial infarction (TIMI) risk score is a tool used to predict
the chances of having or dying from a heart event for people with:
• Unstable Angina, a heart condition that causes chest pain
• Non-ST-segment elevation myocardial infarction (NSTEMI).
12. The TIMI risk score is calculated by taking seven factors into account. Some
of these are determined by performing specialized heart tests or asking about
a person’s medical history. One point is given for each of the following trusted
source:
• Age more than 65 years.
• Using aspirin within the last week.
• Having at least two angina episodes in the last 24 hours
• Having elevated serum cardiac biomarkers
• Having ST-segment deviation on an electrocardiogram
• Having known coronary artery disease
• Having at least three risk factors for heart disease, which include:
o high blood pressure (greater than 140/90)
o smoking (being a current smoker)
o low HDL cholesterol (less than 40 mg/dL)
o Diabetes Mellitus.
o Family history of heart disease

13. TIMI score can help doctors to accurately assess the chances of having or dying
from a heart-related event in the next 14 days. The scores are calculated and
matched with a predicted risk. A study published in JAMA found that TIMI risk
scores are useful and accurate at predicting a future heart event. The following
chart includes possible scores and their corresponding risk percentages:
Score Risk of Heart Event
0-1 4-7%
2 8.3%
3 13.2%
4 19.9%
5 26.2%
6-7 At least 40.9%

14. The TIMI risk score for a heart-related event can be lowered, by lifestyle
modification as follows:
• Eating healthy, whole foods
• Exercising daily
• Maintaining a healthy weight

26
 • Avoiding cigarette smoking and limiting alcohol consumption
• Keeping cholesterol and blood pressure levels in check
• Managing diabetes (if you’re diabetic)
• Lowering stress levels

15. Several tools and scores have been developed to assist in the workup of STEMI.
These tools must be used with caution and in the appropriate context as none
have been definitively shown to be superior to clinician judgment. Some common
tools available are the TIMI (Thrombolysis in Myocardial Infarction) risk score
as discussed above, the GRACE (Global Registry of Acute Coronary Events)
risk score, the SANCHIS score, the Vancouver rule, HEART (History, ECG,
Age, Risk Factors, and Troponin) score, HEARTS3 score, and Hess prediction
rule. The HEART score was specifically developed for emergency department
patients and has gained popularity in this setting.

How to recognize symptoms of STEMI.

16. The advisability of calling 108 ambulance services, if symptoms are unimproved
or worsening after 5 minutes, despite feelings of uncertainty about the symptoms
and fear of potential embarrassment. A plan for appropriate recognition and
response to a potential acute cardiac event that includes the phone number to
access emergency medical services (EMS), generally 108 or Central call centre
ambulance services. Morbidity and mortality due to STEMI can be reduced
significantly if patients and bystanders recognize symptoms early, activate the
EMS system, and thereby shorten the time to definitive treatment. Patients with
possible symptoms of STEMI should be transported to the hospital by ambulance
rather than by friends or relatives because there is a significant association
between arrival at the emergency department (ED) by ambulance and early
reperfusion therapy.

Onset of STEMI (Out-of-Hospital Cardiac Arrest)

17. All communities should create and maintain a strong “Chain of Survival” for out-of-
hospital cardiac arrest that includes early access (recognition of the problem and
activation of the EMS system by a bystander), early cardiopulmonary resuscitation
(CPR), early defibrillation for patients who need it, and early advanced cardiac life
support (ACLS).
18. Family members of patients experiencing STEMI should be advised to take
CPR training and familiarize themselves with the use of an automated external
defibrillator (AED). In addition, they should be referred to a CPR training program
that has a social support component for family members of post-STEMI patients.
The links in the chain include early access (recognition of the problem and
activation of the EMS system by a bystander), early CPR, early defibrillation for
patients who need it, and early ACLS.

Need for Pharmaco-invasive approach

19. In the Indian context, even small towns are densely populated, traffic congestions
and transfer to hospitals take a long-time causing delay in time to treatment.

27
 Initial delay is by the patient due to lack of awareness. Next delay is due to lack of
transfer facilities or unavailability of hospital with PCI capabilities. The third delay
is possible within a tertiary care PCI capable hospital were reaching from casualty/
emergency department to establishing Thrombolysis In Myocardial Infarction
(TIMI) grade 3 flow has delays due to various factors viz. finances, obtaining
consent, round the clock man power (cardiologist and staff) and availability of PCI
lab in busy hours. However, early patient presentation, rapid diagnosis and early
reperfusion in patients presenting with acute chest pain constitute the pillars of
success in STEMI management.
20. Fibrinolytic therapy and primary PCI are two commonly used reperfusion strategies
in its management, and they are conventionally viewed as mutually exclusive
alternative therapeutic modalities”. However, well established principles and a
great deal of recently acquired clinical evidence support the view that the two
in combination are synergistic and their combination is referred as “pharmaco-
invasive therapy”.
21. Pharmaco-invasive therapy means first administering early fibrinolysis and then
systematically performing an angiography (and a PCI if needed) within 3 to 24 hours
after the start of fibrinolytic therapy, regardless of whether fibrinolysis results in
successful reperfusion or not. In the event of fibrinolytic failure, a rescue PCI should
be immediately performed where one need not wait for the initial 3-hour window.
22. Outcome of patients with STEMI is strongly influenced by the time from symptom
onset to successful re-perfusion. A study has found that 1 year mortality is
increased by 7.5% for each 30 min delay in treatment. Early fibrinolytic therapy
can compensate for PCI related delay. PI approach could possibly improve
myocardial salvage and ultimately improve clinical outcomes. Prompt fibrinolytic
treatment improved the likelihood of aborted myocardial infarction and the greatest
incidence occurred in those patients treated within 1 hour of symptom onset, with
a sharp drop off after 3 hours.
23. Pharmaco-invasive approach is appropriate for patients with STEMI who are
eligible for treatment with fibrinolytic drugs and in whom “transfer time” ≥ 30 min
or door- balloon time > 90 min [Door into Door out time is ≥ 120 min]. The other
indication being PCI related delay: (door-to-balloon) minus (door to needle) > 60
minutes. The key characteristics of various thrombolytic agents in use is as follows:
Characteristics Streptokinase Alteplase Reteplase Tenecteplase
Allergic reactions Yes No No No
Plasminogen
Indirect Direct Direct Direct
activation
Fibrin specificity - ++ + +++
Dose 1.5 MU 15 mg bolus 10 + 10 units 0.53 mg/kg
/administration infusion over plus 90-min double bolus single bolus
60 infusion up to given over 2 given over 5
min 85mg min with 30 seconds
minutes apart
Plasma half life 18 5 18 20
Resistance to PAI-I No No No Yes

28
 Characteristics Streptokinase Alteplase Reteplase Tenecteplase
Activity on platelet
- ++ + +++
rich clot
Patency at
+ +++ +++(+?) +++ (+?)
90 min
TIMI grade 3 flow
32 54 60 63
(%)
Systemic fibrinogen marked mild moderate minimal

Choice of Fibrinolytic agent

First Generation
24. Streptokinase: It is still a commonly used thrombolytic agent in India. Streptokinase
is isolated from bacteria and hence is antigenic. Potential disadvantages
also include IV infusion needed, low fibrin specificity, shorter half-life, risk of
anaphylactic reactions and hemorrhage.
Second Generation
25. Tissue Plasminogen Activator (t-PA, alteplase): It is a second generation fibrinolytic
and produces only mild systemic fibrinogen depletion. t-PA is administered in an
accelerated dose regimen over 90 minutes. Although a fibrin specific agent (++),
the use may be limited since an IV infusion is required.
Third Generation
26. They have increased fibrin specificity, increased resistance to inhibition by
plasminogen activators and longer half-life.
(a) Reteplase is a third-generation variant of the t-PA molecule. It is a fibrin
specific agent (+) and administered as a double bolus; each dose consists of
10 units given over two minutes 30 minutes apart.
(b) Tenecteplase: Tenecteplase, most recently approved for the treatment
of STEMI, is a third-generation variant of the t-PA molecule. Unlike its
predecessors, Tenecteplase can be administered as a single bolus over five
seconds. It has highest fibrin specificity (+++) and resistance to inactivation
by plasminogen activator inhibitor-1 (PAI-1), desirable in a fibrinolytic agent.
It has an advantage of ease of administration, weight- adjusted, single-bolus
administration.31 Thus administration of third generation agents (Tenecteplase/
Reteplase) could be crucial in early fibrinolysis and transfer of a STEMI patient
to a tertiary care hospital.
Prehospital Fibrinolysis
27. Establishment of a prehospital fibrinolysis protocol is reasonable in (1) settings
in which MD Medicines are present in the ambulance or in (2) well-organized
EMS systems with full-time paramedics who have 12-lead ECGs in the field
with transmission capability, paramedic initial and ongoing training in ECG
interpretation and STEMI treatment, online medical command, a medical director
with training/experience in STEMI management, and an ongoing continuous
quality-improvement program.

29
 28. Prehospital fibrinolysis is reasonable in those settings in which MD
Medicines are present in the ambulance or prehospital transport times are
more than 60 minutes in high-volume (more than 25,000 runs per year) EMS
systems. Other considerations for implementing a prehospital fibrinolytic service
include the ability to transmit ECGs, paramedic initial and ongoing training in ECG
interpretation and myocardial infarction (MI) treatment, online medical command,
a medical director with training/experience in management of STEMI, and full-
time paramedics.27
29. Almost all of the pharmaco-invasive strategies have been clinically evaluated with
IV bolus agents only. Fibrinolytic therapy with contemporary adjunctive medical
therapy is recommended in patients presenting with symptom onset less than 6
hours. The fibrinolytic agents recommended as per level of evidence (LOE) is as
follows:
Fibrinolytic
LOE Recommended Dosage
Agent
Grade 1A Tenecteplase 0.53 mg/kg single bolus IV over 5 seconds.
Grade 1B Reteplase 10-MU bolus-30 min + 10-MU bolus 30 min later.
Grade 1C Alteplase 15mg IV bolus, 0.75 mg/kg over 30 min then 0.5 mg/
kg over 60 min IV.
Grade 2B Streptokinase 1.5 million units over 30-60 min. To be considered
only in those patients where newer fibrin specific
fibrinolytics are unaffordable or unavailable.

Contraindications for Thrombolytic Therapy

30. The absolute & relative contraindication for the thrombolytic therapy is tabulated below:

ABSOLUTE CONTRAINDICATIONS FOR THROMBOLYTIC

THERAPY
- Recent intracranial hemorrhage (ICH)
- Structural cerebral vascular lesion
- Intracranial neoplasm
- Ischemic Stroke within 3 months
- Possible aortic dissection
- Active bleeding or bleeding diathesis
- Head injury or facial trauma within 3 months
- Recent intracranial or spinal surgery
- Severe uncontrolled hypertension
- History of taking Streptokinase injection within six months

30
 RELATIVE CONTRAINDICATIONS FOR THROMBOLYTIC THERAPY
- History of severe and poorly controlled hypertension
- Severe hypertension at presentation (systolic blood pressure more
than 180 mm Hg
or diastolic blood pressure more than 110 mmHg
- Prolonged (>10 min) cardiopulmonary resuscitation (CPR) or major
surgery within
three weeks
- History of Ischemic Stroke
- Dementia
- Internal bleeding within 2 to 4 weeks
- Noncompressible vascular punctures
- Pregnancy
- Active peptic ulcer
- Current therapy of anticoagulant associated with an elevated
international normalized ratio higher than 1.7 or a prothrombin time (PT)
longer than 15 seconds.

Monitoring of Patients after Thrombolytic Therapy

31. Patients receiving thrombolytic therapy must undergo a constant neurologic
and cardiovascular evaluation with blood pressure monitoring every 15 minutes
during and after tPA infusion for at least 2 hours, then half hourly for 6 hours
and hourly for the next 16 hours after injection. Strict BP monitoring is essential
to prevent complications. Thrombolytic therapy should be stopped urgently with
any signs of neurologic deterioration, and the patient should receive emergency
computed tomography (CT). Fibrinolytic agents or any anticoagulants must be
stopped immediately with any evidence of bleeding complications in a patient
with ongoing fibrinolytic therapy. In the next step, supportive measures should be
instituted, including volume correction and blood factor transfusion.
 

31
 Appendix ‘D’
STEMI MEDICAL EQUIPMENT LIST
Categories Remarks
Equipment (Capex)
Gap Analysis is
Equipment Maintenance (Opex) (7% of Capex) applicable after recommended for
warranty period procurement planning
ECG Training per Facility for MOs per facility (Lump sum per annum) of medical equipment
for STEMI based
IT Dashboard per Facility per annum (Capex + Opex) on the Availability
Total Cost-Capex One Time (INR) (@Funding from XVFC PHC of Equipment at the
Health Grant) public health facility to
avoid duplication.
Total Cost-Opex per Annum (INR)

DRUGS FOR STEMI MANAGEMENT

Sl.
Name of the Drug A/U Strength
No.
1. Tab Aspirin Soluble/Chewable No. 325 mg
2. Tab Aspirin Soluble/Chewable No. 75 mg
3. Tab Clopidogrel No. 75 mg
4. Tab Metoprolol No. 25 mg
5. Tab Metoprolol No. 50 mg
6. Tab Ramipril No. 2.5 mg
7. Tab Ramipril No. 5 mg
8. Tab Enalapril No. 10 mg
9. Tab Enalapril No. 5 mg
10. Tab Atorvastatin No. 20 mg
11. Tab Atorvastatin No. 40 mg
12. NTG Spray 0.4mg Can 14.7 ml
13. Inj Morphine sulphate Amp 10 mg/ml
14. Inj Heparin (LMWH) ml 1000IU
15. Inj Heparin (LMWH) ml 5000IU
16 Inj Tenecteplase Amp 40 mg
17. Inj Tenecteplase Amp 20 mg
18. Inj Streptokinase Amp 750000IU
19. Inj Streptokinase Amp 1500000IU
20. Inj Enoxaparin Amp 40mg/0.4 ml
21. Inj Enalapril Amp 1.25mg/ml
22. Inj Metoprolol Amp 1mg/ml

32
MINIMUM MEDICAL EQUIPMENT SUGGESTED FOR STEMI MANAGEMENT
Sl. No. Name of the Equipment Level of Health care
1. ECG machine Single Channel with PC compatibility PHC
12 Channel ECG Machine with all accessories PC
2. CHC, SDH/DH
compatible
3. Multipara Monitor (with 5 parameter) CHC, SDH/DH
4. Automatic External Defibrillator (AED) At all levels
5. SpO2 (Finger probe) PHC
6. Syringe infusion pump At all levels
7. Crash Cart Trolley At all levels
8. Suction machine (Foot & Electric operated) At all levels
9. Oxygen Cylinder At all levels
10. Hospital Bed (Fowler) At all levels

CONSUMABLES
Sl. No. Name of the Drug A/U
1. Troponin-I rapid test kit (10 piece) Kit
2. ECG Paper Roll Roll
3. ECG gel 250 ml Tube
4. Disposable ECG Electrodes Piece

33