Authors
Arshad M, Interventional Cardiologist, SK Hospital, Trivandrum
Abstract
Introduction: Primary Angioplasty in Myocardial Infarction (PAMI), also known as Primary Percutaneous Coronary Intervention (PPCI), is an emergency, life-saving procedure to revascularize a completely occluded culprit vessel during an ongoing myocardial infarction. This involves balloon angioplasty to crush blockages and often stent insertion to restore and maintain blood flow.
Guidelines and Recommendations: PAMI is recommended as the treatment of choice over thrombolysis for ST-segment elevation myocardial infarction (STEMI) at skilled PCI centers, provided rapid initiation is possible. Critical time metrics include Door-to-Balloon (DTB) time of less than 90 minutes and Door-to-Needle (DTN) time of less than 30 minutes for fibrinolysis. An invasive strategy is preferred for high-risk STEMI cases, such as those with cardiogenic shock, contraindications to fibrinolysis, or late presentation (more than 3 hours after symptom onset). Fibrinolysis becomes the preferred revascularization strategy when skilled PCI is unavailable, vascular access is difficult, or prolonged transport to an interventional center is anticipated. The principle of “Time is Muscle” is paramount, as each 30-minute delay in reperfusion increases the relative risk of 1-year mortality by 8%. While PAMI benefits are typically obtained up to 12 hours post-symptom onset, reperfusion therapy can be considered beyond this period in patients with persistent symptoms and ST-segment elevation.
Outcomes and Challenges: Compared to fibrinolysis, primary angioplasty significantly lowers mortality (4.4% vs. 6.5%), reduces the combination of death or non-fatal reinfarction (7.2% vs. 11.9%), and decreases stroke incidence (0.7% vs. 2.0%). However, an Indian study revealed significant delays in achieving the target 90-minute DTB time, primarily due to patient consent (19.6 min) and financial approval processes (39.2 min). This highlights a notable gap in public awareness regarding acute MI and its management, and systemic financial hurdles, contrasting sharply with practices in developed countries where such factors are rarely considered facets of DTB time.