Journal of the Practice of Cardiovascular Sciences

: 2021  |  Volume : 7  |  Issue : 3  |  Page : 182--189

Use of thrombolytic agents for ST-elevation myocardial infarction care in India: An expert consensus

Arun Chopra1, Suresh V Patted2, Mukesh Parikh3, Rajeev Agarwal4, K Jaishankar5, Nitin Modi6,  
1 Department of Cardiac Sciences, Fortis Hospital, Amritsar, Punjab, India
2 Department of Cardiology, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
3 Varun Cardiac Clinic, Ghatkopar, Mumbai, Maharashtra, India
4 Department of Cardiology, Jaswant Rai Hospital, Meerut, Uttar Pradesh, India
5 Department of Cardiology and Electrophysiology, Miot Hospital, Chennai, Tamil Nadu, India
6 Department of Cardiology, CHL Hospital, Indore, Madhya Pradesh, India

Correspondence Address:
Arun Chopra
Fortis Hospital, Amritsar, Punjab


In India, ST-elevation myocardial infarction (STEMI) is the predominant form of acute coronary syndrome. It is estimated to affect approximately 30 million people in India. The mainstay treatment approach for STEMI management is primary percutaneous coronary intervention (PCI) within 90 min after the first medical contact. However, due to existent clinical and practical barriers in performing timely PCI, optimal treatment is not offered on a timely basis. The challenges or barriers to timely PCI can be overcome by a pharmaco-invasive approach, in which thrombolysis is performed as soon as the patient is diagnosed with STEMI and transferred for PCI. Pharmaco-invasive approach is effective in shortening time to reperfusion therapy by allowing prompt initiation of thrombolysis followed by PCI as soon as possible. An experts' panel discussion was conducted involving 47 cardiologists all over India to review evidence-based concept of pharmaco-invasive treatment approach and to gain their expert opinion on emergency management of STEMI patients in the Indian setting. The experts highlighted that thrombolysis is the most implemented reperfusion strategy in India, especially when primary PCI is not available for STEMI patients. According to them, pharmaco-invasive approach would be appropriate to gain time to treatment in the event of expected treatment delays. Among thrombolytic agents, the experts recommended using third-generation thrombolytic agents because of their faster patency, more effectiveness, and ease of administration. They also emphasized on various clinical factors and practical considerations to be assessed before employing thrombolytic agents. In their opinion, bolus thrombolytic agents such as tenecteplase and reteplase offer effective, safer, easier, and faster administration for varied clinical profiles in all practical ways.

How to cite this article:
Chopra A, Patted SV, Parikh M, Agarwal R, Jaishankar K, Modi N. Use of thrombolytic agents for ST-elevation myocardial infarction care in India: An expert consensus.J Pract Cardiovasc Sci 2021;7:182-189

How to cite this URL:
Chopra A, Patted SV, Parikh M, Agarwal R, Jaishankar K, Modi N. Use of thrombolytic agents for ST-elevation myocardial infarction care in India: An expert consensus. J Pract Cardiovasc Sci [serial online] 2021 [cited 2022 Jan 20 ];7:182-189
Available from:

Full Text


Cardiovascular diseases (CVD) are a global health concern and are the leading causes of deaths worldwide. Global Burden of Disease 2015 study estimated 422 million cases of CVD and 17.92 million CVD deaths all over the world.[1] In 2016, the prevalence of CVD in India was estimated to be 54.5 million cases and 2.8 million deaths; and 14.1% of the total disability-adjusted life-years were attributed to CVD.[2] In India, ST-elevation myocardial infarction (STEMI) is the predominant form of acute coronary syndrome, affecting nearly 30 million people.[3] For people with STEMI, reperfusion therapy is indicated within the prior 12 h of symptom onset to revascularize the occluded coronary artery and limit myocardial necrosis.[4] Primary percutaneous coronary intervention (PCI) (within 90 min after the first medical contact) is a preferred reperfusion strategy according to most guidelines. However, timely PCI reperfusion therapy is accessible to <10% of STEMI patients in India because of various limitations in medical infrastructure and socioeconomic reasons, especially in rural regions.[5] If primary PCI cannot be made available to the patient, thrombolysis is an alternative reperfusion strategy to be performed within 30 min of hospital arrival.[3],[6] The third practical approach is the pharmaco-invasive strategy in which thrombolytic therapy is administered first, followed by PCI within 3–24 h after thrombolysis. Pharmaco-invasive approach is appropriate in case of unavoidable longer delays (>120 min) in first medical contact to device time.[3],[6] In clinical practice, the current challenge is to shorten the time from symptom to reperfusion and to choose the optimal reperfusion strategy for STEMI patients.[5]

In the event of COVID-19 pandemic 2020, the Cardiological Society of India issued recommendations for the confirmed or suspected COVID-19 patients with STEMI presenting within 12 h. Primary PCI is recommended with the necessary precautions and preparedness, both in hemodynamically stable and unstable patients. Thrombolysis is indicated as the practical choice of therapy amidst logistic problems in performing timely PCI, even if a patient is unstable with a plan for rescue PCI.[7]


Six experts' group meetings involving 47 Indian cardiologists were conducted via Virtual Platform in June 2020. The main purpose of the meetings was to discuss the evidence-based concept of pharmaco-invasive treatment approach and derive clinical opinion on emergency management of STEMI patients in the Indian setting. The discussions included the following main points:

Identifying challenges in STEMI management in IndiaPractical utility of available effective management approaches such as PCI and thrombolysisRole of pharmaco-invasive approach in the Indian settingChoice of thrombolytic drugs and their use in various clinical profiles.

We performed a literature search using PubMed and Google. We identified relevant articles using Boolean operators and/or for search terms/keywords such as STEMI, PCI, reperfusion, thrombolysis, pharmaco-invasive, tenecteplase (TNK), reteplase (rPA), and streptokinase (STK). In all, 28 published research articles, systematic reviews, or meta-analyses performed on humans were used for the preparation of this consensus paper.

This paper summarizes consensus experts' opinions on the pharmaco-invasive approach for STEMI management in India and preferred thrombolytic agents for various clinical profiles. The consensus draft has been formulated by the experts' suggestions. Consensus derived from the experts' discussion follows each section in the article.

 Pharmaco-invasive Approach: Choice of Reperfusion Therapy in Indian Setting

The choice of reperfusion strategy is dependent on many factors, mainly on time from symptom onset to accessibility of treatment.[3] For a patient with STEMI symptoms, early presentation to the hospital, rapid diagnosis, and early and timely reperfusion therapy are crucial steps in the successful management of STEMI.[4],[5] However, the provision and delivery of evidence-based management and care for patients with STEMI are associated with a number of challenges, and optimal STEMI care is not met.[3] In India, patients with STEMI do not often receive timely and adequate reperfusion therapy.[3]

Reperfusion therapy is time dependent; the door-to-needle time for initiation of thrombolytic therapy should be achieved within 30 min, or the door-to-balloon time for PCI should be achieved within 90 min.[4] The challenges to timely reperfusion therapy include patient-related factors, logistic complexities, and suboptimal healthcare system [Figure 1].[3],[4],[5],[8] Data from CREATE registry and Kerala ACS Registry have reported significant time to treatment delays in patient presentation to the hospital and initiation of reperfusion, in addition to the difference in practice patterns and lack of implementation of evidence-based STEMI care.[9],[10] Patients with STEMI conditions often present late after the onset of symptoms due to traffic delays or negligence. In CREATE registry, only 41.6% of patients with STEMI presented within 4 h of the onset of chest pain and 31% of patients presented after 12 h.[4] In addition, a huge proportion of STEMI patients (~70%) present to non-PCI capable hospitals, thus delaying the door-to-balloon time for PCI (>90 min). CREATE registry reported that the median time to reach a hospital was 300 min, and only 8% of STEMI patients could undergo PCI.[9]{Figure 1}

Moreover, use of important treatments varied by socioeconomic status in CREATE registry.[9] In comparison to poor patients, richer patients were given thrombolytics (60·6% vs. 52·3%) and PCI (15·3% vs. 2·0%).[9] Nearly three-quarter of patients belonged to the lower middle class or poor strata.[9] A recent Indian study by Sidhu et al. demonstrated that implementation of evidence-based pharmacotherapy and interventions along with better access to specialized cardiac care could reduce mortality and morbidity from ACS in the low socioeconomic strata.[11] Data from the Kerala ACS Registry strongly establishe opportunities for improving ACS management by decreasing symptom-to-door time, door-to-needle time, and inappropriate use of thrombolysis in addition to increasing use of recommended drugs.[12]

There is a lack of dedicated STEMI care systems in rural regions as well as towns/cities, which lead to poor clinical outcomes and increased mortality in patients with STEMI in India.[8] These clinical gaps highlight the need for integrated STEMI care with faster access to hospitals and affordability of urgent and optimal treatment and management.[9] Since clinical benefits of timely PCI are not achieved in most of the patients, the practical role of early thrombolysis is considered in such cases.[4]

 Thrombolysis Versus Primary Percutaneous Coronary Intervention

In spite of the strength of evidence regarding the benefits of primary PCI in STEMI, this therapy is available to a very small proportion of STEMI patients in India.[3] In addition, this procedure needs a high degree of expertise inclusive of an experienced team of interventional cardiologists and skilled support staff.[4]

Thrombolysis and PCI are conventionally observed as mutually exclusive alternative therapeutic reperfusion strategies.[3] In the event of delay to PCI, prompt thrombolysis proves beneficial if the expected time to PCI is more than 60 min.[4] Thrombolytic therapy aims at establishing vessel patency and providing myocardial salvage. It also preserves ejection fraction, regional wall motion, and end-systolic volume. Furthermore, thrombolytic therapy reduces mortality as a result of electrical stabilization, limitation of expansion of the infarct zone, and provision of collateral flow in patients with multivessel disease.[13]

 Consensus 1

The experts agreed to the fact that primary PCI is not readily available for many patients with STEMI. The common barriers to timely primary PCI include traffic congestion, lack of funds, unavailability of cath labs, patient preference for noninvasive procedure, consent of relatives, as well as unawareness of the importance of PCI. In addition, the presence of comorbidities severe diabetes mellitus, chronic kidney disease, or any other chronic disease makes it difficult to move patients to PCI centers. Thus, thrombolysis plays a major role in managing patients with PCI. Although thrombolysis is preferred due to practical reasons, PCI remains the gold standard of STEMI management. It must be noted that CREATE and Kerala ACS registries cannot be generalized to the entire country, and the situation might be even worse. It would be challenging to formulate and implement a primary PCI program for the entire country in the near future, thus making use of fibrinolytic even more crucial.

 Concept of “Thrombolyse Now and Stent Later”

Primary PCI is the gold standard treatment for the management of STEMI. It is undoubtedly more effective than thrombolysis for restoration of perfusion (90% vs. 50%–55%).[14] However, limited accessibility and delays to PCI are quite prevalent worldwide, especially in developing countries. On the other hand, thrombolysis is widely available and is a quicker method but is not as effective as primary PCI. Thus, there has been a long dispute over the ideal reperfusion strategy.[14] The concept of “thrombolyse now and stent later” involves employing a combination of both the strategies for practical use:

Early pharmacological reperfusion by easily available and quick thrombolysis to recover as much myocardium as possible[4],[14]Early angiography and immediate PCI after thrombolysis to ensure reperfusion in case of failure of thrombolysis as well as prevention of reocclusion and reinfarction.[4],[14]

Pharmaco-invasive approach offers synergistic action of the two reperfusion strategies to effectively revascularize the myocardium. It is safe and effective as indicated by well-established principles and clinical evidences.[5] The French Registry on Acute STEMI (FAST-MI) reported that early use of pharmaco-invasive strategy is associated with similar early and 1-year survival rates to those of primary PCI.[15] Recommendations from 2013 ACCF/AHA indicate that if primary PCI cannot be performed within the time interval, or at a non-PCI capable hospital, thrombolytic therapy should be administered to the patients within 12 h of symptom onset, followed by immediate transfer to a PCI-capable center. In addition, thrombolytic therapy should be given within 30 min of hospital arrival.[6] Likewise, if the expected transportation delay to PCI center is more than 120 min, pharmaco-invasive approach would be appropriate to gain time for treatment.[3]

TRANSFER-AMI study compared the pharmaco-invasive strategy of transfer for routine PCI within 6 h after fibrinolysis with standard treatment after fibrinolysis (including rescue PCI and delayed cardiac catheterization for patients who do not require rescue PCI). The study demonstrated that among high-risk STEMI patients who were treated with fibrinolysis, transfer for PCI within 6 h after fibrinolysis was associated with significantly fewer ischemic complications than that with standard treatment.[16] The study also highlighted that nearly one-third of the patients in the standard therapy group underwent urgent catheterization within 12 h after fibrinolysis, suggesting that transfer to PCI centers should be initiated immediately after thrombolysis without waiting to see whether reperfusion is successful.[17]

 Prehospital Fibrinolysis

It is advisable to administer prehospital fibrinolytic therapy in health-care settings where it is feasible.[4] In CAPTIM trial, patients randomized 2 h after symptom onset demonstrated a strong trend toward lower 30-day mortality with prehospital thrombolysis, compared with those randomized to primary PCI (2.2% vs. 5.7%, P = 0.058). The results indicated that prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 h after symptom onset.[18]

STREAM study demonstrated that effective reperfusion was observed in patients with early STEMI (who could not undergo primary PCI within 1 h after the first medical contact) and who underwent prehospital fibrinolysis with timely coronary angiography. There was no significant difference in the primary endpoint (composite of death, shock, congestive heart failure, or reinfarction up to 30 days) between fibrinolysis and PCI (12.4% vs. 14.3%, P = 0.21).[19]

 Pharmaco-invasive Approach can be Indicated in Following Cases[5]

If the patient transfer time ≥30 minDoor-to-balloon time >90 min (or first medical contact to balloon time is ≥120 min)Door to balloon − door to needle >60 min.

Given the prevailing time to treatment challenges, pharmaco-invasive strategy presents as an optimal reperfusion strategy in Indian patients with STEMI. It shortens time to reperfusion therapy by allowing prompt initiation of thrombolysis followed by PCI as soon as possible; and in such cases, an efficient thrombolytic agent would play an important role in achieving maximum benefit.[4],[5]

 Consensus 2

The experts highlighted that in case of expected treatment delays to primary PCI, pharmaco-invasive approach is preferred. Thrombolysis should be immediately performed in such cases and the patient should be transferred to the PCI facility as soon as possible. The experts highlighted that the usual lag time for the PCI procedure is ~5–6 h. There should be an arrangement for sharing electrocardiogram (ECG) details with the specialist to confirm diagnosis without delay. Furthermore, the paramedic should be well equipped with knowledge regarding the use of emergency medicines. In addition, they stated that prehospital thrombolysis is feasible; however, good training and expertise are required.

 Choice of Thrombolytic Therapy

Thrombolysis is the most preferred reperfusion strategy in India, especially when primary PCI is not available for STEMI patients.[3] They are associated with reperfusion and restoration of blood flow and time-dependent reduction in mortality and morbidity rates within 12 h after symptom onset.[3],[20] An ideal thrombolytic agent is expected to cause rapid dissolution of pathologic clot without disrupting physiologic thrombi necessary for normal hemostatic balance.[21] The features of an ideal thrombolytic agent are given in [Figure 2].{Figure 2}

Thrombolytic agents approved for the management of STEMI are STK, TNK, rPA, and alteplase or recombinant tissue plasminogen activator (rtPA). Thrombolytic agents which are fibrin-specific are called fibrinolytics and are preferred over nonfibrin-specific agents.[3] A fibrin-specific agent has class I A recommendation from the European Society of Cardiology guidelines for the management of STEMI.[22] STK, a first-generation nonfibrin specific agent, is widely used for the management of STEMI. It lacks fibrin-binding ability and causes an indirect conformational change in plasminogen molecules.[4],[20] However, it is associated with limited efficacy and unfavorable side effect profile due to antigenicity.[4],[20] Alteplase or rtPA is a second-generation fibrin-specific agent, which converts plasminogen to plasmin in the presence of fibrin. It produces more rapid thrombolysis and superior reperfusion than STK. The limitations of alteplase include bleeding complications, delay in the time to patency, and complex infusion protocol.[4]

 Third-Generation Fibrinolytic Agents

Third-generation fibrinolytic agents were developed by genetically modifying the wild-type t-PA. The main objective of development of third-generation fibrinolytic agents was to improve safety, efficacy, and ease of administration of previous generations of thrombolytic drugs.[4],[20] TNK, a novel third-generation fibrinolytic agent, is derived from modification of native tPA at three sites. It has a longer half-life which allows single bolus administration compared to infusion requirement with alteplase. It also has greater fibrin specificity than alteplase. rPA is a first third-generation recombinant form of t-PA with high fibrin specificity and low fibrin affinity. It has longer half-life and greater thrombolytic potency in comparison to t-PA.[4],[20] TNK and rPA have safety and efficacy profiles similar to that of alteplase but have bolus administration advantage.[23] [Table 1] depicts key characteristics of fibrinolytic agents.[3],[4],[20]{Table 1}

 Infusion Versus Bolus Thrombolytic Agents

The efficacy of a thrombolytic drug can be assessed by two features – (1) the ability to achieve early and complete reperfusion and (2) ease of administration which enables early treatment initiation.[4] The third-generation thrombolytic agents, TNK and rPA, have the advantage of bolus administration, thus providing ease of administration compared to first- and second-generation thrombolytic agents.[23] In emergency situations including expected large treatment delays, infusion administration protocols for STK and alteplase are cumbersome and time consuming. Bolus thrombolytic agents are preferred in such cases, because of ease of treatment, suitability of prehospital treatment, and decrease in medication errors [Figure 3].{Figure 3}

Ease of treatment

Early treatment is associated with greater myocardial salvage and improved prognosis to improve survival. Use of bolus fibrinolytic agents could enable a reduction in time to treatment and more rapid treatment of STEMI. The complicated infusion regimens of the second-generation drugs may not be preferred in emergency situations.[4]

Prehospital treatment

The time from symptom onset to initial treatment with fibrinolysis can be optimized by employing prehospital treatment with fibrinolytic agents in the ambulance or at home itself.[4]

Decrease in medication errors

The “therapeutic window” for thrombolytic therapy is small and is associated with medication errors, thereby leading to an increased risk of mortality.[24] Clinical studies such as Global Use of Strategies To Open Occluded Coronary Arteries-I trial and Intravenous NPA for Treatment of Infarcting Myocardium Early-II trial have demonstrated higher medication errors with infusion thrombolytic agents such as alteplase or STK. In addition, incorrect dosing or infusion length was associated with higher mortality in patients with medication errors.[4],[24] Thus, bolus thrombolytic agents may offer simpler and rapid administration with accurate dosing and improvement in overall clinical outcome.[4],[24]

 Consensus 3

The experts emphasized that third-generation thrombolytic agents are more preferable because of their faster patency, added efficacy, and ease of administration. They are better and safer than first- and second-generation thrombolytic agents and thus can be considered more user-friendly drugs. In addition, the most important factor in choosing a thrombolytic agent is the cost. Moreover, the experts emphasized using bolus thrombolytic agents over infusion thrombolytic agents, especially in emergency setting and treatment delays, they provide the feasibility of prehospital thrombolysis and enable faster treatment.

 Factors Affecting Choice of Thrombolytic Agents

Given the availability of a number of thrombolytic agents, specific clinical factors and practical considerations are assessed before employing any one of the thrombolytic agents. Clinical factors to be assessed for using thrombolytic agents include patients with non-Q MI and unstable angina, patients with non-diagnostic ECGs, patients whose pain began more than 4-6 h and earlier, and the risk of bleeding.[25],[26]

Practical factors include patient's age, ease of administration, time window for administering the agent, and cost of the therapy.[25],[26] Ease of administration with bolus fibrinolytic agents could reduce medication errors.[4] Thrombolytic agents with greater therapeutic windows are advisable.[4] In context to cost, fibrin-specific agents are more expensive compared to STK which is the most commonly used thrombolytic agent in India.[3]

 Consensus 4

The experts agreed that before choosing a thrombolytic agent, the clinical profile of a patient must be assessed thoroughly. The presence of anterior/inferior wall MI, thrombus burden, hypogenic shock, reperfusion arrhythmias, and presence of comorbidities are factors that might affect the choice of thrombolytic agents. In addition, practical reasons that may affect thrombolytic choice include patient's demographic factors (age/gender), lifestyle (smoking habits/alcohol), ability or feasibility to measure patient's weight, availability of thrombolytic in the hospital, and cost of thrombolytic.

 Clinical Profiles for Thrombolytic Agents


Bleeding is a common adverse event of fibrinolytic agent in ~5%–6% of patients. It is suggested that bleeding risk is reduced by using more fibrin-specific agents.[27] TNK has the highest degree of fibrin specificity and binding thus is associated with lesser bleeding risk.[4],[28] It also has a higher resistance to plasminogen activator inhibitor-1 than both alteplase and rPA. Other benefits of TNK include faster onset of action, longer half-life, and weight-based accurate dosing.[28]

In elderly patients

In the Indian ELAXIM registry, single intravenous bolus dose of indigenously developed TNK was administered to 6000 patients with STEMI. The study demonstrated clinically successful thrombolysis (CST) in 90.93% of patients with the highest success rate (93.2%) in patients treated within 3 h and overall mortality of 3.23%. In addition, the elderly (≥65 years; 24.58%) showed CST of 87.73%. In terms of safety, TNK was safer in elderly patients with a similar risk of intracranial hemorrhage, severe bleeding, stroke, and ventricular tachyarrhythmia as that of the other patients in the study.[29]

In high-risk patients

An Indian study assessed the efficacy and safety of single intravenous bolus administration of indigenously developed TNK in 15,222 STEMI patients, including the high-risk groups such as hypertensives, diabetics, smokers, and hyperlipidemic patients. Overall, 95.43% of patients had CST and high-risk groups showed comparable CST rates to the general patients. In addition, the incidence of intracranial hemorrhage and other bleeding was similar among all high-risk patients.[28]


rPA demonstrates loose and reversible binding to fibrin, which is associated with better clot penetration and lysis.[4],[22] It also has a high resistance to inhibition by plasminogen activators.[22] rPA has less lytic efficacy in platelet-rich plasma clots and aged clots. It preserves hemostatic plugs and may produce fewer bleeding complications than those with higher fibrin affinity.[4]

In obese patients

Visual approximation of patient's weight, especially in emergency situations, may cause significant dosing errors with weight-based dosing of thrombolytic agents.[4] The weight-based dosing and administration of TNK indicate that the ideal dose to be administered to patients with weight ≥90 kg is 50 kg. However, 50 kg of TNK is not available in the market, thus patients with weight >90 kg will be mostly underdosed.[4] In addition, in the ASSENT-3 PLUS study, TNK was administered in a prehospital setting to 20% of patients, who received >105% of the correct dosage of weight-based single-bolus of TNK. The incorrect dosing was found to be associated with an approximately twofold rate of intracerebral hemorrhage versus lower doses among patients receiving unfractionated heparin as the concomitant antithrombin agent.[4] rPA is administered as a fixed double bolus regardless of age and weight of the patient. Its nonweight dosing aspect offers safe and convenient treatment administration and has the potential to decrease treatment errors as a result of underdoing or overdosing.[4]

In diabetic patients

In PRECISE-IN Study (Post-rPA Evaluation of Clinical Safety and Efficacy in Indian Patients), a total of 228 patients were included, of which 140 patients had diabetes mellitus. The study demonstrated 50% resolution of ST elevation in 90.50% of patients and resolution of chest pain in 95.4% of patients. In addition, there was no statistically significant difference between diabetes and nondiabetes patients with respect to efficacy parameters. Moreover, excellent to good efficacy with rPA was reported by majority of patients. rPA was also good to moderately tolerated by almost 100% of patients and there was no statistically significant difference in adverse events between diabetes and nondiabetes people.[22]


STK is cheaper, more easily available than the fibrin-specific agents. It is the most frequently used thrombolytic agent in India.[3] Most of the people from low socioeconomic strata of society attend tertiary care hospitals that only afford STK.[30] [Table 2] highlights beneficial characteristics and suggested clinical profiles for use of commonly employed thrombolytic agents.{Table 2}

 Consensus 5

The experts opined that it might be beneficial to use a specific thrombolytic agent for a specific clinical profile on the basis of the agent characteristics. They suggested that weight-based dosing of TNK allows for accurate dosing, especially in patients with low weight and the elderly. The dose can be decreased and adjusted according to patient weight and thus bleeding risk can be reduced. rPA can be preferred for overweight or obese people with or without diabetes where weight-based dosing of TNK would be impractical, especially in emergency situations. Moreover, STK seems to be preferred because of its ready availability, low cost, and affordability.


Thrombolysis is the preferred reperfusion strategy in most of the parts of India because of no timely availability of PCI facilities and large treatment delays due to transportation. Pharmaco-invasive approach is an excellent option to gain time to treatment if the expected transportation delay to PCI center is more than >120 min. Third-generation thrombolytic agents, TNK and rPA, are bolus drugs and offer the advantage of ease of administration in prehospital settings and emergency situations. Their simple administration protocol also decreases medication errors which are commonly observed with infusion thrombolytic drugs. Regarding suitable clinical profiles for use of thrombolytic agents, the experts suggested that STK is a preferred thrombolytic agent because of its readily availability, low cost, and affordability. High fibrin specificity and weight-based accurate dosing of TNK are effective and safe in the elderly and low weight patients, as its dose can be adjusted based on patient weight, and thus bleeding risk can be reduced. On the other hand, rPA can be preferred for overweight or obese people wherein visual approximation of weight is not possible, especially in the emergency setting. Thus, weight-based dosing of TNK would be impractical in obese people (≥90 kg). Moreover, rPA has shown good efficacy and favorable safety in Indian diabetic patients with STEMI.

Ethics clearance

Not applicable


We would like to acknowledge Scientimed Solutions Pvt. Ltd., for assistance in developing this manuscript. We gratefully acknowledge the contribution of experts who gave their expert opinion in conceptualization and finalization of consensus in advisory board meetings.

Financial support and sponsorship

The expert meetings were sponsored by Abbott Healthcare Pvt. Ltd. The views expressed and discussed in the meetings and stated in this consensus article are the views of the authors and not of Abbott Healthcare Pvt. Ltd.

Conflicts of interest

There are no conflicts of interest.


1Roth GA, Johnson C, Abajobir A, Abd-Allah F, Abera SF, Abyu G, et al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol 2017;70:1-25.
2India State-Level Disease Burden Initiative CVD Collaborators. The changing patterns of cardiovascular diseases and their risk factors in the states of India: The Global Burden of Disease Study 1990-2016. Lancet Glob Health 2018;6:e1339-51.
3Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, et al. Cardiological Society of India: Position statement for the management of ST elevation myocardial infarction in India. Indian Heart J 2017;69 Suppl 1:S63-97.
4Dalal J, Sahoo PK, Singh RK, Dhall A, Kapoor R, Krishnamurthy A, et al. Role of thrombolysis in reperfusion therapy for management of AMI: Indian scenario. Indian Heart J 2013;65:566-85.
5Dalal JJ, Alexander T, Banerjee PS, Dayasagar V, lyengar SS, Kerkar PG, et al. 2013 consensus statement for early reperfusion and pharmaco-invasive approach in patients presenting with chest pain diagnosed as STEMI (ST elevation myocardial infarction) in an Indian setting. J Assoc Physicians India 2014;62:473-83.
6O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e362-425.
7Kerkar PG, Naik N, Alexander T, Bahl VK, Chakraborty RN, Chatterjee SS, et al. Cardiological Society of India: Document on acute MI care during COVID-19. Indian Heart J 2020;72:70-4.
8Chopra HK. Challenges of STEMI care in India and the real world. Indian Heart J 2015;67:15-7.
9Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. Lancet 2008;371:1435-42.
10Huffman MD, Prabhakaran D, Abraham AK, Krishnan MN, Nambiar AC, Mohanan PP, et al. Optimal in-hospital and discharge medical therapy in acute coronary syndromes in Kerala: Results from the Kerala acute coronary syndrome registry. Circ Cardiovasc Qual Outcomes 2013;6:436-43.
11Sidhu NS, Rangaiah SK, Ramesh D, Veerappa K, Manjunath CN. Clinical characteristics, management strategies, and in-hospital outcomes of acute coronary syndrome in a low socioeconomic status cohort: An observational study from Urban India. Clin Med Insights Cardiol 2020;14:1-7.
12Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: Results from the Kerala ACS Registry. Eur Heart J 2013;34:121-9.
13Kleiman NS. Goals of thrombolytic therapy. Am J Cardiol 1991;68:67C-71C.
14Verheugt FW. Lyse now, stent later: The grace of GRACIA. Lancet 2004;364:1014-5.
15Danchin N, Coste P, Ferrières J, Steg PG, Cottin Y, Blanchard D, et al. Comparison of thrombolysis followed by broad use of percutaneous coronary intervention with primary percutaneous coronary intervention for ST-segment-elevation acute myocardial infarction: Data from the french registry on acute ST-elevation myocardial infarction (FAST-MI). Circulation 2008;118:268-76.
16Cantor WJ, Fitchett D, Borgundvaag B, Heffernan M, Cohen EA, Morrison LJ, et al. Rationale and design of the Trial of Routine ANgioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI). Am Heart J 2008;155:19-25.
17Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 2009;360:2705-18.
18Steg PG, Bonnefoy E, Chabaud S, Lapostolle F, Dubien PY, Cristofini P, et al. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: Data from the CAPTIM randomized clinical trial. Circulation 2003;108:2851-6.
19Armstrong PW, Gershlick AH, Goldstein P, Wilcox R, Danays T, Lambert Y, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013;368:1379-87.
20Hilleman DE, Tsikouris JP, Seals AA, Marmur JD. Fibrinolytic agents for the management of ST-segment elevation myocardial infarction. Pharmacotherapy 2007;27:1558-70.
21Baker WF Jr. Thrombolytic therapy: Clinical applications. Hematol Oncol Clin North Am 2003;17:283-311.
22Singh RK, Trailokya A, Naik MM. Post-reteplase evaluation of clinical safety and efficacy in Indian patients (Precise-In Study). J Assoc Physicians India 2015;63:30, 32-5.
23Ellis K, Brener S. New fibrinolytic agents for MI: As effective as current agents, but easier to administer. Cleve Clin J Med 2004;71:20, 23-5, 29-30 passim.
24Cannon CP. Thrombolysis medication errors: Benefits of bolus thrombolytic agents. Am J Cardiol 2000;85:17C-22C.
25Rutherford JD, Braunwald E. Thrombolytic therapy in acute myocardial infarction. Chest 1990;97:136S-45.
26Karloopia SD. Thrombolysis in myocardial infarction. Med J Armed Forces India 1995;51:1-3.
27Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: A comprehensive review of contemporary management options. J Am Coll Cardiol 2007;50:917-29.
28Iyengar SS, Nair T, Hiremath JS, Jadhav U, Katyal VK, Kumbla D, et al. Pharmacologic reperfusion therapy with indigenous tenecteplase in 15,222 patients with ST elevation myocardial infarction – The Indian Registry. Indian Heart J 2013;65:436-41.
29Iyengar SS, Nair T, Hiremath JS, Jadhav U, Katyal VK, Kumbla D, et al. Efficacy and safety of tenecteplase in 6000 patients with ST-elevation myocardial infarction from the Elaxim Indian Registry. Indian Heart J 2011;63:104-7.
30Bawaskar HS, Bawaskar PH, Bawaskar PH. Preintensive care: Thrombolytic (streptokinase or tenecteplase) in ST elevated acute myocardial infarction at peripheral hospital. J Family Med Prim Care 2019;8:62-71.