Myocardial Infarction Treatment in India and UAE | Complete Patient Guide

• ELIGIBILITY FOR PRIMARY PCI (STEMI): Patients presenting with ≥1 mm ST elevation in ≥2 contiguous leads or new left bundle branch block (LBBB) within 12 hours of symptom onset; symptom onset up to 24 hours in select haemodynamically unstable patients.

• ELIGIBILITY FOR URGENT/EARLY INVASIVE STRATEGY (NSTEMI/UA): High-risk NSTEMI defined by GRACE score >140, recurrent ischaemia, dynamic ST changes, elevated troponin, LVEF <40%, haemodynamic instability, or sustained ventricular arrhythmias — requiring coronary angiography within 2–24 hours.

• ELIGIBILITY FOR CABG POST-MI: Three-vessel or left main coronary artery disease (SYNTAX Score >33), diabetes with multi-vessel disease, failed PCI, or mechanical MI complications (VSR, papillary muscle rupture).

• ELIGIBILITY FOR MEDICAL MANAGEMENT / SECONDARY PREVENTION (STABLE POST-MI): Patients with non-obstructive CAD, contraindications to intervention, patient preference, or those already revascularised requiring optimised pharmacotherapy and cardiac rehabilitation.

• REQUIRED DIAGNOSTICS PRE- AND PERI-PROCEDURE: 12-lead ECG (serial, every 15–30 minutes in acute phase); high-sensitivity cardiac troponin I/T (hs-cTnI/T) at 0, 1, and 3 hours (ESC 0/1h algorithm); transthoracic echocardiography (TTE/2D-ECHO) for LVEF, wall motion abnormality, pericardial effusion, and mechanical complication assessment; coronary angiography (invasive gold standard); CT coronary angiography (CTCA) in selected stable NSTEMI; fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) for haemodynamic lesion assessment; cardiac MRI (CMR) for myocardial viability, infarct size, and microvascular obstruction in subacute phase; complete blood count, renal and hepatic function, coagulation profile, HbA1c, lipid panel, and BNP/NT-proBNP.

• CONTRAINDICATIONS / HIGH-RISK CONSIDERATIONS: Active major bleeding or high bleeding risk (HAS-BLED ≥3) limiting anticoagulation/DAPT; severe contrast allergy without pre-medication protocol; advanced chronic kidney disease (eGFR <15 mL/min) increasing contrast nephropathy risk; cardiogenic shock with multi-organ failure (may still warrant emergent PCI with haemodynamic support); recent ischaemic stroke within 1 month (relative contraindication to thrombolytics); severe aortic stenosis or hypertrophic obstructive cardiomyopathy as alternative diagnoses; pregnancy (radiation and contrast considerations apply).

REPERFUSION STRATEGIES:

1. PRIMARY PERCUTANEOUS CORONARY INTERVENTION (PRIMARY PCI) — Gold Standard for STEMI Performed via radial artery access (transradial approach preferred: reduces bleeding and vascular complications versus transfemoral), the culprit coronary artery is crossed with a 0.014-inch coronary guidewire, the thrombus aspirated (selective use, not routine), the stenosis pre-dilated with a compliant balloon, and a drug-eluting stent (DES) deployed — specifically thin-strut, biodegradable-polymer platforms (e.g., Orsiro, Synergy, or Ultimaster) which demonstrate lower rates of target lesion failure and stent thrombosis versus first-generation DES. Intravascular imaging with optical coherence tomography (OCT) or intravascular ultrasound (IVUS) is increasingly used to optimise stent sizing, landing zone, and expansion, reducing stent-related adverse events. Complete revascularisation of non-culprit lesions guided by FFR/iFR (staged or ad-hoc) is recommended in haemodynamically stable multi-vessel disease post-STEMI.

2. PHARMACOINVASIVE STRATEGY / THROMBOLYSIS Where primary PCI is unavailable within 120 minutes of first medical contact (relevant for patients in remote areas), fibrinolytic therapy with tenecteplase (weight-adjusted, single bolus) or alteplase is administered, followed by transfer for routine coronary angiography within 3–24 hours. Success is defined by >50% ST resolution at 60–90 minutes and cessation of chest pain.

3. CORONARY ARTERY BYPASS GRAFTING (CABG) Indicated for complex multi-vessel or left main disease (Heart Team decision, SYNTAX Score-guided), failed or unsuitable PCI anatomy, or mechanical complications. Off-pump CABG (OPCAB) avoids cardiopulmonary bypass — reducing neurological complications and renal injury — and is performed by high-volume surgeons at Indian and UAE centres. Arterial grafting with bilateral internal mammary arteries (BIMA) or use of the radial artery in addition to the left internal mammary artery (LIMA-to-LAD being the benchmark graft) provides superior 10-year patency versus saphenous vein grafts alone. Minimally invasive direct CABG (MIDCAB) and hybrid coronary revascularisation (LIMA-to-LAD via mini-thoracotomy + PCI for other vessels) represent advanced options at select high-volume centres.

4. HAEMODYNAMIC SUPPORT DEVICES Intra-aortic balloon pump (IABP): diastolic augmentation, commonly used in cardiogenic shock or high-risk PCI. Percutaneous left ventricular assist devices (Impella 2.5, CP, 5.0): axial flow pumps providing up to 5.0 L/min of cardiac output support during high-risk PCI or as a bridge in refractory cardiogenic shock. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO): reserved for refractory cardiogenic shock unresponsive to Impella or IABP.

5. OPTIMISED MEDICAL THERAPY (OMT) — POST-MI SECONDARY PREVENTION Guideline-directed medical therapy (GDMT) post-MI includes: high-intensity statins (rosuvastatin 20–40 mg or atorvastatin 40–80 mg) targeting LDL-C <55 mg/dL; DAPT (aspirin 75–100 mg + ticagrelor 90 mg BD for 12 months, or prasugrel in PCI-treated patients without stroke/TIA history); beta-blockers (bisoprolol, metoprolol succinate) for heart rate control and LV remodelling prevention; ACE inhibitors (ramipril, perindopril) or ARBs (valsartan) for LVEF ≤40% or anterior MI; mineralocorticoid receptor antagonists (eplerenone) for LVEF ≤35% with symptoms; SGLT2 inhibitors (dapagliflozin, empagliflozin) for HFrEF with or without diabetes — now Class I recommended post-MI with LV dysfunction; and PCSK9 inhibitors (evolocumab, alirocumab) for persistent LDL elevation despite maximum statin therapy.

6. CARDIAC REHABILITATION Structured, phase II cardiac rehabilitation — exercise stress testing, supervised aerobic training, dietary counselling, psychosocial support, and smoking cessation — commences in-hospital and continues for 8–12 weeks post-discharge, demonstrably reducing 5-year cardiovascular mortality by 20–25%.

PHASE 1 — EMERGENCY PRESENTATION AND TRIAGE (Hours 0–2) The patient arrives at the emergency department or is transported by ambulance. A 12-lead ECG is obtained and interpreted within 10 minutes of first medical contact. High-sensitivity troponin is drawn. STEMI activation of the cardiac catheterisation laboratory (cath lab) team is initiated immediately. Aspirin 300 mg and ticagrelor 180 mg loading doses are administered. IV access, oxygen (if SpO2 <90%), and analgesia (morphine or fentanyl with caution) are provided. The interventional cardiologist reviews the ECG, and the patient is taken directly to the cath lab — bypassing the emergency bay — aiming for door-to-balloon time ≤90 minutes.

PHASE 2 — PRIMARY PCI PROCEDURE (Hours 1–3) Under local anaesthesia and conscious sedation, a 6 Fr radial sheath is placed in the right radial artery. Coronary angiography delineates the culprit lesion and overall coronary anatomy. The culprit artery is crossed with a coronary guidewire, the occlusion is crossed and balloon pre-dilated, and a drug-eluting stent is deployed with IVUS or OCT guidance for optimal sizing. TIMI 3 flow restoration is confirmed. The procedure typically takes 45–90 minutes. Post-procedure, the patient is transferred to the Cardiac Intensive Care Unit (CICU).

PHASE 3 — CARDIAC ICU MONITORING (Days 1–3) Continuous telemetry for arrhythmia detection (risk of ventricular fibrillation peaks in first 48 hours). Serial ECGs and troponin trending. Transthoracic echocardiography at 24–48 hours to assess LVEF, wall motion abnormalities, and mechanical complications. DAPT, anticoagulation (for 24–48 hours post-PCI), statin, beta-blocker, and ACE inhibitor initiated or titrated. Glycaemic control (target glucose 140–180 mg/dL). Haemodynamic monitoring; vasopressors (norepinephrine) or Impella support weaned as tolerated. Multidisciplinary team review.

PHASE 4 — STEP-DOWN WARD AND MOBILISATION (Days 3–7) Transfer from CICU to cardiac step-down ward. Supervised early mobilisation by cardiac physiotherapist — sitting, standing, and walking short distances from Day 3–4. Patient education on GDMT adherence, lifestyle modification, and warning signs of re-infarction. Dietitian review. Renal function monitored for contrast-induced nephropathy (peak at Day 3–5). Radial access site check. Echo repeated if LVEF was depressed. Eplerenone or SGLT2 inhibitor initiated if LVEF ≤40%. Discharge planning commences.

PHASE 5 — DISCHARGE AND EARLY RECOVERY (Days 5–14) For uncomplicated primary PCI patients: discharge typically by Day 4–5 with full GDMT prescription, cardiac rehab referral, and 1-week follow-up appointment. For CABG patients: discharge by Day 10–14 with sternal precautions (no lifting >5 kg for 6 weeks, no driving for 4–6 weeks), wound care instructions, and respiratory physiotherapy continuation. For patients with reduced LVEF: wearable cardioverter-defibrillator (LifeVest) considered for 40-day bridging period until reassessment.

PHASE 6 — FIT-TO-FLY ASSESSMENT AND OUTPATIENT FOLLOW-UP (Weeks 2–6) The GAF Healthcare care coordinator schedules a pre-departure cardiology review including resting ECG, blood pressure check, and symptom assessment. Post-PCI patients with LVEF >45% and no arrhythmias are typically cleared to fly at 2–3 weeks. Post-CABG patients require a minimum of 4–6 weeks before long-haul flight, given sternal stability, DVT risk, and hypoxia tolerance at cabin pressure. Cardiac MRI at Week 4–6 assesses final infarct size and LVEF recovery. A detailed discharge summary, imaging CDs, and a 90-day medication supply prescription are provided. Telehealth follow-up via GAF Healthcare's platform continues remotely.

PHASE 7 — LONG-TERM SECONDARY PREVENTION (Months 3–12+) Phase II cardiac rehabilitation (8–12 weeks). LDL-C reassessment at 4–6 weeks: intensify or add PCSK9 inhibitor if target not achieved. DAPT reassessment at 12 months (or earlier with bleeding risk). LVEF reassessment by echo at 6 months: ICD implantation considered if LVEF remains ≤35% despite ≥3 months of GDMT. Annual cardiology review.