==== Front JACC Asia JACC Asia JACC Asia 2772-3747 Elsevier S2772-3747(23)00140-0 10.1016/j.jacasi.2023.05.006 Letter To the Editor Reply Underutilization of Fibrinolysis Despite Timely Arrival in STEMI: A Missed Opportunity! Bhatia Kirtipal MD Qamar Arman MD, MPH Hendrickson Michael MD Arora Sameer MD, MPH Gupta Mohit D. MD, DM drmohitgupta@yahoo.com ∗ ∗ Room 125, Academic Block, Department of Cardiology, GB Pant Institute of Postgraduate Medical Education and Research, Jawahar Lal Nehru Marg, New Delhi, India 110002 drmohitgupta@yahoo.com 20 6 2023 6 2023 20 6 2023 3 3 535535 © 2023 The Authors 2023 https://creativecommons.org/licenses/by/4.0/ This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). ==== Body pmcWe welcome the interest of Gnanaraj and colleagues in our analysis from the NORIN-STEMI (The North Indian ST-segment elevation myocardial infarction) registry.1 The use of fibrinolysis was low in our study despite most patients presenting to a health care facility early after symptom onset. We attribute this to a lack of standardized treatment protocols or trained staff at health care centers where patients first made contact, many of which were primary health care centers. Additionally, prohibitive out-of-pocket expenses is a big reason for transfer to government-funded tertiary facilities, which possibly caused patients to defer medical therapy offered at the first center. The patient population included in our study had baseline characteristics comparable to other prior Indian registries.2 However, because most of the patients in our cohort were referred from other health care centers, survivorship bias possibly affected the observed in-hospital mortality. This is evidenced by the fact that those receiving percutaneous coronary intervention (PCI) at less than 24 hours after symptom onset had higher mortality compared to those receiving PCI more than 72 hours after symptom onset (5% vs 3%; P < 0.001), and this may point to patients with less severe cases surviving naturally and subsequently receiving PCI. Gnanaraj and colleagues also highlight the high proportion of patients receiving PCI in late-presenting patients with non–ST-segment elevation myocardial infarction (STEMI). Although current guidelines recommend against PCI in asymptomatic patients, PCI is still considered reasonable among patients with persistent symptoms, with signs of heart failure, or with a large area of demonstrable viable myocardium at risk.3 Patients in our cohort had high rates of ventricular systolic dysfunction on presentation likely caused by delays in receiving timely reperfusion therapy. Revascularization in these patients may have been aimed at improving ventricular function. This again reinforces the unmet need of timely reperfusion for STEMI patients in India, which requires systemic reform at the national level. A total of 310 (10%) patients were lost to follow-up at 1 year, and these patients had similar baseline characteristics compared to those who completed follow-up. Regardless, by virtue of incomplete follow-up, it is possible that 1-year mortality may be underestimated. Dr Qamar reports receiving institutional grant support from Novo Nordisk and the NorthShore Auxiliary Research Scholar Fund as well as fees for educational activities from the American College of Cardiology, Society for Vascular Medicine, Society for Cardiovascular Angiography and Interventions, Janssen and Janssen, Pfizer, Medscape, and Clinical Exercise Physiology Association. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center. ==== Refs References 1 Qamar A. Bhatia K. Arora S. Clinical profiles, outcomes, and sex differences of patients with STEMI: findings from the NORIN-STEMI Registry JACC: Asia 3 2023 431 442 2 Xavier D. Pais P. Devereaux P.J. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data Lancet 371 9622 2008 1435 1442 18440425 3 Lawton J.S. Tamis-Holland Jacqueline E. Bangalore S. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization J Am Coll Cardiol 79 2 2022 e21 e129 34895950