Timely thrombolytic therapy is vital for acute ischemic stroke and STEMI, as delays increase tissue damage, worsen recovery, and raise mortality. A 24×7 thrombolysis service within the Emergency Department can reduce door-to-needle times, improve access in resource-limited settings, and enhance outcomes. This review highlights the rationale, epidemiology, clinical evidence, infrastructure, training, implementation, cost-effectiveness, barriers, and future directions. A model for Uttar Pradesh is proposed, focusing on ED integration, task-sharing, point-of-care diagnostics, a “one-room unit,” and robust monitoring, governance, and research linkages, tailored to the Indian context.

Keywords: Acute Myocardial Infarction, Emergency Medicine, Ischemic Stroke, Point-of-Care Testing, Thrombolysis Service, Universal Health Coverage

Acute ischaemic stroke and acute myocardial infarction (AMI) continue to exert a large burden of morbidity and mortality worldwide, and the time‐sensitive nature of reperfusion therapy has transformed them into medical emergencies where every minute counts.¹ In India, with its vast population and growing burden of cardiovascular and cerebrovascular disease driven by urbanisation, an ageing population, rising prevalence of hypertension, diabetes, dyslipidaemia, and sedentary lifestyle, the need for timely reperfusion is particularly acute.² In stroke, the window for intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is ideally within 4.5 hours from symptom onset; beyond this, the benefit declines, and the risk of intracranial hemorrhage rises.³ In AMI, earlier reperfusion (via thrombolysis or primary percutaneous coronary intervention [PCI]) results in greater salvage of myocardium, improved left ventricular function, fewer complications, and improved survival.⁴ Despite strong evidence, many rural and resource-limited hospitals face delays in diagnosis, transport, and thrombolytic therapy due to limited specialists (especially the Neurologists & Cardiologists)  and emergency staff. To address this, the Uttar Pradesh Department of Medical Education is upgrading emergency departments into 24×7 integrated thrombolysis centers.⁵ This paper outlines the need, design, benefits, and challenges of establishing thrombolysis services in India.

Epidemiologic rationale: why a dedicated thrombolysis service?

1. Burden of disease: The incidence of ischemic stroke and acute MI is increasing globally and in India, with stroke prevalence estimated at 147–300 per 100,000 population. Rising cases in rural and semi-urban areas and high STEMI-related mortality persist due to delays in diagnosis, treatment, and rehabilitation.⁶
2. Time-sensitivity and outcomes: Rapid IV thrombolysis significantly improves outcomes and reduces mortality in stroke and myocardial infarction. ESO guidelines recommend alteplase within 4.5 hours of stroke onset, while early reperfusion in MI (“golden hour”) enhances myocardial salvage and survival. Due to pre- and intra-hospital delays and limited specialist availability in India, establishing dedicated thrombolysis services in emergency departments is vital to minimize door-to-needle time and improve patient outcomes.⁷
3. Access gap in peripheral settings: Many upgraded medical colleges and district hospitals lack round-the-clock neurology and cardiology services, leading to delays or missed thrombolysis opportunities. Establishing an ED-based thrombolysis service with trained emergency staff and support protocols can effectively bridge this gap.

Evidence favouring thrombolysis care in stroke & myocardial infarction

Stroke: Early IV rt-PA improves functional outcomes when given within 3–4.5 hours; delays reduce recovery. Trials like EXTEND and ECASS-4 refine timing and patient selection. In peripheral Indian centers, ED-based thrombolysis enables timely treatment without waiting for specialists.^8,9

Myocardial infarction: Thrombolysis remains essential when PCI is delayed or unavailable. Agents like tenecteplase reduce mortality and improve reperfusion, especially in rural or resource-limited settings. Intracoronary thrombolysis adjuncts to PCI improve outcomes without major bleeding risk. ^[10-11]

Safety and special situations: MI after rt-PA for stroke is rare (~0.5%). Risks like cardiac rupture after recent STEMI exist, highlighting the need for strict protocols, imaging, and cardiology–neurology collaboration.

Operational design: infrastructure and workflow of a thrombolysis unit in ED

Unit location and setup: A “one-room unit” within the ED is practical and space-efficient. It should be clearly visible, accessible from triage/resuscitation areas, and well-marked for staff, patients, and relatives. Key equipment for the unit includes:

1. 1 ECG machine
2. 1–2 multi-parameter cardio-respiratory monitors
3. 1–2 stand-alone non-invasive blood pressure (NIBP) monitors
4. Access to rapid imaging (CT head for stroke; ideally CT brain + angiography)
5. Access to laboratory/point-of-care tests: random blood sugar, cardiac troponin, full blood count/coagulation panel, renal/liver function
6. Thrombolytic drugs: ideally, bolus agents such as tenecteplase (TNK) or standard alteplase (rt-PA), depending on cost and availability
7. Dedicated protocols, checklists, and printed/pictorial algorithms in the unit for stroke and STEMI thrombolysis

Diagnostics and point-of-care lab: To reduce door-to-needle time, a point-of-care lab (POC-L) should be placed within or near the ED. Essential POC tests include rapid cardiac troponin, glucose, coagulation/INR, platelet count, and fast CT interpretation for head imaging. This enables parallel diagnostics and imaging, speeding up clinical decisions.

Workflow and triaging

1. Patient arrives at ED (via ambulance/private) → triage identifies ‘time-sensitive vascular event’ (signs of stroke or STEMI)
2. Immediate registration & alert to the thrombolysis unit team
3. Simultaneous actions: ECG/CT head scanning/blood sample collection and physician evaluation
4. If criteria met (diagnostic confirmation, exclusions checked), decision to proceed with thrombolysis is made — and drug administered within target door-to-needle time (ideally < 60 minutes for stroke; shorter if possible)
5. Post-thrombolysis monitoring in a designated area (monitoring of vitals, neurological status in stroke; cardiac monitoring in MI)
6. Transfer to the appropriate ward/ICU or cath lab as required
7. Recording key timepoints (symptom onset, arrival, imaging, lab, decision, drug administration) for quality control and auditing

Drug selection: alteplase vs tenecteplase: Tenecteplase (bolus) offers practical advantages—simpler administration, minimal infusion setup, and reduced nursing time. In India, guidelines recommend weight-based dosing, particularly for low-weight or elderly patients at higher bleeding risk. For stroke, ESO notes its potential in large vessel occlusion, but evidence remains limited compared to alteplase.¹¹

Governance, quality indicators, and monitoring: Implementation should track KPIs like door-to-needle and door-to-imaging times, treatment rates, complications, in-hospital mortality, and functional outcomes. Monthly audit meetings with feedback to ED staff, along with integration into hospital information systems and stroke/MI registries, enable continuous monitoring and improvement.

Addressing specialist shortage: training and role-sharing strategy: Peripheral hospitals often lack 24/7 specialists. A task-sharing model trains EMOs, doctors, nurses, and paramedics through rotations, structured courses, simulations, protocols, and tele-consultation support. This enables non-specialists to safely deliver thrombolysis, extending service reach without replacing specialists.

Implementation in the uttar pradesh context: strategy and steps: Given the particular context of Uttar Pradesh – large population, mixed rural-urban distribution, many recently upgraded district hospitals/medical colleges, variable availability of imaging and specialist staff – the following strategy is proposed:

1. Pilot phase: Select 1–2 district hospital EDs with existing CT imaging and minimal staffing gaps.
2. Infrastructure set-up: The “one-room” thrombolysis unit within the ED, equipped with monitors/ECG/POC lab as above.
3. Protocol development: Create standard operating procedures (SOPs) for triage, stroke/stemi pathways, checklists, contraindication screening, and informed consent (where applicable).
4. Training: Intensive initial training for EMOs/residents/nurses/paramedics in common life-saving procedures, including tele-consultation, etc.
5. Tele-mentoring with a tertiary centre, in the format of a “Hub & Spoke model”, wherein the consenting cardiology and/or Neurology departments (Hub) of more established older Institutions in the state, function as a Hub for offering digital online consultation to the EDs of peripheral medical Institutions & hospitals (Spoke) connected with their respective Hub. The ED professional, whenever required, may seek an opinion about the findings in the patient’s ECG (suspected STEMI patients), CT-head (suspected stroke patients), injection Tenecteplase dosage, or any other patient-related issues, including referring the patients, after initial acute care, to the respective Hub institution for further follow-up.     
6. 24×7 Roster: Ensure ED staff are assigned in rotational blocks with dedicated thrombolysis service responsibility, with on-call backup from cardiology/neurology via tele-link.
7. Data collection and audit: Register all cases of suspected stroke/MI, record times (onset, arrival, imaging, drug administration), outcomes, complications.
8. Scale-up: Based on pilot results, expand to additional hospitals in phases, ensuring funding/maintenance.
9. Public awareness and pre-hospital network: Conduct community awareness campaigns (stroke symptoms, MI symptoms, “time is brain/heart”), improve pre-hospital ambulance triage and direct routing to thrombolysis-capable centres.
10. Governance: Form a state-level thrombolysis oversight committee under the Department of Medical Education to monitor, guide, benchmark, and publish results.

Cost-effectiveness and economic considerations: Early thrombolysis in stroke and STEMI is cost-effective, reducing disability, hospital stay, and long-term care costs. In India, using affordable agents like tenecteplase and existing ED infrastructure improves feasibility, with global evidence supporting its benefit, especially in rural and low-income settings.¹²

Barriers, challenges, and facilitators

Barriers

1. Delays in patient presentation (many rural patients reach the hospital late, beyond the window)
2. Limited availability of CT scanning (especially 24×7) and lab turnaround times
3. Lack of trained staff, especially permanently posted within EDs
4. Resistance to change/new protocols, fear of complications (intracranial bleed, haemorrhage)
5. Drug cost, supply chain issues (especially thrombolytic agents)
6. Monitoring and audit systems are absent or weak
7. Pre-hospital transport & referral network constraints.

Facilitators

1. government policy support (department of medical education in uttar pradesh backing the initiative)
2. simplicity of the “one‐room” unit, bolus drug administration (tenecteplase)
3. use of protocols and checklists reduces variability
4. training and task-sharing model enabling service despite specialist shortage
5. data collection and audit createa continuous improvement cycle
6. public awareness campaigns reduce the delay in presentation

Risk management and safety

The safety of thrombolysis depends heavily on correct patient selection. Guidelines (e.g., ESO stroke guideline) emphasise strict adherence to contraindications, blood pressure control, and imaging exclusion of haemorrhage.  For STEMI, bleeding risk must be balanced with myocardial salvage benefit; older patients and those with renal/hepatic dysfunction require careful monitoring. The governance framework should include quality assurance, adverse event monitoring, and regular morbidity/mortality reviews.¹³

Future directions and research opportunities: Advanced imaging and telemedicine enable early or extended-window thrombolysis. Pharmaco-invasive STEMI care, integration with emergency services, and innovations like AI and mobile CT improve outcomes, while local research guides cost-effective implementation.

Emergency and trauma services are the frontline of any hospital, reflecting its capacity to provide timely, life-saving care. In India, with high rates of accidents and acute illnesses, integrated emergency, trauma, ICU, and reperfusion systems are urgently needed. Dedicated thrombolysis units in EDs—with essential diagnostics, trained staff, and point-of-care labs—can improve stroke and MI outcomes, support education, training, and research. Achieving this requires policy support, infrastructure investment, and workforce development to ensure resilient, patient-centred, and equitable emergency care, even in rural areas.

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