At 4:40 a.m. on May 4, 2026, a 40-year-old man came to Khanna Sub-divisional Hospital’s emergency department with sweating and chest pain. Within minutes, the staff nurse and Emergency Medical Officer (EMO) had checked his heart rate, blood pressure, blood sugar and more importantly, conducted an electrocardiogram (ECG).
The ECG result was sent on WhatsApp to the hospital’s medicine consultant, Shiney Aggarwal, who diagnosed it as an ST-elevated myocardial infarction (STEMI) case and asked the EMO to administer the injection tenecteplase.
Dr Shiney Aggarwal with the emergency staff at SDH Khanna.
| Photo Credit:
Swagata Yadavar
STEMI is a severe, life-threatening heart attack with significant coronary artery blockage. The injection tenecteplase is used for thrombolysis or dissolving the clot, by acting on the protein holding it together, restoring blood supply to the heart.
The patient received the injection within half an hour of his ECG results and soon felt relief. Out of danger, he was referred to Government Medical College Patiala (54 km) for further investigations and treatment.
This case marked the 100th thrombolysis case of the hospital and the highest recorded by any centre in Punjab. A few years ago, any chest pain patient in secondary health centres such as sub-divisional and district hospitals would have been immediately referred to medical colleges for further treatment.
Had that happened in this case, the 40-70 minutes that the patient lost in transportation and further diagnosis would have meant irreversible damage to his heart muscles and their ability to work in the future.
ICMR project to a state-wide mission
Since July 2025, the Punjab government has implemented Mission AMRIT (Acute Myocardial Reperfusion in Time) across the State where staff members of sub-divisional hospitals and district hospitals (spokes) are equipped with drugs, equipment and training to conduct thrombolysis under the guidance of a cardiologist or a specialist in the medical colleges (hubs).
Till date, about 34,000 people with chest pain have been registered in the spokes out of which 1900 were identified as STEMI cases, 900 have received thrombolysis and many of them received angiography and angioplasty in the hubs. The initiative has expanded the work done by the Indian Council of Medical Research (ICMR)’s STEMI ACT project implemented in one district of 7 states and one union territory between 2020-2024.
“In our study, at least around 8000 patients have been thrombolised and we are able to almost triple the thrombolysis rate where nothing was happening before,” said S. Ramakrishnan, consultant cardiologist, AIIMS and National Principal Investigator, ICMR ACT project, that concluded in December 2024. He said the current focus of the study is on increasing access to thrombolysis and not increasing the rate of angioplasties due to paucity of cath labs and the high cost of the procedure.
According to Hitinder Kaur, Director, Health Services of Department of Health and Family Welfare, Punjab, STEMI patients are receiving Rs 35,000 worth of treatment free of cost within minutes, providing timely treatment. This work continued even during the 2025 floods and in challenging (Pakistan bordering) districts including Tarn Taran and Ferozepur during Operation Sindoor.
The model operates simply – the spokes are equipped with ECG machines, defibrillators, heart monitors and refrigerators to store tenecteplase. The staff is trained to conduct ECGs and administer the injection. These staff are then added to WhatsApp groups with senior cardiologists who are able to provide oversight around the clock.
When a person with STEMI reaches the spoke within the time frame (up to 12 hours of a heart attack) with no complications, they get thrombolysed and are referred to the hubs for further angiography and angioplasty. This strategy is known as the pharmaco-invasive strategy and is ideal for low-resource settings such as India where the patient demand far outweighs the number of catheterisation labs.
Pyramid model for thrombolysis decision making, credit: DMC Ludhiana
| Photo Credit:
Swagata Yadavar
Dr Bishav Mohan pointing to the ECG received in the Mission AMRIT WhatsApp group.
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Special Arrangement
A unique feature of ICMR’s project in Ludhiana was that it was led by Bishav Mohan, who works in who works in Dayanand Medical College, a private medical college and also provides the technical support for Mission AMRIT. Another exception of the Ludhiana project was the inclusion of three private centres as spokes in the pilot, though private involvement was discontinued in the actual programme.
“It has taken us a long time and consistent efforts to work on the hesitancy and fear of staff for managing an acute emergency condition like heart attack/STEMI at a secondary health-care level through capacity building,” said Ashu Gupta, NCD cell, Department of Health and Family Welfare. “We are happy that despite the challenges we are able to run the project successfully without any additional manpower,” she said.
Dr. Parminder Singh Manghera, Assistant Professor, Cardiology with the nursing staff at GMC Amritsar.
| Photo Credit:
Swagata Yadavar
Getting appropriate care in the spokes has also had a great effect in improving patient outcomes in the medical colleges. Amritsar’s Government Medical Centre (GMC) acts as a hub for six districts around it. In the past 10 months the hub received 272 patients who were thrombolysed in the spokes out of which 265 underwent angioplasty at GMC, said Parminder Singh Manghera, Assistant Professor, Cardiology, GMC.
Many of them could avail the procedure free of cost under Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) or Punjab government’s Mukhyamantri Sehat Bima Yojana that provides Rs. 10 lakh coverage to each family.
Running the programme across the state
The success of the project has depended heavily on the efforts of health officials such as Dr. Gupta who spends a lot of her personal time engaging with doctors in the centres through WhatsApp groups, coordinating with them, collecting data and also maintaining the supply of tenecteplase across 65 centres. Similarly, Dr. Bishav Mohan spends hours every day answering queries, advising the doctors on the treatment required and encouraging them to conduct more thrombolyses through multiple WhatsApp groups.
Infrastructural gaps, staff transfer and shortage and high patient numbers exist in many of these emergency departments; so keeping these overwhelmed medical teams interested requires motivational talks, treating nurses as equal partners, use of Punjabi during training and technical materials, awarding best performers from the districts on a monthly basis and also organising award ceremonies by the health minister, said Dr Mohan. “Once people start working, they see that they are able to save lives, this in itself is a morale booster and helps sustain the initiative”,” he said.
STEMI models across India
After the successful Tamil Nadu-STEMI pilot that showed how a hub-and-spoke model can improve reperfusion rates and reduce mortality, it was implemented in many States including Tamil Nadu, Goa, Karnataka, and Andhra Pradesh. In most States, spokes are Community Health Centres (CHCs), sub-divisional hospitals and district hospitals and medical colleges with cath labs are the hubs.
Tamil Nadu has been the most successful state which has thrombolysed over 72,000 patients over five years with a 67% annual increase in STEMI patients receiving thrombolysis and a 68% increase in patients receiving primary angioplasties.
But including only the government hospitals as hubs is reducing the effectiveness of the model, said cardiologist Thomas Alexander who along with Ajit Mullasari piloted the TN-STEMI model. “Patients covered under government insurance schemes should have access to the nearest reperfusion centre—public or private—with safeguards to prevent overuse and overcharging,” he said.
Way ahead
In Punjab, a year after Mission AMRIT’s implementation, some limitations of the model are obvious–it relies on individual interest and effort. While some spokes like SDH Khanna are doing exceptional work many other spokes have only conducted a handful of thrombolyses despite availability of drugs and trained staff. Also, at the moment there is no follow-up as to what happens to patients after they leave the spokes . This follow-up with tertiary care institutes is part of the next phase of the mission, said Dr. Mohan.
However, despite the challenges, officials say the programme has improved access, “We are seeing more women from villages above the age of 50 with symptoms turning up in spoke centres because it is close to home and accessible, we would have missed this demographic before,” said Dr Mohan.
(Swagata Yadavar is an independent journalist. swagatayadavar@gmail.com)
(This article is the second of a three-part series by Nivarana, a digital public health platform, on the health system’s response to emergency cardiac care in India. It is supported by Sunfox Technologies)