On May 4, 2026, at 4:40 am, a 40-year-old man came to the emergency department of Khanna Sub-Divisional Hospital with sweating and chest pain. Within minutes, the staff nurse and emergency medical officer (EMO) checked his heart rate, blood pressure, blood sugar and most importantly, performed an electrocardiogram (ECG).
The ECG result was sent to the hospital’s drug consultant Shiny Agarwal on WhatsApp, Who diagnosed it as an ST-elevated myocardial infarction (STEMI) case and asked the EMO to give him injected tenecteplase.
Dr. Shiney Aggarwal with emergency staff at SDH Khanna. | Photo Courtesy: Swagata Yadwar
STEMI is a serious, life-threatening heart attack caused by a significant blockage in a coronary artery. Injection tenecteplase is used for thrombolysis, or dissolution of the clot, by acting on the proteins that hold it together, restoring blood supply to the heart.
The patient received the injection within half an hour of the ECG results and soon felt relief. Out of danger, he was referred to Government Medical College, Patiala (54 km) for further investigation and treatment.
The case is the hospital’s 100th thrombolysis case and the highest number of cases reported by any center in Punjab. A few years ago, any patient with chest pain in secondary health centers like sub-divisional and district hospitals was immediately referred to medical colleges for further treatment.
If this had 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 muscle and their ability to function in the future.
ICMR project for a statewide mission
From July 2025, the Punjab government has implemented Mission AMRUT (Acute Myocardial Reperfusion in Time) across the state, where staff members of sub-divisional hospitals and district hospitals (spokes) are equipped with medicines, equipment and training to perform thrombolysis under the guidance of a cardiologist or specialist from medical colleges (hubs).
So far, around 34,000 people suffering from chest pain have been registered, of which 1900 were identified as STEMI cases, 900 have received thrombolysis and many of them have received angiography and angioplasty at the hub. This initiative expands the work done by the STEMI ACT project of the Indian Council of Medical Research (ICMR), implemented in one district of 7 states and one Union Territory between 2020-2024.
S., consultant cardiologist at AIIMS and national principal investigator of the ICMR ACT project, who concluded in December 2024. “In our study, at least about 8000 patients have been thrombolysed and we have been able to almost triple the thrombolysis rate where nothing was happening before,” Ramakrishnan said. process costing.
According to Hitinder Kaur, director of health services, Punjab Health and Family Welfare Department, STEMI patients are getting free treatment worth Rs 35,000 within minutes, providing timely treatment. This work also continued in challenging (bordering Pakistan) districts including Tarn Taran and Ferozepur during the 2025 floods and during Operation Sindoor.
The model operates simply – the spokes are equipped with ECG machines, defibrillators, heart monitors and refrigerators to store tenecteplase. The staff are trained to perform ECGs and administer injections. These staff are then added to WhatsApp groups with senior cardiologists who are able to provide round-the-clock monitoring.
When a person suffering from STEMI reaches the spoke within the time limit (up to 12 hours after the heart attack) without any complications, they are thrombolyzed and sent to the center for further angiography and angioplasty. This strategy is known as a pharmaco-invasive strategy and is ideal for low-resource settings such as India where patient demand far exceeds the number of catheterization laboratories.
Pyramid model for thrombolysis decision making, Credit: DMC Ludhiana | Photo Courtesy: Swagata Yadwar
Dr. Bishav Mohan pointing towards ECG received in Mission Amrit WhatsApp group. | Photo Credit: Special Arrangement
A unique feature of ICMR’s project in Ludhiana was that it was led by Vishwa Mohan, who works at Dayanand Medical College, a private medical college and also provides technical support for Mission Amrit. Another exception to the Ludhiana project was the inclusion of three private centers as a pilot, although private participation was discontinued in the actual programme.
Ashu Gupta, NCD Cell, Department of Health and Family Welfare, said, “It has taken us a long time and sustained efforts to work on the hesitation and fear of the staff to manage serious emergencies like heart attack/STEMI at the secondary health care level through capacity building.” “We are happy that despite the challenges, we have been able to successfully run the project without any additional manpower,” he said.
Dr. Parminder Singh Mangera, Assistant Professor of Cardiology with the nursing staff at GMC Amritsar. | Photo Courtesy: Swagata Yadwar
Medical colleges have also had a significant impact in improving patient outcomes by providing access to appropriate care. The Government Medical Center (GMC) of Amritsar serves as a hub for the six districts around it. Parminder Singh Manghera, assistant professor of cardiology at GMC, said that in the last 10 months, 272 patients who came to the hub were thrombolysed at the spoke, of which 265 underwent angioplasty at GMC.
Many of them can avail the free procedure under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) or the Punjab government’s Chief Minister Sehat Bima Yojana, which provides Rs. Coverage of Rs 10 lakh to each family.
running programs across the state
The success of the project largely depends on the efforts of health officials like Dr Gupta, who spends most of his personal time connecting with doctors at the centers through WhatsApp groups, coordinating with them, collecting data and maintaining the supply of tenecteplase across the 65 centres. Similarly, Dr. Bishav Mohan spends hours every day answering questions, advising doctors about necessary treatments and encouraging them to thrombolyse more through several WhatsApp groups.
Many of these emergency departments suffer from lack of infrastructure, shifting and understaffing, and high patient volumes; Therefore, to keep these overwhelmed medical teams interested, motivational talks, treating nurses as equal partners, use of Punjabi during training and technical material, giving awards to the best performers from the districts on a monthly basis and organizing award ceremonies by the Health Minister are also necessary, said Dr Mohan. “Once people start working, they see that they are able to save lives, that in itself is a morale booster and helps sustain the initiative,” he said.
STEMI model across India
Following the successful Tamil Nadu-STEMI pilot, which showed how a hub-and-spoke model could improve reperfusion rates and reduce mortality, it was implemented in several states including Tamil Nadu, Goa, Karnataka and Andhra Pradesh. In most states, there are community health centers (CHCs), sub-divisional hospitals and district hospitals and medical college centers with cath labs.
Tamil Nadu has been the most successful state, performing thrombolysis of more than 72,000 patients in five years, with a 67% annual increase in STEMI patients receiving thrombolysis and a 68% increase in patients receiving primary angioplasty.
But including only government hospitals as hubs is reducing the effectiveness of the model, said cardiologist Thomas Alexander, who piloted the TN-STEMI model with Ajit Mullasari. “Patients covered under government insurance schemes should have access to the nearest reperfusion center – public or private – with safeguards in place to prevent overuse and overcharging,” he said.
way ahead
In Punjab, a year after the implementation of Mission AMRUT, some limitations of the model are evident – it depends on individual interest and effort. While some spokespersons like SDH Khanna are doing extraordinary work, many other spokespersons have thrombolyzed only a handful despite the availability of medicines and trained staff. Additionally, there is currently no monitoring of what happens to patients after they stop speaking. This follow-up with tertiary care institutions is part of the next phase of the mission, Dr. Mohan said.
However, despite the challenges, officials say the program has improved access. “We are seeing more women over 50 from villages coming to the spoke center because it is close to home and accessible, we would have missed this demographic earlier,” said Dr. Mohan.
(Swagatayadavar is an independent journalist. swagatayadavar@gmail.com)
(This article is the second of a three-part series by Nivaran, a digital public health platform on the health system response to emergency cardiac care in India. It is supported by Sunfox Technologies)
