Reperfusion therapy for ST elevation myocardial infarction in low- to middle-income countries: a clinical consensus statement of the Association for Acute CardioVascular Care (ACVC), the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Association of Preventive Cardiology (EAPC), the ESC Working Group on Thrombosis, and the Stent-Save a Life! Initiative

Araiza-Garaygordobil D. Alexander T. Huber K. Halvorsen S. Ahrens I. Alviar C. Arias-Mendoza A. Dippenaar A. Gorog D.A. Campo G. Rakisheva A. Mouine N. Gabulova R. Orlić D. Pereira H. Barbato E. Candiello A. Sobhy M. Piek J.J.
1 November 2025 Oxford University Press

European Heart Journal: Acute Cardiovascular Care
2025 #14 Issue 11 690 - 697 pp.

Suboptimal care for ST-elevation myocardial infarction (STEMI) in low- and middle-income countries is a significant problem. Registries from Latin America, Africa, and Asia show that <65% of patients receive reperfusion therapy, and widespread treatment delays and a lack of access to optimal therapies lead to preventable deaths and complications. While current guidelines provide a blueprint for care, their implementation in low-resource settings requires specific guidance that considers geographical, logistical, and economic realities. This clinical consensus offers a new framework for developing STEMI care systems in these countries. We propose a flexible, three-model pathway, based on the initiatives such as STEMI India and Stent-Save a Life. The models include a fibrinolysis model, a pharmaco-invasive strategy model, and a primary percutaneous coronary intervention (PCI) model. This approach emphasizes adaptability, allowing local STEMI systems to be tailored to specific circumstances. The framework also addresses specific, common challenges, such as delayed access to primary PCI, reperfusion in patients with cardiogenic shock and expected delayed PCI, fibrinolysis in patients with a high risk of bleeding, and the absence of fibrin-specific fibrinolytics, catheterization labs, or reperfusion therapies at all. The consensus also highlights the importance of continuous improvement, patient education, and adopting secondary prevention strategies. Ultimately, this framework is designed to help healthcare providers and leaders in developing countries improve their regional STEMI care systems.

Acute coronary syndromes , Developing countries , ESC documents , Low- to middle-income countries , Reperfusion , STEMI

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Unidad Coronaria, Instituto Nacional de Cardiología Ignacio Chávez, Juan Badiano 1, Tlalpan, Ciudad de México, Mexico
Department of Cardiology, Kovai Medical Center and Hospital, Coimbatore, India
Faculty of Medicine, Sigmund Freud University, Vienna, Austria
Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Augustinerinnen Hospital, Cardiology and Medical Intensive Care, Cologne, Germany
Faculty of Medicine, University of Freiburg, Freiburg, Germany
Leon H. Charney Division of Cardiology, New York University Grossman School of Medicine, Bellevue Hospital, New York, NY, United States
Royal Infirmary of Edinburgh, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
SA Endovascular, South African Heart Association, Johannesburg, South Africa
Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, Hatfield, United Kingdom
School of Cardiovascular and Metabolic Medicine & Sciences, King’s College London, London, United Kingdom
Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Italy
Cardiology Department, Almaty City Cardiology Center, Almaty, Kazakhstan
Cardiology Department, Mohammed V Military Hospital of Rabat, Rabat, Morocco
Education Therapeutic Hospital, Azerbaijan Medical University, Baku, Azerbaijan
University Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
Cardiology Department, Hospital Garcia de Orta, EPE, Almada, Portugal
Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
Division of Cardiology, Sant’Andrea University Hospital, Rome, Italy
Instituto Cardiovascular de Buenos Aires, División de Cardiología Intervencionista, Buenos Aires, Argentina
Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, Netherlands

Unidad Coronaria
Department of Cardiology
Faculty of Medicine
Department of Cardiology
Institute of Clinical Medicine
Augustinerinnen Hospital
Faculty of Medicine
Leon H. Charney Division of Cardiology
Royal Infirmary of Edinburgh
SA Endovascular
Faculty of Medicine
Centre for Health Services Research
School of Cardiovascular and Metabolic Medicine & Sciences
Cardiology Unit
Cardiology Department
Cardiology Department
Education Therapeutic Hospital
University Clinical Center of Serbia
Cardiology Department
Department of Clinical and Molecular Medicine
Division of Cardiology
Instituto Cardiovascular de Buenos Aires
Department of Cardiology
Amsterdam UMC

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