Reperfusion therapy in resource-limited settings

¹Department of Internal Medicine and Therapeutics, Tamale Teaching Hospital, Tamale, Ghana

^&Corresponding author
Abdul-Subulr Yakubu, Department of Internal Medicine and Therapeutics, Tamale Teaching Hospital, Tamale, Ghana

To the editors of the Pan African Medical Journal    

Reperfusion therapy is central to the management of acute cardiovascular emergencies, including ischemic stroke, pulmonary embolism, and acute coronary syndromes. In resource-limited settings, reperfusion options remain scarce and often unavailable [1]. The severe shortage of cardiac catheterization laboratories and trained interventionalists makes thrombolysis the most practical reperfusion option for eligible patients in these settings. Yet thrombolysis is profoundly underutilized, hindered by high drug costs, limited clinician familiarity, and diagnostic delays [2,3]. Effective implementation of guideline recommendations in resource-limited settings requires context-appropriate solutions that address geographic constraints, logistical challenges, and economic realities [4]. Thrombolytic agents are plasminogen activators that convert the inactive precursor plasminogen into plasmin, the enzyme responsible for degrading fibrin cross-links and dissolving thrombi [5]. Streptokinase, the first fibrinolytic compound, originally isolated from bacterial cultures in 1933, continues to be widely used in many resource-limited settings despite its limitations [5]. Although relatively affordable and accessible, streptokinase requires continuous infusion, carries a high risk of allergic reactions, demonstrates lower efficacy compared with fibrin-specific agents, and lacks approval for stroke [6].

These limitations reduce its value as a thrombolytic agent. Fibrin-specific activators, such as tissue-type plasminogen activator, preferentially target fibrin-bound plasminogen, producing plasmin that is shielded from rapid inhibition. This selectivity enhances clot dissolution while minimizing systemic activation of the fibrinolytic system. Third-generation agents such as Tenecteplase offer additional advantages, including a prolonged half-life that enables single bolus administration [7]. Their ease of use minimizes medication errors, shortens treatment delays, and facilitates prehospital thrombolysis and interhospital transfers [8]. Given these practical advantages, government-subsidized programs prioritizing third-generation thrombolytics could improve accessibility and uptake of thrombolysis as a reperfusion strategy. Late presentation remains a defining challenge in emergency cardiovascular disease management across sub-Saharan Africa, contributing significantly to delays or absence of reperfusion therapy [9]. Contributing factors include poor public awareness of cardiovascular symptoms, inadequate ambulance services, low clinical suspicion among physicians, and delays in obtaining diagnostic investigations such as electrocardiograms (ECGs) and computed tomography scans. Addressing these barriers requires public education campaigns, improved access to diagnostic imaging, training in early ECG interpretation, and strengthened emergency transport systems.

Telemedicine-enabled ECG interpretation and streamlined referral coordination can further enhance timely thrombolysis, particularly in prehospital environments and regions lacking on-site specialists. The establishment of specialized thrombolysis units, either stand-alone or integrated within stroke and coronary care units, staffed by clinicians familiar with thrombolytic agents, their administration, and side-effect profiles, can facilitate thrombolysis as a reperfusion strategy. Despite its utility, thrombolysis carries inherent limitations: reperfusion fails in about half of cases, and contraindications exclude some otherwise eligible patients. These constraints underscore the need for parallel investment in transcatheter reperfusion capabilities, even as efforts expand access to thrombolysis. A flexible pathway that prioritizes thrombolysis, with clear protocols for invasive strategies where feasible, is a pragmatic approach in resource-limited settings [10]. Establishing STEMI networks through a hub-and-spoke model can maximize resource utilization by linking thrombolysis-based centers with facilities equipped to deliver transcatheter interventions. In conclusion, thrombolysis is a practical and viable reperfusion strategy in resource-limited settings. Promoting wider uptake requires a multi-faceted approach, including public education, sustainable financing mechanisms to support access to third-generation fibrin-specific agents with simplified administration, and the integration of telemedicine to extend specialist support to facilities lacking on-site specialists.

Competing interests    

The author declares no competing interests.

Author contributions     

Abdul-Subulr Yakubu conceptualised, drafted and wrote the final version of the manuscript. The author have read and agreed to the final version of this manuscript.

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