New Delhi: On a cold February morning, Jassuram Khanna, a farmer from Sujau village in Chakrata in Uttarakhand, felt a tightness in his chest on his way to the market. After waiting a few minutes, he called his son Suresh to come and take him to the doctor. They hired a private car and went to the local Primary Health Centre (PHC), where the health worker checked his blood pressure and sent him to Vikasnagar, a nearby Tehsil town.
After reaching Vikasnagar, Community Health Centre (CHC), 55 km away, they found no doctor there. Finally, at around 3 pm, they found help at Swami Vivekanand Charitable Hospital in Dharamwala, about 70 km from his hometown. This is where Jassuram finally got an electrocardiogram (ECG) done, which indicated he had suffered a heart attack. The doctors rushed him for an angiography, where they found he had a 100% blockage in one of his heart vessels. They performed an angioplasty where a balloon was sent to the blocked heart blood vessel to widen it, and a mesh tube called a stent was placed there. The time taken from his first symptoms at 10:30 am to his first ECG was 4.5 hours, and it would be another 40 minutes before he went for the angioplasty procedure.
The ideal time that guidelines recommend for a patient with a heart attack to get an ECG and have it interpreted is ten minutes of contact with a medical team.
Jassuram’s long journey for an ECG is typical of what patients in rural areas face.
(Original illustration of a balloon angioplasty by Dr. Gayatri)
While poor access to healthcare in rural India is a well-known fact, does living in a city guarantee timely care? In December 2025, Usha Amin, a retired teacher, felt breathless for two consecutive days on her morning walk; she found her pulse to be 33 on her electronic BP machine (normal pulse being 60-80beats/min). Alarmed, she called her son and rushed to the nearest multispecialty hospital in Thane, which falls in Mumbai Metropolitan Region.
The ECG showed Usha had developed a third degree heart block, a serious condition where the electrical signals from the upper chambers of the heart are completely blocked from reaching the lower chambers of the heart that can lead to cardiac arrest. However the doctor on duty informed them that the cardiologist was unavailable at the moment.
Since Amin looked stable, the family was told that there was no need to worry, and she was advised to schedule an appointment with the cardiologist and return the next day. Amin’s daughter, an occupational therapist, realised the possible gravity of the extremely low pulse rate and asked them to go to another hospital’s emergency department, which correctly diagnosed her. They immediately admitted her and fitted her with a temporary pacemaker and scheduled her for surgery to fit a permanent pacemaker the next day.
“I feel extremely lucky that my mother did not face complications due to the delay, and we could refer her to another hospital,” her daughter Kritika Amin told Nivarana over the phone.
(Original illustration of a complete heart block by Dr Gayatri, media editor at Nivarana)
Heart disease is the most common cause of death in India, accounting for 28.6 lakh deaths according to the Global Burden of Disease, 2021. It is estimated that nearly 27% of all deaths in India are due to heart disease, while 62% of all deaths due to cardiovascular disease (CVD) in the country are premature between the ages of 40 and 69 years. In 2014, the World Economic Forum and Harvard School of Public Health estimated India’s economic loss due to CVD between 2012 and 2030 to be approximately $2.17 trillion--about half of India’s 2025 GDP of $4.5 trillion. Yet, despite the rapid development of medical facilities in the country, there remains a lacuna when it comes to an appropriate and timely response to emergency heart conditions. In this first article of a three-part series on the state of cardiac care in India, we at Nivarana look at the various gaps in the healthcare system that delay treatment for heart disease and the cost that we pay for it.
Most PHCs are not Equipped with ECGs
The first step in diagnosing a heart attack is undergoing an ECG test, which records the heart's electrical activity using sticky patches called electrodes and gives out a report as a wave graph. The test can help diagnose heart attacks, irregular heartbeats (arrhythmias) and problems with blood flow. An ECG can detect a heart attack as ST-segment elevation Myocardial Infarction (STEMI) cases-- or non-STEMI within minutes and help doctors plan further treatment. However, even access to this ECG is not common in India.
ECGs are currently available in District hospitals and Community Health Centres in India, which are tertiary healthcare centres. Most Primary Health Centres (PHCs), which are the first point of contact for patients in rural areas and are equipped with medical officers, yet do not have ECG machines, which is why Jassuram Khanna mentioned earlier, to travel 70 km from his village to get the first ECG done, despite reaching his nearest PHC on time. While the 2025 National Essential Diagnostic List recommends ECG to be available at the PHC level, its implementation is expected to take time, which would already be too late.
Meanwhile the availability in higher centres is also not guaranteed.“ECGs are not available in many of the CHCs here and patients have to travel all the way to the district hospital (2-3 hours away) to get an ECG done, ” said a doctor who works in a non-profit working in the tribal district of Surguja in North-Chhattisgarh.
Despite being easy to conduct and comparatively inexpensive, the availability of ECGs is restricted to big metros and hospitals in India, and there is a shortage of trained personnel to interpret the results, said Dr Yogendra Singh, Director-Interventional Cardiology at Max Healthcare, Dehradun.
“If a patient gets chest pain in Uttarkashi [in Uttarakhand], he has to travel at least 40-50 km to get an ECG done without which he cannot even be given an Ecospirin [a blood thinner]”, he said, adding the need to make ECGs available and accessible to people to detect heart attacks early. Doctors are not necessary to be present to read the ECGs, several studies (here and here) have shown how tele-ECG conducted by frontline health workers can be electronically sent to doctors and nurses for further interpretation and advice, saving crucial time and money, in reaching higher centres.
Mortality of Indians after a Heart Attack is Double that of Sweden
When it comes to heart disease, Indians suffer from heart disease about 10 years before the Western population, while our deaths due to heart attacks is twice that of Sweden, even as their patients are 15 years older, said Dr S Ramakrishnan, senior cardiologist at All India Institute of Medical Sciences (AIIMS), New Delhi.
While the average age at first heart attack in Western Europe, China, and Hong Kong is 63 years, it is 53 years in South Asia, and about 10% of our patients are below the age of 40 years. A number of factors, like high blood pressure, poor cholesterol control, diabetes, sedentary lifestyle, high abdominal fat, poor diet, as well as genetic factors, play a role along with lifestyle factors like smoking and prolonged stress. Poverty also plays a role--poor are more likely to consume tobacco and alcohol and not consume fruits, vegetables, fish and fibre--that increases risk for heart disease.
(Dr S Ramakrishnan, senior cardiologist at All India Institute of Medical Sciences (AIIMS), New Delhi.)
What’s worse is that most people do not know that they are at risk for heart disease due to inadequate screening and poor awareness. “In India, major heart attacks and death are often the first symptoms of heart disease,” said Ramakrishnan. Despite having 315 million with high blood pressure and 101 million with diabetes according to ICMR’s INDIAB study, there is low awareness of blood pressure and blood glucose, even among those with the disease, and 57% of the population does not meet the WHO guidelines for physical activity.
Further, various studies have shown that patients with heart disease in India have a higher proportion of STEMI cases. STEMI is a more severe type of heart attack caused by the complete blockage of a coronary artery, restricting blood to the major part of the heart and requiring urgent emergency care. Further, the studies show that STEMI patients in India are likely to be poorer, show symptoms late, get inappropriate treatment and have a higher likelihood of dying within a month of the first month.
While timely treatment of STEMI cases in India will improve the quality of life and also save lives,“The most common treatment an average Indian gets for a heart attack is no treatment,” said Ramakrishnan. Either patients do not reach the hospital in time, or the hospitals they reach do not have the infrastructure or expertise to treat heart attacks, he added. Late treatment increases the risk of death and complications, increases chances of muscle damage and even if the patient survives ends up having heart failure, he further said.
‘Time is Muscle’
When it comes to the heart, cardiologists often like to repeat the phrase ‘time is muscle,’ for every minute of delay in getting treatment causes irreversible death of the heart muscle. Restoring blood supply to the heart can reduce damage to the heart, improve survival rates and prevent death.
In STEMI cases, for example treatment is reperfusion, which involves opening the blocked blood vessel is the key strategy. It can be done either by giving thrombolytic therapy, which is drugs that bust the clots in the artery or through primary percutaneous coronary intervention (PCI) or angioplasty. While PCI is the gold standard of treatment, a very small percentage of Indian patients get PCI as treatment, and even getting thrombolytic therapy in the treatment window is not widespread. Various registry databases show that only 5 to 10 in 100 undergo timely PCI while 36-60 out of 100 undergo thrombolysis.
Another approach of combining the two, called pharmaco-invasive therapy, where thrombolytic drugs are given to the patient till the patient can be transferred to a hospital with a cath lab, has been successfully implemented as a hub-and-spoke model in many parts of the country (which we will discuss in detail in the second story).
In other cases such as the conduction defect faced by Amin, cardiac muscle dies because of the irregular pumping of the heart. Immediately addressing it via drugs or a temporary pacemaker ensures that the damage to the heart muscle is kept to a minimum.
In case of any emergency heart condition, detecting and treating immediately is of paramount importance to ensure that as much of the heart muscle as possible can be saved.
Treatment Windows
The most critical time for intervention is between 1-3 hours of the heart attack (refer to the image). Global guidelines for treating heart attacks state that the time from the first contact with the health team to conducting and interpreting an ECG should be less than ten minutes. The ideal time to conduct an angioplasty is within 120 minutes or two hours of the first medical contact.
Treatment most beneficial within three hours of a heart attack.
+*
(Source:.https://doi.org/10.12688/f1000research.10553.1)
Jassuram and his son had to waste four and half precious hours travelling from one centre to another before getting the treatment that could save his life. Yet he was fortunate that he went to a centre that performed angioplasty. Most Indian patients reach the hospital between 6 hours on average and up to 12 hours in the hilly states of India, according to various heart registries, after suffering significant damage to their heart muscles. A study in Denmark has shown that one hour delay in starting treatment after the first contact in the health system leads to an 15% increase in deaths within three and half years while it is doubled if the delay is of three hours.
Treatment Windows in the Indian context
|
Metric |
Target Time |
Description |
Source |
|
Door-to-Needle (Thrombolysis) |
≤30 minutes |
From hospital arrival to starting thrombolysis at spoke/non-PCI centres. |
CSI/MoHFW; aligns with AHA. droracle+1 |
|
Door-to-Balloon (primary PCI) |
≤90 minutes |
Arrival at PCI-capable hub to balloon inflation. |
CSI/TN-STEMI; median achieved ~62 min in some studies. healthcare-bulletin+1 |
|
First Medical Contact (FMC) to Reperfusion |
≤120 minutes |
FMC to PCI or thrombolysis; ≤90 min preferred for direct PCI. |
CSI/WHO-adapted for India. pmc.ncbi.nlm.nih+1 |
|
Symptom Onset to Reperfusion |
Within 12 hours |
Best <6 hours; pharmacoinvasive PCI 3-24 hours post-thrombolysis. |
CSI/TN-STEMI hub-spoke model. pmc.ncbi.nlm.nih+1 |
|
First Medical Contact-to-Needle (prehospital) |
≤120 minutes |
Community-level goal for thrombolysis initiation. |
National STEMI guidelines. nhmmizoram |
(Source: Guidelines by Cardiological Society of India, American Heart Association, TN-STEMI model, National STEMI guidelines)
(Original illustration by Dr Gayatri)
Reasons for the Delay in Getting Treatment
Lack of Awareness
A 2023 study, which audited civil-registered premature (30–69 years) deaths due to acute cardiac events or strokes in Faridabad, Haryana, found that only about 11% of the patients reached an appropriate health facility within one hour. About 4 in 10 of them did not reach the correct facility due to a delay in recognising the symptom or its seriousness, 2 in 10 did not reach the correct facility due to a delay in reaching the hospital--due to lack of transport, absence of an attendant or reaching a centre without appropriate facilities and lastly 1 in 10 due to unaffordability or lack of a specialist.
This was similar to what was found by analysing the results of the CREATE registry--a prospective study of 20,937 acute coronary syndrome (ACS) patients across 89 Indian hospitals between 2001-2005--poor awareness of symptoms, logistical challenges in reaching the hospitals and health system gaps--as main reasons why patients got delayed treatment.
(Dr. H.S. Isser, Professor and Head of Department at Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi.)
“Sometimes there is ignorance, sometimes there is denial that it will get relieved with local treatment or an antacid,” said Dr. H.S. Isser, Professor and Head of Department at Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi. If the heart attack is very severe, the patient may collapse and is immediately rushed to the nearest hospital, but if the symptoms are mild, like sweating, pain, and breathlessness, patients often try home remedies and wait for one or two hours before reaching the hospital, he added.
Lack of cath labs in public settings, over-crowded tertiary care centres
Even when patients reach hospitals, many of them are not equipped with ECG machines or the manpower to interpret them. Even with ECGs available, patients are often referred to higher centres, which have the presence of cardiologists and cath labs, where angioplasties are conducted. There are about 2500 cath labs in the country, most of them in the metros of the developed states of Maharashtra, Kerala, Gujarat, Tamil Nadu and New Delhi.
Thrombolysis use has also been limited because non-specialist doctors do not want to risk giving clot-busting drugs, which can have side effects like internal bleeding, without the presence of cardiologists. There are about 6500 cardiologists in India, less than 0.45 per 100,000 population and most of them are concentrated in urban cities like Mumbai, Bengaluru and Kolkata.
Also, despite the increasing number of cath labs, 90% of them are in the private sector, and most states, especially in the North and the East, have to make-do with having only one tertiary centre in the state capital with a cath lab-- leading to overcrowding and long waiting times for patients.
Treatment delay due to unaffordability
Even if the treatment is accessible and available, the question that bogs down most families is how expensive it would be. Given the lack of diagnostic facilities in the public sector and long waiting lines, most patients rely on private hospitals for hospitalisation due to cardiac conditions, but this has led to high out-of-pocket expenses in patients. Nearly half heart patients experience catastrophic health expenses-- when the health expense is greater than 40% of the family’s annual income--due to hospitalisation while 43% face it due to OPD expenses.
The presence of Pradhan Mantri Jan Arogya Yojana (PMJAY) has improved the access to heart procedures that were out of reach for average Indians--the rate of angioplasties rose by 61% and angiographies by 132%--after the launch of the scheme in Kashmir, notes a 2025 study. While this is a welcome change, there is over-reliance on the private sector--79% of all cardiac procedures under the scheme are conducted in the private sector. This has led to cases of malpractice -an Ahmedabad-based private hospital conducted cardiac camps and conducted angiographies and angioplasties on patients who did not need them, leading to five deaths, on one hand and denial of the scheme on the other. In 2025, 650 hospitals in Haryana refused to provide treatment under PMJAY due to nonpayment of dues, leaving millions without coverage.
(57-year-old Raiz travelled 100 km to Delhi’s Govind Ballabh Pant Hospital because he was told PMJAY was not available in Jaypee Hospital in Bulandshahr.)
Many patients we met outside Delhi’s public hospitals claimed to have been told the scheme is not available in the private hospitals in their districts, which forced them to seek care in crowded but public hospitals, even if they face delays. Like 57-year-old Raiz (he uses only his first name), who suffered a heart attack on 30 December in Bulandshahr’s Shikarpur but came all the way to Delhi government’s Govind Ballabh Pant Hospital 100 km away, because the treatment will be free of cost. Raiz, a labourer, had first done preliminary tests like ECG and 2D ECHO in Jaypee Hospital, Chitta, but refused further treatment when he was told that an angiography would cost Rs. 30,000.
While the hospital is empanelled under PMJAY scheme for cardiology according to PMJAY’s website, Raiz says the hospital said they do not accept Ayushman Card patients and Raiz decided to wait. Like most Indian patients who set out on a journey, he tried to attend to all his unfinished business--that included getting one of his daughters married. A heart attack that should have been attended to within the first two hours would only be treated a month later.
Dr Sheespal Bhagel, head of medical operations at the hospital said, “Our name has changed from Jaypee Hospital to Manush Jaypee Hospital on January 14, 2026 which has caused a change in the status on the [PMJAY] portal, we have sent applications to Lucknow so that the hospital with its new name is empanelled again.”
[We have reached out to the National Health Authority, that implements PMJAY, for comments. We will update the article when we receive their response.]
What Happens after a Heart Attack?
Once a person has a heart attack, they have to take medicines for life. There is however, an absence of a mechanism to ensure patients have access to affordable drugs in the public system. “Patients do not get their prescribed medicines in PHCs or CHCs but have to travel all the way to the district hospital to get them,” said the doctor we quoted earlier from Chhattisgarh. Given the cost, intermittent unavailability of medicines and the time involved most patients have to buy the drugs out-of-pocket from the private sector, he added.
The situation is not better in Delhi’s tertiary care hospitals, which cater to patients within the state and other neighbouring states. Many of the patients we met at the cardiology OPD of Delhi’s tertiary care hospitals, like All India Institute of Medical Sciences (AIIMS), Safdarjung Hospital, and GB Pant hospital did not know whether they had suffered a heart attack; they had been going from hospital to hospital without a clear diagnosis or a plan. It took them weeks to get their reports ready and get a chance to see the doctor while the waiting time for procedures was in weeks or months.
The waiting period of cardio-thoracic and vascular surgery is up to two years in AIIMS Delhi due to heavy patient load, according to an answer given in Parliament in July 2025, by Prataprao Jadhav, union minister of state in the health ministry.
(Scene inside Safdarjung Hospital’s Heart Command Centre dedicated for emergency cardiac cases.)
Just a few metres away is another government tertiary care hospital, Vardhman Mahavir Medical College and Safdarjung Hospital, with a fully equipped 12 bedded ‘Heart Command Centre’ that is trying to reduce delays in treatment for heart patients. While the patients in general emergency patients may suffer delays in getting identified and referred for angioplasty, they get quickly triaged and receive thrombolysis and angioplasty here. The centre boasts of four Cath labs with two being available 24/7. “This is a rare kind of set-up in the public setup, we do 20 angioplasties daily out of which 5-10 are heart attack patients receiving emergency angioplasties,” said Dr H S Isser, Professor and Head of Cardiology at the hospital. The hospital, which gets patients from Delhi and other North Indian states, has a capacity of 110 beds for cardiac patients but sometimes faces a shortage, he said.
What if heart patients did not have to travel long distances to other cities and were treated near their homes? We will answer the question in the next story as we examine the impact of the STEMI hub-and- spoke model implemented in more than eight Indian states.
This is the first part of a three-part series on the health system’s response to heart attacks. This series has been supported by Sunfox Technologies
Edited by Christianez Ratna Kiruba
Images by Gayatri
This story was first published in The Hindu here
