Prehospital aspirin for acute coronary syndrome in India: modelling the health loss from a national protocol gap

Abstract India records about 1.65 million ischaemic heart disease deaths each year, yet its Standard Treatment Workflow for unstable angina and non-ST-elevation myocardial infarction begins at the primary health centre and is silent on aspirin before a patient reaches a facility, on chewing, and on formulation. Comparable international guidelines recommend 150–325 mg of non-enteric-coated aspirin, chewed, at first medical contact. We modelled what that gap costs. The counterfactual is not aspirin versus no aspirin: Indian registry data show that 97–98% of patients who reach a facility do receive antiplatelet therapy. The incremental value of a prehospital protocol therefore arises from three channels - patients who die before reaching care and so receive nothing at all, substitution of plain chewed aspirin for enteric-coated formulations, and earlier platelet inhibition among those who do arrive - net of fatal bleeding. At 55% achieved coverage the model estimates 23,867 net deaths averted annually (95% uncertainty interval 11,452 − 40,498) and 216,406 quality-adjusted life years gained (102,359–386,362), at US$ 363 per quality-adjusted life year (117–949). Benefit exceeded harm in 99.98% of 10,000 simulations. Had India adopted the protocol after ISIS-2 with realistic diffusion, 506,868 deaths (251,798–822,888) would have been averted between 1988 and 2024. Given United States inputs the model returns 8028 deaths averted against a published estimate of 13,016, indicating that it is conservative. Revising the Standard Treatment Workflow to specify prehospital, chewed, non-enteric-coated aspirin is among the least expensive interventions available to India's health system.