Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Management of ST-segment elevation myocardial infarction in comparison to European society of cardiology guidelines in Alexandria University Hospitals, Egypt

Management of ST-segment elevation myocardial infarction in comparison to European society of... Background For patients with ST-elevation myocardial infarction (STEMI), early reperfusion with primary percutane- ous coronary intervention (PPCI) or thrombolytic treatment is essential to prevent major adverse cardiac events. The aim of the study is to compare the current status of managing STEMI patients at **** with European Society of Cardi- ology guidelines recommendations. Prospective cohort of all patients presenting with ST-elevation myocardial infarc- tion (STEMI) between March 2020 and February 2021 in Alexandria University hospitals. Reporting patterns, causes of delay, and reperfusion status for all STEMI patients were noted. MACE: (Mortality, Re-infarction, Stroke, or Heart failure) was reported and compared among different management strategies. Results The study was conducted over one year on 436 patients, 280 (64.2%) of them underwent PPCI, 32 (7.3%) received thrombolysis, and 124 (28.5%) had a conservative strategy. Patients’ mean age was 55.2 years, 72.2% were smokers and 80.9% were men. Family history was positive in 14.2% of patients, 33.5% had diabetes, 7.3% had renal impairment, and 41.5% had hypertension. The median pre-hospital waiting time was 360 min; the mean pre-hospital waiting time was 629.0 ± 796.7 min. The median Emergency Room waiting time was 48.24 ± 89.30 min. The median time from CCU admission to wire crossing was 40.0 min with a mean value 53.86 ± 49.0 min. The mean ischemia duration was 408 min, while the total ischemic time was 372 min. All patients who presented within 12 h received reperfusion therapy either a PPCI or thrombolysis at a rate of 71.5%, with 35.0% of those patients achieving prompt reperfusion in accordance with ESC guidelines. The PPCI group mortality rate was 2.9%, in comparison to 12.9% in the conservative group, which was statistically significant (P < 0.001). Overall in-hospital mortality was 5.5%, and total MACE was 27.3%. A statistically significant difference was observed between the three management groups as regards MACE rate, being 15%, 28.1%, and 54.8% in PPCI, thrombolysis, and conservative groups, respectively. Conclusions Despite financial and technical constraints, appropriate, timely reperfusion was near to achieving the ESC guidelines for the management of STEMI. The most common reperfusion strategy was PPCI, with an in-hospital death rate of less than 5% in the PPCI group. There was a concern about the increase in the total ischemia time due to some financial and technical constraints. Keywords Primary percutaneous coronary intervention, Reperfusion therapy, ST elevation myocardial infarction, Thrombolytic therapy *Correspondence: University, Champollion Street, Azareeta, Alexandria, Egypt Amr Kamal AMR.KAMAL@alexmed.edu.eg Cardiology and Angiology Department, Faculty of Medicine, Alexandria © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 2 of 8 Interventional procedures and adjunctive medications Background All patients undergoing primary PCI were given 300 mg An ST-elevation myocardial infarction (STEMI) is a acetylsalicylic acid (ASA) and Clopidogrel (loading major cause of morbidity and mortality worldwide dose of 600  mg) or Ticagrelor (loading dose of 180  mg) [1]. The acute therapy of STEMI focuses on the reca - together with high-intensity statins and anticoagulation nalization of the occluded coronary artery to provide (intravenous unfractionated heparin 70–100 IU/kg) regu- immediate efficient reperfusion of the myocardium. larly. Radial or femoral access was used to perform PPCI. Primary PCI, as opposed to fibrinolysis, has proved The culprit lesion was bridged with a guide wire, and the to improve outcomes in STEMI patients when treated infarct-related artery was engaged with an adequately within 120  min of diagnosis and has thus become the sized guiding catheter. Standard procedures were used preferred reperfusion technique [2, 3]. STEMI patients to insert stents or dilate balloons. All patients received referred to or presented to the Emergency room (ER) drug-eluting stents (DES). PPCI was restricted to Infarct experience a significant and preventable PPCI-related Related Artery (IRA) in the event of multi-vessel illness. delay due to many causes. First, ER routines and paper- The TIMI flow grade was reported at baseline and follow - work consume a major preventable delay. Second, ing the procedure. missed diagnosis by under-trained personnel due to miss interpretation of patient symptoms or miss inter- pretation of electrocardiogram (ECG). Third, delay in Data collection performing ECG due to system overload. Finally, trans- Detailed history and physical examination were applied ferring the patient from ER to Critical Care Unit (CCU) to all subjects, time variables and delays either pre-hos- or cath-lab plays a role in overall delay [4]. Ongoing pital, ER or CCU were documented. Intra-procedural enhancement of interventions and policies imple- and post-procedural complications were also reported. mented in the past few decades have led to improve- Follow up within hospital stay to detect any in-hospital ment in diagnosis. International recommendations urge events (mortality, re-infarction, stroke, bleeding compli- conventional, research-based management. However, cation, arrhythmias, heart failure). significant variance in the clinical results and manage - ment of STEMI published in various countries suggests Statistical analysis inadequate implementation [5]. In order to ensure bet- With the aid of the IBM SPSS software package ver- ter implementation of guidelines and provide a higher sion 20.0, data were uploaded into the computer and quality of care, It is recommended to develop measur- evaluated. (Armonk, NY: IBM Corp). Numbers and per- able quality indicators and conduct periodic audits to centages were used to represent qualitative data. The ensure the best possible care [6]. Our study focuses on normality of the distribution was examined using the reporting and monitoring the implementation of the Kolmogorov–Smirnov test. Interquartile range (IQR), 2017 European Society of Cardiology (ESC) Guidelines mean, standard deviation, median, and range (minimum for STEMI management in our center. and maximum) were used to characterize quantitative data. At a 5% significance level, the obtained results were considered significant. Methods Population study Results A total of 444 patients were admitted to Alexandria Uni- Baseline characteristics were summarized in Table  1, versity Hospitals Cardiology department between March Age ranged from 27.0 to 89.0  years with mean value 2020 and February 2021 with STEMI. Patients were 55.23 ± 10.41  years. The majority of studied sample treated either conservatively (n = 124), by thrombolysis were male (80.9%) while (19.1%) were females. Smoking (n = 32), or by Primary Percutaneous Coronary Inter- was the most prevalent cardiac risk factor, which was vention (PPCI) (n = 288). Eight patients from the PPCI detected in 72.2% of the patients. There were 181 (41.5%) group were excluded due to the presence of pre-specified patients with hypertension and 146 (33.5%) individuals exclusion criteria. Admission within 12 h of the onset of with diabetes mellitus. chest discomfort qualified patients for inclusion, while According to the management strategy, subjects were those who were admitted later (with no ongoing pain) distributed into three groups; PPCI group, the throm- were excluded from the reperfusion strategy. Report- bolytic group, and the conservative group. Table  2 rep- ing patterns, causes of delay, and reperfusion status for resents the number of subjects in each group and the all STEMI patients were noted. MACE events (Mortality, reasons for not choosing PPCI as a strategy of choice. Re-infarction, Stroke, or Heart failure) were reported and Two hundred and eighty patients (64.2%) underwent compared among different management strategies. K amal et al. The Egyptian Heart Journal (2023) 75:5 Page 3 of 8 Table 1 Demographic and clinical data (N = 436) Table 3 Time variables Risk factor No % Mean ± SD Mean ± SD Median (IQR) Age 55.23 ± 10.41 Pre-hospital delay (min) (N = 436) 629.0 ± 796.7 360.0 (240.0–600.0) Male 353 80.9 ER delay (min) (N = 436) 48.24 ± 89.30 40.0 (30.0–52.50) Female 83 19.1 CCU delay 53.86 ± 49.0 40.0 (30.0–60.0) Smoker 315 72.2 Door to crossing time (N = 280) 92.86 ± 54.66 70.0 (60.0–110.0) Cannabis 61 14 Total ischemic time (min.) (280) 409.71 ± 176.80 409.71 ± 176.80 Hypertension 181 41.5 Door to crossing (min) (N = 280) No % Diabetic 146 33.5 ≤ 60 98 35 Hyperlipidemia 134 30.7 60–90 100 35.7 History of Acute Coronary 51 11.7 91–120 32 11.4 Syndrome (ACS) > 120 50 17.9 History of PCI 23 5.3 Cause of pre-hospital delay History of stroke 14 3.2 (N = 436) History of CABG 2 0.5 No delay (< 60) 3 0.7 Family history of ACS 62 14.2 Distance 73 16.7 CKD 32 7.3 Missed diagnosis 78 17.9 Killip class Delay seeking medical care 199 45.6 I 289 66.3 Refereed from other hospital 83 19 II 118 27.1 Cause of ER delay (N = 436) III 26 6 No Delay (< 15 min) 7 1.6 IV 3 0.7 Missed diagnosis 44 10.1 Transfer delay 268 61.5 Diagnosis delay 117 26.8 Door to crossing time 92.86 ± 54.66 Table 2 Management strategy and cause Type of management No % Mean ± SD PCI 280 64.2 the median time from CCU admission to wire crossing PPCI 276 63.3 was 40.0 min. The mean ischemia duration was 408 min Rescue PCI 4 0.9 (6.8  h), while the overall ischemic time was 372  min Thrombolytic 32 7.3 (6.2  h). All STEMI patients who presented within 12  h Operator not available 12 37.5 received reperfusion therapy (PPCI or thrombolysis) at Cath lab malfunction 20 62.5 a rate of 71.5 percent, with 35.0% achieving prompt rep- FMC to wire crossing(min) 48.13 ± 14.85 erfusion in accordance with ESC guidelines for the man- Conservative 124 28.4 agement of STEMI (Tables 4, 5). Evolved 103 83.0 Figure  1 and Table  6 compare the various examined Arrested before PCI 2 1.6 care options according to hospital events and reveals Cath lab malfunction statistically significant differences in favor of the PPCI Not candidate for thrombolytic 10 8.1 group for mortality (P < 0.001), bleeding complications Refusal of thrombolytic 3 2.4 (P = 0.010), heart failure (P < 0.001) and in hospital Major CI to thrombolytic 6 4.8 adverse cardiac events (MACE) (P < 0.001). Regression analysis for different parameters affecting in-hospital MACE is depicted below (Table 7). PPCI, thirty-two patients (7.3%) had thrombolytic ther- Discussion apy and 124 patients (28.4%) had a conservative strategy. Healthcare system performance, as well as patient edu- As mentioned in Table  3 the mean pre-hospital delay cation and behavior, are the cornerstone in the manage- was 629.0 ± 796.7  min (10.4  h), while the median was ment of STEMI and improving clinical outcomes. The 360 min; 45.6% of cases were primarily caused by a delay emerging need to conduct this study is clear with the lack in seeking medical attention. of a STEMI network in Alexandria. Reperfusion delays In contrast, the average ER delay time was are the most easily audited index in STEMI management 48.24 ± 89.30 min. With a mean value of 53.86 ± 49.0 min, of quality care. A patient’s delay or a healthcare system’s Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 4 of 8 Table 4 Comparison between the different studied types of management according to risk factors and Killip Class on presentation Risk factor Total (n = 436) PCI (n = 280) Thrombolytic (n = 32) Conservative (n = 124) No % No % No % No % Age; mean ± SD 55.23 ± 10.41 54.73 ± 10.27 52.06 ± 8.72 57.18 ± 10.84 Male 353 80.9 226 80.7 29 90.6 98 79.0 Female 83 19.1 54 19.3 3 9.4 26 21.0 Smoker 315 72.2 201 71.8 29 90.6 85 68.5 Cannabis 61 14 38 13.6 5 15.6 18 14.5 Hypertension 181 41.5 115 41.1 8 25.0 58 46.8 Diabetic 146 33.5 87 31.1 14 43.8 45 36.3 Hyperlipidemia 209 47.9 127 45.4 16 50.0 66 53.2 History of acute coronary 51 11.7 31 11.1 4 12.5 16 12.9 syndrome (ACS) History of PCI 23 5.3 17 6.1 1 3.1 5 4.0 History of stroke 14 3.2 7 2.5 0 0.0 7 5.6 History of CABG 2 0.5 2 0.7 0 0.0 0 0.0 Family history of ACS 62 14.2 34 12.1 9 28.1 19 15.3 CKD 32 7.3 17 6.1 2 6.3 13 10.5 Killip class I 289 66.3 221 78.9 22 68.8 46 37.1 II 118 27.1 56 20.0 6 18.8 56 45.2 III 26 6 3 1.1 4 12.5 19 15.3 IV 3 0.7 0 0.0 0 0.0 3 2.4 Table 5 Comparison between the different studied types of management according to different pre and in-hospital delay times Total (n = 436) PCI (n = 280) Thrombolytic (n = 32) Conservative (n = 124) Pre-hospital delay (min) Mean ± SD 629.0 ± 796.7 316.9 ± 167.6 291.9 ± 126.7 1420.9 ± 1137.3 Median (IQR) 360 (240–600) 290 (180–420) 240 (195–360) 920 (570–1800) ER delay (min) Mean ± SD 48.24 ± 89.30 39 ± 23.49 27.81 ± 10.16 74.38 ± 161.0 Median (IQR) 40 (30–52.5) 35 (30–45) 30 (20–30) 59 (40–60) CCU delay Mean ± SD 53.86 ± 49 – – Median (IQR) 40 (30–60) – – Pre-hospital delay (min) Mean ± SD 629.0 ± 796.7 316.9 ± 167.6 291.9 ± 126.7 1420.9 ± 1137.3 Median (IQR) 360 (240–600) 290 (180–420) 240 (195–360) 920 (570–1800) ER delay (min) Mean ± SD 48.24 ± 89.30 39 ± 23.49 27.81 ± 10.16 74.38 ± 161.0 Median (IQR) 40 (30–52.5) 35 (30–45) 30 (20–30) 59 (40–60) CCU delay Mean ± SD 53.86 ± 49 – – Median (IQR) 40 (30–60) – – Tables 4 and 5 compare different types of management studied in this research based on risk factors and Killip Class on presentation and pre- and in-hospital delay times, respectively K amal et al. The Egyptian Heart Journal (2023) 75:5 Page 5 of 8 Fig. 1 Comparison between the different studied types of management according to hospital events (n = 436) Table 6 Comparison between the different studied types of management according to hospital events Hospital events Total (n = 436) Type of management χ P PCI (n = 280) Thrombolytic (n = 32) Conservative (n = 124) No % No % No % No % Mortality 24 5.5 8 2.9 0 0.0 16 12.9 18.686 < 0.001 MC Re-infarction 3 0.7 1 0.4 0 0.0 2 1.6 2.173 P = 0.375 MC Stroke 2 0.5 1 0.4 1 3.1 0 0.0 3.978 P = 0.216 Left ventricular thrombus 40 9.2 20 7.1 3 9.4 17 13.7 4.449 0.108 * MC * Bleeding complication 9 2.1 6 2.1 3 9.4 0 0.0 8.542 P = 0.010 Ventricular tachycardia 31 7.1 17 6.1 3 9.4 11 8.9 1.288 0.525 High degree AV block 24 5.5 16 5.7 3 9.4 5 4.0 1.462 0.481 MC SVT (AFIB) 12 2.8 5 1.8 1 3.1 6 4.8 3.234 P = 0.160 * * Heart failure 106 24.3 39 13.9 9 28.1 58 46.8 50.658 < 0.001 # * * In hospital MACE 119 27.3 42 15.0 9 28.1 68 54.8 68.747 < 0.001 Statistically significant at P ≤ 0.05 All variables with P < 0.05 was included in the multivariate delay is what delays the reperfusion strategy. Delay in the registry. The mean age was 61.0  year. The majority were healthcare system is the period between FMC and rep- males (76.9%), smoking and diabetes were less in per- erfusion. A delay in the healthcare system can occur at centage than our study 45.7% and 26.7%, respectively, many stages: Emergency Medical Services (EMS) delay, while hypertension (47.9%), hyperlipidemia (38.5%) ER delay and CCU delay. were higher in percentage than in our study. In a meta- As regarding baseline characteristics, Zeymer et al. [7] analysis studying STEMI epidemiology, management, described reperfusion strategy and in-hospital outcomes and outcomes in five Asian-Pacific countries, twenty for STEMI patients based on 11,462 patients in Associa- studies, including 158 420 patients, were under inves- tion for Acute Cardiovascular Care (ACVC)- European tigation. Tern et  al. [8] stated that 78.7% of them were Association of Percutaneous Coronary Intervention males, 30.5% were diabetic, 36.7% had Hyperlipidemia. (EAPCI) EurObservational programme (EORP) STEMI Those results are similar to demographic data in our Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 6 of 8 Table 7 Univariate and multivariate logistic regression analysis for the parameters affecting in-hospital MACE (n = 119 vs. 317) In hospital MACE Univariate Multivariate No (n = 317) Yes (n = 119) OR (LL–UL 95%C.I) P OR (LL–UL 95%C.I) P Type of management * * PCI 238 (75.1%) 42 (35.3%) 0.181 (0.115–0.285) < 0.001 0.337 (0.136–0.832) 0.018 Thrombolytic 23 (7.3%) 9 (7.6%) 1.046 (0.469–2.330) 0.913 * * Conservative 56 (17.7%) 68 (57.1%) 6.214 (3.908–9.882) < 0.001 2.549 (1.014–6.407) 0.047 Age (years) 54.58 ± 10.0 56.97 ± 11.29 1.023 (1.002–1.044) 0.034 1.016 (0.992–1.040) 0.195 Hypertension 125 (39.4%) 56 (47.1%) 1.365 (0.893–2.088) 0.151 Diabetic 99 (31.2%) 47 (39.5%) 1.437 (0.928–2.227) 0.104 Smoker 235 (74.1%) 80 (67.2%) 0.716 (0.453–1.131) 0.152 Type of STEMI * * Extensive anterior 32 (10.1%) 25 (21.0%) 2.369 (1.336–4.200) 0.003 19.701 (3.467–111.94) 0.001 * * Anterior 134 (42.3%) 73 (61.3%) 2.167 (1.408–3.335) < 0.001 9.844 (1.941–49.911) 0.006 Inferior 137 (43.2%) 22 (18.5%) 0.298 (0.178–0.498) < 0.001 2.479 (0.523–11.743) 0.253 Lateral 20 (6.3%) 2 (1.7%) 0.254 (0.058–1.103) 0.067 Posterior 51 (16.1%) 8 (6.7%) 0.376 (0.173–0.818) 0.014 1.329 (0.488–3.618) 0.578 OR Odd`s ratio, C.I Confidence interval, LL lower limit, UL upper limit Statistically significant at P ≤ 0.05 All variables with P < 0.05 were included in the multivariate analysis study except for the mean age of STEMI patients that was immediately to the CCU laboratory. Direct transfer to the higher (61.6 years), hypertension as risk factor was higher CCU was linked to a quicker time between the onset of (53.7%) and smoking was less (53.0%) (Table 4). symptoms and admission to the CCU (244 vs. 292  min; The mean value of pre-hospital delay in our study was P < 0.001) and a higher reperfusion rate (61.7% vs. 53.1%; 629.0 ± 796.7  min (10.4  h) (Table  5). The main cause of P = 0.001). Choosing not to use the ER also decreased Pre-hospital delay was a delay in seeking medical care five-day mortality rates (4.9% v 8.6%; P = 0.01). (45.6%), which indicates the poor application of medical As the primary PCI center, Door to balloon was cal- education to the general population. 17.9% of the patients culated from the first medical contact in our emergency had been missed diagnosed, which on the other hand, department through CCU to Cath lab. Mean door to indicates deficient medical training for ER physicians and crossing time was 92.86 ± 54.66  min, and the median General practitioners. Lack of PCI capable facilities led time was 70.0 (60.0–110.0). ESC latest guidelines for the to long distance and difficult transportation for 16.7% management of STEMI described Timely PPCI in PPCI of the patients. Zeymer et  al. [7] reported that average capable hospital as less than 60 min from door to balloon, time from symptoms onset to first medical contact was Zeymer et  al. [7] reported 54.4% of the studied popula- 221.6 ± 460.6 min which is significantly lower than in our tion had timely reperfusion, while in our center as PPCI study. Shaheen et  al. [9] studied the current practice of capable center had 35% timely reperfusion. Tern et  al. STEMI management in Egypt and reported that delay in [8] stated that the median door to balloon time was 63.5 seeking medical advice is the main cause of pre-hospital (39.7–87.2), which was consistent with our study. delay and 24% of patients presenting to PPCI hospitals In-hospital mortality, in our study was 5.5% (n = 436) arrive to the hospital within 2  h of chest pain which is irrespective of the type of management, while in the significantly higher than in our study. PPCI group, 2.9% (n = 280), and 12.9% (n = 124) in the ER delay was appointed as the time from ER admis - conservative management group, with a statistically sig- sion to CCU admission. Upon analysis, the main fac- nificant difference (P < 0.001). Within one-month mortal- tor of delay was transfer delay (61.5%) due to deficient ity rate was 3.4% irrespective of the type of management, numbers of transporting equipment and personnel. ER with the highest in the conservative group, 8.2%, with high volume admissions with the lack of ER beds and a statistically significant difference from other groups equipment also play an important role as it delays reach- (MCp = 0.001). MACE rate was 27.3% (n = 436) irre- ing to diagnosis. Steg et  al. [10] studied a total of 1204 spective of the type of management, while the MACE patients, 33.1% of them were taken to the ER before being rate was 15% in the PPCI group, 28.1% in the thrombo- admitted to the CCU, whereas 66.9% were admitted lytic group, and 54.8 in the conservative group with a K amal et al. The Egyptian Heart Journal (2023) 75:5 Page 7 of 8 AA contributed in data revision, MM was responsible on data collection. All statistically significant difference (P < 0.001). One month authors read and approved the final manuscript. follow-up MACE rate was 17.9% irrespective of the type of management, with the highest in the conservative Funding This study received no funding or grants. group at 34.1%, with a statistically significant difference from other groups (P = 0.001) (Table  6). Song et  al. [11] Availability of data and materials reported an in-hospital mortality rate in primary PCI- The dataset used during the current study is available from the corresponding author on reasonable request. treated patients of 3.2%, a heart failure rate of 11.3%, and MACE rate of 16.9%, which is consistent with our study Declarations in mortality but less in heart failure rate and higher in MACE rate. Zeymer et  al. [7] reported in-hospital mor- Ethics approval and consent to participate tality of 4.4% (n = 11,462) irrespective of the type of man- AMS Ethical committee (Alexandria Medical School Ethical Committee) approved the study on May 23, 2020, with reference number 116/2020. Writ- agement, while mortality occurred in 3.1% of the PPCI ten informed consent to participate in the study was taken from patients or group (n = 8275), 4.4% (n = 2160) in thrombolytic group their legal guardians in case patient was less than 18 years old. and 14.1% (n = 1027) conservative management group, Consent for publication which is consistent with our study. Written informed consent was taken from the patients for the procedure and In-hospital mortality was observed by Shaheen et  al. publication. In case, patient was less than 18 years old, consent was taken [12] to be 4.65% in Egypt, 2.10% in primary PCI, 4.97% from legal guardian. in thrombolysis, and 18.87% in no-reperfusion patients, Competing interests: which was higher than our study in no-reperfusion The authors declare that they have no competing interests. group. Received: 28 November 2022 Accepted: 16 January 2023 Conclusions Despite financial and technical constraints, timely reper - fusion was near to achieving the ESC guidelines for the References management of STEMI. The most common reperfusion 1. Townsend N, Wilson L, Bhatnagar P, Wickramasinghe K, Rayner M, Nichols strategy was PPCI, with an overall in-hospital death rate M (2016) Cardiovascular disease in Europe: epidemiological update 2016. Eur Heart J 37(42):3232–3245 of less than 5%. There was a concern about the increase 2. Zijlstra F, Hoorntje JC, de Boer MJ et al (1999) Long-term benefit of in the total ischemia time due to some financial and tech - primary angioplasty as compared with thrombolytic therapy for acute nical constraints. myocardial infarction. N Engl J Med 341(19):1413–1419 3. Keeley EC, Boura JA, Grines CL (2003) Primary angioplasty versus intrave- This study emphasized the essential need for the expan - nous thrombolytic therapy for acute myocardial infarction: a quantitative sion of public awareness and patient education and suffi - review of 23 randomised trials. Lancet 361(9351):13–20 cient training of general practitioners and ER physicians 4. Wenner JB, Wong GC, Cairns JA et al (2020) Impact of patient- and system-level delays on reperfusion among patients with ST-elevation to improve STEMI management. Design and application myocardial infarction. CJC Open 2(3):94–103 of the STEMI network while improving the EMS perfor- 5. Szummer K, Wallentin L, Lindhagen L et al (2017) Improved outcomes mance in **** are a must. in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995–2014. Eur Heart J 38(41):3056–3065 Abbreviations 6. Schiele F, Gale CP, Bonnefoy E et al (2017) Quality indicators for acute STEMI ST-elevation myocardial infarction myocardial infarction: a position paper of the acute cardiovascular care PCI Percutaneous coronary intervention association. Eur Heart J Acute Cardiovasc Care 6(1):34–59 MACE Major adverse cardiac events 7. Zeymer U, Ludman P, Danchin N et al (2021) Reperfusion therapies and ESC European Society of Cardiology in-hospital outcomes for ST-elevation myocardial infarction in Europe: the PPCI Primary percutaneous coronary intervention ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology. ER Emergency room Eur Heart J 42(44):4536–4549 CCU Critical care unit 8. Tern PJW, Ho AKH, Sultana R et al (2021) Comparative overview of ST- ECG Electrocardiogram elevation myocardial infarction epidemiology, demographics, manage- DES Drug-eluting stents ment, and outcomes in five Asia-Pacific countries: a meta-analysis. Eur IRA Infarct-related artery Heart J Qual Care Clin Outcomes 7(1):6–17 ACS Acute coronary syndrome 9. Shaheen S, Helal A, Anan I (2021) Barriers to the implementation of pri- EMS Emergency medical services mary PCI in the management of STEMI in Egypt. Cardiovasc Innov Appl 6(2):69–79 Acknowledgements 10. Steg PG, Cambou JP, Goldstein P et al (2006) Bypassing the emergency Not applicable room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry. Heart 92(10):1378–1383 Author contributions 11. Song F, Yu M, Yang J et al (2016) Symptom-onset-to-balloon time, ST- AK was the idea creator, he analyzed and interpreted the patients’ data segment resolution and in-hospital mortality in patients with ST-segment regarding the catheterization data and the PPCI and was a major contribu- elevation myocardial infarction undergoing primary percutaneous tor in writing the manuscript, AZ performed revision of collected data, and Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 8 of 8 coronary intervention in China: from china acute myocardial infarction registry. Am J Cardiol 118(9):1334–1339 12. Shaheen S, Wafa A, Mokarab M et al (2020) Presentation, management, and outcomes of STEMI in Egypt: results from the European Society of Cardiology Registry on ST elevation myocardial infarction. Egypt Heart J 72(1):35 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The Egyptian Heart Journal Springer Journals

Management of ST-segment elevation myocardial infarction in comparison to European society of cardiology guidelines in Alexandria University Hospitals, Egypt

Loading next page...
 
/lp/springer-journals/management-of-st-segment-elevation-myocardial-infarction-in-comparison-xGHyY6oP4o

References (16)

Publisher
Springer Journals
Copyright
Copyright © The Author(s) 2023
eISSN
2090-911X
DOI
10.1186/s43044-023-00332-x
Publisher site
See Article on Publisher Site

Abstract

Background For patients with ST-elevation myocardial infarction (STEMI), early reperfusion with primary percutane- ous coronary intervention (PPCI) or thrombolytic treatment is essential to prevent major adverse cardiac events. The aim of the study is to compare the current status of managing STEMI patients at **** with European Society of Cardi- ology guidelines recommendations. Prospective cohort of all patients presenting with ST-elevation myocardial infarc- tion (STEMI) between March 2020 and February 2021 in Alexandria University hospitals. Reporting patterns, causes of delay, and reperfusion status for all STEMI patients were noted. MACE: (Mortality, Re-infarction, Stroke, or Heart failure) was reported and compared among different management strategies. Results The study was conducted over one year on 436 patients, 280 (64.2%) of them underwent PPCI, 32 (7.3%) received thrombolysis, and 124 (28.5%) had a conservative strategy. Patients’ mean age was 55.2 years, 72.2% were smokers and 80.9% were men. Family history was positive in 14.2% of patients, 33.5% had diabetes, 7.3% had renal impairment, and 41.5% had hypertension. The median pre-hospital waiting time was 360 min; the mean pre-hospital waiting time was 629.0 ± 796.7 min. The median Emergency Room waiting time was 48.24 ± 89.30 min. The median time from CCU admission to wire crossing was 40.0 min with a mean value 53.86 ± 49.0 min. The mean ischemia duration was 408 min, while the total ischemic time was 372 min. All patients who presented within 12 h received reperfusion therapy either a PPCI or thrombolysis at a rate of 71.5%, with 35.0% of those patients achieving prompt reperfusion in accordance with ESC guidelines. The PPCI group mortality rate was 2.9%, in comparison to 12.9% in the conservative group, which was statistically significant (P < 0.001). Overall in-hospital mortality was 5.5%, and total MACE was 27.3%. A statistically significant difference was observed between the three management groups as regards MACE rate, being 15%, 28.1%, and 54.8% in PPCI, thrombolysis, and conservative groups, respectively. Conclusions Despite financial and technical constraints, appropriate, timely reperfusion was near to achieving the ESC guidelines for the management of STEMI. The most common reperfusion strategy was PPCI, with an in-hospital death rate of less than 5% in the PPCI group. There was a concern about the increase in the total ischemia time due to some financial and technical constraints. Keywords Primary percutaneous coronary intervention, Reperfusion therapy, ST elevation myocardial infarction, Thrombolytic therapy *Correspondence: University, Champollion Street, Azareeta, Alexandria, Egypt Amr Kamal AMR.KAMAL@alexmed.edu.eg Cardiology and Angiology Department, Faculty of Medicine, Alexandria © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 2 of 8 Interventional procedures and adjunctive medications Background All patients undergoing primary PCI were given 300 mg An ST-elevation myocardial infarction (STEMI) is a acetylsalicylic acid (ASA) and Clopidogrel (loading major cause of morbidity and mortality worldwide dose of 600  mg) or Ticagrelor (loading dose of 180  mg) [1]. The acute therapy of STEMI focuses on the reca - together with high-intensity statins and anticoagulation nalization of the occluded coronary artery to provide (intravenous unfractionated heparin 70–100 IU/kg) regu- immediate efficient reperfusion of the myocardium. larly. Radial or femoral access was used to perform PPCI. Primary PCI, as opposed to fibrinolysis, has proved The culprit lesion was bridged with a guide wire, and the to improve outcomes in STEMI patients when treated infarct-related artery was engaged with an adequately within 120  min of diagnosis and has thus become the sized guiding catheter. Standard procedures were used preferred reperfusion technique [2, 3]. STEMI patients to insert stents or dilate balloons. All patients received referred to or presented to the Emergency room (ER) drug-eluting stents (DES). PPCI was restricted to Infarct experience a significant and preventable PPCI-related Related Artery (IRA) in the event of multi-vessel illness. delay due to many causes. First, ER routines and paper- The TIMI flow grade was reported at baseline and follow - work consume a major preventable delay. Second, ing the procedure. missed diagnosis by under-trained personnel due to miss interpretation of patient symptoms or miss inter- pretation of electrocardiogram (ECG). Third, delay in Data collection performing ECG due to system overload. Finally, trans- Detailed history and physical examination were applied ferring the patient from ER to Critical Care Unit (CCU) to all subjects, time variables and delays either pre-hos- or cath-lab plays a role in overall delay [4]. Ongoing pital, ER or CCU were documented. Intra-procedural enhancement of interventions and policies imple- and post-procedural complications were also reported. mented in the past few decades have led to improve- Follow up within hospital stay to detect any in-hospital ment in diagnosis. International recommendations urge events (mortality, re-infarction, stroke, bleeding compli- conventional, research-based management. However, cation, arrhythmias, heart failure). significant variance in the clinical results and manage - ment of STEMI published in various countries suggests Statistical analysis inadequate implementation [5]. In order to ensure bet- With the aid of the IBM SPSS software package ver- ter implementation of guidelines and provide a higher sion 20.0, data were uploaded into the computer and quality of care, It is recommended to develop measur- evaluated. (Armonk, NY: IBM Corp). Numbers and per- able quality indicators and conduct periodic audits to centages were used to represent qualitative data. The ensure the best possible care [6]. Our study focuses on normality of the distribution was examined using the reporting and monitoring the implementation of the Kolmogorov–Smirnov test. Interquartile range (IQR), 2017 European Society of Cardiology (ESC) Guidelines mean, standard deviation, median, and range (minimum for STEMI management in our center. and maximum) were used to characterize quantitative data. At a 5% significance level, the obtained results were considered significant. Methods Population study Results A total of 444 patients were admitted to Alexandria Uni- Baseline characteristics were summarized in Table  1, versity Hospitals Cardiology department between March Age ranged from 27.0 to 89.0  years with mean value 2020 and February 2021 with STEMI. Patients were 55.23 ± 10.41  years. The majority of studied sample treated either conservatively (n = 124), by thrombolysis were male (80.9%) while (19.1%) were females. Smoking (n = 32), or by Primary Percutaneous Coronary Inter- was the most prevalent cardiac risk factor, which was vention (PPCI) (n = 288). Eight patients from the PPCI detected in 72.2% of the patients. There were 181 (41.5%) group were excluded due to the presence of pre-specified patients with hypertension and 146 (33.5%) individuals exclusion criteria. Admission within 12 h of the onset of with diabetes mellitus. chest discomfort qualified patients for inclusion, while According to the management strategy, subjects were those who were admitted later (with no ongoing pain) distributed into three groups; PPCI group, the throm- were excluded from the reperfusion strategy. Report- bolytic group, and the conservative group. Table  2 rep- ing patterns, causes of delay, and reperfusion status for resents the number of subjects in each group and the all STEMI patients were noted. MACE events (Mortality, reasons for not choosing PPCI as a strategy of choice. Re-infarction, Stroke, or Heart failure) were reported and Two hundred and eighty patients (64.2%) underwent compared among different management strategies. K amal et al. The Egyptian Heart Journal (2023) 75:5 Page 3 of 8 Table 1 Demographic and clinical data (N = 436) Table 3 Time variables Risk factor No % Mean ± SD Mean ± SD Median (IQR) Age 55.23 ± 10.41 Pre-hospital delay (min) (N = 436) 629.0 ± 796.7 360.0 (240.0–600.0) Male 353 80.9 ER delay (min) (N = 436) 48.24 ± 89.30 40.0 (30.0–52.50) Female 83 19.1 CCU delay 53.86 ± 49.0 40.0 (30.0–60.0) Smoker 315 72.2 Door to crossing time (N = 280) 92.86 ± 54.66 70.0 (60.0–110.0) Cannabis 61 14 Total ischemic time (min.) (280) 409.71 ± 176.80 409.71 ± 176.80 Hypertension 181 41.5 Door to crossing (min) (N = 280) No % Diabetic 146 33.5 ≤ 60 98 35 Hyperlipidemia 134 30.7 60–90 100 35.7 History of Acute Coronary 51 11.7 91–120 32 11.4 Syndrome (ACS) > 120 50 17.9 History of PCI 23 5.3 Cause of pre-hospital delay History of stroke 14 3.2 (N = 436) History of CABG 2 0.5 No delay (< 60) 3 0.7 Family history of ACS 62 14.2 Distance 73 16.7 CKD 32 7.3 Missed diagnosis 78 17.9 Killip class Delay seeking medical care 199 45.6 I 289 66.3 Refereed from other hospital 83 19 II 118 27.1 Cause of ER delay (N = 436) III 26 6 No Delay (< 15 min) 7 1.6 IV 3 0.7 Missed diagnosis 44 10.1 Transfer delay 268 61.5 Diagnosis delay 117 26.8 Door to crossing time 92.86 ± 54.66 Table 2 Management strategy and cause Type of management No % Mean ± SD PCI 280 64.2 the median time from CCU admission to wire crossing PPCI 276 63.3 was 40.0 min. The mean ischemia duration was 408 min Rescue PCI 4 0.9 (6.8  h), while the overall ischemic time was 372  min Thrombolytic 32 7.3 (6.2  h). All STEMI patients who presented within 12  h Operator not available 12 37.5 received reperfusion therapy (PPCI or thrombolysis) at Cath lab malfunction 20 62.5 a rate of 71.5 percent, with 35.0% achieving prompt rep- FMC to wire crossing(min) 48.13 ± 14.85 erfusion in accordance with ESC guidelines for the man- Conservative 124 28.4 agement of STEMI (Tables 4, 5). Evolved 103 83.0 Figure  1 and Table  6 compare the various examined Arrested before PCI 2 1.6 care options according to hospital events and reveals Cath lab malfunction statistically significant differences in favor of the PPCI Not candidate for thrombolytic 10 8.1 group for mortality (P < 0.001), bleeding complications Refusal of thrombolytic 3 2.4 (P = 0.010), heart failure (P < 0.001) and in hospital Major CI to thrombolytic 6 4.8 adverse cardiac events (MACE) (P < 0.001). Regression analysis for different parameters affecting in-hospital MACE is depicted below (Table 7). PPCI, thirty-two patients (7.3%) had thrombolytic ther- Discussion apy and 124 patients (28.4%) had a conservative strategy. Healthcare system performance, as well as patient edu- As mentioned in Table  3 the mean pre-hospital delay cation and behavior, are the cornerstone in the manage- was 629.0 ± 796.7  min (10.4  h), while the median was ment of STEMI and improving clinical outcomes. The 360 min; 45.6% of cases were primarily caused by a delay emerging need to conduct this study is clear with the lack in seeking medical attention. of a STEMI network in Alexandria. Reperfusion delays In contrast, the average ER delay time was are the most easily audited index in STEMI management 48.24 ± 89.30 min. With a mean value of 53.86 ± 49.0 min, of quality care. A patient’s delay or a healthcare system’s Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 4 of 8 Table 4 Comparison between the different studied types of management according to risk factors and Killip Class on presentation Risk factor Total (n = 436) PCI (n = 280) Thrombolytic (n = 32) Conservative (n = 124) No % No % No % No % Age; mean ± SD 55.23 ± 10.41 54.73 ± 10.27 52.06 ± 8.72 57.18 ± 10.84 Male 353 80.9 226 80.7 29 90.6 98 79.0 Female 83 19.1 54 19.3 3 9.4 26 21.0 Smoker 315 72.2 201 71.8 29 90.6 85 68.5 Cannabis 61 14 38 13.6 5 15.6 18 14.5 Hypertension 181 41.5 115 41.1 8 25.0 58 46.8 Diabetic 146 33.5 87 31.1 14 43.8 45 36.3 Hyperlipidemia 209 47.9 127 45.4 16 50.0 66 53.2 History of acute coronary 51 11.7 31 11.1 4 12.5 16 12.9 syndrome (ACS) History of PCI 23 5.3 17 6.1 1 3.1 5 4.0 History of stroke 14 3.2 7 2.5 0 0.0 7 5.6 History of CABG 2 0.5 2 0.7 0 0.0 0 0.0 Family history of ACS 62 14.2 34 12.1 9 28.1 19 15.3 CKD 32 7.3 17 6.1 2 6.3 13 10.5 Killip class I 289 66.3 221 78.9 22 68.8 46 37.1 II 118 27.1 56 20.0 6 18.8 56 45.2 III 26 6 3 1.1 4 12.5 19 15.3 IV 3 0.7 0 0.0 0 0.0 3 2.4 Table 5 Comparison between the different studied types of management according to different pre and in-hospital delay times Total (n = 436) PCI (n = 280) Thrombolytic (n = 32) Conservative (n = 124) Pre-hospital delay (min) Mean ± SD 629.0 ± 796.7 316.9 ± 167.6 291.9 ± 126.7 1420.9 ± 1137.3 Median (IQR) 360 (240–600) 290 (180–420) 240 (195–360) 920 (570–1800) ER delay (min) Mean ± SD 48.24 ± 89.30 39 ± 23.49 27.81 ± 10.16 74.38 ± 161.0 Median (IQR) 40 (30–52.5) 35 (30–45) 30 (20–30) 59 (40–60) CCU delay Mean ± SD 53.86 ± 49 – – Median (IQR) 40 (30–60) – – Pre-hospital delay (min) Mean ± SD 629.0 ± 796.7 316.9 ± 167.6 291.9 ± 126.7 1420.9 ± 1137.3 Median (IQR) 360 (240–600) 290 (180–420) 240 (195–360) 920 (570–1800) ER delay (min) Mean ± SD 48.24 ± 89.30 39 ± 23.49 27.81 ± 10.16 74.38 ± 161.0 Median (IQR) 40 (30–52.5) 35 (30–45) 30 (20–30) 59 (40–60) CCU delay Mean ± SD 53.86 ± 49 – – Median (IQR) 40 (30–60) – – Tables 4 and 5 compare different types of management studied in this research based on risk factors and Killip Class on presentation and pre- and in-hospital delay times, respectively K amal et al. The Egyptian Heart Journal (2023) 75:5 Page 5 of 8 Fig. 1 Comparison between the different studied types of management according to hospital events (n = 436) Table 6 Comparison between the different studied types of management according to hospital events Hospital events Total (n = 436) Type of management χ P PCI (n = 280) Thrombolytic (n = 32) Conservative (n = 124) No % No % No % No % Mortality 24 5.5 8 2.9 0 0.0 16 12.9 18.686 < 0.001 MC Re-infarction 3 0.7 1 0.4 0 0.0 2 1.6 2.173 P = 0.375 MC Stroke 2 0.5 1 0.4 1 3.1 0 0.0 3.978 P = 0.216 Left ventricular thrombus 40 9.2 20 7.1 3 9.4 17 13.7 4.449 0.108 * MC * Bleeding complication 9 2.1 6 2.1 3 9.4 0 0.0 8.542 P = 0.010 Ventricular tachycardia 31 7.1 17 6.1 3 9.4 11 8.9 1.288 0.525 High degree AV block 24 5.5 16 5.7 3 9.4 5 4.0 1.462 0.481 MC SVT (AFIB) 12 2.8 5 1.8 1 3.1 6 4.8 3.234 P = 0.160 * * Heart failure 106 24.3 39 13.9 9 28.1 58 46.8 50.658 < 0.001 # * * In hospital MACE 119 27.3 42 15.0 9 28.1 68 54.8 68.747 < 0.001 Statistically significant at P ≤ 0.05 All variables with P < 0.05 was included in the multivariate delay is what delays the reperfusion strategy. Delay in the registry. The mean age was 61.0  year. The majority were healthcare system is the period between FMC and rep- males (76.9%), smoking and diabetes were less in per- erfusion. A delay in the healthcare system can occur at centage than our study 45.7% and 26.7%, respectively, many stages: Emergency Medical Services (EMS) delay, while hypertension (47.9%), hyperlipidemia (38.5%) ER delay and CCU delay. were higher in percentage than in our study. In a meta- As regarding baseline characteristics, Zeymer et al. [7] analysis studying STEMI epidemiology, management, described reperfusion strategy and in-hospital outcomes and outcomes in five Asian-Pacific countries, twenty for STEMI patients based on 11,462 patients in Associa- studies, including 158 420 patients, were under inves- tion for Acute Cardiovascular Care (ACVC)- European tigation. Tern et  al. [8] stated that 78.7% of them were Association of Percutaneous Coronary Intervention males, 30.5% were diabetic, 36.7% had Hyperlipidemia. (EAPCI) EurObservational programme (EORP) STEMI Those results are similar to demographic data in our Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 6 of 8 Table 7 Univariate and multivariate logistic regression analysis for the parameters affecting in-hospital MACE (n = 119 vs. 317) In hospital MACE Univariate Multivariate No (n = 317) Yes (n = 119) OR (LL–UL 95%C.I) P OR (LL–UL 95%C.I) P Type of management * * PCI 238 (75.1%) 42 (35.3%) 0.181 (0.115–0.285) < 0.001 0.337 (0.136–0.832) 0.018 Thrombolytic 23 (7.3%) 9 (7.6%) 1.046 (0.469–2.330) 0.913 * * Conservative 56 (17.7%) 68 (57.1%) 6.214 (3.908–9.882) < 0.001 2.549 (1.014–6.407) 0.047 Age (years) 54.58 ± 10.0 56.97 ± 11.29 1.023 (1.002–1.044) 0.034 1.016 (0.992–1.040) 0.195 Hypertension 125 (39.4%) 56 (47.1%) 1.365 (0.893–2.088) 0.151 Diabetic 99 (31.2%) 47 (39.5%) 1.437 (0.928–2.227) 0.104 Smoker 235 (74.1%) 80 (67.2%) 0.716 (0.453–1.131) 0.152 Type of STEMI * * Extensive anterior 32 (10.1%) 25 (21.0%) 2.369 (1.336–4.200) 0.003 19.701 (3.467–111.94) 0.001 * * Anterior 134 (42.3%) 73 (61.3%) 2.167 (1.408–3.335) < 0.001 9.844 (1.941–49.911) 0.006 Inferior 137 (43.2%) 22 (18.5%) 0.298 (0.178–0.498) < 0.001 2.479 (0.523–11.743) 0.253 Lateral 20 (6.3%) 2 (1.7%) 0.254 (0.058–1.103) 0.067 Posterior 51 (16.1%) 8 (6.7%) 0.376 (0.173–0.818) 0.014 1.329 (0.488–3.618) 0.578 OR Odd`s ratio, C.I Confidence interval, LL lower limit, UL upper limit Statistically significant at P ≤ 0.05 All variables with P < 0.05 were included in the multivariate analysis study except for the mean age of STEMI patients that was immediately to the CCU laboratory. Direct transfer to the higher (61.6 years), hypertension as risk factor was higher CCU was linked to a quicker time between the onset of (53.7%) and smoking was less (53.0%) (Table 4). symptoms and admission to the CCU (244 vs. 292  min; The mean value of pre-hospital delay in our study was P < 0.001) and a higher reperfusion rate (61.7% vs. 53.1%; 629.0 ± 796.7  min (10.4  h) (Table  5). The main cause of P = 0.001). Choosing not to use the ER also decreased Pre-hospital delay was a delay in seeking medical care five-day mortality rates (4.9% v 8.6%; P = 0.01). (45.6%), which indicates the poor application of medical As the primary PCI center, Door to balloon was cal- education to the general population. 17.9% of the patients culated from the first medical contact in our emergency had been missed diagnosed, which on the other hand, department through CCU to Cath lab. Mean door to indicates deficient medical training for ER physicians and crossing time was 92.86 ± 54.66  min, and the median General practitioners. Lack of PCI capable facilities led time was 70.0 (60.0–110.0). ESC latest guidelines for the to long distance and difficult transportation for 16.7% management of STEMI described Timely PPCI in PPCI of the patients. Zeymer et  al. [7] reported that average capable hospital as less than 60 min from door to balloon, time from symptoms onset to first medical contact was Zeymer et  al. [7] reported 54.4% of the studied popula- 221.6 ± 460.6 min which is significantly lower than in our tion had timely reperfusion, while in our center as PPCI study. Shaheen et  al. [9] studied the current practice of capable center had 35% timely reperfusion. Tern et  al. STEMI management in Egypt and reported that delay in [8] stated that the median door to balloon time was 63.5 seeking medical advice is the main cause of pre-hospital (39.7–87.2), which was consistent with our study. delay and 24% of patients presenting to PPCI hospitals In-hospital mortality, in our study was 5.5% (n = 436) arrive to the hospital within 2  h of chest pain which is irrespective of the type of management, while in the significantly higher than in our study. PPCI group, 2.9% (n = 280), and 12.9% (n = 124) in the ER delay was appointed as the time from ER admis - conservative management group, with a statistically sig- sion to CCU admission. Upon analysis, the main fac- nificant difference (P < 0.001). Within one-month mortal- tor of delay was transfer delay (61.5%) due to deficient ity rate was 3.4% irrespective of the type of management, numbers of transporting equipment and personnel. ER with the highest in the conservative group, 8.2%, with high volume admissions with the lack of ER beds and a statistically significant difference from other groups equipment also play an important role as it delays reach- (MCp = 0.001). MACE rate was 27.3% (n = 436) irre- ing to diagnosis. Steg et  al. [10] studied a total of 1204 spective of the type of management, while the MACE patients, 33.1% of them were taken to the ER before being rate was 15% in the PPCI group, 28.1% in the thrombo- admitted to the CCU, whereas 66.9% were admitted lytic group, and 54.8 in the conservative group with a K amal et al. The Egyptian Heart Journal (2023) 75:5 Page 7 of 8 AA contributed in data revision, MM was responsible on data collection. All statistically significant difference (P < 0.001). One month authors read and approved the final manuscript. follow-up MACE rate was 17.9% irrespective of the type of management, with the highest in the conservative Funding This study received no funding or grants. group at 34.1%, with a statistically significant difference from other groups (P = 0.001) (Table  6). Song et  al. [11] Availability of data and materials reported an in-hospital mortality rate in primary PCI- The dataset used during the current study is available from the corresponding author on reasonable request. treated patients of 3.2%, a heart failure rate of 11.3%, and MACE rate of 16.9%, which is consistent with our study Declarations in mortality but less in heart failure rate and higher in MACE rate. Zeymer et  al. [7] reported in-hospital mor- Ethics approval and consent to participate tality of 4.4% (n = 11,462) irrespective of the type of man- AMS Ethical committee (Alexandria Medical School Ethical Committee) approved the study on May 23, 2020, with reference number 116/2020. Writ- agement, while mortality occurred in 3.1% of the PPCI ten informed consent to participate in the study was taken from patients or group (n = 8275), 4.4% (n = 2160) in thrombolytic group their legal guardians in case patient was less than 18 years old. and 14.1% (n = 1027) conservative management group, Consent for publication which is consistent with our study. Written informed consent was taken from the patients for the procedure and In-hospital mortality was observed by Shaheen et  al. publication. In case, patient was less than 18 years old, consent was taken [12] to be 4.65% in Egypt, 2.10% in primary PCI, 4.97% from legal guardian. in thrombolysis, and 18.87% in no-reperfusion patients, Competing interests: which was higher than our study in no-reperfusion The authors declare that they have no competing interests. group. Received: 28 November 2022 Accepted: 16 January 2023 Conclusions Despite financial and technical constraints, timely reper - fusion was near to achieving the ESC guidelines for the References management of STEMI. The most common reperfusion 1. Townsend N, Wilson L, Bhatnagar P, Wickramasinghe K, Rayner M, Nichols strategy was PPCI, with an overall in-hospital death rate M (2016) Cardiovascular disease in Europe: epidemiological update 2016. Eur Heart J 37(42):3232–3245 of less than 5%. There was a concern about the increase 2. Zijlstra F, Hoorntje JC, de Boer MJ et al (1999) Long-term benefit of in the total ischemia time due to some financial and tech - primary angioplasty as compared with thrombolytic therapy for acute nical constraints. myocardial infarction. N Engl J Med 341(19):1413–1419 3. Keeley EC, Boura JA, Grines CL (2003) Primary angioplasty versus intrave- This study emphasized the essential need for the expan - nous thrombolytic therapy for acute myocardial infarction: a quantitative sion of public awareness and patient education and suffi - review of 23 randomised trials. Lancet 361(9351):13–20 cient training of general practitioners and ER physicians 4. Wenner JB, Wong GC, Cairns JA et al (2020) Impact of patient- and system-level delays on reperfusion among patients with ST-elevation to improve STEMI management. Design and application myocardial infarction. CJC Open 2(3):94–103 of the STEMI network while improving the EMS perfor- 5. Szummer K, Wallentin L, Lindhagen L et al (2017) Improved outcomes mance in **** are a must. in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995–2014. Eur Heart J 38(41):3056–3065 Abbreviations 6. Schiele F, Gale CP, Bonnefoy E et al (2017) Quality indicators for acute STEMI ST-elevation myocardial infarction myocardial infarction: a position paper of the acute cardiovascular care PCI Percutaneous coronary intervention association. Eur Heart J Acute Cardiovasc Care 6(1):34–59 MACE Major adverse cardiac events 7. Zeymer U, Ludman P, Danchin N et al (2021) Reperfusion therapies and ESC European Society of Cardiology in-hospital outcomes for ST-elevation myocardial infarction in Europe: the PPCI Primary percutaneous coronary intervention ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology. ER Emergency room Eur Heart J 42(44):4536–4549 CCU Critical care unit 8. Tern PJW, Ho AKH, Sultana R et al (2021) Comparative overview of ST- ECG Electrocardiogram elevation myocardial infarction epidemiology, demographics, manage- DES Drug-eluting stents ment, and outcomes in five Asia-Pacific countries: a meta-analysis. Eur IRA Infarct-related artery Heart J Qual Care Clin Outcomes 7(1):6–17 ACS Acute coronary syndrome 9. Shaheen S, Helal A, Anan I (2021) Barriers to the implementation of pri- EMS Emergency medical services mary PCI in the management of STEMI in Egypt. Cardiovasc Innov Appl 6(2):69–79 Acknowledgements 10. Steg PG, Cambou JP, Goldstein P et al (2006) Bypassing the emergency Not applicable room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry. Heart 92(10):1378–1383 Author contributions 11. Song F, Yu M, Yang J et al (2016) Symptom-onset-to-balloon time, ST- AK was the idea creator, he analyzed and interpreted the patients’ data segment resolution and in-hospital mortality in patients with ST-segment regarding the catheterization data and the PPCI and was a major contribu- elevation myocardial infarction undergoing primary percutaneous tor in writing the manuscript, AZ performed revision of collected data, and Kamal et al. The Egyptian Heart Journal (2023) 75:5 Page 8 of 8 coronary intervention in China: from china acute myocardial infarction registry. Am J Cardiol 118(9):1334–1339 12. Shaheen S, Wafa A, Mokarab M et al (2020) Presentation, management, and outcomes of STEMI in Egypt: results from the European Society of Cardiology Registry on ST elevation myocardial infarction. Egypt Heart J 72(1):35 Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations.

Journal

The Egyptian Heart JournalSpringer Journals

Published: Jan 21, 2023

Keywords: Primary percutaneous coronary intervention; Reperfusion therapy; ST elevation myocardial infarction; Thrombolytic therapy

There are no references for this article.