|Year : 2022 | Volume
| Issue : 1 | Page : 97-102
Changing trends of patients undergoing thrombolysis for acute ST-elevated myocardial infarction in tertiary care hospital in Maharashtra, India
Shilpa Deshmukh Kadam
Department of Cardiology, MGM Medical College and Hospital, MGM Institute of Health Sciences (MGMIHS) (Deemed to be University), Navi Mumbai, Maharashtra, India
|Date of Submission||02-Nov-2021|
|Date of Acceptance||13-Jan-2022|
|Date of Web Publication||23-Mar-2022|
Dr. Shilpa Deshmukh Kadam
Department of Cardiology, MGM Medical College and Hospital, MGM Institute of Health Sciences (MGMIHS) (Deemed to be University), Navi Mumbai 410209, Maharashtra.
Source of Support: None, Conflict of Interest: None
Background: Coronary artery disease (CAD) is becoming a major cause of morbidity and mortality burden in the developing world. Indians have been associated with a more severe form of CAD that has its onset at a younger age group with a male predominance. Reperfusion of the occluded coronary artery at the earliest is the most important aim of management of acute ST-elevation myocardial infarction (STEMI). Aim: The aims of this work were to (1) study the changing trends in patients presenting with STEMI, (2) the outcomes of patients undergoing thrombolysis in a tertiary care hospital, and (3) the increasing trend of CAD in young (CADY). Materials and Methods: A total of 500 patients undergoing thrombolysis between January 2017 and December 2019 were studied retrospectively. We studied the age of presentation, sex, agents used for thrombolysis, their angiography findings, and their management and outcome. Results: CADY in less than 45 years of age was noted in 26.2% in our study. It was more common in men. Left anterior descending coronary artery (LAD) was the most common artery to be involved in single-vessel coronary artery disease (SVCAD) patients followed by the right coronary artery (RCA). Door to needle time in our study was 28 min. Conclusion: The prevalence of CADY Indians in our study was significantly high. The most common age group of men presenting with STEMI was 51–55 years, followed by 45–50 years. The most common age group of women presenting with CAD was 61–65 years.
Keywords: Acute ST-elevation myocardial infarction, coronary artery disease in the young, thrombolysis
|How to cite this article:|
Kadam SD. Changing trends of patients undergoing thrombolysis for acute ST-elevated myocardial infarction in tertiary care hospital in Maharashtra, India. MGM J Med Sci 2022;9:97-102
|How to cite this URL:|
Kadam SD. Changing trends of patients undergoing thrombolysis for acute ST-elevated myocardial infarction in tertiary care hospital in Maharashtra, India. MGM J Med Sci [serial online] 2022 [cited 2022 May 17];9:97-102. Available from: http://www.mgmjms.com/text.asp?2022/9/1/97/340596
| Introduction|| |
Cardiovascular disease (CVD) is the number one cause of death in India and accounted for approximately 21% of deaths in the year 2010, with 10% of all deaths occurring due to CAD. The Global Burden of Disease study estimate of the age-standardized CVD death rate is 272 per 100,000 in the Indian population, which is higher than the global average of 235 per 100,000 population. The CREATE registry showed that 60% of the acute coronary syndrome (ACS) are constituted by acute ST-elevation myocardial infarction (STEMI), whereas in the Kerala ACS registry STEMI constituted only 40% of all patients.,, Indians are affected by CAD is a decade earlier as compared to the western populations.
The noncommunicable diseases commonly include CVD, various cancers, chronic respiratory illnesses, diabetes, and so on which are estimated to account for around 60% of all deaths. CVDs such as ischemic heart disease and cerebrovascular such as stroke account for 17.7 million deaths and are the leading cause. In accordance with the World Health Organization, India accounts for one-fifth of these deaths worldwide, especially in the younger population. The results of the Global Burden of Disease study state an age-standardized CVD death rate of 272 per 100,000 population in India which is much higher than that of the global average of 235. CVDs strike Indians a decade earlier than the western population.
| Materials and methods|| |
We retrospectively studied 500 patients who were thrombolyzed for acute STEMI according to the Fourth Universal Definition of myocardial infarction (MI) between January 2017 and December 2019. The age group of patients ranged from 24 years to 70 years. A total of 402 patients (80.4%) were males and 98 patients (19.6%) were females [Figure 1]. Male-to-female ratio was 4:1. Types of MI, various agents used for thrombolysis were studied. Thrombolyzed patients undergoing Coronary angiography, angioplasty, and CABG in our hospital were studied. The proposed retrospective research had been approved by the Institutional Ethics Committee vide their Approval no. N-EC/2021/09/70 dated October 11, 2021.
| Results|| |
The average period in which patients with STEMI reached the hospital was about 8 h. Door to Needle time on average was 28 min. Age-wise distribution of thrombolyzed patients is shown in [Figure 2]. Thrombolyzed patients were predominantly males. STEMI in men was most commonly noted in the 51–55 years age group, followed by 46–50 years. Women presented with STEMI at a later age group compared to men. Women most commonly presented with STEMI in the 61–65 years age group followed by 65–70 years.
Anterior wall MI was noted in 338 patients (67.6%) and Inferior wall MI was noted in 145 patients (29%). Fourteen patients were thrombolyzed for acute pulmonary embolism, two patients were having stuck Mitral valve, and one patient was post-PTCA [Figure 3].
A total of 411 patients (82.2%) were thrombolyzed with streptokinase, 78 patients (15.6%) were thrombolyzed with Reteplase, and 11 patients (2.2%) were thrombolyzed with Tenecteplase [Figure 4]. Post-thrombolysis mortality was noted in 30 patients (6%) within 1 week.
Out of the remaining 470 patients, 20 patients refused Intervention. Coronary Angiography was done for 450 patients. Single-vessel coronary artery disease (SVCAD) was noted in 261 patients (58%), double-vessel CAD was noted in 98 patients (21.7%). Triple-vessel coronary artery disease was noted in 71 patients (15.7%). Recanalized LAD was noted in 14 patients. Recanalized RCA was noted in 4 patients. Insignificant CAD was noted in two patients [Figure 5].
Radial coronary angiography was done in 270 patients (60%) and femoral coronary angiography was done in 180 patients (40%). Femoral angiography was preferred in elderly patients above 65 years of age due to tortuosity of the Subclavian artery.
Percutaneous Transluminal Coronary Angioplasty’s (PTCAs) with Drug-Eluting stents were done for 359 thrombolyzed patients with SVCAD’s and DVCAD’s (79.7%). Details are provided in [Figure 6] and [Figure 7]. LAD (65%) was the most common artery to be involved in 261 SVCAD patients followed by RCA. The most common coronaries involved in 98 DVCAD patients were LAD and RCA (51%), followed by LAD and LCX. Out of 71 patients with TVCAD, 55 (11.7%) underwent CABG and 16 patients with diffuse distal artery disease were advised medical management. Stent thrombosis was noted in seven patients (2%). Causes of stent thrombosis were non-adherence to dual antiplatelets due to low socio-economic conditions and travel to villages where drugs were not available.
| Discussion|| |
STEMI is the most common form of ACS in India, accounting for 40%–60% of ACS cases. The task force for the universal definition of MI defines “STEMI as new ST elevation at the J point in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads or the limb leads in the absence of left ventricular (LV) hypertrophy or left bundle-branch block (LBBB).”
The INTERHEART-South Asia study identified eight coronary risk factors–abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, low fruit and vegetable consumption, and lack of physical activity. These eight factors accounted for 89% of the cases of acute MI in Indians.ApoB/ApoA1 showed the strongest association with the risk of acute MI in Indians.
James Herrick describes the autopsy of his first patient in his seminal paper in 1912,’ attributing MI to coronary artery thrombus. Fibrinolytic activity of β hemolytic streptococci was first described by Tillett and Garner. The first therapeutic intervention of fibrinolysis was to dissolve a fibrinous pleural effusion in 1948. After 2 decades, in 1971, the efficacy of Streptokinase in acute MI was shown. Rentrop et al. showed selective intracoronary thrombolysis with streptokinase, and the clinical benefit of same was shown in terms of myocardial salvage by Markis et al. In the same year. This was a huge landmark in medicine as the “Open Artery hypothesis” could now be implemented without open-heart surgery.
Primary PCI in STEMI has been proven worldwide as the gold standard of treatment. Primary angioplasty in myocardial infarction (PAMI) has shown major advantages over IV thrombolysis. Yet, especially in Indian conditions, IV thrombolysis is the cornerstone of initial treatment choice because of the ease of administration, cost involved, and feasibility issues. With the availability of third-generation single push thrombolytics, the role of IV thrombolytic should be redefined.
Thrombolytic therapy has greater benefit in patients treated within 1 h of symptom onset with a sharp drop off after 3 h. Thrombolysis prevents approximately 30 early deaths per 1000 patients treated within 6 h after symptom onset.
Significant 17% reduction in early mortality with pre-hospital treatment (21 lives saved per 1000 patients treated). Complication rates are similar in both community-initiated and hospital-initiated thrombolysis.,,,,,,,,
Failure of thrombolytic treatment at 1–2 h is associated with a 30-day mortality >15%. The criterion that appears to be most established is the failure of the elevated ST segment to fall by 50% or more. If measured 2 h after the start of thrombolysis the diagnostic accuracy is approximately 80%–85% for failure to achieve TIMI 3 flow.
The rising incidence of CAD in young (CADY) Indians is of particular concern. The incidence of CADY population in Western countries is 2–5%, whereas it is 11–16% in Asian Indians. CADY in less than 45 years of age was noted in 26.2% of men in our study.
A growing number of “young” AMI patients are a population yet not presented in evidence. This population contains mainly thrombus in the occluded coronary artery. Subjecting these for primary stenting would mean a foreign body in a young person for no reason. These individuals respond dramatically to early and effective thrombolysis.
Echocardiography in the acute phase of STEMI is valuable in clarifying the diagnosis in patients presenting with nondiagnostic ECG changes. Regional wall motion abnormalities appear early after coronary artery occlusion. An echocardiogram is useful to identify regional wall motion abnormalities in presence of left bundle branch block (LBBB).
| Conclusion|| |
CADY is steadily rising. Anterior wall MI is the most common cause of STEMI. Reperfusion is the key strategy in acute STEMI care and it is time-dependent. Importance of home-cooked healthy diet, regular exercise of 30 min 5 days a week, Stress relieving measures such as Pranayam and Yoga, regular health check-ups for early diagnosis of blood pressure and diabetes, quitting smoking and tobacco chewing and avoiding junk food is of paramount importance for heart health.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The Institutional Ethics Committee (IEC) of MGM Medical College, Navi Mumbai, Maharashtra, India has reviewed and approved the retrospective research entitled “Changing trends of thrombolyzed patients for acute ST-elevated myocardial infarction in a tertiary care hospital in Maharashtra, India” in the IEC meeting held on 30 September 2021. The approval has been communicated vide their letter no. N-EC/2021/09/70 dated October 11, 2021.
| References|| |
World Health Organization. WHO Fact Sheet No. 310; 2011. Available from: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds). [Last accessed on 2021 Oct 2].
Brindis RG, Fitzgerald S, Anderson HV, Shaw RE, Weintraub WS, Williams JF The American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR): Building a national clinical data repository. J Am Coll Cardiol 2001;37:2240-5.
Mandelzweig L, Battler A, Boyko V, Bueno H, Danchin N, Filippatos G, et al
; Euro Heart Survey Investigators. The Second Euro Heart Survey on acute coronary syndromes: Characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean basin in 2004. Eur Heart J 2006;27:2285-93.
Fox KA, Goodman SG, Klein W, Brieger D, Steg PG, Dabbous O, et al
. Management of acute coronary syndromes: Variations in practice and outcome; findings from the global registry of acute coronary events (GRACE). Eur Heart J 2002;23:1177-89.
Guha S, Sethi R, Ray S, Bahl VK, Shanmugasundaram S, Kerkar P, et al
. Cardiological Society of India: Position statement for the management of ST-elevation myocardial infarction in India. Indian Heart J 2017;69: S63-97.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al
; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Circulation 2012;126:2020-35.
Karthikeyan G, Teo KK, Islam S Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: An analysis from the INTERHEART Study. J Am Coll Cardiol 2009;53:244-53.
White HD, Van de Werf FJ Thrombolysis for acute myocardial infarction. Circulation 1998;97:1632-46.
Tillett WS, Garner RL The fibrinolytic activity of hemolytic streptococci. J Exp Med 1933;58:485-502.
Tillett WS, Sherry S The effect in patients of streptococcal fibrinolysin (Streptokinase) and streptococcal desoxyribonuclease on fibrinous, purulent, and sanguineous pleural exudations. J Clin Invest 1949;28:173-90.
European Working Party. Streptokinase in recent myocardial infarction: A controlled multicentre trial. European working party. Br Med J 1971;3:325-331.
Rentrop P, Blanke H, Karsch KR, Kaiser H, Köstering H, Leitz K Selective intracoronary thrombolysis in acute myocardial infarction and unstable angina pectoris. Circulation 1981;63:307-17.
Markis JE, Malagold M, Parker JA, Silverman KJ, Barry WH, Als AV, et al
. Myocardial salvage after intracoronary thrombolysis with streptokinase in acute myocardial infarction. N Engl J Med 1981;305:777-82.
Proctor P, Leesar MA, Chatterjee A Thrombolytic therapy in the current era: Myocardial infarction and beyond. Curr Pharm Des 2018;24:414-26.
Hiremath JS Medicine update, chapter 70: Thrombolysis in acute myocardial infarction. 2008;18:535-9.
Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: Collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. Lancet 1994;343:311-22. Erratum in: Lancet1994;61:343-742.
Castaigne AD, Hervé C, Duval-Moulin AM, Gaillard M, Dubois-Rande JL, Boesch C, et al
. Prehospital use of APSAC: Results of a placebo-controlled study. Am J Cardiol 1989;64:30A-33A; discussion 41A-42A.
McNeill AJ, Cunningham SR, Flannery DJ, Dalzell GW, Wilson CM, Campbell NP, et al
. A double blind placebo controlled study of early and late administration of recombinant tissue plasminogen activator in acute myocardial infarction. Br Heart J 1989;61:316-21.
Barbash GI, Roth A, Hod H, Miller HI, Modan M, Rath S, et al
. Improved survival but not left ventricular function with early and prehospital treatment with tissue plasminogen activator in acute myocardial infarction. Am J Cardiol 1990;66:261-6.
Schofer J, Büttner J, Geng G, Gutschmidt K, Herden HN, Mathey DG, et al
. Prehospital thrombolysis in acute myocardial infarction. Am J Cardiol 1990;66:1429-33.
The GREAT Group. Feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplaseTrial. BMJ 1992;305:548-53.
McAleer B, Ruane B, Burke E, Cathcart M, Costello A, Dalton G, et al
. Prehospital thrombolysis in a rural community: Short- and long-term survival. Cardiovasc Drugs Ther 1992;6:369-72.
The European Myocardial Infarction Project Group. Prehospital thrombolytic therapy in patients with suspected acute myocardial infarction. N Engl J Med 1993;329:383-9.
Weaver WD, Cerqueira M, Hallstrom AP, Litwin PE, Martin JS, Kudenchuk PJ, et al
. Prehospital-initiated vs hospital-initiated thrombolytic therapy: The myocardial infarction triage and intervention trial. JAMA 1993;270:1211-6.
Sutton AG, Campbell PG, Price DJ, Grech ED, Hall JA, Davies A, et al
. Failure of thrombolysis by streptokinase: Detection with a simple electrocardiographic method. Heart 2000;84:149-56.
Murray LJ, Lopez AD The Global Burden of Disease. A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Boston, MA: The Harvard School of Public Health; 1996.
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