To determine baseline prognostic factors of in-hospital mortality in Thai patients with non-ST-elevation acute coronary syndrome (NSTE-ACS).Among 5,537 NSTE-ACS patients enrolled in Thai Acute Coronary Syndrome Registry, a univariate analysis and multivariate analysis were used to estimate the relationship of baseline clinical variables and in-hospital mortality. Variables examined included demographics, history and presenting characteristics.The in-hospital mortality rate was 9.5%. The statistically significant, adjusted baseline prognostic factors of in-hospital death were older age > or =65 years) (odds ratio [OR] 2.2, 95% confidence interval [CI] = 1.54-3.09), shock at presentation (OR 4.6, 95%CI = 2.91-7.32), heart failure (OR 3.1, 95%CI = 2.15-4.38), positive cardiac marker (OR 1.7, 95%CI = 1.18-2.53), arrhythmia (OR 12.3, 95%CI = 8.71-17.35), major bleeding (OR 2.9, 95%CI = 1.84-4.51), and cerebrovascular accident (OR 4.9, 95% CI = 2.42-9.97). While dyslipidemia (OR 0.6, 95%CI = 0.45-0.87), having percutaneous coronary intervention (OR 0.6, 95% CI = 0.39-0.94), receiving aspirin (OR 0.6, 95%CI = 0.33-0.94), beta-blocker (OR 0.5, 95% CI = 0.40-0.73), angiotensin converting enzyme inhibitor (OR 0.6, 95% CI = 0.43-0.78) and nitrate (OR 0.5, 95%CI= 0.35-0.76) were associated with lower in-hospital mortality.The in-hospital mortality is higher in Thai NSTE-ACS patients compared to other populations. The present study supports and confirms the prognostics importance of several baseline characteristics reported in previous studies.
Clinical predictors of high-risk STEMI patients may guide physicians to the type of treatment, as high-risk patients need more aggressive treatment than low-risk patients. There was no previous registry of STEMI patients in Thailand.To determine the clinical predictors of in-hospital mortality in STEMI patients from the Thai ACS MATERIAL AND METHOD: A multi-center prospective nationwide Thai Acute Coronary Syndrome Registry (TACSR) was done between August 1, 2002 and October 31, 2005. The STEMI patients were registered to Thai ACS web site. Clinical and demographic characteristics, coronary risk factors, presenting symptoms, in-hospital treatments, reperfusion procedures and the patients' outcomes were recorded and analyzed.3,836 STEMI patients were studied. The mean age was 62.2 +/- 12.8 years and 68% of the patients were male. The mortality rate of Thai STEMI patients was 17% (86.8% from cardiac causes) and the main cause of death was pumping failure (61.3%). The patients with older age > or = 75 years, patients with diabetes, shock, and cardiac arrhythmias had a higher mortality (29.4, 21.2, 43.4 and 37.24% respectively), while patients who underwent primary percutaneous coronary intervention (primary PCI) had a lower mortality rate (12.66%). Patients who received treatment with ASA, beta-blocker ACE inhibitor/ARB and statin had lower in-hospital mortality.The clinical predictors of high in-hospital mortality in STEMI patients from the TACSR were older age > or = 75 years, diabetes, shock, and cardiac arrhythmias. The treatments that can decrease the mortality were primary PCI, ASA, beta-blocker, ACE inhibitor/ARB and statin.
OBJECTIVE To assess the efficacy and safety of transradial approach compared with transfemoral approach for coronary angiography and ad hoc angioplasty in Phramongkutklao hospital at the time of initiation of transradial program. MATERIAL AND METHOD Prospective data collection of consecutive patients who underwent coronary angiography with ad hoc angioplasty during October 2004 to January 2005 was conducted. Baseline demographic data and the details of the procedure were recorded. The complications were assessed by a single doctor using standard protocol. RESULTS There were 75 included in our study. Transradial approach and transfemoral approach was performed in 23 cases (30.7%) and 52 cases (69.3%), respectively. The baseline characteristics, procedure results were similar except the there was higher prevalence of NST-ACS symptoms (92.31% vs. 65.22%, p = 0.004) and access site complications in transfemoral group (23.08% vs. 4.35%, p = 0.035). The success rate was very high (> 90%) and not significantly different in both groups. However the transradial group was associated with lower assess site complications earlier ambulation and better patient's satisfaction. CONCLUSION Even at the time of initiation of transradial program, transradial approach for coronary angiography and ad hoc angioplasty can be performed with similar efficacy, less local complication, earlier ambulation and better patient's satisfaction compared to the standard transfemoral approach.
RESULTSA total of 1,451 patients were included.The mean age of the patients was 63.7 ± 14.4 years, and 49.7% were male.One-year, five-year and ten-year mortality rates in Thai patients admitted for acute decompensated heart failure were 28.0%, 58.2% and 73.3%, respectively.Independent predictors of increased mortality were identified.There were more cardiovascular-related deaths than non-cardiovascular-related deaths (54.6% vs. 45.4%,respectively). CONCLUSIONSThe ten-year mortality rate in Thai patients admitted for acute decompensated heart failure was 73.3%.Many factors were found to be independently associated with increased mortality, including left ventricular ejection fraction.
Objective: To compare the outcome after immediate thrombolytic therapy in the emergency department versus primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) in Phramongkutklao Hospital. Methods: We prospectively enrolled 24 hemodynamically stable acute STEMI patients presenting within 12 hours of the clinical onset. All of them were treated with standard medical regimen, and then randomly assigned to undergo primary PCI or to receive intravenous thrombolytic therapy with tenecteplase tissue type plasminogen activator (TNK-tPA) in the emergency department followed by standard care. Coronary angiography was performed within 1 week after thrombolysis in all patients. The primary endpoint was a composite of outcomes of death, recurrent myocardial infarction (MI) and stroke at 30 days. The secondary endpoints were recurrent ischemia, heart failure, cardiogenic shock, arrhythmia, repeat revascularization (rescue PCI, further PCI), coronary artery bypass graft (CABG), usage of intra-aortic balloon pump (IABP), mechanical ventilator support, major bleeding, cost and length of stay at 30 days. Results: Twenty-four patients with acute STEMI were enrolled. The median time interval from symptom onset to random assignment was 2.1 hours in the TNK-tPA group and 2.5 hours in the PCI group. The median time to needle and time to balloon inflation were 116 minutes and 122 minutes respectively, (p = 0.90). The primary end-point was only one patient in the PCI group had re-infarction and hemorrhagic stroke. However, half of the patients in the thrombolytic group still required further PCI. The cost was 248,714 ± 266,854 baht in the PCI group and 191,960 ± 110,029 baht in theTNKtPA group (p = 0.95). The duration of hospital stay was 10.6 ± 14 days in the PCI group and 6 ± 3 days in theTNK-tPA group (p = 0.88). Conclusion: This pilot study shows that the immediate TNK-tPA intravenous therapy in the emergency department for treating patients with acute uncomplicated STEMI appears to be safe and may be a worthy alternative treatment in selected patients. Thai Heart J 2009; 22 : 69-78 E-Journal : http://www.thaiheartjournal.org Introduction Acute ST-segment elevation myocardial infarction (STEMI) is a serious medical condition, affecting people Corresponding author: Nakorn Sithinamsuwan, MD Division of Cardiology, Department of Medicine, Phramongkutklao Hospital. 315 Rajvithi road, Phrayathai district, Rachatavee, Bangkok, Thailand 10400. E mail address: Nink_MD@hotmail.com worldwide (1). It has been recognized that there are approximately 500,000 patients suffering annually in the United States from this condition (1). In Thailand, around 1,000 patients per year were diagnosed with STEMI (2). Additionally, our medical institute has had about 50 newly diagnosed STEMI patients per annum. It is widely accepted that STEMI is not only a common medical problem, but also a fatal condition. It occurs because of a clot-occluded coronary artery through multiple pathogeneses. Hence, cardiac muscle ischemia and then THAI HEART JOURNAL Vol. 22 No.3 July 2009 THAI HEART JOURNAL Vol. 22 No.3 July 2009 Nakorn Sithinamsuwan, MD infarction occur. The STEMI mortality in the GRACE registry and Thailand were 7% and 17% respectively (2). Prompt and complete restoration of coronary flow is the principal mechanism that improves survival and other clinical outcomes in patients with acute STEMI (1). Nevertheless, reperfusion therapy for STEMI is different among hospitals. At selected centers, coronary angioplasty, especially primary percutaneous coronary intervention (PCI), can be performed expeditiously in such patients, resulting in better coronary blood flow and 30-day survival rates than patients who received intravenous thrombolytic therapy (3-14). In general, the problem is that a PCI facility is available in only certain medical centers, so that physicians need to choose other available treatments. Another standard strategy to combat acute STEMI is intravenous thrombolytic therapy. It has many favorable properties such as high efficacy, widespread availability and reduces mortality in some reports (16). Therefore, this strategy has been used in more than a million patients over the past decade (1). Tenecteplase tissue type plasminogen activator (TNK-tPA) is a thrombolytic agent, which has been recently used. It is a variant of the native tissue type plasminogen activator (tPA) molecule that has a 16-fold greater fibrin specificity than alteplase, a longer half-life, slower plasma clearance, and 80-fold greater resistance to inhibition by plasminogen activator inhibitor type 1 (15-18). Its half-life of 18 minutes allows a singlebolus administration. Moreover, in comparative clinical trials, tenecteplase was found to have equivalent efficacy to recombinant tPA (alteplase) (17-18). The rate of intracranial hemorrhage with tenecteplase was similar to that with alteplase, and tenecteplase was associated with fewer non-cerebral complications and less need for blood transfusions (17). Furthermore in the Thai Acute Coronary Syndrome (ACS) Registry (2), the average door-to-balloon time in the Primary PCI group were more than 120 minutes, so thrombolytic therapy may have a role in treating the STEMI patients. The use of TNK-tPA in the Emergency Department may further reduce the differences in outcome between thrombolysis and coronary intervention. Therefore, the aim of this study was to compare the outcome after immediate thrombolytic therapy in the emergency department versus primary PCI in patients with acute STEMI in Phramongkutklao Hospital. Methods Study design This study was a prospective randomized trial, performed at Phramongkutklao Hospital from June 1st to December 31st, 2007. Eligible patients Patients presenting within 12 hours after the onset of acute myocardial infarction, who had chest pain lasting at least 20 minutes, accompanied by electrocardiographic (ECG) with ST-segment elevation of at least 0.1 mV in two or more contiguous leads or new left bundle branch block or posterior wall myocardial infarction (MI) (STsegment depression at least 0.1 mV with tall R wave in lead V1-2), were eligible for enrollment. The exclusion criteria Figure 1. Stratified randomization flow chart
Coronary heart disease is the leading cause of mortality and morbidity in men as well as in women. Women have their first cardiac event 6 to 10 years later than men do. Whereas, the cardiovascular death rates are declining in men, they remain constant in women. In cardiovascular studies with age limits, women are naturally the minority, amounting to < 40%.Determine the effect of gender on treatment and clinical outcomes in acute ST elevation myocardial infarction (STEMI) patients.This is a multicenter study including 13 government and 4 private institutions. Between August 1, 2002 and October 31, 2005, 3,836 consecutive patients with ST elevation myocardial infarction were enrolled. The patient characteristics, treatment, and hospital outcome were collected and validated. In-hospital management and outcomes were compared between men and women, without adjustment, with adjustment for age alone and with adjustment for age and other covariates by means of multivariate stepwise logistic regression analysis. In each model tested, gender was forced into the model, whereas other predictors were selected in a stepwise mannerWomen were 1,223 patients (31.9%) of all patients and were 8 years older than men (67.5 +/- 12.0 vs. 59.7 +/- 12.4 years). Women had a higher incidence of diabetes and hypertension (46.9% vs. 31.0%, p < 0.001 and 62.1% vs. 45.3%, p < 0.001). Smoking and family risk factor were found in men more than in women (17.5% vs. 52.5%, p < 0.001 and 7.4% vs. 11.2%, p< 0.001). Women presented more frequently with cardiac dyspnea and shock than men (35.3% vs. 22.2%, p < 0.001 and 21.5% vs. 13.8%, p < 0.001). There was no difference in time to admission between men and women. Beta blocker, statin, angiotensin converting enzyme inhibitor (ACEI) and angiotensin II receptor inhibitor (ARB) were less frequently used in women. Coronary angiogram was performed less often in women and less abnormal angiogram were found (57.8% vs. 65.0%, p < 0.001 and 55.5% vs. 63.9%, p < 0.001). A lower percentage of women received thrombolytic therapy (28.1% vs. 31.4%, p = 0.039) as well as percutaneous coronary intervention (PCI) (39.0% vs. 48.5%, p < 0.001).Unadjusted in-hospital mortality was significantly higher in women than in men (23.6% vs. 13.9%, unadjusted OR (95% CI) 1.90 (1.60-2.26), p < 0.001). After adjustment of other covariables (age group> 75 years, hospital group (metropolitan, regional), chest pain, cardiac dyspnea, shock, post cardiac arrest, diabetes, hypertension, family history, smoking, dyslipidemia, refer time to admission < or = 12 hours (hour), aspirin, beta blocker calcium antagonist, statin, ACEI, ARB, nitrate, coronary angiogram, thrombolysis, PCI, coronary artery bypass grafting, congestive heart failure, arrhythmia, stroke, bleeding), the gender difference in-hospital mortality no longer existed (adjusted OR (95% CI) 1.03 (0.80-1.33), p = 0.814). The incidence of congestive heart failure as a complication was significantly higher in women than in men (55.6% vs. 38.7%, p < 0.001, adjusted OR (95% CI) 1.29 (1.08-1.54), p = 0.005).Women with acute ST elevation myocardial infarction were older and had a higher incidence of hypertension and diabetes than men. Women were less likely than men to undergo coronary angioplasty. Women in the authors' registry had a higher risk for in-hospital morbidity and mortality than men. Early and aggressive treatment might improve the clinical outcomes in women with STEMI.
Objective: To describe differences in in-hospital morbidity and mortality, presenting characteristics and management practices of diabetic and non-diabetic patients with non-ST elevation myocardial infarction using data from Thai ACS registry. Material and Method: Thai ACS registry is a multi-center, prospective project of nationwide registration in Thailand. Results: The present study consisted of 3,548 patients with non-ST elevation myocardial infarction from 17 hospitals in about a 3-year period. About 50% of the patients with diabetes were more often female, with a greater prevalence of hypertension and dyslipidemia. The diabetic group was at an increased risk for congestive heart failure (adjusted odds ratio 1.84) but not increased risk for cardiac arrhythmia, cardiac mortality, and in-hospital mortality. Conclusion: There was a very high prevalence of diabetes in non-ST elevation myocardial infarction from Thai ACS registry. These patients were at increased risk for congestive heart failure as index of hospitalization but were not at increased risk for in-hospital mortality when compared with patients without diabetes. Keywords: Non-ST elevation myocardial infarction, Diabetes, The Thai acute coronary syndrome registry
The open artery theory has been proposed that late reperfusion of an occluded coronary artery favorably affects clinical outcome. Myocardial reperfusion can be achieved in acute myocardial infarction (AMI) by coronary angioplasty. Coronary stenting improves initial success rate and reduces rate of restenosis. However, there are limited data regarding intermediate outcome of late angioplasty with stenting.Between June 1998 and August 1999, one hundred and twenty-three patients with AMI, and forty-four patients (37 males, 7 females) underwent late coronary stenting. Mean age was 57 +/- 10 years. Echocardiography was performed before the procedure and at 6-months follow-up.There were 36 Q-MI and 8 non Q-MI. The infarct-related artery (IRA) was left anterior descending artery (LAD) 55 per cent, left circumflex artery (LCX) 15 per cent, and right coronary artery (RCA) 30 per cent. Coronary stenting was successfully performed in all patients. Pre- and post-procedural diameter stenosis were 90.5 +/- 8.9 per cent and 2.2 +/- 6.5 per cent. Stent indications were suboptimal results (68.2%), intimal dissection (20.4%), and acute closure (11.4%). Over all in-hospital mortality was 2.27 per cent from sudden cardiac death. Mean follow-up was 11.41 +/- 4.79 months. There were 1 MI (2.3%), 2 CHF (4.65%), 1 unstable angina pectoris (2.3%), 1 transient ischemic attack (TIA) (2.3%), and no cardiac death. LVEF showed improvement at 6-months follow-up (47.75 +/- 11.55% vs 54.89 +/- 14.76%, p value < 0.001)Late coronary stenting of the IRA of patients with AMI is feasible, with few complications. There was improved LVEF and intermediate clinical outcome.
