Clinical Results of Acute ST Elevation Myocardial Infarction Patients with the Fast Tract Management System in Naresuan University Hospital
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Background: Acute ST-elevation myocardial infarction (STEMI) is a life-threatening emergency cardiovascular condition. Mortality is still high in rural region. Objective: to identify mortality rate and evaluate the clinical outcomes of acute STEMI patients using the fast tract management system at Naresuan University Hospital (NUH) Material and Method: Descriptive review of clinical parameters from STEMI patients who participated in the fast tract management system Results: Between Jan 2010 to Sep 2013 , 191 STEMI patients were enrolled. The 147 patients (77%) were referrals and 44 patients (23%) were non-referrals. They were predominantly male patients with an average age of 65 years. The risk factors of coronary artery disease (CAD) were dyslipidemia (86.9%), hypertension (61.3%), smoking (51.3%) and diabetes mellitus (18.3%). Cardiac arrest was found in 16.2% and 14.1% presented with cardiogenic shock. 86.4% received reperfusion therapy with 37.2% got primary percutaneous coronary intervention (PCI). The median door to balloon time and door to needle time for non-referral patients were 89 and 58 minutes, respectively. The median time to treatment was 226 min in the thrombolytic group and 234 min in the primary PCI group. The overall mortality rate was 11.5% which was much lower than the previous data of NUH (33.3%). For the referred patients, the median first medical contact (FMC) to device time was 344 min. Mortality rate of primary PCI in referral group (17.9%) was higher than in non-referral group (6.3%). Conclusion: The mortality rate at NUH is lower than before having established fast tract management system but still high as compare to standard of care. Fibrinolytic therapy is preferred for the treatment of choice at non-PCI capable hospital and PCI will be considered for failed fibrinolysis or presence of contraindication to fibrinolysis. Shortening of pain to treatment time by fast tract management system is the mainstay to improve survival in the patients who suffer from STEMI. Keywords: ST elevation myocardial infarction, fast tractKeywords:
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Primary percutaneous transluminal coronary intervention (PCI) and thrombolytic therapy (TT) are alternative means of achieving reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI).To compare the outcomes between both reperfusion strategies. The authors sought to compare in-hospital outcomes after PCI or TT for patients with acute STEMI.From August 2002 through June 2004, data from all patients who received reperfusion therapy for acute STEMI were collected prospectively. The decision regarding type of reperfusion strategy was at the attending cardiologist's discretion. The patient's data on demographics, procedures, medications, and in-hospital outcomes were analyzed.From August 2002 through June 2004, 234 patients were admitted to the authors' institute with the diagnosis of acute STEMI. Of the 146 patients who received reperfusion therapy, 91 were treated with primary PCI and 55 received intravenous TT as the reperfusion modality. In the TT group, 51 (93%) patients received streptokinase and 11 (21.6%) underwent rescue angioplasty. The two groups had similar baseline characteristics. Both patient groups had frequent presence of diabetes (PCI 44.2% vs. TT 39.6%, p = 0. 6). Cardiogenic shock on admission was present in 11% of the PCI patients and 7.3% of the TT patients (p = ns). In-hospital mortality was not significantly different in the two groups (PCI 14.3% vs. TT 10. 9%, p = 0.56). In the TT group, there was a trend toward a higher rate of major bleeding (PCI 6.6% vs. TT 16.4%, p = 0.06) and stroke (PCI 2.2% vs. TT 7.3%, p = 0.13) complications without statistical significance.The present findings suggest that both PCI and TT are comparable alternative methods of reperfusion among STEMI patients in terms of in-hospital mortality. In certain subgroups that are at increased risk of bleeding or stroke, primary PCI may be the preferred treatment strategy.
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Cíl: Perkutánní koronární intervence (PCI) se stala standardem péče o pacienty s akutními koronárními syndromy (AKS). Česká republika patří mezi evropské země s dobře propracovanou sítí spolupracujících nemocnic provádějících PCI a nemocnic, které tento výkon neprovádějí. Z řady registrů je k dispozici množství údajů o pacientech léčených pomocí PCI. Mnohem méně se toho ví o způsobu léčby a výsledném stavu pacientů s AKS hospitalizovaných v nemocnicích bez katetrizačních sálů. Cílem registru ALERT-CZ bylo konkrétně analyzovat údaje těchto pacientů dopravených do místních nemocnic neprovádějících PCI a zjistit, zda se v místních, malých nemocnicích uplatňují doporučené postupy Evropské kardiologické společnosti.Metody a výsledky: Do projektu bylo zařazeno celkem 6 265 pacientů poprvé hospitalizovaných pro AKS ve 32 českých komunitních nemocnicích bez katetrizačních sálů během tříletého období (7/2008-6/2011). Průměrný věk těchto pacientů byl 69,7 ± 12,3 roku, ve 39,5 % šlo o ženy, 35,4 % mělo diagnózu diabetes mellitus, 76,0 % hypertenzi, 28,3 % již dříve prodělalo infarkt myokardu a 12,0 % cévní mozkovou příhodu. Pětadvacet procent pacientů vykazovalo známky akutního srdečního selhání (Killipova třída II v 19,0 %, třída III v 4,8 % a třída IV v 1,1 % případů). Diagnózou při propuštění byl infarkt myokardu s elevací úseku ST (STEMI) ve 26,1 %, infarkt myokardu bez elevací úseku ST (non-STEMI) v 53,1 % a nestabilní angina pectoris (NAP) ve 20,9 % případů. Naléhavý převoz mezi nemocnicemi k provedení koronarografie a PCI do 12 hodin od nástupu symptomů byl indikován u 73,4 % pacientů se STEMI, plánovaná koronarografie u 15,9 % pacientů se STEMI; koronarografie nebyla indikována u 9,9 % pacientů se STEMI, a 0,9 % pacientů se STEMI odmítlo její provedení. Z pacientů s non-STE AKS byla koronarografie provedena do 24 hodin u 16,2 %, mezi 24 a 72 hodinami u 18,2 %, ještě později u 38,1 %,koronarografie nebyla indikována u 22,7 %, provedení koronarografie odmítlo 4,8 % pacientů. Průměrná délka pobytu v zařízení s možností provést PCI byla 2,0 dne a pouze 37 % pacientů se po koronarografii (± PCI) vrátilo do původní komunitní nemocnice, ostatní byli propuštěni přímo domů. U pacientů se STEMI byl medián intervalů následující: bolest - první kontakt s lékařem (first medical contact - FMC) 120 min, FMC - dveře komunitní nemocnice 30 min, příjezd ke dveřím komunitní nemocnice a odvoz rychlou záchrannou službou od dveří komunitní nemocnice 23 min. Trombolýza byla provedena u 0,4 % pacientů se STEMI, a to ve vzácných případech, kdy nebyl z logistických důvodů okamžitý převoz z komunitní nemocnice možný.Perkutánní koronární intervence byla provedena celkem u 41,6 % pacientů (65,9 % se STEMI, 35,8 % non-STEMI a 26,4 % s NAP). Koronární bypass (CABG) byl proveden celkem u 2,9 % pacientů (2,1 %, resp. 3,1 % a 3,6 % podle výše uvedených diagnóz). Podrobné údaje o farmakoterapii i nepřímé porovnání se samostatnými registry zařízení s vybavením pro provádění PCI přesahují rozsah tohoto abstraktu a budou uvedeny jinde.Celková nemocniční mortalita činila 7,2 %. Mortalita podle konečné diagnózy byla 9,5 % (STEMI), 8,7 % (non-STEMI) a 0,5 % (NAP). Hodnoty mortality podle věkových skupin byly 16,2 % (> 80 let), 8,0 % (70-80 let) a 2,4 % (< 70 let).Závěr: Pacienti přivezení do nemocnic nevybavených pro provádění PCI absolvují revaskularizační výkony méně často než nemocní transportovaní přímo do nemocnic s katetrizačními sály. To může souviset s rozdíly ve vstupní charakteristice a výsledky mohou být těmito skutečnostmi ovlivněny.
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Aim. To study a treatment of patients with acute myocardial infarction (AMI) before and during hospitalization in a Khabarovsk hospital, which has an opportunity of primary percutaneous coronary intervention (PCI), as well as hospital outcomes according to the AMI Register. Material and methods. 321 patients consecutively hospitalized in the Khabarovsk Regional Vascular Center were included into AMI Register: 177 patients with ST-segment elevation AMI (STEMI; 55.1%); 135 patients non-ST-segment elevation AMI (non-STEMI; 42.1%); 9 patients with early recurrence of AMI and early post-infarction stenocardia (2.8%). Results. Before reference AMI a frequency of administration of statins was 13.7%, angiotensin-renin blockers – 29.3%, acetylsalicylic acid – 28.7%, beta-blocker – 25%. Among patients with atrial fibrillation only 7 ones (17%) were treated with oral anticoagulants. 141 patients (79.6%) with STEMI underwent PCI procedure: primary PCI – 82.3% and delayed PCI – 17.7%. PCI with coronary stenting was performed in 86.5% of patients with STEMI. Frequency of PCI in non-STEMI patients was 42%: primary PCI – 43.9%, delayed PCI – 56.1%, PCI with coronary stenting – 43.9%. Gender and age of the patients did not influence the choice of tactics of revascularization in STEMI and non-STEMI (PCI(+), PCI(-), PCI with coronary stenting) (p<0.05). Medication in hospital: double antithrombotic therapy (DATT) was prescribed in 86.9% of patients; direct anticoagulants – in 91.2%, statins – in 97.2%, beta-blockers – in 88.5%; renin-angiotensin-aldosterone system inhibitors – in 90.6%. A total lethality in STEMI was 15.2%, and in non-STEMI – 1.5%. Lethality in PCI-negative patients with STEMI was higher than this in patients with non-STEMI (p<0.001). In STEMI patients lethality was 3.3 times lower in PCI-positive patients in comparison with PCI-negative patients. Conclusion. AMI Register demonstrated that before reference AMI very few patients were covered with modern medicines influencing prognosis. AMI hospital treatment in Khabarovsk Regional Vascular Center was characterized by a high rate of primary PCI, DATT, enoxaparin, and high-dose statin therapy.
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Abstract Aim: To investigate the outcome of primary percutaneous coronary interventions (PCI) in elderly patients (≥≥75 years) with ST‐elevation myocardial infarction (STEMI). Methods and Results: Between 1995 and 2003, a total of 319 consecutive patients with acute ST‐elevation myocardial infarction presenting within 6–12 hr after onset of symptoms were prospectively enrolled in a registry. Of 296 patients undergoing primary PCI, 40 patients were ≥≥75 years old (group A) and 256 patients younger than 75 years (group B). Elderly patients presented with a lower ejection fraction (49 ± 14% vs. 53 ± 13%, P = 0.046) and a higher number of cardiovascular risk factors. PCI success was achieved in 80% (group A) and 91% (group B, P = 0.031), respectively with comparable door‐to‐balloon times (87 ± 49 and 95 ± 79 min, P = ns). Periprocedural complications in both groups were low and major adverse cardiac events (death, myocardial infarction, target vessel revascularization and cardiac rehospitalization) after 6 months amounted to 23% (group A) and 20% (group B, P = ns), respectively. Conclusions: Clinical outcome of elderly patients (≥≥75 years) with acute STEMI is favorable and comparable with the middle‐aged population. However, procedural success was significantly lower in elderly (80%) compared to younger patients (90%). Acute percutaneous coronary intervention appears to be safe and not associated with higher periprocedural complications, in elderly patients. © 2007 Wiley‐Liss, Inc.
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To investigate the association between hyperglycemia and outcome in elderly patients with acute ST segment elevation myocardial infarction (STEMI) underwent primary percutaneous coronary intervention (PCI).This retrospective analysis was performed on 284 elderly patients (age > or = 60 years) with acute STEMI underwent primary PCI between January 2000 to April 2004 in our department. Patients were divided into 3 groups according to the level of blood glucose on admission: group A, < 7.8 mmol/L; group B, 7.8 - 10.9 mmol/L; group C, > or = 11.0 mmol/L.(1) The proportion of female in group B and group C was greater than that of group A (33.3% vs. 26.5%, P < 0.01; 40.2% vs. 26.5%, P < 0.01). The hospital stay time of group B and group C was significantly longer than that of group A (16.0 days vs. 13.9 days, P < 0.05; 16.6 days vs. 13.9 days, P < 0.05). There were more patients with history of hypertension in group C than that in group A (72.1% vs. 54.9%, P < 0.01). (2) After PCI, the proportion of patients with TIMI myocardial perfusion grade (TMPG) 0-1 in group B and C was greater than that of group A (22.6% vs. 13.3%, P < 0.05; 34.1% vs. 13.3%, P < 0.05). The proportion of patients with TMPG 3 in group B and C was less than that in group A (74.3% vs. 84.4%, P < 0.05; 57.6% vs. 84.4%, P < 0.05). The complication rate of PCI was significantly higher in group C than in group A (42.5% vs. 20.6%, P < 0.01) and group B (42.5% vs. 26.6%, P < 0.01). IABP use was significantly more in group C than that in group A (19.5% vs. 4.9%, P < 0.01) and group B (19.5% vs. 6.4%, P < 0.01). (3) There were more patients with grade of Killip class > or = 2 in group C than that in group A (44.8% vs. 23.5%, P < 0.01) and group B (44.8% vs. 27.7%, P < 0.01). The in-hospital mortality rate (8.0% vs. 1.1%, P < 0.05) and one-year mortality rate (18.7% vs. 3.4%, P < 0.05) of group C were significantly higher than those in group A.Hyperglycemia at admission was associated with poor tissue perfusion, cardiac function and prognosis in elderly patients with acute STEMI underwent primary PCI.
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INTRODUCTION. Mortality in ST elevation myocardial infarction (STEMI) ranges from 4-24% and is dependent on the variety of patients? clinical characteristics (CC) that are present prior to and within the first hours of the onset of MI, affecting reliability of the diagnosis. The higher mortality rate of patients with STEMI should be associated with a higher rate of applied reperfusion therapy according to guidelines and randomized study results, which is in opposition to everyday hospital practice. OBJECTIVE. The aim of this study was to analyze the mortality of STEMI patients in relationship to their clinical characteristics at presentation, their age, sex, risk factors, prior coronary disease, and time interval from symptom onset to hospital presentation, complications and administered therapy. METHOD. The analysis involved patients treated in five coronary care units, four Belgrade Hospital Centres and the Belgrade Emergency Centre of the Clinical Centre of Serbia. Evaluated data was obtained from the Serbian National Registry for Acute Coronary Syndrome (REAKSS) and databases of local coronary care units (CCU). RESULTS. During 2005 and 2006, a total of 2739 patients with STEMI, of average age 63.3?11.7, with 64.9% males aged 61.3?11.7 and 35.1% females aged 67.0?10.7 (p<0.01) who underwent treatment. Most of the patients (80.5%) were distributed within the elderly groups of 60, 70 and 80 years of age, with the highest percent of mortality rate (45.9%) noted at age 80 years. Anterior localization of myocardial infarction was observed in 40.2% of patients, with lethal outcome in 21.4% patients, while 59.8% of patients suffered inferiorly localized MI with much lower mortality rate (12.2%, p<0.01). In 2005, STEMI was registered in 48.7%, while in 2006 in 44.7% of patients. Prior angina pectoris was present in 19.9% of patients, more frequently among women (p<0.05), prior MI in 14.5% of patients, more often among males (p<0.05), while aortocoronary revascularization was found in 3.9% of patients. Hospital mortality rate due to STEMI was higher in the group of patients with a history of prior MI (19.1% vs. 15.7%; p>0.05). Regarding risk factors, hypertension was present in 61.8% of patients, more often among women (69.1% vs.57.9%) (p<0.01), carrying a higher mortality rate of 18.9% vs. 9.9% among males (p<0.01). Hyperlipidemia was found in 31.9% of patients; more frequently among women 34.8% vs. 30.4% males (p<0.05), as well as diabetes mellitus observed in 25.1% of patients; 22.4 % males and 30.1% females (p<0.01). 39.6% of patients were smokers; 46.9% males and 28.0% females (p<0.01). Heart failure had 33.4% of patients; mortality rate was registered in 28.2% of patients, and was significantly higher than in the non heart failure group (7.9%, p<0.01). Heart rhythm disorders were registered in 21.3% of patients, more frequently involving posterior MI 55.3% vs 44.7% of anterior MI (p>0.05), and was significantly higher among females 23.5% vs. 20.1% in males (p<0.05). In 2005 in Belgrade hospitals, reperfusion therapy (RT) was performed in 34.6% of patients, mostly as thrombolytic therapy (TT) (in 99.0% of patients), and as percutaneous coronary intervention (PCI) in 1.0% of patients. STEMI mortality rate was 12.8%. In 2006, in the CCU of the In the Emergency Center RT was applied in 48.0% of patients, TT in 13.8% and PCI in 34.2%, while classical therapy without RT was applied in 52.0% of patients. CONCLUSION. Clinical characteristics significantly influence mortality in STEMI; a significantly higher mortality is among women, patients in their 80?s and 90?s, anterior MI localization and prior coronary disease. RT significantly lowers mortality in STEMI compared to the use of classical therapeutic approach and therefore STEMI patients with a higher mortality determined by their prehospital charactheristics, i.e. higher risk, are those who have higher benefit of RT, which should be taken into consideration when making decision about the therapy of choice.
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Introduction: Primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in hospitals without on-site cardiac surgery capability, despite receiving only a class IIb recommendation in the ACC/AHA practice guidelines, can be per-formed effectively and safely. We reviewed the first 3 years of our experience. Materials and Methods: This is a retrospective single centre review of all patients receiving primary PCI for STEMI between 2003 and 2005. Demographic, procedural and outcome data were analysed. Results: There were 259 patients who underwent primary PCI. The mean age was 55.3 ± 12.3 years. Median door-to-balloon time was 97.5 minutes and 45.2% and 52.9% had anterior and inferior STEMI, respectively. The majority of patients presented with Killip class I (87.6%); however, 5.8% were in Killip class IV. Single vessel disease was found in 47.1%. Angiographic PCI success (defined as residual stenosis <50% with TIMI 3 flow) was achieved in 89.1%. Usage of stents, distal protection and aspiration devices were 97.2%, 27.8% and 34.1 %, respectively; 9.3% required intra-aortic balloon pump insertion. No patients required transfer for emergency coronary bypass surgery as a result of PCI complications. Post-PCI ST resolution >50% was achieved in 80.6%. The mean post-infarct left ventricular ejection fraction was 44.1%. In-hospital, 30-day, 6-month and 1-year mortality rates were 2%, 2.8%, 4.0% and 4.8%, respectively. Clini-cally driven target lesion revascularisation rate was 2.8% at 1 year. Conclusions: Our results are comparable to those from on-site surgical centres. This supports the feasibility and safety of primary PCI in cardiac centres without on-site cardiac surgery. Key words: Emergency, PCI, STEMI, Transfer
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Objective
To investigate the effect and safety of primary percutaneous coronary intervention (PCI) of acute ST-segment elevation myocardial infarction (STEMI) in elderly patients.
Methods
103 consecutive patients with STEMI treated by primary PCI were divided into two groups according to the age: the elderly group 〔aged≥65 years, with a mean age of (75.7±6.2) years(n = 49), the non-elderly group 〔aged<65 years, with a mean age of (43.0±8.6) years(n = 54). Clinical characteristics, complications related to PCI procedure and success rate were analyzed, and major cardiovascular events (MACE) were followed up for(5.7±1.2)months.
Results
The proportion of female, patients with Killip ≥Ⅲ, three vessels disease and higher level of serum brain natriuretic peptide were higher in elderly group than in non-elderly group (all P 0.05). Patients were followed up for (5.7±1.2) months. The in-hospital and one-month mortalities were higher in elderly group than in non-elderly group 〔8.2% (4 cases)vs. 0% (0 case), 10.2%(5 cases) vs. 0 % (0 case), respectively, all P<0.05〕. There was no significant difference in six-month mortality and MACE between the two groups. Multivariate logistic regression analysis showed that Killip ≥Ⅲ was related with the increase of one-month mortality in patients with STEMI undergoing primary PCI, whereas age was not.
Conclusions
Primary PCI is effective and safe in elderly patients with STEMI.
Key words:
Myocardial infarction; Angioplasty, transluminal, Percutaneous cornary
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