door to needle time of streptokinase and st segment resolution

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J Ayub Med Coll Abbottabad 2010;22(1)
DOOR TO NEEDLE TIME OF STREPTOKINASE AND ST SEGMENT
RESOLUTION ASSESSING THE EFFICACY OF REPERFUSION
THERAPY AT KARACHI INSTITUTE OF HEART DISEASES
Riffat Sultana, Nuzhat Sultana, Abdul Rasheed, Zahid Rasheed, Mansoor Ahmed,
Muhammad Ishaq, Abdus Samad
Karachi Institute of Heart Diseases, Karachi, Pakistan
Background: Early start of treatment including coronary revascularisation has been recognised as
crucial variable in the outcome of acute ST-segment Elevation Myocardial Infarction (STEMI).
Objectives of the study were to determine the magnitude of ST-segment resolution after thrombolytic
therapy predicts short- and long-term outcomes in patients with an Acute Myocardial Infarction (AMI).
Methods: The duration of quasi experimental study was 3 years, from July 2006 to June 2009,
conducted at Karachi Institute of Heart Diseases. Total 1,023 patients of STEMI treated with
streptokinase (SK) were enrolled in the study. Result: Of the total 1023, 689 (67.3%) patients were
males and 334 (32.6%) were females. Six hundred and twenty-nine (61.5%) were successfully resolved
after thrombolytic therapy while in 395 (38.5%) patients ST-segment could not resolve into 3
conventional ST-segment resolution categories at 60 minute and 90 minute after thrombolysis. Three
hundred and twelve (30%) and 444 (43.4%) with complete resolution, 344 (33.62%) and 325 (31.76%)
with partial resolution, 367 (35.8%) and 491 (19.29%) were with no resolution at 60 and 90 minutes
respectively. Conclusion: Shock, congestive heart failure, and recurrent angina and ischemia occurred
more often in patients with partial or no ST resolution as compare to complete resolution.
Keywords: myocardial infarction, thrombolysis, ST-segment elevation, congestive heart failure
INTRODUCTION
ST-Elevation Myocardial Infarction (STEMI) is defined
as ST elevation on the ECG, which is the electrical
manifestation of the pathophysiological changes that
follow a thrombotic occlusion of an epicardial coronary
artery.1 Although a single ECG presents about 10
seconds of waveform morphology, acute STEMI
displays its dynamic behaviour over time, both
spontaneously and in response to therapy.2 The STsegment resolution stratified by Schroder into 3
categories (complete resolution, ≥70%; partial
resolution, 30–70%; and no resolution, <30%) after
reperfusion therapy has been identified as a prognostic
indicator for patients with acute myocardial infarction
(AMI).3
Early resolution of ST-segment elevation has
been demonstrated to be a simple and useful predictor of
final infarct size, left ventricular function, and clinical
outcomes after both thrombolytic and coronary
interventional approaches.4 Thrombolytic therapy for
acute myocardial infarction reduces fatality and
improves clinical outcomes. However, in 60% of
patients the treatment does not restore perfusion in the
myocardium at risk and such failure indicates a worse
prognosis.5
Reperfusion therapy in STEMI is the most
important component of treatment, as it strongly
influences short- and long-term patient outcome. The
main objective of healthcare providers should be to
achieve at least 75% of reperfusion therapy applied to
patients of STEMI in a timely manner, and preferably
150
within the first 3 hours after onset of symptoms.6 In the
past, reperfusion was commonly assessed in terms of
coronary blood flow, achievement of Thrombolytic
Induced Myocardial Infarction (TIMI)-3 flow being a
favourable sign.7
By contrast, ST-segment resolution 60–90
minutes after thrombolysis is an excellent marker of
successful myocardial reperfusion. The ischemic time,
door-to-balloon time and clinical risk are important
determinants of favourable outcome and a strong
predictor of survival and preservation of left ventricular
function.8 Longer delays from symptom onset to
hospital presentation were associated with reduced
likelihood of receiving primary reperfusion therapy, and
even among those treated, late presenters had
significantly longer door-to-balloon and door-to-drug
times.9
The aim of our study was to correlate the
incidence of complications with ST-segment resolution,
thereby reinforcing the role of ST-resolution as a marker
of improved clinical outcome in cases of STEMI.
MATERIAL AND METHODS
The duration of quasi experimental study was 3 years
from July 2006 to June 2009, conducted at Karachi
Institute of Heart Diseases.
Inclusion criterion was age 30–75 years,
admission to the coronary care unit with chest pain of
≤4 hour duration, and ECG evidence of transmural
ischemia (1–2 mm ST-segment elevation in ≥2 limb
leads and/or ≥2 mm ST-segment elevation in ≥2
precordial leads).
http://www.ayubmed.edu.pk/JAMC/PAST/22-1/Sultana.pdf
J Ayub Med Coll Abbottabad 2010;22(1)
Exclusion criteria were past Q-wave
myocardial infarction, severe cardiac failure, systolic
blood pressure <90 mm Hg, AMI within the
preceding 7 days, moderate to severe valvular heart
disease, known allergy to any of the protocol
medications, and contraindications to use of SK
(streptokinase administration within the previous 6
months, allergy to the drug, surgery or
cerebrovascular accident within previous 6 weeks,
warfarin therapy, active peptic ulcer disease, bleeding
disorders, uncontrolled hypertension).
The study population was divided into 3
groups at 60 minutes and 90 minutes after
administration of streptokinase.
1: Patients with complete (>70%) ST-segment resolution
2: Patients with partial (30–70%) ST-resolution, and
3: Patients with no ST-segment resolution.
The endpoint was a composite of recurrent
ischemic chest pain, Heart failure, arrhythmia or
death. ST elevation was recorded in millimetres from
the lead in which maximum elevation was observed.
Repeat ECG was performed after 60 and 90 minutes
of administration of Streptokinase. Follow-up was
conducted for each patient throughout his or her
hospital stay.
RESULTS
Total 1023 patients of STEMI treated with
streptokinase were enrolled in our study. Six hundred
and eighty-nine (67.3%) were males and 334 (32.6%)
were females. Six hundred and twenty-nine (61.5%)
were successfully resolved after thrombolytic therapy
while in 395 (38.5%) patients ST-segment could not
resolved.
Table-1 shows smoking/tobacco chewing
habits,
history
of
diabetes,
hypertension,
hypercholesterolemia, peripheral vascular diseases,
previous history of Unstable Angina (USA),
myocardial infarction and revascularisation. Among
the patients who reached early to hospital and
received streptokinase 587 (88.57%) showed
successful resolution of ST-segment, only in 76
(11.46%) thrombolysis failed because of reasons like
severe hypotension, bleeding from different sites,
anaphylactic
reactions
during
infusion
of
streptokinase, and not getting full dose of
thrombolytic therapy.
Anterior wall myocardial infarction was
seen in 690 (67.44%) patients, 429 (62%) had good
results while 261 (37.8%) failed to resolve ST
segment. Lateral wall MI was present in 178
(17.39%) patients. Among them 112 (63%)
successfully resolved ST-segment while 66 (37%)
failed to resolve. Inferior MI was evident in 145
(14%) of patients. Here 103 (71%) had good results
and 42 (29%) had failure to resolve. Ten (1%)
patients were with posterior MI, among them 8
(0.8%) had ST-segment resolution and 2 (0.2%)
failed to resolve ST-segment. Thirty-eight (3.7%)
patients developed pulmonary oedema, 18.42% had
successful thrombolysis and 21 (55.26%) could not
resolve ST-segment.
Table-2
stratifies
patients
into
3
conventional ST segment resolution categories at 60
minute and 90 minute after thrombolysis. Three
hundred and twelve (30%) and 444 (43.4%) patients
were with complete resolution, 344 (33.62%) and 325
(31.76%) were with partial resolution, and 367
(35.8%) and 491 (19.29%) were with no resolution
respectively. Frequency of stroke, shock, re-ischemia,
re-infarction, congestive heart failure and death were
more with persistent elevation of ST-segment as
compare to complete resolution.
Table-1:- Patients’ characteristics in relation to
ST-segment resolution (Success) and nonresolution (Failure)
Variables
Total patients given
Streptokinase
Male
Total
1023
689
(67.3%)
334
Female
(32.6%)
766
Smoker/tobacco chewer
(74.8%)
435
Diabetes
(42.5%)
640
Hypertension
(62.56%)
488
Hypercholesterolemia
(47.7%)
Peripheral vascular disease
15
(1.46%)
658
Previous angina
(64.3%)
440
Previous myocardial
(43%)
infarction
55
Previous revascularization
(5.37%)
663
Door to needle time within
(64.8%)
1-hour
690
Anterior infarct
(67.44%)
178
Lateral infract
(17.39%)
145
Inferior infarct
(14%)
10
Posterior infarct
(1%)
72
Heart rate (bpm)
(60–84)
Mean (Range)
Systolic blood pressure
132
(118–150)
Mean (Range)
38
Killip class >I
(3.7%)
897
Peak creatine kinase MB
(87.63%)
≥5 UNL
http://www.ayubmed.edu.pk/JAMC/PAST/22-1/Sultana.pdf
Success
629
(61.5%)
418
(60.66%)
211
(63%)
525
(83.4%)
298
(68.5%)
515
(80.46%)
390
(80%)
11
(73.3%)
550
(83.58%)
339
(77%)
32
(58%)
587
(88.53%)
429
(62%)
112
(63%)
103
(71%)
8
(0.8%)
73
(63– 85)
135
(120–150)
7
(1%)
722
(80%)
Failure
394
(38.5%)
271
(39.33%)
123
(36.8%)
241
(61%)
137
(31.49%)
125
(19.53%)
98
(20%)
4
(26.6%)
108
(16.4%)
101
(23%)
23
(41.8%)
76
(11.46%)
261
(37.8%)
66
(37%)
42
(29%)
2
(0.2%)
74
(64–86)
135
(120–150)
21
(5.3%)
175
(19.50%)
p
0.440
<0.001
<0.001
<0.001
<0.001
0.07
<0.001
<0.001
0.600
<0.001
0.510
0.660
0.010
0.220
<0.001
<0.001
151
J Ayub Med Coll Abbottabad 2010;22(1)
Table-2: Baseline characteristics and clinical
outcome after 6-weeks according to ST-segment
resolution category after 60 and 90 minute
Outcome
Patients with 60
min ST-resolution
Shock
Stroke
Re-Ischemia
Re-Infarction
Death
CCF
Patients with 90
min ST-resolution
Shock
Stroke
Re-Ischemia
Re-infarction
Death
CCF
ST- Resolution
Complete
Partial
None
(≥70%) (30 to <70%) (<30%)
312 (30%)
15 (4.8%)
3 (1%)
44 (14%)
13 (4.16)
5 (1.6%)
36 (11.53%)
344 (33.62%)
19 (5.5%)
5 (1.4%)
58 (16.8%)
33 (10.57%)
9 (2.6%)
65 (18.9%)
367 (35.8%)
27 (7.35%)
8 (2.17%)
63 (17%)
48 (15.38%)
12 (3.2%)
98 (26.7%)
p
0.340
0.430
0.500
0.003
0.380
<0.001
444 (43.4%)
39 (8.78%)
9 (2%)
48 (10.81%)
29 (6.53%)
12 (2.70%)
59 (13.28%)
325 (31.76%)
44 (13.53%)
11 (3%)
55 (16.9%)
32 (9.84%)
18 (5.53%)
65 (20%)
254 (24.8%)
49 (19.29)
15 (6%)
59 (23.2%)
46 (18%)
29 (11.41%)
72 (28.34%)
<0.001
0.020
<0.001
<0.001
<0.001
<0.001
Table-3 demonstrates Thrombolysis in
Myocardial Infarction (TIMI) flow grading after
angiography. Three hundred and twenty-six patients
presented with Left Anterior Descending Artery
(LAD) artery lesions among them 20 patients in
TIMI 0/1, 57 with TIMI 2 and 77 with TIMI 3 flow
in patients with resolving ST-segment, while 85, 54,
and 33 with TIMI I, II, and III flow respectively in
non-resolve ST-segment. Left Circumflex Artery
(LCX) lesions in 188 patients 15, 14, and 56 with
TIMI I, II, and III respectively, 50, 36 and 17 in nonresolving ST-segment. One hundred forty-eight
patients with Right Coronary Artery (RCA) stenosis
here 8, 26, 33 patients were showing TIMI I, II, and
III respectively while 25, 18, and 38 showing TIMI I,
II, and III respectively in persistent ST-elevation.
This indicates TIMI scoring improved with resolving
ST- segment. Our study proved as ejection fraction
also improved with resolving ST elevation.
Table-3: Baseline characteristics according to TIMI flow grade categories after angiography
Group/
Variable
Total
LAD
LCX
RCA
Others
Ejection Fraction
Total
678
326
188
148
16
TIMI 0/1
ST-Resolved
45
20 (6%)
15 (8%)
8 (5.4%)
2 (12.5%)
30–35%
TIMI 0/1
ST-Persisted
165
85 (26%)
50 (26.5%)
25 (17%)
5 (31%)
25–30%
DISCUSSION
This study comparatively assesses the predictive
accuracy of early (60 minute and 90 minutes) standard
12-lead ECG against post-infarction clinical endpoints
and later ECGs. Patients with AMI arrive at our hospital
relatively rapidly due to its central location and most of
the patients could utilise maximum benefit of
thrombolytic therapy because streptokinase (SK) was
provided by government free of cost. Several modes of
reperfusion therapy for evolving Myocardial Infarction
(MI) have been developed which differ in terms of
effectiveness, complexity and cost.10 Currently, the most
relevant treatment options are: SK (1.5 MU over 1
hour), reteplase (2 boluses of 10 MU), and alteplase
(tissue plasminogen activator, t-PA, 100 mg over 1.5
hour) and immediate angioplasty.11 Streptokinase is the
least costly treatment option while direct angioplasty is
expensive and complex.12 We used SK due to cost
effectiveness. Treatment of acute STEMI with
thrombolytic therapy showed greater mortality
reduction.13,14 Thrombolytic therapy with SK and other
agents reduces mortality and is now well accepted as the
mainstay of revascularisation options for most patients
after an acute myocardial infarction.15
Streptokinase is as efficacious as alteplase
(recombinant tissue plasminogen activator; Rt-PA),
anistreplase, reteplase and saruplase in reducing
mortality.16 Enoxaparin is superior to unfractionated
152
TIMI 2
ST-Resolved
99
57 (17.5%)
14 (7.44%)
26 (17.56%)
2 (12.5%)
35–40%
TIMI 2
ST-Persisted
132
54 (16.56%)
36 (19%)
38 (25.67%)
4 (25%)
35–40%
TIMI 3
ST-Resolved
168
77 (23.6%)
56 (29.8%)
33 (22.29%)
2 (12.5%)
>45%
TIMI 3
ST-Persisted
69
33 (10%)
17 (9%)
18 (12%)
1 (6.25%)
>45%
p
0.170
0.020
0.050
0.740
heparin, it also proved as fibrinolytic therapy with
combination of SK and the potent anticoagulant agent
resulted in similar adjusted outcomes compared with
more costly regimens utilising a fibrin-specific lytic.17
Thrombotic coronary artery occlusion is now recognised
as the usual cause of acute myocardial infarction.
Following coronary occlusion, myocardial necrosis
begins within 40 minutes in the subendocardium and
progresses outward toward the epicardium over the next
several hours. The intracoronary infusion of SK will
produce lysis of the occluding thrombus in up to 80% of
patients.18 The SK regimen (1.5 MU/60 minutes) has
remained unchanged for the past 20 years in patients
with STEMI due to fear of hypotension (a specific effect
of this thrombolytic agent) and of haemorrhagic
complications.19 Restoration of infarct vessel patency
has become one of the cornerstones of treatment for
acute ST-elevation (Q wave) myocardial infarction.20
Intravenous fibrinolytic agents are the most widely used
means for acute reestablishment of vessel patency, and
their use has become routine as large clinical trials have
shown their unequivocal benefit.21 Risk assessment
based on clinical information, exercise stress testing,
and an estimate of left ventricular function contribute
with prognostic information in thrombolysed MI
patients.22 We perform coronary angiogram and assess
TIMI flow as well as ejection fraction of left ventricle,
showed improvement of TIMI flow and ejection
http://www.ayubmed.edu.pk/JAMC/PAST/22-1/Sultana.pdf
J Ayub Med Coll Abbottabad 2010;22(1)
fraction in patients with resolve ST-segment after
thrombolytic therapy. Thrombolytic therapy with SK is
most effective if given within the first 1.5 hours after the
onset of symptoms of acute myocardial infarction.23
Determination of ST-segment resolution 60 minutes
after the administration of thrombolytic therapy allows
accurate risk stratification for mortality and congestive
heart failure.24 Although primary angioplasty should be
the preferred treatment strategy when inter-hospital
transfer can be completed within 2 hours.25 Our results
showed 2.7% mortality in complete resolution while
11.4% with no resolution of ST-segment.
CONCLUSIONS
9.
10.
11.
12.
13.
Thrombolytic therapy initiated within 1 hour of a patient
presenting to a hospital with AMI reduces the mortality
rates. Using simple measurements of ST-segment
elevation high and low risk groups of patients can be
identified as early as 60 and 90 minutes after initiating
thrombolysis after AMI. Patients with failure of STsegment resolution after thrombolytic therapy or who
re-infarct after early ST-segment resolution warrant
aggressive treatment.
14.
15.
16.
17.
ACKNOWLEDGEMENT
We wish to acknowledge Mr. Shah Amir Haq and
Syeda Saba for their valuable support for this study.
18.
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Address for Correspondence:
Dr. Riffat Sultana, Consultant Cardiologist, Karachi Institute of Heart Diseases, Block 16, FB Area, Karachi-75950,
Pakistan. Cell: +92-301-3332643
Email: [email protected]
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