VIMS Journal: December 2015

Original Article

A Study on Patient with ST Elevation Myocardial Infarction and Use of Thrombolytics in Ramakrishna Mission Seva Pratishthan

Dr. J. Nawaz , Dr. J. Chakraborty , Dr. P. Mukherjee

Abstract :
Introduction :
STEMI is an medical emergency caused by acute occlusion of coronary arteries. Mortality is directly related to total ischemia time. Treatment include rapid recognition, diagnosis and prompt reperfusion therapy by different thrombolytic agents (Streptokinase, Tenecteplase / Reteplase). Cost effectiveness is to be concerned.

Aims:
To note the prevalence of STEMI among the patients admitted with chest pain in ICU of RKMSP and effects of of different thrombolytic drugs.

Methods:
The study group in this Retrospective observationl study included patients admitted with chest pain in our ICU during the period june 2013 to june 2015 out of which data of STEMI patients who were thrombolysed were retrieved from medical record section and collected data was analysed.

Results:
245 patients admitted with chest pain in ICU of RKMSP during the period of June 2013 to June 2015 out of which 76.73% (188/245) patients had ACS. Among 188 ACS patients 43.61% (82/188) patients had STEMI. Out of 82 STEMI patients 67 patients were eligible for thrombolysis and thrombolysed with different thrombolytic agents as per affordability of the patient party not of the discretion of the physician. Out of 67 thrombolysed patients 91.04% (61/67) were male, 8.95% (6/67) were female, 47.76% (32/67) patients came during night time (8pm-8am), 25.37% (17/67) patients came during morning time (8am-2pm), 26.86% (18/67) patients came during evening time (2pm-8pm), 29 patients had been thrombolysed with tenecteplase out of which successful thrombolysis was 82.75% (24/29) failure was 17.25% (5/29), cerebral bleeding was 6.89% (2/29), noncerebral bleeding was 3.44% (1/29), 12 patients had been thrombolysed with reteplase out of which successful thrombolysis was 91.66% (11/12), failure was 8.33% (1/12), cerebral bleeding was 0% (0/12), noncerebral bleeding was 8.33% (1/12), 26 patients had been thrombolysed with streptokinase out of which successful thrombolysis was 80.76% (21/26), failure was 19.23% (5/26), cerebral bleeding was 0% (0/26), noncerebral bleeding was 3.84% (1/26).

Conclusion:
Prevalence of STEMI patients was 43.61% among ACS patients. Success rate of thrombolysis is highest with Reteplase (91.66%). Success rate of with Streptokinase was comparable with Tenecteplase (80.76% Vs 82.75%) with much less bleeding complication.

Keywords: STEMI, Thrombolysis, Reperfusion.

Introduction:
ST elevation myocardial infarction (STEMI) is an medical emergency caused by acute total occlusion of an epicrdial coronary artery. Mortality is directly related to total ischemia time. So keys to treatment of STEMI include rapid recognition and diagnosis, coordinated mobilization of health care resources and prompt repurfusion therapy. Repurfusion can be done by different thrombolytic agents like lower cost Streptokinase, much higher cost Tenecteplase/ Reteplase. For a resource limited set up it is necessary to know the distribution of time of admission of STEMI patients and cost effective thrombolytic agent.

Aims:
This study was done to note the prevalence of ST elevation MI (STEMI) among the patients admitted with chest pain and distribution of time of admission of STEMI patients in our ICU in last two years. We want to study the use of different thrombolytic drugs, their success rate, failure rate and complication rate.

Methods:
In this Retrospective observationl study, patients admitted with chest pain in our ICU during the period of June 2013 to June 2015 written in admission register book were taken as study group, out of which data of STEMI patients who were thrombolysed with different thrombolytic agents were retrieved from medical record section and collected data was analysed.

ECG Criteria for STEMI :
New ST elevation at J-point > 0.1mV in two contiguous leads other than leads V2-V3, where the cut points are
- = 0.2mV for men above 40 years
- = 0.25mV for men below 40 years
- = 0.15mV for women
Thrombolysis was done with those STEMI patients who came within 12 hrs of ischemic symptoms by different thrombolytic agents as per affordability of the patient party not of the discretion of the treating physicians.

ECG criteria for successful thrombolysis :
Resolution of ST segment elevation > 70% within 90 min after thrombolysis was considered as successful thrombolysis in this study.

Results:
Total no of patients admitted with chest pain in our ICU during the period of June 2013 to June 2015 were 245, out of which 76.73% (188/245) patients had acute coronary syndrome (ACS). Among 188 ACS patients 23.40% (44/188) patients had unstable angina (UA), 32.97% (62/188) patients had non ST elevation MI (NSTEMI) and 43.61% (82/188) patients had ST elevation MI (STEMI). Out of 82 STEMI patients 67 patients were eligible for thrombolysis. They were thrombolysed with different thrombolytic agents as per affordability of the patient party not of the discretion of the physician. Out of 67 thrombolysed patients 91.04% (61/67) were male, 8.95% (6/67) were female, 47.76% (32/67) patients came during night shift (8pm-8am), 25.37% (17/67) patients came during morning shift (8am-2pm), 26.86% (18/67) patients came during evening shift (2pm-8pm), 29 patients had been thrombolysed with tenecteplase out of which successful thrombolysis was 82.75% (24/29) failure was 17.25% (5/29), cerebral bleeding was 6.89% (2/29), noncerebral bleeding was 3.44% (1/29), 12 patients had been thrombolysed with reteplase out of which successful thrombolysis was 91.66% (11/12), failure was 8.33% (1/12), cerebral bleeding was 0% (0/12), noncerebral bleeding was 8.33% (1/12), 26 patients had been thrombolysed with streptokinase out of which successful thrombolysis was 80.76% (21/26), failure was 19.23% (5/26), cerebral bleeding was 0% (0/26), noncerebral bleeding was 3.84% (1/26).

Distribution of patients according to types of chest pain N =245 Distribution of patients according to types of Acute Coronary Syndrome (ACS)
Distribution of time of admission of thrombolysed STEMI patients

Distribution of thrombolysed STEMI patients according to sex


Comparison of different thrombolytic agents in respect to success rate, failure rate, cerebral hemorrhage, non-cerebral hemorrhage

Discussion:
Prevalence of STEMI patients was 43.61% among ACS patients. Success rate of thrombolysis is highest with Reteplase and it was 91.66%. Success rate of thrombolysis with Streptokinase was comparable with that of Tenecteplase (80.76% Vs 82.75%) with much less bleeding complications. Cerebral hemarrhage was highest with Tenecteplase which was 6.89%. Among the thrombolysed STEMI patients prevalence of male was much higher than that of female (91.04% Vs 8.95%), most of the STEMI patients came during night time (47.76%). Initial trials of streptokinase performed in1980s showed a pronounced mortality benefit[1,2]. The GUSTO-1 trial showed a slight mortality benefit (14%) with Alteplase infused over 90 minutes compared with streptokinase at the cost of two extra strokes per 1000 patients randomized[3]. In subsequent studies showed Reteplase and Tenecteplase were equivalent to accelerated Alteplase[4]. One study had been conducted in south India by RANAKISHORE PELLURI and others and they showed in terms of efficacy the Reteplase (93.33%) was good as compared to Streptokinase (86.77%) & Tenecteplase (80.00%), the p-value was < 0.001[5].

References
  1. GISSI. Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet. 1986:397-402.

  2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction. Lancet. 1988 Aug 13;2 (8607):349-60.

  3. The GUSTO Investigators. An International Randomized Trial Comparing Four Thrombolytic Strategies for Acute Myocardial Infarction, N Engl J Med 1993; 329:673-682.

  4. The GUSTO III Investigators. A Comparison of Reteplase with Alteplase for Acute Myocardial Infarction, N Engl J Med 1997; 337:1118-1123.

  5. Ranakishore Pelluri et al. Safety and efficacy of streptokinase, reteplase and tenecteplase in patients with acute ST elevated myocardial infarction in an intensive cardiac care unit of a tertiary care teaching hospital, Int J Pharm Bio Sci 2014 Oct; 5(4): (P) 29 - International Journal of Pharma and Bio Sciences ISSN 0975-6299.

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