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Research Article - Current Trends in Cardiology (2021) Volume 5, Issue 6

National Heart Institute registry for ST segment elevation myocardial infarction patients managed by primary PCI.

Ahmad M. Alkonaiesy*, Mohamed A. Elbordy, Abdel-Rahman G. Abdelaleem, Abdrabo A. Hassaan, Medhat M. Elsayed, Khaled M. El-Tohamy, Layla I. Shalaby, Osama M. Taha, Gamal M. Shaban

1Department of Cardiology, National Heart Institute, Cairo, Egypt

Corresponding Author:
Ahmad Mohammad Nooreldeen Alkonaiesy
Department of Cardiology,
National Heart Institute,
Cairo, Egypt
E-mail:
[email protected]

Accepted date: 16 September, 2021

Citation: Alkonaiesy AM, Elbordy MA, Abdelaleem ARG, et al. National Heart Institute registry for ST segment elevation myocardial infarction patients managed by primary PCI. Curr Trend Cardiol. 2021; 5(6):74-81.

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Abstract

Background: Little investigations addressed the results of STEMI patients managed by primary PCI in Egyptian population, especially in high volume tertiary cardiac hospital centers. The aim of the current study was to assess cardiovascular risk factors, angiographic and interventional characteristics, short term mortality and morbidity of STEMI patients undergoing PPCI presenting to our hospital.

Methods: We include all the patients admitted to our STEMI unite managed by primary PCI since November 2018 till 6 months afterwards (n=1354). We excluded patients presenting to ER with STEMI more than 48 hours, and patients with contraindication for primary PCI. We utilized angiographic characteristics, in-hospital mortality, and rates of procedural complications in all patients, being analyzed with appropriate statistical tests. Media of time to first medical contact in our ER and time to wire crossing of culprit artery were recorded and analyzed as well.

Results: Patients were young with a mean age of 54.45 and SD of 11.04, 97.5% were less than 75 years old while only 2.5% were more than 75 years old, 83.3% males and 16.7% females. The period elapsed from the onset of symptoms and the contact for medical help was longer for our patients: 120.0 (60.0; 240.0) minutes, and longer median time to wire crossing to culprit artery 95 (20.0; 170) minutes. The staff of ER was the first medical help (85% of patients). The admission mode was on the basis of individual presentation in 89% of patients. Anterior MI was found in 67.0% of cases presenting ECG. Reperfusion therapy was performed by PPCI to culprit artery in 90% of cases. In-hospital mortality was 3.9%.

Conclusion: Most of STEMI patients in our study were young males, current smokers, diabetics, showed higher prevalence of premature CAD, had significant time delays from the onset of symptoms to the contact for medical help, and more individual presenting rather than EMS presenting. Femoral access was the dominantly used access for PPCI. All stents used were drug eluting stents. Culprit only revascularization was the mainly used strategy, multi vessel disease staging intervention was done after hospital discharge. In-hospital mortality was comparable to other national registries.

Keywords

Acute coronary syndrome, Acute myocardial infarction, ST-Elevated Myocardial Infarction (STEMI), Primary percutaneous coronary intervention.

Introduction

Coronary Artery Disease (CAD) is currently one of the most common origins of death with increasing prevalence. European studies, however, demonstrated a general trend for a decreased CAD mortality in the last three decades [1]. Despite of the large variations between countries, CAD now is responsible for almost more than one million deaths/year (representing 20% of different types of deaths in Europe) [2].

The mortality of STEMI patients is affected by several factors like advanced age, Killip class at presentation, delayed treatment, the existence of well-structured STEMI dedicated networks of Emergency Medical System (EMS), strategy of management, MI history, renal insufficiency, diabetes mellitus, number of diseased coronaries, and Left Ventricular Ejection Fraction (LVEF) [3].

Many current investigations demonstrated decrements in the acute and long- term mortality in STEMI patients having more utilization of reperfusion therapy, primary Percutaneous Coronary Intervention (PCI), newer antithrombotics, as well as secondary preventive measures [4,5]. However, mortality is still concerning; the in- hospital mortality of STEMI patients in the national clinical registries of the ESC countries differed from 4 to 12% [6], and 10% for while the 1-year mortality among STEMI patients in angiography registries [7,8].

Primary Percutaneous Coronary Intervention (PPCI) is considered the best reperfusion strategy in STEMI patients within 12 h of the symptoms onset, provided it is carried out promptly (i.e., in less or equal to 120 min from STEMI diagnosis) by a competent team. A competent team contains not only interventional cardiologists but also proficient nurses, cardiovascular technician.

Studies demonstrated that the mortality rates were low among patients undergoing primary PCI in centers with a high volume of PCI procedures being performed [9]. Actual data proved that when primary PCI is carried out promptly and in high-volume centers, it leads to lower mortality [10]. Randomized clinical trials in high-volume, competent centers showed that if time delayed to treatment is comparable, primary PCI is superior to fibrinolysis in the reduction of Major Adverse Cardiac Events (MACE); namely, re-infarction, mortality, or stroke [11-14].

National Heart Institute (NHI) hospital center is the largest tertiary cardiovascular disease center in Egypt. About 3000 patients annually are admitted to NHI by myocardial infarction. Primary PCI is now the main reperfusion therapy for STEMI patients in NHI center.

This study aimed to explain the attributes of such patients, to assess STEMI management patterns with reference to the present usage of the reperfusion therapies, to evaluate the outcome of the in-hospital patients, and to compare Egyptian STEMI patients presenting to NHI center with other national Egyptian registries.

Methodology

STEMI unite observational registry approach

STEMI unite is a highly specialized coronary care unit in national heart institute center where only STEMI patients are admitted. We enrolled all patients presenting with unequivocal STEMI in their initial qualifying ECG since 20 October 2018 till 6 months afterwards. Patients were eligible for enrollment in the registry if they presented within 48 hours of symptom onset of STEMI defined as at least 1 chest pain episode lasting at least 20 minutes, demonstrated acute STEMI on their qualifying ECG with unequivocal changes (≥ 0.1 mV of ST-segment elevation in ≥ 2 adjacent limb leads or ≥ 0.2 mV in ≥ 2 contiguous precordial leads or new pathological Q waves) on surface electrocardiogram on admission, with no contraindication to primary PCI, and intended to be managed with primary PCI.

We excluded patients presenting to ER with STEMI more than 48 hours, patients with contraindication for primary PCI, and patients with concomitant valvular disease.

Data collection in the form of demographic characteristics including; age, sex, family history, cardiovascular risk factors, history of chronic illness, previous MI, onset of chest pain, duration before admission, and initial management of AMI.

Time from First Medical Contact (FMC) till wire crossing (reperfusion).

Findings of general and local examinations, ECG findings, angiographic characteristics and procedural complications were recorded [15-18].

Results

Baseline characteristics

This study included a total of (n=1354) patient, mean age of 54.45 and SD of 11.04, (n=1320) 97.5% were less than 75 years old while only (n=34) 2.5% were more than 75 years old, 83.3% males (n=1129) and 16.7% (n=225) females as illustrated in Figures 1 and 2 and Table 1.

Figure 1: Baseline characteristics.

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Figure 2: Major cardiovascular risk factors.

Demographic data All patients
N (%) 1354 (100%)
Age (years)  
Mean ± SD 54.45 ± 11.04
Range 14-87
Gender  
Male 1128 (83.3%)
Female 226 (16.7%)
Risk factors  
Smoking 705 (52.1%)
HTN 451 (33.3%)
DM 376 (27.8%)
Dyslipidemia 28 (2.1%)

Table 1. Demographic data.

STEMI patients with age less than or equal to 45 years old

296 patients were found, constituting 21.8% of all patients. The youngest presenting patient was 14 years old patient with a presentation of inferior wall myocardial infarction (STEMI) Killip class I and had primary PCI to an occluded PLV branch with adequate reperfusion and smooth in-hospital course. Further investigation and genetic testing revealed homozygous hereditary homocysteinaemia with significantly deficient methylene tetrahydrofolate reductase enzyme.

Further gender correlational analysis of cardiovascular risk factors revealed statistically significant findings; smoking is the most predominant risk factor in males (P-value<0.001), while diabetes and hypertension are in females (P-value<0.001 for each) as illustrated in Table 2. Dyslipidemia didn’t show gender correlation (P-value 0.209).

  Sex Test of sig.
Male female Value p value sig.
N % N %
Smoking No 438 38.80% 210 93.30% X2=223.62 <0.001 S
yes 691 61.20% 15 6.70%
HTN No 796 70.50% 107 47.60% X2=44.48 <0.001 S
yes 333 29.50% 118 52.40%
DM No 858 76.00% 120 53.30% X2=48.04 <0.001 S
yes 271 24.00% 105 46.70%
Dyslipidemia No 1108 98.10% 218 96.90% Fisher exact test 0.209 NS
Yes 21 1.90%   7 3.10%

Table 2. Demographic data.

Further age correlational analysis, revealed that male patients were younger than females (P-value<0.001), smoking patients are younger than non-smokers (P- value<0.001) as illustrated in Table 3.

 

Age

t-test

N

Mean

SD

T

p value

sig.

Sex

male

1129

53.41

10.97

-83.3

<0.001

S

female

225

59.58

9.91

Smoking

no

649

57.05

10.5

8.47

<0.001

S

yes

705

52.05

10.99

HTN

no

903

53.27

11.32

-5.63

<0.001

S

yes

451

56.84

10.03

DM

no

978

53.35

11.58

-5.99

<0.001

S

yes

376

57.35

8.85

Dyslipidemia

no

1326

54.5

11.03

1.12

0.264

NS

yes

28

52.14

11.56

Table 3. Demographic data.

As illustrated in Table 4 and Figure 3; mean heart rate was 80.27 ± 11.59, mean systolic blood pressure of 126.93 ± 19.52, and mean diastolic blood pressure of 81.21 ± 36.1. 907 cases (67%) presented with anterior ST elevation myocardial infarction (including 8 cases presented with global ST elevation) while 436 cases (32.2%) presented with Inferior ST segment elevation m

yocardial infarction (including 8 cases presented with global ST elevation). 18 cases (1.3%) presented with lateral ST segment elevation myocardial infarction. 1 case (0.1%) presented with posterior ST segment elevation.

Admission clinical and ECG data All patients
N (%) N=1354 (%)
HR (beat/min)  
Mean ± SD 80.27 ± 11.59
Range 45-140
SBP (mmHg)  
Mean ± SD 126.93 ± 19.52
Range 80-200
DBP (mmHg)  
Mean ± SD 81.21 ± 36.1
Range 50-100
STEMI ECG type  
Anterior 907 (67.0%)
Inferior 436 (32.2%)
Lateral 18 (1.3%)
Posterior 1 (0.1%)

Table 4. Admission clinical and ECG data.

Figure 3: STEMI ECG types.

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As illustrated in Table 5 correlational analysis of the type of myocardial infarction and cardiovascular risk factors didn’t reveal statistically significant correlations.

  MI Chi square test
Anterior Inferior Lateral
N % N % N % χ2

p value sig.
Smoking

No

426 64.90% 219 33.40% 11 1.70% 0.94 0.625 NS

Yes

481 68.20% 217 30.70% 7 1.00%
HTN

No

623 68.50% 275 30.20% 12 1.30% 4.47 0.107 NS

Yes

284 63.00% 161 35.70% 6 1.30%
DM

No

664 67.40% 309 31.40% 12 1.20% 2.65 0.266 NS

Yes

243 64.60% 127 33.80% 6 1.60%
Dyslipidemia

No

890 67.70% 425 31.90% 18 1.40% 1.08 0.583 NS

Yes

17 60.70% 11 39.30% 0 0.00%

Table 5. Correlation of location of MI and major CV risk factors.

Characteristics of interventional management

Procedural and in-hospital complications: The rates of procedural and in-hospital complications were; All-Cause Mortality 54 cases (3.9%), Dissection 20 cases (1.4%), Thrombus Propagation 15 cases (1.1%), Perforation 5 cases (0.3%), Tamponade 2 cases (0.1%), Failed PCI 23 cases (1.6%), and No Reflow 63 cases (4.6%).

Stented length: As illustrated in Table 6; mean length is 38.13 ± 17.29 and further analysis by correlation of stented length and conventional cardiovascular risk factors didn’t reveal statistically significant correlations as illustrated in Table 7.

Parameter All patients
N (%) 1354 (100%)
Time from FMC to Wire crossing (min.)  
Median (Range) 95 (20.0;170)
Time from Symptoms to FMC (min.)  
Median (Range) 120.0 (60.0;240.0)
Contrast Amount (ml)  
Mean ± SD 165.14 ±63.418
Median (Range) 150 (50 – 400)
Vascular access  
Radial 96 (7.1%)
Femoral 1256 (92.7%)
Revascularization strategy  
Primary PCI cases (total count) 1354 (100%)
Primary PCI to Culprit artery only 1218 (90%)
Total revascularization 33 (2.4%)
CABG 88 (6.5%)
Medical treatment 15 (1.1%)
Procedural complications  
All-Cause Mortality 54 (3.9%)
Dissection 20 (1.4%)
Thrombus Propagation 15 (1.1%)
Perforation 5 (0.3%)
Tamponade 2 (0.1%)
Failed PCI 23 (1.6%)
No Reflow 11 (0.8%)
Maneuvers and tools ( 1251 patients)  
Direct stenting / Total PCI 813 (65%)
Pre-dilatation / Total PCI 437 (34.9%)
Thrombectomy 1 (0.07%)
Angiographic characteristics  
LM 93 (6.9%)
LAD-D 1095 (80.9%)
LCx-OM 475 (35.1%)
RCA 628 (46.4%)
Final TIMI flow grade  
TIMI 0 20 (1.5%)
TIMI I 43 (3.2%)
TIMI II 82 (6.1%)
TIMI III 1209 (89.4%)
Stented length  
Mean ± SD 38.13 ± 17.29
Range 14- 114

Table 6. Baseline data of interventional management of the whole registry population.

  Length t test
N Mean SD t p- value sig.
Smoking

No

601 38.47 17.63 0.65 0.519 NS

Yes

650 37.81 16.98
HTN

No

838 37.72 17.15 -1.12 0.264 NS

Yes

413 38.91 17.55
DM

No

904 37.57 17.16 -1.76 0.078 NS

Yes

347 39.57 17.55
Dyslipidemia

No

1225 38.07 17.22 -0.88 0.379 NS

Yes

26 41.5 20.8

Table 7. Correlation of stented length and major CV risk factors.

Median time to FMC and median time to wire crossing: In this study the median time in minutes from symptoms onset to first medical contact in registered cases was 120.0 (60.0; 240.0). ER staff was the first medical contact (85% of patients), self and individual presentation was the mode of admission in 89% of patients. In our hospital the median time in minutes from first medical contact to wire crossing is 95 (20.0; 170).

Procedural aspects

Vascular access: Regarding vascular access in primary PCI management of cases, femoral access was utilized in 1256 cases (92.7%), while radial access was in 96 cases 7.1%. as illustrated in Table 6.

Contrast utilization: A mean of 165.14 ml and SD of 63.418 of contrast used in PPCI

Revascularization strategy: Primary PCI of the culprit Infarct Related Artery (IRA) only strategy was the mainly utilized strategy being used in 90% of cases (1218 cases) while total revascularization was done in 2.4% of cases (33 of cases), CABG was done in 6.5% of cases, and medical management only was used in 1.1% (15 cases) as illustrated in Table 6 and Figures 4a and 4b.

Figure 4a: Revascularization strategy.

Figure 4b: Procedural and in-hospital complications.

Angiographic results

Angiographic results from this registry (single center data) showed a LM disease in 93 cases (6.9%), LAD-D disease in 1095 (80.9% cases), LCx-OM disease in 475 (35.1%), RCA in 628 (46.4%). From numeric prospective non-obstructive CAD was found in 7 cases (0.5%), single vessel CAD was found in 671 (49.6%), two vessel CAD was found in 443 (32.7%), three vessel CAD in 233 (17.2%), multi- vessel CAD in 676 cases (49.18%) (Figure 5).

Figure 5: Diagnostic angiographic characteristics.

equation

Final TIMI Flow Grade (TFG)

A thrombolysis in myocardial infarction flow (TIMI Flow) Grade III was achieved in 1204 cases (89.4%) identified as flow that implies a comparable flow rate of an infarct-related artery to a non- culprit artery, TIMI II in 80 cases (5.9%) identified as partial perfusion, TIMI I in 43 cases (3.2%) minimal perfusion, TIMI 0 in 20 cases (1.5%) identified as flow that signifies occlusion. Assessing No-reflow Phenomenon (NRP) after reperfusion in STEMI patients is mandatory in clinical practice. However, standardized no-reflow estimations by angiography are limited.

No-reflow is a dynamic phenomenon, and angiography can only demonstrate no-reflow early in its course in patients subjected to PPCI. General consensuses of the experts suggest assessing (NRP) at angiography with 2 major essential components; a TIMI flow grade of 0 and 1 and patent epicardial coronary artery. Moreover, coronary angiography cannot assess the microcirculation. Being at the initial point of angiography, it may not relate to Cardiac Magnetic Resonance (CMR) imaging, the ongoing gold standard for assessing Micro Vascular Obstruction (MVO). In the literature predominance of angiographic no-reflow in patients was assessed to be about 2.3% 18. In this study the no-reflow phenomenon was found in 63 cases (4.6%) (Figure 6).

Figure 6: Final TIMI flow grade.

Maneuvers and tools

In our registry, PCI was done to 1251 patients. Pre-dilation was used in 438 cases (35%) while direct stenting was used in 813 cases (65%). Thrombectomy catheter was used in 1 case only (0.0007%) (Figure 7).

Figure 7: Maneuvers and tools.

equation

Discussion

It is well known according to data from Egyptian Society of cardiology (EgSc) and European Society Of Cardiology (ESC) that intended reperfusion treatment for STEMI in Egypt vs. different countries was primary PCI in 50.59% vs. 85.50%, thrombolysis in 43.14% vs. 5.55%, and no reperfusion in 6.05% vs. 4.72%. Taking into consideration that Egyptian contribution in this analysis was achieved through participation with 1356 patient from 19 Egyptian centers (multicenter data) [1].

As national heart institute is one of the largest cardiac centers in Egypt, our aim was to apply such type of reperfusion modality in Egyptian STEMI patients presenting to our center.

In our registry, mean patients’ age was 54.45 ± 11.04. Our patients were younger than EU countries (62.9 ± 12.4). Only 2.5% were more than 75 years, compared to 19.41% in EU countries.17 Patients with age less than 45 years represent 21.8%.

In our study we have fewer females (18.44%) as compared to female patients in EU countries (25.63%1), this may be due to youthfulness of the Egyptian population, poor control of risk factors, as well as non-adherence to medical treatment. Smoking is the most predominant risk factor (52.1%). Hypertensive patients represent 33.3% of our patients, while diabetic patients were only 27.8%.

The high incidence of smoking in Egypt was also detected by other studies such as that done by Shaheen et al. in which smoker represent 59.05% of the Egyptian patients, while hypertensive and diabetic patients represent 37.23% and 40.79% respectively. On the contrary, in EU countries hypertensive patients represent the majority (52.65%), and incidence of smoking (42.81%) was less than our registry 17. This raises the importance of increasing awareness of smoking cessation benefits.

Median time to FMC and median time to wire crossing

In the current study, the median time (min.) from symptoms onset to first medical contact in registered cases was 120.0 vs. 100 minutes in EU countries. The long time in may be due defect in the medical awareness of patients, reluctance in seeking medical attention and lack of well-organized referring emergency medical system with sufficient infrastructural support.

In this study the median time in minutes from symptoms onset to first medical contact in registered cases was 120.0 vs. 100 minutes in EU countries. The long time in may be due defect in the medical awareness of patients, reluctance in seeking medical attention and lack of well-organized referring emergency medical system with sufficient infrastructural support. In this study the median time in minutes from first medical contact to wire crossing is 95 minutes. In the guidelines, the ideal time should be less than 60 minutes [3]. Time delays may be related to logistics, the availability of 24 hour/7 day a week catheterization laboratory, availability of supplies.

On the controversy of that ESC guidelines recommendation that prefer radial access in primary PCI, our operators used femoral access in the majority of patients. This may be explained by defect in the supplies.

Culprit artery PCI only was done in the majority of the patients compared to total revascularization (90% vs. 2.4%). The latter technique was used by fewer operators in the presence of simple lesions in other arteries. Other patients who required PCI to other arteries were done after hospital discharge, and not before discharge as mentioned in the guidelines.

A TIMI Flow Grade III was accomplished in 1204 cases (89.4%). In another Egyptian study, TIMI flow grade III was completed in 80% of the patients with PCI within 3-10 hours after thrombolytic therapy. This may be due to earlier time of PCI. Mortality rate in this study was 3.9%. In another Egyptian multi-center study, where overall mortality rate in multiple hospital centers was 2.1% in patients with 1 ry PCI. The mortality rate of the Egyptian primary PCI patients is suggestive of better outcome compared to another study in which the in- hospital mortality rate among STEMI patients treated with primary PCI was 6.5% 17, while the rate of procedural complications was 5.3%.

Limitation of the study

Despite we try to restrict to the guidelines in our registry, the availability of the supplies may affect our decision in PCI. Absence of long term follow up is another limitation of our study.

Conclusion

Our single center experience suggests that STEMI patients in Egyptian population are likely to be younger, more current male smokers, diabetics, had higher prevalence of premature CAD, had significant time delays between symptoms onset to first medical contact, and more individual presenting rather than EMS presenting. Femoral access was the dominantly used access for PPCI. All stents used were drug eluting stents. Culprit only revascularization was the mainly used strategy, multi vessel disease staging intervention was done after hospital discharge. In-hospital mortality was comparable to other national registries.

Acknowledgment

All the authors contributed equally to this manuscript.

References

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