الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
 |  | from | 154 |  |  |
| | | from | 154 | | |
Abstract
Background: Contemporary guidelines for patients with acute ST-segment elevation myocardial infarction (STEMI) recommend primary percutaneous coronary intervention (PCI) as the preferred reperfusion strategy, this approach is contingent on performing PCI in a timely fashion. Since most patients do not present to a PCI-capable hospital, this factor presents a major logistic challenge in many regions. Aim of the study: To compare the strategy of early fibrinolysis followed by coronary angiography within 6-24 hours or rescue PCI if needed with standard primary PCI in STEMI patients with at least 2 mm ST-elevation in 2 contiguous leads presenting within 3 hours of symptom onset and unable to undergo primary PCI within 1 hour.
Patients and Methods:
This study included 100 patients presented to the ER of the National Heart Institute with STEMI < 3hours from onset symptoms.
Inclusion criteria: Age ≥18 y, Onset of symptoms <3 h before randomization, 12-Lead ECG indicative of an acute STEMI.
Patients were classified into two groups according to the availability of primary PCI:
group A: Fifty Patients presented with a ST-elevation myocardial infarction within 3 hours of symptom onset. Patients were selected to fibrinolysis with Striptokinase combined with clopidogrel, aspirin, and followed by timely cardiac catheterization within 6 to 24 hours, or rescue coronary intervention if reperfusion fails within 90 minutes of fibrinolysis
group B: Fifty Patients were selected to have standard primary PCI Exclusion criteria: Hospitalization for cardiac reason within past 48 h, Recent administration of any IV or SC anticoagulation within 12 h, including unfractionated heparin, enoxaparin, and/or bivalirudin or current use of oral anticoagulation, Active bleeding or known bleeding disorder/diathesis or the clinical diagnosis known to be associated with increased bleeding risk, Any history of central nervous system damage or recent trauma to the head or cranium (ie, <3 m), Known acute and/or subacute bacterial endocarditis, Severe hepatic dysfunction, including hepatic failure, cirrhosis, portal hypertension (esophageal varices), and active hepatitis, Long-term dialysis or known renal insufficiency, Arterial aneurysm and known arterial/venous malformation, Known hypersensitivity to any of the drug regimen prescribed
Follow Up: In-hospital outcomes was reviewed and reported. Clinical follow-up was done at 30 days.
Data Collection
Clinical characteristics and procedural information, including angiographic data and complications, were recorded during the in-hospital period and at follow-up on standardized forms and were entered into a computerized database as a Microsoft Excel spreadsheet.
Statistical Analysis
Descriptive statistics were done including mean, standard deviation and incidence. Comparison between the two groups was done using chi-square test and paired student’s t-test. P < 0.05 was considered significant
Results:
There was no significant difference between the 2 groups regarding the number of diseased vessels, the infarct related artery, complex C lesion, calcific lesion, bifurcation lesion, reference vessel diameter and lesion length (P > 0.05 There was no significant difference between the 2 groups regarding the duration from symptom onset till ED arrival, the duration from symptom onset till fibrinolysis was 115 ± 18.7 minutes for group A and duration from symptom onset till PCI was 126 ± 20.5 minutes and the difference was significant (P < 0.05). The duration from symptom onset till PCI was 16.7 ± 5.3 hours for group A and it was 2.6 ± 0.3 hours for group B and the difference was significant (P < 0.001). The door to balloon time was significantly higher in group A (15.4 ± 4.9 hours) than that of group B (1.5 ± 0.4 hours) (P < 0.001)
There was no significant difference between the 2 groups regarding all death, and cardiac death (P > 0.05). The incidence of minimal bleeding and severe bleeding were 22% for group A versus 8% for that in group P and the difference between the 2 groups was significant (P < 0.001). The overall complication rate was in 32 patients (64%) in group A vs 23 patients (46%) in group B. The difference between the 2 groups was significant (P < 0.001).
On a univariate analysis of the different factors studied and the predictors of cardiac death Diabetes Mellitus was associated with high risk of cardiac death. Also the use of bare metal stent was a significant predictor of cardiac death. The duration of MI and post-procedure TIMI flow were not found to be a significant predictor of cardiac death.
Analysis of the different factors studied and the predictors of the occurrence of Major cardiovascular events were 10 years age increment, Diabetes Mellitus. Left ventricular Ejection Fraction < 40% and Bare metal stent utilization were associated with high risk of MACE. Reference vessel diameter, lesion length (1 mm increase) and more than one lesion treated were not found to be a significant predictor of MACE.