Two-year follow-up data from the STEPP-AMI study: A prospective, observational, multicenter study comparing tenecteplase-facilitated PCI versus primary PCI in Indian patients with STEMI

STEMI India: reimagining STEMI networks in low- and middle-income countries: Reimagining STEMI

Effective treatment for ST-elevation myocardial infarction (STEMI) includes the 24/7 availability of reperfusion therapy, which is crucial for good clinical outcomes. In low- and middle-income countries, this is hindered by disparities in resource utilisation, irregularities in access to health care and organisational gaps. Due to the inaccessibility of primary percutaneous coronary intervention (PCI) for most patients, the more feasible and practical approach of pharmacoinvasive management must be incorporated into the systems of care for STEMI. This review focuses on the development of STEMI India, a not-for-profit organisation that aims to advance the field of STEMI management by imparting and disseminating the latest information from around the world on STEMI management to all those involved in STEMI care. The STEMI India model system of care includes a 3-model framework, based on infrastructure and workforce availability, and tailored to meet the needs of the society it caters to. After the successful implementation of the "Tamil Nadu STEMI" project, a nationwide system of care for STEMI has been developed, which has been endorsed by the Cardiological Society of India (CSI) and the Association of Physicians of India (API).

The comparison of procedural and clinical outcomes of thrombolytic-facilitated and primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction (STEMI): Findings from PROVE/ACS study

BACKGROUND

There is still a controversy in the preferred method of reperfusion in acute ST-segment elevation myocardial infarction (STEMI), when the achievement of well-defined "golden time" is difficult. We sought to evaluate the procedural and in-hospital outcomes of the strategy of "thrombolytic administration and rescue or routine percutaneous coronary intervention (PCI)" versus "primary PCI (PPCI)" strategy in acute STEMI.

METHODS

In this observational prospective study, the data of 237 patients with acute STEMI presented or referred to Chamran Cardiovascular Research Center in Isfahan, Iran, were collected (PROVE/ACS study). Baseline characteristics, thrombolysis in myocardial infarction (TIMI) flow grade of infarct-related artery (IRA), left ventricular ejection fraction (LVEF), and in-hospital outcomes were evaluated.

RESULTS

The mean age of patients was 61.4 ± 13.0 years, 86.9% were men, 13.1% were diabetic, and 67.9% had anterior STEMI. Patients in the "thrombolytic then PCI" group were younger, more smoker, more often male with higher body weight and lower systolic blood pressure (SBP). The pre-PCI TIMI flow grade 3 was more often seen in the "thrombolytic then PCI" group (39.4% vs. 21.0%, P < 0.001) and less thrombectomy was performed in this group of patients (12.9% vs. 26.7%, P = 0.011). Time to reperfusion was significantly longer in PPCI group (182.4 ± 233.7 minutes vs. 44.6 ± 93.4 minutes, respectively, P < 0.001). No difference in mortality, mean of LVEF, and incidence of atrial fibrillation (AF) was observed in two groups.

CONCLUSION

If the PPCI strategy could not be performed in the golden time, the strategy of thrombolytic administration and rescue or routine PCI leads to more initial IRA patency and less thrombectomy with similar clinical outcomes.

Presentation, management, and outcomes of STEMI in Egypt: results from the European Society of Cardiology Registry on ST elevation myocardial infarction

Background

Apart from few small single-center studies, there are limited data about STEMI patients in Egypt. Nineteen Egyptian centers (with and without PCI facilities) participated in this registry with 1356 patients who were compared to 7420 patients from other ESC countries. The aims of this study were to describe the characteristics of patients with STEMI, to assess STEMI management patterns particularly the current use of reperfusion therapies, to evaluate the organization of STEMI networks across Egypt, to evaluate in-hospital patient outcome, and to compare Egyptian patients with other ESC countries.

Results

Compared to other ESC countries, Egyptian patients were younger (mean age 55.4 ± 11.3 vs. 62.9 ± 12.4; p < 0.001 and 4.36% vs. 19.41%% were ≥ 75 years old; p < 0.001) with fewer females (18.44% vs. 25.63%; p < 0.001). Egypt had longer median time between symptoms onset and first medical contact: 120.0 (60.0; 240.0) vs.100.0 (50.0; 240.0) p < 0.001. Self-presentation rather than EMS presentation was the mode of admission in 86.06% in Egypt vs. 25.83% in EU countries (p < 0.001). On qualifying ECG, anterior STEMI was in 57.08% in Egypt vs. 45.98% in other countries (p < 0.001). Initial reperfusion therapy was 49.12%, 43.07%, and 7.26% for primary PCI, thrombolytic therapy and no reperfusion in Egypt vs. 85.42%, 7.26%, and 7.82% for EU countries, respectively. In-hospital mortality was 4.65% in Egypt vs. 3.50% in other countries p 0.040 and was 18.87% in no reperfusion vs. 2.10% in primary PCI vs. 4.97% in thrombolysis (p < 0.001) among Egyptians. Patients were discharged on aspirin in 98.61%, clopidogrel in 91.07%, ticagrelor in 7.31%, DAPT in 97.69%, beta blockers in 82.83%, ACE inhibitors in 84.76%, MRAs in 10.01%, and statins in 99.77%.

Conclusion

Compared to other ESC countries, Egyptian STEMI patients were younger, more frequently current smokers and diabetics, and had longer time between symptoms onset and first medical contact with more self-presentation rather than EMS presentation. Thrombolytic therapy is still a common reperfusion therapy in Egypt while primary PCI was offered to half of the patients. In-hospital mortality was significantly higher in Egypt and was highest among no reperfusion patients and lowest among PPCI patients.

Comparative Effectiveness of Reperfusion Strategies in Patients with ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) Trial

Introduction

Substantial heterogeneity exists in reperfusion strategies for patients with ST-segment myocardial infarction (STEMI) in low- and middle-income countries (LMICs). We sought to compare outcomes associated with primary percutaneous coronary intervention (PPCI) and non-primary percutaneous coronary intervention (nPPCI) reperfusion strategies in patients with STEMI in Kerala, India.

Methods

We performed a retrospective analysis of patients with STEMI (n = 8665) from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) randomized trial receiving either PPCI (n = 6623) or nPPCI (n = 2042). nPPCI included all PCI strategies implemented when PPCI was not available including all post-fibrinolysis PCI strategies and PCI without fibrinolysis. Clinical outcomes among patients undergoing PPCI and nPPCI were compared after propensity-score matching. The main outcomes were the rates of in-hospital and 30-day major adverse cardiovascular events (MACE), defined as the composite of death, reinfarction, stroke, and major bleeding.

Results

In the propensity-score matched cohort (n = 1266 in each group), nPPCI had longer symptom onset to hospital arrival time (347.5 vs. 195.0 minutes, p < 0.001), door to balloon time (108 minutes vs. 75 minutes, p < 0.001), and were less likely to receive a coronary stent (89.4% vs. 95%, p < 0.001), including drug-eluting stents (89.5% vs. 94.4%, p < 0.001). There were no clinically meaningful differences in discharge medical therapy. However, patients treated with nPPCI were less commonly referred for cardiac rehabilitation (20.2% vs. 24.2%; p = 0.019). In-hospital (3.6% vs. 3.3%, p = 0.74%) and 30-day (4.4% vs. 4.6%, p = 0.77) MACE did not differ between nPPCI and PPCI matched groups.

Conclusion

In a large, contemporary population of STEMI patients from a LMIC, patients treated with a nPPCI reperfusion strategy had comparable short- and intermediate-term outcomes compared to PPCI despite differences in hospital presentation time and coronary stent use. These findings are reassuring but highlight the need for continued quality improvement in the delivery of STEMI care in resource-limited settings.

Acute care for the three leading causes of mortality in lower-middle-income countries: A systematic review

According to the World Health Organization, the three leading causes of mortality in lower-middle-income countries (LMIC) are ischemic heart disease (IHD), stroke, and lower respiratory infections (LRIs), causing 111.8, 68.8, and 51.5 annual deaths per 100,000, respectively. Due to barriers to healthcare, patients frequently present in critical stages of these diseases. Measured implementations in critical care in LMIC have been published; however, the literature has not been formally reviewed. We performed a systematic review of the literature indexed in PubMed as of October 2017. Abstracts were limited to human studies in English, French, and Spanish, conducted in LMIC, and containing quantitative data on acute care of IHD, stroke, and LRI. The search resulted in 4994 unique abstracts. Through multiple rounds of screening using criteria determined a priori, 161 manuscripts were identified: 38 for IHD, 20 for stroke, 26 for adult LRI, and 78 for pediatric LRI. These studies, predominantly from Asia, demonstrate successful diagnostic and treatment measures used in providing acute care for patients in LMIC. Given that, only four manuscripts originated in Central or South America, original research from these areas is lacking. IHD, stroke, and LRIs are significant causes of mortality, especially in LMIC. Diagnostic and therapeutic interventions for IHD (monitoring, medications, thrombolytics, percutaneous intervention, coronary artery bypass graft), stroke (therapeutic hypothermia, medications, and thrombolytics), and LRI (oxygen saturation measurement, diagnostic ultrasound, administration of oxygen, appropriate antibiotics, and other medications) have been studied in LMIC and published.

Left ventricular global longitudinal strain following revascularization in acute ST elevation myocardial infarction - A comparison of primary angioplasty and Streptokinase-based pharmacoinvasive strategy

Objective

Tenecteplase-based pharmacoinvasive percutaneous coronary intervention (PCI) has been shown to yield outcomes comparable to primary PCI in the setting of acute ST elevation myocardial infarction (STEMI). This study was designed to compare the efficacy of pharmacoinvasive PCI following successful thrombolysis with Streptokinase versus primary PCI in patients with STEMI.

Methodology

We conducted a prospective single center observational study in 120 patients with STEMI who underwent primary PCI (n = 60) and Streptokinase-based pharmacoinvasive PCI (n = 60). Patients with Killips class 3 or 4 at presentation, and those with evidence of failed fibrinolysis were excluded. The primary outcome was LV systolic function after angioplasty, as assessed by 2D global longitudinal strain (GLS) using speckle tracking echocardiography (STE), as well as 2D LVEF using Simpson's biplane method.

Results

LV systolic function after PCI was significantly lower in the pharmacoinvasive arm as compared to the primary PCI arm, both by 2D STE (GLS: −9% vs −11%; p = 0.03) and 2D Simpson's biplane method (LVEF: 40.7% vs 45.1%; p = 0.02). TIMI flow in the culprit vessel prior to angioplasty was better in the pharmacoinvasive arm indicating successful thrombolysis, whereas post angioplasty flow was not different. There was no in-hospital mortality in either group. There was a trend toward increased incidence of acute kidney injury in the pharmacoinvasive arm.

Conclusion

LV systolic function is significantly better after primary angioplasty as compared to pharmacoinvasive PCI following successful thrombolysis with Streptokinase.

The impact of systems-of-care on pharmacoinvasive management with streptokinase: The subgroup analysis of the TN-STEMI programme

Objectives

We evaluated the impact of implementation of the TN-STEMI programme on various characteristics of the pharmacoinvasive group by comparing clinical as well as angiographic outcomes between the pre- and post-implementation groups.

Methods

The TN-STEMI programme involved 2420 patients of which 423 patients had undergone a pharmacoinvasive strategy of reperfusion. Of these, 407 patients had a comprehensive blinded core-lab evaluation of their angiograms post-lysis and clinical evaluation of various parameters including time-delays and adverse cardio- and cerebro-vascular events at 1 year. Streptokinase was used as the thrombolytic agent in 94.6% of the patients.

Results

In the post-implementation phase, there was a significant improvement in ‘First medical contact (FMC)-to-ECG’ (11 vs. 5 min, p < 0.001) and ‘Lysis-to-angiogram’ (98.3 vs. 18.2 h, p < 0.001) times. There was also a significant improvement in the number of coronary angiograms performed within 24 h (20.7% vs. 69.3%, p < 0.001). The ‘Time-to-FMC’ (160 vs. 135 min, p = 0.07) and ‘Total ischemic time’ (210 vs. 176 min, p = 0.22) also showed a decreasing trend. IRA patency rate (70.2% vs. 86%, p < 0.001) and thrombus burden (TIMI grade 0: 49.1% vs. 73.4%, p < 0.001) were superior in this group. The MACCE rates were similar except for fewer readmissions (29.8% vs. 12.6%, p = 0.0002) and target revascularizations at 1 year (4.8% vs. none, p = 0.002) in the post-implementation group.

Conclusion

The implementation of a system-of-care (hub-and-spoke model) in the pharmacoinvasive group of the TN-STEMI programme demonstrated shorter lysis-to-angiogram times, better TIMI flow patterns and lower thrombus burden in the post-implementation phase.