|Year : 2018 | Volume
| Issue : 4 | Page : 132-136
Primary percutaneous coronary intervention for the treatment of acute ST-segment elevated myocardial infarction: Initial single-center experience from Kathmandu, Nepal
Om Murti Anil MD, DM, 1, Sayami Arun MD, 2, Nepal Rajesh MD, DM, 2, Niroj Bhattarai MD, 1, Nabin Chaudhary MD, 1
1 Department of Cardiology, Grande International Hospital, Dhapasi, Kathmandu, Nepal
2 Department of Cardiology, Manmohan Cardiothoracic Vascular and Transplant Centre, Maharajgunj, Kathmandu, Nepal
|Date of Web Publication||15-Oct-2018|
Dr. Om Murti Anil
Department of Cardiology, Grande International Hospital, Dhapasi, Kathmandu
Source of Support: None, Conflict of Interest: None
Introduction: Primary percutaneous coronary intervention (PPCI) has become the preferred initial revascularization strategy in patients with acute ST-segment elevation myocardial infarction (STEMI). This study aims to find out the clinical profile and in-hospital outcomes of initial 100 patients undergoing PPCI in a newly established cath laboratory at Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu, Nepal. Methodology: This is an observational study including initial 100 cases treated with PPCI at Manmohan Cardiothoracic Vascular and Transplant Center starting from September 2012. All patients with STEMI arriving at the hospital within recommended period were included in the study. Data on safety and outcome were obtained and analyzed from records of the emergency room, cath laboratory, coronary care unit, and discharge records. Results: The mean age of the study population was 52.5 ± 13.5 years. Of the total patients, 41% presented with anterior wall MI, 51% presented with inferior wall MI, and 5% had true posterior MI. Single-vessel disease was seen in 59%. Left anterior descending artery was the most common culprit vessel (43%). Mean window period and door-to-balloon time were 8 ± 3.15 h and 59 ± 11.25 min, respectively. Drug-eluting stents were deployed in 82% of the cases. In our study, in-hospital mortality was 3%. Conclusion: PPCI can be an initial strategy to treat STEMI even at a newly established cardiac center if it is performed by a dedicated team with an experienced operator within recommended period.
Keywords: Acute ST-segment elevated myocardial infarction, outcome, primary percutaneous coronary intervention
|How to cite this article:|
Anil OM, Arun S, Rajesh N, Bhattarai N, Chaudhary N. Primary percutaneous coronary intervention for the treatment of acute ST-segment elevated myocardial infarction: Initial single-center experience from Kathmandu, Nepal. J Clin Prev Cardiol 2018;7:132-6
|How to cite this URL:|
Anil OM, Arun S, Rajesh N, Bhattarai N, Chaudhary N. Primary percutaneous coronary intervention for the treatment of acute ST-segment elevated myocardial infarction: Initial single-center experience from Kathmandu, Nepal. J Clin Prev Cardiol [serial online] 2018 [cited 2019 Jan 17];7:132-6. Available from: http://www.jcpconline.org/text.asp?2018/7/4/132/243251
| Introduction|| |
Percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction (STEMI), commonly known as primary angioplasty or primary percutaneous coronary intervention (PPCI), has become the standard method of revascularization. The considerable body of evidence now suggests that revascularization with PPCI provides better outcome as compared to pharmacological treatment.
PPCI significantly reduces mortality, reinfarction, and stroke rates. Therefore, PPCI is always the first treatment option for patients with STEMI, if an experienced interventional cardiologist and properly equipped catheterization laboratory are available, and if the procedure can be performed safely in time. Although there is a limited number of PPCI capable centers in South East Asian countries, it is gradually emerging as the preferred treatment strategy in this region. Various studies from India, Bangladesh, and Pakistan have confirmed safety and efficacy of this procedure in this region.
Our center is a tertiary-level hospital located in Kathmandu valley, the capital city of Nepal with cardiac surgery backup, which has been providing regular (24 × 7) interventional cardiology services since September 2012. There are only a few hospitals in Nepal which provide regular PPCI service and there is limited data on the outcomes of PPCI in Nepalese patients.,
The objective of the present study was to evaluate the clinical profile, procedural, and clinical outcomes of the initial 100 consecutive patients undergoing PPCI at our tertiary-care center. The main aim was to determine procedural safety, benefits, and in-hospital mortality in our population. The result of this study may help to improve overall safety outcome of STEMI patients in a newly established cardiac center, particularly in a resource-limited setting.
| Methodology|| |
All patients who presented with STEMI within 24 h of onset of chest pain and underwent PPCI as an initial reperfusion strategy at Manmohan Cardiothoracic Vascular and Transplant Center were retrospectively reviewed, from September 2012. Initial 100 cases of primary angioplasty were enrolled in this study. All procedures were performed by a single trained interventional cardiologist. Data were obtained from hospital records of the cath laboratory, coronary care unit, and discharge sheet.
- Patients presenting with chest pain, ECG changes suggestive of STEMI and
- a) Duration of pain <12 h
b) Duration of chest pain 12–24 h with persistent or recurrent chest pain, hemodynamic compromise, pulmonary edema, large area of myocardium at risk, arrhythmia on presentation, or known case of coronary artery disease.
- Patients presenting with cardiogenic shock
- Chest pain >24 h
- Failed thrombolysis (rescue PCI)
- Multiple major comorbidities presumed to directly influence patient outcome.
Medications and technique
All patients received aspirin 300 mg, clopidogrel 300 mg, and atorvastatin 40 mg at the emergency department immediately after diagnosis. In cath laboratory intravenous unfractionated heparin (5000 international unit) was given in every case before initiation of PPCI. Heparin was further added as required as boluses of 1000–2500 units to keep ACT around 300 s. IV GPIIb/IIIa receptor blockers, bolus followed by IV infusion, was started after crossing the lesion when thrombus burden appeared large, and was continued for 12–24 h depending on procedural outcome, ST-segment resolution, and bleeding risk.
From the emergency department, patients were shifted directly to the cath laboratory. All cases were approached through femoral approach with 6F or 7F sheath. The femoral venous line was also obtained in all cases with a 7F sheath. Sheaths were removed after ACT fell to below 180 s and holding infusion of GPIIb/IIIa receptor blockers for 1 h. Temporary pacemaker was put if significant bradycardia or heart block was present at the presentation. Thrombosuction before balloon inflation was done with 6F/7F export catheter only when thrombus burden was found to be high, and risk of distal embolization was anticipated. Predilatation with semicompliant balloon was done if lesion morphology was complex and critical. Direct stenting was performed when obstructive lesion was discrete or less critical.
In most of the cases, we deployed drug-eluting stents (DES), except when clinical condition demanded bare-metal stent (BMS) or the patient was not affording for a DES. Postdilatation with a noncompliant balloon was performed in the majority of the cases as a routine unless small-sized stents were deployed at high pressure with no obvious unexpanded struts visible.
Continuous variables were expressed as mean with range and categorical variables as count with percentage. Groups were compared using Chi-square test (cross tabulation method) for categorical variables. P < 0.05 was considered statistically significant with 95% confidence interval.
| Results|| |
A total of 100 the initial patients meeting inclusion and exclusion criteria were included in this study from September 2012. The youngest patient was 29-year-old. The most aged patient was 89-year-old. The mean age of the study population was 52.5 ± 13.5 years. About 32% of the patients were younger than 40 years. Majority of the patients were male (81%) [Table 1].
Cardiovascular risk factor (CVRF) analysis showed that 63% were hypertensive, 32% diabetic, 74% dyslipidemic, and 33% of obese. While 34% of the patients were current smokers and 7% had positive family history of coronary artery disease. Of the total patients, 41% presented with anterior MI, which included anteroseptal, anterior, extensive anterior, and anterolateral in decreasing order. There were 51% of cases with inferior wall MI, 5% with true posterior MI, and 3% with left main coronary artery (LMCA) involvement [Table 2] and [Table 3].
Single-vessel disease was the most common angiographic finding (59%), double-vessel disease was present in 27% of the patients, and 11% had triple-vessel disease. Only 3% of the patients had involvement of LMCA. Left anterior descending artery was the culprit vessel in 43% of the cases, the right coronary artery was in 36%, left circumflex artery was in 18%, and LMCA was in 3% of cases. Heavy thrombus burden was seen in 35% of the cases. Angiography revealed 83% of culprit vessel to be totally occluded (thrombolysis in MI [TIMI] 0 distal flow), while the remaining 17% showed some distal flow (TIMI I) visually (95%–99% occlusion) [Table 4]a and [Table 4]b.
Window period of all patients enrolled was 30 min to 18 h with a mean of 8 ± 3.15 h. At our center, door-to-balloon time was 30 min to 90 min with a mean of 59 ± 11.25 min [Table 5]. We could cross the lesion in all except one case, where wire could not be crossed due to underlying chronic lesion and this patient was managed conservatively without any clinical deterioration. Thrombus suction catheters were used after crossing the lesion in 15% of the cases with successful thrombus extraction in 12%. GPIIb/IIIa inhibitors were used in 60 cases depending on high-thrombus burden, slow flow/no-reflow, side branch occlusion, and overall procedural outcome. Balloon predilatation was done in 80% of the cases and direct stenting was done in 15% (9% after thrombosuction and 6% without thrombosuction) [Table 6]a.
DES was deployed in 82% of the cases, while BMS was deployed in 9% and no stent was used in 9% of the cases. Reasons for not putting stents were failure to cross the lesion in 1%, no flow in 2%, excessive thrombus with slow flow in 1%, and good flow (TIMI III) after thrombosuction in 5% where no underlying stenosis was observed [Table 6]b.
During the procedure, significant arrhythmias were seen in 12 cases. Transient bradycardia, idioventricular rhythm, and frequent premature beats were the most common. DC cardioversion for ventricular tachycardia was required in one case. Temporary pacemaker was inserted in seven cases for complete heart block. Transient hypotension during the procedure was observed in 18 cases, which was treated with IV fluid and mephentermine. Only two cases were treated with intraaortic balloon counterpulsation support. TIMI 0, one flow was seen in three cases, which was treated with distal-bed perfusion with intracoronary nitroglycerine, along with intracoronary adenosine and eptifibatide. No patients developed cardiac arrest during the procedure. Cardiac tamponade developed in one case requiring pigtail drainage. No patient required emergency bypass surgery as a result of procedural-related complications [Table 7].
In-hospital mortality in our study population was 3%. Among three patients who died, two developed severe sepsis due to pneumonia requiring ventilator support and finally died due to septic shock [Table 8]. One patient who had a good result after PPCI (TIMI III flow) developed hypotension and refractory shock after transfer to CCU. No obvious cause for hypotension was detected. Despite every effort, the patient died within 1 h of angioplasty. We suspected serious allergic reaction with stent material. No patient died of arrhythmia or pump failure during hospital stay after the procedure. Eighteen cases developed heart failure (Killip II and III) during hospital stay. They were managed with IV diuretics and nitroglycerine infusion along with other supportive measures. Altogether 15 cases required moderate-to-high doses of dobutamine infusion, 7 cases required dual inotropes (dobutamine + dopamine), while 5 cases required noradrenaline infusion in addition.
| Discussion|| |
PPCI is the preferred treatment for acute STEMI cases. It should be available for every patient not only in central and metropolitan cities but also in small towns and periphery. However, in Nepal, it is still not a widely used primary reperfusion strategy due to lack of facilities. Hurdles for making this service available to the general population in developing countries like Nepal are expensive equipment (Cath laboratory), consumables, stents, and insufficient trained interventional cardiologists.
However, in the last 10 years, with the development of interventional cardiology in the country, the number of cath laboratories has increased, and PPCI service is gradually increasing across the country. Altogether there are about 14 government and private centers where this facility has started.
Our study showed more young people developing acute STEMI and undergoing PPCI as a lifesaving procedure. Compared to other studies,,, our patients had a lower mean age of 52.5 ± 13.5 years with the lowest being 29 years. The prevalence of CVRFs in our study cohort was similar to other studies,, done in South East Asia and Nepal., Hypertension, diabetes, and dyslipidemia were the most common CVRFs.
In-hospital mortality rate (3%) was low in our study, which is comparable to international data which showed in-hospital mortality of 5.2% in the second national registry of MI (NRMI2) and 3% in the assessment of the safety and efficacy of a new thrombolytic regimen trial. In this study, two patients out of 100 patients were died due to sepsis whereas one patient was died due to hypersensitivity reaction. However, there was not any death encountered due to cardiogenic shock during our initial experience. Studies from India conducted by Reddy et al. showed an in-hospital mortality of 2.2% in noncardiogenic shock group, similar outcomes were observed in a study by Jafary et al. with mortality of 43.9% and 2.1% in patients undergoing primary angioplasty for STEMI with and without cardiogenic shock, respectively. Moreover, study from Nepal by Adhikari et al. showed that in-hospital mortality due to noncardiogenic shock was 2.7% which is consistent with our results.
PPCI holds a survival advantage if it can be performed in a timely fashion. The principle that “time is myocardium” applies to both fibrinolysis (door to needle) and PPCI (door to balloon). According to the American College of Cardiology/American Heart Association guidelines, the recommended door-to-balloon time is 90 min. However, in developing and low-socioeconomic countries like Nepal due to financial constraints and delay in decision-making due to lack of knowledge on behalf of patients and their relatives regarding importance of time in the management of critical illness like MI, turned out to be the major obstacle in following door-to-balloon time recommendations. In our hospital, maximum door-to-balloon time was 90 min, minimum of 30 min with a mean of 59 ± 11.25 min. Our door-to-balloon time was internationally comparable but slightly more than the western cohort.,
In this study, patients often arrived late after onset of chest pain. They also took more time to take decision for PPCI. These two factors directly affected the procedural and clinical outcomes and increased window period and door-to-balloon time. Despite higher mean window period and door-to-balloon time, final outcome in our cohort of patients is acceptable. Being the initial 100 cases, procedural and clinical outcomes can be considered encouraging. Reasons for good outcome at our center were most likely to be due to proper case selection, treatment of concurrent illness in time, extensive postprocedural care, and availability of dedicated team of cardiology residents, radiographers, anesthetists, cardiac surgeons, trained nurses, and CCU staff led by a trained interventional cardiologist.
PPCI can be performed with good safety outcome even at a newly established cath laboratory if patients are treated by a team of dedicated and trained workforce with experienced primary operator. Availability of consumables, stents, and emergency medicines including GpIIbIIIa inhibitors is crucial for a new center. Lack of sufficient stents of different sizes was the most important limitations in our cath laboratory. Presence of variety of hardwares to deal with difficult cases and procedural complications is important. It also requires good supportive critical care team and well-equipped CCU for postprocedural care and concomitant comorbid conditions.
There are two main limitations of this study which might have affected the safety and outcome of the study. First, experience of single operator might have contributed to lower adverse complications. Second, relatively fewer cases of severe hypotension and complex coronary artery disease may be reason for lesser mortality in this study.
| Conclusion|| |
PPCI done in our newly established center has overall good safety outcome which is comparable to the other well-established national and international centers. PPCI can be an initial strategy to treat STEMI even at a newly established cardiac center if it is performed by a dedicated team with an experienced operator within recommended period.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Andersen HR, Nielsen TT, Rasmussen K, Thuesen L, Kelbaek H, Thayssen P, et al.
A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med 2003;349:733-42.
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: A quantitative review of 23 randomised trials. Lancet 2003;361:13-20.
Meijer A, Verheugt FW, Werter CJ, Lie KI, van der Pol JM, van Eenige MJ, et al.
Aspirin versus coumadin in the prevention of reocclusion and recurrent ischemia after successful thrombolysis: A prospective placebo-controlled angiographic study. Results of the APRICOT study. Circulation 1993;87:1524-30.
Reddy NK, Raju PR, Kapoor S, Rao MS, Reddy RP, Sastry BK, et al.
Prospective observational study of primary angioplasty of the infarct-related artery for acute myocardial infarction. Indian Heart J 1999;51:167-72.
Reza AQ, Islam AH, Munwar S, Talukder S. Study on primary percutaneous coronary intervention (PCI) in patient with acute myocardial infarction: In-hospital and 30-days survival outcome. Cardiovasc J 2010;2:212-7.
Shaikh AH, Siddiqui MS, Hanif B, Malik F, Hasan K, Adhi F, et al.
Outcomes of primary percutaneous coronary intervention (PCI) in a tertiary care cardiac centre. J Pak Med Assoc 2009;59:426-9.
Dubey L, Sharma SK, Bhattacharya R, Guruprasad S, Subramanyam G. Percutaneous coronary intervention without onsite cardiac surgery backup. JNMA J Nepal Med Assoc 2013;52:267-71.
Adhikari CM, Bhatta YD, Malla R, Maskey A, Rajbandari R, Regmi SR, et al
. Outcomes of primary percutaneous coronary intervention at Shahid Gangalal National Heart Centre, Kathmandu, Nepal. J Adv Interna Med 2013;2:6.
Tiefenbrunn AJ, Chandra NC, French WJ, Gore JM, Rogers WJ. Clinical experience with primary percutaneous transluminal coronary angioplasty compared with alteplase (recombinant tissue-type plasminogen activator) in patients with acute myocardial infarction: A report from the second national registry of myocardial infarction (NRMI-2). J Am Coll Cardiol 1998;31:1240-5.
Van de Werf F, Ross A, Armstrong P, Granger C. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): Randomised trial. Lancet 2006;367:569-78.
Jafary FH, Ahmed H, Kiani J. Outcomes of primary percutaneous coronary intervention at a joint commission international accredited hospital in a developing country – Can good results, possibly similar to the west, be achieved? J Invasive Cardiol 2007;19:417-23.
McNamara RL, Wang Y, Herrin J, Curtis JP, Bradley EH, Magid DJ, et al.
Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2006;47:2180-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]