|Year : 2022 | Volume
| Issue : 1 | Page : 5-9
Clinical Presentation, Treatment, and In-hospital Outcomes of ST-Segment Elevation Myocardial Infarction: A North East Indian Study
Chandra Kumar Das1, Animesh Mishra1, Manish Kapoor1, Amit Malviya1, Swapan Saha2
1 Department of Cardiology, NEIGRIHMS, Mawdiangdiang, Shillong, Meghalaya, India
2 Department of Cardiology, Dishan Hospital, Siliguri, West Bengal, India
|Date of Submission||25-Sep-2021|
|Date of Decision||07-Dec-2021|
|Date of Acceptance||01-Feb-2022|
|Date of Web Publication||21-Apr-2022|
MD, DM Animesh Mishra
Department of Cardiology, NEIGRIHMS, Mawdiangdiang, Shillong, Meghalaya - 793 018
Source of Support: None, Conflict of Interest: None
Background: India has a substantial burden of acute coronary syndromes, yet awareness regarding treatment and outcome of these conditions is limited. Thus, the present study aimed to document the characteristics, treatments, outcomes, and reasons for prehospital delay in patients with ST-segment elevation myocardial infarction (STEMI) admitted to a tertiary care hospital in North East India. Materials and Methods: A prospective, hospital-based, observational study was conducted at a tertiary care hospital in North East India between December 2016 and November 2017. All consecutive patients presenting with electrocardiographic evidence of STEMI were included in the study. Results: A total of 100 patients were assessed. Of these patients, 84 (84.0%) were male and 59 (59.0%) were urban residents. Smoking, hypertension, and dyslipidemia were the most common risk factors observed in 71 (71.0%), 55 (55.0%), and 43 (43.0%) patients, respectively. Anterior wall myocardial infarction was the most frequent type of STEMI observed in 59 (59.0%) patients. Only 54 (54.0%) patients reached the hospital within the window period. The average time to reach the hospital was 355 min. Thirty-three (33.0%) patients underwent thrombolysis, while 14 (14.0%) patients underwent primary percutaneous coronary intervention. Inhospital mortality occurred in 5 (5.0%) patients. Conclusion: Most patients were in the 60–69 years' age group, urban residents, and smokers. They received late medical care and received emergency therapies less often. In most cases, prehospital delay was due to patient inability to recognize symptoms at onset. Strategies to curb tobacco use, decrease prehospital delay, and improve urgent care could reduce morbidity and mortality in this patient subset.
Keywords: Acute coronary syndrome, non-ST-segment elevation, primary percutaneous coronary intervention, ST-segment elevation, thrombolysis
|How to cite this article:|
Das CK, Mishra A, Kapoor M, Malviya A, Saha S. Clinical Presentation, Treatment, and In-hospital Outcomes of ST-Segment Elevation Myocardial Infarction: A North East Indian Study. J Clin Prev Cardiol 2022;11:5-9
|How to cite this URL:|
Das CK, Mishra A, Kapoor M, Malviya A, Saha S. Clinical Presentation, Treatment, and In-hospital Outcomes of ST-Segment Elevation Myocardial Infarction: A North East Indian Study. J Clin Prev Cardiol [serial online] 2022 [cited 2022 Jul 6];11:5-9. Available from: https://www.jcpconline.org/text.asp?2022/11/1/5/343644
| Introduction|| |
Acute coronary syndrome (ACS) is a significant contributor to mortality, morbidity, and financial burden in both developed and developing countries such as India. The syndrome encompassing unstable angina and both ST-segment elevation myocardial infarction (STEMI) and non-STEMI is a common cause of emergency hospital admission. According to evidence amassed by several large, multicentric, well-conducted registries, management practices for ACS continue to change. It has been demonstrated that if attention is focused on evidence-based treatments, diagnostic evaluation, and processes of inpatient care, favorable positive outcomes can be achieved. Furthermore, simple algorithms or quality improvement programs can improve the utilization of evidence-based care. It is well accepted that the quality of health care in ACS patients, especially revascularization in ACS patients with ST-segment elevation on electrocardiogram, requires improvement in many countries. Thus, the aim of the present was trifold: (i) to determine the characteristics of hospitalized ACS patients with ST-segment elevation on electrocardiography, (ii) to assess the management strategies for STEMI patients, and (iii) to identify the factors for prehospital delay in STEMI patients.
| Materials and Methods|| |
Study design and patient population
This prospective, hospital-based, observational study was conducted at a tertiary care hospital in North East India between December 2016 and November 2017. All consecutive patients presenting with STEMI admitted to the Coronary Care Unit were included in the study. A diagnosis of STEMI was fulfilled according to the following criteria: (i) symptoms of ischemia and (ii) ST-segment elevation at the J point in at least 2 contiguous leads of ≥2 mm (0.2 mV) in men or ≥1.5 mm (0.15 mV) in women in leads V2–V3 and/or ≥1 mm (0.1 mV) in other contiguous chest leads or limb leads. Patients transferred from other hospitals were included regardless of time spent at the transferring hospital. Patients (i) diagnosed with ACS without ST-segment elevation, (ii) brought dead or who had died before informed consent could be obtained, or initially treated elsewhere and referred to the study center only for additional management or interventional therapy without reliable documentation of previous treatments received were excluded from the study. The study was approved by the Institutional Review Committee and Institutional Medical Ethical Committee. All patients provided written informed consent for study participation.
Echocardiography (VIVID S-5 General Electric Medical System 3.6 MHz) was performed according to the American Society of Echocardiography guidelines. Left ventricular ejection fraction (LVEF) was evaluated using visual assessment or modified Simpson's method whenever required. Left ventricular dysfunction was defined as mild, moderate, and severe dysfunction according to LVEF of 45%–54%, 30%–44%, and <30%, respectively.
All study patients underwent radial or femoral route coronary angiography performed by experienced cardiologists and reported by consultant cardiologists. Coronary stenoses were assessed visually by experienced angiographers or cardiologists. Significant coronary stenosis was defined as the presence of ≥70% luminal diameter narrowing of an epicardial stenosis and ≥50% luminal diameter narrowing of a left main stenosis by visual assessment in the “worst view” angiographic projection. Infarct-related artery was graded according to thrombolysis in myocardial infarction classification. Percutaneous coronary intervention (PCI) was performed in patients with significant stenosis.
All patients were given standard treatment of ACS as per protocol with antiplatelets, statins, and anticoagulants. Morphine, nitroglycerine, and other medications for treatment of other comorbidities were administered as per patient profile. The decision of early revascularization was dependent upon window period, persisting chest pain, or Killip class at presentation. Thrombolysis and primary PCI were performed depending upon indications as well as affordability of the patients. Streptokinase and recombinant tissue plasminogen activator were used for thrombolysis.
Outcomes were evaluated in terms of inhospital major adverse cardiovascular events (MACE). MACE was defined as recurrent angina, re-infarction, stent thrombosis (acute/subacute/late), urgent revascularization, heart failure, and cardiovascular mortality.
Hypertension was defined as previous use of antihypertensive medications, systolic pressure >140 mmHg, or diastolic pressure >90 mmHg in at least two separate measurements. Diabetes mellitus was considered as previous history of diabetes with or without drug therapies or fasting blood glucose ≥126 mg/dL. Current smokers were considered as those who had smoked for some period during the past year. Re-infarction was defined as new ST-T changes and serum creatine kinase myocardial band level five times the upper limit of normal. Stent thrombosis was defined as abrupt onset of cardiac symptoms, elevation of biomarker levels, or electrocardiographic evidence of myocardial injury or angiographic evidence of a flow limiting thrombus near the previously implanted stent. Cardiovascular mortality was defined as unexplained sudden death, death due to acute myocardial infarction, heart failure, and/or arrhythmia.
Data such as patient demographics, physical examination on admission, medical history, residential details, and clinical and laboratory data were recorded. Duration from symptom onset to hospital admission, reasons for delayed admission, pharmacological interventions during hospitalization, and adverse outcomes were also recorded for each patient.
Continuous variables were expressed as mean ± standard deviation, and categorical data were expressed as percentages. The statistical evaluation of data was done using the Statistical Package for the Social Sciences (SPSS, Chicago, IL, USA) software version 20.
| Results|| |
A total of 100 patients were included in this study. The mean age of study patients was 56.81 ± 12.25 years. Majority of the patients belonged to the age group of 60–69 years followed by the 50–59 years' age group. The age distribution of study patients according to age group is illustrated in [Figure 1]. Males accounted for 84 (84.0%) study patients. Urban and semi-urban residents contributed 59 (59.0%) and 31 (31.0%) study patients, respectively, whereas rural residents contributed only 10 (10.0%) study patients. The most common risk factors were smoking, hypertension, dyslipidemia, and diabetes mellitus observed in 71 (71.0%), 55 (55.0%), 43 (43.0%), and 39 (39.0%) patients, respectively. The sociodemographic details are outlined in [Table 1].
Clinical presentation and investigations
On presentation, the mean heart rate was 84.07 ± 23.84 beats per minutes. The mean systolic blood pressure was 128.36 ± 27.35 mmHg and mean diastolic pressure was 84.07 ± 23.84 mmHg. Forty-five (45.0%) and 42 (42.0%) patients belonged to Killip's Classes III and IV, respectively. Anterior wall myocardial infarction was the most common type of STEMI observed in 59 (59.0%) study patients followed by inferior wall myocardial infarction observed in 37 (37.0%) study patients. The most common electrocardiographic abnormalities were 2:1 atrioventricular (AV) block and first-degree AV block which occurred in 11 (11.0%) and 7 (7.0%) patients, respectively. The clinical presentation and investigative details are demonstrated in [Table 2].
Admission and procedural details
Only 35 (35.0%) patients directly presented to our tertiary care hospital. Of the 100 patients, only 54 (54.0%) presented to any hospital within 6 h of suffering a myocardial infarction. The mean time to reach the hospital was 322 min. The causes of delay for those unable to reach a hospital within 6 h were inability to recognize symptoms, confusion with gastritis, and other reasons in 27 (58.6%), 14 (30.1%), and 5 (10.8%), respectively. A total of 33 (33.0%) patients underwent thrombolysis. Single-vessel disease was observed in 29 (40.2%) patients. Left anterior descending coronary artery was the culprit vessel in 43 (59.7%) patients. PCI was performed in 51 (51%) study patients. Primary PCI was performed in 14 (14.0%) study patients. The admission and procedural details are given in [Table 3].
Adverse outcomes and medical therapy
Inhospital death occurred in 5 (5.0%) study patients. Out of a total of 12 complications, heart failure occurred in 12 (12.0%) study patients and re-infarction occurred in 2 (2.0%) study patients, both died. Cardiac arrest occurred in 5 (5.0%) study patients, none could be revived. The treatment administered to patients during hospitalization is detailed in [Table 4].
| Discussion|| |
Indians are burdened with STEMI a decade earlier than Western populations. Two earlier registries conducted in India recorded 5.3% and 74.5% STEMI prevalence in patients below the age of 40 years., In line with these findings, the present study observed 10.0% STEMI prevalence in patients below 40 years of age. Similarly, the Kerala ACS Registry and the CREATE Registry recorded 22.4% and 33.9% STEMI prevalence in patients below the age of 50 years, respectively. These findings corroborate earlier reference to early manifestation of STEMI in the Indian population.
Epidemiological transition may partially justify rising prevalence of cardiovascular risk in the Indian youth. Smoking, the most frequently observed risk factor, was observed in 71.0% of the study patients, which is alarmingly higher than several international registries (37.3%–59.1%),,,,,,, and Indian registries (27.9%–62.9%). Hypertension, the second most frequently observed risk factor, was observed in 55.0% of the study patients. This was also higher than several international registries (37.2%–52.7%),,,, and Indian registries (10.0%–35.3%).,,, These findings are indeed suggestive of epidemiological transition. Differing trends in clinical and risk profiles between young and elderly patients have also been described earlier.
Urban and semi-urban residents accounted for 59.0% and 31.0% of the study patients, whereas rural residents accounted for only 10.0%. Among Indian registries, the CREATE Registry observed 62.5% and 19.9% of the urban and semi-urban residents and 17.0% of the rural residents. The lower proportion of rural residents may be due to less referral from rural centers or inability to diagnose myocardial infarction in such rural centers. In contrast to the aforementioned observations, urban residents accounted for only 17.6% of the study patients, while rural residents accounted for 82.4% of the study patients in the Multicenter HP ACS Registry.
In the present study, 35% of the patients were directly admitted to a hospital with PCI facility, and the remaining patients were referred from peripheral hospitals lacking proper cardiac care facilities. Only 54% of the patients were able to reach a health-care facility within 6 h. The mean time to admission was 5.92 h (355 min). Similarly, earlier Indian ACS registries have recorded median time to hospital admission of 300 min, 600 min, and 780 min. However, more developed countries were able to decrease mean time to admission. The time to admission was 154 min in the J-MINUET Registry, 260 min in the Polish Registry of ACSs. Despite the prevalence of numerous hurdles hindering attempts to lower prehospital delay, adequate social health awareness and availability of health-care facilities with expertise in cardiac care can decrease all indicators of hospital delay such as time from symptom onset to hospital admission/presentation, and time from admission to medical treatment.
A total of 33% patients underwent thrombolysis. This is lower than other Indian registries such as the Kerala ACS and CREATE that performed thrombolysis on 41.0% and 58.5% of the patients, respectively. This could be explained due to lack of facilities for thrombolysis or unavailability of either thrombolytic agents or specialized health-care professionals in situations in which patients are able to reach the facility within the window period.
A few limitations of the present study deserve mention. First, the sample size was small. Second, the study was designed as an observational study and thus limited ability to evaluate causation. Third, the lack of follow-up prevented detection of outcomes after patient discharge. Most of the patients were referred from other hospitals in which data were collected on the basis of documents they provided which may be not completely reliable. Moreover, all the referral centers are not comparable with regard to cardiac care facilities. Finally, mortality rates could be underestimated, as deaths before admission to hospital or in emergency departments may have been missed.
| Conclusion|| |
The present study concludes occurrence of STEMI in patients of younger age. Patients were mostly urban residents, and many suffered from comorbidities such as smoking/tobacco chewing, hypertension, dyslipidemia, and diabetes mellitus. Patients delayed seeking medical care and sought emergency therapies less often. Most patients were unable to recognize symptoms at onset. Strategies to curb tobacco use, decrease prehospital delay, and improve urgent care could reduce morbidity and mortality in STEMI patients. However, further studies are warranted to validate these observations and to adopt strategies to overcome these lapses as prevalence of STEMI is growing with each passing day.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Huffman M, Jeemon P, Prabhakaran D, Harikrishnan S, Leeder S. A Race Against Time: The Challenge of Cardiovascular Diseases in Developing Economies. 2nd
ed. New Delhi, India: Centre for Chronic Disease Control; 2014.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44:E1-211.
Widimsky P, Wijns W, Fajadet J, de Belder M, Knot J, Aaberge L, et al.
Reperfusion therapy for ST elevation acute myocardial infarction in Europe: Description of the current situation in 30 countries. Eur Heart J 2010;31:943-57.
O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr., Chung MK, de Lemos JA, et al.
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78-140.
Negi PC, Merwaha R, Panday D, Chauhan V, Guleri R. Multicenter HP ACS Registry. Indian Heart J 2016;68:118-27.
Deora S, Kumar T, Ramalingam R, Nanjappa Manjunath C. Demographic and angiographic profile in premature cases of acute coronary syndrome: Analysis of 820 young patients from South India. Cardiovasc Diagn Ther 2016;6:193-8.
Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al.
Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: Results from the Kerala ACS Registry. Eur Heart J 2013;34:121-9.
Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al.
Treatment and outcomes of acute coronary syndromes in India (CREATE): A prospective analysis of registry data. Lancet 2008;371:1435-42.
Shaheen S, Wafa A, Mokarab M, Zareef B, Bendary A, Abdelhameed T, et al.
Presentation, management, and outcomes of STEMI in Egypt: Results from the European Society of Cardiology Registry on ST elevation myocardial infarction. Egypt Heart J 2020;72:35.
Donataccio MP, Puymirat E, Vassanelli C, Blanchard D, le Breton H, Perier MC, et al.
Presentation and revascularization patterns of patients admitted for acute coronary syndromes in France between 2004 and 2008 (from the National Observational Study of Diagnostic and Interventional Cardiac Catheterization [ONACI]). Am J Cardiol 2014;113:243-8.
Ghadri JR, Jaguszewski M, Sacron A, Srikantharupan S, Pfister P, Siddique A, et al.
Current outcome of acute coronary syndromes: Data from the Zurich-acute coronary syndrome (Z-ACS) registry. Cardiovasc Med 2013;13:115-22.
Srimahachota S, Boonyaratavej S, Kanjanavanit R, Sritara P, Krittayaphong R, Kunjara-Na-ayudhya R, et al.
Thai Registry in Acute Coronary Syndrome (TRACS) – An extension of Thai Acute Coronary Syndrome registry (TACS) group: Lower in-hospital but still high mortality at one-year. J Med Assoc Thai 2012;95:508-18.
Ishihara M, Fujino M, Ogawa H, Yasuda S, Noguchi T, Nakao K, et al.
Clinical presentation, management and outcome of Japanese patients with acute myocardial infarction in the troponin era – Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET). Circ J 2015;79:1255-62.
Zubaid M, Rashed WA, Saad H, Attiya A, Al-Banat BA, Ridha M, et al.
Kuwait acute coronary syndromes registry: Baseline characteristics, management practices and in-hospital outcomes of patients hospitalized with acute coronary syndromes in Kuwait. Med Princ Pract 2007;16:407-12.
Poloński L, Gasior M, Gierlotka M, Kalarus Z, Cieśliński A, Dubiel JS, et al.
Polish Registry of Acute Coronary Syndromes (PL-ACS). Characteristics, treatments and outcomes of patients with acute coronary syndromes in Poland. Kardiol Pol 2007;65:861-72.
Tawfeek H, Nour MK, Bary AA, Fattah AA. Contemporary retrospective analysis of acute coronary syndrome. An Egyptian study. Egypt J Crit Care Med 2016;4:79-84.
Revaiah PC, Vemuri KS, Vijayvergiya R, Bahl A, Gupta A, Bootla D, et al.
Epidemiological and clinical profile, management and outcomes of young patients (≤40 years) with acute coronary syndrome: A single tertiary care center study. Indian Heart J 2021;73:295-300.
Sharma YP, Santosh Vemuri K, Bootla D, Kanabar K, Pruthvi CR, Kaur N, et al.
Epidemiological profile, management and outcomes of patients with acute coronary syndrome: Single centre experience from a tertiary care hospital in North India. Indian Heart J 2021;73:174-9.
[Table 1], [Table 2], [Table 3], [Table 4]