Determination of risk factors associated with adverse outcomes of thrombolysis in acute ST Elevation Myocardial Infarction (STEMI)

Objective: Thrombolysis is the standard treatment for STEMI in most developing countries. However, adverse events attributable to thrombolysis occur, and must be considered in risk -benefit decisions. We aimed to estimate the local incidence of thrombolysis complications, whilst determining factors predisposing to adverse outcomes. Design and Methodology: A multicentre, prospective, observational cohort study was conducted; including consecutive adults with STEMI presenting to 3 Emergency Departments (EDs). Primary outcomes were complications and 30-day mortality. Results: 236 participants were enrolled (78.0% Indo- Trinidadian; 72.9% Male; 46.2% Hypertensive; 44.9% Diabetic; 57.9% Smokers). 27.5% of patients experienced complications; mainly a c u t e h e a r t f a i l u r e ( AHF) (8.5%) and cardiogenic shock (8.1%). In-hospital and 30-day mortality rates were 5.9 % and 9.2% respectively. Adverse outcomes of thrombolysis occurred in 9 (3.8%) patients (one intracerebral haemorrhage). No deaths were directly attributable to thrombolysis. No risk factor correlated with complications of thrombolysis, however a t r i o v e n t r i c u l a r ( AV) block (OR 9.73, CI 1.70 - 55.87, p = 0.011) and b l o o d u r e a n i t r o g e n ( BUN) (OR 1.09, CI 1.04 - 1.14, p < 0.001) were associated with increased in hospital mortality. Age ≥ 75 (OR 16.72, CI 1.45 - 192.44, p = 0.024), Systolic blood pressure (SBP) (OR 0.97, CI 0.96 - 0.99, p = 0.009) and BUN (adjusted OR 1.08, CI 1.03 - 1.13, p = 0.002) correlated with increased 30-day mortality. Conclusion: Thrombolysis for STEMI was associated with a low incidence of adverse events and similar mortality to developed nations. No factor was associated with adverse outcomes, although older age, high BUN, low SBP or AVB increased mortality risk. These findings can guide local physicians counselling patients/relatives regarding thrombolysis for STEMI.

Thrombolytic therapy in the Caribbean

Over the past 30 years, mortality from acute myocardial infarction (MI) has decreased substantially in developing countries. While this decline is attributed, in part to a reduction in coronary risk factors, some reports have identified improved theraputic management as being equally responsible for decline. Currently available treatment for patients presenting with ST segment elevation MI (MIs associated with complete occlusion of a coronary artery) includes the concomitant administration of aspirin ƒ-blockers, angiotensin-converting enzyme (ACE) inhibitors, and either thrombolytics or primary percutaneous transluminal angioplasty (PTCA) (AU)

Management of acute myocardial infarction in the public sector in the Bahamas

In 1996 and 1997, 52 patients were admitted to the Princess Margaret Hospital, Nassau, Bahamas, with a confirmed diagnosis of acute myocardial infarction (AMI). The average time to presentation after the onset of symptoms was 18 hours, with 56 percent of patients presenting within 12 hours. Risk factors identified for ischaemic heart disease were hypertension (77 percent), obesity (62 percent), diabetes mellitus (35 percent), tobacco smoking (25 percent), a family history of coronary heart disease (17 percent) and hypercholesterolaemia (8 percent). Medications administered in the treatment of AMI included oral nitrates (96 percent), intravenous heparin (90 percent), beta-blockers (65 percent), morphine (15 percent) thrombolytic agents (8 percent) and lignocaine (4 percent). In hospital post myocardial infarction complications were angina (23 percent), arrhythmias (12 percent) and cardiac failure (10 percent). The average hospital stay was eight days, with a mortality rate of 19 percent. These results show that there is considerable room for improvement, particularly in the use of thrombolytic therapy, to ensure that all patients receive optimal acute and post myocardial infarction care. (AU)

Thrombolytic therapy in acute myocardial infarction in Barbados: report of initial experience with intravenous streptokinase - abstract

It has been shown in the last decade, that intravenous throbolytic therapy is associated with a significant reduction in mortality, when given early in the course of an acute myocardial infarction (MI). Streptokinase, a bacterial-derived protein plasminogen activator, was approved for use at the Queen Elizabeth Hospital in June 1990 and thrombolytic therapy for acute MI commenced in October 1990. During the next 13 months, 129 patients were admitted to the Queen Elizabeth Hospital with the diagnosis of acute MI, and 35 of these (27 percent) received intravenous streptokinase. Nine other patients who received streptokinase were subsequently proven not to have infarcted. Forty-three per cent (43 percent) of the patients received thrombolytic therapy within six hours of the onset of symptoms, the ideal window period for treatment. Using non-invasive clinical criteria, reperfusion was suspected in 77 percent of patients. No major complications were seen. Three (3) patients had mild allergic reactions, and mild hypotension and bradycardia were seen in 19 patients. One patient who did not have an acute MI but an acute aortic dissection developed a hemiparesis which resolved within a week. There were 6 deaths recorded, all thought to be unrelated to streptokinase, but rather due to the extensive nature of the infarct. We have reported on a protocol-controlled series of patients given thrombolytic therapy for acute MI in Barbados, and have concluded that it can be given safely and effectively in carefully selected patients (AU)