الفهرس 
Reperfusion Strategies in Treatment of ST ElevationOnly 14 pages are availabe for public view
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Abstract
Worldwide, coronary artery disease (CAD) is the single most frequent cause of death. Over seven million people every year die from CAD, accounting for 12.8% of all deaths. The in-hospital mortality of STEMI patients in the national registries of the European society of cardiology (ESC) countries varies between 6% and 14%.
Primary percutaneous coronary intervention (PCI) is an effective treatment for myocardial infarction with ST-segment elevation when it can be performed rapidly. Many patients with myocardial infarction with ST-segment elevation present to hospitals that do not have the capability of performing PCI and therefore cannot undergo PCI within the timelines recommended in the guidelines; instead, they receive fibrinolysis as the initial reperfusion therapy. Despite the effectiveness and worldwide availability of intravenous thrombolysis, the usefulness of this therapy is greatly threatened by a high proportion of failed reperfusion and a substantial rate of reocclusion.
Pharmaco-invasive strategy performed between 3 and 24 hours appears beneficial and safe. The rationale for following fibrinolysis with PCI is that many patients have a persistent reduction in flow in the infarct-related artery. Although fibrinolysis restores patency (TIMI grade 2 or 3) in 80% of infarct- related arteries, normalization of blood flow (TIMI grade 3) is seen in only 50 to 60% of arteries.
Cardiac MRI is the gold slandered technique for assessment of cardiac functions, transmurality of infarction, infarction size and areas of microvascular obstruction (MVO).
The aim of the present study is to assess the effect of immediate fibrinolysis (with streptokinase “The widely available fibrinolytic in Egypt”) in patients presented with acute STEMI followed by transferal and PCI within 3-
24 hours compared to primary PCI and ischemia driven PCI on infarction size and microvascular obstruction.
The present study is a randomized case-control study that was conducted on 60 patients with 1st attack of acute STEMI who have symptom onset within
12 h. The patients were randomized to 4 groups (15 patients each): primary PCI
for patients presented to PPCI-capable centers (group I), transfer to PCI if
presented to non-PCI capable center (group II), pharmaco-invasive strategy
(group III) and fibrinolytic (streptokinase) and ischemia driven PCI (group VI).
The primary endpoint is the infarct size assessed by cardiac MRI on 3-5 days post MI. Death, reinfarction or disabling stroke constituted the clinical (secondary) endpoints. The key safety (secondary) endpoint was be the incidence of major bleeding.
The mean age of the study population was 49.6 years ranging from 30 to
65 years. The risk factors was equally distributed among the study groups. The estimated patient delay (about 6.1+2.5 hours) and the mean differences between
the 4 groups were insignificant. The system delay was 57+56 min in group I,
175.7+29 min in group II, 40.7+8.6 min in group III and IV.
Pharmaco-invasive strategy (group III) led to significantly smaller infarction size and significant decrease in MACCE compared to group IV. It also led to smaller infarction size and decrease in MACCE -but not significant- compared to group I and II. But minor bleeding was significantly higher in pharmaco-invasive group compared to other groups due puncture site related bleeding.
It was concluded that, compared to fibrinolysis followed by ischemia guided intervention, pharmaco-invasive strategy using streptokinase with PCI within 3-24 hours resulted in effective reperfusion and smaller infarction size in patients with acute STEMI. However, pharmaco-invasive strategy was associated with a slightly increased risk of minor bleeding.