ORIGINAL ARTICLE In-hospital Mortality with Relation to Time of Presentation in Patients with Acute ST Elevation Myocardial Infarction ABDUL SATTAR, ABDUL BARI, MOAZAM ALI NAQVI, AHMAD NOEMAN ABSTRACT Aim: To determine the frequency of in-hospital mortality in different groups with relation to time of presentation in patients of acute ST Elevation Myocardial Infarction (STEMI). Methods: This Descriptive Case Series conducted in the Department of Cardiology, Punjab Institute of Cardiology, Lahore from December 2011 to June 2012.Two hundred patients of acute ST elevation myocardial infarction fulfilling the inclusion criteria from emergency department of PIC Lahore were enrolled after informed consent. This study population was divided into four groups. Group I was consisted of patients presenting in <3 hours of onset of symptoms, Group II, patients presenting in 3- 6 hours after symptom onset, Group III, patients presenting in 6-12 hours and Group IV was comprise of patients presenting after 12 hours of onset of symptoms of acute myocardial infarction. Routine protocol was offered to each patient and all patients will be followed for mortality for four days. Results: Mean age of the patients was 55.5 +13.2 years. Out of 200 patients 148 (74%) were male and 52 (26%) were female. Out of 200 patients, 108 (54%) were smokers. Hypertension was found in 94 (47%) of the patients. 80 (40%) were having diabetes. Out of 200 patients 37(18.5%) died during hospital admission. Conclusion: Delayed presentation is associated with older age and female gender. Patients presenting late are in more advanced Killip class and are less frequently thrombolysed and are predisposed to increased in-hospital mortality. Keywords: Acute ST Elevation Myocardial Infarction; Acute coronary syndromes; In-hospital mortality; Reperfusion therapy; Killip class. INTRODUCTION within 1 hour of symptom onset and by 23% if it is The burden of cardiovascular disease is growing achieved within 3 hours of symptom onset 7 . In one worldwide. Ischemic heart disease is the leading trial, delaying treatment by 30 minutes reduced cause of death in the United States and other average life expectancy by 1 year. 8 In another recent developed countries and is projected to emerge as study of 565 patients undergoing angioplasty for AMI, the No. 1 cause of death worldwide by the year those who received the first balloon inflation within 60 2020 1,2 . minutes of arrival at the hospital had a 30-day More than 50% of the 1.2 million people who mortality rate of 1%, but for every 15 minutes longer suffer an acute myocardial infarction (AMI) or than 1 hour the odds of death increased 1.6 times. 5 coronary death each year in the United States die in Delay also affects morbidity. A shorter interval an emergency department (ED) or before reaching a between symptom onset and treatment is associated hospital within an hour of symptom onset 1 . with better cardiac function 7 . The level of cardiac Delay to treatment for acute coronary function is the best predictor of morbidity, as well as syndromes (ACS) and stroke is a major contributor to of mortality 8,9 . Thus, early treatment with reperfusion, the morbidity burden of cardiovascular disease as well as with other agents such as angiotensin- because a significant number of individuals who con verting enzyme inhibitors, β -blockers, and aspirin, delay seeking care develop potentially preventable can reduce mortality and morbidity. complications 3,4 . In the United States, median delay time from Delay has been an important predictor of patient symptom onset to hospital arrival ranges from 1.5 to morbidity and mortality outcomes in numerous clinical 6.0 hours 4,10 . Data from the Atherosclerosis Risk in trials of reperfusion therapy 3-6 . Survival rates are Communities Study indicate no improvement in delay improved by up to 50% if reperfusion is achieved from 1987 through 2000: 49.5% of patients delayed ----------------------------------------------------------------------- >4 hours. 11 This study is designed to evaluate the Department of Carciology, Punjab Institute of Cardiology, impact of delayed presentation on in-hospital Lahore outcome of acute myocardial infarction. This study Correspondence to Dr. Abdul Sattar,Assistant Professor of will be helpful to find out the frequency of late Cardiology, Email: drabdulsattar66@yahoo.com presentation of myocardial infarction patients and to P J M H S Vol. 8, NO. 1, JAN – MAR 2014 99
In-hospital Mortality with Relation to Time of Presentation in Patients with Acute ST Elevation MI help the general public by educating them regarding presenting late p<0.097. There were 80(40%) the symptoms and importance of early treatment. diabetics with similar number of patients in all the groups p<0.359. Overall 108(54%) were smokers MATERIAL AND METHODS and 94(47%) patients were hypertensive with similar percentages in all the four groups (Table 2). This study was conducted in the Department of Mean heart rate at the time of presentation was Cardiology, Punjab Institute of Cardiology, Lahore, 81.1±13.2 per minute. Mean heart rate was similar in over a period of six months from December 2011 to all the four groups. Mean systolic blood pressure was June 2012.It was a descriptive case series. Sample 121.5±27.6 mm Hg and mean diastolic BP was size of 200 cases was taken by non probability 75.2±16.8 mm Hg. Mean blood pressure, systolic and purposive sampling calculated with 95% confidence diastolic at the time of presentation was similar in all level, 4% margin of error and taking expected groups. Table 3:Overall 126(63%) patients presented percentage of in hospital mortality in group -1 (within in Killip class I, 32(61%) in class II, 24(12%) in class or upto 3 hours) i.e., 9.03% (least among all groups) III and 18(9%) in class IV. There was tendency of after onset of symptoms till arrival in patients of presenting in advanced killip class with delayed STEMI presenting in a tertiary care hospital. presentation. In Group I, 36(72%) patients presented Adult patients with acute STEMI between 30-70 in Killip class I, 7(14%) in class II, 4(8%) in class III, years of age and of both genders were included. We 3(6%) in class IV. In patients presenting late i.e. excluded patients who were already hospitalized at Group IV 25(50%) patients presented in Killip class I, the time of occurrence of symptoms. 9(18%) in class II, 12(24%) in class III and 4(8%) in Two hundred patients of Acute ST Elevation class IV p<0.018. Table 4. Site of myocardial Myocardial Infarction fulfilling the inclusion criteria infarction was similar in all the four groups as from emergency department of PIC Lahore were 103(51.5%) patients had anterior wall myocardial enrolled after informed consent. This study infarction, 69(34.5%) had inferior wall MI, 20(10%) population were divided into four groups. Group I was had lateral wall MI and 8(4%) had LBBB. Table 5: consisted of patients presenting in <3 hours of onset Overall 144(74%) patients received streptokinase of symptoms, Group II, patients presenting in 3-6 therapy. In Group I, 48(98%) patients received hours after symptom onset, Group III, patients streptokinase with a gradual decline with delayed presenting in 6-12 hours and Group IV was presentation as 49(98%) patients in Group II received comprised of patients presenting after 12 hours of Streptokinase, 41(82%) in Group III and 6(12%) in onset of symptoms of acute myocardial infarction. Group IV received streptokinase p<0.0001.Table 6: Routine protocol was offered to each patient and all Door to needle time of <30 minutes was observed in patients were followed for mortality for four days. 94(47%) patients, 37(74%) in Group I, 31(62%) in Data Analysis Procedure : All the collected Group II, 21(42%) in Group III and 5(10%) in Group information was entered and analyzed using SPSS IV p<0.0001. Door to needle time of 30 minutes to 1 version 10.0. Quantitative variables like age was hour was observed in 42(21%), 10(20%) in Group I, presented by calculating mean and standard 15(30%) in Group II, 16(32%) in Group III and 1(2%) deviation. Qualitative variables like gender, groups of in Group IV. Door to needle time was prolonged to >1 presenting time and in-hospital mortality in each hour in 8(4%) patients, 1(2%) in Group I, 3(6%) in group were presented by calculating frequency and Group II, 4(8%) in Group III and 0(0%) in Group IV. percentage. Data was stratified for DM, HTN, Table 7; there was an increasing trend in Smoking, family history to address effect modifiers. complications like VSD, MR, Cardiogenic Shock, Reinfarction, CVA,VT/VF, asystole and CHB with RESULTS delayed presentation. Table 8: In-hospital mortality was 37(18.5%). Mean age of the study population was 55.5±13.2 There was an increasing, trend in in-hospital mortality years. Mean age was similar in all the groups. Table with delayed presentation. As mortality was 5(10%) in 1. There were 148(74%) males and 52(26%) Group I, 6(12%) in Group II, 8(16%) in Group III and females. Lesser number of female patients 9(18%) 18(36%) in Group IV p<0.001 presented early as compared to 20(40%) patients 100 P J M H S Vol. 8, NO. 1, JAN – MAR 2014
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