Intervensi Koroner Perkutan Primer untuk Infark Miokard Elevasi ST di Pusat Jantung Pemula di Indonesia: 100 pasien pertama

Background: The benefits of Primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) have been demon-strated, but most studies were conducted in experienced centres in western world. Experience, logistics and patient characteristics may differ in other parts of the world, particularly in a starting center.Methods: Data on all consecutive STEMI patients treated with primary PCI in Cinere hospital, Jakarta, Indonesia were collected in a prospective database.Results:,Between July 2006 and December 2008, a total of 100 patients with STEMI were treated by primary PCI. Mean age was 56.9 ±10.4 years (range 37-82), 88% was male. Mean time between onset of chest pain and admission was 369 ± 388 minutes. The mean time between admission and balloon inflation was 258 minutes. Before PCI, 50% of patients had TIMI 0 flow. After primary PCI 94% of patients had TIMI 2/3 flow. There were no deaths in the catheterisation room, and no emergency coronary bypass surgery was needed as a result of PCI complications. Mean left ventricular ejection fraction as measured by echocardiography after 1 day was 48 ± 12 %.Conclusions: Outcome after primary PCI at a starting center is excellent in this series. Primary PCI was effective in restoration of TIMI flow, without complications. Time delay between symptom onset, admission and balloon inflation was long and all efforts should be encouraged to shorten this.Latar belakang: Manfaat Intervensi perkutan primer (IKP) untuk Infark Miokard Elevasi ST (IMEST) telah terbukti, namun-demikian kebanyakan penelitian mengenai ini di laksanakan dipusat layanan jantung yang berpengalaman di dunia barat, Pengalaman , logistik dan karakteristik pasien mungkin berbeda di belahan dunia ini, terutama di pusat yang baru mulai.Metode: Seluruh data pasien konsekutif dengan IMEST yang ditangani dengan IKP primer di pusat jantung Cinere , Jakarta, Indonesia dihimpun melalui seperangkat data yang dilaksanakan secara propekstif.Hasil: Antara Juli 2006 dan Desember 2008, dari seluruh jumlah 100 pasien dengan IMEST yang ditangani dengan IKP primer. Rerata usia adalah 56,9 tahun ± 10,4 tahun (berkisar 37-82 tahun), 88 % diantaranya adalah pria. Rerata waktu antara onset nyeri dada dan masuk rumah sakit adalah 369 ± 388 menit. Rerata waktu antara masuk rumah sakit dengan inflasi balon adalah 258 menit. Sebelum IKP, 50 % pasien dengan aliran TIMI 0. Setelah IKP primer 94 % pasien memperoleh aliran TIMI 2/3. Tidak ada kematian didalam ruang kateterisasi maupun diperlukan tindakan bedah graft pintas arteri koroner yang gawat akibat komplikasi dari IKP. Rerata fraksi ejeksi yang diukur dengan ekokardiografi setelah 1 hari adalah 48±12 %.Kesimpulan: Hasil akhir yang diperoleh setelah IKP primer pada pusat jantung yang baru dimulai adalah baik pada serial ini. IKP primer efektif dalam memeperbaiki aliran TIMI, tanpa komplikasi. Keterlambatan waktu antara permulaan gejala, saat masuk dan inflasi balon masih panjang dan segala usaha harus diupayakan untuk memendekan waktu ini

Symptom-onset-to-balloon time and mortality in patients with acute myocardial infarction treated by primary angioplasty

AbstractObjectivesThe aim of the study was to evaluate the relationship between symptom-onset-to-balloon time and one-year mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty.BackgroundDespite the prognostic implications demonstrated in patients with STEMI treated with thrombolysis, the impact of time-delay on prognosis in patients undergoing primary angioplasty has yet to be established.MethodsOur study population consisted of 1,791 patients with STEMI treated by primary angioplasty from 1994 to 2001. All clinical, angiographic and follow-up data were collected. Subanalyses were conducted according to patient risk profile at presentation and preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow.ResultsA total of 103 patients (5.8%) had died at one year. Symptom-onset-to-balloon time was significantly associated with the rate of postprocedural TIMI 3 flow (p = 0.012), myocardial blush grade (p = 0.033), and one-year mortality (p = 0.02). A stronger linear association between symptom-onset-to-balloon time and one-year mortality was observed in non-low-risk patients (p = 0.006) and those with preprocedural TIMI flow 0 to 1 (p = 0.013). No relationship was found between door-to-balloon time and mortality. At multivariate analysis, a symptom-onset-to-balloon time >4 h was identified as an independent predictor of one-year mortality (p < 0.05).ConclusionsThis study shows that, in patients with STEMI treated by primary angioplasty, symptom-onset-to-balloon time, but not door-to-balloon time, is related to mortality, particularly in non–low-risk patients and in the absence of preprocedural anterograde flow. Furthermore, a symptom-onset-to-balloon time >4 h was identified as independent predictor of one-year mortality

Angiographic assessment of reperfusion in acute myocardial infarction by myocardial blush grade

Background-Angiographic successful reperfusion in acute myocardial infarction has been defined as TIMI 3 flow. However, TIMI 3 flow does not always result in effective myocardial reperfusion. Myocardial blush grade (MBG) is an angiographic measure of myocardial perfusion. We hypothesized that optimal angiographic reperfusion is defined by TIMI 3 flow and MBG 2 or 3. Methods and Results-In 924 consecutive patients with TIMI 3 flow after angioplasty for acute myocardial infarction, we prospectively studied the value of MBG. End points were death, MACE, enzymatic infarct size, and residual left ventricular ejection fraction. Follow-up was 16+/-11 months. Of the 924 patients, 101 (11%) patients had MBG 0 or 1. Mortality was significantly higher in patients with MBG 0 or 1 compared with patients with MBG 2 or 3 (relative risk, 4.7; 95% CI, 2.3 to 9.5; P Conclusions -MBG is a strong angiographic predictor of mortality in patients with TIMI 3 flow after primary angioplasty. Enzymatic infarct size is larger and residual left ventricular ejection fraction is lower in patients with MBG 0 or 1 compared with MBG 2 or 3. Angiographic definition of successful reperfusion should include both TIMI 3 flow as well as MBG 2 or 3

NT-proBNP level before primary PCI and risk of poor myocardial reperfusion: Insight from the On-TIME II trial.

Background N-terminal fragment of the brain natriuretic peptide prohormone (NT-proBNP), a marker for neurohumoral activation, has been associated with adverse outcome in patients with myocardial infarction. NT-proBNP levels may reflect extensive ischemia and microvascular damage, therefore we investigated the potential association between baseline NTproBNP level and ST-resolution (STR), a marker of myocardial reperfusion, after primary percutaneous coronary intervention (pPCI).Methods we performed a post-hoc analysis of the On-TIME II trial (which randomized ST-elevation myocardial infarction (STEMI) patients to pre-hospital tirofiban administration vs placebo). Patients with measured NT-proBNP before angiography were included. Multivariate logistic-regression analyses was performed to investigate the association between baseline NTproBNP level and STR one hour after pPCI.Results Out of 984 STEMI patients, 918 (93.3%) had NT-proBNP values at baseline. Patients with STR 70% had higher NT-proBNP values compared to patients with complete STR (70%) [Mean +/- SD 375.2 +/- 1021.7 vs 1007.4 +/- 2842.3, Median (IQR) 111.7 (58.4-280.0) vs 168.0 (62.3-601.3), P < .001]. At multivariate logistic regression analysis, independent predictors associated with higher risk of poor myocardial reperfusion (STR < 70%) were: NT-proBNP (OR 1.17, 95%CI 1.041.31, P = .009), diabetes mellitus (OR 1.87, 95%CI 1.14-3.07, P = .013), anterior infarct location (OR 2.74, 95% CI 2.00-3.77, P < .001), time to intervention (OR 1.06, 95%CI 1.01-1.11, P = .021), randomisation to placebo (OR 1.45, 95%CI 1.05-1.99, P = .022).Conclusions In STEMI patients, higher baseline NT-proBNP level was independently associate with higher risk of poor myocardial reper fusion, suppor ting the potential use of NT-proBNP as an early marker for risk stratification of myocardial reperfusion after pPCI in STEMI patients

Age-dependent differences in diabetes and acute hyperglycemia between men and women with ST-elevation myocardial infarction: a cohort study

BACKGROUND: Both acute hyperglycemia as diabetes results in an impaired prognosis in ST-elevation myocardial infarction (STEMI) patients. It is unknown whether there is a different prevalence of diabetes and acute hyperglycemia in men and women within age-groups. METHODS: Between 2004 and 2010, 4640 consecutive patients (28% women) with STEMI, were referred for primary PCI. Patients were stratified into two age groups, < 65 years (2447 patients) and ≥65 years (2193 patients). Separate analyses were performed in 3901 patients without diabetes. Diabetes was defined as known diabetes or HbA1c ≥6.5 mmol/l at admission. RESULTS: The prevalence of diabetes was comparable between women and men in the younger age group (14% vs 12%, p = 0.52), whereas in the older age group diabetes was more prevalent in women (25% vs 17% p < 0.001). In patients without diabetes, admission glucose was comparable between both genders in younger patients (8.1 ± 2.0 mmol/l vs 8.0 ± 2.2 mmol/l p = 0.36), but in older patients admission glucose was higher in women than in men (8.7 ± 2.1 mmol/l vs 8.4 ± 2.1 mmol/l p = 0.028). After multivariable analyses, the occurrence of increased admission glucose was comparable between men and women in the younger age group (OR 1.1, 95%CI 0.9-1.5), but increased in women in the older age group (OR 1.3, 95% CI 1.1-1.7). Both diabetes and hyperglycemia were associated with a higher one-year mortality in both men and women. CONCLUSIONS: The differences between men and women in hyperglycemia and diabetes in patients with STEMI are age dependent and can only be observed in older patients. This may have implications for medical treatment and should be investigated further

The impact of glucose-insulin-potassium infusion in acute myocardial infarction on infarct size and left ventricular ejection fraction [ISRCTN56720616]

BACKGROUND: Favorable clinical outcomes have been observed with glucose-insulin-potassium infusion (GIK) in acute myocardial infarction (MI). The mechanisms of this beneficial effect have not been delineated clearly. GIK has metabolic, anti-inflammatory and profibrinolytic effects and it may preserve the ischemic myocardium. We sought to assess the effect of GIK infusion on infarct size and left ventricular function, as part of a randomized controlled trial. METHODS: Patients (n = 940) treated for acute MI by primary percutaneous coronary intervention (PCI) were randomized to GIK infusion or no infusion. Endpoints were the creatinine kinase MB-fraction (CK-MB) and left ventricular ejection fraction (LVEF). CK-MB levels were determined 0, 2, 4, 6, 24, 48, 72 and 96 hours after admission and the LVEF was measured before discharge. RESULTS: There were no differences between the two groups in the time course or magnitude of CK-MB release: the peak CK-MB level was 249 ± 228 U/L in the GIK group and 240 ± 200 U/L in the control group (NS). The mean LVEF was 43.7 ± 11.0 % in the GIK group and 42.4 ± 11.7% in the control group (P = 0.12). A LVEF ≤ 30% was observed in 18% in the controls and in 12% of the GIK group (P = 0.01). CONCLUSION: Treatment with GIK has no effect on myocardial function as determined by LVEF and by the pattern or magnitude of enzyme release. However, left ventricular function was preserved in GIK treated patients