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ARYA Atheroscler. 2012 Spring; 8(1): 46–49.
PMCID: PMC3448456
Evaluation of fibrinolytic medical therapy for patients with acute myocardial infarction
Ali Maleki,(1) Arman Shariari,(2) Masoumeh Sadeghi,(3) Negin Rashidi,(4) Farshid Alyari,(5) Saeid Forughi,(6) Behjat Nabatchi,(7) and Reza Ghanavati(8)
1Assistant Professor, Department of Cardiology, Lorestan University of Medical Sciences, Khorramabad, Iran
2General Practitioner, Lorestan University of Medical Sciences, Khorramabad, Iran
3Associate Professor, Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
4Internist, Borujerd Hospitals, Borujerd University of Medical Sciences, Borujerd, Iran
5Pathologist, Imam Khomeini Hospital, Lorestan University of Medical Sciences, Khorramabad, Iran
6MSc, School of Nursing, Lorestan University of Medical Sciences, Khorramabad, Iran
7BSc, Nurse, Borujerd Hospitals, Borujerd University of Medical Sciences, Borujerd, Iran
8Cardiologist, Borujerd Hospitals, Borujerd University of Medical Sciences, Borujerd, Iran
Correspondence To: Ali Maleki, Email:dralimaleki/at/yahoo.com
Received January 5, 2012; Accepted March 12, 2012.
BACKGROUND
Fibrinolytic therapy is the standard therapeutic method for patients with acute myocardial infarction (AMI). This study endeavored to assess the delay in arrival to the emergency department and door to needle time for thrombolytic therapy.
METHODS
This study was conducted on 80 patients with AMI whom referred to our clinic from January 2009 to January 2010. We measured time of arrival, needle time and door to needle time for all patients. Moreover, the relations of these times to some variables such as age, gender and the referred shift of emergency department personnel were calculated.
RESULTS
A total of 80 patients, 62 (77.5%) male and 18 (22.5%) female were evaluated for thrombolytic therapy. The arrival time of overnight shifts was 14.59 ± 1.23 minutes shorter than other shifts. The median door to needle time was 46.56 minutes and the mean time of the onset of chest pain to arrival at the emergency department was 19.44 minutes. Seventy-two patients (90%) received fibrinolytic therapy within the first 30 minutes of arrival. The needle time was significantly longer in the night shift (P < 0.05) (between 8 to 14 minutes), while the time of receiving Streptokinase therapy in the other shifts was not meaningfully different. Finally there was a statistically significant difference between the referred shifts and needle time (P < 0.05).
CONCLUSION
Despite our good results for door to needle time, to improve and attain the gold standard’s limits in administering fibrinolytic therapy, improvement of policies like training the personnel to shorten this time is recommend.
Keywords: Fibrinolytic Therapy, Door to Needle Time, Acute Myocardial Infarction
The incidence and prevalence of coronary heart disease (CHD) and acute myocardial infarction (AMI) among the Iranian population has increased. However, acute ST-elevation myocardial infarction (STEMI) is a cardiac emergency with a high early (first hour) mortality rate.1However, recently advancement in coronary interventional techniques and medical therapy has been introduced. For maintenance of the patency of STEMI in the patients, direct precutaneous recanalization and systemic anticoagulation following fibrinolytic therapy, is recommended.2,3The management of AMI patients at first time of referral is crucial. There are some care considerations for MI victims to minimize the patients discomfort and distress. These methods include initial diagnosis and early risk stratification. Early care, subsequent care for latent complications and risk assessment prevent coronary artery disease (CAD) progression.4Patients with AMI, as diagnosed by clinical symptoms, and ST segment elevation must receive fibrinolytic medicines with the minimum of dosage. A realistic aim is to initiate fibrinolysis within90 minutes of the moment patients call for medical treatment (needle time) or within 30 minutes of arrival at the hospital (door to needle time).Thrombolytic therapy should not be administrated to patients who arrive with infraction after more than 12 hours.5-8Streptokinase (SK) is one of fibrinolytic therapy regimes which has the advantages of low cost and availability in Iran. But this therapy consumption had the golden time of three hours; its efficacies decrease dramatically afterwards, and become absolutely useless after 12 hours. The aim of the present study was to evaluate the door to needle time and needle time due to the importance of timely diagnosis of AMI.
In this descriptive study eighty patients with acute ST elevation MI (aged 59 ± 10.85, male = 62) referred to the emergency heart clinic from January 2009 to January 2010. Diagnosis of acute myocardial infarction was confirmed via ST segment elevation in initial EKG and cardiac enzymes measurement. All these patients were qualified for SK therapy. Furthermore, due to the importance of early fibrinolytic therapy in prognosis of the patients with AMI, the time of arrival, needle time and door to needle time were recorded. In addition, the relations of these times to some other variables such as age, referred shift and gender were calculated. We used SPSS for Windows, version 11.5 (SPSS Inc., Chicago, IL, USA) for all statistical procedures. Data were expressed as mean ± SD or as proportions of the sample size. Differences in proportions were judged by χ2 test. A two-tailed P-valve of smaller than 0.05 was considered statistically significant.
In this study 62 (77.5%) males and 18 (22.5%) females were evaluated for SK therapy. Most of these patients (63) had between 50 to 69 years of age. Our studied patients referred to our clinic during different shifts. 23 (28.8%), 21 (26.3%), 14 (17.5%) and 22(27.5%) patients referred in the morning (7 am -1pm), noon (1pm-7 pm), afternoon (7pm-12 am) and night (12 am-7 am) shifts, respectively. There was no significant difference between our studied individuals in various shifts (P > 0.05). The arrival time at night was 14.59 ± 1.23 minutes shorter than other shifts. Door to needle time was equal between different gender and different shifts. Evaluation of our patients’ showed that the shortest SK therapy was in the morning (42.62 minutes), and then the noon shift (43.33 minutes). Seventy-two patients (90%) received fibrinolytic therapy within the first 30 minutes of arrival time. in addition; we observed a maximum of 180 minutes for arrival time. The needle time was significantly longer in the night shift (P < 0.05) (between 8 to 14 minutes), while receiving SK therapy, in the other shifts did not show a meaningful difference (Table 1). The longest delay for administration of fibrinolytic therapy was related to the ages between 40-49 years. Finally there was a statistically significant difference between different referred shifts and needle time (P < 0.05). (Figure 1).
Table 1
Table 1
Evaluation of the measured duration related to gender and referred shift
Figure 1
Figure 1
Measured duration related to fibrinolytic therapy in this study
The results of this study showed that fibrinolytic therapy was administrated to the majority of patients with AMI within 46 minutes of arriving at the hospital. Comparing the duration of our door to needle time with the other study centers revealed that our center’s records was markedly shorter.8-10 This finding could be emphasizing not only our health center workers’ talent but also the general population’s eagerness to reduce the delay in referring to the hospital after onset of the chest pain. There are many factors associated with prolonged delay for fibrinolytic therapy like age, sex and having symptoms during different shifts. Some previous studies identified gross waiting time for fibrinolytic agent to arrive from the pharmacy, but they could not find any data to support their observation.11
Abba et al. reported the mean door to needle time to be 95 minutes, and the mean time of onset of chest pain to arrival ED to be 5 hours.8Tahoe N. et al. evaluated door to needle time of seventeen hospitals in the USA and found that admission time to the emergency department lasted 12 minutes and only48.8% of studied patients received fibrinolytic therapy within the first30 minutes.12Moreover only 12% of studied individuals in the study of Brahmajee K. et al. reported the same amount of time until receiving fibrinolytic therapy.13Tahoe N. et al. found the longest prolonged door to needle time within female patients of more than 75 years of age.12Furthermore, our study supported their findings and reported a significantly higher needle time for female patients however, we found this delay to be maximum (59.73minutes) for ages between 40 to 49 years. Moreover, the door to needle time in patients of higher than 70years of age (39.11 minutes) was second in rank after patients with lower than 40 years of age (27.6minutes). This difference is probably related to the different cultural backgrounds of the study participants. In addition, our results indicated that our patients experience shorter delay in ED for diagnosis and initiation of the first therapeutic interventions by the emergency personnel (physicians, nurses or cardiology consultants).
Even though, our records were close to those of approved global records, we are still far from the gold standards, which need more hard work. It is known, that to improve the administration of fibrinolytic therapy in time, a center should set well-established policies like training the personnel and/or reevaluating the processes and steps of admission and diagnosis of the patients.
Footnotes
Conflicts of Interest
Authors have no conflict of interests.
1. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 FocusedUpdate of the ACC/AHA 2004 Guidelines for theManagement of Patients With ST-ElevationMyocardial Infarction: a report of the AmericanCollege of Cardiology/American Heart AssociationTask Force on Practice Guidelines: developed incollaboration With the Canadian CardiovascularSociety endorsed by the American Academy ofFamily Physicians: 2007 Writing Group to ReviewNew Evidence and Update the ACC/AHA 2004Guidelines for the Management of Patients With STElevationMyocardial Infarction, Writing on Behalfof the 2004 Writing Committee. Circulation. 2008;117(2):296–329. [PubMed]
2. Antman EM. The search for replacements forunfractionated heparin. Circulation. 2001;103(18):2310–4. [PubMed]
3. Hirsh J, O'Donnell M, Eikelboom JW. Beyondunfractionated heparin and warfarin: current andfuture advances. Circulation. 2007;116(5):552–60. [PubMed]
4. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al. Management ofacute myocardial infarction in patients presentingwith persistent ST-segment elevation: the Task Forceon the Management of ST-Segment Elevation AcuteMyocardial Infarction of the European Society ofCardiology. Eur Heart J. 2008;29(23):2909–45. [PubMed]
5. Antman EM, Bennett JS, Daugherty A, Furberg C, Roberts H, Taubert KA. Use of nonsteroidalantiinflammatory drugs: an update for clinicians: ascientific statement from the American HeartAssociation. Circulation. 2007;115(12):1634–42. [PubMed]
6. Fox KA, Mehta SR, Peters R, Zhao F, Lakkis N, Gersh BJ, et al. Benefits and risks of the combinationof clopidogrel and aspirin in patients undergoingsurgical revascularization for non-ST-elevation acutecoronary syndrome: the Clopidogrel in Unstableangina to prevent Recurrent ischemic Events (CURE)Trial. Circulation. 2004;110(10):1202–8. [PubMed]
7. Beinart SC, Kolm P, Veledar E, Zhang Z, Mahoney EM, Bouin O, et al. Long-term cost effectiveness ofearly and sustained dual oral antiplatelet therapy withclopidogrel given for up to one year afterpercutaneous coronary intervention results: from theClopidogrel for the Reduction of Events DuringObservation (CREDO) trial. J Am Coll Cardiol. 2005;46(5):761–9. [PubMed]
8. Abba AA, Wani BA, Rahmatullah RA, Khalil MZ, Kumo AM, Ghonaim MA. Door to needle time inadministering thrombolytic therapy for acutemyocardial infarction. Saudi Med J. 2003;24(4):361–4. [PubMed]
9. Nallamothu BK, Bates ER. Percutaneous coronaryintervention versus fibrinolytic therapy in acutemyocardial infarction: is timing (almost) everything? Am J Cardiol. 2003;92(7):824–6. [PubMed]
10. Gonzalez ER, Jones LA, Ornato JP, Bleecker GC, Strauss MJ. Hospital delays and problems withthrombolytic administration in patients receivingthrombolytic therapy: a multicenter prospectiveassessment. Virginia Thrombolytic Study Group. AnnEmerg Med. 1992;21(10):1215–21. [PubMed]
11. Sharkey SW, Bruneete DD, Ruiz E, Hession WT, Wysham DG, Goldenberg IF, et al. An analysis oftime delays preceding thrombolysis for acutemyocardial infarction. JAMA. 1989;262(22):3171–4. [PubMed]
12. Tahoe N, Kannel WB, Wilson A. Thrombolitictherapy in acute Myocardial infarction. JAMA. 2003;261:1757–62.
13. Brahmajee K, Pharoah PO, Ventava SK. Reperfusiontherapy in Myocardial infarction. Am J Pulic Health. 2003;151:7–13.
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