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Chapter 1 Introduction / Background 1.

1 Overview of the study Acute Myocardial Infarction Myocardial infarction remains a major cause of morbidity and mortality worldwide according to White & Chew, 2008.Coronary heart disease (CHD) or Cardiovascular disease (CVD) on the other hand as reported by World Health Organisation (WHO, 2008) is still the leading cause of death worldwide. This is reported in their fact sheet on The Top Ten Causes of death. The total number of death in 2004 was 59 million, and out of this figure, 7.2 million died of CHD. The British Heart Foundation, 2004 as cited in Clinical Guidelines and Evidence Review for Post Myocardial Infarction (2007) stated that: ³« has estimated that there are about 147 000 myocardial infarctions (MIs) per year in men of all ages in the UK and 121,000 in women, giving a total of 268 000 cases. In the UK, about 838 000 men and 394 000 women have had an MI´.

Myocardial Infarction accounts for 9 to 13% of all deaths, except in France, which is approximately 5%, according to registries done in European countries (Bergman, 2009). However, an update on Heart Disease and Stroke Statistics in Circulation by Roger et al (2011) reported that there is a decreasing trend in deaths from CHD (see Appendix 1). Nevertheless, compared to cancer (n=831), it remains in the top spot (n=560) (see Appendix 2). They claimed that this downward trend of the disease is attributed to the result of aggressive steps taken by department of health in starting vigorous programme that

encourages healthful lifestyles to prevent these diseases. For example, the implementation of Clinical Guideline 48(CG48) [Myocardial infarction: full guideline Final (May 2007)] , is a detailed guideline for patients who had MI that covers, i) Lifestyle Changes & Cardiac Rehabilitation, ii) Secondary Prevention Drug Treatment, iii) Cardiological Assessment. On the contrary, this trend may not be applicable to the developing countries where health care services are not well developed. According to White & Chew (2008), urbanisation has led to increasing rates of obesity and diabetes thus this resulting in an emerging epidemic of coronary heart disease. They further reiterated that clinical and system-specific lessons learned in the developed world should be effectively applied to the address the upcoming epidemic and this is a crucial task in the global health agenda.

A significant finding gathered from the Malaysian National Cardiovascular DatabasePercutaneous Coronary Intervention Registry (MNCVD-PCIR), 2007 annual report shows that 71.4% of patients who had Myocardial infarction that had undergone elective PCI. It is found from this registry that PCI in Acute Myocardial Infarction is performed at mean age of 56.7 years which is comparatively younger than in most developed countries (56.7 year old in MNCVD-PCI vs. 65.7 years old in Swedish Coronary Angiography and Angioplasty Register (SCAAR).

The American Heart Association journal, Circulation (2011), revealed 2007¶s mortality rate data from Cardiovascular Disease (CVD). It stated that more than 2200 Americans die each day, an average of 1 death every 39 seconds. A total of 406 351deaths was reported in 2007. This report highlights the criticality of monitoring the cost of healthcare utilisation apart from

emphasising adherence to the clinical guidelines. This is to ensure quality healthcare delivery with regard to CVD. Besides, critical data provided in the update include estimates of direct and indirect healthcare cost of treating CVD and stroke, estimated to be $286 billion. It is costly to treat CVD, in fact more than any other diagnostic group according to this report. Likewise, the National Health Service (NHS), (Squire 2002) reported on the devastating effects of death from CHD and stroke to the sufferers as well as the family members. There in lies the implication of incurred cost incurred.

In a study to calculate cost incurred for revascularisation, Weintraub, et al (2000) carried out a randomized trial that compared, by intention to treat, the clinical outcome and costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary bypass grafting (CABG) for multi vessels coronary artery disease. They found that the primary procedural costs of CABG are more than those for Percutaneous Transluminal Coronary Angioplasty (PTCA). Total 8-year cumulative costs were $46,548 for CABG and $44,491 for PTCA (p = 0.37). Cost information as well as the aggregate of patients with a particular diagnosis is crucial data that form the basis for health care planning and resource allocation (Thygesen, et al 2007).

Management of Acute Myocardial Infarction Acute Myocardial Infarction (AMI) is a medical emergency that requires early diagnosis, speed of action and early reperfusion therapy (Antman, et al 2007). This is according to the 2007 Updated Guidelines by the American Heart Association (AHA) / American College of Cardiology (ACC) and European Society of Cardiology (ESC) Guidelines on AMI management to improve survival rate.

Definition of Myocardial Infarction Acute myocardial infarction is defined as myocardial cell death due to prolonged myocardial ischemia as a result of blocked coronary artery. The Global Task Force comprising of the ESC, ACC, AHA and World Heart Federation (WHF) 2007, convened and redefined acute myocardial infarction. The outcome of this decision available in µExpert Consensus Document¶ thereby replaces the 2004 guideline. The redefinition as stated by these experts arises from and is compatible with the latest scientific knowledge and advances in technology, particularly with regard to the use of bio-markers, high quality electrocardiography and imaging techniques. Consequently, this redefinition will also have impact on the identification, prevention, and treatment of cardiovascular disease throughout the world. The team acknowledges the critical consequences of the change in MI definition in the less developed and developing countries as this will affect the overall cost in the management of this disease as more resources are required.

According to the updated guideline myocyte necrosis is better determined by the biomarkers troponins in the setting of ischemia. These biomarkers, Troponin T & I, are more sensitive and specific measurement of myocyte necrosis as compared to creatine kinase or creatine kinaseMB. The great majority of patients will show a typical rise of these biomarkers. The clinical signs and symptoms presented by patients are chest pain for •20 min, shortness of breath and ST-segment elevation persistent on the ECG of >1 mm in •2 or more standard or •2 mm in •2 contiguous precordial leads or the presence of left bundle branch block are the hallmark. Cardiogenic shock is still relatively common in patients with AMI.

Management of STEMI The management of STEMI is based on the 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction (Antman et al.  Type 4b ± Myocardial infarction associated with verified stent thrombosis. but death occurring before blood samples could be obtained. STEMI patients presenting to a hospital with PCI capability should be treated with primary PCI within 90 minutes of first medical contact as a systems goal.  Type 5 ± Myocardial infarction associated with CABG. or hypotension.  Type 2 ± Myocardial infarction secondary to ischemia due to imbalance between oxygen demand and supply e. Drugs used in early thrombolysis are discussed by NICE. 2010. or verified coronary thrombus by angiography or autopsy.  Type 3 ± Sudden cardiac death with symptoms of ischemia. 2007). Primary PCI i. accompanied by new ST elevation or LBBB. coronary spasm. fissuring or dissection. anaemia.  Type 4a ± Myocardial infarction associated with PCI.g. Appended below is the current treatment recommendation by the 2007 Focused Update: Reperfusion Therapy: 1. .AMI is clinically classified into 4 different types namely:  Type 1 ± Spontaneous myocardial infarction related to ischemia due to a primary coronary event such as plague erosion or rupture.

Facilitated PCI using regimen other than full-dose fibrinolytic therapy might be considered in higher risk patient.ii. This is the current 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2005 Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines by Kushner. Immediate or Emergency Invasive Strategy and Rescue PCI  A strategy of coronary angiography with the intent to perform PCI(or emergency CABG) is recommended for patients who have received fibrinolytic therapy and have any of the following: a. Severe congestive cardiac failure and/or pulmonary oedema c. b. However in 2009 the task force once again convened for a focused update after receiving new results from clinical. Hemodynamically compromising ventricular arrhythmias. iii. Cardiogenic shock in patients less than 75 years who are suitable candidates for revascularisation. when PCI is not immediately available within 90 minutes and bleeding risk is low. Thrombolytic Therapy  STEMI patients presenting to a hospital without PCI capability and who cannot be transferred to a PCI centre and undergo PCI within 90 minutes of first medical . 2. et al (2009) stated that the terms facilitated PCI and rescue PCI are no longer used for the recommendations. They believe that these terms are potentially misleading.

Tenecteplase and Streptokinase.  Examples of Fibrinolytic Agents are: Alteplase.contact should be treated with thrombolytic / fibrinolytic therapy within 30 minutes of hospital presentation as a systems goal unless fibrinolytic therapy is contraindicated. As such the incidence of myocardial infarction may be taken as a proxy. According to these authors it is difficult to measure the prevalence of coronary artery disease in a population.´ (Thygesen. It is therefore critical to have a consistent definition when comparing populations of different countries. Significance of the Subject Cardiovascular disease is a global health problem of which about one-third of the world¶s mortality arise from coronary artery disease and stroke. 80% of these deaths occur in developing countries (Thygesen. Reteplase. p. et al 2007. Fibrinolytic Agents derive the greatest benefit within 30 minutes± 3 hours particularly with large inferior wall MI. Thygesen. during and after thrombolysis as well as strict compliance to absolute and relative contraindications of the treatment strategy are of utmost importance. . et al 2007). Adherence to treatment protocol before.14). of which myocardial infarction is a major manifestation. et al further stated ³the greater proportion of deaths is due to heart disease and specifically coronary heart disease. Sadly.

72). according to Mathews (2006) is the systematic study of materials and sources in order to reach new conclusions from established facts. However. outlined the following strategies to be employed in order achieve optimum patient outcomes in myocardial infarction. it is the writer¶s genuine interest to explore the wealth of research on the subject as it is has direct relationship to the area of present practice placement. White & Chew (2008) pointed out that a crucial task in the global health agenda is to translate the clinical and system specific lessons learned from research especially to those not well represented in clinical trials that remain at increased risk of adverse events. The findings from research are then disseminated and translated into practice (Parahoo. ii) Proven therapies. explicit. The successful promotion and protection of health and well-being is achieved through research (DH 2005). and judicious use of current best evidence in making decisions about the care of individual patients. states that developing practice policies as well as making practice decision should be based on . 2006). The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research«´ (Sackett. White & Chew (2008). i) Accurate risk stratification. Personally. the bottom line is the delivery of safe and quality care to all patients through the successful translation and implementations of the research findings (Parahoo. Crombie (2000) stated that there must be a substantial body of research that involves different studies in order for the new research findings to be accepted. such as elderly patients and those with renal failure. 2006). et al 1996. These are shown as. et al state that ³« Evidence based medicine is the conscientious.Similarly. p. iii) Effective systems (see Appendix 3). Ultimately. Research. Sackett. Johnson (2001).

every nurse is responsible to engage in one or more roles in the continuum of research participation. according to Polit & Beck (2008). 1. Objectives To examine the outcomes following the treatment in terms of: Mortality Reinfarction Stroke Quality of Life (QoL) Economic evaluation y y y y y Chapter 2 Methodology .Elevation Myocardial Infarction (STEMI) that had undergone Percutaneous Coronary Intervention (PCI) compared to those treated with thrombolysis. Besides.evidence from research.1 Research Objectives Aim of Assignment The aim of this assignment is to explore and analyse the evidence pertaining to the management of patients who have suffered ST.

This helps one to familiarise with the knowledge base (Polit et al. Findings from research are utilised for example. Reliability according to Polit and Beck (2006). these key words and medical subject heading (Me SH) were utilised µMyocardial infarction treatment¶ or µrevascularisation¶ or µthrombolysis¶ or µpercutaneous coronary intervention¶ or µoutcome¶ or . For the initial search. It is impossible to retrieve and analyse all of the articles within this short time frame. The result of this literature search is therefore akin to seeing the tip of an ice berg. is the accuracy and consistency of the information obtained plus the validity of the of the study¶s evidence. Subject Identification After getting a good overview of the subject. the next task was to conduct an extensive literature search. it must is must be closely monitored and evaluated (Holloway & Wheeler 2002). However. The aim of searching the literature is to gather and identify available published evidence to answer questions about practice or the questions that researchers pose (Gerrish & Lacey 2010). A research article needs to be reliable and valid. It is hereby acknowledged that this is a limited and non-exhaustive review as there is such a vast collection of research on this subject. Manual and internet based search engines were employed using key words and phrases to access and retrieve the relevant articles. However. 2005). an updated Clinical Guidelines is one of the ways of translating evidence into practice.To obtain a good overview of the subject of interest. an initial reading must be performed to identify and gather the current trends and practices concerning it. Cormack (2000) stated that not all articles that are published are of the same quality and they possess both strengths and weaknesses.

2011). The search engine Summon was used as it enables one to search for journal articles in selected database as well as in more than one databases at the same time. the university¶s webpage. settings and circumstances. A combination of more than one key words and synonyms is required in order to derive more specific results (Burns and Grove. 2001). 2003). The Cumulative Index to Nursing & Allied Health Literature (CINAHL) and Medical . The greater strength of evidence according to the hierarchy is by systematic reviews of randomised controlled trials. Uncontrolled trials. i) linked full text ii) abstract available iii) published date within the last 15 years (1995-2011) iv) English language articles only v) research based and randomised controlled trial articles (see Appendix 5). Literature Type It is crucial to consider the type of literature chosen based on the hierarchy of evidence. Searching Technique Electronic search for relevant articles from the electronic databases was initiated through Metalib. 1995). descriptive studies and expert opinion are ranked lower in strength of evidence (Evan. The following inclusion criteria were identified. The principal of Boolean logic was used with the search terms to obtain a much wider search of electronic data (Cohen.µquality of life¶ or µmortality¶. It is important to consider the choice of inclusion criteria as it has implication on the interpretation of results and generalisability of findings (Polit et al. Limiting the search Limiting a search is a valuable part of the search strategy. randomised controlled trials and multicentre studies because they are derived from multiple populations.

Foreword and backward searches on names of scholars cited in relevant articles were done as well. This framework is a useful tool in helping one to stay focus on the . veterinary medicine and health care and is popular with nurse researchers. CINAHL and MEDLINE are two electronic databases that are most reliable and useful for nurse researchers. For this purpose obtaining the best available evidence is vital for end-users (National Health Service (NHS) Centre for Reviews and Dissemination. MEDLINE is a premier source of biomedical literature covering medicine. The review of the literature is carried out in an organised manner. 2004). 2006). However. The result was 188625 hits. pharmacy. Exhaustive searches were performed by using keywords and medical subject headings. this was further narrowed and specified until only the most relevant articles were retrieved after selection and regrouping.Literature Analysis and Retrieval System Online (MEDLINE) were used as being more appropriate for the subject chosen. The intent is to present a strong knowledge base for the conduct of research project and to develop a sound study foundation (Wood & Haber. The most relevant articles retrieved were reviewed using Cormack (2000) framework to assist in the identification of strengths and weaknesses of the articles (see Appendix 6). 1996). Managing and abstracting the Literature Research must be evaluated for credibility and integrity before it is utilised to develop practice guidelines and clinical recommendations or implementing the results in area of practice. midwifery and allied health as well as books and book chapters (Polit and Beck. nursing. CINAHL covers literature related to all aspects of nursing. dentistry.

The Ethical Issues The ethical aspect of undertaking a research must be complied with. . For example. Playle. Access to the electric databases via the university¶s blackboard for journal and electronic books were easy and reliable. critical appraisal of the study¶s strengths and limitations. A time frame was given to accomplish the project. as statement to provide guidance to physicians and other participants in medical research involving human subjects. The principles of Ethical Codes include beneficence which is the duty to do good while non maleficence is to minimise harm during research (Royal College of Nursing RCN 2004). 2000). repeatability. reliability. (2000) added that a research that is credible possesses good validity. Each selected article is summarised according to the headings and these summaries are expanded in the main body of the literature review. predictive ability. Resources The university has assigned a supervisor to provide support and assistance for the project. The criteria that are crucial in all research are validity and reliability.aims and objectives. Interactions and feedback from supervisors via Unimail is possible and available at all times. The veracity and credibility of findings are judged based on these (Cormack. Critical Analysis A research critique according to Polit & Beck (2006) is a careful. and discriminative ability. the Nuremburg Code (1949) provided a basis for the World Health Organisations Declaration of Helsinki in 1964. specificity.

reinfarction. with . The results of this review showed a statistically significant benefit for people receiving immediate angioplasty over hospital thrombolysis. morbidity and quality of life (Qol) and its cost effectiveness. ii) reinfarction rates of 50% reduced risk. Examine the outcomes in terms of mortality. two updated RCTs and four new RCTs to examine the clinical effectiveness of immediate angioplasty. Explore the Evidence Pertaining to the Management of STEMI. Chapter 3 Results The final articles chosen in hierarchy of level of evidence are twelve in total. three randomised controlled trials. The studies included in this review were those published before December 2002. was undertaken by Hartwell. A research that is of poor quality will not be useful as it does not contribute to the existing knowledge and such is considered unethical (DH 2005). i) mortality there was a 30% reduced risk. with Absolute Risk Reduction (ARR) of 2%. et al (2005). bleeding. Informed consent from all participating subjects and maintaining confidentiality are of utmost importance. five observational studies on registries. stroke and cost of treatment. Systematic Reviews A systematic review of eleven RCTs. comprising of three systematic reviews of randomised controlled trials.All research that involve human subjects need to be submitted to the local research ethical committee (LERC) for approval and monitoring to ensure that they are ethically sound. On the outcomes. taking into account its effect on mortality. Comparing Percutaneous Coronary Intervention (PCI) and Thrombolysis (TL) .

They posed the question. where geography does not allow PPCI in all patients with MI. Limitations acknowledged were that the clinical evidence came mainly from the USA. fibrinolysis remains a legitimate option in low risk patients because of the small absolute risk reduction in this cohort.763 patients from 22 clinical trials published between January 1990 and December 2002. the risk score might be used to select those higher risk patients who benefit most from PPCI. µDoes time matter?¶ bringing into focus the . The authors adhered fully with the research protocol in undertaking the systematic review.5%. This is a large scale study of the highest level of evidence. with ARR 1. they emphasised that if access to the PCI-able facility is >2 hours. Limitations were not mentioned. They suggested that in regions where hospitals with PCI facility are rare. a systematic. There was no vested interest on the part of the authors in performing the review. The following were the outcomes of the review: i) PPCI is consistently associated with a strong reduction in 30-day mortality irrespective of patients baseline risk and should be considered as the first choice of reperfusion therapy whenever feasible. However. To find out the clinical benefits of PPCI compared with in-hospital fibrinolysis (FL). In terms of economic evaluation the authors found that PCI appeared to be cost effective compared to thrombolysis for people with AMI providing additional benefits in health at a higher cost. This involved a systematic review of 6. De Boer et al (2011) evaluated on the efficacy and safety of Primary Percutaneous Coronary Intervention (PPCI) versus Fibrinolysis. iii) stroke rates 65% reduced risk. Their objectives were to i) find out which category of MI patients would benefit most from the strategy of PPCI.ARR 4%. pooled analysis of 22 randomised clinical trials (n=6763) was carried out by Boersma et al (2006). ii) to examine whether the relative and absolute mortality reductions by PPCI were modified by the estimated baseline mortality risk.

that PPCI reduced the risk of re-infarction in the overall cohort as well as reduced re-infarction and mortality among patients randomised at referral hospitals. The findings after 7. It was discovered that PCIrelated delay exceeding 50 minutes would nullify its benefits. they suggested that it would be ideal to conduct a large randomised trial by enrolling a broad spectrum of AMI in preference to meta-analysis. From this large scale review they concluded the following: i) Overall death was 6. i) 1129 at a referral hospitals ii) 443 patients at invasive hospitals to PPCI or fibrinolysis (FL).7% of FL and 2.4% in PPCI. a RCT was undertaken by Nielson et al (2010) called the Danish Acute Myocardial Infarction 2 (DANAMI-2) in which subjects were enrolled from December 1997 till October 2001. To investigate whether the benefit of PPCI was maintained at a long-term follow-up. The study complied fully with the research protocol.9% was from fibrinolysis while 5. Randomised Controlled Trials Newal and Bernard (2006) stated that a Randomised Controlled Trial is said to be the gold standard method of demonstrating in rigorously scientific manner that a new treatment is effective. This finding reinforces that PPCI should be offered to STEMI patients when inter hospital transport . They made an important conclusion here by recommending that timely treatment is vital and time matters. The primary end point was a composite of death or clinical re-infarction.familiar adage in the cardiovascular community that µtime is myocardium¶. In this RCT a total of 1572 STEMI patients were randomised.8 years follow-up were: i) the benefits of PPCI over fibrinolysis was maintained at a long-term follow-up.6% within 30-day of randomisation ii) 30-day death rate of 7.3% death from PPCI iii) 30-day mortality increased two fold as the presentation delay increased from less than 1 hour to 6 hours iv) reinfarction occurred in 6. Lastly. They acknowledged the limitation that selection of trials may be prone to bias.

A total of 266 patients (age range: 75-94 years old) were . The authors acknowledged that this might be attributed to limitation. there was a shorter treatment delay in fibrinolysis over angioplasty. However. It was a randomised multicentre. However. Bonnefoy et al (2002) carried out a multicentre RCT that recruited 840 patients from June 30.to a PCI centre can be completed within 2 hours. The study was done from 2005-2007. They concluded that primary angioplasty is no better than pre-hospital fibrinolysis followed by transfer for possible emergency coronary angioplasty. open-label clinical trial that adhered to all ethical aspects of a trial process. The European guidelines differ slightly in that they recommend fibrinolytic treatment if PPCI cannot be reliably performed by a hospital system within 90 minutes of first medical contact when symptom duration is <2 hours but accept up to 120 minutes since first medical contact when symptom duration is >2 hours. The American guidelines recommend fibrinolytic therapy if PPCI cannot be reliably performed by a hospital system within 90 minutes of first medical contact. the authors acknowledged that this conclusion differs from the American and the European guidelines. ii) In the primary angioplasty arm there was lower recurrence of re-infarction and stroke. This study complied fully with the research protocol. At 30-day follow-up the results were. The results of the study were rather unexpected compared to other studies. i) in the fibrinolysis arm the mortality was unexpectedly low. 2000. The purpose was to find out whether primary angioplasty was better than pre-hospital fibrinolysis. In addition. Bueno et al (2011) chose to compare PPCI and fibrinolysis in the very old patients (•75years old) with STEMI in whom head to head comparisons were scarce. The target number of enrolment was 1200 patients but it was not achieved due to termination of funding. consistent with previous findings. 1997 to September 30. the investigators randomised relatively young patients with average age of 58 years old.

re-infarction or stroke at 30 days. There was no difference in re-infarction (4.successfully randomised. Observational studies also contribute good clinical evidence.2%.18). the study was terminated prematurely before the planned enrolment could be met due to slow recruitment. female gender.4%no early PCI). .2% in the TL group. early contemporary fibrinolytic therapy may be a safe alternative to PPCI in the elderly when this is not available particularly when it is initiated early. Independent predictors of a higher hospital mortality were shock.43). they stated that primary PCI seemed to be the best reperfusion therapy for STEMI even in the oldest patients. 17. p= 0. Nevertheless. p=0. Out of 266 patients.2% in patients receiving early PCI.3 vs. Finally.8 vs. Out of the 34. 487 received angioplasty and 10. 3. Unfortunately.0%. the authors reported these findings: i) the results provided good evidence that PPCI improved outcomes. It was noted that hospital mortality was 7. The aim was to study the current use. The authors also did a pooled analysis with two previous reperfusion trials in older patients and it showed an advantage of PPCI over fibrinolysis in reducing death. The authors acknowledged that there could be selection bias in this study as treatment to early PCI was totally at the discretion of the physician. predictors and clinical outcome of early PCI in patient with STEMI. re-infarction (5.2%.6 vs. Nevertheless. Koeth et al (2008) undertook a prospective multi-centre observational study of 34. compared to 11.6%early PPCI / 4. p=0. 134 were allocated to PPCI and 132 to fibrinolysis. A non significant reductions were found in death (13. 8.600 were treated with thrombolysis (TL).276 consecutive patients from 1994-2002 from a data pool of current treatment of AMI.113 received PCI >24 hours after thrombolysis. age >65 years.276 patients 10. an anterior STEMI and a pre-hospital delay of >3 hours.35) or disabling stroke (0.

iv) mortality for patients treated by TL between 3. in terms of staffing which plays important role. They stated these findings. i) PPCI was the dominant reperfusion strategy in 16 countries and thrombolysis (TL) in 8 countries. i) that the number of countries that participated may not be representative of the national registries as well as not representative of the countries¶ total population. ii) the use of PPCI strategy varied between 5 and 92%. The authors found that. 99 (3. Another prospective.5 and 14% while mortality by PPCI was between 2. It comprised of data collected in years 2007-2008 for most countries. ii) data gathered were not of the same period.617 patients. The study involved 30 ESC countries that offered non-stop 24 hours/day and 7 days/week PPCI services. but in 2005 or 2006 for a few who had no recent data available. iii) it is possible that hospitals using primary PCI have better resources allocation and organisation that allow better management of all aspects of AMI for e. iii) in-hospital mortality of all consecutive STEMI patients varied between 4. systematic study was done by Littieri et al (2005).7 and 8%.g.5%.Widimsky et al (2009) conducted a comparative analysis study on the use of reperfusion treatments for STEMI across Europe at the time when these new European Society of Cardiology (ESC) guidelines were published. The study population was 2. that had undergone emergency PCI with an established regional network. A few limitations acknowledged were. They evaluated the inhospital and post discharge outcomes of with regard to vital and neurological status of STEMI patients surviving out-of-hospital cardiac arrest (OUCHA). iv) this retrospective study lacked rigour in defining the same entry criteria. and the use of TL between 0 and 55% of all STEMI. a) in-hospital i) mortality was higher among OUCHA .2 and 13. as well as identified factors predicting in-hospital mortality.8%) of whom had experienced an OUCHA. This was a large scale study that portrayed a more current data on the actual practices.

c) At 12 months 67 (87%) survivors showed almost complete neurological recovery. The limitation of the study was that 20% of the OUCHA data were collected retrospectively and therefore may lack the power of analysis.patients but a much lower mortality rate compared to previous series of OUCHA. An observational study on the impact of delay door-to-needle time on mortality was carried out by McNamara et al (2007). ii) there was a need for further urgent revascularisation. There was a reduction in door to needle time of 62 minutes in 1990 to 38 minutes in 1999. Dudek et al (2008) undertook a study to monitor the components and timings of the interventional treatment of patients with STEMI in the setting of transfer networks. iii) major bleeding was significantly more frequent. This study focused specially on the timing of abciximab application and related clinical outcomes. i) shorter door-to-needle time was associated with lower in-hospital mortality. A multinational European Registry (EUROTRANSFER). ii) in-hospital mortality rates were 8.5% in patient treated within 15 minutes. d) At 1 year two thirds had favourable neurological outcome.2% in patients with door-to-needle time >100 minutes and 2.470 patients using detailed patient-level data from the National Registry of MI (NRMI) from 1999 to 2002. they said that door-to-needle time may be a proxy for general quality of care. Finally. These results confirmed other earlier studies that longer door to needle time increased mortality.650 patients from the 15 STEMI networks from 7 . after discharge the rate of death and re-infarction and revascularisation were similar among those with or without OUCHA. This is a large database which was reasonably generalisable. The analysis was carried out on 67. In the limitation they stated that more than half of the patients who received thrombolysis were subsequently transferred to another hospital. 1. b) At 6/12. The results were. the relation with mortality may reflect unobserved quality measures.

i) lowest mortality rates found in the 727 patients who received early abciximab ever reported in STEMI registries (in-hospital at 2.8% and 3. Chapter 4 Discussion Management of STEMI as noted from these articles are either by giving thrombolytics or by percutaneous coronary intervention. 1 year and even at 8 years seemed to be lower than patients treated with thrombolytics. .086 (66%) of patients were administered abciximab. they noted that a slight and insignificant increase in bleeding was seen in the early abciximab group.European countries from November 2005 to January 2007. the incidences of re-infarctions were also found to be reduced in PCI versus thrombolysis. The findings through these extensive reviews of RCTs and registries showed the predominance of PCI over thrombolsis. It is an accepted and established finding from many studies that clinicians choose PCI as the first option of reperfusion therapy for STEMI as proven by the better outcomes. iii) Where cost of treatment is concerned PCI is more expensive but there is better outcome in quality of life post treatment. They reported that this was the most up-to-date treatment patterns and clinical outcomes under real-life conditions in patients transferred for PPCI in European STEMI network. at 6 month. i) 727 patients received abciximab early while 359 patients formed the late abciximab group. However. 1. ii) Similarly. i) The rate of mortality inhospital.9% at 30-day. The outcomes were. iii) there were lower rates of bleeding or stroke in PCI as compared to thrombolysis. ii) a higher mortality was observed in the late abciximab group. Out of the above figure.

et al 2010). though PCI derives better outcomes. This applies in regions where PPCI is not an option. The emergency medical system (EMS) network needs to be established and manned by trained personnel that can diagnose AMI or able to transmit ECG to the emergency department for Physician to interpret so that treatment can be initiated. II. Recommendations PCI is a better reperfusion strategy in the treatment of STEMI over thrombolysis as found by the literatures discussed. door-to-needle time must be within 30 minutes. What matters most according to the authors was the issue of timely treatment. Field triage of all patients to reduce time delay is a crucial point.On the other hand. Timely fibrinolysis in this case is a very acceptable standard of STEMI care (Lambert. thrombolysis still plays an important role as reported by the authors. III. In order to address this: I. . However in both strategies the issue of timeliness is of utmost importance. Transfer of patients who are suitable for PPCI should be done immediately to a PCIable facility. Both therapies required the health care team to adhere to the golden hour reducing time is saving the myocardium and saving the lives of AMI patients. In developing countries thrombolysis is the only option due to the shortage of resources. Ambulance personnel should be trained to give pre-hospital thrombolysis.

However. As a member of the team in the care of the patient it has resulted in a better appreciation of the roles played by the other members of the team in particular the clinicians. Therefore. References Antman. we must stay current by keeping in touch with the best information. This has been a very challenging time but I have learned so much and I thoroughly enjoyed the experience. et al (2007) Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction: A Report of the . the lack of time made it impossible to explore it in wider aspects and this is only the tip of the iceberg. This exercise has enhanced my understanding and knowledge on the current update of STEMI treatment. M.. This subject is of great importance to the writer as there was no opportunity prior to this to undertake this deeper search. This will result in updates of older practices guidelines to be replaced by the better ones as new evidences are found. Management of this disease is dynamic as evidences are always changing as more and more researches are done. Hand.Reflections & Conclusion I have benefited very much through this literature review. E.

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Appendix 1 Chart 3-3. . Deaths due to diseases of the heart (United States: 1900±2007).

Cardiovascular disease (CVD) deaths versus cancer deaths by age (United States: (2007). Adapted from Roger. V. L.123:e18-e20 : Deaths from CVD(Chart 3-3) & Death from CVD vs Cancer(Chart 3-6) Appendix 3 . Circulation 2011. et al. Source: National Center for Health Statistics.Appendix 2 Chart 3-6.

Pages 570-584 : Framework for optimising patient outcomes in acute Myocardial infarction Appendix 4 Figure 1.117:296-329 : Options for Transportation of STEMI Patients and Initial Reperfusion Treatment Goals . Options for Transportation of STEMI Patients and Initial Reperfusion Treatment Goals Adapted from Antman. Issue 9638.Figure 1. et al (2008) 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction in Circulation. 16 August 2008-22 August 2008. Adapted from The Lancet Volume 372. 2008.

If EMS is not capable of administering prehospital fibrinolysis and the patient is transported to a non±PCI-capable hospital. PCI can be initiated promptly within 90 minutes from EMS arrival-to-balloon time at the PCI-capable hospital.Medical System Goals: EMS Transport (Recommended): y y y y If EMS has fibrinolytic capability and the patient qualifies for therapy.Boolean/Phrase Interface . it is appropriate to consider emergency interhospital transfer of the patient to a PCI-capable hospital for mechanical revascularization if There is a contraindication to fibrinolysis.Also search within the full text of the articles Search modes .MEDLINE 247015 Edit S2 .e. "rescue PCI"). If EMS is not capable of administering prehospital fibrinolysis and the patient is transported to a PCI-capable hospital. the EMS arrival-to-balloon time should be within 90 minutes. Published Date from: 19950301-20110331. English Language Expanders .Linked Full Text.EBSCOhost Search Screen . English Language.Linked Full Text.EBSCOhost Search Screen . Research Article.MEDLINE 188625 Edit S3 S2 Myocardial infarction treatment or revascularisation or thrombolysis or percutaneous coronary intervention or outcome or quality of life or mortality Limiters . Appendix 5 Record of Search S3 Myocardial infarction treatment or revascularisation or thrombolysis or percutaneous coronary intervention or outcome or quality of life or mortality Limiters .CINAHL.Advanced Search Database . If EMS takes the patient to a non±PCI-capable hospital.Also search within the full text of the articles Search modes . Abstract Available. prehospital fibrinolysis should be started within 30 minutes of arrival of EMS on the scene. the door-to-needle time should be within 30 minutes for patients for whom fibrinolysis is indicated. Published Date from: 19950301-20110331. Fibrinolysis is administered and is unsuccessful (i.Advanced Search Database .. Randomized Controlled Trial Expanders .CINAHL.Boolean/Phrase Interface .

5%) . ARR 1.guided by the principles for undertaking with systematic review . D. Since the benefits of thrombolysis are greater when . Four previous systematic reviews of 11 Randomised Controlled Trials(RCT).Also search within the full text of the articles Search modes . morbidity and quality of life (QoL). taking into account its effect on mortality. Hartwell.systematic review applies consistent methods of critical appraised and presentation .clinical evidence. ARR 4%) -stroke rates (65% reduced risk.Linked Full Text. 2 updated RCTs and 4 new RCTs Systematic review and economic evaluation. Systematic review of evidence from systematic reviews of RCTs and subsequent RCTs with observational studies. Published Date from: 19950301-20110331. came mainly from the USA . Research Article Expanders . References Available. et al (2005) Purpose Samples Methodology Results Critique To examine the clinical effectiveness of immediate angioplasty.Independent of vested interest . The meta analyses of the four previous showed statistically significant benefit for people receiving immediate angioplasty over hospital thrombolysis on outcomes of .CINAHL 3483 Appendix 6 Critical Analysis Framework ± Cormack (2000) Author & date 1.reinfraction rates (50% reduced risk. and to estimate its cost effectiveness compared with other users of resources.Advanced Search Database . English Language.there is little evidence comparing pre hospital thrombolysis with angioplasty.S1 Myocardial infarction treatment or revascularisation or thrombolysis or percutaneous coronary intervention or outcome or quality of life or mortality Limiters .EBSCOhost Search Screen . Abstract Available. 1.CABG rates (30% reduced Strengths .Boolean/Phrase Interface .mortality (30% reduced risk ARR 2%) .used research protocol Limitations .

This is a large scale study. this could affect the relative costeffectiveness. S. Economic evaluation finding . with PCI providing additional benefits in health status at a higher cost.risk. Limitation The authors acknowledged that patients who participate in these randomised trials might not be representative of all patients. If access to PCI is longer than 2 hours. respectively. ARR 40%) 2. In regions where hospital with PCI facilities are rare.PCI appears to be cost effective compared with thrombolysis for people with AM1. It has positive findings. et al (2011) To evaluate the efficacy and safety of Primary Percutaneous Coronary Intervention(PPCI ) versus fibrinolysis. De Boer. .763 patients (from 22 trials published between January 1990 and December 2002) Systematic analysis of randomised trials PPCI is consistently associated with a strong relative reduction in 30day mortality irrespective of patient baseline risk. and should therefore be considered as the first choice of reperfusion therapy whenever feasible. Which category of MI patients would benefit most from the strategy of PPCI? To examine whether the relative and absolute mortality reductions by PPCI were modified by the estimated baseline mortality risk 6. fibrinolysis remains a legitimate option. the risk score might be used to select those higher risk patients who given earlier. 2. where geography does not allow primary PCI in all patients with MI.

1572 STEMI patients . Ethical approval obtained. 4. Randomised The benefits of Controlled Trial PPCI over fibrinolysis was maintained at a long-term followup. P. PPCI reduced the risk of reinfarction in the overall cohort and reduced reinfarction and mortality among patients randomised at referral hospitals. et al (2002) PCI versus Pre hospital 840 patients (Target of Randomised controlled trial At 30 days . 3.benefit most from PPCI. an up-todate pharmacoinvasive strategy of fibrinolysis with the addition of Clopidogrel.1129 at referral hospitals . et al (2010) To investigate whether the benefit of PPCI was maintained at a long-term follow-up.This finding reinforces that PPCI should be offered to STEMI patients when inter hospital transport to a PCI centre can be completed within 2 hours. Similarly. Ethics approval available 2. E.443 patients at invasive hospitals. 3. Bonnefoy. . Limitation This present study analysis may underestimate the mortality benefit of current state-ofthe PPCI compared to the time this study was done. Nielson. Complied with the Declaration of Helsinki. enoxaparin and cardiac catheterisation within 24 hours may compare favourably with DANAMI-2 fibrinolysis strategy. 1. The authors reported that this study represented both the longest follow-up and the largest randomised study on this issue performed to date.

2. study.30-day mortality increased twofold as the presentation This is a large scale study Limitation Selection of trial may be prone to bias. 1200 was not achieved due to termination of funding). Overall .Fibrinolysis .Mortality in fibrinolysis group was unexpected low might be attributed to limitation . (Multicentre trial of 840 patients).6% death within 30 days of randomisation. et al (2006) To find out the clinical benefits of PPCI compared with in-hospital Fibrinolysis (FL) 22 randomised trials (n=6763) patients -3383 patients randomised to Fibrinolysis (FL) -3380 patients randomised to PPCI Systematic review 1.9% for FL . To find out whether primary angioplasty was better than prehospital fibrinolysis.Rescue angioplasty in 26% of this group. 1997 ± Sept 30. Recruited between June 30.3% those randomised to PPCI 3. .Lower recurrent infarction and stroke. Ideally a large randomized trial enrolling a broad spectrum of AMI patients would be .6. 2000. Recruited relatively young patient.Short treatment delay in fibrinolysis over angioplasty. result is consistent with previous findings. i)Fibrinolysis . ii)Primary Angioplasty .5. Average :58 years old 5.Boersma.30-day death rate was 7. Primary angioplasty is no better than prehospital fibrinolysis followed by transfer for possible emergency coronary angioplasty. E.

elevation myocardial infarction (STEMI). Most clinicians are strongly convinced of the superiority of PPCI. in whom head to head comparisons between both are scarce.7% of FL & 2. 6. open-label clinical trial.4% in PPCI. The results complement previous work suggesting that PPCI may offer clinical advantage over fibrinolytic therapy as manifested by the trends towards improvement in the combined endpoint of death. It would be desirable to do a large communitybased confirmation trial but that is unlikely.134 allocated to PPCI . H.(Trials published between January 1990 and December 2002) delay increased from less than 1 hour to over 6 hours. (Age range: 75-94years) . . 4.Timely treatment is the important finding.PCI-related delay exceeding 50 min would nullify its benefit. re-infarction. et al (2011) To compare primary percutaneous coronary intervention (PPCI) and fibrinolysis in the very old patients with ST. and stroke at 30 days in the oldest patient. Time matters.132 allocated to fibrinolysis (2005-2007) Randomised multi centre. 6.Reinfarction occurred in 6. 266 patients •75 years old. preferable to meta-analysis. The result provides good evidence that PPCI improves outcomes in this setting. Since state-of- Ethics approval obtained Limitation The study was halted prematurely before the planned enrolment could be met due to slow recruitment. 5. Bueno.

observational data pool of current treatment of AMI Hospital mortality was 7. Treatment with early PCI was left to the discretion of the physician.: Is it an early PCI.10.2% in patients receiving early PCI. thrombolysis Thrombolysis + PCI >24 hrs after thrombolysis or not at all.276 patients with Thrombolysis + STEMI PCI <24 hrs consecutive Angioplasty within from 199424 hours after 2002.10. . particularly when initiated early. female gender.6%) received angioplasty COMPARED with .4%) received PCI >24 hrs after thrombolysis or not at all. compared to 11. Observational Study Registry (Data concerning the early intra hospital period (first 48 hrs) were collected by the use of a record from within the first 2-3 days at the intensive care unit). . Koeth.the-art fibrinolysis appears to be safe.113 (95.600 Current use. . compared to 11. O.4%no early PCI). (MITRA plus REGISTRY) Maximal Individual Therapy of Acute Myocardial Infarction Plus Registry. There was no difference in reinfarction (4.9%) predictors and treated with outcome. Cost not documented. (30.Primary PCI was the dominant reperfusion This is a large scale comparative analysis. et al (2009) To analyse the Involved 30 use of reperfusion European treatments for Society of Analysis of registries in all 30 countries . This could result in selection bias which cannot be fully eliminated by a multivariate analysis e.2% in the other group It was noted that hospital mortality was 7. et al (2008) To compare 34. it may be considered as a valuable alternative when PPCI is not available. age >65 years.2% in patients receiving early PCI. multi centre. Prospective. controlled study. thrombolysis in pts with STEM1. an anterior STEMI and a pre-hospital delay of >3 hours.487 (4. Not a randomized. Independent predictors of a higher hospital mortality were shock.2% in the other group. a rescue or a facilitated PCI? 8. 7. Widimsky P.g.6%early PPCI / 4.

It is possible that hospitals using primary PCI have better resources allocation and organization that allows for better overall management of all aspects for AMI e.2 and 13. (Comparative Analysis) study.g. et al (2005) To evaluate the in-hospital and 2. Primary PCI service centre (24/7) was defined as PCI hospital not using Thrombolysis (TL) for the treatment of STEMI patients. in whom most recent data were not available.STEMI across Europe at the time when these new ESC guidelines were published. All existing PCI hospitals offering nonstop (24/7) primary PCI services. Cardiology (ESC) countries. . 24 hours/day and 7 days/week.5% (ii) mortality for patients treated by TL between 3.7 and 8%. 20% of pre hospital data for .This analysis is retrospective in nature of multiple national registries therefore lack rigour in defining the same entry criteria to these variable registries. Littieri.5 and 14% (iii) Mortality for patients treated by PPCI between 2. . C. Data collected in years 20072008 for most countries.Data were not gathered during the same period in 2005. In-hospital 1. 9. (a) 1. . 2006 or 2007.617 STEM1 pts. strategy in 16 countries and thrombolysis in 8 countries. in other words hospital performing primary PCI in all STEMI patients. (i) In-hospital mortality of all consecutive STEMI patients varied between 4. Staffing of these centres may play an important role.The use of primary Percutaneous Coronary Intervention (pPCI) strategy varied between 5 and 92% (of all STEMI patients) and the use of thrombolysis (TL) between 0 and 55%. Limitations The number of centres that participated in some of the national registries or surveys may not be representatives of the national registries or surveys may not be representative of the country¶s total population. 99 of Registry (Prospective. but in 2006 or 2005 for a few. .

8%) had experienced Out of Hospital Cardiac Arrest (OHCA) PCI with thrombolysis systematic database ) mortality is higher among OHCA pts but a much lower mortality compared with previous series of OHCA. (c) At 12 months 67 (87%) of OHCA survivors showed almost complete neurological recovery. 2. Funding not stated.post discharge outcomes with regard to vital and neurological status of STEM1 patients surviving out-of-hospital cardiac arrest (OHCA) and undergoing emergency PC1 within an established regional network and to identify factors predicting in hospital mortality Also to compare outcome with pts not experiencing OHCA in-hospital and 6-month whom (3. Need for further urgent revascularization is similar in the 2 groups. Big scale study with positive findings. Limitation of the study was: more than half of .470 patients from 1999-2002. after discharge. COHORT Study using detailed patient-level data from National Registry of MI 1. 3. 10. this may limit the power of analysis.McNamara . Major bleeding was significantly more frequent in OHCA pts. et al (2007) Impact of delay in Door-to-Needle Time On Mortality in Pts with STSegment Elevation Myocardial 67. (d) At 1 year. two thirds of them had favourable neurological outcome. Rate of death. (b) At 6/12. myocardial infarction and revascularization were similar among those with or without OHCA. Shorter doorto-needle time was associated with lower in hospitality mortality. OHCA patients were collected retrospectively from the EMS records. 2.

-There is decrease doorto-needle time of 62 mins in 1990 to 38 mins in 1999. (NRMI) 2. the patients who received thrombolysis were subsequently transferred to another hospital.Infarction. In-hospital mortality rates were 8.5% in pts treated within 15 mins. Patients received acute fibrinolytic reperfusion therapy. . -The result confirmed earlier studies that longer door-to-needle time has increase mortality.2% in pts with door-toneedle time >100 mins and 2.

3. Ethics approval obtained. et al (2008) To monitor the components and timings of the interventional treatment of patients with STEMI in the setting of transfer networks.9% 2.086(66%) Out of this 727 patients received early abciximab (EA). Limitations acknowledged.Dudek.11.8%. Higher mortality seen in the late abciximab group. .650 patients Abciximab administered to 1. Quality control observed through monitoring visits. A special focus was on the timing of abciximab application and related clinical outcomes. A slight and insignificant increase in bleeding seen in the early abciximab group requiring transfusions. 1. 359 patients form the late abciximab (LA) [Involved 15 STEMI networks from 7 European countries (November 2005-January 2007)] Multinational Registry (EUROTRANS FER) This study reflects most upto-date treatment patterns and clinical outcomes under real-life conditions in patients transferred for primary PCI in European STEMI network. 1. Lowest mortality rates noted in the 727patients (EA) ever reported from STEMI registries (inhospital at 2. 30-day at 3.