13 September 2021: Human Study
Size of Acute Myocardial Infarction Correlates with Earlier Time of Initiation of Reperfusion Therapy with Cardiac Perfusion Scintigraphy: A National Single-Center StudyHajdin Çitaku1ABCDF, Ramë Miftari23ACDEF*, David Stubljar4ACDF, Xhevdet Krasniqi56ADE
Med Sci Monit Basic Res 2021; 27:e933214
BACKGROUND: BACKGROUND The aim of this study was to determine the correlation between the size of acute myocardial infarction (AMI) and the time of initiation of reperfusion therapy with cardiac perfusion scintigraphy. MATERIAL AND METHODS Overall, 80 patients with acute ST elevation myocardial infarction (STEMI) were examined. All patients were treated with primary percutaneous coronary intervention (pPCI). Data on patient and system delay expressed in minutes were recorded and compared with recommended timelines. Cardiac scintigraphy was performed with 99m Tc-sestamibi single-photon emission computed tomography (SPECT). The median time of cardiac scintigraphy was 20 days. The correlation between the size of infarction and the time of initiation of reperfusion therapy was evaluated. RESULTS The mean age of patients was 60.5±11.5 years, and 72.5% were male. The average system delay was 348 min, and the average patient delay was 173 min. The mean total ischemic time was 800 min. There was a correlation between time delays of reperfusion therapy and infarct size. Patients with a shorter time delay to patent artery after FMC showed smaller infarct size when compared to the patients with longer delay times. Multiple linear regression analysis showed that FMC, being male, and smokers had statistical significance when predicting infarct size. CONCLUSIONS There is a correlation between the size of myocardial infarction and the time of initiation of reperfusion therapy determined by perfusion myocardial scintigraphy. The study showed that there are time delays in starting the treatment of AMI with pPCI when compared to the recommended time, which requires an action plan in the near future to ensure earlier treatment for our patients.
MATERIAL AND METHODS:
Keywords: Angioplasty, Anterior Wall Myocardial Infarction, Technetium Tc 99m Sestamibi, Time Factors, Aged, Female, Heart, Humans, Middle Aged, Myocardial Infarction, Myocardial Reperfusion, percutaneous coronary intervention, perfusion imaging, Tomography, Emission-Computed, Single-Photon
Treatment of patients with ST elevation myocardial infarction (STEMI) consists of reperfusion therapy with the aim to restore blood circulation into the ischemic myocardium. The benefits of angioplasty are maximal when the procedure is performed within 2 h after the onset of symptoms, resulting in reduced mortality, heart failure, and rehospitalizations . When primary percutaneous coronary intervention (pPCI) is performed between 3 and 6 h after the onset of symptoms the patient can still benefit, but to a lesser degree. A large number of observational studies have confirmed that any delay of at least 30 min in treatment resulted in a 7.5% per year increase of the risk of mortality in patients with myocardial infarction . Thus, earlier time to reperfusion therapy is crucial. Additional risk factors leading to worse outcomes of AMI include comorbid diabetes, hypertension, peripheral artery disease, older age, reduced renal function, and history of stroke . Infarct size and microvascular obstruction (MVO) are the main independent predictors of long-term mortality and heart failure in STEMI survivors [4,5]. MVO is defined as insufficient myocardial perfusion after successful mechanical opening of the infarct related artery (IRA), and is caused by various factors .
Use of single-photon emission computed tomography (SPECT) and cardiac magnetic resonance (CMR) for determination of myocardial infarct size is relatively new and may be useful for post-discharge risk stratification . The purpose of this study was to assess delays and their impact on infarct size, as the data for our country are lacking, and thus assess a possible correlation between the size of AMI and the time of initiation of reperfusion therapy with cardiac perfusion scintigraphy. The Republic of Kosovo is part of the Western Balkan, South-East Europe region and has 1.78 million inhabitants . Currently only 1 center, the University Clinical Center of Kosovo (UCCK), offers services for treatment of AMI with pPCI 24 h per day, 7 days per week. In early 2018, the start of 24-hour service at the Unit of Invasive Cardiology enabled treatment with pPCI for AMI. However, there is no functioning health insurance system or fully operational health information system, nor is there a database for tracking treatment delays, so this study is the first attempt at gathering national data.
Material and Methods
All statistical analyses were performed using SPSS Statistics 21 (IBM, New York, USA). For categorical data, correlation between groups was assessed with the Pearson’s chi-square test or Fisher exact test; fore continuous data, the differences were assessed by analysis of variance or the Kruskal-Wallis test for data with non-normal distribution. Continuous variables were presented as mean or median values. Time delay was defined as the time from the onset of symptoms to the FMC; it was considered as a continuous variable and was expressed in minutes. Patient delays were log-transformed for further analysis. The effect of each potential predictor for infarct size was assessed by multiple linear regression analysis. All analyses were performed at a level of 5% significance.
The study included a total of 80 patients with AMI who underwent primary percutaneous coronary intervention (pPCI). Data on basic patient characteristics are presented in Table 1. Coronary angiography findings showed involvement of the left anterior descending artery (LAD) in 42 (52.5%) patients, right coronary artery (RCA) in 23 (28.9%), and circumflex artery (LCX) in 15 (18.8%). Regarding the number of arteries, 40% of patients had single-vessel coronary heart disease, 31% had 2-vessel coronary artery disease, and 29% had 3-vessel coronary artery disease.
The average system delay was 348 min. The average patient delay was 173 min (range 45–180 min). The door-to-balloon inflation time was 114 min (0–65 min). The average distance to the regional hospital was 50 km, which resulted in an average delay of 950 min.
Patients were divided into 2 groups according to the timing of reperfusion therapy: the first group received reperfusion therapy within the first 180 min (3 h), and the second group after 180 min (more than 3 h). Patients with a different patent artery after FMC showed no significant differences between the 2 groups except for the FMC to patent artery (Table 2).
Our research did not differentiate the patients according to diabetes status, although this has been identified as a risk factor. We also did not compare mortality between the 2 PCI groups, as this was not the primary nor secondary endpoint of the study, but we rather focused on the size of infarction, which has been correlated in the past with higher mortality rates.
There was a good correlation between time delays of reperfusion therapy and infarct size, as shown in the Figure 1, with r=0.36. Patients with a shorter time of patent artery after FMC had smaller infarct size compared to patients with longer delay times. Moreover, multiple linear regression analysis showed that FMC, being male, and being a smoker were statistically significant (P<0.05) in predicting infarct size. Meanwhile, LAD as culprit artery did not show any significance (Table 3).
Our analysis has some limitations. The data were analyzed retrospectively, impacting the quality of the dataset. Measurements of time delays could be biased and thus result in errors. Only patients who had full records were included, resulting in a relatively small sample size. A larger-scale study might have found a stronger correlation between time delays and infarct size. Lastly, this was a single-center study with a small number of patients for the multiple timepoint measurements.
We found a significant relationship between the size of myocardial infarction and the time of initiation of reperfusion therapy as determined by perfusion myocardial scintigraphy. The study showed that there are long delays in starting the treatment of AMI with pPCI compared to the recommended timelines. Evidence-based studies show that infarct size will improve with earlier management of STEMI patients, by better identification of those with large infarcts. Our results suggest the need for an action plan to reduce time delays, as well as the need for improved management systems to significantly reduce delays in treatment of STEMI patients.
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