Kliniğimize ST Yükselmeli Miyokart İnfarktüsü Nedeniyle Başvuran Hastalarda Tercih Edilen Tedavi Stratejilerinin Karşılaştırılması (Yaşam İçin Trombolitik Tedavi)

Giriş:Bu çalışmada, kliniğimize ST-yükselmeli miyokartinfarktüsü (STEMI) ile başvuran hastalara uygulanan tedavi stratejilerikarşılaştırıldı.Hastalarve Yöntem: STEMI tanısı ile başvuran 165hastanın reperfüzyon stratejisi belirlendi. Hastaların kapı-balon ve kapı-iğnesüreleri kaydedildi.Bulgular: Ortalama kapı-balon süresi sevk edilen hastalarda 240dakika, doğrudan acil servise başvuran hastalarda 64.6 dakika bulundu (p=0.000). Sevk edilen hastaların mekanik reperfüzyon süreleri AHA (American HeartAssociation) kılavuzuna göre sadece %7 hastada uygunken, ESC (European Societyof Cardiology) kılavuzuna göre %26 hastada uygundu. Doğrudan acil servisebaşvuran hastalarda bu oranlar sırasıyla %86 ve %97 idi. Kapı-iğne ortalamasüreleri, dış merkezlerde trombolitik tedavi (TT) verilen ve kliniğimize yönlendirilenhastalarda 41.3 dakika, merkezimizde TT verilen hastalarda 35 dakika idi. İkisiarasında anlamlı fark saptanmadı (p= 0.454).Sonuç: STEMI tanısı ile dış merkezlerdensevk edilen hastaların reperfüzyon süreleri kliniğimize doğrudan başvuran hastalarınreperfüzyon süreleriyle karşılaştırıldığında, ikinci grupta güncel kılavuzlaradüşük oranda uyulduğu gösterildi. Trombolitik tedavi kullanımında ise iki hastagrubunda da kapı-iğne zamanının kabul edilebilir sınırlar içinde olduğugörüldü. Bulgularımız, dış merkezlerden sevk edilen hastalarda, güncelkılavuzlara göre hareket edildiği taktirde, trombolitik tedavinin etkili birreperfüzyon stratejisi olarak öne çıktığını göstermektedir.

Comparison of Treatment Strategies Preferred in Patients Admitted to Our Clinic with ST-Segment Elevation Myocardial Infarction (Thrombolytic Therapy for Life)

Introduction: The aim ofthis study was to compare treatment strategies for patients admitted to ourclinic with ST-segment-elevation myocardial infarction.Patients and Methods:Reperfusion strategies were determined in 165 patients admitted with STEMI.Door-to-balloon and door-to-needle times were recorded for the patients.Results: The meandoor-to-balloon time was 240 minutes for refferred patients, and was 64.6minutes for patients directly presenting to our emergency department (p=0.000). Among patients referred from other centers, mechanical perfusion timeswere appropriate in only 7% of the patients according to the AHA (AmericanHeart Association) guidelines, and in 26% of the patients according to the ESC(European Society of Cardiology) guidelines. These rates were 86% and 97%,respectively, among patients directly presenting to our emergency department.The mean door-to-needle times were 41.3 minutes and 35 minutes in patients whoreceived thrombolytic treatment (TT) in other centers and in our center,respectively. There was no significant difference in the mean door-to-needletimes between the two patient groups (p= 0.454).Conclusion: Comparison of reperfusion times ofpatients referred from other centers with the diagnosis of STEMI and of thosedirectly presenting to our hospital showed a low level of compliance with thecurrent guidelines in the latter group. Concerning TT use, the door-to-needletimes were within acceptable limits in the two patient groups. Our findingsshow that TT can be an effective reperfusion strategy among patients referredfrom other centers, provided that decisions are made in accordance with thecurrent guidelines.

Kaynakça

1. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Executive summary: heart disease and stroke statistics-2010 update: a report from the American Heart Association. Circulation 2010;121:948-54.

2. Chatterjee K. Complications of acute myocardial infarction. Curr Probl Cardiol 1993;18:1-79.

3. Greenberg H, Case RB, Moss AJ, Brown MW, Carroll ER, Andrews ML, et al., Analysis of mortality events in the Multicenter Automatic Defibrillator Implantation Trial (MADIT-II). J Am Coll Cardiol 2004;43:1459-65.

4. Grines CL, Cox DA, Stone GW, Garcia E, Mattos LA, Giambartolomei A, et al. Coronary angioplasty with or without stent implantation for acute myocardial infarction. Stent Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med 1999;341:1949-56.

5. Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, Abramsky SJ, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med 2006;355:2395-407.

6. Sgarbossa EB, Pinski SL, Barbagelata A, Underwood DA, Gates KB, Topol EJ, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med 1996;334:481-7.

7. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008;29:2909-45.

8. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44:671-719.

9. Smith SC Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, et al. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)-executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 2001;37:2215-39.

10. Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ. Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis. Jama 2000;283:2686-92.

11. Bonnefoy E, Lapostolle F, Leizorovicz A, Steg G, McFadden EP, Dubien PY, et al. Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomised study. Lancet 2002;360:825-9.

12. Steg PG, Bonnefoy E, Chabaud S, Lapostolle F, Dubien PY, Cristofini P, et al. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial. Circulation 2003;108:2851-6.

13. Karaarslan Ş, Alihanoğlu Yİ, Yıldız BS, Sönmez O, Soylu A, Bacaksız A, et al. Appropriateness of the current guidelines on reperfusion treatment for patients applying to our hospital with ST-segment elevation acute myocardial infarction. Turk Kardiyol Dern Ars 2012;40:493-8.

14. Bozkurt Ş. Acil servise göğüs ağrısı ile başvuran hastaların akut koroner sendrom tanısı açısından değerlendirilmesinde “glycogen phosphorylase isoenzyme bb”nin tanısal ve prognostik değerliliği (tez). Ankara: Hacettepe Üniversitesi; 2006.

15. Eren ŞH, Yılmaz K, Korkmaz İ, Aktaş C, Oğuztürk H, Alagözlü H. Acil serviste akut miyokard enfarktüsü tanısı almış hastalarda trombolitik tedavi uygulanmasını etkileyen faktörler. Fırat Tıp Dergisi 2006;11:163-5.

16. Huynh T, Perron S, O’Loughlin J, Joseph L, Labrecque M, Tu JV, et al. Comparison of primary percutaneous coronary intervention and fibrinolytic therapy in ST-segment-elevation myocardial infarction: bayesian hierarchical meta-analyses of randomized controlled trials and observational studies. Circulation 2009;119:3101-9.

17. Pinto DS, Kirtane AJ, Nallamothu BK, Murphy SA, Cohen DJ, Laham RJ, et al. Hospital delays in reperfusion for ST-elevation myocardial infarction: implications when selecting a reperfusion strategy. Circulation 2006;114:2019-25.

18. Vasaiwala S, Vidovich MI. Door-to-balloon and door-to-needle time for ST-segment elevation myocardial infarction in the U.S. J Am Coll Cardiol 2009;53:902; author reply 902-3.

19. Eagle KA, Nallamothu BK, Mehta RH, Granger CB, Steg PG, Van de Werf F, et al. Trends in acute reperfusion therapy for ST-segment elevation myocardial infarction from 1999 to 2006: we are getting better but we have got a long way to go. Eur Heart J 2008;29:609-17.

20. Kala V. Fibrinolitik tedavi verilen ST-yükselmeli miyokard enfarktüsü olgularında fibrinojen ve D-dimer düzeyleri ile fibrinolitik tedavi başarısızlığı arasındaki ilişki (tez). İzmir: Dokuz Eylül Üniversitesi Tıp Fakültesi; 2008.

21. Gümrükçüoğlu HA, Akdağ S, Şimşek H, Şahin M, Tuncer M. Primer perkütan koroner girişim: Bir yıllık sonuçlarımız. TGKD 2011;15:11-4.

22. Birkhead JS, Weston C, Lowe D. Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study. BMJ 2006;332:1306-11.