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Byline: Tehreem Younus, Rehana Khadim, Sajjad Hussain, Fauzia Nazir, Sohail Aziz and Farhan Tuyyab

Keywords: Myocardial infarction, PPCI, STEMI.


Segment Elevation Myocardial infarction is a global epidemic. As a leading cause of morbidity and mortality, this is a major public health problem. It is caused by a prolonged period of blocked blood supply that affects a large area of the heart. Segment Elevation Myocardial Infarctions (STEMIs) are caused by the sudden occlusion of a major coronary artery. For 25 years, clinical research has focused on ways to quickly open these blocked arteries, which reduces the chance of dying from a STEMI1. This was accomplished first by clot dissolving "thrombolytic" drugs, which unfortunately are in effective 33% of the time and can cause life-threatening bleeding2. Re-occlusion causing a repeat heart attack often occurs following their use. Restoring blood supply to the affected heart muscle using immediate or "direct" coronary angioplasty and stenting has been demonstrated to be an option markedly superior to thrombolytic therapy for treatment of STEMIs2.

In order to provide emergent STEMI care, a medical center must have 24/7 interventional cardiology facilities and personnel as well as cardiac surgery backup3. Controversy still surrounds the best treatment of STEMI patients who do not have easy access to medical centers capable of providing coronary angioplasty. Data suggests that every 10-minute delay in treatment can result in a 1% higher chance of dying from an acute myocardial infarction a substantial risk of death and disability and calls for a quick response2,4. In STEMI patients, Ischemia Time was a better predictor than Door to Balloon time for infarct size, clinical outcomes and mortality. The focus of STEMI care should be directed at early initiation of therapy and minimizing ischemia time rather than on door to balloon time alone5.

A recent analysis of 12,675 STEMI patients in the FITT-STEMI (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction) trial emphasizes the strong impact of time delays on mortality, particularly in STEMI patients with cardiogenic shock or out-of-hospital cardiac arrest. In shock without out-of-hospital cardiac arrest, every 10 min treatment delay between 60-180 min from the first medical contact resulted in 3.3 additional deaths per 100 PCI-treated patients, and in 1.3 additional deaths after out-of-hospital cardiac arrest without cardiogenic shock. In stable STEMI patients, time delays were substantially less relevant (0.3 additional deaths per 100 PCI-treated patients for every 10 min delay between 60-180 min from the first medical contact). Thus, high-risk STEMI patients with cardiogenic shock or out-of-hospital cardiac arrest are those who benefit most from expediting all steps of the care pathway6.

Heart Failure is associated with various quantitative and qualitative parameters. Qualitative include Gender, presence of Diabetes Mellitus, hypertension, smoking, obesity, family history of coronary artery disease, history of previous PCI/CABG. Quantitative parameters include Age, infarct size, left ventricular ejection fraction (LVEF), Killip class, serum creatinine may all predict the development HF after PPCI during hospitalization7. Current guidelines for ST-elevation myocardial infarction (STEMI) recommend early revascularization with optimal ischemic time <120 min and door-to-balloon time <90 min7. Between December 2008 and April 2013, 786 patients with STEMI were treated in STEMI center, and 262 of these had cardiac magnetic resonance imaging 3-5 days after the index event. Ischemic time is time from symptom onset to device activation, while door to balloon time is the time hospital arrival to device activation.

Patients were divided into three groups according to Ischemic time (<120, 120-239, [greater than or equal to]240 min) and into four groups according to Door to balloon time (360 minutes as shown in the figure.


The principle of 'time is muscle, time is life' is generally accepted to guide acute myocardial infarction management decisions. Timely myocardial reperfusion with primary PCI is the central therapy for STEMI. Armed Forces Institute of Cardiology and National Institute of Heart Diseases has developed rapid reperfusion strategies with primary PCI for patients with STEMI.10 In the context of modern STEMI treatment, this study investigated whether ischemic time was associated with development of heart failure and adverse in-hospital outcome. The major finding was; less the ischemic time and less is the development of heart failure in patients with STEMI undergoing primary PCI12. Previous studies have shown that an important gap still exists between the clinical performance of timely reperfusion therapy and the guideline-recommended timing for patients with STEMI.

The CPACS-1 study, which including 2973 patients admitted to 51 hospitals in 18 provinces of China between September 2004 and May 2005, showed that only 6.6-16.3% of patients with STEMI underwent PCI within twelve hours of symptom onset6. To bridge the substantial evidence-practice gap, the CPACS-2 study was conducted in 75 hospitals throughout China between October 2007 and August 2010 with the aim of improving the quality of care for acute coronary syndrome by implementing clinical pathways which showed that most patients with STEMI were not treated with PCI in a timely fashion, with significant delays in total ischemic time11. According to previous studies and our clinical observations, the significantly longer total ischemic time can be accounted for mainly by patients' lack of knowledge about heart attack symptoms and underuse of ambulances, the delay in obtaining informed consent, and the procedural complexity of hospital admission and PCI team activation.

Thus, further improvement of the quality of reperfusion therapy for patients with STEMI, through patient education and redesign of procedures involving EMS, emergency departments, and cardiac catheterization, is critically needed12,13. These results are similar to those of a German chest pain unit registry study, but differ from those of a retrospective study conducted in the UK,a registry study conducted in Italy10 and a prospective study conducted in the USA11. The significant variation in ischemic time among countries indicates that pre-hospital delay is a widespread issue for patients with STEMI, and that urgent measures should be taken to address it. Results of previous studies have suggested that patient awareness about cardiac arrest symptom, EMS usage, and traffic could account for the difference in onset-to-door time between offhours and regular hours.

Therefore, further efforts must focus on patient knowledge about high-risk chest pain and use of EMS, and the optimization of EMS procedures for patients with STEMI12,14. These findings indicate the need to improve public education about heart attacks and redesign the health care system for patients with STEMI15. They also underline the importance of shortening total ischemic time and implementing quality improvement initiatives for reperfusion programs to improve the prognoses of patients with STEMI16-17.


Total ischemic time was associated with mortality. The present study suggests that additional efforts are needed to shorten total ischemic time including patient and pre-hospital systemic delay for better prognosis after primary PCI.


This study has no conflict of interest to be declared by any author.


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Publication:Pakistan Armed Forces Medical Journal
Date:Feb 28, 2019

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