International Journal of Cardiology 187 (2015) 128–129

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Letter to the Editor

Reperfusion therapy for ST elevation acute myocardial infarction in Yemen: Description of the current situation Data from Gulf Registry of Acute Coronary Events (the Gulf RACE-I) A-Nasser Munibari a, Ahmed Al-Motarreb a, Ahmed Alansi a, Sara Cimino b, Giuseppe La Torre c, Luciano Agati b,⁎ a b c

Cardiac Center, AlThawra Modern Teaching General Hospital, Sana'a, Yemen Department of Cardiology, “Sapienza” University of Rome, Italy Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Italy

a r t i c l e

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Article history: Received 20 March 2015 Accepted 21 March 2015 Available online 23 March 2015 Keywords: Thrombolytic therapy Acute coronary syndrome Gulf RACE Yemen

Yemen, one of the countries participating in Gulf Registry of Acute Coronary Events (RACE) [1,2], has limited resources with no program of primary PCI yet. Gulf RACE-I is a prospective, multinational, multicenter survey of consecutive patients hospitalized with the final diagnosis of acute coronary syndrome (ACS) in six Arabian Peninsula/Gulf countries over a period of 6 months. Details on the survey were previously published [1,2]. We refer the Gulf RACE data regarding Yemeni patients with ST elevation myocardial infarction (STEMI) aiming to highlight the characteristics of STEMI among Yemeni patients, predisposing risk factors, type and rate of reperfusion therapy, and cardiac mortality rate. Primary end-point of the present study was to assess the incidence of in-hospital, 1-month and 1-year cardiac mortality. The in-hospital occurrence of cardiogenic shock, malignant arrhythmias and congestive heart failure was also collected. Vital status was monitored by means of a phone contact at 1-month and at 1-year follow-up. All management decisions were at the discretion of the treating physician. The study received ethical approval from the institutional ethical bodies in the Ministry of Health in Yemen. From all Gulf States, 6706 ACS patients entered in the survey, 1054 ACS patients were enrolled in Yemen, 779 (12%) of them with STEMI.

⁎ Corresponding author at: Policlinico Umberto I, Department of Cardiology, Sapienza University of Rome, Viale del Policlinco 155, 00192 Roma, Italy. E-mail address: [email protected] (L. Agati).

http://dx.doi.org/10.1016/j.ijcard.2015.03.348 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.

Out of 779 Yemeni STEMI patients, only 218 (28%) arrived in the hospital within 12 h from symptom onset and were eligible for reperfusion therapy. The remaining 561 (72%) were admitted in the hospital too late (N 12 h) and did not receive any reperfusion treatment. Clinical characteristics of the entire STEMI population were summarized in Table 1. In brief, mean age was 57 ± 12 years, with a strong male predominance (77%). Khat chewing was referred in 77% of patients, and prominent smoking habit in 46%. Arterial hypertension was observed in 30%, diabetes mellitus in 20.9%, and dyslipidemia in 13% of patients. Echocardiogram at admission had shown low LV ejection fraction (b 35%) in 55% of patients, Killip class at presentation N1 occurred in 25% of cases and congestive heart failure in 18%. In the entire STEMI population, 81 (10%) patients died during hospitalization, 149 (21%) at 1-month and 142 (26%) at 1-year. Only thrombolytic therapy was used. Among reperfused patients, Streptokinase was the most commonly preparation used (95%) followed by Reteplase (4.1%) and t-PA (0.5%). The mean door to needle in this subset of patients was 59 ± 102 min. As compared to no-reperfused, patients undergoing thrombolysis were significantly younger (p = 0.001), more frequently male (p b 0.001) and smokers (p = 0.006). Higher incidence of low LV ejection fraction (p b 0.001) at presentation was detected in thrombolytic group. Major adverse coronary events were summarized in Table 2. Congestive heart failure was the most common in-hospital complication and occurred more frequently in no-reperfused patients (p = 0.011), while no significant differences were observed as for cardiogenic shock and malignant arrhythmia's. In-hospital mortality rate was significantly higher in no-reperfused patients (p = 0.045). This difference further significantly increases at 30 days (p = 0.02) and at 1 year follow-up (p = 0.003). Relative risk reduction for patients who underwent thrombolysis as compared to no-reperfused was −41% for in-hospital congestive heart failure, − 44% for in-hospital mortality, − 37% for 30-day mortality and −33% for 1-year mortality (Table 2). This is the first report from Gulf RACE-I database describing clinical characteristics, management and major adverse coronary events of Yemeni patients with STEMI over a period of 6 months. The most important finding of the present survey is that nearly two-third of patients with STEMI in Yemen presented to the hospital N12 h after symptom onset and were not eligible for any reperfusion treatment. Therefore, the in-hospital mortality rate is significantly higher as compared to Western counties. The mortality rate further dramatically

A.-N. Munibari et al. / International Journal of Cardiology 187 (2015) 128–129 Table 1 Baseline clinical characteristics and major adverse coronary events of the entire Yemeni STEMI population enrolled in the survey. Parameter

N

Valid cases

ST-elevation myocardial infarction Age Body mass index Thrombolysis, n (%) Male sex, n (%) Diabetes, n (%) Smokers, n (%) Kath chewing, n (%) Hypertension, n (%) Dyslipidemia, n (%) Killip class N1, n (%) LV ejection fraction b35%, n (%) In-hospital congestive heart failure In-hospital mortality, n (%) 30 day mortality, n (%) 1 year mortality, n (%) History of angina, n (%) History of coronary angioplasty, n (%) History of coronary artery by-pass graft, n (%) History of myocardial infarction, n (%) History of valvular heart disease, n (%)

779 57.49 ± 12 25.6 ± 5 218 (28%) 605 (77%) 175 (22%) 369 (47%) 584 (74%) 235 (30%) 98 (12%) 199 (25.6%) 431 (55.4%) 143 (18%) 81 (10%) 149 (21%) 143 (26%) 162 (20.8%) 17 (2.2%) 4 (0.6%) 62 (8%) 3 (0.3%)

779 779 779 779 779 779 779 779 779 779 779 779 779 779 698 549 779 779 779 779 779

increases at 1-month and at 1-year follow-up. Characteristics of STEMI population in Yemen are significantly different from that reported by previous surveys in western countries. Yemeni patients are younger, predominantly male, with high incidence of khat chewing and smoking habit. Traditional risk factors in high-income countries, such as hypertension, diabetes and dyslipidemia, occur less frequently. Yemen represents a low-income country in Middle East [3] and primary PCI is not available in all regions of this country. However, in major hospitals, thrombolytic therapy may be delivered as a first line revascularization therapy. Unfortunately, Yemen data showed a dramatically high rate of late presentation, nearly 70% of patients presented after 12 h from symptoms onset and were not eligible for any reperfusion treatment. This could be related to the socioeconomic status and literacy rate (65%) [3] that may play an important role in late presentation. The incidence of no-reperfused patients reported by previous surveys in high-income countries was significantly lower and improves over time. The GRACE registry in 2002 indicated that nearly 30% of cases had presented after 12 h of symptom onset [4]. TETAMI registry [5] in 2005 reported a delay presentation (N12 h) in 40% of acute STEMI. Female gender and older age were independent predictors of late presentation [5]. Similarly, the French registry in 2005 showed that nearly 30% of STEMI patients arrived too late and were not reperfused [6]. The Euro Heart Survey ACS-III data set (2 years of inclusions between 2006 and 2008, 138 centers in 21 countries), showed the rate of STEMI patients not reperfused decreased from 23 to 19% during the survey [7]. More recently, the EURHOBOP study [8] showed that only 18% of STEMI patients did not received

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any revascularization therapy during hospitalization. Missing the golden hours [9] for reperfusion therapy in Yemeni STEMI patients is associated with high rate of mortality. Advocacy programs directed toward medical and patient's population may affect the early presentation rate. The low reperfusion rate in Yemen (28%) reflects the lack of organization of health facility, the lack of national treatment protocols and the scarcity of training of medical teams. There is a strong need for improving the health system in Yemen [10]. More public education may increase early presentation of STEMI patients. By improving the treatment of patients with STEMI, the unacceptable high incidence of congestive heart failure occurring in this country may be significantly reduced. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] K. Alhabib, S.S. Jolly, S. Yusuf, et al., Impact of access to hospitals with catheterization facilities in the second Gulf Registry of Acute Coronary Events (Gulf RACE-2), Coron. Artery Dis. 24 (5) (Aug 2013) 412–418. [2] A. Shehab, B. Al-Dabbagh, K.F. AlHabib, et al., Gender disparities in the presentation, management and outcomes of acute coronary syndrome patients: data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), PLoS One 8 (2) (2013) e55508. [3] Library of Congress, Federal Research Division Country Profile: Yemen, http:// lcweb2.loc.gov/frd/cs/profiles/Yemen.pdfAugust 2008. [4] K.A. Eagle, S.G. Goodman, A. Avezum, et al., Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE), Lancet 359 (2002) 373–377. [5] M. Cohen, G.F. Gensini, F. Maritz, et al., The role of gender and other factors as predictors of not receiving reperfusion therapy and of outcome in STEMI, J. Thromb. Thrombolysis 19 (2005) 155–161. [6] N. Danchin, E. Puymirat, G. Steg, et al., Five-year survival in patients with ST-segment elevation myocardial infarction according to modalities of reperfusion therapy. The French registry on Acute ST-elevation and non-ST-elevation Myocardial Infarction (FAST-MI) 2005 cohort, Circulation 129 (2014) 1629–1636. [7] F. Schiele, M. Hochadel, M. Tubaro, et al., Reperfusion strategy in Europe: temporal trends in performance measures for reperfusion therapy in ST-elevation myocardial infarction, Eur. Heart J. 31 (2010) 2614–2624. [8] R. André, V. Bongard, R. Elosua, et al., International differences in acute coronary syndrome patients' baseline characteristics, clinical management and outcomes in Western Europe: the EURHOBOP study, Heart 100 (2014) 1201–1207. [9] M. Francone, C. Bucciarelli-Ducci, I. Carbone, et al., Impact of primary coronary angioplasty delay on myocardial salvage, infarct size and microvascular damage in patients with ST-elevation myocardial infarction: insight from cardiovascular magnetic resonance, J. Am. Coll. Cardiol. 54 (2009) 2145–2153. [10] The UNICEF organization fact sheets website, http://www.unicef.org/infobycountry/ yemen_statistics.html.

Table 2 Major adverse coronary events by reperfusion status. Parameter

Thrombolysis

Non-thrombolysis

P value

RR (95% CI)

Valid cases

Cardiogenic chock CHF (in-hospital) In-hospital mortality 30-day mortality 1-year mortality

20 (9.2%) 25 (11.5%) 14 (6.4%) 29 (14.3%) 32 (18.7%)

167 (12%) 118 (21.1%) 67 (11.9%) 120 (24%) 111 (29.7%)

0.326 0.011 0.045 0.018 0.003

0.78 (0.48–1.2) 0.59 (0.39–0.88) 0.56 (0.32–0.98) 0.63 (0.43–0.92) 0.67 (0.47–0.96)

779 (218 + 561) 779 (218 + 561) 779 (218 + 561) 698 (204 + 494) 549 (175 + 374)

CHF: congestive heart failure.