Impact of type of thrombolytic agent on in-hospital outcomes in ST-segment elevation myocardial infarction patients in the Middle East

A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Streptokinase in the Management of Myocardial Infarction in Developing Countries

Myocardial infarction (MI) is a significant cause of morbidity and mortality in low- and middle-income countries. Fibrinolytic agents and percutaneous coronary intervention (PCI) are the main approaches for the recanalization and reperfusion of the myocardium following MI. Many studies have shown that PCI is superior to thrombolytics due to better outcomes and decreased mortality. Nevertheless, PCI's mortality gain over thrombolysis decreases as the time between presentation and PCI procedure increases. Furthermore, PCI is not widely available in most developing countries; thus, it cannot be delivered promptly. Most patients in developing countries cannot afford the cost of PCI. Thus, thrombolytic therapy remains essential to managing MI in developing countries and should not be disregarded. Tenecteplase (TNK) and streptokinase (SK) are the two most widely used fibrinolytics in managing MI in underdeveloped nations. Despite their widespread availability, comparative studies on them have been inconclusive. This study aims to review the available literature on the effectiveness and safety of TNK versus SK in managing MI in resource-poor nations. The study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search for studies comparing TNK and STK was conducted on EMBASE, Cochrane Library, Web of Science, CINAHL, Scopus, Google Scholar, and Ovid version of MEDLINE databases. A reference list of the eligible articles and systematic reviews was also screened. A narrative synthesis of the available data was done by representing the data on the effect direction plot, followed by vote counting. Of the 2284 references retrieved from the databases, only 17 studies met the inclusion criteria and were selected for final analysis. The study suggested that TNK is more effective in complete ST-segment resolution (80% vs 10% on the effect direction plot) and symptom relief (80% vs 20%) than SK. SK and TNK were comparable in achieving successful fibrinolysis (50% vs 50%). For the safety parameters, TNK is associated with a lesser risk of major bleeding than SK (88.9% vs 11.1%) and minor bleeding (25% vs 75%). SK was linked with a higher risk of hypotension/shock (77.8% vs 11.1%) and anaphylaxis/allergy (100% vs 0%). Long-term mortality was higher in the SK arm (100% vs 0%). In-hospital mortality is comparable between the two agents (37.5% vs 37.5%). There is conflicting evidence regarding other safety and efficacy endpoints. Compared to SK, TNK results in better complete ST-segment resolution and symptom relief. A higher risk of long-term mortality, increased risk of major and minor bleeding, hypotension, and allergy/anaphylaxis was observed in patients who received SK. Both agents were comparable in terms of in-hospital mortality and successful fibrinolysis. Controversy exists regarding which agent is linked with increased risk of 30-35-day mortality benefit and stroke. Randomized controlled trials (RCTs) with large sample sizes are needed to establish TNK vs SK superiority in efficacy and safety. The long-term duration of follow-up of the mortality rate of the two agents is also essential, as most patients in these regions cannot afford the recommended PCI post-fibrinolysis.

The outcomes of reperfusion therapy with streptokinase versus tenecteplase in ST-elevation myocardial infarction (STEMI): a propensity-matched retrospective analysis in an Asian population

Background Fibrinolysis using streptokinase or tenecteplase remains the primary reperfusion strategy for ST-elevation myocardial infarction (STEMI) in many Asian countries, including Malaysia. Comparative outcomes of these two fibrinolytic agents in the Asian population were inconclusive despite being widely used. Aim We aimed to assess and compare the outcomes of streptokinase versus tenecteplase in STEMI reperfusion of an Asian population. Method This single-centre retrospective study analysed data on STEMI patients who received fibrinolytic therapy from 2016 to 2020 in the Emergency Department of the largest tertiary hospital in Malaysia. Total population sampling was used in this study. Based on the propensity score matching, 359 patients receiving streptokinase were matched against 359 patients receiving tenecteplase by incorporating 16 variables that potentially affect mortality. 30-day mortality, stroke and major bleeding were the primary outcome measures. Results There was no significant difference in 30-day mortality between streptokinase (n = 39, 11.2%) and tenecteplase (n = 46, 13.2%) groups (p = 0.418). The rates of ischemic strokes [streptokinase (n = 1, 0.3%) versus tenecteplase (n = 3, 0.9%), p = 0.624], intracranial haemorrhage [streptokinase (n = 3, 0.9%) versus tenecteplase (n = 1, 0.3%), p = 0.624] and major bleeding [streptokinase (n = 4, 1.1%) versus tenecteplase (n = 3, 0.9%), p = 0.624], were comparable for the two groups. The incidences of failed thrombolysis were significantly higher in the tenecteplase arm. Hypotension and allergic reaction were significantly higher in the streptokinase arm. Conclusion Streptokinase and tenecteplase are fibrinolytic agents with similar efficacy and safety in STEMI reperfusion therapy in our Asian population.

Effects of atorvastatin and ticagrelor combination therapy on renal function and the levels of suppression of tumorigenicity 2 and interleukin-33 in patients with ST-segment elevation myocardial infarction

OBJECTIVE

We evaluated the effects of atorvastatin and ticagrelor combination therapy on renal function and the levels of suppression of tumorigenicity 2 (ST2) and interleukin 33 (IL-33) in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

Eighty-four STEMI patients who underwent emergency percutaneous coronary intervention at our hospital from January 2015 to March 2018 were retrospectively analyzed and divided into a control group (n = 44) and an observation group (n = 40). The control group was treated with atorvastatin as routine STEMI treatment, whereas the observation group was concurrently administered ticagrelor.

RESULTS

After treatment, significantly better outcomes were observed in the control group than in the observation group in terms of clinical indices, including chest pain relief, enzyme levels, duration of reperfusion-associated arrhythmia, and depression of the ST segment. Both groups exhibited improvements in cardiac ultrasound indices, whereas the observation group showed lower left ventricular end-diastolic and end-systolic diameters and higher left ventricular ejection fractions than the control group.

CONCLUSIONS

Atorvastatin and ticagrelor combination therapy is clinically effective and safe for STEMI patients as it reduces the degree of myocardial infarction, protects the heart and renal functions, improves inflammation, and reduces adverse cardiac event incidences.

Cardiovascular disease in the Eastern Mediterranean region: epidemiology and risk factor burden

The Eastern Mediterranean region (EMR) comprises 22 countries or territories spanning from Morocco in the west to Pakistan in the east, and contains a population of almost 600 million people. Like many other developing regions, the burden of disease in the EMR has shifted in the past 30 years from primarily communicable diseases to noncommunicable diseases such as cardiovascular disease (CVD). Cardiovascular mortality in the EMR, mostly attributable to ischaemic heart disease, is expected to increase more dramatically in the next decade than in any other region except Africa. The most prominent CVD risk factors in this region include tobacco consumption, physical inactivity, depression, obesity, hypertension, and diabetes mellitus. Many individuals living in the EMR are unaware of their risk factor status, and even if treated, these risk factors are often poorly controlled. Furthermore, infrequent use of emergency medical services, delays in access to care, and lack of access to cardiac catheterization affects the timely diagnosis of CVD. Treatment of CVD is also suboptimal in this region, consisting primarily of thrombolysis, with insufficient provision of timely revascularization. In this Review, we summarize what is known about CVD burden, risk factors, and treatment strategies for individuals living in the EMR. This information will hopefully aid decision-makers when devising strategies on how to improve CVD prevention and management in this region.

Clinical Profile, Management, and Outcome in Patients With Out-of-Hospital Cardiac Arrest and ST Segment Elevation Myocardial Infarction: Insights From a 20-Year Registry

AIM OF THE STUDY

We studied the clinical profile, management, and outcomes of patients with out-of-hospital cardiac arrest (OHCA) with and without ST-elevation myocardial infarction (STEMI).

METHODS

Retrospective analysis of the 20-year registry data (January 1991- June 2010) was conducted on patients with cardiac disease hospitalized at Hamad General Hospital and Qatar Heart Hospital, Doha, Qatar.

RESULTS

A total of 987 patients with OHCA were admitted to the cardiology department during the study period; among them, 296 (30%) patients had STEMI. Compared to the patients with OHCA without STEMI, the patients who had OHCA with STEMI were younger (53 ± 13 vs 58 ± 16 years; P = .001), more likely to be male (78% vs 34%; P = .001), smokers (35% vs 14%) but less likely to have hypertension (30% vs 48%; P = .001), diabetes (32% vs 47%, P = .001), and chronic renal failure (3.4% vs 9%; P = .002). The use of thrombolytic treatment in patients with STEMI increased from 21.6% (period 1991-1095) to 44.4% (period 2006-2010); P = .04.

CONCLUSION

Percutaneous coronary intervention had increased significantly during the last quarter of the study. There was a decline in the in-hospital mortality among patients with STEMI during the last quarter of the study.

Intracranial haemorrhage 4 days after receiving thrombolytic therapy in a young woman with myocardial infarction

Intracranial haemorrhage is a known complication after fibrinolytic therapy and occurs usually in the first 24 h. We report a 35-year-old woman who presented with severe central chest pain and she was diagnosed as anterior ST elevation myocardial infarction. She was given fibrinolytic therapy with Tenecteplase. She responded well to the treatment with a decrease in the intensity of chest pain and resolution of the ST segment elevation. She was taken for coronary angiogram the next day, which revealed an occlusion of the left anterior descending (LAD) artery, and stenting of LAD was carried out. Four days later, she developed severe headache, confusion, slurring of speech and right haemiparesis. CT brain revealed intracerebral haemorrhage and she was referred to an neurosurgeon who advised for conservative management. Her condition gradually improved with physiotherapy and was discharged home with no marked functional impairment.