Abstract


Background: Coronary artery disease is a major cause of death in the world. In Yemen acute myocardial infarction (AMI) has increased sharply in recent years due to change in lifestyle of Yemenis. Intensive care units are now available in the big cities. There is no report available to show the pattern of the acute myocardial infarction management including thrombolytic therapy in Yemen. Therefore, we conducted a multicentre study in Sana’a City to determine the in-hospital management of AMI patients, in-hospital morbidity and mortality and the feasibility of establishing a nation-wide and long duration registry in Yemen.
Methods: A prospective study enrolled all patients who have been diagnosed as AMI and admitted to the intensive care units in three general hospitals in Sana’a City during the month of May 2000. A specialist filled the data collection form for each patient.

Results: 44 patients were admitted with diagnosis of AMI. 86.4% (38 patients) were male and 13.6% (6 patients) were female. All of the patients were Yemenis with a mean age of 51 (±55 years). Compared to the other risk factors current smoking was high at 50% across all age group. History of previous AMI, diabetes, and hypertension, was 6.8%, 6.8% and 18.2% respectively. Two patients (4.5%) gave a history of hypercholesterolemia. Thrombolytic therapy was given to 16 patients (36.4%). These patients presented to hospital within 12 hours from the onset of the symptoms and had no contraindications to thrombolytic therapy. Cardiogenic shock occurred in 10 patients (22.7%), heart failure in 4 patients (9.1%), recurrent ischemia in 4 patients (9.1%) and re-infarction in one patient (2.3%). No stroke or major bleeding was recorded and the total In-hospital mortality rate was 9.1 Prescribing medications at discharge among survivors was 90.5% for aspirin, 72.1% for nitrates, 67.4% for ACE inhibitors, 37.2% for beta-blockers, 11.6% for diuretics, 4.7% for calcium channel blockers and 0% for lipid lowering drugs.

Conclusion: The rates of diabetes, smoking, hypercholesterolemia and hypertension were high among our patients being 52.3%, 50%, 22.72% and 18.2% respectively. The use of thrombolytic therapy was not appropriate and need to be improved. The rate of use aspirin and nitrates were adequate while that of b-blockers, ACE inhibitors and lipid lowering drugs need improvement. Heart Views. 2005;6(3):93-97 © 2005 Gulf Heart Association.
key Words ¨ AMI Type Myocardial Infarction ¨ AMI Management ¨ Yemen

Introduction

countries due to lack of knowledge about the risk factors of AMI, its complication and the importance of early management. Moreover, there are no adequate risk factors prevention programs. The full benefit of coronary care units, early thrombolytic therapy, primary PTCA still has to be achieved in the developing countries4.
In Yemen, there is no report or study concerning the management of acute myocardial infarction and its morbidity and mortality. Therefore, we have conducted a prospective multi-centre study to determine the clinical profile
of patients with acute MI, the current practice of in-hospital management and morbidity and mortality of AMI as well as assessment of the feasibility of establishing a long duration registry of acute MI in the Yemen.

Methed

We conducted this Survey among three general hospitals: Al-Thawra Hospital, Al-Jomhori Hospital, and Military Hospital. These hospitals are located in Sana’a governorate and provide services to patients from all over Yemen. Al-Thawra hospital is a general hospital with a cardiac unit. The study prospectively included all patients admitted with a final diagnosis of AMI over one month period, from 1st to 31 of May 2000.
A specialist filled the standard data collection for each patient during hospitalization. All possible risk factors were included. The diagnosis of AMI was based on the presence of new pathologic Q waves, 1-mm ST-segment elevation in any two or more contiguous limb leads or a new left bundle branch block or a new persistent ST-T wave changes diagnostic of a non-Q-wave MI. The diagnosis of AMI had to be confirmed by CK enzyme elevation more than twice the normal value.
Thrombolytic therapy was given for eligible patients who presented within 12 hours from symptoms onset if there were no contraindication to thrombolytic therapy. Patient care was performed according to the usual practice in each hospital. Fasting blood sugar and fasting cholesterol were considered elevated when they exceed the following normal values: 6.4 mmol/dl and 5.2 mmol/dl respectively.
All data were analyzed using SPSS program and a p-value 0f Ž0.05 was considered statistically significant.

Results

Of the patients included in the study, 45.45% were admitted in Al-Thawra hospital, 36.36% in Al-Jomhori hospital and 18.18% in the military hospital. Al-Thawra hospital was a referral hospital which receives patients from all over the country. The ICU of the Al-Jomhori hospital was recent during the conduction of this study while the military hospital was restricted to the military personnel only.
Forty four (44) patients were admitted with a diagnosis of AMI. Table 1 shows the clinical


 

Table 1: Clinical characteristics, personal details from 44 patients presented with AMI

 

characteristics and personal details of the patients. The patients were predominantly male (86.4%). The mean age was 51 years, ± 55 years. We reported 2 male cases with age of 24 and 25 years old. One of them is a smoker with no other identified risk factors. History of previous MI, diabetes and hypertension was recorded in 6.8%, 6.8%, and 18.2% respectively. Fifty percent of the patients had a history of previous smoking and they were still current smokers up to the date of the admission. 52.3% were found to have their fasting blood sugar
Ž 6.4 mmol. 6.8% where known to have non-insulin dependent diabetes mellitus (NIDDM) and there were no reported case with a history of insulin-dependent diabetes mellitus (IDDM). High blood glucose was found in 45.45% of the
cases without any history of diabetes mellitus. History of hypercholesterolemia was reported in 2 patients (4.5%) while 10 patients (22.72%) were found to have fasting level of cholesterol of Ž 5.2mmol during hospitalization. The overall incidence of diabetes and hypercholesterolemia among our patients were 52.3% and 27.27% respectively. 93.2% of patients presented with ST-segment elevation. 65.9% of patients presented with anterior MI and 27.27% had inferior MI.


Drugs therapy

Thrombolytic therapy was given to 16 patients (36.4%) out of 21 patients who arrived within 12 hours from the onset of symptoms. Streptokinase (SK) was the only thrombolytic therapy available. These 16 patients were identified eligible for thrombolytic therapy by diagnostic changes on initial ECG and presentation to hospital within 12 hours from the onset of the symptoms and with no contraindications to thrombolytic therapy. Among those patients deemed eligible the thrombolytic therapy rate was 100%.
Overall, the rate of prescribing medications at discharge among survivors was 90.5% for aspirin, 72.1% for nitrate, 67.4% for ACE inhibitors, 37.2%, for B-blockers, 11.6 for diuretics, 4.7% calcium channel. blocker and 0% for lipid lowering drugs. 66.6% of diabetic patients had received ACE inhibitors at discharge. All hypertensive patients received ACE inhibitors at discharge.


Morbidity and mortality

Cardiogenic shock occurred in 10 patients (22.7%), heart failure was recorded in 4 patients (9.1%), recurrent ischemia in 4 patients (9.1%) and re-infarction in one patient (2.3%). No stroke or major bleeding was recorded and the total In-hospital mortality rate was 9.1%.

Discussion

This is the first registry of AMI practice pattern to be carried out in Yemen. This includes the major participating hospitals treating AMI. Making this registry represents the clinical practice in the main hospitals, which deal with AMI in Yemen.
The mean age of our patients was 51 years ± 55 as compared to another country in the region such as Kuwait where the mean age was 55.4
years, ± 13.54. This finding supported a previous study where more than half of the patients (61%) were less than 55 years5. This indicates that AMI in Yemen affects relatively young patients.
Smoking was reported in half of the patients, 33% of whom were women. Although this study shows less smoking among AMI patients than a pervious study where 83% of patients were smokers, the prevalence of smoking is considerably high. This is probably because of khat chewing which increases the desire to active smoking5.
The fasting cholesterol was high in 22.72% of the patients who had no history of hypercholesterolemia. This means that a substantial number of the people do not know that they have high lipid level in their blood. The overall incidence of diabetes mellitus and systemic hypertension were 52.3% and 18.2% respectively. Undiagnosed high blood glucose (type-2) was found in 45.45% of the cases without history of diabetes mellitus or impaired glucose tolerance tests. This high prevalence of non-diabetic hyperglycemia after AMI is shown to be associated with an increased risk of in-hospital mortality and the importance of vigorous treatment in critically ill patients is recommended6. Intensive insulin treatment reduced long-term mortality despite high admission blood glucose7. Control of khat chewing, smoking, diabetes mellitus, hypertension, and promotion of healthy diet with life style modification of would be expected to reduce the prevalence of AMI in Yemen.
Thrombolytic therapy rate in our study was not as high as it should be among eligible patients. Only twenty-one patients (47.7%) arrived within 12 hours from symptom onset. 76.2% (16 patients) received streptokinase and 23.8% (5 pts) of them did not receive it. Although benefit from thrombolytic therapy is demonstrated among the patients who presented at least 12 hours from symptom of onset, it is well-documented that earlier treatment produces greater benefits8. Therefore, people should be educated about the AMI risk factors and symptoms of the heart attack. They should be aware of the importance of coming early to the hospital as soon as they get the symptoms to get the best benefit of thrombolytic therapy and mechanical re-vascularization.
Primary percutaneous transluminal coronary angioplasty (PTCA) is shown to be the most effective reperfusion strategy in AMI. It reduces

mortality in patients presenting within 3 hours of symptom onset9. PTCA has better clinical outcome in patients with AMI compared to thrombolytic therapy10. This advantage of the PTCA was associated with lower risk of bleeding complications in elderly patients11. In Yemen primary PTCA is not applied yet in any hospital and it is time to implement primary PTCA to further reduce the morbidity and mortality of the AMI.
Streptokinase was the only thrombolytic therapy used in our practice as primary PTCA was not available at the time of this study. The most important limitation factor for using thrombolytic therapy was the time factor where 52.3% of the patients arrived after passing 12 hours from the onset of symptoms (23 patients). This shows that people awareness about the heart attack symptoms is very poor. In addition, this reflects under utilization of Emergency medical services, e.g. ambulance. Public education concerning the symptoms of a heart attack, the time factor in the management of such disease as part of a large and comprehensive medical and health educational program is needed.
We couldn’t accurately determine the time of hospital arrival, as it was not a routine practice to in our hospitals. Mostly, the patient spends much time at home as they do not know the symptoms of AMI or they are coming from other cities to these hospital where AMI was known to be managed. Arranging transport to the hospital is another problem leading to delays in patients arriving at a suitable time. The time spent in the emergency room waiting to be seen by a physician is another factor, which was variable and this was not recorded. The emergency rooms at these hospitals were general and most of the time overcrowded. Moreover, only CCUs could administer thrombolytic therapy and this may contribute to the delay in instituting appropriate thrombolytic treatment, hence the maximum benefit from thrombolytic therapy were not achieved.
On the other hand, among survivors, the rate of prescribing medications at discharge was 90.5% for antiplatelets (aspirin). 72.1% for nitrate, 67.4% for ACE inhibitors, 37.2%, for B-blocks, 11.6 for diuretics, Calcium C. blocker 4.7% and 0% for lipid lowering drugs. Considering that a proportion of patients will have contraindications to some medication, it is reasonable to include that aspirin and nitrates are adequately prescribed in our patients. B-blockers, ACE inhibitors, calcium channel

blocker and lipid lowering drugs were not adequately prescribed to patients following AMI. The feasible explanation might be that cardiologists do not follow the guidelines. Data from randomized trials involving more than 1000 patients support the early use of ACE inhibitors in the treatment of AMI (0 to 36 hours) show benefit particularly in patients with heart failure and anterior myocardial infarction12. However, the presence of contraindications or intolerance to drugs cannot explain the low rate of prescription of lipid lowering agents, ACE inhibitors, B-Blocker and calcium channel blockers in our study. Apart from that, some of these drugs are expensive which most of our patient cannot afford, as they are not covered by medical insurance. Insurance coverage affects treatment in patients with AMI as self-paying patients are more likely to receive less-expensive therapies and insured patients more likely to receive invasive treatment as well13. Therefore, we believe that availability of medical insurance is important to cover expensive and not affordable medications and primary PTCA for the AMI patients.


Study Limitation

The major limitations of our study are the small sample size and the short duration of the study (one month).


Conclusions

1. The actual practice in the main hospital in Sana’a city has been reflected by this pilot study.
2. Khat chewing was not involved because of this study was part of large study involved many Arab countries and the questionnaire was united for all countries.
3. The rate for smoking, diabetes and hyperlipidemia are high and cardiovascular risk factors prevention program must started as soon as possible.
4. Time to treatment in these hospitals needs to be improved and measures to avoid delay of therapy must be applied.
5. The rate of prescription of appropriate medical therapy such as ACE inhibitors, B-Blockers and lipid lowering drugs should be improved.
6. Medical insurance should be established to cover the cost of therapies including primary PTCA.
7. AMI registry all over Yemen should be started as soon as possible.¨



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