• Interventional Techniques & Devices
• Myocardial Infarction

• Interventional Techniques & Devices
• Myocardial Infarction
• Cardiology

The prevalence of ischemic heart disease is increasing among the 340 million people who live in the Arab world. Thus, a program that improves the management of ST-elevation myocardial infarction (STEMI) and access to coronary revascularization therapies is needed. Habib Gamra, MD, Fattouma Bourguiba University Hospital, Monastir, Tunisia, discussed ways to improve the management of STEMI in the Arab world.

The ACCESS Registry is a prospective, observational, multinational registry of patients from 134 sites in 19 countries in Latin America, the Middle East, and Africa who were hospitalized for an acute coronary syndrome (ACS) between January 2007 and January 2008. Of the 11,731 patients with confirmed ACS, 46% were diagnosed with STEMI and 54% with non-ST Elevation ACS (non-ST Elevation Myocardial Infarction (NSTEMI) or unstable angina). Diabetes, hypertension, abdominal obesity, and smoking were identified as significant risk factors for ACS.

While hospitalized, the majority of patients received aspirin (93%), lipid-lowering medication (94%), β-blocker (78%) and angiotensin-converting enzyme inhibitor (68%). Death at 12 months was higher in patients with STEMI (8.4%) as compared with NSTEMI (6.3%, p<0.0001). Although the use of evidence-based, pharmacologic therapies occurred in the majority of patients with ACS, the majority of patients with STEMI who were eligible for reperfusion therapy did not receive either fibrinolysis or primary percutaneous coronary intervention (PCI). These data suggests further work is necessary in order to increase access of patients in developing countries to reperfusion therapies and other therapies which reduce the risk of long-term ischemic events in patients with ACS [ACCESS Investigators. Am Heart J 2011].

While percutaneous revascularization has been shown to be preferable to thrombolysis for the management of patients with STEMI, thrombolysis is more commonly used in the Middle East. Of the 1470 patients with STEMI followed in the Monastir for Acute MI [MIRAMI] registry, 23.6% received primary angioplasty (PAMI) and 34.5% received streptokinase. Thrombolytic success (defined as chest pain relief <5 using a scale of 1 to 10 and ST-elevation resolution >50% from baseline) was achieved in 70% of the patients who received treatment within 3 hours from chest pain onset. Predictors of success were short time to treatment (<3 years), smoking, and inferior STEMI while severe heart failure was a predictor of thrombolytic failure.

The Gulf Registry of Acute Coronary Events (Gulf Race) followed 8169 consecutive patients (74% men) with ACS patients from six Middle Eastern countries. In this registry, women were more likely than men to present with unstable angina and more often had atypical presentations of STEMI. In contrast, men presented with STEMI (45%) more frequently than women (22%). Compared with men, women were significantly less likely to be treated with β-blockers and antiplatelet therapy. Among patients with STEMI eligible for reperfusion therapy, 83% received thrombolytic therapy. PCI was performed in 9% of eligible patients; another 8% were eligible but did not undergo reperfusion therapy. The percentage of patients who were eligible for reperfusion but were not treated was higher in women as compared with men (15% vs 8%; p=0.001). Women had higher in-hospital mortality and had poorer outcomes than men [El-Menyar A et al. Am J Cardiol 2009]. The finding of inadequate use of reperfusion therapy among patients with STEMI in Arab countries has also been documented in other studies [Moustaghfir A et al. Arch Cardiovasc Dis 2012]. To better achieve guideline-based treatment, the Middle East needs more catheterization laboratories with adequate geographic distribution capable of running a primary PCI program 24 hours a day [Knot J et al. EuroIntervention 2009]. There is also a critical need for education of the general population regarding ACS and more training for healthcare providers.

Prof. Gamra's concluded with the observation that in patients with STEMI, thrombolysis is effective if initiated soon after the onset of symptoms but primary PCI is the preferred method of revascularization.

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