Kliniğimize ST elevasyonlu miyokard infarktüsü nedeniyle başvuran hastalarda tercih edilen tedavi stratejilerinin karşılaştırılması
The comparision of the treatment strategies prefered in the patients admitted to our clinic due to the myocardial infarction with ST elevation
Yazar: MAHMUT ÖZDEMİR
Danışman: YRD. DOÇ. MUSA ŞAHİN
Yüzüncü Yıl Üniversitesi / Tıp Fakültesi / Dahili Tıp Bilimleri Bölümü / Kardiyoloji Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2013
Konu: Kardiyoloji = Cardiology
Dizin: Koroner hastalık = Coronary disease ; Miyokard = Myocardium ; Miyokard enfarktüsü = Myocardial infarction ; Reperfüzyon = Reperfusion ; Reperfüzyon lezyonu = Reperfusion injury ; ST segmenti = ST segment ; Trombolitik terapi = Thrombolytic therapy

Özet:
Amaç: Kliniğimize ST elevasyonlu miyokard infarktüsü ile başvuran hastaların hastaneye başvuru zamanı ile müdahale arasındaki süreyi tespit etmek, başvuru anındaki klinik durumunu değerlendirmek, seçilen tedavi metodlarını irdelemek, tedavi metodu seçilmesinde etkili olan parametreleri değerlendirmek ve tedavi stratejilerini karşılaştırmaktır.Metod: Fakültemize ST segment elevasyonlu miyokard infarktüsü tanısı ile başvuran 165 hastanın reperfüzyon stratejisi belirlendi. İlk tıbbi temas anından TIMI 3 (Miyokard infarktüsünde tromboliz) akımın sağlandığı zamana kadar geçen süre kapı-balon süresi, ilk tıbbi temas anından fibrinolitiğin başlandığı zamana kadar geçen süre ise kapı-iğne süresi olarak belirlendi. Trombolitik tedavi verilen hastaların trombolitik başlama anı kaydedildi. Trombolitik tedavi verilen hastalardaki tedavinin etkinliği reperfüzyon kriterleri temel alınarak başarılı ya da başarısız şeklinde kaydedildi. Primer perkütan koroner girişim (balon anjiyoplasti ve/veya stent yerleştirme) lezyon tipine göre yalnızca infarktüsle ilişkili artere uygulandı. Akut fazdaki işlem başarısı, her bir girişim sonucunda enfarktüsle ilişkili arterde darlığın %50'nin altına düşmesi ve TIMI III akımın sağlanması olarak tanımlandı.Bulgular: Kapı-balon süresi sevk edilen hastalarda ortalama 240 dk, doğrudan acilimize başvuran hastalarda ise ortalama 64,6 dk olarak hesaplandı. Sevk edilen hastaların mekanik reperfüzyon süreleri AHA (Amerıcan Heart Association) kılavuzuna göre sadece %7 hastada uygunken, ESC (European Society of Cardiology) kılavuzuna göre %26 hastada uygundu. Doğrudan acilimize başvuran hastalarda ise bu oranlar AHA kılavuzuna göre %86 iken ESC kılavuzuna göre %97 idi. Çalışmamızda dış merkezlerde trombolitik tedavi verilen hastalarda ortalama kapı-iğne zamanı 41,3 dakika iken, trombolitik tedavi verilen 20 hastadan 10'unda kapı-iğne süresinde hedefe ulaşılabildiği tespit edildi. Bizim merkezimizde trombolitik tedavi uygulanan hastalarda ortalama kapı-iğne süresi 35 dakika saptanmış olup, kapı-iğne süresinde trombolitik tedavi verilen 19 hastadan 10'unda hedef değer olan 30 dakikanın altında kalınabilmiştir. Primer perkütan koroner girişim için başarı oranının %93 olduğu, trombolitik tedavi başarı oranının ise %84,6 olduğu saptanmıştır.Sonuç: Kliniğimize ST segment elevasyonlu miyokard infarktüsü tanısı ile dış merkezlerden merkezimize sevk edilen ve fakültemize direkt başvuran hastaların hastaneye başvurma süreleri değerlendirildiğinde güncel kılavuzlara düşük oranda uyulduğu ortaya çıkmıştır. Aslında çok iyi organize edilmiş çalışmalar dışında gelişmiş ülkelerde de bu oranlar düşüktür. Özellikle dış merkezlerden hastanemize sevk edilen hastaların %74,7'sine reperfüzyon stratejisinin uygun şekilde gerçekleştirilemediği tespit edilmiştir. Bu bulgu uygun zamanda trombolitik tedavi verilebilecek çok sayıda hastanın yanlış olarak sevk edildiğini göstermektedir. Bu uygulamanın sebebi kılavuzların takip edilmemesinin yanında hekimin sorumluluk almaktan kaçınması ya da hastaların ısrarla fakültemize sevk istemesine bağlı olabilir. Ayrıca sevk ve ulaşıma bağlı süre uzamasından kaynaklandığını düşündüğümüz primer perkütan koroner girişim için dış merkezlerden sevk edilen hastalarda kapı-balon süresinde kılavuzlarda belirtilen değerlerin çok altında kalınması uyguladığımız reperfüzyon stratejilerini tekrar gözden geçirmemiz, özellikle bölgemiz koşullarınıda gözönüne alarak trombolitik tedaviyi daha fazla kullanım konusunda ciddi çalışmaların yapılması gerekmektedir. Çalışmamız sırasında tespit ettiğimiz gecikme sebeplerine bakacak olursak gerek sağlık camiası bakımından gerekse ülke politikası bakımından ciddi derecede tedbirler almamız gerektiği ortadadır.Anahtar Kelimeler: ST segment elevasyonlu miyokard infarktüsü, Reperfüzyon stratejileri, Kapı-iğne ve kapı-balon zamanı.

Abstract:
Objective: The objective of this study is to determine the time interval between the time of the patients' admission to our clinic, who are presenting ST-elevation myocardial infarction, and the intervention time of hospital, to evaluate the clinical status of the selected treatment methods during the moment of application, to examine the choice of methods of treatment and also to evaluate and compare the parameters that are influential in selecting the methods of the treatment.Method: The 165 patients applying to our hospital with ST-segment elevation myocardial infarction reperfusion strategy was determined. The process from the time of first medical contact to the time of TIMI 3 (Thrombolysis in myocardial infarction) current provided was called door-to-balloon time, and the process from the time of first medical contact to the time of to fibrinolytic current provided was called door-to-needle time. Moment of the starting thrombolytic therapy in patients treated with thrombolytic was recorded. The effectiveness of treatment in patients treated with fibrinolytic therapy was recorded as successful or failure by taking the criteria of eperfusion as the basis. According to the type of lesion, the primary percutaneous coronary intervention (balloon angioplasty and / or stent placement) was applied to only the infarct-related artery. The success of the acute phase process, the result of each attempt was defined as the provision of the infarction-related artery stenosis and the flow of TIMI III falling below 50% .Findings: The mean door-to-balloon time in patients referred was 240 minutes and the average time in the patients admitted directly to the our emergency service was 64,6 minutes. According to AHA (American Heart Association) guidelines only 7% of the referred patients, whereas according to ESC (European Society of Cardiology) guidelines, 26% of referred patients' duration of mechanical reperfusion was appropriate. These rates in patients applying directly to our emergency service were 86% according to AHA, whereas this rate 97% according to the guidelines of ESC. In our study, the average door-to-needle time for thrombolytic therapy in patients received in external centers was 41.3 minutes, whereas the targetof he door-to-needle time was achieved only in 10 out of the 20 patients having thrombolytic therapy. In our institution, the average door-to-needle time of patients treated with thrombolytic therapy have been found to be 35 minutes, and the door-to-needle time of 10 out of 19 patients given thrombolytic therapy was 30 minutes which is under the target value. The success rate was 93% for primary percutaneous coronary intervention and the success rate of thrombolytic therapy was found to be 84,6%.Conclusıon: When evaluating the admission of the hospital duration for the patients with the diagnosis of ST-segment elevation myocardial infarction were referred to our center from other centers and applying to our faculty directly low rate of current guidelines following has been determined. In fact, apart from a very well-organized studies in the developed countries, these rates are generally low. It has been determined, particularly, that the eperfusion strategy could not be performed properly in 74,7% of patients were referred our hospital from external centers. This finding shows that many patients that could be given thrombolytic therapy at the appropriate time were incorrectly referred to the our center. The reason of this application may stem from failure to follow the guidelines, as well as physician's avoiding taking theresponsibility or may be because of the persistent request of patients to be refered to our faculty. In addition, we consider that due to prolonged period of time referral and the access, the door-to-balloon time in patients referred from other centers remain below guidelines specified values for primary percutaneous coronary intervention. Therefore, we should re-revise our applied reperfusion strategies, especially by taking the region conditions into account and serious efforts are needed to for further use of thrombolytic therapy. If we look at the reasons for the delay we have detected during our study, we hould take serious measures both in terms of the policy of the country and in terms of the health community.Keywords: ST-segment elevation myocardial infarction, reperfusion strategies, door-to-needle and door-to-balloon time.Objective: The objective of this study is to determine the time interval between the time of the patients' admission to our clinic, who are presenting ST-elevation myocardial infarction, and the intervention time of hospital, to evaluate the clinical status of the selected treatment methods during the moment of application, to examine the choice of methods of treatment and also to evaluate and compare the parameters that are influential in selecting the methods of the treatment.Method: The 165 patients applying to our hospital with ST-segment elevation myocardial infarction reperfusion strategy was determined. The process from the time of first medical contact to the time of TIMI 3 (Thrombolysis in myocardial infarction) current provided was called door-to-balloon time, and the process from the time of first medical contact to the time of to fibrinolytic current provided was called door-to-needle time. Moment of the starting thrombolytic therapy in patients treated with thrombolytic was recorded. The effectiveness of treatment in patients treated with fibrinolytic therapy was recorded as successful or failure by taking the criteria of eperfusion as the basis. According to the type of lesion, the primary percutaneous coronary intervention (balloon angioplasty and / or stent placement) was applied to only the infarct-related artery. The success of the acute phase process, the result of each attempt was defined as the provision of the infarction-related artery stenosis and the flow of TIMI III falling below 50% .Findings: The mean door-to-balloon time in patients referred was 240 minutes and the average time in the patients admitted directly to the our emergency service was 64,6 minutes. According to AHA (American Heart Association) guidelines only 7% of the referred patients, whereas according to ESC (European Society of Cardiology) guidelines, 26% of referred patients' duration of mechanical reperfusion was appropriate. These rates in patients applying directly to our emergency service were 86% according to AHA, whereas this rate 97% according to the guidelines of ESC. In our study, the average door-to-needle time for thrombolytic therapy in patients received in external centers was 41.3 minutes, whereas the targetof he door-to-needle time was achieved only in 10 out of the 20 patients having thrombolytic therapy. In our institution, the average door-to-needle time of patients treated with thrombolytic therapy have been found to be 35 minutes, and the door-to-needle time of 10 out of 19 patients given thrombolytic therapy was 30 minutes which is under the target value. The success rate was 93% for primary percutaneous coronary intervention and the success rate of thrombolytic therapy was found to be 84,6%.Conclusıon: When evaluating the admission of the hospital duration for the patients with the diagnosis of ST-segment elevation myocardial infarction were referred to our center from other centers and applying to our faculty directly low rate of current guidelines following has been determined. In fact, apart from a very well-organized studies in the developed countries, these rates are generally low. It has been determined, particularly, that the eperfusion strategy could not be performed properly in 74,7% of patients were referred our hospital from external centers. This finding shows that many patients that could be given thrombolytic therapy at the appropriate time were incorrectly referred to the our center. The reason of this application may stem from failure to follow the guidelines, as well as physician's avoiding taking theresponsibility or may be because of the persistent request of patients to be refered to our faculty. In addition, we consider that due to prolonged period of time referral and the access, the door-to-balloon time in patients referred from other centers remain below guidelines specified values for primary percutaneous coronary intervention. Therefore, we should re-revise our applied reperfusion strategies, especially by taking the region conditions into account and serious efforts are needed to for further use of thrombolytic therapy. If we look at the reasons for the delay we have detected during our study, we hould take serious measures both in terms of the policy of the country and in terms of the health community.Keywords: ST-segment elevation myocardial infarction, reperfusion strategies, door-to-needle and door-to-balloon time.