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ORIGINAL ARTICLE
Year : 2023 | Volume
: 24
| Issue : 2 | Page : 93-97
Clinical characteristics and outcome of percutaneous coronary intervention in Yemeni patients
Taha AL-Maimoony1, Nora AL-Sageer1, Mervat Alnajjar1, Mohammed Ghaleb Ali Kaid2, Mohammed Rajeh2, Ahmed Lutf Al-Motarreb1
1 Department of Cardiology, Faculty of Medicine, Sanaa University, Sanaa, Yemen
2 Military Cardiac Center, Sanaa, Yemen
Correspondence Address:
Prof. Ahmed Lutf Al-Motarreb
Department of Cardiology, Faculty of Medicine, Sanaa University, Sanaa
Yemen
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/heartviews.heartviews_98_22
Abstract
Background: Percutaneous coronary intervention (PCI) is increasingly used in the management of acute coronary syndromes (ACSs). PCI has decreased the demand for coronary artery bypass grafting, and more patients with ACS are now undergoing PCI. No previous data about the characteristics and outcome of patients performing PCI in Yemen. This study aimed to assess the patient presentation, characteristics, and outcome among Yemeni patients having PCI in the Military Cardiac Center.
Methods: All patients who underwent PCI either primary or elective in the Military Cardiac Center in Sanaa City were included over 6 months. Clinical, demographic, procedural, and outcome data were extracted and analyzed.
Results: During the study period, 250 patients underwent PCI. The mean ± standard deviation age was 57 ± 11 years, with 84% being male. Of all the patients, 61.6% (156) smoked tobacco, 56% (140) had hypertension, 37% (93) had Type 2 diabetes, 48.4% (121) had hyperlipidemia, and 8% (20) had a family history of ischemic heart disease. Coronary artery presentation was in the form of acute ST-elevation myocardial infarction at 41% (102), non-STEMI at 5.2% (58), stable angina at 31% (77), and unstable angina at 5.2% (13). Coronary artery interventions were elective PCI in 81% (203), emergency in 11% (27), and urgent in 8% (20) with only 3% radial artery access and 97% femoral access. PCI was mainly in the left anterior descending artery in 82% (179), right coronary artery in 41% (89), left circumflex artery in 23% (54), and left main in 1.25% (3). All stents were drug-eluting stents during the registry time. Complication occurred in 17.6% (44) and case fatality was 2% (5).
Conclusions: Despite the current situation in Yemen, PCI was performed with success in a large number of patients with a low incidence of inhospital complications and mortality that is comparable to high- or middle-income settings.
Keywords: Angina, elective, myocardial infarction, percutaneous coronary intervention, registry
Introduction 
Coronary artery disease (CAD) is the most common cardiovascular disease (CVD) with a prevalence that increases with age.[1] Over three-quarters of CVD deaths take place in low- and middle-income countries.[2] Individuals of low socioeconomic status carry a substantial burden of CVD and are more likely to experience increased event rates and poorer outcomes.[3]
Early and complete (thrombolysis in myocardial infarction Grade 3 flow) infarct-related artery patency and prompt myocardial salvage are of paramount importance to improve the clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI).[1] Timely and high-quality primary percutaneous coronary intervention (PPCI) reduces mortality from acute STEMI by over 50% and makes it one of the most important interventions available in medicine.[4] Percutaneous coronary intervention (PCI) prevents cardiac death, and myocardial infarction (MI) in patients with unstable angina[5] and also with stable angina. PCI results in less angina, a better quality of life, less urgent revascularizations, and fewer spontaneous MIs compared to medical treatment alone.
With using the latest-generation drug-eluting stent technology, featuring thin struts, improved anti-restenosis drugs, and better drug-release technology and kinetics in addition to the operator experience have contribute to the current high success rates and low periprocedural complications. Technology refinement, improved stent designs, and operator experience have contributed to the current high success rates and low periprocedural complications.[6]
Registries improve patient care by identifying and monitoring gaps in the delivery of appropriate therapies, driving key practice change. Myocardial salvage by early PCI is of supreme importance to improve clinical outcomes, particularly for patients with STEMI.[1]
In Yemen, no previous study has described PCI patients' characteristics and the outcome of patients who underwent PCI. Hence, this is the first registry to assess the daily interventional performance and reflect the most recent work using the most recent drug-eluting stents.
Methods All patients who underwent PCI, either primary or elective, were included in a prospective registry in the Military Cardiac Center in Sanaa City. These patients were enrolled in a 6-month study period (May 15, 2021–November 15, 2021). Patients with ST-segment elevation who arrived at the emergency room (ER) and were indicated for PPCI were shifted from ER to the catheterization laboratory, and elective PCI patients were referred to the catheterization laboratory from the cardiac outpatient clinics. The inclusion criteria were the indication for cardiac revascularization which included patients with ST-segment elevation, non-ST-segment elevation MI (NSTEMI) unstable angina, and stable angina in addition to angina equivalent such as shortness of breath, dyspnea, and arrhythmias. The exclusion criteria were critical left main stenosis, complex coronary artery stenosis, chronic total occlusion (CTO), stenosis <50%, coagulopathy and absence of surgical support, severe left ventricular hypocontractility, severe renal impairment, and refusal to go for PCI. Cardiac risk factors were assessed by history taking, clinical examination, and laboratory blood tests.
Once a patient who is indicated to do PCI arrives to the catheterization laboratory, the procedure starts immediately with mainly a femoral approach. Protocol to tackle the occluded arteries are according to international protocols and guidelines with full safety precaution.
The Military Cardiac Center started its cardiac catheterization services in September 2010. Since then, a total of 20,690 cardiac catheterizations have been performed including PCI, balloon mitral valvotomy, and congenital defect device implantation. Most of the centers' specialists and technical staff were trained outside and inside Yemen.
Clinical, demographic, procedural, and outcome data were systematically collected. The data were entered into the IBM SPSS Statistics for Windows, version 26 (IBM Corp, Armonk, N.Y, USA). Quantitative variables were summarized using mean ± standard deviation (SD) if the data were normally distributed or median (interquartile) otherwise. Categorical variables were summarized as frequencies and percentages taking into account missing values.
Results [Table 1] shows the baseline characteristics of the 250 patients who underwent PCI in this study. The mean ± SD age was 57 ± 11 years while 84% were male.
The clinical presentation of the coronary artery was in the form of STEMI 41% (102), NSTEMI 5.2% (58), stable angina 31% (77), and unstable angina 5.2% (13). Coronary artery intervention status was elective PCI in 81% (203), emergency in 11% (27), and urgent (20).
Out of 102 patients with STEMI, 26.5% had PPCI. Of all patients, 61.6% (156) smoked tobacco, 56% (140) had hypertension, 37% (93) had Type 2 diabetes, 48.4% (121) had hyperlipidemia, and 8% (20) had a family history of ischemic heart disease. Radial access represented 3% (8) and 97% (242) had femoral artery access. Stenosis of the left anterior descending artery (LAD) represented 82% (197), followed by the right coronary artery (RCA) at 41% (98) and then the left circumflex artery (LCX) at 23% (54), and the left main represented 1.25% (3). Single-stent deployment was in 53% (132), two stents in 33.2% (83), three stents in 10.4% (26), four stents 1.6% (4), no stents in 0.8%, and failed stenting in 1.2% (3).
All stents in this registry were drug-eluting stents. Long stents (>32–38 mm stents) were implanted in 68% (117) in LAD, 60% (44 stents) in RCA, and 30% (15 stents) in LCX. Two stents in the same artery were 18% (45 stents), 4% (10 stents) in the RCA, and the second stent in LCX.
Coronary perforation was in 11 cases (4.6%),cardiac tamponade in 11 cases (4.6%), coronary dissection was in 2 cases (0.8%), no-reflow in 2 cases (0.8%), cerebrovascular accident in 2 cases (0.8%), bleeding within 72 h were in 5 cases (2.1%), MI in 2 cases (0.8%) and case fatality was 5 cases (2%) [Table 2].
Discharge medications were aspirin 96% (230), clopidogrel 93% (225), ticagrelor 0.8% (2), ticlopidine 0.4% (1), statin 96% (230), beta-blockers 78% (188), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 83% (198) [Table 3]. Most patients (230 patients, 92%) were discharged home, and 5.6% (14 cases) were shifted to the cardiac care unit. One case shifted to cardiac surgery and 2% (5 cases) was the mortality rate.
Discussion PCI is a safe and effective procedure to reconstitute myocardial perfusion and has been demonstrated to improve prognosis in patients with acute coronary syndrome (ACS).
In Yemen, PCI has increasingly been used to manage the emergency state of STEMI, urgent cases as well as elective cases. Many facilitated cardiac centers are available, in particular the main big cities, and not available in most of other cities.
This registry is the first one to assess the real practice of PCI in Yemen, in particular the Military Cardiac Center. The main age of our patients was 57 ± 11 years, and this age is similar to the Omani Registry patients 58 ± 11[7] but younger than the Swedish Coronary Angiography and Angioplasty Registry registry by a decade (the mean age was 67 years).[8] Males were predominant which represent 84%.
The main risk factors of ischemic heart disease in this registry were smoking tobacco 61.6%, hypertension 56%, dyslipidemia 48.4%, and diabetes mellitus 37%. Smoking was slightly higher than the Egyptian patients at 59.05%,[9] Oman at 20%,[7] and among men in Michigan, United States of America (USA), at 34.5%[10] followed by hypertension at 56% which is lower than hypertension in Egypt and almost similar to that of Oman but less than hypertension among men in the USA (71.9%). Dyslipidemia was higher than in Egypt but less than in Oman and the USA.
Coronary artery presentation was STEMI 40.8% (102 patients), and only 26.5% of these STEMI patients reached the center in the indicated time for PPCI. Reasons behind the low rate of PPCI are; social awareness about the symptoms of ACS, misdiagnosis of acute myocardial infarction, patients present themselves to non-PCI facilitated centers, self-presentation to hospital rather than ambulance, lack of medical centers in many areas, and financial factor all of these reasons are the possible causes of the pre-hospital delay in Yemen.
This delay was similar to low medical resources in China,[11] and in India where old age, rural residence, and symptom misinterpretation resulted in a significant delay in reaching the hospital,[12] whereas in Europe, the use of telemedicine for prehospital diagnosis and triage of patients directly to the catheter laboratory is feasible and allows 89% of patients living up to 95 km from the invasive center to be treated with PPCI within 120 min of the emergency medical service call.[13]
Elective PCI was the most common way of performing PCI in our center representing 81% (203 patients). Elective PCI was the most common way of performing PCI in our cardiac center representing 81% (203 patients); stable angina represent 36.5% (74 patients), elective in STEMI patients represent 31% (63 patients present themselves too late), NSTEM represent 26.6% of the elective cases (54 patients) and unstable angina represent 5.9% of the elective PCI.
Elective coronary artery angiography is indicated in low-risk patients if they have positive signs of ischemia on noninvasive tests. Depending on the results of coronary angiography, elective PCI is indicated according to ESC or AHA/ACC guidelines.
A total of 888 patients with stable CAD and (at least one hemodynamically significant coronary stenosis) were randomized to PCI plus medical therapy or medical therapy alone. At 5-year follow-up, the primary composite clinical outcome (death, MI, or urgent coronary revascularization) occurred less frequently with PCI than with medical therapy alone (13.9% vs. 27.0%) and about 50% of the medical-therapy-only patients crossed over to PCI which suggests a much larger benefit of elective PCI.[14]
Patients with stable angina seek medical treatment for their symptoms. Most of our doctors believe that PCI is the best way of management to relieve the symptoms, prevent future progress of stable angina to unstable angina, prevent MI, and improve the quality of a patient's life.
Published data showed that the benefits of PCI in stable ischemic heart disease depend on its effect on the quality of life, including angina, physical activity, and emotional well-being. PCI decreases angina and the need for antianginal medications, and increases exercise capacity and quality of life, compared with baseline status and compared with medical therapy without PCI.[5] Despite the benefit of PCI in stable angina regarding symptom relief and quality of life, there is no evidence of an effect on MI and mortality in this group of patients, while in unstable angina, PCI prevents death, cardiac death, and MI.[15]
Revascularization by PCI within 12 h of symptom onset is currently the treatment of choice in STEMI.[16] In our patients, only 11% of STEMI patients had been arrived at the center within the eligible time and treated with PPCI. Patients with STEMI who had been present themselves late represent 31%. These patients had been treated by PCI. This was based on reports indicating benefits from PPCI in late-presenting patients mainly for patients with ongoing chest pain.[17]
In our registry, post-STEMI patients without chest pain or symptoms had been managed with PCI, in particular in multivessel disease and the not culprit arteries and significant stenosis or total occlusion in the culprit arteries. Viability study in our center was not routinely performed and doctors rely upon their clinical assessment despite that viability assessment.
Functional testing can identify subgroups that may benefit from late PCI.[18] However, another study found similar efficacy and long-term outcome in early PCI (3–14 days) and late PCI (>14 days) using a second drug-eluting stent.[19] Therefore, late PCI is considered in our patients without documented follow-up to assess the long-term outcome. Latecomers post-MI with total occlusion in the coronary angiogram were treated by PCI as a treatment strategy in our center. Reports had shown benefits from opening the total occlusion arteries. Park et al. have reported a 10-year follow-up study comparing PCI to optimal medical therapy (OMT) and concluded that as an initial treatment strategy, CTO-PCI might reduce late cardiac death compared with OMT in patients with CTO.[20] In addition, CTO PCI is shown to improve symptoms, reduce ischemia, and improve left ventricular function.[21] Further studies are warranted to assess the gap between the guidelines and the real PCI practice in Yemen.
Conclusions This registry is the first one in Yemen. It shows part of the interventional management of ACS with very low PPCI. Latecomers and very latecomers still receive the PCI revascularization strategy. A viability study is not performed in our center during this registry and no long-term documented follow-up. Further studies with follow-up are warranted to assess the gap between the guidelines and the real practice in Yemen.
Study limitation
This is the first descriptive registry, but it does not represent the actual PCI practice in YemenLack of previous similar studiesLack of follow-upDuring wartime and the tight economic crises, many patients could not afford the PCI fees even in government hospitals and they simply did not go for PCI.Highlights
This study is the first documented Yemeni PCI experienceOur patients are younger than their European counterparts with males predominantMost of the PCI patients were elective cases and few cases were emergency cases due to very latecomersRecent techniques, drugs, and drug-eluting stents were used in this studyLow complications and mortality may be because of younger age and elective PCI procedures.Acknowledgments
I am glad to all of those who worked hard to complete this work.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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