Efficacy and safety of thrombolysis in COVID19 related ARDS.

INTRODUCTION: COVID19 causes significant pulmonary microthrombi in some individuals, which can lead to ARDS and death. Thrombolysis could be an effective approach in some patients with severe ARDS. We describe our experience with usage of thrombolytic agents in COVID19 critically ill patients, who were in worsening respiratory failure. METHODOLOGY: Retrospective chart analysis was done in patients who were thrombolysed between May 2020- Sept 2020. Analysis was done to find out factors associated with improvement in oxygenation and survival. RESULTS: Twenty seven patients with severe ARDS [all had respiratory rate >30, FiO2 >0.6(on NIV/HFNC) and PiO2/FiO2 ratio<120] were thrombolysed in our ICU for COVID19 causes. C.T. Pulmonary Angiography could not be done in any of the 27 patients due to poor general condition, but 2D echo was normal in most (5 had dilated RA,RV) and none of the patients was in shock. So there was no conventional indication of thrombolysis in these patients, yet after thrombolysis, we saw dramatic changes in oxygenation (defined by decrease in FiO2 by ≥0.2) in twenty patients. Five patients had major bleed. Eleven patients survived (survival rate of 40.7%) and survival rate was high { 66% (8/12)} in patients who were thrombolysed within 2 days of oxygen requirement. CONCLUSION: In this unprecedented pandemic with high mortality rates, efficacy of early thrombolysis needs to be further explored in randomised controlled trials.

Drug-induced pericarditis

Though not common, drug-induced pericarditis is a serious condition, since pericardial tamponade, should it develop, may be life-threatening. As the number of drugs is constantly expanding, so does the proportion of those capable of causing pericarditis. The authors reviewed the relevant literature in the PubMed database and complemented it with information from the VigiBase database. In their article, the authors present current knowledge about the mechanisms of origin and level of risk of drug-induced pericarditis and discuss relevant information on individual drugs divided into 7 classes. Some medicines are associated with a high risk of developing pericarditis, a fact to be taken into account when treating patients with these agents. © 2022 Czech Society of Cardiology Z.S. All rights reserved.

Successful Treatment of Subclavian Artery Thrombosis by Catheter-Based Thrombus Aspiration and Thrombolytic Therapy: A Case Report

Clinical Information Patient Initials or Identifier Number: BP4****/22 Relevant Clinical History and Physical Exam: A 55 Y / Female C/C : Pain, numbness, cold sensation & weakness of left upper limb for 2 hours. Risk Factor : Hypertension, diabetes mellitus O/E : Pale, cold and absent of radial, ulnar, brachial pulse of left upper limb. Muscle power 3/5 left side. So2 86%, BP undetectable. Right upper limb were normal. BP 160/90 mm of hg, pules : 112 b/min, RR : 26/min. Body Temperature 37.5 C [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: CBC : WBC 7450, HB % 10.8 g/dl, ESR 20mm in 1st hour, Platelets : 262000, SARS Cov2 Antigen : Negative PT 14.3 sec, INR : 1.07 APTT : 32.4 sec. blood group: O positive Serum Creatinine : 1.1 mg/dl Plasma glucose 9.7 mmmol/l HIV Ab : Negative HBs Ag : Negative Anti-HCV : Negative Urine R/E : Normal lipid profile : Cholesterol 280mg/dl Vascular duplex ultrasound of left upper limb : A dilated echogenic thrombus had blocked the left subclaviav artery lumen. Relevant Catheterization Findings: Conventional angiography with the lowest amount of contrast agent through the right femoral artery, revealed that left subclavian artery thrombosis with total occlusion distal to Left internal mammary artery. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: A5Fr MPA catheter with side holes was negotiated through a right femoral sheath and was placed in the left subclavian artery. Initially thrombus aspiration was done with Eliminate aspiration catheter (TERUMO) with no success. Then suction was done with the MPA catheter itself with partial removal of thrombus. Then a 5Fr Pigtail catheter was placed inside the thrombus and kept in situ. For residual thrombus 250,000u of Inj. Streptokinase as a thrombolytic drug was given through the Pigtail catheter as bolus over 30 min. The maintenance dose 100,000 u per hour was given over 24 hours through the Pigtail catheter via infusion pump. After 24 hours of thrombolytic therapy, her pain was reduced, the left hand became slightly warm, and distal pulses were feebly palpable. Moreover, the skin colour returned to near normal with improvement of pallor. Bleeding was well controlled at the catheter site. Doppler sounds revealed partial improvement of arterial flow. After evaluation of partial improvement, a low dose 1000 iu per hour of heparin (UFH)was infused intravenously for 24 hours. After 48 hours, repeat angiography via the inserted catheter at the site did not reveal any atherosclerotic plaque and confirm the thrombosis-dissolution. The latter practice demonstrated a good blood flowto the left upper distal limb leaving a little thrombus in the superficial palmer arch. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Catheter-based thrombus aspiration and thrombolytic therapy is primarily reserved for patients with acute viable limb ischemia. As observed in the presented case, thrombus aspiration and thrombolytic therapy is recommended to be considered as an alternative therapeutic method for patients with arterial thrombosis due to the rapid response, shorter treatment time and lower cost, compared to common and sometimes unsuccessful therapies.Copyright © 2023

Pharmacoinvasive Therapy in Treating Acute STEMI Patients in COVID-19 Era-Thrombolysis by Tenecteplase (TNK) / Streptokinase (STK) Followed by Rescue PCI of the Culprit Vessel

Background: Treating acute STEMI patients by primary PCI has dramatically fallen globally in covid era as there is chances of potential threat of spreading Covid among the non-Covid patient. Thereby, thrombolysis of acute STEMI patient either by Streptokinase (STK) or Tenecteplase (TNK) in grey zone till Covid RT PCR report to come, was the mode of treatment of acute myocardial infarction patient in our hospital. Post thrombolysis, Covid positive cases were managed conservatively in a Covid dedicated unit. Covid negative cases were treated by rescue PCI of the culprit lesion. Exact data on benefit of thrombolysis either by TNK or STK of STEMI patients in Covid era, is not well addressed in our patient population. Thereby, we have carried out this prospective observational study to see the outcomes of thrombolysis and subsequent intervention. Method(s): STEMI Patient who represented to our ER with chest pain and ECG and hs-TROP-I evidenced acute ST segment elevated myocardial infarction (STEMI), were enrolled in the study. Total 139 patients enrolled (Male:120, Female :19);average age for Male: 54yrs., female was: 56yrs. All patients were admitted in the grey zone of CCU where thrombolysis done either by TNK or STK. Positive for COVID-19, were patients excluded from intervention and managed conservatively in Covid-19 dedicated ward. Covid Negative patients were kept transferred to CCU green zone. Result(s): COVID-19 test was carried out on all studied patients. Among them, Covid-19 positive were 7.9% (11) patients and managed conservatively in dedicated Covid ward, Covid-19 negative were 92.1% (128). Primary PCI was performed in 5.03% (7). Rest was managed by Pharmacoinvasive therapy either by TNK or STK. Thrombolysis by Tenecteplase in 64% (89), Streptokinase in 17.9% (25) patient, 12.9% (18) patient did not receive any thrombolysis due to late presentation and primary PCI done in 5.4% (7). On average 2.1 days after Fibrinolysis, elective PCI carried out. Data analysis from 48 patients;chest pain duration (3.71 +/-2.8 hr., Chest pain to contact time 3.3+/-2.8hr., Chest pain to needle time 7.2 +/-12.7hr., thrombolysis to balloon time 117.5+/-314.8hr., as many of the patient develop LVF post thrombolysis. More than 50% stenosis resolution observed in 41.6% (20) patients, chest pain resolution with one hour of thrombolysis observed in 43.8% (21) patients and development of LVF in 20.8% (10) patients. Door to needle time was 30 min. At presentation of STEMI;Ant Wall MI 46.8% (65), Inferior Wall MI 52.5% (73) and high Lateral 0.7% (1). Average Serum hs Trop-I was 16656 for male and 12109 for female. LVEF were 41% for male and 48% for female. HbA1C were in Male 8.34%: Female 8.05%, SBP for Male 120mmHg: Female 128 mmHg. Total, 88 stents were deployed in 83 territories. CABG recommended for 5.03% (7) patients, PCI in 58.3% (81), remaining were kept on medical management. Stented territory was LAD 45.7% (37) and RCA 39.5% (32) and LCX 14.8% (12). Common stent used;Everolimus 61.4% (54), Sirolimus 25% (22), Progenitor cell with sirolimus 2.3%(2) and Zotarolimus 11.4% (10) Conclusion(s): In the era of COVID-19, in this prospective cohort study, on acute STEMI patient management, we found that Pharmaco therapy by Tenecteplase and Streptokinase, reduced patient symptom and ST resolution partially. Therefore, coronary angiogram and subsequent Rescue PCI by Drug Eluting Stents (DES) are key goals of complete revascularization.Copyright © 2023

Impact of COVID-19 pandemic on STEMI thrombolysis and Emergency Department's performance in a non-PCI capable tertiary hospital.

INTRODUCTION: Some guidelines had recommended "thrombolysis first" in ST-elevated myocardial infarction (STEMI) during the Coronavirus Disease 2019 (COVID-19) outbreak. The impact of COVID-19 solely on STEMI thrombolysis is lacking as most studies reported outcomes related to percutaneous coronary intervention (PCI) setting. Thus, this study aimed to assess the impact of the COVID-19 pandemic on STEMI thrombolysis outcomes and the Emergency Department's performance in a non-PCI capable centre. METHODS: This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays. RESULTS AND DISCUSSION: We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02-4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic. CONCLUSION: STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.

Evaluation Time As Most Effective Factor In Success Of Thrombolysis With Streptokinase In Patients With Acute STEMI During COVID 19 Pandemic

Objective: The objective of this study to evaluate time as most effective factor in success of thrombolysis with streptokinase in patients with acute STEMI during covid 19 pandemic. Study Design: Prospective observational study Place and Duration of Study: This study was conducted at the Kashmir institute of Cardiology, Mirpur Azad Jammu and Kashmir, from April 2020 to December 2020 for a period of nine months. Materials and Methods: Patients presenting in emergency department with Acute STEMI were included, patients were analyzed via history, clinical examination and ECG findings of Acute STEMI. Results: Total of 110 patients were included in study. 80% (88) patients were male and 20%(22) patients were female. Which shows increase in the number of female patients with acute STEMI In this study we have tried to compare ECG based success criterion with international data and our data back in 2016. During the study we found successful thrombolysis around 45% during covid 19 pandemic. Conclusion: Time from onset of symptoms of Acute STEMI and start of streptokinase treatment was proven to be most effective method to improve the chances of success of streptokinase treatment and reduce mortality in such patients, as regard to my previous study in 2016 in same institute success of thrombolysis was markedly reduced with streptokinase during the covid 19 pandemic using the same treatment parameters. © 2022 Medical Forum Monthly. All rights reserved.

TCTAP C-005 Conundrum of a ‘Primary’ Angioplasty: Provisional Stenting of Left Main Stem / Left Anterior Descending During STEMI With Double Bifurcation

Clinical Information Patient Initials or Identifier Number: R Relevant Clinical History and Physical Exam: A 64-year-old lady with underlying dyslipidemia presented to our emergency department with typical chest pain. Immediate electrocardiogram was performed which showed sinus rhythm, ST elevation at lead 1, aVL and V1, hyperacute T wave at V2 till V3 with ST depression at leads II, III and aVF. Hence a diagnosis of acute anterolateral myocardial infarction, Killip 1 was given and urgent referral to cardiologist was made. Subsequently, she was subjected for primary angioplasty. Relevant Test Results Prior to Catheterization: Blood results showed sodium of 134 mmol/L, potassium of 3.5 mmol/L, urea of 3.2 mmol/L and creatinine of 67 mmol/L. Liver enzymes were within normal limits with aspartate transaminase of 38 U/L and alkaline phosphatase of 91 U/L. Creatinine kinase was 330 U/L but increased to 2861 U/L during subsequent day. In addition, COVID-19 RTK antigen was negative. Relevant Catheterization Findings: Coronary angiogram revealed mild disease at proximal right coronary artery and proximal left circumflex. Minimal disease was noted at distal left main stem, but severe disease was observed from proximal left anterior descending till mid left anterior descending. Heterogenous plague suggesting thrombus was seen at ostial first diagonal as well. [Formula presented] [Formula presented] Interventional Management Procedural Step: Right femoral assess was obtained with 7Fr sheath, and SL 3.5 7Fr guiding catheter was engaged to left coronary artery. Intracoronary heparin and tirofiban were given prior to wiring. First diagonal was wired with Sion Blue while left anterior descending was wired with Runthrough Floppy. Post-wiring both vessels, coronary flow remained TIMI 3 and hence we decided to proceed with IVUS. From IVUS, noted fibrous elastic plague with heavy thrombus burden. Intracoronary streptokinase was given and noted improvement of thrombus from IVUS. BMW wired to left circumflex. Lesion predilated with scoring balloon and associated with no reflow events, resolved post vasodilators. Left main stem was stented with Onyx 3.5 x 26 mm and deployed at 16 atm. Both side branches wires were rewired into same branches via Crusade microcatheter. LMS stent was post dilated with NC Euphora 4.5 mm at nominal pressure. Noted impingement of both ostium diagonal and circumflex branches. Balloon kissing inflation was performed for both LAD/Diagonal bifurcation and LMS/LAD/circumflex bifurcation. POT was performed post balloon kissing inflation with NC Euphora 3.5 mm and 4.5 mm for both LAD and LMS respectively. Next, IVUS was repeated for mid LAD stent length and Onyx 3.0 mm X 15 mm was deployed at nominal pressure. IVUS repeated and noted under-expansion of overlapped segments and post dilated with NC Euphora 3.0 mm at high pressure. [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusions: Our clinical vignette demonstrated few learning points including utilization of IVUS during primary angioplasty. Understanding of plague characteristic ensures adequate stents expansion especially with fibro elastic plague. In addition, we also demonstrated several precautions in dealing with bifurcation lesions including usage of double lumen microcatheter for wiring the side branches. Even though we opted for provisional stenting, balloon kissing inflation played pivotal role in preserving flow into side branches.

A Complicated Case of COVID-19-Induced Inferolateral Wall Myocardial Infarction Successfully Treated With Streptokinase.

The treatment of myocardial infarction (MI) in coronavirus disease 2019 (COVID-19)-positive patients is both controversial and challenging, particularly in a healthcare setup unable to fulfill COVID-19 protocols. In this report, we describe a case of a COVID-19-positive patient admitted with COVID-19 pneumonia treated symptomatically with a non-rebreathing mask, dexamethasone, remdesivir, and low-molecular-weight heparin (LMWH). On day two of the hospital stay, the patient developed inferolateral wall myocardial infarction (MI) without hemodynamic instability. He was treated successfully with thrombolytic (streptokinase) with no severe complications. However, his hospital stay was further complicated by decreasing oxygen saturation and rising inflammatory markers including procalcitonin and IL-6, suggesting superimposed bacterial infection. Thereafter, he was placed on BiPAP oxygen, and aggressive antibiotic therapy including tigecycline along with clindamycin and moxifloxacin was initiated. He showed gradual daily improvements and was discharged after a prolonged hospital stay. To decrease the exposure and spread of COVID-19 infection among the healthcare workers, when there is a deficiency in medical staff, and no negative-pressure catheterization laboratory, thrombolytic can be used for treatment in low-risk, hemodynamically stable MI during this pandemic. However, this needs further research.