A comparative study on the effect of streptokinase between diabetic and non-diabetic myocardial infarction patients

A prospective interventional study was carried out to compare the thrombolytic effect of streptokinase between diabetic and non-diabetic myocardial infarction patients. Out of 187 study subjects with acute ST segment elevation myocardial infarction, admitted at coronary care unit, 126 patients were nondiabetic and 61 patients were diabetic. Streptokinase was administered to all patients. Resolution (reduction) of elevated ST segment was evaluated after 90 min of streptokinase administration. Successful reperfusion (≥70% ST-resolution) was significantly higher in non-diabetic than diabetic (p<0.001), while failed reperfusion (<30% ST resolution) was significantly higher in diabetic patients (p<0.001). It may be concluded that diabetes mellitus might affect the thrombolytic outcome of acute myocardial infarction patients with diabetes mellitus. Article Info Received: 28 January 2008 Accepted: 6 April 2008 Available Online: 11 April 2008 DOI: 10.3329/bjp.v3i1.822 Cite this article: Chowdhury MAR, Hossain AKMM, Dey SR, Akhtaruzzaman AKM, Islam NAF. A comparative study on the effect of streptokinase between diabetic and non-diabetic myocardial infarction patients. Bangladesh J Pharmacol. 2008; 3: 1-7. A comparative study on the effect of streptokinase between diabetic and non-diabetic myocardial infarction patients Md. Anup Rahman Chowdhury1, A.K.M. Mosharrof Hossain1, Sudhangshu Ranjan Dey2, A.K.M. Akhtaruzzaman2, and Nur-A-Farhana Islam3 Department of Pharmacology and Cardiology, Sylhet M. A. G. Osmani Medical College Hospital, Sylhet 3100, Bangladesh; Department of Biochemistry, North East Medical College, Sylhet 3100, Bangladesh. This work is licensed under a Creative Commons Attribution 4.0 License. You are free to copy, distribute and perform the work. You must attribute the work in the manner specified by the author or licensor. (streptokinase, anistreplase, urokinase) and b) Recombinant tissue-type plasminogen activator (alteplase, duteplase, reteplase). Streptokinase was the first thrombolytic drug to be described and introduced in the treatment of myocardial infarction since 1958 (Hermentin et al., 2005). However, newer fibrinolytic agents are equivalent but not superior to older non-selective agents (Sabatine et al., 2005). Use of streptokinase in patients with acute myocardial infarction is considered up to 12 hours after the onset of chest pain (Maxwell, 1999). But it is the 1st hour considered golden hour for thrombolytic therapy. The outcome of acute myocardial infarction treated with fibrinolytic therapy can be evaluated either by coronary angiographic measurement of TIMI (Thrombolysis In Myocardial Infarction) blood flow or by the measurement of ST segment resolution at 90 min after streptokinase infusion, in 12 lead electrocardiogram (Zairis et al., 2004). Although successful recanalization of the epicardial vessel is a necessary condition, it is the micro -vascular flow that most strongly correlates with outcome. ST-segment changes reflect myocardial rather than epicardial flow and hence yield prognostic information beyond that provided by coronary angiogram alone (Kenner et al., 1995; Van t’Hof et al., 1997; Santoro et al., 1998). ST segment resolution within 90 min is a simple measure of assessing reperfusion in patients receiving fibrinolytics (de Lemos et al., 2000). Mortality after acute myocardial infarction in patients with diabetes is about twice that of non-diabetic patients (Woodfield et al., 1996). It is uncertain whether this difference in mortality is due to a lower rate of successful thrombolysis, increased re-occlusion after successful thrombolysis, greater ventricular injury or more adverse clinical profile in diabetic patients. In Bangladesh, 90-95% of all diabetes patients belong to type 2 diabetes (Mahtab et al., 2003). Current thrombolytic treatment of acute myocardial infarction, derived from large clinical trials has dramatically improved survival in both non-diabetic and diabetic patients. However despite these improvements, diabetes still doubles the fatality rate. As because diabetes profoundly affects cardiovascular disease, one could argue that clinical trial with potential implications for the care of patients with ischemic heart disease, should be specifically designed to evaluate the effect of thrombolytic therapy in diabetic patients. In this study, we evaluated the impact of type 2 diabetes in intravenous thrombolysis effectiveness by using a 12-lead ECG. Materials and Methods This prospective interventional study was carried out during the period of July 2006 to June 2007. The patients, who were admitted in coronary care unit with the diagnosis of ST elevation myocardial infarction, were taken as the study subjects. Initially 199 patients with acute myocardial infarction were selected. Among them, 12 were excluded (7 due to uninterruptible ECG, 5 died during streptokinase therapy). Of the rest 187, 126 patients were non-diabetic and 61 were diabetic. Inclusion criteria werepatients with STEMI came within 12 hours of chest pain, known diabetic or established during hospital stay by repeated blood glucose estimation. Exclusion criteria were late presentation, after 12 hours of chest pain, type 1 diabetes, IGT, history of previous myocardial infarction. Streptokinase was given to each patient at a dose of 1.5 million units, diluted in 100 mL of normal saline, in 1 hour. Informed written consent of the patient/attendant was taken. Fasting plasma glucose was recorded from all patients, in the morning of day following hospital admission. For differentiating new case of diabetes, stress hyperglycemia and non-diabetic, fasting plasma glucose measurements were repeated in stable condition prior to discharge from hospital. Complications like hypotension, shock, hemorrhagic manifestation following streptokinase were noted. In normal 12-lead ECG, ST segment lies between QRS complex and the ‘T’ wave. The normal ST segment begins at the ‘J’ point, the first point of inflexion on the upstroke of the ‘S’ wave and is situated on the isoelectric linethat is at the same level to the part between ‘T’ wave and next ‘P’ wave (Carley et al,. 2002). Elevation of ST segment occurs during acute myocardial infarction, which returns to the iso-electric line within 48 to 72 hours if not treated with thrombolytics. Reduction of height of ST segment elevation (ST resolution) towards baseline within 90 min after streptokinase infusion has been shown to be a useful predictor of successful reperfusion (Bassand et al., 2005). The STsegment elevation resolution stratified by Schroder et 2 Bangladesh J Pharmacol 2008; 3: 1-7