Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : FC01 - FC05 Full Version

Comparative Efficacy between Streptokinase, Tenecteplase and Reteplase in ST Elevated Myocardial Infarction among Patients Attending Tertiary Care Hospital of Odisha


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55784.17184
Lorika Sahu, Nirmal Kumar Mohanty, Siddhartha Goutam, Trupti Rekha Swain

1. Junior Resident, Department of Pharmacology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India. 2. Associate Professor, Department of Cardiology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India. 3. Senior Resident, Department of Pharmacology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India. 4. Professor and Head, Department of Pharmacology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India.

Correspondence Address :
Dr. Trupti Rekha Swain,
Professor and Head, Department of Pharmacology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack-753001, Odisha, India.
E-mail: drtruptiswain@gmail.com

Abstract

Introduction: ST Elevation Myocardial Infarction (STEMI) is one of the most fatal emergencies contributing to significant morbidity and mortality due to coronary artery disease. Fibrinolytic agents are most effective agents used for the management of STEMI. However, there is a relative paucity of data comparing the effectiveness of thrombolytic agents that can provide insight for proper selection of this class of drugs.

Aim: To compare the efficacy of streptokinase, tenecteplase, and reteplase in patients of STEMI in terms of post-thrombolytic resolution by observing reduction of ST-segment elevation at 90 minutes of thrombolytic and assessing for mortality within 30 days of therapy.

Materials and Methods: This prospective, single-centre, observational, hospital-based study was conducted in the Department of Cardiology in collaboration with the Department of Pharmacology at Srirama Chandra Bhanja Medical College and Hospital, Odisha, India, from February 2020 to January 2022. The study involved 300 patients (100 patients in each group) being treated with streptokinase, or tenecteplase,or reteplase. A reduction of ≥50% of the initial ST elevation was considered as successful thrombolysis. The efficacy of the thrombolysis with these agents was assessed based on the extent of ST resolution in Electrocardiogram (ECG) at 90 minutes and observing 30 day mortality thereafter. Categorical data were evaluated using Chi-square test and the means were evaluated using Analysis of Variance (ANOVA).

Results: There was no statistically significant difference between the three groups with respect to ST segment reduction. At 90 minutes of thrombolysis, 75%, 76%, 72% patients showed reduction in the ST segment in the Streptokinase, Tenecteplase and Reteplase group, respectively (p-value=0.79). A total of nine, five and eight deaths were seen in the streptokinase, tenecteplase and reteplase group, respectively within a span 30 days (p-value=0.52).

Conclusion: Streptokinase, tenecteplase and reteplase were equally efficacious for thrombolysis in terms of thrombus resolution and preventing mortality, when started early.

Keywords

Acute coronary syndrome, Cardiology, Fibrinolytic agents, Mortality, Thrombolysis

Acute Coronary Syndrome (ACS) is a culmination of pathophysiological and clinical changes seen in the myocardium following acute myocardial ischaemia and is one of the most important causes of death globally (1). Among the various ACS, ST Elevation Myocardial Infarction (STEMI) is a fatal emergency occurring commonly, but can have a lesser effect when treated promptly and appropriately (2). However, for the treatment to be successful, time of intervention is crucial (3).

Fibrinolytic agents are the most effective agents for the management of STEMI. When administered within 12 hours of onset of symptoms, they can achieve reperfusion and restore blood flow to the infarcted region (4), restore normal cardiac function and can save lives. Fibrinolytic therapy administered within the golden hour can abort Myocardial Infarction (MI) and dramatically reduce mortality. Four fibrinolytic agents are approved by the United States-Food and Drug Administration, namely, streptokinase, alteplase, reteplase and tenecteplase. Streptokinase is one of the safest drugs but being a bacterial extract, it may induce anaphylaxis (5). Thus, it should not be used again after four days of administration (6). Subsequent episodes of thrombotic events are thus treated with recombinant tissue Plasminogen Activators (rtPA) such as alteplase, tenecteplase and reteplase (7). Tenecteplase is administered as a single bolus intravenous injection within 5-10 seconds (8). It is highly potent but is expensive. Reteplase is administered as a double-bolus regimen, 30 minutes apart. Although it has reduced fibrin selectivity (9), it has a higher coronary reperfusion rate in patients with Acute Myocardial Infarction (AMI) (10).

However, there is a relative paucity of data regarding the efficacy of the various thrombolytic agents in terms of ST segment resolution, coronary reperfusion and short-term mortality in the Indian context. Incidence of acute MI is increasing in an alarming rate in India (11),(12). Fibrinolytic agents like streptokinase, reteplase and tenecteplase are frequently used to manage acute coronary events which save lives when instituted early in therapy. However, recently many recombinant Deoxyribonucleic Acid (rDNA) products have been launched in the market. Streptokinase, being the oldest and cheapest of the above, possess certain demerits in terms of clinical utility. Preliminary surveys found that reteplase and tenecteplase are frequently preferred by the cardiologists/physicians (13),(14). A study by Dasbiswas A et al., reviewed that although primary Percutaneous Coronary Intervention (PCI) was the gold standard treatment, it was not feasible an option many a times in the Indian setting and hence third generation fibrinolytics like reteplase and tenecteplase are emerging as reperfusion strategies to manage STEMI (14). A network meta-analysis study revealed that tenecteplase and reteplase showed equal efficacy and safety as treatment options for AMI with no significant differences in the parameters such as risk of mortality, TIMI grade 3 flow at 90 mins, infarction or any major bleeding (13). Tenecteplase has proven to be cost effective and thus, emerged as the fibrinolytic of choice in resource-limited settings (15),(16).

Hence, the present study was planned to give a definitive direction to the clinicians about the efficacy of these three thrombolytic agents. The present study aimed to make a head-to-head efficacy comparison between streptokinase, tenecteplase and reteplase used in the tertiary care hospital set-up for the management of STEMI patients in terms of post-thrombolytic resolution by observing reduction of ST segment elevation at 90 minutes of thrombolytic and assessing for mortality within 30 days of therapy.

Material and Methods

This prospective, single-centre, observational, hospital-based, study was conducted in the Department of Cardiology in collaboration with the Department of Pharmacology, at Srirama Chandra Bhanja Medical College and Hospital, Odisha, India, from February 2020 to January 2022. Ethical approval was obtained from the Institutional Ethics Committee of Srirama Chandra Bhanja Medical College prior to the initiation of the study (IEC application no.130).

Sample size calculation: Taking the prevalence of the coronary heart disease at 6% (17),(18), precision at 5% and 10% assumed to be a loss to follow-up, a total of 300 patients were recruited, 100 in each group.

Inclusion criteria: Patients of either gender aged >18 years, who presented to the emergency Department or Cardiology Outpatient Department with acute STEMI were included in the study.

Exclusion criteria: Patients undergoing percutaneous coronary intervention were excluded from the study.

ECG was done at the time of admission and those with ST elevation were enrolled after obtaining consent. The patients were treated with streptokinase, tenecteplase or reteplase as preferred by the cardiologists.

Streptokinase group (n=100): The dose of streptokinase administered was 1.5 million units intravenous (i.v.) given over 30-60 minutes.

Tenecteplase group (n=100): Tenecteplase was given as a single i.v. bolus, the dose of which was calculated according to the patient’s weight.

Reteplase group (n=100): Reteplase was administered as i.v bolus of 10 units two times at a gap of 30 minutes.

All the study drugs were made available by the hospital free of cost.

Study Procedure

All the enrolled participants were evaluated for demographic and clinical details in a predesigned case record form. The efficacy of the thrombolytic agents was assessed based on the extent of ST resolution in Electrocardiogram (ECG) at 90 minutes of thrombolysis. A reduction of ≥50% of initial ST elevation was considered as successful thrombolysis. The time of presentation to the hospital was evaluated and any admission beyond 12 hours from the onset of symptoms was labelled as delayed presentation. The participants were followed-up for 30 days, from the day of thrombolysis, over phone or when they revisited the Outpatient Department and any death within the aforesaid period was recorded. Repeat ECG was mandated on first follow-up and advised on subsequent follow-ups, if there were signs of infarction (Table/Fig 1).

Statistical Analysis

The data was analysed using descriptive statistics like mean and standard deviation, percentages and proportions. Categorical data were evaluated using Chi-square test and the means were evaluated using Analysis of variance (ANOVA). The results were drawn using appropriate statistical tests using Microsoft Excel sheet and Statistical Package for Social Sciences (SPSS) version 20.0. Mortality was assessed using log-rank test.

Results

The baseline characteristics of the participants of all the treating groups were comparable (Table/Fig 2). The minimum age of the study participants was 37 years and the maximum was 87 years. Most of the patients belonged to the age group of 41-60 years. Diabetes mellitus was the most common risk factor found in the sample.

Anterior wall STEMI was the most common type encountered. There was a significant difference in the time of presentation from the onset of symptoms among the STEMI patients (Table/Fig 3). There was no statistically significant difference among the three groups with respect to post-thrombolytic ST segment resolution after 90 minutes of the administration of the thrombolytic agent.

Most number of deaths occurred either within the first 24 hours or first week of thrombolysis. Maximum number of deaths within 24 hours was seen with streptokinase, followed by tenecteplase and reteplase.

The association between smoking and co-morbidities like diabetes and hypertension with ST segment resolution (hence the outcome of thrombolysis) was also, studied. A comparison of ST resolution at 90 mins between smokers and non smokers, diabetics and non diabetics, and hypertensives and non hypertensives was made in all the three arms. There was no statistically significant difference among the aforesaid groups in any of the treatment groups (Table/Fig 4).

As evident from (Table/Fig 3), the number of study participants who presented before and after 12 hours of onset of symptoms varied significantly (p-value=0.003). Within groups comparison in all the three treatment groups, showed no statistically significant difference in ST resolution at 90 mins between those who presented before and after 12 hours of onset of symptoms.

The intragroup comparison of success of thrombolysis with streptokinase, tenecteplase and reteplase was found to be similar in patients presenting before and after 12 hours in the respective arms (Table/Fig 5). (Table/Fig 6) depicts an intergroup comparison where the success of thrombolysis (defined by ≥50% ST resolution at 90 mins) was compared among the patients presenting before and after 12 hours of onset of symptoms in the three treatment arms, separately. In both the above scenarios, results were statistically non significant. The estimated 30-day survival in tenecteplase group was 94.5% followed by reteplase (91.3%) and streptokinase (90.7%). There was no significant difference between the treatment arms (log-rank test; p=0.96) (Table/Fig 7). This data is further supported by the Cumulative hazard function, which was 0.05 in tenecteplase group, followed by 0.09 in reteplase group, and 0.99 in the streptokinase group. This implied that the risk of death after 30 days of treatment was least with tenecteplase.

Discussion

The study focused on three thrombolytic agents commonly prescribed in the study set-up, namely, streptokinase, reteplase and tenecteplase. The aim was to evaluate their efficacy in terms of ST segment resolution ≥50% of initial rise and mortality up to 30 days of thrombolysis. This study found no significant difference in the aforesaid parameters among the three agents used. In the present study, there was a significant difference in the number of patients turning up with early (<12 hours) and delayed (>12 hours) presentations.The primary outcome was to assess the success of thrombolysis, defined by ST segment resolution ≥50% of initial rise, within each treatment group (intragroup) as well as between the three treatment options (intergroup) with respect to the time of presentation. The end results were similar and there was no significant difference in the outcome of thrombolysis (p-value >0.05).

In the present study, the most common site of infarction was in the anterior wall i.e. AW-STEMI. Studies by Pandey R et al., (19) and Hashmi SF et al., (20) found that IW-STEMI are more common than AW-STEMI. Anteroseptal MI was found to be the most prevalent MI in a study by Mohammed OS et al., followed by inferior wall MI and anterior wall MI (21). Irreversible injury occurs within 2-4 hours of ischaemia, hence thrombolysis is most effective in the first two hours. Thrombolytic therapy after 12 hours of the onset of symptoms increases the risk of intracranial bleeding out weighing any benefit (22),(23). In the present study, 60% of the presentations were after 12 hours and only 40% presented before 12 hours. A study by Lakshmi NR et al., showed that earlier the thrombolysis, better the success rate it holds (23). When thrombolysis was done within 3 hours, the success rate was 51.4% compared to 3-6 hours and >6 hours, where the rate of success reduced to 34.3% and 14.3%, respectively. It is a common clinical observation that diabetic subjects have diminished pain perception and hence, higher chances of asymptomatic infarctions. Among the diabetics, 40% presented within 12 hours and among the non diabetics, it was 42%. The results corroborate with another study by Kentsch M et al., which found that there appears to be no difference in clinical symptoms of AMI in patients with or without diabetes. AMI with little or no angina was also frequently found in non diabetics (24). A qualitative study by Berman N et al., showed that attenuated symptoms in MI among people with diabetes mellitus often led to delay in seeking attention and hence, a delay in receiving treatment (25).

The overall success rate of thrombolysis with streptokinase, tenecteplase and reteplase was 75%, 76% and 72%, respectively. A retrospective study done by Lee YY et al., on 192 patients concluded that streptokinase had a failure rate as high as 56.8% (26). It also stated that history of diabetes mellitus, hypertension and longer door-to-needle time were predictive factors for the therapeutic failure of streptokinase. This was in contrast to the index study where association of co-morbidities like diabetes mellitus, hypertension did not affect the overall outcome of thrombolysis (p-value >0.05). Another study by Girdhar DR et al., done on 104 patients found a success rate of 67.3% with streptokinase (27). A study by Srinivasan K, revealed 54% of successful thrombolysis with streptokinase (28). Also, the rate of success was more among non smokers as compared to smokers. This was in contrast with the present study, where smoking had no role to play in the success or failure of the treatment, with thrombolytics.

Tenecteplase had a success rate of 76% in the present study. This was in line with other studies where tenecteplase showed a very high success rate. A study by Iyengar SS et al., done with 6000 study participants showed a success rate as high as 90.93% (29). Another study with 2162 study participants also proved a high count of successful thrombolysis with tenecteplase i.e. 83.9% (30). In the present study, tenecteplase was found to have the highest 30-day survival rate (94.5%) among all the three thrombolytics. This corroborated with a study by Chua KW et al., where the group receiving tenecteplase had greater survival rate, at 30 days and overall mortality (31). The overall success rate was 79% which was similar to the findings of the present study.

Reteplase had a success rate of 72% and the estimated 30-day survival was 91.3%, second to tenecteplase. A study by Singh RK et al., on 228 patients revealed a successful thrombolysis in 90.5% of study participants with IV reteplase (32). The 30-day survival rate of reteplase was equivalent to that of streptokinase in the present study. This finding corroborated with a study (INJECT study) where 35-day survival rate was evaluated on 5986 patients, and it too revealed, that double bolus (10U+10U) administration of reteplase was equivalent to one hour infusion of 1.5 million units of streptokinase (33).

The present study also evaluated, if there was any difference in the time of presentation among smokers and non smokers with acute MI and observed no significant difference (p-value=0.15). In the present study, the post-thrombolytic resolution in the three groups i.e., streptokinase (75%), tenecteplase (76%) and reteplase (72%) were comparable. A study at Telangana by Guha S et al., revealed that reteplase was the safest and most efficacious in resolution of ST elevation (34). In another study by Siddiquei MA et al., tenecteplase was found to be superior to streptokinase in terms of faster complete ST resolution (35). The study showed that there was no significant difference in ST segment resolution among smokers versus non smokers, diabetics versus non diabetics or hypertensives versus non hypertensives. In a study by Wong CK et al., there was reduced effectiveness of thrombolytic therapy in diabetic patients versus non diabetic patients (36).

In the present study, the overall mortality was 9% in streptokinase group, 8% in reteplase group, and 5% in tenecteplase group. A meta-analysis showed that the use of thrombolytic agents significantly reduces the mortality at 30 days of thrombolysis (37). In the present study, there was no significant difference in mortality between the three treatment arms. Similar results were found in a study, where they compared tenecteplase, reteplase, and accelerated alteplase. In a study by Mega JL et al., women undergoing fibrinolysis for STEMI, were at a higher risk of short-term mortality (38).

Limitation(s)

Since, the study was aimed to evaluate the efficacy of these thrombolytic agents for an acute event, the safety profile could not be studied due to short hospital stay. Further, a well-planned cost effective analysis could have been implemented to add to the conclusion, which is in process. Future studies on safety profile of the different thrombolytic agents used and long term mortality with higher sample size can give a clearer picture.

Conclusion

Streptokinase, tenecteplase and reteplase are equally efficacious with respect to ST resolution and 30-day mortality among the patients of ST elevation myocardial infarction in the study set-up and judicious use of these thrombolytic agents at proper time, can save precious lives.

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DOI and Others

DOI: 10.7860/JCDR/2022/55784.17184

Date of Submission: Feb 19, 2022
Date of Peer Review: Apr 30, 2022
Date of Acceptance: Sep 13, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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