RESEARCH ARTICLE. Incidence and Associated Risk Factors of LV Clot Among Patients with Myocardial Infarction of Urmia Seyyed-O- Shohada Heart Center

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1 ISSN Journal of Global Pharma Technology Available Online at RESEARCH ARTICLE Incidence and Associated Risk Factors of LV Clot Among Patients with Myocardial Infarction of Urmia Seyyed-O- Shohada Heart Center Kamal Khademvatani 1, Alireza Rostamzadeh 2*, Mir Hosein Seyyed Mohammadzad 2, Mohammad Reza Rajabi 3 1 Associated Professor of Cardiology, University of Medical Sciences, Urmia, Iran. 2 Assistant Professor of Cardiology, University of Medical Sciences, Urmia, Iran. 2 Student Cardiology, Urmia University of Medical Sciences, Urmia, Iran. *Corresponding Author : Alireza Rostamzadeh Abstract Background Based on previous experiments with a limited number of samples, it seems that the use of anticoagulants (heparin or subcutaneous high dose heparin) reduces by % 50of the progression of left ventricular embolism. In this study, we determined to investigate the incidence and factors associated with left ventricular in patients with acute myocardial infarction admitted to S eyyed alshohada University Hospital. Methods: In this analytic cohort study, patients with myocardial infarction were included and risk factors of LV clot following of myocardial infarction as, diabetes mellitus, smoking, hypertension, dyslipidemia, higher age, gender, extent of cardiac involvement, LV diastolic dysfunction and reperfusion were evaluated. Also, other echocardiography parameters as LV size, LV systolic and diastolic dysfunction, assessed and recorded in a check list. Finally effect of each factor on incidence of LV clot was evaluated separately. Results In our study, we found no significant association between underlying disease, diabetes, history of prior MI, history of hyperlipidemia, smoking and SK infusion, but there was a significant association between the type of MI and clots in the left ventricle. In this study, we found no significant association between the incidence of within the left ventricle and Primary PCI. Also receiving Heparin and/or Enoxaparin and Metoral are not significantly associated with LV clots. However, there is no significant association between LV size and count of involved leads in the incidence of left ventricular. Conclusion Finally, according to the results of the study it can be said that the time from onset of the pain until revascularization in the hospital, had an important role in preventing LV clots and the outcomes of the patient. Keywords: Incidence, Risk factors, LV clot, Myocardial infarction. Introduction Myocardial infarction occurs following clot on a wound atherosclerotic plaque. These clots following a complete blockage of blood vessels prevent blood containing oxygen and nutrients to reach the tissues, the blocked blood vessels are responsible for blood supply to the area. According to WHO and AHA, myocardial infarction is known through 2 out of 3 of the following include chest pain indicate heart (pressing pain for more than half an hour), certain changes in ECG of the patient (with a minimum 1 mm ST segment elevation at least two related leads) and increase and then decrease in cardiac biomarkers. Coronary artery disease is the leading cause of death and disability in the world and especially in western countries. In 2004, 9.4% (2.5 million) of deaths in low income countries and 16.3% (1.3 million) of deaths in high-income countries have constituted ischemic heart disease. Approximately 935,000 Americans suffer from an attack of myocardial infarction, of , JGPT. All Rights Reserved. 27

2 who one-third are suffering from acute STsegment elevation myocardial infarction. Despite the progress made, acute myocardial infarction is a major problem of public health that decreases the 15 years of individual s life, and imposes 165 billion dollars a year in America. Of myocardial infarction complications can be pointed out arrhythmias, heart failure, in farced heart septum rupture, blood clot on in farcted heart septum and cardiac autism that each has its own special significance and treatment [1]. Endocardium inflammation during acute phase myocardial infarction provides a thrombogenic level to create clot in left ventricular. It seems the incidence of ventricular thrombi following STEMI is reduced from 20% to 5%, followed by more aggressive use of anticoagulants [2]. Prospective studies have shown that patients with clot formation in the first 24 to 48 have very poor premature prognosis and high mortality due to MI complications. Although se ptal clot sticks to myocardial in farced surface of endocardium, the surface can be removed, leading to systemic arterial emboli. Although, estimates of its prevalence vary according to selected patients, but about 10 percent of se ptal clots will lead to systemic emboli. [3-5]. Based on previous experiments with limited sample size, it seems that the use of anticoagulants (intravenous or subcutaneous heparin with high-dose) reduces 50% of the progression of left ventricular emboli. Fibrinolysis reduces clot formation and the shape, so they are less swollen. However, detailed information about fibrinolytic tests is difficult due to interventional effect of anticoagulation with heparin.et al. [6] [3] Suggestions for anticoagulation treatment are markedly different and fibrinolysis results in the fatal emboli. However, anticoagulation therapy with warfare for 3 to 6 months is recommended for most patients with sepal clot. [7] Based on available data, our experience is the use of anticoagulation (intravenous heparin to increase PTT 1. 5 to 2 times normal, and the use of warfare for at least 3 to 6 months) in the following clinical situations: Embolic event occurs Patients with a large anterior infarction with or without the presence of visible in echocardiography We also want to use the same method of anticoagulation for patients with infarction, except in anterior area where have clots or severe sepal motion abnormalities. Although aspirin may not be able to influence the size of the clot, however, may prevent greater platelet deposition on the previous clot and also prevent further ischemia. Aspirin should be used in combination with warfarin for patients undergoing long-term anticoagulation therapy based on mentioned indications. Despite numerous studies in the area of medical sciences in clinical [8-11] and service fields [12] very little researches have been done in this area. However, anticoagulation therapy with warfare for 3 to 6 months is recommended for most patients with sepal clot [3]. Given that very few studies have been done in this area and even such study is not found in Iran, and given the lack of a regional survey that reflects the state of our society, this study was conducted not only to compare the current state of our society, but also based on knowledge gained planned for the prevention of disability in the society. Methods In the present analytical study a group of patients with diagnosis of myocardial infarction were enrolled, finally 100 patients, who were referred consecutively with myocardial infarction diagnosis since the start of plan to Se yyed-al-shohada Hospital, were selected. And factors affecting clot in the heart after myocardial infarction were reviewed, which include the presence of diabetes, smoking, hypertension, lipid disorders, age, gender, area affected in the heart, left ventricular diastolic dysfunction and restore blood flow in affected vessels and data were collected in , JGPT. All Rights Reserved. 28

3 a checklist that have been prepared from information of patient records. The patients were monitored on days 2 and 7 by me and fellowship echocardiography professors, in terms of in the left ventricle as well as other echocardiography parameters were evaluated including survey of area affected, size of the left ventricle, the left ventricular systolic dysfunction and diastolic dysfunction of the left ventricle and registered in the form and the effects of factors on the incidence of clot were assessed. Descriptive characteristics of patients are presented in frequency tables and graphs and in surveying the relationship between qualitative and quantitative variables with the occurrence of clots T-test and Chi-square tests were used. To perform these tests SPSS17 software is used. Results In this study 100 patients, who were referred consecutively with myocardial infarction diagnosis since the start of plan to Seyyed-alshohada Hospital, were selected. Of 100 patients studied, 79 patients (79%) were male and 21 patients (21%) were female. Their mean age was ± years, minimum 37 years and maximum 85 years. 63 patients were smokers and 37 were nonsmokers. Only 11 patients (11%) had consumed alcohol, and 38 patients had hypertension, and 62 patients had not hypertension. Diabetes mellitus was reported in 19 patients. And the history of CAD, 13 patients (13%) had positive CAD and 87 patients (87%) had negative CAD. Dyslipidemia in 34 patients (34%) were reported and in 66 patients (66%) were negative. 37 patients (37%) were received SK and 63 patients (63%) were not received SK. Primary PCI was performed in 45 patients (45%) and in 55 patients (55%) was not performed. was reported in 16 patients (16%) and in 84 (84%) left ventricular was not reported. Of 100 patients, in 54 patients (54%) MI was anterior and 46 patients (4%) MI was inferior. Table 1: Frequency distribution of demographic data in the study population Percentage 63% 37% 11% 89% 62% 38% 19% 81% 13% 87% 34% 66% 37% 63% Frequency Variable Smoke Non-smoke Alcohol Non-alcohol hypertension hypertension not Diabetes Non-diabetes Positive CAD Negative Dyslipidemia Non- dyslipidemia Received SK Not Received SK 45% 55% 16% 84% 54% 46% Primary PCI Primary PCI Non- With left ventricular Without left ventricular Anterior MI Inferior Surveying the relationship between sex and clot in the left ventricle, results showed that of 16 patients with left ventricular thrombi 14 patients (87.5%) were male and 2 patients (12.5) were female. Of 84 patients who had not left ventricular, 65 patients (77.4%) were male and 19 patients (22.6%) were female. According to statistical test there is no significant difference between patients with left ventricular thrombi and sex of the patients. (p=0.29) , JGPT. All Rights Reserved. 29

4 In surveying the relationship between clot in the left ventricle and underlying diabetes disease, of 16 patients with left ventricular thrombi 3 patients (18.8%) had diabetes, and 13 patients (81.3%) had not diabetes and of 84 patients who had not left ventricular, 16 patients (19%) had diabetes, and 68 patients (81%) had not diabetes. According to statistical test there is no left ventricular thrombi and underlying diabetes disease. (p=0.64) Table 2: Determination of the relationship between left ventricular and diabetes Diabetes (81.3%)13 (18.8%)3 (81%)68 (19%)16 (81%)81 (19%)19 (P=0.64) Of 16 patients with left ventricular thrombi there was no MI history and of 84 patients that had not left ventricular thrombi 9 patients (10.7%) had a history of previous MI and 75 patients (89.3%) had not a history of MI. According to statistical test there is no left ventricular thrombi and a history of previous MI. (p=0.19) dyslipidemia, 11 patients (68.8%) had not a history of dyslipidemia. Of 84 patients who had not left ventricular, 29 patients (34.5%) had a history of hyperlipidemia and 55 patients (65.5%) had not a history of dyslipidemia. According to statistical test there is no significant difference between patients with left ventricular thrombi and a history of hyperlipidemia. (p=0.55) Of 16 patients with left ventricular, 5 patients (31.3%) had a history of Table 3: Determination of the relationship between left ventricular and a history of hyperlipidemia (68.8%)11 (65.5%)55 (66%)66 (p=0.55) Of 16 patients with left ventricular 10 patients (62.5%) smoked and 6 patients (37.5%) did not smoke. Of 84 patients who had not left ventricular, 53 patients (63.1%) smoked, and 31 patients (36.9%) did not smoke. According to statistical test there is no significant difference between patients with left ventricular thrombi and smoking. (p=0.57) Dyslipidemia (31.3%)5 (34.5%)29 (34%)34 Of 16 patients with left ventricular, 5 patients (31.3%) were received SK and 11 patients (68.8%) were not received SK. Of 84 patients who had not left ventricular, 32 patients (38.1%) were received SK and 52 patients (61.9%) were not received SK. According to statistical test there is no significant difference between patients with left ventricular thrombi and receiving SK. (p=0.41) Table 4: Determination of the relationship between left ventricular and receiving SK (68.8%) (36%)63 (p=0.41) SK (31.3%)5 (38.1%)32 (37%)37 13 patients (81.3%) had anterior MI and , JGPT. All Rights Reserved. 30

5 patients (18.8%) had inferior MI. Of 84 patients who had not left ventricular 41 patients (48.8%) and anterior MI and 43 patients (51.2%) had inferior MI. According to statistical test there is no left ventricular thrombi and receiving MI. (p=0.01) Table 5: Determination of the relationship between left ventricular and MI MI Inferior Anterior (18.8%)3 (81.3%)13 (51.2%)43 (48.8%)41 (46%)46 (54%)54 (p=0.01) 6 patients (37.5%) received Primary PCI and 10 patients (62.5%) did not receive Primary PCI. Of 84 patients who had not left ventricular, 39 patients (46.4%) received Primary PCI and 45 patients (53.6%) did not received Primary PCI. According to statistical test there is no left ventricular thrombi and receiving Primary PCI. (p=0.35) Table 6: Determination of the relationship between left ventricular and receiving Primary PCI (62.5%)10 (53.6%)45 (55%)55 (p=0.35) Primary PCI (37.5%)6 (46.4%)39 (45%)45 81 patients (81%) have received SK or Primary PCI and 19 patients (19%) have not received SK or Primary PCI. 11 patients (68.8%) had received Primary PCI or SK and 5 patients (31.2%) had not received Primary PCI or SK. Of 84 patients who had not left ventricular, 70 patients (83.3%) had received Primary PCI or SK and 14 patients (16.7%) had not received SK or Primary PCI. According to statistical Fisher Exact test there is no significant difference between patients with left ventricular thrombi and receiving Primary PCI or SK. (p=0.15) Table 7: Determination of the relationship between left ventricular and receiving Primary PCI or SK SKor Primary PCI left ventricular (31.2%) (68.8%)11 (16.7%)14 (83.3%)70 (19%)19 (81%)81 (p=0.15) 4 patients (25%) had received Heparin or Enoxaparin and 12 patients (75%) had not received any of the two drugs. Of 84 patients who had not left ventricular, 65 patients (77.4%) had received Heparin or Enoxaparin and 19 patients (22.6%) had not received. According to statistical test there is a left ventricular thrombi and receiving Heparin and Enoxaparin. (p=0.001) , JGPT. All Rights Reserved. 31

6 Table 8: Determination of the relationship between left ventricular and receiving Heparin or Enoxaparin Not received (75%)12 (22.6)19 (31%)31 (p=0.001) 8 patients (50%) had received Met oral and 8 patients (50%) had not received. Of 84 patients who had not left ventricular, 66 patients (78.6%) had received HeparinorEnoxaparin Received (25%)4 (77.4%)65 (69%)69 Met oral and 18 patients (21.4%) had not received. According to statistical test there is a left ventricular thrombi and receiving Met oral. (p=0.02) Table 9: Determination of the relationship between left ventricular and receiving Met oral Not received (50%)8 (21.4%)18 (26%)26 (p=0.02) 12 patients (75%) had received captopril treatment, 4 patients (25%) had not received. Of 84 patients without left ventricular, 72 patients (85.7%) had received Met oral Received (50%)8 (78.6%)66 (74%)74 caporal, 12 patients (14.3%) had not received. According to statistical test there is no left ventricular thrombi and receiving caporal. (p=0.23) Table10: Determination of the relationship between left ventricular and receiving caporal Not received (25%)4 (14.3%)12 (16%)16 (p=0.023) Captopril Received (75%)12 (85.7%)72 (84%)84 Of 16 patients with left ventricular, 1 patient (6.2%) had AF, and 15 patients (93.8%) had not AF. Of 84 patients who had not left ventricular, 1 patient (1.2%) had AF, and 81 patients (98.8%) had not AF. According to statistical Table11: Determination of the relationship between left ventricular and AF test there is no significant difference between patients with left ventricular thrombi and AF. (p=0.30) (93.8)1 (98.8%)83 (98%)98 (p=0.30) AF (6.2%)1 (1.2%)1 (2%)2 Of 16 patients with left ventricular, 5 patients (31.2%) had involvement of 4 leads and 11 patients (68.8%) had more than 4 leads involved. Of 84 patients who had not left ventricular, 47 patients (56%) had less than or equal to 4 leads involvement, 37 patients (44%) had more than 4 leads involvement. According to statistical test there is no left ventricular thrombi and leads involved. (p=0.06) , JGPT. All Rights Reserved. 32

7 Table12: Determination of the relationship between left ventricular and leads involved <4 (68.8%)11 (44%)37 (48%)48 (p=0.06) 14 patients (87.5%) had LV enlargement, and in 2 patients (12.5%) LV was normal. Of 84 patients who had not left ventricular, 73 patients (86.9) had LV Involved lead 4 (31.2%)5 (56%)47 (52%)52 enlargement and in 11 patients (13.1%) LV was normal. According to statistical test there is no significant difference between patients with left ventricular thrombi and size of LV. (p=0.65) Table13: Determination of the relationship between left ventricular and size of LV Normal (12.5%)2 (13.1%)11 (13%)13 (p=0.65) Mean duration of pain to get to the hospital in patients with left ventricular thrombi was ± minutes and in patients without left ventricular was ± According to Log-Rang statistical test there is a significant difference between left ventricular thrombi and onset of pain to get to the hospital. (P=0.01) Mean duration to hospital arrival to onset of SK or PCI in patients with left ventricular thrombi was 341± minutes and in Sizzle Large (87.5%)14 (86.9%)73 (87%)87 patients without left ventricular were ±30.94 minutes. According to Log-Rang statistical test there is a significant difference between left ventricular thrombi and hospital arrival time to onset of SK or PCI. (P=0.02) Comparison of mean and standard deviation of increasing ST, MVDT, WMI, EF, CT ni with left ventricular thrombi is shown in the table below. Table 14: Comparison of mean and standard deviation of increasing ST, MVDT, WMI, EF, CT ni with left ventricular thrombi SD±Mean thrombi Variable Discussion 3 ± ± ± ± ± ± ± ± ± ±8.97 Myocardial infarction occurs following clot on a wound atherosclerotic plaque. These clots following a complete blockage of blood vessels increasingst MVDT WMI EF Ct ni prevent blood containing oxygen and nutrients to reach the tissues, the blocked blood vessels are responsible for blood supply to the area. In 2004, 9.4% (2.5 million) of deaths in low income countries and 16.3% (1.3 million) of deaths in high-income , JGPT. All Rights Reserved. 33

8 countries have constituted ischemic heart disease. Of myocardial infarction complications can be pointed out arrhythmias, heart failure, in farcted heart septum rupture, blood clot on in farcted heart septum and cardiac autism that each has its own special significance and treatment. [4] In this study, men were (79%) and women were (21%) of patients and there was no significant correlation between underlying diabetes disease, previous history of MI, history of hyperlipidemia, smoking and SK, but in our study there is a significant difference between type of MI and left ventricular clots. In the present study it was shown that there is no significant difference between primary PCI and the incidence of in the left ventricle so that of 16 patients with left ventricular thrombi, 11 patients (68.8%) had received primary PCI or SK, and 5 patients (31.2 %) had not received primary PCI or SK. Of 84 patients without clot into the left ventricle, 70 patients (83.3%) had received primary PCI or SK, and 14 patients (16.7%) had not received SK or primary PCI. According to statistical Fisher Exact test there is no significant difference between patients with left ventricular thrombi and receiving Primary PCI or SK. (p=0.15) The results showed that there is a significant difference between patients with left ventricular thrombi and receiving Heparin and Enoxaparin and also left ventricular thrombi and receiving Metoral but there is no left ventricular thrombi and leads involved. However, the mean time from pain onset to hospital arrival in patients with left ventricular thrombi was ± minutes and in patients without left ventricular were ± minutes. The mean time to hospital arrival to onset of SK or PCI in patients with left ventricular thrombi was 341± min and in patients without left ventricular was ±94.30 min. that shows a significant difference in terms of left ventricular and it can be noted that onset of pain and hospital arrival for receiving the first treatment step is an important factor in the development of clots within the left ventricle which can affect the outcome. Mean MVDT in 16 patients with clot into the left ventricle was, ±40.52 and in 84 patients without left ventricular was ± According to statistical t- test there is a significant difference between the thrombi in the left ventricle and MVDT. (P=0.006) Mean WMI in 16 patients with clot into the left ventricle was, 2.03±0.30 and in 84 patients without left ventricular was 1.66±0.33. According to statistical t-test there is a significant difference between the thrombi in the left ventricle and WMI. (P=0.0001) Mean EF in 16 patients with clot into the left ventricle was, 21.56±8.31 and in patients without left ventricular was 36.90±9.78. According to statistical t-test there is a significant difference between the thrombi in the left ventricle and LV size. (P=0.0001) Mean CT ni in 16 patients with clot into the left ventricle was, 24.68±13.98 and in patients without left ventricular was 17.10±8.97. According to statistical t-test there is a significant difference between the thrombi in the left ventricle and CT ni. (P=0.0001) In a study by Jacobs et al.[13] conducted on 10,383 patients with acute myocardial infarction, the use of ACE-I and beta-blockers was associated with a dramatic reduction in the risk of CVA. [13] Which shows the left ventricle is prevented from clogging. However, in our study, only the use of betablockers was significantly associated with a lower incidence of left ventricular. In a study by that was conducted on 70 patients with first anterior myocardial infarction attack, it was shown that the addition of low LVEF, lower MVDT and lower wall motion score index are also associated with left ventricular formation in patients with anterior myocardial infarction that the results are consistent with the results from our study , JGPT. All Rights Reserved. 34

9 In a case study that provided by Dantzig [3] on 2018 patients, almost exclusively left ventricular was occurred in patients with anterior myocardial infarction with a frequency of 39% compared with 0-5% in patients with non-anterior myocardial infarction. [3]In our study also of 16patients with left ventricular, 13 patients (81.3%) had anterior MI, and 3 patients (18.8%) had inferior MI that the above results are consistent with the results from our study. In a study by Zielinska M [5] in Poland on 2911 patients with acute anterior myocardial infarction that 2.5% of patients were with left ventricular thrombi. However, in our study the incidence of left ventricular thrombi was 16% of the patients with myocardial infarction regardless of MI type that seems cause of the high difference is due to this issue and also the presence of neglected MI, less use of anticoagulation in our study and the time of referral. In a study by Arshad Rehan[4], a total of 92 patients following acute STEMI with PCI and treated with inhibitors of glycoprotein IIb / IIIa, only 3.4% of patients had left ventricular that all patients involved were male. In the results of our study also, 5.87% of males were suffered severe left ventricular thrombi that were roughly consistent with the results of Arshad Rehan [4] In a study by Kontury F et al. in 1998 in Norway on 38 patients with acute anterior myocardial infarction, it was shown that in 53.6% of patients developed a clot in the left ventricular that was associated with severe impairment of wall motion in patients that is consistent with our results. In this study, left ventricular clots occurred following heart attack, even by administration of streptokinase that was the same as our study. In a study by in Massachusetts, of 75 patients with acute anterior myocardial infarction 46% had left ventricular. However, in our study the incidence of left ventricular was 16% of patients with myocardial infarction, regardless of the type of MI that seems this is the cause of much difference in the incidence of left ventricular. Also in this study, the incidence of in the left ventricle is increasing with heart wall motion disorders. Patients with left ventricular thrombi have usually much larger systolic and diastolic size than the others [2] which is consistent with the results obtained in our study. In this study comparing patients with and without thrombosis, had similar age and in both groups had similar rates of diabetes, history of myocardial infarction and dyslipidemia, which is consistent with the results obtained in our study. In this study also left ventricular is strongly associated with anterior acute myocardial infarction, EF less than 40% and hypertension. Patients who underwent PCI had a lower incidence of left ventricular. In our study also left ventricular thrombi is associated with acute anterior infarction, lower EF, but was not associated with high blood pressure and performing PCI. In our study also left ventricular thrombi is not associated with the type of received medicine. In a study by Vecchio [7] on 180 patients with first acute anterior myocardial infarction, it was concluded that the incidence of left ventricular thrombi is not different with streptokinase or Tpa treatment. Finally, given the relatively high frequency of in the left ventricle that is the manifestation of our society and given that typically in echocardiography that is performed following acute myocardial infarction a very low percentage of serious accidents are reported. This difference manifested the low sensitivity in the accuracy for detecting left ventricular that the final result of this study highlights the fact that there should be specific and non-specific features used for detecting left ventricular. In addition, to prevent effects of these lesions, we should be more accurate and more sensitive for detecting left ventricular in all patients referred with acute myocardial infarction. [14-16] , JGPT. All Rights Reserved. 35

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