J Gandhara Med Dent Sci

October - December 2025

ORIGINAL ARTICLE

THE INPATIENT OUTCOME OF THROMBOLYSIS FOR AN ACUTE ST-ELEV ATION

MYOCARDIAL INFARCTION IN THE CORONARY CARE UNIT OF AYUB TEACHING HOSPITAL

Aftab Ahmad

, Mohsin Khan

, Mohammad Imran Khan

, Sardar Adnan Saif

, Umair Sharif Mughal

Zia Qamar

, Abdur Rehman

ABSTRACT

OBJECTIVES

This study aimed to determine the outcomes, clinical sequelae, and clinical

characteristics of patients with pharmacological thrombolysis (lytic therapy)

after acute ST-elevated myocardial infarction.

METHODOLOGY

This prospective cohort study was conducted in the Department of

Interventional Cardiology from July 2022 to February 2025. The outcome of

patients presenting with ST-elevated MI was stratiﬁed into successful

thrombolysis and failed thrombolysis based on ECG and symptoms, which

will be assessed after 2 hours of a Standard dose of Streptokinase. In both

arms of the study, complications, sentinel events, hospital stay, and outcome

were recorded. The coronary catheterization and 2-D echo ﬁndings will also

be recorded. The data will be analyzed using SPSS version 21, and a p-value

< 0.05 will be considered statistically signiﬁcant.

RESULTS

Out of 1050 patients, a total of 779 individuals were included in the current

study. The mean age of the studied cohort was 61 ± 9 years. We observed

failed thrombolysis in 28% (215) of patients. On 2D echo, the most common

hypokinetic wall was the inferior wall in both groups, and the diﬀerence was

signiﬁcant (p = 0.00). The frequencies of AKI, shock, and TPM in failed

thrombolysis were 46%, 33%, and 5%, respectively, which were signiﬁcantly

higher than in the successful thrombolysis group. The LAD was the most

common stenotic artery, and the diﬀerence was non-signiﬁcant (p = 0.12).

The SVCAD rate was 2% in the successful thrombolysis group and 6.5% in

the failed thrombolysis group, with a signiﬁcant diﬀerence (p = 0.00).

CONCLUSION

The success rate of thrombolysis was signiﬁcantly poor in diabetic,

hypertensive, ischemic heart disease, and dyslipidemia patients. The NIV use

and ICU admission were high in patients with successful thrombolysis.

KEYWORDS: Failed thrombolysis, thrombolysis in myocardial infarction

(TIMI), NIV non-invasive ventilation, Severe coronary artery disease

(SVCAD), Left anterior descending (LAD).

How to cite this article

Ahmad A, Khan M, Khan MI, Saif

SA, Mughal US, Qamar Z, et al. The

Inpatient Outcome of Thrombolysis

for an Acute St-Elevation Myocardial

Infarction in the Coronary Care Unit

of Ayub Teaching Hospital. J Gandhara

Med Dent Sci. 2025;12(4): 23-27.https://

doi.org/10.37762/jgmds.12-4.712

Date of Submission: 28-03-2025

Date Revised: 03-09-2025

Date Acceptance: 09-09-2025

Resident Department of Cardiology,

Ayub Teaching Hospital, Abbottabad

Associate Professor, Department of

Cardiology and Chair person Medicine

and allied, Ayub Teaching Hospital,

Abbottabad

Resident Department of Cardiology,

Ayub Teaching Hospital, Abbottabad

Resident, Department of Pulmonology,

Ayub Teaching Hospital, Abbottabad

Resident, Department of Pulmonology,

Ayub Teaching Hospital, Abbottabad

Resident, Medical Unit B, Ayub

Teaching Hospital, Abbottabad

Correspondence

Mohsin Khan, Resident, Department

of Pulmonology, Ayub Teaching

Hospital, Abbottabad

+92-306-5531722

mohsinkhan1464@yahoo.com

INTRODUCTION

In developing countries like Pakistan, coronary artery

disease (CAD) is a signiﬁcant health challenge that

contributes signiﬁcantly to mortality and morbidity.

1,2

The CAD, especially acute coronary syndrome (ACS),

is the leading cause of death around the globe,

contributing 16.7 million deaths every year. The World

Health Organization predicted 25 million deaths per

year in 2020 related to CAD, whereas in a developing

country like Pakistan, estimated deaths caused by CAD

are more than 100,000 per year.

Around 25% to 35%

of all patients who suffer myocardial infarction (MI) die

due to ventricular ﬁbrillation before the medical

treatment is initiated.

A recent study done in Pakistan

claimed Ventricular tachycardia as the most common

arrhythmia in post-MI patients.

Milestone studies, such

as GUSTO-1 and ISIS-2, have shown considerable

results of thrombolysis and provided the basis for

current therapeutic practices.

5,6

A study by the

fibrinolytic therapy trialists (FTT) group has shown that

20 to 30% deaths per 1000 patients are prevented by

thrombolysis with reduction in mortality of 25%,

however 90 minutes arterial patency rate after

Streptokinase was only attained in 50 to 60% and

thrombolysis in MI grade 3 ﬂow from angiographical

study was only attained in 30% of patients.

Primary

percutaneous coronary intervention (PCI) and

pharmacological thrombolysis are crucial methods for

thrombolysis and restoring blood ﬂow.

J Gandhara Med Dent Sci

October - December 2025

Pharmacological thrombolysis is an alternative when

primary PCI facilities are not available. In developing

countries like Pakistan, pharmacological reperfusion

remains the primary strategy due to the lack of PCI

facilities. Among the early management of ACS,

thrombolysis forms the foundation and has transformed

the area of cardiac care. However, the eﬀectiveness of

thrombolysis varies among patients, and as a result,

examples of failed thrombolysis (FT) occur. FT is a

worry in STEMI pharmacological perfusion as it is

associated with the worst outcomes, like early

mortality, arrhythmias, and ventricular dysfunction.

Around the globe, diﬀerent studies have shown uneven

rates of FT in STEMI, ranging from 10 to 56.8% for

both ﬁbrin-speciﬁc (Alteplase and Tenecteplase) and

non-fibrin-speciﬁc (streptokinase) thrombolytic agents.

Various factors determine the outcome of thrombolysis.

Some of the factors identiﬁed by certain studies as

predictors of anterior location STEMI include

preexisting diabetes and hypertension, higher Killip

class, higher total leukocyte count, hyperglycemia, and

a higher thrombolysis in myocardial infarction (TIMI)

score of 3. Additionally, the longer the door-to-needle

time and the time from symptom onset to thrombolysis,

the worse the outcome. Age is also another risk factor

and confounder in determining the success rate of

thrombolysis, as STEMI symptoms are often subtle in

octogenarian patients.

Despite advancements in

medical science, the management of ACS remains an

active area of research, with a focus on developing

improved therapeutic interventions and outcomes. This

has evoked the need for a deeper exploration of the

underlying factors and outcomes of this clinical

challenge. A previous study states that there is no

structured policy for managing FT, and many doctors

still follow a conservative approach.

In the above

context, the current study focuses on exploring the

proﬁle of patients who experienced failed thrombolysis

in a tertiary care hospital in Abbottabad.

METHODOLOGY

This was a prospective cohort study conducted in the

interventional cardiology and cardiac care unit of Ayub

Medical Teaching Institute, Abbottabad. The cohort

comprised STEMI patients treated with Streptokinase

and followed for inpatient hospital outcomes and

complications. The study was conducted from July

2022 to November 2024. The non-probability

consecutive sampling of eligible STEMI patients

treated prospectively with Streptokinase was used for

data collection. Ethical approval was obtained from the

research cell of the institute with code no: Ref. No. RC-

EA-2024/053. The data were entered into a predesigned

written proforma after obtaining written consent from

the patients or their nearest blood relatives. All patients

presented with acute ST-elevated myocardial infarction

were assessed for meeting the inclusion criteria.

Patients who met the criteria were added and followed

until they were discharged from the hospital. The

diagnosis of acute ST-elevated Myocardial infarction

was made on the standard 12-lead ECG. Inclusion

criteria: Patients presented with ST-elevated

Myocardial infarction will be assessed for

pharmacological thrombolysis. After excluding relative

and absolute contraindication, a written consent for

pharmacological thrombolysis will be obtained. The

response to pharmacological thrombolysis will be

stratiﬁed into either successful (cohort 1) or

unsuccessful resolution (cohort 2). The successful

resolution is deﬁned as an improvement in acute chest

pain of up to 80% on the Visual Analog Pain Scale,

with the ST segment returning to baseline after 2 hours

of administering Streptokinase. Unsuccessful

thrombolysis is deﬁned as a lack of improvement in

pain on the visual analog scale (greater than 80%) after

2 hours of pharmacological thrombolysis

(Streptokinase, 1.5 MU over 60 minutes) or failure to

resolve ST elevation by 50% or greater on ECG after 90

minutes of thrombolysis. We will label this patient as

having a poor failed thrombolysis. In a limited setting,

only patients who were stratiﬁed in a cohort of failed

thrombolysis are considered for rescue PCI. The pain is

graded on a visual analog scale. The patients who

received an incomplete dose of Streptokinase had non-

ST-elevated MI, absolute contraindication of

pharmacological thrombolysis, and those who refused

to be a part of the study. The rescue PCI was performed

unless contraindicated. The sociodemographic

variables, in-hospital complications, end-organ

assessment, sentinel events, predominant artery

occluded during PCI, echocardiographic ﬁndings, and

discharge status were recorded in patients with failed

thrombolysis. The numeric data was presented in the

form of mean, standard deviation, and range, while the

quantitative data was presented in the form of

frequencies and percentages. Multiple logistic

regression is used to determine the significance of the

thrombolysis outcome (successful vs. failed) as the

dependent variable. The data were analyzed using SPSS

version 21, and a p-value of less than 0.05 was

considered statistically signiﬁcant.

RESULTS

Almost 1050 patients presented with myocardial

infarction, among whom 779 patients (n=779) received

Streptokinase. Of the 576 (74%) patients, 26% are

female, with a male-to-female ratio of 3:1. In 28%

(215) of patients, the resolution is poor after

pharmacological thrombolysis and belongs to cohort 2.

The Inpatient Outcome of Thrombolysis for an Acute

J Gandhara Med Dent Sci

October - December 2025

The details are shown in Table 01.

Table 1: Comparative Statistics of Patients with Good (Cohort 1)

and Poor Resolution (Cohort 02) After Streptokinase

Characteristics Frequency (%) Odds

ratio

CI (95%) P-

values

Cohort

1 (n=564)

Cohort

(n=215)

Low

bou

Uppe

boun

Gender Male 422(75%)

154(72

0.7 0.18

2.92 0.36

Female 142(25%)

61(28%

)

Diabetic

166(29%)

95(44%)

4.2 1.0 17.3 0.000 Diabetic

Hypert

ensive

294(52%)

134(62%)

1.05 0.29 3.42 0.006 Hyperte

nsive

IHD 76(13%) 54(25%)

0.070 0.015 0.31 0.000 IHD

Dyslipi

demia

06(1%) 07(3%) 0.001 -0.00

0.05

0.04 Dyslipi

demia

ADHF 44(8%) 104(48%)

0.027 0.001 0.90

0.000 ADHF

Shock* 68(12%) 70(33%)

3.1 0.000 0.09 0.000 Shock*

Inotropic

use**

70(12%) 74(34%)

- - - 0.000 Inotropi

c use**

Diuretic

use

40(7%) 102(47%)

0.86 0.05 15.0 0.000 Diuretic

use

Rescue

PCI

20(3.5%)

16(7%) 1.03 0.05 1.09 0.001 Rescue

PCI

NIV 38(7%) 02(1%) 1.21 0.00 0.01 0.000 NIV

ICU 30(5%) 02(1%) 0.012 0.00 0.5 0.002 ICU

Enoxap

arin**

00(0%) 36(17%)

- - - 0.000 Enoxap

arin**

AKI 28(5%) 100(46.5

0.001 -

0.005

0.34

0.000 AKI

CPR 32(6%) 24(11%)

0.084 -

0.000

0.01

0.008 CPR

Deﬁbril

lator use

32(6%) 22(10%)

6.2 2.6 14 0.031 Deﬁbril

lator use

TPM 06(1%) 10(5%) 2 0.001 4.2 0.003 TPM

Hypoki

nesia

Anterior 198(35%)

32(15%

)

2.1 -4.0 -2.1 0.000

Anterola

teral

122(22%

)

26(12%

)

Antero-

apical

08(1.4%)

44(20.4

Inferior 214(38%)

44(20.4

Global 04(0.7%)

04(2%)

Stenotic

artery

LAD 20(3.5%)

18(8.3

0.012 -1.0 1.5 0.126

LCX 08(1.4%)

06(3%)

RCA 06(1%) 12(6%)

Angiog

raphy

MVCAD

02(0.3%)

08(4%) 0.008 0.00

0.04 0.000

DVCAD 06(1%) 12(6%)

TVCAD 00(0%) 04(2%)

SVCAD 12(2%) 14(6.5

*Cardiogenic shock, ** because of missing value CI &

OR not computed.

The comparison statistics are detailed in Table 01. The

mean age of patients presenting with MI was 62±9

years, with an age range of 31 to 80 years. The mean

systolic blood pressure at the time of presentation was

119±27.5, and the mean diastolic blood pressure was

74.4±15. The mean pulse at the time of presentation

was 82±8. Many patients get complicated during

admission 19% (148) develop acute decompensated

heart failure (ADHF), 18% (138) cardiogenic shock,

128 (16%) develop AKI, CPR done in 56 (7.2%) of

patients, 54 patients (6.9%) received deﬁbrillator 4%

needs ICU admission, 5% need NIV, TPM was placed

in 16(2%) of patients. During the hospital stay (n = 62),

8% of patients died; the details are shown in Figure 01.

Figure 1: Discharge Status of Patients

DISCUSSION

In the present study, we observed a failure rate of 28%

for thrombolysis. Cardiac complication, including

shock and heart failure, was the most common

complication. The most common non-cardiac

complication was AKI. We have observed that ADHF,

shock, inotropic use, diuretic use, rescue PCI,

enoxaparin use, AKI, CPR, deﬁbrillator use, and TPM

were significantly more prevalent in cohort 2. However,

surprisingly, the use of NIV and ICU admission was

higher in cohort 1, and the diﬀerence was statistically

significant. Diabetes, IHD, HTN, and dyslipidemia are

significant risk factors for poor outcomes, increased

mortality, and failed thrombolysis. The overall

mortality was 8%. When we compared the data with a

national study done in LRH Peshawar, we observed a

diﬀerence in the failure rate of thrombolysis (32%).

The diﬀerence could be due to the high prevalence of

anterior wall MI in our study. One study reported that

the rate of failed thrombolysis in anterior wall MI is

57% and the other highlighted the higher degree of

adverse outcome in anterior wall MI patients.

10,11,15

International study conducted in a Malaysian cohort

reported a failure rate of thrombolysis of up to 13.3%.

A study done by Iqbal et al. in Karachi reported that the

failed thrombolysis group has a high prevalence of

heart failure (21%) and cardiogenic shock (13.5%).

The Inpatient Outcome of Thrombolysis for an Acute

J Gandhara Med Dent Sci

October - December 2025

These ﬁgures are almost in concordance with our

observation, with a minor diﬀerence that could be due

to other underlying comorbidities in our cohort. A

comparative study conducted at AFIC Rawalpindi and

KTH Peshawar reported that the majority of group B

(thrombolysis) participants are diabetic and

hypertensive, which aligns with our study.

The factors

are associated with failed thrombolysis and are

responsible for extensive coronary artery disease and

severe occlusion.

15,16

The in-hospital mortality is much

lower in our hospital than reported before, despite the

high probability of poor prognostic factors in our

cohort, like age, AWMI, comorbidities, etc. Khan SB et

al. reported a mortality rate of 9.4%, while Iqbal N et

al. reported a rate of 18.5%.

17,18

The diﬀerence could be

the larger sample size of our study. This comparative

study provides an in-depth examination of the impact,

effects, complications, and outcomes of thrombolysis.

LIMITATIONS

The time critical for patients with myocardial infarction

and its impact on thrombolysis will not be assessed in

this study. The limited data from angiography were

recorded. The follow-up record was not maintained due

to a lack of resources. The stratification of arterial ﬂow

(TIMI ﬂow) was not recorded during angiography. The

study focused on complications in cohort 2, while

overlooking other complications in cohort 1, such as

bleeding.

CONCLUSIONS

Complications like AKI, shock, and Acute

decompensated heart failure are signiﬁcantly high in

patients with failed thrombolysis, while the study

revealed that the duration of stay in ICU and NIV use

were signiﬁcantly higher in cohort 1. The risk of

intervention, such as TPM, increased 4-fold, and rescue

PCI was increased 2-fold in cohort 2. Comorbidities

like diabetes, ischemic heart disease, hypertension, and

dyslipidemia increased the failure of lytic therapy

(thrombolysis).

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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Aftab Ahmad - Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

Mohsin Khan - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

Mohammad Imran Khan - Concept & Design; Data

Acquisition; Drafting Manuscript; Final Approval

Sardar Adnan Saif - Concept & Design; Data Acquisition;

Drafting Manuscript; Final Approval

Umair Sharif Mughal - Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Final Approval

Zia Qamar - Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

Abdur Rehman - Concept & Design; Data Acquisition;

Drafting Manuscript; Final Approval

The Inpatient Outcome of Thrombolysis for an Acute