An-Najah National University Faculty of Graduate Studies PREVALENCE, PREDICTORS, AND OUTCOMES FOR ST- SEGMANT ELEVATION MYOCARDIAL INFARCTION PATIENT UNDERGOING PERCUTANEOUS CORONARY INTERVENTION By Haneen Alqassarwe Supervisor Dr. Jamal Qaddumi This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Critical Care Nursing, Faculty of Graduate Studies, An-Najah National University, Nablus – Palestine. 2024 II PREVALENCE, PREDICTORS, AND OUTCOMES FOR ST- SEGMANT ELEVATION MYOCARDIAL INFARCTION PATIENT UNDERGOING PERCUTANEOUS CORONARY INTERVENTION By Haneen Alqassarwe This Thesis was Defended Successfully on 21/9/2024 and approved by Dr. Jamal Qaddumi Supervisor Signature Dr. Basma Salameh External Examiner Signature Dr. Imad Thultheen Internal Examiner Signature III Dedication To everyone who has always encouraged me to succeed in my field of work, even in times of challenges, and to everyone who improves my spirits when I'm feeling down to my father, who has always been supportive of me, to remind me of our mutual hopes and unwavering support, and to discuss the future., and to my loving mother. I feel privileged to have you as my mother and love the chance you have given me to be successful in all that I have done To my most loved family members,,,,,,,my treasured brothers and sisters To everyone who was close to me, my best friends Everyone who has supported and encouraged me IV Acknowledgment First, I give all the glory to God, the source of our strength, for granting us both the mental and physical endurance to complete this monumental task. We have made efforts in this project. However, it would not have been possible without the kind support and help, especially from participants, for spending their precious time and collaboration with us to do this research and improve care. Their participation is valued, and their contributions have made a difference. We would like to extend my sincere thanks to all of them. We would like to extend exceptional gratitude to Dr. Jamal Qaddumifor believing in us and her continued support and encouragement throughout this project. I am grateful to the Ministry of Health, An-Najah National University, and IbnSina Specialized Hospital (CCU department). I would like to thank our entire family, especially our loving parents, for their love, understanding, and support. Our thanks and appreciation also go to everyone who gave me the moral support for completing this task. V Declaration I, the undersigned, declare that I submitted the thesis entitled: PREVALENCE, PREDICTORS, AND OUTCOMES FOR ST- SEGMANT ELEVATION MYOCARDIAL INFARCTION PATIENT UNDERGOING PERCUTANEOUS CORONARY INTERVENTION I declare that the work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. _____________________________________ Student's Name: _____________________________________ Signature: _____________________________________ Date: VI List of Contents Dedication ....................................................................................................................... III Acknowledgment ............................................................................................................ IV Declaration ....................................................................................................................... V List of Contents ............................................................................................................... VI List of Tables ............................................................................................................... VIII List of Figures ................................................................................................................. IX List of Appendices ........................................................................................................... X Abstract .......................................................................................................................... XII Chapter One: Introduction and Theoretical Background .................................................. 1 2.2 Introduction ................................................................................................................. 1 1.2 Problem statement ....................................................................................................... 4 1.3 Significance of the study ............................................................................................. 4 1.4 Study hypothesis ......................................................................................................... 5 1.5 Aim of the study ......................................................................................................... 6 1.6 Outcome measures ...................................................................................................... 6 1.7 Literature Review ....................................................................................................... 9 Chapter Two: Method ..................................................................................................... 18 2.1 Design ....................................................................................................................... 18 2.2 Participants ................................................................................................................ 18 2.3 Site and setting .......................................................................................................... 18 2.4 Study period .............................................................................................................. 18 2.5 Inclusion criteria ....................................................................................................... 18 2.6 Exclusion criteria ...................................................................................................... 18 2.7 Procedure .................................................................................................................. 19 2.8 Post operation ........................................................................................................... 19 2.9 Sample size ............................................................................................................... 20 2.10 Study instrument ..................................................................................................... 21 2.11 Data Collection ....................................................................................................... 22 2.12 Statistical Methods .................................................................................................. 23 2.13 Validity and Reliability ........................................................................................... 23 2.14 Ethical Consideration .............................................................................................. 23 Chapter Three: Results .................................................................................................... 24 3.1 Sociodemographic Characteristics ............................................................................ 24 VII Chapter Four: Discussion and Conclusion ...................................................................... 39 4.1 Discussion ................................................................................................................. 39 4.1.1 Evidence to support ............................................................................................... 43 4.1.2 Incongruent Proof .................................................................................................. 44 4.2 Recommendations ..................................................................................................... 46 4.3 Limitations ................................................................................................................ 48 List of Abbreviation ........................................................................................................ 49 References ....................................................................................................................... 50 Appendixes ..................................................................................................................... 60 ب‌ ............................................................................................................................... الملخص VIII List of Tables Table 1: previous medical history and complication among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure .. 27 Table 2: procedure characteristic and complication among ST – segment elevation myocardial infarction patients who underwent a catheterization procedure .. 28 Table 3: Procedure characteristics and Hematoma among ST- segment myocardial infarction patient who underwent a catheterization procedure ...................... 29 Table 4: Procedure characteristics and Arrythmia among ST- segment elevation myocardial infaction patient who underwent a catheterization procedure ..... 30 Table 5: Previous Medical History and Cardiac Arrest among ST- segment elevation myocardial infarction patients who underwent a catherterization procedure 31 Table 6: Procedure characterisics and Cardiac arrest among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure .. 32 Table 7: Pre and post lab (HB, creatnine& troponin) according to participant gender .. 33 Table 8: Pre and post lab ( Hb, creatnine & troponin) according to participant history of IHD ................................................................................................................. 34 Table 9: Pre and post lab ( HB, creatnine& troponin) according to participant history of HTN ................................................................................................................ 34 Table 10: pre and post lab ( Hb, creatnin & troponin) according to participant with history of DM ................................................................................................. 35 IX List of Figures Figure 1: Sample size calculation on Raosoft ................................................................. 20 Figure 2: Universal Pain Assessment Tool ..................................................................... 21 Figure 3: Age & gender distribution among ST segment elevation MI patients who underwent catheterization procedure ............................................................. 25 Figure 4: Complication distribution among ST segment elevation MI patients who underwent catheterization procedure ............................................................. 25 X List of Appendices Appendix A: Data Collection Tool ................................................................................. 60 Appendix B: Consent Form ............................................................................................ 63 Appendix C: IRB ............................................................................................................ 67 Appendix D: Tables of Study ......................................................................................... 68 Table D1: pre and post lab (Hb, creatnine& troponin) according to participant smoking ........................................................................................................ 68 Table D2: Pre and post lab ( Hb, creatnin& troponin) according to participant with history of CKD ............................................................................................. 68 Table D3: pre and post lab (Hb, creatnin & troponin) according to participant outcome (complication) .............................................................................................. 69 Table D4: pre and post lab (Hb, creatnin & troponin) according to participant cardiac arrest ............................................................................................................. 69 Table D5: Demographics and complication among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure .................. 70 Table D6: Demographic and Hematoma among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure .................. 70 Table D7: Previous medical history and hematoma among STEMI patients who underwent a catheterization procedure ........................................................ 70 Table D8: Demographic and Arrhythmia among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure .................. 71 Table D9: Previous medical history and Arrhythmia among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure 71 Table D10: Demographic and Cardiac arrest among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure .................. 72 Table D11: pre and post lab ( Hb, creatinine& troponin) according to participant age . 72 Table D12: pre and post lab ( Hb, creatinine &troponin) according to participant previous history of PCI ............................................................................... 72 Table D13: pre and post lab (Hb, creatinine& troponin) according to participant previous history of CABG ........................................................................... 73 Table D14: pre and post lab (Hb, creatinine& troponin) according to participant Dyslipidemia ................................................................................................ 73 Table D15: pre and post lab (Hb, creatinine& troponin) according to participant hematoma ..................................................................................................... 73 Table D16: pre and post lab ( Hb, creatinine & troponin) according to participant arrhythmia .................................................................................................... 74 Table D17: pre and post lab (Hb, creatinine&troponin) according to participant MI .... 74 XI Appendix E: Facilitating the research mission of the Professional and Ethical Issues Committee of Ibn Sina Hospital Administration ......................................... 75 XII PREVALENCE, PREDICTORS, AND OUTCOMES FOR ST- SEGMANT ELEVATION MYOCARDIAL INFARCTION PATIENT UNDERGOING PERCUTANEOUS CORONARY INTERVENTION By Haneen Alqassarwe Supervisor Dr. Jamal Qaddumi Abstract Background: Various factors such as age, gender, smoking, and underlying conditions including diabetes mellitus (DM), chronic kidney disease (CKD), ischemic heart disease (IHD), and hypertension (HTN) are widely recognized as significant risk factors for patients experiencing ST-segment elevation myocardial infarction (STEMI) and underwent percutaneous coronary intervention (PCI). Methods : This quantitative retrospective cohort study was conducted at IbnSina Specialized Hospital. It involved 278 adult patients diagnosed with ST-segment elevation myocardial infarction (STEMI), aged between 18 and 70 years, who underwent percutaneous coronary intervention (PCI). Data were obtained from patient files post-PCI, extracted from the hospital's computed information system, with approval from the institutional review board (IRB) of An-Najah National University. Results: Out of 278 patients, 71.2% were males and 28.8% were females. The majority (96.4%) were over 40 years old. Significant differences were found in history of CKD, smoking, and average levels of pre- and post-catheterization hemoglobin and creatinine (p < 0.05). Gender, smoking, history of DM, HTN, and CKD significantly different with average levels of hemoglobin, creatinine, and troponin (p < 0.05). CKD, IHD, previous CABG, arterial access, and pre- and post-catheterization creatinine, pre-catheterization troponin, and post-catheterization hemoglobin levels showed significant differences with cardiac arrest (p < 0.05). Femoral artery catheterization resulted in higher hematoma rates than radial artery (12.5% vs. 0%, p > 0.001). Diseased right coronary artery and femoral artery catheterization were associated with higher arrhythmia rates. XIII Conclusion: STEMI patients underwent PCI are at risk of complications like hematoma, arrhythmias, and cardiac arrest. Monitoring and early management are crucial, especially for patients over 40 years old, males, smokers, and those with comorbidities like DM, HTN, CKD, and IHD. According to the finding of the present study, the prevelance of STEMI in people over 40 years and less than 70 years old were(69.4% vs 3.6%) repectively. Therefore, based on the result of the studies that have been reviewed and included in the meta- analysis, the high prevelance of STEMI was reported to be higher in male individual more than 70 years, which is considered a warning for health policymakers regarding the important of this age for diagnosis and screaning procedures of STEMI. Keywords: STEMI; PCI; IHD; complications; CKD. 1 Chapter One Introduction and Theoretical Background 1.1 Introduction Globally, coronary heart disease (CHD) is the primary cause of illness and death. Myocardial infarction is the most prevalent type of CHD. It causes more than 15% of deaths annually, with non-ST-segment elevation myocardial infarction (NSTEMI) accounting for more deaths than ST-segment elevation myocardial infarction (STEMI). In every age group, men are more likely than women to experience myocardial infarction (MI). MI rates are rising in developing nations including South Asia, portions of Latin America, and Eastern Europe, despite the fact that the incidence has dropped in industrialized nations due in part to better health systems and the application of successful public health initiatives (Jayaraj et al., 2019 ; Kim, 2021). In acute myocardial infarction (MI)patients with ST-elevation, as soon as possible myocardial perfusion should be restored. The ideal approach of reperfusion is primary percutaneous coronary intervention , which dramatically reduces the risk of subsequent myocardial necrosis and enhances the quality of life for MI patients (Mo et al., 2022) Percutaneous coronary intervention (PCI) is a procedure used to unblock an artery. The blood vessels that transport oxygen-rich blood throughout your body are called arteries. If there is a buildup of plaque—a fatty, waxy substance—in your arteries, you might require a PCI. Or, following a cardiac attack, a PCI can be necessary to remove blockages. A PCI is also known as a coronary angioplasty. Ischemic Heart Disease is a situation where there is insufficient blood flow, depriving the heart of oxygen, the most common cause of this is an accumulation of plaque, which is made up of both fatty material and cells, in the wall of one of the coronary arteries, which feed blood to the heart. The plaque gradually blocks blood flow as it gets bigger, depriving the heart of oxygen and nourishment. Coronary artery bypass graft commonly known as heart bypass surgery, is a procedure used in medicine to increase the heart's blood flow. It might be required if the coronary arteries, which feed blood to the heart, are clogged or constricted. 2 High blood pressure (HTN) is a prevalent ailment affecting the arteries in the body, another name for it is hypertension. The blood's constant excessive force against the arterial walls is a sign of high blood pressure, to pump blood, the heart has to work harder. Millimeters of mercury, or mm Hg, are used to measure blood pressure. A blood pressure measurement of 130/80 millimeters of mercury (mm Hg) or greater is generally considered hypertension. Diabetes Mellitus (DM)is a disorder brought on too high blood sugar (glucose). It arises when your body isn't reacting to the effects of insulin appropriately or when your pancreas produces too little or no insulin at all, people of all ages are affected by diabetes, all types of diabetes are treatable with medicine and/or lifestyle modifications, and the majority are chronic (lifelong). Dyslipidemia is used to describe elevated blood lipid levels, a major risk factor for cardiovascular (CV) illnesses. Atherosclerosis and other cardiovascular problems can result from dysregulation in these lipid levels, which can be brought on by lifestyle choices or inherited predispositions. Lipid profile tests are frequently used in diagnosis, and goal levels are advised for best CV health Chronic kidney disease also known as chronic renal failure, is characterized by a slow decline in kidney function, urine is the result of your kidneys filtering wastes and extra fluid from your blood, your body may accumulate hazardous amounts of fluid, electrolytes, and waste products if you have advanced chronic renal disease. Left anterior descending artery (LAD) is a left coronary artery branch, it supplies the left ventricle's anterior region, it is regarded as the most significant vessel supplying the left ventricle since it supplies around half of the artery supply to the ventricle, because of the increased risk of death. Right coronary artery (RCA) is an artery that enters the heart at the right aortic sinus, above the right cusp of the aortic valve. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiK0-GDqdOIAxUPVKQEHYgMI6MQFnoECBMQAQ&url=https%3A%2F%2Fwww.msdmanuals.com%2Fhome%2Fhormonal-and-metabolic-disorders%2Fdiabetes-mellitus-dm-and-disorders-of-blood-sugar-metabolism%2Fdiabetes-mellitus-dm&usg=AOvVaw3Jy_3qCZ3oY_6xe1pDjohj&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiK0-GDqdOIAxUPVKQEHYgMI6MQFnoECBMQAQ&url=https%3A%2F%2Fwww.msdmanuals.com%2Fhome%2Fhormonal-and-metabolic-disorders%2Fdiabetes-mellitus-dm-and-disorders-of-blood-sugar-metabolism%2Fdiabetes-mellitus-dm&usg=AOvVaw3Jy_3qCZ3oY_6xe1pDjohj&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiK0-GDqdOIAxUPVKQEHYgMI6MQFnoECBMQAQ&url=https%3A%2F%2Fwww.msdmanuals.com%2Fhome%2Fhormonal-and-metabolic-disorders%2Fdiabetes-mellitus-dm-and-disorders-of-blood-sugar-metabolism%2Fdiabetes-mellitus-dm&usg=AOvVaw3Jy_3qCZ3oY_6xe1pDjohj&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiK0-GDqdOIAxUPVKQEHYgMI6MQFnoECBMQAQ&url=https%3A%2F%2Fwww.msdmanuals.com%2Fhome%2Fhormonal-and-metabolic-disorders%2Fdiabetes-mellitus-dm-and-disorders-of-blood-sugar-metabolism%2Fdiabetes-mellitus-dm&usg=AOvVaw3Jy_3qCZ3oY_6xe1pDjohj&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiK0-GDqdOIAxUPVKQEHYgMI6MQFnoECBMQAQ&url=https%3A%2F%2Fwww.msdmanuals.com%2Fhome%2Fhormonal-and-metabolic-disorders%2Fdiabetes-mellitus-dm-and-disorders-of-blood-sugar-metabolism%2Fdiabetes-mellitus-dm&usg=AOvVaw3Jy_3qCZ3oY_6xe1pDjohj&opi=89978449 https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiK0-GDqdOIAxUPVKQEHYgMI6MQFnoECBMQAQ&url=https%3A%2F%2Fwww.msdmanuals.com%2Fhome%2Fhormonal-and-metabolic-disorders%2Fdiabetes-mellitus-dm-and-disorders-of-blood-sugar-metabolism%2Fdiabetes-mellitus-dm&usg=AOvVaw3Jy_3qCZ3oY_6xe1pDjohj&opi=89978449 3 Circumflex branch of left coronary artery (LCX)‌ is a left coronary artery branch, it follows the coronary sulcus, or atrioventricular groove, around the left side of the heart, it supplies the left ventricle's posterolateral region. Following an ST-segment elevation myocardial infarction (STEMI), regional heart attack services have improved clinical outcomes by encouraging early reperfusion by primary percutaneous coronary intervention. Early release after initial PCI is valued by patients as it enhances the efficacy of medical treatment (Rathod et al., 2021). Troponin clinical predictive value and the patient's clinical profile (signs and symptoms) for cardiac catheterization and other forecasters, such as the outcomes of ECG at the time of presentation. Physicians should pay close attention to the patient's history clinically and current clinical manifestations instead of relying sole on the results of laboratory tests and interpretation of ECG, especially when those results are unclear (Alkaiyat et al., 2019) It does not appear that patients with STEMI receiving PCI have a low overall incidence of Contrast-Induced Nephropathy. High blood pressure, uncontrolled blood sugar, history of previous MI, and age, are the central risk influences that are likely correlated with STEMI patients who underwent PCI (He et al., 2019). Cardio metabolic risk factors are also prevalent, but in young patients with STEMI, smoking and a family history of IHD are more common. Although it is still significant, the mortality rate for young people with STEMI is lower. Public health actions are necessary to reduce the prevalence of these risk factors among the population that is sensitive by nature (Tung et al., 2021). Compared to young adults without diabetes mellitus, those with the disease had worse health at baseline. However, following AMI, they showed notable improvements, and after controlling for baseline covariates, diabetes mellitus was not linked to worsening angina, physical limits, mental functioning, or quality of life(Ding et al., 2019). Of 20 initially stable patients with STEMI underwent primary PCI, only 1 patient experienced an undesirable consequences while in the hospital. The risk of future undesirable consequences was independently predicted by moderate to severe CKD (Amon et al., 2022). 4 A poorer prognosis following primary PCI in STEMI patients was linked to recent smoking, but it had no relation to infarct size. The fact that smokers tend to be younger and have fewer cardiovascular risk factors than nonsmokers may help to explain the smoker's paradox (Redfors et al., 2020). 1.2 Problem statement Many fatalities and disabilities are caused by cardiovascular diseases (CVDs), which are the world's leading cause of mortality especially acute myocardial infarction (AMI). About one-third of all deaths worldwide occurred as a result of CVDs in 2021 alone, accounting for 20.5 million deaths. Cardiovascular problems were often thought to be associated with wealth, but this is no longer the case. Low- and middle-income countries (LMICs) account for more than three-quarters of deaths from CVD (Lindstrom et al., 2022). According to Alkaiyat et al. (2019), coronary heart disease (CHD) accounted for 30.6% of all fatalities in Palestine in 2016, making it the country's biggest cause of death. Also, according to a report issued by the Palestinian Ministry of health, cardiovascular disease remain to be the main cause of mortality in Palestine, where the death rate from theses disease reached 29.9%of all death. The report stated that the cardiovascular disease is the first and main cause of death around the world. It also demonstrate that cardiovascular disease in Palestine often appear as a result of the accumulative of several causes, including: unhealthy lifestyle, physical inactivity, obesity, improper diet, and smoking (MOH, 2020). This is the first study to be conducted in Palestine, so Studies on it were very limited. 1.3 Significance of the study This is the only study prevalence, predictors and outcomes in ST- elevation myocardial infarction patients who underwent percutaneous coronary intervention in Palestine which increase awareness in health care team in hospital about arrhythmia, complication post PCI. STEMI is among the leading causes of morbidity and mortality in patients with CVDs globally and in Palestine according to Alkaiyat et al.(2019) study. It is important to identify the incidence of ST-segment elevation myocardial infarction with specific risk 5 factors for development of this condition, as well as to enhance the speed of diagnosis and appropriate treatment, and the findings of this study will provide this. Thus, the findings of the present study on the factors associated with STEMI patients treated with PCI and their outcomes in Palestine has implications for enhancing the quality of delivered cardiovascular services. It discussed a relevant area of public health concern because of the information which it gathers and compile relating to the incidence of STEMI and its predisposing factors that can be useful for public health interventions. Furthermore, through the assessment of HC performance, this study will constructively contribute to the understanding of the sufficiency of the developed Palestinian HC regarding the management of recognized STEMI cases, including the ratios of PCI intervention availability and access to aggregate times, for example, door- to-balloon and ischemia. These will bring out the deficiencies in the quality of care with special reference to compliance with these guidelines and draw out disparities in the geographical distribution of centres offering PCI services. Finally, the study seeks to compare the structural models, directions, and opportunities of STEMI care pathways in order to inform management and resource allocation decisions and assist administrators and policymakers in enhancing the quality of care to achieve better outcomes for patients in the short and long term. The findings will also benefit the local body of knowledge by providing evidence for future research and policy amendments to promote cardiovascular health in Palestine. The results of this study will be a reference for future researchers, and will be an incentive to conduct similar studies. 1.4 Study hypothesis H1: There is a significant difference at the level 0.05 between previous medical history and tropnin changes for ST elevation myocardial infarction patients who underwent percutanous coronary intervention Null hypothesis: There is no significant difference at the level 0.05 between previous medical history and tropnin changes for ST elevation myocardial infarction patients who underwent percutanous coronary intervention. 6 1.5 Aim of the study The current study aims to investigate the effect of the catheterization procedure on the level of chest pain and changes in the ECG among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure in Adult patient between 18-70 years old. 1.6 Outcome measures The primary outcome is pain intensity measured with the Universal Pain Assessment Tool (UPAT), which uses items from 1 to 10 and classifies pain into 5 types: 0 = no pain; 1-3 = mild pain; 4-6 = moderate pain; 7-9 = severe pain; 10 = worst pain possible Operational Defentions: ST-Elevation Myocardial Infarction (STEMI): refers to a heart attack characterized by the full blockage of the coronary artery, which causes a substantial decrease in blood supply to particular parts of the heart. The conditions is distinguished by distinct alternations in the ECG, notably the presence of ST- segment elevations. It is widely recognized as an urgent medical condition , necessitating prompt restoration of blood supply to the impacted arteries in order to mitigate the damage to the heart muscle (Elendu et al., 2023) . Non- ST-Elevation Myocardial Infarction (NSTEMI): refers to a form of heart attack there is a partial blockage or temporary development of a blood clot in one or more coronary arteries .in contrast to STEMI, NSTEMI may not exhibit notable ST- elevation on the ECG. Nevertheless, there exist other warning signs, for example heightened levels of cardiac biomarkers, which imply the presence of damage to the myocardium. he expeditious evaluation and treatment of NSTEMI is imperative in order to mitigate the risk of additional issues from occurring(Chang et al., 2012) . Cardiac Catheterization is a medical procedural conducted to both diagnose and treat certain heart condition. The process involves the insertion of a catheter, a thin and flexible tube, into a blood vessels, typically situated in the arm or groin area, with the objective of pushing it towards the heart. This approach enables the examination and measurement of blood flow, pressure, and oxygen levels within the cardiovascular systems blood vessels and cardiac chambers. The method of the capacity to enhances 7 the detection of obstructions, assess cardiac precision, and offer direction for medical interventions such as angioplasty or stent implementation (Kern et al., 2015). Theoretical Framework: The theoretical framework for this study is grounded in the Donabedian Model of Quality of Care and the Cardiovascular Continuum Concept. Used as the theoretical frameworks of this research, both the Donabedian Model of Quality of Care and the Cardiovascular Continuum Concept provide a comprehensive framework for analysis of adverse patients with STEMI according to Donabedian, 1988 Libby.(2013).This integrated approach offers a comprehensive conception of patient manipulation, chronic cure, and health care organization. The Donabedian Model, created by Avedis Donabedian, offers a framework for understanding healthcare quality by focusing on three key dimensions: structure, process, and outcome (Donabedian, 1988). When we look at STEMI patients who are undergoing Percutaneous Coronary Intervention (PCI), the structural dimension highlights the importance of having a solid healthcare foundation. This includes not just the physical infrastructure, like hospitals and specialized cardiac care units, but also the technology and equipment needed for effective treatment. It’s about ensuring that healthcare professionals are well-trained and that the institutions are prepared to handle complex cardiovascular emergencies according to Jha et al.(2014). Ultimately, this model emphasizes that quality care begins with a strong structural setup that supports both patients and providers. The process dimension of healthcare quality centers on how clinical management is carried out, including the protocols for diagnosis and intervention strategies. For patients experiencing STEMI, this means quickly assessing their condition, using evidence-based guidelines to make decisions, and employing precise techniques during Percutaneous Coronary Intervention (PCI) according to Thygesen et al.(2018).This model underscores the vital role of standardized, high-quality procedures that not only reduce risks for patients but also enhance the effectiveness of the treatments they receive (Anderson & Morrow, 2017). 8 Using quantifiable metrics such as survival rates, cardiac function recovery, return to daily activities, and quality of life enhancements, the outcome dimension examines the effects of healthcare treatments on patients according to Krumholz.(2013). These results are crucial for determining the efficacy of medical interventions and are crucial in determining the direction of future healthcare plans. The Cardiovascular Continuum Concept offers a dynamic perspective on the progression of cardiovascular disorders in addition to the Donabedian Model according to Libby.(2013). This method tracks the patient's progression from the onset of the illness to acute care and long-term recuperation. Beginning with the early stages of atherosclerosis, it entails determining risk factors, comprehending inflammatory processes, and identifying endothelial function issues (Hansson, 2005). According to Ibanez et al.(2018), the acute event stage is a critical time when immediate medical attention is necessary, especially in cases of STEMI. Understanding how the body reacts physiologically, determining when to intervene, and using prompt and precise therapeutic techniques are crucial throughout this phase. The recovery and rehabilitation phase that follows places an emphasis on heart tissue regeneration, heart function restoration, and the implementation of secondary preventive efforts to lower the likelihood of reoccurring incidents (Levine et al., 2016). This study aims to provide a comprehensive viewpoint on treating STEMI patients by integrating various theoretical frameworks according to Newby et al.(2001). It will look into how different healthcare structural components, efficient intervention techniques, and meticulous patient care all combine to produce the best results. To have a better understanding of patient experiences and travels, the study will also examine significant variables such as patient demographics, current medical problems, risk profiles, and socioeconomic position (Roe et al., 2014). With an emphasis on comprehensive data collection and long-term participant tracking, the study will employ a prospective cohort design according to Westra et al.(2018). We will use sophisticated methods like multivariate regression and survival analysis to examine the data. According to Rothman.(2008)these techniques will assist us in testing significant hypotheses about the efficacy of healthcare interventions and their influence on patient outcomes. 9 With an emphasis on preserving patient privacy, gaining informed consent, and guaranteeing openness in the research's reporting, ethical issues are essential to this study according to Association.(2013). Gaining knowledge that can improve care for STEMI patients, develop individualized intervention plans, and eventually better the provision of cardiovascular healthcare is the main goal (Mensah et al., 2019). Defention: An ST- elevation myocardial infarction (STEMI) is a kind of heart attack that primarily damages the bottom chambers of your heart. They get their name from the way they alter the way your heart's electrical activity appears on a certain kind of diagnostic examination. When compared to other forms of heart attacks, STEMIs are typically more severe and dangerous. 1.7 Literature Review The research literature on the main concepts of this study is examined in this chapter. The literature review serves as a solid foundation for writing a research paper. It contributes to the studies basis and may elicit fresh research ideas. The reports early literature analysis gives readers a foundation for understanding current knowledge about the issues and emphasizes the significance of the new study. Before starting to talk about problems and diseases that affect the heart, such as myocardial infarction, it is necessary to know the composition and dynamics of this vital organ in the human body. Movements that follow the traditional topographical division of cardiac muscle into the left ventricle, right ventricle, and septum are essential to the present knowledge of cardiac dynamics. They have been the subject of separate functional evaluations, which has led to a number of assumptions that this study will define and challenge. In contrast to the heart's five-century-old anatomic description of having a helix and circumferential wrap architectural structure, cardiac dynamics are typically associated with a left ventricle, right ventricle, and septum morphology. This anatomy and structure are described by Torrent Guasp's helical ventricular myocardial band (HVMB), which also explains the six dynamic motions of the heart—narrowing, shortening, lengthening, broadening, twisting, and uncoiling (Buckberg et al., 2018). 10 The most common cause of death globally, ischemic heart disease, can produce fatal perioperative ischemia and infarction. Patients who present for noncardiac surgery and develop acute coronary syndrome as opposed to stable angina have different underlying pathophysiologies, triggering causes, and preventative strategies(Mahmood et al., 2014). Unstable angina, non-ST segment elevated myocardial infarction, and ST segment elevated myocardial infarction are all included in acute coronary syndrome, also referred to as Type 1 myocardial infarction. Vulnerable plaque rupture causes acute coronary syndrome, which is followed by varied degrees of thrombus development, arterial spasm, and consequently coronary occlusion. In contrast, a mismatch between the myocardial oxygen delivery and demand in the context of fixed coronary stenosis causes stable angina(Thygesen et al., 2018). Acute ather othrombotic coronary events are the cause of type-1 AMI; in type-2 AMI, an acute imbalance between oxygen supply (such as hypoxemia, anemia, or hypotension) and demand (such as tachycardia or hypertension) is caused by a condition other than coronary artery disease (CAD). The direct harmful consequences of endogenous or exogenous high circulating catecholamine levels might cause higher cardiac biomarker values in critically ill patients or in individuals having major (non- cardiac) surgery. Type-2 AMI can also be brought on by endothelial dysfunction and/or coronary vasospasm (Lopez-Cuenca et al., 2016). An unstable plaque with variable degrees of occluding thrombus development and coronary vasoconstriction might cause cardiac ischemia. ACS is a platelet-associated disease process that can cause myocardial ischemia-infarction regardless of a normal MDO2-MVO2relationship. It is characterized by abrupt thrombus development or the dislodgement of an embolus linked to plaque rupture(Sakamoto et al., 2022). They found critical variables linked to sudden cardiac arrest 48 hours after percutanous coronary intervention for ST- elevation myocardial infarction. In order to develop methods that effectively reduce the risk of sudden cardiac arrest in the early post-PCI period, further research is required (Abe et al., 2022) . 11 Cardiac arrest affects more than 10% of patients in a current cohort of ST-elevation myocardial infarction patients receiving primary Percutanous coronary intervention, and it is a significant cause of death for patients with in-hospital STEMI. Although cardiac arrest is linked to worse outcomes, it does not increase the risk of long-term mortality in survivors, which emphasizes the need for methods to enhance the care that STEMI patients receiving cardiac arrest get in hospitals(Kumar et al., 2021). Out of 20 initially stable patients with STEMI undergoing primary percutanous coronary intervention, only 1 experienced an adverse event while in the hospital. Future adverse event risk was independently predicted by moderate to severe chronic renal disease. These findings suggest that after reperfusion, most STEMI patients who get primerypercutanous coronary intervention might not need to be routinely admitted to a cardiac intensive care unit(Amon et al., 2022) They may conclude that was a considerable increase in the frequency of acute stent thrombosis following primary percutanous coronary intervention. Whether they were hemodynamically unstable or had acute coronary syndrome stenting for multivessel coronary disorders, patients presenting with STEMI were at significant risk of developing acute stent thrombus (Shaikh et al.,2022) Thirty-day mortality was six times higher in individuals with acute myocardial infarction who received emergency percutanous coronary intervention who had first presented with out of hospital cardiac arrest than in patients without out of hospital cardiac arrest. Independent predictors of out hospital cardiac arrest included younger age, lack of dyslipidemia or diabetes mellitus, or LAD as the culprit lesion, and renal impairment. Clinical outcomes were worse for out hospital cardiac arrest patients who had higher blood glucose levels upon admission, renal impairment, or lesions other than LAD as the causative lesion (Sonoda et al., 2022) While the rates of percutanous coronary intervention failure and no-reflow were greater in ST- elevation myocardial infarction patients with coronary ectasia than in no-ectasia patients, follow-up mortality was similar(Mir et al., 2021) 12 There are no long-term advantages to ischemic postconditioning following percutaneous coronary intervention over traditional percutanous coronary intervention for individuals with ST- elevation myocardial infarction(Mir et al., 2021). A poorer prognosis following primary percutanous coronary intervention in ST- elevation myocardial infarction was linked to recent smoking, but it had no relation to infarct size in the current large-scale individual patient-data pooled analysis. The fact that smokers tend to be younger and have fewer cardiovascular risk factors than nonsmokers may help to explain the smoker's paradox (Redfors et al., 2020). According to previous retrospective study that conducted by Gao & Qi. (2021) in China to identify the mortality rate among patents with STEMI who underwent PCI, this study conducted in three hospitals from 2016-2018, General information, past medical history, clinical information, and prescription information were gathered from the patients and compared between the mortality and survival groups. In-hospital mortality was the main result. All-cause death at admission was referred to as in-hospital mortality. The findings reveled that from 1169 patients 8.13% (95) patients died post PCI during hospitalization, the finding added that some factor leaded to decrease mortality rate post PCI as ideal body mass index, ejection fraction, LDL C level, and use of β-blocker and ACEI/ARB drugs post PCI procedure. de Almeida Torres et al.(2016) conducted retrospective study in Brazil to assess the incidence of major adverse cardiovascular and cerebrovascular MACCE (stroke, death, revascularization, and non-fetal MI) post PCI, this study conducted in one Center in Brazil among diabetic patients between 2012- 2014. The results of this study found that, The mean age of the 158 patients who were included was 65.1 ± 9.1 years. Nine percent of the cases had a lesion in the LMCA, while 44.2% of the cases had a proximal lesion in the left anterior descending artery. Second-generation DES was used for the majority of surgeries (91.1%). The mean duration of follow-up was 1,054 ± 725 days, and 17.4% of patients experienced MACCE. 10.2% of people with a low SYNTAX score (less than 23) had MACCE, but 33.3% of people with a moderate/high SYNTAX score (more than 23) had MACCE (p = 0.003). 7.5% of patients with complete revascularization (zero residual SYNTAX score) advanced with MACCE, whereas 22.0% of patients with incomplete revascularization did so (p = 0.01). 13 Rohla et al.(2023) conducted a study to evaluate clinical outcomes in STEMI (ST- segment elevation myocardial infarction) patients undergoing percutaneous coronary intervention (PCI) based on the time elapsed from symptom onset to balloon inflation. The study focused on "early" (<12 hours), "late" (12–48 hours), and "very late" (>48 hours) presenters, addressing the question of whether PCI timing impacts mortality and target lesion failure (TLF) rates. The analysis included data from the Bern-PCI registry and SPUM-ACS program, covering cases between 2009 and 2019. Among 6,589 STEMI patients who received PCI, 73.9% were early, 17.2% were late, and 8.9% were very late presenters. The average patient age was 63.4 years, and 22% of the cohort were women. One year after the procedure, all-cause mortality was higher among late presenters (5.8%) compared to early presenters (4.4%), with a hazard ratio (HR) of 1.34 (95% CI: 1.01–1.78, P = 0.04). Similarly, very late presenters had a significantly higher mortality rate (6.8%) compared to early presenters (HR 1.59, 95% CI: 1.12–2.25, P < 0.01). However, there was no significant difference in mortality between late and very late presenters (HR 1.18, 95% CI: 0.79–1.77, P = 0.42). The incidence of TLF, encompassing cardiac death, myocardial infarction in the target vessel, and target lesion revascularization, was also greater in late presenters (8.3%) compared to early presenters (6.5%), with an HR of 1.29 (95% CI: 1.02–1.63, P = 0.04). Very late presenters had even higher rates of TLF (9.4%) compared to early presenters (HR 1.47, 95% CI: 1.09–1.97, P = 0.01). However, TLF rates between very late and late presenters were not significantly different (HR 1.14, 95% CI: 0.81–1.60, P = 0.46). Upon adjustment for clinical factors, heart failure, renal impairment, and prior gastrointestinal bleeding emerged as key predictors of adverse outcomes, while the timing of PCI showed less influence on these outcomes. This highlights that patient comorbidities, rather than treatment delays alone, played a more significant role in determining prognosis. Cho et al.(2021)in their study that aimed to explore the characteristics and outcomes of STEMI patients who presented late within the modern era of (PCI). The study analyzed data from the Korea Acute Myocardial Infarction Registry-National Institutes of Health database, encompassing 5,826 STEMI patients treated within 48 hours of symptom onset between 2011 and 2015. Patients were categorized as early presenters (<12 hours, n = 5,202) or late presenters (12–48 hours, n = 624). The primary outcomes assessed 14 were all-cause mortality at 180 days and 3 years post-STEMI. The finding reveled that late presenters experienced significantly poorer clinical outcomes than early presenters. Mortality rates at 180 days (10.7% vs. 6.8%) and 3 years (16.2% vs. 10.6%) were notably higher among late presenters (both log-rank p < 0.001). However, late presentation (≥12 hours) was not independently linked to higher mortality after adjusting for other factors. The frequency of invasive procedures dropped sharply between the first (<12 hours) and second (12–24 hours) 12-hour intervals from symptom onset. The "no primary PCI strategy" increased from 4.9% to 12.4%, and "no PCI" rose from 2.3% to 6.6% during this timeframe (both p < 0.001). Concurrently, mortality escalated, with 180-day mortality climbing from 6.8% to 11.2% and 3-year mortality from 10.6% to 17.3% (both p < 0.05). Mudawi et al.(2024) evaluated outcomes of percutaneous coronary intervention (PCI) at Hadi Clinic, a low-volume center in the Middle East, comparing results with high- volume PCI centers in the UK and Western countries. Data from 567 patients undergoing PCI between January 2018 and December 2020 were analyzed, covering preprocedural characteristics, intra-procedural factors, and postprocedural outcomes. Patients had a mean age of 60.9 years, with 81% male, and common comorbidities included dyslipidemia (90.9%), hypertension (81.2%), and diabetes (61%). Presentations were distributed as stable angina (22.9%), non-ST-elevation acute coronary syndrome (55%), STEMI (22%), and STEMI with cardiogenic shock (10.4% of STEMI cases). Radial access was used in 95.94% of cases, with a mean SYNTAX score of 34.8 and an average of 2.6 stents deployed per patient. PCI success was achieved in 95.1% of cases, with low complication (0.82%) and in-hospital mortality rates (0.27%). The mean door-to-balloon time for primary PCI was 31.8 minutes. Long- term outcomes included a 0.54% rate of readmission with ACS and 0.27% mortality within 12–36 months post-discharge. Overall, the results demonstrated that Hadi Clinic’s PCI outcomes were comparable to those of high-volume centers in Western countries. In their retrospective study, Kim et al.(2020) examined the association between hospital PCI volume and in-hospital AMI outcomes in Korea based on the 2014 Korean PCI registry’s. The study involved 17,121 patients with AMI including 8,839 patients with non-ST-segment elevation myocardial infarction and 8,282 patients with ST-segment 15 elevation myocardial infarction. Among the hospitals, high-volume hospitals admitted at least 400 patients annually for PCI procedures, while low-volume hospitals admitted fewer than 400 annually. The key prespecified end point was a composite of MACCE, consisting of all-cause death, cardiac death, nonfatal MI, definite or probable stent thrombosis, stroke, and urgent PCI during the index hospital stay. The study shows that the low-volume hospital patients experienced more significant MACCE (10.9% vs. 8.6%, p=0.001) and non-cardiac mortality (4.8% vs. 2.6%, p=0.001) compared to the high volume center. Nonetheless, multivariate analysis showed that hospital PCI volume was not predictive of MACCE, potentially due to other variables confounding the relationship. Chacón-Diaz et al.(2022) carried out a retrospective study to investigatedthe outcomes of primary percutaneous coronary intervention (PPCI) versus a pharmacoinvasive strategy (PIs) for treating ST-segment elevation myocardial infarction (STEMI) in Peru, particularly in regions with limited resources. This retrospective cohort study utilized data from the second Peruvian STEMI registry (PERSTEMI II), comparing patient characteristics, in-hospital outcomes, and 30-day mortality between those receiving PPCI within the first 12 hours and those treated with PIs. PIs patients were younger and experienced shorter delays from initial medical contact to reperfusion and total ischemic time. Successful PCI was more frequent in the PIs group (84.4% vs. 71.1%, p = 0.035). However, no significant differences were observed between the two strategies in overall in-hospital mortality (5.2% vs. 6.6%), cardiovascular mortality (4.2% vs. 5.3%), cardiogenic shock, heart failure, or major bleeding. Propensity score-matched analysis further showed comparable rates of cardiovascular mortality, post-infarction heart failure, and successful reperfusion between the groups. Okşen et al.(2022)conducted a study to analyze the short- and long-term outcomes of 1550 patients treated with primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (AMI) at a tertiary care center. The cohort, predominantly male (83.1%) with a mean age of 58.5 years, had an average ischemia duration of 2.85 ± 2.49 hours and a median door-to-device time of 43 minutes. During hospitalization, 4.7% of patients died, and predictors of poor outcomes included advanced age, high Killip class, low left ventricular ejection fraction, low hemoglobin levels, ventricular arrhythmias, and atrioventricular block. Over a median follow-up of 16 49.5 months, 12.4% of discharged patients died, 12.5% experienced recurrent myocardial infarction, and 2.3% had cerebrovascular events. Independent predictors of major adverse cardiac events (MACE) included impaired left ventricular function, reduced glomerular filtration rate, low albumin levels, and prior cerebrovascular disease. Secondary complications included acute kidney injury (16.7%), ventricular arrhythmias (6.1%), atrial fibrillation (7.6%), advanced atrioventricular block (3.7%), and major bleeding (1.6%). The findings highlight the critical role of timely revascularization and the need for diligent long-term follow-up to mitigate AMI’s persistent risks. To investigate factors influencing adverse outcomes in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). Taniwaki et al.(2015) conducting a study via study pooled data from two trials, EXAMINATION (1,504 patients) and COMFORTABLE AMI (1,161 patients), using consistent endpoint definitions and event adjudication. Multivariable Cox regression analysis identified predictors of adverse events, including all-cause mortality, reinfarction, stent thrombosis (ST), and target lesion revascularization (TLR) at one year. High Killip class (III or IV) emerged as the most significant predictor for all-cause death or reinfarction (OR 5.11), definite ST (OR 7.74), and TLR (OR 2.88). Additional predictors of death or reinfections included reduced left ventricular ejection fraction (OR 4.77), suboptimal final TIMI flow (OR 1.93), arterial hypertension (OR 1.69), advanced age (OR 1.68), and elevated peak CK levels (OR 1.25). Use of drug-eluting stents (DES) significantly reduced the risk of definite ST (OR 0.35) and TLR (OR 0.34). These findings emphasize the impact of clinical and procedural factors on outcomes and the protective role of DES in contemporary PCI practices. Liosis et al.(2019) explored the heightened risk of in-hospital adverse events in patients with acute coronary syndromes (ACS) and diabetes mellitus (DM), hypothesizing that this increased risk stems from those with concurrent renal failure (RF), a frequent complication of DM. The study analyzed data from the ALKK-PCI registry, encompassing 69,651 ACS patients undergoing percutaneous coronary intervention (PCI) across 48 hospitals from 2008 to 2013. Patients were categorized into four groups: noDM/noRF, DM/noRF, DM/RF, and RF/noDM. In-hospital mortality rates for STEMI were 3.5%, 6.6%, 21.9%, and 14.1%, respectively, and for NSTE-ACS were 17 1.5%, 2.1%, 7.2%, and 5.4%. Multivariate analysis identified the following odds ratios for mortality predictors: DM without RF (OR 1.62 for STEMI, 1.20 for NSTE-ACS), DM with RF (OR 3.02 for STEMI, 2.72 for NSTE-ACS), and RF without DM (OR 2.13 for STEMI, 2.08 for NSTE-ACS). When stratified by estimated glomerular filtration rate (eGFR), mortality increased as renal function declined, with STEMI rates at 5.0%, 12.8%, 17.7%, and 31.5% across eGFR categories (60–90, 45–60, 30–45, and <30 ml/min) and NSTE-ACS rates at 2.1%, 3.8%, 7.1%, and 12.0% (p for trend <0.0001).The study concluded that co-existing RF is the primary driver of elevated mortality in ACS patients with DM. While DM without RF was a significant predictor in STEMI, it was not in NSTE-ACS. RF, regardless of DM status, posed a stronger risk factor, and mortality escalated with worsening eGFR. 18 Chapter Two Method 2.1 Design In the Critical care unit (CCU) of IbnSinaSpecialized Hospital in Jenin, Palestine, a quantitative, retrospective, cohort study was carried out dataobtained from the patient file post percutaneous coronary intervention and obtained from the hospital computed information system. Approval was achieved from the institutional review board (IRB) of An-Najah National University. The hospital's scientific research organizations approved the study. In adult STEMI patients between 18-70 years old who underwent PCI, show changes in pain, and changes on ECG post PCI. 2.2 Participants  Patients who is ST elevation myocardial infarction.  Those patients with age 18-70 years old.  Patients who admitted to the Critical care unit (CCU). 2.3 Site and setting Critical care unit (CCU) in IbnSina Specialized Hospital Jenin, Palestine. 2.4 Study period From August 2022 to October 2023. 2.5 Inclusion criteria  patients aged from 18-70 years old  ST- elevation myocardial infarction patients 2.6 Exclusion criteria  Non ST- elevation myocardial infarction patients  Patients with history of bleeding  Patients aged less than 18 and more than 70 years old 19 2.7 Procedure After obtaining approval from An-Najah National University, the Ministry of Health and IbnSina Specialized Hospital, I was back to the computer system every day and search for ST-elevation myocardial infarction patients who underwent percoutanous coronary intervention during this period August 2022 to October 2023. After that, I was take all the recorded information about these patients. Everything is recorded about the patient through the system from the time of admission to the time of discharge. For patients in IbnSina Specialized Hospital, the patient admitted to ER department complain of chest pain, put patient on bed, connect to cardiac monitor, taken vital signs, take history from patient or family by nurse and doctor, applied intravenous access take blood sample pre PCI (CBC, BUN, creatnin, cardiac enzyme tropnin and CK-MB), as doctor order, we had an ECG done for the patient, to monitor any changes, give aspirin 300mg and plavix 600mg loading dose take pain score pre PCI as numerical scale if patient sever chest pain give analgesic as doctor order ,do echo by cardiologist, then transferee patient to CCU department , prepare patient to cardiac cath obtained consent form, checklist, shaving on radial and femoral area then transferee to catheterization.. 2.8 Post operation Patient receive from cardiac cath post PCI, placed on bed connect to cardiac monitor vital signs taken and recorded, observe operation site form any oozing, hematoma, bleeding, deflated TR band as protocol (2 ml q 15 minute), We perform a repeat ECG after the catheterization to observe any changes in ECG especially ST elevation, ST depression, QT interval and T inversion , and take pain score post PCI if improve. 20 2.9 Sample size The Raosoft software is used to calculate the required sample size The study sample consisted of (278) male and female, STEMI patients who underwent PCI The margin of error: 5% Confidence level: 95% Population size estimated:1000 Your recommended sample size: 278 Figure 1 Sample size calculation on Raosoft 21 2.10 Study instrument The Universal Pain Assessment Tool (UPAT)  The present investigation employed The Universal Pain Assessment Tool (UPAT) to evaluate the degree of pain experienced by individuals with restricted communication abilities.  It divides pain into five categories on a scale of 1 to 10: The pain scale goes from 0 (no pain) to 10 (worst possible pain). Figure 2 Universal Pain Assessment Tool 22 2.11 Data Collection After IRB Approval and hospital approval, the structured data sheet was prepared based on study objectives, and previous related studies, patients files after percoutanous coronary intervention and was obtained from hospital computed information system. The data collected by using check list, the check list divided into 9 sections: the first section of the sheet contain basic demographic information such as gender (Male, Female), age (18-40 years)(41-70 years), this information taken from patients file. The section two was about previous medical history (IHD, previous MI, previous PCI, previous CABG, HTN, DM, smoker, Dyslipedimia, CKD, free). The section three in concerned with procedural characteristic –Arterial access( Radial Artery, Femoral Artery). The section four is concerned with vessels disease (LAD, RCA, LCX, chronic total occlusions, multi vessels disease). The section five concerned with lab profiles which contain : pre and post (Hb, creatnine, troponin). The section six concerned with ECG which contain: pre and post PCI (sinus rhythm, ST elevation, ST depression, T wave inversion). The section seven concerned with pain scale pre and post PCI (no pain, mild, moderate, sever pain, worst pain possible). The section eight concerned with procedure characteristic contain of: (balloon angioplasty, stent angioplasty, stent and balloon, second stage, medical treatment). The section nine concerned with outcome of PCI which contain: (hemorrhagic complication, hematoma pseudoaneurysm or other vascular complication, acute stent thrombosis, cardiac death, myocardial infarction, Revascularization) Data was retrieved from patient records was obtained from patients computerized records, with the researcher retrieving data from patients records in institution using an authorized account after received approval. Based on the researchers clinical expertise 23 and previous training, whereas the researchers did it all by herself. missing data from the patients records is left blank on the data sheet and is treated as a missing value by statistical analysis software, that statistical measures were done according to all sample value. 2.12 Statistical Methods The data acquired from the medical records analyzed using the statistical package for social science (SPSS) software on windows operating system, using the descriptive and analytical factions.The descriptive results include generating frequencies, percentage, mean, and stander deviation for the variables related to patients demographic data, previous medical history, procedural characteristic, vessels disease, lab profiles, ECG, pain scale, and outcomes of PCI). The following statistical tests were employed to examine the data and assess the study hypotheses, presuming that a P-Value of less than 0.05 indicates significance. 2.13 Validity and Reliability The check list was developed by the researcher and then reviewed by critical care unit doctor and academic doctor who specialized in critical care nursing. their comments were considered when developing the data collection tool to its final form in order to collect data in the most appropriate way for obtaining the best possible data and for the data analysis process Reliability is the consistency of the measurement, or the degree to which an instrument measures the same way each time it is used under the same condition with the same subjects(Drost, 2011) 2.14 Ethical Consideration The approval to begin data collecting was acquired from the Institutional Review Board (IRB) of the faculty of medicine and health sciences at An Najah National University .after that, a facilitating paper was obtained from the IbnSinaSpechalized Hospital in order to collect data, consent was obtained from all Furthermore, the data was kept anonymous, participant information and the results obtained were retained in a secure location where no one could access them, and the data was collected only for research purposes. 24 Chapter Three Results This chapter presents the primary findings from the data analysis conducted to address the objectives of the study on the prevalence, predictors, and outcomes of ST-segment elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). The results are organized to provide a comprehensive understanding of the research questions, starting with demographic and clinical characteristics of the study population. Subsequently, the chapter highlights the prevalence rates, identifies significant predictors of adverse outcomes, and evaluates the short- and long-term patient outcomes following PCI. Through descriptive and inferential statistical analyses, the chapter offers insights into the quality of care, procedural timeliness, and adherence to evidence-based guidelines in managing STEMI cases within the Palestinian healthcare context. These findings serve as the foundation for discussion and interpretation in subsequent chapters. 3.1 Sociodemographic Characteristics Out of 278, males were 198 (71.2%) the largest compared to females 80 (28.8%). Likewise, the age group over 40 years was the highest (96.4%) compared to those under 40 years (3.6%) of among ST- segment elevation MI patient who had a catheterization procedure study participants. See figure 3. 25 Figure 3 Age & gender distribution among ST segment elevation MI patients who underwent catheterization procedure Figure 4 Complication distribution among ST segment elevation MI patients who underwent catheterization procedure The findings found that a highest percentage of previous diseases among the participants among STEMI patients who had a cardiac cath. procedure were patients with high blood pressure (42.1%), diabetes (31.7%), IHD (30.2%), and smoking (62.6%). 3.60% 96.40% 71.20% 28.80% 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 120.00% 18-40 40-70 Male Female Age Gender Hematoma or other vascular Arrhythmia Cardiac Arrest Series1 0.7 5.0 1.8 0.7 5.0 1.8 0.0 1.0 2.0 3.0 4.0 5.0 6.0 COMPLICATION 26 Although, among STEMI patients who had a cardiac cath procedure, the occurrence rate of complications was higher among patients who had a history of IHD (10.7%vs. 7.6%), previous CABG (20% VS. 7.1%), and smoking (10.3% vs. 2.9%) the results found that these differences had no significant difference (p> 0.05). On the other hand, history of chronic kidney failure had a statistically significant difference (p=0.001) in the occurrence rate of complications among STEMI patients who had a cardiac cath. procedure, as the occurrence rate of complications was higher among patients with a history of chronic renal failure than that of patients who haven’t a previous history of chronic renal failure (50 % vs. 6.9%). The results also showed that the percentage of smokers was high (62.6%) among STEMI patients who had a cardiac cath. procedure and it had a statistically significant difference between the smoking and non-smoking participants with the occurrence rate of complications (p=0.023). 27 Table 1 previous medical history and complication among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure Outcome (complications) X 2 P value Previous history Total No Yes IHD No 194(69.8%) 182(93.8%) 12(6.2%) 1.722 .189 Yes 84(30.2%) 75(89.3%) 9(10.7%) MI No 275(98.9%) 254(92.4%) 21(7.6%) .248 .619 Yes 3(1.1%) 3(100.0%) 0(0.0%) PCI No 228(82.0%) 210(92.1%) 18(7.9%) .211 .646 Yes 50(18.0%) 47(94.0%) 3(6.0%) CABG No 268(96.4%) 249(92.9%) 19(7.1%) 2.301 .129 Yes 10(3.6%) 8(80.0%) 2(20.0%) HTN No 161(57.9%) 149(92.5%) 12(7.5%) .006 .941 Yes 117(42.1%) 108(92.3%) 9(7.7%) DM No 190(68.3%) 174(91.6%) 16(8.4%) .646 .421 Yes 88(31.7%) 83(94.3%) 5(5.7%) Smoker No 104(37.4%) 101(97.1%) 3(2.9%) 5.188 .023 Yes 174(62.6%) 156(89.7%) 18(10.3%) Dyslipidemia No 251(90.3%) 230(91.6%) 21(8.4%) 2.444 .118 Yes 27(9.7%) 27(100.0%) 0(0.0%) CKD No 274(98.6%) 255(93.1%) 19(6.9%) 10.470 .001 Yes 4(1.4%) 2(50.0%) 2(50.0%) Free No 192(69.1%) 177(92.2%) 15(7.8%) .059 .807 Yes 86(30.9%) 80(93.0%) 6(7.0%) Table 2 showed that the characteristics of the PCI catheterization procedure in terms of the arterial access, the diseased vessel, and the kind of intervention had a statistically significant difference between the participants and the occurrence rate of complications among STEMI patient who had a cardiac catheterization procedure (p values=0.001, 0.001, 0.005 respectively). 28 The rate of catheter entry through the radial artery was the most widely used (94.2%) compared with femoral artery (5.8%), the LAD artery was the most frequent diseased vessel (30.6%), and the balloon and stent were the most common type of intervention (27.7%). The occurrence rate of complications by radial artery access are less than femoral artery (5.7% vs. 37.5%), the right coronary artery and balloon & stent intervention were higher susceptible to complications (18.4 % & 15.6% respectively). Finally, the percentage of patients who received medical treatment was 43.7%. Table 2 procedure characteristic and complication among ST – segment elevation myocardial infarction patients who underwent a catheterization procedure Outcome (complication) X 2 P value Total No Yes Arterial Access Radial 261(94.2%) 246(94.3%) 15(5.7%) 21.694 .000 Femoral 16(5.8%) 10(62.5%) 6(37.5%) Vessel Disease Normal 123(44.2%) 122(99.2%) 1(0.8%) 17.997 .001 LAD 85(30.6%) 76(89.4%) 9(10.6%) RCA 38(13.7%) 31(81.6%) 7(18.4%) LCX 27(9.7%) 23(85.2%) 4(14.8%) Multi Vessels 5(1.8%) 5(100.0%) 0(0.0%) PCI interventi on type Balloon 10(3.6%) 9(90.0%) 1(10.0%) 14.787 .005 Stent 48(17.3%) 45(93.8%) 3(6.3%) Balloon & Stent 77(27.7%) 65(84.4%) 12(15.6%) Second Stage 21(7.6%) 18(85.7%) 3(14.3%) Medical Treatment 122(43.9%) 120(98.4%) 2(1.6%) Table 3 shows that the arterial access method had a statistically significant difference (p>0.001) and the occurrence rate of hematoma among STEMI patients who had a cardiac cathprocedure, as hematoma occurred among patients who had a catheterization through the femoral artery more than radial artery (12.5% vs. 0% respectively). 29 On the other hand, the diseased artery and the type of the interventions, through the PCI, had no statistically significant difference in the occurrence rate of hematoma among STEMI patients who had a cardiac cathprocedure. Table 3 Procedure characteristics and Hematoma among ST- segment myocardial infarction patient who underwent a catheterization procedure Hematoma X 2 P value Total No Yes Arterial Access Radial 261(94.2%) 261(100.0%) 0(0.0%) 32.862 .000 Femoral 16 (5.8%) 14(87.5%) 2(12.5%) Vessel Disease Normal 123(44.2%) 123(100.0%) 0(0.0%) 6.855 .144 LAD 85(30.6%) 85(100.0%) 0(0.0%) RCA 38(13.7%) 37(97.4%) 1(2.6%) LCX 27(9.7%) 26(96.3%) 1(3.7%) Multi Vessels 5(1.8%) 5(100.0%) 0(0.0%) PCI interve ntion type Balloon 10(3.6%) 10(100.0%) 0(0.0%) 2.721 .606 Stent 48(17.3%) 47(97.9%) 1(2.1%) Balloon & Stent 77(27.7%) 76(98.7%) 1(1.3%) Second Stage 21(7.6%) 21(100.0%) 0(0.0%) Medical Treatment 122(43.9%) 122(100.0%) 0(0.0%) Table 4 shows that the diseased artery had a statistically significant difference (p=0.05) with the occurrence rate of arrhythmia in ECG among STEMI patients who had a catheterization procedure. The arrhythmia occurred more higher among the patients of the diseased right coronary artery (10.5%) and had a catheterization through the femoral artery route (12.5%). As for the method of arterial access and the type of the interventions via the catheter, there was no statistically significant difference with the occurrence rate of ECG arrhythmia among STEMI patients who had a catheterization procedure. 30 Table 4 Procedure characteristics and Arrythmia among ST- segment elevation myocardial infaction patient who underwent a catheterization procedure Arrhythmia X 2 P value Total No Yes Arterial Access Radial 261(94.2%) 249(95.4%) 12(4.6%) 1.962 .161 Femoral 16(5.8%) 14(87.5%) 2(12.5%) Vessel Disease Normal 123(44.2%) 122(99.2%) 1(0.8%) 9.384 .052 LAD 85 (30.6%) 78(91.8%) 7(8.2%) RCA 38(13.7%) 34(89.5%) 4(10.5%) LCX 27(9.7%) 25(92.6%) 2(7.4%) Multi Vessels 5(1.8%) 5(100.0%) 0(0.0%) PCI intervention type Normal 123(44.2%) 123(100.0%) 0(0.0%) 5.630 .229 Balloon 10(3.6%) 9(90.0%) 1(10.0%) Stent 48(17.3%) 46(95.8%) 2(4.2%) Balloon & Stent 77(27.7%) 67(87.0%) 10(13.0%) Second Stage 21(7.6%) 21(100.0%) 0(0.0%) Medical Treatment 122(43.9%) 121(99.2%) 1(0.8%) Table 5: The findings found that there was a statistically significant difference in the occurrence of cardiac arrest attributed to the history of IHD, CKD, and previous CABG (p values= .014, <.001,& .047 respectively) among STEMI patients who had a catheterization procedure. The occurrence rate of cardiac arrest were higher among the participants’ with history of IHD (4.8 %), CKD (25%) and CABG (10%) compared to non IHD (0.5%), non CKD (1.5%) and no history of CABG (1.5%). 31 Although the occurrence of cardiac arrest was higher among the other previous medical history, but these other medical history were not statistically significant (p> 0.05) with the occurrence with cardiac arrest among STEMI patients who had a catheterization procedure. Table 5 Previous Medical History and Cardiac Arrest among ST- segment elevation myocardial infarction patients who underwent a catherterization procedure Cardiac Arrest X 2 P value Total No Yes IHD No 194(69.8%) 193(99.5%) 1(0.5%) 5.985 .014 Yes 84(30.2%) 80(95.2%) 4(4.8%) MI No 275(98.9%) 270(98.2%) 5(1.8%) .056 .814 Yes 3(1.1%) 3(100.0%) 0(0.0%) PCI No 228(82.0%) 225(98.7%) 3(1.3%) 1.673 .196 Yes 50(18.0%) 48(96.0%) 2(4.0%) CABG No 268(96.4%) 264(98.5%) 4(1.5%) 3.950 .047 Yes 10(3.6%) 9(90.0%) 1(10.0%) HTN No 161(57.9%) 158(98.1%) 3(1.9%) .009 .924 Yes 117(42.1%) 115(98.3%) 2(1.7%) DM No 190(68.3%) 188(98.9%) 2(1.1%) 1.891 .169 Yes 88(31.7%) 85(96.6%) 3(3.4%) Smoker No 104(37.4%) 104(100.0%) 0(0.0%) 3.043 .081 Yes 174(62.6%) 169(97.1%) 5(2.9%) Dyslipid emia No 251(90.3%) 246(98.0%) 5(2.0%) .548 .459 Yes 27(9.7%) 27(100.0%) 0(0.0%) CKD No 274(98.6%) 270(98.5%) 4(1.5%) 12.369 .000 Yes 4(1.4%) 3(75.0%) 1(25.0%) Free No 192(69.1%) 187(97.4%) 5(2.6%) 2.281 .131 Yes 86(30.9%) 86(100.0%) (0.0%) Table 6 shows that the arterial catheter access and the catheterization medical procedures had a statistically significant difference (p=0.001&<0.001 respectively) with the occurrence rate of cardiac arrest among STEMI patients who had a catheterization procedure. 32 Cardiac arrest occurred more among patients who had a catheterization through the femoral artery (12.5%) and patients in the second stage (14.3%). The diseased artery had no statistically significant difference (p>0.05) with the occurrence rate of cardiac arrest among STEMI patients who had a catheterization procedure. Table 6 Procedure characterisics and Cardiac arrest among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure Cardiac Arrest X 2 P value Total No Yes Arterial Access Radial 261(94.2%) 258(98.9%) 3(1.1%) 10.958 .001 Femoral 16(5.8%) 14(87.5%) 2(12.5%) Vessel Disease Normal 123(44.2%) 123(100.0%) 0(0.0%) 5.630 .229 LAD 85(30.6%) 83(97.6%) 2(2.4%) RCA 38(13.7%) 36(94.7%) 2(5.3%) LCX 27(9.7%) 26(96.3%) 1(3.7%) Multi Vessels 5(1.8%) 5(100.0%) 0(0.0%) PCI interventi on type Balloon 10(3.6%) 10(100.0%) 0(0.0%) 20.373 .000 Stent 48(17.3%) 48(100.0%) 0(0.0%) Balloon & Stent 77(27.7%) 76(98.7%) 1(1.3%) Second Stage 21(7.6%) 18(85.7%) 3(14.3%) Medical Treatment 122(43.9%) 121 (99.2%) 1(0.8%) Table 7: The pre- and post-catheterization hemoglobin levels had a statistically significant difference (p>0.001) related to gender as the mean of pre and post catheterization hemoglobin levels were higher for males (14.3 and 13.6) compared to the hemoglobin levels for females (12.3 and 11.8). 33 The other pre- and post- catheterization blood tests (Creatinine& Troponin) for STEMI patients who had a catheterization procedure had no statistical significance difference related to gender Table 7 Pre and post lab (HB, creatnine& troponin) according to participant gender Gender N Mean Std. D T P value Pre Hb Male 198 14.3665 2.15304 7.653 <.001 Female 80 12.3207 1.63232 Pre Creatinine Male 197 .9376 .42563 .816 .415 Female 80 .8825 .67299 Pre Troponin Male 197 .6809 2.97506 .358 .721 Female 80 .5500 2.12499 Post Hb Male 198 13.6210 2.10782 6.573 <.001 Female 80 11.8681 1.75358 Post Creatinine Male 197 .8421 .34044 .289 .773 Female 80 .8268 .52221 Post Troponin Male 197 1.5452 7.42861 1.419 .157 Female 80 .3627 .85684 Table 8: The mean of pre- and post-catheterization creatinine levels had a statistically significant difference (p=0.002, 0.003) related to the previous medical history of IHD as the mean of pre and post catheterization creatinine levels were higher for males (1.06 and 0.94) compared to the free IHD participants (0.8 and 0.79). The other averages of pre- and post- catheterization blood tests (Hb& Troponin) for ST- SEMI patients who had a catheterization procedure had no statistical significance difference related to previous medical history of IHD. 34 Table 8 Pre and post lab ( Hb, creatnine & troponin) according to participant history of IHD IHD N Mean Std. D T P value Pre Hb No 194 13.6711 2.09 -1.220 .224 Yes 84 14.0242 2.46945 Pre Creatinine No 194 .8594 .45457 -3.166 .002 Yes 83 1.0673 .59538 Pre Troponin No 194 .6772 2.93805 .315 .753 Yes 83 .5633 2.27858 Post Hb No 194 13.1202 2.02525 .043 .966 Yes 84 13.1081 2.45837 Post Creatinine No 194 .7908 .34618 -3.020 .003 Yes 83 .9472 .49044 Post Troponin No 194 1.2821 6.59393 .316 .752 Yes 83 1.0204 5.58535 Table 9: The table shows that there is a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin and creatinine related to the presence of a history of hypertension (p values < 0.05). The average levels of hemoglobin were higher among the study participants who did not have a history of hypertension, while the average levels of creatinine were higher among those with a history of hypertension. Table 9 Pre and post lab ( HB, creatnine& troponin) according to participant history of HTN HTN N Mean Std. D T P value Pre Hb No 161 14.2839 1.92343 4.625 .000 Yes 117 13.0815 2.40737 Pre Creatinine No 161 .8505 .31754 -2.777 .006 Yes 116 1.0205 .68129 Pre Troponin No 161 .5029 2.51650 -.998 .319 Yes 116 .8376 3.05271 Post Hb No 161 13.4974 1.96511 3.517 .001 Yes 117 12.5925 2.31169 Post Creatinine No 161 .7709 .18456 -3.331 .001 Table 10: The table shows that there is a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin and creatinine related to the presence of a history of DM (p values < 0.05). 35 The average levels of hemoglobin were higher among the study participants who did not have a history of DM, while the average levels of creatinine were higher among those with a history of DM. Table 10 pre and post lab ( Hb, creatnin & troponin) according to participant with history of DM DM N Mean Std. D T P value Pre Hb No 190 14.1246 2.20778 3.930 .000 Yes 88 13.0290 2.05867 Pre Creatinine No 189 .8404 .25731 -4.001 .000 Yes 88 1.0963 .79569 Pre Troponin No 189 .6020 2.69069 -.363 .717 Yes 88 .7312 2.89749 Post Hb No 190 13.5258 2.05906 4.823 .000 Yes 88 12.2330 2.12106 Post Creatinine No 189 .7816 .19933 -3.481 .001 Yes 88 .9580 .63369 Post Troponin No 189 1.2841 6.67475 .311 .756 Yes 88 1.0311 5.43935 Table D1 in Appendix D: the table shows that there is a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin related to the smoking (p values < 0.05). The average levels of hemoglobin were higher among the study participants who are smoker (14.3) compared to the hemoglobin average for non-smokers, (12.8). Table D2 in Appendix D: The table shows that there is a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin and creatinine and pre- catheterization troponin related to the presence of a history of CKD (p values < 0.05). While troponin after did not have any statistically significant difference. The average levels of hemoglobin were lower among the study participants who have a CKD, while the average levels of creatinine were higher among those with a CKD. Table D3 in Appendix D: The table shows that there is a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin and creatinine related to the occurrence of complications (p values < 0.05). 36 While averages of pre- and post-catheterization troponin did not have any statistically significant difference. The average levels of hemoglobin were lower among the study participants who have among patients developed complication, while the average levels of creatinine were higher among those developed complication. Table D4 in Appendix D: The table shows that there is a statistically significant difference between the average levels of the mean of pre- and post-catheterization creatinine, pre- catheterization troponin and post catheterization Hb among those develop cardiac arrest (p values < 0.05). Creatinine was higher before and after catheterization among the participants who had a cardiac arrest while hemoglobin in post catheterization was lower among the participants who has had cardiac arrest. While pre catheterization Hb and post catheterization troponin did not have any statistically significant difference. Table D5 in Appendix D: Despite the presence of these differences between males and females as well as the age group, these differences did not have any statistical significance (p> 0.05) with the existence rate of complications among ST- SEMI patients who had a catheterization procedure. However, the occurrence rate of complications among males was higher(8.6%) than females (5%). Likewise, complications occurred more among the age group over forty years old (7.8%) compared to the age group under forty years old (0%) In the follow tableD6 in Appendix D: The findings reveled that the percentage of hematoma occurrence was 0.7% among ST- segment elevation myocardial infarction patients who underwent a catheterization procedure. Although the occurrence rate of hematoma was higher among males (1%) and the age group over 40 years (0.7%), these differences had no statistical significant with the occurrence of hematoma among STEMI patients who underwent a catheterization procedure (p>0.05). 37 In the next table D7 in Appendix D: The finding sclarified that there was no statistically significant difference attributed to the previous medical history of the participants and the occurrence of hematoma among STEMI patients who underwent a catheterization procedure. Table D8 in Appendix D: The findings reveled that the incidence of arrhythmia in the ECG was 5.2% among ST- SEMI patients who had a cardiac cath procedure. Despite the arrhythmia occurrence rate was higher among males (5.6%) and the age over 40 years (5.2%), but these differences had no statistical significant with the occurrence rate of arrhythmia among ST- SEMI patients who had a cardiac cathprocedure(p>0.05). Table D9 in Appendix D: The findings found that there was no statistically significant difference (p> 0.05) attributable to the previous medical history of the study participants with the occurrence rate of arrhythmia by ECG among STEMI patients who had a catheterization procedure. Table D10in Appendix D: The results showed that the occurrence of cardiac arrest was 1.79% among STEMI patients who had a catheterization procedure.. Despite the cardiac arrest occurrence rate was higher among males (2.0%) and the age over 40 years (1.9%), but these differences had no statistical significant with the occurrence rate of arrhythmia among STEMI patients who had a catheterization procedure ( p>0.05). Table D11 in Appendix D: The results of pre- and post- catheterization blood tests (Hb, Creatinine, & Troponin) for STEMI patients who had a catheterization procedure. had no statistical significance difference related to age, with the exception of the mean of post catheterization hemoglobin level, which had a statistically significant difference attributable to age (p=0.045), where the post catheterization hemoglobin mean level was higher among the group age who< 40 years compared to the age group who > 40 years (14.46 vs.13 respectively). History of previous PCI had no statistical significance (p value > 0.05) for the mean of pre- and post-catheterization of blood tests (Hb, creatinine, & troponin). See table D12 in Appendix D for more information. 38 History of previous CABG had no statistical significance (p value > 0.05) for the mean of pre- and post-catheterization of blood tests (Hb, creatinine, & troponin). See table D13 in Appendix Dfor more information. History of Dyslipidemia had no statistical significance (p value > 0.05) for the mean of pre- and post-catheterization of blood tests (Hb, creatinine, & troponin). See table D14 in Appendix Dfor more information. Table D15 in Appendix D: the development of hematoma had no statistically significant difference (p value>0.05)attributed to the averages of pre- or post-catheterization blood tests (Hb, creatinine, & troponin). See table D15 for more information. Table D16 in Appendix D: There is no statistically significant difference between the averages of pre- or post-catheterization blood tests (Hb, creatinine, & troponin) between the participants who developed arrhythmia in the ECG and those who did not, with the exception of the post catheterization hemoglobin average, as it was lower in the participants who developed arrhythmia in their ECG (11.8 vs. 13.1), and this difference was statistically significant(p=0.026). History of MI had no statistical significance (p value > 0.05) for the mean of pre- and post-catheterization blood tests (Hb, creatinine, & troponin).See table D17 in Appendix Dfor more information. 39 Chapter Four Discussion and Conclusion 4.1 Discussion In a discussion chapter we provided the current study findings, in which the researcher presents a comprehensive critique of the results from their own point-of-view and compares the current findings with the previous literature results. The current study outcomes corroborate those of Qamar et al.(2023),study, which found in comparison between gender, STEMI male patient largest compared to female patient who underwent Percutanous coronary intervention. Similar to this study Abdel-Ghany et al.(2021) also discover to combat coronary heart disease at the community level, programs that target the common modifiable cardiovascular risk factors—HTN, DM, CRF, and smoking—are essential. Despite the presence of these differences between males and females as well as the age group, these differences did not have any statistical significance (p> 0.05) with the occurrence rate of patient who underwent a catheterization procedure complications among (STEMI) patient. However, the occurrence rate of complications was higher among males compared to females . Likewise, complications occurred more among the groupage who over 40 years old compared to the age group under 40 years old , corroborate those of (Osman et al., 2021) The present study's findings the highest percentage among STEMI patient who underwent a catheterization procedure patients, the occurrence rate of complications was higher among patients who had a history of IHD , previous CABG , and smoking the results found that these differences had no significant difference (p> 0.05). On the other hand, history of CKD had a statistically significant difference (p=0.001) in the occurrence rate of complications among STEMI patient who underwent a catheterization procedure, as the occurrence rate of complications was higher among patients with a history of chronic renal failure than that of patients without a history of chronic renal failure as study (El-Ahmadi et al., 2019). 40 The results also showed that the percentage of smokers was high among STEMI patient who underwent a catheterization procedure, and it had a statistically significant difference between the smoking and non-smoking participants with the occurrence rate of complications (p=0.023) As study (Redfors et al., 2020). Our result is in alignment with Batra et al.(2020)investigated the rate of catheter entry through the radial artery was the most widely used compared with femoral artery, the LAD artery was the most frequent diseased vessel , and the balloon and stent were the most common type of intervention. The occurrence rate of complications by radial artery access are less than femoral artery, the right coronary artery and balloon & stent intervention were higher susceptible to complications. Similar to the current study, Batra et al.(2020)also discovered that the arterial access method had a statistically significant difference (p>0.001) and the occurrence rate of hematoma among STEMI patient who underwent PCI, as hematoma occurred among patients who had a catheterization through the femoral artery more than radial artery. The result showed that the diseased artery had a statistically significant difference (p=0.05) with the occurrence rate of arrhythmia in ECG among STEMI patient who underwent a catheterization as study (Khani et al., 2022) The arrhythmia occurred more higher among the patients of the diseased right coronary artery and had a catheterization through the femoral artery route. Similar to the current study showed that the occurrence rate of cardiac arrest among STEMI patient who underwent a catheterization procedure was higher among males and the age over 40 years , but these differences had no statistical significant with the occurrence rate of arrhythmia among STEMI patient who underwent a catheterization procedure ( p>0.05). 41 The study by Samanta et al.(2019),which revealed that the results showed there was a statistically significant difference in the occurrence of cardiac arrest attributed to the history of IHD, CKD, and previous CABG among STEMI patient who underwent a catheterization procedure. The occurrence of cardiac arrest was higher among the other previous medical history, but these other medical history were not statistically significant (p> 0.05) with the occurrence with cardiac arrest among STEMI patient who underwent a catheterization procedure. The current study outcomes corroborate those of Batra et al.(2020)study, which found in the arterial catheter access and the catheterization medical procedures had a statistically significant difference with the occurrence rate of cardiac arrest among STEMI patient who underwent a catheterization procedure. Cardiac arrest occurred more among patients who had a catheterization through the femoral artery and patient in the second stage. The current study outcomes corroborate those of Separham et al.(2021) study ,The results of pre- and post- catheterization blood tests (Hb, Creatinine, & Troponin)for STEMI patient who underwent a catheterization procedure had no statistical significance difference related to age, with the exception of the mean of post catheterization hemoglobin level, which had a statistically significant difference attributable to age (p=0.045), where the post catheterization hemoglobin mean level was higher among the age group below 40 compared to the age group above 40 years. History of diabetes , Dyslipidemia, previous PCI and previous CABG, had no statistical significance (p value > 0.05) for the mean of pre- and post-catheterization blood tests (Hb, creatinine, & troponin).. The study by Hoffmann et al.(2022) Which revealed that the results showed there is a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin and creatinine related to the presence of a history of hypertension (p values < 0.05). 42 The average levels of hemoglobin were higher among the study participants who did not have a history of hypertension, while the average levels of creatinine were higher among those with a history of hypertension. The study by Gleerup et al.(2020), Which revealed that the results showed a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin related to the smoking (p values < 0.05). The average levels of hemoglobin were higher among the study participants who are smoker compared to the hemoglobin average for non-smokers. Similar to the current study, Zhu et al.(2023) ,also discovered that the average levels of hemoglobin were lower among the study participants who have a CKD, while the average levels of creatinine were higher among those with a CKD. There is a statistically significant difference between the average levels of the mean of pre- and post-catheterization hemoglobin and creatinine and pre- catheterization troponin related to the presence of a history of CKD (p values < 0.05). While troponin after did not have any statistically significant difference. The study by Yang & Huang .(2022)which revealed that the results showed the average levels of hemoglobin were lower among the study participants who have among patients developed complication, while the average levels of creatinine were higher among those developed complication. Similar to the current study, Khalid et al.(2020), also discovered there is a statistically significant difference between the average levels of the mean of pre- and post- catheterization hemoglobin and creatinine related to the presence of a history of DM (p values < 0.05). The current study outcomes corroborate those of Gkargkoulas et al.(2019)study, there is no statistically significant difference between the averages of pre- or post- catheterization blood tests (Hb, creatinine, & troponin) between the participants who developed arrhythmia in the ECG and those who did not, with the exception of the post catheterization hemoglobin average, as it was lower in the participants who developed arrhythmia in their ECG, and the difference was statistically significant(p=0.026) Similar to the current study, Samanta et al.(2019), also discovered there is a statistically 43 significant difference between the average levels of the mean of pre- and post- catheterization creatinine, pre- catheterization troponin and post catheterization Hb among those develop cardiac arrest Creatinine was higher before and after catheterization among the participants who had a cardiac arrest while hemoglobin in post catheterization was lower among the participants who has had cardiac arrest.While pre catheterization Hb and post catheterization troponin did not have any statistically significant difference. The study by Homorodean