" (Jaiwa, 2006, p.1) Jaiwa reports a more recent study that states findings that out of 52 patients with chest pain only 13 patients or 25% of the 52 received aspirin. The stated reason for not giving aspirin to the other 39 patients included that "chest pain was not felt to be cardiac in thirteen (33%), ten patients (26%) had already taken aspirin on that day, the medical provider was a basic level emergency medical technician who could not administer aspirin to six patients (15%), pain subsided prior to arrival of emergency medical services in three patients." (2006, p.1)

Conclusion of the investigators were that the primary reason that paramedics failed to administer aspirin was "...their belief that the chest pain was not of a cardiac nature while the other common reason being their inability to administer aspirin." (Jaiwa, 2006, p.1) Jaiwa states that billions of individuals throughout the world are taking aspirin as a preventative measure for heart and artery disease. Aspirin has approved the use of aspirin for reduction of risk in the following conditions:

(1) Heart attack in people who have stable angina, predictable chest pain due to impaired blood flow to the heart;

(2) Death in people having heart attack;

(3) Second heart attack in people who have already suffered a heart attack or have unstable angina, chest pain caused by unpredictable impairment of blood flow;

(4) Second stroke in people who have already had one ischemic stroke because of blockage in blood vessel which supplies to brain or those experiencing transient ischemic attack (TIAs). (Jaiwa, 2006, p.1)

Jaiwa states that this situation has improved a great deal however, there are people "dying needlessly because they are not taking the drug when they should." (Jaiwa, 2006, p.1) There have been aspirin foundations formed throughout the world by health care professionals for promoting the use of Aspirin in the indications that have been well-established. The Pakistan Foundation conducted the Aspirin Awareness and Usage Study (AAUS) to examine the knowledge in terms of awareness and the use of Aspirin in Acute Coronary Syndromes presenting for admission at hospitals and coronary care units.

The patterns of aspirin being prescribed as well as other cardiovascular drugs at discharge from hospitals were also examined. Male and female patients of all ages with coronary artery disease as well as unstable angina, acute myocardial infarction "both STEMI and NSTEMI were included." (Jawai, 2006, p.1) Those excluded were individuals with known bleeding disorders, those suffering from peptic ulcer disease and those who were either 36 weeks in gestation and with known G6PD deficiency and those with hypersensitivity to aspirin.

Jawai reports that in all of the 1527 Proformas only 1400 were complete enough for inclusion in the final evaluation as those with incomplete information were excluded. The condition-specific classifications in this study are the following: (1) Six hundred six (43%) patients were suffering from unstable angina; (2) The patients enrolled included 68.1% males and 31.9% females; (3) The presenting symptoms as revealed in this study were chest pain in 1299 patients (91.1%); (4) shortness of breath 602 patients (42.3%) and syncope 187 patients (6.1%); (5) The mean age of patients was 52.2±10.7 years which is almost a decade earlier than seen in the West. (Jawai, 2006, p.1)

Stated to be the most startling disclosure in the study "was that the majority of the heart attack patients reach hospitals after a mean of 13.2±6.2 hours delay after the onset of symptoms. This means that the time for thrombolytic therapy to be of any use is already over. Only 50% of patients suffering from acute coronary syndrome were prescribed aspirin at the time of discharge from hospitals." (Jawai, 2006, p.1)

Jawai (2006) states the following facts: "While 71.7% patients were given Aspirin in wards only 59.9% of patients reaching the emergency room were given aspirin. About 20.8% of patients were prescribed aspirin therapy by the family physicians and only 16% took aspirin at home when they suffered from chest pain. Out of these 1400 patients, four hundred forty four (31.2%) were taking aspirin before the onset of symptoms. Findings of this study also showed that incidence of myocardial infarction has also increased in women to over 30% as against previously reported figures of 10-15%." (p.1) In the area of adverse reactions only 3.1% of patients had allergic reactions including G.I. (0.9%), bleeding (2.1%) as well as others (1.1%) which are stated to be "quite negligible proving once again the safety and efficacy of this wonder drug." (Jaiwai, 2006, p.1) Major risk factors stated to be contributing to acute coronary syndromes were "family history of hypertension 51.8% smoking 51.3%, hypertension 54.3%, family history of IHD 43.9% and family history of hyperli- pidemias 54.3%.

Other risk factors included family history of diabetes 35.6%, IHD 38.2%, diabetes mellitus 37.2% and hyperlipidemias 18%. Only 3% of the patients enrolled in the study died, 17% were referred for investigations and 13% were stable with symptoms." (Jawai,...

Similarly most of the patients should have been given aspirin as soon as they reported in the emergency room. Again only 20.8% of family physicians prescribed aspirin therapy which shows that educational programs for the doctors on medical uses of aspirin needs to be further intensified. Despite the fact that aspirin is a safe and effective household medication for acute coronary syndromes, its use in Pakistan is still far less than optimal goal and major time delays still occur on the part of the patients to reach hospitals after the onset of symptoms like chest pain and shortness of breath.
Since over 91% of patients presented with chest pain and shortness of breath was the other major symptoms in 42.3% of patients, it is not at all difficult to diagnose these patients suffering from AMI at the family physicians level where if aspirin therapy is administered within six hours, it can save many precious lives." (2006, p.1) Individuals in poor countries are not able to buy drugs that are priced economically and it is held among the population that only the most expensive of the drugs are effective. Individuals in poorer countries were also found to have a tendency to under and over-use of aspirin.

STATEMENT OF THE PROBLEM

Aspirin has been found by many studies across many decades to be effective in treating patients with heart disease including myocardial infarction however, the problem is that many patients cannot successful take aspirin due to complicating factors including conditions that result in bleeding being triggered by aspirin.

PURPOSE OF THE STUDY

The hydrolysis of aspirin markedly reduced its antiplatelet activity. This has prevented the development of an effective IV formulation of aspirin that would improve the treatment of acute coronary syndromes. This study reports the development of a formulation that is believed to have the capacity to resist hydrolysis and preserve platelet inhibition.

ORGANIZATION OF THE STUDY

The following Chapter or Chapter 2 will contain a literature review in this area of study. Chapter three will contain the methods of the research as well as the research summary and conclusion.

TERMS & DEFINITIONS

CI confidence interval

COX cyclo-oxygenase

CRP C-reactive protein

CRT cardiac resynchronization therapy

ECG electrocardiographic/electrocardiogram

GP glycoprotein h hour

HDL high-density lipoprotein

INR international normalized ratio

i.v. intravenous

LDL low-density lipoprotein

LMWH low-molecular-weight heparin

LV left ventricular min minute

MBG myocardial blush grade

MRI magnetic resonance imaging

NSAID non-steroidal anti-inflammatory drug

NYHA New York Heart Association

OR odds ratio

PCI percutaneous coronary intervention

PDA personal digital assistant

PET positron emission tomography

s seconds

s.c. subcutaneous

SCD sudden cardiac death

SPECT single-photon emission computed tomography

STEMI acute ST-segment elevation myocardial infarction

TIMI thrombolysis in myocardial infarction

IV ASPIRIN FOR ACUTE MYOCARDIAL INFARCTION PATIENTS

CHAPTER TWO

LITERATURE REVIEW

Myocardial infarction is stated in the work of Van de Werf, et al. (2008) to be defined "from a number of different perspectives related to clinical, electrocardiographic (ECG) biochemical and pathological characteristics." (p.2912) The present guidelines are stated to pertain to patients "presenting with ischaemic symptoms and persistent ST-segment elevation on the ECG (STEMI). The great majority of these patients will show a typical rise of biomarkers of myocardial necrosis and progress to Q-wave myocardial infarction." (Van de Werf, et al., 2008, p.2913)

According to Van de Werf, et al. The majority of cases of STEMI are caused "by an occlusion of a major coronary artery. Coronary occlusion and reduction in coronary blood flow are usually due to physical disruption of an atherosclerotic plaque with subsequent formation of an occluding thrombus. Concomitant coronary vasoconstriction and microembolization may be involved to some extent." (Van de Werf, et al., 2008, p.2913)

It is less common however there is the possibility of the formation of a thrombus due to a "superficial erosion of the endothelial surface. The risk of plaque disruption depends on plaque composition and vulnerability (plaque type) and degree of stenosis (plaque size). As many as three-quarters of all infarct-related thrombi appear to evolve over plaques causing only mild to moderate stenosis." (Van de Werf, et al., 2008, p.2913)

It is related that portions of the coronary…