Long-term follow-up of mesh-covered stent implantation in patients with ST-segment elevation myocardial infarction

BACKGROUND

The MGuard stent (a bare-metal stent wrapped externally in a polymer mesh sleeve) was introduced to reduce the risk of distal embolisation and no-reflow phenomenon during percutaneous coronary intervention (PCI) in thrombus containing lesions, including ST-segment elevation myocardial infarction (STEMI). However, data on the long-term performance of the MGuard stent is limited.

AIM

To assess the long-term safety and efficacy of MGuard stent implantation during primary PCI for STEMI.

METHODS AND RESULTS

In this multicentre study, a total of 60 patients with STEMI ≤12 h treated with the MGuard stent were enrolled. Angiographic success of PCI was achieved in 96.7%, with the final TIMI grade 3 flow in 90.0% of patients. At six months, the overall rate of major adverse cardiac and cerebrovascular events (MACCE; composite of cardiac death, nonfatal target vessel reinfarction, target lesion revascularisation, and stroke) was 1.7%. A long-term follow-up of the study was successfully performed in 57 patients (mean follow-up of 38.7 ± 3.1 months). The long-term cardiac mortality was 7.0%, with a MACCE rate of 8.8%. There was no decrease in the left ventricular ejection fraction and no enlargement of the left ventriclebetween index and long-term follow-up echocardiogram.

CONCLUSIONS

The early safety and efficacy of the MGuard stent was maintained during the long-term follow-up. However, comparative data from ongoing randomised clinical trials are still required to confirm the long-term efficacy of MGuard stent implantation in patients with STEMI.

Impact of hypertension on distal embolization, myocardial perfusion, and mortality in patients with ST segment elevation myocardial infarction undergoing primary angioplasty

Hypertension is a well-known risk factor for atherosclerosis. However, data on the impact of hypertension in patients with ST elevation myocardial infarction (STEMI) are inconsistent and mainly related to studies performed in the thrombolytic era, with very few data on patients undergoing primary angioplasty. The aim of the present study was to evaluate the impact of hypertension on distal embolization, myocardial perfusion, and mortality in patients with STEMI undergoing primary percutaneous coronary intervention. Our population is represented by 1,662 patients undergoing primary angioplasty for STEMI included in the Early Glycoprotein IIb-IIIa inhibitors in Primary angioplasty database. Myocardial perfusion was evaluated by myocardial blush grade and ST segment resolution. Follow-up data were collected within 1 year after primary angioplasty. Hypertension was observed in 700 patients (42.1%). Hypertension was associated with more advanced age (p <0.001), female gender (p <0.001), diabetes (p <0.001), hypercholesterolemia (p <0.001), previous revascularization (p <0.001), anterior myocardial infarction (p = 0.006), longer ischemia time (p = 0.03), more extensive coronary artery disease (p = 0.002), more often treated with abciximab (p <0.001), and less often smokers (p <0.001). Hypertension was associated with impaired postprocedural myocardial blush grade 2 to 3 (68.2% vs 74.2%, p = 0.019) and complete ST segment resolution (51.7% vs 61.1%, p = 0.001). By a mean follow-up of 206 ± 158 days, 70 patients (4.3%) had died. Hypertension was associated with a greater mortality (6.2% vs 2.9%, hazard ratio 2.31, 95% confidence interval 1.42 to 3.73, p <0.001), confirmed after correction for baseline confounding factors (hazard ratio 1.82, 95% confidence interval 1.03 to 3.22, p <0.001). In conclusion, this study showed that among patients with STEMI undergoing primary angioplasty, hypertension is associated with impaired reperfusion and independently predicts 1-year mortality.

Primary angioplasty in patient with ST-segment elevation myocardial infarction in the setting of intentional carbon monoxide poisoning

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) due to coronary artery occlusion in the setting of acute carbon monoxide (CO) poisoning is a very rare presentation.

OBJECTIVE

Our aim was to report on the use of primary angioplasty in a patient with STEMI in the setting of CO poisoning.

CASE REPORT

A 36-year-old man with retrosternal chest pain was admitted after exposure to CO. The initial electrocardiogram (ECG) showed ST depression in I, aVL, and V3-V4 with slight ST elevation in II, III, aVF leads. Toxic carboxyhemoglobin level of 22% and troponin I of 2.19 μg/L were confirmed. After oxygen therapy the chest pain diminished, but after about 15 h it returned. The repeat ECG revealed normalization of previous ST depression with persistent ST elevation in II, III, aVF leads. The troponin I concentration was 5.94 μg/L. An echocardiogram demonstrated an apex hypokinesia involving the adjacent segments of the anterior and lateral wall. On the coronary angiogram, an acute occlusion of the distal left anterior descending coronary artery was confirmed. Primary percutaneous coronary intervention (PCI) of the infarct-related artery was performed. After PCI, the patient was symptom free and had partial ST-segment elevation resolution. The patient was discharged home after 7 days, with persistent ST-T changes and mild hypokinesia of the apex suggesting myocardial injury.

CONCLUSIONS

Patients with toxic CO exposure who have symptoms of STEMI should be carefully evaluated with serial ECG, cardiac necrosis marker measurements, and an echocardiogram. When there is evidence of myocardial injury, a wider use of coronary angiography can identify patients who could benefit from PCI.

Predictive utility of NT-pro BNP for infarct size and left ventricle function after acute myocardial infarction in long-term follow-up

PURPOSE: The aim of the study was to evaluate the utility of N-terminal pro-B-type natriuretic peptide (NT-pro BNP, pg/ml) assessment to predict infarct size and left ventricle function after ST-segment elevation myocardial infarction (STEMI) at long-term follow-up.

METHODS: In 45 patients with first STEMI less than 3 hours from symptom onset treated with mechanical reperfusion NT-pro BNP was assessed early (at admission) and at 6 months. Cardiac magnetic resonance (CMR) parameters (delayed enhancement infarct size (IS, %), left ventricular end-diastolic (LVEDVI, ml/m2) and end-systolic (LVESVI, ml/m2) volume indexes) were assessed at 6 months.

RESULTS: No significant correlation was found between baseline NT-pro BNP assessment and IS and left ventricle function after 6 months. There was a significant correlation between 6-month NT-pro BNP and IS (r = 0.65, p < 0.001) and left ventricle remodeling at 6 months (LVEDVI, r = 0.53, p = 0.001; LVESVI, r = 0.51, p = 0.002).

CONCLUSIONS: Assessment of NT-pro BNP level 6 months after STEMI remains a good indicator of infarct size and left ventricle function at long-term follow-up.

Impact of smoking status on outcome in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

There are some data showing lower mortality of smokers comparing to non-smokers in patients with ST-segment elevation myocardial infarction (STEMI) when treated with thrombolysis or without reperfusion therapy. However, the role of smoking status is less established in patients with STEMI undergoing mechanical reperfusion. We evaluate the influence of smoking on outcome in patients with STEMI treated with primary percutaneous coronary intervention (PCI). A total of 1,086 patients enrolled into EUROTRANSFER Registry were included into present analysis. Patients were divided according to smoking status during STEMI presentation into those who were current smokers (391 patients, 36 %) and non-smokers (695 patients, 64 %). Current smokers were younger and more often men and less frequently had high-risk features as previous myocardial infarction, history of chronic renal failure, previous PCI, diabetes mellitus, anterior wall STEMI, and multivessel disease. Unadjusted mortality at 1 year was lower in current smokers comparing to non-smokers (3.3 vs. 9.5 %; OR 0.33 CI 0.18–0.6; p = 0.0001). However, after adjustment for age and gender by logistic regression, there was no longer significant difference between groups (OR 0.7; CI 0.37–1.36; p = 0.30). In conclusion, current smokers with STEMI treated with primary PCI have lower mortality at 1 year comparing to non-smokers, but this result may be explained by differences in baseline characteristics and not by smoking status itself. Current smokers developed STEMI more than 10 years earlier than non-smokers with similar age and sex-adjusted risk of death at 1 year. These results emphasize the role of efforts to encourage smoking cessation as prevention of myocardial infarction.

Predictors of coronary and carotid atherosclerosis in patients with severe degenerative aortic stenosis

BACKGROUND

Patients with degenerative aortic stenosis (AS) exhibit elevated prevalence of coronary artery disease (CAD) and internal carotid artery stenosis (ICAS). Our aim was to investigate prevalence of significant CAD and ICAS in relation to demographic and cardiovascular risk profile among patients with severe degenerative AS.

METHODS

We studied 145 consecutive patients (77 men and 68 women) aged 49-91 years (median, 76) with severe degenerative AS who underwent coronary angiography and carotid ultrasonography in our tertiary care center. The patients were divided into two groups according to the presence of either significant CAD (n=86) or ICAS (n=22).

RESULTS

The prevalence of significant CAD or ICAS was higher with increasing number of traditional risk factors (hypertension, hypercholesterolemia, diabetes, smoking habit) and decreasing renal function. We found interactions between age and gender in terms of CAD (p=0.01) and ICAS (p=0.06), which was confirmed by multivariate approach. With the reference to men with a below-median age, the prevalence of CAD or ICAS increased in men aged >76 years (89% vs. 55% and 28% vs. 14%, respectively), whereas the respective percentages were lower in older vs. younger women (48% vs. 54% and 7% vs. 17%).

CONCLUSIONS

In severe degenerative AS gender modulates the association of age with coronary and carotid atherosclerosis with its lower prevalence in women aged >76 years compared to their younger counterparts. This may result from a hypothetical "survival bias", i.e., an excessive risk of death in very elderly women with severe AS and coexisting relevant coronary or carotid atherosclerosis.

Age-related differences in treatment strategies and clinical outcomes in unselected cohort of patients with ST-segment elevation myocardial infarction transferred for primary angioplasty

Data concerning the benefits and risks of primary PCI in the elderly patients presenting with ST-segment elevation myocardial infarction (STEMI) are limited. Thus, the objective of the study was to assess age-dependent differences in the treatment and outcomes of STEMI patients transferred for primary PCI. Data were gathered on 1,650 consecutive STEMI patients from hospital networks in seven countries of Europe from November 2005 to January 2007 (the EUROTRANSFER Registry population). Patients <65, 65 to 74, 75 to 84, and ≥ 85 years of age comprised 49.3, 27.5, 20.2, and 3 % of the registry population, respectively. Elderly patients were higher risk individuals and have experienced longer delays to reperfusion than their younger counterparts and were more likely to be treated conservatively after coronary angiography. Despite similar frequency of TIMI 3 flow before PCI, elderly patients were less likely to achieve TIMI 3 flow and ST-segment resolution >50 % after PCI, and were more likely to have PCI complications. The rates of death at 30 days, as well as at 1 year were increased with age. In the Cox regression analysis model age was an independent predictor of 30-day mortality. A trend toward higher risk of major bleeding requiring transfusion was observed. Age was an important determinant of treatment strategies selection and clinical outcomes in the group of consecutive STEMI patients transferred for primary PCI. Further efforts should be made to reduce delays and to optimize treatment of STEMI, regardless of patients' age.

Parental history of premature coronary artery disease does not affect plasma levels of asymmetric dimethylarginine in young healthy adults

INTRODUCTION

Family history of premature coronary artery disease (CAD) is a risk factor of atherogenesis and adverse coronary events.

OBJECTIVES

The aim of the study was to establish whether asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide formation, might be elevated in the asymptomatic offspring of patients with early‑onset CAD and whether it might contribute to subclinical atherosclerosis.

PATIENTS AND METHODS

We studied 20 healthy subjects (10 men and 10 women) aged from 19 to 30 years with a parental history of documented CAD before 60 years of age, and 20 controls with no evidence of parental CAD. ADMA and its isomer, symmetric dimethylarginine (SDMA), were determined by enzyme‑linked immunosorbent assays. Mean intima‑media thickness (IMT) of the common carotid arteries was assessed by B‑mode ultrasound.

RESULTS

Characteristics of the 2 groups were similar, except for insignificant tendencies towards higher low‑density lipoprotein (LDL) cholesterol (P = 0.07) and estimated glomerular filtration rate (eGFR) (P = 0.06) in the group with a positive family history. Compared with controls, subjects with a parental history of premature CAD had increased IMT (0.54 ±0.05 vs. 0.48 ±0.05 mm; P <0.001) and similar levels of ADMA (0.66 ±0.17 vs. 0.74 ±0.15 μmol/l; P = 0.14) and SDMA (0.49 ±0.07 vs. 0.50 ±0.07 μmol/l; P = 0.61). The results did not change substantially on adjustment for LDL cholesterol and eGFR. In a multivariate analysis, parental CAD (P = 0.005) and LDL cholesterol (P = 0.06), but not ADMA, were independent positive IMT predictors.

CONCLUSIONS

Our preliminary data suggest that elevated ADMA is not a part of the proatherogenic risk profile in the young adult offspring of patients with premature CAD.

From pharmacologically assisted early transfer to a universal primary angioplasty service: the experience of the Małopolska region

The current article summarises more than 12 years' experience in the treatment of ST-segment elevation myocardial infarction in the Małopolska region (southern part of Poland). Data on the development phase of the STEMI treatment network, as well as the current status of interventional treatment of acute coronary syndromes in that region of Poland are provided.

Impact of preprocedural TIMI flow on myocardial perfusion, distal embolization and mortality in patients with ST-segment elevation myocardial infarction treated by primary angioplasty and glycoprotein IIb/IIIa inhibitors

BACKGROUND

Despite optimal epicardial recanalization, primary angioplasty for ST-elevation myocardial infarction (STEMI) is still associated with suboptimal reperfusion in a relatively large proportion of patients. The aim of the current study was to evaluate the impact of preprocedural TIMI flow on myocardial perfusion, distal embolization, and survival among STEMI patients undergoing primary angioplasty with glycoprotein (GP) IIb/IIIa inhibitors.

METHODS

Our population is represented by a total of 1637 patients undergoing primary angioplasty for STEMI treated with GP IIb/IIIa inhibitors. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty.

RESULTS

Poor preprocedural TIMI flow (TIMI 0-1) was observed in 1039 patients (63.5%), and was associated with higher Killip class at presentation (P=.006), longer time-to-treatment (P=.03), less often with early administration of GP IIb/IIIa inhibitors (P<.001), impaired postprocedural epicardial (P=.001) and myocardial perfusion (determined by myocardial blush grade, P<.001 and/or ST-segment resolution (P<.001), and distal embolization (P=.041). At 206 ± 158 days follow-up, poor preprocedural recanalization was associated with a significantly higher mortality (adjusted odds ratio, 0.58; 95% CI, 0.34-0.96; P=.034).

CONCLUSION

This study shows that among patients with STEMI undergoing primary angioplasty with GP IIb/IIIa inhibitors, poor preprocedural TIMI flow is associated with higher incidence of distal embolization and impaired epicardial and myocardial perfusion, and significantly higher mortality.

Imaging of inflamed carotid artery atherosclerotic plaques with the use of 99mTc-HYNIC-IL-2 scintigraphy in end-stage renal disease patients

PURPOSE

Identification of vulnerable plaques remains crucial for better cardiovascular risk assessment. At least 20% of inflammatory cells within unstable (vulnerable) plaques comprise T lymphocytes, which contain receptors for interleukin-2 (IL-2); those receptors can be identified by scintigraphy with radiolabelled IL-2.The aim of this study was to identify the "inflamed" (vulnerable) plaques by scintigraphy using IL-2 labelled with (99m)Tc in the selected, high cardiovascular risk group of end-stage renal disease (ESRD) patients.

METHODS

A total of 28 patients (18 men, 10 women, aged 55.2 ± 9.6 years, 17 on peritoneal dialysis, 11 on haemodialysis) underwent common carotid artery (CCA) scintigraphy with the use of (99m)Tc-hydrazinonicotinamide (HYNIC)-IL-2. In all cases, ultrasound examination of the CCA was performed and levels of selected proinflammatory factors, atherogenic markers and calcium-phosphate balance parameters were measured. Finally, the target to non-target (T/nT) ratio of IL-2 uptake in atherosclerotic plaques with intima-media thickness (IMT), classic cardiovascular risk factors and concentrations of the measured factors were compared.

RESULTS

Increased (99m)Tc-HYNIC-IL-2 uptake in atherosclerotic plaques in 38/41 (91%) cases was detected. The median T/nT ratio of focal (99m)Tc-HYNIC-IL-2 uptake in atherosclerotic plaques was 2.35 (range 1.23-3.63). The mean IMT value on the side of plaques assessed by scintigraphy was 0.79 ± 0.18 mm (median 0.8, range 0.5-1.275). Correlations between T/nT ratio and homocysteine (R = 0.22, p = 0.037), apolipoprotein B (apoB) (R = 0.31, p = 0.008), apoB to apoA-I ratio (R = 0.29, p = 0.012) and triglyceride concentration (R = 0.26, p = 0.021) were detected. A lower T/nT ratio in patients with better parameters of nutritional status (haemoglobin, albumin, adiponectin) in comparison with patients with worse nutritional parameters (3.20 ± 0.5 vs 2.16 ± 0.68, p = 0.025) was revealed as well as a difference between values of T/nT ratio in groups of patients with values of apoB, soluble CD40 ligand and asymmetric dimethylarginine above and below median (3.18 ± 0.52 vs 2.16 ± 0.68, p = 0.031). No statistically significant association was found between T/nT ratio and mean value of either IMT or classic cardiovascular risk factors.

CONCLUSION

Scintigraphy with the use of (99m)Tc-HYNIC-IL-2 can be a tool for inflamed atherosclerotic (vulnerable) plaque visualization within CCA in ESRD patients. Quantitative results of carotid artery scintigraphy with (99m)Tc-HYNIC-IL-2 correlate with serum concentration of selected cardiovascular risk markers.