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.

Time-to-reperfusion therapy influences outcome of patients with myocardial infarction subjected to facilitated PCI

AIM

The purpose of this study was to evaluate the impact of time-to-reperfusion on outcome after facilitated percutaneous coronary intervention (PCI) i.e. PCI following early pharmacological reperfusion therapy in ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

The study population consisted of 262 consecutive patients with STEMI, aged <75 years, without cardiogenic shock, presenting <12 hours of chest pain onset, transferred from community hospitals to a catheterization laboratory with time delay >90 min after pharmacological reperfusion therapy (alteplase i.v. bolus 15 mg followed by an infusion - 35 mg/60 min; abciximab i.v. bolus 0.25 mg/kg followed by a 12-hour infusion - 0.125 microg/kg/min; unfractionated heparin i.v. bolus 40 U/kg [maximum 3000 U]). One hundred seventeen patients (44.7%) received pharmacological reperfusion therapy <3 h after chest pain onset, 101 (38.5%) at 3-6 h and 44 patients (16.8%) >6 h. Patent infarct-related artery rates at initial angiography were similar among the study groups. PCI significantly improved epicardial flow in all three groups. Mortality at 12 months was significantly related to time-to-pharmacological reperfusion (3.4% [<3 h], 4.0% [3-6 h], 13.6% [>6 h], p = 0.027). At 6 months left ventricular ejection fraction was significantly improved in the two groups of patients with time-to-pharmacological reperfusion <6 hours and the time-to-pharmacological reperfusion was the independent predictor of lack of left ventricular ejection fraction recovery.

CONCLUSION

Our study shows that among STEMI patients undergoing facilitated PCI, time-to-pharmacological reperfusion significantly affects left ventricular function recovery and long-term mortality.

P5536Comparison of safety and effectiveness between right and left radial artery approach in percutaneous coronary intervention for acute coronary syndrome. Propensity score analysis of data from the ORPKI

Introduction

The use of the radial approach (RA) for percutaneous coronary intervention (PCI) has gradually increased. Several studies demonstrated that radial artery is associated with significant reduction in major adverse cardiac events for both coronary angiography and PCI in acute coronary syndrome (ACS). However, it is still unclear if the side of RA has influence on clinical outcomes in an all-comer population in ACS settings.

Purpose

We sought to evaluate safety, feasibility, and clinical outcomes of right radial approach (RRA) compared to left radial approach (LRA) during PCI in “real-world” patients with ACS.

Methods

A total of 234,087 consecutive patients with ACS treated with PCI and stent implantation via radial approach between 2014 and 2017 in 151 invasive cardiology centers on the Polish territory. Data was based on the ORPKI Polish National Registry. Patients treated with RRA and LRA were compared using a propensity score analysis to avoid possible selection bias. The analysis was done in an “as-treated” manner.

Results

Procedure was conducted using RRA and LRA in 180,378 (77.1%) and 53,709 (22.9%) patients, respectively. After propensity score matching higher total amount of contrast (174.28 (±75.56) vs. 166.95 (±70.57) [ml]; P=0.001) and radiation doses were reported in PCI with left radial artery utilization (1210.21 (±1003.53) vs. 1054.07 (±1024.17) [mGy]; p=0.001). No differences were observed between RRA and LRA in rate of periprocedural adverse events such as myocardial infarction (0.08% vs. 0.08%; p=0.9) stroke (0.02% vs. 0.01%; p=0.1), no-reflow phenomenon (0.64%vs. 0.56%; p=0.1) and death (0.25% vs. 0.24%; p=0.7). A trend towards a lower rate of access-site-related bleeding during PCI was observed in RRA group (0.08% vs. 0.05%; p=0.066). Coronary artery perforation (0.21% vs. 0.16%; p=0.05) and cardiac arrest (0.56% vs 0.42%; p=0.01) were reported more often during PCI conducted with LRA.

Conclusions

Both radial approaches seems to be equally effective in the setting of PCI in ACS. However, utilization of left radial artery was associated with trend toward increased risk of access-site bleeding and higher rate of periprocedural complications as compared to RRA. Higher amount of contrast and radiation doses used in LRA procedures might be equivalent of generally lower experience with this access site.

Acknowledgement/Funding

None

Management and mortality in patients with non-ST-segment elevation vs. ST-segment elevation myocardial infarction. Data from the Malopolska Registry of Acute Coronary Syndromes

BACKGROUND

According to the presenting electrocardiogram, acute myocardial infarction (MI) can by categorised generally as non-ST-segment elevation MI (NSTEMI) and ST-segment elevation MI (STEMI).

AIM

To assess the impact of the different acute MI categories on in-hospital management and mortality in hospitals without on-site invasive facilities.

METHODS

We identified 380 NSTEMI and 334 STEMI patients treated in the Malopolska Registry of Acute Coronary Syndromes from February to March 2005 and from December 2005 to January 2006. Data concerning in-hospital management and mortality were assessed.

RESULTS

Patients with NSTEMI were older and were more likely to have prior angina, prior MI and prior heart failure symptoms than STEMI patients. The NSTEMI patients were less likely to be transferred for invasive treatment (23.9 vs. 41.9%, p <0.0001) and receive glycoprotein IIb/IIIa inhibitors during index hospital stay. The use of low-molecular-weight heparin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin II antagonists, nitrates and statins was more frequent in NSTEMI patients. Among patients treated non-invasively, in-hospital mortality was high, but was lower in NSTEMI than STEMI patients (12.1 vs. 22.7%, p <0.0001). Independent predictors of in-hospital death in this group were age, cardiogenic shock, chronic obstructive pulmonary disease, and STEMI.

CONCLUSIONS

Despite current recommendations, NSTEMI patients are still less likely to be transferred for invasive treatment than STEMI patients. Among patients treated non-invasively during index hospital stay, NSTEMI is associated with more favourable prognosis than STEMI, but the risk of in-hospital death is high. The hospital network should implement more frequently the strategy of early and urgent invasive treatment of NSTEMI patients.

[Late thrombosis after bare metal stent implantation in a patient with acute coronary syndrome]

We present a case of a 47-year-old man with ST-segment-elevation myocardial infarction (STEMI), successfully treated with bare metal stent implantation. After 20 months the patient was readmitted with another episode of STEMI due to in-stent thrombosis following voluntary withdrawal of anti-platelet therapy. The implications of late stent thrombosis after bare metal stent implantation are discussed. We compare this phenomenon with thrombosis after implantation of drug-eluting stents. Various aspects and potential causes of late stent thrombosis are reviewed, especially the issues pertaining the use of anti-platelet therapy and duration of this therapy.

Patients with non-ST-elevation myocardial infarction and without chest pain are treated less aggressively and experience higher in-hospital mortality

BACKGROUND

Lack of chest pain or atypical pain does not exclude acute coronary syndrome (ACS).

AIM

To assess demographic and clinical characteristic as well as treatment strategies in patients with atypical chest pain on admission in hospitals without on-site invasive facility (IF).

METHODS

Twenty-nine community hospitals participated in the Registry of Acute Coronary Syndromes. A total of 2382 patients with ACS were enrolled. Patients admitted to hospitals with suspected ACS were stratified according to their pain symptoms as either typical (TS) or atypical which also included lack of pain (ATS).

RESULTS

Of all patients with initial ACS diagnosis 152 (6.4%) presented without chest pain on admission. Patients from group ATS in comparison to group TS were more often women (49 vs. 39%; p=0.01), and less frequently had past medical history of coronary artery disease (54.3 vs. 72.5%; p <0.0001), myocardial infarction (15.2 vs. 32.1%; p <0.0001), arterial hypertension (65.6 vs. 74.5; p <0.0001) or renal insufficiency (1.3 vs. 5%; p=0.04). Invasive treatment was undertaken in 9.2% of patients from group ATS and in 14.6% from group TS (p=0.049). In-hospital mortality among all patients remaining in community hospitals for conservative treatment was similar in both groups (ATS vs. TS: 8.7 vs. 5.9%; p=NS). Among patients with typical and atypical symptoms the occurrence of ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) was similar. Patients with NSTEMI and UA with atypical symptoms were less likely transferred for invasive diagnostic, for NSTEMI 9.4 vs. 18.1% (p=0.03) and for UA 6.1 vs. 12.9% (p=0.04). In-hospital mortality was similar among typical and atypical groups in STEMI and UA patients. However, it was significantly higher among NSTEMI patients with atypical chest pain treated conservatively (3.6 vs. 0%; p=0.05).

CONCLUSIONS

There is a significant group of ACS patients without chest pain on admission who are usually women with less severe past medical history. This subset of patients is treated less aggressively in terms of antiplatelet therapy and invasive approach. It is patients with diagnosis of NSTEMI who due to being misdiagnosed due to their atypical chest pain have poorer outcome.

Angiographic and clinical outcome after percutaneous coronary interventions following combined fibrinolytic therapy in acute myocardial infarction

INTRODUCTION

Combined therapy with fibrinolytic agent and platelet GPIIb/IIIa inhibitor not followed by an interventional procedure does not improve prognosis in patients presenting with acute ST-segment elevation myocardial infarction (STEMI) when compared to fibrinolysis alone. On the other hand, in the past percutaneous coronary interventions (PCI) performed after fibrinolysis were associated with low angiographic efficacy, a high risk of bleeding and a high rate of early cardiovascular events.

AIM

Evaluation of angiographic and clinical outcomes in patients with STEMI treated with PCI following combined fibrinolytic therapy.

METHODS AND RESULTS

Complete angiographic and clinical data of 187 patients who underwent PCI immediately after combined fibrinolytic therapy were obtained from a survey of 669 consecutive patients with STEMI <12 hours, at age <75 years, without cardiogenic shock, who were transferred from regional hospitals to the catheterisation laboratory within 90 minutes and after the initiation of combined fibrinolytic therapy (alteplase 15 mg iv as a bolus followed by an infusion of 35 mg over 60 minutes; abciximab iv bolus of 0.25 mg/kg followed by a 12 h infusion of 0.125 microg/kg per minute; unfractionated heparin). At baseline angiographic examination revealed no flow (TIMI 0+1) in the infarct-related artery in 17.1% of patients, impaired flow (TIMI 2) in 17.1% and normal (TIMI 3) in 65.8% of cases. After immediate PCI, a significant improvement in epicardial perfusion (TIMI 2+3, 99.5%) and in microcirculation was achieved. This favourable effect was seen only in the group of patients with baseline TIMI 0+1 flow, whereas PCI in the group with baseline TIMI 3 flow did not cause any further improvement in microcirculatory perfusion. The rate of cardiovascular events within the first 30 days and 12 months after the procedures were similar in the studied subgroup of patients.

CONCLUSIONS

PCI performed after combined fibrinolytic therapy in STEMI patients is associated with high efficacy and improvement in indices of epicardial perfusion and microcirculation. These benefits are confined mainly to patients with primarily impaired flow in the infarction-related artery (TIMI 0+1). However, the clinical results of this strategy, particularly in patients undergoing PCI following successful combined fibrinolytic therapy, must still be proved in further randomised trials.

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.

Management of myocardial infarction with ST-segment elevation in district hospitals without catheterisation laboratory--Acute Coronary Syndromes Registry of Małopolska 2002-2003

INTRODUCTION

Early reperfusion therapy significantly reduces mortality and improves outcome in ST-elevation myocardial infarction (STEMI). Primary percutaneous intervention has been proven to be a better therapeutic option than fibrinolysis when it can be performed by an experienced team of interventional cardiologists, within 90 minutes from the first medical contact. Despite the publication of guidelines of the European and American Scientific Societies (ESC and ACC/AHA), treatment of patients with STEMI is far from the optimum. The registry is an effective and reliable method to estimate the quality of treatment and demographic and epidemiologic characteristics of the population of a given region.

AIM

To evaluate the therapeutic strategies of treatment of STEMI in district hospitals without a catheterisation laboratory in Małopolska.

METHODS

29 district hospitals from Cracow and Małopolska province participated in the Registry of Acute Coronary Syndromes in Małopolska. Finally, 2382 patients with an initial diagnosis of acute coronary syndrome were included. In 867 of them, STEMI was finally diagnosed.

RESULTS

In district hospitals, most patients with STEMI (63%) did not receive any reperfusion therapy (25% of them were >75 years old, in 20% chest pain lasted longer than 12 hours, in 7% cardiogenic shock was diagnosed and 12% had contraindications for thrombolysis or were at increased risk of haemorrhagic complications). Fifteen percent of all 867 patients were transferred to the interventional cardiology centre (63% for primary PCI, 20% for facilitated PCI and the remaining 17% for rescue PCI). Fibrinolysis was applied in 21% of all patients with STEMI. In-hospital mortality rate was 14.3% in patients treated with fibrinolysis as compared to 15.9% in those treated conservatively. Multivariate logistic regression revealed that younger age (OR 0.93; 95% CI 0.91-0.95; p <0.0001), lack of diabetes (OR 0.54; 95% CI 0.30-0.98; p=0.04) and higher systolic blood pressure (OR 0.93; 95% CI 1.00-1.02; p=0.006) were independent factors predicting the referral of patients with STEMI for PCI. GP IIb/IIIa inhibitors were used in 5% of all patients and in 30% of those referred for PCI.

CONCLUSIONS

Only one in every 7 patients with STEMI is qualified for PCI. Patients transferred to the centre with PCI facilities are younger, have no diabetes or hypotension. The use of GP IIb/IIIa inhibitors is limited. There is a need to establish local networks of hospitals with 24-hour catheterisation laboratory availability to increase frequency and efficacy of reperfusion therapy, especially in regions far from centres of interventional cardiology.

Effects of high-dose statin administered prior to coronary angioplasty on the incidence of cardiac events in patients with acute coronary syndrome

INTRODUCTION

Statins given after acute coronary syndrome without ST elevation (NSTE-ACS) reduce the incidence of major adverse cardiac events (MACE) in long-term follow-up.

AIM

To evaluate the effects of high-dose statin administered in patients with NSTE ACS and increased CRP level prior to percutaneous coronary intervention (PCI) on the incidence of MACE in long-term follow-up.

METHODS

The study involved 140 consecutive patients with NSTE ACS and increased CRP level at baseline. Patients from group A (n=54) did not receive statin before PCI, whereas subjects in group B (n=86) were given 80 mg of atorvastatin. Patients in both groups received typical cardiological therapy including aspirin, thienopyridine and low molecular weight heparin. After PCI all patients received 40 mg of atorvastatin. Incidence of MACE (death, myocardial infarction (MI), re-PCI) during long-term followup was evaluated in both groups.

RESULTS

Study groups did not differ with respect to demographic parameters and rate of ischaemic heart disease risk factors. Also, no differences occurred regarding CRP level (group A vs. B: hsCRP 10.8+/-1.8 mg/l vs. 8.2+/-2.8 mg/l; p=NS) and TIMI Risk Score (group A vs. B: 4.3+/-0.71 vs. 4.37+/-0.79; p=NS). During long-term follow-up the incidence of MI (9.25% vs. 1.2%, p=0.03), composite endpoint: death + MI (14.8% vs. 2.32%, p=0.013) and death + MI + re PCI (25.9% vs. 8.1%, p=0.006) was significantly higher in group A than group B.

CONCLUSIONS

Administration of high-dose statin in NSTE ACS patients before PCI was associated with significant reduction of MACE in long-term follow-up. This effect was observed despite the same therapy given after PCI.

Inferior wall myocardial infarction with or without right ventricular involvement--treatment and in-hospital course

INTRODUCTION

Right ventricular infarction (RVI) is most commonly associated with inferior wall infarction (20-50% of cases). Clinical presentation of RVI may vary.

AIM

Assessment of outcome and clinical course of myocardial infarction in patients with inferior wall myocardial infarction with or without RVI. Additionally, risk stratification was attempted in the above-mentioned groups of patients.

METHODS

The analysis involved 181 consecutive patients (pts) with inferior wall myocardial infarction hospitalised between 1 July 2000 and 1 July 2002.

RESULTS

Nineteen in-hospital deaths were noted in the study group (mortality 10.5%), reinfarction occurred in 6 (3.3%) pts, ischaemic stroke in 1 (0.6%) patient, and 2 (1.1%) pts had transient ischaemic attack. Cardiogenic shock occurred in 20 (11.0%) pts , ventricular fibrillation in 15 (8.3%) pts, and pulmonary oedema in 9 (4.9%) pts. In the subgroup of 161 pts without cardiogenic shock 8 (4.9%) pts died. Thrombolytic therapy was administered in 96 (53%) subjects. Isolated inferior wall myocardial infarction was diagnosed in 94 (51.9%) of 181 pts and RVI in 65 (35.9%) pts. Mortality rate in the RVI group was significantly higher than in inferior wall myocardial infarction without RVI and was 18.5% vs 2.12% (p=0.0003), respectively (excluding patients with cardiogenic shock: 11.1% vs 1.2%, respectively; p=0.016). In patients with RVI aged above 70 years, the mortality rate was significantly higher than in younger patients (32% vs 10%, p=0.002). In a subgroup with RVI treated with thrombolysis mortality was considerably higher in subjects aged >70 years compared to patients below 70 years (38.5% vs 7.7%, p=0.017).

CONCLUSIONS

RVI is associated with worse prognosis and increased number of in-hospital complications. Older patients aged >70 years have definitely poorer prognosis. Thrombolytic therapy in a subgroup of older patients with RVI remains ineffective.

In-Hospital Levels of Circulating MicroRNAs as Potential Predictors of Left Ventricular Remodeling Post-Myocardial Infarction

Background and Objectives: Biochemical and molecular regulation of both adaptive and pathological responses of heart tissue to ischemic injury is widely investigated. However, it is still not fully understood. Several biomarkers are tested as predictors of left ventricle (LV) remodeling after myocardial infarction (MI). The aim of this study was to assess the relationship between selected microRNAs (miRNAs) and LV function and morphology in patients after MI. Materials and Methods: Selected miRNAs related to heart failure were assessed in the acute phase of MI: miR-150-3p, miR-21-5p, miR-19b-3p, miR-155-5p, miR-22-5p. Echocardiography with 3D imaging was performed at baseline and after 6 months. Remodeling was defined as >20% increase in LV end-diastolic volume, whereas reverse remodeling was defined as >10% reduction in LV end-systolic volume. Results: Eighty patients entered the registry. Remodeling occurred in 26% and reverse remodeling was reported in 51% of patients. In the presented study, none of the analyzed miRNAs were found to be a significant LV remodeling predictor. The observed correlations between miRNAs and other circulating biomarkers of myocardial remodeling were relatively weak. Conclusions: Our analysis does not demonstrate an association between the analyzed miRNAs and LV remodeling in patients with MI.

Outcomes of COVID-19 patients with STEMI undergoing primary PCI

Introduction and aim

Coronavirus disease (COVID-19) has substantial impact on acute myocardial infarction (AMI) clinical course and outcome.

In Poland during early phase of COVID-19 pandemic a network of dedicated hospitals was set to treat SARS-Cov2 positive patients. There is scarce data on STEMI patients outcome treated in this setting.

Our aim was to compare outcomes of STEMI patients treated with primary PCI in hospitals dedicated to treat COVID-19 and referral high volume haemodynamic centres.

Methods

Study was a retrospective analysis of 115 consecutive COVID-19 patients with STEMI, treated with primary PCI, admitted to 4 high volume centres (2 referral hospitals and 2 COVID dedicated sites) in southern Poland between May 2020 and November 2021. Data was obtained from patients' electronic medical records.

Results

Detailed characteristics are presented in Table 1 and 2. In general in all hospitals, patients were similar in terms of age (median 69 y.o., IQR: 60–73), with similar profile of comorbidities. All patients used acetylsalicylic acid and unfractioned heparin.

In referral centres, as compared with COVID-19 dedicated sites, there was a higher use of mechanical thrombectomy (p&lt;0.001) and adenosine (p&lt;0.001). Overall mortality rate was higher in COVID-19 centres (50% vs 25%, p=0.008). Detailed results are presented in Table 3.

Conclusions

There is a significantly higher mortality in COVID patients who develop STEMI than in patients with STEMI who were tested positive on admission.

Patients in COVID-19 hospitals had higher levels of CRP and NT-proBNP at baseline.

There are substantial differences in treatment of patients in referral centres and COVID dedicated hospitals.

Funding Acknowledgement

Type of funding sources: None.

Local hospital networks for STEMI treatment for a population of half a million inhabitants increase the use of invasive treatment of acute coronary syndromes to the European recommended level. The Małopolska Registry of Acute Coronary Syndromes 2005-2006

BACKGROUND

According to the European Society of Cardiology (ESC) consensus, over 75% of patients with ST-elevation myocardial infarction (STEMI) should receive reperfusion therapy. An early invasive strategy is also advocated for high-risk non-ST elevation acute coronary syndromes (NSTE ACS). Until 2005, a single high-volume percutaneous coronary intervention (PCI) centre provided 24-hour service for the population of 3.2 million inhabitants in the Krakow Hospital Network Region. In August 2005 and December 2005 two additional round-the-clock duty PCI centres were launched in remote municipal hospitals (Tarnow and Nowy Sacz).

METHODS

29 non-PCI centres participated in the Registry of ACS in February-March 2005 (Period 1) and in December 2005-January 2006 (Period 2), so while Period 2 was conducted, three PCI centres provided 24-hour service for the Małopolska Region.

RESULTS

A total of 1404 patients with ACS were enrolled - 695 during Period 1 and 709 in Period 2. In comparison to Period 1, a non-significant trend towards more frequent mechanical reperfusion of STEMI patients with chest pain onset <12 hours was observed in Period 2 (54 vs. 60%; p=NS). A steep and significant rise was observed particularly among STEMI patients treated in non-PCI centres outside of the Krakow City Network (51 vs. 78%; p=0.001). In the newly established Tarnow and Nowy Sacz (eastern Małopolska) PCI networks the reperfusion rates for STEMI patients with chest pain <12 hours were 78% and 88%, respectively, in comparison to 55% in western Małopolska (p=0.001). The transfer rate for invasive treatment of NSTE ACS has increased from 13.8% in Period 1 to 19% in Period 2 (p=0.031) in the entire region. The in-hospital mortality for patients receiving conservative treatment in community hospitals has decreased among NSTE ACS patients (6.8 vs. 3.9%; p=0.045) and remained unchanged in STEMI (21.3 vs. 19%; p=NS).

CONCLUSIONS

Opening of new PCI centres, based on population magnitude and structure, improves local adherence to the guideline-recommended invasive approach in high-risk ACS patients. The Małopolska Programme model showed that one high-volume 24-hour duty PCI centre with a network of cooperating non-PCI centres for a population of 0.5 million might be sufficient to provide invasive treatment according to the ESC guidelines for eligible patients.

[Can cardiac surgery be deferred when acute myocardial infarction is complicated by interventricular septum rupture? -- two case reports]

Although in patients with interventricular septum rupture complicating acute myocardial infarction urgent cardiac surgery is suggested as a method of choice by current ESC and ACC/AHA guidelines, mortality is high. In some patients, intra-aortic counterpulsation and optimisation of medical therapy may stabilise patients condition and increased the safety of elective cardiac surgery which can be performed a few weeks later. In this report we describe two patients with this condition who were successfully treated using a conservative approach and subsequent elective surgery.

[Primary percutaneous coronary interventions in acute myocardial infraction with ST-segment elevation. Experience in a heart catheterization unit without surgical backup]

BACKGROUND

Primary percutaneous coronary intervention (PCI) in patients (pts) with ST-segment elevation myocardial infarction is regarded as treatment superior to thrombolysis. Coronary stents and GP IIb/IIIa receptor inhibitors improved safety and clinical outcome of interventional procedures. Safety of primary PCI procedure in catheterisation laboratories which do not have on-site surgical backup is still under evaluation.

METHODS

In a cohort of 249 consecutive patients we analysed short and long-term clinical outcome of primary PCI performed in catheterisation laboratory which is located several kilometres from a cardiac surgery department, with an effective transfer time < 30 minutes.

RESULTS

Coronary stents were implanted in 43% pts. GP IIb/IIIa receptor inhibitors were used in 54.2% pts. Cardiogenic shock on admission was diagnosed in 7.2% pts. Intra-aortic balloon counterpulsation usage was necessary in 6.4% pts. In-hospital mortality was 6% (3.5% in non-shock pts). In two pts (0.8%) during hospitalization repeat PCI was performed--in one case due to reinfarction. No urgent cardiosurgery intervention was necessary. Mortality and myocardial infarction rate after hospital discharge during 6 month follow up was 2.4% and 2.8% respectively. In 4% pts repeated PCI was performed due to restensosis. Cumulative event free survival was 84%.

CONCLUSION

Primary PCI procedure for acute myocardial infarction seems to be feasible and safe in catheterisation laboratories without on-site surgical backup provided usage of stents, GPIIb/IIIa receptor inhibitors and intraaortic balloon counterpulsation and cooperation with a nearby cardiosurgery department with short transfer time.

Relationship between chronic obstructive pulmonary disease and in-hospital management and outcomes in patients with acute myocardial infarction

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with unfavourable short- and long-term outcome in patients with coronary artery disease undergoing revascularisation procedures.

AIM

To assess the associations of COPD with in-hospital management and mortality in patients with acute myocardial infarction (MI) admitted to hospitals without on-site invasive facilities.

METHODS

We identified 81 (11.3%) patients with COPD and 633 (88.7%) without COPD treated in the Krakow Registry of Acute Coronary Syndromes from February 2005 to March 2005 and from December 2005 to January 2006. Data concerning in-hospital management and mortality were assessed.

RESULTS

Patients with COPD were older and were more likely to have prior angina, prior heart failure symptoms, prior stroke, and lower left ventricular ejection fraction. Patients with COPD diagnosis were less likely to be transferred for invasive treatment [COPD (-) vs. COPD (+), 12.3 vs. 34.9%; p < 0.0001] and to receive aspirin and clopidogrel during index hospital stay. In-hospital mortality was higher in patients with COPD diagnosis [COPD (-) vs. COPD (+), 58 of 412 (14.1%) vs. 21 of 71 (29.6%); p = 0.002]. COPD was an independent predictor of in-hospital death in multivariate Cox regression analysis.

CONCLUSIONS

Coexistence of COPD with acute MI may be associated with less frequent transfer for invasive treatment, less aggressive pharmacotherapy, and higher in-hospital mortality in patients admitted to community hospitals without on-site invasive facilities. These differences may be partially driven by a higher risk profile of COPD patients.