[Patency, perfusion and prognosis in acute myocardial infarct]

Angiographic predictors of outcome in myocardial infarction patients presenting with cardiogenic shock: a CULPRIT-SHOCK angiographic substudy

AIMS

The aim of this study was to determine the prognostic impact of pre- and post-PCI TIMI flow grade and TIMI myocardial perfusion grade (TMPG) in a well-defined group of patients with cardiogenic shock due to acute myocardial infarction.

METHODS AND RESULTS

Patients with infarct-related cardiogenic shock randomised into the CULPRIT-SHOCK trial were included in the angiographic predictor analysis whenever their TIMI flow grade or TMPG was available in the core lab database (96.9% of cases). A multivariable logistic regression analysis, adjusted on non-angiographic covariates, was performed to investigate whether TIMI flow grade or TMPG was independently associated with all-cause mortality or renal replacement therapy up to one year. Pre-PCI TIMI flow grade and TMPG did not impact on mortality. When analysed in separate multivariable models, post-PCI TIMI 3 flow and TMPG grade 3 were both significantly associated with reduced risk of 30-day mortality: aOR 0.61 (95% CI: 0.38-0.97, p=0.037) and 0.46 (95% CI: 0.29-0.72, p<0.001), respectively. When considered in the same multivariable model, only TMPG was significantly associated with 30-day mortality (aOR 0.38 [0.20-0.71], p=0.002), the 30-day composite of all-cause mortality and renal replacement therapy (aOR 0.34 [0.18-0.66], p=0.001) and mortality at one-year follow-up (aOR 0.46 [0.24-0.88], p=0.02).

CONCLUSIONS

Post-PCI TIMI flow grade and TMPG are associated with mortality after PCI. TMPG is a better discriminator, supporting microcirculation rather than epicardial reperfusion for prognosis estimation.

Factors Associated With Normal Flow (TIMI 3) After Thrombolysis With Streptokinase in ST-Elevation Myocardial Infarction: A Prospective Observational Study

Background

Thrombolysis with streptokinase (STK) is the most widely used reperfusion strategy for ST elevation myocardial infarction (STEMI) in India. Achieving full reperfusion as evidenced by thrombolysis in myocardial infarction (TIMI) flow grade 3 in coronary angiography (CAG) is associated with better outcomes. Recent studies show that hematological indices like neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) estimated before thrombolysis could predict TIMI 3 flow. We studied clinical, electrocardiographic and hematological parameters associated with TIMI 3 flow after thrombolysis with STK.

Methods

We prospectively studied 201 adult patients with STEMI presenting within 12 hours of onset of chest pain. Before thrombolysis, blood sample was collected for estimating NLR and MPV. Timing of CAG after thrombolysis was decided by consultant cardiologists. Patients were followed up for one month after discharge.

Results

Of 201 patients, 162 (81%) had relief of chest pain and 131 (65%) had ST segment recovery of ≥50% at 90 minutes after thrombolysis. CAG was performed within median (IQR) of four (3-5) days after thrombolysis. TIMI 3 flow was observed in 112 (56%) patients. NLR and MPV had no significant association with TIMI 3 flow. In multivariable analysis, ST-segment recovery of ≥50% at 90 minutes was associated with TIMI 3 flow (adjusted OR 3.47, 95% CI: 1.84-6.53, P= <0.001). Of 198 patients followed up for one month after discharge, 13 (6.5%) died.

Conclusions

In patients with STEMI, ST-segment recovery of ≥50% at 90 minutes after thrombolysis with STK predicted TIMI 3 flow independently. NLR and MPV values were not predictive of TIMI 3 flow.

[Registries of myocardial infarction in Germany. Consequences for drug therapy of patients with acute ST elevation myocardial infarction]

Current national and international guidelines for patients with ST elevation myocardial infarction (STEMI) are mainly based on the results of randomised clinical trials. However, it is well perceived that patients in such trials often represent a low risk population. Therefore the results of randomised clinical trials are not necessarily applicable to patients in clinical practice. This gap can be filled by prospective registries. Since the early nineties a number of prospective large registries in patients with STEMI have been performed in Germany. It could be shown that guideline adherent acute therapies and secondary prevention therapies were associated with an improvement in inhospital and mid-term outcomes. The benefit of guideline adherent therapy observed was especially high in patients with higher baseline risk. Registries are not able to replace randomised clinical trials, but can help to test if the results of these trials are comprehensible in clinical practice. Therefore prospective STEMI registries are an important part of clinical research to optimize therapies and improve outcome in patients with STEMI.

Surgery for myocardial salvage in acute myocardial infarction and acute coronary syndromes

This article addresses the pathophysiology, the treatment options, and their rationale in the setting of life-threatening acute myocardial infarction and acute on chronic ischemia. Although biases may exist between cardiologists and surgeons, with this review, we hope to provide the reader with information that will shed light on the options that best suit the individual patient in a given set of circumstances.

ST resolution in a single electrocardiographic lead: a simple and accurate predictor of cardiac mortality in patients with fibrinolytic therapy for acute ST-elevation myocardial infarction

BACKGROUND

The extent of ST-segment resolution in the 12-lead electrocardiograph (ECG) obtained early after reperfusion therapy in patients with ST-elevation myocardial infarction (MI) has been shown to predict short- and long-term mortalities. To improve the ease of this method in clinical practice, we sought to evaluate the optimal cutoffs and the prognostic value of ST resolution (STR) measured in a single ECG lead.

METHODS

In conjunction with the Intravenous nPA for the Treatment of Infarcting Myocardium Early (InTIME)-2 study, in which patients with an ST-elevation MI of <6 hours' duration were treated with alteplase or lanoteplase, 12-lead ECGs were obtained at baseline and 90 minutes after the start of fibrinolytic therapy in 3030 patients.

RESULTS

There was a close correlation between the extent of the sum STR and single-lead ST-elevation resolution ( r = 0.94). The optimal cutoffs for definition of single-lead complete, partial, and no-STR groups were 70% and 50% for anterior infarcts and 70% and 20% for inferior infarcts. The cardiac 30-day mortality rates for the 2 sets of risk groups by sum or single-lead STR were as follows: no resolution, 9.5% vs 10.3%; partial resolution, 5.0% vs 3.6%; complete resolution, 2.0% vs 1.2%. The predictive power was significantly better for single-lead STR.

CONCLUSIONS

ST resolution obtained in a single lead is an easy and accurate prognosticator of cardiac 30-day mortality in patients with ST-elevation MI. It is therefore useful for early identification of low- and high-risk subgroups after fibrinolysis and as a surrogate end point in clinical trials.

Evaluation of the percusurge guardwire plus temporary occlusion and aspiration system during primary angioplasty in acute myocardial infarction

Thirty patients with acute myocardial infarction (AMI) underwent primary angioplasty under distal protection of PercuSurge GuardWire Plus Temporary Occlusion and Aspiration System. Before angioplasty, protection of the distal circulation was achieved with the system, followed by balloon angioplasty and/or stenting and debris aspiration. Technical device success was 100%. Distal occlusion was well tolerated in all patients. Mean total distal occlusion time was 7.3 +/- 5.4 min. Macroscopically visible debris was aspirated from 29 cases (96.7%). Postprocedural Thrombolysis in Myocardial Infarction flow grade 3 was achieved in all cases (100%, vs. 16.7% at baseline). Myocardial blush flow grade 3 was achieved in 26 cases (86.7%). Regression of ST segment elevation >/= 50% was shown in 23 cases (76.7%). No patient developed angiographic evidence of no-reflow or distal embolization. Both angiographic and procedural success were 100%. The system is feasible, safe, and effective for distal protection against embolism during primary angioplasty in AMI.

Resolution of ST-segment elevation in acute myocardial infarction--early prognostic significance after thrombolytic therapy. Results from the COBALT trial

In acute myocardial infarction, early identification of patients at a high mortality risk is important for planning further therapeutic strategies. Previous studies have demonstrated that the extent of early resolution of ST-segment elevation may represent a simple, quick and noninvasive assessment to identify high risk groups of patients. In a subgroup of the COBALT Study population (Continuous Infusion vs Double Bolus Administration of Alteplase), ST-segment elevation was measured before and 90 to 120 minutes after treatment with alteplase. The subgroup of n = 1,760 patients was not different from the total COBALT population of n = 7169 patients regarding most clinical parameters except Killip Class before treatment. However, the overall 30-day mortality differed significantly between the main study and the substudy (7.76% vs 3.52%; p < 0.001). Three groups of ST-segment resolution were defined: 1. complete resolution (resolution > or = 70%; 762 patients), 2. partial resolution (< 70% and > 30%; 491 patients), 3. no resolution (< 30%; 507 patients). Mortality rate at 30 days for complete, partial and no resolution of ST-segment elevation was 1.31%, 4.28% and 6.11%, respectively (p < 0.001). While this significant correlation between the extent of ST-segment resolution and mortality could be observed for inferior acute myocardial infarction, it could not be found in patients with anterior acute myocardial infarction. This in part may be due to a selection bias that leads to an extremely divergent mortality rate of anterior acute myocardial infarction in the main study and the substudy (10.1% vs 3.94%; p < 0.0001). Despite this limitation, resolution of ST-segment elevation in acute myocardial infarction after thrombolytic therapy allows to identify patients at a high mortality risk and may help to select patients for early invasive procedures such as PTCA. Patients with complete ST-segment resolution showed a particularly low mortality rate, irrespective of the alteplase regimen used (front-loaded alteplase vs double bolus alteplase).