STEMI care 2021: Addressing the knowledge gaps

Association between serum albumin-to-creatinine ratio and clinical outcomes among patients with ST-elevation myocardial infarction after percutaneous coronary intervention: a secondary analysis based on Dryad databases

Background

The prognostic value of the serum albumin-to-creatinine ratio (sACR) in patients with ST-elevation myocardial infarction (STEMI) remains unclear. This study aims to investigate the impact of the sACR on incident major adverse cardiovascular events (MACEs) among revascularized patients with STEMI at long-term follow-up.

Methods

A total of 461 patients with STEMI who underwent successful primary percutaneous coronary intervention (PCI) were enrolled to explore the association between the sACR and MACE during a 30-month follow-up. The Cox regression proportional hazard model was used to evaluate the prognostic value of the sACR. Heterogeneity among specific groups was investigated by subgroup analysis.

Results

A total of 118 patients developed MACE during the follow-up. A negative association between the sACR and MACE was found after adjusting for other MACE-related risk factors. In subgroup analyses, the sACR was inversely associated with MACE in patients aged ≥ 60 years [hazard ratio (HR), 0.478; 95% confidence interval (CI), 0.292-0.784], male (HR, 0.528; 95% CI, 0.327-0.851), with hypertension history (HR, 0.470; 95% CI, 0.271-0.816), and with anterior wall myocardial infarction (HR, 0.418; 95% CI, 0.239-0.730). Meanwhile, the negative association between the sACR and MACE remained significant in a sensitivity analysis that excluded patients with low serum albumin levels (HR, 0.553; 95% CI, 0.356-0.860).

Conclusions

Patients with STEMI who underwent successful PCI with a low sACR had a higher risk of developing MACE, indicating that the sACR could be used to identify patients with STEMI who are at high risk of developing MACE.

Clinical and epidemiological profile of ST-segment elevation myocardial infarction patients in a megacity of west of Iran

Background and Aims

Low- and middle-income nations account for at least three-quarters of cardiovascular disease deaths worldwide. This study aimed to obtain real knowledge about ST segment elevation myocardial infarction (STEMI) patients and provide the context for developing a principles for care quality improvement.

Method

This cross-sectional study was conducted from July 2018 through December 2019. The study sample consisted of1169 eligible patients based on inclusion criteria. The data were collected using the standard EROP and three specialized, trained questionnaires. The collected data were checked by the quality control officer and analyzed using Stata Version 14.

Results

Patient baseline characteristics showed that body mass index, low-density lipoprotein, high-density lipoprotein, total cholesterol, and triglyceride levels were higher in women. Also, females recorded a considerable history of diabetes mellitus, hypertension, and hypercholesterolemia compared to men. The results also showed that most men were smokers (46.80%). Aspirin (94.27%), statins (91.48%), and clopidogrel (90.68%) were the common medications used at hospital discharge for patients.

Conclusion

The present study suggests that identifying and managing modifiable risk factors can improve cardiovascular disease outcomes. Also, considering the early identification of STEMI patients with new therapies can effectively decrease the rate of cardiovascular disease and its attributed health outcomes.

Frequency and outcomes of STEMI patients presenting between 12 and 24 h after symptom onset: Late-presenting STEMI

OBJECTIVES

To assess the characteristics and prognosis of ST-elevation myocardial infarction (STEMI) patients, presenting between 12 and 24 h after symptom onset, in contemporary regional STEMI systems of care in the United States.

BACKGROUND

Previous observational studies have been inconsistent regarding the benefit of primary percutaneous coronary intervention (PCI) compared with conservative management for late-presenting STEMI patients and the majority of randomized trials are from the fibrinolytic era.

METHODS

Using a two-center registry-based cohort from March 2003 to December 2020, we evaluated the frequency, clinical characteristics, and outcomes of STEMI patients, stratified by symptom onset to balloon time: <3, 3-6, 6-12, and 12-24 h (late presenters).

RESULTS

Among 5427 STEMI patients with available symptom onset time, 6.2% were late presenters, which increased to 11% during the early phase of the Covid-19 pandemic. As symptom onset to balloon time increased, patients were more likely to be older, female, and have a history of hypertension and diabetes mellitus. Late presenters with an identifiable culprit lesion were less likely to be revascularized with PCI (96%, 96%, 95%, and 92%; p for trend = 0.004) and had a longer median door-to-balloon time (82, 109, 107, and 117 min; p for trend < 0.001). In-hospital and 1-year death risks were comparable between late and earlier presenters.

CONCLUSION

Despite the unfavorable risk profile and longer door-to-balloon time, clinical outcomes of late presenters were similar to those presenting within 12 h of symptom onset.

GP IIb/IIIa Receptor Inhibitors in Mechanically Ventilated Patients with Cardiogenic Shock due to Myocardial Infarction in the Era of Potent P2Y12 Receptor Antagonists

Objective: To investigate the association between GP IIb/IIIa receptor inhibitors (GPI) and mortality and bleeding in patients with cardiogenic shock (CS) due to myocardial infarction (MI) who were mechanically ventilated on admission. Methods: We retrospectively divided 153 patients into two groups (with or without GPI). Thirty-day and one-year all-cause mortality and bleeding were studied. Results: The observed 30-day and one-year all-cause mortality were similar in both groups [54 (69.2%) with GPI vs. 62 (82.7%) without GPI; p = 0.06, and 60 (76.9%) with GPI vs. 64 (85.3%) without GPI; p = 0.22, respectively]. Patients with GPI suffered fewer unsuccessful PCI (TIMI 0/1 was 10% in the GPI group vs. 57% in the group without GPI), experienced more improvements in TIMI ≥ 1 flow [68 (87.2%) in the GPI group vs. 38 (50.7%) without GPI; p < 0.0001], and they achieved better cerebral performance category (CPC) scores (1.61 ± 0.99 with GPI vs. 2.76 ± 1.64 without GPI; p = 0.005). The bleeding rate was similar in patients with and without GPI [33 (42.3%) vs. 31 (41.3%): p = 1.00], in patients with P2Y12 receptor antagonists (P2Y12) [18 (46.1%) with GPI vs. 21 (46.7%) without GPI; p = 1.00], and in patients with potent P2Y12 [8 (30.8%) with GPI vs. 9 (37.5%) without GPI; p = 0.77]. Conclusions: Due to the study design (limited sample size, retrospective inclusion with high risk of selection bias), our analysis does not allow us to draw conclusions about the effectiveness of GPI in this context. Despite all these limitations, GPI were associated with improved TIMI flow after PCI in our multivariable model without increasing bleeding rates. In addition, better CPC scores were observed, but no association between GPI and outcome was found. Our analysis suggests that selective use of GPI may be beneficial in mechanically ventilated patients with MI in CS without additional bleeding risk, even in the era of potent P2Y12.

Association between Platelet to Neutrophil Ratio (PNR) and Clinical Outcomes in STEMI Patients after Successful pPCI: A Secondary Analysis Based on a Cohort Study

Purpose

This study was aimed at investigating whether the platelet-to-neutrophil ratio (PNR) is independently related to the prognosis of patients with ST-elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (pPCI).

Methods

This was a secondary analysis of data retrieved from the DATADRYAD database, which was a prospective cohort study. A total of 464 STEMI patients who underwent successful pPCI were recruited between January 2010 and October 2014. The target-independent variable, PNR, was measured at the baseline. The dependent variable in the current study was the occurrence of major adverse cardiovascular events (MACEs) during the 30-month follow-up.

Results

Two patients were excluded from the final analysis because their platelet counts were unavailable. The average age of the 462 participants was 63 ± 11.92 years, and approximately 76.6% were male. After adjusting for age, sex, anterior wall myocardial infarction (MI), history of MI, apelin-12, apelin-12 change rate, left ventricular end-diastolic diameter, peak cardiac troponin I, pathological Q wave, Killip classification grade, fasting blood glucose, albumin, GENSINI score, and estimated glomerular filtration rate, a nonlinear relationship was found between the PNR and MACEs in the included cohort. The threshold value of the PNR for MACEs was 23.1. Over this cutoff value, the incidence rate of MACEs increased by 43% per 10-unit change in PNR (95% CI: 1.16–1.75, p = 0.0006).

Conclusion

There was a threshold relationship between PNR and MACEs in patients with STEMI who underwent successful pPCI. The incidence of MACEs was positively associated with the PNR when the PNR exceeded 23.1.

[Empagliflozin alleviates cardiac microvascular ischemia/reperfusion injury by maintaining myocardial mitochondrial homeostasis]

OBJECTIVE

To evaluate the effect of empagliflozin (EMPA) in mitigating microvascular and endothelial damage induced by myocardial ischemia-reperfusion (I/R) injury.

METHODS

Fifteen male C57BL/6J mice were randomized into shamoperated group, I/R group and I/R+EMPA group, and in the latter two groups, myocardial I/R injury was induced by ligating the left anterior descending coronary artery followed by reperfusion for 2 h. EMPA treatment was administered at the daily dose of 10 mg/kg for 7 days. After the treatment, the changes in myocardial microvascular structure of the mice were observed under electron microscopy. In the cell experiment, cultured human coronary artery endothelial cells (HCAECs) were treated with 10 μmol/L EMPA before exposure to hypoxia for 45 min followed normoxic culture for 2 h. Western blotting and immunofluorescence assay were performed to observe fibrin accumulation and endothelial cell protein expressions in the myocardial tissues of the mice and in HCAECs, and RT-qPCR was used to detect the expressions of pro-inflammatory cytokines.

RESULTS

Electron microscopy revealed significant myocardial microvascular wall thickening and lumen narrowing in mice with myocardial I/R injury. Fibrin accumulation and ICAM1 expression in the microvessels were more pronounced in I/R group than in the sham-operated and I/R + EMPA groups (P < 0.05). EMPA treatment obviously alleviated microvascular occlusion and microthrombus formation induced by I/R injury. At the cellular level, the protein levels of p-eNOS, Fak, and Src kinases in hypoxic exposure group were significantly lower than those in the control and EMPA treatment groups (P < 0.05). Hypoxic exposure significantly reduced mitochondrial DNA replication and transcription and lowered the expression levels of Cox-Ⅰ and Cox-Ⅱ in HCAECs, and these changes were obviously improved by EMPA treatment (P < 0.05).

CONCLUSION

EMPA can alleviate myocardial I/R injury by maintaining mitochondrial homeostasis to protect the microvascular system.