Update on primary PCI for patients with STEMI

FDY-5301: An Innovative Approach to The Treatment of Revascularization Coronary Injury

After experiencing an acute ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) is a preferred method of restoring blood flow to the heart. While this reperfusion has long-term benefits, it can result in reperfusion injury in the short term, which involves the formation of reactive oxygen species (ROS) and neutrophil recruitment. FDY-5301 is a sodium iodide-based drug that acts as a catalyst in the conversion of hydrogen peroxide to water and oxygen. FDY-5301 is designed to be administered as an intravenous bolus following a STEMI, before reperfusion with PCI, to reduce the damage associated with reperfusion injury. Clinical trials have shown FDY-5301 administration to be safe, feasible, and fast-acting in its ability to increase plasma iodide concentration, and the results are favorable in demonstrating potential efficacy. FDY-5301 shows potential in its use to reduce the effects of reperfusion injury, and ongoing Phase 3 trials will allow for continued evaluation of its performance.

Influence of time-to-diagnosis on time-to-percutaneous coronary intervention for emergency department ST-elevation myocardial infarction patients: Time-to-electrocardiogram matters

Objectives

Earlier electrocardiogram (ECG) acquisition for ST-elevation myocardial infarction (STEMI) is associated with earlier percutaneous coronary intervention (PCI) and better patient outcomes. However, the exact relationship between timely ECG and timely PCI is unclear.

Methods

We quantified the influence of door-to-ECG (D2E) time on ECG-to-PCI balloon (E2B) intervention in this three-year retrospective cohort study, including patients from 10 geographically diverse emergency departments (EDs) co-located with a PCI center. The study included 576 STEMI patients excluding those with a screening ECG before ED arrival or non-diagnostic initial ED ECG. We used a linear mixed-effects model to evaluate D2E's influence on E2B with piecewise linear terms for D2E times associated with time intervals designated as ED intake (0-10 min), triage (11-30 min), and main ED (>30 min). We adjusted for demographic and visit characteristics, past medical history, and included ED location as a random effect.

Results

The median E2B interval was longer (76 vs 68 min, p < 0.001) in patients with D2E >10 min than in those with timely D2E. The proportion of patients identified at the intake, triage, and main ED intervals was 65.8%, 24.9%, and 9.7%, respectively. The D2E and E2B association was statistically significant in the triage phase, where a 1-minute change in D2E was associated with a 1.24-minute change in E2B (95% confidence interval [CI]: 0.44-2.05, p = 0.003).

Conclusion

Reducing D2E is associated with a shorter E2B. Targeting D2E reduction in patients currently diagnosed during triage (11-30 min) may be the greatest opportunity to improve D2B and could enable 24.9% more ED STEMI patients to achieve timely D2E.

Sociodemographic determinants of gender disparity in primary percutaneous coronary intervention in Pakistan

OBJECTIVES

This study aims to contribute to the body of literature on gender disparities after acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PPCI).

METHODS

We identified all adult patients who had AMI between January 2017, and December 2022 and were in follow-up at our institute. We collected data on PPCI, revascularization strategy, sociodemographic characteristics, and in-hospital complications in the years following the procedure.

RESULTS

A total of 5,872 patients who underwent PCI for AMI were included in the study, out of which 2,058 (35%) were women and 3,814 (65%) were men. Regarding the timing of PCI, female patients had a significantly longer median door-to-balloon time compared to male patients (136 minutes vs 108 minutes, P-value = 0.006). Female patients had a significantly higher rate of in-hospital mortality compared to male patients (5.5% vs 1.2%, P-value = 0.011). Multivariate logistic regression analysis showed that female gender, older age, and lower household income were independent predictors of longer door-to-balloon time.

CONCLUSION

This study highlights gender disparities in PPCI in Pakistan, with female patients facing longer door-to-balloon times and higher in-hospital mortality rates. The findings suggest the need for targeted interventions to improve the access and quality of care for female patients with AMI.

Ticagrelor vs. clopidogrel for coronary microvascular dysfunction in patients with STEMI: a meta-analysis of randomized controlled trials

Purpose

Approximately half of ST-segment elevation myocardial infarction (STEMI) patients who undergo revascularization present with coronary microvascular dysfunction. Dual antiplatelet therapy, consisting of aspirin and a P2Y12 inhibitor (e.g., clopidogrel or ticagrelor), is recommended to reduce rates of cardiovascular events after STEMI. The present study performed a pooled analysis of randomized controlled trials (RCTs) to compare effects of ticagrelor and clopidogrel on coronary microcirculation dysfunction in STEMI patients who underwent the primary percutaneous coronary intervention.

Methods

The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for eligible RCTs up to September 2022, with no language restriction. Coronary microcirculation indicators included the corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC), myocardial blush grade (MBG), TIMI myocardial perfusion grade (TMPG), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR).

Results

Seven RCTs that included a total of 957 patients (476 who were treated with ticagrelor and 481 who were treated with clopidogrel) were included. Compared with clopidogrel, ticagrelor better accelerated microcirculation blood flow [cTFC = -2.40, 95% confidence interval (CI): -3.38 to -1.41, p < 0.001] and improved myocardial perfusion [MBG = 3, odds ratio (OR) = 1.99, 95% CI: 1.35 to 2.93, p < 0.001; MBG ≥ 2, OR = 2.57, 95% CI: 1.61 to 4.12, p < 0.001].

Conclusions

Ticagrelor has more benefits for coronary microcirculation than clopidogrel in STEMI patients who undergo the primary percutaneous coronary intervention. However, recommendations for which P2Y12 receptor inhibitor should be used in STEMI patients should be provided according to results of studies that investigate clinical outcomes.

Long-term outcomes of delayed percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction: A propensity score-matched retrospective study

The best time window of percutaneous coronary intervention (PCI) is within 12 hours for ST-segment elevation myocardial infarction (STEMI). However, there is limited evidence about the proper time of PCI for delayed STEMI patients.From June 2014 to June 2015, a total of 268 patients receiving PCI with second-generation drug-eluting stent in a Chinese hospital after 3 days of STEMI onset were enrolled in this retrospective study, who were divided into the early group (3-14 days) and the late group (>14 days). A propensity score match was conducted to reduce the baseline difference. The primary endpoint of all-cause death and secondary endpoints of major adverse cardiac and cerebrovascular event (myocardial infarction [MI], stroke, emergent revascularization, and rehospitalization due to heart failure) were compared using survival analysis.At last, 182 cases were matched after propensity score match, with no statistical difference in baseline characteristics and PCI data. Kaplan-Meier survival curve demonstrated no difference in all-cause death of the 2 groups (P = .512). However, the early group presented a higher incidence of MI than the late group (P = .036). The multivariate Cox regression analysis also demonstrated that the early PCI was an independent risk factor for MI compared with late PCI (hazard ratio = 3.83, 95%CI [1.91-8.82], P = .001). There was no statistical difference in other major adverse cardiac and cerebrovascular event, including stroke, emergent revascularization, and rehospitalization due to heart failure.Using the 2nd drug-eluting stent, early PCI (3-14 days) and late PCI (>14 days) have comparable efficacy and outcomes. However, patients receiving early PCI are subjected to a relatively higher risk of recurrent MI.

Improved Cardiac Function and Attenuated Inflammatory Response by Additional Administration of Tirofiban during PCI for ST-Segment Elevation Myocardial Infarction Patients

ST-segment elevation myocardial infarction (STEMI) is one of the acute coronary syndromes, and it is the main cause of cardiac death worldwide. The purpose of this study was to investigate whether tirofiban improves cardiac function and attenuates inflammatory response in STEMI patients undergoing percutaneous coronary intervention (PCI). From May 2016 to May 2019, a total of 124 patients who admitted into our hospital due to STEMI fulfilled inclusion and exclusion criteria and were randomly assigned to PCI + tirofiban and PCI groups, 62 cases per groups. Intravenous administration of 10 μg kg-1 min-1 tirofiban was performed 30 min prior to PCI. During PCI, tirofiban infusion through a micropump with 0.15 μg kg-1 min-1 lasted for 48 h. It was found that the PCI + tirofiban group was significantly different from the PCI group in total corrected TIMI frame count (CTFC) after PCI (15.88 ± 5.11 vs. 22.47 ± 6.26, P < 0.001). At day 7 and day 30 post-PCI, a significant time-dependent decrease in the levels of brain natriuretic peptide (BNP), cardiac troponin I (cTnI), and creatine kinase isoenzyme (CK-MB) in both groups was observed after PCI (P < 0.001). More importantly, the patients in the PCI + tirofiban group had much lower levels of BNP, cTnI, and CK-MB compared with those in the PCI group at days 7 and 30 post-PCI (P < 0.001). At day 7 following PCI, the left ventricular ejection fraction (LVEF) was statistically higher in the PCI + tirofiban group than in the PCI group (P < 0.05). At day 30 post-PCI, increased LVEF concomitant with reduced left ventricular end diastolic diameter (LVEDD) and left ventricular end systolic diameter (LVESD) was observed in the PCI + tirofiban group compared with the PCI group. At day 7 and day 30 post-PCI, both groups displayed a time-dependent decline in the levels of C reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and procalcitonin (PCT) after PCI (P < 0.05). Additionally, the patients in the PCI + tirofiban group had lower levels of CRP, TNF-α, IL-6, and PCT compared with those in the PCI group at days 7 and 30 post-PCI (P < 0.05). All patients in the PCI + tirofiban and PCI groups were followed up for 12 months by outpatient or telephone after discharge. There were fewer patients with LVEF < 50% in the PCI + tirofiban group than the PCI group (P=0.044). Furthermore, it was found that the incidence rate of major adverse cardiovascular events (MACEs) in the PCI + tirofiban group was evidently lower than that in the PCI group (12.90% vs. 29.03%, P=0.028). Taken together, our data suggest that additional administration of tirofiban could improve cardiac function and attenuate inflammatory response in STEMI patients undergoing PCI, which is worthy of promotion in clinic.

Retrieval medicine and pre-hospital care in remote Australia

Retrieval medicine and pre-hospital care in remote Australia are challenging, requiring competencies in major trauma, high-risk obstetrics, critical care in adults and children, severe mental health-related agitation and envenomation. They keep a city-based retrieval and pre-hospital care doctor on their toes. Cultural fluencies to enhance care for Aboriginal and remote communities are critical during the long hours taken for the patient journey from the accident scene or clinic to definitive care.

The Utility of New Biomarker-based Predictive Model for Clinical Outcomes Among ST-elevation Myocardial Infarction Patients

Aim:

To determine the discriminative potency of score to prognosticate poor clinical outcomes in ST-Segment Elevation Myocardial Infarction (STEMI) patients.

Methods:

From the entire population of STEMI (n=268), we enrolled 177 individuals with acute STEMI who underwent complete revascularization with primary Percutaneous Coronary Intervention (PCI). Clinical assessment, echocardiography, Doppler, and biomarkers’ measure were performed at baseline.

Results:

Combined endpoint (Major Cardiovascular Events - MACEs [composite of cardiovascular death, recurrent myocardial infarction, newly diagnosed Heart Failure] and hospitalization) was determined in 75 patients with acute STEMI population (40.6%). Newly onset heart failure (HF) was reported in 46 patients (26.0%), Cardiovascular (CV) death occurred in 12 patients (6.8%), MACEs were determined in 58 patients (32.8%), and recurrent hospitalization due to CV reasons was found in 17 (9.6%). The conventional risk predictive models were engineered by a combination of TIMI risk score +acute HF Killip class ≥ II + the levels of NT-pro brain natriuretic peptide > 300 pg / mL and troponin >0.05 ng/mL. We developed a new predictive model based on the presentation of T786С genotype of endothelial NO syntase gene (rs 2070744), А1166С in angiotensin-ІІ receptor-1 gene (rs5186) and serum levels of soluble suppressor tumorigenicity ≥35 pg/mL, vascular endothelial growth factor ≤172 pg/mL and macrophage inhibitory factor ≥2792.7 pg/mL. STEMI patients who had >5 score points demonstrated significantly worse prognosis than those who had ≤5 score points.

Conclusion:

Here we have reported that a new original predictive model is better than a conventional model in discriminative ability to predict combined clinical outcome in STEMI patients.

The association between CRP / Albumin ratio and in-stent restenosis development in patients with ST-segment elevation myocardial infarction

BACKGROUND

Although interventional methods are the first-line treatment options in ST-segment elevation myocardial infarction (STEMI), the incidence of stent restenosis (SR) is frequent. We investigated the relationship between CRP/albumin ratio (CAR), a novel indicator of inflammatory response, and SR in this study.

METHOD

This study was carried out on the patients who underwent coronary angiography in our clinic between January 2017 and September 2017. Two groups were generated according to restenosis status (group 1: restenosis (-), group 2: restenosis (+)), and clinical biochemical and angiographical features were compared. As baseline demographic and angiographic characteristics are slightly different in two groups, propensity score matching analysis was performed to reduce bias. 45 SR patients were matched on a 1:1 basis were enrolled final cohort.

RESULTS

The mean age of the patients was 55 ± 5.1 and 80% were male; Cox regression model was performed to demonstrate independent predictor of restenosis development; and during the one-year follow-up period, CAR (P < 0.001) was found an independent predictor of SR CONCLUSION: In this study, we demonstrate that there may be a strong relationship between SR development and CAR. We implied that inflammatory reaction may be an important diagnostic tool for prediction of SR development in STEMI patients.

Comparison of drug-eluting balloon versus drug-eluting stent for treatment of coronary artery disease: a meta-analysis of randomized controlled trials

Background

Drug-eluting balloons (DEB) have significant value for treating coronary artery disease (CAD). However, the merits of using DEB versus drug-eluting stents (DES) to treat CAD remain controversial. Herein, we conducted a meta-analysis to compare the safety and efficacy of DEB and DES for treatment of CAD.

Methods

We searched MEDLINE, EMBASE, and CENTRAL databases for eligible trials comparing DEB with DES for treatment of CAD. The primary endpoint was major adverse cardiac events (MACE); the secondary endpoints included in-lesion late lumen loss (LLL), binary restenosis (BR), myocardial infarction (MI), target lesion revascularization (TLR) and mortality.

Results

Twenty-three trials with a total of 2712 patients were included. There were no significant differences in the primary endpoint of MACE between the DEB and DES groups (Risk Ratio (RR) 1.19; 95% confidence interval (CI) (0.87, 1.63); P = 0.27), or in the clinical outcomes of each of MACE’s components, including TLR, MI and mortality. However, efficacy was significantly different between the DEB and DES groups, especially when we compared DEB to second-generation DES: in-lesion LLL (Mean Difference (MD) 0.11; (0.01, 0.22); P = 0.03); binary restenosis (RR 1.46; (1.00, 2.13); P = 0.05).

Conclusions

DEB is equivalent to DES in terms of safety for managing CAD, and DEB may be considered as an alternative choice for treatment of CAD.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0771-y) contains supplementary material, which is available to authorized users.