Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings

Time to Treatment Delay and Clinical Indicators in Patients with ST-Segment Elevation Myocardial Infarction: A Descriptive Cross-sectional Study

Introduction

ST-segment elevation myocardial infarction (STEMI) continues to be a significant global health issue, necessitating ongoing monitoring of care processes to enhance quality. This study aimed to examine time to treatment delay and clinical indicators in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).

Methods

This descriptive cross-sectional study was conducted with the recruitment of 313 patients with STEMI treated with PPCI Tabriz (Iran) in 2023. Data were analyzed using descriptive statistics, the Mann-Whitney U test, the Kruskal-Wallis test, the chi-square test, and regression analysis in SPSS v.13 software.

Results

Most of the patients were men and half of them were 60 years old or younger. The median door-to-balloon time [IQR] was 80 [49-140] minutes. The pre-PCI center delay time and treatment delay time were 191 and 310 minutes, respectively. There was a statistically significant association between the patient's place of residence, the admission type in the PCI center, and the pre-PCI center delay time. In addition, there was a statistically significant association between treatment delay time, left ventricular ejection fraction (LVEF), baseline troponin I level, angioplasty outcome, and receiving acute coronary syndrome (ACS) drugs at the pre-PCI center.

Conclusion

The longer pre-PCI center delay time resulted in a longer total treatment delay. To reduce delays, it is proposed to improve the logistics surrounding these procedures for patients with STEMI and to provide appropriate education about the STEMI management program to all stockholders.

Sex-Related Differences in Heart Failure Development in Patients After First Myocardial Infarction: The Role of Galectin-3

Backgrounds: Galectin-3 (gal-3) is upregulated in remodeling, and failing myocardium and gal-3 levels are increased in hypertrophy, fibrosis and inflammation. The aim of this study was to investigate the potential role of sex-related differences in the following: risk factors, left ventricular (LV) structural and functional changes, coronary angiography, expression of the gal-3 encoding gene LGALS-3 and plasma gal-3 levels in heart failure (HF). Materials and Methods: This prospective study included 137 men and 44 women with first MI who underwent Doppler echocardiography within 2-4 days of MI and after 6 months. Relative LGALS-3 mRNA expression in peripheral blood mononuclear cells (PBMCs) was detected using TaqMan® technology. Plasma gal-3 concentration was determined by ELISA method. Results: In the acute phase of MI, LV end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI) were significantly lower in women compared to men (58.2 ± 13.1 vs. 46.3 ± 11.1, p < 0.001; 33.7 ± 9.5 vs. 27.0 ± 9.2, p < 0.001, respectively). The incidence of LV hypertrophy (LVH) and HF was significantly higher in women compared to men (70.0% vs. 44.6%, p = 0.03; 37.5% vs.19.5%, p = 0.02, respectively). There was a significant correlation between the grade of LV diastolic dysfunction (LVDD) and plasma gal-3 levels (p < 0.001). The relative expression of LGALS-3 mRNA in PBMCs was higher in females (fold induction = 1.326, S.E. range = 0.748-2.587, p = 0.007). Plasma gal-3 levels were higher in women compared to men (44.66 ± 28.04 vs. 16.30 ± 12.68, p < 0.001) and higher in patients with HF than in patients without HF (31.14 ± 27.09 vs.21.39 ± 18.17, p = 0.025). Conclusions: Gender-specific factors such as LVH, LVDD, LGALS-3 mRNA expression and plasma gal-3 levels may explain the increased incidence of HF in women. The differences in the model and determinants of HF between men and women may be relevant for further therapeutic strategies including the inhibition of gal-3.

The contemporary management and coronary angioplasty outcomes in young patients with ST-Elevation myocardial infarction (STEMI) age < 40 years old: the insight from nationwide Thai PCI registry

BACKGROUND

Cardiovascular disease (CVD) remains one of the major causes of death around the world in which ST elevation MI (STEMI) is in the lead. Although the mortality rate from STEMI seems to decline, this result might not be demonstrated in young adults who basically have different baseline characteristics and outcomes compared with older patients.

METHODS

Data of the STEMI patients aged 18 years or older who underwent PCI during May 2018 to August 2019 from Thai PCI Registry, a prospective, multi-center, nationwide study, was included and aimed to investigate the predisposing factors and short-term outcomes of patients aged < 40 years compared with age 41-60, and > 61 years.

RESULTS

Data of 5,479 STEMI patients were collected. The patients' mean age was 62.6 (SD = 12.6) years, and 73.6% were males. There were 204, 2,154, and 3,121 patients in the youngest, middle, and oldest groups. The young patients were mainly male gender (89.2% vs. 82.4% and 66.6%; p < 0.001), were current smokers (70.6%, 57.7%, 34.1%; p < 0.001), had BMI ≥ 25 kg/m2 more frequently (60.8%, 44.1%, 26.1%; p < 0.001), and had greater family history of premature CAD (6.9%, 7.2%, 2.9%; p < 0.001). The diseased vessel in the young STEMI patients was more often single vessel disease with the highest percentage of proximal LAD stenosis involvement. Interestingly, there were trends of higher events of procedural failure (2.9%, 2.1%, 3.3%; p = 0.028) and procedural complications (8.8%, 5.8%, 9.4%; p < 0.001) in both youngest and oldest groups compared to the middle-aged group. In-hospital death was found in 3.4% in the youngest group compared to 3.3% in the middle-aged patients and 9.2% in the older patients (p < 0.001).

CONCLUSIONS

Despite experiencing higher rates of procedural failure and complications during treatment compared to middle-aged and older patients, young STEMI individuals demonstrate a significantly lower risk of death during hospitalization and within one year of the event. Younger patients might have a more robust physiological reserve or benefit from more aggressive post-procedure management. However, the higher prevalence of modifiable risk factors like smoking and obesity in younger individuals underscores the need for preventative measures. Encouraging smoking cessation and weight control in this demographic is crucial not only to prevent STEMI but also to potentially improve their long-term survival prospects.

Association between haemoglobin decline and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention

OBJECTIVE

To explore the association between in-hospital haemoglobin decline and long-term mortality and major adverse cardiovascular and cerebrovascular events (MACCE) among ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI).

METHODS

This retrospective analysis included adult patients who underwent primary PCI for STEMI. Haemoglobin levels were recorded at admission and 48-72 h later. Patients were divided into two groups based on the extent of haemoglobin decline: low (<3 g/dl or no decline) and high (≥3 g/dl). The primary endpoint was all-cause mortality at long-term follow-up. The secondary endpoint was MACCE.

RESULTS

Patients were divided into two groups: low group (n = 665) and high group (n = 111). The mortality rate was significantly higher in the high group (72 of 111 patients; 65%) than in the low group (185 of 655 patients; 28%). Propensity score matching confirmed this association, with higher mortality (41 of 79 patients [52%] versus 25 of 79 patients [32%]) and MACCE rates (56 of 79 patients [71%] versus 41 of 79 patients [52%]) in the high group compared with the low group, respectively.

CONCLUSION

There was a significant association between in-hospital haemoglobin decline, even without visible bleeding, and increased long-term mortality and MACCE in STEMI patients undergoing primary PCI.

Multifaceted Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on ST-Elevation Myocardial Infarction (STEMI): A Literature Review of Incidence, Treatment Modalities, and Outcomes

The global repercussions of coronavirus disease 2019 (COVID-19) include substantial worldwide mortality and have brought to light existing gaps in healthcare systems. Particularly, diseases requiring time-sensitive treatment, such as ST-elevation myocardial infarction (STEMI), have faced significant challenges due to the impact and revelations of the COVID-19 pandemic on healthcare infrastructure. This review addresses the impact of the pandemic on STEMI, exploring incidence, treatment modalities, and clinical outcomes. Through a critical examination of existing literature, the intricate relationship between the pandemic and cardiovascular health, specifically STEMI, is elucidated. The COVID-19 pandemic has had a significant impact on the management of STEMI, with changes in hospitalization rates, treatment strategies, and the presentation of the disease posing significant challenges. The contradictory results of COVID-19 and post-vaccine myocardial infarction, as well as gender differences in reported cases, highlight the need for further research to clarify these relationships.

Experience and Outcomes of Primary Percutaneous Coronary Intervention in a Tertiary Care Hospital in South Punjab, Pakistan

BACKGROUND

Primary percutaneous coronary intervention (PCI) is the emergency procedure and gold standard for the treatment of ST-Elevation Myocardial Infarction (STEMI).

OBJECTIVE

To share the experience and outcomes of primary PCI in a tertiary care hospital in South Punjab, Pakistan.

METHODS

A descriptive cross-sectional study was planned from the 1st of April, 2023 to the 30th of September, 2023. All patients presenting with acute STEMI undergoing primary PCI were included in the study. Data regarding patient demographics, risk factors, procedural characteristics, time variables, and in-hospital events was observed.

RESULTS

A total of 1132 patients were included in the study. There were 934 (82.5%) males. Smoking is the most common risk factor among all the patients. Anterior wall myocardial infarction is the most common STEMI and the left anterior descending artery is the culprit vessel in 58.3% (n=660) of patients. Single vessel disease was present in 34.6% (n=392) of the patients. Thrombolysis in Myocardial Infarction (TIMI )Flow III was achieved in 80% (n=906) of patients after primary PCI. The average total ischemic time of the patients included in the study was 5 hours and 48 minutes, with a standard deviation of 3 hours and 55 minutes. Our mortality was 3.5% (n=40).

CONCLUSION

Our patients take a longer time to present to the PCI-capable centers. Despite their late presentation, primary PCI has better outcomes for treating acute STEMI.

Effect of Thrombolysis on Circulating Microparticles in Patients with ST-Segment Elevation Myocardial Infarction

Objective

We demonstrated that circulating microparticles (MPs) are increased in patients with coronary heart disease (both chronic coronary syndrome (CCS) and acute coronary syndrome). Whether thrombolysis affects MPs in patients with ST-segment elevation myocardial infarction (STEMI) with or without percutaneous coronary intervention (PCI) is unknown.

Methods

This study was divided into three groups: STEMI patients with thrombolysis (n = 18) were group T, patients with chronic coronary syndrome (n = 20) were group CCS, and healthy volunteers (n = 20) were the control group. Fasting venous blood was extracted from patients in the CCS and control groups, and venous blood was extracted from patients in the T group before (pre-T) and 2 hours after (post-T) thrombolysis. MPs from each group were obtained by centrifugation. After determining the concentration, the effects of MPs on endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in rat myocardial tissue in vitro were detected by immunohistochemistry and western blotting. Changes in nitric oxide (NO) and oxygen free radicals (O2•-) were also detected. The effect of MPs on vasodilation in isolated rat thoracic aortae was detected.

Results

Compared with that in the control group (2.60 ± 0.38 mg/ml), the concentration of MPs was increased in patients with CCS (3.49 ± 0.72 mg/ml) and in STEMI patients before thrombolysis (4.17 ± 0.58 mg/ml). However, thrombolysis did not further increase MP levels (post-T, 4.23 ± 1.01 mg/ml) compared with those in STEMI patients before thrombolysis. Compared with those in the control group, MPs in both CCS and STEMI patients before thrombolysis inhibited the expression of eNOS (both immunohistochemistry and western blot analysis of phosphorylation at Ser1177), NO production in the isolated myocardium and vasodilation in vitro and stimulated the expression of iNOS (immunohistochemistry and western blot analysis of phosphorylation at Thr495), and the generation of O2•- in the isolated myocardium. The effects of MPs were further enhanced by MPs from STEMI patients 2 hours after thrombolysis.

Conclusion

Changes in MP function after thrombolysis may be one of the mechanisms leading to ischemia-reperfusion after thrombolysis.

The abnormal level and prognostic potency of multiple inflammatory cytokines in PCI-treated STEMI patients

OBJECTIVE

Inflammatory cytokines modulate atherogenesis and plaque rupture to involve in ST-segment elevation myocardial infarction (STEMI) progression. The present study determined eight inflammatory cytokine levels in 212 percutaneous coronary intervention (PCI)-treated STEMI patients, aiming to comprehensively investigate their potency in estimating major adverse cardiac event (MACE) risk.

METHODS

Serum tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-17A, vascular cell adhesion molecule-1 (VCAM-1), and intercellular adhesion molecule-1 (ICAM-1) of 212 PCI-treated STEMI patients and 30 angina pectoris patients were determined using enzyme-linked immunosorbent assay.

RESULTS

TNF-α (52.5 (43.9-62.6) pg/ml versus 46.4 (39.0-59.1) pg/ml, p = 0.031), IL-8 (61.6 (49.6-81.7) pg/ml versus 46.7 (32.5-63.1) pg/ml, p = 0.001), IL-17A (57.4 (45.7-77.3) pg/ml versus 43.2 (34.2-64.6) pg/ml, p = 0.001), and VCAM-1 (593.6 (503.4-811.4) ng/ml versus 493.8 (390.3-653.7) ng/ml, p = 0.004) levels were elevated in STEMI patients compared to angina pectoris patients, while IL-1β (p = 0.069), IL-6 (p = 0.110), IL-10 (p = 0.052), and ICAM-1 (p = 0.069) were of no difference. Moreover, both IL-17A high (vs. low) (p = 0.026) and VCAM-1 high (vs. low) (p = 0.012) were linked with increased cumulative MACE rate. The multivariable Cox's analysis exhibited that IL-17A high (vs. low) (p = 0.034) and VCAM-1 high (vs. low) (p = 0.014) were independently associated with increased cumulative MACE risk. Additionally, age, diabetes mellitus, C-reactive protein, multivessel disease, stent length, and stent type were also independent factors for cumulative MACE risk.

CONCLUSION

IL-17A and VCAM-1 high level independently correlate with elevated MACE risk in STEMI patients, implying its potency in identifying patients with poor prognoses.

Risk Factors for No-Reflow in Patients with ST-Elevation Myocardial Infarction Who Underwent Percutaneous Coronary Intervention: A Case-Control Study

Methods

This case-control study retrospectively reviewed the medical data of patients treated with primary percutaneous coronary intervention within 12 h after STEMI onset between January 2010 and January 2013 at the Department of Cardiology of the Beijing Anzhen Hospital.

Results

A total of 902 patients were included in the analysis. The basic characteristics between the reflow and no-reflow groups were similar, except for time-to-hospital admission, heart rate, plasma glucose, high-sensitivity C-reactive protein (hsCRP)/prealbumin (PAB), neutrophil count, intraaortic balloon pump, and aspiration thrombectomy. The multivariable analysis showed that hsCRP/PAB (OR = 1.003, 95% CI: 1.000–1.006, P=0.022), neutrophil count (OR = 1.085, 95% CI: 1.028–1.146, P=0.003), plasma glucose levels (OR = 1.086, 95% CI: 1.036–1.138, P=0.001), diabetes mellitus (OR = 0.596, 95% CI: 0.371–0.958, P=0.033), Killip classification >1 (OR = 2.002, 95% CI: 1.273–3.148, P=0.003), intraoperative intraaortic balloon pump (IABP) use (OR = 3.257, 95% CI: 1.954–5.428, P=0.001), and aspiration thrombectomy (OR = 3.412, 95% CI: 2.259–5.152, P=0.001) were independently associated with no-reflow.

Conclusion

hsCRP/PAB, neutrophil count, plasma glucose levels, diabetes mellitus, Killip classification, intraoperative IABP use, and aspiration thrombectomy were independent risk factors for no-reflow in patients with STEMI.