Primary PCI for myocardial infarction with ST-segment elevation

Ventricular Pseudoaneurysm and Free Wall Rupture After Acute Myocardial Infarction: JACC Focus Seminar 4/5

Postinfarction ventricular free-wall rupture is a rare mechanical complication, accounting for <0.01% to 0.02% of cases. As an often-catastrophic event, death typically ensues within minutes due to sudden massive hemopericardium resulting in cardiac tamponade. Early recognition is pivotal, and may allow for pericardial drainage and open surgical repair as the only emergent life-saving procedure. In cases of contained rupture with pseudo-aneurysm (PSA) formation, hospitalization with subsequent early surgical intervention is warranted. Not uncommonly, PSA may go unrecognized in asymptomatic patients and diagnosed late during subsequent cardiac imaging. In these patients, the unsettling risk of complete rupture demands early surgical repair. Novel developments, in the field of transcatheter-based therapies and multimodality imaging, have enabled percutaneous PSA repair as a feasible alternate strategy for patients at high or prohibitive surgical risk. Contemporary advancements in the diagnosis and treatment of postmyocardial infarction ventricular free-wall rupture and PSA are provided in this review.

Impact of primary percutaneous coronary intervention on ST-segment elevation myocardial infarction patients: A comprehensive analysis

BACKGROUND

Myocardial infarction, particularly ST-segment elevation myocardial infarction (STEMI), is a key global mortality cause. Our study investigated predictors of mortality in 96 STEMI patients undergoing primary percutaneous coronary intervention at Erbil Cardiac Center. Multiple factors were identified influencing in-hospital mortality. Significantly, time from symptom onset to hospital arrival emerged as a decisive factor. Consequently, our study hypothesis is: "Reducing time from symptom onset to hospital arrival significantly improves STEMI prognosis."

AIM

To determine the key factors influencing mortality rates in STEMI patients.

METHODS

We studied 96 consecutive STEMI patients undergoing primary percutaneous coronary intervention (PPCI) at the Erbil Cardiac Center. Their clinical histories were compiled, and coronary evaluations were performed via angiography on admission. Data included comorbid conditions, onset of cardiogenic shock, complications during PPCI, and more. Post-discharge, one-month follow-up assessments were completed. Statistical significance was set at P < 0.05.

RESULTS

Our results unearthed several significant findings. The in-hospital and 30-d mortality rates among the 96 STEMI patients were 11.2% and 2.3% respectively. On the investigation of independent predictors of in-hospital mortality, we identified atypical presentation, onset of cardiogenic shock, presence of chronic kidney disease, Thrombolysis In Myocardial Infarction grades 0/1/2, triple vessel disease, ventricular tachycardia/ventricular fibrillation, coronary dissection, and the no-reflow phenomenon. Specifically, the recorded average time from symptom onset to hospital arrival amongst patients who did not survive was significantly longer (6.92 ± 3.86 h) compared to those who survived (3.61 ± 1.67 h), P < 0.001. These findings underscore the critical role of timely intervention in improving the survival outcomes of STEMI patients.

CONCLUSION

Our results affirm that early hospital arrival after symptom onset significantly improves survival rates in STEMI patients, highlighting the critical need for prompt intervention.

The illness perceptions of patients with percutaneous coronary intervention compared to patients with no percutaneous intervention, for acute myocardial infarction, in cardiac rehabilitation

PURPOSE

Patients who receive percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) have been found to have low attendance at cardiac rehabilitation (CR). It has been suggested that this is because PCI patients have a benign perception of their coronary disease; however, this has never been quantitatively investigated. The aim of this prospective study was to evaluate the illness perceptions (IP) of patients with AMI treated with PCI.

METHODS

The Heart Health Illness Perception Questionnaire (modified version of the Brief Illness Perception Questionnaire) and the Cardiac Beliefs Questionnaire were used to assess patients' IP and cardiac disease misconceptions, respectively. Patients in phase 2 of CR were recruited from the Royal Alexandria Hospital, Paisley, UK. One hundred two patients were identified from the cardiac unit database over a 16-week period and sent questionnaires.

RESULTS

Fifty-six patients returned questionnaires suitable for analysis (54.9% response rate). There was a significant difference in the IP scores of the 3 groups [primary-PCI (pPCI) = 0.18 ± 1.44, elective-PCI = 5.27 ± 15.65, non-PCI = 9.94 ± 11.19; P = 0.046]. PCI patients had a significantly lower IP score than non-PCI patients (PCI = 1.62 ± 12.76, non-PCI = 9.94 ± 11.19; P = 0.027). pPCI patients had a significantly lower IP score than non-pPCI patients (pPCI = 0.18 ± 11.44, non-pPCI = 8.04 ± 13.11; P = 0.021). Of the PCI patients 22.9% agreed they were 'fixed for life' and a lower IP score was found to predict this opinion (P = 0.032).

CONCLUSION

PCI patients, particularly pPCI patients, perceive their coronary disease to be relatively benign. Further research is required to investigate if this predicts poor attendance at CR.

Impact of Prior Statin Therapy on In-Hospital Outcome of STEMI Patients Treated with Primary Percutaneous Coronary Intervention

Background: Prior statin therapy has a cardioprotective effect in patients undergoing elective or urgent percutaneous coronary intervention (PCI). However, data on patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI are still controversial. We retrospectively evaluated the effect of prior statin therapy on in-hospital clinical outcomes in consecutive STEMI patients undergoing primary PCI. Methods: A total of 1790 patients (mean age 67 ± 11 years, 1354 men) were included. At admission, all patients were interrogated about prior (>6 months) statin therapy. The primary endpoint of the study was the composite of in-hospital mortality, acute pulmonary edema, and cardiogenic shock in patients with or without prior statin therapy. Results: A total of 427 patients (24%) were on prior statin therapy. The incidence of the primary endpoint was similar in patients with or without prior statin therapy (15% vs. 16%; p = 0.38). However, at multivariate analysis, prior statin therapy was associated with a lower risk of the primary endpoint, after adjustment for major prognostic predictors (odds ratio 0.61 [95% CI 0.39−0.96]; p = 0.03). Conclusions: This study demonstrated that prior statin therapy is associated with a better in-hospital clinical outcome in patients with STEMI undergoing primary PCI compared to those without prior statin therapy.

Intracoronary eptifibatide with vasodilators to prevent no-reflow in diabetic STEMI with high thrombus burden. A randomized trial

INTRODUCTION AND OBJECTIVES

To study the impact of injecting intracoronary eptifibatide plus vasodilators via thrombus aspiration catheter vs thrombus aspiration alone in reducing the risk of no-reflow in acute ST-elevation myocardial infarction (STEMI) with diabetes and high thrombus burden.

METHODS

The study involved 413 diabetic STEMI patients with high thrombus burden, randomized to intracoronary injection (distal to the occlusion) of eptifibatide, nitroglycerin and verapamil after thrombus aspiration and prior to balloon inflation (n=206) vs thrombus aspiration alone (n=207). The primary endpoint was post procedural myocardial blush grade and corrected Thrombolysis in Myocardial Infarction (TIMI) frame count (cTFC). Major adverse cardiovascular events were reported at 6 months.

RESULTS

The intracoronary eptifibatide and vasodilators arm was superior to thrombus aspiration alone regarding myocardial blush grade-3 (82.1% vs 31.4%; P=.001). The local intracoronary eptifibatide and vasodilators arm had shorter cTFC (18.16±6.54 vs 29.64±5.53, P=.001), and better TIMI 3 flow (91.3% vs 61.65%; P=.001). Intracoronary eptifibatide and vasodilators improved ejection fraction at 6 months (55.2±8.13 vs 43±6.67; P=.005). There was no difference in the rates of major adverse cardiovascular events at 6 months.

CONCLUSIONS

Among diabetic patients with STEMI and high thrombus burden, intracoronary eptifibatide plus vasodilators injection was beneficial in preventing no-reflow compared with thrombus aspiration alone. Larger studies are encouraged to investigate the benefit of this strategy in reducing the risk of adverse clinical events.

Intracoronary artery retrograde thrombolysis combined with percutaneous coronary interventions for ST-segment elevation myocardial infarction complicated with diabetes mellitus: A case report and literature review

Background

The management of a large thrombus burden in patients with acute myocardial infarction and diabetes is still a worldwide problem.

Case presentation

A 74-year-old Chinese woman presented with ST-segment elevation myocardial infarction (STEMI) complicated with diabetes mellitus and hypertension. Angiography revealed massive thrombus formation in the mid-segment of the right coronary artery leading to vascular occlusion. The sheared balloon was placed far from the occlusion segment and urokinase (100,000 u) was administered for intracoronary artery retrograde thrombolysis, and thrombolysis in myocardial infarction (TIMI) grade 3 blood flow was restored within 7 min. At last, one stent was accurately implanted into the culprit’s vessel. No-reflow, coronary slow flow, and reperfusion arrhythmia were not observed during this process.

Conclusion

Intracoronary artery retrograde thrombolysis (ICART) can be effectively and safely used in patients with STEMI along with diabetes mellitus and hypertension, even if the myocardial infarction exceeds 12 h (REST or named ICART ClinicalTrials.gov number, ChiCTR1900023849).

Relationship Between Work Mode, Time of Admission, and Mortality in St-Segment Elevation Myocardial Infarction: Results From the TURKMI Registry

Treatment of acute myocardial infarction has evolved steadily. However, limited studies exist regarding the effect of all innovations on mortality. We aimed to investigate the effect of time of admission and work mode on 1-year outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI). Based on the TURKMI registry, we analyzed 735 STEMI patients recruited consecutively and prospectively from 50 PCI-capable cardiology clinics within a prespecified two-week period. Centers were categorized as "on-call" and "on-duty" according to their work mode. At 1-year follow-up, all-cause mortality and cardiovascular mortality were the primary outcomes. The secondary outcome was a composite of coronary revascularization, re-infarction/stroke, and recurrent angina. One-fifth of the participants (19.5%) were treated in the on-call group. All-cause mortality (7.9 vs 10.5%, aHR: 1.16, P = .650) and cardiovascular mortality rates (6.1 vs 9.1%, aHR: 1.35, P = .413) were similar between centers' modes of work. Likewise, both groups were equally likely to undergo coronary revascularization (P = .278), re-MI/stroke (P = .280), recurrent angina (P = .175), and the composite outcome of these components (P = .482). No significant difference was observed in primary outcomes between weekend and weekday admissions. In conclusion, we observed similar outcomes between the on-call and on-duty groups among STEMI patients.

Comprehensive safety profile evaluation of bivalirudin in Chinese ST-segment elevation myocardial infarction patients receiving percutaneous coronary intervention: a prospective, multicenter, intensive monitoring study

Background

This prospective, multi-center, intensive monitoring study aimed to systematically assess the occurrence of adverse events (AEs) and adverse drug reactions (ADRs), especially thrombocytopenia and bleeding, as well as their risk factors in Chinese ST-segment elevation myocardial infraction (STEMI) patients receiving bivalirudin as anticoagulant for percutaneous coronary intervention (PCI).

Methods

In total, 1244 STEMI patients undergoing PCI and receiving bivalirudin as anticoagulant were enrolled in the present study. Safety data were collected from hospital admission to 72 h after bivalirudin administration; in addition, patients were further followed up at the 30th day with safety data collected at that time.

Results

AEs, severe AEs, ADRs and severe ADRs were reported in 224 (18.0%), 15 (1.2%), 49 (3.9%) and 5 (0.4%) patients, respectively. Importantly, 4 (0.3%) patients were submitted to hospitalization and 6 (0.5%) patients died due to AEs, while 1 (0.1%) patient was submitted to hospitalization but no (0.0%) patient died due to ADRs. Meanwhile, thrombocytopenia and bleeding occurred in 24 (1.9%) and 21 (1.7%) patients, respectively. Further multivariate logistic analysis identified several important independent factors related to AEs, ADRs, thrombocytopenia or bleeding, which included history of cardiac surgery and renal function impairment, high CRUSADE risk stratification, elective operation and combination with glycoprotein IIb/IIIa inhibitors. Moreover, 4 multivariate models were constructed based on the above-mentioned factors, which all showed acceptable predictive value for AEs, ADRs, thrombocytopenia and bleeding, respectively.

Conclusion

Bivalirudin is a well-tolerant anticoagulant in Chinese STEMI patients undergoing PCI procedure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02716-4.

Prehospital identification of ST-segment elevation myocardial infarction and mortality (ANZACS-QI 61)

BACKGROUND

Early recognition of ST-segment elevation myocardial infarction (STEMI) is needed for timely cardiac monitoring and reperfusion therapy.

METHODS

Three anonymously linked New Zealand national datasets (July 2016-November 2018) were used to assess the utilisation of ambulance transport in STEMI cases, the concordance between ambulance initial clinical impressions and hospital STEMI diagnoses, and the association between initial paramedic clinical impressions and 30-day mortality. The St John Ambulance electronic record captures community call-outs and paramedic initial clinical impressions. The national cardiac (ANZACS-QI) registry and national administrative datasets capture all New Zealand public hospital admission diagnoses and mortality data.

RESULTS

Of 5465 patients with STEMI, 73% were transported to hospital by ambulance. For these patients, the initial paramedic impression was STEMI in 50.7%, another acute coronary syndrome (ACS) diagnosis in 19.9% and non-ACS diagnosis in 29.7%. Only 37% of the 5465 patients with STEMI were both transported by ambulance and clinically suspected of STEMI by paramedics. Compared with patients with paramedic-'suspected STEMI', 30-day mortality was over threefold higher for patients thought to have a non-ACS condition (10.9% and 34.9%, respectively), but after adjustment for available covariates, this was substantially ameliorated (HR 1.48, 95% CI 1.22 to 1.80).

CONCLUSIONS

In this national data linkage study, only 4 out of every 10 patients with STEMI were both transported by ambulance and had STEMI suspected by paramedics. Although patients with STEMI not suspected of an ACS diagnosis by paramedics had the highest mortality rate, this is largely explained by the different risk profile of these patients.

Factors associated with difficulty in crossing the culprit lesion of acute myocardial infarction

In percutaneous coronary intervention (PCI) to the culprit lesion of acute myocardial infarction (AMI), unsuccessful guidewire crossing causes immediate poor outcomes. It is important to determine the factors associated with unsuccessful guidewire crossing in AMI lesions. The purpose of this study was to find factors associated with difficulty in crossing the culprit lesion of AMI. We defined the difficult group when the guidewire used to cross the culprit lesion was a polymer jacket type guidewire or a stiff guidewire. We included 937 patients, and divided those into the non-difficult group (n = 876) and the difficult group (n = 61). Proximal reference diameter was significantly smaller in the difficult group than in the non-difficult group (p < 0.001), and degree of calcification was severer in the difficult group than in the non-difficult group (p < 0.001). In the multivariate stepwise logistic regression analysis, proximal reference diameter [odds ratio (OR) 0.313, 95% confidence interval (CI) 0.185–0.529, p < 0.001)], previous PCI (OR 3.065, 95% CI 1.612–5.830, p = 0.001), moderate-severe calcification (OR 4.322, 95% CI 2.354–7.935, p < 0.001), blunt type obstruction (OR 12.646, 95% CI 6.805–23.503, p < 0.001), and the presence of collateral to the culprit lesion (OR 2.110, 95% CI 1.145–3.888, p = 0.017) were significantly associated with difficulty in crossing the culprit lesion. In conclusion, previous PCI, calcification, blunt type obstruction, and the presence of collateral were associated with difficulty in crossing the culprit lesion, whereas proximal reference diameter was inversely associated with difficulty. Our study provides a reference to recognize the difficulty in crossing the culprit lesions of AMI for PCI operators, especially junior operators.

Association of Asymptomatic Low Ankle-Brachial Index with Long-Term Clinical Outcomes in Patients after Acute Myocardial Infarction

AIMS

Peripheral arterial disease (PAD) is the well-known risk factor for cardiovascular events. Although low ankle-brachial index (ABI) is recognized as a risk factor in general population, low ABI without any symptoms of PAD has not been established as a prognostic marker in patients with acute myocardial infarction (AMI) yet. The purpose of this retrospective study was to examine whether asymptomatic low ABI was associated with long-term clinical outcomes in AMI patients without treatment history of PAD.

METHODS

We included 850 AMI patients without a history of PAD and divided them into the preserved ABI (ABI ≥ 0.9) group (n=760) and the reduced ABI (ABI ＜0.9) group (n=90) on the basis of the ABI measurement during the hospitalization. The primary endpoint was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and hospitalization for heart failure.

RESULTS

During the median follow-up duration of 497 days (Q1: 219 days to Q3: 929 days), a total of 152 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the reduced ABI group than in the preserved ABI group (p＜0.001). The multivariate COX hazard analysis revealed that reduced ABI was significantly associated with MACE (hazard ratio 2.046, 95% confidence interval 1.344-3.144, p=0.001) after controlling confounding factors.

CONCLUSIONS

Reduced ABI was significantly associated with long-term adverse events in AMI patients without a history of PAD. Our results suggest the usefulness of ABI as a prognostic marker in AMI patients irrespective of symptomatic PAD.

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with coronary heart disease and type 2 diabetes mellitus: Cumulative meta-analysis

Previous meta‐analyses showed that coronary artery bypass grafting (CABG) has lower all‐cause mortality than percutaneous coronary intervention (PCI) for the management of coronary heart disease (CHD), but the long‐term outcomes were not analyzed thoroughly in patients with type 2 diabetes mellitus (T2DM). To perform a meta‐analysis of randomized controlled trials (RCTs) to explore the long‐term effectiveness between CABG and PCI in patients with T2DM and study the temporal trends using a cumulative meta‐analysis. PubMed, Embase, Cochrane library, and Clinical Trials Registry for eligible RCTs published up to September 2020. The outcomes were all‐cause death, cardiac death, myocardial infarction, repeat revascularization, and stroke. Nine RCTs and 4566 patients were included. CABG resulted in better outcomes than PCI in terms of all‐cause death (RR = 1.41, 95%CI: 1.22–1.63, p < 0.001), cardiac death (RR = 1.56, 95%CI: 1.25–1.95, p < 0.001), and repeat revascularization (RR = 2.68, 95%CI: 1.86–3.85, p < 0.001), but with difference regarding the occurrence of myocardial infarction (RR = 1.20, 95%CI: 0.78–1.85, p = 0.414), while PCI was associated with better outcomes in terms of stroke occurrence (RR = 0.51, 95%CI: 0.34–0.77, p = 0.001). The cumulative meta‐analysis for all‐cause death showed that the differences between CABG and PCI started to be significant at 3 years of follow‐up, while the difference became significant at 5 years for cardiac death. In patients with CHD and T2DM, CABG results in better outcomes than PCI in terms of all‐cause death, cardiac mortality, and repeat revascularization, while PCI had better outcomes in terms of stroke. The differences are mainly observed over the long‐term follow‐up.

The FAST-STEMI Network in Biella From 2013 to 2019: Impact of the Delocalization of the Hospital Facilities on Ischemia Time and In-hospital Outcomes

BACKGROUND

The optimization of the strategies for myocardial revascularization has improved the outcomes of patients with ST-segment elevation myocardial infarction. In Piedmont, the FAST-STEMI regional network was created for improving the management and transportation of ST-segment elevation (STEMI) patients to primary percutaneous coronary intervention facilities, reducing the time to reperfusion. Within this network, the Hospital of Biella was delocalized in December 2014 to a new suburban structure designed for an easier access, which might have shortened the duration of patients' transportation and ischemia, with potential positive prognostic effects. The aim of the present study was to define the impact of the decentralization of the hospital structure on the time to reperfusion and in-hospital outcomes among STEMI patients admitted to the Hospital of Biella.

METHODS

We included STEMI patients admitted to our urban hospital between 2013 and 2019 and included in the FAST-STEMI database. The primary endpoint was the duration of ischemia, defined as pain to balloon (PTB). The primary outcome endpoint (PE) was in-hospital mortality.

RESULTS

We included 276 consecutive patients with STEMI undergoing primary percutaneous coronary intervention between 2016 and 2019 in the new hospital facility, which were compared with 170 patients treated between 2013 and June 2014 in the prior structure. Patients' characteristics included a mean age of 67.5 ± 12.5 years, 72.1% males and 18.7% patients with diabetes. In the new facility, the median PTB was 188 minutes [interquartile range: 125-340 min], reduced as compared with the period 2013-2014 [215 (128.5-352 min), P = 0.002]. The median in-hospital stay was also shorter (P = 0.004), whereas a nonsignificant improvement was noted for ejection fraction (EF) at discharge (P = 0.14). A linear relationship was demonstrated between PTB and the EF (r = -0.183, P = 0.003) in patients treated between 2016 and 2019 while not affecting the length of hospitalization or in-hospital outcomes. In fact, in-hospital death occurred in 36 patients, 8% in the new structure versus 7.7% in 2013-2014 [hazard ratio (HR) (95% confidence interval [CI]) = 1.20 (0.59-2.42), P = 0.62]. The independent predictors of mortality were patients' age and EF at discharge (age ≥ 75 y: adjusted HR [95% CI] = 6.75 [1.51-30.1], P = 0.01; EF: adjusted HR [95% CI] = 0.91 [0.88-0.95], P < 0.001).

CONCLUSIONS

The present study shows that, among the STEMI patients treated in our center, the delocalization of the hospital facilities and the optimization of the FAST-STEMI network reduced the duration of ischemia, with positive effects on left ventricular function at discharge. However, this did not translate into a significant benefit in survival, which was instead conditioned by the aging of the population.

Berberine Protests the Heart from Ischemic Reperfusion Injury via Interference with Oxidative and Inflammatory Pathways

BACKGROUND

Ischemia and reperfusion (I/R) is a pathological condition characterized by an initial restriction of blood supply to an organ followed by the subsequent restoration of perfusion and concomitant reoxygenation.

OBJECTIVE

The aim of the study is to assess the possible cardioprotective potential effect of berberine in myocardial ischemia reperfusion injury induced by ligation of coronary artery in a male rat model.

METHODS

Total amount of 28 adult male albino rats were randomized into 4 equal groups: 1) Sham group, rats underwent the same anesthetic and surgical procedure as the control group except for LAD ligation; 2), Active control group, rats subjected to regional ischemia for 30 min by ligation of LAD coronary artery and reperfusion for 2 hours, 3), Control vehicle group, rats received dimethyl sulphoxide (DMSO) (vehicle of berberine) via IP route and subjected to ischemia for 30 minutes before ligation of LAD coronary artery & reperfusion for 2 hr; 4), Berberine treated group, rats pretreated with berberine10 mg/kg via IP injection 30minutes before ligation of LAD coronary artery & then subjected to reperfusion for 2 hr.

RESULTS

In the control group, as compared with sham, tissue TNF-α, IL-6, IL-10, caspase-3 and BAX, plasma cTn-T and serum MDA significantly increased (P<0.05), while serum GSH significantly decreased (P<0.05). The histopathological control group showed a significant cardiac injury (P<0.05) compared with the sham group. Berberine significantly counteracted (P<0.05) the increase of TNF-α, IL-6, caspase-3 and BAX and counteracted the increase in plasma cTn-T and serum MDA. Berberine produces a significant elevation (P<0.05) in cardiac IL-10 and serum GSH with a significant reduction in (P<0.05) cardiac injury.

CONCLUSION

Berberine attenuates myocardial I/R injury in male rats via interfering with inflammatory reactions and apoptosis which were induced by I/R injury.

Low Ankle-Brachial Index is Associated with Microvascular Coronary Obstruction After Primary PCI

Introduction

Percutaneous coronary intervention (PCI) has improved recanalization of infarct-related arteries (IRA); however, TIMI-III flow does not always mean an efficient myocardial reperfusion. Myocardial blush grade (MBG) is used as a predictor for coronary microvascular obstruction. We assessed the association between ankle-brachial index (ABI), a widely used method for diagnosis of peripheral arterial disease (PAD), and coronary microvascular obstruction (MVO) as detected by MBG after primary PCI.

Patients and Methods

The study included 335 patients with ST-elevation myocardial infarction who had primary PCI. History taking, clinical examination, laboratory assessment, ECG and Echocardiography were done for every participant. MBG was assessed for patients after PCI procedure. ABI for all participating patients was calculated.

Results

Two hundred and sixty-one patients fulfilled the inclusion criteria with mean age 58.8 ± 10.7 years, 84% were males. Sixty-one percent had anterior wall myocardial infarction. After primary PCI, despite achieving TIMI flow III in all study patients, only 37% had normal MBG. There was a statistically significant relationship between MBG and site of infarction, left ventricular ejection fraction and ABI. Low ABI was found to predict poor MBG.

Conclusion

Coronary artery disease (CAD) is well linked to PAD. MBG can be used to assess coronary MVO after primary PCI. Poor MBG is associated with low ABI. This could establish a relationship between PAD and coronary MVO after primary PCI.

COVID-19 pandemic is associated with mechanical complications in patients with ST-elevation myocardial infarction

OBJECTIVE

Although there are regional reports that the COVID-19 pandemic is associated with a reduction in acute myocardial infarction presentations and primary percutaneous coronary intervention (PCI) procedures, little is known about the impact of the COVID-19 pandemic on mechanical complications resulting from ST-segment elevation myocardial infarction (STEMI) and mortality.

METHODS

This single-centre retrospective cohort study analysed presentations, incidence of mechanical complications, and mortality in patients with STEMI before and after a state of emergency was declared due to the COVID-19 pandemic by the Japanese government on 7 April 2020.

RESULTS

We analysed 359 patients with STEMI hospitalised before the declaration and 63 patients hospitalised after the declaration. The proportion of patients with late presentation was significantly higher after the declaration than before (25.4% vs 14.2%, p=0.03). The incidence of late presentation was significantly higher during the COVID-19 pandemic than before (incidence rate ratio (IRR), 2.41; 95% CI, 1.37 to 4.05; p=0.001, even after adjusting for month (IRR, 2.61; 95% CI, 1.33 to 5.13; p<0.01). Primary PCI was performed significantly less often after the declaration than before (68.3% vs 82.5%, p=0.009). The mechanical complication resulting from STEMI occurred in 13 of 359 (3.6%) patients before the declaration and 9 of 63 (14.3%) patients after the declaration (p<0.001). However, the incidence of in-hospital death (before, 6.2% vs after, 6.4%, p=0.95) was comparable.

CONCLUSIONS

Following the COVID-19 pandemic, an increased incidence of mechanical complications resulting from STEMI was observed. Instructing people to stay at home, without effectively educating them to immediately seek medical attention when suffering symptoms of a heart attack, may worsen outcomes in patients with STEMI.

Mitochondrial Biomarkers in Patients with ST-Elevation Myocardial Infarction and Their Potential Prognostic Implications: A Prospective Observational Study

Background: Mitochondrial biomarkers have been investigated in different critical settings, including ST-elevation myocardial infarction (STEMI). Whether they provide prognostic information in STEMI, complementary to troponins, has not been fully elucidated. We prospectively explored the in-hospital and long-term prognostic implications of cytochrome c and cell-free mitochondrial DNA (mtDNA) in STEMI patients undergoing primary percutaneous coronary intervention. Methods: We measured cytochrome c and mtDNA at admission in 466 patients. Patients were grouped according to mitochondrial biomarkers detection: group 1 (−/−; no biomarker detected; n = 28); group 2 (−/+; only one biomarker detected; n = 283); group 3 (+/+; both biomarkers detected; n = 155). A composite of in-hospital mortality, cardiogenic shock, and acute pulmonary edema was the primary endpoint. Four-year all-cause mortality was the secondary endpoint. Results: Progressively lower left ventricular ejection fractions (52 ± 8%, 49 ± 8%, 47 ± 9%; p = 0.006) and higher troponin I peaks (54 ± 44, 73 ± 66, 106 ± 81 ng/mL; p = 0.001) were found across the groups. An increase in primary (4%, 14%, 19%; p = 0.03) and secondary (10%, 15%, 23%; p = 0.02) endpoint rate was observed going from group 1 to group 3. The adjusted odds ratio increment of the primary endpoint from one group to the next was 1.65 (95% CI 1.04–2.61; p = 0.03), while the adjusted hazard ratio increment of the secondary endpoint was 1.55 (95% CI 1.12–2.52; p = 0.03). The addition of study group allocation to admission troponin I reclassified 12% and 22% of patients for the primary and secondary endpoint, respectively. Conclusions: Detection of mitochondrial biomarkers is common in STEMI and seems to be associated with in-hospital and long-term outcome independently of troponin.

Prehospital Administration of Unfractionated Heparin in ST-Segment Elevation Myocardial Infarction Is Associated With Improved Long-Term Survival

OBJECTIVE

Administration of unfractionated heparin to STEMI patients by the ambulance service is an established practice in Scotland, but the efficacy is unknown. We studied the effects of unfractionated heparin in STEMI patients treated by primary percutaneous coronary intervention, on infarct artery patency and mortality.

METHODS AND RESULTS

Consecutive patients (n = 1000) admitted to Ninewells Hospital, Dundee, from 2010 to 2014 for primary percutaneous coronary intervention were allocated to 2 groups: 437 (44%) prehospital heparin (PHH) administered by paramedics, and 563 (56%) in-hospital heparin. A trained medical student assessed coronary flow at presentation and collected the data. Mortality status was ascertained at 30 days and 5 years. Cox proportional hazards regression models were generated. The patient groups were similar, although PHH had shorter symptom onset-treatment time (187 vs. 251 minutes, P < 0.001) and less cardiogenic shock (3.9% vs. 8.0%, P = 0.008). Initial coronary flow was not different between the groups. Thirty day mortality in PHH was 2.5% versus 8.3%, P < 0.001. Independent predictors of 30-day mortality were age (odds ratio 1.07, 95% CI 1.04-1.09), cardiogenic shock (5.97, 3.33-10.69), radial access (0.53, 0.28-0.98), and PHH (0.33, 0.17-0.66). Five-year mortality in PHH was 13.0% versus 21.6%, P < 0.001. Significant predictors of long-term mortality were age (1.07, 1.06-1.09), cardiogenic shock (3.40, 2.23-5.17), and PHH (0.68, 0.49-0.96).

CONCLUSIONS

PHH was associated with reduced short- and long-term mortality after adjusting for important potential confounders.

Multivessel Coronary Artery Disease and Subsequent Thrombolysis in Myocardial Infarction Flow Grade After Primary Percutaneous Coronary Intervention

Background

In underdeveloped countries, coronary artery disease (CAD) has developed into a serious health issue due to the high rates of risk factors such as obesity and smoking amongst the population. This study has been performed to find the rate of multivessel CAD (MVD) and subsequent thrombolysis in myocardial infarction (TIMI) flow grade III in patients undergoing primary percutaneous coronary intervention (PCI).

Methods

This transverse study was carried out involving 110 patients from the emergency department of the National Institute of Cardiovascular Diseases, Karachi, Pakistan, from August 2015 to March 2016. All patients were diagnosed as ST-segment elevation myocardial infarction (STEMI) and had gone through primary PCI. Pre-procedure angiographic findings regarding the number of vessels involved and post-procedure TIMI flow grade were assessed and analysed.

Results

The average age of the study sample was 56.3 ± 11.4 years. The proportion of male patients was 81.8% (n=90), and hypertension was the most prevalent risk factor followed by type II diabetes with a frequency of 67.3% (n=74) and 40.0% (n=44), respectively. Coronary angiography showed MVD in 50.0% (n=55) of the patients, of whom 34 patients had two-vessel disease, and the remaining 21 had three-vessel disease. Ninety percent (n=99) of the patients exhibited TIMI flow grade III after the procedure with no significant difference between patients with MVD and those with single-vessel disease with a rate of 87.3% (n=48/55) versus 92.7% (n=51/55, P=0.527), respectively.

Conclusion

Post-procedure TIMI flow grade III was accomplished in almost 90% of the subjects with or without MVD. It can be concluded that primary PCI has a significant role in the early restoration of myocardial blood flow following STEMI regardless of the vessels involved.

The Role of Fractional Flow Reserve and Instantaneous Wave-Free Ratio Measurements in Patients with Acute Coronary Syndrome

PURPOSE OF REVIEW

The role of fractional flow reserve to guide revascularization in patients with stable angina is well established. The instantaneous wave-free ratio (iFR) is an emerging adenosine-free resting index that is non-inferior to FFR and has potential to streamline the functional evaluation of coronary artery disease. The feasibility and utility of intracoronary physiology in patients with acute coronary syndrome (ACS) is unclear. This review will discuss the physiological principles and validity of using FFR and iFR in patients presenting with ACS. We will also provide an overview of the available evidence for their role in guiding revascularization in this patient group.

RECENT FINDINGS

The use of intracoronary physiology in culprit lesions of patients presenting with STEMI is not recommended and its accuracy is uncertain in patients with NSTEMI. In contrast, the physiological assessment of non-culprit vessels with FFR and IFR is a reliable measure of lesion-specific ischemia. Recent studies have demonstrated that FFR-guided revascularization of non-culprit lesions improves clinical outcomes although the role of iFR in this patient cohort is unknown. Physiology-guided revascularization of non-culprit ACS lesions improves clinical outcomes. Future studies investigating the complementary role of plaque morphology, biomechanics, and systemic inflammation may provide clinicians with a more comprehensive framework to guide treatment decisions.

One-Month Clinical Outcomes of ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention at a High-volume Cardiac Tertiary Center: Routine Hours Versus Off-hours

Primary percutaneous coronary intervention (PCI) is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI). We aimed to compare 1-month major adverse cardiac events (MACE) of patients undergoing primary PCI between 2 routine-hour and off-hour working shifts. In this cross-sectional study, 1791 STEMI patients were retrospectively evaluated who underwent primary PCI. The patients were classified into 2 groups of routine and off-hour according to the PCI start time and date [495 patients (27.7%) in routine-hour group; 1296 patients (72.3%) in off-hour group]. Cardiovascular risk factor, angiographic, procedural data, door-to-device time, and 1-month follow-up data of patients were compared between 2 groups. There was a statistical difference in door-to-device time between routine-hour and off-hour group [55 minutes (40-100 minutes) in off-hour group vs. 49 minutes (35-73 minutes) in routine-hour group; P ≤ 0.001]. However, most of the patients in both groups had door-to-device time ≤60 minutes. The frequency of 1-month MACE was 8.5% in off-hour group and 6.9% in routine-hour group (P = 0.260). After adjustment for possible confounders, the procedure result, in-hospital death, and 1-month MACE were not significantly different between both study groups. We found that STEMI patients treated with primary angioplasty during off-hour shifts had similar 1-month clinical outcomes to routine-hour shifts. Considering the high number of patients requiring primary PCI during off-hours, the importance of early revascularization in acute myocardial infarction, and the comparable clinical outcomes and procedural success, full-time provision of primary PCI services seems to be beneficial.

Off-Pump Coronary Artery Bypass Grafting in Acute Coronary Syndrome: Focus on Safety and Completeness of Revascularization

Background Emergency coronary artery bypass grafting (CABG) in the setting of acute coronary syndrome (ACS) has been associated with increased morbidity and mortality. Avoiding cardiopulmonary bypass might be advantageous, but the role of off-pump CABG (OPCAB) remains controversial, as it has been associated with incomplete revascularization in several studies. The objective of this study was to evaluate the feasibility, efficacy, and outcome of OPCAB surgery in ACS patients.

Methods We performed a retrospective review of ACS patients who underwent on-pump CABG (ONCAB) or OPCAB, either emergently or delayed, at our institution.

Results Between January 2015 and December 2016, a total of 205 consecutive ACS patients underwent either ONCAB (109 patients, 53.2%) or OPCAB surgery (96 patients, 46.8%). EuroSCORE II levels (5.6 ± 7.2 vs 4.9 ± 6.5, p = 0.226) and demography were comparable between groups.

A trend towards lower postoperative mortality was observed in OPCAB patients (2.1 vs 5.5%). The incidence of postoperative stroke and low cardiac output syndrome, as well as the duration of inotropic support and the need for re-sternotomy, was significantly lower in the OPCAB group (p < 0.05).

CABG performed instantly in an emergency situation was not associated with increased mortality or morbidity when compared with delayed procedures, and OPCAB surgery in emergency patients was associated with lower postoperative morbidity and shorter stays in the intensive care unit (p < 0.05).

There were no differences in completeness of revascularization between groups (median 1 [1–1.33;0.33–1.67] OPCAB versus median 1 (1–1.33;0.67–2) ONCAB, p = 0.617), even in the emergency setting.

Conclusion OPCAB surgery is safe and effective in ACS and may be considered in hemodynamically stable patients in the emergency setting.

KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.

Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis

OBJECTIVES

The present Bayesian network meta-analysis aimed to compare the various strategies for acute ischemic stroke: direct endovascular thrombectomy within the thrombolysis window in patients with no contraindications to thrombolysis (DEVT); (2) direct endovascular thrombectomy secondary to contraindications to thrombolysis (DEVTc); (3) endovascular thrombectomy in addition to thrombolysis (IVEVT); and (4) thrombolysis without thrombectomy (IVT).

METHODS

Six electronic databases were searched from their dates of inception to May 2017 to identify randomized controlled trials (RCTs) comparing IVT versus IVEVT, and prospective registry studies comparing IVEVT versus DEVT or IVEVT versus DEVTc. Network meta-analyses were performed using ORs and 95% CIs as the summary statistic.

RESULTS

We identified 12 studies (5 RCTs, 7 prospective cohort) with a total of 3161 patients for analysis. There was no significant difference in good functional outcome at 90 days (modified Rankin Scale score ≤2) between DEVT and IVEVT. There was no significant difference in mortality between all treatment groups. DEVT was associated with a 49% reduction in intracranial hemorrhage (ICH) compared with IVEVT (OR 0.51; 95% CI 0.33 to 0.79), due to reduction in rates of asymptomatic ICH (OR 0.47; 95% CI 0.29 to 0.76). Patients treated with DEVT had higher rates of reperfusion compared with IVEVT (OR 1.73; 95% CI 1.04 to 2.94).

CONCLUSIONS

To our knowledge, this is the first network meta-analysis to be performed in the era of contemporary mechanical thrombectomy comparing DEVT and DEVTc. Our analysis suggests the addition of thrombolysis prior to thrombectomy for large vessel occlusions may not be associated with improved outcomes.

Criteria for ECG detection of acute myocardial ischemia: Sensitivity versus specificity

BACKGROUND

Criteria for electrocardiographic detection of acute myocardial ischemia recommended by the Consensus Document of ESC/ACCF/AHA/WHF consist of two parts: The ST elevation myocardial infarction (STEMI) criteria based on ST elevation (ST↑) in 10 pairs of contiguous leads and the other on ST depression (ST↓) in the same 10 contiguous pairs. Our aim was to assess sensitivity (SE) and specificity (SP) of these criteria-and to seek their possible improvements-in three databases of 12‑lead ECGs.

METHODS

We used (1) STAFF III data of controlled ischemic episodes recorded from 99 patients (pts) during percutaneous coronary intervention (PCI) involving either left anterior descending (LAD) coronary artery, right coronary artery (RCA), or left circumflex (LCx) coronary artery. (2) Data from the University of Glasgow for 58 pts with acute myocardial infarction (AMI) and 58 pts without AMI, as confirmed by MRI. (3) Data from Lund University retrieved from a centralized ECG management system for 100 pts with various pathological ST changes-other than acute coronary occlusion-including ventricular pre-excitation, acute pericarditis, early repolarization syndrome, left ventricular hypertrophy, and left bundle branch block. ST measurements at J-point in ECGs of all 315 pts were obtained automatically on the averaged beat with manual review and the recommended criteria as well as their proposed modifications, were applied. Performance measures included SE, SP, positive predictive value (PPV), and benefit-to-harm ratio (BHR), defined as the ratio of true-positive vs. false-positive detections.

RESULTS

We found that the SE of widely-used STEMI criteria can be indeed improved by the additional ST↓ criteria, but at the cost of markedly decreased SP. In contrast, using ST↑ in only 3 additional contiguous pairs of leads (STEMI13) can boost SE without any loss of SP. In the STAFF III database, SE/SP/PPV were 56/98/97% for the STEMI, 79/79/79% for the STEMI with added ST↓ and 67/97/96% for the STEMI13. In the Glasgow database, corresponding SE/SP/PPV were 43/98/96%, 84/90/89%, and 55/98/97%. For the Lund database, SP was 56% for the STEMI, 24% for the STEMI with ST↓, and 56% for the STEMI13.

CONCLUSION

Current recommended criteria for detecting acute myocardial ischemia, involving ST↓, boost SE of widely-used STEMI criteria, at the cost of SP. To keep the SP high, we propose either the adjustment of threshold for the added ST↓ criteria or a selective use of ST↓ only in contiguous leads V2 and V3 plus ST↑ in lead pairs (aVL, -III) and (III, -aVL).

Causes of delay in door-to-balloon time in south-east Asian patients undergoing primary percutaneous coronary intervention

Objective

To evaluate causes and impact of delay in the door-to-balloon (D2B) time for patients undergoing primary percutaneous coronary intervention (PPCI).

Subjects and methods

From January 2009 to December 2012, 1268 patients (86% male, mean age of 58 ± 12 years) presented to our hospital for ST-elevation myocardial infarction (STEMI) and underwent PPCI. They were divided into two groups: Non-delay defined as D2B time ≤ 90 mins and delay group defined as D2B time > 90 mins. Data were collected retrospectively on baseline clinical characteristics, mode of presentation, angiographic findings, therapeutic modality and inhospital outcome.

Results

202 patients had delay in D2B time. There were more female patients in the delay group. They were older and tend to self-present to hospital. They were less likely to be smokers and have a higher prevalence of prior MI. The incidence of posterior MI was higher in the delay group. They also had a higher incidence of triple vessel disease.

The 3 most common reasons for D2B delay was delay in the emergency department (39%), atypical clinical presentation (37.6%) and unstable medical condition requiring stabilisation/computed tomographic imaging (26.7%). The inhospital mortality was numerically higher in the delay group (7.4% versus 4.8%, p = 0.12).

Conclusions

Delay in D2B occurred in 16% of our patients undergoing PPCI. Several key factors for delay were identified and warrant further intervention.

Unmet goals in the treatment of Acute Myocardial Infarction: Review

Reperfusion therapy decreases myocardium damage during an acute coronary event and consequently mortality. However, there are unmet needs in the treatment of acute myocardial infarction, consequently mortality and heart failure continue to occur in about 10% and 20% of cases, respectively. Different strategies could improve reperfusion. These strategies, like generation of warning sign recognition and being initially assisted and transferred by an emergency service, could reduce the time to reperfusion. If the first electrocardiogram is performed en route, it can be transmitted and interpreted in a timely manner by a specialist at the receiving center, bypassing community hospitals without percutaneous coronary intervention capabilities. To administer thrombolytic therapy during transport to the catheterization laboratory could reduce time to reperfusion in cases with expected prolonged transport time to a percutaneous coronary intervention center or to a center without primary percutaneous coronary intervention capabilities with additional expected delay, known as pharmaco-invasive strategy. Myocardial reperfusion is known to produce damage and cell death, which defines the reperfusion injury. Lack of resolution of ST segment is used as a marker of reperfusion failure. In patients without ST segment resolution, mortality triples. It is important to note that, until recently, reperfusion injury and no-reflow were interpreted as a single entity and we should differentiate them as different entities; whereas no-reflow is the failure to obtain tissue flow, reperfusion injury is actually the damage produced by achieving flow. Therefore, treatment of no-reflow is obtained by tissue flow, whereas in reperfusion injury the treatment objective is protection of susceptible myocardium from reperfusion injury. Numerous trials for the treatment of reperfusion injury have been unsuccessful. Newer hypotheses such as “ controlled reperfusion”, in which the interventional cardiologist assumes not only the treatment of the culprit vessel but also the way to reperfuse the myocardium at risk, could reduce reperfusion injury.

Experience and Outcomes of Primary Percutaneous Coronary Intervention for Patients with ST-Segment Elevation Myocardial Infarction of Tertiary Care Center in Bosnia and Herzegovina

BACKGROUND

Primary percutaneous coronary intervention (PCI) is an emergent percutaneous catheter intervention in the setting of ST-segment elevations myocardial infarction (STEMI), without previous fibrinolytic treatment.

AIM

To evaluate the feasibility and outcomes of primary percutaneous coronary interventions for STEMI in regional tertiary care cardiac centre in Bosnia and Herzegovina.

METHODS

Between January 2014 and December 2016, consecutive 549 STEMI patients who underwent primary PCI were prospectively enrolled in a primary PCI registry. The most of coronary angiography procedures were performed using the radial artery route. Patient demographics, risk factors, procedural characteristics, time variables and in-hospital events were assessed.

RESULTS

On admission, 297 (64.7%) of the patients were current smokers, 234 (42.6%) were hypertensive, 172 (31.3%) were diabetics, and 68 (12.3%) had cardiogenic shock. The mean duration of time from symptom onset to hospital arrival 193±118.2 minutes, and the mean door-to-balloon time was 37±11.3 minutes and median total ischemic time was 265(60-897) minutes. Infarct-related artery (IRA) was the left anterior descending artery in 47.1%, multivessel disease was present in 49.7%. Primary PCI involved balloon dilatation (2.7%) and stent implantation (97.3%). The incidence of postprocedural angiographic no-reflow was 6.7%. All-cause mortality occurred in 17 patients (3.1%).

CONCLUSION

This study has shown feasibility and efficiency in performing of primary PCI with good outcomes in the first regional interventional center in Bosnia and Herzegovina. Experiences and results of our hospital can be very useful in creating primary PCI networks in our countries and developing countries as well.

Correlation and prognostic role of neutrophil to lymphocyte ratio and SYNTAX score in patients with acute myocardial infarction treated with percutaneous coronary intervention: A six-year experience

BACKGROUND/PURPOSE

The neutrophil/lymphocyte ratio (NLR) has been proposed as a prognostic marker in acute myocardial infarction (AMI). The aim of our study is to demonstrates the correlation between SYNTAX score (SXs) and NLR and its association with 1-year cardiovascular (CV) mortality in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI).

METHODS/MATERIALS

Over 6 consecutive years, (1st January 2010 and 1st January 2016) 6560 patients (4841 males and 1719 females, mean age 64.36±11.77years) were admitted for AMI and treated with PCI within 24-h. The study population was divided into tertiles based on the SXs.

RESULTS

Both in STEMI and NSTEMI groups, neutrophils and the SXs were significantly higher (p<0.0001) in upper versus lower among NLR tertiles and a significant correlation was found between the NLR and SXs (r=0.617, p<0.0001 and r=0.252, p<0.0001 for STEMI and NSTEMI groups, respectively). One-year CV mortality significantly raised up among the NLR tertiles in both STEMI and NSTEMI patients (p<0.0001). Multivariate analysis revealed that, after adjusting SXs and PAD, an NLR (≥3.9 and ≥2.7 for STEMI and NTEMI patients, respectively) was an independent significant predictor of 1-year CV mortality (OR 2.85, 95% CI 1.54-5.26, p=0.001 and OR 2.57, 95% CI 1.62-4.07, p<0.0001 for STEMI and NSTEMI respectively.) CONCLUSIONS: NLR significantly correlates with SXs and is associated with 1-year CV mortality in patients with STEMI or NSTEMI treated with PCI within 24-h.

Factors influencing choice of pre-hospital transportation of patients with potential acute coronary syndrome: An observational study

OBJECTIVE

To determine factors associated with ambulance use in patients with confirmed and potential acute coronary syndrome presenting to the ED.

METHODS

A convenience sample of patients (n = 247) presenting to the ED from April 2014 to January 2015 with suspected acute coronary syndrome were included in the study. Data on mode of transport and patient demographics were collected from the Emergency Department Information System database. Clinical data were collected from chart records and information systems. A questionnaire assessed reasons for using a chosen method of transport, symptom timing and characteristics, acute coronary syndrome knowledge, and awareness of the National Heart Foundation Early Warning Symptoms campaign.

RESULTS

Approximately half the patients (49.4%) assessed with symptoms of potential acute coronary syndrome used ambulance transport to the ED. Patients who arrived by ambulance were older than those not arriving by ambulance (mean 56.7 years vs 51.7 years, P = 0.01). Risk factors were not associated with ambulance use. Dizziness (P < 0.01), sweating (P = 0.03), nausea (P = 0.03) and vomiting (P = 0.04) were associated with increased ambulance use. Mean systolic blood pressure was lower in the ambulance group (136 mmHg, standard deviation [SD] = 19.8) than in the non-ambulance group (143 mmHg, SD = 25.9). Awareness of the National Heart Foundation Heart Attack Warning Signs campaign was not associated with ambulance use.

CONCLUSIONS

Patients with possible ischaemic symptoms who are at a high risk of cardiac disease do not utilise ambulance services more than low risk patients. In general, transport to hospital using ambulance services by patients with symptoms of possible acute coronary syndrome is low despite community campaigns.

Validation of the vessel-specific leads (VSLs) for detection of acute ischemia on a dataset with non-ischemic ST-segment deviation

BACKGROUND

Existing criteria recommended by ACC/ESC for identifying patients with ST elevation myocardial infarction (STEMI) from the 12-lead ECG perform with high specificity (SP) but low sensitivity (SE). In our previous studies, we found that the SE of acute ischemia detection can be markedly improved without any loss of SP by calculating, from the 12-lead ECG, ST deviation in 3 "optimal" vessel-specific leads (VSLs). To further validate the method, we evaluated the SP performance using a dataset with non-ischemic ST-segment changes.

METHODS

12-lead ECGs of 100 patients (75 males/25 females, age range 12-83years, average age 52years) were retrieved from a centralized ECG management system at Skåne University Hospital, Lund, Sweden. These ECGs were chosen to represent five subgroups with various causes of pathological ST deviation, other than acute coronary occlusion: a) ventricular preexcitation (n=12), b) acute pericarditis (n=26), c) early repolarization syndrome (ERS) (n=14), d) left ventricular hypertrophy (LVH) with "strain" (n=26), and e) left bundle branch block (LBBB) (n=22). ECGs with inadequate signal quality, heart rate exceeding 120bpm and/or atrial flutter were not selected for this study population. Both STEMI criteria and VSLs criteria with and without a new augmented LVH-specific derived lead were tested. SP, calculated for each subgroup and combined, was used as the performance measure for comparison.

RESULTS

SP test results for the STEMI criteria vs. the VSLs method without the augmented LVH lead were 100% vs. 92%, 4% vs. 88%, 29% vs. 100%, 100% vs. 77%, and 64% vs. 68% for the five subgroups with preexcitation, pericarditis, ERS, LVH, and LBBB, respectively. For the whole group, SP was 57% for the STEMI criteria and 83% for the VSLs criteria; this improvement was statistically significant (p<0.001). With the augmented LVH lead, SP for the VSLs improved from 77% to 96% for the LVH subgroup and SP for the other subgroups remained unchanged. For the whole study group, SP improved from 83% to 88%.

CONCLUSION

Based on these results, we conclude that the VSLs criteria are not only more sensitive in detecting acute ischemia but also more specific in recognizing patients with non-ischemic ST deviation than the existing STEMI criteria. This finding needs to be further corroborated on a larger patient population with AMI prevalence typical of the population presenting to the emergency room.

Health Care Exceptionalism? Performance and Allocation in the US Health Care Sector

The conventional wisdom for the healthcare sector is that idiosyncratic features leave little scope for market forces to allocate consumers to higher performance producers. However, we find robust evidence - across several different conditions and performance measures - that higher quality hospitals have higher market shares and grow more over time. The relationship between performance and allocation is stronger among patients who have greater scope for hospital choice, suggesting that patient demand plays an important role in allocation. Our findings suggest that healthcare may have more in common with "traditional" sectors subject to market forces than often assumed.

Combined effect of left ventricular ejection fraction and post-cardiac depressive symptoms on major adverse cardiac events after successful primary percutaneous coronary intervention: a 12-month follow-up

BACKGROUND

Despite the technical advancement of percutaneous coronary intervention, major adverse cardiac events after percutaneous coronary intervention are still a critical issue in Korea as well as in western society. Recently, low left ventricular ejection fraction and depressive symptoms have been regarded as independent predictors of adverse outcomes after successful primary percutaneous coronary intervention. However, there are few studies on the combined effect of left ventricular ejection fraction at baseline and post-cardiac depressive symptoms on major adverse cardiac events after percutaneous coronary intervention.

AIM

The aim of the current study is to examine the combined effect of low left ventricular ejection fraction and post-cardiac depressive symptoms on major adverse cardiac events after successful primary percutaneous coronary intervention.

METHODS

A total of 221 patients who underwent successful percutaneous coronary intervention were assessed for left ventricular ejection fraction and depressive symptoms at baseline and 1 month after discharge, using the patient health questionnaire 9. Major adverse cardiac event-free survival rates during the 12-month follow-up period were analysed by Kaplan-Meier survival curves and Cox proportional hazard regression methods.

RESULTS

We found that the combined effect of baseline left ventricular ejection fraction less than 60% and depressive symptoms at 1 month after discharge were significantly correlated with increased incidence of major adverse cardiac events after successful primary percutaneous coronary intervention (hazard ratio 4.049; 95% confidence interval 1.365-12.011) after adjusting for sex, high sensitivity C-reactive protein, depressive symptoms at baseline and comorbidity.

CONCLUSIONS

Our results suggest that healthcare professionals should be aware of the necessity of early screening for post-cardiac depressive symptoms after discharge in percutaneous coronary intervention patients with a low left ventricular ejection fraction.

Coordinated regional care of myocardial infarction in a rural area in Brazil: Minas Telecardio Project 2

Aims

In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities.

Methods and results

The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay - transport time) decreased by 40% (95% confidence intervals: -66%, -13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin [94.2-100% (P = 0.003)] and P2Y12 inhibitors [87.5-100% (P < 0.001)]. The odds of in-hospital death showed a non-significant decrease [odds ratio 0.73 (95% confidence intervals: 0.34-1.60)].

Conclusion

The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.

Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke: A Matched-Pairs Analysis

BACKGROUND AND PURPOSE

Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear.

METHODS

We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2.

RESULTS

From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group.

CONCLUSIONS

In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted.

Postinfarct Left Ventricular Remodelling: A Prevailing Cause of Heart Failure

Heart failure is a chronic disease with high morbidity and mortality, which represents a growing challenge in medicine. A major risk factor for heart failure with reduced ejection fraction is a history of myocardial infarction. The expansion of a large infarct scar and subsequent regional ventricular dilatation can cause postinfarct remodelling, leading to significant enlargement of the left ventricular chamber. It has a negative prognostic value, because it precedes the clinical manifestations of heart failure. The characteristics of the infarcted myocardium predicting postinfarct remodelling can be studied with cardiac magnetic resonance and experimental imaging modalities such as diffusion tensor imaging can identify the changes in the architecture of myocardial fibers. This review discusses all the aspects related to postinfarct left ventricular remodelling: definition, pathogenesis, diagnosis, consequences, and available therapies, together with experimental interventions that show promising results against postinfarct remodelling and heart failure.

Myocardial Infarct Size in Patients on Long-Term Statin Therapy Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Statin pretreatment has been reported to have a cardioprotective effect in patients undergoing elective or urgent percutaneous coronary intervention (PCI). However, data on patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI are still controversial. We prospectively evaluated the effect of long-term statin therapy on infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) in consecutive patients with STEMI who underwent primary PCI. Two-hundred thirty patients with STEMI (mean age 61 ± 11 years, 183 men) who underwent primary PCI were evaluated with cardiac magnetic resonance (CMR) imaging during hospitalization (median 4 days after primary PCI). In all patients, we measured peak troponin I level, whereas IS, MSI, and MVO were determined by CMR. Fifty patients (22%) were on long-term statin therapy and showed a significantly lower troponin I peak value compared to patients without previous statins (54 ± 47 vs 88 ± 106 ng/ml; p = 0.02). At CMR evaluation, IS related to the index event was significantly smaller (12.5 ± 11.5 vs 18.5 ± 18.5 g, p = 0.05), and MSI was higher (0.68 ± 0.25 vs 0.52 ± 0.30; p <0.01) in patients with previous statin therapy. MVO was also less frequent (10% vs 20%; p = 0.14) in this group. At multivariate analysis, previous statin therapy remained significantly associated with IS and MSI (p = 0.05 and 0.02, respectively). In conclusion, this study suggests that long-term statin therapy before primary PCI in patients with STEMI is associated with smaller IS and higher MSI. Future studies are warranted to confirm these findings and to investigate potential clinical implications.

Characteristics and Outcomes of Patients with Acute Myocardial Infarction at Non-PCI Capable Hospitals in 2007 and in 2014

Background. There is little known about whether characteristics and outcomes of patients with acute myocardial infarction (AMI) have changed over the years in non-PCI capable hospitals in real-life. Our aim was to assess them between 2007 and 2014. Methods. It was a retrospective cohort study. Characteristics and in-hospital mortality (standardized in cases of different characteristics between the groups by original simple method) were assessed for all patients with non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI) at two non-PCI capable hospitals: one in 2007 (n = 104) and another in 2014 (n = 58). Results. In 2014, females were older than in 2007 (80.18 ± 7.54 versus 76.15 ± 8.77, p = 0.011), males were younger (71.61 ± 11.22 versus 79.20 ± 7.63, p = 0.019), less had renal failure (RF) (19% versus 34.6%, p < 0.0001) and reinfarction (13.8% versus 35.6%, p < 0.0001), and the proportion of males (31% versus 43.3%, p = 0.001) and the proportion of NSTEMI (60.3 versus 69.2, p < 0.0001) decreased. In cases of STEMI there were no differences in patient characteristics. STEMI (18.8% versus 21.7%) and standardized mortalities by gender, RF, and reinfarction NSTEMI (19.47%, 15.34%, and 17.5%, resp., versus 17.1%) showed no differences between 2007 and 2014. Conclusions. There were some differences in patient characteristics but not in mortality for AMI at non-PCI capable hospitals between 2007 and 2014.

Field triage in the ambulance versus referral via non-percutaneous coronary intervention centre in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: A systematic review

AIMS

The purpose of this study was to determine whether direct ambulance transport of ST-elevation myocardial infarction (STEMI) patients to a percutaneous coronary intervention (PCI) hospital (field triage) leads to a lower 30-day mortality compared to transport via a referral non-PCI hospital (referral via a spoke centre) in STEMI patients.

METHODS AND RESULTS

We performed a systematic review of interventions. An experienced librarian searched in PubMed, EMBASE.com and The Cochrane Library (via Wiley) from January 1980-February 2013. Studies that examined field triage and/or referral via a spoke centre in STEMI patients treated with primary or facilitated PCI were included. Two authors independently conducted the study selection and data extraction. Multivariable frequency weighted logistic regression analysis was performed to assess the effect of the type of transfer on the outcome measures. We identified 14 randomised clinical trials (RCTs), including 20 transfer groups and 4474 participants. Thirty-day mortality was lower in patients who underwent field triage (3.0%; 95% confidence interval (CI) 2.2-4.2) compared to patients who were referred via a spoke centre (4.7%; 95% CI 4.0-5.5). In multivariable frequency weighted logistic regression analysis, field triage was independently associated with a lower incidence of 30-day mortality (odds ratio (OR): 0.58; 95% CI 0.37-0.89).

CONCLUSION

Field triage compared to referral via a spoke centre leads to a lower 30-day mortality in STEMI patients. Therefore, direct ambulance transport to a PCI hospital should become the transfer type for STEMI patients.

Routine diversion of patients with STEMI to high-volume PCI centres: modelling the financial impact on referral hospitals

OBJECTIVE

To quantify possible revenue losses from proposed ST-elevation myocardial infarction (STEMI) patient diversion policies for small hospitals that lack high-volume percutaneous coronary intervention (PCI) capability status (ie, 'STEMI referral hospitals').

BACKGROUND

Negative financial impacts on STEMI referral hospitals have been discussed as an important barrier to implementing regional STEMI bypass/transfer protocols. However, there is little empirical data available that directly quantifies this potential financial impact.

METHODS

Using detailed financial charges from Florida hospital discharge data, we examined the potential negative financial impact on 112 STEMI referral hospitals from losing all inpatient STEMI revenue. The main outcome was projected revenue loss (PRL), defined as total annual patient with STEMI charges as a proportion of total annual charges for all patients. We hypothesised that for most community hospitals (>90%), STEMI revenue represented only a small fraction of total revenue (<1%). We further examined the financial impact of the 'worst case' scenario of loss of all acute coronary syndrome (ACS) (ie, chest pain) patients.

RESULTS

PRLs were $0.33 for every $100 of patient revenue statewide for STEMI and $1.73 for ACS. At the individual hospital level, the 90th centile PRL was $0.74 for STEMI and $2.77 for ACS. PRLs for STEMI were not greater in rural areas compared with major metropolitan areas. Hospital revenue centres that would be most impacted by loss of patients with STEMI were cardiology procedures and intensive care units.

CONCLUSIONS

Loss of patient with STEMI revenues would result in only a small financial impact on STEMI referral hospitals in Florida under proposed STEMI diversion/rapid transfer protocols. However, spillover loss of patients with ACS would increase revenue loss for many hospitals.

Dual isotope simultaneous imaging to evaluate the effects of intracoronary bone marrow-derived mesenchymal stem cells on perfusion and metabolism in canines with acute myocardial infarction

Stem cell therapy on acute myocardial infarction (AMI) has been performed for over a decade. In the present study, cardiac perfusion, metabolism and function in dogs with AMI treated by intracoronary injection of bone marrow-derived mesenchymal stem cells (MSCs) were evaluated by dual isotope simultaneous acquisition (DISA) of single positron emission computed tomography (SPECT). Dogs (n=12, 20-30 kg) were randomly assigned to two groups: A graft study (n=6) and control group (n=6). Bone marrow mesenchymal aspirate was collected 3 weeks before surgical procedure. Stem cells were induced by 5-azacytidine for differentiation into myocytes. The dog AMI model was produced by blocking the blood stream at 1/3 of the distinct left anterior descending coronary artery for 90 min. For dogs in the grafting group, MSCs were transplanted by intracoronary injection, and for the control group, 0.9% NaCl was injected instead. At 1 and 10 weeks after MSCs were grafted, respectively, SPECT DISA was performed for each dog in the two groups with ^99mTc-SPECT MIBI (925 MBq) and ¹⁸F-FDG (222 MBq) for evaluation of myocardial perfusion and metabolism. After the dogs were sacrificed, heart tissue was stained by myocyte-specific antibodies for newborn vessels, troponin T and bromodeoxyuridine (BrdU). Following induction by 5-azacytidine, the morphological features with colony formation, microfilament, as well as atrial granules and positive stainings of α-actinin, myosin and troponin I demonstrated strongly that the MSCs differentiated into myocytes. The number of viable myocardial segments was 10 in the grafting group, which was significantly greater compared with the control group. The ejection fraction of the infarcted left ventricle (LVEF,%) increased from 53.80±9.58 to 70.00±7.52 (change, 16.20±2.93) at 1 and 10 weeks after MSCs engraftment, whilst in the control group, LVEF was 50.50±8.02 and 56.50±7.24 (change, 5.50±2.69), respectively. The LVEF difference was statistically significant (P<0.05) between the graft and control groups. Furthermore, immunostaining of all the myocyte-specific antibodies (for newly born vessels, troponin T and BrdU) was positive. In conclusion, direct intracoronary injection of bone marrow MSCs into injured myocardium in the experimental dog AMI model can significantly improve cardiac function with new vessel formation and myocyte-specific biomarker expression, and in particular, the present study further shows that DISA SPECT can be used for the assessment of stem cell transplantation in the heart.

Impact of a rapid access protocol on decreasing door-to-balloon time in acute ST elevation myocardial infarction

Objective:

Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI.

Methods:

Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann–Whitney U test and presented graphically with Kaplan–Meier curves.

Results:

Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67–108) preprotocol to 62 minutes (IQR 40–80) postprotocol (p &lt; 0.001).

Conclusion:

In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI.

Relationship Between Physiological Parameters and Acute Coronary Syndrome in Patients Presenting to the Emergency Department With Undifferentiated Chest Pain

The investigators of this study sought to examine whether abnormal physiological parameters are associated with increased risk for acute coronary syndrome (ACS) in patients presenting to the emergency department (ED) with chest pain.

METHODS

We used prospectively collected data on adult patients presenting with suspected ACS in 2 EDs in Australia and New Zealand. Trained research nurses collected physiological data including temperature, respiratory rate, heart rate, and systolic blood pressure (SBP) on presentation to the ED. The primary endpoint was ACS within 30 days of presentation, as adjudicated by cardiologists using standardized guidelines. The prognostic utility of physiological parameters for ACS was examined using risk ratios.

RESULTS

Acute coronary syndrome was diagnosed in 384 of the 1951 patients (20%) recruited. Compared with patients whose SBP was between 100 and 140 mm Hg, patients with an SBP of lower than 100 mm Hg or higher than 140 mm Hg were 1.4 times (95% confidence interval, 1.2-1.7) more likely to have ACS. Similarly, compared with patients whose temperature was between 36.5°C and 37.5°C, patients with temperature of lower than 36.5°C or higher than 37.5°C were 1.4 times (95% confidence interval, 1.1-1.6) more likely to have ACS. Heart rate and respiratory rate were not predictors of ACS.

CONCLUSIONS

Patients with abnormal temperature or SBP were slightly more likely to have ACS, but such risk was of too small a magnitude to be useful in clinical decision making. Other physiological parameters (heart rate and respiratory rate) had no prognostic value. The use of physiological parameters cannot reliably confirm or rule out ACS.