Latest STEMI treatment: a focus on current and upcoming devices

Paramedic Ability in Interpreting Electrocardiogram with ST-segment Elevation Myocardial Infarction (STEMI) in Saudi Arabia

Objective

To evaluate paramedic ability in recognizing 12-lead Electrocardiogram (ECG) with ST-segment Elevation myocardial infarction (STEMI) in Saudi Arabia.

Methods

This is a quantitative exploratory cross-sectional study using an electronic survey of paramedics was conducted between June and September 2021. The survey included demographics, educational and clinical experiences, and multiple 12-lead ECG strip questions to assess participants’ ability to recognize STEMI. We reported the overall sensitivity, specificity, and correct proportions with 95% Confidence Intervals (CI).

Results

Eighty-four paramedics completed the survey, and 65% of them were between 24 and 29 years old, with a median, of three years of field experience. Overall sensitivity and specificity were 58.39% (95% CI, 50.4% to 66.1%) and 29.01% (95% CI, 25.15% to 33.1%), respectively. In total, 67.1% correctly identified inferior STEMI, whereas only 50% correctly identified lateral STEMI. Both STEMIs were correctly identified by 41%, and the majority misinterpreted STEMI mimics (ECG rhythms with similar ECG morphology to STEMI). The proportion who correctly recognized left bundle branch block was 14.8%, pericarditis was 10.9%, and ventricular pacing was 1.4%. However, almost third of participants correctly identified right bundle branch block (32.9%) and left ventricle hypertrophy (30.7%). Overall, there was no correlation between the correct ECG interpretation of STEMIs and educational and clinical experiences.

Conclusion

Paramedics were able to identify STEMI events in prehospital settings with moderate sensitivity and low specificity with limited ability to differentiate between STEMI and STEMI mimics. Therefore, additional training in ECG interpretation could improve their clinical decision-making, and to ensure that proper care and treatment is provided. Further research on a large, representative sample of paramedics across the country could provide more definitive evidence to establish a greater degree of accuracy in detecting STEMI in prehospital settings.

Nomogram for Predicting In-Hospital Mortality in Patients with Acute ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock after Primary Percutaneous Coronary Intervention

Background

Mortality after percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients with cardiogenic shock (CS) remains high. However, the real-world risk factors for mortality in these patients are poorly defined.

Objective

The aim of this study is to establish a clinical prognostic nomogram for predicting in-hospital mortality after primary PCI in STEMI patients with CS.

Methods

This retrospective, multicenter, observational study included STEMI patients with CS who underwent PCI at 39 hospitals in Hebei Province from January 2018 to December 2019. A multivariate logistic regression model was used to identify the factors associated with in-hospital mortality. These factors were then incorporated into a nomogram and its performance was evaluated by discrimination, calibration, and clinical utility.

Results

This study included 274 patients, among whom 179 died in hospital. Sex, random blood glucose on admission, ejection fraction after PCI, no-reflow, and intra-aortic balloon pump (IABP) were independently associated with in-hospital mortality (all P < 0.05). In the training set, the nomogram showed a C-index of 0.819, goodness-of-fit of 0.08, and area under the receiver operating characteristic curve (AUC) of 0.819 (95%CI = 0.759–0.879). In the testing set, the C-index was 0.842, goodness-of-fit was 0.585, and AUC was 0.842 (95%CI = 0.715–0.970). The results indicate that the nomogram had good discrimination and good prediction accuracy and could achieve a good net benefit.

Conclusion

We established and validated a nomogram that provided individual prediction of in-hospital mortality for STEMI patients with CS after PCI in a Chinese population.

Impact of thrombus aspiration in frail STEMI patients

BACKGROUND

Despite primary percutaneous coronary intervention (PPCI) is generally considered the best therapy in older frail adults with ST-segment elevation myocardial infarction (STEMI), the incidence of re-hospitalization for cardiovascular diseases remains significant in these patients.

AIMS

We hypothesized that thrombus aspiration (TA) before PPCI could be a useful treatment for reducing mortality and rehospitalizations in frail patients undergoing PPCI for STEMI.

METHODS

We conducted a study comparing PPCI alone vs TA + PPCI in frail STEMI patients. We examined a cohort of consecutive frail patients aged ≥ 65 years with first STEMI treated with PPCI between February 2008 and July 2015 at the Department of Cardiology of the "Cardarelli" Hospital in Naples, Italy.

RESULTS

The study was completed by 389 patients (PPCI: 195, TA + PPCI: 194). At 1-month follow-up, the rate of death from any cause was 7.0% in patients treated with PPCI alone vs 3.0% in patients treated with TA + PPCI (p 0.036), whereas death from cardiovascular causes was 6.0% in the PPCI group vs 3.0% in the TA + PPCI group (p 0.028). Equally important, the rate of re-hospitalization due to heart failure was 7.5% in the PPCI group vs 4.0% in TA + PPCI group (p 0.025) and the rate of re-hospitalization due to acute coronary syndrome was 10.0% in the PPCI group vs 4.5% in the TA + PPCI group (p 0.016).

CONCLUSION

These results indicate the importance of TA in the treatment of STEMI in a group of high-risk patients such as elderly with frailty.

Comparison of Efficacy and Safety of Recombinant Human Prourokinase and Alteplase in the Treatment of STEMI and Analysis of Influencing Factors of Efficacy

OBJECTIVE

To compare the efficacy and safety of recombinant human prourokinase (rhPro-UK) and alteplase for thrombolytic therapy in acute ST-segment elevation myocardial infarction (STEMI) and to analyze the related factors affecting efficacy.

METHODS

From January 2017 to December 2019, 100 patients diagnosed with STEMI were selected and randomly divided into the control group (n = 50) and the observation group (n = 50). Based on conventional treatments, the control group was treated with alteplase, and the observation group was treated with rhPro-UK, and both were treated for 7 days. After treatment, the vascular recanalization, left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVEDD), and left ventricular ejection fraction (LVEF) were compared. The bleeding and major adverse cardiovascular events (MACE) were recorded in both groups. According to the patient's vascular recanalization, it was divided into two subgroups: recanalization group and occlusion group. Multiple logistic regression models were used to analyze the related factors that affect the efficacy.

RESULTS

The recanalization rate of the observation group (96.00%) was higher than that of the control group (84.00%) (P < 0.05). After treatment, LVDs and LVEDD in both groups were lower than those before treatment, and LVEF was higher than that before treatment. The LVDs and LVEDD in the observation group were lower than those in the control group, and the LVEF was higher than that in the control group (P < 0.05). The incidence of bleeding in the observation group (2.00%) was lower than that in the control group (12.00%), and the incidence of MACE (4.00%) was lower than that in the control group (16.00%) (P < 0.05). Univariate analysis showed that age, smoking history, diabetes history, myocardial infarction history, infarct location, and intravenous thrombolysis time were related to the efficacy after treatment (P < 0.05). Multivariate logistic analysis showed that age, history of diabetes, vascular infarction site, and venous thrombolysis time were independent influencing factors after treatment (P < 0.05).

CONCLUSION

Both rhPro-UK and alteplase thrombolytic therapy can effectively recanalize blood vessels and improve the cardiac function of patients with STEMI. However, rhPro-UK has better effect than alteplase and is safer and worth promoting. The curative effect is related to age, diabetes history, vascular infarction site, and venous thrombolysis time.

Physiologic Assessment of Coronary Stenosis: Current Status and Future Directions

PURPOSE OF REVIEW

Percutaneous coronary intervention (PCI) is a commonly used treatment option in coronary artery disease (CAD). Reduced major adverse cardiovascular events (MACE) in those randomized to PCI compared to optimal medical therapy have been demonstrated only if it is performed for physiologically significant coronary lesions. Despite data demonstrating improved outcomes primarily in stable CAD and then acute settings, physiology-guided PCI remains underutilized. This review summarizes the evidence and commonly used methods for physiologic assessment of coronary stenosis.

RECENT FINDINGS

Fractional flow reserve (FFR) is the gold standard for the analysis of lesion severity. Its use is limited by the need for adenosine, which adds time, complexity, and potential adverse effects. Non-hyperemic instantaneous wave-free ratio-guided revascularization and quantitative flow reserve ratio assessment both have shown safety and effectiveness with improved patient outcomes. Coronary physiological assessment solves the ambiguity of coronary angiography. Detecting physiologically significant stenoses is crucial to decide which lesion needs to be treated. Technological advances have led to the development of new assessment indices in addition to FFR.

The Relationship Between the Level of Serum ESM-1 and Lp-PLA2 in Patients With Acute ST-Segment Elevation Myocardial Infarction

Acute ST‐segment elevation myocardial infarction (STEMI) is the most lethal coronary heart disease with vascular endothelium dysfunction and inflammation in the disease development process. Endothelial cell‐specific molecule 1 (ESM‐1) and lipoprotein‐associated phospholipase A2 (Lp‐PLA2) are important for the diagnosis and characterization of STEMI. To date, no studies have reported the correlation between ESM‐1 and Lp‐PLA2 levels in patients with STEMI, which may be an important predictor of the fatal disease. To measure the level of serum ESM‐1 and Lp‐PLA2, and to evaluate the relationship and the clinical significance of these two biomarkers in patients with acute STEMI, 37 inpatients with acute STEMI were sequentially enrolled in the research group and 24 study objects with normal coronary artery function were included in the control group. The measurement of the relative parameters was done by enzyme‐linked immunosorbent assay using blood samples taken from the median cubital vein while the inpatients were enrolled. The levels of serum SEM‐1 and Lp‐PLA2 were significantly higher in patients with acute STEMI than in study objects with normal coronary artery function (P < 0.05). A significant correlation of serum SEM‐1 and Lp‐PLA2 was observed, leading to close linearity (r² = 0.8131, P < 0.0001). In conclusion, the endothelium dysfunction factor ESM‐1 and inflammatory factor Lp‐PLA2 are significantly higher and correlated in patients with acute STEMI. These two factors could be novel and effective biomarkers for acute STEMI diagnosis and evaluation.

Numerical analysis of aortic hemodynamics under the support of venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump

BACKGROUND AND OBJECTIVE

A gap still exists in the hemodynamic effect of intra-aortic balloon pump (IABP), venoarterial extracorporeal membrane oxygenation (VA-ECMO), and VA-ECMO plus IABP on the blood perfusion of the coronary artery, brain, and lower limb; the relation between heart flow and ECMO flow; and the wall stress of vessels.

METHODS

A finite-element model of the aorta, ECMO, and IABP was proposed to calculate the mechanical response via fluid-structure interaction. Heart failure (HF), IABP, ECMO, and ECMO plus IABP were utilized to study the effect of support models.

RESULTS

For the pressure curve, VA-ECMO weakened the dicrotic notch of pressure compared with HF and the pulsatile index (0.494 vs. 0.706 vs. 0.471 vs. 0.613). IABP, ECMO, and ECMO plus IABP increased the perfusion of the coronary, brain, and renal artery compared with HF. However, ECMO and ECMO plus IABP clearly reduced the blood flow of the left arteria femoralis compared to that of the right arteria femoralis (ECMO: 194.04 vs. 730.80 mL/min; ECMO plus IABP: 342.15 vs. 947.22 mL/min). In addition, the flow of ECMO accessed the renal artery more than the left ventricular flow. Greater ventricular flow perfused to the renal artery at a diastolic period for ECMO plus IABP, especially at the time points of 2.192 s and 2.304 s. Compared to the velocity distribution with ECMO, the flow of the right arteria femoralis was increased in the process of IABP-on. According to these four cases, the stress of the vascular wall was increased for ECMO support at the systolic period. The peak wall stress of ECMO is increased by 20% at 1.68 s.

CONCLUSIONS

ECMO plus IABP is more conducive to the blood supply than other cases from the result of numerical simulation. The location of blood intersection was generated in the region of the renal artery, which is estimated carefully.