Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology

Validation of Decisions for Percutaneous Coronary Intervention Using Smartphone-Based Electrocardiogram Device Spandan: A Cross-Sectional Observational Study

Background

India bears a high burden of acute coronary syndrome, with younger patients and a high prevalence of ST-elevation myocardial infarction (STEMI). Spandan is, therefore, an attractive smartphone-based electrocardiogram (ECG) device that could allow for potentially early diagnosis as well as enabling timely intervention which may even save lives in resource-poor settings. The study aimed to assess the performance and diagnostic capability of the Spandan smartphone-based ECG device in decision-making for percutaneous coronary intervention (PCI) by analyzing the initial ST-segment elevation, which was compared to a 12-lead ECG as the gold standard (BPL Cardiart ECG Machine).

Methods

This was an observational cross-sectional study involving 184 eligible participants with chest pain presenting to the local hospital, in Meerut, Uttar Pradesh, India. The study was conducted for the evaluation of the diagnostic appropriateness of the Spandan ECG device for the detection of ST elevation as compared to standard 12-lead ECGs so that the cardiologists could be more easily guided in their decisions relative to PCI. Patients with the onset of chest pain within or after 120 h and ST elevation above 1 mm in two or more leads were enrolled and patients with dementia, bundle branch block, cardiogenic shock, and ECG artifacts were excluded. The analysis included calculating response characteristics and estimating correlation coefficients and confusion matrix to compare both appraisal methods.

Results

The Spandan device performed with good agreement with the gold standard ECG, particularly in the leads II, III, and AVF, with Pearson correlation coefficients close to 1. The ST elevation in the Spandan device showed no statistical difference compared to the 12-lead ECG. The device exhibited a sensitivity of 94% and a positive predictive value of 94% for ST-elevation detection, thus having supportive evidence for possible usefulness for decision-making in PCI.

Conclusions

ECG findings, such as that of the smartphone-based device (Spandan Pro ECG, a single channel autoswitched ECG machine), demonstrated comparable accuracy with the gold standard 12-lead ECG for the diagnosis of ST elevation and helped in making clinical decisions in patients requiring PCI, especially in resource-limited settings.

Mon4 as a novel monocyte subset with distinct profile and predictor of poor outcomes in individuals with myocardial infarction

Recently, a new monocyte subset known as Mon4, characterized by distinct gene expressions, has been identified but remains poorly characterized. In this study, our objective was to comprehensively characterise Mon4 in healthy individuals and explore its correlation with major adverse cardiovascular events (MACE) in patients with ST-elevation myocardial infarction (STEMI). Our study enrolled 20 healthy individuals and 245 STEMI patients who underwent primary percutaneous coronary intervention (PCI). We analysed monocyte subsets using flow cytometry and collected bone marrow samples from 11 healthy individuals. Cardiac function assessments were performed in STEMI patients through echocardiography within 3 days post-PCI. Mon4 displayed significant differences compared to Mon1, Mon2, and Mon3 in various parameters among healthy individuals, underscoring its distinct profile. In STEMI patients, above-median Mon4 counts were associated with a increased risk of MACE (hazard ratio [HR] 3.11, 95% confidence interval [CI] 1.55-6.24, p = 0.01) and heart failure (HR 3.25, 95% CI 1.14-9.24, p = 0.03) after adjusting for other predictive factors. This study highlights the unique characteristics of Mon4 and its clinical significance. The distinctive gene signature of Mon4, coupled with its association with MACE and heart failure, suggests its potential utility as a biomarker for risk assessment in MI patients. Further investigations are warranted to explore the therapeutic potential of targeting Mon4 in reducing cardiovascular complications following MACE.

Ten-year prognosis of acute atrial fibrillation in ST-elevation myocardial infarction: recurrence and risk stroke

AIMS

Atrial fibrillation (AF) often complicates ST-elevation acute myocardial infarction (STEMI), with associated risks including stroke and mortality. Anticoagulation therapy for these patients and AF prognosis remain controversial. The aim was to evaluate long-term prognosis of STEMI patients complicated with AF in the acute phase.

METHODS AND RESULTS

We performed a retrospective analysis on a prospective register involving 4184 patients admitted for STEMI to the intensive cardiac care unit of two tertiary centres from 2007 to 2015. Patients with pre-existing permanent AF were excluded. Out of these, 269 (6.4%) patients developed AF within the first 48 h after STEMI and were matched with a control group based on age and left ventricular ejection fraction. After matching, a total of 470 patients were included (n = 235, AF-STEMI; n = 235, control group). Mean age was 69.0 years, and 31.7% were women. No differences were found in gender, cardiovascular risk factors, or ischaemic heart disease. AF-STEMI patients experienced more sustained ventricular tachycardia, advanced atrioventricular block, heart failure, and cardiogenic shock. In-hospital mortality was also higher in AF-STEMI patients (11.9% vs. 7.2%, P = 0.008). After a 10-year follow-up, the AF-STEMI group had remained with higher mortality (50.5% vs. 36.2%; P = 0.003) and a greater recurrence of AF (44.2% vs. 14.7%; P < 0.001), without differences in stroke incidence (10.1% vs. 9.3%).

CONCLUSION

As a conclusion, patients with AF complicating STEMI have higher rates of heart failure, cardiogenic shock, and in-hospital mortality. After a 10-year follow-up, they exhibit a high risk of AF recurrence and mortality, with no significant differences in stroke incidence.

Comparison of complete vs. culprit-only revascularization in acute myocardial infarction

BACKGROUND

The diagnosis and treatment of acute myocardial infarction (AMI) complicated with multivessel disease (MVD) by percutaneous coronary intervention (PCI) has been well recognized. However, the use of PCI in non-infarct-related coronary arteries remains controversial. We aimed to study the clinical outcome of complete vs. culprit-only revascularization for AMI with MVD before discharge.

METHODS

173 AMI with MVD who received emergent PCI between January 2013 and December 2018 were retrospectively analyzed. Patients were divided into complete revascularization (CR) group (n = 85) and culprit-only revascularization (COR) group (n = 88). Major adverse cardiovascular and cerebral events (MACCE) at 1, 6, and 12 months after PCI were compared, including recurrent angina, recurrent MI, in-stent thrombosis, new-onset atrial fibrillation (AF), and worsen heart failure (HF).

RESULTS

Baseline characteristics of two groups were comparable. There was no significantly statistical difference in MACCE between COR group and CR group, 36.2% vs. 33.3% (P = 0.715), 42.0% vs. 29.7% (p = 0.125) and 44.9% vs. 36.5% (p = 0.304) at 1-, 6- and 12-month follow up respectively. Compared with the CR group, a higher rate of recurrent angina was in COR group (20.3% vs. 5.4%, P = 0.007) at the 6th month. Subgroup analysis showed that hypertensive patients benefited more from complete revascularization at the 6- (OR:0.31, 95%CI: 0.13-0.76) and 12-month (OR:0.38, 95%CI: 0.16-0.90) follow up.

CONCLUSIONS

Complete revascularization before discharge does not supply additional benefit on long time MACCE as compared with culprit-only intervention strategy in patients presenting with AMI for urgent PCI with multivessel disease.

Prognostic Significance of Homocysteine Levels in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: A Propensity Score Matching and Weighting Analysis

Background

Elevated homocysteine (Hcy) levels have been linked to poorer outcomes in acute coronary syndrome. This study aimed to assess the predictive value of elevated Hcy levels for major adverse cardiac events (MACE) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods

This retrospective cohort study included 183 STEMI patients who underwent primary PCI at a tertiary university hospital in southern China from January 2020 to December 2021. Laboratory values, including Hcy levels, were obtained within 24 hours of admission. Patients were categorized into elevated and normal Hcy groups using a threshold of 12 μmol/L. The study outcome was the occurrence of 6-point MACE, defined as cardiac death, nonfatal myocardial infarction, stroke, ischemia-driven revascularization (PCI or coronary artery bypass grafting), heart failure and all-cause death. Survival analyses were conducted using Kaplan-Meier and Cox proportional hazard methods. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) approaches were employed to minimize bias.

Results

The mean age of the patients was 64.8 years, with 76.0% being male. After adjusting with PSM or IPTW, covariate imbalances between the two groups were corrected. Over a median follow-up period of 25.8 months, 55 MACE events occurred, resulting in an event rate of 30.1%. Patients with elevated Hcy levels had a higher incidence of MACE in both unadjusted (hazard ratio [HR] = 2.778; 95% confidence interval [CI]: 1.591-4.850; p < 0.001) and adjusted analyses (PSM: HR = 2.995; 95% CI: 1.397-6.423, p = 0.005; IPTW: HR = 3.2; 95% CI: 1.631-6.280, p < 0.001). Multivariate Cox regression further confirmed that elevated Hcy levels were associated with a worse prognosis across the entire cohort (HR = 1.062, 95% CI: 1.029-1.097, p < 0.001), PSM cohort (HR = 1.089, 95% CI: 1.036-1.145, p < 0.001), and IPTW cohort (HR = 1.052, 95% CI: 1.020-1.086, p = 0.001).

Conclusions

Elevated plasma levels of Hcy (≥12 μmol/L) are associated with worse outcomes in STEMI patients undergoing primary PCI, highlighting the potential role of Hcy as a prognostic marker in this population.

Short-term effects of upstream high bolus dose of tirofiban in patients with ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

No-reflow following primary percutaneous coronary intervention (PPCI) is challenging to treat.

OBJECTIVES

The objective of this study is to evaluate the efficacy and safety of upstream high-bolus-dose tirofiban administration in ST-segment elevation myocardial infarction (STEMI) cases undergoing PPCI on top of dual antiplatelet therapy, including ticagrelor, in comparison to selective bailout administration.

METHODS

This hospital-based, randomized, single-blinded prospective interventional study was conducted on 150 patients at Assiut University Heart Hospital. Patients with STEMI within 12 h after symptom onset who underwent PPCI were randomized to an upstream group (n = 75) and a selective bailout group (n = 75) based on the timing of the tirofiban bolus administration (25 µg/kg intravenously over 5 min).

RESULTS

The bailout group's thrombolysis in myocardial infarction (TIMI) frame count was higher than the upstream group's, despite comparable TIMI flow and myocardial blush grade between the two groups, but only approached statistical significance [14.4 (4-36) vs 12.2 (5-55), P = 0.08]. The enzymatic infarct size tended to be lower in the upstream group. All echocardiographic findings were comparable between the two studied groups, with no significant difference (P > 0.05). There was no significant difference between the two groups regarding clinical outcomes.

CONCLUSION

Compared to selective bailout administration, upstream high bolus dose of tirofiban in STEMI patients undergoing primary coronary intervention did not significantly affect angiographic outcomes, left ventricular remodeling, or function, despite smaller infarction size.

Enhanced fibrotic potential of COL1A1hiNR4A1low fibroblasts in ischemic heart revealed by transcriptional dynamics heterogeneity analysis at both bulk and single-cell levels

Background

Fibroblasts in the fibrotic heart exhibit a heterogeneous biological behavior. The specific subsets of fibroblasts that contribute to progressive cardiac fibrosis remain unrevealed. Our aim is to identify the heart fibroblast (FB) subsets that most significantly promote fibrosis and the related critical genes as biomarkers for ischemic heart disease.

Methods

The single nuclei RNA sequencing (snRNA-seq) and bulk RNA sequencing datasets used in this study were obtained from the Gene Expression Omnibus (GEO). The activity of gene sets related to progressive fibrosis was quantified for each FB cluster using the AddmoleculeScore function. Differentially expressed genes (DEGs) for the specific cell cluster with the highest fibrotic transcription dynamics were identified and integrated with bulk RNA sequencing data for analysis. Multiple machine learning models were employed to identify the optimal gene panel for diagnosing ischemic heart disease (IHD) based on the intersected DEGs. The effectiveness and robustness of the gene-derived diagnostic tool were validated using two independent IHD cohorts.Subsequently, we validated the signature genes using a rat post-myocardial infarction heart failure model.

Results

We conducted an analysis on high-quality snRNA-seq data obtained from 3 IHD and 4 cardiac sarcoidosis heart samples, resulting in the identification of 16 FB clusters. Cluster2 exhibited the highest gene activity in terms of fibrosis-related transcriptome dynamics. The characteristic gene expression profile of this FB subset indicated a specific upregulation of COL1A1 and several pro-fibrotic factors, including CCDC102B, GUCY1A3, TEX41, NREP, TCAP, and WISP, while showing a downregulation of NR4A1, an endogenous inhibitor of the TGF-β pathway. Consequently, we designated this subgroup as COL1A1hiNR4A1low FB. Gene set enrichment analysis (GSEA) shows that the gene expression pattern of COL1A1hiNR4A1low FB was closer to pathways associated with cardiac fibrosis. Through machine learning, ten feature genes from COL1A1hiNR4A1low FB were selected to construct a diagnostic tool for IHD. The robustness of this new tool was validated using an independent cohort and heart failure rats.

Conclusion

COL1A1hiNR4A1low FB possess heightened capability in promoting cardiac fibrosis. Additionally, it offers molecular insights into the mechanisms underlying the regulation of the TGF-β pathway. Furthermore, the characteristic genes of COL1A1hiNR4A1 FB could serve as valuable tools for diagnosing of IHD.

Soluble suppression of tumorigenicity 2 associated with microvascular obstruction in patients with ST-segment elevation myocardial infarction

BACKGROUND

Microvascular obstruction (MVO) develops in approximately 50% of patients with ST-segment elevation myocardial infarction (STEMI) after undergoing percutaneous coronary intervention (PCI). MVO is strongly linked to inflammation, myocardial fibrosis, and adverse clinical outcomes. Soluble suppression of tumorigenicity 2 (sST2) serves as a biomarker for inflammation and myocardial fibrosis. Yet, the correlation between sST2 and MVO in STEMI patients has not been fully elucidated. This study attempts to evaluate the association between sST2 levels and MVO in STEMI patients following pPCI.

METHODS

In this retrospective study, 315 STEMI patients who underwent pPCI at the Affiliated Hospital of Xuzhou Medical University between June 2018 and August 2023 were included. Cardiac magnetic resonance imaging (CMR) was used to assess the characteristics of myocardial infarction and microvascular obstruction (MVO), while sST2 levels were measured upon admission.

RESULTS

The median time for completion of CMR after hospitalization was 5 (4, 6) days. Multivariate regression analysis showed that sST2 (OR 1.01, 95% CI 1.01-1.02, p < 0.001), peak high-sensitivity troponin T (OR 2.40, 95% CI 1.66-3.47, p < 0.001), peak high-C-reactive protein (OR 1.01, 95% CI 1.01-1.02, p < 0.001), left ventricular ejection fraction (OR 0.93, 95% CI 0.89- 0.98, p = 0.009) and age (OR 1.03, 95% CI 1.01- 1.05, p = 0.042)were independently associated with MVO.

CONCLUSION

sST2 is associated with MVO after pPCI in STEMI patients. Incorporating soluble ST2 (sST2) into the risk model for MVO leads to significant improvement.

Left atrial volume assessed by echocardiography identifies patients with high risk of adverse outcome after acute myocardial infarction

BACKGROUND

The left atrial (LA) volume has been demonstrated to be an important predictor of adverse outcome in patients with various cardiac conditions, including acute myocardial infarction (AMI). However, new treatment strategies in patients with AMI have led to better patient outcomes. We hypothesised that increased LA size could still predict mortality in patients with AMI despite improved treatment strategies.

METHODS

We included patients with AMI in a prospective multicenter cohort study and the study patients were enrolled from 2014 to 2022. We recorded echocardiographic and clinical data during their index hospitalisation. Indexed LA volume (LAVi) was assessed in all patients and was used as a continuous variable in the univariate and multivariate Cox regression analysis. The study took place over a period of five years and median follow-up time was 3.8 years (range 3.1 to 5.0 years). The primary study outcomes were all-cause mortality and major adverse cardiac events (MACE). MACE was defined as hospital readmission due to myocardial infarction, cardiac arrest, stroke, heart failure, or onset of new atrial fibrillation.

RESULTS

We included 487 patients (69 ± 12 years old, 26% female) with AMI. During the follow-up period all-cause mortality was 50 (10.3%) and patients who reached the primary outcomes were 153 (31.4%). The deceased patients had higher LAVi compared to survivors (40.0 ± 12.9 mL/m2 vs. 29.7 ± 11.2 mL/m2, p < 0.001). Factors associated with all-cause mortality and MACE were age, year of enrollment, left ventricular (LV) ejection fraction, LV global longitudinal strain (GLS), LV filling pressure, moderate or severe mitral regurgitation and LAVi. GLS and EF were segregated into two distinct models due to their moderately high correlation (r = 0.57, p < 0.001). LAVi remained as an independent echocardiographic predictor of primary outcomes after adjusting for the covariates above in two separates multivariable Cox regression models (hazard ratio 1.02/1.02 mL/m2 [95% CI 1.01-1.03/1.01-1.03], p = 0.006/0.003).

CONCLUSIONS

Our study demonstrated that LA dilatation is an independent echocardiographic predictor of mortality and MACE in patients with AMI despite improved treatment strategies. This finding highlights the potential of using LAVi as a marker for prognostication in these patients.

A huge coronary artery aneurysm with ST-elevation myocardial infarction: A case report and review of literature

Background

Giant coronary artery aneurysms (GCAA), are rare findings often discovered incidentally in adults. GCAAs are defined by a significant enlargement of coronary arteries, posing a heightened risk of myocardial infarction and thrombosis.

Case presentation

A 52-year-old male known case of ischemic heart disease (IHD), presented with chest pain and signs of anterior ST-elevation MI (STEMI). He had a history of MI six years ago and was on a medical regimen. Coronary angiography revealed a huge aneurysm (4.8∗8.2mm) in the left anterior descending artery (LAD) and ectasia in other arteries. Surgical management via coronary artery bypass graft (CABG) was pursued, successfully addressing the aneurysm.

Conclusion

Recent advancements have improved our understanding and imaging capabilities for coronary artery aneurysms (CAAs). Treatment options include medical therapy, percutaneous coronary intervention, or surgery, with decisions tailored to individual cases. Standardized treatment protocols await clarification through further research, including randomized controlled trials.

Optical Coherence Tomography in Myocardial Infarction Management: Enhancing Precision in Percutaneous Coronary Intervention

In acute myocardial infarction (AMI), the urgency of coronary revascularization through percutaneous coronary intervention (PCI) is paramount, offering notable advantages over pharmacologic treatment. However, the persistent risk of adverse events, including recurrent AMI and heart failure post-revascularization, underscores the necessity for enhanced strategies in managing coronary artery disease. Traditional angiography, while widely employed, presents significant limitations by providing only two-dimensional representations of complex three-dimensional vascular structures, hampering the accurate assessment of plaque characteristics and stenosis severity. Intravascular imaging, specifically optical coherence tomography (OCT), significantly addresses these limitations with superior spatial resolution compared to intravascular ultrasound (IVUS). Within the context of AMI, OCT serves dual purposes: as a diagnostic tool to accurately identify culprit lesions in ambiguous cases and as a guide for optimizing PCI procedures. Its capacity to differentiate between various mechanisms of acute coronary syndrome, such as plaque rupture and spontaneous coronary dissection, enhances its diagnostic potential. Furthermore, OCT facilitates precise lesion preparation, optimal stent sizing, and confirms stent deployment efficacy. Recent meta-analyses indicate that OCT-guided PCI markedly improves safety and efficacy in revascularization, subsequently decreasing the risks of mortality and complications. This review emphasizes the critical role of OCT in refining patient-specific therapeutic approaches, aligning with the principles of precision medicine to enhance clinical outcomes for individuals experiencing AMI.

The impact of admission modes on the treatment outcome and in-hospital mortality rate of STEMI patients undergoing PPCI

The current research on ST elevation myocardial infarction (STEMI) patients has been mostly limited to Door-to-Balloon (D-to-B) time. This study aimed to compare the effects of different hospital admission modes to on the time metrics of patients undergoing primary percutaneous coronary intervention (PPCI). It also examined the effects of these modes on in-hospital mortality and other influencing factors. The goal was to prompt healthcare facilities at all levels, including chest hospitals, the Centers for Disease Control and Prevention (CDC), and communities to take measures to enhance the treatment outcomes for patients with STEMI. A total of 1053 cases of STEMI patients admitted to Tianjin Chest Hospital from December 2016 to December 2023 and successfully underwent PPCI were selected for this study. They were divided into three groups based on the admission modes: the ambulances group (363 cases), the self-presentation group (305 cases), and the transferred group (385 cases). Multivariate logistic regression was used to explore the impact of different modes of hospital admission on the standard-reaching rate of key treatment time metrics. The results showed that the S-to-FMC time of transferred patients (OR = 0.434, 95% CI 0.316-0.596, P < 0.001) and self-presentation patients (OR = 0.489, 95% CI 0.363-0.659, P < 0.001) were more likely to exceed the standard than that of ambulance patients; The cath lab pre-activation time of self-presented patients was also less likely to meet the standard than that of ambulance patients (OR = 0.695, 95% CI 0.499-0.967, P = 0.031); D-to-W time of self-presentation patients was less likely to reach the standard than that of ambulance patients (OR = 0.323, 95% CI 0.234-0.446, P < 0.001);However, the FMC-to-ECG time of self-presentation patients was more likely to reach the standard than that of ambulance patients (OR = 2.601, 95% CI 1.326-5.100, P = 0.005). The Cox proportional hazards model analysis revealed that for ambulance patients, the time spent at each key treatment time point is shorter, leading to lower in-hospital mortality rate (HR0.512, 95% CI 0.302-0.868, P = 0.013) compared to patients admitted by other means. We found that direct arrival of STEMI patients to the PCI hospital via ambulance at the onset of the disease significantly reduces the S-to-FMC time, FMC-to-ECG time, D-to-W time, and catheterization room activation time compared to patients who self-present. This admission mode enhances the likelihood of meeting the benchmark standards for each time metric, consequently enhancing patient outcomes.

Associations of fish oil with cardiovascular disease events: results from the Taiwan longitudinal study in aging

BACKGROUND

The effectiveness of fish oil in preventing cardiovascular events is still debating. Some studies indicate a correlation between the use of fish oil supplements and reduced mortality or decreased incidence of stroke. However, other studies show no significant association between fish oil intake and stroke prevention, indicating an ongoing debate. This study aimed at exploring which subjects may benefit more from fish oil supplementation.

METHODS

This study utilized the data obtained through face-to-face interview from the Taiwan Longitudinal Study in Aging (TLSA). A total of 3,652 participants were included from the 2003 baseline data, after excluding patients with pre-existing ischemic heart disease or stroke. Participants were divided into two groups based on whether taking fish oil supplement or not. Participants were followed until 2015, estimating and comparing the all-cause mortality and cumulative incidence rate of stroke between both groups.

RESULTS

The results of the 12-year longitudinal study showed that the cumulative incidence rate of stroke in the fish oil supplementation group was 5.7%, compared to 7.7% in the non-supplemented group (P < 0.05). Additionally, the crude hazard ratio for stroke was significantly lower in the fish oil supplementation group (HR = 0.686;95% CI 0.476-0.987). However, after adjusting potential confounders, the adjusted risk of stroke was lower only for the diabetic patients supplemented with fish oil (aHR = 0.123; 95% CI 0.016-0.930) compared to non-diabetic patients (aHR = 0.917; 95% CI 0.616-1.364).

CONCLUSION

This study suggests that there is an association between fish oil supplementation and a lower cumulative incidence rate of subsequent stroke among diabetic patients.

Demystifying the Contemporary Role of 12-Month Dual Antiplatelet Therapy After Acute Coronary Syndrome

For almost two decades, 12-month dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) has been the only class I recommendation on DAPT in American and European guidelines, which has resulted in 12-month durations of DAPT therapy being the most frequently implemented in ACS patients undergoing percutaneous coronary intervention (PCI) across the globe. Twelve-month DAPT was initially grounded in the results of the CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) trial, which, by design, studied DAPT versus no DAPT rather than the optimal DAPT duration. The average DAPT duration in this study was 9 months, not 12 months. Subsequent ACS studies, which were not designed to assess DAPT duration, rather its composition (aspirin with prasugrel or ticagrelor compared with clopidogrel) were further interpreted as supportive evidence for 12-month DAPT duration. In these studies, the median DAPT duration was 9 or 15 months for ticagrelor and prasugrel, respectively. Several subsequent studies questioned the 12-month regimen and suggested that DAPT duration should either be fewer than 12 months in patients at high bleeding risk or more than 12 months in patients at high ischemic risk who can safely tolerate the treatment. Bleeding, rather than ischemic risk assessment, has emerged as a treatment modifier for maximizing the net clinical benefit of DAPT, due to excessive bleeding and no clear benefit of prolonged treatment regimens in high bleeding risk patients. Multiple DAPT de-escalation treatment strategies, including switching from prasugrel or ticagrelor to clopidogrel, reducing the dose of prasugrel or ticagrelor, and shortening DAPT duration while maintaining monotherapy with ticagrelor, have been consistently shown to reduce bleeding without increasing fatal or nonfatal cardiovascular or cerebral ischemic risks compared with 12-month DAPT. However, 12-month DAPT remains the only class-I DAPT recommendation for patients with ACS despite the lack of prospectively established evidence, leading to unnecessary and potentially harmful overtreatment in many patients. It is time for clinical practice and guideline recommendations to be updated to reflect the totality of the evidence regarding the optimal DAPT duration in ACS.

Initial decrease in the lipoprotein(a) level is a novel prognostic biomarker in patients with acute coronary syndrome

BACKGROUND

Lipoprotein(a) [Lp(a)] is a causal risk factor for atherosclerotic cardiovascular diseases; however, its role in acute coronary syndrome (ACS) remains unclear.

AIM

To investigate the hypothesis that the Lp(a) levels are altered by various conditions during the acute phase of ACS, resulting in subsequent cardiovascular events.

METHODS

From September 2009 to May 2016, 377 patients with ACS who underwent emergent coronary angiography, and 249 who completed ≥ 1000 d of follow-up were enrolled. Lp(a) levels were measured using an isoform-independent assay at each time point from before percutaneous coronary intervention (PCI) to 48 h after PCI. The primary endpoint was the occurrence of major adverse cardiac events (MACE; cardiac death, other vascular death, ACS, and non-cardiac vascular events).

RESULTS

The mean circulating Lp(a) level decreased significantly from pre-PCI (0 h) to 12 h after (19.0 mg/dL to 17.8 mg/dL, P < 0.001), and then increased significantly up to 48 h after (19.3 mg/dL, P < 0.001). The changes from 0 to 12 h [Lp(a)Δ0-12] significantly correlated with the basal levels of creatinine [Spearman's rank correlation coefficient (SRCC): -0.181, P < 0.01] and Lp(a) (SRCC: -0.306, P < 0.05). Among the tertiles classified according to Lp(a)Δ0-12, MACE was significantly more frequent in the lowest Lp(a)Δ0-12 group than in the remaining two tertile groups (66.2% vs 53.6%, P = 0.034). A multivariate analysis revealed that Lp(a)Δ0-12 [hazard ratio (HR): 0.96, 95% confidence interval (95%CI): 0.92-0.99] and basal creatinine (HR: 1.13, 95%CI: 1.05-1.22) were independent determinants of subsequent MACE.

CONCLUSION

Circulating Lp(a) levels in patients with ACS decreased significantly after emergent PCI, and a greater decrease was independently associated with a worse prognosis.

The Use of Thrombectomy during Primary Percutaneous Coronary Intervention: Resurrecting an Old Concept in Contemporary Practice

Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.

Mean Activated Clotting Time of Patients Receiving Intravenous Heparin and Undergoing Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction

Introduction The most prevalent cause of death is acute myocardial infarction (AMI). Primary percutaneous coronary intervention (PPCI) has replaced thrombolysis as the recommended therapeutic option for individuals with ST-segment elevation myocardial infarction (STEMI). However, more effective anticoagulation regimes are required for PCI due to the limitations of unfractionated heparin. Objective This study aimed to ascertain the connection between the mean activated clotting time and the risk of bleeding and infarcts in individuals receiving intravenous heparin during PPCI for STEMI. Methods This was a one-year prospective observational study carried out at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Results The majority (70.15%) were male, with a mean age of 56.08 ± 8.92 years. Following PPCI, the average active clotting time (ACT) was 350.56 ± 39.62 seconds (range 255 to 453), compared to the pre-PPCI mean of 504.15 ± 38.98 seconds. ACT was considerably higher in female patients, smokers, and overweight patients. The mean ACT was not significantly higher in patients with hypertension (HTN) and dyslipidemia (DLD). Conclusion The ACT range in this investigation was 255 to 453 seconds, and there was no discernible relationship between ACT readings and problems related to bleeding and ischemia. To determine who is more at risk, bleeding risk models should be used and improved further before catheterization.

Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report

BACKGROUND

The current guidelines have discouraged the routine use of intra-aortic balloon pump (IABP) in cardiogenic shock complicating acute coronary syndrome (ACS). Since then, the trend of IABP utilization in ACS has been declining. Nevertheless, the guidelines still preserve the recommendation of IABP use in hemodynamic instability or cardiogenic shock caused by post myocardial infarction (MI) ventricular septal rupture (VSR).

CASE PRESENTATION

A 46-years-old diabetic Southeast Asian female was referred from a peripheral facility with intractable heart failure despite treatment with vasoactive agents and diuretics for five days. The ECG suggested a recent anteroseptal myocardial infarction with normal high-sensitivity troponin-I value. The echocardiography detected a regional wall motion abnormality and a 10 mm wide ventricular septal defect. Invasive coronary angiography revealed a severe two-vessel coronary artery disease. We planned a delayed surgical strategy with preoperative optimization using IABP as a bridge to surgery. IABP implantation followed by significant hemodynamic improvement and rapid resolution of heart failure without any inotrope support. Afterwards, coronary artery bypass grafting (CABG) and VSR surgical repair were performed. We safely removed IABP on the third postoperative day with proper weaning and minimal vasoactive support.

CONCLUSION

We report a case where IABP still provided benefits for a patient with intractable heart failure caused by undetermined onset MI complicated by VSR. The use of IABP in such a case is in accordance with the recommendation of the current guidelines. Several studies showed that IABP use during preoperative optimization in the case of post-MI VSR was associated with survival benefits.

LIMD2 is the Signature of Cell Aging-immune/Inflammation in Acute Myocardial Infarction

BACKGROUND

Acute myocardial infarction (AMI) is an age-dependent cardiovascular disease in which cell aging, immunity, and inflammatory factors alter the course; however, cell aging-immune/inflammation signatures in AMI have not been investigated.

METHODS

Based on the GEO database to obtain microRNA (miRNA) sequencing, mRNA sequencing and single-cell sequencing data, and utilizing the Seurat package to identify AMI-associated cellular subpopulations. Subsequently, differentially expressed miRNAs and mRNAs were screened to establish a network of competing endogenous RNAs (ceRNAs). Senescence and immunity scores were calculated by single sample gene set enrichment analysis (ssGSEA), ESTIMATE and CIBERSORT algorithms, and the Hmisc package was used to screen for genes with the highest correlation with senescence and immunity scores. Finally, protein-protein interaction (PPI) and molecular docking analyses were performed to predict potential therapeutic agents for the treatment of AMI.

RESULTS

Four cell types (Macrophage, Fibroblast, Endothelial cells, CD8 T cells) were identified in AMI, and CD8 T cells exhibited the lowest cell aging activity. A ceRNA network of miRNAs- mNRA interactions was established based on the overlapping genes in differentially expressed miRNAs (DEmiRNAs) target genes and differentially expressed mRNAs (DEmRNAs). Twenty-four marker genes of CD8 T cells were observed. LIMD2 was identified as cell aging- immune/inflammation-related hub gene in AMI. This study also identified a potential therapeutic network of DB03276-LIMD2-AMI, which showed excellent and stable binding status between DB03276-LIMD2.

CONCLUSION

This study identified LIMD2 as a cell aging-immune/inflammation-related hub gene. The understanding of the pathogenesis and therapeutic mechanisms of AMI was enriched by the ceRNA network and DB03276-LIMD2-LAMI therapeutic network.

Post-Infarction Ventricular Septal Defect: A quarter century experience

OBJECTIVES

Post-infarction ventricular septal defect (VSD) is one of the known complications after acute myocardial infarction. This study investigated the clinical results after surgical repair of VSD.

METHODS

This retrospective study included all patients undergoing surgical repair of VSD from 1996 to 2020 in Oman.

RESULTS

Out of a total of 75 patients, 62.5% were men, with a mean age of 59 years. The mean follow-up was 17.2 (7.5) years. Of the 75 patients, 34 (45.3%) patients died within 30 days. Total survival was 41.3% at 5 years, while the 10-year survival rate was 33.3%. Outcomes and predictors for 30 days mortality were the number of concomitant coronary involvement and anastomoses performed, residual postoperative shunt and postoperative dialysis.

CONCLUSION

Even with surgical repair, early mortality of post-infarction septal defect is still considerably high. Early repair and the anatomically posterior rupture are predictors of early mortality. In patients surviving the immediate postoperative period, long-term survival is limited by pre-existing coronary artery disease, postoperative renal failure and the presence of a residual postoperative shunt.

Implementation of the ESC STEMI guidelines in female and elderly patients over a 20-year period in a large German registry

AIMS

We investigated the implementation of new guidelines in ST-segment elevation myocardial infarction (STEMI) patients in a large real-world patient population in the metropolitan area of Berlin (Germany) over a 20-year period.

METHODS

From January 2000 to December 2019, a total of 25 792 patients were admitted with STEMI to one of the 34 member hospitals of the Berlin-Brandenburg Myocardial Infarction Registry (B2HIR) and were stratified for sex and age < 75 and ≥ 75 years.

RESULTS

The median age of women was 72 years (IQR 61-81) compared to 61 years in men (IQR 51-71). PCI treatment as a standard of care was implemented in men earlier than in women across all age groups. It took two years from the 2017 class IA ESC STEMI guideline recommendation to prefer the radial access route rather than femoral until > 60% of patients were treated accordingly. In 2019, less than 60% of elderly women were treated via a radial access. While the majority of patients < 75 years already received ticagrelor or prasugrel as antiplatelet agent in the year of the class IA ESC STEMI guideline recommendation in 2012, men ≥ 75 years lagged two years and women ≥ 75 three years behind. Amongst the elderly, in-hospital mortality was 22.6% (737) for women and 17.3% (523) for men (p < 0.001). In patients < 75 years fatal outcome was less likely with 7.2% (305) in women and 5.8% (833) in men (p < 0.001). After adjustment for confounding variables, female sex was an independent predictor of in-hospital mortality in patients ≥ 75 years (OR 1.37, 95% CI 1.12-1.68, p = 0.002), but not in patients < 75 years (p = 0.076).

CONCLUSION

In-hospital mortality differs considerably by age and sex and remains highest in elderly patients and in particular in elderly females. In these patient groups, guideline recommended therapies were implemented with a significant delay.

Effects of intra-aortic balloon pump on in-hospital outcomes and 1-year mortality in patients with acute myocardial infarction complicated by cardiogenic shock

BACKGROUND

The role of intra-aortic balloon counterpulsation (IABP) in cardiogenic shock complicating acute myocardial infarction (AMI) is still a subject of intense debate. In this study, we aim to investigate the effect of IABP on the clinical outcomes of patients with AMI complicated by cardiogenic shock undergoing percutaneous coronary intervention (PCI).

METHODS

From the Medical Information Mart for Intensive Care (MIMIC)-IV 2.2, 6017 AMI patients were subtracted, and 250 patients with AMI complicated by cardiogenic shock undergoing PCI were analyzed. In-hospital outcomes (death, 24-hour urine volumes, length of ICU stays, and length of hospital stays) and 1-year mortality were compared between IABP and control during the hospital course and 12-month follow-up.

RESULTS

An IABP was implanted in 30.8% (77/250) of patients with infarct-related cardiogenic shock undergoing PCI. IABP patients had higher levels of Troponin T (3.94 [0.73-11.85] ng/ml vs. 1.99 [0.55-5.75] ng/ml, p-value = 0.02). IABP patients have a longer length of ICU and hospital stays (124 [63-212] hours vs. 83 [43-163] hours, p-value = 0.005; 250 [128-435] hours vs. 170 [86-294] hours, p-value = 0.009). IABP use was not associated with lower in-hospital mortality (33.8% vs. 33.0%, p-value = 0.90) and increased 24-hour urine volumes (2100 [1455-3208] ml vs. 1915 [1110-2815] ml, p-value = 0.25). In addition, 1-year mortality was not different between the IABP and the control group (48.1% vs. 48.0%; hazard ratio 1.04, 95% CI 0.70-1.54, p-value = 0.851).

CONCLUSION

IABP may be associated with longer ICU and hospital stays but not better short-and long-term clinical prognosis.

A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Streptokinase in the Management of Myocardial Infarction in Developing Countries

Myocardial infarction (MI) is a significant cause of morbidity and mortality in low- and middle-income countries. Fibrinolytic agents and percutaneous coronary intervention (PCI) are the main approaches for the recanalization and reperfusion of the myocardium following MI. Many studies have shown that PCI is superior to thrombolytics due to better outcomes and decreased mortality. Nevertheless, PCI's mortality gain over thrombolysis decreases as the time between presentation and PCI procedure increases. Furthermore, PCI is not widely available in most developing countries; thus, it cannot be delivered promptly. Most patients in developing countries cannot afford the cost of PCI. Thus, thrombolytic therapy remains essential to managing MI in developing countries and should not be disregarded. Tenecteplase (TNK) and streptokinase (SK) are the two most widely used fibrinolytics in managing MI in underdeveloped nations. Despite their widespread availability, comparative studies on them have been inconclusive. This study aims to review the available literature on the effectiveness and safety of TNK versus SK in managing MI in resource-poor nations. The study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search for studies comparing TNK and STK was conducted on EMBASE, Cochrane Library, Web of Science, CINAHL, Scopus, Google Scholar, and Ovid version of MEDLINE databases. A reference list of the eligible articles and systematic reviews was also screened. A narrative synthesis of the available data was done by representing the data on the effect direction plot, followed by vote counting. Of the 2284 references retrieved from the databases, only 17 studies met the inclusion criteria and were selected for final analysis. The study suggested that TNK is more effective in complete ST-segment resolution (80% vs 10% on the effect direction plot) and symptom relief (80% vs 20%) than SK. SK and TNK were comparable in achieving successful fibrinolysis (50% vs 50%). For the safety parameters, TNK is associated with a lesser risk of major bleeding than SK (88.9% vs 11.1%) and minor bleeding (25% vs 75%). SK was linked with a higher risk of hypotension/shock (77.8% vs 11.1%) and anaphylaxis/allergy (100% vs 0%). Long-term mortality was higher in the SK arm (100% vs 0%). In-hospital mortality is comparable between the two agents (37.5% vs 37.5%). There is conflicting evidence regarding other safety and efficacy endpoints. Compared to SK, TNK results in better complete ST-segment resolution and symptom relief. A higher risk of long-term mortality, increased risk of major and minor bleeding, hypotension, and allergy/anaphylaxis was observed in patients who received SK. Both agents were comparable in terms of in-hospital mortality and successful fibrinolysis. Controversy exists regarding which agent is linked with increased risk of 30-35-day mortality benefit and stroke. Randomized controlled trials (RCTs) with large sample sizes are needed to establish TNK vs SK superiority in efficacy and safety. The long-term duration of follow-up of the mortality rate of the two agents is also essential, as most patients in these regions cannot afford the recommended PCI post-fibrinolysis.

Clinical Efficacy of Pre-Hospital Electrocardiogram Transmission in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Rapid reperfusion by primary percutaneous coronary intervention (pPCI) is an established strategy for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Pre-hospital electrocardiogram (PH-ECG) transmission by the emergency medical services (EMS) facilitates timely reperfusion in these patients. However, evidence regarding the clinical benefits of PH-ECG in individual hospitals is limited.This retrospective, observational study investigated the clinical efficacy of PH-ECG in STEMI patients who underwent pPCI. Of a total of 382 consecutive STEMI patients, 237 were enrolled in the study and divided into 2 groups: a PH-ECG group (n = 77) and non-PH-ECG group (n = 160). Door-to-balloon time (D2BT) was significantly shorter in the PH-ECG group (66 [52-80] min), compared to the non-PH-ECG group (70 [57-88] minutes, P = 0.01). The 30-day all-cause mortality rate was 6% in the PH-ECG group, which was significantly lower than that in the non-PH-ECG group (16%) (P = 0.037, hazard ratio [HR]: 0.38, 95% CI: 0.15-0.98). This trend was particularly evident in severely ill patients when stratified by GRACE score.The use of PH-ECG improved the survival rate of STEMI patients undergoing pPCI due to the improved pre-arrival preparation based on the EMS information. Coordination between EMS and PCI-capable institutes is essential for the management of PH-ECG.

Thrombus composition and thrombolysis resistance in stroke

A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.

Role of Mechanical Circulatory Support in Acute MI Management

Cardiogenic shock complicating acute MI carries high mortality and morbidity in many cases. Mechanical circulatory support devices are often used in these cases, aimed at improving patient-centered outcomes, although there is a lack of large randomized clinical trial-based evidence for many of such devices. Various circulatory support devices are available with their associated risks and benefits. Ideal circulatory support device intends to unload the myocardium, halt the spiral of ischemia, provide support for revascularization, and/or allow time for myocardial recovery. In this review paper, the commonly used mechanical circulatory support devices available for use in acute myocardial infarction settings are discussed, and the pros and cons of these devices are examined, considering the contemporary data for each. While this is an evolving field, the authors believe this paper can be helpful to review the current status of the use of mechanical support devices in the setting of acute MI and highlight some of the unmet needs in this field.

Disparity of Performance Measure by Door-to-Balloon Time Between a Rural and Urban Area for Management of Patients With ST-Segment Elevation Myocardial Infarction - Insights From the Nationwide Japan Acute Myocardial Infarction Registry

BACKGROUND

Although a door-to-balloon (D2B) time ≤90 min is recognized as a key indicator of timely reperfusion for patients with ST-segment elevation myocardial infarction (STEMI), it is unclear whether regional disparities in the prognostic value of D2B remain in contemporary Japan.

METHODS AND RESULTS

We retrospectively analyzed 17,167 STEMI patients (mean [±SD] age 68±13 years, 77.6% male) undergoing primary percutaneous coronary intervention. With reference to the Japanese median population density of 1,147 people/km2, patients were divided into 2 groups: rural (n=6,908) and urban (n=10,259). Compared with the urban group, median D2B time was longer (70 vs. 62 min; P<0.001) and the rate of achieving a D2B time ≤90 min was lower (70.7% vs. 75.4%; P<0.001) in the rural group. In-hospital mortality was lower for patients with a D2B time ≤90 min than >90 min, regardless of residential area, whereas multivariable analysis identified prolonged D2B time as a predictor of in-hospital death only in the rural group (adjusted odds ratio 1.57; 95% confidence interval 1.18-2.09; P=0.002). Importantly, the rural-urban disparity in in-hospital mortality emerged most distinctively among patients with Killip Class IV and a D2B time >90 min.

CONCLUSIONS

These data suggest that there is a substantial rural-urban gap in the prognostic significance of D2B time among STEMI patients, especially those with cardiogenic shock and a prolonged D2B time.

Psychopathology, Personality and Depression after Acute Coronary Syndrome: A Network Analysis in an Italian Population

Several biopsychosocial factors are associated with the onset of a Major Depressive Episode (MDE) after cardiovascular events. However, little is known of the interaction between trait- and state-like symptoms and characteristics and their role in predisposing cardiac patients to MDEs. Three hundred and four subjects were selected among patients admitted for the first time at a Coronary Intensive Care Unit. Assessment comprised personality features, psychiatric symptoms and general psychological distress; the occurrences of MDEs and Major Adverse Cardiovascular Events (MACE) were recorded during a two-year follow-up period. Network analyses of state-like symptoms and trait-like features were compared between patients with and without MDEs and MACE during follow-up. Individuals with and without MDEs differed in sociodemographic characteristics and baseline depressive symptoms. Network comparison revealed significant differences in personality features, not state-like symptoms: the group with MDEs displayed greater Type D personality traits and alexithymia as well as stronger associations between alexithymia and negative affectivity (edge differences between negative affectivity and difficulty identifying feelings was 0.303, and difficulty describing feelings was 0.439). The vulnerability to depression in cardiac patients is associated with personality features but not with state-like symptoms. Personality evaluation at the first cardiac event may help identify individuals more vulnerable to development of an MDE, and they could be referred to specialist care in order to reduce their risk.

Clinical Outcomes after Percutaneous Coronary Intervention for Cardiogenic Shock Secondary to Total Occlusive Unprotected Left Main Coronary Artery Lesion-Related Acute Myocardial Infarction

BACKGROUND

Acute myocardial infarction (AMI) with occlusion of an unprotected left main coronary artery (ULMCA) is a rare condition with a high mortality. The literature on clinical outcomes after percutaneous coronary intervention (PCI) for cardiogenic shock secondary to ULMCA-related AMI is scarce.

METHODS

In this retrospective analysis, all consecutive patients undergoing PCI for cardiogenic shock secondary to total occlusive ULMCA-related AMI were included between January 1998 and January 2017. The primary endpoint was 30-day mortality. The secondary endpoints were long-term mortality and 30-day and long-term major adverse cardiovascular and cerebrovascular events. The differences in clinical and procedural variables were assessed. A multivariable model was created to search for independent predictors of survival.

RESULTS

Forty-nine patients were included, and the mean age was 62 ± 11 years. The majority of patients suffered cardiac arrest prior or during PCI (51%). Thirty-day mortality was 78%, of which 55% died within 24 h. The median follow-up of patients who survived 30 days (n = 11) was 9.9 years (interquartile range 4.7-13.6), and long-term mortality was 84%. Long-term all-cause mortality was independently associated with cardiac arrest prior or during PCI (hazard ratio [HR] 2.02, 95% confidence interval 1.02-4.01, p = 0.043). Patients who survived to the 30-day follow-up with severe left ventricular dysfunction had a significantly higher risk of mortality compared to patients with moderate to mild dysfunction (p = 0.007).

CONCLUSIONS

Cardiogenic shock secondary to total occlusive ULMCA-related AMI carries a very high 30-day all-cause mortality. Thirty-day survivors with a severe left ventricular dysfunction have a poor long-term prognosis.

Shorter door-to-balloon time, better long-term clinical outcomes in ST-segment elevation myocardial infarction patients: J-MINUET substudy

BACKGROUND

The impact of shorter door-to-balloon (DTB time on long-term outcomes in ST-segment elevation myocardial infarction (STEMI treated with primary percutaneous coronary intervention (PPCI has not been fully elucidated.

METHODS

We investigated 3283 consecutive patients with acute myocardial infarction selected from a prospective, nationwide, multicenter registry (J-MINUET database comprising 28 institutions in Japan between July 2012 and March 2014. Among the study population, we analyzed 1639 STEMI patients who had PPCI within 12 h of onset. Patients were stratified into four groups (DTB time < 45 min, 45-60 min, 61-90 min, >90 min. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. We performed landmark analysis for incidence of the primary endpoint from 31 days to 3 years among the four groups.

RESULTS

The primary endpoint rate from 31 days to 3 years increased significantly and time-dependently with DTB time (10.2 % vs. 15.3 % vs. 16.2 % vs. 19.3 %, respectively; log-rank p = 0.0129. Higher logarithm-transformed DTB time was associated with greater risk of a primary endpoint from 31 days to 3 years, and the increased number of adverse long-term clinical outcomes persisted even after adjusting for other independent variables.

CONCLUSION

Shorter DTB time was associated with better long-term clinical outcomes in STEMI patients treated with PPCI in contemporary clinical practice. Further efforts to shorten DTB time are recommended to improve long-term clinical outcomes in STEMI patients.

TRIAL REGISTRATION

UMIN Unique trial Number: UMIN000010037.

Dynamic changes of monocytes subsets predict major adverse cardiovascular events and left ventricular function after STEMI

We explored how dynamic changes in monocyte subset counts (as opposed to static values to specific time points), and their phagocytic and NFκB activity relate to major adverse cardiovascular events (MACE) and left ventricular ejection fraction (LVEF) in patients with ST-elevation myocardial infarction (STEMI). Changes in counts, phagocytic activity and intracellular levels of inhibitory κB kinase β (IKKβ) (a marker of NFκB activity) of monocyte subsets (CD14⁺⁺CD16^-CCR2⁺ [Mon1], CD14⁺⁺CD16⁺CCR2⁺ [Mon2] and CD14⁺CD16⁺⁺CCR2^- [Mon3]) were measured by flow cytometry in patients with STEMI at baseline, and again after one week, two weeks, and one month. LVEF was measured by echocardiography at baseline and six months after STEMI. Baseline data included 245 patients (mean ± SD age 60 ± 12 years; 22% female), who were followed for a median of 46 (19-61) months. Multivariate Cox regression demonstrated that more prominent dynamic reduction in Mon2 by week 1 (n = 37) was independently associated with fewer MACE (HR 0.06, 95% CI 0.01-0.55, p = 0.01). Also, less prominent reduction in Mon2 at month 1 (n = 24) was independently predictive of 6-month LVEF. None of the other dynamic changes in monocyte subsets were associated with changes in survival from MACE. Neither phagocytic activity nor IKKβ were associated with survival for each monocyte subset. We showed how distinct pattern of dynamic changes in Mon2 are related to both MACE risk and recovery of cardiac contractility. Further research is needed to understand the mechanism of the monocyte effect and possibilities of their pharmacological manipulation.

Total Ischemic Time on In-Hospital Complication Predictor in ST-Elevation Myocardial Infarction (STEMI) Patients With Renal Dysfunction

Aim The purpose of this study was to examine the impact of total ischemic time (TIT) on in-hospital complications in acute ST-elevation myocardial infarction (STEMI) patients with renal dysfunction (RD). Methods The study included a total of 116 patients. All patients underwent percutaneous coronary intervention. Glomerular filtration rate (GFR) was < 60 ml/min/1.73 m² in all patients. The patients were split into two groups based on the TIT value. All eligible patients were assigned to two groups according to TIT: Group 1 comprised 54 patients with ≤ 6-hour TIT and Group 2 consisted of 62 patients with > 6-hour TIT. The groups' other characteristics were similar. The composite rate of pulmonary edema and cardiogenic shock were compared between groups. Results The mean TIT in Group 1 was 4.37 ± 1.35 and in Group 2 was 9.03 ± 1.59 (p < 0.0001). The incidence of pulmonary edema or cardiogenic shock was higher in Group 2 than in Group 1: 16.1% and 3.7%, respectively (p = 0.034). Conclusion STEMI patients with RD and higher TIT were more likely to develop pulmonary edema and cardiogenic shock.

Identification and validation of senescence-related genes in circulating endothelial cells of patients with acute myocardial infarction

Background

Acute myocardial infarction (AMI) is the main clinical cause of death and cardiovascular disease and thus has high rates of morbidity and mortality. The increase in cardiovascular disease with aging is partly the result of vascular endothelial cell senescence and associated vascular dysfunction. This study was performed to identify potential key cellular senescence-related genes (SRGs) as biomarkers for the diagnosis of AMI using bioinformatics.

Methods

Using the CellAge database, we identified cellular SRGs. GSE66360 and GSE48060 for AMI patients and healthy controls and GSE19322 for mice were downloaded from the Gene Expression Omnibus (GEO) database. The GSE66360 dataset was divided into a training set and a validation set. The GSE48060 dataset was used as another validation set. The GSE19322 dataset was used to explore the evolution of the screened diagnostic markers in the dynamic process of AMI. Differentially expressed genes (DEGs) of AMI were identified from the GSE66360 training set. Differentially expressed senescence-related genes (DESRGs) selected from SRGs and DEGs were analyzed using Gene Ontology (GO) enrichment, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways, and protein-protein interaction (PPI) networks. Hub genes in DESRGs were selected based on degree, and diagnostic genes were further screened by gene expression and receiver operating characteristic (ROC) curve. Finally, a miRNA-gene network of diagnostic genes was constructed and targeted drug prediction was performed.

Results

A total of 520 DEGs were screened from the GSE66360 training set, and 279 SRGs were identified from the CellAge database. The overlapping DEGs and SRGs constituted 14 DESRGs, including 4 senescence suppressor genes and 10 senescence inducible genes. The top 10 hub genes, including FOS, MMP9, CEBPB, CDKN1A, CXCL1, ETS2, BCL6, SGK1, ZFP36, and IGFBP3, were screened. Furthermore, three diagnostic genes were identified: MMP9, ETS2, and BCL6. The ROC analysis showed that the respective area under the curves (AUCs) of MMP9, ETS2, and BCL6 were 0.786, 0.848, and 0.852 in the GSE66360 validation set and 0.708, 0.791, and 0.727 in the GSE48060 dataset. In the GSE19322 dataset, MMP9 (AUC, 0.888) and ETS2 (AUC, 0.929) had very high diagnostic values in the early stage of AMI. Finally, based on these three diagnostic genes, we found that drugs such as acetylcysteine and genistein may be targeted for the treatment of age-related AMI.

Conclusion

The results of this study suggest that cellular SRGs might play an important role in AMI. MMP9, ETS2, and BCL6 have potential as specific biomarkers for the early diagnosis of AMI.

Home-based cardiac rehabilitation: A review of bibliometric studies and visual analysis of CiteSpace (2012-2021)

Home-based cardiac rehabilitation has been a major area in cardiac rehabilitation research for a long time. However, there are few systematic studies in this field using bibliometric analysis. We collected articles and reviews for home-based cardiac rehabilitation from the Web of Science Core Collection. Our objectives were to perform a bibliometric analysis and visualization study to determine hotspots and trends of home-based cardiac rehabilitation, identify collaboration and influence among authors, countries, institutions, and journals, and assess the knowledge base to develop clinical research in the future. This study will provide a valuable reference for researchers concerned with HBCR.

Case report: Oral anticoagulant combined with percutaneous coronary intervention for peripheral embolization of left ventricular thrombus caused by myocardial infarction in a patient with diabetes mellitus

Background

Left ventricular thrombus (LVT) is a well-recognized complication of myocardial infarction (MI) in patients with diabetes. An embolic complication caused by LVT is a key clinical problem and is associated with worsened long-term survival.

Case presentation

A 45-year-old man with persistent left abdominal pain for 1 week and left leg fatigue was admitted to the emergency department. The cause of abdominal pain was embolism of the renal artery, the splenic artery, and the superior mesenteric artery caused by cardiogenic thrombosis, which further led to splenic infarction and renal infarction. It was unclear when MI occurred because the patient had no typical critical chest pain, which may have been related to diabetic complications, such as diabetic peripheral neuropathy. Diabetes plays a pivotal role in MI and LVT formation. Because coronary angiography suggested triple vessel disease, percutaneous transluminal coronary angioplasty (PTCA) was conducted, and two drug-eluting stents were placed in the left anterior descending coronary artery (LAD). Due to a lack of randomized clinical control trials, the therapy of LVT and associated embolization has been actively debated. According to the present guidelines, this patient was treated with low-molecular-weight heparin and warfarin (oral anticoagulants) for 3 months in addition to aspirin (100 mg/day) and clopidogrel (75 mg/day) for 1 year. No serious bleeding complications were noted, and a follow-up examination showed no thrombus in the left ventricle or further peripheral thrombotic events.

Conclusion

Peripheral embolization of LVT caused by MI leading to multiple organ embolization remains a rare occurrence. Diabetes plays a pivotal role in MI and LVT formation. Successful revascularization of the infarct-related coronary artery and anticoagulation therapy is important to minimize myocardial damage and prevent LVT. The present case will help clinicians recognize and manage LVT in patients with diabetes and related peripheral arterial thrombotic events with anticoagulation.

Structure, Process, and Mortality Associated with Acute Coronary Syndrome Management in Guatemala's National Healthcare System: The ACS-GT Registry

Background

Acute coronary syndromes (ACS) include ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). The leading cause of mortality in Guatemala is acute myocardial infarction (AMI) and there is no established national policy nor current standard of care.

Objective

Describe the factors that influence ACS outcome, evaluating the national healthcare system's quality of care based on the Donabedian health model.

Methods

The ACS-Gt study is an observational, multicentre, and prospective national registry. A total of 109 ACS adult patients admitted at six hospitals from Guatemala's National Healthcare System were included. These represent six out of the country's eight geographic regions. Data enrolment took place from February 2020 to January 2021. Data was assessed using chi-square test, Student's t-test, or Mann-Whitney U test, whichever applied. A p-value < 0.05 was considered statistically significant.

Results

One hundred and nine patients met inclusion criteria (80.7% STEMI, 19.3% NSTEMI/UA). The population was predominantly male, (68%) hypertensive (49.5%), and diabetic (45.9%). Fifty-nine percent of STEMI patients received fibrinolysis (alteplase 65.4%) and none for primary Percutaneous Coronary Intervention (pPCI). Reperfusion success rate was 65%, and none were taken to PCI afterwards in the recommended time period (2-24 hours). Prognostic delays in STEMI were significantly prolonged in comparison with European guidelines goals. Optimal in-hospital medical therapy was 8.3%, and in-hospital mortality was 20.4%.

Conclusions

There is poor access to ACS pharmacological treatment, low reperfusion rate, and no primary, urgent, or rescue PCI available. No patient fulfilled the recommended time period between successful fibrinolysis and PCI. Resources are limited and inefficiently used.

Prognostic impact of pre-interventional culprit artery thrombolysis in myocardial infarction (TIMI) flow in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

Background

Primary percutaneous coronary intervention (PCI) is considered the most preferred strategy in ST-segment elevation myocardial infarction (STEMI). However, the prognostic role of spontaneous re-canalization in STEMI patients is still not clear. The purpose of this study is to evaluate the impact of pre-procedural TIMI flow grade in the culprit coronary artery on the short and long term prognosis in Egyptian patients presented with STEMI and treated with primary PCI.

Results

A dual center, prospective observational study that was conducted in the period from January 2019 till June 2020 and enrolled 150 STEMI patients presented within 24 h from onset of chest pain. Initial angiography was done with analysis of TIMI flow grade in the infarct related artery. Of the 150 enrolled patients; 93 patients (62%) were found to have initial TIMI flow grade 0 (group A) and 57 patients (38%) had initial TIMI flow grade I–III (group B). There was a strong association between cardiac mortality and pre-procedural TIMI flow grade. 12 mortalities (8% of total study population) were recorded during our study period; in-hospital mortality was reported in 7 patients in group A, yet no mortalities were recorded in-hospital in group B (P value = 0.033). At 1 year follow up; 5 mortalities were recorded in group A with no mortalities at all in group B (P value = 0.005). There was a trend towards an increase in acute heart failure incidence in group A yet no statistically significant value was achieved (P value = 0.112). Target lesion revascularization was reported in 8 patients in group A and in only 3 patients in group B (P value 0.446).

Conclusions

Despite the evolution in primary PCI strategies and the continuous advancement in anti-thrombotic treatment; pre-interventional infarct related artery TIMI flow grade I–III is associated with better in hospital and 1 year outcome, specifically significantly lower cardiac mortality compared to patients who had TIMI flow grade 0 at initial angiography.

The circulating furin-cleaved/mature PCSK9 ratio has a potential prognostic significance in statin-naïve patients with acute ST elevation myocardial infarction

Background and aims

Proprotein convertase subtilisin/kexin type 9 (PCSK9) circulates as mature and furin-cleaved forms, but their biological functions are uncertain. We investigated whether their levels associate with prognosis in patients with acute ST elevation myocardial infarction (STEMI).

Methods

We enrolled 160 statin-naïve patients with acute STEMI and followed for 3 years. PCSK9 subtype levels were determined by an enzyme-linked immunosorbent assay before and at five timepoints up to 48 h after emergent coronary intervention. The occurrence of coronary and cardiac events was compared between subjects stratified by the PCSK9 level.

Results

One hundred and twenty-six patients completed 3 years of follow-up. In the acute phase, both PCSK9 subtype levels decreased, and thereafter increased from 6 to 48 h (mature: from 198 ± 67 to 334 ± 116 ng/mL, furin-cleaved: from 20 ± 7 to 39 ± 16 ng/mL, both p < 0.01). Major cardiac events occurred in 46 patients. The furin-cleaved/mature PCSK9 ratio at 48 h after coronary intervention predicted the likelihood of experiencing of events; patients in the third tertile had lower event-free survival than those in the first and second tetiles in Kaplan-Meier analysis (p = 0.004). Multivariate Cox regression analysis revealed that this ratio had a greater impact (HR: 1.92; 95% CI: 1.06-3.45, p = 0.03) on events than other known atherosclerosis risk factors.

Conclusions

The furin-cleaved/mature PCSK9 ratio was associated with 3-year cardiovascular events in statin-naïve patients with acute STEMI, suggesting a potential link between furin cleavage process of PCSK9 and its effect on prognosis. (249 words).

A Robustness Evaluation of Machine Learning Algorithms for ECG Myocardial Infarction Detection

An automatic electrocardiogram (ECG) myocardial infarction detection system needs to satisfy several requirements to be efficient in real-world practice. These requirements, such as reliability, less complexity, and high performance in decision-making, remain very important in a realistic clinical environment. In this study, we investigated an automatic ECG myocardial infarction detection system and presented a new approach to evaluate its robustness and durability performance in classifying the myocardial infarction (with no feature extraction) under different noise types. We employed three well-known supervised machine learning models: support vector machine (SVM), k-nearest neighbors (KNN), and random forest (RF), and tested the performance and robustness of these techniques in classifying normal (NOR) and myocardial infarction (MI) using real ECG records from the PTB database after normalization and segmentation of the data, with a suggested inter-patient paradigm separation as well as noise from the MIT-BIH noise stress test database (NSTDB). Finally, we measured four metrics: accuracy, precision, recall, and F1-score. The simulation revealed that all of the models performed well, with values of over 0.50 at lower SNR levels, in terms of all the metrics investigated against different types of noise, indicating that they are encouraging and acceptable under extreme noise situations are are thus considered sustainable and robust models for specific forms of noise. All of the methods tested could be used as ECG myocardial infarction detection tools in real-world practice under challenging circumstances.

New permanent bundle-branch block and long-term prognosis of patients with new onset ST-elevation myocardial infarction who underwent percutaneous coronary intervention

Aim: The aim of the study was to evaluate the potential predictive value of permanent RBBB and LBBB for longer-term prognosis in patients with new-onset STEMI who underwent percutaneous coronary intervention (PCI).

Methods: Patients with new-onset STEMI that underwent emergency PCI at our department from June 2012 to September 2020 were included in the study. Gensini score (GS) was employed to evaluate the severity of coronary lesions. The primary endpoint of the study was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), the composite of cardiac mortality, recurrence of myocardial infarction, cardiac shock, stroke, stent thrombosis, or revascularization. We also set all-cause mortality as a secondary endpoint.

Results: Out of the 547 patients, 29 patients had new-onset permanent LBBB, 51 patients had new-onset permanent RBBB, and 467 patients had no bundle-branch block (BBB). The occurrence of no BBB, new permanent LBBB, or RBBB was not associated with the severity of coronary artery lesions as evaluated by the GS. After follow-up at an average of 43.93 months, MACCEs occurred in 52 patients. Kaplan-Meier analysis showed that patients with new-onset RBBB were at greater risk for MACCEs compared to those with new onset LBBB (χ² = 5.107, p = 0.021). Also, an independent correlation was found between new permanent RBBB and LBBB and MACCEs risk. The adjusted hazard ratios (HRs) were 6.862 [95% confidence interval (CI) of 3.764–12.510] for the new-onset permanent RBBB and 3.395 (95% CI of 1.280–9.005) for LBBB, compared to those with no BBB, respectively (both p < 0.05).

Conclusion: New onset permanent RBBB in patients with new onset STEMI who underwent PCI may be correlated independently with increased risk of poor long-term prognosis.

Systematic Bioinformatics Analysis Based on Public and Second-Generation Sequencing Transcriptome Data: A Study on the Diagnostic Value and Potential Mechanisms of Immune-Related Genes in Acute Myocardial Infarction

Acute myocardial infarction (AMI) is one of the most serious cardiovascular diseases worldwide. Advances in genomics have provided new ideas for the development of novel molecular biomarkers of potential clinical value for AMI.

Recent Advance on Drug Therapy Related to Myocardial Ischemia Reperfusion Injury

Myocardial ischemia reperfusion injury (MIRI) means complete or partial artery obstruction of coronary artery, and ischemic myocardium will be recirculating in a period of time. Although the ischemic myocardium can be restored to normal perfusion, its tissue damage will instead be progressive. An aggravated pathological process. MIRI is a complex entity where many inflammatory mediators play different roles, both to enhance myocardial infarction-derived damage and to heal injury. Therefore, the research and development of drugs for the prevention and treatment of this period has also become the focus. This article first studied pathophysiology of MIRI, and reviewed the research progress of MIRI-related drugs. Research results show that: MIRI is inevitable for myocardial ischemia, with the possible to double damage via the ischemic condition. Therefore, it is a serious complication and one of the most popular diseases in the world. It has always been difficult to find an effective treatment for this disease, because it is difficult to explore the inflammation behind its pathophysiology.

Intra-aortic balloon pump in cardiogenic shock: A propensity score matching analysis

OBJECTIVE

To assess the impact of intra-aortic balloon pumps (IABP) on patients with cardiogenic shock in an intensive care unit setting.

BACKGROUND

IABP counterpulsation is a widely used mechanical circulatory support device, but its performance has been questioned. However, current evidence of IABP use in cardiogenic shock is very limited (mainly from the IABP-SHOCK II trial), which was restricted to cardiogenic shock complicating acute myocardial infarction.

METHODS

This was a retrospective, real-world, cohort study based on the Medical Information Mart for Intensive Care III database. Adult patients with a diagnosis of cardiogenic shock were eligible.

RESULTS

A total of 1028 patients with cardiogenic shock were assessed, including 384 patients who received IABP and 644 patients who did not. The in-hospital mortality was significantly lower in patients who received IABP (adjusted odds ratio: 0.75, 95% confidence interval: 0.62-0.91, p = 0.009). Analysis of secondary endpoints found that the use of IABP was associated with a significantly lower risk of 1-year mortality. After propensity score matching, the in-hospital mortality remained significantly lower in the IABP group (28.10% vs. 37.59%, p = 0.018).

CONCLUSIONS

In the current cohort, IABP treatment was associated with a lower risk of in-hospital mortality in patients with cardiogenic shock. Due to the complexity of pathophysiology in cardiogenic shock and the discrepancies in current evidence, our results should be validated through further studies in the future.

Fasting Blood Glucose but not TMAO is Associated with In-Stent Restenosis in Patients with Acute Coronary Syndrome

Background: The purpose of our study was to assess whether the occurrence of ISR might be associated with plasmaTMAO levels in patients with ACS after DES implantation.Methods: This was a single center retrospective case-control study, in which 64 symptomatic patients with repeatedcoronary angiography after PCI and 15 patients with ISR were included in the ISR group, and 49 patients without ISRwere included in the non-ISR group. High-performance liquid chromatography with tandem mass spectrometry wasused to measure plasma TMAO levels.Results: No significant differences were observed in plasma TMAO between the ISR and non-ISR groups. Plasma TMAO levels showed no significant correlation with ISR, but were significantly positively correlated with diabetes mellitus, serum HbA1c levels and serum creatinine levels; moreover, they were significantly negatively correlated with female sex. ISR was significantly positively correlated with diabetes mellitus, fasting blood glucose levels, the neutrophil to lymphocyte ratio and syntax score; in addition, it was significantly negatively correlated with platelets. Logistic regression analysis indicated that fasting blood glucose was the only independent predictor of ISR.Conclusion: Plasma TMAO may not be associated with ISR and plaque burden in patients with ACS after DES implantation,whereas FBG may predict the development of ISR in these patients.

Predictive Biomarkers for Postmyocardial Infarction Heart Failure Using Machine Learning: A Secondary Analysis of a Cohort Study

Background

There are few biomarkers with an excellent predictive value for postacute myocardial infarction (MI) patients who developed heart failure (HF). This study aimed to screen candidate biomarkers to predict post-MI HF.

Methods

This is a secondary analysis of a single-center cohort study including nine post-MI HF patients and eight post-MI patients who remained HF-free over a 6-month follow-up. Transcriptional profiling was analyzed using the whole blood samples collected at admission, discharge, and 1-month follow-up. We screened differentially expressed genes and identified key modules using weighted gene coexpression network analysis. We confirmed the candidate biomarkers using the developed external datasets on post-MI HF. The receiver operating characteristic curves were created to evaluate the predictive value of these candidate biomarkers.

Results

A total of 6,778, 1,136, and 1,974 genes (dataset 1) were differently expressed at admission, discharge, and 1-month follow-up, respectively. The white and royal blue modules were most significantly correlated with post-MI HF (dataset 2). After overlapping dataset 1, dataset 2, and external datasets (dataset 3), we identified five candidate biomarkers, including FCGR2A, GSDMB, MIR330, MED1, and SQSTM1. When GSDMB and SQSTM1 were combined, the area under the curve achieved 1.00, 0.85, and 0.89 in admission, discharge, and 1-month follow-up, respectively.

Conclusions

This study demonstrates that FCGR2A, GSDMB, MIR330, MED1, and SQSTM1 are the candidate predictive biomarker genes for post-MI HF, and the combination of GSDMB and SQSTM1 has a high predictive value.

Early and late ventricular arrhythmias complicating ST-segment elevation myocardial infarction

BACKGROUND

Ventricular arrhythmias can be life-threatening complications of ST-segment elevation myocardial infarction (STEMI).

AIMS

To describe the incidence, predictors and in-hospital impact of early ventricular arrhythmia (EVA, occurring<day 2 after STEMI) and late ventricular arrhythmia (LVA, occurring≥day 2 after STEMI) in patients with STEMI.

METHODS

Data from 13,523 patients enrolled in a prospective registry were analysed. Logistic and Cox regressions were performed to identify predictors of EVA, LVA and in-hospital all-cause mortality. Predictors of LVA were used to build a risk score.

RESULTS

EVA occurred in 678 patients (5%), whereas 120 patients (0.9%) experienced LVA, at a median timing of 3days after STEMI. EVA was associated with a significantly higher risk of all-cause mortality (hazard ratio: 1.44, 95% confidence interval: 1.17-1.76; P=0.001), whereas no association was observed with LVA (hazard ratio 0.86, 95% confidence interval 0.57-1.28; P=0.45). Multivariable predictors of LVA were: age≥65years; serum creatinine≥85μmol/L on admission; pulse pressure≤45mmHg on admission; presence of a Q wave on admission electrocardiogram; Thrombolysis In Myocardial Infarction flow grade<3 after percutaneous coronary intervention; and left ventricular ejection fraction≤45%. The score derived from these variables allowed the classification of patients into four risk categories: low (0-21); low-to-intermediate (22-34); intermediate-to-high (35-44); and high (≥45). Observed LVA rates were 0.2%, 0.3%, 0.9% and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P=0.23).

CONCLUSIONS

EVA is 5-fold more common than LVA in the setting of STEMI, and portends a higher risk of in-hospital all-cause mortality. LVA is mainly associated with the patient's baseline risk profile and surrogate markers of larger infarct size. We developed and internally validated a risk score identifying patients at high risk of LVA for whom early intensive care unit discharge may not be suitable.

Chitosan as Functional Biomaterial for Designing Delivery Systems in Cardiac Therapies

Cardiovascular diseases are a leading cause of mortality across the globe, and transplant surgeries are not always successful since it is not always possible to replace most of the damaged heart tissues, for example in myocardial infarction. Chitosan, a natural polysaccharide, is an important biomaterial for many biomedical and pharmaceutical industries. Based on the origin, degree of deacetylation, structure, and biological functions, chitosan has emerged for vital tissue engineering applications. Recent studies reported that chitosan coupled with innovative technologies helped to load or deliver drugs or stem cells to repair the damaged heart tissue not just in a myocardial infarction but even in other cardiac therapies. Herein, we outlined the latest advances in cardiac tissue engineering mediated by chitosan overcoming the barriers in cardiac diseases. We reviewed in vitro and in vivo data reported dealing with drug delivery systems, scaffolds, or carriers fabricated using chitosan for stem cell therapy essential in cardiac tissue engineering. This comprehensive review also summarizes the properties of chitosan as a biomaterial substrate having sufficient mechanical stability that can stimulate the native collagen fibril structure for differentiating pluripotent stem cells and mesenchymal stem cells into cardiomyocytes for cardiac tissue engineering.

Reasons for reperfusion delay in ST-elevation myocardial infarction and their impact on mortality

AIMS

The impact of reperfusion delay in ST-elevation myocardial infarction (STEMI) is well known. We aimed to describe the specific reasons for delay to primary percutaneous coronary intervention (pPCI), and their impact on mortality after adjusting for confounders, using the first-medical-contact-to-device (FMCTD) time to measure the delay.

METHODS

Between January 2006 and December 2019, 2149 STEMI patients underwent pPCI at our centre. Delayed pPCI was defined as FMCTD > 90 min or > 120 min in the case of inter-hospital transfer. The causes of delay were classified as system-related (related to the network organization) or patient-related (related to the clinical condition of the patient). Primary outcome was 1-year all-cause mortality.

RESULTS

The pPCI was timely in 69.9% of patients, delayed for system-related causes in 16.4% or for patient-related causes in 13.7%. Different patient-related causes induced variable median FMCTD time (from 114 min for technically difficult pPCI to 159 min for ECG and/or symptom resolution). By multivariable Cox-regression models, the main independent risk factors for mortality were delay due to comorbidities [hazard ratio (HR) 2.19 (1.22-3.91)], or hemodynamic instability [HR 2.05 (1.25-3.38)], after adjusting for Global Registry of Acute Coronary Events risk score tertiles and angiographic success. The difference in risk of mortality is maintained over the entire spectrum of time from symptom onset.

CONCLUSIONS

Different causes of delay had different impacts on mortality, generally more important than the length of the delay. Causes of delay such as hemodynamic instability and comorbidities should prompt specific programs of performance improvement. Timely pPCI maintains prognostic advantages after several hours from symptom onset, mandating prompt reperfusion also in late-presenter patients.

Percutaneous Coronary Intervention After Return of Spontaneous Circulation Reduces the In-Hospital Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiac Arrest

Background and Objective

The role of percutaneous coronary intervention (PCI) after return of spontaneous circulation (ROSC) in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) is controversial. This study aimed to evaluate the effects of PCI on the in-hospital mortality after ROSC in patients with AMI complicated by CA.

Methods

The clinical data of 66 consecutive patients with ROSC after CA caused by AMI from January 2006 to December 2015 at the First Affiliated Hospital of Sun Yat-sen University were collected. Among these patients, 21 underwent urgent PCI. We analyzed the clinical characteristics of the patients during hospitalization.

Results

The patients who underwent PCI had a higher rate of ST-segment elevation, and their initial recorded heart rhythms were more likely to have a shockable rhythm. Further, they had a high PCI success rate of 100%. The in-hospital mortality in the patients who did not undergo PCI was significantly higher than that in the patients who underwent PCI (68.9% vs 9.5%, P<0.05). Multivariate logistic regression analysis showed that cardiogenic shock (odds ratio [OR], 3.537; 95% CI, 1.047–11.945; P=0.042) and Glasgow Coma Scale score of ≤8 after ROSC (OR, 14.992; 95% CI, 2.815–79.843; P=0.002) were the independent risk factors for in-hospital mortality among the patients. Meanwhile, PCI was a protective factor against in-hospital mortality (OR, 0.063; 95% CI, 0.012–0.318; P=0.001). After propensity matching analysis, the results still showed that PCI (OR, 0.226; 95% CI, 0.028–1.814; P=0.0162) was a protective factor for in-hospital death.

Conclusion

The patients with ROSC after CA caused by AMI who underwent PCI had a lower in-hospital mortality than those who did not undergo PCI.