Prognostic Association of Circulating Neutrophil Count with No-Reflow in Patients with ST-Segment Elevation Myocardial Infarction following Successful Primary Percutaneous Intervention

Stress, Hyperglycemia, and Insulin Resistance Correlate With Neutrophil Activity and Impact Acute Myocardial Infarction Outcomes

Introduction Acute insulin resistance (IR) and hyperglycemia are frequently observed during acute myocardial infarction (AMI), significantly influencing both immediate and long-term patient outcomes, irrespective of diabetic status. Neutrophilia and increased neutrophil activity, which are common in these scenarios, have been associated with poorer prognoses, as demonstrated in our recent findings. While it is well established that neutrophils and stress-induced hyperglycemia exacerbate inflammation and hinder recovery, the complex interplay between these factors and their combined impact on AMI prognosis remains inadequately understood. This study aims to investigate the effects of stress hyperglycemia and IR on AMI patients at the onset of the event and to elucidate the relationship between these metabolic disturbances and inflammatory markers, particularly neutrophils. Methods We conducted a longitudinal prospective study on 219 AMI patients at Elias Emergency Hospital in Bucharest, Romania, from April 2021 to September 2022. Patients were included within 24 hours of AMI with ST-segment elevation and excluded if they had acute infections or chronic inflammatory diseases. Blood samples were collected to study inflammatory biomarkers, including neutrophil extracellular traps (NETs), S100A8/A9, interleukin (IL)-1β, IL-18, and IL-6. Diabetic and pre-diabetic statuses were defined using glycated hemoglobin (HbA1c) and medical history (ADA 2019 criteria). To assess glycemic parameters, we employed the glycemia ratio (GR) and the homeostatic model assessment of insulin resistance (HOMA-IR) index, enabling a precise evaluation of stress hyperglycemia, acute IR, and their prognostic implications. Patients were stratified into groups based on GR calculations, categorized as under-average glycemia, normal glycemia, and stress hyperglycemia. Results The majority of patients in the stress hyperglycemia group exhibited an unfavorable prognosis. This group also demonstrated significantly elevated neutrophil counts and neutrophil-to-lymphocyte ratios (NLR). The GR was significantly and positively correlated with inflammation markers, including neutrophil count (Pearson's R = 0.181, P = 0.008) and NLR (Pearson's R = 0.318, P < 0.001), but showed no significant correlation with other evaluated inflammatory markers. Conclusions Our findings suggest that poor outcomes in AMI patients may be associated with stress hyperglycemia, as indicated by GR. AcuteIR, quantified by GR and HOMA-IR, exhibits a strong correlation with neutrophil count and NLR within the first 24 hours of AMI onset. However, no significant correlation was observed with other inflammatory markers, such as IL-1β, IL-18, and IL-6, underscoring the specific interplay between IR and neutrophil activity in this setting.

Relationship Between Systemic Inflammation Index and No-Reflow Phenomenon in Patients With ST-Segment Elevation Myocardial Infarction

This study aimed to evaluate the relationship between no-reflow phenomenon and systemic inflammation index (SII) and to compare the predictive capacity of SII together with the neutrophil-lymphocyte ratio (NLR), and the platelet-lymphocyte ratio (PLR) in patients with ST-elevation myocardial infarction (STEMI). A total of 785 patients were included. The thrombolysis in myocardial infarction (TIMI) flow degree has been used to describe the no-reflow phenomenon. The study population was divided into two groups regarding the presence of no-reflow phenomenon including 110 patients with no-reflow (TIMI frame count 0-2) and 675 patients without no-reflow (TIMI frame count 3). The NLR [6.6 (4.6-11.6) vs 3.2 (2.0-5.3); P < .001], PLR [175 (121.3-220) vs 102.6 (76.1-150.1); P < .001] and SII [1921(1225-2906) vs 738.5 (450.5-1293); P < .001] were significantly higher in the no-reflow group. High NLR (OR: 1.078, 95%CI: 1.027-1.397; P = .021), PLR (OR: 1.009, 95%CI: 1.003-1.021; P = .041) and SII (OR: 1.216, 95%CI: 1.106-1.942; P = .004) were found to be independently associated with no-reflow phenomenon. The comparison of the receiver-operating characteristic curves showed that area under the curve of SII was greater than that of NLR (.789 vs .766, P = .007) and PLR (.789 vs .759, P = .048). SII levels may predict no-reflow phenomenon better than NLR and PLR.

Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients With Symptom Onset >12 Hours: Data from China Acute Myocardial Infarction Registry

To determine whether late percutaneous coronary intervention (PCI) of an infarct-related artery >12 h after ST-segment elevation myocardial infarction onset is beneficial, patients were included from the prospective, nationwide, multicenter China Acute Myocardial Infarction registry. The number of patients who underwent PCI or received drug therapy alone was 4791 and 1149, respectively. Hazard ratio (HR) and associated 95% confidence interval (CI) were calculated. Compared with drug therapy, PCI was associated with lower incidences of 2-year major adverse cardiac and cerebrovascular events (MACCE; 6.43 vs 20.19%; HR, .27; 95% CI, .23-.32; P < .001), all-cause death (4.13 vs 15.74%; HR, .24; 95% CI, .20-.30; P < .001), myocardial infarction (1.73 vs 3.31%; HR, .49; 95% CI, .33-.72; P = .0003), stroke (1.02 vs 2.00%; HR, .47; 95% CI, .28-.77; P = .0026), and revascularization (10.96 vs 27.56%; HR, .32; 95% CI, .26-.39; P < .001). Subgroup analysis consistently indicated that PCI was superior to drug therapy. Moreover, the left ventricular ejection fraction in the PCI group was increased after 2-year follow-up, whereas there was no significant increase in the drug therapy group. In conclusion, late PCI is common in Chinese clinical practice, and it is associated with significant improvements in cardiac function and survival compared with drug therapy alone.

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

Methods

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

Results

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

Conclusion

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

Role of Neutrophils in Cardiac Injury and Repair Following Myocardial Infarction

Neutrophils are first-line responders of the innate immune system. Following myocardial infarction (MI), neutrophils are quickly recruited to the ischemic region, where they initiate the inflammatory response, aiming at cleaning up dead cell debris. However, excessive accumulation and/or delayed removal of neutrophils are deleterious. Neutrophils can promote myocardial injury by releasing reactive oxygen species, granular components, and pro-inflammatory mediators. More recent studies have revealed that neutrophils are able to form extracellular traps (NETs) and produce extracellular vesicles (EVs) to aggravate inflammation and cardiac injury. On the contrary, there is growing evidence showing that neutrophils also exert anti-inflammatory, pro-angiogenic, and pro-reparative effects, thus facilitating inflammation resolution and cardiac repair. In this review, we summarize the current knowledge on neutrophils’ detrimental roles, highlighting the role of recently recognized NETs and EVs, followed by a discussion of their beneficial effects and molecular mechanisms in post-MI cardiac remodeling. In addition, emerging concepts about neutrophil diversity and their modulation of adaptive immunity are discussed.

Inflammation during Percutaneous Coronary Intervention-Prognostic Value, Mechanisms and Therapeutic Targets

Periprocedural myocardial injury and myocardial infarction (MI) are not infrequent complications of percutaneous coronary intervention (PCI) and are associated with greater short- and long-term mortality. There is an abundance of preclinical and observational data demonstrating that high levels of pre-, intra- and post-procedural inflammation are associated with a higher incidence of periprocedural myonecrosis as well as future ischaemic events, heart failure hospitalisations and cardiac-related mortality. Beyond inflammation associated with the underlying coronary pathology, PCI itself elicits an acute inflammatory response. PCI-induced inflammation is driven by a combination of direct endothelial damage, liberation of intra-plaque proinflammatory debris and reperfusion injury. Therefore, anti-inflammatory medications, such as colchicine, may provide a novel means of improving PCI outcomes in both the short- and long-term. This review summarises periprocedural MI epidemiology and pathophysiology, evaluates the prognostic value of pre-, intra- and post-procedural inflammation, dissects the mechanisms involved in the acute inflammatory response to PCI and discusses the potential for periprocedural anti-inflammatory treatment.

Urinary Alpha1-Microglobulin: A New Predictor for In-Hospital Mortality in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND Alpha1-microglobulin (A1MG) is a small molecular protein related to oxidation and inflammation. It exists in diverse body fluids, including urine. Results from urine tests are sometimes neglected when predicting in-hospital prognosis. It remains unclear whether urinary A1MG (UA1MG) can predict short-term prognosis of ST-elevated myocardial infarction (STEMI). MATERIAL AND METHODS A total of 1854 hospitalized patients with acute STEMI were retrospectively enrolled in our study. Medical records were used to obtain patient demographic and clinical information, UA1MG values (which were used to divide patients into groups of low, medium, or high), and other laboratory parameters. Principal clinical outcomes of interest were all-cause in-hospital deaths, cardiac deaths, and major adverse cardiac events (MACEs). RESULTS Among the 1854 enrolled patients, 43 (2.3%) died in the hospital, of which 33 (1.8%) were cardiac deaths. MACEs were noted in 113 patients (6.1%) during hospitalization. The group with the highest UA1MG value showed a significantly higher frequency of in-hospital deaths, cardiac deaths, and MACEs, compared to those of the lowest UA1MG value group (4.4% vs. 1.0%, P<0.001; 3.1% vs. 0.6%, P<0.005; and 8.6% vs. 4.7%, P=0.007, respectively). Multivariate regression analysis revealed that UA1MG levels (odds ratio 1.109, 95% confidence interval (CI) 1.027-1.197, P=0.008) independently predicted all-cause in-hospital mortality. A UA1MG value of 3.23 mg/dL was considered as an optimal cutoff point in STEMI to predict all-cause mortality after receiver operating characteristic curve analysis (area under the curve 0.73, 95% CI 0.65-0.80, P<0.001). CONCLUSIONS The UA1MG value at hospital admission could be an independent prognostic factor of all-cause in-hospital mortality in patients with STEMI.

Novel predictors and adverse long-term outcomes of No-reflow phenomenon in patients with acute ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

Objectives

The no-reflow phenomenon occurs in 25% of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and may be associated with adverse outcomes. The aim of our study was to detect novel predictors of no-reflow phenomenon and the resulting adverse long term outcomes.

Methods

We enrolled 400 STEMI patients undergoing primary PCI; 228 patients had TIMI flow 3 after PCI (57%) and the remaining 172 patients had TIMI flow <3 (43%). Fibrinogen to albumin ratio (FAR), high sensitive C-reactive protein to albumin ratio (CAR), and atherogenic index of plasma (AIP) were calculated. Long term mortality and morbidity during 6 months follow up were recorded. These data were compared among both groups.

Results

In multivariate regression analysis, old age (OR = 1.115, 95% CI: 1.032–1.205, P = 0.006), higher troponin level >5.6 ng/mL (OR = 1.040, 95% CI: 1.001–1.080, P = 0.04), diabetes mellitus (OR = 4.401, 95% CI: 1.081–17.923, P = 0.04) and heavy thrombus burden (OR = 16.915, 95% CI: 5.055–56.602, P < 0.001) could be considered as predictors for the development of no-reflow. Interestingly, CAR >0.21, FAR >11.56, and AIP >0.52 could be considered as novel powerful independent predictors (OR = 3.357, 95% CI: 2.288–4.927, P < 0.001, OR = 4.187, 95% CI: 2.761–6.349, P < 0.001, OR = 16.794, 95% CI: 1.018–277.01, P = 0.04, respectively). Higher long term mortality (P < 0.001) and heart failure (P < 0.001) was also strongly related to incidence of no-reflow.

Conclusion

No-reflow could be attributed to novel predictors as CAR, FAR, and AIP. This phenomenon was associated with long term adverse events as higher mortality and pump failure.

Inflammatory and Hematological Indices as Simple, Practical Severity Predictors of Microdysfunction Following Coronary Intervention: A Systematic Review and Meta-Analysis

C-reactive protein (CRP) and high-sensitivity CRP (hsCRP), along with a series of hematological indices, platelet to lymphocyte ratio (PLR), neutrophil to lymphocyte ratio (NLR), mean platelet volume (MPV), platelet distribution width (PDW), and red blood cell distribution width (RDW), are regarded to be related to the incidence of no-reflow or slow flow. Clinical studies were retrieved from the electronic databases of PubMed, EMBASE, Google Scholar, Clinical Trials, and science direct from their inception to August 24, 2019. A total of 21 studies involving 7403 patients were included in the meta-analysis. Pooled analysis results revealed patients with higher hsCRP (odds ratio [OR] = 1.03, 95% confidence interval [CI], 1.01-1.05, P = .006), hsCRP (OR = 1.04, 95% CI: 1.0-1.08, P = .012), NLR (OR = 1.23, 95% CI: 1.11-1.37, P < .0001), PLR (OR = 1.13, 95% CI: 1.07-1.20, P < .0001), and MPV (OR = 2.13, 95% CI: 1.57-2.90, P < .0001) all exhibited significantly higher no-reflow incidence, but there was no significant association between no-reflow risk and RDW or PDW. Patients with higher CRP/hsCRP also performed higher rate of slow flow (OR = 1.06, 95% CI: 1.01-1.11, P = .018). Preangiographic CRP/hsCRP could independently predict no-reflow and slow flow. Moreover, some hematological indices are associated with no-flow.

Shock Index on Admission Is Associated with Coronary Slow/No Reflow in Patients with Acute Myocardial Infarction Undergoing Emergent Percutaneous Coronary Intervention

Objective

Coronary slow/no reflow is not rare after successfully undergoing primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI), and shock index (SI) is an important factor for adverse cardiovascular prognosis. In this study, we are to explore whether SI is associated with coronary slow/no reflow in patients with AMI following primary PCI.

Methods

A total of 153 consecutive AMI patients undergoing primary PCI within 24 hours of symptom onset were included in this study. The participants were divided into normal flow group (n=124) and slow/no reflow group (n=29) according to cineangiograms recorded during the period of PCI. Cardiovascular risk factors, hematologic parameters, preoperative management of antithrombotic therapy, and baseline angiography were collected.

Results

SI, plasma glucose, white blood cells (WBC) and neutrophil count, neutrophil to lymphocyte ratio (PLR), high sensitivity C-reactive protein (hs-CRP), probrain natriuretic peptide (pro-BNP), and Killip classification on admission and thrombus burden on initial angiography were significantly different between patients with and without slow/no reflow. Multivariate analysis revealed that SI≥0.66, thrombus burden, and plasma glucose on admission were independent predictors for coronary slow/no reflow. Preoperative management of tirofiban therapy improves initial thrombolysis in myocardial infarction (TIMI). However, it has no effect on prognosis of slow/no reflow.

Conclusion

Our findings demonstrated that slow/no reflow in patients with AMI following primary PCI was more likely associated with SI≥0.66, thrombus burden, and plasma glucose on admission. SI as a predictor for coronary slow/no reflow should be further confirmed in the following more large-scale and prospective studies. The clinical registration number is ChiCTR1900024447.