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Rehan R, Virk S, Wong CCY, Passam F, Layland J, Keech A, Yong A, White HD, Fearon W, Ng M. Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis. Heart 2024; 110:988-996. [PMID: 38925881 PMCID: PMC11287581 DOI: 10.1136/heartjnl-2024-324078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Despite restoration of epicardial blood flow in acute ST-elevation myocardial infarction (STEMI), inadequate microcirculatory perfusion is common and portends a poor prognosis. Intracoronary (IC) thrombolytic therapy can reduce microvascular thrombotic burden; however, contemporary studies have produced conflicting outcomes. OBJECTIVES This meta-analysis aims to evaluate the efficacy and safety of adjunctive IC thrombolytic therapy at the time of primary percutaneous coronary intervention (PCI) among patients with STEMI. METHODS Comprehensive literature search of six electronic databases identified relevant randomised controlled trials. The primary outcome was major adverse cardiac events (MACE). The pooled risk ratio (RR) and weighted mean difference (WMD) with a 95% CI were calculated. RESULTS 12 studies with 1915 patients were included. IC thrombolysis was associated with a significantly lower incidence of MACE (RR=0.65, 95% CI 0.51 to 0.82, I2=0%, p<0.0004) and improved left ventricular ejection fraction (WMD=1.87; 95% CI 1.07 to 2.67; I2=25%; p<0.0001). Subgroup analysis demonstrated a significant reduction in MACE for trials using non-fibrin (RR=0.39, 95% CI 0.20 to 0.78, I2=0%, p=0.007) and moderately fibrin-specific thrombolytic agents (RR=0.62, 95% CI 0.47 to 0.83, I2=0%, p=0.001). No significant reduction was observed in studies using highly fibrin-specific thrombolytic agents (RR=1.10, 95% CI 0.62 to 1.96, I2=0%, p=0.75). Furthermore, there were no significant differences in mortality (RR=0.91; 95% CI 0.48 to 1.71; I2=0%; p=0.77) or bleeding events (major bleeding, RR=1.24; 95% CI 0.47 to 3.28; I2=0%; p=0.67; minor bleeding, RR=1.47; 95% CI 0.90 to 2.40; I2=0%; p=0.12). CONCLUSION Adjunctive IC thrombolysis at the time of primary PCI in patients with STEMI improves clinical and myocardial perfusion parameters without an increased rate of bleeding. Further research is needed to optimise the selection of thrombolytic agents and treatment protocols.
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Affiliation(s)
- Rajan Rehan
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Concord Hospital, Concord, New South Wales, Australia
| | - Sohaib Virk
- Systematic Reviews, CORE Group, Sydney, New South Wales, Australia
| | - Christopher C Y Wong
- Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
- Stanford Hospital, Stanford, California, USA
| | - Freda Passam
- Department of Hematology, University of Sydney, Sydney, New South Wales, Australia
| | | | - Anthony Keech
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Andy Yong
- Cardiology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Harvey D White
- Cardiology Department, Green Lane Cardiovascular Service and Green Lane Cardiovascular Research Unit, Auckland City Hospital, Auckland, New Zealand
| | | | - Martin Ng
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Department of Cardiology, The University of Sydney, Sydney, New South Wales, Australia
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Ndrepepa G, Kastrati A. Coronary No-Reflow after Primary Percutaneous Coronary Intervention-Current Knowledge on Pathophysiology, Diagnosis, Clinical Impact and Therapy. J Clin Med 2023; 12:5592. [PMID: 37685660 PMCID: PMC10488607 DOI: 10.3390/jcm12175592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/17/2023] [Accepted: 08/26/2023] [Indexed: 09/10/2023] Open
Abstract
Coronary no-reflow (CNR) is a frequent phenomenon that develops in patients with ST-segment elevation myocardial infarction (STEMI) following reperfusion therapy. CNR is highly dynamic, develops gradually (over hours) and persists for days to weeks after reperfusion. Microvascular obstruction (MVO) developing as a consequence of myocardial ischemia, distal embolization and reperfusion-related injury is the main pathophysiological mechanism of CNR. The frequency of CNR or MVO after primary PCI differs widely depending on the sensitivity of the tools used for diagnosis and timing of examination. Coronary angiography is readily available and most convenient to diagnose CNR but it is highly conservative and underestimates the true frequency of CNR. Cardiac magnetic resonance (CMR) imaging is the most sensitive method to diagnose MVO and CNR that provides information on the presence, localization and extent of MVO. CMR imaging detects intramyocardial hemorrhage and accurately estimates the infarct size. MVO and CNR markedly negate the benefits of reperfusion therapy and contribute to poor clinical outcomes including adverse remodeling of left ventricle, worsening or new congestive heart failure and reduced survival. Despite extensive research and the use of therapies that target almost all known pathophysiological mechanisms of CNR, no therapy has been found that prevents or reverses CNR and provides consistent clinical benefit in patients with STEMI undergoing reperfusion. Currently, the prevention or alleviation of MVO and CNR remain unmet goals in the therapy of STEMI that continue to be under intense research.
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Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany;
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstrasse 36, 80636 Munich, Germany;
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, 80336 Munich, Germany
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Association Between Thrombogenicity Indices and Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction. JACC Basic Transl Sci 2021; 6:749-761. [PMID: 34754989 PMCID: PMC8559320 DOI: 10.1016/j.jacbts.2021.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 08/24/2021] [Accepted: 08/28/2021] [Indexed: 12/22/2022]
Abstract
Our study supports the feasibility of measuring thrombogenicity in patients with acute myocardial infarction, with intent to predict periprocedural and long-term clinical events, in real-world clinical practice. Preprocedural assessment of ex vivo thrombogenicity (eg, platelet-fibrin clot strength by thromboelastography) was significantly associated with the risk of coronary microvascular dysfunction. A combined risk stratification with coronary microvascular dysfunction and platelet-fibrin clot strength increased the prognostic implication to predict the rates of long-term clinical outcomes.
The association between thrombogenicity and coronary microvascular dysfunction (CMD) has been poorly explored in patients with acute myocardial infarction (AMI). In our real-world clinical practice (N = 116), thrombogenicity was evaluated with thromboelastography and conventional hemostatic measures, and CMD was defined as index of microcirculatory resistance of >40 U using the invasive physiologic test. High platelet-fibrin clot strength (P-FCS) (≥68 mm) significantly increased the risk of postprocedural CMD (odds ratio: 4.35; 95% CI: 1.74-10.89). Patients with both CMD and high P-FCS had a higher rate of ischemic events compared to non-CMD subjects with low P-FCS (odds ratio: 5.58; 95% CI: 1.31-23.68). This study showed a close association between heightened thrombogenicity and CMD and their prognostic implications after reperfusion in acute myocardial infarction patients.
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Key Words
- AMI, acute myocardial infarction
- CFR, coronary flow reserve
- CMD, coronary microvascular dysfunction
- IMR, index of microcirculatory resistance
- LASSO, least absolute shrinkage and selection operator
- MA, maximum amplitude
- MACE, major adverse cardiovascular events
- OR, odds ratio
- P-FCS, platelet-fibrin clot strength
- PCI, percutaneous coronary intervention
- PRU, P2Y12 reaction units
- R, reaction time
- TEG, thromboelastography
- TIMI, Thrombolysis in Myocardial Infarction
- Tmn, mean transit time
- acute myocardial infarction
- cardiovascular event
- clot strength
- coronary microvascular dysfunction
- thrombogenicity
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Siniarski A, Baker SR, Duval C, Malinowski KP, Gajos G, Nessler J, Ariëns RAS. Quantitative analysis of clot density, fibrin fiber radius, and protofibril packing in acute phase myocardial infarction. Thromb Res 2021; 205:110-119. [PMID: 34298252 DOI: 10.1016/j.thromres.2021.06.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 05/04/2021] [Accepted: 06/30/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Coronary artery disease is associated with impaired clot structure. The aim of this study was to investigate acute phase myocardial infarction (AMI) and provide detailed quantitative analysis of clot ultrastructure. MATERIALS AND METHODS Clot formation and breakdown, pore size, fiber density, fiber radius and protofibril packing were investigated in plasma clots from AMI patients. These data were compared to those from healthy controls. RESULTS Analysis on clot formation using turbidity showed increased lag time, suggesting changes in protofibril packing and increased fiber size for AMI patients compared to healthy controls. Additionally, increased average rate of clotting and decreased time to maximum absorbance in AMI patients suggest that clots formed more quickly. Moreover, we observed increased time from max OD to max rate of lysis. Increased fibrinogen and decreased plasminogen in AMI patients were accounted for in represented significant differences. AMI samples showed increased time to 25% and 50% lysis, but no change in 75% lysis, representative of delayed lysis onset, but expediated lysis once initiated. These data suggest that AMI patients formed less porous clots made from more densely packed fibers with decreased numbers of protofibrils, which was confirmed using decreased permeation and increased fiber density, and decreased turbidimetry. CONCLUSIONS AMI plasma formed clots that were denser, less permeable, and lysed more slowly than healthy controls. These findings were confirmed by detailed analysis of clot ultrastructure, fiber size, and protofibril packing. Dense clot structures that are resistant to lysis may contribute to a prothrombotic milieu in AMI.
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Affiliation(s)
- Aleksander Siniarski
- Department of Coronary Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; John Paul II Hospital, Krakow, Poland
| | - Stephen R Baker
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; Department of Physics, Wake Forest University, Winston Salem, NC, USA.
| | - Cédric Duval
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Grzegorz Gajos
- Department of Coronary Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; John Paul II Hospital, Krakow, Poland
| | - Jadwiga Nessler
- Department of Coronary Disease and Heart Failure, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; John Paul II Hospital, Krakow, Poland
| | - Robert A S Ariëns
- Leeds Thrombosis Collective, Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
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Zhuravlev AS, Azarov AV, Semitko SP, Ioseliani DG. [The no-Reflow Phenomenon During Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction due to Massive Coronary Thrombosis. Pathogenesis and Predictors of no-Reflow]. ACTA ACUST UNITED AC 2021; 61:99-105. [PMID: 33715614 DOI: 10.18087/cardio.2021.2.n1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/29/2020] [Indexed: 11/18/2022]
Abstract
Despite successful and timely revascularization of the infarct-related artery, myocardial tissue remains underperfused in some patients. This condition is known as the no-reflow phenomenon, which is associated with a worse prognosis. The first part of the systematic review on no-reflow focuses on description of the no-reflow pathogenesis and predictors. This phenomenon has a complicated, multifactorial pathogenesis, including distal embolization, ischemic injury, reperfusion injury, and a component of individual predisposition. Meanwhile, this phenomenon undergoes spontaneous regression in some patients. Several studies have demonstrated the role of definite biomarkers and clinical indexes as risk predictors for no-reflow. The significance of each pathogenetic component of no-reflow is suggested to be different in different patients, which may warrant an individualized approach in the treatment.
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Affiliation(s)
- A S Zhuravlev
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - A V Azarov
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - S P Semitko
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
| | - D G Ioseliani
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow
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Smulders MW, Van Assche LMR, Bekkers SCAM, Nijveldt R, Beijnink CWH, Kim HW, Hayes B, Parker MA, Kaolawanich Y, Judd RM, Kim RJ. Epicardial Surface Area of Infarction: A Stable Surrogate of Microvascular Obstruction in Acute Myocardial Infarction. Circ Cardiovasc Imaging 2021; 14:e010918. [PMID: 33586449 DOI: 10.1161/circimaging.120.010918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Microvascular obstruction (MO) is a pathophysiologic complication of acute myocardial infarction that portends poor prognosis; however, it is transient and disappears with infarct healing. Much remains unknown regarding its pathophysiology and whether there are predictors of MO that could function as stable surrogates. We tested for clinical and cardiovascular magnetic resonance predictors of MO to gain insight into its pathophysiology and to find a stable surrogate. METHODS Three hundred two consecutive patients from 2 centers underwent cardiovascular magnetic resonance within 2 weeks of first acute myocardial infarction. Three measures of infarct morphology: infarct size, transmurality, and a new index-the epicardial surface area (EpiSA) of full-thickness infarction-were quantified on delayed-enhancement cardiovascular magnetic resonance. RESULTS Considering all clinical characteristics, only measures of infarct morphology were independent predictors of MO. EpiSA was the strongest predictor of MO and provided incremental predictive value beyond that of infarct size and transmurality (P<0.0001). In patients with 3-month follow-up cardiovascular magnetic resonance (n=81), EpiSA extent remained stable while MO disappeared, and EpiSA was a predictor of adverse ventricular remodeling. After 20 months of follow-up, 11 died and 1 had heart transplantation. Patients with an EpiSA larger than the median value (≥6%) had worse outcome than those with less than the median value (adverse events: 6.4% versus 1.9%, P=0.045). CONCLUSIONS The EpiSA of infarction is a novel index of infarct morphology which accurately predicts MO during the first 2 weeks of MI, but unlike MO, does not disappear with infarct healing. This index has potential as a stable surrogate of the presence of acute MO and may be useful as a predictor of adverse remodeling and outcome which is less dependent on the time window of patient assessment.
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Affiliation(s)
- Martijn W Smulders
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (M.W.S., S.C.A.M.B.)
| | - Lowie M R Van Assche
- Duke Cardiovascular Magnetic Resonance Center, Department of Medicine and Radiology, Duke University Medical Center, Durham, NC (L.M.R.V.A., H.W.K., B.H., M.A.P., Y.K., R.M.J., R.J.K.)
| | - Sebastiaan C A M Bekkers
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (M.W.S., S.C.A.M.B.)
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (R.N., C.W.H.B.)
| | - Casper W H Beijnink
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands (R.N., C.W.H.B.)
| | - Han W Kim
- Duke Cardiovascular Magnetic Resonance Center, Department of Medicine and Radiology, Duke University Medical Center, Durham, NC (L.M.R.V.A., H.W.K., B.H., M.A.P., Y.K., R.M.J., R.J.K.)
| | - Brenda Hayes
- Duke Cardiovascular Magnetic Resonance Center, Department of Medicine and Radiology, Duke University Medical Center, Durham, NC (L.M.R.V.A., H.W.K., B.H., M.A.P., Y.K., R.M.J., R.J.K.)
| | - Michele A Parker
- Duke Cardiovascular Magnetic Resonance Center, Department of Medicine and Radiology, Duke University Medical Center, Durham, NC (L.M.R.V.A., H.W.K., B.H., M.A.P., Y.K., R.M.J., R.J.K.)
| | - Yodying Kaolawanich
- Duke Cardiovascular Magnetic Resonance Center, Department of Medicine and Radiology, Duke University Medical Center, Durham, NC (L.M.R.V.A., H.W.K., B.H., M.A.P., Y.K., R.M.J., R.J.K.)
| | - Robert M Judd
- Duke Cardiovascular Magnetic Resonance Center, Department of Medicine and Radiology, Duke University Medical Center, Durham, NC (L.M.R.V.A., H.W.K., B.H., M.A.P., Y.K., R.M.J., R.J.K.)
| | - Raymond J Kim
- Duke Cardiovascular Magnetic Resonance Center, Department of Medicine and Radiology, Duke University Medical Center, Durham, NC (L.M.R.V.A., H.W.K., B.H., M.A.P., Y.K., R.M.J., R.J.K.)
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Memtsas VP, Arachchillage DRJ, Gorog DA. Role, Laboratory Assessment and Clinical Relevance of Fibrin, Factor XIII and Endogenous Fibrinolysis in Arterial and Venous Thrombosis. Int J Mol Sci 2021; 22:ijms22031472. [PMID: 33540604 PMCID: PMC7867291 DOI: 10.3390/ijms22031472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Diseases such as myocardial infarction, ischaemic stroke, peripheral vascular disease and venous thromboembolism are major contributors to morbidity and mortality. Procoagulant, anticoagulant and fibrinolytic pathways are finely regulated in healthy individuals and dysregulated procoagulant, anticoagulant and fibrinolytic pathways lead to arterial and venous thrombosis. In this review article, we discuss the (patho)physiological role and laboratory assessment of fibrin, factor XIII and endogenous fibrinolysis, which are key players in the terminal phase of the coagulation cascade and fibrinolysis. Finally, we present the most up-to-date evidence for their involvement in various disease states and assessment of cardiovascular risk.
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Affiliation(s)
- Vassilios P. Memtsas
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
| | - Deepa R. J. Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London SW7 2AZ, UK;
- Department of Haematology, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- Department of Haematology, Royal Brompton Hospital, London SW3 6NP, UK
| | - Diana A. Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire AL10 9AB, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
- Correspondence: ; Tel.: +44-207-0348841
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Maznyczka AM, McCartney P, Duklas P, McEntegart M, Oldroyd KG, Greenwood JP, Muir D, Chowdhary S, Gershlick AH, Appleby C, Eteiba H, Cotton J, Wragg A, Curzen N, Tait RC, MacFarlane P, Welsh P, Sattar N, Petrie MC, Ford I, Fox KAA, McConnachie A, Berry C. Effect of coronary flow on intracoronary alteplase: a prespecified analysis from a randomised trial. Heart 2021; 107:heartjnl-2020-317828. [PMID: 33436493 DOI: 10.1136/heartjnl-2020-317828] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Persistently impaired culprit artery flow ( METHODS In T-TIME (trial of low-dose adjunctive alTeplase during primary PCI), patients ≤6 hours from onset of ST-elevation myocardial infarction (STEMI) were randomised to placebo, alteplase 10 mg or alteplase 20 mg, administered by infusion into the culprit artery, pre-stenting. In this prespecified, secondary analysis, coronary flow was assessed angiographically at the point immediately before drug administration. Microvascular obstruction, myocardial haemorrhage and infarct size were assessed by cardiovascular magnetic resonance (CMR) at 2-7 days and 3 months. RESULTS TIMI flow was assessed after first treatment (balloon angioplasty/aspiration thrombectomy), immediately pre-drug administration, in 421 participants (mean age 61±10 years, 85% male) and was 3, 2 or 1 in 267, 134 and 19 participants respectively. In patients with TIMI flow ≤2 pre-drug, there was higher incidence of microvascular obstruction with alteplase (alteplase 20 mg (53.1%) and 10 mg (59.5%) combined versus placebo (34.1%); OR=2.47 (95% CI 1.16 to 5.22, p=0.018) interaction p=0.005) and higher incidence of myocardial haemorrhage (alteplase 20 mg (53.1%) and 10 mg (57.9%) combined vs placebo (27.5%); OR=3.26 (95% CI 1.44 to 7.36, p=0.004) interaction p=0.001). These effects were not observed in participants with TIMI 3 flow pre-drug. There were no interactions between TIMI flow pre-drug, alteplase and 3-month CMR findings. CONCLUSION In patients with impaired culprit artery flow ( TRIAL REGISTRATION NUMBER NCT02257294.
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Affiliation(s)
- Annette Marie Maznyczka
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter McCartney
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - Patrycja Duklas
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | | | - Keith G Oldroyd
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John P Greenwood
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Douglas Muir
- James Cook University Hospital, Middlesbrough, UK
| | | | | | - Clare Appleby
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Hany Eteiba
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - James Cotton
- Department of Cardiology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | | | - Nick Curzen
- Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Campbell Tait
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Keith A A Fox
- Department of Cardiology, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Colin Berry
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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9
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McCartney PJ, Maznyczka AM, Eteiba H, McEntegart M, Oldroyd KG, Greenwood JP, Maredia N, Schmitt M, McCann GP, Fairbairn T, McAlindon E, Tait C, Welsh P, Sattar N, Orchard V, Corcoran D, Ford TJ, Radjenovic A, Ford I, McConnachie A, Berry C. Low-Dose Alteplase During Primary Percutaneous Coronary Intervention According to Ischemic Time. J Am Coll Cardiol 2020; 75:1406-1421. [PMID: 32216909 PMCID: PMC7109518 DOI: 10.1016/j.jacc.2020.01.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/08/2020] [Accepted: 01/13/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Microvascular obstruction affects one-half of patients with ST-segment elevation myocardial infarction and confers an adverse prognosis. OBJECTIVES This study aimed to determine whether the efficacy and safety of a therapeutic strategy involving low-dose intracoronary alteplase infused early after coronary reperfusion associates with ischemic time. METHODS This study was conducted in a prospective, multicenter, parallel group, 1:1:1 randomized, dose-ranging trial in patients undergoing primary percutaneous coronary intervention. Ischemic time, defined as the time from symptom onset to coronary reperfusion, was a pre-specified subgroup of interest. Between March 17, 2016, and December 21, 2017, 440 patients, presenting with ST-segment elevation myocardial infarction within 6 h of symptom onset (<2 h, n = 107; ≥2 h but <4 h, n = 235; ≥4 h to 6 h, n = 98), were enrolled at 11 U.K. hospitals. Participants were randomly assigned to treatment with placebo (n = 151), alteplase 10 mg (n = 144), or alteplase 20 mg (n = 145). The primary outcome was the amount of microvascular obstruction (MVO) (percentage of left ventricular mass) quantified by cardiac magnetic resonance imaging at 2 to 7 days (available for 396 of 440). RESULTS Overall, there was no association between alteplase dose and the extent of MVO (p for trend = 0.128). However, in patients with an ischemic time ≥4 to 6 h, alteplase increased the mean extent of MVO compared with placebo: 1.14% (placebo) versus 3.11% (10 mg) versus 5.20% (20 mg); p = 0.009 for the trend. The interaction between ischemic time and alteplase dose was statistically significant (p = 0.018). CONCLUSION In patients presenting with ST-segment elevation myocardial infarction and an ischemic time ≥4 to 6 h, adjunctive treatment with low-dose intracoronary alteplase during primary percutaneous coronary intervention was associated with increased MVO. Intracoronary alteplase may be harmful for this subgroup. (A Trial of Low-Dose Adjunctive Alteplase During Primary PCI [T-TIME]; NCT02257294).
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Affiliation(s)
- Peter J McCartney
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Annette M Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Hany Eteiba
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Margaret McEntegart
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - John P Greenwood
- Leeds University and Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom
| | - Neil Maredia
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Matthias Schmitt
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Gerry P McCann
- University of Leicester and the National Institute for Health Research Leicester Biomedical Research Center, Leicester, United Kingdom
| | - Timothy Fairbairn
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Elisa McAlindon
- New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Campbell Tait
- Department of Hematology, Royal Infirmary, Glasgow, United Kingdom
| | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom
| | - Vanessa Orchard
- West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom
| | - Thomas J Ford
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Gosford Hospital, Gosford, New South Wales, Australia
| | - Aleksandra Radjenovic
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom
| | - Ian Ford
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Center, Golden Jubilee National Hospital, Clydebank, United Kingdom.
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10
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Sezer M, van Royen N, Umman B, Bugra Z, Bulluck H, Hausenloy DJ, Umman S. Coronary Microvascular Injury in Reperfused Acute Myocardial Infarction: A View From an Integrative Perspective. J Am Heart Assoc 2019; 7:e009949. [PMID: 30608201 PMCID: PMC6404180 DOI: 10.1161/jaha.118.009949] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Murat Sezer
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | | | - Berrin Umman
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Zehra Bugra
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Heerajnarain Bulluck
- 3 The Hatter Cardiovascular Institute Institute of Cardiovascular Science University College London London United Kingdom.,4 Papworth Hospital NHS Trust Cambridge United Kingdom
| | - Derek J Hausenloy
- 3 The Hatter Cardiovascular Institute Institute of Cardiovascular Science University College London London United Kingdom.,4 Papworth Hospital NHS Trust Cambridge United Kingdom.,5 National Heart Research Institute Singapore National Heart Centre Singapore Singapore.,6 Cardiovascular and Metabolic Disorders Program Duke-National University of Singapore Singapore.,7 Yong Loo Lin School of Medicine National University Singapore Singapore.,8 The National Institute of Health Research University College London Hospitals Biomedical Research Centre London United Kingdom.,9 Barts Heart Centre St Bartholomew's Hospital London United Kingdom
| | - Sabahattin Umman
- 1 Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
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11
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Polyhedral erythrocytes in intracoronary thrombus and their association with reperfusion in myocardial infarction. Clin Res Cardiol 2019; 108:950-962. [PMID: 30710262 DOI: 10.1007/s00392-019-01425-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/29/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The tightly packed arrays of polyhedral erythrocytes, polyhedrocytes, formed during thrombus contraction, have been detected in some intracoronary thrombi (ICT) obtained from patients with ST-segment elevation myocardial infarction (STEMI). We sought to investigate determinants of polyhedrocyte content in ICT and its association with reperfusion in STEMI. METHODS We assessed the composition of ICT obtained during thrombectomy within 12 h since the symptom onset in 110 STEMI patients, following 300 mg of aspirin (n = 110) and 600 mg of clopidogrel (n = 75). The predominance of fibrin, erythrocytes, polyhedrocytes or platelets was evaluated using scanning electron microscopy. RESULTS Polyhedrocytes were found in 34 (30.9%) ICT, in which they covered 20-50% (median 38.8%) fields of view. Patients with polyhedrocytes in ICT had lower median minimal reference infarct-related artery (IRA) diameter by 20% (p < 0.0001) and area by 31% (p < 0.0001) versus those without polyhedrocytes. Time of ischemia showed association with the polyhedrocyte content (r = 0.26, p = 0.007). By multivariate analysis, minimal IRA diameter (β = - 0.50, p < 0.0001) and ischemia time (β = 0.20, p = 0.035) independently affected polyhedrocyte content in ICT (R2 = 0.45, p < 0.0001). Patients with ischemia time of > 3 h and polyhedrocytes present in ICT had more frequently TIMI-2/3 flow after thrombus aspiration (96% vs. 67%, p = 0.02) and final TIMI-2/3 myocardial perfusion grade (92% vs. 57%, p = 0.044) versus those without polyhedrocytes. CONCLUSIONS Our findings indicate that the presence of polyhedrocytes in ICT, observed in one-third of STEMI patients, is associated with smaller minimal IRA diameter, prolonged ischemia and their formation in late presenters is associated with more effective thrombus aspiration and better myocardial reperfusion.
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12
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McCartney PJ, Eteiba H, Maznyczka AM, McEntegart M, Greenwood JP, Muir DF, Chowdhary S, Gershlick AH, Appleby C, Cotton JM, Wragg A, Curzen N, Oldroyd KG, Lindsay M, Rocchiccioli JP, Shaukat A, Good R, Watkins S, Robertson K, Malkin C, Martin L, Gillespie L, Ford TJ, Petrie MC, Macfarlane PW, Tait RC, Welsh P, Sattar N, Weir RA, Fox KA, Ford I, McConnachie A, Berry C. Effect of Low-Dose Intracoronary Alteplase During Primary Percutaneous Coronary Intervention on Microvascular Obstruction in Patients With Acute Myocardial Infarction: A Randomized Clinical Trial. JAMA 2019; 321:56-68. [PMID: 30620371 PMCID: PMC6583564 DOI: 10.1001/jama.2018.19802] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
IMPORTANCE Microvascular obstruction commonly affects patients with acute ST-segment elevation myocardial infarction (STEMI) and is associated with adverse outcomes. OBJECTIVE To determine whether a therapeutic strategy involving low-dose intracoronary fibrinolytic therapy with alteplase infused early after coronary reperfusion will reduce microvascular obstruction. DESIGN, SETTING, AND PARTICIPANTS Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the United Kingdom within 6 hours of STEMI due to a proximal-mid-vessel occlusion of a major coronary artery were randomized in a 1:1:1 dose-ranging trial design. Patient follow-up to 3 months was completed on April 12, 2018. INTERVENTIONS Participants were randomly assigned to treatment with placebo (n = 151), alteplase 10 mg (n = 144), or alteplase 20 mg (n = 145) by manual infusion over 5 to 10 minutes. The intervention was scheduled to occur early during the primary PCI procedure, after reperfusion of the infarct-related coronary artery and before stent implant. MAIN OUTCOMES AND MEASURES The primary outcome was the amount of microvascular obstruction (% left ventricular mass) demonstrated by contrast-enhanced cardiac magnetic resonance imaging (MRI) conducted from days 2 through 7 after enrollment. The primary comparison was the alteplase 20-mg group vs the placebo group; if not significant, the alteplase 10-mg group vs the placebo group was considered a secondary analysis. RESULTS Recruitment stopped on December 21, 2017, because conditional power for the primary outcome based on a prespecified analysis of the first 267 randomized participants was less than 30% in both treatment groups (futility criterion). Among the 440 patients randomized (mean age, 60.5 years; 15% women), the primary end point was achieved in 396 patients (90%), 17 (3.9%) withdrew, and all others were followed up to 3 months. In the primary analysis, the mean microvascular obstruction did not differ between the 20-mg alteplase and placebo groups (3.5% vs 2.3%; estimated difference, 1.16%; 95% CI, -0.08% to 2.41%; P = .32) nor in the analysis of 10-mg alteplase vs placebo groups (2.6% vs 2.3%; estimated difference, 0.29%; 95% CI, -0.76% to 1.35%; P = .74). Major adverse cardiac events (cardiac death, nonfatal MI, unplanned hospitalization for heart failure) occurred in 15 patients (10.1%) in the placebo group, 18 (12.9%) in the 10-mg alteplase group, and 12 (8.2%) in the 20-mg alteplase group. CONCLUSIONS AND RELEVANCE Among patients with acute STEMI presenting within 6 hours of symptoms, adjunctive low-dose intracoronary alteplase given during the primary percutaneous intervention did not reduce microvascular obstruction. The study findings do not support this treatment. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02257294.
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Affiliation(s)
- Peter J. McCartney
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Clydebank, United Kingdom
| | - Hany Eteiba
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Clydebank, United Kingdom
| | - Annette M. Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Clydebank, United Kingdom
| | - Margaret McEntegart
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Clydebank, United Kingdom
| | - John P. Greenwood
- Leeds University and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Douglas F. Muir
- James Cook University Hospital NHS Trust, Middlesbrough, United Kingdom
| | - Saqib Chowdhary
- South Manchester Hospitals NHS Trust, Manchester, United Kingdom
| | | | - Clare Appleby
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - James M. Cotton
- Royal Wolverhampton University Hospital NHS Trust, Wolverhampton, United Kingdom
| | - Andrew Wragg
- Barts and the London Hospital, London, United Kingdom
| | - Nick Curzen
- University Hospital Southampton Foundation Trust, Southampton, United Kingdom
| | - Keith G. Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Mitchell Lindsay
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - J. Paul Rocchiccioli
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Aadil Shaukat
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Richard Good
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Stuart Watkins
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Keith Robertson
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Christopher Malkin
- Leeds University and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Lynn Martin
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Clydebank, United Kingdom
| | | | - Thomas J. Ford
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Mark C. Petrie
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Clydebank, United Kingdom
| | - Peter W. Macfarlane
- Electrocardiography Core Laboratory, University of Glasgow, Glasgow, United Kingdom
| | - R. Campbell Tait
- Department of Haematology, Royal Infirmary, Glasgow, United Kingdom
| | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Robin A. Weir
- University Hospital Hairmyres, East Kilbride, United Kingdom
| | - Keith A. Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - Ian Ford
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Clydebank, United Kingdom
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Abstract
PURPOSE OF REVIEW Coronary artery no-reflow phenomenon is an incidental outcome of percutaneous coronary intervention in patients presenting with acute myocardial infarction. Despite advances in pharmacologic and non-pharmacologic therapies, coronary no-reflow phenomenon occurs more commonly than desired. It often results in poor clinical outcomes and remains as a relevant consideration in the cardiac catheterization laboratory. In this systematic review, we have sought to discuss the topic in detail, and to relay the most recent discoveries and data on management of this condition. RECENT FINDINGS We discuss several pharmacologic and non-pharmacologic treatments used in the prevention and management of coronary no-reflow and microvascular obstruction. Covered topics include the understanding of pharmacologic mechanisms of current and future agents, and recent discoveries that may result in the development of future treatment options. We conclude that the pathophysiology of coronary no-reflow phenomenon and microvascular obstruction still remains incompletely understood, although several plausible theories have led to the current standard of care for its management. We also conclude that coronary no-reflow phenomenon and microvascular obstruction must be recognized as a multifactorial condition that has certain predispositions and characteristics, therefore its prevention and treatment must begin pre-procedurally and be multi-faceted including certain medications and operator techniques in the cardiac catheterization laboratory.
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Affiliation(s)
- Ahmadreza Karimianpour
- Department of Cardiovascular Diseases, Heart & Vascular Institute, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC, 29425, USA.
| | - Anbukarasi Maran
- Department of Cardiovascular Diseases, Heart & Vascular Institute, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC, 29425, USA
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14
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Gue YX, Gorog DA. Importance of Endogenous Fibrinolysis in Platelet Thrombus Formation. Int J Mol Sci 2017; 18:ijms18091850. [PMID: 28841147 PMCID: PMC5618499 DOI: 10.3390/ijms18091850] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/21/2017] [Accepted: 08/21/2017] [Indexed: 12/13/2022] Open
Abstract
The processes of thrombosis and coagulation are finely regulated by endogenous fibrinolysis maintaining healthy equilibrium. When the balance is altered in favour of platelet activation and/or coagulation, or if endogenous fibrinolysis becomes less efficient, pathological thrombosis can occur. Arterial thrombosis remains a major cause of morbidity and mortality in the world despite advances in medical therapies. The role endogenous fibrinolysis in the pathogenesis of arterial thrombosis has gained increasing attention in recent years as it presents novel ways to prevent and treat existing diseases. In this review article, we discuss the role of endogenous fibrinolysis in platelet thrombus formation, methods of measurement of fibrinolytic activity, its role in predicting cardiovascular diseases and clinical outcomes and future directions.
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Affiliation(s)
- Ying X Gue
- Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire SG1 4AB, UK.
| | - Diana A Gorog
- Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire SG1 4AB, UK.
- Department of Postgraduate Medicine, University of Hertfordshire, Hertfordshire AL10 9AB, UK.
- National Heart & Lung Institute, Imperial College, London SW3 6LY, UK.
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15
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Cenko E, Ricci B, Kedev S, Kalpak O, Câlmâc L, Vasiljevic Z, Knežević B, Dilic M, Miličić D, Manfrini O, Koller A, Dorobantu M, Badimon L, Bugiardini R. The no-reflow phenomenon in the young and in the elderly. Int J Cardiol 2016; 222:1122-1128. [DOI: 10.1016/j.ijcard.2016.07.209] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/28/2016] [Indexed: 10/21/2022]
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16
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Sambola A, García Del Blanco B, Ruiz-Meana M, Francisco J, Barrabés JA, Figueras J, Bañeras J, Otaegui I, Rojas A, Vilardosa Ú, Montaner J, García-Dorado D. Increased von Willebrand factor, P-selectin and fibrin content in occlusive thrombus resistant to lytic therapy. Thromb Haemost 2016; 115:1129-37. [PMID: 26962963 DOI: 10.1160/th15-12-0985] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/17/2016] [Indexed: 11/05/2022]
Abstract
Therapeutic fibrinolysis is ineffective in 40 % of ST-segment elevation acute myocardial infarction (STEMI) patients, but understanding of the mechanisms is incomplete. It was our aim to compare the composition of coronary thrombus in lysis-resistant STEMI patients with that of lysis-sensitive patients. Intracoronary thrombi (n=64) were obtained by aspiration in consecutive STEMI patients. Of them, 20 had received fibrinolysis and underwent rescue percutaneous coronary intervention (r-PCI, lysis-resistant patients) and 44 underwent primary PCI (p-PCI). Lysis-sensitivity was determined in vitro by clot permeability measurements and turbidimetric lysis in plasma of 44 patients undergoing p-PCI and 20 healthy donors. Clot-lysis sensitivity was defined as a clot-lysis time not greater than 1 SD over the mean of healthy donors. Coronary thrombus composition in 20 lysis-resistant and in 20 lysis-sensitive patients was analysed by immunofluorescence with confocal microscopy. Plasma biomarkers (P-selectin, VWF, PAI-1, t-PA, D-dimer, TF pathway markers, plasmin and CD34+) were measured simultaneously on peripheral blood. Lysis-resistant clots had higher levels of fibrin (p=0.02), P-selectin (p=0.03) and VWF (p=0.01) than lysis-sensitive clots. Among thrombi obtained ≤ 6 hours after onset of symptoms, those from lysis-resistant patients showed a higher content in fibrin than those from p-PCI patients (p=0.01). Plasma PAI-1 (p=0.02) and D-dimer levels were significantly higher (p=0.003) in lysis-resistant patients, whereas plasmin levels were lower (p=0.03). Multivariate analysis showed the content of fibrin and VWF within thrombus as predictors of thrombolysis resistance. In conclusion, coronary thrombi in STEMI patients resistant to fibrinolysis are characterised by higher fibrin, P-selectin and VWF content than lysis-sensitive thrombi.
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Affiliation(s)
- Antonia Sambola
- Antonia Sambola, Department of Cardiology, Hospital Universitari Vall d'Hebron, P. Vall d'Hebron, 119-129, 08035 Barcelona, Spain, Tel.: +34 932746002, Fax: +34 932746063, E-mail:
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Evolution of Coronary Flow in an Experimental Slow Flow Model in Swines: Angiographic and Pathological Insights. BIOMED RESEARCH INTERNATIONAL 2015; 2015:623986. [PMID: 26539516 PMCID: PMC4619871 DOI: 10.1155/2015/623986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/06/2015] [Accepted: 08/09/2015] [Indexed: 12/22/2022]
Abstract
Objective. Pathomechanism of coronary slow flow phenomenon remains largely unclear now. Present study observed the pathological and angiographic evolution in a pig model of coronary slow flow. Methods. Coronary slow flow was induced by repeat coronary injection of small doses of 40 µm microspheres in 18 male domestic pigs and angiographic and pathological changes were determined at 3 hours, 7 days, and 28 days after microspheres injection. Results. Compared to control group treated with coronary saline injection (n = 6) and baseline level, coronary flow was significantly reduced at 3 hours and 7 days but completely recovered at 28 days after coronary microsphere injection in slow flow group. Despite normal coronary flow at 28 days after microsphere injection, enhanced myocardial cytokine expression, left ventricular dysfunction, adverse remodelling, and ischemia/microembolism related pathological changes still persisted or even progressed from 3 hours to 28 days after coronary microsphere injection. Conclusions. Our results show that this large animal slow flow model could partly reflect the chronic angiographic, hemodynamic, and pathological changes of coronary slow flow and could be used to test new therapy strategies against the slow flow phenomenon.
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18
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Niccoli G, Scalone G, Lerman A, Crea F. Coronary microvascular obstruction in acute myocardial infarction. Eur Heart J 2015; 37:1024-33. [PMID: 26364289 DOI: 10.1093/eurheartj/ehv484] [Citation(s) in RCA: 269] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 08/25/2015] [Indexed: 12/13/2022] Open
Abstract
The success of a primary percutaneous intervention (PCI) in the setting of ST elevation myocardial infarction depends on the functional and structural integrity of coronary microcirculation. Coronary microvascular dysfunction and obstruction (CMVO) occurs in up to half of patients submitted to apparently successful primary PCI and is associated to a much worse outcome. The current review summarizes the complex mechanisms responsible for CMVO, including pre-existing coronary microvascular dysfunction, and highlights the current limitations in the assessment of microvascular function. More importantly, at the light of the substantial failure of trials hitherto published on the treatment of CMVO, this review proposes a novel integrated therapeutic approach, which should overcome the limitations of previous studies.
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Affiliation(s)
- Giampaolo Niccoli
- Institute of Cardiology, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy
| | - Giancarla Scalone
- Institute of Cardiology, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy
| | - Amir Lerman
- Division of Cardiovascular Disease, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, USA
| | - Filippo Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy
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Dogan NB, Ozpelit E, Akdeniz S, Bilgin M, Baris N. Simple clinical risk score for no-reflow prediction in patients undergoing primary Percutaneous Coronary Intervention with acute STEMI. Pak J Med Sci 2015; 31:576-81. [PMID: 26150847 PMCID: PMC4485274 DOI: 10.12669/pjms.313.7484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 03/28/2015] [Indexed: 11/28/2022] Open
Abstract
Objectives: To identify the STEMI patients at high risk in terms of no-reflow during percutaneous coronary intervention (PCI) with a simple risk score system that can be used before reperfusion. Methods: Total 173 patients who had undergone primary or rescue percutaneous coronary intervention following the diagnosis of STEMI, were classified as “no-reflow” developers and “no-reflow” non-developers, during the procedure. The pre-procedural ECGs, laboratory parameters, demographic data, time for the treatment, and the treatment methods were evaluated with univariate analysis. The independent predictors were identified by multivariate logistic regression analysis among the no-reflow risk factors. Using the independent predictors, we developed a simple risk score system proportional to area under the ROC (AUROC) curves. Results: The independent predictors of “no-reflow” phenomenon were identified as follows: high values of blood glucose at reference; long symptom-onset-to-balloon-time; and low lymphocyte count. The incidence rates of “no-reflow” in patients with low (0-1), moderate (2-3) and high (4-6) risk factors were 13.3%, 40.0%, and 46.7%, respectively. The risk score system demonstrated a good risk prediction between patients with various risk levels of the development of “no-reflow” with a c-statistics of 0.734 (95% CI 0.654-0.814). Conclusion: The development of “no-reflow” which is an adverse event in STEMI treatment can be predicted efficiently by simple clinical risk scoring method.
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Affiliation(s)
- Nazile Bilgin Dogan
- Nazile Bilgin Dogan, MD. Department of Cardiology, Menemen State Hospital, Izmir, Turkey
| | - Ebru Ozpelit
- Ebru Ozpelit, MD. Department of Cardiology, DokuzEylul University Hospital, Izmir, Turkey
| | - Selma Akdeniz
- Selma Akdeniz, MD. Department of Cardiology, AKUT Cardiovascular Hospital, Izmir, Turkey
| | - Muzaffer Bilgin
- Muzaffer Bilgin, M.Sc. Department of Biostatistics, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Nezihi Baris
- Prof. Dr. Nezihi Baris, Professor, Department of Cardiology, DokuzEylul University Hospital, Izmir, Turkey
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20
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Abdi S, Rafizadeh O, Peighambari M, Basiri H, Bakhshandeh H. Evaluation of the Clinical and Procedural Predictive Factors of no-Reflow Phenomenon Following Primary Percutaneous Coronary Intervention. Res Cardiovasc Med 2015; 4:e25414. [PMID: 26393231 PMCID: PMC4571058 DOI: 10.5812/cardiovascmed.4(2)2015.25414] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/10/2015] [Accepted: 02/14/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The no-reflow phenomenon is an uncommon and critical occurrence which myocardial reperfusion does not restore to its optimal level. Several predisposing factors of the no-reflow phenomenon have been identified. However, at present we know little about clinical predictors of no-reflow after percutaneous coronary intervention (PCI). OBJECTIVES In this study, we evaluated clinical predictors of no-reflow phenomenon after PCI in patients with acute STEMI, to plan a better treatment of these patients. PATIENTS AND METHODS During an 18-month period, from 2013 to 2014, 438 patients with acute myocardial infarction (AMI) presenting within the first 24 hours from symptoms onset were treated with primary PCI in the Rajaie Cardiovascular Medical and Research Center. Thrombolysis in myocardial infarction (TIMI) flow was measured in all patients on the first angiography, following stenting. A total of 49 patients were allocated to the case group, based on the no-reflow phenomenon occurred during primary PCI (TIMI grade 0 and 1) and 50 patients without the no-reflow phenomenon (TIMI grade ≥ 3) were randomly selected, as the control group. They were evaluated from the point of demographic variables and also infarction territory, pain duration, maximal ST-change, left ventricle (LV) function, laboratory data, coronary anatomy, culprit vessel, location of lesion, target vessel diameter, lesion length, eccentricity, thrombus grade, tortuosity, lesion angulation, bifurcation, predilation, postdilation, thrombus aspiration, number of stent, in stent thrombosis. Data were then analyzed with the SPSS statistical software. RESULTS Mean age of patients was 59.47 (SD = 12.48) years, of which 75 (75.8%) were male and 24 (24.2%) were female. Based on univariable analysis, white blood cell (WBC) count, pain duration, LV function, maximal ST-change, thrombus grade and eccentricity were identified as predictors of the no-reflow phenomenon. After multivariable logistic regression: WBC count and thrombus grade remained the significant independent predictors of the no-reflow phenomenon (P < 0.05). In case group, slow-flow was seen in 42 (9.5%), while no-reflow was seen in seven (1.6%) patients. CONCLUSIONS The WBC count and thrombus grade are strong, independent predictive factors of developing the no-reflow phenomenon, in AMI patients undergoing primary PCI. There is also an association between the no-reflow phenomenon and pain duration, maximal ST-change, LV function, high sensitivity C-reactive protein (hs-CRP), bifurcation, eccentricity and coronary anatomy.
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Affiliation(s)
- Seifollah Abdi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Omid Rafizadeh
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Omid Rafizadeh, Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Vali-Asr St., Niayesh Blvd, Tehran, IR Iran. Tel: +98-2123921, E-mail:
| | - Mohammadmehdi Peighambari
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hoseinali Basiri
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
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Zalewski J, Bogaert J, Sadowski M, Woznicka O, Doulaptsis K, Ntoumpanaki M, Ząbczyk M, Nessler J, Undas A. Plasma fibrin clot phenotype independently affects intracoronary thrombus ultrastructure in patients with acute myocardial infarction. Thromb Haemost 2015; 113:1258-69. [PMID: 25739375 DOI: 10.1160/th14-09-0801] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 01/10/2015] [Indexed: 11/05/2022]
Abstract
Determinants of intracoronary thrombus (ICT) composition in patients with ST-elevation myocardial infarction (STEMI) are largely unknown. We sought to investigate whether plasma fibrin phenotype and platelet reactivity affect ICT ultrastructure. We assessed the content of fibrin, platelets and erythrocytes including polyhedrocytes by scanning electron microscopy on the surface and inside ICT aspirated from 80 STEMI patients within 12 hours since chest pain onset. Plasma fibrin clot permeability (Ks), which indicates the average pore size, lysis time (t50 %), platelet reactivity index (PRI) and ADP-induced platelet aggregation (ADP5, 20µM) were evaluated on admission. All patients received aspirin and 45 (56.3 %) 600 mg of clopidogrel, 80 (60-120) min prior to aspiration. Higher content of fibrin (61.6 vs 34.3 %, P< 0.0001) and platelets (8.2 vs 4.8 %, P=0.018) and lower erythrocyte content (15.8 vs 42.9 %, P< 0.0001) were found on ICT surface compared with its inner part. After adjustment for fibrinogen, in both ICT parts fibrin content was correlated with Ks (r≤-0.55, P< 0.0001) and t50 % (r≥ 0.29, P≤ 0.02) but not with PRI and ADP5,20µM. Polyhedrocytes were observed in 16 (20 %) patients and their large amount expressed as ≥ 50 % fields of view covered by polyhedrocytes was associated with the lower PRI values (40 vs 69 %, P=0.015), but not Ks or t50 %. By multivariate regression, Ks (β=-0.62, P< 0.0001), clopidogrel pretreatment (β=-0.36, P< 0.001), ischemia time (β=0.19, P=0.044) and family history (β=0.18, P=0.049) independently predicted fibrin content in the whole ICT (R²=0.65, P< 0.0001). Formation of denser plasma fibrin clots is independently associated with high fibrin content within the ICT in STEMI.
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Affiliation(s)
- Jaroslaw Zalewski
- Jaroslaw Zalewski, Department of Coronary Heart Disease, Jagiellonian University, Poland, Pradnicka 80, 31-202 Krakow, Poland, Tel.: +48 12 614 22 18, Fax: +48 12 614 22 19, E-mail:
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22
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Hu L, Bai Y, Gu Y, Yu D, Peng S, Liu X, Zhang M, Liu T, Hu S. Establishment of an experimental angiographic slow coronary flow model by microsphere embolism in swines. Int J Cardiol 2014; 176:1123-5. [PMID: 25147066 DOI: 10.1016/j.ijcard.2014.07.298] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 07/27/2014] [Indexed: 11/15/2022]
Affiliation(s)
- Liqun Hu
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yupeng Bai
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Ye Gu
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Delong Yu
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Sheng Peng
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaogang Liu
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Mingjing Zhang
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Tao Liu
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Shao Hu
- Heart Center at Puai Hospital, Wuhan Puai Hospital, Huazhong University of Science and Technology, Wuhan 430030, China.
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23
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Niccoli G, Cosentino N, Spaziani C, Loria V, Fracassi F, Roberto M, Calvieri C, Lombardo A, Natale L, Napolitano C, Mandurinoa A, Burzotta F, Leone AM, Porto I, Trani C, Bonomo L, Crea F. Concordance of angiographic and electrocardiographic indexes of microvascular obstruction: myocardial haemorrhage role. J Cardiovasc Med (Hagerstown) 2014; 17:382-91. [PMID: 25083721 DOI: 10.2459/jcm.0000000000000178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Angiographic and electrocardiographic (ECG) indexes of microvascular obstruction (MVO) have been described. We aimed at assessing by cardiac magnetic resonance (CMR) anatomical features underlying concordance between them. METHODS Forty-one patients were enrolled. Patients presented with neither angiographic nor ECG indexes of MVO (without MVO) (44%), with either angiographic or ECG indexes of MVO (discordant with MVO) (22%) or with both angiographic and ECG indexes of MVO (concordant with MVO) (34%). All patients underwent in-hospital CMR. Echocardiographic data obtained after 6 months were compared with those obtained in hospital. RESULTS Concordant patients with MVO had larger infarct size, lower myocardial salvage index and higher rate of myocardial haemorrhage (all assessed by CMR) [33% (25-41%), 15% (10-29%) and 88%, respectively] as compared with patients without MVO [12% (9-16%), 66% (52-79%) and 0%; Bonferroni-adjusted P < 0.001, Bonferroni-adjusted P < 0.001 and P < 0.001, respectively], or with discordant ones [25% (21-39%), 35% (20-48%) and 7%; Bonferroni-adjusted P = 0.03, Bonferroni-adjusted P = 0.002 and P = 0.04, respectively]. After 6 months, ejection fraction significantly decreased in concordant patients with MVO (P < 0.001) without significant changes in the other groups. CONCLUSIONS Concordance of angiographic and ECG indexes of MVO reflects more severe myocardial damage translating into unfavourable left ventricular remodelling.
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Affiliation(s)
- Giampaolo Niccoli
- aInstitute of Cardiology, Catholic University of the Sacred Heart bDepartment of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences Sapienza University of Rome cInstitute of Radiology, Department of Bioimaging and Radiological Sciences, Catholic University, Rome, Italy
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24
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Niccoli G, Cosentino N, Spaziani C, Minelli S, Fracassi F, Crea F. New strategies for the management of no-reflow after primary percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2014; 9:615-30. [DOI: 10.1586/erc.11.49] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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25
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The central role of conventional 12-lead ECG for the assessment of microvascular obstruction after percutaneous myocardial revascularization. J Electrocardiol 2014; 47:45-51. [DOI: 10.1016/j.jelectrocard.2013.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Indexed: 02/01/2023]
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26
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Myocardial ‘no-reflow’ — Diagnosis, pathophysiology and treatment. Int J Cardiol 2013; 167:1798-806. [DOI: 10.1016/j.ijcard.2012.12.049] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 11/13/2012] [Accepted: 12/22/2012] [Indexed: 11/24/2022]
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27
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Srikanth S, Ambrose JA. Pathophysiology of coronary thrombus formation and adverse consequences of thrombus during PCI. Curr Cardiol Rev 2012; 8:168-76. [PMID: 22920487 PMCID: PMC3465820 DOI: 10.2174/157340312803217247] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 03/17/2012] [Accepted: 04/12/2012] [Indexed: 02/08/2023] Open
Abstract
Atherosclerosis is a systemic vascular pathology that is preceded by endothelial dysfunction. Vascular inflammation "fuels" atherosclerosis and creates the milieu for episodes of intravascular thromboses. Thrombotic events in the coronary vasculature may lead to asymptomatic progression of atherosclerosis or could manifest as acute coronary syndromes or even sudden cardiac death. Thrombus encountered in the setting of acute coronary syndromes has been correlated with acute complications during percutaneous coronary interventions such as no-reflow, acute coronary occlusion and long term complications such as stent thrombus. This article reviews the pathophysiology of coronary thrombogenesis and explores the complications associated with thrombus during coronary interventions.
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Affiliation(s)
- Sundararajan Srikanth
- Interventional Cardiology Fellow, UCSF Fresno, University of California San Francisco Chief of Cardiology, UCSF Fresno
| | - John A Ambrose
- Professor of Medicine, University of California San Francisco Chief of Cardiology, UCSF Fresno
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28
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Derntl M, Weidinger F. Managing no-reflow during percutaneous coronary intervention. Interv Cardiol 2012. [DOI: 10.2217/ica.12.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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29
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Yang TY, Ko YS, Weng HH, Chang ST, Chung CM, Cheng HW. Sonography characteristics of the intra-graft thrombus: association with procedure success and procedure time of percutaneous transluminal angioplasty for thrombosed prosthetic dialysis graft. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:545-550. [PMID: 22390988 DOI: 10.1016/j.ultrasmedbio.2012.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 01/16/2012] [Accepted: 01/20/2012] [Indexed: 05/31/2023]
Abstract
Percutaneous transluminal angioplasty (PTA) for thrombosed dialysis graft is both difficult and time-consuming that may increase radiation exposure. A predictor of PTA success and procedure time has not been identified yet. Sonography data and the PTA results of 88 grafts were reviewed retrospectively. The echogenicity of the majority of the intra-graft thrombus and the presence/absence of thrombus free space in the grafts were examined. The association between the sonography findings and PTA procedure success and procedure time was analyzed. The echogenicity of the intra-graft thrombus and presence/absence of thrombus free space were the major determinants of procedure success and procedure time. Higher intra-graft echogenicity and lack of thrombus free space were associated with more procedure failures (p < 0.01 vs. p = 0.04) and longer procedure times (p = 0.03 vs. p < 0.01). Thrombi from occluded dialysis grafts may differ in resistance to mechanical/pharmacological thrombolysis. Sonography characteristics of the intra-graft thrombus may help to differentiate them.
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Affiliation(s)
- Teng-Yao Yang
- Cardiovascular Department, Chang Gung Memorial Hospital, Chiayi, Taiwan
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No-reflow phenomenon and endothelial glycocalyx of microcirculation. Biochem Res Int 2011; 2012:859231. [PMID: 22191033 PMCID: PMC3235431 DOI: 10.1155/2012/859231] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 09/20/2011] [Indexed: 12/27/2022] Open
Abstract
The progress in reperfusion therapy dictated the necessity for developing new tools and procedures for adjacent/additional therapy of acute cardiovascular disorders. The adjacent therapy is targeted on the damage of the microcirculation, leading to the unfavorable prognosis for the patients. The no-reflow phenomenon holds special place in the multifactorial etiology of the microcirculation disorders, offering a new challenge in treating the patients associated with ST-segment elevation on ECG at myocardial infarction. One of the numerous causes of no-reflow, the influence of the endothelial glycocalyx of the microcirculation, is analyzed. The results obtained in the studies of the endothelial glycocalyx ultrastructure are generalized, the effect that the fragments of the glycocalyx glycosaminoglycans have on the function of the vascular wall is demonstrated. The trends in searching for correlations between the thickness of the capillary glycocalyx and the cardiovascular disease risk are noted.
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31
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Undas A, Ariëns RAS. Fibrin clot structure and function: a role in the pathophysiology of arterial and venous thromboembolic diseases. Arterioscler Thromb Vasc Biol 2011; 31:e88-99. [PMID: 21836064 DOI: 10.1161/atvbaha.111.230631] [Citation(s) in RCA: 368] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The formation of fibrin clots that are relatively resistant to lysis represents the final step in blood coagulation. We discuss the genetic and environmental regulators of fibrin structure in relation to thrombotic disease. In addition, we discuss the implications of fibrin structure for treatment of thrombosis. Fibrin clots composed of compact, highly branched networks with thin fibers are resistant to lysis. Altered fibrin structure has consistently been reported in patients with several diseases complicated by thromboembolic events, including patients with acute or prior myocardial infarction, ischemic stroke, and venous thromboembolism. Relatives of patients with myocardial infarction or venous thromboembolism display similar fibrin abnormalities. Low-dose aspirin, statins, lowering of homocysteine, better diabetes control, smoking cessation, and suppression of inflammatory response increase clot permeability and susceptibility to lysis. Growing evidence indicates that abnormal fibrin properties represent a novel risk factor for arterial and venous thrombotic events, particularly of unknown etiology in young and middle-aged patients.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine, Krakow, Poland
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Gajos G, Zalewski J, Rostoff P, Nessler J, Piwowarska W, Undas A. Reduced thrombin formation and altered fibrin clot properties induced by polyunsaturated omega-3 fatty acids on top of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention (OMEGA-PCI clot). Arterioscler Thromb Vasc Biol 2011; 31:1696-702. [PMID: 21617138 DOI: 10.1161/atvbaha.111.228593] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The goal of this study was to investigate whether omega-3 polyunsaturated fatty acids (n-3 PUFA) are able to alter plasma fibrin clot properties and reduce thrombin formation in stable coronary artery disease patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS In an investigator-initiated, prospective, double-blind, placebo-controlled, randomized study, patients undergoing PCI who received standard pharmacotherapy were assigned to the treatment with 1 g/day n-3 PUFA (n = 30) or placebo (n = 24) for 1 month. Plasma fibrin clot permeability (K(s)); lysis time (t(50%)); prothrombin fragment 1.2; and peak thrombin generation from automated thrombogram, 8-isoprostaglandin F(2α) (8-iso-PGF(2α), an oxidative stress marker), and C-reactive protein were determined at baseline, 3 to 5 days after randomization, and 30 days after randomization. At baseline, both treatment groups did not differ significantly. A 1-month treatment with n-3 PUFA compared with placebo was associated with 15.3% higher K(s), indicating larger pores in the fibrin network (P = 0.0005); 14.3% shorter t(50%), indicating increased susceptibility to fibrinolysis (P<0.0001); 33.8% lower prothrombin fragment 1.2 (P = 0.0013); 13.4% lower peak thrombin generation (P = 0.04); and 13.1% lower 8-iso-PGF(2α) (P = 0.009). Treatment with n-3 PUFA had no effect on fibrinogen and C-reactive protein. After 1 month of treatment, fibrinogen (r = -0.53, P<0.0001), treatment assignment (r = 0.29, P = 0.006) and 8-iso-PGF(2α) (r = -0.27, P = 0.015) were independently associated with clot permeability (P<0.0001, R(2) = 0.66). CONCLUSIONS Adding n-3 PUFA to standard therapy in stable patients undergoing PCI significantly decreases thrombin formation and oxidative stress and favorably alters fibrin clot properties. These findings indicate novel antithrombotic effects induced by n-3 PUFA in humans.
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Affiliation(s)
- Grzegorz Gajos
- Department of Coronary Disease, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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Niccoli G, Kharbanda RK, Crea F, Banning AP. No-reflow: again prevention is better than treatment. Eur Heart J 2010; 31:2449-55. [DOI: 10.1093/eurheartj/ehq299] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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34
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The effect of chronic kidney disease on fibrin clot properties in patients with acute coronary syndrome. Blood Coagul Fibrinolysis 2010; 21:522-7. [DOI: 10.1097/mbc.0b013e32833a9035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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35
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Galiuto L, Paraggio L, Liuzzo G, de Caterina AR, Crea F. Predicting the no-reflow phenomenon following successful percutaneous coronary intervention. Biomark Med 2010; 4:403-20. [DOI: 10.2217/bmm.10.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In the setting of acute myocardial infarction, early and adequate reopening of an infarct-related artery is not necessarily followed by a complete restoration of myocardial perfusion. This condition is usually defined as ‘no-reflow’. The pathophysiology of no-reflow is multifactorial since extravascular compression, microvascular vasoconstriction, embolization during percutaneous coronary intervention, and platelet and neutrophil aggregates are involved. In the clinical arena, angiographic findings and easily available clinical parameters can predict the risk of no-reflow. More recently, several studies have demonstrated that biomarkers, especially those related to the pathogenetic components of no-reflow, could also have a prognostic role in the prediction and in the full understanding of the multiple mechanisms of this phenomenon. Thus, in this article, we investigate the role of several biomarkers on admission in predicting the occurrence of no-reflow following successful percutaneous coronary intervention.
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Affiliation(s)
| | - L Paraggio
- Institute of Cardiology, Catholic University of the Sacred Heart, Policlinico A Gemelli, Largo A Gemelli, 8, 00168 Rome, Italy
| | - G Liuzzo
- Institute of Cardiology, Catholic University of the Sacred Heart, Policlinico A Gemelli, Largo A Gemelli, 8, 00168 Rome, Italy
| | - AR de Caterina
- Institute of Cardiology, Catholic University of the Sacred Heart, Policlinico A Gemelli, Largo A Gemelli, 8, 00168 Rome, Italy
| | - F Crea
- Institute of Cardiology, Catholic University of the Sacred Heart, Policlinico A Gemelli, Largo A Gemelli, 8, 00168 Rome, Italy
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Undas A, Zalewski J, Krochin M, Siudak Z, Sadowski M, Pregowski J, Dudek D, Janion M, Witkowski A, Zmudka K. Altered Plasma Fibrin Clot Properties Are Associated With In-Stent Thrombosis. Arterioscler Thromb Vasc Biol 2010; 30:276-82. [DOI: 10.1161/atvbaha.109.194936] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anetta Undas
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Jaroslaw Zalewski
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Marek Krochin
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Zbigniew Siudak
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Marcin Sadowski
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Jerzy Pregowski
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Dariusz Dudek
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Marianna Janion
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
| | - Krzysztof Zmudka
- From the Institute of Cardiology (A.U., Z.S., D.D., K.Z.), Jagiellonian University School of Medicine, Cracow, Poland; John Paul II Hospital (J.Z., M.K.), Cracow, Poland; Swietokrzyskie Cardiology Centre (M.S., M.J.), Kielce, Poland; and Department of Hemodynamics (J.P., A.W.), Institute of Cardiology, Warsaw, Poland
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Niccoli G, Burzotta F, Galiuto L, Crea F. Myocardial no-reflow in humans. J Am Coll Cardiol 2009; 54:281-92. [PMID: 19608025 DOI: 10.1016/j.jacc.2009.03.054] [Citation(s) in RCA: 582] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Revised: 03/17/2009] [Accepted: 03/17/2009] [Indexed: 02/06/2023]
Abstract
In a variable proportion of patients presenting with ST-segment elevation myocardial infarction, ranging from 5% to 50%, primary percutaneous coronary intervention achieves epicardial coronary artery reperfusion but not myocardial reperfusion, a condition known as no-reflow. Of note, no-reflow is associated with a worse prognosis at follow-up. The phenomenon has a multifactorial pathogenesis including: distal embolization, ischemia-reperfusion injury, and individual predisposition of coronary microcirculation to injury. Moreover, it is spontaneously reversible in some patients, thus suggesting that it might be amenable to treatment also when we fail to prevent it. Several recent studies have shown that biomarkers and other easily available clinical parameters can predict the risk of no-reflow and can help in the assessment of the multiple mechanisms of the phenomenon. Several therapeutic strategies have been tested for the prevention and treatment of no-reflow. In particular, thrombus aspiration before stent implantation prevents distal embolization and has been recently shown to improve myocardial perfusion and clinical outcome as compared with the standard procedure. However, it is conceivable that the relevance of each pathogenetic component of no-reflow is different in different patients, thus explaining the occurrence of no-reflow despite the use of mechanical thrombus aspiration. Thus, in this review article, for the first time, we propose a personalized management of no-reflow on the basis of the assessment of the prevailing mechanisms of no-reflow operating in each patient.
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Affiliation(s)
- Giampaolo Niccoli
- Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
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Zalewski J, Nycz K, Przewlocki T, Durak M, Cul M, Zajdel W, Zmudka K. Evolution of myocardial perfusion during primary angioplasty in spontaneously reperfused infarct-related artery: impact on long-term clinical outcomes and left ventricular function recovery. Int J Cardiol 2009; 147:25-31. [PMID: 19709768 DOI: 10.1016/j.ijcard.2009.07.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Revised: 05/06/2009] [Accepted: 07/24/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND TIMI myocardial perfusion grade (TMPG) reflects the integrity of microvasculature in ST-elevation myocardial infarction (STEMI). We sought to investigate whether TMPG evolution during primary angioplasty (pPCI) in spontaneously reperfused STEMI patients might predict long-term outcomes. METHODS 392 patients with TIMI-3 flow before pPCI were analyzed. According to pre- and post-pPCI TMPG four reperfusion patterns were created: A. TMPG deterioration from grade 2/3 to 0/1 after pPCI (n = 55, 14.0%), B. TMPG-0/1 before and after pPCI (n = 111, 28.3%), C. TMPG improvement from grade 0/1 to 2/3 (n = 52, 13.3%), D. TMPG-2/3 before and after pPCI (n = 174, 44.4%). 30-day and 1-year mortality and heart failure requiring hospitalization (HF-hosp) were recorded. Left ventricular ejection fraction (LVEF) was measured at first day (1D) and after 6 months (6M). RESULTS 1D-LVEF was similar in A-D groups. After 6M, LVEF improved in pattern D (7.5 ± 5.4%, p<0.01) and C (3.7 ± 3.4%, p < 0.05), deteriorated in pattern A (5.2 ± 3.9%, p<0.01) and did not change in pattern B. 6M-LVEF increased (p < 0.001) and frequency of 1-year HF-hosp decreased (p < 0.001) in stepwise fashion among A-D patterns. A 30-day mortality rate for A-D patterns was 9.1%, 2.7%, 1.9% and 0%, respectively (p < 0.001). 1-year mortality was 16.3%, 7.2%, 5.8% and 0.6%, respectively (p < 0.001). By multivariate analysis (c-index = 0.79), TMPG evolution was independent predictor of 1-year mortality (HR = 2.5, 95%CI 1.3-4.0, p = 0.006). CONCLUSIONS Maintaining TMPG-2/3 or improving TMPG-0/1 through pPCI in STEMI implies LV function recovery and good long-term survival. In contrast, substantial deterioration of TMPG is associated with lack of LV function recovery, and the highest mortality rate.
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Affiliation(s)
- Jaroslaw Zalewski
- Institute of Cardiology, Jagiellonian University School of Medicine, Cracow, Poland.
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