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Welt FGP, Batchelor W, Spears JR, Penna C, Pagliaro P, Ibanez B, Drakos SG, Dangas G, Kapur NK. Reperfusion Injury in Patients With Acute Myocardial Infarction: JACC Scientific Statement. J Am Coll Cardiol 2024; 83:2196-2213. [PMID: 38811097 DOI: 10.1016/j.jacc.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/15/2024] [Accepted: 02/26/2024] [Indexed: 05/31/2024]
Abstract
Despite impressive improvements in the care of patients with ST-segment elevation myocardial infarction, mortality remains high. Reperfusion is necessary for myocardial salvage, but the abrupt return of flow sets off a cascade of injurious processes that can lead to further necrosis. This has been termed myocardial ischemia-reperfusion injury and is the subject of this review. The pathologic and molecular bases for myocardial ischemia-reperfusion injury are increasingly understood and include injury from reactive oxygen species, inflammation, calcium overload, endothelial dysfunction, and impaired microvascular flow. A variety of pharmacologic strategies have been developed that have worked well in preclinical models and some have shown promise in the clinical setting. In addition, there are newer mechanical approaches including mechanical unloading of the heart prior to reperfusion that are in current clinical trials.
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Affiliation(s)
- Frederick G P Welt
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah, USA.
| | | | - J Richard Spears
- Department of Cardiovascular Medicine, Beaumont Systems, Royal Oak, Michigan, USA
| | - Claudia Penna
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain; CIBER de Enfermedades Cardiovasculares, Madrid, Spain; Department of Cardiology, Hospital Fundación Jiménez Díaz, Madrid, Spain
| | - Stavros G Drakos
- Department of Medicine, Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah, USA; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, Utah, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Health System, New York, New York, USA
| | - Navin K Kapur
- The CardioVascular Center and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, Massachusetts, USA
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2
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Falah B, Kotinkaduwa LN, Schonning MJ, Redfors B, de Waha S, Granger CB, Maehara A, Eitel I, Thiele H, Stone GW. Microvascular Obstruction in Patients With Anterior STEMI Treated With Supersaturated Oxygen. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101356. [PMID: 39132455 PMCID: PMC11307792 DOI: 10.1016/j.jscai.2024.101356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/26/2024] [Accepted: 02/08/2024] [Indexed: 08/13/2024]
Abstract
Background Supersaturated oxygen (SSO2) delivered into the left anterior descending coronary artery after percutaneous coronary intervention (PCI) for anterior ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size, but its effects on microvascular obstruction (MVO) are unknown. The aim of this study was to compare MVO in patients with anterior STEMI treated with SSO2 after successful primary PCI from 2 studies (the optimized SSO2 pilot and IC-HOT) with similar patients from 7 randomized trials who underwent primary PCI without SSO2 treatment. Methods A total of 874 patients with anterior STEMI who underwent MVO assessment using cardiac magnetic resonance imaging within 10 days after primary PCI were included, of whom 90 patients (10.3%) were treated with SSO2. The primary end point was the extent of MVO as a continuous measure in a weighted multivariable model. The secondary end point was the presence of MVO. Results SSO2 therapy was independently associated with a lower extent of MVO compared with no SSO2 therapy (coefficient, -1.35; 95% CI, -2.58 to -0.11; P = .03). SSO2 therapy was also associated with a borderline lower risk of any MVO (adjusted odds ratio, 0.56; 95% CI, 0.31-1.00; P = .051). Conclusions In the present individual patient data pooled analysis from 9 studies, SSO2 therapy was associated with less MVO after successful primary PCI for anterior STEMI.
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Affiliation(s)
- Batla Falah
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Lak N. Kotinkaduwa
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Suzanne de Waha
- Heart Center Leipzig at Leipzig University and Leipzig Heart Science, Leipzig, Germany
| | | | - Akiko Maehara
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Ingo Eitel
- University Heart Centre Luebeck, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research, Luebeck, Germany
| | - Holger Thiele
- Heart Center Leipzig at Leipzig University and Leipzig Heart Science, Leipzig, Germany
- University Heart Centre Luebeck, University Hospital Schleswig-Holstein, Luebeck, Germany
- German Centre for Cardiovascular Research, Luebeck, Germany
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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3
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Henry TD, Vallabhajosyula S, Traverse JH. Supersaturated Oxygenation: Impact on Microvascular Obstruction? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101978. [PMID: 39132466 PMCID: PMC11308006 DOI: 10.1016/j.jscai.2024.101978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital Health Network, Cincinnati, Ohio
| | - Saraschandra Vallabhajosyula
- Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Jay H. Traverse
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, University of Minnesota School of Medicine, Cardiovascular Division, Minneapolis, Minnesota
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4
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Zhang H, Hu H, Zhai C, Jing L, Tian H. Cardioprotective Strategies After Ischemia-Reperfusion Injury. Am J Cardiovasc Drugs 2024; 24:5-18. [PMID: 37815758 PMCID: PMC10806044 DOI: 10.1007/s40256-023-00614-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/11/2023]
Abstract
Acute myocardial infarction (AMI) is associated with high morbidity and mortality worldwide. Although early reperfusion is the most effective strategy to salvage ischemic myocardium, reperfusion injury can develop with the restoration of blood flow. Therefore, it is important to identify protection mechanisms and strategies for the heart after myocardial infarction. Recent studies have shown that multiple intracellular molecules and signaling pathways are involved in cardioprotection. Meanwhile, device-based cardioprotective modalities such as cardiac left ventricular unloading, hypothermia, coronary sinus intervention, supersaturated oxygen (SSO2), and remote ischemic conditioning (RIC) have become important areas of research. Herein, we review the molecular mechanisms of cardioprotection and cardioprotective modalities after ischemia-reperfusion injury (IRI) to identify potential approaches to reduce mortality and improve prognosis in patients with AMI.
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Affiliation(s)
- Honghong Zhang
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
| | - Huilin Hu
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China.
| | - Changlin Zhai
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
| | - Lele Jing
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
| | - Hongen Tian
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
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5
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Zaheer K, Daloub S, Suliman M, Mansoor K, Sayyed R. Infarct Size Reduction in an Anterior ST-Elevation Myocardial Infarction Following "Optimized" Supersaturated Oxygen Therapy. Cureus 2024; 16:e53152. [PMID: 38420054 PMCID: PMC10900177 DOI: 10.7759/cureus.53152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
This comprehensive case report documents the treatment of a 37-year-old female patient who presented with anterior ST-elevation myocardial infarction (STEMI). The patient underwent percutaneous coronary intervention (PCI), followed by an innovative therapy - optimized supersaturated oxygen therapy (SSO2). This therapy was chosen due to its potential to enhance myocardial salvage, particularly in severe MI cases like the patient. The report meticulously details the patient's clinical course, including the diagnostic procedures and the rationale behind opting for SSO2 therapy. It highlights the significant improvements observed post-therapy: enhanced left ventricular (LV) function and a remarkable reduction in the size of the LV apical aneurysm. These outcomes suggest a direct benefit of SSO2 in reducing myocardial damage. Finally, the report discusses the broader implications of these findings. It underscores the potential of optimized SSO2 therapy in clinical settings, particularly for patients with anterior MI. The case exemplifies how advanced therapeutic interventions like SSO2 can play a pivotal role in improving clinical outcomes post-MI, thereby advocating for its consideration in similar clinical scenarios.
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Affiliation(s)
- Kamran Zaheer
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Shaden Daloub
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Mohamed Suliman
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Kanaan Mansoor
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Rameez Sayyed
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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6
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Hsieh YK, Wang MT, Wang CY, Chen CF, Ko YL, Huang WC. Recent advances in the diagnosis and management of acute myocardial infarction. J Chin Med Assoc 2023; 86:950-959. [PMID: 37801590 DOI: 10.1097/jcma.0000000000001001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/08/2023] Open
Abstract
With the discovery of new biomarkers for the early detection of acute myocardial infarction (AMI), advancements in valid medication, and percutaneous coronary intervention (PCI), the overall prognosis of AMI has improved remarkably. Nevertheless, challenges remain which require more difficult work to overcome. Novel diagnostic and therapeutic techniques include new AMI biomarkers, hypothermia therapy, supersaturated oxygen (SSO 2 ) therapy, targeted anti-inflammatory therapy, targeted angiogenesis therapy, and stem cell therapy. With these novel methods, we believe that the infarction size after AMI will decrease, and myocardial injury-associated ventricular remodeling may be avoided. This review focuses on novel advances in the diagnosis and management of AMI.
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Affiliation(s)
- Yi-Keng Hsieh
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
- School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan, ROC
| | - Mei-Tzu Wang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan, ROC
| | - Chien-Ying Wang
- School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan, ROC
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Division of Trauma, Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Exercise and Health Sciences, University of Taipei, Taipei, Taiwan, ROC
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Exercise and Health Sciences, University of Taipei, Taipei, Taiwan, ROC
| | - Yu-Ling Ko
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan, ROC
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7
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Heusch G, Andreadou I, Bell R, Bertero E, Botker HE, Davidson SM, Downey J, Eaton P, Ferdinandy P, Gersh BJ, Giacca M, Hausenloy DJ, Ibanez B, Krieg T, Maack C, Schulz R, Sellke F, Shah AM, Thiele H, Yellon DM, Di Lisa F. Health position paper and redox perspectives on reactive oxygen species as signals and targets of cardioprotection. Redox Biol 2023; 67:102894. [PMID: 37839355 PMCID: PMC10590874 DOI: 10.1016/j.redox.2023.102894] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
The present review summarizes the beneficial and detrimental roles of reactive oxygen species in myocardial ischemia/reperfusion injury and cardioprotection. In the first part, the continued need for cardioprotection beyond that by rapid reperfusion of acute myocardial infarction is emphasized. Then, pathomechanisms of myocardial ischemia/reperfusion to the myocardium and the coronary circulation and the different modes of cell death in myocardial infarction are characterized. Different mechanical and pharmacological interventions to protect the ischemic/reperfused myocardium in elective percutaneous coronary interventions and coronary artery bypass grafting, in acute myocardial infarction and in cardiotoxicity from cancer therapy are detailed. The second part keeps the focus on ROS providing a comprehensive overview of molecular and cellular mechanisms involved in ischemia/reperfusion injury. Starting from mitochondria as the main sources and targets of ROS in ischemic/reperfused myocardium, a complex network of cellular and extracellular processes is discussed, including relationships with Ca2+ homeostasis, thiol group redox balance, hydrogen sulfide modulation, cross-talk with NAPDH oxidases, exosomes, cytokines and growth factors. While mechanistic insights are needed to improve our current therapeutic approaches, advancements in knowledge of ROS-mediated processes indicate that detrimental facets of oxidative stress are opposed by ROS requirement for physiological and protective reactions. This inevitable contrast is likely to underlie unsuccessful clinical trials and limits the development of novel cardioprotective interventions simply based upon ROS removal.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Robert Bell
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Edoardo Bertero
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Hans-Erik Botker
- Department of Cardiology, Institute for Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - James Downey
- Department of Physiology, University of South Alabama, Mobile, AL, USA
| | - Philip Eaton
- William Harvey Research Institute, Queen Mary University of London, Heart Centre, Charterhouse Square, London, United Kingdom
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary; Pharmahungary Group, Szeged, Hungary
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mauro Giacca
- School of Cardiovascular and Metabolic Medicine & Sciences, King's College, London, United Kingdom
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom; Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, National Heart Research Institute Singapore, National Heart Centre, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), IIS-Fundación Jiménez Díaz University Hospital, and CIBERCV, Madrid, Spain
| | - Thomas Krieg
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Christoph Maack
- Department of Translational Research, Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Rainer Schulz
- Institute for Physiology, Justus-Liebig -Universität, Giessen, Germany
| | - Frank Sellke
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Ajay M Shah
- King's College London British Heart Foundation Centre of Excellence, London, United Kingdom
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Fabio Di Lisa
- Dipartimento di Scienze Biomediche, Università degli studi di Padova, Padova, Italy.
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8
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Ghobrial M, Bawamia B, Cartlidge T, Spyridopoulos I, Kunadian V, Zaman A, Egred M, McDiarmid A, Williams M, Farag M, Alkhalil M. Microvascular Obstruction in Acute Myocardial Infarction, a Potential Therapeutic Target. J Clin Med 2023; 12:5934. [PMID: 37762875 PMCID: PMC10532390 DOI: 10.3390/jcm12185934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/02/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Microvascular obstruction (MVO) is a recognised phenomenon following mechanical reperfusion in patients presenting with ST-segment elevation myocardial infarction (STEMI). Invasive and non-invasive modalities to detect and measure the extent of MVO vary in their accuracy, suggesting that this phenomenon may reflect a spectrum of pathophysiological changes at the level of coronary microcirculation. The importance of detecting MVO lies in the observation that its presence adds incremental risk to patients following STEMI treatment. This increased risk is associated with adverse cardiac remodelling seen on cardiac imaging, increased infarct size, and worse patient outcomes. This review provides an outline of the pathophysiology, clinical implications, and prognosis of MVO in STEMI. It describes historic and novel pharmacological and non-pharmacological therapies to address this phenomenon in conjunction with primary PCI.
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Affiliation(s)
- Mina Ghobrial
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Bilal Bawamia
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Timothy Cartlidge
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Ioakim Spyridopoulos
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Vijay Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
| | - Mohaned Egred
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Adam McDiarmid
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Matthew Williams
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Mohamed Farag
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK
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9
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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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10
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Martin J. Persistent mortality and heart failure burden of anterior ST-segment elevation myocardial infarction following primary percutaneous coronary intervention: real-world evidence from the US Medicare Data Set. BMJ Open 2023; 13:e070210. [PMID: 37344119 PMCID: PMC10314428 DOI: 10.1136/bmjopen-2022-070210] [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: 11/30/2022] [Accepted: 06/02/2023] [Indexed: 06/23/2023] Open
Abstract
OBJECTIVES We sought to compare the temporal trends in the incidence of death and rehospitalisation for congestive heart failure (CHF) following anterior ST-elevation myocardial infarction (STEMI) in a Medicare cohort of beneficiaries treated with primary percutaneous coronary intervention (PCI) in 2005 (n=1479) with those treated in 2016 through quarter (Q) 2 of 2017 (n=22 432). DESIGN This retrospective analysis examined outcomes using both descriptive and regression analysis to control for differences in patient clinical characteristics over time. PRIMARY OUTCOME MEASURES The primary outcomes are 1 year and 2 year rates of mortality and re-hospitalisation for CHF. RESULTS The 1 year mortality rate was numerically higher in the 2016 cohort at 10.3% (95% CI 9.9 to 10.7) versus 8.9% (CI 7.4 to 10.3; p=0.068). The 2 year mortality rate was significantly higher in the 2016 cohort at 14.5% (CI 13.9 to 15.1) versus 11.4% (CI 9.2 to 13.6; p<0.01). The 1 year rehospitalisation for CHF was lower in the 2016 cohort at 10.6% (CI 10.0 to 11.2) versus 16.7% (CI 14.0 to 19.4; p<0.001), but the 2 year rate was not significantly different at 19.3% (CI 17.7 to 20.9) versus 20.7% (CI 16.4 to 24.9; p=0.55). After adjustment for covariates with two models, the 1 year mortality increased by 2.3% (CI 0.8 to 3.7; p<0.01) and 4.1% (CI 2.6 to 5.6; p<0.001) in the 2016 cohort. The 2 year adjusted mortality also increased by 4.2% (CI 2.0 to 6.4; p<0.001) and 6.5% (CI 4.2 to 8.7; p<0.001) in the 2016 cohort. The risk adjusted trends for rehospitalisation for CHF were similar to the unadjusted findings. CONCLUSIONS Despite prior improvements in STEMI outcomes in the reperfusion era related to the broad adoption of timely PCI, there is a persistent high mortality and CHF burden in Medicare beneficiaries with anterior STEMI. New strategies that address reperfusion injury and enhance myocardial salvage are needed.
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Affiliation(s)
- Jack Martin
- Department of Scientific Affairs, Main Line Health System, Sharpe-Strumia Research Foundation of the Bryn Mawr Hospital, Newtown Square, PA, USA
- Department of Drug Development Solutions, ICON plc, Dublin, Dublin, Ireland
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11
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Alamzaib SM, Jensen JC, Mansoor K, Rabbani NUA, Sayyed R. Novel Intracoronary Infusion of Supersaturated Oxygen Therapy in Patients Presenting With Acute ST Elevation Myocardial Infarction: Does It Help? Cureus 2023; 15:e39915. [PMID: 37273680 PMCID: PMC10239294 DOI: 10.7759/cureus.39915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2023] [Indexed: 06/06/2023] Open
Abstract
Supersaturated oxygen (SSO2) is one of the emerging therapies that has shown benefit for patients suffering from acute ST elevation myocardial infarction (STEMI) in terms of reducing infarct size, which has been used as a prognostic indicator for future heart failure and hospitalizations. Trials investigating SSO2 therapy have shown improvement in infarct size when used as an adjunct therapy to percutaneous trans-luminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (aMI). Here we present a patient with a mid left anterior descending artery (mLAD) STEMI who underwent SSO2 therapy. The patient presented with new onset angina and ST elevations on EKG. He underwent emergent coronary angiography, which confirmed an mLAD complete vessel occlusion. Successful PCI was done with a drug-eluting stent followed by supersaturated oxygen therapy. On follow-up evaluation, the patient had improved left ventricular (LV) ejection fraction from 35% to 60%. This case highlights the safety and efficacy of SSO2 therapy for patients suffering from acute anterior wall myocardial infarction. We recommend further investigation of this therapy for its routine use, safety, and prognostic utility. We also recommend routine use of adjunctive SSO2 therapy for patients suffering acute anterior STEMI.
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Affiliation(s)
- Sardar M Alamzaib
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Jay C Jensen
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Kanaan Mansoor
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Noor Ul Ann Rabbani
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Rameez Sayyed
- Cardiology, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
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12
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Nemani L. Practical Approach to Diagnosis, Prevention, and Management of Coronary No-Reflow. INDIAN JOURNAL OF CARDIOVASCULAR DISEASE IN WOMEN 2023. [DOI: 10.25259/ijcdw_18_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Coronary no-reflow (NR) defined as inadequate myocardial perfusion despite restoration of coronary artery patency is a bane for an interventional cardiologist. It can complicate percutaneous coronary interventions especially in the setting of STEMI and dampens the potential benefits of PPCI. Broadly classified as Reperfusion NR and Interventional NR, mechanism is multifactorial. The basic underlying culprit is microvascular obstruction either secondary to distal embolization, intravascular plugging, or ischemic reperfusion injury. Coronary angiogram is an easy, readily available, and essential modality to diagnose no-reflow, but the gold standard is gadolinium-enhanced cardiovascular magnetic resonance imaging. Preventive strategies for NR should be integral part of prePCI planning especially in clinical scenario where NR is expected such as STEMI with delayed presentation and high thrombus burden, atherectomy, and SVG PCI. The cornerstone of treatment for NR is local vasodilators and antiplatelet therapy to ameliorate vasospasm and thromboembolism respectively, and different combinations of the two should be used in no specific order to achieve reversal of NR. NR phenomenon is associated with poor short-term and long-term prognosis and every attempt should be made to avoid or reverse it. Therapeutic hypothermia, hyperoxemic reperfusion therapy, targeted anti-inflammatory approach, and cellular approach appear proising but further research is mandatory.
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Affiliation(s)
- Lalita Nemani
- Department of Cardiac Sciences, Dr. Ismail Surgical Center, Dubai, United Arab Emirates,
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13
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Case BC. Ice Ice Maybe… Not. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:16-17. [PMID: 36428158 DOI: 10.1016/j.carrev.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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14
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Romeo FJ, Mazurek R, Sakata T, Mavropoulos SA, Ishikawa K. Device-Based Approaches Targeting Cardioprotection in Myocardial Infarction: The Expanding Armamentarium of Innovative Strategies. J Am Heart Assoc 2022; 11:e026474. [PMID: 36382949 PMCID: PMC9851452 DOI: 10.1161/jaha.122.026474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Coronary reperfusion therapy has played a pivotal role for reducing mortality and heart failure after acute myocardial infarction. Although several adjunctive approaches have been studied for reducing infarct size further, both ischemia-reperfusion injury and microvascular obstruction are still major contributors to both early and late clinical events after acute myocardial infarction. The progress in the field of cardioprotection has found several promising proof-of-concept preclinical studies. However, translation from bench to bedside has not been very successful. This comprehensive review discusses the importance of infarct size as a driver of clinical outcomes post-acute myocardial infarction and summarizes recent novel device-based approaches for infarct size reduction. Device-based interventions including mechanical cardiac unloading, myocardial cooling, coronary sinus interventions, supersaturated oxygen therapy, and vagal stimulation are discussed. Many of these approaches can modify ischemic myocardial biology before reperfusion and offer unique opportunities to target ischemia-reperfusion injury.
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Affiliation(s)
- Francisco José Romeo
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Renata Mazurek
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Tomoki Sakata
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | | | - Kiyotake Ishikawa
- Cardiovascular Research InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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15
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Gokhale R. Divergent pattern: Pattern recognition or marker for adverse events. J Nucl Cardiol 2022; 29:3123-3125. [PMID: 35149977 DOI: 10.1007/s12350-022-02913-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/02/2022] [Indexed: 01/14/2023]
Affiliation(s)
- Rohit Gokhale
- Division of Cardiology, NYU Langone Medical Center, New York, NY, USA.
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16
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Novel therapeutic strategies to reduce reperfusion injury after acute myocardial infarction. Curr Probl Cardiol 2022; 47:101398. [PMID: 36108813 DOI: 10.1016/j.cpcardiol.2022.101398] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023]
Abstract
For almost 30 years, urgent revascularization termed primary percutaneous coronary intervention (pPCI) has been a cornerstone of modern care for acute myocardial infarction (AMI). It lowers mortality and improved cardiovascular outcome compared to conservative therapy including thrombolysis. Reperfusion injury, which occurs after successful re-opening of the formerly occluded coronary artery, had been exploited as a potential therapeutic target. When revascularisation became faster and pPCI was successfully performed within 60-90 minutes of symptom onset, the interest in a potential additive effect of targeting reperfusion injury vanished. More recently, several meta-analyses indicated that limiting reperfusion injury prevents microvascular obstruction and reduces final infarct size, thereby lowering the probability of heart failure events and improving quality of life in AMI survivors. Here, we describe the current strategies to limit reperfusion injury and to improve post-AMI outcomes such as systemic or intracoronary hypothermia, left-ventricular unloading, intracoronary infusion of super-saturated oxygen, intermittent coronary sinus occlusion, and C-reactive protein apharesis.
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17
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Schäfer A. Interventional Cardiology: Current Challenges in Acute Myocardial Infarction. J Clin Med 2022; 11:jcm11154504. [PMID: 35956118 PMCID: PMC9369876 DOI: 10.3390/jcm11154504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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18
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Figtree GA, Redfors B, Kozor R, Vernon ST, Grieve SM, Mazhar J, Thiele H, Patel MR, Udelson JE, Selker HP, Ohman EM, Maehara A, Karmpaliotis D, Eitel I, Granger CB, Ben-Yehuda O, Stone GW, Kosmidou I. Clinical Outcomes in Patients With ST-Segment Elevation MI and No Standard Modifiable Cardiovascular Risk Factors. JACC Cardiovasc Interv 2022; 15:1167-1175. [PMID: 35680197 DOI: 10.1016/j.jcin.2022.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/24/2022] [Accepted: 03/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The author recently reported ∼50% excess early mortality in patients with first-presentation ST-segment elevation myocardial infarction (STEMI) without standard modifiable cardiovascular risk factors (SMuRFs); the cause of this is not clear. OBJECTIVES The aim of this study was to examine differences in infarct characteristics and clinical outcomes in patients with versus without SMuRFs (dyslipidemia, hypertension, diabetes mellitus, and smoking). METHODS Individual-level data were pooled from 10 randomized percutaneous intervention (PCI) trials in which infarct size was measured within 1 month by either cardiac magnetic resonance or technetium-99m sestamibi single-photon emission computed tomography imaging. First-presentation STEMI was classified into 2 groups according to the presence or absence of at least 1 SMuRF. RESULTS Among 2,862 patients, 524 (18.3%) were SMuRF-less. After adjusting for study effect, SMuRF-less patients had more frequent poor pre-PCI flow Thrombolysis In Myocardial Infarction 0/1 compared with patients with at least 1 SMuRF (72.0% vs 64.1%; OR: 1.35; 95% CI: 1.08-1.70). There were no independent associations between the presence or absence of SMuRFs at baseline and infarct size (estimate = -0.35; 95% CI: -1.93 to 1.23), left ventricular ejection fraction (estimate = -0.06; 95% CI: -1.33 to 1.20), or mortality at 30 days (HR: 0.46; 95% CI: 0.19-1.07) and 1 year (HR: 0.74; 95% CI: 0.43-1.29). CONCLUSIONS First-presentation STEMI patients with no identifiable baseline SMuRFs had a higher risk of Thrombolysis In Myocardial Infarction flow grade 0/1 pre-PCI. However, after adjustment, there were no significant associations between SMuRF-less status and infarct size, left ventricle ejection fraction, or mortality.
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Affiliation(s)
- Gemma A Figtree
- Kolling Research Institute, University of Sydney, Sydney, Australia; Imaging and Phenotyping Laboratory, Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
| | - Bjorn Redfors
- Clinical Trials Center, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rebecca Kozor
- Kolling Research Institute, University of Sydney, Sydney, Australia
| | - Stephen T Vernon
- Kolling Research Institute, University of Sydney, Sydney, Australia; Imaging and Phenotyping Laboratory, Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, Australia. https://twitter.com/steve_vern
| | - Stuart M Grieve
- Imaging and Phenotyping Laboratory, Charles Perkins Centre and Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jawad Mazhar
- Kolling Research Institute, University of Sydney, Sydney, Australia
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Manesh R Patel
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | - James E Udelson
- Division of Cardiology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Harry P Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - E Magnus Ohman
- Division of Cardiology, Duke University Hospital, Durham, North Carolina, USA
| | | | - Dmitri Karmpaliotis
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Ingo Eitel
- University Heart Center Lübeck and the German Center for Cardiovascular Research, Lübeck, Germany
| | | | - Ori Ben-Yehuda
- Clinical Trials Center, New York, New York, USA; Division of Cardiovascular Medicine, University of California-San Diego, San Diego, California, USA
| | - Gregg W Stone
- Clinical Trials Center, New York, New York, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/GreggWStone
| | - Ioanna Kosmidou
- Clinical Trials Center, New York, New York, USA; Division of Cardiology, Memorial Sloan Kettering Cancer Center and Weill-Cornell College of Medicine, New York, New York, USA. https://twitter.com/IKosmidou
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19
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Annibali G, Scrocca I, Aranzulla TC, Meliga E, Maiellaro F, Musumeci G. "No-Reflow" Phenomenon: A Contemporary Review. J Clin Med 2022; 11:2233. [PMID: 35456326 PMCID: PMC9028464 DOI: 10.3390/jcm11082233] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 12/04/2022] Open
Abstract
Primary percutaneous angioplasty (pPCI), represents the reperfusion strategy of choice for patients with STEMI according to current international guidelines of the European Society of Cardiology. Coronary no-reflow is characterized by angiographic evidence of slow or no anterograde epicardial flow, resulting in inadequate myocardial perfusion in the absence of evidence of mechanical vessel obstruction. No reflow (NR) is related to a functional and structural alteration of the coronary microcirculation and we can list four main pathophysiological mechanisms: distal atherothrombotic embolization, ischemic damage, reperfusion injury, and individual susceptibility to microvascular damage. This review will provide a contemporary overview of the pathogenesis, diagnosis, and treatment of NR.
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Affiliation(s)
| | | | | | | | | | - Giuseppe Musumeci
- Cardiology Department, Azienda Ospedaliera Ordine Mauriziano Umberto I, 10128 Turin, Italy; (G.A.); (I.S.); (T.C.A.); (E.M.); (F.M.)
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20
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Kaluza GL, Creech JL, Furer A, Afari ME, Milewski K, Yi GH, Cheng Y, Conditt GB, McGregor JC, Blum D, Rousselle SD, Granada JF, Burkhoff D. Chronic myocardial and coronary arterial effects of intracoronary supersaturated oxygen therapy in swine with normal and ischemic-reperfused myocardium. Sci Rep 2022; 12:5785. [PMID: 35388096 PMCID: PMC8987078 DOI: 10.1038/s41598-022-09776-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 03/16/2022] [Indexed: 11/08/2022] Open
Abstract
The study assessed chronic myocardial, coronary and systemic effects of intracoronary supersaturated oxygen (SSO2) therapy. Left anterior descending coronary arteries of 40 swine were stented and randomized to 90-min selective intracoronary infusion of SSO2 (pO2 760-1000 mmHg) or normoxemic saline. In 20 out of 40 animals, SSO2 delivery followed a 60-min balloon occlusion to induce myocardial infarction (MI). In both normal and MI models, intracoronary treatment with hyperoxemic SSO2 therapy showed no evidence of coronary thrombosis. There were no biologically relevant differences between treatments at either time point in regard to coronary intervention site healing and neointimal growth. No signs of any myocardial or systemic toxicity were observed after 7 or 30 days. A trend was observed toward reduced incidence of microscopic MI scars and reduced infarct size in histopathology, as well as toward better recovery of echocardiographically evaluated global and regional contractility at 30 days. No treatment related infarcts or thromboemboli were observed in the downstream organs.
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Affiliation(s)
- Grzegorz L Kaluza
- Skirball Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA.
| | | | - Ariel Furer
- Sheba Tel HaShomer City of Health, Ramat Gan, Israel
| | | | | | - Geng-Hua Yi
- Skirball Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA
| | - Yanping Cheng
- Skirball Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA
| | - Gerard B Conditt
- Skirball Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA
| | - Jenn C McGregor
- Skirball Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA
| | | | | | - Juan F Granada
- Skirball Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA
| | - Daniel Burkhoff
- Skirball Center for Innovation, Cardiovascular Research Foundation, Orangeburg, NY, USA
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21
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Schäfer A, Akin M, Diekmann J, König T. Intracoronary Application of Super-Saturated Oxygen to Reduce Infarct Size Following Myocardial Infarction. J Clin Med 2022; 11:jcm11061509. [PMID: 35329835 PMCID: PMC8949147 DOI: 10.3390/jcm11061509] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/03/2022] [Accepted: 03/08/2022] [Indexed: 01/27/2023] Open
Abstract
Optimal medical therapy for secondary prevention following acute myocardial infarction reduces non-fatal ischaemic events. Intensive antithrombotic or lipid-lowering approaches have failed to significantly lower mortality. In the past, reduction of infarct size in patients undergoing primary percutaneous revascularisation for acute myocardial infarction had been considered as a surrogate outcome marker. However, infarct size measured by magnetic resonance imaging or SPECT is strongly associated with all-cause mortality and hospitalization for heart failure within the first year after an acute myocardial infarction. Intracoronary administration of super-saturated oxygen (SSO2) immediately after revascularisation is an approach that can be used to reduce infarct size and, therefore, improve cardiovascular outcome in patients with acute myocardial infarction. In this article, we describe the modulation of pathophysiology by SSO2, review the existing trial data and present our first impressions with the technique in real clinical practice.
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Affiliation(s)
- Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (M.A.); (T.K.)
- Correspondence: ; Tel.: +49-(511)-532-5240
| | - Muharrem Akin
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (M.A.); (T.K.)
| | - Johanna Diekmann
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany;
| | - Tobias König
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; (M.A.); (T.K.)
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22
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Update on Cardioprotective Strategies for STEMI: Focus on Supersaturated Oxygen Delivery. JACC Basic Transl Sci 2021; 6:1021-1033. [PMID: 35024508 PMCID: PMC8733677 DOI: 10.1016/j.jacbts.2021.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 02/01/2023]
Abstract
Despite the fact that door-to-balloon times have been greatly reduced, the rates of death and the incidence of heart failure in patients with ST-segment elevation myocardial infarction (MI) have plateaued. There is still an unmet need to further reduce MI size in the reperfusion era. Most adjunctive therapies to enhance myocardial salvage have failed, but some have shown promise. Currently, the only adjunctive therapy in a pivotal trial that has demonstrated reductions in infarct size is localized delivery of supersaturated oxygen (SSO2) therapy. This review provides background on prior infarct size reduction efforts. The authors describe the preclinical data that shows the effectiveness of SSO2 in reducing MI size, improving regional myocardial blood flow and cardiac function, and reducing adverse left ventricular remodeling-presumably by reducing patchy areas of residual ischemia within the reperfused risk zone. Potential mechanisms by which SSO2 is beneficial are described, including the delivery of high levels of dissolved oxygen through plasma to ischemic, but viable, vascular and myocardial cells, thus allowing their survival and function. The authors then describe the SSO2 clinical trials, demonstrating that in patients with anterior ST-segment elevation MI, SSO2 therapy safely and effectively reduces infarct size, improves cardiac function, and reduces adverse left ventricular remodeling.
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Key Words
- AMI, acute myocardial infarction
- CMR, cardiac magnetic resonance
- FDA, Food and Drug Administration
- HF, heart failure
- LAD, left anterior descending coronary artery
- LM, left main coronary artery
- LV function
- LV remodeling
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MI, myocardial infarction
- NACE, net adverse clinical events
- PCI, percutaneous coronary intervention
- Pao2, partial pressure of oxygen
- SPECT, single-photon emission computed tomography
- SSO2, supersaturated oxygen
- ST-segment elevation myocardial infarction
- STEMI, ST-segment elevation myocardial infarction
- TIMI, Thrombolysis In Myocardial Infarction
- TVR, target vessel revascularization
- myocardial infarct size reduction
- supersaturated oxygen
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23
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Fischesser DM, Bo B, Benton RP, Su H, Jahanpanah N, Haworth KJ. Controlling Reperfusion Injury With Controlled Reperfusion: Historical Perspectives and New Paradigms. J Cardiovasc Pharmacol Ther 2021; 26:504-523. [PMID: 34534022 DOI: 10.1177/10742484211046674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cardiac reperfusion injury is a well-established outcome following treatment of acute myocardial infarction and other types of ischemic heart conditions. Numerous cardioprotection protocols and therapies have been pursued with success in pre-clinical models. Unfortunately, there has been lack of successful large-scale clinical translation, perhaps in part due to the multiple pathways that reperfusion can contribute to cell death. The search continues for new cardioprotection protocols based on what has been learned from past results. One class of cardioprotection protocols that remain under active investigation is that of controlled reperfusion. This class consists of those approaches that modify, in a controlled manner, the content of the reperfusate or the mechanical properties of the reperfusate (e.g., pressure and flow). This review article first provides a basic overview of the primary pathways to cell death that have the potential to be addressed by various forms of controlled reperfusion, including no-reflow phenomenon, ion imbalances (particularly calcium overload), and oxidative stress. Descriptions of various controlled reperfusion approaches are described, along with summaries of both mechanistic and outcome-oriented studies at the pre-clinical and clinical phases. This review will constrain itself to approaches that modify endogenously-occurring blood components. These approaches include ischemic postconditioning, gentle reperfusion, controlled hypoxic reperfusion, controlled hyperoxic reperfusion, controlled acidotic reperfusion, and controlled ionic reperfusion. This review concludes with a discussion of the limitations of past approaches and how they point to potential directions of investigation for the future.
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Affiliation(s)
- Demetria M Fischesser
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, 2514University of Cincinnati, Cincinnati, OH, USA
| | - Bin Bo
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, 2514University of Cincinnati, Cincinnati, OH, USA
| | - Rachel P Benton
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, 2514University of Cincinnati, Cincinnati, OH, USA
| | - Haili Su
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, 2514University of Cincinnati, Cincinnati, OH, USA
| | - Newsha Jahanpanah
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, 2514University of Cincinnati, Cincinnati, OH, USA
| | - Kevin J Haworth
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, College of Medicine, 2514University of Cincinnati, Cincinnati, OH, USA
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24
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Myocardial preservation during primary percutaneous intervention: It's time to rethink? Indian Heart J 2021; 73:395-403. [PMID: 34474749 PMCID: PMC8424360 DOI: 10.1016/j.ihj.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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25
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Vidal-Calés P, Cepas-Guillén PL, Brugaletta S, Sabaté M. New Interventional Therapies beyond Stenting to Treat ST-Segment Elevation Acute Myocardial Infarction. J Cardiovasc Dev Dis 2021; 8:jcdd8090100. [PMID: 34564118 PMCID: PMC8469769 DOI: 10.3390/jcdd8090100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022] Open
Abstract
Myocardial infarction remains the principal cause of death in Europe. In patients with ST-segment-elevation myocardial infarction (STEMI), a promptly revascularization with primary percutaneous intervention (PCI) has transformed prognosis in the last decades. However, despite increasing successful PCI procedures, mortality has remained unchanged in recent years. Also, due to an unsatisfactory reperfusion, some patients have significant myocardial damage and suffer left ventricular adverse remodeling with reduced function—all that resulting in the onset of heart failure with all its inherent clinical and socioeconomic burden. As a consequence of longer ischemic times, distal thrombotic embolization, ischemia-reperfusion injury and microvascular dysfunction, the resultant myocardial infarct size is the major prognostic determinant in STEMI patients. The improved understanding of all the pathophysiology underlying these events has derived to the development of several novel therapies aiming to reduce infarct size and to improve clinical outcomes in these patients. In this article, based on the mechanisms involved in myocardial infarction prognosis, we review the new interventional strategies beyond stenting that may solve the suboptimal results that STEMI patients still experience.
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Affiliation(s)
- Pablo Vidal-Calés
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain; (P.V.-C.); (P.L.C.-G.); (S.B.)
| | - Pedro L. Cepas-Guillén
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain; (P.V.-C.); (P.L.C.-G.); (S.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Salvatore Brugaletta
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain; (P.V.-C.); (P.L.C.-G.); (S.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Manel Sabaté
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, 08036 Barcelona, Spain; (P.V.-C.); (P.L.C.-G.); (S.B.)
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red. Enfermedades Cardiovasculares (CIBERCV) CB16/11/00411, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-932-275-519
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26
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Abella BS, Otterspoor L, Nichol G, Martin JL. ST-Elevation Myocardial Infarction Track. Ther Hypothermia Temp Manag 2021; 11:65-70. [PMID: 33819429 DOI: 10.1089/ther.2021.29091.bab] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Benjamin S Abella
- Center for Resuscitation Science and Department of Emergency Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Luuk Otterspoor
- Heart Centre Eindhoven, Catharina Hospital, Eindhoven, Netherlands
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, Seattle, Washington, USA
| | - Jack L Martin
- ICON plc., North Wales, Pennsylvania, USA.,Sharpe-Strumia Research Foundation, Bryn Mawr, Pennsylvania, USA
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27
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De Maria GL, Garcia-Garcia HM, Scarsini R, Finn A, Sato Y, Virmani R, Bhindi R, Ciofani JL, Nuche J, Ribeiro HB, Mathias W, Yerasi C, Fischell TA, Otterspoor L, Ribichini F, Ibañez B, Pijls NHJ, Schwartz RS, Kapur NK, Stone GW, Banning AP. Novel device-based therapies to improve outcome in ST-segment elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:687-697. [PMID: 33760016 DOI: 10.1093/ehjacc/zuab012] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/28/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Primary percutaneous coronary intervention (PPCI) has dramatically changed the outcome of patients with ST-elevation myocardial infarction (STEMI). However, despite improvements in interventional technology, registry data show little recent change in the prognosis of patients who survive STEMI, with a significant incidence of cardiogenic shock, heart failure, and cardiac death. Despite a technically successful PPCI procedure, a variable proportion of patients experience suboptimal myocardial reperfusion. Large infarct size and coronary microvascular injury, as the consequence of ischaemia-reperfusion injury and distal embolization of atherothrombotic debris, account for suboptimal long-term prognosis of STEMI patients. In order to address this unmet therapeutic need, a broad-range of device-based treatments has been developed. These device-based therapies can be categorized according to the pathophysiological pathways they target: (i) techniques to prevent distal atherothrombotic embolization, (ii) techniques to prevent or mitigate ischaemia/reperfusion injury, and (iii) techniques to enhance coronary microvascular function/integrity. This review is an overview of these novel technologies with a focus on their pathophysiological background, procedural details, available evidence, and with a critical perspective about their potential future implementation in the clinical care of STEMI patients.
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Affiliation(s)
- Giovanni Luigi De Maria
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, UK
| | - Hector M Garcia-Garcia
- MedStar Washington Hospital Centre-Interventional Cardiology Department, 110 Irving St NW, Washington, DC, USA
| | - Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - Aloke Finn
- CVPath Institute, Gaithersburg, 19 Firstfield Rd, Gaithersburg, MD 20878, USA.,School of Medicine, University of Maryland, Baltimore, 655 W Baltimore St, Baltimore, MD 21201, USA
| | - Yu Sato
- CVPath Institute, Gaithersburg, 19 Firstfield Rd, Gaithersburg, MD 20878, USA
| | - Renu Virmani
- CVPath Institute, Gaithersburg, 19 Firstfield Rd, Gaithersburg, MD 20878, USA
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Reserve Road, ST. Leonard 2065, Sydney, Australia
| | - Jonathan L Ciofani
- Department of Cardiology, Royal North Shore Hospital, Reserve Road, ST. Leonard 2065, Sydney, Australia
| | - Jorge Nuche
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Calle Melchor Fernández Almagro 3, 28029, Madrid, Spain.,Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Cordoba avenue, 28041, Madrid, Spain.,CIBERCV, Av. Monforte de Lemos, 3-5. Pabellón, 11. Planta 0 28029, Madrid, Spain
| | - Henrique B Ribeiro
- Heart Institute (InCor), Clinic Hospital, The University of Sao Paulo School of Medicine, Sao Paulo, State of Sao Paulo 05403-000, Brazil
| | - Wilson Mathias
- Heart Institute (InCor), Clinic Hospital, The University of Sao Paulo School of Medicine, Sao Paulo, State of Sao Paulo 05403-000, Brazil
| | - Charan Yerasi
- MedStar Washington Hospital Centre-Interventional Cardiology Department, 110 Irving St NW, Washington, DC, USA
| | - Tim A Fischell
- Michigan State University, 426 Auditorium Road, East Lansing, MI 48824, USA
| | - Luuk Otterspoor
- Department of Cardiology, Catharina Hospital, Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Piazzale Aristide Stefani 1, 37126, Verona, Italy
| | - Borja Ibañez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Calle Melchor Fernández Almagro 3, 28029, Madrid, Spain.,CIBERCV, Av. Monforte de Lemos, 3-5. Pabellón, 11. Planta 0 28029, Madrid, Spain.,IIS-Fundación Jiménez Díaz, Calle Isaac Peral, 28015 Madrid, Spain
| | - Nico H J Pijls
- Department of Cardiology, Catharina Hospital, Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Robert S Schwartz
- Minneapolis Heart Institute, 920 E 28th St Ste 100, Minneapolis, MN 55407, USA
| | - Navin K Kapur
- The Cardiovascular Centre, Tufts Medical Centre, 800 Washington St, Boston, MA 02111, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, New York, NY 10029, USA
| | - Adrian P Banning
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford OX3 9DU, UK
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Riching AS, Song K. Cardiac Regeneration: New Insights Into the Frontier of Ischemic Heart Failure Therapy. Front Bioeng Biotechnol 2021; 8:637538. [PMID: 33585427 PMCID: PMC7873479 DOI: 10.3389/fbioe.2020.637538] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/29/2020] [Indexed: 12/17/2022] Open
Abstract
Ischemic heart disease is the leading cause of morbidity and mortality in the world. While pharmacological and surgical interventions developed in the late twentieth century drastically improved patient outcomes, mortality rates over the last two decades have begun to plateau. Following ischemic injury, pathological remodeling leads to cardiomyocyte loss and fibrosis leading to impaired heart function. Cardiomyocyte turnover rate in the adult heart is limited, and no clinical therapies currently exist to regenerate cardiomyocytes lost following ischemic injury. In this review, we summarize the progress of therapeutic strategies including revascularization and cell-based interventions to regenerate the heart: transiently inducing cardiomyocyte proliferation and direct reprogramming of fibroblasts into cardiomyocytes. Moreover, we highlight recent mechanistic insights governing these strategies to promote heart regeneration and identify current challenges in translating these approaches to human patients.
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Affiliation(s)
- Andrew S. Riching
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Gates Center for Regenerative Medicine and Stem Cell Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- The Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Pharmacology Graduate Program, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kunhua Song
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Gates Center for Regenerative Medicine and Stem Cell Biology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- The Consortium for Fibrosis Research & Translation, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Pharmacology Graduate Program, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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29
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Wheeler C, De Puy F, Schatz R. Novel intracoronary supersaturated oxygen treatment for anterior myocardial infarction. Future Cardiol 2021; 17:847-853. [PMID: 33448870 DOI: 10.2217/fca-2020-0133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Primary percutaneous coronary intervention (PCI) is now the recommended reperfusion technique for patients with acute ST-segment elevation myocardial infarction. However, despite early reperfusion in the majority of patients, PCI does not achieve effective myocardial reperfusion in a significant proportion of patients due to the prevalence of coronary microvascular obstruction. The amount of infarcted myocardium has been considered to be a reliable indicator of major adverse cardiovascular events and resultant adverse left ventricular remodeling. The purpose of this paper is to review the clinical benefits of supersaturated oxygen therapy following PCI for ST-segment elevation myocardial infarction.
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Affiliation(s)
- Carmen Wheeler
- Interventional Cardiology, Clinical Research, John R Anderson Medical Pavilion, 9898, Genesee Avenue La Jolla, CA 92037, USA
| | - Federico De Puy
- Interventional Cardiology, Scripps Clinic, John R Anderson Medical Pavilion, 9898, Genesee Avenue La Jolla, CA 92037, USA
| | - Richard Schatz
- Interventional Cardiology, Scripps Clinic, John R Anderson Medical Pavilion, 9898, Genesee Avenue La Jolla, CA 92037, USA
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30
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Redfors B, Mohebi R, Giustino G, Chen S, Selker HP, Thiele H, Patel MR, Udelson JE, Ohman EM, Eitel I, Granger CB, Maehara A, Ali ZA, Ben-Yehuda O, Stone GW. Time Delay, Infarct Size, and Microvascular Obstruction After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2021; 14:e009879. [PMID: 33440999 DOI: 10.1161/circinterventions.120.009879] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Symptom-to-balloon time (SBT) and door-to-balloon time (DBT) are both considered important metrics in patients undergoing primary percutaneous coronary intervention (pPCI) for ST-segment-elevation myocardial infarction (STEMI). We sought to assess the relationship of SBT and DBT with infarct size and microvascular obstruction (MVO) after pPCI. METHODS Individual patient data for 3115 ST-segment-elevation myocardial infarction patients undergoing pPCI in 10 randomized trials were pooled. Infarct size (% left ventricular mass) was assessed within 1 month after randomization by technetium-99 m sestamibi single-photon emission computerized tomography (3 studies) or cardiac magnetic resonance imaging (7 studies). MVO was assessed by cardiac magnetic resonance. Patients were stratified by short (≤2 hours), intermediate (2-4 hours), or long (>4 hours) SBTs, and by short (≤45 minutes), intermediate (45-90 minutes), or long (>90 minutes) DBTs. RESULTS Median [interquartile range] SBT and DBT were 185 [130-269] and 46 [28-83] minutes, respectively. Median [interquartile range] time to infarct size assessment after pPCI was 5 [3-12] days. There was a stepwise increase in infarct size according to SBT category (adjusted difference, 2.0% [95% CI, 0.4-3.5] for intermediate versus short SBT and 4.4% [95% CI, 2.7-6.1] for long versus short SBT) but not according to DBT category (adjusted difference, 0.4% [95% CI, -1.2 to 1.9] for intermediate versus short DBT and -0.1% [95% CI, -1.0 to 3.0] for long versus short SBT). MVO was greater in patients with long versus short SBT (adjusted difference, 0.9% [95% CI, 0.3-1.4]) but was not different between patients with intermediate versus short SBT (adjusted difference, 0.1 [95% CI, -0.4 to 0.6]). There was no difference in MVO according to DBT. Results were similar in multivariable analysis with SBT and DBT included as continuous variables. CONCLUSIONS Among 3115 patients with ST-segment-elevation myocardial infarction undergoing infarct size assessment after pPCI, SBT was more strongly correlated with infarct size and MVO than DBT.
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Affiliation(s)
- Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.).,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | - Reza Mohebi
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.G., G.W.S.)
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.G., G.W.S.)
| | - Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.)
| | - Harry P Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (H.P.S.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Germany (H.T.)
| | - Manesh R Patel
- Duke University Medical Center, Durham, NC (M.R.P., E.M.O., C.B.G.)
| | - James E Udelson
- Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U.)
| | - E Magnus Ohman
- Duke University Medical Center, Durham, NC (M.R.P., E.M.O., C.B.G.)
| | - Ingo Eitel
- University Heart Center Lübeck, and the German Center for Cardiovascular Research, Lübeck, Germany (I.E.)
| | | | - Akiko Maehara
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.)
| | - Ziad A Ali
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.).,St. Francis Hospital, Roslyn, NY (Z.A.A.)
| | - Ori Ben-Yehuda
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,Department of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY (B.R., S.C., A.M., Z.A.A., O.B.-Y.)
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (B.R., R.M., S.C., A.M., Z.A.A., O.B.-Y., G.W.S.).,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.G., G.W.S.)
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31
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Poorahmadieh F, Salmani N, Kalani Z. The effect of oxygen inhalation on cardiac biomarkers in patients presenting with acute ST-segment elevation myocardial infraction: A randomized clinical trial. Med J Islam Repub Iran 2021; 35:6. [PMID: 33996657 PMCID: PMC8111649 DOI: 10.47176/mjiri.35.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Indexed: 11/18/2022] Open
Abstract
Background: It is assumed giving oxygen to patients with acute myocardial infraction may increase the oxygenation of the ischemic tissue; however, the usefulness of oxygen in these patients has become a challenging topic. Thus, the present study aimed to determine the effect of oxygen inhalation on cardiac biomarkers in patients with acute myocardial infarction. Methods: This randomized clinical trial study was performed on 2 groups of intervention and control within 2 days of admission to critical care unit (CCU). A total of 64 patients with ST-segment elevation acute myocardial infarction who referred to Zeyaei hospital, Ardakan, were selected using simple random sampling. In the intervention group, the pulse oximetry was monitored and they only breathed regular air and received supplemental oxygen in case their oxygen level dropped below 94%. The levels of creatine kinase-MB and troponin I enzymes were measured. Data were analyzed using SPSS version 20 through repeated measure ANOVA, t test, and chi-squared test. Significance level was set at 0.05. Results: This study showed that during the 48 hours of hospitalization, there were no significant differences between the 2 groups regarding the levels of creatine kinase-MB (p=0.509) and troponin I (p=0.604). Conclusion: Since the level of cardiac biomarkers is a sign of the extent of infracted area, it is assumed receiving supplemental oxygen in patients with acute myocardial infarction has no effect on decreasing the infracted area.
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Affiliation(s)
- Fatemeh Poorahmadieh
- Department of Nursing, School of Nursing and Midwifery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Naiire Salmani
- Meybod Nursing School, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Zohreh Kalani
- Department of Nursing, School of Nursing and Midwifery, Research Center for Nursing and Midwifery Care, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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32
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Effect of Smoking on Outcomes of Primary PCI in Patients With STEMI. J Am Coll Cardiol 2020; 75:1743-1754. [PMID: 32299585 DOI: 10.1016/j.jacc.2020.02.045] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/23/2020] [Accepted: 02/13/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Smoking is a well-established risk factor for ST-segment elevation myocardial infarction (STEMI); however, once STEMI occurs, smoking has been associated with favorable short-term outcomes, an observation termed the "smoker's paradox." It has been postulated that smoking might exert protective effects that could reduce infarct size, a strong independent predictor of worse outcomes after STEMI. OBJECTIVES The purpose of this study was to determine the relationship among smoking, infarct size, microvascular obstruction (MVO), and adverse outcomes after STEMI. METHODS Individual patient-data were pooled from 10 randomized trials of patients with STEMI undergoing primary percutaneous coronary intervention. Infarct size was assessed at median 4 days by either cardiac magnetic resonance imaging or technetium-99m sestamibi single-photon emission computed tomography. Multivariable analysis was used to assess the relationship between smoking, infarct size, and the 1-year rates of death or heart failure (HF) hospitalization and reinfarction. RESULTS Among 2,564 patients with STEMI, 1,093 (42.6%) were recent smokers. Smokers were 10 years younger and had fewer comorbidities. Infarct size was similar in smokers and nonsmokers (adjusted difference: 0.0%; 95% confidence interval [CI]: -3.3% to 3.3%; p = 0.99). Nor was the extent of MVO different between smokers and nonsmokers. Smokers had lower crude 1-year rates of all-cause death (1.0% vs. 2.9%; p < 0.001) and death or HF hospitalization (3.3% vs. 5.1%; p = 0.009) with similar rates of reinfarction. After adjustment for age and other risk factors, smokers had a similar 1-year risk of death (adjusted hazard ratio [adjHR]: 0.92; 95% CI: 0.46 to 1.84) and higher risks of death or HF hospitalization (adjHR: 1.49; 95% CI: 1.09 to 2.02) as well as reinfarction (adjHR: 1.97; 95% CI: 1.17 to 3.33). CONCLUSIONS In the present large-scale individual patient-data pooled analysis, recent smoking was unrelated to infarct size or MVO, but was associated with a worse prognosis after primary PCI in STEMI. The smoker's paradox may be explained by the younger age and fewer cardiovascular risk factors in smokers compared with nonsmokers.
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Severino P, D’Amato A, Pucci M, Infusino F, Adamo F, Birtolo LI, Netti L, Montefusco G, Chimenti C, Lavalle C, Maestrini V, Mancone M, Chilian WM, Fedele F. Ischemic Heart Disease Pathophysiology Paradigms Overview: From Plaque Activation to Microvascular Dysfunction. Int J Mol Sci 2020; 21:E8118. [PMID: 33143256 PMCID: PMC7663258 DOI: 10.3390/ijms21218118] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
Ischemic heart disease still represents a large burden on individuals and health care resources worldwide. By conventions, it is equated with atherosclerotic plaque due to flow-limiting obstruction in large-medium sized coronary arteries. However, clinical, angiographic and autoptic findings suggest a multifaceted pathophysiology for ischemic heart disease and just some cases are caused by severe or complicated atherosclerotic plaques. Currently there is no well-defined assessment of ischemic heart disease pathophysiology that satisfies all the observations and sometimes the underlying mechanism to everyday ischemic heart disease ward cases is misleading. In order to better examine this complicated disease and to provide future perspectives, it is important to know and analyze the pathophysiological mechanisms that underline it, because ischemic heart disease is not always determined by atherosclerotic plaque complication. Therefore, in order to have a more complete comprehension of ischemic heart disease we propose an overview of the available pathophysiological paradigms, from plaque activation to microvascular dysfunction.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Andrea D’Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Mariateresa Pucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Fabio Infusino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Francesco Adamo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Lucrezia Netti
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Giulio Montefusco
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
| | - William M. Chilian
- Department of Integrative Medical Sciences, Northeast Ohio Medical University, Rootstown, OH 44272, USA;
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161 Rome, Italy; (P.S.); (A.D.); (M.P.); (F.I.); (F.A.); (L.I.B.); (L.N.); (G.M.); (C.C.); (C.L.); (V.M.); (M.M.)
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Joner M, Lahmann AL. Cardioprotection for Reduction of Infarct Size - Ancient Dogma for Some Time to Come. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1585-1586. [PMID: 32952080 DOI: 10.1016/j.carrev.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Michael Joner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Munich, Germany; Munich Heart Alliance, Munich, Germany.
| | - Anna Lena Lahmann
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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Ciofani JL, Allahwala UK, Scarsini R, Ekmejian A, Banning AP, Bhindi R, De Maria GL. No-reflow phenomenon in ST-segment elevation myocardial infarction: still the Achilles' heel of the interventionalist. Future Cardiol 2020; 17:383-397. [PMID: 32915083 DOI: 10.2217/fca-2020-0077] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Improvements in systems, technology and pharmacotherapy have significantly changed the prognosis over recent decades in patients presenting with ST-segment elevation myocardial infarction. These clinical achievements have, however, begun to plateau and it is becoming increasingly necessary to consider novel strategies to further improve outcomes. Approximately a third of patients treated by primary percutaneous coronary intervention for ST-segment elevation myocardial infarction will suffer from coronary no-reflow (NR), a condition characterized by poor myocardial perfusion despite patent epicardial arteries. The presence of NR impacts significantly on clinical outcomes including left ventricular dysfunction, heart failure and death, yet conventional management algorithms neither assess the risk of NR nor treat NR. This review will provide a contemporary overview on the pathogenesis, diagnosis and treatment of NR.
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Affiliation(s)
- Jonathan L Ciofani
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia.,Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Usaid K Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Roberto Scarsini
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK.,Division of Cardiology, University of Verona, Verona, Italy
| | - Avedis Ekmejian
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Adrian P Banning
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
| | - Ravinay Bhindi
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, NIHR Biomedical Research Centre, Oxford University Hospitals, Oxford, UK
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36
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Giblett JP, Bulluck H. Cardioprotection for Acute MI in Light of the CONDI2/ERIC-PPCI Trial: New Targets Needed. ACTA ACUST UNITED AC 2020; 15:e13. [PMID: 32944081 PMCID: PMC7479528 DOI: 10.15420/icr.2020.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/28/2020] [Indexed: 02/07/2023]
Abstract
Protection against ischaemia-reperfusion injury after revascularisation in acute myocardial infarction remains an enigma. Many targets have been identified, but after the failure of the recent Effect of Remote Ischaemic Conditioning on Clinical Outcomes in ST-elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention (CONDI2/ERIC-PPCI) trial to show translation to clinical benefit, there is still no pharmacological or mechanical strategy that has translated to clinical practice. This article addresses the results of the CONDI2/ERIC-PPCI trial in the context of previous studies of ischaemic conditioning, and then considers the prospects for other potential targets of cardioprotection. Finally, the authors examine the pitfalls and challenges in trial design for future investigation of cardioprotective strategies. In particular, this article highlights the need for careful endpoint and patient selection, as well as the need to pay attention to the biology of cardioprotection during the study.
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Affiliation(s)
- Joel P Giblett
- Department of Cardiology, Liverpool Heart and Chest Hospital Liverpool, UK
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37
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Chen S, David SW, Khan ZA, Metzger DC, Wasserman HS, Lotfi AS, Hanson ID, Dixon SR, LaLonde TA, Généreux P, Ozan MO, Maehara A, Stone GW. One-year outcomes of supersaturated oxygen therapy in acute anterior myocardial infarction: The IC-HOT study. Catheter Cardiovasc Interv 2020; 97:1120-1126. [PMID: 32649037 PMCID: PMC8246818 DOI: 10.1002/ccd.29090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/26/2020] [Accepted: 05/31/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Supersaturated oxygen (SSO2 ) has recently been approved by the U.S. Food and Drug Administration for administration after primary percutaneous coronary intervention (pPCI) in patients with anterior ST-segment elevation myocardial infarction (STEMI) based on its demonstration of infarct size reduction in the IC-HOT study. OBJECTIVES To describe the 1-year clinical outcomes of intracoronary SSO2 treatment after pPCI in patients with anterior STEMI. METHODS IC-HOT was a prospective, open-label, single-arm study in which 100 patients without cardiogenic shock undergoing successful pPCI of an occluded left anterior descending coronary artery were treated with a 60-min SSO2 infusion. One-year clinical outcomes were compared with a propensity-matched control group of similar patients with anterior STEMI enrolled in the INFUSE-AMI trial. RESULTS Baseline and postprocedural characteristics were similar in the two groups except for pre-PCI thrombolysis in myocardial infarction 3 flow, which was less prevalent in patients treated with SSO2 (9.6% vs. 22.9%, p = .02). Treatment with SSO2 was associated with a lower 1-year rate of the composite endpoint of all-cause death or new-onset heart failure (HF) or hospitalization for HF (0.0% vs. 12.3%, p = .001). All-cause mortality, driven by cardiovascular mortality, and new-onset HF or HF hospitalization were each individually lower in SSO2 -treated patients. There were no significant differences between groups in the 1-year rates of reinfarction or clinically driven target vessel revascularization. CONCLUSIONS Infusion of SSO2 following pPCI in patients with anterior STEMI was associated with improved 1-year clinical outcomes including lower rates of death and new-onset HF or HF hospitalizations.
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Affiliation(s)
- Shmuel Chen
- Clinical Trials Center, Cardiovascular Research Foundation, New York.,Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York
| | | | | | | | | | - Amir S Lotfi
- Baystate Medical Center, Springfield, Massachusetts
| | | | | | - Thomas A LaLonde
- Ascension St. John Hospital, Detroit, Michigan.,Wayne State University School of Medicine, Detroit, Michigan
| | - Philippe Généreux
- Clinical Trials Center, Cardiovascular Research Foundation, New York.,Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey.,Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - M Ozgu Ozan
- Clinical Trials Center, Cardiovascular Research Foundation, New York
| | - Akiko Maehara
- Clinical Trials Center, Cardiovascular Research Foundation, New York.,Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York.,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York
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38
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Egred M, Bagnall A, Spyridopoulos I, Purcell IF, Das R, Palmer N, Grech ED, Jain A, Stone GW, Nijveldt R, McAndrew T, Zaman A. Effect of Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) on infarct size in anterior STEMI: PiCSO in ACS study. IJC HEART & VASCULATURE 2020; 28:100526. [PMID: 32435689 PMCID: PMC7229496 DOI: 10.1016/j.ijcha.2020.100526] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this clinical research was to investigate the effects of Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) on infarct size at 5 days after primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI). METHODS AND RESULTS This comparative study was carried out in four UK hospitals. Forty-five patients with anterior STEMI presenting within 12 h of symptom onset received pPCI plus PiCSO (initiated after reperfusion; n = 45) and were compared with a propensity score-matched control cohort from INFUSE-AMI (n = 80). Infarct size (% of LV mass, median [interquartile range]) measured by cardiac magnetic resonance (CMR) at day 5 was significantly lower in the PiCSO group (14.3% [95% CI 9.2-19.4%] vs. 21.2% [95% CI 18.0-24.4%]; p = 0.023). There were no major adverse cardiac events (MACE) related to the PiCSO intervention. CONCLUSIONS PiCSO, as an adjunct to pPCI, was associated with a lower infarct size at 5 days after anterior STEMI in a propensity score-matched population.
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Key Words
- ACS, acute coronary syndrome
- AMI, acute myocardial infarction
- BARC, Bleeding Academic Research Consortium
- CI, Confidence interval
- CMR, Cardiac magnetic resonance
- CRT, Cardiac Resynchronization Therapy
- IMR, Index of microcirculatory resistance
- Infarct size reduction
- LAD, left anterior descending artery
- LV, Left ventricle
- MACE, Major adverse cardiac events
- PiCSO, Pressure-controlled intermittent coronary sinus occlusion
- Pressure-controlled intermittent coronary sinus occlusion (PICSO)
- SD, Standard deviation
- ST-segment elevation myocardial infarction (STEMI)
- STEMI, ST-segment elevation myocardial infarction
- TIMI, Thrombosis in myocardial infarction
- pPCI, Primary percutaneous coronary intervention
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Affiliation(s)
| | | | | | | | - Rajiv Das
- Freeman Hospital, Newcastle upon Tyne, UK
| | - Nick Palmer
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | - Ajay Jain
- St. Bartholomew’s Hospital, London, UK
| | | | - Robin Nijveldt
- Radboud University Medical Center, Nijmegen, Netherlands
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39
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Effects of Protective Controlled Coronary Reperfusion on Left Ventricular Remodeling in Dogs With Acute Myocardial Infarction: A Pilot Study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1579-1584. [PMID: 32417208 DOI: 10.1016/j.carrev.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/26/2020] [Accepted: 05/04/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Coronary artery obstruction causes ischemia of cardiac tissue, leading to acute myocardial infarction (AMI). The treatment of choice for reducing acute myocardial ischemic injury is early, effective vascular reperfusion using thrombolytic therapy or primary percutaneous coronary intervention. However, reperfusion can cause cardiomyocyte injury. Currently, there is no effective therapy to prevent cardiac reperfusion-related tissue damage. This study evaluated whether Protective Controlled Coronary Reperfusion (PCCR), selectively delivered to ischemic tissue, is associated with decreased myocardial scarring, contractile deterioration and reperfusion-associated myocardial edema. METHODS Three hours of cardiac ischemia was induced in 10 mongrel dogs, and followed by either 30-minute PCCR or sham treatment. Cardiac performance was evaluated 2, 4 and 6 months later. Trichrome staining was used to distinguish collagen from viable myocardial tissue and to evaluate mean scar area. RESULTS One hour following reperfusion, PCCR significantly attenuated the relative increase (edema) in left ventricular end diastolic posterior wall thickness compared with sham treatment. At 6 months follow-up, the PCCR group showed a modest corrected increase in left ventricular ejection fraction (c∆LVEF) in comparison to the sham group where it deteriorated (2.3 ± 10.5% vs. -16.4 ± 10.3%, respectively, p = 0.043). Histomorphometric assessments of the hearts showed the PCCR group had smaller area of scarring, as compared to sham-treated animals (9.0 ± 2.4% vs. 14.0 ± 3.3%, p = 0.047). CONCLUSIONS In this pilot study, PCCR reduced myocardial edema, modestly increased in c∆LVEF and resulted in a smaller scar area. Further studies are needed to fully ascertain the mechanisms that underlie the potential benefits of PCCR therapy prior to initiating clinical trials in human subjects with AMI.
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40
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Hofmann R, Witt N, Lagerqvist B, Jernberg T, Lindahl B, Erlinge D, Herlitz J, Alfredsson J, Linder R, Omerovic E, Angerås O, Venetsanos D, Kellerth T, Sparv D, Lauermann J, Barmano N, Verouhis D, Östlund O, Svensson L, James SK. Oxygen therapy in ST-elevation myocardial infarction. Eur Heart J 2019; 39:2730-2739. [PMID: 29912429 DOI: 10.1093/eurheartj/ehy326] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/21/2018] [Indexed: 01/05/2023] Open
Abstract
Aims To determine whether supplemental oxygen in patients with ST-elevation myocardial infarction (STEMI) impacts on procedure-related and clinical outcomes. Methods and results The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial randomized patients with suspected myocardial infarction (MI) to receive oxygen at 6 L/min for 6-12 h or ambient air. In this pre-specified analysis, we included only STEMI patients who underwent percutaneous coronary intervention (PCI). In total, 2807 patients were included, 1361 assigned to receive oxygen, and 1446 assigned to ambient air. The pre-specified primary composite endpoint of all-cause death, rehospitalization with MI, cardiogenic shock, or stent thrombosis at 1 year occurred in 6.3% (86 of 1361) of patients allocated to oxygen compared to 7.5% (108 of 1446) allocated to ambient air [hazard ratio (HR) 0.85, 95% confidence interval (95% CI) 0.64-1.13; P = 0.27]. There was no difference in the rate of death from any cause (HR 0.86, 95% CI 0.61-1.22; P = 0.41), rate of rehospitalization for MI (HR 0.92, 95% CI 0.57-1.48; P = 0.73), rehospitalization for cardiogenic shock (HR 1.05, 95% CI 0.21-5.22; P = 0.95), or stent thrombosis (HR 1.27, 95% CI 0.46-3.51; P = 0.64). The primary composite endpoint was consistent across all subgroups, as well as at different time points, such as during hospital stay, at 30 days and the total duration of follow-up up to 1356 days. Conclusions Routine use of supplemental oxygen in normoxemic patients with STEMI undergoing primary PCI did not significantly affect 1-year all-cause death, rehospitalization with MI, cardiogenic shock, or stent thrombosis.
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Affiliation(s)
- Robin Hofmann
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Sjukhusbacken 10, Stockholm, Sweden
| | - Nils Witt
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Sjukhusbacken 10, Stockholm, Sweden
| | - Bo Lagerqvist
- Cardiology, Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, Entrance 40, floor 5, Uppsala, Sweden
| | - Tomas Jernberg
- Cardiology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Mörbygårdsvägen 5, Stockholm, Sweden
| | - Bertil Lindahl
- Cardiology, Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, Entrance 40, floor 5, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Johan Herlitz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Health Sciences, University of Borås, Borås, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Rikard Linder
- Cardiology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Mörbygårdsvägen 5, Stockholm, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dimitrios Venetsanos
- Department of Medical and Health Sciences, Linköping University, Sandbäcksgatan 7, Linköping, Sweden.,Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Örebro University Hospital, Örebro, Sweden
| | - David Sparv
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Jörg Lauermann
- Division of Cardiology, Department of Internal Medicine, Ryhov Hospital, Sjukhusgatan, Jönköping, Sweden
| | - Neshro Barmano
- Division of Cardiology, Department of Internal Medicine, Ryhov Hospital, Sjukhusgatan, Jönköping, Sweden
| | - Dinos Verouhis
- Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Ollie Östlund
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, Uppsala, Sweden
| | - Leif Svensson
- Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Centre for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Jägargatan 20, Stockholm, Sweden
| | - Stefan K James
- Cardiology, Department of Medical Sciences, Uppsala University, Akademiska sjukhuset, Entrance 40, floor 5, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, Uppsala, Sweden
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41
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Spears JR. Reperfusion Microvascular Ischemia After Prolonged Coronary Occlusion: Implications And Treatment With Local Supersaturated Oxygen Delivery. HYPOXIA 2019; 7:65-79. [PMID: 31696129 PMCID: PMC6814765 DOI: 10.2147/hp.s217955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/20/2019] [Indexed: 12/16/2022]
Abstract
Following a prolonged coronary arterial occlusion, heterogeneously scattered, focal regions of low erythrocyte flow are commonly found throughout the reperfused myocardium. Experimental studies have also demonstrated the presence of widespread, focally patchy regions of microvascular ischemia during reperfusion (RMI). However, the potential contribution of RMI to tissue viability and function has received little attention in the absence of practical clinical methods for its detection. In this review, the anatomic/functional basis of RMI is summarized, along with the evidence for its presence in reperfused myocardium. Advances in microcirculation research related to obstructive responses of vascular endothelial cells and blood elements to the effects of hypoxia and low shear stress are discussed, and a potential cycle of intensification of RMI from such responses and progressive loss of functional capillary density is presented. In capillaries with impaired erythrocyte flow, compensatory increases in the delivery of oxygen, because of its low solubility in plasma, are effective only at high partial pressures. As discussed herein, attenuation of the cycle with oxygen at hyperbaric levels in plasma is, very likely, responsible for improved tissue level perfusion noted experimentally. Observed clinical benefits from intracoronary SuperSaturated oxygen (SSO2) delivery, including infarct size reduction, can be attributed to attenuation of RMI with improvement in microvascular blood flow.
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Affiliation(s)
- James Richard Spears
- Cardiovascular Research Laboratory, Department of Medicine, Division of Cardiology, Beaumont Heart & Vascular Center, Dearborn, MI 48124, USA
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42
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Advancing Procedural Success in Cardiogenic Shock Among Elderly Patients: How Can We Improve? JACC Cardiovasc Interv 2019; 12:1860-1862. [PMID: 31537287 DOI: 10.1016/j.jcin.2019.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/07/2019] [Accepted: 06/11/2019] [Indexed: 11/22/2022]
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43
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Blankenship JC. A hot lead on reducing infarct size. Catheter Cardiovasc Interv 2019; 93:891-892. [PMID: 30953409 DOI: 10.1002/ccd.28202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/14/2019] [Indexed: 11/06/2022]
Abstract
The intracoronary hyperoxemic oxygen therapy study, designed to demonstrate the safety of supersaturated oxygen (SSO2 ) infused into the left main coronary after percutaneous coronary intervention for anterior ST-elevation myocardial infarction (STEMI), demonstrated a net adverse clinical event rate of 7.1%, lower than the Food and Drug Administration-set goal of 10.7%. SSO2 , which has reduced infarct size in clinical STEMI trials, might become an important strategy for treating anterior STEMIs. Larger postmarketing trials are needed to determine whether decreases in infarct size are observed in real-world populations, whether they translate into improved clinical outcomes, and whether modifications in technique can streamline the administration of SSO2 therapy.
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Affiliation(s)
- James C Blankenship
- Department of Cardiology 27-75, Geisinger Medical Center, Danville, Pennsylvania
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44
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Khoshnood A. High time to omit oxygen therapy in ST elevation myocardial infarction. BMC Emerg Med 2018; 18:35. [PMID: 30342466 PMCID: PMC6196022 DOI: 10.1186/s12873-018-0187-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/11/2018] [Indexed: 12/23/2022] Open
Abstract
Supplemental oxygen (O2) therapy in patients with chest pain has been a cornerstone in the treatment of suspected myocardial infarction (MI). Recent randomized controlled trials have, however, shown that supplemental O2 therapy has no positive nor negative effects on cardiovascular functions, mortality, morbidity or pain in normoxic patients with suspected MI and foremost patients with ST Elevation Myocardial Infarction (STEMI). O2 therapy in normoxic STEMI patients should therefore be omitted. More studies are needed in discussing hemodynamically unstable STEMI patients, as well as patients with non-STEMI, unstable angina and other emergency conditions.
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Affiliation(s)
- Ardavan Khoshnood
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Emergency and Internal Medicine, Skåne University Hospital Lund, Lund, Sweden.
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45
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David SW, Khan ZA, Patel NC, Metzger DC, Wood FO, Wasserman HS, Lotfi AS, Hanson ID, Dixon SR, LaLonde TA, Généreux P, Ozan MO, Maehara A, Stone GW. Evaluation of intracoronary hyperoxemic oxygen therapy in acute anterior myocardial infarction: The IC‐HOT study. Catheter Cardiovasc Interv 2018; 93:882-890. [DOI: 10.1002/ccd.27905] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/20/2018] [Accepted: 08/29/2018] [Indexed: 01/30/2023]
Affiliation(s)
| | - Zubair A. Khan
- Providence‐Providence Park Hospital Southfield Michigan
- North Alabama Medical Center Florence Alabama
| | | | | | | | | | | | | | | | | | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center Morristown New Jersey
- Hôpital du Sacré‐Coeur de Montréal Montréal Québec Canada
- Cardiovascular Research Foundation New York New York
| | | | - Akiko Maehara
- Cardiovascular Research Foundation New York New York
- Columbia University Medical Center New York New York
| | - Gregg W. Stone
- Cardiovascular Research Foundation New York New York
- Columbia University Medical Center New York New York
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46
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Reperfusing the myocardium - a damocles Sword. Indian Heart J 2018; 70:433-438. [PMID: 29961464 PMCID: PMC6034085 DOI: 10.1016/j.ihj.2017.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 10/03/2017] [Accepted: 11/07/2017] [Indexed: 12/11/2022] Open
Abstract
Return of blood flow after periodic ischemia is often accompanied by myocardial injury, commonly known as lethal reperfusion injury (RI). Experimental studies have shown that 50% of muscle die of ischemia and another 50% die because of reperfusion. It is characterized by myocardial, vascular, or electrophysiological dysfunction that is induced by the restoration of blood flow to previously ischemic tissue. This phenomenon reduces the efficiency of the present modalities used to combat the ischemic myocardium. Moreover, despite an improved understanding of the pathophysiology of this process and encouraging preclinical trials of multiple agents, most of the clinical trials to prevent RI have been disappointing and leaves us at ground zero to explore newer approaches.
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47
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Kosmidou I, Redfors B, Selker HP, Thiele H, Patel MR, Udelson JE, Magnus Ohman E, Eitel I, Granger CB, Maehara A, Kirtane A, Généreux P, Jenkins PL, Ben-Yehuda O, Mintz GS, Stone GW. Infarct size, left ventricular function, and prognosis in women compared to men after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: results from an individual patient-level pooled analysis of 10 randomized trials. Eur Heart J 2018; 38:1656-1663. [PMID: 28407050 DOI: 10.1093/eurheartj/ehx159] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/13/2017] [Indexed: 11/14/2022] Open
Abstract
Aim Studies have reported less favourable outcomes in women compared with men after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI). Whether sex-specific differences in the magnitude or prognostic impact of infarct size or post-infarction cardiac function explain this finding is unknown. Methods and results We pooled patient-level data from 10 randomized primary PCI trials in which infarct size was measured within 1 month (median 4 days) by either cardiac magnetic resonance imaging or technetium-99m sestamibi single-photon emission computed tomography. We assessed the association between sex, infarct size, and left ventricular ejection fraction (LVEF) and the composite rate of death or heart failure (HF) hospitalization within 1 year. Of 2632 patients with STEMI undergoing primary PCI, 587 (22.3%) were women. Women were older than men and had a longer delay between symptom onset and reperfusion. Infarct size did not significantly differ between women and men, and women had higher LVEF. Nonetheless, women had a higher 1-year rate of death or HF hospitalization compared to men, and while infarct size was a strong independent predictor of 1-year death or HF hospitalization (P < 0.0001), no interaction was present between sex and infarct size or LVEF on the risk of death or HF hospitalization. Conclusions In this large-scale, individual patient-level pooled analysis of patients with STEMI undergoing primary PCI, women had a higher 1-year rate of death or HF hospitalization compared to men, a finding not explained by sex-specific differences in the magnitude or prognostic impact of infarct size or by differences in post-infarction cardiac function.
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Affiliation(s)
- Ioanna Kosmidou
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA.,Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Björn Redfors
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA
| | - Harry P Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Holger Thiele
- University Heart Center and the German Center for Cardiovascular Research, Lübeck, Germany
| | | | - James E Udelson
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | | | - Ingo Eitel
- University Heart Center and the German Center for Cardiovascular Research, Lübeck, Germany
| | | | - Akiko Maehara
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA.,Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Ajay Kirtane
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA.,Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Philippe Généreux
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA.,Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA.,Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.,Morristown Medical Center, Morristown, NJ, USA
| | | | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA.,Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Gary S Mintz
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA
| | - Gregg W Stone
- Cardiovascular Research Foundation, 1700 Broadway, 9th Floor, New York, NY 10019, USA.,Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
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48
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Heusch G, Gersh BJ. The pathophysiology of acute myocardial infarction and strategies of protection beyond reperfusion: a continual challenge. Eur Heart J 2018; 38:774-784. [PMID: 27354052 DOI: 10.1093/eurheartj/ehw224] [Citation(s) in RCA: 273] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/12/2016] [Indexed: 12/15/2022] Open
Abstract
The incidence of ST segment elevation myocardial infarction (STEMI) has decreased over the last two decades in developed countries, but mortality from STEMI despite widespread access to reperfusion therapy is still substantial as is the development of heart failure, particularly among an expanding older population. In developing countries, the incidence of STEMI is increasing and interventional reperfusion is often not available. We here review the pathophysiology of acute myocardial infarction and reperfusion, notably the temporal and spatial evolution of ischaemic and reperfusion injury, the different modes of cell death, and the resulting coronary microvascular dysfunction. We then go on to briefly characterize the cardioprotective phenomena of ischaemic preconditioning, ischaemic postconditioning, and remote ischaemic conditioning and their underlying signal transduction pathways. We discuss in detail the attempts to translate conditioning strategies and drug therapy into the clinical setting. Most attempts have failed so far to reduce infarct size and improve clinical outcomes in STEMI patients, and we discuss potential reasons for such failure. Currently, it appears that remote ischaemic conditioning and a few drugs (atrial natriuretic peptide, exenatide, metoprolol, and esmolol) reduce infarct size, but studies with clinical outcome as primary endpoint are still underway.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Hufelandstr. 55, 45122 Essen, Germany
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN, USA
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49
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Shohoudi A, Stephens DA, Khairy P. Bayesian adaptive trials for rare cardiovascular conditions. Future Cardiol 2018; 14:143-150. [PMID: 29405070 DOI: 10.2217/fca-2017-0040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Escalating costs of cardiovascular trials are limiting medical innovations, prompting the development of more efficient and flexible study designs. The Bayesian paradigm offers a framework conducive to adaptive trial methodologies and is well suited for the study of small populations. Bayesian adaptive trials provide a statistical structure for combining prior information with accumulating data to compute probabilities of unknown quantities of interest. Adaptive design features are useful in modifying randomization schemes, adjusting sample sizes and providing continuous surveillance to guide decisions on dropping study arms or premature trial interruption. Advantages include greater efficiency, minimization of risks, inclusion of knowledge as it is generated, cost savings and more intuitive interpretability. Extensive high-level computations are facilitated by an expanding armamentarium of available tools.
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Affiliation(s)
- Azadeh Shohoudi
- Montreal Health Innovations Coordinating Center (MHICC), Montreal, Canada
| | - David A Stephens
- Department of Mathematics & Statistics, McGill University, Montreal, Canada
| | - Paul Khairy
- Montreal Health Innovations Coordinating Center (MHICC), Montreal, Canada.,Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
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50
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An Injectable Oxygen Release System to Augment Cell Survival and Promote Cardiac Repair Following Myocardial Infarction. Sci Rep 2018; 8:1371. [PMID: 29358595 PMCID: PMC5778078 DOI: 10.1038/s41598-018-19906-w] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/10/2018] [Indexed: 01/15/2023] Open
Abstract
Oxygen deficiency after myocardial infarction (MI) leads to massive cardiac cell death. Protection of cardiac cells and promotion of cardiac repair are key therapeutic goals. These goals may be achieved by re-introducing oxygen into the infarcted area. Yet current systemic oxygen delivery approaches cannot efficiently diffuse oxygen into the infarcted area that has extremely low blood flow. In this work, we developed a new oxygen delivery system that can be delivered specifically to the infarcted tissue, and continuously release oxygen to protect the cardiac cells. The system was based on a thermosensitive, injectable and fast gelation hydrogel, and oxygen releasing microspheres. The fast gelation hydrogel was used to increase microsphere retention in the heart tissue. The system was able to continuously release oxygen for 4 weeks. The released oxygen significantly increased survival of cardiac cells under the hypoxic condition (1% O2) mimicking that of the infarcted hearts. It also reduced myofibroblast formation under hypoxic condition (1% O2). After implanting into infarcted hearts for 4 weeks, the released oxygen significantly augmented cell survival, decreased macrophage density, reduced collagen deposition and myofibroblast density, and stimulated tissue angiogenesis, leading to a significant increase in cardiac function.
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