One-Year Outcomes After Low-Dose Intracoronary Alteplase During Primary Percutaneous Coronary Intervention: The T-TIME Randomized Trial

Intracoronary antithrombotic therapy during primary percutaneous coronary intervention in patients with STEMI: A systematic review and network meta-analysis

INTRODUCTION

The efficacy of intracoronary (IC) antithrombotic therapy, which may best prevent the no-reflow phenomenon during percutaneous coronary intervention (PCI), remains unclear. Therefore, we compared the efficacy and safety of different IC antithrombotic agents.

MATERIALS AND METHODS

This systematic review and network meta-analysis of randomized controlled trials (RCTs) compared IC fibrinolytic agents (recombinant tissue plasminogen activators [rtPAs] and non-rtPAs) or glycoprotein IIb/IIIa inhibitors (small molecules and monoclonal antibodies) with placebo by searching the relevant studies published before September 21, 2022. Bayesian network meta-analyses were performed using random-effects models.

RESULTS

Twenty-five RCTs with 4546 patients were included. Non-rtPAs and small molecules were significantly more effective in achieving thrombolysis in myocardial infarction (TIMI) grade 3 flow than placebo (odds ratio [OR] 2.28, 95 % credible intervals [CrI] 1.24-4.13; OR 2.06, 95 % CrI 1.17-3.46). Moreover, these agents' efficacy was observed in other microcirculation-related outcomes, including TIMI myocardial perfusion grade 3, complete ST-segment resolution, and corrected TIMI frame counts. Within 6 months, small molecules were associated with both an improved left ventricular ejection fraction (MD 3.90, 95 % CrI 0.48-7.46) and major adverse cardiac events (MACE) reduction (OR 0.36, 95 % CrI 0.20-0.61). Non-rtPAs demonstrated a reduced MACE incidence within 6 months (OR 0.51, 95 % CrI 0.31-0.81). The results were consistent in the subgroup with a total ischemic time > 6 h. No significant differences in mortality or bleeding events were observed.

CONCLUSIONS

IC non-rtPAs and small molecules may be effective for adjunctive therapy to PCI, particularly in patients with longer ischemia periods.

Demographic, multi-morbidity and genetic impact on myocardial involvement and its recovery from COVID-19: protocol design of COVID-HEART-a UK, multicentre, observational study

BACKGROUND

Although coronavirus disease 2019 (COVID-19) is primarily a respiratory illness, myocardial injury is increasingly reported and associated with adverse outcomes. However, the pathophysiology, extent of myocardial injury and clinical significance remains unclear.

METHODS

COVID-HEART is a UK, multicentre, prospective, observational, longitudinal cohort study of patients with confirmed COVID-19 and elevated troponin (sex-specific > 99th centile). Baseline assessment will be whilst recovering in-hospital or recently discharged, and include cardiovascular magnetic resonance (CMR) imaging, quality of life (QoL) assessments, electrocardiogram (ECG), serum biomarkers and genetics. Assessment at 6-months includes repeat CMR, QoL assessments and 6-min walk test (6MWT). The CMR protocol includes cine imaging, T1/T2 mapping, aortic distensibility, late gadolinium enhancement (LGE), and adenosine stress myocardial perfusion imaging in selected patients. The main objectives of the study are to: (1) characterise the extent and nature of myocardial involvement in COVID-19 patients with an elevated troponin, (2) assess how cardiac involvement and clinical outcome associate with recognised risk factors for mortality (age, sex, ethnicity and comorbidities) and genetic factors, (3) evaluate if differences in myocardial recovery at 6 months are dependent on demographics, genetics and comorbidities, (4) understand the impact of recovery status at 6 months on patient-reported QoL and functional capacity.

DISCUSSION

COVID-HEART will provide detailed characterisation of cardiac involvement, and its repair and recovery in relation to comorbidity, genetics, patient-reported QoL measures and functional capacity.

CLINICAL TRIAL REGISTRATION

ISRCTN 58667920. Registered 04 August 2020.

Adjunctive Intracoronary Fibrinolytic Therapy During Primary Percutaneous Coronary Intervention

Despite routinely restoring epicardial coronary patency, with primary percutaneous coronary intervention (PCI), microvascular obstruction affects approximately half of patients and confers an adverse prognosis. There are no evidence-based treatments for microvascular obstruction. A key contributor to microvascular obstruction is distal embolisation and microvascular thrombi. Adjunctive intracoronary fibrinolytic therapy may reduce thrombotic burden, potentially reducing distal embolisation of atherothrombotic debris to the microcirculation. In this review, the evidence from published randomised trials on the effects of adjunctive intracoronary fibrinolytic therapy during primary PCI is critically appraised, the ongoing randomised trials are described, and conclusions are made from the available evidence. Clinical uncertainties, to be addressed by future research, are highlighted.

Effect of coronary flow on intracoronary alteplase: a prespecified analysis from a randomised trial

OBJECTIVES

Persistently impaired culprit artery flow (

METHODS

In T-TIME (trial of low-dose adjunctive alTeplase during primary PCI), patients ≤6 hours from onset of ST-elevation myocardial infarction (STEMI) were randomised to placebo, alteplase 10 mg or alteplase 20 mg, administered by infusion into the culprit artery, pre-stenting. In this prespecified, secondary analysis, coronary flow was assessed angiographically at the point immediately before drug administration. Microvascular obstruction, myocardial haemorrhage and infarct size were assessed by cardiovascular magnetic resonance (CMR) at 2-7 days and 3 months.

RESULTS

TIMI flow was assessed after first treatment (balloon angioplasty/aspiration thrombectomy), immediately pre-drug administration, in 421 participants (mean age 61±10 years, 85% male) and was 3, 2 or 1 in 267, 134 and 19 participants respectively. In patients with TIMI flow ≤2 pre-drug, there was higher incidence of microvascular obstruction with alteplase (alteplase 20 mg (53.1%) and 10 mg (59.5%) combined versus placebo (34.1%); OR=2.47 (95% CI 1.16 to 5.22, p=0.018) interaction p=0.005) and higher incidence of myocardial haemorrhage (alteplase 20 mg (53.1%) and 10 mg (57.9%) combined vs placebo (27.5%); OR=3.26 (95% CI 1.44 to 7.36, p=0.004) interaction p=0.001). These effects were not observed in participants with TIMI 3 flow pre-drug. There were no interactions between TIMI flow pre-drug, alteplase and 3-month CMR findings.

CONCLUSION

In patients with impaired culprit artery flow (

TRIAL REGISTRATION NUMBER

NCT02257294.

Collapse

Key Words

• acute myocardial infarction

Collapse

MESH Headings Collapse

Grants

• FS/16/74/32573 British Heart Foundation
• MC_PC_12037 Medical Research Council
• MC_PC_15113 Medical Research Council

Collapse

Affiliation(s)

Annette Marie Maznyczka Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Peter McCartney Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
Patrycja Duklas Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
Margaret McEntegart Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
Keith G Oldroyd Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
John P Greenwood Department of Cardiology, Leeds General Infirmary, Leeds, UK Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
Douglas Muir James Cook University Hospital, Middlesbrough, UK
Saqib Chowdhary Manchester University NHS Foundation Trust, Manchester, UK
Anthony H Gershlick Division of Cardiology, University of Leicester, Leicester, UK
Clare Appleby Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
Hany Eteiba Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
James Cotton Department of Cardiology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
Andrew Wragg Barts and The London Hospital, London, UK
Nick Curzen Wessex Cardiac Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
R Campbell Tait Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
Peter MacFarlane Electrocardiology Group, Royal Infirmary, Glasgow, UK
Paul Welsh British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Naveed Sattar British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Mark C Petrie British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
Ian Ford Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
Keith A A Fox Department of Cardiology, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
Alex McConnachie Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
Colin Berry Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

Collapse