Normal flow (TIMI-3) before mechanical reperfusion therapy is an independent determinant of survival in acute myocardial infarction: analysis from the primary angioplasty in myocardial infarction trials

Artificial Intelligence Driven Prehospital ECG Interpretation for the Reduction of False Positive Emergent Cardiac Catheterization Lab Activations: A Retrospective Cohort Study

OBJECTIVES

Data suggest patients suffering acute coronary occlusion myocardial infarction (OMI) benefit from prompt primary percutaneous intervention (PPCI). Many emergency medical services (EMS) activate catheterization labs to reduce time to PPCI, but suffer a high burden of inappropriate activations. Artificial intelligence (AI) algorithms show promise to improve electrocardiogram (ECG) interpretation. The primary objective was to evaluate the potential of AI to reduce false positive activations without missing OMI.

METHODS

Electrocardiograms were categorized by (1) STEMI criteria, (2) ECG integrated device software and (3) a proprietary AI algorithm (Queen of Hearts (QOH), Powerful Medical). If multiple ECGs were obtained and any one tracing was positive for a given method, that diagnostic method was considered positive. The primary outcome was OMI defined as an angiographic culprit lesion with either TIMI 0-2 flow; or TIMI 3 flow with either peak high sensitivity troponin-I > 5000 ng/L or new wall motion abnormality. The primary analysis was per-patient proportion of false positives.

RESULTS

A total of 140 patients were screened and 117 met criteria. Of these, 48 met the primary outcome criteria of OMI. There were 80 positives by STEMI criteria, 88 by device algorithm, and 77 by AI software. All approaches reduced false positives, 27% for STEMI, 22% for device software, and 34% for AI (p < 0.01 for all). The reduction in false positives did not significantly differ between STEMI criteria and AI software (p = 0.19) but STEMI criteria missed 6 (5%) OMIs, while AI missed none (p = 0.01).

CONCLUSIONS

In this single-center retrospective study, an AI-driven algorithm reduced false positive diagnoses of OMI compared to EMS clinician gestalt. Compared to AI (which missed no OMI), STEMI criteria also reduced false positives but missed 6 true OMI. External validation of these findings in prospective cohorts is indicated.

Investigating the Correlation between Serum Amyloid A and Infarct-Related Artery Patency Prior to Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients

Serum amyloid A (SAA) is a cardiovascular risk factor and may serve as a predictor of infarct-related artery (IRA) patency in patients with ST-segment elevation myocardial infarction (STEMI). We measured SAA levels in STEMI patients who underwent percutaneous coronary intervention (PCI) and investigated their association with IRA patency. According to the Thrombolysis in Myocardial Infarction (TIMI) flow grade, 363 STEMI patients undergoing PCI in our hospital were divided into an occlusion group (TIMI 0-2) and a patency group (TIMI 3). The SAA level before PCI was significantly higher in STEMI patients with IRA occluded than in those with patent ones. At a cutoff value of 36.9 mg/L, SAA had a sensitivity of 63.0% and a specificity of 90.6% (area under the ROC curve [AUC] = .833, 95% CI: .793-.873, P < .001). Multivariate logistic regression analysis showed that SAA was an independent predictor of IRA patency in STEMI patients before PCI (odds ratio [OR] = 1.041, 95% CI: 1.020-1.062, P < .001). SAA can be used as a potential predictor of IRA patency in STEMI patients before PCI.

Aortic Arch Calcification in Predicting Unfavorable Angiographic Outcomes for Patients with ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

BACKGROUND

Despite advances in treatment, no-reflow, large thrombus burden (LTB), and myocardial blush grade (MBG) are associated with adverse cardiovascular outcomes in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). Aortic arch calcification (AAC) is associated with subclinical atherosclerosis and adverse cardiovascular events. We aimed to examine the relationship between AAC and unfavorable angiographic outcomes such as no-reflow, MBG, and LTB in STEMI patients undergoing PCI.

METHODS

A total of 269 consecutive patients who presented with STEMI and underwent primary PCI were included in the study prospectively. Patients were divided into 3 groups according to AAC degree: grade 0, grade 1, and grade 2/3. The relationship between AAC and the predictors of unfavorable angiographic outcomes, including LTB, no-reflow, and MBG, was specifically examined.

RESULTS

LTB, no-reflow, and MBG 0/1 were significantly higher in the grade 2/3 AAC group compared to the grade 0 and grade 1 groups (all p < 0.05). Moreover, grade 2/3 AAC was found to be an independent predictor for LTB, MBG 0/1, and no-reflow (p = 0.002, p = 0.005, p = 0.004, respectively). Patients were then classified according to thrombus burden, MBG, and no-reflow status. Grade 2/3 AAC was significantly higher than grade 0/1 AAC in the LTB, MBG 0/1, and no-reflow groups (all p < 0.05).

CONCLUSION

AAC can be used as a reliable indicator in predicting no-reflow, MBG 0/1, and LTB in STEMI patients undergoing primary PCI.

Single Bolus r-SAK Before Primary PCI for ST-Segment-Elevation Myocardial Infarction

BACKGROUND

It is uncertain whether adjunctive thrombolysis is beneficial for patients with ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) within 120 minutes of presentation. This study was to determine whether in patients presenting with ST-segment-elevation myocardial infarction a single bolus recombinant staphylokinase (r-SAK) before timely PCI leads to improved patency of the infarct-related artery and reduces the infarct size.

METHODS

This is an open-label, prospective, multicenter, randomized study. We enrolled patients aged 18 to 75 years who were within 12 hours of symptom onset of ST-segment-elevation myocardial infarction and expected to undergo PCI within 120 minutes. Patients were administered loading doses of aspirin and ticagrelor and intravenous heparin and were randomized to receive 5 mg bolus of r-SAK or normal saline intravenously before PCI. The primary end point was Thrombolysis in Myocardial Infarction flow grade 2 to 3 or grade 3 in the infarct-related artery 60 minutes after thrombolysis. The infarct size was detected by cardiac magnetic resonance 5 days after randomization. The safety end point was major bleeding (Bleeding Academic Research Consortium ≥3) during 30-day follow-up.

RESULTS

A total of 283 patients were screened from 8 centers and 200 were randomized (median age, 58.5 years; 14% female). The median symptom to thrombolysis time was 252.5 (interquartile range, 142.8-423.8) minutes and thrombolysis to coronary arteriography was 50.0 (interquartile range, 37.0-66.0) minutes. Patients randomized to r-SAK compared with normal saline more often had Thrombolysis in Myocardial Infarction flow grade 2 to 3 (69.0% versus 29.0%; P<0.001) and Thrombolysis in Myocardial Infarction flow grade 3 (51.0% versus 18.0%; P<0.001) and had smaller infarct size (21.91±10.84% versus 26.85±12.37%; P=0.016). There was no increase in major bleeding (r-SAK, 1.0% versus control, 3.0%; P=0.616).

CONCLUSIONS

A single bolus r-SAK before primary PCI for ST-segment-elevation myocardial infarction improves infarct-related artery patency and reduces infarct size without increasing major bleeding.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05023681.

Impact of HAT2CH2 Score on the Development of No-Reflow Phenomenon in Patients With ST-Segment Elevation Myocardial Infarction

The HAT2CH2 score [Hypertension (1 point), Age > 75 years (1 point), Stroke/Transient ischemic attack (2 points), Chronic obstructive pulmonary disease (1 point), and Heart failure (2 points)] was originally developed to predict the occurrence of new-onset atrial fibrillation. The aim of the present study was to examine whether this score could predict the development of no-reflow phenomenon (NR) in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Patients (n = 1552) with STEMI were consecutively enrolled in this single-center retrospective study. The SYNTAX score (SXscore) and HAT2CH2 score were calculated. The presence of thrombolysis in myocardial infarction (TIMI) score ≤2, without significant residual stenosis and mechanical obstruction, indicated the presence of NR. The HAT2CH2 score was significantly higher in the NR (+) group compared with the NR (-) group [2.29 ± 1.43 vs 1.46 ± 1.24, p < .001]. In multivariable logistic regression analysis, the HAT2CH2 score [OR = 1.585, p < .001] and SXscore [OR = 1.028, p = .017] were found to be independent predictors of NR. Receiver operating characteristic curve analysis showed that the HAT2CH2 score with a cutoff value of >2 determined NR, with 50.2% sensitivity and 79.4% specificity (AUC = .669, p < .001). In conclusion, the HAT2CH2 score may facilitate risk stratification in estimating NR in STEMI patients undergoing pPCI.

Pretransfer Aspirin Administration and Its Impact on Angiographic Outcomes for Patients with ST-Elevation Myocardial Infarction

Although guidelines recommend early aspirin administration after diagnosis of ST-elevation myocardial infarction (STEMI), the decision of pretransfer aspirin administration is at the discretion of the primary physicians. Therefore, this study aimed to determine whether pretransfer aspirin administration was associated with better angiographical outcomes in patients with STEMI. This study compared the angiographic findings of thrombolysis in myocardial infarction (TIMI) flow grade in the infarct-related artery before percutaneous coronary intervention (PCI) between patients who received pretransfer aspirin and those who did not. In total, 28 patients (11.2%) were administered aspirin before transfer and 219 (88.8%) were administered aspirin upon arrival at the hospital. Propensity score matching yielded 135 patients [27 patients (20%) who were administered aspirin before transfer and 108 patients (80%) who were administered aspirin upon arrival at the hospital]. Patients who received pretransfer aspirin had a higher rate of TIMI-3 flow before PCI compared to those who did not receive pretransfer aspirin [8 (28.6%) versus 15 (6.8%), P < 0.01, in all study patients; 8 (26.6%) versus 7 (6.5%), P < 0.01, in propensity-score-matched patients]. Multivariable logistic regression analysis revealed that pretransfer aspirin administration was significantly associated with the presence of TIMI-3 flow before PCI, independent of age, gender, transfer time, and statin use (OR: 5.43, 95% CI: 1.94-15.2, P < 0.01, in all study patients; OR: 6.17, 95% CI: 1.86-20.46, P < 0.01, in propensity-score-matched patients). Pretransfer aspirin administration could lead to the early restoration of coronary blood flow in patients with STEMI, supporting its active use in STEMI care.

Efficacy and safety of a bolus of half-dose r-SAK prior to primary PCI in ST-elevation myocardial infarction: Rationale and design of the OPTIMA-6 trial

BACKGROUND

Time to reperfusion is the key to the treatment of patients with ST-elevation myocardial infarction (STEMI). It is uncertain whether adjunctive thrombolytic therapy combined with contemporary antiplatelet agent ticagrelor improves outcomes as administered prior to primary percutaneous coronary intervention (PCI) expected to be performed within 120 minutes.

METHODS

OPTIMA-6 is a multicenter, randomized, double-blind, placebo-controlled, and superiority trial to evaluate the efficacy of a bolus of half-dose recombinant staphylokinase (r-SAK) vs placebo prior to timely primary PCI in patients with STEMI. Enrollment began in April 2023 and is expected to enroll 2,260 patients at approximately 50 centers. Patients with acute STEMI presenting ≤12 hours of symptom onset and expected to undergo primary PCI within 120 minutes but more than 30 minutes are to be randomized to a bolus of half-dose r-SAK or placebo. All recruited patients will be mandatory to take aspirin and ticagrelor and receive a bolus of loading dose heparin before the thrombolytic therapy. The primary efficacy endpoint is major adverse cardiovascular events (MACE) within 90 days, and the MACE is defined as a composite of all-cause death, reinfarction, unplanned target vessel revascularization, heart failure or cardiogenic shock, and major ventricular arrhythmia. The primary safety endpoints are major bleeding events (BARC 3, 5) within 90 days.

CONCLUSIONS

OPTIMA-6 will reveal the efficacy and safety of a contemporary facilitated PCI with a bolus of half-dose r-SAK in combination with ticagrelor in patients with STEMI.

Impact of age on pre-procedural TIMI flow in STEMI patients undergoing primary percutaneous coronary intervention

BACKGROUND

Advanced age is a major determinant of impaired prognosis among patients with ST-segment elevation myocardial infarction (STEMI). However, the mechanisms associated with suboptimal reperfusion and enhanced complications are still largely undefined. The aim of the present study was to assess the impact of age on the angiographic findings and the procedural results of primary percutaneous coronary intervention (pPCI) in patients with STEMI.

METHODS

A consecutive cohort of patients admitted for STEMI treated with pPCI were included. Infarct-related artery (IRA) patency was defined for preprocedural TIMI flow 3.

RESULTS

We included 520 patients, divided according to age tertiles (<61; 61-72; ≥73). Elderly patients were more often females, with hypertension, renal failure, prior myocardial infarction or PCI, with lower rates of smoking history, haemoglobin, leukocytes and cholesterol (P < 0.001), lower ejection fraction (P = 0.02), higher use of renin angiotensin system inhibitors, statins, ASA, calcium antagonists, diuretics and beta blockers. At angiography, for the IRA, percentage of thrombus (P = 0.02) and stenosis (P = 0.01), direct stenting (P = 0.02) and glycoprotein IIb-IIIa inhibitors (P = 0.04) inversely related with age, but for higher restenosis (P = 0.04). IRA patency was more common in patients aged ≥73 years (27.9% vs. 32.3% vs. 41.1%, P = 0.01). The impact of age on preprocedural TIMI flow was confirmed at multivariate analysis [adjusted odds ratio (95% confidence interval) = 0.68 (0.47-0.98), P = 0.04].

CONCLUSION

The present study shows that among STEMI patients undergoing primary PCI, more advanced age represents an independent predictor of preprocedural IRA patency. Future studies will define the implications on procedural results and long-term prognosis.

Prepercutaneous coronary intervention Zalunfiban dose-response relationship to target vessel blood flow at initial angiogram in st-elevation myocardial infarction - A post hoc analysis of the cel-02 phase IIa study

BACKGROUND

Zalunfiban (RUC-4) is a novel, subcutaneously administered glycoprotein IIb/IIIa inhibitor (GPI) designed for prehospital treatment to initiate reperfusion in the infarct-related artery (IRA) before primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction (STEMI). Since GPIs have been reported to rapidly reperfuse IRAs, we assessed whether there was a dose-dependent relationship between zalunfiban treatment and angiographic reperfusion indices and thrombus grade of the IRA at initial angiogram in patients with STEMI.

METHODS

This was a post hoc analysis from the open-label Phase IIa study that investigated the pharmacodynamics, pharmacokinetics, and tolerability of three doses of zalunfiban - 0.075, 0.090 and 0.110 mg/kg - in STEMI patients. This analysis explored dose-dependent associations between zalunfiban and three angiographic indices of the IRA, namely coronary and myocardial blood flow and thrombus burden. Zalunfiban was administered in the cardiac catheterization laboratory prior to vascular access, ∼10 to 15 minutes before the initial angiogram. All angiographic data were analyzed by a blinded, independent, core laboratory.

RESULTS

Twentyfour out of 27 STEMI patients were evaluable for angiographic analysis (0.075 mg/kg [n=7], 0.090 mg/kg [n=9], and 0.110 mg/kg [n=8]). TIMI flow grade 2 or 3 was seen in 1/7 patients receiving zalunfiban at 0.075 mg/kg, in 6/9 patients receiving 0.090 mg/kg, and in 7/8 patients receiving 0.110 mg/kg (ptrend = 0.004). A similar trend was observed based on TIMI flow grade 3. Myocardial perfusion was also related to zalunfiban dose (ptrend = 0.005) as reflected by more frequent TIMI myocardial perfusion grade 3. Consistent with the dose-dependent trends in greater coronary and myocardial perfusion, TIMI thrombus ≥4 grade was inversely related to zalunfiban dose (ptrend = 0.02).

CONCLUSION

This post hoc analysis found that higher doses of zalunfiban administered in the cardiac catheterization lab prior to vascular access were associated with greater coronary and myocardial perfusion, and lower thrombus burden at initial angiogram in patients with STEMI undergoing primary percutaneous coronary intervention.

Three-Year Clinical Outcomes Based on Pre-Percutaneous Coronary Intervention Coronary Blood Flow Grade and Symptom-to-Balloon Time in Patients with Non-ST-Segment Elevation Myocardial Infarction

We compared the 3-year clinical outcomes according to the degree of pre-percutaneous coronary intervention thrombolysis in myocardial infarction flow grade (pre-PCI TIMI) and symptom-to-balloon time (SBT) individuals who underwent successful stent implantation with a diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI). A total of 4910 patients with NSTEMI were divided into two groups: pre-PCI TIMI 0/1 (SBT < 48 h: n = 1328, SBT ≥ 48 h: n = 558) and pre-PCI TIMI 2/3 (SBT < 48 h: n = 1965, SBT ≥ 48 h: n = 1059). The primary outcome was a 3-year all-cause death rate, and the secondary outcome was the composite endpoint of 3-year all-cause death, recurrent MI, or any repeat revascularization rate. After adjustment, in the pre-PCI TIMI 0/1 group, the 3-year all-cause death (p = 0.003), cardiac death (CD, p < 0.001), and secondary outcome (p = 0.030) values were significantly higher in the SBT ≥ 48 h group than in the SBT < 48 h group. However, patients with pre-PCI TIMI 2/3 had similar primary and secondary outcomes, regardless of the SBT group. Within the SBT < 48 h group, the pre-PCI TIMI 2/3 group exhibited significantly higher rates of 3-year all-cause death, CD, recurrent MI, and secondary outcome values than the pre-PCI TIMI 0/1 group. Patients in the SBT ≥ 48 h group with either pre-PCI TIMI 0/1 or TIMI 2/3 had similar primary and secondary outcomes. Our results suggest that shortening the SBT may confer a survival benefit in patients with NSTEMI and those in the pre-PCI TIMI 0/1 group compared to those in the pre-PCI TIMI 2/3 group.

Biomarkers of Thrombotic Status Predict Spontaneous Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction

BACKGROUND

Spontaneous reperfusion, seen in ∼20% of patients with ST-segment elevation myocardial infarction (STEMI), manifests as normal epicardial flow in the infarct-related artery, with or without ST-segment resolution, before percutaneous coronary intervention (PCI). The drivers mediating this are unknown.

OBJECTIVES

The authors sought to relate spontaneous reperfusion to the thrombotic profile.

METHODS

In a prospective study, blood from STEMI patients (n = 801) was tested pre-PCI to assess in vitro, point-of-care, occlusion times (OT) and endogenous lysis times (LT). Spontaneous reperfusion was defined as infarct-related artery Thrombolysis In Myocardial Infarction flow grade 3 before PCI. Patients were followed for major cardiovascular events (death, myocardial infarction, or stroke).

RESULTS

Spontaneous reperfusion was associated with a longer OT (435 seconds vs 366 seconds; P < 0.001) and a shorter LT (1,257 seconds vs 1,616 seconds; P < 0.001), lower troponin, and better left ventricular function. LT was superior to OT for predicting spontaneous reperfusion (area under the curve for LT: 0.707; 95% CI: 0.661-0.753; area under the curve for OT: 0.629; 95% CI: 0.581-0.677). Among patients with spontaneous reperfusion, those with complete, vs partial ST-segment resolution, had a longer OT (P = 0.002) and a shorter LT (P < 0.001). Spontaneous reperfusion was unrelated to clinical characteristics or pain-to-angiography times. Over 4 years, patients with spontaneous reperfusion experienced fewer major adverse cardiovascular events than those without (4.1% vs 10.6%; P = 0.013), especially in those with both spontaneous reperfusion and complete ST-segment resolution (1.5% vs 10.1%; P = 0.029).

CONCLUSIONS

We demonstrate a novel hematological signature in STEMI patients with spontaneous reperfusion, namely, decreased platelet reactivity and faster endogenous fibrinolysis, relating to smaller infarcts and improved survival. This finding indicates a role for modulating thrombotic status early after STEMI onset, to facilitate spontaneous reperfusion and improve outcomes.

Early versus late delayed percutaneous coronary intervention in elderly patients with ST-segment elevation myocardial infarction

BACKGROUND AND OBJECTIVE

There are a substantial proportion of elderly patients with ST-segment elevation myocardial infarction (STEMI) miss the optimal time window (12 h from symptom onset) of primary percutaneous coronary intervention (PCI). For these patients, the ideal timing of delayed PCI remains undetermined. Therefore, this study compared the clinical outcomes of early versus late delayed PCI in elderly patients with STEMI.

METHODS

From January 2014 to September 2019, 512 patients aged ≥ 65 years with STEMI who underwent delayed PCI after 12 h from symptom onset were included and then categorized into the early PCI group (12-48 h, n = 111) and late PCI group (48 h-28 days, n = 401) according to the timing of delayed PCI. Propensity score matching (PSM) was conducted to adjust the confounding factors between groups. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, cardiac death, recurrent myocardial infarction (MI), stroke, and ischemia-driven revascularization.

RESULTS

During a mean follow-up of 77 months, 163 (31.8%) patients developed MACCE and 93 (18.2%) died. Early or late delayed PCI did not make a significant difference in clinical outcomes of MACCE (Before PSM: HR 0.773, 95% CI 0.520-1.149, P = 0.203; After PSM: HR 0.869, 95% CI 0.498-1.517, P = 0.622), all-cause death, cardiac death, recurrent MI, stroke, and ischemia-driven revascularization in both overall patients and the PSM cohorts.

CONCLUSION

Early delayed PCI (12-48 h from symptom onset), for elderly patients with STEMI who present > 12 h after symptom onset is not associated with better long-term clinical outcomes compared with late delayed PCI (48 h-28 days).

Spontaneous Reperfusion in Patients with Transient ST-Elevation Myocardial Infarction-Prevalence, Importance and Approaches to Management

Patients with transient ST-elevation myocardial infarction (STEMI) or spontaneous resolution (SpR) of the ST-segment elevation on electrocardiogram could potentially represent a unique group of patients posing a therapeutic management dilemma. In this review, we discuss the potential mechanisms underlying SpR, its relation to clinical outcomes and the proposed management options for patients with transient STEMI with a focus on immediate versus early percutaneous coronary intervention. We performed a structured literature search of PubMed and Cochrane Library databases from inception to December 2020. Studies focused on SpR in patients with acute coronary syndrome were selected. Available data suggest that deferral of angiography and revascularization within 24-48 h in these patients is reasonable and associated with similar or perhaps better outcomes than immediate angiography. Further randomized trials are needed to elucidate the best pharmacological and invasive strategies for this cohort.

Role of fibrinogen, albumin and fibrinogen to albumin ratio in determining angiographic severity and outcomes in acute coronary syndrome

BACKGROUND

Coronavirus disease 2019 (COVID-19) pandemic unmasked the huge deficit in healthcare resources worldwide. It highlighted the need for efficient risk stratification in management of cardiovascular emergencies.

AIM

To study the applicability of the old, available and affordable nonconventional biomarkers: albumin and fibrinogen in their ability to predict angiographic severity and clinical outcomes in patients with acute coronary syndrome (ACS).

METHODS

In this prospective, observational study, 166 consecutive patients with ACS were enrolled. Fibrinogen, albumin and their ratio were determined from serum. Patients with underlying chronic liver disease, active malignancy, autoimmune disease, active COVID-19 infection and undergoing thrombolysis were excluded.

RESULTS

Mean age of the population was 60.5 ± 1.5 years, 74.1% being males. ST elevation myocardial infarction (STEMI) was most common presentation of ACS seen in 57% patients. Fibrinogen albumin ratio (FAR) ≥ 19.2, had a sensitivity of 76.9% and specificity of 78.9 % [area under the receiver operating characteristic curves (AUROC) = 0.8, P = 0.001] to predict ≤ thrombolysis in myocardial infarction (TIMI) 1 flow in culprit artery in STEMI patients. Even in non-STEMI patients, FAR ≥ 18.85 predicted the same with 80% sensitivity and 63% specificity (AUROC = 0.715, P = 0.006).

CONCLUSION

Novel biomarkers, with their high cost, lack of availability and long turn over time are impractical for real-world use. Identifying ≤ TIMI 1 flow in the culprit artery has significant impact of management and outcome. Our study has shown that readily available biomarkers like fibrinogen and albumin can help identify these high-risk patients with good accuracy. This allows risk-stratification and individualization of treatment in ACS.

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

Background

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

Results

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

Conclusions

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

Pretreatment with heparin in patients with ST-segment elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

BACKGROUND

Unfractionated heparin (UFH) is frequently administered before percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI).

AIMS

The aim of the study was to investigate if pretreatment with UFH prior to arrival at the catheterisation laboratory affects coronary artery occlusion, mortality, and in-hospital major bleeding in patients with STEMI undergoing PCI.

METHODS

Patients with a first STEMI event undergoing PCI between 2008 and 2016 were extracted from the Swedish Coronary Angiography and Angioplasty Registry. Risk ratios for UFH pretreatment versus no pretreatment regarding coronary artery occlusion at presentation in the catheterisation laboratory, 30-day mortality, and bleeding were obtained using adjusted Poisson regression models with robust standard errors. Analyses of propensity score (PS)-matched groups were performed to obtain absolute risk differences.

RESULTS

In all, 41,631 patients were included, 16,026 (38%) with and 25,605 (62%) without UFH pretreatment. Adjusted risk ratios were 0.89 (95% confidence interval [CI]: 0.87 to 0.90) for coronary artery occlusion, 0.87 (0.77 to 0.99) for mortality, and 1.01 (0.86 to 1.18) for bleeding. In the PS-matched analyses, the absolute risk differences were -0.087 (-0.074 to -0.099) for coronary artery occlusion, -0.011 (-0.017 to -0.0041) for mortality, and 0 (-0.0052 to 0.0052) for bleeding.

CONCLUSIONS

Pretreatment with UFH was associated with a reduction in coronary artery occlusion among patients with STEMI, with a number needed to treat (NNT) of 12, without increasing the risk of major in-hospital bleeding. Regarding mortality, a reduction was found with UFH pretreatment, with an NNT of 94, but this effect was not robust over all sensitivity analyses and residual confounding cannot be excluded.

Prognostic significance of thrombus burden on short- and long-term clinical outcomes in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVE

Large thrombus burden (LTB) observed during ST-segment elevation myocardial infarction (STEMI) may end up with worse clinical outcomes. The relationship between LTB and long-term mortality and major adverse cardiac events (MACE) in STEMI patients undergoing percutaneous coronary intervention (PCI) is unclear. In this study, we aimed to investigate the relationship of LTB with short- and long-term mortality and MACE in STEMI patients undergoing PCI.

METHODS

Thrombus burden (TB) was evaluated in STEMI patients who underwent PCI between December 2010 and April 2012. After infarct-related arterial flow was restored, TB was reclassified. LTB was defined as thrombus with the largest dimension of at least two vessel diameters. Patients were evaluated for 1-month, 1-year, and 10-year follow-ups in terms of MACE and mortality.

RESULTS

Four hundred ninety-nine patients with clinical information and TB classification were analyzed. Three hundred sixty-six patients (73.3%) were in the small TB (STB) group, and 133 patients (26.7%) were in the LTB group. No-reflow (10.6% vs. 5.2%; P = 0.033) and stent thrombosis (7.5% vs. 3.3%; P = 0.042) were observed at a higher rate in the LTB group compared with the STB group. Thirty-day mortality (9.8% vs. 3.8%; P = 0.009) and MACE (16.5% vs. 9.6%; P = 0.030) were higher in the LTB group than in the STB group. Although 10-year MACE (56.4% vs. 46.2%; P = 0.044) was observed higher in the LTB group, no significant difference was observed between the two groups in terms of 10-year mortality (35.3% vs. 32.8%; P = 0.589). LTB was found to be an independent predictor for 10-year MACE (OR, 1.62; 95% CI, 1.01-2.61; P = 0.045).

CONCLUSION

LTB was associated with short- and long-term clinical events in STEMI patients undergoing PCI, but the mortality effect disappeared at the end of 1 year. Nevertheless, hospitalizations due to heart failure became significant in 10-year follow-up.

The state of platelet and plasma hemostasis as a predictor of coronary blood flow in patients with acute myocardial infarction

Aim      To study the relationship of the platelet function and plasma homeostasis with the blood flow in the infarct-related artery (IRA) and with the course of acute myocardial infarction (AMI).Material and methods  This study included 93 patients with AMI (75 patients with ST-elevation AMI and 18 patients without ST segment elevation). 63 patients had TIMI 0-1 blood flow in the IRA and 30 patients had TIMI 2-3. Rotational thromboelastometry, impedance aggregometry, the endothelium-dependent vasodilation (EDVD) test, and the thrombodynamics test were performed for all patients. The primary clinical endpoint included the totality of in-hospital complications of AMI, and the secondary endpoint included the totality of out-of-hospital complications of AMI. Major bleedings (BARC 3-5) and minor bleedings (BARC 1-2) were evaluated separately.Results Patients with IRA TIMI 0-1 flow were characterized by a shorter blood clotting time (BCT), larger thrombus size and density, more intense platelet aggregation induced by arachidonic acid and ADP, and lower values of the EDVD test. It was found that the parameters of platelet aggregation induced by arachidonic acid (AUC Asa) in combination with BCT allowed assessment of the severity of IRA blood flow disorder (sensitivity 76 %, specificity 71 %) in patients with AMI, regardless of the presence of ST segment elevation on the ECG. In addition, the incidence of the primary endpoint was greater in patients with IRA TIMI 0-1 flow (41.3% and 16.7%, respectively; p=0.015). In patients with TIMI 2-3 flow in the long-term period of the disease, the incidence of minor bleedings was significantly higher (8.5% and 30.4 %, respectively; p=0.045).Conclusion      Compared to patients with preserved blood flow, patients with AMI and IRA TIMI 0-1 flow are characterized by endothelial dysfunction and more intense processes of thrombogenesis and platelet aggregation. It has been shown for the first time that the combination of two simple criteria for assessing hemostasis (AUC Asa; BCT) allows assessment of the degree of IRA blood flow disorder in patients with AMI.

Development and Validation of a Novel Risk Stratification Model for Slow-Flow/No-Reflow During Primary Percutaneous Coronary Intervention (the RK-SF/NR Score)

In this study, we developed and validated a novel risk stratification model to predict slow-flow/no-reflow (SF/NR) during the primary percutaneous coronary intervention (PCI), namely the RK-SF/NR score. A total of 1,711 consecutive patients with ST-segment elevation myocardial infarction (STEMI) undergone primary PCI. A novel risk stratification model was developed in the development dataset and tested in the validation dataset. The overall incidence rate of SF/NR during the procedure was 28.8% (493/1,711). The final solution consisted of 9 variables: female gender (points = 2), total ischemic time ≥8 hours (points = 1), cardiac arrest at presentation (points = 2), left ventricular end-diastolic pressure ≥24 mm Hg (points = 3), left ventricular ejection fraction ≤30% (points = 2), culprit proximal left anterior descending artery (points = 3), thrombus grade ≥4 (points = 6), preprocedure thrombolysis in myocardial infarction (TIMI) 0 flow (points = 2), and lesion length ≥35 mm (points = 3). In the validation set, the area under the curve the RK-SF/NR score was 0.775 (0.722 to 0.829) and a score ≥10 has sensitivity of 77.9% (68.2% to 85.8%), negative predictive value of 87.3% (82.3% to 91.0%), specificity of 62.6% (56.0% to 68.9%), and positive predictive value of 46.3% (41.4% to 51.2%). In conclusion, RK-SF/NR score had shown good discriminating power for predicting SF/NR during primary PCI with good sensitivity and negative predictive value. Hence, the proposed model can have good clinical utility for screening patients at high risk of developing SF/NR during primary PCI.

​Circulating Cytokines in Myocardial Infarction Are Associated With Coronary Blood Flow

Background

The level of systemic inflammation correlates with the severity of the clinical course of acute myocardial infarction (AMI). It has been shown that circulating cytokines and endothelial dysfunction play an important role in the process of clot formation. The aim of our study was to assess the concentration of various circulating cytokines, endothelial function and blood clotting in AMI patients depending on the blood flow through the infarction-related artery (IRA).

Methods

We included 75 patients with AMI. 58 presented with ST-elevation myocardial infarction (STEMI) and 17 had non-ST-elevation myocardial infarction (non-STEMI). A flow-mediated dilation test (FMD test), thrombodynamics and rotational thromboelastometry as well as assessment of 14 serum cytokines using xMAP technology were performed.

Findings

Non-STEMI-patients were characterized by higher levels of MDC, MIP-1β, TNF-α. Moreover, we observed that patients with impaired blood flow through the IRA (TIMI flow 0-1) had higher average and initial clot growth rates, earlier onset of spontaneous clots, C-reactive protein (CRP) and IL-10 compared to patients with preserved blood flow through the IRA (TIMI flow 2-3). Patients with TIMI 2-3 blood flow had higher level of IP-10. IL-10 correlated with CRP and pro-inflammatory cytokines levels, initial clot growth rate and clot lysis time in TIMI 0-1 patients. All these differences were statistically significant.

Interpretation

We demonstrated that concentrations of the inflammatory cytokines correlate not only with the form of myocardial infarction (STEMI or non-STEMI), but also with the blood flow through the infarct-related artery. Inflammatory response, functional state of endothelium, and clot formation are closely linked with each other. A combination of these parameters affects the patency of the infarct-related artery.

Interobserver Variability Among Experienced Electrocardiogram Readers To Diagnose Acute Thrombotic Coronary Occlusion In Patients with Out of Hospital Cardiac Arrest: Impact of Metabolic Milieu and Angiographic Culprit

OBJECTIVES

We sought to evaluate interobserver concordance among experienced electrocardiogram (ECG) readers in predicting acute thrombotic coronary occlusion (ATCO) in the context of abnormal metabolic milieu (AMM) following resuscitated out of hospital cardiac arrest (OHCA).

METHODS

OHCA patients with initial shockable rhythm who underwent invasive coronary angiography (ICA) were included. AMM was defined as one of: pH < 7.1, lactate > 2 mmol/L, serum potassium < 2.8 or > 6.0 mEq/L. The initial ECG following ROSC but prior to ICA was adjudicated by 2 experienced readers using classic ST elevation myocardial infarction [STEMI] and expanded criteria and their combination to predict ATCO on ICA.

RESULTS

152 consecutive patients (mean age 58 years, 76% male) met inclusion criteria. AMM was present in 77%; and 42% had ATCO on ICA. Sensitivity, specificity, PPV, NPV using classic STEMI criteria were 50%, 98%, 94%, 72% (c-statistic 0.74); whereas for combined (STEMI + expanded) criteria they were 69%, 88%, 81%, 79% respectively (c-statistic 0.79). Inter-observer agreement (kappa) was 0.7 for classic STEMI criteria, and 0.66 for combined criteria. Agreement between readers was consistently higher when ATCO was absent and with NMM (kappa 0.78), but lower in AMM (kappa 0.6).

CONCLUSIONS

Despite experienced ECG readers, there was only modest overall concordance in predicting ATCO in the context of resuscitated OHCA. Significant interobserver variations were noted dependent on metabolic milieu and angiographic ATCO. These observations fundamentally question the role of the 12-lead ECG as primary triaging tool for early angiography among patients with OHCA.

The Impact of Lesion Complexity and the CHA2DS2-VASc Score on Spontaneous Reperfusion in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND

In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), a patent infarct-related artery (IRA) on initial angiography is defined as spontaneous reperfusion (SR).

OBJECTIVE

The present study aimed to determine the impact of lesion complexity and the CHA₂DS₂-VASc score on SR in patients with STEMI.

METHODS

A total number of 1,641 consecutive patients with STEMI undergoing primary PCI were assessed for this study. Patients were divided into 2 groups, those with SR, SR(+) (n = 239), and those without SR, SR(-) (n = 1402), according to their initial angiography and SR status. CHA₂DS₂-VASc scores were calculated for all patients. The lesion complexity of coronary artery disease was assessed with the SYNTAX score.

RESULTS

The CHA₂DS₂-VASc and SYNTAX scores were significantly lower in the SR(+) group compared to the SR(-) (mean CHA₂DS₂-VASc, 1.36 ± 0.64 vs. 2.01 ± 0.80, p < 0.001; mean SYNTAX score, 15.51 ± 5.94 vs. 17.08 ± 8.29, p < 0.001). After the multivariate regression analysis, a lower CHA₂DS₂-VASc (OR = 0.288, p < 0.001), SYNTAX score (OR = 0.920, p=0.007), uric acid (OR = 0.868, p=0.005), CRP (OR = 0.939, p=0.001), BNP (OR = 0.998, p=0.004), and troponin (OR = 0.991, p=0.001) were independent predictors of SR. In-hospital mortality rates were significantly lower in the SR(+) group compared to the SR(-) (0% vs. 6.7%, p < 0.001).

CONCLUSION

Our study demonstrated that lesion complexity and the CHA₂DS₂-VASc score are independently associated with spontaneous reperfusion.

Mechanical complications in ST-elevation myocardial infarction: The impact of pre-hospital delay

AIMS

Mechanical complications (MC) (i.e., free wall rupture (FWR), papillary muscle rupture (PMR) and ventricular septal rupture (VSR)) are rare complications of ST- elevation acute myocardial infarction (STEMI). Incidence of MC according to pre-hospital delay remains unknown. We aimed to determine the rates of MC according to pre-hospital delay.

METHODS

Analysis was conducted on the MODIF registry data. Patients were allocated to four groups according to pre-hospital delay: 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h.

RESULTS

6185 patients with complete data were analyzed. Mean age was 64.1 years old and 75.7% of patients were males. Eighty-three patients (1.34%) presented with MC: 44 (0.71%) experienced a FWR, 17 (0.27%) a PMR, and 22 (0.36%) a VSR. Global rates of MC were 0.82%, 1.43%, 1.24% and 5.07% in the four groups of pre-hospital delays - 0 to 12 h, 12 to 24 h, 24 to 36 h and 36 to 48 h - respectively (p < 0.001). In-hospital mortality rates were high: 44.2%, 47.1% and 54.6% for FWR, PMR and VSR, respectively. In multivariate analysis, factors independently related to the occurrence of MC were older age, female sex, simultaneous COVID-19 infection, absence of dyslipidemia, initial TIMI flow 0 or 1 in the culprit artery, 36 to 48 h-pre-hospital delay and absence of revascularization by percutaneous coronary intervention (PCI) with stent implantation.

CONCLUSION

The probability of MC in STEMI increases with pre-hospital delay. Mechanical complications of STEMI remain associated with a very poor prognosis.

Impact of COVID-19 pandemic restrictions on ST-elevation myocardial infarction: a cardiac magnetic resonance imaging study

AIMS

The severity of myocardial tissue damage following ST-elevation myocardial infarction (STEMI) strongly determines short- and long-term prognosis. This study explored the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated public health restrictions on infarct severity.

METHODS AND RESULTS

STEMI patients treated with primary percutaneous coronary intervention (PCI) and included in the prospective Magnetic Resonance Imaging in Acute ST-Elevation Myocardial Infarction (MARINA-STEMI) cohort study from 2015- 2020 (n = 474) were categorized according to (i) timeframes with and without major public health restrictions in 2020, and (ii) timeframes of major public health restrictions during 2020 and during the corresponding timeframes between 2015-2019. Myocardial damage was evaluated by cardiac magnetic resonance imaging. During major public health restrictions in 2020 (n = 48), there was an increase in infarct size (22 [IQR 12-29] vs. 14 [IQR 6-23]%, P < 0.01), a higher frequency (77% vs. 52%, P < 0.01) and larger extent of microvascular obstruction (1.5 [IQR 0.1-11.4] vs. 0.2 [IQR 0.0-2.6]%, P < 0.01) and a higher rate of intramyocardial haemorrhage (56% vs. 34%, P = 0.02) as compared to the phases without major restrictions in 2020 (n = 101). These findings were confirmed in adjusted analysis and were consistent when comparing patients admitted in 2020 versus patients admitted in the "pre-pandemic" era (2015-2019). Patient characteristics were comparable between groups, except for a significantly longer total ischemia time (P < 0.01) and higher frequency of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow 0 during times of major restrictions (P = 0.03).

CONCLUSION

This study provides novel mechanistic insights demonstrating a significant increase in myocardial damage in STEMI patients admitted during the COVID-19 pandemic with a temporal relation to major public health restrictions.

Plaque characteristics in patients with ST-segment elevation myocardial infarction and early spontaneous reperfusion

BACKGROUND

Early spontaneous reperfusion (ESR) is not an uncommon phenomenon in clinical settings.

AIMS

The aim of this study was to detect potential mechanisms of ESR in patients with STEMI.

METHODS

This prospective study enrolled a total of 241 consecutive patients with STEMI undergoing optical coherence tomography (OCT) from July 2016 to August 2019. Forty-five patients (18.7%) met angiographic ESR criteria (TIMI 3 flow on the initial angiogram). Among those without ESR (TIMI 0 flow on initial angiogram), 45 patients were assigned to the control group according to propensity score matching with the ESR group.

RESULTS

Although the baseline characteristics of the groups were comparable, non-ruptured plaque (62.2% vs 35.6%) predominated and plaque rupture (37.8% vs 64.4%) was less common in the ESR group (p=0.011). Red thrombus (44.4% vs 77.8%) was also less common in the ESR group (p=0.001). Lastly, compared to the control group, the ESR group underwent fewer emergent stent placements (68.9% vs 91.1%, p=0.008).

CONCLUSIONS

Relief of coronary occlusion induced by a non-ruptured plaque may contribute to ESR in patients with STEMI.

Electrocardiographic Diagnosis of Acute Coronary Occlusion Myocardial Infarction in Ventricular Paced Rhythm Using the Modified Sgarbossa Criteria

STUDY OBJECTIVE

Ventricular paced rhythm is thought to obscure the electrocardiographic diagnosis of acute coronary occlusion myocardial infarction. Our primary aim was to compare the sensitivity of the modified Sgarbossa criteria (MSC) to that of the original Sgarbossa criteria for the diagnosis of occlusion myocardial infarction in patients with ventricular paced rhythm.

METHODS

In this retrospective case-control investigation, we studied adult patients with ventricular paced rhythm and symptoms of acute coronary syndrome who presented in an emergency manner to 16 international cardiac referral centers between January 2008 and January 2018. The occlusion myocardial infarction group was defined angiographically as thrombolysis in myocardial infarction grade 0 to 1 flow or angiographic evidence of coronary thrombosis and peak cardiac troponin I ≥10.0 ng/mL or troponin T ≥1.0 ng/mL. There were 2 control groups: the "non-occlusion myocardial infarction-angio" group consisted of patients who underwent coronary angiography for presumed type I myocardial infarction but did not meet the definition of occlusion myocardial infarction; the "no occlusion myocardial infarction" control group consisted of randomly selected emergency department patients without occlusion myocardial infarction.

RESULTS

There were 59 occlusion myocardial infarction, 90 non-occlusion myocardial infarction-angio, and 102 no occlusion myocardial infarction subjects (mean age, 72.0 years; 168 [66.9%] men). For the diagnosis of occlusion myocardial infarction, the MSC were more sensitive than the original Sgarbossa criteria (sensitivity 81% [95% confidence interval [CI] 69 to 90] versus 56% [95% CI 42 to 69]). Adding concordant ST-depression in V4 to V6 to the MSC yielded 86% (95% CI 75 to 94) sensitivity. For the no occlusion myocardial infarction control group of ED patients, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 96% (95% CI 90 to 99) versus 97% (95% CI 92 to 99); negative likelihood ratio (LR) 0.19 (95% CI 0.11 to 0.33) versus 0.45 (95% CI 0.34 to 0.65); and positive LR 21 (95% CI 7.9 to 55) versus 19 (95% CI 6.1 to 59). For the non-occlusion myocardial infarction-angio control group, additional test characteristics of MSC and original Sgarbossa criteria, respectively, were as follows: specificity 84% (95% CI 76 to 91) versus 90% (95% CI 82 to 95); negative LR 0.22 (95% CI 0.13 to 0.38) versus 0.49 (95% CI 0.35 to 0.66); and positive LR 5.2 (95% CI 3.2 to 8.6) versus 5.6 (95% CI 2.9 to 11).

CONCLUSION

For the diagnosis of occlusion myocardial infarction in the presence of ventricular paced rhythm, the MSC were more sensitive than the original Sgarbossa criteria; specificity was high for both rules. The MSC may contribute to clinical decisionmaking for patients with ventricular paced rhythm.

Risk Stratification of Patients with Acute Coronary Syndrome

Defining the risk factors affecting the prognosis of patients with acute coronary syndrome (ACS) has been a challenge. Many individual biomarkers and risk scores that predict outcomes during different periods following ACS have been proposed. This review evaluates known outcome predictors supported by clinical data in light of the development of new treatment strategies for ACS patients during the last three decades.

Percutaneous Myocardial Revascularization in Late-Presenting Patients With STEMI

BACKGROUND

The optimal management of patients with ST-segment elevation myocardial infarction (STEMI) presenting late->12 hours following symptom onset-is still under debate.

OBJECTIVES

The purpose of this study was to describe characteristics, temporal trends, and impact of revascularization in a large population of latecomer STEMI patients.

METHODS

The authors analyzed the data of 3 nationwide observational studies from the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) program, conducted over a 1-month period in 2005, 2010, and 2015. Patients presenting between 12 and 48 hours after symptom onset were classified as latecomers.

RESULTS

A total of 6,273 STEMI patients were included in the 3 cohorts, 1,169 (18.6%) of whom were latecomers. After exclusion of patients treated with fibrinolysis and patients deceased within 2 days after admission, 1,077 patients were analyzed, of whom 729 (67.7%) were revascularized within 48 hours after hospital admission. At 30-day follow-up, all-cause death rate was significantly lower among revascularized latecomers (2.1% vs 7.2%; P < 0.001). After a median follow-up of 58 months, the rate of all-cause death was 30.4 (95% CI: 25.7-35.9) per 1,000 patient-years in the revascularized latecomers group vs 78.7 (95% CI: 67.2-92.3) per 1,000 patient-years in the nonrevascularized latecomers group (P < 0.001). In multivariate analysis, revascularization of latecomer STEMI patients was independently associated with a significant reduction of mortality occurrence during follow-up (HR: 0.65 [95% CI: 0.50-0.84]; P = 0.001).

CONCLUSIONS

Coronary revascularization of latecomer STEMI patients is associated with better short and long-term clinical outcomes.

Temporal trends in the pre-procedural TIMI flow grade among patients with ST- segment elevation myocardial infarction - From the ACSIS registry

•

Preprocedural TIMI flow grade remains of prognostic significance.

•

Patients with TIMI 0 have a poorer prognosis than their counterparts with TIMI 1-3.

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In-hospital complications have decreased among patients with TIMI 0 over time.

•

30-d MACE and 1-year mortality remained unchanged in those with TIMI 0 or 1-3.

Background

Pre-procedural TIMI coronary flow grade in patients with ST segment elevation myocardial infarction (STEMI) is associated with adverse clinical outcomes. There have been great advances in pharmacologic and invasive treatment of STEMI patients in the current era. We aimed to assess the temporal trends in clinical outcomes according to the TIMI flow grade amongst these patients.

Methods

Data of patients with STEMI from the acute coronary syndrome Israeli Survey (ACSIS) registry. A time-dependent analysis stratifying patient by TIMI flow grade 0 and TIMI flow grade 1–3 was performed. Survey years were divided to early (2008–2010) and late period (2013–2018). Clinical outcomes included in-hospital complications, 30d MACE (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality.

Results and Conclusions: Included were 2453 patients. The majority of patients had pre-procedural TIMI flow 0 (58.9% in the early period and 58.7% in the late period, P = 0.97). In-hospital complications of patients with TIMI flow 0 has significantly decreased over time (36.1% vs 26.8%, P < 0.001) but not amongst patients with TIMI flow 1–3. Compared with TIMI flow 1–3, patients with TIMI flow 0 had worse 30d MACE and 1-year mortality. There was no temporal change of these outcomes in either TIMI flow grade group. TIMI flow grade 0 is still more common among patients with STEMI and is associated with poorer prognosis. Nevertheless, over time, in-hospital complications have decreased among patients with TIMI 0, while 30d MACE and 1-year mortality has remained unchanged.

Association of pre-percutaneous coronary flow grade and clinical outcomes in patients with non-ST-segment elevation myocardial infarction: Data from the Korea Acute Myocardial Infarction Registry

Because of a paucity of published data, we compared the 2-year major clinical outcomes between pre-percutaneous coronary intervention (pre-PCI) thrombolysis in myocardial infarction (TIMI) flow grade 0/1 (pre-TIMI flow grade [pre-TIMI] 0/1) group and pre-PCI TIMI flow grade 2/3 (pre-TIMI 2/3) group in patients with non-ST-segment elevation myocardial infarction (NSTEMI) who underwent successful implantation of newer-generation drug-eluting stent.A total of 7506 NSTEMI patients were divided into 2 groups: pre-TIMI 0/1 group (n = 3157) and pre-TIMI 2/3 group (n = 4349). The primary outcome was major adverse cardiac events defined as all-cause death, recurrent myocardial infarction, or any repeat revascularization. The secondary outcome was stent thrombosis (ST).After propensity score-matched (PSM) analysis, 2 PSM groups (2473 pairs, n = 4946, C-statistic = 0.684) were generated. Major adverse cardiac events (hazard ration [HR], 1.294; 95% confidence interval [CI]: 1.065-1.572; P = .009), all-cause death (HR, 1.559, P = .003), cardiac death (HR: 1.641, P = .005), and all-cause death or MI (HR: 1.531, P = .001) rates were significantly higher in the pre-TIMI 0/1 group than in the pre-TIMI 2/3 group. Moreover, these differences were more prominent during the first 1 month after the index PCI. However, the cumulative incidences of recurrent myocardial infarction, any revascularization, and ST were similar between the 2 groups.Among a contemporary cohort of NSTEMI, these data suggest that the presence of a pre-PCI patency of the infarct-related artery showed better mortality reduction capacity than those with a lack of patency.

Pre-hospital heparin use for ST-elevation myocardial infarction is safe and improves angiographic outcomes

AIMS

This study aims to evaluate if pre-hospital heparin administration by paramedics is safe and improves clinical outcomes.

METHODS AND RESULTS

Using the multicentre Victorian Cardiac Outcomes Registry, linked with state-wide ambulance records, we identified consecutive patients undergoing primary percutaneous coronary intervention for STEMI between January 2014 and December 2018. Information on thrombolysis in myocardial infarction (TIMI) flow at angiography was available in a subset of cases. Patients receiving pre-hospital heparin were compared to those who did not receive heparin. Findings at coronary angiography and 30-day clinical outcomes were compared between groups. Propensity-score matching was performed for risk adjustment. We identified a total of 4720 patients. Of these, 1967 patients had TIMI flow data available. Propensity-score matching in the entire cohort yielded 1373 matched pairs. In the matched cohort, there was no observed difference in 30-day mortality (no-heparin 3.5% vs. heparin 3.0%, P = 0.25), MACCE (no-heparin 7% vs. heparin 6.2%, P = 0.44), and major bleeding (no-heparin 1.9% vs. heparin 1.4%, P = 0.64) between groups. Propensity-score analysis amongst those with TIMI data produced 552 matched pairs. The proportion of cases with TIMI 0 or 1 flow in the infarct-related artery (IRA) was lower among those receiving pre-hospital heparin (66% vs. 76%, P < 0.001) compared to those who did not.

CONCLUSION 

In this multicentre, propensity-score matched study, the use of pre-hospital heparin by paramedics was safe and is associated with fewer occluded IRAs in patients presenting with STEMI.

Relationship Between C-Reactive Protein to Albumin Ratio and Infarct-Related Artery Patency in Patients With ST-Segment Elevation Myocardial Infarction

The C-reactive protein to albumin ratio (CAR) is a predictive marker of systemic inflammatory state in atherosclerotic coronary disease when compared with the predictive value of these 2 markers separately. We investigated the relationship between CAR and infarct-related artery (IRA) patency in patients with ST-segment elevation myocardial infarction (STEMI). The study population (n = 1047) was divided into 2 groups according to IRA patency which was assessed by the Thrombolysis in Myocardial Infarction (TIMI) flow grade. Nonpatent flow was defined as TIMI grade 0 (no-reflow), 1, and 2 flows, and normal flow was defined as TIMI 3 flow. There was a significant positive correlation between CAR and SYNTAX score (r = 0.312, P < .001) and a negative correlation between CAR and TIMI grade flow (r = -0.210, P < .001). At a cutoff level of 0.693, the CAR predicted TIMI no-reflow with a sensitivity of 65.4% and a specificity of 65.5% (area under the curve: 0.670, 95% CI: 0.62-0.71, P < .001). Multivariate logistic regression analyses showed that CAR was an independent predictor of IRA patency (0.003 [0.001-0.029]; P < .001). A higher CAR is a significant and independent predictor of IRA patency in patients with STEMI.

Impact of preprocedural coronary flow grade on duration of dual antiplatelet therapy in acute myocardial infarction

We investigated the impact of pre-percutaneous coronary intervention (pre-PCI) thrombolysis in myocardial infarction (TIMI) flow grade (pre-TIMI) on 3-month (3-mo) and 12-mo of dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI). This was a post hoc analysis of the TICO trial. A total of 2083 patients with AMI (pre-TIMI 0/1: n = 1143; pre-TIMI 2/3: n = 940) were evaluated. The primary outcome was the occurrence of net adverse clinical events (NACE), defined as a composite of TIMI major bleeding and major adverse cardiac and cerebrovascular events (MACCE) within 12-mo following PCI. The secondary outcomes were the occurrence of the individual components of TIMI bleedings and MACCE. In the pre-TIMI 0/1 group, the primary and second outcomes were not significantly different between the 3-mo and 12-mo DAPT groups. However, in the pre-TIMI 2/3 group, the occurrences of TIMI minor (adjusted hazard ratio [aHR]: 0.294; p = 0.016) and major or minor bleeding (aHR: 0.483; p = 0.014) on intention-to-treat analysis were significantly higher in the 12-mo than in the 3-mo DAPT group. The occurrence of MACCE was similar between the two groups. A higher bleeding tendency in 12-mo DAPT compared with 3-mo DAPT was more obvious in the pre-TIMI 2/3 group than in the pre-TIMI 0/1 group.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02494895.

Enhancement patterns detected by multidetector computed tomography are associated with the long-term prognosis of patients with acute myocardial infarction

The present study investigated the clinical value of myocardial contrast-delayed enhancement (DE) with multidetector computed tomography (MDCT) without iodine re-injection immediately after primary percutaneous coronary intervention (PCI) for predicting future cardiovascular events after acute myocardial infarction (AMI). We performed a prospective study in which 263 consecutive patients with first AMI successfully treated with primary PCI were enrolled. Sixty-four-slice MDCT without the re-injection of contrast medium was performed immediately after PCI. Myocardial DE was considered to be transmural when involving myocardial thickness ≥ 75% (Group A; n = 104), subendocardial (< 75%, Group B; n = 108), or normal (Group C; n = 51). A semiquantitative scale score was defined for 17 left ventricular segments to investigate the extent of the DE area assessed. We examined the relationship between the presence or absence of transmural DE and long-term cardiovascular event rates. The median follow-up period was 3.5 years. Kaplan-Meier survival curves showed that patient prognosis was poorer in the group with Group A than that in the group with Group B, which was equivalent to that with Group C. A multivariate analysis identified the presence of transmural DE as the strongest predictor for future cardiovascular events (hazard ratio: 3.7; P = 0.023). Transmural myocardial DE immediately following primary PCI without an iodine re-injection for AMI is a major risk factor for future cardiovascular events.

Two-Year Clinical Outcomes According to Pre-PCI TIMI Flow Grade and Reperfusion Timing in Non-STEMI After Newer-Generation Drug-Eluting Stents Implantation

The 2-year clinical outcomes according to pre-percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) flow grade and reperfusion timing were investigated in patients with non-ST-segment elevation myocardial infarction (NSTEMI) who received newer-generation drug-eluting stents. A total of 7506 NSTEMI patients were divided into 2 groups: early (PCI ≤ 24 hours: n = 6398; pre-PCI TIMI 0/1 [n = 2729], pre-PCI TIMI 2/3 [n = 3669]) and delayed (PCI > 24 hours: n = 1108; pre-PCI TIMI 0/1 [n = 428], pre-PCI TIMI 2/3 [n = 680]) invasive groups. Major adverse cardiac events were defined as all-cause death, recurrent myocardial infarction, or any repeat revascularization. All-cause death (P = 0.005 and 0.009, respectively) and cardiac death (P = .003 and 0.046, respectively) were significantly higher in pre-PCI TIMI 0/1 patients than in pre-PCI TIMI 2/3 patients both in the early and delayed invasive groups. In pre-PCI TIMI 0/1 patients, all-cause death rate was significantly higher in the delayed group (P = .023). In pre-PCI TIMI 2/3 patients, the clinical end point was similar between the 2 groups. An early invasive strategy is preferred to a delayed invasive strategy in reducing all-cause death in patients with pre-PCI TIMI 0/1. However, in patients with pre-PCI TIMI 2/3, both treatment strategies are acceptable.

Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction

OBJECTIVE

In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI.

METHODS

We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL.

RESULTS

808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography.

CONCLUSIONS

Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.

Comparison of First- and Second-Generation Drug-Eluting Stents in Patients with ST-Segment Elevation Myocardial Infarction Based on Pre-Percutaneous Coronary Intervention Thrombolysis in Myocardial Infarction Flow Grade

This study aims to investigate the two-year clinical outcomes between first-generation (1G) and second-generation (2G) drug-eluting stents (DES) based on pre-percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) flow grade (pre-TIMI) in patients with ST-segment elevation myocardial infarction (STEMI). Overall, 17,891 STEMI patients were classified into two groups: pre-TIMI 0/1 group (n = 12,862; 1G-DES (n = 4318), 2G-DES (n = 8544)) and pre-TIMI 2/3 group (n = 5029; 1G-DES (n = 2046), 2G-DES (n = 2983)). During a two-year follow-up period, major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction (re-MI), or any repeat revascularization and stent thrombosis (ST) were considered as the primary and the secondary outcomes. In the pre-TIMI 0/1 and 2/3 groups, the cumulative incidences of MACEs (adjusted hazard ratio (aHR): 1.348, p < 0.001, and aHR: 1.415, p = 0.02, respectively) and any repeat revascularization (aHR: 1.938, p < 0.001, and aHR: 1.674, p = 0.001, respectively) were significantly higher in the 1G-DES than in the 2G-DES. However, sirolimus-eluting stent showed similar cumulative incidence of any repeat revascularization compared with zotarolimus-eluting stent and biolimus-eluting stent in both pre-TIMI 0/1 and 2/3 groups. The cumulative incidences of all-cause death, re-MI, and ST were similar between the 1G-DES and 2G-DES groups. In this study, 2G-DES showed better clinical outcomes than 1G-DES concerning MACEs and any repeat revascularization regardless of pre-TIMI. However, more research is needed to support these results.

Factors Associated With Normal Flow (TIMI 3) After Thrombolysis With Streptokinase in ST-Elevation Myocardial Infarction: A Prospective Observational Study

Background

Thrombolysis with streptokinase (STK) is the most widely used reperfusion strategy for ST elevation myocardial infarction (STEMI) in India. Achieving full reperfusion as evidenced by thrombolysis in myocardial infarction (TIMI) flow grade 3 in coronary angiography (CAG) is associated with better outcomes. Recent studies show that hematological indices like neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) estimated before thrombolysis could predict TIMI 3 flow. We studied clinical, electrocardiographic and hematological parameters associated with TIMI 3 flow after thrombolysis with STK.

Methods

We prospectively studied 201 adult patients with STEMI presenting within 12 hours of onset of chest pain. Before thrombolysis, blood sample was collected for estimating NLR and MPV. Timing of CAG after thrombolysis was decided by consultant cardiologists. Patients were followed up for one month after discharge.

Results

Of 201 patients, 162 (81%) had relief of chest pain and 131 (65%) had ST segment recovery of ≥50% at 90 minutes after thrombolysis. CAG was performed within median (IQR) of four (3-5) days after thrombolysis. TIMI 3 flow was observed in 112 (56%) patients. NLR and MPV had no significant association with TIMI 3 flow. In multivariable analysis, ST-segment recovery of ≥50% at 90 minutes was associated with TIMI 3 flow (adjusted OR 3.47, 95% CI: 1.84-6.53, P= <0.001). Of 198 patients followed up for one month after discharge, 13 (6.5%) died.

Conclusions

In patients with STEMI, ST-segment recovery of ≥50% at 90 minutes after thrombolysis with STK predicted TIMI 3 flow independently. NLR and MPV values were not predictive of TIMI 3 flow.

The association between T wave inversion in leads with ST-elevation and patency of the infarct-related artery

Background

Up to over half of the patients with ST-segment elevation myocardial infarction (STEMI) are reported to undergo spontaneous reperfusion without therapeutic interventions. Our objective was to evaluate the applicability of T wave inversion in electrocardiography (ECG) of patients with STEMI as an indicator of early spontaneous reperfusion.

Methods

In this prospective study, patients with STEMI admitted to a tertiary referral hospital were studied over a 3-year period. ECG was obtained at the time of admission and patients underwent a PPCI. The association between early T wave inversion and patency of the infarct-related artery was investigated in both anterior and non-anterior STEMI.

Results

Overall, 1025 patients were included in the study. Anterior STEMI was seen in 592 patients (57.7%) and non-anterior STEMI in 433 patients (42.2%). Among those with anterior STEMI, 62 patients (10.4%) had inverted T and 530 (89.6%) had positive T waves. In patients with anterior STEMI and inverted T waves, a significantly higher TIMI flow was detected (p value = 0.001); however, this relationship was not seen in non-anterior STEMI.

Conclusion

In on-admission ECG of patients with anterior STEMI, concomitant inverted T wave in leads with ST elevation could be a proper marker of spontaneous reperfusion of infarct related artery.

Prediabetes versus type 2 diabetes mellitus based on pre-percutaneous coronary intervention thrombolysis in myocardial infarction flow grade in patients with ST-segment elevation myocardial infarction after successful newer-generation drug-eluting stent implantation

BACKGROUND

We compared the 2-year clinical outcomes between prediabetes and type 2 diabetes mellitus (T2DM) according to the pre-percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) flow grade in patients with ST-segment elevation myocardial infarction.

METHODS

Overall, 6448 STEMI patients were divided into two groups: pre-PCI TIMI 0/1 group (n = 4854) and pre-PCI TIMI 2/3 group (n = 1594). They were further divided into patients with normoglycemia, prediabetes, and T2DM. The major endpoint was major adverse cardiac events (MACEs), defined as all-cause death, recurrent myocardial infarction, or any repeat revascularization.

RESULTS

In the pre-PCI TIMI 0/1 group, all-cause death rate was higher in both prediabetes (adjusted hazard ratio [aHR]: 1.633, p = 0.045) and T2DM (aHR: 2.064, p = 0.002) groups than in the normoglycemia group. In the pre-PCI TIMI 2/3 group, any repeat revascularization rate was also higher in both prediabetes (aHR: 2.511, p = 0.039) and T2DM (aHR: 3.156, p = 0.009) than normoglycemia. In each group (pre-PCI TIMI 0/1 or 2/3), the MACEs and all other clinical outcomes rates were similar between the prediabetes and T2DM groups.

CONCLUSIONS

Prediabetes showed comparable worse clinical outcomes to those of T2DM regardless of the pre-PCI TIMI flow grade.

Frequency of Thrombolysis in Myocardial Infarction III Flow in Patients With Primary Percutaneous Coronary Intervention: Not All Culprit Vessels Are Completely Occluded in ST Elevation Myocardial Infarction

Background

ST elevation myocardial infarction (STEMI) is classically characterized by total occlusion of the culprit coronary artery. However during primary percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) 0 flow is not observed in all patients' culprit arteries in angiographic views. This study was conducted to find out the frequency of TIMI flow in acute STEMI patients in view of the above concept. The aim of this study was to evaluate the frequency of pre-procedural TIMI III flow in those patients who underwent primary PCI for acute STEMI in a public sector hospital in Karachi, Pakistan.

Methodology

This study is an audit of already saved data in the catheterization laboratory of the National Institute of Cardiovascular Diseases (NICVD), Karachi, that was collected prospectively from January 2016 to December 2018. These data were collected after taking consent from those patients who presented to hospital within 12 hours of symptoms and underwent primary PCI. Data were entered and analyzed on Statistical Package for the Social Sciences (SPSS) version 19 (IBM Corp., Armonk, NY, USA).

Results

A total of 8018 patients were included in this study who presented with STEMI and underwent primary PCI. Out of them 80.9% were males. Hypertension was the leading risk factor in 54.1% (4340) of patients. TIMI III flow was present in 11.4% of patients before primary PCI, while TIMI 0, I and II flow were present in 57.1%, 15.1%, and 16.3% of patients respectively (p<0.001). Fourteen percent of patients with TIMI III flow were of age group 51 to 60 years. Among those who had TIMI III flow, 11.2% were those with door to balloon time of <90 minutes. In 11% of cases, left anterior descending (LAD) artery had TIMI III flow as compared to other vessels (p<0.001). The length of the lesion was significantly smaller in patients who had TIMI III flow compared to those who had TIMI 0-II flow.

Conclusions

This study revealed that not all patients with acute STEMI had totally occluded culprit coronary artery but some of them had angiographic TIMI I-III flow in the infarct-related artery. Further studies are needed to find the reason for re-establishment of flow in the culprit vessel in STEMI patients before PCI.

Association of culprit lesion plaque characteristics with flow restoration post-fibrinolysis in ST-segment elevation myocardial infarction: an intravascular ultrasound-virtual histology study

Background

Not every patient achieves normal coronary flow following fibrinolysis in STEMI (ST-segment elevation myocardial infarction). The culprit lesion plaque characteristics play a prominent role in the coronary flow before and during percutaneous coronary intervention. The main purpose was to determine the culprit lesion plaque features by virtual histology-intravascular ultrasound (VH-IVUS) in patients with STEMI following fibrinolysis in relation to baseline coronary angiogram TIMI (thrombolysis in myocardial infarction) flow. Pre-intervention IVUS was undertaken in 61 patients with STEMI after successful fibrinolysis. After the coronary angiogram, they were separated into the TIMI1–2 flow group (n = 31) and TIMI 3 flow group (n = 30). Culprit lesion plaque composition was evaluated by VH-IVUS.

Results

On gray-scale IVUS, the lesion external elastic membrane cross-sectional area (EEM CSA) was significantly higher in the TIMI 1–2 groups as compared to the TIMI 3 group (15.71 ± 3.73 mm² vs 13.91 ± 2.94 mm², p = 0.041) with no significant difference in plaque burden (82.42% vs. 81.65%, p = 0.306) and plaque volume (108.3 mm³ vs. 94.3 mm³, p = 0.194). On VH-IVUS, at the minimal luminal area site (MLS), the fibrous area (5.83 mm² vs. 4.37 mm², p = 0.024), necrotic core (NC) area (0.95 mm² vs. 0.59 mm², p < 0.001), and NC percentage (11% vs. 7.1%, p = 0.024) were higher in the TIMI 1–2 groups in contrast to the TIMI 3 group. The absolute necrotic core (NC) volume (8.3 mm³ vs. 3.65 mm³, p < 0.001) and NC percentage (9.3% vs. 6.0%, p = 0.007) were significantly higher in the TIMI 1–2 groups as compared to the TIMI 3 group. Absolute dense calcium (DC) volume was higher in TIMI 1–2 groups with a trend towards significance (1.0 mm³ vs.0.75 mm³, p = 0.051). In multivariate analysis, absolute NC volume was the only independent predictor of TIMI 1–2 flow (odds ratio = 1.561; 95% CI 1.202–2.026, p = 0.001). Receiver operating characteristic curves showed absolute NC volume has best diagnostic accuracy (AUC = 0.816, p < 0.001) to predict TIMI 1–2 flow with an optimal cutoff value of 4.5 mm³ with sensitivity and specificity of 79% and 61%, respectively.

Conclusions

This study exemplifies that the necrotic core component of the culprit lesion plaque in STEMI is associated with the coronary flow after fibrinolysis. The absolute necrotic core volume is a key determinant of flow restoration post-fibrinolysis and aids in prognostication of less than TIMI 3 flow.

Outcome of inter-hospital transfer versus direct admission for primary percutaneous coronary intervention: An observational study of 25,315 patients with ST-elevation myocardial infarction from the London Heart Attack Group

Background and aims:

In patients with ST-segment elevation myocardial infarction (STEMI), mortality is directly related to time to reperfusion with guidelines recommending patients be delivered directly to centres for primary percutaneous coronary intervention (PCI). The aim of this study was to describe the impact of inter-hospital transfer on reperfusion time and to assess whether or not treatment delays influenced clinical outcomes in comparison with direct admission to a primary PCI centre in a large regional network.

Method and results:

We undertook an observational cohort study of patients with STEMI treated with primary PCI between 2005 and 2015 in London, UK. Patient details were recorded at the time of the procedure in databases using the British Cardiovascular Intervention Society PCI dataset. The primary end-point was all-cause mortality at a median of 4.1 years (interquartile range: 2.2–5.8 years). Secondary outcomes were in-hospital major adverse cardiac events. Of 25,315 patients, 17,560 (69.4%) were admitted directly to a primary PCI centre and 7755 (31.6%) were transferred from a non-primary PCI centre. Patients in the direct admission group were older and more likely to have left ventricular impairment compared with the inter-hospital transfer group. Median time from call for help to reperfusion in transferred patients was 52 minutes longer compared with patients admitted directly (p &lt;0.001). However, call to first hospital admission was similar. Kaplan–Meier analysis demonstrated significantly lower mortality rates in patients who were transferred directed to a primary PCI centre compared with patients who were transferred from a non-PCI centre (17.4% direct vs. 18.7% transfer, p=0.017). Furthermore, after propensity matching, direct admission for primary PCI was still a predictor of all-cause mortality (hazard ratio: 0.89, 95% confidence interval: 0.64–0.95).

Conclusions:

In this large registry of over 25,000 STEMI patients treated by primary PCI survival was better in patients admitted directly to a cardiac centre versus patients transferred for primary PCI, most likely due to longer call to balloon times in patient transferred from other hospitals.

Systemic and local factors associated with reduced thrombolysis in myocardial infarction flow in ST-segment elevation myocardial infarction patients with plaque erosion detected by intravascular optical coherence tomography

Local factors of plaque rupture (e.g. lipid burden) are related to preprocedural thrombolysis in myocardial infarction (TIMI) flow grade during primary percutaneous coronary intervention (PCI). However, the pathological mechanism differs between plaque erosion and rupture. We aimed to identify the factors associated with reduced TIMI flow in plaque erosion. A total of 329 ST-segment elevation myocardial infarction (STEMI) patients with optical coherence tomography (OCT) identified plaque erosion were divided into 2 groups by preprocedural TIMI flow grade [TIMI 0-1 group (n = 219) and TIMI 2-3 group (n = 110)]. Patients in TIMI 0-1 group were older (age > 50 years, 68.5% vs. 51.8%, P = 0.003), and had more diabetes mellitus (18.3% vs. 8.2%, P = 0.015). Plaque erosion with TIMI flow 0-1 was less frequently located in the left anterior descending artery (LAD, 58.4% vs. 72.7%, P = 0.011), but more frequently located in the right coronary artery (RCA, 34.2% vs. 7.3%, P = 0.001) than those with TIMI flow 2-3. TIMI 0-1 group had more lipid plaques (53.9% vs. 41.8%, P = 0.039), macrophage accumulation (59.8% vs. 41.8%, P = 0.002), and calcification (34.2% vs. 21.8%, P = 0.020). In the multivariable analysis, age > 50 years, diabetes mellitus, RCA location, and macrophage accumulation were the independent predictors of reduced TIMI flow grade in STEMI patients with plaque erosion. Systemic factors (older age and diabetes mellitus) and local factors (RCA location and macrophage accumulation) were independently associated with reduced coronary flow in STEMI patients with plaque erosion. CLINICAL TRIAL REGISTRATION : ClinicalTrials.gov NCT03084991 May 17, 2017 (retrospectively registered).

Prehospital Administration of Unfractionated Heparin in ST-Segment Elevation Myocardial Infarction Is Associated With Improved Long-Term Survival

OBJECTIVE

Administration of unfractionated heparin to STEMI patients by the ambulance service is an established practice in Scotland, but the efficacy is unknown. We studied the effects of unfractionated heparin in STEMI patients treated by primary percutaneous coronary intervention, on infarct artery patency and mortality.

METHODS AND RESULTS

Consecutive patients (n = 1000) admitted to Ninewells Hospital, Dundee, from 2010 to 2014 for primary percutaneous coronary intervention were allocated to 2 groups: 437 (44%) prehospital heparin (PHH) administered by paramedics, and 563 (56%) in-hospital heparin. A trained medical student assessed coronary flow at presentation and collected the data. Mortality status was ascertained at 30 days and 5 years. Cox proportional hazards regression models were generated. The patient groups were similar, although PHH had shorter symptom onset-treatment time (187 vs. 251 minutes, P < 0.001) and less cardiogenic shock (3.9% vs. 8.0%, P = 0.008). Initial coronary flow was not different between the groups. Thirty day mortality in PHH was 2.5% versus 8.3%, P < 0.001. Independent predictors of 30-day mortality were age (odds ratio 1.07, 95% CI 1.04-1.09), cardiogenic shock (5.97, 3.33-10.69), radial access (0.53, 0.28-0.98), and PHH (0.33, 0.17-0.66). Five-year mortality in PHH was 13.0% versus 21.6%, P < 0.001. Significant predictors of long-term mortality were age (1.07, 1.06-1.09), cardiogenic shock (3.40, 2.23-5.17), and PHH (0.68, 0.49-0.96).

CONCLUSIONS

PHH was associated with reduced short- and long-term mortality after adjusting for important potential confounders.

Serum apelin predicts spontaneous reperfusion of infarct-related artery in patients with ST-segment elevation myocardial infarction

BACKGROUND

Spontaneous reperfusion (SR) was associated with significant myocardial salvage, decreased mortality rates, better clinical outcomes, and lower incidences of major adverse cardiovascular events. It was found that apelin inhibited thrombin-induced and collagen-induced platelet activation and aggregation. This study was carried out to assess whether serum apelin correlates with SR of the infarct-related coronary artery in ST-elevation myocardial infarction (STEMI) patients.

PATIENTS AND METHODS

Blood samples were obtained on admission in 280 consecutive patients with STEMI before primary percutaneous coronary intervention. Blood chemistry and apelin levels were tested. Coronary arteriography and echocardiography were performed after admission.

RESULTS

Frequencies of the patients with preinfarct angina, history of smoking, and pathoglycemia were higher in the non-SR group than in the SR group (P=0.03, 0.001, and 0.002, respectively). Peak values of plasma troponin-I and frequencies of the patients with Killip 2-3 were significantly higher in the non-SR group (P<0.05, respectively) compared with the SR group. Left ventricular systolic and diastolic functions improved markedly in the SR group compared with the non-SR group. Gensini scores were lower in the SR group than the non-SR group (P=0.02). Serum apelin was significantly higher in patients with SR compared with patients with non-SR (0.82±0.34 vs. 0.35±0.22 ng/ml, P=0.04). A cut-off value of 0.75 ng/ml had a predictive value of 77% to identify patients with SR. In the non-SR group, patients who died in the hospital had much lower apelin levels compared with those who survived (P<0.001). Apelin level in the high thrombus load group was much lower compared with the other group (P<0.001). Apelin level in the group undergoing successful reperfusion was much higher than that in the group without successful reperfusion (P<0.001).

CONCLUSION

Patients with SR have better cardiac systolic function and improved diastolic function. An increased serum apelin level is an independent and novel predictor of SR for STEMI patients.

Correlates and Long-Term Implications of Left Ventricular Mechanical Dispersion by Two-Dimensional Speckle-Tracking Echocardiography in Patients with ST-Segment Elevation Myocardial Infarction

BACKGROUND

Left ventricular (LV) mechanical dispersion (LVMD), measured with speckle-tracking echocardiography (STE) after ST-segment elevation myocardial infarction (STEMI), has been proposed as a measurement of regional heterogeneity of myocardial contraction and may reflect changes in the myocardial structure (e.g., fibrosis or edema). Further insight into this parameter may aid in the risk stratification of STEMI patients.

METHODS

A total of 1,000 STEMI patients (77% male, 60 ± 12 years) treated with primary percutaneous coronary intervention were retrospectively analyzed. The LVMD was assessed with two-dimensional STE within 48 hours following the index infarction. Patients were followed for the occurrence of all-cause mortality.

RESULTS

After a median follow-up of 117 months, 229 (23%) patients died. Nonsurvivors showed worse LV ejection fraction (43% ± 10% vs 48% ± 9%; P < .001) and global longitudinal strain (-12.0% ± 3.5% vs -14.2% ± 3.5%; P = .001) and prolonged LVMD (63 [interquartile range, 50-85] msec vs 52 [interquartile range, 42-63] msec; P < .001) compared with survivors. Increasing age, systolic blood pressure, and heart rate at discharge as well as diabetes mellitus, anterior STEMI, TIMI flow < 2, less usage of angiotensin converter enzyme inhibitors or angiotensin receptor blockers, and impaired LV global longitudinal strain were independently associated with more prolonged LVMD. On multivariable analysis, prolonged LVMD was independently associated with increased risk of all-cause mortality (hazard ratio = 1.012; 95% CI, 1.005-1.018; P = .001) and had incremental value for all-cause mortality over clinical and echocardiographic parameters.

CONCLUSIONS

In contemporary STEMI patients, prolonged LVMD was associated with various clinical and echocardiographic parameters. Prolonged LVMD was associated with worse long-term outcome.