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Młynarska E, Czarnik W, Fularski P, Hajdys J, Majchrowicz G, Stabrawa M, Rysz J, Franczyk B. From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion. Int J Mol Sci 2024; 25:7295. [PMID: 39000400 PMCID: PMC11242737 DOI: 10.3390/ijms25137295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/30/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.
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Affiliation(s)
- Ewelina Młynarska
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Witold Czarnik
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Piotr Fularski
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Joanna Hajdys
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Gabriela Majchrowicz
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Magdalena Stabrawa
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
| | - Beata Franczyk
- Department of Nephrocardiology, Medical University of Lodz, ul. Zeromskiego 113, 90-549 Lodz, Poland
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Attar A, Namvar S, Hosseinpour A, Azami P, Shekari A, Jamali L, Goudarzi N. Effect of different reperfusion strategies on recovery of ventricular function after ST-segment elevation myocardial infarction: A longitudinal single-center study. Health Sci Rep 2024; 7:e2220. [PMID: 38933425 PMCID: PMC11199175 DOI: 10.1002/hsr2.2220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/09/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Background and Aims Although the clinical benefit of percutaneous coronary intervention (PCI) on cardiovascular outcomes has been widely investigated, the impact of this revascularization strategy compared to other alternatives on the degree of left ventricular function recovery is poorly demonstrated. In this regard, we investigated whether time delays between the presentation of ST-segment elevation myocardial infarction (STEMI) and PCI in reperfusion strategies have different impacts on left ventricular function recovery. Methods In this single-center study, all the patients who presented with STEMI and a reduced left ventricular ejection fraction (LVEF ≤ 40%) were enrolled. Included patients were subjected to four different treatment groups of primary, rescue (immediate transfer for angioplasty due to failed fibrinolytic therapy), facilitated (fibrinolytic therapy followed by angioplasty within 24 h), and deferred (successful fibrinolytic therapy and PCI after 24 h) PCI based on hospital facilities. Echocardiography was performed for all the patients at the time of hospitalization and 6 months later. Results A total of 128 patients were included in this study. The LVEF improved by 15.3 ± 6.3%, 11.5 ± 3.61%, 4.0 ± 1.0%, and -1.3 ± 7.0% in primary, rescue, facilitated, and deferred PCI groups, respectively (p < 0.001). Patients undergoing deferred PCI experienced a significantly lower improvement in LVEF compared with primary and rescue PCI (p < 0.001). Conclusion Primary PCI demonstrated the most promising recovery in left ventricular function following STEMI compared to other alternative strategies. Performing PCI as soon as possible provides better recovery of LVEF.
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Affiliation(s)
- Armin Attar
- Department of Cardiovascular Medicine, TAHA Clinical Trial GroupShiraz University of Medical SciencesShirazIran
| | - Soheila Namvar
- Department of Cardiovascular Medicine, TAHA Clinical Trial GroupShiraz University of Medical SciencesShirazIran
| | - Alireza Hosseinpour
- Department of Cardiovascular Medicine, TAHA Clinical Trial GroupShiraz University of Medical SciencesShirazIran
- School of MedicineShiraz University of Medical SciencesShirazIran
| | - Pouria Azami
- Department of Cardiovascular Medicine, TAHA Clinical Trial GroupShiraz University of Medical SciencesShirazIran
| | - Arash Shekari
- Cardiovascular Diseases Research Institute, Tehran Heart CenterTehran University of Medical SciencesTehranIran
| | - Leila Jamali
- Department of Cardiovascular Medicine, TAHA Clinical Trial GroupShiraz University of Medical SciencesShirazIran
| | - Neda Goudarzi
- Department of Cardiovascular Medicine, TAHA Clinical Trial GroupShiraz University of Medical SciencesShirazIran
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Alexander T, Kumbhani DJ, Mullasari Sankardas A. The Future of Pharmacoinvasive Therapy for ST-Segment-Elevation Myocardial Infarction Reperfusion in the Post-STREAM Era. Circulation 2024; 149:732-733. [PMID: 38437483 DOI: 10.1161/circulationaha.123.066703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Thomas Alexander
- Department of Cardiology, Kovai Medical Center and Hospital, Coimbatore, India (T.A.)
| | - Dharam J Kumbhani
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX (D.J.K.)
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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5
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Akhtar KH, Khan MS, Baron SJ, Zieroth S, Estep J, Burkhoff D, Butler J, Fudim M. The spectrum of post-myocardial infarction care: From acute ischemia to heart failure. Prog Cardiovasc Dis 2024; 82:15-25. [PMID: 38242191 DOI: 10.1016/j.pcad.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 01/21/2024]
Abstract
Heart failure (HF) is the leading cause of mortality in patients with acute myocardial infarction (AMI), with incidence ranging from 14% to 36% in patients admitted due to AMI. HF post-MI develops due to complex inter-play between macrovascular obstruction, microvascular dysfunction, myocardial stunning and remodeling, inflammation, and neuro-hormonal activation. Cardiogenic shock is an extreme presentation of HF post-MI and is associated with a high mortality. Early revascularization is the only therapy shown to improve survival in patients with cardiogenic shock. Treatment of HF post-MI requires prompt recognition and timely introduction of guideline-directed therapies to improve mortality and morbidity. This article aims to provide an up-to-date review on the incidence and pathogenesis of HF post-MI, current strategies to prevent and treat onset of HF post-MI, promising therapeutic strategies, and knowledge gaps in the field.
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Affiliation(s)
- Khawaja Hassan Akhtar
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Suzanne J Baron
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerry Estep
- Section of Heart Failure & Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York City, NY, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA; Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
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6
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 498] [Impact Index Per Article: 498.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Patail H, Bali A, Sharma T, Frishman WH, Aronow WS. Review and Key Takeaways of the 2021 Percutaneous Coronary Intervention Guidelines. Cardiol Rev 2023:00045415-990000000-00151. [PMID: 37729589 DOI: 10.1097/crd.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
The 2021 Percutaneous Coronary Intervention guidelines completed by American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions provide a set of guidelines regarding revascularization strategies. With emphasis on equity of care, multidisciplinary heart team use, revascularization for acute coronary syndrome, and stable ischemic heart disease, the guidelines create a thorough framework with recommendations regarding therapeutic strategies. In this comprehensive review, our aim is to summarize the 2021 revascularization guidelines and analyze key points regarding each recommendation.
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Affiliation(s)
- Haris Patail
- From the Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Atul Bali
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Tanya Sharma
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
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Badianyama M, Mutyaba A, Nel S, Tsabedze N. ST-segment elevation myocardial infarction heart of Charlotte one-year (STEMI HOC-1) study: a prospective study protocol. BMC Cardiovasc Disord 2023; 23:396. [PMID: 37568090 PMCID: PMC10422761 DOI: 10.1186/s12872-023-03416-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) is a clinically distinguishable yet lethal sequela of ischaemic heart disease (IHD). In sub-Saharan Africa (SSA), death due to acute STEMI is increasing. In South Africa, there is a paucity of data available on the clinical outcomes of acute STEMI within one year for individuals treated in the public healthcare sector. This study primarily seeks to determine the one-year all-cause mortality rate of acute STEMI. The study also assesses the value of serum cardiac biomarkers of myocardial damage and serum uric acid in predicting all-cause mortality in STEMI. METHODS This is a single-centre observational prospective cohort of all consecutive individuals presenting with an acute STEMI to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa. Research data will be sourced on admission through electronic medical records, blood laboratory results and coronary angiography reports, and at follow-up through periodic telephonic interviews and standardised echocardiograms. At least 355 eligible participants will be continuously followed over one year, and clinical outcomes will be measured 30 days, three months, six months and one year after the index hospitalisation. DISCUSSION This study provides insights into the demographic, risk factors and clinical profiles of individuals with STEMI in South Africa. Its findings may improve the risk stratification, prognostication, and therapeutic management of STEMI patients in our setting. By comparing the clinical outcomes between the different coronary reperfusion strategies, our results may guide clinicians in providing better patient treatment, particularly in sub-Saharan Africa, where access to percutaneous coronary intervention may be limited. Furthermore, the study offers insights into the routine use of baseline serum uric acid as a potential low-cost prognostic biomarker of all-cause mortality in STEMI. Finally, this study's findings may be of public health significance to local policymakers to aid in reinforcing primary prevention strategies and developing structured referral networks for timely coronary reperfusion of acute STEMI.
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Affiliation(s)
- Marheb Badianyama
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 2193, Johannesburg, South Africa
| | - Arthur Mutyaba
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 2193, Johannesburg, South Africa
| | - Samantha Nel
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 2193, Johannesburg, South Africa
| | - Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 2193, Johannesburg, South Africa.
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9
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Lu X, Xia W, Wang X, Xie F, Sun X. Factors Associated with Symptom-to-Door Delay in Patients with ST-Segment Myocardial Infarction: A Systematic Review. Prehosp Disaster Med 2023; 38:485-494. [PMID: 37485671 DOI: 10.1017/s1049023x23006039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
BACKGROUND Decreasing symptom-to-door (S2D) delay is of vital importance for reducing morbidity and mortality in patients with ST-segment elevation myocardial infarction (STEMI). The factors associated with S2D delay in STEMI patients have not been well-characterized. OBJECTIVES The aim of this study was to identify factors associated with S2D delay in patients with STEMI. METHODS The PubMed, CINAHL, and Embase databases were searched for data. References from the selected articles and relevant background papers were also manually searched to identify additional eligible studies. The included articles were reviewed and assessed for risk of bias. The level of evidence for each identified factor was evaluated using a semiquantitative synthesis. RESULTS Twelve (12) papers were included in the review. Factors associated with S2D delay were complex and could be divided into sociodemographic, clinical history, and onset characteristics. The level of evidence regarding female sex and diabetes was strong, and the evidence was moderate regarding older age, smoking, history of hypertension, self-transport, or referral. CONCLUSIONS Female sex, older age, previous diabetes, previous hypertension, smoking, and self-transport are all strong or moderate risk factors for S2D time delay in patients with ST-segment myocardial infarction. More efforts should be made to educate at-risk populations concerning symptoms of STEMI and the importance of seeking early medical assistance.
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Affiliation(s)
- Xiuyan Lu
- Cardiology Department, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, Shandong Province, China
| | - Wei Xia
- Cardiology Department, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, Shandong Province, China
| | - Xinru Wang
- Nursing Department, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Fangyu Xie
- Cardiology Department, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, Shandong Province, China
| | - Xiujie Sun
- Nursing Department, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, Shandong Province, China
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10
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De Marqui Moraes PI, Galhardo A, Barbosa AHP, de Sousa JMA, Alves CMR, Bianco HT, Dos Santos Povoa RM, Stefanini E, Goncalves I, de Almeida DR, Fonseca FAH, de Oliveira Izar MC, Moises VA, Lopes RD, Carvalho AC, Caixeta A. Metrics of care and cardiovascular outcomes in patients with ST-elevation myocardial infarction treated with pharmacoinvasive strategy: a decade-long network in a populous city in Brazil. BMC Cardiovasc Disord 2023; 23:300. [PMID: 37322425 PMCID: PMC10268408 DOI: 10.1186/s12872-023-03340-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 06/09/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Pharmacoinvasive strategy is an effective myocardial reperfusion therapy when primary percutaneous coronary intervention (p-PCI) cannot be performed in a timely manner. METHODS Authors sought to evaluate metrics of care and cardiovascular outcomes in a decade-long registry of a pharmacoinvasive strategy network for the treatment of ST-elevation myocardial infarction (STEMI). Data from a local network including patients undergoing fibrinolysis in county hospitals and systematically transferred to the tertiary center were accessed from March 2010 to September 2020. Numerical variables were described as median and interquartile range. Area under the curve (AUC-ROC) was used to analyze the predictive value of TIMI and GRACE scores for in-hospital mortality. RESULTS A total of 2,710 consecutive STEMI patients aged 59 [51-66] years, 815 women (30.1%) and 837 individuals with diabetes (30.9%) were analyzed. The time from symptom onset to first-medical-contact was 120 [60-210] minutes and the door-to-needle time was 70 [43-115] minutes. Rescue-PCI was required in 929 patients (34.3%), in whom the fibrinolytic-catheterization time was 7.2 [4.9-11.8] hours, compared to 15.7 [6.8-22,7] hours in those who had successful lytic reperfusion. All cause in-hospital mortality occurred in 151 (5.6%) patients, reinfarction in 47 (1.7%) and ischemic stroke in 33 (1.2%). Major bleeding occurred in 73 (2.7%) patients, including 19 (0.7%) cases of intracranial bleeding. C-statistic confirmed that both scores had high predictive values for in-hospital mortality, demonstrated by TIMI AUC-ROC of 0.80 [0,77-0.84] and GRACE AUC-ROC of 0.86 [0.83-0.89]. CONCLUSION In a real world registry of a decade-long network for the treatment of ST-elevation myocardial infarction based on the pharmacoinvasive strategy, low rates of in-hospital mortality and cardiovascular outcomes were observed, despite prolonged time metrics for both fibrinolytic therapy and rescue-PCI. Register Clinicaltrials.gov NCT02090712 date of first registration 18/03/2014.
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Affiliation(s)
- Pedro Ivo De Marqui Moraes
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil.
| | - Attilio Galhardo
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Adriano Henrique Pereira Barbosa
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Jose Marconi Almeida de Sousa
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Claudia Maria Rodrigues Alves
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Henrique Tria Bianco
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Rui Manuel Dos Santos Povoa
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Edson Stefanini
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Iran Goncalves
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Dirceu Rodrigues de Almeida
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Francisco Antonio Helfenstein Fonseca
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Maria Cristina de Oliveira Izar
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Valdir Ambrosio Moises
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Renato Delascio Lopes
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
- Duke University Hospital, Duke Clinical Research Institute, DUMC, 2400 Pratt Street, Terrace Level Room 0311, Box 3850, Durham, NC, 27705, USA
| | - Antonio Carlos Carvalho
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
| | - Adriano Caixeta
- Discipline of Cardiology, Department of Medicine, Universidade Federal de Sao Paulo, Rua Napoleao de Barros, 715, Ground Floor, Hospital Sao Paulo, Vila Clementino, Sao Paulo, SP, CEP (ZIP) 04024-002, Brazil
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - Morumbi, Sao Paulo, SP, CEP (ZIP) 05652-900, Brazil
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11
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Broughton N, Comer K, Casey-Gillman O, Moore L, Antoniou S, Patel R, Fhadil S, Wright P, Ozkor M, Guttmann O, Baumbach A, Wragg A, Jain AJ, Choudry F, Mathur A, Rathod KS, Jones DA. An exploration of the early discharge approach for low-risk STEMI patients following primary percutaneous coronary intervention. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2023; 13:32-42. [PMID: 37213314 PMCID: PMC10193248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/17/2023] [Indexed: 05/23/2023]
Abstract
Recently, there has been growing interest in the early discharge strategy for low-risk patients who have undergone primary percutaneous coronary intervention (PCI) to treat ST-segment elevation myocardial infarction (STEMI). So far findings have suggested there are multiple advantages of shorter hospital stays, including that it could be a safe way to be more cost- and resource-efficient, reduce cases of hospital-acquired infection and boost patient satisfaction. However, there are remaining concerns surrounding safety, patient education, adequate follow-up and the generalisability of the findings from current studies which are mostly small-scale. By assessing the current research, we describe the advantages, disadvantages and challenges of early hospital discharge for STEMI and discuss the factors that determine if a patient can be considered low risk. If it is feasible to safely employ a strategy like this, the implications for healthcare systems worldwide could be extremely beneficial, particularly in lower-income economies and when we consider the detrimental impacts of the recent COVID-19 pandemic on healthcare systems.
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Affiliation(s)
- Nicole Broughton
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
| | - Katrina Comer
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Oliver Casey-Gillman
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Lizze Moore
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Riyaz Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Sadeer Fhadil
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Paul Wright
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Muhiddin Ozkor
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Oliver Guttmann
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Andrew Wragg
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Ajay J Jain
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Fizzah Choudry
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Krishnaraj S Rathod
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
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12
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Saito Y, Oyama K, Tsujita K, Yasuda S, Kobayashi Y. Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond. J Cardiol 2023; 81:168-178. [PMID: 35882613 DOI: 10.1016/j.jjcc.2022.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 10/16/2022]
Abstract
Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.
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Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Kazuma Oyama
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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13
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Nicolau JC. Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST Tratado com Intervenção Coronária Percutânea Primária: A Importância de Dados Locais. Arq Bras Cardiol 2022; 119:458-459. [PMID: 36074377 PMCID: PMC9438528 DOI: 10.36660/abc.20220557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Purpose of Review Ischemic cardiomyopathy refers to systolic left ventricular dysfunction in the setting of obstructive coronary artery disease and represents the most common cause of heart failure worldwide. It is often the combination of an irreversible loss of viable mass following an acute myocardial infarction (AMI) with a dysfunctional, but still viable, myocardium in the context of a chronically reduced myocardial blood flow and reduced coronary reserve. Medical treatments aiming at modulating neurohumoral response and restoring blood flow to the ischemic cardiomyocytes were shown to dramatically abate the occurrence of ventricular dysfunction and adverse remodeling in ischemic cardiomyopathy. Recent Findings Novel therapeutic approaches, such as mechanical unloading and modulation of the inflammatory response, appear to be promising. Furthermore, the understanding of the mechanisms by which, despite optimal treatment, heart failure ensues after AMI, with or without adverse remodeling and systolic dysfunction, is a critical step in the search for novel ways to tackle heart failure risk beyond preservation of left ventricular volumes and systolic function. Summary In this review article, we explore the principal pathophysiological mechanisms and pathways of heart failure in ischemic cardiomyopathy, therapeutic opportunities, and knowledge gaps in this area.
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15
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Associations Between Industry Payments to Physicians for Antiplatelet Drugs and Utilization of Cardiac Procedures and Stents. J Gen Intern Med 2022; 37:1626-1633. [PMID: 34378113 PMCID: PMC9130441 DOI: 10.1007/s11606-021-06980-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND A study has shown that industry payments to physicians for drugs are associated not only with higher drug prescriptions but also with higher non-drug costs due to additional utilization of healthcare services. However, the association between industry payments to cardiologists for antiplatelet drugs and the costs and number of percutaneous coronary interventions they perform has not been investigated. OBJECTIVE To examine the association between industry payments to cardiologists for antiplatelet drugs and the costs and number of percutaneous coronary interventions they perform. DESIGN Using the 2016 Open Payments Database linked to the 2017 Medicare Provider Utilization and Payment Data, we examined the association between the value of industry payments related to the antiplatelet drugs prasugrel and ticagrelor and healthcare spending and volume for cardiovascular procedures, adjusted for potential cofounders. SUBJECTS A total of 7456 cardiologists who performed diagnostic cardiac catheterizations on Medicare beneficiaries in 2017. MAIN MEASURES Primary outcomes included (1) healthcare spending on cardiac procedures, (2) diagnostic cardiac catheterization volumes, and (3) rates of coronary stenting. Secondary outcomes were total expenditures for all drugs and for antiplatelet drugs. KEY RESULTS Industry payments for antiplatelet drugs were associated with higher healthcare spending on cardiac procedures (adjusted difference, +$50.9 for additional $100 industry payments; 95% CI, +$25.5 to +$76.2; P < 0.001), diagnostic cardiac catheterizations (+0.1 procedures per cardiologist; 95% CI, +0.03 to +0.1; P=0.001), and stent use (+0.5 per 1000 diagnostic cardiac catheterizations per cardiologist; 95% CI, +0.2 to +0.9; P=0.002). Industry payments for antiplatelet drugs were associated with higher total costs for all drugs and antiplatelet drugs. CONCLUSIONS Industry payments to cardiologists for antiplatelet drugs were associated with both prescribing of antiplatelet drugs and the use of cardiac procedures and stents. Further research is warranted to understand whether the observed associations are causal or reflect a greater propensity for higher volume proceduralists to have relationships with industry.
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16
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Bergmark BA, Mathenge N, Merlini PA, Lawrence-Wright MB, Giugliano RP. Acute coronary syndromes. Lancet 2022; 399:1347-1358. [PMID: 35367005 PMCID: PMC8970581 DOI: 10.1016/s0140-6736(21)02391-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 12/14/2022]
Abstract
Although substantial progress has been made in the diagnosis and treatment of acute coronary syndromes, cardiovascular disease remains the leading cause of death globally, with nearly half of these deaths due to ischaemic heart disease. The broadening availability of high-sensitivity troponin assays has allowed for rapid rule-out algorithms in patients with suspected non-ST-segment elevated myocardial infarction (NSTEMI). Dual antiplatelet therapy is recommended for 12 months following an acute coronary syndrome in most patients, and additional secondary prevention measures including intensive lipid-lowering therapy (LDL-C <1·4 mmol/L), neurohormonal agents, and lifestyle modification, are crucial. The scientific evidence for diagnosis and management of acute coronary syndromes continues to evolve rapidly, including adapting to the COVID-19 pandemic, which has impacted all aspects of care. This Seminar provides a clinically relevant overview of the pathobiology, diagnosis, and management of acute coronary syndromes, and describes key scientific advances.
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Affiliation(s)
- Brian A Bergmark
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Njambi Mathenge
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Piera A Merlini
- 4th Division of Cardiology, Cardiocenter De Gasperis, ASST GOM Niguarda and Bicocca University, Milan, Italy
| | - Marilyn B Lawrence-Wright
- Division of Cardiology, Department of Medicine, The University of the West Indies at Mona, Kingston, Jamaica
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Janjani P, Motevaseli S, Salehi N, Heidari Moghadam R, Siabani S, Nalini M. Predictors of 1-Year Major Cardiovascular Events after ST-Elevation Myocardial Infarction in a Specialized Cardiovascular Center in Western Iran. J Tehran Heart Cent 2022; 17:62-70. [PMID: 36567930 PMCID: PMC9748231 DOI: 10.18502/jthc.v17i2.9839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/20/2022] [Indexed: 12/27/2022] Open
Abstract
Background: Identifying the long-term predictors of recurrent cardiovascular events may help improve the quality of care and prevent subsequent events. We aimed to investigate the predictors of 1-year major cardiovascular events (MACE) in patients discharged after ST-elevation myocardial infarction (STEMI) in a tertiary hospital in Iran. Methods: This registry-based cohort study included consecutive STEMI patients between 2016 and 2019 in Imam-Ali Hospital, Kermanshah, Iran. All patients discharged alive from STEMI hospitalization were followed up for 1 year for MACE, consisting of all-cause mortality, nonfatal MI, and nonfatal stroke. We estimated the hazard ratio (HR) and the 95% confidence interval (95% CI) using Cox proportional-hazard models to evaluate potential predictors, including demographic characteristics, medical history, cardiovascular risk factors, laboratory tests, reperfusion therapy, and medications. Results: During 2187.2 person-years, 21 patients were lost to follow-up (success rate =99.1%). Of 2274 post-discharge STEMI patients (mean age =60.26 y; 21.9% female), 151 (6.6%) experienced MACE, including, all-cause mortality (n=115, 5.1%), nonfatal MI (n=20, 0.9%), and nonfatal stroke (n=16, 0.7%). Independent predictors of MACE were age (HR:1.02; 95% CI: 1.00-1.04), no education vs ≥12 years of formal schooling (HR: 2.07; 95% CI: 1.17-3.67), stroke history (HR: 2.37; 95% CI: 1.48-3.81), the glomerular filtration rate (HR: 0.98; 95% CI: 0.97-1.00), the body mass index (HR: 0.94; 95% CI:, 0.89-0.99), peak creatine kinase-MB (HR: 1.00; 95% CI: 1.00-1.002), thrombolysis vs primary percutaneous coronary intervention (HR: 1.85; 95% CI: 1.21-2.81), and left ventricular ejection fraction <35% vs ≥50% (HR: 2.82; 95% CI: 1.46-5.47). Conclusion: Age, education, stroke history, the glomerular filtration rate, the body mass index, peak creatine kinase-MB, reperfusion therapy, and left ventricular function can be independently associated with 1-year MACE.
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Affiliation(s)
- Parisa Janjani
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Sayeh Motevaseli
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Nahid Salehi
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Reza Heidari Moghadam
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Soraya Siabani
- Department of Health Education and Health Promotion, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Mahdi Nalini
- Cardiovascular Research Center, Health Institute, Imam-Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Corresponding Author: Mahdi Nalini, Assistant Professor of Research in Clinical Sciences and Epidemiology, Cardiovascular Research Center, Imam-Ali Hospital, Shahid Beheshti Blvd, Kermanshah, Iran. 6715847145. Tel: + 98 83 38376525. Fax: +98 83 360043. E-mail: .
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18
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Li K, Zhang B, Zheng B, Zhang Y, Huo Y. Reperfusion Strategy of ST-Elevation Myocardial Infarction: A Meta-Analysis of Primary Percutaneous Coronary Intervention and Pharmaco-Invasive Therapy. Front Cardiovasc Med 2022; 9:813325. [PMID: 35369319 PMCID: PMC8970601 DOI: 10.3389/fcvm.2022.813325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background Pharmaco-invasive therapy (PIT), combining thrombolysis and percutaneous coronary intervention, was a potential complement for primary percutaneous coronary intervention (pPCI), while bleeding risk was still a concern. Objectives This study aims to compare the efficacy and safety outcomes of PIT and pPCI. Methods A systematic search for randomized controlled trials (RCTs) and observational studies were conducted on Pubmed, Embase, Cochrane library, and Scopus. RCTs and observational studies were all collected and respectively analyzed, and combined pooled analysis was also presented. The primary efficacy outcome was short-term all-cause mortality within 30 days, including in-hospital period. The primary safety outcome was 30-day trial-defined major bleeding events. Results A total of 26,597 patients from 5 RCTs and 12 observational studies were included. There was no significant difference in short-term mortality [RCTs: risk ratio (RR): 1.14, 95% CI: 0.67–1.93, I2 = 0%, p = 0.64; combined results: odds ratio (OR): 1.09, 95% CI: 0.93–1.29, I2 = 0%, p = 0.30] and 30-day major bleeding events (RCTs: RR: 0.44, 95% CI: 0.07–2.93, I2 = 0%, p = 0.39; combined results: OR: 1.01, 95% CI: 0.53–1.92, I2 = 0%, p = 0.98). However, pPCI reduced risk of in-hospital major bleeding events, stroke and intracranial bleeding, but increased risk of in-hospital heart failure and 30-day heart failure in combined analysis of RCTs and observational studies, despite no significant difference in analysis of RCTs. Conclusion Pharmaco-invasive therapy could be an important complement for pPCI in real-world clinical practice under specific conditions, but studies aiming at optimizing thrombolysis and its combination of mandatory coronary angiography are also warranted.
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Affiliation(s)
- Kaiyin Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bin Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First hospital, Beijing, China
- *Correspondence: Bo Zheng,
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First hospital, Beijing, China
- Yan Zhang,
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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19
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Zhang Y, Wang S, Cheng Q, Zhang J, Qi D, Wang X, Zhu Z, Li M, Hu D, Gao C. Reperfusion strategy and in-hospital outcomes for ST elevation myocardial infarction in secondary and tertiary hospitals in predominantly rural central China: a multicentre, prospective and observational study. BMJ Open 2021; 11:e053510. [PMID: 34930741 PMCID: PMC8689172 DOI: 10.1136/bmjopen-2021-053510] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To assess differences in reperfusion treatment and outcomes between secondary and tertiary hospitals in predominantly rural central China. DESIGN Multicentre, prospective and observational study. SETTING Sixty-six (50 secondary and 16 tertiary) hospitals in Henan province, central China. PARTICIPANTS Patients with ST elevation myocardial infarction (STEMI) within 30 days of symptom onset during 2016-2018. PRIMARY OUTCOME MEASURES In-hospital mortality, and in-hospital death or treatment withdrawal. RESULTS Among 5063 patients of STEMI, 2553 were treated at secondary hospitals. Reperfusion (82.0% vs 73.0%, p<0.001) including fibrinolytic therapy (70.3% vs 4.4%, p<0.001) were more preformed, whereas primary percutaneous coronary intervention (11.7% vs 68.6%, p<0.001) were less frequent at secondary hospitals. In secondary hospitals, 53% received fibrinolytic therapy 3 hours after onset, and 5.8% underwent coronary angiography 2-24 hours after fibrinolysis. Secondary hospitals had a shorter onset-to-first-medical-contact time (176 min vs 270 min, p<0.001). Adjusted in-hospital mortality (adjusted OR 1.23, 95% CI 0.89 to 1.70, p=0.210) and in-hospital death or treatment withdrawal (adjusted OR 1.18, 95% CI 0.82 to 1.70, p=0.361) were similar between secondary and tertiary hospitals. CONCLUSIONS With fibrinolytic therapy as the main reperfusion strategy, the reperfusion rate was higher in secondary hospitals, whereas in-hospital outcomes were similar compared with tertiary hospitals. Public awareness, capacity of primary and secondary care institutes to treat STEMI, and establishment of deeper cooperation among different-level healthcare institutes need to further improve. TRIAL REGISTRATION NUMBER NCT02641262.
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Affiliation(s)
- You Zhang
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Shan Wang
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Qianqian Cheng
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Junhui Zhang
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Datun Qi
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xianpei Wang
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhongyu Zhu
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Muwei Li
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dayi Hu
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan, China
- Institute of Cardiovascular Disease, Peking University People's Hospital, Beijing, China
| | - Chuanyu Gao
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, Henan, China
- Henan Institute of Cardiovascular Epidemiology, Zhengzhou, Henan, China
- Henan Key Laboratory for Prevention and Control of Coronary Heart Disease, Central China Fuwai Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Orvad H, Savage L, Smith T, Hamiduzzaman M, Schmidt D. Not All STEMI Patients Receive Timely Reperfusion: Considerations for Rural Emergency Departments. J Multidiscip Healthc 2021; 14:3103-3108. [PMID: 34785903 PMCID: PMC8580293 DOI: 10.2147/jmdh.s337197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/20/2021] [Indexed: 11/23/2022] Open
Abstract
Early reperfusion for ST-elevation myocardial infarction (STEMI) is well known to improve patient outcomes. A review of patient records in one rural health service in New South Wales, Australia, suggested that not all STEMI patients were receiving timely reperfusion. Consequently, the aim of this study was to further investigate factors influencing clinical decision making by primary care providers in relation to rural STEMI patients. This cross-sectional observational study was in two phases, a retrospective audit of patient records and a survey of rural general practitioners (GPs). In the first phase, patients with STEMI who were referred from small rural hospitals to a regional hospital emergency department (ED) were identified through the local health district database. In phase two, information from the database informed questions for a survey distributed to the GP visiting medical officers (VMOs) at small rural hospitals in the region. The survey was designed to ascertain factors that may contribute to delays in the care of STEMI patients. Of the STEMI patients identified (n = 139), 15% (21) who were eligible for medical reperfusion were not administered thrombolysis within 4 hours of triage. Auditing of this group's records found that ECGs were inaccurately interpreted for 76% of the missed STEMI patients. In the survey, about 55% of the GP respondents said they “very much agree” with the statement that they felt competent in STEMI management. Only 64% of the GP VMOs agreed they felt competent in diagnosis and management of a failed thrombolysis and not all respondents were aware of the relevant clinical guideline. Patients with missed STEMI are at higher risk of morbidity and mortality and increased length of stay, adding burden to the patient, carer and health service. Without addressing gaps in service provision and better adherence to clinical guidelines, unacceptable delays in STEMI management in rural health services are likely to continue.
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Affiliation(s)
- Helen Orvad
- Hunter New England Local Health District, Tamworth, NSW, Australia
| | - Lindsay Savage
- Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Tony Smith
- University of Newcastle Department of Rural Health, Taree, NSW, Australia
| | | | - David Schmidt
- Health Education and Training Institute, Australia Health Education and Training Institute, Sydney, NSW, Australia
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21
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Gao H, Peng H, Sun Z, Chen H, Di B, Li H. Contemporary Implications of ECG to Activation Time on Long-term Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention. Clin Ther 2021; 43:2104-2115. [PMID: 34750020 DOI: 10.1016/j.clinthera.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/04/2021] [Accepted: 10/12/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE The prognosis of door to balloon time (DBT) after primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction (STEMI) has been extensively studied. However, the clinical implications of the ECG to activation time (EAT), as a component of DBT, on long-term outcomes are less well established. This study evaluates the association of EAT with major adverse cardiovascular events (MACEs) in more contemporary patients undergoing PPCI and investigates factors that influence EAT. METHODS A total of 1082 consecutive patients with STEMI who underwent PPCI from 2013 to 2019 were classified into 3 groups according to EAT: EAT ≤30 minutes, EAT of 30 to 60 minutes, and EAT >60 minutes. We analyzed the incidence of MACEs, including all-cause death, nonfatal recurrence of MI, or nonfatal stroke during a median follow-up of 37 months. FINDINGS The median EAT was 58 minutes (interquartile range, 44-80 minutes), which explained 90% of the variability in DBT and had the strongest correlation with DBT (r = 0.95, P < 0.001). Achieving an EAT of ≤30 minutes resulted in a 94.1% chance of achieving a DBT ≤90 minutes. The incidence of MACEs had a concurrent increase with increased EAT (10.2% for EAT ≤30 minutes, 14.3% for EAT of 30-60 minutes, and 17.3% for EAT >60 minutes; P = 0.027) that was driven by more mortality (4.2% for EAT ≤30 minutes, 6.9% for EAT of 30-60 minutes, and 9.8% for EAT >60 minutes; P = 0.020). An EAT >30 minutes was independently associated with risk-adjusted long-term MACEs (hazard ratio = 1.99; 95% CI, 1.07-3.69; P = 0.030). Critically ill status in emergency department (P = 0.001) and time required for consent of revascularization (P < 0.001) were significantly associated with delayed EAT. IMPLICATIONS Achieving an EAT ≤30 minutes was key to achieving the guideline-recommended target time of DBT in contemporary practice. As a strong driver of overall DBT, EAT >30 minutes was associated with worse clinical outcome in patients with STEMI undergoing PPCI. These data suggest that efforts to minimize EAT are needed to reduce long-term MACEs in contemporary population. (Clin Ther. 2021;XX:XXX-XXX) © 2021 Elsevier HS Journals, Inc.
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Affiliation(s)
- Hui Gao
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hui Peng
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhijun Sun
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hui Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Beibing Di
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hongwei Li
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China; Department of Internal Medical, Medical Health Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China; Beijing Key Laboratory of Metabolic Disorder Related Cardiovascular Disease, Beijing, People's Republic of China.
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22
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Ma J, Tai Y, Fan M, Wang Z. Cardiac Rehabilitation of Patients with Acute ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention in a Han Population in Northern China: A Prospective Cohort Study. Int J Gen Med 2021; 14:4959-4965. [PMID: 34483684 PMCID: PMC8409762 DOI: 10.2147/ijgm.s326725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 07/30/2021] [Indexed: 11/28/2022] Open
Abstract
Background Cardiac rehabilitation (CR) has been associated with improved cardiac function in cardiovascular diseases. Our aim was to explore the factors associated with cardiac function and CR. Methods This prospective cohort study had 473 STEMI patients admitted for primary percutaneous coronary intervention (PCI) who were divided into a CR group (group A, n = 104) and a non-CR group (group B, n = 369) based on whether they could complete CR. Patients’ clinical features, such as age, hyperlipidemia, family history of premature coronary heart disease (FHPCHD), smoking history, body mass index (BMI, kg/m2), number of diseased vessels, arrhythmia during PCI, N-terminal pro–B-type natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF) and major adverse cardiac events (MACEs) at 6 months after PCI were compared. Then, the clinical characteristics of patients were further analyzed according to those with MACEs (n = 78) and those without MACEs (n = 395). Results After CR of 6 months, NT-proBNP levels (p = 0.027), 6-MWD (meter, P = 0.000), LVEF (P = 0.000) were significantly improved in group A compared to group B, but not for SMWA (P = 0.875). Multivariate analysis indicated that even though patients in group A (OR 3.06, 95% CI 1.132–8.274, p = 0.03) have a higher incidence of hyperlipidemia, their MACEs (OR 0.191, 95% CI 0.038–0.961, p = 0.05) at 6 months were significantly lower than in group B, mainly because the average patient low age (<65 years, OR 0.917, 95% CI 0.859–0.979, p = 0.01) and significant improvement of 6-MWD (OR 7.999, 95% CI 4.342–14.737, P = 0.00) and the LVEF at 6 months (OR 1.112, 95% CI 1.072–1.154, p = 0.00). Further analysis based on the MACES outcomes showed that there were 6 factors associated with the occurrence of MACEs, they were age >65 years (OR 1.032, 95% CI 1.009–1.009, p = 0.007), smoking history (OR 0.485, 95% CI 0.238–0.989, p = 0.046), education level (OR 2.646, 95% CI 1.370–5.108, p = 0.004), 6-MWD (OR 1.688, 95% CI 1.104–2.811, p = 0.044), LVEF (OR 0.958, 95% CI 0.926–0.991, p = 0.013) and CR (OR 6.271, 95% CI 2.236–17.590, p = 0.000). Conclusion CR, including exercise rehabilitation, is a beneficial option to reduce MACEs in STEMI patients treated with primary PCI.
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Affiliation(s)
- Jingru Ma
- Department of Cardiology, The Second Affiliated Hospital, Shenyang Medical College, Shenyang, 110035, People's Republic of China
| | - Yuling Tai
- Department of Cardiology, Tongliao City Hospital, Tongliao, 028000, People's Republic of China
| | - Mengmeng Fan
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang, 453000, People's Republic of China
| | - Zhansheng Wang
- Department of Cardiology, Fourth People's Hospital of Shenyang, Shenyang, 110034, People's Republic of China
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23
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Alexander T, Mullasari A, Nallamothu B. Management strategies for acute STEMI in low- and middle-income countries: experience of the Tamil Nadu ST-segment elevation myocardial infarction programme: Management strategies for STEMI in LMIC. ASIAINTERVENTION 2021; 7:27-34. [PMID: 34912999 PMCID: PMC8670567 DOI: 10.4244/aij-d-21-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/27/2021] [Indexed: 06/14/2023]
Abstract
Appropriate and timely management of ST-elevation myocardial infarction is a major challenge in developing countries due to inadequate infrastructure and trained manpower. The TN-STEMI Program was a successful STEMI system of care that was run in the South Indian state of Tamil Nadu. Lessons learnt from this programme could help to understand the challenges and provide solutions to running similar programmes in low- and middle-income countries.
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Affiliation(s)
- Thomas Alexander
- Kovai Medical Centre and Hospital, 99 Avanashi Rd, Coimbatore, Tamil Nadu, 641014, India. E-mail:
| | - Ajit Mullasari
- Department of Cardiology, Madras Medical Mission, Chennai, India
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24
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Case Selection During the COVID-19 Pandemic: Who Should Go to the Cardiac Catheterization Laboratory? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:27. [PMID: 33758493 PMCID: PMC7972331 DOI: 10.1007/s11936-020-00892-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 12/14/2022]
Abstract
Purpose of review To summarize the best available evidence and recommendations regarding case selection for cardiac catheterization laboratory (CCL) during the coronavirus disease 2019 (COVID-19) pandemic with emphasis on ST segment elevation myocardial infarction (STEMI) management. Recent findings The restructuring of cardiovascular services to preserve hospital beds and personal protective equipment during the COVID-19 pandemic had a profound effect on healthcare delivery around the world with unintended consequences. In the United States, a significant 38% reduction in CCL activations for STEMI was noted in the early phase of the pandemic. Similarly, a 34% decline in utilization of invasive angiography, an 18% reduction in primary percutaneous coronary intervention (PPCI), and a 19% increase in door-to-balloon (D2B) times were also observed. These trends coincided with a significant increase in out-of-hospital cardiac arrests and late MI presentations. A shift to pharmacological reperfusion has been advocated in Asia, which resulted in increased morbidity and mortality. Summary COVID-19 has negatively affected many aspects of STEMI care, including timely access to mechanical reperfusion, which has resulted in increased morbidity and mortality. Balancing optimal STEMI care with the risk of infection to healthcare workers during the pandemic is challenging. Recommendations provided by consensus documents are a helpful guidance.
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25
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Fernando H, Dinh D, Duffy SJ, Brennan A, Sharma A, Clark D, Ajani A, Freeman M, Peter K, Stub D, Hiew C, Reid CM, Oqueli E. Rescue PCI in the management of STEMI: Contemporary results from the Melbourne Interventional Group registry. IJC HEART & VASCULATURE 2021; 33:100745. [PMID: 33786363 PMCID: PMC7988313 DOI: 10.1016/j.ijcha.2021.100745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/12/2021] [Accepted: 02/19/2021] [Indexed: 12/01/2022]
Abstract
Background Fibrinolysis is an important reperfusion strategy in the management of ST-elevation myocardial infarction (STEMI) when timely access to primary percutaneous coronary intervention (PPCI) is unavailable. Rescue PCI is generally thought to have worse outcomes than PPCI in STEMI. We aimed to determine short- and long-term outcomes of patients with rescue PCI versus PPCI for treatment of STEMI. Methods and results Patients admitted with STEMI (excluding out-of-hospital cardiac arrest) within the Melbourne Interventional Group (MIG) registry between 2005 and 2018 treated with either rescue PCI or PPCI were included in this retrospective cohort analysis. Comparison of 30-day major adverse cardiac events (MACE) and long-term mortality between the two groups was performed. There were 558 patients (7.1%) with rescue PCI and 7271 with PPCI. 30-day all-cause mortality (rescue PCI 6% vs. PPCI 5%, p = 0.47) and MACE (rescue PCI 10.3% vs. PPCI 8.9%, p = 0.26) rates were similar between the two groups. Rates of in-hospital major bleeding (rescue PCI 6% vs. PPCI 3.4%, p = 0.002) and 30-day stroke (rescue PCI 2.2% vs. PPCI 0.8%, p < 0.001) were higher following rescue PCI. The odds ratio for haemorrhagic stroke in the rescue PCI group was 10.3. Long-term mortality was not significantly different between the groups (rescue PCI 20% vs. PPCI 19%, p = 0.33). Conclusions With contemporary interventional techniques and medical therapy, rescue PCI remains a valuable strategy for treating patients with failed fibrinolysis where PPCI is unavailable and it has been suggested in extenuating circumstances where alternative revascularisation strategies are considered.
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Affiliation(s)
- Himawan Fernando
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anand Sharma
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia
| | - David Clark
- Department of Cardiology Austin Health, Melbourne, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Department of Cardiology, Alfred Hospital, Melbourne, Australia.,Atherothrombosis Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Melbourne, Australia
| | - Chin Hiew
- Department of Cardiology, Barwon Health, Geelong, Victoria, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRE), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia
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26
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Chen Z, Wang D, Ma M, Li C, Wan Z, Zhang L, Zhu Y, Wang M, Wang H, He S, Peng Y, Wei J, Huang B, He Y. Rationale and design of the OPTIMAL-REPERFUSION trial: A prospective randomized multi-center clinical trial comparing different fibrinolysis-transfer percutaneous coronary intervention strategies in acute ST-segment elevation myocardial infarction. Clin Cardiol 2021; 44:455-462. [PMID: 33634478 PMCID: PMC8027583 DOI: 10.1002/clc.23582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 02/05/2023] Open
Abstract
Primary percutaneous coronary intervention (PPCI), the preferred reperfusion strategy for all acute ST‐segment elevation myocardial infarction (STEMI) patients, is not universally available in clinical practice. Pharmacoinvasive strategy has been proposed as a therapeutic option in patients with STEMI when timely PPCI is not feasible. However, pharmacoinvasive strategy has potential delay between clinical patency and complete myocardial perfusion. The optimal reperfusion strategy for STEMI patients with anticipated PPCI delay according to current practice is uncertain. OPTIMAL‐REPERFUSION is an investigator‐initiated, prospective, multicenter, randomized, open‐label, superiority trial with blinded evaluation of outcomes. A total of 632 STEMI patients presenting within 6 hours after symptom onset and with an expected time of first medical contact to percutaneous coronary intervention (PCI) ≥120 minute will be randomized to a reduced‐dose facilitated PCI strategy (reduced‐dose fibrinolysis combined with simultaneous transfer for immediate invasive therapy with a time interval between fibrinolysis to PCI < 3 hours) or to standard pharmacoinvasive treatment. The primary endpoint is the composite of death, reinfarction, refractory ischemia, congestive heart failure, or cardiogenic shock at 30‐days. Enrollment of the first patient is planned in March 2021. The recruitment is anticipated to last for 12 to 18 months and to complete in September 2023 with 1 year follow‐up. The OPTIMAL‐REPERFUSION trial will help determine whether reduced‐dose facilitated PCI strategy improves clinical outcomes in patients with STEMI and anticipated PPCI delay. This study is registered with the ClinicalTrials.gov (NCT04752345).
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Affiliation(s)
- Zhongxiu Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Min Ma
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Chen Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Zhi Wan
- Department of Emergency Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Li Zhang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Ye Zhu
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Mian Wang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Hua Wang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Sen He
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yong Peng
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jiafu Wei
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Baotao Huang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yong He
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
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27
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Comparative Effectiveness of Reperfusion Strategies in Patients with ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) Trial. Glob Heart 2020; 15:68. [PMID: 33150133 PMCID: PMC7566530 DOI: 10.5334/gh.868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Introduction: Substantial heterogeneity exists in reperfusion strategies for patients with ST-segment myocardial infarction (STEMI) in low- and middle-income countries (LMICs). We sought to compare outcomes associated with primary percutaneous coronary intervention (PPCI) and non-primary percutaneous coronary intervention (nPPCI) reperfusion strategies in patients with STEMI in Kerala, India. Methods: We performed a retrospective analysis of patients with STEMI (n = 8665) from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) randomized trial receiving either PPCI (n = 6623) or nPPCI (n = 2042). nPPCI included all PCI strategies implemented when PPCI was not available including all post-fibrinolysis PCI strategies and PCI without fibrinolysis. Clinical outcomes among patients undergoing PPCI and nPPCI were compared after propensity-score matching. The main outcomes were the rates of in-hospital and 30-day major adverse cardiovascular events (MACE), defined as the composite of death, reinfarction, stroke, and major bleeding. Results: In the propensity-score matched cohort (n = 1266 in each group), nPPCI had longer symptom onset to hospital arrival time (347.5 vs. 195.0 minutes, p < 0.001), door to balloon time (108 minutes vs. 75 minutes, p < 0.001), and were less likely to receive a coronary stent (89.4% vs. 95%, p < 0.001), including drug-eluting stents (89.5% vs. 94.4%, p < 0.001). There were no clinically meaningful differences in discharge medical therapy. However, patients treated with nPPCI were less commonly referred for cardiac rehabilitation (20.2% vs. 24.2%; p = 0.019). In-hospital (3.6% vs. 3.3%, p = 0.74%) and 30-day (4.4% vs. 4.6%, p = 0.77) MACE did not differ between nPPCI and PPCI matched groups. Conclusion: In a large, contemporary population of STEMI patients from a LMIC, patients treated with a nPPCI reperfusion strategy had comparable short- and intermediate-term outcomes compared to PPCI despite differences in hospital presentation time and coronary stent use. These findings are reassuring but highlight the need for continued quality improvement in the delivery of STEMI care in resource-limited settings.
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28
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Engel Gonzalez P, Omar W, Patel KV, de Lemos JA, Bavry AA, Koshy TP, Mullasari AS, Alexander T, Banerjee S, Kumbhani DJ. Fibrinolytic Strategy for ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Interv 2020; 13:e009622. [DOI: 10.1161/circinterventions.120.009622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The ongoing coronavirus disease 2019 pandemic has resulted in additional challenges for systems designed to perform expeditious primary percutaneous coronary intervention for patients presenting with ST-segment–elevation myocardial infarction. There are 2 important considerations: the guideline-recommended time goals were difficult to achieve for many patients in high-income countries even before the pandemic, and there is a steep increase in mortality when primary percutaneous coronary intervention cannot be delivered in a timely fashion. Although the use of fibrinolytic therapy has progressively decreased over the last several decades in high-income countries, in circumstances when delays in timely delivery of primary percutaneous coronary intervention are expected, a modern fibrinolytic-based pharmacoinvasive strategy may need to be considered. The purpose of this review is to systematically discuss the contemporary role of an evidence-based fibrinolytic reperfusion strategy as part of a pharmacoinvasive approach, in the context of the emerging coronavirus disease 2019 pandemic.
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Affiliation(s)
- Pedro Engel Gonzalez
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Wally Omar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Kunal V. Patel
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - James A. de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Anthony A. Bavry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Thomas P. Koshy
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
| | - Ajit S. Mullasari
- The Institute of Cardio-Vascular Diseases, Madras Medical Mission, Chennai, India (A.S.M.)
| | - Thomas Alexander
- Department of Cardiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India (T.A.)
| | - Subhash Banerjee
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
- VA North Texas Health Care System, Dallas (S.B.)
| | - Dharam J. Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (P.E.G., W.O., K.V.P., J.A.d.L., A.A.B., T.P.K., S.B., D.J.K.)
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29
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Mentias A, Girotra S. Pharmaco-Invasive Strategy: The Answer to Improving ST-Elevation-Myocardial Infarction Care. J Am Heart Assoc 2020; 9:e016831. [PMID: 32500798 PMCID: PMC7429034 DOI: 10.1161/jaha.120.016831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Amgad Mentias
- University of Iowa Carver College of Medicine Iowa City IA
| | - Saket Girotra
- University of Iowa Carver College of Medicine Iowa City IA.,Center for Access and Delivery Research and Evaluation Iowa City Veterans Affairs Medical Center Iowa City IA
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30
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Fazel R, Joseph TI, Sankardas MA, Pinto DS, Yeh RW, Kumbhani DJ, Nallamothu BK. Comparison of Reperfusion Strategies for ST-Segment-Elevation Myocardial Infarction: A Multivariate Network Meta-analysis. J Am Heart Assoc 2020; 9:e015186. [PMID: 32500800 PMCID: PMC7429064 DOI: 10.1161/jaha.119.015186] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background We systematically reviewed trials comparing different reperfusion strategies for ST-segment-elevation myocardial infarction and used multivariate network meta-analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST-segment-elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as "facilitated PCI" when the median time interval between fibrinolysis to PCI was <2 hours (n=2259) and as a "pharmacoinvasive approach" when this interval was ≥2 hours (n=2747). We evaluated outcomes of death, nonfatal reinfarction, stroke, and major bleeding using a multivariate network meta-analysis and a Bayesian analysis. Among the strategies evaluated, primary PCI was associated with the lowest risk of mortality, nonfatal reinfarction, and stroke. For mortality, primary PCI had an odds ratio of 0.73 (95% CI, 0.61-0.89) when compared with fibrinolytic therapy. Of the remaining strategies, the pharmacoinvasive approach was the next most favorable with an odds ratio for death of 0.79 (95% CI, 0.59-1.08) compared with fibrinolytic therapy. The Bayesian model indicated that when the 2 strategies examining routine early invasive therapy following fibrinolysis were directly compared, the probability of adverse outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions A pharmacoinvasive approach is safer and more effective than facilitated PCI and fibrinolytic therapy alone. This has significant implications for ST-segment-elevation myocardial infarction care in settings where timely access to primary PCI, the preferred treatment for ST-segment-elevation myocardial infarction, is not available.
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Affiliation(s)
- Reza Fazel
- Division of Cardiovascular Medicine Department of Medicine Beth Israel Deaconess Medical Center Boston MA
| | | | - Mullasari A Sankardas
- Department of Cardiology Institute of Cardiovascular Diseases The Madras Medical Mission Chennai India
| | - Duane S Pinto
- Department of Medicine Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Robert W Yeh
- Department of Medicine Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA
| | - Dharam J Kumbhani
- Division of Cardiology Department of Medicine UT Southwestern Medical Center Dallas TX
| | - Brahmajee K Nallamothu
- Veterans Affairs Ann Arbor Health Services Research and Development Center of Excellence Ann Arbor Veterans Affairs Medical Center Ann Arbor MI.,Division of Cardiovascular Medicine Department of Internal Medicine University of Michigan Medical School Ann Arbor MI
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