Early detection of coronary artery flow and myocardial perfusion impairment in hypertensive patients evidenced by myocardial blush grade (MBG) and thrombolysis in myocardial infarction (TIMI) frame count (TFC)

Left Ventricular Diastolic Function: Comparison of Slow Coronary Flow Phenomenon and Left Ventricular Hypertrophy in the Absence of Obstructive Coronary Disease

Background An interplay of myocardial structural abnormalities and coronary arterial dysfunction underlies the worsening left ventricular compliance. The conventionally used angina drugs have demonstrated a beneficial effect on both angina and coronary flow in cases with microvascular dysfunction and non-obstructive coronary disease. Despite that, vasoactive therapy only partially affects diastolic function in this patient population. Purpose This retrospective study was planned to evaluate the association of myocardial mass, delayed epicardial coronary flow, and vasoactive drugs with parameters of diastolic function in two cohorts with preserved left ventricular function and non-obstructive coronary disease in patients with slow coronary flow phenomenon (SCFP) and patients with the hypertensive disease and left ventricular hypertrophy. Material and methods The epicardial coronary flow was evaluated in 48 patients with unstable angina in the absence of coronary stenosis >50%, by applying the methods of corrected thrombolysis in myocardial infraction frame count (cTFC). The abnormalities in the left ventricular function were assessed by echocardiography using PW-Doppler of the diastolic mitral inflow and tissue Doppler imaging. Twenty-one (43.8%) patients were diagnosed with SCFP, and twelve patients (25%) had slow epicardial coronary flow, hypertensive disease, and ventricular hypertrophy (SFLVH). The remaining 15 (31.3%) were patients with ventricular hypertrophy, hypertension, and non-delayed epicardial coronary flow (NFLVH). Results The patients with SFLVH showed reduced peak early diastolic lateral mitral annular velocity (e'L) when compared to SCFP (7.1±1.9cm/s vs 8.6±2.1 cm/s, p=0.045) and NFLVH (7.1±1.9 cm/s vs 8.7±1.8 cm/s, p=0.018). A borderline significant difference was observed for the peak early diastolic septal mitral annular velocity (e'S) between the patients with SFLVH and SCFP ( 7.0±1.3 cm/s vs 8.3±2.1 cm/s, p=0.057). The ratio of mitral diastolic inflow velocity to early diastolic velocity of the mitral annulus (E/e') in the SFLVH group was a tendency higher than E/e' of the patients with SCFP (9.8±3.1 vs. 8.2±2.1, p=0.084) and NFLVH (9.8±3.1 vs. 7.8±1.5, p=0.051) .In the group with left ventricular hypertrophy, E/e' >10 was more frequently observed in patients with a marked delay in the epicardial flow (33.1 ± 13.1 frames vs. 25.4 ± 11.8 frames, p=0.011) and higher left ventricular mass (146.9 ± 17.7 g/m2 vs. 126.1 ± 121.5 g/m2, p=0.027). Conclusions Patients with microvascular angina represent a diverse population. The echocardiographic parameters of left ventricular relaxation (e') and end-diastolic pressure (E/e') are abnormally altered in the population with left ventricular hypertrophy compared to SCFP. The delayed epicardial flow further impairs diastolic function in hypertensive patients with hypertrophy and non-obstructive coronary disease.

Assessment of the relationship between reperfusion success and T-peak to T-end interval in patients with ST elevation myocardial infarction treated with percutaneous coronary intervention

Objective:

T-peak–T-end (TPE) interval, which represents the dispersion of repolarization, is defined as the interval between the peak and end of the T-wave, and is associated with increased malignant ventricular arrhythmia and sudden cardiac death (SCD) in patients with ST elevation myocardial infarction (STEMI). Although prolonged TPE interval is associated with poor short- and long-term outcomes, even in patients with STEMI treated with successful primary percutaneous coronary intervention (pPCI), clinical, angiographic, and laboratory parameters that affect TPE remain to be elucidated. The aim of our study was to evaluate the potential relationship between prolonged TPE interval and reperfusion success using ST segment resolution (STR) in patients with STEMI undergoing pPCI.

Methods:

In the current study, 218 consecutive patients with STEMI who underwent pPCI were enrolled; after exclusion, 164 patients were included in the study population.

Results:

Patients were divided into two groups according to the presence of complete (STR%≥70) or incomplete (STR%<70) STR. Preprocedural corrected TPE (cTPE_PRE;116±21 ms vs. 108±21 ms; p=0.027), postprocedural TPE (TPE_POST; 107±16 ms vs. 92±21 ms; p<0.001), and postprocedural cTPE (cTPE_POST; 119±19 ms vs. 102±17 ms; p<0.001) intervals were significantly longer in patients with incomplete STR than in patients with complete STR, whereas there was no statistically significant difference between the two groups in terms of pre- and postprocedural and corrected QT intervals. cTPE_PRE and cTPE_POST were found to be independent predictors for incomplete STR.

Conclusion:

To our knowledge, this is the first study that evaluated the relationship between TPE interval and no-reflow defined by STR in patients with STEMI who were treated with pPCI.

The predictive value of R-wave peak time on no-reflow in patients with ST-elevation myocardial infarction treated with a primary percutaneous coronary intervention

Background

Coronary no-reflow (NR) is a dreadful complication of primary percutaneous coronary intervention (pPCI) that is seen in nearly 50% of cases. A great effort is being done to discover simple tools that could predict such a complication. We aimed primarily to study the predictive power of R-wave peak time (RWPT) on NR.

Methods

From October 2017 to March 2018, we enrolled 123 patients with STEMI treated with pPCI at Benha University Hospital and National Heart Institute. We measured RWPT from infarct-related artery (IRA) leads and assessed the development of NR in all finally included 100 patients (after exclusions).

Results

Based on occurrence of NR, patients were divided into 2 groups; Group I (n = 39) with NR and group II (n = 61) without NR. Smoking, DM, HTN, longer reperfusion times and higher thrombus burden were significantly associated with NR. Both pre- and postprocedural RWPT were significantly higher in group I than Group II. Preprocedural RWPT > 46 ms predicted NR with a sensitivity and specificity of 79.5% and 86.9% respectively (AUC 0.891, 95% CI 0.82-0.962, P < 0.001). In adjusted multivariate analysis, preprocedural RWPT was found to be among independent predictors for NR (OR: 26.2, 95% CI: 6.5-105.1, P < 0.001). The predictive power of preprocedural RWPT was statistically non-inferior to ST-resolution (STR)% (difference between area under curves = 0.029, P = 0.595).

Conclusion

RWPT is strongly associated with and significantly predicts the development of NR. This association was statistically non-inferior to the well-known association between STR% and NR.

Relationship between R-wave peak time and no-reflow in ST elevation myocardial infarction treated with a primary percutaneous coronary intervention

OBJECTIVES

Coronary no-reflow (NR) is observed in nearly half of ST segment elevation myocardial infarction (STEMI) patients who undergo a primary percutaneous coronary intervention (pPCI) despite epicardial coronary vessel patency. Several methods used to define NR include thrombolysis in myocardial infarction grade, corrected thrombolysis in myocardial infarction frame count, myocardial blush grade, ST-segment resolution, contrast echocardiography, and MRI. The aim of our study was to evaluate the relationship between NR and R-wave peak time (RWPT) measured from infarct-related artery leads METHOD: We enrolled 282 consecutive STEMI patients treated with pPCI in Kafkas University Hospital from January 2014 to January 2015. After exclusion, the remaining 233 patients were included in the study population RESULTS: Patients were divided into two groups according to the development of NR. We observed that increased preprocedural (31 (27-37) vs 27 (21-30) p<0,001) and postprocedural RWPT(35±7 vs 22±6 p<0,001) was associated with the development of NR and preprocedural RWPT(OR: 1.254 95% CI: 1.104-1.425 p<0,001) was found to be independent predictor of NR. The association between postprocedural RWPT and angiographic NR was statistically noninferior to that between ST-segment resolution % and NR(difference between area under curves: 0.0232, p= 0.38) CONCLUSION: the present study is the first to report a significant correlation between NR and RWPT in STEMI patients treated with primary pPCI.

Non-dipper hypertension is associated with slow coronary flow among hypertensives with normal coronary angiogram

AIM

A person with a drop of more than 10% in nocturnal arterial blood pressure during the circadian rhythm is referred to as a dipper and one with a smaller decrease is referred to as a non-dipper. In our study, we aimed to compare the thrombolysis in myocardial infarction (TIMI) frame count in non-dipper and dipper hypertensive patient groups who had normal coronary artery angiography.

METHODS

Patients with normal coronary arteries and with ambulatory blood pressure monitoring follow ups were retrospectively investigated and 60 patients (35%, female) were included in our study. The patients were grouped as dipper (n = 30) and non-dipper (n = 30) hypertensives.

RESULTS

The TIMI frame counts in all three coronary arteries and the mean TIMI frame count in the dipper hypertensive patient group were significantly lower than those of the non-dipper hypertensives (right coronary artery TIMI frame count: 16.83 ± 3.70; 21.63 ± 3.44, p < 0.001; circumflex artery TIMI frame count: 21.28 ± 3.52; 25.65 ± 3.61, p < 0.001; left anterior descending artery TIMI frame count: 34.20 ± 2.80; 37.05 ± 3.30, p = 0.001; corrected left anterior descending artery TIMI frame count: 20.05 ± 1.63; 21.74 ± 1.95, p = 0.001; mean TIMI frame count: 19.31 ± 2.3; 22.94 ± 2.61, p < 0.001). The body mass index (BMI) was 23.79 ± 2.81 kg/m2 in the dipper patient group, while it was 25.47 ± 2.92 in the non-dippers. BMI was found to be significantly higher in the non-dipper group than in the dipper group (p = 0.027).

CONCLUSION

In this study, TIMI frame count, which is a simple, productive, objective and reproducible method for determination of microvascular changes, was found to be higher in non-dipper hypertensive patients than in the dipper patients.

No-Reflow Phoenomenon by Intracoronary Thrombus in Acute Myocardial Infarction

Recently, percutaneous coronary intervention has been the treatment of choice in most acute myocardial infarction cases. Although the results of percutaneous coronary interventions have ben good, the no-reflow phenomenon and distal embolization of intracoronary thrombus are still major problems even after successful interventions. In this article, we will briefly review the deleterious effects of no-reflow and distal embolization of intracoronary thrombus during percutaneous coronary interventions. The current trials focused on the prevention and treatment of the no-reflow phenomenon and intracoronary thrombus.

Impact of hypertension on distal embolization, myocardial perfusion, and mortality in patients with ST segment elevation myocardial infarction undergoing primary angioplasty

Hypertension is a well-known risk factor for atherosclerosis. However, data on the impact of hypertension in patients with ST elevation myocardial infarction (STEMI) are inconsistent and mainly related to studies performed in the thrombolytic era, with very few data on patients undergoing primary angioplasty. The aim of the present study was to evaluate the impact of hypertension on distal embolization, myocardial perfusion, and mortality in patients with STEMI undergoing primary percutaneous coronary intervention. Our population is represented by 1,662 patients undergoing primary angioplasty for STEMI included in the Early Glycoprotein IIb-IIIa inhibitors in Primary angioplasty database. Myocardial perfusion was evaluated by myocardial blush grade and ST segment resolution. Follow-up data were collected within 1 year after primary angioplasty. Hypertension was observed in 700 patients (42.1%). Hypertension was associated with more advanced age (p <0.001), female gender (p <0.001), diabetes (p <0.001), hypercholesterolemia (p <0.001), previous revascularization (p <0.001), anterior myocardial infarction (p = 0.006), longer ischemia time (p = 0.03), more extensive coronary artery disease (p = 0.002), more often treated with abciximab (p <0.001), and less often smokers (p <0.001). Hypertension was associated with impaired postprocedural myocardial blush grade 2 to 3 (68.2% vs 74.2%, p = 0.019) and complete ST segment resolution (51.7% vs 61.1%, p = 0.001). By a mean follow-up of 206 ± 158 days, 70 patients (4.3%) had died. Hypertension was associated with a greater mortality (6.2% vs 2.9%, hazard ratio 2.31, 95% confidence interval 1.42 to 3.73, p <0.001), confirmed after correction for baseline confounding factors (hazard ratio 1.82, 95% confidence interval 1.03 to 3.22, p <0.001). In conclusion, this study showed that among patients with STEMI undergoing primary angioplasty, hypertension is associated with impaired reperfusion and independently predicts 1-year mortality.