Primary percutaneous coronary intervention in ‘early’ latecomers with ST-segment elevation acute myocardial infarction: the role of the infarct-related artery status

Late Percutaneous Coronary Intervention is Associated with Better Prognosis of Patients with Acute Myocardial Infarction

Background

The optimal timing of invasive coronary revascularization in patients with late presentation of acute myocardial infarction (AMI) remains unclear.

Objective

This study aimed to investigate whether late percutaneous coronary intervention (PCI) is associated with the prognosis of AMI patients with HFpEF presenting >24h after symptom onset.

Methods

We enrolled 680 AMI patients with HFpEF. Patients were divided into 3 groups: early-PCI strategy (defined as the time to open IRA from symptom onset <24 h), late-PCI strategy (defined as the time of PCI-mediated reperfusion was >24 h) and non-revascularization group.

Results

A total of 144 (21.2%) experienced a MACE, including 118 (17.4%) all-cause deaths and 26 (3.8%) re-hospitalization for HF during a follow-up period of 30.20±15.62 months. After adjusting for gender, age, smoking, diabetes mellitus, NT-proBNP and eGFR, late-PCI was a significant and independent predictor of MACE (hazard ratio 0.367; 95% confidence interval 0.202–0.665; p<0.001). Kaplan–Meier analysis showed that late-PCI decreased cumulative risk of MACE (p< 0.001).

Conclusion

Late-PCI and early-PCI strategies are associated with a reduced risk of MACE in AMI patients with HFpEF presenting >24 h after symptom onset, compared to conservative strategies.

Comprehensive Assessment of the Left Ventricular Systolic Function in the Elderly with Acute Myocardial Infarction Using Echocardiography

Aim

To evaluate the left ventricular (LV) systolic function in elderly with non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI) using real-time three-dimensional echocardiography (RT-3DE) and two-dimensional speckle tracking imaging (STI).

Methods

Forty NSTEMI and forty STEMI patients after undergoing percutaneous coronary artery intervention (PCI) were enrolled. The myocardial segments were supplied by the infarct-related artery (Myo-_IRA) which were indicated by the selective coronary arteriography (SCA). The LV end-diastolic volume (LVEDV), end-systolic volume (LVESV), stroke volume (LVSV) and ejection fraction (LVEF) were acquired by 4D LV Volume Tom Tec. LV longitudinal peak systolic strain (LPSS), radial peak systolic strain (RPSS), circumferential peak systolic strain (CPSS) of Myo-_IRA segments, LV rotational peak degree in the base (rot-_base) and in the apex (rot-_apex), and twist were acquired by strain analysis software. Forty older healthy individuals were included as normal controls.

Results

The LVEF of the NSTEMI and STEMI patients at 1 week after PCI were significantly lower (P<0.05), then, this parameter was improved in both groups after 3 months, but was still significantly lower than that of the controls (P<0.05). The LPSS, RPSS, CPSS of the Myo_−IRA segments, rot_−Base, rot_−Apex and twist in both groups were significantly lower than those in the controls. The LPSS and CPSS of the Myo-IRA segments, rot_−Base, rot_−Apex and twist in NSTEMI patients were obviously higher than those in STEMI patients in 1 week and 3 months after PCI (P<0.05). After 3 months, the RPSS of NSTEMI patients was improved notably and was obviously higher than that of STEMI patients (P<0.05). All these values in STEMI and NSTEMI patients were improved after 3 months, apart from LPSS in STEMI patients (P>0.05), but were still significantly lower than those in the controls (P<0.05).

Conclusion

RT-3DE and STI can sensitively assess LV systolic function with different extents of transmural damage.

Barriers and facilitators to healthcare professional behaviour change in clinical trials using the Theoretical Domains Framework: a case study of a trial of individualized temperature-reduced haemodialysis

BACKGROUND

Implementing the treatment arm of a clinical trial often requires changes to healthcare practices. Barriers to such changes may undermine the delivery of the treatment making it more likely that the trial will demonstrate no treatment effect. The 'Major outcomes with personalized dialysate temperature' (MyTEMP) is a cluster-randomised trial to be conducted in 84 haemodialysis centres across Ontario, Canada to investigate whether there is a difference in major outcomes with an individualized dialysis temperature (IDT) of 0.5 °C below a patient's body temperature measured at the beginning of each haemodialysis session, compared to a standard dialysis temperature of 36.5 °C. To inform how to deploy the IDT across many haemodialysis centres, we assessed haemodialysis physicians' and nurses' perceived barriers and enablers to IDT use.

METHODS

We developed two topic guides using the Theoretical Domains Framework (TDF) to assess perceived barriers and enablers to IDT ordering and IDT setting (physician and nurse behaviours, respectively). We recruited a purposive sample of haemodialysis physicians and nurses from across Ontario and conducted in-person or telephone interviews. We used directed content analysis to double-code transcribed utterances into TDF domains, and inductive thematic analysis to develop themes.

RESULTS

We interviewed nine physicians and nine nurses from 11 Ontario haemodialysis centres. We identified seven themes of potential barriers and facilitators to implementing IDTs: (1) awareness of clinical guidelines and how IDT fits with local policies (knowledge; goals), (2) benefits and motivation to use IDT (beliefs about consequences; optimism; reinforcement; intention; goals), (3) alignment of IDTs with usual practice and roles (social/professional role and identity; nature of the behaviour; beliefs about capabilities), (4) thermometer availability/accuracy and dialysis machine characteristics (environmental context and resources), (5) impact on workload (beliefs about consequences; beliefs about capabilities), (6) patient comfort (behavioural regulation; beliefs about consequences; emotion), and (7) forgetting to prescribe or set IDT (memory, attention, decision making processes; emotion).

CONCLUSIONS

There are anticipatable barriers to changing healthcare professionals' behaviours to effectively deliver an intervention within a randomised clinical trial. A behaviour change framework can help to systematically identify such barriers to inform better delivery and evaluation of the treatment, therefore potentially increasing the fidelity of the intervention to increase the internal validity of the trial. These findings will be used to optimise the delivery of IDT in the MyTEMP trial and demonstrate how this approach can be used to plan intervention delivery in other clinical trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02628366 . Registered November 16 2015.

Registry of "early latecomer" patients with acute ST-segment elevation myocardial infarction at the Instituto Nacional Cardiovascular INCOR - Peru

OBJECTIVE

To assess the features of asymptomatic patients with acute ST segment elevation myocardial infarction who presents to the emergency with more than 12h of evolution, and if there is a benefit of an invasive versus medical therapy.

METHODS

Retrospective, cohort study from January 2012 to December 2014, we compare the outcomes at 6 and 12 months of follow up of the invasive group versus the conservative group.

RESULTS

There were no differences in outcomes at 12 months between an invasive versus a conventional strategy; but, looking at the reperfusion state, we found more risk of death and heart failure at 12 months in the no-reperfused group versus the reperfused group (40% versus 0%, OR: 2, CI: 1.2-3.1, p=0.028 for mortality and 53% versus 0%, OR: 2.2, CI: 1.3-3.98, p=0.007 for heart failure).

CONCLUSIONS

In patients with ST elevation acute myocardial infarction with more than 12h of evolution, the invasive strategy with optimal reperfusion is better than the conservative management or no reperfusion in terms of less mortality and heart failure at 12 months of follow up.

Benefit of percutaneous coronary intervention in early latecomers with acute ST-segment elevation myocardial infarction

The clinical benefit of percutaneous coronary intervention (PCI) is controversial in stable early latecomers with ST-segment elevation myocardial infarction (STEMI). We evaluated the efficacy of PCI in 2,344 stable patients with STEMI presenting 12 to 72 hours after symptom onset. Patients who had impaired hemodynamics or who had undergone fibrinolysis or immediate or urgent PCI were excluded. The patients were divided into the PCI group (n = 1,889) and medical treatment group (n = 455). The 12-month clinical outcome was compared between the 2 groups. After adjustment using propensity score stratification, the PCI group had lower mortality (3.1% vs 10.1%; hazard ratio 0.31; 95% confidence interval 0.20 to 0.47; p <0.001) and a lower incidence of composite death/myocardial infarction (3.8% vs 11.2%; hazard ratio 0.36; 95% confidence interval 0.25 to 0.53; p <0.001) at 12 months. The benefit of PCI was consistent across all subgroups, including patients presenting without chest pain. In conclusion, in stable patients with STEMI presenting 12 to 72 hours after symptom onset, PCI was associated with significant improvement in the 12-month clinical outcome.