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Geum MJ, Yu YM, Jeon J, Lee HW, Shin J, Chung WY, Hahn J, Ah YM. Intracoronary antithrombotic therapy during primary percutaneous coronary intervention in patients with STEMI: A systematic review and network meta-analysis. Thromb Res 2024; 233:127-134. [PMID: 38041878 DOI: 10.1016/j.thromres.2023.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/21/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION The efficacy of intracoronary (IC) antithrombotic therapy, which may best prevent the no-reflow phenomenon during percutaneous coronary intervention (PCI), remains unclear. Therefore, we compared the efficacy and safety of different IC antithrombotic agents. MATERIALS AND METHODS This systematic review and network meta-analysis of randomized controlled trials (RCTs) compared IC fibrinolytic agents (recombinant tissue plasminogen activators [rtPAs] and non-rtPAs) or glycoprotein IIb/IIIa inhibitors (small molecules and monoclonal antibodies) with placebo by searching the relevant studies published before September 21, 2022. Bayesian network meta-analyses were performed using random-effects models. RESULTS Twenty-five RCTs with 4546 patients were included. Non-rtPAs and small molecules were significantly more effective in achieving thrombolysis in myocardial infarction (TIMI) grade 3 flow than placebo (odds ratio [OR] 2.28, 95 % credible intervals [CrI] 1.24-4.13; OR 2.06, 95 % CrI 1.17-3.46). Moreover, these agents' efficacy was observed in other microcirculation-related outcomes, including TIMI myocardial perfusion grade 3, complete ST-segment resolution, and corrected TIMI frame counts. Within 6 months, small molecules were associated with both an improved left ventricular ejection fraction (MD 3.90, 95 % CrI 0.48-7.46) and major adverse cardiac events (MACE) reduction (OR 0.36, 95 % CrI 0.20-0.61). Non-rtPAs demonstrated a reduced MACE incidence within 6 months (OR 0.51, 95 % CrI 0.31-0.81). The results were consistent in the subgroup with a total ischemic time > 6 h. No significant differences in mortality or bleeding events were observed. CONCLUSIONS IC non-rtPAs and small molecules may be effective for adjunctive therapy to PCI, particularly in patients with longer ischemia periods.
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Affiliation(s)
- Min Jung Geum
- Department of Pharmacy, Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Yun Mi Yu
- Department of Pharmacy and Yonsei Institute of Pharmaceutical Sciences, College of Pharmacy, Yonsei University, Incheon, Republic of Korea; Department of Pharmaceutical Medicine and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Jinyoung Jeon
- Department of Pharmaceutical Medicine and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea; Department of Pharmacy, National Cancer Center Hospital, Goyang, Republic of Korea
| | - Hyun Woo Lee
- Department of Pharmaceutical Medicine and Regulatory Science, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Jaekyu Shin
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
| | - Woo-Young Chung
- Department of Internal Medicine, Seoul National University Boramae Medical Center and College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - JongSung Hahn
- College of Pharmacy, Jeonbuk National University, Jeonju, Republic of Korea.
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan, Republic of Korea.
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Kaddoura R, Mohamed Ibrahim MI, Al-Badriyeh D, Omar A, Al-Kindi F, Arabi AR. Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials. PLoS One 2022; 17:e0263270. [PMID: 35512007 PMCID: PMC9071172 DOI: 10.1371/journal.pone.0263270] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Thrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden. OBJECTIVES This meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI). METHODS A comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)). RESULTS Twelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85-7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60-8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48-11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13-0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes. CONCLUSIONS Compared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Amr Omar
- Department of Cardiothoracic Surgery/Cardiac Anesthesia, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fahad Al-Kindi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdul Rahman Arabi
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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3
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Yoon GS, Ahn SG, Woo SI, Yoon MH, Lee MJ, Choi SH, Seo JY, Kwon SW, Park SD, Seo KW. The Index of Microcirculatory Resistance after Primary Percutaneous Coronary Intervention Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction. J Clin Med 2021; 10:jcm10204752. [PMID: 34682875 PMCID: PMC8538070 DOI: 10.3390/jcm10204752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/11/2021] [Accepted: 10/14/2021] [Indexed: 11/16/2022] Open
Abstract
The index of microcirculatory resistance (IMR) is a simple method that can measure microvascular function after primary percutaneous coronary intervention (PCI) in patients with ST-segment Elevation Myocardial Infarction (STEMI). This study is to find out whether IMR predicts clinical long-term outcomes in STEMI patients. A total of 316 patients with STEMI who underwent primary PCI from 2005 to 2015 were enrolled. The IMR was measured using pressure sensor/thermistor-tipped guidewire after primary PCI. The primary endpoint was the rate of death or hospitalization for heart failure (HF) over a mean follow-up period of 65 months. The mean corrected IMR was 29.4 ± 20.0. Patients with an IMR > 29 had a higher rate of the primary endpoint compared to patients with an IMR ≤ 29 (10.3% vs. 2.1%, p = 0.001). During the follow-up period, 13 patients (4.1%) died and 6 patients (1.9%) were hospitalized for HF. An IMR > 29 was associated with an increased risk of death or hospitalization for HF (OR 5.378, p = 0.004). On multivariable analysis, IMR > 29 (OR 3.962, p = 0.022) remained an independent predictor of death or hospitalization for HF with age (OR 1.048, p = 0.049) and symptom-to-balloon time (OR 1.002, p = 0.049). High IMR was an independent predictor for poor long-term clinical outcomes in STEMI patients after primary PCI.
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Affiliation(s)
- Gwang-Seok Yoon
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Sung Gyun Ahn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Seong-Ill Woo
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
- Correspondence: (S.-I.W.); (M.H.Y.); Tel.: +82-32-890-2445 (S.I.W.); Fax: 82-32-890-2447 (S.-I.W.)
| | - Myeong Ho Yoon
- Department of Cardiology, Ajou University School of Medicine, Suwon 16499, Korea; (J.-Y.S.); (K.-W.S.)
- Correspondence: (S.-I.W.); (M.H.Y.); Tel.: +82-32-890-2445 (S.I.W.); Fax: 82-32-890-2447 (S.-I.W.)
| | - Man-Jong Lee
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Seong Huan Choi
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Ji-Yeon Seo
- Department of Cardiology, Ajou University School of Medicine, Suwon 16499, Korea; (J.-Y.S.); (K.-W.S.)
| | - Sung Woo Kwon
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Sang-Don Park
- Division of Cardiology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22332, Korea; (G.-S.Y.); (M.-J.L.); (S.H.C.); (S.W.K.); (S.-D.P.)
| | - Kyoung-Woo Seo
- Department of Cardiology, Ajou University School of Medicine, Suwon 16499, Korea; (J.-Y.S.); (K.-W.S.)
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4
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Meier D, Fournier S, Masci PG, Eeckhout E, Antiochos P, Tzimas G, Stoyanov N, Muenkaew M, Monney P, Schwitter J, Muller O, Harbaoui B. Impact of manual thrombectomy on microvascular obstruction in STEMI patients. Catheter Cardiovasc Interv 2021; 97:1141-1148. [PMID: 32277793 DOI: 10.1002/ccd.28907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/27/2020] [Accepted: 03/31/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the effect of manual thrombectomy (MT) on microvascular obstruction (MVO) using cardiac magnetic resonance (CMR) in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). METHODS AND RESULTS Three hundred and eighty-three patients admitted for STEMI and undergoing CMR fulfilled the inclusion criteria and were categorized into two groups (did or did not undergo MT). The two primary endpoints were the occurrence and extent of MVO, analyzed as a categorical variable and as a semicontinuous variable. Among the 383 patients, 49.1% exhibited MVO. Both the incidence of MVO and the median number of segments presenting with MVO were significantly higher in the MT group than in the no-MT group, (59.5 vs. 38.9%, p < .001) and (1.5 [0;4] vs. 0 [0;2], p < .001). Analysis stratified on coronary thrombus grade showed similar results, only in patients with a high thrombus burden (60.7 vs. 43.5%, p = .004, and 2 [0;4] vs. 0 [0;3], p = .001. When adjusting for baseline differences, MT remained a determinant of MVO occurrence and extent (odds ratio, OR 1.802 [95% confidence interval, CI 1.080-3.009], p = .024) and β = .137, p = .024) in patients with a high thrombus grade. CONCLUSION In STEMI patients, MT was associated with the occurrence and extent of MVO, on CMR, especially in patients with a high thrombus burden.
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Affiliation(s)
- David Meier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.,Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Italy
| | - Pier G Masci
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Eric Eeckhout
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Georgios Tzimas
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nikolay Stoyanov
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Muenpetch Muenkaew
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Juerg Schwitter
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, Lausanne University, Lausanne, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Brahim Harbaoui
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland.,Department of Cardiology, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
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5
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Xu J, Lo S, Juergens CP, Leung DY. Impact of Targeted Therapies for Coronary Microvascular Dysfunction as Assessed by the Index of Microcirculatory Resistance. J Cardiovasc Transl Res 2020; 14:327-337. [PMID: 32710373 DOI: 10.1007/s12265-020-10062-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 07/19/2020] [Indexed: 11/25/2022]
Abstract
Coronary microvascular dysfunction (CMD) has emerged as an important therapeutic target in the contemporary management of ischemic heart disease. However, due to a lack of a reliable traditional "gold standard" test for CMD, optimal treatment remains undefined. The index of microcirculatory resistance (IMR) is an intra-coronary wire-based technique that provides a more reliable and quantitative assessment of CMD and has been increasingly used as a preferred endpoint for evaluating CMD treatment strategies in recent studies. IMR can help diagnose CMD in angina patients with non-obstructive epicardial coronary disease, predict peri-procedural myocardial infarction in stable patients undergoing coronary stenting, and predict long-term prognosis after acute myocardial infarction. Studies of IMR in the setting of non-ST-elevation acute coronary syndromes are still lacking. This review critically appraises the current published literature evaluating targeted therapies for CMD using IMR as the assessment tool and provides insights into evidence gaps in this important field. The index of microcirculatory resistance has rapidly evolved from a research tool to being the new "gold standard" test for evaluating coronary microvascular dysfunction.
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Affiliation(s)
- James Xu
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia.
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Craig P Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Dominic Y Leung
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, 2170, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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6
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Maznyczka AM, Oldroyd KG, McCartney P, McEntegart M, Berry C. The Potential Use of the Index of Microcirculatory Resistance to Guide Stratification of Patients for Adjunctive Therapy in Acute Myocardial Infarction. JACC Cardiovasc Interv 2020; 12:951-966. [PMID: 31122353 DOI: 10.1016/j.jcin.2019.01.246] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/20/2018] [Accepted: 01/03/2019] [Indexed: 12/31/2022]
Abstract
The goal of reperfusion therapies in ST-segment elevation myocardial infarction has evolved to include effective reperfusion of the microcirculation subtended by the culprit epicardial coronary artery. The index of microcirculatory resistance is measured using a pressure- and temperature-sensing coronary guidewire and quantifies microvascular dysfunction. The index of microcirculatory resistance is an independent predictor of microvascular obstruction, infarct size, and adverse clinical outcomes. It has the advantage of being immediately measurable in the catheterization laboratory, before the results of blood biomarkers or noninvasive imaging become available. This provides an opportunity for additional intervention that may alter outcomes. In this review, the authors provide a critical appraisal of the published research on the emerging role of the index of microcirculatory resistance as a tool to guide the stratification of patients for adjunctive therapeutic strategies in acute ST-segment elevation myocardial infarction.
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Affiliation(s)
- Annette M Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Keith G Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Peter McCartney
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Margaret McEntegart
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom.
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7
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D. Clarke JR, Kennedy R, Duarte Lau F, I. Lancaster G, W. Zarich S. Invasive Evaluation of the Microvasculature in Acute Myocardial Infarction: Coronary Flow Reserve versus the Index of Microcirculatory Resistance. J Clin Med 2019; 9:jcm9010086. [PMID: 31905738 PMCID: PMC7019371 DOI: 10.3390/jcm9010086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/24/2019] [Accepted: 12/27/2019] [Indexed: 01/10/2023] Open
Abstract
Acute myocardial infarction (AMI) is one of the most common causes of death in both the developed and developing world. It has high associated morbidity despite prompt institution of recommended therapy. The focus over the last few decades in ST-segment elevation AMI has been on timely reperfusion of the epicardial vessel. However, microvascular consequences after reperfusion, such as microvascular obstruction (MVO), are equally reliable predictors of outcome. The attention on the microcirculation has meant that traditional angiographic/anatomic methods are insufficient. We searched PubMed and the Cochrane database for English-language studies published between January 2000 and November 2019 that investigated the use of invasive physiologic tools in AMI. Based on these results, we provide a comprehensive review regarding the role for the invasive evaluation of the microcirculation in AMI, with specific emphasis on coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR).
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Affiliation(s)
- John-Ross D. Clarke
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
- Correspondence: ; Tel.: +1-203-260-4510
| | - Randol Kennedy
- Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, OH 44115, USA;
| | - Freddy Duarte Lau
- Department of Internal Medicine, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Gilead I. Lancaster
- The Heart and Vascular Institute, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA; (G.I.L.); (S.W.Z.)
| | - Stuart W. Zarich
- The Heart and Vascular Institute, Yale-New Haven Health/Bridgeport Hospital, Bridgeport, CT 06610, USA; (G.I.L.); (S.W.Z.)
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8
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Rios-Navarro C, Marcos-Garces V, Bayes-Genis A, Husser O, Nuñez J, Bodi V. Microvascular Obstruction in ST-Segment Elevation Myocardial Infarction: Looking Back to Move Forward. Focus on CMR. J Clin Med 2019; 8:E1805. [PMID: 31661823 PMCID: PMC6912395 DOI: 10.3390/jcm8111805] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 12/14/2022] Open
Abstract
After a myocardial infarction (MI), despite the resolution of the coronary occlusion, the deterioration of myocardial perfusion persists in a considerable number of patients. This phenomenon is known as microvascular obstruction (MVO). Initially, the focus was placed on re-establishing blood flow in the epicardial artery. Then, the observation that MVO has profound negative structural and prognostic repercussions revived interest in microcirculation. In the near future, the availability of co-adjuvant therapies (beyond timely coronary reperfusion) aimed at preventing, minimizing, and repairing MVOs and finding convincing answers to questions regarding what, when, how, and where to administer these therapies will be of utmost importance. The objective of this work is to review the state-of-the-art concepts on pathophysiology, diagnostic methods, and structural and clinical implications of MVOs in patients with ST-segment elevation MIs. Based on this knowledge we discuss previously-tested and future opportunities for the prevention and repair of MVO.
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Affiliation(s)
| | | | - Antoni Bayes-Genis
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), 28029 Madrid, Spain.
- Cardiology Department and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol (Badalona) and Department of Medicine Universitat Autonoma de Barcelona, 08916 Barcelona, Spain.
| | - Oliver Husser
- Department of Cardiology, St-Johannes Hospital, 44137 Dortmund, Germany.
| | - Julio Nuñez
- Institute of Health Research INCLIVA, 46010 Valencia, Spain.
- Cardiology Department, Hospital Clínico Universitario, 46010 Valencia, Spain.
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), 28029 Madrid, Spain.
- Department of Medicine, Universidad de Valencia, 46010 Valencia, Spain.
| | - Vicente Bodi
- Institute of Health Research INCLIVA, 46010 Valencia, Spain.
- Cardiology Department, Hospital Clínico Universitario, 46010 Valencia, Spain.
- Centro de Investigación Biomédica en Red-Cardiovascular (CIBER-CV), 28029 Madrid, Spain.
- Department of Medicine, Universidad de Valencia, 46010 Valencia, Spain.
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9
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Intracoronary Glycoprotein IIb/IIIa Inhibitors Improve Short-Term Mortality and Reinfarction in East Asian Patients with ST-Segment Elevation Myocardial Infarction after Thrombus Aspiration: A Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:5174714. [PMID: 30186355 PMCID: PMC6114074 DOI: 10.1155/2018/5174714] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/15/2018] [Accepted: 07/30/2018] [Indexed: 11/30/2022]
Abstract
Objective Intracoronary (IC) glycoprotein IIb/IIIa inhibitors (GPIs) after thrombus aspiration (TA) for patients with ST-segment elevation myocardial infarction (STEMI), as compared with percutaneous coronary interventions (PCI) alone, is still on debate. To address this issue, we performed a meta-analysis of results from prospective or randomized controlled trials on the topic. Methods We searched electronic and printed sources (up to June 20, 2016) according to the selection criteria. Data were abstraction and meta-analysis was performed using RevMan 5.3 software. Results The cohorts involved 14 articles describing 1,918 participants were included. The incidence of the short-term major adverse cardiac events (MACE) was significantly reduced with intracoronary GPIs after TA (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.13 to 0.65, p=0.003). Benefits were noted for short-term mortality (OR: 0.31; 95% CI: 0.17 to 0.57, p=0.0002) and reinfarction (OR: 0.28; 95% CI: 0.10 to 0.78, p=0.01) in subjects who received intracoronary GPIs after TA. Moreover, the Thrombolysis in Myocardial Infarction (TIMI) trial grade 3 postprocedure (OR: 2.29; 95% CI: 1.72 to 3.04, P<0.00001) and complete ST-segment resolution (STR) rate (OR: 2.68; 95% CI: 1.85 to 3.87, P<0.00001) were both improved with intracoronary GPIs after TA. As a result, left ventricular ejection fraction (LVEF) at short-term follow-up showed a significant difference (OR: 7.33; 95% CI: 5.60 to 9.06, p<0.0001) in favor of the TA and intracoronary GPIs administration. Conclusions Our study demonstrates that intracoronary GPIs may have a synergistic effect with thrombus aspiration on short-term mortality, reinfarction, and cardiac functional recovery.
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10
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Abstract
Traditionally, invasive coronary physiological assessment has focused on the epicardial coronary artery. More recently, appreciation of the importance of the coronary microvasculature in determining patient outcomes has grown. Several invasive modalities for interrogating microvascular function have been proposed. Angiographic techniques have been limited by their qualitative and subjective nature. Doppler wire-derived coronary flow reserve has been applied in research studies, but its clinical role has been limited by its lack of reproducibility, its lack of a clear normal value, and the fact that it is not specific for the microvasculature but interrogates the entire coronary circulation. The index of microcirculatory resistance—a thermodilution-derived measure of the minimum achievable microvascular resistance—is relatively easy to measure, more reproducible, has a clearer normal value, and is independent of epicardial coronary artery stenosis. The index of microcirculatory resistance has been shown to have prognostic value in patients with ST-segment–elevation myocardial infarction and cardiac allograft vasculopathy after heart transplantation. Emerging data demonstrate its role in evaluating patients with chest pain and nonobstructive coronary artery disease. Increasingly, the index of microcirculatory resistance is used as a reference standard for invasively assessing the microvasculature in clinical trials.
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Affiliation(s)
- William F. Fearon
- From the Division of Cardiovascular Medicine, Stanford University, CA
| | - Yuhei Kobayashi
- From the Division of Cardiovascular Medicine, Stanford University, CA
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11
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Bulluck H, Foin N, Tan JW, Low AF, Sezer M, Hausenloy DJ. Invasive Assessment of the Coronary Microcirculation in Reperfused ST-Segment-Elevation Myocardial Infarction Patients: Where Do We Stand? Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004373. [PMID: 28242607 DOI: 10.1161/circinterventions.116.004373] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
For patients presenting with an acute ST-segment-elevation myocardial infarction, the most effective therapy for reducing myocardial infarct size and preserving left ventricular systolic function is primary percutaneous coronary intervention (PPCI). However, mortality and morbidity remain significant. This is partly attributed to the development of microvascular obstruction, which occurs in around 50% of ST-segment-elevation myocardial infarction patients post-PPCI, and it is associated with adverse left ventricular remodeling and worse clinical outcomes. Although microvascular obstruction can be detected by cardiac imaging techniques several hours post-PPCI, it may be too late to intervene at that time. Therefore, being able to predict the development of microvascular obstruction at the time of PPCI may identify high-risk patients who might benefit from further adjuvant intracoronary therapies, such as thrombolysis, vasodilators, glycoprotein IIb/IIIa inhibitors, and anti-inflammatory agents that may reduce microvascular obstruction. Recent studies have shown that invasive coronary physiology measurements performed during PPCI can be used to assess the coronary microcirculation. In this article, we provide an overview of the various invasive methods currently available to assess the coronary microcirculation in the setting of ST-segment-elevation myocardial infarction, and how they could potentially be used in the future for tailoring therapies to those most at risk.
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Affiliation(s)
- Heerajnarain Bulluck
- From the Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.); The National Institute of Health Research, University College London Hospitals, Biomedical Research Centre, United Kingdom (H.B., D.J.H.); Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore (H.B., N.F., D.J.H.); National Heart Research Institute Singapore, National Heart Centre Singapore (H.B., N.F., J.W.T., D.J.H.); National University Heart Centre, Singapore (A.F.L.); Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Turkey (M.S.); Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (D.J.H.); and Yong Loo Lin School of Medicine, National University Singapore (D.J.H.)
| | - Nicolas Foin
- From the Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.); The National Institute of Health Research, University College London Hospitals, Biomedical Research Centre, United Kingdom (H.B., D.J.H.); Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore (H.B., N.F., D.J.H.); National Heart Research Institute Singapore, National Heart Centre Singapore (H.B., N.F., J.W.T., D.J.H.); National University Heart Centre, Singapore (A.F.L.); Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Turkey (M.S.); Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (D.J.H.); and Yong Loo Lin School of Medicine, National University Singapore (D.J.H.)
| | - Jack W Tan
- From the Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.); The National Institute of Health Research, University College London Hospitals, Biomedical Research Centre, United Kingdom (H.B., D.J.H.); Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore (H.B., N.F., D.J.H.); National Heart Research Institute Singapore, National Heart Centre Singapore (H.B., N.F., J.W.T., D.J.H.); National University Heart Centre, Singapore (A.F.L.); Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Turkey (M.S.); Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (D.J.H.); and Yong Loo Lin School of Medicine, National University Singapore (D.J.H.)
| | - Adrian F Low
- From the Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.); The National Institute of Health Research, University College London Hospitals, Biomedical Research Centre, United Kingdom (H.B., D.J.H.); Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore (H.B., N.F., D.J.H.); National Heart Research Institute Singapore, National Heart Centre Singapore (H.B., N.F., J.W.T., D.J.H.); National University Heart Centre, Singapore (A.F.L.); Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Turkey (M.S.); Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (D.J.H.); and Yong Loo Lin School of Medicine, National University Singapore (D.J.H.)
| | - Murat Sezer
- From the Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.); The National Institute of Health Research, University College London Hospitals, Biomedical Research Centre, United Kingdom (H.B., D.J.H.); Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore (H.B., N.F., D.J.H.); National Heart Research Institute Singapore, National Heart Centre Singapore (H.B., N.F., J.W.T., D.J.H.); National University Heart Centre, Singapore (A.F.L.); Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Turkey (M.S.); Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (D.J.H.); and Yong Loo Lin School of Medicine, National University Singapore (D.J.H.)
| | - Derek J Hausenloy
- From the Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, United Kingdom (H.B., D.J.H.); The National Institute of Health Research, University College London Hospitals, Biomedical Research Centre, United Kingdom (H.B., D.J.H.); Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore (H.B., N.F., D.J.H.); National Heart Research Institute Singapore, National Heart Centre Singapore (H.B., N.F., J.W.T., D.J.H.); National University Heart Centre, Singapore (A.F.L.); Department of Cardiology, Istanbul University, Istanbul Faculty of Medicine, Çapa, Turkey (M.S.); Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom (D.J.H.); and Yong Loo Lin School of Medicine, National University Singapore (D.J.H.).
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Niu XW, Zhang JJ, Bai M, Peng Y, Zhang Z. Combined thrombectomy and intracoronary administration of glycoprotein IIb/IIIa inhibitors improves myocardial reperfusion in patients undergoing primary percutaneous coronary intervention: a meta-analysis. J Geriatr Cardiol 2017; 14:614-623. [PMID: 29238362 PMCID: PMC5721196 DOI: 10.11909/j.issn.1671-5411.2017.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 09/06/2017] [Accepted: 10/10/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Suboptimal myocardial reperfusion is common in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Furthermore, it results in increased infarct size and mortality rates. We performed a meta-analysis to evaluate the role of aspiration thrombectomy (AT) combined with intracoronary administration of glycoprotein IIb/IIIa inhibitors (GPI) in the improvement of myocardial reperfusion and clinical outcomes. METHODS PubMed, Embase, Web of Science, and CENTRAL databases were searched for randomized controlled trials (RCTs) investigating combined AT and intracoronary GPI treatment versus AT alone. Outcomes of interest were thrombolysis in myocardial infarction myocardial perfusion grade (TMPG), infarct size (IS) assessed by cardiac magnetic resonance imaging, left ventricular ejection fraction (LVEF), major adverse cardiac events (MACE) at short-term (≤ 1 month) and long-term (6-12 months) follow-up, and bleeding complications during the hospital stay. RESULTS Eight trials involving 923 patients were included. Compared with AT alone, combined AT and intracoronary GPI significantly increased TMPG 3 flow (RR: 1.15, 95% CI: 1.04 to 1.26), reduced IS [mean difference (MD): -3.46, 95% CI: -5.18 to -1.73], and improved LVEF (MD: 1.44, 95% CI: 0.54 to 2.33). Furthermore, GPI use decreased the risk of MACE at long-term follow-up (RR: 0.60, 95% CI: 0.37 to 0.98). There was no significant difference between the two groups in the incidence of minor and major bleeding complications. CONCLUSIONS Our findings showed that compared with AT alone, combined AT and intracoronary GPI treatment resulted in improved myocardial reperfusion, better cardiac function, and MACE-free survival benefits at the long-term follow-up for patients with STEMI undergoing PPCI.
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Affiliation(s)
- Xiao-Wei Niu
- The First Clinical Medical School, Lanzhou University, Lanzhou, China
| | | | - Ming Bai
- Department of Cardiology, the First Hospital of Lanzhou University, Lanzhou, China
| | - Yu Peng
- Department of Cardiology, the First Hospital of Lanzhou University, Lanzhou, China
| | - Zheng Zhang
- Department of Cardiology, the First Hospital of Lanzhou University, Lanzhou, China
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Johnson NP, Gould KL, Di Carli MF, Taqueti VR. Invasive FFR and Noninvasive CFR in the Evaluation of Ischemia: What Is the Future? J Am Coll Cardiol 2017; 67:2772-2788. [PMID: 27282899 DOI: 10.1016/j.jacc.2016.03.584] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/07/2016] [Accepted: 03/15/2016] [Indexed: 12/14/2022]
Abstract
This review provides an integrative and forward-looking perspective on the gamut of coronary physiology for the diagnosis and management of atherosclerosis. Because clinical events serve as the ultimate gold standard, the future of all diagnostic tests, including invasive fractional flow reserve and noninvasive coronary flow reserve, depends on their ability to improve patient outcomes. Given the prominent role of acute coronary syndromes and invasive procedures in cardiology, we practically consider 2 broad categories of patients with coronary disease: acute and stable. For patients with acute coronary disease, coronary physiology may potentially refine treatment of the culprit lesion. For both patients with stable and acute nonculprit disease, reducing hard endpoints with revascularization potentially occurs at the severe end of the focal physiological spectrum, an area under-represented in existing trials. Nonepicardial disease and diffuse atherosclerosis remain underexplored aspects of coronary physiology for testing of novel treatments.
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Affiliation(s)
- Nils P Johnson
- Weatherhead PET Center For Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas.
| | - K Lance Gould
- Weatherhead PET Center For Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, McGovern Medical School at UTHealth and Memorial Hermann Hospital, Houston, Texas
| | - Marcelo F Di Carli
- Departments of Medicine and Radiology, Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, and the Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Viviany R Taqueti
- Departments of Medicine and Radiology, Noninvasive Cardiovascular Imaging Program, Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Medicine, and the Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Index of Microvascular Resistance and Microvascular Obstruction in Patients With Acute Myocardial Infarction. JACC Cardiovasc Interv 2016; 9:2172-2174. [DOI: 10.1016/j.jcin.2016.08.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/10/2016] [Accepted: 08/10/2016] [Indexed: 11/20/2022]
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15
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Aspiration thrombectomy and intracoronary tirofiban in ST-segment elevation myocardial infarction. Herz 2016; 41:732-740. [DOI: 10.1007/s00059-016-4426-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/06/2016] [Indexed: 01/27/2023]
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16
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The impact of initial and residual thrombus burden on the no-reflow phenomenon in patients with ST-segment elevation myocardial infarction. Coron Artery Dis 2015; 26:245-53. [DOI: 10.1097/mca.0000000000000197] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Aspiration thrombectomy: Just another piece of the puzzle - intuitive, but not sufficient. Rev Port Cardiol 2014; 33:761-4. [PMID: 25481781 DOI: 10.1016/j.repc.2014.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/29/2014] [Indexed: 11/22/2022] Open
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18
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Aspiration thrombectomy: Just another piece of the puzzle – Intuitive, but not sufficient. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2014.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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19
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Rioufol G, Finet G. Invasive coronary microcirculation assessment during myocardial infarction: one step forward or two steps back? J Am Coll Cardiol 2014; 64:1905-7. [PMID: 25444144 DOI: 10.1016/j.jacc.2014.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/06/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Gilles Rioufol
- Interventional Cardiology Department, Hospices Civils de Lyon, Claude Bernard University Lyon 1 and CARMEN INSERM 1060, Bron, France.
| | - Gérard Finet
- Interventional Cardiology Department, Hospices Civils de Lyon, Claude Bernard University Lyon 1 and CARMEN INSERM 1060, Bron, France
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Fernández-Rodríguez D, Alvarez-Contreras L, Martín-Yuste V, Brugaletta S, Ferreira I, De Antonio M, Cardona M, Martí V, García-Picart J, Sabaté M. Does manual thrombus aspiration help optimize stent implantation in ST-segment elevation myocardial infarction? World J Cardiol 2014; 6:1030-1037. [PMID: 25276303 PMCID: PMC4176794 DOI: 10.4330/wjc.v6.i9.1030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/22/2014] [Accepted: 09/10/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of thrombus aspiration (TA) on procedural outcomes in a real-world ST-segment elevation myocardial infarction (STEMI) registry.
METHODS: From May 2006 to August 2008, 542 consecutive STEMI patients referred for primary or rescue percutaneous coronary intervention were enrolled and the angiographic results and stent implantation characteristics were compared according to the performance of manual TA.
RESULTS: A total of 456 patients were analyzable and categorized in TA group (156 patients; 34.2%) and non-TA (NTA) group (300 patients; 65.8%). Patients treated with TA had less prevalence of multivessel disease (39.7% vs 54.7%, P = 0.003) and higher prevalence of initial thrombolysis in myocardial infarction flow < 3 (P < 0.001) than NTA group. There was a higher rate of direct stenting (58.7% vs 45.5%, P = 0.009), with shorter (24.1 ± 11.8 mm vs 26.9 ± 15.7 mm, P = 0.038) and larger stents (3.17 ± 0.43 mm vs 2.93 ± 0.44 mm, P < 0.001) in the TA group as compared to NTA group. The number of implanted stents (1.3 ± 0.67 vs 1.5 ± 0.84, P = 0.009) was also lower in TA group.
CONCLUSION: In an “all-comers” STEMI population, the use of TA resulted in more efficient procedure leading to the implantation of less number of stents per lesion of shorter lengths and larger sizes.
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