Technical consideration in acute myocardial infarction with cardiogenic shock: A review of antithrombotic and PCI therapies

Immediate Platelet Inhibition Strategy for Comatose Out-of-Hospital Cardiac Arrest Survivors Undergoing Percutaneous Coronary Intervention and Mild Therapeutic Hypothermia

Background: Comatose survivors of out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI) and target temperature management (TTM) are at increased risk of stent thrombosis (ST), partly due to delayed platelet inhibition even with more potent P2Y12 agents. We hypothesized that periprocedural cangrelor would induce immediate platelet inhibition, bridging the "P2Y12 inhibition gap". Methods: In our pilot study, we randomized 30 comatose OHCA patients undergoing PCI and TTM (32-34 °C) into cangrelor and control groups. Both groups received unfractioned heparin, acetylsalicylic acid, and ticagrelor via enteral tube. The cangrelor group also received an intravenous bolus of cangrelor followed by a 4 h infusion. Platelet inhibition was measured using VerifyNow® and Multiplate® ADP at baseline and 1, 3, 5, and 8 h post PCI. Results: Patient characteristics did not differ between groups. VerifyNow® showed significantly decreased platelet reactivity with cangrelor at 1 h (30 vs. 221 PRU; p < 0.001) and 3 h (24 vs. 180 PRU; p < 0.001), with differences at 5 and 8 h. Similarly, the proportion of patients with high on-treatment platelet reactivity (HPR) in the cangrelor group was significantly lower at 1 h (0% vs. 67%; p < 0.001) and 3 h (0% vs. 47%; p = 0.007). Multiplate® ADP was also decreased at 1 h (14 vs. 48 U; p < 0.001) and 3 h (11 vs. 42 U; p = 0.001), with no difference at 5 and 8 h. The occurrence of bleeding events was similar in both groups. Conclusions: Cangrelor safely induced immediate and profound platelet inhibition. We observed no significant drug-drug interaction with ticagrelor.

Effect of cardiac rehabilitation care after coronary intervention on cardiac function recovery and negative mood in patients with myocardial infarction

BACKGROUND

Cardiovascular disease, particularly myocardial infarction (MI) profound impact on patients' quality of life and places a substantial burden on the healthcare and economy systems. Developments in medical technology have led to the emergence of coronary intervention as an essential method for treating MI.

AIM

To assess the effects of cardiac rehabilitation care on cardiac function recovery and negative emotions in MI after coronary intervention.

METHODS

This study included a total of 180 patients with MI during the period from June 2022 to July 2023. Selected patients were divided into two groups: An observation group, which receiving cardiac rehabilitation care; a control group, which receiving conventional care. By comparing multiple observation indicators such as cardiac function indicators, blood pressure, exercise tolerance, occurrence of adverse cardiac events, and negative emotion scores between the two groups of patients. All the data were analyzed and compared between two groups.

RESULTS

There were 44 males and 46 females in the observation group with an average age of 36.26 ± 9.88 yr; there were 43 males and 47 females in the control group, with an average age of 40.87 ± 10.5 yr. After receiving the appropriate postoperative nursing measures, the results of the observation group showed significant improvement in several indicators compared with the control group. Indicators of cardiac function, such as left ventricular end-diastolic internal diameter and left ventricular ejection fraction were significantly better in the observation group than in the control group (P < 0.05). Exercise endurance assessment showed that the 6-minute walking test distance was significantly increased in the patients of the observation group (P < 0.01). In addition, the incidence of adverse cardiac events was significantly lower in the observation group, and negative mood scores were significantly reduced (P < 0.05).

CONCLUSION

Cardiac rehabilitation care after coronary intervention has a significant positive impact on functional recovery. This emphasizes the importance of cardiac rehabilitation care to improve patient recovery.

Efficacy of thrombus aspiration in cardiogenic shock complicating acute myocardial infarction and high thrombus burden

INTRODUCTION AND OBJECTIVES

Current guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI.

METHODS

We included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V).

RESULTS

No significant difference was found in in-hospital death (28.9% vs 33.5%; P=.28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HRadj: 0.80; 95%CI, 0.59-1.09; P=.16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HRadj: 0.59; 95%CI, 0.41-0.85; P=.004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted Pint=.03).

CONCLUSIONS

Routine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008).

Effects of Dapagliflozin in Combination with Metoprolol Sustained-Release Tablets on Prognosis and Cardiac Function in Patients with Acute Myocardial Infarction after PCI

Objective

To find the effects of dapagliflozin in combination with metoprolol sustained-release tablets on cardiac function and prognosis in acute myocardial infarction patients after PCI.

Methods

A total of 84 patients with myocardial infarction who experienced PCI from February 2020 to February 2022 were included and allocated into 3 groups: groups A, B, and C (n = 28/per group). Group A was given dapagliflozin combined with metoprolol sustained-release tablets, group B was given dapagliflozin, and group C was given the placebo. Left ventricular end diastolic diameter (EDD), left ventricular ejection fraction (LVEF), and end systolic diameter (ESD) were measured before and after treatment in all groups; myocardial infarction areas were matched among all three groups at 3 months posttreatment. The serum concentrations of interleukin-6 (IL-6), hypersensitive C-reactive protein (hs-CRP), superoxide dismutase (SOD), and malondialdehyde (MDA) were detected in all three groups before and after treatment. The levels of N-terminal probrain natriuretic peptide (NT-pro BNP), lipoprotein (a) (Lp(a)), ischemia-modified albumin (IMA), and secreted frizzled-related protein 5 (SFRP5) were also detected in the serum of all groups. Adverse reactions and cardiovascular adverse events were matched between all groups.

Results

The levels of LVEF in groups A and B were increased after treatment, while the levels of EDD and ESD were decreased. The improvement degree of LVEF and EDD levels in groups A and B was found greater compared to group C (P < 0.05). No significant difference was found in myocardial infarction area among the three groups at 3 months postoperation (P > 0.05). Serum concentrations of MDA, hs-CRP, IL-6, IMA, NT-proBNP, and Lp(a) were found to decrease in all three groups after treatment, while the levels of SOD and SFRP5 were increased. The improvement degree of serum hs-CRP, IL-6, SOD, MDA, IMA, NT-proBNP, Lp(a), and SFRP5 levels was greater in both groups A and B compared to group C. The improvement degree of serum hS-CRP, SOD, MDA, IMA, Nt-probNP, Lp(a), and SFRP5 levels was significantly greater in group A compared to group B (P < 0.05). No adverse effect was observed in all three groups (P > 0.05). Total occurrence of cardiovascular adverse effects such as stent thrombosis, heart failure, ventricular fibrillation, and death was 10.71% in group A, 25.00% in group B, and 53.75% in group C. There was statistical significance in the onset of cardiovascular adverse effects 3 months postoperation among all three groups (P < 0.05).

Conclusion

Dapagliflozin with metoprolol sustained-release tablets can be effective in improving the heart function, inflammatory response, oxidative stress response, and prognosis in patients after PCI.

Diagnostic and Prognostic Significance of microRNA-208a in Acute Myocardial Infarction

Objective

To determine the prognostic and diagnostic significance of microRNA-208a (miR-208a) in acute myocardial infarction (AMI).

Methods

Totally, 84 AMI patients hospitalized in our hospital between Jan. 2019 and Feb. 2021 were enrolled as the patient group (Pat group), and 50 healthy individuals over same time span as the control group (Con group). qRT-PCR assay was carried out to quantify serum miR-208a in the patients and receiver-operating characteristic (ROC) curves for analysing its diagnostic value in AMI patients and its predictive value in clinical efficacy and adverse events in the patients after therapy. The changes of miR-208a and clinical indexes ((lactate dehydrogenase (LDH), creatine kinase (CK) as well as Creatine kinase-MB (CK-MB)) in the patients before and after therapy were evaluated. Pearson's test was adopted to analyse the associations of miR-208a with clinical indexes. Additionally, the target genes of miR-208a were forecasted.

Results

The patient group showed a higher miR-208a level than the control group (p < 0.05), and the area under the curve (AUC) of miR-208a in diagnosing AMI was >0.9. After therapy, patients presented notable decreases in serum miR-208a, LDH, CK, and CK-MB (all p < 0.05). Serum miR-208a presented positive associations with LDH, CK, as well as CK-MB both before and after therapy (all p < 0.05). Before therapy, the ineffective group presented a higher miR-208a level than the effective group (p < 0.05), and miR-208a had an AUC of 0.784 in forecasting efficacy. Additionally, the group with adverse events presented a higher miR-208a level than the group without them before therapy (p < 0.05), and miR-208a had an AUC of 0.713 in forecasting adverse events. According to enrichment analysis, the target genes of miR-208a were bound up with signal pathways of cellular senescence, MTOR and Wnt.

Conclusion

With high expression in AMI cases, miR-208a is a promising potential biomarker for diagnosis and prognosis forecasting of AMI.

Clinical Nursing Pathway Improves Therapeutic Efficacy and Quality of Life of Elderly Patients with Acute Myocardial Infarction

Purposes

To clarify the impacts of clinical nursing pathway (CNP) on therapeutic efficacy and quality of life (QOL) of senile acute myocardial infarction (AMI) patients.

Methods

The clinical records of 177 elderly AMI patients who received treatment in the First Hospital of Quanzhou Affiliated to Fujian Medical University were retrospectively studied. They were assigned into the control group (the Con; n = 79; from June 2019 to January 2020) and the research group (the Res; n = 98; from February 2020 to July 2020). Emergency percutaneous coronary intervention (PCI) was performed in all the cases. Additionally, the Con and the Res were given routine care and CNP, respectively. The two groups were compared in total emergency treatment time, hospital stay, medical expenses, recurrence rate of myocardial infarction (MI), overall response rate (ORR), incidence of complications, cardiac function indexes, negative mood scores, QOL, and nursing satisfaction.

Results

The ORR was higher, and the incidence of complications was lower in the Res versus the Con; the Res presented significantly less emergency treatment time and hospitalization and statistically lower medical expenses and recurrence rate of MI; the Res outperformed the Con in cardiac function indexes, alleviation of negative mood, QOL, and nursing satisfaction.

Conclusions

While effectively improving clinical efficacy and reducing the incidence of complications, CNP can relieve the bad mood of elderly patients with AMI and improve their cardiac function, QOL, and nursing satisfaction, which is worthy of clinical promotion.

Postprocedure Anticoagulation in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

OBJECTIVES

This study sought to assess the association between postprocedural anticoagulation (PPAC) use and several clinical outcomes.

BACKGROUND

PPAC after primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI) may prevent recurrent ischemic events but may increase the risk of bleeding. No consensus has been reached on PPAC use.

METHODS

Using data from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome registry, conducted between 2014 and 2019, we stratified all STEMI patients who underwent pPCI according to the use of PPAC or not. Inverse probability of treatment weighting and a Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality and the primary safety endpoint was major bleeding.

RESULTS

Of 34,826 evaluable patients, 26,272 (75.4%) were treated with PPAC and were on average younger, more stable at admission with lower bleeding risk score, more likely to have comorbidities and multivessel disease, and more often treated within 12 hours of symptom onset than those without PPAC. After inverse probability of treatment weighting adjustment for baseline differences, PPAC was associated with significantly reduced risk of in-hospital mortality (0.9% vs 1.8%; HR: 0.62; 95% CI: 0.43-0.89; P < 0.001) and a nonsignificant difference in risk of in-hospital major bleeding (2.5% vs 2.2%; HR: 1.05; 95% CI: 0.83-1.32; P = 0.14).

CONCLUSIONS

PPAC in STEMI patients after pPCI was associated with reduced mortality without increasing major bleeding complications. Dedicated randomized trials with contemporary STEMI management are needed to confirm these findings.

The Clinical Efficacy of Tirofiban Combined with Ticagrelor and Aspirin in Treating Acute Myocardial Infarction by Percutaneous Coronary Intervention and Its Effect on Patients’ Cardiac Function

Objective. To explore the clinical efficacy of tirofiban combined with ticagrelor and aspirin in acute myocardial infarction treatment by percutaneous coronary intervention and its effect on patients’ cardiac function. Methods. We selected 102 patients with acute myocardial infarction who came to The First Hospital of LanZhou University for treatment from July 2018 to May 2021. On the basis of conventional treatment, patients were separated into a joint group (tirofiban combined with ticagrelor and aspirin) comprising 55 cases and a control group (conventional ticagrelor and aspirin dual treatment) involving 47 cases. Blood flow classification of the two groups of patients was immediately recorded and compared after the myocardial infarction thrombolysis test (TIMI). Left ventricular function-related indicators, platelet-related parameters, neutrophil/lymphocyte ratio (NLR), red blood cell distribution width (RDW), and platelet/lymphocyte ratio (PLR) before treatment and 7 days after PCI were evaluated and compared between the groups before treatment and 3 months after treatment. ELISA was utilized to detect the serum levels of inflammatory factors, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and hypersensitive C-reactive protein (hs-CRP) before and after treatment. Incidence of major adverse cardiovascular events (MACEs) and adverse reaction incidence was put into comparison between the two groups in the course of the 3-month follow-up period. Compared with the control group, the joint group accounted for more patients with TIMI blood flow classification level 3 ( $P<0.05$ ) and showed more drastic improvement on the left ventricular function, platelet-related parameters, and serum inflammatory factors ( $P<0.05$ ). Moreover, patients of the joint group suffered less fluctuation from RDW, NLR, and PLR ( $P<0.05$ ), and their incidence of MACE was drastically lower in contrast with the control group ( $P<0.05$ ). No notable changes were presented in terms of incidence of adverse reaction ( $P>0.05$ ). For patients who suffered from acute myocardial infarction and treated with percutaneous coronary intervention, the application of tirofiban combined with ticagrelor and aspirin could effectively reduce the incidence of no reflow or slow blood flow, improve myocardial perfusion function, and have marked curative effects. It is worthy of clinical promotion and application.

Acute Myocardial Infarction and Cardiogenic Shock Interventional Approach to Management in the Cardiac Catheterization Laboratories

Despite advances in early reperfusion and a technologic renaissance in the space of Mechanical Circulatory Support (MCS), Cardiogenic Shock (CS) remains the leading cause of in-hospital mortality following Acute Myocardial Infarction (AMI). Given the challenges inherent to conducting adequately powered randomized controlled trials in this time-sensitive, hemodynamically complex, and highly lethal syndrome, treatment recommendations have been derived from AMI patients without shock. In this review, we aimed to (1) examine the pathophysiology and the new classification system for CS; (2) provide a comprehensive, evidence-based review for best practices for interventional management of AMI-CS in the cardiac catheterization laboratory; and (3) highlight the concept of how frailty and geriatric syndromes can be integrated into the decision process and where medical futility lies in the spectrum of AMI-CS care. Management strategies in the cardiac catheterization laboratory for CS include optimal vascular access, periprocedural antithrombotic therapy, culprit lesion versus multi-vessel revascularization, selective utilization of hemodynamic MCS tailored to individual shock hemometabolic profiles, and management of cardiac arrest. Efforts to advance clinical evidence for patients with CS should be concentrated on (1) the coordination of multi-center registries; (2) development of pragmatic clinical trials designed to evaluate innovative therapies; (3) establishment of multidisciplinary care models that will inform quality care and improve clinical outcomes.

Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.

Impact of bleeding on mortality in patients with acute myocardial infarction complicated by cardiogenic shock

AIMS

Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with substantial mortality, although there are limited data available on bleeding in this critical condition. This study sought to investigate the incidence and impact of major in-hospital bleeding on all-cause mortality in patients with AMICS who undergo percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Between 2015 and 2017, a total of 3411 patients hospitalized within 24 h after symptom onset were prospectively enrolled in the Japan Acute Myocardial Infarction Registry (JAMIR) and followed up for a median of 293 (interquartile range, 22-375) days. AMICS developed in 335 (9.8%) patients (mean age, 71.3 ± 13.6 years). Overall, the rate of major in-hospital bleeding (Bleeding Academic Research Consortium types 3 and 5) and in-hospital mortality was 14.6% and 28.7%, respectively. The majority of major in-hospital bleeding (73.5%) occurred within 48 h after PCI. Compared to patients without major in-hospital bleeding, those with it had higher rates of renal failure, left main coronary artery culprit lesion, and intra-aortic balloon pump or extracorporeal membrane oxygenation support, and had longer door-to-device time. The cumulative incidence of 1-year all-cause mortality was significantly higher in the major bleeding group compared to the non-major bleeding group (63.8% vs. 25.5%; log-rank P < 0.001). After adjusting for confounders, major in-hospital bleeding was independently associated with increased all-cause mortality (hazard ratio, 1.70; 95% confidence interval, 1.08-2.69).

CONCLUSIONS

These findings of JAMIR indicate that major in-hospital bleeding is associated with all-cause mortality in patients with AMICS who undergo PCI.

Multicenter and all-comers validation of a score to select patients for manual thrombectomy, the DDTA score

BACKGROUND

Routine manual thrombectomy (MT) is not recommended in primary percutaneous coronary intervention (P-PCI) but it is performed in many procedures. The objective of our study was validating the DDTA score, designed for selecting patients who benefit most from MT.

METHODS

Observational and multicenter study of all consecutive patients undergoing P-PCI in five institutions. Results were compared with the design cohort and the performance of the DDTA was analyzed in all patients. Primary end-point of the analyses was TIMI 3 after MT; secondary endpoints were final TIMI 3, no-reflow incidence, in-hospital mortality and in-hospital major cardiovascular events (MACE). In-hospital prognosis was assessed by the Zwolle risk score.

RESULTS

Three hundred forty patients were included in the validation cohort and no differences were observed as compared to the design cohort (618 patients) except for lower use of MT and higher IIb/IIIa inhibitors or drug-eluting stents. The probability of TIMI 3 after MT decreased as delay to P-PCI was higher. If DDTA score, MT was associated to TIMI 3 after MT (OR: 4.11) and final TIMI 3 (OR: 2.44). There was a linear and continuous relationship between DDTA score and all endpoints. DDTA score ≥ 4 was independently associated to lower no-reflow, in-hospital MACE or mortality. The lowest incidence of in-hospital mortality or MACE was in patients who had DDTA score ≥ 4 and Zwolle risk score 0-3.

CONCLUSIONS

MT is associated to higher rate of final TIMI3 in patients with the DDTA score ≥ 4. Patients with DDTA score ≥ 4 had lower no-reflow and in-hospital complications.