Microvascular reperfusion of fibrinolysis followed by percutaneous coronary intervention versus primary percutaneous coronary intervention for ST-segment-elevation acute myocardial infarction

Background

Primary percutaneous coronary intervention (PPCI) has been widely recognized as the preferred treatment for ST-segment-elevation myocardial infarction (STEMI). However, substantial numbers of STEMI patients cannot receive timely PPCI. Early fibrinolysis followed by routine percutaneous coronary intervention (FPCI) has been proposed as an effective and safe alternative for eligible patients. To date, few studies have compared FPCI with PPCI in terms of microvascular reperfusion. This study aimed to evaluate the microvascular function of FPCI and PPCI.

Methods

STEMI patients at the Peking University First Hospital and Miyun Hospital were enrolled in this retrospective study between January 2015 to December 2020. Microvascular function documented by the coronary angiography-derived index of microvascular resistance (caIMR) was measured at the final angiogram after revascularization. The primary end point was the caIMR of the culprit vessels. The secondary end points were in-hospital and follow-up major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal recurrent myocardial infarction, target-vessel revascularization (TVR), and non-fatal stroke/transient ischemic attacks (TIA). Details of the adverse clinical events were obtained from telephone interviews and electronic medical record systems until January 2022.

Results

In total, 496 STEMI patients were enrolled in this cross-sectional retrospective study. Of these patients, 81 underwent FPCI, and 415 underwent PPCI. At the baseline, the PPCI patients had a higher-risk profile than the FPCI patients. The time from symptom onset to reperfusion therapy was significantly shorter in the FPCI group than the PPCI group (median 3.0 vs. 4.5 hours; P<0.001). The caIMR was significantly lower in the FPCI group than the PPCI group (median 20.34 vs. 40.33; P<0.001). The median follow-up duration was 4.1 years. During the follow-up period, the rate of MACE was lower in the FPCI group than the PPCI group [7 (10.1%) vs. 82 (20.8%), P=0.048]. After propensity score matching to adjust for the imbalances at the baseline, the caIMR remained significant and the clinical outcomes did not differ significantly between the two groups.

Conclusions

In eligible STEMI patients, clinically successful FPCI may be associated with better microvascular reperfusion and comparable clinical outcomes as compared with PPCI.

No-Reflow after PPCI-A Predictor of Short-Term Outcomes in STEMI Patients

The no-reflow phenomenon following primary percutaneous coronary intervention (PPCI) in acute ST-elevation myocardial infarction (STEMI) patients is a predictor of unfavorable prognosis. Patients with no-reflow have many complications during admission, and it is considered a marker of short-term mortality. The current research emphasizes the circumstances of the incidence and complications of the no-reflow phenomenon in STEMI patients, including in-hospital mortality. In this case-control study, conducted over two and a half years, there were enrolled 656 patients diagnosed with STEMI and reperfused through PPCI. Several patients (n = 96) developed an interventional type of no-reflow phenomenon. One third of the patients with a no-reflow phenomenon suffered complications during admission, and 14 succumbed. Regarding complications, the majority consisted of arrhythmias (21.68%) and cardiogenic shock (16.67%). The anterior localization of STEMI and the left anterior descending artery (LAD) as a culprit lesion were associated with the highest number of complications during hospitalization. At the same time, the time interval >12 h from the onset of the typical symptoms of myocardial infarction (MI) until revascularization, as well as multiple stents implantations during PPCI, correlated with an increased incidence of short-term complications. The no-reflow phenomenon in patients with STEMI was associated with an unfavorable short-term prognosis.

Long-term compound danshen dripping pills therapy reduces the no-reflow phenomenon in nondiabetes mellitus patients after primary percutaneous coronary intervention for acute myocardial infarction

BACKGROUND

Cases with no-reflow increased significantly and accounted for about 5-50% of cases in primary percutaneous coronary intervention (PPCI) patients in recent years. It is important to identify patients at high risk of no-reflow. Ingredients of compound danshen dripping pills (CDDP), a popular Chinese traditional medicine, can alleviate myocardial ischemia, inhibit inflammation and angiotensin convert enzyme, and reduce cell apoptosis, among other effects. In this study, we aimed to assess whether long-term treatment with CDDP (>1 year, could reduce the no-reflow phenomenon in non-diabetes mellitus (DM) patients after PPCI for acute myocardial infarction (AMI).

METHODS

We enrolled patients according to inclusion and exclusion criteria. Clinical and PPCI data were collected. Patients were divided into 2 groups according to history of CDDP therapy. Data of the CDDP group and non-CDDP group were compared. Single and multivariate analysis was used to find factors associated with no-reflow.

RESULTS

Among these 399 patients, the no-reflow phenomenon occurred in 96 patients (24.1%). The results showed that patients with long-term CDDP treatment had lower incidence of no-reflow than those without CDDP treatment within 1 year (9/68 vs. 87/331, 13.2% vs. 26.3%, P=0.0219). Univariate and multivariate stepwise logistic regression analysis identified a few admission parameters associated with the no-reflow phenomenon: prior myocardial infarction (MI) [odds ratio (OR) 3.13, 95% CI: 1.42-4.89], systolic blood pressure (SBP) <100 mmHg (OR 1.78, 95% CI: 1.28-4.06), cardiac troponin T (cTnT) (OR 1.78, 95% CI: 1.28-4.06), high-sensitivity C-reactive protein (hs-CRP) (OR 1.08, 95% CI: 1.01-1.15), brain natriuretic peptide (BNP) (OR 3.76, 95% CI: 1.31-9.75), interleukin-6 (IL-6) (OR 1.42, 95% CI: 1.17-3.29), ejection fraction (EF) (OR 1.39, 95% CI: 1.09-3.28), left ventricular end-diastolic diameter (LVEDD) (OR 1.28, 95% CI: 1.05-4.23), anterior wall infarction (OR 2.83, 95% CI: 1.69-5.76), and long-term CDDP treatment (OR 0.44, 95% CI: 0.89-0.21).

CONCLUSIONS

Prior MI, SBP, cTnT, hs-CRP, BNP, and IL-6 on admission, along with EF, LVEDD, and anterior wall infarction are all predictors for no-reflow phenomenon. Long-term treatment with CDDP can reduce no-reflow phenomenon.

Effect of sequential nicorandil on myocardial microcirculation and short-term prognosis in acute myocardial infarction patients undergoing coronary intervention

Background

This study aims to observe the effects of the intracoronary and peripheral venous administration of nicorandil for the postoperative myocardial microcirculation and short-term prognosis of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI) treatment.

Methods

A total of 140 STEMI patients were divided into three groups according to different patterns of administration: sequential nicorandil group, intracoronary nicorandil group and control group. The main observation indexes included coronary blood flow and myocardial perfusion immediately after PPCI, while the secondary observation indexes included major adverse cardiovascular events (MACE) and left ventricular ejection fraction (LVEF) during the period of hospitalization.

Results

After PPCI, the difference in the proportion of patients with thrombolysis in myocardial infarction (TIMI) flow grade 3 among the three groups was statistically significant (P=0.036), where this proportion was higher in the sequential nicorandil group and intracoronary nicorandil group than in the control group (P=0.022 and P=0.047); The difference in corrected TIMI frame count (CTFC) among the three groups was statistically significant (P=0.022), where CTFC was lower in the sequential nicorandil group and intracoronary nicorandil group than in the control group (P=0.010, P=0.031); The differences in the proportion of patients with complete ST resolution (STR) and advancing of enzyme peak time to within 12 h between each two groups were statistically significant (P<0.001), where this proportion was the highest in the sequential nicorandil group; The difference in the CK-MB peak among the three groups was statistically significant (P=0.036), where the CK-MB peak was lower in the sequential nicorandil group than in the control group (P=0.012); The difference in the incidence of MACE between each two groups was statistically significant (P<0.001), where this incidence was the lowest in the sequential nicorandil group; The differences in the proportion of patients with advancing of enzyme peak time to within 14 h and LVEF among the three groups were not statistically significant (P=0.722 and P=0.284).

Conclusions

Compared with intracoronary use alone, the intracoronary and peripheral intravenous use of nicorandil can better improve myocardial microcirculation and short-term prognosis.