Outcomes of COVID-19 patients with STEMI undergoing primary PCI

Introduction and aim

Coronavirus disease (COVID-19) has substantial impact on acute myocardial infarction (AMI) clinical course and outcome.

In Poland during early phase of COVID-19 pandemic a network of dedicated hospitals was set to treat SARS-Cov2 positive patients. There is scarce data on STEMI patients outcome treated in this setting.

Our aim was to compare outcomes of STEMI patients treated with primary PCI in hospitals dedicated to treat COVID-19 and referral high volume haemodynamic centres.

Methods

Study was a retrospective analysis of 115 consecutive COVID-19 patients with STEMI, treated with primary PCI, admitted to 4 high volume centres (2 referral hospitals and 2 COVID dedicated sites) in southern Poland between May 2020 and November 2021. Data was obtained from patients' electronic medical records.

Results

Detailed characteristics are presented in Table 1 and 2. In general in all hospitals, patients were similar in terms of age (median 69 y.o., IQR: 60–73), with similar profile of comorbidities. All patients used acetylsalicylic acid and unfractioned heparin.

In referral centres, as compared with COVID-19 dedicated sites, there was a higher use of mechanical thrombectomy (p<0.001) and adenosine (p<0.001). Overall mortality rate was higher in COVID-19 centres (50% vs 25%, p=0.008). Detailed results are presented in Table 3.

Conclusions

There is a significantly higher mortality in COVID patients who develop STEMI than in patients with STEMI who were tested positive on admission.

Patients in COVID-19 hospitals had higher levels of CRP and NT-proBNP at baseline.

There are substantial differences in treatment of patients in referral centres and COVID dedicated hospitals.

Funding Acknowledgement

Type of funding sources: None.

Heterogeneous and overlapping mechanisms of myocardial ischemia in patients with ischemia and non-obstructive coronary arteries. Preliminary results from the MOSAIC-COR Registry

Background

Patients with ischemia and non-obstructive coronary arteries (INOCA) account for 30–70% of all patients undergoing elective coronary angiography for angina. In these group of patients various mechanisms may be responsible for myocardial ischemia, including increased microvascular resistance, epicardial spasm or microvascular spasm. There are limited data on the prevalence and coexistence of different mechanisms in patients with INOCA.

Purpose

The primary objective was to assess the occurrence of coronary microcirculatory disease (CMD), epicardial vasospastic angina (EVSA), microvascular vasospastic angina (MVSA) and their coexistance in patients with INOCA. The secondary objective was the analysis of subgroups' clinical characteristics.

Methods

This was a single-center, prospective, observational study. In the absence of significant coronary artery stenosis, a complex functional coronary assessment was performed. Values of fractional flow reserve (FFR), RFR, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were determined. Coronary artery and microvascular vasoreactivity was tested using the provocative acetylcholine test.

Results

We enrolled 90 consecutive patients with INOCA. Overlapping of CMD and CMD/EVSA phenomenon was observed. Accordingly, we distinguished 6 subgroups of INOCA patients in comparison to the CorMicA trial. Mixed pathophysiology (CMD+EVSA and CMD+MVSA) was diagnosed in 33% of patients. In the CMD+EVSA subgroup, 73% of subjects were male, while in the CMD+MVSA only 7.1% were male (p=0.005). Typical cardiovascular risk factors were common in the whole INOCA group.

Conclusions

The INOCA population is a heterogeneous group with various pathophysiology of myocardial ischemia. Overlapping of different pathomechanisms is a frequent phenomenon, which has to be consider for treatment optimization and future research.

Funding Acknowledgement

Type of funding sources: None.

Discrepancy between RFR and FFR based decision on revascularization – is coronary microcirculatory dysfunction responsible?

Introduction

Confirmation of significant ischemia is crucial for proper management of coronary artery disease. Non-hypaeremic indices along with fractional flow reserve are endorsed by current guidelines to prove ischemia. However some discrepancies between hyperaemic and non-hyperaemic decision on revascularisation is present in significant percentage of cases.

Aim

Aim of our study was to determine frequency of coronary microcirculatory dysfunction in patients with discrepant RFR and FFR measurements compared to concordant group.

Methods

Resting full cycle ratio (RFR) was measured in 69 left anterior descending arteries, all patients had symptoms of chronic coronary syndromes (CCS II-III). Cut-off values for ischemia detection were ≤0.80 for FFR and ≤0.89 for RFR. Coronary microcirculatory dysfunction (CMD) was defined as CFR <2.0 or IMR ≥25 according to current guideline.

Results

Discrepancy between FFR and RFR decision on revascularisation was present in 18 (26.1%) of cases. Mean age of patients was 65 (SD=8.5), all patients were similar in terms of diabetes, prior MI or hypertension and statin use (p=NS for all comparisons). Group with discordant RFR and FFR results had higher prevalence of CMD compared to patients with concordant result (44.4% vs 21.6% respectively, p=0.004), however median values of CFR and IMR were similar (see table).

Conclusions

• Patients with discrepant results have more frequently coronary microcirculatory dysfunction.

• Coronary microcirculatory dysfunction should be further investigated as it could explain discrepancies between RFR and FFR based decision on revascularisation.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Jagiellonian University statutory grant

Correlations between fractional flow reserve and a novel non-hyperemic index: resting full-cycle ratio in patients with an ambiguous coronary artery stenosis

Background

Fractional flow reserve (FFR) measurement has been the gold standard for invasive assessment of coronary ischemia. Resting full cycle ratio (RFR) is a new non-hyperemic index used to define physiologic significance of coronary artery stenosis. However, there are limited data available to establish optimal cut-off value of RFR for decision making on revascularization.

Aim

The aim of our study was to assess optimal cut-off value of RFR at which to predict FFR of 0.8.

Methods

The RFR and FFR values were recorded during invasive coronary angiography in vessels with angiographic stenosis 40–70% according to visual assessment. Maximum hyperemia for FFR measurement was achieved with adenosine iv. infusion at 140 μg/kg/min. Left main disease, acute myocardial infarction and systolic left ventricular dysfunction (EF <40%) were the main exclusion criteria.

Results

We evaluated 332 vessels, including 189 (56.9%) left anterior descending arteries, 77 (23.2%) left circumflex arteries and 66 (19.9%) right coronary arteries. Median diameter stenosis as assed by QCA was 45% (IQR 40; 50). Median RFR and FFR values were 0.90 [IQR 0.85; 0.94] and 0.86 [IQR 0.81; 0.92] respectively, with significant correlation (p<0.001, Figure 1, panel A). Optimal cut-off value for RFR to detect FFR 0.80 was 0.90 with area under the curve of 90.3%, sensitivity of 81.4% and specificity 88.0% (Figure 1, panel B).

Conclusions

Our data confirm RFR cut-off value ≤0.90 as an optimal threshold to detect ischemic lesions with good sensitivity and specificity in comparison to FFR assessment. Further research is necessary to assess outcomes of RFR-guided revascularization strategy.

Figure 1. RFR–FFR correlation and ROC analysis

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Jagiellonian University statutory grant

Serum rantes, transforming growth factor-β1 and interleukin-6 levels correlate with cardiac muscle fibrosis in patients with aortic valve stenosis

Regulated on Activation Normal T Expressed and Secreted (RANTES) chemokine is involved in the initiation of inflammation and immune-cell recruitment. Interleukin -6 (IL-6) is used as a general index of severity of the chronic inflammatory process. Finally, transforming growth factor-β (TGF-β) is an immune biomarker potentially involved in the regulation of valve fibrosis and calcification. The aim of this study was to analyze selected biomarkers associated with the different stages of immune-pathogenesis in aortic stenosis. Forty consecutive patients with moderate to severe aortic stenosis (AS) and without previous myocardial infarction history were included in the study and divided into two groups. Two imaging techniques, echocardiography and magnetic resonance, were used to estimate the degree of AS and left ventricular muscle function. Inflammatory biomarker serum levels including CCL5/RANTES, IL-6, and TGF-β1 were determined based on ELISA measurements. Mean levels of RANTES, IL-6, and TGF-β1 did not significantly differ between both groups. A negative correlation was found between RANTES serum level and left ventricle (LV) mass as assessed by MRI (r = -0.3358, P = 0.0341). A positive correlation (r = 0.3283, P = 0.0387) was found between IL-6 serum levels and LV mass as measured by MRI. In addition, a positive correlation (r = 0.6803, P = 0.01) was seen between IL-6 serum levels and LV muscle mass with positive late gadolinium enhancement (LGE). There was a positive correlation between TGF-β1 serum level and ejection fraction as measured by echocardiography (r = 0.3217, P = 0.043). The relationship between selected inflammatory biomarkers, LV ejection fraction, LV mass, and LV muscle mass with LGE appeared to be independent of valvular pathobiologic process severity, as we did not observe differences in IL-6, RANTES, or TGF-β1 between groups differing in severity. On the contrary, these markers appear to be linked to myocardial function and remodeling, which may provide valuable insights into the pathobiology of AS and provide a basis for future detection strategies of AS.

Chemokine RANTES is increased at early stages of coronary artery disease

Cardiovascular diseases, and in particular coronary artery disease (CAD), are the leading causes of death in Europe and represent around 50% of overall mortality. Numerous cardiovascular markers have been proposed in relation to cardiovascular risk prediction, in relation to cardiac and vascular and cerebral events. Chemokines which regulate immune cell vascular chemotaxis, including CCL5/RANTES are points of great interest. We hypothesized that chemokine RANTES level measured in peripheral blood may be associated with severity of atherosclerosis in patients with stable angina undergoing coronary angiography. RANTES and interleukin 18 (IL-18) levels were measured by ELISA. Classical and novel cardiovascular risk factors like brachial flow mediated dilation and intima-media thickness were analyzed in the context of chemokine levels and severity of atherosclerosis. Study included 62 consecutive patients with coronary atherosclerosis demonstrated by coronary angiography, (mean age 59.3 years (S.D. = 7.4)), divided into two groups: group I with lower severity of atherosclerosis, (n = 45) and group 2 with severe CAD (n = 17) based on coronary angiography. Groups were well balanced for classic risk factors for atherosclerosis. Mean RANTES level were significantly higher in patients in group I (67.9 ng/ml, S.E.M. = 3.97) than in group II (50.5 ng/ml, S.E.M. = 7.49; P = 0.03). In contrast, IL-18 levels were similar in both groups (255 pg/ml in group I and 315 pg/ml, S.E.M. = 40.91 in group I, P = 0.12), as well as hsCRP concentration (3.45 S.E.M. = 2.66 ng/ml and 4.69 ng/ml S.E.M.= 1.64 ng/ml respectively; P = 0.47). Flow-mediated dilatation (FMD) values have been significantly lower in group II than in group I (6.31; S.E.M. = 0.61; vs 4.41; S.E.M. = 0,56, respectively, P = 0.026), while nitroglycerine-mediated dilatation (NMD) did not differ, indicating more pronounced endothelial dysfunction. No significant correlations between chemokine RANTES levels and intima-media thickness (IMT), FMD measurements have been found in the total population studied. Chemokine RANTES level could become a useful marker of severity of coronary artery disease. Its lower levels were observed in patients with more diffuse disease. Elevated level of chemokine RANTES in patients with stable angina pectoris may evaluate patients to high risk group in plaque formation at early stages of atherosclerosis.