Outcomes of patients with myocardial infarction and cardiogenic shock treated with culprit vessel-only versus multivessel primary PCI

INTRODUCTION AND OBJECTIVES

Multivessel primary percutaneous coronary intervention (pPCI) is still often used in patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and multivessel coronary disease (MVD) treated with culprit vessel-only pPCI or multivessel-pPCI during the initial procedure.

MATERIAL AND METHODS

From 2016 to 2020, 23,703 primary PCI patients with STEMI were included in a national all-comers registry of cardiovascular interventions. Of them, 1,213 (5.1%) patients had CS and MVD at admission to the hospital. Initially, 921 (75.9%) patients were treated with culprit vessel (CV)-pPCI and 292 (24.1%) with multivessel (MV)-pPCI.

RESULTS

Patients with 3-vessel disease and left main disease had a higher probability of being treated with MV-pPCI than patients with 2-vessel disease and patients without left main disease (28.5% vs. 18.6%; p < 0.001 and 37.7% vs. 20.6%; p < 0.001). Intra-aortic balloon pump, extracorporeal membrane oxygenation (ECMO), and other mechanical circulatory support systems were more often used in patients with MV-pPCI. Thirty (30)-day and 1-year all-cause mortality rates were similar in the CV-pPCI and MV-pPCI groups (odds ratio, 1.01; 95% confidence interval [CI] 0.77 to 1.32; p = 0.937 and 1.1; 95% CI 0.84 to 1.44; p = 0.477). The presence of 3-vessel disease and the use of ECMO were the strongest adjusted predictors of 30-day and 1-year mortality.

CONCLUSIONS

Our data from an extensive all-comers registry suggests that selective use of MV-pPCI does not increase the all-cause mortality rate in patients with CS-STEMI and MVD compared to CV-pPCI.

Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock: Results of the ECMO-CS Randomized Clinical Trial

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used for circulatory support in patients with cardiogenic shock, although the evidence supporting its use in this context remains insufficient. The ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) aimed to compare immediate implementation of VA-ECMO versus an initially conservative therapy (allowing downstream use of VA-ECMO) in patients with rapidly deteriorating or severe cardiogenic shock.

METHODS

This multicenter, randomized, investigator-initiated, academic clinical trial included patients with either rapidly deteriorating or severe cardiogenic shock. Patients were randomly assigned to immediate VA-ECMO or no immediate VA-ECMO. Other diagnostic and therapeutic procedures were performed as per current standards of care. In the early conservative group, VA-ECMO could be used downstream in case of worsening hemodynamic status. The primary end point was the composite of death from any cause, resuscitated circulatory arrest, and implementation of another mechanical circulatory support device at 30 days.

RESULTS

A total of 122 patients were randomized; after excluding 5 patients because of the absence of informed consent, 117 subjects were included in the analysis, of whom 58 were randomized to immediate VA-ECMO and 59 to no immediate VA-ECMO. The composite primary end point occurred in 37 (63.8%) and 42 (71.2%) patients in the immediate VA-ECMO and the no early VA-ECMO groups, respectively (hazard ratio, 0.72 [95% CI, 0.46-1.12]; P=0.21). VA-ECMO was used in 23 (39%) of no early VA-ECMO patients. The 30-day incidence of resuscitated cardiac arrest (10.3.% versus 13.6%; risk difference, -3.2 [95% CI, -15.0 to 8.5]), all-cause mortality (50.0% versus 47.5%; risk difference, 2.5 [95% CI, -15.6 to 20.7]), serious adverse events (60.3% versus 61.0%; risk difference, -0.7 [95% CI, -18.4 to 17.0]), sepsis, pneumonia, stroke, leg ischemia, and bleeding was not statistically different between the immediate VA-ECMO and the no immediate VA-ECMO groups.

CONCLUSIONS

Immediate implementation of VA-ECMO in patients with rapidly deteriorating or severe cardiogenic shock did not improve clinical outcomes compared with an early conservative strategy that permitted downstream use of VA-ECMO in case of worsening hemodynamic status.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02301819.

Trends in outcomes of women with myocardial infarction undergoing primary angioplasty-Analysis of randomized trials

Background

Sex- and gender-associated differences determine the disease response to treatment.

Aim

The study aimed to explore the hypothesis that progress in the management of STE-myocardial infarction (STEMI) overcomes the worse outcome in women.

Methods and results

We performed an analysis of three randomized trials enrolling patients treated with primary PCI more than 10 years apart. PRAGUE-1,-2 validated the preference of transport for primary PCI over on-site fibrinolysis. PRAGUE-18 enrollment was ongoing at the time of the functional network of 24/7PCI centers, and the intervention was supported by intensive antiplatelets. The proportion of patients with an initial Killip ≥ 3 was substantially higher in the more recent study (0.6 vs. 6.7%, p = 0.004). Median time from symptom onset to the door of the PCI center shortened from 3.8 to 3.0 h, p < 0.001. The proportion of women having total ischemic time ≤3 h was higher in the PRAGUE-18 (OR [95% C.I.] 2.65 [2.03-3.47]). However, the percentage of patients with time-to-reperfusion >6 h was still significant (22.3 vs. 27.2% in PRAGUE-18). There was an increase in probability for an initial TIMI flow >0 in the later study (1.49 [1.0-2.23]), and also for an optimal procedural result (4.24 [2.12-8.49], p < 0.001). The risk of 30-day mortality decreased by 61% (0.39 [0.17-0.91], p = 0.029).

Conclusion

The prognosis of women with MI treated with primary PCI improved substantially with 24/7 regional availability of mechanical reperfusion, performance-enhancing technical progress, and intensive adjuvant antithrombotic therapy. A major modifiable hindrance to achieving this benefit in a broad population of women is the timely diagnosis by health professional services.

Impact of COVID-19 pandemic on the occurrence and outcome of cardiogenic shock complicating acute myocardial infarction

Background

The COVID-19 pandemic had influenced the patient's behavior and impacted the homeostasis to a pro-thrombotic niveau.

Aim

The study aimed to follow the impact of COVID-19 on the incidence and prognosis of cardiogenic shock complicated initially acute myocardial infarction (CS-AMI).

Methods

We used data entered into a large national all-comers registry of coronary intervention over five years. From 1/2016 to 12/2020, 50,745 AMI patients were included, and 2,822 (5.6%) initially had CS.

Results

The incidence of CS-AMI was significantly higher in the COVID period (2020) than the mean incidence in 2016–2019 (5.5% vs 6%, p=0.032). The difference was caused by significant increase of CS in acute STEMI (7.6% vs. 8.7%, p=0.011); it was 7.1% in 2016, 7.8% (2017), 7.6% (2018), 7.8% (2019), and 8.7% (2020). The CS complicated 2.3% (2016), 2.7% (2017), 2.7% (2018), 2.8% (2019), and 2.8% (2020) of NSTEMI.

The observed rise in CS-STEMI incidence each month during the pandemic compared to the average incidence in non-pandemic years correlated with the substantial increase in the number of COVID infected/hospitalized (Table 1). In these months, no changes in time delay to reperfusion layout were observed in CS-STEMI patients (Table 2).

Except of less frequent history of previous PCI (13.9% and 8.2%, p&lt;0.001), we found no significant differences in the followed CS-STEMI patient characteristics in 2016–2019 and 2020; men 72.7% and 75.4% (p=0.1), mean age (SD) 66.3 (12.3)yrs and 66.3 (12.2) yrs, Diabetes 20.9% and 19.1% (p=0.2), CKD 5.4% and 5.7% (p=0.4), previous CABG 4.5 and 4.2% (p=0.5), left main disease (14.3% and 16%, p=0.5), one vessel disease 24.9% and 32.1% (p=0.9), pre-PCI TIMI flow 0 64.4% and 66.2% (p=0.6), post-PCI TIMI flow 3 76.7% and 76.9%.

The COVID pandemic didn't influence the proportions of pre-hospital resuscitated CS-AMI patients (57.5% and 58.7%, p=0.6) and those on mechanical ventilation (67.8% and 68.3%, p=0.8).

The 30-day mortality trend of CS-AMI was 53.7% in 2016, 51.6% (2017), 49.7% (2018), 49.3% (2019), and 47.9% (2020). And in CS-STEMI it was 50.8%, 47.1%, 46.4%, 44.1%, and 45.3% (P2019 vs. 2020 =0.8), respectively.

Conclusion

Data from a large national all-comer registry showed an increase in the proportion of patients admitted to hospitals with STEMI complicated by CS in the year of the COVID pandemic. The CS rise correlated with the increase in the COVID infected population. Factors other than the patient's cardiovascular risk profile or prolongation of a time delay to reperfusion influenced this trend. We suggest that the availability of health care and patient adherence may have affected the risks control. We did not observe any effect of the pandemic on CS-AMI mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of the Czech Republic

All-cause mortality of patients with STEMI, cardiogenic shock and multivessel coronary disease treated with culprit vessel only versus multivessel primary PCI

Background

Patients with ST elevation myocardial infarction (STEMI) and cardiogenic shock (CS) treated with primary percutaneous coronary intervention (pPCI) have high mortality. A recent trial demonstrated that a culprit vessel-only strategy (CV-pPCI) was superior to immediate multivessel PCI (MV-pPCI) for patients with CS and multivessel coronary artery disease (MVD). Irrespective of it and current guidelines, multivessel PCI is still often used in these patients.

Purpose/Methods

The study aimed to compare the characteristics and prognosis of patients with CS-STEMI and MVD treated with culprit vessel only pPCI or multivessel PCI during initial procedure. From 2016 to 2020, 23703 primary PCI patients with STEMI were included in the national all-comers registry of cardiovascular interventions. From them, a total of 1213 (5.1%) patients had cardiogenic shock and MVD at admission to the hospital. Initially 921 (75.9%) patients were treated with CV-pPCI and 292 (24.1%) with MV-pPCI.

Results

CV-pPCI was a preferred strategy to MV-pPCI in men (74.6% vs 25.4%; p&lt;0,001) and women (79.8% vs 20.2%; p&lt;0,001) with CS-STEMI and MVD. Patients with 3-vessel disease and left main disease had higher probability to be treated with MV-pPCI than patients with 2-vessel disease and without left main disease (28.5% vs 18.6%; p&lt;0,001 and 37.7% vs 20.6%; p&lt;0,001).The CV-pPCI and MV-pPCI group patients did not differ in age (68.1±11.2 vs 66.2±11.4 years; p=0.780), previous PCI (16.1% vs 12.0%; p=0.890) and CABG (6.2% vs 4.8%; p=0.376), chronic kidney disease (6.8% vs 8.2%; p=0.426), cardiopulmonary resuscitation (60.4% vs 58.9%; p=0.657) and pulmonary ventilation (66.8% vs 70.5%; p=0.227) at admission, localization of myocardial infarction (anterior 50.8.% vs 58.9%; p=0.671), time to reperfusion (&lt;2 hours 5.2% vs 4.8%; p=0.722) and TIMI flow 0 before PCI (63.1% vs 64.0%; p=0.675). Based on the results of logistic regression analysis, 30-days (odds ratio, 0.99; 95% CI 0.76 to 1.29; p=0.937) and 1-year (odds ratio, 0.91; 95% CI 0.69 to 1.19; p=0.477) all-cause mortality rates were similar in CV-pPCI and MV-pPCI groups. The presence of 3-vessel disease was the strongest adjusted predictor of 30-days (odds ratio, 1.61; 95% CI 1.27 to 2.04; p&lt;0.001) and 1-year (odds ratio, 1.64; 95% CI 1.30 to 2.08; p&lt;0.001) all-cause mortality in patients with STEMI and CS treated with pPCI.

Conclusion

Immediate multivessel primary PCI is still used in patients with CS-STEMI and MVD in routine clinical practice. We did not find difference in 30-days and 1-year mortality among patients with CS-STEMI and MVD treated either with culprit vessel-only or multivessel primary PCI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NV19-02-00086 supported by Ministry of Health of the Czech Republic

Myocardial Involvement Detected Using Cardiac Magnetic Resonance Imaging in Patients with Systemic Sclerosis: A Prospective Observational Study

Introduction and objectives: Cardiac involvement in systemic sclerosis (SSc) patients affects mortality. Cardiac magnetic resonance (CMR) is capable of detecting structural changes, including diffuse myocardial fibrosis that may develop over time. Our aim was to evaluate myocardial structure and function changes using CMR in patients with SSc without known cardiac disease during a 5-year follow-up and find possible correlations with selected biomarkers. Methods: A total of 25 patients underwent baseline and follow-up CMR examinations according to a pre-specified protocol. Standard biochemistry, five biomarkers (hsTnI, NT-proBNP, galectin-3, sST2, and GDF-15), and disease-specific functional parameters enabling the classification of disease severity were also measured. Results: After five years, no patient suffered from manifest heart disease. Mean extracellular volume (ECV) and T1 mapping values did not change significantly (p ≥ 0.073). However, individual increases in native T1 time and ECV correlated with increased galectin-3 serum levels (r = 0.56; p = 0.0050, and r = 0.71; p = 0.0001, respectively). The progression of skin involvement assessed using the Rodnan skin score and a decrease in the diffusing capacity of the lungs were associated with increased GDF-15 values (r = 0.63; p = 0.0009, and r = −0.51; p = 0.011, respectively). Conclusions: During the 5-year follow-up, there was no new onset of heart disease observed in patients with SSc. However, in some patients, CMR detected progression of sub-clinical myocardial fibrosis that significantly correlated with elevated galectin-3 levels. GDF-15 values were found to be associated with disease severity progression.

Stent Selection for Primary Angioplasty and Outcomes in the Era of Potent Antiplatelets. Data from the Multicenter Randomized Prague-18 Trial

Drug-eluting stents (DES) are the recommended stents for primary percutaneous coronary intervention (PCI). This study aimed to determine why interventional cardiologists used non-DES and how it influenced patient prognoses. The efficacy and safety outcomes of the different stents were also compared in patients treated with either prasugrel or ticagrelor. Of the PRAGUE-18 study patients, 749 (67.4%) were treated with DES, 296 (26.6%) with bare-metal stents (BMS), and 66 (5.9%) with bioabsorbable vascular scaffold/stents (BVS) between 2013 and 2016. Cardiogenic shock at presentation, left main coronary artery disease, especially as the culprit lesion, and right coronary artery stenosis were the reasons for selecting a BMS. The incidence of the primary composite net-clinical endpoint (EP) (death, nonfatal myocardial infarction, stroke, serious bleeding, or revascularization) at seven days was 2.5% vs. 6.3% and 3.0% in the DES, vs. with BMS and BVS, respectively (HR 2.7; 95% CI 1.419–5.15, p = 0.002 for BMS vs. DES and 1.25 (0.29–5.39) p = 0.76 for BVS vs. DES). Patients with BMS were at higher risk of death at 30 days (HR 2.20; 95% CI 1.01–4.76; for BMS vs. DES, p = 0.045) and at one year (HR 2.1; 95% CI 1.19–3.69; p = 0.01); they also had a higher composite of cardiac death, reinfarction, and stroke (HR 1.66; 95% CI 1.0–2.74; p = 0.047) at one year. BMS were associated with a significantly higher rate of primary EP whether treated with prasugrel or ticagrelor. In conclusion, patients with the highest initial risk profile were preferably treated with BMS over BVS. BMS were associated with a significantly higher rate of cardiovascular events whether treated with prasugrel or ticagrelor.

Clinical outcomes with drug-eluting stents, bare-metal stents, and bioresorbable scaffolds implanted in patients with AMI treated with primary PCI. Data from the Prague-18 trial

Background

Drug-eluting stents (DESs) are the recommended choice of stents for primary PCI.

Purpose/Methods

The study aimed to determine why interventional cardiologists used non-DESs and how they had influenced the patient prognosis. The efficacy and safety outcomes of the different stents were also compared in treated with either prasugrel or ticagrelor.

Results

Of the PRAGUE 18 study patients, 749 (67.4%) were treated with DESs, 296 (26.6%) with BMS, and 66 (5.9%) with BVS. Cardiogenic shock at presentation and the left main disease, especially as culprit lesion, and right coronary artery stenosis were the reasons for BMS selection.

The incidence of the primary net-clinical EP (CV death, nonfatal MI, stroke, major bleeding, or revascularization) at 7 days was 2.6% vs. 6.5%, and 3.0% in the DESs, BMSs, and BVSs, respectively (HR 2.7; 95% CI 1.419–5.15, P=0.002 for BMS vs. DES and 1.25 (0.29–5.39) for BVS vs. DES, P=0.76). Patients with BMSs were at higher risk of death at 30 days (HR 2.20; 95% CI 1.01–4.76; for BMS vs. DES, P=0.045), and at one year (HR 2.1; 95% CI 1.19–3.69; P=0.01); they also had higher composite of cardiac death, re-MI and stroke (HR 1.66; 95% CI 1.0–2.74; P=0.047) at one year. BMSs were associated with significantly higher rate of primary EPs either treated with prasugrel or ticagrelor.

Conclusion

Patients with the highest risk profile were preferably treated with BMS the contrary to BVS. BMSs were associated with a significantly higher rate of cardiovascular events either treated with prasugrel or ticagrelor.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Charles University Cardiovascular Research Program P-35 and Q-38, Charles University, Czech Republic

Uricemia in the acute phase of myocardial infarction and its relation to long-term mortality risk

Aim: Although uric acid has antioxidant effects, hyperuricemia has been established as an indicator of increased cardiovascular mortality in various patient populations. Treatment of asymptomatic hyperuricemia in patients with acute myocardial infarction (MI) is not routinely recommended, and the efficacy of such treatment in terms of cardiovascular risk reduction remains doubtful. Materials & methods: In a prospective cohort study, we followed 5196 patients admitted for a MI between 2006 and 2018. We assessed the relationship between baseline uricemia and the incidence of all-cause death and cardiovascular mortality and the effect of long-term allopurinol treatment. Hyperuricemia was defined as serum uric acid >450 μmol/l in men and >360 μmol/l in women. Results: In the entire cohort, the 1-year all-cause and cardiovascular mortality rates were 8 and 7.4%, and the 5-year rates were 18.3 and 15.3%, respectively. Using a fully adjusted model, hyperuricemia was associated with a 70% increased risk of both all-cause death and cardiovascular mortality at 1 year, and the negative prognostic value of hyperuricemia persisted over the 5-year follow-up (for all-cause death, hazard risk ratio = 1.45 [95% CI: 1.23-1.70] and for cardiovascular mortality, hazard risk ratio = 1.52 [95% CI: 1.28-1.80], respectively). Treatment of asymptomatic hyperuricemia with allopurinol did not affect mortality rates. Conclusion: Hyperuricemia detected in patients during the acute phase of an MI appears to be independently associated with an increased risk of subsequent fatal cardiovascular events. However, hyperuricemia treatment with low-dose allopurinol did not prove beneficial for these patients.

MiR-126-3p and MiR-223-3p as Biomarkers for Prediction of Thrombotic Risk in Patients with Acute Myocardial Infarction and Primary Angioplasty

Aim. This study was designed to evaluate the relationship between microRNAs (miRNAs), miR-126-3p and miR-223-3p, as new biomarkers of platelet activation, and predicting recurrent thrombotic events after acute myocardial infarction (AMI). Methods and Results. The analysis included 598 patients randomized in the PRAGUE-18 study (ticagrelor vs. prasugrel in AMI). The measurements of miRNAs were performed by using a novel miRNA immunoassay method. The association of miRNAs with the occurrence of the ischemic endpoint (EP) (cardiovascular death, nonfatal MI, or stroke) and bleeding were analyzed. The miR-223-3p level was significantly related to an increased risk of occurrence of the ischemic EP within 30 days (odds ratio (OR) = 15.74, 95% confidence interval (CI): 2.07-119.93, p = 0.008) and one year (OR = 3.18, 95% CI: 1.40-7.19, p = 0.006), respectively. The miR-126-3p to miR-223-3p ratio was related to a decreased risk of occurrence of EP within 30 days (OR = 0.14, 95% CI: 0.03-0.61, p = 0.009) and one year (OR = 0.37, 95% CI: 0.17-0.82, p = 0.014), respectively. MiRNAs were identified as independent predictors of EP even after adjustment for confounding clinical predictors. Adding miR-223-3p and miR-126-3p to miR-223-3p ratios as predictors into the model calculating the ischemic risk significantly increased the predictive accuracy for combined ischemic EP within one year more than using only clinical ischemic risk parameters. No associations between miRNAs and bleeding complications were identified. Conclusion. The miR-223-3p and the miR-126-3p are promising independent predictors of thrombotic events and can be used for ischemic risk stratification after AMI.

The prognostic significance of periprocedural infarction in the era of potent antithrombotic therapy. The PRAGUE-18 substudy

BACKGROUND

The prognostic significance of periprocedural myocardial infarction (MI) remains controversial.

METHODS AND RESULTS

The study aims to investigate the incidence of periprocedural MI in the era of high sensitivity diagnostic markers and intense antithrombotics, and its impact on early outcomes of patients with acute MI treated with primary angioplasty (pPCI). Data from the PRAGUE-18 (prasugrel versus ticagrelor in pPCI) study were analyzed. The primary net-clinical endpoint (EP) included death, spontaneous MI, stroke, severe bleeding, and revascularization at day 7. The key secondary efficacy EP included cardiovascular death, spontaneous MI, and stroke within 30 days. The incidence of peri-pPCI MI was 2.3% (N = 28) in 1230 study patients. The net-clinical EP occurred in 10.7% of patients with, and in 3.6% of patients without, peri-pPCI MI (HR 2.92; 95% CI 0.91-9.38; P = 0.059). The key efficacy EP was 10.7% and 3.2%, respectively (HR 3.44; 95% CI 1.06-11.13; P = 0.028). Patients with periprocedural MI were at a higher risk of spontaneous MI (HR 6.19; 95% CI 1.41-27.24; P = 0.006) and stent thrombosis (HR 10.77; 95% CI 2.29-50.70; P = 0.003) within 30 days. Age, hyperlipidemia, multi-vessel disease, post-procedural TIMI <3, pPCI on circumflex coronary artery, and periprocedural GP IIb/IIIa inhibitor were independent predictors of peri-pPCI MI.

CONCLUSIONS

In the era of intense antithrombotic therapy, the occurrence of peri-pPCI MI is despite highly sensitive diagnostic markers a rare complication, and is associated with an increased risk of early reinfarction and stent thrombosis.

Relationship between symptom-onset-to-balloon time and outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention

Background

Time delay is an important prognostic factor and indicator of quality of care for patients with AMI indicated for primary percutaneous coronary intervention (PCI).

Purpose

Assessment of total ischaemia time and its relationship to catheterization findings and the incidence of ischaemic events within 1 year in patients treated with primary PCI.

Method

The analysis included 1230 patients with AIM and primary PCI randomized in the Prague-18 study (prasugrel vs. ticagrelor). We evaluated the total ischaemia time and two the intermediate intervals: A - from the symptom onset to the arrival to the hospital and B - from the entry the hospital to balloon time. We assessed the time delay in relation to patient characteristics, PCI results and ischaemic endpoints (death, reIM, stroke) within 30 days and 1 year.

Results

Median total ischaemia time was 3.2 hours. Its prolongation resulted in more frequent incidence of TIMI flow &lt;2 before PCI (p=0.029), TIMI flow &lt;3 after PCI (p=0.004) and suboptimal PCI (p=0.018). The interval A was significantly prolonged in women (p=0.001) and obese patients with BMI ≥30 kg / m2 (p=0.001). The interval B &lt;30 min was achieved in 70% of patients, only 5.3% had interval &gt;90 min. In 717 (61,6%) patients with increased risk (at least 1 criterion: age &gt;70 years, STEMI anterior wall or LBBB, Killip II-IV, history of MI and CABG, SBP &lt;100 mmHG and HR &gt;100 / min), the prolongation of total ischaemia time (≤2 vs. 2.1–4 vs. 4.1–6 vs. &gt;6 hours) resulted in a more frequent incidence of combined ischaemic endpoints within 1 year (p=0.034) and left ventricular systolic dysfunction (p=0.028).

Conclusion

The extension of total ischaemia time in patients treated with primary PCI resulted in a more frequent suboptimal result with TIMI flow &lt;3. Female gender, older age and obesity in women were associated with an increase in total ischaemia time. In patients with increased risk, time delay resulted in a higher incidence of combined ischaemic endpoints within 1 year and left ventricular systolic dysfunction.

Funding Acknowledgement

Type of funding source: None

The Effect of Diabetes on Prognosis Following Myocardial Infarction Treated with Primary Angioplasty and Potent Antiplatelet Therapy

Purpose: To investigate the prognostic significance of diabetes mellitus (DM) in patients with high risk acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (pPCI) in the era of potent antithrombotics. Methods: Data from 1230 ST-segment elevation myocardial infarction (STEMI) patients enrolled in the PRAGUE-18 (prasugrel vs. ticagrelor in pPCI) study were analyzed. Ischemic and bleeding event rates were calculated for patients with and without diabetes. The independent impact of diabetes on outcomes was evaluated after adjustment for outcome predictors. Results: The prevalence of DM was 20% (N = 250). Diabetics were older and more often female. They were more likely to have hypertension, hyperlipoproteinemia, multivessel coronary disease and left main disease, and be obese. The primary net-clinical endpoint (EP) containing death, spontaneous nonfatal MI, stroke, severe bleeding, and revascularization at day 7 occurred in 6.1% of patients with, and in 3.5% of patients without DM (HR 1.8; 95% CI 0.978–3.315; p = 0.055). At one year, the key secondary endpoint defined as cardiovascular death, spontaneous MI, or stroke occurred in 8.8% with, and 5.5% without DM (HR 1.621; 95% CI 0.987–2.661; p = 0.054). In those with DM the risk of total one-year mortality (6.8% vs. 3.9% (HR 1.773; 95% CI 1.001–3.141; p = 0.047)) and the risk of nonfatal reinfarction (4.8% vs. 2.2% (HR 2.177; 95% CI 1.077–4.398; p = 0.026)) were significantly higher compared to in those without DM. There was no risk of major bleeding associated with DM (HR 0.861; 95% CI 0.554–1.339; p = 0.506). In the multivariate analysis, diabetes was independently associated with the one-year risk of reinfarction (HR 2.176; 95% Confidence Interval, 1.055–4.489; p = 0.035). Conclusion: Despite best practices STEMI treatment, diabetes is still associated with significantly worse prognoses, which highlights the importance of further improvements in the management of this high-risk population.

3300MiR-126-3P and MiR-223-3p in Prediction of Thrombotic Risk in Patients with Acute Myocardial Infarction and Primary Angioplasty, The Prague-18 Genetic Sub-study

Background

Balancing the intensity and duration of antiplatelet therapy according to thrombotic risk is a fundamental need in order to optimize therapy effectiveness and safety. Incorporation of new predictors in thrombotic risk stratification is therefore of a crucial importance for antiplatelet therapy net clinical benefit.

Purpose

The present analysis aimed to evaluate the relation of miR-126-3p and miR-223-3p, new markers of platelet activation, in order to facilitate prediction of recurrent thrombotic events after acute myocardial infarction (AMI).

Method

The analysis included 598 patients (age median 62 years, men 77.8%) randomized in the Prague-18 study (ticagrelor vs. prasugrel in AIM treated with primary PCI). During the study follow up, 40.6% of patients switched to clopidogrel. Determination of miR was evaluated 24 hours after admission; miR-126-3p and miR-223-3p were normalized by miR-423-3p and miR-150-5p. Quantitative determination of selected miRNAs was performed with a novel microRNA immunoassay method.

Selected miRNAs were compared with key efficacy endpoints (cardiovascular death, nonfatal MI and stroke), stent thrombosis and all hemorrhagic events, and analysed using univariate and multivariate logistic regressions.

Results

Increased values of miR-223-3p were significantly related to the occurrence of combined ischemic endpoint within 30 days [OR (95% CI) 15.739 (2.066; 119.932) p=0.008] and within one year [3.175 (1.40; 7.186) p=0.006]. Decreased ratio of miR-126-3P/miR-223-3p was significantly related to the occurrence of combined ischemic endpoint within 30 days [0.137 (0.031; 0.609) p=0.009] and one year [0.372 (0.169; 0.819) p=0.014]. MiRNAs were identified as independent predictors even after adjustment for confounding clinical predictors (Study arm, Switch to Clopidogrel, Age, Men, BMI, Smoking, History of Hyperlipidemia, Hypertension, DM, MI, PCI, CABG, Chronic heart failure, Chronic renal failure, Peripheral arterial disease, LBBB, RBBB, TIMI <3 after PCI, Number of diseased vessels >1, Stem disease, Suboptimal of failure of PCI, Time to hospital). Adjusted ORs (95% CI) are 11.828 (1.472; 98.011), p=0.022 and 2.394 (1.021; 5.610), p=0.045 for increased value of miR-223-3p and the occurrence of combined ischemic endpoint within 30 days and one year respectively; 0.151 (0.030; 0.757), p=0.022 and 0.407 (0.179; 0.925), p=0.032 for decreased ratio of miR-126–3P/miR-223-3p and the occurrence of combined ischemic endpoint within 30 days and one year respectively. No association between miRNA and bleeding complications was identified.

Conclusion

The miR-223-3p and miR-126-3p to miR-223-3p ratio are strong independent predictors of thrombotic ischemic events and can be used to stratify patients post AMI.

P1727Prognosis predictors of patients with initial cardiogenic shock complicated acute myocardial infarction treated with primary angioplasty and intense antiplatelet therapy. PRAGUE-18 shock substudy

Background

Early reperfusion of the infarct related artery is the only treatment improving prognosis of patients with initial cardiogenic shock (CGS) complicated acute myocardial infarction (AMI) (Killip class IV at admission).

Purpose

The analysis focused on subgroup of patients with initial CGS randomized into the multicenter PRAGUE-18 study (prasugrel vs. ticagrelor in primary PCI).

Methods

In the PRAGUE-18 study, patients with acute myocardial infarction (AMI) (n=1230) treated with primary percutaneous coronary intervention (pPCI) were immediately randomized to prasugrel or ticagrelor with intended treatment duration of 12 months. 53.6% (n=659) switched to clopidogrel after discharge. Major ischemic and bleeding events were followed throughout the entire study period. Beside standard laboratory tests, efficacy of ticagrelor and prasugrel was measured by flow cytometric VASP evaluation in patients selected for a laboratory sub-study (n=218). Acute heart failure (KILLIP >1) was present in 11.8%, and 46 patients (3.7%) randomized to the study were in CGS.

Results

Patients with CGS were older [66.7 (48,3; 83,3) years] than those without CGS (KILLIP <4), and had the highest prevalence of bundle brunch block on the initial ECG (RBBB in 6.5%, LBBB in 8.7%, p=0.003 for difference in bundle brunch blocks). Time delay to hospital admission [1,7 (0,4; 36,0) hs] was significantly shorter than in patients KILLIP <4 [2,8 (0,8; 28,3hs; p=0.003]. Significantly more CGS patients had history of previous MI (19.6% vs 7.9%, p=0.011) and bypass graft surgery (6.5% vs 1.5%, p=0.041). 67.4% of CGS patients had multivessel disease and in 17.4% of these patients primary PCI was evaluated as suboptimal result or procedural failure (compared to 4.3% in patients without shock, p<0.001).

No difference was observed in clinical (primary and secondary endpoints, p=0.564) or laboratory efficacy between prasugrel and ticagrelor treated patients with CGS (p=0.800 for VASP index difference between prasugrel and ticagrelor 20±4 hs after loading doses). We did not find any difference in initial platelet activation (VASP index before P2Y12 inhibitors administration) in patients without acute heart failure (KILLIP I) [83.2 (54.1–94.2) %] and with KILLIP > I [82.5 (65.7–96.9), p=0.999], and this was also confirmed for the difference between KILLIP I and KILLIP IV patients (p=0.416).

Conclusion

Results of the present analysis and defined predictors of mortality showed that prognosis of patients with initial cardiogenic complicated AMI treated with pPCI cannot be influenced by more potent platelet inhibition (than in AMI patients without CGS). Furthermore, the concluding evidence underscored adherence to the current guidelines' recommendation of the earliest possible reperfusion of infarct related artery as well as administration of prasugrel or ticagrelor.

Factors influencing the accuracy of non-invasive blood pressure measurements in patients admitted for cardiogenic shock

BACKGROUND

Although invasively measured blood pressure (invBP) is regarded as a "gold standard" in critically ill cardiac patients, the non-invasive BP is still widely used, at least at the initiation of medical care. The erroneous interpretation of BP can lead to clinical errors. We therefore investigated the agreement of both methods with respect to some common clinical situation.

METHODS

We included 85 patients hospitalized for cardiogenic shock. We measured BP every 6 h for the first 72 h of hospitalization, in all patients. Each set of BP measurements included two invasive (invBP), two auscultatory (auscBP), and two oscillometric (oscBP) BP measurements. InvBP was considered as a gold standard. Mean non-invasive arterial pressure (MAP) was calculated as (diastolic pressure + (pulse pressure ÷ 3)). We used Bland-Altman analysis and we calculated concordance correlation coefficients to assess agreement between different BP methods.

RESULTS

We obtained 967 sets of BP measurements. AuscMAP and oscMAP were on average only 0.4 ± 8.2 and 1.8 ± 8.5 mmHg higher than invMAP, respectively. On the other hand, auscSBP and oscSBP were on average - 6.1 ± 11.4 and - 4.1 ± 9.8 mmHg lower than invSBP, respectively. However, the mean differences and variability for systolic and diastolic BP variability were large; the 2 standard deviation differences were ± 24 and 18 mmHg. In hypotension, non-invasive BP tended to be higher than invBP while the opposite was true for high BP values. Clinical conditions associated with hypotension generally worsened the accuracy of non-invasive MAP.

CONCLUSIONS

Mean arterial pressure measured non-invasively appears to be in good agreement with invasive MAP in patients admitted for cardiogenic shock. Several clinical associated with hypotension can affect accuracy of non-invasive measurement. Auscultatory and oscillometric measurements had similar accuracy even in patients with arrhythmia.

High-sensitivity Troponins after a Standardized 2-hour Treadmill Run

BACKGROUND

The aim of this study was to examine high-sensitivity troponin T and I (hsTnT and hsTnI) after a treadmill run under laboratory conditions and to find a possible connection with echocardiographic, laboratory and other assessed parameters.

METHODS

Nineteen trained men underwent a standardized 2-hour-long treadmill run. Concentrations of hsTnT and hsTnI were assessed before the run, 60, 120 and 180 minutes after the start and 24 hours after the run. Changes in troponins were tested using non-parametric analysis of variance (ANOVA). The multiple linear regression model was used to find the explanatory variables for hsTnT and hsTnI changes. Values of troponins were evaluated using the 0h/1h algorithm.

RESULTS

Changes in hsTnT and hsTnI levels were statistically significant (p<0.0001 and p<0.0001, respectively). In a multiple regression model (adjusted R2: 0.60, p=0.005 for hsTnT and adjusted R2: 0.60, p=0.005 for hsTnI), changes in both troponins can be explained by relative left wall thickness (LV), training volume, body temperature after the run and creatinine changes. According to the 0h/1h algorithm, none of the runners was evaluated as negative.

CONCLUSIONS

Relative LV wall thickness, creatinine changes, training volume and body temperature after the run can predict changes in hsTnT and hsTnI levels. When medical attention is needed after physical exercise, hsTn levels should be tested only when clinical suspicion and the patient's history indicate a high probability of myocardial damage.

Prasugrel Versus Ticagrelor in Patients With Acute Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Multicenter Randomized PRAGUE-18 Study

BACKGROUND

No randomized head-to-head comparison of the efficacy and safety of ticagrelor and prasugrel has been published in the 7 years since the higher efficacy of these newer P2Y₁₂ inhibitors were first demonstrated relative to clopidogrel.

METHODS

This academic study was designed to compare the efficacy and safety of prasugrel and ticagrelor in acute myocardial infarction treated with primary or immediate percutaneous coronary intervention. A total of 1230 patients were randomly assigned across 14 sites to either prasugrel or ticagrelor, which was initiated before percutaneous coronary intervention. Nearly 4% were in cardiogenic shock, and 5.2% were on mechanical ventilation. The primary end point was defined as death, reinfarction, urgent target vessel revascularization, stroke, or serious bleeding requiring transfusion or prolonging hospitalization at 7 days (to reflect primarily the in-hospital phase). This analysis presents data from the first 30 days (key secondary end point). The total follow-up will be 1 year for all patients and will be completed in 2017.

RESULTS

The study was prematurely terminated for futility. The occurrence of the primary end point did not differ between groups receiving prasugrel and ticagrelor (4.0% and 4.1%, respectively; odds ratio, 0.98; 95% confidence interval, 0.55-1.73; P=0.939). No significant difference was found in any of the components of the primary end point. The occurrence of key secondary end point within 30 days, composed of cardiovascular death, nonfatal myocardial infarction, or stroke, did not show any significant difference between prasugrel and ticagrelor (2.7% and 2.5%, respectively; odds ratio, 1.06; 95% confidence interval, 0.53-2.15; P=0.864).

CONCLUSIONS

This head-to-head comparison of prasugrel and ticagrelor does not support the hypothesis that one is more effective or safer than the other in preventing ischemic and bleeding events in the acute phase of myocardial infarction treated with a primary percutaneous coronary intervention strategy. The observed rates of major outcomes were similar but with broad confidence intervals around the estimates. These interesting observations need to be confirmed in a larger trial.

CLINICAL TRIAL REGISTRATION

URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02808767.

Incidence of severe coronary stenosis in asymptomatic patients with peripheral arterial disease scheduled for major vascular surgery

BACKGROUND

Peripheral arterial disease (PAD) has the risk equivalent of coronary heart disease. The biochemical parameters associated with functionally significant coronary artery stenosis were investigated in asymptomatic patients with PAD who were scheduled for major vascular intervention.

METHODS

A total of 50 PAD patients asymptomatic for coronary heart disease were examined using coronary computed tomography angiography (CTA). A stress myocardial CT perfusion (CTP) test was performed in patients who exhibited coronary stenosis >40%. In patients with stress-induced perfusion defects, the severity of stenosis was assessed using invasive coronary angiography including fractional flow reserve assessment. The CT findings were correlated with both classical and more recently developed parameters of atherosclerosis.

RESULTS

According to the combined CT examination (CTA and stress CT perfusion), 36% of patients exhibited significant coronary stenosis. Stress-induced hypoperfusion was observed in 95.7% of severe stenotic lesions. After adjustment for confounders, the level of high-sensitivity troponin I was associated with severe coronary stenosis (OR 1.260 [95% CI 1.054 to 1.505]). Other biochemical parameters did not correlate with coronary stenosis. The annual mortality rate was 4%.

CONCLUSIONS

The results of the present study confirm a significant diagnostic contribution of a complex cardiac CT examination in patients scheduled for major vascular surgery. A high prevalence of asymptomatic coronary heart disease was observed in this particular patient group. High-sensitivity measurements of troponin I correlated with the extent of the coronary stenosis.

Acute myocardial infarction complicated by shock: outcome analysis based on initial electrocardiogram

OBJECTIVES

To assess the relation between initial ECG findings, presence of risk factors, coronary angiography findings, and clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (CS).

DESIGN

Data from a total of 5572 acute myocardial infarction patients admitted to the four tertiary hospitals during a period of 3 years were analyzed. CS on admission was present in 358 patients (6.4%). They were divided into four groups based on the admission ECG: ST-segment elevation (STEMI), ST-segment depression (STDMI), bundle branch block (BBBMI), and other ECG acute myocardial infarction.

RESULTS

CS developed most frequently among BBBMI patients (in 12.1% of all BBBMIs, p < 0.001 vs. STEMI), followed by STEMI (6.7%), STDMI (4.4%), and other ECG acute myocardial infarction (2.3%). The risk of CS development was similar in patients with left bundle branch block (LBBB) (13.3%) and right bundle branch block (RBBB) (11.2%). The one-year mortality was highest among RBBBMI patients (66.7%, p < 0.001), followed by LBBBMI (48.6%), other ECG (47.1%), STEMI (41.7%), and STDMI patients (38.1%).

CONCLUSIONS

RBBB on admission ECG is associated with the highest risk of CS development, frequent left main coronary artery affection, and unsuccessful revascularization. It is also an independent predictor of one-year mortality.