Circulation: Cardiovascular Interventions Editors’ Picks

Total revascularization of coronary disease at the time of primary percutaneous coronary intervention.

"Goldilocks" Approach to Deferred Stenting in ST-Segment-Elevation Myocardial Infarction.

Association Between Intraprocedural Thrombotic Events and Adverse Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction (a Harmonizing Outcomes With RevasculariZatiON and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Substudy)

Management of Acute Coronary Syndromes

<i>Circulation: Cardiovascular Imaging</i> Editors’ Picks

Reperfusion Strategies in ST-Elevation Myocardial Infarction

Fibrinolytic therapy (FT) and primary percutaneous coronary intervention (PCI) are both well-accepted reperfusion therapies in ST-segment elevation myocardial infarction (STEMI). The evidence of randomized clinical trials indicates a relatively modest difference in 30-day mortality (≈1%) in favor of primary PCI over fibrin-specific FT and was based on very timely primary PCI (ie, a primary PCI–related delay of 40 minutes [door-to-balloon less door-to-needle time]).1 Longer delays to primary PCI, which are far more frequent in clinical practice,2 are associated with attenuated benefit or no benefit at all, particularly when compared with fibrin-specific FT.3,4 The benefit of timely primary PCI over FT is likely to especially apply to higher-risk patients.5,6 Irrespective of the method of reperfusion, the potential for myocardial salvage and better clinical outcome is inversely proportional to ischemic time or its only available clinical surrogate, symptom duration.7–12 These considerations underpin the notion expressed in the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of STEMI that timely reperfusion therapy is likely more important in determining outcome than whether FT or primary PCI is the chosen reperfusion method.13 Response by Armstrong et al p 1310 The ACC/AHA STEMI guidelines highlight the time point of 3 hours of symptom duration in guiding the choice of reperfusion therapy. They state that if symptom duration is <3 hours, no preference exists between FT and primary PCI provided that treatment is timely (for FT, door-to-needle time <30 minutes; for primary PCI, door-to-balloon time <90 minutes and ≤60 minutes between estimated needle time and estimated balloon time). However, if symptom duration exceeds 3 hours, these guidelines favor primary PCI over FT, again provided that primary PCI can be performed in a timely fashion.13 This article reexamines the evidence that may or may not be the basis …

A 52-year-old obese male without a prior history of diabetes mellitus (DM) presented with angina and an anterior ST-segment–elevation myocardial infarction (STEMI). Physical examination and chest x-ray were consistent with congestive heart failure. Admission glucose was 230 mg/dL. Coronary angiography revealed an occluded left anterior descending coronary artery, and stenting reestablished TIMI grade 2 flow in that artery within 90 minutes of symptom onset. Left ventricular ejection fraction was 35% with severe anterior hypokinesis. Peak creatine kinase was 600 IU. The next day, fasting glucose was 180 mg/dL. An echocardiogram performed 6 weeks after discharge revealed an ejection fraction of 35% without change in the anterior wall motion. Fasting glucose as an outpatient was 156 mg/dL. The scenario described above is commonly encountered and illustrates how hyperglycemia can affect the outcome of patients with STEMI. Hyperglycemia could have affected the following features of this case: (1) Congestive heart failure was present despite only modest myocardial injury by creatine kinase level; (2) despite successful percutaneous coronary intervention, subnormal coronary perfusion was observed; and (3) left ventricular recovery after STEMI did not occur. Cardiologists need to be cognizant of the hazards associated with hyperglycemia in this setting because these patients will be encountered more frequently as a result of the increasing prevalence of insulin resistance syndromes. Acute hyperglycemia is common in patients with STEMI even in the absence of a history of type 2 DM. Hyperglycemia is encountered in up to 50% of all STEMI patients, whereas previously diagnosed DM is present in only 20% to 25% of STEMI patients.1 The prevalence of type 2 DM or impaired glucose tolerance may be as high as 65% in MI patients without prior DM when oral glucose tolerance testing is performed.2 Elevated …

Creating an ideal system of care to address the care forpatients with ST-elevation myocardial infarction (STEMI) iscomplex from both the system’s and patient/family’s perspec-tives. In general, this care is unlike most other hospital care.It typically involves very fast and complex decision makingand, often, sudden transportation to another facility forpercutaneous coronary intervention (PCI). All of this occurswith a potentially critically ill patient and at a time when thefamily is often not immediately available. In this report, weaddress key perspectives from the patient and public point ofview of the current system of care for STEMI patients andhighlight the barriers and gaps that must be addressed by anideal system of care (Table 1).

Fibrinolytic therapy has been an important means of establishing reperfusion for decades. However, limitations to the use of thrombolytic therapy include perceived or definite contraindications, intracranial bleeding, inability to establish Thrombosis In Myocardial Infarction (TIMI-3) flow in many patients, and high rates of recurrent ischemia and reocclusion. Accordingly, primary percutaneous coronary intervention (PCI) has emerged as the preferred reperfusion strategy. Nearly all acute myocardial infarction (AMI) patients are eligible for emergency catheterization. Knowledge of the coronary anatomy allows immediate triage to surgery, medical therapy, or primary PCI, when appropriate, and results in earlier hospital discharge compared to thrombolytic therapy.1 Primary PCI establishes TIMI-3 flow in >90% of patients and is associated with reduced rates of recurrent ischemia and reocclusion. With the addition of stenting, reocclusion has been further reduced to 5% at routine 6-month angiography.2,3 Small studies have suggested that pharmacological adjuncts to PCI such as abciximab may improve myocardial perfusion and limit infarct size4,5 without the risk of bleeding observed with thrombolytic therapy.6 Finally, new technologies such as coronary thrombectomy, distal projection, and systemic cooling are easily applied in the catheterization laboratory and may further improve myocardial perfusion and infarct size. Although primary PCI has been in use for more than 25 years, the first trials randomizing PCI to intravenous thrombolytics therapy were not published until 1993.7 A meta-analysis of the first 10 randomized trials demonstrated a reduction in death, reinfarction, and stroke with primary PCI in all subgroups, but the greatest absolute benefit was observed in high-risk patients.8 On the basis of these early results, many experienced interventionalists were no longer willing to randomize patients to thrombolytic therapy. Therefore, the next decade of research was focused on perfecting the primary PCI technique, with studies randomizing patients to intraaortic balloon pumps, stents, glycoprotein …

Management of Acute Coronary Syndromes

A Multidisciplinary Approach to Reducing Door-to-Balloon Time in a Community Hospital

We evaluated data on blacks and whites with acute ST-segment-elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention from the National Registry of Myocardial Infarction (NRMI)-4 and -5 participating centers between July 2000 and December 2006 to determine race-related differences in bleeding and outcomes. We found that among patients with ST-segment-elevation myocardial infarction receiving fibrinolysis, the bleeding rates were higher for blacks (n2283) than whites (n42 243; 10.9% versus 10.3%; adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.43). Similarly, in patients receiving primary percutaneous coronary intervention, the bleeding rates were higher in blacks (n2826) than whites (n46 332; 10.3% versus 7.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.13-1.56). Bleeding was associated with a higher risk of death in both ethnic groups. However, there was no overall racial difference in in-hospital mortality among those with bleeding or without bleeding treated with either fibrinolysis or primary percutaneous coronary intervention. We concluded that race-related differences existed in bleeding risk among patients with ST-segmentelevation myocardial infarction receiving reperfusion therapy that portend poor prognosis. Thus, the efficacy and safety of many new drugs or treatment strategies for any disease observed in clinical trials that enroll predominantly white patients may not be similar in other ethnic groups that are underrepresented in these trials.

Metabolic syndrome with its associated cardiovascular risk factors and prothrombotic, procoagulant and proinflammatory properties and its detrimental effects on coronary microcirculation may play a role in the occurrence of poor myocardial perfusion after primary percutaneous coronary intervention in patients with acute myocardial infarction. Accordingly, this study was designed to evaluate the association between metabolic syndrome and myocardial perfusion grade in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. The study population included 283 consecutive patients (229 men, mean age=62+/-8 years) admitted to our hospital with ST-elevation myocardial infarction and who underwent primary percutaneous coronary intervention. Thrombolysis in myocardial infarction (TIMI) myocardial perfusion grade (TMPG) was graded densitometrically on the basis of visual assessment of relative contrast opacification of the myocardial territory subtended by the infarct vessel in relation to epicardial density. Metabolic syndrome was diagnosed according to the National Cholesterol Education Program Adult Treatment Panel III criteria. Patients were divided into two groups on the basis of the myocardial perfusion grade determined after percutaneous coronary intervention. Group I consisted of 223 patients with good myocardial perfusion (TMPG 2-3) after successful percutaneous coronary intervention and group II of 60 patients with poor myocardial perfusion (TMPG 0-1). The prevalence of metabolic syndrome was found to be significantly higher in patients with poor myocardial perfusion than in those with good myocardial perfusion (40 vs. 20%, respectively, P=0.002). Moreover, we detected an independent association between metabolic syndrome and the occurrence of poor myocardial perfusion grade (adjusted OR=2.54, 95% CI=1.35-4.75, P=0.003). We have shown, for the first time, a significant association between metabolic syndrome and impaired myocardial perfusion after percutaneous coronary intervention in patients with acute myocardial infarction. This data may partially explain the poor short and long-term outcomes of acute myocardial infarction in patients with metabolic syndrome.

Objective To analyze the value of plane QRS-T angle on prediction of malignant ventricular arrhythmia (MVA) occurred after emergency percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). Methods The clinical data of 418 patients with STEMI who underwent PCI within 12 h of symptom onset were retrospectively analyzed, and the patients were divided into plane QRS-T angle ≤ 90° group (324 cases) and plane QRS-T angle >90° group (94 cases) according to the plane QRS-T angle after PCI. The clinical data were compared between 2 groups. Results Compared with patients in plane QRS-T angle ≤ 90° group, patients in plane QRS-T angle >90° group was older: (67.4 ± 11.8) years vs. (63.6 ± 12.0) years, QTc interval was longer: (438.60 ± 34.97) ms vs. (425.24 ± 25.49) ms, rate of left ventricular ejection fraction (LVEF) 90° was an independent risk factor of MVA after PCI in STEMI patients (OR = 9.640,P = 0.001), and using of beta-blockers was a protective factor (OR = 0.266,P = 0.028). Conclusions Plane QRS-T angle >90° is an independent risk factor of MVA after PCI in STEMI patients, while the use of beta-blockers is a protective factor. Paients with STEMI after PCI should be alert to the occurrence of MVA in the condition of plane QRS-T angle >90° and not taking beta-blockers. Key words: Myocardial infarction; Arrhythmias, cardiac; Angioplasty, balloon, coronary; Plane QRS-T angle