Impact of P2Y12 inhibitor pretreatment on angiographic findings and clinical outcomes in patients with ST-elevation myocardial infarction

Interventional therapy of coronary artery disease in China: retrospective and perspective

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

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)

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 …

Introduction: We have recently reported the cause of microcirculatory damage after percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients can be evaluated by analyzing the thermodilution-derived coronary blood flow pattern (CBFP), and only the capillary destruction pattern was associated with poor mid-term clinical outcomes. In this study, we extend our research on the contribution of acute hyperglycemia on microcirculatory damage and long-term clinical outcomes in STEMI patient. Methods: Ninety-seven consecutive STEMI patients undergoing primary PCI were prospectively enrolled. Using a pressure sensor/thermistor-tipped guidewire, CBFP was assessed from the thermodilution-curves immediately after successful PCI. All patients were classified into 3 groups according to the shape of thermodilution curve: no microvascular damaged group (n=47), arteriole microemboli group (n=33), or capillary destruction group (n=17). Blood glucose levels were measured on admission. Major adverse cardiac events (MACE) were defined as a composite of cardiac death, myocardial infarction, and heart failure rehospitalization within 3 years. Results: Mean admission glucose level was significantly higher in the capillary destruction group than in the microemboli and no microvascular damaged groups (259±134, 162±66, and 153±60 mg/dL, respectively, p&lt;0.0001). These findings were similar when the analysis was limited to non-diabetic patients. The incidence of MACE was also higher in the capillary destruction group compared with the microemboli and no microvascular damaged groups (71, 19, and 16%, respectively, p&lt;0.0001). On multivariate Cox regression analysis, the capillary destruction pattern was the independent predictor of MACE (hazard ratio, 9.41; 95%CI 2.28-38.8; p=0.001). In the multivariate logistic regression analysis, higher glucose level on admission remained as an independent risk factor of the capillary destruction pattern (per 10mg/dL increase, odds ratio, 1.10; 95%CI 1.10-1.22; p=0.002). Conclusions: Hyperglycemia on admission increases the risk of microvascular damage secondary to the capillary destruction and subsequent poor long-term clinical outcomes in STEMI patients.

The impact of large thrombus burden (LTB) on very long-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) is unknown. We compared very long-term clinical outcomes in STEMI patients with either LTB or small thrombus burden (STB). Between 2002 and 2004, thrombus burden (TB) was evaluated in consecutive patients with STEMI undergoing percutaneous coronary intervention (PCI). In occluded infarct-related arteries, TB was reclassified after flow restoration. LTB was defined as thrombus ≥2 vessel diameters. Major adverse cardiac event (MACE) rate was evaluated at 10-year follow-up and survival data were collected up to 15 years post PCI. A total of 812 patients were enrolled, and TB assessment was available for 806 patients (99.3%); 580 patients (72.0%) had STB and 226 patients (28.0%) had LTB. Patients with LTB experienced more no reflow (4.0% vs 0.5%; P<.01) and distal embolization (17.3% vs 3.4%; P<.001) than STB patients. Ten-year MACE rate (42.5% vs 42.4%; P=.59), 10-year mortality rate (27.0% vs 26.4%; P=.75), and 15-year mortality rate (31.9% vs 35.9%; P=.29) were similar between STB and LTB groups, respectively. By landmark analysis, MACE rate was higher in the LTB group (15.9% vs 8.8%; P<.01) at 30 days, but not beyond (31.6% vs 36.9%; P=.28). There was no difference in mortality at any time point (at 30 days, 9.7% vs 6.2%; P=.08; beyond 30 days, 17.3% vs 20.5%; P=.48). LTB was an independent predictor of MACE at 30 days post PCI (hazard ratio, 1.60; 95% confidence interval, 1.01-2.51; P=.04). In STEMI patients, LTB might identify a subpopulation at high risk of no-reflow, distal embolization, and early ischemic events, but is not associated with worse clinical outcomes at long-term follow-up.

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BackgroundThrombolysis in Myocardial Infarction (TIMI) 0 flow often characterizes ST-segment Elevation Myocardial Infarction (STEMI) patients, but may also feature in non-ST-segment Elevation Acute Coronary Syndrome (NSTE-ACS). Since recanalization usually occurs later in NSTE-ACS patients, the aim of this study was to assess whether patients presenting with NSTE-ACS and TIMI 0 flow have worse clinical outcomes as compared to patients presenting with STEMI and TIMI 0 flow.MethodsA single-center retrospective cohort study was conducted with patients treated for NSTE-ACS and STEMI with TIMI 0 flow at diagnostic angiogram between January 2015 and December 2019. The two patient groups were 1:1 matched using a propensity score logistic regression model. The primary outcome was Major Adverse Cardiac Events (MACE), a composite of all-cause mortality, any myocardial infarction, coronary artery bypass graft, urgent target vessel revascularization or stroke during long term follow-up.ResultsThe total population consisted of 1255 ACS patients, of which 249 NSTE-ACS and 1006 STEMI patients. After propensity score matching, 234 NSTE-ACS patients were matched with 234 STEMI patients. In this matched population, the mean age was 62.6 (±12.4) years and 75.2 % of the patients was male. The median follow-up time was 3.2 years. MACE rates during follow-up were similar between the two matched groups (HR = 0.84 [95 % CI 0.60 – 1.12] with p = 0.33) with cumulative event-free survival of 63.3 % in the NSTE-ACS group vs 59.3 % in the STEMI group at 6 year follow-up.ConclusionIn this retrospective study, a culprit lesion with TIMI 0 flow has similar clinical outcome in NSTE-ACS and STEMI patients. Further research is warranted to determine optimal the timing of PCI in NSTE-ACS patients with TIMI 0 flow.

Background— There is conflicting evidence regarding sex-based differences in myocardial salvage and clinical outcome in patients after ST-elevation myocardial infarction (STEMI). The aim of this study was to investigate whether there are sex-associated differences in infarct characteristics (myocardial salvage, infarct size, microvascular obstruction) and clinical outcome in STEMI patients who are reperfused by primary angioplasty. Methods and Results— In this study, we included 96 women and 239 men with STEMI undergoing primary angioplasty &lt;12 hours after symptom onset. T2-weighted and contrast-enhanced cardiac MRI was used to assess myocardial salvage, infarct size, and microvascular obstruction. The primary clinical end point was mortality within 6 months after the index event. The amount of myocardium at risk and final infarct size did not differ significantly between women and men. Consequently, myocardial salvage was similar between groups ( P =0.36). Women had a higher in-hospital (3% versus 10%; P =0.03) and 30-day (5% versus 11%; P =0.05) mortality rate than did men. Six months after infarction, no significant sex differences in survival were obvious (11% versus 7%; P =0.21). After adjustment for baseline differences (age, diabetes, hypertension), female sex was not an independent predictor of mortality and major adverse cardiac events. Conclusions— The efficacy of primary percutaneous coronary intervention (myocardial salvage) in patients with STEMI is not sex dependent. Although women STEMI patients had worse unadjusted in-hospital and 30-day clinical outcomes than did men, multivariate analysis revealed that the observed sex-based differences in early death after STEMI were likely related to differences in baseline risk and clinical characteristics.

Influence of Second- and Third-Degree Heart Block on 30-Day Outcome Following Acute Myocardial Infarction in the Drug-Eluting Stent Era

Association of Controlling Nutritional Status Score With 2-Year Clinical Outcomes in Patients With ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BackgroundIn-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI.MethodsBaseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient.ResultsIn-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 ​years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P ​< ​.001), and the model demonstrated good discriminative power (c-statistic ​= ​0.81) and calibration (Hosmer-Lemeshow, P ​= ​.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high–risk score categories, respectively).ConclusionsThe risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) with high-grade thrombus is a high-risk intervention associated with poor clinical outcomes. Circulatory support with an intra-aortic balloon pump (IABP) during PCI may potentially improve coronary hemodynamics and clinical outcomes in such patients. As existing data on this situation are sparse, we did an observational study to determine short-term outcomes of PCI with IABP support in STEMI patients with high thrombus burden. To determine whether IABP has a potential role in improving outcomes in patients with STEMI with high thrombus burden who are undergoing PCI. Thirty consecutive patients of STEMI with high thrombus burden undergoing PCI with IABP assistance were included. Ninety-three percent of patients had a cardiogenic shock. Clinical and angiographic outcomes assessed include a change in left ventricular ejection fraction (LVEF), 30-day mortality, and assessment of TIMI (thrombolysis in myocardial infarction) flow, TIMI frame count, and TIMI myocardial perfusion grade in the culprit vessel.IABP was initiated before coronary angiography in 36.6% (n=11), between angiography and PCI in 30% (n=9), and after PCI in 33.3% (n=10) of patients. During the 30-dayfollow-up period, 50% (n=15) of patients died. 86.6% (n=13) of survivors had pre-PCI IABP initiation compared to only 46.6% (n=7) among those who died (p=0.020). With pre-PCI IABP initiation (n=20), 30-day mortality was 35% (n=7) compared to 80% (n=8) with post-PCI IABP initiation (n=10) (p=0.020). IABP initiation before PCI in STEMI complicated by cardiogenic shock andhigh angiographic thrombus burden can decrease mortality without any effect on angiographic parameters.

Background:Available data from randomized trials on thrombectomy in patients with ST-elevation myocardial infarction (STEMI) have shown favorable trends in myocardial reperfusion. However, few data are available on the effect of thrombectomy on clinical outcome. Thus we have designed a collaborative individual patient-data meta-analysis which aimed to assess the long-term clinical outcome in STEMI patients randomized to percutaneous coronary intervention (PCI) with or without thrombectomy.Method:After a thorough database search, the principal investigators of randomized trials comparing thrombectomy with standard PCI in patients with STEMI were contacted. Principal investigators as authors of 11 randomized studies agreed to participate and were asked to complete a structured database by providing a series of key pre-PCI clinical and angiographic data as well as the longest available clinical outcome of the patients enrolled in the corresponding trial. The primary end-point of this pooled analysis is the comparison of overall survival rates between patients randomized to PCI with thrombectomy or PCI without thrombectomy. The secondary end-points are survival free from myocardial infarction (MI), target lesion revascularization (TLR), major adverse coronary events (MACE: death + MI + TLR) and death + MI between patients randomized to PCI with thrombectomy or PCI without thrombectomy. A pre-defined subgroup analysis is planned considering the following variables: type of thrombectomy device used, diabetes, rescue PCI, IIb/IIIa-inhibitors use, time-to-reperfusion, infarct-related artery, and pre-PCI TIMI flow.Implications:This study will provide useful data on the effect of the reported improved myocardial perfusion associated with thrombectomy on the long-term clinical outcome in patients with STEMI.

This study aimed to evaluate the clinical prognostic implications of postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow in acute myocardial infarction patients. A total of 2796 ST-elevation myocardial infarction (STEMI) and 1720 non ST-elevation myocardial infarction (NSTEMI) patients treated in 8 hospitals affiliated with the Catholic University of Korea and Chonnam National University Hospital were analyzed. The study populations were divided according to the final TIMI flow. The primary outcome were the major adverse cardiac events (MACE), defined as a composite of cardiac deaths (CD), nonfatal myocardial infarctions (MI), and target lesion revascularization (TLR). Over a median follow-up of 3.3 years (minimum 2 to maximum 5 years), MACE and CD occurred more frequently in STEMI patients with TIMI ≤ 2 group than those with TIMI 3 (MACE: adjusted hazard ratio [aHR], 1.962; 95% confidence interval [CI] 1.513 to 2.546, P < 0.001, CD: aHR, 3.154, CI 2.308 to 4.309, P < 0.001). However, there was no significant difference between the two subgroups in NSTEMI (aHR, 0.932; 95% CI 0.586 to 1.484, P = 0.087). In STEMI patients, good postprocedural TIMI flow after PCI was associated with favorable clinical outcomes. And the effect of poor TIMI flow in STEMI was on death, not the components of MACE. Meanwhile, postprocedural TIMI flow had no effect on long-term outcomes in NSTEMI patients.