The Association of Peak Glycemia and No‐Reflow Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention

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

Angiographic assessment of epicardial coronary artery blood flow has played a pivotal role in our understanding of the “time-dependent open artery hypothesis” and in the evaluation of reperfusion strategies over the past 2 decades.1–8 It has become increasingly apparent, however, that clinical outcomes are not only associated with angiographic flow in the epicardial artery, but also with angiographic flow in the myocardium.9–13 To this end, the goal of reperfusion therapies has shifted to include reperfusion downstream at the level of capillary bed, and it might be more appropriate that the hypothesis now be termed “the time dependent open artery and open microvascular hypothesis.” The goal of this article is to review angiographic methods used to evaluate myocardial ischemia and infarction and to discuss the insights into the pathophysiology of acute coronary syndromes provided by these angiographic indexes of coronary artery blood flow and myocardial perfusion. For nearly 2 decades now, the Thrombolysis In Myocardial Infarction (TIMI) flow grade classification scheme has been successfully used to assess coronary blood flow in acute coronary syndromes1 (Table). It has been a valuable tool to compare angiographic outcomes following reperfusion, and the association of the TFGs with clinical outcomes (including mortality) has been well documented.2–8 The relationship between TFG and mortality does satisfy what some consider to be 3 criteria required to validate a surrogate end point for mortality, as follows: (1) There is an association between TIMI grade 3 flow and mortality, (2) an agent such as recombinant tissue plasminogen activator improves TIMI grade 3 flow by 22% over another agent such as streptokinase, and (3) the agent tissue plasminogen activator improves mortality 1.1% over streptokinase. View this table: Definitions of the TFG and the TMPG Systems On the basis of this relationship between TIMI flow and mortality observed in the GUSTO …

Association between elevated blood glucose level on admission and long-term mortality in patients with acute decompensated heart failure

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

Objective To investigate the clinical characteristics and risk factors of non-premature STEMI patients underwentprimaryPCI with multivessel disease. Methods Data of clinic and coronary angiographic features were retrospectively compared between group of 371 younger STEMI patients (male age <55 years, female <65 years)and group of 662 older STEMI patients. All patients were admitted to hospital from January 2005 to January 2015 and treated with primary PCI. The patients’ gender, smoking history, family history of coronary heart disease (CHD), hypertension, type 2 diabetes mellitus, previous myocardial infarction and revascularization, stroke history, serum uric acid, lipids etc. were documented. The comparison of coronary artery disease characteristics and the incidence of adverse events during hospitalization were also carried out between two groups. Results (1) Prevalence of males(88.4% vs.76.9%), smokers(74.9% vs.51.5%), family history of CHD(21.0% vs.9.7%)and levels of diastolic blood pressure, total cholesterol, low density lipoprotein cholesterol (LDL-c), triglycerides, and low cholesterol were significantly higher in the non-prematuregroup than in the premature group (all P<0.01), while high density lipoprotein cholesterol (HDL-c)was lower in non-prematuregroup (P<0.01). (2) The incidence of in-hospital events in both groups were low. There was less ventricular tachycardia in the non-premature group (1.5% vs.0.3%)(P<0.05). (3) There were no statistically significant differences in the number of infarct vessels, site ofinfarctbetween two groups.(4) Logistic regression analysis showed that smoking(OR=2.22, 95%CI: 1.588-3.108)(P<0.05), family history of CHD(OR=2.12, 95%CI: 1.431-3.140)(P<0.05), triglyceride concentration(OR=1.971, 95%CI: 1.475-2.635)(P<0.05), LDL-c(OR=1.193, 95%CI: 1.008-1.413)(P=0.04)were independent risk factors fornon-premature STEMI withmultivessel disease. Conclusion Smoking, family history of CHD, triglyceride concentration, LDL are main risk factors of younger age STEMI patients with multiple vessel disease; Compared with younger age patients, older age patients during hospitalization are more likely to occur ventricular tachycardia. Regardless of age difference, the characteristics of coronary artery lesions show no significant difference. Key words: ST-segment elevation myocardial infarction; Multivessel disease; Non-premature; Risk factors; Clinical features; Primary percutaneous coronaryintervention; Smoking; Family history; Dyslipidemia

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

<i>Circulation</i> Editors' Picks

Creating synergy in our health system: The challenges of primary angioplasty

Treatment delay in ST elevation myocardial infarction care in a community hospital – a cautionary tale

ST-Segment Elevation Myocardial Infarction (STEMI) patients with the multivessel disease have distinctive plaque characteristics in non-IRA lesions. Intensive statin therapy was a potential approach to treat STEMI patients with the non-IRA disease. However, there is still poor evidence about the therapeutic effect. In this study, we have evaluated the detailed therapeutic effect of statin plus ezetimibe intensive therapy. For STEMI patients with non-IRA disease undergoing primary Percutaneous Coronary Intervention (PCI), 183 control STEMI patients without non-IRA disease undergoing primary PCI, and 200 STEMI patients with non-IRA disease undergoing primary PCI were introduced into this study. 200 STEMI patients with non-IRA disease undergoing primary PCI were divided into Normal group, Intensive group, Normal & Combined group, and Intensive & Combined group. The baseline information for each participant was recorded. Meanwhile, the physiological and biochemical indicators of each member with different treatments were collected after one-year follow-up. For STEMI patients with non-IRA disease undergoing primary PCI, no differences could be detected in multiple indexes such as OCT examination results, age, stroke, etc. However, diabetes mellitus, smoking, and coronary Gensini score were different between different groups (P<0.05). After one year follow-up, cholesterol, low-density lipoprotein, coronary Gensini score, thin-cap fibroatheroma, length of non-infarcted arterial lesions, non-infarct artery lesion range, myocardial infarction again, and revascularization again were significantly different between different groups (P<0.05). The results mentioned above suggested that pitavastatin combined with ezetimibe was an effective approach for STEMI patients with non-IRA disease undergoing primary PCI. The results obtained in this study have provided a novel method for the treatment of STEMI patients with non-IRA disease undergoing primary PCI.

Purpose: Acute Kidney Injury (AKI) is mostly defined as an increase in serum creatinine and is observed in up to 19% of ST-Elevation Myocardial Infarction (STEMI) patients. Important mechanisms of AKI in STEMI patients are renal hypoperfusion due to a large infarcts, the use of nephrotoxic agents in particular during Primary Percutaneous Coronary Intervention (PPCI), activation of sympathetic and renin-angiotensin-aldosteron system, inflammation, etc. Our purpose was to evaluate the incidence of AKI in STEMI patients, the impact of AKI upon survival in STEMI patients and predictors of AKI in STEMI patients. Methods: We retrospectively evaluated 681 STEMI patients, admitted in 2008-2010 (68,9% men, mean age 63.6±12.6 years). Reperfusion strategy was PPCI combined with antithrombotic therapy. AKI was defined as an increase of serum creatinine of more than 50% within 24-48 hours. We registered 30-day and six-month mortality in all STEMI patients, survival in AKI-STEMI subpopulation and predictors of AKI such as reperfusion strategy (PPCI), markers of ischemic necrosis (admission and peak troponin I), of inflammation (admission CRP) and of in-hospital heart failure (in-hospital EF and NT-proBNP). Results: PPCI was performed in 89.7% of all STEMI patients. AKI was observed in 12.3%. 30-day mortality of all STEMI patients was 12.5%, six-month mortality 15.4%. In STEMI patients with AKI survival was less likely than in non-AKI patients within 30 days (41.7% vs 94%, p<0.001) and within six months (34.6% vs 91.7%, p<0.001). AKI-STEMI patients in comparison to non-AKI ones were significantly older (69.6±11 vs 62.7±12.5 years, p<0.001) with significantly increased mean admission troponin I (20.7±30.5 μg/l vs 10.6±22.3 μg/l, p<0.001) and peak troponin I (64.6±37.7 μg/l vs 47.2±35.2 μg/l, p<0.001), admission CRP (26.9±54 mg/l vs 14.3±32.3 mg/l, p<0.003) and in-hospital NT-proBNP (1642±1275 vs 528.4±843.7 pmol/l, p<0.001), but significatly decreased in-hospital EF (32.3±15.9% vs 45.4±13.0%, p<0.001), less likely performed PPCI (76.1% vs 91.6%, p<0.001) in particularly within 12 hours of chest pain (63% vs 77.5%, p<0.04). Most significant independent predictor of AKI in STEMI patients was in-hospital NT-proBNP (c2 13.433, OR 1.002, 95% CI 1.001 to 1.003, p<0.001) as demonstrated by logistic regression. Conclusions: AKI was present in more than 10% of STEMI patients and associated with less frequent and later performance of PPCI, increased NT-proBNP and decreased survival. Increased NT-proBNP, being a marker of heart failure seemed most significant predictor of AKI in STEMI patients.

Reperfusion Strategies in ST-Elevation Myocardial Infarction

In this study, we aimed to assess the value of admission time CBC parameters in predicting post-primary PCI corrected TIMI frame count. Recent years have witnessed a large series of studies evaluating different laboratory variables to predict no-reflow phenomenon following primary PCI (PPCI) in patients with STEMI. However, a general agreement about the most reliable predictor of the no-reflow phenomenon is challenging and also intriguing. The current study concluded 208 consecutive patients who underwent primary PCI for ST-Elevation Myocardial Infarction (STEMI) from January 2014 to February 2016. Blood samples were obtained after taking ECG. Complete blood samples were collected and analyzed within 5 minutes from sampling. Post-PCI corrected Thrombolysis in Myocardial Infarction (TIMI) frame count was determined by one interventional cardiologist blinded to patients' clinical data. The correlation between admission time blood parameters and post-primary PCI corrected TIMI frame count in patients with STEMI were assessed. Corrected TIMI frame count was positively correlated with WBC count (R: 0.18, P-value: <0.01), neutrophil count (R: 0.34, P-value: <0.01), and platelet count (R: 0.23, P-value: <0.01) and negatively correlated with lymphocyte count (R: -0.2, P-value: <0.01). Multiple linear regression results demonstrated that corrected TIMI frame count was positively correlated with neutrophil count (P < 0·001) and platelet count (P < 0·001) and negatively correlated with lymphocyte count (p=0.004). High counts of WBC, neutrophil, and platelet and low count of lymphocyte may be predictors of no-reflow in STEMI patients undergoing PPCI. The clinical significance of such predictive parameters becomes clear as we consider the treatment approach in STEMI patients. Appropriate risk stratification leads to better treatment planning and allocation of resources.

Prognostic Value of Total Bilirubin in Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Coronary Intervention

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).