Acute Inferior ST-elevation Myocardial Infarction Research Articles

Limitation of Marginal Arteries Flow and Its Impact on Clinical Prognosis In Patients with Acute Inferior ST-Elevation Myocardial Infarction treated with primary Percutaneous Coronary Intervention

Limitation of Marginal Arteries Flow and Its Impact on Clinical Prognosis In Patients with Acute Inferior ST-Elevation Myocardial Infarction treated with primary Percutaneous Coronary Intervention

Abstract 16172: Impella Use in Large Post-Infarct Ventricular Septal Rupture

Background: Ventricular Septal Rupture (VSR) is a deleterious complication associated with myocardial infarction (MI). The most common form of mechanical circulatory support (MCS) utilized in post-MI complications is intra-aortic balloon pump (IABP). Impella is a far less commonly used modality as there is the potential for right-to-left shunting and a chance of mechanical perforation of the heart. Below is a case where an Impella 5.5 catheter was necessary to bridge a patient for surgical repair. Case presentation: A 76-year-old male patient presented to an outside hospital with an acute inferior ST-elevation myocardial infarction. He was treated with thrombolysis and was emergently taken to the catheterization lab where he underwent stenting of his RCA with plan to medically manage his non-culprit disease. His hospital course was complicated by cardiogenic shock with an echocardiogram that demonstrated a large VSR (Figure 1). A right heart catheterization demonstrated a significant left-to-right shunt (Qp/Qs ratio of 6:1) which necessitated mechanical support with an IABP as per standard of care. Post-IABP his Qp/Qs ratio improved to 1.6:1 but he continued to be under supported and remained in cardiogenic shock. Surgical repair of the VSR was planned for 1-week post-MI so he was transitioned to an Impella 5.5 catheter in order to stabilize and bridge him for surgery. Patient underwent surgical VSR repair and CABG on hospital day 7. Post-op he did well and was later discharged to rehabilitation center with subsequent recovery. Conclusions: If properly managed, utilization of an Impella catheter can be an effective tool to stabilize patients in post-MI VSR with refractory cardiogenic shock and bridge patients towards surgical repair. It is particularly effective when additional MCS support is required beyond the contemporary IABP and it can be used to stabilize patients for longer durations to ultimately avoid emergent surgery.

Develop a risk stratification model and clinical analysis to predict the impact of primary percutaneous coronary intervention on complete AV block in acute inferior STEMI patients

Background: Acute inferior ST-elevation myocardial infarction (STEMI) is medical emergency entailing immediate intervention to restore blood flow and mitigate myocardial damage. Primary percutaneous coronary intervention (PCI) has replaced thrombolytic therapy as preferred treatment strategy for having superior outcomes. Objectives: To develop a risk stratification model incorporating the identified predictors to estimate the individual risk of complete AV block in patients undergoing primary PCI for acute inferior STEMI. Methods: This study enrolled 139 patients diagnosed with acute inferior STEMI who underwent primary PCI at the hospital. They were divided into two groups, i.e. pre-operative and post-operative carrying 54 and 85 patients, respectively. On admission, demographic, clinical data and peak values of cardiac biomarkers were obtained and the complications associated with PCI were elaborated. Results: Mean age of patients was 59.81+8.19 years, and comprised significantly more male (97) than female (42) patients (p<0.05). Proportion of patients with a history of complete AV block was 10.79%. Comorbidities included diabetes mellitus (33.09%), hypertension (49.64%), and dyslipidemia (64.74%).Coronary angiography findings for predicting AV block in patients with STEMI were categorized by location of culprit lesion in coronary vessels.

Potential use of prophylactic intracoronary atropine in reducing reperfusion vagal reflex-related events in ST-elevation myocardial infarction

In this study, we evaluated the potential use of atropine in reducing reperfusion vagal reflex-related events during emergency percutaneous coronary intervention (PCI) for acute inferior ST-elevation myocardial infarction (STEMI). Retrospectively, we included 142 patients with inferior wall STEMI, who were treated between October 2015 and October 2020, in this study. The patients were divided into an experimental group (n = 70) and a control group (n = 72) depending on whether they received prophylactic intracoronary atropine. The experimental group was then subdivided into a low-dose group (0.5 – 1 mg atropine, n = 40) and a high-dose group (2 mg atropine, n = 30). We compared the incidence of reperfusion vagal reflex-related events and the application of temporary pacemakers between these groups. The results showed that the incidence of bradycardia (24.3% vs. 45.8%, P = 0.007), hypotension (18.6% vs. 40.3%, P = 0.005), ventricular tachycardia (4.3% vs. 19.4%, P = 0.005), and ventricular fibrillation (8.6% vs. 20.8%, P = 0.040) as well as the application of temporary pacemakers (14.3% vs. 29.2%, P = 0.032) were all much lower (all P < 0.05) in the experimental group than in the control group. In addition, the incidence of bradycardia (10% vs. 35%, P = 0.016), hypotension (6.7% vs. 27.5%, P = 0.027), ventricular tachycardia (6.7% vs. 25%, P = 0.044), and ventricular fibrillation (0 vs. 15%, P = 0.034) as well as the application of temporary pacemakers (3.3% vs. 22.5%, P = 0.036) were all much lower (all P < 0.05) in the high-dose group than the low-dose group. Our findings demonstrate that atropine pretreatment could prevent reperfusion vagal reflex-related events and reduce the application of temporary pacemakers during emergency PCI for acute inferior STEMI. These effects can be significantly enhanced by high-dose (2 mg) atropine pretreatment.

Outcome of Primary Percutaneous Coronary Intervention Among Patients of Complete Atrioventricular Block with Acute Inferior St-Elevation Myocardial Infarction

Aim: To assess the outcomes of primary percutaneous coronary intervention among patients of complete atrioventricular block with acute inferior ST-elevation myocardial infarction Methods: We conducted an observational study of patients with CAVB and STEMI who underwent Primary PCI at interventional cardiology department, national institute of cardiovascular diseases Karachi during the period from January 1, 2022 to July 31, 2022. The primary outcomes were in-hospital mortality and CAVB resolution. Results: A total of 100 patients were included in the study. The mean age was 60.63±5.63 years, and 61% were male. The median door-to-balloon time was 89.96±17.97 minutes. In hospital mortality rate was 4%. CAVB was resolved in 93%. Conclusion: For patients with CAVB and STEMI, Primary PCI is a safe and successful treatment with a low rate of in-hospital mortality. These findings support the use of primary PCI in this patient population. Keyword: Primary PCI, CAVB, STEMI

Abstract 10966: Autoimmune Limbic Encephalitis Mimicking Inferior Myocardial Infarction on ECG

Case Presentation: A 64 year-old man was brought to the emergency department (ED) after being found down, awake, but unresponsive by family. In the ED, he denied chest pain and shortness of breath. His past medical history included coronary artery disease status-post coronary artery bypass grafting, heart failure with reduced ejection fraction, and paroxysmal atrial fibrillation. On physical exam, he was hemodynamically stable, oriented to self and place with no other significant neurological findings. The field and ED electrocardiograms (ECGs) (Figure 1) were consistent with an acute inferior ST elevation myocardial infarction (STEMI). The patient underwent emergent coronary angiography via left heart catheterization which showed no acute lesions requiring intervention. Initial pertinent lab work included a peak troponin-I of 0.095 ng/mL and serum sodium of 126 mmol/L. Collateral information revealed that the patient has progressive memory loss and intermittent episodes of hand tremors with non-purposeful eye movements. He also had a witnessed faciobrachial dystonic seizure, which is pathognomonic for Leucine-rich, Glioma Inactivated-1 (LGI-1) autoimmune encephalitis. Serum and CSF analyses were positive for LGI-1 IgG antibodies, confirming the diagnosis. The patient was treated with high-dose steroids, IVIG, and valproic acid with improvement in seizure activity and cognitive status, and discharged on prednisone and levetiracetam. Discussion: Per review of the current literature, central nervous system pathology may induce sympathetic overactivity causing transient myocardial injury, referred to as neurogenic stunned myocardium. This can manifest as left ventricular dysfunction, myocardial injury, and/or ECG changes consistent with myocardial infarction. This case presentation highlights an example of a seizure leading to neurogenic stunned myocardium with an ECG showing an acute inferior STEMI.

Comparison of In-Hospital Mortality between Acute Inferior Wall STEMI Patients with and without Right Ventricular Infarction Undergoing Primary PCI

Background: Patients with acute inferior wall ST elevation myocardial infarction (STEMI) with right ventricular infarction (RVI) involvement have a worse prognosis. However, most patients in the previous studies were treated with intravenous fibrinolysis and they were in the Caucasian populations. Objective: To compare the in-hospital mortality rate of patients with acute inferior wall STEMI with and without RVI treated with primary percutaneous coronary intervention (PPCI). Materials and Methods: The present study was a retrospective descriptive study that enrolled patients with acute inferior wall STEMI treated with PPCI in King Chulalongkorn Memorial Hospital between January 1, 2007, and December 31, 2016. Results: Among 452 acute inferior wall STEMI patients treated with PPCI, 99 patients had RVI. The in-hospital mortality rate was 23.2% compared with 5.1% in patients without RVI (p<0.001). Patients with RVI had a significantly higher incidence of cardiogenic shock at 48.5% versus 15.6% (p<0.001), lower left ventricle ejection fraction at 51.15±17.27% versus 55.79±12.46% (p=0.037), higher incidence of complete heart block at 33.3% versus 11.9% (p<0.001), and ventricular tachycardia at 15.2% versus 5.9% (p=0.003). After adjustment for age, female gender, cardiogenic shock on admission, left ventricular ejection fraction (LVEF), ventricular tachycardia, and complete heart block, the RVI had a tendency to be the poor predictor for in-hospital death (adjusted HR 1.96; 95% CI 0.73 to 5.23; p=0.18). Nevertheless, the RVI was the significant independent predictor for 1-year mortality (adjusted HR 2.12; 95% CI 1.03 to 4.36; p=0.041). Conclusion: Patients with acute inferior wall STEMI and RVI treated with PPCI had higher in-hospital mortality compared to no RVI. The RVI tended to have worse outcomes than those without RVI. Keywords: Acute inferior wall STEMI; Right ventricular infarction; Mortality

Acute provoked pulmonary embolism masquerading as inferior wall myocardial infarction with right ventricular infarction

We present an extreme rare case of acute pulmonary embolism in an 83-year-old male presenting as acute inferior wall ST-elevated myocardial infarction with right ventricular infarction (RVMI) in electrocardiogram (ECG). Acute pulmonary embolism presenting as acute inferior wall ST-elevation myocardial infarction with RVMI has not been described in the world literature so far. Our case is unique and first to describe the presentation of acute pulmonary embolism in the form of inferior wall ST-elevated myocardial infarction with evidence of RVMI in the ECG. It is of utmost important for the treating cardiologist and critical care physician to differentiate the same as treatment modalities of both conditions varies markedly and wrong therapeutic measures can land up in a catastrophe.

Electrocardiogram predictors of multivessel disease in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Objective: The objective was to study the role of 12-lead electrocardiogram (ECG) changes in predicting the association of severe stenosis of other coronary arteries along with infarct-related artery in patients who presented with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Materials and Methods: We studied the admission ECG, clinical records, and coronary angiography of 201 patients with STEMI who underwent primary PCI within the first 12 h of symptoms. Patients with first episode of STEMI and coronary angiogram showing coronary artery disease between January 2015 and July 2016 were included in this study. Results: Most of the patients in this study were males (82.1%). The mean age of the patients was 55.20 ± 11.79 years. Diabetic mellitus (37.8%), hypertension (37%), and smoking (49.7%) were the main risk factors. This study had 117 (58.2%) patients of anterior wall myocardial infarction (MI) (Group I) while inferior wall MI was present in 84 (41.8%) patients (Group II). In Group I, 83 (70.9%) patients had single-vessel disease (SVD) while 34 (29.1%) patients had multivessel disease (MVD). The presence of ST-segment depression ≥0.1 mV in leads I, aVL, and V6 significantly correlated with the presence of MVD (P = 0.001, 0.001, and 0.001, respectively). In Group II, 39 (51.3%) patients had SVD while 37 (48.7%) patients had MVD. The presence of ST-segment depression in leads aVL, V5, and V6 significantly correlated with the presence of MVD (P = 0.049, 0.001, and 0.001, respectively). Conclusion: The presence of ST-segment depression of ≥0.1 mv in leads I, aVL, and V6 on admission ECG in the setting of acute anterior wall STEMI and in leads aVL, V5, and V6 on admission ECG in the setting of acute inferior wall STEMI was associated with MVD.

Inferior ST-Segment Elevation Myocardial Infarction with First-Degree Atrioventricular Block: A Case Report and Literature Review

Background: Atrioventricular (AV) block complicating acute inferior wall ST-elevation myocardial infarction (STEMI) is known to be associated with poor outcomes and increased rate of mortality.
 Case Report: We present the case of a 69-year old male patient, an active smoker, presented to the emergency department due to syncope 2 hours prior to admission. He reported symptoms while farming with sudden onset of diaphoresis, mild dizziness, and breathlessness followed by loss of consciousness for several minutes. Blood pressure was 79/55 mmHg, respiratory rate was 23, pulse was 46 bpm. Electrocardiogram showed inferior wall STEMI with first-degree AV block. Laboratory data revealed a significantly marked increase of CK-MB 82,5 U/L. STEMI protocol and fibrinolytic therapy has been done. The mechanisms of AV block and its spontaneous resolution in the setting of acute inferior wall STEMI are discussed. Attention is drawn to the patient due to our hospital categorized as an incapable cath lab sub-district hospital.
 Discussion: Clinical signs and examination suggested that this patient had a first-degree AV block complicating inferior wall STEMI on admission and fulfill the criteria of successful reperfusion 30 minutes following fibrinolytic therapy. Immediately after fibrinolysis, breathlessness was relieved, ST-T segment was reduced, spontaneous resolution of first-degree AV block occurred, and absence of Q-wave formation.
 Conclusion: Immediate reperfusion therapy is the core management of STEMI patients, including fibrinolytic therapy. Signs of successful therapy could be seen in this case and also relieved of the complication associated with STEMI. We found it as an incidence not much reported and thus reporting the case herewith.

Impact of Primary Percutaneous Coronary Intervention on Complete Atrioventricular Block With Acute Inferior ST-Elevation Myocardial Infarction.

Background and aimsComplete atrioventricular block (CAVB) is associated with poor clinical outcomes in ST-elevation myocardial infarction (STEMI). This study determined the frequency and outcomes of primary percutaneous coronary intervention (PPCI) in patients with CAVB with acute inferior STEMI.MethodsWe conducted an observational, prospective study and enrolled 151 patients who were diagnosed with inferior STEMI. All patients received PPCI. The clinical outcomes were compared in patients with and without CAVB. The data was recorded on a collection form and analyzed on Statistical Package for Social Sciences (SPSS) software. Descriptive statistics were applied. For quantitative variables, standard deviation and mean were obtained, and statistical tests were also applied.ResultsBaseline characteristics were homogeneous in all patients. Half of the study population was either diabetic or hypertensive. Out of 151 participants, 21 (13.9%) developed CAVB. Two-thirds of the patients, who had developed heart block, reverted after PPCI. After a follow-up of two weeks, in-hospital mortality did not differ between the groups.ConclusionWe conclude that PPCI can improve outcomes of CAVB-complicated acute inferior STEMI and suggest that primary PCI should be the preferred reperfusion therapy in patients with CAVB with STEMI.

A pseudoaneurysm of the left atrium as a rare source of coronary artery embolization.

A 67years old woman with history of surgical Mitral valve replacement underwent transoesophageal echocardiography for evaluation of mild dyspnoea. It revealed a large narrow-necked outpouching from medial portion of the inferior wall of the left atrium (LA) that was extended to the interatrial septum. A diagnosis of the LA pseudoaneurysm was made. It contained a fresh clot. Five days later, the patient presented with an acute inferior ST-elevation myocardial infarction. Coronary angiography revealed an occluded right coronary artery at its distal part by a large thrombus. Thromboaspiration was done and resulted in restoration of a Thrombolysis in Myocardial Infarction Score (TIMI) flow 3 without underlying stenosis.

Acute inferior ST-elevation myocardial infarction due to delirium tremens: a case report

BackgroundDelirium tremens is a severe form of alcohol withdrawal syndrome. Literature documenting acute coronary events in the setting of alcohol withdrawal remains scarce. An accepted hypothesis for the underlying process is focused on the hyperadrenergic state that leads to coronary vasospasm and increased myocardial oxygen demand.Case presentationA 47-year-old Caucasian man with a past medical history of tobacco and alcohol abuse, hypertension, and anxiety presented to the emergency department for crampy epigastric abdominal pain with intractable nausea and vomiting for the past 2 days. His reported last alcoholic intake was about 10 days prior; however, outpatient records indicated otherwise. He was admitted for electrolyte replacement and fluid resuscitation secondary to gastrointestinal losses from presumed early alcohol withdrawal syndrome. The following night, he developed acute substernal chest pain with elevated cardiac enzymes. Electrocardiography showed an acute inferoposterior infarct with reciprocal changes in leads V1–V4. The patient was taken for emergent catheterization, and a drug-eluting stent was placed in the middle of the left anterior descending artery. Postcatheterization electrocardiography showed sustained inferolateral ST elevations consistent with acute injury pattern. The patient had not required any benzodiazepines until this point. On the morning of catheterization, the patient’s Clinical Institute Withdrawal Assessment for Alcohol–Revised score was 19 with a high of 25, and he was actively hallucinating. He was treated for delirium tremens and an acute coronary event along with an incidental pneumonia. He did not require any benzodiazepines during the last 4 days of admission, and he made a full recovery.ConclusionsThe prevalence of alcohol dependence in hospitalized patients is substantial. Although our patient was being treated with the standard protocols for alcohol withdrawal, he rapidly developed delirium tremens, which led to an acute inferior ST-elevation myocardial infarction in the setting of nonoccluded coronary vessels. This case report adds to the sparse literature documenting acute coronary events in the setting of alcohol withdrawal and suggests that our patient’s ST-elevation myocardial infarction is not fully explained by the current coronary vasospasm hypothesis, but rather was in part the result of direct catecholamine-associated myocardial injury. Further research should be conducted on prophylactic agents such as β-blockers and calcium channel blockers.

LARGE VENTRICULAR SEPTAL DEFECT CAUSED BY AN ACUTE INFERIOR ST ELEVATION MYOCARDIAL INFARCTION

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Septal rupture is an uncommon, but fatal, complication of myocardial infarction (MI) which usually occurs 3-5 days after an acute MI, however, in rare instances it may develop within the first 24 hours or as late as 2 weeks. It is associated with a tremendously high mortality rate (41-80%) which has been unchanged during the last few decades [1]. We hereby report one such rare instance when this complication occurred within 48 hours following MI. CASE PRESENTATION: A 59 year old male with a history of coronary artery disease status post percutaneous coronary intervention in 2011 presented to the emergency room with chest pain for 1 hour prior to admission. Initial electrocardiogram showed acute inferior ST elevation MI. Emergent cardiac catheterization showed occlusion of the right coronary artery and a drug eluting stent was placed. The patient was transferred to intensive care unit for close monitoring, however, 5 hours later he developed sudden increasing shortness of breath. Physical examination revealed a new systolic murmur and an echocardiogram was performed showing a large ventricular septal defect (VSD) (Image-1). Overnight he developed atrial fibrillation and became hemodynamically unstable with a systolic blood pressure in the 60's. He was then cardioverted without success and amiodarone was bolused followed by a continuous infusion. The decision was made for emergent coronary artery bypass grafting and repair of the VSD the next day. The defect was successfully closed with a Dacron patch after timely and prompt correction of atrial fibrillation. DISCUSSION: There are 3 life threatening complications of acute MI which include rupture of the left ventricular free wall, rupture of the interventricular septum and development of severe mitral regurgitation. One study compared 225 patients who had a first MI and experienced one of the mechanical complications to 1012 patients without complications to analyze the reason behind these complications. They reported that delayed hospitalization (>24hours), excessive in-hospital physical activity and recurrent ischemia as some of the risk factors for rupture [2]. Early retrospective studies noted lower mortality rates in patients undergoing surgical repair > 6 weeks after infarction than those who went in earlier, however these studies had selection bias as patients with normal ejection fraction and smaller defects survived to become low risk surgical candidates [3]. Hence, optimal approach varies with the clinical presentation. In patients like ours who develop cardiogenic shock, death is inevitable without urgent surgical intervention. CONCLUSIONS: This case is an unusual scenario where this fatal complication occurred within 48 hours following MI even after prompt revascularization. It is unique because it was further complicated with atrial fibrillation, which can further reduce survival probability, yet he survived and defied the odds. Reference #1: Saplaouras A1, Sakellaropoulou A1, Mililis P1, Bazoukis G1, Kolokathis AM1, Konstantinidou E1, Anagnostou A1, Panagopoulou N1, Vlachos K1, Lakoumentas I1, Sideris A1. Ventricular septal rupture following myocardial infarction: A potentially fatal complication. Clin Case Rep. 2019 Jan 9;7(2):397-400 Reference #2: Figueras J, Cortadellas J, Calvo F, Soler-Soler J. Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction: study in 225 patients with free wall, septal or papillary muscle rupture. J Am Coll Cardiol 1998; 32:135. Reference #3: Daggett WM, Guyton RA, Mundth ED, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977; 186:260 DISCLOSURES: No relevant relationships by John Mikhail, source=Web Response No relevant relationships by Mohammed Shariff, source=Web Response

Diagnosis and Management of an Inferior ST-elevation Myocardial Infarction: A Simulation Scenario

Immediate diagnosis and management of ST-elevation myocardial infarction (STEMI), a condition resulting from the complete occlusion of a coronary artery, is critical to achieving optimal patient outcomes. This report outlines an acute inferior STEMI simulation which can be used for teaching different levels of learner including novice, intermediate and advanced. It focuses on the presentation, diagnosis, and management of inferior myocardial infarctions. Additionally, it incorporates the advanced cardiovascular life support (ACLS) protocol for more advanced learners and uses the CanMEDS collaborator/communicator role as an adjunct objective for all learners.

Successful capture of red thrombus in acute inferior ST-elevation myocardial infarction.

Successful capture of red thrombus in acute inferior ST-elevation myocardial infarction.

Transient prominent anterior QRS forces in the setting ST segment elevation coronary syndrome: Left septal fascicular block

Numerous successive publications have shown that transient prominent anterior QRS forces (PAF) in the setting of acute coronary syndrome (ACS) is suggestive of critical proximal obstruction of left anterior descending coronary artery (LAD) before its first septal perforator branch (S1). Transient ischemia of the left septal fascicle resulting in left septal fascicular block has been proposed as the causative mechanism. We present a case of acute inferior ST-elevation myocardial infarction caused by acute proximal occlusion of the right coronary artery associated with proximal critical obstruction of the left anterior descending coronary artery.

Acute aortoiliac occlusive disease during percutaneous transluminal angioplasty in the setting of ST-elevation myocardial infarction: a case report

BackgroundAortoiliac occlusive disease, which is also referred to as Leriche syndrome, is a chronic atherosclerotic occlusive disease that occurs at the level of the aortic bifurcation. It is often thought to present with a triad of clinical symptoms: (1) intermittent lower extremity vascular claudication, (2) impotence, and (3) weak/absent femoral pulses.Case presentationWe report a case of a 47-year-old Caucasian woman who presented with an acute inferior ST-elevation myocardial infarction. During percutaneous transluminal angioplasty, our patient suddenly developed severe bilateral lower extremity pain, absent femoral pulses, and cool extremities. Distal aortogram revealed 95% stenosis with an apple core-like lesion in the mid-abdominal aorta. Stent placement resulted in improved blood flow to the distal aortic segment and resolution of symptoms.ConclusionsThe presence of significant peripheral vascular disease, significant cardiac risk factors, and/or difficulty accessing the femoral artery should caution a transfemoral approach during percutaneous transluminal angiography. This approach may precipitate aortoiliac occlusion and/or thromboembolism to the lower extremities. We encourage interventional cardiologists to (1) take extra caution when manipulating the wire and catheter and (2) strongly consider using a transradial approach in such patients.

Partial posteromedial papillary muscle rupture as an early complication after acute inferior ST-elevation myocardial infarction treated with primary percutaneous intervention.

Partial posteromedial papillary muscle rupture as an early complication after acute inferior ST-elevation myocardial infarction treated with primary percutaneous intervention.

Response to the letter regarding the article "Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction".

Response to the letter regarding the article "Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-elevation myocardial infarction".