ST-segment Elevation Acute Myocardial Infarction Patients Research Articles

Influence of Medical Coverage on the Treatment and Prognosis of ST-segment Elevation Myocardial Infarction. SCAR Registry Subanalysis

Background: The Acute Coronary Syndromes in Argentina (SCAR) registry analyzed in-hospital myocardial infarction outcomein patients with different medical coverage provided by the healthcare system; this has led to the present subanalysisderived from the SCAR registry.Objective: The aim of this study was to determine the influence of medical coverage on myocardial infarction in-hospitalprognosis.Methods: The SCAR registry was a cross-sectional, prospective, multicenter study including 476 patients with ST-segmentelevation acute myocardial infarction (STEMI). Medical coverage was classified in prepaid health insurance, social securityinsurance, PAMI and without medical coverage (except public coverage).Results: Eighty percent of STEMI patients received reperfusion therapy, 75% by primary transluminal coronary angioplasty(PTCA). PTCA was more frequent in those with prepaid health insurance [OR 5.5 (2.5-12.4); p<0.001] and less frequent inPAMI patients [OR 0.47 (0.24-0.87), p=0.02] or in those without any medical coverage [OR=0.34 (0.2-0.6), p<0.001]. Thirteenpercent of patients were transferred to another hospital, more frequently if they were PAMI patients (p=0.002). Time toPTCA was longer in patients with PAMI [240 (88-370) min, p=0.0005] and shorter in patients with prepaid health insurance[80 (42-120) min, p<0.001]. Overall in-hospital STEMI mortality was 8%, 2.8% in patients with prepaid health insurance,4.3% in patients with public medical coverage, 6.88% in patients with social security insurance and 25% in patients coveredby PAMI (ANOVA <0.001). Mortality was significantly lower in patients with prepaid health insurance [OR=0.27 (0.08-0.91),p=0.035] and higher in patients with PAMI, even after adjusting by sex, age and comorbidities [OR 2.40 (1.1-5.8), p=0.05].Conclusion: STEMI treatment and mortality were different according to the type of medical coverage.

Angiopoietin-like 4 serum levels on admission for acute myocardial infarction are associated with no-reflow

BackgroundNo-reflow in ST-segment elevation acute myocardial infarction (STEMI) is associated with a poor clinical prognosis. Its pathophysiological mechanisms are not fully elucidated yet but enhanced vascular permeability plays a key role in this phenomenon. Angiopoietin-like 4 (ANGPTL4) has been implicated in vascular permeability in experimental models of acute myocardial infarction (AMI). We therefore sought to investigate whether baseline ANGPTL4 serum levels are associated with no-reflow after primary percutaneous coronary intervention (PPCI). MethodsWe studied a group of 41 patients presenting with a first STEMI within 12h of onset of symptoms and who underwent successful PPCI. Blood samples were obtained from all patients on admission before the start of the procedure, for ANGPTL4 level measurement. No-reflow was assessed by cardiac magnetic resonance imaging (MRI), the reference method. ResultsMRI-detected no-reflow was observed in 20 patients (48.8%). Variables independently associated with no-reflow on multivariate logistic regression analysis were: lower ANGPTL4 serum levels (odds ratio 0.82, 95% CI 0.70–0.98, P=0.02), higher troponin T peak (odds ratio 1.03, 95% CI 1.00–1.05, P=0.03), higher incidence of left anterior descending coronary artery (LAD) as culprit artery (odds ratio 14.61, 95% CI 1.24–172.49, P=0.03), and higher C-reactive protein levels (odds ratio 1.18, 95% CI 1.00–1.39, P=0.05). ConclusionANGPTL4 serum levels predict MRI-detected no-reflow after successful PPCI in STEMI patients. Given the recently demonstrated therapeutic role of ANGPTL4 in diminishing no-reflow and limiting infarct size in pre-clinical animal models, these findings in humans may open up new possibilities in the field of research.

Expression of functional tissue factor by neutrophil extracellular traps in culprit artery of acute myocardial infarction.

Neutrophil extracellular traps (NETs) are chromatin filaments released by activated polymorphonuclear neutrophils (PMNs) and decorated with granule proteins with various properties. Several lines of evidence implicate NETs in thrombosis. The functional significance and the in vivo relevance of NETs during atherothrombosis in humans have not been addressed until now. Selective sampling of thrombotic material and surrounding blood from the infarct-related coronary artery (IRA) and the non-IRA was performed during primary percutaneous revascularization in 18 patients with ST-segment elevation acute myocardial infarction (STEMI). Thrombi isolated from IRA contained PMNs and NETs decorated with tissue factor (TF). Although TF was expressed intracellularly in circulating PMNs of STEMI patients, active TF was specifically exposed by NETs obtained from the site of plaque rupture. Treatment of NET structures with DNase I abolished TF functionality measurement. In vitro treatment of control PMNs with plasma obtained from IRA and non-IRA was further shown to induce intracellular up-regulation of TF but not NET formation. A second step consisting of the interaction between PMNs and thrombin-activated platelets was required for NET generation and subsequent TF exposure. The interaction of thrombin-activated platelets with PMNs at the site of plaque rupture during acute STEMI results in local NET formation and delivery of active TF. The notion that NETs represent a mechanism by which PMNs release thrombogenic signals during atherothrombosis may offer novel therapeutic targets.

Plasma Soluble Lectin-Like Oxidized Low-Density Lipoprotein Receptor-1 as a Novel Prognostic Biomarker in Patients With ST-Segment Elevation Acute Myocardial Infarction

Soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) level is a reliable prognostic biomarker in acute coronary syndrome. However, it is unclear whether its plasma level at acute phase is related to the long-term prognosis in patients with ST-segment elevation acute myocardial infarction (STEMI). METHODS AND RESULTS: We prospectively examined the relation between plasma sLOX-1 level on admission and prognosis in 153 consecutive STEMI patients admitted within 24 h of onset. Primary percutaneous coronary intervention was performed in 144 patients. The patients were divided into 2 groups by the median value (71 pg/ml) of plasma sLOX-1 level on admission [sLOX-1 level ≤71 pg/ml (n=77) and >71 pg/ml (n=76)], and were followed for median of 1,156 days. All-cause mortality and the combined endpoints of major adverse cardiovascular events (MACE) defined as cardiovascular mortality and recurrent MI were both significantly higher in patients with sLOX-1 values above median than in those below median (25.0% vs. 3.9%, P<0.001, and 19.4% vs. 6.5%, P=0.019 by log-rank test, respectively). Even after adjustment for confounders, a level of sLOX-1 above median was an independent predictor for all-cause mortality (hazard ratio (HR): 5.893; 95% confidence interval (CI): 1.665-20.854, P=0.006) and MACE (HR: 3.457; 95% CI: 1.164-10.270, P=0.030). Elevated plasma sLOX-1 level on admission independently predicts long-term all-cause mortality and MACE after STEMI.

Combined effects of admission serum creatinine concentration with age and gender on the prognostic significance of subjects with acute ST-elevation myocardial infarction in China.

Objectiveto explore the impact of admission serum creatinine concentration on the in-hospital mortality and its interaction with age and gender in patients with acute ST-segment elevation myocardial infarction (STEMI) in China.Methods1424 acute STEMI patients were enrolled in the study. Anthropometric and laboratory measurements were collected from every patient. A Cox proportional hazards regression model was used to determine the relationships between the admission serum creatinine level (Cr level), age, sex and the in-hospital mortality. A crossover analysis and a stratified analysis were used to determine the combined impact of Cr levels with age and gender.ResultsFemale (HR 1.687, 95%CI 1.051∼2.708), elevated Cr level (HR 5.922, 95%CI 3.780∼9,279) and old age (1.692, 95%CI 1.402∼2.403) were associated with a high risk of death respectively. After adjusting for other confounders, the renal dysfunction was still independently associated with a higher risk of death (HR 2.48, 95% CI 1.32∼4.63), while female gender (HR 1.19, 95%CI 0.62∼2.29) and old age (HR 1.77, 95%CI 0.92∼3.37) was not. In addition, crossover analysis revealed synergistic effects between elevated Cr level and female gender (SI = 3.01, SIM = 2.10, AP = 0.55). Stratified analysis showed that the impact of renal dysfunction on in-hospital mortality was more pronounced in patients <60 years old (odds ratios 11.10, 95% CI 3.72 to 33.14) compared with patients 60 to 74 years old (odds ratios 5.18, 95% CI 2.48∼10.83) and patients ≥75years old (odds ratios 3.99, 95% CI 1.89 to 8.42).ConclusionSerum Cr concentration on admission was a strong predictor for in-hospital mortality among Chinese acute STEMI patients especially in the young and the female.

Impact of Timing of Eptifibatide Administration on Preprocedural Infarct-Related Artery Patency in Acute STEMI Patients Undergoing Primary PCI.

The appropriate timing of eptifibatide initiation for acute ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. This study aimed to analyze the impact of timing of eptifibatide administration on infarct-related artery (IRA) patency in STEMI patients undergoing primary PCI. Acute STEMI patients who underwent primary PCI (n = 324) were enrolled in this retrospective study; 164 patients received eptifibatide bolus ≤ 30 minutes after emergency department (ED) admission (group A) and 160 patients received eptifibatide bolus > 30 minutes after ED admission (group B). The primary endpoint was preprocedural IRA patency. Most patients in group A (90%) and group B (89%) were late presenters (> 2 hours after symptom onset). The two groups had similar preprocedural thrombolysis in myocardial infarction 2 or 3 flow of the IRA (26 vs. 24%, p = not significant [NS]), similar creatine kinase-MB (CK-MB) levels at 8 hours after admission (339 vs. 281 U/L, p = NS), similar left ventricular ejection fraction (LVEF) (52 vs. 50%, p = NS), and similar 30-day mortality (2 vs. 7%, p = NS). Compared with group B, patients in group A had shorter door-to-device time (p < 0.001) and shorter procedural time (p = 0.004), without increased bleeding risk (13 vs. 18%, p = NS). Earlier intravenous administration of eptifibatide before primary PCI did not improve preprocedural IRA patency, CK-MB level at 8 hours after admission, LVEF and 30-day mortality compared with patients who received intravenous eptifibatide that was administered later.

Left transradial access is safe and effective in acute STEMI patients undergoing primary percutaneous coronary intervention: results from CROSS-STEMI (CROatian Single center Study in STEMI patients)

Aim: In the last few years University Hospital Center Sestre milosrdnice, Zagreb has become dedicated to the radial approach with nearby 90% of percutaneous coronary interventions (PCI) performed with either left or right radial access route. In time, left radial approach has become the first choice option for most of the patients (pts) with acute ST-segment elevation myocardial infarction (STEMI). The aim of this study was to compare the efficacy and safety of left transradial access (L-TRA) with the right transradial (R-TRA) and transfemoral (TFA) access in the setting of primary (PCI) for acute (STEMI). Patients and Methods: This single-center, retrospective study included 767 consecutive acute STEMI patients, treated with primary PCI from January 2011 to May 2013, who were divided in three groups according to the arterial access site: L-TRA group (413 patients, 53.85%), R-TRA group (110 patients, 14.34%) and TFA group (244 patients, 31.81%). We collected data on the procedure success, procedure, door-to-balloon and fluoroscopy time and bleeding complications. Of all the patients, 43.5% of them were admitted directly through the emergency department and 56.5% of them were transported from other hospitals being the part of the Croatian PCI network. Results: Procedural success was similar among the three groups (L-TRA vs TFA 93.2% : 88.5%, p=0.495; and L-TRA vs R-TRA 93.2% : 90.1%, p=0.855). Additionally, all investigated procedural characteristics were similar among compared groups, including total procedure time (L-TRA vs TFA 71.9±18.4 : 73.3±21min, p=0.366; and L-TRA vs R-TRA 71.9±18.4 : 72.7±21.3min, p=0.966) and fluoroscopy time (L-TRA vs TFA 11.1±6.9 : 11.6±9.3min, p=0.461; and LTRA vs R-TRA 11.1±6.9 : 12.8±8.2min, p=0.128). When considering the bleeding complications (change in the concentration of haemoglobin), there were no differences between the three groups (L-TRA vs TFA 10±10.1 : 11±10.8 g/L, p=0.308; and L-TRA vs R-TRA 10±10.1 : 10±11.8 g/L, p=0.254). Conclusion: In a PCI center committed to PCI, left transradial approach for acute STEMI patients undergoing primary PCI, is as equally effective and safe as transfemoral or right transradial approach.

0402: Angiopoietin-like 4 serum levels on admission for acute myocardial infarction are associated with no-reflow

No-reflow in ST-segment elevation acute myocardial infarction (STEMI) is associated with a poor clinical prognosis. Its pathophysiologal mechanisms are not totally elucidated yet but enhanced vascular permeability plays a key role in this process. ANGPTL4 has been implicated in vascular permeability in experimental models of AMI. We therefore sought to investigate whether baseline ANGPTL4 serum levels are associated with no-reflow after primary percutaneous coronary intervention (PPCI). A group of 41 consecutive patients with a first STEMI, undergoing successful PPCI within 12h of onset of symptoms were enrolled. Blood samples were obtained from all patients on admission for ANGPTL4 levels measurement. No-reflow was assessed by cardiac magnetic resonance imaging (MRI), the reference method. MRI-detected no-reflow was observed in 20 patients (48.8%). Variables independently associated with no-reflow at multivariate logistic regression analysis were: lower ANGPTL4 plasma levels (odds ratio 0.82, 95% CI 0.70-0.98, P=0.02), higher troponin T peak (odds ratio 1.03, 95% CI 1.00-1.05, P=0.03), higher incidence of left anterior descending coronary artery (LAD) as culprit artery (odds ratio 14.61, 95% CI 1.24-172.49, P=0.03), and higher C-reactive protein levels (odds ratio 1.18, 95% CI 1.00-1.39, P=0.05). ANGPTL4 serum levels predict MRI-detected no-reflow after successful PPCI in STEMI patients. Given the recently demonstrated therapeutic role of ANGPTL4 in diminishing no-reflow and therefore infarct size in pre-clinical animal models, these findings in humans may open new fields of research.

0227: Fragmented QRS in patients with STEMI undergoing PCI: relation to ST-segment resolution and determinism

fragmented QRS complex (fQRS) is a marker of myocardial scarring and has prognostic significance. ST-segment resolution (STR) in STsegment elevation acute myocardial infarction (STEMI) is characteristic of tissue reperfusion. This study investigates the relationship between fQRS and STR in STEMI patients undergoing primary percutaneous coronary intervention (PCI) and determines the predictors of fQRS. we analyzed the electrocardiograms (ECGs) of 256 patients included in a multicenter prospective STEMI-PCI study. fQRS and STsegment resolution were evaluated upon arrival in the ambulance (ECG-amb) and 1 h post-PCI (ECG-post). Major clinical cardiac events were assessed at 30 days and 6 months. fQRS was present in 33 patients (13.6%) on ECG-amb and in 30 patients (12%) on ECG-post. The presence of fQRS at either time was not associated with STR or clinical outcomes. In a multivariable analysis, the independent predictors of fQRS on ECG-amb were female sex (p=0.04), cardiac troponin Ic level at 72 h (p=0.01), TIMI 0-1 flow rate pre-PCI (p=0.002), and inferior STEMI location (p=0.04). Patients with fQRS on ECG-amb presented a larger necrosed mass on cardiac MRI than patients without fQRS (p=0.04). No predictors of fQRS post-PCI were identified. the presence of fQRS at the time of presentation or 1 h after PCI was not associated with STR. However, fQRS was related to enzymatic infarct size, inferior STEMI location, and low TIMI flow rate.

Abstract P375: Decade Long Trends in the Magnitude, Treatment, and Outcomes of Young Adults Hospitalized with ST-Segment Elevation Myocardial Infarction and Non-ST-Segment Elevation Myocardial Infarction

Background: Although acute myocardial infarction (AMI) occurs primarily in the elderly, this disease also affects young adults. Few studies have, however, presented data on relatively young patients hospitalized with AMI. The objectives of this population-based study were to examine recent trends in the magnitude, management, and in-hospital and long-term-outcomes associated with either an initial ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment elevation acute myocardial infarction (NSTEMI) in patients between the ages of 30-54 years old. Methods: We reviewed the medical records of 745 residents of the Worcester (MA) metropolitan area between the ages of 30 and 54 years who were hospitalized for an initial STEMI or NSTEMI in 6 annual periods between 1997 and 2007 at 11 greater Worcester medical centers. Results: Between 1997 and 2007, the proportion of young adults hospitalized with an initial STEMI decreased from approximately two-thirds to two-fifths of all patients. Patients with STEMI were less likely to have a history of heart failure, hypertension, hyperlipidemia, and kidney disease than NSTEMI patients. Both groups were similarly treated with evidence-based therapies during their acute hospitalization with encouraging trends in the prescribing of various cardiac medications observed over time (Figures 1A and B). Important in-hospital clinical complications and mortality were low and no significant differences in these endpoints were observed between STEMI and NSTEMI patients. One year post-discharge death rates were also similar in both groups (1.9% vs. 2.8%). Conclusion: The present results demonstrate recent decreases in the proportion of relatively young patients diagnosed with an initial STEMI. Patients with STEMI and NSTEMI had similar in-hospital outcomes and long-term survival. Trends in these and other important outcomes warrant continued monitoring.

Prognostic Value of the Leuko-glycemic Index in Acute Myocardial Infarction. Results from the SCAR Multicenter Registry

Background: Leukocytosis and hyperglycemia correlate with worse short-term prognosis in patients with acute coronarysyndrome, but their new relationship, called leuko-glycemic index (LGI), has been scarcely evaluated.Objectives: The aim of this study was to analyze the prognostic value of LGI in patients with ST-segment-elevation acutemyocardial infarction (STEMI) and its added value to classical risk scores.Methods: Patients diagnosed with STEMI from the SCAR (Acute Coronary Syndromes in Argentina) Multicenter Registrywere analyzed. The final endpoint was death or in-hospital Killip-Kimball 3-4 (KK 3-4). The LGI was analyzed as a continuousvariable and in quartiles according to 25, 50 and 75 percentile values.Results: The study evaluated 405 out of 476 patients with final STEMI diagnosis. Presence of the primary endpoint significantlyincreased per LGI quartile: 0%, 7.60%, 9.30% and 30.60% (p < 0.0001). The LGI area under the ROC curve for the compositeendpoint was 0.77 [(95% CI 0.71-0.88); p = 0.0001]; the best prognostic cut-off value was 1000. Presence of death or KK 3-4was 0% and 13% in STEMI patients with LGI below or above 1000, respectively. In a multivariate logistic regression model,LGI was independently associated with death or KK 3-4. The area under the ROC curve of the TIMI risk score for STEMIwas 0.58. The addition of LGI increased its discriminatory capacity to 0.66 (p = 0.001).Conclusions: The LGI was an independent predictor of adverse outcome in STEMI patients (death or KK 3-4), adding prognosticvalue to the TIMI risk score.

Utilization of Radial Artery Access for Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction in New York

This study sought to determine the utilization and outcomes for radial access for percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in common practice. Radial access for PCI has been studied considerably, but mostly in clinical trials. All patients undergoing PCI for STEMI in 2009 to 2010 in New York were studied to determine the frequency and the patient-level predictors of radial access. Differences in in-hospital/30-day mortality between radial and femoral access were also studied. Radial access increased from 4.9% in the first quarter of 2009 to 11.9% in the last quarter of 2010. Significant independent predictors were higher body surface area, non-Hispanic ethnicity, Caucasian race, stable hemodynamic state, ejection fraction <30% and ≥50% onset of STEMI from 12to 23 h before the index procedure, and peripheral vascular disease. Mortality was not related to access site after adjustment for covariates (for radial vs. femoral access, adjusted odds ratio: 0.86, 95% confidence interval: 0.59 to 1.25), but the radial access site was trending toward lower mortality for the 9 hospitals that used it for more than 10% of their patients (adjusted odds ratio: 0.61, 95% confidence interval: 0.36 to 1.02). The use of a radial access site for PCI in STEMI patients increased between 2009 and 2010, but was still infrequent in 2010, and was used for lower-risk STEMI patients. There was no significant difference in mortality by access site, but there was a trend toward a mortality advantage for patients with a radial access site among hospitals that used it relatively frequently.

No-reflow during emergency percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction：an analysis of influencing factors

Objective To identify the factors of no-reflow during emergency percutaneous coronary intervention(PCI)in patients with acute ST-segment elevation myocardial infarction(STEMI).Methods A total of 92patients with acute STEMI treated with PCI were divided into normal reflow group(73patients)and no-reflow group(19patients)from June2012to January 2013.The influencing factors of no-reflow were clarified by comparing clinical symptoms of the two groups.Results The no-reflow rate after undergoing emergency PCI was 20.7% in 92acute STEMI patients.The systolic blood pressure(SBP),type 2diabetes,troponin T peak,period from disease onset to reperfusion,balloon expansion times and stent number of the target blood vessel were significantly different between the two groups(P0.05).Multivariate logistic regression analysis identified that low SBP(SBP100mmHg,1mmHg=0.133kPa),type 2diabetes,balloon expansion times,troponin T peak,right coronary artery lesions and period from disease onset to reperfusion were the risk factors for noreflow during PCI in patients with STEMI.Conclusion No-reflow following emergency PCI in acute STEMI patients is associated with six clinical factors:SBP100 mmHg,type 2diabetes,balloon expansion times,troponin T peak,right coronary artery lesions and period from disease onset to reperfusion.

High-Dose Erythropoietin in Acute ST-Segment Elevation Myocardial Infarction: A Meta-Analysis of Randomized Controlled Trials

We sought to perform a meta-analysis to evaluate the potential influence of high-dose erythropoietin (EPO) on cardiac function parameters in patients with acute ST-segment elevation myocardial infarction (STEMI). By searching PubMed, EMBASE, and the Cochrane Library (up to December 2012), seven randomized controlled trials (RCTs) reporting cardiac functional parameters with a total of 1,250 acute STEMI patients were identified. When applied to patients with acute STEMI, high-dose EPO was relatively safe and no increase in all-caused death and severe adverse effects were indicated. Estimates were pooled from fixed or random effects models. Compared with controls, high-dose EPO resulted in a slight but significant improvement in left ventricular ejection fraction of 1.02% [95% confidence interval (CI) 0.17-1.88, P=0.019, I (2)=0%] and an improvement in left ventricular end-systolic volume of -4.61ml (95% CI -7.64 to -1.58, P=0.003, I (2)=27.7%). Available evidence suggested that high-dose EPO has limited cardio-protective effects in patients with STEMI. However, considering the relatively short follow-up durations and small patient populations in the current RCTs, the effects of high-dose EPO on clinical outcomes in patients with STEMI need to be evaluated in larger prospective RCTs of longer duration.

Therapie des akuten ST-Streckenhebungs-Myokardinfarkts in Krankenhäusern mit und ohne Herzkatheterlabor

The goal of treatment of patients with ST-segment elevation acute myocardial infarction (STEMI) is to restore perfusion as soon as possible, preferably by primary percutaneous coronary intervention (PCI). The aim of this study of the German Myocardial Infarction Registry (DHR) was to document acute care and in-hospital course of STEMI patients in Germany. Over three months patients with STEMI were consecutively included and their basic data, treatments and in-hospital complications were centrally recorded using an internet-based standardized questionnaire. Included were 6,330 patients from 243 hospitals, in group 1 (primary admission in 136 hospitals with cath lab) 4,656 patients (74%) and in group 2 (primary admission in 107 hospitals without cath lab) 1,674 (26%). Reperfusion therapy was performed more frequently in patients of group 1 (91.1% PCI, 2.7% fibrinolysis) than in group 2 (80.7% PCI after transfer, 6.4% fibrinolysis). In-hospital mortality was 7.3% in all patients, 7.0% in group 1 and 8.3% in group 2. The DHR data show that about three quarters of patients with STEMI are primarily admitted to hospitals with cath labs. Primary PCI is the preferred treatment option both in hospitals with and without cath labs (in the latter after transfer); it is performed in about 85% of STEMI patients. In-hospital mortality is with over 7% higher in real-life than in randomized studies.

Determinants and outcomes of atrial fibrillation complicating myocardial infarction: the EURHOBOP study in Portugal

Background: Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) associated with increased morbidity and mortality. This association is less well defined across the spectrum of acute coronary syndromes. We sought to study the incidence, predictors and prognosis of new-onset AF complicating ST-segment elevation AMI (STEMI) and non-ST-segment elevation AMI (NSTEMI). Methods: We studied 977 episodes of STEMI and 1357 of NSTEMI, within a sample of acute coronary syndrome cases from 10 Portuguese hospitals, consecutively discharged within each hospital, in 2009. The discharge notes and electronic/paper medical files were retrospectively reviewed by trained data extractors. Patients with unstable angina or AMI that could not be classified as STEMI vs NSTEMI (either due to left bundle branch block of unknown age or subacute presentation) were excluded from this analysis. We fitted logistic regression models to estimate odds ratios (OR) and 95% confidence intervals (95% CI). Results: A total of 208 patients (8.9%) with AMI developed new-onset AF during the index hospitalization, with no difference between STEMI and NSTEMI (8.8% vs 9.0%, p=0.87). The incidence of AF increased with age in both STEMI (<60 years: 3.1%; ≥ 60 <80 years: 11.8%; ≥80 years: 17.0%, p<0.001) and NSTEMI (2.3%, 10.9% and 14.3%, respectively, p<0.001). In STEMI, left ventricular systolic dysfunction (LVSD), coronary anatomy, peak troponin and invasive treatment were not associated with AF. On other hand, in NSTEMI, revascularization procedures reduced the risk of AF by a half (age, sex and LVSD-adjusted OR 0.48; 95% CI 0.29-0.77). Among NSTEMI patients who underwent coronary angiography, increasing severity of coronary anatomy increased the risk of AF (1-, 2- and 3-vessel disease: 4.6%, 6.1%, 9.3%, respectively, p=0.15).New-onset AF resulted in adverse in-hospital outcomes defined by the composite endpoint clinical heart failure or death (16.1% vs 6.6%, p<0.001). This endpoint was significantly associated with new-onset AF, when adjusting for age, sex, LVSD and revascularization in both STEMI (OR 2.90; 95% CI 1.74-4.80) and NSTEMI (OR 1.69; 95% CI 1.11-2.58) patients. Conclusion: New-onset AF affected STEMI and NSTEMI with similar likelihood and similar consequences, with a 2-fold increase in death or heart failure. However, its predictors differed with type of AMI presentation. Our results suggest that myocardial ischemia may be explaining AF in NSTEMI.

Long-term outcomes of patients receiving zotarolimus-eluting stents in ST elevation myocardial infarction, non-ST elevation acute coronary syndrome, and stable angina: Data from the Resolute program

Outcome data are limited in patients with ST-segment elevation acute myocardial infarction (STEMI) or other acute coronary syndromes (ACSs) who receive a drug-eluting stent (DES). Data suggest that first generation DES is associated with an increased risk of stent thrombosis when used in STEMI. Whether this observation persists with newer generation DES is unknown. The study objective was to analyze the two-year safety and effectiveness of Resolute™ zotarolimus-eluting stents (R-ZESs) implanted for STEMI, ACS without ST segment elevation (non-STEACS), and stable angina (SA). Data from the Resolute program (Resolute All Comers and Resolute International) were pooled and patients with R-ZES implantation were categorized by indication: STEMI (n=335), non-STEACS (n=1416), and SA (n=1260). Mean age was 59.8±11.3 years (STEMI), 63.8±11.6 (non-STEACS), and 64.9±10.1 (SA). Fewer STEMI patients had diabetes (19.1% vs. 28.5% vs. 29.2%; P<0.001), prior MI (11.3% vs. 27.2% vs. 29.4%; P<0.001), or previous revascularization (11.3% vs. 27.9% vs. 37.6%; P<0.001). Two-year definite/probable stent thrombosis occurred in 2.4% (STEMI), 1.2% (non-STEACS) and 1.1% (SA) of patients with late/very late stent thrombosis (days 31-720) rates of 0.6% (STEMI and non-STEACS) and 0.4% (SA) (P=NS). The two-year mortality rate was 2.1% (STEMI), 4.8% (non-STEACS) and 3.7% (SA) (P=NS). Death or target vessel re-infarction occurred in 3.9% (STEMI), 8.7% (non-STEACS) and 7.3% (SA) (P=0.012). R-ZES in STEMI and in other clinical presentations is effective and safe. Long term outcomes are favorable with an extremely rare incidence of late and very late stent thrombosis following R-ZES implantation across indications.

Early application of an intra-aortic balloon pump in patients with ST-segment elevation acute myocardial infarction scheduled for elective percutaneous coronary intervention

This study evaluated the effect of early application of intra-aortic balloon pump (IABP) counterpulsation in patients with ST-segment elevation acute myocardial infarction (STEMI), scheduled for elective percutaneous coronary intervention (PCI). Patients who had experienced STEMI for 12-72 h received (IABP group) or did not receive (control group) IABP counterpulsation for 3-5 days before PCI. One hundred patients were included. Frequencies of infarct-related artery thrombolysis in acute myocardial infarction (TIMI) flow rate classes 0, I and II in the IABP group (11.5, 1.9 and 7.7%, respectively) were significantly lower than in the control group (29.1, 14.6 and 22.9%, respectively) before PCI. After PCI, the frequency of TIMI class III flow rate in the IABP group (96.2%) was significantly higher than that in the control group (81.3%). Four weeks after PCI, the left ventricular ejection fraction (LVEF) was significantly higher, and the incidence of major cardiac events was significantly lower, in the IABP group compared with the control group. Early use of IABP counterpulsation in STEMI patients scheduled for PCI was effective, with a favourable safety profile. IABP counterpulsation reduced the incidence of major adverse cardiac events and improved LVEF. However, IABP devices must be used at an early stage, to obtain optimal results.

Prognostic Value of High-sensitivity C - reactive protein in Acute ST-segment Elevation Myocardial Infarction in Hospitalized Patients

Acute Myocardial Infarction (AMI) is an inflammatory condition. C-reactive protein (CRP) is a sensitive inflammatory marker. Elevated plasma CRP levels detected in the first few days of AMI is a predictor of unfavourable short and long term outcome. This cross sectional comparative study included 60 patients of 28-85 years with acute ST segment elevation myocardial infarction (STEMI) admitted within 24 hours of onset of chest pain in coronary care unit (CCU) of Sylhet MAG Osmani Medical College Hospital. Based on high-sensitivity C-reactive protein (hS-CRP) levels on the first day, the patients were divided into two groups: Group-I Low hs-CRP group (?10 mg/L, n=22); Group-II High hs-CRP group (?10 mg/L, n=38). Clinical and echocardiographic prognostic variables were compared between two groups. The mean values of 1st and 3rd day hs-CRP levels of acute STEMI patients who developed the worse outcomes and who did not develop the outcomes are also compared. Among the in-hospital outcomes in group-I and group-II, (recurrent angina, cardiogenic shock, heart failure (HF), arrythmias, left ventricular ejection fraction (LVEF), wall motion abnormality (WMA), hospital stay and mortality) only arrhythmia was found significantly higher in high hs-CRP group (36.4% vs 76.3%, P&lt;0.01). On the other hand, the patients who developed these worse outcomes had significantly higher mean values of both 1st day and 3rd day hs-CRP compared to those who did not develop these outcomes. Mean values of 1st and 3rd day hs-CRP (mg/L) of patients who develops recurrent angina or not was 68.42 (SD 12.56) and 110.14 (SD 10.66) vs 29.08 (SD 5.83) and 36.74 (SD 6.64) p&lt;0.01. Among patients with arrhythmias, the values were 62.77 (SD 9.06) and 83.94 (SD 10.0) vs 14.23 (SD 2.92) and 35.20 (SD 7.65) p&lt;0.001. Hs-CRP can be used as a simple and cost effective tool for prediction of in-hospital prognosis in patients with acute STEMI. DOI: http://dx.doi.org/10.3329/medtoday.v24i1.14113 Medicine TODAY Vol.24(1) 2012 pp.36-39

Prognostic Role of Heart Rate Variability in Patients with ST-Segment Elevation Acute Myocardial Infarction Treated by Primary Angioplasty

Objectives: The aim of our study was to assess the prognostic value of heart rate variability (HRV) in ST-segment elevation acute myocardial infarction (STEMI) patients treated by percutaneous transluminal coronary angioplasty (PTCA) and optimal medical therapy. Methods: We enrolled 182 consecutive patients with a first STEMI (59.1 ± 11 years; 82.4% men) treated by primary PTCA. HRV was assessed on 24-hour Holter ECG recordings before discharge and 1 and 6 months after discharge. The primary end point was the occurrence of major clinical events (MCE), defined as death or new acute myocardial infarction (AMI). Results: At a follow-up of 42 ± 23 months, MCE occurred in 14 patients (7.6%; 3 deaths and 11 re-AMIs). HRV parameters before discharge were significantly lower in patients with MCE, with standard deviation of all RR intervals (SDNN) and very low frequency and low frequency (LF) amplitude being the most predictive variables. HRV assessed at follow-up instead did not significantly predict MCE. At multivariate analysis, only SDNN (HR 0.97; p = 0.02) and LF (HR 0.90; p = 0.04) remained significantly associated with MCE. Lower tertile SDNN and LF values were associated with a multivariate HR of 3.91 (p = 0.015) and of 2.92 (p = 0.048), respectively. Similar results were observed considering re-AMI only as the end point. Conclusions: In STEMI patients treated by PTCA, HRV assessed before discharge was an independent predictor of MCE and re-AMI.