Acute ST-segment Myocardial Infarction Research Articles

Role of Colchicine in Reduction of No Reflow Phenomenon in Patients with Acute ST-Segment Myocardial Infarction, Undergoing Primary Percutaneous Coronary Intervention

Abstract Aim and objectives The aim of this work is to study the efficacy of colchicine administration as a preventive tool for No Reflow in patients with STEMI undergoing primary PCI. Patients and Methods The study included 100 patients who presented with acute STEMI to the cardiology department of Ain Shams university hospitals and underwent primary PCI (percutaneous coronary intervention). They were divided into two groups where the first group received colchicine (1 mg) besides guideline recommended therapy before primary PCI and the 2nd group served as a control group and received guideline recommended therapy. Post interventional thrombolysis in myocardial infarction (TIMI) flow grade and myocardial blush grade (MBG) were recorded. Results The majority of patients in both groups had the LAD as the culprit vessel for their presentation(63%). In the control group there were 19 patients with TIMI flow less than 3 and 20 patients with MBG less than 3. Meanwhile in the cases group there was 8 patients with TIMI flow less than 3 and 7 patients with MBG less than 3. This difference was statistically significant with a P value of 0.013. There were 40 patients in the cases group who received loading clopidogrel (600 mg) as premedications before Primary PCI (80%) vs 25 patients (50%) in the control group which was statistically highly significant with a P value of 0.002. In addition, Intracoronary medications (adrenaline, verapamil, tirofiban that where given during the procedure) used in 2 patients from the cases group vs 10 from the control group which was statistically significant with a P value of 0.014. There was not a statistically significant difference between the two groups regarding presenting balloon dilatation. Whereas, Post stenting balloon dilatation showed a statistically significant relationship of P value 0.014 which was done in 2 patients from the cases group vs 10 patients from the control group. Conclusion Colchicine loading before primary PCI resulted in improved postprocedural TIMI flow, MBG.

Early detection of inflammation-prone STEMI patients using the CRP Troponin Test (CTT)

Abstract Background Elevated concentrations of C-reactive protein (CRP) early after acute coronary syndrome (ACS) may reflect the magnitude of the inflammatory response to myocardial damage and are associated with worse outcome. However, the routine measurement of both CRP and cardiac troponin simultaneously in the setting of ST segment myocardial infarction (STEMI) is not used broadly. Here, we sought to identify and characterize individuals who are prone to an elevated inflammatory response following STEMI using the CRP Troponin test (CTT) and determine their short- and long-term outcome. Material and methods We retrospectively examined 1,186 patients with the diagnosis of acute STEMI, who had at least two successive measurements of combined CRP and cardiac troponin (up to 6 hours apart), all within the first 48 hours of admission. We used Chi-Square Automatic Interaction Detector (CHAID) tree analysis to determine which parameters, timing (baseline vs. serial measurements), and cut-offs should be used to predict mortality. Results Patients with high CRP concentrations (above 90th percentile, >33mg/L) had higher 30 day- and all-cause mortality rates regardless of their troponin test status (above or below 118,000 ng/L); 14.4% vs 2.7%, p<0.01. Furthermore, patients with both high CRP and high Troponin levels on their second measurement had the highest 30-day mortality rates compared to the rest of the cohort; 21.4% vs. 3.7%, p<0.01. These patients also had the highest all-cause mortality rates after a median follow up of 4.5 years compared to the rest of the cohort; 42.9% vs 12.7%, p<0.01 (Figure 1). Conclusions In conclusion, serial measurements of both CRP and cardiac troponin might detect patients at increased risk for short-and long-term mortality following STEMI. We suggest the future use of the combined CRP Troponin-test (CTT) as a potential early marker for inflammatory-prone patients with worse outcomes following ACS. This sub-type of patients might benefit from early anti-inflammatory therapy such as colchicine and anti-IL-1β agents. Funding Acknowledgement Type of funding sources: None.

Coronary Artery Bypass Graft Surgery Brings Better Benefits to Heart Failure Hospitalization for Patients with Severe Coronary Artery Disease and Reduced Ejection Fraction.

Objectives: We compared the outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) for revascularization in patients with reduced ejection fraction (EF) and severe coronary artery disease (CAD). Methods: Between February 2006 and February 2020, a total of 797 patients received coronary angiograms due to left ventricular EF ≤ 40% at our hospital. After excluding diagnoses of dilated cardiomyopathy, valvular heart disease, prior CABG, acute ST-segment myocardial infarction, and CAD with low Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score (≤22), 181 patients with severe coronary artery disease (CAD) with SYNTAX score >22 underwent CABG or PCI for revascularization. Vascular characteristics as well as echocardiographic data were compared between CABG (n = 58) and PCI (n = 123) groups. Results: A younger age (62 ± 9.0 vs. 66 ± 12.1; p = 0.016), higher new EuroSCORE II (8.6 ± 7.3 vs. 3.2 ± 2.0; p < 0.001), and higher SYNTAX score (40.5 ± 9.8 vs. 35.4 ± 8.3; p < 0.001) were noted in the CABG group compared to those in the PCI group. The CABG group had a significantly higher cardiovascular mortality rate at 1-year (19.6% vs. 5.0%, p = 0.005) and 3-year (25.0% vs. 11.4%, p = 0.027) follow-ups but a lower incidence of heart failure (HF) hospitalization at 1-year (11.1% vs. 28.2%, p = 0.023) and 3-year (3.6% vs. 42.5%, p = 0.001) follow-ups compared to those of the PCI group. Conclusions: Compared with PCI, revascularization with CABG was related to a lower incidence of HF hospitalization but a worse survival outcome in patients with severe CAD and reduced EF. CABG-associated reduction in HF hospitalization was more notable when SYNTAX score ≥33.

Early Detection of Inflammation-Prone STEMI Patients Using the CRP Troponin Test (CTT).

Elevated concentrations of C-reactive protein (CRP) early during an acute coronary syndrome (ACS) may reflect the magnitude of the inflammatory response to myocardial damage and are associated with worse outcome. However, the routine measurement of both CRP and cardiac troponin simultaneously in the setting of ST-segment myocardial infarction (STEMI) is not used broadly. Here, we sought to identify and characterize individuals who are prone to an elevated inflammatory response following STEMI by using a combined CRP and troponin test (CTT) and determine their short- and long-term outcome. We retrospectively examined 1186 patients with the diagnosis of acute STEMI, who had at least two successive measurements of combined CRP and cardiac troponin (up to 6 h apart), all within the first 48 h of admission. We used Chi-Square Automatic Interaction Detector (CHAID) tree analysis to determine which parameters, timing (baseline vs. serial measurements), and cut-offs should be used to predict mortality. Patients with high CRP concentrations (above 90th percentile, >33 mg/L) had higher 30 day and all-cause mortality rates compared to the rest of the cohort, regardless of their troponin test status (above or below 118,000 ng/L); 14.4% vs. 2.7%, p < 0.01. Furthermore, patients with both high CRP and high troponin levels on their second measurement had the highest 30-day mortality rates compared to the rest of the cohort; 21.4% vs. 3.7%, p < 0.01. These patients also had the highest all-cause mortality rates after a median follow-up of 4.5 years compared to the rest of the cohort; 42.9% vs. 12.7%, p < 0.01. In conclusion, serial measurements of both CRP and cardiac troponin might detect patients at increased risk for short-and long-term mortality following STEMI. We suggest the future use of the combined CTT as a potential early marker for inflammatory-prone patients with worse outcomes following ACS. This sub-type of patients might benefit from early anti-inflammatory therapy such as colchicine and anti-interleukin-1ß agents.

Circulating miR-1 as a potential predictor of left ventricular remodeling following acute ST-segment myocardial infarction using cardiac magnetic resonance.

The identification of patients with a high likelihood of left ventricular (LV) remodeling with a high-risk prognosis has critical implications for risk stratification after acute ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate the relationship between circulating miR-1 and 6-month post-infarct LV remodeling based on cardiac magnetic resonance (CMR) imaging. A total of 80 patients with a first STEMI treated with primary percutaneous coronary intervention (PCI) who underwent CMR imaging 1 week and 6 months after STEMI were evaluated. The percentage changes of LV ejection fraction (LVEF), LV end-diastolic volume (LVEDV), LV end-systolic volume index (LVESV) at 1 week and 6 months after PCI (%ΔLVEF, %ΔLVEDV and %ΔLVESV) were calculated. miR-1 was measured using polymerase chain reaction (PCR)-based technologies in plasma samples that were collected at admission. The study group was divided into two groups based on a 10% cutoff value for the percentage of change in the LV end-diastolic volume (%ΔLVEDV): remodeling at high risk of major adverse cardiac events (MACEs) (%ΔLVEDV ≥10%, termed the LV remodeling group) and remodeling at lower risk of MACEs (%ΔLVEDV <10%, termed the non-LV remodeling group). The associations of miR-1 expression with the %ΔLVEDV, percentage change in the LV end-systolic volume (%ΔLVESV), and percentage change in the LV ejection fraction at follow-up were estimated. Twenty-two patients (27.5%) showed adverse LV remodeling, and 58 patients (72.5%) did not show adverse LV remodeling at the 6-month follow-up of CMR. The mean LVEF, LVEDV index, and LVESV index values at 1 week were 50.6%±8.2%, 74.6±12.8 mL/m2, and 37.2±10.2 mL/m2, respectively. Mean LVEF at follow-up (53.5%±10.6%) was increased compared with baseline (P<0.001). There were significant decreases in LVEDV index and LVESV index values at follow-up (72.0±14.9 mL/m2 and 33.7±11.0 mL/m2, respectively; P=0.009 and P<0.001, respectively). The expression of miR-1 at admission was positively correlated with the %ΔLVEDV (r=0.611, P<0.001) and %ΔLVESV (r=0.268, P=0.016). Receiver operating characteristic (ROC) analysis showed that miR-1 expression predicted LV remodeling with an area under the curve (AUC) value of 0.68 (95% CI: 0.56-0.78). Compared with the clinical factors of peak creatine kinase-myocardial band (CK-MB) and peak troponin T level, peak logNT-proBNP showed the highest predictive power, with an AUC value of 0.75 (95% CI: 0.64-0.84). A model including the clinical, CMR, and miR-1 factors showed greater predictive power (P=0.034) than a model including only clinical and CMR factors, with AUCs of 0.89 (95% CI: 0.80-0.95) and 0.81 (95% CI: 0.71-0.89), respectively. Circulating miR-1 at admission is an independent predictor of LV remodeling 6 months after STEMI. miR-1 showed incremental value in predicting LV remodeling compared with the clinical and CMR measurements.

Previously diagnosed cancer and mortality after ST-segment elevation acute myocardial infarction treated with primary angioplasty.

We investigated if a previous cancer diagnosis influences the outcome of patients with STEMI treated with primary coronary intervention (PCI). ST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both have a high incidence and prevalence. Prospective cohort observational study, The primary end-point was total mortality. We included 917 patients, 53 of them (5.8%) were cancer survivors. During follow-up (median, 643 days [interquartile range, 258 to 1,015 days]), 100 patients died, 88 (10.2%) patients without a cancer diagnosis and 12 (22.6%) patients with a previous cancer diagnosis, which was significantly different (log-rank test = 8.4, p = .004). Cancer patients were older (73.4 (11.5) vs. 65.2 (13.8) years, p < .001), with a lower prevalence of previous stroke (1.1% vs. 2.2%, p = .002). Their hemoglobin concentration was also lower (13.4 (2.1) vs. 14.4 (1.7) g/L, p = .001). A trend towards a lower use of coronary stents in cancer survivors was noted (p = .061). Cancer was associated with a high probability of death (HR = 2.37, 95% confidence interval [CI] 1.30-4.34, p = .005). When confounding variables were included, this association was no longer significant (HR = 1.63, 95% CI 0.84-3.18, p = .150). Patients with a previous cancer diagnosis who had an acute STEMI treated by primary PCI did not seem to have a worse prognosis. The difference in the crude mortality rate can be explained by the baseline differences between both groups. Previous cancer diagnosis should not be included in the clinical decision process when a patient is having an acute STEMI.

Postoperative ‘STEMI’ in Intracerebral Hemorrhage due to Arteriovenous Malformation: A Case Report and Review of Literature

Electrocardiogram (ECG) changes suggestive of cardiac ischemia are frequently demonstrated in patients with ischemic stroke and subarachnoid hemorrhage. However, little is known of such changes particularly acute ST segment myocardial infarction (STEMI) in patients with intracerebral hemorrhage (ICH), especially after neurosurgery. We present a patient with intraparenchymal hemorrhage due to cerebral arteriovenous malformation (AVM) who exhibited acute STEMI after neurosurgery. Serial cardiac biomarkers and echocardiograms were performed which did not reveal any evidence of acute myocardial infarction. The patient was managed conservatively from cardiac stand point with no employment of anticoagulants, antiplatelet therapy, fibrinolytic agents, or angioplasty and recovered well with minimal neurological deficit. This case highlights that diffuse cardiac ischemic signs on the ECG can occur in the setting of an ICH after neurosurgery, potentially posing a difficult diagnostic and management conundrum.

Pentraxin 3 genotyping in relation to serum levels of pentraxin 3 in patients with acute ST-segment elevation myocardial infarction

ObjectiveThe aim of the study was to investigate the association of serum Pentraxin 3 and genotyping with the risk of developing AMI and its severity. Patients and methodsFifty patients admitted to the coronary care unit presented with STEMI (acute ST segment myocardial infarction) at the Cardiology Department, Menoufia University Hospital in the period from October 2014 to April 2015 and another 20 subjects age- and gender-matched were taken as the control group. All patients and control groups were subjected to the following: Full history taking, complete clinical examination. ECG and echocardiography and Laboratory investigation including: estimation of lipid profile, urea and creatinine, CKMB, troponin I, serum pentraxin 3 and Genotyping of pentraxin 3 A/G SNP (rs2305619). ResultsThe patients with myocardial infarction had significantly higher levels of pentraxin 3 than the controls. The cut-off values for PTX3 and troponin I were 4.35ng/ml and 0.34μg/l respectively. Pentraxin 3 showed the highest diagnostic accuracy of coronary artery disease (96%), with sensitivity (96%) and specificity (95%). The highest serum pentraxin 3 levels were in the AA mutant homozygous type. ConclusionPTX3 is one of the earliest biomarkers for detecting acute coronary syndrome. rs2305619 AA genotyping of the pentraxin 3 gene might be a candidate risk factor for development of coronary artery disease, presumably by increased pentraxin 3 levels.

The Speed of Sound

Figure: CT angiogram demonstrating dissection at the arch of the aorta.FigureFigureFigureIf you'll remember, last month we discussed a 69-year-old woman who presented with extremity weakness in her left arm and right leg, and was subsequently found to be hypotensive. Initial evaluation in the ED revealed a normal head CT but a widened mediastinum on chest x-ray. Bedside ultrasound demonstrated that an intimal flap was present to the aorta. When we left the case last month, the patient was en route to radiology for an emergent CT angiogram of the aorta. The patient's CTA revealed a complex type A aortic dissection. The intimal flap extended into her left carotid, left subclavian, and right innominate arteries, and traveled distally through the abdominal aorta to occlude her right common femoral artery. Once these findings were discovered, she was immediately consented for emergent surgical repair. This case demonstrates some of the pitfalls in diagnosing acute aortic dissection. Classically, acute aortic dissection is described as a sudden tearing or ripping chest pain that is greatest at onset. Most patients are described as being hypertensive and having pulse deficits on presentation, but few patients actually present with this classic picture. Aortic dissection can be a great mimicker of other conditions depending on the anatomic distribution of the vessels affected. Patients can present with syncope, abdominal or flank pain, shortness of breath, neurologic symptoms resembling an acute CVA, or findings consistent with an acute ST segment myocardial infarction. Hypotension is an atypical finding in patients with aortic dissection, and is a red flag for complications. This patient's case provides us with the opportunity to review the possible etiologies of hypotension in dissection. Beginning proximally, a type A dissection can cause acute aortic regurgitation by involving the aortic valve. Acute aortic regurgitation causes an abrupt increase in left ventricular end-diastolic volume and subsequently causes acute heart failure, pulmonary edema, and cardiogenic shock. If the dissection involves the pericardium, pericardial effusion and resulting tamponade can cause profound hypotension. A dissection involving the ostia of the coronary arteries can also lead to acute myocardial ischemia and acute heart failure. Rupture is another serious and life-threatening cause of hypotension in aortic dissection. Increased shearing forces can lead to dissection through the adventitia and result in exsanguinations into the thoracic and abdominal cavities.Figure: View of the aortic valve demonstrating regurgitation.Figure: Reconstructed CT angiogram demonstrating the extensive nature of the dissection.Figure: Parasternal long axis view demonstrating presence of a pericardial effusion. The free wall of the right ventricle (arrow) can be seen to be bowed inward, indicating mass effect and possible tamponade.Diagnosing acute aortic dissection remains challenging in the ED because its presentation is often atypical. CT angiography is considered the test of choice, but bedside ultrasound can be used, as it was in this case to help confirm the diagnosis once it is considered. The abdominal aorta can be visualized from the xiphoid process to its bifurcation at approximately the umbilicus. It should be less than 3 cm with a smooth inner wall. The thoracic aorta can be more difficult to evaluate by ultrasound because of the surrounding lung, but it can be examined at its root (using the parasternal long axis cardiac view), at its arch (using the suprasternal view), and in a portion of its descent (in the apical cardiac view). These views should be examined for enlargement of the aorta and the presence of an intimal flap. Bedside ultrasound also has great power to evaluate for complications of dissection, most notably pericardial effusion and acute aortic regurgitation. An effusion can be quickly identified using standard cardiac windows (subxiphoid or parasternal views). Signs of tamponade include right atrial or ventricular collapse during diastole and IVC dilation from elevated right atrial pressure. Using the parasternal long axis or apical views, color Doppler can be applied to the aortic valve to assess for regurgitation. The patient in this case underwent an extensive repair of her aorta. She was transferred to the ICU in critical condition, and was weaned off mechanical ventilation over the next several weeks. She did well, and was discharged to a rehab facility. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

Left Ventricular Filling Pressure Assessed by Doppler Echocardiography as a Predictor of Inhospital Outcome in Patients of ST-segment Elevation Myocardial Infarction

Background: Left ventricular (LV) filling pressure is an important predictor of short and long term outcome in patients with coronary artery disease. Non invasive assessment of this pressure by Doppler echocardiography provides valuable information regarding the prognosis of patient with ST-segment elevation myocardial infarction. Elevated filling pressure is associated with increased incidence of morbidly and mortality due to ventricular remodeling, neuro-hormonal activation &amp; increased excitability. The aim of this study was to assess LV diastolic dysfunction and left ventricular filling pressure in patients of ST-segment elevation myocardial infarction to predict their in-hospital outcome. Methods: The prognostic cohort study was conducted in National Institute of Cardiovascular Diseases, Dhaka from May 2011 to November 2011. A total of 100 Patients with acute ST-segment elevation myocardial infarction who has received streptokinase therapy were enrolled by purposive sampling. In addition to normal 2D &amp; M mode study, Pulsed wave Doppler assessment of mitral valve inflow patterns was done in apical 4-chamber view to see Peak early (E) and peak late (A) flow velocities, E/A ratio and deceleration time of early mitral flow velocity (DT). Tissue Doppler Imaging (TDI) assessment was done at the lateral mitral annulus in apical 4-chamber view to assess Mitral annular diastolic velocity (E?) and E/E? ratio. Patients were divided into two groups based on Doppler echocardiography derived Left ventricular filling characteristics. In group I 50 patients with E/E? ratio &lt;15 and in group II 50 patients with E/E’ &gt;15. Patients were followed up for next 7 days and in-hospital outcomes were compared between groups. Results: The mean age of group-I &amp; II were 53.84 ± 9.2 &amp; 55.14 ± 8.5 years respectively. Male female ratio was 8.9:1.1. Age, sex and risk factors between two groups were statistically insignificant. Regarding in-hospital out come in group-I were hospital stay 5.28 ± 1.06 days, heart failure 28%, arrhythmia 8% and mortality was 2%. On the other hand in group-II hospital stay was 6.04±1.07 days, heart failure 68%, and arrhythmia 24% &amp; mortality was 6%. All these were statistically significant between two groups except mortality. Conclusion: From this study it may be concluded that, left ventricular filling pressure assessed by Doppler echocardiograph predicts in-hospital outcome after acute ST segment myocardial infarction and prognosis is worse with increased left ventricular filling pressure. DOI: http://dx.doi.org/10.3329/cardio.v7i2.22244 Cardiovasc. j. 2015; 7(2): 72-78

Prognostic significance and relationship of worst lead residual ST segment elevation with myocardial damage assessed by cardiovascular MRI in myocardial infarction

ObjectiveTo investigate the relation of residual worst lead ST segment elevation (WL-STE) after ST segment myocardial infarction (STEMI) with infarct size and microvascular injury assessed by cardiovascular magnetic resonance (CMR)...

Value of modified selvester QRS score in prediction of successful reperfusion in patients with acute myocardial infarction

Background Reperfusion therapy basically aims to restore full antegrade flow in the infarct-related epicardial coronary artery. The modified Selvester QRS score, basically developed to estimate infarct size, was used with good predictive value to predict ST-resolution in acute myocardial infarction (AMI) treated with fibrinolysis. However, little data are available about its role in predicting reperfusion in ST-segment myocardial infarction (STEMI) patients undergoing primary percutaneous coronary interventions (PCI). Objectives Was to examine the value of modified Selvester QRS score in predicting ST-segment resolution in patients with first acute STEMI after thrombolytic therapy or primary PCI. Methods Sixty patients with acute STEMI were enrolled in the study, 56 males and 4 females; and their mean age was 56.4 ± 8.4 years. We excluded patients with bundle branch block, paced rhythm, left fascicle block, ECG signs of ventricular hypertrophy, cardiogenic shock and prior STEMI. All patients were submitted to full history taken and clinical examination, admission 12-leads electrocardiography (ECG) with estimation of modified Selvester QRS score and sum of ST-elevation, another ECG after 90 minutes of thrombolysis with estimation of the sum of ST-elevation and ST-resolution, cardiac enzymes, thrombolysis for 45 patients and primary PCI for 15 patients, echocardiographic assessment with measuring of left ventricular ejection fraction (EF) and wall motion score index (WMSI), and coronary angiography. Results Population characteristics and risk factors for coronary artery disease (CAD) were comparable between the two groups. In patients with QRS score > 4, time to admission was significantly higher, EF was significantly lower, WMSI was significantly higher, number of patients with no ST-segment resolution was significantly lower, number of patients with myocardial blush grade (MBG) 1 was significantly higher, number of patients with MBG 3 was significantly lower, and number of patients with three-vessel disease was significantly higher. Sensitivity of QRS score ⩽ 4 in predicting ST-segment resolution ⩾ 50% was 59.3%, specificity was 100%, positive predictive value was 62.1%, negative predictive value was 86%, and overall accuracy was 75.6%. There was a highly significant negative correlation between ST-segment resolution and QRS score (r = −0.483, p = 0.00078). Conclusion Selvester QRS scoring system is regaining its clinical value in patients with first STEMI. It can provide valuable information as regard area of myocardium at risk, prediction of residual left ventricular function, making treatment decisions. Though somewhat difficult, it is worthy to calculate QRS score from admission ECG in every patient presenting with STEMI. In patients who are controversial as regard thrombolytic therapy, QRS score could help in determining those who will get benefit from such therapy.

The Relationship between Coronary Artery Movement Type andStenosis Severity with Acute Myocardial Infarction.

The severity of coronary artery stenosis which leads to myocardial infarction (MI) has been a matter of controversy. Historical data are in favor of mild luminal stenosis (<50% diameter stenosis) while recent studies suggest hemodynamically-significant coronary stenosis as the main substrate for subsequent MI. Also, mechanical stress resulted from coronary artery movement (CAM) may be responsible for plaques rupture. In this study, we evaluated the severity of plaques leading to MI and common CAM patterns in the involved coronary segments. In a cross-sectional descriptive-analytical study, on patients with acute ST-segment myocardial infarction (STEMI) undergoing coronary angiography, the relationship between coronary artery movement type and stenosis severity with acute MI was evaluated. Lesions with stenosis diameter greater than 50 percent were defined as moderate and those equal or higher than 70% were defined as severe stenosis. Three different patterns of coronary artery motion including compression, bending and displacement types were evaluated in segments with culprit lesion. One hundred and sixty two patients were enrolled. Ninety patients (55.6%) were male and 72 (44.4%) were female. Mean age of the patients was 60.56±13.43 years. In terms of Infarct related lesions (IRLs), 86% of the cases had at least moderate stenosis and in 67%, severe stenosis was present. More than 50% stenosis was found in all patients with anterior STEMI involving LAD. Among three types of coronary motion patterns, compression pattern was significantly higher in LAD (P<0.001), RCA (P<0.001), Diagonal artery (P<0.001) and OM branch (P=0.044), but not in proper LCX (P=0.307). Most of the lesions leading to myocardial infarction have a diameter stenosis of at least 50% and mainly are located in the coronary segments with compression movement pattern.

Shortest door-to-balloon time in primary percutaneous coronary intervention for a young resident physician suffering from in-hospital inferior ST-segment elevation myocardial infarction

Percutaneous coronary intervention (PCI) for patients with ST-segment myocardial infarction (STEMI) significantly improves clinical outcomes but can't possibly be accomplished in less than 20min for pre- and in-hospital delays[1]. Here we report a young resident physician of a tertiary referral hospital who suffered acute inferior STEMI and junctional bradycardia during working hours and was successfully rescued by primary PCI within a very short door-to-balloon period of 11min. Thus, with the patient's rapid presentation and the system's availability, acute STEMI could be intervened by primary PCI speedily, especially for those working in tertiary referral hospitals and having easier access to medical facilities.

Mitral regurgitation in acute ST segment myocardial infarction: It still matters

Mitral regurgitation in acute ST segment myocardial infarction: It still matters

“Register and Roll”: A Novel Initiative to Improve First Door-to-Balloon Time in ST Elevation Myocardial Infarction

Objective. We examined the cause of transfer delay in patients with an acute ST-segment myocardial infarction (STEMI) from non percutaneous coronary intervention (PCI) capable to PCI capable hospitals. We then implemented a novel, simple, and reliable initiative to improve the transfer process. Background. Guidelines established by the ACC/AHA call for door-to-balloon times of ≤90 minutes for patients with STEMI. When hospital transfer is necessary, this is only met in 8.6% of cases. Methods. All patients presenting with STEMI to a non-PCI capable hospital from April 2006 to February 2009 were analyzed retrospectively. After identifying causes of transfer delay the “Register and Roll” initiative was developed. An analysis of effect was conducted from March 2009 to July 2011. Results. 144 patients were included, 74 pre-initiative and 70 post- initiative. Time to EMS activation was a major delay in patient transfer. After implementation, the EMS activation time has significantly decreased and time to reperfusion approaches recommended goal (Median 114 min versus 90 min, P < 0.001), with 55% in <90 minutes. Conclusion. “Register and Roll” streamlines the triage process and improves hospital transfer times. This initiative is easily instituted and reliable in a community hospital setting where resources are limited.

Lack of long‐term clinical benefit of thrombus aspiration during primary percutaneous coronary intervention with paclitaxel‐eluting stents or bare‐metal stents: Post‐hoc analysis of the PASSION‐trial

Although current clinical guidelines recommend the use of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI), previous studies evaluating TA demonstrated contradictory results. The aim of this study was to evaluate long-term clinical outcome after TA in adjunct to PPCI for acute ST-segment myocardial infarction (STEMI), as compared with conventional treatment, with the use of paclitaxel-eluting stents or bare-metal stents. We analyzed data of the PASSION trial, in which 619 patients with STEMI were randomly assigned to a paclitaxel-eluting stent or a bare-metal stent. TA was performed in 311 patients (50.2%). Clinical endpoints at 2 years were compared between patients who received TA during PPCI with patients who underwent conventional PPCI. The primary outcome of interest was a composite of cardiac death, recurrent myocardial infarction (MI), or target-lesion revascularization (TLR). A propensity score model was made to account for baseline differences that could have affected the probability of performing TA. Complete follow-up was available for 598 patients (96.6%). The cumulative incidence of the combined outcome measure of cardiac death, recurrent MI, or TLR was 40 (13.0%) in the TA group and 41 (13.5%) in the conventional PPCI group (HR 0.96; 95% CI 0.62-1.47; P = 0.84). Also after adjusting for propensity score, no significant difference in event rate was observed between both treatment groups. In this post-hoc analysis of the PASSION trial, TA in adjunct to PPCI did not affect rates of major adverse cardiac events at 2 years follow-up, as compared with conventional PPCI.

Abstract P115: First Door-to-Balloon Time: Improving Door-to-Balloon Times in Patients Transferred for Primary Percutaneous Intervention

Objective: We sought to identify the cause of delay in the first door-to-balloon times (1stD2B) in patients presenting with an acute ST-segment myocardial infarction (STEMI) requiring transfer to a PCI capable hospital with post hoc implementation of novel yet simple and reliable initiative “Register and Roll” to improve the overall D2B. Background: National guidelines established by the ACC/AHA call for door-to-balloon (D2B) times of ≤ 90 minutes for patients presenting with STEMI undergoing PCI to facilitate timely reperfusion and salvage of the ischemic myocardium. In patients presenting to non-PCI capable hospitals the timely reperfusion (D2B ≤ 90 min) is met in only 8.6% of patients. Methods: A retrospective analysis was performed from April 2006 to May 2009 in all STEMI patients transferred for primary PCI (PPCI) to Providence Hospital's Heart Institute from non-PCI capable hospitals. Patient charts and available electronic records were reviewed. Patients under 18 years of age and those with indeterminate initial electrocardiogram were excluded. The” Register and Roll Initiative” designed to facilitate transfer to our PCI center was implemented in all transfer patients starting in June 2009 to December 2010. Results: A total of 148 patients were transferred for PPCI with 47 patients included post “Register and Roll”. Three local hospitals were involved in transferring of patients. The time to ECG, time to EMS activation, door-in-door-out, EMS transport time, and the first-door-to-balloon time were compared pre and post implementation. The door in-door out time played a major role in prolonging the time to reperfusion and after implantation; the patients were transferred sooner for PPCI resulting in improved 1stD2B. (140 min vs. 100 min, P &lt; 0.05) Conclusion: Our novel initiative, “Register and Roll”, to facilitate prompt transfer of STEMI patients for primary PCI involves simple guideline, a CATH KIT and EMS notification, which improved delays in door-in-door-out time. This initiative is simple and reliable to follow in a community hospital setting, where resources are limited. AHA's “Lifeline Mission” recommends every health system to implement their own methods to facilitate the transfer and achieve the goal.

Clinical Summaries

Clinical Summaries

Abstract 5335: Significant Decline in the Age Adjusted Mortality From Acute St Segment Elevation Myocardial Infarction in the United States Regardless of Race or Gender With Persistent Higher Mortality Rate for Female and African American Population

Back ground: Treatment of acute ST segment myocardial infarction (STEMI) has improved over the last 2 decades. The goal of this study was to determine trends in the mortality of patients with acute STEMI in the United States over the years based on gender and race. Method: The Nationwide Inpatient Sample (NIS) database was used to analyze the age adjusted mortality rates for STEMI from 1988 to 2004 for inpatients above the age of 40. ICD-9-CM codes consistent with acute STEMI were utilized. Results : A total of 163,915 hospital deaths occurred during the study period. From 1988 the age-adjusted mortality rate declined regardless of gender or race. However, women and African Americans had higher rate of acute STEMI related mortality in comparison to men and Caucasians over the years studied (For 1988 age adjusted mortality rate from STEMI for women was 508 per 100,000 vs. 371 per 100,000 in men. For 2004 age adjusted mortality rate from STEMI for women was 347 per 100,000 vs. 262 per 100,000 in men p&lt; 0.001). For 1988, age adjusted mortality rate from STEMI for Caucasians was 412 per 100,000 vs. 521 per 100,000 in African Americans. For 2004, age adjusted mortality rate from STEMI for Caucasians was 277 per 100,000 vs. 447 per 100,000 in African Americans, p&lt; 0.001, see figures ). Conclusion: Age adjusted mortality from acute STEMI has significantly declined over the last decade regardless of gender race with persistent higher mortality rate in women and African Americans over the years.