Angioplasty For Myocardial Infarction Research Articles

A tale of two culprits: a case report

Acute thrombotic closure of more than one coronary artery causing STEMI is an infrequent finding in coronary angiography during primary angioplasty in myocardial infarction (PAMI). We presented a case of 37 years old male with acute inferior wall myocardial infarction (IWMI) with complete heart block (CHB) with left ventricular failure (LVF). Coronary angiography showed thrombotic occlusion in right coronary artery (RCA) and circumflex arteries. Clinical condition improved only after percutaneous transluminal coronary angioplasty (PTCA) of both arteries. Given this unique presentation, the best management is not standardized. Further studies are needed to better predict outcomes and guide future management.

Study of Demographic Profile, Clinical Manifestations, and a Short-term Follow-up of Young Patients Presenting with Myocardial Infarction at a Tertiary Care Hospital

Background: The present study was undertaken to analyze the clinical manifestations, treatment, and outcome of young patients presenting with myocardial infarction (MI) at a tertiary care hospital. Materials and Methods: The present study was a cross-sectional, observational hospital-based study conducted on patients with MI younger than 40 years. Results: Among the 50 patients, there were 49 males and one female. The age group ranged from 25 to 40 years—most of the patients presented with typical chest pain. Dyslipidemia was the most common risk factor 64%, followed by hypertension 42%, smoking 30%, high altitude area (HAA) 18%, positive family history 12%, metabolic syndrome 06%, and chronic kidney disease 02%. Serial creatine kinase-MB was elevated in 33 (66%) patients and normal in 17 (34%) patients. Troponin T/I was positive in 41 (82%) patients and negative in 09 (18%) patients. On echocardiogram, almost all patients had regional wall motion abnormality. The left ventricular ejection fraction <30% (2%), 30%–40% (18%), 41%–50% (32%), and >50% (22%). All 50 patients underwent a coronary angiogram, 19 had small vessel disease (38%), and 30 had recanalized/slow flow noted in coronaries (60%). Most of the patients, 36 (72%), underwent thrombolysis and had evidence of recanalized coronaries on coronary angiography; one patient was taken up for primary angioplasty in MI, 14 patients underwent percutaneous transluminal coronary angioplasty with stenting. Conclusion: The study describes the clinic-demographic profile of MI in young. The role of dyslipidemia, hypertension, smoking, high altitude area, and positive family history may need further elucidation in these patients.

Changing Concepts in Treatment of ST-Segment Elevation Myocardial

ST-Segment Elevation Myocardial (STEMI) is a lifethreatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe, reperfusion as quickly as possible- the management process is complicated and is affected by multiple factors including location, patient and practitioners’ characteristics. Indeed, treatment of acute STEMI has progressed considerably over the past 100 years, from the early stages of bed rest and development of thrombolytics and myocardial reperfusion, to today’s current strategy with a variety of mechanical and pharmacologic modalities. But the debate continues regarding optimal antithrombotic/anticoagulant and interventional strategies employed. Given the scientific and technological advantages, treatment strategies can be catered to better suit the patient and their presentation. Fibrinolytic therapy did save the lives compared to placebo, but at best restored Thrombolysis in Myocardial Infarction (TIMI) 3 Flow in 55-70% cases with increased incidence of recurrent ischaemia and infarction and intracranial haemorrhage. From Primary Angioplasty in Myocardial Infarction (PAMI) to 23 RCTs of Thrombolysis in Myocardial Infarction (TIMI) Vs Lysis showed that there is significant reduction in death (7.0% Vs 9.3%), Re-infarction (2.5% Vs 6.8%), haemorrhagic stroke (0.1% Vs 1.0%) and total stroke (1.0%) in Percutaneous Coronary Intervention (PCI) group. STEMI success has plateaued because of suboptimal salvage of myocardium and high rates of non-culprit lesion related events and reperfusion injury. Promising approaches should be further explored like hypothermia, stem cell and super-saturated oxygen therapy and PiCSO to enhance myocardial recovery and reduce infarct size. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 182

Clinical Outcome of Revascularization Deferral With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A 5-Year Follow-Up Substudy From the iFR-SWEDEHEART Trial.

Background Although physiology-based assessment of coronary artery stenosis using instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) are established methods of guiding coronary revascularization, its clinical outcome in long-term deferral needs further evaluation, especially with acute coronary syndrome as a clinical presentation. The aim was to evaluate the long-term clinical outcome of deferral of revascularization based on iFR or FFR. Methods and Results This is a substudy of the iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trial, where patients deferred from revascularization from each study arm were selected. Nine hundred eight patients deferred from coronary revascularization with iFR (n=473) and FFR (n=435) were followed for 5 years. The national quality registry, SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), was used for patient data collection and clinical follow-up. The end point was major adverse cardiac events and their individual components all-cause death, cardiovascular death, noncardiovascular death, nonfatal myocardial infarction, and unplanned revascularization. No significant difference was found in major adverse cardiac events (iFR 18.6% versus FFR 16.8%; adjusted hazard ratio, 1.08 [95% CI, 0.79-1.48]; P=0.63) or their individual components. Conclusions No differences in clinical outcomes after 5-year follow-up were noted when comparing iFR versus FFR as methods for deferral of coronary revascularization in patients presenting with stable angina pectoris and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166736.

Severe Acute Respiratory Syndrome Coronavirus 2 Antibodies in ST-segment Elevation Myocardial Infarction Patients and its Impact on Thrombus in the Coronaries

Objective: Higher thrombus load and poorer outcomes have been reported in coronavirus disease 2019 (COVID-19) patients with ST-segment elevation myocardial infarction (STEMI). The presence of antibodies to the COVID-19 infection has been linked to excess thrombus. This retrospective study compared the thrombus burden and outcomes in STEMI during primary angioplasty in myocardial infarction (PAMI) between the two groups with Sars antibody positive (SAP) and Sars antibody negative (SAN). Materials and Methods: Consecutive STEMI patients undergoing PAMI from November 2020 to July 2021 admitted to this single center were included. All patients were ruled out for an active infection by a negative rapid antigen and subsequently by reverse transcription polymerase chain reaction test. Participants were divided into SAP and SAN groups based on COVID-19 antibody results performed with the Roche kit. The primary aim was to compare thrombus load, coronary risk factors, and demographic characteristics between SAP and SAN patients and the secondary aim was to compare the inhospital and 30-day mortality between the two groups after primary percutaneous coronary intervention (PPCI). Results: The study included 261 consecutive STEMI patients (≥18 years; average age: 60.32 + 11.5 [standard deviation]). COVID antibody test results were available for 177 patients (36 SAP and 141 SAN), and these patients were included in the analysis; 144 were male, and 33 were female. There was no significant difference in baseline demographic characteristics between the two groups. Inflammatory markers, such as C-reactive protein (P = 0.479), troponin-T (P = 0.466), or D-dimer (P = 0.681) levels, and thrombus load status (G0 to G5) were not statistically significantly different (P = 0.344) between the two groups. Two patients in the SAP group and none in the SAN group (P = 0.005) died. The 30-day mortality rate (one patient in each group; P = 0.272) was not statistically significantly different between the two groups. Conclusion: Positive COVID-19 antibody levels in the blood did not produce changes in thrombus load and presentation in STEMI PAMI patients. The inhospital mortality rates and 30-day mortality rates were not affected by the antibody levels to COVID-19 infection.

Safety of early hospital discharge following admission with ST-elevation myocardial infarction treated with percutaneous coronary intervention: a nationwide cohort study.

The Second Primary Angioplasty in Myocardial Infarction (PAMI-II) risk score is recommended by guidelines to identify low-risk patients with ST-elevation myocardial infarction (STEMI) for an early discharge strategy. We aimed to assess the safety of early discharge (≤2 days) for low-risk STEMI patients treated with primary percutaneous coronary intervention (PCI). Using nationwide data from the SWEDEHEART registry, we identified patients with STEMI treated with primary PCI during the period 2009-2017, of whom 8,092 (26.4%) were identified as low risk with the PAMI-II score. Low-risk patients were stratified according to their length of hospital stay (≤2 days vs >2 days). The primary endpoint was major adverse cardiovascular events (MACE, including death, reinfarction treated with PCI, stroke or heart failure hospitalisation) at one year, assessed using a Cox proportional hazards model with propensity score as well as an inverse probability weighting propensity score of average treatment effect to adjust for confounders. A total of 1,449 (17.9%) patients were discharged ≤2 days from admission. After adjustment, the one-year MACE rate was not higher for patients discharged at >2 days from admission than for patients discharged ≤2 days (4.3% vs 3.2%; adjusted HR 1.31, 95% confidence interval [CI]: 0.92-1.87, p=0.14), and no difference was observed regarding any of the individual components of the main outcome. Results were consistent across all subgroups with no difference in MACE between early and late discharge patients. Nationwide observational data suggest that early discharge of low-risk patients with STEMI treated with PCI is not associated with an increase in one-year MACE.

Large-Bore Aspiration Thrombectomy: Catalyst for a Revolution in Treating Pulmonary Embolism

Large-Bore Aspiration Thrombectomy: Catalyst for a Revolution in Treating Pulmonary Embolism

Can we simplify or improve long-term risk stratification for patients with ST-segment elevation myocardial infarction undergoing primary intervention?

Abstract Background Various scores have been developed to predict early to mid-term prognosis after ST-elevation myocardial infarction (STEMI). The aim of this study was to compare the predictive value of 7 popular risks scores for the long-term outcome of STEMI patients undergoing primary intervention, and to find an easy model with similar or superior predictive and discriminative ability. Methods Patients who underwent primary PCI from January 2003 through August 2007 in a single tertiary-center were analysed (n=665) using a dedicated prospective registry. Global Registry for Acute Coronary Events (GRACE), GRACE 6 months, Thrombolysis In Myocardial Infarction (TIMI) STEMI, dynamic TIMI, TIMI risk index, Primary Angioplasty in Myocardial Infarction (PAMI) and Zwolle primary percutaneous coronary intervention (PCI) index were calculated for each patient. We assessed, through the C statistic in receiver-operating characteristic analysis, the predictive accuracy of these scores using all-cause mortality at 5 year as an endpoint. With multivariate regression analysis the variables with highest predictive ability were applied to build a model. Results All-cause mortality at 5 years after primary PCI was 22.1%. The risk scores showed moderate predictive ability, GRACE (0.759, 95% confidence interval (CI) 0.712–0.805), GRACE 6 months (0.802, 95% CI 0.759–0.845), TIMI STEMI (0.744, 95% CI 0.696–0.791), dynamic TIMI (0.774, 95% CI 0.727–0.820), TIMI risk index (0.757, 95% CI 0.710–0.803), PAMI (0.753, 95% CI 0.707–0.800) and Zwolle index (0.749, 95% CI 0.703–0.795). Six independent predictors of 5-year mortality were identified (age >70 years, history of MI, history of stroke, heart tare above 85 beats per min, 3-vessel disease and in-hospital adverse events) and the model built had similar discriminative performance in estimation of probabilities of death (0.804, 95% CI 0.762–0.846, p=0.953 for difference with GRACE score). Conclusions The prediction values of currently recommended risk scores are moderate for long-term perspective (5-year). The simplified risk stratification score for STEMI and primary angioplasty using only six variables demonstrates accuracy similar to the more advanced risk scores. Funding Acknowledgement Type of funding sources: None.

Clinical and Angiographic Profile of Acute Coronary Syndrome Patients (<40 Years) and Short-Term Prognosis

Background: The rapidly changing economic stature and lifestyle choices of young individuals have affected healthcare in India. An increased prevalence of acute coronary syndrome (ACS) in young individuals has been observed. Aims and Objectives: The present cross-sectional, observational study was designed to record the clinical and angiographic profiles of young individuals (<40 years) with ACS. Materials and Methods: This cross-sectional, observational study was also designed to analyze the associations of lifestyle risk factors such as obesity, smoking, and alcohol on the occurrence of ACS and short-term (1 month) prognosis (rehospitalization and mortality). The inclusion criteria were age between 18 and 40 years with angina pectoris or equivalent at presentation and later diagnosed ACS per the consensus paper from the European Society of Cardiology/American College of Cardiology/American Heart Association/World Heart Federation joint task force. Patients with a previous history of ACS/coronary revascularization, atypical chest pain, valvular heart disease, hypertrophic cardiomyopathy, and/or congenital heart disease were excluded. Results: Out of the 403 patients that were screened, 162 young patients (18–40 years, mean ± standard deviation: 31.5 ± 4.64) were enrolled from a single tertiary cardiac care center located at Pune, Maharashtra, from May 2014 to May 2016. Most of the patient population were males (n [%]:151 [93.2]) of which 50% had positive addiction status for alcohol and smoking, family history of coronary artery disease (CAD) and a quarter of the patients had comorbidities of diabetes mellitus, hypertension, and/or abnormal lipid profile. The majority of the young ACS patients had ST-elevated myocardial infarction (STEMI: 87%), wherein anterior wall myocardial infarction was the most common electrocardiogram presentation, and primary angioplasty in myocardial infarction (PAMI) was the preferred modality of treatment in most of the young patients (61.7% vs. 38.3% thrombolysis). Conclusion: The prevalent angiographic profile of this study participants included obstructive CAD, single vessel disease, left ventricular ejection fraction (LVEF) <45, Angina Class IV, New York Heart Association (NYHA) class I, and Killip class I. Low LVEF, NYHA class IV, and Killip class IV showed association with short-term outcomes (mortality). The present study adds to the pool of information related to the western Indian population. However, a larger cohort study with a long-term follow is warranted to analyze the detailed ACS progression status in young individuals.

Clinical Profile and Approach to Osteal LAD Lesion During Primary Angioplasty in Myocardial Infarction (PAMI)

Isolated Coronary Artery Stenoses (CAS) involving the ostium of the Left Anterior Descending (LAD) artery is very challenging, especially in a setting of primary Angioplasty in Myocardial Infarction (PAMI). Intimal atherosclerosis in the Left Main Coronary Artery (LMCA) bifurcation is primarily in area of low shear stress which is the lateral wall, close to the LAD and Left Circumflex (LCx). Thus, carina is usually free of disease, which can explain why single-stent strategy can be successful. However, precise stent placement is often difficult due to unwanted stent movement within vessel or its proximity to side branches. A decision must be made at the outset, to decide on the approach to be employed, to treat osteal LAD lesions. Limited data is available on patients undergoing primary PCI of osteal LAD lesions. Here, we present our experience and problems encountered during the management of osteal LAD lesions in the setting of PAMI.

Predictive Power of In-Hospital and Long-Term Mortality of the GRACE, TIMI, Revised CADILLAC and PAMI Score in NSTEMI Patients with Diabetes - Data from TSOC ACS-DM Registry.

Risk score is widely used in non-ST segment elevation myocardial infarction (NSTEMI) patients to predict the in-hospital outcome for immediate coronary angiography decision and care of unit selection. This study compared the performances of the thrombolysis in myocardial infarction (TIMI), Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), and Revised Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (Revised CADILLAC) risk scores in predicting in-hospital and long-term outcomes in diabetic NSTEMI patients. A total of 750 diabetic NSTEMI patients from 27 hospitals were enrolled between January 2013 and December 2015 in the nationwide registry initiated by the Taiwan Society of Cardiology. Four score systems were calculated with receiver operator characteristic analysis used to compare outcome discrimination performance. No studied risk scores reached acceptable discrimination per area under curve (AUC) in the prediction of in-hospital outcome except for the revised CADILLAC score which reached acceptable discrimination in new-onset cardiogenic shock (AUC = 0.7191) and acute renal failure (AUC = 0.7283). In long-term outcomes, only the revised CADILLAC score reached acceptable discrimination of mortality prediction at 6, 12 and 24 months (AUC = 0.7261 at 6 months, 0.7319 at 12 months, and 0.7256 at 24 months). Subgroup analysis based on the revised CADILLAC score risk class showed a significant difference in adjusted mortality rate between low-risk group/intermediate-risk group and high-risk group. Only the revised CADILLAC score showed acceptable accuracy to predict the long-term mortality outcome among the scores studied.

Fractional flow reserve-guided multivessel angioplasty in myocardial infarction: three-year follow-up with cost benefit analysis of the Compare-Acute trial.

The Compare-Acute trial showed superiority of fractional flow reserve (FFR)-guided acute complete revascularisation compared to culprit-only treatment in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) at one year. The aim of this study was to investigate the outcome at three years, together with cost analysis of this strategy. After primary percutaneous coronary intervention (PCI), 885 patients with STEMI and MVD were randomised (1:2 ratio) to FFR-guided complete revascularisation (295 patients) or infarct-related artery (IRA)-only treatment (590 patients). After 36 months, the primary endpoint (composite of death, myocardial infarction, revascularisation, stroke) occurred significantly less frequently in the FFR-guided complete revascularisation group: 46/295 patients (15.6%) versus 178/590 patients (30.2%) (HR 0.46, 95% CI: 0.33-0.64; p<0.001). This benefit was driven mainly by the reduction of revascularisations in the follow-up (12.5% vs 25.2%; HR 0.45, 95% CI: 0.31-0.64; p<0.001). Cost analysis shows benefit of the FFR-guided complete revascularisation strategy, which can reduce the cost per patient by up to 21% at one year (8,150€ vs 10,319€) and by 22% at three years (8,653€ vs 11,100€). In patients with STEMI and MVD, FFR-guided complete revascularisation is more beneficial in terms of outcome and healthcare costs compared to IRA-only revascularisation at 36 months.

Timely discharge of low-risk STEMI patients admitted for primary PCI in an Essex cardiothoracic centre.

Data for low-risk ST-elevation myocardial infarction (STEMI) patients in the Essex cardiothoracic centre (CTC) during a three-month period were evaluated and the average duration of admission was calculated to be 67.2 hours. The data were sifted by applying Second Primary Angioplasty in Myocardial Infarction (PAMIII) criteria for low-risk STEMI patients who could be safely discharged after 48 hours. After application of a proforma as a quality improvement intervention tool, data were re-assessed and the average time of admission observed for a similar cohort of patients dropped down to an average of 55.2 hours. Overall, there was a 13% average increase in rate of early discharge for low-risk STEMI patients.

Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort.

BackgroundEarly risk stratification after primary percutaneous coronary intervention (PPCI) for ST‐segment–elevation myocardial infarction is currently challenging. Identification of a low‐risk group may improve triage of patients to alternative clinical pathways and support early hospital discharge. Our aim was to assess whether the index of microcirculatory resistance (IMR) at the time of PPCI can identify patients at low risk of early major cardiac complications and to compare its performance against guideline‐recommended risk scores.Methods and Results IMR was measured using a pressure–temperature sensor wire. Cardiac complications were defined as the composite of cardiac death, cardiogenic shock, pulmonary edema, malignant arrhythmias, cardiac rupture, and presence of left ventricular thrombus either before hospital discharge or within 30‐day follow‐up. In total, 261 patients undergoing PPCI who were eligible for coronary physiology assessment were prospectively enrolled. Twenty‐two major cardiac complications were reported. Receiver operating characteristic curve analysis confirmed the utility of IMR in predicting complications and showed significantly better performance than coronary flow reserve, the Primary Angioplasty in Myocardial Infarction II (PAMI‐II), and Zwolle score (P≤0.006). Low microvascular resistance (IMR ≤40) was measured in 159 patients (61%) of the study population and identified all patients who were free of major cardiac complications (sensitivity: 100%; 95% CI, 80.5–100%).Conclusions IMR immediately at the end of PPCI for ST‐segment–elevation myocardial infarction reliably predicts early major cardiac complications and performed significantly better than recommended risk scores. These novel data have implications for early risk stratification after PPCI.

The Compare-Acute trial of fractional flow reserve-guided multivessel angioplasty in myocardial infarction.

The Compare-Acute trial demonstrates the relative safety and utility of performing multivessel FFR to examine the significance of non-culprit lesions during primary PCI. Patients who had an FFR-guided PCI strategy for non-culprit lesions during the index hospitalisation had fewer adverse cardiovascular events, essentially unplanned revascularisations, as compared to patients who were treated for the infarct-related artery only.

Complete Immediate Revascularization of the Patient With ST-Segment-Elevation Myocardial Infarction Is the New Standard of Care.

Opposing Viewpoint, see p 1574 Approximately half of patients with ST-segment–elevation myocardial infarction (STEMI) have angiographically significant multivessel disease and, in these patients, the European (2012) and US (2013) guideline recommendations have been that only the culprit artery should be treated acutely. In the setting of cardiogenic shock, the guidelines recommend treating any nonculprit arteries to achieve as complete a revascularization as possible. Both of these recommended strategies are based on level C evidence (observational studies and consensus opinion). In the past 4 years, there have been 3 new randomized trials that have contributed to the knowledge base in this area (Table). View this table: Table. Contemporary Randomized Controlled Trials of Culprit-Only Percutaneous Coronary Intervention Versus Complete Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction The PRAMI trial (Preventive Angioplasty in Myocardial Infarction) was a UK-based multicenter randomized trial of culprit only percutaneous coronary intervention (PCI) in comparison with immediate complete revascularization. On the recommendation of the data safety and monitoring board, recruitment to the PRAMI trial was halted in January 2013, after 465 patients had been randomly assigned. After an average of 2 years follow-up, the relative risk reduction in the primary end point of cardiovascular death, nonfatal myocardial infarction (MI), and refractory ischemia in patients randomly assigned to complete revascularization was 65% ( P <0.001), more than double that estimated in the original power calculation. The between-group difference in the secondary end point of cardiovascular death and nonfatal MI remained statistically significant ( P <0.001).1 The CvLPRIT (Complete versus Lesion-only Primary …

Fractional Flow Reserve–Guided Multivessel Angioplasty in Myocardial Infarction

BackgroundIn patients with ST-segment elevation myocardial infarction (STEMI), the use of percutaneous coronary intervention (PCI) to restore blood flow in an infarct-related coronary artery improves outcomes. The use of PCI in non–infarct-related coronary arteries remains controversial.MethodsWe randomly assigned 885 patients with STEMI and multivessel disease who had undergone primary PCI of an infarct-related coronary artery in a 1:2 ratio to undergo complete revascularization of non–infarct-related coronary arteries guided by fractional flow reserve (FFR) (295 patients) or to undergo no revascularization of non–infarct-related coronary arteries (590 patients). The FFR procedure was performed in both groups, but in the latter group, both the patients and their cardiologist were unaware of the findings on FFR. The primary end point was a composite of death from any cause, nonfatal myocardial infarction, revascularization, and cerebrovascular events at 12 months. Clinically indicated elective revascularizations performed within 45 days after primary PCI were not counted as events in the group receiving PCI for an infarct-related coronary artery only.ResultsThe primary outcome occurred in 23 patients in the complete-revascularization group and in 121 patients in the infarct-artery-only group that did not receive complete revascularization, a finding that translates to 8 and 21 events per 100 patients, respectively (hazard ratio, 0.35; 95% confidence interval [CI], 0.22 to 0.55; P<0.001). Death occurred in 4 patients in the complete-revascularization group and in 10 patients in the infarct-artery-only group (1.4% vs. 1.7%) (hazard ratio, 0.80; 95% CI, 0.25 to 2.56), myocardial infarction in 7 and 28 patients, respectively (2.4% vs. 4.7%) (hazard ratio, 0.50; 95% CI, 0.22 to 1.13), revascularization in 18 and 103 patients (6.1% vs. 17.5%) (hazard ratio, 0.32; 95% CI, 0.20 to 0.54), and cerebrovascular events in 0 and 4 patients (0 vs. 0.7%). An FFR-related serious adverse event occurred in 2 patients (both in the group receiving infarct-related treatment only).ConclusionsIn patients with STEMI and multivessel disease who underwent primary PCI of an infarct-related artery, the addition of FFR-guided complete revascularization of non–infarct-related arteries in the acute setting resulted in a risk of a composite cardiovascular outcome that was lower than the risk among those who were treated for the infarct-related artery only. This finding was mainly supported by a reduction in subsequent revascularizations. (Funded by Maasstad Cardiovascular Research and others; Compare-Acute ClinicalTrials.gov number, NCT01399736.)

The Impact of the ‘PRAMI’ Trial on Interventional Practice in Patients with ST Elevation Myocardial Infarction at a University Hospital

Background: Randomized controlled trials, notably PRAMI (Randomized trial of preventive angioplasty in myocardial infarction) demonstrated that immediate percutaneous coronary intervention (PCI) in significantly stenosed non-culprit vessels in patients with ST elevation myocardial infarction (STEMI) reduces adverse outcomes. However, the impact on clinical practice is unknown. Aims: To investigate whether the number of immediate and staged non-culprit PCIs has changed after the publication of PRAMI and the impact on mortality. Methods: A retrospective analysis of STEMI patients with significant multi-vessel disease presenting 1 year before and after PRAMI were included. Patients were divided into those who had immediate PCI, staged PCI or medical management of the non-culprit vessel. Mortality data for each patient group was analyzed. Results: Significant multi-vessel disease was present in 426 patients, with 202 patients in the pre-PRAMI group and 224 in the post-PRAMI group. The number of immediate non-culprit PCIs pre- PRAMI was 9.4% and increased to 12.5% post- PRAMI [p=ns]. Combining both groups, immediate PCI of the non-culprit vessel was associated with higher mortality than staged PCI [p=0.005]. There was no significant difference in all cause mortality in patients having non-culprit vessel PCI (immediate or staged) when compared to the medically managed cohort. Conclusion: Our center demonstrated a trend towards increased immediate PCI of the non-culprit vessel during the index procedure however, this practice was not widely adopted as recommended by PRAMI. Immediate PCI of non- culprit vessels was associated with increased mortality compared with staged PCI or medical management. However, given the small number of patients undergoing Immediate PCI, larger trials are required to confirm our results.

An Interview with Robert Califf.

In the late 1970s, when Robert Califf was in medical school, the heart was still a kind of medical terra incognita. Most cardiologists believed that a class of untimely heartbeats, known as premature ventricular contractions (PVCs), could predict sudden cardiac death. During his third year at Duke University Medical School, Califf, and his colleagues, showed that impaired left ventricular function was the true culprit. A few years later, as new clot-busting agents were being developed, Califf, by then a Duke faculty member, and colleagues predicted that one of the drugs, tissue plasminogen activator (tPA), would be most effective when followed immediately by angioplasty. They ran a multicenter clinical trial—the first of a series collectively known as Thrombolysis and Angioplasty in Myocardial Infarction (TAMI)—which showed the opposite: waiting to do the artery-opening procedure led to better outcomes. Inspired by the power of clinical trials to topple even his own beliefs, Califf embarked, with colleagues, on an ambitious series of groundbreaking trials comparing tPA and another clot-buster, streptokinase. The study—known as the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO)—established the superiority of tPA and also Califf's reputation as one of the most creative clinical scientists of his generation. In 1995, he founded the Duke Clinical Research Institute, which has grown to become one of the world's largest academic research organizations, having enrolled more than 1.2 million participants in 65 countries and with over 1300 employees. Admired for his ability to bring people from academia and clinical medicine together with members of industry—a connection that caused some to object when he was later nominated by President Obama for the post of Commissioner of the Food and Drug Administration (FDA)—Califf is also one of the top 10 most cited medical authors. Until recently, he continued to see patients …

Stenting the Non-Culprit Lesion during Primary Angioplasty of the Infarct-Related Coronary Artery: The Long and Winding Road

Submit Manuscript | http://medcraveonline.com J Cardiol Curr Res 2015, 4(3): 00141 treatment of choice for ST-segment elevation myocardial infarction (STEMI) [3]. Considering the fact that patients with multivessel coronary heart disease (CHD) comprise over half of the STEMI population, it is not an uncommon finding to observe a significant non-culprit lesion besides the occluded infarctrelated coronary artery during primary PCI. These patients with multivessel disease in this context have a worse prognosis than patients with single vessel disease [4,5]. Now, the problem is what to do with the non-culprit significant stenosis once the infarctrelated coronary artery was already treated. Should we proceed and stent the non-culprit lesion turning unstable a coronary plaque that was previously stable and jeopardize another wall in a patient that already has an infarcted territory? It seems logical to think that treating all significant coronary stenosis would provide a better clinical outcome. However, although there is recent data in favor of this therapeutic management, the 2013 ACCF/ AHA guidelines for the management of ST-elevation myocardial infarction discouraged this approach due to a significant increase in adverse outcomes for patients undergoing multivessel PCI in the setting of STEMI, and recommended a restrictive approach that discourages treatment of non-culprit lesions during the index PCI, unless the patient is in cardiogenic shock [6]. Moreover, the 2014 ESC/EACTS guidelines on myocardial revascularization are in accordance with the latter approach [7]. They stated that evidence supporting immediate (preventive) intervention in noninfarct-related lesions is a matter of debate [8,9]. On the other hand, patients with extensive CHD in vessels remote from the infarct-related artery have reduced success in reperfusion and an adverse prognosis following primary PCI [8]. They concluded that at present, multivessel PCI during STEMI should be considered in patients with cardiogenic shock in the presence of multiple, critical coronary stenosis, and if there is persistent ischemia after PCI on the supposed culprit lesion [6]. It is well known that patients with stable CHD and multivessel disease benefit from achieving complete revascularization [1013]. The question is if this assumption also holds true in the setting of STEMI if a more aggressive approach leading to more complete revascularization is performed. This is a controversial subject if we analyze current data based on observational studies and compare them to the results of recent randomized clinical trials in the era of drug eluting stents. In fact, observational data suggested that this approach was not beneficial and might be even harmful, with slightly better outcome depending on the timing of the nonculprit PCI [14,15]. On the other hand, recent evidence obtained from randomized trials documented significant reductions in composite ischemic endpoints by performing multivessel revascularization during STEMI [16,17]. However, there had been some inconsistencies in the analysis of the results. For example, the PRAMI (Preventive Angioplasty in Myocardial Infarction) trial [16], was stopped prematurely due to a much higher than expected treatment efficacy. They found a 65% reduction in ischemic events with complete revascularization during the index PCI in 465 patients. It seems a little surprising to achieve such high statistically significant results with a relatively small number of patients and of clinical events raising concerns of a chance finding magnified by the early termination of the trial. In addition, the CVLPRIT (Complete Versus Lesion-Only Primary PCI) trial [17] did not show reductions in hard endpoints, and the benefit demonstrated in the composite endpoint was obtained by repeat revascularizations. This open-label clinical trial randomized 296 patients in 7 UK centers to either inhospital complete revascularization (n: 150), or culprit lesiononly revascularization (n: 146). Complete revascularization was performed in the index hospitalization either at the time of primary PCI or before hospital discharge. The primary endpoint of mortality, recurrent myocardial infarction, heart failure, or ischemia-driven revascularization within 12 months occurred in Editorial