Clinical Outcomes In ST-segment Elevation Myocardial Infarction Patients Research Articles

Treatment and Care of Patients with ST-Segment Elevation Myocardial Infarction—What Challenges Remain after Three Decades of Primary Percutaneous Coronary Intervention?

Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment elevation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital cardiac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.

Impact of Total Ischemic Time on No Reflow Phenomenon

Background: Ischemic heart disease, particularly ST-segment elevation myocardial infarction (STEMI), remains a major cause of morbidity and mortality globally. Despite advancements in primary percutaneous coronary intervention (PPCI), the no-reflow phenomenon, characterized by inadequate myocardial reperfusion despite successful vessel recanalization, continues to pose significant challenges, affecting clinical outcomes adversely. Objective: This study aims to investigate the relationship between total ischemic time and the incidence of the no-reflow phenomenon in STEMI patients undergoing PPCI, to identify potential strategies for improving therapeutic outcomes. Methods: Conducted at Hayatabad Medical Complex, Peshawar, this retrospective cohort study included 160 STEMI patients treated over eight months (February to October 2022). We collected data on demographic characteristics, clinical presentation, and outcomes. Inclusion criteria were patients over 18 years, undergoing PPCI within 12 hours of symptom onset, without prior MI, severe bleeding disorders, or previous significant revascularization. Statistical analysis was performed using SPSS 25.0, considering P ≤0.05 as statistically significant. Results: The average total ischemic time was significantly longer in patients experiencing no-reflow (Group I, 7.91 hours) compared to those with normal reperfusion (Group II, 3.41 hours) (P=0.001). Group I also showed higher rates of cardiogenic shock (17.6% vs. 6.8%, P=0.012) and reinfarction (11.8% vs. 2.9%, P=0.010). Mortality was significantly higher in Group I (5.8% vs. 1.9%, P=0.020). Conclusion: Longer total ischemic time is associated with an increased risk of the no-reflow phenomenon and poorer clinical outcomes in STEMI patients. Reducing ischemic time could be crucial in improving reperfusion success and reducing complications post-PPCI.

Impact of Total Ischemic Time on Clinical Outcome in Stemi Patients Undergoing Percutaneous Coronary Intervention

Background: ST-segment elevation myocardial infarction (STEMI) represents a critical condition requiring prompt treatment to minimize myocardial damage. Percutaneous coronary intervention (PCI) is the preferred reperfusion strategy, with the total ischemic time (TIT) being a crucial determinant of clinical outcomes. Despite the recognized importance of minimizing door-to-balloon (DTB) time, the impact of TIT on STEMI outcomes necessitates further exploration. Objective: This study aimed to evaluate the association between TIT and clinical outcomes in STEMI patients undergoing PCI, specifically focusing on all-cause mortality, re-hospitalization, and revascularization rates. Methods: A descriptive study was conducted at the cardiology ward of Lady Reading Hospital from May 2023 to October 2023. Ninety patients diagnosed with STEMI and undergoing PCI were enrolled. Patients were excluded if they had a history of cardiac surgeries or a DTB time >90 minutes. TIT was categorized into ≤120 minutes (Group A) and >120 minutes (Group B). Clinical outcomes assessed at 6 months post-PCI included all-cause mortality, cardiac mortality, re-hospitalization, and revascularization. Data were analyzed using SPSS version 25, employing Chi-Square tests for categorical variables, with a p-value ≤ 0.05 considered statistically significant. Results: Among the participants, Group A (TIT ≤ 120 mins) comprised 33 patients, while Group B (TIT > 120 mins) included 57 patients. Increased TIT was associated with higher rates of all-cause mortality (21.1% in Group B vs. 6.1% in Group A, p=0.05), re-hospitalization (22.8% vs. 6.1%, p=0.04), and revascularization (29.8% vs. 12.1%, p=0.05). Cardiac mortality was also higher in Group B (10.5%) compared to Group A (3.0%), though this difference was not statistically significant (p=0.20). Conclusion: The study highlights the significant impact of TIT on the prognosis of STEMI patients undergoing PCI. Shorter TIT is associated with markedly better clinical outcomes, emphasizing the need for healthcare systems to adopt strategies that reduce both pre-hospital and in-hospital delays.

Impact of the Integrated Activation System on Door-to-Balloon Times and Clinical Outcomes in STEMI Patients Receiving Primary PCI.

The door-to-balloon (D2B) time is a critical quality measure in managing ST-segment elevation myocardial infarction (STEMI) patients receiving primary percutaneous coronary intervention (PCI). We developed an integrated STEMI activation system, named Acute Myocardial Infarction Software Aids (AMISTAD), to optimize care for STEMI patients. This study aimed to evaluate the impact of the AMISTAD system on D2B times and clinical outcomes. We retrospectively collected data of consecutive STEMI patients receiving primary PCI between July 2017 and December 2018 at a single center. The patients were categorized into AMISTAD and non-AMISTAD groups. Outcomes included D2B time, length of hospital stay, and 12-month cardiovascular outcomes. Data were analyzed using multiple regression models; subgroup and sensitivity analyses were applied to examine the robustness of the results. A total of 114 STEMI patients were enrolled (38 AMISTAD, 76 non-AMISTAD). The AMISTAD group had a significantly shorter mean D2B time (66.7 ± 13.2 vs. 76.6 ± 24.9 minutes, p = 0.02) and non-significantly shorter length of hospital stay (4.7 vs. 7.2 days, p = 0.09). The 12-month cardiovascular outcomes between the two groups were not significantly different (adjusted hazard ratio 0.79, 95% confidence interval 0.30-2.09, p = 0.64). Subgroup and sensitivity analyses had consistent outcomes. Integrating the AMISTAD system into the STEMI workflow was associated with a reduced D2B time and shorter hospital stay. Further research involving larger cohorts and extended follow-up periods is needed to assess the generalizability and impact on cardiovascular outcomes. The AMISTAD system has the potential to improve the quality of care for STEMI patients.

Pretreatment with parenteral anticoagulation in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

Abstract Background and Aim According to ESC guidelines, parenteral anticoagulation is recommended for all patients presenting with ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (PPCI). However, no specific recommendations are made regarding the timing of administration. In fact, whether upstream anticoagulation improves clinical outcomes in STEMI patients is not well established. We conducted a systematic review and meta-analysis of current evidence on parenteral anticoagulation timing for patients presenting with STEMI. Methods We performed a systematic search of electronic databases (PubMed, CENTRAL and Scopus) until December 2022. Studies were considered eligible if they a) compared upstream anticoagulation with administration at the catheterization lab; and b) enrolled patients with STEMI undergoing PPCI. Studies comparing different anticoagulants were excluded from the analysis. Random-effects meta-analyses were performed. Efficacy outcomes included TIMI flow-grade pre- and post-PPCI, in-hospital cardiogenic shock (CS) and 30-day all-cause mortality. Safety outcome was defined as major in-hospital bleeding events. Results Overall, 9 studies were included (all non-randomized), with a total of 69,571 patients (30,693 in the pretreatment arm). In all but one, anticoagulation strategy was exclusively based on unfractionated heparin. Pretreatment was associated with a significant reduction in the incidence of 30-day all-cause mortality (OR 0.61; 95% CI 0.47-0.80; p<0.001) and in-hospital CS (OR 0.69; 95% CI 0.59-0.81; p<0.001). Upstream anticoagulation was also associated with a significant increase of spontaneous reperfusion of the culprit artery before PPCI (pre-PPCI TIMI > 0: OR 1.47; 95% CI 1.35-1.60; p<0.001) and TIMI flow ≥ 2 after coronary intervention (OR 1.28; 95% CI 1.05-1.56; p=0.016). Regarding safety outcomes, pretreatment was not associated with an increase of in-hospital major bleeding (OR 1.01; 95% CI 0.70-1.44; p=0.970). Multiple sensitivity analyses, including propensity-matched populations, showed consistent results. Conclusions Upstream anticoagulation was associated with a significant lower risk of 30-day all-cause mortality, incidence of in-hospital cardiogenic shock and improved reperfusion of culprit artery. These benefits were not accompanied by an increased risk of major bleeding, suggesting an overall clinical benefit of early anticoagulation in patients presenting with STEMI. These results require confirmation in a randomized clinical trial.

Impact of smoking on outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

Smoking is a well‑established risk factor for cardiovascular diseases. However, in patients with ST‑segment elevation myocardial infarction (STEMI), smoking has been associated with better clinical outcomes; this phenomenon became known as the "smoker's paradox." The aim of this study was to evaluate the association between smoking and clinical outcomes in STEMI patients treated with primary percutaneous coronary intervention (PCI), using 3 large national registries. We retrospectively analyzed the data of 82 235 hospitalized STEMI patients treated with primary PCI. Among the analyzed population, 30 966 patients (37.96%) were smokers, and 51 269 (62.36%) were nonsmokers. We evaluated the baseline characteristics, pharmacotherapy, clinical outcomes, and readmission causes in a 36‑month follow‑up. The smokers were significantly younger (median [interquartile range] age, 58 [52-64] vs 68 [59-77] years; P <0.001) than the nonsmokers, and there were more men in this group. The patients who smoked were less likely to have traditional risk factors, as compared with the nonsmokers. In the unadjusted analysis, in‑hospital and 36‑month mortality and rehospitalization rates were lower in the smokers group. However, after adjustment for baseline characteristics that differed between the 2 groups, the multivariable analysis showed that tobacco use was one of the independent risk factors for 36‑month mortality (hazard ratio, 1.11; 95% CI, 1.06-1.18; P <0.001). In the present large‑scale, registry‑based analysis, the observed lower 36‑month crude rates of adverse events among the smokers, as compared with the nonsmokers, might be partially explained by a significantly lower burden of traditional risk factors and younger age of the smokers. After accounting for age and other baseline differences, smoking was found to be one of the independent risk factors for 36‑month mortality.

Myeloperoxidase and global longitudinal strain in prognostication of clinical events after ST segment elevation myocardial infarction

Elevated levels of several inflammatory cytokines and chemokines, such as myeloperoxidase (MPO) and some characteristics of damaged myocardium such as myocardial deformation (global longitudinal strain — GLS) seem to be promising biomarkers for acute coronary syndrome, but their predictive ability for clinical outcomes amongst ST segment elevation myocardial infarction (STEMI) patients having obesity remained unclear.&#x0D; The aim of the study was to to determine the impact of MPO and GLS on prediction of 1‑year combined clinical events in STEMI patients successfully treated with primary percutaneous coronary intervention (PCI) depending on abdominal obesity presentation.&#x0D; Materials and methods. We prospectively enrolled 102 individuals with STEMI who were successfully treated with primary PCI. All patients gave their consent to participate in the study. The biomarkers (MPO, cardiac troponins), echocardiographic and Doppler parameters including global longitudinal strain (GLS) were evaluated at the baseline.&#x0D; Results. The MPO level in the entire population of patients with STEMI was 129.45 [48.48 — 179.70] ng/ml. The group was divided into two cohorts depending on the median level of MPO (≥ 98.34 ng/ml and &lt; 98.34 ng/ml). We observed 26 combined end‑points (10 and 17 in patients with MPO ³ 98.34 ng/ml and &lt; 98.34 ng/ml, respectively (F test = 0.064285; ε2 = 4.29; р = 0.046). Multivariate linear regression showed that the only GLS and MPO remained independent predictors for the clinical outcomes.&#x0D; Conclusions. Global longitudinal strain was the best predictor for 1‑year combined clinical outcomes in STEMI patients who were undergone successful primary PCI. Body fat accumulation seems to show borderline significance when compared with GLS, while it was sufficiently better than MPO.

Prediction of one-year adverse clinical outcomes by macrophage migration inhibitory factor in stemi patients

Biomarkers have taken one of the first places as diagnostic and prognostic tools in ST-segment elevation myocardial infarction (STEMI) and are consequently widely used as predictors of short-term and long-term prognosis. One of the promising biomarkers for early cardiovascular outcomes prediction is the pro-inflammatory cytokine macrophage migration inhibitory factor (MIF).&#x0D; The aim of the study was to elucidate a plausible predictive value of the MIF levels for one-year clinical outcomes in STEMI patients who underwent primary percutaneous coronary intervention (PCI).&#x0D; Materials and methods. 134 STEMI patients were enrolled in the study after receiving voluntary informed consent. All patients underwent conventional investigations, and additionally, the MIF levels were determined at baseline, directly before and after PCI. During 1-year follow-up, 37 % of patients reached the endpoint, which was composite and included all-cause mortality, non-fatal myocardial infarction, non-fatal stroke, hospitalization for unstable angina, heart failure decompensation, and urgent revascularization.&#x0D; Results. We have found that pre-PCI MIF levels &gt; 3934 pg/mL (AUC=0.7; 95 % CI 0.578 to 0.753; Youden index=0.31; p=0.008) might be an independent predictor of composite endpoints with sensitivity 54 % and specificity 82 %. A positive correlation between MIF and inflammatory biomarkers was revealed (WBC count r=0.33, p=0.0001; CRP r=0.19, p=0.032). Adverse outcomes associated with higher pre- and post-PCI MIF levels (OR 1.0, 95 % CI 1.0001–1.0008; p=0.013 and OR 1.0, 95 % CI 1.0001–1.0009; p=0.019) and CRP that determined during the first week after the event (OR 1.0, 95 % CI 1.005–1.2, p=0.03). Kaplan-Meier analysis has shown a substantially lower long-term survival rate in patients with a MIF level &gt; 3493 pg/ml compared to a MIF level ≤ 3493 pg/ml (Log rank=0.00025).&#x0D; Conclusions. The MIF levels exceeding 3934 ng/ml were associated with a higher risk of one-year adverse clinical outcomes in STEMI patients who underwent primary PCI.

Plasma random glucose levels at hospital admission predicting worse outcomes in STEMI patients undergoing PCI: A case series

BackgroundThe effects of impaired plasma glucose levels on predicting clinical outcomes and in-hospital events in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is unknown. Therefore, we evaluated random blood glucose at admission and its association with clinical outcomes in STEMI patients treated with PCI. MethodsPatients with STEMI undergoing PCI were enrolled and were divided into 4 tertiles according to random blood glucose levels. Tertile 1 had levels below 100 mg/dL, tertile 2 had 100–200 mg/dL, tertile 3 had 200–300 mg/dL, and tertile 4 had random blood glucose levels >300 mg/dL. The cumulative rates of in-hospital mortality and major adverse cardiovascular events were calculated. ResultsBoth the incidence of all-cause deaths and cumulative rates of major adverse cardiovascular events were significantly the lowest in patients within tertile 1. The cumulative incidence of in-hospital events was 14.3% in tertile 1, 17.6% in tertile 2, 23.5% in tertile 3, and 30.8% in tertile 4. The odds ratio of major adverse cardiovascular events was 1.286 [0.397–4.161] in tertile 2, 1.846 [0.492–6.927] in tertile 3, and 2.667 [0.693–10.254] in tertile 4. The cumulative proportion of adverse events was seen higher in tertile 4 on Kaplan-Meier log-rank (chi-square: 8.094, p = 0.044). ConclusionPoor glycemic control or stress hyperglycemia on admission experienced the highest rates of major adverse cardiovascular events including deaths. Plasma random glucose was predictive of a worse prognosis for STEMI patients undergoing PCI in our study.

Impact of BMI on Long-Term Outcomes in Patients with ST-Segment Elevation Myocardial Infarction after Primary Percutaneous Coronary Intervention.

Aim Obesity paradox remains a point of debate in ST-segment elevation myocardial infarction (STEMI) patients. The aim of this study was to examine the relationship between body mass index (BMI) and clinical outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). Methods Outcomes were assessed in 1429 STEMI patients undergoing PPCI between January 2009 and January 2010 in Beijing. Patients were classified into 6 groups according to age (the younger and elderly groups consisting of patients ≤65 and > 65 years old) and baseline BMI (normal weight, BMI < 24 kg/m2; overweight, 24 kg/m2 ≤BMI < 28 kg/m2; obese, BMI ≥ 28 kg/m2). The primary outcome was death, acute myocardial infarction (AMI), or revascularization. Results On long-term follow-up (mean follow-up of 59 months), 13.9% of patients experienced the adverse event. Multivariate logistic regression analyses showed that low BMI was a significant predictor of the primary outcome only in the younger group. The odds ratio for overweight in comparison with normal weight was 0.741 (95% CI: 0.413–0.979; p = 0.038), the odds radio for obesity in comparison with normal-weight patients was 0.508 (95% CI: 0.344–0.750; p = 0.016) in the younger group. In the elderly group, diabetes, hypertension, triple disease, regular exercise, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blockers (ARBs) use after discharge, and bleeding complication were associated with primary outcome. Conclusion The obesity paradox was recognized only in the younger age group in STEMI patients undergoing PPCI.

The Index of Microcirculatory Resistance after Primary Percutaneous Coronary Intervention Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction.

The index of microcirculatory resistance (IMR) is a simple method that can measure microvascular function after primary percutaneous coronary intervention (PCI) in patients with ST-segment Elevation Myocardial Infarction (STEMI). This study is to find out whether IMR predicts clinical long-term outcomes in STEMI patients. A total of 316 patients with STEMI who underwent primary PCI from 2005 to 2015 were enrolled. The IMR was measured using pressure sensor/thermistor-tipped guidewire after primary PCI. The primary endpoint was the rate of death or hospitalization for heart failure (HF) over a mean follow-up period of 65 months. The mean corrected IMR was 29.4 ± 20.0. Patients with an IMR > 29 had a higher rate of the primary endpoint compared to patients with an IMR ≤ 29 (10.3% vs. 2.1%, p = 0.001). During the follow-up period, 13 patients (4.1%) died and 6 patients (1.9%) were hospitalized for HF. An IMR > 29 was associated with an increased risk of death or hospitalization for HF (OR 5.378, p = 0.004). On multivariable analysis, IMR > 29 (OR 3.962, p = 0.022) remained an independent predictor of death or hospitalization for HF with age (OR 1.048, p = 0.049) and symptom-to-balloon time (OR 1.002, p = 0.049). High IMR was an independent predictor for poor long-term clinical outcomes in STEMI patients after primary PCI.

Serum Soluble Tumor Necrosis Factor Receptors 1 and 2 Are Early Prognosis Markers After ST-Segment Elevation Myocardial Infarction.

Background: As inflammation following ST-segment elevation myocardial infarction (STEMI) is both beneficial and deleterious, there is a need to find new biomarkers of STEMI severity.Objective: We hypothesized that the circulating concentration of the soluble tumor necrosis factor α receptors 1 and 2 (sTNFR1 and sTNFR2) might predict clinical outcomes in STEMI patients.Methods: We enrolled into a prospective cohort 251 consecutive STEMI patients referred to our hospital for percutaneous coronary intervention revascularization. Blood samples were collected at five time points: admission and 4, 24, 48 h, and 1 month after admission to assess sTNFR1 and sTNFR2 serum concentrations. Patients underwent cardiac magnetic resonance imaging at 1 month.Results: sTNFR1 concentration increased at 24 h with a median of 580.5 pg/ml [95% confidence interval (CI): 534.4–645.6]. sTNFR2 increased at 48 h with a median of 2,244.0 pg/ml [95% CI: 2090.0–2,399.0]. Both sTNFR1 and sTNFR2 peak levels were correlated with infarct size and left ventricular end-diastolic volume and inversely correlated with left ventricular ejection fraction. Patients with sTNFR1 or sTNFR2 concentration above the median value were more likely to experience an adverse clinical event within 24 months after STEMI [hazards ratio (HR): 8.8, 95% CI: 4.2–18.6, p < 0.0001 for sTNFR1; HR: 6.1, 95% CI: 2.5 –10.5, p = 0.0003 for sTNFR2]. Soluble TNFR1 was an independent predictor of major adverse cardiovascular events and was more powerful than troponin I (p = 0.04 as compared to the troponin AUC).Conclusion: The circulating sTNFR1 and sTNFR2 are inflammatory markers of morphological and functional injury after STEMI. sTNFR1 appears as an early independent predictor of clinical outcomes in STEMI patients.

Multivessel percutaneous coronary intervention with thin-strut biodegradable versus durable polymer drug-eluting stents in ST-segment elevation myocardial infarction: A subgroup analysis of the BIOSTEMI randomized trial

BackgroundRandomized evidence comparing newer-generation drug-eluting stents for multivessel percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is limited. We sought to investigate clinical outcomes in STEMI patients undergoing multivessel PCI with thin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus durable polymer everolimus-eluting stents (DP-EES). MethodsWe performed a subgroup analysis of the BIOSTEMI (NCT02579031) randomized trial, which included individual patient data from STEMI patients enrolled into the BIOSCIENCE (NCT02579031) study. STEMI patients randomly allocated to BP-SES or DP-EES were divided into those undergoing multivessel versus culprit lesion-only PCI. The primary endpoint was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial re-infarction or clinically indicated target lesion revascularization (TLR), within 24 months. ResultsAmong 1707 STEMI patients, 145 patients underwent multivessel PCI. At 2 years, TLF occurred in 2 patients (2.8%) treated with BP-SES and 13 patients (18.7%) treated with DP-EES (hazard ratio [HR], 0.14; 95% confidence interval (CI), 0.03–0.61; p = 0.009) in the multivessel PCI group, and in 40 (5.3%) and 61 (8.2%) patients treated with BP-SES and DP-EES respectively (HR, 0.64; 95%CI, 0.43–0.96; p = 0.03; p for interaction = 0.050) in the culprit lesion-only PCI group. In the multivessel PCI group, the rates of clinically indicated TLR (0% vs. 12.4%) and target vessel myocardial re-infarction (0% vs. 4.6%) at 2 years were lower in patients treated with BP-SES compared with DP-EES. ConclusionIn a subgroup analysis of the BIOSTEMI trial, BP-SES were associated with lower 2-year TLF rates compared to DP-EES in STEMI patients undergoing multivessel PCI.

Lack of prognostic significance for major adverse cardiac events of soluble suppression of tumorigenicity 2 levels in patients with ST-segment elevation myocardial infarction.

Elevation of soluble suppression of tumorigenicity 2 (sST2) is associated with cardiac fibrosis and hypertrophy. Under investigation herein, was whether sST2 level is associated with major adverse cardiac events (MACE) and left ventricular (LV) remodeling after primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). In total, this study included 184 patients who underwent successful primary PCI. A subsequent guideline-based medical follow-up was included (61.4 ± 11.8 years old, 85% male, 21% with Killip class ≥ I). sST2 concentration correlations with echocardiographic, angiographic, laboratory parameters, and clinical outcomes in STEMI patients were evaluated. The median sST2 level was 60.3 ng/mL; 6 (3.2%) deaths occurred within 1 year. The sST2 level correlated with LV ejection fraction (LVEF) changes from baseline to 6 months (r= -0.273; p = 0.006) after adjustment for echocardiographic parameters including wall motions score index (WMSI). Recovery of LVEF at 6 months was highest in the tertile 1 group (Δ6 months - baseline LVEF; tertile 1, p = 0.001; tertile 2, p = 0.319; tertile 3, p = 0.205). The decrease in WMSI at 6 months was greater in the tertiles 1 and 2 groups than in the tertile 3 group (Δ6 months - baseline WMSI; tertile 1, p = 0.001; tertile 2, p = 0.013; tertile 3, p = 0.055). There was no association between sST2 levels and short-term (log rank p = 0.598) and long-term (p = 0.596) MACE. sST2 concentration have predictive value for LV remodeling on echocardiography in patients with STEMI who underwent primary PCI. However, sST2 concentration was not associated with short-term and long-term MACE.

Relationship between primary percutaneous coronary intervention time of day, infarct size, microvascular obstruction and prognosis in ST-segment elevation myocardial infarction.

Whether the time of day of primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI) is associated with infarct size, microvascular obstruction (MVO), and prognosis is uncertain. We compared infarct size assessed by cardiac MRI (CMR) and clinical outcomes in STEMI patients according to the pPCI time of day from a large, individual patient-data pooled database. We pooled patient-level data from five randomized pPCI trials in which infarct size was measured within 1 month by CMR. Patients were categorized according to the pPCI time of day. Among 1519 patients with STEMI, 794 (52.2%) underwent pPCI between 8:00 h and 15:59 h, 431 (28.4%) between 16:00 h and 23:59 h, and 294 (19.4%) between 24:00 h and 7:59 h. Infarct size was assessed in 1331 patients at a median of 3.0 days (interquartile range 2.0-5.0) after pPCI. Compared with patients who underwent PCI between 8:00 h and 15:59 h, infarct size was not significantly different for patients undergoing PCI from 16:00 h to 23:59 h [adjusted difference -0.7%, 95% confidence interval (CI) -3.1 to 1.7%, P = 0.46] or 24:00 h to 7:59 h (adjusted difference 0.9%, 95% CI -1.2 to 3.1%, P = 0.29). The time of day of pPCI was also unrelated to MVO and the 1-year risks of death or heart failure hospitalization. In this large-scale, individual patient data pooled analysis, no association was found between the time of day of pPCI and infarct size, MVO, or prognosis after STEMI.

Two-year clinical performance of Absorb BVS compared to Xience EES in ST-segment elevation myocardial infarction: a pooled analysis of AIDA and COMPARE-ABSORB trials

Abstract Introduction Bioresorbable vascular scaffolds (BVS) use appears theoretically attractive in patients presenting with ST-segment elevation myocardial infarction (STEMI) as acute lesions are generally composed of soft plaques, in which optimal BVS deployment and expansion is easier to achieve. Furthermore, those patients are generally younger and would benefit longer from the promise of vascular restoration therapy. Purpose In this patient level pooled analysis of two clinical trials, we evaluated the clinical outcomes of Absorb BVS versus Xience everolimus-eluting stent (EES) in STEMI patients at 2-year follow-up. Methods We performed an individual patient-level pooled analysis of the AIDA and COMPARE-ABSORB trials in which 3515 patient were randomly assigned to Absorb BVS (n=1772) or Xience EES (n=1743). Clinical outcomes in STEMI patients were analyzed by randomized treatment assignment cumulative through 2 years. The primary efficacy outcomes measure was target lesion failure (cardiac death, target-vessel myocardial infarction or target lesion revascularization), and the primary safety outcome measure was device thrombosis at 2-year follow-up. Results 350 (19.8%) STEMI patients were allocated to Absorb BVS versus 328 (18.8%) to Xience EES. The mean age of patient presenting with STEMI was 60 years old, 76.0% were males and 15.3% had diabetes mellitus. At 2-years target lesion failure occurred in 8.4% of BVS STEMI patients and 6.2% of EES STEMI patients (p=0.253). The 2-year rates of cardiac death (2.6% vs 1.6%, p=0.332), TV-MI (4.7% vs 2.5%) and TLR (6.8% vs 4.1%) were not significantly different. The 2-year incidence of definite device thrombosis was 4.7% in Absorb BVS versus 1.8% in Xience EES (p=0.045). Conclusion In the present patient-level pooled analysis of the AIDA and COMPARE-Absorb trials, BVS was associated with increased rates of device thrombosis in STEMI patients compared to Xience EES. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Abbott

Clinical outcome following late reperfusion with percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction.

Up to 40% of patients with ST-segment elevation myocardial infarction (STEMI) present later than 12 hours after symptom onset. However, data on clinical outcomes in STEMI patients treated with primary percutaneous coronary intervention 12 or more hours after symptom onset are non-existent. We evaluated the association between primary percutaneous coronary intervention performed later than 12 hours after symptom onset and clinical outcomes in a large all-comer contemporary STEMI cohort. All STEMI patients treated with primary percutaneous coronary intervention in eastern Denmark from November 2009 to November 2016 were included and stratified by timing of the percutaneous coronary intervention. The combined clinical endpoint of all-cause mortality and hospitalisation for heart failure was identified from nationwide Danish registries. We included 6674 patients: 6108 (92%) were treated less than 12 hours and 566 (8%) were treated 12 or more hours after symptom onset. During a median follow-up period of 3.8 (interquartile range 2.3-5.6) years, 30-day, one-year and long-term cumulative rates of the combined endpoint were 11%, 17% and 25% in patients treated 12 or fewer hours and 21%, 29% and 37% in patients treated more than 12 hours (P<0.001 for all) after symptom onset. Late presentation was independently associated with an increased risk of an adverse clinical outcome (hazard ratio 1.42, 95% confidence interval 1.22-1.66; P<0.001). Increasing duration from symptom onset to primary percutaneous coronary intervention was associated with an increased risk of an adverse clinical outcome in patients with STEMI, especially when the delay exceeded 12 hours.

Effect of remote ischaemic conditioning on platelet reactivity and endogenous fibrinolysis in ST-elevation myocardial infarction: a substudy of the CONDI-2/ERIC-PPCI randomized controlled trial.

Remote ischaemic conditioning (RIC) has been shown to reduce myocardial infarct size in animal models of myocardial infarction. Platelet thrombus formation is a critical determinant of outcome in ST-segment elevation myocardial infarction (STEMI). Whether the beneficial effects of RIC are related to thrombotic parameters is unclear. In a substudy of the Effect of Remote Ischaemic Conditioning on clinical outcomes in STEMI patients undergoing Primary Percutaneous Coronary Intervention (ERIC-PPCI) trial, we assessed the effect of RIC on thrombotic status. Patients presenting with STEMI were randomized to immediate RIC consisting of an automated autoRIC™ cuff on the upper arm inflated to 200 mmHg for 5 min and deflated for 5 min for four cycles (n = 53) or sham (n = 47). Venous blood was tested at presentation, discharge (48 h) and 6-8 weeks, to assess platelet reactivity, coagulation, and endogenous fibrinolysis using the Global Thrombosis Test and thromboelastography. Baseline thrombotic status was similar in the two groups. At discharge, there was some evidence that the time to in vitro thrombotic occlusion under high shear stress was longer with RIC compared to sham (454 ± 105 s vs. 403 ± 105 s; mean difference 50.1 s; 95% confidence interval 93.7-6.4, P = 0.025), but this was no longer apparent at 6-8 weeks. There was no difference in clot formation or endogenous fibrinolysis between the study arms at any time point. RIC may reduce platelet reactivity in the first 48 h post-STEMI. Further research is needed to delineate mechanisms through which RIC may reduce platelet reactivity, and whether it may improve outcomes in patients with persistent high on-treatment platelet reactivity.

Impact of glycemic control status on patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

BackgroundThe combined effects of diabetes mellitus (DM), admission plasma glucose (APG), and glycated hemoglobin (HbA1c) levels on predicting long-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) are unknown. Therefore, we evaluated their combined effects on long-term clinical outcomes in STEMI patients treated with pPCI.MethodsIn total, 350 consecutive patients with STEMI undergoing pPCI were enrolled. Patients were divided into 3 groups according to DM history and APG and HbA1c levels. The cumulative rates of 24-month all-cause deaths and major adverse cardiac and cerebrovascular events (MACCEs) were calculated.ResultsBoth the incidence of all-cause deaths and cumulative rates of MACCEs were significantly the lowest in patients without a DM history and admission HbA1c level < 6.5%. DM patients with poor glycemic control or stress hyperglycemia on admission experienced the highest rates of all-cause deaths, MACCEs, and cardiac deaths. Admission HbA1c levels, Triglyceride (TG) levels, hemoglobin levels, DM history, and admission Killip class > 1 correlated with 24-month all-cause death; HbA1c levels on admission, DM history, APG levels, history of stroke, history of coronary heart disease, and TG levels on admission were significantly associated with MACCEs through the 24-month follow-up. The predictive effects of combining DM and APG and HbA1c levels were such that for STEMI patients undergoing pPCI, DM patients with poor glycemic control or with stress hyperglycemia on admission had worse prognosis than other patients.ConclusionStrict control of glycemic status may improve the survival of patients who have both DM and coronary heart diseases.

Association of plasma pentraxin 3 concentration with angiographic and clinical outcomes in patients with acute ST-segment elevation myocardial infarction treated by primary angioplasty.

To evaluate the association of plasma long pentraxin 3 (PTX3) concentration with angiographic and clinical outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty. Whether concentration of PTX3, a sensitive marker of inflammation, associates with angiographic and clinical outcomes in STEMI patients treated by primary angioplasty is unknown. We prospectively enrolled 335 consecutive patients with acute STEMI undergoing primary angioplasty. Blood samples for plasma PTX3 measurement were drawn in all patients at the emergency department before primary angioplasty, and were measured by ELISA method. The median PTX3 concentrations were higher in patients with thrombus burden grade 4 and 5 versus grade <4 on initial coronary angiogram (0.29 ng/ml vs. 0.24 ng/ml, p = .02), thrombolysis in myocardial infarction (TIMI) grade <3 vs. TIMI grade-3 flow after primary angioplasty (0.31 ng/ml vs. 0.24 ng/ml, p < .001), incomplete versus complete ST-segment resolution within 12 hr after angioplasty (0.29 ng/ml vs. 0.22 ng/ml, p = .001) and in patients who did not survive versus those who survived at 30 days (0.44 ng/ml vs. 0.26 ng/ml, p = .001). A linear correlation was observed between PTX3 concentration and baseline leukocyte count (Spearman correlation = 0.21, p < .001). After adjustment for laboratory and selected clinical variables, patients in the highest quartile of PTX3 concentration (≥0.4 ng/ml) were associated with increased risk of 30-day mortality (hazard ratio = 11.83; 95% confidence interval = 1.52-92.27, p = .01). This study suggests that higher plasma PTX3 concentration associates with worse angiographic and clinical outcomes in STEMI patients treated by primary angioplasty.