Complete ST-segment Resolution Research Articles

The prognostic significance of single-lead ST-segment resolution in ST-segment elevation myocardial infarction patients treated with primary PCI – A substudy of the randomized TOTAL trial

BackgroundST-segment elevation myocardial infarction (STEMI) is associated with high morbidity and mortality worldwide. Simple electrocardiogram (ECG) tools, including ST-segment resolution (STR) have been developed to identify high-risk STEMI patients after primary percutaneous coronary intervention (PCI). Subjects and MethodsWe evaluated the prognostic impact of STR in the ECG lead with maximal baseline ST-segment elevation (STE) 30-60 minutes after primary PCI in 7,654 STEMI patients included in the TOTAL trial. Incomplete or no STR was defined as <70% STR and complete STR as ≥70% STR. The primary outcome was the composite of cardiovascular death, recurrent myocardial infarction (MI), cardiogenic shock, or new or worsening New York Heart Association (NYHA) class IV heart failure at one-year follow-up. ResultsOf 7,654 patients, 42.9% had incomplete or no STR and 57.1% had complete STR. The primary outcome occurred in 341 patients (10.4%) in the incomplete or no STR group and in 234 patients (5.4%) in the complete STR group. In Cox regression analysis, adjusted hazard ratio for STR <70% to predict the primary outcome was 1.56 (95% confidence interval 1.321.89; p<0.001)(model adjusted for all baseline comorbidities, clinical status during hospitalization, angiographic findings, and procedural techniques). ConclusionIn a large international study of STEMI patients, STR <70% 30-60 minutes post primary PCI in the ECG lead with the greatest STE at admission was associated with an increased rate of the composite of cardiovascular death, recurrent MI, cardiogenic shock, or new or worsening NYHA class IV heart failure at one-year follow-up. Clinicians should pay attention to this simple ECG finding.

Intracoronary antithrombotic therapy during primary percutaneous coronary intervention in patients with STEMI: A systematic review and network meta-analysis

IntroductionThe efficacy of intracoronary (IC) antithrombotic therapy, which may best prevent the no-reflow phenomenon during percutaneous coronary intervention (PCI), remains unclear. Therefore, we compared the efficacy and safety of different IC antithrombotic agents. Materials and methodsThis systematic review and network meta-analysis of randomized controlled trials (RCTs) compared IC fibrinolytic agents (recombinant tissue plasminogen activators [rtPAs] and non-rtPAs) or glycoprotein IIb/IIIa inhibitors (small molecules and monoclonal antibodies) with placebo by searching the relevant studies published before September 21, 2022. Bayesian network meta-analyses were performed using random-effects models. ResultsTwenty-five RCTs with 4546 patients were included. Non-rtPAs and small molecules were significantly more effective in achieving thrombolysis in myocardial infarction (TIMI) grade 3 flow than placebo (odds ratio [OR] 2.28, 95 % credible intervals [CrI] 1.24–4.13; OR 2.06, 95 % CrI 1.17–3.46). Moreover, these agents' efficacy was observed in other microcirculation-related outcomes, including TIMI myocardial perfusion grade 3, complete ST-segment resolution, and corrected TIMI frame counts. Within 6 months, small molecules were associated with both an improved left ventricular ejection fraction (MD 3.90, 95 % CrI 0.48–7.46) and major adverse cardiac events (MACE) reduction (OR 0.36, 95 % CrI 0.20–0.61). Non-rtPAs demonstrated a reduced MACE incidence within 6 months (OR 0.51, 95 % CrI 0.31–0.81). The results were consistent in the subgroup with a total ischemic time > 6 h. No significant differences in mortality or bleeding events were observed. ConclusionsIC non-rtPAs and small molecules may be effective for adjunctive therapy to PCI, particularly in patients with longer ischemia periods.

Point-of-care biomarkers of thrombotic status predict spontaneous reperfusion in ST-segment elevation MI and clinical outcomes

Abstract Background Spontaneous reperfusion, seen in ∼20% of patients with ST-segment elevation myocardial infarction (STEMI), manifests as normal epicardial flow in the infarct-related artery (IRA), with or without ST-segment resolution, before percutaneous coronary intervention (PCI). The drivers mediating this are unknown. Purpose We aimed to assess whether the thrombotic profile of patients with and without spontaneous reperfusion differed significantly, and whether such patients had better outcomes. Methods We performed a prospective, observational study in consecutive patients presenting with STEMI. Blood samples were taken from a 6 Fr arterial sheath immediately before emergency angiography, before PPCI, after dual antiplatelet therapy loading, but before the administration of heparin or other anticoagulant. Blood samples were tested using a point-of-care global test of thrombotic status, measuring occlusion (OT) and endogenous fibrinolysis (LT) times. Spontaneous reperfusion was defined as IRA TIMI III flow pre-PCI. Patients were followed for major cardiovascular events (MACE; death, myocardial infarction, stroke). Results Spontaneous reperfusion was associated with longer OT (435s vs. 366s, p&amp;lt;0.001) and shorter LT (1257s vs. 1616s, p&amp;lt;0.001), lower troponin and better LV function. LT was superior to OT for predicting spontaneous reperfusion (AUC for LT: 0.707, 95% CI 0.661-0.753; AUC for OT: 0.629, 95% CI 0.581-0.677). Amongst patients with spontaneous reperfusion, those with complete, versus partial ST-segment resolution, had longer OT (p=0.002) and shorter LT (p&amp;lt;0.001). Spontaneous reperfusion was unrelated to clinical characteristics or pain-to-angiography times. Over 4-years, patients with spontaneous reperfusion experienced fewer MACE than those without (4.1% vs. 10.6%, p=0.013), especially in those with both spontaneous reperfusion and complete ST-segment resolution (1.5% vs. 10.1%, p=0.029). Conclusions We demonstrate a novel haematological signature in STEMI patients with spontaneous reperfusion, namely reduced platelet reactivity and faster endogenous fibrinolysis, relating to smaller infarcts and improved survival. This indicates a role for modulating thrombotic status early following STEMI-onset, to facilitate spontaneous reperfusion and improve outcomes.Visual abstractThrombotic profile predicts outcome

ROLE OF ST SEGMENT RESOLUTION ALONE AND IN COMBINATION WITH THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI) FLOW IN PRIMARY PERCUTANEOUS CORONARY INTERVENTION FOR ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

This study aimed to assess the effect of ST-segment resolution (STR) alone and in combination with TIMI flow after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI). The study was conducted at the Department of Cardiology, Peshawar Institute of Cardiology, Hayatabad Peshawar, KPK, from August 2022 to July 2023. Ninety patients with acute myocardial infarction were enrolled, and STR was considered successful if it reached 50% or complete STR (ST-segment back to the equipotential line). TIMI flow was evaluated after PPCI, and the primary outcome was two-year all-cause mortality. Results showed that each STR &lt;50%, STR ≥50%, and complete STR occurred in 33.3% of the patients. Successful STR was the only independent predictor of 2-year death among all clinical factors. Combining TIMI flow and STR showed different 2-year mortality rates in subgroups; the lowest was seen in successful STR and TIMI 3 flow, the middle when either of these measures was decreased, and the greatest when both were abnormal. The study concluded that analyzing both STR and TIMI flow provides additional prognostic information beyond what either measure could provide. Therefore, it can be used as a reliable and convenient surrogate endpoint for determining successful PPCI. Additionally, the study found that post-PPCI STR is a strong long-term prognosticator for ST-segment elevation myocardial infarction.

Direct Stenting versus Conventional Stenting in Patients with ST-Segment Elevation Myocardial Infarction-A COMPARE CRUSH Sub-Study.

Direct stenting (DS) compared with conventional stenting (CS) after balloon predilatation may reduce distal embolization during percutaneous coronary intervention (PCI), thereby improving tissue reperfusion. In contrast, DS may increase the risk of stent underexpansion and target lesion failure. In this sub-study of the randomized COMPARE CRUSH trial (NCT03296540), we reviewed the efficacy of DS versus CS in a cohort of contemporary, pretreated ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. We compared DS versus CS, assessing (1) stent diameter in the culprit lesion, (2) thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery post-PCI and complete ST-segment resolution (STR) one-hour post-PCI, and (3) target lesion failure at one year. For proportional variables, propensity score weighting was applied to account for potential treatment selection bias. This prespecified sub-study included 446 patients, of whom 189 (42%) were treated with DS. Stent diameters were comparable between groups (3.2 ± 0.5 vs. 3.2 ± 0.5 mm, p = 0.17). Post-PCI TIMI 3 flow and complete STR post-PCI rates were similar between groups (DS 93% vs. CS 90%, adjusted OR 1.16 [95% CI, 0.56-2.39], p = 0.69, and DS 72% vs. CS 58%, adjusted OR 1.29 [95% CI 0.77-2.16], p = 0.34, respectively). Moreover, target lesion failure rates at one year were comparable (DS 2% vs. 1%, adjusted OR 2.93 [95% CI 0.52-16.49], p = 0.22). In this contemporary pretreated STEMI cohort, we found no difference in early myocardial reperfusion outcomes between DS and CS. Moreover, DS seemed comparable to CS in terms of stent diameter and one-year vessel patency.

The relation between ST-segment resolution and in-hospital mortality after primary percutaneous coronary interventions

Objective:&#x0D; The resolution of ST-segment elevation (&gt;50%) indicates successful reperfusion with thrombolytic therapy. The aim of this study is to evaluate the relation of ST-segment resolution post-primary percutaneous cardiac intervention (PCI) with in-hospital mortality and coronary thrombolysis in myocardial infarction (TIMI) blood flow.&#x0D; Methods:&#x0D; This study is a single-centred retrospective study. The study enrolled 100 patients who were referred to the Nasiriya Heart Centre for primary PCI. We measured the ST segment amplitude in the lead with the highest elevation prior to primary PCI and assessed the ST-segment elevation post-primary PCI. The ratio of ST-segment resolution was calculated and considered complete if reaches ≥70% from the initial ST-segment elevation. We assessed the association of ST-segment resolution with in-hospital mortality.&#x0D; Results:&#x0D; Analysis of the electrocardiogram (ECG) showed that 21 patients (21%) had complete ST-segment (≥ 70%) resolution. No significant association was shown between ST-segment resolution and in-hospital mortality. Two out of 21 patients with complete ST-segment resolution died in the hospital and 6 out of 79 patients with incomplete ST-segment resolution died (P=0.77). There is no significant association between ST-segment resolution and coronary TIMI flow grades. In patients with complete ST-segment resolution, 19 patients had TIMI III flow and 2 patients had TIMI II flow. In patients with incomplete ST-segment resolution, 72 patients had TIMI III flow, 6 patients had TIMI II flow; and 1 patient had no-reflow (P=0.84).&#x0D; &#x0D; Conclusion:&#x0D; Complete ST-segment resolution in post-primary PCI settings has no significant association with in-hospital mortality. Absent or incomplete ST-segment resolution is not necessarily an indicator of coronary artery re-occlusion after primary PCI.

A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Streptokinase in the Management of Myocardial Infarction in Developing Countries.

Myocardial infarction (MI) is a significant cause of morbidity and mortality in low- and middle-income countries. Fibrinolytic agents and percutaneous coronary intervention (PCI) are the main approaches for the recanalization and reperfusion of the myocardium following MI. Many studies have shown that PCI is superior to thrombolytics due to better outcomes and decreased mortality. Nevertheless, PCI's mortality gain over thrombolysis decreases as the time between presentation and PCI procedure increases. Furthermore, PCI is not widely available in most developing countries; thus, it cannot be delivered promptly. Most patients in developing countries cannot afford the cost of PCI. Thus, thrombolytic therapy remains essential to managing MI in developing countries and should not be disregarded. Tenecteplase (TNK) and streptokinase (SK) are the two most widely used fibrinolytics in managing MI in underdeveloped nations. Despite their widespread availability, comparative studies on them have been inconclusive. This study aims to review the available literature on the effectiveness and safety of TNK versus SK in managing MI in resource-poor nations. The study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension and analyzed according to Cochrane guidelines on synthesis without meta-analysis. A comprehensive literature search for studies comparing TNK and STK was conducted on EMBASE, Cochrane Library, Web of Science, CINAHL, Scopus, Google Scholar, and Ovid version of MEDLINE databases. A reference list of the eligible articles and systematic reviews was also screened. A narrative synthesis of the available data was done by representing the data on the effect direction plot, followed by vote counting. Of the 2284 references retrieved from the databases, only 17 studies met the inclusion criteria and were selected for final analysis. The study suggested that TNK is more effective in complete ST-segment resolution (80% vs 10% on the effect direction plot) and symptom relief (80% vs 20%) than SK. SK and TNK were comparable in achieving successful fibrinolysis (50% vs 50%). For the safety parameters, TNK is associated with a lesser risk of major bleeding than SK (88.9% vs 11.1%) and minor bleeding (25% vs 75%). SK was linked with a higher risk of hypotension/shock (77.8% vs 11.1%) and anaphylaxis/allergy (100% vs 0%). Long-term mortality was higher in the SK arm (100% vs 0%). In-hospital mortality is comparable between the two agents (37.5% vs 37.5%). There is conflicting evidence regarding other safety and efficacy endpoints. Compared to SK, TNK results in better complete ST-segment resolution and symptom relief. A higher risk of long-term mortality, increased risk of major and minor bleeding, hypotension, and allergy/anaphylaxis was observed in patients who received SK. Both agents were comparable in terms of in-hospital mortality and successful fibrinolysis. Controversy exists regarding which agent is linked with increased risk of 30-35-day mortality benefit and stroke. Randomized controlled trials (RCTs) with large sample sizes are needed to establish TNK vs SK superiority in efficacy and safety. The long-term duration of follow-up of the mortality rate of the two agents is also essential, as most patients in these regions cannot afford the recommended PCI post-fibrinolysis.

Intracoronary versus intravenous glycoprotein IIb/IIIa inhibitors during primary percutaneous coronary intervention in patients with STEMI: a systematic review and meta-analysis

BackgroundIntracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) has been studied as an adjunctive therapy to improve outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of IC administration of GPIs compared with those of intravenous (IV) administration in patients with STEMI.MethodsWe searched the MEDLINE, Embase, and Cochrane CENTRAL databases for relevant studies published before September 21, 2022. In total, 22 randomized controlled trials involving 7,699 patients were included.ResultsThe proportions of patients achieving thrombolysis in myocardial infarction grade 3 flow, myocardial blush grade 2/3, and complete ST-segment resolution were significantly higher in the IC group than in the IV group. Major adverse cardiac events (MACE) (RR: 0.54, 95% CI: 0.37–0.80) and heart failure (RR: 0.48, 95% CI: 0.25–0.91) within 1 month were significantly lower in the IC group than in the IV group; however, after 6 months, no difference was observed in MACE risk. Additionally, the risks of death and bleeding did not differ between the two routes of administration.ConclusionsWhen considering adjunctive GPI administration for patients with STEMI, the IC route may offer greater benefits than the IV route in terms of myocardial reperfusion and reduced occurrence of MACE and heart failure within 1 month. Nonetheless, when making decisions for IC administration of GPIs, the absence of a benefit for bleeding risk and difficulty accessing the administration route should be considered.

FACTORS AFFECTING ADEQUATE MYOCARDIAL PERFUSION IN PATIENTS WITH ACUTE ST-ELEVATION MYOCARDIAL INFARCTION WITH SUCCESSFUL EPICARDIAL FLOW

Aim: The aim of this study was to evaluate and compare multifarious parameters between complete and incomplete ST-segment resolution (STR) patients groups and to identify associates of STR in patients with acute ST-segment elevation myocardial infarction (STEMI) after successful primary percutaneous coronary intervention (pPCI). &#x0D; Material and Methods: 888 consecutive patients were divided into two groups according to the STR

Biomarkers of Thrombotic Status Predict Spontaneous Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction

BackgroundSpontaneous reperfusion, seen in ∼20% of patients with ST-segment elevation myocardial infarction (STEMI), manifests as normal epicardial flow in the infarct-related artery, with or without ST-segment resolution, before percutaneous coronary intervention (PCI). The drivers mediating this are unknown. ObjectivesThe authors sought to relate spontaneous reperfusion to the thrombotic profile. MethodsIn a prospective study, blood from STEMI patients (n = 801) was tested pre-PCI to assess in vitro, point-of-care, occlusion times (OT) and endogenous lysis times (LT). Spontaneous reperfusion was defined as infarct-related artery Thrombolysis In Myocardial Infarction flow grade 3 before PCI. Patients were followed for major cardiovascular events (death, myocardial infarction, or stroke). ResultsSpontaneous reperfusion was associated with a longer OT (435 seconds vs 366 seconds; P < 0.001) and a shorter LT (1,257 seconds vs 1,616 seconds; P < 0.001), lower troponin, and better left ventricular function. LT was superior to OT for predicting spontaneous reperfusion (area under the curve for LT: 0.707; 95% CI: 0.661-0.753; area under the curve for OT: 0.629; 95% CI: 0.581-0.677). Among patients with spontaneous reperfusion, those with complete, vs partial ST-segment resolution, had a longer OT (P = 0.002) and a shorter LT (P < 0.001). Spontaneous reperfusion was unrelated to clinical characteristics or pain-to-angiography times. Over 4 years, patients with spontaneous reperfusion experienced fewer major adverse cardiovascular events than those without (4.1% vs 10.6%; P = 0.013), especially in those with both spontaneous reperfusion and complete ST-segment resolution (1.5% vs 10.1%; P = 0.029). ConclusionsWe demonstrate a novel hematological signature in STEMI patients with spontaneous reperfusion, namely, decreased platelet reactivity and faster endogenous fibrinolysis, relating to smaller infarcts and improved survival. This finding indicates a role for modulating thrombotic status early after STEMI onset, to facilitate spontaneous reperfusion and improve outcomes.

Intracoronary Thrombolysis in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: an Updated Meta-analysis of Randomized Controlled Trials.

Primary percutaneous coronary intervention (PPCI) is the standard reperfusion treatment in ST-segment elevation myocardial infarction (STEMI). Intracoronary thrombolysis (ICT) may reduce thrombotic burden in the infarct-related artery, which is often responsible for microvascular obstruction and no-reflow. We conducted, according to the PRISMA statement, the largest meta-analysis to date of ICT as adjuvant therapy to PPCI. All relevant studies were identified by searching the PubMed, Scopus, Cochrane Library, and Web of Science. Thirteen randomized controlled trials (RCTs) involving a total of 1876 patients were included. Compared to the control group, STEMI ICT-treated patients had fewer major adverse cardiac events (MACE) (OR 0.65, 95% CI, 0.48-0.86, P = 0.003) and an improved 6-month left ventricular ejection fraction (MD 3.78, 95% CI, 1.53-6.02, P = 0.0010). Indices of enhanced myocardial microcirculation were better with ICT (Post-PCI corrected thrombolysis in myocardial infarction (TIMI) frame count (MD - 3.57; 95% CI, - 5.00 to - 2.14, P < 0.00001); myocardial blush grade (MBG) 2/3 (OR 1.76; 95% CI, 1.16-2.69, P = 0.008), and complete ST-segment resolution (OR 1.97; 95% CI, 1.33-2.91, P = 0.0007)). The odds for major bleeding were comparable between the 2 groups (OR 1.27; 95% CI, 0.61-2.63, P = 0.53). The present meta-analysis suggests that ICT was associated with improved MACE and myocardial microcirculation in STEMI patients undergoing PPCI, without significant increase in major bleeding. However, these findings necessitate confirmation in a contemporary large RCT.

Direct stenting versus stenting after predilatation in STEMI patients with high thrombus burden: a subanalysis from the randomized COMPARE CRUSH trial

Abstract Background/Introduction Direct stenting has been proposed to reduce vessel wall damage and distal embolization in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). However, studies comparing direct stenting with stenting after predilatation have shown mixed results so far. Patients presenting with high thrombus burden in the culprit lesion represent a subgroup of STEMI patients that may particularly benefit from direct stenting, as high thrombus burden is associated with suboptimal reperfusion and poor clinical outcomes. Purpose We sought to determine the efficacy of direct stenting compared with stenting after predilatation in STEMI patients presenting with high thrombus burden. Methods The randomized COMPARE CRUSH trial assessed the efficacy of pre-hospital administration of crushed versus integral prasugrel tablets in patients presenting with STEMI planned for primary PCI. We assessed Thrombolysis In Myocardial Infarction (TIMI) flow, corrected TIMI frame count (cTFC) and myocardial blush grade at the end of primary PCI, as well as the occurrence of complete (≥70%) ST-segment resolution 1 hour post-PCI in STEMI patients presenting with high thrombus burden in the culprit lesion (defined as a TIMI thrombus grade ≥3). Results A total of 417 STEMI patients were included in the current analysis of which 336 (81%) presented with high thrombus burden on initial angiography with 144 patients (43%) being treated with direct stenting. Patients undergoing direct stenting exhibited significantly lower cTFC post-PCI compared with stenting after predilatation (16 [12–24] vs. 20 [13–29], p=0.02). Moreover, direct stenting patients more frequently exhibited complete ST-segment resolution 1 hour post-PCI compared with stenting after predilatation (72% vs. 59%, OR 1.82 [95% CI, 1.11–2.99], p=0.02). In contrast, we found no differences in the occurrence of TIMI 3 flow (DS 92% vs. 92%, OR 1.02 [0.47–2.22], p=0.97) or myocardial blush grade 3 (DS 63% vs. 54%, OR 1.45 [95% CI, 0.83–2.52], p=0.19) post-PCI between groups. Conclusion STEMI patients presenting with high thrombus burden treated with direct stenting showed improved markers of early myocardial reperfusion compared with patients treated with stenting after predilatation, indicating that a direct stenting strategy may benefit the subgroup of STEMI patients that present with high thrombus burden. Randomized trials are warranted to further investigate whether the potential benefits of direct stenting outweigh potential hazards over the long-term. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Daiichi-Sankyo and Shanghai MicroPort Medical

Intracoronary thrombolysis facilitated primary percutaneous coronary intervention in ST-segment elevation myocardial infarction patients: an updated meta-analysis of randomized controlled trials

Abstract Background Primary percutaneous coronary intervention (PPCI) is the standard reperfusion treatment in ST-segment elevation myocardial infarction (STEMI). However, PPCI is often complicated by microvascular obstruction. Intracoronary thrombolysis (ICT) may mitigate thrombotic burden. Methods We conducted, according to the PRISMA statement, the largest meta-analysis of ICT as adjuvant therapy to PPCI. All relevant studies were identified by searching the PubMed, Scopus, Cochrane Library, and Web of Science, with no time or language restriction. The odds ratio (OR) and mean difference (MD) with a 95% confidence interval (CI) were calculated. Studies included STEMI patients undergoing PPCI receiving ICT. Both safety and efficacy outcomes were analyzed. Data were combined using a random-effects model. Results Thirteen randomized controlled trials (RCTs) involving a total of 1876 (1014 ICT) patients were included. Compared with the control group, ICT in STEMI patients could reduce the incidence of major adverse cardiac events (MACE) (OR 0.65, 95% CI, 0.48–0.86, P=0.003) and improve 6 months left ventricular ejection fraction (MD 3.78, 95% CI, 1.53–6.02, P=0.0010). Indices of enhanced myocardial microcirculation were more common with ICT [Post PCI corrected thrombolysis in myocardial infarction (TIMI) frame count (MD −3.57; 95% CI, −5.00 to −2.14, P&amp;lt;0.00001); myocardial blush grade (MBG) 2/3 (OR 1.76; 95% CI, 1.16–2.69, P=0.008), and complete ST-segment resolution (OR 1.97; 95% CI, 1.33–2.91, P=0.0007). The incidence rate of major bleeding was comparable between the 2 groups (OR 1.27; 95% CI, 0.61–2.63, P=0.53). Conclusions Intracoronary thrombolysis was associated with improved MACE and myocardial microcirculation in patients with STEMI undergoing PPCI, without any significant increase in major bleeding. Our meta-analysis suggests that a targeted ICT is safe and potentially effective to improve PPCI. Nonetheless, the above results necessitate verification in a contemporary large RCT. Funding Acknowledgement Type of funding sources: None.

Effects of Nicorandil Administration on Infarct Size in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: The CHANGE Trial.

Background Nicorandil was reported to improve microvascular dysfunction and reduce reperfusion injury when administered before primary percutaneous coronary intervention. In this multicenter, prospective, randomized, double-blind clinical trial (CHANGE [Effects of Nicorandil Administration on Infarct Size in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention]), we investigated the effects of nicorandil administration on infarct size in patients with ST-segment-elevation myocardial infarction treated with primary percutaneous coronary intervention. Methods and Results A total of 238 patients with ST-segment-elevation myocardial infarction were randomized to receive intravenous nicorandil (n=120) or placebo (n=118) before reperfusion. Patients in the nicorandil group received a 6-mg intravenous bolus of nicorandil followed by continuous infusion at a rate of 6 mg/h. Patients in the placebo group received the same dose of placebo. The predefined primary end point was infarct size on cardiac magnetic resonance (CMR) imaging performed at 5 to 7 days and 6 months after reperfusion. CMR imaging was performed in 201 patients (84%). Infarct size on CMR imaging at 5 to 7 days after reperfusion was significantly smaller in the nicorandil group compared with the placebo (control) group (26.5±17.1 g versus 32.4±19.3 g; P=0.022), and the effect remained significant on long-term CMR imaging at 6 months after reperfusion (19.5±14.4 g versus 25.7±15.4 g; P=0.008). The incidence of no-reflow/slow-flow phenomenon during primary percutaneous coronary intervention was much lower in the nicorandil group (9.2% [11/120] versus 26.3% [31/118]; P=0.001), and thus, complete ST-segment resolution was more frequently observed in the nicorandil group (90.8% [109/120] versus 78.0% [92/118]; P=0.006). Left ventricular ejection fraction on CMR imaging was significantly higher in the nicorandil group than in the placebo group at both 5 to 7 days (47.0±10.2% versus 43.3±10.0%; P=0.011) and 6 months (50.1±9.7% versus 46.4±8.5%; P=0.009) after reperfusion. Conclusions In the present trial, administration of nicorandil before primary percutaneous coronary intervention led to improved myocardial perfusion grade, increased left ventricular ejection fraction, and reduced myocardial infarct size in patients with ST-segment-elevation myocardial infarction. Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT03445728.

Impact of intracoronary reteplase during primary percutaneous coronary intervention on infarct size in large anterior myocardial infarction: rationale and design of the RECOVER II trial

Thrombus embolization and microvascular obstruction during percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) is commonly detected, which causes inadequate myocardial perfusion and elevated infarct size. An approach with low-dose intracoronary fibrinolytic treatment for reducing distal embolization and improving myocardial reperfusion in high-risk STEMI cases remains controversial. The RECOVER II study represents a multicenter, randomized, double-blind, parallel-group trial assessing low-dose adjunctive intracoronary reteplase during primary PCI in individuals with large anterior myocardial infarction and thrombus determined by angiography. The trial will enroll 306 cases who present within 12 h following STEMI for proximal or mid left anterior descending artery occlusion undergoing primary PCI. Cases will be randomized to receive a bolus intracoronary reteplase at 9 mg or 18 mg vs. placebo. The drug will be delivered over 2 minutes proximal to culprit lesions with an intracoronary catheter early after wire-crossing and before thrombus aspiration or balloon dilation. The primary outcome will be infarct size assessed by late gadolinium-enhanced magnetic resonance imaging (MRI) (% of left ventricular mass) on day 7 after enrollment. Secondary outcomes will include the amount of microvascular obstruction and myocardial salvage index examined via MRI on day 7, angiographic measures of reperfusion [Thrombolysis in Myocardial Infarction (TIMI) coronary flow grade, TIMI frames count and myocardial blush grade], incidence of complete ST-segment resolution at 2 hours after reperfusion, area under the curve for troponin T, and rates of major adverse cardiovascular events at 30 days. RECOVER II will determine whether the addition of low-dose intracoronary reteplase early after wire-crossing as an adjunct to reperfusion treatment reduces infarct size in individuals with large anterior myocardial infarction. ClinicalTrials.gov Identifier: NCT04571580.

Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials.

BackgroundThrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden.ObjectivesThis meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI).MethodsA comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)).ResultsTwelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85–7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60–8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48–11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13–0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes.ConclusionsCompared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.

Elevated plasma homocysteine level is associated with poor ST-segment resolution in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention at high altitude

Abstract Background and purpose: Poor ST-segment resolution (STR) is strongly associated with poor prognosis in patients with ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). previous studies suggested higher HCY level in the people who live in high altitudes, so a retrospective analysis is conducted to examine the potential relationship between elevated serum HCY and poor STR after PPCI at high altitudes. Methods: This retrospective analysis included 308 high-altitude dwelling patients (1800-2200 meters elevation from the sea level) undergoing PPCI for STEMI during a period from September 2021 to March 2022. Clinical data were collected and statistically analyzed. Results: In comparison to the patients with normal plasma homocysteine (≤15 mmol/L; n = 155), patients with elevated homocysteine (&gt;15 mmol/L) had higher percentage of men (92.81% vs. 80.00%; p = 0.001) and smoker (79.08% vs. 63.87%; p = 0.003), but no difference in other key baseline characteristics. The rate of complete ST-segment resolution after PPCI (≥ 70%) was 83.23% in the control group and 49.67% in the elevated HCY group (p ≤ 0.001). In multivariable regression analysis, poor ST-segment resolution (&lt;70%) was independently associated with longer pain-to-balloon time (OR 0.832; 95%CI: 0.775–0.894), lower uric acid (OR 1.003; 95%CI: 1.000-1.005), and elevated HCY (OR 0.957 vs. normal HCY; 95%CI: 0.937–0.977). Conclusion: Elevated plasma HCY level was associated with poor ST segment resolution in patients undergoing PPCI STEMI at high altitude.

Primary Percutaneous Coronary Intervention with High-Bolus Dose Tirofiban: The FASTER (Favorite Approach to Safe and Effective Treatment for Early Reperfusion) Multicenter Registry.

Objectives To investigate the safety and clinical efficacy of tirofiban during primary percutaneous coronary interventions (pPCI). Background Gp IIb/IIIa inhibitors (GPI) use during pPCI has declined over years, mainly for the increased hemorrhagic risk associated to their use and for the availability of potent, fast-acting oral antiplatelet drugs. However, several pharmacodynamic studies showed suboptimal platelet inhibition with P2Y12-blockers, such as prasugrel or ticagrelor. Methods Patients with ST-segment elevation myocardial infarction (STEMI) undergoing pPCI were prospectively enrolled in a multicenter registry conducted in high-volume centers in Italy. All patients received intraprocedural tirofiban. The primary safety endpoint was the occurrence of in-hospital bleedings according to the Bleeding Academic Research Consortium definition. In-hospital major adverse coronary events (MACE, defined as death, reinfarction, stent thrombosis, and target vessel revascularization), final TIMI flow, myocardial blush grade, and ST-segment resolution were also evaluated. Results A total of 472 patients (mean age 61 ± 11 years, 83% males) were enrolled in 16 Italian centers from October 2015 to June 2018. Mean basal thrombus grade score was 3.47 ± 1.25. PCI was performed by transradial approach in 88% of patients. We observed a very low rate of 30 days BARC bleedings (2.1%) and MACE (0.8%). Complete (>70%) ST-segment resolution was observed in 67% of patients. Conclusions In the FASTER registry, the use of tirofiban during primary PCI, performed with a transradial approach in most cases, in patients with high thrombus burden was associated with high rates of complete ST-segment resolution and low rates of in-hospital bleeding and MACE.

Association of Total Ischemic Times and In-Hospital Outcomes of Acute STEMI Patients who Underwent Primary Angioplasty at a Tertiary Cardiac Care Facility

Aims: To determine the association between total ischemic time and in-hospital outcome of acute ST elevation myocardial infarction (STEMI) patients who underwent primary angioplasty.&#x0D; Study Design: Prospective observational study.&#x0D; Place &amp; Duration of Study: Department of Cardiology, Dow university of health sciences Karachi between October 2017 till March 2021.&#x0D; Methodology: Data for total ischemic time analysis were collected from 366 STEMI patients who consecutively underwent primary angioplasty. Total ischemic time was measured from the onset of chest pain to o the first balloon inflation during primary angioplasty and in hospital outcome was measured.&#x0D; Results: Total ischemic times were available in 366 STEMI patients which was ≥ 30 minutes and &lt; 24 hours: ≤ 2 hours in 15.5%, &gt;2-3 hours in 11.4%, &gt;3-5 hours in 25.4%, and &gt;5 hours in 47.5% of STEMI patients. In addition, STEMI patients with total ischemic times &lt;5 hours demonstrated complete ST-segment resolution and reduced death rate than those with total ischemic times &gt;5 hours.&#x0D; Conclusion: This study showed that shorter ischemic times are significantly related to improved myocardial reperfusion and decreased mortality.

Intravenous nicorandil during primary percutaneous coronary intervention in patients with ST-Elevation myocardial infarction: Rationale and design of the Clinical Efficacy and Safety of Intravenous Nicorandil (CLEAN) trial

The efficacy and safety of intravenous infusion of nicorandil during primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) remain uncertain. The primary objective of the CLinical Efficacy and sAfety of intravenous Nicorandil (CLEAN) trial is to evaluate the long-term efficacy and safety of intravenous administration of nicorandil as adjuncts to reperfusion therapy in patients with STEMI undergoing primary PCI. The CLEAN trial is a multicenter, randomized, double-blind, placebo-controlled trial that will enroll 1,500 patients from 40 centers across china. patients were randomly (1:1) assigned to receive intravenous nicorandil (6 mg as a bolus before reperfusion, followed by 48 hours of continuous infusion at a dose of 6 mg/h after coronary intervention) or the same dose of placebo according to randomization. The primary efficacy outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, target vessel revascularization, and unplanned hospitalization for heart failure within 12 months. The secondary efficacy outcomes included the individual components of the combined efficacy endpoint, incidence of slow coronary flow after PCI, and incidence of complete ST-segment resolution at 2 hours after PCI. the safety outcomes included the incidence of hypotension after drug infusion and other adverse events during medication. CLEAN will determine whether the addition of intravenous nicorandil as adjuncts to reperfusion therapy reduces the major adverse cardiovascular events in STEMI patients undergoing primary PCI. ClinicalTrials.gov, NCT04665648.