Contemporary ST-segment Elevation Myocardial Infarction Research Articles

Impact of diabetes on epicardial reperfusion and mortality in a contemporary STEMI population undergoing mechanical reperfusion: insights from the ISACS STEMI COVID 19 Registry

Background and AimDiabetes has been shown in last decades to be associated with a significantly higher mortality among patients with ST‐segment elevation myocardial infarction (STEMI) treated with primary PCI (PPCI). Therefore, the aim of current study was to evaluate the impact of diabetes on times delays, reperfusion and mortality in a contemporary STEMI population undergoing PPCI, including treatment during the COVID pandemic. Methods and ResultsThe ISACS-STEMI COVID-19 is a large-scale retrospective multicenter registry involving PPCI centers from Europe, Latin America, South-East Asia and North-Africa, including patients treated from 1st of March until June 30, 2019 and 2020. Primary study endpoint of this analysis was in-hospital mortality. Secondary endpoints were postprocedural TIMI 0-2 flow and 30-day mortality. Our population is represented by 16083 STEMI patients. A total of 3812 (23,7%) patients suffered from diabetes. They were older, more often males as compared to non-diabetes. Diabetic patients were less often active smokers and had less often a positive family history of CAD, but they were more often affected by hypertension and hypercholesterolemia, with higher prevalence of previous STEMI and previous CABG. Diabetic patients had longer ischemia time, had more often anterior MI, cardiogenic shock, rescue PCI and multivessel disease. They had less often out-of-hospital cardiac arrest and in-stent thrombosis, received more often a mechanical support, received less often a coronary stent and DES. Diabetes was associated with a significantly impaired postprocedural TIMI flow (TIMI 0-2: 9.8% vs 7.2%, adjusted OR [95% CI] = 1.17 [1.02-1.38], p = 0.024) and higher mortality (in-hospital: 9.1% vs 4.8%, Adjusted OR [95% CI] =1.70 [1.43-2.02], p < 0.001); 30-day mortality (10.8% vs 6%, Adjusted HR [95% CI] =1.46 [1.26-1.68], p < 0.001) as compared to non-diabetes, particularly during the pandemic. ConclusionsOur study showed that in a contemporary STEMI population undergoing PPCI, diabetes is significantly associated with impaired epicardial reperfusion that translates into higher in-hospital and 30-day mortality, particularly during the pandemic.

Association of Frailty With In-hospital and Long-term Outcomes Among STEMI Patients Receiving Primary Percutaneous Coronary Intervention

BackgroundFrailty is generally a marker of worse prognosis. The impact of frailty on both in-hospital and long-term outcomes in ST-segment-elevation myocardial infarction (STEMI) patients has not been well described. Given this context, we aimed to determine the prevalence and impact of frailty on in-hospital and 1-year outcomes in STEMI patients undergoing primary percutaneous coronary intervention (pPCI). MethodsThis retrospective study reviewed STEMI patients aged ≥ 65 years who underwent pPCI at 1 of the 2 pPCI-capable hospitals at Vancouver Coastal Health. A frailty index (FI) was determined using a deficit-accumulation model, with those with an FI > 0.25 being defined as frail. The primary outcome was 1-year all-cause mortality. The secondary outcomes included in-hospital all-cause mortality, a composite of adverse in-hospital outcomes (all-cause mortality, cardiogenic shock, heart failure, reinfarction, major bleeding, or stroke), and the individual components of the composite. ResultsA total of 1579 patients were reviewed, of which 228 (14.4%) were determined to be frail. After multivariable adjustment, greater frailty (ie, increasing FI) was associated with increased in-hospital all-cause mortality (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.50-2.35, P < 0.001), the composite adverse in-hospital outcome (OR, 1.46; 95% CI, 1.27-1.68, P < 0.001), and 1-year all-cause mortality (OR, 1.48; 95% CI, 1.10-2.00, P = 0.011). ConclusionsIn a contemporary STEMI cohort of older patients receiving pPCI, 1 in 7 patients were frail, with greater frailty being independently associated with increased in-hospital and long-term adverse outcomes. These findings highlight the need for the early recognition of frailty and implementation of an interdisciplinary approach toward the management of frail STEMI patients.

Race-Based Differences in ST-Segment-Elevation Myocardial Infarction Process Metrics and Mortality From 2015 Through 2021: An Analysis of 178 062 Patients From the American Heart Association Get With The Guidelines-Coronary Artery Disease Registry.

Systems of care have been developed across the United States to standardize care processes and improve outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). The effect of contemporary STEMI systems of care on racial and ethnic disparities in achievement of time-to-treatment goals and mortality in STEMI is uncertain. We analyzed 178 062 patients with STEMI (52 293 women and 125 769 men) enrolled in the American Heart Association Get With The Guidelines-Coronary Artery Disease registry between January 1, 2015, and December 31, 2021. Patients were stratified into and outcomes compared among 3 racial and ethnic groups: non-Hispanic White, Hispanic White, and Black. The primary outcomes were the proportions of patients achieving the following STEMI process metrics: prehospital ECG obtained by emergency medical services; hospital arrival to ECG obtained within 10 minutes for patients not transported by emergency medical services; arrival-to-percutaneous coronary intervention time within 90 minutes; and first medical contact-to-device time within 90 minutes. A secondary outcome was in-hospital mortality. Analyses were performed separately in women and men, and all outcomes were adjusted for age, comorbidities, acuity of presentation, insurance status, and socioeconomic status measured by social vulnerability index based on patients' county of residence. Compared with non-Hispanic White patients with STEMI, Hispanic White patients and Black patients had lower odds of receiving a prehospital ECG and achieving targets for door-to-ECG, door-to-device, and first medical contact-to-device times. These racial disparities in treatment goals were observed in both women and men, and persisted in most cases after multivariable adjustment. Compared with non-Hispanic White women, Hispanic White women had higher adjusted in-hospital mortality (odds ratio, 1.39 [95% CI, 1.12-1.72]), whereas Black women did not (odds ratio, 0.88 [95% CI, 0.74-1.03]). Compared with non-Hispanic White men, adjusted in-hospital mortality was similar in Hispanic White men (odds ratio, 0.99 [95% CI, 0.82-1.18]) and Black men (odds ratio, 0.96 [95% CI, 0.85-1.09]). Race- or ethnicity-based disparities persist in STEMI process metrics in both women and men, and mortality differences are observed in Hispanic White compared with non-Hispanic White women. Further research is essential to evolve systems of care to mitigate racial differences in STEMI outcomes.

Sex-stratified differences in early antithrombotic treatment response in patients presenting with ST-segment elevation myocardial infarction

The mechanisms underlying the increased risk of bleeding that female patients with ST-segment Elevation Myocardial Infarction (STEMI) exhibit, remains unclear. The present report assessed sex-related differences in response to pre-hospital dual antiplatelet therapy (DAPT) initiation in patients with STEMI. The COMPARE CRUSH trial randomized patients presenting with STEMI to receive a pre-hospital loading dose of crushed or integral prasugrel tablets in the ambulance. In this substudy, we compared platelet reactivity levels and the occurrence of high platelet reactivity (HPR; defined as platelet reactivity ≥208) between sexes at 4 prespecified time points after DAPT initiation, and evaluated post-PCI bleeding between groups. Out of 633 STEMI patients, 147 (23%) were female. Females compared with males presented with significantly higher levels of platelet reactivity and higher HPR rates at baseline (232 [IQR, 209-256] vs 195 [IQR, 171-220], P < .01, and 76% vs 41%, OR 4.58 [95%CI, 2.52-8.32], P < .01, respectively). Moreover, female sex was identified as the sole independent predictor of HPR at baseline (OR 5.67 [95%CI, 2.56-12.53], P < .01). Following DAPT initiation, levels of platelet reactivity and the incidence of HPR were similar between sexes. Post-PCI bleeding occurred more frequently in females compared with males (10% vs 2%, OR 6.02 [95%CI, 2.61-11.87], P < .01). Female sex was an independent predictor of post-PCI bleeding (OR 3.25 [95%CI, 1.09-9.72], P=.04). In this contemporary STEMI cohort, female STEMI patients remain at risk of bleeding complications after primary PCI. However, this is not explained by sex-specific differences in the pharmacodynamic response to pre-hospital DAPT initiation.

Contemporary approach to thrombus containing lesions during primary percutaneous coronary interventions in ST-segment elevation myocardial infarction (from the ORPKI National Registry in Poland)

Abstract Background In the era of potent P2Y12 inhibitors, according to current guidelines on ST-segment elevation myocardial infarction (STEMI), treatment with glycoprotein IIb/IIIa inhibitors (GPI) should be limited to selected bail-out or highly thrombotic situations. Similarly, aspiration thrombectomy (AT) is downgraded in current guidelines for very selective but not routine usage. Both recommendations make the treatment of thrombus containing lesions somewhat defensive, underlining the need for an individualized approach to STEMI patients. However, data concerning current clinical practice of such approach are limited. Purpose We examined the prevalence, procedural characteristics, and predictors of GPI administration and AT usage in all-comers contemporary STEMI patients referred to primary PCI in Poland. Methods We focused on 116,873 consecutive STEMI patients undergoing primary PCI in Poland between 2015 and 2020. Results GPIs were administered in 29.3% of patients and AT was used in 11.6%, with combined treatment with GPI and AT in 6.1% of patients. There was a slight trend towards a decrease in GPI and AT usage during the analyzed years. On the opposite, there was a rapid growth of the ticagrelor/prasugrel usage rate from 6.5% in 2015 to 48.1% in 2020 (Figure 1). Patients with periprocedural GPI administration and combined strategy with GPI and AT were younger, more often men, with history of smoking and presented with cardiogenic shock on admission. They were less likely to have diabetes, chronic kidney disease and previous stroke. Occluded infarct-related artery in baseline angiography and no-reflow during PCI were the strongest independent predictors of GPI administration and combined usage of GPI and AT in a multivariate logistic regression model. Similarly, administration of ticagrelor/prasugrel was an independent predictor of both adjunctive treatment strategies (see table for details). Conclusions Despite the rapid growth of potent P2Y12 inhibitors usage in Poland in recent years, GPI and AT are selectively used at a stable level during primary PCI in highly thrombotic STEMI lesions. Funding Acknowledgement Type of funding sources: None.

Predictors and periprocedural outcomes of access crossover during primary percutaneous coronary interventions - a contemporary report from the Polish ORPKI registry.

The radial artery became preferable access for percutaneous coronary interventions (PCI). The latest European Society of Cardiology guidelines strongly recommended transradial access in patients with ST-segment elevation myocardial infarction (STEMI). Though, in a significant portion of the coronary artery, invasive procedure crossover to femoral is necessary. This study aimed to determine the ratio, risk factors, and periprocedural outcomes of crossover from radial to femoral access during PCI in a contemporary STEMI registry. Based on data from the Polish registry ORPKI, we analyzed 90245 patients with a diagnosis of STEMI that were intended to be treated invasively via transradial access between 2014 and 2019. In 1484 (1.6 %) individuals, a switch to femoral access was necessary during the procedure. The most important independent predictors of vascular crossover were female sex, previous coronary artery bypass graft, class 3 and 4 of the Killip scale, left main disease, as well as any complications during coronary angiography. In that cohort, the risk of bleeding at the puncture site was over 20-fold higher. Major disparities in periprocedural outcomes (death during procedure, cardiac arrest during PCI, Thrombolysis In Myocardial Infarction (TIMI) after PCI, and no-reflow) between these groups resulted from disparities in initial characteristics, and they were not associated with crossover itself. Even though the risk of crossover to femoral is currently low, it appears to be indispensable to sustain operators' experience both in radial and femoral approaches to achieve the best outcomes in these patients.

Sex differences in time to primary percutaneous coronary intervention and outcomes in patients presenting with ST-segment elevation myocardial infarction.

We assessed sex differences in treatment and outcomes in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI). Historically, delays to timely reperfusion and poorer outcomes have been described in women who suffer STEMI. However, whether these sex discrepancies still exist with contemporary STEMI treatment remains to be evaluated. Consecutive STEMI patients treated with primary PCI patients over a 10-year period (January 1, 2010 to December 31, 2019) from a tertiary referral center were assessed. Comparisons were performed between patient's sex. Primary outcomes were 30-day and 1-year mortality. Secondary outcomes were STEMI performance measures. Most patients (n = 950; 76%) were male. Females were on average older (66.8vs. 61.4 years males; p < 0.001). Prehospital treatment delays did not differ between sexes (54 min [IQR: 44-65] females vs. 52 min [IQR: 43-62] males; p = 0.061). STEMI performance measures (door-to-balloon, first medical contact-to-balloon [FMCTB]) differed significantly with longer median durations in females and fewer females achieving FMCTB < 90 min (28% females vs. 39% males; p < 0.001). Women also experienced greater rates of initial radial arterial access failure (11.3% vs. 3.1%; p < 0.001). However, there were no significant sex differences in crude or adjusted mortality between sexes at 30-days (3.6% male vs. 5.1% female; p = 0.241, adjusted OR: 1.1, 95%CI: 0.5-2.2, p = 0.82) or at 1-year (4.8% male vs. 6.8% female; p = 0.190, adjusted OR: 1.0, (95%CI: 0.5-1.8; p = 0.96). Small discrepancies between sexes in measures of timely reperfusion for STEMI still exist. No significant sex differences were observed in either 30-day or 1-year mortality.

Postprocedure Anticoagulation in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

This study sought to assess the association between postprocedural anticoagulation (PPAC) use and several clinical outcomes. PPAC after primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI) may prevent recurrent ischemic events but may increase the risk of bleeding. No consensus has been reached on PPAC use. Using data from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome registry, conducted between 2014 and 2019, we stratified all STEMI patients who underwent pPCI according to the use of PPAC or not. Inverse probability of treatment weighting and a Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality and the primary safety endpoint was major bleeding. Of 34,826 evaluable patients, 26,272 (75.4%) were treated with PPAC and were on average younger, more stable at admission with lower bleeding risk score, more likely to have comorbidities and multivessel disease, and more often treated within 12 hours of symptom onset than those without PPAC. After inverse probability of treatment weighting adjustment for baseline differences, PPAC was associated with significantly reduced risk of in-hospital mortality (0.9% vs 1.8%; HR: 0.62; 95%CI: 0.43-0.89; P< 0.001) and a nonsignificant difference in risk of in-hospital major bleeding (2.5% vs 2.2%; HR: 1.05; 95%CI: 0.83-1.32; P = 0.14). PPAC in STEMI patients after pPCI was associated with reduced mortality without increasing major bleeding complications. Dedicated randomized trials with contemporary STEMI management are needed to confirm these findings.

Predictive Utility of Reperfusion Criteria in Predicting Occluded Infarct-Related Artery in Patients With ST-Elevation Myocardial Infarction

Current guidelines recommend resolution of angina and >50% resolution in ST-elevation as criteria for successful fibrinolysis in ST-segment elevation myocardial infarction (STEMI). However, these criteria were determined from small studies during the streptokinase era and have not been re-validated in modern pharmacoinvasive regimens. This study sought to evaluate the predictive utility of reperfusion criteria following fibrinolysis to diagnose occluded infract-related artery (IRA) in contemporary STEMI management.

Post-procedure anticoagulation in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background Post-procedural anticoagulation (PPAC) after primary percutaneous coronary intervention (pPCI) in patient with ST-segment elevation myocardial infarction (STEMI) may prevent recurrent ischemic events but may increase the risk of bleeding. No consensus has been reached on PPAC use. Methods Using data from the CCC-ACS registry, conducted between 2014 and 2019, we stratified all STEMI patients who underwent pPCI according to the use of PPAC or not. Inverse probability of treatment weighting (IPTW) and Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality, and the primary safety endpoint was major bleeding. Results Of 34,826 evaluable patients 26,272 (75.4%) were treated with PPAC, and were on average younger, more stable at admission with lower bleeding risk score, more likely to have comorbidities and multivessel disease, and more often treated within 12 hours of symptom onset than those without PPAC. After IPTW adjustment for baseline differences, PPAC was associated with significantly reduced risk of in-hospital mortality (0.9% vs. 1.8%; hazard ratio (HR): 0.62 [95% confidence interval 0.43, 0.89]; p&amp;lt;0.001) and a nonsignificant difference in risk of in-hospital major bleeding (2.5% vs. 2.2%; HR: 1.05 [0.83, 1.32]; p=0.14). Conclusions PPAC in STEMI patients after pPCI was associated with reduced mortality without increasing major bleeding complications. Dedicated randomized trials with contemporary STEMI management are needed to confirm these findings. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The Improving Care for Cardiovascular Disease in China – Acute Coronary Syndrome (CCC-ACS) project is a collaborative study of the American Heart Association (AHA) and the Chinese Society of Cardiology (CSC). The AHA has been funded by Pfizer and AstraZeneca for quality improvement initiatives through an independent grant. In-hospital clinical outcomes

Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post-ST-Segment-Elevation Myocardial Infarction.

BackgroundGuidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post‐Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real‐world utilization of MRAs for patients with ST‐segment–elevation myocardial infarction (STEMI) with left ventricular dysfunction.Methods and ResultsThe prospective, population‐based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post‐STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis‐dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow‐up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26–1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11–1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription.ConclusionsIn this contemporary STEMI cohort, only 1 in 4 MRA‐eligible patients were prescribed an MRA within 3 months following hospitalization despite high‐quality evidence for use. Novel decision‐support tools are required to optimize pharmacotherapy decisions during hospitalization and follow‐up to target this gap in post‐STEMI care.

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.

Correlates and Long-Term Implications of Left Ventricular Mechanical Dispersion by Two-Dimensional Speckle-Tracking Echocardiography in Patients with ST-Segment Elevation Myocardial Infarction

Left ventricular (LV) mechanical dispersion (LVMD), measured with speckle-tracking echocardiography (STE) after ST-segment elevation myocardial infarction (STEMI), has been proposed as a measurement of regional heterogeneity of myocardial contraction and may reflect changes in the myocardial structure (e.g., fibrosis or edema). Further insight into this parameter may aid in the risk stratification of STEMI patients. A total of 1,000 STEMI patients (77% male, 60±12years) treated with primary percutaneous coronary intervention were retrospectively analyzed. The LVMD was assessed with two-dimensional STE within 48hours following the index infarction. Patients were followed for the occurrence of all-cause mortality. After a median follow-up of 117months, 229 (23%) patients died. Nonsurvivors showed worse LV ejection fraction (43%±10% vs 48%±9%; P<.001) and global longitudinal strain (-12.0%±3.5% vs -14.2%±3.5%; P=.001) and prolonged LVMD (63 [interquartile range, 50-85] msec vs 52 [interquartile range, 42-63] msec; P<.001) compared with survivors. Increasing age, systolic blood pressure, and heart rate at discharge as well as diabetes mellitus, anterior STEMI, TIMI flow < 2, less usage of angiotensin converter enzyme inhibitors or angiotensin receptor blockers, and impaired LV global longitudinal strain were independently associated with more prolonged LVMD. On multivariable analysis, prolonged LVMD was independently associated with increased risk of all-cause mortality (hazard ratio=1.012; 95% CI, 1.005-1.018; P=.001) and had incremental value for all-cause mortality over clinical and echocardiographic parameters. In contemporary STEMI patients, prolonged LVMD was associated with various clinical and echocardiographic parameters. Prolonged LVMD was associated with worse long-term outcome.

On- Versus Off-Hours Presentation and Mortality of ST-Segment Elevation Myocardial Infarction Patients Treated With Primary Percutaneous Coronary Intervention

ObjectivesThe authors sought to assess the association between admission time with patient’s care, procedure characteristics, and clinical outcomes within a contemporary ST-segment elevation myocardial infarction (STEMI) network of patients referred for primary percutaneous coronary intervention (PCI). BackgroundThe effect of admission time on STEMI patient's outcomes remains controversial when primary PCI is the preferred reperfusion strategy. MethodsCharacteristics and clinical outcomes of 2,167 consecutive STEMI patients admitted in a tertiary PCI-capable center were collected. On-hours were defined as admission from Monday through Friday between 8 am and 6 pm and off-hours as admission during night shift, weekend, and nonworking holidays. In-hospital and 1-year all-cause mortality were assessed as well as key time delays. ResultsA total of 1,048 patients (48.3%) were admitted during on-hours, and 1,119 patients (51.7%) during off-hours. Characteristics were well-balanced between the 2 groups, including rates of cardiac arrest (7.9% vs. 8.8%; p = 0.55) and cardiogenic shock (12.3% vs. 14.7%; p = 0.16). Median symptom-to-first medical contact time and median first medical contact-to-sheath insertion time did not differ according to on- versus off-hours admission (120 min vs. 126 min; p = 0.25 and 90 min vs. 93 min; p = 0.58, respectively), as well as the rate of radial access for catheterization (85.6% vs. 87.5%; p = 0.27). There was no association between on- versus off-hours groups and in-hospital (8.1% vs. 7.0%; p = 0.49) or 1-year mortality (11.0% vs. 11.1%; p = 0.89), respectively. ConclusionsIn a contemporary organized STEMI network, patients admitted in a high-volume tertiary primary PCI center during on-hours or off-hours had similar management and 1-year outcomes.

P957Survival benefits of routine glycoprotein IIb/IIIa inhibitors during primary PCI in ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials

Abstract Background Cardiovascular guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPI) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI). Purpose This study aimed to evaluate routine GPI use in STEMI treated with primary PCI. Methods Online databases were systematically searched for randomised controlled trials (RCTs) of routine GPI vs. control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis using Mantel-Haenszel estimates of risk ratios (RR) as summary statistics. Results After systematic review, twenty-one RCTs with 8,585 patients were included: ten trials randomized tirofiban (T), nine abciximab (A), one eptifibatide (E), one trial used A+T; only one trial used DAPT with prasugrel/ ticagrelor. Routine GPI were associated with a significant reduction in all-cause mortality at 30 days (2.4% (GPI) vs. 3.2%; risk ratio (RR) 0.72; p=0.01) and 6 months (3.7% vs. 4.8%; RR 0.76; p=0.02), and a reduction in recurrent MI (1.1% vs. 2.1%; RR 0.55; p=0.0006), repeat revascularization (2.5% vs. 4.1%; RR 0.63; p=0.0001), TIMI flow &lt;3 after PCI (5.4% vs. 8.2%; RR 0.61; p&lt;0.0001) and ischemic stroke (RR 0.42; p=0.04). Major (4.7% vs. 3.4%; RR 1.35; p=0.005) and minor bleedings (7.2% vs. 5.1%; RR 1.39; p=0.006) but not intracranial bleedings (0.1% vs. 0%; RR 2.7; p=0.37) were significantly increased under routine GPI. Conclusions Routine GPI administration during primary PCI in STEMI resulted in mortality reduction, driven by reductions in recurrent ischemic events – however predominantly in trials pre-prasugrel/ticagrelor. Trials in contemporary STEMI management are needed to confirm these findings.

Risk factors of late cardiogenic shock and mortality in ST-segment elevation myocardial infarction patients.

The incidence of cardiogenic shock (CS) in patients with ST-segment elevation myocardial infarction (STEMI) is as high as 10%. The majority of patients are thought to develop CS after admission (late CS), but the incidence in a contemporary STEMI cohort admitted for primary percutaneous intervention remains unknown. The aim of this study was to assess the incidence and time of CS onset in patients with suspected STEMI admitted in two high-volume tertiary heart centres and to assess the variables associated with the development of late CS. We included consecutive patients admitted for acute coronary angiography with suspected STEMI in a 1-year period. Cardiogenic shock was based on clinical criteria and subdivided into patients with shock on admission, patients developing shock during catheterisation and patients developing shock later during hospitalisation. Follow-up for all-cause mortality was done using registries. A total of 2247 patients with suspected STEMI were included, whereof 225 (10%) developed CS. The majority (56%) had CS on admission, 16% developed CS in the catheterisation laboratory and 28% developed late CS. Thirty-day mortality was 3.1% versus 47% in non-CS versus CS patients ( plogrank < 0.0001). Age, stroke, time from symptom onset to intervention, anterior STEMI, heart rate/systolic blood pressure ratio and being comatose after resuscitation from cardiac arrest were independently associated with the development of late CS. In this study, 10% of patients admitted with suspected STEMI for acute coronary angiography presented with or developed CS. Most were in shock on admission. Irrespective of the timing of shock, mortality was high.

Abstract 20119: Incidence and Predictors of Left Ventricular Thrombus in ST Elevation Myocardial Infarction

Introduction: Anticoagulation with coumadin is often employed after anterior ST-segment elevation myocardial infarction (STEMI) complicated by left ventricular (LV) dysfunction to prevent LV thrombus and cardioembolic events. However, the combination of dual antiplatelet therapy used for coronary stents and coumadin has been repeatedly shown to have a high incidence of bleeding. The current guidelines give coumadin a class II recommendation and support an individualized approach to treatment. Hypothesis: Determining the incidence and predictors of LV thrombus in a contemporary STEMI population at high risk for LV thrombus may assist in clinical decision making. Methods: Anterior STEMI patients at our institution between 2006 and 2013 treated with primary percutaneous intervention (PCI) that had an echocardiogram performed within 1 week and an ejection fraction of less than 40% or less than 50% with anterior apical akinesis were retrospectively identified. 687 patients with anterior STEMI were screened and 310 met inclusion. Demographic, clinical, and angiographic data was extracted from the medical record. Patients were categorized in 2 groups according to echocardiographic findings (no LV thrombus or probable/definite LV thrombus). The groups were compared by chi squared or T-test where appropriate. Logistic regression analysis was performed. Results: The mean age of the study population was 61.8% and 71.5% were male. The incidence of LV thrombus was 15% (n=263 no thrombus; n=47 probable/definite thrombus). Patients with LV thrombus were less likely to have hyperlipidemia, and more likely to have post procedure TIMI 0-1 flow and no stent use compared to patient with no LV thrombus. After adjustment, variables associated with LV thrombus risk were cardiac arrest (OR 4.06, 1.3-12.7), unfractionated heparin post PCI (2.43, 1.16-5.1), and stent use (DES 0.22, .06-.77, BMS 0.23 .07-.75, compared to balloon angioplasty). Conclusions: The incidence of LV thrombus in at risk STEMI patients remains high in contemporary practice. Development of a clinical risk score is limited by the lack of a sufficient number of predictive variables. Further investigation is needed to determine the optimal anticoagulation strategy in these patients.

Repeated echocardiography after first ever ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention – is it necessary?

Changes in left ventricular (LV) function using echocardiography and cardiac magnetic resonance (CMR) imaging were assessed in a contemporary ST-segment elevation myocardial infarction (STEMI) population to assess whether repeated imaging is necessary. In a prospective study patients with first STEMI were treated with primary percutaneous coronary intervention (PCI) and examined with 2D-echocardiography and CMR at baseline (<72 h) and at a three-month follow-up. A total of 138 patients were included (60±11 years). Using 2D-echocardiography at baseline preserved left ventricular ejection fraction (LVEF) (>50%) was found in 48 patients (35%), mild/moderate systolic dysfunction (35-50%) in 76 patients (55%) and severe dysfunction (<35%) in 14 patients (10%). Improvement in systolic function group was seen in 58 patients (64%) and 11 patients (79%) with severe systolic dysfunction at baseline were re-classified as having preserved or mild/moderate systolic dysfunction at follow-up. Irrespective of baseline LVEF, deterioration in systolic function group was noted in 14 patients (11%), but no patients declined from preserved to severe systolic dysfunction. The recovered myocardium measured with the myocardial salvage index by CMR was significantly lower with declining LVEF at baseline. The majority of patients with severely depressed LVEF immediately after STEMI significantly improved systolic function after three months. This study emphasises the importance of a repeated LV function assessment at follow-up in patients with mild/moderate or severe systolic dysfunction after STEMI, but re-assessment may not be needed in patients with preserved LVEF at baseline.

Comparison of Outcomes in Patients Aged

ST-segment elevation myocardial infarction (STEMI) is common in older adults and has high age-related mortality. We describe contemporary STEMI care using the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Network Registry-Get With The Guidelines (ACTION-GWTG) database. Patients with STEMI (n = 30,188) from 285 ACTION-GWTG sites from January 1, 2007 to June 30, 2008 were grouped by age (<75, 75 to 84, and ≥ 85 years) to compare baseline characteristics, reperfusion, and in-hospital outcomes. In this population, 79.7% (24,070) were <75 years old, 14.2% (4,273) were 75 to 84 years old, and 6.1% (1,845) were ≥ 85 years old (the oldest old). Compared to younger patients, the oldest-old patients (median age 88 years, interquartile range 86 to 91) were more often women, had more hypertension, and end-organ co-morbidity (heart failure and stroke, p <0.0001 for all). More than 42% of the oldest old were also cited as having contraindications to reperfusion, but with absolute or relative contraindications noted in only 10%, and patient preference was the most common reason indicated (45%). Even in reperfusion-eligible patients, the oldest old were less likely to receive it. Although patients who received reperfusion had better outcomes than those who did not, this was significant only for younger patients (< 75 years old, odds ratio 0.58, confidence interval 0.40 to 0.84). In conclusion, > 42% of the oldest old have reported contraindications to reperfusion, with neither mortality benefit nor harm in those who receive it. Disparities in process of care and co-morbidity may explain these observational findings. Whether efforts to optimize patient selection and initiate reperfusion therapy can improve outcomes in the oldest old with STEMI is unknown.