Reperfusion Criteria Research Articles

Expanding boundaries in stroke treatment: New horizons in revascularization strategies and critical decision-making

Ischemic stroke is one of the leading causes of mortality and long-term disability worldwide, emphasizing the need for rapid and effective acute management. Revascularization therapies are critical to this strategy, demanding swift intervention. Intravenous thrombolysis (IVT) with alteplase (ALT) was traditionally recommended within 4.5 h from symptom onset for acute ischemic stroke (AIS) patients. However, landmark studies, such as ECASS IV, EXTEND, and EPITHET have demonstrated that IVT may be extended up to 9 h in select patients, identified through perfusion imaging with computed tomography or magnetic resonance imaging, enabling differentiation of viable, at-risk brain tissue in the ischemic penumbra from the infarct core. This allows treatment in cases with favorable “mismatch” profiles, Similarly, endovascular procedures for large vessel occlusions (LVOs) were initially recommended within 6 h, but trials, such as DEFUSE-3 and DAWN have established efficacy for thrombectomy up to 16 – 24 h from the last known well time, using perfusion imaging to guide patient selection. These advancements prioritize tissue viability over rigid temporal thresholds. Despite significant progress, optimal revascularization strategies for AIS remain uncertain in complex clinical contexts, such as posterior circulation strokes, large infarct core AIS, distal vascular occlusions, and mild clinical deficit LVO-related AIS. Recent research aims to address these gaps, expanding reperfusion criteria and exploring new thrombolytic agents with potential benefits over ALT. Collectively, these studies aim to refine and broaden therapeutic criteria, improving outcomes for a wider AIS patient population.

Valor prognóstico do escore SYNTAX residual nos desfechos clínicos intra- hospitalares e de acompanhamento em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST submetidos à estratégia farmacoinvasiva

Background Multivessel coronary artery disease is a challenge in clinical practice. An individualized approach should consider not only the patient characteristics, but also a multidisciplinary approach, together with the Heart Team. Multiple angiographic scores have been proposed with the aim of quantifying the risk associated with multivessel coronary artery disease. Residual SYNTAX score has been proposed as a method to systematically characterize and quantify residual coronary disease after percutaneous coronary intervention. There are few data in the literature correlating the residual SYNTAX score in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive strategy. The objective of this study was to evaluate the SYNTAX score and residual SYNTAX score as predictors of in-hospital and medium-term outcomes (180 to 380 days) in patients with multivessel coronary artery disease in the setting of ST-segment elevation myocardial infarction, after successful fibrinolytic therapy. Methods In a cross-sectional, analytical, and prospective study, we evaluated residual SYNTAX score as predictor of in-hospital and medium-term outcomes (6 months to 1 year), in patients with multivessel coronary artery disease, in the setting of ST-segment elevation myocardial infarction after pharmacoinvasive strategy. Results Between August 2019 and December 2020, 108 patients with ST-segment elevation myocardial infarction after fibrinolysis, with reperfusion criteria, were analyzed. The mean SYNTAX score was 13.98 (±4.87) and the mean residual SYNTAX score was 7.56 (±4.47). High residual SYNTAX score was associated with contrast-induced nephropathy and major adverse cardiac event. It was also an independent predictor of major adverse cardiac event with a 9.69-fold increased risk (p=0.0274). Conclusion High residual SYNTAX score confers worse prognosis in patients with ST-segment elevation myocardial infarction after pharmacoinvasive strategy.

Role of fibrinolysis after the generalization of the primary percutaneous coronary intervention in the setting of ST-Elevation Acute Myocardial Infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Primary percutaneous coronary intervention (PCI) is the treatment of choice in patients with ST-Elevation Acute Myocardial Infarction (STEMI). Fibrinolysis is relegated to situations in which the intervention cannot be performed in the appropriate time. The indications for fibrinolysis and the criteria for reperfusion were established long ago. Furthermore, in many areas, patients undergoing fibrinolysis therapy represent a minority due to increased access to primary PCI-centres. Purpose We sought to evaluate the effectiveness of fibrinolysis and its safety compared to primary PCI in a real-world analysis. Methods This is a retrospective, observational, single-centre study in which we included patients with STEMI diagnosis admitted to the coronary unit from June-2011 to August-2022. It was differentiated if the patients underwent primary PCI or fibrinolysis (time to catheterization room >2 hours). The efficacy of fibrinolysis regarding the coronary reperfusion capability was analysed using the TIMI coronary grade flow scoring system. Similarly, the need for rescue PCI (<50% ST normalization, persistent chest pain or hemodynamic instability) was observed. We compared the baseline characteristics of the patients who underwent fibrinolysis versus those who only underwent a primary angioplasty strategy and the results in terms of complications and in-hospital mortality. Results 1604 patients were included with an average age of 62 years, in which 137 (8,4%) of them underwent a fibrinolysis strategy. The rate of patients with coronary occlusion (TIMI 0) at the time of PCI was significantly lower in the fibrinolysis group (77.1% vs 36.1%; p<0.001), which represents an estimated effectiveness of coronary recanalization of 53.2%. Initially, we found more smokers (46,0% vs 57,4% p = 0.01), and a younger age (62 vs 58, p<0,01) among patients who underwent fibrinolysis. No other differences were found in the remaining baseline characteristics (Table). A higher rate of ventricular arrhythmias (10,4% vs 16,0%; p=0.04) was demonstrated in the fibrinolysis group, but without showing differences in terms of mortality (5.7% vs 2.1%; p= NS.). No significant differences in bleeding (8.9% vs 10.9%; p=NS.) or intracranial hemorrhage (0.1% vs 0.7%, p= NS.) were found. Regarding rescue-PCI, it was necessary in 81 (59,12%) of the patients who underwent fibrinolysis. 70% of the patients who underwent rescue PCI had TIMI 0-1. In the patients treated with fibrinolysis who underwent early-PCI but not rescue-PCI, only 3 patients (6,5%) presented coronary occlusion (TIMI 0) at catheterization. Conclusion Fibrinolysis should continue to play an important role in patients who cannot reach PCI on time, given its effectiveness and because it does not represent a significant increase in mortality or adverse effects, except for ventricular arrhythmias. Likewise, the reperfusion criteria seem to be effective in differentiating patients with coronary reperfusion.

Diagnostic accuracy of reperfusion criteria following fibrinolysis for ST-elevation myocardial infarction

Diagnostic accuracy of reperfusion criteria following fibrinolysis for ST-elevation myocardial infarction

An unusual congenital coronary anomaly: A circumflex coronary artery arising in ``shotgun`` with the right coronary artery in anterior ST – elevation myocardial infarction

Objective: Coronary anomalies do not generate symptoms, it is incidental findings when performing a coronary angiography in a patient with ischemic heart disease or valvular heart disease. The anomalous origin of the circumflex (LCX) of the right coronary artery (RCA) is one of the common anomalies. We describe a case of CX orifice arising from right coronary sinus in a ``shotgun`` manner with orifice of RCA and successful percutaneous coronary intervention (PCI). Case Report: In this case, the anomalous incidental finding was the arising of the CX artery in “shotgun” shape with the RCA (separate ostium) in a clinic scenario of anterior ST-segment elevation myocardial infarction wherein the patient received fibrinolytic therapy with alteplase, presenting reperfusion criteria (&qt;50% ST-segment resolution at 60 minutes and relief angina) and then underwent to successful PCI. Conclusion: The ectopic origin of the CX is a well-recognized variant, which is considered the most common coronary anomaly. Although this anomaly is classified as benign and asymptomatic, a few cases of sudden death, myocardial infarction, and angina pectoris in the absence of atherosclerotic lesion have been reported. We shared successful PCI in such coronary anomaly in a patients with ST elevation anterior myocardial infarction. Such coronary anomalies should be considered as well in patients with STEMI undergoing PCI.

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.

Clinical outcomes of fibrinolytic therapy for prehospital treatment of acute myocardial infarction

Fibrinolytic Therapy (FT) is an important form of treatment for cases of Acute Myocardial Infarction (AMI), especially in those places where Primary Percutaneous Coronary Intervention (PPCI) is not available, which is the main form of treatment and can be used even in the prehospital care. Aimed to describe the clinical outcomes of the use of FT in prehospital care for treating patients with AMI. This research covered a total of 53 patients and was carried out from march to october 2017, referring to the care provided from january 2015 to december 2016 in two stages, in which the first occurred with the Mobile Emergency Service (SAMU) and Walk-in Emergency Care Units (UPA), and the second in the referenced hospital services as gateways to those units. Data were collected from secondary sources. The clinical outcomes of FT considered in the form of absolute and relative frequencies and measures of central tendency were considered. The main signs and symptoms at admission were chest pain (84.62%), sweating (36.54%), dyspnea (26.92%), hypertension (19.23%), nausea (17.31%), malaise (17.31%) and emesis (13.46%). The main characteristic of chest discomfort was chest pain (70.45%). The FT drug administered in all patients was tenecteplase. The median time from symptom-to-door was 180 minutes, while symptom-reperfusion was 300 minutes and door-to-needle 160 minutes. Regarding the outcome, 74.47% had clinical improvement, 19.15% died, 4.25% had refractory AMI and 2.13% had reinfarction. The main characteristic of clinical improvement was the reversal of chest pain (68.57%), characterized as myocardial reperfusion criteria. The present study presented the main outcomes of FT use with improvement of those patients who were treated with it, and shorter times related to chest discomfort and the administration of FT were responsible for increasing the outcomes of clinical improvement and decreasing the outcome of death.

STEMI treatment in remote areas – challenges of the only interventional angioplasty center located in an archipelago

Abstract Background In remote islands lack of specialized medical facilities, long distance transfer and emergency medical system organization remains a challenge and fibrinolysis is necessary to achieve revascularization in optimal timing in ST-elevation myocardial infarction (STEMI) patients. Our angioplasty center is the only one located in an archipelago composed of nine islands, six of which do not have hospital facilities and only have small family health care units. Purpose To evaluate the reality and outcomes of our interventional angioplasty center and compare cardiovascular outcomes between STEMI patients from the main island and remote islands. Methods We retrospectively evaluated 103 patients with STEMI admitted to our center between 2018 and 2019. Patients from the main island where the center is located underwent primary percutaneous coronary intervention (PCI) (group 1, n=55) and patients from remote islands underwent fibrinolytic therapy followed by transference to our center with facilitated or rescue PCI (group 2, n=48). A subanalysis of the far remote islands without hospital facilities was also performed. Primary outcome was defined as cardiovascular death or re-infarction at two years and secondary outcome as intrahospital haemorrhagic complications. Results Mean age was 58,15±12,6 years, 85,4% were males and follow up period was 30,30±6,46 months. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes and 17 (15,5%) were obese. Troponin I peak was 117,42±129,06 ug/L and 14 (13,6%) were in Killip Class III/IV. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). In group 1 reperfusion after PCI was obtained in 91,5%. In group 2, 73,5% met criteria for reperfusion after fibrinolysis and 23,6% after rescue PCI. Mean time from fibrinolysis to PCI was 558±349 minutes. Rates of successful revascularization did not differ between groups, as well as complete patency of the culprit-vessel defined as thrombolysis in myocardial infarction (TIMI) flow 3 (91,5% vs. 97,2% and 90,0% vs. 93,0% respectively for group 1 and 2). Cardiovascular death at two years occurred in 4 (3,9%) patients and re-infarction in 11 (10,7%) and were similar between groups (3 (5,5%) vs. 1 (2,1%) and 8 (14,5%) vs. 3 (6,3%) respectively) as well as haemorrhagic complications (1 (1,8%) vs. 5 (10,4%) respectively). Nineteen (18,4%) patients were from far remote islands without hospital facilities and when comparing these patients with the others there was also no difference in primary outcome. Conclusion Even in remote islands, an organized STEMI network with attempted fibrinolytic treatment and coordinated transference of patients for facilitated or rescue PCI can provide successful revascularization with cardiovascular outcomes similar to those submitted to primary PCI. Funding Acknowledgement Type of funding sources: None.

Inferior ST-Segment Elevation Myocardial Infarction with First-Degree Atrioventricular Block: A Case Report and Literature Review

Background: Atrioventricular (AV) block complicating acute inferior wall ST-elevation myocardial infarction (STEMI) is known to be associated with poor outcomes and increased rate of mortality.
 Case Report: We present the case of a 69-year old male patient, an active smoker, presented to the emergency department due to syncope 2 hours prior to admission. He reported symptoms while farming with sudden onset of diaphoresis, mild dizziness, and breathlessness followed by loss of consciousness for several minutes. Blood pressure was 79/55 mmHg, respiratory rate was 23, pulse was 46 bpm. Electrocardiogram showed inferior wall STEMI with first-degree AV block. Laboratory data revealed a significantly marked increase of CK-MB 82,5 U/L. STEMI protocol and fibrinolytic therapy has been done. The mechanisms of AV block and its spontaneous resolution in the setting of acute inferior wall STEMI are discussed. Attention is drawn to the patient due to our hospital categorized as an incapable cath lab sub-district hospital.
 Discussion: Clinical signs and examination suggested that this patient had a first-degree AV block complicating inferior wall STEMI on admission and fulfill the criteria of successful reperfusion 30 minutes following fibrinolytic therapy. Immediately after fibrinolysis, breathlessness was relieved, ST-T segment was reduced, spontaneous resolution of first-degree AV block occurred, and absence of Q-wave formation.
 Conclusion: Immediate reperfusion therapy is the core management of STEMI patients, including fibrinolytic therapy. Signs of successful therapy could be seen in this case and also relieved of the complication associated with STEMI. We found it as an incidence not much reported and thus reporting the case herewith.

Evolutionary and Prognostic Aspects of Thrombolysed Patients for Acute Coronary Syndrome ST+ at CHU Ernesto Guevara De La Serna. Las Tunas (Cuba)

Introduction: Acute myocardial infarction (IDM) occupies the first place in terms of mortality, among ischemic pathologies. Thrombolysis in the case of medical treatment for acute myocardial infarction (AMI) is undoubtedly the most revolutionary performed to date in this context, with a significant reduction in the mortality rate. The aim of our study was to describe the epidemiological aspects, the criteria for myocardial reperfusion post thrombolysis, the complications during thrombolysis and the complications of acute myocardial infarction in the cardiology department of the CHU Ernesto Guevara De La Serna of Las Tunas (Cuba). Methods: A retrospective cross-sectional descriptive study was carried out from June 2009 to December 2011. The patients hospitalized during this period in the USIC (coronary intensive care unit) for SCA ST(+) were included in the study. The variables studied were: Age, sex, myocardial reperfusion criteria, complications during thrombolysis and complications of myocardial infarction. Results: A total of 207 patients were included. The male sex represented 72.5% of the cases, giving a sex ratio of 2.63. The age group > 60 years was predominant with 54.2% of the cases. Thrombolysed patients represented 65.2% of the cases. Myocardial reperfusion criteria were observed in the majority of thrombolysed patients: relief of precordial pain (77%), regression of the ST segment to 50% of its previous level (81.5% of patients). Bleeding was observed in 1.5% of thrombolysed cases. Complications were encountered in 57% of non thrombolysed patients with a lethality of 5.6%. Conclusion: The male sex was the most affected. Thrombolysis was effective in the majority of patients. The post thrombolysis bleeding rate was low. More than half of the cases of SCA ST(+) not thrombolysed presented complications.

P5522ST elevation myocardial infarction networks: relationship of hub-spoke distance with transfer time and clinical outcomes in rescue PCI

Abstract Background In the establishment of ST elevation myocardial infarction (STEMI) systems of care, transfer times between primary care units (PCU) and the cardiac catheterization lab (CCL) are pillars to therapeutic success. Objective: To analyze the relationship between PCU-CCL distance with transport time and main clinical outcomes in STEMI patients (p) treated with pharmaco-invasive therapy (PIT) and referred for rescue PCI after failed fibrinolysis. Methods Between January 2010 and December 2018, of the 2241 patients who received tenecteplase in PCU inserted in a large city STEMI network, 801 (35.7%) evolved without reperfusion criteria after 90 minutes (persistence of chest pain, less than 50% reduction on ST elevation or hemodynamic instability), being urgently transferred to the CCL. The PCU were divided according to the distance to the tertiary center in Group 1: between 5 and 9km (N=208p), Group 2: between 16 and 18km (N=315p) and Group 3: between 22 and 30km=266p). Considering an alpha of 0.05, sample size n=801 and an effect size of 0.11, a power of 0.80 was obtained. Results The groups were comparable for baseline features (Table 1). Group 2 (intermediate distances) had the highest median transport time (G1 260 interquartile 145–437 min vs G2 355 interquartile 206–573 min vs G3 241 interquartile 125–418 min; p<0.01 for G2). There were no differences between the groups regarding cardiogenic shock (G1 24.5% vs G2 23.3% vs G3 24.1%, p=0.9) or in-hospital death (G1 17.4% vs G2 12.3% vs G3 13.0%, p=0.2). Table 1. Group's baseline features G1: Short distances G2: Intermediate distances G3: Long distances p value (5–9 km) N=208 (16–18 km) N=315 (22–30 km) N=266 Age (median) 57.5 (51–64) 57 (49–66) 59 (52–67) 0.27 Female 29.7% 28.3% 35.1% 0.19 Hypertension 67.3% 60.9% 64.4% 0.31 Diabetes 37.0% 32.1% 37.8% 0.30 Renal failure 10.3% 9.7% 6.3% 0.21 Anterior STEMI 56.1% 58.4% 62.4% 0.36 Pain-to-needle time (median min) 197.5 (137–330) 195 (120–295) 195 (125–345) 0.38 Conclusion In STEMI patients with failed fibrinolysis treated with pharmaco-invasive therapy, the PCU-CCL distance was not related to transfer time or to outcomes of in-hospital death and cardiogenic shock. The longer transport time of hospitals located at intermediate distance can possibly reflect local logistical difficulties and are not due to hub-spoke distance. Continuous improvement in structuring and coordination of public STEMI networks is aimed.

ST elevated myocardial infarction: clinical manifestation and outcomes of thrombolysis in a tertiary care hospital

Background: Acute myocardial infarction has reached enormous proportion in the developing countries and it is speculated that atherosclerotic heart disease will replace infectious disease as the leading cause of death in India. It has been shown that the thrombolytic therapy is underutilized. So, the study was taken to study the clinical manifestations and outcome of thrombolytic therapy in STEMI.Methods: The study was conducted for a period of 18 months in a tertiary care centre during which 100 cases of STEMI admitted to ICCU were included in the study, after fulfilling the inclusion criteria for thrombolysis, data related to clinical profile and outcome of thrombolysis was collected. SPSS 16 was used to analyse the data. Descriptive statistics like proportions mean and SD were computed.Results: Incidence of STEMI was high among subjects in the age group 51-60 years. Males were more affected (72%). Smoking, hypertension, hyperlipidemia and diabetes mellitus were the most common risk factors. Chest pain (92%) was the most common symptom. Majority (56%) were admitted within 6 hours of onset of symptoms. Anterior wall infarction was most common type of myocardial infarction. Majority (82%) were admitted in either Killips I/II class. Left Ventricular failure and Arrhythmias were most common complication. 64% patients had objective evidence in a form of ECG with ST-T resolution (>50%) between 1-6 hours, 18% between 6-24 hours and 18% patients had no significant resolution even after 24 hours. Echocardiography showed good left ventricle function (LVEF >45%) in 70% and 30% of the patients showed reduced ejection fraction (LVEF<45%). Mortality was seen in 8% of cases.Conclusions: Smoking, hyperlipidemia, diabetes mellitus and hypertension were most important risk factors for MI in the study. Coronary pain relief was most frequent and early marker of reperfusion. The ST segment elevation resolution has been widely accepted as most reliable objective criteria of coronary reperfusion. Hence ST segment resolution is regarded as a marker of salvaged myocardium by post-thrombolytic reperfusion. Early reperfusion of the ischaemic myocardial tissue with thrombolytic therapy decreases the morbidity and mortality.

Reperfusion Criteria in Patients Submitted to Fibrinolysis: Is There Room for Improvement?

Reperfusion Criteria in Patients Submitted to Fibrinolysis: Is There Room for Improvement?

Regional QT Interval Dispersion as an Early Predictor of Reperfusion in Patients with Acute Myocardial Infarction after Fibrinolytic Therapy.

BackgroundPatients with ST-elevation acute myocardial infarction attending primary care centers, treated with pharmaco-invasive strategy, are submitted to coronary angiography within 2-24 hours of fibrinolytic treatment. In this context, the knowledge about biomarkers of reperfusion, such as 50% ST-segment resolution is crucial.ObjectiveTo evaluate the performance of QT interval dispersion in addition to other classical criteria, as an early marker of reperfusion after thrombolytic therapy.MethodsObservational study including 104 patients treated with tenecteplase (TNK), referred for a tertiary hospital. Electrocardiographic analysis consisted of measurements of the QT interval and QT dispersion in the 12 leads or in the ST-segment elevation area prior to and 60 minutes after TNK administration. All patients underwent angiography, with determination of TIMI flow and Blush grade in the culprit artery. P-values < 0.05 were considered statistically significant.ResultsWe found an increase in regional dispersion of the QT interval, corrected for heart rate (regional QTcD) 60 minutes after thrombolysis (p = 0.06) in anterior wall infarction in patients with TIMI flow 3 and Blush grade 3 [T3B3(+)]. When regional QTcD was added to the electrocardiographic criteria for reperfusion (i.e., > 50% ST-segment resolution), the area under the curve increased to 0.87 [(0.78-0.96). 95% IC. p < 0.001] in patients with coronary flow of T3B3(+). In patients with ST-segment resolution >50% and regional QTcD > 13 ms, we found a 93% sensitivity and 71% specificity for reperfusion in T3B3(+), and 6% of patients with successful reperfusion were reclassified.ConclusionOur data suggest that regional QTcD is a promising non-invasive instrument for detection of reperfusion in the culprit artery 60 minutes after thrombolysis.

Use of low dose of alteplase in high risk of bleeding patients

Background: Peru has had an increasing tendency in acute stroke cases, causing a huge public health impact. Acute management in our conutry is limited only to IV thrombolysis. Many of our patientes come after that 3 hours and some of them have Relative exclusion criteria for acute reperfusion. The authors present 08 patients treated with a dose of 0.6 mg/kg of rTPA, aiming to assess equal efficacy and safety than the 0.9 mg/kg dose.

Protocolo sobre estratificación y factores de riesgo en pacientes con síndrome coronario agudo

Resumen Objetivos de la estratificacion del riesgo La evaluacion del riesgo en los pacientes con sindrome coronario agudo tiene varios objetivos: informar y aconsejar al paciente y a su familia, identificar a los pacientes con riesgo elevado de muerte o infarto susceptibles de mejorar su pronostico con un tratamiento adecuado, identificar a los sujetos con un riesgo muy bajo que no requieren estudios invasivos, de manera que se eviten los costes y riesgos innecesarios de estas tecnicas, y planificar la rehabilitacion cardiaca y la prevencion secundaria tras el episodio agudo. Estratificacion precoz del riesgo Se realiza durante la fase aguda intrahospitalaria valorando la magnitud del dano miocardico, los criterios de reperfusion exitosa y la presencia de marcadores clinicos de alto riesgo. La utilizacion de escores de prediccion del riesgo son de gran ayuda, siendo las puntuaciones GRACE y TIMI las mas utilizadas. Estratificacion tardia del riesgo Se realiza antes del alta e incluye la valoracion de una serie de marcadores clinicos para optimizar el manejo y el tratamiento a largo plazo.

COMPARATIVE RESULTS OF RECOMBINANT NON-IMMUNOGENIC STAPHYLOKINASE AND TENECTEPLASE USE IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION IN REAL CLINICAL PRACTICE

Aim . To compare the efficacy and safety of thrombolytic therapy with recombinant non-immunogenic staphylokinase and tenecteplase in ST elevation myocardial infarction (STEMI) in real clinical practice. Material and methods . 84 patients with onset of STEMI symptoms up to 12 hours ago were included into the non-experimental study with mixed design. Recombinant non-immunogenic staphylokinase and tenecteplase were used in 38 and 46 patients, respectively. The dynamics of the ST segment on the ECG, angiographic reperfusion criteria were evaluated as well as clinical outcomes – mortality, reinfarction, stroke, bleeding and allergic reactions. Results . The ST-segment resolution by 70% after 180 min was achieved in 66% and 66% of patients in recombinant non-immunogenic staphylokinase group and in tenecteplase group, respectively (p=0.66) as well as antegrade coronary blood flow through the infarct-related artery TIMI II-III in 61% and 67% of patients, respectively (p=0.63). Mortality and the rate of reinfarction, intracranial bleeding, stroke, cardiogenic shock, left ventricle aneurism and thrombosis were similar in both groups. Large bleeding (otherwise intracranial one) and allergic reactions were not registered. Conclusion . In real clinical practice the efficacy and safety of recombinant non-immunogenic staphylokinase and tenecteplase in STEMI are similar.

Renal Dysfunction on Admission Predicts No-Reflow Phenomenon in Patients Undergoing Manual Thrombus Aspiration during Primary Percutaneous Coronary Intervention.

No-reflow is a frequent complication during percutaneous coronary intervention (PCI) for acute ST segment elevation myocardial infarction (STEMI). Available data is limited regarding its impact on short-term outcomes in patients undergoing manual thrombus aspiration. Renal impairment is also associated with higher complication rates in STEMI. Herein, we aimed to evaluate the impact of baseline renal dysfunction on the no- reflow phenomenon and the association of no-reflow phenomenon with early clinical outcomes. A total of 94 consecutive STEMI patients who underwent primary stent-based PCI and thrombus aspiration were enrolled. No-reflow was established by the use of angiographic and electrocardiographic reperfusion criteria, respectively. Additionally angiographic and clinical follow-up data were also recorded. In our study, the no-reflow phenomenon was observed in 10 patients (11%) angiographically and in 23 patients (24%) electrocardiographically. Whereas, the the estimated glomerular filtration rate (eGFR) [odds ratio (OR) 10.4], hypertension (OR 6.2), previous MI (OR 6.5), previous PCI history, (OR 4.2), predilatation (OR 7.2), final balloon pressure (OR 0.9) were found to be the significant predictors of angiographic no-reflow, only reperfusion time was the predictor of electrocardiographic no-reflow (OR 1.12) at univariate analysis. After adjustment, lower eGFR (OR 14.8) was found to be the independent predictor for angiographic no-reflow. In-hospital mortality was more common in patients with either no-reflow condition separately. Longer ischemic time and lower initial eGFR values were associated with no-reflow phenomenon. Irrespective of poor reperfusion criteria, no-reflow phenomenon is associated with in-hospital outcome. Future efforts should be made to reduce the incidence of no-reflow especially in patients with lower initial eGFR values. Acute myocardial infarction • Glomerular filtration rate • No-reflow phenomenon • Primary percutaneous coronary intervention.

The usefulness of fQRS and QRS distortion for predicting reperfusion success and infarct-related artery patency in patients who underwent thrombolytic therapy.

The aim of this study is to determine whether the presence of fragmented QRS (fQRS) and QRS distortion on admission ECG can be used to predict the success of treatment before beginning thrombolytic therapy (TT). Two hundred and three eligible patients with acute ST elevation myocardial infarction who received TT consecutively between 1 January 2009 and 1 July 2013 were enrolled. The presence of fQRS and QRS distortion was analyzed at admission ECG. The electrocardiographic criteria of reperfusion were defined as 50% or more of ST resolution (STR), whereas the angiographic criteria of reperfusion were defined as thrombolysis in myocardial infarction 2/3 flow in the infarct-related artery. fQRS was detected in 63 (31%) patients. Compared with patients with non-fQRS, STR was lower (46.1±17.7 vs. 73.6±20.9, respectively; P<0.001), thrombolysis failure was higher (44.4 vs. 9.3%, respectively; P<0.001), and thrombolysis in myocardial infarction 0/1 flow was more common (39.7 vs. 10.7%, respectively; P<0.001) in patients with fQRS. Higher numbers of fQRS derivations were significantly related to low percentages of STR (r=-0.615, P<0.001). In predicting occluded infarct-related artery, we found no difference between the negative predictive values of fQRS and inadequate STR after TT (89.3 vs. 95.1%; P>0.05). However, there was no relationship between QRS distortion and failed thrombolysis. fQRS was detected in just 31% of the patients, but we found that it can be used to predict thrombolytic failure. Patients who have this simple marker on admission ECG may be directed to percutaneous interventions as a first-line therapy without any delay.

SPECTRAL HEART RATE VARIABILITY PARAMETERS, DELAYED VENTRICULAR POTENTIALS AND RATE TURBULENCE AS MARKERS OF CORONARY PERFUSION IN STEMI

Aim. To assess the dynamics of parameters representing rhythmical activity of the heart related to the efficacy of pharmaco-invasive revascularization in STEMI patients. Material and methods. Totally 56 STEMI patients included that had undergone effective thrombolysis by ECG criteria of reperfusion, after that in 3-24 hours the coronary arteriography and stenting was done. Before and after PCI the telemetric ECG registration was done via “Astrocard® — Telemetry” (Meditek Ltd.,Russia). The automatic analysis of spectral parameters was done for HRV, LVP, RT. Results. In coronary artery re-thrombosis development there is a decrease of spectrum power (TotP) (p=0,001) and increase of vagosympathic balance (L/H) (p=0,005) that points on the increase of autonomic regulation and decentralization of heart activity management. Backward dynamics is registered after successful PCI that might be related with the balance restoration between sympathetic and parasympathetic systems in effective revascularization. The tendency revealed to the increase of QRSf in re-thrombosis group and it is shown that in delayed PCI there is a growth of RMS (p=0,04), that points on the higher risk of electrical instability development. Conclusion. The markers of developing re-thrombosis of infarction-related artery in STEMI are increase of lower frequency parameters of HRV (VLfp and LfP), decrease of total spectrum power of HRV, increase of L/H index and increase of the duration of QRSf. In delayed PCI there are higher values of RMS that represents electrical instability of myocardium for this type of patients. Telemetric ECG monitoring in STEMI patients significantly increases opportunities of the dynamic evaluation of coronary flow and electrical instability of myocardium.