Culprit Artery Research Articles

Abstract 13343: Is the Early Invasive Strategy Really the Optimal Time for Patients at High-risk of Acute Coronary Syndromes Without ST-segment Elevation?

Introduction: An early invasive strategy has become the standard of care for pts at high-risk of NSTE-ACS in the latest guidelines, however the optimal timing of coronary intervention in this pts is still a matter of debate. Hypothesis: To compare the prognosis between pts at high-risk of NSTE-ACS submitted an early (<24h) versus a delayed invasive strategy (24-72h). Methods: A retrospective multicenter observational study including 6722 pts at high-risk NSTE-ACS (established diagnosis of NSTE-ACS based on cardiac troponins OR dynamic ST/T-changes OR GRACE score>140). Low, intermediate and very high-risk of NSTE-ACS pts were excluded, such as pts with an invasive strategy >72h. Pts were divided into two groups: group 1 - pts at high-risk of NSTE-ACS submitted an early invasive strategy (<24h) (n=3351,49.9%); group 2 - pts at high-risk of NSTE-ACS submitted a delayed invasive strategy (24-72h) (n=3371,50.1%). Primary endpoint was the occurrence of death at 1 year. Results: The sample was formed by 74.5% men and 25.5% women, with mean age of 65±12 years. Group 2 pts had a higher prevalence of hypertension (69.4% vs 73.0%,p=0.001), dyslipidaemia (63.1% vs 66.7%,p=0.002), CKD (3.2% vs 4.9%,p<0.001), previous MI (19.9% vs 24.3%, p<0.001) and HF (2.4% vs 3.4%, p=0.012). On admission, group 1 pts had more chest pain (96.9% vs 95.7%, p=0.010) compared to group 2 pts that had more dyspnea (1.1% vs 1.9%,p=0.007) and presented more to a non-PCI center (36.0% vs 46.3%,p<0.001). During hospitalization, group 2 had more often HF (3.3% vs 4.5%,p=0.013) and LVEF≤40% (5.9% vs 7.6%,p=0.042). Group 1 pts were more likely to have coronary revascularization (78.9% vs 74.6%,p<0.001), with the culprit artery being less identified in group 2 (20.8% vs 25.2%,p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts at high-risk of NSTE-ACS submitted an early strategy had the same risk of 1-year mortality compared to those submitted a delayed invasive strategy [OR0.76,p=0.280]. Conclusion: In Portugal, only half of patients at high risk of NSTE-ACS undergo an early invasive strategy. However the early invasive coronary evaluation did not improve overall long-term clinical outcome compared with delayed invasive strategy.

Acute Coronary Syndrome in the Era of SARS-CoV-2 Infection: A Registry of the French Group of Acute Cardiac Care

BackgroundIn this study, we aimed to report clinical characteristics and outcomes of patients with and without SARS-CoV-2 infection who were referred for acute coronary syndrome (ACS) during the peak of the pandemic in France. MethodsWe included all consecutive patients referred for ST-elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) during the first 3 weeks of April 2020 in 5 university hospitals (Paris, south, and north of France), all performing primary percutaneous coronary intervention. ResultsThe study included 237 patients (67 ± 14 years old; 69% male), 116 (49%) with STEMI and 121 (51%) with NSTEMI. The prevalence of SARS-CoV-2-associated ACS was 11% (n = 26) and 11 patients had severe hypoxemia on presentation (mechanical ventilation or nasal oxygen > 6 L/min). Patients were comparable regarding medical history and risk factors, except a higher prevalence of diabetes mellitus in SARS-CoV-2 patients (53.8% vs 25.6%; P = 0.003). In SARS-CoV-2 patients, cardiac arrest on admission was more frequent (26.9% vs 6.6%; P < 0.001). The presence of significant coronary artery disease and culprit artery occlusion in SARS-CoV-2 patients respectively, was 92% and 69.4% for those with STEMI, and 50% and 15.5% for those with NSTEMI. Percutaneous coronary intervention was performed in the same percentage of STEMI (84.6%) and NSTEMI (84.8%) patients, regardless of SARS-CoV-2 infection, but no-reflow (19.2% vs 3.3%; P < 0.001) was greater in SARS-CoV-2 patients. In-hospital death occurred in 7 SARS-CoV-2 patients (5 from cardiac cause) and was higher compared with noninfected patients (26.9% vs 6.2%; P < 0.001). ConclusionsIn this registry, ACS in SARS-CoV-2 patients presented with high a percentage of cardiac arrest on admission, high incidence of no-reflow, and high in-hospital mortality.

Effect of Management Strategy of ST Elevation Myocardial Infarction Patients Presented with Cardiogenic Shock on Hospital Mortality

Background: Patients with acute myocardial infarction (MI) and shock are at increased risk of mortality, we divided the managing strategies and also sought to determine whether the revascularization strategy of coronary arteries makes difference regarding to mortality.Methods: We prospectively analyzed sixty patients presented by ST elevation myocardial infarction and complicated by cardiogenic shock admitted to National Heart Institute CCU foe one year who had recent history of acute STEMI within 24 hours of onset of symptoms and complicated by cardiogenic shock. They were divided in to two groups: Group1 with cardiogenic shock received thrombolytic. Group2 has PCI with two Subgroups: PCI for only Culprit artery. Another had total revascularization. Hospital mortalities in all shocked patient were studied according to revascularization strategy Results: We included 60 patients with a mean age of 59 years. Females were (36.7%). CA was present in 26.7%. Hospital mortality was 26.7% (16 out of the 60 patients included in the study 50% in group 1 and 20% in culprit only subgroup and only 10% in total revascularization subgroup). After adjustment, higher mortality was in patients with thrombolytic group compared to patients with revascularization. Conclusions:Total revascularization, when the anatomy is favorable, is the better revascularization strategy regarding mortality rather than culprit only revascularization, but the worst outcome and mortality was with patients in thrombolytic group without intervention. Risk factors; Dyslipidemia, DM, history of CAD and LVEF%, Post PCI TIMI flow (< grade III), were all associated with high mortality.

Right coronary artery as a culprit artery for better prognosis in patients with acute myocardial infarction (AMI) with or without shock

Abstract Background Although patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, morbidity and mortality remain high even with early revascularization and modern intensive care. Culprit artery and prognosis were associated in patients with acute myocardial infarction. Purpose Evaluation of short- and long-term prognosis of AMI with cardiogenic shock by right coronary artery (RCA) and left coronary artery (LCR) Method We investigated 3400 AMI patients (age 68.8±12.7 y.o.) were enrolled from Mie ACS registry. They were divided into 4 groups according to the culprit artery and presence or absence of cardiogenic shock: RCA without shock n=1114, RCA with shock n=74, LCA without shock n=2028, LCA with shock n=184. Primary endpoint was defined as all-cause mortality. Results During the median follow-up periods with 743 days, 12.6% of the patients experienced all-cause death. RCA and LAC with shock groups demonstrated significantly higher in-hospital mortality compared to groups without shock (p&amp;lt;0.001, Figure 1A). Interestingly, after discharge, LCA with shock group showed significant higher all-cause mortality compared with other 3 groups. Surprisingly, RCA with shock group showed similar favorable prognosis to that of without shock groups (Figure 1B). Multivariate analyses for after discharge mortality showed that LCA with shock group was strongest independent poor prognostic factor with hazard ratio of 2.3 (95% CI 1.4–3.7), but RCA with shock group was not. Conclusion Association of cardiogenic shock is the hazardous risk factor for cases with AMI, especially LCA infarction. Surprisingly, RCA AMI cases with shock showed favorable prognosis as well as AMI without shock. Kaplan-Meier survival curves Funding Acknowledgement Type of funding source: None

Radiomics applied to carotid CT angiograms can identify significant differences between culprit and non-culprit lesions in patients with stroke and transient ischaemic attack

Abstract Background Carotid artery atherosclerosis is an important cause of ischaemic stroke. In oncology, textural analysis (“radiomics”) of computed tomography (CT) images can predict the metastatic potential and prognosis of several types of malignant tumours. We investigated whether this quantitative approach could be applied in carotid artery disease. Purpose (1) To evaluate the feasibility of computed tomography angiography (CTA) texture analysis in differentiating symptomatic from asymptomatic patients. (2) To investigate whether CTA carotid texture analysis can identify culprit lesions in patients with stroke and transient ischaemic attack (TIA). Methods Carotid CTAs of consented research subjects were included in the study. Symptomatic patients had confirmed carotid artery-related ischaemic stroke or TIA in the 7 days before CTA imaging. Asymptomatic (ASX) patients had no prior stroke/TIA. Both TexRAD, a research texture analysis software, and PyRadiomics, a Python package for radiomics studies, were used to extract 99 first-order and higher-order texture features from regions-of-interest (ROI) drawn around the outer wall of the carotid artery. Single-slice analysis compared the carotid bifurcations of symptomatic and asymptomatic patients, and of culprit (CC) and non-culprit (NC) arteries in symptomatic patients. Multi-slice analysis was conducted using a 3D volume defined by ROIs drawn on 14 consecutive CT slices of 3mm thickness, covering 3cm of carotid artery. The Mann-Whitney U test was used for inter-subject comparisons (ASX vs CC; ASX vs NC) and the Wilcoxon signed-rank test was used for intra-subject comparisons (CC vs NC). A p value &amp;lt;0.0005 was deemed statistically significant after Bonferroni correction for multiple comparisons. Non-normally distributed variables are reported as median (interquartile range). Results The dataset comprised 82 carotid arteries from 41 symptomatic patients (41 culprit; 41 non-culprit) and 50 carotid arteries from 25 asymptomatic patients. Single-slice analysis revealed greater homogeneity in asymptomatic carotids versus symptomatic culprit carotids (Uniformity: ASX 0.11 (0.05); CC 0.08 (0.05), p&amp;lt;0.0005) and non-culprit carotids (NC 0.08 (0.18), p&amp;lt;0.0005). In multi-slice analysis, culprit and non-culprit carotid arteries displayed greater heterogeneity than asymptomatic carotids (GLSZM zone entropy: CC 6.57 (0.59); NC 6.76 (0.65); ASX 6.21 (0.32), p&amp;lt;0.0005). Multi-slice analysis of symptomatic culprit versus non-culprit carotids revealed greater heterogeneity in culprit carotids than non-culprit carotids (GLRLM run entropy CC 6.57 (0.59); NC 5.05 (0.70), p&amp;lt;0.0001). Conclusion Textural analysis of carotid CTAs reveal significant differences between symptomatic and asymptomatic patients and between culprit and non-culprit carotid arteries within symptomatic patients. This approach could be used to identify patients at high risk of further stroke for aggressive medical therapy and surveillance. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): EPVL is undertaking a PhD funded by the Cambridge School of Clinical Medicine and the Medical Research Council's Doctoral Training Partnership

Contrast CT classification of asymptomatic and symptomatic carotids in stroke and transient ischaemic attack with deep learning and interpretability

Abstract Background Convolutional neural networks (CNNs), part of deep learning, are used widely for computer vision tasks and in some medical domains, such as mammography interpretation. The application of deep learning to carotid artery imaging is scarce. We investigated the ability of deep learning to correctly classify contrast CT images of the carotid arteries without the need for prior feature selection. Purpose (1) To assess the ability of deep learning to differentiate symptomatic patients (had prior stroke or transient ischaemic attack [TIA]) from asymptomatic patients (no prior stroke/TIA) using contrast CT scans alone. (2) To investigate whether deep learning can further discriminate between culprit and non-culprit carotid arteries in symptomatic patients. (3) To assess the interpretability of the deep learning models. Methods Carotid contrast CT scans of consented research subjects were included in the study. Symptomatic patients had confirmed carotid artery-related ischaemic stroke or TIA in the 7 days before CT imaging, and asymptomatic patients had no prior cerebrovascular events. The dataset comprised 1148 axial symptomatic slices (covering a 3cm area of each carotid artery in 41 patients; 41 culprit and 41 non-culprit carotids) and 700 asymptomatic slices (from the bilateral carotid arteries of 25 patients). The dataset was split such that 75% was used for training and 25% for testing. A 30x30 bounding box was used to create patches of the carotid arteries from these axial slices for use as input to the CNN, a modified VGG16 architecture initialised with ImageNet weights to leverage transfer learning (the application of a model trained in one domain to a different domain) implemented in Python. Data augmentation was applied to the training set and the model was trained for 100 epochs using a cyclic learning rate, the RMSProp optimizer and binary cross-entropy loss. Class activation heatmaps were generated using the GradCAM method to highlight the areas of the image that were most important to the model for making its classification decision. Results The deep learning model was 92% accurate in correctly identifying carotid arteries from symptomatic patients versus those from asymptomatic patients. Discriminating between culprit versus non-culprit carotid arteries in symptomatic patients alone was 71% accurate. The class activation heatmaps demonstrated how the model learnt to localise the carotid artery within the image patch, and to ignore the arterial lumen when making its classification decision. Conclusions Deep learning can be used to differentiate between symptomatic and asymptomatic carotid CT scans from stroke/TIA subjects without the need for prior feature engineering. The model learns to identify relevant features in the image that predict the patients' symptom state. If further validated, this approach could be used to identify high-risk patients for intensive medical therapy. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): EPVL is undertaking a PhD funded by the Cambridge School of Clinical Medicine and the Medical Research Council's Doctoral Training Partnership

The role of single nucleotide polymorphism of val66met (rs6265) of the brain-derived neurotropic factor in formation of endpoints after st-segment elevation myocardial infarction

Abstract Background The single nucleotide polymorphism (SNP) Val66Met (rs6265) of the brain-derived neurotrophic factor (BDNF) gene is a possible candidate that is associated with the development of psychopathology and combines it with cardiovascular events. Purpose To research the possible associations of single-nucleotide polymorphism of Val66Met BDNF gene with the occurrence of endpoints after 6 months of follow-up after ST segment elevation myocardial infarction (STEMI). Methods 256 acute STEMI patients after successful primary percutaneous coronary intervention (PCI) were enrolled in the study. TIMI III blood flow restoring through culprit artery was determined. The study of SNP of Val66Met (rs6265) of the BDNF gene was performed by real-time polymerase chain reaction. The emotional state of the patients and its relationship with stress were assessed with the questionnaire “Depression, Anxiety and Stress-21”. All acute STEMI patients received adjuvant treatment due to current ESC recommendations. All procedures performed in the study involving human participants were in accordance with the ethical standards and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards and approved by the local ethics committee. Written inform consent was obtained from each patient. The primary endpoint was combined event (follow-up major adverse cardiac events – MACEs and hospitalization) that occurred within 6-month of the discharge from the hospital. MACEs were defined as the composite of CV death, recurrent angina, newly diagnosed heart failure. Results The frequency of genotypes Val66Met gene for BDNF in STEMI patients (n=256) was the following: 66ValVal=74.2% (n=190), 66ValMet + 66MetMet – 25.8% (n=66). The 66ValMet + 66MetMet polymorphism in the BDNF gene, stress and anxiety on 10–14 days before the event, as well as reduced left ventricular ejection fraction (LVEF), were independently associated with combined 6 months clinical end point after STEMI. Severity of depression according to depression scale was more profound in individuals with 66ValMet+66MetMet polymorphysms in BDNF gene (P=0.045) than in patients with 66ValVal genotype. Univariate and multivariate linear regressions has shown that 66ValMet+66MetMet genotype in BDNF gene, anxiety and stress before event, LVEF had independent power on dependent variable entitled combined end point after 6 month observation for STEMI patients with successful revascularization (P=0.0395). Kaplan-Meier curves demonstrated that STEMI patients with 66ValVal genotype in BDNF gene had a lower accumulation of combined end point compared with acute STEMI patients with 66ValMet+66ValMet polymorphism (Cox-criterion, P=0.019; log-rang criterion, P=0.03). Conclusion The Val66Met polymorphism in BDNF gene was found as an independent predictor for combined 6-month clinical end points after acute STEMI treated primary PCI. Funding Acknowledgement Type of funding source: None

Do the ESC guidelines improve the treatment of acute myocardial infarction due to acute circumflex artery occlusion?

Abstract Background The left circumflex artery (LCX) and its branches are less often recognized as infarct related artery (IRA) in STEMI compared to NSTEMI patients because of lower ability to detect posterior AMI on 12leads ECG. Significant proportion of patients with acute LCX occlusion therefore did not receive immediate reperfusion therapy. The recent ESC guidelines recommendation of immediate coronary angiography for NSTEMI with ongoing ischemia should change the situation. Objectives To estimate the change in proportion of patients receiving immediate reperfusion therapy for acute LCX occlusion within last 20 years. Methods Prospective registry of patients with acute coronary syndromes treated in the cardiac centre. The group of patients treated with direct PCI as STEMI and the group of patients treated as NSTE ACS were compared. Results Of 369 STEMI patients treated with primary PCI in 1995–2000, the LCX was recognized as IRA in only 29 (8%) patients. In the group of 809 STEMI patients treated in period 2008–2011, the LCX was detected as IRA in 133 (16%). In he recent group of 1006 patients treated as STEMI in period 2016–2019 the LCX was IRA in 166 (16.5%) patients. LAD, LM and RCA were detected as IRA in 407 (40.5%), 17 (1.7%) and 415 (41%) patients respectively. In the parallel group of 1087 NSTE-ACS patients the proportion of LCX, LAD, LM and RCA as culprit artery was 271 (25%), 438 (40%), 52 (5%) and 326 (30%) respectively. The difference of LCX involvement in STEMI (16%) compared to NSTE-ACS patients (25%) was highly significant (p&amp;lt;0,001). Conclusion The disproportion of LCX involvement among the patients with STEMI and NSTE-ACS is not decreasing in the course of last 10 years. Our data show that still significant part of patients with acute LCX occlusion are diagnosed as having NSTE-ACS and are not treated with adequate immediate reperfusion. So even in recent era of modern reperfusion therapy these patients which mostly suffer posterior AMIs have a lower chance to receive the proper treatment in our region. The new ESC guidelines did not change this fading yet. Better diagnostics of AMI due to the acute LCX occlusion (including 15 leads ECG) is routinely needed or every suspected NSTEMI patient should undergo the acute coronary angiogram as he would be a STEMI patient. Funding Acknowledgement Type of funding source: None

Coronary artery ectasia in acute myocardial infarction: to be culprit or not to be?

Abstract Background Coronary artery ectasia (CAE), is only found in about 1% of acute myocardial infarction (AMI), but represents a clinical challenge in the setting of percutaneous coronary intervention (PCI), considering 1) culprit lesion or not, 2) a solely CAE or mixt 3) number, localization and size of CAE, 4) etiology and 5) therapeutic strategies. Only few studies from small cohorts have focused on infarct-related arteries. We aim to assess the impact of CAE as culprit artery on management strategy. Methods From 2010 to 2019, this study prospectively analyzed the characteristics, and management of 70 consecutive admitted for an AMI and with CAE at coronary angiography. Patients with ectatic infarcted-related artery (ERIA) were compared with patients without ectasia localized on infarcted-related (No ERIA). Results Among the 70 patients included, most had ERIA 47 (67%). ERIA patients had more frequently diabetes than patients without ERIA (32 vs 4%, p=0.01). The rate of other CV risk factors, and chronic medications, including antiplatelet agents and anticoagulants,.were similar for the 2 groups. Moreover, no difference was observed between the 2 groups for clinical parameters and biological data. Whatever the group, the ectatic artery is mainly located on the right coronary artery (RCA) (73%), of which most were ERIA (77%). ERIA group had less frequently anterior wall location STEMI (18 vs 65%, p= &amp;lt;0.001). The rate of diffuse coronary artery disease (91 vs 92%) and maximum CAE diameter (6.36 (6.00–7.00) mm vs 6.14 (5.53–7.64) mm, p=0.571) were similar for the 2 groups. SYNTAX was lower in ERIA patients (9.5 (2.0–18.0) vs 13.5 (7.0–23.0), p=0.031). A complete reperfusion was more frequently achieved in no ERIA group (70 vs 47%, p=0.073). PCI data and hospital mortality are shown in Table. Conclusion CAE management is strongly dependent on the presence of CAE on IRA. Although rare, the optimal treatment strategy of patients with AMI and CAE remains to be elucidated. The place of intravascular ultrasound imaging needs to be investigated. Funding Acknowledgement Type of funding source: None

Clinical assessment and angiographic finding in patients with non ST-elevation myocardial infarction

Abstract Background Non ST-elevation myocardial infarction is considered the intermediate form of acute coronary syndrome between unstable angina and ST-elevation myocardial infarction. Blockage either occurs in a minor coronary artery or causes partial obstruction of a major coronary artery. The rate of NSTEMI has increased to be 50% of all acute coronary syndrome. Purpose To compare some demographic, clinical risk assessments and angiographic data among high, intermediate and low risk NSTEMI patients. Methods We classified one hundred twenty (120) NSTEMI patients into 3groups by GRACE risk score (high risk group &amp;gt;140, intermediate risk group from 109 to 140 and low risk group ≤108). The patients were evaluated by personal history taking, risk factors, clinical examination, ECG, laboratory investigations, echocardiography and percutaneous coronary intervention. Results We found that low risk group percentage was 47.5%, intermediate risk group percentage was 32.5% and high-risk group percentage was 20%. As regarding culprit lesion, LAD represent most affected artery (48.3% of patients).Recurrent ischemia and MI represent the highest percentage of major adverse cardiac event (MACE) among studied groups. All patients with LM disease have a MACE while 41.2% of MACE patients have significant LAD lesion. As time of intervention delayed the incidence of MACE increases among different groups. High risk group has significantly high percentage of type C lesion and TIMI 0/1 while type A lesion and TIMI III lesion highest among low risk patients. As regarding contour of the lesion, the irregularity increases as the clinical risk increases. Also as regarding occlusion of culprit artery, the incidence of total occlusion increases as the clinical risk increases. Conclusions We recommend selection of high-risk NSTEMI patient to direct them for early invasive therapy. Very high-risk directed for immediate revascularization like STEMI patient. NSTEMI considered precursors to STEMI and an early warning signal that aggressive medical intervention needed. Association between time to intervention Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): University budget

Identification of the high-risk patient in primary percutaneous coronary intervention: development and validation of a novel predictive index

Abstract Background Primary percutaneous coronary intervention (PPCI) is the best treatment for patients with ST elevation myocardial infarction (STEMI). Several risk scores have been created to help risk-stratify these patients but few of these can be calculated in-lab, during the acute event. Development of a score that could be applied during PPCI could aid operators' decisions regarding adjunctive therapies and post-procedural surveillance which could improve patient outcomes. This study aimed to develop a simple, practical risk model that could be applied during PPCI to identify high-risk patients. Methods Demographic, clinical and outcome data were collected for all patients, as part of the HEAT-PPCI trial, who underwent PPCI for suspected STEMI between February 2012 and November 2013 at our hospital. Independent predictors of the composite outcome of 28-day mortality or severe impairment of LV function (ejection fraction ≤35%) were identified using multiple logistic regression. A risk model was fitted and internal validation was performed by bootstrapping. External validation was performed on a separate cohort of patients with STEMI. Results The derivation cohort included 1271 patients, with 131/1271 = 10.3% experiencing the composite outcome of 28-day mortality or poor LV function. Three variables were required to predict the outcome: age (OR:2.07, 95% CI 1.55 to 2.78), location of the culprit artery (OR:6.16, 95% CI 4.00 to 9.47), myocardial blush grade post-PPCI (OR:2.32, 95% CI 1.39 to 3.88). External validation was performed on 324 patients undergoing PPCI from a different centre. The model showed good discrimination on ROC-curve analysis (c statistic 0.79, 95% CI 0.75 to 0.83) and performed well on external validation (c statistic 0.87, 95% CI 0.72 to 0.95). Accuracy of the risk model on the validation data was improved by simple recalibration. The model was used to create a risk prediction chart that can be used in-lab during PPCI (Figure 1). Conclusions We have developed a risk model that accurately predicts 28-day mortality or poor LV function following STEMI using age, culprit location and myocardial blush grade. The model can assist operators in identifying high-risk patients during PPCI. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): National Health Service, UK

The importance of highly effective lipid-lowering therapy with atorvastatin in the normalization of the autonomic regulation of heart rate in patients with STEMI

Abstract Purpose To assess the importance of highly effective lipid-lowering therapy with atorvastatin in the normalization of the autonomic regulation of cardiac activity in patients with myocardial infarction with ST segment elevation (STEMI). Methods The study included 130 patients with STEMI aged 51.3±8.9 years, the majority of males (91%). Inclusion criteria: age from 35 to 70 years, STEMI confirmed by ECG and the level of biomarkers (troponin I, CK-MB), the presence of hemodynamically significant stenosis of a culprit artery according to coronary angiography provided that other coronary arteries are occluded no more than 50%, left main coronary artery - not more than 30%. Exclusion criteria: a history of myocardial infarction, CHF III-IV NYHA, bundle branch block, atrial fibrillation, artificial pacemaker. All patients took atorvastatin at a dose of 40–80 mg/day for 48 weeks after STEMI. As part of a further study at the 7th-9th day and 48 weeks after STEMI, 24-hour ECG monitoring was performed with the Astrocard system. The spectral parameters of heart rate variability (HRV) were evaluated: TotP (ms2), ULF (ms2), VLF (ms2), LF (ms2), HF (ms2), LF / HF. By the 48th week of treatment, patients were divided into groups depending on the achievement of the target level of low density lipoproteins (LDL) of less than 1.4 mmol / l or less than 50% of the initial values: 64 people who reached target values of LDL and formed the group of high-effective lipid-lowering therapy “H”, the group of low effective treatment “L” included 66 patients whose LDL did not meet the recommended level. The groups were matched by gender, age, and anthropometric data. Results In the “H” group, by the 48th week, a pronounced power amplification of all spectral components was obtained. The TotP parameter increased from 13021 (95% CI 10967; 15076) ms2 to 20988 (95% CI 17617; 24358) ms2 (p=0.0001); HF - from 164 (95% CI 105; 222) ms2 to 249 (95% CI 178; 321) ms2 (p=0.003). An increase in the low-frequency components of HRV was observed: an increase in ULF from 10695 (95% CI 8985; 12406) ms2 to 20401 (95% CI 15099; 25703) ms2 (p=0.0001), VLF - from 1473 (95% CI 1212; 1734) ms2 to 1734 (95% CI 1478; 1990) ms2 (p=0.01), LF - from 761 (95% CI 573; 949) ms2 to 909 (95% CI 736; 1082) ms2 (p=0.02). Against the background of an increase in all parameters of the frequency spectrum, the sympathovagal balance coefficient LF / HF decreased from 6.6 (95% CI 5.7; 7.6) to 5.2 (95% CI 4.3; 6.1) ( p=0.004). An analysis of the HRV indicators dynamics in the L group revealed an increase in only the total spectrum power - TotP from 12740 (95% CI 10947; 14533) ms2 to 20195 (95% CI 16619; 23770) ms2. Conclusions Highly effective therapy with atorvastatin in STEMI patients helps to normalize the parameters of the autonomic regulation of heart rate in the post-infarction period due to the increased effects of parasympathetic activity. Funding Acknowledgement Type of funding source: None

Clinical and angiographic characteristics of patients with STEMI and confirmed diagnosis of COVID-19: an experience of Tanta University Hospital

BackgroundPatients with established cardiovascular diseases have a poor prognosis when affected by the coronavirus disease 2019 (COVID-19). Also, the cardiovascular system, especially the heart, is affected by COVID-19. So we aimed to evaluate the angiographic and clinical characteristics of COVID-19 patients presented by ST-elevation myocardial infarction (STEMI).ResultsOur retrospective study showed that STEMI patients with COVID-19 had elevated inflammatory markers with mean of their CRP (89.69 ± 30.42 mg/dl) and increased laboratory parameters of thrombosis with mean D-dimer (660.15 ± 360.11 ng/ml). In 69.2% of patients, STEMI was the first clinical presentation and symptoms suggestive of COVID-19 developed during the hospital stay; about one third of patients had a non-obstructive CAD, while patients with total occlusion had a high thrombus burden.ConclusionSTEMI may be the initial presentation of COVID-19. A non-obstructive CAD was found in about one third of patients; on the other hand, in patients who had a total occlusion of their culprit artery, the thrombus burden was high. Identification of the underlying mechanism responsible for the high thrombus burden in these patients is important as it may result in changes in their primary management strategy, either primary PCI, fibrinolytic therapy, or a pharmaco-invasive strategy. Furthermore, adjunctive anticoagulation and antiplatelet therapy may need to be revised.

Value of multidetector computed tomography angiography before bronchial artery embolization in hemoptysis management and early recurrence prediction: a prospective study

BackgroundMultidetector computed tomography (MDCT) angiography is a useful examination to detect the source of the bleeding in patients with hemoptysis. The aim of the study was to prospectively evaluate the role and clinical efficacy of MDCT angiography before bronchial artery embolization (BAE) for the management of hemoptysis, and to investigate the predictors of early recurrence.MethodsIt is a double-center study which included 57 hemoptysis patients undergoing MDCT angiography prior to BAE from August 2019 to July 2020. A prospective analysis of culprit arteries detected by MDCT angiography allowed an evaluation of the role of this technique. A follow-up was done to assess the efficacy of BAE with preprocedural MDCT angiography and to explore the risk factors of early recurrent hemoptysis.ResultsThe accuracy of MDCT angiography in the identification of culprit arteries was as high as 97.5%. The average number of total culprit arteries per patient was 2.75 ± 1.73. Among which, the average numbers of culprit ectopic bronchial arteries (BAs) and non-bronchial systemic arteries (NBSAs) per patient were 0.21 ± 0.41 and 1.04 ± 1.57, respectively. The immediate clinical success rate, total hemoptysis recurrence rate, and early hemoptysis recurrence rate of BAE following MDCT angiography were 94.7, 18.5, 16.7%, respectively. Aspergilloma (HR = 6.63, 95% CI: 1.31–33.60, p = 0.022) was associated with an increase in the risk of early recurrence.ConclusionsMDCT angiography should be performed before BAE for the management of hemoptysis. Aspergilloma was an independent predictor for early recurrence.

Evaluation of Left Atrial Strain Parameter in Coronary Artery Stenosis: A New Tool to Predict LCX Stenosis

Introduction: Speckle tracking echocardiography (STE) based on frame-to-frame tracking of acoustic speckles is a novel angle-independent method, used for evaluating myocardial deformation and recently to assess left atrium (LA) function.Aim: To the best of our knowledge, there is no investigation evaluating the predictor role of LA strain parameters in detection of coronary artery stenosis in ischemic heart disease. In this study, we assessed this parameter for predicting the culprit artery in patients underwent selective coronary angiography (SCA) in Mashhad, Iran. Patients and Methods: This was a case-control study, which was performed in Imam Reza and Quaem Hospitals in Mashhad, Iran between 2017 and 2018 in patients referred for SCA. Subjects with two or three- vessel diseases were excluded .Sixty-five cases were included in the study and divided into four groups according to the vessel involved : Group (1): normal coronary artery subjects (n=36); group (2): patients with left anterior descending (LAD) artery stenosis (n=12); group (3): patients with left circumflex artery (LCX) stenosis (n= 7) and group 4: patients with right coronary artery (RCA) stenosis (n=10). Patients underwent routine TTE and Speckle Tracking Imaging.Results: The mean age of participants was 56.72± 10.69 years old. The male/female ratio was 0.96. Mean absolute value of LA strain was 24.74% in normal subjects, while in groups with stenotic coronary artery disease, less values were defined as 18.63%, 16.03% and 19.05%, respectively (p value=0.05). The amounts of left ventricle end systolic volume (LVESV), LV global longitudinal strain (GLS) and Em of septal annulus were significantly different between normal group and those with LCX stenosis. Among different echocardiographic parameters, LA strain, LVESV and Em of septal annulus were defined as predictors of LCX occlusion with regression analysis. Conclusion: LA strain in subjects with coronary artery stenosis was lower than the strain in normal group and could predict isolated LCX occlusion.

Complete Revascularization Versus Treatment of the Culprit Artery Only in ST Elevation Myocardial Infarction: A Multicenter Registry.

ResumoFundamento São restritos os dados sobre o manejo e o prognóstico dos pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) com acometimento multiarterial no Brasil, o que mostra a necessidade de investigar as estratégias de revascularização disponíveis.Objetivo Avaliar os desfechos relacionados à revascularização completa em comparação com o tratamento da artéria culpada em pacientes multiarteriais com IAMCSST.Métodos Foi realizada um estudo de coorte prospectiva em dois centros de hemodinâmica do Sul do Brasil, com seguimento de 1 ano após a intervenção índice. O desfecho primário foi composto de óbito cardiovascular, reinfarto ou angina recorrente e secundários acidente vascular encefálico, parada cardiorrespiratória não fatal, sangramento maior ou necessidade de reintervenção. A probabilidade de ocorrência de desfechos foi comparada entre os grupos através de regressão logística binária. Considerou-se como estatisticamente significativo o valor de probabilidade < 0,05.Resultados Participaram 85 pacientes, com média de idade de 62±12 anos, sendo 61 (71,8%) do sexo masculino. Cinquenta e oito (68,2%) pacientes receberam a estratégia de revascularização completa e 27 (31,8%), a de revascularização incompleta. A chance de ocorrência tanto do desfecho primário quanto do secundário foi significativamente maior entre os indivíduos tratados com revascularização incompleta quando comparados com os tratados com estratégia completa [razão de chances (OR) 5,1, intervalo de confiança de 95% (IC95%) 1,6-16,1 vs. OR 5,2, IC95% 1,2-22,9, respectivamente], assim como os óbitos cardiovasculares (OR 6,4, IC95% 1,2-35,3).Conclusão Dados deste registro regional, de dois centros do Sul do Brasil, demonstram que a estratégia de revascularização completa esteve associada à redução significativa dos desfechos primário e secundário no seguimento de 1 ano quando comparada à estratégia de revascularização incompleta. (Arq Bras Cardiol. 2020; 115(2):229-237)

Rationale and design of the MULTISTARS AMI Trial: A randomized comparison of immediate versus staged complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease

About half of patients with acute ST-segment elevation myocardial infarction (STEMI) present with multivessel coronary artery disease (MVD). Recent evidence supports complete revascularization in these patients. However, optimal timing of non-culprit lesion revascularization in STEMI patients is unknown because dedicated randomized trials on this topic are lacking. STUDY DESIGN: The MULTISTARS AMI trial is a prospective, international, multicenter, randomized, two-arm, open-label study planning to enroll at least 840 patients. It is designed to investigate whether immediate complete revascularization is non-inferior to staged (within 19-45 days) complete revascularization in patients in stable hemodynamic conditions presenting with STEMI and MVD and undergoing primary percutaneous coronary intervention (PCI). After successful primary PCI of the culprit artery, patients are randomized in a 1:1 ratio to immediate or staged complete revascularization. The primary endpoint is a composite of all-cause death, non-fatal myocardial infarction, ischemia-driven revascularization, hospitalization for heart failure, and stroke at 1 year. CONCLUSIONS: The MULTISTARS AMI trial tests the hypothesis that immediate complete revascularization is non-inferior to staged complete revascularization in stable patients with STEMI and MVD.

Comparison of Intravascular Ultrasound Virtual Histology Parameters in Diabetes versus Non-Diabetes with Acute Coronary Syndrome

Introduction: The progression and pattern of coronary atherosclerosis in diabetes mellitus (DM) is different from non-DM, leading to a higher rate of vascular complications in DM. Objective: This study aims to assess and compare the high-risk plaque characteristics in the culprit artery of DM and non-DM patients with acute coronary syndrome (ACS) using virtual histology intravascular ultrasound (VH-IVUS). Methods: A total of 158 ACS patients were included, 63 of whom were known to have DM. IVUS analysis was done in the de novo target vessel and culprit lesion for which percutaneous coronary intervention was planned. Culprit lesions with a visual-estimate angiographic stenosis of <70% were excluded. Results: The mean age of patients was 52.4 ± 11.6 years. The study group comprised 82% men, 31% with hypertension, and 39.87% with DM. No significant difference was observed between the DM and non-DM groups in relation to quantitative IVUS parameters like lesion length, minimal lumen area, and plaque area. However, there was a significant difference in VH-IVUS parameters like higher necrotic core and dense calcium in the DM patients than in the non-DM patients (p < 0.01). The occurrence of VH-derived thin-cap fibroatheroma (VH-TCFA) in the culprit vessel was significantly higher in the DM group than in the non-DM group (25.3 vs. 5.2%; p < 0.01). Positive vessel-wall remodeling was noted in both groups without any significant difference (p = 0.74). Conclusion: The DM patients had high-risk plaque composition features like a higher necrotic core, which is a marker of plaque vulnerability. Thus, aggressive medical therapy targeting vascular inflammation using high-dose statins would help in the stabilization of unstable plaque morphology and the reduction of major cardiovascular events.

ANTIPLATELET ADHERENCE AT SIX MONTHS AFTER PRIMARY PERCUTANEOUS CORONARY INTERVENTION PERFORMED AT A RURAL SATELLITE CENTER

Objectives: To determine the frequency of dual antiplatelet adherence at six months after primary PCI performed at rural satellite center. Methodology: This was a descriptive study conducted at Rural Satellite Center (Larkana) of the National Institute of Cardiovascular Disease, Pakistan from October 2017 to March 2018. Patients of either gender between the ages of 20-80 years who underwent primary Percutaneous Coronary Intervention (PCI) at least six months ago were included in this study. Compliance with antiplatelet therapy was assessed by interview at follow up. Patients were labeled as compliant if they took both aspirin and clopidogrel at the time of follow up at six months. Results: Of the total of 241 patients, 208 (86.3%) were male. The mean age of the patients was 53.37 ± 11.07 years. Hypertension was present in 170 (70.5%), 101 (41.9%) were diabetic, 104 (43.2%) were smokers and 18 (7.5%) were obese. The most common culprit artery was left anterior descending (LAD) artery, 149 (61,8%), followed by the right coronary artery (RCA) in 83 (34.4%) patients. Nearly 12.1% (31) patients had the three-vessel disease, whereas, 53.9% (130) patients had single-vessel involved. Compliance with antiplatelet therapy at six months was found to be 89.6%, 219 (90.9%) were compliant to aspirin while 218 (90.5%) were compliant to clopidogrel. Conclusion: In our population, a significant number of patients (10.4%) were not compliant with dual antiplatelet therapy after six months of primary PCI. The dual antiplatelet adherence, in our population, is lower than in developed countries. Therefore, efforts should be made to increase compliance. Keywords: ACS, Aspirin, clopidogrel, Dual antiplatelet, Myocardial infarction

A Dynamic Systems Approach for Detecting and Localizing of Infarct-Related Artery in Acute Myocardial Infarction Using Compressed Paper-Based Electrocardiogram (ECG).

Timely evaluation and reperfusion have improved the myocardial salvage and the subsequent recovery rate of the patients hospitalized with acute myocardial infarction (MI). Long waiting time and time-consuming procedures of in-hospital diagnostic testing severely affect the timeliness. We present a Poincare pattern ensemble-based method with the consideration of multi-correlated non-stationary stochastic system dynamics to localize the infarct-related artery (IRA) in acute MI by fully harnessing information from paper-based Electrocardiogram (ECG). The vectorcardiogram (VCG) diagnostic features extracted from only 2.5-s long paper ECG recordings were used to hierarchically localize the IRA—not mere localization of the infarcted cardiac tissues—in acute MI. Paper ECG records and angiograms of 106 acute MI patients collected at the Heart Artery and Vein Center at Fresno California and the 12-lead ECG signals from the Physionet PTB online database were employed to validate the proposed approach. We reported the overall accuracies of 97.41% for healthy control (HC) vs. MI, 89.41 ± 9.89 for left and right culprit arteries vs. others, 88.2 ± 11.6 for left main arteries vs. right-coronary-ascending (RCA) and 93.67 ± 4.89 for left-anterior-descending (LAD) vs. left-circumflex (LCX). The IRA localization from paper ECG can be used to timely triage the patients with acute coronary syndromes to the percutaneous coronary intervention facilities.