Culprit Coronary Artery Research Articles

Totally Occluded Culprit Coronary Artery in Patients with Non-ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

The short- and long-term implications of identifying totally occluded culprit coronary arteries (TOCCA) in patients presenting with non-ST-elevation myocardial infarction (NSTEMI) have not been well studied. This study compares clinical characteristics, short- and long-term outcomes of patients with NSTEMI identified with TOCCA to that of patients with non-TOCCA undergoing percutaneous coronary intervention (PCI). We analyzed data from patients with NSTEMI undergoing single-vessel PCI within the Melbourne Interventional Group multi-center registry between 2005 and 2017. Those with TOCCA were compared to those with non-TOCCA. The primary endpoint was 30-day major adverse cardiac events (MACE). Secondary endpoints included 12-month MACE and long-term mortality. A total of 6,829 patients with NSTEMI had single-vessel PCI of which 954 (14%) had TOCCA. Most TOCCA were non-left anterior descending (right coronary artery 39% versus circumflex 33% versus left anterior descending 26%; p <0.001). Cardiogenic shock and left ventricular dysfunction were higher in the TOCCA group, but non-TOCCA patients had more baseline comorbidities. Thirty-day MACE was higher in the TOCCA group (6.7% versus 3.8%; p <0.001). Long-term mortality with an average follow-up of 4.9 years was higher in the non-TOCCA group (12% versus 18%, p <0.01). Multivariable Cox-proportional hazards regression identified TOCCA as an independent predictor of 30-day MACE (HR=1.93; 95%CI: 1.4-2.6), but not long-term mortality, which was predicted by baseline comorbidities. In conclusion, while patients with NSTEMI with TOCCA undergoing PCI represent a more unstable subgroup early on, long-term outcomes appear more dependent on baseline comorbidities.

Assessment of therapeutic effects of statin on cardiac sympathetic nerve activity after reperfusion therapy in patients with first ST-segment elevation myocardial infarction and normal low-density lipoprotein cholesterol

BackgroundStatin treatment reduces enhanced cardiac sympathetic nerve activity (CSNA) in patients with heart disease, and reduces adverse cardiac events in patients with coronary artery disease. MethodsWe retrospectively evaluated the first ST-segment elevation myocardial infarction (STEMI) patients and low-density lipoprotein cholesterol < 120 mg/dL in our database who underwent 123I-metaiodobenzylguanidine (MIBG) scintigraphy 3 weeks after admission. Sixty STEMI patients after primary coronary angioplasty were selected, and used propensity score matching to compare patients treated with strong statin (n = 30), and those who did not (n = 30). Moreover, echocardiographic left ventricular (LV) parameters were determined, and plasma procollagen type III amino terminal peptide (PIIINP) was also measured before and 3 weeks after treatment. ResultsFollowing primary angioplasty, age, gender, risk factors, culprit coronary artery, peak serum creatine phosphokinase concentration, and recanalization time were similar in the two groups. However, the statin group showed significantly lower delayed total defect score and washout rate evaluated by 123I-MIBG scintigraphy (22.4 ± 8.1 vs. 29.6 ± 10.5; P < 0.01, and 30.4 ± 8.9% vs. 40.1 ± 11.4%; P < 0.005, respectively) and higher delayed heart/mediastinum count ratio (2.17 ± 0.38 vs. 1.96 ± 0.30, P < 0.05) compared with the non-statin group. Moreover, the degree of change in LV parameters and PIIINP was more favorable in the statin group than in the non-statin group. ConclusionsAdministration of statin improves CSNA after reperfusion therapy in patients with first STEMI.

Assessment of no-reflow phenomenon by non-constrast computed tomography in patients with acute myocardial infarction undergoing primary percutaneous coronary angioplasty

Funding AcknowledgementsType of funding sources: None.Background Coronary no-reflow phenomenon after primary percutaneous coronary angioplasty (pPCI) is an independent predictor of adverse clinical outcomes after AMI regardless of infarct size. The incidence of no-reflow varies widely depending on the diagnostic methods used. PurposeShowing whether non-contrast CT performed after pPCI might be usefull as a diagnosis of no-reflow phenomenon.MethodsSix STEMI patients (mean age = 68.3 y/o) underwent revascularization by pPCI and stent placement within 6 hours after onset of angina and within less than 90 minutes of door-to-balloon time. Due to the outbreak of SARS-Cov-2, chest CT scanning was indicated in all patients before coronary unit admission (192 ± 102 mins after pPCI). Results Three patients with a higher time than the mean angina time and than the mean door-to-ballon time (190 ± 149.3 versus 170 ± 107.5 and 63 ± 6.08 vs 56 ± 11.5, respectively) developed an interventional type of no-reflow phenomenon (Table 1) and CT scanning showed regional myocardial contrast retention related to the culprit coronary artery (Figure 1). On the other hand, three patients with a lower time than the mean angina time and than the mean door-to-ballon time showed TIMI III flow after pPCI (Table 1) and CT scanning showed no regional myocardial contrast retention (Figure 2). ConclusionMyocardial regional contrast retention, evaluated by non-contrast and non-ECG-gated computed tomography after pPCI, might be usefull for no-reflow diagnosis.TABLE 1AGE ANGINA-TIME DOOR-TO-BALLON-TIME BASAL/cTnT POST-pPCI/cTnT CHANGE/cTnTPTS 68 ± 17y/o 170 ± 107mins 56 ± 11mins 1635 ± 2549ng/L 9621 ± 4586ng/L 588% (N = 6)NO-REFLOWPATS 65 ± 25y/o 190 ± 149mins 63 ± 6mins 761 ± 837ng/L 11151 ± 2787ng/L 1465%(N = 3)TIMI-III FLOWPTS 72 ± 9y/o 117 ± 76mins 49 ± 12mins 2219 ± 3653ng/L 18091 ± 6148ng/L 364%(N = 3) Figure 1 Figure 2

Assessment of tissue mitral annular displacement in patients with coronary artery stenosis.

BACKGROUNDThe high incidence of coronary heart diseases requires early diagnosis to prevent complications. This study aims to assess the mean value of tissue mitral annular displacement (TMAD), using Speckle tracking echocardiography (2D STE) in patients with coronary artery stenosis.METHODS149 patients aged 50 to 76 years were included in this cross-sectional study who were admitted with primary diagnosis of acute coronary syndrome (ACS) to the emergency department. In all patients, the TMAD data were measured using 2D speckle tracking technology.RESULTS149 patients with a mean age of 61.83 ± 7.14 years old were studied. Regarding the involved coronary artery as left anterior descending (LAD), right coronary artery (RCA), or left circumflex artery (LCX), the TMAD data was reduced significantly (P < 0.001) in the relevant walls [base of anterior and anteroseptum (4.46 ± 3.53 mm), base of inferior and inferoseptum (4.91 ± 3.81 mm), and base anterolateral and inferolateral walls (5.53 ± 3.827 mm), respectively.] TMAD in anterior, inferior, and lateral ST-elevation myocardial infarction (STEMI) were 2.64 ± 0.870, 4.78 ± 3.8, and 2.80 ± 0.83 mm, respectively which were significantly reduced compared to the non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (P < 0.001). TMAD in different LV function categories was only reduced in those with LAD lesion and with severe LV systolic dysfunction (2.47 ± 0.834 mm, P < 0.001).CONCLUSIONThe current study describes a significant relationship between TMAD and left ventricular function, ACS type, and the culprit coronary artery. In different types of ACS, the TMAD value was worse in the subgroups of STEMI and in the walls affected by the stenosed coronary artery. This method might be helpful in defining the culprit coronary artery.

Inferior acute myocardial infarction caused by left anterior descending coronary artery, worse prognosis? experience in our center

Abstract Funding Acknowledgements Type of funding sources: None. I Key diagnostic test in acute myocardial infarction with ST segment elevation(STEMI)is 12-lead electrocardiogram, which guides initial treatment and informs about area at necrosis risk, necrosis extension, and culprit coronary artery. ST elevation in leads II, III, aVF is related to obstruction of right coronary artery(RCA)or circumflex artery. Inferior STEMI with occlusion of left anterior descending artery(LAD)has been described. Our goal is to analyse incidence and characteristics of inferior STEMI due to LAD occlusion. M Observational retrospective study, of patients admitted to our Coronary Care Unit due to inferior STEMI, between08/2011-12/2020. We analysed all patients whose culprit artery was LAD and a random sample of138patients among those with RCA as culprit. Chi-square, Student-t or Mann-Whitney tests were used. R there were a total of2498acute coronay syndromes, 1541were STEMI. 47.7%of them(n:735)were from inferior wall. From inferior STEMI, 12were caused by LAD occlusion(1.6%, 95%confidence interval0.8-2.8%), representing0.8%of all STEMI. There were21.3%women(n:32)and a mean age of61.6 ± 12.5years, without differences by culprit artery. STEMI related with RCA presented a 28.3% of either right ventricular dysfunction or atrioventricular block, versus none of those related to LAD(p0.037). There was difference in dominance: STEMI caused by LAD presented right dominance in72.7%of cases, while caused by RCA in94.4%(p0.034). All inferior LAD STEMIs had normal left ventricular ejection fraction(LVEF) at admission. There was no statistically significant difference in LVEF at discharge(RCA54.3 ± 7.6vsLAD50.5 ± 13.6), but there was in maximum troponin, which was higher in those STEMI related to RCA(2208 ± 1756mg/dl vs 4095 ± 3833mg/dl, p0.040). Complementary comparisons in Table. Conclusion we found that1.6%of inferior STEMI are caused by LAD occlusion instead of RCA or circumflex coronary artery. These STEMI do not cause more severe affectation of left ventricle and run without typical complications of inferior STEMI. RCALADSite of occlusion-nProximal65(47.1%)5(41.7%)Medium41(29.7%)5(41.7%)Distal32(23.2%)2(16.7%)Worst Killip-Kimbal-nI112(81.2%)10(83.3%)II11(8.0%)1(8.3%)III2(1.4%)1(8.3%)IV13(9.4%)0

Incidence and impact of totally occluded culprit coronary artery in patients with non-ST segment elevation myocardial infarction acute coronary syndrome

BackgroundSignificance of totally occluded culprit coronary artery in patients presenting with non-ST segment elevation myocardial infarction (NSTEMI) is underestimated. The aim of the study was to evaluate the incidence and impact of totally occluded culprit artery on in-hospital and 6 months follow-up outcomes of NSTEMI acute coronary syndrome (ACS) patients.ResultsWe collected retrospectively data of 500 NSTEMI patients who presented to our hospital from June 2016 to June 2017. All patients underwent PCI within 72 h of presentation. We excluded patients with cardiogenic shock, prior CABG, and STEMI. Patients were divided into two groups according to pre-procedural culprit vessel thrombolysis in myocardial infarction (TIMI) flow. Group 1, TIMI flow 0 total coronary occlusion, included 112 patients (22.4%). Group 2, TIMI flow 1–3 non-total occlusion, included 388 patients (77.6%). Group 1 patients had significantly higher incidence of smoking (p=0.01), significantly higher level of cardiac enzymes (p<0.001), significantly more collaterals (p<0.001), and significantly more LCX and RCA as the culprit vessel (p<0.01), while group 2 patients had significantly higher incidence of diabetes (p=0.02) and significantly more LAD as the culprit vessel. There were no significant differences between the two groups regarding the major adverse cardiac and cerebrovascular events (MACCE) in-hospital (5.3% in totally occluded group vs. 1% in non-totally occluded group, p=0.07), but group 1 patients had significantly higher incidence of in-hospital arrhythmia (8.9% in group 1 vs. 1% in group 2, p=0.007). After 6 months follow-up, there were no significant differences regarding MACCE between the 2 groups after 6 months follow-up (5.4% in group 1 vs. 4.6% of group 2, P=0.24).Conclusion22.4% of NSTEMI patients have a totally occluded culprit artery. The presence of an occluded culprit artery did not significantly affect the clinical outcomes of NSTEMI patients either in-hospital or after 6 months follow-up but was associated with significantly higher incidence of in-hospital arrhythmia.

A126 GIST – GLUE IN STROMAL TUMOR

Abstract Background Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and typically located in the stomach. Gastrointestinal bleeding is a frequent complication of GISTs with surgery being the treatment of choice. Managing GIST bleeding endoscopically can be challenging by an underlying friable neovascularization. The use of cyanoacrylate basis glue has well-established utility in the endoscopic management of variceal bleeding. However, the role of cyanoacrylate basis glue in the management of GIST bleeding is exceptionally rare. Aims We present a case of a bleeding GIST that was successfully managed through the utilization of cyanoacrylate basis glue allowing for elective surgical resection. Methods A chart review was undertaken. Also, a literature review of the topic was also conducted using the terms “GIST, Cyanoacrylate Glue, Bleeding” Results A 75-year-old male presented with a four week history of exertional chest pain. He had noticed persistent black stools for the previous two weeks. His past medical history was relevant for coronary artery disease; two years earlier he had drug eluting stents placed. His medications included ASA 81mg PO OD and Pantoprazole 40mg OD. Physical examination revealed stable vital signs, a soft abdomen and melena on rectal examination. Laboratory investigations showed a hemoglobin of 75 g/L, and 2 weeks prior his hemoglobin had been 120 g/L. Platelets were 149. His liver enzymes and liver function tests were unremarkable. His BUN was 9.9 mmol/L and creatinine of 96.0 umol/L. An esophagogastroduodenoscopy (EGD) revealed a 5cm smooth mass with a central deep depression, in the antrum, that was actively bleeding. Attempts to clip were unsuccessful due to the width of the central depression which was the source of bleeding. (See image 1). The endoscopist chose to inject 1cc of cyanoacrylate basis glue directly into the bleeding site. A subsequent CT scan revealed a 5.2cm polypoid mass in the gastric antrum, favored to be a GIST with no evidence of metastatic disease. Surgery and Cardiology were involved in the care of this patient, and emergency surgery was delayed due to the patient having an intercurrent acute coronary syndrome. Post EGD, the patient underwent an angiogram and the culprit coronary artery was stented and patient was started on dual antiplatelet therapy. Patient then successfully underwent a laparoscopic gastric wedge resection for his GIST, this was completed 1 week after EGD. The pathology of the resected area was in keeping with a GIST. Of note, the patient’s hemoglobin had been stable from the time of EGD until surgical intervention. Conclusions Managing GIST bleeding endoscopically can be challenging, and surgical resection is the recommended treatment modality. In situations where surgical intervention is contraindicated, endoscopic therapy with cyanoacrylate basis glue can be considered to achieve hemostasis in GIST bleeding. Funding Agencies None

Gensini Score and Thrombus Burden Add Predictive Value to the SYNTAX Score in Detecting No-Reflow after Myocardial Infarction.

ResumoFundamento O fenômeno de no-reflow após a intervenção coronária percutânea está associado a um pior prognóstico em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). O escore SYNTAX é um bom preditor de no-reflow.Objetivo Nosso objetivo foi avaliar se a carga aterosclerótica (escore Gensini) e a carga trombótica na artéria coronária culpada melhorariam a capacidade do escore SYNTAX para detectar o no-reflow.Métodos Neste estudo coorte prospectivo, foram estudados pacientes com IAMCSST consecutivos que se apresentaram dentro de 12 horas a partir do início dos sintomas. O no-reflow foi definido como fluxo TIMI < 3 ou fluxo TIMI =3 mas grau de blush miocárdico (myocardial blush grade) < 2. A carga trombótica foi quantificada de acordo com o grau TIMI de trombo (0 a 5).Resultados Foram incluídos 481 pacientes no estudo, com idade média de 61±11 anos. O fenômeno de no-reflow ocorreu em 32,8% dos pacientes. O escore SYNTAX (OR=1,05, IC95% 1,01–1,08, p<0,01), a carga trombótica (OR=1,17, IC95% 1,06–1,31, p<0,01), e o escore Gensini (OR=1,37, IC95% 1,13–1,65, p<0,01) foram preditores independentes do no-reflow. Os escores combinados apresentaram uma maior área sob a curva quando comparados ao escore SYNTAX isolado (0,78 [0,73–0,82] vs 0,73 [0,68–0,78], p=0,03). A análise da melhora da reclassificação líquida (NRI) categórica (0,11 [0,01–0,22], p=0,02) e contínua (NRI>0) (0,54 [0,035–0,73], p<0.001) mostrou melhora na capacidade preditiva do no-reflow no modelo combinado, com melhora da discriminação integrada (IDI) de 0,07 (0,04–0,09, p<0,001).Conclusões Nossos achados sugerem que, em pacientes com IAMCSST submetidos à intervenção coronária percutânea, a carga aterosclerótica e a carga trombótica na artéria culpada adicionam valor preditivo ao escore SYNTAX na detecção do fenômeno no-reflow. (Arq Bras Cardiol. 2021; [online].ahead print, PP.0-0)

Longitudinal change in cardiac structure and function following acute coronary syndrome stratified by culprit coronary artery lesion site

Abstract Funding Acknowledgements Type of funding sources: None. Background Acute coronary syndrome (ACS) has adverse consequences for the myocardium and subsequent cardiac function and structure. No reports exist comparing the differences in impact of culprit coronary artery lesion site on longitudinal remodeling and changes left ventricular structure and function. Method A total of 299 ACS patients treated with PCI were included in the present study. All patients had two echocardiographic examinations performed. The first was performed median 2 (IQR: 1; 3) days following PCI, while the second was performed median 240 (IQR: 81; 881) days after the first. Patients were grouped based on culprit coronary artery lesion (left anterior descending artery (LAD), right coronary artery (RCA) and circumflex artery (Cx)). Patients with multiple lesions were excluded from the present study. Univariable linear regression analysis was utilised to assess the association between culprit coronary artery lesion site and longitudinal change in cardiac structure and function. Results Mean age was 63 ± 11 years and 77% were male. At follow-up, mean left ventricular ejection fraction was 42 ± 9% and global longitudinal strain (GLS) was -13 ± 4%. Culprit coronary artery lesion was allocated as follows; 168 ACS patients were treated in LAD, 95 patients were treated in RCA, and 36 patients were treated in Cx. In the linear regression analysis, LAD patients displayed a greater improvement in GLS (b =-0.116, p = 0.048) compared to the two other lesion sites. LAD patients had the poorest GLS at both baseline and follow-up echocardiography (Figure). RCA lesions were associated with the largest decrease in left atrial maximum volume (LAVmax) (b = -0.156, p = 0.011) and the largest increase in relative wall thickness (RWT) (b = 0.139, p = 0.030), consequently resulting in an LAVmax smaller and an RWT larger at follow-up than other lesion sites (Figure). Lastly, Cx lesions were significantly associated with the largest decrease in ratio between peak early diastolic transmitral flow velocity and peak early diastolic mitral annular tissue velocity (E/e’) (b = -0.262, P &amp;lt;0.001). Cx lesion patients were observed to have elevated E/e’ at baseline, which generally normalised at follow-up (Figure). Conclusion The present study suggests that culprit coronary artery lesion site has a differential impact on cardiac remodeling. This information can potentially aid the clinical understanding of cardiac structure and function following ACS according to coronary artery lesion site. Abstract Figure

OUTCOME OF PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION ARRIVING IN ARMY CARDIAC CENTER LAHORE

Objective: To evaluate the feasibility and outcomes of primary percutaneous coronary intervention (PCI) as a mode of treatment in acute ST segment elevation myocardial infarction (STEMI).&#x0D; Study Design: Descriptive cross sectional study.&#x0D; Place and Duration of Study: The study was conducted in Army Cardiac Center Lahore, from Nov 2019 to Feb 2020.&#x0D; Methodology: All patients diagnosed as acute ST-segment elevation myocardial infarction during the study period were offered primary percutaneous coronary intervention among treatment options. Patients who chose primary percutaneous coronary intervention were included in the study. Informed consent was taken. Patient demographics, risk factors, time variables, procedural characteristics and in-hospital adverse events were evaluated.&#x0D; Results: On admission, Out of 50, 30 (60%) of the patients were current smokers, 25 (50%) were hypertensive, 22 (44%) were diabetic, and 1 (2%) had cardiogenic shock. The mean time from symptom onset to hospital arrival was 5 hours and the mean door-to-balloon time was 34 minutes. Culprit coronary artery was the left anterior descending artery (LAD) in 56% cases and multi-vessel disease was present in 38% cases. Primary percutaneous coronary intervention involved balloon dilatation (2%) and stent implantation (98%). The incidence of postprocedural angiographic no-reflow was 0%. All-cause mortality was 1%.&#x0D; Conclusion: This study has shown efficiency, feasibility and safety in performing of primary percutaneous coronary intervention with excellent outcomes in Army Cardiac Center Lahore. In order to further improve its outcomes, our goal should be to decrease reperfusion time which can be achieved by reducing patient delay, increasing public awareness and improving the management of first medical contact.

Nomogram Containing Simple Routine Clinical and Biochemical Parameters Can Predict Pathologic Ventricular Remodeling in STEMI Patients

SUMMARYHeart failure is the leading cause of morbidity and mortality worldwide, with ischemic heart disease being one of the most important etiologic factors. Heart failure develops due to ventricular remodeling, which leads to increases in left ventricular end-systolic and end-diastolic volumes. In this prospective observational study, we included 101 patients with first episode of ST-segment elevation myocardial infarction in whom percutaneous coronary intervention was conducted within 12 h and Thrombolysis in Myocardial Infarction III flow was achieved. The aim was to determine which clinical and biochemical parameters can help predict pathologic ventricular remodeling 1 year after myocardial infarction. We created a nomogram based on routinely used blood tests and vital parameters which showed highest correlation with pathologic ventricular remodeling. The nomogram included NTproBNP value 12 h after reperfusion, aspartate transaminase value 12 h after reperfusion, systolic blood pressure value on admission, and culprit coronary artery. We performed ROC analysis which yielded great predictive value of the nomogram. The area under curve was 0.907 (95% CI 0.842-0.973). The nomogram value of -3.54 had 91.4% sensitivity and 74.0% specificity. We believe that this nomogram, once validated, could offer a widely available, low-cost option that would help identify patients at risk of developing pathologic left ventricular remodeling and achieve this at a very early stage of myocardial infarction (12 h after reperfusion has been achieved).

Tasmanian STEMI Network - A Whole of System Evaluation

ST-elevation myocardial infarction (STEMI) is a time critical emergency requiring rapid restoration of flow through the occluded culprit coronary artery. Optimal management requires a co-ordinated system involving ambulance services, retrieval, emergency departments and interventional cardiology teams. Best practice treatment for STEMI is reperfusion within 90 mins of first medical contact, although this target can be challenging to achieve outside of metropolitan areas. The Tasmanian STEMI Network was implemented on April 30, 2018 to streamline state-wide STEMI management and improve reperfusion times.

Frequency of Thrombolysis in Myocardial Infarction III Flow in Patients With Primary Percutaneous Coronary Intervention: Not All Culprit Vessels Are Completely Occluded in ST Elevation Myocardial Infarction.

BackgroundST elevation myocardial infarction (STEMI) is classically characterized by total occlusion of the culprit coronary artery. However during primary percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) 0 flow is not observed in all patients' culprit arteries in angiographic views. This study was conducted to find out the frequency of TIMI flow in acute STEMI patients in view of the above concept. The aim of this study was to evaluate the frequency of pre-procedural TIMI III flow in those patients who underwent primary PCI for acute STEMI in a public sector hospital in Karachi, Pakistan.MethodologyThis study is an audit of already saved data in the catheterization laboratory of the National Institute of Cardiovascular Diseases (NICVD), Karachi, that was collected prospectively from January 2016 to December 2018. These data were collected after taking consent from those patients who presented to hospital within 12 hours of symptoms and underwent primary PCI. Data were entered and analyzed on Statistical Package for the Social Sciences (SPSS) version 19 (IBM Corp., Armonk, NY, USA).ResultsA total of 8018 patients were included in this study who presented with STEMI and underwent primary PCI. Out of them 80.9% were males. Hypertension was the leading risk factor in 54.1% (4340) of patients. TIMI III flow was present in 11.4% of patients before primary PCI, while TIMI 0, I and II flow were present in 57.1%, 15.1%, and 16.3% of patients respectively (p<0.001). Fourteen percent of patients with TIMI III flow were of age group 51 to 60 years. Among those who had TIMI III flow, 11.2% were those with door to balloon time of <90 minutes. In 11% of cases, left anterior descending (LAD) artery had TIMI III flow as compared to other vessels (p<0.001). The length of the lesion was significantly smaller in patients who had TIMI III flow compared to those who had TIMI 0-II flow.ConclusionsThis study revealed that not all patients with acute STEMI had totally occluded culprit coronary artery but some of them had angiographic TIMI I-III flow in the infarct-related artery. Further studies are needed to find the reason for re-establishment of flow in the culprit vessel in STEMI patients before PCI.

Assessment of myocardial damage after acute myocardial infarction by diastolic deceleration time of coronary flow velocity using echocardiography and contrast-enhanced magnetic resonance imaging.

There are limited data available regarding the use of diastolic deceleration time (DDT) of three major arteries measured by transthoracic echocardiography (TTE) for assessing coronary microvascular damage after acute myocardial infarction (AMI). Therefore, we aimed to compare the DDT of three major arteries using TTE with the transmural extent of infarction (TEI) and infarct size, which were classified using contrast-enhanced magnetic resonance imaging (CE-MRI), in patients with AMI. The DDT of the culprit coronary artery was measured in 74 patients using TTE and CE-MRI 1week after the onset of AMI. The TEI was graded based on the transmural extent of the hyper-enhanced tissue (grades 1-4). The assessable rate for the DDT was 95%; individual rates were 100% for the left anterior descending coronary artery, 90% for the left circumflex artery, and 93% for the right coronary artery. The DDT decreased gradually as the TEI grade progressed (P=.021). Infarct size was significantly correlated with the DDT (r=-0.51, P<.0001). Univariate analysis revealed that the left ventricular (LV) end-systolic volume, LV ejection fraction, and DDT were significantly associated with TEI grade 4. After adjustment via multiple logistic regression analysis, the DDT was independently remained. With a cutoff value of 950ms, as determined by the ROC curve, DDT could detect TEI grade 4 with 81.1% sensitivity and 80.1% specificity. The DDT of three major coronary arteries measured by TTE 1week after the onset of AMI can assess the extent of myocardial damage, which is determined by CE-MRI.

Low-dose intracoronary alteplase during primary percutaneous coronary intervention in patients with acute myocardial infarction: the T-TIME three-arm RCT

Background Microvascular obstruction commonly affects patients with acute ST-segment elevation myocardial infarction and is independently associated with adverse outcomes. Objective To determine whether or not a strategy involving low-dose intracoronary fibrinolytic therapy infused early after coronary reperfusion will reduce microvascular obstruction. Design This was a multicentre, randomised, double-blind, parallel-group, placebo-controlled, dose-ranging trial. Setting The trial took place at 11 hospitals in the UK between 17 March 2016 and 21 December 2017. Participants Patients with acute ST-segment elevation myocardial infarction and a symptom onset to reperfusion time of ≤ 6 hours were eligible for randomisation. Radial artery access was a requirement, and further angiographic criteria included a proximal-to-middle coronary artery occlusion or impaired coronary flow in the presence of a definite thrombus in the culprit coronary artery. Exclusion criteria included a functional coronary collateral supply to the infarct-related artery, any contraindication to fibrinolysis and lack of informed consent. Additional exclusion criteria for safety were (1) requirement for immunosuppressive drug therapy for ≤ 3 months and (2) treatment with an antimicrobial agent. Intervention A total of 440 participants were randomly assigned 1 : 1 : 1 to treatment with placebo (n = 151), 10 mg of alteplase (n = 144) or 20 mg of alteplase (n = 145) administered by manual infusion directly into the infarct-related coronary artery over 5–10 minutes. The intervention was scheduled to happen after reperfusion and before stent implantation. Outcomes The primary outcome was the amount of microvascular obstruction (percentage of left ventricular mass) demonstrated by contrast-enhanced cardiac magnetic resonance imaging at 2–7 days after enrolment. The primary analysis was the comparison between the 20 mg of alteplase group and the placebo group; if this comparison was not significant, the comparison of the 10 mg of alteplase group with the placebo group was considered as a secondary analysis. Sample size A total of 618 patients (minimum of 558 patients). Recruitment was halted on 21 December 2017 given that conditional power for the primary outcome based on a prespecified analysis of the first 267 randomised participants was &lt; 30% in both treatment groups (futility criterion). Methods The primary outcome was compared between groups using a stratified Wilcoxon rank-sum test (van Elteren test), stratified by the location of the myocardial infarction. Results Among the 440 patients (mean age of 60.5 years; 15% women), the primary end point was measured in 396 (90%) patients, 17 (3.9%) withdrew, seven died and all other patients were followed up to 3 months. The amount (mean percentage of left ventricular mass) of microvascular obstruction was 2.3% versus 2.6% versus 3.5% in the placebo, 10 mg of alteplase and 20 mg of alteplase groups, respectively. In the primary analysis, microvascular obstruction did not differ between the 20 mg of alteplase group and the placebo group: 3.5% versus 2.3%, estimated difference 1.16% (95% confidence interval –0.08% to 2.41%; p = 0.32). In the secondary analysis, microvascular obstruction did not differ between the 10 mg of alteplase group and the placebo group: 2.6% versus 2.3%, estimated difference 0.29% (95% confidence interval –0.76% to 1.35%; p = 0.74). By 3 months, major adverse cardiac events (cardiac death, non-fatal myocardial infarction and unplanned hospitalisation for heart failure) had occurred in 15 (10.1%) patients in the placebo group, 18 (12.9%) in the 10 mg of alteplase group and 12 (8.2%) in the 20 mg of alteplase group. Conclusions Adjunctive low-dose intracoronary alteplase given during the primary percutaneous intervention did not reduce microvascular obstruction compared with placebo. Limitations Premature discontinuation of enrolment limited the power of the secondary and safety analyses. Future work Low-dose intracoronary alteplase or tenecteplase could be compared with placebo at the end of primary percutaneous coronary intervention in patients with an ischaemic time of &lt; 4 hours. Trial registration This trial is registered as ClinicalTrials.gov NCT02257294. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 7, No. 5. See the NIHR Journals Library website for further project information.

The comparison of the chronic-phase vascular healing between bioabsorbable and durable polymer drug eluting stent by using optical coherence tomography

Abstract Background Bioabsorbable polymer drug eluting stents (BP-DESs) were designed to reduce a vascular inflammatory reaction compared to durable polymer drug eluting stents (DP-DESs). However, few studies have compared vascular responses to BP-DESs and DP-DESs. Methods We enrolled 88 consecutive patients with single culprit coronary artery lesions (31 lesions with acute coronary syndrome) undergoing a single stent-implantation. BP-DESs and DP-DESs were implanted in 50 (57%) and 38 patients (43%), respectively. All lesions underwent optical coherence tomography examination at chronic phase and intrastent OCT findings at the follow-up were evaluated in every 1-mm cross-sections (CSs). Results A total of 1887 CSs (BP-DES: 1096, DP-DES: 791) were analyzed. The median period of follow-up OCT was 293 (250–374) days. There were no differences in the patient, lesion, and initial clinical presentation of acute coronary syndrome (ACS). BP-DESs had significantly higher percent neointimal hyperplasia area, defined as neointimal hyperplasia area divided by stent area x 100 (18.4±9.0% vs. 16.1±9.9%, p&amp;lt;0.001), fewer malapposed struts (1.7% vs. 3.9%, p=0.005), fewer uncovered struts (3.6% vs. 5.8%, p=0.02) but higher frequency of superficial low intensity neointima (LIN) (7.7% vs. 3.4%, p&amp;lt;0.001). Multivariate logistic analysis showed that BP-DES (OR: 2.5, 95% CI: 1.49–4.08, p&amp;lt;0.001) and the initial clinical presentation of ACS (OR: 2.31, 95% CI: 1.47–3.62, p&amp;lt;0.001) are independent predictive factors for LIN. Conclusion BP-DESs showed homogenous neointimal growth and complete stent coverage quantitatively. Meanwhile, the significant relationships of BP-DES with LIN may suggest that the neointimal quality remains immature in BP-DESs in this period. Funding Acknowledgement Type of funding source: None

Effect of late culprit coronary artery revascularization on prognosis of patients with ST-elevation myocardial infarction

Aim. To evaluate the effect of culprit coronary artery revascularization after 48 hours from the symptoms’ onset on the prognosis of patients with ST-elevation myocardial infarction (STEMI).Material and methods. Of the 1172 patients admitted to City Clinical Hospital № 13 in 2018 due to STEMI, 43 patients (4%) were included in the retrospective study. There were following inclusion criteria: hospitalization after 48 hours from the symptoms’ onset, no clinical signs of myocardial ischemia, and complete coronary artery occlusion according to angiography. The mean age of the subjects was 61,3±10,6 years, 34 (79%) men and 9 (21%) women. The subjects were divided into two groups: group 1 (n=22) — management with percutaneous coronary intervention (PCI), group 2 (n=21) — management with medications. The groups differ only in the severity of coronary atherosclerosis according to SYNTAX score: group 1 — 14,0 [11.0; 19.5], group 2 — 26,0 [16,5; 31,0] (p=0,009). At the end of inpatient treatment, patients underwent echocardiography. Death and myocardial infarction were monitored during hospitalization and for 12 months after discharge.Results. During hospitalization, 2 patients died (4,7%; one in each group, p=1,00). No recurrent MI were reported. The left ventricular ejection fraction in the PCI group was 50 [46; 54] %, in the group with drug therapy — 43 [38; 50] % (p=0,01). Out of 43 included patients, long-term outcomes were followed up in 32 (74%). Among them, 1 (5,8%) patient died in group 1, 6 (33,3%) patients — in group 2 (p=0,04). In total, death or recurrent MI in the first group was observed in 2 (12%) patients, in the second group — in 5 (33%) patients (p=0,14).Conclusion. Revascularization of a fully occluded culprit coronary artery in stable patients with STEMI after 48 hours of symptoms’ onset is associated with a higher inhospital left ventricular ejection fraction and a decrease in 12-month mortality.

A novel risk stratification system “Angiographic GRACE Score” for predicting in-hospital mortality of patients with acute myocardial infarction: Data from the K-ACTIVE Registry

BackgroundThe Global Registry of Acute Coronary Events (GRACE) score is the most accurate risk assessment system for acute myocardial infarction (AMI), which was proposed in Western countries. However, it is unclear whether GRACE score is applicable to the present Japanese patients with a high prevalence of emergent percutaneous coronary intervention (PCI) and vasospasm. This study aimed to clarify the usefulness of GRACE risk score for risk stratification of Japanese AMI patients treated with early PCI and to evaluate a novel risk stratification system, “angiographic GRACE score,” which is the GRACE risk score adjusted by the information of the culprit coronary artery and its flow at pre- and post-PCI, to improve its predicting availability. MethodsThe subjects were 1817 AMI patients who underwent PCI within 24 h of onset between October 2015 and August 2017 and were registered in Kanagawa Acute Cardiovascular (K-ACTIVE) Registry via survey form. The association between the clinical parameters and in-hospital mortality was investigated. ResultsA total of 79 (4.3%) in-hospital deaths were identified. The C-statistics for the in-hospital mortality of the GRACE score was 0.86, which was higher than that of the other conventional risk factors, including age (0.65), systolic blood pressure (0.70), heart rate (0.62), Killip classification (0.77), and serum levels of creatinine (0.68) and peak creatine kinase (0.74). The angiographic GRACE score improved the C-statistics from 0.86 of the original GRACE score to 0.89 (p < 0.05). In the setting of the cut-off value at 200, in-hospital mortality in the patients with the angiographic GRACE score <200 was 0.6%, which was relatively lower than those with ≥200, 9.4%. ConclusionsThe GRACE score is a useful predictor of in-hospital mortality among Japanese AMI patients in the PCI era. Moreover, the angiographic GRACE score could improve the predicting availability.

Cell Free and Exosomal Micro RNAs: Novel Biomarkers for Adverse Cardiac Remodelling and Heart Failure

The prevalence of heart failure (HF) due to cardiac remodelling after acute myocardial infarction (AMI) does not decrease regardless of implementation of new technologies supporting opening culprit coronary artery and solving of ischemia-relating stenosis with primary percutaneous coronary intervention (PCI). Numerous studies have examined the diagnostic and prognostic potencies of circulating cardiac biomarkers in acute coronary syndrome / AMI and HF after AMI, and even fewer have been depicted the utility of biomarkers in AMI patients undergoing primary PCI. The aim of the review is focused an attention on non-coding cell-free and exosomal micro RNA as biomarkers of HF. Although there is a large number of evidence regarding predicative value of signature of miRNA in adverse cardiac remodelling and HF with different phenotypes, large clinical trials are required to be performed in the future to clearly elucidate whether miRNAs could be suitably for personalizing HF therapy.

Absolute microvascular resistance by continuous thermodilution predicts microvascular dysfunction after ST-elevation myocardial infarction

AimsContinuous thermodilution using intracoronary saline infusion is a novel technique able to provide accurate measurements of absolute coronary blood flow and microvascular resistance (Rmicro). The aim of this study was to assess the ability of Rmicro, measured by continuous thermodilution, to predict microvascular dysfunction in patients with ST-elevation myocardial infarction. Methods and resultsIn this prospective observational study, continuous thermodilution was used to measure Rmicro in the culprit coronary artery of 32 patients with STEMI (mean age ± SD, 66 ± 10 years; 78% male) immediately post-primary percutaneous coronary intervention (PCI). Concomitant measurements of the index of microvascular resistance (IMR) and coronary flow reserve (CFR) were obtained by bolus thermodilution. Microvascular dysfunction was defined as an IMR > 40 or a CFR < 2. Rmicro was higher in patients with microvascular dysfunction based on the predefined thresholds; for IMR: 863 (IQR, 521–1079) vs 474 (IQR, 337–616) Wood units, p = .004 and for CFR: 633 (IQR, 455–1039) vs 474 (IQR, 271–579) Wood units, p = .02. Receiver-operator characteristic analysis demonstrated that Rmicro was predictive of microvascular dysfunction; area under curve (AUC) 0.800 (95% CI: 0.637–0.963, p = .005) for IMR-defined microvascular dysfunction and AUC 0.758 (95% CI: 0.593–0.924, p = .02) for CFR-defined microvascular dysfunction. An Rmicro threshold of greater than 552 Wood units was optimal for predicting microvascular dysfunction defined by IMR > 40. ConclusionsRmicro is able to identify STEMI patients in whom IMR and CFR measurements suggest significant microvascular dysfunction at the end of primary PCI.