Culprit Coronary Artery Research Articles

Intra-coronary morphine versus placebo in the treatment of acute ST-segment elevation myocardial infarction: the MIAMI randomized controlled trial

BackgroundExperimental studies suggest that morphine may protect the myocardium against ischemia-reperfusion injury by activating salvage kinase pathways. The objective of this two-center, randomized, double-blind, controlled trial was to assess potential cardioprotective effects of intra-coronary morphine in patients with ST-segment elevation myocardial infarction (STEMI) referred for primary percutaneous intervention.MethodsNinety-one patients with STEMI were randomly assigned to intracoronary morphine (1 mg) or placebo at reperfusion of the culprit coronary artery. The primary endpoint was infarct size/left ventricular mass ratio assessed by magnetic resonance imaging on day 3–5. Secondary endpoints included the areas under the curve (AUC) for troponin T and creatine kinase over three days, left ventricular ejection fraction assessed by echocardiography on days 1 and 6, and clinical outcomes.ResultsInfarct size/left ventricular mass ratio was not significantly reduced by intracoronary morphine compared to placebo (27.2% ± 15.0% vs. 30.5% ± 10.6%, respectively, p = 0.28). Troponin T and creatine kinase AUCs were similar in the two groups. Morphine did not improve left ventricular ejection fraction on day 1 (49.7 ± 10.3% vs. 49.3 ± 9.3% with placebo, p = 0.84) or day 6 (48.5 ± 10.2% vs. 49.0 ± 8.5% with placebo, p = 0.86). The number of major adverse cardiac events, including stent thrombosis, during the one-year follow-up was similar in the two groups.ConclusionsIntracoronary morphine at reperfusion did not significantly reduce infarct size or improve left ventricular systolic function in patients with STEMI. Presence of comorbidities in some patients may contribute to explain these results.Trial registrationClinicalTrials.gov, NCT01186445 (date of registration: August 23, 2010).

Muscle squeezing immediately after coronary reperfusion therapy using postconditioning with lactate-enriched blood

BackgroundWe recently reported a new approach for cardioprotection, postconditioning with lactate-enriched blood (PCLeB), and a patient with ST-segment elevation myocardial infarction (STEMI), in whom muscle squeezing of the culprit coronary artery was observed immediately after reperfusion with PCLeB. In this study, we examined the prevalence of muscle squeezing immediately after reperfusion in patients with anterior STEMI treated using PCLeB. Methods and resultsPCLeB is a modified postconditioning protocol that comprises intermittent reperfusion and timely coronary injections of lactated Ringer's solution. We treated 30 consecutive patients with anterior STEMI using PCLeB. Among the 30 patients, 4 patients exhibited muscle squeezing of the left anterior descending artery (LAD) immediately after reperfusion. We performed follow-up coronary angiography in 23 patients and found another patient who exhibited muscle squeezing of the LAD. Thus, of 30 patients, 5 were confirmed to have myocardial bridging and 4 exhibited muscle squeezing immediately after reperfusion with PCLeB. No patient died or experienced re-hospitalization for heart failure or recurrent ischemic events at 6 months except for one patient with malignancy. ConclusionMuscle squeezing immediately after reperfusion therapy is not a rare phenomenon in patients with anterior STEMI treated using PCLeB.

Clinical characteristics of occluded culprit arteries and collaterals in patients with non-ST-segment elevation myocardial infarction and impact on clinical outcomes.

The presence of an occluded culprit artery or collaterals in non-ST-segment elevation myocardial infarction (NSTEMI) is relatively common; however, limited data are available regarding their clinical significance. The aim of the current study was to determine the clinical characteristics of occluded culprit arteries and coronary collaterals in patients with NSTEMI and their impact on patient outcomes. A total of 345 patients diagnosed with NSTEMI via coronary angiography between February 2006 and May 2013 were evaluated in the present study. Patient demographics, procedural characteristics and clinical outcomes of patients were analyzed according to the presence of an occluded culprit artery and coronary collaterals. A total of 78 (22.6%) and 166 patients (48.1%) exhibited an occluded artery and coronary collaterals, respectively. The left anterior descending artery is a more common location of culprit arteries in patients with NSTEMI with patent artery (NSTEMIPA) and distal parts of the artery are more common location of culprit arteries in patients with NSTEMI with occluded arteries (NSTEMIOA). Patients with NSTEMIOA exhibited higher peak creatine kinase-MB (CKMB) and troponin-I levels compared with patients that had NSTEMIPA. The presence of coronary collaterals is associated with a lower mean left ventricular ejection fraction, higher regional wall motion score index and extensive coronary artery disease. However, the clinical outcomes of patients with collaterals did not differ, irrespective of the presence of an occluded culprit artery or coronary collaterals. In the current study, ~25% of patients with NSTEMI had an occluded culprit coronary artery whereas 50% of patients with NSTEMI had coronary collaterals. The presence of an occluded artery and/or coronary collaterals did not affect clinical outcomes. Further studies are required to evaluate the long-term prognostic impact of an occluded artery and collaterals.

Coronary Thermodilution Waveforms After Acute Reperfused ST-Segment-Elevation Myocardial Infarction: Relation to Microvascular Obstruction and Prognosis.

BackgroundInvasive measures of microvascular resistance in the culprit coronary artery have potential for risk stratification in acute ST‐segment–elevation myocardial infarction. We aimed to investigate the pathological and prognostic significance of coronary thermodilution waveforms using a diagnostic guidewire.Methods and ResultsCoronary thermodilution was measured at the end of percutaneous coronary intervention, (PCI) and contrast‐enhanced cardiac magnetic resonance imaging (MRI) was intended on day 2 and 6 months later to assess left ventricular (LV) function and pathology. All‐cause death or first heart failure hospitalization was a pre‐specified outcome (median follow‐up duration 1469 days). Thermodilution recordings underwent core laboratory assessment. A total of 278 patients with acute ST‐segment elevation myocardial infarction EMI (72% male, 59±11 years) had coronary thermodilution measurements classified as narrow unimodal (n=143 [51%]), wide unimodal (n=100 [36%]), or bimodal (n=35 [13%]). Microvascular obstruction and myocardial hemorrhage were associated with the thermodilution waveform pattern (P=0.007 and 0.011, respectively), and both pathologies were more prevalent in patients with a bimodal morphology. On multivariate analysis with baseline characteristics, thermodilution waveform status was a multivariable associate of microvascular obstruction (odds ratio [95% confidence interval]=5.29 [1.73, 16.22];, P=0.004) and myocardial hemorrhage (3.45 [1.16, 10.26]; P=0.026), but the relationship was not significant when index of microvascular resistance (IMR) >40 or change in index of microvascular resistance (5 per unit) was included. However, a bimodal thermodilution waveform was independently associated with all‐cause death and hospitalization for heart failure (odds ratio [95% confidence interval]=2.70 [1.10, 6.63]; P=0.031), independent of index of microvascular resistance>40, ST‐segment resolution, and TIMI (Thrombolysis in Myocardial Infarction) Myocardial Perfusion Grade.ConclusionsThe thermodilution waveform in the culprit coronary artery is a biomarker of prognosis and may be useful for risk stratification immediately after reperfusion therapy.

P777Incidence and impact of occluded culprit coronary arteries in patients with non-ST-segment elevation myocardial infarction

P777Incidence and impact of occluded culprit coronary arteries in patients with non-ST-segment elevation myocardial infarction

P-Selectin Glycoprotein Ligand-1 (PSGL-1) Expressing CD4 T Cells Contribute Plaque Instability in Acute Coronary Syndrome.

Adhesion molecules have essential roles in the development of atherosclerosis. We investigated whether P-selectin glycoprotein ligand-1 (PSGL-1)-expressing CD4 T cells contribute to plaque instability in acute coronary syndrome (ACS).Methods and Results:We studied the adhesion molecules on CD4 T cells from consecutive patients with ACS treated with thrombus-aspirating device and compared them with healthy controls (n=48 each). Blood, thrombi, and plaque samples from the culprit coronary arteries were collected by thrombus aspiration performed during emergency coronary artery angiography. According to flow cytometry results, peripheral CD4 T cells from ACS patients strongly expressed PSGL-1 and integrin β2 (P<0.05 for both) more than those from controls; culprit coronary arteries contained an abundance of PSGL-1+(P<0.001) but not integrin β2+CD4 T cells. In addition, immunohistochemical analysis of the thrombus-aspirating device samples revealed numerous PSGL-1+CD4 T cells in plaques from the culprit lesions. Results from the selectin-binding assay demonstrated that activated PSGL-1+CD4 T cells from ACS patients bound to P- or E-selectin after triggering the T-cell receptor, and adhered to endothelial cells under laminar flow conditions (P<0.05 and P<0.05, respectively), inducing their apoptosis (P<0.01) via activated caspase-3, which correlated with PSGL-1 expression (R=0.788, P=0.021) and was suppressed by application of a PSGL-1-specific antibody (P<0.05). PSGL-1 contributed to cytotoxic CD4 T cell homing to the culprit coronary artery and promoted plaque instability in ACS.

Imaging of chemokine receptor CXCR4 expression in culprit and nonculprit coronary atherosclerotic plaque using motion-corrected [68Ga]pentixafor PET/CT

PurposeThe chemokine receptor CXCR4 is a promising target for molecular imaging of CXCR4+ cell types, e.g. inflammatory cells, in cardiovascular diseases. We speculated that a specific CXCR4 ligand, [68Ga]pentixafor, along with novel techniques for motion correction, would facilitate the in vivo characterization of CXCR4 expression in small culprit and nonculprit coronary atherosclerotic lesions after acute myocardial infarction by motion-corrected targeted PET/CT.MethodsCXCR4 expression was analysed ex vivo in separately obtained arterial wall specimens. [68Ga]Pentixafor PET/CT was performed in 37 patients after stent-based reperfusion for a first acute ST-segment elevation myocardial infarction. List-mode PET data were reconstructed to five different datasets using cardiac and/or respiratory gating. Guided by CT for localization, the PET signals of culprit and various groups of nonculprit coronary lesions were analysed and compared.ResultsEx vivo, CXCR4 was upregulated in atherosclerotic lesions, and mainly colocalized with CD68+ inflammatory cells. In vivo, elevated CXCR4 expression was detected in culprit and nonculprit lesions, and the strongest CXCR4 PET signal (median SUVmax 1.96; interquartile range, IQR, 1.55–2.31) was observed in culprit coronary artery lesions. Stented nonculprit lesions (median SUVmax 1.45, IQR 1.23–1.88; P = 0.048) and hot spots in naive remote coronary segments (median SUVmax 1.34, IQR 1.23–1.74; P = 0.0005) showed significantly lower levels of CXCR4 expression. Dual cardiac/respiratory gating provided the strongest CXCR4 PET signal and the highest lesion detectability.ConclusionWe demonstrated the basic feasibility of motion-corrected targeted PET/CT imaging of CXCR4 expression in coronary artery lesions, which was triggered by vessel wall inflammation but also by stent-induced injury. This novel methodology may serve as a platform for future diagnostic and therapeutic clinical studies targeting the biology of coronary atherosclerotic plaque.

Electrocardiogram criteria of limb leads predicting right coronary artery as culprit artery in inferior wall myocardial infarction: A meta-analysis.

Background:Prior studies have proposed several electrocardiogram (ECG) criteria in limb leads for identifying the culprit coronary artery (CCA) in patients with acute inferior wall myocardial infarction (IWMI). The aim of our study was to conduct an evidence-based evaluation and test accuracy comparison of these criteria.Methods:We searched the PubMed, Embase, and Ovid. Eligible studies to assess the diagnostic performance of ECG criteria predicting CCA in IWMI were reviewed for inclusion. A diagnostic meta-analysis of bivariate approach was performed for pooled estimates of sensitivity and specificity, and meta-regression was implemented to investigate sources of heterogeneity.Results:Twenty-four studies with 4431 unique participants met the inclusion criteria. The pooled sensitivity and specificity for ST-segment elevation (STE) in III > II, ST-segment depression (STD) in I, STD in aVL, STD in aVL > I, STE in III > II, and STD in aVL > I were 0.91 (0.88–0.94) and 0.69 (0.53–0.81), 0.80 (0.73–0.87) and 0.69 (0.62–0.76), 0.90 (0.81–0.95) and 0.41 (0.22–0.62), 0.84 (0.75–0.91) and 0.72 (0.48–0.88), and 0.79 (0.62–0.90) and 1.00 (0.37–1.00), respectively. Heterogeneity investigation showed that whether multi-vessel diseased patients were excluded, sample size, publication year, etc., could influence the diagnostic performance.Conclusion:STE in III > II performed better than other criteria for predicting RCA as CCA in IWMI, and STE in III > II and STD in aVL > I were potential and simple algorithms. ECG could be an effective tool to identify the CCA, but future studies are clearly needed to address the potential of diagnostic and prognostic value.

4D Quantitative Coronary Artery Motion Analysis: A Novel Method for Culprit Lesion Prediction

This study aims to determine if measuring four-dimensional quantitative coronary artery motion (QCAM) and change in tortuosity (∆T) on invasive biplane coronary angiogram is predictive of the location of culprit lesions responsible for myocardial infarctions. Invasive coronary angiograms have no current clinical application for the prediction of future coronary events. Previous studies have shown promise in demonstrating the effects of coronary artery motion on plaque formation and location, but this has yet to fully translate into a directed diagnostic method. QCAM and ΔT were calculated with CAAS QCA4D prototype software (Pie Medical Imaging, the Netherlands) for sections of the culprit coronary artery using biplane coronary angiograms of fourteen patients undergoing percutaneous coronary intervention for myocardial infarction. Prediction of the artery section containing the culprit lesion was performed using one sample t-testing, generalised linear latent and mixed statistical modelling with grouping by patient, and logistic regression modelling. QCAM was a significant predictor of the location of culprit lesions (p = 0.047). ΔT was not a significant predictor of the location of culprit lesions (p=0.49). QCAM has a role in predicting the location of culprit lesions, and may allow for targeted local therapy to prevent future events.

Mechanical interventricular dependency supports hemodynamics in tako-tsubo cardiomyopathy.

Although morphological abnormalities of the heart appear to be remarkable, most patients with tako-tsubo cardiomyopathy (TTC) remain clinically stable. We investigate real time changes in the left ventricular (LV) and right ventricular (RV) mechanics and function to explore the mechanism to preserve hemodynamics. With deformation and Doppler echocardiography, we evaluated myocardial mechanics and ventricular function/hemodynamics simultaneously in 103 consecutive TTC patients admitted from 01/01/2008 through 12/31/2015. The coronary angiography and left ventriculography were performed to rule out culprit coronary artery stenosis (CAS). We included 66 patients in a control group with matched age, sex, and risk factors for coronary artery disease (CAD), and 41 patients in a group of myocardial infarction induced cardiogenic shock, who required circulatory supporting devices to maintain hemodynamic stability. Although systolic myocardial strain in most of the LV segments was significantly impaired, 4 basal LV segments remained functionally active during acute stage of TTC. The impairment in the myocardial strain of the RV apex could extend to the middle segments, but basal RV systolic strain was also preserved. Despites comparable apical to basal strain gradients, LV and RV displayed discrepant functional/hemodynamic status. In contrast to LV, RV functional/hemodynamic parameters appeared to be hyper-dynamic. This unique RV strain pattern remained unchanged in patients with atypical (mid-LV cavity) TTC. In 41 patients with myocardial infarction induced cardiogenic shock, RV exhibited comparable mechanic and functional features with those in TTC patients. The identified LV and RV mechanic changes appear to support interventricular hemodynamic dependence during TTC, which may represent a universal rescue mechanism in a jeopardized or injured heart.

On-treatment platelet reactivity in peripheral and coronary blood in patients undergoing primary PCI for ST-segment elevation myocardial infarction (STEMI)

Dual antiplatelet therapy is recommended in patients undergoing primary percutaneous coronary intervention (p-PCI) for ST-segment elevation myocardial infarction (STEMI). Pre-analytical variables may influence platelet function analysis results. Our aim was to evaluate the on-treatment platelet reactivity in peripheral artery vs coronary blood in patients with STEMI. We enrolled one hundred and nine patients who consecutively underwent p-PCI at Cardiology Unit of Padua University Hospital between June 2014 and June 2015. Before the procedure, all patients received intravenous aspirin 250 mg and either of the thienopyridines; clopidogrel 600 mg, prasugrel 60 mg or ticagrelor 180 mg. ASPI-test and ADP-test using multiple electrode aggregometry (MEA) were performed in samples collected from both a peripheral artery and the culprit coronary artery. ‘Low responders’ were patients with an ASPI-test or ADP-test value greater than or equal to a pre-established normal range. No significant differences were observed in ASPI-test values between peripheral (19 (median) [3–49 (10–90 percentiles)] U) vs coronary (12 [1–40] U, p = .06) blood and in ADP-test (40 [14–82] U vs 33 [7–79] U, p =.68) blood. In peripheral blood, fifteen (14%) patients were ‘low aspirin’ and forty-one (38%) ‘low thienopyridines’ responders. The prevalence of ‘low clopidogrel’ responders was higher (45%) than prasugrel (36%) and ticagrelor (33%). Similar results were observed in coronary blood. In patients undergoing p-PCI for STEMI, MEA platelet function observed in coronary arteries was consistent with peripheral artery blood’s independently of the antiplatelet drug used. The clinical significance of peripheral and coronary on-aspirin/thienopyridines platelet reactivity needs further clarification.

The prognosis of Different Types of Reciprocal ST-segment Depression (R-ST-D) on Electrocardiograms in Acute Myocardial Infarction

Summary Background We investigated how to define the culprit coronary artery according to different reciprocal ST-segment depression (R-ST-D) types on electrocardiograms in ST-segment elevation acute myocardial infarction (STEMI), as well as the high-risk factors. Methods To analyze the prognosis of different R-ST-D types to define the culprit coronary artery and high-risk factors, 967 patients with STEMI were included and divided into four groups according to STEMI infarction sites and R-ST-D type: group I (type I), without R-ST-D (n = 143); group II (type II), R-ST-D less than or equal to the amplitude of ST-segment elevation (n = 664); group III (type III), R-ST-D greater than or equal to the amplitude of ST-segment elevation (n = 93); and group IV (type IV), the amplitudes of R-ST-D and ST-segment elevation were both elevated (n = 67). Results The incidence of type II was the highest at 68.7%, followed by that of type I, which was mainly due to anterior descending branch stenosis. Type IV was mainly caused by complete occlusion of multiple vessels including the anterior descending branch and circumflex branch and/or right coronary artery. Type III was always related to a higher incidence of malignant complications, ventricular wall motion disorders, and ejection fraction index ≤50% compared with types I and II (p Conclusion Different high-risk stratifications of R-ST-D in patients with STEMI, especially type III and IV, can be used as objective independent indices to predict and assess the culprit coronary artery and life-threatening prognosis.

First 24 h in the management of non-ST segment elevation myocardial infarction

Non-ST elevation acute coronary syndrome comprises of unstable angina and non-ST segment elevation myocardial infarction (NSTEMI), depending upon normal or increase in cardiac biomarkers. NSTEMI patients are more prone to recurrent ischaemic events including risk of death or myocardial infarction because of subtotal occlusion of culprit coronary artery and ongoing myocardial ischaemia. The short- and long-term outcome in these patients can be improved by aggressive medical and/or interventional therapy instituted at the earliest possible. The goals of treatment are reliving ongoing ischaemia, prevent further thrombosis and correct haemodynamic and electric instability. The management includes pharmacotherapy with antiplatelet and antithrombotic drugs, glycoprotein IIb/IIIa inhibitors, nitrates and statins along with invasive treatment in selected group of patients. This article reviews the variables of risk stratification for recurrent ischemia or death, strategies of treatment within the first 24 hours after presentation and indications for invasive approach with coronary angioplasty.

Fragmented QRS; as a new sign on ecg for pre-diagnosis of non-ST elevation myocardial infarction

Aim: The aim of this study is to evaluate the predictive value of fragmented QRS (fQRS) wave to detect non-ST elevation myocardial infarction (Non-STEMI). Material and Methods: The study included patients who were diagnosed with Non-STEMI in emergency department and underwent percutaneous coronary intervention in the cardiology clinic. Coronary artery circulation is anatomically divided as the left anterior descending coronary artery (LAD) (V1-V5), the left Circumflex (LCx) (I, aVL and V5,V6) and the right coronary artery (RCA) (II, III and aVF). Results: Our study included 191 patients. Significant fQRS was detected in 139 (%73) patients and ST/T was detected in 79 (%41) patients. The sensitivity, specificity, of fQRS in the inferior leads to predictRCAlesion was 76%, 46%, respectively. The sensitivity, specificity, of ST/T in the inferior leads to predictRCA lesion was 12%, 93%, respectively. The sensitivity, specificity of fQRSin the lateral leads to predictLCx lesion were 44%and 83%, respectively. The sensitivity, specificity of ST/T in the lateral leads to predictLCxlesion were 34%, 74%, respectively. The sensitivity, specificity of fQRSin the anterior leads to predict leftLAD lesion were 34% and 82%, respectively. The sensitivity, specificity of ST/T in the anterior leads to predictLAD lesion were 38%, and 81%, respectively. Conclusion: We have compared to fQRS and ST/T on ECG; fQRS has higher sensitivity than ST/T to predict culprit coronary artery lesion. Therefore, evaluation of fQRS in addition to ST/T on ECG may be more valuable in pre-diagnosis of Non-STEMI.

Design of DISCO—Direct or Subacute Coronary Angiography in Out-of-Hospital Cardiac Arrest study

Acute coronary syndrome is a common cause of out-of-hospital cardiac arrest (OHCA). In patients with OHCA presenting with ST elevation, immediate coronary angiography and potential percutaneous coronary intervention (PCI) after return of spontaneous circulation are recommended. However, the evidence for this invasive strategy in patients without ST elevation is limited. Observational studies have shown a culprit coronary artery occlusion in about 30% of these patients, indicating the electrocardiogram's (ECG's) limited sensitivity. The aim of this study is to determine whether immediate coronary angiography and subsequent PCI will provide outcome benefits in OHCA patients without ST elevation. We describe the design of the DIrect or Subacute Coronary angiography in Out-of-hospital cardiac arrest study (DISCO)-a pragmatic national, multicenter, randomized, clinical study. OHCA patients presenting with no ST elevation on their first recorded ECG will be randomized to a strategy of immediate coronary angiography or to standard of care with admission to intensive care and angiography after 3days at the earliest unless the patient shows signs of acute ischemia or hemodynamic instability. Primary end point is 30-day survival. An estimated 1,006 patients give 80% power (α = .05) to detect a 20% improved 30-day survival rate from 45% to 54%. Secondary outcomes include good neurologic recovery at 30days and 6months, and cognitive function and cardiac function at 6months. This randomized clinical study will evaluate the effect of immediate coronary angiography after OHCA on 30-day survival in patients without ST elevation on their first recorded ECG.

Falsos positivos en la activación por IAMCEST en una red regional: análisis integral e impacto clínico. Resultados del registro Codi Infart de Cataluña

Introduction and objectivesST-segment elevation myocardial infarction (STEMI) network activation by a noncardiologist reduces delay times but may increase the rate of false-positive STEMI diagnoses. We aimed to determine the prevalence, predictors, and clinical impact of false-positive activations within the Catalonian STEMI network (Codi Infart). MethodsFrom January 2010 through December 2011, all consecutive patients treated within the Codi Infart network were included. Code activations were classified as appropriate if they satisfied both electrocardiogram and clinical STEMI criteria. Appropriate activations were classified as false positives using 2 nonexclusive definitions: a) “angiographic” if a culprit coronary artery was not identified, and b) “clinical” if the discharge diagnosis was other than STEMI. ResultsIn total, 5701 activations were included. Appropriate activation was performed in 87.8% of the episodes. The rate of angiographic false positives was 14.6%, while the rate of clinical false positives was 11.6%. Irrespective of the definition, female sex, left bundle branch block, and previous myocardial infarction were independent predictors of false-positive STEMI diagnoses. Using the clinical definition, hospitals without percutaneous coronary intervention and patients with complications during the first medical contact also had a false-positive STEMI diagnoses rate higher than the mean. In-hospital and 30-day mortality rates were similar for false-positive and true-positive STEMI patients after adjustment for possible confounders. ConclusionsFalse-positive STEMI diagnoses were frequent. Outcomes were similar for patients with a true-positive or false-positive STEMI diagnosis treated within a STEMI network. The presence of any modifiable predictors of a false-positive STEMI diagnosis warrants careful assessment to optimize the use of STEMI networks.Full English text available from: www.revespcardiol.org/en

Clinical characteristics of patients with Takotsubo syndrome diagnosed without coronary artery evaluation: A retrospective nationwide study

BackgroundAlthough the current diagnostic criteria require that culprit coronary artery disease be ruled out before the diagnosis of Takotsubo syndrome (TTS) is made, performing coronary artery evaluation (CAE) in patients with serious backgrounds is sometimes challenging. MethodsWe conducted a retrospective cohort study using the Diagnosis Procedure Combination database in Japan. We identified patients in whom TTS was diagnosed at Japanese Circulation Society board-certified teaching hospitals from April 2011 to March 2014 and divided eligible patients into those who underwent CAE (coronary angiography or coronary computed tomography angiography) during hospitalization and those who did not. We compared the patient characteristics and in-hospital mortality between the groups. ResultsTTS was diagnosed in 5274 patients; 3255 (61.7%) underwent CAE and 2019 (38.3%) did not. Patients who did not undergo CAE were older; were more often male; showed higher proportions of an underweight status, impaired activities of daily living, and impaired consciousness; and showed higher proportions of several comorbidities (malignancy: 16.1% versus 5.7%; pneumonia: 15.0% versus 6.7%; and cerebrovascular disease: 13.7% versus 4.0%; all p<0.001) but lower proportions of coronary risk factors than patients who underwent CAE. Multivariable logistic regression analysis showed that older age [adjusted odds ratio: 0.98 (95% confidence interval: 0.97–0.98)], underweight [0.77 (0.65–0.91)], impaired consciousness [0.25 (0.18–0.35)], several comorbidities, and early requirement for surgery [0.13 (0.08–0.21)] were significantly associated with a lower likelihood of undergoing CAE. Crude in-hospital mortality was significantly higher in patients without than with CAE (12.8% versus 4.9%; p<0.001). However, propensity score-matching analysis revealed no significant difference in in-hospital mortality between the two groups (8.8% versus 7.2%; p=0.252). ConclusionsAmong patients diagnosed with TTS, CAE was less likely to be performed in patients with more serious backgrounds. CAE itself may not be associated with in-hospital mortality in patients with TTS.

Left Circumflex Coronary Artery as the Culprit Vessel in ST-Segment-Elevation Myocardial Infarction.

The prevalence of the left circumflex coronary artery (LCx) as the culprit vessel in ST-segment-elevation myocardial infarction (STEMI) is reportedly lowest among that of the 3 main epicardial arteries, and has not been described for non-STEMI (NSTEMI) and stable angina pectoris. We sought to define the distribution of culprit arteries in these clinical presentations and suggest mechanisms for the differences. We reviewed 189 coronary angiograms of patients with STEMI, 203 with NSTEMI, and 548 with stable angina (n=940), and compared distributions of stenotic and culprit coronary arteries (lesions prompting intervention). Obstructive coronary lesions (≥50% narrowing) were more prevalent in the left anterior descending coronary artery (LAD) (36%-38%) and similar in the LCx and right coronary artery (RCA) (27%-29%), regardless of clinical presentation (P <0.01). In NSTEMI and stable angina, culprit vessels and total obstructive disease had the same distribution. In STEMI, however, a culprit LCx was significantly less prevalent (17%) than was total obstructive disease (27%; P <0.01), or a culprit LAD (47%) or RCA (34%) (both P <0.001). In our computed tomographic angiographic model of coronary longitudinal strain (percentage of shortening), LCx strain was only 1.5% ± 2.4%, versus 9.5% ± 2.9% for LAD strain and 10.1% ± 3.9% for RCA strain. In STEMI, LCx plaques seem less prone to rupturing. Culprit and total disease distributions are similar in NSTEMI and angina, suggesting a different ischemic pathophysiology in these presentations. Lower LCx longitudinal strain might contribute to reduced plaque rupture in STEMI.

CORONARY ANGIOGRAPHY IN OUT OF HOSPITAL CARDIAC ARREST (OHCA): A PRACTICAL GUIDE TO DECISION MAKING

Early coronary angiography remains controversial in patients without ST-segment elevation following OHCA. Observational studies have demonstrated a potential survival benefit, but are potentially confounded by selection bias. Physician decision making is further complicated by the lower incidence of culprit lesions in patients without ST-elevation; and, the difficulty in determination of neurological prognosis at the time of presentation. The Cardiac Arrest Hospital Prognosticator (CAHP) score utilizes seven variables (age, non-shockable rhythm, time from collapse to basic life support, time from basic life support to return of spontaneous circulation, location of cardiac arrest, epinephrine dose, and arterial pH) and has been shown to be a reliable predictor of neurologic outcomes (Maupain et al. 2016). ST-segment deviation and prior history of CAD have been proposed to help identify OHCA survivors without ST-elevation who might benefit from angioplasty in deciding to pursue early angiography (Wong et al. CJC 2017). The aim of this study was to evaluate the ability of the CAHP score to help guide decision making regarding the need for urgent coronary angiography in survivors of OHCA; and, to determine the association between dynamic ST-segment changes, or a history of angina or CAD with the presence of a culprit coronary artery lesion in those patients without ST elevation. Based on these findings, we have developed a decision pathway for the use of angiography in survivors of OHCA. A retrospective chart review of 336 OHCA patients admitted to the Foothills Medical Center Cardiac Intensive Care Unit (CICU) between 2009 and 2016 was conducted. Chi-squared and t-tests were used to assess differences in categorical and continuous variables respectively. Associations were assessed using odds ratios. A CAHP score of >200 demonstrated a specificity for in-hospital death of 93.94% (89.9-96.74%), and was inversely associated with the decision to pursue angiography in patients with and without ST-elevation, but not with early angiography. ST deviation but not prior CAD/angina was predictive of a culprit lesion in patients without ST-elevation (Figure 1). These factors were not found to be associated with the decision to pursue early coronary angiography. Given the paucity of data supporting the benefit of early angiography in patients without ST-elevation, an elevated CAHP score (≥ 200) conferring poor prognosis is a reasonable indication for deferring angiography. We propose that CAHP scores and predictive factors for culprit coronary disease (ST-deviation and prior CAD/angina) be used to guide timing of coronary angiography.

ASSOCIATION OF LEFT ANTERIOR CORONARY ARTERY INVOLVEMENT ON CLINICAL OUTCOMES AMONG STEMI PATIENTS PRESENTING WITH AND WITHOUT OUT-OF-HOSPITAL CARDIAC ARREST

Acute ST elevation myocardial infarction (STEMI) complicated by out-of-hospital cardiac arrest (OHCA) is associated with greater in-hospital mortality compared to STEMI patients without cardiac arrest. However, there has been no prior attempt to discern if there is an independent association of culprit coronary artery involvement with outcomes of STEMI patients with and without OHCA. This study aimed to describe such an independent association. We identified all 1020 patients within the Vancouver Coastal Health Authority (VHCA) who presented with an acute STEMI and who underwent primary percutaneous coronary intervention (pPCI) between June 26, 2007 and March 31, 2016. Among these, there were 91 patients with and 929 without a preceding OHCA. Logistic regression was used to examine the impact of ischemic territory and OHCA on mortality and other outcomes. STEMI patients with OHCA had more in-hospital-cardiac arrest (43.3% vs 8.3% p < 0.001), heart failure (50.5% vs 11.3% p < 0.001), cardiogenic shock (49.5% vs 5.7% p < 0.001) and mortality (35.2% vs 3.3% p < 0.001) compared to STEMI patients without OHCA. Left anterior coronary artery (LACA) involvement was identified in 57.1% of STEMI patients with OHCA and in 47.7% of STEMI patients without OHCA (p=0.085). Among non-OHCA patients, LACA involvement was associated with increased heart failure (18.1% vs 5.2% p < 0.001), in-hospital cardiac arrest (10.7% vs 6.2% p < 0.014), cardiogenic shock (8.4% vs 3.3% p < 0.001) and mortality (5.2% vs 1.3% p=0.003) compared to no LACA involvement, but not in OHCA patients. Logistic regression demonstrated that LACA involvement and OHCA were both independently associated with increased in-hospital mortality, but there was no significant association between the presence of OHCA and LACA involvement (Figure 1). Compared to STEMI patients without OHCA, those with OHCA experienced worse in-hospital outcomes. Similarly, compared to non-ACA involvement, ACA involvement was also associated with worse in-hospital outcomes, but only among STEMI patients without OHCA. This data suggests that ACA involvement in STEMI confers a worse prognosis among STEMI patients without OHCA, and suggests that OHCA patients have other high risk features that drive their poor outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)