Diagnosis Of ST-elevation Myocardial Infarction Research Articles

In-hospital outcomes of anterior versus non-anterior st elevation myocardial infarction complicated with complete atrioventricular block

Abstract Background Complete atrioventricular block (CAVB) is an infrequent complication of acute ST-elevation myocardial infarction (STEMI), and information on its outcomes is scarce. We aimed to address the characteristics and in-hospital outcomes of patients with anterior versus non-anterior STEMI complicated with CAVB in a contemporary, nationwide, all-comer registry, in the U.S. Methods Using the National Inpatient Sample (NIS) database, we identified patients who were hospitalized with STEMI, complicated with CAVB between 2016- 2019. Patients with any cardiac implantable electronic device (CIED) in-situ were excluded. Baseline characteristics, in-hospital procedures and outcomes including time to temporary or permanent pacemaker (PPM)/implantable cardioverter defibrillator (ICD) implantation, length of stay and mortality were collected. Results A total of 17470 patients, were hospitalized with a primary diagnosis of STEMI and concomitant diagnosis of CAVB, 2755(15.8%) with Anterior and 14715(84.2%) with non-anterior STEMI. Non-anterior STEMI patients included more women, had higher prevalence of hypertension, dyslipidemia, smoking history and chronic pulmonary disease, while anterior STEMI patients had higher prevalence of chronic kidney disease and ischemic cardiomyopathy. Anterior STEMI patient had significantly higher rate of in hospital death [955 (35%) vs 2220 (15%), p<0.001], CPR, VT/VF, cardiac arrest, acute heart failure, respiratory failure, mechanical ventilation >96 hours and acute kidney injury. In both groups 40% received temporary pacemaker, but mean time to implantation was longer in anterior STEMI patients [1.1±3.3 vs 0.3±1.2 days, p<0.001]. Rate of any permanent CIED implantation was also significantly higher in the anterior STEMI patients with longer time to PPM implantation, [3.3±3.5 vs 2.8±2.8 days, p<0.001]. Use of mechanical circulatory support devices was significantly higher in anterior STEMI patients. Conclusion In STEMI patients complicated with CAVB, in-hospital outcomes of anterior STEMI were worse comparing to non-anterior STEMI, with significantly higher rates of in-hospital death, in-hospital complications and CIED implantations.

Impact of CYP2C19 Gene Variants on Long-Term Treatment with Atorvastatin in Patients with Acute Coronary Syndromes.

The effectiveness of lipid-lowering therapies may be insufficient in high-risk cardiovascular patients and depends on the genetic variability of drug-metabolizing enzymes. Customizing statin therapy, including treatment with atorvastatin, may improve clinical outcomes. Currently, there is a lack of guidelines allowing the prediction of the therapeutic efficacy of lipid-lowering statin therapy. This study aimed to determine the effects of clinically significant gene variants of CYP2C19 on atorvastatin therapy in patients with acute coronary syndromes. In total, 92 patients with a confirmed diagnosis of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI) were sequenced for target regions within the CYP2C19 gene on the Illumina Miniseq system. The CYP2C19 poor metabolizer phenotype (carriers of CYP2C19*2, CYP2C19*4, and CYP2C19*8 alleles) was detected in 29% of patients. These patients had significantly lower responses to treatment with atorvastatin than patients with the normal metabolizer phenotype. CYP2C19-metabolizing phenotype, patient age, and smoking increased the odds of undertreatment in patients (∆LDL-C (mmol/L) < 1). These results revealed that the CYP2C19 phenotype may significantly impact atorvastatin therapy personalization in patients requiring LDL lipid-lowering therapy.

Early unfractionated heparin treatment in patients with STEMI – trial design and rationale

The early unfractionated heparin (UFH) treatment in patients with ST-elevation myocardial infarction (STEMI) is a single-center, open-label, randomized controlled trial. The study population are patients with STEMI that undergo primary percutaneous coronary intervention (PPCI). The trial was designed to investigate whether early administration of unfractionated heparin immediately after diagnosis of STEMI is beneficial in terms of patency of infarct-related coronary artery (IRA) when compared to established UFH administration at the time of coronary intervention. The patients will be randomized in 1:1 fashion in one of the two groups. The primary efficacy endpoint of the study is Thrombolysis in myocardial infarction (TIMI) flow grades 2 and 3 on diagnostic coronary angiography. Secondary outcome measures are: TIMI flow after PPCI, progression to cardiogenic shock, 30-day mortality, ST-segment resolution, highest Troponin I and Troponin I values at 24 hours. The safety outcome is bleeding complications. The study of early heparin administration in patients with STEMI will address whether pretreatment with UFH can increase the rate of spontaneous reperfusion of infarct-related coronary artery.

Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction

Rapid reperfusion during primary percutaneous coronary intervention (PCI) is associated with improved outcomes among patients with ST-elevation myocardial infarction (STEMI). Although attempts at reducing the time from STEMI diagnosis to arrival at the catheterization laboratory have been widely investigated, intraprocedural strategies aimed at reducing the time to reperfusion are lacking. To evaluate the effect of culprit lesion PCI before complete diagnostic coronary angiography (CAG) vs complete CAG followed by culprit lesion PCI on reperfusion times among patients with STEMI. This open-label, prospective, randomized clinical trial was conducted between April 1, 2021, and August 31, 2022, among patients admitted to a tertiary center in Jerusalem, Israel, with a diagnosis of STEMI undergoing primary PCI. All patients were followed up for 1 year. Analysis was on an intention-to-treat basis. Patients were randomized in a 1:1 ratio to undergo either culprit lesion PCI before complete CAG or complete CAG followed by culprit lesion PCI. A needle-to-balloon time of 10 minutes or less. A total of 216 patients were randomized, with 184 patients (mean [SD] age, 62.9 [12.2] years; 155 men [84.2%]) included in the final intention-to-treat analysis; 90 patients (48.9%) were randomized to undergo culprit lesion PCI before CAG, and 94 (51.1%) were randomized to undergo to CAG followed by PCI. Patients who underwent culprit lesion PCI before complete CAG had a shorter mean (SD) needle-to-balloon time (11.4 [5.9] vs 17.3 [13.3] minutes; P < .001). The primary outcome of a needle-to-balloon time of 10 minutes or less was achieved for 51.1% of patients (46 of 90) who underwent culprit lesion PCI before CAG and for 19.1% of patients (18 of 94) who underwent complete CAG followed by culprit lesion PCI (odds ratio, 4.4 [95% CI, 2.2-9.1]; P < .001). Rates of adverse events were similar between groups. In a subgroup analysis, the effect of culprit lesion PCI before complete CAG on the primary outcome was consistent. There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality. In this randomized clinical trial of patients with STEMI, culprit lesion PCI before complete CAG resulted in shorter reperfusion times. Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes. ClinicalTrials.gov Identifier: NCT05415085.

Enhancing ST-Elevation Myocardial Infarction Diagnosis and Management: The Integral Role of Echocardiography in Patients Rushed to the Cardiac Catheterization Laboratory.

Coronary artery disease (CAD) remains a significant global health concern, necessitating timely and precise diagnosis, especially for acute coronary syndromes (ACSs). Traditional diagnostic methods like electrocardiograms (ECGs) are critical, yet the advent of echocardiography has revolutionized cardiac care by providing comprehensive insights into heart function. This article examines the integration of echocardiography in the cardiac catheterization laboratory, emphasizing its role in augmenting traditional diagnostics, enhancing patient outcomes, and preparing for targeted interventions. Specifically, we argue for the routine use of focused echocardiographic evaluations in patients presenting with ST-Elevation Myocardial Infarction (STEMI) to the cath lab, illustrating how this practice can significantly refine diagnostic accuracy, identify concurrent life-threatening conditions, and inform the management of STEMI and its complications.

Correlation of left ventricular contractile function with the presence of collateral coronary circulation in non-reperfused acute myocardial infarction

To assess the association between coronary collateral circulation and ventricular contractile function in patients with non-reperfused acute myocardial infarction. A retrospective and descriptive clinical study was conducted on patients with ST-elevation myocardial infarction (STEMI) at a reference cardiovascular center, from January 2006 to December 2022. Coronary angiographies and echocardiograms were reviewed to evaluate coronary collateral circulation and ventricular function, respectively. Patients were divided into groups based on the presence of collateral circulation. Both groups were compared and mortality during the index hospitalization was analyzed. Out of a total of 14,985 patients with acute coronary syndrome, 8134 (54.3%) had the diagnosis of STEMI. We excluded 12,880, leaving a total of 2105 non-reperfused STEMI patients who underwent coronary angiography, revealing lesions. There were more patients without collateral circulation: 1547 (73.5%) vs. 558 (26.5%) (p = 0.025). Patients without collateral circulation had a higher left ventricular ejection fraction (median of 47% vs. 42%; p < 0.001). Mortality in patients with collateral circulation was higher compared to those without it (11.6% vs. 9.8%; p = 0.225), but statistical significance was not reached. Non-reperfused STEMI patients did not show protection from collateral circulation when assessing left ventricular systolic function. We did not find a difference in mortality compared to the population without development of collateral circulation.

Structural Complications Following ST-Elevation Myocardial Infarction: An Analysis of the National Inpatient Sample 2016 to 2020.

ST-elevation myocardial infarction (STEMI) is a life-threatening emergency that can result in cardiac structural complications without timely revascularization. A retrospective study from the National Inpatient Sample included all patients with a diagnosis of STEMI between 2016 and 2020. Primary outcomes of interest were in-hospital mortality, length of stay (LoS), and healthcare costs for patients with and without structural complications. There were 994,300 hospital admissions included in the analysis (median age 64 years and 32.2% female). Structural complications occurred in 0.78% of patients. There was a three-fold increase in patients with cardiogenic shock (41.6% vs. 13.6%) and in-hospital mortality (30.6% vs. 10.7%) in the group with structural complications. The median LoS was longer (5 days vs. 3 days), and the median cost was significantly greater (USD 32,436 vs. USD 20,241) for patients with structural complications. After adjustments, in-hospital mortality was significantly greater for patients with structural complications (OR 1.99, 95% CI 1.73-2.30), and both LoS and costs were greater. There was a significant increase in mortality with ruptured cardiac wall (OR 9.16, 95% CI 5.91-14.20), hemopericardium (OR 3.20, 95% CI 1.91-5.35), and ventricular septal rupture (OR 2.57, 95% CI 1.98-3.35) compared with those with no complication. In conclusion, structural complications in STEMI patients are rare but potentially catastrophic events.

The impact of the site of myocardial infarction on in-hospital outcomes for patients with STEMI.

The territory and vessel involved in ST-elevation myocardial infarction (STEMI) is an important and there are limited contemporary studies from the national perspective. A retrospective cohort study was undertaken of national representative hospital admission in the National Inpatient Sample with a diagnosis of anterior or non-anterior STEMI between 2017 and 2020. Multiple logistic regression and multiple linear regressions were used to determine if there are any differences in in-hospital mortality, length of stay (LOS) and cost for anterior and non-anterior STEMI. A total of 655 915 admissions with STEMI were included in the analysis (267 920 anterior STEMI, and 387 995 non-anterior STEMI). Non-anterior STEMI was associated with a significant reduction in mortality (OR 0.91 95% CI 0.89-0.99, P = 0.011) and LOS (coefficient -0.15 95% CI -0.22 to -0.08, P < 0.001) compared to anterior STEMI but there was no significant difference in healthcare costs (-297 95% CI -688 to 74). Analyses considering the infarct-related artery showed that the worse outcomes were associated with left main lesions and left-sided lesions had worse outcomes than right coronary artery lesions. Non-anterior STEMI is associated with reduced mortality and LOS compared to anterior STEMI. Left-sided coronary lesions had worse outcomes, compared to right coronary lesions. STEMI should be considered in terms of the vessel or territory affected, in relation to outcomes and healthcare costs.

Case Series Study on Recovery of Left Ventricle Systolic Function After Percutaneous Coronary Intervention In ST-Segment Elevation Myocardial Infarction Patients at FMIC Hospital in Kabul, Afghanistan.

Background Left ventricle dysfunction is the most recurrent consequence of ST-elevated myocardial infarction, and still, it is a powerful predictor of mortality. The percutaneous coronary intervention of the culprit artery disease in acute coronary syndrome is related to a significant improvement of left ventricle segmental function. It is a retrospective case series study on a patient population with the diagnosis of ST-elevated myocardial infarction patients who presented to the hospital within 12 hours and underwent percutaneous coronary intervention at the French Medical Institute of Mother and Children Hospital. Data was collected retrospectively from the patient's medical record files and analyzed. We took the patients with Left ventricle dysfunction on echocardiography on the first presentation before percutaneous coronary intervention and saw the left ventricle function after three months of follow-up. We reviewed the charts of 102 patients (78.4% male and 21.6% female) with a diagnosis of St-elevated myocardial infarction who presented within 12 hours of chest pain. Of 102 patients, 55.9% had hypertension, 21.6% diabetes, 22.5% dyslipidemia, and 19.6% history of smoking, and their mean age was 58.11 ± 11.993 years. We noticed that percutaneous coronary intervention led to significant left ventricle dysfunction improvement in the patient population with ST-elevated myocardial infarction who presented within 12 hours of chest pain.

Application of remote electrocardiogram monitoring systems in chest pain centers for patients with high-risk chest pain.

Chinese chest pain centers (CPCs) have been expanding and maturing for the past decade, but patient wait times for pre-hospital care remain long. To demonstrate that the remote electrocardiogram (ECG) monitoring system can ensure more efficient treatment for patients with ST-elevation myocardial infarction (STEMI) in CPCs, we compared patients with high-risk chest pain who used remote ECG monitoring systems to those who used conventional ECGs in retrospective cohort study. Based on the inclusion and exclusion criteria, 290 patients who visited our CPC between June 2019 and March 2022 with acute chest pain and a diagnosis of STEMI as well as patients who had undergone an emergency primary percutaneous coronary intervention were selected. Among them, 73 patients with STEMI had employed remote real-time dynamic 12-lead ECG monitoring devices, while 217 patients with STEMI (i.e., the controls) had used conventional ECG monitoring. The effectiveness of treatment procedures for the two groups was investigated. As statistical measures, the symptom onset-to-wire times, first medical contact (FMC)-to-wire times, door-to-wire times, major adverse cardiac events in hospital, and the troponin T levels were analyzed. Compared with the control group, the patients with remote real-time dynamic 12-lead ECG monitoring devices showed shorter times for both symptom onset-to-wire (234.8 ± 95.8 min vs. 317.6 ± 129.6 min, P= 0.0321) and from symptom onset-to-FMC (170.5 ± 86.3 min vs. 245.3 ± 115.6min, P= 0.0287); this group also had a lower 30-day mortality rate (2.73% vs. 4.14%, P= 0.003). The differences between the two groups were statistically significant (P< 0.05). With remote real-time dynamic 12-lead ECG monitoring equipment, myocardial ischemia can be treated more quickly, leading to fewer possible cardiac events and a better prognosis.

Validity of Computer-interpreted "Normal" and "Otherwise Normal" ECG in Emergency Department Triage Patients.

Chest pain is the second most common chief complaint for patients undergoing evaluation in emergency departments (ED) in the United States. The American Heart Association recommends immediate physician interpretation of all electrocardiograms (ECG) performed for adults with chest pain within 10 minutes to evaluate for the finding of ST-elevation myocardial infarction (STEMI). The ECG machines provide computerized interpretation of each ECG, potentially obviating the need for immediate physician analysis; however, the reliability of computer-interpreted findings of "normal" or "otherwise normal" ECG to rule out STEMI requiring immediate intervention in the ED is unknown. We performed a prospective cohort analysis of 2,275 ECGs performed in triage in the adult ED of a single academic medical center, comparing the computerized interpretations of "normal" and "otherwise normal" ECGs to those of attending cardiologists. ECGs were obtained with a GE MAC 5500 machine and interpreted using Marquette 12SL. In our study population, a triage ECG with a computerized interpretation of "normal" or "otherwise normal" ECG had a negative predictive value of 100% for STEMI (one-sided, lower 97.5% confidence interval 99.6%). None of the studied patients with these ECG interpretations had a final diagnosis of STEMI, acute coronary syndrome, or other diagnosis requiring emergent cardiac catheterization. In our study population, ECG machine interpretations of "normal" or "otherwise normal" ECG excluded findings of STEMI. The ECGs with these computerized interpretations could safely wait for physician interpretation until the time of patient evaluation without delaying an acute STEMI diagnosis.

Comparison between myocardial infarction with non-obstructive coronaries (MINOCA) and myocardial infarct patients with coronary artery disease (MI-CAD): A single-center retrospective cohort study.

The coronary angiography results in a group of patients with myocardial infarction (MI) are normal or near-normal; which is diagnosed as myocardial infarction with non-obstructive coronary arteries (MINOCA). This study aimed to compare the mortality rate and risk factors between MINOCA and myocardial infarction with obstructive coronary artery (MI-CAD). This retrospective cohort study was conducted from January 1, 2018, to December 31, 2019. A total of 679 patients admitted to Afshar Hospital in Yazd with a diagnosis of ST-elevation myocardial infarction (STEMI) from 2018-2019 who underwent primary Percutaneous Coronary Intervention (PCI) were enrolled in the study. Demographic, and clinical variables, ECG finding and one-year mortality, were extracted using MI registry data from the Yazd Cardiac Research Center. The estimated frequency of MINOCA was 4.6%. Patients with MINOCA (47.14±6.2) were younger than patients with MI-CAD (57.61±9.1) (P <0.0001). MINOCA patients (47.4±9.47) had a considerably greater left ventricular ejection fraction (LVEF) than MI-CAD patients (43.5±6.8) (P =0.018). The majority site of MI in MINOCA patients was located in the non-anterior wall (p <0.0001). A comparison of MINOCA and MI-CAD patients' one-year mortalityrevealed no significant difference (P =0.07). The prevalence of patients with MINOCA in Yazd was similar to other communities. Although these patients probably do not have a better prognosis, despite being younger and having better LV systolic function and lower CAD risk factors.

Interhospital Variation in Admissions Managed With Critical Care Therapies or Invasive Hemodynamic Monitoring in Tertiary Cardiac Intensive Care Units: An Analysis From the Critical Care Cardiology Trials Network Registry.

Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. The median age of the study population was 66 (56-77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%-87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST-elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.

Smartphone AI vs. Medical Experts: A Comparative Study in Prehospital STEMI Diagnosis.

Prehospital telecardiology facilitates early ST-elevation myocardial infarction (STEMI) detection, yet its widespread implementation remains challenging. Extracting digital STEMI biomarkers from printed electrocardiograms (ECGs) using phone cameras could offer an affordable and scalable solution. This study assessed the feasibility of this approach with real-world prehospital ECGs. Patients suspected of having STEMI by emergency medical technicians (EMTs) were identified from a policy research dataset. A deep learning-based ECG analyzer (QCG™ analyzer) extracted a STEMI biomarker (qSTEMI) from prehospital ECGs. The biomarker was compared to a group of human experts, including five emergency medical service directors (board-certified emergency physicians) and three interventional cardiologists based on their consensus score (number of participants answering "yes" for STEMI). Non-inferiority of the biomarker was tested using a 0.100 margin of difference in sensitivity and specificity. Among 53 analyzed patients (24 STEMI, 45.3%), the area under the receiver operating characteristic curve of qSTEMI and consensus score were 0.815 (0.691-0.938) and 0.736 (0.594-0.879), respectively (p=0.081). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of qSTEMI were 0.750 (0.583-0.917), 0.862 (0.690-0.966), 0.826 (0.679-0.955), and 0.813 (0.714-0.929), respectively. For the consensus score, sensitivity, specificity, PPV, and NPV were 0.708 (0.500-0.875), 0.793 (0.655-0.966), 0.750 (0.600-0.941), and 0.760 (0.655-0.880), respectively. The 95% confidence interval of sensitivity and specificity differences between qSTEMI and consensus score were 0.042 (-0.099-0.182) and 0.103 (-0.043-0.250), respectively, confirming qSTEMI's non-inferiority. The digital STEMI biomarker, derived from printed prehospital ECGs, demonstrated non-inferiority to expert consensus, indicating a promising approach for enhancing prehospital telecardiology.

Improving myocardial infarction emergency care: a joint intervention study of the Berlin Brandenburg Myocardial Infarction Registry (B2HIR) and emergency medical services (QS-Notfall)

Abstract Background Rapid myocardial reperfusion is needed to improve clinical outcome after a ST-elevation myocardial infarction (STEMI). Missed early explicit STEMI diagnoses were shown to unfavourably delay STEMI care. A networked approach between emergency medical systems (EMS) and cardiology hospital departments is useful to establish early valid pre-hospital STEMI diagnoses. Purpose The publicly funded "QS-Notfall" joint health services research study intended to improve STEMI care in Berlin (BE) and Brandenburg (BB) by implementing pre-hospital tele-ECG transmission and online ECG training for EMS personnel. Methods As part of B2HIR, 21 cardiology hospital departments (19 in BE, 2 in BB) together with EMS (BE firefighters and regional BB EMS), supported by the Berlin Medical Chamber, established 2 joint interventions to accelerate STEMI care. All EMS and hospitals implemented GDPR compliant telemedical transmission and structured handling of pre-hospital ECGs from patients with chest pain. In addition, we developed an ECG e-learning for emergency physicians and EMS personnel ("STEMI einfach erkennen") and communication between EMS and hospitals was enforced. Patients with acute myocardial infarction (AMI) and symptom onset ≤24h were enrolled. Symptom onset, first medical contact, time of hospital admission ("door"), time of guidewire passage into the coronary artery (reperfusion), and respective care delays were assessed. First obtained ECGs were blindly validated by 3 expert cardiologists. We compared a reference period to a 12-month intervention period with regard to care delays. In addition, STEMI care was analyzed according to the actual use of telemedical ECG transmission and according to the validity of ECG diagnoses. Results N=7303 cases were enrolled (reference period 3657, intervention period 3646, age 66.9y, 27.1% female, STEMI 49.4%). The usage of ECG transmission varied notably between hospitals (7.5%–74%). Tele EMS ECG usage in STEMI was associated with shorter door to reperfusion time (BB 11min, p&amp;lt;0.04, BE 12min, p&amp;lt;0.001) compared to STEMI care w/o ECG transmission. The difference was more pronounced during hospital off-hours (BB 30min, p=0.003 and BE 14min, p&amp;lt;0.001). An unmistaken EMS STEMI diagnosis related to a shorter door to reperfusion time (BE: by 106min; BB: by 49min) compared to an unsettled STEMI diagnosis (p&amp;lt;0.001). The rate of ECG transmission for STEMI patients in BE was 21.4%, in BB 55.7%. Accordingly, we found no significant difference in STEMI door to reperfusion delays between the reference period and the intervention period in BE (+1min) and a shorter reperfusion delay (by 11min) in BB (p=0.049). Conclusions The universal implementation of a joint intervention to improve STEMI care in a complex system of various EMS and hospital departments is challenging. Telemedical ECG transmission and an unmistaken early STEMI diagnosis are associated with a significantly shorter time delay to myocardial reperfusion.

The influence of early post-STEMI inflammation on diastolic function: diagnostic and therapeutic implications

Abstract Introduction We know that diastolic dysfunction (DD) after ST elevation myocardial infarction (STEMI) is associated with patients prognosis. Systolic dysfunction is easy to diagnose but the identification of DD remains difficult. After STEMI, inflammation can lead to DD and vice- versa. Less information exists on the relationship DD - inflammation in the specific post-infarction setting, while the potential prognostic and therapeutic impact is important. We focused on the relationship between the level of main inflammatory biomarkers in the first 48 hours post-STEMI and the presence of DD at 1 month. Purpose Our aim was to look for a post-STEMI early inflammatory phenotype that could be able to identify a group of patients at high risk of developing DD at one month. Methods The study cohort was constituted by patients admitted to our institution with a diagnosis of STEMI from 2016 to 2019. Serum from patients were collected at 4 time-points: Admission, 4 hours after revascularization (H4), H24 , and H48. Inflammatory biomarkers serum levels were assessed using ELISA assays (cytokines, chemokines and endothelial activation biomarkers).Diastolic function and infarct size were assessed at one month by transthoracic echocardiogram and cardiac MRI, respectively. Diastolic function was evaluated using the latest EACVI guidelines. Patients were followed for 12 months, all individual data were collected in a prospective database. Results We included 236 patients. 163 patients had normal diastolic function and 73 patients had DD. The probability of having a MACE during the first 12 months after STEMI was higher in the DD group than in the normal diastolic function group (HR = 3.0 CI [1.1-7.9], p=0.01), as well as the level of BNP (197.0 ng/L versus 68 ng/L, p&amp;lt;0.001). There was no significant difference in Left Ventricular Ejection Fraction (LVEF) (58 versus 54%, p=0.0523), or in infarct size (13 versus 17% of left ventricular mass, p = 0.06) between the two groups. In the first 48 hours post STEMI, in the DD group we found significantly higher seric levels for : CRP AUC (660.2 mg.h.L -1 vs 361.4 mg.h.L -1 p=0.02), IL-6 AUC (206.0 pg.h.mL -1 vs 173.1 pg.h.mL -1 p=0.03) sTNFR1 AUC (27.6 ng.h.mL -1 versus 24.1 ng.h.mL -1 , p=0.03), sTNFR2 AUC (44.7 ng.h.mL -1 vs 43.5 ng.h.mL -1 ,p=0.03) sST2 AUC (30.4 pg.h.mL -1 vs 27.3 pg.h.mL -1 , p=0.046), GDF15 AUC (10.8 ng.h.mL -1 vs 8.1 ng.h.mL -1 , p=0.050) and IL-10 AUC (174.6 pg.h.mL -1 vs 122.8 pg.h.mL -1 , p=0.02). No significant difference was found for Leucocytes, MCP1, MET, HSP 70, VCAM, RANTES, HGF 24-48h between the two groups. Conclusions Early inflammation is critical post-STEMI and could play a key role in DD development or progression. The proposed inflammatory biomarker profile has shown a significant association with DD at 1 month, potentially identifying a subgroup of patients at high risk (of MACE and death) and in which tailored anti-inflammatory therapy might be efficient.

Impact of ambulance paramedics missing STEMI diagnosis on subsequent management

Abstract Background/introduction Acute ST elevation myocardial infarction (STEMI) is defined by acute changes in the electrocardiograph (ECG) reflecting acute occlusion of a coronary artery. Rapid and complete reperfusion of the culprit lesion improves immediate mortality and long-term outcomes. Systems of care have been developed to optimise recognition and management of acute STEMI to facilitate the best possible patient outcomes. Pre-hospital diagnosis by ambulance paramedics and activation of Code STEMI teams has been shown to significantly impact treatment times and patient outcomes. But what is the outcome if the diagnosis is missed? Methods We studied 559 consecutive STEMI cases presenting to our health network with two 24/7 interventional sites over a three-year period (2020-2022 inclusive), comparing the impact of arrival by ambulance or self-presentation. Ambulance arrival cases were further stratified by whether Code STEMI was activated prior to hospital arrival or afterwards. Patients who developed STEMI after presentation to hospital or who were transferred from another institution were excluded from this analysis. Only patients proceeding to percutaneous intervention of the culprit lesion were included. First medical contact (FMC) is either hospital door time or time of ambulance paramedic arrival at patient. ECG time reflects first recorded ECG, either by ambulance paramedic or hospital emergency department. Results Results are depicted in the table below. Patients with STEMI had similar FMC to treatment times if diagnosed pre-hospital by the ambulance paramedic or after self-presentation to the emergency department. Interestingly, patients self-presenting to the emergency department had a longer symptom duration, perhaps reflecting uncertainty regarding the cause for symptoms and the rationale for not utilising ambulance services. Patients presenting via ambulance, where the diagnosis and activation of Code STEMI did not occur prior to hospital arrival, had less ST elevation and a significant delay in definitive treatment. Conclusion(s) Ambulance paramedics successfully diagnosed 69% of STEMI cases they transported, activating a Code STEMI prior to hospital arrival. Cases that were not pre-notified had less marked ST elevation, potentially creating uncertainty as to the diagnosis. Strategies to enable direct discussion of equivocal ECG changes and symptoms between ambulance paramedics and interventional cardiologists my assist in more complete recognition of all STEMI cases without creating excessive false activations.Table 1:Results

Abstract 12803: Disparities in Care Among COVID-19 Patients With ST-Elevation Myocardial Infarction Admitted in Rural and Urban Teaching Centers

Introduction: During the pandemic of COVID-19, resources ran scarce in various regions, which impacted access and availability of treatment options. Our study aims to compare outcomes of COVID-19-positive patients (CPP) who reported a diagnosis of ST-elevation myocardial infarction (STEMI) in either rural centers (RC) or urban teaching centers(UTC). Methods: De-identified data of CPP adults with STEMI from the 2020 National Inpatient Sample for admissions between April-December 2020 were analyzed. Patient characteristics and outcomes between RC and UTC were compared. Results: We found 4690 STEMI cases among CPP. Most cases were hospitalized in UTC(4255 cases, 90.7%), with 9.3% seeking care RC (Table 1). Cases in UTC were younger (mean age 66.28 years) and with a higher mean Charlson Comorbidity Index (CCI) score (mean score 4.31) than those at RC (mean age 71.75 years, p&lt;0.01, mean CCI score 4.00, p&lt;0.01). Medicare primarily covered both centers. A higher proportion of patients in RC were Whites (77.4%), while 50.0% of AMI cases at UTC were Whites. Patients at UTC also had a higher prevalence of prior stroke (6.3% vs. 3.4%, p=0.016) and lipid disorder (53.3% vs. 43.7%, p&lt;0.01) than those in RC but showed a lower prevalence of diabetes (44.3% vs. 50.6%, p=0.012). No differences in the prevalence of prior myocardial infarction, hypertension, smoking, obesity, chronic kidney disease, and sex were noted. Cases in UTC reported a higher incidence of cardiogenic shock (18.2% vs. 3.4%, aOR 6.631, 95% CI 3.850-11.421, p&lt;0.01), PCI use (42.1% vs. 20.7%, aOR 2.482, 95% CI 1.910-3.225, p&lt;0.01), and death (44.4% vs. 40.2%, aOR 1.513, 95% CI 1.197-1.912, p&lt;0.01). Conclusions: Adults with COVID-19 with STEMI admitted UTC were sicker with a higher mean CCI score and reported higher PCI use and mortality. Further studies investigating the distribution of resources during the pandemic and proposals to improve care access in rural and urban teaching hospitals should be conducted.

Abstract 15112: Characteristics and Clinical Outcomes of Patients With Sarcoidosis Admitted for ST-Elevation Myocardial Infarction

Background: Multisystem involvement is often seen in sarcoidosis. This study aims to explore the characteristics and clinical outcomes following hospitalization for ST-elevation myocardial infarction (STEMI) in patients with sarcoidosis when compared to patients without sarcoidosis. Methods: Patients with and without sarcoidosis admitted for STEMI were identified and compared from the 2016-2020 National Inpatient Sample (NIS) database whilst adjusting for confounders via logistic regression models. Results: A total of 851290 patients hospitalized with a primary diagnosis of STEMI between 1 st January 2016 to 31 st December 2020 were identified. Around 1215 (0.1%) had a diagnosis of sarcoidosis consisting of 58.4% males. When compared to patients without sarcoidosis, patients with sarcoidosis had a longer mean length of stay (LOS: 4.76 vs. 4.01 days, p&lt;0.01), a greater prevalence of diabetes (42.4% vs. 32.4%, p&lt;0.01), cirrhosis (1.6% vs. 0.5%, p&lt;0.01), depression (9.1% vs. 6.7%, p&lt;0.01), peripheral vascular disease (7.8% vs. 5.1%, p&lt;0.01), obesity (24.3% vs. 17.8%, p&lt;0.01), chronic kidney disease (25.9% vs. 13.1%, p&lt;0.01) and prior stroke (7.4% vs. 5.2%, p&lt;0.01). However, patients without sarcoidosis had a higher incidence of percutaneous coronary intervention (PCI) (79.8% vs. 75.3%, p&lt;0.01), smoking (52% vs. 35.4%, p&lt;0.01), drug abuse (2.8% vs. 1.2%, p&lt;0.01) and alcohol abuse (3.5% vs. 2.1%, p&lt;0.01) (Table 1A). Moreover, patients with sarcoidosis were less likely to have cardiogenic shock during their hospitalization (12.3% vs. 13.7%, aOR 0.768, 95% CI 0.636-0.927, p&lt;0.01). No statistically significant differences were seen for CABG or PCI use, events of Acute Kidney Injury, acute ischemic stroke and death (Table 1AB). Conclusion: Patients with sarcoidosis admitted for STEMI had a longer length of stay and fewer cardiogenic shock incidence when compared to patients without sarcoidosis. Complications and mortality was otherwise comparable.

ЛЕПТИНОРЕЗИСТЕНТНОСТЬ И ЕЕ КЛИНИКО-ПРОГНОСТИЧЕСКУЮ ЗНАЧИМОСТЬ ВО ВЗАИМОСВЯЗИ С МЕТАБОЛИЧЕСКИМИ НАРУШЕНИЯМИ В ГОСПИТАЛЬНОМ ПЕРИОДЕ ИНФАРКТА МИОКАРДА

Introduction. Leptin resistance (LR) is characterized by a weakening of the positive metabolic effect of leptin, despite its elevated level, while maintaining some of the pleiotropic effects, including those on the cardiovascular system. However, since most of the data have been obtained in cellular and animal models, the role of LR in cardiovascular diseases remains unclear. The lack of precise diagnostic criteria for assessing LR limits the study of this phenomenon. As a result, data on the incidence and contribution of LR in MI are critically scarce today, in addition, they are extremely contradictory. Purpose: to evaluate the prevalence of LR and its clinical and prognostic significance in conjunction with metabolic disorders in the hospital period of myocardial infarction (MI). Materials and methods. The study included 114 men with an established diagnosis of ST elevation MI. Patients on the 1st and 12th day of MI measured the concentration of leptin, the leptin receptor. The free leptin index (FLI) was calculated as the ratio of leptin concentration (ng/mL) to the concentration of soluble leptin receptor (ng/mL) multiplied by 100. LR was recorded at leptin &gt; 6.45 ng/mL and LL &gt;25. Assessment of glucose, lipid spectrum (total cholesterol, TAG, LDL-C, VLDL-C, HDL-C, FFA) in blood serum was performed using standard test systems from Thermo Fisher Sientific on an automatic biochemical analyzer Konelab 30i (Finland) , the content of C-peptide and insulin were determined using enzyme immunoassay (Monobind, USA) according to the protocol established by the manufacturer. To determine insulin resistance (IR), the QUICKI index was calculated, the severity of IR was assessed according to A. Katz et al. A comparative analysis of clinical and anamnestic characteristics and cardiovascular prognosis between patients with and without PR was carried out. Data analyzed using Statistica 10.0. Results. In patients with MI in the whole group in the hospital period, there was an increased content of leptin relative to the reference interval of 2.0-5.6 ng/ml. On the 1st and 12th days of the disease, the leptin concentration in patients with MI was 11.6 [6.6;20.5] ng/ml and 11.5 [5.4;13.9] ng/ml, respectively. . The content of the leptin receptor did not go beyond the established reference interval. LSI on the 1st day of the disease was 32.7 [14.3; 70.5], on the 12th day - 31.9 [16.2; 64.5]. The prevalence of LR in the hospital period for MI was 64%. LR was associated with CVD risk factors - hereditary burden for cardiovascular pathology (p=0.02), arterial hypertension (p=0.01), dyslipidemia (p=0.001), obesity (p=0.001). When assessing the metabolic profile, a statistically significant increase in the content of glucose (p=0.02), insulin (p=0.02) and C-peptide (p=0.03) on the 1st day of MI, insulin (p=0 .01) and C-peptide (p=0.03) on the 12th day of the disease, a decrease in the QUICKI index (p=0.03) throughout the hospital period in patients with PR compared with patients without PR. In the group of patients with PR, 45 people (61.8%) had a moderate and severe degree of IR, in patients without PR - in 12 patients (29.2%). When conducting a correlation analysis, a significantly significant direct relationship was found between the level of insulin on the 12th day of MI and LSI (r=0.509, p=0.02), as well as an inverse correlation between the QUICKI index on the 12th day and LSI (r= -0.367, p=0.01). Among the studied parameters of lipid metabolism, only the content of FFA on the 1st day of the disease in the group of patients with LR was higher than in the group without LR (p=0.03). Patients with LR were more often prone to early postinfarction angina (p=0.03), recurrent MI (p=0.001), rhythm and conduction disturbances (p=0.03) during the hospital period of MI. Prognostic significance in relation to the risk of adverse cardiovascular events in the hospital period of MI, according to logistic regression analysis, had LSI both on the 1st and 12th days of the disease, as well as FFA levels on the 1st day of the disease. Conclusion. Patients with MI are characterized by a high prevalence of LR in the hospital period. LR is associated with CVD risk factors, metabolic disorders, and IR formation. The identified features in the presence of LR can probably contribute to the development of adverse cardiovascular events in the hospital period of MI.