Early Infarction Research Articles

Long‐Term Outcome and Quality of Life in Patients With Stroke Presenting With Extensive Early Infarction

Background The benefit of mechanical thrombectomy in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) for short‐term outcomes is debatable and long‐term outcomes remain unknown. This retrospective, monocentric cohort study aimed to assess the association between reperfusion grade and the long‐term functional outcome measured with modified Rankin scale as well as the long‐term health‐related quality of life recorded at the last follow‐up in patients according to baseline ASPECTS (0–5 versus 6–10). Methods Deceased patients were identified from the Swiss population register and follow‐up telephone interviews were conducted with all surviving patients with stroke treated with mechanical thrombectomy between January 1, 2010, and December 31, 2018. Favorable outcome was defined as modified Rankin scale 0 to 3; health‐related quality of life was assessed using the 3‐level version of the EuroQol 5‐dimensional questionnaire. The EuroQol 5‐dimension utility index was calculated for statistical analyses. The reperfusion grade was core laboratory adjudicated using the expanded treatment in cerebral ischemia score. Adjusted odds ratios for the association between the reperfusion grade assessed by expanded treatment in cerebral ischemia and outcomes were calculated from multivariable logistic regression. Results Of the 1114 patients with available long‐term follow‐up records (median follow‐up, 3.67 years), 997 were included in the final analysis. Respectively, patients with low ASPECTS more often had complaints regarding mobility (67.1% versus 42.1%, P <0.001), self‐care (53.4% versus 31.2%, P <0.001), and usual activities (65.8% versus 41.4%, P <0.001) than patients with high ASPECTS, whereas reported pain/discomfort (65.7% versus 69.9%, P =0.49) and anxiety/depression (71.2% versus 78.9%, P =0.17) did not differ. In patients with low ASPECTS, increasing reperfusion grade was associated with a higher likelihood of long‐term favorable functional outcome (adjusted odds ratio, 1.43; 95% CI, 1.09–1.88 [ P= 0.01]) and health‐related quality of life (adjusted linear correlation coefficient, 0.05; 95% CI, 0.02–0.08) despite early extensive infarction. Conclusion Despite low baseline ASPECTS, a higher reperfusion grade results in better functional outcomes and may improve health‐related quality of life in the long term.

Multielectrode Unipolar Voltage Mapping and Electrogram Morphology to Identify Post-Infarct Scar Geometry: Validation by Histology.

This study sought to evaluate the ability of uni- and bipolar electrograms collected with a multielectrode catheter with smaller electrodes to: 1) delineate scar; and 2) determine local scar complexity. Early reperfusion results in variable endocardial scar, often overlaid with surviving viable myocardium. Although bipolar voltage (BV) mapping is considered the pillar of substrate-based ablation, the role of unipolar voltage (UV) mapping has not been sufficiently explored. It has been suggested that bipolar electrograms collected with small electrode catheters can better identify complex scar geometries. Twelve swine with early reperfusion infarctions were mapped with the 48-electrode OctaRay catheter and a conventional catheter during sinus rhythm. BV electrograms with double components were identified. Transmural (n=933) biopsy specimens corresponding to mapping points were obtained, histologically assessed, and classified by scar geometry. OctaRay UV (UVOcta) and BV (BVOcta) amplitude were associated with the amount of viable myocardium at a given location, with a stronger association for UVOcta (R2=0.767 vs 0.473). Cutoff values of 3.7mV and 1.0mV could delineate scar (area under the curve: 0.803 and 0.728 for UVOcta and BVOcta, respectively). The morphology of bipolar electrograms collected with the OctaRay catheter more frequently identified areas with 2 layers of surviving myocardium than electrograms collected with the conventional catheter (84% vs 71%). UV mapping can generate a map to delineate the area of interest when using a multielectrode catheter. Within this area of interest, the morphology of bipolar electrograms can identify areas in which a survivingepicardial layer may overlay a poorly coupled, potentially arrhythmogenic, endocardium.

EROSION III: A Multicenter RCT of OCT-Guided Reperfusion in STEMI With EarlyInfarctArteryPatency.

The aim of this study was to test whether optical coherence tomographic (OCT) guidance would provide additional useful information beyond that obtained by angiography and lead to a shift in reperfusion strategy and improved clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) with early infarct artery patency. Angiography is limited in assessing the underlying pathophysiological mechanisms of the culprit lesion. EROSION III (Optical Coherence Tomography-Guided Reperfusion in ST-Segment Elevation Myocardial Infarction With Early Infarct Artery Patency) is an open-label, prospective, multicenter, randomized, controlled study approved by the ethics committees of participating centers. Patients with STEMI who had angiographic diameter stenosis≤ 70% and TIMI (Thrombolysis In Myocardial Infarction) flow grade 3 at presentation or after antegrade blood flow restoration were recruited and randomized to either OCT guidance or angiographic guidance. The primary efficacy endpoint was the rate of stent implantation. Among 246 randomized patients, 226 (91.9%) constituted the per protocol set (112 with OCT guidance and 114 with angiographic guidance). The median diameter stenosis was 54.0% (IQR: 48.0%-61.0%) in the OCT guidance group and 53.5% (IQR: 43.8%-64.0%) in the angiographic guidance group (P=0.57) before randomization. Stent implantation was performed in 49 of 112 patients (43.8%) in the OCT group and 67 of 114 patients (58.8%) in the angiographic group (P=0.024), demonstrating a 15% reduction in stent implantation with OCT guidance. In patients treated with stent implantation, OCT guidance was associated with a favorable result with lower residual angiographic diameter stenosis (8.7% ± 3.7% vs 11.8% ± 4.6% in the angiographic guidance group; P< 0.001). Two patients (1cardiac death, 1 stable angina) met the primary safety endpoint in the OCT guidance group, as did 3 patients (3 cardiac deaths) in the angiographic guidance group (1.8% vs 2.6%; P=0.67). Reinfarction was not observed in either group. At 1 year, the rates of predefined cardiocerebrovascular events were comparable between the groups (11.6% after OCT guidance vs 9.6% after angiographic guidance; P=0.66). In patients with STEMI with early infarct artery patency, OCT guidance compared with angiographic guidance of reperfusion was associated with less stent implantation during primary percutaneous coronary intervention.These favorable results indicate the value of OCT imaging in optimizing the reperfusion strategy of patientswith STEMI. (EROSION III: OCT- vs Angio-Based Reperfusion Strategy for STEMI; NCT03571269).

The Role of Immunohistochemical Markers in the Diagnosis of Early Myocardial Infarction.

Introduction: Pathological diagnosis of acute myocardial infarction can be difficult if death from ischemic injury has occurred within a short period of time. In this study, we aimed to determine the role of immunohistochemical markers in the diagnosis of early myocardial infarction.Methods: The myocardium samples of 20 cases whose autopsies were performed at the Morgue Department of the Council of Forensic Medicine were evaluated. Hematoxylin and Eosin (H&E) stained slides and fibronectin, CD59, myoglobulin, troponin T, desmin, cathepsin S stained slides of 20 cases diagnosed with early myocardial infarction were retrospectively re-examined. The diagnosis of myocardial infarction was analyzed in two groups: Group 1: first eight hours, Group 2: 8-24 hours. The immunohistochemical staining patterns in these two groups were compared.Results: Of the cases, 55% (n=11) had myocardial infarction consistent with the first eight hours, 45% (n=9) 8-24 hours with light microscopic examination. With fibronectin, 50% (n=10) of the cases showed Grade 1 staining, 5% (n=1) Grade 2, 15% (n=6) Grade 3 staining. The slides of three cases could not be reached. With CD59, 10% (n=2) of the cases showed Grade 1, 10% (n=2) Grade 2, 80% (n=16) Grade 3 staining. With troponin T, 50% (n=10) of the cases showed Grade 1, 45% (n=9) Grade 2, 5% (n=1) Grade 3 depletion. With cathepsin S, 10% (n=2) of the cases showed Grade 1 and 80% (n=16) Grade 3 depletion. The slides of two cases could not be reached. With desmin, 75% (n=15) had Grade 1 and 25% (n=5) Grade 2 depletion. Grade 3 depletion with myoglobulin was observed in all cases.Conclusion: The diagnosis of early myocardial infarction, which may pose a problem for the forensic pathologist, may become easier with immunohistochemical methods. In cases where morphological findings are insufficient, it is more useful for diagnosis to be applied as a panel.

Abstract 91: Large Vessel Occlusion Stroke Patients With Rapid Early Infarct Progression And Poor Collaterals Are Vulnerable To Blood Pressure Reductions

Introduction: The precise interactions between collateral perfusion, hemodynamics, and infarct growth after large vessel occlusion (LVO) require further definition. This study examined whether patients with poor collateral circulation and rapid early infarct progression are more vulnerable to reductions in blood pressure (BP). Methods: We prospectively enrolled patients with LVO stroke who underwent thrombectomy. Volumes of arterial tissue delay and relative cerebral blood flow (CBF) were estimated with RAPID software; a poor collateral profile was defined by a hypoperfusion intensity ratio &gt;0.4. Early infarct growth rate (EIGR) was defined as ischemic core volume (CBF&lt;30%) divided by the time from symptom onset to imaging. A fast progressor profile was assigned to patients whose EIGR was &gt;10 mL/h. The final infarct growth rate (FIGR) was the quotient of final infarct volume (FIV) and time from symptom onset to reperfusion. BP reduction was measured as the difference between admission mean arterial pressure (MAP) and lowest MAP before reperfusion. Results: Fifty-five patients (mean age 69 + 15, mean NIHSS 13) with successful reperfusion (TICI 2B/3) were included in the analysis. The median MAP reduction was 17 (IQR 9, 32). Poor collateral perfusion and EIGR were independent predictors of FIV after adjusting for age and admission NIHSS (mean FIV 70 vs. 31 mL, p=0.012 and 60 vs. 29 mL, p=0.01, respectively). A significant interaction was found between MAP reduction and both collateral status (p=0.04) and progressor profile (p=0.01). For every 10 mmHg MAP reduction, patients with poor collaterals experienced an average increase in FIGR of 3.6 mL/h (Fig. 1A). Above a critical MAP reduction threshold of 30 mmHg, mean FIV was significantly larger in patients with rapidly progressing infarcts (p&lt;0.01, Fig. 1B). Conclusions: Patients with poor collaterals and rapid early infarct growth are at higher risk of accelerated infarct growth and larger FIV related to BP reductions.

Abstract 119: The Effect Of Neuroprotectant NA1 On Early Infarct Growth Following Endovascular Therapy: The REPERFUSE-NA1 Study

Background: Early infarct growth after endovascular therapy (EVT) may lead to unfavorable outcomes despite successful reperfusion. The REPERFUSE-NA1 study replicated the preclinical NA1 experiment by investigating the effect of NA1 on early DWI infarct growth in acute ischemic stroke patients receiving EVT. Methods: REPERFUSE-NA1 was a sub-study of the randomized controlled trial ESCAPE-NA1 (ClinicalTrialGov NCT02930018). Patients received MRI within 5 hours and 24 hours of EVT. The primary outcome was early diffusion weighted (DWI) infarct growth. The secondary outcome was region-specific DWI infarct growth in the white matter, cortical grey matter and basal ganglia. Results: A total of 71 patients was included, of whom 67 had sufficient MR imaging at 5h and 24h post-EVT. For patients who received NA1 compared to placebo, the median age (68.8 v 67.5), baseline NIHSS (15.5 v 16), time from symptom onset to reperfusion (161 v 167 minutes) and mTICI 2b-3 (94.4% v 94.3%) were statistically not different. Median DWI volumes post-EVT (5h) were 13.0 mL (IQR, 5.9-28.1) in NA1 and 13.3 mL (IQR, 3.1-27.0) in placebo. At 24h median DWI volumes increased to 22.6 mL (IQR, 11.2-63.4) in the NA1 group and 22.4 mL (IQR, 7.4-52.3) in the placebo group, equating to a 48.4% DWI volume growth in the NA1 group and a 66.0% growth in the placebo group. Median DWI volume growth was 55.1% for NA1 patients who received alteplase compared to 41.3% for NA1 patients who did not receive alteplase (p=0.65). In terms of region-specific infarct volumes, absolute growth was 2.27mL (IQR, 0.70-6.19) in the white matter, 3.93 mL (IQR, 0.18-12.40) in cortical grey matter, and 1.20 mL (IQR, 0.31-2.62) in basal ganglia in the overall cohort. Between the NA1 and the placebo groups, lesion growth in the white matter (1.96 mL v 2.77mL), cortical gray matter (3.93 mL v 4.07 mL) and basal ganglia (1.62 mL v 0.89 mL) did not differ significantly. Conclusion: There was substantial infarct growth early after EVT, with the largest absolute growth in cortical grey matter. No significant effect of NA1 on early infarct growth was observed.

Abstract WP144: Safety Of Eptifibatide Use In Ischemic Stroke Patients Undergoing Endovascular Thrombectomy: A Matched Cohort Analysis

Introduction: Small studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following IV thrombolysis (tPA) or during endovascular therapy (EVT) for large vessel occlusion (LVO), however larger studies are called upon to evaluate the safety of EPT use in this setting. Methods: A stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for LVO was queried. Patients treated with EPT were matched with 3 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, early infarct size (Alberta Stroke Program Computed Tomography Scale [ASPECTS] score), and number of thrombectomy passes. ICH, parenchymal hematoma (PH-2), symptomatic ICH (sICH), and 90-day modified Rankin Scale (mRS) score were compared between matched groups. Results: A total of 236 patients were included, 59 of whom (25%) received EPT. IV tPA was non-significantly more utilized in EPT patients (41%, p=0.22). Rate of any ICH was similar between groups (p=0.23), while PH-2 was significantly more frequent with EPT (21% v. 7% v. 3% v. 0%; p= 0.0001). There were no significant differences in sICH (7% EPT v. 7% v. 5% v. 2%; p=0.57), 90-day mRS (p=0.84), or 90-day mortality (p=0.92) between EPT and control groups. Conclusion: In this single center analysis, EPT during EVT was associated with a higher rate of PH-2 grade hemorrhages but not with differences in sICH, 90-day mRS, or 90-day mortality. Larger prospective studies are needed to confirm these findings.

Clinical Analysis of Early Cerebral Infarction in the Treatment of Urokinase Intravenous Thrombolysis

Clinical Analysis of Early Cerebral Infarction in the Treatment of Urokinase Intravenous Thrombolysis

The Benefit of Thrombectomy in Patients With Low ASPECTS Is a Matter of Shades of Gray-What Current Trials May Have Missed.

Randomized trials supporting the benefit of endovascular treatment in acute ischemic stroke patients with a large early infarction are not yet available. Few retrospective studies exist that suggest a potential positive treatment effect on functional outcome, as well as procedural safety. However, potential benefit or harm of MT in patients with low initial ASPECTS is still a subject of current debate, and in particular, how to select these patients for treatment. The purpose of this pilot study was to evaluate how early tissue water uptake in acute ischemic brain might determine lesion fate and functional outcome in low ASPECTS patients undergoing MT. We observed that the degree of early water uptake measured by quantitative NWU was significantly associated with functional outcome in low ASPECTS patients, yielding a higher diagnostic power compared to other parameters such as ASPECTS, age, or NIHSS. No conclusive evidence of a beneficial effect of successful reperfusion was observed in patients with low ASPECTS and high NWU, which highlights the potential of NWU as a tool to specify patient selection.

CHEST PAIN IN WOMEN. IS IT ALWAYS ATHEROSCLEROTIC?

Patients both male and female with diagnosis of Acute Coronary Syndrome (ACS) present with chest pain as presenting complaint. Lichtman JH et al. in his study with ACS showed that 93% of women presented with chest pain or discomfort.1 As compared to men women experience more associated symptoms as primary complaint. The associated symptoms are fatigue, dyspnea, backache, flue like symptoms, indigestion, palpitations and most common is anxiety &amp; feeling scarry.2 Keeping these scenarios in mind one should inquire this associated presentation along with chest pain or discomfort in evaluating ACS in women. In continuation with symptoms there is quite a debate on pathophysiology of Acute Myocardial infraction in men and women regarding coronary pathologic features.3 Type 1 plaque rupture most common in both genders with plaque erosion most common in women in non-obstructive coronary artery disease.4 Spontaneous coronary artery dissection (SCAD) having high mortality exists in the absence of risk factor of ACS.5 It was found in women up to 35% of patients with mean age of 42 to 53 years with a MACE (Major acute coronary event) of 47.4% and 10 years mortality rate of 7.7%2 SCAD seen in peripartum cases, oral contraception use, lack of exercise, connective tissue disorders and vasculidites. It is important for the physician to have in mind these disorders to avoid complications of coronary interventions. In a scientific statement from AHA, Mehte LS et al. showed a lower prevalence of atheroscrotic CAD in women.3 These are certain scoring system,6 that under present women because of vague symptoms and presentation. These scoring systems lead to decrease hospital admission and less noninvasive cardiac testing. For risk satisfaction of chest pain female gender should not be taken as sole criteria for presence or absence of coronary events in presence of other multiple factors. The last but not the least is the psychosocial stress more in women than in men. It has been found that young women who present with early onset myocardial infarction have more psychosocial risk factors in comparison to men of similar age,3 probably having high rates of poverty and trauma exposure during childhood because of various reasons.7 Different studies are endorsing relationship between depression and ischemic heart disease as prognostic factor after ACS.7 In our population where there is lack of education, poverty, awareness of disease especially in women the physician should ponder on different factors mentioned above i.e. presentation perceptions, prevalence, pathophysiology and psychosocial stress for evaluation and management of chest pain.

Identification of early invisible acute ischemic stroke in non-contrast computed tomography using two-stage deep-learning model.

Rationale: Although non-contrast computed tomography (NCCT) is the recommended examination for the suspected acute ischemic stroke (AIS), it cannot detect significant changes in the early infarction. We aimed to develop a deep-learning model to identify early invisible AIS in NCCT and evaluate its diagnostic performance and capacity for assisting radiologists in decision making.Methods: In this multi-center, multi-manufacturer retrospective study, 1136 patients with suspected AIS but invisible lesions in NCCT were collected from two geographically distant institutions between May 2012 to May 2021. The AIS lesions were confirmed based on the follow-up diffusion-weighted imaging and clinical diagnosis. The deep-learning model was comprised of two deep convolutional neural networks to locate and classify. The performance of the model and radiologists was evaluated by the area under the receiver operator characteristic curve (AUC), sensitivity, specificity, and accuracy values with 95% confidence intervals. Delong's test was used to compare the AUC values, and a chi-squared test was used to evaluate the rate differences.Results: 986 patients (728 AIS, median age, 55 years, interquartile range [IQR]: 47-65 years; 664 males) were assigned to the training and internal validation cohorts. 150 patients (74 AIS, median age, 63 years, IQR: 53-75 years; 100 males) were included as an external validation cohort. The AUCs of the model were 83.61% (sensitivity, 68.99%; specificity, 98.22%; and accuracy, 89.87%) and 76.32% (sensitivity, 62.99%; specificity, 89.65%; and accuracy, 88.61%) for the internal and external validation cohorts based on the slices. The AUC of the model was much higher than that of two experienced radiologists (65.52% and 59.48% in the internal validation cohort; 64.01% and 64.39% in external validation cohort; all P < 0.001). The accuracy of two radiologists increased from 62.00% and 58.67% to 92.00% and 84.67% when assisted by the model for patients in the external validation cohort.Conclusions: This deep-learning model represents a breakthrough in solving the challenge that early invisible AIS lesions cannot be detected by NCCT. The model we developed in this study can screen early AIS and save more time. The radiologists assisted with the model can provide more effective guidance in making patients' treatment plan in clinic.

Deep Learning-Based Diffusion-Weighted Magnetic Resonance Imaging in the Diagnosis of Ischemic Penumbra in Early Cerebral Infarction.

The prefiltered image was imported into the local higher-order singular value decomposition (HOSVD) denoising algorithm (GL-HOSVD)-optimized diffusion-weighted imaging (DWI) image, which was compared with the deviation correction nonlocal mean (NL mean) and low-level edge algorithm (LR + edge). Regarding the peak signal-to-noise ratio (PSNR), root mean square error (RMSE), sensitivity, specificity, accuracy, and consistency, the application effect of the GL-HOSVD algorithm in DWI was investigated, and its adoption effect in the examination of ischemic penumbra (IP) of early acute cerebral infarction (ACI) patients was evaluated. A total of 210 patients with ACI were selected as the research subjects, who were randomly rolled into two groups. Those who were checked by conventional DWI were set as the control group, and those who used DWI based on the GL-HOSVD denoising algorithm were set as the observation group, with 105 people in each. Positron emission tomography (PET) test results were set as the gold standard to evaluate the application value of the two examination methods. It was found that under different noise levels, the peak signal-to-noise ratio (PSNR) of the GL-HOSVD algorithm and the root mean square error (RMSE) of the FA parameter were better than those of the nonlocal means (NL-means) of deviation correction and low-rank edge algorithm (LR + edge). The sensitivity, specificity, accuracy, and consistency (8.76%, 81.25%, 87.62%, and 0.52) of the observation group were higher than those of the control group (57.78%, 53.33%, 57.14%, and 0.35) (P < 0.05). Moreover, the apparent diffusion coefficient (ADC) of the DWI images of the observation group was basically consistent with that of the PET images, while the control group had a poor display effect and low definition. In summary, under different noise levels, the GL-HOSVD algorithm had a good denoising effect and greatly reduced fringe artifacts. DWI after denoising had high sensitivity, specificity, accuracy, and consistency in the detection of IP, which was worthy of clinical application and promotion.

Outcomes of post-mi vsr surgical repair in-patients operated in different time periods upon acute myocardial infarction evolvement

Aim: The article highlights problematic issues of surgical treatment of mechanical complications of acute myocardial infarction (AMI), specifically, post-myocardial infarction ventricular septum rupture (post-MI VSR). Based on the study of the results of surgical treatment of post-MI VSR in patients with different terms of surgical intervention upon AMI evolvement, the most rational approach to ventricular septum defect (VSD) repair in such patients has been determined. Specifically, subject to hemodynamic stability in patients with post-MI VSR within the first two weeks after AMI evolvement, given the risk of mortality (42.1%), the wait-and-see tactics of surgical treatment is deemed a wise measure. Since the third week after AMI the stabilization of operative mortality rate (up to 10.5-15.8%) has been observed this lays the grounds for active surgical treatment tactics. Notably, analysis of the dynamics of echocardiographic characteristics and changes in the degree of tolerance to physical activity (PA) in patients with post-MI VSR who underwent surgery in different periods after AMI evolvement have been particularly addressed. It has been found that the probability of achievement the most favourable clinical condition corresponding to class I by New York Heart Association (NYHA) classification (χ2 (2, n=65) = 20,791; p&lt;0,001) increases when patients performed are operated on in later periods after AMI. Thus, given the risk of mortality in the early post myocardial infarction period, the most appropriate measure in the tactics of managing patients with post-MI VSR is surgical intervention aimed at VSD repairing 2 weeks after AMI. Nonetheless, the decision on the necessity of emergency surgery patients with post-MI VSR must be also based on the potential stabilization of systemic hemodynamic system characteristics using drug therapy and endovascular practices. Material and Methods: In the study we have presented the retrospectively analysis of data of 90 ischemic heart disease (IHD) patients with post-MI VSR complications. The age of post-MI VSR in-patients ranged from 29 to 81 (60.0 ± 9.6). Among such patients men prevailed (72.3%). Duration of hospitalization of those post-MI VSR from AMI onset varied from 1 to 462 days (n=90). Depending on the time of surgery to be performed after AMI suffered, all patients were divided into groups: group 1 – up to 28 days (n=28); group 2 – from 29 to 56 days n=26); group 3 – from 57 days (n=36). Among the 90 patients who participated in the study, the surgical treatment of post-MI VSR was used in 93.3% (n=84) of patients. LV aneurysm repair according to W. M. Dagget’s technique (14) was performed in 54.8% of patients (n=46), according to T. E. David’s technique (7) – in 36.9% of patients (n=31). Results: Overall surgical mortality among 84 patients has been observed in 22.6% (n=19). In patients of group 1 there occurred 10 lethal cases, in group 2 there were 5, and in group 3 – there were 4 deaths ( n=84)observed. Starting from the 3rd week after AMI onset, significant decrease in operative mortality from 42.1% to 10.5-15.8% has been observed. Study of the dynamics of echocardiography characteristics show less marked changes in LVESV and LVEDV in group 1 compared to groups 2 and 3 testify, in the latter, in favor of completed post-infarction "heart remodeling" with LV aneurysm formed. Conclusion: 1. When planning the scope of surgical intervention at a later date from AMI evolvement, account must be taken of individual dynamics of post-myocardial infarction "cardiac remodeling". 2. Postoperative decrease in ECHO values of LVESV, LVEDV and LVSV in patients with post-MI VSR speaks for the effectiveness of surgical intervention aimed at repairing VSD and restoring LV geometry. 3. The probability of achieving the most favorable NYHA class I clinical state increases when surgery is performed in patients at the later time after AMI suffered.

Вторичная профилактика у пациентов с ишемической болезнью сердца после реваскуляризации миокарда

Objective of the Review: Help the doctor in a conversation with the patient to additionally motivate him to follow the recommendations for secondary prevention in the period after myocardial revascularization. Key points. The article discusses the main risk factors that contribute to the progression of cardiovascular diseases (overweight and obesity, smoking, physical inactivity, depression and anxiety, dyslipidemia, diabetes mellitus, arterial hypertension), as well as various methods of secondary prevention after myocardial revascularization, based on modern data of evidence-based medicine: weight loss, regular physical training, psychopharmacotherapy, high adherence to drug therapy. Conclusion. Conducting secondary prevention measures is extremely important for patients after myocardial revascularization, since the progression of coronary artery atherosclerosis continues after surgery. Therefore, in the postoperative period, the likelihood of developing cardiovascular events, in particular, early periprocedural myocardial infarction, stent thrombosis, and late restenosis, remains. Optimal drug and non-drug preventive measures improve the quality of life and improve the prognosis in this category of patients. Keywords: ischemic heart disease, cardiovascular disease, secondary prevention, myocardial revascularization, healthy lifestyle.

İskemi modifiye albümin düzeylerinin NSTEMI hastalarını iskemik olmayan kontrollerden ayırt etmedeki rolü ve hastalık şiddeti ile ilişkisi

Purpose: The aim of this study was to investigate the diagnostic value of ischemia modified albumin (IMA) in early non-ST elevation myocardial infarction (NSTEMI) patients diagnosed with high-sensitive cardiac troponin (hs-cTn)assays.&#x0D; Materials and Methods: In the first three hours of symptom onset, one hundred sixty-two patients without cardiovascular disease history admitted to our hospital with NSTEMI were enrolled between March 2018 and August 2019. The patients' IMA levels were compared with IMA levels of randomly selected, age and the sex-matched control group comprised of 61 subjects with normal coronary angiography results. &#x0D; Results: IMA levels of NSTEMI patients were higher than the control group. In receiver operating characteristic (ROC) curve analysis, a value equal or greater than 0.3855 ABSU has an 82% sensitivity and a 99.4% specificity for diagnosing NSTEMI (AUC: 0.962, 95% CI: 0.937 – 0.986,). In addition, ROC curve analysis revealed moderate predictive power for distinguishing three-vessel disease (cut-off value: 0.4290 ABSU, sensitivity 78.4% and specificity 56.3%, AUC: 0.696, 95% CI: 0.616 – 0.776,). IMA levels were positively correlated with Gensini scores of the patient group.&#x0D; Conclusion: Ischemia-modified albumin, when used alone, was very useful in distinguishing NSTEMI from non-ischemic controls. Besides, IMA levels were positively correlated with CAD severity.

Revascularization strategies in patients with multivessel coronary artery disease: a Bayesian network meta-analysis.

Summary Treatment modalities for multivessel disease have rapidly evolved, yet the preferred strategy remains controversial. This meta-analysis compared outcomes after on-pump (ONCAB), off-pump coronary artery bypass grafting (OPCAB), percutaneous coronary intervention (PCI) or hybrid coronary revascularization. A comprehensive search for observational studies and randomized controlled trials published by August 2020 was performed. A Bayesian network meta-analysis was conducted for early (<30 days) and late (>12 months) outcomes. A total of 119 studies were included (n = 700 458 patients). The main analysis was confined to 31 randomized controlled trials (n = 24 932 patients). PCI was associated with lower early mortality [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.31–0.79] and stroke (OR 0.22, 95% CI 0.06–0.60) rates compared with ONCAB, whereas a reduced risk of early myocardial infarction was observed with OPCAB compared with ONCAB (OR 0.53, 95% CI 0.32–0.83). Late target vessel revascularization and major adverse cardiac and cerebrovascular events were both increased with PCI compared with ONCAB, OPCAB and hybrid coronary revascularization (by 127–203% and 59–64%, respectively), and late major adverse cardiac events were increased in PCI compared with ONCAB and OPCAB (by 64% and 59%). However, PCI was associated with a significantly lower risk of late stroke compared with ONCAB (OR 0.70, 95% CI 0.52–0.89). Sensitivity analyses (i) including observational studies and (ii) limiting to studies with recent cohorts confirmed the findings of the main analysis. Surgical approaches for revascularization remain superior to PCI in patients with multivessel disease. Hybrid coronary revascularization might be viable for some patients, although more evidence from randomized controlled trials is warranted.

Rate of Infarct–Edema Growth on CT Predicts Need for Surgical Intervention and Clinical Outcome in Patients with Cerebellar Infarction

BackgroundUp to 20% of patients with cerebellar infarcts will develop malignant edema and deteriorate clinically. Radiologic measures, such as initial infarct size, aid in identifying individuals at risk. Studies of anterior circulation stroke suggest that mapping early edema formation improves the ability to predict deterioration; however, the kinetics of edema in the posterior fossa have not been well characterized. We hypothesized that faster edema growth within the first hours after acute cerebellar stroke would be an indicator for individuals requiring surgical intervention and those with worse neurological outcomes.MethodsConsecutive patients admitted to the neurological intensive care unit with acute cerebellar infarction were retrospectively identified. Hypodense regions of infarct and associated edema, “infarct–edema”, were delineated by using ABC/2 for all computed tomography (CT) scans up to 14 days from last known well. To examine how rate of infarct–edema growth varied across clinical variables and surgical intervention status, nonlinear and linear mixed-effect models were performed over 2 weeks and 2 days, respectively. In patients with at least two CT scans, multivariable logistic regression examined clinical and radiological predictors of surgical intervention (defined as extraventricular drainage and/or posterior fossa decompression) and poor clinical outcome (discharge to skilled nursing facility, long-term acute care facility, hospice, or morgue).ResultsOf 150 patients with acute cerebellar infarction, 38 (25%) received surgical intervention and 45 (30%) had poor clinical outcome. Age, admission National Institutes of Health Stroke Scale (NIHSS) score, and baseline infarct–edema volume did not differ, but bilateral/multiple vascular territory involvement was more frequent (87% vs. 50%, p < 0.001) in the surgical group than that in the medical intervention group. On 410 serial CTs, infarct–edema volume progressed rapidly over the first 2 days, followed by a subsequent plateau. Of 112 patients who presented within two days, infarct–edema growth rate was greater in the surgical group (20.1 ml/day vs. 8.01 ml/day, p = 0.002). Of 67 patients with at least two scans, after adjusting for baseline infarct–edema volume, vascular territory, and NIHSS, infarct–edema growth rate over the first 2 days (odds ratio 2.55; 95% confidence interval 1.40–4.65) was an independent, and the strongest, predictor of surgical intervention. Further, early infarct–edema growth rate predicted poor clinical outcome (odds ratio 2.20; 95% confidence interval 1.30–3.71), independent of baseline infarct–edema volume, brainstem infarct, and NIHSS.ConclusionsEarly infarct–edema growth rate, measured via ABC/2, is a promising biomarker for identifying the need for surgical intervention in patients with acute cerebellar infarction. Additionally, it may be used to facilitate discussions regarding patient prognosis.

The Clinical Efficacy of Ginkgo biloba Leaf Preparation on Ischemic Stroke: A Systematic Review and Meta-Analysis.

Background Ginkgo biloba leaf preparations (GLPs) are widely used in ischemic stroke, and uncertainty remains regarding their clinical efficacy. To evaluate systematically the clinical efficacy and safety of GLPs in the treatment of ischemic stroke, we examine evidence from randomized controlled trials (RCTs). Methods We examine studies published prior to November 2021 that were found from searching the following sources: PubMed, China National Knowledge Infrastructure (CNKI), WANFANG DATA, Chongqing VIP (CQVIP) databases, and Chinese Biomedical Literature (CBM). We evaluated the quality of the included references according to the Cochrane Manual of Systematic Evaluation and Meta-analysis (MA) performed using RevMan 5.2 software. Results We included a total of 13 RCTs with clinical therapeutic effects, the National Institute of Health Stroke Scale (NIHSS), Barthel Index (BI), hemorheology index, and adverse reaction index as evaluation criteria. There were 631 cases in the observation group and 629 cases in the control group. MA results showed the following: NIHSS WMD = −3.89, 95% CI: [−4.22, −3.56], I2 = 19%, P < 0.00001. This index is often used with nerve injury and can also be used to judge the recovery of nerve function. A lower score means less nerve damage and a better chance of recovery. The BI results were WMD = 11.30, 95% CI: [9.83, 12.77], I2 = 7%, P < 0.00001. This index was used to assess patients' ability to take care of themselves, with a higher score indicating a stronger ability to live independently. Clinical effective rate results were WMD = 3.79, 95% CI: [2.49, 5.78], I2 = 0%, P < 0.00001, and this measure can be used to evaluate the effect of treatment clearly and objectively. Hemorheological index results show that plasma viscosity has WMD = −0.16, 95% CI: [−0.20, −0.12], I2 = 40%, P < 0.00001 and fibrinogen (FIB) has WMD = −1.13, 95% CI: [−1.23, −1.04], I2 = 0%, P < 0.00001. Plasma viscosity is mainly related to the amount of fibrinogen, and fibrinogen degradation is an important function of the fibrinolytic system. The imbalance of the fibrinolytic system plays an important role in the pathogenesis of cerebral infarction. Fibrinogen is a risk factor of ischemic cerebrovascular disease. Studies have shown that the infarct size of patients with secondary cerebral infarction after CEREBRAL infarction is correlated with their FIB level. In addition, FIB elevation is also one of the risk factors for early infarction after thrombolysis. Therefore, FIB can be used as a detection index for the prevention of cerebral infarction recurrence adverse reactions. Our MA results for FIB show WMD = 0.81, 95% CI: [0.38, 1.73], I2 = 0%, P = 0.58, and RR < 1. Conclusion The existing clinical evidence shows that GLP has a good therapeutic effect on patients with ischemic stroke and can improve their hemorheology indices. In addition, GLP is shown to be relatively safe.

Screening for Familial Hypercholesterolemia in Small Towns: Experience from 11 Brazilian Towns in the Hipercolbrasil Program.

ResumoFundamento A hipercolesterolemia familiar (HF) é uma doença genética dominante que se caracteriza por níveis sanguíneos elevados de colesterol de lipoproteína de baixa densidade (LDL-C), e está associada à ocorrência de doença cardiovascular precoce. No Brasil, o HipercolBrasil, que é atualmente o maior programa de rastreamento em cascata para HF, já identificou mais de 2.000 indivíduos com variantes genéticas causadoras de HF. A abordagem padrão baseia-se no rastreamento em cascata de casos índices referidos, indivíduos com hipercolesterolemia e suspeita clínica de HF.Objetivos Realizar rastreamento direcionado de 11 pequenos municípios brasileiros com suspeita de alta prevalência de indivíduos com HF.Métodos A seleção dos municípios ocorreu de 3 maneiras: 1) municípios em que houve suspeita de efeito fundador (4 municípios); 2) municípios em uma região com altas taxas de infarto do miocárdio precoce, conforme descrito pelo banco de dados do Sistema Único de Saúde (2 municípios); e 3) municípios geograficamente próximos a outros municípios com alta prevalência de indivíduos com HF (5 municípios). A significância estatística foi considerada como valor p < 0,05.Resultados Foram incluídos 105 casos índices e 409 familiares de primeiro grau. O rendimento dessa abordagem foi de 4,67 familiares por caso índice, o qual é significativamente melhor (p < 0,0001) do que a taxa geral do HipercolBrasil (1,59). Identificamos 36 CIs com variante patogênica ou provavelmente patogênica para HF e 240 familiares de primeiro grau afetados. Conclusão: Nossos dados sugerem que, uma vez detectadas, regiões geográficas específicas justificam uma abordagem direcionada para a identificação de aglomerações de indivíduos com HF.

Investigation of Scavenger Receptor Class B Type I gene variants in patients with coronary heart disease with a history of early myocardial infarction.

The scavenger receptor class B type 1 (SR-BI, SCARB1), which is a high-density lipoprotein (HDL) receptor that mediates selective cholesteryl ester uptake, plays an important role in reverse cholesterol transport. This study investigated the distribution of polymorphic variants of the SR-BI gene in patients with coronary heart disease (CHD) with a history of early myocardial infarction (MI) at an early age and their effects on their serum lipid levels. SR-BI rs5888(T>C), rs4238001(C>T), and rs10846744(G>C) were analyzed in 100 male patients with CHD with a history of MI (MI+) who were younger than 50 years and 89 male control subjects without MI history (MI-) using real-time polymerase chain reaction (PCR) and mutant-allele-specific PCR techniques. SR-BI rs4238001 common-CC genotype was found to be more frequent in patients with MI+ than in control subjects (MI-; odds ratio 4.046, p<0.001). The rs10846744 rare-C allele showed a significant association with increased total cholesterol (p=0.014) and triglyceride (p=0.009) levels in the MI+ CHD group. Logistic regression analysis confirmed that there may be an association between the rs4238001-CC genotype (p=0.002), smoking (p=0.026), and MI+ CHD in the presence of other risk factors associated with CHD, whereas haplotype analysis confirmed that patients with MI+ CHD (rs5888-C, rs10846744-G, and rs4238001-C alleles) and CCC (rs5888-C, rs10846744-C, and rs4238001-C alleles) haplotypes were highly frequent (p<0.01 and p=0.027, respectively). These results indicated that SR-BI gene variants show different distribution in patients with MI+ CHD compared with that in MI- control subjects, and these variants may have effects in favor of dyslipidemia.