Primary Primary Percutaneous Coronary Intervention Era Research Articles

In-Hospital Outcomes of Patients with Anterior Wall Myocardial Infarction and Right Bundle Branch Block in the Primary PCI Era: Impact and Prognostic Factors

Objective: This study investigates the in-hospital outcomes of patients presenting with Anterior Wall Myocardial Infarction (AWMI) and Right Bundle Branch Block (RBBB) during the primary Percutaneous Coronary Intervention (PCI) era. It aims to assess the impact of primary PCI on these patients and identify factors contributing to poor outcomes. Methodology: A prospective observational study was conducted at the Department of Cardiology, Hayatabad Medical Complex (HMC), Peshawar, Pakistan. The study enrolled 150 patients diagnosed with AWMI and RBBB, undergoing reperfusion therapy. Data on demographics, clinical characteristics, and treatment outcomes were collected and analyzed using IBM SPSS version 21.0. Results: Among the 150 patients included in the study, there was a balanced gender distribution with a mean age of 51.15 years. The majority of patients, 136 (90.7%), survived their hospital stay. Primary PCI was significantly associated with improved survival rates compared to medical management alone. Factors such as TIMI and GRACE risk scores were crucial for risk stratification, highlighting the need for personalized management strategies. Conclusion: The findings underscore the effectiveness of primary PCI in improving in-hospital outcomes for patients with AWMI and RBBB. This study highlights the necessity of timely reperfusion therapy and personalized risk stratification to enhance patient prognosis. By documenting the impact of primary PCI and identifying factors leading to poor outcomes, this research provides valuable insights that aid in the optimization of treatment protocols for this high-risk patient group.

Incidence and Predictors of Left Ventricular Thrombus Formation After Acute Myocardial Infarction With ST-Segment Elevation.

Background and objective Our prospective study aimed to evaluate the frequency and risk factors of left ventricular thrombus (LVT) occurring after acute ST-segment elevation myocardial infarction (STEMI) in the era of primary percutaneous coronary intervention (PCI). Methods Our study included 131 patients diagnosed with acute STEMI who were followed up and treated. The presence of the thrombus was determined by transthoracic echocardiography (TTE). Study patients were evaluated as cases of thrombus (+) and thrombus (-). The relationship of electrocardiographic measurements such as the number of leads with pathological Q waves, ST segment deviation score, QT dispersion, and echocardiographic measurements such as ejection fraction (EF), end-systolic and end-diastolic volumes, and wall motion score index (WMSI) with LVT was investigated. LVT risk factors were identified. Results The median age of the study patients was 59.7 ± 11.7 years, and 84.7% were male. The incidence of LVT was 17.6% (23 patients). While the anterior STEMI rate was 86.9% in the thrombus (+) group, it was 50.9% in the thrombus (-) group (p<0.001). While WMSI was 2.1 ± 0.44 in the thrombus (+) group, it was calculated as 1.40 ± 0.31 in the thrombus (-) group (p<0.001). In the thrombus (+) group, EF was found to be lower, end-systolic and end-diastolic volumes were higher, and the rate of moderate and severe mitral regurgitation and the rate of aneurysmatic segment detection were higher. LVT had a moderate correlation with WMSI (r: 0.613; p<0.001), the presence of an aneurysmatic segment (r: 0.549; p<0.001), and EF (r: -0.514; p<0.001). Presentation with anterior STEMI (odds ratio [OR]: 4.266; p<0.001), WMSI (OR: 7.971; p=0.012), the number of leads with pathological Q waves detected at discharge (OR: 3.651; p=0.009), the presence of an aneurysmatic segment (OR: 2.089, p=0.009), and EF (OR: 1.129, p=0.006) were identified as independent risk factors of the presence of LVT. The area under the curve for WMSI was found to be 0.910 (95% CI: 0.852-0.968). A WMSI cut-off of 1.56 identified LVT with 91% sensitivity and 70% specificity (Youden index: 0.617). Conclusion In the primary PCI era, LVT incidence after acute STEMI is still significant. Anterior STEMI, the number of leads with pathological Q waves detected at discharge, WMSI, aneurysm formation, and low EF are independent risk factors for LVT. Among these risk factors, the variable with the highest diagnostic power is WMSI.

Usefulness of contrast echocardiography for detection of left ventricular thrombus in a real-world population with acute anterior myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction The treatment of ST-elevation myocardial infarction (STEMI) has considerably changed in recent years, with early, mainly transcatheter reperfusion therapy improving survival. However, left ventricular thrombus (LVT) is still reported as a relatively common complication especially in anterior STEMI. Two-dimensional transthoracic echocardiography (TTE) is the most commonly used diagnostic modality in this setting due to its wide availability and low cost but can lead to misdiagnoses. The use of ultrasound contrast agents has dramatically improved the visualization of cardiac chambers and thus detection of LVT. Purpose The purpose of this study was to assess the value of contrast echocardiography (CE) for the detection of apical LVT in a real-world population of patients with acute anterior myocardial infarction (MI) in the modern era. Methods The population of this prospective study consisted of consecutive patients presenting within a year with acute anterior MI in a tertiary hospital with capability of primary percutaneous coronary intervention (PCI). Patients with confirmed COVID-19 infection and/or current use of anticoagulant medication were excluded from the study. All patients underwent TTE without and with contrast within 7 days post-MI by an experienced cardiologist. CE was considered the reference standard. Results A total of 102 patients (mean age 61±13 years, 19% female) with anterior STEMI were prospectively recruited in our study. Ninety-eight patients underwent primary PCI, 3 patients underwent rescue PCI after unsuccessful thrombolysis, 1 patient underwent surgical revascularization. Two patients did not receive contrast agent (1 due to known hypersensitivity to contrast agent and 1 due to cardiogenic shock). Mean ejection fraction (EF) was 46% ± 10% in total population and was significantly lower in patients with LVT (42% ± 7% vs 47% ± 10%, p = 0.025). The incidence of confirmed LVT by CE was 28% (28/100) within 7 days post-MI. In total, 8 out of 28 LVT cases (28.5%) would have been missed using TTE without contrast within 7 days post-MI (sensitivity 71%, specificity 100%, positive predictive value 100% and negative predictive value 90%). Example of missed LVT on TTE without and with contrast (left and right panel respectively) is shown in Figure 1. Conclusions LVT is not uncommon after anterior STEMI in the modern era of primary PCI. LVT would have been missed in a significant proportion of patients with anterior STEMI if CE was not used, depriving these patients from the option of early anticoagulation treatment.

VALIDITY OF MEHRAN RISK SCORE FOR PREDICTING CONTRAST INDUCED NEPHROPATHY IN MODERN PRIMARY PERCUTANEOUS CORONARY INTERVENTIONS ERA

Objectives: Contrast induced nephropathy (CIN) is a common complication and found to be associated with increased morbidity and mortality after primary percutaneous coronary intervention (PCI). The objective of this study was to validate the Mehran Risk Score (MRS) for the risk stratification of CIN in patients undergone primary PCI. Methodology: A cohort of consecutive patients undergone primary PCI at a tertiary care cardiac center were included for this study. Patients in Killip class IV at presentation, patents history of any PCI, and chronic kidney diseases were excluded from this study. MRS was calculated at baseline and post procedure serum creatinine level increase of either 25% or 0.5 mg/dL was taken as CIN. Results: A total of 547 patients were included, of which 79.3%(434) were male. CIN after primary PCI was observed in 62(11.3%) patients. The area under the curve (AUC) for the MRS was 0.712 [0.641 to 0.783]. Cut-off value of ≥6.5 had sensitivity of 61.3% [48.1%-73.4%] with positive predictive value of 21.2% [17.5%-25.6%] and specificity of 70.9% [66.7%-74.9%] with negative predictive value of 93.5% [91.3%-95.2%]. MRS ≥6.5 was found to be an independent predictor on multivariable analysis with adjusted odds ratios (OR) of 3.86 [2.23-6.68] along with multi-vessel diseases with OR of 2.31 [1.27-4.19]. Conclusion: MRS has shown to have a good discriminating power. However low positive predictive value of the optimal cutoff value of ≥6.5 for prediction of CIN suggests need of modification to the MRS to improve its clinical utility in the modern era of primary PCI.

Role of renin–angiotensin system antagonists on long-term mortality post-percutaneous coronary intervention in reduced and preserved ejection fraction

AimsThe use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II-receptor blockers (ARBs) post-myocardial infarction (MI) is supported by evidence based on trials performed in the thrombolysis era. This was prior to primary percutaneous coronary intervention (PCI) being routine practice, and with little direct evidence for the use of these medications in patients with preserved left ventricular (LV) function. This study sought to determine whether there is an association between ACEi/ARB use after PCI for acute coronary syndrome (ACS) and long-term all-cause mortality, with a particular focus on patients with preserved LV function.MethodsThis multicentre, observational study evaluated prospectively collected data of 21,388 patients (> 18 years old) that underwent PCI for NSTEMI and STEMI between 2005 and 2018, and were alive at 30 day follow-up.ResultsIn total, 83.8% of patients were using ACEi/ARBs. Kaplan–Meier analysis demonstrated ACEi/ARB use was associated with a significantly lower mortality in the entire cohort (15.0 vs. 22.7%; p < 0.001) with a mean follow-up of 5.58 years; and independently associated with 24% lower mortality by Cox proportional hazards modelling (HR 0.76, CI 0.67–0.85, p < 0.001). ACEi/ARB therapy was also associated with significantly lower mortality in patients with reduced or preserved LV function, with greater survival benefit with worse LV dysfunction.ConclusionACEi/ARB therapy post-PCI is associated with significantly lower long-term mortality in patients with reduced and preserved LV function. These findings provide contemporary evidence for using these agents in the current era of routine primary PCI, including those with preserved EF.Graphical abstract

Clinical impact of complete atrioventricular block in patients with ST-segment elevation myocardial infarction.

Complete atrioventricular block (CAVB) is a common complication of ST‐segment elevation myocardial infarction (STEMI). Although STEMI patients complicated with CAVB had a higher mortality in the thrombolytic era, little is known about the impact of CAVB on STEMI patients who underwent primary percutaneous coronary intervention (PCI). The study aimed at evaluating the clinical impact of CAVB on STEMI patients in the primary PCI era. We consecutively enrolled 1295 STEMI patients undergoing primary PCI within 24 hours from onset. Patients were divided into two groups according to the infarct location: anterior STEMI (n = 640) and nonanterior STEMI (n = 655). The outcomes were all‐cause death and major adverse cardiocerebrovascular events (MACCE) with a median follow‐up period of 3.8 (1.7–6.6) years. Eighty‐one patients (6.3%) developed CAVB. The incidence of CAVB was lower in anterior STEMI patients than in nonanterior STEMI (1.7% vs 10.7%, p < .05). Anterior STEMI patients with CAVB had a higher incidence of all‐cause deaths (82% vs 20%, p < .05) and MACCE (82% vs 25%, p < .05) than those without CAVB. Although higher incidence of all‐cause deaths was found more in nonanterior STEMI patients with CAVB compared with those without CAVB (30% vs 18%, p < .05), there was no significant difference in the incidence of MACCE (24% vs 19%). Multivariate analysis showed that CAVB was an independent predictor for all‐cause mortality and MACCE in anterior STEMI patients, but not in nonanterior STEMI. CAVB is rare in anterior STEMI patients, but remains a poor prognostic complication even in the primary PCI era.

P1322 Role of echocardiography in the assessment of mechanical complications of acute myocardial infarction: case report series

Abstract INTRODUCTION The incidence of the mechanical complications of acute myocardial infarction (AMI) has noticeably decreased throughout the world after the era of primary percutaneous coronary intervention (PCI); nonetheless, when they present, the mortality rate continues being high, requiring for their diagnosis an adequate clinical suspicion, followed by intensive care therapy and in most cases, surgical treatment. In the current report we present 4 cases of mechanical complications using transthoracic echocardiography (TTE) as diagnostic tool: a ventricular septal defect, a papillary muscle rupture, a left ventricular (LV) free wall rupture and a ventricular aneurysm. PATIENT 1: A 71-year-old male who presented with inferior AMI and no reperfusion therapy, complicated with transitory AV block, ventricular fibrillation and severe mitral regurgitation secondary to posteromedial papillary muscle rupture (Panel A). He followed surgery with biological mitral valve replacement and PCI of the right coronary artery (RCA). PATIENT 2: A 71-year-old male who presented with anterior AMI and no reperfusion therapy, suddenly showed signs of cardiogenic shock. The TTE demonstrated pericardial effusion associated with an image of thrombus fixed to the antero-apical wall of the LV of 21 mm in dimension, apical segments akinesia and left ventricular ejection fraction (LVEF) of 40% (Panel B). These findings concluded LV free wall rupture, that required urgent surgical repair of the apical region with sphacelated myocardium. PATIENT 3: A68-year-old male, with history of hospitalization 2 months prior for an event of acute coronary syndrome. Admitted again for chest pain, with a TTE that demonstrated a ventricular septal defect associated with intramyocardial dissection, apical thrombus of 17x11 mm in dimension, apical dyskinesis and LVEF of 30% (Panel C). Coronary angiography documented critical obstruction of proximal left anterior descending coronary artery (LAD) and chronic total occlusion of the RCA. He was taken to surgical repair of the defect and coronary artery bypass (CABG). PATIENT 4: A 77-year-old male, with a history of PCI in 2009 (unknown coronary vessel), presented with inferior AMI and no reperfusion therapy. TTE demonstrated an aneurysm in the basal inferior segment of 55x44 mm in dimension, partially thrombosed, with a neck of 23 mm, severe mitral regurgitation and LVEF of 45% (Panel D). Coronary angiography documented multivessel disease with unsuitable coronary anatomy for CABG. CONCLUSIONS The incidence of AMI mechanical complications has decreased noticeably to less than 1% in the era of primary PCI. These include free wall rupture (0.17%), papillary muscle rupture (0.26%) and LV free wall rupture (0.17%). Immediate echocardiographic assessment is needed when clinical findings suggest such complications; urgent treatment is fundamental to improve short term prognosis. Abstract P1322 Figure. Bidimensional TTE images.

Uticaj srčane insuficijencije kao komplikacije akutnog infarkta miokarda na jednogodišnji mortalitet kod bolesnika lečenih primarnom perkutanom koronarnom intervencijom

Introduction: Cardiac insufficiency is the most common and most severe complication of patients with acute ST segment elevation myocardial infarction (STEMI). So far, there has been little data on the incidence and prognosis of cardiac insufficiency in patients with STEMI in primary percutaneous coronary intervention (PCI) era. Aim: The aim of this investigation is to determine the incidence and impact of cardiac insufficiency on one-year mortality in patients with STEMI treated with primary PCI method. Material and methods: Data on consecutive patients with STEMI was analyzed who were treated with primary PCI in the Coronary Care Unit of the Emergency Center in Belgrade, due to acute STEMI. The assessment of cardiac insufficiency was done according to the Killip classification. The primary outcome of the study was one-year mortality. Results: Out of 700 consecutive patients with STEMI treated with primary PCI, cardiac insufficiency occurred in 160 patients (22.9%). One-year mortality in patients with heart failure was significantly higher than in patients who did not develop this complication (34.4% versus 5.4%; p < 0.001). Using the multivariate Cox regression analysis, independent predictors of one-year mortality were isolated. Cardiac insufficiency was the strongest predictor of mortality. Patients with cardiac insufficiency were at the seven-fold higher risk of fatal outcome compared to patients without heart failure (HR 7.16; 95% CI 4.47-11.48; p < 0.001). Conclusion: Cardiac insufficiency is a frequent complication of acute ST segment elevation myocardial infarction in the primary PCI era. The occurrence of cardiac insufficiency as a complication of STEMI is associated with a seven-fold higher risk for one-year mortality.

The prognostic effect of left ventricular thrombus formation after acute myocardial infarction in the contemporary era of primary percutaneous coronary intervention: A meta-analysis

Backgrounds: The prognosis and management of left ventricular thrombus (LVT) following acute myocardial infarction (AMI) have not been well evaluated since the advent of primary percutaneous coronary intervention (PCI). We therefore conducted a meta-analysis to assess the prognostic effect of LVT after AMI in primary PCI era and investigate the impact of triple therapy on outcomes. Methods: We searched MEDLINE, EMBASE and the Cochrane Library for studies conducted in primary PCI era up to 29 March 2019, compering the incidence of embolic events and mortality after AMI between LVT patients and Non-LVT patients. Random-effect models were used. Subgroup analysis was done by comparing triple therapy treated LVT group with Non-LVT group. Result: A total of 12 studies were included. LVT was associated with increased risk of embolic events and long-term mortality (RR 3.97, 95%CI 2.68–5.89, P < 0.0001; RR 2.34, 95%CI 1.38–3.96, P = 0.002). Subgroup analysis was also done by comparing triple therapy treated LVT group with Non-LVT group. Despite a downward tendency was observed, the embolic risk of triple therapy subgroup was higher than non-LVT group (RR 2.79, 95%CI 1.32–5.91, P = 0.007). Triple therapy subgroup had a similar mortality rate compared with non-LVT group (RR 0.93, 95%CI 0.34–2.52, P = 0.88). Conclusion: In primary PCI era, LVT formation after AMI indicated a fourfold increased embolic risk and twofold long-term mortality rate. Triple therapy may be a safe way to improve the outcomes, but still need to be confirmed by future trials.

Mortality pattern and cause of death in a long-term follow-up of patients with STEMI treated with primary PCI

ObjectiveWe aimed to assess the pattern of mortality and cause of death in a cohort of patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).MethodsConsecutive...

Acute kidney injury among ST elevation myocardial infarction patients treated by primary percutaneous coronary intervention: a multifactorial entity.

Acute kidney injury is a frequent complication among ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), and is associated with adverse outcomes. While contrast nephropathy is considered the most important reason for worsening of renal function, recent data have suggested the role of other important factors among this specific patient population. In the present review, we examine the various factors leading to renal impairment in STEMI patients and place the findings in the context of this specific patient population in the era of primary PCI. These factors include contrast nephropathy, time to coronary reperfusion, cardiac pump function and hemodynamics as well as various inflammatory and metabolic markers.

Differential Clinical Implications of High-Degree Atrioventricular Block Complicating ST-Segment Elevation Myocardial Infarction according to the Location of Infarction in the Era of Primary Percutaneous Coronary Intervention.

Background and ObjectivesThe clinical implication of high-degree (second- and third-degree) atrioventricular block (HAVB) complicating ST-segment elevation myocardial infarction (STEMI) is ripe for investigation in this era of primary percutaneous coronary intervention (PCI). We sought to address the incidence, predictors and prognosis of HAVB according to the location of infarct in STEMI patients treated with primary PCI.Subjects and MethodsA total of 16536 STEMI patients (anterior infarction: n=9354, inferior infarction: n=7692) treated with primary PCI were enrolled from a multicenter registry. We compared in-hospital mortality between patients with HAVB and those without HAVB with anterior or inferior infarction, separately. Multivariate analyses were performed to unearth predictors of HAVB and to identify whether HAVB is independently associated with in-hospital mortality.ResultsSTEMI patients with HAVB showed higher in-hospital mortality than those without HAVB in both anterior (hazard ratio [HR]=9.821, 95% confidence interval [CI]: 4.946-19.503, p<0.001) and inferior infarction (HR=2.819, 95% CI: 2.076-3.827, p<0.001). In multivariate analyses, HAVB was associated with increased in-hospital mortality in anterior myocardial infarction (HR=19.264, 95% CI: 5.804-63.936, p<0.001). However, HAVB in inferior infarction was not an independent predictor of increased in-hospital mortality (HR=1.014, 95% CI: 0.547-1.985, p=0.901).ConclusionIn this era of primary PCI, the prognostic impact of HAVB is different according to the location of infarction. Because of recent improvements in reperfusion strategy, the negative prognostic impact of HAVB in inferior STEMI is no longer prominent.

β-Blocker Therapy in the Era of Primary Percutaneous Intervention for ST Elevation Myocardial Infarction

Objectives: With the present therapeutic advances in the era of primary percutaneous coronary intervention (PCI), the role of β-blockers in ST elevation acute myocardial infarction (STEMI) has remained contentious. Methods: We analyzed the data and clinical outcomes of 901 STEMI patients who had undergone primary PCI. We classified the patients into β-blocker (n = 598) and non-β-blocker groups (n = 303). Results: The cumulative incidence of all-cause death was 10.0% in the β-blocker group and 25.4% in the non-β-blocker group (p < 0.001). The incidence of major adverse cardiac events (MACE) was 22.1% in the β-blocker group and 34.3% in the non-β-blocker group (p < 0.001). The relative hazard ratio (HR) of β-blockers for all-cause death and MACE with low left ventricle ejection fraction (LVEF; <50%) was 0.55 [95% confidence interval (CI) 0.35-0.86, p = 0.009] and 0.75 (95% CI 0.51-1.09, p = 0.125), respectively. In patients with normal LVEF (≥50%), the relative HR of β-blockers for death and MACE were 0.50 (95% CI 0.29-0.88, p = 0.016) and 0.75 (95% CI 0.51-1.12, p = 0.162), respectively. After propensity score matching of the difference of the baseline characteristics, the Kaplan-Meier survival curve demonstrated lower mortality in the β-blocker group than in the non-β-blocker group with both low LVEF and normal LVEF (p = 0.02 and p = 0.001, respectively). Conclusions: β-Blockers have beneficial clinical outcomes in the era of primary PCI for STEMI, regardless of the LVEF.

Correlates for mortality in patients presented with acute myocardial infarct complicated by cardiogenic shock

This study aimed to explore the correlates for mortality in patients treated with both primary percutaneous coronary intervention (PCI) and intra-aortic balloon pump counter-pulsation (IABP). Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with high mortality rates. From a cohort of patients with AMI, treated with both primary PCI and IABP and who met strict definitions for CS to identify correlates associated with mortality, the study compared patients who died in-hospital to those who survived to discharge. A cohort of 93 patients met the inclusion/exclusion criteria. Of them, 66.7% were male, and the average age was 64.96±13.06years. The overall in-hospital mortality rate for this cohort was 33%. The baseline characteristics were balanced save for older average age and left ventricular ejection fraction in those who died (p=0.049 and p=0.014, respectively). Insertion of IABP pre-PCI and cardiac arrest at the catheterization lab were more frequent in those who died (p=0.027 and p=0.008, respectively). The insertion of IABP pre-PCI, cardiac arrest at the cath lab, and lower ejection fraction were correlated with in-hospital mortality (ORs 2.68, 5.93, and 0.02, respectively). In the era of primary PCI and IABP as standard of care in AMI complicated by CS, patients with low EF, those who necessitate IABP insertion pre-PCI, and those who necessitate cardiopulmonary resuscitation during PCI are at higher risk for in-hospital mortality and should be considered for more robust hemodynamic support devices with an attempt to improve their prognosis.

Clinical manifestation of early phase left ventricular rupture complicating acute myocardial infarction in the primary PCI era

ObjectiveBefore reperfusion therapy was introduced, the incidence of ventricular septal and left ventricular free wall rupture complicating acute myocardial infarction (AMI) was 1–3%. Primary percutaneous coronary intervention (PCI) was expected to reduce the incidence of such mechanical complications. MethodsWe retrospectively analysed 1290 AMI patients referred to our institute from January 2005 to January 2011. Primary PCI was done in 1002 cases of the study patients (77.7%). ResultsVentricular septal rupture (VSR) occurred in 19 cases (1.5%) and left ventricular free wall rupture (LVFR) in 17 cases (1.3%). Mean observation periods from onset to VSR and LVFR were 2.6 days. We demonstrated that risk factors for LV rupture were advanced age, female sex, absence of history of angina or myocardial infarction, lack of previous PCI, and absence of previous hypertension. Coronary angiography revealed that the culprit lesions of the left anterior descending artery or single vessel disease were the risk factors for LV rupture. Furthermore, in the present observation, 9 patients (47.4%) with VSR and 8 patients (47.1%) with LVFR developed LV rupture within 24h after symptoms onset (early rupture). The early rupture demonstrated extremely poor outcome compared with late rupture (in-hospital mortality was 88.2% in early rupture and 63.1% in late rupture). ConclusionEven in the patients’ cohort with higher prevalence of primary PCI, LV rupture cases were not decreased in contrast to our expectations. More attention should be paid to early LV rupture cases within 24h from symptom onset in those cases.

035 INCIDENCE AND PREDICTORS OF LEFT VENTRICULAR MURAL THROMBUS AFTER ST-ELEVATION MYOCARDIAL INFARCTION IN THE CONTEMPORARY ERA OF PRIMARY PCI

Background In patients presenting with ST elevation myocardial infarction (STEMI), early and aggressive reperfusion therapy increases myocardial salvage and improves survival. Left ventricular mural thrombus (LVT) is more likely to occur after full thickness infarction. The aim of this study was to define the incidence of LVT and its predictors in the contemporary era of effective primary percutaneous coronary intervention (PCI). Methods We retrospectively analysed 1220 patients with STEMI admitted directly to our centre for primary PCI (1 January 2009–31 August 2012). Patients received dual antiplatelet and anticoagulant therapy at the operator9s discretion (unfractionated heparin, bivalirudin and/or abciximab). A transthoracic echocardiogram (TTE) was performed in all cases prior to discharge. Echo-contrast was used when appropriate. Results LVT was detected by TTE in 41 patients (3.9%). There were no significant differences in baseline demographic in patients with and without LVT. LV systolic function, an anterior location of infarction and apical akinesis all predicted LVT. Univariate analysis also demonstrated a relationship between LVT and ejection fraction (EF). Mean EF in patients with LVT was 34% (95% CI 31.7 to 36.6); without LVT EF was 48% (95% CI 47% to 48.6%) p Conclusions In the contemporary era of primary PCI, the incidence of LVT in patients with STEMI is significantly lower than the previous literature suggests. Formation of LVT is predicted by anterior location of MI, reduced LV systolic function and the presence of an apical akinetic segment.

The role of fibrinolysis in the era of primary percutaneous coronary intervention

Most cases of acute myocardial infarction are caused by disruption of an atherosclerotic plaque followed by coronary thrombosis (1). In ST-elevation myocardial infarction (STEMI), the thrombus occludes a major epicardial coronary artery. Such an occlusion is an emergency situation, and flow in the occluded vessel should be restored as fast as possible. Various strategies for reperfusion are available, namely pharmacological reperfusion by fibrinolytic therapy or mechanical reperfusion by primary percutaneous coronary intervention (PCI). Primary PCI has been established as the preferred reperfusion strategy today (2). The percentage of STEMI-patients treated with primary PCI is steadily increasing, and in most European countries, primary PCI is the leading reperfusion strategy (3). In this era of primary PCI, one might wonder whether fibrinolytic therapy should remain a part of the therapeutic armamentarium of acute STEMI. In this overview, we will briefly present the evidence for the benefit of fibrinolytic therapy in STEMI and discuss the role of fibrinolysis in this era of primary PCI. Benefit of fibrinolytic therapy

Sudden cardiac death and left ventricular ejection fraction during long-term follow-up after acute myocardial infarction in the primary percutaneous coronary intervention era: results from the HIJAMI-II registry

Objective:To determine the incidence of sudden cardiac death (SCD) according to left ventricular ejection fraction (LVEF) in survivors of myocardial infarction (MI) in the primary percutaneous coronary intervention (PCI) era.Design:A...

Abstract 2832: Which Cardiac Marker is Most Useful to Predict Final Infarct Size and Cardiac Function Following Primary Percutaneous Coronary Intervention For Acute Myocardial Infarction?

Background: Assessment of cardiac biomarker release has been traditionally used to estimate the size of myocardial damage after acute myocardial infarction (AMI). However, the significance of cardiac biomarkers in the setting of primary percutaneous coronary intervention (PCI) has not been systematically studied in a large patient cohort. We evaluated the usefulness of serial and single time-point measures of various cardiac biomarkers (creatine kinase (CK), CK-MB, troponin T and I) in predicting infarct size and left ventricular ejection fraction (LVEF) after primary PCI. Methods: EVOLVE (Evaluation of MCC-135 for Left Ventricular Salvage in AMI) was a randomized double-blind, placebo-controlled trial comparing the efficacy of intracellular calcium modulator as an adjunct to primary PCI in patients with first large AMI. Levels of cardiac biomarkers (CK, CK-MB mass, troponin T and I) were determined in 375 patients at baseline before PCI and 2, 4, 12, 24, 48 and 72 hours thereafter. Single photon emission computed tomography imaging was performed to measure infarct size and LVEF on day 5. Results: Area under curve and peak concentrations of all cardiac markers: CK, CK-MB mass, troponin T and troponin I were significantly correlated with myocardial infarct size and LVEF determined on day 5 (Spearman correlation, all P&lt; 0.001; Table ). Troponin I, however provided the best predictor and a single measure at 72 hr was a strong indicator of both infarct size and LVEF. Using receiver operator characteristics curve, troponin I cutoff value of &gt;55 pg/mL at 72 hr has 90% sensitivity and 70% specificity for detection of large infarct size≥10% ( c =0.88; P&lt; 0.001). Conclusions: Plasma levels of CK, CK-MB, troponin T and troponin I remain useful predictors of infarct size and cardiac function in the era of primary PCI for AMI. A single measurement of circulating troponin I at 72 hours can provide an effective and convenient indicator of infarct size and LVEF in clinical practice. Correlation of cardiac biomarkers with Day 5 SPECT determined infarct size and LVEF