In-hospital Recurrent Ischemia Research Articles

VARIOUS DELAYS AND ITS DETERMINANTS IN THE TIMELINE OF ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Objectives: To assess the various delays in the timeline of STEMI, its determinants, and impact on in-hospital outcomes.
 Methodology: In this study we included STEMI patients who were either presented late to ER or procedure was delayed. Pre-hospital delay was defied as chest pain (CP) to ER arrival time ≥120 minutes and hospital delay was defined as ER to procedure time ≥90 minutes. Reasons for pre-hospital and hospital delays and in-hospital complications and outcomes were recorded.
 Results: A total of 103 patients, 72.8%(75) male, with mean age of 54.75±11.8 years were enrolled. Median duration between CP and ER arrival 240[420-144.5] minutes with ≥120 minutes for 89.3%(92). Procedure was performed in 120[180-60] minutes of ER arrival with ≥90 minutes for 61.2% (63). Pre-hospital delay was caused by unawareness of symptoms (53.3%) followed by unavailability of transportation (29.3%), while, hospital delayed was caused by unavailability of resources (69.8%). Pre-hospital delay of ≥360 minutes was associated with higher rate of LV thrombus, 21.4% vs. 1.3%; p<0.001, and in-hospital re-current ischemia, 32.1% vs. 12%; p=0.017.
 Conclusions: In this study we observed that the most common causes of pre-hospital delay in our population are unawareness of symptomology and unavailability of transportation, while, the major cause of hospital delay was unavailability resources. Pre-hospital delay was associated with significantly higher rate of LV thrombus and in-hospital re-current ischemia.

VARIOUS DELAYS AND ITS DETERMINANTS IN THE TIMELINE OF ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Objectives: To assess the various delays in the timeline of STEMI, its determinants, and impact on in-hospital outcomes. Methodology: In this study we included STEMI patients who were either presented late to ER or procedure was delayed. Pre-hospital delay was defied as chest pain (CP) to ER arrival time ≥120 minutes and hospital delay was defined as ER to procedure time ≥90 minutes. Reasons for pre-hospital and hospital delays and in-hospital complications and outcomes were recorded. Results: A total of 103 patients, 72.8%(75) male, with mean age of 54.75±11.8 years were enrolled. Median duration between CP and ER arrival 240[420-144.5] minutes with ≥120 minutes for 89.3%(92). Procedure was performed in 120[180-60] minutes of ER arrival with ≥90 minutes for 61.2% (63). Pre-hospital delay was caused by unawareness of symptoms (53.3%) followed by unavailability of transportation (29.3%), while, hospital delayed was caused by unavailability of resources (69.8%). Pre-hospital delay of ≥360 minutes was associated with higher rate of LV thrombus, 21.4% vs. 1.3%; p<0.001, and in-hospital re-current ischemia, 32.1% vs. 12%; p=0.017. Conclusions: In this study we observed that the most common causes of pre-hospital delay in our population are unawareness of symptomology and unavailability of transportation, while, the major cause of hospital delay was unavailability resources. Pre-hospital delay was associated with significantly higher rate of LV thrombus and in-hospital re-current ischemia.

Impact of in-hospital recurrent ischemia event: Findings from Gulf RACE-2

Impact of in-hospital recurrent ischemia event: Findings from Gulf RACE-2

Impact of in-hospital recurrent ischemia event: findings from GULF RACE-2

Background Little in the literature is known about the long term outcome of patients with acute coronary syndrome (ACS) and in-hospital recurrent ischemic event. Accordingly; our objectives were to determine the baseline characteristics of patients, the predictors, and the long term outcome of patients with recurrent ischemia. Methods The population compromised 7930 enrolled in the second Gulf Registry of Acute Coronary Events (Gulf RACE-2). Results Out of the 7930 ACS patients, 172 (2.2%) had Re-MI during their hospital stay. Patients with Re-MI were more likely to be older (mean age 59.12 ± 13.5 vs. 56.8 ± 12.4, P = 0.016), had significantly higher rate of prior history of angina (48% vs. 38.2%, P = 0.006), and hyperlipidemia (45.2% vs. 37.3%, P = 0.027) than patients without Re-MI. On admission patients with Re-MI had significantly higher HR, lower systolic BP, Killip class 4 and high GRACE risk score than those without Re-MI (27.3% vs. 17.6%), (11% vs. 4.8%), (8.1% vs. 3.2%), and (31.8% vs. 21.5%, P Conclusion Recognizing patients at high risk of Re-MI is important as modifying the risk factors, and managing the patient aggressively may reduce the incidence of such events and the associated morbidity and mortality.

Impedance Cardiography and Heart Rate Variability for Long-Term Cardiovascular Outcome Prediction After Myocardial Infarction

The objective of our study was to evaluate the predictive power of a combined assessment of heart rate variability (HRV) and impedance cardiography (ICG) measures in order to better identify the patients at risk of serious adverse events after ST-segment elevation myocardial infarction (STEMI): all-cause or cardiac mortality (primary outcomes) and in-hospital recurrent ischemia, recurrent nonfatal MI, and need for revascularization (secondary outcomes). A total of 213 study patients underwent 24-hour electrocardiogram (used for HRV analysis) and thoracic bioimpedance monitoring (used for calculation of hemodynamic measures) immediately after admission. The patients were examined on discharge and contacted after 1 and 5 years. Cox regression analysis was used to determine the predictors of selected outcomes. RESULTS. The standard deviation of all normal-to-normal intervals (SDNN) and cardiac power output (CPO) were found to be the significant determinants of 5-year all-cause mortality (SDNN ≤ 100.42 ms and CPO ≤ 1.43 W vs. others: hazard ratio [HR], 11.1; 95% CI, 4.48-27.51; P<0.001). The standard deviation of the averages of NN intervals (SDANN) and CPO were the significant predictors of 5-year cardiac mortality (SDANN ≤ 85.41 ms and CPO ≤ 1.43 W vs. others: HR, 11.05; 95% CI, 3.75-32.56; P<0.001). None of the ICG measures was significant in predicting any secondary outcome. The patients with both impaired autonomic heart regulation and systolic function demonstrated by decreased heart rate variability and impedance hemodynamic measures were found to be at greater risk of all-cause and cardiac death within a 5-year period after STEMI. An integrated analysis of electrocardiogram and impedance cardiogram helps estimate patient's risk of adverse outcomes after STEMI.

Characteristics, Management, and In-Hospital Outcomes of Diabetic Patients with Acute Coronary Syndrome in the United Arab Emirates

We describe the baseline characteristics, management, and in-hospital outcomes of patients in the United Arab Emirates (UAE) with DM admitted with an acute coronary syndrome (ACS) and assess the influence of DM on in-hospital mortality. Data was analyzed from 1697 patients admitted to various hospitals in the UAE with a diagnosis of ACS in 2007 as part of the 1st Gulf RACE (Registry of Acute Coronary Events). Of 1697 patients enrolled, 668 (39.4%) were diabetics. Compared to patients without DM, diabetic patients were more likely to have a past history of coronary artery disease (49.1% versus 30.1%, P < 0.001), hypertension (67.2% versus 36%, P < 0.001), and prior revascularization (21% versus 11.4%, P < 0.001). They experienced more in-hospital recurrent ischemia (8.5% versus 5.1%; P = 0.004) and heart failure (20% versus 10%; P < 0.001). The mortality rate was 2.7% for diabetics and 1.6% for nondiabetics (P = 0.105). After age adjustment, in-hospital mortality increased by 3.5% per year of age (P = 0.016). This mortality was significantly higher in females than in males (P = 0.04). ACS patients with DM have different clinical characteristics and appear to have poorer outcomes.

Treatment and Outcomes of First Troponin-Negative Non–ST-Segment Elevation Myocardial Infarction

Little is known about non-ST-segment elevation myocardial infarction (MI) in patients with an initial negative troponin finding. The aim of this study was to determine in post hoc analysis of a large regional medical center presenting clinical characteristics, treatment differences, and in-hospital and 6-month outcomes of first troponin-negative MI (FTNMI). In this study, 659 of 1,855 consecutive patients with non-ST-segment elevation MI (35.5%) were classified as having FTNMI. In-hospital cardiac catheterization rates were similar between the 2 groups (70.1% vs 71.5%, p = 0.53) In hospital, patients with FTNMI were less likely to receive statins (48.9% vs 59.9%, p <0.001). On discharge, patients with FTNMI were less likely to be on clopidogrel (53.1% vs 59.0%, p = 0.019) and statins (67.7% vs 75.2%, p <0.001). At 6-month follow-up, patients with FTNMI were less likely to be on clopidogrel (43.5% vs 55.2%, p = 0.01) In-hospital recurrent ischemia was 2 times as common in FTNMI (20.1% vs 11.5%, p <0.001). There were no differences, however, in congestive heart failure, cardiogenic shock, cardiac arrest, stroke, or death in hospital. At 6 months, patients with FTNMI were 2 times as likely to have had recurrent MI (12.0% vs 6.6%, p <0.001). Combined end points of death at 6 months, MI, stroke, and rehospitalization were higher for FTNMI (47.7% vs 40.9%, p = 0.017); however, this was due to higher rates of recurrent MI. In conclusion, patients with FTNMI received less aggressive pharmacotherapy and were 2 times as likely to have recurrent MI at 6 months. FTNMI is common and represents a clinical entity that should be treated more aggressively.

A comparison of systematic stenting and conventional balloon angioplasty during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction

OBJECTIVESIn a multicenter, randomized trial, systematic stenting using the Wiktor stent was compared to conventional balloon angioplasty with provisional stenting for the treatment of acute myocardial infarction (AMI).BACKGROUNDPrimary angioplasty in AMI is limited by in-hospital recurrent ischemia and a high restenosis rate.METHODSA total of 211 patients with AMI <12 h from symptom onset, with an occluded native coronary artery, were randomly assigned to systematic stenting (n = 101) or balloon angioplasty (n = 110). The primary end point was the binary six-month restenosis rate determined by core laboratory quantitative angiographic analysis.RESULTSAngiographic success (Thrombolysis in Myocardial Infarction [TIMI] flow grade 3 and residual diameter stenosis <50%) was achieved in 86% of the patients in the stent group and in 82.7% of those in the balloon angioplasty group (p = 0.5). Compared with the 3% cross-over in the stent group, cross-over to stenting was required in 36.4% of patients in the balloon angioplasty group (p = 0.0001). Six-month binary restenosis (≥50% residual stenosis) rates were 25.3% in the stent group and 39.6% in the balloon angioplasty group (p = 0.04). At six months, the event-free survival rates were 81.2% in the stent group and 72.7% in the balloon angioplasty group (p = 0.14), and the repeat revascularization rates were 16.8% and 26.4%, respectively (p = 0.1). At one year, the event-free survival rates were 80.2% in the stent group and 71.8% in the balloon angioplasty group (p = 0.16), and the repeat revascularization rates were 17.8% and 28.2%, respectively (p = 0.1).CONCLUSIONSIn the setting of primary angioplasty for AMI, as compared with a strategy of conventional balloon angioplasty, systematic stenting using the Wiktor stent results in lower rates of angiographic restenosis.

Long-term clinical events following creatine kinase–myocardial band isoenzyme elevation after successful coronary stenting

OBJECTIVEWe sought to evaluate the impact of intermediate creatine kinase–myocardial band isoenzyme (CK-MB) elevation on late clinical outcomes in patients undergoing successful stent implantation in native coronary arteries.BACKGROUNDElevations of CK-MB after percutaneous coronary interventions are frequent. An association between high level of CK-MB elevation (>5 times normal) and late mortality after balloon and new device angioplasty has been reported previously. However, significant controversy remains on the long-term clinical importance of lower CK-MB elevations (one to five times normal) after percutaneous coronary revascularization. Moreover, the incidence and prognostic importance of cardiac enzyme elevation after coronary stenting have not been well established.METHODSProspectively collected data from 900 consecutive patients (1,213 lesions) undergoing successful stenting in native vessels were analyzed. Based on the CK-MB levels after coronary stenting, patients were classified into three groups: normal group 1 (n = 585), elevation of >1 to 5 times normal group 2 (n = 238) and elevation of >5 times normal group 3 (n = 77).RESULTSPatients in group 3 had more in-hospital recurrent ischemia (p = 0.001) and pulmonary edema (p = 0.01) than patients in groups 1 and 2. Long-term clinical end points were similar between groups 1 and 2. However, patients in group 3 had an increased incidence of late mortality compared with patients in groups 2 and 1 (6.9%, 1.2% and 1.7%, respectively, p = 0.01). Multivariate analysis showed that patients with CK-MB >5 times normal after coronary stenting had an increased risk of major adverse clinical events (relative risk: 1.70, p < 0.05) and death (relative risk: 3.25, p < 0.05) that was not observed in patients with lower CK-MB rise.CONCLUSIONSPatients with CK-MB elevation >5 times normal had higher late mortality and more unfavorable event-free survival than those patients with normal or lower CK-MB rise after coronary stenting. While intermediate CK-MB elevation (>1 to 5 times normal) is frequent after coronary stenting (26%), this was not associated with an increased risk of late mortality or major adverse clinical events.

Prospective, Multicenter Study of the Safety and Feasibility of Primary Stenting in Acute Myocardial Infarction: In-Hospital and 30-Day Results of the PAMI Stent Pilot Trial

Objectives. The goals of this study were to examine the safety and feasibility of a routine (primary) stent strategy in acute myocardial infarction (AMI).Background. Limitations of reperfusion by primary percutaneous transluminal coronary angioplasty (PTCA) in AMI include in-hospital recurrent ischemia or reinfarction in 10% to 15% of patients, restenosis in 37% to 49% and late infarct-related artery reocclusion in 9% to 14%. By lowering the residual stenosis and sealing dissection planes created by PTCA, primary stenting may further improve short- and long-term outcomes after mechanical reperfusion.Methods. Three hundred twelve consecutive patients treated with primary PTCA for AMI at nine international centers were prospectively enrolled. After PTCA, stenting was attempted in all eligible lesions (vessel size 3.0 to 4.0 mm; lesion length ≤2 stents; and the absence of giant thrombus burden after PTCA, major side branch jeopardy or excessive proximal tortuosity or calcification). Patients with stents were treated with aspirin, ticlopidine and a 60-h tapering heparin regimen.Results. Stenting was attempted in 240 (77%) of 312 patients, successfully in 236 (98%), with Thrombolysis in Myocardial Infarction grade 3 flow restored in 230 patients (96%). Patients with stents had low rates of in-hospital death (0.8%), reinfarction (1.7%), recurrent ischemia (3.8%) and predischarge target vessel revascularization for ischemia (1.3%). At 30-day follow-up, no additional deaths or reinfarctions occurred among patients with stents, and target vessel revascularization was required in only one additional patient (0.4%).Conclusions. Primary stenting is safe and feasible in the majority of patients with AMI and results in excellent short-term outcomes.

Stent implantation in acute myocardial infarction

Among 138 patients treated with coronary angioplasty during acute myocardial infarction (AMI), 35 (25%) had stent implantation. Mean age was 56 years and 83% were men. Mean onset of chest pain was 6.0 ± 5.3 hours, and previous thrombolytic therapy was given to 10 patients (29%). Infarct location was anterior in 19 (54%), inferior in 14 (40%), and lateral in 2 patients (6%). Thrombolysis In Myocardial Infarction trial flows 0, 1, and 2 were seen in 24 (69%), 6 (17%), and 5 patients (14%), respectively. The culprit vessel was the left anterior descending artery in 18 (51%), right coronary artery in 14 (40%), left circumflex in 2 (6%), and left main coronary artery in 1 patient (3%). Mean vessel diameter was 3.3 ± 0.3 mm. Indications were: primary in 5 (14%), suboptimal result in 8 (23%), nonocclusive dissection in 14 (40%), and occlusive dissection in 8 patients (23%). Angiographic thrombus after initial angioplasty was present in 12 patients (34%). A total of 46 stents were implanted; mean balloon diameter and pressure were 3.4 ± 0.4 mm and 15.5 ± 2.2 atm, respectively. Residual diameter stenosis was 4 ± 7%. There were 2 deaths: sudden in I, and after elective coronary artery bypass grafting in the other; 2 patients (6%) had groin hematomas. Mean hospitalization was 9.9 ± 5.0 days. Repeat angiography revealed no stent occlusion. With initial intravenous heparin for 3 to 7 days, all patients received aspirin and ticlopidine for 1 month. Thus, AMI is not a contraindication for stent implantation. The benefits of stenting are a high success rate, low residual diameter stenosis, and low incidence of in-hospital recurrent ischemia. Reduction in restenosis rate in this setting is likely but remains to be determined.

Coronary thrombi increase PTCA risk. Angioscopy as a clinical tool.

The presence of angiographically identified intracoronary thrombus has been variably associated with complications after coronary angioplasty. Angiography has been shown to be less sensitive than angioscopy for detecting subtle details of intracoronary morphology, such as intracoronary thrombi. The clinical importance of thrombi detectable by angioscopy but not by angiography is not known. Percutaneous coronary angioscopy was performed in 122 patients undergoing conventional coronary balloon angioplasty (PTCA) at six medical centers. Unstable angina was present in 95 patients (78%) and stable angina in 27 (22%). Therapy was not guided by angioscopic findings, and no patient received thrombolytic therapy as an adjunct to angioplasty. Coronary thrombi were identified in 74 target lesions (61%) by angioscopy versus only 24 (20%) by angiography. A major in-hospital complication (death, myocardial infarction, or emergency bypass surgery) occurred in 10 of 74 patients (14%) with angioscopic intracoronary thrombus, compared with only 1 of 48 patients (2%) without thrombi (P = .03). In-hospital recurrent ischemia (recurrent angina, repeat PTCA, or abrupt occlusion) occurred in 19 of 74 patients (26%) with angioscopic intracoronary thrombi versus only 5 of 48 (10%) without thrombi (P = .03). Relative risk analysis demonstrated that angioscopic thrombus was strongly associated with adverse outcomes (either a major complication or a recurrent ischemic event) after PTCA (relative risk, 3.11; 95% CI, 1.28 to 7.60; P = .01) and that angiographic thrombi were not associated with these complications (relative risk, 0.85; 95% CI, 0.36 to 2.00; P = .91). The presence of intracoronary thrombus associated with coronary stenoses is significantly underestimated by angiography. Angioscopic intracoronary thrombi, the majority of which were not detected by angiography, are associated with an increased incidence of adverse outcomes after coronary angioplasty.