Infarct-related Artery In Patients Research Articles

AS-176 Circulating Endothelial Progenitor Cell is Related to Total Occlusion of Infarct-related Artery in Patients with Acute Non-ST Segment Elevation Myocardial Infarction

AS-176 Circulating Endothelial Progenitor Cell is Related to Total Occlusion of Infarct-related Artery in Patients with Acute Non-ST Segment Elevation Myocardial Infarction

Patent coronary artery and myocardial infarction in the era of primary angioplasty: assessment of an old problem in a new setting with data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

The purpose of this study was to evaluate factors that contribute to a patent IRA (infarct - related artery) and the prognostic impact of a patent IRA in patients with ST-elevation myocardial infarction. Using the Swedish angiography and angioplasty registry (SCAAR) we included all patients with STEMI and one-vessel coronary artery disease who underwent primary PCI of the culprit lesion only from May 2005 to December 2007. A patent IRA was found in 1,104 of 3,284 patients. Patients with an occluded IRA had significantly increased 7-day mortality (HR, 3.03, 95% CI 1.68-5.46, P<0.001). The incidence of an occluded IRA increased with higher age, in patients over 80 years of age (OR, 1.23, 95% CI; 0.92-1.64), lower in patients on lipid-lowering drugs (OR, 0.68, 95% CI; 0.54-0.86) and lower in patients pre-treated with heparin (OR 0.71, 95% CI; 0.60-0.83) or GPIIb/IIIa receptor blockade (OR 0.77, 95% CI; 0.61-0.97). Treatment with acetylsalicylic acid or clopidogrel had no effect on IRA patency. IRA patency was associated with a lower 7-day mortality. Older STEMI patients and patients not taking lipid-lowering drugs or pre-treated with heparin or GPIIb/IIIa receptor blockers seem to constitute risk groups for having an occluded IRA.

Relation of homocysteine levels with patency and flow rate of infarct related artery in patients receiving fibrinolytic therapy

Elevated homocysteine levels induce a hypercoagulable state and make the clot more resistant to fibrinolysis. In this prospective observational study, we investigated the influence of homocysteine levels on infarct-related artery (IRA) patency and flow as determined with regard to thrombolysis in myocardial infraction (TIMI) flow grade and corrected TIMI frame count (CTFC). Sixty-one patients who received fibrinolytic therapy for a first ST elevation myocardial infarction (STEMI) within 12 hours of chest pain were included. Coronary angiography was performed according to the Judkins technique within 72 hours after fibrinolytic therapy. Total plasma homocysteine level was determined by the high-performance liquid chromatography method with fluorescence detection. Statistical analysis was performed using Chi-square, Student's t and Pearson correlation tests. Logistic regression analysis was used to determine the predictors of IRA occlusion. Of the 61 patients, 22 (36.1%) had an occluded IRA (group 1), 39 (63.9%) had a patent IRA (group 2). Mean plasma homocysteine levels were found to be significantly higher in the group 1 compared to the group 2 (18.5±9.6 µmol/L vs 14.3±5 µmol/L, p=0.04). In addition, we found a significant positive correlation between CTFC and plasma homocysteine levels (r=0.415; p=0.01). In multiple logistic regression analysis, high levels of plasma homocysteine (OR=1.2; 95% CI 1.1-1.25; p=0.03) and being a non-smoker (OR=5.9; 95% CI 1.1-31.6; p=0.03) were found to be significant independent predictors of having an occluded IRA. There is an inverse relation between plasma homocysteine levels and IRA patency and flow in patients receiving fibrinolytic therapy for STEMI.

Recanalization of a chronic total occlusion in ST-segment elevation myocardial infarction patients: why and when?

Current guidelines recommend that primary percutaneous coronary intervention should be limited to the infarct-related artery in patients with acute myocardial infarction and multivessel disease. However, patients with acute myocardial infarction and concomitant multivessel coronary artery disease have a worse prognosis, mainly due to the presence of a chronic total occlusion (CTO) in a nonculprit lesion. Few studies have addressed the specific issue of CTO treatment in the setting of acute myocardial infarction. We review the currently available literature regarding coronary revascularization of the nonculprit CTO in ST-segment elevation myocardial infarction patients, starting with a clinical case of an infero–postero–lateral ST-segment elevation myocardial infarction in a multivessel coronary artery disease patient with concurrent left anterior descending CTO complicated by hemodynamic instability.

AS-80: Clinical Outcomes of the Routinely Used PercuSurge Device for High-Burden Thrombus Formation in the Infarct-Related Artery in Patients with ST-Segment Elevation Acute Myocardial Infarction: A Single-Center Experience

AS-80: Clinical Outcomes of the Routinely Used PercuSurge Device for High-Burden Thrombus Formation in the Infarct-Related Artery in Patients with ST-Segment Elevation Acute Myocardial Infarction: A Single-Center Experience

The ECG in localizing the culprit lesion in acute inferior myocardial infarction: a plea for lead V4R?

This editorial refers to ‘Distinguishing the right coronary artery from the left circumflex coronary artery as the infarct-related artery in patients undergoing primary percutaneous coronary intervention for acute inferior myocardial infarction’ by N.J. Verouden et al., on page 1517 The electrocardiogram (ECG) is being used for decades as a reliable and inexpensive tool to diagnose acute myocardial infarction in the patient with chest pain. More recently, an emphasis has been made on ECG features that allow better identification of the coronary occlusion site and thereby better estimation of the size of the area at risk, which is important for selection of the preferred type of reperfusion. On average the left anterior descending coronary artery supplies 50% of blood flow and the right coronary artery (RCA) and circumflex (Cx) coronary artery each supply 25% of blood flow to the left ventricular myocardium. In addition, RCA irrigates most of the right ventricle. The closer the occlusion site to the origin of the coronary artery, the larger the ischaemic area and the greater the necessity of a rapid reperfusion attempt. The ECG findings considered to be helpful to localize the occlusion site in the culprit coronary artery have been described by several authors and are summarized elsewhere. 1 In the current issue of the journal, Verouden et al. looked at the value of the standard 12-lead ECG to distinguish the RCA from the Cx coronary artery as an infarct-related vessel in a large series of patients with acute inferior MI undergoing primary percutaneous coronary intervention shortly thereafter. 2 ST-segment elevation in lead III more than in lead II, combined with ST-segment depression in lead I or aVL was used as a marker, suggesting that the culprit lesion was located in RCA. The study is important because of the large number of patients and the short time interval between the 12-lead ECG and the coronary angiogram. The findings can be summarized that using this ECG algorithm a correct diagnosis as to the coronary occlusion site did not reach a pre-specified sensitivity threshold of 90% in the whole group. Of interest is that when the authors applied algorithms published by other investigators using ST-segment deviation in the extremity leads, even lower sensitivity was observed. Only in the case of a total 12-lead ST-segment deviation score of more than 18.5 mm, a sensitivity of more than 90% was found. We are not informed about the accuracy of the algorithm in relation to the degree of ST-segment deviation. Is there a critical threshold of

Distinguishing the right coronary artery from the left circumflex coronary artery as the infarct-related artery in patients undergoing primary percutaneous coronary intervention for acute inferior myocardial infarction

Aim of this study was to investigate the diagnostic accuracy of the conventional electrocardiogram (ECG) algorithm [ST-segment elevation (STE) in lead III exceeding that in lead II combined with ST-segment depression in lead I or aVL] for identification of the infarct-related artery (IRA) in a large cohort of patients undergoing primary percutaneous coronary intervention (PCI) for inferior wall STE myocardial infarction (STEMI). We included 1131 patients with inferior STEMI, who underwent primary PCI between 2000 and 2007 and of whom a pre-procedural 12-lead ECG was available, recorded immediately prior to PCI. The IRA was determined during emergency angiography. Coronary angiography confirmed the right coronary artery (RCA) as the IRA in 895 patients (79%) with inferior wall STEMI. Application of the ECG algorithm resulted in 624 true positive cases of acute RCA obstruction (sensitivity: 70%, 95% CI: 67 -73%) and 170 cases with true negative result (specificity: 72%, 95% CI: 66-77%). Sensitivity of >90% was established in patients with cumulative ST-segment deviation above median (>18.5 mm). The conventional ECG algorithm showed a low sensitivity for the non-invasive diagnosis of RCA occlusion in an all-comer, inferior STEMI cohort undergoing primary PCI. Sensitivity was only sufficient in patients with extensive ST-segment deviation.

Primary Percutaneous Coronary Angioplasty With and Without Eptifibatide in ST-Segment Elevation Myocardial Infarction

Background— Primary percutaneous coronary intervention, if performed promptly, is the preferred strategy to restore flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. We sought to determine whether eptifibatide, a platelet glycoprotein IIb/IIIa inhibitor, given before catheterization would improve clinical outcomes in patients referred for primary percutaneous coronary intervention. Methods and Results— We randomly assigned a total of 400 patients with ST-segment elevation myocardial infarction referred for primary percutaneous coronary intervention to treatment initiated before cardiac catheterization, with either heparin plus eptifibatide (201 patients) or heparin alone (199 patients), in addition to oral aspirin (160 mg) and high-dose clopidogrel (600 mg). The primary end point was a composite of death from any cause, recurrent myocardial infarction, or recurrent severe ischemia during the first 30 days after randomization. At 30 days, the primary end point was reached by 13 patients (6.47%) assigned to heparin plus eptifibatide and by 11 patients (5.53%) assigned to heparin alone (relative risk, 1.18; 95% CI, 0.52 to 2.70; P =0.69). The rates of major or minor bleeding were higher in patients assigned to heparin plus eptifibatide than that in patients assigned to heparin alone (22.4% versus 14.6%; relative risk, 1.69; 95% CI, 1.01 to 2.83; P =0.04). Conclusions— In patients pretreated with high-dose clopidogrel who were referred for primary PCI, treatment with heparin plus eptifibatide, when compared with heparin alone, did not improve clinical outcomes and was associated with more bleeding complications.

Predictors of no-reflow after percutaneous coronary intervention for culprit lesion with plaque rupture in infarct-related artery in patients with acute myocardial infarction

We investigated the predictors of the no-reflow phenomenon after percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) patients with plaque rupture (PR). The study group comprised 112 AMI patients who underwent pre- and post-PCI intravascular ultrasound (IVUS) and stent implantation. Angiographic no-reflow was defined as TIMI flow grade 0, 1, and 2 after PCI. IVUS findings included multiple ruptured plaques (PRs separated by a >5-mm length of artery containing smooth lumen contours), thrombus (had a layered lobulated appearance, evidence of blood flow within the mass, and speckling or scintillation), and plaque prolapse (tissue extrusion through the stent struts). Of 112 patients, no-reflow was observed in 17 patients (15.2%). High-sensitivity C-reactive protein (hs-CRP) was significantly higher (6.2+/-6.0 mg/dl vs. 2.2+/-2.9 mg/dl, p=0.002) and baseline TIMI flow grade was significantly lower in no-reflow group (TIMI flow grade<3: 59% vs. 18%, p<0.001). Lesion site plaque plus media area was significantly greater (12.9+/-2.6 mm(2) vs. 10.8+/-4.2 mm(2), p=0.009), remodeling index was significantly higher (1.14+/-0.17 vs. 1.03+/-0.20, p=0.031), and the presence of IVUS-detected thrombus (88% vs. 56%, p=0.012), culprit lesion multiple PRs (71% vs. 37%, p=0.009), and plaque prolapse (65% vs. 34%, p=0.015) were significantly more common in no-reflow group. In the multivariate analysis, plaque prolapse (OR=33.02; 95% CI 3.38-322.75, p=0.003), hs-CRP (OR=1.03; 95% CI 1.01-1.05, p=0.013), and culprit lesion multiple PRs (OR=15.73; 95% CI 1.61-153.46, p=0.018) were independent predictors of post-PCI no-reflow in AMI patients with PR. Elevated hs-CRP and IVUS-detected multiple PRs and plaque prolapse are associated with no-reflow after PCI for PR-containing culprit lesion in infarct-related arteries in AMI patients.

AS-98: Thrombus Aspiration during Primary Percutaneous Coronary Intervention Improves Myocardial Reperfusion with and without Use of Platelet Glycoprotein IIb/IIIa Receptor Blockers

Primary percutaneous coronary intervention (PCI) is effective in opening the infarct-related artery in patients with ST-segment elevation myocardial infarction. However, myocardial reperfusion following primary PCI (pPCI) is limited by microembolism and atherothrombotic events. Platelet glycoprotein (GP) IIb/IIIa receptor blockers and thrombus aspiration both reduce the incidence of such events during PCI. This was a prospective, randomized study intended to compare effectiveness of upstream use of Clotinab (a product made in Isu Abxis), aspiration devices, and both strategies in reducing microembolic complications during pPCI.

Late Reperfusion of A Totally Occluded Infarct-Related Artery Increases Granulocyte-Colony Stimulation Factor and Reduces Stroma-Derived Factor-1.ALPHA. Blood Levels in Patients With Ongoing Ischemia After Acute Myocardial Infarction

After acute myocardial infarction (AMI), reopening of a totally occluded infarct-related artery (IRA) at a subacute stage is still controversial in symptom-free patients. However, in patients with persistent ischemic symptoms and inadequate collaterals to the infarct area, recanalization is thought to provide beneficial effects. In addition to augmenting myocardial perfusion, we hypothesized that the benefit of recanalization involves the manipulation of circulating stem cell-mobilizing cytokines. This study included 30 patients with a totally occluded IRA and ongoing ischemic symptoms (the study group) and 30 patients with a partially occluded IRA (the control group). All patients underwent successful angioplasty and/or stenting. Before and immediately after the coronary intervention, blood granulocyte-colony-stimulating factor (G-CSF), stem-cell factor (SCF), vascular endothelial growth factor (VEGF), and stroma-derived factor-1 (SDF-1alpha) were measured. After recanalization, G-CSF levels significantly increased in the study group compared to the control group (P=0.03). SDF-1alpha levels in the study group decreased relative to the controls (P=0.02). However, no significant changes in VEGF or SCF levels between the two groups were found. In the multivariate analysis, reopening of a totally occluded IRA was independently and significantly associated with changes in G-CSF and SDF-1alpha levels after recanalization. In conclusion, our data suggest that the benefits of late reperfusion of a totally occluded IRA in patients with ongoing myocardial ischemia may involve mechanisms associated with stem cell-mobilizing and plaque-stabilizing cytokines. This study provides the rationale to investigate serial changes in cytokines and the numbers of circulating progenitors after reperfusion in the future.

Initial patency of the infarct-related artery in patients with acute ST elevation myocardial infarction is related to platelet response to aspirin

Introduction A proportion of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary angiography (PCI) presents with patent infarct-related artery (IRA) on initial angiography. We tested the hypothesis that stronger platelet response to aspirin in these patients at admission might be associated with higher initial coronary flow in the IRA. Methods Platelet response to aspirin was assessed with Multiplate ® ASPI-test before coronary angiography in 70 patients on previous aspirin treatment admitted for acute STEMI. Coronary flow on initial angiogram was evaluated quantitatively according to the Thrombolysis in Myocardial Infarction (TIMI) grading system. Depending on the degree of arachidonic acid (AA) induced platelet aggregation in ASPI-test, patients were stratified into four quartiles and compared according to initial TIMI flow. Results When TIMI flow was compared according to quartiles of platelet aggregation in ASPI-test, we have found significantly higher frequency of TIMI-2 and TIMI-3 flow among patients with low values of ASPI-test, i.e. with stronger aspirin response ( P = 0.014). None of the patients in the highest quartile of ASPI-test had TIMI flow of 2 or 3. Conclusions Patients with stronger antiplatelet response to aspirin therapy in acute STEMI are more likely to present with spontaneous IRA recanalization.

A Bayesian Meta‐Analysis Comparing AngioJet® Thrombectomy to Percutaneous Coronary Intervention Alone in Acute Myocardial Infarction

The purpose of this meta-analysis was to compare outcomes for AngioJet thrombectomy versus percutaneous coronary intervention (PCI) without thrombectomy in acute myocardial infarction (AMI) patients. PCI is the preferred treatment for revascularizing the infarct-related artery in patients with AMI. There is controversy about the benefits of thrombectomy as an adjunct to PCI. AMI studies published between January 1, 1999, and March 1, 2007, were used to compare AngioJet thrombectomy plus PCI to PCI alone. Bayesian meta-analytic estimates were used to estimate the odds ratios (95% CI) for short-term mortality, major adverse cardiac events (MACE), and final TIMI 3 flow. The AngioJet data included 11 studies and 1,018 patients. The PCI data included 81 studies and 24,076 patients. The AngioJet group included more patients with large thrombus burden, rescue PCI after failed thrombolytic therapy, and longer symptom duration compared to the PCI group. Despite the higher risk profile of AngioJet patients, the groups had similar odds of short-term mortality, 0.98 (0.53, 1.50), MACE, 1.25 (0.54, 2.40), and final TIMI 3 flow, 1.12 (0.70, 2.27). AngioJet thrombectomy results in clinical and angiographic outcomes that are similar to PCI in lower risk AMI patients. These observations suggest that AngioJet thrombectomy may reduce the additional risk associated with visible thrombus in the infarct-related lesion.

Thrombus Aspiration during Primary Percutaneous Coronary Intervention

Primary percutaneous coronary intervention (PCI) is effective in opening the infarct-related artery in patients with myocardial infarction with ST-segment elevation. However, the embolization of atherothrombotic debris induces microvascular obstruction and diminishes myocardial reperfusion. We performed a randomized trial assessing whether manual aspiration was superior to conventional treatment during primary PCI. A total of 1071 patients were randomly assigned to the thrombus-aspiration group or the conventional-PCI group before undergoing coronary angiography. Aspiration was considered to be successful if there was histopathological evidence of atherothrombotic material. We assessed angiographic and electrocardiographic signs of myocardial reperfusion, as well as clinical outcome. The primary end point was a myocardial blush grade of 0 or 1 (defined as absent or minimal myocardial reperfusion, respectively). A myocardial blush grade of 0 or 1 occurred in 17.1% of the patients in the thrombus-aspiration group and in 26.3% of those in the conventional-PCI group (P<0.001). Complete resolution of ST-segment elevation occurred in 56.6% and 44.2% of patients, respectively (P<0.001). The benefit did not show heterogeneity among the baseline levels of the prespecified covariates. At 30 days, the rate of death in patients with a myocardial blush grade of 0 or 1, 2, and 3 was 5.2%, 2.9%, and 1.0%, respectively (P=0.003), and the rate of adverse events was 14.1%, 8.8%, and 4.2%, respectively (P<0.001). Histopathological examination confirmed successful aspiration in 72.9% of patients. Thrombus aspiration is applicable in a large majority of patients with myocardial infarction with ST-segment elevation, and it results in better reperfusion and clinical outcomes than conventional PCI, irrespective of clinical and angiographic characteristics at baseline. (Current Controlled Trials number, ISRCTN16716833.)

A Citywide Protocol for Primary PCI in ST-Segment Elevation Myocardial Infarction

If primary percutaneous coronary intervention (PCI) is performed promptly, the procedure is superior to fibrinolysis in restoring flow to the infarct-related artery in patients with ST-segment elevation myocardial infarction. The benchmark for a timely PCI intervention has become a door-to-balloon time of less than 90 minutes. Whether regional strategies can be developed to achieve this goal is uncertain. We developed an integrated-metropolitan-area approach in which all patients with ST-segment elevation myocardial infarction were referred to a specialized center for primary PCI. We sought to determine whether there was a difference in door-to-balloon times between patients who were referred directly from the field by paramedics trained in the interpretation of electrocardiograms and patients who were referred by emergency department physicians. Between May 1, 2005, and April 30, 2006, a total of 344 consecutive patients with ST-segment elevation myocardial infarction were referred for primary PCI: 135 directly from the field and 209 from emergency departments. Primary PCI was performed in 93.6% of patients. The median door-to-balloon time was shorter in patients referred from the field (69 minutes; interquartile range, 43 to 87) than in patients needing interhospital transfer (123 minutes; interquartile range, 101 to 153; P<0.001). Door-to-balloon times of less than 90 minutes were achieved in 79.7% of patients who were transferred from the field and in 11.9% of those transferred from emergency departments (P<0.001). Guideline door-to-balloon-times were more often achieved when trained paramedics independently triaged and transported patients directly to a designated primary PCI center than when patients were referred from emergency departments.

Oxidative stress and antioxidative defense parameters early after reperfusion therapy for acute myocardial infarction

Reperfusion of ischemic myocardium evokes rapid release of free radicals in experimental models. The aim of the study was to investigate the oxidative stress and antioxidative defense during first minutes after reopening of the infarct related artery in patients treated for acute myocardial infarction. The study group consisted of 15 patients with first ST elevation myocardial infarction (STEMI) due to left anterior descending artery occlusion. The control group included ten patients with stable ischemic heart disease (IHD). Blood samples from coronary sinus were drawn before, immediately after and about 15 min after angioplasty. Activity of superoxide dysmutase (SOD), concentration of glutathione as well as the concentrations of lipid peroxides, malodialdehyde (MDA) and 4-hydroxy-2-nonenal (HNE) were measured. There was significantly higher concentration of MDA and HNE and higher SOD activity in STEMI patients before the reperfusion, as compared to the stable IHD group. After the reperfusion concentration of HNE in erythrocytes from STEMI patients was higher than in IHD group. At the same time the activity of SOD significantly decreased in patients with impaired tissue perfusion (myocardial blush grade <2). In conclusion, there is a slightly higher concentration of oxidative stress parameters in patients with STEMI. Diminished antioxidative defense after reperfusion is associated with impaired myocardial perfusion.

The Late Open Infarct‐related Artery Hypothesis: Evidence‐based Medicine or Not?

Randomized clinical trials have clearly shown that early reperfusion of coronary arteries is the established treatment of myocardial infarction preserving left ventricular function and reducing mortality. However, late patency of the infarct-related artery is an independent predictor of survival leading to the late open-artery hypothesis. This concept implies restoration of antegrade blood flow of the infarct-related artery in patients with myocardial infarction to improve survival by mechanisms less time-dependent or even time-independent. Possible explanations for this benefit include improved left ventricular function and electrical stability by perfusion of hibernating myocardium, accelerated infarct healing and limitation of ventricular remodeling. This review focuses on the evidence of late recanalization of occluded infarct-related arteries in patients with coronary artery disease.

Integrated backscatter for the assessment of myocardial viability

Ultrasonic tissue characterization is a non-invasive diagnostic method that uses myocardial integrated backscatter analysis to determine contractile performance and myocardial viability independent of wall motion. This review discusses recent clinical findings regarding the application of ultrasonic tissue characterization for the assessment of myocardial viability. As this technique is non-invasive, ultrasonic tissue characterization can be used to predict the patency of infarct-related arteries in patients in the early stage of acute myocardial infarction. Several recent studies have shown that this technique is useful in identifying myocardial contractile reserve. The accuracy of ultrasonic tissue characterization for predicting functional recovery after coronary reperfusion is comparable to dobutamine echocardiography and radionuclide methods. Several studies have suggested that the cyclic variation of myocardial integrated backscatter reflects myocardial viability rather than contractile reserve. The cyclic variation of integrated backscatter is associated with myocardial viability confirmed by the integrity of the microvasculature identified by contrast echocardiography. In addition, the cyclic variation of integrated backscatter better reflects myocardial viability confirmed by the integrity of cellar metabolism than contractile reserve. Ultrasonic tissue characterization with integrated backscatter is a useful non-invasive method that can provide unique information for the assessment of myocardial viability.

Differentiating the Infarct-Related Artery on Initial Electrocardiogram in Single or Multi-Vessel Disease in Acute Inferior Myocardial Infarction and Evaluating Involvement of Vessels Using Correspondence Analysis

Initial electrocardiography changes were compared prospectively with the findings of coronary angiography to predict the infarct-related artery (IRA) in cases of single- and multi-vessel disease and to demonstrate the relationship between other coexisting coronary involvements and IRA in patients who presented with acute inferior myocardial infarction (AMI). ST elevations or depressions of at least 1 mm (0.1 mV) were evaluated in the leads I, aVL, and V1-V6. Of the 160 patients hospitalized due to inferior AMI, 153 (96%) underwent coronary angiography using standard methods. The angiograms were screened for stenotic lesions using quantitative coronary angiography to confirm significance, which was considered >50% vessel lumen diameter reduction. Among single-vessel involvements, the IRA was either the circumflex artery (Cx) or right coronary artery (RCA). In conditions in which IRA was detected as either Cx or RCA, 1-, 2-, and 3-vessel involvements were also detected. Correspondence analysis was performed to show the vessel involvements accompanying IRA. Compared with patients with IRA as RCA, the presence of ST depressions in the leads V1 or V2 and aVL were more frequently seen in patients with IRA as Cx (p=0.000, p=0.015, respectively). Among all vessel involvements in which IRA was either Cx or RCA, a ST-segment depression in leads V1 or V2 (p=0.000) and aVL (p=0.000) and a ST-segment elevation in lead I (p=0.005) were considered to be significant for Cx, and a ST-segment depression in lead I for RCA involvement (p=0.010). According to correspondence analysis, the most frequent single-vessel involvement seen in inferior AMI was RCA; when IRA was RCA, a multi-vessel involvement included RCA and Cx; and when IRA was Cx, a single-vessel involvement included the left anterior descending (LAD) artery most frequently, and RCA+LAD less frequently (p=0.000). In inferior AMI, RCA was the most common IRA; however, the possibility of multi-vessel disease is increased when Cx is found to be the IRA. In patients presenting with inferior AMI, the presence of ST-depression in the leads aVL and V1-2 is a sensitive finding that indicates Cx stenosis rather than RCA stenosis and is not affected by coexisting other coronary artery involvements.

Early and long-term outcome of elective stenting of the infarct-related artery in patients with viability in the infarct-area: Rationale and design of the Viability-guided Angioplasty after acute Myocardial Infarction-trial (The VIAMI-trial)

BackgroundAlthough percutaneous coronary intervention (PCI) is becoming the standard therapy in ST-segment elevation myocardial infarction (STEMI), to date most patients, even in developed countries, are reperfused with intravenous thrombolysis or do not receive a reperfusion therapy at all. In the post-lysis period these patients are at high risk for recurrent ischemic events. Early identification of these patients is mandatory as this subgroup could possibly benefit from an angioplasty of the infarct-related artery.Since viability seems to be related to ischemic adverse events, we initiated a clinical trial to investigate the benefits of PCI with stenting of the infarct-related artery in patients with viability detected early after acute myocardial infarction.MethodsThe VIAMI-study is designed as a prospective, multicenter, randomized, controlled clinical trial. Patients who are hospitalized with an acute myocardial infarction and who did not have primary or rescue PCI, undergo viability testing by low-dose dobutamine echocardiography (LDDE) within 3 days of admission. Consequently, patients with demonstrated viability are randomized to an invasive or conservative strategy. In the invasive strategy patients undergo coronary angiography with the intention to perform PCI with stenting of the infarct-related coronary artery and concomitant use of abciximab. In the conservative group an ischemia-guided approach is adopted (standard optimal care).The primary end point is the composite of death from any cause, reinfarction and unstable angina during a follow-up period of three years.ConclusionThe primary objective of the VIAMI-trial is to demonstrate that angioplasty of the infarct-related coronary artery with stenting and concomitant use of abciximab results in a clinically important risk reduction of future cardiac events in patients with viability in the infarct-area, detected early after myocardial infarction.