Infarct-related Coronary Artery Research Articles

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

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

Impact of preventive substrate catheter ablation on implantable cardioverter-defibrillator interventions in patients with ischaemic cardiomyopathy and infarct-related coronary chronic total occlusion.

Primary prevention patients with ischaemic cardiomyopathy and chronic total occlusion of an infarct-related coronary artery (CTO) are at a particularly high risk of implantable cardioverter-defibrillator (ICD) therapy occurrence. The trial was designed to evaluate the efficacy of preventive CTO-related substrate ablation strategy in ischaemic cardiomyopathy patients undergoing primary prevention ICD implantation. The PREVENTIVE VT study was a prospective, multicentre, randomized trial including ischaemic patients with ejection fraction ≤40%, no documented ventricular arrhythmias (VAs), and evidence of scar related to the coronary CTO. Patients were randomly assigned 1:1 to a preventive substrate ablation before ICD implantation or standard therapy with ICD implantation only. The primary outcome was a composite of appropriate ICD therapy or unplanned hospitalization for VAs. Secondary outcomes included the primary outcome's components, the incidence of appropriate ICD therapies, cardiac hospitalization, electrical storm, and cardiovascular (CV) mortality. Sixty patients were included in the study. During the mean follow-up of 44.7 ± 20.7 months, the primary outcome occurred in 5 (16.7%) patients undergoing preventive substrate ablation and in 13 (43.3%) patients receiving only ICD [hazard ratio (HR): 0.33; 95% confidence interval (CI): 0.12-0.94; P = 0.037]. Patients in the preventive ablation group also had fewer appropriate ICD therapies (P = 0.039) and the electrical storms (Log-rank: P = 0.01). While preventive ablation also reduced cardiac hospitalizations (P = 0.006), it had no significant impact on CV mortality (P = 0.151). Preventive ablation of the coronary CTO-related substrate in patients undergoing primary ICD implantation is associated with the reduced risk of appropriate ICD therapy or unplanned hospitalization due to VAs.

VARIOUS ASPECTS OF PERCUTANEOUS CORONARY INTERVENTIONS AS PREDICTORS OF DEATH IN MYOCARDIAL INFARCTION AND CORONARY MICROVASCULAR OBSTRUCTION (NO-REFLOW)

HighlightsThe review analyzed the role of various preoperative indicators as predictors of long-term mortality in patients with myocardial infarction and coronary microvascular obstruction (no-reflow) that developed during percutaneous coronary intervention. As a result of a multifactorial analysis, taking into account the confounders available for evaluation, we have found that predilation serves as an independent predictor of death within two years. AbstractAim. To evaluate the role of various aspects of percutaneous coronary interventions (PCI) as predictors of long-term death in myocardial infarction (MI) and coronary microvascular obstruction (CMVO, no-reflow).Methods. The unmatched case-control study included 232 patients with type 1 MI and CMVO developed during PCI. CMVO criteria were as follows: TIMI flow grade <3, Myocardial blush grade <2, ST segment resolution after PCI <70%. The “cases” group consisted of 54 (23.3%) patients who died within the next two years, the “controls” group consisted of 178 (76.7%) patients who survived. The analysis included the following indicators: predilation, high-pressure balloon post-dilation, vacuum assisted manual thromboaspiration, intra-aortic balloon pump, intracoronary administration of isosorbide dinitrate and verapamil hydrochloride, glycoprotein IIb/IIIa inhibitors and “potent” p2y12 inhibitors usage, bare-metal stents, stent implantation with exceeded rated burst pressure, 3 or more stents usage, PCI on more than one artery, the ratio of contrast agent volume to glomerular filtration rate (GFR) >3.0. A univariate comparative analysis of the groups regarding PCI aspects and potential confounders was performed (Mann-Whitney, Fisher). To control the confounders, a multivariate analysis was carried out (logistic regression).Results. Differences were obtained for the following indicators: “predilation” – in 51 (94%) patients in the “cases” group and in 139 (78%) in the “control” group, p-value = 0.005; “intra-aortic balloon pump” – in 9 (17%) and 7 (4%) patients respectively, p-value = 0.003; “the ratio of contrast agent volume to GFR >3.0” – in 26 (48%) and 48 (27%) patients, p-value = 0.005. Multivariate analysis revealed that only predilation was an independent predictor of death within two years – odds ratio 7.38 (95% confidence interval 1.70–49.04, p-value = 0.005).Conclusion. Predilation of the infarct-related coronary artery is an independent predictor of death within two years in MI patients who develop CMVO during PCI.

Arrhythmias in patients with acute ST-elevation myocardial infarction induced by various risk factors during the first day after myocardial reperfusion by primary percutaneous coronary intervention

Introduction. Acute coronary syndrome, in particular acute ST-elevation myocardial infarction (STEMI), is often accompanied by complex hemodynamically significant arrhythmias and conduction disorders. Such patients have a worse prognosis compared to patients with sinus rhythm. Arrhythmias in patients with STEMI are facilitated by the presence of comorbidities such as arterial hypertension, diabetes mellitus, obesity, and post-COVID-19 syndrome. The aim of the study. To elucidate the nature of arrhythmias in patients with acute STEMI induced by various risk factors during the first day after myocardial reperfusion by primary percutaneous coronary intervention. Materials and methods. The study involved 50 patients aged 45 to 83 years (average age – 63,4 ± 9,6 years; men – 70,97 %, women – 29,03 %), who were treated during 2021-2023 at the cardiology and reperfusion therapy department of Cardio-vascular center of ʺSaint Panteleimon Hospital in Lvivʺ and the infarction department of ʺLviv Regional Clinical Cardiological Centerʺ. The patients under investigation were subjected to daily electrocardiogram (ECG) monitoring for 24 hours after stenting of the infarct-related coronary artery, using a 7-channel ECG recorder Solvaig 06000.7 with computer processing of the recording using the DiaCard2 software. The obtained material was further subjected to software packages Microsoft Excel 2022, Statistica 10. Results. It was established that among supraventricular rhythm disturbances the most common were premature contractions, the average number of which per patient was significantly higher in the presence of obesity. Similarly high it was in post COVID-19 patients, as well as in those with hypertension. In post-coronavirus infection and in hypertension cases, extrasystoles were often in the form of pairs, triplets, bigemia, and trigemia; paroxysms of supraventricular tachycardia were also recorded in these patients. Among the ventricular arrhythmias also the most frequent were premature cardiac contractions, significantly more oftenly recorded in patients with hypertension and those experienced COVID-19; only in these patients were documented extrasystoles in the form of pairs, triplets, bigeminy, trigeminy, runs of ʺR to Tʺ, which are currently considered as harbingers of life-threatening ventricular arrhythmias. In the presence of hypertension and post-COVID-19, episodes of unstable ventricular tachycardia were also observed. Conclusions. In patients with STEMI, both supraventricular and ventricular premature contractions and episodes of supraventricular and unstable ventricular tachycardia are quite common during the first day after primary percutaneous coronary intervention with infarct-related coronary artery stenting, which is evidence of myocardial electrical instability. The nature of rhythm disturbances in the presence of hypertension and post-COVID-19 is prognostically unfavorable and indicates a higher risk of lifethreatening arrhythmias in these patients. Myocardial revascularization should be supplemented with optimal medical treatment in order to prevent the adverse cardiovascular events in post-STEMI patients. Further research should be directed toward elucidation of predictive value of detected arrhythmias with respect to the occurrence of unfavorable cardiovascular events in the early and long-term post-infarction period.

Assessing heterogeneity on cardiovascular magnetic resonance imaging: a novel approach to diagnosis and risk stratification in cardiac diseases.

Cardiac disease affects the heart non-uniformly. Examples include focal septal or apical hypertrophy with reduced strain in hypertrophic cardiomyopathy, replacement fibrosis with akinesia in an infarct-related coronary artery territory, and a pattern of scarring in dilated cardiomyopathy. The detail and versatility of cardiovascular magnetic resonance (CMR) imaging mean it contains a wealth of information imperceptible to the naked eye and not captured by standard global measures. CMR-derived heterogeneity biomarkers could facilitate early diagnosis, better risk stratification, and a more comprehensive prediction of treatment response. Small cohort and case-control studies demonstrate the feasibility of proof-of-concept structural and functional heterogeneity measures. Detailed radiomic analyses of different CMR sequences using open-source software delineate unique voxel patterns as hallmarks of histopathological changes. Meanwhile, measures of dispersion applied to emerging CMR strain sequences describe variable longitudinal, circumferential, and radial function across the myocardium. Two of the most promising heterogeneity measures are the mean absolute deviation of regional standard deviations on native T1 and T2 and the standard deviation of time to maximum regional radial wall motion, termed the tissue synchronization index in a 16-segment left ventricle model. Real-world limitations include the non-standardization of CMR imaging protocols across different centres and the testing of large numbers of radiomic features in small, inadequately powered patient samples. We, therefore, propose a three-step roadmap to benchmark novel heterogeneity biomarkers, including defining normal reference ranges, statistical modelling against diagnosis and outcomes in large epidemiological studies, and finally, comprehensive internal and external validations.

Frequency, predictors and clinical outcomes of AMI patients with triple regression of coronary atherosclerosis: A sub-analysis of the PACMAN AMI trial

Abstract Background Recent studies have shown that coronary artery disease regression is not limited to atheroma reduction but also includes plaque stabilization in patients treated with high-intensity lipid-lowering therapy. The frequency and characteristics of patients who simultaneously show atheroma volume reduction and plaque stabilization defined as reduction in plaque lipid content and increase in fibrous cap thickness (i.e., triple regression) are unknown. Purpose This study sought to determine the percentage and determinants of both plaque volume reduction and plaque stabilization in patients with acute myocardial infarction (MI) and treated wiTh alirocumab or placebo added to high-intensity statin therapy. Methods The PACMAN-AMI trial employed serial intravascular ultrasound, near-infrared spectroscopy and optical coherence tomography to compare the effects of alirocumab vs. placebo (1:1) in 265 patients (537 non–infarct-related coronary arteries) receiving high-intensity statin therapy. Triple regression was defined by the combined presence of reduction in percent atheroma volume (PAV), reduction in maximum lipid core burden index (maxLCBI4mm) and increase in minimal fibrous cap thickness (FCT). Clinical outcomes of patients with or without triple regression were assessed at one year follow-up. Results Overall, 199 (75.1%) patients showed PAV reduction, 180 (67.7%) maxLCBI4mm reduction and 172 (77.6%) minimal FCT increase, with a total of 84 (31.7%) patients having triple regression (40.8% in the alirocumab group vs. 23.0% in the placebo group, p=0.002). The percentage of patients with triple regression was similar among the groups with PAV reduction, maxLCBI4mm reduction or minimal FCT thickening (42%, 51% or 49%, respectively, p=0.30). Similar baseline clinical features and a higher reduction in low-density lipoprotein cholesterol (LDL-C, -27.1 [37.7 to -16.6] mg/dl, p<0.001) and apolipoprotein B levels (-18.5 [-26.0 to -11.0] p<0.001) were observed patienst with vs. without triple regression. A higher reduction in PAV (-1.54 [-2.14 to -0.95] %, p<0.001), maxLCBI4mm (-111.24 [-140.46 to -82.02], p<0.001) and a higher increase in minimal FCT (56.39 [38.67 to 74.11] µm, p<0.001) were found in patients with triple regression. At multivariable analysis, factors independently associated with triple regression included higher baseline maxLCBI4mm (1.03, 1.01 to 1.06, p=0.013) and alirocumab treatment (2.83, 1.57 to 5.16, p=0.001). The composite clinical endpoint of death, MI and ischemia-driven revascularization occurred less frequently in patients with versus without triple regression (8.3% vs 18.2%, p=0.042). Conclusions Triple regression occurred among one third of acute AMI patients receiving high-intensity lipid lowering therapy. Alirocumab treatment and higher baseline lipid accumulation were independent predictors of triple regression. Triple regression was associated with a reduced rate of adverse cardiovascular events.

Impact of the infarct-related coronary artery on inflammatory profiles and outcomes in patients presenting with acute coronary syndromes: insights from a prospective multicenter real-world cohort

Abstract Background Patients with a total coronary occlusion (TCO) of the infarct-related artery (IRA) frequently present as ST-segment elevation myocardial infarction (STEMI). However, patients presenting as non-ST-segment elevation acute coronary syndromes (NSTE-ACS) on a routine ECG may actually have TCO at angiography, typically involving left circumflex (LCx) or right coronary artery (RCA) as the IRA. These patients might be at higher risk of MACE due to a delayed diagnosis and, consequently, an inappropriately prolonged time window to revascularization. Herein, we aimed to describe clinical characteristics and outcomes of IRA location in patients presenting with ACS enrolled in a real-world prospective cohort. Methods Between 2009 and 2017, 4,787 ACS patients were prospectively recruited in the SPUM-ACS prospective study. The primary outcome measure was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction and non-fatal stroke at one year. Multivariable-adjusted Cox regression models were fit using backward selection. Coronary angiographies were reviewed by operators of each site to assess the IRA location and TCO was defined in the presence of TIMI 0 flow. Results 4,542 ACS patients (95% of the total cohort) had angiographic studies available. Patients with left main (n=75) and bypass graft (n=55) as culprit artery were excluded and a final sample size of 4,412 patients were included in the present analysis; 56% (n=2469) presented with ST-elevation myocardial infarction (STEMI) and 44% (n=1943) with NSTE-ACS. Overall, the IRA was the right coronary artery (RCA) in 33.9% (n=1494), the left-anterior descending coronary artery (LAD) in 45.6% (n=2013) and the left circumflex (LCx) in 20.5% (n=905). In those presenting with STEMI, patients with LAD as IRA had an increased risk of MACE (1.43, 95% CI 1.02-2.00, p = 0.04) as compared to those with RCA and LCx. In those presenting with NSTE-ACS, LCx and RCA as IRA had more frequently a TCO compared to the LAD (27% and 24%, respectively, vs. 9%, p<0.001). Features of patients with NSTE-ACS associated with TCO of the IRA included elevated lymphocyte and neutrophil counts, higher hs-CRP and hs-TnT, lower eGFR, and absent history of MI. Among patients with NSTE-ACS, LCx as IRA but not LAD and RCA was associated with an increased risk of MACE at one 1 year (fully adjusted HR 1.68, 95% CI 1.10-2.59, p=0.02; reference: RCA and LAD). Conclusion Among all ACS patients included in the SPUM-ACS, those with NSTE-ACS at initial ECG and RCA and LCx involvement had more often a TCO of the IRA, but only LCx as IRA was an independent predictor of MACE during follow-up. Hs-CRP levels, lymphocytes and neutrophils counts, hs-TnT, eGFR and history of MI at admission were found to be independent predictors of IRA occlusion at angiography. Thus, NSTE-ACS patients showing such features should further be evaluated for timely PCI.

Strategy of delayed intervention without stent implantation in myocardial infarction with ST segment elevation caused by massive thrombosis of the infarct-related artery

Aim. TIntroduction. To evaluate in-hospital angiographic and five-year posthospital clinical outcomes of percutaneous intervention strategy without stent implantation with immediate coronary artery stenting technique in STEMI patients with massive coronary thrombosis.Material and methods. The study enrolled 116 patients with primary STEMI myocardial infarction with the signs of massive thrombosis in the lumen of the main epicardial coronary artery with TIMI thrombus grade greater than 3 after antegrade blood flow restoration. In the 1st group of delayed intervention at the primary stage the blood flow was restored by small diameter balloon inflation and/ or manual vacuum thrombus aspiration until stable TIMI grade 3 blood flow was achieved, at control CAG on day 5-6 in 36 people the stent was not implanted due to insignificance of infarct-related coronary artery stenosis (stenosis less than 50% according to QCA). Immediate stent implantation was performed in 78 patients (group 2). The primary endpoint was the incidence of adverse cardiovascular events, including total mortality, recurrent myocardial infarction, repeated revascularization of the infarct-responsive artery. Secondary endpoint: frequency of achieving optimal myocardial perfusion as measured by angiography – TIMI blood flow and Myocardial Blush Grade.Results. The median follow-up period was 47 months. The incidence of the primary end point (MACE) was 15,8% in group 1 and 23,1% in group 2, with no statistically significant difference (p=0,408). Overall mortality (10,5% and 11,7%), the rate of repeat myocardial infarction (2,6% and 5,1%), and the rate of repeat target vessel revascularization (2,6% and 6,4%) were without significant advantage between subgroups. Optimal reperfusion (TIMI-3 and Myocardial Blush Grade 2-3 after primary procedure was achieved in significantly (p=0,02) more patients in group 1 (89%) than in group 2 (69,2%) ST segment resolution ≥70% after intervention was achieved in 87% of cases in group 1 and in 64,1% of cases in group 2 (p=0,011).Conclusion. In STEMI patients with massive coronary thrombosis, the method of delayed percutaneous intervention increases the rate of achieving optimal blood flow and allows avoiding stent implantation in the infarct-related artery in 50% of cases as compared to the method of immediate stenting. Both methods have comparable hospital and five-year clinical risks.

Predictors of diastolic deceleration time of coronary flow velocity of infarct related and reference coronary artery assessed by transthoracic Doppler echocardiography in the chronic phase of successfully reperfused anterior myocardial infarction: relation to infarct size.

High-frequency transthoracic Doppler echocardiography (TDE) enables the assessment of flow velocity and velocity pattern in different coronary arteries, including the assessment of diastolic deceleration time (DDT) of coronary flow velocity. Short DDT of infarct related artery (IRA) (<600 msec) in the acute phase of anterior myocardial infarction (MI) is the predictor of adverse left ventricular (LV) remodeling and prognosis. The significance of DDT of coronary flow velocity assessment in the chronic phase of anterior MI is not well established. Our study aimed to establish the predictors of DDT of the coronary flow velocity of infarct related (left anterior descendent-DDT of LAD) and reference coronary artery, evaluated by TDE, and to assess their relation to infarct size in the chronic phase of successfully reperfused first anterior MI. Our study included 40 consecutive patients (34 men, mean age 52 ± 12 years) one month after the first anterior STEMI and single vessel disease successfully treated with primary PCI. All patients underwent SPECT MPI for the assessment of LV volumes, ejection fraction, and percentage of the myocardium with fixed perfusion abnormalities and echocardiographic examination including the evaluation of DDT of IRA and reference coronary artery TDE. DDT of LAD correlated significantly to the WMSI (r = -0.467, p = 0.002), LV end-systolic volume (r = -0.412, p = 0.008), LV ejection fraction (r = 0.427, p = 0.006), while the strongest correlation was observed between DDT of LAD and the extent of fixed perfusion abnormality (r = -0.627, p < 0.0001), Multivariate analysis revealed percentage of fixed perfusion abnormalities along with DDT of reference coronary artery as the independent predictors of DDT of IRA. DDT of IRA shorter than 886 msec predicts large fixed perfusion abnormalities (>20%) with a sensitivity of 89% and specificity of 62% (AUC 0.842). DDT of LAD assessed by TDE in the chronic phase of successfully reperfused first anterior MI is a usefull variable for the assessment of microcirculatory function that exclusively reflects the extent of microvascular damage and relates to infarct size.

Dilation of the Infarct-Related Coronary Artery to Reduce the Incidence of the No-Reflow Phenomenon in STEMI Patients

Background: The pathogenesis of slow/no-reflow phenomena is a critical socio-medical problem due to high mortality and work disability rates in patients with ST-segment elevation myocardial infarction (STEMI). Slow/no-reflow phenomena are multifactorial involving 4 key elements: 1) distal embolization of the coronary bed of the infarct-related coronary artery; 2) ischemic damage to the myocardium; 3) reperfusion injury of the heart muscle; 4) individual (genetic) susceptibility of the microcirculation to injury. Objective: To analyze the outcomes of percutaneous coronary interventions (PCI) in patients with STEMI and TIMI 0 blood flow of an infarct-related coronary artery based on the strategy to restore antegrade blood flow (balloon predilation or dilation of an infarctrelated artery). Materials and methods: We analyzed treatment outcomes of 209 patients with STEMI and TIMI 0 blood flow. The patients were grouped based on the PCI strategy: group 1 included 147 patients who underwent balloon angioplasty to restore antegrade blood flow, and group 2 included 62 patients who underwent dilation of an infarct-related coronary artery. Results: Our study found that direct stenting in STEMI patients was associated with statistically significantly lower risk of slow/noreflow phenomena (P = 0.001, Pearson’s χ2) and, as a result, better functional outcomes of treatment (chronic heart failure grade classified according to Strazhesko-Vasilenko and by left ventricular ejection fraction) that were also statistically significant (P = 0.001, Pearson’s χ2). Conclusions: Our study demonstrated that the risk of slow/no-reflow phenomena in patients with TIMI 0 blood flow of an infarctrelated coronary artery was statistically significantly lower (P = .001, Pearson’s χ2) in the group of patients who underwent dilation of an infarct-related coronary artery to restore antegrade blood flow. Functional outcomes (chronic heart failure grade and overall survival) were also better in this group of patients (P = .001, Pearson’s Chi-square). Moreover, dilation of an infarct-related coronary artery was associated with preserved left ventricular ejection fraction compared with the group of patients who underwent balloon angioplasty to restore antegrade blood flow (P &lt; 0.001, Pearson’s χ2).

SILENT MYOCARDIAL ISCHEMIA IN PATIENTS WITH ACUTE CORONARY SYNDROME AND DIABETES MELLITUS

ST-segment elevation myocardial infarction, stenting of the infarct-related coronary artery, silent (painless) myocardial ischemia, diabetes mellitus, 24-hour electrocardiographic monitoring.&#x0D; Introduction. Currently, approximately 422 million people in the world have diabetes mellitus, and over 1.3 million individuals in Ukraine are diagnosed with diabetes mellitus. Diabetic neuropathy is known to contribute to the development of atypical and painless variants of ischemic heart disease in individuals with diabetes. This poses a challenge for timely diagnosis and obscures the course of ischemic heart disease, as the prevalence of silent myocardial ischemia is significantly high in these patients. Therefore, the aim of this study is to investigate the occurrence of myocardial ischemia episodes in patients with ST-elevation myocardial infarction within the first day following stenting of the infarct-related coronary artery. Furthermore, we aimed to demonstrate the painless nature of these episodes in the presence of type 2 diabetes mellitus through a clinical case presentation.&#x0D; Materials and methods. 30 patients with ST-segment elevation myocardial infarction were examined, and 24-hour electrocardiographic monitoring was performed during the first day after the infarct-related coronary artery stenting. Results. Episodes of transient myocardial ischemia were registered in 50% of people. We found that the majority of episodes (80%) were painless. In the presence of diabetes mellitus, only episodes of painless myocardial ischemia were noted that is supported by the example of a clinical case. The study highlighted the informativeness of 24-hour electrocardiographic monitoring in identifying episodes of myocardial ischemia, particularly in its painless variant. The results demonstrate that patients with ST-elevation myocardial infarction (STEMI) experience episodes of transient myocardial ischemia within the first day after coronary artery stenting, with a majority of these episodes being painless. Furthermore, in the presence of diabetes mellitus, ischemic episodes tend to be painless. Therefore, 24-hour electrocardiographic monitoring serves as a valuable method for the detection of myocardial ischemia.

Occlusion of the infarct-related coronary artery presenting as acute coronary syndrome with and without ST-elevation: impact of inflammation and outcomes in a real-world prospective cohort.

Patients with ST-segment elevation typically feature total coronary occlusion (TCO) of the infarct-related artery (IRA) on angiography, which may result in worse outcomes. Yet, relying solely on electrocardiogram (ECG) findings may be misleading and those presenting with non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) may have TCO as well. Herein, we aimed to delineate clinical characteristics and outcomes of patients with ACS stratified by IRA location. A total of 4787 ACS patients were prospectively recruited between 2009 and 2017 in SPUM-ACS (ClinicalTrials.gov Identifier: NCT01000701). The primary endpoint was major adverse cardiovascular events (MACEs), a composite of all-cause death, non-fatal myocardial infarction and non-fatal stroke at 1 year. Multivariable-adjusted survival models were fitted using backward selection. A total of 4412 ACS patients were included in this analysis, 56.0% (n=2469) ST-elevation myocardial infarction (STEMI) and 44.0% (n=1943) NSTE-ACS. The IRA was the right coronary artery (RCA) in 33.9% (n=1494), the left-anterior descending coronary artery (LAD) in 45.6% (n=2013), and the left circumflex (LCx) in 20.5% (n=905) patients. In STEMI patients, TCO (defined as TIMI 0 flow at angiography) was observed in 55% of cases with LAD, in 63% with RCA, and in 55% with LCx. In those presenting with NSTE-ACS, TCO was more frequent in those with LCx and RCA as compared to the LAD (27 and 24%, respectively, vs. 9%, P<0.001). Among patients with NSTE-ACS, occlusion of the LCx was associated with an increased risk of MACE during 1 year after the index ACS (fully adjusted hazard ratio 1.68, 95% confidence interval 1.10-2.59, P=0.02; reference: RCA and LAD). Features of patients with NSTE-ACS associated with TCO of the IRA included elevated lymphocyte and neutrophil counts, higher levels of high-sensitivity C reactive protein (hs-CRP) and high-sensitivity cardiac troponin T, lower eGFR, and notably a negative history of MI. In NSTE-ACS, both LCx and RCA involvement was associated with TCO at angiography despite the absence of ST-segment elevation. Involvement of the LCx, but not the LAD or RCA, as the IRA represented an independent predictor of MACE during 1-year follow-up. Hs-CRP, lymphocyte, and neutrophil counts were independent predictors of total IRA occlusion, suggesting a possible role of systemic inflammation in the detection of TCO irrespective of ECG presentation.

High mobility group box 1 derived mainly from platelet microparticles exacerbates microvascular obstruction in no reflow

IntroductionNo reflow manifests coronary microvascular injury caused by continuous severe myocardial ischemia and reperfusion. Microvascular obstruction (MVO) has emerged as one fundamental mechanism of no reflow. However, the underlying pathophysiology remains incompletely defined. Herein, we explore the contribution of high mobility group box 1 (HMGB1), derived mainly from platelet microparticles exacerbating MVO in no reflow. Materials and methods44 STEMI patients undergoing successful primary percutaneous coronary intervention (PCI) were included in our study. Plasma HMGB1 levels in both the peripheral artery (PA) and infarct-related coronary artery (IRA) were measured by ELISA. Flow cytometry and confocal microscopy assessed the level of HMGB1+ platelet derived microparticles (PMPs) and platelet activation. Flow cytometry and western blot evaluated the procoagulant activity (PCA) and the release of inflammatory factors of human microvascular endothelial cells (HCEMCs). ResultsHMGB1 levels were significantly higher in the IRA in no-reflow patients. The levels of HMGB1+ PMPs were considerably higher in the IRA of patients with no reflow and were strongly associated with platelet activation. Moreover, our results show that HMGB1 interacts with human microvascular endothelial cells primarily through TLR4, inducing HCMEC proinflammatory, procoagulant phenotype, and monocyte recruitment, accelerating microvascular obstruction and facilitating the development of no reflow. ConclusionOur results illustrate a novel mechanism by which HMGB1, derived mainly from PMPs, plays a crucial role in the pathogenesis of no-reflow, revealing a novel therapeutic target.

Elevated Native T1 Values in the Remote Myocardium Supplied by Obstructive Non-Infarct Related Coronary Arteries in Post-STEMI Cardiac Magnetic Resonance

Introduction: Native T1 mapping values are elevated in acutely injured myocardium. We sought to study whether native T1 values, in the non-infarct related myocardial territories, might differ when supplied by obstructive or nonobstructive coronary arteries. Methods: Consecutive patients (N = 60, mean age 59 years) with the first STEMI following primary percutaneous coronary intervention, underwent cardiac magnetic resonance within 5 ± 2 days. A retrospective review of coronary angiography reports classified coronary arteries as infarct-related coronary artery (IRA) and non-IRA. Obstructive coronary artery disease (CAD) was defined as stenosis ≥50%. Native T1 values were presented using a 16-segment AHA model according to the three main coronary territories: left anterior descending (LAD), left circumflex (LCX), and right coronary artery (RCA). Results: The cutoff native T1 value for predicting obstructive non-IRA LAD was 1,309 msec with a sensitivity and specificity of 67% and 82%, respectively (AUC 0.76, 95% CI: 0.57–0.95, p = 0.04). The cutoff native T1 value for predicting obstructive non-IRA RCA was 1,302 msec with a sensitivity and specificity of 83% and 55%, respectively (AUC 0.7, 95% CI: 0.52–0.87, p = 0.05). Logistic regression model adjusted for age and infarct size demonstrated that native T1 was an independent predictor for the obstructive non-IRA LAD (OR 4.65; 1.32–26.96, p = 0.05) and RCA (OR 3.70; 1.44–16.35, p = 0.03). Conclusion: Elevated native T1 values are independent predictors of obstructive non-IRA in STEMI patients. These results suggest the presence of concomitant remote myocardial impairment in the non-infarct territories with obstructive CAD.

The relationship between platelet indices and residual SYNTAX score in patients with ST-segment elevation myocardial infarction

Objectives: Our aim is to investigate the relationship between thrombocyte indices, which have previously been proven to be associated with many cardiovascular diseases and adverse events, and residual SYNTAX (SYNergy between percutaneous coronary interventionwith TAXus and cardiac surgery) score (rSS) in patients with ST-segment elevation myocardial infarction (STEMI). Methods: Our study included 534 patients who underwent primary percutaneous coronary intervention (PCI) for STEMI between January 2018 and June 2021. In our study, only patients who underwent infarct-related coronary artery revascularization in the index procedure were evaluated. First of all, patients were compared as two groups as low rSS (rSS ≤ 8) and high rSS (rSS &amp;gt; 8). Our definition of platelet indices includes mean platelet volume (MPV), platelet distribution width (PDW), plateletcrit (Pct), MPV to platelet ratio (MPVPR), platelet to lymphocyte ratio (PLR), and MPV to lymphocyte ratio (MPVLR). Results: The mean age of the study patients was 56.4 ± 10.3 years and 78.8% were male. The high rSS group had higher C-reactive protein, lower lymphocyte count, and significantly higher platelet indices other than PLR and MPV. Among the platelet indices, MPVLR was found to have the best correlation with rSS (r: 0.398, p &amp;lt; 0.001). MPVLR (AUC: 0.820, 95% CI: 0.701-0.899) was determined as the best diagnostic power index with 5.08 cut-off value in predicting high rSS with 88% sensitivity and 76% specificity (Youden index: 0.64). Age, right coronary artery involvement as culprit lesion, ejection fraction, diabetes mellitus and MPVLR (OR: 5.966 [2.489-8.413], p &amp;lt; 0.001) and PDW were identified as independent risk factors for predicting high rSS. Conclusions: In conclusion, increased MPVLR is associated with high rSS in STEMI patients. There is a significant positive correlation between MPVLR and rSS. MPVLR is an independent predictor of high rSS.

Intra-aortic balloon pump in patients with myocardial infarction and cardiogenic shock of stages A and B

This article presents two clinical cases of patients with myocardial infarction and stage A (at risk) and B (beginning) cardiogenic shock who underwent intra-aortic balloon counterpulsation (IABP). In patients with a high risk of classic cardiogenic shock and/or the no-reflow phenomenon, stenting of the infarct-related coronary artery during this type of mechanical circulatory support was performed without complications. Theoretical and practical aspects of using IABP at different stages of cardiogenic shock are discussed.

Dynamics of the Indicators of Low Dose Dobutamine Stress-Echocardiography under the Influence of High Doses of Atorvastatin in Patients with ST Elevation Myocardial Infarction

The aim of investigation: to study the effect of early administration high doses of atorvastatin in the acute period of STEMI on the indicators of low dose dobutamine stress-echocardiography and parameters of left ventricular remodeling. Material and Methods: The study included 164 patients with STEMI All patients underwent myocardial revascularization (TLT or PCI) within the first 6 hours. The 1st group included 82 patients who received basic therapy (atorvastatin 20 mg), the 2nd group included 82 patients who took a loading dose of atorvastatin (at a dose of 80 mg per day). Low dose dobutamine stress-echocardiography was performed to detect myocardial stunning after stabilization of the patients condition on 4–6 days of the disease. In addition to general clinical and conventional laboratory research methods, on the 1st day and on the 10th day of treatment, the level of CPK MB, ESR, the number of blood leukocytes, and the level of fibrinogen (FN) were determined. Results: On the 10th day of therapy in patients of both groups, there was a significant increase in ESR (in the 1st group by 2.1 times, in the 2nd - by 1.6 times) and a decrease in the level of CRP (by 3 and 2.65 times, respectively) compared to the first day. The dynamics of these indicators reflects the regular processes of the course of AMI. A more significant change in these parameters was recorded in patients of the 2nd group who took atorvastatin at a dose of 80 mg. At the same time, on the 10th day of AMI, the number of peripheral blood leukocytes significantly decreased in them (p&lt;0.05 when compared between groups). The number of dobutamine-responsive segments (segments with reversible dysfunction) in the group of patients treated with atorvastatin at a dose of 80 mg during myocardial reperfusion was significantly higher than in the control group (p&lt;0.05). Conclusion: It was revealed that conducting of myocardium reperfusion in infarct-related coronary artery with simultaneous use of atorvastatin’s high doses promoted the limitation of myocardial necrosis development, reducing ischemic and reperfusion injuries of myocardium and influenced on the formation of myocardial stunning zones which is a reversible disfunction. The use of atorvastatin in the dose of 80 mg/per day in the first hours after acute myocardial infarction development promotes the improvement of LV systolic indices, prevents the progressing of LV cavity postinfarction dilatation.

Variations in Blood Platelet Proteome and Transcriptome Revealed Altered Expression of Transgelin-2 in Acute Coronary Syndrome Patients.

Proteomic analyses based on mass spectrometry provide a powerful tool for the simultaneous identification of proteins and their signatures. Disorders detection at the molecular level delivers an immense impact for a better understanding of the pathogenesis and etiology of various diseases. Acute coronary syndrome (ACS) refers to a group of heart diseases generally associated with rupture of an atherosclerotic plaque and partial or complete thrombotic obstruction of the blood flow in the infarct-related coronary artery. The essential role in the pathogenesis of ACS is related to the abnormal, pathological activation of blood platelets. The multifactorial and complex character of ACS indicates the need to explain the molecular mechanisms responsible for thrombosis. In our study, we performed screening and comparative analysis of platelet proteome from ACS patients and healthy donors. Two-dimensional fluorescence difference gel electrophoresis and nanoscale liquid chromatography coupled to tandem mass spectrometry showed altered expressions of six proteins (i.e., vinculin, transgelin-2, fibrinogen β and γ chains, apolipoprotein a1, and tubulin β), with the overlapping increased expression at the mRNA level for transgelin-2. Dysregulation in protein expression identified in our study may be associated with an increased risk of thrombotic events, correlated with a higher aggregability of blood platelets and induced shape change, thus explaining the phenomenon of the hyperreactivity of blood platelets in ACS.

Improved prediction of electrical storm in patients with prior myocardial infarction and implantaImproved prediction of electrical storm in patients with prior myocardiable cardioverter defibrillator

Abstract Funding Acknowledgements Type of funding sources: None. Aims To evaluate predictors of electrical storm (ES), including chronic total occlusion in an infarct-related coronary artery (infarct-related artery CTO, IRACTO), in a cohort of patients with prior myocardial infarction (MI) and implantable cardioverter-defibrillators (ICD). Methods Multicenter observational cohort study including 643 consecutive patients with prior MI and a first ICD implanted between 2005 and 2018 at three tertiary hospitals. All the patients included in the study had undergone a diagnostic coronary angiography before ICD implantation. The variable prior ventricular arrhythmias (VA+) was positive in patients with secondary prevention ICDs and in those with at least one appropriate ICD therapy after primary prevention implantation. Results During a median follow-up of 42 months 59 patients (9%) suffered ES. The presence of at least one IRACTO not revascularized (IRACTO-NR) was associated with a significantly higher cumulative incidence of ES (14.5% vs 4.8%, p&amp;lt;0.001). IRACTO-NR maintained a significant association with ES after adjustment for potential confounders (HR 2.3, p=0.005) and was an independent predictor of ES together with VA+ and LVEF. The best cut-off of LVEF to predict ES was ≤38%. A risk-prediction model based on IRACTO-NR, VA+ and LVEF≤38% identified three categories of ES risk (low, intermediate and high), with progressively increasing cumulative incidence of ES (2.2%, 9% and 20%). Conclusion In a cohort of patients with prior MI and ICD, IRACTO-NR is an independent predictor of ES. A new risk-prediction model allowed the identification of three categories of risk, with potentially important clinical implications.

Arteriovenous shunt fraction as a marker for early diagnosis of acute respiratory distress syndrome against the background of cardiogenic pulmonary edema: a case report

Introduction . In recent years, there has been a trend towards an increase in the use of mechanical ventilation (MV) in patients with acute myocardial infarction and cardiogenic shock. Probably, currently there is an underdiagnosis of acute respiratory distress syndrome (ARDS) against the background of cardiogenic pulmonary edema, which does not allow timely use of effective treatment strategies. We propose to use the pulmonary shunt fraction (Qs/Qt) as an additional diagnostic method. Case . A 70-year-old male patient entered the сardiovascular intensive care unit with acute ST-segment elevation myocardial infarction complicated by cardiogenic shock. Emergency percutaneous coronary intervention 50 minutes after hospitalization allowed revascularization of the infarct-related coronary artery and 1:1 intra-aortic balloon counterpulsation was initiated. Against the background of non-invasive ventilation, paraclinical signs of severe respiratory failure persisted — S/F (SpO 2 /FiO 2 ): 108, PaO 2 / FiO 2 (Horowitz index): 78-103, Qs/Qt: 27,3-48,3%). Therefore, MV was started. According to the obtained data (24 hours from the admission), severe ARDS was verified. Renal replacement therapy session was started for non-renal indications. On the 4th day of hospitalization, therapy improved the patient’s condition. A 63-hour session of renal replacement therapy was completed. Against the background of gradual weaning from mechanical ventilation, the patient was extubated. Conclusion . In the above case, the use of shunt fraction (Qs/Qt) contributed to the earliest possible verification of ARDS before the onset of full-scale clinical picture, an increase in biochemical markers and X-ray abnormalities, which made it possible to start targeted therapy in a timely manner.