Management Of ST-elevation Myocardial Infarction Research Articles

Drug-coated balloon versus drug-eluting stenting coronary angioplasty for ST-elevation myocardial infarction: a systematic review and meta-analysis of real-world studies

Abstract Funding Acknowledgements None. Introduction In the realm of ST-elevation myocardial infarction (STEMI), drug-eluting stent angioplasty (DES) is a well-established strategy for urgent revascularization. However, several challenges arise when selecting stents for these patients. These challenges include dealing with endothelial oedema and vasospasm during acute thrombotic occlusion. Moreover, there are concerns surrounding DES-related complications. These complications include the need for prolonged anti-platelet therapy, which increases the risk of bleeding, late stent thrombosis, and in-stent restenosis (ISR). In light of these issues, drug-coated balloons (DCB) have emerged as a compelling alternative. Purpose: This study aims to explore the safety and efficacy of DCB compared to conventional DES angioplasty in the management of STEMI. Methods A systematic literature search was conducted across electronic databases (PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, reference lists of relevant publications, and grey literature sources) for studies published from the inception of DCB up to 31st August 2023. Results Nine eligible studies, consisting of four randomised controlled trials and two retrospective propensity-matched studies, were included. These studies, all single-center, involved a total of 2,122 patients (934 in the DCB versus 1,188 in the DES group) over a median follow-up period of 15 months (ranging from 6 to 36 months). The meta-analysis showed no statistically significant differences between DCB and DES angioplasty in terms of technical success (OR: 1.82, 95% CI: 0.22-15.08, p = 0.58), major adverse cardiovascular events (MACE) (OR: 1.24, 95% CI: 0.60–2.56, p = 0.57), all-cause mortality (OR: 1.20, 95% CI: 0.83–1.75, p = 0.33), cardiac death (OR: 1.40, 95% CI: 0.47-4.17, p = 0.54), cardiovascular-related hospitalization (OR: 0.72, 95% CI: 0.32-1.65, p = 0.44), recurrent myocardial infarction (OR: 0.99, 95% CI:0.34-2.90, p = 0.99), target lesion revascularization (OR: 1.15, 95% CI: 0.56–2.34, p = 0.71), late luminal loss (SMD: -0.25mm, 95% CI: -1.05 to 0.54, p = 0.53), postoperative TIMI flow (OR: 1.16, 95% CI: 0.54-2.50, p = 0.71), fractional flow reserve (MD: 0.012, 95% CI -0.018 to 0.032, p = 0.27), and bleeding risk (7.2% in DCB versus 7.5% in DES). It's noteworthy that 8.2% of patients in the DCB group required bailout stenting due to coronary artery dissection type C, a rate 10 times higher than that in the DES group (p < 0.005). Additionally, DCB angioplasty displayed a statistically significant presence of residual stenosis compared to DES angioplasty (OR: 6.48, 95% CI: 1.13-37.2, p = 0.04). Conclusion DCB angioplasty demonstrates promise but presents unique challenges in STEMI management, particularly in complex scenarios requiring bailout stenting and residual stenosis. The study contributes to the ongoing discussion about the role of DCBs in optimizing STEMI treatment, highlighting their potential benefits and areas of concern.

A 10-year review of presentation, management and outcomes of STEMI in a high-volume regional tertiary Australian centre

ObjectiveTo assess the trends and impact of changes in management of ST Elevation Myocardial Infarction (STEMI) from 2010 to 2019. DesignRetrospective analysis of data from STEMI hospitalisations including demographic, comorbidity, angiographic and outcome data. Setting/participantsHigh-volume non-surgical regional Australian tertiary referral centre. Main outcome measurementsIndex & 12-month mortality (all-cause & cardiovascular), door-to-balloon time, target-vessel failure, target-vessel revascularisation & procedure-related bleeding. ResultsFrom 2010 to 2019, 1299 patients presented with STEMI. The cardiovascular risk factor profile did not significantly change over the 10-year study period, p = 0.23. There was a significant trend toward culprit vessel percutaneous coronary intervention with stenting, rather than balloon angioplasty followed by surgical revascularisation, p = 0.029. The mean door-to-balloon time was 88 +/− 5.7 min and demonstrated a statistically significant improvement across the decade, p = 0.035. Radial access became the preferred angiographic approach (2010 92% femoral, 2019 91% radial). Drug-eluting stents (DES) replaced bare metal stent use. There was a statistically significant reduction in 12-month cardiovascular mortality across the decade (p = 0.042). However index hospitalisation (cardiovascular and all-cause) and 12-month all cause mortality did not reduce. Young patients and women are important sub-groups of STEMI presentations with different risk factor profile. ConclusionsAdvances in management of STEMI such as radial access, use of DES and a significant reduction in door-to-balloon time across the decade resulted in a reduction of 12-month cardiovascular mortality over the decade however there was no significant reduction in all-cause mortality or index hospitalisation cardiovascular mortality. Further research is needed to ensure non-mortality outcomes, such as heart failure hospitalisation and quality of life, also demonstrate temporal improvement with STEMI management advances. Earlier cardiovascular risk assessment should be considered in smokers than is currently recommended in Australian guidelines (≥45yo for most individuals).

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management.

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management.

Multifaceted Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on ST-Elevation Myocardial Infarction (STEMI): A Literature Review of Incidence, Treatment Modalities, and Outcomes.

The global repercussions of coronavirus disease 2019 (COVID-19) include substantial worldwide mortality and have brought to light existing gaps in healthcare systems. Particularly, diseases requiring time-sensitive treatment, such as ST-elevation myocardial infarction (STEMI), have faced significant challenges due to the impact and revelations of the COVID-19 pandemic on healthcare infrastructure. This review addresses the impact of the pandemic on STEMI, exploring incidence, treatment modalities, and clinical outcomes. Through a critical examination of existing literature, the intricate relationship between the pandemic and cardiovascular health, specifically STEMI, is elucidated. The COVID-19 pandemic has had a significant impact on the management of STEMI, with changes in hospitalization rates, treatment strategies, and the presentation of the disease posing significant challenges. The contradictory results of COVID-19 and post-vaccine myocardial infarction, as well as gender differences in reported cases, highlight the need for further research to clarify these relationships.

Impact of antiplatelet therapy on microvascular thrombosis during ST-elevation myocardial infarction.

During an acute coronary syndrome, atherosclerotic plaque rupture triggers platelet activation and thrombus formation, which may completely occlude a coronary artery leading to ST-elevation myocardial infarction (STEMI). Although emergency percutaneous coronary intervention (PCI) is effective in re-opening the main coronary arteries, the downstream microvasculature can become obstructed by embolised plaque material and thrombus. Dual antiplatelet therapy is recommended by guidelines and used routinely for the management of STEMI to reduce the risk of recurrent atherothrombotic events. However it is unclear to what extent antiplatelet therapy reduces microvascular thrombosis, largely because most tools to assess microvascular thrombosis only became available after antiplatelet therapy was already used in the majority of patients. Platelets play a central role in key aspects of microvascular thrombosis, such as atherosclerotic plaque-induced thrombus development, inflammation and microvascular dysfunction, making them a potential target for novel therapeutic interventions. Currently, more potent antiplatelet agents like GPIIb/IIIa inhibitors may be administered during PCI directly into coronary arteries with high thrombus burden but it is not well-established whether this reduces microvascular thrombosis and they significantly increase the risk of bleeding. In this review article we discuss the role of platelets in microvascular thrombosis, describe how microvascular thrombosis and obstruction can be assessed clinically and explore potential new antiplatelet treatments for this. In particular, we highlight novel antiplatelet drugs targeting the platelet receptor GPVI, as well as PAR4, GPIb-IX-V and 5HT2A receptors. We also discuss the potential benefit of P-selectin inhibitors as they have proven to be effective in reducing microvascular thrombosis in sickle-cell disease which could translate into potential benefits in acute coronary syndrome.

Enhancing ST-Elevation Myocardial Infarction Diagnosis and Management: The Integral Role of Echocardiography in Patients Rushed to the Cardiac Catheterization Laboratory.

Coronary artery disease (CAD) remains a significant global health concern, necessitating timely and precise diagnosis, especially for acute coronary syndromes (ACSs). Traditional diagnostic methods like electrocardiograms (ECGs) are critical, yet the advent of echocardiography has revolutionized cardiac care by providing comprehensive insights into heart function. This article examines the integration of echocardiography in the cardiac catheterization laboratory, emphasizing its role in augmenting traditional diagnostics, enhancing patient outcomes, and preparing for targeted interventions. Specifically, we argue for the routine use of focused echocardiographic evaluations in patients presenting with ST-Elevation Myocardial Infarction (STEMI) to the cath lab, illustrating how this practice can significantly refine diagnostic accuracy, identify concurrent life-threatening conditions, and inform the management of STEMI and its complications.

Outcome of Primary Percutaneous Coronary Intervention for STEMI due to Stent Thrombosis

Background: Stent thrombosis (ST) is a critical complication following percutaneous coronary intervention (PCI), contributing significantly to morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI). Advances in drug-eluting stent technology and antiplatelet therapy have mitigated, but not eliminated, the risk of ST. The management of STEMI due to ST in resource-limited settings remains a challenging endeavor, necessitating a comprehensive evaluation of treatment outcomes. Objective: To assess the mortality rates and clinical outcomes following primary PCI in patients with STEMI attributed to stent thrombosis in a resource-constrained setting, and to analyze the association of mortality with patient age and TIMI flow grade post-PCI. Methods: This quasi-experimental study was conducted at Lady Reading Hospital, Peshawar, from July to December 2023. A total of 150 patients presenting with STEMI due to ST and undergoing PCI were included. Diagnostic measures included electrocardiography, troponin levels, echocardiography, and angiography to assess left ventricular function and stent thrombosis. The procedures were performed by experienced interventional cardiologists, followed by standard post-procedure management. Data analysis was performed using SPSS version 25, focusing on mortality rates, the association of mortality with patient age, and TIMI flow grades. Results: Among the 150 patients studied, mortality was observed in 36 cases (24%). The mean age of patients who died was 48.33 years (SD = 14.267), compared to 42.47 years (SD = 12.618) for survivors, with a significant association between age and mortality (P = 0.02). Analysis of TIMI flow grade post-PCI revealed a strong correlation with mortality; patients with TIMI flow grades I and II exhibited higher mortality rates, with a highly significant P value of 0.0001. Conclusion: The study highlights a significant mortality rate among patients with STEMI due to stent thrombosis undergoing primary PCI in a resource-limited setting. Advanced age and lower TIMI flow grades post-PCI were significantly associated with increased mortality. These findings underscore the necessity for vigilant post-PCI monitoring and tailored management strategies to improve clinical outcomes in this high-risk population.

Impact of total ischemic time (TIT) on 1-month clinical outcomes at a tertiary cardiology centre (TCC) with a limited primary percutaneous coronary intervention (LPPCI) service in the management of ST-elevation myocardial infarction (STEMI)

Impact of total ischemic time (TIT) on 1-month clinical outcomes at a tertiary cardiology centre (TCC) with a limited primary percutaneous coronary intervention (LPPCI) service in the management of ST-elevation myocardial infarction (STEMI)

Arg389Gly beta-1-adrenergic receptor polymorphism determines neutrophil-stunning-associated cardioprotection by metoprolol

Abstract Background Cardioprotective strategies to limit infarct size (IS) have become crucial. The damaged inflicted on the myocardium is the result of the processes of Ischemia and Reperfusion (I/R). In the clinical trial METOCARD-CNIC, it was shown that the intravenous (i.v.) pre-reperfusion administration of the β1-selective antagonist metoprolol reduces IS and improves long-term cardiac function in patients after acute myocardial infarction (1). However, the small sample size precludes a definite conclusion. Despite not having demonstrated a solid clinical benefit in terms of hard endpoints reduction, the clinical guidelines for the management of ST-Elevation Myocardial Infarction (STEMI) recommend the early administration of i.v. β-blockers in patients undergoing Primary Coronary Intervention. Additionally, our group has recently described that the beneficial effect of metoprolol against myocardial I/R injury is due to neutrophil stunning (2), which represents a one-of-a-kind property not shared by other i.v. β-blockers, such as atenolol or propranolol (3). Purpose Since β1-adrenergic receptor (ADRB1) is one of major targets of pharmacological therapy, great efforts are now underway to account for the relevance of the polymorphic variation. Here we explore whether the cardioprotection exerted by metoprolol is dependent on genetic polymorphisms in human ADRB1. Methods Patients included in the METOCARD-CNIC trial were grouped into the different variants for the ADRB1, rs1801252 and rs1801253 (SerGly49 and Arg389Gly, respectively), which might affect their response to the beta-1 modulation exerted by metoprolol on neutrophils and thus its cardioprotective effect. Additionally, the polymorphic-dependent effect of metoprolol on neutrophil migration was evaluated in healthy volunteers, whose neutrophils were exposed across the transwell filter to the CXCL1 in the presence or absence of metoprolol. Drug-receptor interaction properties were evaluated in silico. Results We found that Arg389Gly polymorphism of the human ADRB1 impacts the cardioprotective effect of metoprolol in STEMI patients. Therefore, Arg389 homozygosity was associated with lower infarcts (Figure 1) and better long-term left ventricle ejection fraction when metoprolol was intravenously administered prior reperfusion. Moreover, the disrupting effect of metoprolol on neutrophil migration was only observed in Arg389 homozygote volunteers (Figure 2). These differences were attributed to alterations in the drug-receptor complex stability when Gly residues are present in position 389 of the ADRB1. Conclusions From our perspective, these results are the first showing a polymorphic implication in drug response against myocardial I/R injury. All the data presented refine cardiovascular pharmacotherapy, and have major implications for the prospective clinical trial design aiming at positioning metoprolol as the beta-blocker of choice to reduce hard endpoints in STEMI patients.CardioprotectionNeutrophil migration

Impact of ambulance paramedics missing STEMI diagnosis on subsequent management

Abstract Background/introduction Acute ST elevation myocardial infarction (STEMI) is defined by acute changes in the electrocardiograph (ECG) reflecting acute occlusion of a coronary artery. Rapid and complete reperfusion of the culprit lesion improves immediate mortality and long-term outcomes. Systems of care have been developed to optimise recognition and management of acute STEMI to facilitate the best possible patient outcomes. Pre-hospital diagnosis by ambulance paramedics and activation of Code STEMI teams has been shown to significantly impact treatment times and patient outcomes. But what is the outcome if the diagnosis is missed? Methods We studied 559 consecutive STEMI cases presenting to our health network with two 24/7 interventional sites over a three-year period (2020-2022 inclusive), comparing the impact of arrival by ambulance or self-presentation. Ambulance arrival cases were further stratified by whether Code STEMI was activated prior to hospital arrival or afterwards. Patients who developed STEMI after presentation to hospital or who were transferred from another institution were excluded from this analysis. Only patients proceeding to percutaneous intervention of the culprit lesion were included. First medical contact (FMC) is either hospital door time or time of ambulance paramedic arrival at patient. ECG time reflects first recorded ECG, either by ambulance paramedic or hospital emergency department. Results Results are depicted in the table below. Patients with STEMI had similar FMC to treatment times if diagnosed pre-hospital by the ambulance paramedic or after self-presentation to the emergency department. Interestingly, patients self-presenting to the emergency department had a longer symptom duration, perhaps reflecting uncertainty regarding the cause for symptoms and the rationale for not utilising ambulance services. Patients presenting via ambulance, where the diagnosis and activation of Code STEMI did not occur prior to hospital arrival, had less ST elevation and a significant delay in definitive treatment. Conclusion(s) Ambulance paramedics successfully diagnosed 69% of STEMI cases they transported, activating a Code STEMI prior to hospital arrival. Cases that were not pre-notified had less marked ST elevation, potentially creating uncertainty as to the diagnosis. Strategies to enable direct discussion of equivocal ECG changes and symptoms between ambulance paramedics and interventional cardiologists my assist in more complete recognition of all STEMI cases without creating excessive false activations.Table 1:Results

A novel therapy in microvascular obstruction in ST-elevation myocardial infarction: pressure-controlled intermittent coronary sinus occlusion therapy.

Percutaneous coronary intervention has transformed the management of ST-elevation myocardial infarction (STEMI) due to a reduction in early mortality and need for repeat revascularization. However, the conventional revascularization strategy, combined with state-of-the-art anti-thrombotic and antiplatelet therapies, can still be associated with poor clinical outcome in some patients, because of reperfusion injury and microvascular obstruction contributing to the infarct size. To address this important therapeutic need, a broad-range of device-based treatments have been introduced. This is an overview of the pressure-controlled intermittent coronary sinus occlusion (PiCSO) device (Miracor Medical SA) which has been proposed for STEMI patients. PiCSO therapy could lead to an improved perfusion, decrease microvascular dysfunction, and thus potentially reduce infarct size.

Characteristics and Outcomes of Young Patients With ST-Elevation Myocardial Infarction Without Standard Modifiable Risk Factors

Patients with ST-elevation myocardial infarction (STEMI) with no standard modifiable risk factors (SMuRFs: hypertension, diabetes mellitus, hypercholesterolemia, and smoking) have worse short-term mortality than those with SMuRFs. Whether this association extends to younger patients is unclear. A retrospective cohort study was performed of patients aged 18 to 45 years with STEMI at 3 Australian hospitals between 2010 and 2020. Nonatherosclerotic causes of STEMI were excluded. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 1 and 2-year mortality. Cox proportional hazards analysis was used. Of 597 patients, the median age was 42 (interquartile range 38 to 44) years, 85.1% were men and 8.4% were SMuRF-less. Patients who are SMuRF-less were >2 times more likely to have cardiac arrest (28.0% vs 12.6%, p=0.003); require vasopressors (16.0% vs 6.8%, p=0.018), mechanical support (10.0% vs 2.3%, p=0.046), or intensive care admission (20.0% vs 5.7%, p <0.001); and have higher rate of left anterior descending artery infarcts than those with SMuRFs (62.0% vs 47.2%, p=0.045). No significant differences in thrombolysis or percutaneous intervention were observed. Guideline-directed medical therapy at discharge was high (>90%), and not different in the SMuRF-less. 30-day mortality was almost fivefold higher in the SMuRF-less (hazard ratio 4.70, 95% confidence interval 1.66 to 13.35, p=0.004), remaining significant at 1 and 2 years. In conclusion, young patients who are SMuRF-less have a higher 30-day mortality after STEMI than their counterparts with SMuRFs. This may be partially mediated by higher rates of cardiac arrest and left anterior descending artery territory events. These findings further highlight the need for improved prevention and management of SMuRF-less STEMI.

Management of ST-segment elevation myocardial infarction in comparison to European society of cardiology guidelines in Alexandria University Hospitals, Egypt

BackgroundFor patients with ST-elevation myocardial infarction (STEMI), early reperfusion with primary percutaneous coronary intervention (PPCI) or thrombolytic treatment is essential to prevent major adverse cardiac events. The aim of the study is to compare the current status of managing STEMI patients at **** with European Society of Cardiology guidelines recommendations. Prospective cohort of all patients presenting with ST-elevation myocardial infarction (STEMI) between March 2020 and February 2021 in Alexandria University hospitals. Reporting patterns, causes of delay, and reperfusion status for all STEMI patients were noted. MACE: (Mortality, Re-infarction, Stroke, or Heart failure) was reported and compared among different management strategies.ResultsThe study was conducted over one year on 436 patients, 280 (64.2%) of them underwent PPCI, 32 (7.3%) received thrombolysis, and 124 (28.5%) had a conservative strategy. Patients’ mean age was 55.2 years, 72.2% were smokers and 80.9% were men. Family history was positive in 14.2% of patients, 33.5% had diabetes, 7.3% had renal impairment, and 41.5% had hypertension. The median pre-hospital waiting time was 360 min; the mean pre-hospital waiting time was 629.0 ± 796.7 min. The median Emergency Room waiting time was 48.24 ± 89.30 min. The median time from CCU admission to wire crossing was 40.0 min with a mean value 53.86 ± 49.0 min. The mean ischemia duration was 408 min, while the total ischemic time was 372 min. All patients who presented within 12 h received reperfusion therapy either a PPCI or thrombolysis at a rate of 71.5%, with 35.0% of those patients achieving prompt reperfusion in accordance with ESC guidelines. The PPCI group mortality rate was 2.9%, in comparison to 12.9% in the conservative group, which was statistically significant (P < 0.001). Overall in-hospital mortality was 5.5%, and total MACE was 27.3%. A statistically significant difference was observed between the three management groups as regards MACE rate, being 15%, 28.1%, and 54.8% in PPCI, thrombolysis, and conservative groups, respectively.ConclusionsDespite financial and technical constraints, appropriate, timely reperfusion was near to achieving the ESC guidelines for the management of STEMI. The most common reperfusion strategy was PPCI, with an in-hospital death rate of less than 5% in the PPCI group. There was a concern about the increase in the total ischemia time due to some financial and technical constraints.

COVID-19 as an independent predictor of aspiration thrombectomy in STEMI. National data from the ORPKI register in the years 2020-2022.

Coronavirus disease 2019 (COVID-19) exacerbates intravascular thrombosis that occurs in the coronary artery in ST-elevation myocardial infarction (STEMI). To analyze the impact of COVID-19 on the application and effect of thrombectomy in STEMI patients. 29915 STEMI patients were analyzed, of whom 3139 (10.5%) underwent thrombectomy. COVID-19 (+) was reported in 311 (10.8%). The clinical characteristics and management of STEMI in COVID-19 (+) and COVID-19 (-) patients were compared. A multivariable logistic regression analysis was performed in search of factors influencing thrombectomy. COVID-19 (+) patients had higher Killip class (IV class; n = 33 (12.31%) vs. n = 138 (5.84%); p < 0.0001) and cardiac arrest at baseline was more frequent in this group (n = 25 (8.04%) vs. n = 137 (4.84%); p = 0.016). Thrombolysis in myocardial infarction (TIMI) 3 after percutaneous coronary intervention was less frequent (n = 248 (80.52%) vs. n = 2388 (87.19%); p = 0.001) in the COVID-19 (-) group. Periprocedural mortality was similar in both groups (n = 28 (0.99%) vs. n = 4 (1.29%); p = 0.622). In multivariable regression analysis COVID-19 increased the risk of thrombectomy (OR = 1.23; 97.5% CI: 1.05-1.43; p = 0.001). STEMI patients undergoing aspiration thrombectomy who were COVID-19 (+) were more likely to be in a severe clinical condition (higher Killip class, more frequent cardiac arrest before the procedure) than COVID-19 (-) patients. Despite more intensive antiplatelet and anticoagulant treatment, PCI procedures were less likely to result in an optimal TIMI 3 effect. COVID-19 is an independent strong predictor of patient qualification for aspiration thrombectomy in STEMI.

STEMI Pakistan; A National Heart Attack Management Program.

Coronary artery disease (CAD) accounts for more than two-thirds of these deaths. It is indicated per the latest information that one in four Pakistani adults over 40 has CAD.&#x0D; The stable coronary disease has a relatively low annual mortality, while acute myocardial infarction (MI) carries a high mortality and morbidity. Though recent advancements in coronary interventions have however revolutionized the management of acute myocardial infarction, resulting in a significant reduction of cardiovascular morbidity and mortality in the developed world but in Pakistan, the majority of ST-elevation myocardial infarction (STEMI) patients still remain sub-optimally managed. Urban areas are relatively better equipped, but this does not necessarily translate into universal access to quality and timely cardiac care. There is not only substantial variation in accessibility and practices amongst cardiac healthcare facilities between rural and urban areas but also amongst major city hospitals. Such variations clearly indicate an urgent need for a nationwide standardized STEMI management program to ensure that everyone with an acute STEMI will have speedy access to quality and standard acute care without being economically burdened.

Abstract 9820: Heart Failure at Admission in Patients With ST-Elevation Myocardial Infarction. Registry ARGEN-IAM-ST

Introduction: Heart failure (HF) is a frequent complication of ST-elevation myocardial infarction (STEMI). Despite advances in the management of STEMI, when associated with HF, its prognosis continues to be ominous. Knowing the reality and the management of these patients is a necessity that will guide us for future strategies. Objective: To evaluate incidence, associated factors, relationship with reperfusion strategies, treatment at admission, and evolution of patients (pts) with STEMI who present HF at admission. Material and Method: Data from the National Registry of ST-Elevation Myocardial Infarction of Argentina (ARGEN-IAM-ST) were analyzed from 1/1/2016 to 9/30/2020. Based on Killip and Kimball variable at admission, the population was divided into 2 groups, those pts with Killip and Kimball equal to 1 were grouped as pts without HF (noHF) at admission and those with Killip and Kimball greater to 1 as with HF at admission. Demographic characteristics, clinical, electrocardiographic, laboratory variables, and admission treatment were compared. Hospital mortality was compared. Results: 3,174 pts were analyzed. Pts with HF were 22.31%. Mean age (noHF vs HF) was 59.80 years (SD±11.45) and 64.01 years (SD±12.14), p&lt;0.0001; predominance of women in HF (24.50% vs 18.50%, p&lt;0.001). The baselines characteristics can be seen in Table 1. Reperfusion strategy was less used in HF group [87.57% vs 92.58%, OR 0.56 (95%CI 0.43-0.74), p&lt;0.001] and its success was less frequent (Table 2). Pharmacological treatment is shown in Figures 1 and 2. Mortality was 3.00% in noHF vs 28.39% in HF, p&lt;0.001. In the multivariate analysis, the variables associated with changes in mortality are described in Table 3; HF was associated with an increase in mortality. Conclusions: Pts with STEMI associated with HF at admission are a different group with a higher risk. The reperfusion strategy and certain pharmacological treatments on admission are less frequent in these pts.

Abstract 12220: Right Bundle Branch and Bifascicular Blocks: Insensitive Prognostic Indicators for Acute Myocardial Infarction

Introduction: The clinical significance of right bundle branch block (RBBB) or bifascicular block (BFB) in the setting of ST-elevation myocardial infarction (STEMI) is uncertain. Informed by studies demonstrating higher rates of complete occlusion of the infarct-related artery in patients presenting with RBBB, the latest guidelines on STEMI management suggest patients with persistent ischemic symptoms and RBBB be considered for emergent coronary angiography. However, there has been little study of the prognostic implication of either RBBB or BFB in the setting of undifferentiated acute chest pain, and even less of the degree of ST-elevation in concomitant RBBB. Methods and Results: A total of 7626 patient encounters presenting to the Baylor St. Luke’s Medical Center between July 2018 and July 2020 with a chief complaint of “chest pain” were identified via electronic health record query. Of these encounters, 211 (2.8%) patients were found to have RBBB. Of that cohort, 18 (8.5%) presented with acute coronary syndrome, with STEMI accounting for 6 (2.8%), non-STEMI 9 (4.3%), and unstable angina 3 (1.4%). New or presumed new RBBBs were found in 59 (28%) of total RBBB patients, of which only 5 (8.5%) were found to have acute coronary syndrome and only 2 (3.4%) STEMI specifically. Similarly, 90 (42.7%) patients with chest pain and RBBB were found to have a BFB. New or presumed new BFBs were found in 40 (19%) patients, of which only 4 (10%) were also found to have acute coronary syndrome. No patients with new-onset BFB had STEMI. Furthermore, real-time diagnosis of anterior STEMI was complicated in two patients presenting with acute coronary syndrome by the masking of ST elevation in leads V1-3 by concomitant RBBB. Conclusions: In a large cohort of undifferentiated patients who presented with chest pain and RBBB or BFB (regardless if new or presumed new), only a small fraction had acute coronary syndrome, and even fewer STEMI. These data suggest patients with undifferentiated chest pain and RBBB on ECG with clinical suspicion for acute myocardial infarction and any degree of ST-elevation in leads V1-3 be considered for emergent coronary angiography rather than RBBB or BFB without ST-segment elevation.

Management of st-segment elevation myocardial infarction in comparison to european society of cardiology guidelines in alexandria university hospitals

Abstract Aim The aim of this study was to determine the major contributors to reperfusion delay in ST- elevation myocardial infarction (STEMI) patients in Alexandria University hospitals and the adherence to ESC clinical practice guidelines. Methods and results Prospective cohort of all patients presented with ST-elevation myocardial infarction (STEMI) with chest pain or discomfort between March 2020 and February 2021 in Alexandria university hospitals. A total of 436 patients were enrolled, 280 patients (64.2%) underwent PPCI, 32 patients (7.3%) had thrombolytic therapy and 124 patients (28.4%) had conservative strategy. In regard to the demographics and risk factors, the mean age of our cohort was 55.2 years. The majority were males (80.9%) and smokers (72.2%). Hypertension was a risk factor in 41.5% of our population, diabetes in 33.5%, and a family history was present in 14.2%, while 7.3% had renal impairment. The median pre-hospital delay was 360 minutes; mainly due to delay in seeking medical care which was the cause in 45.6%, whereas the mean ER time delay was 48.24 ± 89.30 minutes. The median time from CCU admission to wire crossing was 40.0 minutes with a mean value 53.86 ±49.0 minutes. The total ischemic time was 372 minutes (6.2 hours) with a mean ischemic time of 408 minutes (6.8 hours). The rate of reperfusion therapy (PPCI or thrombolysis) was 71.5 percent among all STEMI patients who presented within 12 hours, with achievement of timely reperfusion according to ESC guidelines for management of STEMI in 35.0%. The majority of our patients (70.7%) had door to wire crossing time of less than 90 minutes. In-hospital overall mortality was 5.5%. The PPCI group had a mortality rate of 2.9 percent, whereas the conservative management group had a mortality rate of 12.9 percent, with a statistically significant difference (P&amp;lt;0.001) between the two groups. In-hospital overall MACE was 27.3%. The PPCI group had MACE rate of 15%, the thrombolytic group had MACE rate of 28.1%, and the conservative management group had MACE rate of 54.8%, with a statistically significant difference (P&amp;lt;0.001) between the three groups. Conclusions Regardless of the financial and technical limitations in our center, timely reperfusion rate and performance are not far from meeting ESC 2017 guidelines for the management of STEMI. Primary PCI was the most frequently used treatment modality, and the associated total in- hospital mortality was below 5%. An enormous increase in the total ischemic time is a major concern due. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Inferior STEMI as the challenge of predicting the right coronary artery vs. the left circumflex artery as culprit lesion using the ECG criteria: a case report

Background: The morbidity and mortality in Inferior ST-elevation myocardial infarction (STEMI) is also determined by the location of the occlusion. Early Identification of the occlusion site is necessary to assist in the appropriate management of Inferior STEMI. This case study aims to evaluate the Electrocardiogram (ECG) examination, which has a basic role in the diagnosis of STEMI, both in determining the location of myocardial infarction and predicting the location of the culprit lesion. Case Presentation: A 48-year-old male patient complained of dull chest pain, such as being pressured by a heavy object and radiating to the back, followed by nausea, vomiting and cold sweats, and shortness of breath for 2 hours before coming to the hospital. On arrival, the patient was fully conscious with a blood pressure of 110/70 mmHg, pulse rate of 129x/minute with a SpO2 of 95% with electrocardiography (ECG) results showing atrial fibrillation with inferoposterolateral STEMI. Shortly after the ECG examination, the patient became unconscious, with blood pressure dropping to 60/palpation and bradycardia at 48 beats/minute. The patient underwent a fibrinolytic revascularization strategy with Streptokinase 1,500,000 U for 30 minutes, but soon the patient became unconscious with the ECG monitor showing ventricular fibrillation (VF). Hence, cardiopulmonary resuscitation was immediately performed with 360 J defibrillation twice, and the ECG returned to sinus rhythm. After stabilizing, the patient was referred for Rescue Percutaneous Coronary Intervention (PCI). The results of Coronary Angiography showed that the culprit lesion, in this case, was the Left Circumflex Artery with the Right Coronary Artery normal small, and non-dominant. Conclusion: ECG is still an important supporting examination in diagnosing and managing Acute Coronary Syndrome (ACS). An ECG can also help determine the culprit lesion in STEMI before angiography. Inferoposterolateral STEMI can be caused by blockage of the Right Coronary Artery (RCA) or Left Circumflex Artery (LCx).

Practice and Evaluation of a Protocol for Collating Information Related to the Emergency Clinical Pathway for Patients With Acute ST-Segment Elevation Myocardial Infarction.

Acute ST elevation myocardial infarction (STEMI) is a common acute and critical disease that requires rapid treatment within a limited window of time. In this study, we attempt to introduce a clinical pathway for the whole-process management of emergency STEMI based on the creation of a specific information system that matches the characteristics of emergency clinical work and evaluates their clinical value by quality control analysis. We deployed this system for 3 years and found that complications, heart failure, and medical costs during hospitalization were significantly reduced (p = 0.019) in patients with STEMI. By analyzing each link in the clinical pathway, our research indicates the clear clinical importance of developing methods to continuously improve data quality. Collectively, out research led to the optimization of an information system that will facilitate the clinical management of patients with STEMI.