Myocardial Blush Grade Research Articles

Short-term effects of upstream high bolus dose of tirofiban in patients with ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

No-reflow following primary percutaneous coronary intervention (PPCI) is challenging to treat. The objective of this study is to evaluate the efficacy and safety of upstream high-bolus-dose tirofiban administration in ST-segment elevation myocardial infarction (STEMI) cases undergoing PPCI on top of dual antiplatelet therapy, including ticagrelor, in comparison to selective bailout administration. This hospital-based, randomized, single-blinded prospective interventional study was conducted on 150 patients at Assiut University Heart Hospital. Patients with STEMI within 12 h after symptom onset who underwent PPCI were randomized to an upstream group (n = 75) and a selective bailout group (n = 75) based on the timing of the tirofiban bolus administration (25 µg/kg intravenously over 5 min). The bailout group's thrombolysis in myocardial infarction (TIMI) frame count was higher than the upstream group's, despite comparable TIMI flow and myocardial blush grade between the two groups, but only approached statistical significance [14.4 (4-36) vs 12.2 (5-55), P = 0.08]. The enzymatic infarct size tended to be lower in the upstream group. All echocardiographic findings were comparable between the two studied groups, with no significant difference (P > 0.05). There was no significant difference between the two groups regarding clinical outcomes. Compared to selective bailout administration, upstream high bolus dose of tirofiban in STEMI patients undergoing primary coronary intervention did not significantly affect angiographic outcomes, left ventricular remodeling, or function, despite smaller infarction size.

The procedural success of primary angioplasty in a tertiary care center in Pakistan.

This study was conducted to evaluate the procedural success of primary angioplasty in terms of TIMI flow and myocardial blush grade (MBG). We used cross-sectional population data of the patients who underwent primary PCI in Emergency Angiography department of Punjab Institute of Cardiology, Lahore from January 2021 to September 2021. TIMI flow and myocardial blush grades (MBG) were assessed before and after the procedure. All PCIs in which there was improvement in blood flow in infarct related artery of ≥2 grades in TIMI flow and/or in MBG were considered successful. A total of 106 patients were enrolled, 91 patients were male and 15 patients were female with the age range from 22 to 75 (48.7 ± 11.8) years. TIMI flow and MBG was improved ≥ 2 grades in 69 and 58 patients respectively. Improvement in TIMI flow was noted similar in all three vessels. Overall 65% patients showed improvement in TIMI flow and 55% in MBG. Onset of chest pain to balloon time was the most important parameter, shorter the time better the result. The patients in whom MBG was improved, the time was 234.26 ± 156.06 vs 323.59 ± 252.64 minutes. Primary angioplasty is quite effective procedure for the restoration of blood flow in acute ST elevation myocardial infarction but still it is far away from the ideal one. Although most patients benefit from primary PCI, a significant minority of individuals do not, particularly if they present late. What could be the ideal therapy, the answer is still to be answered.

Safety and Efficacy of Aspiration Thrombectomy With Intracoronary Tirofiban in Patients Undergoing Primary Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

BACKGROUND: Primary percutaneous coronary intervention (PPCI) may be complicated by heavy intracoronary thrombus burden leading to decrease in myocardial perfusion and increase in infarct size. The current meta-analysis aims to investigate the clinical outcomes of aspiration thrombectomy (AT) with intracoronary tirofiban during PPCI. METHODS: A systematic search for randomized controlled trials that evaluate the safety and efficacy of AT with intracoronary tirofiban in ST-elevation myocardial infarction (STEMI) patients who underwent PPCI was done using PubMed, MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov., and Herdin PH. Studies included those published between 2010 and 2023 and involved human subjects. Search terms included “aspiration thrombectomy,” “intracoronary tirofiban,” “primary percutaneous coronary intervention,” and “STEMI patients.” RESULTS: Four randomized controlled trials (n = 490 participants) were included in this metaanalysis comparing AT with intracoronary tirofiban versus AT alone in STEMI patients undergoing PPCI. The results revealed no statistically significant difference in ST-segment resolution (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.97–1.08; P = 0.41, I2 = 0%), myocardial blush grade 2–3, (RR, 1.04; 95% CI, 0.97–1.12; P = 0.22, I2 = 62%), and Thrombolysis In Myocardial Infarction 3 flow (RR, <1.0; 95% CI, 0.95–1.04; P = 0.87). The occurrence of major adverse cardiovascular events did not significantly differ between the two groups (RR, 0.46; 95% CI, 0.19–1.09; P = 0.08, I2 = 0%). There was no statistically significant difference in terms of bleeding when combining intracoronary tirofiban to standard medical therapy (RR, 1.35; 95% CI, 0.64–2.84; P = 0.78, four trials [490 patients]). CONCLUSION: In PPCI, major adverse cardiovascular event outcomes of AT with intracoronary tirofiban were similar to those for AT alone in terms of improving myocardial perfusion in STEMI patients without increasing the risk for bleeding. Our meta-analysis suggests that AT alone may be the more acceptable standard during PPCI when encountering heavy thrombus burden. Future validated studies may help further investigate the strategy of adding tirofiban during AT.

Effect of empagliflozin on no-reflow in patients with st elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background Primary percutaneous coronary intervention (PPCI) restores myocardial tissue perfusion successfully in over 90 % of ST-elevation myocardial infarction (STEMI) patients .However there remains a small proportion of patients who exhibit no-reflow.(1) Empagliflozin is a sodium glucose co-transporter 2 (SGLT2) inhibitor that acts as a powerful anti-oxidant and has beneficial effects on endothelial function and reducing burden of ischemia in-vitro.(2) Aim and Objectives: To Assess the effect of Empagliflozin preloading in non-diabetic STEMI patients before PPCI on procedural, in-hospital outcomes and short-term Major Adverse Cardiovascular events (MACE) in a single tertiary center. Patients and Methods: The study was carried out on 200 non-diabetic STEMI patients presenting to our university hospital within the first 8 hours of symptom onset. Patients were randomised into 2 groups , the intervention group received 10mg Empagliflozin before PPCI with the standard medical therapy while the control group received only the standard medical therapy. Patients were assessed for demographic data, risk factors, procedural outcomes, clinical and in-hospital outcomes, and short-term MACE up to 1 month. Results: Our study found a significant difference between the intervention and control groups regarding contrast volume with a mean of 131 ml in the intervention group and 144 ml in control group with a p value of 0.009, incidence of no-reflow with 34.5% in the control group and only 18.2% in the intervention group and a p value of 0.014 and myocardial blush grade (MBG) were 84.1% of the patients in intervention group had MBG III after PCI while only 65.5% of the patients in the control group showed the same results with a p value of 0.019. Also, there was a significant difference in St-segment resolution post PCI as 59.1% of patients in the intervention group had complete ST segment resolution and only 39.1% of the patients in the control group had complete resolution with a p-value of 0.027, and total MACE in the first month which affected 44.8% of the patients in the control group and only 28.4% of those in the intervention group with a p-value of 0.024. Conclusion Our study showed that pre-loading of STEMI patients with Empagliflozin resulted in improvement in procedural outcomes, decreasing the incidence of coronary no-reflow, improvement in patient’s course during hospital stay and short-term MACE. Improvement in MACE was mainly due to reduced HF hospitalisations and anginal symptoms.

Safety and efficacy of aspiration thrombectomy with intracoronary tirofiban VS aspiration thrombectomy alone in patients undergoing primary PCI: a systematic review and meta-analysis

Abstract Background Primary percutaneous coronary intervention (PPCI) may be complicated by intracoronary thrombus accumulation in ST elevation myocardial infarction (STEMI) leading to decrease in myocardial perfusion and increase in infarct size. The utilization of aspiration thrombectomy and intracoronary tirofiban in STEMI patients undergoing PPCI hold clinical relevance by removal of thrombus burden, potentially reducing distal embolization and improving myocardial perfusion and by targeting platelet aggregation to mitigate thrombotic complications, respectively. Given the paramount importance of achieving rapid and effective reperfusion in STEMI, the evaluation of these interventions is warranted to assess overall impact on patient outcomes in terms of safety and efficacy. Purpose The current meta-analysis aims to investigate the clinical outcomes of aspiration thrombectomy (AT) with intracoronary tirofiban versus AT alone during PPCI. Methods A systematic search for randomized controlled trials that evaluate the safety and efficacy of aspiration thrombectomy with intracoronary tirofiban in STEMI patients who underwent PPCI was done using PubMed, MEDLINE, Embase, Cochrane, Clinicaltrials.gov. and Herdin PH. Studies included those between 2010 - 2023 and involved human subjects. Search terms included "Aspiration Thrombectomy", "Intracoronary Tirofiban", "Primary Percutaneous Coronary Intervention" and "STEMI patients". Results Four RCTs (n: 490 participants) were included in this meta-analysis comparing aspiration thrombectomy with intracoronary tirofiban versus aspiration thrombectomy alone in STEMI patients undergoing PPCI. The results revealed no statistically significant difference in ST segment resolution (RR 1.02, 95%, CI: 0.97 - 1.08, P = 0.41, I2 = 0%), myocardial blush grade 2-3, (risk ratio of 1.04, 95%, CI: 0.97 – 1.12, P = 0.22, I2 = 62%) and TIMI 3 flow (risk ratio of 1.0, 95% CI: 0.95 - 1.04, P = 0.87). The occurrence of major adverse cardiovascular events did not significantly differ between the two groups (RR 0.46, 95% CI: 0.19 – 1.09, P = 0.08, I2 = 0%). There was no statistically significant difference in terms of bleeding when combining intracoronary tirofiban to standard medical therapy (RR 1.35, 95% CI: 0.64 – 2.84, P= 0.78, 4 trials [490 patients]). Conclusion In primary percutaneous coronary intervention, MACE outcomes of aspiration thrombectomy with intracoronary tirofiban were similar to that for aspiration thrombectomy alone in terms of improving myocardial perfusion in STEMI patients without increasing the risk for bleeding. Our meta-analysis suggests that AT alone may be the more acceptable standard during PPCI when encountering heavy thrombus burden. Future validated studies may help further investigate the strategy of adding tirofiban during aspiration thrombectomy.1. Primary Outcomes2. Secondary Outcomes

Cangrelor use in ticagrelor-loaded ST-elevation myocardial infarction patients with high residual platelet reactivity: a randomized controlled trial

Abstract Background Despite the use of potent P2Y12 inhibitor, many patients still present with high platelet reactivity (HPR) at the time of primary percutaneous coronary intervention (PCI). HPR is associated with impaired myocardial reperfusion and the subsequent poor outcome. Purpose We sought to determine the impact of Cangrelor -a rapid and potent intravenous P2Y12 inhibitor- on myocardial reperfusion in patients with HPR admitted for primary PCI in a randomized trial. Methods Patients pre-treated with ticagrelor and aspirin with residual HPR (baseline platelet reactivity unit (PRU) > 208) were randomly assigned in a 1:1 ratio to receive cangrelor (experimental group) or not (control group) just before PCI. The primary endpoint was optimal myocardial reperfusion defined as a final myocardial blush grade (MBG) 3 assessed by an independent core laboratory. Results After screening of 128 patients, a total of 60 patients were with HPR were enrolled and randomized. The ticagrelor loading dose to PRU measurement times were 83 ± 32 and 90 ± 47 minutes in the experimental and control groups, respectively. Baseline PRU were 245 ± 30 and 252 ± 35 in the experimental and standard group, respectively. A final MBG 3 was observed in 21/30 (55%) and 17/30 (45%) the experimental and standard groups (p=0.29). A final TIMI flow grade 3 was observed in 30/30 (100%) and 27/30 (90%) the experimental and standard groups (p=0.24). Peak troponin levels after PCI were 51381 ± 50047 and 51078 ± 63960 ng/L (p=0.98) in the experimental and standard group, respectively. At the end of the PCI, control PRU were 36 ± 57 and 198 ± 107 (p<0.0001) in the experimental and standard group, respectively. One patient of the experimental group presented an in-hospital major bleeding (BARC 3). Conclusion In ticagrelor-loaded STEMI patients with residual HPR at the time of PCI, cangrelor use was associated with a more effective platelet inhibition but failed to significantly improve the rates of optimal final myocardial blush grades.

Relation between Myocardial Blush Grade and Left Ventricular Systolic and Diastolic Function after Primary Percutaneous Coronary Intervention in Patients with Type 2 Diabetes Mellitus

Relation between Myocardial Blush Grade and Left Ventricular Systolic and Diastolic Function after Primary Percutaneous Coronary Intervention in Patients with Type 2 Diabetes Mellitus

Prognostic value of no-reflow phenomenon in myocardial infarction: the role of the severity of ischemic damage

Aim. To create a scale for assessing the myocardial ischemia severity and to study the effect of concomitant ischemia on the prognosis of myocardial infarction (MI) complicated by no-reflow phenomenon during percutaneous coronary intervention (PCI).Material and methods. A single-center cohort study was conducted. There were following inclusion criteria: MI, PCI, total ischemic time <48 h and no-reflow (TIMI flow grade <3 or Myocardial blush grade <2 or ST segment resolution <70%). The proposed scale included infarction-related lesion in the left main coronary artery or proximal left anterior descending artery — 2 points; total ischemic time >12 h — 1 point; TIMI flow grade 0-1 before PCI — 1 point; Rentrop collateral circulation grade 0-1 — 1 point. Severe ischemia — more than 3 points. Propensity score matching was used to correct differences between the groups. Median follow-up was 979 [743; 1318] days.Results. A total of 18079 patients with acute coronary syndrome were analyzed, while 219 were included. After comparison, 105 patients remained as follows: group 1 — 75 patients without assessed severe ischemia; group 2 — 30 patients with assessed severe ischemia. During the hospital stage, 6 (8,0%) and 9 (30,0%) patients died, respectively, p<0,001. The left ventricular ejection fraction was 47 [42; 50]% and 41 [39; 45]%, respectively, p<0,001. Severe ischemia was associated with a 4,15-fold increase in the long-term death risk (95% confidence interval 1,87-9,20; p<0,001).Conclusion. Concomitant severe ischemic damage in MI complicated by no-reflow during PCI is associated with worse left ventricular function and a higher death risk at the hospital stage and in the long-term follow-up period.

Value of Cardiac Magnetic Resonance Imaging in Assessment of the Myocardial Reperfusion after Primary Percutaneous Coronary Intervention with or without Thrombus Aspiration in Patients with ST-Elevation Myocardial Infarction with High Thrombus Burden

Abstract Background 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. Objective The study aims to evaluate the efficacy and safety of the manual thrombus aspiration during primary PCI for the acute ST-elevation myocardial infarction (STEMI) patients with high thrombus burden. Patients and Methods The current study was prospective cohort study which was conducted on 100 patients presenting to cardiology department in Ain Shams University hospitals with STEMI in the first 12 hours of presentation, comparing two group (50 patients in each group): the thrombus aspiration group(group A) who underwent manual thrombus aspiration before the provisional stenting and the conventional PCI group (group B) who underwent provisional stenting using standard technique without thrombus aspiration.). every patient is assigned to a particular group based on the operator’s preference. The blood flow of the culprit coronary artery in the thrombolysis in myocardial infarction (TIMI) and the myocardial blush grade(MBG) was recorded immediately after the emergency PCI operation in each group, then an echocardiogram was performed to determine the left ventricular dimensions and ejection fraction within in 1 week after the operation, cardiac MRI was performed 3 months after the operation to determine the left ventricular dimensions, ejection fraction, stroke volume and size of infarction and finally the data on major adverse cardiovascular events (MACE) during the 6 months of postoperative follow-up were collected. Results There were no statistically significant differences between the two groups in terms of the demographic data, the cardiovascular risk factors, the vital data at the time of the hospital admission, the Killip class and the pain to door. The postoperative final TIMI flow was TIMI III flow in 46 patients (92%) of the thrombus aspiration group vs 34 patients (68%) in the conventional PCI group with P- value = 0.003 (statically highly significant). The final MBG was grade III in 40 patients (80%) of the thrombus aspiration group vs 30 patients (60 %) in the conventional PCI group, grade II in 10 patients (20 %) vs 16 patients (32%) and grade 0 only in 4 patients (4 %) in the conventional PCI group with P- value = 0.033 (statically significant). The post operative ECHO showed smaller Left ventricular dimensions with higher Left ventricular systolic and diastolic function in the thrombus aspiration group than the conventional PCI group with p value = 0.000 (statically highly significant). The postoperative cardiac MRI showed smaller Left ventricular end -systolic and end -diastolic volumes index with higher Left ventricular systolic function and Left ventricular Stroke volume index in the thrombus aspiration group than the conventional PCI group with p value = 0.000 (statically highly significant). Moreover, the postoperative cardiac MRI showed smaller LV Size of infarction (LV myocardia scar) in the thrombus aspiration group than the conventional PCI group with p value = 0.000 (statically highly significant).finally, there was a significant reduced rate of cardiovascular death and major adverse cardiovascular events (MACE) with no difference regarding the rate of the cerebrovascular stroke within 6 months post procedure in the thrombus aspiration group compared to the conventional PCI group with p value = 0.027 (statically significant).

Failed Thrombus Aspiration and Reduced Myocardial Perfusion in Patients With STEMI and Large Thrombus Burden

BackgroundThrombus aspiration (TA) is used to decrease large thrombus burden (LTB), but it can cause distal embolization. ObjectivesThe aim of this study was to investigate the impact of TA failure on defective myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI) and LTB. MethodsIn total, 812 consecutive patients with STEMI and LTB (thrombus grade ≥3) were enrolled, who underwent manual TA during the primary percutaneous coronary intervention. TA failure was defined as the absence of thrombus retrieval, presence of prestenting thrombus residue, or distal embolization. The final TIMI flow grades and other myocardial perfusion parameters of the failed TA group were matched with those of the successful TA group. ResultsThe proportion of final TIMI flow grade 3 was lower (74.6% vs 82.2%; P = 0.011) in the failed TA group (n = 279 [34.4%]) than in the successful TA group (n = 533 [65.6%]). The failed TA group also had lower myocardial blush grade, lower ST-segment resolution, and a higher incidence of microvascular obstruction than the successful TA group. TA failure was independently associated with low final TIMI flow grade (risk ratio: 1.525; 95% CI: 1.048-2.218; P = 0.027). Old age, Killip class ≥III, vessel tortuosity, calcification, and a culprit vessel other than the left anterior descending coronary artery were associated with TA failure. ConclusionsTA failure is associated with reduced myocardial perfusion in patients with STEMI and LTB. Advanced age, hemodynamic instability, hostile coronary anatomy such as tortuosity or calcification, and non–left anterior descending coronary artery status might attenuate TA performance. (Gangwon PCI Prospective Registry [GWPCI]; NCT02038127)

Clinical, electrocardiographic, echocardiographic, and angiographic predictors for the final infarct size assessed by cardiac magnetic resonance in acute STEMI patients after primary percutaneous coronary intervention

BackgroundFinal infarct size (IS) after ST segment elevation myocardial infarction (STEMI) is a major predictor of mortality. Seeking early predictors for final IS can guide individualized therapeutic strategies for those recognized to be at higher risk.ResultsEighty STEMI patients successfully treated with primary percutaneous coronary intervention (pPCI) underwent baseline (within 48 h) 2D, 3D echocardiography with speckle tracking and then underwent cardiac magnetic resonance (CMR) at 3 months to assess the final IS. After recruitment, 4 patients were excluded for uncontainable claustrophobia while 76 patients completed the final analysis. The mean ± standard deviation age was 54.1 ± 10.9 years, 84% were males, 25% had diabetes, 26% were hypertensives, 71% were current smokers, 82% had dyslipidemia, and 18% had a family history of premature coronary artery disease. By 3 months, CMR was performed to accurately evaluate the final IS. In univariate regression analysis, the admission heart rate, baseline and post-pPCI ST elevation, STEMI location (anterior vs. inferior), highest peri-procedural troponin, large thrombus burden, baseline thrombolysis in myocardial infarction flow grade, the final myocardial blush grade, the 2D and 3D left ventricular ejection fraction (LVEF), and the 2D and 3D global longitudinal strain (GLS) parameters were significant predictors for the final IS. In the multivariate regression analysis, four models were constructed and recognized the residual post-PCI ST segment elevation, the highest peri-procedural troponin, the 2D-LVEF, 3D-LVEF, and 2D-GLS as significant independent predictors for final IS.ConclusionsIn STEMI patients who underwent successful pPCI, early predictors for the final IS are vital to guide therapeutic decisions. The residual post-pPCI ST elevation, the highest peri-procedural troponin, and the baseline 2D-LVEF, 3D-LVEF, and 2D-GLS can be excellent and timely tools to predict the final IS.

The value of viscoelastic platelet function measurements with Sonoclot in patients with acute coronary syndrome undergoing percutaneous coronary intervention

PurposePlatelets play an important role in the pathogenesis of acute coronary syndrome (ACS), and adequate platelet inhibition is a cornerstone during invasive management with percutaneous coronary intervention (PCI). Despite this, pivotal role routine measurement of platelet function is not done. We aimed at using the using the Sonoclot device for measuring platelet activity and predicting outcome in patients with ACS undergoing PCI.MethodsThis was a cohort longitudinal study involving 50 patients who were admitted with ACS and undergoing emergent PCI in the critical care department at Cairo University from November 2020 to July 2021. Three parameters will be obtained: platelet function, ACT, and coagulation rate.ResultsAccording to the 1st parameter (platelet function), adequate platelet inhibition was achieved in 54% of our cases. To study the impact of this analysis, our population was classified into 2 groups (well-inhibited platelets vs. poorly inhibited platelets). The 2nd and 3rd parameters (ACT, CR) could separate our patients into 2 groups according to whether patients were well anticoagulated or not. Classification 1, well vs. poorly inhibited platelets, both groups were comparable. However, epicardial coronary flow (TIMI flow) and myocardial blush grade post-stenting were better in the well-inhibited platelets group. Classification 2, well vs. poor anticoagulation, there were no significant differences between the 2 groups.ConclusionAdequate platelet inhibition as measured by Sonoclot device can predict better outcomes in patients with ACS undergoing PCI.

Ticagrelor versus Clopidogrel in Prevention of No Reflow after 1ry PCI in Diabetic Patients with STEMI

Abstract Background Adequacy of coronary flow can be judged upon using several methods like TIMI Grade and myocardial blush grade. No-reflow phenomenon, defined as incomplete reperfusion at the microvascular level despite adequate patency of the occluded artery, remains an important limitation of primary percutaneous intervention in STEMI patients nowadays. We aim in this study to investigate the relationship between the antiplatelet loading dose whether to be Ticagrelor or Clopidogrel and post intervention coronary flow, bleeding risk in these patients. Aim of the Work To compare between the effects of preoperative loading dose of Ticagrelor and clopidogrel in Diabetic STEMI patients undergoing primary percutaneous coronary intervention regarding prevention of no reflow, Instent thrombosis and short term bleeding risk. Myocardial reperfusion was judged upon using TIMI Grade and myocardial blush grade. Patients and Methods a single center prospective randomized controlled trial based at the coronary care units in Ain shams university hospitals. The study included Three hundred Diabetic patients presenting to Ain shams university hospitals diagnosed with STEMI in the ER fulfilling the inclusion criteria were randomized to receive Ticagrelor (150 patients) or receiving clopidogrel (150 patients) Results As regard TIMI flow there was statistically highly significant highly significant difference between two studied groups with P value 0.000 where in group A 64 % of patients developed TIMI III flow, 22.7 % with TIMI II flow, 12.7% with TIMI I and 0.7% with TIMI 0 While in group B 86% of patients developed TIMI III flow, 9.3% of them developed TIMI II, 3.3 % developed TIMI I flow and 1.3 % developed TIMI 0. As regard MBG there was statistically highly significant difference between two groups with P value 0.00 where in group A where percentage of patients with MBG grades 0,1,2 and 3 were 4%, 16 %,18 % and 62 % respectively while in group B percentage of patients with MBG grades 0,1,2 and 3 were 1.3 %, 3.3 %, 9.3 % and 86 % respectively. As regard echo EF, there was statistically significant difference between two groups with P value 0.036 where mean EF in patients with group A was 40.50 ± 7.93 while the mean EF in patients with group B was 42.55 ± 8.88 . Conclusion Ticagrelor loading before primary PCI resulted in improved post-procedural TIMI flow. It also increased the post-procedural MBG. This resulted in a significant increase in the number of patients having more post-procedural Ejection fraction as measured by modified Simpson’s method. However, it did not decrease incidence of in-hospital MACE. Also there was no significant increase in risk of major nor minor bleeding in both young and elderly patients.

Ticagrelor versus Clopidogrel in Prevention of No Reflow after 1ry PCI in Diabetic Patients with STEMI

Abstract Background Adequacy of coronary flow can be judged upon using several methods like TIMI Grade and myocardial blush grade. No-reflow phenomenon, defined as incomplete reperfusion at the microvascular level despite adequate patency of the occluded artery, remains an important limitation of primary percutaneous intervention in STEMI patients nowadays. We aim in this study to investigate the relationship between the antiplatelet loading dose whether to be Ticagrelor or Clopidogrel and post intervention coronary flow, bleeding risk in these patients. Aim of the Work To compare between the effects of preoperative loading dose of Ticagrelor and clopidogrel in Diabetic STEMI patients undergoing primary percutaneous coronary intervention regarding prevention of no reflow, Instent thrombosis and short term bleeding risk. Myocardial reperfusion was judged upon using TIMI Grade and myocardial blush grade. Patients and Methods a single center prospective randomized controlled trial based at the coronary care units in Ain shams university hospitals. The study included Three hundred Diabetic patients presenting to Ain shams university hospitals diagnosed with STEMI in the ER fulfilling the inclusion criteria were randomized to receive Ticagrelor (150 patients) or receiving clopidogrel (150 patients) Results As regard TIMI flow there was statistically highly significant highly significant difference between two studied groups with P value 0.000 where in group A 64 % of patients developed TIMI III flow, 22.7 % with TIMI II flow, 12.7% with TIMI I and 0.7% with TIMI 0 While in group B 86% of patients developed TIMI III flow, 9.3% of them developed TIMI II, 3.3 % developed TIMI I flow and 1.3 % developed TIMI 0. As regard MBG there was statistically highly significant difference between two groups with P value 0.00 where in group A where percentage of patients with MBG grades 0,1,2 and 3 were 4%, 16 %,18 % and 62 % respectively while in group B percentage of patients with MBG grades 0,1,2 and 3 were 1.3 %, 3.3 %, 9.3 % and 86 % respectively. As regard echo EF, there was statistically significant difference between two groups with P value 0.036 where mean EF in patients with group A was 40.50 ± 7.93 while the mean EF in patients with group B was 42.55 ± 8.88 . Conclusion Ticagrelor loading before primary PCI resulted in improved post-procedural TIMI flow. It also increased the post-procedural MBG. This resulted in a significant increase in the number of patients having more post-procedural Ejection fraction as measured by modified Simpson’s method. However, it did not decrease incidence of in-hospital MACE. Also there was no significant increase in risk of major nor minor bleeding in both young and elderly patients.

COMPARATIVE EFFICACY OF INTRACORONARY VERAPAMIL AND ADRENALINE IN MANAGING CORONARY NO-REFLOW DURING PRIMARY PCI IN STEMI PATIENTS AT A TERTIARY CARE HOSPITAL

Coronary No-Reflow (CNR) is a significant complication during Primary Percutaneous Coronary Intervention (PPCI) for ST-Elevation Myocardial Infarction (STEMI), often leading to poor clinical outcomes. Management strategies for CNR include various pharmacological agents, among which intracoronary verapamil and intracoronary adrenaline are commonly used alongside Glycoprotein IIb/IIIa inhibitors. Objective: This study aims to compare the effectiveness of intracoronary verapamil versus intracoronary adrenaline, alongside Glycoprotein IIb/IIIa inhibitors, in managing Coronary No-Reflow (CNR) during Primary Percutaneous Coronary Intervention (PPC1) for STEMI patients. Methodology: This randomized-control-trial was conducted at the Department of Cardiology, MTI Lady Reading Hospital Peshawar, Pakistan, from May 2023 to April 2024. Fifty patients diagnosed with CNR during PPC1 were randomised into two groups: adrenaline and verapamil. The primary outcome measures were TIMI Flow Grade (TFG) and Myocardial Blush Grade (MBG) immediately post-intervention. In contrast, secondary outcomes included Major Adverse Cardiovascular Events (MACE), myocardial infarction, stroke, target vessel revascularisation, mortality, and Left Ventricular Ejection Fraction (LVEF) assessed at baseline and one-month follow-up. Statistical analyses were performed using IBM SPSS version 20, with significance at P<0.05. Results: Baseline characteristics, procedural details, and initial TIMI flow grades were similar between groups. Adrenaline achieved universal TIMI 3 flow compared to 84% with verapamil (p=0.049), but no significant differences were noted in myocardial blush grades. Adrenaline led to significantly higher follow-up LVEF (45.0 ± 9.0 vs. 39.0 ± 9.0, p=0.027) and a more significant percentage change in LVEF (20.97% vs. 8.94%, p=0.042) than verapamil. Adverse event rates were comparable except for lower MACE incidence at 30 days with adrenaline (8.0% vs. 24.0%, p=0.039). Conclusion: Adrenaline notably enhanced TIMI 3 flow rates, improved left ventricular ejection fraction, and decreased significant adverse cardiovascular events at 30 days compared to verapamil. These findings suggest that adrenaline may be a superior option for improving coronary blood flow and early clinical outcomes in this patient population.

Aortic Arch Calcification in Predicting Unfavorable Angiographic Outcomes for Patients with ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Background: Despite advances in treatment, no-reflow, large thrombus burden (LTB), and myocardial blush grade (MBG) are associated with adverse cardiovascular outcomes in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI). Aortic arch calcification (AAC) is associated with subclinical atherosclerosis and adverse cardiovascular events. We aimed to examine the relationship between AAC and unfavorable angiographic outcomes such as no-reflow, MBG, and LTB in STEMI patients undergoing PCI. Methods: A total of 269 consecutive patients who presented with STEMI and underwent primary PCI were included in the study prospectively. Patients were divided into 3 groups according to AAC degree: grade 0, grade 1, and grade 2/3. The relationship between AAC and the predictors of unfavorable angiographic outcomes, including LTB, no-reflow, and MBG, was specifically examined. Results: LTB, no-reflow, and MBG 0/1 were significantly higher in the grade 2/3 AAC group compared to the grade 0 and grade 1 groups (all p < 0.05). Moreover, grade 2/3 AAC was found to be an independent predictor for LTB, MBG 0/1, and no-reflow (p = 0.002, p = 0.005, p = 0.004, respectively). Patients were then classified according to thrombus burden, MBG, and no-reflow status. Grade 2/3 AAC was significantly higher than grade 0/1 AAC in the LTB, MBG 0/1, and no-reflow groups (all p < 0.05). Conclusion: AAC can be used as a reliable indicator in predicting no-reflow, MBG 0/1, and LTB in STEMI patients undergoing primary PCI.

Efficacy and Safety of Alprostadil in Microcirculatory Disturbances During Emergency PCI: A Meta-Analysis of Randomized Controlled Trials.

The clinical advantage of alprostadil [prostaglandin E1 (PGE1)] in the treatment of microcirculatory disturbances (defined as no-reflow or slow-flow) in acute percutaneous coronary intervention (PCI) is still disputed. The purpose of our study was to review the efficacy of PGE1 supplements in patients with acute myocardial infarction (AMI) who had urgent PCI. This study was a meta-analysis of randomized controlled trials. PubMed, Embase, the Cochrane Library, Ovid, ProQuest, Scopus, the Chinese BioMedical Literature Database, China National Knowledge Internet, the China Science and Technology Journal Database, and the Wanfang Data Knowledge Service Platform were used as sources. We included randomized controlled trials including PGE1 for the treatment of intraoperative microcirculatory disorders and major cardiovascular adverse events in emergency PCI in people with AMI. Independent data extraction was conducted, and study quality was assessed. The meta-analysis was carried out by using random effects models to calculate the risk ratio (RR) of microcirculatory disorders between groups receiving PGE1 and those receiving placebo, nitroglycerin, or tirofiban. The primary endpoint of the study was the incidence of microcirculatory disturbances. Secondary outcomes included corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC), the percentage of patients with TIMI myocardial perfusion grade 3 (TMPG3), and the percentage of patients with myocardial blush grade 3 (MBG3) as efficacy indicators. Additionally, major adverse cardiovascular events (MACE) at 30 days and 180 days were assessed as safety indicators. There were 18 trials involving a total of 1458 participants. PGE1 significantly reduced the occurrence of microcirculation disorders compared with conventional medications and placebo [risk ratio 0.48, 95% confidence interval (CI) 0.36-0.63, I2 = 46%; cTFC (RR -4.74, 95% -6.85 to -2.63, I2 93%); percentage of patients with TMPG3 (RR 1.34, 95% CI 1.07-1.68, I2 70%) or MBG3 (RR 1.33, 95% CI 1.19-1.49, I2 0%); major adverse cardiovascular events (MACEs) in 30 days (RR 0.48, 95% CI 0.27-0.86, I2 0%); and MACEs in 180 days (RR 0.41, 95% CI 0.28-0.60, I2 0%)]. We found thatPGE1 decreased the occurrence of micro-circulation disturbance in AMI and enhanced the outcome of PCI.Additional studies should be conducted to confirm these findings.

Provocative Strategies for Primary PCI in STEMI: Time to Rethink Guidelines

Background: The primary percutaneous coronary intervention (PCI) is now the reference treatment for ST-segment elevation myocardial infarction (STEMI). Findings from randomized controlled trials suggest that PCI is superior to thrombolytic therapy in preventing death and recurrent myocardial infarction. However, longer delays for PCI implementation and variability in outcomes among different operators and centers may affect its efficacy. The European guidelines recommend fibrinolytic therapy if PCI cannot be performed within 120 minutes of the first medical contact. Objective: The main objective of the study was to evaluate the efficacy of adjunctive provocative strategies in primary PCI for STEMI and their impact on procedural success and clinical outcomes. Methods: This retrospective observational study was conducted at Luqman International Hospital, Mingora Swat, from December 2022 to June 2023. Data were collected from 230 STEMI patients, including demographic information, clinical characteristics, procedural details, and outcomes. The primary outcome measure was the occurrence of major adverse cardiac events (MACE) within 30 days and one year after primary PCI. Secondary outcomes included procedural success rate, myocardial blush grade, and left ventricular ejection fraction (LVEF) during follow-up assessments. Statistical analyses were performed using SPSS version 25, with continuous variables expressed as means and standard deviations and categorical variables as frequencies and percentages. Comparisons between groups were conducted using chi-square tests for categorical variables and Student’s t-tests or Mann-Whitney U tests for continuous variables, with a p-value of less than 0.05 considered statistically significant. Results: Of the 230 patients, 120 (52%) received conventional strategies, while 110 (48%) received adjunctive provocative strategies. The provocative strategy group had higher rates of successful reperfusion (95.5% vs. 83.3%), improved myocardial blush grades (mean ± SD: 3.2 ± 0.6 vs. 2.7 ± 0.8), and lower rates of the no-reflow phenomenon (9.1% vs. 20.8%). At 30 days post-PCI, the incidence of MACE was lower in the provocative strategy group (9.1% vs. 12.5%). At one year, the provocative strategy group continued to show lower MACE rates (16.4% vs. 20.8%). Conclusion: Adjunctive provocative strategies in primary PCI for STEMI show promise in enhancing reperfusion efficacy and preserving myocardial function. While trends towards improved procedural success and short-term outcomes were observed, larger prospective studies are needed to validate these findings. The exploration of provocative strategies represents an important avenue for advancing STEMI management and improving patient outcomes in interventional cardiology.

Influence of chronic obstructive pulmonary disease on hospital outcomes of percutaneous coronary interventions in patients with acute coronary syndrome

To evaluate the impact of chronic obstructive pulmonary disease (COPD) on hospital outcomes of percutaneous coronary interventions (PCI) in patients with acute coronary syndrome (ACS). A cohort prospective study of the COPD effect on mortality and coronary microvascular obstruction (CMVO, no-reflow) development after PCI in ACS was carried out. 626 patients admitted in 2019-2020 were included, 418 (67%) - men, 208 (33%) - women. Median age - 63 [56; 70] years. Myocardial infarction with ST elevation identified in 308 patients (49%), CMVO - in 59 (9%) patients (criteria: blood flow <3 grade according to TIMI flow grade; perfusion <2 points according to Myocardial blush grade; ST segment resolution <70%). 13 (2.1%) patients died. Based on the questionnaire "Chronic Airways Diseases, A Guide for Primary Care Physicians, 2005", 2 groups of patients were identified: 197 (31%) with COPD (≥17 points) and 429 (69%) without COPD (<17 points). Groups were compared on unbalanced data (÷2 Pearson, Fisher exact test). The propensity score was calculated, and a two-way logistic regression analysis was performed. The data were balanced by the Kernel "weighting" method, logistic regression analysis was carried out using "weighting" coefficients. Results as odds ratio (OR) and 95% confidence interval. The conducted research allowed us to obtain the following results, depending on the type of analysis: 1) analysis of unbalanced data in patients with COPD: OR death 3.60 (1.16-11.12); p=0.03; OR CMVO 0.65 (0.35-1.22); p=0,18; 2) two-way analysis with propensity score: OR death 3.86 (1.09-13.74); p=0.04; OR CMVO 0.61 (0.31-1.19); p=0.15; 3) regression analysis with "weight" coefficients: OR death 12.49 (2.27-68.84); p=0.004; OR CMVO 0.63 (0.30-1.33); p=0.22. The presence of COPD in patients with ACS undergoing PCI increases mortality and does not affect the incidence of CMVO.

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 &lt;3, Myocardial blush grade &lt;2, ST segment resolution after PCI &lt;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) &gt;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 &gt;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.