Persistent ST-segment Elevation Research Articles

Right ventricular infarction: epidemiological, clinical, and angiographic characteristics and the outcomes through the experience of a Moroccan cardiology department

Background: Acute myocardial infarction (MI) is a major cause of cardiovascular mortality, which is the leading cause of death in the world. Our objective in this study was to evaluate the epidemiological, clinical, and angiographic features of right ventricular infarction (RVI), as well as its complications and its therapeutic approaches. Patients and methods: It is a single-centered retrospective descriptive study conducted over a period of 2 years from November 2018 to October 2020. The authors included 82 patients with RVI hospitalized in the cardiovascular ICU during the initial phase of acute coronary syndrome with persistent ST segment elevation. Patients who were diagnosed with RVI at electrocardiogram and echocardiography were recruited. Results: The authors included 500 patients hospitalized for STEMI, 82 had MI extended to the RV, reflecting a rate of 16.4%. The mean age in our study was 64±12.3 years. Dyslipidemia, diabetes mellitus, and hypertension were the most common cardiovascular risk factors among these patients. RVI co-existed with inferior MI in 62.2 of cases and in 37.8% of anterior MI, while isolated RVI was seen in only one patient. Transthoracic echocardiography showed right ventricular (RV) systolic dysfunction in 24.39% of cases, while RV dilatation was seen in only 10.9% of patients. Therapeutic approach was based essentially on revascularization with thrombolysis and coronary angiography +/- PCI. The percentage of mortality was 2.4%. Conclusion: RVI is relatively rare and is mostly related to an extension of an inferior MI. Early diagnosis, prompt treatment, and appropriate are the keys to improve prognosis, and reduce complications.

Characterisation of Patients with Acute Coronary Syndrome: A 10-Year Experience

Introduction: Coronary intervention is a therapeutic method for acute coronary syndrome. Objectives: Characterise patients with acute coronary syndrome treated by percutaneous coronary intervention. Method: Analytical, observational, retrospective, and cross-sectional study of 1,469 patients with the diagnosis of acute coronary syndrome, treated with percutaneous coronary intervention at the Hermanos Ameijeiras Hospital, Havana, Cuba, between 2010–2019. Results: The mean age of the patients was 61.1±10.6 years, 72% were male, and 68.3% had acute coronary syndrome without persistent ST-segment elevation. The commonest risk factor was hypertension (69%). Radial access was used in 75.0% of procedures, and 82.0% had a single occluded epicardial coronary artery (42.4% anterior descending artery, 29.7% right coronary artery). One (63.3%) bare metal stent was implanted in 70.7% of patients, with a 96.0% angiographic success rate. There were complications in 1.1% of cases. Diabetes was significantly associated with the failure of the procedure. Conclusions: Most of the patients were middle-aged, with hypertension and a diagnosis of non-ST-segment elevation acute coronary syndrome, where the most frequently treated artery is the left anterior descending artery, and the radial artery is the most commonly used vascular access route with an elevated number of successful procedures. The presence of diabetes is significantly associated with the failure of the procedure.

Acute Coronary Syndrome in Women at the CHU le Luxembourg of Bamako

Introduction: Acute coronary syndromes have been very little studied in the female population in black Africa. Our series showed an increase in the prevalence of acute coronary syndromes in the female population compared to previous studies. Through this retrospective study, we evaluated the epidemiological, clinical, paraclinical, therapeutic and evolutionary specifications of acute coronary syndromes in women. Methodology: This was a retro and prospective study, concerning patients admitted for an acute coronary syndrome over a period of 3 years from September 1, 2019, to August 30, 2022, in the interventional cardiology unit at the CHU le Luxembourg of Bamako. Results: During the study period, 74 patients’ files were collected out of 251 patients, i.e., a frequency of ACS in women of 29.5%. The average age of the patients was 59.31 ± 10.89 years (37 and 83 years) and the age group 45-65 years was the most affected. The risk factors were essentially high blood pressure 66.2% (n=49), physical inactivity 66.2% (n=49) and diabetes 59.5% (n=44). The predominant functional signs were atypical chest pain in 56.8% of cases (n=42). The electrical aspect was mainly persistent ST-segment elevation in 61% (n=45). Seventy-six percent (n=56) of patients were treated 12 hours after the first medical contact. The approach for coronary angiography was radical in 93%. Coronary angiography was pathological in 92% (n=68). Lesions were single vessel in 29.7% of cases and multi-vessel in 62.2% of cases. Conclusion: Acute coronary syndrome in women is characterized by atypical of symptoms with a delay in diagnosis and management. Coronary lesions are characterized by multi-vessel involvement in the majority of cases.

Evaluation of antioxidant activity in without persistent ST-segment elevation

Aims: Coronary artery disease is the most common cause of mortality and morbidity worldwide. Oxidative stress is involved in the pathogenesis of many diseases, including atherosclerosis. Thiols are important antioxidants for the elimination of reactive oxygen radicals and oxidative stress. In this study, we aimed to compare patients suffering from without persistent ST-segment elevation (NSTMI) and volunteers with normal coronary arteries in terms of antioxidants. Methods: The study included 105 patients diagnosed with NSTMI and 51 controls. Plasma total thiol, native thiol, and disulfide levels were measured. Results: Baseline demographic characteristics were similar between the groups. The ejection fraction was lower in the patient group. In terms of biochemical and hematologic parameters, glucose, AST, ALT, white blood cell count, and troponin were higher in the patient group, while other parameters were similar. Plasma native thiol (344.32 ± 81.28 µmol/L versus 403.62 ± 62.36 µmol/L, p < 0.0001) and total thiol (382.90 ± 91.13 µmol/L versus 444.17 ± 65.53 µmol/L, p < 0. 0001) levels were lower in NSTMI patients compared to control patients, while disulfide (19.29± 3.19 versus 20.27± 8.10, p = 0.77) levels were similar between the groups. Conclusion: In this study, we found that native thiol and total thiol levels, which are antioxidant markers, were lower in patients with NSTMI compared with the control group. Our study shows that antioxidant activity is affected in NSTMI, and antioxidant levels are decreased.

Knowledge and perception of coronary angiography and coronary angioplasty by physicians involved in the management of cardiovascular emergencies in Togo

Objectives: Interventional cardiology is emerging in Togo. The aim of this study is to assess the knowledge and attitudes regarding coronary angiography and angioplasty of physicians involved in the management of cardiovascular emergencies in Togo. Materials and methods: This was a cross-sectional study that was conducted for three months from January 15 to June 30, 2022 and that focused on doctors involved in the management of cardiovascular emergencies in Togo, who volunteered to participate in the study. Results: We interviewed 150 doctors with an average age of 32.8 5.6 years. Eight (10.7%) physicians reported having no knowledge of coronary angiography. All physicians recognized acute coronary syndromes (ACS) with persistent ST-segment elevation, the positive myocardial ischemia test as an indication of coronary angiography. Indications of coronary angiography, such as ventricular rhythm disorders, unexplained heart failure and stable angina were not well understood by 20 (13.3%), 19 (12.7%) and 9 (6.0%) respectively. All doctors knew that angioplasty could be accompanied by complications, but 48% were unaware of the skin complications of irradiation. The availability of coronary angiography and angioplasty in cardiac practice in Togo was ignored by 23 physicians or 15.3%. Coronary angiography and coronary angioplasty were perceived as very expensive by 70.7% of physicians. The cost of these procedures was a barrier to their prescription among 78 doctors (52. %). Conclusion: Coronary interventional cardiology is performed routinely in Togo. Physicians involved in the management of cardiovascular emergencies have a level of knowledge and attitudes that need to be improved.

Predicting 30-Day Mortality Using ST-Segment Elevation Resolution in ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention: An Indian Scenario.

The relationship between ST-segment elevation (STE) resolution and 30-day mortality has been evaluated, although limitedly, in non-Indian patients undergoing primary percutaneous coronary intervention (pPCI). We aimed to evaluate the prognostic utility of STE resolution in predicting 30-day mortality in Indian patients undergoing pPCI for ST-elevation myocardial infarction (STEMI). This prospective, single-center, observational study investigated the correlation between 30-day mortality rate and extent of STE resolution in real-world Indian patients undergoing pPCI for STEMI. A total of 64 patients underwent pPCI for STEMI at a tertiary care center in India. The patients were classified into three groups based on the extent of STE resolution: complete resolution (≥70%), partial resolution (30-70%), and no resolution (<30%). The primary endpoint of the study was occurrence of major adverse cardiovascular events consisting of all-cause death, reinfarction, disabling stroke, and ischemia-induced target vessel revascularization at 30 days follow-up. The study enrolled 56 patients. The mean age of patients was 59.7±6.8 years and there were 46 (82.1%) males. Complete STE resolution (≥70%) occurred in 7.1%, partial resolution (<70-30%) in 82.1% and no resolution (<30%) in 10.7%. The mortality rate was 2.1% and 33.3% in patients with partial and no STE resolution. No mortality was seen in patients with complete STE resolution. The 30-day survival analysis revealed significant differences between the three groups (P<0.01). STE resolution served as an independent predictor of 30-day mortality across all clinical variables, including patients with post-PCI thrombolysis in myocardial infarction (TIMI) 3 flow. Persistent STE after PCI is a reliable indicator of 30-day mortality in real-world STEMI patients. The extent of STE resolution can be used as a simple and affordable tool to stratify patients by the risk of mortality soon after the acute event. Due to their higher mortality at 30 days follow-up, individuals with persistent STE should be the focus for further treatment interventions.

After an acute coronary syndrome: levosimendan or dobutamine? this is our impression

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Inotropic support is frequently needed after acute coronary syndromes(ACS) at coronary care units(CCU). Despite it has being long time since approval of levosimendan(LV) as inotropic support to cardiogenic shock, dobutamine(DB) still being the basis of this treatment. We think levosimendan is a secure and effective alternative. Purpose To analyse the use of levosimendan and dobutamine done in our ACS patients to determine if we have followed some clear criteria of selection, and try to draw a defined pattern for future use. Method Retrospective, analytic, observational study of all ACS admitted to our CCU between 08/2011- 02/2022. We confront patients treated with dobutamine versus levosimendan. X2, U-Mann Whitney and T-Student were used when necessary. Statistical significance: p-value&amp;lt;0.05. Result 2881patients were admitted with ACS, 6.49%of them(n: 187) needed ionotropic support. Out of these, 60.96%(n: 114) were supported with dobutamine, 28.88%(n: 54) with levosimedan and 10.16%(n: 19)received in some time both drugs, so were excluded from the analysis. Mean age: 68.43±11.48years old. 66.66%(n: 112) men. 54.76%(n: 92)with persistent ST-segment elevation. No difference was found between groups, neither in past medical history, including cardiovascular risk factors, history of arrhythmias(11.3% of patients), previous use of betablockers(30.4%), antiarrhythmic drugs(0.6%) or having pacemaker(1.2%). 114 patients(67.86%)needed norepinephrine(70.17%with DB and 62.96% LV, p:0.35); 29(17.26%) were supported with intra-aortic balloon pump(20.18% in DB group and 11.11% in LV group, p:0.134), without differences by drug. 62 patients(36.9%) presented atrial fibrillation(33.33% in DB and 44.44% in LV, p:0.166), 58(34.52%)ventricular arrhythmias[sustained ventricular tachycardia/ventricular fibrillation](33.33% in DB and 37.04% in LV, p:0.638). In-hospital mortality of these patients was 29.17%(n:49), 29.82% in DB and 27.77% in LV, p:0.785. In multivariate analysis adjusted by clinic and epidemiologic factors, only cardiogenic shock resulted an independent predictor of in-hospital death. Pattern of use we use DB in those patients with worst Killip-kimball(KK) state(73.54%in DB group with KK-IV vs53.70%in LV´s) and LV in those in intermediate states of instability(38.88%LV in KK-II/III vs 8.84%DB in KK-II/III),p&amp;lt;0.001. We chose DB in those who became unstable in CCU and LV in those who became unstable in hospitalization room, p:0.049. Finally, we noted a significant change in trend of use during the period of study, falling use of DB in favour of LV(p&amp;lt;0.001). Conclusion In our experience, dobutamine has been the most frequent ionotropic drug used in last 11 years after an acute coronary syndrome. Nevertheless, a substitution by levosimendan trend is evolving. We did not detect differences in complications or prognosis dependent on the inotropic drug used, but the use of dobutamine were predominant in those patients with more severe situation.

De-escalation in intensity or duration of dual antiplatelet therapy in patients with coronary artery disease: More than alternative treatment options

Antithrombotic therapy represents the mainstay of pharmacological treatments in patients with acute or chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI) [ [1] De Servi S. Landi A. Savonitto S. et al. Tailoring oral antiplatelet therapy in acute coronary syndromes: from guidelines to clinical practice. J Cardiovasc Med. 2023; 24 Crossref Scopus (1) Google Scholar ]. Since the CURE study [ [2] Mehta S.R. Yusuf S. Peters R.J.G. et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet. 2001; 358: 527-533 Abstract Full Text Full Text PDF PubMed Scopus (3042) Google Scholar ], dual antiplatelet therapy (DAPT) consisting of aspirin and an oral P2Y12 inhibitor has represented the standard of care for acute coronary syndrome (ACS) or PCI patients due to the greater ischemic protection compared with aspirin alone. Current guidelines recommend 6 or 12 months as default DAPT durations in patients with CCS or ACS undergoing PCI, respectively [ [3] Valgimigli M. Bueno H. Byrne R.A. et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J. 2018; 39: 213-260 Crossref PubMed Scopus (1840) Google Scholar , [4] Collet J.-.P. Thiele H. Barbato E. et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42: 1289-1367 Crossref PubMed Scopus (1705) Google Scholar ]. Yet, there is mounting evidence suggesting that prolonging DAPT is unavoidably associated with higher risks of major bleeding which carry similar or even worse impact on mortality than a recurrent myocardial infarction (MI) [ [5] Valgimigli M. Landi A. Ischemic and bleeding risk in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention: is it time to REACT?. Eur Heart J Acute Cardiovasc Care. 2021; 10: 1125-1128 Crossref PubMed Google Scholar ].

Are the ESC 2020 recommendations on acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) concerning the delays in management and the non-pretreatment with P2Y12 inhibitors (IP2Y12) applied? The experience in artois

Are the ESC 2020 recommendations on acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) concerning the delays in management and the non-pretreatment with P2Y12 inhibitors (IP2Y12) applied? The experience in artois

Epidemiological-clinical and paraclinical particularities of acute coronary syndrome without persistent ST-segment elevation in type 2 diabetes mellitus: Retrospective comparative study in a Malagasy population.

This study aimed at determining the epidemiological-clinical and paraclinical particularities of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in Malagasy with type 2 diabetes mellitus (T2DM). This was a retrospective, descriptive and comparative study between patients with and without T2DM, carried out over a period of 38 months. The diagnosis of NSTE-ACS was retained in front of the association of chest discomfort, electrical abnormalities and elevations beyond fivefold the upper reference limit of high-sensitivity cardiac troponin. With 130 patients included, the overall prevalence of NSTE-ACS was 4.1%, of which 68 patients (52.3%) had T2DM. Compared to without T2DM, NSTE-ACS in T2DM was characterized by young age (p= .0002), high-frequency hypertension (OR 2.92 [1.23-7.25]; p= .0041), overweight/obesity (OR 4.39 [1.72-12.4]; p= .0002) and microalbuminuria (p< .0001), accelerated heart rate (p= .0104), atypical chest discomfort (OR 5.57 [2.21-15.7]; p< .0001), pulmonary crepitations (OR 2.25 [1.02-5.14]; p= .0224), high GRACE score (p= .0016), damage of extensive anterior leads (OR 2.11 [1.02-4.98]; p= .0402) and septal lead (OR 3.64 [1.41-10.3]; p= .0015), significant increase in cardiac troponin (p< .0001), high left ventricular filling pressure (OR 3.39 [1.51-7.90]; p= .001). NSTE-ACS in T2DM is frequent, with an atypical clinical and severe paraclinical presentations. Adequate and multidisciplinary management of cardiovascular risk factors, including T2DM, could thus minimize the occurrence of NSTE-ACS and improve this profile.

MINOCA-myocardial infarction with nonobstructive coronary arteries

Myocardial infarction with nonobstructive coronary arteries (MINOCA) accounts for 5-10% of all presentations of acute myocardial infarction. To outline the role of cardiovascular magnetic resonance (CMR) in patients with suspected MINOCA. Current guidelines for the use of CMR in suspected MINOCA are summarized. Clinical cases with typical CMR findings are presented. In 2019, the American Heart Association published arevised definition of the term MINOCA, which was recently adopted in the European Society of Cardiology 2020 guidelines on acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS). The guidelines indicate that aCMR is recommended (class1B) in all MINOCA cases with no obvious cause. The major strength of CMR imaging is to differentiate nonischemic from ischemic etiologies of myocardial injury. This makes CMR the most important noninvasive diagnostic tool for the differential diagnosis of patients with suspected MINOCA.

Risk of complications after a non-ST segment elevation acute myocardial infarction in a Latin-American cohort: An application of the ACTION ICU score

BackgroundEuropean Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (NSTEMI) recommend Intensive Care Unit (ICU) surveillance during the first 24–48 h. Interestingly, the in-hospital mortality of NSTEMI patients has consistently decreased, giving some patients the option to be managed in general hospital wards. The ACTION ICU score has been proposed to identify high-risk patients with NSTEMI and guide the selective risk-based need for ICU care. ObjectiveTo evaluate the usefulness of the ACTION ICU score to predict patients’ risk of developing complications requiring ICU care in a Latin-American cohort with NSTEMI. MethodsWe applied the ACTION ICU score in a retrospective cohort. A composite primary outcome included: cardiorespiratory arrest, shock, high-grade atrio-ventricular block, respiratory failure, stroke, or death. The predictive performance of this model was estimated with a conditional multivariable logistic regression analysis. ResultsOf 1,062 patients with NSTEMI, the primary outcome was present in 75 patients (7.1%), and 1,019 (96%) were admitted to ICU. The most common event was respiratory failure (4.0%), followed by cardiogenic shock (3.7%), and cardiac arrest (1.7%). The presence of heart failure signs or symptoms had the highest association with the primary outcome (OR:2.16; 95%CI:1.61–2.92). The best cut-off point for this population was 3 (complications risk: 4.0%, SEN:96%, SP:15.4%, NPV:98.1%, PPV:7.9%). ConclusionThe ACTION ICU score may be a promising tool to identify the need for ICU care in Latin-American patients with NSTEMI. Furthermore, additional research is needed to evaluate the cost-effectiveness of this strategy.

A Simple Risk Score to Differentiate Between Coronary Artery Obstruction and Coronary Artery Spasm of Patients With Acute Coronary Syndrome Without Persistent ST-Segment Elevation.

The aim of this study was to create a risk scoring model to differentiate obstructive coronary artery (CA) from CA spasm in the etioology of acute coronary syndrome (ACS).Methods and Results: We included 753 consecutive patients with ACS without persistent ST-segment elevation (p-STE). The exclusion criteria were: (1) out-of-hospital cardiac arrest; (2) cardiogenic shock; (3) hemodialysis; (4) atrial fibrillation/flutter; (5) severe valvular disease; (6) no coronary angiography; (7) non-obstructive coronary artery without "definite" vasospastic angina definition; and/or (8) missing data. From the multivariate logistic regression analysis for prediction of obstructive CA, an integer score of 2 to each 0.5 increment in odds ratio was given, and values were divided into quartiles according to the total score. The scores were as follows: age >70 years (6 points), non-STE myocardial infarction (9 points), diabetes mellitus (5 points), B-type natriuretic peptide >90 pg/mL (7 points), neutrophil to lymphocyte ratio >2 (5 points), and high-density lipoprotein cholesterol <50 mg/dL (5 points). CA spasm-induced ACS occurred in 50.0% in Quartile 1 (total score: 0-13), 20.5% in Quartile 2 (total score: 14-19), 4.9% in Quartile 3 (total score: 20-26), and 2.2% in Quartile 4 (total score: 27-37) (P<0.001), indicating that a total score of <20 was a potential clinical indicator of CA spasm-induced ACS. CA spasm-induced ACS should be suspected if a total score of <20, and a spasm provocation test was being considered.

Whats new in 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST segment elevation?

The article sumarizes the 2020 ESC Guidelines for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation. The diagnostics of ACS consists in assessment of chest pain, EKG and cardiac troponin. Troponin should be evaluated by high sensitivity assay. 0h/1h algorithms should be used to rule-in or rule-out ACS. Patients with a positive troponin have higher risk of cardivascular events and mortality and the early invasive treatment should be applied in these patients. In the guidelines several antithrombotic stretegies for different clinical conditions are mentioned, where the cornerstone for the length and intensity of antithrombotic treatment is the evaluation of bleeding risk. Further on the revascularization aspects and strategies are debated in the guidelines. Finally there are mentioned two specific conditions of ACS - Myocardioal infarction with non-obstructive coronary arteries and Spontaneous coronary artery dissection.

Особливості зміни показників кумулятивного виживання пацієнтів з гострим коронарним синдромом без стійкої елевації сегмента ST, яким перкутанні коронарні втручання проводили в різні терміни від початку захворювання

Мета роботи – оцінити вплив реваскуляризації міокарда, яка була виконана хворим з гострим коронарним синдромом без стійкої елевації сегмента ST у різні терміни від початку симптомів, на ультразвукові показники скорочувальної функції лівого шлуночка та на функціональний клас стенокардії через 12 місяців спостереження. Матеріали і методи. Пацієнти з гострим інфарктом міокарда без стійкої елевації сегмента ST (NSTEMI), які увійшли в дослідження (n=128), були поділені на групи за часом проведення реваскуляризації (ургентна або планова реваскуляризація), а також за способом реваскуляризації (коронарне стентування або шунтування) на 5 груп, у тому числі групу хворих з NSTEMI, яким стентування не проводили. 1-шу групу (n=28) становили пацієнти, яким були виконані ургентні коронарографія та стентування ad hoc у перші 72 год від початку симптомів. У 2-гу групу (n=61) увійшли пацієнти, яким коронарографію і стентування проводили планово через 72 год і більше до кількох місяців від початку розвитку симптоматики. У 3-тю групу (n=12) увійшли пацієнти, яким у плановому порядку виконували коронарне шунтування. 4-та група (n=27) складалася з пацієнтів, яким після коронарографії реваскуляризацію не проводили («контрольна група»). 5-ту групу (n=101) склали пацієнти вищеозначених груп, яким була проведена будь-яка реваскуляризація. Результати та обговорення. Ефективність лікування і частота виникнення серйозних кардіоваскулярних подій у пацієнтів з NSTEMI статистично значуще залежить від наявності в стратегії лікування перкутанних і хірургічних методик реваскуляризації. Доповнення процедури реваскуляризації статистично значуще поліпшує прогноз, статистично значуще знижує комбінований показник МАСЕ (major adverse cardiac events, серйозні кардіоваскулярні події) у період спостереження за пацієнтами (до 48 міс) порівняно з групою контролю (p=0,000001). При прямому порівнянні групи ургентного коронарного стентування (протягом 72 год від початку симптомів) пацієнтів з NSTEMI з GRACE Score &gt;140 балів виявлено статистично значущу розбіжність за кількістю серйозних кардіоваскулярних подій за 48 міс спостереження (p&lt;0,05) порівняно з групою контролю GRACE Score &gt; 140.Висновки. Віддалені результати стентування пацієнтів з NSTEMI з високим ризиком ускладнень (група ургентного стентування) не мали переваг перед результатами лікування стабільних пацієнтів з NSTEMI (група планового стентування) після їх ефективної стабілізації на тлі оптимальної медикаментозної терапії. При порівнянні частоти МАСЕ у цих двох групах перевагу зі слабким ступенем статистичної значущості (p&lt;0,05) було виявлено в групі стабілізованих пацієнтів, що повністю підтверджує стратегію стратифікації хворих з нестабільним коронарним кровоплином на групи ризику ускладнень. Однак ургентні втручання абсолютно показані пацієнтам з високим ризиком ускладнень у перші дні від початку симптомів дестабілізації.

Parenteral anticoagulants in the treatment of acute coronary syndrome: what modern clinical guidelines say

Parenteral administration of high (therapeutic) doses of anticoagulants is a mandatory component of the initial treatment of acute coronary syndrome (ACS) unless contraindicated. In ACS, intravenous administration of unfractionated heparin, the use of low molecular weight heparin enoxaparin, selective antagonist of activated X clotting factor fondaparinux sodium and direct thrombin antagonist bivalirudin are possible. The review presents current approaches to the choice of drugs and the specifics of parenteral anticoagulant use depending on ACS variant (with or without persistent ST-segment elevations on ECG), approaches to myocardial revascularization, previous use of oral anticoagulants, renal function, risk of major bleeding, presented in current versions of European Society of Cardiology and Russian Society of Cardiology guidelines, approved by the Russian Ministry of Health. It is shown that, according to the results of randomized controlled trials and expert opinion, for most ACS treatment scenarios (streptokinase thrombolytic therapy or no reperfusion therapy in ACS with persistent ST elevation on ECG, ACS without persistent ST elevation) the optimal approach is parenteral administration of sodium fondaparinux. Exceptions include primary percutaneous coronary intervention and very early invasive treatment of ACS without persistent ST-segment elevation, but initial treatment with sodium fondaparinux does not prevent these approaches. Additional advantages of sodium fondaparinux are the absence of the need to monitor the coagulation system, a fixed dose, as well as the possibility of use in patients with significant thrombocytopenia. If short-term use of parenteral anticoagulant is expected (in early invasive treatment of ACS), there are contraindications or limitations to the use of sodium fondaparinux and sodium enoxaparin, the means of choice for most cases is intravenous administration of unfractionated heparin.

An Elderly Woman With Persistent Chest Pain

A previously healthy 60-year-old woman was transferred to our emergency department following fibrinolysis for an anterior wall myocardial infarction. She complained of persistent chest pain and shortness of breath. On arrival, she had a blood pressure of 70/53 mm Hg, a pulse rate of 126 beats/min, a respiratory rate of 26 breaths/min, and an oxygen saturation of 90% on ambient air. A 12-lead ECG showed persistent ST-segment elevations from V1 to V4. Point-of-care transthoracic echocardiography revealed pericardial effusion containing a clot with features of cardiac tamponade (Figure 1 and Videos 1, 2, and 3).

Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients.

BackgroundThe European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST‐segment elevation (non‐ST‐segment elevation myocardial infarction [NSTEMI]) has recommended immediate (<2 h) percutaneous coronary intervention (PCI) in very‐high risk patients and early (<24 h) PCI in high‐risk patients.HypothesisTo examine the ESC NSTEMI guidelines adherence in a nationwide survey in Israel using the Acute Coronary Syndrome Israeli Survey (ACSIS). We hypothesized that adherence to the guidlines' recommnded PCI timing in NSTEMI pateints will be inadequate, partly due to the inconsistent evidence regarding its effect on clinical outcomes.MethodsAll NSTEMI patients who underwent PCI during the ACSIS surveys in 2016 and 2018 were included in the analysis.ResultsOut of 1793 NSTEMI patients, 1643 (92%) patients underwent PCI, and door to balloon time was documented in 1078 of them. One hundred and fifty‐six (14.5%) patients and 922 (85.5%) patients were defined as very high‐risk and high‐risk NSTEMI patients, respectively. Of the very high‐risk NSTEMI patients, only 10 (6.4%) underwent immediate coronary angiography, and 50 (32.1%) underwent early coronary angiography. Acute heart failure 139 (89.1%) was the main reason for including NSTEMI patients in the very high‐risk category. Of the high‐risk patients, early coronary angiography was performed in only 405 (43.9%) patients. Patients in whom coronary angiography was postponed were older and had more comorbidities.ConclusionsDespite guidelines recommendations for immediate and early PCI in very high‐risk and high‐risk NSTEMI patients, respectively, most patients do not undergo immediate or early PCI according to contemporary guidelines. Further studies are needed to better understand the reasons for guidelines' nonadherence in those high‐risk patients.

Is It ST-Segment-Elevation Myocardial Infarction?

A 76-year-old man presented with acute-onset chest pain and dyspnea. He had a history of coronary artery disease, ischemic cardiomyopathy (left ventricular ejection fraction, 25%), recent non-ST-segment-elevation myocardial infarction (NSTEMI), and stenting of the left anterior descending coronary artery (LAD) one month before the current presentation. Soon thereafter, he underwent stenting of the left main coronary artery (LMCA), obtuse marginal branch (OMB), and left circumflex coronary artery. His chest pain subsided soon after arrival at the emergency department. His cardiac troponin I level was 22 ng/mL (normal level, &lt;0.03 ng/mL), and his brain natriuretic peptide level was 841 pg/mL (normal level, &lt;100 pg/mL). Figure 1 shows his electrocardiogram (ECG).What is the diagnosis?C) STEMI due to first OMB or ramus intermedius occlusionThe ECG shows sinus rhythm, mild ST-segment elevation (STE) with T-wave inversion in lead aVL, ST-segment depression with positive T waves in leads II, III, aVF, and V3 through V6, and an isoelectric ST segment in leads I and V1 through V2. The Fourth Universal Definition of Myocardial Infarction1 says, “More profound ST-segment shifts or T-wave inversions involving multiple leads/territories are associated with a greater degree of myocardial ischaemia, and a worse prognosis. For example, ST-segment depression ≥1 mm in 6 leads, which may be associated with STE in lead aVR or lead V1 and hemodynamic compromise, is suggestive evidence of multivessel disease or left main disease” (eliminating answer A). This is considered a high-risk ECG pattern for which invasive intervention within 2 hours is recommended, in accordance with the 2020 European Society of Cardiology guidelines for managing acute coronary syndromes without persistent STE.2 Our patient's ECG shows ST-segment depression in 7 leads but no significant STE in lead aVR or V1. In contrast, STE with negative T waves is seen in lead aVL.Patients with a nonischemic early repolarization pattern can have STE in lead aVL. However, the T waves are usually positive, and there is often a J-point notch. The pattern here suggests a reperfused or more advanced stage of STEMI,3 and the patient's clinical presentation (symptom resolution after hospital arrival) supports this diagnosis.New STE in 2 contiguous leads is necessary for the diagnosis of STEMI.1 However, this is an epidemiologic (not pathophysiologic) criterion, to minimize false-positive diagnosis. Acutely occluded arterial branches may cause STE in only one lead with diffuse ST-segment depression.4 The STE in leads aVL and V2 through V5 is caused by LAD occlusion proximal to the first diagonal branch (eliminating answer B),4 and STE in leads aVL and V2 without STE in leads V3 through V5 suggests an occluded first diagonal branch. The ST-segment depression in the anterolateral and inferior leads is incompatible with the typical presentation of takotsubo cardiomyopathy (answer D). The STE in lead aVL, incompatible with ischemic cardiomyopathy (answer E), is accompanied by ST-segment depression in lead V2, suggesting obstruction of the first OMB. Our patient had an isoelectric ST segment in lead V2, so the differential diagnosis is an occluded OMB or ramus intermedius.4 A coronary angiogram on the second day of admission showed subacute thrombotic occlusion of the first OMB (Fig. 2, arrow), and stenting restored patent flow.Disclosures: NoneFunding/support: None

Inferior ST-segment elevation due to metastatic cardiac tumor

There are numerous causes for ST-segment elevation on ECG, the tumoral invasion of the heart being a rarer one. Because the management will differ one should always keep in mind the presence of such entity. Here we report a case of persistent ST-segment elevation due to a metastatic cardiac tumor.