Post ST-elevation Myocardial Infarction Research Articles

Effect Of Membrane Sealing Copolymer Poloxamer188 On Cardiac Mitochondrial Subpopulations In A Porcine Model Of Acute Myocardial Infarction

Acute myocardial infarction (AMI) is characterized by the sudden loss of blood supply to the coronary arteries, leading to permanent cell death if left untreated. Every year, around 800,000 Americans are affected by AMI. Currently, the only successful treatment for AMI is the restoration of blood flow using angioplasty and fibrinolytic drugs. In spite of a higher success rate post treatment, AMI greatly increases the risk of future arrhythmia, stroke and cardiac arrest. Additionally, the abrupt reintroduction of oxygen to the ischemic tissue causes reperfusion injury (RI). In the mitochondria, RI leads to calcium overload, increased ROS production, opening of mitochondrial permeability transition pore (MPTP) and release of caspases, all contributing to cell death. Hence, mitochondria offer a promising target in reducing reperfusion injury post AMI. Previously, we showed that the administration of the membrane sealing copolymer Poloxamer188 (P188) post ST‐elevation myocardial infarction (STEMI) reperfusion reduced infarct size and improved cardiac myocardial and mixed mitochondrial function in pigs. In this current study, our aim was to identify the specific effects of P188 in improving the mitochondrial function post STEMI of the two cardiac mitochondrial subpopulations‐subsarcolemmal (SSM) and interfibrillar (IFM) mitochondria. Female pigs that underwent 45 minutes of partial left anterior descending artery (LAD) occlusion were randomized to be reperfused with P188 (250 mg/kg, n=5) or saline(n=5). Each of these animals received an initial intracoronary bolus of either drug for 30 minutes, followed by an intravenous drip of the same dose for 3 hours. At 4 hours post reperfusion, the hearts were harvested and cardiac SSM and IFM were isolated from both the ischemic (LAD) and healthy circumflex (Circ) area through differential centrifugation. Their functions were assessed by measuring mitochondrial oxygen consumption and calcium buffering capacity. Initial results show that P188 likely improved complex 1 mediated mitochondrial oxygen consumption in the SSM (not significant) while there was no effect on IFM. P188 also improved the calcium buffering capacity of cardiac SSM and IFM (p=0.009 for SSM and p=0.03 for IFM) in the ischemic area. Together these results show a potential treatment benefit of P188 on cardiac SSM. Future studies include measurement of the levels of reactive oxygen species and total calcium content in the mitochondria, assessment of mitochondrial damage through electron microscopy as well as investigation of the mechanism of benefit conferred by P188 in the mitochondria. To our knowledge, this is the first study to investigate the effect of P188 in cardiac mitochondrial subpopulations. Results from this study will help in the development of better targeted compounds with greater accuracy for the treatment of heart disease.Support or Funding InformationSource of funding: National Institutes of Heath, RO1 HL122323‐01A1This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

VENTRICULAR MURAL THROMBUS IN PATIENT WITH LEFT VENTRICULAR ANEURYSM AFTER MYOCARDIAL INFARCTION

On the example of the clinical case of newly diagnosed mural thrombus in patient with post ST-elevation myocardial infarction chronic aneurysm formation, probable risk of further tromboembolism and anticoagulation benefit was discussed. Recommendations on lifestyle modification and medicament treatment tactics are described for prevention of new mural thrombi formation. Left ventricular thrombus is an important complication of acute myocardial infarction that impacts embolic event risk and anticoagulant therapy. Improved understanding of post-MI thrombus in the current era is critical for optimization of diagnostic testing strategies. Advances in MI management, including prompt and effective coronary reperfusion, have yielded improvements in LV function and remodeling. Widespread use of antiplatelet agents may potentiate the benefits of reperfusion, thereby lessening the likelihood of LV thrombus.

Impact of a 'stent for life' initiative on post-ST elevation myocardial infarction heart failure: a 15year heart failure clinic experience.

AimsMultidisciplinary heart failure (HF) clinics are a cornerstone of contemporary HF management. The stent‐for‐life (SFL) initiative improves mortality after ST elevation myocardial infarction (STEMI), but its impact in post‐STEMI HF is not well characterized. Here we assessed the impact of SFL among patients referred to a multidisciplinary HF clinic over a 15 year time period.Methods and resultsBetween 2001 and 2015, 1921 patients were admitted to our HF clinic. In 2009, Catalonia established the Codi IAM network, a regional STEMI network that prioritizes primary percutaneous coronary intervention in STEMI. Patients admitted during the study period were divided into two groups based on admission date: pre‐SFL (2001–June 2009; n = 1031) and post‐SFL (July 2009–2015; n = 890). Compared with those in the pre‐SFL group, patients admitted in the post‐SFL period had better New York Heart Association (NYHA) functional class (22.1 vs. 38.7 NYHA classes III–IV; P < 0.001) and higher left ventricular ejection fraction (LVEF) (36.1 ± 19.6 vs. 32.6 ± 13.4; P < 0.001). Among STEMI survivors, 101 (6.7%) pre‐SFL patients and 40 (2%) post‐SFL patients (P < 0.001) fulfilled the criteria for HF clinic referral (Killip–Kimball class ≥ 2 during index admission and/or LVEF of <40%). Furthermore, among patients admitted to the HF clinic, post‐STEMI HF with reduced ejection fraction patients comprised 8.9% of the pre‐SFL group and only 4.2% of the post‐SFL group (P < 0.001).ConclusionsAmong patients treated at our multidisciplinary HF clinic, the adoption of an SFL network has decreased the prevalence of post‐STEMI HF with reduced ejection fraction.

Improving Communication with General Practitioners post ST elevation Myocardial Infarction

Introduction: Coronary artery disease remains one of the leading causes of death worldwide. NICE guidelines recommend all patients post ST elevation myocardial infarction (STEMI) should be discharged on specific classes of medication and with clear information for their general practitioner. Short description of practice change implemented: We delivered a teaching session on discharge communication guidelines post STEMI to junior staff rotating through our unit. Aim and theory of change: To assess and improve the compliance with guidelines on communication with general practitioners through education of our junior staff. Targeted population and stakeholders: Patient Group: Patients diagnosed with ST elevation Myocardial Infarction. Target for Intervention: Junior Doctors working in Cardiology Service. Stakeholders: Cardiology Service. General Practitioners. Patients. Timeline: March 2016: Audit performed on all STEMI discharges for 2015. April 2016: Teaching Session delivered comprising of initial audit results and guidelines on communication. July 2016: Re-Audit performed of STEMI discharges for June 2016. Highlights: We show the importance of continuing education of junior staff rotating through specialist services in order to improve communications and continuity of care between primary and tertiary services. Improving this communication may improve our patients long term outcomes, by ensuring they are on the optimum secondary prevention regimen post STEMI. Comments on sustainability: Due to staff turnover, a brief overview ( Comments on transferability: This intervention is a simple, cost neutral way to ensure increased standardisation of discharge summaries through education despite high rates of staff turnover. Conclusions: We achieved a significant improvement in rates of communication with general practitioners with regard to duration of antiplatelet therapy (51.2% vs 88.2%, p Discussions: Given many medications cannot be uptitrated to maximally tolerated doses during brief inpatient stays, the GP plays a key role in ensuring this is done as an outpatient. Clear instructions on discharge are essential as GPs may be reluctant to make changes to medications prescribed by specialists. Junior staff may also be uncomfortable dictating plans for patient in a specialist service unless they themselves are explicitly informed of the same by their senior colleagues. If the medication is not titrated up to the maximally tolerated dose, the patient may not derive maximum benefit and may suffer an increased risk of major adverse cardiac events (MACEs). Lessons learned: Education of junior staff on guidelines is an essential component of ensuring a high standard of continuity of care between tertiary and primary care services.

E-CPR as a bridge for decision in the cath lab

Aim: Refractory cardiogenic shock (CS) complicates 5–7% of cases with ST-elevation myocardial infarction (STEMI), and is a leading cause of hospital death after myocardial infarction.1 CS complicating acute myocardial infarction (AMI) continues to have a high mortality of 40–50% despite early revascularization and adjunctive therapies.2 Extracorporeal membrane oxygenation (ECMO) technology has advanced significantly and is readily available at the bedside. This is a viable option for short-term support in the setting of acute cardiac ischemia. According to the 2003 USA National Registry of cardiopulmonary resuscitation (CPR), in-hospital cardiac arrest has a poor prognosis with an overall survival to hospital discharge rate of 17% with conventional CPR.3 One of the most common causes of cardiac arrest is ventricular fibrillation (VF) secondary to ischemia, which carries an improved prognosis if successfully defibrillated, with the rate of survival to hospital discharge being 34%.3 In cases with refractory ischemic VF, definitive therapy with percutaneous coronary intervention (PCI) may not be possible without anoxic brain injury secondary to hemodynamic collapse. CPR was introduced in the 1960s as a lifesaving method in patients with cardiac arrest.3 To supplement CPR in select patients, ECMO is used successfully for witnessed in-hospital cardiac arrest.3 In the setting of an AMI, bridging to a revascularization procedure is important in improving neurological outcome and overall survival. We report the profile and the outcome of patients in refractory VF resistant to defibrillation on ECMO support. Subsequent to revascularization, the patient's cardiac rhythm converted back to sinus rhythm with a single defibrillation shock with excellent neurological recovery. Methods: Since January 2014, we have been reviewing patients who had suffered from progressive severe refractory CS post STEMI undergoing emergency PCI on percutaneous veno-arterial (VA)-ECMO support. Results: For 11 male patients (mean age 50 ± 18 years), the mean duration of support was 7 ± 4 days. Of these patients, 9 (81%) were weaned successfully from ECMO. However, two patients on ECMO support died: one due to massive gastrointestinal bleeding and the other due to septic shock. Three other patients also died; one due to occluded stent on third day post-ECMO removal, one due to intracranial hemorrhage on second day post-ECMO removal, and one due to septic shock on fourth day post-ECMO removal. The 30-day survival was 54% (6/11 patients) without any neurological deficit. Conclusion: VA-ECMO has shown to be an option to bridge patients in CS and/or refractory VF to allow for a successful revascularization procedure and ultimately good neurological and survival outcome.

Does Pre-Discharge Transthoracic Echocardiogram (TTE) Influence the Prescription of Cardio Protective Agents Post STEMI?

Aim: To identify the influence of pre-discharge TTE on real world medication prescription in ST elevation myocardial infarction (STEMI) patients with impaired left ventricular function Method: We studied 204 consecutive STEMI patients between August 2013 and December 2016 admitted to a single tertiary referral centre who also had a pre discharge echo that demonstrated at least moderate Left ventricular dysfunction, the haemodynamic, discharge prescriptions and dosages were collected for angiotensin convertase enzyme inhibitor (ACE inhibitors)/(angiotensin receptor blocker) ARB blockers, beta blockers (BB) and, mineralocorticoid receptor antagonist (MRA). Results: Of 654 patients who had TTEs post STEMI, 204 had at least moderate LV dysfunction of which 78.9% were male with average age of 62. At the time of discharge, 183 patients out of the 204 were alive. The average HR and BP on admission were 85.40 and 124.37 respectively. The HR and BP on discharge were 74.71 and 112 respectively. Of the 183 patients, 89% were on either ACE I or ARB, 67% on Heart Failure Specific (HFrEF) BB, 96% on any BB and only 26% were on MRA at the time of discharge. The most common limiting factors for prescribing ACEI/ARB and MRA were kidney function, and age. SBP didn’t seem to correlate. Conclusion: Pre-discharge echo enabled prescription of cardio protective agents of ACEI/ARB and HFrEF specific beta blocker with MRA prescription being lower than expected. Older age and low eGFR were the main predictors for underprescribing.

Assessment of the longitudinal changes in infarct heterogeneity post myocardial infarction.

BackgroundInfarct heterogeneity, as assessed by determination of the peri-infarct zone (PIZ) by cardiac magnetic resonance imaging, has been shown to be an independent predictor for the development of cardiac arrhythmias and mortality post myocardial infarction (MI). The temporal evolution of the PIZ post MI is currently unknown. Thus, the main objective of our study was to describe the temporal evolution of the PIZ over a 6 month time period in contemporarily managed ST elevation myocardial infarction (STEMI) patients. Further, given the poor prognosis associated with microvascular obstruction (MVO) post STEMI, we sought to compare the temporal evolution of the PIZ in patients with and without MVO. We hypothesized that patients with MVO would show a relative persistence of PIZ over time when compared to those without MVO.MethodsTwenty-one patients post primary percutaneous coronary intervention were enrolled and treated with evidence based therapy. Each patient had three cardiac MRI scans at 48 h, 3 weeks and 6 months post infarction. Repeated Measures Analysis of Variance (ANOVA) was used to assess the evolution of core infarct size and peri-infarct zone size across the three time frames.ResultsThe patients in this study were predominantly male, with ~40 % LAD territory infarction and a mean LVEF of 46 ± 7 %. Core infarct size and PIZ size both decreased significantly across the three time frames. The presence of microvascular obstruction (MVO), a known adverse prognostic factor, influenced PIZ size. Both patients with and without MVO had a significant reduction in core infarct size over time. Patients with MVO did not have a significant change in PIZ size over time (11.9 ± 6.8 %, 12.2 ± 7.5 %, 10.7 ± 6.6 % p = 0.77). In contrast, non-MVO patients did have a significant decrease in PIZ size over time (7.0 ± 5.5 %, 7.1 ± 6.5 %, 2.7 ± 2.6 %, p = 0.01).ConclusionsPeri-infarct zone size, like core infarct size, varies depending upon the timing of measurement. Patients with MVO displayed a persistence of the PIZ over time.

Assessment of infarct-specific cardiac motion dysfunction using modeling and multimodal magnetic resonance merging.

To propose a cardiac motion tracking model that evaluates wall motion abnormality in postmyocardial infarction patients. Correlation between the motion parameter of the model and left ventricle (LV) function was also determined. Twelve male patients with post-ST elevation myocardial infarction (post-STEMI) and 10 healthy controls of the same gender were recruited to undergo cardiac magnetic resonance imaging (MRI) using a 1.5T scanner. Using an infarct-specific LV division approach, the late gadolinium enhancement (LGE) MRI images were used to divide the LV on the tagged MRI images into infarct, adjacent, and remote sectors. Motion tracking was performed using the infarct-specific two-parameter empirical deformable model (TPEDM). The match quality was defined as the position error computed using root-mean-square (RMS) distance between the estimated and expert-verified tag intersections. The position errors were compared with the ones from our previously published fixed-sector TPEDM. Cine MRI images were used to calculate regional ejection fraction (REF). Correlation between the end-systolic contraction parameter (αES ) with REF was determined. The position errors in the proposed model were significantly lower than the fixed-sector model (P < 0.01). The median position errors were 0.82 mm versus 1.23 mm. The αES correlates significantly with REF (r = 0.91, P < 0.01). The infarct-specific TPEDM combines the morphological and functional information from LGE and tagged MRI images. It was shown to outperform the fixed-sector model in assessing regional LV dysfunction. The significant correlation between αES and REF added prognostic value because it indicated an impairment of cardiac function with the increase of infarct transmurality. 3 J. Magn. Reson. Imaging 2017;45:525-534.

Remote Zone Extracellular Volume and Left Ventricular Remodeling in Survivors of ST-Elevation Myocardial Infarction

The natural history and pathophysiological significance of tissue remodeling in the myocardial remote zone after acute ST-elevation myocardial infarction (STEMI) is incompletely understood. Extracellular volume (ECV) in myocardial regions of interest can now be measured with cardiac magnetic resonance imaging. Patients who sustained an acute STEMI were enrolled in a cohort study (BHF MR-MI [British Heart Foundation Magnetic Resonance Imaging in Acute ST-Segment Elevation Myocardial Infarction study]). Cardiac magnetic resonance was performed at 1.5 Tesla at 2 days and 6 months post STEMI. T1 modified Look-Locker inversion recovery mapping was performed before and 15 minutes after contrast (0.15 mmol/kg gadoterate meglumine) in 140 patients at 2 days post STEMI (mean age: 59 years, 76% male) and in 131 patients at 6 months post STEMI. Remote zone ECV was lower than infarct zone ECV (25.6±2.8% versus 51.4±8.9%; P<0.001). In multivariable regression, left ventricular ejection fraction was inversely associated with remote zone ECV (P<0.001), and diabetes mellitus was positively associated with remote zone ECV (P=0.010). No ST-segment resolution (P=0.034) and extent of ischemic area at risk (P<0.001) were multivariable associates of the change in remote zone ECV at 6 months (ΔECV). ΔECV was a multivariable associate of the change in left ventricular end-diastolic volume at 6 months (regression coefficient [95% confidence interval]: 1.43 (0.10-2.76); P=0.036). ΔECV is implicated in the pathophysiology of left ventricular remodeling post STEMI, but because the effect size is small, ΔECV has limited use as a clinical biomarker of remodeling. URL: https://www.clinicaltrials.gov. Unique identifier: NCT02072850.

52. Early revascularization on veno-arterial ECMO for patients with cardiogenic shock post stemi

Refractory Cardiogenic shock (CS) complicates 5–7% of cases of ST-elevation myocardial infarction (STEMI), and is a leading cause of hospital death after myocardial infarction. CS complicating acute myocardial infarction continues to have a high mortality of 60–80% despite early revascularization and adjunctive therapies. We studied the effectiveness of veno-arterial (VA) – Extracorporeal Membrane Oxygenator (ECMO) for the patients with CS post STEMI during coronary angiography at our institute. Between January 2014 to April 2015, 8 male patients who suffered from progressive severe refractory CS post STEMI underwent emergent peripheral VA-ECMO implantation while performing cardiopulmonary resuscitation during coronary angiography. 7 patients of underwent PCI, while 1 patient was not amenable to PCI or CABG. The mean duration of support was 8.5 ± 5.8 days. 6 patients were successfully weaned from ECMO. While on ECMO support, 2 patients died. Mean EF after ECMO explantation was 32.5% ± 10.5%. The 30-day survival was 50%. Early revascularization on ECMO allows supporting hemodynamic efficiently in cardiogenic shock patients.

Diabetes is an independent predictor of right ventricular dysfunction post ST-elevation myocardial infarction.

BackgroundDiabetes mellitus (DM) is estimated to become the 7th leading cause of death by 2030. Right ventricular dysfunction (RVD) complicating ST elevation myocardial infarction (STEMI) is independently associated with a higher mortality; however the relationship between DM and RVD is currently unknown. The purpose of this study was to determine whether DM is an independent predictor for the presence of right ventricular dysfunction (RVD) post STEMI.Methods106 patients post primary PCI for STEMI were enrolled in the study. Cardiac MRI was performed within 48–72 h after admission in order to assess ventricular function. Statistical analysis consisted initially of descriptive statistics including Chi square, Fisher’s exact, or the Wilcoxon rank sum as appropriate. Subsequently, logistic regression analysis was performed to determine independent predictors of RVD.ResultsThe median age in the study was 58 years (IQR 53, 67). 30 % of the patients had diabetes. Of 99 patients for which RV data was available, 40 had RVD and 59 did not. Patients with DM were significantly more likely to have RVD when compared to those without diabetes (45 vs 22 %, p = 0.03). There was no significant difference in age, hypertension, smoking status, dyslipidemia, serum creatinine or peak CK levels between the two groups. After adjusting for other factors, presence of DM remained an independent predictor for the presence of RV dysfunction (OR 2.78, 95 % CI 1.12, 6.87, p = 0.03). Amongst diabetic patients, those with HbA1C ≥ 7 % had greater odds of having RVD vs those with HbA1C < 7 % (OR 5.58 (1.20, 25.78), p = 0.02).ConclusionsThe presence of DM conferred an approximately threefold greater odds of being associated with RVD post STEMI. No other major cardiovascular risk factors were independently associated with the presence of RVD.

POST STEMI SURVEY OF PATIENT PERCEPTIONS AND BEHAVIOURS COMPARING CANADIANS AND SAUDI PATIENTS

ST elevation myocardial infarction (STEMI) requires urgent and timely medical attention. Limiting reperfusion delay is crucial to management and health care outcomes. Patients’ education, awareness of these symptoms and utilization of medical resources can vary among different cultures. We aim to explore those differences between patients in Canada and the Kingdom of Saudi Arabia (KSA). A standard questionnaire designed to assess knowledge, behaviors and factors related to seeking medical attention was used. The questionnaire was administered post STEMI in conjunction with the Canadian ‘Which Early ST-Elevation Therapy’ study and subsequently post STEMI in KSA. The sample included 211 participants, 111 Canadian patients and 100 KSA patients. The symptom onset occurred at home in 62.4% of Canadians and 76% of KSA STEMI patients. More than two-thirds of the KSA patients tried a conservative method such as relaxing or praying as the first response to symptoms compared to approximately one-third of Canadians (65% vs 38.6%) with patients first action shown in figure. The onset of symptoms was at rest in 49.1% Canadians vs. 66% of KSA and during active exertion in 50.9% vs. 34% respectively. Chest discomfort/pain at presentation was described in 21.6% of Canadians 28.5% of KSA and was described as severe (≥7/10) in 73% and 61% respectively. Regarding first medical contact, Canadians activated the pre-hospital EMS ambulance system 74% oif the time compared to only 4% in KSA. Of those Canadian STEMI not activating EMS: 45% stated it was easier to drive and 27% quoted cost concerns. In KSA STEMI patients: 62% stated they did not think of an ambulance and 20% stated it would be easier to drive. The majority of Canadians were prompted about the possible cardiac nature of their symptoms early on by a family member vs. only 16 % in KSA. The educational background varied widely between the two groups, with 45% of Canadians carrying a higher education from a university or college vs. only 7% in KSA. This cross-sectional study demonstrates some similarities in the clinical presentation of STEMI between the two groups. However, differences in health care seeking behaviors among STEMI patients exist. These findings may be related to differences in health literacy, cultural factors, or the structure of the health care system. Further research to identify the underlying factors is needed to guide the need for interventions to improve rapid identification of heart attack symptoms and health care access.

One-year outcome of the sevoflurane in acute myocardial infarction randomized trial.

Sevoflurane is an inhalation anesthetic that has cardioprotective effects. There is limited information regarding its use outside of the operating room and its potential protective effect for patients presenting with myocardial infarction. In the Sevoflurane In Acute Myocardial Infarction trial, patients with a first acute ST-elevation myocardial infarction (STEMI) who were treated by primary percutaneous coronary intervention were randomized to inhalation of sevoflurane or oxygen (control). From the time of the patient's arrival for cardiac catheterization, the anesthesia team administered sevoflurane or oxygen for 30 min using a tight-fitting mask. In this substudy, we report the one-year outcomes. Patients were followed clinically for one year; they underwent a thallium cardiac viability study at six months and an echocardiogram at one year. Forty-six patients completed follow-up. One patient in the sevoflurane group died. The mean [standard deviation (SD)] ejection fraction by single-photon emission computed tomography at six months was 51.7 (7.7)% in the sevoflurane group and 51 (9.1)% in the control group (mean difference, 0.7%; 95% confidence interval [CI], -5.9 to 7.3; P = 0.831). The median [interquartile range] amount of scarring at six months was 0% [0 - 8] in the sevoflurane group and 2.5% [0 - 7.1] in control group (mean difference, -0.1%; 95% CI, -4.6 to 4.4; P = 0.700). The mean (SD) percentage of hibernating myocardium was similar in both groups 0% [0, 5] (mean difference, -1.3%; 95% CI, -3.4 to 0.9; P = 0.259). The mean (SD) ejection fraction at one year increased compared with baseline by 8.0 (9.1)% (P < 0.001). In this study, we did not find an effect of sevoflurane on left ventricular function or myocardial injury at one year post STEMI. This trial was registered at www.clinicaltrials.gov ; identifier: NCT00971607.

Prognostic value of low QRS voltage in patients with acute coronary syndrome

I have read the article by Tan et al. [ [1] Tan N.S. Goodman S.G. Yan R.T. et al. GRACE ECG substudy and Canadian ACS I Registry investigators. Prognostic significance of low QRS voltage on the admission electrocardiogram in acute coronary syndromes. Int. J. Cardiol. 2015; 190: 34-39 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar ] with great interest, recently published in your journal. Authors reported that low QRS voltage was found to be an independent predictor of in-hospital mortality, and there was a consistent trend toward higher 6-month cumulative mortality in patients with acute coronary syndrome (ACS) and low QRS voltage. In the present study of Tan et al. there are no data about patient group medications on admission and at discharge. It is well known that optimal medical therapy significantly reduces in-hospital and long term mortality in ACS patients. According to guidelines, it is recommended to use statins, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin-receptor blockers (ARB), oral beta-blockers, long term acetylsalicylic acid, and dual antiplatelet therapy for at least 12 months to reduce the mortality in ACS patients [ 2 Steg P.G. James S.K. Atar D. et al. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur. Heart J. 2012; 33: 2569-2619 Crossref PubMed Scopus (139) Google Scholar , 3 Hamm C.W. Bassand J.P. Agewall S. et al. ESC Committee for Practice Guidelines. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur. Heart J. 2011; 32: 2999-305 Google Scholar ]. In addition, approximately half of the patients have impaired left ventricle systolic function in the present study of Tan et al. It has been demonstrated that aldosterone antagonists reduce mortality significantly in post-ST elevation myocardial infarction patients with left ventricle systolic dysfunction (ejection fraction <40%) [ [4] Pitt B. Remme W. Zannad F. et al. Eplerenone post-acute myocardial infarction heart failure efficacy and survival study investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N. Engl. J. Med. 2003; 348: 1309-1321 Crossref PubMed Scopus (4028) Google Scholar ]. Therefore, Authors should state the incidence of treatment with statins, dual antiplatelet therapy, beta-blockers, aldosterone antagonists, and ACEI/ARB for both groups and compare the groups regarding their medications. Less medication with optimal medical therapy may be another significant reason for higher mortality rates in patients with low QRS voltage.

Predictive value of segmental extent of late gadolinium enhancement and peak circumferential systolic strain in predicting improvement and normalisation of dysfunctional segments post STEMI

Background Segmental infarct transmurality on late gadolinium enhancement (LGE) acutely post ST-elevation myocardial infarction (STEMI) has been shown to predict segmental function in a few small studies. The predictive power of segmental area of enhancement (n=45) and myocardial salvage (n=34) have been analysed in one small study each. Feature Tracking (FT) quantifies strain on routinely acquired SSFP cine images. There are no published large studies assessing segmental area of enhancement or FT-derived circumferential strain (Ecc) in predicting segmental function and improvement in the short and medium term post STEMI.

Assessment of risk factors for patients with anatomical left ventricular aneurysm post acute ST-elevation myocardial infarction by use of multiple-risk-factor assessment models

To set up the multiple risk factors model of patients with anatomical left ventricular aneurysm (LVA) post acute ST-elevation myocardial infarction (STEMI) and quantitatively assess the pathopoiesis of all the factors. A total of 518 consecutive inpatients with acute STEMI hospitalized from June 2010 to December 2013 in our hospital were enrolled in this study, patients were divided into two groups: LVA group (n = 106, 20.5%) and non-LVA group (n = 412, 79.5%). All demographic and clinical data were collected by cardiologists. Finally, all of the risk factors for anatomical LVA in the acute STEMI patients were quantitatively analyzed by a binary logistic regression model. The multiple risk factors logistic regression model was set up for the anatomical LVA in patients with acute STEMI. Anterior wall myocardial infarction, occlusion of the left anterior descending branch, two or three vessels stenosis, high systolic blood pressure, sinus tachycardia and white blood cell count over 10 000 per microliter were all independent risk factors of the LVA in acute STEMI, with the odds ratio (OR) 18.21, 21.56, 4.22, 7.16, 1.98 and 1.57, respectively (all P < 0.05) . However, first medical contact less than 12 hours (OR = 0.60), collateral circulation of the coronary arteries(OR = 0.53), primary percutanous coronary intervention(OR = 0.23) and venous thrombolysis(OR = 0.12) were all protecting factors of the LVA in acute STEMI patients (all P < 0.05). Anterior wall STEMI, occlusion of the left anterior descending branch, two or three vessels stenosis, high systolic blood pressure, sinus tachycardia and white blood cell count over 10 000 per microlitre are independent risk factors of the LVA in acute STEMI patients. However, first medical contact less than twelve hours, collateral circulation of the coronary arteries, together with the primary percutanous coronary intervention and venous thrombolysis are protective factors of the LVA in patients with acute STEMI. It is important for cardiologists to assess the risks of LVA and make emergent and suitable efforts to reduce the risk of developing LVA in STEMI patients.

PM091 Is restrictive filling post ST elevation myocardial infarction (STEMI) treated by primary percutaneous intervention a predictor for development of heart failure?

PM091 Is restrictive filling post ST elevation myocardial infarction (STEMI) treated by primary percutaneous intervention a predictor for development of heart failure?

243 MONOCYTE SUBPOPULATION COUNTS AND TNF ALPHA ASSOCIATIONS WITH CLINICAL OUTCOME POST ST ELEVATION MYOCARDIAL INFARCTION

Background Monocytes are implicated in the initiation and progression of the atherosclerotic plaque contributing to its instability and rupture. Although peripheral monocytosis has been related to poor clinical outcome post ST elevation myocardial infarction (STEMI), only scarce information is available of mechanisms of this association. Tumour necrosis factor alpha (TNFα) is a key cytokine in the acute phase inflammatory response, and it is predominantly produced by inflammatory macrophages. Little is known about TNFα association with circulating monocyte subpopulations post STEMI. Method A total of 142 STEMI patients (mean age 62±13 years; 72% male) treated with percutaneous revascularization were recruited with blood samples obtained within first 24 hours from the onset and on day 10-14. Peripheral blood monocyte subpopulations were enumerated and characterized using flow cytometry after staining for CD14, CD16 and CCR2 and were defined as: CD14++CD16-CCR2+ (Mon1), CD14++CD16+CCR+ (Mon2) and CD14+CD16++CCR2- (Mon3) cells. Plasma levels of TNFα were measured by enzyme-linked immunosorbent assay (ELISA, Peprotec system, UK). Major adverse cardiac events (MACE), defined as recurrent STEMI, new diagnosis of heart failure and death were recorded at follow up, mean of 164±134 days. Results TNFα levels were significantly higher 24 hours post STEMI, compared to day 14 (paired t-test, p <0.001) with day 1 levels weakly correlated with total monocyte count as well as Mon1 (Spearman’s correlation, r=0.19, p=0.02 and r=0.22, p=0.01, respectively). There was no correlation between TNFα and Mon2 or Mon3 subpopulations. TNFα levels were significantly higher in patients with a recorded MACE (n=28, Mann-Whitney test, p<0.001) (figure 1).⇓

242 EXPRESSION OF RECEPTORS TO INTERLEUKIN 6 AND ADHESION MOLECULES ON CIRCULATING MONOCYTE SUBSETS IN MYOCARDIAL INFARCTION:

Introduction Coronary artery disease (CAD) and myocardial infarction (MI) are diseases of inflammatory aetiology, in which monocytes have been implicated. However, monocytes may also have benefical roles in myocardial recovery after MI. This diversity of roles is thought to be due to functional heterogeneity of monocyte subsets. Adhesion molecules are a key component of the inflammatory process and the mechanism by which monocytes are recruited to activated endothelium and inflamed myocardium. Additionally, a growng body of evidence has implicated the interleukin-6 receptor (IL6r) in the pathogenesis of atherosclerosis. Monocytes are a major type of IL6r expressing cell in circulation. However, limited data are available on expression of receptors to adhesion molecules and IL6r by the three human monocyte subsets after MI. Having observed marked differences in expression of adhesion molecules and IL6r between monocyte subsets in healthy humans, we aimed to evaluate the dynamics of monocyte subset expression of receptors to vascular cell adhesion molecule (VCAM-1r), intercellular adhesion molecule (ICAM-1r), and IL6r after ST-elevation MI (STEMI), which has not been previously evaluated. Methods Expression of VCAM-1r, ICAM-1r and IL6r was quantified by flow cytometry of venous blood on days 1, 3, 7 and 30 post STEMI (n=50). All STEMI patients were treated with primary percutaneous coronary intervention. STEMI patients were compared with an age and sex-matched control group with stable CAD (n=40). Monocyte subsets were defined as CD14++CD16 (Mon1), CD14++CD16+(Mon2) and CD14+CD16++(Mon3). Exclusion criteria comprised factors known to affect monocyte count. Expression of surface markers was quantified as median fluorescent intensity (MFI). Inter- and intra-assay reproducibility for surface marker assays in our laboratory is Results On day1 after STEMI, VCAM-1r expression was reduced on Mon1 (p=0.002), Mon2 (p=0.007) and Mon3 (p=0.005). There was no change in monocyte ICAM-1r expression after MI, whilst its expression on Mon1 reduced by day 30 (p=0.001). IL6r expression by Mon2 was reduced on day1 after STEMI, with no differences seen for the other subsets. A gradual upregulation of IL6r expression was seen by Mon1 and Mon2 during follow-up. Conclusions There are marked differences in expression of adhesion molecules and IL6r by monocyte subsets after STEMI. Monocyte subsets involved in inflammatory responses (Mon2) have reduced IL6r expression in the acute phase following STEMI. This may represent a regulatory feed-back mechanism aiming to re-balance the marked inflammation which is typically present after STEMI. There is also a decrease in VCAM-1r density on monocytes after STEMI. This may reflect the selective homing of monocytes with high VCAM-1r expression to damaged myocardium. Selective pharmacological modulation of monocyte subset expression of adhesion molecules and IL6r may represent a novel target for the treatment of MI and CAD.

Prevalence and extent of infarct and microvascular obstruction following a range of reperfusion techniques in ST-elevation myocardial infarction

Background Cardiac MRI (CMR) provides unique characterization of myocardial injury post acute ST-Elevation Myocardial Infarction (STEMI). It is the gold standard for non-invasive measurement of Infarct Size (IS) and tissue perfusion during STEMI. Microvascular obstruction describes suboptimal tissue perfusion despite restoration of flow in the infarct-related artery (IRA). IS and MVO are independent predictors o fa dverse remodelling and prognosis post STEMI. MVO is generally assumed to be related primarily to reperfusion. There is a paucity of data on the prevalence and extent of MVO in clinical practice using a range of different reperfusion methods, and in particular in those without reperfusion. We hypothesize that the extent and presence of MVO are primarily related to the extent of ischaemia than reperfusion per se. Methods