pre-PCI Thrombolysis In Myocardial Infarction Research Articles

Cardiovascular magnetic resonance characteristics and clinical outcomes of patients with ST-elevation myocardial infarction and no standard modifiable risk factors-A DANAMI-3 substudy.

IntroductionA higher 30-day mortality has been observed in patients with first-presentation ST elevation myocardial infarction (STEMI) who have no standard modifiable cardiovascular risk factors (SMuRFs), i. e., diabetes, hypertension, hyperlipidemia, and current smoker. In this study, we evaluate the clinical outcomes and CMR imaging characteristics of patients with and without SMuRFs who presented with first-presentation STEMI.MethodsPatients from the Third DANish Study of Acute Treatment of Patients With ST-Segment Elevation Myocardial Infarction (DANAMI-3) with first-presentation STEMI were classified into those with no SMuRFs vs. those with at least one SMuRF.ResultsWe identified 2,046 patients; 283 (14%) SMuRFless and 1,763 (86%) had >0 SMuRF. SMuRFless patients were older (66 vs. 61 years, p < 0.001) with more males (84 vs. 74%, p < 0.001), more likely to have left anterior descending artery (LAD) as the culprit artery (50 vs. 42%, p = 0.009), and poor pre-PCI (percutaneous coronary intervention) TIMI (thrombolysis in myocardial infarction) flow ≤1 (78 vs. 64%; p < 0.001). There was no difference in all-cause mortality, non-fatal reinfarction, or hospitalization for heart failure at 30 days or at long-term follow-up. CMR imaging was performed on 726 patients. SMuRFless patients had larger acute infarct size (17 vs. 13%, p = 0.04) and a smaller myocardial salvage index (42 vs. 50%, p = 0.02). These differences were attenuated when the higher LAD predominance and/or TIMI 0-1 flow were included in the model.ConclusionDespite no difference in 30-day mortality, SMuRFless patients had a larger infarct size and a smaller myocardial salvage index following first-presentation STEMI. This association was mediated by a larger proportion of LAD culprits and poor TIMI flow pre-PCI.Clinical trial registrationclinicaltrials.gov, unique identifier: NCT01435408 (DANAMI 3-iPOST and DANAMI 3-DEFER) and NCT01960933 (DANAMI 3-PRIMULTI).

A score system to predict no-reflow in primary percutaneous coronary intervention: The PIANO Score.

Angiographic no-reflow is associated with poor outcomes in patients with ST-segment elevation myocardial infarction (STEMI). We sought to develop and validate a score system to predict angiographic no-reflow in primary percutaneous coronary intervention (PCI). ST-segment elevation myocardial infarction patients undergoing primary PCI were consecutively enrolled and were randomly divided into the training and validation set. Angiographic no-reflow was defined as thrombolysis in myocardial infarction (TIMI) flow grade 0 to 2 after PCI. In the training set, independent predictors were identified by logistic regression analysis, and a score system (PredIction of Angiographic NO-reflow, the PIANO score) was constructed based on the β-coefficient of each variable. The established model was evaluated for discrimination and calibration. Angiographic no-reflow occurred in 362 (17.8%) of 2036 patients. Age ≥70years, absence of pre-infarction angina, total ischaemic time ≥4h, left anterior descending as culprit artery, pre-PCI TIMI flow grade ≤1 and pre-PCI TIMI thrombus score ≥4 were independent predictors of angiographic no-reflow. The PIANO score ranged from 0 to 14 points, yielding a concordance index of 0.857 (95% confidence interval: 0.833 to 0.880), with good calibration. In the high-risk (≥8 points) group, the probability of angiographic no-reflow phenomenon was 38.7%, while it was only 4.8% in the low-risk (<8 points) group. The score system performed well in the validation set. We establish and validate a score system based on six clinical variables to predict angiographic no-reflow in STEMI patients undergoing primary PCI, which may help choose the optimal individual treatment strategy.

Impact of COVID-19 pandemic restrictions on ST-elevation myocardial infarction: a cardiac magnetic resonance imaging study.

AimsThe severity of myocardial tissue damage following ST-elevation myocardial infarction (STEMI) strongly determines short- and long-term prognosis. This study explored the impact of the coronavirus disease 2019 (COVID-19) pandemic and associated public health restrictions on infarct severity.Methods and resultsSTEMI patients treated with primary percutaneous coronary intervention (PCI) and included in the prospective Magnetic Resonance Imaging in Acute ST-Elevation Myocardial Infarction (MARINA-STEMI) cohort study from 2015- 2020 (n = 474) were categorized according to (i) timeframes with and without major public health restrictions in 2020, and (ii) timeframes of major public health restrictions during 2020 and during the corresponding timeframes between 2015-2019. Myocardial damage was evaluated by cardiac magnetic resonance imaging. During major public health restrictions in 2020 (n = 48), there was an increase in infarct size (22 [IQR 12-29] vs. 14 [IQR 6-23]%, P < 0.01), a higher frequency (77% vs. 52%, P < 0.01) and larger extent of microvascular obstruction (1.5 [IQR 0.1-11.4] vs. 0.2 [IQR 0.0-2.6]%, P < 0.01) and a higher rate of intramyocardial haemorrhage (56% vs. 34%, P = 0.02) as compared to the phases without major restrictions in 2020 (n = 101). These findings were confirmed in adjusted analysis and were consistent when comparing patients admitted in 2020 versus patients admitted in the “pre-pandemic” era (2015-2019). Patient characteristics were comparable between groups, except for a significantly longer total ischemia time (P < 0.01) and higher frequency of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow 0 during times of major restrictions (P = 0.03).ConclusionThis study provides novel mechanistic insights demonstrating a significant increase in myocardial damage in STEMI patients admitted during the COVID-19 pandemic with a temporal relation to major public health restrictions.

Post percutaneous coronary intervention hemoglobin levels predict in-hospital mortality in patients with STEMI treated with primary percutaneous coronary intervention.

In this study, we aimed to determine whether admission hemoglobin versus post-percutaneous coronary intervention (PCI) hemoglobin level at 24 hours is a predictor of in-hospital mortality for patients with ST elevation myocardial infarction (STEMI) without evidence of clinical hemorrhage who underwent primary PCI. In this study, we included 1,444 consecutive patients with STEMI who underwent primary PCI at a tertiary heart hospital. The primary outcome of the study was the in-hospital all-cause mortality. We used the penalized maximum likelihood estimation (PMLE) logistic regression method to examine the relationship between primary outcome and candidate predictors. In total, 172 (11.9%) patients died during the in-hospital course. According to a PMLE logistic regression analysis, age, KILLIP class ≥2, pre-PCI thrombolysis in myocardial infarction (TIMI) flow <3, systolic blood pressure, creatinine, glycoprotein IIb/IIIa inhibitor use, and post-PCI hemoglobin levels at 24 hours were predictors of in-hospital mortality. The relative importance of post-PCI hemoglobin at 24 hours (contributing 6% of the explainable outcome in the model) was significantly higher than admission hemoglobin (contributing only 0.1% of the explainable outcome in the model). This study demonstrated that post-PCI hemoglobin levels were independently associated with in-hospital survival in patients with STEMI without evidence of bleeding following primary PCI. In addition, post-PCI hemoglobin was a better predictor of in-hospital mortality than admission hemoglobin for patients with STEMI who underwent primary PCI.

Association of pre-percutaneous coronary flow grade and clinical outcomes in patients with non-ST-segment elevation myocardial infarction: Data from the Korea Acute Myocardial Infarction Registry.

Because of a paucity of published data, we compared the 2-year major clinical outcomes between pre-percutaneous coronary intervention (pre-PCI) thrombolysis in myocardial infarction (TIMI) flow grade 0/1 (pre-TIMI flow grade [pre-TIMI] 0/1) group and pre-PCI TIMI flow grade 2/3 (pre-TIMI 2/3) group in patients with non-ST-segment elevation myocardial infarction (NSTEMI) who underwent successful implantation of newer-generation drug-eluting stent.A total of 7506 NSTEMI patients were divided into 2 groups: pre-TIMI 0/1 group (n = 3157) and pre-TIMI 2/3 group (n = 4349). The primary outcome was major adverse cardiac events defined as all-cause death, recurrent myocardial infarction, or any repeat revascularization. The secondary outcome was stent thrombosis (ST).After propensity score-matched (PSM) analysis, 2 PSM groups (2473 pairs, n = 4946, C-statistic = 0.684) were generated. Major adverse cardiac events (hazard ration [HR], 1.294; 95% confidence interval [CI]: 1.065–1.572; P = .009), all-cause death (HR, 1.559, P = .003), cardiac death (HR: 1.641, P = .005), and all-cause death or MI (HR: 1.531, P = .001) rates were significantly higher in the pre-TIMI 0/1 group than in the pre-TIMI 2/3 group. Moreover, these differences were more prominent during the first 1 month after the index PCI. However, the cumulative incidences of recurrent myocardial infarction, any revascularization, and ST were similar between the 2 groups.Among a contemporary cohort of NSTEMI, these data suggest that the presence of a pre-PCI patency of the infarct-related artery showed better mortality reduction capacity than those with a lack of patency.

Two-Year Clinical Outcomes According to Pre-PCI TIMI Flow Grade and Reperfusion Timing in Non-STEMI After Newer-Generation Drug-Eluting Stents Implantation.

The 2-year clinical outcomes according to pre-percutaneous coronary intervention (PCI) thrombolysis in myocardial infarction (TIMI) flow grade and reperfusion timing were investigated in patients with non-ST-segment elevation myocardial infarction (NSTEMI) who received newer-generation drug-eluting stents. A total of 7506 NSTEMI patients were divided into 2 groups: early (PCI ≤ 24 hours: n = 6398; pre-PCI TIMI 0/1 [n = 2729], pre-PCI TIMI 2/3 [n = 3669]) and delayed (PCI > 24 hours: n = 1108; pre-PCI TIMI 0/1 [n = 428], pre-PCI TIMI 2/3 [n = 680]) invasive groups. Major adverse cardiac events were defined as all-cause death, recurrent myocardial infarction, or any repeat revascularization. All-cause death (P = 0.005 and 0.009, respectively) and cardiac death (P = .003 and 0.046, respectively) were significantly higher in pre-PCI TIMI 0/1 patients than in pre-PCI TIMI 2/3 patients both in the early and delayed invasive groups. In pre-PCI TIMI 0/1 patients, all-cause death rate was significantly higher in the delayed group (P = .023). In pre-PCI TIMI 2/3 patients, the clinical end point was similar between the 2 groups. An early invasive strategy is preferred to a delayed invasive strategy in reducing all-cause death in patients with pre-PCI TIMI 0/1. However, in patients with pre-PCI TIMI 2/3, both treatment strategies are acceptable.

Effect of Ticagrelor on Left Ventricular Remodeling in Patients With ST-Segment Elevation Myocardial Infarction (HEALING-AMI).

The aim of this study was to evaluate the effect of ticagrelor versus clopidogrel on left ventricular (LV) remodeling after reperfusion of ST-segment elevation myocardial infarction (STEMI) in humans. Animal studies have demonstrated that ticagrelor compared with clopidogrel better protects myocardium against reperfusion injury and improves remodeling after myocardial infarction. In this investigator-initiated, randomized, open-label, assessor-blinded trial performed at 10 centers in Korea, patients were enrolled if they had naive STEMI successfully treated with primary percutaneous coronary intervention (PCI) and at least 6-month planned duration of dual-antiplatelet treatment. The coprimary endpoints were LV remodeling index (LVRI) (a relative change of LV end-diastolic volume) measured on 3-dimensional echocardiography and N-terminal pro-B-type natriuretic peptide level at 6months. Among initially enrolled patients with STEMI (n=336), 139 in each group completed the study. LVRI at 6months was numerically lower with ticagrelor versus clopidogrel (0.6 ± 18.6% vs. 4.5 ± 16.5%; p=0.095). Ticagrelor significantly reduced the 6-month level of N-terminal pro-B-type natriuretic peptide (173 ± 141 pg/ml vs. 289 ± 585 pg/ml; p=0.028). These differences were prominent in patients with pre-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade 0. By multivariate analysis, ticagrelor versus clopidogrel reduced the risk for positive LV remodeling (LVRI >0%) (odds ratio: 0.56; 95% confidence interval: 0.33 to 0.95; p=0.030). The LV end-diastolic volume index remained unchanged during ticagrelor treatment (from 54.7 ± 12.2 to 54.2 ± 12.2ml/m2; p=0.629), but this value increased over time during clopidogrel treatment (from 54.6 ± 11.3 to 56.4 ± 13.9ml/m2; p=0.056) (difference-2.3ml/m2; 95% confidenceinterval:-4.8 to 0.2ml/m2; p=0.073). Ticagrelor reduced LV end-systolic volume index (from 27.0 ± 8.5 to 24.7± 8.4ml/m2; p<0.001), whereas no reduction was seen with clopidogrel (from 26.2 ± 8.9 to 25.6 ± 11.0ml/m2; p=0.366) (difference-1.8ml/m2; 95% confidence interval:-3.5 to-0.1ml/m2; p=0.040). Ticagrelor was superior to clopidogrel for LV remodeling after reperfusion of STEMI with primary PCI. (High Platelet Inhibition With Ticagrelor to Improve Left Ventricular Remodeling in Patients With ST Segment Elevation Myocardial Infarction [HEALING-AMI]; NCT02224534).

Degree of ST-segment elevation in patients with STEMI reflects the acute ischemic burden and the salvage potential

BackgroundST-segment elevation myocardial infarction (STEMI) is clinically diagnosed by significant ST-segment elevation (STE) in the electrocardiogram (ECG). The importance of the sum of significant ST-segment elevation (∑STE) before primary percutaneous coronary intervention (PPCI) – considered an indicator of the degree of ischemia - is sparse. We evaluated the association of ∑STE before PPCI with respect to area at risk, infarct size and myocardial salvage. MethodsA total of 503 patients with STEMI and available cardiac magnetic resonance (CMR) were included. CMR was performed at day 1 (interquartile range [IQR], 1–1) and at follow-up at day 92 (IQR, 88–96). The ECG before PPCI with the most prominent STE was used for analysis. Results∑STE divided into quartiles were progressive linearly associated with area at risk (p < 0.001), final infarct size (p < 0.001) and extent of microvascular obstruction (p < 0.001) and inverse linearly associated with final myocardial salvage (p < 0.001). Similar results were found for linear regression analyses. However, ∑STE was not associated with final myocardial salvage in patients with pre-PCI TIMI (thrombolysis in myocardial infarction) flow 0/1 (p = 0.24) in contrast to patients with pre-PCI TIMI flow 2/3 (p ≤ 0.001). ConclusionIn patients with STEMI presenting within 12 h of symptom onset, the degree of STE in the ECG before PPCI is a marker of the extent of myocardium at risk that in turn affects the infarct size in patients with pre-PCI TIMI flow 0/1, whereas the degree of STE in patients with pre-PCI TIMI flow 2/3 is a marker of the extent of the myocardium at risk as well as myocardial salvage – both affecting the myocardial damage.

Predictive Value of Fasting Blood Glucose for Microvascular Obstruction in Nondiabetic Patients with ST-Segment Elevation Myocardial Infarction after Primary Percutaneous Coronary Intervention.

Background The relationship between fasting blood glucose (FBG) and microvascular obstruction (MVO) after primary percutaneous coronary intervention (PCI) remains unclear in nondiabetic patients with ST-segment elevation myocardial infarction (STEMI). This study aimed to determine the predictive value of FBG in MVO in nondiabetic STEMI patients. Methods A total of 108 nondiabetic STEMI patients undergoing primary PCI were enrolled in this study. The patients were classified into either the MVO group or non-MVO group based on cardiac magnetic resonance imaging (CMR). Results FBG in the MVO group was higher than in the non-MVO group. Univariate analysis showed that FBG, peak high-sensitive troponin T (TnT), pre-PCI thrombolysis in myocardial infarction (pre-PCI TIMI) flow, left ventricular ejection fraction (LVEF), infarction size, left ventricular end-diastolic diameter (LVEDd), left ventricular end-diastolic volume (LVEDV), and global longitudinal strain (GLS) were likely predictive factors of MVO. After adjustment for other parameters, FBG, peak TnT, LVEF, and LVEDV remained independent predictors for MVO. Conclusion FBG was independently associated with MVO in nondiabetic STEMI patients.

Incidence of bifurcation coronary lesion as a culprit lesion in patients with acute myocardial infarction: Impact of treatment strategy on short and long term outcomes

Background: Although, there are several studies comparing single and two-stent techniques in patients with bifurcation lesions, evidence in patients presenting with myocardial infarction (MI) is still insufficient. We aimed to assess the short and long term outcomes of provisional and two-stent techniques of bifurcation lesions in patients with ACS. Methods: 2992 patients with MI who underwent percutaneous coronary intervention (PCI) were enrolled in the present study. Of 2992 patients, 385 patients with MI had bifurcation lesions. The Synergy between PCI with TAXUS™ and Cardiac Surgery (SYNTAX) score, pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow, post-PCI TIMI flow, duration of procedure, angiographic features, post-PCI side branch loss, 1- and 12-month mortality rates were noted. Results: 169 (43.9 %) patients had ST segment elevation MI, whereas 216 (56.1%) patients had non-ST segment elevation MI. 355 (92.2%) patients underwent provisional stenting and 30 (7.8%) patients underwent two-stent technique. Side branch loss was observed in 40 patients (11.2 %) in the provisional group and 1 patient (3.3%) in the two-stent group (p=0.2). Compared to provisional group, durations of angiography and revascularization in two-stent group were significantly longer (p<0.001 and p<0.001). Both 1-month and 12-month mortality rates were similar in provisional and two-stent groups (4.2% vs. 3.3%, p=0.8 and 11.5% and 13.3%, p=0.7; respectively). Conclusion: In patients presenting with ACS and bifurcation lesions, procedural success, side branch loss, as well as short and long term mortality were similar in both provisional and two-stent techniques.

The comparison of procedural and clinical outcomes of thrombolytic-facilitated and primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction (STEMI): Findings from PROVE/ACS study.

BACKGROUNDThere is still a controversy in the preferred method of reperfusion in acute ST-segment elevation myocardial infarction (STEMI), when the achievement of well-defined "golden time" is difficult. We sought to evaluate the procedural and in-hospital outcomes of the strategy of "thrombolytic administration and rescue or routine percutaneous coronary intervention (PCI)" versus "primary PCI (PPCI)" strategy in acute STEMI.METHODSIn this observational prospective study, the data of 237 patients with acute STEMI presented or referred to Chamran Cardiovascular Research Center in Isfahan, Iran, were collected (PROVE/ACS study). Baseline characteristics, thrombolysis in myocardial infarction (TIMI) flow grade of infarct-related artery (IRA), left ventricular ejection fraction (LVEF), and in-hospital outcomes were evaluated.RESULTSThe mean age of patients was 61.4 ± 13.0 years, 86.9% were men, 13.1% were diabetic, and 67.9% had anterior STEMI. Patients in the "thrombolytic then PCI" group were younger, more smoker, more often male with higher body weight and lower systolic blood pressure (SBP). The pre-PCI TIMI flow grade 3 was more often seen in the "thrombolytic then PCI" group (39.4% vs. 21.0%, P < 0.001) and less thrombectomy was performed in this group of patients (12.9% vs. 26.7%, P = 0.011). Time to reperfusion was significantly longer in PPCI group (182.4 ± 233.7 minutes vs. 44.6 ± 93.4 minutes, respectively, P < 0.001). No difference in mortality, mean of LVEF, and incidence of atrial fibrillation (AF) was observed in two groups.CONCLUSIONIf the PPCI strategy could not be performed in the golden time, the strategy of thrombolytic administration and rescue or routine PCI leads to more initial IRA patency and less thrombectomy with similar clinical outcomes.

Outcomes in spontaneous reperfused Stemi using clinical vs angiographic criteria: A Tunisian cohort

Spontaneous reperfusion (SR) in ST-elevation myocardial infarction has traditionally been assessed by coronary angiography. Recently, spontaneous reperfusion would be defined by reduction of ST-segment elevation and resolution of pain. In our study, we undertook a systematic assessment of SR using both clinical and angiographic techniques. To determine predictors of better prognosis in spontaneous reperfused STEMI. This was a retrospective study which included all patients diagnosed with STEMI and hospitalized in the cardiology department of Monastir hospital, Tunisia and treated by primary PCI, between 2008 and 2017. We compared clinical characteristics and outcomes in the two groups. Three hundred fifty-five patients are treated by primary percutaneous coronary intervention (PCI) and were studied: Electrocardiographic SR (>/ = 70% ST-segment resolution) occurred in 18% of patients and angiographic SR (pre-PCI Thrombolysis in Myocardial Infarction (TIMI) 3 flow) in 17.7% of patients. Thirty-day clinical outcomes of patients with ECG SR versus no ECG SR tended to have lower mortality (0% vs. 2.4%, P = .061), a lower composite of death/shock/congestive heart failure (6.9% vs. 12.2%, P = .148), and significant reductions in death/reinfarction (0% vs. 5.6%, P = .014). By contrast, no such significative differences were evident in patients with angiographic SR versus no SR for death (2.8% vs. 3.0%, P = 1.00), death/shock/congestive heart failure (10.3% vs. 11.8%, P = .498), or death/reinfarction (2.3% vs. 5.2%, P = .409). The frequency of SR was comparable using either ECG or angiographic criteria. Clinical outcomes were better assessed with ECG SR. These results support the role of ECG in detecting reperfusion versus infract-related artery epicardial patency alone.

Long-Term Outcome of Acute Coronary Syndromes in Patients on Chronic Oral Anticoagulants: Data from the EPICOR Study.

To analyze characteristics, management and outcomes of patients with acute coronary syndromes (ACS) receiving chronic oral anticoagulant (OAC) therapy enrolled in the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients) prospective, international, observational study of antithrombotic management patterns in ACS survivors (NCT01171404). This post-hoc analysis evaluated the association between OAC use at baseline (OACb) and time from hospital admission to percutaneous coronary intervention (PCI) (tHA-PCI), pre-PCI thrombolysis in myocardial infarction (TIMI) 3 flow, stent type, length of hospitalization, and clinical endpoints; death, non-fatal MI, and non-fatal stroke, a composite of these ± bleeding, over 2 years' followup. Of 10,568 ACS patients, 345 (3.3%) were on OACb (non-ST-segment elevation ACS [NSTEACS], n=268; ST-segment elevation MI [STEMI], n=77). OACb patients were older with more comorbidities. In NSTE-ACS OACb patients, tHA-PCI was longer (median 57.4 vs. 27.8 h; p=.008), and TIMI 3 flow rarer (26.0 vs. 33.5%; p=0.035). OACb patients had longer mean hospital stay (NSTEACS: 8.9 vs. 7.6 days; p<0.001; STEMI: 9.5 vs. 7.8 days; p=0.015), and higher rates of the composite endpoint (NSTE-ACS: 16.8 vs. 8.8%; p<0.0001; STEMI: 23.4 vs. 5.9%; p<0.0001). Bleeding events were more common with OACb (NSTE-ACS: 6.0 vs. 3.3%; p=0.01; STEMI: 6.5 vs. 2.8%; p=0.04). At 2-years, OACb use was associated with an increased risk of cardiovascular and bleeding events in STEMI and NSTE-ACS. NSTE-ACS patients on OACb experienced prolonged time to intervention, lower rates of TIMI 3 flow and longer hospitalization.

Morphine and Ticagrelor Interaction in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: ATLANTIC-Morphine.

Morphine adversely impacts the action of oral adenosine diphosphate (ADP)-receptor blockers in ST-segment elevation myocardial infarction (STEMI) patients, and is possibly associated with differing patient characteristics. This retrospective analysis investigated whether interaction between morphine use and pre-percutaneous coronary intervention (pre-PCI) ST-segment elevation resolution in STEMI patients in the ATLANTIC study was associated with differences in patient characteristics and management. ATLANTIC was an international, multicenter, randomized study of treatment in the acute ambulance/hospital setting where STEMI patients received ticagrelor 180mg ± morphine. Patient characteristics, cardiovascular history, risk factors, management, and outcomes were recorded. Opioids (97.6% morphine) were used in 921 out of 1862 patients (49.5%). There were no significant differences in age, sex or cardiovascular history, but more morphine-treated patients had anterior myocardial infarction and left-main disease. Time from chest pain to electrocardiogram and ticagrelor loading was shorter with morphine (both p = 0.01) but not total ischemic time. Morphine-treated patients more frequently received glycoprotein IIb/IIIa inhibitors (p = 0.002), thromboaspiration and stent implantation (both p < 0.001). No significant difference between the two groups was found regarding pre-PCI ≥ 70% ST-segment elevation resolution, death, myocardial infarction, stroke, urgent revascularization and definitive acute stent thrombosis. More morphine-treated patients had an absence of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) 3 flow (85.8% vs. 79.7%; p = 0.001) and more had TIMI major bleeding (1.1% vs. 0.1%; p = 0.02). Morphine-treatment was associated with increased GP IIb/IIIa inhibitor use, less pre-PCI TIMI 3 flow, and more bleeding. Judicious morphine use is advised with non-opioid analgesics preferred for non-severe acute pain. clinicaltrials.gov identifier: NCT01347580.

Prognostic impact of pre-percutaneous coronary intervention TIMI flow in ST and non-ST elevation myocardial infarction patients: Results from the FAST-MI 2010 registry

Thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3 before percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) is associated with improved outcomes. No recent data, however, are available on its impact beyond one year and/or by type of AMI. To assess the prognostic impact of pre-PCI TIMI flow at 30 days and 3 years in ST-elevation (STEMI) and non-ST-elevation (NSTEMI) AMI patients. We compared long-term outcomes associated with TIMI flow grade 2/3 versus 0/1 in patients referred for PCI in the FAST-MI 2010 nationwide French registry. TIMI flow grade 2/3 was found in 41% of STEMI and 69% of NSTEMI patients. It was associated with lower 30-day death in STEMI patients (OR: 0.30; 95% CI: 0.12 to 0.77, P = 0.01) but not in NSTEMI patients (OR 0.57; 95% CI: 0.22 to 1.42, P = 0.23). TIMI grade flow 2/3 was also associated with lower risk of 3-year death in STEMI patients (HR: 0.69; 95% CI: 0.49 to 0.98, P = 0.04) but not in NSTEMI patients (HR 0.79; 95% CI: 0.56 to 1.11, P = 0.17). TIMI flow grade 2/3 is observed more often in NSTEMI patients. It represents an independent predictor of early and late survival in STEMI patients but is not significantly related to early or long-term survival in NSTEMI patients. Clinicaltrials.gov identifier: NCT01237418 .

Prognostic impact of prepercutaneous coronary intervention TIMI flow in patients with ST-segment and non-ST-segment elevation myocardial infarction: Results from the FAST-MI 2010 registry

Thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3 before percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) is associated with improved outcomes. However, no recent data are available on its impact beyond 1year and/or by type of AMI. To assess the prognostic impact of prePCI TIMI flow at 30days and 3years in patients with ST-segment elevation (STEMI) or non-ST-segment elevation (NSTEMI) AMI. We compared long-term outcomes associated with TIMI flow grade 2/3 versus 0/1 in patients referred for PCI in the nationwide French registry of acute ST-segment elevation or non-ST-segment elevation myocardial infarction (FAST-MI) 2010. TIMI flow grade 2/3 was found in 41% of patients with STEMI and 69% of patients with NSTEMI; it was associated with a lower risk of 30-day death in patients with STEMI (odds ratio 0.30, 95% confidence interval [CI] 0.12-0.77; P=0.01), but not in patients with NSTEMI (odds ratio 0.57, 95%CI 0.22-1.42; P=0.23). TIMI grade flow 2/3 was also associated with a lower risk of 3-year death in patients with STEMI (hazard ratio 0.69, 95%CI 0.49-0.98; P=0.04), but not in patients with NSTEMI (hazard ratio 0.79, 95%CI 0.56-1.11; P=0.17). TIMI flow grade 2/3 is observed more often in patients with NSTEMI; it is an independent predictor of early and late survival in patients with STEMI, but is not significantly related to early or long-term survival in patients with NSTEMI.

TCTAP A-014 Optimal Timing of Invasive Strategy in Stable Non-ST-segment Elevation Myocardial Infarction: Impact of Immediate Intervention

Background: The optimal timing of intervention in non-ST-elevation myocardial infarction (NSTEMI) remains controversial. We sought to assess impact of immediate percutaneous coronary intervention (PCI) for NSTEMI. Methods: 6,134 NSTEMI patients undergoing PCI from the Korea Acute Myocardial Infarction Registry were divided into group 1 (immediate PCI within 4 h, n = 1,132) and group 2 (deferred PCI after 4 h, n = 5,002). Patients with recurrent or refractory ischemia, systolic blood pressure Results: In all patients and propensity-matched cohort (n = 1,131 in each group), group 1 had higher peak troponin level, higher rate of pre-PCI Thrombolysis In Myocardial Infarction (TIMI) grade 0 or 1, higher use of glycoprotein IIb/IIIa inhibitor, and lower use of unfractionated heparin and nitrates. In all patients, 12-month rates of MI and death/MI were higher in group 1. No differences were observed in 12-month death and major adverse cardiac events (MACE: composite of death, MI, target-vessel revascularization, and coronary artery bypass graft surgery). In the propensity-matched cohort, no significant differences were observed in 12-month rates of death, MI, death/MI or MACE. However, group 1 had less major bleeding (0.8% vs. 3.0%, p = 0.024) and shorter hospital stay. In the propensity-matched cohort, the effect of PCI on 12-month outcome showed a U-shaped relationship with time to PCI: rates of MI and death/MI (≤4 h, 4-12 h, 12-24 h, 24-72 h, >72 h after arrival) were 2.7%, 1.3%, 1.1%, 1.9%, 2.2% and 6.5%, 4.2%, 3.9%, 5.2%, 6.1%, respectively. PCI 4-12 h and 12-24 h after arrival was associated with lower risk of 12-month MI (hazard ratio [HR]: 0.49, 95% confidence interval [CI]: 0.25 to 0.93, p = 0.03 and HR: 0.40, 95% CI: 0.22 to 0.72, p = 0.002) and death/MI (HR: 0.64, 95% CI: 0.44 to 0.93, p = 0.02 and HR: 0.60, 95% CI: 0.43 to 0.84, p = 0.003), respectively. Conclusions: Immediate PCI for stable NSTEMI did not confer an advantage with respect to hard clinical endpoints at 12 months. PCI within 4-24 h after arrival was associated with lower risk of adverse events.

Clinical impact of immediate invasive strategy in patients with non-ST-segment elevation myocardial infarction

BackgroundImmediate invasive approach for non-ST-segment elevation myocardial infarction (NSTEMI) may permit treatment of the underlying plaque rupture as early as possible with subsequent reduction of death and myocardial infarction (MI). We sought to assess clinical impact of immediate percutaneous coronary intervention (PCI) for NSTEMI. MethodsA total of 6134 NSTEMI patients undergoing PCI from the Korea Acute Myocardial Infarction Registry were divided into group 1 (immediate PCI within 4h, n=1132) and group 2 (non-immediate PCI after 4h, n=5002). Propensity-matched 12-month clinical outcome was compared. ResultsIn all patients and propensity-matched cohort (n=1131 in each group), group 1 had higher peak troponin level, higher rate of pre-PCI Thrombolysis In Myocardial Infarction (TIMI) grade 0 or 1, higher use of glycoprotein IIb/IIIa inhibitor, and lower use of unfractionated heparin and nitrates. In all patients, 12-month rates of MI and death/MI were higher in group 1. No differences were observed in 12-month death and major adverse cardiac events (MACE: composite of death, MI, target-vessel revascularization, and coronary artery bypass graft surgery). In propensity-matched cohort, no significant differences were observed in 12-month rates of death, MI, death/MI or MACE. However, group 1 had less major bleeding (0.8% vs. 3.0%, p=0.024) and shorter hospital stay. ConclusionsImmediate PCI for patients with NSTEMI was associated with lower pre-PCI culprit vessel patency and not with improved 12-month clinical outcome.

Impact of residual platelet reactivity on reperfusion in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Whether high platelet reactivity (HPR) immediately after diagnostic angiography is associated with worse coronary reperfusion prior to and after primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) is unknown. This study aimed to assess the impact of P2Y12-mediated HPR on angiographic outcomes in patients with STEMI undergoing PPCI. STEMI patients undergoing PPCI and pretreated with a P2Y12 receptor antagonist underwent platelet function testing with the VerifyNow™ assay at the time of angiography. Light transmission aggregometry (LTA) was performed in a subgroup. HPR was defined according to expert consensus definitions. Pre-PCI coronary patency, thrombotic burden and indices of impaired post-PCI reperfusion were compared between HPR and non-HPR patients. Among 164 patients, the prevalence of VerifyNow™-derived HPR was 71.3% at a median (interquartile range (IQR)) of 55 (40-75) minutes after a P2Y12 inhibitor loading dose. Compared with non-HPR patients, those with HPR had significantly lower rates of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow grades 2 or 3 (51.1% vs. 32.5%, p = 0.04), higher rates of thrombus score (TS) grade 3/4 (29.8% vs. 52.1%, p = 0.015) and 4 (14.9% vs. 32.5%, p = 0.037) and lower median (IQR) corrected TIMI frame count (cTFC; 23.2 (15.8-32.5) vs. 26.0 (21.0-35.0), p = 0.02), respectively. These findings were consistent using LTA-based data. HPR and TS grade 4 were predictors of higher cTFC. In patients with STEMI undergoing PPCI pretreated with P2Y12 receptor inhibitors, pre-PPCI HPR was found to be associated with lower pre-PCI coronary patency, higher thrombotic burden and a worse index of post-PCI coronary reperfusion.

Abstract 19286: Pharmacoinvasive Strategy versus Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction: A Propensity Score Matched Analysis From the Korea Acute Myocardial Infarction Registry

Background: There is a paucity of data comparing pharmacoinvasive treatment (PI) versus primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) in real world patients. Methods: We employed the Korea Acute Myocardial Infarction Registry to identify patients with STEMI who received either PI defined as fibrinolysis followed by PCI (rescue/urgent or elective) or PPCI. Patients receiving facilitated PCI within 3 hours from fibrinolysis were excluded. Propensity-matched 12-month clinical outcome was compared between the 2 groups. Results: In all patients (n = 9,586), PI group (n = 708) was younger, more often male, smokers, more likely to have typical chest pain and off-hour hospital arrival. PPCI group (n = 8,878) was more likely to have diabetes, lower blood pressure, higher Killip class and to receive glycoprotein IIb/IIIa inhibitors. PI group had shorter symptom-to-first medical contact (FMC) time (60 min vs. 80 min, p &lt; 0.001), symptom-to-reperfusion time (165 min vs. 255 min, p &lt; 0.001), and higher rate of pre-PCI Thrombolysis In Myocardial Infarction (TIMI) 3 (50.6% vs. 13.6%, p &lt; 0.001). However, rate of post-PCI TIMI 3 was similar between the 2 groups. After propensity matching (n = 708 for each group), PI group had similar symptom-to-FMC time but had shorter symptom-to-reperfusion time (165 min vs. 240 min, p &lt; 0.001), higher pre-PCI TIMI 3 rate (15.8% vs. 50.6%, p &lt; 0.001) with similar post-PCI TIMI 3 rate. In all patients, PI group had lower rates of 12-month death (4.4% vs. 6.4%, hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.44 to 0.92, p = 0.015) and major adverse cardiac events (MACE: composite of death, recurrent myocardial infarction, repeat revascularization) (7.5% vs. 9.5%, HR: 0.69, 95% CI: 0.52 to 0.92, p = 0.010). In propensity-matched cohorts, 12-month mortality and MACE were similar between PI and PPCI: 4.4% vs. 2.8%, HR: 1.60, 95% CI: 0.91 to 2.84, p = 0.105 and 7.5% vs. 7.6%, HR: 0.96, 95% CI: 0.65 to 1.41, p = 0.827, respectively. Conclusions: In this large observational study with propensity-matched analysis, STEMI patients receiving PI, compared to PPCI, had shorter symptom-to-reperfusion time, higher culprit-vessel patency, and similar 12-month clinical outcome.