Primary Percutaneous Coronary Intervention In Patients Research Articles

Immediate Procedural Success of Primary Percutaneous Intervention in Patients with Acute ST Segment Elevation Myocardial Infarction

Objective: To determine the frequency of immediate procedural success of Primary PCI in patients with Acute ST segment elevation Myocardial infarction. Methodology: This observational study was conducted at Cardiology unit of P.I.M.S, Islamabad from April 2018 to October 2018. Study included 43 patients with STEMI. All of them had primary PCI. The main outcome variable was frequency of procedural success which was described as frequency distribution table. Results: Procedural success was achieved among all (100%) patients. There were 16.3% patients who developed contrast induced nephropathy (recovered), they all were diabetics. There were 4.6% patients who developed hematoma. No other complications seen Conclusions: Immediate procedural success of primary PCI is high (almost successful in every case) and should be offered to the patients with STEMI whenever the facility is available. Keywords: ST-segment elevation myocardial infarction; primary percutaneous coronary intervention.

Adverse events in acute myocardial infarction patients: the DAPT Score for risk stratification in an Asian population

Abstract Background Dual antiplatelet therapy (DAPT) is essential in mitigating adverse ischemic events after myocardial infarction (MI), and current guidelines have recommended the therapy to be administered for at least 1 year. Though prolonged DAPT helps to reduce ischemic events in high-risk patients, it can also increase the risk of significant bleeding. Risk stratification tools, such as the DAPT Score, can help to identify patients who are most or least likely to benefit from prolonged DAPT. Purpose To evaluate the performance of the DAPT Score as a predictor of major adverse cardiovascular events (MACE) in an Asian cohort who underwent percutaneous coronary intervention (PCI) for MI. Methods The analysis cohort consisted of 2086 MI patients (86% of primary PCI patients) who were admitted to Singaporean hospitals between 2012 and 2014. Demographic, clinical and therapeutic data regarding the index hospitalisation and 12-month follow-up period were collected. Patients were grouped according to their DAPT Score (high ischemic vs high bleeding risk) and DAPT duration (12 vs <12 months; Figure 1). The primary endpoint was MACE (all-cause mortality, recurrent MI and stroke). MACE as an outcome was evaluated using multivariable Cox regression adjusted for age, gender, ethnicity, smoking status, prior MI, PCI or coronary artery bypass graft, hypertension, dyslipidaemia, cerebrovascular disease, diabetes mellitus, family history of coronary artery disease, vein graft stent and type of MI at presentation. Results The overall incidence rate of MACE in this cohort was 12.3%. There was a significantly higher MACE rate in Group 2 patients compared to Group 1 patients (high ischemic risk and <12-month DAPT vs high ischemic risk and 12-month DAPT; hazard ratio: 1.37, 95% confidence interval: 1.02–1.83, P=0.038). No other significant differences in MACE rates were observed among the rest of the groups (Group 3: 1.44 [0.89–2.34]; Group 4: 1.15 [0.61–2.16], P>0.050). Furthermore, MACE was independently associated with diabetes, hypertension, prior MI and cerebrovascular disease (1.49 [1.10–2.02], 1.43 [1.00–2.05], 1.41 [1.01–1.98], 3.06 [2.15–4.37], respectively, P<0.050). Patients <65 years and males were found to be protected against MACE (0.71 [0.51–0.99], 0.72 [0.52–0.99], respectively, P<0.050). The overall bleeding rate was 2.2% (Group 1: 2.0%; Group 2: 1.7%; Group 3: 6.0%; Group 4: 0.7%). Conclusions The DAPT Score predicted MACE up to 12 months after PCI in MI patients with high ischemic risk and <12 months of DAPT. This highlights the importance of adequate duration of DAPT in high ischemic risk MI patients. Moreover, the elderly, female, diabetic, hypertensive and those with prior cerebrovascular disease or MI were at increased risk for MACE. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council - Health Services Research Grants (Ministry of Health, Singapore) CohortsCox regression for MACE

Angiographic and Clinical Predictors of Mild Non-Culprit Coronary Lesion Progression in Acute ST-Elevation Myocardial Infarction Managed by Primary Percutaneous Coronary Intervention: A Prospective Cohort Study

Abstract Aims To identify the angiographic and clinical predictors of mild non-culprit coronary lesion (NCCL) progression in acute ST-elevation myocardial Infarction (STEMI). Methods and Results The present prospective cohort study evaluated 200 patients with acute STEMI underwent primary percutaneous coronary intervention (PPCI) (either PPCI or pharmaco-invasive PCI) divided into2groups based on whether the clinically driven non culprit lesion PCI existed or not into: Control group-1: 157 patients(78.5%) with non-progressed non culprit lesion (no additional PCI to the non-culprit lesion) and Study group-2: 43 patients(21.5%) with clinically driven non culprit lesion PCI (underwent additional PCI to progressed non-culprit lesions). Our study end point was the clinically driven non culprit lesion PCI (additional PCI to progressed non-culprit lesions). Asymptomatic patients were followed up by exercise ECG at 12 months and myocardial perfusion stress testing at 24 months. Multivariate regression analysis showed that the strongest independent predictor for progression of mild NCCL was complex morphology of culprit lesion (p < 0.001). Finally, a receiver operating characteristic (ROC) curve was performed to assess a cutoff value for predictors for NCCL progression after PPCI in Patients with STEMI. Conclusions Our novel angiographic independent predictor was complex morphology of culprit lesion. And our novel clinical independent predictors were CRP cutoff more than 7.05mg/l, peak cardiac troponin I value cutoff more than 27.5 ng/ml, and age cutoff less than 57.5 years, could be used for early prediction of mild NCCL progression after PPCI for acute STEMI patients. This could be used for early diagnosis to avoid repeated PCI and proper management for better outcomes.

Effect of high dose statin preloading on TIMI flow in patients presenting with ST-Elevation Myocardial Infarction undergoing Primary Percutaneous Coronary Intervention

Abstract Aim and objectives The aim of this study was to assess the impact of high intensity statins used prior to primary PCI in patients presenting with acute STEMI (ST-elevation Myocardial Infarction) on myocardial perfusion and in-hospital MACE (major adverse cardiac events). Patients and Methods The study included 170 patients who presented with acute STEMI to the cardiology department of Ain Shams university hospitals and underwent primary PCI (percutaneous coronary intervention). They were divided into two groups where the first group received high intensity statins (40-80mg of atorvastatin or 20-40mg of rosuvastatin) besides guideline recommended therapy before primary PCI and the 2nd group served as a control group and received guideline recommended therapy, and high intensity statins after going back to the coronary care unit after primary PCI. Post interventional thrombolysis in myocardial infarction (TIMI) flow grade and myocardial blush grade (MBG) were recorded and ST-segment resolution was measured. Results The majority of patients in both groups had the LAD as the culprit vessel for their presentation. In the control group there were 4 patients with TIMI I flow and MBG I, 13 with TIMI II flow and MBG II and 68 with TIMI III flow and MBG III. Meanwhile in the cases group there was 1 patient with TIMI I flow and MBG I, 3 with TIMI II flow and MBG II and 81 with TIMI III flow and MBG III. This difference was statistically significant with a P value of 0.010. There were 34 patients in the cases group who showed complete ST-segment resolution (40%) vs 19 patients (22.4%) in the control group which was statistically significant with a P value of 0.013. In addition, ejection fraction measured by M-mode had values of Mean+-SD of 45.91 ± 5.49 in cases group vs 43.01 ± 8.80 in control group which was statistically significant with a P value of 0.011. There was not a statistically significant difference between the two groups regarding in-hospital death of all causes and stroke after primary PCI. Conclusion High intensity statin loading before primary PCI resulted in improved post-procedural TIMI flow, MBG, complete ST-segment resolution and ejection fraction as measured by M-mode but did not decrease incidence of in-hospital MACE.

Comparison between preoperative loading dose with Ticagrelor and Clopidogrel on myocardial perfusion during intervention in patients with STsegment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Aim and Objectives The aim of this study is to compare between clopidogrel and ticagrelor loading doses used prior to primary PCI in patients presenting with acute STEMI (ST-elevation Myocardial Infarction) on myocardial perfusion and in-hospital MACE (major adverse cardiac events). Patients and Methods The study included 170 patients who presented with acute STEMI to the cardiology department of Ain Shams university hospitals and underwent primary PCI. They were divided into 2 groups where the1st group 85 patients received clopidogrel loading dose (600mg) and the 2nd group 85 patients received ticagrelor loading dose (180mg). Post interventional thrombolysis in myocardial infarction (TIMI) flow grade and myocardial blush grade (MBG) were recorded. Results The majority of patients in both groups had the LAD as the culprit vessel for their presentation (71.8% in the clopidogrel group and 50.6% in ticagrelor group). In the clopidogrel group there were 4 patients with TIMI I flow and MBG I, 13 with TIMI II flow and MBG II and 68 with TIMI III flow and MBG III. Meanwhile in the ticagrelor group there was 2 patients with TIMI I flow and MBG I, s with TIMI II flow and MBG II and 81 with TIMI III flow and MBG III. There was no statistical significance between the two groups regarding in-hospital death of all causes and stroke after primary PCI. Conclusion Ticagrelor loading before primary PCI resulted in improved TIMI flow, MBG but did not decrease incidence of in-hospital MACE.

EARLY DISCHARGE OF PRIMARY PCI PATIENTS

BACKGROUND There is increasing evidence that low-risk patients with ST Elevation Myocardial Infarction (STEMI) can be safely discharged at ≤72hours from admission. Assessment of patients as low-risk is based on clinical judgement and no consistent criteria are used in practice. At this time, assumption is made that low-risk patients are predominantly undergoing early discharge, but no definitive data exists that categorizes these patients in our institution (Tertiary Care Center). The objective of the study is to describe the patients undergoing early discharge and to determine if they meet the early discharge criteria that is recommended in guidelines. METHODS AND RESULTS The Zwolle score was retrospectively applied to all ST elevation myocardial infarction patients treated with primary PCI between January 2019 and January 2021 at a large Canadian teaching hospital. The Zwolle index is an externally validated risk score that has been used to identify low-risk primary PCI patients who can safely be discharged from the hospital within 48 h to 72 h. The length of stay was defined as the time (in days) from first balloon inflation to the date and time of discharge. Data were collected on 1255 patients. 622 of these patients were repatriated to other hospitals and 570 patients were directly discharged from our institution. Of the patients discharged directly, 426 (75%) underwent early discharge and 144 (25%) were late discharge. Early discharge patients tended to be younger (63±11.4, p < 0.01), with higher EF (43±5.7, p < 0.01), lower Killip score (1.37±0.59, p < 0.01) and lower creatinine (84±22, p < 0.01) than the late discharge cohort (table 1). No significant difference between the early discharge and cohort undergoing repatriation. In the early discharge group, 64% of the patients had Zwolle score of 3 or lower, identifying them as low risk. The average Zwolle score was 6 in the high-risk patients that underwent early discharge. 30-day hospital visit and readmission was 13% in the high risk group and 20% at 1 year. CONCLUSION This study provided significant insight into the characteristics of patients currently being discharged from a tertiary cardiac care unit. Some high-risk patients are undergoing early discharge for which the early discharge criteria was not validated. More data is needed to determine if there is a signal of potential adverse outcome in this high-risk population. There is increasing evidence that low-risk patients with ST Elevation Myocardial Infarction (STEMI) can be safely discharged at ≤72hours from admission. Assessment of patients as low-risk is based on clinical judgement and no consistent criteria are used in practice. At this time, assumption is made that low-risk patients are predominantly undergoing early discharge, but no definitive data exists that categorizes these patients in our institution (Tertiary Care Center). The objective of the study is to describe the patients undergoing early discharge and to determine if they meet the early discharge criteria that is recommended in guidelines. The Zwolle score was retrospectively applied to all ST elevation myocardial infarction patients treated with primary PCI between January 2019 and January 2021 at a large Canadian teaching hospital. The Zwolle index is an externally validated risk score that has been used to identify low-risk primary PCI patients who can safely be discharged from the hospital within 48 h to 72 h. The length of stay was defined as the time (in days) from first balloon inflation to the date and time of discharge. Data were collected on 1255 patients. 622 of these patients were repatriated to other hospitals and 570 patients were directly discharged from our institution. Of the patients discharged directly, 426 (75%) underwent early discharge and 144 (25%) were late discharge. Early discharge patients tended to be younger (63±11.4, p < 0.01), with higher EF (43±5.7, p < 0.01), lower Killip score (1.37±0.59, p < 0.01) and lower creatinine (84±22, p < 0.01) than the late discharge cohort (table 1). No significant difference between the early discharge and cohort undergoing repatriation. In the early discharge group, 64% of the patients had Zwolle score of 3 or lower, identifying them as low risk. The average Zwolle score was 6 in the high-risk patients that underwent early discharge. 30-day hospital visit and readmission was 13% in the high risk group and 20% at 1 year. This study provided significant insight into the characteristics of patients currently being discharged from a tertiary cardiac care unit. Some high-risk patients are undergoing early discharge for which the early discharge criteria was not validated. More data is needed to determine if there is a signal of potential adverse outcome in this high-risk population.

Non-Fasting Hypertriglyceridemia as an Independent Risk Factor for Coronary In-Stent Restenosis after Primary Bare Metal Stent Implantation in Patients with Coronary Artery Disease.

After a percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD), in-stent neoatherosclerosis may pose a risk of in-stent restenosis (ISR). To clarify whether non-fasting hypertriglyceridemia contributes to ISR, we examined the relationship between non-fasting hypertriglyceridemia (i.e., triglyceride (TG) level ≥ 200 mg/dL) and ISR after stenting with a bare metal stent (BMS) post-primary PCI in patients with CAD by means of a single-site retrospective analysis. A total of 1,039 patients with CAD were enrolled, and 86 patients (112 lesions) were evaluated for BMS-ISR 3-6 months post-primary PCI. The percentage of patients with non-fasting hypertriglyceridemia was significantly higher in the ISR (+) group than in the ISR (-) group (P < 0.009). The follow-up period and number of patients in the ISR (+) group were significantly smaller than those in the ISR (-) group (P < 0.001). There were no significant between-group differences in the other baseline patient characteristics before the primary PCI or at the time of the follow-up coronary angiography. However, at the follow-up period, the ISR (+) group had significantly lower diastolic blood pressure and high-density lipoprotein cholesterol levels (P = 0.015) and significantly higher TG levels (P = 0.012) than the ISR (-) group. A multiple logistic regression analysis demonstrated that non-fasting hypertriglyceridemia and a follow-up period of ≥ 6 months were independent risk factors for ISR after primary PCI in patients with BMS implantation for stenotic CAD (P = 0.006), with an adjusted odds ratio of 8.232 (1.201-56.410) and 0.006 (95% confidence interval < 0.001-0.045), respectively. Non-fasting hypertriglyceridemia may be an additional independent risk factor for BMS-ISR after primary PCI in patients with CAD.

Safety of Selective Intracoronary Hypothermia During Primary Percutaneous Coronary Intervention in Patients With Anterior STEMI.

The aim of this study was to determine the safety of selective intracoronary hypothermia during primary percutaneous coronary intervention (PPCI) in patients with anterior ST-segment elevation myocardial infarction (STEMI). Selective intracoronary hypothermia is a novel treatment designed to reduce myocardial reperfusion injury and is currently being investigated in the ongoing randomized controlled EURO-ICE (European Intracoronary Cooling Evaluation in Patients With ST-Elevation Myocardial Infarction) trial (NCT03447834). Data on the safety of such a procedure during PPCI are still limited. The first 50 patients with anterior STEMI treated with selective intracoronary hypothermia during PPCI were included in this analysis and compared for safety with the first 50 patients randomized to the control group undergoing standard PPCI. In-hospital mortality, occurrence of rhythm or conduction disturbances, stent thrombosis, onset of heart failure during the procedure, and subsequent hospital admission were assessed. In-hospital mortality was 0%. One patient in both groups developed cardiogenic shock. Atrial fibrillation occurred in 0 and 3 patients (P=0.24), and ventricular fibrillation occurred in 5 and 3 patients (P=0.72) in the intracoronary hypothermia group and control group, respectively. Stent thrombosis occurred in 2 patients in the intracoronary hypothermia group; 1 instance was intraprocedural, and the other occurred following interruption of dual-antiplatelet therapy consequent to an intracranial hemorrhage 6days after enrollment. No stent thrombosis was observed in the control group (P=0.50). Selective intracoronary hypothermia during PPCI in patients with anterior STEMI can be implemented within the routine of PPCI and seems to be safe. The final safety results will be reported at the end of the trial.

Immediate Versus Staged Multivessel PCI Strategies in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Systematic Review and Meta-Analysis

BackgroundRecent guidelines and randomized clinical trials favor the multivessel percutaneous coronary intervention (MV-PCI) strategy undertaken immediately or staged after primary PCI in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease. However, the optimal strategy of MV-PCI remains unknown. MethodsWe conducted a search of PUBMED, EMBASE, Web of Science, the Cochrane database (CENTRAL), clinicaltrial.gov, and Google Scholar for studies comparing immediate versus staged MV-PCI in patients with STEMI and multivessel disease. Pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated using random-effects models. ResultsEighteen (4 randomized clinical trials) studies with 8100 patients fulfilled the inclusion criteria. Relative to staged MV-PCI, immediate MV-PCI was associated with higher short-term (within 30 days) (OR, 3.96; 95% CI, 2.07–7.59; P < 0.0001) and long-term (above 6 months) mortality (OR, 2.12; 95% CI, 1.46–3.07; P < 0.0001), short-term major adverse cardiovascular events (MACE)(OR, 1.99; 95% CI, 1.13–3.50; P = 0.02) and cardiac death (OR, 4.78; 95% CI, 2.17–10.53; P = 0.0001). There was a nonsignificant trend towards higher long-term MACE (OR, 1.23; 95% CI, 0.98–1.54; P = 0.07) and cardiac death (OR, 1.75; 95% CI, 0.93–3.30; P = 0.08) with immediate versus staged MV-PCI. Revascularization, myocardial infarction, and safety endpoints including stroke, major bleeding, and renal failure were similar between immediate versus staged MV-PCI. However, pooled analysis of randomized clinical trials did not show any significant differences in long-term MACE, all-cause mortality, myocardial infarction, and revascularization. ConclusionsOur meta-analysis suggests that among patients with STEMI and multivessel disease, staged instead of immediate MV-PCI may be the optimal revascularization strategy.

Right ventricular branch compromise after percutaneous coronary intervention and baseline chronic kidney disease: A high-risk combination associated with long-term prognoses in acute inferior myocardial infarction

Background: Right ventricular branch compromise (RVBC) following percutaneous coronary intervention (PCI) in patients with acute inferior myocardial infarction (AIMI) is associated with short-term adverse clinical outcomes. Chronic kidney disease (CKD) is also known to be a major risk factor after PCI in AIMI. However, little is known about the impact of RVBC and CKD on long-term prognosis. Methods: From January 2009 to January 2019, we retrospectively enrolled 90 consecutive patients with ST-elevation AIMI who had a culprit lesion in the proximal-to-mid right coronary arteries and underwent PCI in our institution. After the measurement of the Thrombolysis in Myocardial Infarction frame counts in RV branches using post-PCI angiography, we divided them into two groups (RVBC, n = 49; non-RVBC, n = 41), and investigated their long-term prognosis for 43±31 months. The primary endpoint was the incidence of major adverse cardiac events (MACEs), including all-cause death, nonfatal MI, congestive heart failure requiring hospitalization, and life-threatening arrhythmia.Results: Both groups showed similar clinical characteristics; however, the baseline right ventricular function after PCI was significantly worse in RVBC than in non- RVBC. Twenty-four MACEs occurred during the follow-up (RVBC vs. non-RVBC: 37% vs. 14%, p = 0.002). In the multivariate analysis, both RVBC and baseline CKD were powerful predictors of MACEs (RVBC: hazard ratio [HR] 2.85, CKD: HR 2.29). Baseline CKD showed higher hazard ratios of MACEs in RVBC (CKD: HR 7.19 vs. non-CKD: HR 0.24).Conclusions: The prognoses of RVBC after primary PCI in patients with AIMI were poor. Baseline CKD and RVBC were associated with poor long-term clinical outcomes.

A multicentre, prospective, randomised controlled trial to assess the safety and effectiveness of cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction: the COOL AMI EU Pivotal Trial.

Despite primary PCI (PPCI), ST-elevation myocardial infarction (STEMI) can still result in large infarct size (IS). New technology with rapid intravascular cooling showed positive signals for reduction in IS in anterior STEMI. We investigated the effectiveness and safety of rapid systemic intravascular hypothermia as an adjunct to PPCI in conscious patients, with anterior STEMI, without cardiac arrest. Hypothermia was induced using the ZOLL® Proteus™ intravascular cooling system. After randomisation of 111 patients, 58 to hypothermia and 53 to control groups, the study was prematurely discontinued by the sponsor due to inconsistent patient logistics between the groups resulting in significantly longer total ischaemic delay in the hypothermia group (232 vs 188 minutes; p<0.001). There were no differences in angiographic features and PPCI result between the groups. Intravascular temperature at wire crossing was 33.3+0.9°C. Infarct size/left ventricular (IS/LV) mass by cardiac magnetic resonance (CMR) at day 4-6 was 21.3% in the hypothermia group and 20.0% in the control group (p=0.540). Major adverse cardiac events at 30 days increased non-significantly in the hypothermia group (8.6% vs 1.9%; p=0.117) while cardiogenic shock (10.3% vs 0%; p=0.028) and paroxysmal atrial fibrillation (43.1% vs 3.8%; p<0.001) were significantly more frequent in the hypothermia group. The ZOLL Proteus intravascular cooling system reduced temperature to 33.3°C before PPCI in patients with anterior STEMI. Due to inconsistent patient logistics between the groups, this hypothermia protocol resulted in a longer ischaemic delay, did not reduce IS/LV mass and was associated with increased adverse events.

The effect of pre-infarction angina on no-reflow phenomenon and in-hospital MACE in primary PCI patients

Abstract Funding Acknowledgements Type of funding sources: None. Background No reflow has detrimental outcomes in STEMI patients undergoing primary PCI (PPCI). It leads to poor post PCI LV function and higher mortality. The protective effect of ischemic pre-conditioning ( clinically manifested as pre-infarction angina) was controversial in the literature. Purpose Our aim was to study the effect of pre-infarction angina on the occurrence of no-reflow phenomenon and in-hospital major adverse cardiac events (MACE) in PPCI patients. Methods After obtaining ethical approvals and informed consents, we prospectively studied 120 STEMI patients admitted for PPCI in a consecutive manner. Patients with history of CABG or previous PCI and in-stent restenosis were excluded. The definition of in-hospital MACE included cardiac death, myocardial reinfarction, stent thrombosis, or target vessel revascularization. The data were analysed by professional statisticians using SPSS software. Results 15 patients ( 12.5%) had no-reflow, 5 patients ( 4.2%) had cardiac death and one patient had both(0.8 %). The admission characteristics of the studied groups are presented in table 1. Pre-infarction angina was present in 43 patients in the normal flow group and 6 patients in the no-reflow/MACE group. The odds ratio for no-reflow/MACE in those who had pre-infarction angina was 0.52 (95% CI 0.19-1.45, P = 0.21). Conclusion In our studied group, pre-infarction angina has not shown to be protective against no-reflow and in-hospital MACE in PPCI patients. The loss of the protective effect of ischemic pre-conditioning might be secondary to higher admission random plasma glucose levels in our patients compared to those included in similar studies. Similar effect was previously shown in studies on mice. Further in-human studies are needed to confirm the negative effect of hyperglycemia on ischemic pre-conditioning. Characteristics of studied groups Normal flow (n = 99) No-reflow/MACE(n = 21) P value Age (mean ± SD) 56.3 ± 10.3 62.3 ± 7.9 0.014 Male sex (n) 75 13 0.19 Diabetes (n) 37 12 0.094 Hypertension (n) 48 7 0.21 Smokers (n) 52 9 0.42 Dyslipidemia (n) 54 15 0.16 Family history of IHD (n) 17 2 0.52 Pre-infarction angina 43 6 0.21 Admission random plasma glucose in mg/dl(mean ± SD) 186.4 ± 84.7 275.3 ± 104.1 0.001

Safety of primary PCI with early discharge? A comparative study of 36 vs &gt; 36 hours primary PCI discharge protocol”.

Objectives: In this study we aimed at establishing the safety of a very early discharge within 24 to 36 hours after a primary PCI. Study Design: Prospective Comparative study. Setting: Punjab Institute of Cardiology, Lahore. Period: July to December 2019. Material &amp; Methods: We randomly assigned a ≤ 36 hours discharge protocol to the very low risk patients after a primary PCI. FASTEST score was used to identify the low risk group. Comparison was made at 30 days between early discharge and ordinary discharge low risk groups for outcomes like reinfarction, stent thrombosis (ST), target lesion revascularization (TLR), bleeding, stroke and death. Results: Among 329 very low risk primary PCI patients, 161 were randomly assigned to early discharge group and 168 to ordinary discharge group. The outcomes were similar at 01 month in early vs ordinary discharge groups. There was no significant difference in the rate of reinfarction (1.24% vs 1.79%, P value 0.68), ST (1.24% vs 1.19%, P values 0.96), TLR (1.24% vs 1.19%, P value 0.96) and bleeding (0.62% vs 0.59%, P value 0.97). There was no mortality or stroke. Conclusions: Using any of the scoring systems, very low risk patients should be routinely identified after primary PCI. Short term major adverse outcomes remain at a low and a very early discharge protocol can be safely implemented in this subgroup. In addition to saving health costs, this can be of particular value during outbreaks like COVID-19

Early reperfusion strategy selection and prognosis analysis in patients with acute ST segment elevation myocardial infarction: based on the data of 49 hospitals in Hebei Province

To explore the selection of strategies for early reperfusion therapy and its impact on prognosis in patients with acute ST segment elevation myocardial infarction (STEMI). The treatment data and 3-year follow-up results of acute myocardial infarction (AMI) patients in 49 hospitals in Hebei Province from January to December 2016 were collected. Patients with STEMI who received either intravenous thrombolytic therapy (ITT) or primary percutaneous coronary intervention (PPCI) within 12 hours of onset were enrolled. Baseline data, the time from the first diagnosis to the start of reperfusion (FMC2N for ITT patients and FMC2B for PPCI patients), vascular recanalization rate, in-hospital mortality, 1-year mortality, and 3-year mortality were compared between ITT and PPCI groups. The efficacy and prognosis of ITT and PPCI at different starting time of reperfusion (FMC2N ≤ 30 minutes, FMC2N > 30 minutes, FMC2B ≤ 120 minutes, FMC2B > 120 minutes) were analyzed. A total of 1 371 STEMI patients treated with ITT or PPCI were selected, including 300 patients in the ITT group and 1 071 patients in the PPCI group. 1 055 patients were actually followed up (205 patients in the ITT group and 850 patients in the PPCI group), with a rate of 79.4%. There were no significant differences in age, gender, and previous history between the two groups. The time from the first diagnosis to the start of reperfusion in the ITT group was shorter than that in the PPCI group [minutes: 63 (38, 95) vs. 95 (60, 150), U = -9.286, P = 0.000], but was significantly longer than the guideline standard. Compared with the ITT group, the vascular recanalization rate in the PPCI group was higher [95.5% (1 023/1 071) vs. 88.3% (265/300), P < 0.01], and in-hospital mortality was lower [2.1% (22/1 071) vs. 6.7% (20/300), P < 0.01], but there were no significant differences in the 1-year mortality and 3-year mortality [5.3% (45/850) vs. 4.4% (9/205), 9.5% (81/850) vs. 9.3% (19/205), both P > 0.05]. Between ITT group and PPCI group with different reperfusion starting time, the FMC2N > 30 minutes group had the lowest vascular recanalization rate and the highest in-hospital mortality. Pairwise comparison showed that the vascular recanalization rate of the FMC2B ≤ 120 minutes group and the FMC2B > 120 minutes group were significantly higher than those of the FMC2N > 30 minutes group [95.5% (654/685), 95.6% (369/386) vs. 88.0% (220/250), both P < 0.008], the in-hospital mortality was significantly lower than that of the FMC2N > 30 minutes group [2.0% (14/685), 2.1% (8/386) vs. 7.6% (19/250), both P < 0.008]. There was no significant difference in 1-year mortality (χ2 = 2.507, P = 0.443) and 3-year mortality (χ2 = 2.204, P = 0.522) among the four groups. For STEMI patients within 12 hours of onset, reperfusion therapy should be performed as soon as possible. PPCI showed higher infarct related artery opening rate and lower in-hospital mortality compared with ITT, and had no effect on 1-year and 3-year mortality.

Efficacy and safety of pharmacoinvasive strategy compared with primary PCI in patients with STEMI presenting to non-PCI hubs: A real world study

Abstract Funding Acknowledgements Type of funding sources: None. Background Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). Clinical practice guidelines recommend performing pPCI &amp;lt;120 minutes after the diagnosis of STEMI. Nevertheless, in a real world model this treatment is not always the fastest option. This is mostly due to the transfer delays when patients arrive to non-PCI capable hubs. These delays can decrease the benefits of the PPCI. Regional networks have been created to speed up these times and administer reperfusion therapy as early as possible. The pharmacoinvasive strategy (PIs) consists of the administration of fibrinolytic drugs in the non-pPCI setting followed by the immediate transfer of the patient to a pPCI center. Purpose To compare the efficacy and safety of pharmacoinvasive strategy compared with referral for primary PCI in patients with STEMI presenting to non PCI hubs. Methods A retrospective analysis of the PHASE-MX study (ClinicalTrials.gov Identifier: NCT03974581) including patients with STEMI whom initially presented to non-PCI hospitals and underwent either systemic fibrinolysis followed by pharmaco-invasive strategy or were transfer to perform primary PCIc according to the decision made by the doctor in the non-PCI center, the ease of referring the patient and the proximity of the PCI center. The primary composite endpoint included the occurrence of cardiovascular death, cardiogenic shock, recurrent MI or congestive heart failure at 30 days of follow-up. Results A total of 448 patients were included, of whom 273 (60.9%) underwent PIs and 175 (39.0%) were transfered for pPCI. Mean age was 58+-10 years, and most patients (86.8%) were male. No statistically significant differences in risk factors and other clinically meaningful variables were found. There was a 40% reduction in the risk of the primary composite endpoint (HR 0.60 for PIs: 95% CI:0.36-0.99; p = 0.048) for those undergoing PIs compared with pPCI, (Figure 1). Conclusion The pPCI main limitation is the impossibility to use it in the entire population due to its limited geographic availability and the delays involved in the transfer of patients from non-pPCI centers to reference hospitals. Through the PIs patients who arrive at non-PCI hospitals with STEMI and receive thrombolysis and then are redirect to PCI center there was a 40% reduction in the risk of a major endpoint occurring. Abstract Figure 1

ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement

BackgroundAmong patients with acute coronary syndrome following transcatheter aortic valve replacement (TAVR), those presenting with ST-segment elevation myocardial infarction (STEMI) are at highest risk. ObjectivesThe goal of this study was to determine the clinical characteristics, management, and outcomes of STEMI after TAVR. MethodsThis was a multicenter study including 118 patients presenting with STEMI at a median of 255 days (interquartile range: 9 to 680 days) after TAVR. Procedural features of STEMI after TAVR managed with primary percutaneous coronary intervention (PCI) were compared with all-comer STEMI: 439 non-TAVR patients who had primary PCI within the 2 weeks before and after each post-TAVR STEMI case in 5 participating centers from different countries. ResultsMedian door-to-balloon time was higher in TAVR patients (40 min [interquartile range: 25 to 57 min] vs. 30 min [interquartile range: 25 to 35 min]; p = 0.003). Procedural time, fluoroscopy time, dose-area product, and contrast volume were also higher in TAVR patients (p < 0.01 for all). PCI failure occurred more frequently in patients with previous TAVR (16.5% vs. 3.9%; p < 0.001), including 5 patients in whom the culprit lesion was not revascularized owing to coronary ostia cannulation failure. In-hospital and late (median of 7 months [interquartile range: 1 to 21 months]) mortality rates were 25.4% and 42.4%, respectively (20.6% and 38.2% in primary PCI patients), and estimated glomerular filtration rate <60 ml/min (hazard ratio [HR]: 3.02; 95% confidence interval [CI]: 1.42 to 6.43; p = 0.004), Killip class ≥2 (HR: 2.74; 95% CI: 1.37 to 5.49; p = 0.004), and PCI failure (HR: 3.23; 95% CI: 1.42 to 7.31; p = 0.005) determined an increased risk. ConclusionsSTEMI after TAVR was associated with very high in-hospital and mid-term mortality. Longer door-to-balloon times and a higher PCI failure rate were observed in TAVR patients, partially due to coronary access issues specific to the TAVR population, and this was associated with poorer outcomes.

Budget impact analysis of antiplatelet therapy with cangrelor in patients with acute coronary artery disease undergoing percutaneous coronary intervention in Belgium

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Ferrer, Barcelona, Spain Background Cangrelor is a novel, intravenous, potent, fast onset, direct-acting, P2Y12 receptor antagonist that blocks adenosine diphosphate-induced platelet activation and aggregation with a half-life of 3-6 min. Co-administered with acetylsalicylic acid, it is indicated for reducing thrombotic cardiovascular events in patients with coronary artery disease (CAD) (ST-elevation myocardial infarction (STEMI), non-STEMI, stable CAD) undergoing percutaneous coronary intervention (PCI) who have not received an oral P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) prior to PCI procedure and in whom oral therapy with P2Y12 inhibitors is not feasible or desirable. Purpose To assess the economic implications of incorporating cangrelor into the hospital formulary for the acute care of CAD patients undergoing PCI in Belgium. Methods A budget impact model (BIM) was developed. The 3-year pharmacological and clinical event costs of two hypothetical scenarios, without and with cangrelor in the formulary for the total PCI population (base case) in Belgium were compared. Also, the primary PCI (STEMI) and a PCI population with special needs (e.g., unable to swallow) were assessed as complementary setups. Epidemiological, efficacy (stent thrombosis, myocardial infarction (MI), ischaemia-driven revascularization, death), safety (Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria) and costs (€, 2019) data were based on clinical trials, meta-analyses and on Belgian registries. Only the pharmacological costs of pre-treatment (preload) with oral P2Y12 inhibitors and glycoprotein IIb-IIIa inhibitors (GPI) for bail-out were considered. One-way sensitivity analysis established the effect of uncertainty on BIM results. Results The model assumes that the primary PCI population grows from 4,790 to 4,935 adults (age 68 years, mean) over three years in Belgium. Pre-treatment with oral P2Y12 inhibitors increases from 3,544 to 3,652 patients, and uptake of cangrelor rises from 20.60% to 38.30% in the same period. The number of primary PCI patients receiving cangrelor grows from 730 to 1,399. At current usage of antithrombotics and at existing pharmacological and management costs, adding cangrelor into the hospital formulary represents 1.1 million euros over 3 years in Belgium. 6 additional stent thromboses, 3 ischaemia-driven revascularisations and 2 cardiovascular related deaths are avoided while three extra minor bleedings occur over 3 years. Similar pharmacoeconomic findings emerge in the base case and complementary setups. Results are most sensible to the percentage of patients on GPI bail-out. Conclusions Under BIM assumptions, introducing cangrelor for the acute care of CAD patients undergoing primary PCI represents a safe and affordable option in Belgium, particularly when the required control of thrombosis is not certain with oral pre-treatment.

Incidence and outcome of no flow after primary percutaneous coronary intervention in acute myocardial infarction

&#x0D; Background: Mechanical revascularization of the infarct-related artery (IRA)&#x0D; is the most effective treatment modality in ST-segment elevation myocardial&#x0D; infarction (STEMI).No flow occurs in ∼8.8-10% of cases of primary&#x0D; percutaneous coronary intervention(PCI) in STEMI patients. Our aim was to study &#x0D; actual incidence and outcome of no flow patients.&#x0D; Methods: Five hundred and eighty primary PCI patients&#x0D; were studied over a period of two years i.e. January 2016 to December 2017.&#x0D; Drug eluting stents were used in all cases. Majority of our patients(&gt;90%) came 6&#x0D; hours after onset of chest pain. There were many patients where there was &#x0D; no flow even after mechanical thrombus aspiration and pharmacological&#x0D; vasodilator therapy. We have studied primary outcome(mortality) of no flow in&#x0D; those patients. &#x0D; Results: There were 44 cases of no flow in our&#x0D; series(7.75%). Left anterior descending artery(LAD )was involved in eighteen&#x0D; patients. Right coronary artery(RCA) was culprit in twenty four cases. Only&#x0D; two cases were seen in LCX territory. One month mortality rate in no flow group&#x0D; was 50% and 6.25% in successful recanalization group. One year mortality was&#x0D; 12.5% in successful recanalization group and 66% in no flow group.&#x0D; Conclusion: Refractory no flow during primary PCI in STEMI is associated&#x0D; with high mortality and morbidity. There is no established strategy to solve&#x0D; this phenomenon.&#x0D; &#x0D;

The relationship between Fibroblast Growth Factor 23 (FGF23) and cardiac MRI findings following primary PCI in patients with acute first time STEMI.

BackgroundFibroblast growth factor 23 (FGF23) is a regulator of mineral metabolism, that has been linked to myocardial remodeling including development of left ventricular (LV) hypertrophy and myocardial fibrosis. The aim of this study was to investigate the relationship between intact FGF23 (iFGF23), myocardial infarct size and LV remodeling following a first acute ST-elevation myocardial infarction (STEMI).Methods and resultsForty-two consecutive patients with first-time STEMI, single vessel disease, successfully treated with primary percutaneous coronary intervention were included. Cardiac magnetic resonance (CMR) imaging was performed at day 2, 1 week, 2 months and 1 year post MI, and blood samples were drawn at admittance and at the same time points as the CMRs. The cohort was divided according to the presence or not of heart failure post MI. In the total cohort, iFGF23 (mean ± SD) was significantly lower at day 0 (33.7 ± 20.6 pg/ml) and day 2 (31.5 ± 23.4 pg/ml) compared with a reference interval based on 8 healthy adults (43.9 pg/ml ± 19.0 pg/ml). iFGF23 increased to normal levels (55.8 ± 23.4 pg/ml) seven days post MI. In the subset of patients with signs of acute heart failure, FGF23 was higher at all measured timepoints, reaching significantly higher FGF23 levels at 2 months and 1 year following revascularization.ConclusionThere was a reduction in iFGF23 levels during the acute phase of MI, with a normalization at seven days following revascularization. During one-year follow-up, there was a gradual increase in iFGF23 levels in patients with heart failure.

Trimetazidin hatása a primer perkután koronáriaintervención átesett akut koronáriaszindrómás betegekben : Szisztematikus irodalmi áttekintés és metaanalízis

Effect of trimetazidine in patients with acute coronary syndrome, undergoing primary percutaneous coronary intervention. Systematic review and meta-analysis Aims: The aim of our study is to review and meta-analytically analyze data from studies published comparing patients with acute coronary syndrome who have undergone primary PCI and received trimetazidin additionally to the optimal medical therapy or placebo during the reperfusion procedure. Methods and results: Our meta-analysis follows the points of PRISMA protocol and meets all of their criteria. We managed a search in three scientific database using the following keyword combination (coronar* OR heart disease ORacs) AND (trimetazidine). 917 publications were collected and a statistical analysis was performed on nine ran­domized-controlled trials (RCT). Three outcomes was analyzed by mean difference calculation, changes in left ventricle ejection fraction (LVEF), cardiac troponin I (cTnI) and high-sensitivity C-reactive protein (hs-CRP) levels. For the LVEF a significant increase was observed in the trimetazidin group (MD: 3.4%, CI: 1.393–5.408, P=0.001). There was significant improvement in the level of cTnI compared pre- and post-procedurally. (MD: 0.426, CI: 0.060–0.791, P=0.022). Non-significant improvement was measured in the hs-CRP level (MD: 1,214, CI: –0.122–2.549, P=0.075). Conclusions: Based on the results of our meta-analysis it can be suggested that the trimetazidine administered as adjunctive therapy in the treatment of primary PCI in patients with ACS yielded significant results in two of the three parameters we studied, which were improvement in LVEF and change in cTnI, while the third parameter, in the case of hs-CRP not-significant change was measurable. In evaluating our results, we took into account whether the participants did or did not fully receive optimal medical therapy (OMT) and numerous limitating factors.