Primary Percutaneous Coronary Intervention In ST-segment Elevation Myocardial Infarction Patients Research Articles

Artificial intelligence-derived ECG bio-index as a tool for predicting the prognosis of patients with ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention

Abstract Background/Introduction Electrocardiogram (ECG) changes after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients, such as the recovery of ST elevation, are associated with prognosis, but quantifying them is challenging. Deep-learning algorithms (DLA) can diagnose STEMI and quantify the probability as a bio-index. However, the prognostic value of this index has yet to be well studied. Purpose This study aims to investigate the feasibility of predicting the prognosis of patients with STEMI by analyzing serial ECGs post-primary PCI using an DLA designed to detect AMI and STEMI. Methods We developed a DLA to detect acute myocardial infarction (AMI) and STEMI using 12-lead ECGs from hospital A. The DLA was based on convolutional neural network and presented the index for probability of AMI and STEMI as a number between 0 and 1. We subsequently analyzed serial ECGs from hospital B, taken more than one month prior to the STEMI event (baseline), at pre-PCI (at emergency department [ED]), immediate post-PCI, 6h, 24h, 1 month after PCI, using the DLA. The primary endpoint was a post-STEMI heart failure defined as left ventricular ejection fraction (LVEF) less than 50%. Results A total of 22,259 ECGs (13,916 ECGs of non-AMI and 8,343 ECGs of AMI) from 15,113 patients were used to develop and validate the DLA. The area under the curve (AUC) of the final DLA was 0.950 for AMI and 0.954 for STEMI. Serial ECGs of 639 STEMI patients were analyzed. The mean index value at different time points were as follows: 0.061 ± 0.158 in baseline ECG, 0.801 ± 0.333 in ECG at ED, 0.525 ± 0.429 in immediate post-PCI, 0.467 ± 0.425 in 6-hour, 0.482 ± 0.423 in 24-hour, and 0.273 ± 0.348 in 1-month after PCI (ANOVA P-value <0.001). To evaluate the predictive value of the DLA index, we stratified the study population into low, intermediate, and high-risk group based on the DLA index, with thresholds of 0.03 and 0.45 of the immediate post-PCI AI indices. The mean LVEF was 53.0 ± 10.1% in the low-risk group, 49.6 ± 10 %, and 47.4 ± 10.2 % in the intermediate and the high-risk group (ANOVA P-value < 0.001). The prevalence of post-STEMI heart failure was 30.6%, 46.4%, and 60.6%, respectively (P < 0.001). Furthermore, the DLA index was significantly associated with the recovery of left ventricular function. The prevalence of heart failure in 3-month follow-up echocardiography was highest in the high-risk group (15.4% vs. 27.1% vs. 31.8%, respectively, P = 0.022). Conclusion Our study shows that the DLA-derived bio-index is an effective tool to quantify ECG changes after primary PCI in STEMI patients and predict post-AMI heart failure. The DLA index is also associated with left ventricular function recovery, indicating its potential as a prognostic marker. Further studies are needed to validate our results and explore the use of the DLA index in assessing myocardial reperfusion after primary PCI.

COMPARISON OF INTRACORONARY EPINEPHRINE TO STANDARD TREATMENTS ALONE FOR REFRACTORY CORONARY NO-REFLOW IN STEMI PATIENTS UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Refractory no-reflow is a serious primary percutaneous coronary intervention (PPCI) complication in ST-segment elevation myocardial infarction (STEMI) patients associated with worse clinical outcomes. Intracoronary epinephrine has been suggested as a potential adjunctive therapy to improve myocardial perfusion in these patients, but its efficacy and safety remain unclear. This study included 58 STEMI patients with refractory no-reflow during PPCI treated with either intracoronary epinephrine or conventional treatments alone. The primary outcome was the improvement in myocardial perfusion assessed by the TIMI frame count at the end of the procedure. Secondary outcomes included rates of adverse cardiovascular events and clinical outcomes at 30 days. Intracoronary epinephrine was associated with significantly improving myocardial perfusion compared to conventional treatments alone (mean TIMI frame count 24.1 ± 6.7 vs. 33.6 ± 7.9, p < 0.001). This benefit was consistent across all subgroups of patients with TIMI 0-1 flow. Patients treated with intracoronary epinephrine had significantly lower rates of adverse cardiovascular events at 30 days than those who received conventional treatments alone (12.5% vs. 43.8%, p = 0.02). The two groups had no significant differences in major bleeding, recurrent myocardial infarction, or all-cause mortality. Based on the results, the use of intracoronary epinephrine during PPCI in STEMI patients with refractory no-reflow is associated with improved myocardial perfusion and lower rates of adverse cardiovascular events. These findings support the use of intracoronary epinephrine as a safe and effective adjunctive therapy in this population, but further studies are needed to determine optimal dosing and timing of administration.

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Venoarterial extracorporeal membrane oxygenation in acute myocardial infarction

Relationship between microvascular obstruction and infarct size assessed early after primary PCI and all-cause mortality, reinfarction and hospitalization for heart failure

Abstract Background Rapid reperfusion of the epicardial coronary artery by primary percutaneous coronary intervention (PCI) is the guideline-recommended treatment for ST-segment elevation myocardial infarction (STEMI). However, in a substantial proportion of patients, despite restored patency of the epicardial coronary artery, perfusion to the distal coronary microvasculature is not fully achieved. The principal cause of this phenomenon is severe microvascular dysfunction or loss of integrity leading to microvascular obstruction (MVO). Objectives Aim of the research was to understand the relationship between microvascular obstruction (MVO) and/or infarct size (IS) and/or left ventricular ejection fraction (LVEF) assessed early after PCI in STEMI patients and subsequent all-cause mortality, reinfarction, and hospitalization for heart failure (HF). Methods A literature review was performed with no restrictions in terms of geography or design of study. Publications related to the validation and/or comparison of methods to quantify microvascular obstruction or infarct size were discarded. Results Search criteria yielded 23 references. After exclusion of validation studies, 13 publications were retained. Most of these papers were authored by the same group of investigators. A pooled patient-level analysis from 10 randomized primary PCI trials (total 2,632 patients) established that IS was strongly associated with all-cause mortality and hospitalization for HF but not significantly related to subsequent infarction. Pooled analysis of patient data from 7 of these 10 randomized primary PCI studies showed that MVO was also significantly associated with all-cause mortality and hospitalization for HF but not related to subsequent infarction. 5 of these 10 randomized primary PCI trials allowed categorization of patients by time of the day of the primary PCI intervention. No association was found between the time of day and IS, MVO, or prognosis after STEMI. A similar analysis concluded that recent smoking was unrelated to IS or MVO but was associated with a worse prognosis after primary PCI in STEMI. No correlation was established between body mass index and IS, MVO or LVEF, or one-year rates of death or HF hospitalization. A sub-study of a nationwide randomized investigation in Denmark assessed the impact of age of STEMI on IS and LVEF and the composite endpoint of death and re-hospitalization for HF. Patients <60 had smaller final infarcts and higher LVEF, but after adjusting for confounders, age did not remain significantly associated with IS and LVEF. During 4-year follow-up, the composite endpoint depended on both age and IS. Conclusions MVO and IS assessed early after primary PCI in STEMI are strongly associated with death and hospitalization for HF within one year. Innovative technologies that limit IS by improving microcirculation function during STEMI are of great individual and socioeconomic value. Funding Acknowledgement Type of funding sources: Private company.

A nomogram risk prediction model for no-reflow after primary percutaneous coronary intervention based on rapidly accessible patient data among patients with ST-segment elevation myocardial infarction and its relationship with prognosis.

BackgroundNo-reflow occurring after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) can increase the incidence of major adverse cardiovascular events (MACE). The present study aimed to construct a nomogram prediction model that can be quickly referred to before surgery to predict the risk for no-reflow after PCI in STEMI patients, and to further explore its prognostic utility in this patient population.MethodsResearch subjects included 443 STEMI patients who underwent primary PCI between February 2018 and February 2021. Rapidly available clinical data obtained from emergency admissions were collected. Independent risk factors for no-reflow were analyzed using a multivariate logistic regression model. Subsequently, a nomogram for no-reflow was constructed and verified using bootstrap resampling. A receiver operating characteristic (ROC) curve was plotted to evaluate the discrimination ability of the nomogram model and a calibration curve was used to assess the concentricity between the model probability curve and ideal curve. Finally, the clinical utility of the model was evaluated using decision curve analysis.ResultsThe incidence of no-reflow was 18% among patients with STEMI. Killip class ≥2 on admission, pre-operative D-dimer and fibrinogen levels, and systemic immune–inflammation index (SII) were independent risk factors for no-reflow. A simple and quickly accessible prediction nomogram for no-reflow after PCI was developed. This nomogram demonstrated good discrimination, with an area under the ROC curve of 0.716. This nomogram was further validated using bootstrapping with 1,000 repetitions; the C-index of the bootstrap model was 0.706. Decision curve analysis revealed that this model demonstrated good fit and calibration and positive net benefits. Kaplan–Meier survival curve analysis revealed that patients with higher model scores were at a higher risk of MACE. Multivariate Cox regression analysis revealed that higher model score(s) was an independent predictor of MACE (hazard ratio 2.062; P = 0.004).ConclusionsA nomogram prediction model that can be quickly referred to before surgery to predict the risk for no-reflow after PCI in STEMI patients was constructed. This novel nomogram may be useful in identifying STEMI patients at higher risk for no-reflow and may predict prognosis in this patient population.

The Comparison between Two Risk Scores as for the Prediction of Coronary Microvascular Obstruction during Primary Percutaneous Intervention.

ResumoFundamento:Para pacientes com infarto do miocárdio com elevação do segmento ST (IAMCST) que sofrem de obstrução coronariana microvascular funcional e estrutural (OCM) subsequente, nenhuma abordagem terapêutica específica e definitiva de atenuação foi comprovada como válida em testes de larga escala atuais, o que destaca a necessidade de abordar seu reconhecimento precoce.Objetivos:Este estudo teve como objetivo comparar o desempenho de dois escores de risco clínico com uma medida objetiva de OCM durante intervenção coronária percutânea (ICP) em casos de IAMCSTMétodos:A medição do índice de resistência microcirculatória (IRM) foi realizada e os parâmetros clínicos e angiográficos basais também foram registrados. Os pacientes foram divididos em entre os grupos OM (obstrução microvascular) e NOM (não-obstrução microvascular), de acordo com o valor de IRM pós-procedimento. O risco de OCM foi avaliado para todos os participantes pelos escores preditivos SAK e ATI, respectivamente. Cada sistema foi calculado somando-se as pontuações de todas as variáveis. As curvas de características do operador receptor (ROC) e a área sob a curva (AUC) de dois modelos de risco foram utilizadas para avaliar o desempenho discriminatório. Um ecocardiograma foi realizado sete dias após o procedimento para avaliar a fração de ejeção do ventrículo esquerdo (FEVE). Um valor P bicaudal de <0,05 foi considerado estatisticamente significativo.Resultados:Entre os 65 pacientes elegíveis com IAMCST, 48 foram alocados no grupo NOM e 17 no grupo OM, com uma incidência de OCM de 26,15%. Não houve diferença significativa na AUC entre os dois escores. A FEVE avaliada para o grupo NOM foi maior do que para o grupo OM.Conclusão:Os escores SAK e ATI tiveram bom desempenho para estimar o risco de OCM após ICP primário para pacientes com IAMCST.

Intracoronary Thrombolysis in no Flow after Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction

Introduction: Mechanical revascularization of the infarct-related artery (IRA) is the most effective treatment modality in ST-segment elevation myocardial infarction (STEMI).No-reflow occurs in ∼8.8-10% of cases of primary percutaneous coronary intervention(PCI) in STEMI patients. Intracoronary tenectaplase was used when there was huge thrombus causing no flow in coronary artery following primary PCI in STEMI patients. Methods: Five hundred and eighty primary PCI patients were studied over a period of two years i.e. January 2016 to December 2017. Drug eluting stents were used in all cases. Majority of our patients (&gt;90%) came 6 hours after onset of chest pain. There were many patients where there was no flow even after mechanical thrombus aspiration and pharmacological vasodilator therapy. We have given 20 mg of tenectaplase through microcatheter in those cases. Results: There were 44 cases of no flow in our series (7.75%). TIMI 3 Flow was reestablished in thirty two patients after intracoronary tenectaplase (72%). Amongst twelve failure cases LAD involvement was most common eight cases. RCA was involved in four patients. One month mortality rate in no flow group was 50% and 6.25% in successful recanalization group. One year mortality was 12.5% in successful recanalization group and 66% in no flow group. Both were statistically significant. Conclusion: Refractory no reflow during primary PCI in STEMI is associated with high mortality and morbidity. There is no established strategy to solve this phenomenon. Intracoronary thrombolysis is an option to salvage these patients.

Impact of Thrombus Aspiration one-year Cardiac Mortality During Primary PCI in STEMI Patients with total Occlusion; from Korea Acute Myocardial Infarction Registry National Institute of Health

Background: The clinical impact of intracoronary thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) is unclear. We investigated to evaluate whether TA during primary PCI reduces one-year mortality. Methods: From the Korea Acute Myocardial Infarction Registry-National Institute of Health, 3749 patients with STEMI who were undergoing primary PCI within 12 hours (60.8±12.9 years, 18.7% women) and shown pre-procedural Thrombolysis In Myocardial Infarction (TIMI) flow 0, 1 in coronary angiography were enrolled between November 2011 and November 2015 during one-year follow up. The patients were divided into two groups according to TA during primary PCI: PCI with TA (n=1630) and PCI alone (n=2119). The primary end-point was major adverse cardiac events (MACE), defined as the composite of cardiovascular death (CVD), stroke or recurrent MI at one-year. The secondary efficacy end-point were all-cause of mortality and CVD at one-year. Results: PCI with TA did not reduce the risk of MACE (OR: 0.598, 95% CI: 0.737-1.160, p=0.499), all-cause mortality (OR: 0.898, 95% CI: 0.705-1.144, p=0.383) and CVD (OR: 0.893, 95% CI: 0.683-1.168, p=0.408) in all patients during one-year follow up. The trend did not change after propensity score matching. In subgroup analysis, there was no efficacy of clinical outcome during one-year follow up. Conclusions: Primary PCI with TA did not reduce MACE and all-cause mortality among patients with STEMI and pre-procedural TIMI flow 0,1 during one-year follow up.

Utilization of an Optimized Radiation Strategy in Primary Percutaneous Coronary Intervention for Patients with ST-Segment-Elevation Myocardial Infarction.

Background Recent reports about radiation risk gradually raised the safety concerns for interventional therapy. However, limited data exist on the optimized radiation strategy in primary percutaneous coronary intervention (P-PCI) for patients with ST-segment-elevation myocardial infarction (STEMI). Methods A total of 214 STEMI patients undergoing P-PCI were retrospectively analyzed. Patients were divided into the optimized radiation strategy (ORS) group (N = 151) and normal radiation strategy (NRS) group (N = 63) according to the radiation protocol utilized. The primary endpoint was the relative dose reduction of total air kerma. The secondary endpoint was 30-day major adverse cardiac and cerebrovascular events (MACCE), as a composite of all-cause death, reinfarction, ischemia-driven target vessel revascularization, and stroke. Results Patient groups were well matched for baseline characteristics. There were no differences in terms of age, body mass index, radial artery access, nonculprit vessel PCI, and fluoroscopy time between 2 groups. With optimized radiation strategy, a 40.9% radiation dose reduction (901.2 ± 628.7 mGy versus 1524.0 ± 866.6 mGy, p < 0.001) was obtained for total air kerma. No significant differences were found for 30-day MACCE between 2 groups (2.0% versus 1.6%, adjusted hazard ratio: 0.7, 95% confidence interval: 0.1 to 8.6, p=0.772). Conclusion With optimized radiation strategy, significant radiation dose reduction could be achieved in P-PCI for STEMI patients. It appears to be feasible and safe to carry out the optimized radiation strategy in P-PCI for STEMI patients.

Serum cystatin C levels relate to no-reflow phenomenon in percutaneous coronary interventions in ST-segment elevation myocardial infarction.

Background/AimNo-reflow is a serious and frequent event during primary percutaneous coronary intervention (PPCI) for acute ST segment elevation myocardial infarction (STEMI). The aim of this study was to identify possible predictors for no-reflow.Patients and methodsWe investigated 218 patients with acute anterior STEMI who underwent PPCI from December 2016 to December 2018. No-reflow was defined as a coronary TIMI flow grade of ≤ 2. TIMI flow grade 3 was defined as normal reflow.ResultsIn our study, the no-reflow phenomenon was observed in 39 patients (18%) during angiography. The patients of no-reflow group were found to be more older, diabetics, longer pain-to-balloon time, lower blood pressure, higher platelet counts and higher levels of D-Dimer and Cystatin C (Cys-C). In multivariate logistic regression analysis, only diabetes (OR = 0.371, 95% CI: 0.157–0.872, P = 0.023), longer pain-to-balloon time (OR = 1.147, 95% CI: 1.015–1.297, P = 0.028) and higher Cys-C level (OR = 10.07, 95% CI: 2.340–43.377, P = 0.002) were predictors for no-reflow.ConclusionCys-C might be a useful predictor for the no-reflow phenomenon after PPCI in STEMI patients. It might help to screen STEMI patients with high risk of no-reflow on admission.

Optimal timing of staged percutaneous coronary intervention in ST-segment elevation myocardial infarction patients with multivessel disease.

BackgroundStudies have shown that staged percutaneous coronary intervention (PCI) for non-culprit lesions is beneficial for prognosis of ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease. However, the optimal timing of staged revascularization is still controversial. This study aimed to find the optimal timing of staged revascularization.MethodsA total of 428 STEMI patients with multivessel disease who underwent primary PCI and staged PCI were included. According to the time interval between primary and staged PCI, patients were divided into three groups (≤ 1 week, 1–2 weeks, and 2–12 weeks after primary PCI). The primary endpoint was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal re-infarction, repeat revascularization, and stroke. Cox regression model was used to assess the association between staged PCI timing and risk of MACE.ResultsDuring the follow-up, 119 participants had MACEs. There was statistical difference in MACE incidence among the three groups (≤ 1 week: 23.0%; 1–2 weeks: 33.0%; 2–12 weeks: 40.0%; P = 0.001). In the multivariable adjustment model, the timing interval of staged PCI ≤ 1 week and 1–2 weeks were both significantly associated with a lower risk of MACE [hazard ratio (HR): 0.40, 95% confidence intervals (CI): 0.24–0.65; HR: 0.54, 95% CI: 0.31–0.93, respectively], mainly attributed to a lower risk of repeat revascularization (HR: 0.41, 95% CI: 0.24–0.70; HR: 0.36, 95% CI: 0.18–0.7), compared with a strategy of 2–12 weeks later of primary PCI.ConclusionsThe optimal timing of staged PCI for non-culprit vessels should be within two weeks after primary PCI for STEMI patients.

Effects of intracoronary arterial injection of tirofiban on no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention

Objective: To compare the effect of intracoronary arterial injection of tirofiban and sodium nitroprusside (SNP) on no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction (STEMI) underwent primary percutaneous coronary intervention (PCI). Methods: A total of 68 patients with acute STEMI who had no-reflow phenomenon during PCI were chosen and randomly divided into SNP group (n = 34) and tirofiban group (n = 34). Aiming at no-reflow phenomenon during PCI, with the use of microcatheters, intracoronary arterial injection of tirofiban was given in tirofiban group, while intracoronary bolus of SNP was given in SNP group. Coronary angiography was conducted to record TIMI flow grade of the infarct-related artery after 10 minutes. Plasma brain natriuretic peptide (BNP) was monitored before and after PCI (in 24 hours). With the help of ultrasound cardiogram, left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD) and left ventricular endsystolic dimension (LVESD) were recorded and compared in 30 days after PCI. Results: The ratio of TIMI grade 3 blood flow in tirofiban group was significantly higher than that in SNP group [76.5% (26/34) vs. 52.9% (18/34), p = .03]. BNP levels in two groups had no statistical significance before PCI ( p = .16), but in 24 h after PCI, BNP levels in tirofiban group were significantly lower than those in SNP group [(439.00 ± 4.90) μmol/L vs. (632.00 ± 3.63) μmol/L, p = .02]. In 30 days after PCI, LVEF, LVEDD and LVESD in tirofiban group were all superior to those in SNP group (all p < .05). Conclusions: Intracoronary arterial injection of tirofiban was superior to SNP in improving no-reflow phenomenon in STEMI patients after PCI in the emergency treatment. Tirofiban therapy can increase coronary blood flow and myocardial perfusion after the occurrence of no-reflow phenomenon during PCI in STEMI patients, and improve long-term prognosis.

Association Between Early Q Waves and Reperfusion Success in Patients With ST-Segment-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: A Cardiac Magnetic Resonance Imaging Study.

Pathological early Q waves (QW) are associated with adverse outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) may therefore be less beneficial in patients with QW than in patients without QW. Myocardial salvage index and microvascular obstruction (MVO) are markers for reperfusion success. Thus, to clarify the benefit from primary PCI in STEMI patients with QW, we examined the association between baseline QW and myocardial salvage index and MVO in STEMI patients treated with primary PCI. The ECG was assessed before primary PCI for the presence of QW (early) in 515 STEMI patients. The patients underwent a cardiac magnetic resonance imaging scan at day 1 (interquartile range [IQR], 1-1) and again at day 92 (IQR, 89-96). Early QW was observed in 108 (21%) patients and was related to smaller final myocardial salvage index (0.59 [IQR, 0.39-0.69] versus 0.65 [IQR, 0.46-0.84]; P<0.001) and larger MVO (1.4 [IQR, 0.0-5.4] versus 0.0 [IQR, 0.0-2.4]; P<0.001) compared with non-QW. QW remained associated with both final myocardial salvage index (β=-0.12; P=0.03) and MVO (β=0.18; P=0.001) after adjusting for potential confounders. Patients presenting with their first STEMI and early QW in the ECG had smaller myocardial salvage index and more extensive MVO than non-QW despite treatment within 12 hours after symptom onset. However, final myocardial salvage index in patients with QW was substantial, and patients with QW still benefit from primary PCI. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01435408.

Morphine Does Not Affect Myocardial Salvage in ST-Segment Elevation Myocardial Infarction.

Recent studies have proposed intravenous (IV) morphine is associated with delayed action of antiplatelet agents in acute myocardial infarction. However, it is unknown whether morphine results in increased myocardial damage in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). We investigated myocardial salvage index (MSI) to determine whether IV morphine affects myocardial injury adversely in STEMI patients undergoing primary PCI. 299 STEMI patients underwent contrast-enhanced magnetic resonance imaging a median of 3 days after PCI. Infarct size was measured on delayed-enhancement imaging, and area at risk was quantified on T2-weighted imaging. MSI was calculated as ‘[area at risk–infarct size] X 100 / area at risk’. IV morphine was administrated in 32.1% of patients. Patients treated with morphine had shorter symptom to balloon time and higher prevalence of Thrombolysis in Myocardial Infarction flow grade 0 or 1. The morphine group showed a trend toward larger MSI and infarct size and significantly greater area at risk than the non-morphine group. After propensity score matching (90 pairs), MSI was similar between the morphine and non-morphine group (46.1% versus 43.5%, P = .11), and infarct size and area at risk showed no difference. In propensity score-matched analysis, IV morphine prior to primary PCI in STEMI patients did not cause adverse impacts on myocardial salvage.

Short-term and long-term prognostic outcomes of patients with ST-segment elevation myocardial infarction complicated by profound cardiogenic shock undergoing early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention

BackgroundThis study investigated the 30-day and long-term prognostic outcomes in patients with ST-segment elevation myocardial infarction (STEMI) complicated with profound cardiogenic shock (CS) undergoing early routine extracorporeal membrane oxygenator (ECMO)-assisted primary percutaneous coronary intervention (PCI). MethodsBetween December 2005 and December 2014, 65 consecutive STEMI patients with profound CS underwent routine ECMO-supported primary PCI. ResultsThe incidences of acute pulmonary edema, respiratory failure with requirement of mechanical ventilatory support upon presentation, and 30-day mortality rate were 100%, 95.4%, and 43.1%, respectively. The duration of hospitalization, mean long-term follow-up, and survival rate were 32.1±53.1 (days), 733.6±986.7 (days), and 32.3%, respectively. The mean APACHE score (32.6±8.3 vs. 28.5±7.5), peak serum creatinine level (4.3±2.4 vs. 1.7±1.2mg/dL), incidences of failed ECMO weaning (57.1% vs. 0%), successful ECMO weaning but in-hospital death (40.0% vs. 0%) were significantly lower in 30-day survivors than those in non-survivors (all p<0.05), whereas final thrombolysis in myocardial infarction (TIMI)-3 flow [53.6% vs. 91.9%] showed an opposite pattern compared to that of APACHE score in the two groups (p<0.02). Multivariate analysis demonstrated that unsuccessful reperfusion, failed ECMO weaning, and peak creatinine level were independent predictors of 30-day mortality (all p<0.01). ConclusionsEarly ECMO-supported primary PCI in STEMI patients with profound CS was feasible as a life-saving strategy with acceptable 30-day and long-term prognostic outcomes.

Association of monocyte to HDL cholesterol level with contrast induced nephropathy in STEMI patients treated with primary PCI.

Contrast induced nephropathy (CIN) has been proven to be a clinical condition related to adverse cardiovascular outcomes. In recent studies, the monocyte to high density lipoprotein ratio (MHR) has been postulated as a novel parameter associated with adverse renal and cardiovascular outcomes. In this study we investigated the association of MHR with CIN in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI). Consecutive STEMI patients treated with primary PCI were prospectively recruited. Subjects were categorized into two groups; as patients who developed CIN (CIN+) and patients who did not develop CIN (CIN-) during hospitalization. CIN was defined as either a 25% increase in serum creatinine from baseline or 44.20 µmol/L increase in absolute value, within 72 h of intravenous contrast administration. A total number of 209 patients were included in the study. Thirty-two patients developed CIN (15.3%). In the CIN (+) patients, monocytes were higher [1.02 (0.83-1.39) vs. 0.69 (0.53-0.90) 109/L, p<0.01] and HDL cholesterol levels were lower [0.88 (0.78-1.01) vs. 0.98 (0.88-1.14) mmol/L, p<0.01]. In addition, MHR was significantly higher in the CIN (+) group [1.16 (0.89-2.16) vs. 0.72 (0.53-0.95) 109/mmol, p<0.01]. In multivariate logistic regression analysis, MHR, Mehran score, AGEF score and CV/eGFR were independently correlated with CIN. Higher MHR levels may predict CIN development after primary PCI in STEMI patients.

Measuring hospital performance in the management of acute coronary syndromes

Measuring hospital performance in the management of acute coronary syndromes

Variable penetration of primary angioplasty in Europe – what determines the implementation rate?

Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). A survey conducted in 2008 in the European Society of Cardiology (ESC) countries reported that the annual incidence of hospital admissions for acute STEMI is around 800 patients per million inhabitants. The survey also showed that STEMI patients' access to reperfusion therapy and the use of PPCI or thrombolytic therapy (TT) vary considerably among countries. Northern, Western and Central Europe already had well-developed PPCI services, offering PPCI to 60-90% of all STEMI patients. Southern Europe and the Balkans were still predominantly using TT and had a higher proportion of patients who were left without any reperfusion treatment. The survey concluded that a nationwide PPCI strategy results in more patients being offered reperfusion therapy. To address the inequalities in STEMI patients' access to life-saving PPCI and to support the implementation of the ESC STEMI treatment guidelines in Europe, the Stent for Life (SFL) Initiative was launched jointly by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and EuroPCR in 2008. The aim of the SFL Initiative is to improve the delivery of life-saving PPCI for STEMI patients. Currently, 10 national cardiac societies support the SFL Initiative in their respective countries. SFL national action programmes have been developed and are being implemented in several countries. The formation of regional PPCI networks involving emergency medical services, non-PPCI hospitals and PPCI centres is considered to be a critical factor in implementing PPCI services effectively. Better monitoring of STEMI incidence and prospective registration of PPCI in all countries is required to document improvements in health care and to identify areas where further effort is required. Furthermore, studies on potential factors or characteristics that explain the national penetration of PPCI are needed. Such knowledge will be necessary to increase the effectiveness and efficiency of the implementation, and will be the first step in ensuring equal access to PPCI treatment for STEMI patients in Europe. Establishing the delivery of PPCI in an effective, high-quality and timely manner is a great challenge.

Early Angio-Guided Complete Revascularization versus Culprit Vessel PCI Followed by Ischemia-Guided Staged PCI in STEMI Patients with Multivessel Disease

Optimal management of multivessel disease (MVD) in ST-segment elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PCI) is still unclear. To compare short- and long-term clinical outcomes of early-staged, angio-guided approach and delayed, ischemia-guided treatment of non-infarct-related arteries (IRAs). Consecutive patients with STEMI and MVD treated with primary PCI in 6 tertiary care centers were retrospectively selected and analyzed. Major adverse cardiac events (MACE) were defined as the composite end-point of death, MI, and repeat revascularization. All the events were adjudicated according to the Academic Research Consortium (ARC) definitions. In the time period 2004-2008, 800 primary PCIs in STEMI patients with MVD were performed. Four hundred and seventeen were addressed to early-staged, angio-guided PCI of non-IRAs (CR group) and 383 to an incomplete revascularization (IncR group). During the hospital stay, no difference in terms of death and repeat revascularization was found between groups but the incidence of periprocedural MI/reinfarction and MACE was significantly higher in the CR group (13.9% vs. 3.1%, P = 0.01 and 14.1% vs. 9.1%, P = 0.017, respectively). At a mean follow-up of 642 ± 545 days, no difference in terms of death and MI was found between the CR and IncR group. The MACE-free survival was significantly higher in the IncR group (73.8% vs. 57%, log rank 0.05), mainly driven by the lower incidence of re-PCI. Early complete revascularization based only on angiographic findings in patients with STEMI and MVD is associated with an excess of periprocedural/re-MI and with a significantly higher incidence of MACE at follow-up.

Sex Differences of the Clinical Characteristics and Early Management in the Korea Acute Myocardial Infarction Registry

Background and Objectives:The first on-line registration of Korea Acute Myocardial Infarction patients (KAMIRs) has been carried out throughout the 41 primary percutaneous coronary intervention (PCI) centers that are supported by the Korean Circulation Society (KCS), as reported in the memorandum of the 50th Anniversary of the KCS. Subjects and Methods:Between Nov 2005 and June 2006, 4905 patients were enrolled in KAMIR and 4110 eligible patients (2855 males and 1255 females; mean age=64.3±13.5 years) were analyzed. The treatment strategy for acute myocardial infarction (AMI) was analyzed according to the gender differences in the area of acute ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI). Results:For the initial selection of a treatment strategy for STEMI, primary PCI was more commonly performed in males than females (69.8% vs. 68.3%, respectively, p=0.008), but age was the most important predictors after multivariate adjustment. During the hospital stay, PCI regardless of its subtype was more commonly done in the males than in the females with both STEMI and NSTEMI (STEMI: 89.1% vs. 84.9%, respectively, p=0.004; NSTEMI: 74.7% vs. 63.5%, respectively, p<0.001). The success rate of PCI in STEMI patients was not different between the genders (95.0% vs. 93.6%, respectively, p=0.399), but that of NSTEMI was higher in the males than the females (96.9% vs. 95.8%, respectively, p=0.004). Conclusion:For the initial treatment of AMI in Korea, females are treated more conservatively than males, but age was the most important predictor for invasive treatment. The success rate of PCI was higher for the males than the females. (Korean Circulation J 2007;37:64-71)