Primary Percutaneous Coronary Intervention Treatment Research Articles

Correlation Between Ischemia Time and Left Ventricular Failure After Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction (STEMI) Patients.

Primary percutaneous coronary intervention (PPCI) is pivotal in treating ST-elevation myocardial infarction (STEMI) patients, yet ischemia time significantly impacts outcomes, particularly left ventricular failure (LVF). This study aimed to investigate the impact of ischemia duration and other variables associated with severe left ventricular systolic dysfunction in STEMI patients receiving PPCI treatment. This prospective cohort was carried out at Lady Reading Hospital in Peshawar, Pakistan, from January to June 2023. The study included 236 patients aged 18 to 70 with acute myocardial infarction who underwent PPCI within 12 hours of symptom onset. Patients with coronary dissection, late presenters (more than 12 hours after onset), those without stenting, and those with prior coronary artery intervention were excluded. Additionally, patients with systolic heart failure, a history of arrhythmias such as ventricular tachycardia or ventricular fibrillation, or a previous acute coronary syndrome event were excluded. Demographic information, clinical background, and ischemia duration were recorded and associated with left ventricular ejection fraction (LVEF) after PPCI. To identify predictors of severe left ventricular dysfunction, statistical analysis using SPSS Statistics version 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.) included multivariate regression, Pearson's correlation, and descriptive statistics. The patients' average age was 61.2 years (SD ± 12.3), with 35.59% of them being female (84 patients) and 64.41% of them being male (152 patients). Diabetes (33.05%, 78 patients) and hypertension (43.22%, 102 patients) were common comorbidities, and 14.41% (34 patients) had previously had a cardiac episode. Fifty-two patients (22.03%) of the total had ischemia within three hours, 94 patients (39.83%) had ischemia within six hours, 60 patients (25.42%) had ischemia within nine hours, and 30 patients (12.71%) had ischemia within 12 hours. Analysis of LVEF showed that 9.32% of patients (n=22) had LVEF <30% and 24.58% of patients (n=58) had LVEF 30-40%. Significant predictors of severe left ventricular systolic dysfunction were shown by multivariate regression to include ischemia duration (OR 1.45, p<0.001), age (OR 1.02, p=0.015), diabetes (OR 2.34, p=0.001), hypertension (OR 1.76, p=0.031), and previous cardiac events (OR 2.89, p=0.002); 20.33% of the patients (n=48) had LVF during the six-month follow-up, highlighting the therapeutic significance of prompt management in STEMI patients after PPCI. Prolonged ischemia, advanced age, diabetes, hypertension, and previous cardiac events that predict severe left ventricular dysfunction are associated with a greater risk of LVF following PPCI. Timely intervention and thorough therapy are essential for enhancing results for STEMI patients at high risk.

The effects of prophylactic intravenous injection of rhBNP on prognosis in patients with STEMI undergoing PPCI.

This experiment was carried out to observe the application value of recombinant human brain natriuretic peptide (rhBNP) in patients with ST-segment elevation myocardial infarction (STEMI) by primary percutaneous coronary intervention (PPCI), to provide reference for the future treatment of STEMI. In this study, we selected STEMI patients who underwent PPCI treatment in our hospital from October 2019 to December 2021 were selected as the study subjects, of which 46 received intravenous injections of rhBNP (research group), and 36 STEMI patients underwent PPCI (control group). There was no difference in clinical efficacy between the two groups (P>0.05). After treatment, high-sensitivity cardiac troponin I (hs-cTnI), creatine kinase-MB (CK-MB) and plasma N-terminal pro-BNP (NT-proBNP) levels decreased in both groups, with the research group lower than the control group; cardiac output (CO), cardiac index (CI) and mean arterial pressure (MAP) of the research group were lower than the control group's (P<0.05). The left ventricular ejection fraction (LVEF) in the research group was higher than that in the control group at 1 week and 1 month after treatment, while left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter (LVESD) were lower than those in the control group (P<0.05). There was also no difference in the rate of prognostic risk events between the two groups at 6 months of follow-up (P>0.05). Combining the results of these experiments above, we believe that the intravenous injection of rhBNP in STEMI patients undergoing PPCI treatment can improve cardiac function and promote the recovery of hemodynamics.

A Comparative Study on Ticagrelor and Clopidogrel in Patients With Acute Coronary Syndrome Treated With Primary Percutaneous Coronary Intervention.

To compare the efficacy and safety of ticagrelor and clopidogrel in patients with acute coronary syndrome (ACS) treated with primary percutaneous coronary intervention (PPCI). 3,528 consecutive patients with ACS treated with PPCI were divided into the ticagrelor and clopidogrel groups based on their dual antiplatelet therapy regimen at hospital discharge. Patient follow-up visits were completed 1, 6, and 12 months after PPCI treatment. Major adverse cardiac events (MACEs) and Bleeding Academic Research Consortium (BARC) bleeding events were assessed in both groups. In total, 2,501 cases were included in the ticagrelor group, and 817 cases were included in the clopidogrel group. The incidence of MACEs was lower in the ticagrelor group than in the clopidogrel group (P < 0.05). Ticagrelor group had lower incidence of all-cause death and cardiac death compared with clopidogrel group, the difference was significant (P<0.05). The incidences of study endpoints, including recurrent myocardial infarction and repeat revascularization, were not significantly different between the groups (P > 0.05). The incidences of BARC total and major bleeding events were not significantly different between the groups (P > 0.05). However, the incidences of BARC Types 1 and 2 bleeding events were lower in the ticagrelor group than in the clopidogrel group (P < 0.05). The multivariate COX regression analysis suggested that ticagrelor could decrease all-cause death compared with clopidogrel (P = 0.021).In patients with ACS treated with PPCI, ticagrelor could significantly reduce the risk of MACEs compared with clopidogrel, without increasing the risk of bleeding. This article is protected by copyright. All rights reserved.

Prediction of microvascular obstruction by coronary artery angiography score after acute ST-segment elevation myocardial infarction: a single-center retrospective observational study

BackgroundSome coronary artery angiography (CAG) scores are associated with the no-reflow phenomenon after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). However, quality evidence regarding the association between the CAG scores and microvascular injury is still needed. Our study aimed to validate the ability of the CAG scores in predicting microvascular obstruction (MVO) detected by cardiac magnetic resonance (CMR) imaging.MethodsFrom October 2020 to October 2021, 141 consecutive patients with acute STEMI who underwent primary PCI and CMR were retrospectively reviewed. CMR imaging was performed between 3 and 7 days after PCI. The patients were divided into MVO and non-MVO group based on the CMR results. Three CAG scores (SYNTAX score, SYNTAX II score and Gensini score) were used to assess the severity of coronary artery atherosclerotic burden.ResultsA total of 122 patients were included (mean age 60.6 ± 12.8 years). MVO occurred in 51 patients (41.8%). Patients with MVO had higher SYNTAX scores, SYNTAX II scores and Gensini scores than those without MVO (all p < 0.001). The Gensini score (r = 0.567, p < 0.001) showed the strongest correlation with infarction size than SYNTAX score (r = 0.521, p < 0.001) and SYNTAX II score (r = 0.509, p < 0.001). The areas under the receiver operator characteristic curves of SYNTAX score, SYNTAX II score and Gensini score for predicting MVO patients were 0.726, 0.774 and 0.807. In multivariable regression analysis, peak troponin I (odd ratio [OR] = 1.236, p = 0.001) and SYNTAX II score (OR = 11.636, p = 0.010) were identified as independent predictors of MVO.ConclusionsIn patients with acute STEMI undergoing primary PCI treatment, the peak troponin I and SYNTAX II score may be an independent predictor of MVO.

The prognostic value of myocardial infarct size measured by cardiovascular magnetic resonance in patients with acute ST-segment elevation myocardial infarction

Objective: To investigate the prognostic value of infarct size (IS) in patients with acute ST-segment elevation myocardial infarction (STEMI) underwent primary percutaneous coronary intervention (PCI). Methods: A total of 104 patients with acute STEMI who underwent primary PCI treatment in Shengjing Hospital of China Medical University from February 2017 to November 2018 were included in the present study. All patients underwent cardiovascular magnetic resonance (CMR) within one week after primary PCI treatment. The subjects were followed up for two years. Major adverse cardiac events (MACE) included new onset congestive heart failure and/or recurrent nonfatal myocardial infarction and/orcardiac death. The optimal IS cutoff value for MACE was determined by receiver operating character (ROC) curve. Based on the IS cutoff value, the patients were divided into the high IS group and the low IS group. Clinical characteristics between the two groups were compared. A cox regression model was used to analyze the prognostic value of IS in acute STEMI patients treated with primary PCI for the adverse events. Results: The IS cutoff value determined by ROC curve was 13.55%. 50 patients were in the high IS group (IS≥13.55%) and 54 patients were in the low IS group (IS<13.55%). More female patients [14 cases (28.0%) vs. 6 cases (11.1%)] were in the IS group, and a higher proportion of patients in the high IS group had anterior myocardial infarction [27 cases (54.0%) vs. 16 cases (29.6%)] or microvascular obstruction [32 cases (64.0%) vs. 16 cases (29.6%)]. White blood cell counts [11.25(8.90, 13.38) ×109/L vs. 9.25(7.58, 11.00) ×109/L], troponin I levels [50.63(16.56, 76.30)μg/L vs. 16.58(2.66, 38.42)μg/L] and brain natriuretic peptide levels [178.10(79.70, 281.95)μg/L vs. 79.60(42.83, 183.90)μg/L] in the high IS group were higher than those in the low IS group (P<0.05), and left ventricular ejection fraction [(45.15±10.65)% vs. (51.95±12.91)%] in the high IS group was lower than that in the low IS group (P<0.05). Multivariate Cox regression analyses showed that IS was independently associated with the risk of cardiac death in patients with acute STEMI two years after primary PCI(P=0.033, HR=1.075, 95%CI1.006-1.148). Every 1% increase in IS was associated with a 7.5% increase in cardiac death. Conclusions: Infarct size, measured by CMR within one week after primary PCI, is strongly associated with cardiac death in patients with acute STEMI two years after primary PCI. IS could be used as an index for the prognosis of patients with acute STEMI.

Time delays in each step from symptom onset to treatment in acute myocardial infarction: Results from a nation-wide TURKMI registry.

In this study, we aimed to analyze the TURKMI registry to identify the factors associated with delays from symptom onset to treatment that would be the focus of improvement efforts in patients with acute myocardial infarction (AMI) in Turkey. The TURKMI study is a nation-wide registry that was conducted in 50 centers capable of 24/7 primary percutaneous coronary intervention (PCI). All consecutive patients (n=1930) with AMI admitted to coronary care units within 48 hours of symptom onset were prospectively enrolled during a predefined 2-week period between November 1, 2018, and November 16, 2018. All the patients were examined in detail with regard to the time elapsed at each step from symptom onset to initiation of treatment, including door-to-balloon time (D2B) and total ischemic time (TIT). After excluding patients who suffered an AMI within the hospital (2.6%), the analysis was conducted for 1879 patients. Most of the patients (49.5%) arrived by self-transport, 11.8% by emergency medical service (EMS) ambulance, and 38.6% were transferred from another EMS without PCI capability. The median time delay from symptom-onset to EMS call was 52.5 (15-180) min and from EMS call to EMS arrival 15 (10-20) min. In ST-segment elevation myocardial infarction (STEMI), the median D2B time was 36.5 (25-63) min, and median TIT was 195 (115-330) min. TIT was significantly prolonged from 151 (90-285) min to 250 (165-372) min in patients transferred from non-PCI centers. The major significant factors associated with time delay were patient-related delay and the mode of hospital arrival, both in STEMI and non-STEMI. The baseline evaluation of the TURKMI study revealed that an important proportion of patients presenting with AMI within 48 hours of symptom onset reach the PCI treatment center later than the time proposed in the guidelines, and the use of EMS for admission to hospital is extremely low in Turkey. Patient-related factors and the mode of hospital admission were the major factors associated with the time delay to treatment.

Reperfusion of ST-Segment-Elevation Myocardial Infarction in the COVID-19 Era: Business as Usual?

Reperfusion of ST-Segment-Elevation Myocardial Infarction in the COVID-19 Era: Business as Usual?

Modeling of cardiac function of patients with acute myocardial infarction based on Type-D personality: Mediating role of negative emotions

Context: Cardiac function of patients with acute myocardial infarction (MI) plays a central role in their prognosis. Aims: The purpose of this study was to model the cardiac function of these patients based on Type-D personality and the mediating role of negative emotions (anger, depression, and anxiety) in this relationship. Setting and Design: This correlational study was performed using the structural equation modeling method, and specifically the regression equations (combination of path analysis and second-order factor analysis). Material and Methods: The study population was the patients with acute ST-segment elevation MI (STEMI) who were hospitalized at Mazandaran Cardiovascular Hospital and underwent under primary percutaneous coronary intervention treatment in 2017 and 2018. Using Mueller's formula modeling formula (1996) based on a sample size-to-free parameter ratio, the sample size was calculated to 220 patients were chosen by the purposive method. Data were collected using Denollet'sType-DScale-14, the Spielberger's state-trait anxiety inventory, short-form of the beck depression inventory-13, and Spielberger's state-trait anger expression inventory-2. Statistical Analysis Used: Data analysis was performed using SPSS-18 and AMOS 23. Results: Type-D personality can directly predict of the cardiac function of patients with acute STEMI. This variable also predicts the the cardiac function of these patients via the mediation of negative emotions (anger, depression, and anxiety). Conclusion: Type-D personality affects the incidence and prognosis of myocardial infarction via negative emotions. It is, therefore, recommended to screen the susceptible populations for this personality type.

Epidemiology of heart failure in myocardial infarction treated with primary angioplasty: Analysis of the Codi IAM registry

Introduction and objectivesThe epidemiology of heart failure (HF) that complicates ST-segment elevation myocardial infarction (STEMI) is not well defined. Our aim was to analyze the epidemiology and prognosis of HF that complicates STEMI treated with primary percutaneous coronary intervention (PCI). MethodsMulticentre registry of 14070 patients with STEMI treated with primary PCI from January 2010 to December 2015. ResultsPatients with HF were older, more frequently female, and diabetic and had chronic ischaemic heart disease. Only 10.3% of patients with STEMI treated with primary PCI had HF on admission and the majority of them had the mildest form (Killip–Kimball II 77.8%). HF was associated with high mortality (30-day mortality was 2.9% of patients in Killip–Kimball I, 9.5% of Killip–Kimball II and 17.4% in Killip–Kimball III, P<.005, and 1-year mortality in patients who survived 30 days was 2.9%, 9.3% and 14.3%, P<.005, respectively). Both the presence of Killip–Kimball class II and III were independently associated with 30-day and 1-year mortality in 30-day survivors. Up to 6% and 15% of patients in Killip–Kimball II and III on admission worsened to cardiogenic shock, and the onset of cardiogenic shock during hospitalization was independently associated with mortality at 30-day and 1-year follow-up. ConclusionsHF complicates 10.3% of patients with STEMI treated with primary PCI and it was associated with a higher risk of developing cardiogenic shock and with 30-day and 1-year mortality in 30-day survivors. In this high-risk population, primary PCI and posterior medical treatment should be prioritized to avoid worsening of HF.

Reduction of No Reflow with a Loading Dose of Atorvastatin before Primary Angioplasty in Patients with Acute ST Myocardial Infarction

No reflow defined as an altered myocardial reperfusion and failure at microvascular level is a frequent complication in acute myocardial infarction that attenuates beneficial effect of reperfusion therapy leading to poor outcomes. There is not enough evidence to support that previous use of statins improves coronary flow in patients undergoing primary percutaneous coronary intervention (PCI). To determine if a loading dose of 80mg of atorvastatin before primary angioplasty reduces the frequency of no reflow, hs-CRP, IL6 intracoronary levels, and major combined cardiovascular events at 30d. In this controlled clinical trial, we randomly assigned 103 adult patients within the 12h of acute ST-elevation myocardial infarction (STEMI) to receive 80mg of atorvastatin additional to standard treatment (AST) before performing primary PCI versus standard treatment (ST) alone. The primary outcomes were the occurrence of no reflow and high sensitivity C-reactive protein (hs-CRP) and interleukin 6 levels and secondary outcomes were major adverse cardiovascular events at 30d. 103 patients were analyzed, 49 (48%) received AST, 54 (52%) ST. Frequency of no reflow among groups was 27 vs. 63% respectively, p ≤0.0001. hs-CRP level was 2.69mg/dL for AST vs. 2.2mg/dL in ST, meanwhile IL-6 levels were 5.2 pg/mL vs. 6.35 pg/mL respectively, p=ns. Cox regression model demonstrated that the treatment assigned is an independent predictor for no reflow occurrence (HR 0.34 95%, CI 0.18-0.61, p ≤0.001). The administration of a loading dose of 80mg atorvastatin before primary PCI is an effective strategy for prevention of no reflow improving also clinical outcomes and free survival rate for the presentation of major adverse cardiovascular events at 30d.

Myocardial reperfusion with tirofiban injection via aspiration catheter : Efficacy and safety in STEMI patients with large thrombus burden.

There is no consensus on the use of thrombus aspiration (TA) in primary percutaneous coronary intervention (PPCI), and few studies have focused on the performance of tirofiban via TA catheter after PPCI. Our study investigated the clinical outcome of tirofiban injection through TA in acute ST-segment elevation myocardial infarction (STEMI) patients with large thrombus burden undergoing PPCI treatment. The study comprised 122 STEMI patients who underwent TA during PPCI. Participants were randomly divided into two groups. GroupA received intravenous tirofiban injection and tirofiban injection via aTA catheter to the infarcted coronary artery after aspiration (n = 61). GroupB received intravenous tirofiban injection only (n = 61). Baseline clinical information and follow-up data were collected for both groups. Coronary angiography, electrocardiography, and echocardiography findings as well as major adverse cardiovascular events (MACE) were recorded. There were significant differences in postprocedural Thrombolysis in Myocardial Infarction (TIMI) grade2 and 3 flow between the two groups (p = 0.021, p = 0.006, respectively). The incidence of slow-flow in groupA was significantly lower than that of groupB (p = 0.011). An increased incidence of no ST-segment resolution was observed in groupB (p = 0.011). There were fewer major adverse cardiovascular events in groupA than in groupB, but the difference was not statistically significant. Selective tirofiban injection via TA catheter during PPCI may improve myocardial reperfusion in STEMI patients with large thrombus burden.

Effects of remote ischemic post-conditioning on platelet activation of AMI patients.

The recovery of ischemic myocardium blood perfusion is the main treatment option for acute myocardial infarction (AMI). However, this treatment option has multiple side effects that directly affect the quality of life of the patients. The activation of platelet function plays an important role in the occurrence, development and treatment of AMI. The aim of the present study was to analyze the effects of remote ischemic post-conditioning on platelet activation of AMI patients with primary PCI treatment and clinical prognosis. A total of 71 patients with AMI were treated with primary percutaneous coronary intervention (PCI). They were randomly divided into control group (n=34) and observation group (n=37). The patients in the observation group were treated with remote ischemic post-conditioning. Further, flow cytometer was used to detect the platelet alpha granule membrane glycoprotein (CD62P) and the percentages of activated IIb/IIIa (PAC-1). The maximum platelet aggregation rate induced by adenosine diphosphate (ADP) and arachidonic acid (AA) was measured by light transmittance aggrometer. The incidence of major adverse cardiac events (MACE) was compared between the two groups during the follow-up period of 6 months. The percentage of CD62P (24 h after PCI) in the observation group was significantly lower than control group (P<0.05). Further, the incidence of MACE in the observation group was also lower than that of the control group (P<0.05). Remote ischemic post-conditioning could reduce the incidence of MACE in patients with AMI after primary PCI treatment. Moreover, the above observation may be related to the improvement of platelet CD62P activation.

Effect of primary percutaneous coronary intervention on ventricular repolarization through evaluation of QT dispersion in patient with acute myocardial infarction

Background: Cardiovascular disease is the most common cause of death around the world. QT dispersion is one of the parameters that used for evaluation of ventricular arrhythmia. Primary PCI increases probability of coronary artery and reperfusion of the ventricular arrhythmia. The aim of this study was to determine effect of primary percutaneous coronary intervention (PCI) on ventricular repolarization through evaluation of QT dispersion in patient with acute myocardial infarction. Methods: In this pre-post test study, 77 patients with acute ST with elevated myocardial infarction under primary PCI were investigated. The ECG and ST dispersion before PCI and 24 hours after PCI were determined and then the amount of QTd was calculated. The repeated measurement ANOVA was used to compare QTd of pre- PCI treatment and QTd in 24 hours after PCI. Data analysis was performed using statistical software SPSS ver.17. Results: From 77 participants, 60 were male and 17 were female. 43 (55.8%) had a MI position in ANT, PRE, and EXT, 33 (42.9%) had in the INF, and only one person (1.3%) had a MI position in LAT. The results showed that mean QT dispersion in ECG, 24h after primary PCI, for most of measured variables was deceased compare to before primary PCI, but the difference was not significant. Conclusions: The amount of QTd 24 hours after PCI decreased but its decline was not significant. With regards to lack of convenience data, more researches are recommended in this field.

Clinical characteristics and value in early reperfusion therapy for new onset right bundle branch block in patients with acute myocardial infarction.

The value of the right bundle branch block (RBBB) in the treatment of acute myocardial infarction remains unclear. Studies on the RBBB may significantly influence the treatment of acute myocardial infarction. A total of 845 patients with acute myocardial infarction who underwent primary coronary angiography at Henan Provincial People's Hospital were analyzed. Higher peak enzyme levels, a higher ratio of Killip ≥II and closer proximal occlusion of infarct-related artery (IRA) were observed in patients with RBBB compared with those without. The ratio of TIMI flow 0/1 of IRA and ratio of received primary percutaneous coronary intervention (PCI) to IRA in the RBBB group were significantly higher compared with those in the left (L) BBB or no BBB groups. The in-hospital major adverse cardiac events (MACE) incidence in the RBBB group was higher compared with that in the no BBB group, but there was no significant difference between the RBBB and LBBB groups. Logistic regression revealed that proximal occlusion and TIMI flow 0/1 of IRA were predictive factors of RBBB. Cox regression analysis identified RBBB [risk ratio (RR), 4.682; P<0.001] and LBBB (RR, 3.687; P<0.001) as independent predictors of in-hospital MACE. The cumulative one-year survival rate in the RBBB group was significantly lower than those in the no BBB group (P<0.05) and the LBBB group (P<0.05). Similar to the guidelines regarding new onset of LBBB, new onset RBBB should be considered as a standard indicator for reperfusion therapy; as RBBB is associated with more severe symptoms, and higher incidents of complete occlusion of IRA and primary PCI treatment compared with LBBB.

Short-Term Prognostic Value of Strain Echocardiography in Patients with STEMI

Objectives: Left ventricular (LV) systolic function is major predictor of outcome after acute myocardial infarction (AMI). In recent years, speckle-tracking echocardiography (STE) derived strain measurement has been demonstrated to directly reflect myocardial deformation patterns and to be superior to conventional echocardiographic measurements. Our study aimed to reveal the prognostic value of strain parameters for 30-day mortality in patients with ST elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI). Methods: We prospectively included patients with STEMI after primary PCI treatment. The primary endpoint was 30-day mortality. 2D STE was used to determine LV strain parameters. Results: 414 patients were selected. 30-day mortality occurred in 15 patients (3.6%). LV global longitudinal strain (GLS) was significantly impaired in the 30-day mortality group compared with survivors (-8.0±2.6% vs. -15.4±3.8%, p&lt;0.001). Multivariate regression revealed that LV GLS was independently associated with 30-day mortality (OR 1.71, 95% CI 1.23-2.38, p&lt;0.001). Adding GLS into the clinical and echocardiographic model improved model performance. Conclusion:The LV GLS parameter is an independent predictor of 30-day mortality in patients with STEMI after primary PCI treatment. Adding LV GLS into the prediction model improved its predictive performance.

Impact of CYP2C19 genotypes on antiplatelet therapy among Chinese patients with acute myocardial infarction after percutaneous coronary intervention

Objective: To investigate the impact of CYP2C19 genetic variants on antiplatelet therapy in Chinese patients with acute myocardial infarction(AMI) after primary percutaneous coronary intervention(PCI), and compare the antiplatelet effect between clopidogrel and ticagrelor with various CYP2C19 genotypes. Methods: From June 2014 to May 2015, 347 patients with AMI who underwent PCI treatment at Fuwai Hospital were enrolled in this single center prospective study, 221 cases were in clopidogrel group and 126 patients were in ticagrelor group.Two candidate single nucleotide polymorphisms (SNPs) (636 and 681 loci) of CYP2C19 gene were detected by polymerase chain reaction-restriction endonuclease method.Adenosine diphosphate (ADP)-induced platelet aggregation was measured by thromboelastography (TEG) at 24-48 hours after primary PCI. Results: There were 93 non-carriers (42.1%, 93/221), and 128 carriers (57.9%, 128/221) in clopidogrel group. There were 48 non-carriers (38.1%, 48/126), 78 carriers (61.9%, 78/126) in ticagrelor group. CYP2C19 genotype frequency was similar between two groups. TEGADP was significantly lower in clopidogrel group than in ticagrelor group (63.08±27.78 vs. 78.08±25.62, P<0.001), both for non-carriers (68.16±25.17 vs. 82.79±22.45, P=0.002) and for carriers (59.37±29.06 vs. 75.15±27.15, P<0.001). TEGADP was significantly higher in non-carriers than in carriers in clopidogrel group (P=0.02) and similar between non-carriers and carriers in ticagrelor group (P>0.05). Conclusion: The CYP2C19 gene mutation is high in the patients with AMI.The effect of antiplatelet of ticagrelor is stronger than clopidogrel, and this effect is not affected by CYP2C19 gene mutations.

Antithrombotic therapy for patients with STEMI undergoing primary PCI.

Antithrombotic therapy, including antiplatelet and anticoagulant agents, is the cornerstone of pharmacological treatment to optimize clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Intravenous anticoagulant drugs available for PPCI include the indirect thrombin inhibitors unfractionated heparin and low-molecular-weight heparin, and the direct thrombin inhibitor bivalirudin. Intravenous antiplatelet drugs mainly include glycoprotein IIb/IIIa inhibitors and the P2Y12-receptor inhibitor cangrelor. Dual antiplatelet therapy with aspirin and an oral P2Y12-receptor inhibitor is pivotal for the acute and long-term treatment of patients with STEMI undergoing PPCI. Prasugrel and ticagrelor provide a more prompt, potent, and predictable antiplatelet effect compared with clopidogrel, which translates into better clinical outcomes. Therefore, these agents are the first-line treatment in PPCI. However, patients can still experience adverse ischaemic events, which might be in part attributed to alternative pathways triggering thrombosis. Thrombin has an important role, suggesting the need for strategies directly targeting circulating thrombin or other factors of the coagulation cascade, such as oral anticoagulants (rivaroxaban), and the thrombin receptor on the platelet membrane (vorapaxar). In this Review, we provide an overview of currently available antithrombotic therapies used in patients with STEMI undergoing PPCI, results from pivotal clinical trials and their implications for guidelines, as well as recommendations for clinical practice.

Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction.

We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST-PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST-elevation myocardial infarction (STEMI). Current standard therapy for STEMI is PPCI. However, FAST-PCI may shorten ischemic time (IT) and improve outcomes. Eligible STEMI patients received prehospital, reduced dose fibrinolysis along with standard therapy, and were transported for urgent percutaneous coronary intervention, or else they received usual treatment without prehospital fibrinolysis. Patients were divided retrospectively into four groups based on IT (<120, 120-179, 180-239 min, ≥240) for a mortality analysis cohort, and into three groups (<120, 120-179, ≥180 min) for a CMR analysis cohort. Within each IT group, patients were compared by FAST-PCI vs. PPCI strategy. Between 1/2007 and 2/2014, 1,112 STEMI patients were treated. FAST-PCI was employed in 551 and PPCI in 561. Of these, 357 (32.1%) underwent CMR. The treatment groups were well matched. In STEMI patients with short IT (<120 and 120-179 min groups), those treated by FAST-PCI had lower 30-day mortality and myocardial scar sizes compared with PPCI treatment. For IT ≥180 min, the mortalities and myocardial scar sizes were equivalent for both groups. In STEMI patients with IT <180 min, FAST-PCI may reduce 30-day mortality and myocardial scar size compared with PPCI. This suggests that infarct interventions must be instituted within 3 hr of symptom onset in order to detect an optimal beneficial effect both clinically and by CMR measurement. © 2016 Wiley Periodicals, Inc.

Spontaneous Coronary Artery Dissection: Efficient Clinical Outcome through Percutaneous Coronary Intervention

A 70 years-old male with a history of diabetes mellitus and hypertension, presented an acute squeezing chest tight of 5 hours duration in precordium after emotional stress. He was admitted to emergency department with blood pressure 171/100 mmHg. Electrocardiogram (ECG) showed frequent ventricular premature contractions and complete left bundle branch block which did not happen before. Laboratory examination showed elevated cardiac Troponin I (0.83 μg/L reference range, 0 to 0.15μg per liter) Creatine Kinase (268 U/L reference range, 30 to 170 IU per liter) and Creatine Kinase isoenzyme MB (31 U/L reference range, 0 to 25 IU per liter). Pharmacological management were included nitrate (Isosorbide mononitrate and glonoin) before primary percutaneous coronary intervention (PCI), His coronary angiogram showed a significant about 15mm lesion, dissection at the proximal left anterior descending artery(LAD) (Figure1) and diffuse severe stenosis in middle part of right coronary artery (RCA). There were no signs of dissection in the left circumflex coronary (LCx). Our strategy was combining pharmacological management and PCI which mean implanting a stent in the dissection of LAD. The procedure of cardiac catheterization was supported by intraaortic balloon pump (IABP) and temporary pacemaker (TPM), considering the patient with frequent ventricular premature and heart failure [ejection fraction 28% detected by transthoracic echocardiogram (TTE)]. Firstly a 40 ml IABP was implanted in aorta with adjusted counterpulsation pressure 110 to 130mmHg. Then TPM was transported in the right ventricular apex with 60 t/min setted. A Stent (4.0×24mm) was successfully implanted after balloon dilated from the LAD near end. Repeat angiography revealed that the LAD dissection noted earlier was resolved and far-end flowing blood improved after 30min observation. The patient continued the therapy by treating dual anti-platelet (oral aspirin 100mg and clopidogrel 75mg), blood pressure controlled (oral perindopri 2mg), and blood sugar controlled. After 1 week observation, we decided to implant two Stents (3.5×30mm 4.0×18mm) in the RCA to improve the far-end flowing (Figure 3). Meanwhile we did a angiography which also showed LAD dissection disappeared and no stenosis caused again (Figure 2). The patient did not complain discomfort through the procedure. He was maintained dual anti-platelet blood pressure and blood sugar controlled after revascularization. TTE showed a nearly normal ejection fraction (48%) after 2 years of following up. Spontaneous coronary artery dissection (SCAD) is a rare myocardial ischemic disease that threatens patients’ life. Various risk factors are associated with SCAD, such as smoking, severe hypertension and psychological reasons. Considering the formation of dissection, SCAD can be divided into intimal tear type or intraluminal hemorrhage type. The clinical presentation of SCAD depends on the extent and severity of progression of dissection and may present as unstable angina, acute myocardial infarction, ventricular arrhythmias or asymptom. Treatment of SCAD usually includes percutaneous coronary intervention (PCI), bypass graft surgery or medical therapy depending on the range of dissection. Herein, we report a 70 years-old male diagnosed with dissection in the left anterior descending artery by coronary arteriography. Despite the patient’s exposure to the ventricular arrhythmias, he had a good prognosis and survived at 2 years of following up. We found PCI treatment is suitable for the patient who had SCAD.

Change of plasma microRNA-208 level in acute myocardial infarction patients and its clinical significance.

To study the change of cardiac-specific microRNA-208 (miRNA-208) level in acute myocardial infarction (AMI) patients and to explore the role of miRNA-208 in AMI progression. The consecutive subjects including 42 AMI patients, 22 patients with unstable angina (UA), and 40 healthy subjects in our hospital from January 2013 to December 2013 were enrolled in this study. The peripheral miRNA-208 level was measured with real-time reverse-transcription polymerase chain reaction (RT-PCR), and the plasma cardiac troponin I (cTnI) and creatine kinase-MB (CK-MB) levels were determined using electrogenerated chemiluminescence (ECL) method. Patients in the AMI group were further grouped according to the number of stenosed coronary vessels and primary percutaneous coronary intervention (PCI) or not, and the difference in peripheral miRNA-208 level among these subgroups was analyzed. The miRNA-208 level was significantly higher in AMI group than in UA group and healthy controls immediately after admission (P<0.01). In the AMI patients, the plasma miRNA-208 level had a positive correlation with serum cTnI level (r=0.700, P=0.000). In 24 AMI patients who had undergone coronary angiography, the expression of miRNA-208 was significantly higher in patients with two or three stenosed coronary vessels. In 17 AMI patients who had successfully received emergent PCI treatment, the 24-h plasma miRNA-208 level was significantly lower than that immediately after admission (P<0.01). The peripheral plasma miRNA-208 level remarkably increases after cardiac infarction and may dramatically change along with the increase of the myocardial damage. Thus, it may be a new biomarker for AMI.