Primary Percutaneous Coronary Intervention Research Articles

The Use of Thrombectomy during Primary Percutaneous Coronary Intervention: Resurrecting an Old Concept in Contemporary Practice

Optimal myocardial reperfusion during primary percutaneous coronary intervention (pPCI) is increasingly recognized to be beyond restoring epicardial coronary flow. Both invasive and non-invasive tools have highlighted the limitation of using this metric, and more efforts are focused towards achieving optimal reperfusion at the level of the microcirculation. Recent data highlighted the close relationship between thrombus burden and impaired microcirculation in patients presenting with ST-segment elevation myocardial infarction (STEMI). Moreover, distal embolization was an independent predictor of mortality in patients with STEMI. Likewise, the development of no-reflow phenomenon has been directly linked with worse clinical outcomes. Adjunctive thrombus aspiration during pPCI is intuitively intended to remove atherothrombotic material to mitigate the risk of distal embolization and the no-reflow phenomenon (NRP). However, prior trials on the use of thrombectomy during pPCI did not support its routine use, with comparable clinical endpoints to patients who underwent PCI alone. This article aims to review the existing literature highlighting the limitation on the use of thrombectomy and provide future insights into trials investigating the role of thrombectomy in contemporary pPCI.

A case report of successful primary percutaneous coronary intervention to an occluded anomalous left main coronary artery arising from the right coronary sinus

Abstract Background Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus is a rare congenital abnormality that may be encountered during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Case summary A 65 year old man presented with chest pain and signs of heart failure. Electrocardiogram demonstrated atrial fibrillation with ST elevation in the high lateral leads, and he was taken emergently to the cardiac catheterization laboratory for primary PCI. Coronary angiography identified the culprit to be an occluded anomalous left main coronary artery (LMCA) arising from the right coronary cusp, and primary PCI was successfully performed in the LMCA and LAD. Computed tomography angiography (CTA) confirmed a benign retroaortic course of the anomalous LMCA with no additional high risk features, as well as a new left atrial appendage thrombus. He subsequently developed deep venous thrombosis, acute pulmonary embolism, and acute kidney injury secondary to renal artery embolism with associated infarction. Workup for patent foramen ovale and thrombophilia were negative, and he was discharged in a stable condition. At 2-month follow-up, he was asymptomatic with no evidence of myocardial ischemia on stress cardiac magnetic resonance imaging. Discussion We present the first reported case of an occluded anomalous LMCA arising from the right coronary sinus in a patient presenting with STEMI. Rapid recognition of this congenital anomaly and selection of an appropriate guide catheter were keys to achieving timely reperfusion and a good outcome in this case.

Utility of Global Registry of Acute Coronary Event Score (GRACE) and Thrombolysis in Myocardial Infarction Risk Score (TIMI Score) in predicting 30-day Mortality in patients undergoing primary angioplasty at a Tertiary care center – A record-based study

Background This research work aims to assess the effectiveness of Global Registry Of Coronary Events (GRACE) and Thrombolysis In Myocardial Infarction (TIMI) risk scores in predicting outcomes for patients who underwent primary Percutaneous Coronary Intervention (PCI). The study included a cohort from a tertiary care centre. Methods This record-based study enrolled 94 patients who underwent primary PCI after a diagnosis of ST segment elevation myocardial infarction (STEMI). The data, for this study, was extracted from sources including, medical records. These records contained the computation and documentation of both GRACE and TIMI scores. The study also conducted Receiver Operating Curve (ROC) curve analysis, subsequently yielding the area under the curve alongside a 95% confidence interval, which was duly reported. Results The current study attempts a comparative analysis of the capacities of TIMI and GRACE scores. Accordingly, the study highlights that both are equally effective in predicting 30-day mortality for patients with STEMI. The TIMI Risk Score, with 85% sensitivity and 99% specificity metrics (also p-value = 0.008), and the GRACE Score, with 85% sensitivity and 99% specificity metrics (also p-value = 0.006), exhibit a strong similarity in the prognostic performance. Also, the sensitivity and specificity metrics were obtained after a thorough analysis of the receiver operating characteristic curve (ROCC). Conclusions The study utilized the TIMI score which demonstrated a sensitivity of 85% and specificity of 99% and the GRACE Score with 85% sensitivity and 99% specificity to predict 30-day mortality in STEMI patients. This included more than one month of observation period. Post observations, the results of the experiment suggested an improvement in the left ventricular functionwhich helped to infer that recovery after primary PCI is gradual rather than an immediate and pronounced recovery.

Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience.

Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.

Intravenous antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention : A report from the INVEST-STEMI group.

The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized. The aim is to evaluate the effectiveness and safety of periprocedural intravenous administration of cangrelor or tirofiban in a contemporary ST-segment elevation myocardial infarction (STEMI) population undergoing PPCI. This was a multicenter prospective cohort study including consecutive STEMI patients who received cangrelor or tirofiban during PPCI at seven Italian centers. The primary effectiveness measure was the angiographic evidence of thrombolysis in myocardial infarction (TIMI) flow < 3 after PPCI. The primary safety outcome was the in-hospital occurrence of BARC (Bleeding Academic Research Consortium) 2-5 bleedings. The study included 627 patients (median age 63years, 79% males): 312 received cangrelor, 315 tirofiban. The percentage of history of bleeding, pulmonary edema and cardiogenic shock at admission was comparable between groups. Patients receiving cangrelor had lower ischemia time compared to tirofiban. TIMI flow before PPCI and TIMI thrombus grade were comparable between groups. At propensity score-weighted regression analysis, the risk of TIMI flow < 3 was significantly lower in patients treated with cangrelor compared to tirofiban (adjusted OR: 0.40; 95% CI: 0.30-0.53). The risk of BARC 2-5 bleeding was comparable between groups (adjusted OR:1.35; 95% CI: 0.92-1.98). These results were consistent across multiple prespecified subgroups, including subjects stratified for different total ischemia time, with no statistical interaction. In this real-world multicenter STEMI population, the use of cangrelor was associated with improved myocardial perfusion assessed by coronary angiography after PPCI without increasing clinically-relevant bleedings compared to tirofiban.

Non-O Blood Group is Associated with High Thrombus Burden and Poor short- and long-term Prognosis in STEMI Patients.

This study investigates how non-O blood groups relate to thrombus burden (TB) and prognosis in STEMI patients, aiming to shed light on their association with thrombotic complications in cardiovascular diseases. Retrospectively, 1180 STEMI patients undergoing primary percutaneous coronary intervention were included. The study population was divided into groups according to TB status and the groups were compared in terms of basic clinical characteristics, laboratory parameters and ABO blood group types. In addition, short- (30 days) and long-term (12 months) clinical outcomes were assessed to evaluate the prognostic implications. The analysis revealed a significant association between non-O blood groups and increased thrombus burden in STEMI patients (p = 0.001). Non-O blood group was independently associated with high thrombus burden (OR: 1.726, 95% CI: 1.279-2.330, p < 0.001). Additionally, patients with non-O blood groups had higher short and long-term mortality rates (HR: 2.480, 95% CI: 1.361-4.520, p = 0.003; HR: 2.347, 95% CI: 1.433-3.844, p = 0.001; respectively). This study emphasizes the significance of the ABO blood group system in STEMI outcomes, associating non-O blood groups with higher thrombus burden and poorer clinical outcomes. While proposing personalized treatment strategies based on blood group status to improve reperfusion interventions and outcomes, additional trials are needed to comprehensively evaluate their impact.

Safety and adverse events during primary care paramedic interfacility transfer of stable STEMI patients

ABSTRACT Objective Current guidelines recommend that patients presenting with ST-elevation myocardial infarction (STEMI) to hospitals not capable of performing primary percutaneous coronary intervention (PCI) be transferred to a PCI-capable hospital if reperfusion can be accomplished within 120 minutes. Most STEMI patients are accompanied by an advanced care paramedic (ACP, equivalent to EMT-P), nurse, or physician who can manage complications should they arise. In our region, stable STEMI patients are transported by primary care paramedics (PCPs, similar scope of practice to advanced EMT) in cases where a nurse, physician, or ACP paramedic is not available. Our goal was to describe adverse events and need for advanced interventions among initially stable STEMI patients during interfacility transfer by PCPs. Methods We reviewed ambulance and hospital records of initially stable STEMI patients (as determined by first set of vital signs documented by paramedics) transferred to a PCI-capable hospital by PCPs between March 1, 2014, and December 31, 2019. We identified whether pre-determined adverse clinical events occurred during the transport as well as the potential need for advanced care interventions not within the PCP scope of practice. Adverse events upon arrival in the PCI lab were also identified. Results Of 346 STEMI patients transferred, 179 met inclusion criteria. The mean age of included patients was 61 years (SD 12.1) and 74.9% (134/179) were male. Median transport interval was 36 minutes (IQR 3.0). During transport, 47/179 (26.0%) patients experienced pre-defined adverse events; for 16/47 (34%), one or more adverse events was major. Three patients met criteria for ACP interventions. One patient suffered a cardiac arrest and was promptly resuscitated with defibrillation by the PCPs. Conclusions We found PCP-interfacility transport of initially stable STEMI patients was safe and associated with a moderate proportion of adverse events, the majority of which did not require an advanced care intervention. These findings may help decision-making to avoid delays transferring stable patients to PCI-capable centers.

FFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction.

The benefit of fractional flow reserve (FFR)-guided complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease remains unclear. In this multinational, registry-based, randomized trial, we assigned patients with STEMI or very-high-risk non-STEMI (NSTEMI) and multivessel disease who were undergoing primary percutaneous coronary intervention (PCI) of the culprit lesion to receive either FFR-guided complete revascularization of nonculprit lesions or no further revascularization. The primary outcome was a composite of death from any cause, myocardial infarction, or unplanned revascularization. The two key secondary outcomes were a composite of death from any cause or myocardial infarction and unplanned revascularization. A total of 1542 patients underwent randomization, with 764 assigned to receive FFR-guided complete revascularization and 778 assigned to receive culprit-lesion-only PCI. At a median follow-up of 4.8 years (interquartile range, 4.3 to 5.2), a primary-outcome event had occurred in 145 patients (19.0%) in the complete-revascularization group and in 159 patients (20.4%) in the culprit-lesion-only group (hazard ratio, 0.93; 95% confidence interval [CI], 0.74 to 1.17; P = 0.53). With respect to the secondary outcomes, no apparent between-group differences were observed in the composite of death from any cause or myocardial infarction (hazard ratio, 1.12; 95% CI, 0.87 to 1.44) or unplanned revascularization (hazard ratio, 0.76; 95% CI, 0.56 to 1.04). There were no apparent between-group differences in safety outcomes. Among patients with STEMI or very-high-risk NSTEMI and multivessel coronary artery disease, FFR-guided complete revascularization was not shown to result in a lower risk of a composite of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only PCI at 4.8 years. (Funded by the Swedish Research Council and others; FULL REVASC ClinicalTrials.gov number, NCT02862119.).

Factors Contributing to Delayed Presentation In ST-Elevation Myocardial Infarction and Implication for In-Patient Outcomes

Introduction: ST-elevation myocardial infarction (STEMI) is a significant cause of mortality and morbidity among patients with ischemic heart disease. Early intervention, such as primary percutaneous coronary intervention (PPCI) or thrombolysis has been shown to improve patient outcomes. However, delayed presentation in STEMI results in larger infarct size and increased complications.Objectives: This retrospective descriptive study aimed to identify factors contributing to delayed presentation in STEMI and in-patient outcomes.Methodology: A retrospective descriptive study was conducted. All the STEMI patients who underwent primary percutaneous coronary intervention at National Hospital Kandy from February 2019 to December 2019 were studied.Results: A total of 243 STEMI patients who underwent PPCI at the National Hospital Kandy from February 2019 to December 2019 were studied. Among the study population, 31.27% were delayed presenters and 68.72% were non–delayed presenters. Atypical chest pain was identified as the main reason for a delayed presentation. Female gender was not associated with delayed presentation, contrary to the findings in other studies. Diabetes mellitus and the location of the culprit lesion did not significantly contribute to delayed presentation in this study group. Complications during hospital stay and average duration of hospital stay were not significantly different between delayed and non-delayed presenters. However, delayed presenters exhibited lower left ventricular ejection fraction on discharge, which is a critical predictor of short and long-term outcomes.Conclusions: Community awareness programs are essential to minimize pre-hospital delays in STEMI presentation. Early recognition of atypical symptoms, irrespective of gender, and timely intervention are vital for improving outcomes in STEMI patients. Further research is warranted to explore the impact of other risk factors and co-morbidities on the duration of presentation in STEMI patients.

Microvascular Obstruction in Patients With Anterior STEMI Treated With Supersaturated Oxygen

BackgroundSupersaturated oxygen (SSO2) delivered into the left anterior descending coronary artery after percutaneous coronary intervention (PCI) for anterior ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size, but its effects on microvascular obstruction (MVO) are unknown. The aim of this study was to compare MVO in patients with anterior STEMI treated with SSO2 after successful primary PCI from 2 studies (the optimized SSO2 pilot and IC-HOT) with similar patients from 7 randomized trials who underwent primary PCI without SSO2 treatment. MethodsA total of 874 patients with anterior STEMI who underwent MVO assessment using cardiac magnetic resonance imaging within 10 days after primary PCI were included, of whom 90 patients (10.3%) were treated with SSO2. The primary end point was the extent of MVO as a continuous measure in a weighted multivariable model. The secondary end point was the presence of MVO. ResultsSSO2 therapy was independently associated with a lower extent of MVO compared with no SSO2 therapy (coefficient, −1.35; 95% CI, −2.58 to −0.11; P = .03). SSO2 therapy was also associated with a borderline lower risk of any MVO (adjusted odds ratio, 0.56; 95% CI, 0.31-1.00; P = .051). ConclusionsIn the present individual patient data pooled analysis from 9 studies, SSO2 therapy was associated with less MVO after successful primary PCI for anterior STEMI.

TCTAP A-007 Diagnostic Accuracy of Platelet to Lymphocyte Ratio for Predicting No Slow Reflow After Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

TCTAP A-007 Diagnostic Accuracy of Platelet to Lymphocyte Ratio for Predicting No Slow Reflow After Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

TCTAP A-016 1 Year Clinical Outcomes of Patients Treated With DynamX Bioadaptor Drug Eluting Stent in Primary Percutaneous Coronary Intervention

TCTAP A-016 1 Year Clinical Outcomes of Patients Treated With DynamX Bioadaptor Drug Eluting Stent in Primary Percutaneous Coronary Intervention

Association between the insufficient improvement of the quantitative flow ratio and worsening outcomes in ST-segment elevated myocardial infarction: a multicentre prospective cohort study.

Improved coronary physiological function after percutaneous coronary intervention (PCI) has been shown to improve prognosis in stable ischaemic heart disease, but has not yet been explored in ST-segment elevated myocardial infarction (STEMI). The study sought to determine whether an improvement in the quantitative flow ratio (QFR) could improve the prognosis of STEMI patients undergoing primary PCI. Patients diagnosed with STEMI who were receiving primary PCI were recruited for the study. Those with thrombolysis in myocardial infarction (TIMI) flow <2 after wiring were excluded. The ΔQFR was calculated using the following formula: ΔQFR = post-PCI QFR - pre-stent QFR. The primary endpoint was the composite event, including recurrent myocardial infarction (MI) and acute heart failure (AHF). In total, 515 STEMI patients with a median follow-up of 364 days were enrolled in the study. Based on the cut-off value from the receiver operator characteristic (ROC) curve, the patients were divided into the following two groups: the lower ΔQFR group (≤0.25, N=332); and the normal ΔQFR group (>0.25, N=183). Patients with a lower ΔQFR had a relatively higher rate of MI/AHF (10.5% vs. 4.4%, P=0.019) and AHF (7.2% vs. 2.7%, P=0.044). A lower ΔQFR was significantly associated with a higher incidence of MI/AHF [hazard ratio (HR) =2.962, 95% confidence interval (CI): 1.358-6.459, P=0.006, respectively] after adjusting for potential confounders. Pre-stent angiographic microvascular resistance [odds ratio (OR) =1.027, 95% CI: 1.022-1.033, P<0.001] and the stent-to-vessel diameter ratio <1.13 (OR =1.766, 95% CI: 1.027-3.071, P=0.04) were independent predictors of a lower ΔQFR. An insufficient improvement in the QFR contributes to worsening outcomes and might be a useful tool for risk stratification in STEMI.

Prehospital crushed versus integral prasugrel loading dose in STEMI patients with a large myocardial area.

The effect of administering a crushed prasugrel loading dose is uncertain in patients presenting with a large myocardial infarction and ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate if patients with a large myocardial infarction may benefit from prehospital administration of a crushed prasugrel loading dose. Patients from the CompareCrush trial with an available ambulance electrocardiography (ECG) were included in the study. An independent core laboratory confirmed a prehospital large myocardial area. We compared pre- and postprocedural angiographic markers, including Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the infarct-related artery, high thrombus burden, and myocardial blush grade 3, in STEMI patients with and without a prehospital large myocardial area. Ambulance ECG was available for 532 patients, of whom 331 patients were identified with a prehospital large myocardial area at risk. Crushed prasugrel significantly improved postprocedural TIMI 3 flow rates in STEMI patients with a prehospital large myocardial area at risk (92% vs 79%, odds ratio [OR] 3.00, 95% confidence interval [CI]: 1.50-6.00) but not in STEMI patients without a prehospital large myocardial area at risk (91% vs 95%, OR 0.47, 95% CI: 0.14-1.57; pinteraction=0.009). Administration of crushed prasugrel may improve postprocedural TIMI 3 flow in STEMI patients with signs of a large myocardial area at risk on the ambulance ECG. The practice of crushing tablets of prasugrel loading dose might, therefore, represent a safe, fast and cost-effective strategy to improve myocardial reperfusion in this high-risk STEMI subgroup undergoing primary percutaneous coronary intervention.

BRIDGING THE GAP: ADDRESSING DISPARITIES IN REPERFUSION THERAPY FOR ELDERLY PATIENTS WITH ACUTE MYOCARDIAL INFARCTION IN EASTERN EUROPE

This paper addresses disparities in reperfusion therapy, particularly primary percutaneous coronary interventions (PCI), for elderly patients experiencing acute myocardial infarction (AMI). Despite proven benefits, our center’s data reveals a stark contrast in PCI rates between younger and older patients, leading to significantly higher mortality among the elderly. Rooted in concerns about comorbidities, the reluctance to administer PCI prompts ethical questions and necessitates a critical examination of age-based clinical decision-making. The paper advocates for optimized AMI management protocols, emphasizing an individualized approach and evidence-based guidelines. Recognizing challenges in accurate AMI diagnosis in the elderly, educational initiatives target healthcare professionals and the population, disseminating information about symptoms and treatment benefits. To combat age-related stereotypes, digital tools like virtual consultations and telemedicine enhance accessibility to information. The paper proposes policy initiatives prioritizing clinical condition over age in treatment decisions, ensuring equitable care. In conclusion, urgent action is required to bridge the gap in reperfusion therapy for elderly AMI patients. By fostering inclusivity, implementing education, and advocating policy changes, we aim to ensure every patient, irrespective of age, receives timely and appropriate life-saving interventions.

Avaliable data for adverce cardiac events prognostication after ST segment elevation myocardial infarction

The treatment of acute myocardial infarction (AMI) is aimed at the long‑term survival of patients, so attention should be given to predicting adverse outcomes, specifically the development of heart failure, recurrent AMI, cardiovascular death, and so on. The combination of various data obtained in recent decades has helped improve prognosis, but challenges with long‑term survival after ST segment elevation myocardial infarction (STEMI) still exist.&#x0D; Objective — to find the optimal combination of data collected from patients with STEMI and prospectively analyzed during one‑year observation to improve the quality of prognostication.&#x0D; Materials and methods. One hundred and twenty‑eight enrolled patients visited research center to clinical examination and estimation of left ventricular (LV) function in 365±14 days follow up period after STEMI. End points such as major adverce cardiac events (MACE) — composite of cardiovascular death, recurrent MI, newly diagnosed heart failure, rhythm, and conduction disturbances were estimated. Primary percutaneous coronary intervention was successful, and all included patients had TIMI (Thrombolysis In Myocardial Infarction) &gt;2. Patients was divided into two cohorts depending on the presence of MACE: global longitudinal strain and mechanical dispersion are independent factors of it (p=0.0006 and p &lt;0.0001respectively).&#x0D; Results. We found the optimal combination of different data for prognostication of adverce outcome after 1 year after STEMI, among them occurred global longitudinal strain, left atrium volume index, left ventricular end diastolic diameter, mechanical dispersion, LV ejection fraction. They all reflect different hemodynamic sides of LV remodeling after STEMI.&#x0D; Conclusions. The model is simple and avaliable for use in medical practice.&#x0D;  

High Dose Statin as Upstream Therapy and the Frequency of Slow-Flow Phenomenon in Patients Undergoing Primary PCI or Immediate Invasive Therapy

High Dose Statin as Upstream Therapy and the Frequency of Slow-Flow Phenomenon in Patients Undergoing Primary PCI or Immediate Invasive Therapy

Development and validation of a prognostic model for predicting post-discharge mortality risk in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI)

BackgroundAccurately predicting post-discharge mortality risk in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) remains a complex and critical challenge. The primary objective of this study was to develop and validate a robust risk prediction model to assess the 12-month and 24-month mortality risk in STEMI patients after hospital discharge.MethodsA retrospective study was conducted on 664 STEMI patients who underwent PPCI at Xiangtan Central Hospital Chest Pain Center between 2020 and 2022. The dataset was randomly divided into a training cohort (n = 464) and a validation cohort (n = 200) using a 7:3 ratio. The primary outcome was all-cause mortality following hospital discharge. The least absolute shrinkage and selection operator (LASSO) regression model was employed to identify the optimal predictive variables. Based on these variables, a regression model was constructed to determine the significant predictors of mortality. The performance of the model was evaluated using receiver operating characteristic (ROC) curve analysis and decision curve analysis (DCA).ResultsThe prognostic model was developed based on the LASSO regression results and further validated using the independent validation cohort. LASSO regression identified five important predictors: age, Killip classification, B-type natriuretic peptide precursor (NTpro-BNP), left ventricular ejection fraction (LVEF), and the usage of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (ACEI/ARB/ARNI). The Harrell's concordance index (C-index) for the training and validation cohorts were 0.863 (95% CI: 0.792–0.934) and 0.888 (95% CI: 0.821–0.955), respectively. The area under the curve (AUC) for the training cohort at 12 months and 24 months was 0.785 (95% CI: 0.771–0.948) and 0.812 (95% CI: 0.772–0.940), respectively, while the corresponding values for the validation cohort were 0.864 (95% CI: 0.604–0.965) and 0.845 (95% CI: 0.705–0.951). These results confirm the stability and predictive accuracy of our model, demonstrating its reliable discriminative ability for post-discharge all-cause mortality risk. DCA analysis exhibited favorable net benefit of the nomogram.ConclusionThe developed nomogram shows potential as a tool for predicting post-discharge mortality in STEMI patients undergoing PPCI. However, its full utility awaits confirmation through broader external and temporal validation.

Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction

Rapid reperfusion during primary percutaneous coronary intervention (PCI) is associated with improved outcomes among patients with ST-elevation myocardial infarction (STEMI). Although attempts at reducing the time from STEMI diagnosis to arrival at the catheterization laboratory have been widely investigated, intraprocedural strategies aimed at reducing the time to reperfusion are lacking. To evaluate the effect of culprit lesion PCI before complete diagnostic coronary angiography (CAG) vs complete CAG followed by culprit lesion PCI on reperfusion times among patients with STEMI. This open-label, prospective, randomized clinical trial was conducted between April 1, 2021, and August 31, 2022, among patients admitted to a tertiary center in Jerusalem, Israel, with a diagnosis of STEMI undergoing primary PCI. All patients were followed up for 1 year. Analysis was on an intention-to-treat basis. Patients were randomized in a 1:1 ratio to undergo either culprit lesion PCI before complete CAG or complete CAG followed by culprit lesion PCI. A needle-to-balloon time of 10 minutes or less. A total of 216 patients were randomized, with 184 patients (mean [SD] age, 62.9 [12.2] years; 155 men [84.2%]) included in the final intention-to-treat analysis; 90 patients (48.9%) were randomized to undergo culprit lesion PCI before CAG, and 94 (51.1%) were randomized to undergo to CAG followed by PCI. Patients who underwent culprit lesion PCI before complete CAG had a shorter mean (SD) needle-to-balloon time (11.4 [5.9] vs 17.3 [13.3] minutes; P < .001). The primary outcome of a needle-to-balloon time of 10 minutes or less was achieved for 51.1% of patients (46 of 90) who underwent culprit lesion PCI before CAG and for 19.1% of patients (18 of 94) who underwent complete CAG followed by culprit lesion PCI (odds ratio, 4.4 [95% CI, 2.2-9.1]; P < .001). Rates of adverse events were similar between groups. In a subgroup analysis, the effect of culprit lesion PCI before complete CAG on the primary outcome was consistent. There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality. In this randomized clinical trial of patients with STEMI, culprit lesion PCI before complete CAG resulted in shorter reperfusion times. Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes. ClinicalTrials.gov Identifier: NCT05415085.

1-Year Mortality Prediction through Artificial Intelligence Using Hemodynamic Trace Analysis among Patients with ST Elevation Myocardial Infarction

Background and Objectives: Patients presenting with ST Elevation Myocardial Infarction (STEMI) due to occlusive coronary arteries remain at a higher risk of excess morbidity and mortality despite being treated with primary percutaneous coronary intervention (PPCI). Identifying high-risk patients is prudent so that close monitoring and timely interventions can improve outcomes. Materials and Methods: A cohort of 605 STEMI patients [64.2 ± 13.2 years, 432 (71.41%) males] treated with PPCI were recruited. Their arterial pressure (AP) wave recorded throughout the PPCI procedure was analyzed to extract features to predict 1-year mortality. After denoising and extracting features, we developed two distinct feature selection strategies. The first strategy uses linear discriminant analysis (LDA), and the second employs principal component analysis (PCA), with each method selecting the top five features. Then, three machine learning algorithms were employed: LDA, K-nearest neighbor (KNN), and support vector machine (SVM). Results: The performance of these algorithms, measured by the area under the curve (AUC), ranged from 0.73 to 0.77, with accuracy, specificity, and sensitivity ranging between 68% and 73%. Moreover, we extended the analysis by incorporating demographics, risk factors, and catheterization information. This significantly improved the overall accuracy and specificity to more than 76% while maintaining the same level of sensitivity. This resulted in an AUC greater than 0.80 for most models. Conclusions: Machine learning algorithms analyzing hemodynamic traces in STEMI patients identify high-risk patients at risk of mortality.