Primary Percutaneous Coronary Intervention Research Articles

Fractalkine Inhibition in Acute Myocardial Infarction leads to reduced intramyocardial haemorrhage

Abstract Background The fractalkine receptor CX3CR1 has been linked to the development of microvascular obstruction (MVO) in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). Pre-clinical studies have demonstrated a reduction in infarct size, inflammation and intramyocardial haemorrhage (IMH) with inhibition of CX3CR1. Purpose The FRACTAL study is a phase IIa, pilot, randomized, 2-arm parallel group, placebo-controlled, double blinded, multi-centre trial. In addition to assessing the safety and tolerability of the fractalkine inhibitor KAND567 in STEMI patients, a subgroup exploratory analysis was performed. We investigated into the translation of MRI and blood samples characteristics between the two groups. Methods Patients with an anterior STEMI who had an occluded proximal to mid left anterior descending (LAD) artery were recruited. These patients had to present within 5 hours of the onset of their chest pain. They were subsequently randomised on a 1:1 basis to receive either KAND567 or placebo. Patients then underwent an MRI at day 3, and subsequently a comparator at 3 months. Additionally, throughout the period of their follow-up, patients would regularly undergo blood sampling to assess multiple parameters. Results Of the 71 patients recruited into the study, 29 patients in the KAND567 arm and 28 patients in the placebo arm received both MRIs. The KAND567 arm had shown a similar troponin rise at day 1 compared to placebo (4357 vs 4286). Baseline MRI demonstrated an identical infarct size between both arms. The presence and absence of IMH was then analysed defining IMH+ as presence of IMH and IMH- as IMH absence. The presence of IMH in patients showed a larger infarct size. The infarct size of IMH+ were the same between KAND567 and placebo, which was a similar finding in the IMH- arm too. However, when compared to day 90 MRI demonstrated a numerically smaller infarct size in the KAND567 group with a smaller percentage of IMH. This was consistent with a lower rate of IMH in the KAND567 arm too, when compared between the groups (35.5% vs 55.2%; p=0.15) (see table below). This seemed to be related to the smaller distribution IMH+, as the IMH+ infarcts were much larger in both arms, whilst overall infarct size in IMH subgroup were identical. Conclusion KAND567 appears to prevent the transition from IMH- to IMH+, while it doesn’t change infarct size in the respective subgroups of IMH+ or IMH-.MRI Comparator Table

Prognostic value of combined myocardial performance index in patients with acute ST-elevation myocardial infarction

Abstract Background Myocardial performance index (MPI) also known as Tei index is a unique echocardiographic parameter which can estimate both systolic and diastolic performances of left and right ventricles. We previously suggested the echocardiographic parameter combined MPI (CMPI) as a new predictor of the prognosis of acute ST-elevation myocardial infarction (STEMI). The CMPI is the sum of left ventricular (LV) MPI and right ventricular (RV) MPI (CMPI = LV MPI + RV MPI). We supposed that CMPI might be a better predictor in STEMI, because it reflects both ventricular systolic and diastolic functions. Objectives The purpose of this study is to assess the prognostic value of a new echocardiographic parameter CMPI in STEMI patients calculated in acute phase. Methods 240 STEMI patients who underwent primary PCI have been included in the study. Echocardiography (EchoCG) was performed, and LV MPI and RV MPI were assessed within 24 hours after the symptom onset, prior to primary PCI. The MPI was calculated as the sum of isovolumic contraction time (ICT) and isovolumic relaxation time (IRT), divided by the ejection time (ET): MPI = (ICT + IRP) / ET. 50 % of the patients had anterior STEMI. 30 patients (12.5%) had concomitant RV myocardial infarction (MI). Patients were divided into two groups: Group 1 – CMPI > 0.9 (110 patients), Group 2 – CMPI ≤ 0.9 (130 patients). Baseline demographic and clinical characteristics were similar in both groups. Also, there were no differences in LV MI localization and concomitant RV MI between the groups. Primary endpoints were in-hospital and the one-year cardiovascular mortality rates. The secondary endpoint was the one-year heart failure hospitalization rate. Results In Group 1 the in-hospital mortality rate was 9.1%, and 3.1% in Group 2 (p = 0.0489). One-year cardiovascular mortality rate was 12.7% in and 5.4%, respectively (p = 0.0465). One-year heart failure hospitalization was also significantly lower in Group 2 (22.7% vs. 12.3%, p = 0.0332). Conclusion CMPI can be offered as a new predictor for the in-hospital and one-year cardiovascular mortality and one-year heart failure hospitalization rate in patients with acute STEMI.

Telemedicine through social media to enhance guideline-directed revascularization in STEMI: a five-year analysis in a developing nation

Abstract Background Timely reperfusion reduces mortality in ST segment Elevation Myocardial infarction (STEMI). Telemedicine and social media have been variably used to improve STEMI care in community settings. We established a new care system for STEMI in a public health setting serving a population of over 80 million, in a state with from a developing nation. Purpose To enhance guideline directed revascularisation (GDR) in STEMI by networking non-percutaneous coronary intervention (PCI) capable hospitals to PCI capable hospitals in a hub-and-spoke model and implementing telemedicine via social media platforms (Whatsapp) over five years(2019-2023). Methods Eighteen Government medical college hospitals were identified as hubs and were provided with cardiac catheterisation laboratories and empowered to provide either round the clock (Phase I hubs) or office hour primary PCI (Phase II hubs). They were linked to 188 Taluk or District-level, non-PCI capable Government hospitals identified as spokes to form 18 STEMI clusters. Separate social media groups on WhatsApp were created for each of the clusters, facilitating the sharing of de-identified ECGs and clinical data from spokes for guidance on diagnosis and management by hub hospital cardiologists. Transfer to hub hospitals for catheter based therapies were coordinated through prior intimation in the cluster WhatsApp group to ensure timely arrival and treatment. A customised uniform protocol for STEMI management was developed and health care personnel were trained accordingly. Human resource support was provided to collect and submit cumulative daily data on the number of STEMIs, the revascularisation provided and mortality through online free web forms. Annual cumulative data on STEMI volumes and GDR were analysed. Results 71,907 STEMI patients were treated from 2019 to 2023. We observed a 67% increase in STEMIs treated per year from over five years (11,363 in 2019 to 18565 in 2023). Use of pharmaco-invasive therapy increased from 7.9% to 31.7% (Figure-1). There was a marginal increase in use of primary PCI. The count of patients without GDR decreased by 20%. There was a 6.7 fold (672 in 2019 to 4,535 in 2023) rise in patients referred from spoke to hub hospitals for catheter-based revascularization. Over five years, there was an increase in the proportion of patients receiving GDR. This increase was more evident in Phase II hubs (52% in 2019 to 87.1% in 2023). Commensurate with the increase in GDR, phase II hubs demonstrated a tangible decrease in mortality (Figure-2). Conclusion We have shown that networking of non-PCI-capable hospitals with PCI-capable hospitals in a hub and spoke model using social media groups, facilitates telemedicine, leading to improved GDR in STEMI. This innovative approach not only enhances connectivity but also contributes to more efficient and timely cardiac care in resource-constrained settings.Figure 1. Revascularisation in STEMIFigure 2.Mortality Trends in STEMI (hubs)

Prospective assessment of risk factors for appropriate ICD intervention in patients with ischemic cardiomyopathy: results of PARCADIA trial

Abstract Background There is still a big unmet need for better risk stratification tools to identify patients at high risk for sudden cardiac death in the era of primary prevention ICD therapy. Scar burden on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging may be a risk marker for the prediction of ventricular arrhythmia in post-myocardial infarction (MI) patients. Purpose The aim of the PARCADIA trial was to assess whether scar characteristics, determined via LGE-CMR, or other baseline risk markers are associated with appropriate ICD therapy. Methods In this prospective, multi-center, clinical trial, we enrolled post-MI patients with an indication for de novo primary prevention ICD. Main exclusion criteria were indication for cardiac resynchronization therapy and NYHA class IV. Prior to the ICD implantation, LGE-CMR was performed to analyze the amount of scar tissue (LGE core mass + grey zone mass) and LV function / volumes. A 24h Holter recording was performed to collect information on potential triggers like premature ventricular beats (PVB) and sympathetic-vagal balance based on heart rate variability (HRV). Follow-ups were performed in-office every 6 months, including remote monitoring. Appropriate ICD therapy was used as primary endpoint and adjudicated by a clinical event committee. Results 199 patients were enrolled at 5 investigational sites in Europe. Patients mean age was 64.3 years, with a mean LVEF of 27.7 %, timing from the index MI was 9.1 years, and 42.7% received a primary PCI on index MI. After a median follow-up duration of 47.7 months, 23.1% of patients received appropriate ICD therapy. In 135 patients (67.8%), quality of LGE-CMR was sufficient for detailed analysis. The mean LGE core mass (20.5 vs. 19,7 g) and grey zone mass (10.5 vs. 11.4 g) was not different in patients with or without appropriate ICD therapy, also not when corrected for LV mass. However, LVEF (28.5 vs. 32.9 %) was lower, while diastolic myocardial mass (141 vs. 125 g), and end-diastolic volume (265.0 vs. 226.7 ml) were significantly higher in patients with appropriate ICD therapy. On 24h Holter the mean PVB burden (3695 vs. 1643 beats), and non-sustained ventricular tachycardia (12 vs. 0.9), were higher in patients with appropriate ICD therapy, while the HRV (96.1 vs. 113.1 SDNN) was lower. In univariate analysis the variables LVEF, timing to index MI, primary PCI on index MI, PVB burden and HRV appeared to be predictors for appropriate ICD intervention, while in multivariate analysis LVEF and PVB burden remained predictive. Conclusion In post-MI patients with appropriate ICD therapy, scar burden was not different from patients without appropriate ICD therapy. Only LVEF and PVB burden were independent predictors of increased arrhythmogenicity. Improved CMR analysis on scar characteristics (conduction channels) to identify potential arrhythmogenic regions might be the topic for future research.

Combined 3D left ventricular-arterial coupling and 3D left atrial-ventricular coupling indices could better predict MACE in young patients with STEMI

Abstract Background Left ventricular arterial coupling index (VAC) proved to be a key determinant of cardiovascular performance. Previous trials also emphasized the prognostic value of left atrial-ventricular coupling index (LACI) that was independently associated with cardiovascular death and all-cause mortality. Both indices have been associated with disease severity and adverse outcomes. Purpose We aimed to evaluate the prognostic role of 3D VAC, 3D LACI and their combination assessed by 3D echocardiography in a cohort of young patients with STEMI. Patients and methods In this prospective study we enrolled 76 young consecutive patients (under 50 years old) with STEMI treated by primary PCI who underwent both 2D and 3D echocardiography. 3D VAC was calculated as the ratio between arterial elastance (EA) and end-systolic left ventricular elastance (EES), based on a formula proposed by Chen. 3D LACI was determined as the ratio between 3D left atrial end-diastolic volume (minimal atrial volume) and 3D left ventricular end-diastolic volume. Patients were followed up for one year after STEMI and the primary endpoint was the occurrence of MACE defined as death from cardiovascular causes, heart failure requiring hospital admission, or repeat revascularisation. Results Out of 76 patients, 15.8% had an adverse event during the 12 months follow up period. We divided the patients in two groups according to the presence or absence of MACE. Patients with MACE had higher VAC (2.15±0.62 vs. 1.25±0.29%, p<0.0001) and higher LACI (25.1±7.17% vs. 18.3±6.58%, p=0.002). In ROC analysis VAC and LACI combined had the best AUC for MACE prediction (AUC 0.961, p<0.0001), followed by VAC (AUC 0.922, P<0.0001), and then, LACI (AUC 0.772, P<0.001). For each variable we determined a cut off value. A value over 1.7 for VAC and 23.83% for LACI can predict unfavourable outcome with 83.3% sensitivity and 97.1% specificity for VAC and 67% sensitivity and 80% specificity for LACI. In both univariate and multivariate COX regression analysis, both VAC and LACI remained independent predictors for MACE. Moreover, their combination proved to have better predictive value for adverse events compared to each taken separately. We divided the study population into 4 groups: Group 1: VAC < 1.7 and LACI < 23.83%. Group 2: VAC <1.7 and LACI > 23.83%. Group 3: VAC > 1.7 and LACI < 23.83% and Group 4: VAC > 1.7 and LACI >0.23.83%. Kaplan Meier analysis shows significant differences among groups (log rank χ2 = 35.48, p < 0.0001). Calculation of Kaplan-Meier curves for the four groups indicated that the combination of the VAC > 1.7 and LACI > 23.83% had the strongest predictive power for MACE. Conclusion In conclusion 3D VAC and 3D LACI combined are better at predicting adverse events than each variable taken separately and could be used for a more accurate risk stratification in young patients with STEMI.

Influence of acute kidney injury and chronic kidney disease on 3-year clinical outcomes in patients with AMI treated by contemporary PCI and optimal medical therapy; insights from J-MINUET study

Abstract Background The influence of acute kidney injury (AKI) and chronic kidney disease (CKD) on long-term outcomes following AMI in the era of modern primary PCI with optimal-medical-therapy (OMT) is still in debate. Methods A total of 3,281 patients with acute myocardial infarction (AMI) were enrolled in the J-MINUET registry with primary PCI of 93.1% in STEMI Consecutive patients hospitalized within 48 h of onset of AMI at 28 Japanese medical institutions were enrolled in the J-MINUET study (UMIN000010037). AKI was defined as an increase in serum-creatinine ≥0.3mg/dL or ≥50% within-48h during-hospitalization. CKD was defined as estimated glomerular filtration-rate [eGFR]<60mL/min/1.73m2. Major adverse cardiac event (MACE) was defined as a composite of all-cause death, cardiac-failure, MI and stroke. Patients were divided into 4 groups based on the presence or absence of CKD and the occurrence or non-occurrence of AKI. The parameters were assessed by the Cox proportional hazards model. Differences were considered statistically significant at P<0.05. Results Of the 3,281 patients with AMI, 3220 patients had complete data set. The average age was 69±13 years old and 75.3% of the patients were male. Of the 3220 patients, 1375 patients had CKD (42.7%) and AKI occurred in 365 patients (11.3%) during the initial hospital stay. AKI more frequently occurred in 305 CKD patients (22.2%) than 60 non-CKD patients (3.3%) (p<0.0001). A total of 898 MACE occurred (27.4%) during follow-up period (median of 768days). Kaplan-Meier curves illustrated event-free survival for MACE over 3 years stratified by the 4 groups (Figure). Conclusions While both CKD without AKI and non-CKD with AKI showed similar effect on the incidence of MACE, the worst clinical outcome was observed in patients having AKI on pre-existed CKD.

Angiotensin-II receptor type 1 and endothelin-1 receptor type A agonistic autoantibodies in patients with STEMI: new kids on the block

Abstract Background The Prognosis after ST-elevation myocardial infarction (STEMI) remains poor. Angiotensin-II and endothelin-1 contribute to adverse prognosis after STEMI through molecular mechanisms that lead to myocardial inflammation, fibrosis and, ultimately, adverse myocardial remodeling. Functional autoantibodies against angiotensin II type 1 (AT1R-AAs) and endothelin-1 type A (ETAR-AAs) receptors bind to the same receptors as natural ligands, eliciting similar (and amplified) responses. In patients with STEMI, AT1R-AAs and ETAR-AAs have been associated with a higher risk of developing microvascular obstruction and left ventricular remodeling. Both microvascular obstruction and left ventricular remodeling are associated with a poor prognosis. Purpose To assess the prognostic role of AT1R-AAs and ETAR-AAs after STEMI. Methods Consecutive STEMI patients who underwent primary percutaneous coronary intervention within 12 h after pain onset were enrolled in this prospective study. The levels of AT1R-AAs and ETAR ETAR-AAs at the time of hospital admission were measured using an enzyme-linked immunosorbent assay (ELISA) in all patients. The incidence of major adverse cardiovascular events (MACE, defined as a composite of cardiovascular mortality, myocardial re-infarction, and hospitalizations for heart failure) during follow-up was the primary outcome. Autoantibody seropositivity was defined according to ELISA’s kit manufacturer’s instructions (levels > 10 U/mL). Results Two hundred patients with STEMI were enrolled. The baseline characteristics of the patients are shown in Table 1. Of these, 110 (55%) were seronegative for both autoantibodies, 44 (22%) were seropositive for one autoantibody (but not both), and 46 (23%) were seropositive for both autoantibodies. The incidence of MACE over a 14-month median follow-up was higher in patients with double (31%) and single (25%) seropositivity than in seronegative patients (13%, p=0.009 and p=0.06, respectively). Survival free from MACE was significantly different across the different degrees of autoantibody seropositivity (Figure 1). In the multivariable Cox regression analysis, adjusted for the variables that were significant in the univariate analysis (highlighted in bold in Table 1), double seropositivity was independently associated with an increased risk of MACE (hazard ratio 2.386, 95 % CI 1.471-3.864, p<0.001). Conclusions The degree of seropositivity for AT1R-AAs and ETAR-AAs is associated with an increased risk of MACE after STEMI. Our findings provide valuable mechanistic insights into the pathophysiology of STEMI and pave the way for future therapies focused on the improvement of long-term prognosis after acute coronary syndromes.

The activation of cardiac sympathetic nervous system in the non-culprit lesion is a strong prognostic predictor in patients with acute myocardial infarction

Abstract Background The activation of cardiac sympathetic nervous system is associated with poor prognosis in patients with acute myocardial infarction (AMI). However, it remains to be determined whether regional assessment of cardiac sympathetic nerve activity (CSNA) in the culprit and non-culprit lesion of the cardiac MIBG SPECT imaging could have prognostic value in patients with AMI. Purpose The purpose of this study is to investigate the prognostic impact of regional CSNA in patients with AMI. Methods We prospectively enrolled 122 patients with AMI who visited our emergency department and underwent primary percutaneous coronary intervention. The late heart-to-mediastinum ratio (HMR) and washout rate (WR) was calculated to assess CSNA in the whole heart from planar images of in the cardiac MIBG imaging. The MIBG SPECT image parameters were calculated for each coronary artery, and the average WR in the culprit and non-culprit lesion were evaluated to assess the regional status of CSNA in patients with AMI. Abnormal WR in planar image was defined as 34% or more, as previously reported. The cut-off value of late HMR in planar image, WR in the culprit and non-culprit lesions were determined by ROC analysis. The primary endpoint was major adverse cardiac event (MACE) including all cause death, myocardial infarction, hospitalization for heart failure and target lesion revascularization. Results During a mean follow-up period of 3.1±1.8 years, 25 of 122 patients underwent MACE. The late HMR (p=0.004), WR in planar image (p=0.002), WR in the culprit lesion (p=0.023), and WR in the non-culprit lesion (p<0.001) were significantly associated with MACE at univariate Cox proportional hazard analysis. The increased WR in the non-culprit lesion (defined as 28.3% or more: AUC 0.697 [0.576-0.817]) was significantly independently associated with MACE (hazard ratio: 4.36 [1.45-13.11], p=0.009) even adjusted by late HMR, WR in planar image or WR in the culprit lesion, while decreased HMR, abnormal WR in planar image and increased WR in the culprit lesion showed no significant association with MACE in the multivariate model with WR in the non-culprit lesion. Kaplan-Meier analysis revealed that patients with increased WR in the non-culprit lesion had significantly higher risk for MACE than those without increased WR (45% vs 11% p<0.001). Conclusion(s) The activation of cardiac sympathetic nervous system in the non-culprit lesion is particularly associated with poor prognosis in patients with acute myocardial infarction.MACE risk by WR in non-culprit lesion

Clinical impact of helicopter transport with a physician in cardiogenic shock complicating acute coronary syndrome

Abstract Introduction Cardiogenic shock (CS) remains the leading cause of death in patients with acute coronary syndrome (ACS). Helicopter transport with a physician may improve the prognosis through reduction of the ischemic time and an early critical care. However, the impact of transfer of a physician-staffed helicopter and outcomes of CS complicating ACS is uncertain. Purpose The aim of the present study was to evaluate compare the clinical characteristics and long-term outcome between helicopter transport with a physician and ground transport in CS complicating ACS patients. Methods We retrospectively investigated 2324 consecutive patients with ACS who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death. Results Among the 2324 eligible patients, 273 ACS patients (11.7%) were complicated by CS. Of 273 CS complicating ACS, a total of 81 (29.7%) patients were transported by helicopter, 166 (60.8%) patients were transported by ambulance, and 26 (9.5%) patients did not use emergency medical service. The mean age was 71 years, 75% of patients were male, STEMI was seen in 87%, and mechanical circulatory support was used in 64%. Kaplan-Meier analysis showed that CV mortality up to 30 days was significantly lower with helicopter transport group compared those with ground transport (P = 0.0407). The rate of long-term CV death was comparable between groups (P = 0.19). Multivariate Cox regression analysis showed helicopter transport was significantly associated with lower 30-day CV mortality (adjusted HR 0.56, 95%CI 0.32-0.99, P = 0.0447). Conclusions Helicopter transport with a physician may improve cardiovascular outcomes of CS complicating ACS.Figure 1.Figure 2.

Association of Neutrophil extracellular traps burden with clinical and angiographic characteristics in patients with ST-elevation myocardial infarction

Abstract Background The precise triggers for arterial plaque rupture and the underlying pathophysiology of thrombogenesis remain elusive. Polymorphonuclear neutrophils (PMN), particularly their formation of Neutrophil Extracellular Traps (NETs), have garnered attention in the context of coronary atherothrombosis. This study sought to explore the association of NETs burden with clinical and angiographic characteristics in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI) and thrombus aspiration (TA). Methods This study included 336 consecutive STEMI patients undergoing pPCI and TA. Aspirated thrombi underwent histological analysis and NETs quantification via immunohistochemistry. Potential associations of clinical variables and angiographic outcomes with NETs burden were assessed. Results Manual TA was selectively performed in 72 cases with increased thrombotic burden and 60 thrombi were suitable for analysis. Most thrombi specimens displayed lytic features (63%) and almost three out of four specimens were identified as white thrombi. Increased NETs burden was significantly associated with prolonged pain-to-balloon time (>300 minutes) OR=10.29 (95% CI 2.11-42.22, p=0.001) and stress-induced hyperglycemia (SIH) OR=6.58 (95% CI 1.23-52.63, p=0.04) after multivariate regression analysis. Additionally, distal embolization (DE), a predictor of adverse outcomes, was more frequent among patients with an elevated NETs burden OR=16.9 (95% CI 4.23-44.52, p<0.001). Conversely, no significant association between NETs burden and final TIMI flow=3 was observed. Conclusion Elevated NETs burden in STEMI thrombi is linked to delayed reperfusion, SIH and increased risk of DE. Further research is needed to elucidate the role of NETs as a potential therapeutic target in acute atherothrombosis.

Acute echocardiographic assessment of patients with ST-elevation myocardial infarction in detecting clinically hidden hemodynamic deterioration

Abstract Background Transthoracic echocardiography (TTE) offers an immediate non-invasive assessment of cardiac morphology and function that can be performed bedside. Acute TTE in the catheterization laboratory (cath.lab.) may be helpful to identify markers of subsequent development of cardiogenic shock (CS) in patients with ST-elevation myocardial infarction (STEMI) in addition to the previously validated ORBI risk score. This relationship has not been investigated thoroughly previously. Purpose To investigate the association between acute TTE estimates of left ventricular (LV) function prior to primary percutaneous coronary intervention (pPCI) in STEMI patients and pro-B-type natriuretic peptide (proBNP) as a proxy associated with of CS development. Method From September 2023 all non-CS STEMI patients at one tertiary heart center underwent acute bedside TTE in the cath.lab. and ORBI risk score assessing the risk of CS development aiming for inclusion of 500 patients. The 5 minutes TTE-protocol consisted of LV ejection fraction (EF), LV outflow tract velocity time integral (LVOT VTI), mitral inflow (E and E/A), mitral deceleration time, and mitral annular early diastolic velocity é lateral. The primary endpoint was proBNP measured 24 hours (h) after pPCI (12-36h) stratified in quartiles (Q4 vs. Q1-3). The correlation between proBNP and TTE measurements and proBNP and ORBI risk score was examined using univariate linear regression models. Results Until now 153 STEMI patients (mean age 64 years, 25% female) were studied. Anterior STEMI was present in 36%, and median time from cath. lab. arrival to first wire over the culprit lesion was 28 minutes (IQR 24; 37). Patients with high proBNP level (Q4 vs. Q1-3) had significantly higher heart rate (median 84 bpm vs. 72 bpm) and Killip Class>1 (16% vs. 0%) at admission, but similar lactate levels (1.8mM vs. 1.5mM), systolic blood pressure (130 mmHg vs. 137 mmHg), and out-of-hospital cardiac arrest (11% vs. 12%). Patients with high proBNP levels (Q4 vs. Q1-3) had significantly lower LVEF (35% vs. 50%), higher E/é lateral (median 11.4 vs. 7.9), and higher ORBI risk score (median 8 vs. 4). LVEF, LVOT VTI, E/é lateral, and ORBI risk score were significantly associated with proBNP (Figure 1). Two patients developed CS after the pPCI; one with high proBNP level Q4, and one deceased prior to proBNP measurement. Conclusion Acute TTE is an easy tool for assessment of the acute hemodynamic status in STEMI patients bedside in the cath.lab., and it can be without delaying time to revascularization. LVEF, LVOT VTI, E/é lateral, and ORBI were all parameters associated with increased levels of the hemodynamic biomarker proBNP, and may together with the ORBI risk score improve the assessment and risk stratification of STEMI-patients at risk of CS-development.Figure 1.

Impact of sex and age on culprit plaque type of acute coronary syndrome in Japanese patients from TACTICS registry

Abstract Background In acute coronary syndrome (ACS), plaque rupture (PR) is the most frequent etiology followed by plaque erosion (PE) while calcified nodule (CN) is the least etiology. These three are known as major etiologies of ACS. Traditionally, it has been believed that sex and age have impact on etiology of ACS. For example, plaque erosion was thought to often occur in young female while calcified nodule often occur in elderly patients. However, impact of sex and age have not been well described. Methods This is a sub-study from TACTICS registry which consist of 702 Japanese ACS patients who underwent primary percutaneous coronary intervention under optical coherence tomography (OCT) from multicenter. Based on the OCT findings, patients were divided into PR, PE, CN and others. These data were stratified by sex and ages (<50, 50s, 60s, 70s, 80 or over). In this sub-study, we mainly focused on 3 major etiologies of ACS (PR, PE, CN) and compared incidence and clinical characteristics based on sex and ages. Results Distribution of culprit plaque type in ACS patients are shown in figure 1A (male) and 1B (female). PR remained top etiology of ACS in any sex and any age category. However, trend of PE was different between male and female. In male, as patients get younger, incidence of PE increased. In male patients under 50, incidence of PE was almost similar as PR. On the other hand, in female, incidence of PE was greatest in 70s followed by 80 or over. Surprisingly, young female showed the least incidence of PE. CN was the least etiology of three but increased especially from 80. Clinical characteristics are shown in table 1A (male) and 1B (female). In male, most of the baseline characteristics differ between different ages while in female, most of the baseline characteristic did not differ between different ages. Conclusion In our data, PE was more distinct in younger male ACS patients while PE was not that distinct in younger female ACS patients. The impact of sex and age on culprit plaque type of ACS might be variable depending on population.

Platelet-large cell ratio predicts no-reflow in patients undergoing primary coronary angioplasty for ST-segment elevation myocardial infarction

Abstract Background Increased platelet indices have been shown to reflect higher degree of platelet activation and have been related to poorer short- and long-term outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI). Purpose We aimed to evaluate the ability of a validated marker of platelet activation (i.e., the platelet-large cell ratio [P-LCR]) to predict the occurrence of no-reflow in patients undergoing primary percutaneous coronary intervention (pPCI) for STEMI. The ability of P-LCR to predict other markers of thrombotic charge (i.e., use of glycoprotein IIb/IIIa inhibitors and/or thrombus aspiration) was also investigated. Methods Use of glycoprotein IIb/IIIa inhibitors and/or thrombus aspiration, occurrence of the ‘no-reflow’ phenomenon and P-LCR values on admission were recorded in 836 consecutive patients treated by pPCI for STEMI. Patients’ demographic data and symptom onset-to-cardiac catheterization laboratory time intervals were also recorded. Correlations between P-LCR values and the presence of thrombotic charge markers were evaluated. Results No-reflow occurred in 124 (14.8%) of the study patients; glycoprotein IIb/IIIa inhibitors and thrombus aspiration were used in 228 (27.3%) and in 289 (34.5%) of patients, respectively. Mean P-LCR values were 27.1 ± 7.6%. P-LCR values on admission were significantly higher in patients who presented no-reflow than in those who did not (29.1 ± 5.6% vs. 25.3 ± 5.8%, p = 0.03). Similarly, P-LCR were significantly higher in patients in whom glycoprotein IIb/IIIa inhibitors (29.5 ± 6.1% vs. 25.2 ± 5.3%, p = 0.04) and/or thrombus aspiration (28.4 ± 5.7% vs. 24.8 ± 5.4%, p = 0.03) were used. A P-LCR value ≥26.9% predicted the occurrence of no-reflow with 70.9% sensitivity and 55.4% specificity (p = 0.04). Conclusions In the present cohort, P-LCR values on admission predicted the presence of thrombotic charge markers in patients undergoing pPCI for STEMI. Evaluating P-LCR on admission could help identify patients at increased risk of no-reflow, in whom more intensive antiplatelet strategies may be of interest.

Prognostic value of echocardiographic parameters in predicting major adverse cardiac events one year following st-segment elevation myocardial infarction

Abstract Approximately 50% of patients who survive an ST-segment elevation myocardial infarction (STEMI) experience irreversible damage to the heart muscle, which increases long-term risk of developing heart failure. Moreover, cardiovascular mortality constitutes half of all deaths. This research aimed to determine the best combination of patient data collected during a one-year follow-up period to enhance the accuracy of outcome predictions for patients with STEMI. Methods In this study, 246 patients who experienced STEMI and older than 18 were prospectively monitored. All participants received primary percutaneous coronary intervention treatment. The study's primary outcomes, observed over the year following hospital discharge, included cardiovascular death, recurrent myocardial infarction, newly diagnosed heart failure, and arrhythmias or conduction issues. Of the patients, 18% of patients reached the primary outcomes. Two-dimensional transthoracic echocardiography was conducted 3-5 days after the initial event to assess left ventricular global longitudinal strain (GLS) using 2D speckle-tracking echocardiography on the apical four-chamber, two-chamber, and long-axis views. Left ventricular mechanical dispersion was calculated as the standard deviation of the time from the Q/R wave onset to peak GLS across 17 segments of the left ventricle. Results The findings revealed that the overall GLS was -10.70 (-12.61 to -8.40), but in patients who met the study's primary outcomes, GLS was significantly lower at -7.83 (-8.70 to -6.90), compared to -12.02 (-13.11 to -10.17) in those who did not, with a significant difference (p=0.00001). Mechanical dispersion was 40.24±26.56 in the entire cohort but significantly higher at 65.62±22.57 in the outcome group compared to 25.79±14.81 in the non-outcome group (p=0.00001). The ejection fraction averaged 48.97±7.69% across all patients, 47.22±7.16% in those with outcomes, and 49.92±7.84% in those without, with a statistically significant difference (p=0.039). Cox regression analysis identified key predictors of major adverse cardiac events (MACE) within one year after STEMI, including global longitudinal strain (p=0.0006), left atrium volume index (p=0.0448), left ventricular end-diastolic diameter (p=0.045), and mechanical dispersion (p<0.0001). A multivariate logistic regression analysis demonstrated that a combination of GLS, left ventricular end-systolic volume (LVESV), mechanical dispersion, and ejection fraction could predict 1-year MACE with high accuracy (χ2 = 85.18; p<0.0001, AUC=0.961 [0.903-0.989]). In conclusion, this study identifies crucial metrics, such as global longitudinal strain, left ventricular end-systolic volume, mechanical dispersion, and ejection fraction, as predictive factors for MACE one year following STEMI. This predictive model is straightforward, reproducible, and can be easily implemented in cardiology practice.

Efficacy and safety of dapagliflozin in non-diabetic patients with primary anterior ST-elevation myocardial infarction initiated in early hospital period

Abstract Background The effectiveness of SGLT2 inhibitors has been proven in all types of chronic heart failure (HFpEF, HFmrEF, and HFrEF), regardless of the presence of diabetes mellitus. There are still no clear recommendations regarding the timing of SGLT2 inhibitor administration after myocardial infarction (MI) and its influence on prognosis. It can be assumed that it is appropriate to consider the possibility that, if started quickly after the presentation of acute MI, SGLT inhibition might enhance outcomes in patients. Objective This study aims to investigate the efficacy and safety of the SGLT2 inhibitor Dapagliflozin in primary anterior ST-segment elevation myocardial infarction (STEMI) initiated in early hospital period, irrespective of heart failure manifestation. Methods The study includes 124 non-diabetic patients with primary anterior STEMI who underwent primary PCI and had left ventricular ejection fraction (LV EF) ≤45% and NT-proBNP > 900 pg/ml at symptom onset within 24 hours, regardless of heart failure symptom manifestation. Patients with cardiogenic shock were excluded. 62 patients received standard medical treatment including beta-blockers, ACE inhibitors (Control group), while the other 62 patients were administered the SGLT2 inhibitor Dapagliflozin 10 mg once a day during the first 48 hours of inpatient treatment, in addition to standard therapy (Dapa group). All patients were followed up for one year. Echocardiography was performed during the first 24 hours. Echocardiography and NT-proBNP were repeated at the end of the year. The primary endpoint was the one-year heart failure hospitalizations and secondary endpoints included one year cardiovascular mortality and changes in NT-proBNP, plasma creatinine and glycosylated hemoglobin levels. Results The study shows a significant difference in heart failure hospitalization between the groups. In the Control group, it was 25.8%, and in the Dapa group, it was 8.1% (p = 0.008). Initially, there were no significant changes in NT-proBNP levels; 1152.2 ± 222.4 pg/ml in the Control group and 1197.3 ± 279.8 pg/ml in the Dapa group (p= 0.33). At the end of a year, NT-proBNP increased in the Control group (1827.4 ± 317.8 pg/ml), whereas in the Dapa group, it significantly decreased (613.5 ± 215.6 pg/ml) (p < 0.01). One-year cardiovascular mortality in the Control and Dapa groups was 9.7% and 4.8%, respectively(p=0.491). Other blood markers did not differ, and side effects were comparable during the in-hospital period as well as at the end of the year. Conclusion Early administration of Dapagliflozin among non-diabetic patients with primary anterior STEMI is associated with a significant decreasing of heart failure hospitalization rate and NT-proBNP level. Additionally, early administration of dapagliflozin does not impact on safety indicators.

To evaluate coronary microvascular obstruction by myocardial contrast echocardiography and its influence on prognosis in patients with ST-segment elevation myocardial infarction

Abstract Background The goal of primary PCI (pPCI) is not only to restore epicardial coronary blood flow quickly but also to provide continuous myocardial tissue level reperfusion through coronary microcirculation. However, the incidence of coronary microvascular obstruction (MVO) after pPCI is as high as 50%-60%, which is closely related to the occurrence of heart failure and increased mortality of patients. Myocardial contrast echocardiography (MCE) is a new noninvasive technique for real-time observation of myocardial microcirculation perfusion in a specific imaging mode. At present, there are few studies on the application of MCE in the evaluation of coronary MVO in STEMI patients in China. Purpose To evaluate coronary MVO by MCE and its influencing factors and prognosis value after pPCI in patients with STEMI. Methods Patients with STEMI who received pPCI from October 2020 to June 2023 in the CCU were enrolled. MCE examination was performed on the 5th to 7th day after pPCI. The patients were divided into the MVO group and Non-MVO group. Major adverse cardiovascular events (MACE) were observed by 6-month follow-up after STEMI onset. Multiple Logistic regression analysis was used to analyze the risk factors for MVO, Multiple Cox regression analysis of the risk factors for MACE and Kaplan-Meier survival curve to compare the cumulative event-free survival of the two groups. Results A total of 98 patients were included in the analysis. The age was 59.88±11.71 years old, and 76(77.55%) were male. MCE examination showed 52 cases in the MVO group and 46 cases in the Non-MVO group. The incidence of MVO was 53.1% (52/98). There were 15 patients with MACE during follow-up. The results of stepwise Multivariate Logistic regression analysis showed that the peak value of cardiac troponin T (cTnT) (OR=1.354,95%CI 1.103-1.661, P=0.004) and without thrombus aspiration (TA) were independent risk factors for MVO (OR=5.588,95%CI 1.915-16.308, P=0.002). Multivariate Cox regression analysis indicated that female (HR=2.891, 95%CI 1.027-8.135, P=0.044), left ventricular ejection fraction (LVEF) <40% (HR=9.960, 95%CI 3.370-29.435, P<0.001) and MVO (HR=5.759,95%CI 1.279-25.935, P=0.023) were independent risk factors for MACE. Kaplan-Meier survival curve showed that the cumulative event-free survival rate in the Non-MVO group was higher than that in the MVO group, and the difference was statistically significant (P=0.0047). Conclusion The incidence of coronary MVO was higher in STEMI patients after pPCI, the peak value of cTnT and without TA were independent risk factors of MVO. The independent risk factors for MACE were female, LVEF < 40%, and MVO.

Incidence and risk factors for cardiac rupture after ST-segment elevation myocardial infarction in contemporary era: findings from the improving care for cardiovascular disease in China-Acute Coronary Syndrome project.

Cardiac rupture (CR) is fatal mechanical complication of ST-segment elevation myocardial infarction (STEMI). We systematically analyzed the clinical features of STEMI patients with CR, as well as predictors and treatments associated with risk of CR in contemporary era. In this nationwide database, 49,284 patients admitted within 48 h after STEMI were enrolled, and were stratified according to CR status. We analyzed patients' clinical characteristics, case fatality rate, and independent correlates of CR. A total of 188 (0.38%) patients had CR, of which 42.6% died during hospitalization. Older age, female gender, higher heart rate, history of diabetes, and worse cardiac function were risk factors of CR in patients with STEMI, while a previous history of myocardial infarction was associated with a reduced risk of CR. CR patients were less likely to undergo primary percutaneous coronary intervention (PCI). After adjustment, primary PCI was associated with 56% decreased risk of CR (OR 0.44, 95% CI 0.29-0.67). This result was consistent in the propensity-score matching analysis and inverse probability of treatment weighting analysis. CR was associated with high in-hospital mortality among STEMI patients. Multiple factors were associated with CR occurrence, primary PCI was associated with lower risk of CR, indicating that early intervention targeting the risk factors and implementation of primary PCI may improve its prognosis. Clinical trial registration ClinicalTrials.gov; Number: NCT02306616; URL: www.clinicaltrials.gov.

Evaluation of Pharmaco-invasive PCI in Terms of in Hospital Clinical Outcome of Acute Anterior ST Segment Elevation Myocardial Infarction Patients Compared to Primary PCI

Background: The strategic reperfusion early after Myocardial Infarction trial and the French Registry of Acute Anterior ST segment elevation MI suggested that pharmaco-invasive strategy compares favorably with primary percutaneous coronary intervention (PPCI). Objectives: To evaluate in hospital clinical outcome of patients with acute anterior ST segment elevation myocardial infarction undergoing Primary PCI and pharmaco-invasive PCI. Methods: This cross sectional study was conducted in United Hospital, Dhaka. A total of 120 patients were studied. These patients were categorized into two groups. Those with acute anterior ST segment elevation MI who underwent primary PCI was denoted as group A (n= 55) and those with acute anterior ST segment elevation thrombolysed by streptokinase followed by PCI confined to pharmaco-invasive PCI was denoted as group B (n=65). Results: Acute LVF was more in pharmaco-invasive group than in primary PCI group and was statistically significant (p= 0.032). 02 patients (3.6%) died in primary PCI group: one of which was due to ventricular fibrillation followed by asystole 3 hours after procedure and the other died due to cardiac arrest 10 hours after the procedure. No major bleeding incidence was found in both groups. Conclusion: Acute anterior ST segment elevation myocardial infarction patients receiving pharmaco-invasive treatment compared with the Primary PCI had higher incidence of acute LVF and no significant discrepancy was observed regarding bleeding events, death, stent thrombosis, arrythymia, heart block and cardiac arrest. J Shaheed Suhrawardy Med Coll 2023; 15(1): 34-38

Long-term outcomes and operators' experience in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

Primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) is typically performed by experienced operators. Therefore, the safety of pPCI for STEMI performed by less experienced operators with the support of experienced operators remains unknown. We aimed to investigate the long-term outcomes of pPCI for STEMI performed by less experienced operators with the support of experienced operators. In total, 775 STEMI patients were enrolled and divided into groups according to operator experience in PCI: less experienced (n = 384) and experienced (n = 391) operator groups. Experienced operators were defined as those who had performed > 50 elective PCI procedures per year as the first operator or instructional assistant, whereas less experienced operators were defined as others. When less experienced operators performed the pPCI, experienced operators supported them. The primary endpoint was any cardiovascular event, defined as a composite of cardiovascular death, nonfatal myocardial infarction, and unplanned hospitalization for heart failure. In the propensity score-matched analysis, 324 patients were included in each group. The cumulative incidence of the primary endpoint over a median of 5years in the less experienced operator group was similar to that in the experienced operator group (15% vs. 18%, P = 0.209). In the multivariate Cox proportional hazards model, there was no excess risk for patients operated upon by less experienced operators for the primary endpoint (adjusted hazard ratio, 0.85; 95% confidence interval, 0.58-1.25; P = 0.417). pPCI for STEMI by less experienced operators did not increase the risk of in-hospital mortality or 5-year long-term cardiovascular events if supported by experienced operators.

Primary Percutaneous Coronary Intervention in Multivessel Disease: Complete versus Culprit-only Revascularization

Objective: To compare the clinical outcomes of complete revascularization and culprit-only revascularization in patients with multivessel coronary artery disease (CAD) who presented with ST-segment elevation myocardial infarction (STEMI) at Hayatabad Medical Complex, Peshawar. Methodology: A prospective, randomized controlled trial was conducted, enrolling 400 patients with multivessel CAD. Patients were randomly assigned to either the complete revascularization group (n=200) or the culprit-only revascularization group (n=200). The primary outcomes assessed included cardiovascular death, reinfarction, and the need for repeat revascularization over a six-month follow-up period. Statistical analysis was performed using chi-square tests and Kaplan-Meier survival analysis. Results: Complete revascularization significantly reduced the rates of major adverse cardiovascular events compared to culprit-only revascularization. Cardiovascular death was lower in the complete revascularization group (4% vs 9%, p = 0.02), as was reinfarction (5% vs 11%, p = 0.01), and repeat revascularization (7% vs 15%, p = 0.004). Kaplan-Meier analysis showed a significant improvement in event-free survival in the complete revascularization group. Conclusion: Complete revascularization significantly improves clinical outcomes in patients with multivessel CAD presenting with STEMI, reducing cardiovascular death, reinfarction, and repeat revascularization. This study supports complete revascularization as a preferred treatment strategy in such patients to improve long-term outcomes. Keywords: coronary artery disease, STEMI, complete revascularization, culprit-only PCI, cardiovascular outcomes