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

Provocative Strategies for Primary PCI in STEMI: Time to Rethink Guidelines

Background: The primary percutaneous coronary intervention (PCI) is now the reference treatment for ST-segment elevation myocardial infarction (STEMI). Findings from randomized controlled trials suggest that PCI is superior to thrombolytic therapy in preventing death and recurrent myocardial infarction. However, longer delays for PCI implementation and variability in outcomes among different operators and centers may affect its efficacy. The European guidelines recommend fibrinolytic therapy if PCI cannot be performed within 120 minutes of the first medical contact. Objective: The main objective of the study was to evaluate the efficacy of adjunctive provocative strategies in primary PCI for STEMI and their impact on procedural success and clinical outcomes. Methods: This retrospective observational study was conducted at Luqman International Hospital, Mingora Swat, from December 2022 to June 2023. Data were collected from 230 STEMI patients, including demographic information, clinical characteristics, procedural details, and outcomes. The primary outcome measure was the occurrence of major adverse cardiac events (MACE) within 30 days and one year after primary PCI. Secondary outcomes included procedural success rate, myocardial blush grade, and left ventricular ejection fraction (LVEF) during follow-up assessments. Statistical analyses were performed using SPSS version 25, with continuous variables expressed as means and standard deviations and categorical variables as frequencies and percentages. Comparisons between groups were conducted using chi-square tests for categorical variables and Student’s t-tests or Mann-Whitney U tests for continuous variables, with a p-value of less than 0.05 considered statistically significant. Results: Of the 230 patients, 120 (52%) received conventional strategies, while 110 (48%) received adjunctive provocative strategies. The provocative strategy group had higher rates of successful reperfusion (95.5% vs. 83.3%), improved myocardial blush grades (mean ± SD: 3.2 ± 0.6 vs. 2.7 ± 0.8), and lower rates of the no-reflow phenomenon (9.1% vs. 20.8%). At 30 days post-PCI, the incidence of MACE was lower in the provocative strategy group (9.1% vs. 12.5%). At one year, the provocative strategy group continued to show lower MACE rates (16.4% vs. 20.8%). Conclusion: Adjunctive provocative strategies in primary PCI for STEMI show promise in enhancing reperfusion efficacy and preserving myocardial function. While trends towards improved procedural success and short-term outcomes were observed, larger prospective studies are needed to validate these findings. The exploration of provocative strategies represents an important avenue for advancing STEMI management and improving patient outcomes in interventional cardiology.

Ventricular Arrhythmias After Primary Percutaneous Coronary Intervention for STEMI

Currently, mortality risk for patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) with an uncomplicated postprocedure course is low. Less is known regarding the risk of in-hospital ventricular tachycardia (VT) and ventricular fibrillation (VF). To evaluate the risk of late VT and VF after primary PCI for STEMI. This cohort study included adults aged 18 years or older with STEMI treated with primary PCI between January 1, 2015, and December 31, 2018, identified in the US National Cardiovascular Data Registry Chest Pain-MI Registry. Data were analyzed from April to December 2020. Multivariable logistic regression was used to evaluate the risk of late VT (≥7 beat run of VT during STEMI hospitalization ≥1 day after PCI) or VF (any episode of VF≥1 day after PCI) associated with cardiac arrest and associations between late VT or VF and in-hospital mortality in the overall cohort and a cohort with uncomplicated STEMI without prior myocardial infarction or heart failure, systolic blood pressure less than 90 mm Hg, cardiogenic shock, cardiac arrest, reinfarction, or left ventricular ejection fraction (LVEF) less than 40%. A total of 174 126 eligible patients with STEMI were treated with primary PCI at 814 sites in the study; 15 460 (8.9%) had VT or VF after primary PCI, and 4156 (2.4%) had late VT or VF. Among the eligible patients, 99 905 (57.4%) at 807 sites had uncomplicated STEMI. The median age for patients with late VT or VF overall was 63 years (IQR, 55-73 years), and 75.5% were men; the median age for patients with late VT or VF with uncomplicated STEMI was 60 years (IQR, 53-69 years), and 77.7% were men. The median length of stay was 3 days (IQR, 2-7 days) for the overall cohort with late VT or VF and 3 days (IQR, 2-4 days) for the cohort with uncomplicated STEMI with late VT or VF. The risk of late VT or VF was 2.4% (overall) and 1.7% (uncomplicated STEMI). Late VT or VF with cardiac arrest occurred in 674 patients overall (0.4%) and in 117 with uncomplicated STEMI (0.1%). LVEF was the most significant factor associated with late VT or VF with cardiac arrest (adjusted odds ratio [AOR] for every 5-unit decrease ≤40%: 1.67; 95% CI, 1.54-1.85). Late VT or VF events were associated with increased odds of in-hospital mortality in the overall cohort (AOR, 6.40; 95% CI, 5.63-7.29) and the cohort with uncomplicated STEMI (AOR, 8.74; 95% CI, 6.53-11.70). In this study, a small proportion of patients with STEMI treated with primary PCI had late VT or VF. However, late VT or VF with cardiac arrest was rare, particularly in the cohort with uncomplicated STEMI. This information may be useful when determining the optimal timing for hospital discharge after STEMI.

Hypertension, microvascular obstruction and infarct size in patients with STEMI undergoing PCI: Pooled analysis from 7 cardiac magnetic resonance imaging studies

Mortality after ST-segment elevation myocardial infarction (STEMI) is increased in patients with hypertension. The mechanisms underlying this association are uncertain. We sought to investigate whether patients with STEMI and prior hypertension have greater microvascular obstruction (MVO) and infarct size (IS) compared with those without hypertension. We pooled individual patient data from 7 randomized trials of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) in whom cardiac magnetic resonance imaging was performed within 1 month after reperfusion. The associations between hypertension and MVO, IS, and mortality were assessed in multivariable adjusted models. Among 2174 patients (61.3 ± 12.6 years, 76% male), 1196 (55.0%) had hypertension. Patients with hypertension were older, more frequently diabetic and had more extensive coronary artery disease than those without hypertension. MVO and IS measured as percent LV mass were not significantly different in patients with and without hypertension (adjusted differences 0.1, 95% CI -0.3 to 0.6, P = .61 and -0.2, 95% CI -1.5 to 1.2, P = .80, respectively). Hypertension was associated with a higher unadjusted risk of 1-year death (hazard ratio [HR] 2.28, 95% CI 1.44-3.60, P < .001), but was not independently associated with higher mortality after multivariable adjustment (adjusted HR 1.04, 95% CI 0.60-1.79, P = .90). In this large-scale individual patient data pooled analysis, hypertension was not associated with larger IS or MVO after primary PCI for STEMI.

The Influence of Presentation Timing and Door to Balloon Timing on the Clinical Outcomes in Primary Percutaneous Coronary Intervention

For best clinical results, ST-segment elevation myocardial infarction (STEMI) must be treated quickly. This prospective observational study, conducted at Peshawar institute of cardiology (PIC), Pakistan, from November 23, 2022, to August 16, 2023, examines the connection between clinical outcomes in 120 primary Percutaneous Coronary Intervention (PCI) cases, presentation timing (the period of time from symptom onset to hospital arrival), and Door-to-Balloon (D2B) time. Objective: to pave the road for more efficient, patient-centered care by fostering a more thorough awareness of the complexities involved in the management of acute STEMI. Methods: Demographic data, presentation timing, D2B times, and clinical outcomes were collected. Correlation analysis and regression modeling were employed to investigate the impact of presentation timing on D2B time and clinical outcomes. Sub-group analyses were conducted based on age and gender. Results: The relevance of an early presentation was highlighted by the study's substantial negative association between presentation timing and D2B time (r = -0.62, p 0.001). Smaller myocardial infarct sizes and a decreased frequency of major adverse cardiac events (MACE) were seen in patients with D2B times under 90 minutes. Age and gender differences were seen in this connection, according to subgroup analysis. Conclusion: Timely patient presentation is crucial in achieving shorter D2B times, leading to improved clinical outcomes in primary PCI for STEMI. These findings underscore the need for public awareness campaigns and streamlined hospital protocols to optimize STEMI management.

The Index of Microcirculatory Resistance After Primary PCI: A Pooled Analysis of Individual Patient Data

BackgroundDespite treatment with primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI), the risk of heart failure and late death remains high. Microvascular dysfunction, as assessed by the index of microcirculatory resistance (IMR), after primary PCI for STEMI has been associated with worse outcomes. It is unclear whether IMR after primary PCI predicts cardiac death. ObjectivesThe aims of this analysis were: 1) to determine if IMR is an independent predictor of cardiac death; 2) to assess the optimal cutoff value of IMR after STEMI; and 3) to compare IMR with several cardiac magnetic resonance parameters, including infarct size. MethodsIn a collaborative, pooled analysis of individual patient data from 6 cohorts that measured IMR directly after primary PCI, cardiac mortality up to 5 years was estimated using Kaplan-Meier analyses. The primary endpoint was cardiac death using the predefined IMR cutoff value of 40. ResultsIn total, 1,265 patients were included in this study with a median follow-up of 2.8 years (IQR: 1.2-5.0 years). Cardiac death at 5 years occurred in 2.2% and 4.9% of patients (HR: 2.81; 95% CI: 1.34-5.88; P = 0.006) in the IMR ≤40 and IMR >40 groups, respectively. The composite of cardiac death or hospitalization for heart failure occurred in 4.9% and 8.9% (HR: 1.98; 95% CI: 1.20-3.29; P = 0.008) in the IMR ≤40 and IMR >40 groups, respectively. IMR was an independent predictor of cardiac death, whereas coronary flow reserve was not. The optimal cutoff value of IMR for the prediction of cardiac death in this cohort was 70 (HR: 4.73; 95% CI: 2.27-9.83; P < 0.001). Infarct size was 17.6% ± 13.3% and 23.9% ± 14.6% of the left ventricular mass in the IMR ≤40 and IMR >40 groups, respectively (P < 0.001). Microvascular obstruction and intramyocardial hemorrhage occurred more frequently in the IMR >40 group than in the IMR ≤40 group. ConclusionsIn this large, pooled analysis of individual patient data, IMR measured directly after primary PCI in STEMI was an independent predictor of cardiac death. IMR may be used as a tool to identify patients at the time of primary PCI who are at highest risk for late cardiac mortality and who might benefit most from additional cardioprotective therapies and monitoring.

Optical Coherence Tomography–Guided Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: Rationale and Design of the ATLAS-OCT Study

Even after successful revascularization with primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), subsequent adverse events still occur. Previous studies have suggested potential benefits of intravascular imaging, including optical coherence tomography (OCT). However, the feasibility of OCT-guided primary PCI has not been systematically examined in these patients. The ATLAS-OCT (ST-elevation Acute myocardial infarcTion and cLinicAl outcomeS treated by Optical Coherence Tomography-guided percutaneous coronary intervention) trial was designed to investigate the feasibility of OCT guidance during primary PCI for STEMI in experienced centers with expertise on OCT-guided PCI as a prospective, multicenter registry of consecutive patients with STEMI who underwent a primary PCI. The sites' inclusion criteria are as follows: (1) acute care hospitals providing 24/7 emergency care for STEMI, and (2) institutions where OCT-guided PCI is the first choice for primary PCI in STEMI. All patients with STEMI who underwent primary PCI at participating sites will be consecutively enrolled, irrespective of OCT use during PCI. The primary end point will be the rate of successful OCT imaging during the primary PCI. As an ancillary imaging modality to angiography, OCT provides morphologic information during PCI for the assessment of plaque phenotypes, vessel sizing, and PCI optimization. Major adverse cardiac events, defined as a composite of all-cause death, myocardial infarction, and target vessel revascularization at 1year, will also be recorded. The ATLAS-OCT study will clarify the feasibility of OCT-guided primary PCI for patients with STEMI and further identify a suitable patient group for OCT-guided primary PCI.

Effectiveness and safety of P2Y12 inhibitor pretreatment for primary PCI in STEMI: Systematic review and meta-analysis.

Dual antiplatelet therapy (DAPT) with both aspirin and P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction (STEMI) has been shown to be associated with better outcomes. Yet, there is uncertainty regarding the optimal timing for its initiation. We performed a systematic review and meta-analysis of evidence on pretreatment with P2Y12 inhibitors in combination with aspirin in patients with STEMI undergoing primary percutaneous coronary intervention (PCI).We performed a systematic search of electronic databases Pubmed, CENTRAL, and Scopus until April 2022. Studies were eligible if they compared P2Y12 inhibitor upstream administration to downstream use in patients with STEMI submitted to PCI. Studies with patients receiving fibrinolysis or medical therapy only were excluded. Outcomes were assessed at the shortest follow-up available.Out of 2491 articles, 3 RCT and 16 non-RCT studies were included, with a total of 79300 patients (66.1% pretreated, 66.0% treated with Clopidogrel). Pretreatment was associated with reduction in definite stent thrombosis (OR 0.61 [0.38-0.98]), all-cause death (OR 0.77 [0.60-0.97]), and cardiogenic shock (OR 0.60 [0.48-0.75]). It was also associated with a lower incidence of TIMI flow <3 pre-PCI (OR 0.78 [0.67-0.92]). However, incidence of recurrent MI was not significantly reduced (OR 0.93 [0.57-1.52]). Regarding safety, pretreatment was not associated with a higher risk of major bleeding events (OR 0.83 [0.75-0.92]).Pretreatment with DAPT, including a P2Y12 inhibitor, was associated with better pre-PCI coronary perfusion, lower incidence of definite stent thrombosis, cardiogenic shock, and, possibly, all-cause mortality with no sign of potential harm encountered.

Diabetes Mellitus Is Still a Strong Predictor of Periprocedural Outcomes of Primary Percutaneous Coronary Interventions in Patients Presenting with ST-Segment Elevation Myocardial Infarction (from the ORPKI Polish National Registry).

The impact of diabetes mellitus (DM) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was confirmed by several studies. However, it is unclear whether this effect is still present in large groups of unselected patients undergoing up-to-date treatment. Thus, we sought to assess the impact of DM on periprocedural outcomes of primary PCI in STEMI using data from the Polish National Registry of PCI. Data on 150,782 STEMI patients undergoing primary PCI were collected. Of them, 26,360 (17.5%) patients had DM. Patients with DM were higher-risk individuals who experienced longer reperfusion delays and were less likely to have closed infarct-related artery at baseline (TIMI 0 + 1 flow: 73.2% vs. 72.0%; p &lt; 0.0001) and achieve optimal reperfusion after PCI (TIMI 3 flow: 91.8% vs. 88.5%; p &lt; 0.0001). The periprocedural mortality (1.1% vs. 1.9%; p &lt; 0.0001) was higher in patients with DM and DM was identified as an independent predictor of periprocedural death. In conclusion, despite continuous progress in STEMI treatment, DM remains a strong predictor of periprocedural mortality. However, this detrimental effect of DM may be partially explained by the overall higher risk profile of diabetic patients.

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

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

Impact of Total Ischemic Time on the Recovery of Regional Wall Motion Abnormality after STEMI in the Modern Reperfusion Era.

Background Total ischemic time (TIT) is an important factor for predicting mortality among patients with ST-segment elevation myocardial infarction (STEMI). However, the correlation between TIT and the extent of wall motion abnormality has not been well studied. Therefore, we investigated changes in the wall motion score index (WMSI) value based on TIT in STEMI patients who underwent primary percutaneous coronary intervention (PCI) and subsequent transthoracic echocardiography. Methods STEMI patients who underwent primary PCI and follow-up coronary angiography were analyzed after the exclusion of cases of in-stent restenosis (ISR). WMSI values were calculated by dividing the sum of scores by the number of segments visualized. Results A total of 189 patients underwent primary PCI for STEMI, and 151 had no ISR with a median follow-up of 12.3 months. TIT was 180 (117–369) minutes in a subset of 151 patients (mean age of 62 years; 76% male). Among patients without ISR, 109 (72%) demonstrated a decrease in the WMSI value during the follow-up period. The WMSI values of patients with TITs of 180 minutes or less were significantly decreased relative to those among patients with TITs of greater than 180 minutes (p=0.020). Among patients with TITs of 180 minutes or less, the TIT was significantly shorter among those with a reduction in the WMSI value than among those with an increase in the WMSI value (106 [81–124] vs. 133 [100–151] minutes; p=0.018). TIT was an independent predictor for a reduction in the WMSI value among these patients (adjusted hazard ratio: 0.976 (0.957–0.995); p=0.016). Conclusions In the modern reperfusion era of STEMI, patients with TITs of 180 minutes or less experienced a significant degree of recovery from regional wall motion abnormalities.

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

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

The Obstacle Course of Reperfusion for ST-Segment-Elevation Myocardial Infarction in the COVID-19 Pandemic.

The Obstacle Course of Reperfusion for ST-Segment-Elevation Myocardial Infarction in the COVID-19 Pandemic.

Effect of continuous use of metformin on kidney function in diabetes patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

BackgroundDiabetes patients presenting with ST-segment elevation myocardial infarction (STEMI) scheduled for primary percutaneous coronary intervention (PCI) have an increased risk of contrast induced-acute kidney injury (CI-AKI). The effects of continuous use of metformin on kidney function are still controversial in patients submitted to primary PCI. This study aimed to assess continuous metformin therapy on kidney function in diabetic patients undergoing coronary intervention.MethodsTwo hundred eighty-four patients with metformin-treated diabetes, who underwent coronary intervention within 24 h for STEMI, were enrolled in the retrospective study. All the patients had estimated glomerular filtration rate (eGFR) of > 30 mL/min/1.73 m2. According to the physicians’ decisions after admission, 119 patients continued metformin treatment after primary PCI, while 165 patients discontinued it > 48 h after the procedure. Serum creatinine was collected at admission and within 48 h post primary PCI to evaluate the incidence of CI-AKI. We performed a multiple logistic regression analysis to examine the determinants of CI-AKI.ResultsNo statistical difference in CI-AKI incidence between the continuous and the discontinuous metformin group (12.6%vs10.3%, p = 0.545). Multivariable logistic regression analysis indicated eGFR ≤60 ml/min/1.73 m2[p = 0.025, OR: 3.131; 95% CI (1.156–8.482)] and contrast volume [p = 0.002, OR: 1.010; 95% CI (1.004–1.016)] were predictive factors of CI-AKI. Metformin therapy was irrelevant to CI-AKI [p = 0.365, OR: 0.698; 95% CI (0.320–1.521)]. No case of lactic acidosis was found in this study. Besides, the study supported discontinuation of metformin was not beneficial for patients’ blood glucose control after admission.ConclusionsThe study indicated that the metformin continuation after primary PCI for STEMI in diabetic patients with eGFR > 30 ml/min / 1.73 m2 did not increase the risk of CI-AKI.

P16 Relationship of plasma long Pentraxin-3 concentration with clinical and angiographic outcomes of patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary

Abstract Background Inflammation has an important role for the progression of coronary plaque vulnerability to acute coronary thrombosis. Long pentraxin-3 (PTX3) is a sensitive marker of inflammation released upon exposure to primary inflammatory signals. Whether concentration of PTX3 affects coronary thrombus severity and impaired coronary flow in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is unknown. Purpose This study sought to evaluate the relationship of plasma PTX3 concentration with coronary thrombus severity and final TIMI flow after primary PCI in patients with acute STEMI. Methods We prospectively enrolled 335 consecutive patients with acute STEMI undergoing primary PCI between 1 January 2018 and 2 August 2018. Plasma PTX3 concentrations were measured at admission by ELISA method. Results Compared to low PTX3 group (&amp;lt;0.33 ng/mL; N = 223), patients in the high PTX3 group (≥ 0.33 ng/mL; N = 112) had higher proportion of thrombus grade 4 and 5 on initial coronary angiogram (83% vs. 72%, p= 0.03), final TIMI flow &amp;lt;3 (66% vs. 51%, p= 0.01), incomplete ST segment resolution after primary PCI (85% vs. 72%, p= 0.002) and Killip classification II-IV at entry (34.8% vs. 13%, adjusted odds ratio= 3.38, p&amp;lt; 0.001). High PTX3 concentration was associated with an increased risk of 30-day mortality (adjusted hazard ratio= 3.41, 95% confidence interval, 1.27 to 9.11, p= 0.01). Conclusion High plasma PTX3 concentration is associated with worse clinical and angiographic outcomes among patients undergoing primary PCI for STEMI. Further study is needed to eludicate whether PTX3 is a causal agent for adverse outcomes and whether therapies directed at reducing PTX3 levels are effective. Table 1. Variable Hazard ratio (95% confidence interval) P-value Long pentraxin-3 ≥0.33 ng/mL 3.41 (1.27 - 9.11) 0.01 Age &amp;gt;65 years 0.38 (0.11 - 1.41) 0.15 Male gender 0.43 (0.13 - 1.44) 0.16 Diabetes Mellitus 1.24 (0.44 - 3.52) 0.68 Hypertension 0.64 (0.23 - 1.80) 0.39 Baseline creatinine ≥1.3 mg/dL 4.06 (1.43 - 11.53) 0.009 TIMI risk score &amp;gt; 4 8.31 (2.69 - 25.59) &amp;lt; 0.001 Multivariable Cox regression analysis showing association between PTX3 concentration and selected confounding variables for all-cause death at 30 day.

P5011Impact of guideline-recommended medical therapy at discharge on long-term mortality in patients with or without left ventricular dysfunction after primary PCI for STEMI

Abstract Background Clinical practice guidelines provide class I recommendation for the use of angiotensin-converting enzyme inhibitors (ACE-I) and beta-blockers in patients with prior myocardial infarction and left ventricular (LV) dysfunction, whereas their use in patients without LV dysfunction is considered to be a class IIa recommendation. Purpose Our aim was to comparatively assess the impact of ACE-I and/or beta-blockers on 3-year mortality in patients with or without impaired left ventricular (LV) function undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Methods The analysis included 4425 patients admitted for primary PCI during 2009–2015 from a prospective, electronic registry of a high-volume tertiary center, who survived initial hospitalization, and for whom information on LV function and discharge medication were available. Patients were stratified according to LV systolic dysfunction, defined as LVEF &lt;40%. Unadjusted and adjusted Cox regression models were created to investigate the impact of beta-blocker and/or ACE-I therapy on 3-year mortality. Results 22.9% (n=1013) had LV dysfunction, 23.0% (n=1017) received either an ACE-I or a beta-blocker and 72.2% received both medications at discharge (n=3197). The concurrent use of both ACE-I and beta-blockers was not different in LVEF≥40% vs. LVEF&lt;40% (72.4% vs. 71.7%, p=0.43). The use of at least one of the guideline-recommended medications was associated with a significantly lower 3-year mortality in both patients with LVEF≥40% (18.7% if neither was used, 11.2% if either a beta-blocker or an ACE-I were used and 9.4% if both were used, p=0.001), and LVEF&lt;40% (55.4% if neither was used, 32.5% if either a beta-blocker or an ACE-I were used and 22.9% if both were used, p&lt;0.001) (Figure). After adjusting for significant mortality predictors including older age, diabetes, hypertension, renal failure, previous stroke, Killip class ≥2 and non-culprit chronic total occlusion (CTO), the concurrent use of both a beta-blocker and an ACE-I remained independently associated with lower 3-year mortality in both patients with LVEF&lt;40% (HR 0.30, p&lt;0.001) and LVEF≥40% (HR=0.41, p=0.001). The use of a single agent was independently associated with lower mortality in patients with LVEF&lt;40% (HR 0.45, p=0.002), but not in patients with LVEF≥40% (HR 0.61, p=0.07). Conclusions Guideline-recommended use of both a beta-blocker and an ACE-I in post-MI patients was associated with a lower 3-year mortality regardless of the LV function, whereas using only one of the two agents was associated with improved prognosis only in patients with LV dysfunction, but not in patients without LV impairment.

P4612Elevated pentraxin-3 level is associated with impaired post procedural myocardial perfusion assessed by quantitative blush evaluator in patients with acute STEMI undergoing primary PCI

Abstract Background Long Pentraxin-3 (PTX3) has been known as an emerging cardiac biomarker and has potential diagnostic and prognostic value in coronary heart disease. Whether plasma PTX3 level is associated with post procedural myocardial perfusion assessed by quantitative blush evaluator (QuBE) in acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) is unknown. Purpose This study sought to evaluate the association between plasma PTX3 level and post procedural myocardial perfusion assessed by QuBE in patients with acute STEMI undergoing primary PCI. Methods We enrolled 217 patients with acute STEMI who underwent primary PCI (men=191, women=26). Post procedural myocardial perfusion was evaluated using QuBE. PTX3 level was measured at admission by an ELISA method. We used 0.33 ng/mL for PTX3 level as a cut off point for future worse clinical outcome as shown by previous study. Impairment of myocardial perfusion was defined as QuBE &lt;9 arbitrary unit as also shown by previous studies. Results Plasma PTX3 level had an inverse correlation with QuBE score (r=−0.64, p&lt;0.001). Patients in elevated PTX3 group (≥0.33 ng/mL; N=80) had lower median QuBE score compared with lower PTX3 group (&lt;0.33ng/mL; N=137), with QuBE score (8.6 arbitrary unit vs. 15.1 arbitrary unit, P&lt;0.001). Multivariate logistic analysis showed that plasma PTX3 level ≥0.33 ng/mL (OR=7.65, p&lt;0.001) along with Diabetes Mellitus (OR=2.30, p=0.04), and Killip class II-IV (OR=2.57, p=0.04) were independent predictors of impaired myocardial perfusion, as shown by QuBE score &lt;9 arbitrary unit. Analysis between PTX3 and low QuBE score Variables Multivariate OR (95% CI) P value PTX3 ≥0.33 ng/mL 7.65 (3.37–17.36) &lt;0.001 Diabetes Mellitus 2.30 (1.01–5.23) 0.04 Hypertension 1.15 (0.47–2.82) 0.75 Killip class II-IV 2.57 (1.04–6.35) 0.04 IRA LAD 3.79 (1.64–8.78) 0.002 Thrombus grade 4 &amp; 5 3.36 (1.06–11.98) 0.04 Post PPCI TIMI flow &lt;3 5.29 (2.09–13.36) 0.001 PTX3, pentraxin-3; QuBE, quantitative blush evaluator; IRA, infarct related artery. Conclusions Patients with acute STEMI with high plasma PTX3 level were associated with reduced myocardial perfusion after primary PCI shown by low QuBE score. Elevated PTX3 level may be used as a marker for persistent impairment of myocardial perfusion after primary PCI in STEMI

TCT-346 Primary PCI in STEMI with sirolimus eluting FANTOM bioresorbable vascular scaffold first guided with optical coherence tomography– acute results from a FANTOM STEMI pilot study.

There is paucity of data on acute performance of Fantom (REVA Medical, CA, USA), a second generation sirolimus eluting bioresorbable scaffold (BRS), in ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). Clinical and imaging

CRT-100.19 Utility Of Post-Procedural Anticoagulation after Primary PCI for STEMI: Cardiac Magnetic Resonance and 2D-Echocardiographic Findings

Controversy exists as to whether and how long anticoagulation is necessary after primary percutaneous coronary intervention (PCI) in the era of current ST-segment elevation myocardial infarction (STEMI). Our aim was to study the impact of prolonged (>24 hours) or brief (≤24 hours) anticoagulation

Long-term prognostic value of single-photon emission computed tomography myocardial perfusion imaging after primary PCI for STEMI.

The aim of this study was to determine the long-term prognostic value of infarct size and myocardial ischaemia on single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). In total, 1092 STEMI patients who underwent primary PCI and SPECT MPI within 1-6 months were included (median follow-up time of 6.9 years). In the entire cohort, SPECT infarct size was independently associated with the composite of cardiac death or reinfarction [hazard ratio (HR) per 10% increase in summed rest score 1.33; 95% confidence interval (95% CI) 1.12-1.58; P = 0.001], whereas myocardial ischaemia was not (HR per 5% increase in summed difference score 1.18; 95% CI 0.94-1.48; P = 0.16). Addition of SPECT infarct size to a model including the clinical variables provided significant incremental prognostic value for the prediction of cardiac death or reinfarction (global χ2 13.8 vs. 24.2; P = 0.002), whereas addition of SPECT ischaemia did not add significantly (global χ2 24.2 vs. 25.6; P = 0.24). In the subgroup of patients with left ventricular ejection fraction (LVEF) ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction (HR 1.59; 95% CI 1.15-2.22; P = 0.006), whereas in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction (HR 1.28; 95% CI 1.00-1.63; P = 0.050). In patients with first STEMI and primary PCI, SPECT infarct size was independently associated with cardiac death and/or reinfarction, whereas myocardial ischaemia was not. In patients with LVEF ≤ 45%, SPECT infarct size was independently associated with cardiac death or reinfarction, whereas myocardial ischaemia was not. Conversely, in patients with LVEF > 45%, only SPECT ischaemia was independently associated with cardiac death or reinfarction.

Predictors of Left Ventricular Ejection Fraction Improvement After Primary Stenting in ST-Segment Elevation Myocardial Infarction (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction Trial)

The predictors of improvement in left ventricular ejection fraction (LVEF) after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) are poorly understood. We sought to determine the prevalence and clinical and angiographic predictors of LVEF improvement after primary PCI in STEMI. In the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction trial, 3,602 patients presenting with STEMI were randomized to heparin + a glycoprotein IIb/IIIa inhibitor versus bivalirudin. Routine 13-month angiographic follow-up was performed in a prespecified substudy of 656 stented patients. The median [25%, 75%] change in LVEF from baseline to 13 months was +2.4% [-5.9%, 11.8%]; LVEF increased or remained unchanged in 379 patients (57.8%; median Δ +9.8% [4.3%, 16.4%]) and fell in 277 patients (42.2%; median Δ -7.0% [-11.8%, -3.6%]). Independent predictors of LVEF improvement were female gender (p = 0.002), lower baseline LVEF (p <0.0001), Thrombolysis in Myocardial Infarction 3 flow after PCI (p = 0.03), shorter lesion length (p = 0.04), and lower post-PCI peak MB isoenzyme of creatine kinase (p <0.0001). In conclusion, in the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction trial, although LVEF improved during follow-up after primary PCI in more than half of patients, left ventricular function worsened over time in a substantial proportion, the occurrence of which may be predicted by clinical, angiographic, and laboratory variables.