Primary Thrombolysis Research Articles

Observation and Safety Analysis of Recombinant Human Urokinase Primary Thrombolysis in Acute Myocardial Infarction

Observation and Safety Analysis of Recombinant Human Urokinase Primary Thrombolysis in Acute Myocardial Infarction

The Advantages of Dual Antiplatelet Therapy Combinations in Predicting Recurrent Cardiovascular Events in Obese Patients after Myocardial Infarction

The purpose of the study was to analyze the incidence of recurrent cardiovascular events in obese patients after a myocardial infarction during a 6-month follow-up period, depending on the combination of ticagrelor or clopidogrel with acetylsalicylic acid as a part of dual antiplatelet therapy. Materials and methods. The study involved 75 patients with acute myocardial infarction with ST segment elevation and concomitant obesity. The patients were divided into 2 subgroups: the first included 31 patients who received the combination of acetylsalicylic acid and ticaglelor, and the second – 44 patients treated with the combination of acetylsalicylic acid and clopidogrel in dual antiplatelet therapy. The GRACE scale was used to stratify the risk of hospital and 6-month mortality. Control of the recurrent cardiovascular events presence was carried out after 6 months. Results and discussion. Acute myocardial infarction with ST elevation is still the main cause of mortality and invalidisation of able-bodied population. Regardless of the primary percutaneous coronary intervention or thrombolysis, dual antiplatelet therapy remains the main therapeutic strategy, both in the acute ST-elevation myocardial infarction period and in the remote – for the secondary prevention of possible adverse cardiovascular events, and is a combination of acetylsalicylic acid and a P2Y12 receptor inhibitor. To date, the issue of the choice of a P2Y12 receptor inhibitor in the dual antiplatelet therapy that is used in the treatment of ST-elevation myocardial infarction is an urgent subject of scientific discussion. While observing patients after a myocardial infarction with concomitant obesity over a period of 6 months, it was found that 28 patients had a recurrent myocardial infarction and / or unstable angina, which was 37.56% of all patients. The analysis of the GRACE scale scores in a cohort of patients with recurrent cardiovascular events revealed that all patients were included in high risk group (> 118 points). In the group of patients who received dual antiplatelet therapy with the involvement of acetylsalicylic acid and ticagrelor in 11 people recorded a repeated myocardial infarction and / or unstable angina, which was 14.76%. At the same time, in a group of patients receiving dual antiplatelet therapy in a combination of acetylsalicylic acid with clopidogrel, re-cardiovascular catastrophes were detected in 17 patients, which was 22.8% of all patients with ST-elevation myocardial infarction on the background of concomitant obesity. Conclusion. The patients with obesity after a myocardial infarction who are included in the GRACE high risk group are recommended to be treated with the combination of acetylsalicylic acid and ticagrelor as a result of a notable reduction in the risk of recurrent cardiovascular catastrophes compared with the combination of acetylsalicylic acid and clopidogrel

Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives

Risk stratification is one of the cornerstones of the management of acute pulmonary embolism (PE) and determines the choice of both diagnostic and therapeutic strategies. The first step is the identification of patent circulatory failure, as it is associated with a high risk of immediate mortality and requires a rapid diagnosis and prompt reperfusion. The second step is the estimation of 30-day mortality based on clinical parameters (e.g., original and simplified version of the pulmonary embolism severity index): low-risk patients without right ventricular dysfunction are safely managed with ambulatory anticoagulation. The remaining group of hemodynamically stable patients, labeled intermediate-risk PE, requires hospital admission, even if most of them will heal without complications. In recent decades, efforts have been made to identify a subgroup of patients at an increased risk of adverse outcomes (intermediate-high-risk PE), who might benefit from a more aggressive approach, including reperfusion therapies and admission to a monitored unit. The cur-rent approach, combining markers of right ventricular dysfunction and myocardial injury, has an insufficient positive predictive value to guide primary thrombolysis. Sensitive markers of circulatory failure, such as plasma lactate, have shown interesting prognostic accuracy and may play a central role in the future. Furthermore, the improved security of reduced-dose thrombolysis may enlarge the indication of this treatment to selected intermediate–high-risk PE.

Short- and long-term outcomes in patients with right ventricular infarction according to modalities of reperfusion strategies in China: data from China Acute Myocardial Infarction (CAMI) Registry

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Twelfth Five-Year Planning Project of the Scientific and Technological Department of China Purpose We sought to investigate the short- and long-term outcomes in patients with right ventricular infarction in China. Methods Data from China Acute Myocardial Infarction (CAMI) Registry for patients with right ventricular infarction between January 2013 and September 2014 were analyzed. Results Of the 1,988 patients with right ventricular infarction, 733 patients did not receive reperfusion therapy, 281 patients received thrombolysis therapy, and 974 patients underwent primary PCI. Primary PCI and thrombolysis were all associated with lower risks of in-hospital (3.1% vs 12.6%; adjusted OR: 0.48; 95% CI: 0.27–0.87; P = 0.0151 and 5.7% vs 12.6%; adjusted OR: 0.43; 95% CI: 0.22–0.85; P = 0.0155, respectively) and two-year all-cause mortality (6.3% vs 20.9%; adjusted HR: 0.50; 95% CI: 0.34–0.73; P = 0.0003 and 11.0% vs 20.9%; adjusted HR: 0.59; 95% CI: 0.38–0.92; P = 0.0189, respectively) compared with no reperfusion therapy. Meanwhile, primary PCI was superior to thrombolysis in reducing the risks of in-hospital atrial-ventricular block (4.2% vs 8.9%; adjusted OR: 0.46; 95% CI: 0.23–0.91; P = 0.0257), cardiogenic shock (5.3% vs 13.9%; adjusted OR: 0.43; 95% CI: 0.23–0.83; P = 0.0115), and heart failure (8.5% vs 23.5%; adjusted OR: 0.35; 95% CI: 0.22–0.56; P < 0.0001). Primary PCI could reduce the risk of two-year major adverse cardiac and cerebrovascular event (19.1% vs 33.3%; adjusted HR: 0.72; 95% CI: 0.56–0.92; P = 0.0092) relative to no reperfusion therapy, whereas thrombolysis may increase the risk of two-year revascularization (15.5% vs 8.7%; adjusted HR: 1.90; 95% CI: 1.15–3.16; P = 0.0124) compared with no reperfusion therapy. Conclusions Timely reperfusion therapy is essential for patients with right ventricular infarction. Primary PCI should be considered as the default treatment strategy for patients with right ventricular infarction in the contemporary primary PCI era.

English

Angioplasty is considered superior to fibrinolytic therapy in acute myocardial infarction (AMI) if the patient receives it within the therapeutic window. It is unclear if such advantages are available for patients who need to travel from a community hospital to a facility where invasive care is available, since primary thrombolysis often re-establishes coronary artery blood flow in patients with ST elevation acute myocardial infarction (STEMI). At the most severe end of the range of acute coronary syndromes is ST - segment elevation myocardial infarction (STEMI), which generally occurs when a fibrin-rich thrombus fully occludes an epicardial coronary artery. The diagnosis of STEMI is based on clinical features and persistent ST-segment elevation as evidenced by 12 - lead electrocardiography. Patients with STEMI should have a quick reperfusion treatment evaluation and a reperfusion strategy should be performed immediately following contact with the system. All patients with AMI who had chest pain within 12 hours were evaluated. The detailed history of chest pain, character, and radiation, had been taken in terms of duration from the beginning of chest pain in minutes. After 10 minutes, patients were given 10 mg of sublingual isosorbide dinitrate and repeated ECG. Patients were excluded if chest pain or ST elevation was resolved after 10 minutes of nitrate administration. In the analysis only those cases in which chest pain and ST shift were not resolved following sublingual nitrates. Serum CKMB estimates have been performed. All patients were treated with 1.5 million IU streptokinase in 100 ml of normal saline for more than 45 minutes. Clinical assessment for 2 hours every half hour was done to evaluate: 1. Chest pain reduction in a subjective scale percentage and to assess changes in the Killip class. 2. Continuous ECG monitoring of reperfusion rhythm occurrences. Patients are assessed at the end of 2 hours of follow-up for: a. Percentage reduction in subjective chest pain a. A 12 lead ECG to identify changes in the ST height c. Repeat CK-MB estimate. Patients with thrombolysis were classified into two classes on the basis of presence or absence of SCR at the end of two hours of initiation. Those with successful reperfusion were grouped into the SCR Group and into the SCR (negative) Group without successful reperfusion. Coronary prognostic index is a set of questionnaires which prognosticate the outcome in AMI. This review describes the role of Coronary Prognostic Index and thrombolysis in patients of STEMI. KEY WORDS ECG, AMI, STEMI, Angioplasty

Influence of Oxidative Stress Markers on Coronary No-reflow After Primary Percutaneous Coronary Intervention for Patients with Acute Myocardial Infarction

Background: ST-elevation myocardial infarction (STEMI) is one of the leading causes of mortality and morbidity worldwide. However, survival after acute STEMI has considerably improved due to increasing symptom recognition, accurate diagnosis and effective timely reperfusion. This study aimed to investigate the relation between the level of oxidative stress markers and coronary no-reflow after primary percutaneous coronary intervention for patients with acute myocardial infarction. Patients & Methods: This prospective cohort study included 90 patients admitted with acute STEMI at cardiovascular medicine department Naser Institute hospital, during the period from June 2018 till 12 months. Patients were divided into 2 groups according to the post primary PCI thrombolysis in myocardial infarction (TIMI) flow score into: Group I: 45 patients with no-reflow phenomenon. Group II: 45 patients with TIMI flow ≥ 2 after primary PCI. They all underwent primary PCI within 24 hours of presentation. Results: This study showed increased concentrations of Malondialdehide (MDA) in the circulation of patients with no-reflow indicating increased lipid peroxidation which could be attributed to a deficiency of antioxidant defense mechanism. In group I, pt with coronary no-reflow MDA level ranged from 2.8-4.5 nmol/mL with mean 3.9±1.5 nmol/mL, while in group II control group, MDA level ranged from 1.1 – 2.1 nmol/mL with mean 1.55±0.4 nmol/mL, there was statistically significant difference between the two groups (P value<0.004). Conclusions: no-reflow phenomenon after primary PCI can be predicted using the oxidative stress markers.

Risk of arrhythmias after myocardial infarction in patients with left ventricular systolic dysfunction according to mode of revascularization: a Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) substudy.

The Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) study was an observational trial including 312 patients with acute myocardial infarction (MI) and left ventricular ejection fraction (LVEF) <40%. Primary percutaneous intervention (pPCI) was introduced 2 years after start of the enrolment, dividing the population into two groups: pre- and post-pPCI. This substudy sought to describe the influence of the mode of revascularization on long-term risk of new-onset atrial fibrillation (AF), bradyarrhythmia, and ventricular tachycardia and the subsequent risk of relevant major cardiovascular events (MACE). The study included the 268 patients without a history of AF. All patients received an implantable cardiac monitor (ICM) and were followed for 2 years. The choice of revascularization was made by the treating team independently of the trial and retrospectively divided into pPCI, subacute PCI, primary thrombolysis, or no revascularization. Endpoints were new-onset arrhythmia and MACE.A total of 77 patients received no revascularization, whereas 49 received thrombolysis only and 142 received any PCI. The adjusted hazard ratio (HR) for developing any arrhythmia and the subsequently risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients (any arrhythmia, non-revascularization: HR = 1.7, P = 0.01 and thrombolysis: HR = 1.6, P = 0.05; MACE, non-revascularization: HR = 3.1, P = 0.05 and thrombolysis: HR = 3.1, P = 0.08). All HRs were adjusted for significant baseline and clinically considered covariates and stratified for calendar year. This study is the first to demonstrate that the long-term risk of arrhythmia documented by an ICM and the subsequent risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients in a post-MI population with LVEF <40%.

P1868Risk of arrhythmias after myocardial infarction in patients with left ventricular systolic dysfunction according to mode of revascularization: a CARISMA substudy

Abstract Introduction The CARISMA trial was the first study to use continuous monitoring for documentation of long-term arrhythmias in post-infarction patients with left ventricular dysfunction. During the study duration (2000–2005), primary PCI (pPCI) as treatment of acute myocardial infarction was introduced approximately midway (2002) on the enrolling centres. Purpose The aim of this study was to describe the influence of mode of revascularization after myocardial infarction (AMI) on long-term risk of risk of new onset atrial fibrillation, ventricular tachyarrhythmias and brady arrhythmias. Methods The study is a sub-study on the CARISMA study population that consisted of patients with AMI and left ventricular ejection fraction ≤40%, which received an implantable loop recorder and was followed for 2 years. After exclusion of 15 patients who refused device implantation and 26 with pre-existing arrhythmias, 268 of the 312 patients were included. Choice of revascularization was made by the treating team independently of the trial and was retrospectively divided into primary percutaneous intervention (pPCI), subacute PCI (24 hours to 2 weeks after AMI), primary thrombolysis or no revascularization. Endpoints were new-onset of arrhythmias and major cardiovascular events (MACE). The Kaplan-Meier (figure 1) and Mantel-Byar methods were used for time to first event risk analysis. Results A total of 77 patients received no revascularization, whereas 49 received thrombolysis only and 142 received PCI. At two-years follow up patients treated with any PCI had a significant lower risk (0.40, n=63) of any arrhythmia compared to patients treated with trombolysis (0.60, n=30) or no revascularization (0.68, n=16) (p&lt;0.001, unadjusted) (figure 1). Risk of MACE was significant higher in patients with any arrhythmia (0.25, n=76) compared to no arrhythmia (0.11, n=93) at two years follow-up (p=0.004, unadjusted). Figure 1 Conclusion(s) The long-term risk of new onset arrhythmias after AMI was significantly lower in patients treated with any PCI compared to patients not revascularized or treated with thrombolysis. Risk of MACE was significantly higher in patients with new onset arrhythmias compared to patients with no arrhythmias.

Elevated levels of circulating soluble ST2 at discharge predict late adverse ventricular remodeling in patients with ST-segment elevation myocardial infarction

Introduction: The aim of this study was to investigate whether the circulating level of sST2 would predict adverse LV remodeling in STEMI patients with TIMI III flow through the myocardial infarctrelated coronary artery six months after intervention.&#x0D; Methods: The study retrospectively included 65 patients with STEMI and TIMI-III flow after primary or facilitated percutaneous coronary intervention (PCI). These patients were admitted to the intensive care unit of L.T. Malaya Therapy National Institute between August 2016 and July 2018. Primary PCI with bare-metal stent implantation was performed in 33 patients, and 32 patients were previously treated with primary thrombolysis followed by PCI within 12 hours after initial STEMI confirmation. Angiographic, clinical, and biochemical parameters were evaluated. B-mode, Tissue Doppler, Strain Echocardiography, and blood sampling for biomarker assays were performed at admission, at discharge from the hospital, and at six months after STEMI.&#x0D; Results: Late adverse LV remodeling is defined as an increase of LV end-diastolic volume (EDV) six months post STEMI (first cohort, n=29), while other patients (second cohort, n=36) did not demonstrate a decreasing trend of LV EDV, or they had never revealed any decrease of this parameter. There was a significant difference between the two cohorts in the serum level of sST2 at discharge, while the levels of natriuretic peptides, troponin I were similar (P=0.24). Indeed, the circulating level of sST2 in the first cohort was higher than that of the second cohort (59.72 ng/mL; 95% confidence interval [CI] = 36.99 ng/mL -139.53 ng/mL versus 44.75 ng/mL; 95%CI =28.25 ng/mL -77.32 ng/mL, P=0.039, respectively). ROC-analyses showed that the best balanced cut-off point for sST2 to predict adverse remodeling at 6 months post PCI was 35 ng/mL (AUC=0.672 95% C 0.523-0.799; P=0.0344 sensitivity = 46.7% and specificity = 85.7%).&#x0D; Conclusions: We showed that the circulating level of sST2 measured at discharge in acute STEMI patients intervented by PCI could predict late adverse LV remodeling six months post PCI. These findings offer a new biomarker to stratify patients with successful coronary re-vascularization at risk of HF.&#x0D;

Reperfusion in STEMI patients: still a role for cardioprotection?

Ischemic heart disease remains a leading cause of death worldwide, responsible for an estimated 17.5 million deaths in 2012. Mortality from ST-elevation myocardial infarction STEMI have decreased over the last 3 decades. However, despite the success of reperfusion therapy by primary percutaneous coronary intervention (PPCI) or thrombolysis, STEMI is still of significant concern. A recent patient-level meta-analysis emphasized the pivotal importance of infarct size within 1 month after PPCI as a determinant of all-cause mortality and hospitalization for heart failure at 1 year. Although timely and complete reperfusion is the most effective way of limiting infarct size (IS) and subsequent ventricular remodeling, reperfusion per se adds an additional component of irreversible injury to the myocardium (known as ischemia/reperfusion injury, IRI), and the coronary circulation and it contributes to final infarct size. The prevention and treatment of lethal IRI and coronary microvascular dysfunction pose a continued and formidable barrier to successful myocardial perfusion as opposed to establishing patency of the epicardial infarct-related artery (IRA), and in this context the need for additional cardioprotective strategies to reduce IS and coronary microvascular dysfunction remains the 'last frontier' of reperfusion therapy.

Treating ST-elevation myocardial infarction.

Treatment of patients with acute ST-elevation myocardial infarction (STEMI) has moved from thrombolysis to primary percutaneous coronary intervention (PPCI) over the past 20 years. This is a result of evidence that the latter has superior long-term benefits for patients. However, there is little research on whether patients who present after the mandated time of less than 120 minutes from onset of signs and symptoms could benefit from primary thrombolysis followed by rescue percutaneous coronary intervention (PCI), referred to here as angiography. This article, which includes a case study, describes the pathophysiology of cardiovascular disease, acute coronary syndrome, and STEMI, and examines some of the literature that compares primary PCI to thrombolysis followed by angiography. It also highlights gaps in research, and encourages practitioners to consider administering thrombolysis to patients who do not present within 120 minutes of the onset of signs and symptoms of STEMI.

Bypass for primary percutaneous intervention or thrombolysis at the nearest hospital for patients suffering ST-elevation myocardial infarction

Bypass for primary percutaneous intervention or thrombolysis at the nearest hospital for patients suffering ST-elevation myocardial infarction

Le remodelage cardiaque après un infarctus : nouvelles données sur la prévention et le traitement

Cardiac remodelling (REM) is the most important cause of heart failure after myocardial itifarct. It is characterised by cardiac dilation and an evolution towards the fetal phenotype and myocardial fibrosis. The " primum movens " is cardiac cell death caused by necrosis andlor apoptosis. Therapeutic approaches include early reperfusion by primary angioplasty or thrombolysis. Pharmaceutical interventions are completed by cardiac resynchronization. LVAD placement, stem cell infusion and gene therapy, i.e. transfer of SERCA-2 or protein phosphatase 1 inhibition, and exercise, a simple and inexpensive modality.

Reperfusion strategy for patients with renal dysfunction presenting with STEMI: which is better in the North African context?

Background Patients with renal insufficiency experience worse prognosis after STEMI. The current guidelines do not clearly draw specific strategies for patients with renal dysfunction (RD).Aim The aim of this study is to compare primary PCI (PPCI) and thrombolysis results as well as in-hospital mortality after successful reperfusion between the RD patients (RD+) and patients with normal renal function (RD-).Methods We retrospectively reviewed data for 1,388 patients admitted for STEMI between January 1995 and October 2011. Two groups were identified: PPCI (315 patients) and thrombolysis (379 patients). Ninety patients (13%) had RD defined by creatinine levels at admission > 130 μmol/l, they were equally treated by PPCI and thrombolysis.Results In the PPCI group, despite a similar pre-procedural TIMI flow (P = 0.82), TIMI III restoring was significantly lower in the RD+ group (78.6% vs. 91.8%, P= 0.013). Suboptimal result was also higher in the RD+ group (13.6% vs. 2.7%, P< 0.001), but ST regression after TIMI III achievement was similar in the 2 groups (P = 0.43), probably reflecting no microvascular damage. In the thrombolysis group, successful reperfusion was also significantly lower when RD exists (58% vs. 74%, P= 0.03). After successful reperfusion, RD+ patients experienced higher in-hospital mortality in the PPCI group (29% vs. 4.3%; P< 0.001), whereas mortality was similar in the thrombolysis group (3% vs. 0%, P= 0.42).Conclusion RD reduces either PPCI or thrombolysis success, with no proven microvascular damage after PPCI. In-hospital prognosis, however, is worse in the RD group only after successful PPCI, but not after successful streptokinase thrombolysis.

M-Guard Stent in Stemi Patients with High Thrombus Burden Lesions: A Prospective, Single Arm Study

Introduction: Primary PCI is the preferred modality to restore blood perfusion in STEMI patients, but myocardial reperfusion is sometimes lower than optimal. Distal embolization seems to play the leading role. There is rare evidence suggestive of M-Guard stents; a recent innovation which protects against distal embolization may be beneficial in this circumstance. Materials and Methods:This was a prospective single arm study. Patients with acute STEMI admitted at the Cardiac Emergency Unit of Imam Reza Hospital from July 2011 to November 2012 who had a large bulk of thrombus in their angiogram, underwent M-Guard stenting and were followed up for six months for chest pain and secondary revascularization. Results: The 23 patients, aged between 34 and 84; 65.2%, were male and had undergone primary PCI, mechanical thrombus aspiration, and M-Guard stenting. Left Anterior Descending (LAD) (63.9%) and Right Coronary Artery (RCA) (39.1%) were most commonly involved. 78.2%, 13.1%, and 8.9% of patients had primary Thrombolysis in Myocardial Infarction (TIMI) Thrombus grade five, four, and three. Among them, 86.9% achieved TIMI Flow grade three and 13.04% TIMI Flow grade two. The rate of transient no-reflow phenomenon was 21%. One patient died after stenting in the setting of cardiogenic shock. There was one case of in-stent restenosis five months after the procedure. Of the other 15 accessible patients, after six months, none experienced a second angioplasty or any ischemic symptoms. Conclusion: Using M-Guard stents in acute STEMI patients having undergone primary PCI with high thrombus burden is probably associated with lower rates of the no-reflow phenomenon and improved vessel reperfusion.

Abstract 185: Risk-adjusted Comparison of Good Functional Outcome at 3 Months after Primary Endovascular Therapy or Intravenous Thrombolysis Alone. Results from an Observational, Population-based Study

Background: Evidence clearly supports intravenous thrombolysis (IVT) as first-line therapy for AIS. Yet, endovascular treatment (EVT) might be an alternative for patients with IVT contraindications. Our aim was to study whether patients treated with primary EVT in daily practice did as well as those treated with IVT alone in terms of functional outcome. Methods: Observational, population-based study of consecutive AIS patients treated with either isolated EVT or IVT within 2011 and 2012 in Catalonia. Patients were prospectively included in a health-administration based registry with external monitoring of completeness. Inclusion criteria: EVT or IVT delivered under routine conditions. Exclusion criteria: combined IVT+EVT therapy, pre-stroke mRS &gt;2, lacunar stroke subtype, unusual stroke etiology, baseline NIHSS &gt;25 and onset-to-treatment (OTT) &gt; 400 minutes. We determined the risk-adjusted probability [adjustment variables: age, NIHSS, OTT, pre-morbid mRS, hypertension, dyslipidemia, diabetes, AF, OCSP classification and etiology] of achieving functional independence at 3 months (mRS &lt;=2) and performed subgroup analyses. Results: 1149 patients underwent IVT and 129 (10.1%) EVT. Patients in the EVT arm were younger (71.2+/-11.5 vs. 74.3+/-11.9), had higher NIHSS scores (18 [12-20] vs. 11 [7-18]), were treated later (198 [150-270] vs. 140 [105-190]) and more frequently had concomitant AF (55% vs. 21.9%), heart failure (12.4% vs. 4.9%), and were on anticoagulants (49.6% vs. 5.4%). Dyslipidemia (45.4% vs. 36.4%) and antiplatelets (42.7% vs. 26.4%) were more frequent in the IVT arm. Overall, the risk-adjusted likelihood of good functional outcome was better for EVT (OR: 1.56; 95% CI: 0.97-2.52). Subgroup analyses showed that patients with NIHSS =&gt;14 (OR: 1.92; 95% CI: 1.10-3.46) and those treated within 180-270 minutes post-stroke (OR: 3.44; 95% CI: 1.41-8.39) benefited more from EVT. Conclusions: In a population-based study of reperfusion therapies for AIS, patients undergoing isolated EVT were more likely to achieve functional independence at 3 months as compared to patients treated with IVT, particularly those with severe strokes or those treated within 3-4.5 hours post-stroke. These findings need to be confirmed in a RCT.

ST-Segment Elevation Myocardial Infarction

Patients with acute coronary syndrome fall into two groups: those with unstable angina or non—ST segment elevation (formerly non—Q wave) myocardial infarction (NSTEMI) and those with acute ST segment elevation (formerly Q wave) myocardial infarction (STEMI). STEMI is the focus of this chapter. The epidemiology, pathophysiology, diagnosis, differential diagnosis, and complications of STEMI are elaborated. Reperfusion therapy (including time to reperfusion; diagnostic coronary angiography; primary, facilitated, rescue, and late percutaneous coronary intervention [PCI]; thrombolytic therapy and choice of thrombolytic agent; early invasive strategy; coronary artery bypass grafting; and therapeutic hypothermia), medical therapy (including aspirin, P2Y12 inhibitors, glycoprotein IIb/IIIa inhibitors, anticoagulants, nitrates, beta blockers, inhibition of the renin-angiotensin-aldosterone system, oxygen, analgesia, lipid-lowering therapy, prophylactic antiarrhythmics, and magnesium), risk stratification, secondary prevention, and post-STEMI care are also covered. Tables delineate classifications of MI as defined by proximal cause of myocardial ischemia, Killip classification of acute MI and mortality rates, differential diagnosis of ST segment elevation, contraindications for administering thrombolytic agents, and major recommendations for antithrombotic therapy in patients with STEMI treated with primary PCI and thrombolysis. Algorithms indicate a diagnostic approach to acute coronary syndromes and corresponding pathology and reperfusion strategies. Electrocardiogram changes in STEMI and corresponding territory of myocardium are depicted. A variety of graphs are included. This review contains 11 highly rendered figures, 6 tables, and 151 references.

Carotid intima-media thickness as a risk factor for predicting the outcomes in STEMI patients

Background: Carotid-artery intima and media thickness (CIMT) is associated with the increased risk of myocardial infarction. We studied whether CIMT predict the prognosis of patients with acute ST-elevation myocardial infarction (STEMI). Methods: A total of 348 acute STEMI patients (men 82.8%, age 59±13 years) treated with primary percutaneous coronary intervention or thrombolysis were prospectively investigated in three centers. Carotid IMT was measured with high-resolution ultrasonography in all patients. The primary endpoint was major adverse cardiac event (death, heart failure, MI, revascularization and stroke) over a median follow-up period of 569 days (1.6 years). Results: The mean CIMT was 0.77±0.14mm and 20.7% of the patients had carotid plaque. Of total patients, 11.8% experienced a major adverse cardiovascular event (MACE). Carotid plaque was independently associated with higher incidence of MACE (adjusted OR 4.76; 95% CI 2.295-9.872; p <0.001). Door-to-balloon time or peak cardiac-specific troponins I (cTnI) did not predict the outcomes of acute STEMI. Area under the ROC curve for CIMT tertile (0.71±0.05) was significantly larger compared to door-to-balloon time (0.59±0.05) or peak cTnI (0.45±0.05) (p <0.001, Fig.1). After adjusting for age, the event rate was 19.0% in the 3rd tertile CIMT (≥0.83mm) group, 12.1% in the 2nd tertile (0.70∼0.82mm) group and 4.3% in the 1st tertile (≤0.69mm) group (p=0.01) (Fig. 2). After adding CIMT to a model with peak cTnI, net proportion of patients reclassified correctly by CIMT was 28.7% and net classification improvement was 0.56 (95% CI 0.46 to 0.66, p <0.001) (Fig. 3). ![Figure][1] Conclusions: Carotid plaque and IMT was a strong prognosticator to predict future cardiovascular events in first STEMI patients than was door-to balloon time or peak cTnI. [1]: pending:yes

038 LARGER INFARCT SIZE ASSOCIATED WITH DYSGLYCEMIA AT THE TIME OF ST-ELEVATION MYOCARDIAL INFARCTION IS RELATED TO LATER PRESENTATION

Introduction Patients with dysglycaemia at the time of ST-elevation myocardial infarction (STEMI) have a worse prognosis. The reasons for this are not entirely clear. Admission hyperglycaemia has been associated with larger infarct size. The aims of this study were to examine the relation of acute and chronic glycaemic state to myocardial scar and salvage characteristics in patients with reperfused ST-elevation myocardial infarction. Methods Fifty-six patients treated for first ST-elevation myocardial infarction (STEMI) without a pre-existing diagnosis of Diabetes mellitus were prospectively enrolled between January and December 2010. Glycosylated haemoglobin (HbA1c) and glucose levels were sampled on admission to the emergency cardiac ward. Patients underwent cardiac magnetic resonance (CMR) examination during the index admission (median day 2 for CMR, IQR 2 days), with assessment of area-at-risk (STIRs), Infarct size (IS%), late microvascular obstruction (MVO%), and left ventricular function. Population characteristics are presented in table 1. There were no significant differences between patients receiving Primary Percutaneous Coronary Intervention (PPCI) or thrombolysis, so these were grouped for analysis. Patients were dichotomised into groups above and below the median both for admission glucose level and separately for HbA1c level before comparison between groups using Independent samples t test. Spearman9s rank correlation was used to compare non-parametric data. Correlations with a p Results When patients were dichotomised into glucose levels below ( Dichotomising patients by HbA1c into levels below the median ( Correlations between infarct characteristics and admission glucose and HbA1c are shown in table 2. Admission glucose correlated significantly with age and IS%, while HbA1c correlated significantly with time to reperfusion and MSI%. On multivariate linear regression analysis however, glucose was not a predictor of IS% (R=0.549, R2=0.302, Age t=3.441, p=0.001, time to reperfusion t=2.708, p=0.009, glucose- not significant), and HbA1c was not a predictor of MSI% (R=0.453, R2=0.206, age t=−2.529, p=0.015, time to reperfusion t=−2.237, p=0.030, HbA1c-not significant). Conclusions/implications Admission Glucose levels are associated with larger infarct size, and HbA1c levels are associated with reduced myocardial salvage. However, glycaemic status is not an independent predictor of infarct size or salvage when time to reperfusion is taken in to consideration.

AS-018: Which Reperfusion Therapy is Better by Primary Percutaneous Coronary Intervention versus Thrombolysis in Patients with ST-Segment Elevation Myocardial Infarction within 3 Hours of the Onset of Symptoms in DES Era? : From Korea Acute Myocardial Infarction Registry (KAMIR)

AS-018: Which Reperfusion Therapy is Better by Primary Percutaneous Coronary Intervention versus Thrombolysis in Patients with ST-Segment Elevation Myocardial Infarction within 3 Hours of the Onset of Symptoms in DES Era? : From Korea Acute Myocardial Infarction Registry (KAMIR)