Reperfused ST-elevation Myocardial Infarction Research Articles

Safety and efficacy of aspiration thrombectomy with intracoronary tirofiban VS aspiration thrombectomy alone in patients undergoing primary PCI: a systematic review and meta-analysis

Abstract Background Primary percutaneous coronary intervention (PPCI) may be complicated by intracoronary thrombus accumulation in ST elevation myocardial infarction (STEMI) leading to decrease in myocardial perfusion and increase in infarct size. The utilization of aspiration thrombectomy and intracoronary tirofiban in STEMI patients undergoing PPCI hold clinical relevance by removal of thrombus burden, potentially reducing distal embolization and improving myocardial perfusion and by targeting platelet aggregation to mitigate thrombotic complications, respectively. Given the paramount importance of achieving rapid and effective reperfusion in STEMI, the evaluation of these interventions is warranted to assess overall impact on patient outcomes in terms of safety and efficacy. Purpose The current meta-analysis aims to investigate the clinical outcomes of aspiration thrombectomy (AT) with intracoronary tirofiban versus AT alone during PPCI. Methods A systematic search for randomized controlled trials that evaluate the safety and efficacy of aspiration thrombectomy with intracoronary tirofiban in STEMI patients who underwent PPCI was done using PubMed, MEDLINE, Embase, Cochrane, Clinicaltrials.gov. and Herdin PH. Studies included those between 2010 - 2023 and involved human subjects. Search terms included "Aspiration Thrombectomy", "Intracoronary Tirofiban", "Primary Percutaneous Coronary Intervention" and "STEMI patients". Results Four RCTs (n: 490 participants) were included in this meta-analysis comparing aspiration thrombectomy with intracoronary tirofiban versus aspiration thrombectomy alone in STEMI patients undergoing PPCI. The results revealed no statistically significant difference in ST segment resolution (RR 1.02, 95%, CI: 0.97 - 1.08, P = 0.41, I2 = 0%), myocardial blush grade 2-3, (risk ratio of 1.04, 95%, CI: 0.97 – 1.12, P = 0.22, I2 = 62%) and TIMI 3 flow (risk ratio of 1.0, 95% CI: 0.95 - 1.04, P = 0.87). The occurrence of major adverse cardiovascular events did not significantly differ between the two groups (RR 0.46, 95% CI: 0.19 – 1.09, P = 0.08, I2 = 0%). There was no statistically significant difference in terms of bleeding when combining intracoronary tirofiban to standard medical therapy (RR 1.35, 95% CI: 0.64 – 2.84, P= 0.78, 4 trials [490 patients]). Conclusion In primary percutaneous coronary intervention, MACE outcomes of aspiration thrombectomy with intracoronary tirofiban were similar to that for aspiration thrombectomy alone in terms of improving myocardial perfusion in STEMI patients without increasing the risk for bleeding. Our meta-analysis suggests that AT alone may be the more acceptable standard during PPCI when encountering heavy thrombus burden. Future validated studies may help further investigate the strategy of adding tirofiban during aspiration thrombectomy.1. Primary Outcomes2. Secondary Outcomes

CD14 blockade preserves left ventricular structure and systolic function in a murine model of ST-elevation myocardial infarction

Abstract Background Cluster of differentiation-14 (CD14) facilitates the excessive pro-inflammatory monocyte-macrophage response to myocardial injury. Both acute and chronic infiltration of pro-inflammatory macrophages are implicated in the immunological progression of ischemic heart failure. However, investigation of clinically practicable strategies of CD14 blockade are yet to be reported. Purpose This fully blinded and randomised preclinical study evaluated the efficacy of a neutralising anti-CD14 antibody given at reperfusion in a murine model of reperfused ST-elevation myocardial infarction (STEMI) with key clinical features. Methods Large anterior STEMI was induced in 48 adult mice by left anterior descending coronary artery occlusion for 1 h prior to reperfusion and randomisation to receive anti-CD14 antibody, isotype control (IgG2a) or saline weekly for four weeks (independently blinded). Outcome measures included functional assessments by 9.4T cardiac magnetic resonance (CMR) imaging and ultra-high-resolution echocardiography at 21- and 28-days post-STEMI, respectively. Results Multi-plane short axis CMR at 21-days post-STEMI revealed greater left ventricular (LV) ejection fraction in the anti-CD14 antibody-treated group compared with saline- and isotype-treated controls (30±1 vs 19±1 and 20±1 %, respectively, p<0.001; Figure 1A). CMR also revealed reduced LV dilatation with anti-CD14-treatment compared to control groups (76±5 vs 102±8 and 107±7 µl EDV in saline- and isotype-treated controls, respectively, p<0.05). Parasternal long axis echocardiography at 28 days post-STEMI confirmed that anti-CD14 antibody treatment was associated with greater LV systolic function compared to saline and isotype controls (30±1 vs 24±1 and 25±2 % EF, respectively, p<0.05; Figure 1B). Preservation of LV end-diastolic (86±4 vs 111±6 and 101±5 µl, p<0.01) and end-systolic (61±3 vs 84±5 and 77±5 µl, p<0.01) volumes was also observed with anti-CD14 treatment. Global longitudinal strain (GLS) of the LV was also significantly greater at 28 days post-STEMI with anti-CD14 treatment relative to saline and isotype controls (-8.5±0.4 vs -6.8±0.3 and -6.6±0.4 %, respectively, p<0.05). Conclusion(s) The findings of this fully blinded and randomised preclinical study provide evidence of a clinically practicable strategy of CD14 blockade initiated at reperfusion to mitigate progressive LV systolic dysfunction and dilatation post-STEMI.Figure 1.Functional outcome measures

Characterization of dynamic changes in cardiac microstructure after reperfused ST-elevation myocardial infarction by biphasic diffusion tensor cardiovascular magnetic resonance.

Microstructural disturbances underlie dysfunctional contraction and adverse left ventricular (LV) remodelling after ST-elevation myocardial infarction (STEMI). Biphasic diffusion tensor cardiovascular magnetic resonance (DT-CMR) quantifies dynamic reorientation of sheetlets (E2A) from diastole to systole during myocardial thickening, and markers of tissue integrity [mean diffusivity (MD) and fractional anisotropy (FA)]. This study investigated whether microstructural alterations identified by biphasic DT-CMR: (i) enable contrast-free detection of acute myocardial infarction (MI); (ii) associate with severity of myocardial injury and contractile dysfunction; and (iii) predict adverse LV remodelling. Biphasic DT-CMR was acquired 4 days (n = 70) and 4 months (n = 66) after reperfused STEMI and in healthy volunteers (HVOLs) (n = 22). Adverse LV remodelling was defined as an increase in LV end-diastolic volume ≥ 20% at 4 months. MD and FA maps were compared with late gadolinium enhancement images. Widespread microstructural disturbances were detected post-STEMI. In the acute MI zone, diastolic E2A was raised and systolic E2A reduced, resulting in reduced E2A mobility (all P < .001 vs. adjacent and remote zones and HVOLs). Acute global E2A mobility was the only independent predictor of adverse LV remodelling (odds ratio .77; 95% confidence interval .63-.94; P = .010). MD and FA maps had excellent sensitivity and specificity (all > 90%) and interobserver agreement for detecting MI presence and location. Biphasic DT-CMR identifies microstructural alterations in both diastole and systole after STEMI, enabling detection of MI presence and location as well as predicting adverse LV remodelling. DT-CMR has potential to provide a single contrast-free modality for MI detection and prognostication of patients after acute STEMI.

Position statement for improvement in reperfusion of ST-elevation myocardial infarction in Latin America

Position statement for improvement in reperfusion of ST-elevation myocardial infarction in Latin America

Position statement for improvement in reperfusion of ST-elevation myocardial infarction in Latin America

The treatment of ST-segment elevation myocardial infarction has barriers depending on the geographic region. Primary coronary angioplasty is the treatment of choice, if it is performed on time and by experienced operators. However, when it is not available, the administration of fibrinolysis and referral for rescue angioplasty, in case of negative reperfusion, is the best strategy. In the same way, coronary angioplasty, as part of a pharmacoinvasive strategy, is the best alternative when there is positive reperfusion. The development of infarct treatment networks increases the number of patients reperfused within the recommended times and improves outcomes. In Latin America, national myocardial infarction treatment programs should focus on improving outcomes, and long-term success depends on working toward defined goals and enhancing functionality, therefore programs should develop capacity to measure their performance. The following document discusses all of these alternatives and suggests opportunities for improvement.

Incidence and predictors of heart failure with reduced and preserved ejection fraction after ST-elevation myocardial infarction in the contemporary era of early percutaneous coronary intervention.

The development and incidence of de-novo heart failure after ST-elevation myocardial infarction (STEMI) in the contemporary era of rapid reperfusion are largely unknown. We aimed to establish the incidence of post-STEMI heart failure, stratified by left ventricular ejection fraction (LVEF) and to find predictors for its occurrence. Furthermore, we investigated the course of left ventricular systolic and diastolic function after STEMI. A total of 1172 all-comer STEMI patients from the CardioLines Biobank were included. Patients were predominantly male (74.5%) and 64 ± 12 years of age. During a median follow-up of 3.7 years (2.0, 5.5) we found a total incidence of post-STEMI heart failure of 10.9%, of which 52.1% heart failure with reduced ejection fraction (HFrEF), 29.4% heart failure with mildly reduced ejection fraction and 18.5% heart failure with preserved ejection fraction (HFpEF). Independent predictors for the development of HFrEF were male sex (β = 0.97, p = 0.009), lung crepitations (β = 1.09, p = 0.001), potassium level (mmol/L, β = 0.43, p = 0.012), neutrophil count (109/L, β = 0.09, p = 0.001) and a reduced LVEF (β = 1.91, p < 0.001) at baseline. Independent predictors for the development of HFpEF were female sex (β = 0.99, p = 0.029), pre-existing kidney failure (β = 1.95, p = 0.003) and greater left atrial volume index (β = 0.04, p = 0.033) at baseline. Follow-up echocardiography (median follow-up 20 months) showed an improvement in LVEF (p < 0.001), whereas changes in diastolic function parameters showed both improvement and deterioration. In the current era of early STEMI reperfusion, still one in 10 patients develops heart failure, with approximately half of the patients with a reduced and half with a mildly reduced or normal LVEF. Predictors for the development of HFrEF were different from HFpEF.

Determinants and Prognoses of Visual-Functional Mismatches After Mechanical Reperfusion in ST-Elevation Myocardial Infarction.

Discordance between the anatomy and physiology of the coronary has important implications for managing patients with stable coronary disease, but its significance in ST-elevation myocardial infarction has not been fully elucidated. The retrospective study involved patients diagnosed with ST-elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), along with quantitative coronary angiography (QCA) and quantitative flow ratio (QFR) assessments. Patients were stratified into four groups regarding the severity of the culprit vessel, both visually and functionally: concordantly negative (QCA-diameter stenosis [DS] ≤ 50% and QFR > 0.80), mismatch (QCA-DS > 50% and QFR > 0.80), reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80), and concordantly positive (QCA-DS > 50% and QFR ≤ 0.80). Multivariable logistic regression analyses were conducted to identify the clinical factors linked to visual-functional mismatches. Kaplan‒Meier analysis was conducted to estimate the 18-month adverse cardiovascular events (MACE)-free survival between the four groups. The study involved 310 patients, with 68 presenting visual-functional mismatch, and 51 exhibiting reverse mismatch. The mismatch was associated with higher angiography-derived microcirculatory resistance (AMR) (adjusted odds ratio [aOR]=1.016, 95% CI: 1.010-1.022, P<0.001). Reverse mismatch was associated with larger area stenosis (aOR=1.044, 95% CI: 1.004-1.086, P=0.032), lower coronary flow velocity (aOR=0.690, 95% CI: 0.567-0.970, P<0.001) and lower AMR (aOR=0.947, 95% CI: 0.924-0.970, P<0.001). Additionally, the mismatch group showed the worst 18-month MACE-free survival among the four groups (Log rank test p = 0.013). AMR plays a significant role in the occurrence of visual-functional mismatches between QCA-DS and QFR, and the mismatch group showed the worst prognosis.

Cardiovascular magnetic resonance imaging-derived intraventricular pressure gradients in ST-segment elevation myocardial infarction: a long-term follow-up study.

Recently, novel post-processing tools have become available that measure intraventricular pressure gradients (IVPGs) on routinely obtained long-axis cine cardiac magnetic resonance (CMR) images. IVPGs provide a comprehensive overview of both systolic and diastolic left ventricular (LV) functions. Whether IVPGs are associated with clinical outcome after ST-elevation myocardial infarction (STEMI) is currently unknown. Here, we investigated the association between CMR-derived LV-IVPGs and major adverse cardiovascular events (MACE) in a large reperfused STEMI cohort with long-term outcome. In this prospectively enrolled multi-centre cohort study, 307 patients underwent CMR within 14 days after the first STEMI. LV-IVPGs (from apex-to-base) were estimated on the long-axis cine images. During a median follow-up of 9.7 (5.9-12.5) years, MACE (i.e. composite of cardiovascular death and de novo heart failure hospitalisation) occurred in 49 patients (16.0%). These patients had larger infarcts, more often microvascular injury, and impaired LV-IVPGs. In univariable Cox regression, overall LV-IVPG was significantly associated with MACE and remained significantly associated after adjustment for common clinical risk factors (hazard ratio (HR) 0.873, 95% confidence interval (CI) 0.794-0.961, P = 0.005) and myocardial injury parameters (HR 0.906, 95% CI 0.825-0.995, P = 0.038). However, adjusted for LV ejection fraction and LV global longitudinal strain (GLS), overall LV-IVPG does not provide additional prognostic information (HR 0.959, 95% CI 0.866-1.063, P = 0.426). Early after STEMI, CMR-derived LV-IVPGs are univariably associated with MACE and this association remains significant after adjustment for common clinical risk factors and measures of infarct severity. However, LV-IVPGs do not add prognostic value to LV ejection fraction and LV GLS.

Correlation of Electrocardiogram Changes with Epicardial and Myocardial Perfusion in ST-Elevation Myocardial Infarction

Background: The present study was aimed to find the correlation of electrocardiographic changes with epicardial thrombolysis in myocardial infarction (TIMI) flow grade and TIMI myocardial perfusion grade (TMPG) after reperfusion in ST-elevation myocardial infarction (STEMI). Methods: One hundred and fifty patients with STEMI were included. Reperfusion was done either by thrombolysis or primary percutaneous coronary intervention. The summed absolute ST-segment deviation and summed relative ST-segment deviation were calculated. TIMI and TMPG were assessed. The primary outcome measures were to study the correlation of summed absolute ST deviation and summed relative ST deviation with TIMI flow grade and TMPG after reperfusion. The secondary outcome measures were to compare TIMI flow grade and TMPG with respect to time since symptom onset to treatment and T-wave inversion after reperfusion. Results: There was a significant positive correlation between relative ST-segment deviation that occurred after reperfusion with TIMI flow grade (r = 0.475) and TMPG (r = 0.376). There was a significant negative correlation between absolute ST-segment deviation that occurred after reperfusion with TIMI flow grade (r = −0.194) and TMPG (r = −0.288). A significantly higher percentage (87.4%) of patients who got treatment within 1 h showed TMPG 2 and 3. A significantly higher percentage of patients who had T-wave inversion after reperfusion had TIMI flow Grade 3 and TMPG 2 and 3. Conclusions: There was a significant positive correlation between relative ST-segment deviation and significant negative correlation between absolute ST-segment deviation after reperfusion with TIMI flow grade and TMPG.

Management of no Reflow during Percutaneous Transcoronary Angioplasty with Catheter-Directed Intracoronary Thrombolysis: A Retrospective Observational Study.

Intracoronary thrombus is common in patients with ST-elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) is the treatment of choice for these patients. Intracoronary thrombus is still a challenge during PCI in STEMI, even with dual antiplatelets, glycoprotein IIb/IIIa inhibitor, and anticoagulation. Intracoronary thrombus can cause distal or nonculprit vessel embolization and no-reflow state. No reflow results in large infarct size, adverse left ventricular remodeling, arrhythmias, and death. Recently, catheter-directed intracoronary thrombolysis (ICT) is gaining acceptance in patients with no-reflow due to a large thrombus burden. Evaluation of catheter-directed ICT in patients with acute STEMI who develop no reflow due to large thrombus burden during PCI. This was a retrospective observational study conducted after approval of the institutional ethics committee in a tertiary care hospital of north India from April 15, 2021 to April 14, 2022, included 1020 adult patients who had undergone coronary evaluation. 37.25% patients had PCI, among these 10% had PCI for acute STEMI. Thrombolysis in myocardial infarction (TIMI) Grade 5 in 79.17% and Grade 4 in 20.83%. ICT was done with low-dose tenecteplase (15 ± 5 mg). The TIMI flow III in 91.67% and II in 8.33% of patients was achieved after intracoronary thrombolysis. Major risk factor was tobacco smoking in 41.67%, and the major complication was left ventricular failure in 33.33%. Catheter-directed ICT is safe and effective in reducing thrombus burden, thus improving myocardial reperfusion in STEMI. This condition has a grave prognosis and can lead to adverse cardiac outcomes. There are many drugs that have been tried to manage no reflow. The use of ICT to treat no-reflow state can be life saving with minimal systemic side effects.

Late myocardial reperfusion in ST-elevation myocardial infarction: protocol for a systematic review and meta-analysis

IntroductionST-segment elevation myocardial infarction (STEMI) is the most severe clinical form of acute myocardial infarction, for which the current treatment consists of effective and timely myocardial reperfusion (within 12 hours...

Predictors of hospital prenotification for STEMI and association of prenotification with outcomes

BackgroundDelay to reperfusion in ST-elevation myocardial infarction (STEMI) is detrimental, but can be minimised with prehospital notification by ambulance to the treating hospital. We aimed to assess whether prenotification was...

Sonothrombolysis Augments Reperfusion in ST-Elevation Myocardial Infarction With Primary Percutaneous Coronary Intervention: Insights From the SONOSTEMI Study

Reperfusion injury is common following primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction. In a prospective Canadian single-arm study of 15patients, the use of myocardial contrast echocardiography with high mechanical index ultrasound impulses (sonothrombolysis) initiated prior to primary PCI resulted in 7 patients with pre-PCI thrombolysis in myocardial infarction-2/3 flow (46.7%). Following reperfusion, all 15 patients had thrombolysis in myocardial infarction-3 flow, and 14 patients achieved ST-segment resolution ≥ 50% at 30 minutes post-PCI (93.3%). At 90 days, 12 patients had normal left ventricular ejection fraction ≥ 50% (80.0%). Our results demonstrate the feasibility of a novel technique to enhance reperfusion in ST-elevation myocardial infarction and provide a rationale for a randomized Canadian study.

Use of Helicopters to Reduce Health Care System Delay in Patients With ST-Elevation Myocardial Infarction Admitted to an Invasive Center

Timely reperfusion in ST-elevation myocardial infarction (STEMI) is essential. This study aimed to evaluate the reduction in system delay (time from emergency medical service [EMS] call to primary percutaneous coronary intervention [PPCI]) in patients with STEMI when using helicopter EMS (HEMS) rather than ground-based EMS (GEMS). This was a retrospective, nationwide cohort study of consecutive patients with STEMI treated with PPCI at 5 PPCI centers in Denmark. Polynomial spline curves were constructed to describe the association between system delay and distance to the PPCI center stratified by transportation mode. A total of 26,433 patients with STEMI were treated with PPCI between January 1, 1999, and December 31, 2016. In 16,436 patients field triaged directly to the PPCI center, the proportion treated within 120 minutes of the EMS call was 75% for those living 0 to 25 km from the PPCI center compared with 65% for all patients transported by GEMS (median transport distance 50 km [interquartile range 23 to 90]) and 64% for all patients transported by HEMS (median transport distance 119 km [interquartile range 99 to 142]). The estimated reduction in system delay owed to using HEMS rather than GEMS was 14, 16, 20, and 29 minutes for patients living 75, 100, 125, and 170 km from a PPCI center. In conclusion, this study confirmed that using HEMS ensures that most patients with STEMI, living up to 170 km from a PPCI center, can be treated within 120 minutes of their EMS call provided they are field triaged directly to the PPCI center.

The outcomes of reperfusion therapy with streptokinase versus tenecteplase in ST-elevation myocardial infarction (STEMI): a propensity-matched retrospective analysis in an Asian population.

Background Fibrinolysis using streptokinase or tenecteplase remains the primary reperfusion strategy for ST-elevation myocardial infarction (STEMI) in many Asian countries, including Malaysia. Comparative outcomes of these two fibrinolytic agents in the Asian population were inconclusive despite being widely used. Aim We aimed to assess and compare the outcomes of streptokinase versus tenecteplase in STEMI reperfusion of an Asian population. Method This single-centre retrospective study analysed data on STEMI patients who received fibrinolytic therapy from 2016 to 2020 in the Emergency Department of the largest tertiary hospital in Malaysia. Total population sampling was used in this study. Based on the propensity score matching, 359 patients receiving streptokinase were matched against 359 patients receiving tenecteplase by incorporating 16 variables that potentially affect mortality. 30-day mortality, stroke and major bleeding were the primary outcome measures. Results There was no significant difference in 30-day mortality between streptokinase (n = 39, 11.2%) and tenecteplase (n = 46, 13.2%) groups (p = 0.418). The rates of ischemic strokes [streptokinase (n = 1, 0.3%) versus tenecteplase (n = 3, 0.9%), p = 0.624], intracranial haemorrhage [streptokinase (n = 3, 0.9%) versus tenecteplase (n = 1, 0.3%), p = 0.624] and major bleeding [streptokinase (n = 4, 1.1%) versus tenecteplase (n = 3, 0.9%), p = 0.624], were comparable for the two groups. The incidences of failed thrombolysis were significantly higher in the tenecteplase arm. Hypotension and allergic reaction were significantly higher in the streptokinase arm. Conclusion Streptokinase and tenecteplase are fibrinolytic agents with similar efficacy and safety in STEMI reperfusion therapy in our Asian population.

Impact of paramedic education on door-to-balloon times and appropriate use of the primary PCI pathway in ST-elevation myocardial infarction

ObjectiveEvidence supports improved outcomes and reduced mortality with rapid reperfusion through primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). UK national audit data (Myocardial Ischaemia National Audit Project...

Not All STEMI Patients Receive Timely Reperfusion: Considerations for Rural Emergency Departments.

Early reperfusion for ST-elevation myocardial infarction (STEMI) is well known to improve patient outcomes. A review of patient records in one rural health service in New South Wales, Australia, suggested that not all STEMI patients were receiving timely reperfusion. Consequently, the aim of this study was to further investigate factors influencing clinical decision making by primary care providers in relation to rural STEMI patients. This cross-sectional observational study was in two phases, a retrospective audit of patient records and a survey of rural general practitioners (GPs). In the first phase, patients with STEMI who were referred from small rural hospitals to a regional hospital emergency department (ED) were identified through the local health district database. In phase two, information from the database informed questions for a survey distributed to the GP visiting medical officers (VMOs) at small rural hospitals in the region. The survey was designed to ascertain factors that may contribute to delays in the care of STEMI patients. Of the STEMI patients identified (n = 139), 15% (21) who were eligible for medical reperfusion were not administered thrombolysis within 4 hours of triage. Auditing of this group's records found that ECGs were inaccurately interpreted for 76% of the missed STEMI patients. In the survey, about 55% of the GP respondents said they “very much agree” with the statement that they felt competent in STEMI management. Only 64% of the GP VMOs agreed they felt competent in diagnosis and management of a failed thrombolysis and not all respondents were aware of the relevant clinical guideline. Patients with missed STEMI are at higher risk of morbidity and mortality and increased length of stay, adding burden to the patient, carer and health service. Without addressing gaps in service provision and better adherence to clinical guidelines, unacceptable delays in STEMI management in rural health services are likely to continue.

The Role of STEMI Communication Network with Major Adverse Cardiac Event Incidence in STEMI Patients Hospitalized in Saiful Anwar General Hospital Malang

Background : Patient with ST-Elevation Myocardial Infarction (STEMI) requires urgent reperfusion either with fibrinolytic or primary Percutaneous Coronary Intervention (PCI). In Malang, a communication network of STEMI has been developed. It connects Saiful Anwar General Hospital with all of the Public Health Centers (PHC) in Malang Raya to shorten system delay since 2015. Objective : To elucidate Malang’s communication network’s role in decreasing Major Adverse Cardiac Event (MACE) in STEMI patients. Methods : This is a retrospective cohort study. Study sample was taken from medical record. Non-network: 96 patients and 88 network patients. Statistical tests using SPSS version 20.0 software. Results : Bivariate analysis showed network-group has a significantly lower MACE (p=0.001). Door-to-balloon time was also lower in network-group (p=0.026). Multivariate analysis without confounder showed that network-group had significantly shorter door-to-reperfusion time (p=0.032) and lower MACE (p=0.035) compared to non-network group. But multivariate analysis with confounder door-to-balloon and door-to-needle failed to explain lower MACE incidence. Network-group (p=0.005) and reperfusion with primary PCI (p=0.05) significantly decreased MACE incidence. Conclusion : Malang’s STEMI communication network and reperfusion with primary PCI reduced MACE in STEMI patients in Saiful Anwar General Hospital Malang.

Cardio-pulmonary transit-time by cardiac magnetic resonance imaging: associates to infarct severity and adverse events after reperfused STEMI

Abstract Background Cardiac magnetic resonance (CMR) data on cardiopulmonary-transit-time (cpTT) and its associates with infarct characteristics and clinical outcome after reperfused ST-elevation myocardial infarction (STEMI) are lacking so far. Purpose cpTT may serve as surrogate parameter for integrative cardiac performance and has been linked to heart failure. Methods A total of 207 patients (179 men [87%], median age 55 [interquartile range (IQR) 49–64] with acute STEMI underwent CMR on day 3 [IQR 2–4] and 4 months (m) [IQR 4–5] after primary percutaneous coronary intervention. cpTT was taken as the time between the peaks of time-intensity curves of gadolinium contrast to pass from the right ventricle (RV) to the left ventricle (LV). Infarct size, extent of microvascular obstruction (MVO), RV and LV dimensions and function were assessed at both occasions. Results cpTT decreased significantly between baseline and 4m CMR scan (8.6 seconds [IQR 7.5–9.6] to 7.8 sec [IQR 7–8.7], respectively, p&amp;lt;0.0001). Patients with presence of MVO had significantly prolonged cpTT at baseline and 4m follow-up (all p&amp;lt;0.022). According to Cox regression analysis (“functional model”) baseline cpTT (hazard ratio (HR) 1.5, 95% confidence interval (CI) 1.1–2.2; p=0.008) remained significantly associated to the occurrence of major adverse cardiac events (MACE) after adjustment for LV ejection fraction (EF) and cardiac index. According to Cox regression analysis (“tissue model”) baseline cpTT (HR 1.462, 95% CI 1.02–2.09, p=0.039) as well as extent of MVO (HR 1.196, 95% CI 1.081–1.324, p=0.001) remained significantly associated to MACE after adjustment for infarct size. Baseline cpTT (area under the curve [AUC]: 0.725, 95% confidence interval [CI] 0.57–0.88; p&amp;lt;0.009) was significantly higher for the prediction of MACE compared to LV ejection fraction (AUC: 0.686, 95% CI 0.51–0.87; p=0.031. AUC difference: 0.039, p&amp;lt;0.03). In Kaplan-Meier analysis, cpTT ≥9 sec was associated with clinical adverse cardiovascular events (p=0.008). Conclusion Following reperfused STEMI, cpTT predicts prognosis independently of infarct size and systolic function. Moreover, cpTT provides significantly higher prognostic implication in comparison with LV ejection fraction. Funding Acknowledgement Type of funding sources: None. cpTT over the cardiac cycle.Computation of cpTT in 2 STEMI patients.

Acute phase segmental radial strain correlates with recovery and late gadolinium extent in ST-elevation myocardial infarction (STEMI): analysis of the abciximab intracoronary versus intravenously drug application in STEMI substudy.

The role of regional strain evaluation in patients with acute reperfused ST-elevation myocardial infarction (STEMI) is not well determined. The objective of this study was the description of regional strain characteristics in the acute and chronic phase of myocardial infarction and its correlation with symptom-to-balloon time and final extent of myocardial scar assessed by cardiac magnetic resonance imaging. The study cohort has been derived from the randomized controlled Abciximab Intracoronary versus Intravenously Drug Application in STEMI (AIDA STEMI) trial enrolled at the University of Ulm. All patients received comprehensive cardiac magnetic resonance imaging examinations in the acute phase and 6 months later. There was a significant improvement of all global deformation indices over time (global longitudinal strain: -13.1%±5.1% to -15.5%±5.8%, P=0.001; global circumferential strain: -14.4%±3.7% to -16.8%±3.6%, P<0.0001; global radial strain: 28.1%±8.7% to 31.9%±9.2%, P=0.0002). Mean radial strain of ischemic segments significantly improved (16.6%±10.8% to 23.7%±12.8%, P<0.0001), while mean radial strain of remote segments remained unchanged (40.2%±9.4% to 39.4%±9.4%, P=0.570). There was a significant correlation between acute phase radial strain of ischemic segments and either symptom-to-balloon time (P=0.013), as well as extent of late gadolinium enhancement at follow-up (P<0.0001). Using a cut-off of ≤27%, acute phase radial strain predicted infarction of the corresponding segment with high sensitivity and specificity (74.4% and 69.0% respectively, P<0.001). Segmental radial strain in the acute phase of infarction showed a significant correlation to either symptom-to-balloon-time and the extent of late gadolinium enhancement at follow-up, thus potentially serving as early surrogate for left ventricular remodeling and outcome in STEMI.