Reperfusion Strategy Research Articles

Postprocessing Method for Enhanced Left Ventricular Thrombus Detection in Echocardiography

Background and Objectives: The incidence of left ventricular thrombus has decreased in recent years due to advancements in reperfusion strategies for acute myocardial infarction and the use of medications to reduce ventricular remodeling. However, the accurate detection of thrombus remains crucial. Echocardiography is a primary diagnostic tool for thrombus detection, but in cases where the apex of the left ventricle is not clearly visualized, contrast injection is often required for diagnosis. We developed a postprocessing Left Ventricular Thrombus Detection Method (LVTDM) to enhance image details in the region of interest, enabling diagnosis without additional contrast injection. A purpose of our study is the evaluation of Left Ventricular Thrombus Detection Method. Materials and Methods: We analyzed echocardiography video files from 29 patients with apical wall motion abnormalities using LVTDM to identify the presence or absence of thrombus in the left ventricular apex. The results were verified with diagnoses obtained from the same echocardiography examinations following contrast injection. Our method demonstrated a sensitivity of 100% and a specificity of 83%, with a negative predictive value of 100% for ruling out thrombus. There was a strong correlation in thrombus detection/ruling out between LVTDM and contrast echocardiography. The Left Ventricular Thrombus Detection Method can be integrated into routine echocardiography examinations to effectively rule out thrombus when the apex is not clearly visualized. The implementation of this method has the potential to reduce the need for contrast injection by approximately half for detecting left ventricular thrombus.

Prognostic impact of the extent of coronary artery disease in patients with acute transmural myocardial infarction undergoing complete percutaneous revascularization

Abstract Background The management of acute myocardial infarction has been revolutionised by the introduction of early coronary angiography and the reperfusion strategies. Recent studies support the standard of care of complete myocardial revascularization in all patients with ST-elevation myocardial infarction (STEMI) without assessing the prognostic role of the extent of coronary artery disease (CAD). Purpose To evaluate whether the extent of CAD in patients with STEMI has a prognostic impact independent of complete myocardial revascularization. Methods Observational cohort study of 365 patients with STEMI who underwent complete revascularization. For each patient the extent of CAD has been quantified using Gensini Score (GS), which takes into account both the severity and location of the lesions. The primary endpoint of the study was all-cause mortality, while cardiovascular mortality and a composite of major adverse cardiovascular events (MACE: cardiovascular mortality, recurrent acute myocardial infarction or myocardial revascularization and stroke) were defined as secondary endpoints. To assess the prognostic role of GS in predicting all-cause mortality, the area under the curve (AUC) was calculated. The best cut-off was determined as the one that maximized Youden's index (sensitivity + specificity - 1). Results Patients with a GS >80, indicating extensive coronary disease, had significantly higher rates of both cardiovascular [4 (16.7%) vs. 12 (3.5%); p = 0.002] and all-cause mortality [5 (20.8%) vs. 24 (7%); p = 0.016], than those with a GS ≤80. A GS >80 was demonstrated to be an independent predictor of all-cause mortality [hazard ratio = 5; 95% confidence interval: 1.5-16.8; p = 0.01] Conclusions The Gensini Score can identify high-risk patients with STEMI who may benefit from more intensive therapies to improve prognosis, although current guidelines do not specify treatment based on the extent of coronary disease.Long-term outcomes according to GSPrognostic value of GS

Nap1L1 Ubiquitination Degradation-dependent Protective Effects of Wnt2 on Cardiac Ischemia/Reperfusion Injury

Abstract Background Cardiomyocyte death during ischemia/reperfusion (I/R) injury occurs following the restoration of blood flow for obstructed coronary arteries, posing a challenge to timely reperfusion strategy for ischemic heart disease. This study aimed to investigate the potential protective role of Wnt2 against cardiomyocyte death after I/R injury. Methods Serum Wnt2 levels in patients with acute myocardial infarction (AMI) before and after percutaneous coronary intervention (PCI) and in mice subjected to I/R were measured by ELISA. Cardiomyocyte death, including apoptosis and ferroptosis, which were examined by TUNEL and thiobarbituric acid reactive substances (TBARs) assay, respectively. TMT6-based proteomics analysis was used to identify critical molecules mediating the effects of Wnt2. Results Serum Wnt2 level decreased after PCI in patients with MI and was negatively correlated with cTNT and CK-MB levels within the first 48 hours post-PCI. Wnt2 also decreased in I/R mice in compared with sham group.Supplement of rbWnt2 ameliorated I/R injury as characterized by the improved cardiac function and decreased infarct area and level of asynchronicity. Proteomics analysis KEGG Enrichment top 20 of differentially expressed proteins (DEPs) included reactive oxygen species (ROS). RbWnt2 inhibited cardiomyocytes apoptosis and ferroptosis by suppressed ROS level following I/R in vivo and in vitro. Based on proteomics analysis data, most of differentially expressed proteins (DEGs) were enriched in cytoplasm or nucleus. Among them, Nucleosome assembly protein-like 1(Nap1L1) was progressively increased in hearts following I/R, and showed a negative correlation with cardiac Wnt2 level during the I/R procedure. RbWnt2 treatment significantly attenuated the upregulation of Nap1L1 induced by I/R injury in vivo and in vitro. Hypoxia/Normoxia injury elicited Nap1L1 increased both in nucleus and cytoplasm, which was attenuated by rbWnt2 treatment in AMCMs. AAV9 mediated knockdown of Nap1l1 protects heart from apoptosis and ferroptosis while overexpression of Nap1l1 partly abolished the protective effects of Wnt2 in I/R mice. Mechanistically, Wnt2 upregulated anti-oxidative enzymes (Gpx1, Gpx4, Ucp3, Sod1, Sod2) by regulation of Nap1l1 to suppress ROS level and protect cardiomycoytes following I/R injury. Further analysis revealed that binding of Wnt2 and Lrp6 enhanced the expression of Tripartite motif 11 (TRIM11, a ubiquitin E3 ligase) and subsequently promoted the degradation of Nap1l1 in cardiomyocytes, which contributes to cardiac protection following I/R injury. Conclusions Wnt2 protects the heart against I/R-induced injury by inducing Nap1L1 degradation through Lrp6/Trim11 signaling, which was mediated by suppressing ROS levels via enhancing anti-oxidation enzymes to inhibits cardiomyocytes apoptosis and ferroptosis. These findings may offer new insights for developing therapeutic strategies to prevent I/R injury.Abstract GraphConclusion

Thrombolysis versus primary percutaneous coronary intervention in patients with suspected ST-elevation myocardial infarction - a SWEDEHEART observational study

Abstract Background Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy in ST-elevation myocardial infarction (STEMI) patients provided time to reperfusion is ≤120 minutes. In patients presenting early with an estimated time to reperfusion >120 minutes, thrombolytic therapy should be considered according to European Society of Cardiology guidelines. However, there is a lack of contemporary data on patients treated with thrombolysis. Aims Our aim was to determine how often thrombolysis was administered in STEMI patients having an estimated time to reperfusion of >120 minutes and to study outcome differences between patients treated with thrombolysis compared to those treated with primary PCI. Methods We calculated transport times to nearest primary PCI centre using three-digit zip codes for each patient enrolled in the SWEDEHEART registry from 2008–2021 in the five geographic areas in Sweden routinely using thrombolysis and included those with >120 min estimated transportation time to reperfusion time. Patients without ST-elevations on prehospital ECG and ongoing chest pain as well as patients with left bundle branch block, pacemaker rhythm and patients with contraindications to thrombolysis were excluded. Patients were grouped by received reperfusion therapy with prehospital thrombolysis or no prehospital thrombolysis and studied with regard to 1- and 3-year mortality using Kaplan-Meier failure estimates and Cox regression adjusted for difference in baseline characteristics. Results A total of 1,840 patients were included of whom 1,381 (75.1%) received thrombolysis. A final diagnosis of STEMI was observed in 92.6% of patients receiving thrombolysis and 80.2% of patients treated with primary PCI. The median transport time estimate to a PCI centre was 153 minutes in both groups. Median time from onset of symptoms to reperfusion therapy was 131 minutes for the thrombolysis group and 255 minutes for the PCI group. Patients who received thrombolysis were on average 2 years younger and had fewer comorbidities such as diabetes, cancer and heart failure. Among patients treated with thrombolysis, a total of 42.7% of patients underwent rescue PCI. There was no significant difference in 365-day mortality (6.7% vs 11.8%, adjusted HR 0.84, 95% CI: 0.59-1.19, p=0.33) or 3-year mortality rates (10.3% vs 16.6%, adjusted HR 0.89, 95% CI: 0.66-1.19, p=0.44) between patients treated with thrombolysis and primary PCI groups. Conclusions In this population-based study of patients where primary PCI cannot be expeditiously used, we observed a commendable adherence rate of 75% to the ESC guidelines for thrombolysis treatment. Moreover, our findings revealed that the administration of thrombolysis was not associated with any discernible benefits or harm.Unadjusted and adjusted Cox-modelKaplan-Meier survival analysis

Impact of late reperfusion therapy in patients with inferior ST-segment elevation myocardial infarction and right ventricular dysfunction: one size never fits all

Abstract Background A significant proportion of ST-segment elevation myocardial infarction (STEMI) patients present late to the emergency room with limited evidence of benefit of reperfusion after 12 hours of symptom onset. Inferior myocardial infarction (MI) with right ventricle (RV) dysfunction is associated with high morbidity and mortality, however, the RV has a unique physiology that allows it to withstand ischemia better and recover faster. Purpose To compare adverse in-hospital cardiovascular events in latecomers with inferior STEMI and RV dysfunction admitted to a cardiovascular intensive care unit (CICU) from a low-to-middle-income country, who underwent late reperfusion treatment versus conservative treatment. Methods A retrospective cohort study was conducted from March 2022 to April 2023. Patients with inferior STEMI and RV dysfunction who received late reperfusion treatment were included. RV dysfunction was defined as a TAPSE <17 mm, tricuspid annular systolic velocity on TDI <9.5 cm/s, or a fractional area change <35%. Late reperfusion was defined as primary percutaneous coronary intervention (PCI) performed after 12 hours of symptom onset or rescue PCI after 12 hours of failed fibrinolysis. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were cardiovascular death, reinfarction, stroke, cardiogenic shock, and mechanical complications. Results During the specified period, a total of 106 patients met the inclusion criteria from a total of 1,786 patients admitted to the CICU in our center. Only 60 patients underwent late PCI, accounting for 56% of the cases, with a median time of onset of symptoms to reperfusion of 19.4 hours (IQR: 15.7, 30.2). The average age was 66.5 ± 10.4 years, and 28% were women. Although the all-cause death rate was lower among late PCI group (13.3% vs 26.1%; p=0.096), this difference did not reach statistical significance in the bivariate analysis. Stratified by cardiogenic shock, a lower rate of all-cause mortality was also observed (33% vs 55%, p=0.15). The incidence of reinfarction was significantly lower in the late PCI group (0% vs 13%, p=0.004). In the multivariate analysis, adjusting for those who underwent PCI between 12-48 hours, revascularization of latecomers was independently associated with a significant reduction of mortality (adjusted OR 0.22; 95% CI 0.05-0.92; p=0.038). In a post-hoc analysis, late PCI showed a lower association with the composite outcome of all-cause mortality and reinfarction (adjusted OR 0.16, 95% CI 0.04-0.56; P=0.004). Conclusion(s) Our study demonstrates that implementing a reperfusion strategy in latecomers with inferior STEMI and RV dysfunction significantly reduces the risk of in-hospital mortality and reinfarction. This suggests a potential benefit of expanding the therapeutic window for PCI in this high-risk population. However, prospective studies are needed to conclude these preliminary findings.

Trends in major cardiac events after ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from 2003 to 2017: the western Denmark heart registry

Abstract Background In Denmark, primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003. We recently reported a gradual decline in 1-year mortality in patients treated with pPCI-treated STEMI from 2003 to 2017. To elucidate potential causes of this observation, we examined temporal trends in the 1-year risk of major adverse cardiovascular events (MACE). Purpose To examine trends in 1-year risks of MACE following STEMI treated with pPCI from 2003 to 2017. Methods Using the Western Denmark Heart Registry, we identified STEMI patients undergoing first-time pPCI from 2003 to 2017 and divided the patients into four time periods. The main outcome was 1-year risk of MACE, defined as recurrent myocardial infarction, ischaemic stroke, or cardiovascular death. Cause-specific adjusted hazard ratios (HR) were used to assess temporal trends using the first period (2003-2006) as reference. Further, temporal trends were compared to an age-, sex-, and calendar-year matched general population. Results From 2003 to 2017, 18,540 pPCI-treated STEMI patients were identified (median [Q1-Q3] age, 64 [55-74] years); 13,639 men [74%]). Trends in 1-year risk of MACE showed a gradual reduction over time from 13.0% in 2003-2006, 11.8% in 2007-2010, 9.7% in 2011-2014, to 8.7% in 2015-2017 (Figure). The adjusted relative risk reduction was 33% when comparing 2015-2017 with 2003-2006 (adjusted HR 0.67, 95% CI 0.58-0.76). Comparable relative risk reductions were observed for all three individual components of MACE of 33-35%. Compared to the matched general population, the 1-year risk difference in MACE decreased from 11% in 2003-2006 to 7% in 2015-2017. Conclusions In a high-income European country with a fully implemented pPCI strategy, 1-year risk of MACE declined by approximately one-third after first-time STEMI between 2003 to 2017. This MACE reduction was substantially larger than observed in the matched general population, i.e., confirming an important reduction in the excess risk associated with STEMI.

Impact of a prehospital mobile cloud ECG transmission system on door-to-balloon time, myocardial damage and mid-term all-cause mortality in patients with ST-elevation myocardial infarction

Abstract Background Guidelines recommend to establish a regional reperfusion strategy to maximize the efficiency of care for patients diagnosed with ST-elevation myocardial infarction (STEMI). In Addition, the recently developed mobile cloud-based 12-lead electrocardiogram (ECG) transmission system enables the transmission of prehospital ECGs at a low cost. Medical staff can use electronic devices to access and review ECGs from anywhere. However, the effectiveness of the prehospital mobile cloud ECG system has not yet been clearly established. Objective This single-center study aims to evaluate the impact of the prehospital mobile cloud ECG system on reducing Door-to-Balloon Time (DTBT), myocardial damage, and mid-term all-cause mortality in patients with STEMI. Methods In June 2018, eight prehospital Mobile Cloud ECG Transmission systems were integrated into the regional Emergency Medical Service (EMS) in our region. This study examined and compared Door-to-Catheterization Laboratory Time (DTCT), DTBT, Onset-to-Reperfusion Time (OTRT), peak creatine kinase-MB (CK-MB) levels, and one-year mortality rates of STEMI patients in the five years before and after introducing the prehospital mobile cloud ECG system. From June 2013 to May 2023, our institute received a total of 426 STEMI patients via ambulances from these two EMS departments. After excluding 23 patients with OTRT exceeding 24 hours and 76 patients who were transferred without the system post-introduction, 327 consecutive STEMI patients who underwent emergency percutaneous coronary intervention (PCI) were included in the study. The patients were divided into two groups: 169 patients before the prehospital mobile cloud ECG system introduction and 158 patients after that. Results There were no significant differences in age, gender, past medical history, and Killip Class IV between the two groups, except for the proportion of left main trunk (LMT) lesions, which was significantly higher in the ECG group. Significant reductions were observed in both DTCT and DTBT in the group after introduction, with differences noted as (DTCT: 42 min vs. 26 min; p < 0. 001, and DTBT: 74 min vs. 56 min; p < 0.001, respectively). However, the OTRT did not show a significant difference. Peak creatine kinase-MB (CK-MB) levels did not differ between the two groups, and Kaplan-Meier analysis revealed no significant difference in one-year mortality between them. Multivariate Cox regression analysis, which included variables such as age, peak CK-MB levels, Killip Class IV, LMT lesions, OTRT and the prehospital mobile cloud ECG transmission system usage, revealed that only Killip Class IV was significantly associated with one-year mortality (hazard ratio of 2.82 and a 95% confidence interval of 1.61-4.94; p=0.0003). Conclusion The prehospital mobile cloud ECG transmission system significantly reduced DTBT, but did not lead to a reduction in myocardial damage or an improvement in mid-term prognosis.Effect of the ECG Transmission SystemKaplan-Meier analysis

A case report of acute myocardial infarction with hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disorder characterized by epistaxis, gastrointestinal bleeding, iron deficiency anemia, and arteriovenous malformations (AVMs) affecting the lungs, liver, and brain. Owing to its rarity and diagnostic challenges, early identification is often elusive. Underdiagnosis and prolonged diagnostic delays are prevalent. Here, we present the case of a 63-year-old male who presented with chest pain and was diagnosed with an ST-elevation myocardial infarction (STEMI). Subsequently, he underwent placement of a drug-eluting stent in the right coronary artery (RCA). However, recurrent postoperative epistaxis resulted in severe anemia, prompting further investigation leading to the diagnosis of hereditary hemorrhagic telangiectasia through comprehensive medical history and genetic testing. Future studies are warranted to evaluate reperfusion strategies in HHT patients presenting with myocardial infarction.

Effects of reperfusion grade and reperfusion strategy on the clinical outcome: Insights from ESCAPE-NA1 trial.

We evaluated the association of reperfusion quality and different patterns of achieved reperfusion with clinical and radiological outcomes in the ESCAPE NA1 trial. Data are from the ESCAPE-NA1 trial. Good clinical outcome [90-day modified Rankin Scale (mRS) 0-2], excellent outcome (90-day mRS0-1), isolated subarachnoid hemorrhage, symptomatic hemorrhage (sICH) on follow-up imaging, and death were compared across different levels of reperfusion defined by expanded Treatment in Cerebral Infarction (eTICI) Scale. Comparisons were also made between patients with (a) first-pass eTICI 2c3 reperfusion vs multiple-pass eTICI 2c3; (b) final eTICI 2b reperfusion vs eTICI 2b converted-to-eTICI 2c3; (c) sudden reperfusion vs gradual reperfusion if >1 pass was required. Multivariable logistic regression was used to test associations of reperfusion grade and clinical outcomes. Of 1037 included patients, final eTICI 0-1 was achieved in 46 (4.4%), eTICI 2a in 76 (7.3%), eTICI 2b in 424 (40.9%), eTICI 2c in 284 (27.4%), and eTICI 3 in 207 (20%) patients. The odds for good and excellent clinical outcome gradually increased with improved reperfusion grades (adjOR ranging from 5.7-29.3 and 4.3-17.6) and decreased for sICH and death. No differences in outcomes between first-pass versus multiple-pass eTICI 2c3, eTICI 2b converted-to-eTICI 2c3 versus unchanged eTICI 2b and between sudden versus gradual eTICI 2c3 reperfusion were observed. Better reperfusion degrees significantly improved clinical outcomes and reduced mortality, independent of the number of passes and whether eTICI 2c3 was achieved suddenly or gradually.

Improved Door-to-Needle Time After Implementation of Tenecteplase as the Preferred Thrombolytic for Acute Ischemic Stroke at a Large Community Teaching Hospital Emergency Department.

Background: Acute ischemic stroke is a leading cause of death and long-term disability. To improve patient outcomes, timely restoration of blood flow to the ischemic brain tissue is vital. One reperfusion strategy includes the administration of thrombolytics. Historically, alteplase has been the thrombolytic of choice for acute ischemic stroke; however, given recent safety and efficacy data, tenecteplase has gained popularity due to its optimal pharmacokinetic profile. Objectives: This study compares outcomes between adult patients with acute ischemic stroke who received tenecteplase as the preferred thrombolytic versus alteplase. Methods: This was a single center, retrospective cohort study that included adult patients who received intravenous thrombolytic therapy, either tenecteplase 0.25 mg/kg or alteplase 0.9 mg/kg, for acute ischemic stroke from May 2021 to December 2023. The primary outcome was door-to-needle time. Secondary safety outcomes included the incidence of symptomatic intracerebral hemorrhage (ICH), any ICH on 24-hour follow-up imaging, major extracranial bleeding, and angioedema. Secondary efficacy outcomes included discharge with a favorable neurological outcome, discharge disposition, ICU length of stay, and overall length of stay. Secondary stroke metric times evaluated include door-to-computed tomography (CT) time, CT-to-needle time, neurologist notification-to-needle time, and thrombolytic decision-to-needle time. Results: Fifty patients were included in the alteplase group and 50 patients were included in the tenecteplase group. The primary outcome, door-to-needle time, was significantly shorter in the tenecteplase group (36 vs 30 minutes, P = .006). There were no statistically significant differences found in the secondary safety and efficacy outcomes. Patients who received tenecteplase experienced significantly faster CT-to-needle times (17 vs 11 minutes, P = .006), neurologist notification-to-needle times (32 vs 25 minutes, P = .001), and thrombolytic decision-to-needle times (9 vs 5 minutes, P < .001). Conclusions: In this retrospective, observational study, there was a statistically significant decrease in door-to-needle time with tenecteplase compared to alteplase. No significant differences in secondary safety and efficacy outcomes were observed.

Angiographic Outcomes in STEMI Patients: Evaluating Pre-dilatation and Thrombus Aspiration Effects

Introduction ST-elevation myocardial infarction (STEMI) poses significant challenges in cardiovascular care, necessitating rapid and effective reperfusion strategies. The present study assesses the angiographic outcomes of pre-dilatation and thrombus aspiration (PD+TA) versus conventional treatment without thrombus aspiration (NOTA) in patients undergoing PPCI for STEMI. Methods This prospective cohort study included a total of 155 patients, with 78 assigned to the PD+TA group and 77 to the NOTA group. Baseline demographics, cardiovascular risk factors, and angiographic assessments including TIMI flow, TMPG flow, corrected TIMI frame count (CTFC), ST segment changes, and ejection fraction were compared between the groups. Results The PD+TA group exhibited significantly lower systolic (p-value: 0.021) and diastolic blood pressures (p-value: 0.046), better glucose control (p-value: 0.015), and a more pronounced reduction in ST segment elevation (p-value: 0.027) compared to the NOTA group. Although ejection fraction at presentation was similar between groups, the PD+TA group (52.29±8.80%) demonstrated a statistically significant improvement at one-month follow-up from NOTA (49.14±8.20%). TIMI 3 and TMPG 3 flow rates were comparable between groups before and after drug administration, with significant improvements in CTFC observed in the PD+TA group. Conclusion Pre-dilatation and TA during PPCI for STEMI patients may lead to improved acute angiographic outcomes, including enhanced myocardial reperfusion and reduced ischemic burden. The significant improvement in ejection fraction at one-month follow-up further supports the potential benefits of PD+TA in cardiac function recovery. Larger studies with longer-term follow-up are needed to validate these findings and determine the broader clinical implications of TA in STEMI management. Clinical trial registration: CTRI/2019/02/017520, 7th February 2019, https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=Mjk5Mjc=&amp;Enc=&amp;userName=CTRI/2019/02/017520

Reevaluate the effect of ACEI/ARB therapy at discharge on patients with STEMI in the contemporary reperfusion era.

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) had beneficial effects on clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) in the pre-reperfusion or thrombolytic era. It is unknown if the benefits persist in the contemporary reperfusion era. We sought to determine if ACEI/ARB improves clinical outcomes of patients with STEMI in the contemporary reperfusion era according to the reperfusion strategy. 12596 patients were analyzed from the prospective, nationwide, multicenter China Acute Myocardial Infarction (CAMI) Registry. These patients were classified into the no reperfusion group (n=6004) and the primary percutaneous coronary intervention (PCI) group (n=6592). Two-year all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE) were compared. In the no reperfusion group, ACEI/ARB therapy at discharge may reduce the incidences of 30-day MACCE (4.7% vs 7.4%; adjusted hazard ratio [HR]: 0.67; 95% confidence interval [CI]: 0.53-0.85; P<0.001), stroke (0.5% vs 1.1%; adjusted HR: 0.41; 95% CI: 0.21-0.83; P=0.01), and revascularization (2.1% vs 3.1%; adjusted HR: 0.66; 95% CI: 0.46-0.94; P=0.02) compared to patients not treated with ACEI/ARB. Patients treated with ACEI/ARB also showed a lower rate of two-year MACCE (17.0% versus 19.1%; adjusted HR: 0.87; 95% CI: 0.76-0.99; P=0.04). No differences were observed in the remaining outcomes. In the primary PCI group, no differences were observed for all examined outcomes before and after multivariate adjustments. Treatment with ACEI/ARB at discharge may reduce cardiovascular events in STEMI patients not receiving reperfusion, while no significant benefits were observed in those receiving primary PCI.

Extracorporeal Membrane Oxygenation and Reperfusion Strategies in High-Risk Pulmonary Embolism Hospitalizations.

To investigate the contemporary use of extracorporeal membrane oxygenation (ECMO) in conjunction with reperfusion strategies in high-risk pulmonary embolism (PE). Observational epidemiological analysis. The U.S. Nationwide Inpatient Sample (NIS) (years 2016-2020). High-risk PE hospitalizations. Use of ECMO in conjunction with thrombolysis-based reperfusion (systemic thrombolysis or catheter-directed thrombolysis) or mechanical reperfusion (surgical embolectomy or catheter-based thrombectomy) with regards to in-hospital mortality and major bleeding. We identified high-risk PE hospitalizations in the NIS (years 2016-2020) and investigated the use of ECMO in conjunction with thrombolysis-based (systemic thrombolysis or catheter-directed thrombolysis) and mechanical (surgical embolectomy or catheter-based thrombectomy) reperfusion strategies with regards to in-hospital mortality and major bleeding. Among 122,735 hospitalizations for high-risk PE, ECMO was used in 2,805 (2.3%); stand-alone in 1.4%, thrombolysis-based reperfusion in 0.4%, and mechanical reperfusion in 0.5%. Compared with neither reperfusion nor ECMO, ECMO plus thrombolysis-based reperfusion was associated with reduced in-hospital mortality (adjusted odds ratio [aOR] 0.61; 95% CI, 0.38-0.98), whereas no difference was found with ECMO plus mechanical reperfusion (aOR 1.03; 95% CI, 0.67-1.60), and ECMO stand-alone was associated with increased in-hospital mortality (aOR 1.60; 95% CI, 1.22-2.10). In the cardiac arrest subgroup, ECMO was associated with reduced in-hospital mortality (aOR 0.71; 95% CI, 0.53-0.93). Among all patients on ECMO, thrombolysis-based reperfusion was significantly associated (aOR 0.55; 95% CI, 0.33-0.91), and mechanical reperfusion showed a trend (aOR 0.75; 95% CI, 0.47-1.19) toward reduced in-hospital mortality compared with no reperfusion, without increases in major bleeding. In patients with high-risk PE and refractory hemodynamic instability, ECMO may be a valuable supportive treatment in conjunction with reperfusion treatment but not as a stand-alone treatment especially for patients suffering from cardiac arrest.

Thrombectomy Alone or Alongside Intravenous Thrombolysis in Managing Acute Ischemic Stroke Caused by Basilar Artery Occlusion: A Multicenter Observational Study.

It remains unclear whether the combination of endovascular treatment (EVT) with intravenous thrombolysis (IVT) results in a more favorable functional outcome than EVT alone in managing cases of acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO). Thus, this study aimed to compare the outcomes of two approaches-direct EVT (DEVT) and bridging therapy (IVT plus EVT)-in acute BAO patients presenting within 4.5 hours of stroke onset. This multicenter retrospective cohort study included 153 acute BAO patients presenting within 4.5 hours of stroke onset. Of these patients, 65 (42.5%) and 88 (57.5%) underwent DEVT and bridging therapy, respectively. The primary outcome was defined as good functional outcome (modified Rankin Scale, 0-3) at 90 days. Additionally, pre-operative clinical features, thrombectomy attempts, successful reperfusion rates, incidences of symptomatic intracranial hemorrhage (sICH), and mortality were compared between the two groups. At 90 days, the rate of good functional outcome was comparable between the DEVT (44.6%) and bridging-therapy (39.8%) groups (adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 0.55-2.31; p = 0.753). The bridging-therapy group exhibited a lower percentage of patients requiring ≥ 3 attempts of stent retrieval (aOR, 0.39; 95% CI, 0.16-0.93; p = 0.034). Pre-operative clinical features, rate of successful reperfusion, sICH, and mortality were similar between the two groups. In patients with BAO-induced AIS, DEVT demonstrates a comparable functional outcome to bridging therapy within 4.5 hours of symptom onset, but IVT reduces the number of thrombectomy attempts. AIS, acute ischemic stroke; LVO, large-vessel occlusion; EVT, endovascular treatment; IVT, intravenous thrombolysis; BAO, basilar artery occlusion; DEVT, direct endovascular treatment; sICH, symptomatic intracranial hemorrhage; RCT, randomized controlled trial; IRIS, Improving Reperfusion Strategies in Ischemic Stroke; TOAST, Trial of ORG 10172 in Acute Stroke Treatment; mTICI, modified thrombolysis in cerebral infarction; SD, standard deviation; IQR, interquartile range; ICAS, intracranial atherosclerotic stenosis.

The Role of Vericiguat in Early Phases of Anterior Myocardial Infarction: A Potential Game-Changer?

Anterior myocardial infarction is a critical condition with significant implications for cardiac function and patient prognosis. Despite advancements in reperfusion therapies, optimizing recovery during the early phases of myocardial infarction remains challenging. Anterior myocardial infarction can lead to substantial long-term effects on a patient's health due to extensive damage to the heart muscle, particularly the left ventricle, impacting both quality of life and overall prognosis. Vericiguat, a soluble guanylate cyclase stimulator, has shown promise in heart failure, but its role in early anterior myocardial infarction has not yet been fully explored. By enhancing soluble guanylate cyclase activity, vericiguat may increase cyclic guanosine monophosphate production, leading to vasodilation, inhibition of platelet aggregation, and potential cardioprotective effects. Currently, treatment options for anterior myocardial infarction primarily focus on reperfusion strategies and managing complications. However, there is a critical need for adjunctive therapies that specifically target the pathophysiological changes occurring in the early phases of myocardial infarction. Vericiguat's mechanism of action offers a novel approach to improving vascular function and myocardial health, potentially contributing to innovative treatment strategies that could transform the care and prognosis of patients with anterior myocardial infarction.

Double Anterior Interventricular Arteries: Prevalence and Morphological Types-A Dissection Study.

This study aimed to evaluate the prevalence of double anterior interventricular artery using the dissection method. A retrospective study was conducted between 2010 and 2024 at the Anatomy and Embryology Laboratory of the Victor Babes University of Medicine and Pharmacy in Timisoara. Eighty cases were analyzed for morphological variants of the coronary arteries, especially the anterior interventricular artery. Two cases of double anterior interventricular arteries were identified. In the first case, the two anterior interventricular arteries originated from the anterior interventricular branch of the left coronary artery. In the second case, an additional anterior interventricular artery with an aortic origin was found running along the lower third of the two interventricular grooves. This shape has not been described before in the specialized literature. Knowing the potential variations of the double left anterior descending artery is critical for interpreting cardiac imaging and choosing and planning percutaneous and surgical reperfusion strategies.

Current and Future Roles of Glycoprotein IIb-IIIa Inhibitors in Primary Angioplasty for ST-Segment Elevation Myocardial Infarction.

Acute myocardial infarction still represents the major cause of mortality in high-income countries. Therefore, considerable efforts have been focused on the treatment of myocardial infarctions in the acute and long-term phase, with special attention being paid to reperfusion strategies and adjunctive antithrombotic therapies. In fact, despite the successful mechanical recanalization of the epicardial conduit, a substantial percentage of patients still experience poor myocardial reperfusion or acute/subacute in-stent thrombosis. Due the delayed onset of action of currently available oral antiplatelet therapies, glycoprotein (GP) IIb-IIIa inhibitors could be expected to improve clinical outcomes, especially when administrated in the early phase of the infarction, due to the larger platelet composition of fresh thrombi, the dynamic nature of early thrombi, and the larger amount of viable myocardium existing in the early, as compared to a delayed, phase. Considerable evidence has accumulated regarding the benefits from GP IIb-IIIa inhibitors on mortality, especially among high-risk patients and when administered as an upstream strategy. Therefore, based on currently available data, GP IIb-IIIa inhibitors can be considered when the drug can be administered within the first 3 h of symptom onset and among high-risk patients (e.g., those with advanced Killip class or an anterior myocardial infarction). Even though it is not universally accepted, in our opinion, this strategy should be implemented in a pre-hospital setting (in an ambulance) or as soon as possible when arriving at the hospital (at the Emergency Room or Coronary Care Unit, irrespective of whether they are in spoke or hub hospitals). A new, second-generation GP IIb-IIIa inhibitor (zalunfiban) appears to be highly suitable as a pre-hospital pharmacological facilitation strategy at the time of first medical contact due to its favourable features, including its simple subcutaneous administration, rapid onset of action (15 min), and limited time of action (with a half-life of ~1 h), which is likely to minimize the risk of bleeding. The ongoing CELEBRATE trial, including 2499 STEMI patients, may potentially provide compelling data to support the upstream treatment of STEMI patients undergoing mechanical reperfusion. In fact, although the current therapeutic target of increased rates of timely reperfusion has been achieved, the future goal in myocardial infarction treatment should be to achieve the most rapid reperfusion prior to primary percutaneous coronary intervention, thus further minimizing myocardial damage, or, in some cases, even preventing it completely, and improving survival.

“A stratified pathway to stent-free reperfusion: Selecting suitable patients in ST-elevation myocardial infarction”

BackgroundThe DANAMI-3 DEFER study demonstrated that deferring stent implantation in ST-elevation myocardial infarction (STEMI) is safe, although not superior to immediate stenting. It is possible that an individualized revascularization strategy in STEMI, achieved through appropriate patient selection, could be feasible and effective. MethodsThis prospective, non-randomized study included 198 patients with STEMI who underwent primary percutaneous coronary intervention (PCI) between October 2019 and November 2021. Patients were assigned to either the deferred stenting (DS) group (n = 19) or the control group (C) undergoing immediate stenting (n = 179) based on a multimodal approach integrating coronary angiography, intravascular imaging, physiological assessments, and clinical judgment. The primary endpoints included all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). ResultsThe DS group showed a significantly lower rate of stent implantation (10.5 % vs. 97.7 %, p < 0.001) and a higher use of thrombus aspiration (89.5 % vs. 30.7 %, p < 0.001) and glycoprotein IIb/IIIa inhibitors (31.6 % vs. 6.7 %, p < 0.001) compared to the C group. No significant differences were observed between the groups in terms of all-cause mortality (5.3 % vs. 8.9 %, p = 0.59) or MACCE (10.5 % vs. 8.4 %, p = 0.71). ConclusionsThis study demonstrates the feasibility of implementing individualized reperfusion strategies in STEMI within a real-world clinical setting. The findings, while limited by the study design, generate valuable hypotheses that warrant further investigation to refine patient selection criteria and optimize outcomes.

KLF4-induced upregulation of SOCS1 ameliorates myocardial ischemia/reperfusion injury by attenuating AC16 cardiomyocyte damage and enhancing M2 macrophage polarization.

Reperfusion strategies, the standard therapy for acute myocardial infarction (AMI), may result in ischemia/reperfusion (I/R) damage. Suppressor of cytokine signaling1 (SOCS1) exerts a cardioprotective function in myocardial I/R damage. Here, we investigated epigenetic modulators that deregulateSOCS1 in cardiomyocytes under hypoxia/reoxygenation (H/R) conditions. Human AC16 cardiomyocytes were exposed to H/R conditions to generate a cell model of myocardial I/R damage. Expression of mRNA and protein was detected by quantitative PCR and western blot analysis, respectively. Cell migratory and invasive abilities were evaluated by transwell assay. Cell apoptosis and M2 macrophage polarization were assessed by flow cytometry. TNF-α, IL-1β, and IL-6 levels were examined by ELISA. The interaction of KLF4 with SOCS1 was verified by chromatin immunoprecipitationand luciferase assays. SOCS1 and transcription factor KLF4 protein levels were underexpressed by 75% and 57%, respectively, in H/R-exposed AC16 cardiomyocytes versus control cells. Under H/R conditions, forced SOCS1 expression (2.7 times) induced cell migration (2.2 times) and invasion (1.9 times) and hindered cell apoptosis (by 45%) of AC16 cardiomyocytes as well as enhanced M2 macrophage polarization (4.6 times). Mechanistically, KLF4 upregulation promoted SOCS1 transcription (2.6 times) and expression (2.6 times) by binding to the SOCS1 promoter. Decrease of SOCS1 (by 51%) reversed the effects of KLF4 upregulation on cardiomyocyte migration, invasion and apoptosis, and M2 macrophage polarization under H/R conditions. Additionally, SOCS1 and KLF4 were underexpressed by 56% and 63%, respectively, in AMI serum. Our study indicates that KLF4-induced upregulation of SOCS1 can attenuate H/R-triggered apoptosis of AC16 cardiomyocytes and enhance M2 macrophage polarization.

Five-year follow-up of OCT-guided percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction.

Compared with intravascular ultrasound guidance, there is limited evidence for optical coherence tomography (OCT) guidance during primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) patients. We investigated the role of OCT in guiding a reperfusion strategy and improving the long-term prognosis of STEMI patients. All patients who were diagnosed with STEMI and who underwent pPCI between January 2017 and December 2020 were enrolled and divided into OCT-guided versus angiography-guided cohorts. They had routine follow-up for up to 5 years or until the time of the last known contact. All-cause death and cardiovascular death were designated as the primary and secondary endpoints, respectively. A total of 3,897 patients were enrolled: 2,696 (69.2%) with OCT guidance and 1,201 (30.8%) with angiographic guidance. Patients in the OCT-guided cohort were less often treated with stenting during pPCI (62.6% vs 80.2%; p<0.001). The 5-year cumulative rates of all-cause mortality and cardiovascular mortality in the OCT-guided cohort were 10.4% and 8.0%, respectively, significantly lower than in the angiography-guided cohort (19.0% and 14.1%; both log-rank p<0.001). All 4 multivariate models showed that OCT guidance could significantly reduce 5-year all-cause mortality (hazard ratio [HR] in model 4: 0.689, 95% confidence interval [CI]: 0.551-0.862) and cardiovascular mortality (HR in model 4: 0.692, 95% CI: 0.536-0.895). After propensity score matching, the benefits of OCT guidance were consistent in terms of all-cause mortality (HR: 0.707, 95% CI: 0.548-0.913) and cardiovascular mortality (HR: 0.709, 95% CI: 0.526-0.955). Compared with angiography alone, OCT guidance may change reperfusion strategies and lead to better long-term survival in STEMI patients undergoing pPCI. Findings in the current observational study should be further corroborated in randomised trials.