Reperfusion Therapy In Patients Research Articles

Estimation of ischemic core in acute ischemic stroke with CT angiography and non-contrast CT: Attenuation changes in ASPECTS regions vs. automated ASPECTS scoring.

PurposeReperfusion therapies for acute ischemic stroke due to large-vessel occlusion (AIS-LVO) are highly time-dependent, and large infarction is related to poor outcomes and risk of symptomatic hemorrhage. It is of significance to investigate and optimize the screening means and selection criteria for reperfusion therapies to identify more appropriate patients with better outcomes. This study aimed to compare the performance of attenuation changes vs. automated Alberta Stroke Program Early CT Score (ASPECTS) and using CT angiography (CTA) source images vs. non-contrast CT (NCCT) in distinguishing the infarction extent of ischemic core volumes ≥ 70 ml within different time windows.MethodsA total of 73 patients with AIS-LVO who received multimodal CT were analyzed. The automated software was used to calculate ASPECTS. Attenuation change was defined as the sum of products of relative Hounsfield unit (rHU) values times weighting factors of all 10 ASPECTS regions. rHU value of each region was the HU of the ischemic side over that of the contralateral. The corresponding weighting factors were the regression coefficients derived from a multivariable linear regression model which was used to correlate regional rHU with ischemic core volumes, because each region in the ASPECTS template is weighted disproportionally in the ASPECTS system. Automated ASPECTS and attenuation changes were both calculated using CTA and NCCT, respectively.ResultsAttenuation changes were correlated with ischemic core volumes within different time windows (Rho ranging from 0.439 to 0.637). In classification of the ischemic core ≥ 70 ml, the performances of attenuation changes were comparable with ASPECTS (area under the curve [AUC] ranging from 0.799 to 0.891), with DeLong’s test (P = 0.079, P = 0.373); using CTA (AUC = 0.842) was not different from NCCT (AUC = 0.838).ConclusionAttenuation changes in ASPECTS regions were correlated with ischemic core volumes. In the classification of infarction volumes, attenuation changes had a high diagnostic ability comparable with automated ASPECTS. Measurement of attenuation changes is not involved in complicated scoring algorithms. This measurement can be used as an available, rapid, reliable, and accurate means to evaluate infarction extent within different time windows. The usefulness of infarction volumes measured by attenuation changes to identify more appropriate patients for reperfusion therapies can be validated in future clinical trials.

Acute stroke reperfusion therapies in patients with Posterior Reversible Encephalopathy Syndrome (P5-10.006)

Acute stroke reperfusion therapies in patients with Posterior Reversible Encephalopathy Syndrome (P5-10.006)

Which is the best reperfusion therapy in patients with acute pulmonary embolism?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pulmonary embolism (PE) represents the third most common cause of cardiovascular death. Reperfusion therapy is recommended in patients with high-risk PE, while in intermediate-risk PE is controversial but could be indicated in those patients with a higher risk of hemodynamic instability and death due to right ventricular failure. Currently, the recommended reperfusion strategy in this group of patients is systemic thrombolysis. Catheter directed therapy can also be considered with less clinical evidence. Purpose Determine the safety and efficacy of catheter directed therapy compared with systemic thrombolysis in patients with acute PE who required reperfusion therapy. Methods A single-center retrospective observational cohort study was carried out in patients who were admitted for PE in a University Hospital from 2008 to 2021. Patients with intermediate-high and high risk PE, according to ESC guidelines, who underwent reperfusion therapies based on an institutional clinical practice guideline were included. Reperfusion was recommended in high-risk patients and those with intermediate-high risk who presented right ventricular dilatation associated with at least two of the following: heart rate ≥ 100bpm, systolic blood pressure ≤100mmHg or lactic acid ≥2mmol / L. Patients with surgical thrombectomy were excluded. In-hospital outcomes and 30-day follow-up between both strategies were analyzed. Results Catheter directed therapy was performed in 66% and systemic thrombolysis in 34% of the population. The prevalence of hemodynamic instability was 28.1% and in-hospital mortality was 25%. Baseline characteristics of both populations were similar and there were no differences in the location of the thrombi between both groups. In-hospital mortality and major bleeding rates between catheter directed therapy and systemic thrombolysis were similar between both strategies (27.2% vs. 23.8%) and (9.0% vs. 4.7%) respectively. Both treatment groups presented a significant reduction in right ventricular diameters after reperfusion. Only catheter directed therapy showed an improvement in right ventricular function and a reduction in pulmonary pressures. Conclusion In this population no differences were observed in terms of safety and efficacy between both reperfusion therapies. Both strategies significantly reduced right ventricular diameters after reperfusion but only catheter directed therapy improved right ventricular function and reduced pulmonary pressures after 30 days which could have implications in a lower incidence of chronic thromboembolic pulmonary hypertension.

Therapeutic Induction of Collateral Flow.

Therapeutic induction of collateral flow as a means to salvage tissue and improve outcome from acute ischemic stroke is a promising approach in the era in which endovascular therapy is no longer time-dependent but collateral-dependent. The importance of collateral flow enhancement as a therapeutic for acute ischemic stroke extends beyond those patients with large amounts of salvageable tissue. It also has the potential to extend the time window for reperfusion therapies in patients who are ineligible for endovascular thrombectomy. In addition, collateral enhancement may be an important adjuvant to neuroprotective agents by providing a more robust vascular route for which treatments can gain access to at risk tissue. However, our understanding of collateral hemodynamics, including under comorbid conditions that are highly prevalent in the stroke population, has hindered the efficacy of collateral flow augmentation for improving stroke outcome in the clinical setting. This review will discuss our current understanding of pial collateral function and hemodynamics, including vasoactivity that is critical for enhancing penumbral perfusion. In addition, mechanisms by which collateral flow can be increased during acute ischemic stroke to limit ischemic injury, that may be different depending on the state of the brain and vasculature prior to stroke, will also be reviewed.

Safety and efficacy of intra-arterial tirofiban infusion in patients with acute cardiogenic cerebral embolism undergoing endovascular reperfusion therapy

Objective: To evaluate the safety and efficacy of intra-arterial tirofiban infusion during endovascular reperfusion therapy in patients with acute cardiogenic cerebral embolism. Methods: Clinical data of 72 patients with acute cardiogenic cerebral embolism caused by large artery occlusion were retrospectively analyzed in Department of Neurology, Strategic Support Force Medical Center from August 2015 to August 2020.Among those, 52 patients were treated with intra-arterial tirofiban, the other 20 patients were treated with control medication. The baseline characteristics, modified thrombolysis in cerebral infarction (mTICI) score of responsible vessels, modified Rankin scale (mRS) score 90 days after operation, incidence of symptomatic intracranial hemorrhage and mortality were evaluated and compared in two groups. Results: The proportion of effective recanalization of the offending vessels (mTICI≥2b) in tirofiban group was higher than that in control group (92.3% vs. 75.0%), but the difference was not statistically significant (P=0.104). At 90 days after operation, the rate of patients with good prognosis (mRS≤2) in tirofiban group (61.5%) was significantly higher than that in control group (35.0%) (P<0.05). The incidence of symptomatic intracranial hemorrhage and mortality were comparable between the two groups (P>0.05). Conclusion: Intra-arterial tirofiban infusion in patients with acute cardiogenic cerebral embolism is effective and feasible, which improves the prognosis without increasing the risk of intracranial bleeding complications.

Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy.

Intravenous thrombolytics and endovascular thrombectomy for ischemic stroke have evolved in parallel. However, the best approach to combine these reperfusion therapies in patients eligible for both strategies remains uncertain. Initial randomized trials of endovascular thrombectomy included administration of intravenous thrombolytics to all eligible patients. However, whether that is of net benefit has been questioned and parallels drawn with treatment of ST-segment-elevation myocardial infarction, where intravenous thrombolytics are only given if first medical contact to percutaneous intervention is expected to be >90 minutes. Six randomized trials of a direct thrombectomy approach versus intravenous thrombolytics followed by endovascular thrombectomy have now reported their results. With exception of a minority of patients in one trial, the trials all used alteplase rather than potentially more effective tenecteplase. This review examines the current state of evidence and implications for clinical practice. Importantly, these trials only apply to patients who present to a hospital with immediate access to endovascular thrombectomy and are not relevant to patients who receive thrombolytic and are then transferred to an endovascular-capable hospital. Although 2 of the 6 randomized trials met their prespecified noninferiority margin, these margins were large compared with the absolute benefit of alteplase. Overall, functional outcome was similar, with slight trends favoring bridging thrombolytics and a significant increase in final reperfusion. Symptomatic hemorrhage was increased by ≈1.8% in the bridging group but death was nonsignificantly lower. The workflow in direct thrombectomy trials involved delaying thrombolytic administration until eligibility for thrombectomy and the trials was established and randomization completed. This reduced the time available for thrombolytics to occur prethrombectomy compared with standard practice. We conclude that, pending individual-patient data meta-analyses, intravenous thrombolytics retain an important role alongside endovascular thrombectomy. Further efforts to accelerate and enhance reperfusion with thrombolytics and perform individual patient-level pooled subgroup analyses are warranted.

Use of reperfusion therapy and time delay in patients with ischaemic stroke by immigration status: A register-based cohort study in Denmark.

Background and purposeReperfusion therapy is the mainstay of treatment for acute ischaemic stroke (AIS); however, little is known about the use of reperfusion therapy and time delay amongst immigrants.MethodsThis is a Danish nationwide register‐based cohort study of patients with AIS aged ≥18 years (n = 49,817) recruited from 2009 to 2018. Use of reperfusion therapy (intravenous thrombolysis and/or mechanical thrombectomy) and time delay between immigrants and Danish‐born residents were compared using multivariable logistics and quantile regression.ResultsOverall, 10,649 (39.8%) Danish‐born residents and 452 (39.0%) immigrants with AIS were treated with reperfusion therapy in patients arriving <4.5 h following stroke onset. Compared with Danish‐born residents, immigrants had lower odds of receiving reperfusion therapy after adjustment for prehospital delay, age, sex, stroke severity, sociodemographic factors and comorbidities (adjusted odds ratio 0.67; 95% confidence interval 0.49‒0.92, p = 0.01). The lowest odds were observed amongst immigrants originating from Poland and non‐Western countries. Similarly, immigrants had a longer prehospital delay than Danish‐born residents in the fully adjusted model in patients arriving <4.5 h after stroke onset (15 min; 95% confidence interval 4‒26 min, p = 0.03). No evidence was found that system delay and clinical outcome differed between immigrants and Danish‐born residents in patients eligible for reperfusion therapy after adjustment for sociodemographic factors and comorbidities.ConclusionImmigration status was significantly associated with lower chances of receiving reperfusion therapy and there may be differences in patient delay between immigrants and Danish‐born residents in patients arriving to a stroke unit <4.5 h after stroke onset.

Sex and Economic Disparity Related to Reperfusion Therapies for Patients with Acute Ischemic Stroke in South Korea across a 10-Year Period: A Nationwide Population-Based Study Using the National Health Insurance Database.

A complete enumeration study was conducted to evaluate trends related to reperfusion therapies (intravenous thrombolysis (IVT) and endovascular treatment (EVT)) in acute ischemic stroke (AIS) in South Korea, according to sex, economic status, and age, over a 10-year period retrospectively, using the National Health Information Database (NHIS-2020-1-481). This study included AIS patients aged ≥20 years who were hospitalized in a general hospital or tertiary hospital for ≥4 days and underwent brain imaging during the same period. Study participants were classified by sex, economic status (Medical Aid beneficiaries and National Health Insurance beneficiaries) and age (20–44, 45–64, 65–79, and ≥80 years). Women showed a significantly lower OR (Odds ratio) than men in IVT (OR: 0.75; 95% CI: 0.73–0.77), EVT (OR: 0.96; 95% CI: 0.93–0.99), and any therapy (OR: 0.82; 95% CI: 0.80–0.84). The Medical Aid beneficiaries showed significantly lower OR in IVT (OR 0.91, 95% CI 0.88–0.95), EVT (OR 0.93, 95% CI 0.89–0.98), and either therapy (OR 0.92, 95% CI 0.90–0.95) than the National Health Insurance beneficiaries. This study showed sex and economic disparity related to reperfusion therapies in patients with AIS in Korea.

Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil.

ObjectivesCerebral reperfusion therapy is recommended for the treatment of acute ischemic stroke. However, the outcomes of patients receiving this therapy in middle- and low-income countries should be better defined. This study aimed to evaluate the clinical and functional outcomes of cerebral reperfusion therapy in patients with ischemic stroke.Materials and MethodsThis retrospective study included patients with ischemic stroke treated with cerebral reperfusion therapy, including intravenous thrombolysis (IVT), mechanical thrombectomy (MT), and IVT with MT. The primary outcomes were death and disability, assessed using the modified Rankin scale (mRS), and stroke severity, assessed using the National Institutes of Health Stroke Scale (NIHSS), after intervention and 90 days after ictus. The association between the type of treatment and the primary outcome was assessed using binary logistic regression after adjusting for confounding variables. Furthermore, receiver operating characteristic (ROC) curves were generated to identify the cutoff point of the NIHSS score that could best discriminate the mRS score in all types of treatments.ResultsPatients (n = 291) underwent IVT only (n = 241), MT (n = 21), or IVT with MT (n = 29). In the IVT with MT group, the incidence of death within 90 days increased by five times (OR, 5.192; 95% CI, 2.069–13.027; p = 0.000), prevalence of disability increased by three times (OR, 3.530; 95% CI, 1.376–9.055; p = 0.009) and NIHSS score increased after IVT (from 14.4 ± 6.85 to 17.8 ± 6.36; p = 0.045). There was no significant difference between the initial NIHSS score and that after MT (p = 0.989). Patients' NIHSS score that increased or decreased by 2.5 points had a sensitivity of 0.74 and specificity of 0.65, indicating severe disability or death in these patients.ConclusionAltogether, a 2.5-point variation in NIHSS score after reperfusion is an indicator of worse outcomes. In our particular context, patients receiving the combination of IVT and MT had inferior results, which probably reflects challenges to optimize MT in LMIC.

Attenuation of ischemia–reperfusion injury by intracoronary chelating agent administration

Ischemia–reperfusion (IR) injury accelerates myocardial injury sustained during the myocardial ischemic period and thus abrogates the benefit of reperfusion therapy in patients with acute myocardial infarction. We investigated the efficacy of intracoronary ethylenediaminetetraacetic acid (EDTA) administration as an adjunctive treatment to coronary intervention to reduce IR injury in a swine model. We occluded the left anterior descending artery for 1 h. From the time of reperfusion, we infused 50 mL of EDTA-based chelating agent via the coronary artery in the EDTA group and normal saline in the control group. IR injury was identified by myocardial edema on echocardiography. Tetrazolium chloride assay revealed that the infarct size was significantly lower in the EDTA group than in the control group, and the salvage percentage was higher. Electron microscopy demonstrated that the mitochondrial loss in the cardiomyocytes of the infarcted area was significantly lower in the EDTA group than in the control group. Echocardiography after 4 weeks showed that the remodeling of the left ventricle was significantly less in the EDTA group than in the control group: end-diastolic dimension 38.8 ± 3.3 mm vs. 43.9 ± 3.7 mm (n = 10, p = 0.0089). Left ventricular ejection fraction was higher in the EDTA group (45.3 ± 10.3 vs. 34.4 ± 11.8, n = 10, respectively, p = 0.031). In a swine model, intracoronary administration of an EDTA chelating agent reduced infarct size, mitochondrial damage, and post-infarct remodeling. This result warrants further clinical study evaluating the efficacy of the EDTA chelating agent in patients with ST-segment elevation myocardial infarction.

Temporal trends in reperfusion therapy for patients with acute ischemic stroke.

ObjectivesTo analyze the temporal trends in thrombolysis rates after implementation of a regional emergency network for acute ischemic stroke (AIS).MethodsWe conducted a retrospective study based on a prospective multicenter observational registry. The AIS benefited from reperfusion therapy included in 1 of the 5 primary stroke units or 1 comprehensive stroke center and 37 emergency departments were included using a standardized case report form. The population covers 3 million inhabitants.ResultsIn total, 32,319 AIS was reported in the regional hospitalization database of which 2215 thrombolyzed AIS patients were included in the registry and enrolled in this study. The annual incidence rate of thrombolysis continuously and significantly increased from 2010 to 2018 (10.2% to 17.3%, P‐trend = 0.0013). The follow‐up of the onset‐to‐door and the door‐to‐needle delays over the study period showed stable rates, as did the all‐cause mortality rate at 3‐months (13.2%).ConclusionAlthough access to stroke thrombolysis has increased linearly since 2010, the 3‐month functional outcome has not evolved as favorably. Further efforts must focus on reducing hospital delays.

Prehospital Thrombolysis Program Reduces the Time to Reperfusion Therapy in Patients Suffering STEMI in Rural and Regional NSW

Prehospital Thrombolysis Program Reduces the Time to Reperfusion Therapy in Patients Suffering STEMI in Rural and Regional NSW

Clinical utility of MRI in acute stroke beyond reperfusion therapy.

ABSTRACTBackground:Stroke is primarily a clinical diagnosis. It can be hemorrhagic or ischemic in etiology. Computed tomography (CT) brain is usually the initial investigation in most patients with suspected stroke. Although it has excellent accuracy in diagnosing hemorrhage, ischemic changes may not be apparent in the first few hours. Some centers use focused magnetic resonance imaging (MRI) studies to help in selecting appropriate patients for reperfusion therapy. However, clinicians often use this investigation even when reperfusion therapy is not being considered. This study aims to find out whether doing an MRI in addition to a CT scan has any clinical utility in this situation.Primary Objective:To determine the proportion of patients who undergo a change in their management based on MRI findings.Secondary Objectives:1. To determine the time duration from the onset of symptoms to presentation at the hospital. 2. To determine the time duration from presentation to the hospital to get CT performed. 3. To determine the proportion of patients who had MRI in addition to CT. 4. To determine the time duration from CT performed to MRI performed.Materials and Methods: Study Design:Retrospective, descriptive observational study.Inclusion Criteria:Patients above age 18 admitted at a tertiary hospital with a clinical diagnosis of stroke between 1/8/2018 and 30/7/2019.Exclusion Criteria:Patients who had already undergone MRI before presentation to the hospital and patients undergoing thrombolysis. Patients meeting the inclusion and exclusion criteria were identified from the hospital information system and the ward admission register and by manual examination of the patients’ case notes. Relevant data were obtained from the case notes and collected on a google form and downloaded in Microsoft Excel 2019. SPSS version 22 was used for data analysis.Results:Out of the 106 patients, 54% (n = 57) were diagnosed as having ischemic stroke, whereas 46% (n = 49) were diagnosed with hemorrhagic stroke after initial assessment and CT scan. Only 2.8% (n = 3) of the patients presented within 4.5 hours of the onset of symptoms. 43.4% (n = 46) presented between 4.5 and 24 hours from the onset, whereas 53.8% (n = 57) presented more than 24 hours after the onset. Twenty-seven patients had their CT scan performed prior to their presentation at the center. For the remaining 79, the median time from presentation to CT scanning was 2 ± 1.5 hours. 24.5% (n = 26) of all patients had an MRI performed in addition to the CT scan. There was wide variation in the time from CT scanning to the MRI. Among the patients who had an MRI, additional information was obtained by the investigation in 58% (n = 15). However, this led to a change in management in only three (11.5%) of the patients. On review, it was found that the change was justified in only two patients. Furthermore, one patient who was diagnosed with tuberculoma had a long history of fever which was missed on initial evaluation. Considering these, MRI can be credited for a meaningful change in management in only 4% (n = 1) of the cases.Conclusion:The findings of this study do not support the routine use of MRI in patients who are not candidates for reperfusion therapy. Their use should be restricted to cases where some specific information is sought or where there is diagnostic uncertainty. Allocation of resources in developing integrated acute stroke pathways is likely to give a better value for money.

Outcomes after reperfusion therapies in patients with ACA stroke: A multicenter cohort study from the EVATRISP collaboration

BackgroundPatients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown. MethodsPatients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis. ResultsIncluded were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (±bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p = 0.044) and proximal ACA occlusions (43% vs. 24%, p = 0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p = 0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT. DiscussionTreatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.

Exacerbated VEGF up-regulation accompanies diabetes-aggravated hemorrhage in mice after experimental cerebral ischemia and delayed reperfusion

Reperfusion therapy is the preferred treatment for ischemic stroke, but is hindered by its short treatment window, especially in patients with diabetes whose reperfusion after prolonged ischemia is often accompanied by exacerbated hemorrhage. The mechanisms underlying exacerbated hemorrhage are not fully understood. This study aimed to identify this mechanism by inducing prolonged 2-hour transient intraluminal middle cerebral artery occlusion in diabetic Ins2Akita/+ mice to mimic patients with diabetes undergoing delayed mechanical thrombectomy. The results showed that at as early as 2 hours after reperfusion, Ins2Akita/+ mice exhibited rapid development of neurological deficits, increased infarct and hemorrhagic transformation, together with exacerbated down-regulation of tight-junction protein ZO-1 and up-regulation of blood-brain barrier-disrupting matrix metallopeptidase 2 and matrix metallopeptidase 9 when compared with normoglycemic Ins2+/+ mice. This indicated that diabetes led to the rapid compromise of vessel integrity immediately after reperfusion, and consequently earlier death and further aggravation of hemorrhagic transformation 22 hours after reperfusion. This observation was associated with earlier and stronger up-regulation of pro-angiogenic vascular endothelial growth factor (VEGF) and its downstream phospho-Erk1/2 at 2 hours after reperfusion, which was suggestive of premature angiogenesis induced by early VEGF up-regulation, resulting in rapid vessel disintegration in diabetic stroke. Endoplasmic reticulum stress-related pro-apoptotic C/EBP homologous protein was overexpressed in challenged Ins2Akita/+ mice, which suggests that the exacerbated VEGF up-regulation may be caused by overwhelming endoplasmic reticulum stress under diabetic conditions. In conclusion, the results mimicked complications in patients with diabetes undergoing delayed mechanical thrombectomy, and diabetes-induced accelerated VEGF up-regulation is likely to underlie exacerbated hemorrhagic transformation. Thus, suppression of the VEGF pathway could be a potential approach to allow reperfusion therapy in patients with diabetic stroke beyond the current treatment window. Experiments were approved by the Committee on the Use of Live Animals in Teaching and Research of the University of Hong Kong [CULATR 3834-15 (approval date January 5, 2016); 3977-16 (approval date April 13, 2016); and 4666-18 (approval date March 29, 2018)].

Remifentanil protects heart from myocardial ischaemia/reperfusion (I/R) injury via miR-206-3p/TLR4/NF-κB signalling axis.

Myocardial I/R injury is one of the most serious complications after reperfusion therapy in patients with myocardial infarction. Remifentanil has been found to protect the heart against I/R injury. However, its underlying mechanism remains uncertain in myocardial I/R injury. The myocardial I/R injury rat model was established by 30 min of ischaemia followed by 24 h of reperfusion. The animal model was evaluated by the levels of TC, ALT and AST and H&E staining. The binding of miR-206-3p and TLR4 was predicted and verified using TargetScan software, luciferase reporter and RNA pull-down assays. The functional role and mechanism of remifentanil were identified by ultrasonic echocardiography, oxidative stress markers, H&E, Masson and TUNEL staining and western blot. The rat myocardial I/R injury model displayed a significantly high level of TC, ALT, AST, TLR4, p-IκBα and p-p65 and the presence of disorganized cells and inflammatory cell infiltration. The model also showed increased levels of LVEDD, LVESD, MDA, fibrosis and apoptosis and decreased levels of EF, FS, SOD and GSH, which were reversed with remifentanil treatment. Knockdown of miR-206-3p damaged cardiac function and aggravated oxidative stress. miR-206-3p could directly bind to TLR4. TLR4 overexpression destroyed cardiac function, exacerbated oxidative stress, increased levels of p-IκBα and p-p65 and aggravated pathology manifestation affected by remifentanil. Our results elucidated that remifentanil alleviated myocardial I/R injury by miR-206-3p/TLR4/NF-κB signalling axis.

Intravenous nicorandil during primary percutaneous coronary intervention in patients with ST-Elevation myocardial infarction: Rationale and design of the Clinical Efficacy and Safety of Intravenous Nicorandil (CLEAN) trial

The efficacy and safety of intravenous infusion of nicorandil during primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) remain uncertain. The primary objective of the CLinical Efficacy and sAfety of intravenous Nicorandil (CLEAN) trial is to evaluate the long-term efficacy and safety of intravenous administration of nicorandil as adjuncts to reperfusion therapy in patients with STEMI undergoing primary PCI. The CLEAN trial is a multicenter, randomized, double-blind, placebo-controlled trial that will enroll 1,500 patients from 40 centers across china. patients were randomly (1:1) assigned to receive intravenous nicorandil (6 mg as a bolus before reperfusion, followed by 48 hours of continuous infusion at a dose of 6 mg/h after coronary intervention) or the same dose of placebo according to randomization. The primary efficacy outcome was a composite of death from cardiovascular causes, nonfatal myocardial infarction, target vessel revascularization, and unplanned hospitalization for heart failure within 12 months. The secondary efficacy outcomes included the individual components of the combined efficacy endpoint, incidence of slow coronary flow after PCI, and incidence of complete ST-segment resolution at 2 hours after PCI. the safety outcomes included the incidence of hypotension after drug infusion and other adverse events during medication. CLEAN will determine whether the addition of intravenous nicorandil as adjuncts to reperfusion therapy reduces the major adverse cardiovascular events in STEMI patients undergoing primary PCI. ClinicalTrials.gov, NCT04665648.

Predictors of mortality in patients with intermediate risk pulmonary embolism

Abstract Introduction Information about treatment and outcome of patients with pulmonary embolism (PE) intermediate risk remains limited. Little is known about the benefits of reperfusion therapy in patients with intermediate risk PE and evidence of right ventricular dysfunction. Objective To evaluate clinical outcomes and predictors of mortality in patients admitted to ICU with pulmonary embolism and intermediate risk. Methods In a prospective single-center study 103 normotensive patients with an established diagnosis of pulmonary embolism confirmed by pulmonary CT were included. All patients met intermediate risk criteria according to the European Society of Cardiology guidelines (ESC 2019) for pulmonary embolism using severity index [PESI] with signs of right ventricular dysfunction and elevated cardiac biomarkers. The average age of patients was 67.6 years (95% CI, 65.1–70.5), 42 (41%) of them were men. Thrombolysis with standard dose of alteplase was performed in 54 (52%) patients. CT scan and echocardiography were done for all patients. Results Outcome data were collected for all patients through the 30-day and 180-day follow-up. During 30 days follow up 14 patients died (13,6%, 95% CI, 6,9–20%). The all-cause mortality rate after 180 days was 22,2% (95% CI, 13,5–31%) - 22 patient. In the thrombolysis group only 2 patients died after 180-day follow-up, mortality rate was 4,4% (95% CI, 1,7–10,6%), the mortality rate in patients not treated by thrombolysis was 40% (95% CI, 25,3–54,7%). Thrombolysis was associated with a significant decrease in mortality [OR 0.07 (95% CI, 0.01–0.31)]. In the thrombolysis group 2 patients (4.1%; 95% CI, 1.1–10%) had a non-fatal major bleeding event. The presence of chronic heart failure [OR 6 (95% CI, 1.8–20.2)] and previous stroke [OR 4.3 (95% CI, 0.9–21.1)] were higher among non-survivors when compared to survivors (p≤0.05). TAPSE less than 16 mm was found to be negatively associated with survival [OR 5.5 (95% CI, 0.9–40.3)], p=0.02. Conclusion In our study thrombolysis in patients with pulmonary embolism and intermediate-risk was associated with improved prognosis. Predictors of mortality were the presence of CHF, previous stroke and TAPSE of less than 16 mm. Funding Acknowledgement Type of funding sources: None. Kaplan-Meier mortality curves. p&amp;lt;0.05

Assessment of therapeutic effects of statin on cardiac sympathetic nerve activity after reperfusion therapy in patients with first ST-segment elevation myocardial infarction and normal low-density lipoprotein cholesterol

BackgroundStatin treatment reduces enhanced cardiac sympathetic nerve activity (CSNA) in patients with heart disease, and reduces adverse cardiac events in patients with coronary artery disease. MethodsWe retrospectively evaluated the first ST-segment elevation myocardial infarction (STEMI) patients and low-density lipoprotein cholesterol < 120 mg/dL in our database who underwent 123I-metaiodobenzylguanidine (MIBG) scintigraphy 3 weeks after admission. Sixty STEMI patients after primary coronary angioplasty were selected, and used propensity score matching to compare patients treated with strong statin (n = 30), and those who did not (n = 30). Moreover, echocardiographic left ventricular (LV) parameters were determined, and plasma procollagen type III amino terminal peptide (PIIINP) was also measured before and 3 weeks after treatment. ResultsFollowing primary angioplasty, age, gender, risk factors, culprit coronary artery, peak serum creatine phosphokinase concentration, and recanalization time were similar in the two groups. However, the statin group showed significantly lower delayed total defect score and washout rate evaluated by 123I-MIBG scintigraphy (22.4 ± 8.1 vs. 29.6 ± 10.5; P < 0.01, and 30.4 ± 8.9% vs. 40.1 ± 11.4%; P < 0.005, respectively) and higher delayed heart/mediastinum count ratio (2.17 ± 0.38 vs. 1.96 ± 0.30, P < 0.05) compared with the non-statin group. Moreover, the degree of change in LV parameters and PIIINP was more favorable in the statin group than in the non-statin group. ConclusionsAdministration of statin improves CSNA after reperfusion therapy in patients with first STEMI.

June 2021 Stroke Highlights

June 2021 <i>Stroke</i> Highlights