Revascularization Of Infarct-related Artery Research Articles

Effect of Complete Revascularization vs. Staged PCI of Secondary Lesion on LV Systolic Function in Patient with STEMI

After a myocardial infarction, early restoration of normal coronary perfusion reduces infract size, preserves left ventricular function, and lowers mortality. Reperfusion therapy's major goal is to not only restore the culprit epicardial vessel's patency, but also to reperfuse tissue to preserve myocyte viability and hence LV function. The pathophysiology of myocardial infarction, on the other hand, is not limited to the culprit vessel. The treatment of non-culprit lesions in STEMI is a contentious issue. Previously published guidelines (the 2011 PCI and 2013 STEMI guidelines) recommended treating the culprit lesion only if the patient was in cardiogenic shock. These guidelines are based on expert opinions rather than randomized controlled trials, which take into account safety concerns such as complications from repeated intervention, a low technical success rate, a high incidence of coronary restenosis, and renal insufficiency after contrast agent use. The aim of this work is to Long-term outcomes Lt ventricular ejection fraction (6 months) between complete revascularization and culprit-only revascularization (followed by staged percutaneous coronary intervention of secondary lesions) in STEMI patients with multi vessel coronary disease undergoing primary angioplasty. This prospective analysis included 50 patients with acute ST elevation myocardial infarction who were amenable to primary coronary intervention and were admitted to the critical care unit. And was blindly randomized alternatively into 2 groups: Group A: Complete coronary revascularisation during primary percutaneous intervention. Group B: Culprit-only revascularization during primary PCI. This study enrolled 50 patients, 35 males (70%) and 15 females (30%); in G I, there were 18 males (72%) and 7 females (18%) while in G II there were 17 males (68%) and 8 females (32%). The age ranged from 34 yrs. to 82 yrs. with mean age: In G I was 61.6 (±8.9) In G II was 62.2 (±12.9) were enrolled in this study, pre-procedural EF% (Mean±St) there was no significant difference between both groups. In G I, patients had a mean EF% 49.9±10.1 Versus 48.0±11.3 seen in G II. (P=0.54) In G I, there was no a significant difference between pre- procedural versus post-procedural mean EF%. (P=0.53) In G II, there was no a significant difference between pre-procedural versus post-procedural mean EF%. (P=0.14) We concluded that There were no significant differences between infarct-related artery revascularization and multivessel revascularization in the rates of 6-month MACE, Also, there were no differences as regard in-hospital mortality, stroke, cardiogenic shock and reinfarction, ejection fraction.

Usefulness of serial post-systolic shortening by speckle tracking echocardiography to predict major adverse cardiovascular events and segmental function improvement after acute myocardial infarction.

The aim is to determine whether serial post-systolic shortening (PSS) using speckle tracking echocardiography (STE) could predict major adverse cardiovascular events (MACE), especially symptom-driven infarct-related artery (IRA) revascularization and improvement in segmental function in post-myocardial infarction patients. Ninety-four patients (average age 61.1 ± 12.5 y, 84 [84.9%] male) with new-onset acute myocardial infarction were enrolled. Serial echocardiography was performed during the initial presentation, and at 3, 6 and 12 months after admission. PSS, strain and systolic strain rate were calculated using STE. Improvement in segmental function was defined as a decrease of ≧1 grade in wall motion score. During the follow-up (29.4 ± 12.7months), 22 patients (23.4%) had MACE and 17 patients had symptom-driven IRA revascularization. In multivariate model, PSS at 3 months was independently predictive for symptom-driven IRA revascularization (Hazard ratio (HR) = 0.5, 95% CI = 0.26-0.97) and for MACE (HR = 0.4, 95% CI = 0.24-0.67) (p < 0.05). Segmental function improvements were found in 255 segments (66.1%) and ROC curve analyses showed that AUC (95% CI) of the initial PSS was 0.7(0.65-0.77) (cut-off values = -1.08, sensitivity = 58%, specificity = 73% specificity). Post-systolic shortening at 3 months is an independent predictor for symptom-driven IRA revascularization and MACE. Regional wall motion recovery also could be predicted by initial PSS. Serial assessment of two-dimensional STE should be investigated in post-myocardial infarction patients in the future.

Complete interventional revascularization versus infarct-related artery revascularization only in stemi patients – part I

Multivessel coronary artery disease is a frequent fi nding during primary PCI procedures in patients with ST-elevation myocardial infarction (STEMI). Optimal therapy of the infarct-related lesion has been largely elucidated and is stipulated in current guideline documents. Therapeutic options for the additional lesions are a subject of active debate and clinical trial worldwide – both the target degree of revascularization and its timing in relation to the index procedure remain unclear.

Coronary perivascular epicardial adipose tissue and major adverse cardiovascular events after ST segment-elevation myocardial infarction

Background and aimsPerivascular epicardial adipose tissue (pEAT) plays a key role in the progression of atherosclerosis, plaque rupture, and thrombosis. However, the relationship between pEAT and prognosis after revascularization of ST-segment elevation myocardial infarction (STEMI) is unknown. This study aimed to investigate the relationship between pEAT thickness and prognosis after STEMI. MethodsWe studied 180 STEMI patients (mean age 59.4 ± 13.3 years, 78.9% male) who underwent cardiac magnetic resonance (CMR) imaging within 1 week of prompt infarct-related artery revascularization and 52 age/sex/body mass index-matched controls (mean age 59.9 ± 13.5 years, 78.9% male). pEAT thickness indexed to body surface area at five locations, infarct size, left ventricular ejection fraction (LVEF), and coronary microvascular obstruction (MVO) were evaluated by CMR. Associations between pEAT index and 1-year composite major adverse cardiovascular events (MACE), infarct size, LVEF, and MVO were analyzed. ResultsMean pEAT indices were significantly higher in STEMI patients than controls. In STEMI patients, higher pEAT indices at the superior and inferior interventricular groove (SIVG and IIVG, respectively) were significantly associated with larger infarct size, higher prevalence of MVO, and inversely correlated with post-infarct LVEF. SIVG pEAT index was an independent predictor of composite MACE in post-STEMI patients with an odds ratio of 2.26 (95% confidence interval 1.63–3.13; p < 0.0001) after adjustment for age, sex, LVEF, and 2.71 (95% confidence interval 1.93–3.80; p < 0.0001) after adjustment for age, sex, previous myocardial infarction, diabetes mellitus, and renal function. ConclusionsSTEMI patients have significantly higher pEAT indices than controls. SIVG pEAT index independently predicts composite MACE in revascularized STEMI patients, underscoring the potentially prognostic value of this variable.

Long-Term Follow-Up of Complete Versus Lesion-Only Revascularization in STEMI and Multivessel Disease: The CvLPRIT Trial

BackgroundRandomized trials have shown that complete revascularization in patients with ST-segment elevation myocardial infarction (MI) with multivessel disease results in lower major adverse cardiovascular events (MACE) (all-cause death, MI, ischemia-driven revascularization, heart failure). ObjectivesThe goal of this study was to determine whether the benefits of complete revascularization are sustained long-term and their impact on hard endpoints. MethodsCvLPRIT (Complete versus Lesion-only Primary PCI Trial) was a randomized trial of complete inpatient revascularization versus infarct-related artery revascularization only at the index admission. Randomized patients have been followed longer-term. The components of the original primary endpoint were collected from physical and electronic patient records, and from local databases for all readmissions. ResultsThe median follow-up (achieved in >90% patients) from randomization to first event or last follow-up was 5.6 years (0.0 to 7.3 years). The primary MACE endpoint rate at this time point was 24.0% in the complete revascularization group but 37.7% of the infarct-related artery–only group (hazard ratio: 0.57; 95% confidence interval: 0.37 to 0.87; p = 0.0079). The composite endpoint of all-cause death/MI was 10.0% in the complete revascularization group versus 18.5% in the infarct-related artery–only group (hazard ratio: 0.47; 95% confidence interval: 0.25 to 0.89; p = 0.0175). In a landmark analysis (from 12 months to final follow-up), there was no significant difference between MACE, death/MI, and individual components of the primary endpoint. ConclusionsLong-term follow-up of the CvLPRIT trial shows that the significantly lower rate of MACE in the complete revascularization group, previously seen at 12 months, is sustained to a median of 5.6 years. A significant difference in composite all-cause death/MI favoring the complete revascularization was also observed. (Complete versus Lesion-only Primary PCI Trial; ISRCTN70913605)

Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials including 7,423 patients (CR = 3,574 and IRA = 3,849), with a follow-up of 2.0±0.8 years were included. There was a significant reduction in MACE with CR versus IRA (10.7% vs 18.6%, relative risk [RR] 0.64, 95% confidence interval [CI] 0.51 to 0.81, p = 0.002, I2 = 66%), with higher risk reduction with immediate versus stages revascularization (RR 0.40, 95% CI 0.32 to 0.5 vs RR 0.69, 95% CI 0.54 to 0.89, P-interaction = 0.002). Complete revascularization was associated with lower rates of repeat revascularization (4.0% vs 11.7%, RR 0.44, 95% CI 0.28 to 0.70, p<0.0001, I2 = 81%), and a nonsignificant trend toward lower cardiovascular mortality (2.8% vs 3.7%, RR 0.78, 95% CI 0.60 to 1.03, p = 0.08, I2 = 0%). However, there was no difference between the 2 strategies in all-cause mortality (4.6% vs 4.8%, RR 0.90, 95% CI 0.73 to 1.12, p = 0.36, I2 = 0%), myocardial infarction (5.2% vs 6.5%, RR 0.73, 95% CI, 0.58 to 1.08, p = 0.08, I2 = 30%), stroke (1.5% vs 1.2%, RR 1.14, 95% CI 0.56 to 2.29, p = 0.33, I2 = 14%), or contrast-induced nephropathy (1.6% vs 1.2%, RR 1.35, 95% CI 0.85 to 2.15, p = 0.78, I2 = 0%). In conclusion, CR in patients with STEMI is associated with significant reduction in MACE compared with IRA. This reduction is derived mainly by the low rates of repeat revascularization in the CR group.

Value of Two-Dimensional Strain Imaging in Prediction of Myocardial Function Recovery After Percutaneous Revascularization of Infarct-Related Artery

Background: Acute myocardial infarction (MI) is often accompanied by impaired regional myocardial systolic function. A novel approach known as two-dimensional speckle tracking echocardiography was used to quantify regional LV function. Objective: The aim of the current study was to evaluate of the role of Speckle Tracking Echocardiography in prediction of left ventricular function recovery after percutaneous coronary intervention to left anterior descending coronary artery in patients with anterior ST segment elevation myocardial infarction with impaired left ventricular ejection fraction. Patients and methods: This study included 50 patients and 15 normal control adult persons. Patients had suffered from first attack of anterior STEMI. They were admitted at the CCU units of Al-Azhar University Hospitals from September 2016 to September 2018 and treated with thrombolytic therapy. Each patient was subjected to conventional transthoracic echocardiography before hospital discharge and before reperfusion. Speckle tracking echocardiography and resting SPECT were done one week after MI. Percutaneous coronary intervention to LAD within one week after MI for patients with demonstrated myocardial viability by resting SPECT. Three months after percutaneous revascularization to LAD, all patients were reevaluated using conventional TTE and strain imaging. The studied population were divided into 2 Groups; group A: 24 patients who showed post-PCI LV function recovery and Group B: 26 patients who did not showed post-PCI LV function recovery. Results: There was statistically significant increase in the prevalence of diabetes mellitus, smoking and dyslipidemia in group B. There was high statistically significant difference between the two groups as regard baseline LVEF (%), baseline wall motion score index (WMSI), mean baseline and follow up WMSI values, baseline number of affected left anterior descending (LAD) segments as assessed by WMSI, baseline and 90 days follow up mean number of affected LAD segments, baseline strain values at both global LV and territorial LAD segments. Control group showed mean territorial LAD strain was - 20.41± 0.61, mean baseline territorial LAD strain of group (A) - 13.20 ± 2.05 and mean baseline territorial LAD strain of group (B) - 8.47 ± 2.12. Regarding mean baseline territorial LAD strain and mean GLS of the LV, Receiver Operating Characteristic curve was done between group A and B for obtaining a cut off value of – 11.3 % and – 11.8 % respectively. Conclusion: LV global and territorial strain measured by 2D STE is a good predictor of LV function recovery in STEMI patients after percutaneous revascularization of infarct–related artery.

Value of Two-Dimensional Strain Imaging in Prediction of Myocardial Function Recovery After Percutaneous Revascularization of Infarct-Related Artery

Value of Two-Dimensional Strain Imaging in Prediction of Myocardial Function Recovery After Percutaneous Revascularization of Infarct-Related Artery

Complete percutaneous myocardial revascularization in patients with STEMI complicated by cardiogenic shock

Background/Aim. Despite considerable progress in terms of early myocardial revascularization and the use of mechanical circulatory support, cardiogenic shock continues to be the leading cause of death in acute myocardial infarction. The current recommendations of the European Society of Cardiology advocate early revascularization of all critical stenosis or highly unstable lesions in the state of cardiogenic shock, while recently published studies favour the early revascularization of the infarct related artery only, in patients with acute myocardial infarction with the ST segment elevation (STEMI) presenting with cardiogenic shock. The aim of the study was to assess the impact of the complete early percutaneous myocardial revascularization in an acute myocardial infarction complicated by cardiogenic shock on intra- hospital mortality. Methods. The research was conducted as a retrospective observational analysis of data obtained from the hospital registry for cardiogenic shock. The study group consisted of 235 patients treated in the period from August 2007 until October 2016 for STEMI complicated by cardiogenic shock. Three groups were formed. The first group consisted of patients with one vessel disease who underwent revascularization of infarct related artery; the second group of patients had multi-vessel disease and only culprit lesions were revascularized and the third one consisted of patients with multi-vessel disease and the complete myocardial revascularization performed. Additional subgroups were formed in reference to the intra-aortic balloon pump (IABP) implantation. Intra-hospital mortality was analyzed in all groups and subgroups. Results. Revascularization of the culprit lesion alone among patients with multivessel disease was performed in 142 (60.4%) patients while the complete revascularization (revascularization of ?culprit? and other significant lesions) was performed in 28 (11.9%) patients with multi-vessel disease. There were 65 (27.7%) patients with single-vessel disease who underwent revascularization of infarct related artery. The lowest mortality was found in the group of patients with multi-vessel coronary disease who underwent complete myocardial revascularization and had IABP implanted (mortality was 35.7%). The difference in the mean value of the left ventricular ejection fraction (EF) between the surviving and deceased patients was statistically significant (p &lt; 0.005). The average EF of survivors was 44% (35%?50%) while 30% (25%?39.5%) deceased of patients. Based on the obtained data, the mathematically predictive model was tested. The receiver operating characteristic (ROC) curve showed that our model is a good predictor of fatal outcome (p &lt; 0.0005; AUROC = 0.766) with the sensitivity of 80.3%, and the specificity of 67%. Conclusion. STEMI complicated by cardiogenic shock is still associated with a high mortality rate. Complete myocardial revascularization independently as well as in combination with an IABP, significantly reduces mortality in patients with acute STEMI complicated by cardiogenic shock.

Complete revascularization for patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease: a meta-analysis of randomized trials.

Despite the recent findings in randomized clinical trials (RCTs) with limited sample sizes and the updates in clinical guidelines, the current available data for the complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) at the time of primary percutaneous coronary intervention (PCI) are still contradictory. The aim of this meta-analysis of the existing RCTs was to assess the efficacy of the CR versus revascularization of infarct-related artery (IRA) only during primary PCI in patients with STEMI and multivessel disease (MVD). We searched PubMed, MEDLINE, Embase, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases aiming to find RCTs for patients with STEMI and MVD which compared CR with IRA-only. Random effect risk ratios (RRs) were calculated for efficacy and safety outcomes. Ten RCTs with 3291 patients were included. The median follow-up duration was 17.5 months. Major adverse cardiac events (RR=0.57; 0.43-0.76; P<0.0001), cardiac mortality (RR=0.52; 0.31-0.87; P=0.014), and repeat revascularization (RR=0.50; 0.30-0.84; P=0.009) were lower in CR compared with IRA-only strategies. However, there was no significant difference in the risk of all-cause mortality, recurrent nonfatal myocardial infarction, stroke, major bleeding events, and contrast-induced nephropathy. For patients with STEMI and MVD undergoing primary PCI, the current evidence suggests that the risk of major adverse cardiac events, repeat revascularization, and cardiac death is reduced by CR. However, the risk for all-cause mortality and PCI-related complications is not different from the isolated culprit lesion-only treatment. Although these findings support the cardiac mortality and safety benefit of CR in stable STEMI, further large trials are required to provide better guidance for optimum management of such patients.

Multivessel Revascularization Does Not Increase Contrast-Induced Acute Kidney Injury Incidence in Acute Myocardial Infarction: A Meta-Analysis.

Recent studies and meta-analysis have shown that complete revascularization (CR) compared with infarct-related artery revascularization (IRA) during percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) is associated with decreased mortality. However, it is unclear if CR versus IRA in STEMI during indexed hospitalization is associated with risk of contrast-induced acute kidney injury (CI-AKI). A database search was conducted for all randomized controlled trials that enrolled STEMI patients and compared CR versus IRA and reported CI-AKI. Comprehensive Meta-Analysis Version 2.0 (Wiley, Chichester) was used to determine summary effect size with a fixed-effect model and expressed as a risk ratio with 95% confidence intervals. A total of four trials were identified and had a mean follow-up of 24.5±9.9months, a total sample size of 1537, a mean age of 63.8±1.2 versus 64.2±2.1years, 31.2±5.3 versus 30.1±4.7% three-vessel disease, and 33.7±4.1 versus 37.2±4.5% anterior STEMI in the CR versus IRA groups, respectively. A total of 276.7±25.2 versus 186.7±15.3mL contrast was used in the CR versus IRA respectively (p=0.006). There were no statistical significant differences between the two groups in the reported incidence of CI-AKI (1.3% CR vs. 1.9% IRA; p=0.4), major bleeding (1.7% CR vs. 2.5% IRA; p=0.4) and stroke (1.1% CR vs. 0.4% IRA; p=0.24). However, there was a significantly increased incidence of cardiovascular death (2.0% CR vs. 4.7% IRA; p=0.01) and ischemia-driven revascularization (6.2% CR vs. 18.3% IRA; p<0.01). In the index hospitalization, CR in STEMI patients is associated with significant risk reduction in cardiac death and revascularization and a non-significant reduced trend of CI-AKI, despite increased use of contrast when compared with IRA.

Complete infarct-related artery revascularization in acute myocardial infarction patients. CORAMI Registry.

IntroductionThere are still limited data on the occurrence of multiple stenotic lesions within the infarct-related artery (IRA) in acute myocardial infarction (MI), and there is no consensus on the optimal treatment of this patient subgroup, which varies between centers and operators.AimTo analyse the clinical efficacy of percutaneous coronary intervention (PCI) strategy of culprit lesion only in patients with myocardial infarction.Material and methodsPatients with acute MI with the presence of at least two significant lesions in the IRA – (1) the target culprit lesion which required immediate stenting (> 50–100% stenosis) and (2) a second distal critical lesion (70–90%) – were included in the registry. Both lesions in the IRA were considered to be independent lesions requiring two separate stent platforms to be covered (no overlap). The decision on the treatment strategy of either complete (CR) or culprit-lesion-only (CLO) revascularization was at the discretion of the operator.ResultsThere were altogether 95 patients enrolled in the registry, 63 (66%) in the group with CR of the IRA and 32 (34%) with CLO revascularization, which did not differ in terms of baseline demographics. In-hospital and long-term outcomes were similar between the groups. Stent thrombosis at 1 year occurred in 1.6% in CR and in 6.2% in CLO groups respectively (statistically not significant). There were no patients from the CLO group who had a planned percutaneous coronary intervention (PCI) of the 2nd lesion in the IRA during 1-year observation.ConclusionsAt 1 year the clinical outcome was similar between those with complete and CLO PCI. Complete coverage of significant lesions did not increase the risk of stent thrombosis or need for repeated revascularization in long-term observation.

Non-culprit lesion percutaneous coronary intervention during acute myocardial infarction - the road not taken?

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Witberg G, Kornowski R. Editorial commentNon-culprit lesion percutaneous coronary intervention during acute myocardial infarction – the road not taken?. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2015;11(2):71-73. doi:10.5114/pwki.2015.52277. APA Witberg, G., & Kornowski, R. (2015). Editorial commentNon-culprit lesion percutaneous coronary intervention during acute myocardial infarction – the road not taken?. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 11(2), 71-73. https://doi.org/10.5114/pwki.2015.52277 Chicago Witberg, Guy, and Ran Kornowski. 2015. "Editorial commentNon-culprit lesion percutaneous coronary intervention during acute myocardial infarction – the road not taken?". Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej 11 (2): 71-73. doi:10.5114/pwki.2015.52277. Harvard Witberg, G., and Kornowski, R. (2015). Editorial commentNon-culprit lesion percutaneous coronary intervention during acute myocardial infarction – the road not taken?. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 11(2), pp.71-73. https://doi.org/10.5114/pwki.2015.52277 MLA Witberg, Guy et al. "Editorial commentNon-culprit lesion percutaneous coronary intervention during acute myocardial infarction – the road not taken?." Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, vol. 11, no. 2, 2015, pp. 71-73. doi:10.5114/pwki.2015.52277. Vancouver Witberg G, Kornowski R. Editorial commentNon-culprit lesion percutaneous coronary intervention during acute myocardial infarction – the road not taken?. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2015;11(2):71-73. doi:10.5114/pwki.2015.52277.

Impact of percutaneous coronary intervention on biomarker levels in patients in the subacute phase following myocardial infarction: the Occluded Artery Trial (OAT) biomarker ancillary study

BackgroundThe purpose of the Occluded Artery Trial (OAT) Biomarker substudy was to evaluate the impact of infarct related artery (IRA) revascularization on serial levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and dynamics of other biomarkers related to left ventricular remodeling, fibrosis and angiogenesis.MethodsPatients were eligible for OAT-Biomarker based on the main OAT criteria. Of 70 patients (age 60.8 ± 8.8, 25% women) enrolled in the substudy, 37 were randomized to percutaneous coronary intervention (PCI) and 33 to optimal medical therapy alone. Baseline serum samples were obtained prior to OAT randomization with follow up samples taken at one year. The primary outcome was percent change of NT-proBNP from baseline to 1 year. The secondary outcomes were respective changes of matrix metalloproteinases (MMP) 2 and 9, tissue inhibitor of matrix metalloproteinase 2 (TIMP-2), Vascular Endothelial Growth Factor (VEGF), and Galectin-3.ResultsPaired (baseline and one-year) serum samples were obtained in 62 subjects. Baseline median NT-proBNP level was 944.8 (455.3, 1533) ng/L and decreased by 69% during follow-up (p < 0.0001). Baseline MMP-2 and TIMP-2 levels increased significantly from baseline to follow-up (p = 0.034, and p = 0.027 respectively), while MMP-9 level decreased from baseline (p = 0.038). Levels of VEGF and Galectin-3 remained stable at one year (p = NS for both). No impact of IRA revascularization on any biomarker dynamics were noted.ConclusionsThere were significant changes in measured biomarkers related to LV remodeling, stress, and fibrosis following MI between 0 and 12 month. Establishing infarct vessel patency utilizing stenting 24 hours-28 days post MI did not however influence the biomarkers’ release.

Non–infarct-related artery revascularization during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A systematic review and meta-analysis

In patients with ST-elevation myocardial infarction (STEMI) and multivessel disease, guidelines recommend infarct-related artery (IRA) only intervention during primary percutaneous coronary intervention (PCI) except in patients with hemodynamic instability. To assess the available evidence, we performed a systematic review and meta-analysis comparing outcomes of non-IRA PCI as an adjunct to primary PCI (same sitting PCI [SS-PCI]) with IRA only PCI (IRA-PCI) in the setting of STEMI. A comprehensive search identified 14 studies [11 cohort, 3 randomized controlled trials] comprising of 35,239 patients. For cohort studies, patients undergoing SS-PCI had higher rate of anterior infarction (48% vs. 45%, P = .04) and cardiogenic shock (11% vs. 9%, P = .0001) at baseline compared with IRA-PCI. The primary composite end point of death, myocardial infarction and revascularization was higher in the SS-PCI group in the short term (OR, 1.63; CI, 1.12-2.37) and long term (OR, 1.60; CI, 1.18-2.16). However, after excluding patients with shock, there was no difference in primary endpoint for the short (OR, 1.33; CI, 0.67-2.63) and long term (OR, 1.39; CI, 0.80-2.42) follow-up. In analyses limited to randomized controlled trials, primary end point was similar during short term (OR, 0.79; CI, 0.19-3.28) and significantly lower for SS-PCI group in the long term (OR, 0.55; CI, 0.34-0.91). There is paucity of randomized data to guide management of STEMI patients with multivessel disease. SS-PCI group in cohort studies has higher baseline risk compared to IRA-PCI. The primary end point is higher for SS-PCI in observational cohort studies but this difference did not persist after exclusion of shock patients and for analysis limited to randomized controlled trials. These findings underscore the need of a large randomized controlled trial to guide therapy for a commonly encountered clinical situation.

TCT-469: Comparison of Clinical Outcomes between Infarct-Related Artery Revascularization only and Multivessel revascularization in Patients with Acute Myocardial Infarction and Cardiogenic Shock

TCT-469: Comparison of Clinical Outcomes between Infarct-Related Artery Revascularization only and Multivessel revascularization in Patients with Acute Myocardial Infarction and Cardiogenic Shock

001 Thromboaspiration before primary PCI in STEMI patients reduces infarct size, but not microvascular obstruction: a magnetic resonance imaging study

Thromboaspiration (TA) during primary percutaneous intervention (PCI) is effective in opening infarct related artery (IRA) in patients (pts) with ST elevation acute myocardial infarction (STEMI), leading to better reperfusion and outcome. Microvascular obstruction (MVO) after successful IRA revascularization is associated with greater myocardial damage, left ventricular (LV) impairment and higher mortality. We evaluated relationships between (i) TA and MVO 5 days after STEMI; (ii) TA and infarct size at 5 days and 6 months; (iii) TA and LV remodelling at 6 months. 51 pts aged <75, with first STEMI and totally occluded IRA, referred for primary PCI within 12 hours of onset of symptoms were enrolled. All pts underwent TA before stenting. Pts were categorized according to positive or negative TA. MVO, infarct size and remodelling were assessed by contrast-enhanced cardiac magnetic resonance imaging (MRI) at 3T performed 5 days and 6 months after STEMI. Infarct size was measured by assessing global myocardial extent of hyperenhancement on delayed contrast-enhanced MRI. MVO was defined as subendocardial areas of hypoenhanced signal surrounded by hyperenhanced myocardial tissue and expressed as % of total myocardium. See table. Positive TA during primary PCI was associated with infarct size reduction at 5 days and 6 months follow-up in STEMI pts with TIMI 0 flow IRA. Although this phenomenon led to positive LV remodelling, it was not associated with a reduction in MVO. Negative TA (N = 34) Positive TA (N = 17) p TIMI III flow post PCI (%) 91% (31/34) 94% (16/17) 0.86 MVO at 5 days (%) 7.1 ± 5.7 6.8 ± 4.9 0.85 Infarct size at 5 days (%) 20.6 ± 8.1 9.9 ± 7.2 <10-5 Infarct size at 6 months (%) 16.4 ± 9.9 7.2 ± 8.1 .0007 LVSVI at 6 months (ml/m 2 ) 27.5 ± 9.3 36.4 ± 12.2 0.01 LVSVI = left ventricular stroke volume index

Erythropoietin in Patients With Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background— Erythropoietin improves myocardial function in experimental models of myocardial infarction. The aim of the present study was to determine the value of erythropoietin in patients with acute ST-elevation myocardial infarction. Methods and Results— This randomized, double-blind study included 138 patients admitted with acute ST-elevation myocardial infarction and treated with primary percutaneous coronary intervention. Patients were randomly assigned to receive epoetin-β (3.33×104 U, n=68) or placebo (n=70) immediately and at 24 and 48 hours after percutaneous coronary intervention. The primary end point was left ventricular ejection fraction after 6 months measured by MRI. Other end points included infarct size at 5 days and 6 months. Clinical adverse events (death, recurrent myocardial infarction, stroke, and infarct-related artery revascularization) were investigated at 30 days and 6 months. Left ventricular ejection fraction at 6-month follow-up was 52.0±9.1% in the erythropoietin group compared with 51.8±9.3% in the placebo group ( P =0.92). Five days after percutaneous coronary intervention, left ventricular ejection fraction was 49.4±8.0% in the erythropoietin group and 50.8±7.3% in the placebo group ( P =0.32); infarct size was 26.8±20.9% and 28.3±24.4% ( P =0.76) and decreased to 17.3±14.3% and 20.9±16.4% at 6-month follow-up ( P =0.27). The cumulative 6-month incidence of death, recurrent myocardial infarction, stroke or target vessel revascularization was 13.2% in the erythropoietin group and 5.7% in the placebo group (hazard ratio, 2.36; 95% confidence interval, 0.73 to 7.66; P =0.15). Conclusions— In patients with acute ST-elevation myocardial infarction treated with primary percutaneous coronary intervention, erythropoietin treatment did not improve left ventricular ejection fraction or reduce infarct size but may increase clinical adverse events. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00390832.

One-year clinical outcomes with abciximab in acute myocardial infarction: results of the BRAVE-3 randomized trial

In the Bavarian Reperfusion Alternatives Evaluation (BRAVE)-3 study upstream administration of abciximab additional to 600 mg clopidogrel loading did not reduce the infarct size in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions. The aim of this study was to investigate 1-year clinical outcomes in the BRAVE-3 study patients. A total of 800 patients with acute STEMI within 24 h from symptom onset, all treated with 600 mg of clopidogrel were randomized in a double-blind fashion to receive either abciximab (n = 401) or placebo (n = 399) in the intensive care unit before being sent to the catheterization laboratory. The main outcome of interest of the present study, the composite of death, recurrent myocardial infarction, stroke or revascularization of the infarct-related artery (IRA) at 1 year, was 23.0% (92 patients) in the abciximab versus 25.7% (102 patients) in the placebo group [relative risk (RR) = 0.90, 95% confidence interval (CI) 0.67-1.20; P = 0.46]. The combined incidence of death, recurrent myocardial infarction or stroke was 9.3% in the abciximab group versus 6.0% in the placebo group (RR = 1.55, 95% CI 0.93-2.58; P = 0.09). There was a significant reduction of the IRA revascularization with abciximab compared to placebo (16.3 vs. 22.3%, RR = 0.71, 95% CI 0.52-0.98; P = 0.04). In patients with STEMI, all receiving 600 mg clopidogrel, abciximab did not improve overall clinical outcomes at 1 year after primary coronary stenting.

Temporal Changes of Myocardial Capillary Flow after Attempted Reperfusion in Acute Myocardial Infarction

Background and Objectives:As lack of myocardial perfusion was demonstrated Microvascular function after reperfusion of infarct related artery (IRA) can be changed in convalescent stage for several possible mechanisms such as hyperemia and microvascular stunning. Therefore, myocardial contrast echocardiography (MCE) performed early stage after reperfusion of IRA may cause over or underestimation of the extent of myocardial necrosis. The aims of the study were to demonstrate the temporal changes of myocardial perfusion after revascularization of IRA and to explore the association of late changes of myocardial capillary flow with contractile recovery. Methods:MCE was performed 5-7days after the attack of acute myocardial infarction (AMI) in 21 patients (M:F=17:4, age:58±12yrs) who underwent successful reperfusion of IRA. MCE was graded by semiquantitative score (0:no opacification, 0.5:partial opacification, 1:homogenous opacification) by 16 segment model. Every patient underwent 1–2months follow up 2D echocardiography and MCE. Improvement of wall motion score more than 1 at follow up was considered to have contractile recovery. Results:Thirtyone of 71 initially akinetic segments were scored as 1, 30 segments as 0.5 and 10 segments as 0 after attempted reperfusion. Twelve of 30 segments with score of 0.5 and 5 of 10 segments with score of 0 showed late improvement of MCE score to 1 and 0.5. Only 1 of 30 segments with score of 0.5 got worse to score of 0. Every segment with late improvement from 0.5 to 1 showed contractile recovery, whereas none of 5 segments with late improvement from 0 to 0.5 showed contractile recovery. There was no significant difference of predictive value between early and late MCE (p=ns). Conclusion:Temporal changes of myocardial perfusion from 1week to 2 months in AMI were mainly progressive improvement caused by recovery of microvascular function from stunning rather than progressive microvascular damage or reactive hyperemia. However, it may not significantly affect the validity of MCE in predicting contractile recovery. (Korean Circulation J 1999;29(10):1043-1052)