Setting Of ST-elevation Myocardial Infarction Research Articles

Does Timing of Coronary Artery Bypass Grafting after ST-Elevation Myocardial Infarction Impact Early- and Long-Term Outcomes?

The optimal timing of surgical revascularization after ST-elevation myocardial infarction (STEMI) is controversial, with some suggesting higher mortality rates in patients undergoing early surgery. The aim of the study is to determine the effect of the timing of surgical revascularization on 30-day mortality and long-term outcomes in these patients. Retrospective single-center analysis of patients with STEMI undergoing coronary artery bypass grafting (CABG) between January 2008 and December 2019 at our institution. The cohort was split into three groups based on time from symptom onset until surgical revascularization (Group 1: <12 hours, Group 2: 12-72 hours, Group 3: >72 hours). Statistical analyses were performed with and without patients in cardiogenic shock. Primary outcomes were 30-day mortality and 10-year survival. During the study period, 437 consecutive patients underwent surgical revascularization in the setting of STEMI. The mean age was 67.0 years, 96 (22.0%) patients were female, and 281 (64.3%) patients underwent off-pump CABG. The overall 30-day mortality including patients with cardiogenic shock was 12.8%. The 30-day mortality was 16.1, 13.9, and 9.3% in Groups 1, 2, and 3 (p = 0.31), whereas 10-year survival was 48.5, 57.3, and 54.9% (log-rank: p = 0.40). After exclusion of patients in cardiogenic shock, there was no difference between the three groups in 30-day and 10-year mortality. Timing of surgery had no influence on early- and long-term survival. In patients with STEMI, early surgical revascularization achieved similar early- and long-term survival rates compared with a delayed surgical revascularization strategy. Hence, when indicated, an early CABG strategy has no disadvantages in comparison to a delayed strategy.

Disparity in the Under-Utilization of Novel P2Y12 Inhibitors in ST-Elevation Myocardial Infarction Following Percutaneous Coronary Intervention.

The most recent guidelines (European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA)) all favor prasugrel/ticagrelor over clopidogrel in the setting of acute coronary syndrome (ACS). We therefore sought to investigate which P2Y12 inhibitors were being prescribed in our community hospital setting upon discharge among patients undergoing percutaneous coronary intervention (PCI) in the setting of ST-elevation myocardial infarction (STEMI). We identified patients presenting to two Metro Detroit Michigan hospitals with STEMI between January 1, 2018, to December 31, 2021 using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) PCI registry. The primary outcome was the choice of P2Y12 inhibitor prescribed on day of discharge following hospitalization for STEMI, and baseline characteristics were compared including race, sex and type of insurance. A total of 366 patients presented to these two Metro Detroit hospitals from January 1, 2018, to December 31, 2021. Female and non-White patients were more likely to be discharged on clopidogrel than ticagrelor or prasugrel (odds ratio (OR): 1.56, confidence interval (CI): 0.99 - 2.45, and OR: 1.43, CI: 0.91 - 2.25, respectively), however, did not reach statistical significance. Patients without private insurance presenting with STEMI were more likely to be discharged on clopidogrel (OR: 1.83, CI: 1.22 - 2.74), which did reach statistical significance in our cohort. In this retrospective single-center study evaluating BMC2 registry, we demonstrate a clinically significant disparity in prescribing patterns based on insurance, with trends for disparity based on gender and ethnicity.

Strategy to Reduce Mortality Rates of ST-elevation Acute Myocardial Infarction Using Prehospital Thrombolysis: A Meta-analysis

Abstract Importance: Ischemic heart disease is the leading cause of death worldwide. In ST-elevation myocardial infarction (STEMI), delaying reperfusion from the onset of chest pain increases the incidence of mortality and morbidity. Prehospital thrombolysis (PHT) has been evaluated in the setting of STEMI. We performed a systematic analysis of studies of PHT in acute STEMI. Objective: The objective of this study was to evaluate the all-cause mortality benefit in STEMI with PHT during short-term and long-term follow-up. Data Sources: In December 2020, the Cochrane search strategy was used to analyze randomized control trials, nonrandomized control studies, and registry studies in PubMed, EMBASE, Cochrane Library, Google Scholar, ClinicalKey, and Clinical Trial Registries. The search was repeated, and the included studies were updated in June 2023 to include more recent literature. We restricted the analysis to full-text publications in English. Study Selection: Studies using any thrombolytic agent in treating acute myocardial infarction in prehospital and inhospital settings with or without percutaneous Coronary intervention (PCI) were included in the analysis. Selection criteria included patient history and symptoms, electrocardiogram findings, and cardiac markers. Data Extraction: We used the Cochrane Handbook for Systematic Reviews of Interventions for assessing bias, the PRISMA flow diagram to show the process of inclusion and exclusion of studies, and RevMan software to perform meta-analysis. Main Outcomes and Measures: Outcomes include all-cause hospital mortality rate of PHT versus inhospital thrombolysis (IHT), influence of ischemic median time on all-cause mortality with PHT, and effect of PHT before PCI. The measures must have been observed for a follow-up period of up to 35 days, 1-year, and 5-years. Results: Data from 63,814 patients from 32 studies were reviewed. Results indicate a reduction in all-cause mortality in patients assigned to PHT (odds ratio [OR] −0.68, P &lt; 0.00001) compared to IHT. There was a significant reduction in mortality when thrombolytics were administered before PCI (OR − 0.78, P = 0.0001). The overall survival was better with an ischemic time of &lt;2 h. Mortality was higher with longer ischemic time (3 h and 6 h). Among patients who presented within 2 h of the onset of chest pain, mortality was lower compared to primary PCI (pPCI). Conclusion: PHT offers faster reperfusion and reduces all-cause mortality compared to IHT. A strategy of PHT within the first 2-3 h of ischemic pain followed by PCI (if indicated) could offer better survival than pPCI.

In-hospital Outcomes of Rotational Atherectomy in ST-Elevation Myocardial Infarction: Results From the Multicentre ROTA-STEMI Network

BackgroundAlthough the use of rotational atherectomy (RA) is off-label in the setting of ST-elevation myocardial infarction (STEMI), it can be the only option in severely calcified culprit lesions to achieve procedural success. We sought to investigate the safety and feasibility of RA during primary percutaneous coronary intervention (PPCI). MethodsThis was a retrospective observational study of patients who underwent RA during PPCI from 12 European centres. The main outcomes were procedural success (defined as successful stent implantation with final thrombolysis in myocardial infarction [TIMI] flow 3 and residual stenosis < 30%) and in-hospital mortality. A comparison of patients presenting with and without shock was performed. ResultsIn 104 patients with RA during STEMI, the mean age was 72.8 ± 9.1 years, and 35% presented with cardiogenic shock. Bailout RA was performed in 76.9% of cases. Mean burr size was 1.42 ± 0.21 mm. Procedural success was achieved in 86.5% of cases, with no difference between shocked and nonshocked patients (94.4% vs 82.4%; P = 0.13). In-hospital stent thrombosis occurred in 0.96%, perforation in 1.9% and burr entrapment in 2.9% of cases. In spite of equally high procedural success, in-hospital mortality was higher in shocked (50%) compared with nonshocked patients (1.5%; P < 0.0001). ConclusionsPatients presenting with STEMI requiring RA, represent a high-risk population, frequently presenting with cardiogenic shock. In this analysis of selected patients, RA was performed as a bailout strategy in the majority, and, as such, RA seems to be feasible with a high procedural success rate. In the absence of cardiogenic shock, RA-facilitated PCI seems to be associated with low in-hospital mortality.

The added prognostic value of stress induced hyperglycemia to the GRACE risk score for the prediction of 1-year major adverse cardiovascular events in patients with ST-elevation myocardial infarction

Abstract Background There is growing evidence suggesting that Stress Induced Hyperglycemia (SIH) is a risk factor of poor prognosis in acute coronary syndrome (ACS)[1–3]. However, this parameter is not included in risk prediction scores, applied in clinical practice. Ιmportantly, there is no universally accepted definition for SIH especially in the setting of ACS. Across the existing evidence base, SIH is defined either based on admission blood glucose (ABG) levels or by calculating the glycemic gap and the stress hyperglycemia ratio (SHR)[4]. Purpose Considering the variability in SIH definitions and the need for further investigation on the long-term prognostic impact of SIH, we present herein original data concerning the prognostic role of SIH for long-term risk of major adverse cardiovascular and cerebrovascular events (MACCEs) in patients presenting with ST-elevation myocardial infarction (STEMI) on top of a traditional prediction risk score such as the GRACE 2.0 risk score. Methods Our data were derived from a post-hoc analysis of a prospective study (NCT04580173). Every trial procedure was conducted according to the principles set by the declaration of Helsinki. Each participant provided written informed consent before being enrolled in the study. Our analysis included 309 consecutive STEMI patients who were diagnosed with SIH if ABG was &amp;gt; 140 mg/dl and a fasting period of at least 8 hours was confirmed. Each participant was followed-up for a median 1-year period. Baseline characteristics of the included patients are presented in Table 1. The records of all enrolled patients were retrospectively analyzed to calculate the GRACE 2.0 risk score for each patient. Results Cox regression analysis adjusted for age, gender, body mass index (BMI), hypertension, smoking, and SIH was performed but did not identify GRACE risk score&amp;gt;140 as an independent predictor of MACCE (aHR=1.408, 95% CI:0.764-2.594 p=0.273, Figure 1). On the other hand, a similar model adjusted for the same covariates identified the combination of GRACE risk score&amp;gt;140 and SIH as a significant predictor of MACCE occurrence (aHR=2.149, 95% CI:1.224-3.771, p=0.008). Conclusions Our results suggest that SIH combined with the GRACE 2.0 risk score was associated with improved prediction of the risk for 1-year MACCE in STEMI patients as compared to the GRACE 2.0 risk score alone. In this study, SIH was diagnosed based on the levels of admission blood glucose (after 8-hours of fasting) and not based on the SHR. Despite the heterogeneity in SIH definitions, stress hyperglycemia in the setting of STEMI might be an underrated yet robust prognostic marker not only for short term but also for long term adverse clinical events, especially when integrated in existing clinical risk scores.Survival curveBaseline characteristics

Repeated Glutathione Sodium Salt Infusion May Counteract Contrast-Associated Acute Kidney Injury Occurrence in ST-Elevation Myocardial Infarction Patients Undergoing Primary PCI: A Randomized Subgroup Analysis of the GSH 2014 Trial.

Contrast-associated acute kidney injury (CA-AKI) is still a major concern for referring physicians, especially in the setting of ST-elevation myocardial infarction (STEMI) patients undergoing primary-PCI (pPCI). To evaluate whether glutathione sodium salt (GSS) infusion impacts favorably on CA-AKI, an unplanned exploratory data analysis of the GSH 2014 trial was performed. One hundred patients with STEMI were assigned at random to an experimental group (No. 50) or to a placebo group (No. 50). Treatment consisted of an intravenous infusion of GSS lasting over 10 min before p-PCI. The placebo group received the same quantity of normal saline solution. After the interventions, glutathione was administered in the same doses to both groups at 24, 48 and 72 h. CA-AKI occurred in 5 out of 50 patients (10%) allocated to the experimental group (GSS infusion) and in 19 out of 50 patients (38%) allocated to the placebo group (p between groups < 0.001). No patients in either group required renal replacement therapy. After allowing for multiple confounders, GSS administration (OR 0.17, 95% CI 0.04-0.61) and door-to-balloon time (in hours) (OR 1.61, 95% CI 1.01-2.58) have been the only independent predictors of CA-AKI. the results of this sub-study, which show a significant trend towards an improved nephroprotection in the experimental group, led to the hypothesis of a possible new prophylactic approach to counteract CA-AKI using repeated GSS infusion. Subsequent studies with specific clinical outcomes would be necessary to confirm these data.

Impact of Allopurinol Pretreatment on Coronary Blood Flow and Revascularization Outcomes after Percutaneous Coronary Intervention in Acute STEMI Patients: A Randomized Double Blind Clinical Trial.

The generation of reactive oxygen species, which is induced by the activation of the xanthine oxidase (XO) enzymatic system, is one of the primary causes of ischemia-reperfusion injury for an ischemic heart. Allopurinol, as an XO inhibitor, plays an inhibitory role in free radical production in ST-elevation myocardial infarction (STEMI) patients. The aim of this study is to evaluate the impact of allopurinol pre-treatment on post-revascularization outcomes in patients admitted with STEMI. Ninety patients with acute STEMI were enrolled in this randomized double-blind clinical trial and divided into two equal groups. The allopurinol group received a 600 mg allopurinol loading dose before the emergency PCI, and the control group received a placebo medication of the same shape. Thrombolysis in Myocardial Infarction (TIMI) flow, ECG changes, troponin level, and the occurrence of major cardiac events (MACE) during a 1-month follow-up were assessed. In the end, 81 patients were analyzed. The mean age of the patients was 59.52(11.31) and 61.3(9.25) in the allopurinol and control groups, respectively (p = 0.49). The troponin level 48 hours after the PCI and ST-elevation regression showed no significant difference between the groups [(p = 0.25) and (p = 0.21), respectively]. TIMI flow had improved in the allopurinol group compared to the placebo (p = 0.02). The PCI success rate was 78.6% and 61.5% in the case and control groups, respectively (p = 0.09). MACE and other clinical outcomes were similar between the groups (p > 0.05). This study revealed that allopurinol pre-treatment could improve TIMI flow in patients undergoing primary or rescue PCI in an acute STEMI setting.

Abstract 12220: Right Bundle Branch and Bifascicular Blocks: Insensitive Prognostic Indicators for Acute Myocardial Infarction

Introduction: The clinical significance of right bundle branch block (RBBB) or bifascicular block (BFB) in the setting of ST-elevation myocardial infarction (STEMI) is uncertain. Informed by studies demonstrating higher rates of complete occlusion of the infarct-related artery in patients presenting with RBBB, the latest guidelines on STEMI management suggest patients with persistent ischemic symptoms and RBBB be considered for emergent coronary angiography. However, there has been little study of the prognostic implication of either RBBB or BFB in the setting of undifferentiated acute chest pain, and even less of the degree of ST-elevation in concomitant RBBB. Methods and Results: A total of 7626 patient encounters presenting to the Baylor St. Luke’s Medical Center between July 2018 and July 2020 with a chief complaint of “chest pain” were identified via electronic health record query. Of these encounters, 211 (2.8%) patients were found to have RBBB. Of that cohort, 18 (8.5%) presented with acute coronary syndrome, with STEMI accounting for 6 (2.8%), non-STEMI 9 (4.3%), and unstable angina 3 (1.4%). New or presumed new RBBBs were found in 59 (28%) of total RBBB patients, of which only 5 (8.5%) were found to have acute coronary syndrome and only 2 (3.4%) STEMI specifically. Similarly, 90 (42.7%) patients with chest pain and RBBB were found to have a BFB. New or presumed new BFBs were found in 40 (19%) patients, of which only 4 (10%) were also found to have acute coronary syndrome. No patients with new-onset BFB had STEMI. Furthermore, real-time diagnosis of anterior STEMI was complicated in two patients presenting with acute coronary syndrome by the masking of ST elevation in leads V1-3 by concomitant RBBB. Conclusions: In a large cohort of undifferentiated patients who presented with chest pain and RBBB or BFB (regardless if new or presumed new), only a small fraction had acute coronary syndrome, and even fewer STEMI. These data suggest patients with undifferentiated chest pain and RBBB on ECG with clinical suspicion for acute myocardial infarction and any degree of ST-elevation in leads V1-3 be considered for emergent coronary angiography rather than RBBB or BFB without ST-segment elevation.

Layer specific strain analysis and QTc interval in patients with STEMI and TIMI 3 early after percutaneous coronary intervention

Abstract Background Heart rate-corrected (QTc) interval may increase in the setting of ST-elevation myocardial infarction (STEMI) even after complete reperfusion of the infarct-related artery. The remaining ischemia affects ventricular repolarization and may be associated with an increased susceptibility for malignant ventricular arrhythmias. Two-dimensional (2D) speckle tracking echocardiography (STE) is an angle-independent technique for evaluating myocardial function. The study aimed to analyze the layers specific strain using STE in patients after percutaneous coronary intervention (PCI) and find a possible correlation with QTc interval. Methods 74 patients with STEMI and TIMI 3 flow after PCI were enrolled. The study did not include patients with bundle branch block, pacing, or treated with drugs that could increase the QTc interval. The evaluation consisted of clinical examination and laboratory tests. 12 leads electrocardiography evaluated QTc interval. Echocardiographic acquisitions were performed in the first 24–48 hours after PCI, and data were analyzed on the workstation. The global longitudinal strain was measured from apical views, at the level of the endocardium GLSAvgEndo, transmural GLSAvg, epicardium GLSAvgEpi; the difference bewtwen endocardium and epicardium longitudinal strain: GLSAvgEndo-GLSAvgEpi. Layer-specific GLS values were measured as the average of the longitudinal strain of 17 LV segments at each individual layer (Figure 1). Results Patients were diveded in two groups: the first included 32 patients with a single vessel disease (43.24%) and the second, 42 patients (56.75%) with multiple vessel damage, but without other indication for revascularization except the culprit lesion. Values for layers strain and QTc interval in the first group were: GLSAvgEndo: −16.2 (SD 2.98, CV 0.18), GLSAvg: −11.46 (SD 6.98, CV 0.6), GLSAvgEndo-GLSAvgEpi: 3.54 (DS 1.06, CV 0.29), QTc: 452.5 (SD 22.65, CV 0.05) and in the second group: GLSAvgEndo: −13.22 (SD 4.01, CV 0.3), GLSAvg: −11.3 (SD 3.39, CV 0.29), GLSAvgEndo-GLSAvgEpi: 3.47 (CV 1.28, CV 0.37), QTc: 490ms (SD 43.07, CV 0.08). QTc interval correlated with and layers strain in the first group: GLSAvgEndo: r=0.56, GLSAvg: r=0.67, GLSendo-GLSepi: r=0.54, and in the second group: GLSAvgEndo: r=0.73, GLSAvg: r=0.75, GLSAvgEndo-GLSAvgEpi: r=0.62. Conclusions 1. The present study identified decreased longitudinal strain in all myocardial layers in the first days after STEMI, even after a successful PCI. 2. Alterations of QTc dynamicity were more frequent in patients with multivessel lesions 3. The electrical instability related by QTc interval correlated with the myocardial tissue damage related by STE. The correlation was more evident in patients with multivessel disease, even with remaining nonsignificant lesions, suggesting an ongoing process of microcirculatory perfusion damage. Funding Acknowledgement Type of funding sources: None.

Impact of residual coronary lesions on outcomes of myocardial infarction patients with multi-vessel disease

Abstract Background Interest grew in residual disease burden after percutaneous coronary intervention (PCI). The residual SYNTAX score (rSS) is a strong prognostic factor of coronary events and all-cause death in patients who underwent PCI. Its derivative, the SYNTAX Revascularisation Index (SRI), has been used in determining the proportion of coronary artery disease (CAD) that has been treated and has been shown to have prognostic utility in PCI for patients with multi-vessel disease (MVD). Purpose We sought to assess the use of the rSS and the SRI as predictors for in-hospital outcomes and up to two-year follow-up outcomes in patients with MVD who underwent PCI in the setting of ST-Elevation Myocardial Infarction (STEMI) or Non-STEMI (NSTEMI). Methods We recruited 149 patients with either STEMI or NSTEMI in the setting of MVD who underwent PCI. We divided them into tertiles, based on their rSS and SRI values, respectively. We calculated bSS and rSS using the latest version of the web-based calculator, and from these scores we calculated SRI. The endpoints were: In-hospital composite MACE and its components, in-hospital mortality, follow-up MACE, and follow-up all-cause mortality up to 2-years. Results RSS and SRI were not significant predictors of in-hospital death or MACE, while hypertension, ST-segment resolution, LVEF, and significant left main coronary artery (LMCA) lesions were independent predictors of in-hospital MACE. At two-year follow-up, Kaplan-Meier analysis showed significantly increased incidence of death and MACE within the third rSS tertile (rSS &amp;gt;12) compared to the other tertiles (log rank p&amp;lt;0.001), while there was no significant difference between the three SRI tertiles. RSS and SRI were predictors of death and MACE on univariate Cox regression analysis. On multivariate Cox regression, rSS was an independent predictor for MACE (HR=1.0696, 95% CI: 1.0147–1.1275, p=0.0123) and all-cause mortality (HR=1.1114, 95% CI: 1.0430–1.1842, p=0.0011). Of notice, all patients with complete revascularisation survived throughout the entire follow-up period. Conclusions The rSS and SRI were poor predictors of in-hospital death and MACE, while they were good predictors of death and MACE at two-year follow-up, with better overall performance for rSS in comparison to SRI. Patients with rSS values &amp;gt;12 showed significantly higher incidence of MACE and all-cause mortality at two years. The best prognosis was achieved with complete revascularisation. Funding Acknowledgement Type of funding sources: None.

Parenteral Antiplatelet Drugs in ST-Elevation Myocardial Infarction: Current Status and Future Directions.

Oral inhibitors of the platelet P2Y12 receptor are indispensable in the treatment of ST-elevation myocardial infarction (STEMI), improving outcomes and even reducing mortality in some studies. However, these drugs are limited by delayed absorption and suboptimal platelet inhibition at the time of primary percutaneous coronary intervention. Despite efforts to achieve faster and more sustained platelet inhibition, strategies such as prehospital administration, higher loading doses, and crushed formulations have not led to improved coronary reperfusion. Parenteral glycoprotein IIb/IIIa inhibitors act sooner and are more potent than oral P2Y12 inhibitors, but their use has been limited by the increased risk of major bleeding and thrombocytopenia. Hence, there is a clinical need to refine drugs that deliver rapid, effective, yet safe platelet inhibition in the setting of STEMI. Novel parenteral antiplatelet drugs, such as cangrelor, selatogrel, and zalunfiban, have been recently developed to achieve rapid, potent antiplatelet effects while preserving hemostasis. We provide a description of currently available parenteral antiplatelet agents and of those in clinical development for prehospital administration in STEMI patients.

Supplementation With Spirulina Reduces Infarct Size and Ameliorates Cardiac Function in a Pig Model of STEMI.

Background and Aims: Myocardial infarction (MI) is the clinical manifestation of atherosclerotic coronary artery disease. Spirulina is an algae known to ameliorate cardiometabolic disorders and with proven anti-inflammatory and anti-oxidant effects. We investigated, in a highly translatable animal model, whether oral supplementation with spirulina protects against the deleterious effects triggered by ST-elevation MI (STEMI). Methods: Pigs were fed a regular diet supplemented with spirulina (1 g/animal/bid) or placebo-control for 10 days. Thereafter, animals were subjected to 1.5 h percutaneous balloon-induced coronary occlusion (STEMI) followed by 2.5 h reperfusion and then sacrificed. We assessed infarct size and cardiac function. Blood samples and infarcted and remote myocardial tissue were obtained. Results: Spirulina supplementation reduced infarct size by 64%, increased myocardial salvage by 18%, and improved cardiac function by 30% vs. controls (p < 0.05). These benefits were associated with attenuation in DNA-oxidative damage and apoptotic markers and increased iNOS in the infarcted myocardium, higher AMPK activation in the remote myocardium, and lower myocardial MCP-1 expression. Systemically, spirulina attenuated Cox-2 expression in STEMI-activated peripheral blood mononuclear cells and enhanced TNF-α release acutely post-STEMI. Additionally, spirulina decreased weight gain progression over time (p < 0.05) without changes in lipids, glucose, liver or kidney parameters. Conclusion: A 10-day supplementation with spirulina exerts cardioprotection in a preclinical setting of STEMI by limiting cardiac damage and improving ventricular contractility through anti-oxidative, anti-inflammatory, and anti-apoptotic mechanisms.

Outcomes With Impella 5.0 And 5.5 In Cardiogenic Shock

<h3>Background</h3> : Cardiogenic shock is associated with a mortality rate between 40-60%, and as high as 70% in the setting of ST-elevation myocardial infarction.^1-5 In patients with cardiogenic shock, mechanical support is often needed for temporary support as a bridge to decision. The Impella 5.0 and 5.5 (Abiomed, Danvers, Massachusetts) micro-axial pumps are left ventricular assist devices (LVAD) that pull blood from the left ventricle into the ascending aorta.⁶ We sought to describe outcomes and potential complications associated with extended Impella 5.5 and 5.0 in cardiogenic shock. <h3>Methods</h3> We retrospectively evaluated patients who underwent implantation of Impella 5.0 and 5.5 in the operating room due to cardiogenic shock between August 1^st, 2018 and December 31^st, 2020 at our institution. Hemolysis was defined as plasma free hemoglobin level above 50 mg/dL, a lactate dehydrogenase (LDH) level above 500 units/L, and bilirubin increase above 1 mg/dL. <h3>Results</h3> 19 patients underwent insertion of Impella 5.0 or 5.5 in the operating room with 14 patients receiving Impella 5.5 and 5 receiving Impella 5.0. Devices were placed in the axillary artery (14), ascending aorta (3), and carotid artery (2). Mean age was 52.6 ± 13.3 years, and most patients (84%) were male. The mean left ventricular ejection fraction (LVEF) was 13.7 ± 6.8%, with 58% of patients with EF 10% or less. The etiology was acute decompensated heart failure in 14 patients and acute myocardial infarction in 5 patients. The average duration of Impella 5.5/5.0 support was 12.5 days (1, 40). Six patients (32%) had the device for more than 14 days. Four patients had Impella CP placed prior to 5.5 for 4.75 days (1,8), and two patients required support with extracorporeal membrane oxygenation (ECMO), both after CP but prior to 5.0. Seven patients (37%) were successfully bridged to either left ventricular assist device (LVAD) or heart transplantation on average of 13 ± 10.8 days after Impella insertion with 43% (6/14) of the 5.5 cohort, and 20% (1/5) of the 5.0 cohort. Overall survival rate was 32% (6/19) with rate of 36% (5/14) for Impella 5.5 and 20% (1/5) for Impella 5.0<b>.</b> Overall hemolysis rate was 47%, with 60% (3/5) in the 5.0 cohort and 43% (6/14) in the 5.5 cohort. Other complications included significant upper extremity neuropathy (1), improper positioning (6), hematoma (3), thrombus (1), and stroke (3). <h3>Conclusion</h3> : There is high mortality associated with cardiogenic shock. The Impella 5.0 and 5.5 can provide additional cardiac support and help with bridging to LVAD or heart transplantation. About a third of the patients were successfully bridged, but serious complications do occur with extended support, including hemolysis, hematoma, thrombus, and stroke. Six patients survived to discharge.

Clinical Features and Prognoses of Middle-Aged Women With ST-Elevation Myocardial Infarction With a Focus on Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) has become an increasingly recognized cause of acute coronary syndrome, particularly in young women, over the last decade. The goal of this study was to determine the prognoses and characteristics of adult women with SCAD who presented with ST-elevation myocardial infarction (STEMI). This retrospective cohort study enrolled all adult women under the age of 60 who had undergone coronary artery angiography in the setting of STEMI. The patients were divided into 3 groups based on their angiographic characteristics: STEMI-SCAD (STEMI due to SCAD), STEMI-ATH (STEMI caused by an atherosclerotic lesion), and STEMI-others (STEMI due to other etiologies including Takotsubo cardiomyopathy and myopericarditis, as well as STEMI despite a normal epicardial coronary angiography). Fifteen women out of 311 female patients aged below 60 years with STEMI were diagnosed with SCAD (4.8%). There were no significant differences in body mass index, hypertension, dyslipidemia, smoking status, opium addiction status, family history, previous percutaneous coronary intervention, coronary artery bypass grafting, and cerebrovascular accidents between the STEMI-SCAD and STEMI-ATH groups. Nevertheless, the STEMI-SCAD and STEMI-others groups were more likely to be younger, less likely to be diabetic, and less likely to have 3 cardiovascular risk factors or more than was the STEMI-ATH group. The left anterior descending artery was the most common culprit lesion in the STEMI-SCAD group (80%) and the other 2 groups. Out of the 311 patients, 7 patients died during the index hospitalization: 1 patient in the STEMI-SCAD group, 6 patients in the STEMI-ATH group, and 0 patients in the STEMI-others group. None of the patients in the STEMI-others group experienced any major adverse cardiac events during the follow-up. In the other 2 groups, the most experienced outcomes were myocardial infarction and in-hospital cardiac death, followed by target lesion revascularization and target vessel revascularization. STEMI-SCAD is one of the known causes of STEMI in young women. Still, despite the complexity of revascularization in our patients with STEMI-SCAD, they had more favorable prognoses in both conservative and revascularization management modalities than our patients with STEMI-ATH.

Early vs late new-onset atrial fibrillation in STEMI patients: pathophysiological mechanisms and relationship with in-hospital outcomes

Abstract Background New-onset atrial fibrillation (NOAF) represents the most common supraventricular arrhythmia in the setting of ST-elevation myocardial infarction (STEMI), with up to 21% patients affected. The occurrence of NOAF has clinical relevance as previous studies showed that atrial fibrillation (AF), whether pre-existent to the admission or newly developed during STEMI hospitalization, is associated with worse short- and long-term prognosis. More recently, two distinct phenotypes of NOAF have been described, such as early NOAF (EAF) for AF occurring within 24 h from STEMI, and late NOAF (LAF) for AF onset beyond 24h. The mechanisms underlying EAF or LAF are poorly described. Objective To investigate atrial branches occlusion and EAF or LAF onset in STEMI patients undergoing primary percutaneous coronary intervention. Methods Retrospective cohort study including 155 STEMI patients. Patients were divided into 3 groups: sinus rhythm (SR), EAF or LAF. Clinical characteristics, angiographic features including occlusion of atrial branches, namely ramus ostia cavae superioris (ROCS), atrio-ventricular node artery (AVNA), right intermediate atrial artery (RIAA) and left intermediate atrial artery (LIAA), were assessed (Figure 1). We also investigated in-hospital adverse events (AEs) and death. Results Mean age was 63.8±11.9 years; 78.7% of men. NOAF was detected in 22 (14.2%) patients: 10 (6.4%) EAF and 12 LAF (7.7%). Compared to EAF, LAF patients were older (p=0.013), with higher GRACE risk score (p=0.014) and Killip class (p=0.015), depressed ejection fraction (p=0.007), elevated filling pressures (p=0.029), higher c-reactive protein (p=0.014) and more TIMI flow &amp;lt;3 (p=0.015). Compared to SR, EAF was associated with higher prevalence of occluded ROCS (p=0.010), AVNA (p=0.005) and RIAA (p&amp;lt;0.001) (Figure 2). Moreover, EAF patients had more frequently ≥2 diseased atrial branches than SR (19.5%, p&amp;lt;0.001) and LAF (25%, p&amp;lt;0.030) patients. In LAF patients, a higher incidence of AEs (p=0.019 vs SR; p=0.029 vs EAF) and death (p=0.004 vs SR) was found. Conclusions The occlusion of atrial branches is associated with early but not late NOAF following STEMI. LAF patients had worse in-hospital AEs and mortality. Funding Acknowledgement Type of funding sources: None. Anatomy of atrial branchesInvolvement of atrial branches

CARDIOGENIC SHOCK COMPLICATING ST ELEVATION MYOCARDIAL INFARCTION: CONFLICTING DEFINITIONS AND THE IMPACT OF PRIMARY PERCUTANEOUS CORONARY INTERVENTION

<h3>BACKGROUND</h3> In a stark contrast to ∼5% in-hospital mortality in all comer ST Elevation Myocardial Infarction (STEMI) patients, nearly 50% of STEMI patients complicated by cardiogenic shock (STEMI-CS) die during their hospital admission. Despite advancements in pharmaco-mechanical therapies treating STEMI-CS, mortality has remained unchanged. Failure to improve mortality-rate is partly due to our inability to objectively define and identify CS in a "pre-shock state". As per the current guidelines/major studies, CS is defined as either (1) systolic blood pressure (SBP) ≤ 90mmHg, (2) cardiac-index (CI) < 1.8 L/min/m2 or < 2.2 L/min/m2 in presence of inotropic/vasopressor therapy and/or (3) lactate >2 mmol/L; these parameters are used interchangeably. Here, we wish to address this problem by (1) evaluating consecutive STEMI patients to identify the incidence of CS based on the above 3 parameters, (2) evaluating the concordance between the above 3 parameters in CS patients, and (3) determining the impact of primary percutaneous coronary intervention (PPCI) on these 3 parameters. <h3>METHODS AND RESULTS</h3> Consecutive patients with STEMI confirmed with electrocardiography were prospectively recruited upon presentation to the cardiac catheterization lab. Hemodynamic parameters were evaluated continuously pre- and post-PPCI using a whole-body impedance based non-invasive technology. Systolic blood pressure (SBP) and lactate were measured before and after PPCI. Sixty-eight STEMI patients were recruited; 22/68 (32%) were female and the mean age was 65.8±1.5 years (34 – 90 years). At presentation pre-PPCI, mean SBP was 126±4 mmHg; mean CI was 2.8±0.1 L/min/m2 and mean lactate was 3.0±0.5 mmol/L. Based upon SBP, CI and lactate, 12.7%, 23.5% and 37.3% patients were in CS. Poor correlation was observed between these parameters. Post-PPCI, CI (pre-PCI: 2.5±0.1 vs. post-PCI: 2.8±0.1 L/min/m2; p=0.00001) increased, whereas SBP (Pre-PCI: 125±4 vs. post-PCI: 112±3 mmHg; p=0.00006), and lactate (Pre-PCI: 3.2±0.53 vs. post-PCI: 2.4±0.5 mmol/L; p=0.004) decreased. <h3>CONCLUSION</h3> Our study is the first to describe, (1) poor congruity between the current parameters defining CS, (2) PPCI improves CI and reduces lactate, likely aborting impending CS and associated mortality, and (3) that SBP is a suboptimal tool for assessing CI in the setting of STEMI. With ongoing recruitment and 1-month follow-up, we wish to identify outcome [death at 30-days, prolonged (>96 hours) in-hospital stay due to heart failure, refractory arrhythmias, need for inotropic support and/or mechanical circulatory support, including intra-aortic balloon pump insertion during the index hospital admission] associated hemodynamic marker(s) that may help us identify high-risk STEMI patients in a timely fashion.

Efficacy of high-dose atorvastatin or rosuvastatin loading in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials with GRADE qualification of available evidence.

We aimed to summarize current evidence regarding the impact of a high-dose statin loading before percutaneous coronary intervention (PCI) on short-term outcomes in patients presenting with the acute coronary syndrome (ACS). This meta-analysis was based on a search of the MEDLINE, Cochrane Central Register of Controlled Trials, Ovid Journals, and SCOPUS for randomized controlled trials that compared high-dose atorvastatin or rosuvastatin with no or low-dose statin administered before planned PCI in statin-naive patients with ACS. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and all-cause mortality at 30days. Prespecified subanalyses were performed with respect to statin and ACS type. A total of eleven trials enrolling 6291 patients were included, of which 75.4% received PCI. High-dose statin loading was associated with an overall 43% relative risk (RR) reduction in MACCE at 30days (RR 0.57, 95% CI 0.41-0.77) in whole ACS population. This effect was primarily driven by the 39% reduction in the occurrence of MI (RR 0.61, 95% CI 0.46-0.80). No significant effect on all-cause mortality reduction was observed (RR 0.92, 95% CI 0.67-1.26). In the setting of ST-elevation myocardial infarction (STEMI), atorvastatin loading was associated with a 33% reduction in MACCE (RR 0.67, 95% CI 0.48-0.94), while in non-ST-elevation myocardial infarction ACS (NSTE-ACS), rosuvastatin loading was associated with 52% reduction in MACCE at 30days (RR 0.48, 95% CI 0.34-0.66). The level of evidence as qualified with GRADE was low to high, depending on the outcome. A high-dose loading of statins before PCI in patients with ACS reduces MACCE and reduces the risk of MI with no impact on mortality at 30days. Atorvastatin reduces MACCE in STEMI while rosuvastatin reduces MACCE in NSTE-ACS at 30days.

Pre-procedural ATI score (age-thrombus burden-index of microcirculatory resistance) predicts long-term clinical outcomes in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention

BackgroundThe ATI (Age-Thrombus burden-Index of Microvascular Resistance [IMR]) score was developed to predict suboptimal myocardial reperfusion in patients with ST-Elevation Myocardial Infarction (STEMI). When applied in the early phases of revascularization (e.g. before stent insertion), it predicts which patients are most likely to have a larger infarct size. In this study, we assessed the score's utility in determining which STEMI patients are at highest risk of clinical events during follow-up. MethodsThe ATI-score was calculated prospectively in 254 STEMI patients using age (>50 years = 1 point), pre-stenting IMR (>40 U and < 100 U = 1 point; ≥100 U = 2 points) and angiographic thrombus score (4 = 1 point, 5 = 3 points); the cohort was stratified in high vs. low-intermediate ATI-score strata (≥4 vs. < 4, respectively). ResultsAfter 3 years of follow-up, patients with high ATI-score presented a higher rate of Major Adverse Cardiac Events (MACE) defined as the composite of all-cause mortality, resuscitated cardiac arrest and new heart failure diagnosis (Hazard Ratio [HR]: 3.07; 95% Confidence Interval [CI]: 1.19–7.93; p = 0.02). The ATI-score showed a moderate discriminative power (c-stat: 0.69), not significantly different from that of other risk scores used in the STEMI setting. A high ATI-score was an independent predictor of MACE (HR: 3.24; 95% CI: 1.22–8.58; p = 0.018). ConclusionsThe ATI-score can discriminate patients at higher risk of long-term adverse events. The score allows predication of subsequent events even before coronary stenting, and consequently it may allow the option of individualized therapy in the early stages of the clinical care-pathway.

Intravascular lithotripsy for treatment of calcific coronary lesions in ST elevation myocardial infarction.

To describe the utility and safety of intravascular lithotripsy (IVL) in the setting of primary percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI). We performed a retrospective analysis, across six UK sites of all patients in whom IVL was used for coronary calcium modification of the culprit lesion during primary PCI for STEMI. The 72 patients were included. IVL was used in de-novo culprit lesions in 57 (79%) of cases and culprit in-stent restenoses in 11 (15%) of cases. In four cases (6%) it was used in a newly deployed stent when this was under-expanded due to inadequate calcium modification. Of the 30 cases in which intracoronary imaging was available for stent analysis, the average stent expansion was 104%. Intra-procedural stent thrombosis occurred in one case (1%), and no-reflow in three cases (4%). The 30 day MACE rates were 18%. IVL appears to be feasible and safe for use in the treatment of calcific coronary artery disease in the setting of STEMI.

Romanian Patients Who Experience in-Stent Restenosis After St-Elevation Myocardial Infarction: The Experience of a Tertiary Center

Abstract Background and aim. Coronary artery disease (CAD) is one of the most important causes of death worldwide. ST-elevation myocardial infarction (STEMI) is an acute form of presentation in patients with CAD. Percutaneous coronary intervention (PCI) is the treatment of choice in STEMI patients. Generally, a stent is placed after the culprit lesion is dilated in order to ensure the patency of the coronary artery. In-stent restenosis (ISR) is a possible chronic complication in this setting. The following study is one of the few of its kind, since it investigates ISR in a cohort of Romanian patients who underwent PCI in the setting of STEMI. Our current descriptive study aims at highlighting the characteristics of these patients and identifying potential risk factors in this specific population, which could be validated by a further larger study. Methods. We studied 68 patients from “Dr. Carol Davila” Central Military Emergency University Hospital in Bucharest, Romania, who presented with STEMI in 2016. The mean time for angiographic reevaluation was 111 days. Results. 94% (64) of the patients underwent primary PCI, while in 6% (4) of the cases thrombolysis was initially attempted before PCI. The most prevalent risk factors that we identified were: arterial hypertension (61%), dyslipidemia (60%) and smoking or history of smoking (47%). The anterior myocardial infarction was the most prevalent (49%). Only 6% of the patients had a documented history of CAD, while on the other hand chronic occlusions were observed in most patients (85%). Of note is that only 11% of the patients reported recurrent angina before the angiographic reevaluation. Conclusion. Common cardiovascular risk factors are also involved in ISR. Their poor management in the case of Romanian patients with STEMI increases the risk of ISR. The lack of symptoms in patients with ISR constitutes a warning sign for clinicians and shows that ISR is a complication which can be easily omitted. Therefore, its incidence is probably underestimated.