Setting Of ST-elevation Myocardial Infarction Research Articles

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.

Intracoronary bolus of glycoprotein IIb/IIIa inhibitor as bridging or adjunctive strategy to oral P2Y12 inhibitor load in the modern setting of ST-elevation myocardial infarction.

In the acute management of ST-elevation myocardial infarction (STEMI), glycoprotein IIb/IIIa inhibitors (GPIs) bolus not followed by intravenous infusion is potentially advantageous given their fast onset and offset of action, but clinical evidence in a contemporary setting is limited. We collected data from consecutive STEMI patients admitted to the cardiac catheterization laboratory of the IRCCS A. Gemelli University Polyclinic Foundation from October 2017 to September 2019. Out of 423 consecutive STEMI patients, 297 met the inclusion and exclusion criteria and were included in the study. Of them, 107/297 (36%) received an intracoronary GPI bolus-only during primary percutaneous coronary intervention (PPCI) not followed by intravenous infusion and 190/297 (64%) received standard antithrombotic therapy. Of the 107 GPI-treated, 22/107 (21%) had P2Y<inf>12</inf> inhibitor pretreatment (adjunctive strategy) and 85/107 (79%) did not (bridging strategy). During hospital staying, there was no difference in the primary safety endpoint of TIMI major+minor bleeding (P=0.283), TIMI major (P=0.267) or TIMI minor (P=0.685) bleeding between groups. No stroke event occurred in the GPI group. Despite patients receiving GPI having a significantly higher intraprocedural ischemic burden, no significant differences were found in the efficacy outcomes between groups. Consistent findings were observed for patients receiving GPIs bolus before (bridging strategy) or after (adjunctive strategy) P2Y<inf>12</inf> inhibitors, compared to those receiving standard therapy. Multivariate logistic regression analyses did not find any independent predictors significantly associated to the primary and secondary composite endpoints. In a contemporary real-world population of STEMI patients undergoing PPCI, the use of intracoronary GPIs bolus-only in selected patients at high ischemic risk is safe and could represent a useful antithrombotic strategy both in those pretreated and in those naïve to P2Y<inf>12</inf> inhibitors.

In-hospital outcome of primary PCI for patients with acute myocardial infarction and prior coronary artery bypass grafting.

BackgroundThis study aims to analyze the in-hospital outcome of primary percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI) and prior coronary artery bypass grafting (CABG).MethodsThis was a retrospective study. From January 2011 to December 2018, the data of 78 consecutive patients (study group) with prior CABG, who received primary coronary angiography in the setting of ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI), were screened. The study group was compared with another well-matched 78 patients without a history of CABG (control group). The information of the coronary angiograms and clinical data of both groups were analyzed. Multivariate conditional logistic regression models were constructed to test the association between PCI success rate and the prior CABG at age ≥65 and <65 years, respectively.ResultsThe results revealed that the primary PCI success rate in the study group was significantly lower than in the control group (67.9% vs. 92.3%, P<0.001) and in-hospital mortality was significantly higher than in control group (11.5% vs. 2.5%, P=0.03). The multivariate logistic regression analysis indicated that the primary PCI success rate was significantly associated with the history of prior CABG both in young patients [age <65 years; odds ratio (OR) =5.26, 95% confidence interval (CI): 1.69–16.47] and elderly (age ≥65 years; OR =13.76, 95% CI: 2.72–69.75).ConclusionsThe patients who receive primary PCI with AMI and prior CABG have poor in-hospital outcomes, with low PCI success rates and high mortality.

National trends of utilization and readmission rates with intravascular ultrasound use for ST-elevation myocardial infarction.

Randomized trials have confirmed that intravascular ultrasound (IVUS) guidance for percutaneous coronary interventions (PCI) improves long-term clinical outcomes. However, data on real-world utilization of IVUS in ST-elevation myocardial infarction (STEMI) and the impact on short to mid-term outcomes are scarce. We sought to evaluate the utilization and the readmission rates for IVUS-guided PCI in the setting of STEMI. Hospitalizations with a primary diagnosis of STEMI undergoing PCI were included from the Nationwide Readmissions Database (NRD) during 2012-2017. Among 809,601 hospitalizations with STEMI undergoing PCI, 33,644 (4.2%) underwent IVUS-guided PCI. IVUS use increased from 4.2% in 2012 to 5.6% in 2017 (p < .0001). After matching, in-hospital mortality was significantly lower with IVUS use (3.9% vs. 4.6%, p < .0001). The overall readmission rates were similar in both groups. We found that readmission rates due to acute MI at 6months (5.7% vs. 6%, p=.045) and 11 months (5.1% vs. 6.5%, p=.005) as well as the PCI and mortality rates during readmission at 11 months (2.1% vs. 3%, p=.008, and 0.7% vs. 1.4%, p=.002, respectively) were significantly lower in the IVUS group. The utilization of IVUS in STEMI appears to be slowly increasing. Although overall readmission rates were similar, IVUS was associated with lower in-hospital mortality, lower rates of readmission due to acute MI at 6 and 11 months, as well as lower PCI and mortality at 11 months. Randomized trials evaluating long-term benefits of IVUS in STEMI are needed.

Estimating the extent of myocardial damage in patients with STEMI using the DETERMINE score

BackgroundRecently, a simple ECG score (DETERMINE score) has been proposed for estimating myocardial scar in patients with ischaemic cardiomyopathy. We sought to evaluate the usefulness of the DETERMINE score for...

Abstract 341: A Simple Prognostic Tool for In-Hospital Death in Patients Presenting with Out-of-Hospital Cardiac Arrest and ST-Elevation Myocardial Infarction

Background: In the emergent setting of ST-Elevation Myocardial Infarction (STEMI) complicating out-of-hospital cardiac arrest (OHCA), decisions for immediate coronary angiography are made when the likelihood of hospital survival is unknown. Estimating the risk of mortality at the time of hospital arrival might inform decisions for primary percutaneous coronary intervention. Methods: From the Cardiac Arrest Registry to Enhance Survival (CARES), we included adult OHCA patients from 2013-2018 presenting to hospitals with a STEMI. We developed a predictive model for in-hospital mortality using multivariable logistic regression to derive a scoring tool that was internally validated with bootstrap methods. Results: Of 7120 patients with OHCA and STEMI admitted at a hospital (mean age 62±13.2 years, 27% female), 3159 (44.4%) died during hospitalization. Higher age, unwitnessed arrest, non-shockable cardiac arrest rhythm, no sustained return of spontaneous circulation (ROSC) at the time of hospital admission, and resuscitation time on scene were most predictive of mortality (C-index, 0.82). Using the model β coefficients, we developed an integer risk score ranging from 0 to 10 points, corresponding to observed mortality rates of 5% to 100% (Figure 1). The odds of in-hospital mortality doubled for each 1-unit score increase (odds ratio, 2.01; 95% CI, 1.94-2.09; p&lt;0.0001), and a score of ≥6, involving ~15% of patients, was associated with ≥85% in-hospital mortality risk. Conclusions: This risk score, based on simple prehospital characteristics, stratifies the range of in-hospital mortality from 5% to nearly 100% in OHCA patients with STEMI at the time of hospital presentation. The benefits of such a model in decision-making for immediate coronary angiography should be prospectively studied.

Abstract 15343: Increasing Left Ventricular Mass is Associated With Greater Microvascular Obstruction During ST-elevation Myocardial Infarction

Introduction: The development of microvascular obstruction (MVO) in the setting of ST-Elevation Myocardial Infarction (STEMI) is a powerful predictor of reduced left-ventricular (LV) function, adverse LV remodeling and increased mortality. Although MVO is associated with increasing infarct size and ischemic duration, additional causes of MVO have not been clearly identified. Although MVO may arise from intravascular obstruction from embolization of thrombus, it may also arise from compression of the microvasculature due to increased myocardial edema and extravascular compressive forces. Hypothesis: Because left-ventricular hypertrophy (LVH) is associated with increased extravascular compressive forces, we hypothesized that patients with greater LV mass may be more susceptible to the development of MVO during STEMI. Methods: We measured MVO in 385 patients (59.4 + 12.3 years; 77% male) admitted to our Institution with STEMI who underwent cardiac MRI for measurement of LV function and infarct size following successful primary PCI. A total of 219 patients (57%) had MVO on cardiac MRI measured 1-3 days following PCI of which 172 patients had paired measurements of LV mass. Results: Patients with MVO (13.7 + 13.9 grams) had significantly greater infarct size (54 vs. 31 g; p &lt; 0.001) and LV mass (151 vs 140 g; p&lt;0.01) but reduced LVEF (43.1 vs. 47.8%) despite having similar ischemic times. Among patients with MVO, there was a linear increase in MVO with increasing LV mass (Figure). Conclusions: MVO increases with increasing LV mass and may contribute to the known adverse effects of LVH in STEMI.

Diabetes and pre-infarct angina. Time to rethink comorbidities in the reperfusion-injury phenomenon?

Abstract Background Pre-infarct angina (PIA) has been shown to reduce reperfusion injury and infarct size in patients with ST-elevation myocardial infarction (STEMI) and currently represents the most efficient form of myocardial conditioning yet discovered. The role of diabetes on ischemic preconditioning remains controversial – while some pre-clinical studies suggest that diabetes blunts ischemic conditioning, clinical studies are lacking. Methods We retrospectively evaluated consecutive patients with STEMI admitted in our hospital from January 2008 to August 2018 who underwent primary angioplasty (PCI). PIA was defined as chest, arm or jaw pain during the preceding 48h before STEMI diagnosis. Peak creatine kinase and peak Troponin T levels were used as a surrogate of infarct size. Ischemic time (IT) was defined as the time between the onset of symptoms to the restoration of flow after either guidewire passage, thrombus aspiration or first balloon inflation. Results Of the 1143 included patients, 74% (n=845) were male and mean age was 62.6±13.1 years. A quarter of STEMI-patients had diabetes (25%, n=285). Almost a third of the patients (32%, n=359) had a history of angina in the preceding 48h before STEMI (PIA). The proportion of PIA was similar between diabetic and non-diabetic patients. In patients with diabetes, PIA was associated with lower creatine kinase (CK) (1144 [500–2212] vs 1715 [908–3309] U/L, p=0.0029) and Troponin T (TnT 3.30 [1.90–6.58] vs 4.88 [2.50–9.58] ng/mL, p=0.0022) despite similar IT as compared to those without PIA (328 [200–554] vs. 258 [180–530] minutes, p=0.1365). In non-diabetic patients, PIA was not significantly associated with infarct size (TnT 3.74 [2.23–7.11] vs 4.56 [2.44–7.77] ng/mL, p=0.1945; CK 1549 [910 - 2909] vs 1793 [996 - 3078] U/L, p=0.0653) even after adjustment for the increased ischemic time (240 [150–550] vs. 210 [140–405] minutes, p=0.0128) (β=−0.12, p=0.085 for CK and β=−0.11, p=0.183 for TnT). A significant interaction was observed between the existence of PIA and diabetes on peak TnT (p=0.026 for interaction) and CK (p=0.047 for interaction), which was independent of the culprit vessel and IT. During a median follow-up period of 18.0 [12.1–25.5] months, 268 (24.0%) MACE events have occurred (165 deaths, 27 strokes, 46 myocardial infarctions and 26 target vessel revascularization). PIA was associated with a significant reduction in the incidence of MACE (HR 0.66 (95% CI: 0.48–0.89)) driven by a reduction on mortality (HR 0.44 (95% CI: 0.28–0.70)). Diabetes was associated with an increased incidence of MACE (HR 1.42 (95% CI: 1.07–1.89)). No interaction was found between diabetes and PIA on their effect on MACCE events. Conclusion PIA is a strong predictor of favourable outcomes in the setting of STEMI. The effect of PIA on myocardial protection in patients with STEMI undergoing primary PCI seems to be modulated by the presence of diabetes. Distribution of Peak CK and Peak TnT Funding Acknowledgement Type of funding source: None

Influence of myocardial damage on serum procalcitonin in ST-elevation myocardial infarction

Abstract Background Myocardial tissue injury due to acute ST-elevation myocardial infarction (STEMI) initiates an inflammatory response with a release of systemic inflammatory biomarkers including C-reactive protein (CRP) and white blood cell count (WBCc), which, however, hampers the usefulness of these routine biomarkers to identify concomitant infections. The clinical role of Procalcitonin (PCT), a promising marker of bacterial infections, to detect concomitant infections in acute STEMI is unknown, mainly because it is unclear whether myocardial injury per se induces a systemic PCT release. Purpose To investigate release kinetics of serum PCT in the acute setting of STEMI and possible associations with myocardial injury markers as comprehensively assessed by cardiac magnetic resonance (CMR) imaging. Methods In this prospective observational study, we included 141 STEMI patients treated with primary percutaneous coronary intervention (PCI). Concentrations of PCT, high-sensitivity CRP (hs-CRP), WBCc and high-sensitivity cardiac troponin T (hs-cTnT) were measured serially at day 1 and day 2 after infarction. CMR imaging to assess infarct size (IS), extent of microvascular injury (MVI) and occurrence of intramyocardial haemorrhage (IMH) was performed within the first week following STEMI. Results Median concentrations of PCT were 0.07μg/l at both time points. In 140 patients (99%), both PCT values were within the normal range (≤0.5μg/l). Whereas hs-CRP, WBCc, and hs-TnT were significantly correlated with CMR markers of myocardial damage, PCT did not show significant correlations (all p&amp;gt;0.10) with IS (PCT24h: r=0.07; PCT48h: r=0.13) or MVI (PCT24h: r=−0.03; PCT48h: r=0.09). Furthermore, PCT failed to discriminate between large and small IS or MVI or between presence and absence of IMH (AUC values:0.46–0.55). Conclusions In the acute phase after PCI for STEMI, circulating PCT remained unaffected by the extent of myocardial and microvascular tissue damage as visualized by CMR imaging. These data highlight the clinical potential of PCT to identify concomitant infections and to guide antibiotic treatments in STEMI patients. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund, Tiroler Wissenschaftsförderung

Clinical outcome of patients with ST-elevation myocardial infarction and angiographic evidence of coronary artery ectasia

Abstract Background Coronary artery ectasia (CAE) is a relatively frequent finding in patient with ST-elevation myocardial infarction (STEMI) who undergo emergent coronary angiography. However, the long-term outcome of STEMI patients with CAE as compared to Non-CAE has been poorly investigated. Purpose To compare the baseline features and outcome of patients with and without CAE in the clinical setting of STEMI. Methods All patients with STEMI who underwent emergent coronary angiography from January 2012 to December 2017 at our Institution were retrospectively enrolled. Baseline demographic, clinical, instrumental, angiographic and percutaneous coronary intervention (PCI) findings were collected for patients with and without CAE. The study outcome measures were recurrent myocardial infarction (MI) and all-cause death. The propensity score weighting (PSW) technique was used to take into account for potential selection bias in treatment assignment between CAE and Non-CAE groups. Results The study included 534 patients with STEMI (mean age 62.9±12.0 years), 154 were CAE and 380 Non-CAE. The two groups were significantly different in terms of sex (90.9% in CAE vs 72,6% in Non-CAE, p&amp;lt;0.001), diabetes (11.7% vs. 25.8%; p=0.009) and smoking status (72.1% vs. 62.4%; p=0.042). The right coronary artery was more commonly treated in CAE patients (41.6% vs. 30.8%, p=0.023) and, as expected, the stent diameter (p&amp;lt;0.001) and the TIMI frame count (p&amp;lt;0.001) were significantly higher in CAE group. The myocardial blush grade was higher in Non-CAE (p&amp;lt;0.001). The Kaplan-Meyer analysis showed a comparable rate of all-cause death among the two groups (3.4/100 person/years in CAE vs. 3.5 per 100 person/years in Non-CAE, Log-Rank = 0.86). The survival free from recurrent MI was lower, although not statistically significant, in CAE vs. Non-CAE patients (3.1/100 person/years vs. 4.8/100 person/years; Log-Rank = 0.068). After PSW, an optimal balance was obtained as demonstrated by a standardized mean difference &amp;lt;0.1 for all the variables included in the model. The adjusted Cox regression analysis showed a significantly higher risk of recurrent MI in CAE vs. Non-CAE groups (HR = 1.93; p=0.009). No difference in the risk of all-cause death was observed (HR = 0.83, p=0.501). Conclusions Patient with STEMI and angiographic evidence of CAE have a different clinical profile compared to Non-CAE. In this analysis focused on STEMI patients, CAE was associated with a higher risk of recurrent MI at long-term follow-up. Funding Acknowledgement Type of funding source: None

Pre-infarction angina is associated with improved prognosis in diabetic patients with ST-elevation myocardial infarction – data from a contemporary cohort

Pre-infarction angina (PIA) is associated with improved prognosis in patients with ST-elevation myocardial infarction (STEMI). Some studies suggest that diabetes may blunt the effect of ischaemic preconditioning. We sought to study the impact of PIA in diabetic patients with STEMI. Consecutive patients with STEMI who underwent primary angioplasty were included. PIA was defined as ≥1 episode of chest pain during the week preceding STEMI diagnosis. Incident major adverse cardiovascular events (MACE) were defined as the first occurrence of all-cause death, stroke or acute myocardial infarction. Of the 1143 included patients, 25% were diabetic and 32% had a history of PIA. Diabetic patients with PIA had smaller infarct sizes as estimated by peak creatine kinase (CK) [1144 (500-2212) vs. 1715 (908-3309) U/L, P = 0.003] and peak troponin [3.30 (1.90-6.58) vs. 4.88 (2.50-9.58) ng/ml, P = 0.002], compared to diabetics without PIA. They also had a lower likelihood of evolving with moderate to severe reduced left ventricle ejection fraction (LVEF) (25.6%, n = 22 vs. 46.6%, n = 82, P = 0.001). In non-diabetic patients, PIA was associated with reduced peak CK [1549 (909-2909) vs. 1793 (996-3078), P = 0.0497], but not troponin (3.74 [2.23-7.11] vs. 4.56 [2.44-7.77] ng/ml, P = 0.19), and was not associated with reduced LVEF (32.0%, n = 85 vs. 37.4%, n = 207, P = 0.13). Both diabetic and non-diabetic patients with PIA had a lower likelihood of evolving with a Killip class III/VI (non-diabetic patients: 5.6% vs. 14.1%, P = 0.002; diabetic patients: 12.8% vs. 24.6%, P = 0.049). Over a median follow-up of 18.0 (12.1-25.5) months, PIA was associated with a significant reduction in the incidence of MACE [hazard ratio 0.52, 95% confidence interval (CI) 0.37-0.74, P < 0.001], irrespective of diabetes status. PIA is an independent predictor of favourable outcomes in the setting of STEMI for both diabetic and non-diabetic patients.

Assessment of Risk Factor for Developing Acute Kidney Injury in the Setting of Acute ST Elevation Myocardial Infarction

Background: An acute kidney injury (AKI) is a recognized complication in patients with ST elevation myocardial infarction (STEMI) by several mechanisms and it adversely affects morbidity and mortality on long-term bases (1, 2, and 3). Few studies have investigated which patients with STEMI are at risk of developing AKI (6), and this study is aiming to do this assessment. Patients and Methods: We enrolled patients with STEMI who were admitted to the CCU. KDIGO definitions was utilized to search for development of AKI in these patients throughout their stay in the CCU (their baseline serum creatinine was measured and traced daily thereafter; and their urine output was monitored). Common epidemiological and some relevant medical parameters were recorded for all patients. Results and conclusion: low baseline systolic blood pressure, ejection fraction % and estimated glomerular filtration rate (eGFR); in addition to use of diuretics; are the major risk factors for the development of AKI in the setting of STEMI.

Serum neprilysin levels are associated with myocardial stunning after ST-elevation myocardial infarction

BackgroundLeft ventricular remodeling following ST-elevation myocardial infarction (STEMI) is associated with poor outcome, including heart failure (HF). Neprilysin inhibition leads to improved outcome in patients with altered left ventricular ejection fraction (LVEF).MethodsWe aimed to assess the association between serum levels of neprilysin and left ventricular (LV) volumes, function and remodeling in STEMI patients with successful myocardial reperfusion and no clinical sign of HF. Sixty-eight patients were admitted for STEMI and had both plasma neprilysin measurement at baseline and 3D transthoracic echocardiogram at baseline and after a median follow-up of 7 months. We compared 3 groups: a group with a low-level of plasma neprilysin (< 125 pg/mL, i.e. the lower limit of detection of the assay) and the two other groups were defined as being below or above the median value of the remaining samples.ResultsMedian age was 58.5 ± 12.8 years and 56 (82.4%) were men. Median LVEF was 45.0 ± 8.5%. Baseline characteristics were comparable between groups (low-level of neprilysin group [≤125 pg/mL, n = 38], medium-level of neprilysin group [126–450 pg/mL, n = 15] and a high-level group [> 450 pg/mL, n = 15]). At baseline there was a non-significant trend towards lower end-diastolic volume (p = 0.07) but significantly lower LVEF in the high neprilysin group (46.4 ± 8.3%, 47.1 ± 8.1% and 39.1 ± 6.9%, p < 0.01). At follow-up, the magnitude of LVEF increase was significantly more important in the high neprilysin group compared to the other groups (p = 0.022 for relative change in LVEF and 6.6 ± 7.3%, 3.6 ± 9.0% and 11.3 ± 8.4%, p = 0.031 for absolute change in LVEF) resulting in similar LVEF levels at follow-up between all groups (53.0 ± 8.9%, 50.6 ± 9.7% and 50.4 ± 9.9%, p = 0.55).ConclusionsInitial high neprilysin levels may identify patients with stunned myocardium early after STEMI, with a recovery of contractility leading to improved LVEF at follow-up. Future studies will have to assess the role of neprilysin in the setting of STEMI and the potential benefit of its blockade.

Emerging cardiological issues during the COVID-19 pandemic.

Today the modern world is facing an unprecedented health crisis. The COVID‐19 pandemic is putting extensive strain on health care systems, hospitals and medical workers worldwide. Epidemiological data are emerging that COVID‐19 patients with cardiac risk factors or pre‐existing cardiac conditions are at increased risk for complications and mortality from COVID‐19. As we just begin to understand the pathophysiology underlying the disease, the involvement of the heart, whether through direct myocardial infection and damage or due to cardiac complications, is already evident.

Association of Myocardial Injury With Serum Procalcitonin Levels in Patients With ST-Elevation Myocardial Infarction

Myocardial tissue injury due to acute ST-elevation myocardial infarction (STEMI) initiates an inflammatory response that leads to a release of systemic inflammatory biomarkers, including C-reactive protein (CRP) and white blood cells, consequently reducing the usefulness of these routine biomarkers for identifying concomitant infections. The clinical role of procalcitonin (PCT), a promising marker of bacterial infection, to detect concomitant infection in acute STEMI is unknown, mainly because it is unclear whether myocardial injury per se induces systemic PCT release. To investigate the release of serum PCT in the acute setting of STEMI (24 and 48 hours after primary percutaneous coronary intervention) and to elucidate any associations with myocardial injury markers through a comprehensive assessment by cardiac magnetic resonance (CMR) imaging. This prospective cohort study conducted between 2016 and 2018 included 141 consecutive patients with STEMI treated with primary percutaneous coronary intervention. Concentrations of PCT, high-sensitivity CRP (hs-CRP), and high-sensitivity cardiac troponin T (hs-cTnT) and white blood cell counts were measured serially 24 and 48 hours after infarct. Acute STEMI and primary percutaneous coronary intervention. The association of PCT and typical inflammatory marker levels with CMR-determined myocardial damage was assessed. Infarct size, extent of microvascular obstruction, and occurrence of intramyocardial hemorrhage as determined by CMR within the first week following STEMI were also evaluated. In total, 141 patients with STEMI (117 men [83%]) having a median age of 56 years (interquartile range, 50-66 years) were included. The median PCT concentration was 0.07 μg/L (interquartile range, <0.06-0.11 μg/L) 24 hours after intervention and 0.07 μg/L (interquartile range, <0.06-0.09 μg/L) 48 hours after intervention. Whereas hs-CRP and hs-cTnT levels and white blood cell counts were significantly correlated with CMR markers of myocardial damage at both 24 and 48 hours after intervention, the PCT level showed no significant correlation with infarct size (at 24 hours: r = 0.07; P = .40; at 48 hours: r = 0.13; P = .12) or with microvascular obstruction (at 24 hours: r = -0.03; P = .75; at 48 hours: r = 0.09; P = .30). Furthermore, PCT levels at 24 hours (odds ratio, 1.25; 95% CI, 0.63-2.48; P = .52) and 48 hours (odds ratio, 1.56; 95% CI, 0.72-3.41; P = .26) were not significantly associated with the presence of intramyocardial hemorrhage. In the acute phase after percutaneous coronary intervention for STEMI, circulating PCT levels remained unassociated with the extent of myocardial and microvascular tissue damage as visualized by CMR imaging.

Feasibility of primary percutaneous coronary intervention via the distal radial approach in patients with ST-elevation myocardial infarction.

Background/AimsRecently, distal radial approach (DRA), called as snuffbox approach, has gained the interest of interventional cardiologists, but there is a lack of data about the feasibility of DRA as an alternative route for primary percutaneous coronary intervention (PCI).MethodsA total of 138 patients presenting with ST-elevation myocardial infarction (STEMI) in whom primary PCI via the DRA was attempted at three hospitals from October 2017 to September 2019 were analyzed.ResultsThe success rate of snuffbox puncture in the setting of STEMI was 92.8% (128/138). Successful primary PCI via the DRA was achieved in all 128 patients. The snuffbox puncture time, defined as the time interval from local anesthesia induction to successful sheath cannulation, was 2.7 ± 1.6 minutes, and snuffbox puncture was performed within 5 minutes in 95.3% of patients. Moreover, the percentage of the puncture time in the door-to-balloon time was 3.3%. The left DRA was selected in 103 patients (80.5%), and primary PCI via the DRA was performed using a 6-Fr guiding catheter in 125 patients (97.7%). There was no major bleeding; however, there were four cases (3.1%) of access-site complications, including three cases of local hematoma (≤ 5 cm diameter) and one case of local numbness, which improved 3 months later.ConclusionsIn the setting of STEMI, the DRA could be a feasible alternative access route for primary PCI.

Incidence, predictors, and outcomes of new-onset atrial fibrillation in patients with ST-elevation myocardial infarction.

BackgroundAtrial fibrillation (AF) is a common arrhythmia and one of the complications in the setting of ST‐elevation myocardial infarction (STEMI). Our objective of the present study was to investigate the incidence, predictors, and outcomes of NOAF in patients with acute STEMI managed with pharmacoinvasive strategy (PIS) versus those managed with primary percutaneous coronary intervention (PPCI).MethodsThe study included 530 patients with STEMI divided into two groups according to the method of treatment. Group I: 269 patients subjected to pharmacoinvasive strategy (PIS), group II: 261 patients managed with primary percutaneous coronary intervention (PPCI). Incidence, predictors, and outcomes of NOAF were assessed in each group separately.ResultsThe incidence of NOAF was 25 patients (9.3%) in group I and 24 patients (9.2%) in group II. Multivariate regression analysis identified the independent predictors of NOAF that were (advanced age ˃65 years, history of hypertension, left atrial volume index (LAVI) ˃34 ml/m2, E/e’ ratio ˃ 12, right coronary artery (RCA) as a culprit vessel and presence of heart failure). There was no statistically significant difference between both groups regarding the occurrence of MACE.ConclusionNew‐onset AF represents one of the common complications in the setting of STEMI. Advanced age, hypertension, LAVI ˃34 ml/m2, E/e’ ratio ˃12, RCA culprit vessel, and heart failure were the independent predictors of NOAF.

832 Graft Versus Native Vessel Intervention for Patients With Previous Bypass Surgery Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Patients with previous coronary artery bypass graft (CABG) represent a high risk substrate for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI). We sought to determine whether outcomes differed between native vessel vs graft PPCI in patients with prior CABG at our institution. All patients between June 2010 and December 2018 presenting with STEMI to our tertiary centre were reviewed. There were 1837 patients treated with PPCI, of which 98 patients (5.3%) had previous CABG and were included in the study. Data were collected on baseline and procedural characteristics and major adverse cardiovascular events (MACE). In total, there were 49 graft and 49 native vessel interventions. Mean follow-up duration was 22 months. There were no significant differences in baseline characteristics. MACE-free survival was superior in the native vessel PPCI group compared to the graft PPCI group (75.5% vs 53%; HR 1.92; p=0.02). There was a 14.3% mortality rate for which was equal across the two groups. MACE was largely driven by target vessel revascularisation in the native vessel PPCI arm (33.3% of MACE vs 26.1%; p=0.4) and recurrent myocardial infarction in the graft PPCI arm (39% of MACE vs 25%; p=0.4). In patients presenting with STEMI and previous CABG, native vessel intervention is associated with superior outcomes compared to graft intervention. Native vessel intervention should be considered when possible in the setting of STEMI.

P2654Impact of cultural and linguistic diversity on ischaemic time and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI)

Abstract Background Healthcare providers worldwide increasingly must face the challenge of providing care to culturally and linguistically diverse patients who may have limited proficiency in the primary working language of the country they are in. This language discordance may lead to delayed treatment and worse outcomes. The impact of limited English proficiency (LEP), in a predominantly English-speaking country like Australia, on time to reperfusion and outcomes following PCI for STEMI has not been previously studied. Objective Among patients undergoing PCI for STEMI, to compare baseline and procedural characteristics, time to reperfusion, and 30-day clinical outcomes in patients with LEP, compared to their English-proficient counterparts. Method We prospectively collected data on 7,721 patients undergoing PCI for STEMI between January 2013 and December 2017 who were enrolled in the state-wide multi-centre Victorian Cardiac Outcomes Registry. Data linkage to Department of Health administrative datasets was used to identify patients' primary spoken language. Patients who identified a language other than English as their primary spoken language were classified as having LEP. Patients' postcodes were used to identify socioeconomic status through Australian Government census data. The primary endpoint was 30-day major adverse cardiovascular events (MACE) Results Of the 7,721 patients included, 568 (7.4%) had LEP. Patients with LEP were more likely to be older, female, diabetic, have lower socioeconomic status and have severe renal impairment (all p&lt;0.02). They were also more likely to present to a non-PCI capable hospital (p&lt;0.001). Among primary PCI patients (n=5,385), symptom-to-balloon time was longer in the LEP group (237 [IQR 158–429] vs. 195 [IQR 141–326] minutes, p&lt;0.001), driven mostly by longer symptom-to-door times (STDT) (150 [IQR 90–276] vs. 114 [IQR 75–215] minutes, p&lt;0.001). LEP patients were also less likely to have a STDT≥120 minutes (48.8% vs. 41.7%, p-0.004). Patients with LEP had higher 30-day mortality (8.8% vs. 6.5%, p=0.04) and MACE (11.8 vs. 9.1%, p=0.04). They were also more likely to have severe left ventricular (LV) dysfunction post-STEMI (11.2% vs. 8.4%, p=0.003) and heart failure readmissions within 30 days of PCI (5.2% vs. 2.0%, p&lt;0.001). On multivariate analysis, LEP was not an independent predictor of 30-day MACE (OR 1.27, 95% CI 0.82–1.95), but was an independent predictor of STDT≥120 minutes (OR 1.24, 95% CI 1.02–1.52). Comparison of reperfusion times Conclusion Limited English-proficient patients with STEMI undergoing PCI tend to present later than their English-proficient counterparts and are more likely to have severe LV dysfunction and heart failure readmissions. LEP is an independent predictor of prolonged STDT but not 30-day MACE. This suggests that more effort needs to be placed in providing education in different languages to culturally and linguistically diverse patients, to encourage early presentation in the setting of STEMI.