ST-segment Elevation Myocardial Infarction Research Articles

Clinical and angiographic characteristics of patients with familial hypercholesterolemia presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Familial hypercholesterolemia (FH) is a world public health problem that enhances the risk of premature coronary artery disease (CAD) with a high incidence of acute coronary syndrome. This study aimed to evaluate the clinical and angiographic characteristics of the patients with and without FH who had ST-elevation myocardial infarction (STEMI). It included 690 patients who presented with the first attack of STEMI and underwent primary percutaneous coronary interventions (PPCI). The patients were analyzed to diagnose FH according to the Dutch Lipid Clinic Network (DLCN) criteria. All angiograms were analyzed for the number of diseased vessels, Syntax score, thrombus burden grade, and final Thrombolysis in Myocardial Infarction (TIMI) flow grade. The majority of patients were male (72.6%) with a mean age of 54 ± 12 years. Based on DLCN criteria, they were classified into unlikely/possible FH (86.1%) and probable/definite FH (13.9%) groups. Probable/definite FH patients were significantly younger, and higher incidence of males < 55 years compared with unlikely/possible FH patients (p < 0.001 for each). Moreover, probable/definite FH patients had a higher frequency of three-vessel disease (p = 0.007) and Syntax score (p < 0.001) with a moderate positive correlation with the DLCN score (r = 0.592, p < 0.001). Furthermore, probable/definite FH patients showed a higher thrombus burden and final TIMI slow/no-reflow when compared to the unlikely/possible FH patients (p = 0.006 and p = 0.027, respectively). Patients with probable/definite FH and LDL-C level were independent predictors of high thrombus burden besides males < 55 years, and the number of diseased vessels. In conclusion, STEMI patients with FH were younger males and associated with severe CAD with frequent multivessel CAD, high anatomical complexity of CAD, and frequent high thrombus burden. Furthermore, FH was one of the predictors of high thrombus burden.

Revisiting the Efficacy and Safety of Bivalirudin in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials.

Randomized trials of bivalirudin in patients with ST elevation myocardial infarction (STEMI) have yielded heterogeneous results. Our aim was to evaluate the efficacy and safety of four antithrombin regimens-unfractionated heparin (UFH), bivalirudin (stopped soon after percutaneous coronary intervention [PCI]), extended bivalirudin (continued for a few hours after PCI), and combined UFH and a Gp2b3a inhibitors (GPI) in patients who present with STEMI. A PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized clinical trials (RCTs) of the above antithrombin in patients with STEMI. The primary outcome was net adverse cardiovascular events (NACE). The primary ischemic endpoint was major adverse cardiovascular events (MACE), and the primary safety endpoint was major bleeding, and other endpoints included all-cause mortality and stent thrombosis. The primary analysis compared the effect of these antithrombin regimens in reference to UFH using a mixed treatment comparison meta-analysis. In the 14 RCTs evaluating 25,415 patients with STEMI, when compared to UFH monotherapy, extended bivalirudin lowered NACE (OR = 0.71 with 95% CI: 0.53-0.96; moderate level of confidence) driven by a significant decrease in major bleeding (OR = 0.42 with 95% CI: 0.26-0.68; high level of confidence) without any significant difference in MACE or all-cause mortality. When compared with UFH monotherapy, UFH+GPI reduced risk of MACE (OR = 0.76 with 95% CI: 0.60-0.97; high level of confidence) but at the expense of an increase in major bleeding (OR = 1.48 with 95% CI: 1.11-1.98; high level of confidence) with no difference in NACE or all-cause mortality. For major bleeding, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, UFH monotherapy ranked #3, and combined UFH and GPI ranked #4. For NACE, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, combined UFH and GPI ranked #3, and UFH monotherapy ranked #4. Cluster plots for MACE and major bleeding demonstrated that extended bivalirudin had the best balance for efficacy and safety. In patients undergoing PCI for STEMI, extended bivalirudin offers the best balance for primary ischemic (MACE) and safety (major bleeding) outcomes.

Acute Ischemic Stroke and STEMI in A 78-Year-Old Female: A Case Report of Dual Life-Threatening Events and Complicated Recovery

Ischemic stroke and ST-elevation myocardial infarction (STEMI) occurring at the same time, are very rare conditions that cause major difficulties in management and present high mortality rates. This manuscript brings into focus a 78-year-old woman who had known diabetes mellitus (DM), hypertension (HTN), dyslipidemia, and ischemic strokes in the past, who presented with focal neurological deficits in the form of sudden onset slurring of speech and facial asymmetry which on investigation revealed a large left middle cerebral artery (MCA) infarction. Few hours later she developed STEMI with ECG changes and raised troponin levels. The patient experienced respiratory difficulty for which the patient was intubated. A percutaneous intervention (PCI) was attempted with moderate results. Complications included heart failure, atrial fibrillation (AF), and septic shock due to a urinary tract infection (UTI) that delayed her discharge from the hospital. Nevertheless, the effective treatment and cooperation between cardiologists and neurologists, stabilized her condition. This case shows the challenges of managing dual pathology (stroke and STEMI simultaneously); therefore, early diagnosis and multidisciplinary management offer the best prognosis to realize optimal outcomes.

Acute coronary syndrome as the initial manifestation of infective endocarditis in an apparently normal native valve: a case report

Abstract Background Acute coronary syndrome (ACS) is a rare complication of infectious endocarditis (IE). We present the case of a patient with a bicuspid aortic valve who presented an acute ST elevation myocardial infarction (STEMI) of the inferior wall secondary to vegetation that generated obstruction of the ostium of the right coronary artery (RCA). Case summary A 54-year-old patient with only a history of smoking was admitted for chest pain. An acute ST elevation myocardial infarction (STEMI) in the inferior wall was documented; he underwent an emergent coronary angiography, which showed a mass that obstructed the ostium of the right coronary artery that did not allow its channeling. An angiotomography of the aorta was performed, where dissection was ruled out and the presence of a mass in the right coronary sinus that protruded towards the ostium of the coronary artery was confirmed. In the extension studies, a bicuspid aortic valve, thrombosis in the right brachial artery and in the infrarenal abdominal aorta were documented. Discussion The case was taken to a medical meeting and given the embolic and mechanical compromise; it was decided to perform surgery where a mass that invaded the proximal segment of the right coronary artery was resected. The histopathological study documented findings of vegetation; the cultures were positive for Staphylococcus epidermidis, and he finally received antibiotic and anticoagulation treatment.

The Impact of Different Revascularization Strategies Implemented in Acute Myocardial Infarction on the Recovery of Left Ventricular Functional and Deformational Parameters

Background: Despite well-established therapeutic techniques, such as direct revascularization through percutaneous coronary intervention (PCI), acute myocardial infarction (AMI) remains a leading cause of mortality and morbidity. Objectives: To determine if two-dimensional speckle tracking echocardiography (STE) deformation parameters and the early recovery of left ventricular (LV) functions are affected by the timing of PCI in AMI. Methods: A total of 200 cases with newly-onset acute myocardial infarction (AMI) who had a baseline left ventricular ejection fraction (LVEF) higher than 40% and received effective therapy with percutaneous coronary intervention (PCI) were included in this investigation. cases were categorized as either ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI). cases were grouped into four groups according to the time between presentation and PCI. Using standard echocardiography and two-dimensional (2D) ST-elevation STE, individuals were re-evaluated three months later to find out if remodeling had taken place or if the LV function had returned. Results: Of the 200 AMI patients, including 140 males (70%), improvement in global longitudinal strain (GLS) and harmed longitudinal strain (HLS) were better in STEMI and NSTEMI patients received urgent revascularization with PCI (groups I and III) versus patients with pharmacoinvasive strategy or routine invasive strategy (Groups II and IV) (P &lt; 0.05) while there was an insignificant difference between group I and III (P = 0.79). Of the 200 patients, 47 patients (23.5%) presented signs of LV remodeling at 3 months follow up. Age, smoking history, hypertension, dyslipidemia, Killip class, peak creatine phosphokinase - MB level, baseline left ventricular end diastolic volume (LVEDV), HLS, and harmed longitudinal strain rate (HLSR) were all factors that were found to be significantly associated with left ventricular remodeling (P&lt;0.05) in the univariate logistic regression analysis. The following factors were identified as independent predictors of left ventricular remodeling in multivariate logistic regression analysis: damaged left ventricular ejection fraction (EF) and end-systolic volume, peak troponin I, Killip class, culprit left anterior descending (LAD), 2 and 3-vessel coronary artery disease (CAD), and wall motion score index (WMSI). Conclusion: Earlier PCI in AMI helps earlier improvement in myocardial strain parameters. HLS and HLSR are excellent predictors for LV remodeling and may do better than global parameters.

Impella 5.5 as a bridge-to-surgery in acute ischemic mitral regurgitation post-percutaneous coronary intervention: a case report

BackgroundAcute ischemic mitral regurgitation (AIMR) is a significant complication of acute coronary syndrome that leads to severe and immediate hemodynamic deterioration and cardiogenic shock. Intra-aortic balloon pumps (IABP) are commonly used to support patients with AIMR as a bridge to surgery, though they may be insufficient in some cases.Case PresentationA 74-year-old male presented with two days of indigestion and evident hypoxia, and an electrocardiogram revealed inferior and lateral ST-elevation myocardial infarction. Angiography demonstrated severe two-vessel coronary disease with a 100% thrombotic occlusion of the second obtuse marginal artery (OM2, culprit lesion) and an 80% stenosis of the proximal left anterior descending artery (LAD). Despite stenting of OM2, the patient remained hypoxic and hypotensive, necessitating escalated support via an IABP. A follow-up echocardiogram revealed severe mitral regurgitation presumed to be AIMR secondary to a ruptured posteromedial papillary muscle with a flail anterior leaflet (A2). Despite aggressive supportive measures with the IABP, the patient’s hemodynamics continued to show cardiogenic shock and clinical status did not improve. However, the patient was required to abstain from surgery for a P2Y12 inhibitor therapy wash out period. Consequently, the IABP was upgraded to Impella 5.5 as bridge-to-surgery support on day 1 post-admission. Subsequently, the patient’s hemodynamics improved, and he underwent a combined mitral valve replacement and coronary artery bypass grafting surgery on day 7 post-admission without incident. The Impella was successfully explanted on day 25 post-admission. Delay in explant was due to hypotension and respiratory status despite normalizing hemodynamics and echocardiogram revealing recovered left ventricular ejection fraction. The patient developed bacterial pneumonia and acute respiratory distress syndrome and expired on day 27 post-admission.ConclusionAlthough IABP is standard for supporting AIMR patients as a bridge to surgery, it may not provide sufficient hemodynamic support. This case supports a growing body of evidence that alternative forms of hemodynamic support should be considered if the traditional therapeutic modalities for AIMR do not adequately support patients. Clinicians may consider upgrading IABP to Impella to provide increased hemodynamic support and maintain AIMR patient stability while awaiting cardiac surgery.

Triggering type and long-term survival following ST segment elevation-myocardial infarction treated with primary percutaneous coronary intervention.

Physical and emotional stress are recognized triggers of acute coronary syndromes, including ST segment elevation-myocardial infarction (STEMI). We have previously shown that identifiable triggers precede symptoms in over one-third of STEMI patients and inversely correlate with the extent of coronary artery disease (CAD). This study aims to investigate the association between trigger type (physical vs. emotional) and long-term mortality in STEMI patients treated with primary percutaneous coronary intervention (PCI). This retrospective, single-center observational study included all patients admitted with an STEMI diagnosis from January 2008 to December 2013. Physical and emotional triggers were identified retrospectively from patient records. Mortality data were obtained from the Israeli Ministry of Health. Of 1345 consecutive STEMI patients treated with primary PCI, mortality data were available for 1267 patients (median age: 61 years). A trigger preceding symptoms onset was identified in 36.5% of patients, with 85% experiencing physical stress and 15% emotional stress. Triggered STEMI patients tended to be younger with fewer comorbidities and lower incidence of multiple vessel CAD compared with nontriggered patients. Notably, emotionally triggered STEMI patients exhibited improved long-term survival compared with those without emotional triggers or with physical triggers. predictor of enhanced long-term survival post-PCI compared with physical triggering. Emotional triggering was identified as an independent. Patients with emotionally triggered STEMI showed less extensive CAD and improved long-term survival following PCI compared with those with physically triggered STEMI. These findings highlight the importance of considering both the presence and type of trigger in the management of STEMI patients and their long-term prognosis.

Three fatal consequences of one guiding catheter maneuver during primary percutaneous angioplasty in ST elevation myocardial infarction.

Three fatal consequences of one guiding catheter maneuver during primary percutaneous angioplasty in ST elevation myocardial infarction.

Relationship between Myocardial Performance Index (Tei Index) and angiographic severity of coronary artery disease in patients with Acute ST Elevation Myocardial Infarction

Background: Tei index is a Doppler derived measure of combined systolic and diastolic myocardial function and a better predictor of global LV function and outcome in patients with acute STEMI. The objective of this study was to determine the relationship between the myocardial performance index of LV (Tei index) and angiographic severity of coronary artery disease as assessed by SYNTAX score in patients with acute STEMI. Methods: This was a prospective, observational single centered study conducted from March 2022 to November 2022 at Manmohan Cardiothoracic Vascular and Transplant Centre, Institute of Medicine. (MCVTC, IOM). 160 patients with acute STEMI were enrolled. LV Tei index was calculated with the help of 2D and Tissue Doppler imaging, and the lesion severity was categorized with the help of SYNTAX score after the patients underwent coronary angiography. Results: The mean age was 61.23±12.33 years with a male preponderance. 107 (67%) were male with male to female ratio of 2:1. Tei index was significantly higher among the hypertensive (0.74±0.17) and diabetic (0.78±0.18) patients. 64 (40%), 51(31.9%) and 45(28.1%) had Single vessel disease (SVD), Double vessel disease (DVD) and Triple vessel disease (TVD) respectively with the Mean Tei index values 0.57 ± 0.10, 0.76 ± 0.11, and 0.88±0.11 (p&lt;0.05). The Tei index increased when patients were divided into low, mid, and high SYNTAX score groups as 0.58±0.11, 0.61±0.73, 0.88±0.13 respectively, p-value &lt; 0.05). Moreover, the study showed a positive correlation between Tei index and SYNTAX score with increasing severity of coronary artery stenosis. (r=0.654, p-value&lt;0.001). Proximal LAD, LCx and RCA lesions had greater Tei index than the distal lesions. Conclusion: More proximally located LAD, LCx, RCA lesions had higher value of Tei index, as assessed with the SYNTAX score.

Platelet-to-albumin ratio is an independent predictor for ventricular aneurysm formation in ST segment elevation myocardial infarction.

Left ventricular aneurysm (LVA) is a common complication of acute myocardial infarction. We aimed to investigate the association of the platelet-to-albumin ratio (PAR) with LVA formation in patients with acute ST segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). A total of 767 consecutive patients with STEMI were prospectively enrolled. Logistic regression analysis and restricted cubic spline (RCS) were used to assess the association between PAR and LVA formation. The predictive ability of PAR and combined variable for LVA formation were assessed using receiver-operating characteristic (ROC) curve. The prevalence of LVA was 14.1%. Univariable logistic regression analysis revealed that PAR was associated with the risk of LVA at both 1 month [odds ratio (OR) = 4.42, P < 0.001] and 6 months (OR = 4.35, P < 0.001) of follow-up. The predictive value of PAR remained significant even after multivariate logistic regression analysis at 1 month (OR = 3.42, P = 0.004) and 6 months (OR = 4.28, P < 0.001). RCS analysis revealed a nonlinear association between a higher PAR and an increased risk of LVA (nonlinear P < 0.05). In addition, the predictive abilities of PAR for LVA were 0.659. The combination of PAR, hemoglobin, left ventricular ejection fraction, and the use of angiotensin-converting enzym inhibitor/angiotensin receptor blocker significantly enhanced the ability to predict LVA formation (C statistic= 0.887). A higher PAR was significantly associated with an increased risk of LVA formation in patients with acute STEMI who underwent primary PCI.

Safety of Beta-Blocker Administration in STEMI Patients With Risk Factors for Cardiogenic Shock.

Beta-blockers are recommended in the first 24 hours after ST-segment elevation myocardial infarction (STEMI) except in those at risk of cardiogenic shock. This retrospective cohort study aimed to assess if early beta-blocker use was associated with cardiogenic shock development in STEMI patients. Cardiogenic shock was assessed in adult patients with STEMI undergoing percutaneous coronary intervention (PCI) with guideline defined risk factors for shock (age above 70 years, systolic blood pressure below 120 mmHg, and heart rate above 120 bpm or below 60 bpm) who did or did not receive a beta-blocker within 24 hours of PCI. Multivariable logistic regression was used to assess the association between cardiogenic shock development and early beta-blocker administration. A total of 216 patients were included, 85 with early beta-blocker administration and 131 without. Patients who received an early beta-blocker versus those who did not had a median (interquartile range) age of 63 (52-71) versus 66 (54-76; P = .2260) and peak troponin of 58.3 (15.0-132.4) ng/mL versus 51.6 (16.6-139.5; P = .9884). Cardiogenic shock occurred in 4.7% (n = 4) patients with early beta-blocker use versus 12.2% (n = 16; P = .0909) without. After backward stepwise logistic regression, early beta-blocker use was not associated with cardiogenic shock (adjusted odd ratio [aOR] 0.334, 95% confidence interval (CI) 0.106-1.047; P = .0599), but those with a peak troponin over 56 ng/mL had an over three-fold increased risk of developing cardiogenic shock (aOR 3.434, 95% CI 1.191-9.902; P = .0224) regardless of beta blocker administration. Early beta-blocker administration in STEMI patients may not be associated with shock development.

The HALP score predicts no-reflow phenomenon and long-term prognosis in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention.

Despite recent advances in the management of ST-segment elevation myocardial infarction (STEMI), the clinical outcome of some patients is still unsatisfactory. Therefore, early evaluation to identify high-risk individuals in STEMI patients is essential. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score, as a new indicator that can reflect both nutritional status and inflammatory state of the body, can provide prognostic information. In this context, the present study was designed to investigate the relationship between HALP scores assessed at admission and no-reflow as well as long-term outcomes in patients with STEMI. A total of 1040 consecutive STEMI patients undergoing primary PCI were enrolled in this retrospective study. According to the best cutoff value of HALP score of 40.11, the study samples were divided into two groups. The long-term prognosis was followed up by telephone. Long-term mortality was significantly higher in patients with HALP scores lower than 40.11 than in those higher than 40.11. The optimal cutoff value of HALP score for predicting no-reflow was 41.38, the area under the curve (AUC) was 0.727. The best cutoff value of HALP score for predicting major adverse cardiovascular events (MACE) was 40.11, the AUC was 0.763. The incidence of MACE and all-cause mortality was higher in the HALP score <40.11 group. HALP score can independently predict the development of no-reflow and long-term mortality in STEMI patients undergoing PCI.

Clinical, laboratory, and procedural predictors of slow flow/no reflow phenomenon after emergency percutaneous coronary interventions in ST-elevated myocardial infarction

BackgroundEmergency percutaneous coronary intervention (PCI) is a common treatment for ST-elevated myocardial infarction (STEMI) patients. However, the coronary slow flow/no reflow phenomenon (CSF/NRP) can occur as a complication during or after the procedure. Identifying predictors of CSF/NRP after emergency PCI in STEMI patients can help clinicians anticipate and prevent this complication. In this study, we aimed to investigate clinical, laboratory, and procedural factors that may contribute to the development of CSF/NRP in STEMI patients undergoing PCI.ResultsA total of 460 patients were included in this study, with a mean (± SD) age of 60 ± 12.5 years. The incidence of CSF/NRP was 30.2% (n = 139) among the study population. The univariate analysis showed that older age, lower left ventricular ejection fraction (LVEF), initial thrombolysis in myocardial infarction (TIMI)flow grade 0–2, increased creatinine level, lower estimated glomerular filtration rate (eGFR), diffuse target lesion length, and longer length of stent were significantly associated with the occurrence of CSF/NRP (p < 0.05). However, in the multivariate logistic regression model, only eGFR (OR = 0.98, 95% CI: 0.96–0.99, p = 0.005), diffuse target lesion length (OR = 2.15, 95% CI: 1.20–3.83, p = 0.009) and LVEF (OR = 0.96, 95% CI: 0.94–0.98, p = 0.004) remained significant predictors of CSF/NRP.ConclusionsThe present study demonstrated that diffuse lesion length, lower LVEF, and lower eGFR can be considered as independent predictors of CSF/NRP in STEMI patients.

The Impact of Neutrophil-to-High-Density Lipoprotein Ratio and Serum 25-Hydroxyvitamin D on Ischemic Heart Disease.

Background: This study describes the complex association between the neutrophil-to-high-density lipoprotein cholesterol ratio (NHR), 25-hydroxyvitamin D (25(OH)D) levels, and cardiovascular disease (CVD), such as stable ischemic heart disease (IHD), ST elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). Methods: The serum 25(OH)D concentration and NHR values were analyzed in groups of patients with chronic coronary syndrome (CCS) and acute coronary syndrome (ACS). The severity of coronary artery atherosclerosis was determined using the Coronary Artery Surgery Study (CASS) scale. Results: Significant differences in 25(OH)D and NHR concentrations were observed between CCS and (ACS)/STEMI patients (p < 0.01). Higher 25(OH)D concentrations were associated with the diagnosis of CCS, and higher NHR values with the diagnosis of ACS/STEMI. The NHR threshold for ACS was set at 0.10 (p < 0.001). Patients without significant coronary artery stenosis showed significantly higher 25(OH)D levels and lower NHR values (p < 0.01). Conclusions: The significant correlation between 25(OH)D, HDL, and the NHR suggests that vitamin D, through its influence on inflammatory processes and lipid metabolism, may play a role in the pathogenesis of chronic and acute coronary syndromes. The suggested bidirectional relationship between the NHR and 25(OH)D and the role of the NHR as a predictor of vitamin D levels require further well-designed studies.

STEMI in an Adolescent: A Critical Case of Kawasaki Disease.

Acute coronary syndrome (ACS) is a rare cause of chest pain in adolescents and young adults. Kawasaki disease (KD) is an uncommon illness, but coronary artery aneurysms secondary to KD are implicated in approximately 5% of cases of ACS in young adults. Patients with KD may present with catastrophic coronary disease at a young age and thus early recognition of this disease process and lifelong follow-up is essential. Here we discuss a 19-year-old active duty male with no previously recognized medical history who presented with crushing chest pain while deployed. He was diagnosed with an ST elevation myocardial infarction and was found to have a giant aneurysm of the left main coronary artery with obstructive thrombus treated with emergent thrombectomy and balloon angioplasty. He developed cardiogenic shock requiring mechanical circulatory and ventilatory support. After a prolonged recovery and more in-depth history-taking, he was discovered to have been diagnosed with KD as a child without follow-up. Diagnosing ACS in young adults can be challenging, but a history of KD should increase suspicion for coronary disease. This case demonstrates the importance of screening after a childhood diagnosis of KD, specifically when caring for the tactical athlete. It also highlights the impact that social determinants of health can have on patient outcomes. Finally, it demonstrates the importance of communication and coordination between military and civilian medical centers across the globe driving the care of our deployed injured and ill active-duty military personnel.

Risk factor analysis of microvascular obstruction after percutaneous coronary intervention for ST-segment elevation myocardial infarction

ObjectiveThis study aimed to explore the risk factors of microvascular obstruction (MVO) after percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). Materials and MethodsA retrospective analysis was performed on 165 patients with STEMI who successfully underwent emergency PCI and completed cardiac magnetic resonance (CMR) within 1 week after PCI. Total ischemia time (symptom onset to wire, S2W), first medical contact to wire (FMC2W), and door to wire (D2W) were compared with the recommended critical time nodes for STEMI treatment. Left ventricular function was evaluated by CMR cine, and myocardial infarction characteristics and MVO were evaluated by late-gadolinium enhancement (LGE). Binary logistic regression analysis was used to evaluate the effect of delay in treatment of STEMI on the occurrence of MVO after PCI. ResultsIn this study, 89 (53.9%) patients with STEMI presented with MVO after emergency PCI. The FMC2W time and S2W time in the MVO (+) group were significantly longer than those in the MVO (−) group (P<0.05). Compared with the MVO (−) group, the MVO (+) group had larger myocardial infarction size (IS) and lower left ventricular ejection fraction (LVEF) (P<0.05). Patients with FMC2W time >120min and S2W time >300min had greater myocardial IS and MVO than the FMC2W ≤120min and S2W time ≤300min group, respectively. Logistic regression analysis showed that S2W time >300min (P=0.039, OR=2.756, 95% CI=1.053-7.213) was an independent predictor of MVO after PCI in patients with STEMI. ConclusionShortening the total time of myocardial ischemia and increasing the proportion of early reperfusion therapy can prevent or reduce MVO after PCI.

Five-year clinical outcomes of STEMI patients treated with a pre-specified bioresorbable vascular scaffold implantation technique: Final results of the BVS STEMI STRATEGY-IT

BackgroundData on Absorb bioresorbable vascular scaffold (BVS) use in patients presenting with ST-segment elevation myocardial infarction (STEMI) are limited. Furthermore, Absorb studies including STEMI patients lacked a prespecified implantation technique to optimize BVS deployment. This study examines the 5-year outcomes of BVS in STEMI patients using an optimized implantation strategy and the impact of prolonged dual antiplatelet therapy (DAPT). MethodsThe BVS STEMI STRATEGY-IT study is a prospective, non-randomized, single-arm multicenter trial (NCT02601781). It involved 505 STEMI patients undergoing primary percutaneous coronary intervention with a predefined BVS implantation protocol. Key endpoints were a 5-year device-oriented composite endpoint (DOCE) of cardiac death, target-vessel myocardial infarction (TV-MI), and ischemia-driven target lesion revascularization (ID-TLR). The study also compared outcomes based on DAPT duration (36 months vs. shorter). Results502 (99.4 %) patients completed the 5-year follow-up. DOCE rate was 2.4 %. ID-TLR, TV-MI, and cardiac death rates were 1.6 %, 0.8 %, and 0.6 %, respectively. No DOCE occurred between three and five years. Scaffold thrombosis (ScT) was 1 %, all occurring within 24 months. Longer-term DAPT significantly reduced DOCE (1.3 % vs. 4.3 %; HR: 0.29; 95 % CI: 0.1–0.9; p = 0.03) driven by a lower rate of TV-MI (0 % vs. 2.2 %; p = 0.018) compared to shorter-term DAPT, as well as ScT (0 % vs 2.7 %, p = 0.007). ConclusionsThis study shows favorable 5-year outcomes for BVS in selected STEMI patients with an optimized implantation strategy. Prolonged DAPT further improved outcomes, emphasizing its role in reducing adverse events during scaffold resorption. Further research is needed to assess newer-generation bioresorbable devices.

Right bundle branch block in suspected acute coronary syndromes: Diagnostic challenges, treatment and prognosis

BackgroundThere is still conflicting evidence regarding the prognostic implications of right bundle branch block (RBBB) in the general population but also in patients with heart diseases like acute coronary syndromes (ACS). In accordance with current guidelines, RBBB in ACS patients is considered as STEMI equivalent. However, recent studies indicate that further differentiation is necessary in this group, as we will outline below. Methods and resultsA literature search was conducted in PubMed and Google Scholar.In previous studies, RBBB in the general population were mostly considered benign changes of the electrical conduction system. However, recent studies indicate that both complete and incomplete RBBB are associated with increased cardiovascular morbidity and mortality. In addition, among unselected patients with suspected ACS presenting to the emergency department, the prevalence of RBBB was 3 % and it was associated with elevated mortality. The subsequent angiographic identification of a culprit coronary artery stenosis leading to stent implantation was similar at approximately 2 % regardless of the initial ECG presentation with narrow QRS complexes, left bundle branch block (LBBB), or RBBB.Finally, in a group of high-risk patients for ST-elevation myocardial infarction (STEMI), the prevalence of RBBB was 12 %. While RBBB was associated with poor outcome compared to non-BBB and LBBB patients, diagnostic accuracy of STEMI criteria was not affected by the presence of RBBB. However, RBBB patients without distinct STEMI signs in ECG often showed acute STEMI on angiography indicating a potential benefit from immediate transfer to the cardiac catheterization laboratory. ConclusionIn the general population, patients with RBBB and risk factors may need further evaluation. Regarding ACS patients, recent studies support current guidelines that recommend acute invasive evaluation for high-risk ACS patients with RBBB, regardless of ST-T deviations. However, in an unselected group of ACS patients, differential diagnoses should also be investigated through additional diagnostic procedures.

Coronary Angiographic Features of de Winter Syndrome: More Than Just Occlusion of the Left Anterior Descending Artery.

The de Winter electrocardiogram (ECG) pattern is a rare presentation of ST-segment elevation myocardial infarction (STEMI) equivalent. The clinical profile of de Winter syndrome remains to be clarified. Medical records of 1865 consecutive patients with acute myocardial infarction admitted from November 2018 to July 2023 were screened. Twelve patients (0.6%) with de Winter syndrome were included. STEMI patients whose culprit vessel was the left anterior descending artery (LAD) but without de Winter ECG pattern were selected as controls after 1:2 matching for age and sex. The de Winter syndrome patients were all male, aged 49.0 (46.3-52.5) years. The culprit lesion was the proximal LAD in seven patients (58.3%), the middle LAD in three (25%), the left main coronary artery in one (8.3%), and the ramus intermedius artery in the other. All of their culprit lesions had TIMI Thrombus Grade < 4, Cohen-Rentrop Score ≤ 2, and residual stenosis ≥ 80% after pretreatment with thrombus aspiration or balloon predilatation. Intracoronary imaging data were available in four patients, showing severe atherosclerotic stenosis. Compared with STEMI, de Winter syndrome had a higher prevalence of prior recurrent angina (75.0% vs. 37.5%, p = 0.034), better coronary collateralization (Cohen-Rentrop Score: 1 vs. 0, p = 0.001), lower thrombus burden (TIMI grade: 1 vs. 2, p = 0.005) but more severe atherosclerotic stenosis in the culprit lesions (90% vs. 60%, p < 0.001). The culprit lesions of de Winter syndrome have a low thrombus burden, severe atherosclerotic stenosis, and poor collateral circulation protection.

Diagnostic Value of Regional Wall Motion Abnormalities on Resting Transthoracic Echocardiography for Coronary Artery Disease.

Regional wall motion abnormality (RWMA) on transthoracic echocardiography (TTE) is used as a clinical decision-making tool to assess systolic function, but there is limited data regarding the validity of this tool to predict obstructive coronary artery disease (CAD). This study evaluates the utility of RWMA on TTE for detecting obstructive CAD in patients with no prior CAD history. We retrospectively reviewed charts of adults who underwent resting TTE and coronary angiography within 30days, analyzing RWMA in relation to angiographic luminal stenosis. Among 754 patients (mean age 62, 60% male), TTE sensitivity varied with timing relative to angiography: 68.7% after angiography versus 49.5% before. In ST-elevation myocardial infarction (STEMI) patients (n=126 after vs. n=4 before), sensitivity was 89.8%. RWMA correlated with CAD severity, particularly in STEMI cases. TTE specificity remains high, but sensitivity varies significantly by timing, with the highest sensitivity in STEMI patients. These findings could refine decision-making in uncertain STEMI cases, supporting TTE as a valuable adjunctive diagnostic tool.