ST-segment Elevation Myocardial Infarction Research Articles

Morphological characterization of coronary plaques in young indian patients with acute coronary syndrome: A multicentric study

ObjectivesThe prevalence of atherosclerosis and acute coronary syndrome (ACS) is increasing in young Indians (18–50 years of age). However, the characteristics of atherosclerotic plaques in such individuals are poorly understood, presenting distinct challenges for the management of ACS. This study aims to analyze plaque characteristics in young Indian patients with ACS who underwent percutaneous coronary intervention (PCI) using optical coherence tomography (OCT) imaging. MethodsThis was a prospective, multicentric, non-interventional study on patients aged 18–50 years presenting with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction, or unstable angina, and were scheduled to undergo OCT-guided PCI. Major adverse cardiac events (MACE) were assessed post-procedure and at the 6-month and 12-month follow-ups. ResultsThe study included 100 ACS patients (mean age = 43.6 ± 5.2 years), with 51% presenting with STEMI. Pre-PCI OCT assessment showed that fibrous plaques (75%) were most common followed by plaques containing macrophages (27%), microchannels (20%), and calcified nodules (14%). In addition, plaque rupture, plaque erosion, and lipid-rich plaques, along with red, white, and mixed thrombi, were observed in 31%, 25%, 24%, 21%, 14%, and 17% (total thrombus occurrence = 52%) of the patients, respectively. At 12 months, the MACE (coronary artery bypass graft) rate was 1%. ConclusionsYoung Indian patients with ACS displayed a range of plaque morphologies identified through pre-PCI OCT. Among these, fibrous plaques were the most prominent type, followed by plaques containing macrophages. Additionally, plaque rupture, plaque erosion, and lipid-rich plaques were also observed in this population.

Localization of Hemostasis Elements in Aspirated Coronary Thrombi at Different Stages of Evolution.

The structure of aspirated coronary thrombus in ST-segment elevation myocardial infarction (STEMI) is still being studied. Our aims were to characterize coronary thrombi of different ages, focusing on the appearance of activated protein C (APC/PC) and its relation to the elements of neutrophil extracellular traps (NETs), and the factors closely related to fibrin as factor XIII (FXIII) and α2 plasmin inhibitor (α2-PI). The thrombi of n = 24 male patients with atherosclerotic coronary plaque rupture related to native coronary artery occlusion were selected for histopathology analysis. Thrombus age was distinguished as fresh, lytic, and organized, and then analyzed by immunofluorescent staining and confocal microscopy. FXIII was present at a high level and showed a high degree of co-localization with fibrin in all stages of thrombus evolution. The amount of α2-PI was low in the fresh thrombi, which increased significantly to the lytic phase. It was evenly distributed and consistently associated with fibrin. APC/PC appeared in the fresh thrombus and remained constant during its evolution. The presence of NET marker and CD66b was most dominant in the lytic phase. APC/PC co-localization with the elements of NET formation shows its role in NET degradation. These observations suggest the importance of searching for further targeted therapeutic strategies in STEMI patients.

Condiciones geriátricas y estrategia invasiva en pacientes frágiles con IAMSEST. Análisis de subgrupos de un ensayo clínico aleatorizado

Introduction and objectives Invasive management in frail patients with non–ST-segment elevation myocardial infarction (NSTEMI) remains controversial. We investigated the impact of various geriatric conditions.Methods The MOSCA-FRAIL trial included 167 adults aged ≥ 70 years with frailty (Clinical Frailty Scale [CFS] ≥ 4 points) and NSTEMI, who were randomized to either an invasive (n = 84) or conservative (n = 83) strategy. In addition to frailty, we measured activities of daily living (Barthel index), cognitive impairment (Pfeiffer test), and comorbidities (Charlson index). The primary endpoint was the difference (invasive minus conservative) in restricted mean survival time (RMST) for all-cause mortality at a median follow-up of 3.9 years.Results A total of 93 patients died. The RMST difference favored invasive management at the CFS 25th percentile (CFS = 4; 157 days, 95%CI, 18-295; P = .027), which changed to a nonsignificant effect at the 50th and 75th percentiles. The RMST difference remained nonsignificant, irrespective of the severity of other geriatric assessments. In time-to-event analysis, invasive management was associated with an initially lower life expectancy, peaking at around 1 year, among all subgroups. However, patients with CFS = 4 experienced a benefit at the end of follow-up (181 days, 95%CI, 19-343), whereas those with CFS > 4 did not (−16 days, 95%CI, −217 to 186; interaction P = .16). Subgroups defined by other geriatric markers showed a similar time-dependent trend, albeit with weaker statistical interaction.Conclusions Among adults with frailty and NSTEMI, the CFS might be useful for evaluating the relative risks and benefits of invasive management. A CFS > 4 could serve as a valuable threshold for decision-making.

Impella saves lives in a subset of patients with ST-elevation myocardial infarction and cardiogenic shock.

Impella saves lives in a subset of patients with ST-elevation myocardial infarction and cardiogenic shock.

ST-elevation myocardial infarction from spontaneous coronary artery dissection with high thrombus burden

ST-elevation myocardial infarction from spontaneous coronary artery dissection with high thrombus burden

Culprit vessel revascularization prior to complete angiography as a strategy to minimize delays in primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: a systematic review and meta-analysis.

The rapid restoration of blood flow in patients with acute myocardial infarction with ST elevation through percutaneous coronary intervention (PCI) is crucial for the survival of this population. Attempts to decrease the time from diagnosis of ST-segment elevation myocardial infarction (STEMI) to arrival at the catheterization laboratory have been extensively investigated. However, strategies during the procedure aiming to reduce the time to reperfusion are lacking. We conducted a meta-analysis to evaluate culprit vessel revascularization prior to complete angiography as a strategy to minimize delays in primary PCI for patients with STEMI. We searched PubMed, Embase, and Cochrane Central. Outcomes: vascular access-to-balloon, door-to-balloon, and first medical contact-to-balloon times; death, reinfarction in 30 days, Bleeding Academic Research Consortium ≥3 type, coronary artery bypass grafting referral, and left ventricular ejection fraction %. Statistical analysis was performed using the R program (version 4.3.2). Heterogeneity was assessed with I2 statistics. We included 2050 patients from six studies, of which two were randomized controlled trials and four were observational studies. Culprit vessel revascularization prior to complete angiography was associated with a statistically significant decrease of times: vascular access-to-balloon time (mean difference -6.79 min; 95% CI: -8.00 to -5.58; P < 0.01; I2 = 82%) and door-to-balloon time (mean difference -9.02 min; 95% CI: -12.83 to -5.22; P < 0.01; I2 = 93%). In this meta-analysis, performing PCI on the culprit lesion prior to complete coronary angiography led to significantly shorter reperfusion times, with no discernible differences in complication rates.

Clinical presentation, management and outcomes of myocardial infarction in the Heart Center, Al-Thawra Hospital, Sana'a City, Yemen: Stemi cardiac arrest management outcomes

Background and aim: Acute ST-segment elevation myocardial infarction (STEMI) is a critical medical emergency requiring emergency evaluation, diagnosis, and intervention. The aim of the study was to evaluate the clinical presentation, type of treatment, and outcomes of patients with acute ST-segment elevation myocardial infarction at the Heart Center of Al-Thawra Hospital, Sana'a. Methods: prospective study. We enrolled all patients with a final diagnosis of STEMI who have been admitted to the cardiac CCU in the cardiac center in AL-Thawrah Hospital during one year, January to December 2023. Results: A total of 358 patients with STEMI were analyzed. The mean age was 55 ± 8 years old, with male patients representing 80% (286)). The traditional risk factors among these patients were: hypertension 28.23% (101), smoking represents 26.05% (93), diabetes mellitus represents 19% (68), BMI &gt; 30 kg/m2 represents 16.34% (57), and khat chewing represents 78.2% (279). STEMI patients who managed by primary PCI were 14% (50). Patients who have been managed by thrombolytic therapy were 28% (101) and the conventional medical treatment was managed for those who arrived after 12 hours and represent 58%% (204). The most commonly used thrombolytic was streptokinase in 96% (97) of patients who received thrombolytics. Primary PCI within 24 hours has been done in 14% (50) of cases. Heart failure (EF &lt; 50%) represented (26%) (93), cardiovascular shock was 13% (46 cases), and mortality rate was 11% (39 cases))

Thrombus aspiration in ST elevation myocardial infarction: are we done?

Thrombus aspiration in ST elevation myocardial infarction: are we done?

Ethnic Disparities of Arrival Following ST Elevation Myocardial Infarction in South Israel.

Background: Early activation of the emergency medical service (EMS) is crucial for the care of patients with STEMI. Methods: A retrospective cohort study of patients hospitalized with STEMI was conducted. Two groups of patients were compared: Bedouins and Jews. The primary outcome was one-year mortality. The secondary endpoints were 30-day mortality, mode of transportation and door-to-balloon time. Results: There were 445 Bedouin patients (BPs) and 1103 Jewish patients (JPs). BPs with STEMI were significantly younger than JPs, had more diabetes and higher rates of smoking. More JPs arrived at the hospital by ambulance compared to BPs (56.9% vs. 31.9%, p < 0.001). Direct transportation to the catheterization laboratory was observed in 51.9% of JPs and in 43.6% of BsP, p = 0.003. Door-to-balloon time was longer in BPs compared to JPs (median 65 min vs. 62 min, p = 0.044). There were no differences in one-year, 30-day and in-hospital mortality between the two groups. After adjustment by propensity score analysis for JPs vs. BPs, there was a protective factor for one-year mortality (hazard ratio (HR), 0.68; 95% CI 0.48-0.97), p = 0.034. Thirty-day and one-year mortality in the subgroup of BPs that arrived at the hospital from the outpatient clinic was higher compared to JPs (7.1% vs. 4.4%, p = 0.004 and 10.4% vs. 5.6%, p < 0.001, relatively) Conclusions: Underuse of EMS by BPs with STEMI compared to JPs resulted in a delay in direct transportation to the catheterization laboratory, longer door-to-balloon time and a higher 30-day and one-year mortality in the subgroup of BPs who arrived at the hospital after visiting an outpatient clinic.

Incidence and outcomes of transient new-onset atrial fibrillation complicating acute coronary syndromes: results from a systematic review and meta-analysis

Abstract Background The overall risk of long-term adverse events of a transient episode of new-onset atrial fibrillation (AF) in patients with acute coronary syndrome (ACS) remains uncertain. This meta-analysis aimed to assess the prognostic impact of transient new-onset AF complicating ACS. Methods and results Cohort studies examining the risk of adverse events in patients with transient new-onset AF compared to those in sinus rhythm after ACS were identified through a comprehensive search of MEDLINE, Scopus, Cochrane, and Google Scholar Library. Studies reporting the incidence of ischaemic stroke events, recurrent AF, or all-cause mortality at the longest follow-up were included. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CI) were synthesized using inverse variance-weighted random-effects meta-analysis. In the seven observational studies included, comprising 151 735 patients, 6 597 (4.3%) experienced transient new-onset AF, which was associated with an increased risk of ischaemic stroke, recurrent AF, or all-cause mortality (HR: 2.24, 95% CI: 1.75–2.85; P &amp;lt; 0.0001; I2 = 30.76%; seven studies). The results remained consistent across each individual endpoint, including ischaemic stroke (HR 2.38, 95% CI: 1.64–3.44; P &amp;lt; 0.01; I2 = 50.2%; five studies), recurrent AF (HR 4.68, 95% CI: 2.07–10.59; P = 0.0002; I2 = 50.2%; four studies), and all-cause mortality (HR 1.36, 95% CI: 1.08–1.71; P = 0.0089; I2 = 53.25%; four studies). Meta-regression analyses revealed a significant increase in these adverse events associated with ST-elevation myocardial infarction (P = 0.001), while there was a tendency for their decrease associated with oral anticoagulant prescription at discharge (P = 0.07). Conclusions The occurrence of transient new-onset AF is associated with an elevated long-term risk of stroke, recurrent AF, and all-cause mortality in patients with ACS. Consequently, these data urge randomized clinical trials to assess the best antithrombotic regimen while potentially helping the current treatment decision-making process for these patients.

Elevated Circulatory Levels of UL16 Binding Protein 1 Positive Microparticles Are Associated With Acute Myocardial Infarction and its Severity.

Atherosclerosis is a vascular inflammatory disease characterized by the activation and stress of various inflammatory cells, leading to the development of coronary artery disease and subsequently acute myocardial infarction (AMI). Among AMI cases, ST-segment elevation myocardial infarction (STEMI) is typically more severe than non-STEMI (NSTEMI). UL16-binding proteins (ULBPs), which are NKG2D ligands, can be expressed on the surface of stressed and activated cells, prompting these cells to generate microparticles (MPs). Consequently, MPs carrying ULBPs, particularly ULBP1 (ULBP1+ MPs), may be released into the bloodstream. This study aimed to investigate the association between ULBP1+ MPs and the presence of AMI and its severity. We recruited 58 AMI patients and 45 age-matched control subjects. Levels of ULBP1+ MPs and ULBP1+ MPs originating from T lymphocytes (ULBP1+ TMPs) were measured using flow cytometry. Both ULBP1+ MP and ULBP1+ TMP levels were significantly elevated in AMI patients compared to controls. Elevated levels of these MPs were independent risk factors for AMI with odds ratios (OR) of 4.3 (95%CI=1.5-12.3) for ULBP1+ MPs and 5.8 (95%CI=2.0-17.0) for ULBP1+ TMPs. Additionally, ULBP1+ TMP levels were significantly higher in STEMI patients compared to NSTEMI patients, with an independent association observed between ULBP1+ TMPs and STEMI (OR=3.9; 95%CI=1.2-12.8). Elevated levels of ULBP1+ MPs and ULBP1+ TMPs are associated with AMI and its severity. These biomarkers could serve as indicators of vulnerable plaques that lead to AMI.

Coronary artery bypass grafting vs. percutaneous coronary intervention in severe ischaemic cardiomyopathy: long-term survival.

The optimal revascularization strategy in patients with ischaemic cardiomyopathy remains unclear with no contemporary randomized trial data to guide clinical practice. This study aims to assess long-term survival in patients with severe ischaemic cardiomyopathy revascularized by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group registries (from January 2005 to 2018), patients with severe ischaemic cardiomyopathy [left ventricular ejection fraction (LVEF) <35%] undergoing PCI or isolated CABG were included in the analysis. Those with ST-elevation myocardial infarction and cardiogenic shock were excluded. The primary outcome was long-term National Death Index-linked mortality up to 10 years following revascularization. Risk adjustment was performed to estimate the average treatment effect using propensity score analysis with inverse probability of treatment weighting (IPTW). A total of 2042 patients were included, of whom 1451 patients were treated by CABG and 591 by PCI. Inverse probability of treatment weighting-adjusted demographics, procedural indication, coronary artery disease extent, and LVEF were well balanced between the two patient groups. After risk adjustment, patients treated by CABG compared with those treated by PCI experienced reduced long-term mortality [adjusted hazard ratio 0.59, 95% confidence interval (CI) 0.45-0.79, P = .001] over a median follow-up period of 4.0 (inter-quartile range 2.2-6.8) years. There was no difference between the groups in terms of in-hospital mortality [adjusted odds ratio (aOR) 1.42, 95% CI 0.41-4.96, P = .58], but there was an increased risk of peri-procedural stroke (aOR 19.6, 95% CI 4.21-91.6, P < .001) and increased length of hospital stay (exponentiated coefficient 3.58, 95% CI 3.00-4.28, P < .001) in patients treated with CABG. In this multi-centre IPTW analysis, patients with severe ischaemic cardiomyopathy undergoing revascularization by CABG rather than PCI showed improved long-term survival. However, future randomized controlled trials are needed to confirm the effect of any such benefits.

Telemedicine through social media to enhance guideline-directed revascularization in STEMI: a five-year analysis in a developing nation

Abstract Background Timely reperfusion reduces mortality in ST segment Elevation Myocardial infarction (STEMI). Telemedicine and social media have been variably used to improve STEMI care in community settings. We established a new care system for STEMI in a public health setting serving a population of over 80 million, in a state with from a developing nation. Purpose To enhance guideline directed revascularisation (GDR) in STEMI by networking non-percutaneous coronary intervention (PCI) capable hospitals to PCI capable hospitals in a hub-and-spoke model and implementing telemedicine via social media platforms (Whatsapp) over five years(2019-2023). Methods Eighteen Government medical college hospitals were identified as hubs and were provided with cardiac catheterisation laboratories and empowered to provide either round the clock (Phase I hubs) or office hour primary PCI (Phase II hubs). They were linked to 188 Taluk or District-level, non-PCI capable Government hospitals identified as spokes to form 18 STEMI clusters. Separate social media groups on WhatsApp were created for each of the clusters, facilitating the sharing of de-identified ECGs and clinical data from spokes for guidance on diagnosis and management by hub hospital cardiologists. Transfer to hub hospitals for catheter based therapies were coordinated through prior intimation in the cluster WhatsApp group to ensure timely arrival and treatment. A customised uniform protocol for STEMI management was developed and health care personnel were trained accordingly. Human resource support was provided to collect and submit cumulative daily data on the number of STEMIs, the revascularisation provided and mortality through online free web forms. Annual cumulative data on STEMI volumes and GDR were analysed. Results 71,907 STEMI patients were treated from 2019 to 2023. We observed a 67% increase in STEMIs treated per year from over five years (11,363 in 2019 to 18565 in 2023). Use of pharmaco-invasive therapy increased from 7.9% to 31.7% (Figure-1). There was a marginal increase in use of primary PCI. The count of patients without GDR decreased by 20%. There was a 6.7 fold (672 in 2019 to 4,535 in 2023) rise in patients referred from spoke to hub hospitals for catheter-based revascularization. Over five years, there was an increase in the proportion of patients receiving GDR. This increase was more evident in Phase II hubs (52% in 2019 to 87.1% in 2023). Commensurate with the increase in GDR, phase II hubs demonstrated a tangible decrease in mortality (Figure-2). Conclusion We have shown that networking of non-PCI-capable hospitals with PCI-capable hospitals in a hub and spoke model using social media groups, facilitates telemedicine, leading to improved GDR in STEMI. This innovative approach not only enhances connectivity but also contributes to more efficient and timely cardiac care in resource-constrained settings.Figure 1. Revascularisation in STEMIFigure 2.Mortality Trends in STEMI (hubs)

Survival in STEMI in resource limited settings - obstacles and potential solutions. Critical lesson learnt thorough a prospective observational study

Abstract Background Early revascularization in ST segment elevation myocardial infarction(STEMI) by Primary Percutaneous coronary Intervention (PPCI) or fibrinolysis, reduces mortality. In the absence of a well-functioning STEMI care system, patients may not get guideline directed revascularisation (GDR). Objective We sought to determine the prevalent mode of revascularisation for STEMI in the community, to discern the factors contributing to lack of GDR during their initial medical encounter, and to investigate the consequences of not getting GDR. Methods Consecutive patients within 24 hours of STEMI from October 2021 to December 2021 in a public hospital from a developing nation, were enrolled. In addition to baseline data, the details of the first medical contact (FMC) and second medical contacts (SMC) before reaching the study site were collected. The hospitals where patients sought care earlier, could be lysis capable hospitals (LCH), PCI/lysis capable hospitals (PLCH) and non-lysis-capable hospitals (NLCH). Medical records related to these visits were scrutinised and in-depth interviews were conducted with patients and their care givers. Details of GDR offered / received during FMC/SMC and the reasons for not receiving GDR were collected. Results 300 patients were enrolled during the study period. 19 reported directly to the study site, while others had visited 1-3 hospitals en route(Figure-1). The 159 who received fibrinolysis in at least one of their medical contacts, had a significantly lower incidence of cardiogenic shock and in-hospital mortality, compared to the rest(Figure-2). 162(54%) patients had had FMC in NLCH and had to be referred to SMC for GDR. Of the 157 visits by a patient with STEMI in a LCH / PLCH within 6 hours’ time window (6HTW), GDR was provided only 44 visits(28%) (Figure-1). The common reason for not receiving GDR was financial. This revascularisation solutions offered were not affordable. These include, PPCI only or pharmaco-invasive package only in PLCH and high cost bolus lytic only in LCH. Of the 132 patients, who had FMC ≤ 12 hours in LCH, only 33 had lysis. Patients who did not receive revascularisation, despite reaching within 6HTW, had adverse in-hospital outcome. (Figure-2) Conclusion The public awareness of the need for early revascularisation in STEMI and the revascularisation solutions available in the neighbourhood hospitals is low. Most patients with STEMI do not receive GDR despite reaching revascularisation capable hospitals within 6HTW. The common reasons for this include, non-availability of low cost fibrinolytics and lack of financial resources. Hospitals should offer fibrinolysis when patients cannot afford PPCI, and low-cost infusion lytics, when patients cannot afford high cost bolus lytics. Provision of GDR in STEMI at the first medical contact, is a social responsibility. Governmental and non-governmental organisations should work in tandem, to ensure 100% GDR at first medical contact.

Temporal trends in major bleeding after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction from 2003 to 2017: the Western Denmark Heart Registry

Abstract Background Management of patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) has changed during the last two decades. Introduction of more potent platelet inhibitors may carry an increased risk of bleeding complications, while other therapeutic options, such as use of radial artery access and proton pump inhibitors may reduce bleeding risk. The combined impact of these treatment changes on bleeding risk in patients with STEMI remains unknown. Purpose To examine temporal trends in 1-year risk of major bleeding after STEMI treated with primary PCI from 2003 to 2017. Methods We used the Western Denmark Heart Registry to identify first-time PCI-treated patients undergoing primary PCI for STEMI from 2003 to 2017. Patients were divided into 4 calendar periods based on the time of STEMI. The main outcome was 1-year risk of major bleeding defined as a hospital admission for bleeding using a validated definition with high accuracy. Additionally, the 1-year risk of major bleeding in STEMI patients was compared with the risk in an age- and sex-matched general population cohort without prior coronary artery disease. Results From 2003 to 2017, we identified 18,540 patients treated with primary PCI for STEMI (median age 64 years, 75% men)and 92,700 age- and sex-matched individuals. The 1-year risk of major bleeding after STEMI was similar across the different time periods; 4.1% in 2003-2006, 3.8% in 2007-2010, 3.8% in 2011-2014, and 4.5% in 2015-2017. The adjusted HR for bleeding in STEMI patients was 1.03 (95% CI 0.83-1.26) when comparing the latest period with the earliest period. The age- and sex-matched general population exhibited a 1-year risk of major bleeding of around 1% in all time periods (Figure 1). Conclusions Despite changes in management, the 1-year risk of major bleeding remained stable around 4% after primary PCI-treated STEMI from 2003 to 2017. This risk was approximately 4 times higher than the bleeding risk observed in an age- and sex-matched general population.

Factor XI activity in ST-segment elevation myocardial infarction

Abstract Background ST-segment elevation myocardial infarction (STEMI) is characterized by a significant thrombotic burden, where the coagulation cascade, including Factor XI (FXI) activity, plays a crucial role. In STEMI and other thrombotic conditions, FXI levels vary according to patient characteristics and timing from the event. Understanding the changes in FXI activity may offer valuable insights into the optimal patient selection and timing for use of investigational FXI inhibitors. Purpose Our aim was to characterize variations in FXI activity in STEMI patients. Methods In this prospective, observational study, patients admitted with STEMI underwent two measurements of plasma FXI activity, prior to coronary angiography and at discharge, using the HemosIL assay. The variation in FXI activity at these timepoints was compared between patients with and without coronary thrombus, as detected by an angiographic core-lab. Linear regression analyses were conducted to test the association of candidate predictors with FXI variation between admission and discharge (i.e., presence of coronary thrombus, PCI of the culprit artery, Thrombolysis in Myocardial Infarction flow post-PCI, bailout use of glycoprotein IIb/IIIa inhibitors, time to second measurement of FXI activity) and with FXI value at admission (i.e., age, sex, atrial fibrillation, late [&amp;gt;24 hours] STEMI presentation, presence of coronary thrombus). Results From November 2023 to February 2024, 49 STEMI patients were included. The median variation in FXI activity among admission and discharge was +24.8% (interquartile range [IQR] 11.8; 69.0; p&amp;lt;0.001). This variation was observed in both patients with (+41.6% [IQR 14.3; 74.6]; p&amp;lt;0.001) and without (+21.8% [IQR -2.3;40.7]; p=0.008) thrombus at coronary angiography, with significant interaction effects compared to the global STEMI population (p for interaction &amp;lt;0.001). An inverse linear regression relationship was observed between presence of coronary thrombus and changes in FXI activity (coefficient -33.0, 95% CI -59.5 to -7.2; p=0.012). Furthermore, in the model exploring predictors of FXI activity at admission, thrombus presence (coefficient -40.9, 95% CI -75.3 to -6.4; p=0.024) and subacute presentation (coefficient 90.8, 95% CI 21.9 to 159.8; p=0.015) emerged as significant predictors, albeit with contrasting effects on FXI activity. Figure 1 Conclusions Our findings reveal significant increases in FXI activity from admission to discharge in STEMI patients. The inverse relationship between the presence of coronary thrombus and FXI activity variations, along with the contrasting associations among initial FXI levels and subacute patients’ presentation or thrombus presence, support the importance of FXI in the coagulation process during STEMI. These findings suggest targeted FXI inhibition, especially early in STEMI management, could be beneficial, meriting detailed investigation in future studies.Multivariable linear regression analysis

Predicting ECGs masquerading AS STEMI with machine learning

Abstract Background Advancements in the management of ST elevation myocardial infarction (STEMI) in the last 15 years include early STEMI identification in the prehospital setting leading to expedited cardiac catheterisation laboratory (CCL) activation or fibrinolytic therapy. We have previously reported of patients who met the Glasgow algorithm (GA) ECG criteria for STEMI; 50% did not actually have an acute STEMI according to the 4th universal definition of MI (4UDMI)1. Identifying such patients could avoid unnecessary emergency CCL activations or inappropriate fibrinolytic administration. Methods From June 2010 to October 2021, we identified 2992 patients with ECG transmissions to Liverpool Hospital, Sydney Australia which met GA criteria for STEMI. These were adjudicated according to the 4UDMI for true-positive STEMI. We used univariate and multivariate logistic regression to identify likely patient characteristics that were predictive of true-positive STEMI. We then improved model performance using receiver-operator curve (ROC) with simple random forest machine learning algorithms. Results Among 2994 patients with prehospital ECG transmissions that met GA-criteria, 1553 (51%) were adjudicated as true-positive STEMI, which is comparable to previous findings1. All standard modifiable and non-modifiable risk factors were independently predictive of true-positive STEMI; however, in multivariate logistic regression gender, hypertension and diabetes lost significance. Dyslipidemia and current smoking were positively predictive of true-positive STEMI status (OR = 1.64 and 1.32 respectively), whereas age and previous MI were negatively associated (OR = 0.98 (per year increment) and 0.4). Using these identified predictors in a random forest to predict true-positive STEMI yielded an AUC of 0.65 (Figure 1). Conclusion Specific clarification of dyslipidaemia and current smoking status at first medical contact may be the most salient in predicting a true-positive STEMI during prehospital assessment which may assist in avoiding unnecessary emergency CCL activation or inappropriate fibrinolytic administration.ROC of ST elevation STEMI recognition

Differences in treatment and outcome of patients with ST- Elevation Myocardial Infarction (STEMI) and Non-STEMI in Germany

Abstract Background ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are the main diagnoses of acute coronary syndrome (ACS). Although both types of infarction are classed as ACS, the treatment and overall survival rate are different. Methods Health claims data (≈26 million members) were screened for patients with STEMI and NSTEMI from 01/2010 to 12/2018. Patient demographics, hospitalization details, adherence to guideline-directed drug therapy, and survival were assessed. Results The total cohort of acute myocardial infarctions comprised 544,529 patients (mean age 74 (IQR 62 - 82), one third of whom were hospitalized with a STEMI. Patients with STEMI were more likely to be in a life-threatening situation and had higher in-hospital, 30- and 60-day mortality, but better long-term survival. Major adverse cardiac and cerebrovascular events (MACCE), infarct recurrence, chronic kidney disease, peripheral arterial disease, heart failure and cerebrovascular disease were more common in patients with NSTEMI. STEMI-patients received coronary angiography and percutaneous coronary intervention more frequently. Although there was a clear correlation between guideline-compliant therapy and overall survival, adherence to guideline-compliant therapy decreased over time, especially in NSTEMI patients. Conclusion In ACS patients, there are clear differences between STEMI and NSTEMI patients in terms of short- and long-term survival. Guideline-based therapy improved long-term survival in both, but more significantly in STEMI patients.

Relationship between lipoprotein(a) and endogenous fibrinolytic status in patients with STEMI

Abstract Background The risk of myocardial infarction is at least doubled in individuals with lipoprotein(a) (Lp[a]) levels &amp;gt;90th percentile.[1] Lp(a) may exert pro-thrombotic effects by impairing fibrinolysis. Lp(a) has a high degree of homology to plasminogen and can competitively inhibit tissue plasminogen activator (tPA)-mediated plasminogen activation and tPA-mediated clot lysis.[2] Furthermore, Lp(a) stimulates the activity of plasminogen activator inhibitor-1, the major inhibitor of the fibrinolytic system. In patients with ST-segment elevation myocardial infarction (STEMI), impaired endogenous fibrinolysis is a strong, independent risk factor for recurrent cardiovascular events,[3] but the drivers of this are not fully understood. Whether impaired endogenous fibrinolysis is related to increased Lp(a) levels in patients with STEMI, is not known. Purpose We aimed to assess the relationship between Lp(a) and endogenous fibrinolysis in patients with STEMI. Methods In a prospective, observational study, venous blood samples were drawn from patients presenting with STEMI immediately before revascularisation, after dual antiplatelet therapy but before heparin administration. Endogenous fibrinolysis was measured immediately in non-anticoagulated whole blood using the point-of-care Global Thrombosis Test, which measures the time for occlusive thrombus formation under high shear (occlusion time) and the time for spontaneous lysis of the thrombus (lysis time).[3] Assessment of Lp(a) levels, measured by particle enhanced immunoturbidimetric assay, was performed with paired plasma samples, standardized against the International Federation of Clinical Chemistry reference material SRM2B for nmol/L. Lp(a) &amp;gt;32 nmol/L is associated with increased risk of ischaemic heart disease. Results A total of 80 patients were included (age 64±14y, 25% females and 86% Caucasian). There was a positive correlation between Lp(a) level and lysis time (r = 0.330, P = 0.003) (Figure 1). Lysis time was significantly longer in patients with Lp(a) &amp;gt;32 nmol/L (2782 [1626-3683] vs. 1725 [1259-2955] s, P = 0.044). Using a cut-point of lysis time ≥2500 s previously associated with a significantly increased cardiovascular risk in patients with STEMI, we showed that Lp(a) was significantly higher in patients with lysis time ≥2500 s (40 (22-111) vs. 18 (7-73) nmol/L, P = 0.045). Table 1 shows the relationship between clinical characteristics and Lp(a) and lysis time. Lp(a) level was higher in non-Caucasian patients. There was no correlation between Lp(a) and occlusion time (r = 0.156, P = 0.168). Conclusion In patients with STEMI, longer endogenous fibrinolysis time is related to higher Lp(a) level. Raised Lp(a) levels may, in part, contribute to impaired endogenous fibrinolysis. Future studies are required to assess whether reduction in Lp(a) with novel therapies currently in phase 3 trials can favourably modulate fibrinolysis and improve clinical outcomes.Figure 1

Angiotensin-II receptor type 1 and endothelin-1 receptor type A agonistic autoantibodies in patients with STEMI: new kids on the block

Abstract Background The Prognosis after ST-elevation myocardial infarction (STEMI) remains poor. Angiotensin-II and endothelin-1 contribute to adverse prognosis after STEMI through molecular mechanisms that lead to myocardial inflammation, fibrosis and, ultimately, adverse myocardial remodeling. Functional autoantibodies against angiotensin II type 1 (AT1R-AAs) and endothelin-1 type A (ETAR-AAs) receptors bind to the same receptors as natural ligands, eliciting similar (and amplified) responses. In patients with STEMI, AT1R-AAs and ETAR-AAs have been associated with a higher risk of developing microvascular obstruction and left ventricular remodeling. Both microvascular obstruction and left ventricular remodeling are associated with a poor prognosis. Purpose To assess the prognostic role of AT1R-AAs and ETAR-AAs after STEMI. Methods Consecutive STEMI patients who underwent primary percutaneous coronary intervention within 12 h after pain onset were enrolled in this prospective study. The levels of AT1R-AAs and ETAR ETAR-AAs at the time of hospital admission were measured using an enzyme-linked immunosorbent assay (ELISA) in all patients. The incidence of major adverse cardiovascular events (MACE, defined as a composite of cardiovascular mortality, myocardial re-infarction, and hospitalizations for heart failure) during follow-up was the primary outcome. Autoantibody seropositivity was defined according to ELISA’s kit manufacturer’s instructions (levels &amp;gt; 10 U/mL). Results Two hundred patients with STEMI were enrolled. The baseline characteristics of the patients are shown in Table 1. Of these, 110 (55%) were seronegative for both autoantibodies, 44 (22%) were seropositive for one autoantibody (but not both), and 46 (23%) were seropositive for both autoantibodies. The incidence of MACE over a 14-month median follow-up was higher in patients with double (31%) and single (25%) seropositivity than in seronegative patients (13%, p=0.009 and p=0.06, respectively). Survival free from MACE was significantly different across the different degrees of autoantibody seropositivity (Figure 1). In the multivariable Cox regression analysis, adjusted for the variables that were significant in the univariate analysis (highlighted in bold in Table 1), double seropositivity was independently associated with an increased risk of MACE (hazard ratio 2.386, 95 % CI 1.471-3.864, p&amp;lt;0.001). Conclusions The degree of seropositivity for AT1R-AAs and ETAR-AAs is associated with an increased risk of MACE after STEMI. Our findings provide valuable mechanistic insights into the pathophysiology of STEMI and pave the way for future therapies focused on the improvement of long-term prognosis after acute coronary syndromes.