ST-segment Elevation Research Articles

Acute myocardial infarction without ST-segment elevation: an expanded view

Acute myocardial infarction without ST-segment elevation: an expanded view

Effect of Cangrelor on Infarct Size in ST-Segment Elevation Myocardial Infarction Treated By Primary Percutaneous Coronary Intervention: A Randomized Controlled Trial (The PITRI Trial).

Background: The administration of intravenous cangrelor at reperfusion achieves faster onset of platelet P2Y12 inhibition than oral ticagrelor and has been shown to reduce myocardial infarct (MI) size in the pre-clinical setting. We hypothesized that the administration of cangrelor at reperfusion will reduce MI size and prevent microvascular obstruction (MVO) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Methods: This was a Phase 2, multi-center, randomized, double-blind, placebo controlled clinical trial conducted between November 2017 to November 2021 in six cardiac centers in Singapore (NCT03102723). Patients were randomized to receive either cangrelor or placeboinitiated prior to the PPCI procedure on top of oral ticagrelor. The key exclusion criteria included: presenting <6 hours of symptom onset, prior MI and stroke or transient ischemic attack; on concomitant oral anticoagulants; and a contraindication for cardiovascular magnetic resonance (CMR). The primary efficacy endpoint was acute MI size by CMR within the first week expressed as percentage of the left ventricle mass ( %LVmass). MVO was identified as areas of dark core of hypoenhancement within areas of late gadolinium enhancement. The primary safety endpoint was Bleeding Academic Research Consortium (BARC)-defined major bleeding in the first 48 hours. Continuous variables were compared by Mann-Whitney U test [reported as median (1st quartile- 3rd quartile)] and categorical variables were compared by Fisher's exact test. A 2-sided P<0.05 was considered statistically significant. Results: Of 209 recruited patients, 164 patients (78% ) completed the acute CMR scan. There were no significant differences in acute MI size [placebo: 14.9 (7.3 - 22.6) %LVmass versus cangrelor: 16.3 (9.9 - 24.4)%LVmass, P=0.40] or the incidence [placebo: 48% versus cangrelor: 47%, P=0.99] and extent of MVO [placebo:1.63 (0.60 - 4.65)%LVmass versus cangrelor: 1.18 (0.53 - 3.37)%LVmass, P=0.46] between placebo and cangrelor despite a two-fold decrease in platelet reactivity with cangrelor. There were no BARC-defined major bleeding events in either group in the first 48 hours. Conclusions: Cangrelor administered at time of PPCI did not reduce acute MI size or prevent MVO in STEMI patients given oral ticagrelor despite a significant reduction of platelet reactivity during the PCI procedure.

Syncope and Brugada-like ECG pattern in a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Syncope is a brief loss of consciousness caused by reduced blood flow to the brain, characterised by sudden onset, short duration and full recovery without intervention. Anamnesis, physical examination and other diagnostic tests such as laboratory analysis and electrocardiogram (ECG) can be conducted to identify the underlying cause of syncope. A Brugada pattern on an ECG in individuals with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who have syncope symptoms may indicate cardiac issues. A 69-year-old man with hypertension and a history of smoking presented with syncope. His vital signs were within normal limits, with no signs of a neurological deficit. The patient met the diagnostic criteria for SIADH, as evidenced by the presence of hyponatraemia (Na 118 mmol/l), a hyperosmolar condition and euvolemia. Upon arrival, a twelve-lead ECG showed ST-segment anomalies that reflected a Brugada ECG pattern. No ventricular arrhythmias were detected during the 24-hour Holter monitoring. Coronary angiography revealed no abnormalities in the coronary arteries. The ECG demonstrated the normalisation of ST elevations and the disappearance of the Brugada ECG pattern after the correction of hyponatraemia. After three months of follow-up the patient, with a normal sodium level, had no episodes of syncope.

A Case of Left Ventricular Pseudoaneurysm as a Complication of Late-Presenting ST-Segment Elevation Myocardial Infarction

A Case of Left Ventricular Pseudoaneurysm as a Complication of Late-Presenting ST-Segment Elevation Myocardial Infarction

STEMI in young patients: what are we dealing with?

Abstract Funding Acknowledgements None. Background/Introduction Acute Myocardial Infarction with ST-segment Elevation (STEMI) in young adults is infrequent, with an incidence ranging from 2-12%. Our objective is to analyse the clinical characteristics, management, and prognosis of patients aged 45 years or younger with STEMI activation. Methods We conducted a retrospective review of the "Code Infarct" registry at our hospital from January 2020 to March 2023. Out of the 867 codes, 51 patients aged 45 or younger were selected. We studied clinical, angiographic, and echocardiographic parameters. Results Table 1 presents the baseline and clinical characteristics of the patients. The median time from symptom onset to the first medical contact was 126 (30-160) minutes, and the median ischemic time was 226 (122-270) minutes. Figure 1 displays the angiographic findings. Atherothrombotic disease was responsible in 78.4% of patients, with 75% of them having single-vessel coronary disease with similar involvement of the right and anterior descending coronary arteries. Five patients (9.8%) experienced spontaneous dissection, with the majority being women (80%). In 5 cases (9.8%), coronary arteries were found to be normal. The second most commonly used antiplatelet agent was prasugrel (64.7%). Fibrinolysis was performed in 5 patients (9.8%). Only 3 patients (5.9%) required inotropic/vasopressor therapy, and 2 (3.9%) received intra-aortic balloon counterpulsation. The most common complication during hospitalization was the occurrence of tachyarrhythmias (27.4%), followed by heart failure (7.8%). At discharge, 52.9% had a left ventricular ejection fraction (LVEF) &amp;gt;55%, 49.3% had LVEF between 40-55%, and only 7.8% had LVEF &amp;lt;40%. The median length of hospital stay was 5.7 (3-6) days, and there were no in-hospital deaths. One-year survival was 98%. Conclusions Atherothrombotic disease is the leading cause of STEMI in individuals aged 45 or younger in our population. Smoking and dyslipidaemia are the most prevalent risk factors. Ischemic time is longer than desired in this group, mainly due to a delay from symptom onset to initial medical contact. Promoting primary prevention and raising awareness about the clinical signs and importance of early diagnosis in STEMI could help reduce ischemic time in this population.Characteristics and Clinical PresentatioCoronary angiography findings.

Neutrophil gelatinase-associated lipocalin (NGAL) levels for early prediction and ruling out future contrast nephropathy in patients undergoing primary coronary intervention

Abstract Funding Acknowledgements None. Background Neutrophil gelatinase-associated lipocalin (NGAL), is an early marker of acute kidney injury(AKI) . We aimed to investigate the diagnostic utility of sequential NGAL measurements for both prediction and ruling out of contrast induced AKI (CI-AKI) among patients with ST segment elevation (STEMI) undergoing primary coronary intervention (PCI). Methods We included 133 patients with STEMI treated with PCI. Blood samples for plasma NGAL were drawn immediately before PCI (NGAL 0) and 24 hours after PCI (NGAL 24). Optimal threshold for the development of CI-AKI were determined using receiver operating characteristic curves (ROC). Patients were also assessed for the dynamics between NGAL 0 and NGAL 24 levels. Results Mean age was 62 ±13 years and 78% were men, and a total of 20 (15%) developed CI-AKI . Patients with CI-AKI demonstrated higher plasma NGAL 0 levels (164 ± 42 vs. 95 ± 30 ng/mL; p &amp;lt; 0.001) as well as NGAL 24 levels (142 ± 41 vs. 93 ± 36 ng/mL; p &amp;lt; 0.001). There were no significant changes between NGAL 0 &amp; 24 hours within the 2 groups( figure 1). According to the ROC curve analysis (figure 2), the optimal NGAL 0 level for CI-AKI prediction was &amp;gt;125 ng/mL (AUC 0.841, 95% CI 0.801–0.961, p &amp;lt; 0.001), with a sensitivity of and specificity of 70% and 84% respectively, while the negative predictive value of NGAL 0&amp;lt;125 ng/mL was 94%. Conclusions Among STEMI patients, NGAL levels before primary PCI may be utilized both for ruling out and for the prediction of CI-AKI.NGAL 0 vs 24 according to CI-AKINGAL AUC

Subclinical congestion in patients presenting with acute coronary syndrome

Abstract Funding Acknowledgements None. Introduction Patients admitted due to acute coronary syndrome (ACS) are stratified using Killip class for the severity of the post myocardial infarction (MI) heart failure (HF). Killip class classification is mainly based on clinical examination and overt signs and symptoms are usually needed to be present. Purpose To evaluate subclinical congestion with lung ultrasound (LUS) in patients presenting with acute coronary syndrome. Methods For a period of 4 years, we recorded the patients presented to the emergency department of our hospital due to acute coronary syndrome (HF) and no symptoms or signs of heart failure (Killip class I). LUS was performed on admission and patients were classified as having either "wet lung" (&amp;gt;3 b-lines in at least 3 lung fields) or "dry lung". Baseline characteristcs, laboratory findings as well as the result of the coronary angiogram were alse recorded. Results 286 patients were recorded, with mean age 71,2 years, 43,35% were female and 56,6% male. 36.01% of the patients presented with ST elevation MI (STEMI) and 63.98% with non ST elevation MI (NSTEMI). 34.2% of patients were classified as having "wet lung". Of them, 63.98% were STEMI patients and 36.1% NSTEMI. 27.2% were males and 72.8% females and 64.6% older than 60 years old. 10.7% had on admission left ventricular ejection fraction (LVEF) &amp;gt;50% whereas 89.3 % had LVEF &amp;lt;50%.Finally, 12,7% were found to have 1 vessel disease, 23.4% 2 vessel disease and 63.9% 3 vessel disease. Compared to patients classified as having "dry lung", patients with "wet lung" stayed in the hospital 74 days (vs 3.2, p&amp;lt;0.01), and their mean troponin levels were 10721 pg/ml (vs 3254 pg/ml, p&amp;lt;0.01). "Wet lung" patients were found to have mean GFR 56,2 mL/min/1.73 m² (vs 86.7 mL/min/1.73 m² , p&amp;lt;0.05). Conclusion 34.2% of the patients admitted due to ACS Killip 1, were classified as having "wet lung" when examined with LUS, suggesting a status of subclinical congestion. These patients were most often STEMI patients, female and of older age and were found to have reduced LVEF. Compared to the "dry lung" patients had higher troponin levels and most oftenly impaired renal function. LUS could help identify these patients, that although they seem to be asymptomatic in terms of HF, they probably need closer monitoring.

Pediatric Takotsubo cardiomyopathy: a review and insights from a national multicentric registry

Abstract Funding Acknowledgements None. Background Takotsubo syndrome (TTS) in the pediatric population is an infrequent but relevant cause of morbidity and mortality, with limited studies addressing its clinical course and prognosis. Objectives We aimed to analyze the clinical features and prognosis of pediatric TTS in a nation-wide multicenter registry and considering the published literature. Methods we included a total of 54 patients from 4 different hospitals in Spain, as well as pediatric TTS patients from the published literature. Comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between pediatric and adult population features. Results Comparison between the RETAKO general population is detailed in Table 1. Pediatric patients with TTS had a median age of 11 years (IQR = 4-14). When compared to the RETAKO general population, they were more often male (51.9% vs 23.3%, p&amp;lt;0.001), and displayed a higher prevalence of secondary forms (90.7% vs 35.6% in adults, p&amp;lt;0.001). Regarding race, 11 cases (20.4%) were from Asia and 42 (77.8%) were Caucasian; whereas in RETAKO 1420 (94.9%) were Caucasians, with under 5 cases (&amp;lt;0.1%) being Asian. Pediatric patients presented less commonly with angina (11.1% vs 64.1%, p&amp;lt;0.001) or dyspnea (30% vs 41.7%, p&amp;lt;0.001), compared to the general RETAKO cohort. Nevertheless, pediatric patients with TTS exhibited a higher Killip status on admission (Killip IV 74.1% vs 10.5%, p&amp;lt;0.001), and higher needs of vasoactive and mechanical ventilatory support during hospitalization. Regarding complementary exams, pediatric patients presented with lower LVEF on admission (30.5+10.4 vs 36.9+16.9, p = 0.014) together with greater prevalence of atypical (basal or midventricular) TTS patterns on echocardiography (30.2% vs 15.8%, p = 0.006). Additionally, there were significantly less ST-segment alterations in the pediatric population (either ST-segment elevation or depression), without differences on T wave inversion in the admission ECG. During follow-up, all-cause deaths (11.1% vs 12,5%, p = 0.761) and TTS recurrences (3.8% vs 3,8%, p = 0.863) were similar between groups. Conclusions TTS in the pediatric population presents a distinctive clinical profile, with higher prevalence of atypical symptoms and physical triggers; as well as higher rates of cardiogenic shock on admission and similar mortality and recurrence rates than those of the adult population. This study provides valuable insights into understanding pediatric TTS and underscored the necessity for further research in this age group.Table 1

Oxygen targets following immediate percutaneous coronary intervention in comatose survivors of out-of-hospital cardiac arrest - a BOX sub-study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation The Lundbeck Foundation. Background Treatment with supplemental oxygen in patients with acute myocardial infarction (AMI) has previously been associated with poorer outcomes. However, in patients with AMI resuscitated from out-of-hospital cardiac arrest (OHCA) and undergoing immediate revascularization, evidence regarding specific oxygen targets is sparse. Purpose To assess the impact of a restrictive versus a liberal oxygen target on infarct size in OHCA patients undergoing immediate percutaneous coronary intervention (PCI). Methods The current study is a sub-study of the BOX trial, a randomized trial with a 2-by-2 factorial design, in which comatose OHCA patients with a presumed cardiac cause of arrest were randomly assigned to either a restrictive oxygen target (partial pressure of arterial oxygen (Pao2) of 9 to 10 kPa) or a liberal oxygen target (Pao2 of 13 to 14 kPa). In this sub-study we included patients who underwent immediate revascularization with PCI. The primary outcome was myocardial infarct size as assessed by the cardiac enzyme troponin-T (TnT). TnT was measured repeatedly during the first 72 hours and analyzed with a repeated measures variance component model with baseline adjustment. Secondary outcome was one-year all-cause mortality assessed by Kaplan-Meier and Cox proportional hazards analyses. Results A total of 329 patients underwent immediate PCI, whereof 172 patients were randomized to the restrictive oxygen target and 157 to the liberal oxygen target. The oxygen intervention was successful with a significantly higher PaO2 in the liberal oxygen target group during the first 72 hours (p&amp;lt;0.0001). Baseline characteristics and findings on coronary angiography (CAG) were similar in the two oxygen target groups. Thus, median age was 63 (interquartile range (IQR) 55–71), 81% were male, and estimated left ventricular ejection fraction on arrival to hospital was 35% (IQR 25–45%). Further, 74% of the patients had an initial postresuscitation electrocardiogram with ST-segment elevations, and the left anterior descending artery was deemed as culprit lesion in 49% of the patients. There was no difference in peak TnT between the restrictive and liberal oxygen target group (median 2540 (IQR 925–6420) versus 3410 (792–8630), ng/l, p=0.23), nor did TnT differ between the groups during the first 72 hours after admission (Figure 1, p=1.00). Within one year from admission, 120 patients (36.5%) had died. There was no difference in mortality between the restrictive (34%) and liberal (39%) oxygen target group (hazard ratio, 0.80; 95% CI, 0.56-1.14; p=0.21) (Figure 2). Conclusion Targeting a restrictive versus a liberal oxygen level in comatose survivors of OHCA who underwent immediate revascularization did not affect infarct size nor did it result in a significant difference in one-year mortality rate.Figure 1:Troponin-T levelsFigure 2:Kaplan-Meier curves

Electrocardiographic Patterns and Ejection Fraction in Patients with Nonischemic Dilated Cardiomyopathy: A Cross-sectional Retrospective Study

Background:: The relationship between ECG changes in dilated nonischemic cardiomyopathy and ejection fraction (EF) is complex and poorly understood. Thus, this study aimed to identify the most common patterns of ECG associated with dilated nonischemic cardiomyopathy and their relationship to EF. Methods:: A retrospective cross-sectional study was conducted between 2019 and 2022, including 100 consecutive patients with nonischemic dilated cardiomyopathy. ECG data were rate, axis, left (LBBB) and right bundle branch block (RBBB), first-degree heart block, premature ventricular contractions, depth of S wave in leads V1 and V2, length of R wave in leads V2 and V6, the ratio of R/S in the lead V4, left ventricular hypertrophy (LVH), maximum R wave length in leads I, II, and III, poor R wave progression, ST-segment elevation, and T wave inversion. Results:: The most common ECG pattern associated with cardiomyopathy was T-wave inversion (47%). The EF was 23.9± 8.87% in patients with LBBB and 25.5± 8.07% in patients without LBBB (P= 0.361). In patients with T-wave inversion, the EF was 23.4± 8.21%, and it was 26.28± 8.35% in patients without T-wave inversion (P= 0.086). In patients with LVH, the EF was 23.89± 7.84%, and it was 25.5± 8.66% in patients without LVH (P= 0.354). A negative nonsignificant correlation existed between SV1, SV2, RV2, RV6, R/S V4, and maximum R in I, II, III, and EF. Conclusions:: The study showed that T-wave inversion was the most common pattern associated with dilated nonischemic cardiomyopathy. The study provided insight into the negative correlation between EF and SV1, SV2, RV2, RV6, R/S V4, and maximum R in I, II, and III, although it did not reach a significant level.

Prognostic evaluation of ST-segment elevation acute myocardial infarction according to lung ultrasound in the acute phase

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): JC-M received an Original Research Projects Grant from the Catalan Society of Cardiology and LR-S received Scholarship for Training and Research from the Association of Ischemic Heart Disease and Cardiological Critical Care of the Spanish Society of Cardiology. Introduction Lung ultrasound (LUS) has emerged as a useful diagnostic and prognostic tool in heart failure (HF) and has shown promise in risk stratification for ST-segment elevation myocardial infarction (STEMI) in the acute phase. These studies consistently indicate that the degree of pulmonary congestion, assessed by the number of B-lines on LUS, is significantly associated with a worse prgnosis during hospitalization and short-term follow-up in STEMI patients. However, this prognostic value has mainly been evaluated during hospital admission or a few days after discharge without a long-term follow-up. Purpose To assess the prognostic value of LUS at one year in patients admitted for STEMI. Methods In a prospective multicenter cohort study involving STEMI patients, an independent operator performed LUS during the first 24 hours after revascularization and offline B-line counting was conducted. LUS results were assessed both as a categorical [wet (at least one site with ³3 B-lines)/dry lung] and continuous variable (total number of B-lines). The primary endpoint was a composite of death or hospitalization for HF, acute coronary syndrome, or stroke within one year. Results A total of 173 patients were included. The composite endpoint occurred in 13.7% of the patients over a median follow-up of 368 days. LUS was able to predict the composite outcome with hazard ratios (HR) of adjusted hazard ratios of 4.85 (95% CI 2.79-8.43) for having a wet lung and 1.13 (95% CI 1.09-1.18) for each B-line. After and adjustment for sex, age, chronic kidney disease, previous atrial fibrillation, Killip class and left ventricular ejection fraction HR was 1.72 (95% CI 0.91-3.28) for having a wet lung and 1.06 (95% CI 1.00-1.11) for each B-line. Conclusion Detecting B-lines on LUS predicts adverse events at one year in STEMI patients.Kaplan-Meier curves

Ten-year prognosis of acute atrial fibrillation in ST-elevation myocardial infarction: recurrence and stroke risk

Abstract Funding Acknowledgements None. Background Atrial fibrillation (AF) often complicates ST elevation acute myocardial infarction (STEMI), with associated risks including stroke and mortality. Anticoagulation therapy for these patients and AF prognosis remains controversial. The aim was to evaluate long-term prognosis of STEMI patients complicated with AF in the acute phase. Methods We performed a prospective register involving 4,184 patients admitted for STEMI to the intensive cardiac care unit of two tertiary centres from 2007 to 2015. Patients with pre-existing permanent AF were excluded. Out of these, 269 (6.4%) patients developed AF within the first 48 hours after STEMI and were matched with a control group based on age and left ventricular ejection fraction (LVEF). Results After matching, a total of 470 patients were included (n=235, AF-STEMI; n=235, control group). Mean age 69.0 years, and 31.7% women. No differences were found in gender, cardiovascular risk factors or ischemic heart disease. AF-STEMI patients experienced more sustained ventricular tachycardia (12.8% vs. 4.7%; p=0.003), advanced atrioventricular block (13.2% vs. 6.0%; p=0.012), heart failure (28.5% vs. 18.7%; p=0.017), and cardiogenic shock (17.4% vs. 8.5%; p=0.006). In-hospital mortality was also higher in AF-STEMI patients (11.9% vs 7.2%, p=0.008). After 10-years follow-up, the AF-STEMI group had remained with higher mortality (50.5% vs. 36.2%; p=0.003) and a greater recurrence of AF (44.2% vs. 14.7%; p&amp;lt;0.001), without differences in stroke incidence (10.1% vs. 9.3%). Conclusion Patients with AF complicating STEMI have higher rates of heart failure, cardiogenic shock, and in-hospital mortality. After a 10-years follow up, they exhibit a high risk of AF recurrence, with no significant differences in stroke incidence.Kaplan Meier curves

Acute heart failure and acute coronary syndrome: not uncommon duo and dangerous

Abstract Funding Acknowledgements None. Introduction Acute Heart Failure (AHF) is a common cause of hospitalisation. Its ethology and triggering factors influence the prognosis and evolution. Methods and purpose Retrospective analysis of 6330 patients admitted to our hospital's Coronary Care Unit (CCU) between 2012 and 2022. The main objective was to analyse the characteristics during hospital progress and follow-up of patients with AHF after an Acute Coronary Syndrome (ACS) in class Killip III or IV, comparing it with those admitted for AHF not secondary to ACS. Results 698 patients with AHF after ACS and 384 with AHF not secondary to ACS were included. 68.8% of patients presented Acute Coronary Syndrome with ST elevation (STEMI), with a higher prevalence in the anterior location (34,3%). Angioplasty was performed in 53.4% of patiens with STEMI and in 40.3% of patients with NSTEMI. The Cardiovascular risk factors (Figure 1) were similar in both groups, while patients with AHF not secondary to ACS had a history of Coronary Heart Disease (CHD) and atrial fibrilación (AF) more frequently. Patients with AHF after ACS more frequently required treatment with dobutamine and norepinephrine (63.6% and 57.6%, respectively) as well as orotracheal intubation. At the same time, levosimendan was administered more frequently to patients with AHF not secondary to ACS, with non-invasive mechanical ventilation being more frequent in this group. Both groups similarly received neurohormonal treatment, with beta-blockers being used the most. Events during follow-up (Figure 2) were higher in patients with AHF after ACS, except HF events. Cardiovascular mortality was 21.9% in patients with AHF after ACS. Conclusions Patients admitted for ACS complicated with AHF Killip III-IV represented 11.02%. The majority presented previously STEMI. During their admission, compared to patients admitted for AHF not secondary to ACS, they more frequently required vasoactive drugs and orotracheal intubation. Cardiovascular complications and mortality during follow-up were higher in patients with AHF after ACS. Therefore, early identification of patients with ACS at risk of developing AHF and establishing a specific and optimal treatment is crucial in the evolution of these patients.

The biological equivalent and prognostic relevance of c-reactive protein (CRP) velocity in ST segment elevation myocardial infarction

Abstract Funding Acknowledgements None. Background The rate of increase, i.e. the velocity, of circulating C-reactive protein (CRP) concentrations during myocardial infarction has been associated with left ventricular dysfunction. However, the prognostic yield of this biomarker as well as the underlying biological process that links high CRP velocity (CRPv) with increased myocardial injury are not clear. Therefore, we sought to determine the associations between CRPv early during STEMI with short- and long-term mortality and its correlation to myocardial necrosis. Methods We retrospectively examined 1,155 patients with the diagnosis of acute STEMI, who had at least two successive CRP measurements (up to 48 hours apart) and at least one echocardiographic evaluation, all within the first 96 hours of admission. We calculated CRPv and examined its correlation with myocardial injury, measured by cardiac troponin and overall mortality over a median follow-up period of 5.2 years [IQR 3.7-6.5]. Results Patients with high CRPv values (above 90th percentile, &amp;gt; 1 mg/L/h) had higher concentrations of cardiac troponin upon presentation regardless of their left ventricular systolic function (EF above or below 40%; Figure 1). Patients with high CRPv had increased 30-day and long-term mortality rates; OR= 4.6, 95% CI 2.3-9.2, p&amp;lt;0.001 for 30-day mortality and HR= 2.2, 95% CI 1.5-3.2, p&amp;lt;0.001 for long-term mortality. Furthermore, CRPv was associated with increased 30 –day and long term mortality rates even among patients with similar systolic function (EF above or below 40%; Figure 2). Conclusions High levels of CRPv early during STEMI are associated with increased mortality rates and elevated cardiac troponin release across all levels of left ventricular function. The higher mortality risk might be explained by an aggravated systemic inflammatory response to STEMI.CRP velocity and troponinCRP velocity and mortality

The prognostic value of remnant cholesterol in patients with ST segment elevation myocardial infarction

Abstract Funding Acknowledgements None. Background Remnant cholesterol (RC) is the cholesterol content within triglyceride rich lipoproteins. It promotes atherosclerotic cardiovascular disease beyond low density lipoprotein cholesterol (LDL-C). Purpose The prognostic role of RC in patients with ST-segment elevation myocardial infarction (STEMI) is unknown. We aimed to estimate RC-related risk beyond LDL-C in patients with STEMI. Methods A total of 6602 consecutive patients with STEMI treated with primary percutaneous coronary intervention (PCI) from 1999 to 2016 were included. RC was calculated as total cholesterol minus LDL-C minus high-density lipoprotein cholesterol. Adjusted Cox models were used to estimate the association between continuous RC levels and all-cause mortality, cardiovascular death, ischemic stroke, and recurrent myocardial infarction (MI) at long-term (median follow-up of 6.0 years). Besides, discordance analyses were applied to examine the risk of the discordantly high RC (RC percentile rank minus LDL-C percentile rank&amp;gt; 10 units) compared to the discordantly low RC (LDL-C percentile rank minus RC percentile rank&amp;gt; 10 units). The concordance was defined as the percentile rank difference between RC and LDL-C ≤ 10 units. Results The median age of patients was 63 years old [interquartile range (IQR) 54–72] and 74.8% of them were men. There were 2441, 1651 and 2510 people in the discordantly low RC group, concordant group and discordantly high RC group. All outcomes in the discordantly high RC group were higher than the other groups and its event rate of all-cause mortality was 31.87 (event number/patient number in the group*100). In the unadjusted analysis, the discordantly high RC was associated with increased all-cause mortality [hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.63–2.04] and increased cardiovascular death (HR 1.79, 95% CI 1.55–2.06) compared to the discordantly low RC. In an adjusted model RC was associated with higher all-cause mortality (HR 1.14, 95% CI 1.07–1.22). The discordantly high RC was associated with increased all-cause mortality (HR 1.55, 95% CI 1.37–1.75) and increased cardiovascular death (HR 1.47, 95% CI 1.25–1.72) compared to the discordantly low RC. There were no associations between RC and ischemic stroke or recurrent MI. Conclusions In patients with STEMI treated with primary PCI, elevated RC levels beyond LDL-C were independently associated with increased all-cause mortality.Graphical summaryLong-term survival probability

Efficacy and safety of upstream unfractionated heparin compared with downstream administration in ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention

Abstract Funding Acknowledgements None. Background Unfractionated heparin (UFH) is frequently administered before percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI)1,2. However, current guidelines do not provide clear recommendations for UFH pretreatment before arrival at the coronary catheterisation laboratory1,3. Methods Between June and July 2023, we systematically searched PubMed, Embase and Cochrane databases for studies comparing UFH pretreatments in patients with STEMI. A random-effects meta-analysis and meta-regression analyses were performed. Results Fourteen studies were included, of which four were randomised clinical trials (RCTs). A total of 76446 patients were included: 31238 in the pretreatment group and 39208 in the control group. Our meta-analysis revealed a lower all-cause mortality for the pretreatment strategy when compared with the control group, albeit with high heterogeneity (pooled odds ratio (OR) = 0.61, 95% confidence interval (CI) [0.49-0.76], P &amp;lt; 0.01; I² = 77%); lower in-hospital cardiogenic shock (pooled OR = 0.68, 95% CI [0.58-0.78], P &amp;lt; 0.21; I² = 27%) and a higher rate of spontaneous reperfusion events (pooled OR = 1.68, 95% CI [1.47-1.91], P &amp;lt; 0.01; I² = 79%). In terms of major bleeding, the UFH pretreatment strategy further revealed a decreased rate of events (pooled OR = 0.85, 95% CI [0.73-0.99], P = 0.40; I² = 4%). Conclusions From our study, UFH pretreatment in patients with STEMI undergoing primary PCI shows important benefits by reducing all-cause mortality, cardiogenic shock, enhancing reperfusion rates, whilst diminishing major bleeding events High-scale and high-quality RCTs will be required to fully address this clinical question in the future.1) Characteristics of included studies.2) Analyzed outcomes.

Spontaneous Coronary Artery Dissection in a Male Patient With Fibromuscular Dysplasia

Abstract A male patient presented with cardiac arrest attributed to anterior ST-segment elevation myocardial infarction from type 1 spontaneous coronary artery dissection. Subsequent imaging confirmed fibromuscular dysplasia in noncoronary arterial segments. The patient was started on guideline-directed medical therapy and referred to cardiac rehabilitation, showing substantial improvements in clinical status. With greater awareness and advancements in imaging, spontaneous coronary artery dissection has been more frequently recognized, and although as many as 81% to 92% of all cases occur in female patients, it can be seen among men, as well. Adjunctive imaging for arteriopathies may help establish the diagnosis for equivocal causes of acute coronary syndrome in women and men.

Gender differences in ST-segment elevation myocardial infarction: an analysis on treatment, complications and acute-phase mortality

Abstract Funding Acknowledgements None. Background Primary angioplasty is the gold-standard treatment in ST-segment elevation myocardial infarction (STEMI). Previous studies have shown differences in the treatment of STEMI between men and women. Purpose To analyze the differences in the management of STEMI between both genders in a mediterranean settlement when it comes to angioplasty, timing of revascularization, complication rates and 30-day mortality. Methods A prospective, unicentric study of consecutive STEMI patients that were admitted to an Acute Cardiac Care Unit was performed from January 2010 to December 2022. We compared the differences between genders on timing of revascularization, complication rates and 30-day mortality. Results A total of 4616 patients were included between 01/01/2010 and 31/12/2022, 21.75% were women. Women were older than men (68.5 vs 61.4 years, p&amp;lt;0,001), but there were no differences on cardiovascular risk factors, infarct location or ejection fraction. Female sex was associated with higher Killip class (Killip ≥2 on admission 22.6% vs 17.9%, p=0.005), less angioplasty rates (88.4% vs 93.1%, p&amp;lt;0.001), longer timing of revascularization (median time 223 minutes vs 178 minutes, p&amp;lt;0.001), higher rates of heart failure during admission (16.2% vs 11.3%, p&amp;lt;0,001), mechanical complications (2.9% vs 1.4%, p=0.001) and higher 30-day mortality (8.8% vs 5.7%, p&amp;lt;0,001). Conclusions Women with STEMI are less likely to receive revascularization therapy, are admitted with a higher Killip class and have higher rates of post-STEMI complications and 30-day mortality than men.

Cardiogenic shock following ST-segment elevation myocardial infarction in women: complications and outcomes

Abstract Funding Acknowledgements None. Background Differences in women’s prognosis have been described for both ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock (CS). These might reflect asymmetries in clinical management, but also gender-specific comorbidities and pathologic mechanisms. Purpose We aimed to evaluate the risk of in-hospital complications and mid-term outcomes of women with CS following STEMI. Methods We retrospectively studied STEMI patients treated by primary percutaneous coronary intervention (PCI) from 2008 to 2017 in a tertiary care centre, presenting or evolving in Killip class IV (defined as cardiogenic shock or hypotension and organ hypoperfusion). Clinical and demographic characteristics, as well as complications and outcomes, were collected. Major adverse cardio-cerebrovascular events (MACCE) at 1-year follow-up was a composite of death, cerebrovascular accident, new myocardial infarction in any vessel, or target lesion revascularization. Results Among 1131 patients presenting with STEMI, our study included 117 (10.3%) patients in CS, of which 40 (34.2%) were women. Women were older [71.8(±13.4) vs 64.6(±11.72) years, p=0.002] and less frequently smokers (25.0% vs 50.7%, p=0.008). Prevalence of classic cardiovascular risk factors, namely diabetes (34,1% vs 39.2%, p=0.860), hypertension (71.5% vs 60.8%, p=0.212), and dyslipidaemia (47.5% vs 70.0%, p=0.799), was the same for both groups. Body mass index was also similar [26.6(±5.2) vs 26.1(±3.4) kg/m2, p=0.539]. Women had lower haemoglobin [12.4(±1.9) vs 13.8(±1.9) g/dl, p&amp;lt;0.001] and lower creatinine clearance at admission [52.4(±30.6) vs 67.3(±29.4) ml/min, p=0.017]. Door-to-balloon times [80(59-180) vs 68(48-105) min, p=0.302], total ischemic time [210(120-360) vs 203(120-476) min, p=0.302] and prevalence of anterior STEMI (35.0% vs 50.0%, p=0.123) were not significantly different between sexes. The prevalence of in-hospital complications was generally similar for both sexes (Table 1), except for the risk of advanced atrioventricular (AV) block that was higher in women (32.5% vs 10.7%, p=0.004). Also, haemoglobin nadir was lower in women [10.6(±2.1) vs 11.7(±2.1) g/dl, p=0.023]. In a 1-year follow-up, the occurrence of MACCE was similar for both sexes (60.0% vs 59.7%, log-rank P 0.734) (Figure 1). Conclusion Women with STEMI complicated by CS submitted to PCI had a similar prevalence of in-hospital complications as men. Also, mid-term outcomes, assessed by MACCE at 1 year, did not differ between groups.

Incidence of left ventricle thrombus formation in patients with STEMI in the current era of antithrombotic treatment

Abstract Funding Acknowledgements None. Introduction Left ventricular (LV) thrombus formation is a serious complication of acute ST-segment elevation myocardial infarction (STEMI) which may result in ischemic stroke and systemic thromboembolism. There is limited evidence on the incidence and impact of LV thrombus in STEMI patients in the current era of antithrombotic treatment. Purpose To evaluate the incidence of LV thrombus formation in STEMI patients and to assess clinical predictor factors of LV thrombus formation leading to in-hospital major cardiac events (MACCE). Methods We prospective collected data from 504 STEMI patients treated with primary percutaneous intervention (PCI) in our large volume university hospital from April 2019 to September 2019. All patients underwent echocardiography examination at presentation and at hospital discharge. Results Mean age of the patients was 66.2 years and 78.8% were male. The incidence of LV thrombus formation was 5% in overall cohort and 9.4% in anterior STEMI. Among patients with LV thrombus, the majority had anterior STEMI (96% vs 48.4%; p&amp;lt;0.001), lower LV ejection fraction (LVEF)(35% vs 43%; P&amp;lt;0.001), more increased LV dimension /volume (36%vs7.3%; p&amp;lt;0.001), more apical aneurism/dyskinesia presence (36% vs 9%; p&amp;lt;0.001), longer ischemia time (25 hours vs 14 hours; p&amp;lt;0.002), more increased TPI values (p-0.22) and underwent less coronary angiography (p&amp;lt;0.02) and primary PCI (P=0.021). Increased LV dimension/volume was associated with 3.35 times higher risk of having LV thrombus (p=0.023). Also anterior STEMI was associated with 14 times higher risk of having LV thrombus=0.012. Patients with LV thrombus had a numerically higher incidence of in-hospital MACCE events (20% vs 13.5%; p=0.36). Conclusion The incidence of LV thrombus formation in STEMI still remain high regardless of primary PCI treatment and current antithrombotic treatment, and is higher in patients with anterior STEMI, lower LVEF, adverse ventricular remodeling, apical aneurism/dyskinesia presence, late hospital presentation and longer ischemia time. The presence of LV thrombus was independently associated with in-hospital MACCE events.