ST-segment Elevation Research Articles

Long-term prognostic value of microvascular obstruction by cardiac magnetic resonance in ST-segment elevation myocardial infarction

Abstract Background Microvascular obstruction (MVO) has been associated with a higher risk of cardiac remodelling and adverse events following ST-segment elevation myocardial infarction (STEMI). However, long-term prognostic implications of MVO in STEMI beyond five years of follow-up have not been assessed to date. Purpose To investigate the relation of MVO with all-cause mortality and recurrent ischemic events at long-term follow-up after STEMI. Methods This is a pooled analysis of three observational studies including 876 prospectively enrolled reperfused first STEMI patients, who underwent cardiac magnetic resonance imaging with late gadolinium enhancement, between 2003-2019, from four university medical centers in the Netherlands and Spain. Median follow-up duration was 6.3 (IQR 3.6-9.3) years. The primary outcome was all-cause mortality. The secondary outcome was a combined endpoint of all-cause mortality and recurrent ischemic events (i.e. myocardial infarction or stroke). We performed Cox regression analyses with a time-dependent covariate. Model 1 included correction for clinical covariates only, i.e. age, sex, smoking, diabetes mellitus, hypertension, and LAD culprit artery. Model 2 included imaging characteristics, i.e. infarct size and left ventricular ejection fraction, in addition to the clinical covariates. Results The study population consisted of 876 patients, mean age 59 years ± 12, 720 men (82%). MVO was present in 499 patients (58%). The presence of MVO was significantly associated with all-cause mortality up to six years post-STEMI, independent from clinical characteristics (Hazard Ratio [HR] 2.23, 95% CI 1.09-4.57, p=0.029), but not after six years post-STEMI (HR 0.98, 95% CI 0.45-2.12, p=0.958). Presence of MVO was not significantly associated with a combined endpoint of all-cause mortality and recurrent ischemic events before or after six years of follow-up (HR 1.27, 95% CI 0.81-1.99, p=0.294 and HR 0.68, 95% CI 0.35-1.31, p=0.244, respectively). All other traditional prognosticators, except age, also lacked predictive value at long-term follow-up beyond six years. Conclusions In STEMI patients, the presence of MVO by cardiac magnetic resonance imaging is associated with a more than two-fold higher risk of all-cause mortality up to six years after the index event. This relation seems to dissipate beyond this time period. Furthermore, presence of MVO was not associated with recurrent ischemic events at long-term follow-up post-STEMI.

ORBI risk score and inflammatory response in patients with acute ST-elevation myocardial infarction

Abstract Background The ORBI risk score was developed to predict in-hospital cardiogenic shock (CS) in patients with ST-elevation myocardial infarction (STEMI) [1]. An inflammatory response is seen in STEMI and may precede CS. The association between ORBI score and systemic inflammatory response is of interest both for improving risk assessment of CS but also for identifying potential therapeutic targets. Methods Using data from one center in the Third DANish Study of Optimal Acute Treatment of Patients With ST-Segment Elevation Myocardial Infarction (DANAMI 3) trial, the inflammat ory status was detected by peak C-reactive protein level (CRP) and white blood cell count (WBC) analyzed from blood samples taken within 96 hours from percutaneous coronary intervention (PCI). Patients were stratified into two ORBI risk groups: ‘Low’ (0-7) and ‘intermediate-high’ (>=8). Patients with CS at the time of PCI were not included, nor were those with out-of-hospital cardiac arrest. Logistic- and Cox Proportional Hazards regression was used to assess the association between ORBI risk groups and 1/ an above-median inflammatory status, and 2/ one-year mortality when combining risk group with inflammatory status. Results Of 1603 patients included, at least one 0–96-hour CRP was available in 631 (39.4%), and WBC in 628 (39.2%) of patients. Mortality at 96 hours was 1.3%. Median CRP and median WBC in the ‘intermediate-high’ ORBI risk group were 61.5 mg/L (interquartile range (IQR) 16-158) and 12 x 10^9/L (IQR 8.8-15.8) vs. 14 (IQR 5-38.8) and 10 (IQR 8.3-12.8) in the ‘low-risk’ group (p<0.001). ‘Intermediate-high’ ORBI score was associated with increased odds of an above-median CRP (OR 3.34, 95% confidence interval (CI) 2.20-5.18, p<0.001), as well as increased odds of an above-median WBC (OR 2.24, 95%CI 1.50-3.38, p<0.001) in univariate analyses. In patients having CRP levels above the median compared to those below, the median age was higher (66 years vs. 60 years, p<0.001). The prevalence of chronic heart failure was greater (26% vs. 13%, p<0.001), as was the incidence of renal failure (6.1% vs. 1.2%, p=0.003). A higher number of patients were classified within Killip classes 3-4 (24% vs. 2.6%, p<0.001). For patients with WBC above the median versus those below, there was a higher prevalence of chronic heart failure (24% vs. 16%, p=0.009). Killip 3-4 was also more common (22% vs. 4.2%, p<0.001). Patients with CRP and WBC at or above the median and an ‘intermediate-high’ ORBI score faced a higher risk of one-year mortality (HR CRP: 5.23, 95%CI: 2.59-10.6, p<0.001 and HR WBC: 6.15, 95%CI 3.04-12.4, p<0.001, figure 1). Conclusions An ‘intermediate-high’ ORBI risk score in STEMI patients was associated with significantly higher odds of increased levels of systemic inflammation within 0-96 hours of admission. An intermediate-high score combined with an elevated inflammatory response was associated with a five to six-fold increased risk of one-year mortality.Fig. 1:KM-plot, 1 year (scale is 1-0.9)

Clinical significance of 12-lead electrocardiogram QRS scores on admission in ST-segment elevation myocardial infarction

Abstract Background A QRS scoring system by 12-lead electrocardiography (ECG) is a quick and simple method to evaluate degree and extension of myocardial infarction. Previous studies have shown that high QRS scores (≥5) at hospitalization (before reperfusion) related to impaired myocardial reperfusion during percutaneous coronary intervention (PCI) and subsequent poor prognosis in patients with ST-segment elevation myocardial infarction (STEMI) (Figure 1). However, the pathogenesis and associated factors with high QRS scores remain poorly defined. Therefore, this study aimed to explore clinical and lesion characteristics associated with QRS scores at hospitalization in patients with STEMI. Methods This retrospective observational study enrolled 138 broad anterior-wall STEMI patients who underwent PCI in the proximal left anterior descending artery and achieved reperfusion within 3 hours of onset. Patients were divided by QRS scores at hospitalization into low (<5: n=97) and high (≥5: n=41) QRS-scores, and clinical and lesion characteristics were compared between the 2 groups. Lesion characteristics were evaluated by intravascular ultrasound (IVUS). Results Despite early phase of STEMI, QRS scores at hospitalization varied (3 [2-5] points). Clinical characteristics, including onset-to-door time (66 [41-101] min vs. 55 [42-76] min) and onset-to-reperfusion time (112 [88-145] min vs. 106 [81-120] min), were comparable between patients with low and high QRS-scores. In contrast, significantly higher percentages of lipid plaques, plaque rupture and large thrombus were seen at the culprit lesion sites in patients with high versus low QRS scores (Figure 2). As a result, patients with high QRS scores had higher incidence of no-reflow phenomenon during PCI (36.6% vs. 12.6%, p<0.05) and larger infarct size assessed by peak CK values (5333 [3307-7443] IU/l vs. 1941 [759-3559], p<0.05) compared with those with low QRS-scores. Conclusions High QRS scores at hospitalization were associated with vulnerable lesion characteristics, as well as impaired coronary reperfusion and large infarct size. Although the exact mechanisms of the associations require future studies, QRS scores may help risk stratification before reperfusion and prognostic prediction after reperfusion.Figure 1.Figure 2.

Trend in culprit plaque phenotype in ACS patients over the past 10 years

Abstract Background Although the incidence of acute myocardial infarction has been declining over the past decade, the etiology of this trend is unknown. One possible explanation could be changes in coronary plaque phenotype. Purpose The aim of this study was to investigate the changes in plaque characteristics over the last 10 years. Methods Patients who presented with acute coronary syndrome and underwent preintervention optical coherence tomography (OCT) imaging from 2008 to 2018 were included. Patients were divided into 4 periods: (P1) 2008-2010, (P2) 2011-2013, (P3) 2014-2015, and (P4) 2016-2018. Plaque characteristics at culprit lesion in each period were compared. Results Among 1144 patients, 594 (51.9%) presented with ST-segment–elevation myocardial infarction (STEMI). The prevalence of thin-cap fibroatheroma decreased from P1 to P4 in both STEMI group (57.4% to 24.6%, P<0.001) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS) group (40.4% to 17.0%, P<0.001) (Figure). Conclusions The prevalence of OCT features of plaque vulnerability has decreased over the past 10 years. A decrease in plaque vulnerability may explain the favorable trend in cardiovascular events.Prevalence of thin-cap fibroatheroma

Satisfactory self-rated health is associated with better clinical outcomes in patients with ST-segment elevation myocardial infarction

Abstract Background It is well known that health status is a risk factor for cardiovascular diseases, but its specific impact on the prognosis of patients with acute myocardial infarction remains unclear. Purpose This study was aimed to investigate the impact of varying health self-evaluation on the long-term outcomes of patients diagnosed with ST-elevation myocardial infarction (STEMI). Methods Data for this study were obtained from a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospital from 2010 to 2023. Patients were divided into satisfied group and dissatisfied group based on their responses to a self-assessment health questionnaire. Baseline data of the two groups were compared, and the relationship between health status and major cardiovascular and cerebrovascular adverse events (MACCE) was analyzed using multivariate cox regression. MACCE, defined as the composite endpoint of cardiac death, recurrent myocardial infarction, stroke and revascularization, was the primary endpoint, with each component considered a secondary endpoint. Results Among STEMI patients, 25214 patients reported satisfaction with their health, while 375 patients expressed dissatisfaction. The satisfied group exhibited a younger age, fewer females, a higher rate of primary percutaneous coronary intervention (PPCI) and PCI during hospitalization, a better Killips classification and a lower prevalence of concomitant disease such as diabetes, hypertension, chronic kidney disease, and cerebrovascular disease. After a median follow-up of 1626 days, the satisfied group demonstrated significantly lower proportions of total death, cardiac death, recurrent myocardial infarction and stroke compared to dissatisfied group. Multivariate COX regression showed that satisfactory health self-rating was associated with a decreased risk of MACCE (HR 0.813, 95%CI 0.704-0.939, P=0.005), stroke (HR 0.670, 95%CI 0.511-0.878, P=0.003), and recurrent myocardial infarction (HR 0.732, 95%CI 0.548-0.979, P=0.035). Conclusions Satisfactory self-rated health is associated with better clinical outcomes in STEMI patients.

A Bayesian reanalysis of the CULPRIT-SHOCK trial.

The optimal revascularization strategy for patients with acute myocardial infarction (AMI), cardiogenic shock (CS), and multivessel disease remains controversial. The CULPRIT-SHOCK trial compared culprit lesion-only vs. immediate multivessel percutaneous coronary intervention (PCI), providing important data but leaving efficacy questions unresolved. To address lingering uncertainties and gain deeper insights, we performed a Bayesian reanalysis of the CULPRIT-SHOCK trial data. We conducted a Bayesian re-analysis of the CULPRIT-SHOCK trial data using non-informative, sceptical, and enthusiastic priors. Relative risks (RRs) with 95% highest posterior density (HPD) intervals were calculated. We defined the minimal clinically important difference (MCID) as RR < 0.84. We performed subgroup analyses for key patient characteristics and assessed secondary outcomes and safety endpoints. Probabilities of benefit, achieving MCID, and harm were computed. Results are presented as median RR with probabilities of effect sizes. Bayesian reanalysis showed a median RR of 0.82 (95% HPD 0.66-1.04) with a non-informative prior, indicating a 95% probability of benefit and 59% probability of achieving MCID. Subgroup analyses revealed potentially stronger effects in males (RR 0.78, 73% probability of MCID), patients without diabetes (RR 0.76, 79% probability of MCID), and those with non-anterior ST-segment elevation MI (STEMI; RR 0.74, 76% probability of MCID). Secondary outcomes suggested potential benefits in mortality (RR 0.85) and need for renal replacement therapy (RR 0.72) but increased risks of recurrent MI (RR 2.84) and urgent revascularization (RR 2.88). Our Bayesian reanalysis provides intuitive insights by quantifying probabilities of treatment effect sizes, offering further evidence favouring the culprit lesion-only PCI strategy in AMI patients with CS and multivessel disease. The analysis demonstrates a high probability of overall benefit, with a notable chance of achieving a minimally clinically important difference, particularly in specific subgroups. These findings not only support the consideration of culprit lesion-only PCI in certain patient populations but also underscore the need for careful risk-benefit assessment. Furthermore, our hypothesis-generating subgroup analyses, which show varying probabilities of achieving MCID, illuminate promising avenues for future targeted investigations in this critical patient population.

Assessing myocardial tissue in the acute setting with Photon-Counting CT (PCCT) in comparison with Cardiac Magnetic Resonance (CMR)

Abstract Background Cardiac magnetic resonance (CMR) characterization of myocardial tissue is routinely used in clinical practice. Compared to traditional CT, Photon counting CT (PCCT) uses photon-counting detectors offering higher spatial resolution, elimination of electronic noise and improved contrast-to-noise ratio. A comparison between CMR and PCCT for myocardial characterizazion in an urgent setting, however, has not yet been explored. Purpose The aim of this study was to compare the ability to characterize myocardial tissue between PCCT and CMR in patients presenting with acute chest pain in the emergency department (ED). Methods This single-center prospective study enrolled all consecutive patients presenting to the ED of our hospital from November 2023 to January 2024 with chest pain, ECG alterations and troponin rise consistent with myocardial injury. Patients needing urgent coronary angiography according to guidelines were excluded. PCCT was performed urgently for triple rule-out, but also for tissue characterization through post-iodine-contrast administration images. Within 24 hours, all patients underwent a CMR protocol including T2-weighted and late gadolinium enhancement (LGE) images for tissue characterization. Results Six male patients with a mean age of 20 ± 10 years were enrolled. All clinical, PCCT, and CMR parameters are presented in Table 1. All patients presented with diffuse ST-segment elevation and exhibited T2-weighted images (for edema detection) and LGE distribution (subepicardial and intramyocardial) consistent with acute myocarditis. Mean radiation exposure for PCCT was 0.8±0.1 mSv. A strong linear correlation emerged between PCCT-derived delayed enhancement (DE) volume and CMR-derived late gadolinium enhancement (LGE) volume (r = 0.970; p value 0.001) (Table 1). Similar results were achieved when comparing the number of DE and LGE myocardial segments (r = 0.871; p value 0.026). Significant correlations also emerged between DE, LGE, and high-sensitive troponin (hsTN) at presentation (respectively: PCCT-DE vs hsTN r = 0.951, p value 0.004; CMR-LGE vs hsTN r = 0.918, p value 0.010). CMR showed a much higher signal-to-noise ratio (SNR) for the delayed enhanced myocardium and contrast-to-noise (CNR) ratio between the delayed enhanced and normal myocardium with respect to PCCT in post-contrast images (respectively 7.4 ± 3.9 vs 27.2 ± 17.7, p value 0.024 and 5.5 ± 3.7 vs 38.8 ± 30.2, p value 0.023). In T2-weighted images both SNR for the hyperintense myocardium (30.3 [20.4-122.4]) and CNR between the hyperintense and normal myocardium (26.7 [13.3-60.2]) resulted to be higher compared to PCCT (p value 0.027 and 0.045, respectively) (Table 1). Conclusions PCCT appears to be reliable when compared to CMR for detecting myocardial edema through the acquisition of post-contrast images in the acute setting with an acceptable CNR.

Influence of social factors on prompt reperfusion in patients with ST-segment elevation myocardial infarction: results from the KRAMI multicenter registry

Abstract Background The time from symptom onset to reperfusion therapy was particularly important for ST-segment elevation myocardial infarction (STEMI) patients. We sought to investigate the impact of social factors on prompt reperfusion in STEMI patients. Methods A total of 5,264 patients with a diagnosis of STEMI from Korean Registry of Acute Myocardial Infarction (KRAMI) was participated in present study. The association between social factors and process of symptom onset-to-timely reperfusion was evaluated. Process of symptom-to-reperfusion time was included door-to-balloon (DTB) time, symptom-to-door (STD) time and symptom-to-balloon (STB) time. Results In the entire study population, the median times of DTB, STD and STB were 55 min, 117 min and 175 min, respectively. With 3 parameters, only DTB was associated with in-hospital mortality (Fig. 1 and 2). Old age and male were more likely to delay treatment (p for age=0.000; p for gender &amp;lt;0.0001). Moreover, higher education was linked to reduction of STD and STB time (p&amp;lt;0.05). Living alone was associated with prolonged STB time, and symptom appearing outside was linked to delay medical care. Transportation with ambulance was significantly associated with reduction of reperfusion time, and inter-hospital transportation was particularly prominent (STD: OR 5.450, 95% CI 4.796 - 6.193, p&amp;lt;0.0001; STB: OR 4.593, 95% CI 4.038 - 5.225, p&amp;lt;0.0001). In addition, treatment time during off-hours was relatively delayed DTB time. Conclusions Door to balloon time is directy related to in-hospital mortality. Social factors, such as age, gender, and education level, and transportation with ambulance were related to timely reperfusion in STEMI patients.

Prior fecal immunochemical test positivity is associated with adverse prognosis in patients with acute ST-segment elevation myocardial infarction

Abstract Backgrounds While fecal immunochemical testing (FIT) is commonly used for disease screening, its significance in other conditions, particularly in patients with ST-segment elevation myocardial infarction (STEMI), is not extensively researched. Purpose This study aimed to investigate the impact of prior positive FIT results on the clinical prognosis of patients with STEMI. Methods The data for this study were derived from the Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients discharged from 72 hospitals from 2010 to 2023. A total of 76,157 patients with acute STEMI patients were enrolled. Positive FIT was defined as "+-" or higher on the fecal occult blood test. Propensity score matching (PSM) was employed to balance differences between the two groups. Kaplan-Meier analysis with log-rank tests compared endpoint risks between groups, and a multivariable Cox regression model adjusted for potential confounders. The primary endpoint was Net Adverse Clinical Event (NACE), including cardiac death, recurrent myocardial infarction, revascularization, stroke, cerebral hemorrhage, and gastrointestinal bleeding. Results After 1:3 PSM,2,148acute STEMI patients were included, with 537 having prior positive FIT and 1,611 without. Patients with prior positive FIT were more likely to have comorbidities such as hyperlipidemia, prior malignancy, post-coronary artery bypass grafting, renal insufficiency, and prior cerebral hemorrhage. The prior positive FIT group had a higher proportion of prior clopidogrel and indobufen usage, while aspirin use during follow-up was lower. Kaplan-Meier analysis demonstrated a significantly higher risk of NACE in acute STEMI patients with prior positive FIT (before PSM: log-rank P = 0.001, after PSM: log-rank P = 0.005, Figure 1）, as well as increased rates of Major Adverse Cardiac and Cerebral Events (MACCE), all-cause death, and gastrointestinal bleeding (log-rank P &amp;lt; 0.05 for all). Multivariate Cox-proportional hazard analysis adjusted for age, sex, percutaneous coronary intervention during hospitalization, diabetes, hypertension, ischemic stroke, atrial fibrillation, medication during hospitalization, and follow-up showed similar results (Figure 2). Conclusions This study reveals a significant association between prior positive FIT and higher rates of NACE, MACCE, all-cause death, and gastrointestinal bleeding in STEMI patients within 1 year. A history of positive FIT results could serve as a prognostic indicator in this specific patient population.

Exploring the impact of coronary microvascular dysfunction on cardiac remodeling after st-elevation myocardial infarction

Abstract Background The complex interplay between Coronary Microvascular Dysfunction (CMD) and ST-segment Elevation Myocardial Infarction (STEMI) presents significant clinical hurdles. CMD, commonly seen as a complication following STEMI, is associated with adverse cardiovascular outcomes and persistent anginal symptoms. Despite its clinical relevance, the link between CMD post-STEMI and subsequent left ventricular (LV) diastolic dysfunction, along with functional LV remodelling (FLVR), is yet to be fully explored. Purpose Examine the link between CMD 3 months post-STEMI and its impact on FLVR and diastolic dysfunction. Methods This prospective, observational cohort study focused on STEMI patients. At 3-month post-STEMI, a comprehensive coronary physiology assessment of the culprit artery was conducted using the thermodilution method to measure fractional flow reserve (FFR), coronary flow reserve (CFR), and the index of microcirculatory resistance (IMR). CMD was identified with an IMR ≥ 25 or a CFR &amp;lt; 2.0, assuming an FFR &amp;gt; 0.80. Diastolic dysfunction was classified according to ASE/EACVI 2016 guidelines. FLVR was categorized as per Surenjav Chimed et al.'s criteria: Group I with no significant changes in LV size or function, Group II with a decrease in LV ejection fraction (LVEF) greater than 5% without LV dilatation, Group III with an increase in left ventricular end-diastolic volume (LVEDV) ≥ 20%, and Group IV showing both an increase in LVEDV ≥ 20% and a decrease in LVEF over 5%. The study aimed to elucidate the relationship between CMD and the progression of FLVR and diastolic dysfunction, tracked over a 12-month period. Results The study involved 210 patients, mostly men (59.5%), with a median age of 65 (IQR: 58–76). At the 3-month follow-up, CMD was observed in 57 (27.1%) patients. CMD patients had a higher female prevalence (63.2% vs. 32.0%; p &amp;lt; 0.001) and more diabetes (42.1% vs. 17.7%; p &amp;lt; 0.001) compared to non-CMD patients. Both groups shared similar body mass indices, medications, and other risk factors. Laboratory results were similar between groups, except brain natriuretic peptide levels were higher in CMD patients (70.0 vs. 37.0 ng/L; p &amp;lt; 0.001). After 12 months, CMD patients demonstrated significantly less recovery in LVEF (-10.00% vs. 8.00%; p &amp;lt; 0.001), higher prevalence of grade 2 LV diastolic dysfunction (73.08% vs. 1.32%; p &amp;lt; 0.001), and a higher incidence of advanced FLVR (notably in Groups 3 and 4) compared to non-CMD (11.32% vs. 7.28% and 22.64% vs. 1.99%, respectively; p &amp;lt; 0.001). In the adjusted multivariable logistic regression analysis, IMR values independently predicted more severe FLVR and diastolic dysfunction. Conclusions This study highlights that CMD 3 months after STEMI is linked to worse FLVR, diastolic dysfunction, and less recovery in LVEF, emphasizing the need for early CMD detection for better risk assessment. Further research is essential to explore underlying mechanisms and intervention opportunities.LVEF Changes at 12 Months by CMD StatusDiastolic Dysfunction and LV Remodeling

Identifying prognostic factors in patients with cardiogenic shock undergoing VA-ECMO treatment: insights from ECLS-SHOCK using machine learning

Abstract Background/Introduction Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has not been shown to reduce short-term mortality in patients with acute myocardial infarction complicated by cardiogenic shock. However, whether some patients might benefit from VA-ECMO remains to be cleared. Purpose To identify the impact of VA-ECMO therapy on outcomes by leveraging the potential of machine learning. Methods The ECLS-SHOCK trial is a randomized controlled trial where patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early VA-ECMO plus usual medical treatment or usual medical treatment alone. The primary outcome was death from any cause at 30 days. Extreme gradient boosting (XGBoost) was used to develop a model for the prediction of 30-day all-cause mortality and to assess the influence of VA-ECMO on outcomes. Results Overall, 209 patients were randomized to the VA-ECMO and 208 to control. Baseline characteristics between groups were well balanced (median age 63 years, 81% male, 67% presenting with ST-segment elevation myocardial infarction). At 30-days 100 patients in the VA-ECMO and 102 in the control group were dead. The final XGBoost model contained 27 variables and the 10 most influential variables are shown in Fig. 1. On derivation the model predicted mortality with an AUC of 1.00 and on validation with an AUC of 0.80 (95% CI 0.71 to 0.89), with a sensitivity of 95% (95% CI 88% to 100%) and a specificity of 55% (40% to 69%), resulting in a positive predictive value of 65% and a negative predictive value of 92% at a Youden-derived cut-off. Importantly, neither the VA-ECMO therapy nor its complications were among the most influential factors of the model with a relative importance of 1.1% for VA-ECMO therapy and 0.25% for peripheral vascular complications and bleeding complications even being discarded by the model. Conclusion In patients with acute myocardial infarction complicated by cardiogenic shock the influence of VA-ECMO therapy on 30-day mortality, even when investigated with complex machine learning models, is negligibly low.

The clinical characteristics and prognosis of patients with acute ST-segment elevation myocardial infarction complicated with impaired activity daily living

Abstract Background Previous studies have indicated that activities of daily living (ADL) can influence the prognosis of patients with acute myocardial infarction. The purpose of this study is to delineate the clinical characteristics, treatment regimens, and prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) who have impaired ADL. Methods The data for this study were derived from a Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023. The inclusion criteria encompassed patients with a discharge diagnosis of STEMI.ADL prior to STEMI was evaluated using the Barthel index(BI),a widely used assessment tool for evaluating ADL.The patients' BI were obtained from their resident health records.Patients were categorized into two groups: ADL normal group and ADL impaired group. A comparative analysis was conducted between the two groups regarding clinical characteristics, treatment regimens, and prognosis. Results This study included 24,906 STEMI patients with normal ADL and 1,002 STEMI patients with impaired ADL. Baseline data revealed that patients in the ADL impaired group had a higher proportion of females (43.0% vs. 37.8%, p=0.001), were older (74.0[64.0,81.0] vs. 69.0[65.0,75.0], p&amp;lt;0.001), and had a higher proportion of Killip III and above (24.30% vs. 14.10%, p&amp;lt;0.001). Additionally, the ADL impaired group had a higher prevalence of comorbidities. In terms of treatment, the ADL impaired group had lower proportions of patients undergoing percutaneous coronary intervention (PCI) (43.8% vs. 65.3%, p&amp;lt;0.001) and primary PCI (PPCI) (36.4% vs. 55.1%, p&amp;lt;0.001). Additionally, the ADL impaired group exhibited lower utilization rates of antiplatelet drugs, ACEI/ARB, beta-blockers, ARNI, and statins, but higher rates of diuretics and cardiac glycosides. Regarding prognosis, the ADL impaired group had a higher in-hospital mortality rate (5.69% vs. 2.89%, p&amp;lt;0.001). The median follow-up time was 1,220 days. In the ADL impaired group, the rates of all-cause mortality (52.0% vs. 24.7%, p&amp;lt;0.001), cardiovascular mortality (37.3% vs. 17.3%, p&amp;lt;0.001), recurrent non-fatal myocardial infarction (11.1% vs. 8.30%, p=0.002), and recurrent stroke (11.9% vs. 8.66%, p=0.001) were higher. However, the rate of revascularization was lower in the ADL impaired group (6.69% vs. 9.20%, p=0.008), and the risk of cerebral hemorrhage showed no significant difference (1.00% vs. 0.81%, p=0.631). In a multivariate Cox regression analysis adjusting for age, gender, Killip, medical history, and treatment strategies, impaired ADL remained an independent risk factor for increased all-cause mortality (aHR 1.309, 95% CI: 1.195-1.434, p&amp;lt;0.001). Conclusions Impairment of ADL is associated with adverse clinical outcomes in patients with STEMI.Baseline characteristics of patientsMedications of patients

Comparison of GRACE and TIMI risk scores in the prediction of in hospital outcome among NSTEMI patients: a single centre study

Abstract Background Major component of ACS, Non-ST segment elevation myocardial infarction (NSTEMI), has more than twice the incidence compared to ST-segment elevation myocardial infarction (STEMI). GRACE (Global Registry of Acute Coronary Events) and TIMI (Thrombolysis in Myocardial Infarction) risk scores are the two most popular prediction models in ACS due to TIMI’s advantage in its simplicity in clinical application and GRACE’s favorable discriminating power. Nevertheless, limited evidence compared the usefulness of these two major risk scores and their association with in-hospital events. Purpose To compare between the predictive ability of GRACE &amp; TIMI risk scores for In hospital outcomes among the NSTEMI patients . Methods This prospective observational study was carried out from 8th march 2020 to 7th March 2022. Total 2152 acute NSTEMI patients were included. Both GRACE &amp; TIMI risk score were calculated. For GRACE score, patients who scored ≤108 points were low risk,109-139 points were medium risk, ≥140 points were high risk . For TIMI scores patients with 0-2 scores were low risk , 3-4 scores were medium risk and 5-7 score were High risk. In Hospital outcomes were defined as the in hospital composite events which includes acute left ventricular failure, cardiogenic shock, arrhythmia &amp; mortality. Results Among the 2152 patients majority were male (73.5%) with mean age of the study population were 58.33 ± .25 years. Mean Grace score &amp; TIMI score of the study population were 137.81±16.38&amp; 3.29±.97 respectively. Most of the patients were categorized in to Medium risk groups by both GRACE &amp; TIMI risk scores , 70% &amp; 51.3% respectively. However, high risk group percentage were higher in GRACE score group(41.3%) in comparison to TIMI score group(10.3%). GRACE score showed better predictive ability than TIMI score for in-hospital outcomes as evaluated by ROC curve( AUC of GRACE vs TIMI, In hospital ALVF:0.89vs 0.59, P&amp;lt;0.001; Cardiogenic Shock 0.72 vs 0.57, P=0.002; Mortality: 0.75 vs 0.59, P=0.002; arrhythmia 0.72 vs0.63, P=0.003). Conclusion GRACE showed better predictive accuracy than TIMI in NSTEMI patients for in-hospital outcomes. The sequential use of TIMI and GRACE scores provide an easy and promising discriminative tool in predicting outcomes in NSTEMI patients , thus improve the identification of high-risk patients.Pic :ROC curve for prediction of ALVFPic: ROC curve for Mortality prediction

The prognostic utility of troponin T levels in patients undergoing PCI during initial hospitalisation for STEMI

Abstract The prognostic utility of presentation or "peak" high-sensitivity troponin T (hsTnT) levels following ST-segment elevation myocardial infarction (STEMI) has been previously reported, but hsTnT, unlike other bio-markers of myocyte damage, have a 2nd or ‘plateau-phase’ of release which lasts over a week. We have reported correlations between plateau-phase hsTnT levels, and cardiac MRI determined infarct size, though whether these levels are more highly associated with late mortality than "peak" (or highest) levels, needs clarification. Methods Hence we determined late mortality and the combination of cardiovascular death, myocardial infarction and cerebrovascular accident [CD/MI/CVA] among patients with STEMI, and an HsTnT level &amp;gt;36 hours after symptom onset (plateau phase), who underwent percutaneous coronary intervention (PCI), either primary or pharmaco-invasive, during initial hospitalisation between October 2003 and December 2021. HsTnT levels and other potential prognostic factors were determined. Results Amongst 1955 patients, 119 patients (6%) had died by 2 years and 192 (10%) patients experienced CD/MI/Stroke. The highest quartile of plateau phase hsTnT levels (³ 3786 ng/L ng/L), were more highly associated with 2-year mortality, than the highest quartile of "peak" hsTnT levels (³ 7687 ng/L ng/L). The Figure shows Peak and plateau hs-TnT levels in quartile groups were assessed by rank test to obtain p-values. Patients lost to follow-up or with less than 2-years of follow up were considered censored. Peak quartile 1; hs-TnT £ 1611 ng/L, peak quartile 2; hs-TnT 1612 – 3900 ng/L, peak quartile 3; hs-TnT 3901 – 7686 ng/L; peak quartile 4; hs-TnT ³ 7687 ng/L. Plateau quartile 1; hs-TnT £ 1060 ng/L, plateau quartile 2; hs-TnT 1061 – 2135 ng/L; plateau quartile 3; hs-cTnT 2136 – 3785 ng/L. Log rank mortality analyses are shown in the Figure. Peak quartile 1; hs-TnT &amp;lt;1611 ng/L, peak quartile 2; hs-TnT 1612 – 3900 ng/L, peak quartile 3; hs-TnT 3901 – 7686 ng/L; peak quartile 4; hs-TnT ³ 7687 ng/L. Plateau quartile 1; hs-TnT £ 1060 ng/L, plateau quartile 2; hs-TnT 1061 – 2135 ng/L; plateau quartile 3; hs-cTnT 2136 – 3785 ng/L, plateau quartile 4; hs-TnT &amp;gt;3786 ng/L. Multivariate Cox regression analysis incorporating age, sex, smoking status, hypertension, renal function, cardiogenic shock and heart failure hospitalisation found plateau hs-TnT levels (HR, 3.564; 95% CI, 1.674 – 7.590; P = 0.001) were an independent predictor of all-cause mortality at 2-years post-STEMI, whereas peak hs-cTnT levels (HR, 1.965; 95% CI, 0.959 – 4.025; P = 0.065) were not. Conclusions Plateau phase hsTnT levels were of prognostic significance in STEMI patients treated with PCI. Thus, measurement of plateau hs-cTnT levels following STEMI could be an accurate, inexpensive method of long-term prognostic risk stratification.

Impact of late reperfusion therapy in patients with inferior ST-segment elevation myocardial infarction and right ventricular dysfunction: one size never fits all

Abstract Background A significant proportion of ST-segment elevation myocardial infarction (STEMI) patients present late to the emergency room with limited evidence of benefit of reperfusion after 12 hours of symptom onset. Inferior myocardial infarction (MI) with right ventricle (RV) dysfunction is associated with high morbidity and mortality, however, the RV has a unique physiology that allows it to withstand ischemia better and recover faster. Purpose To compare adverse in-hospital cardiovascular events in latecomers with inferior STEMI and RV dysfunction admitted to a cardiovascular intensive care unit (CICU) from a low-to-middle-income country, who underwent late reperfusion treatment versus conservative treatment. Methods A retrospective cohort study was conducted from March 2022 to April 2023. Patients with inferior STEMI and RV dysfunction who received late reperfusion treatment were included. RV dysfunction was defined as a TAPSE &amp;lt;17 mm, tricuspid annular systolic velocity on TDI &amp;lt;9.5 cm/s, or a fractional area change &amp;lt;35%. Late reperfusion was defined as primary percutaneous coronary intervention (PCI) performed after 12 hours of symptom onset or rescue PCI after 12 hours of failed fibrinolysis. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were cardiovascular death, reinfarction, stroke, cardiogenic shock, and mechanical complications. Results During the specified period, a total of 106 patients met the inclusion criteria from a total of 1,786 patients admitted to the CICU in our center. Only 60 patients underwent late PCI, accounting for 56% of the cases, with a median time of onset of symptoms to reperfusion of 19.4 hours (IQR: 15.7, 30.2). The average age was 66.5 ± 10.4 years, and 28% were women. Although the all-cause death rate was lower among late PCI group (13.3% vs 26.1%; p=0.096), this difference did not reach statistical significance in the bivariate analysis. Stratified by cardiogenic shock, a lower rate of all-cause mortality was also observed (33% vs 55%, p=0.15). The incidence of reinfarction was significantly lower in the late PCI group (0% vs 13%, p=0.004). In the multivariate analysis, adjusting for those who underwent PCI between 12-48 hours, revascularization of latecomers was independently associated with a significant reduction of mortality (adjusted OR 0.22; 95% CI 0.05-0.92; p=0.038). In a post-hoc analysis, late PCI showed a lower association with the composite outcome of all-cause mortality and reinfarction (adjusted OR 0.16, 95% CI 0.04-0.56; P=0.004). Conclusion(s) Our study demonstrates that implementing a reperfusion strategy in latecomers with inferior STEMI and RV dysfunction significantly reduces the risk of in-hospital mortality and reinfarction. This suggests a potential benefit of expanding the therapeutic window for PCI in this high-risk population. However, prospective studies are needed to conclude these preliminary findings.

To evaluate coronary microvascular obstruction by myocardial contrast echocardiography and its influence on prognosis in patients with ST-segment elevation myocardial infarction

Abstract Background The goal of primary PCI (pPCI) is not only to restore epicardial coronary blood flow quickly but also to provide continuous myocardial tissue level reperfusion through coronary microcirculation. However, the incidence of coronary microvascular obstruction (MVO) after pPCI is as high as 50%-60%, which is closely related to the occurrence of heart failure and increased mortality of patients. Myocardial contrast echocardiography (MCE) is a new noninvasive technique for real-time observation of myocardial microcirculation perfusion in a specific imaging mode. At present, there are few studies on the application of MCE in the evaluation of coronary MVO in STEMI patients in China. Purpose To evaluate coronary MVO by MCE and its influencing factors and prognosis value after pPCI in patients with STEMI. Methods Patients with STEMI who received pPCI from October 2020 to June 2023 in the CCU were enrolled. MCE examination was performed on the 5th to 7th day after pPCI. The patients were divided into the MVO group and Non-MVO group. Major adverse cardiovascular events (MACE) were observed by 6-month follow-up after STEMI onset. Multiple Logistic regression analysis was used to analyze the risk factors for MVO, Multiple Cox regression analysis of the risk factors for MACE and Kaplan-Meier survival curve to compare the cumulative event-free survival of the two groups. Results A total of 98 patients were included in the analysis. The age was 59.88±11.71 years old, and 76(77.55%) were male. MCE examination showed 52 cases in the MVO group and 46 cases in the Non-MVO group. The incidence of MVO was 53.1% (52/98). There were 15 patients with MACE during follow-up. The results of stepwise Multivariate Logistic regression analysis showed that the peak value of cardiac troponin T (cTnT) (OR=1.354,95%CI 1.103-1.661, P=0.004) and without thrombus aspiration (TA) were independent risk factors for MVO (OR=5.588,95%CI 1.915-16.308, P=0.002). Multivariate Cox regression analysis indicated that female (HR=2.891, 95%CI 1.027-8.135, P=0.044), left ventricular ejection fraction (LVEF) &amp;lt;40% (HR=9.960, 95%CI 3.370-29.435, P&amp;lt;0.001) and MVO (HR=5.759,95%CI 1.279-25.935, P=0.023) were independent risk factors for MACE. Kaplan-Meier survival curve showed that the cumulative event-free survival rate in the Non-MVO group was higher than that in the MVO group, and the difference was statistically significant (P=0.0047). Conclusion The incidence of coronary MVO was higher in STEMI patients after pPCI, the peak value of cTnT and without TA were independent risk factors of MVO. The independent risk factors for MACE were female, LVEF &amp;lt; 40%, and MVO.

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.

Assessment of microvascular occlusion in re-perfused myocardial infarction patients using cardiac magnetic resonance

Abstract Background and objective Primary percutaneous coronary intervention (PPCI) is the gold standard for myocardial reperfusion in ST-segment elevation myocardial infarction (STEMI). Numerous studies have shown that thrombus aspiration can prevent distal embolization, reducing the risk of microvascular obstruction (MVO). Cardiac magnetic resonance (CMR) is considered the gold standard for evaluation of MVO. The aim of this study is to evaluate the efficacy of thrombus aspiration as adjunctive technique to primary PCI, in reducing incidence and extent of MVO in STEMI patients evaluated by CMR. Methods Ninety-three patients with heavy thrombus burden were enrolled in this study, sixty-five met our inclusion criteria. Aspiration thrombectomy followed by PCI was done for thirty-one patients (aspiration group) and conventional PCI, without aspiration thrombectomy, was done for thirty-four patients (conventional group). Primary end points were occurrence and extent of microvascular obstruction (MVO) evaluated by cardiac magnetic resonance (CMR). Results The incidence of microvascular obstruction (MVO) was significantly higher in conventional group (18 patients, 52.9%) when compared with aspiration group (7 patients, 22.6%) (p-value = 0.012). Moreover, significant difference existed between studied groups as regard MVO extent. In aspiration group, MVO extended to &amp;gt; 4 segments in 3 patients (9.7%) while in conventional group, MVO extended to &amp;gt; 4 segments in 13 patients (38.2%) (p-value = 0.012). Conclusion Aspiration thrombectomy as adjunctive technique to PCI in STEMI population maintains the integrity of coronary microvasculature and reduces both incidence and extent of MVO.

Trends in major cardiac events after ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from 2003 to 2017: the western Denmark heart registry

Abstract Background In Denmark, primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003. We recently reported a gradual decline in 1-year mortality in patients treated with pPCI-treated STEMI from 2003 to 2017. To elucidate potential causes of this observation, we examined temporal trends in the 1-year risk of major adverse cardiovascular events (MACE). Purpose To examine trends in 1-year risks of MACE following STEMI treated with pPCI from 2003 to 2017. Methods Using the Western Denmark Heart Registry, we identified STEMI patients undergoing first-time pPCI from 2003 to 2017 and divided the patients into four time periods. The main outcome was 1-year risk of MACE, defined as recurrent myocardial infarction, ischaemic stroke, or cardiovascular death. Cause-specific adjusted hazard ratios (HR) were used to assess temporal trends using the first period (2003-2006) as reference. Further, temporal trends were compared to an age-, sex-, and calendar-year matched general population. Results From 2003 to 2017, 18,540 pPCI-treated STEMI patients were identified (median [Q1-Q3] age, 64 [55-74] years); 13,639 men [74%]). Trends in 1-year risk of MACE showed a gradual reduction over time from 13.0% in 2003-2006, 11.8% in 2007-2010, 9.7% in 2011-2014, to 8.7% in 2015-2017 (Figure). The adjusted relative risk reduction was 33% when comparing 2015-2017 with 2003-2006 (adjusted HR 0.67, 95% CI 0.58-0.76). Comparable relative risk reductions were observed for all three individual components of MACE of 33-35%. Compared to the matched general population, the 1-year risk difference in MACE decreased from 11% in 2003-2006 to 7% in 2015-2017. Conclusions In a high-income European country with a fully implemented pPCI strategy, 1-year risk of MACE declined by approximately one-third after first-time STEMI between 2003 to 2017. This MACE reduction was substantially larger than observed in the matched general population, i.e., confirming an important reduction in the excess risk associated with STEMI.

The sooner the better? What is the optimal timing for coronary angiography in high-risk non-ST-elevation acute coronary syndrome

Abstract Introduction current guidelines recommend an early invasive coronary angiography (ICA), in the first 24 hours, for high-risk non-ST elevation acute coronary syndrome (NSTE-ACS) patients. However, several studies have failed to demonstrate a significant improvement in all-cause mortality, with controversial results regarding recurrent ischemia and myocardial infarction. Purpose to evaluate the optimal timing of ICA in high-risk NSTE-ACS. Methods this was a national multicentre retrospective study of patients hospitalized for NSTE-ACS between October 2010 and October 2023. Patients presenting in Killip class IV, mechanical complications, life-threatening arrhythmias or cardiac arrest were excluded. Participants were divided into three groups, according to the timing of ICA: in the first 24 hours (D0), between 24 and 48 hours (D1) and between 48 and 72 hours (D2). The incidence of in-hospital complications and mortality, as well as 1-year mortality rate and cardiovascular rehospitalization, was compared for the three groups. Results a total of 9949 patients was included, 98.2% with non-ST elevation myocardial infarction (NSTEMI) and 1.8% with unstable angina with high-risk criteria (GRACE risk score &amp;gt;140 or transient ST-segment elevation). Most patients were submitted to early ICA (46.7%), with 26.7% and 26.6% in D1 and D2, respectively. Interestingly, patients in higher Killip class (II or III) were referred for ICA latter than patients in Killip class I (9.0% in D0 vs. 11.3% in D1 vs. 13.5% in D2, p&amp;lt;0.001). Regarding in-hospital complications, early ICA was associated with a lower incidence of acute heart failure (8.5% vs. 11.1% vs. 11.5%, p&amp;lt;0.001) and shorter length of stay (7 vs. 6 vs. 10 days, p=0.01). However, it did not reduce in-hospital mortality (1.2% vs. 0.7% vs. 0.8%, p=0.07), recurrent myocardial infarction (0.9% vs. 1.5% vs. 1.3%, p=0.09), cardiogenic shock (7.9% vs. 5.7% vs. 5.4%, p=0.19), mechanical complications (0.1% vs. 0.2% vs. 0.1%, p=0.50) or sustained ventricular tachycardia (0.8% vs. 0.6% vs. 0.4%, p=0.12). Left ventricular ejection fraction was also similar between groups (54%±12, p=0.97). There were also no significant differences between groups regarding 1-year mortality or cardiovascular rehospitalization (15.1% vs. 15.9% vs. 15.7%, p=0.89). Conclusion in high-risk NSTE-ACS patients, early ICA resulted in lower incidence of acute heart failure and shorter length of stay. However, timing of ICA didn’t show a significant impact on in-hospital mortality or complications, nor in 1-year mortality rate or cardiovascular rehospitalization.