ST-segment Myocardial Infarction Research Articles

Ocena poziomu wiedzy żywieniowej za pomocą kwestionariusza komPAN pacjentów po ostrym zespole wieńcowym hospitalizowanych na oddziale kardiologii inwazyjnej. Doniesienie wstępne

Introduction. Cardiovascular diseases are the major cause of mortality in Poland. Thus, both primary and secondary prevention should include lifestyle modification, including proper nutrition. The aim of the study was to examine dietary habits and nutritional beliefs for the purpose of evaluating the nutrition knowledge of cardiac patients after an acute coronary syndrome [ACS; non-ST-segment myocardial infarction (NSTEMI) and ST-segment myocardial infarction (STEMI)] undergoing invasive treatment. Material and methods. The study included 100 patients, including 35 women and 65 men aged 53.43 ± 10.11 years [mean ± standard deviation (SD)], admitted urgently due to ACS to the 2nd Department of Cardiology. The study used part C of the questionnaire: “Nutrition Beliefs” that consisted of 25 statements assessing nutrition knowledge. For each correct answer (“True” or “False”), 1 point was assigned, and for an incorrect answer or “Hard to say”, 0 points were assigned. Then, the points were added up. Results. It was found that only 20.8% (N = 21) of subjects followed dietary recommendations as advised by a physician. The majority of respondents were diagnosed with an excessive body mass: obesity in 35.4% (N = 35) of subjects, and overweight in 38.4% (N = 38) of subjects. Nutritional self-assessment was reported to be at a good level in 71.3% of patients (N = 72). However, the actual nutrition knowledge was found to be at a good level in only 6.9% (N = 7) of subjects. Conclusion . Patient nutrition knowledge as assessed using the komPAN questionnaire was found to be mostly at a satisfactory level, despite high self-assessment res ults provided by the respondents. There is a great need for regular nutrition education.

ST Segment Elevation Caused by Artifact From Cylindrical Battery Ingestion

Ingestion of cylindrical batteries is uncommon. Management can include removal via upper endoscopy, surgical excision, or observation. This case demonstrates the rare phenomenon of cylindrical battery ingestion causing an electrocardiogram (ECG) artifact that mimics ST segment myocardial infarction (STEMI). A 51-year-old man who ingested 13 small pencils and 18 AA batteries was found to have ST segment elevation in the inferior leads of the ECG. Further cardiac workup including cardiac biomarkers and transthoracic echocardiogram was negative, and his ECG changes resolved after extraction of the batteries. The ST segment changes were most likely caused by electrical artifact from battery ingestion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When faced with an ECG finding that is unexpected and that does not fit the patient's overall clinical picture, emergency physicians should consider artifact as a possible cause. Recognition of artifact as the cause of an ECG abnormality can obviate the need for a prolonged and potentially invasive cardiac workup.

Acute alterations in glucose homeostasis impact coronary microvascular function in patients presenting with ST-segment elevation myocardial infarction.

BackgroundMicrovascular dysfunction in the setting of ST-segment myocardial infarction (STEMI) is thought to be related to stress-related metabolic changes, including acute glucose intolerance. The aim of this study was to assess the relationship between admission glucose levels and microvascular function in non-diabetic STEMI patients.Methods92 consecutive patients with a first anterior-wall STEMI treated with primary percutaneous coronary intervention (PPCI) were enrolled. Blood glucose levels were determined immediately prior to PPCI. After successful PPCI, at 1‑week and 6‑month follow-up, Doppler flow was measured in culprit and reference coronary arteries to calculate coronary flow velocity reserve (CFVR), baseline (BMR) and hyperaemic (HMR) microvascular resistance.ResultsThe median admission glucose was 8.3 (7.2–9.6) mmol/l respectively 149.4 mg/dl [129.6–172.8] and was significantly associated with peak troponin T (standardised beta coefficient [std beta] = 0.281; p = 0.043). Multivariate analysis revealed that increasing glucose levels were significantly associated with a decrease in reference vessel CFVR (std beta = −0.313; p = 0.002), dictated by an increase in rest average peak velocity (APV) (std beta = 0.216; p = 0.033), due to a decreasing BMR (std beta = −0.225; p = 0.038) in the acute setting after PPCI. These associations disappeared at follow-up. These associations were not found for the infarct-related artery.ConclusionElevated admission glucose levels are associated with impaired microvascular function assessed directly after PPCI in first anterior-wall STEMI. This influence of glucose levels is an acute phenomenon and contributes to microvascular dysfunction through alterations in resting flow and baseline microvascular resistance.

Effect of the COVID-19 pandemic on access to primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

The coronavirus disease 2019 (COVID-19) pandemic caused by the emergence of severe acute respiratory syndrome coronavirus 2 has resulted in a health crisis and a significant number of deaths worldwide. The full effect on access to medical care and the treatment for patients with chronic diseases and acute conditions is still unknown. This is an investigation of access to primary percutaneous coronary intervention (PPCI) for patients diagnosed with ST-segment myocardial infarction (STEMI) during the pandemic. Consecutive patients who were diagnosed with STEMI and underwent PPCI during the ongoing COVID-19 pandemic were included in the study. Clinical and angiographic characteristics of the patients were assessed. A control group of patients diagnosed with STEMI and who underwent PPCI during the same time interval a year prior to the outbreak of the disease was analyzed retrospectively for comparison. There was a significant reduction in the number of STEMI cases during the COVID-19 crisis period. Furthermore, these patients had a prolonged ischemic time; they were more likely to have a longer pain-to-balloon (Odds ratio [OR]: 2.0, 95% confidence interval [CI]: 1.1-10.2) and door-to-balloon time (OR: 5.4, 95% CI: 3.1-22.8). Patients diagnosed with STEMI during the pandemic experienced a significant delay between the onset of symptoms and PPCI.

The selection of β-blocker after successful reperfusion in patients with ST-elevation myocardial infarction.

The selection of β-blocker for survivors after primary intervention due to acute ST-elevation myocardial infarction seems crucial to improve the outcomes. However, rare comparison data existed for these patients. We aimed to compare the effectiveness of selective β-blockers to that of carvedilol in patients treated with primary intervention. Among the 1,485 patients in the "INTERSTELLAR" registry between 2007 and 2015, 238 patients with selective β-blockers (bisoprolol, nebivolol, atenolol, bevantolol, and betaxolol) and 988 with carvedilol were included and their clinical outcomes were compared for a 2-year observation period. In the clinical baseline characteristics, the unfavorable trends in the carvedilol group were high Killip presentation, lower ejection fractions, smaller diameters, and longer lengths of deployed stents. Although mortality (2.5% vs. 1.7%; p = 0.414) and the rate of stroke (0.8% vs. 0.6%; p = 0.693) were not different between groups, the rate of recurrent myocardial infarction (4.6% vs. 1.2%; p = 0.001) and of target vessel revascularization (4.2% vs. 0.9%; p < 0.001) were lower in the carvedilol group. After eliminating the difference by propensity matching, the similar outcome result was shown (all-cause death, 0.6% vs. 1.0%, p = 0.678; stroke, 0.6% vs. 1.2%, p = 0.479; myocardial infarction, 5.0% vs. 1.2%, p = 0.003; target vessel revascularization, 4.5% vs. 0.7%, p < 0.006) for 595 matched populations. The use of carvedilol was also determined to be an independent predictor for recurrent myocardial infarctions (hazard ratio = 0.305; p = 0.005; 95% confidence interval = 0.13-0.69). Use of a carvedilol in ST-segment myocardial infarction survivor is associated with lower recurrent myocardial infarction events. Thus, it might be the better choice of β-blocker for secondary prevention in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention.

Previously diagnosed cancer and mortality after ST-segment elevation acute myocardial infarction treated with primary angioplasty.

We investigated if a previous cancer diagnosis influences the outcome of patients with STEMI treated with primary coronary intervention (PCI). ST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both have a high incidence and prevalence. Prospective cohort observational study, The primary end-point was total mortality. We included 917 patients, 53 of them (5.8%) were cancer survivors. During follow-up (median, 643 days [interquartile range, 258 to 1,015 days]), 100 patients died, 88 (10.2%) patients without a cancer diagnosis and 12 (22.6%) patients with a previous cancer diagnosis, which was significantly different (log-rank test = 8.4, p = .004). Cancer patients were older (73.4 (11.5) vs. 65.2 (13.8) years, p < .001), with a lower prevalence of previous stroke (1.1% vs. 2.2%, p = .002). Their hemoglobin concentration was also lower (13.4 (2.1) vs. 14.4 (1.7) g/L, p = .001). A trend towards a lower use of coronary stents in cancer survivors was noted (p = .061). Cancer was associated with a high probability of death (HR = 2.37, 95% confidence interval [CI] 1.30-4.34, p = .005). When confounding variables were included, this association was no longer significant (HR = 1.63, 95% CI 0.84-3.18, p = .150). Patients with a previous cancer diagnosis who had an acute STEMI treated by primary PCI did not seem to have a worse prognosis. The difference in the crude mortality rate can be explained by the baseline differences between both groups. Previous cancer diagnosis should not be included in the clinical decision process when a patient is having an acute STEMI.

P4617Early electrocardiographic changes as markers of coronary microvascular obstruction in acute myocardial infarction with ST segment elevation

Abstract Background Coronary microvascular obstruction (CMVO), occurs frequently even after a quickly epicardial revascularization of the infarct-related artery (IRA), and has been associated with an increased risk of adverse cardiovascular events and poor prognosis in patients with ST-segment myocardial infarction (STEMI). After primary coronary intervention (PCI), incomplete ST-segment elevation (STE) resolution in the ECG has been related to CMVO and worse clinical outcome. However, there is lack of information regarding other ECG changes. The aim of this study is to describe the initial ECG changes in STEMI and evaluate their association with CMVO. Methods From January 2007 to December 2017, all patients with the diagnosis of STEMI that underwent urgent coronary angiography were retrospectively included. Clinical, echocardiographic, and electrocardiographic data were taken from medical records. A univariate and multivariate analysis was performed to evaluate the relationship between initial ECG changes (before PCI) and CMVO defined as final TIMI &lt;3 in the IRA. Results 1022 patients were included; the mean age was 67.8 years (±14), 73.7% were male and 14.4% had previous coronary artery disease. The most frequent IRA was the anterior descending artery in 43.2% of the cases and CMVO was found in 18.3% of the patients. The mean value of STE sum (defined as the sum of STE in V1-V6, I and aVL in anterior STEMI and the sum of II, III, aVF, V5 and V6 in non-anterior STEMI), maximum STE in one lead and number of leads with STE was 11.36mm (± 8.2), 3.65mm (± 2.3) and 4.14mm (± 1.4), respectively. After a univariate analysis, STE sum, maximum STE in one lead and number of leads with STE were associated with CMVO, while only STE sum remained significantly associated with the presence of CMVO after a multivariate analysis (Table). The resolution of STE in the first 2 hours after PCI was a protector factor for CMVO. Univariate and Multivariate Analysis Univariate Multivariate Variables OR 95% CI p OR IC 95% p Sum of STE 1.03 1.01–1.04 0.013 1.03 1.01–1.05 0.005 Number of leads with STE 1.13 1.02–1.26 0.021 1.04 0.87–1.23 0.67 Maximum STE 1.09 1.02–1.16 0.016 1.04 0.92–1.17 0.49 Resolution of STE 0.35 0.25–0.49 &lt;0.001 0.36 0.25–1.18 &lt;0.001 STE, ST-segment elevation. Conclusion Initial ECG changes such as STE sum, number of leads with STE and maximum STE in one lead can be used as early predictors of CMVO and poor prognosis. STE resolution in the first 2 hour was associated with a lower incidence of CMVO as reported in previous studies. Acknowledgement/Funding None

1928P - Antecedent of cancer and mortality after the first ST segment elevation acute myocardial infarction treated with primary coronary angioplasty. A prospective cohort study

BackgroundST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both are highly incident and prevalent. We sought to investigate if a previous diagnosis of cancer influences the outcome of patients with STEMI treated with primary coronary angioplasty. MethodsWe included 917 patients in a prospective cohort observational study, 53 of them (5.8%) cancer survivors. The primary end-point was total mortality. ResultsOut of the 53 patients with history of cancer, all which have been included in the analysis, 12 (23.0%) were treated with chemotherapy, 38 (72.0%) with radiotherapy and 12 (23.0%) had surgical treatment. Cancer locations were: breast cancer in 10 patients (18.9%), gastrointestinal tract in 11 (20.8%), prostate in 10 (18.9%), urologic in 7 (13.2%), hematologic malignancies in 5 (9.4%), respiratory tract in 5 (9.4%) and other locations in 3 (5.7%). One hundred patients died during a median follow-up of 643 days (interquartile range 258 to 1015 days), 88 (10.2%) in patients without cancer and 12 (22.6%) in patients with cancer, being this difference significant (log-rank test=8.4, p=0.004). Cancer patients were older: 73.4 (11.5) vs 65.2 (13.8) years (p<0.001), with a lower prevalence of previous stroke: 1.1% vs 2.2%, p=0.002. The hemoglobin concentration was also lower: 13.4 (2.1) vs 14.4 (1.7) g/L, p=0.001. No significant differences were found in the data gleaned from the primary angioplasty, although a trend towards a lower use of coronary stents in cancer survivors was noted (p=0.061). Cancer was associated with a high probability of death, HR=2.37 (95% confidence interval 1.30 to 4.34), p=0.005. When confounding variables were included in a multivariate Cox regression model, this association was no longer significant: HR=1.63 (0.84-3.18), p=0.150. ConclusionsWe failed to demonstrate a survival advantage of patients with ST-segment myocardial infarction treated with primary coronary angioplasty when patients did not have a previous cancer. The finding of a difference in crude mortality rate can be explained by the baseline differences between both groups. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

6 DIFFERENTIAL EFFECTS OF DELETIONS AND DUPLICATIONS ON AUTISM RISK ACROSS THE GENOME

The rate of mechanical complications of acute myocardial infarction has declined. Recent publications raised concerns over the reduction in cardiac catheterization laboratory activation for ST-segment myocardial infarction (STEMI) during the coronavirus disease-2019 (COVID-19) pandemic. We present 2 recent cases of ventricular septal rupture in patients who presented to our institution with delayed STEMI. (Level of Difficulty: Intermediate.)

Outcomes of different revascularization strategies among patients presenting with acute coronary syndromes without ST elevation

ObjectiveTo compare short- and long-term outcomes of patients hospitalized with non–ST-segment myocardial infarction (NSTEMI) or unstable angina (UA) who were referred for revascularization by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in a real-world national cohort. MethodsThis observational study included 5112 patients, who underwent either CABG or PCI, admitted for NSTEMI or UA and were enrolled in the Acute Coronary Syndrome Israeli Survey between 2000 and 2016. Propensity score-matching analysis compared early outcomes and all-cause mortality in patients who underwent revascularization by PCI with revascularization by CABG. ResultsOf the 5112 patients, 4327 (85%) underwent PCI and 785 (15%) CABG. Following propensity score analysis, 447 pairs were chosen (1:1). Independent predictors for CABG referral included 3-vessel CAD (odds ratio [OR], 5.5; 95% confidence interval [CI], 4.5-6.7, P < .001), absence of on-site cardiac surgery (OR, 1.3; 95% CI, 1.1-1.6, P = .004), no previous PCI (OR, 1.5; 95% CI, 1.2-1.9, P = .002) and no previous myocardial infarction (OR, 1.3; 95% CI, 1-1.7, P = .022). The 10-year mortality risk was significantly lower among those who underwent CABG compared with PCI (20.4% vs 28.4%, P = .006). Consistent with these findings, multivariable analysis showed that referral to CABG was independently associated with a significant 65% reduction in the risk of 10-year mortality (P < .001). This long-term advantage was seen among male patients (P < .001) and not female patients (P = .910). ConclusionsIn a real-life setting, revascularization by CABG provides excellent long-term outcomes in patients with NSTEMI or UA. The advantage of CABG over PCI was seen only in male patients.

Oral post-hydration after primary PCI for STEMI

In patients undergoing percutaneous coronary intervention for ST-segment myocardial infarction (STEMI), acute kidney injury (AKI) occurs in ~11% (~33% when presenting in cardiogenic shock), as compared to ~3% in patients with stable angina (1).

Can WeChat group-based intervention reduce reperfusion time in patients with ST-segment myocardial infarction? A controlled before and after study

Background Pre-hospital identification of acute ST-elevation myocardial infarction and activation of the catheterization laboratory can reduce first medical contact to wire-crossing times. We conducted a study on providing 24-hour tele-electrocardiography services via the WeChat group application, aiming to reduce the time taken for diagnosis and treatment of ST-elevation myocardial infarction. Methods A controlled before and after study was conducted on 140 ST-elevation myocardial infarction patients who were initially seen in non-percutaneous coronary intervention-capable hospital and transferred for primary percutaneous coronary intervention at our percutaneous coronary intervention centre from 1 February to 31 October 2018. The WeChat group had 70 patients with pre-hospital electrocardiography transmission via WeChat and the control group had 70 patients who did not transfer pre-hospital electrocardiography. The reperfusion time of the two groups was compared to evaluate the effect of the WeChat group intervention. Results In the WeChat group versus the control group, the median symptom onset to first medical contact time was similar (129 vs 150 min, p > 0.05), but the median first medical contact to wire, door to wire and first medical contact to catheterization laboratory activity were significantly shorter (132 vs 171 minutes, p < 0.001; 60 vs 95 minutes, p < 0.001; 29 vs 74 minutes, p < 0.001, respectively). Conclusions Pre-hospital electrocardiography transfer via a WeChat group resulted in earlier reperfusion of ST-elevation myocardial infarction patients who were transferred from the non-percutaneous coronary intervention centre.

Complete Versus Culprit only Revascularisation in Patients with Cardiogenic Shock Complicating Acute Myocardial Infarction: Incidence and Outcomes from the London Heart Attack Group

BackgroundDespite advances in technology, patients with Cardiogenic Shock (CS) presenting with ST-segment myocardial infarction (STEMI) still have a poor prognosis with high mortality rates. A large proportion of these patients have multi-vessel coronary artery disease, the treatment of which is still unclear. We aimed to assess the trends in management of CS patients with multi-vessel disease (MVD), particularly looking at the incidence and outcomes of complete revascularisation compared to culprit vessel only. Methods and resultsWe undertook an observational cohort study of 21,210 STEMI patients treated between 2005 and 2015 at the 8 Heart Attack Centres in London, UK. Patients' details were recorded prospectively into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. 1058 patients presented with CS and MVD. Primary outcome was all-cause mortality. Patients were followed-up for a median of 4.1 years (IQR range: 2.2–5.8 years).497 (47.0%) patients underwent complete revascularisation during primary PCI for CS with stable rates seen over time. These patients were more likely to be male, hypertensive and more likely to have poor LV function compared to the culprit vessel intervention group. Although crude, in hospital major adverse cardiac events (MACE) rates were similar (40.8% vs. 36.0%, p = 0.558) between the two groups. Kaplan-Meier analysis demonstrated no significant differences in mortality rates between the two groups (53.8% complete revascularisation vs. 46.8% culprit vessel intervention, p = 0.252) during the follow-up period. After multivariate cox analysis (HR 0.69 95% CI (0.44–0.98)) and the use of propensity matching (HR: 0.81 95% CI: 0.62–0.97) complete revascularisation was associated with reduced mortality. A number of co-variates were included in the model, including age, gender, diabetes, hypertension, hypercholesterolaemia, previous PCI, previous MI, chronic renal failure, Anterior infarct, number of treated vessels, pre-procedure TIMI flow, procedural success and GP IIb/IIIA use. ConclusionIn a contemporary observational series of CS patients with MVD, complete revascularisation appears to be associated with better outcomes compared to culprit vessel only intervention. This supports on-going clinical trials in this area and provides further evidence of the association of complete revascularisation in STEMI with good outcomes.

Postoperative ‘STEMI’ in Intracerebral Hemorrhage due to Arteriovenous Malformation: A Case Report and Review of Literature

Electrocardiogram (ECG) changes suggestive of cardiac ischemia are frequently demonstrated in patients with ischemic stroke and subarachnoid hemorrhage. However, little is known of such changes particularly acute ST segment myocardial infarction (STEMI) in patients with intracerebral hemorrhage (ICH), especially after neurosurgery. We present a patient with intraparenchymal hemorrhage due to cerebral arteriovenous malformation (AVM) who exhibited acute STEMI after neurosurgery. Serial cardiac biomarkers and echocardiograms were performed which did not reveal any evidence of acute myocardial infarction. The patient was managed conservatively from cardiac stand point with no employment of anticoagulants, antiplatelet therapy, fibrinolytic agents, or angioplasty and recovered well with minimal neurological deficit. This case highlights that diffuse cardiac ischemic signs on the ECG can occur in the setting of an ICH after neurosurgery, potentially posing a difficult diagnostic and management conundrum.

Push Notifications Reduce Emergency Department Response Times to Prehospital ST-segment Elevation Myocardial Infarction.

IntroductionPrehospital acquisition of electrocardiograms (ECG) has been consistently associated with reduced door-to-balloon times in the treatment of ST-segment myocardial infarction (STEMI). There is little evidence establishing best hospital practices once the ECG has been received by the emergency department (ED). This study evaluates the use of a push notification system to reduce delays in cardiac catheterization lab (CCL) activation for prehospital STEMI.MethodsIn this prospective before-and-after study, we collected prehospital ECGs with computer interpretation of STEMI from May 2012 to October 2013. Push notifications were implemented June 1, 2013. During the study period, we collected timestamps of when the prehospital ECG was received (email timestamp of receiving account), CCL team activation (timestamp in paging system), and patient arrival (timestamp in ED tracking board). When prehospital ECGs were received in the ED, an audible alert was played via the Vocera WiFi communication system, notifying nursing staff that an ECG was available for physician interpretation. We compared the time from receiving the ECG to activation of the CCL before and after the audible notification was implemented.ResultsOf the 56 cases received, we included 45 in our analysis (20 cases with pre-arrival CCL activation and 25 with post-arrival activation). For the pre-arrival group, the interval from ECG received to CCL activation prior to implementation was 9.1 minutes with a standard deviation (SD) of 5.7 minutes. After implementation, the interval was reduced to 3.33 minutes with a SD of 1.63 minutes. Delay was decreased by 5.8 minutes (p < 0.01). Post-implementation activation times were more consistent, demonstrated by a decrease in SD from 5.75 to 1.63 min (p < 0.01). For patients with CCL activation after arrival, there was no significant change in mean delay after implementation.ConclusionIn this small, single-center observational study, we demonstrated that the use of push notifications to ED staff alerting that a prehospital STEMI ECG was received correlated with a small reduction in, and increased consistency of, ED CCL activation.

Outcomes in patients with acute coronary syndrome in a referral hospital in sub-Saharan Africa.

Coronary artery disease and its acute presentation are being increasingly recognised and treated in sub-Saharan Africa. It is just over a decade since the introduction of interventional cardiology for coronary artery disease in Kenya. Local and regional data, and indeed data from sub-Saharan Africa on long-term outcomes of acute coronary syndromes (ACS) are lacking. A retrospective review of all ACS admissions to the Aga Khan University Hospital, Nairobi (AKUHN) between January 2012 and December 2013 was carried out to obtain data on patient characteristics, treatment and in-patient outcomes. Patient interviews and a review of clinic records were conducted to determine long-term mortality rates and major adverse cardiovascular events. A total of 230 patients were included in the analysis; 101 had a diagnosis of ST-segment myocardial infarction (STEMI), 93 suffered a non-ST-segment myocardial infarction (NSTEMI), and 36 had unstable angina (UA). The mean age was 60.5 years with 81.7% being male. Delayed presentation (more than six hours after symptom onset) was common, accounting for 66.1% of patients. Coronary angiography was performed in 85.2% of the patients. In-hospital mortality rate was 7.8% [14.9% for STEMI and 2.3% for non-ST-segment ACS (NSTE-ACS, consisting of NSTEMI and UA)], and the mortality rates at 30 days and one year were 7.8 and 13.9%, respectively. Heart failure occurred in 40.4% of STEMI and 16.3% of NSTE-ACS patients. Re-admission rate due to recurrent myocardial infarction, stroke or bleeding at one year was 6.6%. In our series, the in-hospital, 30-day and one-year mortality rates following ACS remain high, particularly for STEMI patients. Delayed presentation to hospital following symptom onset is a major concern.

Ischemic postconditioning reduces infarct size and microvascular obstruction zone in acute ST-elevation myocardial infarction - a randomized study.

IntroductionIschemic postconditiong (postcon) has been reported to reduce infarct size in ST-segment myocardial infarction (STEMI). However, recently a few other studies did not show any effect of postcon or suggested that it may even be harmful.AimWe sought to assess whether postcon could reduce infarct size (IS) and the microvascular obstruction (MVO) zone in early presenters with STEMI.Material and methodsSeventy-four STEMI patients treated with primary coronary intervention (PCI) < 4 h from symptoms onset were randomly assigned to the postcon group (n = 37) or standard PCI group (n = 37). Postcon was performed immediately after obtaining reperfusion with 4 balloon occlusions, each lasting 60 s, followed by 60 seconds of reperfusion. Cardiac magnetic resonance was performed in all subjects within 48 to 96 h after admission. To evaluate the infarct size and MVO, the late gadolinium enhancement (LGE) technique was used. Infarct size was defined as an area greater than 50% of the maximal signal intensity within LGE. MVO was defined as the area of the absence or hypoenhancement of contrast surrounded by LGE. Infarct size and MVO were determined by planimetry and the summation of discs method.ResultsPostcon was associated with significantly smaller IS (16.42 ±9.6 vs. 31.2 ±22.2 g; p = 0.007) and higher ejection fraction (59.8 ±9.2% vs. 52.3 ±10.2%). The extent of MVO was significantly lower in the postcon group in comparison to the control group (0.76 ±1.4 g vs. 2.2 ±3.2 g; p = 0.03).ConclusionsIn early presenters with STEMI postcon could significantly reduce infarct size and limit reperfusion injury.

Scientist Led Exercise Stress Testing is Safe with the Equivalent Diagnostic Interpretation as a Cardiologist in Low to Intermediate Risk Patients

Background: The implementation of non-physician led exercise stress testing (EST) has increased over the last 30 years, with endorsement by many cardiovascular societies around the world. The comparable safety of non-physician led EST to physician led studies has been demonstrated, with some studies also showing agreement in diagnostic preliminary interpretations. The study aim was to firstly confirm the safety of non-physician led EST in a large cohort and secondly compare the diagnostic accuracy of cardiac scientist and junior medical officer (JMO) led EST reports to cardiology consultant overreads. Methods: All ESTs performed between 1/7/2010 and 30/6/2013 were included in the study for JMO led tests (n = 1332). ESTs performed for the investigation of coronary artery disease between 1/7/2013 and 30/6/2016 were included for scientist led testing (n = 1904). Preliminary findings by the JMO and the senior cardiac scientist were compared to the cardiology consultant overread to establish diagnostic accuracy. Results: There was one adverse event, an ST segment myocardial infarction during the recovery phase of a JMO led EST. Disease prevalence was similar in the JMO and scientist led groups (p = 0.77). Sensitivity for JMO led tests differed from the cardiologist overread (86.96% vs 96.77%, p = 0.03). There were no other significant differences between the cardiologist overread and the JMO or scientist led interpretation. Conclusion: Scientist led EST is safe in low/intermediate risk patients and their preliminary reports are equally diagnostic as cardiologist overreads. While JMO led ESTs are just as safe, the preliminary reports differ significantly from cardiologist overread with respect to sensitivity.

Comparison of In-Hospital Outcomes of Patients With-Versus-Without Ischemic Cardiomyopathy Undergoing Left Ventricular Assist Device Placement

The objective of this study was to evaluate the impact of heart failure (HF) etiology (ischemic cardiomyopathy [ICM] versus nonischemic cardiomyopathy) on in-hospital outcomes in patients undergoing left ventricular assist device (LVAD) placement using the Nationwide Inpatient Sample database. We identified patients who underwent LVAD placement from 2011 to 2014. The primary end point was the effect of ICM on in-hospital mortality. Secondary end points included periprocedural vascular complications requiring surgery, postoperative myocardial infarction, stroke, and hemorrhage requiring transfusion. We also assessed length of stay and cost of hospitalization. A mixed effects logistic model was used for clinical end points and a linear mixed model was used for cost and length of stay. In 3,511 patients who underwent LVAD placement (23.32% women and 56.23 ± 13.51 years old), the incidence of ICM was 53.5%. After adjusting for patient- and hospital-level characteristics, ICM was not found to influence in-hospital mortality (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.78 to 1.23). ICM was associated with an increased risk in periprocedural hemorrhage requiring transfusion (OR 1.29, 95% CI 1.08 to 1.53), vascular complications requiring surgery (OR 1.58 95% CI 1.10 to 2.28) and postoperative ST-segment myocardial infarction (OR 7.38 95% CI 5.33 to 10.24). In conclusion, ICM did not impact in-hospital mortality in patients who underwent LVAD placement but was associated with increased vascular complications, hemorrhage requiring transfusion, and postoperative myocardial infarction.

Transient ST-segment myocardial infarction: a new category of high risk acute coronary syndrome?

Transient ST-segment myocardial infarction: a new category of high risk acute coronary syndrome?