Stable ST-elevation Myocardial Infarction Research Articles

Safety, feasibility and efficacy of sonothrombolysis with micro boluses of perfluoropropane as a point of care therapy for patients with acute ST-elevation myocardial infarction.

Despite advances in timely revascularisation of ST elevation myocardial infarction (STEMI) patients, there are several practical and unavoidable delays. Sonothrombolysis (administered during micro boluses of Perfluoropropane) initiated bedside as a point-of-care therapy during the initial evaluation of the patient may potentially mitigate this by producing early culprit vessel revascularisation. This was a prospective, single-centre study on hemodynamically stable patients presenting within 12 hours of a first STEMI who consented for study participation. Fifteen patients were recruited over a 1-month period. Eleven were male. Nine patients had anterior wall STEMI and left anterior descending as culprit vessel. There were no significant changes in safety outcomes. Median First Medical Contact (FMC)-Sono time was 12 min (10-15). Median duration of sonothrombolysis was 14 min (12-16). FMC-device time was 97 min (79-128). Six patients had culprit vessel recanalisation before primary percutaneous coronary intervention (PPCI) which was consistent with the reference rates of therapy-associated recanalisation (p = 0.535). Micro bolus sonothrombolysis maybe safely initiated as a point of care therapy adjunctive to PPCI in hemodynamically stable STEMI patients with reasonable efficacy. Further randomised trials are needed to ascertain its applicability in various geographical and clinical settings.

Safety and Adverse Events During Primary Care Paramedic Interfacility Transfer of Stable STEMI Patients

Objective Current guidelines recommend that patients presenting with ST-elevation myocardial infarction (STEMI) to hospitals not capable of performing primary percutaneous coronary intervention (PCI) be transferred to a PCI-capable hospital if reperfusion can be accomplished within 120 min. Most STEMI patients are accompanied by an advanced care paramedic (ACP, equivalent to EMT-P), nurse, or physician who can manage complications should they arise. In our region, stable STEMI patients are transported by primary care paramedics (PCPs, similar scope of practice to advanced EMT) in cases where a nurse, physician, or ACP paramedic is not available. Our goal was to describe adverse events and need for advanced interventions among initially stable STEMI patients during interfacility transfer by PCPs. Methods We reviewed ambulance and hospital records of initially stable STEMI patients (as determined by first set of vital signs documented by paramedics) transferred to a PCI-capable hospital by PCPs between March 1, 2014, and December 31, 2019. We identified whether pre-determined adverse clinical events occurred during the transport as well as the potential need for advanced care interventions not within the PCP scope of practice. Adverse events upon arrival in the PCI lab were also identified. Results Of 346 STEMI patients transferred, 179 met inclusion criteria. The mean age of included patients was 61 years (SD 12.1) and 74.9% (134/179) were male. Median transport interval was 36 min (IQR 3.0). During transport, 47/179 (26.0%) patients experienced pre-defined adverse events; for 16/47 (34%), one or more adverse events was major. Three patients met criteria for ACP interventions. One patient suffered a cardiac arrest and was promptly resuscitated with defibrillation by the PCPs. Conclusions We found PCP-interfacility transport of initially stable STEMI patients was safe and associated with a moderate proportion of adverse events, the majority of which did not require an advanced care intervention. These findings may help decision-making to avoid delays transferring stable patients to PCI-capable centers.

Transcription factor 21 rs12190287 polymorphism is related to stable angina and ST elevation myocardial infarction in a Chinese Population.

Background: Transcription factor 21 (TCF21, epicardin, capsuling, pod-1) is expressed in the epicardium and is involved in the regulation of cell fate and differentiation via epithelial-mesenchymal transformation during development of the heart. In addition, TCF21 can suppress the differentiation of epicardial cells into vascular smooth muscle cells and promote cardiac fibroblast development. This study aimed to explore whether TCF21 gene (12190287G/C) variants affect coronary artery disease risk. Methods: We enrolled 381 patients who had stable angina, 138 with ST elevation myocardial infarction (STEMI), and 276 healthy subjects. Genotyping of rs12190287 of the TCF21 gene was performed. Results: Higher frequencies of the CC genotype were found in the patients with stable angina/STEMI than in the healthy controls. After adjusting for diabetes mellitus, hypertension, age, sex, smoking, body mass index and hyperlipidemia, the patients with the CC genotype of the TCF21 gene were associated with 2.49- and 9.19-fold increased risks of stable angina and STEMI, respectively, compared to the patients with the GG genotype. Furthermore, TCF21 CC genotypes showed positive correlations with both stable angina and STEMI, whereas TCF21 GG genotypes exhibited a negative correlation with STEMI. Moreover, the stable angina and STEMI patients with the CC genotype had significantly elevated high-sensitivity C-reactive protein levels than those with the GG genotype. In addition, significant associations were found between type 2 diabetes mellitus, hypertension, and hyperlipidemia with TCF21 gene polymorphisms (p for trend < 0.05). Conclusion: TCF21 gene polymorphisms may increase susceptibility to stable angina and STEMI.

Outcome following late reperfusion with PCI in stable patients with ST-segment elevation myocardial infarction presenting more than 12 hours from onset of symptoms

Abstract Funding Acknowledgements Type of funding sources: None. Introduction 8-40% of patients with acute ST-elevation myocardial infarction (STEMI) present later than 12 hours after symptom onset. According to guidelines these late presenters maintain indication for primary percutaneous coronary intervention (PCI) when there are signs of ongoing ischemia. However, it prevails uncertainty in relation to the best approach in stable late presenters. Aims Describe the profile of stable late STEMI presenters and evaluate the trends of reperfusion decision in the Portuguese reality; compare early term outcomes between patients submitted to emergent primary PCI and those in which it was preferred an initial conservative approach. Methods Retrospective analysis of patients with STEMI presenting ≥12-48h hours after the beginning of the symptoms between October 2010 and December 2019 without evidence of ongoing ischemia, inserted in a national registry of acute coronary syndromes. Patients were dichotomized and compared according to whether or not were submitted to emergent reperfusion based on primary PCI. Results 274 patients were included (2.3% of all STEMI), predominantly men (67.5%), with a mean age of 68±13 years old. Emergent PCI was performed in a minority (15.7%; n=43); even so, coronarography ended up being executed in 61.3% of the admissions, with angioplasty performed in 47.1% of the cases. Right coronary artery was the most common intervened vessel (50.8%). Inotropes were necessary in 4.6% of the patients, with no reports of ventricular assistance device use. Mean ejection fraction was 51±12% with no differences between groups. Patients submitted to emergent PCI (15.7%) had a lower prevalence of atrial fibrillation (0 vs. 9.3%, p=0.04) and had more commonly electrocardiographic criteria for anterior STEMI (64.3% vs. 41.4%, p=0.006). Nitrates were significantly less prescribed at discharge in this subgroup (4.9% vs. 26.8%; p=0.002). Apart from aborted cardiac arrest, that was more prevalent in patients submitted to emergent reperfusion (4.8% vs. 0.9%, p=0.12), it was observed a tendency toward a lower percentage in this subgroup in all other early hard clinical outcomes such as re-infarction (0 vs. 0.4%, p=1.00), mechanical complications (0 vs. 2.2%; p=1.00), sustained ventricular tachycardia (0 vs. 0.9%, p=1.00) and in-hospital death (0% vs. 4.4%, p=0.37). However, none of the differences have reached statistical significance. Conclusion The study shows that, in the Portuguese reality, emergent reperfusion is adopted in only a minority of late stable STEMI patients, with a clear tendency to perform it more frequently in subacute anterior STEMI. Emergent PCI strategy did not show a clear benefit in terms of left ventricular function, risk of re-infarction, arrhythmic and mechanical complications, and in-hospital death. On the other hand, there was apparently a significant advantage of this strategy in ischemic symptom control.

CLINICAL AND ANGIOGRAPHIC PROFILE OF CORONARY ARTERY DISEASE IN YOUNG WOMEN - A TERTIARY CARE CENTRE STUDY FROM NORTH EASTERN INDIA

Background: Coronary artery disease (CAD) is the biggest killerof women globally.CAD among young women as a group is less easily recognized worldwide. Young women are underrepresented in most of theCAD studies. This study assessed Clinical and angiographic profile of CAD in young women of North-East India to have a better understanding of the nature and courseof the disease. Material and Methods:This was a prospective, observational, single centre analytical study. Totalparticipants were divided into 2 groups – young women less than 55 years and old women more than or equal to 55 years.Modes ofpresentation,riskfactors,clinicalandangiographicprofileofCADwere compared. Risk factors studied were smoking, hypertension, diabetes mellitus,dyslipidaemia, obesity and family history of prematureCAD.CADseveritywas assessedby SyntaxscoreandGensiniscore. Results: A total of 143women were studied. Out of these 57 women were &lt;55 years and 86 women were ≥ 55years of age. Hypertensionwasthe mostcommonriskfactor foundin both groups of women followed by diabetes and dyslipidaemia. Most common presentation among youngerwomen were chronic stable anginafollowed by ST elevation myocardial infarction (STEMI). In younger women most of them had normal Left Ventricular Ejection Fraction, 54.4 % vs 41.9% of patients(p=0.04).Younger women had normal coronaries in19.3% vs. 9.3% in older women (p=0.072).Younger women had significantly lower number of multivessel diseases than older women, 29.8% vs 44.18% (p = 0.045). Left Anterior Descending coronary artery (LAD) was the most common coronary artery involved in both groups (43.9% vs 52.3%). Low Syntax score (≤22) and lowGensini score (≤20) were found in younger women 75.4% vs older women 67.4% (p=0.201)and 56.1% vs. 40.7% (p=0.05), respectively. The increase in Syntax and Gensini score with increase in number of risk factors were found to be statistically significant in both the groups. Conclusion: In younger women, most of the patients presented withchronic stable angina and STEMI with a preceding history of angina. Hypertension and diabetes were most common risk factors both being modifiable needsutmost attention for prevention. Coronary angiography revealedless severe CAD in younger women than older women as assessed by coronary severity score.

Revascularization strategies in STEMI and multivessel disease

Introduction The main treatment for ST-elevation myocardial infarction (STEMI) is the re-establishment of the coronary flow of infarct-related arteries. However, 50% of cases present multivessel disease (MVD), negatively affecting mortality. Complete revascularization (CR) is currently advocated since it reduces major adverse cardiovascular events (MACE). Objective Evaluation of the adopted revascularization strategy and its prognostic value in a Portuguese cohort of STEMI patients with MVD. Material and methods Retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes between 2010 and 2019. Patients were divided in two groups regarding revascularization strategy (complete versus incomplete) and compared. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression. Results A total of 3500 patients were included. A CR strategy was performed in 21.8% of patients, who were younger and healthier. They also presented more hemodynamically stable and had less kidney dysfunction and anaemia. Their coronary anatomy was less complex, with a higher prevalence of 2-vessel and a lower proportion of chronic occlusions. In-hospital and 1-year adverse events were less frequent between patients with CR. Conclusion In hemodynamically stable STEMI patients, CR substantially reduced in-hospital and 1-year all-cause mortality and MACE.

Association between Neutrophil to Lymphocyte Ratio and the Extent of Coronary Artery Disease in Patients with STEMI Versus Patients With Stable Angina Undergoing PCI: An Idea for Investigation of Other Inflammatory Diseases

Background: Inflammation plays an important role in the pathogenesis of diseases such as atherosclerosis and other inflammatory disorders. The inflammatory markers impose a considerable cost on the health system. Recently, neutrophil to lymphocyte ratio (NLR) has been shown to be involved in the prediction of coronary artery disease (CAD). Objectives: This study was conducted to clarify the potential relationship between NLR and the inflammatory extent of CAD. Materials and Methods: Patients with ST-elevation myocardial infarction (STEMI) or stable angina who underwent primary or elective percutaneous coronary intervention (PCI), respectively, were included in this cross-sectional study. Patients with hematologic disorders, recent or active infectious or inflammatory diseases, history of malignancy, and history of treatment with immunosuppressive drugs were excluded from the study. Gensini and SYNTAX scores were calculated for each patient as an indicator of the extent of CAD. Demographic and clinical characteristics were obtained through a questionnaire and NLR was calculated using laboratory results. Results: A total of 446 patients (223 patients in each group) fulfilled the inclusion criteria. NLR had a significant relationship with Gensini score in both stable angina and STEMI patients. Gensini and SYNTAX scores correlated significantly with NLR; however, the correlation was weaker for SYNTAX score. After adjustment for confounding factors, including age and hypercholesterolemia, only one trend remained for the Gensini scores. Conclusion: NLR showed a stronger correlation with Gensini score than SYNTAX score. Our findings are in accordance with previous studies, which show that NLR has a relationship with the extent of CAD. Further studies are required for reaching a definite conclusion. The idea of this study may be useful for the investigation of other inflammatory diseases.

Beneficial Effects of Baduanjin Exercise on Left Ventricular Remodelling in Patients after Acute Myocardial Infarction: an Exploratory Clinical Trial and Proteomic Analysis.

The beneficial effects of physical exercise on cardiac remodelling improvement after myocardial infarction have already been suggested. However, the results of previous clinical trials have not been consistent. Moreover, the putative molecular mechanisms leading to the clinically observed effects of physical exercise still remain elusive. We aimed to evaluate whether the well-defined and strictly controlled traditional Chinese Qigong Baduanjin exercise (BE) would attenuate the adverse left ventricular (LV) remodelling in patients with ST-elevation myocardial infarction (STEMI). A total of 110 clinically stable STEMI patients, following successful revascularization of their infarcted coronary arteries, were randomized and enrolled in two groups: 56 were subjected to a 12-week BE-based cardiac rehabilitation programme (BE group), and the remaining 54 were exposed to the usual physical exercise (control group) for the same time period. The primary outcome was the change from baseline to 6months in the echocardiographic LV end-diastolic volume index (ΔLVEDVi). Proteomic analysis was also performed to uncover associated mechanisms. Compared with the control group, the BE group showed significantly lower ΔLVEDVi (-5.1 ± 1.1 vs. 0.3 ± 1.2mL/m2, P < 0.01). Proteomic analysis revealed BE-induced variations in the expression of 80 proteins linked to regulation the of metabolic process, immune process, and extracellular matrix reorganization. Furthermore, correlation analyses between the validated serum proteomes and primary endpoint demonstrated a positive association between ΔLVEDVi and MMP-9 expression, but a negative correlation between ΔLVEDVi and CXCL1 expression. This is the first study indicating that BE in STEMI patients can alleviate adverse LV remodelling associated with beneficial energy metabolism adaptation, inflammation curbing, and extracellular matrix organization adjustment.

Impact of Routine 24 Hour Coronary Care Unit Stay in Stable Patients After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

With the routine use of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), the rate of short-term complications is low and the optimal length-of-stay in the coronary care unit (CCU) following reperfusion is unknown. We hypothesized that the rate of complications would not differ between two groups of stable patients admitted to the CCU following primary-PCI for STEMI: (1) those for whom a minimum 24-hour stay was enforced (≥24 hour Standard Stay) and (2) those with no minimum length-of-stay (Physician-guided Stay). Data were collected retrospectively. We performed a regression analysis to determine predictors of the primary endpoint (a composite of in-hospital death, re-infarction and/or re-intervention, heart failure requiring intravenous diuretics, cardiac arrest, central nervous system and/or peripheral embolization, bleeding requiring transfusion, arrhythmia resulting in initiation of a class I or III antiarrhythmic drug, initiation of assisted ventilation, requirement for vasopressors or inotropes, or transfer to intensive care). A total of 242 patients were included in the analysis. The rate of the primary endpoint was 8% in the physician-guided stay group and 16% in the standard ≥24 hour stay group (p = 0.06). The most common complication in both groups was heart failure requiring diuretics (42%), which was predicted by the left ventricular end diastolic pressure on catheterization (area under the Receiver-Operator Curve of 0.75). In conclusion, Patients who are stable following primary PCI for STEMI have a low rate of complications. Stable STEMI patients do not appear to benefit from a mandatory ≥24 hours stay in the CCU.

2232Circulating levels of ST2 are associated with myocardial injury, left ventricular function and future adverse clinical events in patients with ST-elevation myocardial infarction

Abstract Background Soluble ST2, a member of the IL-1 receptor family, seems to be associated with adverse outcome in acute myocardial infarction and heart failure (HF), and is suggested to be involved in left ventricular (LV) remodelling. Purpose To elucidate a possible role of ST2 in LV injury, remodelling and prognosis in ST-elevation myocardial infarction (STEMI) patients. The main objectives of the study were to investigate whether circulating ST2 levels were associated with infarct size, LV function, adverse remodeling and clinical outcome in a cohort of patients with STEMI. Methods 270 patients with clinically stable first-time STEMI treated with primary percutaneous coronary intervention (PCI) were included. Blood samples were drawn before and immediately after the PCI procedure, at day 1 (median 18.3 hours after PCI) and after 4 months. Cardiac magnetic resonance (CMR) was performed in the acute phase and after 4 months. Clinical events and all-cause mortality were registered during 12 months' and 70 months' follow-up, respectively. A composite endpoint was defined as death, MI, unscheduled revascularisation &gt;3 months after the index infarction, rehospitalisation for HF or stroke. Associations between ST2 and CMR parameters and clinical events were evaluated with linear regression and logistic regression, respectively. Results There was a significant increase in ST2 levels from the PCI procedure to day 1 with a subsequent decline from day 1 to 4 months in the POSTEMI cohort. Patients with high ST2 levels (&gt;median) at all sampling points during hospitalisation had significantly larger infarct size, lower myocardial salvage, lower LVEF, larger increase in EDV and higher frequency of MVO. After adjustment for relevant clinical variables, peak CRP and peak troponin T, ST2 measured at day 1 remained associated with infarct size (β 2.0 per SD of ST2, p&lt;0.001) and LVEF (β −1.8 per SD of ST2, p=0.02) at 4 months. High levels of ST2 measured at day 1 (&gt;75th percentile) were associated with increased risk of having an adverse clinical event during the first year and with long-term all-cause mortality (Figure). High levels of ST2 measured in a stable phase 4 months after STEMI were also associated with an increased risk of all-cause mortality (Figure). Figure 1 Conclusions High levels of ST2 in STEMI patients were associated with large infarct size, impaired recovery of LV function, and adverse clinical outcome in patients with STEMI. ST2 measured 4 months after STEMI remained associated with all-cause mortality.

Chip-based digital PCR as a novel detection method for quantifying microRNAs in acute myocardial infarction patients.

miRNAs have shown promise as potential biomarkers for acute myocardial infarction (AMI). However, the current used quantitative real-time PCR (qRT-PCR) allows solely for relative expression of nucleic acids and it is susceptible to day-to-day variability, which has limited the validity of using the miRNAs as biomarkers. In this study we explored the technical qualities and diagnostic potential of a new technique, chip-based digital PCR, in quantifying the miRNAs in patients with AMI and ischaemia-reperfusion injury (I/R). In a dilution series of synthetic C.elegans-miR-39, chip-based digital PCR displayed a lower coefficient of variation (8.9% vs 46.3%) and a lower limit of detection (0.2 copies/μL vs 1.1 copies/μL) compared with qRT-PCR. In the serum collected from 24 patients with ST-elevation myocardial infarction (STEMI) and 20 patients with stable coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI), we used qRT-PCR and multiplexed chip-based digital PCR to quantify the serum levels of miRNA-21 and miRNA-499 as they have been validated in AMI in prior studies. In STEMI, I/R injury was assessed via measurement of ST-segment resolution (ST-R). Chip-based digital PCR revealed a statistical significance in the difference of miR-21 levels between stable CAD and STEMI groups (118.8 copies/μL vs 59 copies/μL; P=0.0300), whereas qRT-PCR was unable to reach significance (136.4 copies/μL vs 122.8 copies/μL; P=0.2273). For miR-499 levels, both chip-based digital PCR and qRT-PCR revealed statistically significant differences between stable CAD and STEMI groups (2 copies/μL vs 8.5 copies/μL, P=0.0011; 0 copies/μL vs 19.4 copies/μL; P<0.0001). There was no association between miR-21/499 levels and ST-R post-PCI. Our results show that the chip-based digital PCR exhibits superior technical qualities and promises to be a superior method for quantifying miRNA levels in the circulation, which may become a more accurate and reproducible method for directly quantifying miRNAs, particularly for use in large multi-centre clinical trials.

Is multivessel intervention in ST-elevation myocardial infarction associated with early harm? Insights from observational data.

Appraisal of evidence for recommendations for multivessel coronary intervention in ST-elevation myocardial infarction (STEMI). Multi-vessel disease (MVD) is common in patients with ST-segment elevation myocardial infarction (STEMI). Published observational data has suggested that multi-vessel percutaneous coronary intervention (MVPCI) at the time of initial hospitalization for STEMI may be harmful in contrast to evidence from recent randomized trials. We queried the nationwide inpatient sample (NIS) to identify characteristics of hemodynamically stable STEMI patients undergoing MVPCI on index admission and subsequent mortality in raw and adjusted models. To compare our results with published observational data, we searched multiple databases from inception through July 15, 2015. From 2009-2012, excluding cardiac arrest or cardiogenic shock, there were 11,454 MVPCI and 157,011 single-vessel PCI (SVPCI) for STEMI patients in the NIS. Compared to SVPCI, MVPCI on index admission was not associated with higher in-hospital mortality in unadjusted or propensity-adjusted models (MVPCI 1.91% vs. SVPCI 5.32%, P < 0.001). Our analysis of index hospitalization MVPCI versus infarct-related artery (IRA)-only PCI in the meta-analysis of observational studies (19 studies, N = 76,399) demonstrated no difference in in-hospital mortality with MVPCI compared with IRA-only PCI (OR 0.87, 95% CI 0.65-1.17; P = 0.37), with confirmation in study sequential analysis. MVPCI is uncommonly performed during index hospitalization in hemodynamically stable STEMI patients, likely reflecting widespread adherence to prior guidelines. Based on observational data, there does not appear to be early harm associated with MVPCI on the index admission in hemodynamically stable STEMI patients. © 2016 Wiley Periodicals, Inc.

High-sensitivity troponin T for prediction of left ventricular function and infarct size one year following ST-elevation myocardial infarction

BackgroundData relating high-sensitivity cardiac troponin T (hs-cTnT) to long-term myocardial function and infarct size in patients after ST-elevation myocardial infarction (STEMI) are lacking. We aimed to evaluate the use of early hs-cTnT concentrations for prediction of myocardial function and infarct size assessed by cardiac magnetic resonance imaging (CMR) one year following STEMI. MethodsSixty-six patients, revascularized by primary percutaneous coronary intervention (PCI) for first-time STEMI, were enrolled in this observational study. Serial hs-cTnT, creatine kinase (CK), high-sensitivity C-reactive protein (hs-CRP) and lactate dehydrogenase (LDH) levels were measured on admission, 6h, 12h, and 24h post-PCI. Patients underwent CMR within the first week and 12months thereafter. ResultsExcept for admission hs-cTnT, all single time point and peak hs-cTnT concentrations showed significant correlations with left ventricular ejection fraction (LVEF: r=−0.404 to −0.517, all ps<0.01) and infarct size (IS: r=0.421 to 0.700, all ps<0.01) at baseline and follow-up. The area under the curve (AUC) of peak hs-cTnT was 0.82 (95% CI 0.71–0.92) for the prediction of decreased LVEF (<55%) and 0.89 (95% CI 0.81–0.97) for the prediction of large IS (>8%) at 12months. The combination of all four biomarkers resulted in an AUC of 0.82 and 0.92 for the prediction of reduced LVEF and large IS at 12months, respectively (both ps>0.05). ConclusionIn stable STEMI patients successfully revascularized by primary PCI, serial and peak concentrations of hs-cTnT are closely correlated to long-term LVEF and IS. Combination of hs-cTnT with CK, hs-CRP, or LDH did not add any significant prognostic value as compared with hs-cTnT alone.

PCI in Post Thrombolysis Stable STEMI Patients: A Timeline in Question

ST elevation myocardial infarction (STEMI) occupies a significant portion of the cardiovascular disease spectrum and poses a continuing challenge on the health care delivery system worldwide. A dilemma exists in the clinical triage system for appropriate strategic modalities of treatment, based on underlying triad of patient-hospital-cardiac pathological factors as well as cut off timelines. Current European Society of Cardiology (ESC) guideline recommends percutaneous coronary intervention (PCI) within 3 to 24 hours in post thrombolysis stable patients. This review critically evaluated the evidences underlying the ESC recommendation. Trials included in this review are SIAM III, GRACIA 1, CAPITAL-AMI, CARESS-IN-AMI, NORDISTEMI, PRAGUE-1, WEST and LEIPZIG. Most of the evidences support the notion for immediate post thrombolysis PCI in stable patients within 1.9 to 2.7 hours, which contradicts the ESC timeline of up to 24 hours. Also, there is a reduced generalizability of the trial results due to differences in the design of the various trials, study population, composite endpoints, variations in drug dose & formulation, co-administration of pharmacotherapies and type of stents used. This warrants further research for standardization & optimization of the treatment protocol with respect to post thrombolysis PCI in stable STEMI patients.

CLINICAL OUTCOMES OF EARLY REPATRIATION FOR PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION: A PROPENSITY-MATCHED ANALYSIS

Given limitations on hospitals resources, patients with ST elevation myocardial infarction (STEMI) who undergo successful primary percutaneous coronary intervention (PCI) are often repatriated to non-PCI centers. However, the safety of this practice is not clear, given the transfer of care. Our objective was to evaluate the safety of early repatriation of stable STEMI patients post primary PCI, compared to ongoing treatment at the PCI center. Consecutive STEMI patients who received primary PCI at four PCI hospitals in Toronto, Canada between 2010 and 2012 were identified. Patients in cardiogenic shock or who died within 24 hours of presentation were excluded. In order to account for potential confounders, propensity score matching of repatriated vs. non-repatriated patients was performed. The primary outcomes were 1-year all-cause mortality and re-admission for recurrent myocardial infarction (MI). Secondary outcomes were 30-day all-cause mortality, 30-day re-admission for MI, mean first medical contact to balloon time (minutes) and mean length of stay (days). The overall cohort consisted of 1445 patients, of whom 792 (55%) were repatriated. Patients were repatriated within 1.5 days on average (median 1 day, 95% confidence interval (CI) 1.37-1.63 days). Using the propensity score, 427 well-matched pairs were identified. There was no significant difference between repatriated and non-repatriated groups in 1-year mortality (repatriated 6.6%; non-repatriated 5.6%; Hazard ratio (HR) 1.14, 95% CI 0.66-1.97, p= 0.629). The 1-year re-admission rates for MI were significantly greater for the repatriated group (repatriated: 11.5 %, non-repatriated: 5.9%; HR 1.97, 95% CI 1.22-3.19, p= 0.006). These findings were consistent in the 30-day outcomes (30-day mortality: 2.6% and 4.9% for repatriated and non-repatriated, p-value=0.072; 30-day re-admission for MI 5.6% and 1.9% for repatriated and non-repatriated, p-value =0.004). The mean contact to balloon time was comparable in both groups (repatriated 138 minutes, 95% CI 121-156; non-repatriated 150 minutes, 95% CI 129-172, p= 0.405). Similarly, the mean length of total hospital stay was comparable in both groups (repatriated 6 days, 95% CI 5-6; non-repatriated 5.5 days, 95% CI 4-7, p= 0.947). A strategy of early repatriation of STEMI patients was associated with an increase in re-admission for MI. Our study revisits the safety associated with an early repatriation strategy. Further research is needed to address challenges involved with transfer of care between medical institutions in this population.

CLINICAL BENEFIT OF PERCUTANEOUS CORONARY INTERVENTION IN EARLY LATECOMERS WITH ACUTE ST-ELEVATION MYOCARDIAL INFARCTION

Clinical benefit of percutaneous coronary intervention (PCI) is controversial in stable patients with ST-elevation myocardial infarction (STEMI) presenting between 12 and 72 hours after the symptom onset. We analyzed 2,640 stable STEMI patients with symptom-to-door time between 12 and 72 hours.

Thrombolysis Followed by Early Revascularization: An Effective Reperfusion Strategy in Real World Patients with ST-Elevation Myocardial Infarction

Background: Several trials suggested superiority of primary percutaneous coronary intervention (PPCI) angioplasty over thrombolysis in patients with ST-elevation myocardial infarction (STEMI), but many trials were characterized by low rates of early revascularization in patients treated with initial thrombolysis. We tested the hypothesis that in patients with hemodynamically stable STEMI, initial thrombolysis followed by an active early rescue/definitive revascularization strategy could achieve salutary short- and long-term outcomes. Methods: A prospective registry documented all 212 STEMI patients who received initial thrombolytic therapy over a 2-year period in a single medical center. Median patient age was 58 (range: 29–92) years, 47 (22%) patients were aged >70 years and 18 (8%) >80 years. Fifty-two (25%) patients underwent rescue angioplasty <6 h after thrombolysis for inadequate clinical reperfusion. In 194/212 (92%) patients, coronary angiography was performed during initial hospitalization, PCI in 168 (79%), and coronary bypass surgery in 18 (8%). Results: Thirty-day mortality was 4.7% and 1-year mortality 6.7%. Mortality was not related to diabetes mellitus, hypertension, anterior infarction location, fibrin-specific thrombolytic drug or rescue PCI. By multivariate analysis, in-hospital definitive angiography/revascularization (p < 0.0001) and TIMI risk score >3 on admission (p < 0.01) were significant independent predictors of both 30 day and 12 month outcome. Conclusions: Initial thrombolysis was useful and effective in real-world STEMI patients when coupled with an aggressive policy of rescue angioplasty and early in-hospital revascularization. Outcomes compared favorably with those reported for PPCI trials. The adverse prognosis in older patients with higher TIMI risk score suggests that in those patients alternative initial treatment strategies such as PPCI should be considered.