Successful Primary Primary Percutaneous Coronary Intervention Research Articles

Assessment of Residual Vasospasm in Patients with Plaque Rupture or Plaque Erosion using Optical Coherence Tomography.

Coronary vasospasm is associated with acute coronary syndrome (ACS) and may persist during primary percutaneous coronary intervention (PCI). We aimed to elucidate the incidence, morphological characteristics, and prognostic impact of residual vasospasm in plaque rupture (PR) and plaque erosion (PE) lesions using optical coherence tomography (OCT). We enrolled 142 patients with ACS who underwent OCT-guided primary PCI. All patients received intracoronary vasodilators before OCT examination. Residual vasospasm was identified as intimal gathering and categorised as polygonal- or wavy- patterned depending on the luminal shape. A wavy pattern was defined as a curved intimal surface line. A polygonal pattern was defined as a lumen with multiple angles. The incidence of major cardiovascular events, defined as death, non-fatal myocardial infarction, stroke, and any revascularization, within 1-year of PCI was identified. The prevalence of residual vasospasm in PR and PE was 15.1% (13 of 86) and 21.4% (12 of 56), respectively. Wavy pattern was the major shape of the residual vasospasm. Polygonal-patterned lumen was more frequently observed in PR than in PE (38.5 vs. 8.3 %). The polygonal-patterned lumens had significantly larger lipid arcs (257.9 vs. 78.0 °; P＜0.01), and significantly smaller areas (1.27 vs. 1.88 mm2; P=0.05) than wavy-patterned lumens. Residual vasospasm had a prognostic impact on PR but not PE at 1-year of successful primary PCI. Considerable proportion of ACS including both PR and PE had residual vasospasm with variable morphological feature and different prognostic impact.

Coronary Microvascular Function Assessment using the Coronary Angiography-Derived Index of Microcirculatory Resistance in Patients with ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

Studies reporting the status of coronary microvascular function in the infarct-related artery (IRA) after primary percutaneous coronary intervention (PCI) remain limited. This study utilized the coronary angiography-derived index of microcirculatory resistance (caIMR) to assess coronary microvascular function in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI. We used the FlashAngio system to measure the caIMR after primary PCI in 157 patients with STEMI. The primary endpoint was the occurrence of a major adverse cardiovascular event (MACE), defined as a composite endpoint encompassing cardiac mortality, target vessel revascularization, and rehospitalization due to congestive heart failure (CHF), myocardial infarction (MI), or angina. Approximately 30% of patients diagnosed with STEMI and who experienced successful primary PCI during the study period had a caIMR in the IRA of 40. The caIMR in the IRA was significantly higher than in the reference vessel (32.9 15.8 vs. 27.4 11.1, p 0.001). The caIMR in the reference vessel of the caIMR 40 group was greater than in the caIMR 40 group (30.9 11.3 vs. 25.9 10.7, p = 0.009). Moreover, the caIMR 40 group had higher incidence rates of MACEs at 3 months (25.5% vs. 8.3%, p = 0.009) and 1 year (29.8% vs. 13.9%, p = 0.04), than in the caIMR 40 group, which were mainly driven by a higher rate of rehospitalization due to CHF, MI, or angina. A caIMR in the IRA of 40 was an independent predictor of a MACE at 3 months (hazard ratio (HR): 3.459, 95% confidence interval (CI): 1.363-8.779, p = 0.009) and 1 year (HR: 2.384, 95% CI: 1.100-5.166, p = 0.03) in patients with STEMI after primary PCI. Patients with STEMI after primary PCI often have coronary microvascular dysfunction, which is indicated by an increased caIMR in the IRA. An elevated caIMR of 40 in the IRA was associated with an increased risk of adverse outcomes in STEMI patients undergoing primary PCI.

Factors of Hospital Mortality in Men and Women with ST-Elevation Myocardial Infarction - An Observational, Retrospective, Single Centre Study.

There are well-known gender differences in mortality of patients with ST-elevation myocardial infarction (STEMI). Our purpose was to assess factors of hospital mortality separately for men and women with STEMI, which are less well known. In 2018-2019, 485 men and 214 women with STEMI underwent treatment with primary percutaneous coronary intervention (PCI). We retrospectively compared baseline characteristics, treatments and hospital complications between men and women, as well as between nonsurviving and surviving men and women with STEMI. Primary PCI was performed in 94% of men and 91.1% of women with STEMI, respectively. The in-hospital mortality was significantly higher in women than in men (14% vs 8%, p=0.019). Hospital mortality in both genders was associated significantly to older age, heart failure, prior resuscitation, acute kidney injury, to less likely performed and less successful primary PCI and additionally in men to hospital infection and in women to bleeding. In men and women ≥65 years, mortality was similar (13.3% vs 17.8%, p = 0.293). Factors of hospital mortality were similar in men and women with STEMI, except bleeding was more likely observed in nonsurviving women and infection in nonsurviving men.

Long-Term Prognosis of Different Reperfusion Strategies for ST-Segment Elevation Myocardial Infarction in Chinese County-Level Hospitals: Insight from China Acute Myocardial Infarction Registry

ObjectiveTo evaluate the long-term prognosis of patients with ST-segment elevation myocardial infarction (STEMI) treated with different reperfusion strategies in Chinese county-level hospitals MethodsA total of 2,514 patients with STEMI from 32 hospitals participated in the China Acute Myocardial Infarction registry between January 2013 and September 2014. The success of fibrinolysis was assessed according to indirect measures of vascular recanalization. The primary outcome was 2-year mortality. ResultsReperfusion therapy was used in 1,080 patients (42.9%): fibrinolysis (n = 664, 61.5%) and primary percutaneous coronary intervention (PCI) (n = 416, 38.5%). The most common reason for missing reperfusion therapy was a prehospital delay > 12 h (43%). Fibrinolysis [14.5%, hazard ratio (HR): 0.59, 95% confidence interval (CI) 0.44–0.80] and primary PCI (6.8%, HR = 0.32, 95% CI: 0.22–0.48) were associated with lower 2-year mortality than those with no reperfusion (28.5%). Among fibrinolysis-treated patients, 510 (76.8%) achieved successful clinical reperfusion; only 17.0% of those with failed fibrinolysis underwent rescue PCI. There was no difference in 2-year mortality between successful fibrinolysis and primary PCI (8.8% vs. 6.8%, HR = 1.53, 95% CI: 0.85–2.73). Failed fibrinolysis predicted a similar mortality (33.1%) to no reperfusion (33.1% vs. 28.5%, HR = 1.30, 95% CI: 0.93–1.81). ConclusionIn Chinese county-level hospitals, only approximately 2/5 of patients with STEMI underwent reperfusion therapy, largely due to prehospital delay. Approximately 30% of patients with failed fibrinolysis and no reperfusion therapy did not survive at 2 years. Quality improvement initiatives are warranted, especially in public health education and fast referral for mechanical revascularization in cases of failed fibrinolysis.

30 day outcome after early discharge in low risk ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Current guidelines for management of patients with ST-segment elevation myocardial infarction (STEMI) encourage an early discharge (48-72 h) after a successful primary percutaneous coronary intervention (PCI) in selected low risk patients. Yet, this strategy is not routinely applied. The evidence on the relative outcome of patients discharged early compared to those discharged later, has been limited. Purpose To assess safety of early discharge in low risk STEMI patients treated with primary PCI by analyzing 30 days outcomes relative to early and late discharge strategies. Methods We prospectively enrolled 109 patients presented with STEMI from April 2019 to September 2019, who were categorized as low risk according to Zwolle risk score. 60 (55%) patients were discharged after 48-72 hours and 49 (45%) after > 72 hours. We gathered clinical data at 30 days. Primary endpoints were occurrence of a major adverse event - a composite of death from any cause, nonfatal myocardial infarction and acute stent thrombosis. Secondary endpoints were acute angina and re-hospitalization. Results The mean age was 59.7 +/- 10.5 years in early discharge group compared to 62.8 +/- 10.5 years in late discharge group (p=0.132). 88 (80.7%) patients were male. 58 (53.2%) of them had inferior MI. Mean ejection fraction was 49.25% +/- 4.95%. Median symptom to balloon time was 9.3 +/- 6.7 hour. Median length of stay was 3.4 days +/-0.6. Primary endpoint occurred in one patient in the early discharge group, who had acute stent thrombosis and nonfatal myocardial infarction. No death from any cause was observed in both groups. Secondary endpoint occurred in 3 patients who had acute angina, 2 in late discharge group and 1 in early discharge group. Conclusion(s) Data from our study reveal that an early discharge strategy in selected low risk STEMI patients treated with successful primary PCI is not associated with a significant increase in major adverse events compared to late discharge strategy.

Myeloperoxidase and global longitudinal strain in prognostication of clinical events after ST segment elevation myocardial infarction

Elevated levels of several inflammatory cytokines and chemokines, such as myeloperoxidase (MPO) and some characteristics of damaged myocardium such as myocardial deformation (global longitudinal strain — GLS) seem to be promising biomarkers for acute coronary syndrome, but their predictive ability for clinical outcomes amongst ST segment elevation myocardial infarction (STEMI) patients having obesity remained unclear.
 The aim of the study was to to determine the impact of MPO and GLS on prediction of 1‑year combined clinical events in STEMI patients successfully treated with primary percutaneous coronary intervention (PCI) depending on abdominal obesity presentation.
 Materials and methods. We prospectively enrolled 102 individuals with STEMI who were successfully treated with primary PCI. All patients gave their consent to participate in the study. The biomarkers (MPO, cardiac troponins), echocardiographic and Doppler parameters including global longitudinal strain (GLS) were evaluated at the baseline.
 Results. The MPO level in the entire population of patients with STEMI was 129.45 [48.48 — 179.70] ng/ml. The group was divided into two cohorts depending on the median level of MPO (≥ 98.34 ng/ml and < 98.34 ng/ml). We observed 26 combined end‑points (10 and 17 in patients with MPO ³ 98.34 ng/ml and < 98.34 ng/ml, respectively (F test = 0.064285; ε2 = 4.29; р = 0.046). Multivariate linear regression showed that the only GLS and MPO remained independent predictors for the clinical outcomes.
 Conclusions. Global longitudinal strain was the best predictor for 1‑year combined clinical outcomes in STEMI patients who were undergone successful primary PCI. Body fat accumulation seems to show borderline significance when compared with GLS, while it was sufficiently better than MPO.

Frequency of Incomplete St Segment Resolution After Successful Primary Percutaneous Coronary Intervention

The success of primary Percutaneous Coronary Intervention (PCI) can be verified on electrocardiogram through measuring ST Resolution (STR) and examination if their angiogram. Objective: The purpose of this research was to identify instances of after the primary PCI of partial STR and to investigate the characteristics associated with incomplete STR following primary PCI. Methods: At department of Interventional Cardiology of National Institute of Cardiovascular Disease (NICVD), Karachi, Pakistan, this Descriptive Cross-sectional study was conducted. The inclusion criteria set for data collection were patients with age between 18 to 65 years of both genders presented with complain of chest pain 12 hour previously and now diagnosed with acute STEMI, and undergoing successful primary PCI were included in the study. Results: Out of 196 patients, male was 74.5% while female were 25.5%. The Mean age of patients was 52.78±7.81 years. Out of 196 patients, with acute STEMI, 35.2% (69) had Incomplete STR after a successful primary PCI. When applying chi square on study variables with Incomplete STR after a successful primary PCI was found to be not associated with patient’s baseline characteristics. Conclusions: Our research discovered that a considerable proportion of patients with STEMI have Incomplete STR after first PCI. However, no correlation between STR and baseline patient characteristics was observed

Predictors of Left Ventricular Dysfunction after Percutaneous Primary Coronary Intervention in Acute Anterior Myocardial Infarction

Background: Primary percutaneous coronary intervention (PCI) has revolutionized the outcome and management of acute myocardial infarction. However, the occurrence of left ventricular dysfunction remains relatively common event following acute myocardial infarction and in associated with an adverse prognosis in these patients. this work aimed to investigate to the left ventricular dysfunction predictors following PCI for anterior myocardial infarction (AMI) using different parameters: Tissue Doppler imaging (TDI), Biomarkers (Troponin, CK-MB) and Echocardiography
 Methods: This research was conducted prospectively on 50 patients aged from 40 to 70 years old, presenting by first anterior myocardial infarction and treated with PCI. All cases were subjected to full history, full clinical examination, laboratory investigations, resting 12 leads electrocardiography, two dimensions echocardiography and tissue doppler imaging.
 Results: Highly statistically significant between EF baseline with EF on discharge and EF on discharge with after 3 months p-value was <0.001. Pre balloon dilatation, S wave of tissue Doppler imaging on discharge and S wave tissue Doppler imaging after 3 months were predictors for left ventricular systolic function.
 Conclusions: Persistent LV dysfunction following successful primary PCI is infrequent and is related to poor clinical outcomes at 3 months clinical follow-up. Tissue Doppler on discharge and after three months after myocardial infarction are independent predictors of LV dysfunction after anterior STEMI and can be used to predict occurrence of LV remodelling after 6 months.

Índice de resistencia microcirculatoria y obstrucción microvascular en la resonancia magnética cardiaca tras un IAMCEST

Introduction and objectivesThe index of microcirculatory resistance (IMR) measured after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is associated with microvascular obstruction (MVO) and adverse clinical events. To evaluate MVO after successful primary PCI for STEMI without pressure wires or hyperemic agents, we investigated the feasibility and usefulness of functional angiography-derived IMR (angio-IMR). MethodsThe current study included a total of 285 STEMI patients who underwent primary PCI and cardiac magnetic resonance (CMR). Angio-IMR of the culprit vessel after successful primary PCI was calculated using commercial software. MVO, infarct size, and myocardial salvage index were assessed using CMR, which was obtained a median of 3.0 days [interquartile range, 3.0-5.0] after primary PCI. ResultsAmong the total population, 154 patients (54.0%) showed elevated angio-IMR (> 40 U) in the culprit vessel. MVO was significantly more prevalent in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (88.3% vs 32.1%, P <.001). Infarct size, extent of MVO, and area at risk were significantly larger in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (P <.001 for all). Angio-IMR showed a significantly higher discriminatory ability for the presence of MVO than thrombolysis in myocardial infarction flow grade or myocardial blush grade (area under the curve: 0.821, 0.504, and 0.496, respectively, P <.001). ConclusionsAngio-IMR was significantly associated with CMR-derived infarct size, extent of MVO, and area at risk. An elevated angio-IMR (> 40 U) after primary PCI for STEMI was highly predictive of the presence of MVO in CMR.This trial was registered at ClnicalTrialsgov (Identifier: NCT04828681).

Predictors of Radial to Femoral Artery Access Crossover During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Radial access for primary percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding, when compared to femoral access. However, radial access failure may be associated with an increased door-to-device (DTD) time. To identify predictors of radial access failure requiring crossover to femoral artery access during primary PCI. From 2013 to 2020, 2,256 consecutive patients treated for PPCI at a single tertiary hospital were prospectively recruited into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariable logistic regression was used to identify independent predictors of radial to femoral access crossover. From 2,256 STEMI patients, primary radial access was used in 1,778 (78.8%), with 171 (9.6%) experiencing radial-to-femoral crossover. Patients with failed versus successful radial access experienced longer DTD times (67 mins, interquartile range [IQR] 46-99 vs 54 mins [IQR 39-78]; p<0.001). Independent predictors of radial-to-femoral access crossover included female sex (Adjusted Odds Ratio [AOR] 2.1, 95% Confidence Interval [CI] 1.4-3.0; p<0.001) and baseline hypertension (AOR 1.5, 95% CI 1.1-2.1; p=0.018). In a real-world STEMI registry, almost 1 in 10 patients experienced access crossover from the radial to femoral artery which resulted in longer DTD times. Independent predictors of radial access failure included female sex and baseline hypertension. Knowing which patient characteristics are associated with increased risk of radial artery failure enables catheter laboratory staff to ensure equipment is readily available to maximise successful primary PCI are available.

Functional angiography-derived index of microcirculatory resistance validated with microvascular obstruction in cardiac magnetic resonance after STEMI

Introduction and objectivesThe index of microcirculatory resistance (IMR) measured after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is associated with microvascular obstruction (MVO) and adverse clinical events. To evaluate MVO after successful primary PCI for STEMI without pressure wires or hyperemic agents, we investigated the feasibility and usefulness of functional angiography-derived IMR (angio-IMR). MethodsThe current study included a total of 285 STEMI patients who underwent primary PCI and cardiac magnetic resonance (CMR). Angio-IMR of the culprit vessel after successful primary PCI was calculated using commercial software. MVO, infarct size, and myocardial salvage index were assessed using CMR, which was obtained a median of 3.0 days [interquartile range, 3.0-5.0] after primary PCI. ResultsAmong the total population, 154 patients (54.0%) showed elevated angio-IMR (> 40 U) in the culprit vessel. MVO was significantly more prevalent in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (88.3% vs 32.1%, P <.001). Infarct size, extent of MVO, and area at risk were significantly larger in patients with angio-IMR> 40 U than in those with angio-IMR ≤ 40 U (P <.001 for all). Angio-IMR showed a significantly higher discriminatory ability for the presence of MVO than thrombolysis in myocardial infarction flow grade or myocardial blush grade (area under the curve: 0.821, 0.504, and 0.496, respectively, P <.001). ConclusionsAngio-IMR was significantly associated with CMR-derived infarct size, extent of MVO, and area at risk. An elevated angio-IMR (> 40 U) after primary PCI for STEMI was highly predictive of the presence of MVO in CMR.This trial was registered at ClnicalTrialsgov (Identifier: NCT04828681).

Assessment of Ultra-Early Administration of Sacubitril Valsartan to Improve Cardiac Remodeling in Patients With Acute Myocardial Infarction Following Primary PCI: Rational and Design of a Prospective, Multicenter, Randomized Controlled Trial.

BackgroundDespite coronary re-vascularization, the common complications of acute myocardial infarction (AMI), cardiac remodeling, and heart failure (HF), is increasing globally. Sacubitril valsartan (SV), an angiotensin receptor-neprilysin inhibitor (ARNI), has been previously demonstrated to improve HF. We further hypothesize that ultra-early SV treatment is also effective in preventing cardiac remodeling for patients with AMI following primary percutaneous coronary intervention (PCI).MethodsThe Assessment of ultra-early administration of Sacubitril Valsartan to improve cardiac remodeling in patients with Acute Myocardial Infarction following primary PCI (ASV-AMI) trial is a prospective, multicenter, randomized controlled trial in China planning to enroll at least 1,942 eligible patients from 10 centers. After successful primary PCI of culprit artery within 24 h, AMI patients are randomized to 2 h group or 3–7 days group with SV treatment. The major endpoints are echocardiographic measurement, cardiothoracic ratio, and N-Terminal pro-B-Type Natriuretic Peptide (NT pro-BNP) at baseline, 1, 3, 6, and 12 months. The secondary endpoints included MACE (cardiac arrest, cardiogenic death, myocardial infarction, and target vessel re-vascularization), in-/out-patient HF, EuroQol Five Dimensions Questionnaire (EQ-5D), and Kansas City Cardiomyopathy Questionnaire (KCCQ).DiscussionThe ASV-AMI trial is the first clinical trial of ultra-early administration of SV in the treatment of post-PCI AMI, adding more clinical evidence. Early application of SV to prevent cardiac remodeling in AMI patient is a major focus of this trial.Clinical Trial RegistrationTrial registration Chinese Clinical Trial Registry (http://www.chictr.org.cn; ChiCTR2100051979). Registered on 11 October 2021.

ST-segment elevation myocardial infarction with plaque erosion, to stent or not to stent: utility of intracoronary optical coherence tomography (OCT) imaging—a case report

BackgroundTreating acute myocardial infarction in the setting of insignificant coronary obstruction is an emerging challenge especially with the application of intracoronary imaging like intravascular ultrasound and optical coherence tomography (OCT). The cardiologists dealing with such patients may consider not to stent if there is intracoronary imaging evidence of minimal thrombus without plaque rupture and the vessel appears patent with settling of chest pain and electrocardiogram (ECG) changes.Case summaryA 47-year-old gentleman presented direct to the emergency department after experiencing retrosternal chest pain with an ECG showing hyperacute anterior T waves. He had ongoing chest pain and was therefore brought to the cardiac cath lab on the primary percutaneous coronary intervention (PCI) pathway. The first picture showed that the proximal left anterior descending (LAD) was occluded (TIMI 0 flow) with evidence of large thrombus burden. Pre-dilating with a 2.5 × 15 mm balloon did not change flow. Aspiration with an Export catheter was carried out for several runs. Most of the thrombus was successfully removed; however, some of it did go into the distal LAD but was successfully retrieved with aspiration catheter. The diagonal branch was occluded with thrombus which was wired followed by thrombus aspiration establishing TIMI II flow. The procedure was covered with Eptifibatide boluses and heparin. After thrombectomy, angiographically there was no obvious lesion present within the LAD. Optical coherence tomography confirmed only mild atheroma with a small amount of plaque and minimal thrombus. There was OCT evidence of plaque erosion without any plaque rupture. The area was above 9 mm2 and we decided not to treat that with a stent. The right coronary artery had an anterior take-off and was unobstructed. In conclusion, the patient had successful primary PCI to LAD with thrombus aspiration and balloon angioplasty only. He was placed on 12 months of dual antiplatelets therapy with Aspirin and Prasugrel.DiscussionThis case highlights the rare presentation of patients with acute myocardial infarction with plaque erosion and the usefulness of OCT in formulating a management plan.

Early Hospital Discharge Following PCI for Patients With STEMI

BackgroundRegional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care. ObjectivesThis study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients. MethodsBetween March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in <48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months. ResultsThe median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (>30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for >48 hours (>48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses. ConclusionsSelected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule.

ECHOCARDIOGRAPHIC ASSESSMENT OF RIGHT VENTRICULAR FUNCTION AFTER SUCCESSFUL REVASCULARIZATION FOR ACUTE ANTERIOR MYOCARDIAL INFARCTION WITHOUT RIGHT VENTRICULAR INFARCTION

Background: Right ventricular (RV) affection in acute left ventricular (LV) myocardial infarction (MI) is frequently underestimated in the clinical setting as the diagnostic limitations of the electrocardiogram and echocardiography. Objective: To assess RV function in patients presented with first acute anterior ST elevation myocardial infarction (STEMI) who underwent successful primary percutaneous coronary intervention (PCI) and factors affecting it. Patients and Methods: Forty consecutive patients with anterior STEMI who underwent successful primary PCI in the Cathetrization (cath) labs of Al-Azhar University Hospitals, Cairo, Egypt from March 2019 to April 2020 for first acute anterior STEMI without RV were enrolled in the study. Presence of a coexisting clinical condition that might affect RV function, patients with RV infarction or those having significant stenosis (>50%) affecting RV branch or right coronary artery proximal to RV branch were excluded. Echocardiography was performed during the hospital stay to assess the LV and RV systolic and diastolic functions with special focus on tricuspid annular plane systolic excursion, mid RV end-diastolic dimension, right atrial area, RV fractional area change, and tissue Doppler-derived myocardial performance index. Results: RV dysfunction, according to our definition in the first anterior MI, occurred in (55%) of the study population. Independent predictors for abnormal RV function were left circumflex artery mid or proximal affection, eventful procedure, occurrence of no reflow, glucose level, LV end-systolic dimension, LV end-diastolic dimension, and LV ejection fraction. Conclusion: RV dysfunction is detected in anterior myocardial infarction after successful revascularization. Several echocardiographic parameters may be possible measures for RV dysfunction including RVFAC, TAPSI, MPI and S’.

Primary Percutaneous Coronary Intervention in Patients With Type 2 Diabetes With Late/Very Late Stent Thrombosis and de novo Lesions: A Single-Center Observational Cohort Study of Clinical Outcomes and Influencing Factors.

Background: This study compared differences in the risk factors and clinical outcomes of primary percutaneous coronary intervention (PCI) in type 2 diabetes mellitus (DM) and non-DM patients with de novo lesions (DNLs) and late or very late stent thrombosis (LST/VLST).Methods: We used angiography to screen 4,151 patients with acute coronary syndrome for DNL and LST/VLST lesions. Overall, 3,941 patients were included in the analysis and were allocated to the DM (n = 1,286) or non-DM (n = 2,665) group at admission. The primary endpoint was a composite of major adverse cardiovascular events (MACEs), defined as death, myocardial infarction, revascularization, and ischemic stroke, within a median follow-up period of 698 days.Results: In the group with a total white blood cell count >10 × 109/L (P = 0.004), a neutral granular cell count >7 × 109/L (P = 0.030), and neutrophil–lymphocyte ratio >1.5 (P = 0.041), revascularization was better for DNL than for LST/VLST lesions. Among DM patients with DNLs, each unit increase in age was associated with a 53.6% increase in the risk of MACEs [hazard ratio (HR): 1.536, 95% confidence interval (CI), 1.300–1.815, P < 0.0001]. Older age (≥65 years) was associated with a significantly greater risk of MACEs (P < 0.0001). Furthermore, each standard deviation (SD) increase in the level of peak white blood cell counts was associated with a 50.1% increase in the risk of MACEs (HR, 1.501; 95% CI, 1.208–1.864; P = 0.0002). When stratifying the DM population with DNLs according to the D-dimer baseline and peak levels <0.5 vs. ≥0.5 mg/L, the high D-dimer group at baseline had a 2.066-fold higher risk of MACEs (P < 0.0001), and the high peak level D-dimer group had a 1.877-fold higher risk of MACEs (P = 0.001) compared to the low-level groups. Among DM patients with LST/VLST, each unit increase in age was associated with a 75.9% increase in the risk of MACEs (HR: 1.759, 95% CI, 1.052–2.940, P = 0.032). Furthermore, for each SD increase in the peak D-dimer level, the risk of MACEs increased by 59.7% (HR, 1.597; 95% CI, 1.110–2.295; P = 0.041).Conclusion: Following successful primary PCI, the measurement of baseline and peak D-dimer values may help identify individuals at high cardiovascular risk. This suggests a potential benefit of lowering D-dimer levels among T2DM patients with DNL. Furthermore, age and the peak D-dimer values may facilitate the risk stratification of T2DM patients with LST/VLST.

Lack of prognostic significance for major adverse cardiac events of soluble suppression of tumorigenicity 2 levels in patients with ST-segment elevation myocardial infarction.

Elevation of soluble suppression of tumorigenicity 2 (sST2) is associated with cardiac fibrosis and hypertrophy. Under investigation herein, was whether sST2 level is associated with major adverse cardiac events (MACE) and left ventricular (LV) remodeling after primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). In total, this study included 184 patients who underwent successful primary PCI. A subsequent guideline-based medical follow-up was included (61.4 ± 11.8 years old, 85% male, 21% with Killip class ≥ I). sST2 concentration correlations with echocardiographic, angiographic, laboratory parameters, and clinical outcomes in STEMI patients were evaluated. The median sST2 level was 60.3 ng/mL; 6 (3.2%) deaths occurred within 1 year. The sST2 level correlated with LV ejection fraction (LVEF) changes from baseline to 6 months (r= -0.273; p = 0.006) after adjustment for echocardiographic parameters including wall motions score index (WMSI). Recovery of LVEF at 6 months was highest in the tertile 1 group (Δ6 months - baseline LVEF; tertile 1, p = 0.001; tertile 2, p = 0.319; tertile 3, p = 0.205). The decrease in WMSI at 6 months was greater in the tertiles 1 and 2 groups than in the tertile 3 group (Δ6 months - baseline WMSI; tertile 1, p = 0.001; tertile 2, p = 0.013; tertile 3, p = 0.055). There was no association between sST2 levels and short-term (log rank p = 0.598) and long-term (p = 0.596) MACE. sST2 concentration have predictive value for LV remodeling on echocardiography in patients with STEMI who underwent primary PCI. However, sST2 concentration was not associated with short-term and long-term MACE.

Neutrophil-to-Lymphocyte Ratio at Emergency Room Predicts Mechanical Complications of ST-segment Elevation Myocardial Infarction.

BackgroundThe neutrophil-to-lymphocyte ratio (NLR) has been proven to be a reliable inflammatory marker. A recent study reported that elevated NLR is associated with adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR at emergency room (ER) is associated with mechanical complications of STEMI undergoing primary percutaneous coronary intervention (PCI).MethodsA total of 744 patients with STEMI who underwent successful primary PCI from 2009 to 2018 were enrolled in this study. Total and differential leukocyte counts were measured at ER. The NLR was calculated as the ratio of neutrophil count to lymphocyte count. Patients were divided into tertiles according to NLR. Mechanical complications of STEMI were defined by STEMI combined with sudden cardiac arrest, stent thrombosis, pericardial effusion, post myocardial infarction (MI) pericarditis, and post MI ventricular septal rupture, free-wall rupture, left ventricular thrombus, and acute mitral regurgitation during hospitalization.ResultsPatients in the high NLR group (> 4.90) had higher risk of mechanical complications of STEMI (P = 0.001) compared with those in the low and intermediate groups (13% vs. 13% vs. 23%). On multivariable analysis, NLR remained an independent predictor for mechanical complications of STEMI (RR = 1.947, 95% CI = 1.136–3.339, P = 0.015) along with symptom-to balloon time (P = 0.002) and left ventricular dysfunction (P < 0.001).ConclusionNLR at ER is an independent predictor of mechanical complications of STEMI undergoing primary PCI. STEMI patients with high NLR are at increased risk for complications during hospitalization, therefore, needs more intensive treatment after PCI.

Abstract 14147: Vascular Complication of Distal Transradial Approach in Patients With Acute Myocardial Infarction

Background: The distal transradial approach (dTRA) for coronary catheterisation is a newly introduced alternative to the conventional transradial approach. This study investigated the incidence of vascular complication of the dTRA in patients with acute myocardial infarction (AMI) who underwent primary percutaneous coronary intervention (PCI). Methods: Consecutive 131 patients with AMI who underwent primary PCI between April 2018 and October 2019 were investigated. The dTRA was used as the primary approach whenever feasible in this study period. The bleeding complication after dTRA and the patency of the radial artery were investigated. The patency of the radial artery was examined using Doppler ultrasound in follow-up period. Results: Among the 131 AMI patients, 116 patients (88.5%) underwent successful primary PCI using the dTRA. The patients included 83 men (71.6%), and the mean age was 70.4 ± 12.9 years. A 5- or 6-French sheath (conventional or slender) was used in the primary procedure. The average time to achieving hemostasis was 5.0 ± 4.1 hours; TIMI minor bleeding was observed in 2 patients (1.5%) and there were no TIMI major bleeding. Color Doppler sonography of the radial artery was performed in 94 patients with the mean follow-up period of 273 ± 183 days, and the incidence of radial artery occlusion (RAO) was 1.1% (n=1). Conclusions: The application of dTRA is considered to have low incidences of bleeding complication and radial artery occlusion in the patients with AMI.

Rationale and design of the MULTISTARS AMI Trial: A randomized comparison of immediate versus staged complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease

About half of patients with acute ST-segment elevation myocardial infarction (STEMI) present with multivessel coronary artery disease (MVD). Recent evidence supports complete revascularization in these patients. However, optimal timing of non-culprit lesion revascularization in STEMI patients is unknown because dedicated randomized trials on this topic are lacking. STUDY DESIGN: The MULTISTARS AMI trial is a prospective, international, multicenter, randomized, two-arm, open-label study planning to enroll at least 840 patients. It is designed to investigate whether immediate complete revascularization is non-inferior to staged (within 19-45 days) complete revascularization in patients in stable hemodynamic conditions presenting with STEMI and MVD and undergoing primary percutaneous coronary intervention (PCI). After successful primary PCI of the culprit artery, patients are randomized in a 1:1 ratio to immediate or staged complete revascularization. The primary endpoint is a composite of all-cause death, non-fatal myocardial infarction, ischemia-driven revascularization, hospitalization for heart failure, and stroke at 1 year. CONCLUSIONS: The MULTISTARS AMI trial tests the hypothesis that immediate complete revascularization is non-inferior to staged complete revascularization in stable patients with STEMI and MVD.