Thrombolysis In Myocardial Infarction Grade Research Articles

Impact of Acute Myocardial Ischemia Duration on Reperfusion Outcomes in STEMI Patients

The aim. To analyze the influence of the duration of acute myocardial ischemia, specifically in ST-elevation myocardial infarction (STEMI) electrocardiographic patterns, on the outcomes of reperfusion interventions. We focused on the assessment of immediate angiographic data in the catheterization laboratory after stenting and investigated whether the frequency of the no-reflow phenomenon is dependent on the time since the onset of anginal pain. Our hypothesis of inferior immediate treatment outcomes is based on the pathophysiological course of ischemic-reperfusion injury in patients with late myocardial infarction. Primarily, this is due to the development of myocardial edema, leading to extravascular compression of the vessel, thereby influencing Thrombolysis in Myocardial Infarction grade 0 blood flow.
 Materials and methods. We conducted an analysis of 107 angiograms of STEMI patients, who underwent percutaneous coronary intervention at the Amosov National Institute of Cardiovascular Surgery between 2021 and 2023. The patients were categorized into four groups based on the duration of acute myocardial ischemia. The first group included patients with ischemia duration up to two hours, aligning with the golden window for revascularization recommended by the European guidelines. The second, third, and fourth groups consisted of patients with ischemia durations of 3-12 hours, 12-24 hours, and over 48 hours, respectively.
 Results. Of 104 patients, complete restoration of coronary circulation was achieved in 88 cases, while, unfortunately, 16 patients had TIMI 0/1 blood flow. Such a probability of complication is 15.3% in the studied cohort. According to the clinical profile, the patients were divided into those who had no-reflow (main group) and patients with complete restoration of blood flow (control group). In the group of unrestored blood flow, cardiogenic shock occurred more often, and the infarct-dependent artery was more often occluded than suboccluded. The technique of percutaneous intervention was similar in both groups.
 Conclusion. The frequency of the no-reflow phenomenon increases with the duration of acute myocardial ischemia. Patients presenting later than 48 hours since the onset of ischemia are more prone to no-reflow (62.5% vs 37.5% if less than 48 hours). Cardiogenic shock is associated with a higher likelihood of the no-reflow phenomenon. The most significant reason for the delay in delivering a STEMI patient to catheterization laboratory anamnestically is the patient’s untimely medical care seeking. In our opinion, this delay can be avoided by increasing awareness about the initial signs of myocardial infarction and the necessity of seeking immediate medical care.

Association of Total Ischemia Time with No-Reflow Phenomenon in Patients Presenting with STElevation Myocardial Infarction, Undergoing Primary Percutaneous Coronary Intervention

Objective: To find out the association of total ischemic time with no-reflow phenomenon, in terms of Thrombolysis in Myocardial Infarction (TIMI) flow grade, in patients presenting with ST-Elevation Myocardial Infarction and undergoing Primary Percutaneous Coronary Intervention(PPCI). Study Design: Analytical Cross-Sectional study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases Rawalpindi Pakistan, from Nov, 2022 to Jan, 2023. Methodology: This analytical cross-sectional study was conducted on n=184 patients, recruited through consecutive sampling technique to collect data prospectively. Patients were divided into no-reflow and normal flow group. Patients’ total ischemic time was documented and pre & post-procedural TIMI flow was noted. SPSS version-24:00 was used to enter and analyze data. Chi-square, Fisher exact test and t-test were applied and p-value≤0.05 was taken as statistically significant. Results: Out of 184 study participants, 17(9.2%) were females as compared to 167(90.8%) males. The mean age was 60.23±10.28 years. No-reflow phenomenon was observed in 20(10.9%) patients. The mean age was higher in the no-reflow group than that of the normal flow group (62.65±11.61 vs 59.94±10.12 years). Total ischemic time, pre & post-procedural TIMI flow were found to be significantly associated with no-reflow phenomenon (p<0.05). Conclusion: There exists a strong association between total ischemic time and the occurrence of no-reflow phenomenon. Patients with delayed reperfusion present with greater frequency of no-reflow and low TIMI grade and vice versa.

Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction Patients After Percutaneous CoronaryIntervention:Influencing Factors and Intervention Strategies.

Aim We aim to explore the factors influencing myocardial perfusion in patients with acute ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI)and evaluate the effects of different intervention strategies on myocardial perfusion improvement. Methods A retrospective analysis was conducted on 300 patients withSTEMIwho underwent primary percutaneous coronary intervention (PPCI) at our hospital between January 2020 and December 2022. Based on post-procedural coronary angiography results using the thrombolysis in myocardial infarction (TIMI) blood flow grade and myocardial blush grade (MBG), patients were categorized into two groups: the normal perfusion group (TIMI grade 3 or MBG 2-3, n=180) and the impaired perfusion group (TIMI grades 0-2 or MBG 0-1, n=120). The impaired perfusion group was further divided using a random number table into the thrombus aspiration-only group (control group, n=60) and the thrombus aspiration combined with nicorandil group (nicorandil group, n=60). A 1:1 propensity score matching method was employed to adjust for baseline characteristics between the groups. Clinical characteristics, hematological parameters, coronary lesion features, and percutaneous coronary intervention (PCI) technical parameters were compared between the matched groups. Additionally, a multivariate logistic regression analysis was performed to identify independent risk factors influencing myocardial perfusion. Furthermore, the post-procedural myocardial perfusion, cardiac function, and clinical prognosis were compared between the control and nicorandil groups. Results After matching, the baseline characteristics of the two groups were compared. The impaired perfusion group had older age, higher proportion of male patients, higher rates of diabetes and hypertension, longer time from symptom onset to balloon dilation, higher peak cardiac troponin I (cTnI) levels, higher proportion of left main or multivessel involvement, heavier coronary lesion burden, and lower balloon inflation pressure (P<0.05). Multivariate logistic regression analysis revealed that age of ≥65 years (odds ratio {OR}=2.34, 95% confidence interval {CI}=1.23-4.46, P<0.01), time from symptom onset to balloon dilation of ≥6 hours (OR=3.12, 95% CI=1.67-5.83, P<0.01), peak cTnI level of ≥100 ng/mL (OR=4.27, 95% CI=2.18-8.36, P<0.01), left main or multivessel involvement (OR=2.86, 95% CI=1.51-5.41, P<0.01), and balloon inflation pressure of <8 atm (OR=3.45, 95% CI=1.79-6.65, P<0.01) were independent risk factors affecting myocardial perfusion. In the intervention analysis, the nicorandil group showed superior post-procedural TIMI blood flow grade, MBG, left ventricular ejection fraction (LVEF), and New York Heart Association (NYHA) functional classification compared to the control group (P<0.05). During a six-month follow-up, the nicorandil group had a lower incidence of major adverse cardiovascular events (MACE) compared to the control group (P<0.05). Conclusion Age, time from symptom onset to balloon dilation, peak cTnI level, extent of coronary artery lesions, and balloon inflation pressure were identified as independent risk factors affecting myocardial perfusion in STEMI patients after PCI. Compared to simple thrombus aspiration, thrombus aspiration combined with nicorandil demonstrated better improvement in myocardial perfusion, cardiac function, and clinical outcomes for patients with impaired perfusion.

Risk Factors of Suboptimal Coronary Blood Flow after a Percutaneous Coronary Intervention in Patients with Acute Anterior Wall Myocardial Infarction.

Primary percutaneous coronary intervention (PCI) is regarded as the most preferred strategy in ST-segment elevation myocardial infarction (STEMI). Thrombolysis in Myocardial Infarction (TIMI) flow grade has been an important and cohesive predictor of outcomes in STEMI patients. We sought to evaluate potential variables associated with the risk of suboptimal TIMI flow after PCI in patients with anterior wall STEMI. We evaluated 107 patients admitted to our hospital between 1 January 2019 and 31 December 2021 with a diagnosis of anterior wall STEMI treated with primary PCI. Suboptimal TIMI flow grade (≤2) after PCI occurred in 14 (13%) patients while grade 3 was found in 93 (87%) of them presenting with anterior wall STEMI. Failure to achieve optimal TIMI 3 flow grade after PCI was associated with lower TIMI grade prior to PCI (OR 0.5477, 95% CI 0.2589-0.9324, p = 0.02), greater troponin concentration before (OR 1.0001, 95% CI 1-1.0001, p = 0.0028) and after PCI (OR 1.0001, 95% CI 1-1.0001, p = 0.0452) as well as lower mean minimal systolic blood pressure (OR 0.9653, 95% CI 0.9271-0.9985, p = 0.04). Among predictors of suboptimal TIMI flow grade after PCI, we noted lower TIMI grade flow pre-PCI, greater serum troponin concentrations in the periprocedural period and lower mean minimal systolic blood pressure.

Anterolateral Papillary Muscle Rupture Predicted by Post-Infarction Inflammatory Markers.

BACKGROUND The incidence of papillary muscle rupture (PMR), a mechanical complication of acute myocardial infarction, has decreased in the reperfusion era; however, its fatality rate remains high. Timely recognition and prompt initiation of treatment for PMR are important to avoid prolonged cardiogenic shock; however, the symptoms of PMR are nonspecific, and early diagnosis is often difficult. CASE REPORT A 72-year-old woman with nausea for 2 days presented with ST-segment elevation myocardial infarction with obstruction of the obtuse marginal branch and 75% stenosis of the first diagonal branch. Percutaneous coronary intervention was performed to revascularize the obtuse marginal lesion, which was over thrombolysis in myocardial infarction grade 2 flow. After percutaneous coronary intervention, the patient developed fever, an elevated C-reactive protein level, and an increased neutrophil-to-lymphocyte ratio (NLR). The patient showed no signs of infection but elevated inflammatory marker levels, with C-reactive protein rising to 39.32 mg/dL and NLR to 15. On postoperative day 4, the patient's clinical condition rapidly deteriorated, resulting in circulatory failure. Transthoracic echocardiography showed anterolateral PMR, and urgent surgical mitral valve replacement was performed. On day 32, the patient was discharged from the hospital, and at the 1-year follow-up, she remained in good health. CONCLUSIONS When there are multiple lesions, including the obtuse marginal and diagonal branches, anterolateral PMR should be suspected as the cause of cardiogenic shock. Performing point-of-care echocardiography and closely monitoring C-reactive protein levels and NLR can be helpful to detect PMR early.

Intracoronary versus intravenous glycoprotein IIb/IIIa inhibitors during primary percutaneous coronary intervention in patients with STEMI: a systematic review and meta-analysis

BackgroundIntracoronary (IC) administration of glycoprotein IIb/IIIa inhibitors (GPIs) has been studied as an adjunctive therapy to improve outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of IC administration of GPIs compared with those of intravenous (IV) administration in patients with STEMI.MethodsWe searched the MEDLINE, Embase, and Cochrane CENTRAL databases for relevant studies published before September 21, 2022. In total, 22 randomized controlled trials involving 7,699 patients were included.ResultsThe proportions of patients achieving thrombolysis in myocardial infarction grade 3 flow, myocardial blush grade 2/3, and complete ST-segment resolution were significantly higher in the IC group than in the IV group. Major adverse cardiac events (MACE) (RR: 0.54, 95% CI: 0.37–0.80) and heart failure (RR: 0.48, 95% CI: 0.25–0.91) within 1 month were significantly lower in the IC group than in the IV group; however, after 6 months, no difference was observed in MACE risk. Additionally, the risks of death and bleeding did not differ between the two routes of administration.ConclusionsWhen considering adjunctive GPI administration for patients with STEMI, the IC route may offer greater benefits than the IV route in terms of myocardial reperfusion and reduced occurrence of MACE and heart failure within 1 month. Nonetheless, when making decisions for IC administration of GPIs, the absence of a benefit for bleeding risk and difficulty accessing the administration route should be considered.

Relationship Between High Sensitivity C-reactive Protein to Albumin Ratio With Infarct-related Artery Patency in Patients With Non-ST-segment Elevation Myocardial Infarction.

The C-reactive protein/albumin ratio (CAR) has recently emerged as a marker for poor prognosis or mortality in various patient groups. This study aimed to examine the relationship between serum CAR and infarct-related artery (IRA) patency in 700 consecutive non-ST-segment elevation myocardial infarction (NSTEMI) patients prior to percutaneous coronary intervention. The study population was separated into 2 different groups according to preprocedural IRA patency as assessed by the degree of Thrombolysis in Myocardial Infarction (TIMI) flow. As a result, occluded IRA was defined as TIMI grade 0-1, while patent IRA was defined as TIMI grade 2-3. High CAR (Odds Ratio: 3.153 (1.249-8.022); P < .001) was found to be an independent predictor of occluded IRA. Additionally, CAR was positively correlated with the SYNTAX score, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio; CAR was negatively correlated with left ventricular ejection fraction. The highest cut-off value of CAR predicting occluded IRA was found to be .18 with 68.3% sensitivity and 67.9% specificity. The area under the curve for CAR was .744 (95% CI: .706-.781) after the receiver-operating characteristic curve assessment.

Electrocardiographic QRS Findings Upon Admission Can Predict Prognosis of Acute Myocardial Infarction Caused by Occlusion of Left Main Coronary Artery.

Acute myocardial infarction (AMI) caused by left main coronary artery (LMCA) occlusion is associated with a severe clinical course and catastrophic consequences. We sought to clarify ECG predictors of prognosis in AMI caused by LMCA occlusion. We examined 20 consecutive patients with AMI caused by LMCA occlusion that was treated by primary stenting. The patients were assigned to either a group that survived (S) and was discharged from hospital, or a group that did not survive (NS) and died in hospital. We compared ECG findings upon admission, angiographic findings, laboratory data and clinical outcomes. The rate of having Thrombolysis In Myocardial Infarction (TIMI) grade > 2 coronary flow before PCI and of achieving TIMI grade 3 after PCI was significantly lower in the NS than the S group (14.3% vs. 83.3%, p = 0.003 and 35.7% vs. 100%, p = 0.008). The ECG findings showed longer QRS interval in the NS than in the S group (150.5 ± 37.9 vs. 105.2 ± 15.4, p = 0.022). A QRS interval ≥ 120 msec predicted in-hospital mortality with sensitivity, specificity and positive and negative predictive values of 78.5%, 100%, 100% and 66.7%, respectively, in this population. The QRS duration upon admission was a good predictor of in-hospital mortality among patients with AMI caused by LMCA occlusion. This ECG sign could be useful in the emergency clinical setting.

ST-segment yükselmesiz miyokard enfarktüslü hastalarda serum ürik asit/albümin oranı ile tamamen tıkalı enfarkt ilişkili arter arasındaki ilişki

Aim: Infarct-related artery (IRA) patency before primary percutaneous coronary intervention (pPCI) is linked to improved clinical outcomes and lower mortality in patients with acute coronary syndrome. The purpose of this research was to examine the association between serum uric acid/albumin ratio (UAR) and IRA patency in patients with non-ST-segment elevation myocardial infarction (NSTEMI).Material and Method: We evaluated 430 consecutive patients with NSTEMI in total retrospectively. The study population was divided into 2 groups according to the IRA patency as assessed by the degree of Thrombolysis in Myocardial Infarction (TIMI) flow before pPCI. As a result, completely occluded IRA was defined as TIMI grade 0-1, while patent IRA was defined as TIMI grade 2-3.Results: IRA was found to be occluded in 110 (25.5%) patients prior to the procedure. UAR level (p=&amp;lt;0.001) was found to be higher among the patients with IRA occlusion when compared to the patent group. Regression analysis revealed that UAR (OR:3.125; 95% CI:1.186-8.232, p&amp;lt;0.001), left ventricular ejection fraction (OR:0.917, 95% CI:0.885-0.951, p&amp;lt;0.001) and culprit artery diameter (OR:0.917, 95% CI:0.885-0.951, p&amp;lt;0.001) were independent predictors for an occluded IRA. An UAR cut-off value of &amp;gt;1.40 was detected to prognosticate the occluded IRA with 62.7% sensitivity and 63.8% specificity (AUC: 0.722, 95% CI: 0.671-0.773, p&amp;lt;0.001).Conclusion: UAR is an independent predictor of preprocedural IRA patency in patients with NSTEMI. Thus, UAR may be an easily accessible parameter to diagnose high-risk NSTEMI patients who would benefit from an immediate invasive strategy (&amp;lt;2 hours).

CHA2DS2-VASc Score as a Predictor of New Onset Atrial Fibrillation in Patients With Non-ST Segment Elevation Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

Background: New-onset atrial fibrillation (NOAF) often complicates acute coronary syndromes (ACSs) with adverse short- and long-term consequences. However, the current risk classification model for estimating NOAF during non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear. Some parameters in the CHA2DS2-VASc score are closely related to the development of atrial fibrilation (AF). Methods: This retrospective study was conducted among 670 consecutive NSTEMI patients who applied to our cardiovascular center between June 2020 and June 2022 and underwent percutaneous coronary intervention (PCI). Results: NOAF developed during hospitalization in 55 patients (12.5%). NOAF patients were older and had higher high sensitivity C-reactive protein (hs-CRP), left atrial volume index, Post PCI thrombolysis in myocardial infarction (TIMI) grade &lt;3, CHA2DS2-VASc score, peak troponin I (ng/ml), and SYNTAX score (SS). After univariate logistic regression analysis for the predictors of NOAF development, CHA2DS2-VASc score, post PCI TIMI grade &lt;3, hemoglobin, hsCRP, SS alone were predictors of NOAF, but after multivariate analysis, CHA2DS2-VASc score, post PCI TIMI grade &lt;3, hemoglobin had a determining effect. Conclusions: The CHA2DS2-VASc score can be evaluated as a predictor of NOAF after PCI in NSTEMI. Except for the components of the CHA2DS2-VASc score, post PCI TIMI grade &lt;3 and low hemoglobin levels are independent risk factors for NSTEMI-NOAF.

Safety and efficacy of intracoronary recombinant human prourokinase administration in patients with acute myocardial infarction and ST‑segment elevation: A meta‑analysis of randomized controlled trials.

Slow blood flow or no reflow following percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) typically leads to an adverse prognosis. However, it is controversial whether to use prourokinase (Pro-UK) during PCI in patients with acute STEMI. The present meta-analysis compared the efficacy and safety of intracoronary Pro-UK administration in patients with acute STEMI. Published randomized controlled trials (RCTs) were analyzed to compare Pro-UK with non-Pro-UK treatment in patients with acute STEMI. PubMed, Cochrane Library and China National Knowledge Infrastructure were searched and meta-analysis was performed using Review Manager 5.3 software. A total of 13 RCTs were selected and 1,797 patients were considered in the meta-analysis, including 897 patients who received Pro-UK intervention and 900 patients who were in the control group. No significant heterogeneity was identified across these selected studies. Pro-UK therapy significantly decreased the incidence of major adverse cardiac events [risk ratio (RR), 0.68; 95% CI, 0.56-0.82, P<0.0001], left ventricular end-diastolic diameter [standardized mean difference (SMD), -0.26; 95% CI, -0.40 - -0.12; P=0.0003], corrected thrombolysis in myocardial infarction (TIMI) frame count [SMD, -0.45; 95% CI, -0.62 - -0.28; P<0.00001] and cardiac troponin I [SMD, -0.31; 95% CI, -0.46 - -0.17; P<0.0001]. In addition, Pro-UK administration increased TIMI grade 3 flow (RR, 1.16; 95% CI, 1.07-1.25; P=0.0003), TIMI myocardial perfusion grade 3 (RR: 1.39, 95% CI: 1.12-1.74, P=0.004), ST-segment resolution (RR, 1.23; 95% CI, 1.10-1.36; P=0.0002) and left ventricular ejection fraction (SMD, 0.38; 95% CI, 0.27-0.49; P<0.00001). No significant difference was identified in bleeding (RR, 1.12; 95% CI, 0.85-1.47; P=0.41). The present meta-analysis determined that intracoronary Pro-UK administration is efficacious and safe to decrease slow blood flow or no reflow phenomena following PCI and improve the prognosis of patients with acute STEMI.

Impact of Intramyocardial Hemorrhage on Clinical Outcomes in ST-Elevation Myocardial Infarction: A Systematic Review and Meta-analysis

<h2>Abstract</h2><h3>Background</h3> Intramyocardial hemorrhage (IMH) occurs after ST-elevation myocardial infarction (STEMI) and has been documented using cardiac magnetic resonance imaging. The prevalence and prognostic significance of IMH are not well described, and the small sample size has limited prior studies. <h3>Methods</h3> We performed a comprehensive literature search of multiple databases to identify studies that compared outcomes in STEMI patients with or without IMH. The outcomes studied were major adverse cardiovascular events (MACE), infarct size, thrombolysis in myocardial infarction (TIMI) flow after percutaneous coronary intervention (PCI), left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), and mortality. Odds ratios (ORs) and standardized mean differences with corresponding 95% CIs were calculated using a random effects model. <h3>Results</h3> Eighteen studies, including 2824 patients who experienced STEMI (1078 with IMH and 1746 without IMH), were included. The average prevalence of IMH was 39%. There is a significant association between IMH and subsequent MACE (OR, 2.63; 95% CI, 1.79-3.86; <i>P</i> < .00001), as well as IMH and TIMI grade <3 after PCI (OR, 1.75; 95% CI, 1.14-2.68; <i>P</i> = .05). We also found a significant association between IMH and the use of glycoprotein IIb/IIIa inhibitors (OR, 2.34; 95% CI, 1.42-3.85; <i>P</i> = .0008). IMH has a positive association with infarct size (standardized mean difference, 2.19; 95% CI, 1.53-2.86; <i>P</i> < .00001) and LVEDV (standardized mean difference, 0.7; 95% CI, 0.41-0.99; <i>P</i> < .00001) and a negative association with LVEF (standardized mean difference, −0.89; 95% CI, −1.15 to −0.63; <i>P</i> = .01). Predictors of IMH include male sex, smoking, and left anterior descending infarct. <h3>Conclusions</h3> Intramyocardial hemorrhage is prevalent in approximately 40% of patients who experience STEMI. IMH is a significant predictor of MACE and is associated with larger infarct size, higher LVEDV, and lower LVEF after STEMI.

Comparative diagnostic and prognostic implications of right versus left bundle branch block in patients with suspected ST-segment elevation myocardial infarction

Abstract Background Current ESC guidelines on management of acute myocardial infarction in patients presenting with ST-segment elevation (STEMI) recommend emergent invasive management in patients with ischemic symptoms and bundle branch block (BBB). While left bundle branch block (LBBB) is a well-known high-risk feature in patients with acute myocardial infarction, data on the diagnostic and prognostic impact of right bundle branch block (RBBB) in comparison to LBBB in the context of STEMI are scarce. Methods A prospective cohort of 2,139 patients with suspected STEMI were triaged by the on-call cardiologist to acute coronary angiography based on a prehospital, tele-transmitted digital 12-lead electrocardiogram. All discharge diagnoses were independently adjudicated. The diagnostic accuracy of RBBB or LBBB was calculated. 30-day and 1-year all-cause mortality were from a central national registry and compared for LBBB, RBBB and patients without BBB using the Kaplan Meier method. Unadjusted and adjusted (age, sex, hypertension, hyperlipoproteinemia, smoking status and history of coronary artery disease) hazard ratios for 1-year mortality were calculated for both BBB-types. Results The final diagnosis of STEMI was adjudicated in 1,832/2,139 (85.6%) of patients. RBBB was present in 117 (5.5%), LBBB in 61 (2.9%) patients, respectively. Patients with BBB were older than non-BBB patients: Median age was 69.7 years in RBBB, 68.9 years in LBBB and 62.6 years in non-BBB patients. Comparing both BBB types, LBBB patients more often had prior heart failure (6.3% in RBBB vs 11.5% in LBBB), while RBBB patients more often developed cardiac arrest before angiography (15.3% vs 3.7% in RBBB and LBBB patients respectively) and more frequently revealed Thrombolysis in Myocardial Infarction (TIMI) grade flow of 0 (61.0% vs 47.2%, respectively). Specificity for the final diagnosis of STEMI was not significantly different in both BBB-types: 95.1% (95% CI 92.1–97.0) in RBBB versus 92.8% (95% CI 89.4–95.2) in LBBB patients (p=0.25). Patients with RBBB had significantly higher 30-day and 1-year mortality (Figure 1), while LBBB and non-BBB patients showed similar outcome. Unadjusted hazard ratio for 1-year mortality comparing RBBB to non-BBB patients was 3.35 (95% CI 2.11–5.34, p&amp;lt;0.001) and 1.4 (95% CI 0.57–3.44, p=0.46) when comparing LBBB to non-BBB patients. After adjustment hazard ratio for RBBB patients was 2.3 (95% CI 1.25–4.21, p=0.007). Conclusion In the context of suspected STEMI, RBBB is an ominous sign associated with adverse clinical features like cardiac arrest prior to PCI, TIMI grade 0 flow, compared to LBBB or non-BBB presenters. Consequently, RBBB patients had poorer outcome after 12 months. Our data therefore reinforce current guidelines in designating RBBB-patients as very high-risk, demanding immediate management and triage. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Regional Research Foundation in Region Sjaelland, Denmark

Clinical Manifestation of Cardiac Rupture in Patients with ST-Segment Elevation Myocardial Infarction: Early Versus Late Primary Percutaneous Coronary Intervention.

Background:Cardiac rupture is one of the fatal complications of ST-Segment Elevation Myocardial Infarction (STEMI) in the primary percutaneous coronary intervention (PPCI) era. The present study aims to identify risk factors of cardiac rupture among patients suffering from STEMI, treated with early and late PPCI.Methods:This is a multicenter retrospective cohort study involving STEMI patients with cardiac rupture (CR group), matched with STEMI patients without CR (control group) in a 1:5 ratio. They were divided into the early (≤ 6 h) and the late (> 6 h) PCI groups. Multivariable logistic regression was utilized to identify risk factors for cardiac rupture.Results:Seventy-four patients in the CR and 370 in the control group were included. Multivariable regression identified lateral infarction (OR = 11.89, 95% CI 2.22–63.81, p < 0.01) in the early PCI phase as a significant risk factor for cardiac rupture. Thrombolysis in myocardial infarction (TIMI) grade 0-1 (early PCI: OR = 4.16, 95% CI 1.33-13.0, p = 0.01; late PCI: OR = 4.46, 95% CI 1.59–12.54, p < 0.01) was a risk factor for both early and late PCI groups. In contrast, TIMI grade 2 was associated with a higher rupture risk within the late (OR = 16.87, 95% CI 3.83–74.19, p < 0.001) but not for the early (OR = 5.44, 95% CI 0.76–39.07, p = 0.09) PCI groups. STEMI combined with Killip IV was associated with a higher rupture risk for the late PCI group (OR = 1.43, 95% CI 1.03–1.99, p = 0.04). Intra-aortic balloon pump (IABP) was protective against cardiac rupture within early PPCI (OR = 0.18, 95% CI 0.04–0.89, p = 0.04). In contrast, glycoprotein IIb/IIIa inhibitors were associated with lower rupture risks in both the early and late groups (early PCI: OR = 0.38, 95% CI 0.17–0.87, p = 0.02; late PCI: OR = 0.33, 95% CI 0.15–0.75, p < 0.01).Conclusions:No reflow or slow blood flow is associated with a higher risk of cardiac rupture in early and late PCI patients. Glycoprotein IIb/IIIa inhibitors are beneficial in preventing heart rupture, and the use of IABP in early PPCI is also helpful in preventing heart rupture.

A model for predicting acute heart failure in patients with acute myocardial infarction by taking into account energy and adipokine metabolism indicators

Acute heart failure (AHF) is one of the most common complications of acute myocardial infarction (AMI). Currently, adropin, irisin, fatty acid binding protein 4 (FABP 4) and C1q/TNF-binding protein 3 (CTRP 3) are considered to be valid markers of energy homeostasis and the adipokine system in AMI patients. The aim of the study was to predict the development of AHF in AMI patients by taking into account indicators of energy homeostasis and adipokine system using generalized linear mixed model. The study examined 189 patients with acute ST-segment elevation myocardial infarction. Concentrations of adropin, irisin, insulin, FABP4 and CTRP3 were determined by enzyme-linked immunosorbent assay. Fasting capillary blood glucose level was measured by glucoseoxidase method. Insulin resistance (IR) was assessed using homeostasis model assessment of insulin resistance (HOMA-IR). The study identified thrombolysis in myocardial infarction (TIMI) grade before intervention. A generalized linear mixed model was used to develop a method for predicting AHF in AMI patients. The study showed decreased levels of adropin, irisin and CTRP3 and increased levels of FABP4 in AMI patients. A mathematical model for predicting AHF development in AMI patients was proposed. The model consisted of fixed effects, namely, two one-factor indicators (HOMA-IR and systolic blood pressure (BP)), one two-factor indicator (systolic and diastolic BP) and one three-factor indicator (adropin, irisin and CTRP3) and random effects such as four one-factor indicators (FABP4, TIMI Grade Flow, platelets, total cholesterol). The accuracy of predicting the absence of Killip class I AHF was 100%, Killip class II AHF – 0%, Killip class III AHF – 11%, Killip class IV AHF – 82%. It should be noted that systolic BP on day 1 was a strong negative prognostic factor, while HOMA-IR, the combined effect of adropin, irisin and CTRP3, the combined effect of systolic and diastolic BP were positive prognostic factors. Thus, the model showed a very high sensitivity in predicting Killip class IV AHF. The overall accuracy of the model was 89.4%.

Factors Determining Primary Coronary Slow Flow Phenomenon among Opium Users and Non-users: A Case Control Study in Northern Iran.

Coronary slow flow phenomenon (CSFP) represents a clinical entity with recurrent chest pain leading to living impairment. The present study aimed to investigate whether opium use correlates with primary CSFP. This study included Iranian patients with suspected coronary artery disease who underwent myocardial perfusion imaging. Coronary blood flow was measured quantitatively using the thrombolysis in myocardial infarction (TIMI) frame count and slow flow was defined as TIMI grade 2 standard deviations. Age and clinical conditions including diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), history of chest pain, and opium use were recorded. First, the characteristics of the two groups were compared and then the main analyses were conducted to examine the relationship between CSFP and opium use. Data were analyzed using t test and chi-square test via SPSS 25.0. The significance level was set at P<0.05. This study was conducted on 44 male patients with documented CSFP who had no stenotic lesions and 134 control group male patients who had normal coronary arteries with normal flow. The mean age was similar in the two groups (54.25 vs.52.69, P=0.474). Two groups were significantly different in terms of history of chest pain (P=0.003), but there was no significant difference in HTN (P=0.084), DM (P=0.284), HLP (P=0.183), smoking (P=0.696), and opium use (P=0.107). This study indicated that opium use is not associated with primary CSFP.

Successful visible thrombus aspiration in ST-segment elevation myocardial infarction: associated factors and the clinical impact.

Thrombus aspiration (TA) has been considered a procedure for controlling distal emboli and improving microvascular perfusion. However, current guidelines classify routine TA as class III recommendation, and it has been reported that the efficacy of TA is limited because of the relatively high incidence of failure in retrieval of thrombotic material. The aim of this study was to explore patient characteristics and procedural factors associated with successful TA in ST-elevation myocardial infarction (STEMI) and to assess the clinical impact of successful TA. This single-center retrospective study enrolled 158 STEMI patients who underwent TA as initial recanalization. Factors associated with successful TA, which was defined as retrieving any visible material by aspiration catheter, were explored, and angiographical and short-term outcomes were assessed. In 146 cases (92.4%), the aspiration catheter reached the culprit lesion. Successful TA was achieved in 72 cases (45.6%). The single angiographical characteristic of successful TA was a higher Thrombolysis in Myocardial Infarction grade before TA. Among the procedural characteristics, the rate of successful TA was higher with a 7-French aspiration catheter compared with the rate with a 6-French catheter (57.1% vs. 29.9%, P = 0.01). Thrombolysis in Myocardial Infarction grade 3 flow was more frequent in patients with successful TA immediately after TA (36.1% vs. 16.3%, P = 0.006) and at final angiography (91.7% vs 79.1%, P = 0.04) compared with the grade in patients without successful TA, respectively. The use of a larger aspiration catheter may be effective in retrieving visible thrombus material, and successful TA led to better angiographical results.

Gradual Versus Abrupt Reperfusion During Primary Percutaneous Coronary Interventions in ST-Segment-Elevation Myocardial Infarction (GUARD).

BackgroundIntramyocardial edema and hemorrhage are key pathological mechanisms in the development of reperfusion‐related microvascular damage in ST‐segment–elevation myocardial infarction. These processes may be facilitated by abrupt restoration of intracoronary pressure and flow triggered by primary percutaneous coronary intervention. We investigated whether pressure‐controlled reperfusion via gradual reopening of the infarct‐related artery may limit microvascular injury in patients undergoing primary percutaneous coronary intervention.Methods and ResultsA total of 83 patients with ST‐segment–elevation myocardial infarction were assessed for eligibility and 53 who did not meet inclusion criteria were excluded. The remaining 30 patients with totally occluded infarct‐related artery were randomized to the pressure‐controlled reperfusion with delayed stenting (PCRDS) group (n=15) or standard primary percutaneous coronary intervention with immediate stenting (IS) group (n=15) (intention‐to‐treat population). Data from 5 patients in each arm were unsuitable to be included in the final analysis. Finally, 20 patients undergoing primary percutaneous coronary intervention who were randomly assigned to either IS (n=10) or PCRDS (n=10) were included. In the PCRDS arm, a 1.5‐mm balloon was used to achieve initial reperfusion with thrombolysis in myocardial infarction grade 3 flow and, subsequently, to control distal intracoronary pressure over a 30‐minute monitoring period (MP) until stenting was performed. In both study groups, continuous assessment of coronary hemodynamics with intracoronary pressure and Doppler flow velocity was performed, with a final measurement of zero flow pressure (primary end point of the study) at the end of a 60‐minute MP. There were no complications associated with IS or PCRDS. PCRDS effectively led to lower distal intracoronary pressures than IS over 30 minutes after reperfusion (71.2±9.37 mm Hg versus 90.13±12.09 mm Hg, P=0.001). Significant differences were noted between study arms in the microcirculatory response over MP. Microvascular perfusion progressively deteriorated in the IS group and at the end of MP, and hyperemic microvascular resistance was significantly higher in the IS arm as compared with the PCDRS arm (2.83±0.56 mm Hg.s.cm−1 versus 1.83±0.53 mm Hg.s.cm−1, P=0.001). The primary end point (zero flow pressure) was significantly lower in the PCRDS group than in the IS group (41.46±17.85 mm Hg versus 76.87±21.34 mm Hg, P=0.001). In the whole study group (n=20), reperfusion pressures measured at predefined stages in the early reperfusion period showed robust associations with zero flow pressure values measured at the end of the 1‐hour MP (immediately after reperfusion: r=0.782, P<0.001; at the 10th minute: r=0.796, P<0.001; and at the 20th minute: r=0.702, P=0.001) and peak creatine kinase MB level (immediately after reperfusion: r=0.653, P=0.002; at the 10th minute: r=0.597, P=0.007; and at the 20th minute: r=0.538, P=0.017). Enzymatic myocardial infarction size was lower in the PCRDS group than in the IS group with peak troponin T (5395±2991 ng/mL versus 8874±1927 ng/mL, P=0.006) and creatine kinase MB (163.6±93.4 IU/L versus 542.2±227.4 IU/L, P<0.001).ConclusionsIn patients with ST‐segment–elevation myocardial infarction, pressure‐controlled reperfusion of the culprit vessel by means of gradual reopening of the occluded infarct‐related artery (PCRDS) led to better‐preserved coronary microvascular integrity and smaller myocardial infarction size, without an increase in procedural complications, compared with IS.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT02732080.

Effects of aggressive predilatation, sizing, and postdilatation strategy for coronary bioresorbable vascular scaffolds implantation.

The results of the recent Amsterdam Investigator-Initiated Absorb Strategy All-Comers trial showed that the predilatation, sizing, and postdilatation (PSP) technique did not lower the long-term rates of scaffold thrombosis and adverse events. We evaluated the impact of aggressive PSP bioresorbable vascular scaffold (BRS) implantation on the short- and long-term clinical outcomes. From June 2014 to December 2016, 150 patients with BRS implantation were enrolled and received successful percutaneous coronary intervention (PCI), of whom 104 received aggressive PSP technique (high-pressure predilatation and lesion preparation in addition to the traditional PSP technique). Short- and long-term outcomes were compared. All patients underwent successful PCI and BRS implantation with final Thrombolysis in Myocardial Infarction grade 3 flow. The baseline and procedure characteristics were similar in both groups. Debulking techniques were used in 13 (8.7%) patients. Intracoronary imaging modalities were used in 73 (48.7%) patients. After BRS implantation, no adverse events were observed within 30 days in both groups. During the mean follow-up period of 2.98 ± 0.77 years, 12 (8.0%) patients experienced major adverse cardiovascular events (MACEs), including one cardiovascular death (0.6%), three nonfatal myocardial infarction (2.0 %), and 11 target-vessel revascularization (7.3 %). Multivariate Cox regression analysis showed that aggressive PSP remained an independent protective factor for MACEs. Moreover, the use of intracoronary imaging and rotablation atherectomy was associated with better clinical outcomes. Lesion preparation by aggressive PSP in BRS implantation was associated with better long-term clinical outcomes.

Risk factors for cardiac rupture after acute ST-segment elevation myocardial infarction during the percutaneous coronary intervention era: a retrospective case-control study.

BackgroundIn percutaneous coronary intervention (PCI) era, more clinically valuable risk factors are still needed to determine the occurrence of cardiac rupture (CR). Therefore, we aimed to provide evidence for the early identification of CR in ST-segment elevation myocardial infarction (STEMI).MethodsA total of 22,016 consecutive patients with STEMI admitted to Cangzhou Central Hospital and Tianjin Chest Hospital from January 2013 to July 2021 were retrospectively included, among which 195 patients with CR were included as CR group. From the rest 21,820 STEMI patients without CR, 390 patients at a ratio of 1:2 were included as the control group. A total of 66 patients accepted PCI in the CR group, and 132 patients who accepted PCI in the control group at a ratio of 1:2 were included. The status of first medical contact, laboratory examinations, and PCI characteristics were recorded. Multivariate logistic regression analysis was used to investigate the risk factors related to CR.ResultsThere was a higher proportion of patients with myocardial infarction (MI) in the high lateral wall in the CR group (23.6% vs. 8.2%, P<0.001). The proportion of single lesions was lower in the CR group (24.2% vs. 45.5%, P=0.004). Female (OR =2.318, 95% CI: 1.431–3.754, P=0.001), age (OR =1.066, 95% CI: 1.041–1.093, P<0.001), smoking (OR =1.750, 95% CI: 1.086–2.820, P=0.022), total chest pain time (OR =1.017, 95% CI: 1.000–1.035, P=0.049), recurrent acute chest pain (OR =2.750, 95% CI: 1.535–4.927, P=0.001), acute myocardial infarction (AMI) in the high lateral wall indicated by ECG (OR =5.527, 95% CI: 2.798–10.918, P<0.001), acute heart failure (OR =3.585, 95% CI: 2.074–6.195, P<0.001), and NT-proBNP level (OR =1.000, 95% CI: 1.000–1.000, P=0.023) were risk factors for CR in all patients. In patients who accepted PCI, single lesion (OR =0.421, 95% CI: 0.204–0.867, P=0.019), preoperative thrombolysis in myocardial infarction (TIMI) grade (OR =0.358, 95% CI: 0.169–0.760, P=0.007), and postoperative TIMI grade (OR =0.222, 95% CI: 0.090–0.546, P=0.001) were risk factors for CR.ConclusionsNon-single lesions and preoperative and postoperative TIMI grades were risk factors for CR in patients who accepted PCI. In addition to previously reported indicators, we found that AMI in the high lateral wall maybe helpful in early and accurate identification and prevention of possible CR.