TIMI Myocardial Perfusion Grade Research Articles

Efficacy and safety of intracoronary pro-urokinase combined with low-pressure balloon pre-dilatation during percutaneous coronary intervention in patients with anterior ST-segment elevation myocardial infarction

BackgroundThe efficacy and safety of low-pressure balloon pre-dilatation before intracoronary pro-urokinase (pro-UK) in preventing no-reflow during percutaneous coronary intervention (PCI) remains unknown. This study aimed to evaluate the clinical outcomes of intracoronary pro-UK combined with low-pressure balloon pre-dilatation in patients with anterior ST-segment-elevation myocardial infarction (STEMI).MethodsThis was a randomized, single-blind, investigator-initiated trial that included 179 patients diagnosed with acute anterior STEMI. All patients were eligible for PCI and were randomized into two groups: intracoronary pro-UK combined with (ICPpD group, n = 90) or without (ICP group, n = 89) low-pressure balloon pre-dilatation. The main efficacy endpoint was complete epicardial and myocardial reperfusion. The safety endpoints were major adverse cardiovascular events (MACEs), which were analyzed at 12 months follow-up.ResultsPatients in the ICPpD group presented significantly higher TIMI myocardial perfusion grade 3 (TMPG3) compared to those in the ICP group (77.78% versus 68.54%, P = 0.013), and STR ≥ 70% after PCI 30 min (34.44% versus 26.97%, P = 0.047) or after PCI 90 min (40.0% versus 31.46%, P = 0.044). MACEs occurred in 23 patients (25.56%) in the ICPpD group and in 32 patients (35.96%) in the ICP group. There was no difference in hemorrhagic complications during hospitalization between the groups.ConclusionPatients with acute anterior STEMI presented more complete epicardial and myocardial reperfusion with adjunctive low-pressure balloon pre-dilatation before intracoronary pro-UK during PCI.Trial registration2019xkj213.

Coronary Slow-Flow Phenomenon in Takotsubo Syndrome: The Prevalence, Clinical Determinants, and Long-Term Prognostic Impact.

Patients with takotsubo syndrome (TTS) may present coronary slow flow (CSF) in angiography performed in the acute myocardial infarction (MI). However, the detailed clinical relevance and its long-term impact remain poorly understood. Among 7771 MI patients hospitalized between 2012 and 2019, TTS was identified in 82 (1.1%) subjects. The epicardial blood flow was assessed with thrombolysis in myocardial infarction (TIMI) scale and corrected TIMI frame count (TFC), whereas myocardial perfusion with TIMI myocardial perfusion grade (TMPG). CSF was defined as TIMI-2 or corrected TFC > 27 frames in at least one epicardial vessel. CSF was identified in 33 (40.2%) TTS patients. In the CSF-TTS versus normal-flow-TTS group, lower values of left ventricular ejection fraction on admission (33.5 (25-40) vs. 40 (35-45)%, p = 0.019), more frequent midventricular TTS (27.3 vs. 8.2%, p = 0.020) and the coexistence of both physical and emotional triggers (9.1 vs. 0%, p = 0.032) were noted. Within a median observation of 55 months, higher all-cause mortality was found in CSF-TTS compared with normal-flow TTS (30.3 vs. 10.2%, p = 0.024). CSF was identified as an independent predictor of long-term mortality (hazard ratio 10.09, 95% confidence interval 2.12-48.00, p = 0.004). CSF identified in two-fifths of TTS patients was associated with unfavorable long-term outcomes.

Intracoronary antithrombotic therapy during primary percutaneous coronary intervention in patients with STEMI: A systematic review and network meta-analysis

IntroductionThe efficacy of intracoronary (IC) antithrombotic therapy, which may best prevent the no-reflow phenomenon during percutaneous coronary intervention (PCI), remains unclear. Therefore, we compared the efficacy and safety of different IC antithrombotic agents. Materials and methodsThis systematic review and network meta-analysis of randomized controlled trials (RCTs) compared IC fibrinolytic agents (recombinant tissue plasminogen activators [rtPAs] and non-rtPAs) or glycoprotein IIb/IIIa inhibitors (small molecules and monoclonal antibodies) with placebo by searching the relevant studies published before September 21, 2022. Bayesian network meta-analyses were performed using random-effects models. ResultsTwenty-five RCTs with 4546 patients were included. Non-rtPAs and small molecules were significantly more effective in achieving thrombolysis in myocardial infarction (TIMI) grade 3 flow than placebo (odds ratio [OR] 2.28, 95 % credible intervals [CrI] 1.24–4.13; OR 2.06, 95 % CrI 1.17–3.46). Moreover, these agents' efficacy was observed in other microcirculation-related outcomes, including TIMI myocardial perfusion grade 3, complete ST-segment resolution, and corrected TIMI frame counts. Within 6 months, small molecules were associated with both an improved left ventricular ejection fraction (MD 3.90, 95 % CrI 0.48–7.46) and major adverse cardiac events (MACE) reduction (OR 0.36, 95 % CrI 0.20–0.61). Non-rtPAs demonstrated a reduced MACE incidence within 6 months (OR 0.51, 95 % CrI 0.31–0.81). The results were consistent in the subgroup with a total ischemic time > 6 h. No significant differences in mortality or bleeding events were observed. ConclusionsIC non-rtPAs and small molecules may be effective for adjunctive therapy to PCI, particularly in patients with longer ischemia periods.

Effects of atorvastatin and rosuvastatin on dysfunctional coronary circulation in patients with ST-segment elevation myocardial infarction.

Evidence of therapy for dysfunctional coronary circulation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) is limited. This study was performed to compare the effects of atorvastatin and rosuvastatin on dysfunctional coronary circulation. This retrospective study enrolled 597 consecutive patients with STEMI who underwent pPCI in 3 centers from June 2016 to December 2019. Dysfunctional coronary circulation was defined by the thrombolysis in myocardial infarction (TIMI) grade and the TIMI myocardial perfusion grade (TMPG). Logistic regression analysis was used to evaluate the impact of different statin types on dysfunctional coronary circulation. The incidence of TIMI no/slow reflow did not differ between the two groups, but the incidence of TMPG no/slow reflow was significantly lower in the atorvastatin than rosuvastatin group (44.58% vs. 57.69%, respectively). After multivariate adjustment, the odds ratio with 95% confidence interval of rosuvastatin was 1.72 (1.17-2.52) for after pretreatment TMPG no/slow reflow and 1.73 (1.16-2.58) for after stenting TMPG no/slow reflow. Atorvastatin and rosuvastatin showed no significant differences in clinical outcomes during hospitalization. Compared with rosuvastatin, atorvastatin was associated with better coronary microcirculatory perfusion in patients with STEMI who underwent pPCI.

Ticagrelor vs. clopidogrel for coronary microvascular dysfunction in patients with STEMI: a meta-analysis of randomized controlled trials.

Approximately half of ST-segment elevation myocardial infarction (STEMI) patients who undergo revascularization present with coronary microvascular dysfunction. Dual antiplatelet therapy, consisting of aspirin and a P2Y12 inhibitor (e.g., clopidogrel or ticagrelor), is recommended to reduce rates of cardiovascular events after STEMI. The present study performed a pooled analysis of randomized controlled trials (RCTs) to compare effects of ticagrelor and clopidogrel on coronary microcirculation dysfunction in STEMI patients who underwent the primary percutaneous coronary intervention. The PubMed, Embase, Cochrane Library, and Web of Science databases were searched for eligible RCTs up to September 2022, with no language restriction. Coronary microcirculation indicators included the corrected thrombolysis in myocardial infarction (TIMI) frame count (cTFC), myocardial blush grade (MBG), TIMI myocardial perfusion grade (TMPG), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR). Seven RCTs that included a total of 957 patients (476 who were treated with ticagrelor and 481 who were treated with clopidogrel) were included. Compared with clopidogrel, ticagrelor better accelerated microcirculation blood flow [cTFC = -2.40, 95% confidence interval (CI): -3.38 to -1.41, p < 0.001] and improved myocardial perfusion [MBG = 3, odds ratio (OR) = 1.99, 95% CI: 1.35 to 2.93, p < 0.001; MBG ≥ 2, OR = 2.57, 95% CI: 1.61 to 4.12, p < 0.001]. Ticagrelor has more benefits for coronary microcirculation than clopidogrel in STEMI patients who undergo the primary percutaneous coronary intervention. However, recommendations for which P2Y12 receptor inhibitor should be used in STEMI patients should be provided according to results of studies that investigate clinical outcomes.

Prepercutaneous coronary intervention Zalunfiban dose-response relationship to target vessel blood flow at initial angiogram in st-elevation myocardial infarction – A post hoc analysis of the cel-02 phase IIa study

Zalunfiban (RUC-4) is a novel, subcutaneously administered glycoprotein IIb/IIIa inhibitor (GPI) designed for prehospital treatment to initiate reperfusion in the infarct-related artery (IRA) before primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction (STEMI). Since GPIs have been reported to rapidly reperfuse IRAs, we assessed whether there was a dose-dependent relationship between zalunfiban treatment and angiographic reperfusion indices and thrombus grade of the IRA at initial angiogram in patients with STEMI. This was a post hoc analysis from the open-label Phase IIa study that investigated the pharmacodynamics, pharmacokinetics, and tolerability of three doses of zalunfiban - 0.075, 0.090 and 0.110 mg/kg - in STEMI patients. This analysis explored dose-dependent associations between zalunfiban and three angiographic indices of the IRA, namely coronary and myocardial blood flow and thrombus burden. Zalunfiban was administered in the cardiac catheterization laboratory prior to vascular access, ∼10 to 15 minutes before the initial angiogram. All angiographic data were analyzed by a blinded, independent, core laboratory. Twentyfour out of 27 STEMI patients were evaluable for angiographic analysis (0.075 mg/kg [n=7], 0.090 mg/kg [n=9], and 0.110 mg/kg [n=8]). TIMI flow grade 2 or 3 was seen in 1/7 patients receiving zalunfiban at 0.075 mg/kg, in 6/9 patients receiving 0.090 mg/kg, and in 7/8 patients receiving 0.110 mg/kg (ptrend=0.004). A similar trend was observed based on TIMI flow grade 3. Myocardial perfusion was also related to zalunfiban dose (ptrend=0.005) as reflected by more frequent TIMI myocardial perfusion grade 3. Consistent with the dose-dependent trends in greater coronary and myocardial perfusion, TIMI thrombus ≥4 grade was inversely related to zalunfiban dose (ptrend=0.02). This post hoc analysis found that higher doses of zalunfiban administered in the cardiac catheterization lab prior to vascular access were associated with greater coronary and myocardial perfusion, and lower thrombus burden at initial angiogram in patients with STEMI undergoing primary percutaneous coronary intervention.

Intra-Aortic Balloon Pump During Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction With High Thrombus Burden and Cardiogenic Shock.

Percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) with high-grade thrombus is a high-risk intervention associated with poor clinical outcomes. Circulatory support with an intra-aortic balloon pump (IABP) during PCI may potentially improve coronary hemodynamics and clinical outcomes in such patients. As existing data on this situation are sparse, we did an observational study to determine short-term outcomes of PCI with IABP support in STEMI patients with high thrombus burden. To determine whether IABP has a potential role in improving outcomes in patients with STEMI with high thrombus burden who are undergoing PCI. Thirty consecutive patients of STEMI with high thrombus burden undergoing PCI with IABP assistance were included. Ninety-three percent of patients had a cardiogenic shock. Clinical and angiographic outcomes assessed include a change in left ventricular ejection fraction (LVEF), 30-day mortality, and assessment of TIMI (thrombolysis in myocardial infarction) flow, TIMI frame count, and TIMI myocardial perfusion grade in the culprit vessel.IABP was initiated before coronary angiography in 36.6% (n=11), between angiography and PCI in 30% (n=9), and after PCI in 33.3% (n=10) of patients. During the 30-dayfollow-up period, 50% (n=15) of patients died. 86.6% (n=13) of survivors had pre-PCI IABP initiation compared to only 46.6% (n=7) among those who died (p=0.020). With pre-PCI IABP initiation (n=20), 30-day mortality was 35% (n=7) compared to 80% (n=8) with post-PCI IABP initiation (n=10) (p=0.020). IABP initiation before PCI in STEMI complicated by cardiogenic shock andhigh angiographic thrombus burden can decrease mortality without any effect on angiographic parameters.

Correlation of Electrocardiogram Changes with Epicardial and Myocardial Perfusion in ST-Elevation Myocardial Infarction

Background: The present study was aimed to find the correlation of electrocardiographic changes with epicardial thrombolysis in myocardial infarction (TIMI) flow grade and TIMI myocardial perfusion grade (TMPG) after reperfusion in ST-elevation myocardial infarction (STEMI). Methods: One hundred and fifty patients with STEMI were included. Reperfusion was done either by thrombolysis or primary percutaneous coronary intervention. The summed absolute ST-segment deviation and summed relative ST-segment deviation were calculated. TIMI and TMPG were assessed. The primary outcome measures were to study the correlation of summed absolute ST deviation and summed relative ST deviation with TIMI flow grade and TMPG after reperfusion. The secondary outcome measures were to compare TIMI flow grade and TMPG with respect to time since symptom onset to treatment and T-wave inversion after reperfusion. Results: There was a significant positive correlation between relative ST-segment deviation that occurred after reperfusion with TIMI flow grade (r = 0.475) and TMPG (r = 0.376). There was a significant negative correlation between absolute ST-segment deviation that occurred after reperfusion with TIMI flow grade (r = −0.194) and TMPG (r = −0.288). A significantly higher percentage (87.4%) of patients who got treatment within 1 h showed TMPG 2 and 3. A significantly higher percentage of patients who had T-wave inversion after reperfusion had TIMI flow Grade 3 and TMPG 2 and 3. Conclusions: There was a significant positive correlation between relative ST-segment deviation and significant negative correlation between absolute ST-segment deviation after reperfusion with TIMI flow grade and TMPG.

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.

Abstract 11377: Takotsubo Syndrome Among Patients With Spontaneous Coronary Artery Dissection: A Report of the ISCAD Registry

Introduction: Association of takotsubo syndrome (TTS) with spontaneous coronary artery dissection (SCAD) has been described previously. Characteristics and in-hospital prognosis of SCAD patients with concomitant TTS remain unclear. Methods: Patients with angiography-confirmed SCAD were selected from the iSCAD Registry and underwent core lab adjudication of left ventriculography (LVG) and coronary angiography including assessment of SCAD lesion characteristics, TIMI Flow Grade (TFG), and TIMI Myocardial Perfusion Grade (TMPG). Classic TTS was defined as wall motion abnormality (WMA) presenting as apical ballooning. TTS variants were defined as non-apical WMA discordant to dissected coronary territory with apical sparing. In-hospital event was defined as composite of recurrent myocardial infarction (MI), cerebrovascular accident, heart failure requiring diuretics, or new arrhythmia. Results: On blinded review of LVG from 216 patients, TTS was identified in 38 (17.6%) patients (classic, midventricular, and focal pattern: 86.8%, 2.6%, and 10.5%, respectively). There was no significant difference in age, cardiovascular risk factors, history of anxiety or depression, recreational substance use, emotional or physical stressors, extracoronary vascular abnormalities, peak troponin levels, or TFG of dissected arteries between TTS and non-TTS groups. TTS patients were more likely to present with ST-segment elevation MI (47.4% vs 27.5%; p=0.02), left anterior descending artery (LAD) involvement (89.5% vs 59.0%; p=0.0004), and TMPG &lt; 3 (68.4% vs 48.3%; p=0.02) compared to non-TTS patients. TTS patients had a greater risk of in-hospital events (32.4% vs 15.1%; p=0.01), mainly attributed to new arrhythmia (27.0% vs 6.5%; p=0.0009) and heart failure (11.4% vs 3.0%; p=0.03). Conclusion: Coexistence of TTS and SCAD was associated with ST-elevation MI, LAD involvement, impaired microvascular myocardial perfusion, and adverse in-hospital outcomes.

D-Dimer Is Associated With Coronary Microvascular Dysfunction in Patients With Non-obstructive Coronary Artery Disease and Preserved Ejection Fraction.

BackgroundCoronary microvascular dysfunction (CMVD), an important etiology of ischemic heart disease, has been widely studied. D-dimer is a simple indicator of microthrombosis and inflammation. However, whether an increase in D-dimer is related to CMVD is still unclear.Materials and MethodsThis retrospective study consecutively enrolled patients with myocardial ischemia and excluded those with obstructive coronary artery. D-dimer was measured at admission and the TIMI myocardial perfusion grade (TMPG) was used to distinguish CMVD. Patients were divided into the two groups according to whether the D-dimer was elevated (>500 ng/ml). Logistic models and restricted cubic splines were used to explore the relationship between elevated D-dimer and CMVD.ResultsA total of 377 patients were eventually enrolled in this study. Of these, 94 (24.9%) patients with CMVD had older age and higher D-dimer levels than those without CMVD. After full adjustment for other potential clinical risk factors, patients with high D-dimer levels (>500 ng/ml) had a 1.89-times (95% CI: 1.09–3.27) higher risk of CMVD than patients with low D-dimer levels. A non-linear relationship was found between concentrations of D-dimer and CMVD. With increased D-dimer level, the incidence of CMVD increased and then remained at a high level. Stratified analysis was performed and showed similar results.ConclusionElevated D-dimer level is associated with the incidence of CMVD and potentially serves as a simple biomarker to facilitate the diagnosis of CMVD for patients with angina.

Efficacy and safety of intracoronary pro-urokinase injection during percutaneous coronary intervention in treating ST elevation myocardial infarction patients: a systematic review and meta-analysis of randomized controlled trials.

Intracoronary injection of pro-urokinase (Pro-UK) during percutaneous coronary intervention (PCI) seems to be a promising treatment in improving myocardial perfusion. In this systematic review and meta-analysis, we aimed at investigating the efficacy and safety of intracoronary Pro-UK injection during PCI in ST elevation myocardial infarction (STEMI) patients. A comprehensive literature searched on PubMed, Embase, Cochrane, Ovid-MEDLINE, Ovid-Embase, Ovid-Cochrane Databases and ClinicalTrials.gov from inception until June 1, 2022, in English only. The primary outcome was myocardial perfusion, including thrombolysis in myocardial infarction (TIMI) grades, corrected TIMI frame count (CTFC), TIMI myocardial perfusion grades (TMPG). The secondary outcomes were ST-segment resolution (STR), major adverse cardiovascular events (MACE), myocardial marker, cardiac function and hemorrhagic complications. We identified 5 studies (all RCTs) involving 761 participants. Under PCI procedure, compared with placebo, intracoronary Pro-UK injection may improve myocardial perfusion, including increasing the TIMI grades [odd ratio (OR) 0.46; 95% confidence interval (CI) 0.28-0.75; p = 0.002; I2 = 0%] , CTFC (OR -3.47; 95% CI [-5.60, -1.33]; p = 0.001; I2 = 0%) and TMPG (OR 0.17; 95% CI [0.06-0.44]; p = 0.0003; I2 = 0%), increase the rate of STR (OR 2.25; 95% CI [1.56-3.26]; p < 0.0001; I2 = 0%), reduce the incidence of MACE (OR 0.51; 95% CI [0.33-0.81]; p = 0.004; I2 = 0%) and reduce myocardial infarct size (CK, standardized mean difference [SMD] -0.45; 95% [CI] [-0.62, -0.28]; p < 0.00001; I2 = 10%. CK-MB, [SMD] -0.43; 95% CI [-0.68, -0.18]; p = 0.0007; I2 = 60%. cTnI, [SMD] -0.31; 95% CI [-0.46, -0.17]; p < 0.0001; I2 = 0%). Moreover, the treatment may improve the cardiac functions (LVFE, pooled mean difference [MD] 1.23; 95% CI [0.66-1.79]; p < 0.0001; I2 = 24%. LVEDd, pooled MD -0.13; 95% CI [-0.17, -0.09]; p < 0.00001; I2 = 0%). But there is no statistically significant difference between the Pro-UK group and placebo in the occurrence of hemorrhagic complications (OR 1.19; 95% CI [0.75-1.87]; p = 0.46; I2 = 0%). Intracoronary Pro-UK injection during PCI in STEMI patients is an effective and safe treatment to perform. The treatment may improve myocardial perfusion and rate of STR, as well as decreasing the incidence of MACE and myocardial infarct size. Importantly, the treatment may improve the cardiac functions and life quality. In the future, more multi-centered and massive sample studies are required.

The Association between Vitamin D Levels and Thrombus Burden in Patients with ST-Elevation Myocardial Infarction.

Background: In current practice, establishing the potential predictors of high thrombus burden (HTB) before primary percutaneous coronary intervention (PCI) is crucial for its management. In this research, we aimed to investigate the association between vitamin D levels and HTB in patients with ST-elevation myocardial infarction (STEMI). Methods: This prospective, observational study was conducted on 257 STEMI patients undergoing primary PCI in Van Education and Research Hospital between March 2020 and March 2021. The thrombus burden grade was determined for each subject. The study population was divided into 2 groups: patients with HTB and those with low thrombus burden (LTB) based on the thrombus burden grade. Demographic, laboratory, and angiographic features were compared between the groups. Results: In total, 154 patients (mean age±SD=63.42±11.53 y, 65.6% male) had HTB and 103 patients had LTB (mean age±SD=61.50±10.23 y, 70.9% male). The patients stratified into the HTB group had lower vitamin D levels than those in the LTB group (8.0 ng/mL vs 17.9 ng/mL, respectively; P<0.001). The patients with HTB and low vitamin D levels had lower post-PCI thrombolysis in myocardial infarction (TIMI) flow, TIMI myocardial perfusion grade, and post-PCI ST resolution. In a multivariable analysis, vitamin D was an independent predictor of HTB among the STEMI patients (OR: 0.76, 95%CI: 0.70-0.82; P<0.001). The ideal value of vitamin D to predict HTB was >17.6 ng/mL with a sensitivity of 81.8% and a specificity of 90.3%. Conclusion: The study results showed that vitamin D levels were an independent predictor of HTB in STEMI patients treated by primary PCI.

Assessment of the Efficacy and Safety of Early Intracoronary Nicorandil Administration in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

BackgroundNo-reflow phenomenon (NRP) remains a challenge in ST-elevation myocardial infarction (STEMI) patients. We determined the efficacy and safety of early intracoronary administration of nicorandil as an adjunct to primary percutaneous coronary intervention (pPCI) in STEMI patients to reduce the risk of NRP.Materials and methodsIn this single-center case-control prospective study, 100 STEMI patients who underwent pPCI had thrombectomy performed using a suction catheter, and tirofiban (10 mg/kg) was injected distal to the vascular lesion. All patients were divided into two groups. Group A was a treatment group (nicorandil, n=50) and group B was a control group (placebo, n=50). The primary endpoint was the composite endpoint of in-hospital cardiovascular mortality or unscheduled re-hospitalization due to deterioration of congestive heart failure that was assessed with the help of brain natriuretic peptide (BNP), left ventricular end-diastolic diameter (LVEDD), and left ventricular ejection fraction at six months following pPCI. The secondary endpoints were thrombolysis in myocardial infarction (TIMI) flow grade, TIMI myocardial perfusion grade (TMPG), the incidence of reperfusion arrhythmias like ventricular tachycardia and ventricular fibrillation, and ST segment elevation resolution (STR) on ECG following pPCI.ResultsThe in-hospital cardiovascular mortality and re-hospitalization rates were 2% and 6% in the nicorandil group, whereas it was 6% and 14% in the control group. On the 180th day of admission, the nicorandil group had significantly lower values of brain natriuretic peptide (348.45±112.32 pg/ml vs. 541.11±152.68 pg/ml, p=0.021) and left ventricular end-diastolic diameter (54.12±3.56 mm vs. 60.62±4.98 mm, p=0.011) than the control group. Nicorandil group had a significantly higher number of patients who attained TIMI 3 (p=0.022), TMPG 3 (p=0.034), and STR (p=0.008) than the control group. Ventricular arrhythmia was significantly lower in the nicorandil group than in the control group at 24 hours following pPCI (p=0.012).ConclusionEarly intracoronary administration of nicorandil during pPCI may decrease the occurrence of NRP, in-hospital cardiovascular mortality, and re-hospitalization rates, as well as improve coronary blood flow and reduce reperfusion arrhythmia in STEMI patients.

Intracoronary pharmacological therapy versus aspiration thrombectomy in STEMI (IPAT-STEMI): A systematic review and meta-analysis of randomized trials.

BackgroundThrombus load in STEMI patients remains a challenge in practice. It aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Various strategies have been advocated to reduce thrombus burden.ObjectivesThis meta-analysis aimed to evaluate the effectiveness of intracoronary-administered thrombolytics or glycoprotein IIb/IIIa inhibitors (GPI) in comparison with aspiration thrombectomy (AT) as an adjunct to percutaneous coronary intervention (PCI) among patients presenting with ST-segment elevation myocardial infarction (STEMI).MethodsA comprehensive literature search for randomized trials that compared intracoronary-administered thrombolytics or GPI with AT in STEMI patients who underwent PCI, was conducted using various databases (e.g., MEDLINE, EMBASE, CENTRALE). Primary outcome was procedural measures (e.g., TIMI flow grade 3, TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR)).ResultsTwelve randomized trials enrolled 1,466 patients: 696 were randomized to intracoronary-administered pharmacological interventions and 553 to AT. Patients randomized to PCI alone were excluded. Thrombolytics significantly improved TIMI flow grade 3 (odds ratio = 3.71, 95% CI: 1.85–7.45), complete STR (odds ratio = 3.64, 95% CI: 1.60–8.26), and TMPG 3 (odds ratio = 5.31, 95% CI: 2.48–11.36). Thrombolytics significantly reduced major adverse cardiovascular events (MACE) (odds ratio = 0.29, 95% CI: 0.13–0.65) without increasing bleeding risk. Trial sequential analysis assessment confirmed the superiority of thrombolytics for the primary outcome. Intracoronary GPI, either alone or combined with AT, did not improve procedural or clinical outcomes.ConclusionsCompared with AT, intracoronary-administered thrombolytics significantly improved myocardial perfusion and MACE in STEMI patients.

Postoperative adverse cardiac events in acute myocardial infarction with high thrombus load and best time for stent implantation.

BACKGROUNDMyocardial infarction is one of the most common types of coronary heart disease. It is mainly caused by the rupture of coronary atherosclerotic plaque, which leads to platelet agglutination and thrombosis. The occlusion of coronary arteries and vessels leads to insufficient myocardial blood supply, subsequently causing cardiac interstitial fibrosis, gradual enlargement of ventricles, and heart failure, which affects the quality of life and safety of patients. AIMTo investigate the effects of emergency percutaneous interventional therapy (PCI) and delayed stenting in acute myocardial infarction with high thrombotic load and identify factors related to major adverse cardiovascular events (MACE). METHODSA total of 164 patients with acute myocardial infarction and high thrombotic load who received PCI were included. Of them, 92 patients were treated with delayed stent implantation (delayed group) and 72 patients received emergency PCI (immediate group). Myocardial perfusion after stent implantation was compared between the two groups. Patients were followed up for 12 mo, and the occurrence of MACE was used as the endpoint. Univariate and multivariate models were used to analyze the factors affecting MACE occurrence.RESULTSAfter stent implantation, 66 (71.74%) patients in the delayed group and 40 (55.56%) patients in the immediate group had thrombolysis in myocardial infarction (TIMI) flow grade 3 (P < 0.05), while 61 (66.30%) patients in the delayed group and 39 (54.17%) patients in the immediate group reached TIMI myocardial perfusion grade 3 (P > 0.05). MACE occurred in 29 patients. There were statistically significant differences between the MACE and non-MACE groups in diabetes rate, TIMI grading, stent implantation timing, intraoperative use of tirofiban, and the levels of white blood cells (WBC), neutrophils, red blood cell distribution width (RDW), and uric acid, and high-sensitivity C-reactive protein (hs-CRP) at admission (P < 0.05). Logistic regression analysis showed that TIMI grade 3 and intraoperative use of tirofiban effectively reduced the risk of MACE (P < 0.05), while immediate stent implantation, increased WBC, hs-CRP and RDW on admission increased the risk of MACE (P < 0.05). CONCLUSIONDelayed stent implantation outweighs emergency PCI in improving postoperative myocardial perfusion in acute myocardial infarction with high thrombotic load, and effectively reduces MACE in these patients.

Elevated uric acid is related to the no-/slow-reflow phenomenon in STEMI undergoing primary PCI.

No-/slow-reflow phenomenon (NRP) is a severe complication in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). This study aimed to explore the relationship between elevated serum uric acid (SUA) and NRP in patients with STEMI undergoing pPCI, focusing on inflammation and angiographic findings. A total of 610 patients who received pPCI for STEMI were retrospectively enrolled. Patients were divided into a hyperuricaemia group and a non-hyperuricaemia group according to SUA levels. Clinical information and angiographic indicators were compared between the two groups. Thrombolysis in myocardial infarction (TIMI) flow and TIMI myocardial perfusion grade (TMPG) <3 after stent implantation were defined as TIMI-NRP and TMPG-NRP, respectively. A logistic model was used to analyse the relationship between hyperuricaemia and NRP. The hyperuricaemia group had a higher incidence of TIMI-NRP (24.9% vs 14.0%, p<.001) and TMPG-NRP (33.0% vs 24.9%, p=.03), higher levels of C-reactive protein (7.2 vs 4.1mg/L, p<.001) and worse left ventricular ejection fraction (51.5% vs 54.0%, p=.002) than the non-hyperuricaemia group. As for angiographic findings, there was no significant difference between the two groups in terms of lesion characteristics measured by quantitative coronary angiography. After multivariable adjustment, elevated SUA was significantly associated with TIMI-NRP (odds ratio: 1.94, 95% confidence interval: 1.24-3.01, p=.003). Subgroup analysis showed that the effect of hyperuricaemia in TIMI-NRP was more pronounced in patients with delayed perfusion as well as in patients with diabetes mellitus. Elevated SUA is associated with severe inflammation and has higher incidence of TIMI-NRP in patients with STEMI undergoing pPCI, especially in those with delayed perfusion or diabetes mellitus.

Distal Intracoronary Delivery of Epinephrine versus Verapamil to Prevent No-Reflow During Primary Percutaneous Coronary Intervention: A Randomized, Open-Label, Trial

Background: Previous trials showed a promising potential use of epinephrine in the treatment of no-reflow phenomenon (the no-reflow phenomenon is multiple pathogenetic processes, which may be attributed to ischemic injuries, distal atherothrombotic embolization, coronary-microcirculation susceptibility to injury, and reperfusion injuries (6)). This study aimed to compare the safety and efficacy of distal intracoronary delivery of epinephrine versus verapamil to prevent no-reflow during primary percutaneous coronary intervention (PPCI). Materials and Methods: We conducted a randomized, open-label, trial on patients undergoing PPCI. Patients were randomized to one of three groups: group I who received distal intracoronary administration of epinephrine; group II who received verapamil; and group III who served as a control group. The primary endpoint in our study was the incidence of no-reflow, defined as a post-procedural (Thrombolysis in Myocardial Infarction) TIMI flow grade (TFG) is &lt; 3 or, in the case of a TFG of 3, when TIMI myocardial perfusion grade (TMPG) is 0 or 1. Results: A total of 120 patients were randomized. The angiographic flow and perfusion parameters were significantly improved in group I and II versus the control group, with better results in epinephrine group only TMPG3 was significantly higher with epinephrine (77.5%) than verapamil (55%) (p = 0.037) and TMPG2 was higher in verapamil (32.5%) than epinephrine (7.5%) (p = 0.003). No reflow is lower with epinephrine than verapamil (25% vs 27.5%); however, with no statistically significant difference (P=0.785). Patients in the three groups has no statistical significant difference in (MACE) or heart failure hospitalization. Conclusion: Epinephrine and verapamil are safe and effective in managing patients with no-reflow during PPCIs. Further studies with a larger sample and a longer duration of follow-up are required to confirm these findings

Intracoronary pharmacological therapy versus aspiration thrombectomy in patients presenting with ST-segment elevation myocardial infarction (IPAT-STEMI): a systematic review and meta-analysis

Abstract Background Large thrombus load remains a challenge in the interventional cardiology practice. It precludes direct stent implementation and aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Thus, various strategies have been advocated such as aspiration thrombectomy (AT), and/or localized or intracoronary (IC) treatment with thrombolytic agents and/or glycoprotein IIb/IIIa inhibitors (GPI). Purpose To evaluate the effectiveness of IC-administered pharmacological agents alone or combined with AT compared with AT alone as an adjunct to percutaneous coronary intervention (PCI) in STEMI patients with large thrombus burden. Methods The method was conducted according to the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A systematic search strategy using MEDLINE, EMBASE, CENTRALE, Scopus, ProQuest Public Health, Web of Science databases was performed on February 22, 2020 and updated on February 13, 2021. Eligible trials were randomized controlled trials (RCT) comparing IC-administered thrombolytic agents and/or GPI with or without AT to AT alone in patients presenting with STEMI who underwent PCI. The primary outcomes included coronary reperfusion indices e.g., thrombolysis in myocardial infarction (TIMI) flow grade 3 (G3), TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR). Others included clinical outcomes e.g., major adverse cardiovascular events (MACE). Results Twelve RCT enrolled 1,466 patients were included in the final analysis. The trials were categorized into 3 groups: (1) Thrombolytics [4 RCT], (2) GPI [3 RCT], and (3) GPI+AT [7 RCT]. Groups 2 and 3 included two mutual studies with multiple arms. In comparison with AT alone, thrombolytic therapy, as presented in four RCT, significantly improved TIMI flow G3 (OR = 3.71, 95% CI: 1.85–7.45; P overall effect = 0.0002; heterogeneity = 0%), complete STR (OR = 3.64, 95% CI: 1.60–8.26; P overall effect = 0.002; heterogeneity = 34%) and MACE (OR = 0.47, 95% CI: 0.22–0.99; P overall effect = 0.05; heterogeneity = 46%), but not TMPG 3. Pooling the data of the two studies with similar intervention i.e., thrombolytics + AT further refined the results with statistical improvement of TMPG 3 as well (OR = 5.44, 95% CI: 2.61- 11.34; P overall effect &amp;lt;0.ehab724.211201; heterogeneity = 0%) (Fig. 1). Pooled results for GPI and GPI+AT groups did not show statistical improvement in TIMI flow G3, MBG 2/3, nor complete STR (Fig. 2). Conclusion The findings of this meta-analysis showed that IC-administered thrombolytic agents improved myocardial reperfusion and MACE compared with AT alone in STEMI patients undergoing PCI. Funding Acknowledgement Type of funding sources: None.

Coronary slow-flow phenomenon in takotsubo syndrome: the prevalence, clinical determinants and long-term prognostic impact

Abstract Background Previous studies demonstrated that patients with takotsubo syndrome (TTS) may present with coronary slow-flow (CSF) at coronary angiography performed in the acute phase [1]. However, the exact clinical relevance and its long-term prognostic impact have not been established yet. In the only recently published study Montone et al. proved that TTS patients with CSF were characterized by a worse clinical presentation with higher rate of intrahospital complications and poor long-term clinical outcome [2]. Purpose We sought to investigate the prevalence of CSF in TTS patients, its determinants and long-term prognostic impact. Methods Among 7771 myocardial infarction patients hospitalized in our center in 2012–2019 years, we identified 82 (1.1%) TTS patients with performed coronary angiography (Figure 1A). The coronary flow was assessed quantitatively with TIMI Frame Count (TFC), whereas myocardial perfusion with TIMI myocardial perfusion grade (TMPG). The clinical and angiographic characterstics of 67 TTS patients complying with MINOCA definition were compared with representative 50 non-TTS MINOCA (Figure 1A). Results CSF (TIMI 2) was identified in 33 (40.2%) TTS patients. CSF-TTS patients were characterized with higher TFC and worse TMPG in each analyzed coronary vessel (Figure 1B). CSF was observed in LAD artery in each patient, in 78.8% in LCx and in 33.3% in RCA, respectively. In CSF-TTS lower values of LVEF on admission (33.5 (25–40) vs 40 (35–45)%, P=0.019) as well as more frequent midventricular TTS (27.3 vs 8.2%, P=0.020), nearly normal coronary arteries (&amp;lt;30% stenosis) (75.8 vs 49.0%, P=0.015) and coexistence of both physical and emotional triggers (9.1 vs 0%, P=0.032) were noted. Moreover, CSF was observed significantly more frequent than in non-TTS MINOCA (44.8 vs 10.0%, P&amp;lt;0.001) with different distribution in particular vessels (P&amp;lt;0.001). In median 55 months of long-term observation higher all-cause mortality was stated in CSF-TTS (30.3 vs 10.2%, P=0.024) (Figure 1C) without difference between TTS and non-TTS MINOCA (P=0.42) (Figure 1D). By Cox proportional hazards model the CSF was identified as an independent predictor of long-term mortality (P&amp;lt;0.001). Conclusions As has been shown high proportion of TTS patients were characterized with remarkably marked myocardial perfusion abnormalities, especially in the left coronary vessels, which were associated with unfavorable long-term prognosis. Our study is the first presenting the direct angiographic, clinical and prognostic comparison of TTS MINOCA and non-TTS MINOCA patients. Funding Acknowledgement Type of funding sources: None. Figure 1