Time Of Primary Primary Percutaneous Coronary Intervention Research Articles

Intracoronary thrombolysis in ST-elevation myocardial infarction: a systematic review and meta-analysis

BackgroundDespite restoration of epicardial blood flow in acute ST-elevation myocardial infarction (STEMI), inadequate microcirculatory perfusion is common and portends a poor prognosis. Intracoronary (IC) thrombolytic therapy can reduce microvascular thrombotic...

Pathophysiology and Treatment of the No-Reflow Phenomenon in ST-Segment Elevation Myocardial Infarction: Focus on Low-Dose Fibrinolysis during Primary Percutaneous Intervention.

Primary percutaneous coronary intervention (PCI) is the current class I therapeutic approach to treat acute ST-elevation myocardial infarction (STEMI). While primary PCI can restore adequate flow in the infarcted artery in the majority of cases, some patients experience the 'no-reflow' phenomenon, i.e., an abnormal myocardial reperfusion occurring even after the occluded coronary artery has been opened. No-reflow occurs when microvascular obstruction arises from embolization of thrombus or components of the atheromatous plaques. These embolic materials travel downstream within the infarct-related artery at time of primary PCI, leading to compromised blood flow. Currently, no expert consensus documents exist to outline an optimal strategy to prevent or treat no-reflow. Interventional cardiologists frequently employ intracoronary adenosine, calcium channel blockers, nicorandil, nitroprusside or glycoprotein IIb/IIIa inhibitors. However, evidence suggests that these interventions consistently enhance myocardial blood flow in only a specific subset of patients experiencing no-reflow. A recent and innovative therapeutic approach gaining attention is low-dose fibrinolysis during primary PCI, which offers the potential to augment coronary flow post-myocardial revascularization.

The Index of Microcirculatory Resistance After Primary PCI: A Pooled Analysis of Individual Patient Data

BackgroundDespite treatment with primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI), the risk of heart failure and late death remains high. Microvascular dysfunction, as assessed by the index of microcirculatory resistance (IMR), after primary PCI for STEMI has been associated with worse outcomes. It is unclear whether IMR after primary PCI predicts cardiac death. ObjectivesThe aims of this analysis were: 1) to determine if IMR is an independent predictor of cardiac death; 2) to assess the optimal cutoff value of IMR after STEMI; and 3) to compare IMR with several cardiac magnetic resonance parameters, including infarct size. MethodsIn a collaborative, pooled analysis of individual patient data from 6 cohorts that measured IMR directly after primary PCI, cardiac mortality up to 5 years was estimated using Kaplan-Meier analyses. The primary endpoint was cardiac death using the predefined IMR cutoff value of 40. ResultsIn total, 1,265 patients were included in this study with a median follow-up of 2.8 years (IQR: 1.2-5.0 years). Cardiac death at 5 years occurred in 2.2% and 4.9% of patients (HR: 2.81; 95% CI: 1.34-5.88; P = 0.006) in the IMR ≤40 and IMR >40 groups, respectively. The composite of cardiac death or hospitalization for heart failure occurred in 4.9% and 8.9% (HR: 1.98; 95% CI: 1.20-3.29; P = 0.008) in the IMR ≤40 and IMR >40 groups, respectively. IMR was an independent predictor of cardiac death, whereas coronary flow reserve was not. The optimal cutoff value of IMR for the prediction of cardiac death in this cohort was 70 (HR: 4.73; 95% CI: 2.27-9.83; P < 0.001). Infarct size was 17.6% ± 13.3% and 23.9% ± 14.6% of the left ventricular mass in the IMR ≤40 and IMR >40 groups, respectively (P < 0.001). Microvascular obstruction and intramyocardial hemorrhage occurred more frequently in the IMR >40 group than in the IMR ≤40 group. ConclusionsIn this large, pooled analysis of individual patient data, IMR measured directly after primary PCI in STEMI was an independent predictor of cardiac death. IMR may be used as a tool to identify patients at the time of primary PCI who are at highest risk for late cardiac mortality and who might benefit most from additional cardioprotective therapies and monitoring.

Comparison of Angiographic and Clinical Outcomes After Primary Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction Between Patients With and Without Concomitant COVID-19 Infection.

COVID-19 infection can involve the cardiovascular system and worsen the prognosis of the patients. This study aimed to investigate the adverse effects of COVID-19 on angiographic and clinical outcomes of primary percutaneous coronary intervention (PCI) in patients with acute ST-elevation MI and compare results with those patients without COVID-19 disease. The study was a retrospective observational cohort, in which patients presented with ST-elevation MI from February 2020 to April 2021, treated with primary PCI were divided into 2 groups based on the COVID-19 infection. Then, the procedural and angiographic indices and also clinical outcomes were compared between the 2 groups. A total of 1150 patients were enrolled in the study. Those with established COVID-19 infection had worse baseline thrombolysis in myocardial infarction flow grade and also were at higher risk for worse procedural outcomes such as lower thrombolysis in myocardial infarction frame count, myocardial blush grade, and slow-flow coronary disease, after the primary PCI. Additionally, the presence of COVID-19 at the time of primary PCI was related to a significantly higher duration of hospitalization and in-hospital mortality. Given the potential impact of other factors on outcomes, analysis for all of the primary endpoints was done again after adjustment of these factors and the results were the same as before, suggesting the independent effect of COVID-19 infection. The concomitant COVID-19 infection in the patients undergoing primary PCI is associated with significantly worse angiographic, procedural and clinical outcomes. Surprisingly, this finding is regardless of patients' baseline risk factors and demographical characteristics.

P329Residual platelet reactivity after pre-treatment with ticagrelor prior to primary percutaneous coronary intervention is associated with suboptimal myocardial reperfusion

Abstract Background The evidence of a clinical benefit of P2Y12 inhibitor pre-treatment in primary percutaneous coronary intervention (PCI) and the relation between the level of platelet inhibition and myocardial reperfusion with newer potent P2Y12 inhibitors remain unclear. Objectives We aimed to assess the relationship between platelet reactivity at the time of primary PCI after pre-treatment with aspirin and ticagrelor and the post-PCI myocardial blush grade (MBG). Methods We prospectively included 61 patients. Platelet reaction units for ticagrelor (PRU) and aspirin reaction units (ARU) were measured using the point-of-care test VerifyNow before PCI. The high on-ticagrelor (PRU &gt;208) and on-aspirin (ARU ≥550) platelet reactivity (HPR and HaPR) were assessed. Patients were divided into two groups according to MBG 3 or &lt;3. Results MBG 3 was identified in 28 (46%) patients. Mean PRU was lower in such patients as compared to those with MBG &lt;3 (155.82±90.91 vs 227.42±65.18; p=0.001) while mean ARU was similar between groups. HPR and HaPR were observed in 30 (49.2%) and 11 patients (18%), respectively. HPR but not HaPR was more frequent in the group with impaired MBG (66.7 vs 28.6%; p=0.003 and 21.2 vs 14.3%; p=0.48 respectively). Table 1. Platelet reactivity results Verify Now at admission All Final Blush &lt;3 Final Blush 3 p n=61 (100%) n=33 (54%) n=28 (46%) PRU P2Y12 194.56±85.32 227.42±65.18 155.82±90.91 0.001 Base 193.54±49.01 194.79±45.68 192.07±53.48 0.83 Inhibition of platelet aggregation (%) 15.61±29.85 5.7±17.55 27.29±36.79 0.007 ARU 463.97±76.45 472.58±72.5 453.82±81 0.34 PRU &gt;208 30 (49.1%) 22 (66.7%) 8 (28.6%) 0.003 ARU ≥550 11 (18%) 7 (21.2%) 4 (14.3%) 0.48 Verify Now at day 1 n=57 n=30 n=27 p PRU P2Y12 40.86±41.43 47.27±45.87 33.74±35.35 0.21 Base 196.98±36.19 193.67±30.67 200.81±41.97 0.47 Inhibition of platelet aggregation (%) 79.8±17.96 76.37±20.54 83.77±13.78 0.11 ARU = Aspirin reaction units; PRU = P2Y12 reaction units. Conclusion In conclusion, our study shows that higher PRU and the subsequent HPR at the time of primary PCI, after pretreatment with ticagrelor, are the only correlates of post PCI MBG. These findings support the earliest possible loading with ticagrelor prior to primary PCI. Acknowledgement/Funding The study was supported by grants from Terumo. The funder has no role in any step of the study.

Residual platelet reactivity after pre-treatment with ticagrelor prior to primary percutaneous coronary intervention is associated with suboptimal myocardial reperfusion.

The evidence of a clinical benefit of P2Y12 inhibitor pre-treatment in primary percutaneous coronary intervention (PCI) and the relation between the level of platelet inhibition and myocardial reperfusion with newer potent P2Y12 inhibitors remain unclear. We aimed to assess the relationship between platelet reactivity at the time of primary PCI after pre-treatment with aspirin and ticagrelor and the post-PCI myocardial blush grade (MBG). We prospectively included 61 patients. Platelet reaction units for ticagrelor (PRU) and aspirin reaction units (ARU) were measured using the point-of-care test VerifyNow before PCI. The high on-ticagrelor (PRU >208) and on-aspirin (ARU ⩾ 550) platelet reactivity (HPR and HaPR) were assessed. Patients were divided into two groups according to MBG 3 or <3. MBG 3 was identified in 28 (46%) patients. Mean PRU was lower in such patients as compared with those with MBG <3 (155.82 ± 90.91 vs. 227.42 ± 65.18; p=0.001) while mean ARU was similar between groups. HPR and HaPR were observed in 30 (49.2%) and 11 patients (18%), respectively. HPR but not HaPR was more frequent in the group with impaired MBG (66.7 vs. 28.6%; p=0.003 and 21.2 vs. 14.3%; p=0.48 respectively). Our study shows that higher PRU and the subsequent HPR at the time of primary PCI, after pretreatment with ticagrelor, are the only correlates of post PCI MBG. These findings support the earliest possible loading with ticagrelor prior to primary PCI.

Cardiovascular events associated with nicorandil administration prior to primary percutaneous coronary intervention in patients with acute ST-segment elevated myocardial infarction: a systematic review and meta-analysis

ABSTRACTIntroduction: Nicorandil may exert cardioprotective effects in ischemic heart disease. However, its efficacy in combination with early reperfusion is uncertain. The authors performed a meta-analysis of the short- and long-term clinical outcomes of nicorandil administration at the time of primary percutaneous coronary intervention (PCI) in patients with ST-elevated myocardial infarction (STEMI).Methods: PubMed, MEDLINE, Embase, and the Cochrane Library databases were systematically searched for eligible randomized controlled studies. The primary endpoint was major adverse cardiovascular events (MACE), both in-hospital and post-discharge. The secondary endpoint was the incidence of no-reflow phenomenon.Results: Ten studies were included (n = 1105). Mean patient age was 63.0 ± 10.0 years; 76.6% of patients were male. Compared with controls who received primary PCI, combined nicorandil/primary PCI significantly reduced in-hospital MACE (pooled odds ratio [OR] 0.16; 95% confidence interval [CI] 0.09–0.27), follow-up MACE (pooled OR 0.53; 95% CI 0.37–0.75), and total MACE (pooled OR 0.27; 95% CI 0.15–0.49). The combined treatment also reduced the incidence of no-reflow phenomenon (pooled OR 0.34; 95% CI 0.23–0.50).Conclusion: Nicorandil administration at the time of primary PCI is associated with reduced MACE (both short- and long-term) and no-reflow phenomenon in patients with STEMI.

An analysis of the "door to signature" time and its influencing factors in STEMI patients

Objective To investigate the delay of door to signature time in primary percutaneous coronary intervention (PCI) and its influence in patients with ST segment elevation myocardial infarction (STEMI), therefore to provide a scientific basis for further effective shortening the time of primary PCI in patients with STEMI. Methods A total of 226 patients who diagnosed with STEMI and underwent primary PCI at Henan Provincial People's Hospital from June 2016 to December 2017 were enrolled in the study. Observation indicators include: (1) baseline data of patients; (2) time segments in primary PCI: total ischemic time (TIT), door to balloon time (DTΒT), door-to-signature time (DTST), signature to balloon time (STΒT); (3) the demographic characteristics of the family members who signed informed consent; and (4) the psychological factors and coping strategies of family members before signing informed consent. All data was analyzed using SPSS software (version 22.0). Multiple linear regression analysis was used to analyze the influencing factors of delay of DTST. A P<0.05 was considered statistically significant. Results In this study, 226 patients with STEMI who were first diagnosed in our hospital had a mean age of 55.23±10.80 years, and 181 (80.1%) were male. The median of TIT, DTΒT, DTST, STΒT were 312 min, 166 min, 82 min, and 80 min. The ratio of DTST in DTBT and TIT was 50% and 28.5%, respectively. The multiple linear regression analysis showed that the number of direct family members (P<0.001), the degree of educational in middle school and below (P=0.010), high school/technical secondary school (P=0. 029), families worrying about the high cost of medical care (P=0.020), families consulted each other repeatedly (P=0.022), and consulted the other medical staff (P=0.022) are risk factors of DTST delay, and city residence (P=0.048) is the protection factor of DTST delay. Conclusions The long time of DTS is a reality of the practice of primary PCI in China. The factors that lead to longer DTST include demographic characteristics, psychological factors and coping strategies of family members. The STBT of primary PCI in China should be taken into the value while emphasizing the DTBT. Key words: ST segment elevation myocardial infarction; Door-to-signature time; Influence factor

Culprit versus multivessel coronary intervention in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials.

The 2015 American College of Cardiology/American Heart Association update on primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) recommended PCI of the non-infarct-related artery at the time of primary PCI (class IIb recommendation). Despite evidence supporting complete revascularization in STEMI, its benefit on mortality rates is uncertain. We searched all available databases for randomized controlled trials comparing complete multivessel percutaneous coronary intervention (CMV PCI) with infarct-artery-only revascularization in patients with STEMI. Summary risk ratios and 95% confidence intervals (CIs) were calculated for both the efficacy and safety outcomes. Nine randomized controlled trials fulfilled the inclusion criteria, yielding 2991 patients. Follow-up periods ranged from 6 to 36 months. Compared with infarct-related artery-only PCI, CMV PCI was associated with significantly lower rates of major adverse cardiac events [relative risk (RR)=0.54, 95% CI=0.41-0.71; P<0.00001], cardiovascular mortality (RR=0.48, 95% CI=0.28-0.80; P=0.005), and repeat revascularization (RR=0.38, 95% CI=0.30-0.47; P<0.00001). Although, contrast-induced nephropathy and major bleed rates were comparable between both groups, CMV PCI failed to show any reduction in all-cause mortality (RR=0.75, 95% CI=0.53-1.07; P=0.11) and nonfatal myocardial infarction (RR=0.69, 95% CI=0.43-1.10; P=0.12). Our results suggest that in patients with STEMI and multivessel disease, complete revascularization is safe, and is associated with reduced risks of major adverse cardiac events and cardiac death along with a reduced need for repeat revascularization. However, it showed no beneficial effect on all-cause mortality and nonfatal myocardial infarction.

Non-infarct related artery revascularization in ST-segment elevation myocardial infarction patients with multivessel disease.

Multivessel disease (MVD) is common in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) and is associated with significant risk of future cardiovascular (CV) events including short and longer-term mortality. In this review, we examine the pathophysiologic construct contributing to adverse prognosis of MVD in STEMI, relevant available evidence that currently guides the management of the noninfarct-related artery (IRA) stenosis and define the remaining knowledge gaps for future studies. Results of recent small sized randomized trials, when pooled, suggest improvement in CV outcomes including CV mortality and repeat revascularization with revascularization of the non-IRA stenosis compared with medical management alone. In addition, there does not appear to be an increase in bleeding, contrast-induced nephropathy or stroke, as suggested by earlier observational data. These recent data have led to a Class IIb recommendation in the American College of Cardiology/American Heart Association guidelines stating that non-IRA revascularization may be considered in selected patients with STEMI and MVD who are hemodynamically stable, either at the time of primary PCI or as a planned staged procedure. The ongoing COMPLETE and CULPRIT-SHOCK studies will provide additional data to further inform the role of non-IRA revascularization and its timing in the management of these patients.

Infarct related artery only versus complete revascularization in ST-segment elevation myocardial infarction and multi vessel disease: a meta-analysis.

The 2015 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) focused update on primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) only gives a class II b (weak) indication for non-infarct artery intervention at the time of primary PCI. Recent randomized controlled trials, however, suggest strong evidence supporting complete revascularization. A systematic search was conducted in PUBMED, MEDLINE, EMBASE and Cochrane central register for randomized controlled trials comparing complete versus infarct artery (IRA) only revascularization in patients with STEMI. A meta-analysis was performed using the data extracted from each study. Summary risk ratios (RR) and 95% confidence intervals (CI) were calculated for five outcomes. Six trials fulfilled the inclusion criteria yielding 1,792 patients. Follow up ranged from 6 months to 2.5 years. The incidence of major adverse cardiac events (MACE) was significantly lower in the complete revascularization group compared to the IRA only revascularization (13.8% vs. 25.1%, RR =0.51; 95% CI: 0.41-0.64, P<0.00001). It was attributed to significantly lower repeat revascularization rate in the complete revascularization group (8.2% vs. 18.9%, RR =0.41; 95% CI: 0.31-0.54, P<0.00001). This meta-analysis also showed a significant reduction in cardiovascular mortality (2.0% vs. 4.6%, RR =0.42; 95% CI: 0.24-0.74; P=0.003), non-fatal myocardial infarction (4.37% vs. 5.76%, RR =0.64; 95% CI: 0.34-1.20; P=0.16) and all-cause mortality rates [(4.6% vs. 6%), RR =0.75; 95% CI: 0.49-1.14, P=0.17] in the complete revascularization group, compared to the IRA revascularization group. In patients who present with STEMI, complete revascularization is associated with lower rates of MACE and cardiovascular deaths as compared to revascularization of the IRA alone. Even though the outcomes of all-cause mortality and nonfatal re-infarction rates were lower in the complete revascularization group, they were not significant.

1-Year Outcomes With Intracoronary Abciximab in Diabetic Patients Undergoing Primary Percutaneous Coronary Intervention

BackgroundDiabetic patients are at increased risk for future cardiovascular events after ST-segment elevation myocardial infarction (STEMI). Administration of an intracoronary abciximab bolus during primary percutaneous coronary intervention (PCI) may be beneficial in this high-risk subgroup. ObjectivesThis study sought to report the 1-year clinical outcomes and cardiac magnetic resonance (CMR) findings in STEMI patients with and without diabetes randomized to intracoronary or intravenous abciximab bolus at the time of primary PCI. MethodsPatient-level data from 3 randomized trials were pooled. The primary endpoint was the composite of death or reinfarction. Comprehensive CMR imaging was performed in 1 study. ResultsOf 2,470 patients, 473 (19%) had diabetes and 1,997 (81%) did not. At 1 year, the primary endpoint was significantly reduced in diabetic patients randomized to intracoronary abciximab compared with those randomized to intravenous bolus (9.2% vs. 17.6%; hazard ratio [HR]: 0.49; 95% confidence interval [CI]: 0.28 to 0.83; p = 0.009). The intracoronary abciximab bolus did not reduce the primary endpoint in patients without diabetes (7.4% vs. 7.5%; HR: 0.95; 95% CI: 0.68 to 1.33; p = 0.77), resulting in a significant interaction (p = 0.034). Among diabetic patients, intracoronary versus intravenous abciximab bolus was associated with a significantly reduced risk of death (5.8% vs. 11.2%; HR: 0.51; 95% CI: 0.26 to 0.98; p = 0.043) and definite/probable stent thrombosis (1.3% vs. 4.8%; HR: 0.27; 95% CI: 0.08 to 0.98; p = 0.046). At CMR (n = 792), the myocardial salvage index was significantly increased only in diabetic patients randomized to intracoronary compared with intravenous abciximab (54.4; interquartile range: 35.1 to 78.2 vs. 39.0, interquartile range: 24.7 to 61.7; p = 0.011; p for interaction vs. no diabetes = 0.016). ConclusionsIn diabetic patients with STEMI, the administration of intracoronary abciximab improved the effectiveness of primary PCI compared with the intravenous bolus.

A post hoc analysis of long-term prognosis after exenatide treatment in patients with ST-segment elevation myocardial infarction.

We aimed to assess the effect of exenatide treatment as an adjunct to primary percutaneous coronary intervention (PCI) on long-term clinical outcome. We performed a post hoc analysis in 334 patients with a first STEMI included in a previous study randomised to exenatide (n=175) or placebo (n=159) as an adjunct to primary PCI. The primary endpoint was a composite of all-cause mortality and admission for heart failure during a median follow-up of 5.2 years (interquartile range: 5.0-5.5). Secondary endpoints were all-cause mortality and admission for heart failure, individually. The primary composite endpoint occurred in 24% in the exenatide group versus 27% in the placebo group, p=0.44 (HR 0.80, p=0.35). Admission for heart failure was lower in the exenatide (11%) compared to the placebo group (20%) (HR 0.53, p=0.042). All-cause mortality occurred in 14% in the exenatide group versus 9% in the placebo group (HR 1.45, p=0.20). In this post hoc analysis of patients with a STEMI, treatment with exenatide at the time of primary PCI did not reduce the primary composite endpoint or the secondary endpoint of all-cause -mortality. However, exenatide treatment reduced the incidence of admission for heart failure.

Complete Versus Culprit-Only Revascularization for Patients With Multi-Vessel Disease Undergoing Primary Percutaneous Coronary Intervention: An Updated Meta-Analysis of Randomized Trials.

To perform an updated meta-analysis to determine whether complete revascularization of significant coronary lesions at the time of primary percutaneous coronary intervention (PCI) would be associated with better outcomes compared with culprit-only revascularization. Individual trials have demonstrated conflicting evidence regarding the optimum revascularization strategy at the time of primary PCI. Clinical trials that randomized ST elevation myocardial infarction (STEMI) patients with multi-vessel disease to a complete versus culprit-only revascularization strategy were included. Random effects summary risk ratios (RR) were constructed using a DerSimonian-Laird model. The primary outcome of interest was mortality or myocardial infarction (MI). A total of seven trials with 1,939 patients were included in the analysis. Compared with culprit-only revascularization, complete revascularization was associated with a non-significant reduction in the risk of mortality or MI (RR 0.69, 95% confidence interval (CI) 0.42-1.12, P = 0.14). Complete revascularization was associated with a reduced risk of major adverse cardiac events (MACE) (RR 0.61, 95% CI 0.45-0.81, P < 0.001), due to a significant reduction in urgent revascularization (RR 0.46, 95% CI 0.29-0.70, P < 0.001). The risk of major bleeding and contrast-induced nephropathy was similar with both approaches (RR 0.83, 95% CI 0.41-1.71, P = 0.62, and RR 0.94, 95% CI 0.42-2.12, P = 0.82). Complete revascularization of all significant coronary lesions at the time of primary PCI was associated with a reduction in the risk of MACE due to reduction in the risk of urgent revascularization. This approach appears to be safe, with no excess major bleeding, or contrast-induced nephropathy. © 2015 Wiley Periodicals, Inc.

Outcomes after multivessel or culprit-Vessel intervention for ST-elevation myocardial infarction in patients with multivessel coronary disease: a Bayesian cross-design meta-analysis.

During primary percutaneous coronary intervention (PCI), patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary disease can undergo either multivessel intervention (MVI) or culprit-vessel intervention (CVI) only. Randomized controlled trials (RCTs) support the use of MVI, but cohort studies support the use of CVI. We developed Bayesian models that incorporated parameters for study type and study outcome after MVI or CVI. A total of 18 studies (4 RCTs, 3 matched cohort studies, and 11 unmatched observational studies) enrolled 48,398 patients with STEMI and multivessel CAD and reported outcomes after MVI or CVI-only at the time of primary PCI. Using a Bayesian hierarchical model, we found that the point estimates replicated previously reported trends, but the wide Bayesian credible intervals (BCI) excluded any plausible mortality difference between MVI versus CVI in all three study types: RCTs (odds ratio [OR] 0.60, 95% BCI 0.31-1.20), matched cohort studies (OR 1.37, 95% BCI 0.86-2.24), or unmatched cohort studies (OR 1.16, 95% BCI 0.70-1.89). Both the global summary (OR 1.10, 95% BCI 0.74-1.51) and a sensitivity analysis that weighted the RCTs 1-5 times as much as observational studies revealed no credible advantage of one PCI strategy over the other (OR 1.05, 95% BCI 0.64-1.48). Bayesian approaches contextualize the comparison of different strategies by study type and suggest that neither MVI nor CVI emerges as a preferred strategy in an analysis that accounts mortality differences.

Culprit or multivessel revascularisation in ST-elevation myocardial infarction with cardiogenic shock

ObjectiveThe value of multivessel revascularisation in cardiogenic shock and multivessel disease (MVD) is still not clear. We compared outcomes following culprit vessel or multivessel revascularisation in patients with ST-elevation myocardial...

Complete versus culprit-only revascularization in patients with multi-vessel disease undergoing primary percutaneous coronary intervention: A meta-analysis of randomized trials

BackgroundThe best approach for revascularization of multi-vessel coronary disease in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) is controversial. MethodsWe searched the Medline and Web of Science databases, the Cochrane Register of Controlled Trials, and major conference proceedings for clinical trials that randomized STEMI patients with multi-vessel disease to a complete versus culprit-only revascularization strategy. Random effects summary risk ratios (RR) were constructed using a DerSimonian–Laird model. ResultsA total of 6 trials met our selection criteria, which yielded 1,190 patients. The mean follow-up duration was 20.5months. The incidence of major adverse cardiac events was significantly reduced in the complete revascularization group versus the culprit-only revascularization group (RR 0.57, 95% confidence interval (CI) 0.41–0.78, p<0.001). This was due to a lower risk of urgent revascularization with complete revascularization (RR 0.55, 95% CI 0.35–0.86, p=0.01). A non-significant reduction was observed with complete versus culprit-only revascularization for the combined outcome of mortality or myocardial infarction (RR 0.56, 95% CI 0.30–1.04, p=0.06). ConclusionComplete revascularization of significant coronary lesions at the time of primary PCI in patients with STEMI and multi-vessel disease was associated with better outcomes. This was primarily due to a reduction in the need for urgent revascularization. Larger trials are needed to determine if complete revascularization reduces death or myocardial infarction.

Correlation between burst of thrombin and microvacular obstruction (no reflow) during ST Elevation Myocardial Infarction treated by primary percutaneous coronary Intervention

Background: The thrombotic burden at the acute phase of STEMI is a consequence of platelet and coagulation activation. Objective: To evaluate the generation of thrombin during acute phase of STEMI. In order to study the consequence, thrombin generation was correlated with other markers of coagulation activation, markers of cellular activation, microvascular injury and infarct size. Methods: Thirty six STEMI patients admitted for primary Percutaneous Coronary Intervention (PCI) were enrolled. Blood samples were collected before angioplasty, at the end of angioplasty and 2, 6, 12 and 24 hours after angioplasty. Plasma thrombin antithrombin complexes and d-dimers were evaluated by ELISA methods, fibrinogen by clothing test. Platelets and endothelial microparticles were determined by flow cytometry analysis. Microvascular obstruction was assessed by the myocardial blush grade. Myocardium at risk was determined on angiography and infarct size was assessed by area under the curve of plasma troponin and CK-MB. Results: A burst of thrombin occurred during PCI in 69% of patients and was associated with increased fibrinogen, d-dimer, circulating platelets and endothelials microparticles, when compared with patient without burst (p<0.05). Prolonged ischemic time and significant myocardium at risk were correlated with a higher level of thrombin generation (p<0.05). Thrombin generation was correlated with alteration of myocardial blush (p<0.05) and higher troponin I and CK levels (p<0.05). Conclusion: This study showed a burst of thrombin at the time of primary PCI during STEMI in two third of patients. When present, this burst was associated with more cellular, myocardial and micro-vascular damage.

Bimodal response to aspirin loading in acute ST-elevation myocardial infarction

Patients with stable coronary disease who exhibit platelet hypo-responsiveness to aspirin (ASA) have worse outcomes. Little data exist regarding platelet response to ASA in ST-elevation myocardial infarction (STEMI) patients. Our objective was to assess acute platelet response to ASA loading in STEMI patients undergoing primary percutaneous coronary intervention (PCI). The study comprised 102 consecutive patients with STEMI. All patients received a loading dose of 300 mg chewable ASA upon admission. Platelet reactivity was assessed immediately prior to primary PCI, at a median of 95(63 139) minutes after ASA loading. A bimodal response to arachidonic acid (AA) stimulation was observed, such that two distinct populations could be discerned: “good responders” had a mean AA-induced platelet aggregation of 36 ± 11% vs. 79 ± 9% for “poor responders.” Despite equivalent demographic, clinical, and angiographic characteristics, good responders were significantly more likely to demonstrate early ST-segment resolution ≥70% after primary PCI (80% vs. 48%, p = 0.001), suggestive of better myocardial reperfusion. Early inhibition of AA-induced platelet aggregation post-ASA loading in the setting of STEMI is associated with better tissue reperfusion; however, a sizeable proportion of patients do not achieve significant inhibition of AA-induced platelet aggregation in response to ASA loading at the time of primary PCI.

Adjunctive Antiplatelet Treatment in Primary Percutaneous Coronary Intervention

Background: Despite significant advances in the management of coronary heart disease, myocardial infarction is still associated with high mortality. Thienopyridines and glycoprotein IIb/IIIa inhibitors have been used extensively in the management of ST segment elevation myocardial infarction. Objective: This article discusses the evidence from clinical trials and registries concerning the benefits of thienopyridines, reviews the results of published multicenter, randomized controlled trials of the efficacy and safety of platelet GPIIb/IIIa inhibitors in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (PCI) and presents the recent guidelines. Methods: Data for this review were identified by broad searches of MEDLINE, Current Contents and references from relevant articles (1980-2011); numerous articles were identified through searches of the extensive files of the authors and selected based on their importance, oppurtunity for further reading and up to date information. Search terms included thienopyridines, platelet aggregation inhibitors, percutaneous coronary intervention, antiplatelet therapy, ST elevation myocardial infarction (STEMI), primary percutaneous coronary intervention. Only English language papers were reviewed. No restrictions were set on the type of papers. Results: Clopidogrel is the most commonly used thienopyridine in patients undergoing primary PCI. Recently new inhibitors of P2Y12 receptors, like prasugrel and ticagrelor, have become available, which have a more potent and rapid onset of action, with similar safety profile, which is specifically targeted to the subgroup of primary PCI. On the other hand, the platelet glycoprotein IIb/IIIa inhibitors have aided and abetted medical management of acute coronary syndromes and proved an important adjunctive therapy in percutaneous coronary interventions. Platelet glycoprotein IIb/IIIa inhibitors, although not recommended for routine therapy, have an important role at the time of primary PCI, particularly in high-risk subgroups, like the diabetics and those with a heavy thrombotic burden. Conclusion: Clopidogrel remains the most used thienopyridine together with aspirin in patients undergoing primary PCI but there are currently available new inhibitors of P2Y12 receptors, like prasugrel and ticagrelor, which have a more potent and rapid onset of action, with similar safety profile. Glycoprotein IIb/IIIa antagonists, although not recommended for routine therapy, can be of use at the time of primary PCI, particularly in high-risk subgroups.