Time Of ST-elevation Myocardial Infarction Research Articles

Four to seven year follow-up of pharmacological postconditioning with mangafodipir as an adjunct to primary PCI in ST-segment elevation myocardial infarction.

Adverse left ventricular remodelling (AR) develops over time in approximately 30 % of patients with a history of coronary artery disease. AR manifests as a structural change in the left ventricle (LV) in terms of increased volumes and reduced left ventricular ejection fraction (LVEF). Manganese dipyridoxyl diphosphate (mangafodipir) has demonstrated interesting cardioprotective features in acute myocardial ischemia. Pharmacological postconditioning (PP) with mangafodipir as an adjunct to primary percutaneous coronary intervention may possibly reduce the development of AR over time in ST-elevation myocardial infarction (STEMI). The aim of this four to seven year follow-up study is to investigate the potential benefits of PP with mangafodipir in STEMI patients. Thirteen out of the initial twenty patients that were included in the primary study of Karlsson et al. were followed up between April and June 2017. The study group underwent review of the hospital records, a clinical examination with ECG and blood sample analysis before cardiac magnetic resonance examination of the patient. LVEF, left ventricular diastolic volume, left ventricular end systolic volume, LV mass and myocardial strain in all directions were computed. The PP group showed a decrease in LV volume, mass and higher LVEF at follow-up (p < 0.05) while the individual response of the placebo group showed features that are seen in AR. Although there was no difference in myocardial strain, measurement for the PP-group was higher in absolute terms. Pharmacological postconditioning with mangafodipir in STEMI demonstrated cardioprotective features compared to the placebo group at follow-up. This article is protected by copyright. All rights reserved.

Coronary CT-based FFR in patients with acute myocardial infarction might predict follow-up invasive FFR: The XPECT-MI study

BackgroundWe aimed to evaluate whether invasive fractional flow reserve (FFRi) of non-infarction related (non-IRA) lesions changes over time in ST-elevation myocardial infarction (STEMI) patients. Moreover, we assessed the diagnostic performance of coronary CT angiography-derived FFR(FFRCT) following the index event in predicting follow-up FFRi. MethodsWe prospectively enrolled 38 STEMI patients (mean age 61.6 ​± ​9 years, 23.1% female) who underwent non-IRA baseline and follow-up FFRi measurements and a baseline FFRCT (within ≤10 days after STEMI). Follow-up FFRi was performed at 45–60 days (FFRi and FFRCT value of ≤0.8 was considered positive). ResultsFFRi values showed significant difference between baseline and follow-up (median and interquartile range (IQR) 0.85 [0.78–0.92] vs. 0.81 [0.73–0.90] p ​= ​0.04, respectively). Median FFRCT was 0.81 [0.68–0.93]. In total, 20 lesions were positive on FFRCT. A stronger correlation and smaller bias were found between FFRCT and follow-up FFRi (ρ ​= ​0.86,p ​< ​0.001,bias:0.01) as compared with baseline FFRi (ρ ​= ​0.68, p ​< ​0.001,bias:0.04). Comparing follow-up FFRi and FFRCT, no false negatives but two false positive cases were found. The overall accuracy was 94.7%, with sensitivity and specificity of 100.0% and 90.0% for identifying lesions ≤0.8 on FFRi. Accuracy, sensitivity, and specificity were 81.5%, 93.3%, and 73.9%, respectively, for identifying significant lesions on baseline FFRi using index FFRCT. ConclusionFFRCT in STEMI patients close to the index event could identify hemodynamically relevant non-IRA lesions with higher accuracy than FFRi measured at the index PCI, using follow-up FFRi as the reference standard. Early FFRCT in STEMI patients might represent a new application for cardiac CT to improve the identification of patients who benefit most from staged non-IRA revascularization.

Temporal trends, short- and long-term prognostic impact of pre-hospital delay times in ST elevation myocardial infarction – 20 years national data from the SWEDEHEART registry

Abstract Background Previous studies have demonstrated that total ischaemic time during ST-elevation myocardial Infarction (STEMI) is associated with mortality. However, how duration from symptom onset to hospital admission affects outcomes and how pre-hospital delay times (PHDT) have evolved over time in STEMI in total, as well as in prespecified subgroups, remains unknown. Aim The aim was to explore temporal trends and prognostic impact of PHDT in STEMI patients during the last two decades in Sweden, including the fibrinolytic era as well as the primary percutaneous coronary intervention (PPCI) era. Temporal trends of PHDT was aimed to be studied in the total STEMI cohort as well as in subgroups according to age, sex and presence or absence of diabetes. Method This was an observational retrospective cohort study based on the SWEDEHEART registry including 89,155 STEMI patients between 1998 and 2017. Results In total, the PHDT curve was hump-shaped without any significant trend. The median PHDT was 150 min (Q1 80; Q3 302), and the shortest PHDT of 140 (Q1 85; Q3 274) min was found during the last period. During the fibrinolytic era (1998–2004) there was a significant increase in PHDT while delay times decreased during the PPCI era (2005–2017). There were consistent differences within subgroups; women sought care 25 min later than men, older (&amp;gt;70 years) delayed 30 min longer than younger and patients with diabetes 29 min longer than those without. Higher short- and long-term mortality was seen with increasing delay except for the group seeking care within 1 hour, which had higher short-term mortality. In five years follow up, mortality incrementally increased with delay, from 24.1% (0–1 hours) to 31.1% (&amp;gt;12 hours) of PHDT, p&amp;lt;0.01. When adjusting for confounders the risk of dying within 1 and 5 years was approximately 1% per hour of increase of PHDT (HR 1.011, 95% CI 1.006–1.016 and HR 1.008, 95% CI 1.004–1.013, respectively). Conclusions PHDT is an independent predictor of short- and long-term mortality and reducing PHDT will diminish the risk of heart failure and premature death. We found only a modest decrease in PHDT over time and the trend was hump shaped. Since the implementation of PPCI, with the diagnosis of STEMI made in the ambulances, these have been redirected in the pre-hospital setting, transporting the patient directly to cath lab. This may explain why the PHDT initially increased in the beginning of this era when new routines were being established. Although we did not find any significant trend during the total 20-year period it is reassuring that the PHDT decreased during the PPCI era. Anyhow, there are subgroups with consistently prolonged PHDT, such as women, the elderly, and patients with diabetes, who need to be targeted in future interventions. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): This study was funded with grants from the Medical Research Council of Southeast Sweden (FORSS), Region Östergötland and Linköping University Hospital Research Fund, Sweden.

Validation of ICD-10-AM Coding for Myocardial Infarction Subtype in Hospitalisation Data

International Classification of Disease (ICD) codes are central for identifying myocardial infarction (MI) in administrative hospitalisation data, however validation of MI subtype codes is limited. We measured the sensitivity and specificity of ICD-10-AM (Australian Modification) codes for ST-elevation MI (STEMI) and non-STEMI (NSTEMI). A sample of MI admissions was obtained from a dataset containing all MI hospitalisations in Western Australia (WA) for 2003, 2008 and 2013. Clinical data were collected from hospital medical records (n=799 patients). Cases were classified by ICD-10-AM codes for STEMI, NSTEMI and unspecified MI, and compared to clinical classification from review of available electrocardiographs (ECGs) and cardiac biomarkers (n=660). Sensitivity and specificity for ICD-10-AM coding versus clinical classification was measured, stratified by calendar year of discharge. The majority of classifiable cases had MI recorded in the principal diagnosis field (STEMI n=293, 84.2%; NSTEMI n=202, 74.3%; unspecified MI n=20, 50.0%). Overall sensitivity of the ICD-10-AM STEMI code was 86.3% (95% CI 81.7-90.0%) and was higher when restricted to MI as a principal versus secondary diagnosis (88.8% vs 66.7%). Comparable values for NSTEMI were 66.7% (95% CI 61.5-71.6%), and 68.8% vs 61.4% respectively. Between 2003 and 2013, sensitivity for both MI subtypes increased: 80.2-89.5% for STEMI, and 51.2-73.8% for NSTEMI. Specificity was high for NSTEMI throughout (88.2% 95% CI 84.1-91.6%), although improving over time for STEMI (68.1-76.4%). The sensitivity and specificity of ICD-10-AM codes for MI subtypes in hospitalisation data are generally high, particularly for principal diagnosis cases. However, the temporal improvement in sensitivity in coding of MI subtypes, particularly NSTEMI, may necessitate modification to trend studies using administrative hospitalisation data.

Total ischaemic time in STEMI: factors influencing systemic delay.

Total ischaemic time in ST-elevation myocardial infarction (STEMI) has been shown to be a predictor of mortality. The aim of this study was to assess the total ischaemic time of STEMIs in an Irish primary percutaneous coronary intervention (pPCI) centre. A single-centre prospective observational study was conducted of all STEMIs referred for pPCI from October 2017 until January 2019. There were 213 patients with a mean age 63.9 years (range 29-96 years). The mean ischaemic time was 387 ± 451.7 mins. The mean time before call for help (patient delay) was 207.02 ± 396.8 mins, comprising the majority of total ischaemic time. Following diagnostic electrocardiogram (ECG), 46.5% of patients had ECG-to-wire cross under 90 mins as per guidelines; 73.9% were within 120 mins and 93.4% were within 180 mins. Increasing age correlated with longer patient delay (Pearson's r=0.2181, p=0.0066). Women exhibited longer ischaemic time compared with men (508.96 vs. 363.33 mins, respectively, p=0.03515), driven by a longer time from first medical contact (FMC) to ECG (104 vs. 34 mins, p=0.0021). The majority of total ischaemic time is due to patient delay, and this increases as age increases. Women had longer ischaemic time compared with men and longer wait from FMC until diagnostic ECG. This study suggests that improved awareness for patients and healthcare staff will be paramount in reducing ischaemic time.

Abstract 11895: Impact of Prehospital Mobile Cloud ECG System to Reduce Door to Balloon Time and Onset to Recanalization Time in STEMI

Background: Clinical guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. Recently, mobile cloud 12-lead ECG transmission system (C-ECG) were becoming popular at low cost. Medical staff can immediately review the ECG via PC or personal hand-held devices, and also track the location of the ambulance in a real time manner. Objective: Evaluate the impact of the prehospital C-ECG on DTBT and mortality in patients with STEMI. Methods: In June 2018, eight mobile C-ECG systems (SCUNA®, MEHERGEN GROUP) were integrated into the Uki city and Kamimashiki city regional EMS departments in Kumamoto Prefecture, We compared the DTBT, onset to recanalization time (OTRT) and mortality rates of STEMI cases for 3 years prior to and 3 years after the C-ECG system. Results: For 6 years study period, 267 STEMI patients were transferred by ambulances from two EMS departments. After excluding 14 patients with onset to arrival time more than 24 hours and 54 patients who were transferred without C-ECG, 199 consecutive STEMI cases underwent emergency PCI in which 100 were prior to C-ECG introduction (Pre-C-ECG, from June 2015 to May 2018) and 99 were after C-ECG (Post-C-ECG, from June 2018 to May 2021). Results: No significant differences were found in age, gender, and Killip classification between the groups. The DTBT and OTRT were significantly shorter in the post-C-ECG compared to the pre-C-ECG (Pre: 68 min [IQR; 43-76] vs. Post: 50 min [IQR; 43-76]; p=0.005, Pre: 190 min [IQR; 138-294] vs. Post: 157 min [IQR; 112-276]; P=0.04, respectively). However, peak-CPK and the in-hospital mortality were not significantly different (Pre: 2068 IU/L [IQR; 1168-4200] vs. Post: 2105 IU/L [IQR; 872-4528]; p=0.8, Pre: 7.0% vs. Post: 5.1%; p=0.6, respectively). Conclusion: Although the prehospital mobile C-ECG system significantly reduced both DTBT and OTRT, the DTBT at our institution was short enough that C-ECG did not reduce the peak CPK or mortality.

The Number of Patients with Acute Myocardial Infarction Decreased and Door-to-Balloon Time Delayed in COVID-19.

Background At present, COVID-19 is sweeping the world, and all countries are actively responding. During the COVID-19 epidemic, the treatment of patients with acute myocardial infarction (AMI) may be affected. Methods We reviewed data of patients with AMI from January 23 to April 23, 2020 (2020), and January 23 to April 23, 2019 (2019), who were admitted to two hospitals from Southern China. We collected clinical characteristics, comorbidities, treatment, prognosis, and key time segments to analyze. Results The total number of patients that had been diagnosed with AMI in the two hospitals was 218 in 2020 and 260 in 2019. The number of AMI patients that were admitted to hospitals per day decreased in 2020. The percentage of patients with AMI who refused hospitalization in 2020 was significantly higher than that in 2019 (5.0% vs 1.5%, p=0.028). There is no statistical difference in symptoms of the first medical contact (S2FMC) time between 2020 and 2019 (p=0.552). Door-to-balloon (D2B) time of ST-elevation myocardial infarction (STEMI) patients who were treated with a primary percutaneous coronary intervention (pPCI) in 2020 was 79 (63.75–105.25) mins, while D2B time in 2019 was 57.5 (41.5–76.5) mins, which was statistically different from the two groups. Conclusions COVID-19 had an impact on the number of AMI patients who were admitted to hospitals and the time of treatment. During the COVID-19 epidemic, the number of AMI patients that were admitted to hospitals per day was decreased, while the percentage of AMI patients that refused therapy in these two hospitals increased, and the D2B time of STEMI patients was also delayed.

Left ventricular function and clinical heart failure after myocardial infarction revascularized with percutaneous coronary intervention - comparison between STEMI and NSTEMI in modern practice

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left ventricular systolic dysfunction (LVSD) is a common consequence of myocardial infarction (MI). Data from historic series identified LVSD in up to 60% of patients post-MI. However, in modern practice, with high-sensitivity cardiac biomarkers leading to early detection of MI and widespread use of early revascularization, the prevalence of LVSD in the acute phase of MI and its impact on subsequent clinical heart failure remains unknown. Purpose To ascertain the prevalence of LVSD on pre-discharge echocardiography and its impact on subsequent clinical heart failure after type 1 MI treated with percutaneous coronary intervention (PCI) in a UK tertiary cardiac centre. Methods A retrospective electronic patient records review of consecutive patients with type 1 MI treated with PCI between January 2016 - December 2017. Patients treated conservatively or with surgical revascularization were excluded. Results 1000 consecutive patients were identified and 948/1000 who had an inpatient echocardiogram prior to discharge were included in this analysis – 413 ST elevation MI (STEMI) and 535 non-ST elevation (NSTEMI). Median door to balloon time for STEMI was 42 minutes (IQR 28-79). Median time from symptom onset to intervention for NSTEMI was 3 days (IQR 1-6). LVSD was defined as left ventricular ejection fraction (LVEF) &amp;lt;50% on transthoracic echocardiogram carried out during the hospital episode. LVSD was significantly more prevalent in patients with STEMI compared to NSTEMI (37.4% vs 17.3%, p &amp;lt; 0.001). Median LVEF was significantly lower in the STEMI population (55%, IQR 45-60) compared to patients with NSTEMI (60%, IQR 54-65), p &amp;lt; 0.001. However, rates of clinical heart failure at index presentation with MI did not vary significantly between STEMI and NSTEMI patients (6.1% vs 4.9%, p = 0.414). In stepwise multivariate regression models: age, peak troponin and previous coronary artery bypass grafting were predictors of LVEF, whereas LVEF and previous MI were predictors of clinical heart failure Patients with LVSD on pre-discharge echocardiography had significantly higher rates of 30-day readmission with heart failure (2.9% vs 0.7%, p = 0.017), 30-day all-cause mortality (6.1% vs 2%, p = 0.001), 30-day cardiac mortality (5.7% vs 1%, p &amp;lt; 0.001) and 2-year all-cause mortality (5.7% vs 1.6%, p = 0.001). However, at 2-years, there was no difference in hospital readmission with heart failure (0.8% vs 0.3%, p = 0.276). There were no significant differences between STEMI and NSTEMI patients for these endpoints. Conclusions Early revascularisation with PCI has led to a reduction in the prevalence of early LVSD post-MI compared to historical data. However, the presence of LVSD remains a powerful predictor of adverse clinical outcomes. Despite lower rates of LVSD on pre-discharge echocardiography in patients with NSTEMI compared with STEMI, the incidence of subsequent clinical heart failure is similar. This however may be underestimated due to survival bias.

Contemporary Impact of circadian symptom-onset patterns of acute ST-Segment elevation myocardial infarction on long-term outcomes after primary percutaneous coronary intervention

Background Daytime variation with regard to onset time of ST-elevation myocardial infarction (STEMI) symptoms has been observed. Nevertheless, with the advanced medical therapy, it is not uncertainty if a similar circadian pattern of STEMI symptom onset occurs, as well as its possible impact on clinical outcomes. Few long-term data are available. We assess the impact of circadian symptom-onset patterns of STEMI on major adverse cardiovascular events (MACE) in more contemporary patients treated with primary percutaneous coronary intervention (PPCI). Methods and results A total of 1099 consecutive STEMI patients undergoing PPCI ≤12h from symptom onset during 2013 to 2019 were classified into 4 groups by 6-h intervals according to time-of-day at symptom onset: night (0:00–5:59), morning (6:00–11:59), afternoon (12:00–17:59), and evening (18:00–23:59). Incidence of MACE including cardiovascular death and nonfatal MI during a median follow-up of 48 months was compared among the 4 groups. A morning peak of symptom onset of STEMI was detected during the period 06:00–11:59 (p < .001). Compared with other three 6-h intervals, the incidence of long-term MACE during night onset-time (18.8%, 10.1%, 10.7% and 12.4%, p = .020) was significant higher that was driven by more mortality (13.1%, 6.5%, 7.1%and 7.7%, p = .044). Night symptom-onset STEMI was independently associated with subsequent MACE (hazard ratio = 1.57, 95%CI: 1.09–2.27, p = .017) even after multivariable adjustment. Conclusions Circadian variation of STEMI symptom-onset with morning predominance still exists in contemporary practice. Night symptom-onset STEMI was independently associated with increased risk of MACE in Chinese patients treated with PPCI.

Abstract 14181: Impact of Prehospital Mobile Cloud Electrocardiogram Transmission System to Reduce Door to Balloon Time and Onset to Recanalization Time in ST-elevation Myocardial Infarction

Background: Guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. Objective: To evaluate the impact of the prehospital mobile cloud ECG transmission system (C-ECG) on DTBT and mortality in patients with STEMI. Methods: On June 2018, eight mobile C-ECG systems (SCUNA®, MEHERGEN GROUP) were implemented into the Uki and Kamimashiki fire departments in Kumamoto, Japan. Within two years, 428 ECGs of patients complaining of chest pain, difficulty in breathing and any other symptom that the emergency staff deemed necessary were transmitted to our hospital. 119 patients were diagnosed with ACS, 93 received emergency CAG and 69 were diagnosed with STEMI. After excluding eight patients with onset to arrival over 24 hours, a total of 137 consecutive STEMI patients received emergency PCI during the study period. Among them, 68 received PCI during the pre-C-ECG period (Pre: from June 2016 to May 2018), whereas 69 were received during the post-C-ECG period (Post: June 2018 to May 2020). We compared the DTBT, Onset to Recanalization time (OTRT), and in-hospital mortality between the two periods. Results: There was no significant difference in age, gender, Killip classification, and number of diseased coronary lesion between the two periods. The door to Cath-Lab time (DTCT) and DTBT were significantly shorter in the post-C-ECG period compared to the pre-C-ECG period (Pre: 34 min [IQR; 23-44] vs. Post: 24 min [IQR; 18-38]; P=0.01, Pre: 66 min [IQR; 48-80] vs. Post: 49 min [IQR; 42-71]; P=0.02, respectively). Furthermore, OTRT was also significantly shorter in the post-C-ECG period compared to the pre-C-ECG period (Pre: 190 min [IQR; 137-343] vs. Post: 153 min [IQR; 110-247]; P=0.02). However, peak-CPK and in-hospital mortality were not significantly different between the two periods (Pre: 2254 IU/L [IQR; 1153-4257] vs. Post: 1985 IU/L [IQR; 740-4021]; P=0.2, Pre: 5.9% vs. Post: 4.4%; P=0.7, respectively). Conclusion: Prehospital mobile cloud ECG transmission system reduced not only the DTBT but also OTRT.

CRT-100.47 Elevated LVEDP in STEMI Presentation Does Not Guide Use of Temporary Mechanical Circulatory Support Systems

Presence of cardiogenic shock at time of ST-elevation myocardial infarction (STEMI) presentation carries a 40-50% mortality. Elevated left ventricular end-diastolic pressure (LVEDP) > 18-22 mmHg at presentation is predictive of higher mortality. The role of temporary mechanical circulatory support (

2200Predictors of patient decision time in ST elevation myocardial infarction data from an observational cross sectional survey study

Abstract Background Short time from symptom onset until reperfusion is imperative in ST-elevation myocardial infarction (STEMI). System delay has been successfully shortened but patients delay has had less favorable development. The aim of this study was to find out clinical, contextual, behavioral and cognitive factors associated with decision time in STEMI. Method SymTime was a multicenter observational cross-sectional self-reported survey study performed at five Swedish hospitals representing geographic diversity. Early and late action was defined as decision to seek care &lt;20 min and &gt;90 min, respectively. Results 532 patients were included. Among those 19.5% called Emergency Medical Services (EMS) as first medical contact (FMC) within 20 min, whereas 10.7% acted within 20 min, but did not call EMS as FMC. Twenty-eight % called EMS as FMC, but delayed &gt;20 min and 41.7% neither acted promptly, nor called EMS as FMC. Predictors associated with decision time OR 95% CI Factors associated with decision time &lt;20 min   Previous AF 0.43 0.19–0.94   Believing the symptoms originated from the heart 3.10 1.93–4.96   Symptoms waxing and waning 0.58 0.36–0.94   Getting STEMI off hours 0.66 0.45–0.97   Bystanders calling or recommending EMS (Emergency Medical Services) contact 1.67 1.07–2.59   Bystanders calling or recommending SHD (Swedish healthcare Direct) contact 0.56 0.37–0.85 Factors associated with decision time &gt;90 min   Female gender 1.67 1.06–2.62   Diaphoresis 0.67 0.46–0.998   Nausea 0.60 0.36–0.998   Stomach pain 0.46 0.23–0.91   Believing the symptoms originated from the heart 0.46 0.32–0.68   Getting STEMI off hours 1.68 1.16–2.14   Low educational level 0.58 0.40–0.86   Bystanders calling or recommending EMS contact 0.45 0.30–0.67 Variable significant at the p 0.05 presented. Conclusion Surprisingly, no specific symptom or severity of symptom were associated with early action, neither age, nor gender. Instead correct interpretation of symptoms and bystanders assisting were factors associated with early action. Frightening symptoms such as diaphoresis was negatively associated, whereas female gender and getting MI off hours were positively associated with late action.

P2661Ventricular fibrillation during acute STEMI is not associated with early repolarization pattern on ECG recorded prior to the index ischemic episode

Abstract Background Generally considered as benign, ECG early repolarization (ER) pattern was recently claimed to be an indicator of increased susceptibility to fatal arrhythmias during acute ischemia. The victims of sudden cardiac death have been reported to have high prevalence of ER comparing with survivors of acute coronary event. We aimed to test the association between the ER pattern on resting ECG recorded prior to ST-elevation myocardial infarction (STEMI) and the risk of ventricular fibrillation (VF) during acute phase of STEMI in non-selected population of STEMI patients. Methods For STEMI patients admitted to a tertiary care hospital for primary PCI during 2007–2010 (n=2286), all ECGs recorded prior to the date of admission with STEMI were extracted from a digital archive. The latest ECG recorded prior to the index STEMI was used for analysis. After excluding ECGs with paced rhythm and intraventricular blocks with QRS duration ≥120ms, the remaining ECGs were processed using the Glasgow algorithm allowing automatic ER detection. The association between ER-pattern on historical ECG and VF during the first 48 hours of STEMI was tested using logistic regression. Results Historical ECGs were available for 1584 patients; 124 of them were excluded due to a paced rhythm or wide QRS, leaving 1460 patients available for analysis (age 68±12 years, 67% male). The time from historical ECG to STEMI was 16 (IQR 4–49) months. ER pattern was present on historical ECG in 272 of 1460 (18.6%) (ER+ group), among them in 90 (33%) – in inferior leads, in 116 (43%) – in lateral leads, in 66 (24%) – both in inferior and lateral leads. ER+ patients were younger both at the time of historical ECG (64±13 vs 66±19; p=0.041) and at the time of STEMI (67±12 vs 68±12; p=0.033), and had lower heart rate on historical ECG (68±12 vs 73±15; p&lt;0.001) than ER- patients. ER+ and ER- groups did not differ regarding clinical characteristics and conventional ECG measurements. The course of STEMI was complicated by VF in 106 patients (17 of them from ER+ group). The occurrence of VF during STEMI was not associated with ER-pattern on historical ECG (OR 0.875 95% CI 0.518–1.479; p=0.618). There was no association of ER pattern with VF before reperfusion (OR 0.54 95% CI 0.25–1.21; p=0.135) or reperfusion VF (OR 1.28 95% CI 0.55–3.01; p=0.569). No association was observed with regard to localization (inferior or lateral) of ER-pattern either. Conclusion In a non-selected population of STEMI patients the presence of ER-pattern on ECG recorded prior to the acute coronary event was not associated with VF during the first 48 hours of STEMI.

Impact of Emergency Medical Services Activation of the Cardiac Catheterization Laboratory and a 24-Hour/Day In-Hospital Interventional Cardiology Team on Treatment Times (Door to Balloon and Medical Contact to Balloon) for ST-Elevation Myocardial Infarction

The incremental benefit of emergency medical services (EMS) activation of the cardiac catheterization laboratory (CCL) for ST-elevation myocardial infarction (STEMI) in the setting of an established in-house interventional team (IHIT) is uncertain. We evaluated the impact of EMS activation on door-to-balloon (D2B) time and first medical contact-to-balloon (FMC2B) time for STEMI when coupled with a 24-hour/day IHIT. All patients presenting with STEMI to Loyola University Medical Center had demographic, procedural, and outcome data consecutively entered in a STEMI Data Registry. From 223 consecutive patients presenting between April 2009 and December 2015, a retrospective analysis was performed on 190 patients. Patients were divided into 2 groups depending on CCL activation mode (EMS activation or emergency department activation) and STEMI treatment process times were compared. The primary end point was D2B process times. The secondary end point was FMC2B process times in a subgroup analysis of EMS-transported patients. D2B times were shorter (37 ± 14 minutes vs 57 ± 27 minutes, p < 0.001) with EMS activation. Subgroup analysis of EMS-transported patients demonstrated shorter FMC2B times with EMS activation (52 ± 17 minutes vs 67 ± 32 minutes, p = 0.002). EMS activation was the only predictor of D2B ≤60 minutes in multivariable analysis of EMS-transported patients (odds ratio 9.4; 95% confidence interval 2.1 to 43.0; p = 0.04). In conclusion, EMS activation of the CCL in STEMI was associated with significant improvements in already excellent D2B and FMC2B times even in the setting of a 24-hour/day IHIT.

Door-to-Needle Time in Myocardial Infarction: Small Steps, Huge Dividends

The Himachal Pradesh acute coronary syndrome registry highlighted a prehospital delay of 780 min. Additional door-to-needle time delay by 1 h increases the hazard ratio of death by 20%. We conducted a retrospective (group 1) and a prospective (group 2) analysis of 63 patients each to measure the impact of a fast-track protocol in the emergency department (ED) on the door-to-needle time in ST-elevation myocardial infarction (STEMI). The fast-track protocol involved zero cost to the hospital and saved 63 precious door-to-needle minutes for patients with STEMI. Thrombolysis in ED can save 33 precious minutes wasted in shifting patients to the coronary care unit.

Another important time target in ST-elevation myocardial infarction management—door-in door-out time: Do we meet door-in door-out time targets?

Background: In non-PCI capable hospitals, another important time to be noticed in patients who have been referred for PCI-capable centers; is the time of doo-in door-out (DIDO), defined as the duration of time from patient discharge from the transferrring hospital. In our country, there is no clear information about the duration of DIDO time and transfer time. Consequently, very little is known about how frequently these targets can be met nationally. Objectives: This study aimed to measure door-in door-out time for ST-elevation myocardial infarction diagnosed patients who admitted to emergency department of a hospital capable of non-percutaneous coronary intervention and to measure whether door-in door-out time meets the guidelines. Methods: This single-center, prospective study was conducted in emergency department (non-percutaneous coronary intervention capable) between 1 August 2015 and 1 August 2016 with patients who presented to the emergency department and were diagnosed with ST-segment elevation myocardial infarction. All the times including door-in time, door to electrocardiogram time, door to emergency medical services activation time, door to defined percutaneous coronary intervention hospital, and finally door-in door-out time were measured and recorded. Results: During the study period, 135 of patients met the inclusion criteria and diagnosed with ST-elevation myocardial infarction and referred to another hospital for percutaneous coronary intervention. When the median values (interquartile range of 25%–75%) of the time periods are examined, it is found door-in door-out time was 55 (43–74) min. It was found that the number of patients meeting the recommended duration of door-in door-out (30 min or less) was 12 (8.9%). Of the remaining 123 patients (91.1%), door-in door-out times were found to be over 30 min. Conclusion: In conclusion, our study showed that compliance with door-in door-out time is very poor and is far behind to met the criteria which is recommended by current guidelines.

TCT-306 Angiography-derived functional assessment of non-culprit stenoses with Quantitative Flow Ratio at the time of ST-elevation myocardial infarction

TCT-306 Angiography-derived functional assessment of non-culprit stenoses with Quantitative Flow Ratio at the time of ST-elevation myocardial infarction

High red cell distribution width at the time of ST segment elevation myocardial infarction is better at predicting diastolic than systolic left ventricular dysfunction: A single-center prospective cohort study.

Multiple studies have demonstrated the association of red cell distribution width (RDW) with the ultrasound parameters of both systolic and diastolic heart dysfunction. We aimed to further investigate the clinical associations of RDW in the setting of ST-elevation myocardial infarction (STEMI) and to comparatively evaluate its predictive properties regarding systolic and diastolic dysfunction.A total of 89 patients with STEMI were prospectively analyzed. RDW was obtained at the time of STEMI and compared to the parameters of systolic and diastolic dysfunction obtained by transthoracic heart ultrasound on the 5th through 7th day post-STEMI.The median RDW was 13.9%, and among other factors, RDW was significantly associated with older age (P < .001), arterial hypertension (P = .017), hyperlipoproteinemia 2, nonsmoking (P = .027), increased thrombolysis in myocardial infarction score (P = .004), and multivessel disease (P = .007). A higher RDW was observed in patients with parameters that indicated systolic and diastolic dysfunction (ejection fraction of the left ventricle < 50% [P = .009], early/late diastolic filling wave ratio [E/A] < 1 [P = .001], ratio of peak early transmitral velocity and early diastolic annular velocity [E/E′] >10 [P < .001], and combined E/A < 1 and E/E′ > 10 [P < .001]). The best discriminatory properties were observed for combined E/A < 1 and E/E′ > 10. RDW remained significantly associated with the aforementioned parameters in a series of multivariate regression models.Elevated RDW is significantly associated with the parameters of systolic and diastolic dysfunction even after adjusting for several confounding factors in the setting of STEMI and subsequent percutaneous coronary intervention. RDW seems to be better at discriminating patients with diastolic rather than systolic dysfunction.

Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review.

Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.

Nutritional preconditioning by marine omega-3 fatty acids in patients with ST-segment elevation myocardial infarction: A METOCARD-CNIC trial substudy

BackgroundMarine omega-3 eicosapentaenoic acid (EPA) is readily incorporated into cardiomyocyte membranes, partially displacing the omega-6 arachidonic acid (AA). Whereas AA is a substrate for pro-inflammatory eicosanoids, the release of EPA from cell membranes generates anti-inflammatory lipid mediators, contributing to the infarct-limiting effect observed experimental models. Clinical data are lacking. MethodsIn this observational study conducted in 100 patients with a reperfused anterior ST-elevation myocardial infarction (STEMI), at hospital admission we quantified by gas-chromatography the red blood cell proportions of AA, EPA, and the AA:EPA ratio, a valid surrogate for cardiomyocyte membrane content. Patients underwent cardiac magnetic resonance imaging in the acute phase (one week post-STEMI), and at long-term (6months) follow-up. Infarct size (delayed gadolinium enhancement) and cardiac function (left ventricular ejection fraction [LVEF]) were correlated with exposures of interest by multivariate regression analysis. ResultsAA:EPA ratio directly related to acute infarct size (coefficient [95% CI]: 6.19 [1.68 to 10.69], P=0.008) and inversely to long-term LVEF (coefficient [95% CI]: −4.02 [−7.15 to −0.89], P=0.012). EPA inversely related to acute infarct size (coefficient [95% CI]: −6.58; [−11.46 to −1.70]; P=0.009), while a direct association with LVEF at follow-up (coefficient [95% CI]: 3.67 [0.25 to 7.08]; P=0.036) was observed. ConclusionsA low AA:EPA ratio in red blood cells at the time of STEMI is associated with smaller acute infarct size and preserved long-term ventricular function. Our results are consistent with prior work in experimental models and add to the notion of omega-3 fatty acids as a healthy fat. Trial registrationhttp://www.clinicaltrials.gov/NCT01311700